Prepare now to work with diverse staff
Understanding creates stronger teams
By Ruth E. Davidhizar, RN, DNS, CS, FAAN
Dean of Nursing
Bethel College, Mishawaka, IN
Steven Dowd, EdD, RT(R)(QM), MR
Associate Professor School of Health Related Professions
University of Alabama, Birmingham
Joyce Newman Giger, EdD, RN, CS, FAAN
Professor of Graduate Studies
University of Alabama, Birmingham
The U.S. Census Bureau in Washington, DC, predicts that by as early as 2005, white males will lose their majority standing in the American work force as the nonwhite population increases due to immigration patterns and rising birth rates among minorities. Cultural diversity is especially prevalent in health care organizations. This diversity not only includes ethnicity and culture but also gender, lifestyle, age, and career stages.
Managing a diverse case management staff presents a challenge to case management executives. Not only must you be skilled in working with individuals who are culturally diverse, you also must help staff work with each other in a competent and friendly manner.
Discrimination in the health care workplace is often subtle. When a new individual joins a case management team, other staff members may struggle with acceptance. The challenge to case management executives is to integrate, not assimilate, individuals from diverse gender, age, and cultural backgrounds into the workplace.
You should encourage case managers to understand and work together by discouraging discrimination of all kinds. For example, older workers often experience age discrimination. If it appears an older staff member does not remember an announcement given to the entire staff, jokes about Alzheimer's or age-related memory loss often follow.
Some useful guidelines for relating to staff with gender, age, or cultural differences include:
· Assess personal beliefs of the individual.
· Assess communication variables from a cultural, age, or gender perspective.
· Modify communication approaches to meet individual needs.
· Understand that respect is central to relationship building.
· Communicate with others in an accepting manner.
· Use validating techniques.
· Be considerate of reluctance to talk about subjects that may be considered inappropriate by certain individuals, for example, sexual matters.
· Adopt special approaches with staff whose primary language is not English.
It is important for case management executives and staff to remember that even when both parties speak the same language, establishing communication is often difficult. Meanings of words may differ based on culture and life experiences.
English words have both a connotative and denotative meaning. Denotative refers to the general use of the word by most people. Connotative arises from an individual's personal culture. For example, the word "pig" has the same denotative meaning for most Americans. However, an Ortho dox Jew may react negatively to the word because the word is synonymous with "unclean" and "unholy." To a police officer, the word has another but still negative meaning. Conversely, a farmer may react favorably to the word, equating pigs with financial resources.
Making room
Words are only one component of human communication. You may find that some case managers demonstrate territorial behavior. They often want a space for themselves that they do not want others to disturb. This spatial behavior is also noted in how comfortable individuals feel standing close to others.
Many individuals of Western European background are territorial. It's important for other staff to understand that these individuals "need their space," and that denigrating territorial behavior through jokes is inappropriate.
Social organization also affects behavior in the workplace. For most cultural groups, the family is the most important social organization. In some cultural groups, family is more significant than any other personal, work-related, or national causes. For example, if a family member is ill, it may be extremely important for case managers of Chinese, Mexican, Vietnamese, and Puerto Rican descent to take time off to be with the ill person.
Social issues can be gender- as well as culture-related. The health care industry has always employed a large number of women. As the number of women in the work force increases, the need for management policies and practices that support a woman's ability to meet family commitments and responsibilities also increases.
A female case manager with children must be comfortable that her children are being adequately cared for and that if a child becomes sick, appropriate care is available. If a baby sitter refuses to care for a sick child, a female staff member must be able to respond to this situation.
Another aspect of culture that often affects workplace behavior is the concept of time. A case management executive may find that most case managers are very time conscious, while others are less likely to be punctual. Time orientation is usually described as being either past, present, or future. Understanding the time orientation of your staff can help you manage more effectively. Some time orientations common to different cultural groups include:
· White Americans place future over present orientation.
· Southern African Americans place present over future.
· Puerto Rican Americans place present over future.
· Southerners living in Appalachia have present orientation.
· Mexican Americans have present orientation.
· Traditional Chinese Americans have present orientation.
· Jewish Americans have a strong sense of all three time domains. They have a strong sense of history. They budget time according to present needs but are often future-oriented in terms of planning.
Environmental controls refer to an individual's perception of his or her ability to direct factors in the environment. In the United States, most health care professionals operate from an internal locus of control. This includes planning and directing oneown environment. A case manager with an external locus of control tends to believe more in fate, luck, or chance.
For example, case managers with an external locus of control may be reluctant to provide normally expected interventions. Conversely, case managers with an internal locus of control may clash with patients who have a fatalistic view of health and disease. This clash may result in failure to comply with the treatment plan.
Similarly, older patients sometimes feel they lack control over their environment. This is often due to a number of factors, including poor health status. Some older patients worry that a younger case manager will not understand their need to exert at least partial control over their environment. This concern also may result in lack of compliance with treatment plans.
Creating a positive climate for diversity involves the following four factors:
· assessing employees;
· educating employees;
· providing managerial modeling;
· developing trust and consensus through common goals.
Case management executives must assist a diverse staff in the process of working together as a team. Individuals in some cultural groups lack training in psychosocial skills and may be reluctant to share and work with others in the manner required by case management and patient care teams.
Workshops directed at the value of diversity help employees gain insight concerning sexism; racism; prejudice; group dynamics; and prevention, avoidance, or resolution of conflict. Small group training sessions help maximize openness and encourage free exchange of ideas. Periodic refresher courses reinforce positive changes in the department.
Set a good example
In addition to allocating time and resources for diversity education, case management executives must lead the way in attending and conducting training sessions on diversity. You must establish goals for diversity that have measurable outcomes; for example, one goal might be to have no diversity-related grievances.
Goals must be explicit and tied to consequences. The case management executive must have a plan for rewarding staff who follow the principles of diversity. In addition, executives must interact with all staff in the same manner and take time to relate on a personal level. Such role modeling encourages similar behavior from other case managers.
Developing trust and consensus through common goals is the final stage in creating a climate for diversification. This stage often takes time to develop. If some staff are rigid, even though they deny prejudice, prejudicial behavior still occurs. It is only as interpersonal interactions occur, differences are resolved in a congenial manner, and friendships are established that negative attitudes and stereotypes breakdown.
[Editor's note: For discussion of how diversity impacts the case manager/patient relationship, see Case Management Advisor, June 1998, pp. 97-100, 105. For useful training resources on diversity, see above box.]
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