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Leading and effecting meaningful change in a nursing division culture, such as the type required to achieve Magnet designation, entails senior nurse executives to be well-acquainted not only with the facts and figures of their business but also with the nuances, myths, and cultures that either enable or block a change from occurring. Expert nurse leaders embrace the story being told by data on dashboards and the quality outcomes achieved and look beyond those points of information out to the edges of their division. These nurse executives also seek to understand the pivotal, perhaps seemingly inconsequential things (notions, beliefs, cultural beliefs, and stories) that will block or tip a culture to change and achieve success. At the Hospital of the University of Pennsylvania (HUP), a Magnet-designated organization, the road to Magnet was not straightforward. Instead, the path was a winding, learning journey. Through authentic leadership and the conception and actualization of a professional practice model, the HUP Nursing Excellence in Professional Practice (HUP NEPP) model, Magnet designation was achieved and a nursing culture was transformed.
THIRTY-MILLION PowerPoint presentations are delivered daily. Moreover, 78% of all executives have admitted sleeping through a presentation.1 Humans are simply bombarded by information beyond their ability and/or need to retain the information. However, it is also known that a personal and inspirational story, connected to the overarching message, embedded within a presentation is retained well beyond when the remainder of the presentation has been forgotten. This is a story about transforming a nursing culture, an account of how a professional practice model was conceived, developed, and actualized in the nursing division at the Hospital of the University of Pennsylvania (HUP). While this experience is about nursing in an academic medical setting, the leadership lessons are not unique and are, therefore, transferable to other settings.
HUP is a 704-bed, tertiary, academic medical center located in southwest Philadelphia. While serving primarily adults, HUP also provides services for obstetrics, psychiatry, and rehabilitative services. The hospital is a Level 1 Trauma Center, includes an intensive care nursery, and operates 32 operating rooms, a robust transplantation program and busy oncology, cardiology, and hospitalist programs among many others.
The nursing division at HUP is composed of approximately 1700 RNs, more than 85% of whom hold a BSN or higher as their educational preparation level. Certified nursing assistants (CNAs), patient support associates, and unit secretaries complete the nursing unit-based care team. In addition to physician resident, HUP employs others such as nurse practitioners, physician assistants, respiratory therapists, and physical and occupational therapists as partners in care delivery.
In 2006, the nursing division at HUP was on the journey to Magnet designation. As a result of approximately 5 years of dedicated efforts, most (if not all) of the Forces of Magnetism could be addressed in the application, including research. The Shared Governance structure was implemented and functioning. Direct and worked care hours per patient day were in line with recommended benchmarks. The appropriate consultative and support resources such as nurse managers and clinical nurse specialists at the unit and divisional levels were in place for the professional clinical nurses. Furthermore, a professional care delivery model, primary nursing, and a well-defined philosophy of nursing practice had long been established within the division. Divisional and unit-based dashboards all indicated a solid run rate of steady improvement in the key NDNQI (National Database for Nursing Quality Indicators) nurse-sensitive indicators. Physician involvement was also in place. The UPHS chief medical officer (CMO) was the co-chair of the Magnet Steering Committee in visible collaboration with the chief nursing officer (CNO). Yet, something was missing.
Despite all the efforts and the surplus of data indicating that systems and processes were in place, a general miasma of disconnectedness from the process existed across the division among both the leadership and clinical nurses. While groups of strongly dedicated and invested leaders and clinical nurse Magnet champions existed, the concern about the lack of broad, passionate identification with the goal was difficult to ignore.
In the summer of 2006, the CNO was increasingly concerned by the paucity of connectedness she experienced to the Magnet process. During her routine leadership activities such as Nursing Grand Rounds, RN Open Forum, unit rounding, and shadowing (where she "shadowed" clinical nurses in their roles at the bedside for a shift), she continued to intuit not a lack of understanding about the Magnet process, but, instead a lack of enthusiasm or identification with the overall goal of the Magnet process. It seemed that the process was being viewed as one more "to do." Instead of connecting to the highest-level outcomes to be gleaned from the Magnet designation process via ongoing patient care delivery excellence, it seemed that the nursing division was framing the process as simply another award to be achieved. Like many organizations, HUP had previously received numerous awards and accolades. The challenge confronting the CNO and the nursing leadership team was to have the nursing division connect to the process on a higher, more evolved level. The belief was that the Magnet principles, by that stage, should have been seen as a "lifestyle" or the standard operating procedure-after all, they had all been in place for many years. But, the dots along that continuum toward excellence had somehow not been connected for the majority of stakeholders in the division and hospital at large.
By the fall of 2006, the deadline for the Magnet application loomed. At that time, one critical question needed to be answered: "Are we ready?" The data were conflicting and could not alone answer the question. On paper and by accomplishments and achievements, we knew we should have been ready. However, there were the signs the CNO was picking up. Furthermore, the members of the CNO's senior team, the nursing executive council (NEC), were conflicted. Some felt the division was ready. Others, like the CNO, were concerned by the overall lack of passion for the Magnet process.
The CNO called the entire nursing leadership team, including unit council chairs and Magnet champions, together and asked them the same question: "Are we ready?" The result was expected as it closely mirrored the feeling of the nursing division at large. Some felt overwhelmingly positive while others identified some of the issues we already knew such as the perspective of simply another award or achievement. However, during the gathering, another theme emerged: clinical nurses seemed not to be connecting to the term "Magnet." The gestalt of a portion of the group was that since the majority of clinical nurses had never worked in a Magnet facility, they were having difficulty identifying what "Magnet" looked like in daily operation. This was a powerful revelation. We knew they were fulfilling the Forces of Magnetism, but since the clinical nurses and leadership team were living in it, their filters or lenses made it difficult for them to step outside of themselves and see it. Furthermore, one insightful nurse manager offered, "Why don't we go back to talking about nursing excellence? We all understand those words. It is what we have always been known for and that is what Magnet(TM) is about."
Armed with that powerful insight, the HUP NEC knew that the work remained to be accomplished before moving forward with the Magnet application submission. The CNO, in collaboration with the CMO, COO, and HUP executive director, made the difficult decision to postpone submission and not meet the widely known established deadline. However, that difficult step still did not provide the illumination for the nursing division at large about how to connect what we knew was truly excellence in nursing care delivery with the term "Magnet."
The CNO and NEC were struggling with the next steps. Some believed the answers were in looking externally to what other Magnet-designated organizations had done. However, with the advice of an executive coach, the CNO and NEC decided that the answers needed to be defined for HUP by HUP if it were to be authentic. The executive coach suggested that the leadership team envision what the nursing division would "look like" when all the dots were connected between nursing excellence at HUP and the Forces of Magnetism. He encouraged the team to create that vision in one place and then work backward to define any remaining "to dos." This critical step, completed via a facilitator-led 1-day offsite retreat, led the HUP CNO and NEC and clinician educators from the University of Pennsylvania School of Nursing to visioning of the HUP Nursing Excellence in Professional Practice (HUP NEPP) model-the key step in transforming the HUP nursing culture from ambivalence and disconnectedness to one where a vision of world-class patient care is the unifying divisional symbol and force (Fig 1).
In "The Practice of Primary Nursing," Manthey reminds us that there are 4 characteristics that sociologists generally agree to be descriptive of a profession as opposed to an endeavor or occupation.2 These include (1) an identifiable body of knowledge that can be best transmitted via formal education, (2) autonomy of decision making, (3) peer review of practice, and (4) identification with a professional organization as the standard setter and arbiter of practice. Manthey2 believes that the practice of primary nursing in its original form and in its eventual evolution into relationship-based, resource driven care is the delivery model most closely associated with the practice of professional nursing. However, the practice of primary nursing as a care delivery model alone is not a remedy for an environment that does not support or foster the practice of professional nursing.
The American Nurses Association defines the practice of professional nursing as (1) the attention to the full range of human responses to health and disease; (2) the blending of empirical, objective data with the patient's subjective experience and perspectives; (3) the application of scientific knowledge to diagnosis and treatment; and (4) the provision of a caring relationship.3 The American Organization of Nurse Executives describes the role of the nurse as evolving and the act of professional nursing as a compilation of unique processes that assist a patient in his or her response to illness.4
Literature regarding Magnet hospitals indicates that professional nursing practice in a hospital setting involves autonomy in decision making, control of the practice environment (being able to plan and organize care delivery), consistent proactive communication with physicians, and accountability for care delivery.5-9 However, Clifford reminds us that the essence of professional nursing practice, the nurse-patient relationship, has not changed over time although the context of the care delivery has. The challenge for nurse leaders is to preserve the relationship between the nurse and patient in an environment of morphing values, behaviors, technology, and economics. Clifford states, "Without a relationship between the nurse and the patient, the care is relegated to the administration of tasks and treatments and what the educated and professionally socialized nurse brings to the situation is absent."10(pp1-2)
Professional models of care delivery are a single component of a professional practice model. Furthermore, a professional practice model must exist within professional practice environments if it is to be sustained. According to Arford and Zone-Smith,11 a professional practice environment is necessary to support professional practice models but is not sufficient to create the professional practice of nursing. The authors point out that elements of nursing structures traditionally highly correlated with nurse satisfaction, such as self-scheduling, also do not define a professional practice environment. Furthermore, the literature indicates that professional practice models are most effective when clearly linked with the organization's mission, vision, and value statements to create a culture that motivates employees to achieve a higher purpose.12
The HUP NEPP was an extrapolation of the division's philosophy of nursing and the organizational mission and values. Each component included in the model was viewed as essential to the delivery of excellent nursing care. Each component combined and built on the others, culminating into the delivery of world-class patient care. Wolf and Greenhouse13 describe models as a type of map outlining what needs to occur to move from 1 point to another. This is an apt description of the function the HUP NEPP served in transforming the nursing division. The HUP NEPP, a visual depiction of the definition of excellent care delivery, provided a conduit or a path for the clinical nurses to mentally move from the more theoretical and abstract philosophy, mission statement, and organizational values to the practical reality of care delivery at the bedside. Shared stories also helped.
Joseph Campbell, a life-long student and teacher of the human spirit and mythology of living cultures, emphasized the necessity of the "shared story." It is necessary that all members of an organization can relate their tasks and objectives to a larger organizational aim. Campbell spoke of finding and following one's bliss. However, following this bliss did not just entail doing what one enjoys, and definitely not only what one is told. According to Campbell, following one's bliss was a matter of identifying a pursuit about which one is truly passionate and giving one's self absolutely to it. In doing so, the individual finds his or her fullest potential and serves the community to the greatest extent.14
In conceiving, developing, and actualizing the HUP NEPP, the vision was to create a practice environment that would enable HUP professional nurses, viewed at 21st-century knowledge workers, to be supported not only to practice professional nursing but also to thrive in order to find their bliss in their profession.
Merriam-Webster defines a model as a pattern, plan, representation, or description designed to show the main object or workings of an object, system, or concept. Furthermore, a professional practice model by our view can also be seen as a visual depiction of a goal or a framework for a collection of firmly held beliefs and sanctioned actions.15
A key aspect of a model of any type is the shape or form, as it plays a central role in the conveyance of the overarching message or meaning. While a model can be depicted in any shape, the pyramid shape of the HUP NEPP was chosen for several particular reasons:
* the multidimensional shape is a succinct representation of the complex nature of healthcare delivery;
* the wide, solid base makes the pyramid a stable structure that is not easily toppled or collapsed;
* the association of the shape with well-known structures in ancient history connotes a notion of endurance;
* pyramid structures are constructed of multiple building blocks or compo-nents-also an accurate representation of the multiple aspects healthcare;
* the pyramid shape ascends to a point or an apogee, readily associated with a climax or goal; and
* the meaning of the word pyramid is "fire in the middle," which is derived from the belief that if a pyramid is constructed like the Great Pyramid of Giza, one side faces true north. As long as a pyramid is aligned to the true north-south magnetic axis, it will become charged. The space within the pyramid will accumulate and intensify energy. The notion of the professional practice model of nursing facing a "true north" is also symbolic of leading nursing practice toward the most sophisticated practice.
As mentioned above, the "pyramid model" is composed of multiple components that are viewed as essential for world-class patient care delivery to be delivered. These components are intended to be building from a solid base and culminating at the apex of the structure. However, the placement in the structure is not necessarily meant to convey that one component is more important than the other. All are very important to delivering the highest-quality patient care-with the peak being "world-class patient care." However, robustness, strength, or the mere presence of each component is not intended to convey an "all or nothing" type of conceptualization. Instead, the delivery of the highest-quality patient care is intended to be a journey and a constant striving to improve and enrich each component within the model. The presence of each component enriches the care delivered, while the detriment or absence of a component detracts from the potential care that could be delivered, but does not convey the complete absence of world-class patient care.
The base or underside of the model is a respectful workplace. A respectful workplace in the model is characterized and facilitated by
* ownership, and
* the ability to provide feedback to others.
Treating one another with respect served as the I-beam that supports the entire professional practice model. The presence of respectful workplace as the principle intended to undergird the professional practice model is not meant to portend that issues with respect in the workplace do not exist at HUP. On the contrary, it is intended to acknowledge that in real-world practice environments, issues with interprofessional respect do, at times, exist and are important to the delivery of excellent patient care. Furthermore, the concept of the ideal when kept in focus helps individuals direct their efforts to constantly endeavor to achieve that state. At HUP, this has taken the form of holding firm to the standard that breeches in respect will not be tolerated and addressing this type of behavior from any care team member when it happens. In practice, as the clinical nurses know this, it means that they are held to professional standards of conduct around their interactions and that they will likewise be supported in being treated with respect.
The individual model components are surrounded, enshrouded, and protected by both skilled communication and collaboration. Both of these components are meant to convey a "force field" of interpersonal building blocks that promote world-class care delivery. The mere presence of attention to these 2 factors strengthens the care delivered and makes it more nuanced than had the focus not been on them.
Skilled communication has been detailed in the healthcare literature recently by focusing on communication tools such as SBAR (situation, background, actions, recommendations) as a way to improve patient safety in emergency and high-risk situations such as transitions in care. In addition to that meaning, skilled communication in the professional practice model also conveys a focus on having highly technical care professionals focus on developing skills around how to listen actively and communicate. This component conveys a 2-way dialogue in which people think and decide together. This is often one of the more challenging components in the model to develop because caregivers are educated toward the "inside" components in the model. However, caregivers are usually not taught in formal curricula how to listen and communicate with one another effectively. At HUP, the presence of skilled communication on the professional practice model demonstrated a belief that effective communication enhances care delivery. To that end, in accordance with recommendations for health work environments, every RN and CNA will be training in crucial conversations over the next 3 years.16
Like skilled communication, collaboration is intended to encircle all the actions of professional practice model. Collaboration is defined as a practice culture that exhibits trust; team orientation; respectful, collegial communication and behavior; and a respect for diversity.
The component of collaboration engenders the idea that professional nurses are absolutely central to care delivery and we are not alone. In fact, the belief in collaboration is so firmly held that its absence would signify that care delivery would be incomplete or less excellent. HUP nursing division staff hear this reiterated from nursing leadership via the message, we are not an island and no one delivers the care alone.
These foundational components or blocks are based on the work of Donabedian.17 Structure refers to the manner in which the organization is managed and staffed, process refers to how care is delivered, and outcome is the result or effect of the care given. At HUP, clinical nurses understand these components to mean having the right resources (both human and material) to deliver care; the activities that constitute care; and the outcome being the changes as a result of the process or treatment. Furthermore, the fact that these components are foundational has been evident through watching shared governance unit councils progress from issues surrounding structure and process, such as self-scheduling and other issues that revolve around their own satisfaction, to higher, more self-actualized concepts that truly enrich the care of their patients such as family support groups. This idea of addressing basic structure needs for safety and security also closely parallels Maslow's Hierarchy of Needs. In our experience, until units have the appropriate resources (human and material) and solid, reliable processes to utilize those resources, they seldom seem to ascend to the higher echelons of the professional practice model.
Lifelong learning is also conceived of as a fundamental base block of the HUP NEPP. This is depicted on the model via the color of red extending from structure, process, and outcome over to include lifelong learning. Like structure, process, and outcome, the culture at HUP values lifelong learning as foundational. It is defined as education or learning in which a nurse engages throughout his or her life, and can occur in many forms and via numerous media. In practice, lifelong learning is a foundational principle for the Clinical Advancement and Recognition Program (the clinical ladder), based on Benner's work.18 This component is also enacted via prepaid tuition support for all employees and annual ongoing educational development funds, as well as monthly day and night shift Nursing Grand Rounds and unit-based clinical nurse specialists for support of professional development.
Authentic leadership applies to every member of the nursing division, as every person is a team member in coordinating and delivering care. The professional RN is particularly key in the coordination of care. Many positions with the word coordinator are leadership positions. In fact, at HUP, the off shift nursing "supervisors" are entitled coordinators. Authentic leadership behavior is evidenced by the ability to advance solutions that incorporate "both/and" principles. Authentic leaders at HUP can make sense of competing viewpoints and can also demonstrate results-oriented behavior that models collaboration. Authentic leaders are characterized by self-efficacy and understand that self-reflection and self-renewal are key to leadership.19 These behaviors are instilled in a culture of lifelong learning by the shared belief in the authentic leader as mentor. The Shared Governance Unit Council Chairs have also developed a formalized mentorship model, and its basis derives from the role of the mentor as not to teach but to "dance with the learner."20
Shared governance provides the professional, clinical nurse a voice in decision making. This structure of unit-based councils allows the professional nurse to assume full accountability for nursing practice at both the unit and divisional levels. The shared governance structure provides a system of formalized committees and councils to support the clinical nurse in making decisions pertaining to clinical care, quality improvement, and nursing practice.
The term partnership is used very deliberately to convey a sense of being legally connected to the other members of the healthcare delivery team. The term partnership was employed to convey the notion of being at risk together for the good of the patient. Professional caregivers such as nurses, physicians, and therapists are, in a real sense, legally tied to one another in the pursuit of care delivery. This term brings to bear a different level of working together beyond the term colleague, which means an equal or peer within a discipline.15 However, the partnerships formed are not only intended to be with the fellow caregivers on the team, but partnerships are also developed with the patient and family-again, with the notion of being equally engaged and held accountable for the decision making and outcomes of treatment.
These 2 components of the professional practice model involve integrating the best scientific evidence with clinical expertise and patient values. This systematic approach to problem solving for healthcare providers blends well with conducting and translating research into the "real world." This component is demonstrated via clinical nurses being supported to conduct research, form and participate in journal clubs and Grand Rounds, test and challenge "sacred cows" within practice, and lead practice and quality core councils.
The integrated primary nursing care delivery model endeavors to bring a highly sophisticated patient care delivery model to the patient care setting that supports nurses in their highest calling of care coordinator; patient advocate; promoter of patient adaptation to current health status; and 21st-century knowledge worker, blending the best components of the more traditional Primary Nursing Care Delivery Model with the updated Relationship-Based Care Model. This model has been termed The HUP "Integrated Primary Nursing" care delivery model. The model "integrates" both the traditional primary nursing with the more current relationship-based care together into the current dynamic healthcare environment that is being taxed with shorter stays, avid consumerism, increasing regulation, and a nursing workforce who prefers longer (12 hour) workdays.
This care delivery model is built on 5 core patient care tenants. These are that care is patient- and family-focused, evidence-based, accountable, coordinated, and continuous.
World-class patient care emerges when all components of the HUP NEPP function in an interconnected, synergistic manner. The model as a whole and the delivery of world-class patient care reflect the essence of the HUP nursing culture and is grounded in the HUP nursing philosophy and American Nurses Association Code of Ethics.
The UPHS Core Values, comprising collaboration, are
* individual opportunity,
* teamwork and collaboration, and
These core values guide the service delivered as patients are treated through multiple phases of their healthcare experience. The core values are reflected from the patient care delivery side of the pyramid-shaped HUP NEPP and enhance the delivery of world-class care by being part of a larger system.
The HUP NEPP explicates one's self-reflection from the other 2 sides-the components and the core values. If we refer to the meaning of the word pyramid, "fire in the middle," the combination of the 2 sides with one's own authentic self-reflection is intended to combine to create energy and a magnetic force at the center of each professional's care delivery practice-hence, the notion of finding and feeding one's bliss.
After the HUP NEPP was envisioned and given shape, the essential next step was to have the clinical nurses mentally connect their daily care delivery activities to the components of the professional practice model, nursing excellence, and the Forces of Magnetism collectively. In reality, the clinical nurses were delivering care consistent with the HUP NEPP, but because of their immersion in the HUP care delivery system, they were challenged to step outside of their perspective and see their practice objectively. A shift in perspective and culture was needed.
Preparing people for change requires telling a story-folding together current state data with ideas about the way things ought to be. People and cultures live by stories and myths that capture the essence of a system's values. Nursing divisions are no different. As cultures and environments change, adaptive nursing leaders must be able to intuit which cultural stories and myths are losing power and must be able to intuit where new ones are needed to guide the path to a new reality and cultural norm. Successful new stories must convey a set of ideas that represent the future while remaining true to the current reality. The story must resonate with the organization's deeply held values. Finally, the story must be believable-so, the storyteller must have credibility with the audience.21 The most believable and credible storytellers were the clinical nurses themselves.
An ambitious communication campaign was undertaken where many sessions were held at all times of the day and night to facilitate clinical nurses discussing their care delivery in relation to the HUP NEPP. Each component of the model was introduced, and clinical nurses were asked to provide examples of how they live that component each day. The sessions became increasingly well-attended and interactive as word spread throughout the division of how the nursing leaders facilitating the sessions made the HUP NEPP "come alive." The nurses identified with the model as the symbol of the care they delivered. They began to own the model and what it represented.
According to Professor Sigal Barsade, Wharton School of Business, "a strong organizational culture is expressed through behavioral norms, rituals and symbols that have meaning to those in the organization."22 She goes on to say that when an organization's culture is properly aligned with its structure and strategy, employees can become so excited about their jobs that salary is not the primary motivator.
Through the campaign, more than 90% of the all nursing division staff attended a session. The image of the HUP NEPP began to appear everywhere: screensavers on computers, posters in conference rooms, headers on meeting agendas, and embroidery on the scrubs of the nursing staff. Bulletin boards were developed displaying "...How I lived the model today." Essay contests were sponsored with themes that correlated Magnet to the HUP NEPP. Meals were organized where staff from different units could come together in a relaxed setting to be themselves and to discuss the model and their exemplars of nursing excellence and world-class patient care. Lapel pins in the image of the HUP NEPP were distributed to every nursing division employee with the updated nursing philosophy and a letter from the CNO. The pin was also worn by the hospital senior executive team, physicians, and other partners in care. Writing pens were distributed with the image of the model on the pen so clinical nurses saw the image when they documented about patients. Finally, blank note cards were printed so leadership and clinical nurses could write personal notes of thanks or congratulations on stationary that reflected the division identity of world-class patient care.
Merriam-Webster defines icon as a "sign (as a word or graphic symbol) whose form suggests its meaning."15 A HUP nursing division icon had been created. However, perhaps more importantly, along the way the "tipping point" had been reached. Gladwell23 defines "the tipping point" as a biography of an idea and posits that in the life story of an idea, there is a crucial juncture, which he terms the "tipping point." That point signals a key moment of crystallization that unifies isolated events into a significant trend.23 HUP nurses had tipped from ambivalent and unsure of the Magnet process and had transformed into enthusiastic owners of their model of nursing excellence and world-class patient care delivery culture.
HUP received Magnet designation in June 2007. The celebration involved many activities, but the most poignant moments included a traditional pinning ceremony where HUP nurses were presented their Magnet lapel pin after congratulatory remarks from the deans of the schools of medicine and nursing and the health system CEO and COO, CMO, and CNO among others. The nurses proudly wear both their HUP NEPP and Magnet lapel pins.
As a nursing division, the invigorating aspect of the HUP NEPP is continuing to understand and further develop the model with the clinical nurses every day. In a dynamic healthcare environment, the nuances are infinite. One current and future manifestation of the model has been the development of unit-based joint leadership models involving an attending physician, nurse leaders, and a quality specialist. This team works collaboratively on issues confronting the clinicians at the sharp edge of care delivery. The HUP NEPP is also now serving as a map for ensuring quality transitions in care and eliminating unintended variations in care, such as hospital-acquired infections to enhance care delivery.
Combining storytelling techniques, marketing of an "iconic" image, and authentic and inspirational leadership with the development and actualization of the HUP NEPP was transformational to the HUP nursing division culture. However, beyond facilitating reaching the cultural "tipping point" that led to a successful Magnet designation, the truly magical aspect of the model has been the possibilities it has created for the future. Through serving as a "true north" for the division as a whole, the nursing culture of nursing excellence and world-class patient care has become strong and self-propagating.
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21. James J. The adaptive executive. Talk presented at: SHRM's 58th Annual Conference and Exposition; Master's Series; June 25-28, 2006; Washington, DC. http://www.shrm.org/foundation/06_Masters_Series_-_Exec_Summaries.pdf. Accessed February 24, 2008. [Context Link]
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23. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. New York, NY: Little Brown and Company; 2002. [Context Link]
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