Chapter 3Health Policy and the Delivery SystemCopyri

Chapter 3
Health Policy
and the Delivery System
Copyright © 2018, Elsevier Inc. All Rights Reserved.
The Patient Protection and
Affordable Care Act (PPACA)
� New health care federal reform law signed in 2010
� Largest change in the financing of the American health
care system since Medicare and Medicaid (1965)
� Focus on vulnerable populations: affordability,
accessibility, and financing of health care
� Designed to reduce number of uninsured persons via
expanding Medicaid and establish subsidies
� US Supreme Court upheld the ACA in June 2012
� Likely will change secondary to Trump presidency
Copyright © 2018, Elsevier Inc. All Rights Reserved. 2
Key Features of PPACA
� PPACA lacks bipartisan support

� Change in political landscape may result in
repeal or significant changes
� No exclusion for preexisting conditions
� Health insurance is mandated for everyone
� Marketplace exchange for insurance plans
� All policies must cover essential benefits
� Medicaid expanded; subsidies available
Measuring the Nation’s Health
� Health, United States report (annual)
Ø Informs policymakers of trends in nation’s health
� Healthy People 2020
Ø 10-year agenda for improving nation’s health
Ø Goal is to increase quality and years of healthy life,
and eliminate health disparities
� Central Intelligence Agency (CIA) statistics
Ø Morbidity data
Ø Compares United States with other countries
US Health Trends
� Successes in infection, other diseases
� Concerns: sedentary lifestyle, obesity, chronic

illness
� Health disparities persistent
Ø Contribute to unfavorable US health indicators
Ø Compromise progress in world health
� Vulnerable populations due to age, education,
language, location
� Rise in suicide and drug poisoning deaths esp
involving opioid analgesics
Historical Role of Women
� Nurses have long tradition of health promotion
� Nursing pioneers
Ø Florence Nightingale (Crimean War 1884)—crusaded
for nutritious food, cleanliness, sanitation
Ø Lillian Wald (Henry St Settlement—NYC 1883)
founded NYC visiting nurses association to provide
health services for indigents in tenements
� Through the ensuing decades nurses developed
unique role agents for health promotion

� US Health Care system undergoing changes
Ø Sparked by health care reform politics
Ø Large organizations involved in forming health policy
� Health and medicine division
Ø Previously known as Institute of Medicine (IOM)
Ø Research from a systems approach
Ø Advisement on safe delivery of health care
Ø Health care system (not practitioners) is basic cause
of medical errors
A Safer System
� Overriding objective is for all people (global) to
attain highest possible health
� Current agenda—six goals
Promoting development Enhancing partnerships
Fostering health security Improving performance
Strengthening health systems Harnessing research info
� Budget issues limit achievement of goals
� Huge health disparities in developing nations
Global Health
World Health Organization

� Earliest views were holistic, emerging from
integrated worldview
� Hygiene incorporated into most religions
� Primitive peoples had mystical view of sickness
and cure—tied to religion
� During middle-ages widespread epidemic
diseases leading cause of death ( leprosy,
plague, smallpox, TB)
Historical Influences Health Care
� Adequate food supply prolonged life span
Ø Transportation enhanced food distribution
Ø Technological advances improved food production
� Industrial advances prevented diseases
Ø Flush toilet, sewer systems
Ø Decrease in typhoid, paratyphoid, gastroenteritis
Historical Industrial Influences
� Elizabethan poor laws (1601) England
Ø Relief for infants, sick, elderly, workhouse laborers
� New Law 1834—harsher philosophy

Ø Pauperism in able-bodied workers viewed as moral
failing
Ø Suspicious and punitive view of indigence
� Protestant work ethic (rewards work efforts)
Ø Philosophy brought to United States by Puritans
Ø Influences modern health care—fee-for-service
Historical Socioeconomic
Influences
� Edwin Chadwick—father of public health
� Disease viewed as impediment to ability to self-
support (Chadwick’s view)
� Public health services and welfare combined
creating a more benevolent view of indigence
� Puritan ethic in the United States offered a
harsher view toward indigence and health care
� Health and welfare departments continue to
have contradictory approach to poor
Public Health Influences

� Prior to 20th century infectious diseases (ID)
major cause of death
� Scientific advances → Improved health
Ø Louis Pasteur—germ theory
Ø Joseph Lister—antisepsis
� Innovations: safeguard water, food, and milk
supply; sewage systems; urban housing regs
� Antibiotics (1936-1954) decrease in ID
� ID death persists in vulnerable populations
Scientific Influences
Major milestones with effects on health care
� New Deal (Great Depression)
� Social Security Act 1935
Ø Grants-in-aid for state and local public health
Ø Assistance programs: blind, elderly, disabled
� Medicare and Medicaid (1965)
� Patient Protection and Affordable Care Act
(2010)
Political and Economic Influences

Preventative vs Curative Medicine
� Early prevention directed toward individuals
Ø Originated in medical practice vs public health
Ø Focus was on poor—state welfare programs
� Public health services eventually emerged
Ø Focus on societal prevention vs individual cure
Ø Immunizations, screenings, education
Ø Education and career paths for pubic health vs medical
practitioners remained separate
� 1960s emphasis shifted from individual to societal public
health goals
� Evolution toward greater government in health care
Organization of Delivery System
� Huge system: public and private components
� Multifaceted and complex interrelationships
Ø Providers and consumers
Ø Varied settings: private and public services
� Public sector: nonprofit agencies, government
agencies, organized at local, state, and national
levels (US Department of Health and Human
Services)
� Private sector: for profit services

Private Sector
Independent Practice
� Independent practice—free-market system
Ø Fee-for-service; hallmark is choice of provider
Ø Managed care health organizations evolved
Ø Prevention has gained importance
� Nurse-managed centers
Ø Advanced Practice Nurse serve as primary care
providers
Ø Multidisciplinary collaborative approach
Ø Focus: vulnerable populations
Private Sector
Managed Care
� Managed health care/health maintenance
organizations (HMOs)—emerged 1990s
Ø Groups of providers, contract with HMOs
Ø Comprehensive care for prepaid fee
Ø Motivation and goal is to control costs
� Managed care: key elements
Ø Control costs, regulate health care utilization
Ø PCP gatekeeper to system; coordinate care

Ø Payment based on network status: in-network vs out
Private Sector
Health Maintenance Organizations
� Capitation method of payment
Ø Provider receives fixed payment per enrollee.
Provider provides all necessary care to enrollee
� PCP is gatekeeper
Ø Specialist require referral
Ø Members (patients) may have copays
Ø Must use network providers
� Medicare Advantage plans are HMO alterative to
traditional Medicare
Private Sector
IPAs and ACOs
� Independent practice associations (IPAs)
Ø Physician organizations
Ø Care for HMO members in private office
Ø Several models available
� Accountable Care Organization (ACOs)
Ø Key component in Affordable Care Act

Ø Not yet in place—Medicare reform
Ø Structure will be similar to HMOs
Ø Focus is cost-containment
Private Sector
Concierge and Hospitalists
� Concierge medical practices
Ø Membership fee for enhanced health care
Ø Fewer patients—more time per patient
Ø Focus: personalized, holistic care for higher income
individuals
• Typical household income—$125,000-$250,000
• Typical patient—age 50 and older
� Hospitalist movement
Ø Physicians or APNs who provide comprehensive
hospital care—improved quality and safety of care
Private Sector
POS and HDHPs
� Point-of-service plans (POS)
Ø Additional fee for providers outside of network
Ø Increases consumer choice

� High Deductible Health Insurance Plans
Ø High annual out-of-pocket deduction
Ø Suitable for healthy persons—low monthly premium
Ø Health Savings Account (HSAs)
• Employer contributions plus pretax deposits allowed
• Withdrawals for health-related expenses
• In-network providers offer enhanced savings
Private Sector
PPOs
� Preferred Provider Organization—PPO
� Key elements
Ø Contracted providers who will deliver member
services at prenegotiated rate (discounted)
Ø Extra cost if non-PPO providers used
Ø Copays by members required at time of visit
Ø Preauthorization required for hospitalization or costly
tests and procedures
Ø 52% of employer-sponsored plans are PPOs
Public Sector
Power and Influence

� Source of power—shared federal/state
Ø Federal: tax/spend general welfare
Ø State: health authority based on 10th Amendment
� Influence of political philosophy
Ø Each new administration since 1980s has introduced
new philosophy, bills, or components of health care
Ø Most recent legislation: HIPAA (1996) Medicare
Prescription Drug Act (2003) Affordable Care Act
(2010), Children’s Health Insurance Program (2015)
� National health care debate
Public Sector
Current/Future Policy
� Current political issues re health care
Ø Lack of political consensus—partisan discord
Ø Major factors: cost, access, quality
Ø Discordant partisan views concerning ACA
� Nurse’s role in health care reform
Ø ANA: advocate for single-payer system
Ø Focus on primary care, prevention
Ø Push for nurses to function to full extent of education and
training—remove barriers
Ø Nurses comprise largest segment of health care
workforce—3 million members

Official Health Care Agencies
Type of
Agency
Key Characteristics
Local � Local health department
� Direct services to public
State � State health department
� Policy, planning, program coordination
Federal � Run by executive and legislative branches—
determine health policy
� USHHS—administers policy
(Cont.)
Type of Agency/
Personnel
Key Characteristics
Chief Nursing

Officer
� Serves in US Public Health Service
� Works with US Surgeon General on nursing
and public health policy
Federal
Emergency
Management
Agency (FEMA)
� Part of Department of Homeland Security
� Disaster-related services
� Assists individuals, communities, states
(Cont.)
Type of Agency/
Personnel
Key Characteristics
Military Health
System
� Comprehensive medical care for active
duty personnel, dependents, retirees
� Responds to natural disasters and
humanitarian crisis throughout the world

� Veteran’s Administration: independent
agency under President to provide for
veteran care
Wounded
warrior care
� Extensive care and rehabilitation to
return severely injured soldiers to active
duty or transition to VA health system
Health Care Legislation and
Agencies
Legislation/
Agencies
Key Information
Americans with
Disabilities
� Prohibit job discrimination and require
services to people with disabilities
Patient Self-
Determination Act
� Advanced directives for health care
Federal Health
Information Privacy
� Safeguards security/confidentiality of health

information
International-
WHO
� Worldwide guidance in promoting world
health through standards, programming,
and collaboration
Voluntary (not-for-
profit) Agencies
� Influence policy/legislation
� Philanthropic (nongovernmental)
American Red Cross
� Volunteer-led humanitarian organization
� Congressional charter—officially sanctioned but
no direct government supervision
� 700 local chapters, 500,000 volunteers, 35,000
employees
� Responds to both small local disasters (house
fire) and large natural disasters
� Blood products, health education,
communication for servicemen/families

Financing Health Care
� Costs
Ø Increasing due to multiple factors
Ø Less time in system for health promotion
� Sources
Ø Federal government (Medicare, Medicaid)
Ø State funded programs—Medicaid, CHIP
Ø Third-party payment (insurance)
Ø Employer provided health plan benefits
Ø Independent sources
Ø Out-of-pocket: deductibles, copays, health savings accounts
Ø Affordable care act subsidies
Mechanism for Financing
� Independent practice with fee-for-service—physicians, APNs,
health
care professionals
� Salaried providers—nurses, APNs, physicians
Ø Overtime is uncompensated
Ø Often leads to burnout from overwork
� Hourly compensation
Ø Most hospital and outpatient staff
Ø Workers eligible for overtime

� Capitation—flat fee regardless of services used
Ø Encourages preventive care to keep people healthy
Ø Some individuals make unnecessary visits
Ø HMO sponsors and bears risk of illness
Cost Containment
� Cost-containment initiatives
Ø Prospective payment system, limits on provider
payments, Medicare Advantage (MA) plans
� Care management
Ø Determines and coordinates care
Ø Across continuum of health care services
Ø Reduce waste, improve quality, control costs
� Managed care issues
Ø Quality of care vs cost control
Ø PCP as gatekeeper
Managed Care
� Care management: professional oversees care
Ø Coordination of care
Ø Insuring quality care
Ø Cost containment
� Managed care issues

Ø Renewed importance with Affordable Care Act
Ø Cost containment
Ø Provide high-quality optimum care
Health Insurance
� Private insurance
Ø Traditional insurance companies (BC/BS)
Ø PPOs—“brokers” between insurers/providers
Ø HMOs—prepayment plans
Ø POS—combination of HMOs and PPOs
Ø Self-insurance/self-funded
� Public insurance/assistance
Ø Medicare
Ø Medicaid
Medicare
� Federal program
� Paid through taxes
� Finances medical care for:
Ø People over 65
Ø Disabled
Ø People with end-stage renal disease
Ø Hospice

Medicare (Cont.)
� Part A
Ø Inpatient care in hospitals, skilled nursing facilities, home
health
care, hospice
� Part B
Ø Supplementary voluntary coverage
Ø Pays doctor’s visits
� Part D
Ø Pharmaceutical costs—multiple plans available
� Challenges
Ø Growth in elderly population
Ø Depletion of Medicare resources (trust fund)
Ø Uncovered services (glasses, dental, hearing aids)
Medicaid
� Assistance program managed jointly by federal and
state funds
� State-determined eligibility
� Costs up to 50% of state budgets—open-ended

program
� Benefits vary by state
� Available to:
Ø Certain low-income individuals
Ø No age requirements
Ø Families with children: 5-year lifetime limit
The Uninsured
� Of all developed countries, the United States has the highest
proportion of population with no health insurance
� 2008: 46 million uninsured younger than age 65
� Most uninsured individuals live in families in which there is
at least
one full-time worker
� Groups at most risk
Ø Persons of Mexican origin
Ø Young adults
Ø Working uninsured
Ø Illegal aliens
� ACA expected to reduce uninsured numbers
Affordable Care Act and HIPPA

� The Affordable Care Act is expected to reduce the
number of uninsured people by 60%
Ø Expansion of Medicaid
Ø Subsidies to pay health insurance premiums
Ø Federal mandate requiring citizens to enroll in an
insurance plan—penalties for noncompliance
Ø Provision allowing children to remain on employer family
insurance to age of 26
� Health Insurance Portability and Accountability Act
(HIPAA)
Ø Provisions for maintaining coverage if lose/leave job
Unauthorized Immigrants
� 11.3 million illegal aliens in United States (2014)
Ø 50% from Mexico
Ø Some illegal entry; others overstayed visa
Ø Federal law mandates anyone entering ER must be
treated regardless of ability to pay
� Illegal aliens are vulnerable population
Ø Indigent but not eligible for Medicare or Medicaid
Ø Many do not seek care for fear of deportation
� Immigration reform highly contentious issue

Health Care in Other Countries
� Canadian health care system
Ø Universal coverage; social insurance plan
Ø Private plans available for unpaid services
Ø Issues: two-tiered system, shortage of providers, delays in
service
� German health care system
Ø Nearly universal access (87%), but private insurance (10%)
pays
providers better
Ø Issues: two-tiered system, weakening public system,
increased cost
� UK health care system
Ø National health insurance—spends least on health care per
capita
Nurse’s Role in Health Policy
� Advocate
Ø Individual
Ø Justice in health care system
� Participating in policy decision-making
Ø Voting
Ø Communicating with legislators

Ø Running for political office
Ø Lobbying though professional organizations
Essentials of Organizational Behavior
Fifteenth Edition
Chapter 3
Attitudes and Job Satisfaction
Copyright © 2022, 2018, 2016 Pearson Education, Inc. All
Rights Reserved.
Rights Reserved.
1
Learning Objectives
3.1 Contrast the three components of an attitude.
3.2 Summarize the relationship between attitudes and behavior.
3.3 Compare the major job attitudes.
3.4 Identify the two approaches for measuring job satisfaction.
3.5 Summarize the main causes of job satisfaction.
3.6 Identify three outcomes of job satisfaction.
3.7 Identify four employee responses to job dissatisfaction.
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2

Attitudes
Learning Objective 3.1
Attitudes: evaluative statements – either favorable or
unfavorable – concerning objects, people, or events
Reflect how one feels about something
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Attitudes are statements that make an evaluation about objects,
people, or events. They offer a favorable or unfavorable view
that reflects how one feels about something.
3
The Components of an Attitude (Exhibit 3-1)
Copyright © 2022, 2018, 2016 Pearson Education, Inc. Al l
Rights Reserved.
Attitudes are made up of three components. The cognitive
component is composed of the belief in the way things are. The
affective component is the more critical part of the attitude, as
it calls upon the emotions or feelings. The behavioral
component describes the intention to behave in a certain way
toward someone or something. These three components work
together to aid in our understanding of the complexity of an
attitude and the potential relationship between attitudes and
behavior.
Long Description:
The details of the diagram are as below:
Cognitive: evaluation. My supervisor gave a promotion to a co-
worker who deserved it less than I do. My supervisor is unfair.
Affective: feeling. I dislike my supervisor!
Behavioral: action. I’m looking for other work; I’ve complained

about my supervisor to anyone who would listen.
All three components lead to negative attitude toward
supervisor. The connection is shown via bi-directional arrows.
Connections between the following components is also shown in
this diagram:
Cognitive and affective
Affective and behavioral
Behavioral and cognitive.
Text in the diagram reads: Cognition, affect, and behavior are
closely related.
4
Attitudes and Behavior
The most powerful moderators of the attitude-behavior
relationships are:
Importance
Correspondence to behavior
Accessibility
Social pressures
Direct personal experience
Knowing attitudes helps predict behavior
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Some variables do moderate the relationship between attitude
and behavior. These factors include the importance of the
attitude, the correspondence of the attitude to the behavior, the
accessibility of the attitude, the existence of social pressures on
behavior and the personal and direct experience of the attitude.
These variables will impact the ability to estimate how a certain
attitude will predict behavior.
5

Attitudes and Behavior (1 of 2)
Cognitive dissonance: any inconsistency between two or more
attitudes, or between behavior and attitudes
Individuals seek to minimize dissonance
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Sometimes we observe people who will change what they say so
it doesn’t contradict their behavior. When attitudes and
behaviors don’t line up, individuals will experience cognitive
dissonance. This incongruity is uncomfortable, and individuals
will seek to reduce the dissonance to find consistency.
6
Attitudes and Behavior (2 of 2)
Desire to reduce dissonance is determined by:
The importance of the elements creating the dissonance
The degree of influence the individual believes he or she has
over the elements
The rewards that may be involved in dissonance
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People are willing to live with some discomfort, but the degree
to which this is true depends upon the importance of the
element that is creating the cognitive dissonance, how much
influence the individual has in the situation, and the rewards
that are available.
7
Job Satisfaction and Job Involvement
Job satisfaction

A positive feeling about the job
Job involvement
Degree to which people psychologically identify with their jobs
Psychological empowerment
Beliefs in the degree of influence over the job, competence on
the job, autonomy, and job meaningfulness
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The field of organizational behavior focuses on how attitudes
will influence the workplace.
There are several major job attitudes we will look at throughout
the book. The first is job satisfaction, which is the positive
feeling about the job resulting from an evaluation of its
characteristics. The second is job involvement. Job involvement
looks at the degree of psychological identification with the job.
An additional job attitude is psychological empowerment, the
belief in the degree of influence over the job, competence in the
job, autonomy, and job meaningfulness.
8
Organizational Commitment
Organizational commitment
The degree to which an employee identifies with a particular
organization and its goals and wishes to maintain membership
in the organization
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A very important job attitude is organizational commitment or
identifying with a particular organization and its goals.

Employees who are committed will be less likely to engage in
work withdrawal.
9
Perceived Organizational Support
Perceived organizational support
The degree to which employees believe the organization values
their contributions and cares about their well-being
The influence of power distance
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Employees also respond to how they perceive the organization
supports them or POS. The more support they believe they are
receiving, the more positive their job attitude will be.
An important cultural influence on POS is power distance. In
low power-distance countries people are more likely to view
work as an exchange than as a moral obligation, so employees
look for reasons to feel supported by their organizations.
10
Employee Engagement
Employee engagement
The degree of enthusiasm an employee feels for the job
High cost of disengagement
Affect on organizational outcomes
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Employee engagement is the degree of enthusiasm or devotion
an employee feels for the job. Highly engaged employees have a
passion for their work.

Disengaged employees have created a real concern for
organizations. One study suggests that organizations can lose
up to $550 billion annually in lost productivity due to
disengaged employees.
Employee engagement is moderately linked to many positive
work outcomes – including employee and organizational
performance. Higher levels of engagement have been
associated with higher levels of customer satisfaction and lower
levels of turnover and accidents.
11
How Do I Measure Job Satisfaction?
Measuring job satisfaction:
Single global rating method
Only a few general questions
Remarkably accurate
Summation score method
Identifies key elements in the job and asks for specific feeling
about them
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Job satisfaction is important to recognize because of its bottom
line impact. Two approaches are popular to measure it.
One method for measure is the Single Global Rating method.
This method asks one question such as “How satisfied are you
with your job?” and gives options such as extremely satisfied to
extremely dissatisfied. It does not go into the many facets of a
job, so it does not help the organization break down where the
problems are.
The Summation Score Method is more sophisticated in that it

asks about the various job components and breaks down how
employees are specifically feeling about the different aspects of
the job; thus it offers a more comprehensive look at job
satisfaction.
12
Average Job Satisfaction Levels by Facet (Exhibit 3-2)
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The facets of job satisfaction levels can vary widely. People
have generally been more satisfied with their jobs overall, the
work itself, and their supervisors and coworkers than they have
been with the pay and promotions.
Long Description:
The horizontal axis represents the parameters listed below. The
vertical axis represents the percentage and ranges from 0 to 100,
in increments of 10.
Approximate data corresponding to the average satisfaction
levels are as follows:
Work Itself: 77 percent
Co-workers: 70 percent
Supervision: 65 percent
Pay: 58 percent
Promotion: 21 percent
Overall: 78 percent.
13
Average Levels of Employee Job Satisfaction by Country
(Exhibit 3-3)

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The results of the 2017 World Happiness Report indicate that
over 70% of employees in the 20 largest economies are satisfied
with their jobs.
Long Description:
The horizontal axis represents the various countries listed
below. The vertical axis represents the percentage from 0 to
100, in increments of 10.
Data corresponding to the countries and percentage are
summarized below:
Netherlands: 93.8
Switzerland: 93.7
Canada: 90.5
Germany: 90.4
Australia: 89.2
Spain: 88.1
United Kingdom: 87.4
France: 86.0
Saudi Arabia: 85.7
Brazil: 85.6
Italy: 85.5
United States of America: 85.3
Mexico: 82.4
Turkey: 74.9
Russia: 74.6
Japan: 74.0
South Korea: 74.0
Indonesia: 73.3
India: 71.5
China: 71.4.
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What Causes Job Satisfaction?

Job Conditions
Personality
Pay
Corporate Social Responsibility (CSR)
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Some of the characteristics that are likely to influence job
satisfaction include the job conditions, personality, pay, and
corporate social responsibility.
We examine each of these.
15
Job Conditions
The intrinsic nature of the work itself
Social interactions
Supervision
Big role
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Interesting jobs that provide training, variety, independence,
and control satisfy most employees. Interdependence, feedback,
social support, and positive interactions with coworkers are
strongly related to job satisfaction. Managers play a big role in
employees’ job satisfaction.
Toxic environments lead to dissatisfied employees.
16
Personality
Positive core self-evaluations (CSEs)

Believe in their inner worth and basic competence
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Personality also plays an important role in job satisfaction.
Those individuals who have a positive core self-evaluation
(CSE) are more satisfied with their jobs than those with
negative CSEs.
17
Pay
Pay
after individual reaches a level of comfortable living, the effect
can be smaller
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Pay has an influence on job satisfaction (and overall happiness),
but not as much as one might think. Typically, once a worker
reaches a standard level of comfortable living, pay has a smaller
impact on satisfaction.
18
Corporate Social Responsibility
Corporate Social Responsibility (CSR)
an organization’s self-regulated actions to benefit society or the
environment beyond legal requirements
it’s good for the planet and good for people
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Corporate social responsibility (CSR) reflects an organization’s

self-regulated actions to benefit society or the environment
beyond legal requirements. CSR plays a role in job satisfaction,
especially for younger generations. CSR allows employees to
serve a higher purpose. In general, if an employee’s personal
values fit with those of the organization, the employee is
usually satisfied.
19
Outcomes of Job Satisfaction
Better job and organizational performance
Better organizational citizenship behaviors
Greater levels of customer satisfaction
Improved life satisfaction
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When employees are satisfied with their work, there are many
positive outcomes in the workplace.
Job satisfaction is moderately correlated with OCB; people who
are more satisfied with their jobs are more likely to engage in
citizenship behavior. (These are discretionary behaviors that
contribute to organizational effectiveness but are not part of
employees’ formal job description.)
Satisfied workers tend to have stronger performance and are
more in tune with the organization’s mission and goals. As a
result of that they tend to serve customers better, which
translates into strong customer satisfaction.
Evidence has suggested that job satisfaction and life satisfaction
mutually influence one another. For most individuals, work is
an important part of life, and therefore overall happiness
depends in part on our happiness in our work.

20
The Impact of Job Dissatisfaction
Exit: directs behavior toward leaving the organization
Voice: includes actively and constructively attempting to
improve conditions
Loyalty: passively but optimistically waiting for conditions to
improve
Neglect: passively allows conditions to worsen
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When employees are dissatisfied with their jobs, they have four
basic responses they can utilize. These options are divided into
active and passive choices. The active options are exit and
voice. If employees select to exit, they choose to leave or move
in a direction of leaving the organization. In voice, the
employees will work toward active and constructive attempts to
improve conditions. The passive options are neglect and loyalty.
Employees may choose to neglect their work and just allow
conditions to worsen, or they may choose to remain loyal to the
organization and just wait for change.
21
Counterproductive Work Behavior
Counterproductive Work Behavior (CWB)
Actions that actively damage the organization
deviant behavior in the workplace, or simply withdrawal
behavior
Job dissatisfaction predicts CWB
Absenteeism
Turnover

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Counterproductive work behaviors are those that actively
damage the organization. Managers can try to mitigate CWB,
using techniques such as polling to find out about employee
attitudes. Avoiding mismatches between the job and the
employee’s abilities and values should increase job satisfaction.
Dissatisfied workers are more likely to cause problems in the
workplace by stealing, being absent more frequently, limiting
productivity, and other negative work outcomes. Unsatisfied
employees tend to be absent more often when numerous
alternative jobs are available.
Satisfied workers remain in the job for a longer period of time
than dissatisfied workers. However, as we have seen recently,
workers are willing to stay in jobs where they are not satisfied
because the job market is tight due to tough economic
conditions. A pattern of lowered job satisfaction is the best
predictor of intent to leave.
22
Managers Often “Don’t Get It”
Job satisfaction can impact the bottom line
Be careful of overestimating job satisfaction
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If job attitudes are as important as we believe, organizations
need to use every reasonable method to determine how they can
be improved. Surveys can be very helpful.
Some organizations overestimate how satisfied employees are,

so they do not think there is a problem when there is one.
23
Implications for Managers
Remember that an employee’s job satisfaction level is the best
single predictor of behavior.
Pay attention to your employees’ job satisfaction levels as
determinants of their performance, turnover, absenteeism, and
withdrawal behaviors.
Measure employee job attitudes objectively and at regular
intervals in order to determine how employees are reacting to
their work.
To raise employee satisfaction, evaluate the fit between the
employee’s work interests and the intrinsic parts of the job to
create work that is challenging and interesting to the individual.
Consider the fact that high pay alone is unlikely to create a
satisfying work environment.
Rights Reserved.
Remember that an employee’s job satisfaction level is the best
single predictor of behavior.
Pay attention to your employees’ job satisfaction levels as
determinants of their performance, turnover, absenteeism, and
withdrawal behaviors.
Measure employee job attitudes objectively and at regular
intervals in order to determine how employees are reacting to
their work.
To raise employee satisfaction, evaluate the fit between the
employee’s work interests and the intrinsic parts of the job to
create work that is challenging and interesting to the individual.
Consider the fact that high pay alone is unlikely to create a
satisfying work environment.
24

Discussion Questions
Does your organization survey employees to determine job
satisfaction levels? Why or why not? If your organization does
survey employees, what does your organization do to respond to
the results of the survey?
There is a growing focus on the role of CSR for younger
generations. Do you think this is unique to just younger
generations? Why?
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26
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Chapter 2
Emerging Populations and Health
Copyright © 2018, Elsevier Inc. All Rights Reserved.
� “Health disparities” is an umbrella term that
includes disparities in health and in health care.
Greater obstacles to health care
Ø Obstacles commonly based on racial or ethnic group,
religion, socioeconomic status, gender, age, mental
health, disability, sexual orientation or gender ID,
geographic location
� “Health equity” is the accomplishment of the
highest level of health for all people
Ø Goal: elimination of health care disparities
Health Disparities
and Health Equality

Emerging Populations
� Ethnic minorities
Ø Asian Americans/Pacific Islanders
Ø Blacks/African Americans
Ø Latinos/Hispanic Americans
Ø Native Americans
Ø Arab Americans
� Homeless persons
� Immigrants includes unauthorized immigrants
Ethnic Diversity Concepts
� Race—historically associated with power and
privilege disparities, social injustice, and
prejudice
� Ethnicity—commonalities of culture (language,
history, customs, geographical origin, religion, or
ancestry)
� Minority group—commonly disadvantage in
relation to power, control, and wealth
Health Care Disparities

� Poverty, homelessness, and health care disparities
disproportionately impact racial and ethnic minorities
Homeless man
working as a day
laborer with no
health care benefits
Culture and Values
Value Orientation
� Culture
Ø Integrated patterns of human behavior (language,
thoughts, communications, actions, customs, values,
institutions)
� Values
Ø Belief about the worth of something
Ø Standards which influence behavior and thinking
� Value orientation
Ø Values learned and share through socialization
Ø Reflect “personality type” of particular society
Culture

One cultural norm
of the Moiri in
New Zealand is to
say good-bye by
rubbing noses
� Culture may have impact on people’s
Ø Health
Ø Healing
Ø Wellness belief systems
Ø Perceived causes of illness and disease
Ø Behaviors of seeking health care
Ø Attitudes toward health care providers
� Cultural competency is one of the major
elements in eliminating health disparities
Cultural Competency
Culturally Competent Care
� Knowledge of culture
� Education and training in culturally competent care
� Critical reflection
� Cross-cultural communication
� Culturally competent practice
� Cultural competence in health care systems and

organizations
� Patient advocacy and empowerment
� Multicultural workforce
� Cross-cultural leadership
� Evidence-based practice and research
9Copyright © 2018, Elsevier Inc. All Rights Reserved.
Folk Healing and Nursing
Care Systems
� Folk healing practices
Ø Reflect beliefs, values, treatment of cultural group
Ø Unlicensed: lay midwives, herbalists, spiritualists
� Nurses must avoid ethnocentrism
Ø Viewing other ways as inferior or unnatural
Ø Obstacle in therapeutic provider-patient relationships
� Holistic approach
Ø Incorporates family and support system in care
Ø Considers patient viewpoint
Arab Americans
� Background
Ø Three major waves of immigration from late 1800s to 1960s
Ø Three largest groups: Lebanese, Syrians, Egyptians
Ø Religions: Christianity, Judaism, Islam

� Health concerns and care issues
Ø Adult-onset diabetes mellitus
Ø Coronary artery disease
Ø Role of acculturation
Ø Mental health
Ø Teenage smoking
Arab Americans (Cont.)
� Barriers to care
Ø Islamophobia post 9-11
Ø Religious belief and practices
Ø Cultural norms/modesty
Ø Gender issues regarding providers
Ø Communication difficulty
Ø Folk remedies
Ø Lack of culturally competent providers
� Selected health-related cultural aspects
Ø Role of religion
Ø Importance of family; male-dominated family structure
Ø Present-oriented
Asian Americans/Pacific Islanders
� Background
Ø Many diverse countries/cultures —100 languages
Ø Largest groups: Chinese, Koreans, Filipinos

Ø Often referred to as “model minority”
Ø Value education
Ø Hesitancy to seek early diagnosis/screening
Ø Higher rate of tuberculosis
Ø Mental health problems due to adjustment issues
Ø Lower rate of obesity, hypertension
Asian Americans/
Pacific Islanders (Cont.)
Ø Language barriers
Ø Hesitant to voice disagreement—noncompliance
Ø Stigma to seeking mental heath services
Ø Hesitant to seek GYN care—considered “private” matters
Ø Mistrust and other stigmas with seeking care
Ø Value of collectivism vs individualism
Ø Family most important social institution; respect for elders
Ø Cultural value of passivity to avoid conflict
Ø Taoism: foundation of Chinese medicine “achieving
harmony”
Ø Use of folk medicine/alternative treatment modalities
common

Latino and Hispanic Americans
� Background
Ø Largest ethnic group; second fast growing minority
Ø Mexican, Puerto Ricans, Cubans most common
Ø High rates of poverty; highest rate uninsured
� Health vulnerabilities—higher incidence
Ø Stomach cancer
Ø Diabetes mellitus
Ø Cardiovascular disease
Ø HIV
Latino and Hispanic Americans
(Cont.)
Ø Lack of access to preventive care
Ø Lack of interpreter services in health care
Ø Lack of culturally appropriate health care services
Ø Reliance on folk systems of healing
Ø Family supersedes individual needs
Ø Religion plays a key role
Ø Hot and cold concept of disease
Ø Illness due to supernatural and psychological force
Ø Folk remedies in combo with professional care

Blacks/African Americans
� Background
Ø Second largest minority behind Hispanic/Latino
Ø Most descendants of enslaved persons from Africa
Ø Inequities persists; substantial progress
� High rates for certain diseases
Ø Cancer deaths
Ø HIV
Ø Hypertension
Ø Obesity
Ø Homicide
Blacks/African Americans (Cont.)
Ø Poverty
Ø Lack of health insurance
Ø Inadequate or unsafe environments
Ø Centered on family and religion
Ø Family needs to be involved in care
Ø Churches important in promoting health
Ø Use traditional healing approaches

Native Americans/Alaskan Natives
� Background
Ø Native to North/South America prior to arrival of
Europeans
Ø Experience minority group status; lower education
and income levels compared to other groups
Ø Linked to social and economic conditions
Ø Smoking, substance abuse
Ø Deaths: unintentional injuries, liver disease, cancer
homicide, suicide, pneumonia, diabetes, CVA
Native Americans/Alaskan Natives
(Cont.)
Ø Difficult access to care
Ø Underserved population
Ø Present-oriented; take 1 day at a time
Ø Value cooperation over competition
Ø Share resources
Ø Value families—form kinship systems
Ø Believe health exists when person is in harmony with nature
Ø Traditional health practices important (shaman)

Homeless Persons
� Characteristics
Ø Lack of fixed, regular, adequate residence due to poverty
Ø Considered temporary situation vs permanent condition
Ø For veterans: mental illness, substance abuse, poverty
� Causes of homelessness
Ø Changing housing markets—shortage of affordable rentals
Ø Poor health both effect and cause homelessness
Ø Widespread and unprecedented foreclosures
Ø Poverty, unemployment, decline in public assistance
Ø Substance abuse, domestic violence, mental illness
Homeless Persons (Cont.)
Ø Basic survival issues
Ø Pneumonia, TB, HIV disease are widespread
Ø Dental and vision problems
Ø Mental health issues significant contributing factor
Ø Substance abuse: both cause and consequence
Ø Lack of access; lack of ID
Ø Affordability issues, lack of health insurance
Ø Lack of transportation
Ø Lack of knowledge re where to obtain care

Strategies to Address
Homelessness
� Community involvement in homelessness
� Programs to provide food, clothing, shelter
� Include rural homelessness in programs
� Health care professionals have important
advocacy role
� Educate community members re how to help
homeless persons
� Strengthen professional curriculums and
research to address homelessness
Federal Response to Disparities
� NIH is devoting significant resources to reducing
health disparities
� Congress created National Center on Minority
Health and Health Disparities in 2010
� Healthy People 2020 lists as one of primary
goals to reduce/eliminate health disparities

� Patient Protection and Affordable Care Act 2010
increases funding for indigent care
� Office of Minority Health reauthorized
Nursing’s Response to Emerging
Populations and Health
� American Nurses Association (ANA)
Ø Commitment to provide service regardless of
background or situation
Ø Nurses are responsible to provide for culturally
competent care
� ANA sponsored Ethnic-Minority Fellowship
Program to support minority health
� Culturally relevant publications and journals
offered as resources to health care professionals
Publications Devoted to Culturally
Competent Care
� Journal of Cultural Diversity
� Journal of Multicultural Nursing and Health
� Minority Nurse Newsletter

� Cultural Care Diversity and Universality
Theory—Madeline Leininger (2001)
� Current nursing texts from major publishers now
include chapters on culturally relevant care

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