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Minimizing Deviant Behavior in Healthcare Organizations: The Effects of Supportive Leadership and Job Design C. Logan Chullen, Krannert School of Management, Purdue University, West Lafayette, Indiana; Benjamin B, Dunford, Krannert School of Management, Purdue University, West Lafayette, Indiana; Ingo Angermeier, Spartanburg Regional Healthcare System, Spartanburg, South Carolina; R, Wayne Boss, Leeds School of Business, University of Colorado at Boulder, Boulder, Colorado; and Alan D. Boss, Business Program, University of Washington Bothell, Bothell, Washington

E X E C U T I V E S U M M A R Y In an era when healthcare organizations are beset by intense competition, lawsuits, and increased administrative costs, it is essential that employees perform their jobs efficiently and without distraction. Deviant workplace behavior among healthcare employees is especially threatening to organizational effectiveness, and healthcare managers must understand the antecedents of such behavior to minimize its preva- lence. Deviant employee behavior has been categorized into two major types, indi- vidual and organizational, according to the intended target of the behavior. Behavior directed at the individual includes such acts as harassment and aggression, whereas behavior directed at the organization includes such acts as theft, sabotage, and vol- untary absenteeism, to name a few (Robinson and Bennett 1995).

Drawing on theory from organizational behavior, we examined two important features of supportive leadership, leader-member exchange (LMX) and perceived orga- nizational support (POS), and two important features of job design, intrinsic motiva- tion and depersonalization, as predictors of subsequent deviant behavior in a sample of over 1,900 employees within a large US healthcare organization. Employees who reported weaker perceptions of LMX and greater perceptions of depersonalization were more likely to engage in deviant behavior directed at the individual, whereas employees who reported weaker perceptions of POS and intrinsic motivation were more likely to engage in deviant behavior directed at the organization. These findings give rise to specific prescriptions for healthcare managers to prevent or minimize the frequency of deviant behavior in the workplace.

For more information on the concepts in this article, please contact Mr. Boss at [email protected].

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W orkplace deviance is voluntarybehavior by employees that "vio- lates significant organizational norms and, in so doing, threatens the well- being of the organization or its mem- bers, or both" (Robinson and Bennett 1995, 556). Deviant employee behavior can be directed at organizations (e.g., theft, sabotage, voluntary absenteeism) or at other individuals (e.g., harassment, bullying, aggression) (Robinson and Bennett 1995), but all forms of devi- ance are costly to organizations—up to $200 billion annually (Lloyd and Ogbonna 2006) in lost productivity, legal defenses, court settlements, and administrative expenses.

Deviant behavior is especially detrimental for healthcare organiza- tions, because now more than ever, their effectiveness is driven by human capital (Ramanujam and Rousseau 2006). In a recent study, over three-quarters of CEOs identified "workforce issues" as a primary challenge in managing health- care organizations (Prybil 2003). More- over, in an increasingly competitive and financially challenged economic environment, healthcare organizations cannot afford the distractions and costs of administering disciplinary programs. Currently, US healthcare organizations discipline thousands of employees each year. According to the Federation of State Medical Boards (2004; 2007), over 61,000 disciplinary actions against prac- ticing medical physicians were reported from 1996 to 2007, with a 3.7 percent increase in the incidence of disciplinary action from 2006 to 2007. Similarly, according to the Healthcare Integrity and Protection Data Bank (2007), over 65,000 disciplinary actions against RNs and nurse practitioners were reported

from 1996 to 2007, with a 4.3 percent increase in the incidence of disciplinary actions from 2006 to 2007. Pulich and Tourigny (2004, 290, 301) summarize why minimizing deviant behavior in the healthcare sector is so important: "With competition among healthcare organizations today it is imperative that employees perform their jobs as efficiently and effectively as possible." The authors further state (2004, 301), "Deviant workplace behavior is a serious threat to today's healthcare organiza- tions because it violates organizational norms, jeopardizes goal achievement, and threatens the overall well-being of patients and employees."

Yet deviant behavior in healthcare remains underresearched and under- managed (Pulich and Tourigny 2004; Robeznieks 2009). We are unaware of any empirical research aimed specifically at showing healthcare managers how to minimize or prevent such behavior. To address this gap, we draw on theory and research from organizational behavior to examine how an employee's percep- tions of leadership, organizational man- agement, and job design factors predict deviant behavior over a one-year period in a large US healthcare organization.

F O R M S OF D E V I A N T B E H A V I O R In a seminal paper, Robinson and Ben- nett (1995) classified deviant employee behaviors into two primary categories based on the intended target of the behavior: organizational deviance and interpersonal deviance. Organizational deviance refers to deviant behaviors directed at the organization, such as lateness, tardiness, absenteeism, wasting organizational resources, and stealing

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from the organization. Interpersonal deviance refers to deviant behaviors directed at individuals, including gossip, verbal abuse, harassment, and stealing from coworkers.

Leadership Employees' perceptions of their relation- ships with their leaders have a consid- erable impact on their attitudes and behaviors, including job satisfaction, turnover intentions, and job perfor- mance (Cerstner and Day 1997). One critical leadership perception among employees is called leader-member exchange or LMX (Craen and Scandura 1987), defined as an employee's over- all perception of the quality of his or her relationship with a given leader or supervisor. A high-quality relationship is one in which employees perceive that leaders support them emotionally, trust them, and give them feedback (Dienesch and Liden 1986). Conversely, low-quality relationships are character- ized by low levels of trust, limited sup- port, and infrequent feedback (Dienesch and Liden 1986; Cerstner and Day 1997). LMX theory posits that leaders treat different subordinates differently, depending on whether the latter are part of the "in-group" or the "out-group" (Craen and Scandura 1987), In-group subordinates perform their jobs in accordance with the wishes of leaders, and supervisors can count on them to volunteer for extra work and respon- sibilities (Dienesch and Liden 1986). Out-group subordinates tend to avoid volunteer activities and are less likely to conform to the wishes of leaders (Deluga 1998),

According to social exchange theory, employee behavior is strongly

influenced by the supportiveness of leaders (Blau 1964; Couldner 1960). • When employees observe that they receive support, trust, and other tan- gible and intangible benefits from their leaders, they develop an obligation to reciprocate with appropriate work attitudes and performance (Couldner 1960), In contrast, when employees experience poor leader-member rela- tions and receive inferior resources, responsibilities, and outcomes for the same job title, they are likely to recip- rocate with negative behaviors. Several studies have shown that employees often engage in deviant behavior when they perceive that their supervisor treats them worse than their peers (DeMore, Fisher, and Baron 1988; Creenberg and Scott 1996; Cilliland 1993; Jermier, Knights, and Nord 1994; Skarlicki and Folger 1997). Therefore, we hypothesize that when employees perceive a lack of support, trust, and other tangible and intangible benefits from their leaders, they will reciprocate with an increased likelihood of disruptive and undesir- able job behaviors directed at the individual. More specifically, employees who endure unfavorable differential treatment by their supervisor are likely to respond with negative behaviors, such as improper personal conduct or insubordination. Similarly, employ- ees who belong to the out-group are likely to respond to in-group peers with negative behaviors, such as harassment, because of perceived inequities in the reception of job resources and benefits.

Hypothesis 1 : Employees reporting lower quality LMX relationships with their supervisors will be more likely to engage in deviant behavior directed at the individual.

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Organizational Support In addition to leadership factors, research in organizational behavior demonstrates that employees develop distinct judgments about the support- iveness of their employer as a whole and that these judgments have sig- nificant effects on their performance (Settoon, Bennett, and Liden 1996). One such judgment is perceived orga- nizational support (POS), defined as employees' "global beliefs concerning the extent to which the organization values their contributions and cares about their well-being" (Eisenberger et al. 1986, 501). POS perceptions are driven by numerous factors but are largely influenced by organizations' human resource management (HRM) policies and practices (Allen, Shore, and Criffeth 2003).

Jn recent years, more healthcare organizations have implemented HRM practices that promote employee well- being, reasoning that such investments improve firm performance (Studer 2004). For example, one hospital helps employees balance work-life demands by organizing employee out- ings to amusement parks and athletic events and providing valet parking for staff members in their third trimester of pregnancy (Finkel 2008). Other employers offer educational assistance programs, with some providing up to $2,500 per year for tuition reimburse- ment as well as loans of up to $15,000 [Modem Healthcare 2008a). These examples demonstrate that employee support programs have become increas- ingly common.

Organizational support (OS) theory draws on the social perspec-

tive and the reciprocity norm to explain how employees' POS affects their work attitudes and behaviors (Eisenberger et al. 1986). According to OS theory, when employees feel that their employer cares about their well-being and supports them, they develop trust in the organization and respond with increased commitment, persistence, and improved performance (Eisenberger et al. 1986). POS has been linked to key outcomes among healthcare employees, including organizational commitment (Tansky and Cohen 2001), trust in manage- ment (Armstrong-Stassen and Cameron 2003), and job satisfaction (Burke 2003). POS has also been found to be associated with healthcare performance outcomes, such as nurses' perceptions of the quality of patient care they were able to provide and the adequacy of time they had to spend with their patients (Patrick and Laschinger 1993). All these studies suggest that organiza- tional support is an important factor in healthcare environments.

From OS theory (J^ioades and Eisenberger 2002; Shore and Shore 1995) we reason that when employees perceive that they are supported by the organization (i.e., when the exchange is favorable) they will respond with positive cooperative behavior directed toward meeting organizational goals. Conversely, when employees perceive a lack of support from their employer, they will be more likely to reciprocate by engaging in job behaviors that are counterproductive or harmful to their organization, including absenteeism, unsatisfactory work performance, and violations of healthcare standards.

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Hypothesis 2: Employees reporting lower levels of POS will be more likely to engage in deviant behavior direaed at the organization.

Intrinsic Motivation Intrinsic motivation refers to deriving pleasure and satisfaction from per- forming an activity rather than from the external outcomes ofthat activity (Deci and Ryan 1985; Deci and Ryan 2000). Intrinsically motivated employ- ees work because they enjoy it (Kehr 2004). Intrinsic motivation has long been recognized as a major predictor of work-related behavior, such as elevated levels of persistence, performance, and productivity (Cuay, Vallerand, and Blanchard 2000).

Self-determination theory has been widely used to explain how intrinsic motivation affects behavior (Ryan and Deci 2000). A core premise of self- determination theory is that employees would rather originate their own behav- ior than be pawns of others (deCharms 1968; Deci 1971; Deci, Koestner, and Ryan 1999). Moreover, this theory proposes that employees are naturally inclined toward learning and mastery (Deci 1971). Social contexts that satisfy these needs for autonomy and learn- ing will enhance intrinsic motivation and improve work performance (Ryan and Deci 2000). Studies bear out these predictions, showing that intrinsic moti- vation is enhanced when employees feel greater opportunities for autonomy and mastery (Deci, Connell, and Ryan 1989).

To offer such opportunities, organi- zations provide numerous participative management and employee develop-

ment practices. For example, hospitals have offered employees opportuni- ties to share their thoughts with senior management through periodic employee opinion surveys (Finkel 2008). Similarly, hospitals have shifted away from traditional, hierarchical lead- ership styles by establishing open-door policies between employees and execu- tive management [Modern Healthcare 2008b).

Drawing on the motivation litera- ture, we reason that less intrinsically motivated employees are more likely to engage in deviant behavior directed at the organization because they don't enjoy their work (Ryan and Connell 1989; Crant 2008), are not engaged in it, and are less likely to persist at it (Bazerman, Tenbrunsel, and Wade- Benzoni 1998). Accordingly, they will likely respond to their organization with increased absenteeism and disregard for organizational policies.

Hypothesis 3: Employees reporting lower levels of intrinsic motivation will be more likely to engage in deviant behavior directed at the organization.

Depersonalization Burnout is a psychological response to work-related stress that consists of emotional exhaustion, depersonaliza- tion, and reduced perceptions of per- sonal accomplishment (Maslach 1982; Maslach, Schaufeli, and Leiter 2001). Burnout among healthcare profes- sionals, such as nurses, is linked to job dissatisfaction, family problems, and personal health issues (Song et al. 1997). Burnout is also considered a leading contributor to serious problems

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in nurses' job performance and turnover (Song et al. 1997), with staff turnover a major reason for a worldwide nurs- ing shortage (Persson 1993; Cameron 1994). Institutional costs of burnout in healthcare settings include poor morale, poor quality of care, increased staff stress, and loss of management potential (Maslach and Jackson 1996).

An important dimension of burn- out is depersonalization, which is defined as the degree to which employ- ees become emotionally detached from those around them (clients, customers, and coworkers); feel negative, cynical attitudes toward them; and treat them as objects rather than people (Lee and Ashforth 1996). Depersonalization is the result of exposure to stress when other coping resources are not available (Leiter 1990; Maslach 1982).

Conservation of resources (COR) theory explains how burnout develops and how it affects outcomes such as job performance (Hobfoll 1988; Leiterand Maslach 2005). COR theory suggests that employees have limited resources available to them for managing a wide array of work demands. When certain valued resources are lost or are inad- equate to meet the demands of the situation, or when their investment exceeds their return, employees begin to experience forms of burnout, such as depersonalization. COR theory also asserts that performance decreases when employees burn out because they expe- rience a critical depletion of resources, such as motivation (Hobfoll 1989). When employees experience elevated levels of burnout, they are less interested in social acceptance, less motivated to get along with others, and less likely to

cooperate with others on the job (Hal- besleben and Bowler 2007).

Thus, according to COR theory, employees who are emotionally detached from and have negative, cyni- cal views toward patients may be more prone to commit medical errors because they are less motivated to attend to the patients' needs. Additionally, deper- sonalized employees may take unau- thorized shortcuts or seek to limit their involvement and cooperation with coworkers because they are less inter- ested in social acceptance. We reason that employees who have diminished concerns for relationships and coop- eration with others are more likely to engage in improper personal conduct/ insubordination and harassment toward their peers and patients.

Hypothesis 4: Employees reporting higher levels of depersonalization will be more likely to engage in deviant behavior directed at the individual.

Demographics Some employee demographic character- istics, including gender, age, and tenure, have also been associated with deviant behavior in the workplace. Research shows that women are less likely to engage in workplace aggression than men (Clomb and Hulin 1997; Davis, LaRosa, and Foshee 1992). However, research also shows that women have higher rates of absenteeism and tardi- ness than men (McKee, Markham, and Scott 1992; Scott and McClellan 1990). Evidence also suggests that older employees are less likely to engage in workplace aggression (Ceen 1995) and have lower absenteeism (Hui and Lee

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2000) and theft rates than younger employees. Finally, results regarding the effects of tenure on workplace deviance have been mixed. In one study, workers with longer tenure in a public util- ity had higher records of absenteeism (Carrison and Muchinsky 1977), while in another study, manufacturing work- ers with shorter tenure were tardy more often (Bardsley and Rhodes 1996). Based on these findings, we included gender, age, and tenure as controls.

M E T H O D S

Participants and Procedure A healthcare organization in the south- eastern United States with approxi- mately 5,000 employees and 318 departments provided the data for this study. Multiple sources of data were used for this project, including an employee opinion survey and archi- val (personnel file) data. The opinion survey provided the data on employee attitudes. The survey was adminis- tered online over a two-week period during June 2005, and all employees were asked to participate. We obtained responses from a total of 2,572 employ- ees, making our response rate 51.44 percent. Civen varying levels of miss- ing data in our hypothesized predictor variables of deviant behavior, we used pairwise deletion of missing data in our analysis, resulting in a final sample that consisted of between 1,924 and 2,254 employees. Deviant employee behavior and demographic data were obtained from the human resources department over a period of one year following the close of our employee opinion sur- vey. Employee personnel files indicate

whether or not any form of deviant behavior was recorded by the employ- ee's direct supervisors during that year.

Measures

Independent Variables Leader-member exchange was measured using the LMX-7 (Scandura and Craen 1984), a seven-item measure designed to assess the quality of exchange rela- tionship between supervisors and subordinates. Responses were recorded using a five-point Likert scale (°̂ = .82). Perceived organizational support was measured using an eight-item short scale (Eisenberger et al. 1986) designed to assess employees' beliefs concerning the extent to which the organization values their contributions and cares about their well-being. Responses were recorded using a seven-point Likert scale («: = .89). Intrinsic motivation was measured using Hackman and Lawler's (1971) three-item scale designed to assess employees' pleasure and satisfac- tion derived from performing an activity rather than from its external outcomes. Responses were recorded using a seven- point Likert scale (o= = .80). Deper- sonalization was measured using the five-item depersonalization subscale of the Maslach Burnout Inventory (Maslach and Jackson 1981) designed to assess the tendency to view individu- als as things or objects and to distance oneself from others. Responses were recorded using a seven-point Likert scale ( - = .70).

Dependent Variable Employee deviant behavior data were coded from employee personnel files

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according to Robinson and Bennett's (1995) typology. For employee deviant behavior directed at the individual, we coded the behaviors "personal conduct" and "harassment" as 1 if employees had a record of having engaged in such behavior in the one-year time period following the close of our employee opinion survey and 0 if they had no such record. For employee deviant behavior directed at the organization, we coded the behaviors "unexcused absences," "unsatisfactory work perfor- mance," "failure to follow departmental policy," "failure to complete mandatory training," and "violation of health stan- dards" as 1 if employees had a record of having engaged in such behavior in the one-year time period following the close of our employee opinion survey and 0 otherwise. In this sample, the frequency distributions of the various types of deviant behavior were as follows: unex- cused absences 39.94 percent, unsatis- factory work performance 19.10 percent, violation of health standards 19,25 percent, personal conduct 16,95 per- cent, and 4.76 percent for the remaining behaviors, including harassment and failure to follow departmental policy.

Control Variables To address the possibility of spurious relationships, we controlled for gender, age, and tenure, inasmuch as LMX, POS, intrinsic motivation, and depersonal- ization may be related to both deviant behavior and these variables.

RESULTS The descriptive statistics and correla- tions among all study variables are shown in Exhibit 1, We analyzed

the data using analysis of covariance (ANCOVA) to examine the relationship between independent variables and deviant behavior outcomes (DB-O and DB-1) while accounting for variation in our demographic control variables. The ANCOVA results confirmed that in directions we expected, significant differ- ences existed between deviant employee behavior directed at the individual for LMX and depersonalization, and that significant differences existed between deviant employee behavior directed at the organization for POS and intrinsic motivation. Exhibit 2 reports F statistics and mean differences on each covari- ate for individuals who did and did not engage in deviant behavior. Significant associations between employee deviant behavior and each hypothesized vari- able can be seen in Exhibits 3 through 6.

Moreover, as Exhibit 2 demonstrates in support of our hypotheses, POS and intrinsic motivation were related to DB-O, while LMX and depersonaliza- tion were related to DB-I. Additionally, we found cross-foci effects for LMX on DB-O and for intrinsic motivation on DB-I. Finally, we note that in post hoc analyses, we analyzed the relationship between deviant behavior forms and involuntary turnover using archival data provided to us by the host organization. ANCOVA results, including our demo- graphic control variables (gender, tenure and age), indicated that employees who engaged in deviant behavior directed at the individual (F= 88.38, p < .01) were more likely to be terminated than retained within one year following the survey, as were employees who engaged in deviant behavior directed at the orga- nization (F= 137.92, p < ,01). Stated

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E X H I B I T 3

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differently, employees who engaged in deviant behavior directed at individuals were 18 times more likely to be termi- nated than those who did not. Similarly, employees who engaged in deviant behavior directed at the organization were 11 times more likely to be termi- nated than those who did not.

D I S C U S S I O N In our sample, the likelihood of deviant behavior varied with leadership, orga- nization, and work-related attitudes. Specifically, we found that employees' perceptions of the supportiveness of their leaders (LMX) were inversely related to subsequent deviant behav- ior toward those around them (DB-I), while perceptions of depersonalization showed a positive relationship. We also found that employee perceptions of the supportiveness of the organization as a whole (POS) and their levels of intrin- sic motivation were inversely related to subsequent deviant behavior directed at the organization (DB-O).

Additionally, we found some cross- foci effects, for instance with LMX on deviant behavior directed at the orga- nization and for intrinsic motivation on deviant behavior directed at the individual. The concept of displaced aggression (DoUard et al. 1939; Miller 1941) may explain why employees who have poor LMX relationships with their supervisors may also engage in deviant behavior directed at the organization. Displaced aggression suggests that peo- ple express hostility against convenient and innocent targets when they cannot retaliate directly against the source of provocation. For example, Mitchell and Ambrose (2007) argued that abused

subordinates may express their anger against their organization (rather than their supervisor) when the supervisor is not available to retaliate against or when abused subordinates fear that direct retaliation might evoke further hostility on the supervisor's part. Furthermore, Liao, loshi, and Chuang (2004) argued that some employees may not differenti- ate clearly between the sources respon- sible for their current attitudes and may view supervisors and coworkers as agents of the organization. Accordingly, employees low on intrinsic motivation may retaliate with deviant behavior toward other individuals, believing that they are harming their organization in the process.

Our findings are meaningful, given the importance of employee perfor- mance to organizational effectiveness (Ramanujam and Rousseau 2006), and also in view of the shortage of quali- fied talent in the healthcare industry. It is especially important for managers to identify employees who demon- strate the attitudinal characteristics that predict deviant behavior in light of our finding that employees who engaged in such behavior were more likely to be fired. The Society for Human Resource Management estimates that replac- ing lost workers costs organizations 30 to 50 percent of the annual salary of entry-level employees, 150 percent for middle-level employees, and up to 400 percent for specialized, high-level employees (Blake 2006).

These findings lead to several practical implications for healthcare organizations. As a whole, they sug- gest that managers should regularly monitor employee attitudes involving

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motivation, burnout, leadership, and organizational support. The more that relationships between supervisors and subordinates are based on mutual trust, loyalty, interpersonal affect, and respect for one another, the less likely employ- ees are to engage in deviant behavior.

Intrinsic motivation also appears to play an important role in reducing the likelihood of deviant behavior. Research indicates that giving employees a voice in decision making can enhance motiva- tion and performance (Drucker 1954, 1974; Likert 1967; Spreitzer, Kizilos, and Nason 1997; Pascale and Athos 1981; Angermeier et al. 2009). In the real world, people are faced with many choices every day. Organizations may enhance employees' feelings of auton- omy and motivation through shared decision making, either through paral- lel structure practices, such as quality circles, survey feedback, or suggestion systems, or through work design power- sharing practices, such as job enrich- ment and redesign, self-managing work teams, mini-business units, and partici- pation on decision-making boards and committees that enable employees to use and apply information and knowl- edge effectively (Bloom 2000; Anger- meier et al. 2009).

Lastly, organizations should seek to implement burnout intervention programs. Research examining the effectiveness of such programs suggests that burnout can indeed be reduced, particularly by training professionals to use coping skills such as relaxation techniques, cognitive restructuring, and social skills (Corcoran and Bryce 1983; Higgins 1986). Furthermore, the results of these programs may be strengthened

through enhancing employees' social resources, such as support from supervi- sors and colleagues (van Dierendonck, Schaufeli, and Sixma 1994). ,

Limitations and Future Research First, our focus on a single organiza- tion limits the generalizability of our findings. Future research should inves- tigate the relative importance of differ- ent dimensions of ownership across a broad range of healthcare organizations and among a broad range of employee groups.

Second, we did not investigate all possible causal variables. Future research should investigate other constructs that may have important theoretical and practical implications in understanding why certain employees might be disci- plined by their employer.

Third, although our use of archi- val measures of deviant behavior is an improvement over self-report measures (Stewart et al. 2009), we did not have access to information about the fre- quency or intensity of deviant behavior. Future research should incorporate the frequency as well as the form of deviant behavior.

C O N C L U S I O N A growing body of practitioners and researchers has acknowledged that the effectiveness of healthcare organizations is increasingly tied to their manage- ment of human capital (Prybil 2003; Ramanujam and Rousseau 2006), In an increasingly competitive and resource- constrained environment, it is essential to prevent or minimize "people prob- lems," Thus, it behooves healthcare organizations to understand the factors

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that contribute to deviant behavior and to address behavioral problems before they harm the organization. This study provides evidence that employees who report stronger feelings of LMX and weaker feelings of depersonalization were less likely to engage in deviant behavior directed at the individual, while employees who reported stronger feelings of POS and intrinsic motiva- tion were less likely to engage in deviant behavior directed at the organization. Our findings provide empirical evidence that supportive management practices and enriched work design can build a committed, productive workforce and reduce the occurrence of deviant employee behavior.

R E F E R E N C E S Allen, D. C , I. M. Shore, and R. W. Griffeth.

2003. "The Role of Perceived Organiza- tional Support and Supportive Human Resource Practices in the Turnover Pro- cess." journal of Management 29 (1): 99.

Angermeier, I., B. B. Dunford, A. D. Boss, and R. W. Boss. 2009. "The I m p a a of Par- ticipative Management Perceptions on Customer Service, Medical Errors, Burn- out, and Turnover Intentions." journal of Healthcare Management 54 (2): 1 2 7 - 4 1 .

Armstrong-Stassen, M., and S. J. Cameron. 2003. "Dimensions of Control and Nurses' Reactions to Hospital Amalgama- tion." Intemational journal of Sociology and Social Policy 23, (8/9): 104-28.

Bardsley, 1.1., and S. R. Rhodes. 1996. "Using the Steers-Rhodes (1984) Framework to Identify Correlates of Employee Lateness." journal of Business and Psychology 10 (3): 3 5 1 - 6 5 .

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P R A C T I T I 0 A P P L I C A T

/. Thornton Kirby, FACHE, president and CEO, South Carolina Hospital Association, Columbia, South Carolina

O n behalf of the many patients who receive care in US hospitals each day, I wantto commend the authors on this article. This body of work is sorely needed, and it comes at a time when most leaders have been adequately trained to motivate and praise high performers. However, we still need help with the deviant players in our organizations; they are the ones we find not merely vexing, but nearly impossible to manage.

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