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Human Resource Activities and

Managers Chapter Objectives

After reading this chapter, readers will be able to:

• Identify the services that are almost always, often, and occasionally provided by a human resources department

• Subdivide human resource services according to the major tasks of acquiring, maintaining, retaining, and discharging or separating employees

• Identify the activities for which a department manager can expect contact and involvement with human resources, and the likely extent of that contact and involvement

• Compare and contrast line management and human resource management as to background

• Interpret perspective and other characteristics for the purpose of explaining some of the tensions that develop between the two groups

• Understand and eventually overcome the apparent differences between human resources personnel and line managers

■ CHAPTER SUMMARY

A human resources (HR) department is involved in a number of ac- tivities that together compose four major activity groupings: acquiring employees, maintaining employees, retaining employees, and separating employees. Within these activities, the specific activities of employment and recruitment, compensation and benefits administration, and employee relations are undertaken. Also to be found in many HR departments

C H A P T E R

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are labor relations (if unions are present), training and development, employee health and safety, security, child care, and other employee services. Generally, all of the activities that may be found within a given HR department relate in some way to acquiring, maintaining, retaining, or separating employees.

Human resources services are provided by a staff (as opposed to line) activity. This means that no individual in HR has direct authority over employees in any of the other departments of a healthcare organization. As such, HR is oriented toward service. It exists to provide services to employees at all levels of an organization.

Case Study: Who Has a Recruiting Problem?

Jane Cassidy is director of nursing at Community General Hospital. The institution recently completed a physical expansion that included, among other additions, a new 36-bed medical/surgical unit. Until recently Jane had worked in conjunction with HR employment manager Carrie Smith and had fared reasonably well in keeping her nursing staff up to required levels in spite of a general shortage of nurses in the local area. The opening of the new unit, however, has strained the nursing department’s resources to the extent of leaving the department short several registered nurses.

Community General’s nursing shortage is particularly evident on the evening shift (3:00 p.m. to 11:30 p.m.). There are more than enough people willing to work days, and Jane has been fortunate in having a thoroughly stable crew of nurses who prefer to work nights.

Employment recruiter Carrie has regularly gone out of her way to do ev- erything possible to locate candidates for nursing positions. Being extra cau- tious about the possibility of scaring good candidates off before they can be interviewed, Carrie has been deliberately vague with candidates concerning available shifts and hours. Unless specifically asked, she has not mentioned to anyone that new graduates being hired are expected to work day–evening or day–night rotations.

In response to the long-running recruiting efforts of Jane and Carrie, a well-qualified registered nurse applies for employment. Both are impressed with this nurse. She seems energetic and personable and is immediately available. She is quite willing to take a position on the evening shift.

Unfortunately, although this candidate is willing to work 3:00 p.m. to 11:30 p.m., she stated during her initial screening interview with Carrie that she cannot work any weekends. She will say only that weekend work causes severe inconvenience in her family life, and she repeats her will- ingness to work evenings, straight evenings, but only Monday through Friday. Nevertheless, Carrie refers this candidate to Jane, quietly suggest- ing that Jane see if she can talk her into rotating weekends. The applicant has yet to learn that scheduling practices in Community General’s nursing department require everyone below the level of day, evening, or night

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supervisor to work every other weekend, although Carrie has become aware of a few situations that might constitute quiet exceptions to the scheduling policy.

Considering the critical need for nursing help on evenings as well as weekends, what can Carrie and Jane tell this applicant? If Jane has to adhere rigidly to her scheduling policy and the candidate refuses to accept the job, what problems might Jane face? If Jane alters the scheduling policy and offers the applicant a Monday through Friday position without requiring weekends, a position that she accepts, what problems might Jane then face?

How can Carrie, as an HR professional, provide further help to Jane, a supervisor in nursing services, as she attempts to recruit sufficient staff for the nursing department?

■ THE ACTIVITIES OF HUMAN RESOURCES

Finance, operations, and sales and marketing are examples of organiza- tional subdivisions that are encountered in most companies or businesses. The tasks performed within these functional areas are similar in most organizations, as are the tasks performed within each functional area of a healthcare organization. Human resources, however, differs in that the tasks performed by HR personnel may be quite varied. Only within the past two to three decades have training programs been created to prepare people for careers in the field of human resources.

Regardless of the form or operational purview of a particular health- care organization, whether hospital, long-term care facility, free-standing clinic, urgent care center, physicians’ group practice, or other entity, all HR departments have similar goals and pursue similar overall missions. These working groups exist to provide service to an organization and its employees. Not all HR departments are organized in the same fashion, however, and not all provide the same services or perform exactly the same tasks or activities. Under some organizational structures, activities that are often associated with HR may be performed by other departments or may even be separate departments in their own right.

In the sections that follow, the activities of HR are subdivided into three categories or levels. The first encompasses activities that are commonly associated with HR and usually part of the HR department. The second includes tasks that are often but not always performed by people from an HR department. The third discusses activities that are occasionally associ- ated with HR or sometimes found outside of an HR department structure.

Category I: Typical HR Activities Of the four groups of activities that follow, the first three are invariably components of HR. The fourth is usually part of HR if a union is present in an organization.

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Employment or Recruitment This activity addresses the original function of what was previously described as the employment office. Different names may survive from the past, but employment or recruitment or some variant of either word is usually part of the organizational designation for this activity. The heart of this activity is concerned with finding or identifying prospective employees, screening them, and arranging for them to be interviewed by supervisors and managers throughout the larger organization. The same employees extend official of- fers of employment and perform a number of other tasks that are necessary to bring new hires into an organization.

With a diminishing number of exceptions, employment for an entire healthcare organization is centralized in HR. The few exceptions that may still be encountered, especially in hospitals of medium to large size, typically involve nursing departments that continue to conduct their own recruit- ing. In the past, this was a much more common practice than at present, although some nursing departments maintain a designated nurse recruiter who frequently works closely with HR. Physician recruiting is often co- ordinated by an institution’s medical director although the paperwork is usually delegated to HR.

Compensation and Benefits Administration Historically, administration of benefits was the second significant area of responsibility to be assigned to HR. Depending on an organization’s size and mode of operation, compensation and benefits may be combined as a single activity or may be pursued separately by individuals who specialize in each. This latter situation (separation of the activities) is often the case in larger organizations.

The activities associated with benefits administration ordinarily include explaining benefits and the policies that govern them to employees and answering questions related to benefits. These people assist employees in accessing their benefits. They maintain relationships with benefits providers such as insurance carriers and pension overseers. These HR employees must stay current with regulations that concern benefits and must maintain employee benefits records. They participate in periodic assessments of the appropriateness of benefits. When necessary, they become involved in designing and implementing changes to benefits pro- grams and packages.

Compensation activity is, by definition, concerned with wages and salaries. Primarily, this includes recommending starting pay for new hires consistent with their education and experience as well as taking into ac- count the compensation of existing employees. Compensation encompasses answering questions related to wage and salary issues and recommending corrective action when necessary. Specialists in compensation monitor an organization’s wage structure to ensure that pay equity exists throughout an organization. They recommend changes in the wage structure that are

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consistent with pay changes in the local community, industry, and indi- vidual occupations as necessary.

Employee Relations Some may refer to an activity such as employee relations as being on the soft side of HR. This is in contrast to elements that are on the hard side, primarily compensation and benefits. The distinction is based on the relative ease with which matters can be quantified. Hard issues generally refer to compensation and benefits that can be quantified using dollars and cents or other numerical measures. Soft issues encompass relations with people. An employee relations practitioner is likely to be involved, for example, in advising supervisors and managers on how to proceed in addressing selected employee problems or monitoring applications of the organizational disciplinary process. They may listen to troubled employees and refer them to sources of assistance as needed. Experts in employee relations counsel individual employees as needs arise and serve as employee advocates when necessary. They may represent the organization in relations or negotiations with external advocacy agen- cies such as the State Division of Human Rights. Names of agencies are not uniform and vary from state to state.

Labor Relations Labor relations exists as a separately identified entity in larger organi- zations, but only when some or all of an organization’s nonmanagerial employees are unionized. The emphasis is on larger organizations because in a smaller setting, even with a union present, there may not be enough continuing activity to justify having a specialist in labor relations. When this is the case, labor relations activities become part of another HR prac- titioner’s job. For example, an employee relations specialist or the HR director may take on labor relations activities when this becomes necessary.

The scope of labor relations includes continuing contact and ongoing relations with elected officials of one or more unions representing some or all of an organization’s eligible employees. A majority of labor relations activities consist of hearing and resolving complaints. A collective bargain- ing agreement defines steps for processing grievances. A labor relations specialist represents the employer in related matters such as arbitration hearings and other formal processes. Many organizations have personnel who are actively involved in promoting labor relations or trying to prevent unionization when additional union organizing occurs. After a union is formed, specialists in labor relations participate in contract negotiations and other related activities when necessary.

Category II: Frequent HR Activities Depending on the size of a particular institution, the way in which it is organized, and how its activities are distributed, some of the following may exist as separate departments. Others may be housed within HR.

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Some may not require an individual that is solely dedicated to the task, so the few duties are incorporated into the job descriptions of other HR practitioners.

Employee Health and Safety These may be separate activities. Employee health is often located sepa- rately from safety. In small organizations, they are frequently combined. Either or both may be components of HR. Almost as commonly, they may be contained within other organizational units. Employee health is often found within one of the organization’s medical divisions. However, such a reporting arrangement can create problems with confidentiality of records. The arrangements can become confusing. In theory, employee health should be a subsidiary component of HR, with the director of employee health reporting directly to the chief of HR. The rationale for such an arrange- ment is that employee health renders service to employees by performing pre-employment physical examinations. This activity is clearly related to HR’s employment section. Because physicians render the services, however, they should report to an institution’s medical director or chief of medicine. This is just as clearly not a section of HR.

Training and Development Training and development is often a subsidiary activity of HR. However, depending on organizational size, it is frequently situated as a separate, free-standing entity with a reporting relationship to another department. In healthcare settings, training and development is often a component of a nursing department or an equivalent group with a more broadly encompass- ing name, such as patient care services. Many nursing departments have developed and maintained educational capabilities. These evolved long before spreading to other disciplines because activities of long-standing continuing education (in-service) requirements that were developed by the nursing profession. As a result, in some quarters training and development has long been the province of nursing alone. When educational needs of other professions emerged, nursing simply attended to them. Thus, in many healthcare organizations, this remains the norm: education originates in nursing and is provided by nurses but easily crosses departmental boundar- ies. Sometimes training and development are split. Clinically oriented edu- cation remains in the nursing department, originating and being presented by nurses. Other training that is not clinically based often originates and is presented by personnel from HR.

Security The security department is typically self-contained. The exception occurs in small organizations where it may have a reporting relationship to plant maintenance or building services. A distinctly separate security department with a manager of its own may report to the head of HR. Equally likely is a reporting relationship within the plant facilities chain of command or

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directly to the administrator who oversees general services for an entire organization.

Child Care If a healthcare organization operates a child-care center or child-care pro- gram, it is equally likely that the individual who manages child care will report either to the chief human resource officer or to another person such as the administrator for general services. Because a child-care center is subject to unique state licensing arrangements that govern staffing and facilities, it usually appears as a distinct and separate entity. The rationale for attaching it to HR is the service to employees aspect of the activity. There are differences in how healthcare organizations having child-care programs define their scope of services. Some limit themselves exclusively to an employee clientele, but many are open to any member of the community. Often, child-care programs give priority to employees, but after meeting employees’ needs, they fill the remaining capacity from other persons in the community.

Award and Recognition Programs Responsibility for award and recognition programs will ordinarily be part of some department or group’s assigned duties rather than being a separate entity. Exceptions occur in extremely large organizational settings. The most common exception is a large teaching institution that is an element of a university and thus served by the parent organization’s award and recognition group. In smaller healthcare organizations, awards are often coordinated by a member of a public relations or community relations department or, occasionally, by an administrative assistant. For the major- ity of healthcare organizations, award and recognition programs are the responsibility of HR and often fall to an employee relations practitioner.

Equal Employment Opportunity/Affirmative Action If separate offices for Equal Employment Opportunity (EEO) or Affirmative Action (AA) exist within an organization, then they will usually, although not always, be found within the HR department. A person who is desig- nated to be responsible for compliance with EEO regulations is frequently an employee relations practitioner or HR executive. This person has the primary responsibility for monitoring the organization’s compliance with all applicable antidiscrimination laws. The individual in this position will be charged with some of the responsibilities that were described within the realm of employee relations, particularly those that relate to external advo- cacy agencies such as a state Division of Human Rights and the local branch of the federal Equal Employment Opportunity Commission (EEOC).

Affirmative Action programs are no longer actively mandated for the organizations to which they formerly applied. As a result, HR personnel who had responsibility for Affirmative Action programs have frequently been assigned to other duties. Affirmative Action required organizations

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holding government contracts to demonstrate that positive efforts were being made to align the composition of an organization’s workforce with the demographic characteristics of those living within the organization’s labor market area. In other words, the goal of an Affirmative Action pro- gram was to achieve a workforce in which the percentages of women and minorities mirrored those of women and minorities in the labor market area. Most of the compliance requirements have been reassigned and are now included in EEO mandates. EEO monitoring of workforce composi- tion and compliance with regulations continues.

Category III: Infrequent, Occasional, or Outsourced HR Activities The following activities are sometimes found within the structure of an HR organization.

Risk Management Risk management is present in most healthcare organizations—indeed, in most organizations of any size or type. Interests of risk management include monitoring malpractice and liability actions brought against the organization while overseeing and constantly evaluating forms of insurance coverage. Risk managers study loss trends such as costs associated with Workers’ Compensation. The goal of these activities is to manage risk in an effort to achieve an appropriate balance between costs of doing business and potential exposure to a variety of legal risks.

Although formerly a component of HR in some organizations, risk management is currently found elsewhere in the administrative structure. With its increasingly significant legal implications, risk management is frequently coordinated by a person that reports to the organization’s legal counsel. Increasingly, if risk-management duties are assigned to more than one person, then risk management may become a separate department and its manager often has a legal background.

Executive Compensation Administration This activity is rarely left to persons in HR. More commonly, it is taken care of at the executive level within finance. If executive managers are not included in an organization’s payroll system, then executive compensa- tion is most likely to be accomplished through an external confidential payroll service. Such an arrangement is quite uncommon in healthcare organizations; it is far more likely to be encountered in other businesses. Executive compensation is almost certain to be externally administered if an organization’s top executives are under individual contracts or their salary arrangements include incentive compensation.

Organizational Development Organizational development encompasses a wide variety of tasks. In some organizations, it is little more than management development under a different name. True organizational development, however, goes beyond

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simply providing the continuing education necessary to keep managers current with developments in health care as well as to helping them cope with the changing times. Organizational development encompasses the changing requirements of an entire organization. It asks an ongoing ques- tion: How should this organization be changing its philosophy, mission, and vision, and its organizational structure, to meet the demands brought on by changing social and economic environments and the changing health- care delivery milieu? In many organizations, organizational development is considered to be a luxury. It is often among the first departments to be cut when budgetary limitations arise or other economic hard times occur.

A comprehensive approach to organizational development needs should include succession planning. Succession planning complements manage- ment development and expands upon it by preparing managers and other individuals at all levels not only to keep current but also potentially to advance within the organization. This facet of organizational development emphasizes the internal development of managerial talent. A comprehensive approach to organizational development usually includes some means of identifying and educating potential supervisors and managers from among the employees who do not hold management positions.

Organizational development exists as a separately identified activity in a minority of healthcare organizations. The work is typically coordi- nated by a person reporting directly to the director of HR. Organizational development activities are often conducted in parallel with employment, compensation and benefits, and other HR work. In rare situations, typically in very large healthcare provider entities, organizational development may be found as a separate office parallel to HR. In such a situation, its head reports to the same executive as the director of HR.

Employee Assistance Program An employee assistance program (EAP) is intended to assist employees in addressing particular personal problems that can affect their work per- formance. It is ordinarily described as an employee benefit. An employee assistance program is primarily a referral program that helps individuals to identify and focus on their own needs and problems. Employee assistance programs help to secure professional referrals for troubled employees. A capably functioning EAP can help control absenteeism, tardiness, and other circumstances that can affect job performance. Addressing such personal problems usually contributes to improvements in quality and productivity. Employee assistance programs commonly address alcohol and drug abuse, family and marital difficulties, legal and financial problems, compulsive gambling, and other personal problems and issues.

A majority of healthcare organizations have EAPs. The initial refer- ral point within a healthcare organization is usually an office located in HR or in employee health. The latter may itself be a component of HR.

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The professionals that provide assistance to workers are often employed by an outside entity and provide their services on a contract or retainer basis. Employees may use EAP resources with the assurance that no one within their organization has to know about their personal problems. This improves confidentiality and reduces the opportunities for embarrassing situations to develop in the workplace. The HR role is limited to simply putting an employee who expresses a need in touch with the external EAP coordinator.

Outplacement Services Outplacement involves assisting displaced employees in finding new em- ployment. Outplacement services are offered and provided in instances of reductions in the workforce or elimination of specific management posi- tions. Occasionally, they are offered to individuals as part of a severance or termination package. Because outplacement is costly and not needed on an ongoing basis, outplacement usually does not exist as a permanent component of HR or any other organizational element. However, some- thing that may resemble formal outplacement occasionally occurs when someone in HR or elsewhere in an organization is able to assist a displaced employee in finding a position with another employer.

Payroll The activities of payroll were once a common adjunct to the employment activities of early personnel departments in many organizations. Both of these basic needs impact all employees. Before benefits became common, the only activities required for all employees were hiring them and paying them. There was a compelling logic in having these two activities located in adjoining offices and coordinating their activities. As time passed, payroll requirements became increasingly more complicated.

Financial activities have become increasingly more sophisticated. As a result, payroll has been organizationally relocated.

In some organizations it is still possible to find payroll attached to HR. However, these instances are uncommon, and their number is steadily declining. Today, most payroll activities are performed in one of two lo- cations. In the majority of organizations that process their own payrolls, this activity is part of the finance department. Another department, such as data processing or information systems, which may or may not be part of finance, will make electronic transfers or actually print and distribute checks and reports. A growing number of organizations, especially those of small to medium size, utilize external contractors that specialize in payroll services. When outside payroll services are used, the input information from which they work is usually submitted to them by the finance department. Only occasionally is such information supplied by HR.

The foregoing activities are summarized in Exhibit 4-1.

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Exhibit 4-1 Human Resource Department Organizational Areas or Activities

Category I: Typical HR Activities • Employment or recruitment • Compensation and benefits administration • Employee relations • Labor relations (if one or more unions are present)

Category II: Frequent HR Activities • Employee health and safety • Training and development • Security • Child care • Award and recognition programs • Equal Employment Opportunity/Affirmative Action

Category III: Infrequent, Occasional, or Outsourced Activities • Risk management • Executive compensation administration • Organizational development • Employee assistance programs • Outplacement services • Payroll

Outsourcing Outsourcing is the business term that is currently used to describe the practice of having services that were once performed by organizational employees supplied by outside parties or vendors. Outsourcing sometimes becomes necessary because of changes in organizational structure, reduc- tion in number of employees, or mergers. Reengineering encompasses these circumstances. Reengineering is not the only reason that organizations seek outsiders to perform needed services. A business or organization might con- sider outsourcing for any of several reasons. The services to be performed may require special skills or expertise. The demand for such services may not be sufficient to justify hiring one or more skilled persons to supply them. A convenient example is managing pension fund investments.

Outsourcing is often the solution when a given task requires expensive equipment but there is insufficient work to justify purchasing the equipment. For example, an organization may want to have its annual report printed on special multicolored paper. If owned, the printing equipment would be un- used during the rest of the year. By virtue of specialization or sophistication, an outside supplier may be able to perform a task more economically than

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could company employees. This is one reason why outplacement services for displaced executives are provided on a contract basis by an external entity. Reductions in staff sometimes create a need for tasks that must be completed for which no time is available among employees who are not discharged. Such necessary organizational requirements are sometimes referred to as orphans or orphan functions. A particular necessary task may occur irregu- larly and require insufficient time to justify training and retaining someone to do it. Preparing, publishing, and printing an employee newsletter provides a relatively common example. Finally, some work is of a sufficiently sensi- tive nature that confidentiality is best served by having it performed by an outside vendor. Employee assistance programs and executive compensation programs are two examples of sensitive programs.

The decision to outsource any particular task will ordinarily involve considerations of cost, capability, and confidentiality. Many outplacement decisions are driven by staff reductions brought about by reengineering or organizational downsizing. Often when a decision is made to eliminate a position, many of the responsibilities associated with that job may be eliminated, modified, or transferred to other persons. Remaining essentials may have to be outsourced.

Among the HR activities described in this chapter, the most likely can- didate for outsourcing is outplacement services. This is not only logical but understandable because it is a specialized activity that is only occasionally required. The next most likely activity to be outsourced is an EAP. This is done to maintain employee privacy and confidentiality. Other commonly outsourced HR services are pension plan administration and Workers’ Compensation and disability programs administration.

External vendors (outsourcing) are being used for two other important services: payroll and legal services. Increases in complexity of compensation programs, changes in tax withholding requirements, concern for security, and the desire to achieve economic savings are driving the trend to use out- side vendors for processing payroll. Finally, most healthcare organizations are not sufficiently large to justify employing a full-time attorney, so legal services are most commonly provided by a law firm engaged on a retainer.

■ HUMAN RESOURCES FROM A DIFFERENT PERSPECTIVE

The earlier discussion of HR analyzed the services by categories. Each category included services on the basis of their likelihood of being included in a typical HR department. Alternatively, the services supplied to an or- ganization by HR can be discussed by dividing them into groups on the basis of how they relate to an organization’s employees. These generalized activities include employee acquisition, support or maintenance, retention, and separation (see Exhibit 4-2). This section reflects such organizational groupings.

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Exhibit 4-2 Major Activities of the HR Department

Employee Acquisition • Employment and recruitment activities (representing the

organization at job fairs and professional meetings, placing job advertisements, etc.)

• Pre-employment testing • Checking and verifying of references • Initial organizational orientation

Employee Support or Maintenance • Compensation administration • Benefits administration • Personnel policies and procedures • Performance appraisal programs • Disciplinary and corrective programs • Coordinating grievances (in unionized environments) • Personnel record keeping • Workers’ Compensation programs • Disability programs • Employee assistance program • Labor relations (in unionized environments) • Parking • Communication programs • Employee health clinic • Cafeteria • Savings and investment programs

Employee Retention • Retirement plans • Performance appraisal and management programs • Award and recognition programs • Education, training, and development • Tuition assistance • Child-care assistance • Succession planning programs • Career development opportunities • Career ladders and parallel path progression

Employee Separation • Discharge and dismissal procedure documentation • Unemployment compensation • Outplacement services • Retirement counseling • Exit interviews • Terminal benefits processing

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Employee Acquisition This category of activities includes everything that is undertaken to find employees and bring them into an organization. In most healthcare organizations, this means all employment or recruitment activities. Human resources personnel may attend job fairs at local colleges and training facilities or travel to regional or professional meetings to recruit prospective employees. Placement of advertisements for employees is coordinated by HR, although other persons in the organization may provide input on the copy or text of such ads. Pre-employment testing is usually coordinated by HR even if the actual services are provided by persons elsewhere in the organization or external to it. A critical HR activity is checking references and verifying credentials. All new employees are given the same initial organizational employee orienta- tion by HR. In general, HR coordinates or supplies any activities that are undertaken, from locating employees to successfully situating them in their positions within the organization.

Employee Support or Maintenance Many HR activities are intended to support or maintain employees by addressing needs that arise relative to their employment. These activities include administering compensation and benefit programs, enforcing per- sonnel policies and procedures for the entire organization, and coordinating disciplinary and other corrective processes as needed. In unionized environ- ments, the latter includes formal grievance procedures as outlined in the collective bargaining agreement. Human resources maintains or coordinates personnel record keeping. This includes ensuring that employee records are maintained in a secure location for long periods of time. Human resources may administer Workers’ Compensation and disability programs or coor- dinate them if the services of an external vendor are used. Other ongoing activities related to employees that are often provided or coordinated by HR include employee assistance programs, labor relations activities, security and parking, communications to large groups of employees, and any other services that may be provided for the purpose of supporting or maintaining employees as effective producers. Services that are sometimes coordinated by HR include operating an employee health clinic, maintaining a cafeteria for employees and members of the general public, and coordinating savings and investment programs.

Employee Retention Significant overlap can exist between the tasks of maintaining and retaining employees. Compensation and benefits administration provides a conve- nient example. If compensation for a particular position is not perceived as being fair or equitable when compared with other positions or with com- munity standards, then compensation alone will provide little incentive to

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retain employees in the organization. Likewise, if the contents of a benefit package are clearly less than other employers are providing, then benefits will have minimal to no effect in retaining employees. The importance of compensation and benefits in retaining employees is embodied in the need to keep them competitive so that valued employees will be encouraged to remain loyal to the organization.

Immediate monetary compensation, such as pay and benefits, are not sufficient to motivate good employees. Numerous other incentives, ac- tivities, or perquisites are offered to help retain employees. The variety of such incentives is limited only by the imaginations of organizations offering them or employees requesting them. However, some are fairly common. These include retirement plans, performance appraisal and per- formance management programs, and award and recognition programs. Other non-cash incentives that organizations may offer include oppor- tunities for training and development, tuition assistance programs, and career development and succession planning programs. Some programs may appeal to a relatively small cadre of employees. For those who need them, however, employee assistance programs and child-care assistance are highly appreciated. These are important in both maintaining and retaining employees. All employees not only appreciate but have come to expect physical safety and security in all organizational facilities and reasonable parking accommodations.

Succession planning is critical to the success of any organization. Many in healthcare plan only for the succession of the top few executives and then only when an employee is leaving. Employees appreciate the chance to have input into their careers and welcome the assistance that is often provided by HR. Some relatively large organizations are able to provide opportuni- ties for career development. Promising employees are identified and offered positions on task forces, committees, or other temporary teams. In very large organizations, career ladders and parallel path progressions are possible.

Employee Separation This category includes all activities involved in separating employees from an organization regardless of the reasons for separation. Some paperwork and filing always accompanies any separation. When an employee is discharged for cause, all disciplinary actions must be documented. Activities after dis- charge may involve external agencies. Employees who are laid off must be reported to the state so that they may receive unemployment compensation. Outplacement or access to similar services may be offered. Individuals who retire often appreciate counseling and planning assistance. Administrative work related to a pension plan is required to begin the flow of financial benefits. Occasionally, HR coordinates or arranges retirement celebrations. Every voluntary separation should include an exit interview. Most separa- tions from an organization involve cessation of benefits. An interview or

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some other contact with HR is required to complete the necessary paperwork. When selected benefits are to be continued (for example, health benefits under COBRA legislation), HR usually completes alternative paperwork to ensure that services continue to be provided without interruption.

■ WHERE DEPARTMENT MANAGERS AND HUMAN RESOURCES PERSONNEL MEET

This section will initially identify the points at which a department manager can expect to come into regular contact with employees from HR or with the programs and activities that HR coordinates. A department manager will benefit by learning how to optimally utilize the services offered by HR to the fullest extent possible.

A typical department manager can expect to have frequent contact and considerable involvement in activities involving employment, employee relations, and labor relations (if there are unions present). Depending on the nature of a manager’s supervisory responsibilities, periods of active involvement with training and development may be the norm. A manager should expect to have some involvement with activities involving com- pensation, benefits, safety, employee health, and payroll. The degree of involvement will depend on how such services are organized and provided as well as on the rate of turnover of departmental employees. The same manager should expect minimal involvement with HR personnel related to security, parking, child care, risk management, and other HR concerns. Contact with these services usually occurs when individual employees enter or leave a department’s workforce.

The background, education, and experience of most department manag- ers in healthcare organizations are usually based on their basic education or on their technical or professional specialties. A few have some general business knowledge, but the majority are not overly familiar with HR processes and requirements. Some basic HR knowledge and involvement with HR is necessary for individuals who want to supervise and coordinate their department’s employees in an effective manner.

Employment A successful manager must remain involved in recruitment and employment processes as a normal part of department activities. The intensity of this activity will depend on the turnover rate in the department and on how much employment activity is necessary.

When a manager finds it necessary to acquire a new employee, the initial step is to create or update (as necessary) a job description. A personnel requisition must usually be secured from higher management before HR can be contacted.

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In some instances, a manager may be able to submit a personnel requi- sition directly to HR if the need is for a direct replacement of a departing employee. The requirement for such approval depends on the personnel practices of the organization. If the requisition seeks an additional em- ployee, however, it usually requires thorough justification and subsequent approval by one or more managers in higher positions in the organization. This requirement intensifies when budgets are tight.

When a personnel requisition is received by HR, it is typically assigned to an employment recruiter who identifies an appropriate number of can- didates. A department manager’s next involvement is usually when HR sends a file containing several applications or résumés of applicants who meet the stated minimum requirements of the job. The manager then re- views these documents and advises the HR recruiter which ones should be called for interviews.

An HR recruiter will conduct screening interviews. As long as the can- didates remain appropriate after being reviewed by others for compliance with EEOC, the Americans with Disabilities Act (ADA), and other legal requirements and with organizational hiring guidelines, HR will arrange interviews for them with the department manager. Following the interviews, the manager compiles a list that ranks the candidates. This list is sent to the HR recruiter, who contacts the selected candidates. Depending on the size of an organization, the recruiter or a senior administrator or executive negotiates with the candidate and reaches an agreement on starting pay and other relevant details. One of these people extends a formal job offer and sets the desired starting date for the new employee.

For a variety of reasons that will become evident, formal offers of em- ployment should originate only from HR. The responsibilities of most man- agers focus on providing services or producing products or information, but HR personnel are people professionals. Some senior executives may extend offers of employment should that be the norm for a given organization. Direct supervisors should not negotiate salaries with candidates because of the potential for ill feelings (if a particular salary request is not granted) after the job has been accepted. An offer is ordinarily made contingent upon positive reference checks and having the applicant pass a pre-employment physical examination. Once an applicant has been completely cleared and begins to work, it is a department manager’s responsibility to ensure that the new employee is oriented to the department and properly started on the job in all other respects.

Benefits A department manager should have no active role in administering em- ployee benefits. However, the department manager is ordinarily an indi- vidual employee’s primary source of information about the organization

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as well as the job (or is at least perceived as such by most employees). For this reason, managers can expect to receive regular questions about benefits from their employees. This suggests that a manager should become familiar with or have a reasonable working knowledge of commonly used benefits, such as paid time off (vacation, sick time, personal time, and holidays). Answers to routine questions will save time and allow HR personnel to concentrate on questions concerning more serious or complex problems. When large numbers of managers reply to all questions related to benefits with “I don’t know, go ask HR,” HR appears to be lax in sharing informa- tion. This impression does not support HR in the short term. Over a longer period, an organization will suffer.

Most managers will benefit by having two levels of knowledge about HR. The first is knowing how the organizational benefits structure personally affects a manager. This knowledge will enable a supervisor to answer many common questions that employees might ask. The second is knowing from whom in HR employees should seek answers to more complex questions.

Compensation A department manager must be familiar with an organization’s compen- sation structure because it affects the pay of all departmental employees. This includes knowing about relevant wage scales, what they mean, where departmental employees are relative to the scales, and the relative position of each employee. Information about relative positions is needed to answer questions that are related to others who perform similar tasks and have similar lengths of employment but who might be paid at different rates. A manager should have sufficient knowledge of the compensation structure to recognize when inequities have crept into the department’s pay rates and to raise questions about these inequities to HR.

The best information about how a job is performed resides with the person who does the job and the manager who directs that individual in doing the job. The department manager and an individual employee on the job are the primary repositories of knowledge of how a particular job is or should be performed. A manager must be able to apply this knowledge when creating, reviewing, or revising job descriptions. An accurate, up-to-date job descrip- tion is an absolute necessity when determining the pay grade and salary range for any particular job. Thus, this essential component of compensation ad- ministration is largely the responsibility of a departmental manager. Human resources ordinarily participates in writing and updating job descriptions but cannot create quality job descriptions without departmental input.

Employee Relations Each time a problem arises concerning an employee, the potential exists for a department manager to interact with HR. This involvement can come about because of complaints about employees. These may be made

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by organization employees or by persons from the outside. They may be informal or formal, such as a grievance. Complaints may be filed with agencies such as Human Rights or the Equal Employment Opportunity Commission. They may originate as lawsuits or disciplinary actions. They may be brought by a department manager or other person.

One employee-related activity that requires a manager’s direct inter- action with HR on a regular and recurring basis is compiling and filing performance appraisals. Human resources will ordinarily administer the appraisal system, keep the system up to date, provide training in the system’s use, and follow up on appraisal completion. A manager’s role is to perform the appraisals of employees who are directly supervised according to the guidelines established by HR and in accordance with timetables established by the organization.

Personnel Records Human resources maintains an organization’s personnel records. Department managers have a few regular areas or points of contact with personnel records. Much of the information that is filed comes to HR from department managers. Performance appraisals and disciplinary actions are the most common of these items. Managers occasionally have a need to review some fact or element of a subordinate’s personnel record. Such requests often pertain to the work record and qualifications of someone who wishes to transfer into the department. Organizations create their own guidelines regarding access to personnel records. In general, information contained in personnel records is highly confidential and should not be available to any supervisor without a valid reason for access. Requested information should be provided by an employee from HR. Personnel records should be kept in a secure location, with access restricted to as few people as possible. Competent legal counsel should determine the param- eters governing the long-term storage and retention of personnel records.

■ HUMAN RESOURCES AND THE ORGANIZATION

It is no secret that in many work organizations there is a degree of strain, at times even some animosity, between HR and managers in other depart- ments. This is true of employees in health care as well as in other orga- nizations or professions. Often these differences simply slow down the normal flow of business. Occasionally, however, the differences develop into overt antagonism that can significantly interfere with the efficient conduct of business.

“Line managers and staff human resource professionals spend a great deal of time talking at each other and often past each other and privately questioning each other’s views about what goals and values are important”

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(Leskin, 1986). Why do such differences between HR and department man- agers exist? An examination of the differences between line management and HR may help to develop an understanding of why there is sometimes a credibility gap between the two.

Background and Qualifications The backgrounds of HR practitioners are often varied. Some, a relative few but increasing in numbers over the past 15 years, have received specific training in HR. Despite the increase of people with specialized training, there are individuals working in HR who are educated in a number of different academic backgrounds, including business, psychology, sociology, organi- zational behavior, industrial relations, and education. People who started their careers in clinical or technical specialties have assumed management positions throughout healthcare organizations, but they are not commonly encountered in HR.

Supervisors and department managers in healthcare organizations tend to be trained in specific technical or professional occupations, invariably the operational areas that they manage. On average an HR practitioner’s educa- tion has been liberal and nonspecifically focused. In terms of scientific training, personnel from HR are likely to have training in a so-called soft science such as those already mentioned. In contrast, other supervisors and managers in healthcare organizations are likely to have training in so-called hard sciences such as biology, chemistry, or physics. The educational focus of persons with hard science training tends to be narrower than their colleagues with softer science training. The particular educational backgrounds are relatively un- important; they are simply different. However, people’s initial training often sets a tone for their later outlook on organizational values and influences how they embrace concepts and facts or how they view theory and practice.

Staff Managers Line managers frequently have to supervise and coordinate a variety of people who bring a mix of values into their jobs. Some of these people will require close, nearly constant supervision, while some are capable of independent work. A manager’s working group may include individuals with an extremely broad mix of skills and educational backgrounds, of- ten from within a single discipline. Consider, for example, a nursing man- ager who may supervise a group including nurse practitioners who have training at the masters level as well as a variety of other nursing person- nel with training that ranges from a bachelor’s degree (registered nurses) to an associate’s degree (some registered nurses, licensed practical nurses), to nursing assistants who may have attended certificate programs, and to persons with a high school education (clerical personnel). Such a diversity of educational preparation often poses managerial challenges. Human re- sources departments, in contrast, are usually considerably smaller than most

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line departments. They tend to be relatively cohesive groups composed of people who share similar values and have a common occupational outlook.

Management Style and Approach The supervisor of a line department will ordinarily tend to manage with a downward orientation. Many decisions and supervisory interventions are ac- complished on a one-to-one basis. The downward orientation clearly marks the subordinates of such a manager as being subordinates in the overall scheme of operations. A manager may sometimes have to perform the duties of a practitioner, but depending on department size and workload, such instances tend to be relatively minor components of a manager’s responsibilities.

With the exception of clerical support staff, HR employees (HR practi- tioners) are more likely to view themselves as colleagues who are compa- rable with each other rather than as part of a hierarchical structure. With the exception of the largest healthcare organizations (multisite systems, teaching hospitals, and the like), in most healthcare settings the chief HR officer is likely to have some practitioner duties in addition to supervisory responsibilities. Because of this mix of duties, people throughout the HR de- partment regard these managers and practitioners as organizational equals.

Expectations The positional goals and expectations placed on line managers are usually relatively clear and easy to define. Line managers are expected to perform their assigned job duties to ensure consistency of quality and output. They are simultaneously expected to adhere to policies and procedures of the organization. Furthermore, they are expected to remain faithful to the mission, vision, goals, and objectives of the organization.

The expectations of an HR department may not be nearly as clear or recognizable as those placed on line departments. The expectations associ- ated with HR will influence the manner in which line departments regard HR. Human resources may be perceived as being expected to control the affairs of other departments, retain the status quo, avoid making waves, or innovate. These perceptions will influence whether line departments regard HR with apprehension, indifference, contempt, or caution, or embrace HR as a helpful or useful organizational ally. As long as the expectations of HR and the line departments differ noticeably from each other, there is likely to be a degree of tension among them.

Orientation and Training In regard to matching an appropriate person with each task to be per- formed, line management tends to hold the belief that selection is the most important factor. Put differently, line managers feel that selecting the right person for a job is the most important factor related to accomplishing the task. Human resources practitioners, in contrast, tend to believe that

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development is the most important factor. With proper development, any of several people have the potential to complete a given job. This sometimes leads to sharp differences between line management and HR in the area of recruiting. Human resources may supply several candidates, all having the potential to execute a particular job as expected if they are properly developed. However, none of the candidates may appear to have the exact qualifications or experiences or be precisely the right person for the job. This perception develops because line managers, knowingly or otherwise, often hold out for an ideal fit between candidate and position.

Participation Line managers frequently exhibit a tendency to believe that the notion of employee participation in decision making is no more than a theoretical abstraction, one that complicates matters by slowing things down and generally failing to contribute to departmental success. Human resources practitioners have a different view of employee participation in decision making. Human resources proponents generally feel that when partici- pation is properly implemented it can generate improved organizational performance and increased employee satisfaction.

Employee Empowerment The highest priority for line managers in a healthcare organization is taking care of patients and delivering services. As a result, they are often hesitant to delegate important tasks. More frequently, they adopt an approach reflect- ing the belief that managers or supervisors have the ultimate responsibility to provide needed services. In the extreme, they (the managers) will often provide the required services themselves. The philosophy and priorities of HR are dif- ferent. The highest HR priority is performing a particular job or supplying a needed service. They often advocate employee empowerment as a vehicle for individual growth and development. This approach is taken because of their belief that in order to grow, people must have the freedom to fail.

Control Line managers frequently act according to the belief that exercising control protects a department’s staff and enhances an organization’s ability to deliver care, programs, and services in a timely and cost-efficient manner. The human resources view, however, is that a controlling manager stifles creativity, discourages employee participation, and impedes employee growth and development.

Staff Performance Line managers, especially in departments having a considerable mix of staff skills, qualifications, and educational levels, will ordinarily have to integrate

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or cope with varying levels of individual performance. As a consequence, managers must occasionally provide counseling, criticism, disciplinary action, and termination. Such people problems can consume a consider- able portion of a line manager’s time. In contrast, an HR manager usually supervises professionals and a few support personnel having comparable skills. As a result, their people problems are fewer, and they are far less likely to have to take corrective actions.

Reward Assumptions Line managers often tend to believe that compensation is the most effective means of influencing performance and that their staff members are primarily motivated by the promise of material rewards. Human resources practitioners tend to place organizational culture, supportive management, employee participation, and opportunities for personal development above monetary compensation as providing motivation for employees over the longer run.

Regarding Change The belief system that line managers seem to hold is that effective change occurs slowly over time and that as a consequence, true organizational change is always slow and incremental. The HR view is generally that genuine organizational change is achievable and can occur over a short term if it is driven and supported by top management.

Outlook The orientation of line managers ordinarily views success or failure as occurring in the short run. The typical HR view usually involves a longer- term perspective.

What Results in Practice In summarizing the apparent differences between line management and HR, the following are useful. Line managers believe that HR departments impede progress by frequently obstructing what an operational department manager wants or needs to do. Furthermore, they view HR as being largely obstructionist and commonly citing laws to support their positions on why particular actions cannot be taken. In contrast, HR personnel feel that line department managers regularly try to evade laws and policies and gener- ally insist on making decisions and taking actions that have the potential to cause legal problems for the organization.

What Can Be Done Many rank-and-file employees, along with some department managers, do not trust HR. This often exists to the extent that some employees never go

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to HR with their needs because they feel that doing so will endanger their employment. As a result, these employees never utilize the HR processes and services that are available to them. Many employees apparently do not perceive HR as a resource for them. Rather, they view HR as a depart- ment that relates primarily with their managers and thus mainly serves the corporate hierarchy.

Department managers and HR personnel can both improve their situa- tions by giving each other the benefit of the doubt concerning their motives. Translated, this means that HR’s mission in life is not to obstruct and frustrate department managers and that department managers should not pour their energies into finding ways around HR. Rather, each should try to use every instance of disagreement as an opportunity to know more about the other.

A top priority of HR should be communicating how HR can be an important resource for all employees. This must be demonstrated to rank- and-file employees as well as managers. If HR is not communicating this critical information, then department managers and administration person- nel should take steps to ensure that this does occur. The HR department should never forget why it exists. Human resources represents employees and is an advocate for them. Human resources must ensure that managers are aware of employee needs and are motivating them to perform; HR must continually propose and champion programs and services that appear to be most needed by the employees of the organization that they serve. Senior management must never allow HR to forget why it exists and that it is needed by all in the organization.

■ CONCLUSION

The activities of HR are reviewed from different perspectives. Most HR departments provide three basic services: employment or recruitment, compensation and benefits administration, and employee relations. When unions are present, HR frequently coordinates labor relations. Human resources provides other services in some but not all healthcare settings and may also coordinate employee health and safety activities, training and development, security, child care, award and recognition programs, and Equal Employment Opportunity and Affirmative Action responsibilities. The following activities are occasionally coordinated by HR: risk manage- ment, executive compensation administration, organizational develop- ment, employee assistance programs, outplacement services, and payroll. Alternatively, some of these latter activities may be outsourced.

Viewed from a different organizing perspective, HR activities may be grouped in an alternative manner. The groupings include employee acquisi- tion, employee support or maintenance, employee retention, and employee separation. Line managers throughout an organization and personnel from HR interact most commonly on issues involving a small number of basic

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concepts or areas. These include employment, benefits, compensation, employee relations, and personnel records.

Despite these similarities, readers must remember that all HR depart- ments or operations are not the same. Furthermore, the training and expe- riences of most line managers and HR managers are different. As a result, the expectations of people in these two groups are often different.

Case Study Resolution

Concerning the nurse recruiting situation at Community General Hospital, one might question the degree to which nursing director Jane Cassidy and employment manager Carrie Smith are actually working together. Carrie seems to be putting forth a fair amount of effort to locate candidates. However, she is deliberately vague about hours and shifts. Although she is appropriately sensitive about scaring off good candidates before they can be interviewed, she creates extra work for nursing staff and herself by not being open about hours and shifts and other scheduling requirements. When talking to new graduates, her hesitation in discussing the nursing department’s rotation practices is unfounded because many new nurses seeking hospital employment expect to rotate shifts.

Jane might be considered luckier than many other nursing directors because of the availability of a group of nurses who prefer working steady nights. She has the good fortune to have staffing problems that are con- centrated on one shift instead of two shifts, as is often the case.

Before Carrie and Jane talk with their recent applicant, they should quickly review their scheduling situation and current practices. If Jane continually has to adhere rigidly to her scheduling policy and the candidate nurses refuse the job as a result, then the shortage situation will worsen. A method must be found to recruit and hire qualified nurses during a time of shortage, even if doing so requires some compromise among existing employees and the internal movement of personnel to lessen the impact of any remaining schedule restrictions.

The nursing department and HR’s recruiting personnel should consider closer collaboration. A key component of any new collaboration should include assembling a group of persons from both departments to review all of the nursing department’s scheduling practices and searching for creative alternatives to replace the apparently rigid practices now used when scheduling nurses. The policies and practices governing nurse sched- uling must be revised to reflect the reality of the nursing marketplace. Jane and Carrie must both be involved in this effort. With creative scheduling practices in place, no acceptable reason should exist to reject a qualified nurse applicant during a time of shortage. Considering the fact that quiet exceptions already exist, creative scheduling is already being practiced. This should ease the difficulty of the task.

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SPOTLIGHT ON CUSTOMER SERVICE

Human Resource Activities, Managers, and Customer Service

In a manner similar to that of healthcare providers, human resource profes- sionals often speak of practicing their craft. Over time, they improve their proficiency. This increases the efficiency with which they work while simul- taneously increasing their value to the organizations that employ them.

Most managers become more proficient as their careers progress. They benefit from repetition. However, improved proficiency may be overlooked as managers focus on attaining their next promotions. This is due to changes in the nature of the tasks and responsibilities associated with their new positions.

Human resources provides services to an organization. When talking among themselves, managers often grumble about having to “support” hu- man resources because that department generates no revenue. Such a view may be myopic to an extreme.

Human resource employees spend considerable portions of their working hours explaining regulations and other statutory requirements to employees. Many human resource employees become excellent teachers.

“That is nice,” whisper managers, “but they (human resources) still do not contribute to the organization’s bottom line.”

The contribution to an organization’s bottom line is indirect. One obvi- ous reason should be teaching employees about the importance of customer service. Satisfied customers not only return to purchase additional services but also help to increase their organization’s goodwill. When viewed from the opposite direction, dissatisfied customers rarely return. This reduces, rather than increases the organization’s revenue.

Reference Leskin, B. D. (1986). Two different worlds. Personnel Administrator, 31(12),

58–63.

Discussion Points

1. Outline a long-term approach that you would recommend for narrow- ing a credibility gap that might exist between an organization’s HR department and its department managers.

2. Advance an argument either for or against having the employee health and safety clinic located within an HR department.

3. Describe the objectives and activities of risk management. Is risk man- agement essential in a contemporary healthcare organization? Why, or why not?

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4. Why is it a common practice to outsource an organization’s employee assistance program?

5. List several elements of a hypothetical organizational development program. Explain how and why such a program differs from manage- ment development.

6. Why is it preferable for a department manager to respond directly to the majority of employees’ HR-related questions, rather than simply telling employees to “go ask human resources”?

7. What are screening interviews? Where and why are they ordinarily conducted?

8. Provide several reasons why a department manager should be familiar with the organization’s compensation scales even though the manager is not expected to make specific salary quotations or negotiate salaries with prospective employees.

9. List three or four differing academic backgrounds that might be found among HR practitioners. What are the advantages or disadvantages of each in equipping an individual to provide HR services?

10. Describe the components of a typical outplacement service package. Explain why such services are almost always provided by an external vendor.

Resources

Books Bucknall, H., & Ohtaki, R. (2004). Human resource management. New York:

John Wiley. Churchouse, J., & Churchouse, C. (1998). Managing people. London: Ashgate. Fallon, L. F., & Zgodzinski, E. J. (2005). Essentials of public health management.

Sudbury, MA: Jones and Bartlett Publishers. Fisher, C. (2005). Human resource management. Boston, MA: Houghton Mifflin. Mello, J. A. (2005). Strategic human resource management (2nd ed.). Mason, OH:

Thomson South-Western. Society for Human Resource Management. (2005). SHRM Human Resource

Outsourcing Survey Report: A Study by the Society for Human Resource Management. Alexandria, VA: Society for Human Resource Management.

Sutherland, J., & Canwell, D. (2004). Key Concepts in Human Resource Management. New York: Palgrave Macmillan.

Weinberg, R. B. (2005). HRCI Certification Guide (9th ed.). Alexandria, VA: Society for Human Resource Management.

Periodicals Bowman, B., & Stilson, M. E. (2005). Meeting the nursing shortage: A nursing

camp for prospective nursing students. Journal of Emergency Nursing, 31(5), 512–514.

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Florence, P., et al. (2005). Analysis of adequacy levels for human resources improvement within primary health care framework in Africa. Health Research Policy and Systems, 2(1), 3–8.

Graham, M. M., & Kells, C. M. (2005). The girls in the boys’ club: Reflections from Canadian women in cardiology. Canadian Journal of Cardiology, 21(13), 1163–1164.

Judge, T. A., Martocchio, J. J., & Thoresen, C. J. (1997). Five factor model of personality and employee absence. Journal of Applied Psychology, 82, 745–755.

Lee, R. T., & Ashforth, B. E. (1993). A further examination of managerial burnout: Toward an integrated model. Journal of Organizational Behavior, 14, 3–20.

Lega, F., & DePietro, C. (2005). Converging patterns in hospital organization: Beyond the professional bureaucracy. Health Policy, 74(3), 261–281.

Luzzi, L., Spencer, A. J., Jones, K., & Teuser, D. (2005). Job satisfaction of registered dental practitioners. Australian Dental Journal, 50(3), 179–185.

Mathew, M. (2005). Nursing home staffing. American Journal of Nursing, 105(12), 15–16.

Matthias, R. E., & Benjamin, A. E. (2005). “Intent to stay” among paid home care workers in California. Home Health Care Service Quarterly, 24(3), 39–57.

Mulcahy, C., & Betts, L. (2005). Transforming culture: An exploration of unit culture and nursing retention within a neonatal unit. Journal of Nursing Management, 13(6), 519–523.

West, M. A., Borrill, C., et al. (2002). The link between the management of employees and patient mortality in acute hospitals. International Journal of Human Resource Management, 13(8), 1299–1310.

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