Choose two issues or challenges that the leaders of today’s health care organizations face. Select from among the following topics:

1. Staff Shortage (Physicians, Nurses, Allied Health Providers, Ancillary Services)

2. Reorganization in Response to Merger or Consolidation of Services

3. Layoffs as a Result of Declining Revenues

4. Influx of Registry, Part-Time, and Temporary Contract Staff

5. Poor Performance Outcomes Leading to a Reduction in Medicare Reimbursement Dollars

6. Poor Job Satisfaction Rates Resulting in Turnover

You are the manager of an ancillary service department at a large, 500+ bed hospital. Develop a proposal (750-1,200 words) that is directed toward your staff, in which you address the following:

1. Inform the staff of the two issues (from the topics provided) your organization is facing.

2. Describe the impact of these issues on your department.

3. Describe how improved communication, collaboration, and teamwork can improve conditions in your department.

4. Identify at least two examples from the required or recommended readings of techniques found to foster inclusion and improve communication and collaboration.

5. A minimum of three academic references from credible sources are required for this assignment.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

SPECIAL SYMPOSIUM: INTERVENTIONS TO REDUCE RACIAL AND ETHNIC DISPARITIES IN
HEALTH CARE

A Roadmap and Best Practices for Organizations
to Reduce Racial and Ethnic Disparities in Health Care

Marshall H. Chin, MD, MPH1,2,3, Amanda R. Clarke, MPH1,2, Robert S. Nocon, MHS1,2,3,
Alicia A. Casey, MPH1,2, Anna P. Goddu, MSc1,2,3, Nicole M. Keesecker, MA1,2, and
Scott C. Cook, PhD1,2

1Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change National Program Office, University of Chicago,
Chicago, IL, USA; 2Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA; 3Section of General Internal Medicine,
Department of Medicine, University of Chicago, Chicago, IL, USA.

Over the past decade, researchers have shifted their focus
from documenting health care disparities to identifying
solutions to close the gap in care. Finding Answers:
Disparities Research for Change, a national program of
the Robert Wood Johnson Foundation, is charged with
identifying promising interventions to reduce disparities.
Based on our work conducting systematic reviews of the
literature, evaluating promising practices, and providing
technical assistance to health care organizations, we
present a roadmap for reducing racial and ethnic
disparities in care. The roadmap outlines a dynamic
process in which individual interventions are just one
part. It highlights that organizations and providers need
to take responsibility for reducing disparities, establish a
general infrastructure and culture to improve quality,
and integrate targeted disparities interventions into
quality improvement efforts. Additionally, we summarize
the major lessons learned through the Finding Answers
program. We share best practices for implementing
disparities interventions and synthesize cross-cutting
themes from 12 systematic reviews of the literature.
Our research shows that promising interventions fre-
quently are culturally tailored to meet patients’ needs,
employ multidisciplinary teams of care providers, and
target multiple leverage points along a patient’s pathway
of care. Health education that uses interactive techni-
ques to deliver skills training appears to be more effective
than traditional didactic approaches. Furthermore, pa-
tient navigation and engaging family and community
members in the health care process may improve out-
comes for minority patients. We anticipate that the
roadmap and best practices will be useful for organiza-
tions, policymakers, and researchers striving to provide
high-quality equitable care.

KEY WORDS: disparities; quality of care; race; intervention; equity.
J Gen Intern Med 27(8):

992

–1000

DOI: 10.1007/s11606-012-2082-9

© Society of General Internal Medicine 2012

I n 2005, the Robert Wood Johnson Foundation (RWJF)created Finding Answers: Disparities Research for
Change (www.solvingdisparities.org) as part of its portfolio
of initiatives to reduce racial and ethnic disparities in health
care.1 RWJF charged Finding Answers with three major
functions: administer grants to evaluate interventions to
reduce racial and ethnic disparities in care, perform system-
atic reviews of the literature to determine what works for
reducing disparities, and disseminate these findings national-
ly. Over the past seven years, Finding Answers has funded 33
research projects and performed 12 systematic literature
reviews, including the five papers in this symposium.2–6 We
are now beginning to leverage this research base to provide
technical assistance to organizations that are implementing
disparities reduction interventions, such as those participating
in RWJF’s Aligning Forces for Quality program.7

This paper summarizes the major lessons learned from the
systematic reviews and provides a disparities reduction
framework. Building on our prior work,8–10 we present a
roadmap for organizations seeking to reduce racial and ethnic
disparities in health care. This roadmap may be tailored for
use across diverse health care settings, such as private
practices, managed care organizations, academic medical
centers, public health departments, and federally qualified
health centers. Specifically, we outline the following steps:

1) Recognize disparities and commit to reducing them

2) Implement a basic quality improvement structure and

process
3) Make equity an integral component of quality improve-

ment efforts

JGIM

Electronic supplementary material The online version of this article
(doi:10.1007/s11606-012-2082-9) contains supplementary material,
which is available to authorized users.

992

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http://dx.doi.org/10.1007/s11606-012-2082-9

4) Design the intervention(s)

5) Implement, evaluate, and adjust the intervention(s)

6) Sustain the intervention(s)

FINDINGS FROM THE SYSTEMATIC REVIEWS

The five systematic reviews in the present symposium
examined interventions to improve minority health and
potentially reduce disparities in asthma, HIV, colorectal
cancer, prostate cancer, and cervical cancer.2–6 While
many valuable ideas to address racial and ethnic health
disparities are being pursued outside of the healthcare
system, Finding Answers focuses specifically on what can
be accomplished once regular access to healthcare services
is achieved. Thus, the reviews focused on interventions
that occur in or have a sustained linkage to a healthcare
delivery setting; programs that were strictly community-
based were outside the scope of the project. Additionally,
the reviews examined racial and ethnic disparities in care
and improvements in minority health, rather than geo-
graphic, socioeconomic, or other disparities. For a de-
scription of search strategies employed in these reviews,
see the technical web appendix which can be accessed
online (Electronic Supplementary Material).
Each review identified promising practices to improve

minority health within the healthcare setting. The asthma paper
found that educational interventions were most common, with
culturally tailored, skills-based education showing promise.5

Outpatient support, as well as education for inpatient and
emergency department patients, were effective. Similarly, the
HIV review noted that interactive, skills-based instruction was
more likely to be effective than didactic educational approaches
for changing sexual health behavior.3 The paper identified a
dearth of interventions that target minority men who have sex
with men. The colorectal cancer review found that patient
education and navigation were the most common interventions
and that those with intense patient contact (e.g., in person or by
telephone) were the most likely to increase screening rates.4

The colorectal cancer review identified no articles that
described interventions to reduce disparities in post-screening
follow-up, treatment, survivorship, or end-of-life care. Based on
low to moderate evidence, the cervical cancer review reported
that navigation combined with either education delivered by lay
health educators or telephone support can increase the rate of
screening for cervical cancer among minority populations.2

Telephone counseling might also increase the diagnosis and
treatment of premalignant lesions of the cervix for minority
women. The prostate cancer review focused on the importance
of informed decision making for addressing prostate cancer
among racial and ethnic minority men.6 Educational programs
were the most effective intervention for improving knowledge
among screening-eligible minority men. Cognitive behavioral
strategies improved quality of life for minority men treated for
localized prostate cancer. However, more research is needed

about interventions to improve informed decision making and
quality of life among minority men with prostate cancer.

CROSS-CUTTING THEMES

We looked across these reviews and Finding Answers’
previous research,11–17 and identified several cross-cutting
themes. Our findings showed that promising interventions
frequently were multi-factorial, targeting multiple leverage
points along a patient’s pathway of care. Culturally-tailored
interventions and those that employed a multi-disciplinary
team of care providers also tended to be effective. Addition-
ally, we found that education using interactive methods to
deliver skills training were more effective than traditional,
didactic approaches in which the patient was a passive learner.
Patient navigation and interventions that actively involved
family and community members in patient care showed
promise for improving minority health outcomes. Finally, the
majority of interventions targeted changing the knowledge
and behavior of patients, generally with some form of
education. Interventions directed at providers, microsystems,
organizations, communities, and policies were far less
common, thus representing an opportunity for future research.

ROADMAP FOR REDUCING DISPARITIES

Table 1 summarizes the major steps health care organizations
need to undertake to reduce disparities. Past efforts have
focused on Step 1 (e.g. collecting performance data stratified
by race, ethnicity, and language) or Step 4 (designing a
specific intervention). Our roadmap highlights that these are
crucial steps, but will have limited impact unless the other
steps are addressed. Effective implementation and long-term
sustainability require attention to all six steps.

1) Recognize disparities and commit to reducing them

When health care organizations and providers realize
there are disparities in their own practices,18 they become
motivated to reduce them.19 Therefore, the Patient Protec-
tion and Affordable Care Act of 2010 makes the collection
of performance data stratified by race, ethnicity, and
language (REL) a priority.20 Similarly RWJF’s Aligning
Forces for Quality Program initially focused its disparities
efforts on the collection of REL data in different commu-
nities. The Institute of Medicine (IOM) recently recom-
mended methods to collect REL data,21 and groups such as
the Health Research and Educational Trust (HRET) have
developed toolkits to guide organizations in this effort.22

Besides race-stratified performance data, training in
health disparity issues (e.g., through cultural competency
training) may help providers identify and act on disparities
in their own practices. However, while cultural competency

993Chin et al.: A Roadmap to Reduce Racial DisparitiesJGIM

training and stratified performance data may increase the
readiness of providers and organizations to change their
behavior,19 these interventions will need to be accompanied
by more intensive approaches to ameliorate disparities.
Sequist et al. found that cultural competency training and
performance reports of the quality of diabetes care stratified
by race and ethnicity increased providers’ awareness of
disparities, but did not improve clinical outcomes.23 There-
fore, our roadmap for reducing disparities highlights the
importance of combining REL data collection with inter-
ventions targeted towards specific populations and settings.

2) Implement a basic quality improvement structure and
process

Interventions to reduce disparities will not get very far unless
there is a basic quality improvement structure and process
upon which to build interventions.24,25 Basic elements include

a culture where quality is valued, creation of a quality
improvement team comprised of all levels of staff, a process
for quality improvement, goal setting and metrics, a local
team champion, and support from top administrative and
clinical leaders. If robust quality improvement structures and
processes do not exist, then they must be created and nurtured
while disparities interventions are developed.

3) Make equity an integral component of quality improve-
ment efforts

For too long, disparities reduction and quality improvement
have been two different worlds. People generally thought
about reducing disparities separately from efforts to improve
quality, and oftentimes different people in an organization
were responsible for implementing disparity and quality
initiatives. A major development over the past decade is the
increasing recognition that equity is a fundamental compo-
nent of quality of care. Efforts to reduce disparities need to
be mainstreamed into routine quality improvement efforts
rather than being marginalized.26 That is, we need to think
about the needs of the vulnerable patients we serve as we
design interventions to improve care in our organizations,
and address those needs as part of every quality improvement
initiative. The Institute of Medicine’s Crossing the Quality
Chasm report stated that equity was one of six components
of quality,27 and the IOM’s 2010 report Future Directions for
the National Healthcare Quality and Disparities Reports
highlighted equity further by elevating it to a cross-cutting
dimension that intersects with all components of quality
care.28 Major health care organizations have instituted
initiatives that promote the integration of equity into quality
efforts including the American Board of Internal Medicine
(Disparities module as part of the recertification process),
American College of Cardiology (Coalition to Reduce Racial
and Ethnic Disparities in Cardiovascular Disease Outcomes
[CREDO] initiative),29 American Medical Association (Com-
mission to End Health Care Disparities), American Hospital
Association (Race, ethnicity, and language data collection),22

Joint Commission (Advancing Effective Communication,
Cultural Competence, and Patient- and Family-Centered
Care: a Roadmap for Hospitals),30 and National Quality
Forum (Healthcare Disparities and Cultural Competency
Consensus Standards Development). For many health care
organizations and providers, this integration of equity and
quality represents a fundamental change from generic quality
improvement efforts that improve only the general system of
care, to interventions that improve the system of care and are
targeted to specific priority populations and settings.

4) Design the intervention(s)

While several themes have emerged regarding successful
interventions to reduce health care disparities based on our
systematic reviews and grantees, solutions must be individ-
ualized to specific contexts, patient populations, and

Table 1. Six Steps for Reducing Racial and Ethnic Disparities in Care

1) Recognize disparities and commit to reducing them
a. Stratify performance data by race, ethnicity, and language
b. Provide disparities training for providers and staff

2) Implement a basic quality improvement structure and process
a. Create a culture of quality
b. Designate a quality improvement team
c. Establish a quality improvement process
d. Set goals and metrics
e. Select a local champion
f. Obtain leadership support

3) Make equity an integral component of quality improvement efforts
a. Recognize equity as a cross-cutting dimension of quality
b. Ensure that disparities efforts are not marginalized

4) Design the intervention(s)
a. Determine root causes of disparities in specific context
b. Consider six levels of influence: patient, provider,

microsystem, organization, community, policy
c. Review existing literature

(1) Robert Wood Johnson Foundation – Interventions
database, systematic reviews
(www.solvingdisparities.org)

(2) Agency for Healthcare Research and Quality –
Health Care Innovations Exchange
(www.innovations.ahrq.gov/), forthcoming
Evidence-Based Practice Center Review

(3) Veterans Administration – forthcoming review
d. Learn from peer organizations
e. Use evidence-based strategies

(1) Multifactorial interventions that address key drivers
of disparities

(2) Culturally targeted interventions
(3) Team-based care
(4) Patient navigation
(5) Work with families and non-health care partners
(6) Interactive, skills-based training for patients rather

than passive, didactic education
f. Consider specific types of interventions (Table 3)

5) Implement, evaluate, and adjust the intervention(s)
a. Consider implementation models such as the Consolidated

Framework for Implementation Research
b. Consider best practices (Table 4)
c. Evaluate and adjust intervention

6) Sustain the intervention(s)
a. Institutionalize intervention
b. Create financial model

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organizational settings.31 For example, solutions for reduc-
ing diabetes disparities for African-Americans in Chicago
may differ from the answers for African-Americans in the
Mississippi Delta. We recommend determining the root
causes of disparities in the health care organization or
provider’s patient population and designing interventions
based on a conceptual model that targets six levels of
influence: patient, provider, microsystem, organization,
community, and policy (Table 2).8,9 Each level represents
a different leverage point that can be addressed to reduce
disparities. The relative importance of these levels may vary
across diverse organizations and patient populations.
Specific intervention strategies can then be developed to

target different levels of influence. Table 3 offers an
overview of strategies identified through the review of
approximately 400 disparities intervention studies, including
the 33 Finding Answers projects and 12 systematic literature
reviews. Common intervention strategies include delivering
education and training, restructuring the care team, and
increasing patient access to testing and screening. About half
of the interventions targeted only one of the levels of
influence described above; most efforts were directed at
patients in the form of education or training. Research
evaluating pay-for-performance, on the other hand, was scant
and requires further attention, especially given current
interest in incentive-based programs. Going forward, Finding
Answers aims to categorize each of the approximately 400
studies by level of influence and strategy, and to identify
which combinations are promising for disparities reduction.
Organizations can find practical resources and promising

intervention strategies on the Finding Answers website
(www.solvingdisparities.org) or the Agency for Healthcare
Research and Quality (AHRQ) Health Care Innovations
Exchange (www.innovations.ahrq.gov). Systematic reviews
such as those by Finding Answers and forthcoming ones

from the AHRQ Evidence-Based Practice Center Program
and the Veterans Administration can inform what types of
interventions are most appropriate in different situations. In
addition, organizations can learn about successful projects
from peers through learning collaboratives,24 site visits,
case studies, and webinars.
While there is no silver bullet to reduce disparities,

successful interventions reveal important themes. As previ-
ously noted, we looked across 12 systematic reviews of the
literature and identified promising practices that can inform
the design of future disparities interventions.2–6,11–17 These
include culturally tailoring programs to meet patients’
needs, patient navigation, and engaging multidisciplinary
teams of care providers in intervention delivery. Effective
interventions frequently target multiple leverage points
along a patient’s pathway of care and actively involve
families and community members in the care process.
Additionally, successful health education programs often
incorporate interactive, skills-based training for minority
patients.

5) Implement, evaluate, and adjust the intervention(s)

The National Institutes of Health recently held its fifth
annual conference on the science of dissemination and
implementation to promote further research in this field,
create opportunities for peer-to-peer learning, and showcase
available models and tools. One such model is the
Consolidated Framework for Implementation Research
(CFIR), for which Damschroder et al. reviewed conceptual
models of relevant factors in implementing a quality
improvement intervention and synthesized existing frame-
works into a single overarching model.32 The CFIR covers
five domains: intervention characteristics (e.g. relative
advantage, adaptability, complexity, cost), outer setting
(e.g. patient needs and resources, external policy and

Table 2. Levels of Influence of an Intervention

Intervention Level Definition Examples

Patient Change the knowledge and/or behaviors of patients
to improve their health outcomes

Symptom monitoring
Incentives
Culturally targeted education and outreach
Self-management and goal setting
Patient narratives

Provider Change the knowledge and/or behavior of providers
to improve patient outcomes

Cultural competency training
Disparity report cards

Microsystem Add new members to or shift responsibilities among
the immediate care team, such as the primary care
provider, nurse, and staff

Integration of community health workers or other
staff into the care team
Nurse-led interventions

Organization Change organization operations; may require coordination
among management, providers,
information technology, and/or human resources

Redesigning the system of operations
Instituting new forms of technology
Improving the clinical encounter
Systematic literacy screening of patients

Community Work with people and organizations outside traditional
health settings such as churches, schools, and social
service agencies

Engaging local stakeholders to integrate community
and health care resources

Policy Influence laws, regulations, and/or resource allocation
on a regional or national basis

Medicare reimbursement regulations
Accreditation standards for providers and health care
organizations

Breast cancer screening laws

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incentives), inner setting (e.g. culture, implementation
climate, readiness for implementation), characteristics of
the individuals involved (e.g. knowledge and beliefs about
the intervention, self-efficacy, stage of change), and the
process of implementation (e.g. planning, engaging, exe-
cuting, evaluating). Too often organizations focus on the
content of an intervention without planning its implemen-
tation in sufficient detail. A model such as CFIR supplies a
checklist of factors to consider in implementing an
intervention to reduce disparities.
Through work with our 33 grantees, we have devel-

oped a series of best practices for implementing inter-

ventions to reduce disparities. These lessons were pulled
from detailed qualitative data gathered through the
Finding Answers program, and represent perspectives
from organization leadership, providers, administrators,
and front-line staff. We found common implementation
challenges and solutions across health care settings.
Table 4 summarizes best practices for disparities reduction
efforts, provides the rationale and expected outcomes, and
offers recommended strategies for delivering a high-quality
equity initiative.
Implementation is an iterative process and organiza-

tions are unlikely to get the perfect solution on their first

Table 3. Overview of Disparities Intervention Strategies

Intervention Strategy Definition Examples

Deliver education and training Providing information, tools, and/or teaching skills. Patient education in self-management
Provider training in cultural competency
Education via plays and skits
Communication skills training
Decision-making aid
Prescribed diet/exercise
Continuing Medical Education (CME)

Engage the community Involving organizations and/or individuals outside
the health care delivery setting.

Media education campaign
Church-based care delivery
School-based care delivery
Health/Learning collaborative
Coalition building/advocacy
Outreach to households

Provide psychological support Delivering therapy to promote healthy behavior
and psychological well-being of patients,
their partners, and/or their families.

Group therapy
Partner counseling
Family therapy
Coping skills development
Motivational interviewing
Telepsychiatry
Risk/harm reduction

Provide reminders and feedback Prompting adherence to recommended care
guidelines and sharing information about performance.

Patient reminder to schedule preventive care
Provider reminder of care protocol
Patient health maintenance card/health mini-record
Performance report cards stratified by race,
ethnicity, and language

Restructure the care team Shifting responsibilities among members of the care
team or adding members to the existing care team
to enhance care delivery.

Nurse-led interventions
Pharmacist consultation
Increased involvement of primary care provider
in specialty care

Peer coach/peer educator
Community/lay health workers
Patient navigator

Improve language and literacy
services

Improving communication among providers, specialists
and/or patients.

Health literacy screening
Enhanced interpreter services

Increase access to testing
and screening

Addressing financial and logistical barriers to testing
and screening.

Free screening
Integrated screening
Screen-and-Treat
Rapid test results
Risk assessment

Provide financial incentives Offering money or free/subsidized goods or services
to influence behavior.

Vouchers for care
Reduced out-of-pocket expenses
Free give-aways
Pay for performance

Cultural targeting Customizing the content, approach, or messaging
of an intervention based on characteristics
of the population receiving care.

Culturally targeted education materials
Patient-provider racial/ethnic concordance
Religious messaging

Use technology Using computerized or information technology-assisted
tools to improve care.

Home biomarker measurement transmitted to clinic
Peer storytelling on DVDs
Remote video language interpretation
Computerized reminders
Computer kiosks in clinic waiting room
Interactive computerized education/counseling

Other Intervention strategies that did not meet the criteria
defined above.

Home-based care
Clinic open door policy
Increased referrals/streamlined referral systems

996 Chin et al.: A Roadmap to Reduce Racial Disparities JGIM

attempt. Thus, evaluation of the intervention and adjust-
ments to the program based on performance data stratified
by race, ethnicity, and language are integral parts of the
implementation process. Setting realistic goals is essential
to accurately assess program effectiveness. Processes of
care (e.g. measurement of hemoglobin A1c in patients
with diabetes) generally improve more rapidly than patient
outcomes (e.g. actual hemoglobin A1c value), and may
therefore be better markers of short-term disparities
reduction success, while outcomes could be longer-term
targets.

6) Sustain the intervention(s)

Health care organizations, administrative leaders, and
providers need to proactively plan for the sustainability of
the intervention. Sustainability is dependent upon institu-
tionalizing the intervention and creating feasible financial
models. Too often interventions are dependent upon the
initial champion and first burst of enthusiasm. If that
champion leaves the organization or if staff tire after the
early stages of implementation, then the disparities initiative
is at risk for discontinuation. Institutionalization requires

Table 4. Best Practices for Implementing Interventions to Reduce Racial and Ethnic Disparities in Health Care

Practice Rationale Possible Strategies Outcome

Assess organizational
capacity

Interventions are more likely to succeed
if the organization as a whole is ready
for change.

Assess institutional resources (e.g. trained
staff, materials, technology platforms)
and match them with the needs of the
intervention.

Organizations are equipped
to implement and sustain
the intervention.

Ensure ongoing financial support.
Foster a culture of equity Success is more likely if staff recognize

that disparities exist within the
organization and view inequality as an
injustice that must be redressed.

Institute systems to offer feedback to
providers and incentivize disparities
reduction.

Staff shares a definition of
equitable care and places
high value on its delivery.

Explicitly define equitable health care as a
goal in mission statements.

Build a work force that reflects the
diversity of the patient population.

Appoint staff to disparities
reductions initiatives

A plan to improve equity requires
human resources.

Consider quality improvement specialists
and on-site equity champions to fill
these roles. Mainstream equity into all
quality improvement efforts.

Intervention is given
adequate time and effort.

Anticipate leadership and staff turn-over:
e.g. cross-train staff; incorporate
intervention training into staff
orientation; include program
responsibilities in job descriptions.

Staff is not overtaxed.

Identify and appeal to the
equity rationale that is
most important to your
audience

Staff members are motivated for a
variety of reasons:

Leverage staff motivation to support the
program:

Buy-in across the
organization is secured.

Leadership may respond well to
programs that guarantee a positive
return on investment and leverage
existing resources.

Present data that demonstrate potential for
positive financial impact.

Consistent and accurate
uptake of interventions is
encouraged.

Providers are often concerned with
maximizing efficiency during the
office visit.

Enhance the care team and promote care
management outside of the clinic.

Front-line staff may be wary of
impacting patient flow and room
availability.

Minimize burden and show respect for
staff time.

Everyone cares about patient outcomes. Inspire enthusiasm to help patients.
Incorporate disparities
interventions into existing
systems and anticipate
ripple effects

New programs may create redundant
efforts or conflicting goals with
existing quality improvement
initiatives.

Assess existing systems (e.g., electronic
medical records) and identify
opportunities for integration during the
planning phase.

Workload and schedules
are manageable.

Disruptions and
inconsistencies are
minimized.

Involve members of the
target population during
program planning

Programs that are not culturally
targeted risk rejection by patients.

Involve the target population in program
design in a manner that is meaningful
and inclusive.

Community engagement is
advanced.

Input by minority health workers is not
a proxy for patient involvement.

Engage patients, not just minority health
workers.

Programs are relevant and
effective.

Strike a balance between
adherence and adaptability

While adherence to protocol ensures
consistency, flexibility is key when
working with diverse patients.

Regularly collect process measures,
identify opportunities for improvement,
and adapt the intervention accordingly.

Programs are consistent,
yet flexible.

Use standardized checklists to monitor
adherence.

Be realistic about the time
necessary to move the dial
on disparities

Improvements in minority health take
time because of multiple challenges
inside and outside the clinic.

Plan long-term follow-up to demonstrate
statistically significant improvements in
health outcomes.

A realistic timeline
manages expectations
and maintains ongoing
support.

997Chin et al.: A Roadmap to Reduce Racial DisparitiesJGIM

promoting an organizational culture that values equity,
creating incentives to continue the effort, whether financial
and/or non-financial, and weaving the intervention into the
fabric of everyday operations so that it is part of routine
care as opposed to a new add-on (e.g. Step 3 in Table 1).
In the long-term, however, interventions must be finan-

cially viable. The business case for reducing disparities is
evolving and must be viewed from both societal and
individual organization/provider perspectives.33–35 From a
societal perspective, the business case for reducing dispar-
ities centers on direct medical costs, indirect costs, and the
creation of a healthy national workforce in an increasingly
competitive global economy. Laveist et al. estimate that
disparities for minorities cost the United States $229 billion
in direct medical expenditures and $1 trillion in indirect
costs between 2003 and 2006.36 America’s demographics
are becoming progressively more diverse. The United States
Census Bureau estimates that by 2050, the Hispanic
population will reach 30 %, the black population 13 %,
and the Asian population 8 %.37 Thus, from global and
national economic perspectives, disparities reduction will
become increasingly important if we are to have a healthy
workforce that can successfully compete in the international
marketplace and support the rapidly growing non-working
aging population on the Social Security and Medicare
entitlement programs.
From the perspective of the individual health care organiza-

tion or provider, the immediate incentives are more complex.
Integrated care delivery systems have an incentive to reduce
disparities to decrease costly emergency department visits and
hospitalizations. Large insurers are incentivized to provide
high quality care for everyone to be more competitive in
marketing their products to employers with increasingly
diverse workforces. However, outpatient clinics and providers
in the current, predominantly fee-for-service world, especially
those serving the uninsured and underinsured, frequently do
not have clear incentives to reduce disparities since the money
saved from the prevented emergency department visit or
hospitalization does not accrue to them.34

Currently, it is difficult to accurately predict the results of
health care reform and efforts to contain the Medicare and
Medicaid budgets, but several trends indicate that organ-
izations would be wise to integrate disparities reduction into
their ongoing quality improvement initiatives. Major na-
tional groups such as the Department of Health and Human
Services (HHS), Agency for Healthcare Research and
Quality, Centers for Disease Control (CDC), Centers for
Medicare and Medicaid Services, and Institute of Medicine
have consistently stressed the importance of reducing health
care disparities and using quality improvement as a major
tool to accomplish this goal.28,38–42 The Affordable Care
Act emphasizes collection of race, ethnicity, and language
data.20 Private demonstration projects, such as the Robert
Wood Johnson Foundation Aligning Forces for Quality

Program,7 aim for multistakeholder coalitions of providers,
payers, health care organizations, and consumers to im-
prove quality and reduce disparities on regional levels.
Intense policy attention has been devoted to accountable
care organizations,43 the patient-centered medical home,44

and bundled payments.45 These organizational structures
and financing mechanisms emphasize coordinated, popula-
tion based care that may reduce disparities.
Reducing racial and ethnic disparities in care is the right

thing to do for patients, and, from a business perspective,
health care organizations put themselves at risk if they do
not prepare for policy and reimbursement changes that
encourage reduction of disparities. We believe that health
care organizations and providers would be imprudent if they
did not plan for payment and coverage possibilities such as:

1) Incentives and reimbursements for team-based care.
Team-based care is one of the most consistently
successful types of disparities interventions,9 but current
payment mechanisms often do not create viable business
models for sustainability. We believe that it is likely that
future policies encouraging efficiency will increasingly
reimburse or incentivize team-based care management
activities; reimburse or incentivize use of non-physician
members of the team, such as community health work-
ers, peer educators and patient navigators; and ensure
that downstream savings from care teams, such as
averted hospitalizations and emergency department
visits, flow back to those that generated the savings.

2) Implementation of pay-for-performance programs for
reducing racial and ethnic disparities. Pay-for-performance
is likely to become part of efforts to move from paying for
volume to paying for quality. It will be important to
incorporate safeguards such as pay-for-improvement to
avoid cherry picking of easy patients, patient dropping,
and harming of poorly resourced organizations caring for
predominantly vulnerable populations.16

3) Incentives to create linkages between community and
health care system. The new CDC Health Disparities
and Inequalities Report and HHS National Strategy for
Quality Improvement in Health Care exemplify the rise
of combined public health—health care approaches to
reduce disparities.39,41,46 Integration of community
health workers and other peer-based programming into
the health care team shows potential,4,12 and there is
evidence that directly involving families, schools, and
community-based organizations in health care interven-
tions can improve health outcomes.17

CONCLUSION

As outlined in our roadmap, it is critical to create an
organizational culture and infrastructure for improving

998 Chin et al.: A Roadmap to Reduce Racial Disparities JGIM

quality and equity. Organizations must design, implement,
and sustain interventions based on the specific causes of
disparities and their unique institutional environments and
patient needs. To be most effective, all of these elements
eventually need to be addressed; 24 however, we do not
want to encourage paralysis for those who might perceive a
daunting set of obstacles to overcome. Instead, our
experience has been that it useful for an organization to
start working on disparities by targeting whatever step or
action feels right to them and is thus a priority.46 Eventually
the other steps will need to be addressed, but reducing
disparities is often a dynamic process that evolves over
time. While more disparities intervention research is
needed, we have learned much over the past 10 years about
which approaches are likely to succeed. The time for action
is now.

Acknowledgements:
Contributors: We would like to thank Melissa R. Partin, PhD, who
served as the JGIM Deputy Editor for the six manuscripts in this
Special Symposium: Interventions to Reduce Racial and Ethnic
Disparities in Health Care. Dr. Partin provided valuable advice and
feedback throughout this project. Marshall H. Chin, MD, MPH, and
Amanda R. Clarke, MPH, served as the Robert Wood Johnson
Foundation Finding Answers: Disparities Research for Change
Systematic Review Leadership Team that oversaw the teams
writing the articles in this symposium.

Funding Source: Support for this publication was provided by the
Robert Wood Johnson Foundation Finding Answers: Disparities
Research for Change Program. The Robert Wood Johnson Founda-
tion had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; and prepa-
ration, review, approval, or decision to submit the manuscript for
publication.

Prior Presentations: Presented in part at the Society of General
Internal Medicine Midwest Regional Meeting, September 23, 2010,
Chicago, Illinois; the Society of General Internal Medicine Annual
Meeting, May 5, 2011, Phoenix, Arizona; the American Public Health
Association Annual Meeting, November 1, 2011, Washington, D.C.;
and the Institute for Healthcare Improvement Annual National
Forum, December 4, 2011, Orlando, Florida.

Conflict of Interest: The authors report no conflicts of interest with
this work. Dr. Chin was also supported by a National Institute of
Diabetes and Digestive and Kidney Diseases Midcareer Investigator
Award in Patient-Oriented Research (K24 DK071933), Diabetes
Research and Training Center (P60 DK20595), and Chicago Center
for Diabetes Translation Research (P30 DK092949).

Corresponding Author: Marshall H. Chin, MD, MPH; Section of
General Internal Medicine, Department of Medicine, University of
Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL
60637, USA (e-mail: mchin@medicine.bsd.uchicago.edu).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

• c.11606_2012_Article_2082

A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care
Abstract
FINDINGS FROM THE SYSTEMATIC REVIEWS
CROSS-CUTTING THEMES
ROADMAP FOR REDUCING DISPARITIES
CONCLUSION
REFERENCES

222 JCN/Volume 36, Number 4 journalofchristiannursing.com

the Whole

Person

By Cheryl Swanson, Audrey Thompson, Rachael Valentz, Laurie Doerner, and Kenda Jezek

Theory of Nursing for

A Distinctly Scriptural Framework

Cheryl Swanson, PhD, RN, is an associate professor at Oral
Roberts University, Anna Vaughn College of Nursing (AVCON),
Tulsa, Oklahoma.

Audrey Thompson, PhD, RN, is an associate professor at Oral
Roberts University, AVCON.

Rachael Valentz, MSN, RN, is an instructor at and graduate
of ORU AVCON, and has 14 years of critical care experience.

Laurie Doerner, MSN, RN, is a vascular access nurse at St.
Francis Hospital in Tulsa, Oklahoma. She is a former assistant
professor at ORU AVCON.

Kenda Jezek, PhD, RN, is Dean of the Anna Vaughn College
of Nursing, Oral Roberts University.

The authors declare no conflict of interest.

Accepted by peer-review 4/5/2019.

Copyright  2019 InterVarsity Christian Fellowship/USA.
DOI:10.1097/CNJ.0000000000000656

ABSTRACT: Though unpublished in peer-reviewed literature for more than 40
years, the Theory of Nursing for the Whole Person has been, and remains, a
highly useful framework for nursing practice, education, and research. Used by the
College of Nursing at Oral Roberts University, the theory was developed by the
founding dean, I. Tomine Tjelta. Founded on a Christian worldview, the theory is built
on the basic nursing paradigm concepts, yet functions as a distinctly scriptural frame-
work. The theory’s five conceptual triads describe how nursing addresses the whole-
person health-illness continuum for individuals, families, and communities.

KEY WORDS: education, nursing framework, nursing theory, Oral Roberts
University, Tomine Tjelta, whole-person care

F or more than a century and a half, nurses have sought to define and explain their work through the concepts of person, health, environment,
and nursing. Florence Nightingale was the
first, in Notes on Nursing, published in 1860.
Nightingale (1969/1860) defined nursing as
the act of putting “the patient in the best
condition for nature to act upon him” (p.
133) and emphasized the importance of
promoting a “healing” environment character-
ized by fresh air, pure water, cleanliness, and

light. She recognized that “the same laws of
health or of nursing, for they are in reality the
same, obtain among the well as among the
sick” (person) (p. 9).

Almost a century after Nightingale’s
landmark publication, other nurse scholars
aimed to define and explain the work of
nurses through the development and testing
of theories, again based on the four concepts
of the nursing paradigm. In 1952, Hildegard
Peplau, nursing’s second theorist, proposed a
theory based on interpersonal relationships
(Peplau, 1991). More nurse theorists
published their ideas in the 1960s through
1980s, many refining their work in the
following decades. Each nursing theorist
included the four concepts of person, health,
environment, and nursing, along with
definitions and statements of relationships
among them, as pertained to the central
theme of the theory being developed.
Themes central to the emerging nursing
theories included adaptation (Fawcett,
2002b), human caring (Fawcett, 2002a),
human becoming (Fawcett, 2015), and
self-care (Orem, Taylor, & McLaughlin
Renpening, 2001), among others.

Copyright © 2019 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.

http://www.journalofchristiannursing.com

journalofchristiannursing.com JCN/October-December 2019 223

Tjelta had received these elements, she
proposed definitions of the concepts
and refined them with the input of
the SON faculty. The definitions are
built on Scripture, for as Tjelta stated,
“…in theory building you take as many
facts as you know to be true. For us,
we believe that Scripture is truth. That
source, then, became the foundation for
our theoretical beliefs” (Tjelta, p. 19).

A FRAMEWORK BASED
ON SCRIPTURE

Although the TNWP is structured
around the same four paradigms of
nursing, this framework is different
than other theories developed in the
1960s and 1970s. The theory is based
on the scriptural beliefs that view the
individual as an eternal, spiritual being,
made for communion with God
(Tjelta, 1982). Within the specific
definitions of man (person), health, and
nursing, the TNWP is distinct.

ORIGINS OF THE THEORY
In the 1970s, Dr. I. Tomine Tjelta

developed the Theory of Nursing for the
Whole Person (TNWP) for Oral
Roberts University (ORU). Prior to
becoming the dean of the School of
Nursing (SON) at ORU, Tjelta taught
at the University of Washington, where
Dean Mary Tschudin regarded Tjelta as
the curriculum expert (Tjelta, 1982).
Her professional experience exploring
nursing concepts in relation to curricu-
lum development was one reason that
University President Oral Roberts
offered Tjelta the opportunity to
develop a baccalaureate program and
become the founding dean of the Oral
Roberts University School of Nursing.
In 1972, Roberts requested that Tjelta
create a school of nursing that fulfilled
the University’s vision to raise up
students to hear God’s voice and that
educated the whole person—body,
mind, and spirit.

When she arrived at ORU, Tjelta
believed that she had to develop
something unique that fit with the
philosophy of the university, established
within a Christian worldview (Tjelta,
1982). However, after spending count-
less hours attempting to develop the
curriculum’s framework and having
nothing to show for that effort, Tjelta
told President Roberts that she was
blocked, had nothing, and he should
find someone else to do the job. He
told her to go home and pray, then
wait. Later that evening, after praying
and waiting on God, Tjelta received the
concepts, parameters of nursing, and
conceptual framework of the theory.
As she reviewed the whole of what she
felt the Holy Spirit had given to her,
she saw that the theory was not only
grounded in a Christian worldview, but
also had the advantage of building on
the university’s philosophy to edu-
cate the whole person (Tjelta). Once

iS
to

ck

Copyright © 2019 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.

http://www.journalofchristiannursing.com

224 JCN/Volume 36, Number 4 journalofchristiannursing.com

and wholeness; and 5) promotion,
maintenance, and restoration of health.
Emphasis is placed on the assumption
that each triad is not exclusive of any
other, but that all five are interrelated
(Tjelta, 1982).

The level of health and/or ill-
ness experienced by an individual is
predominately based on the person’s
patterns of interactions with and be-
tween their internal and external en-
vironments. According to the TNWP,
these exchanges are the foundation of
assessment and diagnosis in the nurs-
ing process. An individual’s internal
environment is considered the interior
surroundings that manifest within
a person. Examples of a person’s
internal environment include vari-
ables associated with the body, mind,
and spirit. Elements that demarcate
the processes exhibited by the body
include physicality, genetic predispo-
sition, and neurological, endocrine,
and biochemical status, among others.
Essentials characterizing the indi-
vidual component of the mind involve
intellect, emotions, imagination, and
will–volition, aspects that incorporate
an individual’s thoughts, feelings, and
behaviors. An individual’s spiritual as-
pect is that facet which God made for
communion with himself. Herein lies
a person’s concept of God, which leads
to the development of one’s unique
relationship with God.

In contrast to the internal environ-
ment, the external environment may
be deemed as the peripheral atmo-
sphere that presents to a person. The
external environment consists of
circumstances connected with outside
factors that influence one’s life and
health. These dynamic features include
the physical location where one resides,
which also entails the atmosphere of
the individual’s community or neigh-
borhood, and lastly, the social context
(people, organizations, and relation-
ships) experienced within those
settings (Tjelta, 1982).

The journey or quest for whole-
ness that one travels is marked by that
person’s encounters between himself or
herself, the family, and the community.
The links created during this journey

Man, or person, is defined first as a
spiritual being. The apostle Paul’s prayer
in 1 Thessalonians 5:23 explicitly
recognizes the three parts of a person:
spirit, body, and mind. All persons have
a spirit, which is their eternal aspect.
Although the TNWP is grounded in
a Christian worldview, the definition
of spirit is not implying that a person
only has a Christian spirit. Instead, the
framework recognizes the part of a
person that is eternal (Tjelta, 1982).

Further, the framework defines the
spirit as that “part of man made for
communion with God,” (Tjelta, 1982,
p. 20) thus acknowledging the reality of
God and his desire to have relationship
with his people. A person is also defined
as having a body and mind to complete
the three parts of being, so that a person
is “…a spiritual being who functions in
an integrated biopsychosocial manner
to achieve his quest for wholeness”
(Tjelta, 1982, p. 20).

The body includes the processes that
are physiological (biological) in nature.
The mind includes those processes that
can be described as emotional, voli-
tional, and intellectual. Through the
body and mind, the person lives and
breathes, interacting with the sur-
rounding environments. Integrating the
biological, psychological, and social
sciences within the theory of nursing
provides an understanding of how a
person interacts with the internal
(physical, mental, and spiritual realms)
and external (the individual, family, and
community) environments (Tjelta,
1982). Through these interactions, an
individual searches for wholeness.

A second distinctive within the
TNWP is the concept of health.
Whole-person nursing is central to
the TNWP, as people are on a quest
to be complete (healthy) in all three
areas of their being. Jesus’ ministry
of healing, as recorded in the Gos-
pels, speaks of making individuals
whole (Matthew 9:21, 14:36; Mark
2:17; Luke 8:48). By following this
example, the TNWP defines health
as a state of wholeness in a person’s
physical, mental, and spiritual aspects.
Further, health is considered to ex-
ist on a continuum, where one end

represents the dimension of health,
whereas the other represents the
dimension of illness or the state of
lacking wholeness (Tjelta, 1982). The
concept of a continuum illustrates the
fluidity of this idiom. Health is not a
frozen, motionless status; rather, it is a
dynamic, volatile state of being that is
constantly changing and seeking bal-
ance. This quest for equilibrium leads
individuals on a lifelong journey, in
which they will find themselves at
various points on the health-illness

continuum at any given time. It is
understood that health is highly indi-
vidualized, and each individual has a
unique way in which he or she de-
fines this concept. Like health, illness
also is a dynamic state, reflective of
the person’s interaction with his/her
internal and external environments,
and exists on a continuum of severe
to minimum illness.

A nurse then performs those actions
that assist the patient in his/her unique
process of seeking wholeness, focusing
more on the attainment of health than
on confronting the problem of illness. A
key belief in the TNWP is that nursing is
a goal-directed service to others, directed
by each nurse’s clinical judgment, and
by goals developed within the nurse–
patient relationship to assist the person,
family, and/or community to promote,
maintain, and restore a state of health
and assist along the continuum toward
wholeness (Tjelta, 1982).

FIVE CONCEPTUAL TRIADS
The framework includes the integra-

tion of five triads, where the specifics
of the core beliefs become important:
1) body, mind, and spirit; 2) individual,
family, and community; 3) internal and
external environments and their
patterns of interaction; 4) health, illness,

“In theory building, you
take as many facts as
you know to be true.

For us, we believe that
Scripture is truth.”

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journalofchristiannursing.com JCN/October-December 2019 225

nursing’s actions related to each triad.
Fifteen theoretical statements outline
nursing for the individual, the family,
and the community (Table 2).

BODY-MIND-SPIRIT MODEL
The conceptual framework that

Dr. Tjelta received after praying is sim-
ple in its structure, but rather profound
in the way the model works. As depict-

fashion the matrix of an individual’s
health status and, whether positive
or negative, a response is elicited. An
individual’s response to the effects of
the interrelatedness of these concepts
ultimately determines nursing actions
(Tjelta, 1982). The measures performed
by the nurse fall into the categories
of health promotion, maintenance, and
restoration. Nursing actions focused on
promotion are delivered to educate and
prevent illness. Nurses are to empower
clients to aim for optimal levels of
health, as individually defined. Nursing
actions classified as maintenance pre-
serve and protect the existing, appro-
priately functioning health status of the
client (individual, family, or communi-
ty). Restorative nursing acts are aimed
at reestablishing an optimal level for a
client who has experienced an altera-
tion to optimal health status. Regard-
less of the level of nursing action to be
performed, the TNWP delineates the
performance of care to be executed,
utilizing the appropriate integration of
these interrelated parameters (Tjelta).

The TNWP doesn’t only focus on
the individual—as individuals are
recognized as part of a family unit,
which in turn is recognized as a part of
a community. The family in the TNWP
is considered the basic unit of society.
The family unit is continually shaping
and being shaped by the patterns of
interaction that occur within the
internal and external environments that
exist both within the unit and the
individuals who make up the unit.
How the family responds to those
patterns of interactions determines the
health status to which that family unit
ascribes. The nurse utilizes resources
within the family unit and the health
delivery system to facilitate promotion,
maintenance, and restoration of health
(Tjelta, 1982).

Similarly, the community exists on
the health-illness continuum with
community health being influenced by
and reflecting the wholeness of the
individuals and families within the
populace. Nurses work within the
community and health delivery systems
to utilize and mobilize resources that
promote, maintain, and restore health.

Central to whole-person nursing care
for the individual, family, and commu-
nity is the premise that the nurse can
impact health in others and contribute
to the wholeness of others only as long
as he or she continues to grow both
personally and professionally and
continues a pursuit of wholeness of self
(Tjelta, 1982). The classification of
conceptual triads in Table 1 outlines

Table 1. Classification of TNWP Conceptual Triads
Criteria Conceptual Triad

Parameters, or clientele of nursing: Individuals, families, and communities

Goals of nursing service are assisting individuals,
families, and communities to:

Promote, maintain, and restore health

Desired patient–client outcomes: Health is physical, mental, and spiritual
wholeness. Opposite is illness.

Basis of assessment and diagnoses: Internal environment, external environ-
ment, patterns of interaction between the
internal and external environments

Nature of the internal environment of the individual: Body, mind, and spirit

Source: Tjelta (1982). Used with permission.

Table 2: Theoretical Statements for TNWP
Nursing for the Individual

• The individual is a spiritual being who functions in an integrated biopsychosocial manner to
achieve his/her quest for wholeness.

• The individual interacts with his/her internal and external environments wholistically.
• The whole-person nursing approach focuses simultaneously on spiritual, mental, and physical

aspects of wholeness.
• The nurse, through the health delivery system, facilitates the promotion, maintenance, and

restoration of individual health.
• As the nurse continues the quest for personal wholeness, she or he contributes to the whole-

ness of others.

Nursing for the Family

• The family as the basic unit of society continually shapes and is shaped by the internal and
external environments.

• The family pattern of interaction with environmental forces, both external and internal, deter-
mines the health status of the family unit as a whole.

• Promotion, maintenance, and restoration of family health require mobilization of all re-
sources within the family.

• The nurse, through the health delivery system, facilitates the promotion, maintenance, and
restoration of family health.

• As the nurse continues personal and professional growth, she or he contributes to the whole-
ness of the family.

Nursing for the Community

• Community health is influenced by and reflects the wholeness of persons within it.
• Family health is basic to community health.
• Promotion, maintenance, and restoration of community health require mobilization of all

resources within

the community.

• The nurse, through the health delivery system, facilitates the promotion, maintenance, and

restoration of community health.
• As the nurse continues personal and professional growth, she/he contributes to the health of

the community.

Source: Oral Roberts University Anna Vaughn College of Nursing (2018), p. 11. Used with permission.

Copyright © 2019 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.

http://www.journalofchristiannursing.com

226 JCN/Volume 36, Number 4 journalofchristiannursing.com

1991; Sliep, Poggenpoel, & Gmeiner,
2001). However, during the 1980s to
mid-1990s, testing of the 15 conceptual
statements and constructs of the TNWP
was carried out by the more than 50
students enrolled in the university’s
MSN program. This work was required
as the culminating master’s thesis for
each student, but unfortunately their
work remains archived and unpublished.
However, in spite of the lack of use
outside of ORU, it has continued to
serve as a means to educate undergradu-
ate nursing students at ORU to fully
care for every aspect of the individuals,
families, and communities in which
they come in contact.

The following exemplars are
included to amplify understanding and
application of TNWP. These exemplars
are not exhaustive, but give account of
actual instances where ORU students
utilized the TNWP.

Caring for the individual: A first-
year nursing student was assigned to
care for a nonverbal, older gentleman,
resistant to care. He hit nursing staff
and hadn’t been bathed in several days.
The clinical instructor selected this

ed in Figure 1, the individual—made
up of the body, mind, and spirit—is at
the center of the model, along with
the nurse caring for the whole person.
The individual is then surrounded by
the family and then the community in
concentric rings. Bidirectional arrows
between the rings and the center of
the model allow for the TNWP to
be adapted to different cultures and
situations, while still being effective in
providing whole-person care.

For example, in some cultures it is
necessary to approach the family and
the individual through the overall
community. The direction of the
arrows pointing inward allows the
nurse to work from the community
level toward the family unit and
ultimately impact the individual. In
other cultures, the community cannot

be impacted without starting with the
individual and his/her family unit; the
arrows pointing outward enable the
nurse to work in this direction, as well.
By understanding the interactions
between levels of the model, a global
focus allows for improving health and
addressing health problems. No matter
the avenue that must be taken for
effective nursing care to take place,
TNWP provides the framework
necessary (Ward & Swanson, 2017).

TNWP FRAMEWORK
IN PRACTICE

The TNWP is only found in limited
fashion in nursing literature. An ex-
tensive search reveals only two articles,
both featuring authors who graduated
from the Master of Science in Nursing
(MSN) program at ORU (Poggenpoel,

Central to whole-person nursing care is the premise
that the nurse can impact health and contribute to
the wholeness of others only as long as he or she
continues to grow personally and professionally
and continues a pursuit of wholeness of self.

iS
to
ck
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http://www.journalofchristiannursing.com

journalofchristiannursing.com JCN/October-December 2019 227

CONCLUSION
The Theory of Nursing for the Whole

Person was developed at a time when
whole-person care had become a
focus of nursing. A practical, Chris-
tian framework, the TNWP has
been used by thousands of nurses
since the 1970s in practice, educa-
tion, and for research. The theory is
now, more than ever, a framework
that can impact care provided to

individuals, families, and commu-
nities worldwide. As nurses seek to

promote, maintain, and restore health in
whatever situation they find themselves,
the TNWP provides a framework that
allows them to be the hands and feet of
Christ, seeing each individual as created
in the image of God, and serving indi-
viduals, families, and communities in the
desire to find wholeness.

Fawcett, J. (2002a). The nurse theorists: 21st-century
updates—Jean Watson. Nursing Science Quarterly, 15(3),
214–219. doi:10.1177/089431840201500307

Fawcett, J. (2002b). The nurse theorists: 21st-century
updates—Callista Roy. Nursing Science Quarterly, 15(4),
308–310. doi:10.1177/089431802236795

Fawcett, J. (2015). Evolution of the science of unitary
human beings: The conceptual system, theory develop-
ment, and research and practice methodologies. Visions:
The Journal of Rogerian Nursing Science, 21(1), 9–16.

Nightingale, F. (1969). Notes on nursing: What it is
and what it is not. New York, NY: Dover Publications
(Original work published 1860).

Oral Roberts University Anna Vaughn College of Nurs-
ing. (2018). Oral Roberts University Anna Vaughn College of
Nursing student handbook 2018-2019. Tulsa, OK: Author.

Orem, D. E., Taylor, S., & McLaughlin Renpening, K.
(2001). Nursing: Concepts of practice (6th ed.). St. Louis,
MO: Mosby.

Peplau, H. (1991). Interpersonal relations in nursing: A
conceptual frame of reference for psychodynamic nursing. New
York, NY: Springer Publishing Company.

Poggenpoel, M. (1991). Nursing research education in
the United States of America: One approach. Curationis,
14(3), 15–19. doi:10.4102/curationis.v14i3.332

Sliep, Y., Poggenpoel, M., & Gmeiner, A. (2001). A care
counselling model for HIV reactive patients in rural
Malawi—Part II. Curationis, 24(3), 66–74. doi:10.4102/
curationis.v24i3.855

Tjelta, I. T. (1982, October). Development of the
theoretical framework of Nursing for the Whole Person
at Oral Roberts University. In Oral Roberts University
(Ed.), Proposal for Dr. Tjelta’s papers from annual theory con-
ferences 1982-1991 (pp. 3–27). Tulsa, OK: Oral Roberts
University.

Ward, E., & Swanson, C. (2017). The theory of nursing
for the whole person and its impact on the practice of nursing
school graduates (Unpublished senior research project).
Oral Roberts University Anna Vaughn College of Nurs-
ing, Tulsa, OK.

opportunity to demonstrate
principles of the TNWP and
asked a few students to join in
bathing this patient. After ex-
plaining to the patient what they
were going to do, the students began
to prepare the water and linens for the
bath. Talking to the patient, providing a
caring touch, and even singing a hymn
as they worked, changed the way the
patient responded. Not only did the
patient allow for the bath, but opened
his eyes and thanked the students for
their care, asking them to pray with
him before they left the room. As the
instructor relayed, the care provided
for the patient’s spirit allowed the care
for his body and even produced a
measurable outcome of verbalization,
opening of the eyes, and cessation of
resistance to care.

Caring for the community: Stu-
dents participating in their community
clinical rotation receive assignments
to nontraditional clinical sites and
perform comprehensive assessments of
internal and external environmental
factors to develop a community health
proposal that benefits the targeted
population. For example, a nonprofit
agency serving justice-involved fe-
males was the clinical site for a pair of
senior nursing students. The students
planned an overall goal of developing
a community health program to assist
the women in experiencing optimal
levels of health. Assessment of the
organization included a one-to-one
interview with the agency’s execu-
tive director, questionnaires com-
pleted by staff, and a focus group with
participants in the program. Students
developed a health fair that focused on
physical, mental, and spiritual needs of

interest identified by the population.
Agency staff members discussed the
need for physical activity among this
population because the women were
not frequently exposed to physical
exercise and lacked access or resources
for gym memberships. During the
health fair, students set up an area
to engage the ladies in intermittent
periods of 15 minutes of low-impact
aerobics.

Caring for individuals, families, and
communities cross-culturally: Students
participating in an international clinical
experience wished to offer health
teaching that benefited individuals who
suffered from a variety of chronic
diseases. Most community residents
were wary of the students and would
not speak with them. Realizing that
they needed to work from the com-
munity level to engage the families and
individuals, the students collaborated
with healthcare workers within the
community. These community officials
provided valuable input regarding the
greatest health needs. Students also
received an introduction to the town
mayor. By working through commu-
nity leaders who endorsed the students’
efforts, the health fair went forward.
With public announcements about the
health fair, which was held in the town
square, the majority of the community
attended the fair and received valuable
health information about promoting
their wellness.

Figure 1:
Theory of Nursing
for the Whole-Person
Conceptual Model

Source: © 2018, Oral Roberts
University Anna Vaughn College
of Nursing. Used with permission.

Community
Family

Indi
vidual

SPIRIT

M
IN

D

BO
DY

Nursing for
the Whole

Person
Copyright © 2019 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.

http://www.journalofchristiannursing.com

• 20191000.0-00010

Free To Be You and Me: A Climate of Authenticity Alleviates Burnout
From Emotional Labor

Alicia Grandey and Su Chuen Foo
Pennsylvania State University

Markus Groth and Robyn E. Goodwin
University of New South Wales

Given the emotional nature of health care, patients and their families may express anger and mistreat their
health care providers; in addition, those providers are expected to manage their own emotions when providing
care—two interpersonal stressors that are linked to job burnout. Integrating conservation of resources
(Hobfoll, 2002) and ego depletion (Muraven & Baumeister, 2000) theories, we propose that this creates a
resource loss spiral that can be slowed by the presence of a “climate of authenticity” among one’s coworkers.
We describe this climate and how it differs from other work climates. We then propose that a work unit with
a climate of authenticity should provide a self-regulatory break from emotional labor with patients, thus
replenishing resources and buffering against strain from emotional labor. We tested this multilevel prediction
by surveying 359 health care providers nested within 48 work units at a large, metropolitan hospital. We find
that medical workers experiencing more mistreatment by patients are more likely to be managing emotions
with patients, and this response further contributes to the employees’ job-related burnout. As predicted,
managing emotions with patients was unrelated to burnout for workers in a unit with a climate of authenticity.

Keywords: authenticity, emotion regulation, emotional labor, health care, burnout, mistreatment, work
climate

Job burnout is a state of exhaustion and emotional depletion that is
unhealthy for the employee and is linked to absenteeism, turnover,
and lower job performance (Grandey, Dickter, & Sin, 2004; Halbes-
leben & Bowler, 2007; Wright & Cropanzano, 1998). Moreover,
these outcomes are particularly problematic for health care profes-
sionals, where absence and decreased job performance can harm
patient health as well (Le Blanc, Hox, Schaufeli, & Taris, 2007). Two
socioemotional factors have been identified as sources of burnout for
health care professionals. First, patients and their family members are
often dealing with disease, discomfort, or even death, and they may be
unable to regulate their expressions of fear or anger when interacting
with health care providers due to fatigue or stress (Demerouti, Bakker,
Nachreiner, & Schaufeli, 2001; Leiter & Maslach, 1988; Maslach,
1978). Such negative emotional behavior by patients and their fami-
lies is a predictor of care provider burnout (Bakker & Heuven, 2006;
Bakker, Schaufeli, Sixma, Bosveld, & Van Dierendonck, 2000). Sec-
ond, in addition to accurate diagnoses and safe, efficient treatment,
health care professionals are expected to provide good customer
service to patients (Drach-Zahavy, 2010), often requiring emotional
labor (Hochschild, 1983). Such emotional labor in health care entails

showing interest, concern, and sympathy, while suppressing disgust,
frustration, or anxiety, when interacting with the public (Mann, 2005).
This underappreciated form of labor has been linked to job stress and
burnout (Bono & Vey, 2005; Henderson, 2001). Thus, for health care
providers, burnout may be a function of: 1) being the target of
customers’ negative emotions, and 2) regulating one’s own emotional
expression. Though these predictors are clearly linked, they are nev-
ertheless rarely considered together when examining job burnout (see
Sliter, Jex, Wolford, & McInnerney, 2010 for a recent exception).

A stream of research has begun to identify personal and situa-
tional factors that moderate the burnout from these socioemotional
demands. Most work has focused on individual perceptions of
one’s resources (i.e., self-efficacy, job autonomy), which can buf-
fer against the strain of emotional labor (e.g., Demerouti et al.,
2001; Grandey, Fisk, & Steiner, 2005; Heuven, Bakker, Schaufeli,
& Huisman, 2006). We respond to the call for greater attention to
the broader social context to better understand occupational stress
and identify unit-level interventions (Bacharach & Bamberger,
2007). Recent studies have shown that a company’s health poli-
cies, rewards for service, and formal support groups create unit-
level workplace climates that buffer employees from socioemo-
tional work stressors (Drach-Zahavy, 2008, 2010; Le Blanc, et al.,
2007). We propose that informal social norms in a work unit—
specifically the extent that coworkers value authentic expression of
emotions with each other (i.e., a climate of authenticity)—can
alleviate burnout experienced from engaging in emotional labor
with patients and their families.

Thus, the purpose of this research is to make theoretical, empirical,
and practical contributions to the occupational health literature. First,
we propose that two socioemotional predictors of burnout—
interpersonal mistreatment and emotion regulation—are connected
based on the concepts of self-regulatory depletion and resource loss
spirals (Hobfoll & Freedy, 1993). Second, self-regulatory resources
can be replenished if one has a break from self-regulation (Baumeis-

This article was published Online First August 29, 2011.
Alicia Grandey and Su Chuen Foo, Department of Psychology, Penn-

sylvania State University; Markus Groth and Robyn E. Goodwin, Austra-
lian School of Business, University of New South Wales, Sydney, New
South Wales, Australia.

We thank editor Joseph Hurrell for constructive reviews. This research
was funded by a grant of the Australian Research Council (LP0990427).
An earlier version of the paper was presented at the 26th annual meeting of
the Society for Industrial and Organizational Psychology in Chicago,
Illinois, April 2011.

Correspondence concerning this article should be addressed to Alicia
Grandey, Pennsylvania State University, 111 Moore Building, University
Park, PA 16803. E-mail: Aag6@Psu.edu

Journal of Occupational Health Psychology © 2011 American Psychological Association
2012, Vol. 17, No. 1, 1–14 1076-8998/11/$12.00 DOI: 10.1037/a0025102

1

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ter, Bratslavsky, Muraven, & Tice, 1998), and that such breaks are
more characteristic of a work unit that embraces a climate of authen-
ticity than one that does not. Empirically, we provide evidence for
these outcomes using survey data collected from hospital employees
with direct patient contact (i.e., doctors, nurses, and allied health
professionals) from 48 distinct work units. We test whether climate of
authenticity is a shared, unit-level construct among coworkers, and
whether it reduces (or exacerbates) patient care professionals’ job
burnout from emotional labor. The results have implications for why
and when job burnout occurs, and yield practical implications for
reducing detrimental effects of emotionally demanding work on
health care providers.

Interpersonal Mistreatment and Emotion Regulation
as Causes of Resource Loss

As a resource-based theory of stress, conservation of resources
theory (COR, Hobfoll & Freedy, 1993) provides a theoretical
explanation for whether, and most importantly when, emotion
regulation with patients contributes to burnout (Brotheridge & Lee,
2002). COR recognizes that many factors, both objective (e.g.,
money, a home) and psychological (e.g., self-esteem, social sup-
port), can be viewed as personal resources. When these factors are
threatened or actually lost, these primary resource losses evoke
anxiety and distress in the individual, heightening physiological
arousal and eventually resulting in exhaustion and health issues
(Hobfoll, 2002; Hobfoll & Freedy, 1993). Interpersonal stressors
(e.g., conflict, mistreatment, verbal aggression) are recognized
among the most threatening causes of stress, posing a threat to
self-esteem and self-efficacy, and resulting in greater cortisol
response and perceived distress than other stressors (Almeida,
2005). Similarly, the frequency with which customers, clients, and
patients mistreat their service providers predicts job burnout, even
after controlling for other work and role stressors (Dormann &
Zapf, 2004; Grandey, Kern, & Frone, 2007; Maslach, Schaufeli, &
Leiter, 2001; van Jaarsveld, Walker, & Skarlicki, 2010).

Further, a prediction unique to COR is that by coping with
stressors such as mistreatment can, ironically, induce secondary
resource losses. This occurs when the primary stressor evokes
coping responses that are ineffective, such that gains from engag-
ing in the coping response do not outweigh the losses of the effort
expended (Hobfoll, 2002). Mistreatment from patients is likely to
yield ineffective emotion regulation strategies that simply satisfy
job requirements on the surface (Bolton & Boyd, 2003; Diefen-
dorff, Richard, & Croyle, 2006; Lewis, 2005). A medical profes-
sional cannot respond to patient anger or frustration with similar
emotions; he or she must suppress this emotional response and
possibly bring forth a look of concern. Such emotion management
as part of work expectations is known as “surface acting” (Hoch-
schild, 1983) and is used by employees during interactions with the
public.1 In fact, research has demonstrated that, despite feeling
anger, employees are likely to respond to angry or rude customers
by suppressing or faking emotional expressions (Diefendorff,
Richard, & Yang, 2008; Rupp & Spencer, 2006).

Such self-regulatory efforts may suffice for a single episode, but
frequent emotion management with patients may result in a net
loss of resources, for several reasons. First, the inauthenticity of
faking expressions, or surface acting (Brotheridge & Lee, 2002),
threatens one’s self-worth and self-efficacy as a caring profes-

sional (Erickson & Wharton, 1997). Second, the act of suppressing
emotions requires attentional and energy resources, as exhibited by
heightened physiological arousal, lowered glucose levels, and re-
duced motivation (Baumeister, Vohs, & Tice, 2007; Richards &
Gross, 1999). Third, suppressing felt emotions results in less social
connection with others compared to actually showing, or more
directly changing, those feelings (Butler et al., 2003; Côté, 2005),
and thus reduces social resources. Overall, research has established
that modifying expressions through faking or suppressing felt
emotions is linked to stress, resource depletion (Baumeister et al.,
2007; Gross, 1998), and job burnout (Bono & Vey, 2005), even
when taking other stressors into account (Lee, Lovell, & Brother-
idge, 2010; Zapf, Seifert, Schmutte, Mertini, & Holz, 2001).

Thus, both mistreatment and emotion regulation have been
shown to have unique effects on burnout beyond other stressors.
What is less clear is how these two socioemotional demands work
together to contribute to burnout. One recent study supported that
emotional labor mediates the effects on stress from customer-
instigated incivility (Sliter et al., 2010), though their study was
different from ours in several key ways (i.e., incivility is a low-
intensity and more ambiguous form of mistreatment, this study
was conducted in the less emotionally intense context of financial
transactions). We expected to find that surface acting partially
mediates the relationship of patient-instigated mistreatment and
burnout. We propose partial rather than full mediation because
mistreatment from patients might influence burnout through cog-
nitions, such as perceived unfairness (Bakker et al., 2000; Heuven
et al., 2006), or stress appraisal (Brotheridge & Lee, 2002; Die-
fendorff et al., 2008; Kern & Grandey, 2007).

In summary, based on COR theory and prior evidence, we
predict that mistreatment by patients results in primary resource
losses that evoke the coping response of surface acting. Further-
more, we predict that job burnout is a function of the extent of
mistreatment from patients and their families, and this is partially
due to the secondary resource losses from surface acting during
those interactions (see Figure 1). Thus:

Hypothesis 1. Health care providers who experience more
mistreatment from patients and their families are also more likely
to engage in surface acting when interacting with patients and their
families.

Hypothesis 2. Surface acting partially mediates the relation-
ship between mistreatment by patients and health care providers’
job burnout.

Climate of Authenticity as an Opportunity for
Resource Recovery

We now turn to understanding the conditions that protect em-
ployees from these resource losses. When resource losses have
occurred, the individual is motivated to replenish resources
through “emotional respite” (Hobfoll, 2002). We propose that
understanding the expressive norms among coworkers explains
when self-regulatory efforts with patients result in burnout. Below
we present the concept of climate of authenticity, and then explain
how it may buffer of the strain from emotional labor.

1 Other responses are also possible, such as deep acting (i.e., modifying
feelings), situation avoidance, or venting emotions, but these are less
clearly linked to stress and depletion and are not the focus of this study.

2 GRANDEY, FOO, GROTH, AND GOODWIN

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Climate of Authenticity as a Unit-Level Construct

Work groups are likely to vary in the extent to which they
encourage and support authentic emotional expressions with group
members. For example, qualitative work has revealed that flight
attendants and nurses report coping with emotional demands by
showing their frustration and concerns with coworkers “back-
stage,” out of the public’s view (Hochschild, 1983; Lewis, 2005).
A retail organization encouraged “bounded emotionality,” permit-
ting appropriate expression of felt emotions among coworkers
(Martin, Knopoff, & Beckman, 1998). At the same time, there is
also the perspective that only positive emotional expressions are
healthy for group dynamics (see Fineman, 2006); in fact, expres-
sions of hopelessness, anxiety or frustration may be discouraged
because they are unpleasant and bring down the group’s mood
(Kelly & Barsade, 2001). Moreover, in health care there can be an
expectation for compassionate detachment, such that “getting emo-
tional” is viewed as unprofessional (Henderson, 2001; Lewis,
2005).

We expect that there are unit-level variations that we label the
climate of authenticity: the perceived acceptance of, and respect
for, unit members’ expressing felt emotions when interacting with
coworkers. Members in a unit high in climate of authenticity value
and encourage expressing felt emotions, especially when they are
negative, while those in a unit low in climate of authenticity are
uncomfortable with and discourage such emotional expressions.
These variations may emerge from bottom-up processes (e.g.,
member personality, vicarious learning), or top-down processes
(e.g., professional training, supervisor feedback), creating shared
unit-level norms that meaningfully vary even within the same
organization (Ashforth & Humphrey, 1993; Kelly & Barsade,
2001; Kozlowski & Klein, 2000). We propose that variations in
this unit climate help to explain the extent of emotional regulation
needed while interacting with one’s coworkers, thus potentially
buffering—or perhaps exacerbating—the burnout experienced

from regulating emotions with patients. Before explaining the
interactive effect we differentiate climate of authenticity from
other related constructs; namely, psychological safety, display
rules, and social support.

Climate of authenticity and psychological safety. To de-
velop the idea of a climate of authenticity as a unit-level phenom-
enon, we turned to the climate literature and, specifically, to an
established unit-level norm in hospital settings: Psychological
safety. Psychological safety is defined as a “sense of confidence
that the team will not embarrass, reject, or punish someone for
speaking up . . . it describes a team climate characterized by
interpersonal trust and mutual respect in which people are com-
fortable being themselves” (Edmondson, 1999, p. 354, italics
added by authors). Psychological safety originally acknowledged
four types of interpersonal risks to image (i.e., being seen as
ignorant, incompetent, disruptive, or negative), but the psycholog-
ical safety measurement items and resulting literature has primar-
ily focused on taking risks by asking questions or identifying
mistakes (Edmondson, 1999; Edmondson, 2002). Similarly, theo-
ries of and evidence for psychological safety focus entirely on
unit-level mistakes and learning, not member stress. Our climate of
authenticity construct uses the measurement of psychological
safety as a starting point to assess whether team members feel that
they can express felt negative emotions without interpersonal risk,
and we expand beyond the psychological safety literature by
focusing on the outcome of employee burnout.

Climate of authenticity and organizational display rules.
Our concept of climate of authenticity is related to the idea of
shared norms about expressing emotions, verbally and nonver-
bally, or display rules (Ekman, 1993). Work groups develop con-
ventions for how members should express their feelings, creating
local norms that vary from the broader (e.g., gender, occupational)
norms that guide social interactions (Ashforth & Humphrey, 1993;
Bartel & Saavedra, 2000; Kelly & Barsade, 2001). Such emotional

Figure 1. Multi-level model based on conservation of resources theory.

3CLIMATE OF AUTHENTICITY AND EMOTIONAL LABOR

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norms among coworkers are less constrained than the emotional
norms with customers (Diefendorff & Gregarus, 2009; Tschan,
Rochat, & Zapf, 2005) and thus are potentially more likely to vary
at the unit level. However, we do not use the label “display rules”
because in prior organizational research these are typically mea-
sured as individual-level perceptions (see Diefendorff et al., 2011
for an exception) of organizational requirements for positive dis-
plays during interactions with customers (Brotheridge & Grandey,
2002). In contrast, climate of authenticity is about a shared, unit-
level perception about expressing felt negative emotions during
interactions with coworkers. As such, our construct represents a
unique, unit-level display rule that is not necessarily organization-
ally prescribed, warranting a different label.

Climate of authenticity and social support. Furthermore,
climate of authenticity is expected to be a unique form of social
support. Within COR, social support is viewed as a resource to the
individual (Hobfoll, Freedy, Lane, & Geller, 1990; Hobfoll, 2002),
with behaviors that show that persons “are valued for their own
worth and experiences and are accepted despite any difficulties or
personal faults” (Cohen & Willis, 1985, p. 313). Acceptance of
coworkers’ expressions of felt emotions could certainly fall into
this definition. However, social support is a “metaconstruct,” a
broad label that can include quantity or quality of support, and
perceived opportunity or actual supportive behaviors, including
listening, empathy, instrumental assistance, and advice-giving
(Hobfoll, 2002), which is typically assessed as an individual per-
ception of the work context (Halbesleben, 2006; see Bacharach &
Bamberger, 2007). In contrast, climate of authenticity is a unit-
level perception about a more specific form of supporting the
individual: acceptance of self-expressive behavior, which does not
necessarily result in actions (e.g., advice, listening) by the mem-
bers in response to such expressions. In fact, we propose below
that climate of authenticity has unique effects from social support
and thus warrants separate consideration.

Climate of Authenticity Moderating the Burnout From
Emotional Labor

As proposed above, climate of authenticity is a shared percep-
tion about the extent that the unit values and accepts self-
expression of emotions among members of the unit, specifically
negative emotions. We propose that this is important to under-
standing the strain of emotional labor, in that a climate of authen-
ticity provides an opportunity to recover depleted resources from
the self-regulation of emotional labor.

In an interpersonally challenging interaction, people who are
told to suppress their felt expressions experience more depletion
and perform worse on self-regulatory tasks compared to people
who are told to “just be yourself” (Goldberg & Grandey, 2007;
Richards & Gross, 1999; Baumeister et al., 2007). Linking ideas of
self-regulatory depletion (Baumeister et al., 1998) and conserva-
tion of resources theory (Hobfoll, 1989), this can be explained as
a self-protection impulse to conserve resources by reducing self-
regulation efforts (Muraven, Shmueli, & Burkley, 2006). Simi-
larly, people who frequently regulate their emotions during inter-
actions with some people (i.e., customers) will be able to conserve
resources if they feel able to reduce self-regulation with other
people (i.e., coworkers, supervisors). Situational factors such as
social expectations or consequences may motivate them to con-

tinue to self-regulate (Muraven & Slessareva, 2007), at a cost to
themselves.

Specifically, when the work unit does not have a climate of
authenticity—if it does not value and encourage self-expression—
employees must stifle their impulse to conserve resources and
must continue to regulate their emotions around coworkers, or else
experience additional resource losses due to the social conse-
quences of violating unit norms. In these units, the depletion from
surface acting around patients may be exacerbated by the contin-
ued effort of monitoring and self-regulating among coworkers
(Baumeister et al., 1998). In contrast, within units that have a
climate of authenticity, employees feel safe being authentic—
perhaps expressing previously suppressed frustration or sadness
about work events around coworkers. In other words, they can take
a break from effortfully monitoring and regulating their self-
presentation (Vohs, Baumeister, & Ciarocco, 2005). Although
regulating emotional expressions in one’s job can be draining,
taking a break from self-regulatory activities can improve subse-
quent performance (Trougakos, Beal, Green, & Weiss, 2008).
Similarly, a climate of authenticity provides an opportunity to take
a self-regulatory break and replenish resources lost (Muraven &
Baumeister, 2000; Muraven et al., 2006). Given this reasoning and
evidence that such recovery opportunities reduce self-regulatory
depletion, climate of authenticity in a work unit is expected to
replenish resources from surface acting during patient interactions,
thus reducing burnout from such self-regulation while having little
benefit to those who infrequently surface act with patients.

Moreover, if climate of authenticity works by providing self-
regulatory resource recovery, this effect would be specific to the
relationship of surface acting and burnout, and it would not be
expected to buffer the strain from primary resource losses of
patient-instigated mistreatment. In contrast, if climate of authen-
ticity functions as unit-level organizational display rules, simply
communicating the need to regulate emotions, or as social sharing
and support from others, it would moderate the relationship of
emotional demands (i.e., mistreatment by patients) on both surface
acting and burnout, as found previously (Diefendorff et al., 2011;
Goldberg & Grandey, 2007; McCance, Nye, Wang, Jones, & Chiu,
in press; Le Blanc, et al., 2007). Since we expect that climate of
authenticity works as a self-regulatory break, we predict only that:

Hypothesis 3. Unit-level climate of authenticity moderates
the relationship between surface acting and job burnout; the pos-
itive relationship is strengthened when climate of authenticity is
lower, and is weakened when climate of authenticity is higher.

Method

Participants and Procedure

All health care providers with patient contact at a large metro-
politan hospital in Australia were invited to participate in the study
as part of a wider organizational development project. Out of
approximately 812 patient-contact employees, 492 returned com-
pleted surveys (overall response rate of 60.6%). Given our interest
in unit-level contexts, we limited our analyses to respondents who:
1) spent at least 50% of their time working within a primary work
unit, and 2) worked in units from which we received at least two
survey responses. This reduced our total sample to 359. This final
sample was 86.9% female, with a mean age of 37.17 years (stan-

4 GRANDEY, FOO, GROTH, AND GOODWIN

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dard deviation [SD] � 10.80) and average job tenure of 7.04 years
(SD � 7.64). Out of the 359 participants, 55.3% were nurses,
30.6% were allied health professionals (e.g., speech therapists,
clinical psychologists, physiotherapists, occupational therapists),
and 14.2% were medical professionals (e.g., surgeons, physicians).
Respondents were not financially compensated for their participa-
tion, but did receive edible treats during recruitment. We distrib-
uted the survey in paper-and-pencil format during unit meetings
and also made it available online using password-protected access.
Completed paper-and-pencil surveys were returned to the re-
searchers in person or by using reply paid envelopes. Time was
allocated for staff to complete the surveys during work hours.

The hospital employs a cross-functional team-based structure in
which members provide holistic care to patients, working as teams
within clinical groups (i.e., emergency department, neurology,
orthopedics), professional groups (i.e., psychology, speech pathol-
ogy), or wards (i.e., geographical areas of patient care within the
hospital). Although some hospital employees were part of multiple
teams within the hospital, respondents in our survey were in-
structed to respond to the team-based questions considering only
their primary teams (i.e., the team a respondent spends the most
time with). There were 48 different teams represented by 359
participants and an average of 7.3 respondents per unit, ranging
from 2 to 28 respondents, who averaged 5.06 years (SD � 6.03)
with their team. The exact response rate per team was impossible
to determine because the hospital did not keep team membership
records and members could be on more than one team (though we
limited our sample to those who spent at least 50% of their time
with a primary team). The overall 61% individual response rate
and discussions with hospital unit leaders suggests our response
rate per teams was a representative sampling of team members. If
some units did have very low response rates, this would likely
create unstable or low agreement within the climate of authenticity
measure in those units; however, all but three of the units demon-
strated internal rwg values (an index that conveys mean interrater
agreement within the groups) that exceeded desirable levels (.70).
Overall, the sample was representative of the hospital’s care pro-
viders and work units.

Measures

Means, standard deviations, and correlations can be found in
Table 1. Responses were on a scale from (1) � never to (5) �
always unless stated otherwise.

Climate of authenticity. Climate of authenticity was as-
sessed with a seven-item measure developed for this study. We
modified Edmondson’s (1999) measure of psychological safety
climate to refer to the perceived acceptance in the unit for showing
felt emotions (see Appendix). Respondents were asked the extent
to which the items applied to their primary team, ranging from
(1) � doesn’t apply at all to (5) � applies entirely. Descriptive
statistics at the individual level are shown in Table 1. In the results
section below we provide evidence for aggregating these individ-
ual perceptions into a unit-level construct (Hofmann, 1997), as
well as convergent and discriminant validation evidence.

Mistreatment by patients. We modified the interpersonal
conflict at work scale (ICAWS; Spector & Jex, 1998). The mod-
ified four items specify mistreatment behaviors performed by the
public (i.e., patients and their families), and importantly we ask

about personal experiences as well as observed mistreatment to-
ward other team members (see Appendix). Experienced mistreat-
ment is a low base rate behavior; including observed mistreatment
reduces this statistical issue. This approach also captures mistreat-
ment in the broader employee-patient context; vicarious mistreat-
ment creates a sense of “moral outrage” that is similar to experi-
enced mistreatment (Skarlicki & Rupp, 2010), especially when
person mistreated is a friend or coworker (Spencer & Rupp, 2009).
Finally, including observed mistreatment allows us to meaning-
fully aggregate these items to represent unit-level mistreatment.
Though our main predictions about mistreatment by patients uti-
lize individual perceptions, we recognize that hospital work units
are likely to experience varying levels of mistreatment from pa-
tients (Le Blanc, et al., 2007), and these differences may contribute
to variations in burnout. A one-way analysis of variance
(ANOVA) supported that a significant amount of variation in
mistreatment perceptions was due to the unit [F(47, 308) � 2.85,
p � .01, ICC(1) � 0.30].2 We control for unit-level differences in
mistreatment by patients to isolate the effect of the individual’s
perceptions on burnout.

Surface acting. Emotion regulation was measured with the
most well-validated measure of surface acting (Brotheridge & Lee,
2002), with three items that ask about the frequency of regulating
emotional expressions (i.e., resist expressing, hide true feelings,
pretend to have emotions) when interacting with patients or their
families.

Emotional exhaustion. Emotional exhaustion is the primary
dimension of burnout, measured here with six items by Wharton
(1993). This scale directly assesses the focal construct of job-
related emotional exhaustion rather than other dimensions of burn-
out or other forms or sources of fatigue, and is often used in the
emotional labor literature (e.g., Chau, Dahling, Levy, & Diefen-
dorff, 2009; van Jaarsveld, Walker, & Skarlicki, 2010).

Control variables. We controlled for several variables in our
analyses. First, gender of respondents (1 � male, 2 � female) is
associated with reporting of burnout as well as surface acting
(Johnson & Spector, 2007). Second, tenure with the hospital (i.e.,
length in years) was included as a control because it has been
shown to be a predictor of burnout due to expended energy over
time (Zohar, 1997). Finally, we controlled for respondent occupa-
tional status, specifically whether the respondent was a nurse (1 �
nurse, 0 � other). Nurses spend more face-to-face time caring for
patients than the medical or allied health professionals, and also
tend to be viewed as lower in status due to gender, educational and
occupational differences (Devine, 1978; Fagin & Garelick, 2004;
Fox, 2000). Frequency of contact and status are related to patient-
instigated mistreatment, surface acting, and burnout (Diefendorff
& Greguras, 2009; Grandey et al., 2007), and thus we control for
occupational status to reduce the likelihood that our variables are
spuriously associated.

Results

Since climate of authenticity is a new construct using a modified
scale, we conducted tests for discriminant validity evidence as well

2 Since patient-instigated mistreatment was an additive construct (Chan,
1998), we did not compute the interrater agreement, rwg(j).

5CLIMATE OF AUTHENTICITY AND EMOTIONAL LABOR

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as evidence for aggregation to the group level. We then turn to the
analytic approach and results of the hypothesis testing.

Climate of Authenticity: Psychometric and
Discriminant Validity Evidence

As a preliminary step, we wanted to ensure that individual
perceptions of climate of authenticity were not redundant with
team social support perceptions. A separate sample of hospital
workers who did not meet our main study criteria (N � 211)
received the climate of authenticity items (alpha � .78) and three
team support items (alpha � .81; based on Marks, Mathieu, &
Zaccaro, 2001). Confirmatory factor analyses supported that a
two-factor model was a better fit than a one-factor model
[��2(1) � 133.80, p � .01]. This initial evidence supports the
internal consistency of the climate of authenticity items and that
perceptions of climate of authenticity were discriminant from team
support.

Next, with our main team-based sample we needed to provide
both validity and aggregation evidence. First, we needed to show
that our individual-level self-reported measures were distinct from
each other, and particularly that climate of authenticity perceptions
were unique from burnout, mistreatment by patients, and surface
acting with patients. To do this we conducted a series of confir-
matory factor analyses. First, we compared the fit of our hypoth-
esized four-factor model to one with a single factor (i.e., common
method factor). The overall fit statistics for our four-factor model
indicate a good fit to the data: �2 (164, N � 345) � 327.43, p �
.01; comparative fit index (CFI) � .95; incremental fit index
(IFI) � .95; Tucker-Lewis index (TLI) � .93; root mean square
error of approximation (RMSEA) � .05. The model fit was sig-
nificantly better than that for a one-factor or common method
model [� �2(6) � 1575.50, p � .01], thus climate of authenticity
was discriminant from the other individual perceptions of the work
situation.

We also compared a two-factor model to a one-factor model for
every pair of factors in the measurement model, as suggested by
Bagozzi, Yi, and Phillips (1991). For each combination of mea-
sures, the two factor model had a significantly better fit than the
one-factor model. Finally, we calculated the average variance
extracted for each pair of constructs, which exceeded the square of
the correlation between the two constructs in each case, demon-
strating further evidence of discriminant validity of our measures
(Fornell & Larcker, 1981). These steps confirm that the items

representing individual perceptions of climate of authenticity are
best modeled as a unidimensional structure and are distinct from
the other three self-reported measures in our model. This finding is
also consistent with prior evidence (e.g., Diefendorff & Gregarus,
2007; Tschan et al., 2005); employees differentiate between emo-
tional expressions shown to patients (i.e., surface acting items) and
to coworkers (i.e., climate of authenticity items).

Next, we needed to justify aggregating climate of authenticity
to create a unit-level construct. Doing so requires assessing
both agreement within groups and variability between groups
(Hofmann, 1997). We computed the intraclass correlation co-
efficient, referred to as ICC(1), using one-way random ANOVA
to identify between-groups variability (Bliese, 2002; Shrout &
Fleiss, 1979). Additionally, we computed the rwg(j) as an index
that conveys mean interrater agreement within the groups
(James, 1982). The one-way ANOVA indicated significant
between-groups variance in climate of authenticity [F(48, 310)
� 3.38, p � .01, ICC(1) � 0.34]. The average rwg(j) for climate
of authenticity was .87, which exceeded the minimum level of
average within-group agreement of 0.70 (James, 1982); more-
over, all but three units were above the .70 level, further
justifying our aggregation efforts. Together, these statistics
show acceptable levels of within-group agreement and
between-groups variability in climate of authenticity, and we
can examine this construct at the unit level.

To provide evidence of discriminant validity for the aggregated
construct, we looked at the unit-level relationships of climate of
authenticity and patient mistreatment. If climate of authenticity is
simply a function of unit-level variations in the stress of the work
environment (e.g., the frequency of negative emotions), rather than
unit-level expressive norms, these variables would be positively
correlated. We found evidence for discriminant validity, with
climate of authenticity unrelated to unit-level mistreatment by
patients (r � –.06, p � .10); thus, regardless of frequent negative
interactions with patients and their families, some groups have a
climate of authenticity and others do not.

In short, the evidence supports that responses to the climate of
authenticity items were unidimensional, internally consistent, and
discriminant from perceptions of team support, patient mistreat-
ment, surface acting, and burnout, and were likely to be shared by
unit members and be different across units. Thus we proceeded
with hypothesis testing.

Table 1
Means, Standard Deviations, and Individual-Level Correlations and Reliability Estimates

Variable M SD 1 2 3 4 5 6 7

1. Gendera 1.87 0.34 —
2. Organizational tenure 7.00 7.62 0.14�� —
3. Occupational statusb 0.55 0.50 0.30�� –0.03 —
4. Mistreatment by patients 1.85 0.83 0.12� –0.10 0.35�� 0.90
5. Surface acting with patients 3.29 0.77 0.06 –0.03 0.10 0.17�� 0.68
6. Emotional exhaustion 2.74 0.75 0.12 –0.10 0.14�� 0.31�� 0.17�� 0.88
7. Climate of authenticity 3.72 0.42 0.03 0.04 –0.07 –0.09 –0.11� –0.36�� 0.85

Note. N � 359. Cronbach’s alphas are in italics on the diagonal.
a 1 � male; 2 � female. b 1 � nurse; 0 � other.
� p � .05. �� p � .01.

6 GRANDEY, FOO, GROTH, AND GOODWIN

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Hypothesis Testing: Analytic Approaches and Main
Results

Since we have cross-level predictions and our respondents may
have nonindependent responses due to working in units with
similar physical resources, types of patient care, and coworkers,
we use multilevel analyses in SAS 9.2. This approach permits
assessment of variance at the group and individual level, and
cross-level relationships, without having to aggregate individual
responses to the unit level or disaggregate unit-level constructs to
the individual level (Bryk & Raudenbush, 1987; Hofmann, 1997).

Mistreatment by patients predicting surface acting. Hy-
pothesis 1 predicts that individual-level frequency of mistreatment
by patients and their families is positively related to surface acting
(e.g., hiding or faking emotions) when interacting with those
persons. We tested this prediction at the individual-level, while
also controlling for individual level characteristics and unit-level
variations in mistreatment by patients. As shown in Table 2,
individual perceptions of mistreatment by patients were signifi-
cantly and positively associated to the use of surface acting when
interacting with patients (�40 � 0.17, p � 0.01, lower CL � 0.05,
upper CL � 0.28; Model 1). Thus Hypothesis 1 is supported.
Moreover, unit-level climate of authenticity was unrelated to
individual-level surface acting with patients (�01 � �0.03, p �
.05, lower CL � �0.24, upper CL � 0.18), supporting that group
norms for expressing emotions with coworkers does not influence
the frequency of emotion regulation performed with patients.

Surface acting as partial mediator of mistreatment on burn-
out. We proposed that mistreatment by patients and their fam-
ilies results in primary resource losses, and that surface acting
when interacting with patients creates secondary resource losses

with unique effects that partially explain the burnout from mis-
treatment. We used the conservative four-stage mediation test
(Baron & Kenny, 1986; Kenny, Kashy, & Bolger, 1998), and the
results of the multilevel regression analysis are shown in Table 2.
First, we find that individual perceptions of mistreatment by pa-
tients were significantly and positively associated with emotional
exhaustion (�40 � 0.23, p � 0.01, lower CL � 0.13, upper CL �
0.34; Model 2). Second, mistreatment by patients was associated
with the potential mediator, surface acting, as demonstrated in the
test for Hypothesis 1. For the final steps, both the predictor (i.e.,
mistreatment by patients) and mediator (i.e., surface acting) were
included in the prediction of exhaustion. Surface acting was found
to be positively and significantly associated with emotional ex-
haustion beyond mistreatment (�50 � 0.13, p � .01, lower CL �
0.03, upper CL � 0.23; Model 3), and the effect of mistreatment
by patients on exhaustion was reduced slightly (�50 � 0.21, p �
.01, lower CL � 0.10, upper CL � 0.32; see Model 3), suggesting
support for our prediction of partial mediation (Kenny et al., 1998).
A Sobel test further suggested that mistreatment by patients had an
indirect effect on exhaustion (z � 1.91, p � .05) due to surface
acting (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002).
Overall, both mistreatment by patients and surface acting with
patients have unique effects on burnout, and we find some support
for indirect effects as proposed in Hypothesis 2.

Interaction of surface acting and climate of authenticity on
burnout. Hypothesis 3 proposed that a unit’s climate of authen-
ticity buffers individual employees’ resource depletion from sur-
face acting. First, we assessed the predicted cross-level moderating
effect, to see if the slope of the Level-1 relationship between
surface acting and exhaustion varies based on Level-2 climate of

Table 2
Results From Multilevel Analysis Predicting Surface Acting and Employee Burnout

Level and variable

Surface acting Emotional Exhaustion

Model 1 Model 2 Model 3 Model 4

Effects
Lower

CL

Upper

CL Effects
Lower

CL
Upper
CL Effects
Lower
CL
Upper
CL Effects
Lower
CL
Upper
CL

Level 1: Employee
Intercept 2.93�� 2.34 3.52 2.34�� 1.78 2.90 1.96�� 1.34 2.59 0.98 �1.55 3.50
Gendera 0.07 �0.17 0.32 �0.10 �0.33 0.13 �0.11 �0.34 0.12 �0.06 �0.29 0.16
Organizational tenure 0.00 �0.01 0.01 �0.01 �0.02 0.00 �0.01 �0.02 0.00 �0.01 �0.02 0.00
Occupational statusb 0.04 �0.16 0.23 0.06 �0.13 0.25 0.05 �0.14 0.24 0.03 �0.14 0.21
Mistreatment by patients 0.17�� 0.05 0.28 0.23�� 0.13 0.34 0.21�� 0.10 0.32 0.21�� 0.10 0.31
Surface acting with patients 0.13�� 0.03 0.23 0.90� 0.15 1.65

Level 2: Work unit
Mistreatment by patients �0.05 �0.29 0.19 0.10 �0.13 0.33 0.10 �0.12 0.33 0.08 �0.13 0.29
Climate of authenticity (CA) 0.26 �0.41 0.93

Cross-level
Surface acting � CA �0.21� �0.41 �0.01
SD of Intercept 0.29 0.27 0.31 1.25
SD of Residuals 0.56 0.48 0.48 0.46
�2 Residual Log Likelihood 818.8 770.4 767.8 751.4
� �2 Residual Log Likelihood 48.4 2.6 16.4
n (Level 1) 359 359 359 359
n (Level 2) 48 48 48 48

Note. Lower CL � Lower confidence interval; Upper CL � Upper confidence interval.
a 1 � male; 2 � female. b 1 � nurse; 0 � other.
� p � .05. �� p � .01.

7CLIMATE OF AUTHENTICITY AND EMOTIONAL LABOR

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authenticity. As shown in Table 2 (Model 4), beyond the control
variables and main effects, the interaction term of Level-2 climate
of authenticity and Level-1 surface acting had a significant effect
on emotional exhaustion (�51 � �0.21, p � .05, lower CL �
�0.41, upper CL � �0.01). To facilitate interpretation of the
interaction, we plotted the simple slopes at one standard deviation
above and below the mean of unit-level climate of authenticity (see
Figure 2). For units with low climate of authenticity, the simple
slope for the relationship between surface acting and emotional
exhaustion was significantly positive (b � 0.94, standard error
[SE] � 0.35, � 0.97, t � 2.69, p � .01); for employees working
in units with high climate of authenticity, the relationship between
surface acting and emotional exhaustion did not differ significantly
from zero (b � 1.14, SE � 0.44, � 1.18, t � 2.61, p � .05). This
supports that a low climate of authenticity exacerbates the resource
depletion from self-regulating with patients, but high climate of
authenticity replenishes the self, buffering against depletion. Fur-
thermore, climate of authenticity had little benefit for employees
who infrequently surface acted (see Figure 2), supporting that this
climate specifically provides an opportunity for self-regulatory
recovery, as predicted. Overall, these results support Hypothesis 3.

Additional Analyses

Our theoretical reasoning led us to predict that climate of
authenticity replenishes self-regulatory resources lost by surface
acting (Muraven & Baumeister, 2007). An alternative possibility is
that this climate buffers the primary resource losses from interper-
sonal stressors (i.e., patient-instigated mistreatment), perhaps by
providing social support (McCance, et al., in press). To test for this
alternative, we first tested the cross-level interaction of climate of
authenticity with patient mistreatment on surface acting, and found
it did not have a significant effect (�41 � �0.15, p � 0.10, lower
CL � �0.39, upper CL � 0.09). Second, we included the unpre-
dicted moderator term (i.e., Mistreatment � climate of authentic-
ity) in our equation for burnout to rule out unintended effects
(Muller, Judd, & Yzerbyt, 2005). The unpredicted interaction term
did not have a significant effect (�41 � �0.10, p � 0.10, lower

CL � �0.32, upper CL � 0.12) while the expected interaction
effect with surface acting was still present, although slightly less
robust (�51 � �0.18, p � 0.10, lower CL � �0.39, upper CL �
0.03). Thus, the direct effect of the predictor (i.e., mistreatment) on
the mediator (i.e., surface acting), and its indirect effect through
the mediator on burnout, does not depend on climate of authen-
ticity.3 Overall, climate of authenticity works specifically as a
self-regulatory recovery opportunity rather than a social support
climate.

Discussion

Verbal mistreatment by the public (i.e., patients and their fam-
ilies), and the suppression or modification of emotional expres-
sions when interacting with the public (i.e., surface acting), are two
frequently studied socioemotional demands placed on health care
providers (i.e., Bakker et al., 2000; Lewis, 2005). They are nev-
ertheless seldom jointly examined as predictors of job burnout,
despite earlier arguments for their linkage (Grandey, 2000; Zapf et
al., 2001). We developed and empirically tested a model based on
the ideas of the conservation of resources model (Hobfoll, 2002;
Hobfoll & Freedy, 1993), which conceptualizes patient-instigated
mistreatment as a primary source of resource loss, and surface
acting when interacting with patients as an ineffective coping
response that results in secondary resource losses and thus is
proposed to further explain the phenomenon of job burnout among
health care providers.

Most of the attention that has been given to possible buffers of
such resource losses has been on individual-level factors (Heuven
et al., 2006; Johnson & Spector, 2007), but recent authors have
called for more attention to the broader work context as a buffer of
strain (Bacharach & Bamberger, 2007; Johns, 2006). Consistent
with the COR and self-regulatory resource depletion models
(Baumeister et al., 1998; Muraven et al., 2006), we propose that
working in a context that encourages a break from self-regulation
among coworkers—a “climate of authenticity”—buffers the neg-
ative impacts of self-regulation during interactions with patients.
In doing so, we move the focus from individual-level buffers of
emotional labor to the broader, unit-level social context.

Our study makes several important contributions to the occupa-
tional health literature. First, COR theory was successfully applied
as a theoretical lens to understand how mistreatment by patients
and surface acting work together to cause burnout as primary and
secondary resource losses, respectively. For patient care providers,
frequency of mistreatment by the public (i.e., patients and their
families) seems to result in resource losses, since it is positively
related to a sense of emotional exhaustion. Moreover, the more
frequent the mistreatment from the public, the more likely the care
providers engage in surface acting—suppressing and faking their

3 As an additional test of indirect effects, we ran a bootstrapping analysis
to generate 1,000 estimates of the coefficients and product of coefficients,
and using these generated coefficients, we obtained the 95% bias-corrected
confidence intervals of these coefficients at 1 standard deviation (SD)
above and below the mean for climate of authenticity (Edwards & Lambert,
2007; Stine, 1989). Based on these confidence intervals, which included 0
[�1 SD 95% CI (0.01, 0.08),
1 SD 95% CI (�0.02, 0.02), 95% CI of the
difference (0, 0.08)], climate for authenticity did not moderate the indirect
effect of patient-instigated mistreatment on burnout, consistent with the
regression analysis.

Figure 2. Graph of the individual-level relationship of surface acting and
emotional exhaustion moderated by unit-level climate of authenticity.

8 GRANDEY, FOO, GROTH, AND GOODWIN

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emotional expressions—when caring for those persons (Grandey,
2000; Gross, 1999). Although perhaps effective in the short term,
self-regulating emotional expressions by surface acting results in
depletion and exhaustion beyond the effects of the interpersonal
stressor itself (Richards & Gross, 1999; Vohs et al., 1999). This
evidence is consistent with prior workplace research; in call center
simulations, simulated mistreatment by customers resulted in an-
ger and effortful self-regulation (Rupp & Spencer, 2006), and in
diary studies of service workers, workplace anger events elicited
more emotion regulation (Diefendorff et al., 2008; Grandey, Tam,
& Brauburger, 2002). Unique to our study, we show that this
emotional modification helps to explain who experiences burnout,
beyond mistreatment, consistent with the idea of secondary re-
source losses. Thus, employees who react to mistreatment by
patients by suppressing their emotional responses may do their
health a disservice in the long run.

Second, we extended the ideas of COR to identify an element of the
social context that is likely to moderate the secondary resource losses
attributable to surface acting. Much attention has been given to the
idea of self-regulation working like a muscle (Baumeister et al., 2007)
such that regulation of impulses such as emotional expression results
in depletion and fatigue. Thus, factors that provide a respite from
self-regulation are thought to reduce depletion (Muraven & Baumeis-
ter, 2000). Though many have suggested that health care providers
turn to their coworkers to vent their emotions “backstage” (Hoch-
schild, 1983; Lewis, 2005), we proposed that work units vary in the
extent to which they provide such a break from self-regulation with-
out social consequences.

Specifically, we proposed the existence of a climate of authentic-
ity—the perceived acceptance and safety for expressing felt emotions
with coworkers—that varies by work unit. This construct was mod-
eled on the psychological safety climate construct (Edmondson,
1999), as a shared perception that the group encourages interpersonal
risks without social consequences, but is distinguished from this
earlier construct by our focus on expressive behavior. We argue that
this construct is also unique from perceptions of social support, and
we find that hospital workers differentiate their perceptions of a
climate of authenticity with their unit of coworkers from their per-
ceptions of team support with the same coworkers, supporting the
unique nature of this type of team perception. Moreover, climate of
authenticity was differentiated from organizationally mandated dis-
play rules focused on interactions with the public. In support of this
we found that work units with emotionally demanding patients were
no more or less likely to have a climate of authenticity among
coworkers; some units choose to respond to such conditions by being
more accepting of venting to coworkers and other units respond by
avoiding such emotional expression. Finally, we found that climate of
authenticity was a unidimensional construct that is shared by unit
members and differentiates units from each other.

Most important, we found that this unit-level climate buffered
against the resource depletion of surface acting when interacting with
patients. Prior work has shown that a service climate (i.e., manage-
ment practices that support health, or reward service) moderates the
strain of interpersonal behaviors with patients (Drach-Zahavy, 2008,
2010). To the authors’ knowledge, this is the first study to investi-
gate—and find—unit-level emotion norms as a moderator of the
well-established relationship between surface acting and burnout. Our
results show that a climate of authenticity buffers the strain of surface
acting, and not the strain from mistreatment, which is consistent with

the self-regulation and resource depletion models. Specifically, cli-
mate of authenticity promotes a break from self-regulation (Muraven
et al., 2006), thus it replenishes the resources depleted by self-
regulation (i.e., surface acting) while having little benefit for those not
self-regulating. The fact that climate of authenticity does not moderate
the relationship of mistreatment by patients on surface acting or
burnout supports that it is unique from display rules and social support
(e.g., venting, advice), which have shown such buffering effects
(Diefendorff et al., 2011; McCance, et al., in press). In other words,
mistreatment from patients and their families is associated with burn-
out regardless of the climate of authenticity among coworkers; but if
employees are engaging in surface acting with their patients, the
climate of authenticity is helpful in reducing their strain.

Limitations and Future Directions

Several limitations of this study need to be addressed. Our
variables of interest are measured by self-perceptions consistent
with our theoretical model (i.e., COR; perceived threats, exhaus-
tion); however, our approach increases the likelihood of common
method variance as an explanation for the identified relationships.
We have addressed this limitation in several ways (Podsakoff,
MacKenzie, Lee, & Podsakoff, 2003). First, we assured respon-
dents of confidentiality and had them return their responses di-
rectly to the researchers to reduce social desirability response
biases. Second, we controlled for individual- and unit-level factors
that might spuriously increase relationships among our variables,
and conducted confirmatory factor analyses to provide evidence
against the argument that the construct associations exist merely
due to response biases. Third, while common method variance
may increase the direct individual-level associations (i.e., Hypoth-
eses 1 and 2), it is less likely to explain the cross-level moderated
relationship (i.e., Hypotheses 3).

We cannot rule out the possibility that the variables have a
reversed or reciprocal causal pattern; however, the directionality of
our proposed model and results are informed by established theory
(i.e., COR, ego depletion, emotion regulation). Moreover, recent
longitudinal data have supported this causal flow such that surface
acting predicts subsequent burnout and not the reverse (Hülsheger,
Langa, & Maier, 2010) and lab studies manipulating emotion
regulation have shown causal effects on non-self-reported, physi-
ological indicators of fatigue (Hopp, Rohrmann, Zapf, & Hodapp,
2010). Thus, while reciprocal effects are possible, our proposed
model is consistent with current theories and evidence. A next step
is to replicate our proposed model with longitudinal and within-
person data. For example, a within-person investigation assessing
the emotional demands by time of day would advance our theo-
retical ideas: emotional demands (i.e., mistreatment and surface
acting) should be greater during visiting and waking hours, and
episodic depletion from such shifts is likely to depend on whether
one has both the opportunity to interact with one’s coworkers as
well as a climate that permits recovery of one’s self-regulatory
resources.

Our investigation was restricted to health care professionals at a
large hospital. This may be considered a strength in that this truly
involves managing strong emotions; many prior studies of emo-
tional labor and mistreatment have been conducted in less emo-
tionally demanding service contexts, such as simulated call centers
(Rupp & Spencer, 2006). Our study also benefits from a broader

9CLIMATE OF AUTHENTICITY AND EMOTIONAL LABOR

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sampling than many other related studies of health care providers,
which have focused on certain occupations such as oncology units
or pediatric nurses (Le Blanc, et al., 2007; Lewis, 2005); thus, we
were able to assess unit-level differences in unique ways. How-
ever, because hospitals are distinct contexts in terms of the emo-
tional demands they place on their employees, we must be cautious
in generalizing the results of this study to other service contexts
(e.g., food services). Future research is needed to compare primary
and secondary resource depletion effects and the impact of climate
of authenticity in different team-based service organizations.

Our concept of climate of authenticity is grounded in theory
pertaining to workplace display rules (Diefendorff & Greguras,
2009), psychological safety in teams (Edmondson, 1999), and
social support (Hobfoll, 2002); however, further research is needed
to assess whether climate of authenticity is empirically distinct
from these related concepts and to test the unique contribution
beyond these other concepts. Though some overlap of climate of
authenticity with display rules, psychological safety, and support-
ive climate is likely, the increasing evidence on focal (rather than
molar) climates suggests there is value in the more specific climate
of authenticity for understanding employee health and perfor-
mance. In fact, organizations vary in their level of acceptance of
authentic emotions (Fineman, 2006; Martin et al., 1998), thus,
future research might extend this study by examining unit-level
climate of authenticity within organizational-level variations in
such climates (Zohar & Luria, 2005).

Finally, our model, like most models, is underspecified in that
we do not exhaust all possible predictors of surface acting, job
burnout, or climate of authenticity. Our goal was to provide an
initial test of the relative effects of mistreatment and surface acting
on burnout, and future research should continue to build on these
findings by including additional stressors such as shift work, work
overload and interpersonal conflict between supervisors and co-
workers (Grandey et al., 2007; Lee et al., 2010) to test the robust-
ness of these results. Another possibility is to include emotion
regulation strategies where medical staff may work to modify their
internal thoughts or feelings, known as deep acting, as well as
surface acting (see Bono & Vey, 2005). Expanding the criteria
domain, we would expect that by reducing burnout from surface
acting, climate of authenticity would also improve task perfor-
mance (Baumeister et al., 2007) and reduce absences (Grandey et
al., 2004). One concern is that being free to express negative
emotions among coworkers could exacerbate negative feelings and
result in “breaking character” with patients (Grandey, 2003); how-
ever, our results found no relationship between climate of authen-
ticity and surface acting with patients suggesting differentiation in
expression by target (see also Diefendorff & Greguras, 2009).

Finally, research is needed on the antecedents of this climate of
authenticity. As a bottom-up factor, similarity among members is
likely to increase a sense of safety and self-disclosure with others
(Edmondson, 2002; Phillips, Rothbard, & Dumas, 2009). Thus,
gender, racial and cultural diversity is likely to play a role in the
climate of authenticity, especially given different norms about
emotional displays and regulation (Matsumoto, Yoo, & Fontaine,
2008). As a top-down factor, the behavior of unit leaders and
high-status members is likely to contribute to norms concerning
expression of emotions (Pescosolido, 2002; Wilk & Moynihan,
2005).

Practical Implications

The present research yields some important implications for
managers. First, the results clearly show the cost to employee
health when employees serve persons who verbally abuse them
and, moreover, when they must maintain professional composure
in response to such treatment (Hochschild, 1983; Zapf et al.,
2001). In our sample, we find units reporting no mistreatment
(M � 1.00) were in education (i.e., Professional & Educational
Development, School Therapy, Community Child Health), units
with rare but occasional mistreatment (M � 2.00) were dealing
with challenging illnesses (e.g., Endocrinology, Allergy, Infec-
tious Diseases, Intensive Care Unit), while the units with more
frequent mistreatment from patients and their families deal with
uncontrollable and unpredictable issues (e.g., Outpatient Services,
Child Protection Services, Adolescent Surgical Ward, Inpatient
Mental Health). Identifying such conditions and the practices (i.e.,
long waits, too much paperwork, rude employees) that predict
mistreatment is a first step for decreasing work stress.

However, given the emotional challenge of the hospital setting,
mistreatment by patients and surface acting cannot be completely
eliminated and thus identifying how to reduce such resource losses
is important. In addition to identifying mistreatment-prone units,
another important step is to identify a threshold level of mistreat-
ment from patients or their families (i.e., zero-tolerance vs. three
strikes, specified intensity level) to plan for appropriate interven-
tions (Trougakos et al., 2008). For example, an employee could
say that they are at that critical threshold and thus obtain a break
or switch patient-interactions for other tasks with another em-
ployee. Work breaks where one can interact authentically with
coworkers “backstage,” (Lewis, 1995) or socially withdraw
(Repetti, 1989) should reduce depletion and could be structured
around knowing when the surface acting with patients is likely to
be highest. Our findings suggest that employees need education
and training in effective ways to respond to mistreatment. Em-
ployees who were frequently suppressing and faking their emo-
tions when interacting with customers were more likely to feel
burned out and depleted, even in “caring work” (Brotheridge &
Grandey, 2002); in contrast, the use of deep acting strategies such
as reappraisal were less likely to have such effects (see Bono &
Vey, 2005 for a review). Developing employee efficacy for how to
manage emotions, and when (i.e., with patients vs. with cowork-
ers) is a critical life skill as well as work skill.

Unit-level climate has been shown to be an important determi-
nant of burnout in caring work (Bacharach & Bamberger, 2007; Le
Blanc, et al., 2007), and we identify the climate of authenticity as
a unit-level variable serving as a buffer against the emotional
depletion that results from surface acting. Future research that
identifies antecedents to climate of authenticity will be important
for workplace decisions that affect climate of authenticity. For
example, team composition (e.g., characteristics like gender, team
tenure, skill diversity, cultural background, etc.) may influence
climate of authenticity by influencing the sense of similarity with
members and thus perceived safety to express oneself. Top-down,
unit supervisors can influence emotional norms among coworkers,
and could encourage authentic expressions rather than maintaining
a “positive attitude” (Fineman, 2006; Wilk & Moynihan, 2006).
However, institutionalized sharing (e.g., in meetings) where peo-
ple are encouraged by management to share negative emotions

10 GRANDEY, FOO, GROTH, AND GOODWIN

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(McCance, et al., in press) may not have recovery effects, since
they could simply produce new forms of emotion regulation. A
“bottom-up” climate of authenticity that emerges from peers may
be more effective. Overall, given that employee burnout is linked
to absences, turnover, and performance decrements (e.g., Halbes-
leben & Bowler, 2007; Wright & Cropanzano, 1998), helping
employees feel “free to be you and me” in a work group can be a
critical step in improving employee and organizational well-being.

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(Appendix follows)

13CLIMATE OF AUTHENTICITY AND EMOTIONAL LABOR

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Appendix

Mistreatment by Patients and Their Families
(Modified From Spector & Jex, 1998)

1. How often did patients or their families argue with you or
your team?

2. How often did patients or their families yell at you or your
team?

3. How often did patients or their families speak rudely toward
you or your team?

4. How often did patients or their families swear at or insult you
or your team?

Team Climate of Authenticity (Modified From
Edmondson, 1999)

1. If you show anxiety or distress with this team, it is held
against you (R).

2. Members of this team are able to discuss how they feel about
problems and issues.

3. People in this team reject others for showing irritation or
frustration in the team (R).

4. It is safe to show how you really feel with this team.
5. It is uncomfortable for team members to show sadness or

disappointment with each other (R).
6. No one on this team would deliberately act in a way that

disrespects another member’s feelings.
7. Working with members of this team, expressions of feelings

are respected.

Received February 4, 2011
Revision received July 12, 2011

Accepted July 13, 2011 �

14 GRANDEY, FOO, GROTH, AND GOODWIN

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Interprofessional collaboration: three
best practice models of
interprofessional education
Diane R. Bridges, MSN, RN, CCM1*, Richard A. Davidson,
MD, MPH2, Peggy Soule Odegard, PharmD, BCPS, CDE,
FASCP3, Ian V. Maki, MPH3 and John Tomkowiak, MD, MOL4

1Department of Interprofessional Healthcare Studies,

Rosalind Franklin University of Medicine and

Science, North Chicago, IL, USA; 2Office of Interprofessional Education, University of Florida,
Gainesville, FL, USA; 3Office of the Dean-Regional Affairs, UW School of Medicine, Seattle, WA, USA;
4Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA

Interprofessional education is a collaborative approach to develop healthcare students as future

interprofessional team members and a recommendation suggested by the Institute of Medicine. Complex

medical issues can be best addressed by interprofessional teams. Training future healthcare providers to work

in such teams will help facilitate this model resulting in improved healthcare outcomes for patients. In

this paper, three universities, the Rosalind Franklin University of Medicine and Science, the University of

Florida and the University of Washington describe their training curricula models of collaborative and

interprofessional education.

The models represent a didactic program, a community-based experience and an interprofessional-simulation

experience. The didactic program emphasizes interprofessional team building skills, knowledge of professions,

patient centered care, service learning, the impact of culture on healthcare delivery and an interprofessional

clinical component. The community-based experience demonstrates how interprofessional collaborations

provide service to patients and how the environment and availability of resources impact one’s health status.

The interprofessional-simulation experience describes clinical team skills training in both formative and

summative simulations used to develop skills in communication and leadership.

One common theme leading to a successful experience among these three interprofessional models included

helping students to understand their own professional identity while gaining an understanding of other

professional’s roles on the health care team. Commitment from departments and colleges, diverse calendar

agreements, curricular mapping, mentor and faculty training, a sense of community, adequate physical space,

technology, and community relationships were all identified as critical resources for a successful program.

Summary recommendations for best practices included the need for administrative support, interprofessional

programmatic infrastructure, committed faculty, and the recognition of student participation as key

components to success for anyone developing an IPE centered program.

Keywords: interprofessional; healthcare teams; collaboration; interprofessional education; interprofessional curricula models

Received: 25 January 2011; Revised: 25 March 2011; Accepted: 3 March 2011; Published: 8 April 201

1

T
oday’s patients have complex health needs and

typically require more than one discipline to

address issues regarding their health status (1).

In 2001 a recommendation by the Institute of Medicine

Committee on Quality of Health Care in America

suggested that healthcare professionals working in

interprofessional teams can best communicate and ad-

dress these complex and challenging needs (1, 2). This

interprofessional approach may allow sharing of exper-

tise and perspectives to form a common goal of restoring

or maintaining an individual’s health and improving

outcomes while combining resources (1, 3).

Interprofessional education (IPE) is an approach to

develop healthcare students for future interprofessional

teams. Students trained using an IPE approach are more

likely to become collaborative interprofessional team

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�TREND ARTICLE

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any medium, provided the original work is properly cited.

1

Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035

members who show respect and positive attitudes towards

each other and work towards improving patient outcomes

(3�5).

What is interprofessional collaboration and
practice?
According to the Canadian Interprofessional Health

Collaborative, interprofessional collaboration is a ‘part-

nership between a team of health providers and a client in

a participatory collaborative and coordinated approach

to shared decision making around health and social

issues’ (6). Interprofessional collaborative practice has

been defined as a process which includes communication

and decision-making, enabling a synergistic influence of

grouped knowledge and skills (7). Elements of collabora-

tive practice include responsibility, accountability, coor-

dination, communication, cooperation, assertiveness,

autonomy, and mutual trust and respect (7). It is this

partnership that creates an interprofessional team de-

signed to work on common goals to improve patient

outcomes. Collaborative interactions exhibit a blending

of professional cultures and are achieved though sharing

skills and knowledge to improve the quality of patient

care (8, 9).

There are important characteristics that determine

team effectiveness, including members seeing their roles

as important to the team, open communication, the

existence of autonomy, and equality of resources (9). It is

important to note that poor interprofessional collabora-

tion can have a negative impact on the quality of patient

care (10). Thus skills in working as an interprofessional

team, gained through interprofessional education, are

important for high-quality care.

What is interprofessional education?
IPE has been defined as ‘members or students of two or

more professions associated with health or social care,

engaged in learning with, from and about each other’

(4, 11). IPE provides an ability to share skills and

knowledge between professions and allows for a better

understanding, shared values, and respect for the roles of

other healthcare professionals (5, 11, 12). Casto et al.

described the importance of developing early IPE

curricula and offering them before students begin to

practice in order to build a basic value of working within

interprofessional teams (13, 14). The desired end result is

to develop an interprofessional, team-based, collabora-

tive approach that improves patient outcomes and the

quality of care (5, 15).

In this paper we showcase three exemplary models of

collaborative and interprofessional educational experi-

ences so that other institutions may benefit from these

when creating interprofessional curricula.

Models of interprofessional collaborative
student experiences

Rosalind Franklin University of Medicine and

Science: HMTD 500 Interprofessional Healthcare

Teams course
Rosalind Franklin University of Medicine and

Science (RFUMS) has responded to the challenge of

interprofessional training by designing a one-credit-hour,

pass/fail course called HMTD 500: Interprofessional

Healthcare Teams (2, 16). The course is a required

experiential learning opportunity where students interact

in interprofessional healthcare teams. Students focus on

a collaborative approach to patient-centered care, with

emphasis on team interaction, communication, service

learning, evidence-based practice, and quality improve-

ment.

The course, which was instituted in 2004, spans the

months of August�March every year, and has evolved
into three separate components each with its own course

director: a required didactic component (Table 1), a

required service learning component, and a clinical

component with limited enrollment.

During the course, all first-year students (approxi-

mately 480) are grouped into 16-member interprofessional

teams. Each team has student representation from allo-

pathic and podiatric medicine, clinical laboratory, medical

radiation physic, nurse anesthetists, pathologists’ assis-

tants, psychology, and physician assistants. Each team has

a faculty or staff member, with a minimum of a master’s

degree, serving as a mentor. Mentors are trained prior to

each class, and the lunch hour of every class day is set

aside for mentors to review material and ask questions if

necessary.

Didactic component

During the didactic phase, students attend nine 90-

minute interprofessional small group sessions, currently

held every Wednesday afternoon. Five sessions are

Table 1. RFUMS HMTD 500 interprofessional healthcare

teams course objectives

1. Demonstrate collaborative interprofessional team character-

istics and behavior

2. Analyze a healthcare interaction for qualities of patient-

centered care
3. Reflect on service learning as a way to demonstrate social

responsibility

3. Identify other healthcare providers that may be of benefit to a
particular patient

4. Analyze a medical error situation to formulate a suggestion

for solving the problem

5. Identify situations in which individual, institution, or govern-
ment advocacy may be appropriate

6. Discuss current issues that impact all healthcare professions

Diane R. Bridges et al.

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Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035

devoted to the learning concepts of interprofessional

healthcare teams, collaborative patient-centered care

(functioning as a collaborative team), service learning

and county health assessment, healthcare professions (a

time to learn about their own health profession), and

error cases and advocacy.

The remaining sessions are set aside for discussion,

preparation, presentations, and celebrations of achieve-

ments. Student objectives, case studies, and role-play are

used to develop discussion. Two different students

volunteer each session to moderate the class to develop

their own leadership and communication skills. All

course materials are loaded into our information man-

agement learning system.

Service learning component

Students are tasked with working as an interprofessional

team to identify a community partner and engage in a

community service project. Each team is expected to

perform a service learning project. One of the original

five sessions is designed to allow students time together to

discuss ideas for their projects. Students assess local

community needs in their didactic phase and are given a

list of community projects performed in the past to help

them decide on a project and partner. Two additional

sessions allow them to plan their projects and subse-

quently design a poster which showcases their service

learning experience and reflection. The focus of student

projects is prevention education in the form of physical

fitness training, nutrition education, health screening, or

instruction in making healthy choices.

Service learning allots time for students to process what

they learned about their community: how their knowl-

edge was used to help meet the needs of the community

and how they better understand them as a result of this

activity (17). All HMTD 500 students complete a

reflection form.

The last session of the course culminates each year with

a group reflection and a celebration poster day where our

community partners are invited to visit the university to

review the work our students have accomplished. Com-

munity partners see posters created by each team and are

invited to join their student groups to reflect upon the

service learning project and share with the students how

the project impacted their organization.

The collaborative interprofessional prevention educa-

tion service learning projects have been very rewarding

and well accepted by our community partners and

students, as noted by student surveys and focus groups

and awards received from some community partners.

Student attitudes were positive regarding this aspect of

the course. Post-course survey indicated a majority of

respondents agreed or strongly agreed with statements

regarding collaboration, teamwork, social responsibility,

and diversity (18).

Clinical component

The third component is a clinical experience offered to

interested students. Three students from different profes-

sional programs such as physician assistant, physical

therapy, and podiatry form an interprofessional team and

attend four sessions at a clinical site. This helps put their

didactic knowledge into actual patient care practice.

Approximately four teams are created: as more clinical

sites agree to accept students, more groups will be formed

each year (Table 2).

Phase II � HMTD 501 Culture in Healthcare
RFUMS promotes teaching students the importance of

the impact of culture on healthcare and its delivery. A

second one-credit course entitled HMTD 501 Culture

in Healthcare was developed to accomplish this goal

(Table 3). Students remain in their same HMTD 500

interprofessional groups, and class sessions for this

course are interwoven with the HMTD 500 course dates.

There are two main projects in this course: the proposal

of an education tool and performing a patient interview.

To complete the education tool assignment students

work in interprofessional teams within each group to

present a proposal summary for a culturally appropriate

patient education tool. Students identify a specific health

Table 2. RFUMS clinical component sessions

Session 1 (two hours)
The assigned groups of students attend a two-hour session to

observe patients at the clinic, have an interprofessional

discussion after each, and choose one patient to follow
Session 2 (one hour)
Each group of students meets to discuss the patient history and

their responses to the five interprofessional questions dis-
cussed in the clinic

1. How will medicine, physical therapy, physician assistant

practice, and podiatric medicine contribute to the care of

this patient?
2. What would the treatment objectives be for that care?

3. How would your profession address these objectives?

What is the evidence to support the methods used to

address the issue?
4. Besides medicine, physical therapy, physician assistant

practice, and podiatric medicine, which other professions

would you collaborate with to assist this patient? What is
your rationale for these collaborations?

5. What other information will you need from the patient and

how will it guide the treatment?

Session 3 (30�60 minutes)
Each group of students returns to the clinic for a follow-up

appointment with the chosen patient

Session 4 (one hour)
All four groups of students meet over lunch with the three course

coordinators and present their patient and responses to the

interprofessional questions: due to available sites to perform

this clinical component, enrollment is currently limited, but we

are actively seeking additional clinical sites so we can
eventually offer this experience to all students

Models of interprofessional education

Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035 3
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conditions impacted by cultural beliefs and practices for a

selected target group. They are asked to recognize the role

that culture plays in health beliefs and practices and the

specific impact culture has on health outcomes. Students

propose patient educational materials for the prevalent

identified health conditions for the selected target group.

They then present their proposals to their peers.

To complete the patient interview, student groups

(including third-and fourth-year students who are in

their clinical years) work with facilitators for a class

session (trained interpreters and nurse anesthesia stu-

dents). The university community volunteers as patients.

The scenario of a patient with a ‘pre-diabetes’ condition

is used for the interview. Students are asked to discuss

laboratory findings, collect historical and lifestyle infor-

mation, and elicit a cultural history. Students then have a

post-interview reflection assessment with their mentors to

discuss their communication and cultural sensitivity skills

and to identify best approaches for culturally sensitive

and appropriate patient interactions.

At the end of each HMTD 500 and 501 course, focus

group meetings are held with mentors and another with

students to obtain feedback. Changes are made to the

curriculum for improvement based on this. Student focus

groups yielded positive comments that working in small

groups promotes teamwork and teaches them about the

communication process (18).

University of Florida
Interdisciplinary Family Health

The Interdisciplinary Family Health (IFH) course has

been providing interprofessional community-based learn-

ing experiences for over 10 years. Based in the Office of

Interprofessional Education within the Office of the

Senior Vice-President for Health Affairs, it is a required

course for all first-year students in the Colleges of

Medicine, Dentistry, and Pharmacy, the accelerated and

traditional nursing students in the College of Nursing,

the physical therapy and clinical and health psychology

students from the College of Public Health and Health

Professions, and the nutrition graduate students from the

Institute for Food and Agricultural Sciences. Students

from the College of Veterinary Medicine participate as

volunteers (19). A core faculty representing each of the

involved Health Science Center colleges helps set policy

for the course. Grading of the course is centralized, but

the grading status of the course is determined by each

college. In dentistry and pharmacy the course is part of a

larger first-year course in terms of credit. In the Colleges

of Medicine and Nursing it is a stand-alone course. The

development of the Office of Interprofessional Education

and the course are described elsewhere (20). However, in

summary the office is supported by money from each of

the participating colleges. This institutionalization of the

office and course was essential to its success. The office is

charged with facilitating and supporting multiple cross-

college curricular developments in addition to the IFH

course, but it represents the most widely integrated effort

to date. Over 3,500 students have completed the course,

which resulted in almost 8,000 home visits serving over

500 families from the Gainesville area.

The course lasts for two semesters and is based upon

four home visits, two per semester, with volunteer families

in the local community. Approximately 60 per cent of the

families are underserved. Each family is visited by an

interprofessional team of three students. Four of these

teams make up a small group, which is supervised by two

interdisciplinary faculty members. The distribution of

families to groups is not random; the goal is to provide a

rich diversity of family types to each small group, because

the groups learn a considerable amount about each of the

four teams’ families. One group may include a Medicaid

family with multiple children, a single elder living alone, a

retired university faculty couple, and a hospice patient.

All families sign Health Insurance Portability and

Accountability Act (HIPAA) releases at the time of their

recruitment into the program.

The small groups meet six times during the year, in

two-hour sessions. They are responsible for different

tasks, learning objectives, and responsibilities on each

visit. The ‘raw material’ for the course thus requires

around 615 students, 125 faculty members, 200 families

and 50 meeting rooms. All group meetings are held at the

same time, as each college has made this time available

for IPE. Home visits are scheduled by team members,

who contact the family and arrange an appropriate and

mutually convenient time.

Course content

Our goals for the course are primarily to demonstrate to

students the significant impact of environment and

resources on health status, and emphasize the importance

of interprofessional collaborative effort in providing

services to patients. The overall competencies and learn-

ing objectives are shown in the appendix. Each objective

is evaluated by being linked to a course assignment. The

Table 3. RFUMS cultural course objectives

Discuss the scope and definition of culture

Examine one’s own ethno-cultural heritage and how it impacts

his/her interactions with patients, clients, and co-workers

Analyze one’s own personal and professional stereotypes and
prejudices

To interpret the world of healthcare is a culture in itself

Become familiar with disparities in healthcare and aware of

government involvement in this issue
Identify and discuss the impact of barriers to healthcare

Apply concepts related to the impact of culture, ethnicity, and

religion on the health beliefs, practices, and behaviors of
patients and clients

Diane R. Bridges et al.

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competencies are in three major categories: patient care,

interpersonal and communication skills, and profession-

alism. The assigned tasks for the course are designed to

allow the students to implement learning activities they

have been taught in their didactic coursework. For

instance, all colleges teach students about taking a

family

history or genogram, and during the first home visit

students are required to develop a genogram for their

family. Students who are taught to do vital signs are

expected to take vital signs of the family members.

Assignments vary by visit. After every home visit, each

student submits a report that describes the visit from the

student’s perspective. For the first home visit, students are

asked to submit a family genogram and a ‘windshield

survey’ which describes the neighborhood in which the

family resides, including access to drug and grocery

stores, an assessment of the safety of the location, and

other information that is to be filled out when the

students are driving to their visit. At the second visit,

students fill out an extensive health survey that assesses

the family’s health status, resources, and health behaviors.

After that visit, student teams develop a project that will

hopefully positively address the family’s health status in

some way. This could be preventive (such as an exercise

program for weight loss); social (arranging experiences

and aid for single elders); economic (helping families

enroll in Medicaid or other assistance); or educational

(teaching families about their medical and/or socio-

behavioral concerns). At the third group meeting, a

social worker attends each meeting and provides assis-

tance to the teams with regard to access to resources.

A variety of required reading and discussion questions

are also assigned and discussed during the meetings.

These address such appropriate topics as definitions of

family, techniques specific to family interviewing, caring

for the poor, issues of adherence and compliance, and

healthcare teams and communication.

During the spring semester the teams present their

projects to the family, and the last home visit is to

determine the effectiveness or acceptability of the project

from the family’s perspective. This coming year, for the

first time, we are adding content concerning the colla-

borative aspects of patient safety education.

At the conclusion of the course, teams submit their

family project to their group. This can be done as a

PowerPoint presentation, video, poster, or a written/oral

presentation. The project is done as a team, but all

students must submit a reflection paper discussing

various aspects of their participation in the course and

its impact on their development as a health professional.

Extensive online evaluations of the students and faculty

have taken place over the years, as an entire course and

by discipline.

It is important that we clarify a crucial part of our

program: because the supervising faculty include a range

of disciplines, and the faculty rarely if ever meet the

family directly, we are not providing medical, nursing,

dental, or pharmaceutical care to these families, although

the students may help arrange such services.

Future

Based on evaluations and faculty feedback, we make

changes in the course each year. Because our overarching

goal is to have interprofessional learning experiences in

all years of training, we have been working towards ways

to keep the groups together beyond their first year. This

meets with challenges because the traditional nursing,

physical therapy, and clinical psychology students have a

two-year curriculum, while pharmacy, medicine, and

dentistry have four-year programs. A committee com-

posed of the education deans from all six colleges has

developed a common set of interprofessional competen-

cies for all students. Newly developed interprofessional

coursework based on these competencies will be required

for all

students.

University of Washington
The University of Washington is home to six health

professions schools � medicine, pharmacy, nursing, social
work, public health, and dentistry � and includes the sole
allopathic medical school for the states of Washington,

Wyoming, Alaska, Montana, and Idaho (known as

WWAMI). In 1997 the university established the Center

for Health Sciences Interprofessional Education

(CHSIE), in an effort to integrate better the teaching,

research, and professional activities of these health

science schools, the information school, and the health

sciences libraries. The CHSIE was developed through

grant support from the University Initiatives Fund (21�
24). To date, over 2,300 health sciences students have

participated in formal IPE programs offered through the

CHSIE.

The course catalog for the University of Washington

includes more than 50 collaborative interprofessional

offerings for students in the health sciences, ranging

from issues in treatment of alcoholism to care for

medically underserved populations. The existence of

these courses, and support for them, provides a platform

from which students from diverse health profession

programs can learn ‘with, from, and about’ each other,

outside of their program ‘silos.’ In addition to the

integrated coursework, co-curricular service learning

and experiential training activities are available. Because

healthcare is typically provided by teams, the opportunity

to establish strategic teams of learners has been well

received by collaborating students, faculty, clinical prac-

tice sites, and community organizations, promoting

sustainability of these efforts.

Models of interprofessional education

Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035 5
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Experiential training programs
Interprofessional team simulation

A clinical team training and skills assessment simulation

is currently in development at the University of Wa-

shington for integration into the core curricula of the

Medex, medicine, nursing, and pharmacy programs

through a grant from the Josiah Macy Foundation, using

simulation to promote interprofessional teamwork. In

this project, interprofessional student teams collaborate

to provide urgent care to simulated patients. The

simulated cases involve an acute asthma exacerbation in

an emergency room setting, a serious cardiac arrhythmia

in an intensive care setting, a patient presenting to an

urgent care setting with acute shortness of breath, and

two cases involving disclosure of medical errors. Content

primers using web-based reviews and recorded presenta-

tions are available in preparation for the simulations,

along with appropriate orientation to the simulation tools

(e.g., mannequin, crash cart, monitoring devices). Curri-

cular mapping has been conducted to identify ideal

timing of the simulations in each program to ensure

sustainable curricular integration and comparability in

student clinical preparation for participation. The objec-

tives of the simulations are both formative and summa-

tive, allowing participants to practice and demonstrate

team-based skills including communication, mutual sup-

port, leadership, and situational monitoring (25). To

receive a pass score, students participate in the training

simulations and demonstrate acceptable performance in

the summative assessment simulation. In summer 2010

beta testing of cases took place, with 24 students

participating in the human patient emergency cases

simulator and 20 students in the error disclosure standar-

dized patient simulation. A common set of IPE compe-

tencies (Table 4), based on learning objectives and

competencies published by the Halifax Nursing Associa-

tion, the CHSIE, and the TeamSTEPPS model, were used

to guide development of the simulation (21, 25, 26).

SPARX (student providers aspiring to rural and under-

served experience)

The SPARX program was developed in 1994 as an

interprofessional co-curricular (outside the classroom)

opportunity (27). The goal of SPARX is to provide health

science students with a variety of co-curricular activities,

including exposure to successful practitioners who serve

rural and medically underserved populations. A SPARX

steering committee composed of staff and faculty from

the health science schools created the infrastructure to

link the schools around the program and, in 1996, the

WWAMI Area Health Education Center Program Office

assumed responsibility for administering and funding the

SPARX program.

Staff and students collaboratively develop topics and

projects. Student participants are continually engaged

and asked to suggest new topics and direction for SPARX

to ensure that program offerings resonate with student

interests, which shift over time in response to social and

political events like health reform efforts, emerging

research, and pop culture. SPARX reaches out to

students through a variety of means, including flyers,

advertisements, and social media such as Facebook.

Experience has demonstrated, however, that nothing

substitutes for the effective outreach realized through

student meetings and class orientations.

The SPARX program consists of three elements:

forums and seminars on topics of interest or value for

rural and urban underserved providers to stimulate

student interest, training to develop skills and foster

interprofessional relationships among students, and ser-

vice projects to provide experiential learning and foster

collaborative teamwork across involved health profes-

sions students. Early SPARX projects focused on health

and wellness in rural children, kids’ health screening,

clothing drives, and outreach to migrant farm workers in

the fields. In the late 1990s SPARX supported a mobile

outreach and primary care project for urban homeless

and street-involved youth. More recently, SPARX has

partnered with Seattle Head Start to provide sensory

assessments for children in its programs and larger urban

health fairs targeting medically underserved Latinos.

In 1997 SPARX created the SPARX Participation

Award to allow students to earn a certificate through

attendance at seminars and support for projects. Students

who gain the certificate are named in a letter to their

respective deans and faculty advisors. In 2007 SPARX

and a sister program in the Department of Family

Medicine, the Community Health Advancement Program

(CHAP), linked through a shared role in delivering

program seminars, combined the award. This link

allowed students participating in either program to earn

points towards the shared SPARX/CHAP Award, recog-

nizing that students had increasingly limited time for

Table 4. University of Washington IPE competencies

Respects the roles and approaches to clinical and social

problems of one’s own and other disciplines
Consults with others when outside his/her personal or profes-

sional expertise

Collaborates effectively with others to assess, plan, provide, and

review care that optimizes health outcomes for patients
Collaborates effectively with other health professionals in a

variety of venues and practice settings

Raises issues or concerns that may jeopardize patient outcomes
with other team members

Demonstrates consensus building and appropriate negotiation/

conflict management skills in resolving issues and concerns

Fulfills roles as either a designated or situational team leader
Assists in identifying and overcoming barriers to interprofessional

collaboration

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Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035

service activities and shouldn’t have to choose between

program offerings on account of the certificate.

Demand for and participation in the SPARX program

has increased over time. In 1995�1996 fewer than 100
students participated, and of those more than 70 per cent

were medical students. In 2009�2010 more than 500
students from all the health sciences participated in at

least one SPARX activity and 87 students will receive the

SPARX/CHAP Award. The Latina Health Fair activity

drew over 140 student volunteers, a record for any

University of Washington-sponsored service project ex-

cept the institutional support for the Martin Luther King

Jr Day of Service. In 2009�2010 SPARX offered 13
seminars, panels, and forums and seven service projects,

including sensory screening at Head Start, breakfast

programs at a youth homeless shelter nine days a month,

Martin Luther King Jr Day of Service projects, the One

Night Count of Homeless, the Latina Health Fair, and

mentoring at a school for homeless children. The Latina

Health Fair alone reached over 500 families with health

screenings, education, counseling, and referral to the

community health clinic for follow-up, demonstrating the

ability of these programs to reach far into communities.

Common elements among interprofessional
curriculum models
There are many elements of collaborative practice that

find their way into successful IPE experiences like those

described in this paper. These elements include responsi-

bility, accountability, coordination, communication, co-

operation, assertiveness, autonomy, and mutual trust and

respect (6). A successful interprofessional curriculum will

ensure that students can experience, share, and practice

these traits with each other.

Understanding others’ professions and your own role

in the healthcare team is critical in IPE (28). This

represents a longitudinal developmental goal; as students

become more immersed in their own education they are

likely to gain a better and more comprehensive under-

standing of their role in the healthcare team. Though at

first students may not understand the complexities of the

relationships between their profession and others, it is

important to develop a common framework early in

their education that describes a best practice model of

interprofessional interaction. This will provide a goal that

they can work towards as they move from student to

professional healthcare team member. As a part of this

enhanced understanding, exploring boundaries of each

profession will help students understand better the duties

for his/her profession.

Another key element is for students to ‘see’ the impact

of interprofessional efforts and reflect on the experience

to help reinforce interprofessional learning outcomes.

For students, their attitudes and perceptions regarding

successful models of collaboration, whether clinical or

educational, can be essential to the value of the instruc-

tion. Grading student participation will also add value

for them.

Lastly, the training of mentors/faculty is an important

element in the successful interprofessional curriculum.

Mentors and faculty need to feel confident in their

interactions with students. The significance of any

interprofessional course needs to be shared with faculty

so they can see its importance.

Resources
An interprofessional curriculum requires a significant

commitment from university administration, as well as

deans and faculty from multiple professions who must

be willing to champion the effort. Each curriculum

effort should be critically evaluated, both quantitatively

and qualitatively. In addition, we have found the

following resources to be crucial to the success of the

interprofessional leaning experience.

For didactic learning experiences, consider the

following.

1. Commitment from departments and colleges to set

aside time for students to participate in the course.

2. Curricular mapping between schools can facilitate

activities.

3. Adequate rooms and facilities able to accommodate

large numbers of students, faculty, staff, and com-

munity members.

4. Creation of a space for a sense of community and

shared purpose through ice-breaking activities and

introductions.

5. Technology for web-based conferences to reach all

participants, as well as a learning system to admin-

ister course content materials and grade students.

For community-based learning experiences for stu-

dents, consider the following.

1. Do you have an enthusiastic commitment from

community partners?

2. Create projects which utilize a diversity of profes-

sions.

3. If you are using families or individuals, do you have

clear expectations as to whether this is simply an

educational experience for your students or delivery

of healthcare?

4. Are there contingencies for community participants

who become lost to follow-up?

5. Confidentiality of personal health information must

be a high priority.

6. The university must develop a community presence

so that year after year these relationships can be

strengthened and new partnerships formed.

Models of interprofessional education

Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035 7
(page number not for citation purpose)

7. Remember that reflection is an important part of

service learning programs.

If you are planning an interprofessional simulation

experience for students, consider the following.

1. Calendar and schedule agreement among the parti-

cipating colleges and programs.

2. Evening and weekend activity opportunities.

3. Expertise to develop simulation experiences with

interprofessional objectives in mind.

4. Personnel to debrief experiences.

Summary recommendations
There are several factors that are essential to the success

of interprofessional programs and activities.

1. Administrative support. Coordination of interprofessional

experiences may require significant changes in the

curriculum structure of one or more colleges. Deans,

curriculum committees, and educational administra-

tors must be supportive of these activities.

2. Interprofessional programmatic infrastructure. Fa-

culty resources are essential. Faculty members from

each college are needed to provide leadership and

recruit teaching faculty from their college, as well as

coordinating activities between colleges. Addition-

ally, administrative support is needed to schedule

rooms, confirm mentor availability, submit atten-

dances and grades, and find substitutes when

necessary.

3. Committed, experienced faculty. It takes dedicated

and educated faculty and staff to provide leadership

to student groups, whether in a didactic or a clinical

setting.

4. Acknowledge student efforts through awards, certi-

ficates, or grades.

While there are many barriers to developing successful

interprofessional learning experiences, they can be over-

come with persistence and commitment, as demonstrated

in these examples of successful programs. Given the

importance of quality care outcomes and the recognition

that collaborative practice improves these outcomes,

interprofessional education should be a high priority

for every training instution. We hope our experiences will

guide you to develop rewarding IPE curricula for your

students.

Acknowledgements

The authors would like to acknowledge the Rosalind Franklin

University of Medicine and Science Curriculum Task Force; Rhond-

da Waddell PhD from the University of Florida; and the University

of Washington Center for Health Sciences Interprofessional Educa-

tion and Research and the Josiah Macy Foundation for funding

support for the University of Washington interprofessional simula-

tion research. We also acknowledge the students at our three

institutions, whose buy-in and support allow IPE programs to thrive.

Conflict of interest and funding
The authors have not received any funding or benefits

from industry or elsewhere to conduct this study.

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*Diane R. Bridges
Department of Interprofessional Healthcare Studies
Rosalind Franklin University of Medicine and Science
3333 Green Bay Road
North Chicago, IL 60064, USA
Tel: 847 578 8479
Email: diane.bridges@rosalindfranklin.edu

Models of interprofessional education

Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035 9
(page number not for citation purpose)

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Appendix. University of Florida 2010�2011
Interdisciplinary Family Health required
competencies

(A list of assignments that evaluate each competency

follows the competency. The assignments are given below.)

Patient care competencies
Health professionals must be able to provide patient care

that is compassionate, appropriate, and effective for the

treatment of health problems and the promotion of

health. Our students are expected to:

1. communicate effectively and demonstrate caring and

respectful behaviors when interacting with volun-

teers and their families

2. gather essential and accurate information about

their assigned families

3. evaluate health behavior and develop a family health

project for one of the members in the volunteer

family

4. counsel and educate volunteers and their families

5. provide healthcare information aimed at preventing

health problems or maintaining health

6. develop a basic understanding of the features of the

community in which the volunteer family resides as

they relate to support structures, resources, and

access to healthcare

7. learn and understand key patient safety concepts,

core theories, and terminology, such as adverse

events, close calls, and a culture of safety

8. understand the impact of patient errors on the

family and the provider

9. recognize and respond appropriately to potential

and actual unsafe clinical situations.

Interprofessional and communication skills
competencies
IFH students must be able to demonstrate interpersonal

and communication skills that result in effective informa-

tion exchange and teaming with volunteers, their families,

and professional associates. Students are expected to:

1. communicate and collaborate professionally and

therapeutically with assigned families and students

from different healthcare professions

2. develop skills in eliciting perceptions of health from

family members

3. demonstrate ability to collect a culturally sensitive

and comprehensive health history, including mood,

medication, and nutritional assessment

4. use effective listening skills and elicit and provide

information using effective non-verbal, explanatory,

questioning, and writing skills

5. work effectively with others as a member or leader of

a healthcare team or other professional group

6. demonstrate knowledge of and respect for over-

lapping roles and distinct competencies of different

health professionals

7. present synthesized information related to the health

of the volunteer in a small group setting.

Professionalism competencies
Students must demonstrate a commitment to carrying

out professional responsibilities, adherence to ethical

principles, and sensitivity to a diverse patient population.

IFH students are expected to:

1. demonstrate respect, compassion, and integrity; a

responsiveness to the needs of patients and society

that supersedes self-interest; accountability to pa-

tients, society, and the profession; and a commit-

ment to excellence and ongoing professional

development

2. meet the responsibilities of the IFH course, includ-

ing attending all small group sessions and complet-

ing each assigned home visit by the required date

3. demonstrate a commitment to ethical principles

pertaining to provision or withholding of clinical

care, confidentiality of patient information, in-

formed consent, and business practices

4. demonstrate sensitivity and responsiveness to pa-

tients’ culture, age, gender, and disabilities

5. demonstrate willingness for self- and external eva-

luation and feedback

6. demonstrate a commitment to patient safety as a key

professional value and an essential component of

daily practice.

Assignments

1. Family home visit

2. Home visit reports

3. Genogram

4. Windshield survey

5. Family health survey

6. Small group discussion

7. Family health outline and project

8. Reflection report and presentation

9. Social service consult

10. Peer evaluation

11. Pre-course web-based learning in patient safety

Diane R. Bridges et al.

10
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Citation: Medical Education Online 2011, 16: 6035 – DOI: 10.3402/meo.v16i0.6035

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Rubic_Print_

Format

(100.00%)

5.0%

5.0%

5.0%

Format 5.0%

100%

Course Code	Class Code	Assignment Title	Total Points
AMP-450V	AMP-450V-O500	Developing a Shared Vision	200.0
Criteria	Percentage	Unsatisfactory 0-71% (0.00%)	Less Than Satisfactory 72-75% (75.00%)	Satisfactory 76-79% (79.00%)	Good 80-89% (89.00%)	Excellent 90-	100%	Comments	Points Earned
Content	80.0%
Selection of Two Issues or Challenges From Among Those Provided in the Assignment Instructions	10.0%	Identification /Challenges in health care organizations are not identified.	Issues /Challenges identified are not among those listed in the assignment instructions.	Issues /Challenges are identified but description is unclear or incomplete.	One issue/challenge is identified from among those listed in the assignment instructions.	Two issues/challenges are identified from among those listed in the assignment instructions.
Compelling Memo Describing the Issues, Their Impact on the Organization, Opportunities for Improvement, and Recommendations	70.0%	Memo addressed to ancillary staff is not provided or is incomplete.	Discussion of issues, their impact on the organization, and recommendations is unclear or disorganized.	Discussion of issues includes a brief description of organizational impact and recommendations.	Description of issues includes detailed information regarding organizational impact and opportunities for improvement but recommendations are lacking.	Comprehensive and compelling discussion regarding organizational issues, their impact, opportunities for improvement, and recommendations to foster a shared vision is offered.
Organization and Effectiveness	1				5.0%
Thesis Development and Purpose	Paper lacks any discernible overall purpose or organizing claim.	Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear.	Thesis and/or main claim are apparent and appropriate to purpose.	Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose.	Thesis and/or main claim are comprehensive; contained within the thesis is the essence of the paper. Thesis statement makes the purpose of the paper clear.
Paragraph Development and Transitions	Paragraphs and transitions consistently lack unity and coherence. No apparent connections between paragraphs are established. Transitions are inappropriate to purpose and scope. Organization is disjointed.	Some paragraphs and transitions may lack logical progression of ideas, unity, coherence, and/or cohesiveness. Some degree of organization is evident.	Paragraphs are generally competent, but ideas may show some inconsistency in organization and/or in their relationships to each other.	A logical progression of ideas between paragraphs is apparent. Paragraphs exhibit a unity, coherence, and cohesiveness. Topic sentences and concluding remarks are appropriate to purpose.	There is a sophisticated construction of paragraphs and transitions. Ideas progress and relate to each other. Paragraph and transition construction guide the reader. Paragraph structure is seamless.
Mechanics of Writing (includes spelling, punctuation, grammar, language use)	Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used.	Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present.	Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.	Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.	Writer is clearly in command of standard, written, academic English.
Paper Format (Use of appropriate style for the major and assignment)	2.0%	Template is not used appropriately or documentation format is rarely followed correctly.	Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.	Template is used, and formatting is correct, although some minor errors may be present.	Template is fully used; There are virtually no errors in formatting style.	All format elements are correct.
Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment)	3.0%	No reference page is included. No citations are used.	Reference page is present. Citations are inconsistently used.	Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present.	Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and style is usually correct.	In-text citations and a reference page are complete. The documentation of cited sources is free of error.
Total Weightage