The health care leader as humanist.
Abstract: This paper discusses the nature of humanism in healthcare management and leadership. Humanism in healthcare management should entail serving 1) patients and their families, 2) organizational members, and 3) the community. The article describes how humanism is largely absent from healthcare organizations as a critical and important value. In the twentieth century, a number of models of healthcare leadership were developed that were humanistic in focus. These models primarily stressed the value of attention by leaders on the needs and values of people working in the organization. However, humanistic, healthcare leadership involves not only motivating and empowering employees, but a primary, essential focus is for leaders to create environments that support and uplift patients and their families. Humanistic care in healthcare organizations can be facilitated by leaders establishing positive, supportive, and empowering environments for clinicians and other employees. Secondly, managers can establish programs to develop and train employees to provide humanistic care.
Subject: Health care industry (Social aspects)
Health care industry (Services)
Humanism (Psychological aspects)
Humanism (Analysis)
Medical personnel (Practice)
Medical personnel (Services)
Author: Kilpatrick, Anne Osborne
Pub Date: 03/22/2009
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2009 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2009 Source Volume: 31 Source Issue: 4
Topic: Event Code: 290 Public affairs; 360 Services information; 200 Management dynamics Computer Subject: Health care industry
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033751
Full Text: Discussions and articles on humanism in healthcare generally have focused on clinicians, such as physicians and nurses, and clinician behaviors that promote caring and support for patients. For example, Branch et al. (2001, p.1068) stated that humanism in medicine involves "the physician's attitudes and actions that demonstrate interest in and respect for the patient and that address the patient's concerns and values. These generally are related to patients' psychological, social and spiritual domains." Humanism in medicine clearly focuses on the individual level. However, humanism in healthcare management involves both micro (individual) and macro dimensions, as the scope of leadership and service to others becomes necessarily broader from the standpoint of management. High-level healthcare managers must serve a number of "stakeholders", both within and without the organization. Humanism in healthcare management should entail serving 1) patients and their families, 2) organizational members, and 3) the community.

The Merriam-Webster definition of humanism is that it is "a doctrine, attitude, or way of life centered on human interests or values (Merriam-Webster Online, 2008)." Therefore, concern for the individual in his or her broadest sense is central to a humanistic manager. Similar to what Branch and colleagues noted in their definition of humanism in medicine, the sphere of attention for humanistic managers may include the psychological, social, and the spiritual or self-development elements of their employees. In healthcare, such attention by managers should be even greater to patients than for employees, as patients are by definition much more likely to be in worse condition: physically, mentally, and emotionally.

The leaders of many healthcare organizations in America have been deficient in serving both their employees and their patients. Ironically, in spite of the increasing acceptance of more caring and humanistic models of management, many healthcare organizations and their leaders in the 20th century embraced an impersonal, technical, and financially-focused approach to management. This approach was described in 1925 by Max Weber who extolled the benefits of bureaucratization, where administrative functions were carried out based on "purely objective considerations" (Weber, 1968, p.975). Weber stated, "Bureaucracy develops the more perfectly, the more it is "dehumanized," the more completely it succeeds in eliminating from official business love, hatred, and all purely personal, irrational, and emotional elements which escape calculation."

This focus on organizational objectivity and rationality is described in Victor A Thompson's Without Sympathy or Enthusiasm: The Problem of Administrative Compassion (1975). Thompson notes that "This impersonal, objective, institutional approach to action, while demanded by the norms of an industrial society, is somewhat at war with basic sociopsychological needs of individuals." While there is certainly justification for excluding some strong human emotions and irrationality from the workplace, it is dysfunctional to exclude warmth and caring, particularly in health care. However, many healthcare leaders have continued to accept a restricted, antiquated approach to leadership, similar to what was advocated by Weber - one which is obviously inadequate in caring for human beings.

This paper will describe the development and growth of humanistic models of leadership in the twentieth century through today. It will describe approaches and programs to implement or enhance greater humanism in caring for patients. Organizational inconsistencies and operational/cultural obstacles to creating a positive culture must be addressed and will undermine any efforts for culture change. Finally, the paper describes concrete steps for healthcare leaders who wish to create continuing, humanistic healthcare cultures.

THE DEVELOPMENT OF HUMANISTIC LEADERSHIP

The growth of humanism as a central element of management may be traced to and through the last century. The landmark Hawthorne Studies, in the late 1920s, found that employee relations, solidarity, and sense of belongingness and recognition, were more related to job productivity than working conditions or even benefits (Roethlisberger & Dickson, 1949). The findings from the Hawthorne Studies were the primary fountainhead for a number of related theories of management termed the Human Relations School. What these theories had in common was a strong emphasis on the humanistic component of management.

In the mid-twentieth century, a number of theorists added to the human relations paradigm. The Ohio State Studies identified 1) initiating structure and 2) consideration (the degree to which the manager acts in a friendly and supportive manner to subordinates), as the two critical elements of management (Halpern & Winer, 1957). A very similar diarchy was formulated by Blake and Mouton (1982) in the Managerial Grid: 1) concern for people, and 2) concern for production. Douglas McGregor in such works as Leadership and Motivation (1966) and The Human Side of Enterprise (1985) stressed the need to allow employees self-direction, responsibility, and the opportunity to find self-actualization, as well as being in supportive relationships with their managers. Hersey and Blanchard's model of situational leadership (2000) suggested that only in some situations should managers focus on interpersonal support of employees, and that was determined by the "situational maturity" of the individual involved. This approach reflected a rational approach to how managers led their employees. However, the model stipulates that in many situations, organizational members need "relationship/supportive behavior" from their supervisor.

The ascendance of models such as these provided clear evidence that humanism in management was beginning to be considered at least equally important as a management focus on tasks, production, and operations. Essentially, the human relations school and similar management philosophies shifted the conceptualization of the manager as director and controller to one who helped employees develop and be motivated.

Two theories largely promulgated in the 1970s are relevant to the topic of humanistic leadership: James Burn's theory of transformational leadership (1978) and Robert Greenleaf's servant leadership (1977). According to Burns, in transformational leadership leaders and followers interact and reach higher levels of motivation, conduct, and of aspirations. Both the leader and the follower are transformed and their purposes become fused. Burns' transformational model identifies a mutual exchange and benefit between the leader and the led. Unlike other leadership models, transformational leadership acknowledges a similar or reciprocal contribution by the followers. Transformational leadership is essentially humanistic in its emphasis on the growth, development, and interests of the follower; however, the model does note the benefits for the leader.

Robert Greenleafs model of servant leadership (1998; 1978) identified service to followers as the principle occupation of the servant leader. He contrasted between servant leaders and other types of individuals attracted to leadership, stating that they were characterized by significantly different self-concepts and basic motivations. "It [servant leadership] begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first, perhaps because of the need to assuage an unusual power drive or to acquire material possessions...The difference manifest itself in the care taken by the servant-first to make sure that other people's highest priority needs are being served. The best test, and difficult to administer, is: do those served grow as persons, do they grow while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants (Greenleaf, 1977, p.13)?" Unlike many other leadership models that might be considered humanistic, servant leadership applies to both employees and others who are "served" by the leader. Consequently, this model applies readily to humanistic leadership in healthcare, which seeks to serve employees, patients, and others.

In recent years, Kouzes and Posner (1999) noted a study by the Center for Creative Leadership, which contrasted the highest- and lowest-performing managers. This study noted that the single factor that differed was that the highest-performing managers both expressed and desired affection to a greater degree than the lowest-performing managers. Kouzes and Posner also suggest that the one thing that sustains leaders and gives them courage, is love.

Terms such as "affection" or "love" may seem strange or awkward in the context of leadership. Certainly, the majority of media representations of leaders have been of restrained and emotionally guarded individuals. Nevertheless, it is likely true that the majority of us would feel more content and secure working for a leader who felt and expressed a modicum of warmth and affection toward us, as compared to a more distant and formal manager.

The humanistic leadership models that have been described in this paper exhibit a significant other- orientation and this is consistent with the nature of humanism: to be concerned with the interests and values of others. Thus, a humanistic leader may be focused on providing the most advanced care, and on realizing solid organizational profits. Additionally, this leader will also be concerned about individuals in the organization: how they can be served, empowered, and developed to their highest potential.

In an organization with a strong humanistic orientation, an emphasis on leader traits, charisma, and extraordinary qualities is secondary. In such organizations, the leaders may be uncomfortable with personal recognition and praise: Collins' Level 5 leader combines and intense personal will with extreme genuine humility (Collins, 2001). Thus, a natural corollary of an other- oriented leader, is a diminution of selfishness and self- preoccupation.

HUMANISTIC LEADERSHIP IN HEALTHCARE

Leadership in healthcare organizations is both similar to and different from leadership in other organizations. In other words, the principles and points of the numerous proponents of effective leadership (described earlier in this paper) may be applied to both healthcare workforces and other workforces. However, healthcare differs from most industries and many service industries in that leadership must not only motivate, inspire, and uplift employees, but leadership should also seek to motivate, inspire, and uplift patients and their families. Consequently, healthcare leadership by its very nature is essentially humanistic, and this is as critical and integral as is the leader's attention to high-quality clinical care and technical excellence.

Healthcare leaders themselves generally have minimal personal contact with patients. Doubtless, such contacts can and should be caring and supportive. However, leaders have enormous legitimate scope to influence employees and influence patient care. This is primarily accomplished through enabling and assisting clinicians and staff to provide humanistic care. This is illustrated in Figure 1.

[FIGURE 1 OMITTED]

Although, Figure 1 may seem simplistic to some readers, it does communicate two points that are often overlooked by those who plan humanistic, organizational culture change. The second box in Figure 1 describes two main areas in which managers can enable employees to provide humanistic care. One is to create a positive human relations culture in which employees are largely satisfied with their jobs, and feel motivated and empowered to be caring to and supportive of patients. This could be accomplished through systems of care, such as High Performance Work Systems (HPWS), which also have been referred to as high-involvement work systems and high- performance organizations (Nadler & Gerstien, 1992; Lawler, Mohrman, & Ledford, 1995). The values of this process certainly appear to be similar to those in an efficient, yet humanistic environment. They "represent a mutually reinforcing constellation of core workplace attributes, including involvement, empowerment, trust, goal alignment, training, teamwork, communications, and performance-based rewards." (See Harmon, et al., 2003 for more about HPWS.)

Secondly, managers can establish programs to develop and train employees to provide humanistic care. Some examples of this might include training programs to develop skills: in speaking with terminal patients, in developing interpersonal skills, in being attentive and responsive to patients, in providing positive guest relations, and in being patient advocates. Managers can also institute support groups for clinicians or Balint-type groups for physicians. Mohammadreza Hojat's paper in this symposium issue describes 10 programs that can be adopted to foster humanism in health and human services cultures; managers have a key role to play in initiating and facilitating the development of such programs. Consequently, a positive human relations culture, along with staff training and support programs, are both requisite in organizations that wish their employees to provide humanistic care: this is the love, empathy, support, attentiveness, consideration, and respect listed in the third box of Figure 1.

CONCLUSION

Scholars on organizational change have emphasized the importance of institutionalizing good processes. As Kanter (1983, p. 299) noted, "The actions implied by the changes cannot reside on the level of ideas, as abstractions, but must be concretized in actual procedures or structures or communication channels or appraisal methods or work methods or rewards." The training of employees in how to appropriately practice humanism is a key part of a successful environment. The reward system needs to reward attitudes and behaviors that reflect compassion and caring. For example, Chapman's Radical Loving Care (2003) describes formal recognition processes for individuals and teams, as well as the recognition of units reflecting these values throughout the organization. Chapman, as a leader of large hospitals, advocated and stressed that a contribution could and should be made to humanistic patient care by all employees (e.g., laundry workers, housekeepers, cafeteria cashiers, nurses, physicians). Buy-in and support from high-level internal stakeholders is also critical. For example, board members should be educated about humanism, and affirm these values to be as important as showing a profit. Often several board members may be strong advocates for fostering a caring culture and they can help create the enthusiasm that is essential for creating a new culture.

A recent development in some healthcare organizations is to adopt culture change programs that demand specific mandated behaviors such as "scripting", "rounding", and "thank you notes". Often such programs fail to evoke and affirm among staff the underlying human values of caring and compassion. Examples of programs designed for organizational employees to exhibit specific behaviors and responses include are Disney (2006) and in healthcare, the Studer Group (2004).

Managing this process is a challenge for organizations, and has been the topic of debate for decades. In psychology, behaviorists argue that if one succeeds in getting the behavior changed, the attitude can follow. However, a concern with changing surface behaviors was expressed by Thompson (2007, p.13) who stated, "To sensitive clients, synthetic compassion can seem worse than none at all. In the final analysis, compassion is an individual gift, not an organizational one." Yet, it is an individual gift or value that leaders can help evoke in virtually all organizational members.

The alternative school (to the behaviorists) hold that an attitude change will result in a behavioral change. This view is consonant with a large body of work on vision and values in organizations, which holds that once employees embrace organizational values that support caring and compassion, excessive micromanagement, direction, and supervision concerning their behaviors is unnecessary, and may suppress a healthy spontaneity and individualism. Nevertheless, some oversight is necessary, and it is important to explicitly incorporate expectations and rewards for communication and positive behaviors among employees, clinicians, and managers.

The author of this paper has observed health care organizations seek to implement culture changes to improve patient satisfaction without addressing fundamental deficiencies in their operations. Following is a verbatim communication from a nurse supervisor about a major program/culture change to improve patient relations.

This nurse supervisor's statement illuminates the unmanageable situations that healthcare leaders and managers may create for their staff. A healthcare organization in a financial and human relations crisis, unhealthy itself, is in no position to make unreasonable behavioral and performance demands from its staff. Her statement also reveals the disillusionment that takes place when organizational values are not explicit and consistent at all levels of the organization. If a training program to expand humanistic behaviors is conducted, the CEO and lower level managers should participate fully, and not excuse themselves from what they expect from other members of the organization.

As expressed earlier in this paper, the first, essential step towards a humanistic culture, "... is to create a positive human relations culture in which employees are largely satisfied with their jobs, and feel motivated and empowered to be caring to and supportive of patients." For this to occur, there must be a modicum of stability and predictability in the work environment. Leaders should believe that their organizations must be compassionate and caring, and feel this from the core of their hearts. Humanistic care is too important to be a public relations fad, a marketing ploy, or an empty slogan.

True humanistic leadership, along with quality care, should inevitably have a positive impact on organizational efficiency and the financial "bottom line". As important as this is, ultimately what is more important is this accomplishment: for patients to say after returning to the community, "What a wonderful group of people took care of me during my stay."

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ANNE OSBORNE KILPATRICK

Medical University of South Carolina
I have always been involved with my staff and would round almost
   daily. This [mandated rounding] has created extra work for me,
   because now I have to stop and document all my interactions with my
   staff and external departments. Compounded with having to work
   extra hours due to the hiring freeze and shortages and having to
   accept more responsibility, I find myself becoming unhappy and
   tired from it all. Since my background was OR nursing, I didn't
   have to deal with a patient assignment and families, like the staff
   on the floors. I find most of the training is basic compassion for
   others and common courtesy. This is lacking at this hospital. In
   the hospital there is so much turnover, there is no staff
   continuity for the program. In my department our director and
   managers just do not participate. How they get away with this, I am
   not sure. I feel with the current [negative] financial situation,
   the progress they have made will be lost. I see our customer
   service and employee feedback decreasing again. Staff are being
   sent home with and having to use "paid time off" and no pay. We
   have a hiring freeze. Everyone is having to work harder for less. I
   understand this is what we need to do to get through this period
   but most of the staff blame administration for allowing this to
   happen. They have lost trust and feel insecure about their future.
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