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The process of downsizing a mental health hospital : an ethnography Sage-Hayward, Wendy S. 1996

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T H E P R O C E S S O F DOWNSIZING A MENTAL HEALTH HOSPITAL: AN ETHNOGRAPHY by WENDY S. S A G E - H A Y W A R D B.A., The University of California, Santa Barbara, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF A R T S in T H E FACULTY OF EDUCATION (Department of Counselling Psychology) We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA February 1996 © W e n d y Suzanna Sage-Hayward, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department DE-6 (2/88) II ABSTRACT The purpose of the study was to identify and describe the approach and strategies used to downsize a mental health organization. This ethnographic study was conducted at a psychiatric hospital that is beginning the 4th year of a 10 year downsizing plan. Data were gathered through interviews, informal observations, and field documents. This research design facilitated an understanding of the phenomenon in the context of the practices and beliefs of the executive management team. Semi-structured interviews were conducted with six executive and four middle managers who were involved in the downsizing decision making process. Freeman and Cameron's (1993) definition of downsizing was broadened to encompass not-for-profit reasons for downsizing. Cameron's (1994) downsizing model was supported and an additional best practice called alignment of purpose was proposed in which the leadership of an organization attempts to align the stakeholders with similar goals and objectives for downsizing. The emotional process of downsizing emerged as a key area to address concurrently with job security and other more pragmatic consequences of downsizing. Empathy was suggested as one method of dealing with the emotional process of downsizing. Ill TABLE OF CONTENTS A B S T R A C T ii T A B L E O F C O N T E N T S .'. iii L I S T O F T A B L E S v L I S T O F F I G U R E S ..........vi A C K N O W L E D G M E N T S . . . vii C H A P T E R I. I N T R O D U C T I O N 1 C H A P T E R H . L I T E R A T U R E R E V I E W 4 DEFINITION OF DOWNSIZING , , 4 DOWNSIZING TRENDS 7 EFFECTIVE DOWNSIZING 10 DOWNSIZING IN MENTAL HEALTH 16 DOWNSIZING RESEARCH 19 SUMMARY 22 C H A P T E R HI. F I E L D R E S E A R C H D E S I G N .24 INTRODUCTION TO THE FIELD RESEARCH TRADITION 24 RESEARCH PROBLEM 27 SITE SELECTION .- 29 SITE ACCESS...: : 30 THE ROLE OF THE RESEARCHER 32 Reflexive A nalysis 33 DATA COLLECTION 3 8 DATA ANALYSIS .' ."; 43 C H A P T E R V . DESCRIPTION. . . . . 47 THE ORGANIZATION AND ITS MEMBERS ; '. : 47 The Setting 47 The Participants 49 . The Organizational Culture : : 54 PATIENT DOWNSIZING 59 EMPLOYEE DOWNSIZING 68 Work Force Reduction ...69 Employee Reactions 72 Middle Management Reaction 75 Senior Management Reaction 74 Communication 77 Human Resource Initiatives 79 iv O R G A N I Z A T I O N REDESIGN 81 Program Management 82 Functional Programming : 84 Customer Service • 85 Technological Innovation • 86 S U M M A R Y 87 C H A P T E R V I . A N A L Y S I S & I N T E R P R E T A T I O N O F T H E D A T A 8 8 E F F E C T I V E DOWNSIZING ...88 S Y S T E M I C A N A L Y S I S 106 C O N C L U S I O N S 115 C H A P T E R V T I . I M P L I C A T I O N S O F T H E S T U D Y 1 1 9 L I M I T A T I O N S OF T H E S T U D Y 119 IMPLICATIONS OF T H E S T U D Y 122 Theoretical Implications 122 Practical Implications 126 Future Research Implications 130 R E F E R E N C E S 1 3 2 A P P E N D I X A : I N I T I A L L E T T E R 1 3 6 A P P E N D I X B : I N T E R V I E W S C H E D U L E 1 3 8 A P P E N D I X C : I N T E R V I E W Q U E S T I O N S . 1 3 9 A P P E N D I X D : T H E M E S A F T E R 1 S T I N T E R V I E W 1 4 1 A P P E N D I X E : D O C U M E N T S R E L A T E D T O T H E H O S P I T A L 146 A P P E N D I X F : S E N S I T I Z I N G C O N C E P T S . . . 148 A P P E N D I X G : L I S T C O D E S W I T H D E S C R I P T I O N S 1 4 9 V LIST OF TABLES T A B L E 1: A P P R O X I M A T E H O S P I T A L D O W N S I Z I N G STATISTICS B Y Y E A R 6 2 T A B L E 2 : T Y P E O F W O R K F O R C E R E D U C T I O N S T R A T E G I E S USED F R O M 1 9 9 2 - 1 9 9 5 . . . . 69 T A B L E 3 : R E T I R E M E N T STATISTICS F O R H O S P I T A L E M P L O Y E E S . . . . 71 T A B L E 4 : C L I N I C A L P R O G R A M S W I T H L I S T I N G O F P A T I E N T S E R V I C E UNITS 8 3 T A B L E 5 : K E Y S T A K E H O L D E R S 1 0 7 T A B L E 6 : C H A N G E R O L E S O F K E Y S T A K E H O L D E R S 1 1 3 vi LIST OF FIGURES F I G U R E 1: D O W N S I Z I N G H I S T O R Y & R E L A T E D E V E N T S , 6 0 F I G U R E 2 : T H E S T A K E H O L D E R S A N D S Y S T E M I C R E L A T I O N S H I P S . . . . . 1 0 9 ACKNOWLEDGMENTS The ideas in this paper originate from the thoughts and experiences of the ten participants at The Hospital confronting a long and arduous downsizing process. Without their time and insights, the knowledge gained through this study would not have been possible. Thank you to friends, family, and colleagues for their tolerance in listening to the stories and pains of this process over the past two years. In particular, I would like to thank Mr. Don McLean who spurred many ideas through our discussions and encouraged completion through gentle prodding, Mrs. Tracey Canuel whose tireless transcribing moved this project along quickly, and Christianne Hayward-Kabani for her qualitative expertise and assistance in preparing for my defense. I am especially grateful to my parents and my husband for giving me the encouragement and support to start this endeavour. In particular, I am indebted to my husband and best friend, Ian Hayward, who has been inexhaustible with his support, ideas, and humour throughout this project. I owe a tremendous amount to my thesis supervisor, Dr. Bonnie Long, whose thoughtful and encouraging support always made the next hill seem surmountable and whose direction was invaluable on this project. Thank you also to Dr. Donald Fisher for his close involvement and encouragement with this project. Finally, I am very appreciative of Dr. Colleen Haney for joining the committee at the last hour and carrying through with her role despite her new position at the University of Northern British Columbia. 1 CHAPTER I. INTRODUCTION Society today is in the midst of dramatic structural, political, and economic changes. These changes are evident in every system in which we engage including our personal, organizational, communal, and cultural systems. Conner (1993) maintains that there is more change now than ever before and these changes are increasing in volume, complexity, and momentum. Some writers (Callan, 1993; Conner, 1993) suggest that change has become a dominant aspect of our lifestyle. Therefore, we need to understand change and the effects that accompany it so that we can enhance our organizational practices in response to change. One type of change that has been commonly employed in the last 15 years is downsizing. Downsizing, or work force reduction, is the process of systematically reducing the work force through means such as early retirement, hiring freezes, or termination (Appelbaum, Simpson, & Shapiro, 1987). Cameron (1994) suggests that organizations will continue to use downsizing as a method of becoming more efficient and competitive in today's global market. Unfortunately, some organizations report that their downsizing efforts have not achieved the expected results (Bunning, 1990; Cameron, 1994). There are many explanations for these unsuccessful outcomes including the following: the strategies adopted may be ineffective; the strategies may be implemented poorly; and the downsizing process may create resentment and resistance in employees resulting in discord and disorder. 2 Not all downsizings have been motivated by the need to become financially competitive. Mental health hospitals have been undergoing dramatic downsizing over the past few decades due to the philosophy of deinstitutionalization. Deinstitutionalization refers to the process of decreasing dependency of mentally ill patients on large psychiatric institutions that provide asylum care while relocating them to a normalized community-based facility that encourages independence and rehabilitation. This philosophy is anchored in the belief that community programs and facilities can provide mental health services to patients that are closer to family, permit societal interaction, and encourage independent living. It is assumed the community environment normalizes the experience of living for persons with serious mental illnesses. The purpose of this study is to develop a better understanding of the downsizing process through the analysis of strategies employed by one psychiatric hospital. An ethnographic study was conducted at a mental health institution through interviews with 10 senior and middle managers. The key questions of the study include the following: What initiated the need for downsizing? What were the goals of the downsizing? What strategy or combination of strategies were used to downsize? How were the strategies implemented? Who was involved in decision making? How were decisions communicated to others? What impact did the process have on senior management? Which aspects of the downsizing were favourably and unfavourably viewed by senior management and other stakeholders? What is senior management's perspective on how the process affected employees? What resources were offered and/or subsequently used for support throughout this process? This study is summarized in the following chapters; Chapter 2 contains a literature review of current research and theory on downsizing. Chapter 3 describes how the study was designed and conducted. Chapter 4 provides a rich description of the organization and its downsizing process as characterized by the participants. Chapter 5 provides an analysis and interpretation of the data. Chapter 6 discusses the theoretical, practical, and future research implications of the study. 4 CHAPTER II. LITERATURE REVIEW Although, the body of written material on downsizing is growing, there are few empirical studies in this subject area. The following literature review is a discussion of the relevant theory and research conducted to date on downsizing. First, downsizing is discussed in general terms. A clear and concise definition of the concept is established along with an indication of when and how it might occur. Next, current downsizing trends and strategies for managing this process in industry are described. As an understanding of downsizing develops, this phenomenon is discussed in terms of its application to mental health organizations. Finally, the research on downsizing is reviewed. Definition of Downsizing Organizations often find themselves in a position of needing to downsize In response to change. The term downsizing is sometimes used synonomously with other organizational change terms such as layoffs, decline, or restructuring. Freeman and Cameron (1994) distinguish downsizing from other types of organizational change. Their framework is clear and comprehensive. It provides a theoretical framework that will aid us in examining and contextualizing the downsizing phenomenon, and it is therefore, described in detail. They propose the following definition of downsizing: Organizational downsizing constitutes a set of activities, undertaken by management, designed to improve an organization's efficiency, productivity, and/or effectiveness. It represents a strategy implemented by management 5 that affects the size of the firm's work force and the work processes used. (p. 12) Freeman and Cameron (1993) suggest that downsizing has four key attributes. First, downsizing is an intentional act of an organization by management and not an event that happens to the organization by environmental intrusion. Second, a downsizing typically involves a reduction in personnel through hiring freezes, outplacements, transfers, early retirement, buyout packages, layoffs, and/or attrition. The reduction in personnel may affect one or more parts of the organization. Third, a downsizing may occur as either a reactive measure or a proactive strategy targeted to improve organizational efficiency or effectiveness. Fourth, an organizational downsizing usually impacts work processes. For example, although workload expectations remain stable, fewer employees are available to complete the tasks. These researchers differentiate downsizing from several other organizational constructs such as decline, non-adaptation, growth-in-reverse, and layoffs. Each of these constructs are reviewed briefly in order to understand how they differ from downsizing. Organizational decline is often defined as an unintentional development that happens to an organization through deteriorating performance, increased competition, and maladaptation. However, downsizing is an intentional and sometimes strengthening endeavour. Therefore, Freeman and Cameron (1993) argue that downsizing and decline are separate and distinct constructs. Non-adaptation is a concept used to describe organizational decline and is applied to organizations that do not change to accommodate an environmental demand. 6 Freeman and Cameron (1993) indicate that downsizing may be a strategic move to prevent or minimize poor adaptation but it may also be a proactive measure to increase competitiveness, and in this sense it is unlike non-adaptation. Some writers assume that downsizing is the opposite of organizational growth, in that opposite dynamics seem to be engendered by the two outcomes. However, Freeman and Cameron (1993) suggest that due to the intentional nature of downsizing organizations may experience similar outcomes as with growth. Comparable factors include decentralization, expanded boundaries, and specialization. Therefore, they argue that shrinking is not necessarily the converse of growth. Downsizing is sometimes used synonomously with the concept of layoffs because the termination of employees is a frequently practiced method of conducting a downsizing. However, laying off employees is only one action in the complex redesign inherent in downsizing. Other strategies that may be employed to reduce a work-force size include attrition, buyout packages, and early or phased retirement. Therefore, Freeman and Cameron (1993) argue that downsizing is a broader concept that may be carried out with one or more different strategies and encompasses a reactive or proactive strategy depending on the change required. Freeman and Cameron (1993) propose that organizations downsize during reorientation or convergent periods. Reorientation represents a period when the organization undertakes a fundamental shift in strategy, mission, structure, and systems. During reorientation, senior management leads the change aimed at redesigning the organization. Reorientation is initiated by poor performance or threat to future survival. The strategies associated with this period are extensive 7 communication, introduction of new processes, and change in the distribution of power. The emphasis is on flexibility and adaptation. Convergence represents a period when the organization needs to reinforce existing strategies, processes, and structures. Downsizing during this period is motivated by the desire to do the same functions better. Middle management is the primary driver of the type of change that is geared at achieving greater efficiency in the organization's internal activities and strategies. The downsizing strategies focus on efficiency criteria with an emphasis on stability and control. In summary, Freeman and Cameron (1993) have provided much clarity and definition to the meaning of downsizing. They have also established a framework to understand two basic types of downsizing strategies; those being reorientation and convergence. Downsizing Trends Cameron (1994) indicates that almost every sector of the economy from federal governments to trade unions has downsized. Few industries have escaped this phenomenon. Bennett (cited in Cameron, 1994) reports that more than 85% of the Fortune 500 companies have downsized in the last 5 years and 100% are planning to reduce their workforce within the next 5 years. Manufacturing and service industries have been most severely afflicted (Bunning, 1990). Cameron (1994) argues that fundamental assumptions underlying organizational effectiveness have been called into question during the last decade. These changes in assumptions have contributed to the increase in the number of organizations employing 8 a downsizing strategy. He lists some previous assumptions about organizational effectiveness that include bigger organizations are better, growth is unending and desirable, resource redundancies allow an organization to respond to threats and opportunities, and consistency and congruence are prerequisites to organizational effectiveness. He argues that these assumptions are no longer valid due to technological advances, access to a competitive global marketplace, and a new political climate. He alleges that new assumptions have developed and include ideas such as smaller organizations are better organizations; downsizing and decline are natural and desirable; non-redundancies are associated with adaptability and flexibility; and conflict and inconsistency reflect organizational effectiveness. These revised assumptions have likely contributed to the decision of many organizations to downsize. There are a number of reasons why an organization might be compelled to downsize. However, the key motivation seems to be to improve the organization's efficiency and competitiveness. External driving forces behind work force reduction include telecommunications advances, limited resources, frequent transitions of power, global competition, technological innovations, and environmental distress. These external forces coupled with inexperience in dealing with complex change has led to a general failure of downsizing as a business strategy. Consequently, many downsized organizations experience low worker morale and reduced productivity. A recent survey by Wyatt Company reported that few companies achieve a net competitive advantage from downsizing and that the process of work force reduction often leaves companies in an inordinately long stage of recovery (Restructuring Falls 9 Short, 1994). Of the 148 Canadian corporations surveyed in this investigation, only 17% reported developing a competitive advantage as a result of the work force reduction that was initiated. Furthermore, the Wyatt Company concluded that for many companies, and the remaining employees, the recovery period following the downsizing was in excess of 6 months. The Wyatt Company survey projects that a successful downsizing will be keenly attentive to the remaining employees needs so as to protect against the adverse effects on productivity engendered by tumbling worker morale. However, this article provides no further information or details on how organizations might achieve this keen attentiveness. Organizations may postulate and try out different means of attending to surviving employee needs, but without substantiated evidence of the effectiveness of these methods or greater understanding of exactly what employee's need are, this may be a fruitless and costly exercise. Organizational change invokes strong emotional reactions in employees due to the resulting effect on their future and threats to job security (Martin, 1993). These reactions are sometimes termed 'resistance' and include anger, excitement, denial, anxiety, and depression. Bunker and DeLisle (1991) suggest reasons why people resist change. First, employees may be reluctant to give up something of value in their current environment. They often have a tremendous social and psychological investment in the current situation, and therefore, are unwilling to easily let go of the status quo. Second, they may not fully understand why they need to change or how the change may affect them. Third, employees, and even managers, may believe that the change is 10 inappropriate or unnecessary for the organization to undergo in order to achieve its goals and objectives. Fourth, some employees likely have a low tolerance for personal change and fear risk taking. Effective Downsizing Several authors propose ways to effectively manage organizational downsizing. Cameron (1994) proposes nine best practices for the downsizing process: approach, preparation, involvement, leadership, communication, support, cost cutting, measurement, and implementation. These categories provide a logical and relevant method of examining the downsizing process, and therefore, are used here to organize the discussion of the literature on effective downsizing strategies. The first category, approach, relates the philosophy or assumptions undertaken by management when downsizing. For example, downsizing is approached as a long-term strategy rather than a short-term, single attempt to fix the organization's challenges. Downsizing is viewed as an opportunity for improvement, not a reaction to a problem. Human resources within the organization are viewed as assets rather than liabilities. It is important to note that when organizations regard employees as assets they are likely to communicate and involve them in the process more, and treat them respectfully. In his model for ethically downsizing a work force, Weber (1994) suggests that employees should be treated fairly and with dignity. In organizations where employees are thought to be outdated in their skill sets, resistant to change, or incapable of adapting to a new environment, downsizing will more likely be top down driven with minimal communication and involvement of the 11 staff. In short, when staff are considered a handicap to the organization, their opinion is not likely to be valued or listened to. Cameron's (1994) second category, preparation, suggests that organizations should strategically plan to downsize based on the organization's future mission and its core competencies. A comprehensive downsizing plan is required that identifies the objectives, targets, and deadlines for the process (Van Sumeren, 1986). Planning occurs well in advance of implementation to avoid a shotgun approach to reducing in size. Adamson and Axmith (1983) advise that how a downsizing is conducted and communicated to staff could make a significant difference in long-term success or failure of an organization. Other researchers suggest a plan, or vision, which includes the goals of change, a compelling reason for the change, and a picture of what the new organization might look like (Cauthorne-Lindstrom & Tracy, 1992; Weber, 1994). When designing the vision, the change agents should consider all available alternatives and evaluate the impact of the decisions made (Weber, 1994). Layoffs should be avoided whenever possible due to the impact on laid-off employees, as well as those who remain with the organization. The vision and rationale should be clearly communicated to employees in an open manner, and information should be made easily accessible to all employees (Rice & Dreilinger, 1991). The negative consequences of not making the change should also be pointed out (Conner, 1993). Prokesch (1993) suggests that if the employees commit to the vision, then their resistance may diminish. This would suggest that a vision should be marketed to the 12 work force to increase acceptance. Part of the marketing process may be to frame the new vision positively. Bridges (1991) argues that the problem should be marketed, not the solution. He suggests that if employees understand and agree on the problem, they will be united and helpful in finding a solution to the problem. However, he suggests that if the manager understands the problem and employees do not, then a polarity is established. A third key element of downsizing is involvement (Cameron, 1994). Involvement refers to engaging both internal and external partners in identifying areas for change through downsizing and implementing those changes. External partners are customers and suppliers who can contribute suggestions for improvements in the overall system. Through involvement, both staff and management have ownership of and commitment to a successful outcome (Arndt & Duchemin, 1993). Senge, Kleiner, Roberts, Ross, and Smith (1994) propose that staff should be involved in designing the road map to reach the new vision. This involvement builds commitment to the vision. A road map is a detailed plan outlining what will happen to whom, how, and when. The fourth best practice for downsizing is leadership (Cameron, 1994). An organization's leaders should be visible and accessible to employees effected by the downsizing. Arndt and Duchemin (1993) indicate that all employees benefit from interaction with and communication from senior management during this process, not just those more severely affected. 13 Conner (1993) suggests that leaders or sponsors of change are responsible for creating an environment that enables change and provides proper reinforcement to assure success. Initiative and fortitude, rather than defensiveness and avoidance, from leaders is important to motivate the work force (Cameron, 1994). The fifth best practice in successful downsizing is communication. A high level of communication is required to help members understand the changes and make sense of how these changes will impact their lives (Tichy & Devanna, 1986). Daft and Lengel (1984) suggest that communication from top management is critical to successful downsizing and many types of communication should be employed by organizations undergoing downsizing that is principally driven by redesign. Communication is a critical component to all organizations regardless of whether or not they are undergoing significant change. Detailed information should be communicated candidly and frequently to employees through a variety of mediums throughout the transition process including newsletters, management sessions, and memorandums (Rice & Dreilinger, 1993). Employees should be fully informed of the objectives, strategies, costs, and schedule of the process. Sensitive information should not be hidden or revealed on a need-to-know basis (Cameron, 1994). Employees should be told in person by their immediate supervisor about any change that will directly impact them (Weber, 1994). Open discussion and respect for emotional reactions should be permitted and even encouraged during this process (Lippitt & Lippitt, 1994). A sixth best practice in downsizing is support. Support should be provided to employees who stay, as well as those who leave (Arndt & Duchemin, 1993; Cameron, 14 1993; Rice & Dreilinger, 1991). Types of support for those who leave may include sufficient lead time, financial packages, counselling, outplacement services, and retraining. Training, retraining, and cross-training should be provided to remaining employees to assist them in transitioning to the new environment. For example, some organizations train employees and managers in understanding and managing change (Arndt & Duchemin). Cameron's seventh category, cost cutting, involves examining a variety of cost reduction activities including restricting overtime, eliminating redundancies and inefficiencies, and streamlining work processes. The investigation of multiple cost reduction strategies will likely lessen headcount reductions and lead to improved performance and profitability if sustained over the long term (Kazemek & Channon, 1988). The eighth best practice in effective downsizing is measurement. Cameron (1994) suggests that organizations should measure all activities and processes in the organization related to the organization's products and service to identify improvements other than in outputs. The skills, experience, and future plans of the employees should also be assessed and maintained to facilitate decision making about personnel and assignments when downsizing occurs (Kazemek & Channon, 1988). The ninth best practice in Cameron's model is implementation. A broad range of downsizing strategies should be implemented including work redesign and systemic strategies such as cultural change. An organization going through change needs to create a culture that fosters innovation and risk-taking (Cauthorne-Lindstrom, 1992). Mishra and Mishra (1994) suggest that before embarking on a downsizing process, it is 15 critical to the success of the process that an organization create a culture of mutual trust. Bridges (1991) suggests that trust is critical in the change process because "when people trust their manager they are likely to undertake a change even if it scares them" (p. 78). However, an existing culture may have significant bearing on the success of creating an innovative, risk-taking environment. The process should be implemented equitably and fairly to ensure impacts are not unevenly balanced. Cross-level and cross-functional teams should be engaged to plan and implement the downsizing rather than using normal chains of command. Reward, selection, and employee development systems should be modified to reflect the organization's new vision and goals. Implementation should occur slowly and small successes ensured along the way. The organizational change and downsizing literature offers a foundation for planning and managing organizational transitions. However, little empirical evidence is available to determine the effectiveness of these strategies. For example, scant information is provided about critical elements of the process such as the timing, methods, and style of communicating key information about the downsizing to staff. Detailed approaches for how to involve employees in the process are not proposed. Bridges (1991) has developed a useful framework for managing transitions that provides specific examples and guidelines for this process. Bridge's (1991) model is intended to minimize the distress and disruptions caused by transitions. He presents a three phase process for understanding and managing transitions: ending, neutral zone, and beginning. He argues that transitions begin with letting go of something or ending 16 something and then move into the neutral zone. The neutral zone is where an individual is in between the old reality and the new reality. Bridges indicates that transitions are a time when an individual has let go of the old, but has not yet committed to the new state. The final stage is the beginning of the new reality. Bridges suggests that most organizations start with the new beginning and ignore the ending and neutral zones, which explains why organizations and individuals have great difficulty with change. Bridges (1991) provides ideas and practical methods for managing each stage of his transition model. For example, for the neutral zone he identifies several strategies to help people make the journey to the next stage. These strategies include normalizing the neutral zone, celebrating the loss, and building and using a transition monitoring team. His approach is created from years of experience in delivering seminars on career, family, and organizational transitions. Although, his model has not been empirically tested in relation to downsizing, he provides an interesting perspective from which to view change and transition management. In summary, the literature presents general guidelines that organizations could follow for successfully downsizing an organization. However, few studies document the implementation and success of these guidelines. The research that has been conducted in this regard is reviewed next. Downsizing in Mental Health The healthcare industry is experiencing large scale organizational change. The mental healthcare system has been undergoing significant restructuring and redesign 17 over the past three decades. This change has its roots in the 1950s when the mental healthcare system was highly criticized for its harmful and dehumanizing effects, and violation of the rights of the mentally ill (Grob, 1983). Also, the advent of psychotropic medications and new psychotherapies, and a shift in social, political, and economic structure created a dramatic change in thinking around mental healthcare (Grob, 1983; Pawlicki, 1994). The shift from long-term institutional care to community care was intended to be less restrictive and more responsive to the needs of patients. Community care was also thought to offer the ability to integrate people with mental illness into a normal life, rather than keep them hidden in large, remote institutions. This movement is called deinstitutionalization. It emphasizes a person's right to self-determination and to controi the forces that affect them. The community is considered to be better able to provide those who are affected by mental illness with more control in this regard. The general acceptance of deinstitutionalization has led to a wide-spread reform of large mental health facilities that has resulted in subsequent changes in services provided to patients. Downsizing is one of the methods being employed to reform the mental health system (Moore, 1994). Burda (1993) describes the results of a 1993 survey of 1,147 United States hospitals. The survey indicates that 27% of the hospitals were planning to decrease their workforce size, most by 5% to 14%. The effects of this downsizing are having an enormous impact on the employees that leave, as well as those that remain with the organization, usually referred to in the literature as survivors. Eighty percent of the respondents in Burda's (1993) study indicated that morale has declined due to the 18 uncertainty implicit in downsizing situations. Forty-eight percent indicated that one of their top concerns was the impact of downsizing. Pawlicki (1994), a psychiatric nurse in the United States, argues that downsizing whether implemented quickly or slowly is a traumatic experience for the employees involved. She suggests that downsizing undermines their normal sense of control, connection, and meaning. She believes that long serving employees begin to feel part of a family or community. Downsizing assaults those "family" connections leaving employees feeling resentful, mistrusting, and angry. She suggests that most psychiatric nurses are experiencing high workloads and a demanding environment, are in survival mode, and thus have a limited capacity to make a meaningful contribution to the process of downsizing. Jaspen (1993) reported a study that conducted interviews with 72,250 healthcare workers at 84 hospitals and 200 affiliated clinics. The results indicated that 31% of the average healthcare worker's time was spent doing paperwork, rework, duplicate work, and inappropriate work. Jaspen suggests that hospitals could save millions of dollars by minimizing the bureaucracy and redistributing resources to improve patient care. He says that "when staff size is reduced without redesigning the work, waste' is merely compacted, not eliminated" (p. 19). Numerous other articles and surveys support the impact of downsizing cited above (Begany, 1994; Godfrey, 1994; Moore, 1994). This information leads to the general notion that downsizing is a serious problem for management and employees of North American healthcare organizations. The impact of downsizing seems traumatic and persistent, therefore, it is imperative that we understand this phenomenon better so as 19 to reduce these negative effects. It is also important to understand the responsibility that organizations bear for minimizing the impact to their employees caused by downsizing. Downsizing Research Cameron's (1994) research is reviewed in some detail because it relates closely to the present study. He conducted a 4 year study of 30 automotive industry organizations engaged in downsizing. He examined three elements of the downsizing process: How is downsizing implemented? What are the organizational effects of downsizing? What are the best practices in organizational downsizing? Although the specific number of interviewees was not identified, Cameron indicated that he interviewed the head of each organization every 6 to 9 months and each organization's top managers 5 times during the 4 year study. These interviews investigated the decision-making rationale, activities of top managers, and a chronology of events. Pre- and post-questionnaires were administered to top managers to obtain a description of the organization. A separate questionnaire was administered to 3908 white-collar workers, across the 30 firms, examining downsizing strategies, organizational characteristics, organizational changes, quality, culture, communication patterns, and organizational effectiveness. The response rate was 51%, which yielded 2001 returned questionnaires. Statistical analyses and details of the interviews or questionnaires were not reported in Cameron's article. 20 Cameron (1994) reports several key findings from his study. First, he identifies three primary types of downsizing strategies implemented by one or more of the 30 firms: workforce reduction, work redesign, and systemic relationships. First, work force reduction strategies were implemented in an across the board fashion using methods such as attrition, early retirement, transfers, layoffs, firings, and buy-out packages. This strategy was classified as a short-term payoff measure aimed at reducing headcount. An across the board approach reduces the work force throughout the organization by the same amount without regard to organizational needs or post-downsizing implications. Second, work redesign strategies were intended to improve efficiency and eliminate duplication by redesigning tasks, consolidating and merging units, reducing work hours, and eliminating functions, hierarchical levels, groups, or products. This type of strategy yields medium-term payoffs through increased efficiency, but requires advanced analysis of work areas for redesign or elimination. Third, systemic strategies attempt to change the organization's culture and the attitudes and values of employees. "These strategies involve redefining downsizing as a way of life, as an ongoing process, as a basis for continuous improvement" (Cameron, 1994, p. 198). This long-term payoff strategy requires an upfront investment in areas such as training, diagnosis, and team building. Cameron (1994) argues that short-term workforce reduction strategies sometime seem imperative due to economic difficulties; however, the benefits gained are usually negated by the long-term costs. He advises that firms who employ a combination of all three downsizing strategies tend to perform better and increase organizational 21 effectiveness over those firms who only use one type of downsizing strategy. The long-term costs are associated with a loss of trust, commitment, and loyalty from employees during a downsizing. Interestingly, this study found that management preferred using an "across the board" approach for downsizing because it reduced the time required to complete the process and reduced the time employees had to endure uncertainty. It also ensured that all of the pain was administered at once (Cameron, 1994). It may also be that it is easier psychologically for managers to get the process over with rather than prolonging it given that they are administering the news to the employees. Armstrong-Stassen (1993) administered a questionnaire to 250 management and non-management employees of a telecommunications company 6 weeks after the organization had downsized. She measured differences in perceptions of fairness and job security, methods of coping, and organization outcomes (morale, organizational commitment, and trust) between occupational levels in the same organization. In-depth interviews were also conducted with 9 management and 12 non-management employees. However, no details of the interview schedule were provided. The results of the study showed that non-management employees were more likely to perceive the work force reduction as unfair and report greater job insecurity than management employees. This study raises several concerns. First, the study used self-report data only, therefore, the data may be subject to common method variance. Second, measures used to examine the constructs of interest (perceived fairness, job insecurity, coping mechanisms, and organizational outcomes) are limited and narrow. For example, 22 perceived fairness is evaluated by agreeing or disagreeing with the following statement, "the company's reason for the layoff was fair." The study did not investigate how the. downsizing was conducted, but proceeded to conclude from the self-report data that management failed to communicate with employees about decisions related to the downsizing and that the company should provide all employees with all relevant information concerning layoffs. However, no evidence is cited to support this conclusion. Summary Downsizing is being widely used by organizations across industry as a means to become more efficient and effective. Mental health organizations in particular are using downsizing as a method to facilitate the complex process of reform which is intended to result in cost savings and improved patient care. However, downsizing is a poorly understood phenomenon. This process has severe consequences for those who leave an organization, as well as for those who remain. Organizations often experience an increase in absenteeism, higher turnover, lower morale, and reduced productivity after a downsizing. Very little research has been conducted to improve our understanding of the subject. Several researchers call for more inquiry in this area. This study attempts to further our knowledge of downsizing by examining the process in the context of a large psychiatric hospital undergoing significant reform. An ethnographic methodology was selected to investigate downsizing in a natural setting rather than a laboratory simulation. This research design afforded the opportunity to 23 understand the process in context by interviewing people in the organization who had been involved in the downsizing and gathering relevant documents developed by and for individuals in the setting. A quantitative research design would not have permitted the depth of exploration into the beliefs and values of the organizational leaders. As mentioned earlier, very little research has been conducted on the process of downsizing. The primary focus has been to examine the reactions to the process without regard to understanding how the process unfolded from the perspective of the participants. In addition, no empirical research has been conducted in the healthcare industry, It is hoped that this research project will contribute to this domain. The style and substance of the study will also be useful to counsellors working in organizational settings by assisting them to understand the effects of downsizing. 24 CHAPTER III. FIELD RESEARCH DESIGN This chapter describes how this research study was designed and conducted including the evolution of the research problem, site selection and access process, researcher role, and data collection and analysis strategies. An introduction to the field research tradition is presented to provide background information on ethnographic studies. Introduction to the Field Research Tradition Field research focuses on discovery, insight, and understanding from the perspective of the participant. This tradition attempts to collect rich descriptive data on people, places, symbols, and their systemic interaction in natural settings rather than laboratories. The general approach taken by field researchers seems to have evolved primarily from work completed by anthropologists and sociologists who have attempted to understand social phenomena from the participant's perspective (Burgess, 1984). In the late 19th century, anthropologists were observing natural settings to understand how culture was interpreted by the members living within the social, political, and economic framework of the culture (Bogden & Biklen, 1992). "Within sociology, naturalism emerged as a reaction against the development of the survey research tradition" (Hammersley& Atkinson, 1983, p. 10). Five major characteristics within the field research tradition have been identified (Bogden & Biklen, 1992; Burgess, 1984; Lincoln & Guba, 1985). First, data are collected in the natural setting with the researcher as the instrument. People and social 25 interaction are studied in their natural states rather than in a controlled, laboratory setting in an attempt to document the way things really are (Lincoln & Guba, 1985). Lincoln and Guba assert that "inquiry must be carried out in a natural setting because the phenomena of study...take their meaning as much from their contexts as they do from themselves" (p. 189). Hammersley and Atkinson (1983) propose that it is not a "setting" that field researchers are studying, but rather it is a "case which is those phenomena seen from one particular theoretical angle" (p. 43). From this perspective, the researcher defines the criteria of selection for investigation and uses this criterion platform from which to view the setting and guide the research project. Hammersley and Atkinson also suggest that the researcher may require data from outside the setting, indicating that cases are not restricted by the boundaries of the setting. Hammersley and Atkinson (1983) indicate that research must be conducted in ways that are sensitive to the natural setting by adopting an attitude of respect and appreciation for the people and their surroundings. In essence, the researcher is immersed in the setting to gain cultural insight into its members. However, the researcher minimizes, where possible, the obtrusiveness created by his or her presence in the setting. A second major characteristic of qualitative research is that it is committed to rich, descriptive narration of events, people, and settings being observed. This type of research attempts to understand the various ways individuals construct reality over time as defined by the persons under study (McMillan & Schumacher, 1989). These constructions are then communicated through field research reports, which provide the 26 vehicle for translating, in a descriptive style, the social interactions and experiential qualities of the research setting (Lincoln & Guba, 1985). Third, researchers in this tradition are concerned with the process or formation of the meaning attached to an interaction or event. Hoshmand (1989) describes this approach as the following: The naturalistic-ethnographic approach aims at the holistic description of total phenomena in context and attempts to generate from the descriptions the complex relationships of factors that influence human behavior toward, and belief about, the phenomena (p. 16). Fourth, field research data are analyzed inductively rather than deductively (Glaser & Strauss, 1967). Inductive analysis is the process of categorizing, resorting, and recoding data in order for theories to emerge from the bottom up (Bogden & Biklen, 1992). The theory emerges and becomes more refined as the components are collected, categorized, and examined. Glaser and Strauss (1967) designed a specific method for analyzing inductively gathered data called the constant comparative method. This method proposes a continuous cycle of coding and analyzing that will systematically generate theory. Through this process categories are combined to formulate higher level concepts. These categories and their interrelationships become saturated with meaning and are used to construct grounded theory (Glaser, 1978). The fifth characteristic of qualitative research is that the primary concern is to find the meaning people attach to their surroundings that helps them make sense but of 27 their lives. Herbert Blumer (1969) describes the significance of meaning in symbolic interactionism as follows: Human beings act towards things on the basis of the meanings that the things have for them, such things include everything that the human being may note in his world...the meaning of such things is derived from, or arises out of, the social interaction that one has with one's fellows... these meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he (sic) encounters (p. 2). Blumer continues by saying that meaning occurs through the process of interpretation, which guides and forms an individual's actions. This perspective then suggests that people actively construct the world and as researchers, we follow this construction as it occurs and changes through time. With the above as a brief introduction to field research, I describe how the study was designed based on this methodology. Research Problem The selection of the subject area originates from my interest in the significance and meaning employment has in our lives. Many North America adults spend two thirds of their life working within an organization, thus it seems paramount that work time is productive, satisfying, and meaningful. Many reports of downsizing and its negative impact on the remaining employees, as well as those laid-off appeared regularly in the news! In fact, several clients from my consulting practice downsized during the time that 28 I conducted this study. I witnessed one organization downsize 500 employees, which included half of a management team I had been working with as a consultant. The origin of the research problem stemmed from conversations I had with colleagues and clients on the impacts of downsizing over the past decade. The affects of downsizing on "survivors" or remaining employees interested me greatly. Upon further investigation, it appeared that few researchers had examined the survivor's perspective. The research that had been conducted was primarily studied in a laboratory environment, which I felt could not capture the true experiences of employees involved in such a process. The original research question was "what impact did a downsizing have on remaining employees with regard to workload, emotional response, loyalty, and commitment to the organization?" One particular theory of interest pertained to resilience in employees to manage the downsizing process more effectively. However, after several months of an unsuccessful search to locate a willing participant organization, it became apparent that identifying a research site that would host such a study would be a significant challenge. Their reservations likely stem from the fact that downsizing is a very political and sensitive topic. Finally, a psychiatric hospital (hereinafter referred to as "The Hospital", to retain confidentiality) agreed to consider allowing me to study their downsizing. However, after several months of negotiating, the administration requested that I shift my analysis to a more neutral perspective. In particular, it requested that I examine the process of downsizing rather than the experiences of the survivors. Although the shift from one research problem to the other was significant, enhancing the understanding of the 29 downsizing process itself would also contribute to the body of knowledge on this phenomenon. Site Selection A single organizational site was selected as the sample for this ethnographic study due to the detailed descriptive data sought and limited time frame for the study. A single organizational case study provided the opportunity to gather detailed data regarding the downsizing process of one mental health institution. An opportunity sampling strategy was employed in order to identify the research site for this study. An opportunity sampling strategy is where researchers seize opportunities as they arise for the selection of a setting or they rely on successive participants to refer them to the next group or individual to study (Delamont, 1992). The process began by asking my colleagues in the business community to identify contacts at various organizations in different industries that may be interested in participating in the study. Using these contacts, I sent letters to five contact organizations at a time requesting participation in the study (Refer to Appendix A for a copy of the letter sent to the organizations). A follow-up telephone call was then made to the contact at each organization. All organization's contacted declined except one psychiatric hospital. The other invited organizations indicated that the subject of the study was too sensitive to allow an outsider to investigate at the time. The hospital that volunteered to be involved is a large psychiatric institution serving approximately 870 patients and employing 1600 staff. It took approximately 7 months of 30 negotiations to work out the design of the research project with The Hospital's administrators. Site Access I spent 7 months negotiating with The Hospital's administration to obtain approval for the study. During this negotiation process, the focus of the research was changed at the request of The Hospital. The original study was designed to investigate employee reactions to downsizing. The Hospital's administrators felt that this subject was too volatile given their current status in the downsizing process. Therefore, the focus of the study was shifted to examine senior management perspectives on the strategies used to downsize The Hospital. Hammersley and Atkinson (1983) suggest that researchers may utilize the access process to their advantage in that "the discovery of obstacles to access, and perhaps of effective means of overcoming them, themselves provide insights into the social organization of the setting" (p. 54). An initial letter was sent to a member of The Hospital's research committee whose name was given to me by a colleague. The research committee is responsible for assessing the research design and feasibility of proposed research involving human subjects at The Hospital. The committee member contacted my thesis supervisor at the University of British Columbia to express interest in discussing the proposed research. After preliminary discussions with the contact person, The Hospital's research ethics forms were completed and returned to this committee for approval. Over the next several months, periodic discussions occurred with The Hospital regarding the progress of the approval. It appeared that the committee had concerns 31 regarding the proposed study. I requested a meeting with the contact to discuss the study further, but he declined because formal approval had not yet been obtained for the study. He indicated that it was important to follow the rules as following rules has been the means of survival at The Hospital. One month later, the research committee chair sent a letter outlining The Hospital's concerns with the study. The primary concern was with the small sample size of the study. They felt the opinions solicited would not be representative of The Hospital staff as a whole with only five or six interviewees. They also had concerns regarding the amount of time that would be required of staff as participants in this study. In this correspondence, they also indicated that I had been assigned a new contact for this project. After further discussion and thought, I sent a letter outlining the proposed modifications to the research design: a larger more focused sample and a definition of the time required from each interviewee. Approximately 2 weeks later the research coordinator called to indicate that approval for the research project had been denied, and therefore, I would not be permitted to conduct my study at The Hospital. The research coordinator had no information as to why the study had been denied after 6 months of deliberations and negotiations. My supervisor and I reviewed our alternatives and decided that further pursuit of answers to this rejection was required. She proceeded to follow-up on this outcome with the senior executive from The Hospital responsible for academic affairs. After some discussion, The Hospital agreed to identify potential research design options. Several weeks later the three of us met to discuss an alternate research design. The 32 Hospital requested that the study focus on their downsizing policies, procedures, and decision making rather than the reactions of the remaining employees to the downsizing process. The participants in the study were also restricted to senior and middle management. We agreed. Final approval for the study was received from The Hospital several weeks later. During the course of the study, it was important to be sensitive to the individuals who had the power and authority in the setting (referred to gatekeepers) as these individuals seriously affected the amount and nature of the data collected. For example, gaining the trust and credibility from the President and Chief Executive Officer and the Vice President of Academic Affairs was critical not only to allow the study to be completed, but also insofar as it affected who I was allowed to interview and the information to which I was privy. The Role of the Researcher Participant-as-observer was selected as the most suitable role for this study because it combines the outsider and insider roles to some degree. The participant-observer role allowed me to participate in the setting as an interviewer, as well as, to informally observe activities in the surroundings. There were several potential benefits to be gained by selecting this role, including a reduced amount of time to gain acceptance, entering as a neutral player relative to existing groups, and stimulating uninhibited responses because a reduced threat of transmittal to others (Trice, 1970). It was important for me to assume one role full-time during this study so that I minimized the balancing required between roles and maximized the clarity of my role to 33 myself and the participants involved (Burgess, 1985). It was also important to define and communicate the researcher role to minimize problems of expectations and confidentiality in the research setting: Unfortunately, the observation aspect of this role was limited due to the nature of the setting. Minimal activity occurred outside of the interviews. For example, several times I waited in the coffee room between interviews to observe interaction between organizational members; however, virtually no activity occurred during these times. Reflexive Analysis Regardless of the role selected, it is critical to the validity and reliability of the data that I engaged in self-examination and criticism of the quality of data obtained and problems encountered throughout the research period: Hammersley and Atkinson (1983) refer to an important concept of field research called reflexivity. Reflexivity is the recognition that as researchers conduct observations, interviews, and the like, they are interacting with the respondents and their environment, and therefore, creating interrelationships. Delamont (1992) asserts that researchers should be highly conscious of these relationships and concentrate on understanding the effects they may have on the research. Reflexivity is a significant component throughout the research process and should be explicitly defined and analyzed in the results of all research in this tradition. By illuminating the interactivity in this regard, limitations are recognized, alternatives are assessed, and validity is tested. A reflexive analysis of my role as researcher is presented here. 34 I am a 31-year-old woman with 9 years of business experience as a management consultant and trainer, having worked within all levels of various organizations in North America. My business experience aided me in establishing credibility, communicating in the participant's language, and maintaining a professional relationship with the organizational members throughout the project. For example, business terminology such as quality improvement, customer service, and project management were frequently used in relation to The Hospital's downsizing and redesign process. I was familiar with and understood these terms from my work as a consultant. However, I was unfamiliar with a hospital's operations and environment and this may have hindered my understanding of the milieu to some degree. As an ethnographer, I entered an unfamiliar setting, as an unknown entity to the members of the setting. The members' impressions of my appearance, attitude, and general disposition likely had a significant impact on the type of information I had access to and the manner in which they responded to me. Similarly, my personal biases, values, and beliefs influenced my perceptions and interpretations of the setting and how I interacted with the individuals with whom I had contact. I attempted to enter the setting with an open, non-judgmental and self-aware perspective. However, obtaining site access was a long and arduous process. Due to the reluctance and caution with which the organization accepted the study, I expected the environment to be somewhat hostile and unfriendly. My initial contact with the organization was by letter to the vice-president of medical services requesting access for a master's thesis research project. I assumed this student role throughout the life of the project. This role served to place the . 3 5 members in the setting into a helping role and assisted me in managing my own uncertainty and naivete with The Hospital environment and research process. I shared my business experience as a consultant with one participant only and therefore preserved my student role. When personal opinions, values, or beliefs are made public in ethnographic research it may inhibit or modify the data collection process (Measor, 1985). Blum (1970) advocates that the interviewer limit the areas of exchange of information to objective events to minimize the potential for the interviewee to bias answers in order to please the interviewer. I attempted to assume a more distant, objective role as interviewer in this study. I chose this perspective primarily because the participants in this study were the drivers of the process and had a significant amount of ownership and personal investment in it. A more neutral perspective likely prevented them from feeling defensive about the downsizing process. Appearance management is one strategy which Measor (1985) suggests will assist in building stronger relationships with informants. By dressing professionally, I attempted to identify with the image expectations and ideological perspectives of the interviewees. In essence, with this approach I endeavoured to mask or minimize my identity and create a sense of similarity between myself and the interviewees in hopes that the interviewees would talk, without inhibition and about their own perspectives, thoughts, and feelings regarding the issue at hand. Goffman (1959) discusses the importance of presentation of self in sociological settings. He describes the significance of presentation as follows: 36 When an individual enters the presence of others, they commonly seek to acquire information about him (sic) or to bring into play information about him (sic) already possessed...Information about the individual helps to define the situation, enabling others to know in advance what he will expect of them, and what they expect of him (sic), (p.1) As a young, white, middle class, Anglo-Saxon woman, I was conscious of my appearance to The Hospital management. I attempted to manage my appearance where possible. I chose to dress formally in business attire to provide a sense of professionalism. My natural disposition is relatively friendly and pleasant. I smiled, exchanged the appropriate greetings, and shook hands at the beginning and end of each interview. I developed and practiced a description of my research in reply to participants' questions in this regard. Participants were naturally curious about what I was doing and it was important to know how to describe my role and the research study in a clear, concise manner. I attempted to provide a similar interpretation at each interview. I was somewhat nervous during the first interviews, which likely impacted my clarity in this regard. The interviews were restricted to two 1-hour sessions with each manager. The interview process itself felt comfortable. I am familiar with interviewing techniques as I frequently conduct interviews in my business work and I am currently studying to be a counsellor. The skills used in counselling are similar to some of the skills used to conduct an informal interview. Measor (1985) suggests that qualitative interviews seem to offer an opportunity for participants to talk about their work, grievances, and 37 the infringement that the interviews had on participants' schedules, thus I rarely allowed the interviews to extend beyond the 1 hour time limit. Some researchers (Measor, 1985; Pryce, 1979) suggest that respondents may interact differently with an interviewer depending on age, gender, and ethnicity, as well as other factors. Being a white, young woman likely affected the data I received from my interviewees. Finch (cited in Measor, 1985) suggests that respondents talk more freely about the subjective areas of life with women as emotions are more of a woman's domain in our society. I sensed that some of the male respondents did not feel comfortable talking about their personal experiences of the downsizing. This was evidenced when I attempted to ask direct questions and was met with responses regarding external forces rather than internal experiences. I presented myself as a non-threatening, information seeking researcher. I used the skills that I have learned as a researcher and counsellor to build rapport, trust, and respect early in the interview process. During one interview my "objectiveness" was questioned and I was compared to a reporter or journalist who wanted to uncover the "dirt" on a story. In another interview, I was continuously challenged on my ability to keep the information private. In both cases, I attempted to allay fears by confirming the confidentiality of the interview and reinforcing my position as an objective researcher. I suspect the political position and the organizational culture of The Hospital rather than my demeanor contributed to this lack of trust. ' The interviews may have been legitimized and formalized by the use of a tape recorder. However, this instrument may have also hindered the data collection process as almost all of the participants made reference at one time or another to the tape 38 The interviews may have been legitimized and formalized by the use of a tape recorder. However, this instrument may have also hindered the data collection process as almost all of the participants made reference at one time or another to the tape recorder with comments such as "oh, I forgot we were on tape." One interviewee asked me "Is this something you feel you need to record?...if this is part of your official study, then I will give you official answers." This situation took me off guard. I was unclear as to how to respond. I turned the recorder off and turned it back on later in our discussion. In summary, the participants responded to me with cautious openness. Given there was no previous relationship between myself and the respondents, and the highly political position of this hospital, no extremely sensitive information was revealed. However, clear and informative interviews transpired that provided a good understanding of the downsizing process and some insight into the organizational dynamics of The Hospital. Data Collection Data collection methods employed in this field research included a field diary, field documents, observations, and interviews (Spradley, 1980). Each of these techniques have specific methods and protocols for capturing and recording the information under study. The data collected is referred to as field notes. Data collection began with the first seed of thought for the study. The chronological development of the research problem was documented in a field diary. The field diary included notes on emergent ideas, initial meetings, progress, and informal 39 conversations. This diary also provided a forum for me to note my personal dialogue with the research process and data as it occurred through the progress of the project (Bogden & Biklen, 1992). I maintained a field diary throughout the life of this project. The main data collection technique for this project was the transcription of the interviews with executive and middle managers who participated in designing and/or implementing the downsizing process at The Hospital. The executive management team included the chief executive officer and five vice-presidents. Four middle managers were interviewed who were titled either planning or clinical directors. Two 1-hour Interviews were conducted with each of the 10 participants (Refer to Appendix B for the interview schedule). The participants were interviewed to gain insight into the impetus behind downsizing, the approaches used, and their role in and experiences with this process. The interviews in this study were conducted with an informal, open-ended conversational process of data collection in comparison to the more structured, formal techniques prescribed by the quantitative or survey methodologists. The interview schedule consisted of triggers designed to invite the informants to share new information, thoughts, beliefs, and values of the phenomena under study (Measor, 1985). (Refer to Appendix C to review the interview triggers and questions). This non-directive approach allowed the participant to answer from their own frame of reference (Schatzman & Strauss, 1973). The first of the two interviews conducted with each participant was informal and non-directive so that the researcher could develop an understanding of the cultural language, framework, and perspective of the participant (Spradley, 1980). The 40 interviews were initiated with a description of the subject of interest. An excerpt of the beginning of an interview with one of the directors provides an example of how the interviews were set-up: I am a masters student at UBC and am conducting my research on the process of downsizing as it has happened at your hospital. I am specifically interested in what has occurred, what your role was in the process, what you hoped to achieve, how information was communicated and so on. As you are talking I will ask questions to clarify. This interview will be the first of two. During this interview I would like you to talk about the downsizing process as you have perceived it over the years. I will not be too directive in this interview, but will ask questions as we go along. During the next interview I will be more specific and directive in my questions once I have gathered some information, I'll ask for clarification or elaboration on certain areas. The second interview focused on elaborating and clarifying the themes and concepts that arose from the initial interviews and field documents. I used the categories and themes of the initial analysis of the first interviews to guide the interview. I walked through the list of themes with the respondents (Refer to Appendix D for a list of themes reviewed with the respondents). They commented or elaborated on areas as we went along. During this interview, I also asked them about their personal experiences of this process as illustrated in this excerpt from an interview with a vice-president: Okay, the last area that I wanted to discuss with you was getting back to an issue related to your experience as a senior executive in this organization 41 going through a downsizing. As I reviewed this information, I sat back and realized the overwhelming amount of change you are experiencing and the enormous resistance you are receiving from certain groups and the long duration of the process and I thought, wow, you know, how do you manage it . all? How do you keep it in perspective? Nine of the 10 interviews were taped and transcribed to capture the details of the participants' experiences. Field notes were taken during the non-taped interview and later transcribed with additional thoughts and observations. Field notes were kept on a regular basis to record my thoughts, reactions, and observations of the organizational site and participants. Spradley's (1979) ethnographic interviewing framework was used as the basis for the interviewing process. Spradley's three primary ethnographic elements are explicit purpose, ethnographic explanations, and ethnographic questions. Explicit purpose is when the ethnographer continuously reminds the participant of the purpose and direction of the interview and the research. Ethnographic explanations provide the informant with explanations for requiring the type of information the researcher needs. For example, one interviewee (VP2, first interview) asked, "Well, tell me a bit about what you are looking at? What you are looking for? I am not trying to be too sort of obsessive, but help me out." My response was: Well, I am trying to get a description, in your language, of the process of downsizing at The Hospital in terms of how decisions are made, who makes them, how are decisions communicated and so on. And I am trying to 42 understand the process in sort of a chronological fashion from when you started downsizing to now. Different types of ethnographic questions were used to collect different types of information. Descriptive questions were asked which enabled the researcher to collect data on the participant's language and culture. For example, one question asked of VP3 during interview two was: "when you say institutionalized I think I have an understanding of that, but could you describe that in terms of what you mean?" Other data collection techniques were used to corroborate data. By collecting data using multiple methods, the validity and reliability of the data were enhanced and the robustness of the theory developed was increased. Field documents were collected from The Hospital. Document sources include reports, studies, letters, communication material, and organization charts about the field site (Refer to Appendix E for a list of these documents.) Documents were analyzed and classified for use as evidence and collaboration with data collected through other methods. Limited observational data was gathered during this study. Observations are subjective accounts of a researcher's perception of the setting being observed. Observations can be informal or formal. Informal observations provide a general, holistic perspective of the setting (Lincoln & Guba, 1985). These observations orient the researcher to the culture through the lens of an outsider. Formal observations record detailed descriptions of the conversations and events the interviewer captures during a period of time. 43 No formal observations were initially approved by The Hospital for this study. I did not pursue this avenue further because of the enormous amount of data already gathered during the interviewing process. Therefore, only informal observations were conducted and recorded. As mentioned earlier, these observations were limited due to the lack of activity at the research site during my attendance. Data collection and analysis occurred as a cyclical rather than linear process (Glaser & Strauss, 1967; Spradley, 1980). Hammersley and Atkinson (1983) suggest that the analysis of data is not a distinct stage of the research. The collection of data is guided strategically by the developing theory. Theory building and data collection are "dialectically linked." Therefore, as data were collected, a more in-depth understanding of the process formulated in my mind whjch allowed me to guide the interviews and ask more directed questions. The data collection process occurred over a 5 month time period. During this period, at total of 20 interviews were conducted with 6 executive and 4 middle managers. Reports, memorandums, and other field documents were collected from interviewees and have been used as reference and for corroboration whenever appropriate and possible. The information collected in the study was coded and analyzed using a computer program called Ethnograph (V.4.0). Data Analysis Analysis is a systematic examination of data to determine its parts, the relationship among the parts and their relationship to the whole. Glaser and Strauss's (1967) constant comparative method of analysis as described by Hammersley and Atkinson 44 (1983) was used to code, organize, and theorize the data collected in this study. The five steps to this process are outlined below. Although, these five stages are useful for conceptualizing the analytical process, in practice, the process is iterative, concurrent, and more creative than the stages illustrate. In the first step of analysis, I perused the data to obtain a holistic picture of the general types of information collected. Several sensitizing concepts or general themes developed from the review of the data and the literature. These concepts became the initial categories by which I coded and organized the data. In general, 'sensitizing concepts' provided a basis for structuring the data during the initial collection period (Blumer, 1969). Sensitizing concepts are repeated key words, images, or phrases embedded in data (Refer to Appendix F for a list of sensitizing concepts). As additional data were collected, these concepts were identified, broken into smaller typologies, or merged to form larger conceptual categories. Each category and typology was assigned a unique number or color. Data were coded by marking every instance of each categorization with it's unique number or color in the field notes. In the second step of analysis, every instance of each category located in the data was coded by name based on the identified categories. Other categories and subcategories emerged from the data through this coding process. Instances that fit more than one category were coded and assigned to both categories. As data were being coded patterns and themes emerged that were related to the research question. The categories were reorganized and combined and new categories and subcategories emerged during this process. These categories and themes were 45 mapped and compared to existing research literature (Refer to Appendix G for a list of codes and their descriptions). This comparison assisted me to formulate new ideas and interpret observations about the process and experience of downsizing. Relationships, similarities, and differences among the categories and their subsets continually surfaced and transformed through further analysis and data collection. Glaser and Strauss (1967) call this the constant comparative method from which they suggest theory emerges from the ground up in an inductive process. However, Hammersley and Atkinson (1983) suggest that pure inductive analysis rarely occurs because researchers often utilize theoretical ideas, hunches, and stereotypes to direct their research and analysis. They suggest that analysis of qualitative data is both an inductive and deductive process. The third step in the process was validation. The confidence and trustworthiness of the interpretation of the data was gauged through a validation process to assess the extent to which the categories, typologies, and themes reflect valid and reliable data (Lincoln & Guba, 1985). "This process allows the researcher to relate different sorts of data in such a way as to counteract various possible threats to validity of the analysis" (Hammersley 8c Atkinson, 1983, p. 199). Macmillan and Schumacher (1989) identify three strategies of analysis: negative evidence, triangulation, and data displays. The primary validation strategy used for this research was triangulation. Triangulation is the process of cross validating the various types of information to determine their degree of corroboration (Denzin, 1970). Two types of triangulation were used: data-source and respondent validation (Denzin, 1970; Hammersley & Atkinson, 1983). Data source triangulation involved corroborating inferences drawn from one 46 source with other respondents or sources. Respondent validation was used in the second interviews to allow respondents to elaborate on inferences, patterns, and themes which emerged from the data by reviewing the research findings with them. Negative evidence strategies were employed where available to provide quality verification on the data collected. Discrepancies and exceptions to the emerging themes and patterns were noted. At this time, data were corroborated through documents collected from The Hospital with regards to downsizing. Traditionally, the fourth and fifth stage of data analysis in the field research process are model building and theory development respectively. Model building is the process of identifying an order or structure to the categories and subcategories based on the research question. Theory development is the process of identifying new connections or relationships from the data and with existing knowledge. Model building did not seem to suited to the data gathered during this study. Various physical representations of the data from this study were attempted, but a logical structure or model did not seem to be appropriate for this study. Rather, the interpretations of data were compared and contrasted with existing theory to reflect on interrelationships, missed contributions, and connections. Significant links to existing theory are presented in the analysis and interpretation chapters of this report. 47 CHAPTER V. DESCRIPTION This chapter of the paper is devoted to providing rich description of the organization setting, culture, participants, and downsizing process collected from the interviews, informal observations, and field documents. The Organization and Its Members The Setting The Hospital is a large 80-year-old psychiatric institution with over 50 historical buildings. The Hospital occupies approximately 255 acres of land in a suburban community of a large metropolitan city. The Hospital grounds view like a well manicured park with huge beautiful trees, benches, and enormous lawns. The setting is peaceful and serene. Patients seem to freely stroll the grounds. Due to the downsizing process, some buildings on The Hospital grounds are now closed. These buildings offer reminders to the patients and employees of meaningful events and activities that have occurred over the years. The Hospital admits and treats persons with serious mental illnesses from all over the province. The three clinical programs currently in operation at The Hospital include inpatient assessment, treatment, and rehabilitation. The current patient population totals approximately 870 patients in these programs. Since 1988 The Hospital has been operating under the guidance and direction of a board of trustees appointed by the government. The board of trustees employs a management team to administer The Hospital affairs. The management team consists of a president and chief executive officer and five vice-presidents of various operational 48 areas. The Hospital employs approximately 1600 staff who are unionized with the exception of roughly 30 managerial positions. Job classifications of the employees include nurses, social workers, financial officers, administrative officers, secretaries, computer operators, trades persons, clinical and laboratory technicians, psychologists, teachers, dentists, pharmacists, food service workers, and others. The Hospital has been shrinking in size since the early 1960s. The advent of psychotropic medications was the beginning of a major deinstitutionalization process throughout North America. Other factors contributing to the deinstitutionalization process include a change in philosophy of patient care practices and rising costs of psychiatric care. In 1991, The Hospital was mandated by the government to formally downsize to a smaller, more specialized type of tertiary care facility over a 10 year period. Tertiary care is defined as an in-patient mental health service for people whose mental health cannot be stabilized or restored in the community or general hospital mental health services. The Hospital shrunk in size from 4000 to 1400 beds between the 1960s to the late 1980s. Although The Hospital was already reducing in size informally, formalizing the downsizing process ensured that the funding for each bed closure would be transferred to the community and general hospital sectors for primary and secondary programs and service development. The funding, or fiscal framework agreed upon by the government was roughly $200 per bed per day for each downsized patient. This framework was established during the second year of formal downsizing, which began in 1993. 49 The Participants The 10 participants interviewed for this study were senior and middle managers in their 40s and 50s. The president and chief executive officer, one vice-president, and one middle manager were women; the rest of the interviewees were men. Their length of employment with The Hospital ranged from 2 to 7 years. The senior executive and some middle management offices were located in the administration building. The clinical managers' offices were located in residential buildings. All participants seemed to be extremely busy as scheduling interviews was a challenging task. Rescheduling interviews was not uncommon. During some interviews support staff would interrupt with important information or phone calls. Seven of the interviews were conducted with participants who had offices in the administration building that is centrally located on The Hospital grounds. At one time the building was used as a dormitory for nursing staff. The two-story structure has pictures of The Hospital nursing graduates all along the walls on both floors. The doors and windows are framed with mahogany. The main floor has a large sitting and dining room finely furnished with antiques and collectibles. The inside of the building has a sense of formality and tradition. All senior executive offices were situated along the east side of the building, typically with secretarial staff in adjacent offices or across the hall. One middle manager had an office on the east side of the first floor. A small coffee room was located centrally on the west side of the building. 5 0 Another middle manager was situated in a smaller two story building not far from the administration building. The white walls of the halls in this building were almost completely vacant. Few people were seen walking around or talking informally. This environment felt somewhat sterile. The clinical directors were located in their respective program buildings. In both cases, patients were strolling the halls and several patients said hello or uttered some words as I passed them. These premises reflected a traditional hospital setting. Most of the interviewees were easy to talk to and seemed to share information freely. The participants dressed in semi-formal business attire. The majority of the participants had extensive business knowledge. In particular, the senior executive team and two directors were well-versed in the latest business trends such as quality improvement, customer service, learning organization, and change management. They have researched the downsizing and organizational change literature. A group of them have written a paper to be published in an American journal on the downsizing process at The Hospital. Their paper is focused on the process of downsizing at The Hospital and is similar to the study that I was permitted to conduct. I found this surprising given two papers will now be written on the same subject. Although, I have not discussed this issue with The Hospital administrators, I would explain their behaviour as follows. First, The Hospital is a government organization and thus subject to political and public scrutiny. Over the past couple of years they have had investigations conducted by the Auditor General Office and the Ombudsman. Their political status likely engenders sensitivity in hospital administrators resulting in protective behaviour. Second, The Hospital seeks to establish a strong relationship with 51 the University of British Columbia. By designing a less intrusive study (i.e., only interviewing managers), The Hospital maintained relations with the University while minimizing risk of exposure. This I would consider a very natural reaction given their political position and the sensitivity of downsizing individuals with mental illnesses. The difference in their paper and this research project is that their paper focuses primarily on the downsizing process with minimal reference to context. This research project moves beyond the downsizing process itself to examine the context of the process and the implications for counselling psychology. The president and chief executive officer seemed assertive, articulate, independent, and strategic. Her attire was conservative, she dressed in slacks with a fully buttoned-up blouse. She seemed aware and knowledgeable of the power and control her position affords her. In one of our conversations she said "I'm driving the train and that feels a whole lot better than being a passenger on a train that is being driven." She indicates that she has a personal inclination to embrace change in her life. She spoke frankly in our conversations-several times even using swear words. Many respondents spoke of her with respect and admiration. She apparently always remembers their birthdays with a card or a cake. She values her senior executive team. This quote from our first interview illustrates her perspective in this regard: I am the eldest of eight, so I am pretty directive, but I am also pretty keen to have the group make decisions. I really feel a whole lot less vulnerable if it is a group decision. I think the group brings (pause), we've got a great group of people and each of them bring their own expertise and I don't have a whole lot of expertise. I just come in with one perspective and one set of experiences so 52 I really do believe a team decision is a better decision. I believe that from the bottom of my heart. I know it from lots of personal experience. She was the primary gatekeeper at the site. She would not permit certain documentation to be released to me at the onset of the study. For example, she would not permit me to review the results of a staff satisfaction survey or schedule a formal observations session. However, she was honest and forthright in her reasons for her refusal. She established clear boundaries in our first interview. The staff satisfaction survey feedback apparently contained very negative comments. She indicated that she felt some staff would be embarrassed if the information was released to others. She also suggested that the results had no bearing on my research because the focus had shifted from reactions to process. The vice-presidents were equally professional and articulate. They also expressed strong beliefs and values around team work, which is not surprising given many of them were hand picked by the president. This group seemed to have a strong bond and tremendous respect for one another. They shared a strong underlying philosophy and belief about mental health reform that motivated them to continue their downsizing path despite the sometimes overwhelming opposition received from employees, patients, and families. It felt more challenging to get some of the men in this group to discuss the personal side of downsizing, whereas, the women seemed open and candid about their personal experiences in coping with the process. For example, the following quote is from one of the female interviewees: 53 Like I make sure when I leave here at night, as long as its not dark, that I go home and put on my running shoes and I go around [XYZ] Lake. I don't run, I walk-three times around if it's a bad day. And you know I need that time to just get in touch with nature and look at the ducks and slow my pulse right down. Then I can go home and eat supper. None of the interviewees discussed their negative emotional responses to the downsizing process. This outcome would be expected given I am a stranger and a student researcher, and they are senior executives in a political organization. These managers' political savvy may have also contributed to their limited personal disclosures. Given their busy schedules and status, they were respectful and considerate in our interviews. They seemed genuinely interested in talking about the process of downsizing at The Hospital. One interviewee also spent time exploring career plans with me. This group readily provided documents and reports in relation to my study. They were helpful in all respects. The middle managers were also professional and respectful. A few of them shared similar beliefs and philosophy about mental health reform. However, two middle managers focused more on job security and operational issues than other interviewees. This group was able to provide a better understanding of the impact of downsizing on the employees and patients, in contrast to the senior executives who provided more of a strategic understanding of the process. These managers seemed primarily concerned with patient and staff well being as well as job security. This group seemed more reluctant to release documents and reports to me. When I asked one respondent for a 54 copy of a report, he indicated that he would not be able to find it and directed me to the CEO's secretary. Almost all of the participants seemed acutely aware that our interviews were being tape recorded. One interviewee would not allow our interviews to be taped at all. The same interviewee indicated that I was getting a slanted view of the downsizing process at The Hospital. Another interviewee indicated that I would get the party line because the interviewees did not know me or trust me. This person indicated that The Hospital is part of government and therefore subjected to political scrutiny. He implied that senior managers are rehearsed and practiced in their dealings with the reporters and journalists. They have a stake in painting a picture that makes them look good. Although, I was aware and sensitive to this issue, for the most part, this was not my experience of the process. First, the information being solicited was not highly sensitive, in fact, much of what I was told was available in the many reports and documents given to me. Most of the information shared with me in the interviews was substantiated through the government reports and other field documents, many of which are readily available to the public. Second, many references were made to the challenges The Hospital faces and there seemed to be a direct acknowledgment of the mistakes that have been made in the process. Many of the discussions seemed frank and open. However, I did sense reluctance from the middle managers to discuss the downsizing process critically or personally. The Organizational Culture A description of The Hospital's culture was not a formal part of this research project. However, many of the interviewees referenced The Hospital's culture. In 55 addition, The Hospital's administration permitted a student to conduct a cultural analysis of the organization. Therefore, it is discussed briefly. Schein (1992) formally defines culture as the following: A pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as a correct way to perceive, think, and feel in relation to those problems, (p. 12) The student characterized The Hospital's culture as a traditional, institutional, professional-knows-best culture. The results of this study concur with that analysis and expand the characterization to include two additional elements: bureaucratic and, distrustful. First, the organizational culture was described as institutionalized and paternalistic. Institutionalization was described as a process where people lose a sense of goals and progress and tend to live only in the here and now. Life then becomes routine and reason or judgment are forfeited to rules and procedures. A government report (Listening: A Review of The Hospital) describing an investigation into the administrative practices of The Hospital concluded that the majority of the staff are caring and sincere professionals in their attitude towards and treatment of patients. However, some staff in The Hospital reportedly delivered patient care consistent with an institutionalized setting including hierarchical decision making, regimented daily routines, and administrative rather than patient-centered interaction. Psychiatric care in itself may be characterized as a nurturing, benevolent type of work. Many of the staff at The Hospital were trained in asylum or custodial care and 56 have practiced this type of mental health care for several decades. Custodial care provides a professional-knows-best type of treatment where clinical staff take the responsibility for acting in the best interest and on behalf of the patients. This model is more hierarchical and authoritarian based. The view of the patient is on the past history and present needs of the patient rather than on the future potential for rehabilitation. Several respondents described staff at The Hospital as "a big family." Many of the staff were trained and have worked their entire career at The Hospital. Inter-employee marriages are common. Other family members such as siblings, parents, or children are also employed at The Hospital. Considering this scenario, an entire family income could be devastated with this downsizing if more that one family member were displaced through this process. A second cultural characteristic identified by the participants was bureaucratic. The organization, as an arm of the government, has many policies and procedures to follow. The trade union contract agreements introduce a level of bureaucracy for the organization with respect to their human resource processes and procedures. One interviewee described The Hospital as follows: ...Large organizations are not inherently customer friendly. And the larger they get, the less customer friendly they get. They become quite bureaucratic and folks begin to rely on fixed routine which is not flexible enough when you are dealing with individual customers. This organization is not any different. One participant described how this bureaucracy created challenges in the organization as follows: 57 When you talk about people who are experiencing change, and you say one of the most important things is that they feel safe, and you need to create a safe environment for them to talk about their fears or whatever, when you're in an organization that's riddled with policies and very bureaucratic, that's not exactly what I would call safe. The third cultural characteristic identified by the participants was distrusting. The distrust between the organizational levels was reported to stem from several sources. First, front line staff receive mixed messages from management. For example, the study conducted on The Hospital's culture reveals the following: It appears that those who are resistant to change do not trust management. They perceive management to have a hidden agenda and not presenting the real information to staff. Further, these employees feel that management should give staff specific details associated with the redevelopment of [The Hospital] and less emphasis on generalities. Second, The Hospital is part of government and thus subject to political changes and influences. For example, there is a perception that the government has made decisions in the past and those decisions were either reversed or not implemented. Prior to 1992, staff believed that formal downsizing would not actually come to fruition because it had been threatened for many years without action. Finally, The Hospital staff are members of several powerful trade unions. Some respondents suggested that staff have a union mentality. Unions are designed to protect its members from poor work conditions and counterbalance the power and 58 control of management. This design often creates an organizational dynamic of management against staff. Typically, trust between the two sides is low. Curiously, however, the senior executive team enjoys a high level of trust and support amongst themselves. Numerous references were made to the incredible sense of team and camaraderie felt at this level. One participant described this experience as follows: I carry the torch for a while then I give it to (person x). She'll carry the torch for a while then she'll pass it on to (person y) and he'll take it. Six weeks later he'll come around and I take it and carry it for a while. However, the trust does not extend far beyond this team. One participant would not allow the interview to be recorded and repeatedly told the researcher not to quote him/her. If I did, he/she would deny it. When questioned about these concerns, I was told that no one was trusted in the organization and retribution was feared. At one point this interviewee reported that he/she was encouraged to support senior management's direction, regardless of personal concerns or opposition. The Hospital administrators are planning to change the culture from an institutional, paternalistic culture to one that is more patient-centered and collaborative in nature. The key components of the new culture include customer service orientation, empowerment, continuous learning and education, teamwork, reward and recognition, and calculated risk-taking. They have identified four strategic thrusts to foster this cultural change: meeting or exceeding customer requirements, developing partnerships, managing change, and enhancing the academic role of The Hospital. 59 The Hospital has established a cultural transition team. A recent internal newsletter described the team as follows: The cultural transition team concerns itself with the day to day working environment staff and the impact the many changes are having on this environment...The team is responsible for designing a cultural change plan/process that will moderate the impact of transitions and assist staff with coping. Several interviewees referred to role modeling as an additional method of transforming the culture. They view themselves as key role models in this process. The senior executive team's vision of this new culture is also heavily linked to the redesign of The Hospital discussed later in this chapter. Patient Downsizing This section describes the downsizing process since its onset in 1992. First, the external influences effecting the downsizing effort at The Hospital is presented. Next, the downsizing process itself is described. The Hospital has been informally downsizing for three decades, but this process was not planned, structured, or consultative. In the 1980s, the government moved to reform the mental health system. The objective of this reform movement was to create a comprehensive, integrated system of mental health care. Figure 1 illustrates some of the significant events that occurred in the downsizing process over the past decade. 60 D O W N S I Z I N G R E L A T E D E V E N T S •Mid 80s Government initiated consultation on mental health reform •1987 Mental Health Consultation Report •1988 Established Board of Trustees •1990 Mental Health Initiative Report •1992-93 Hospital mandated to downsize 105 beds Downsized 105 beds, 99 employee positions Developed transition assistance program (TAP) Royal Commission into Health Care & Costs •1993-94 Downsized 50 beds, 78 employee positions The Hospital Organizational Culture Report Fiscal Framework Established Auditor General's Report on Administrative Fairness Staff Satisfaction Survey •1994-95 Downsized 63 beds, 69.5 employee positions Received approval for 320 bed tertiary care facility Report on The Hospital's Administrative Practices Developed multi-year plan Human Resource Plan Figure 1: Downsizing History & Related Events 61 During the mid-1980s, the government began a consultative planning process of the downsizing that involved various individuals and groups involved in the mental health system. These participants represented a variety of perspectives including families, consumers, service providers, interest groups, and educational institutions. In 1987, the government delivered a report based on this planning process that outlined a strategy to reform the mental health system that included replacing The Hospital with a 300 bed tertiary care facility. A second government report was released in 1990 that outlined a plan for implementing the recommendations of the 1987 report to replace The Hospital. This second report also outlined requirements for additional funding to (a) develop community mental health services and facilities, (b) extend the implementation period from 5 to 10 years, and (c) allocate $2.6 million per year to transition costs. However, no formal downsizing process was initiated. In 1991, the government conducted a Royal Commission into the management of costs and services of the mental health care system. This report found that no action had been taken to implement the policies previously recommended in relation to mental health care reform. This report recommended that the ministry of health develop multi-year plans and priorities for the redevelopment of the mental health system including replacement of The Hospital. In the spring of 1992, the government mandated The Hospital to downsize 105 beds for the 1992-1993 fiscal year. This decision was made by the government with little consultation with The Hospital or community mental health care administrators and staff. Furthermore, the development of community residential programs had not yet occurred to accommodate the patients affected by the downsizing. 62 During the first formal year of downsizing, The Hospital closed patient beds through attrition and community placements. Patients were identified from lists of patients who were currently waiting to be discharged to a community facility. All patients during this year were placed in existing residential programs in the community or the general hospital mental health system. Approximately 99 full-time equivalent staff positions were eliminated during this year. Most of these staff positions were downsized by attrition, placements, and transfers. (See Table 1 for approximate downsizing statistics by year). The Hospital identified three wards to downsize during the first year that would accommodate the 105 bed reduction requirement. The ward closures were accomplished by discharging some patients to existing community facilities appropriate for their needs and by restructuring other wards to accommodate transferred patients. At this time, patient's characteristics and individual requirements were assessed using a variety of needs assessment tools. This assessment provided the basis for matching the patient care requirements to the facilities and services available in the community. Table 1: Approximate Hospital Downsizing Statistics by Year Year Bed Closures Patients Employees Funding Downsized Downsized Transferred 1992-1993 105 67 99.0 $6.0 Million 1993-1994 50 46 78.0 $3.7 Million 1994-1995 63 50 69.5 $3.0 Million Total 218 163 246.5 $12.7 Million A transition assistance program was established during this year. This program provided clinical assistance to downsized patients for up to 5 days during the first 6 63 months of a community placement. This assistance is provided through patient visitations and consultation with community service providers. A variety of clinical disciplines have participated in the transition process including nurses, psychologists, social workers, and dietitians. The participants considered the transition program to be successful. Approximately, 90% of downsizing patients access this program. The success results from the patient being transferred to a new environment with the comfort of familiar faces and support. The program also provides mental health care workers with the opportunity to assess the new environment to ensure that it adequately meets its objectives. The program provides a critical bridging component for both the patient and clinical staff in the transition process. It addresses the patient's fears and trepidation about his/her new environment and the staff concerns regarding the safety and well-being of the patients. The staff perhaps do not endorse the program as enthusiastically. A July 1994 downsizing evaluation report indicates that hospital staff were perplexed about the program. The report reads: There was considerable confusion and concern expressed in the focus groups about the transitional assistance program (TAP); what TAP is and what it is used for. One question raised was the number of staff accompanying a patient to a community placement. Another concern raised by the nursing participants was their compensation for assisting a patient in the transition to a community placement, (p. 21-22) 64 A patient monitoring program has been established to track the whereabouts and progress of patients in the community. This program evaluates the placement of patients to ensure that the adjustment to the community environment is optimal. If the placement is unsuitable for the patient, they will be returned to The Hospital, and if possible, to the ward from which they originated. One group of 10 patients downsized in the first year of the process were returned to The Hospital shortly after placement because the facilities and services were ill-suited to this population. The community resources were just not prepared for this particular patient population. At the beginning of formal downsizing, The Hospital administrators and staff were surprised that the government carried through with the initiative in light of many years of unfulfilled warnings. The Hospital reacted quickly, but struggled with the lack of planning time and vision. They recognized the need to partner with the community in this process in order to ensure its success. The community needed to identify how many patients they could accommodate based on what services they could provide. In 1993, The Hospital hired a new president and CEO. This change in leadership was not explored in any depth in the interviews for this study. However, the existing president seems pivotal in that she is setting a clear direction for The Hospital and ensuring that vision is achieved. She has also established a strong team atmosphere amongst the senior managers. The second year of downsizing proved to be more consultative and more community driven, at least in theory. Although only two wards were closed during the second year of downsizing, the patients who were discharged under downsizing came from 17 wards in these two programs. A lot of transferring and restructuring of patients 65 on each ward occurred. Because so many wards were involved in the process, a large number of staff working in The Hospital were affected by the downsizing during this year. To assist in the patient identification process, patient profiles for each downsized patient were developed by multi-disciplinary teams. This profile outlined the patient's history, current care plan, and mental health services required. A fiscal framework was also established during this year. The fiscal framework identifies the amount of funding to be transferred to the community with each bed closure. An additional challenge into the process was introduced with this new framework because downsized patients were found to be more attractive to the community because they were transferred with resources. The regular discharged patients do not transfer with funding, and therefore are less attractive to the community mental health service providers. However, the downsized patients often have a higher acuity of mental illness than others. It is important to note that the normal admittance, treatment, and discharge processes have continued throughout the downsizing. During the third year of downsizing, The Hospital established a bed reduction protocol for identifying and closing downsized wards. The management committee first identified the general type of ward to be downsized, for example, one geriatric and one adult ward. Next, a multi-disciplinary team, consisting of head nurses and doctors, from each of the identified areas, worked with a facilitator to determine which specific wards to downsize. The program director, director of nursing, and head nurse communicated this information to the ward staff. This process proved to increase the level of involvement and decision making of middle managers, thus obtaining more buy-in from 66 front line staff. Rather than senior management giving directives from their distant perspective, this approach involved those who worked with the patients on a daily basis in the process. In July 1994, The Hospital commissioned a consultant to evaluate the 1993-1994 downsizing process from the perspective of the staff. The objective of the evaluation was to assess the effectiveness of staff preparation, problem resolution, communication, and patient placement with regard to patient downsizing. Four 2-hour focus group interviews were conducted with 32 direct care multi-disciplinary team members directly involved in the downsizing process. The overall conclusion was that the staff did not support the decision to downsize the two wards; however, once staff realized the wards would definitely be closed, the process was managed well. The report proposed several key recommendations. First, The Hospital needed a vision in the form of a strategic and operational plan to guide the downsizing initiative. These plans would provide logic and rationale in determining wards to close and patients to downsize. Second, recommendations were made with regards to the protocol of community placements. For example, one person from the ward should be assigned the responsibility of coordinating closure of the ward and one person should be assigned the responsibility of informing patients and their family of any decisions effecting the patient. This person would also be required to notify the team when such notification occurred. Third, the protocol process also centered around recommendations concerning communication and involvement. For example, two recommendations proposed in the report are as follows: 67 6) That a summary assessment of patients to be placed internally be prepared with contribution from all disciplines and that, for purposes of placement, the primary nurse communicate that assessment. 7) That all disciplines are represented, and participate in, discussions about where patients should be placed within The Hospital, (p. 4) During the first 2 years of the patient downsizing, the organization did not give strategic consideration to what services would be most important to protect for the new hospital. The downsizing was planned on a year-by-year basis. A comprehensive long-term plan of the downsizing and replacement facility had not yet taken shape. A long-term plan would have identified a set of expectations with regards to patient transfers and funding, new programs, and services, as well as staff requirements. Staff reportedly grew frustrated and angry with management during information sessions because few details regarding their future were provided. The need for a multi-year plan was identified in a government audit report released in 1994. One major conclusion drawn in this report was that The Hospital did not have a comprehensive long-term plan to work towards and evaluate progress against. This plan was required to provide a well-documented set of expectations for the scope and time frame of the undertaking. This report also identified a need for a long-term human resource plan that would outline the strategies to be undertaken for reducing hospital staff from the current levels. A multi-year plan did begin to take shape after formal approval of a 320 tertiary care facility in December 1994. A draft multi-year plan was completed during the spring 68 of 1995 at which time it was communicated to staff through information sessions delivered by senior management. It is curious that leaders in the mental health care system did not take the initiative to develop a multi-year plan, perhaps yet more startling is the fact that the hospital leadership took little initiative insofar as The Hospital was facing replacement if not closure. References to the size and direction of the replacement hospital were clear in the 1987, 1990, and 1991 government reports that provided the foundation for discussion and planning with the various stakeholders in the system. For example, the 1987 report states that: There will continue to be a need for some medium/long-term psychiatric inpatient care and rehabilitation such as provided at The Hospital. This capacity must continue to exist for the benefit of "patients who do not fit" -the most severely and chronically ill, for whom adequate assessment and treatment is not possible within the acute hospital or community outpatient settings, (p. 13) Employee Downsizing Employee reduction is driven by the number of annual patient bed closures. In this section I describe strategies used to downsize the work force. I also provide a description of how communication is effected with employees, including the messages management attempts to convey to them and the types of support mechanisms in place to assist employees though the transition. 69 Work Force Reduction The primary work force reduction strategies employed by The Hospital are attrition and transfers. No layoffs have reportedly occurred to date. Other strategies that The Hospital has employed to reduce the work force size are retirements, auxiliary hires, and shifts to part-time employment like job sharing. Table 2 illustrates the breakdown of the work force reduction strategies employed during the first 2 years of the downsizing. Table 2: Type of Work Force Reduction Strategies used from 1992-1995 Work Force Reduction 1992-1993 1993-1994 1994-1995 Strategy Percent (%) Percent (%) Percent (%) Attrition 39.2 32.1 19.4 External Placements 29.4 35.8 27.3 Internal Transfers 16.2 5.1 2.9 Retirements 7.1 14.1 38.8 Auxiliary Reductions 5.1 6.4 10.6 Part-Time Positions 3.0 4-3 1.0 Severance 0.0 2.2 0 Total 100.0 100.0 100.0 Employee transfers or placements have occurred internally and externally. External placements have occurred primarily to community mental health programs. The Hospital has arranged for some restricted competition in this system to ensure The Hospital's nurses are placed in community mental health nursing positions. Employees can also transfer internally into vacant, untargeted positions within The Hospital. For example, during 1992-1993, 15 health care workers were retrained as nursing clerks. This retraining program was funded by The Hospital. 70 Auxiliary staff have been hired under the assumption that they will be the first employees to be laid off if that strategy is required in this process. They are considered temporary staff and are told upon selection they will be employed with The Hospital for a maximum of 3 years. These employees do not have access to transitional funding. This employee population is often younger and seeks permanent employment; therefore, they are likely to leave The Hospital once a more secure position is obtained elsewhere. This revolving door of employees presents challenges to management in training, scheduling, and recruiting. Many organizations offer retirement packages as a method of downsizing their employee base. The Hospital has not been permitted to include early retirement settlements as a method of reducing the work force. Retirement packages are a costly means of downsizing. The government has not approved of early retirements because it will begin downsizing in the near future and fears The Hospital will set precedence for other government agencies. The administration has reviewed this decision with the trade unions. This issue may become a key negotiating point for the union in the upcoming collective agreement negotiation process. To aid in human resource planning, The Hospital developed a comprehensive employee profile questionnaire. The questionnaire requested information from the employees on occupation status, professional credentials, education, skills and competencies, and future plans. Approximately 70% of the employees completed the profile. The profile is intended to assist The Hospital in staff development, job placement, and human resource planning as The Hospital progresses through downsizing and redesign of the new hospital. 71 Employee profiles has been input into a computerized human resource information system. This system will be maintained with updated employee information and its currency was considered critical to the success of human resource planning for the future. The future plans section of the survey bore several interesting results. One significant result is that 65% or 840 employees indicated a desire for job placement at the new hospital. This is likely a major challenge for the organization given the new hospital will be a 320 bed facility. Forty-five percent or 572 employees suggested they would consider a career change. Twenty-one percent or 264 employees indicated they would relocate within the province. Seventeen percent or 223 employees will retire between 1995-1999. (Refer to table 4 for statistics on retiring employees). Table 3: Retirement Statistics for Hospital Employees Year of Retirement No. of Staff to Retire Percent 1995 35 2.7% 1996 35 2.7% 1997 32 2.5% 1998 50 4.0% 1999 71 5.5% After 2000 571 45.0% Total to Retire Before 2000 223 17.4% Reactions to the downsizing seem to differ based on the hierarchical levels of the organization from employees to middle management to senior management. Each group's reactions are discussed. 72 Employee Reactions Employee reactions to the downsizing are consistent with the reactions reported in other studies. The primary emotional reactions were anger and frustration. However, the whole range of emotions were reported. Other key employee concerns related to job security and patient well-being. No plan had been communicated with regards to the future vision of The Hospital, and therefore, employees had no information on which to plan their future. Also, there was a lack of confidence in the community system being able to provide adequate care for their patients. The loss of significant relationships with patients including their paternal role likely evokes significant emotional responses from employees during this process. A staff satisfaction survey was conducted in the fall of 1994. The overall response rate to the survey was low (20%). Although, the survey results were not made available to me for this study, a bulletin from the president to the staff responding to the results was reviewed. The bulletin indicated that the staff were primarily concerned about job security and the slow development of community services to replace the downsized hospital services. This theme was consistent with information gathered from the interviews. The community has used the money transferred from The Hospital to invest in existing mental health services and has been slow to develop new services to replace the downsized programs at The Hospital. Consequently, some staff take little comfort in continuing to downsize. This study occurred during the same time that I was applying for and negotiating with The Hospital to conduct this research project. The results of the study are what prompted The Hospital to initially reject my study. Middle Management Reaction A large majority of the middle managers were described by the participants as being unsettled and overwhelmed. These managers handle their regular responsibilities and in addition they must deal with fluctuations in staff levels due to the continuous migration of staff arising from a lack of job security. Unstable staff levels create challenges in manpower forecasting and scheduling. Many of these managers have not committed to The Hospital administration's vision. For the most part, they have not worked with their manager or the president to identify individual needs and aspirations or develop a personal plan for their fit into the new organization.. Due to this lack of planning and the changes expected of them, the managers are greatly concerned about personal job security, staff job security, and patient care. In addition to dealing with their own insecurities, they are frequently confronted with staff concerns regarding the same. They also witness patients and families working through the transition process. With the exception of a few seminars and workshops, middle managers have not been directly targeted with any human resource support initiatives, Middle managers, however, have a great-deal of informal power andinfluence in an organization: They guide, coach, and motivate staff directly. They also have the ability to; block communication and distort meaning as they are often the direct channel of communication. Given the critical position of the middle manager in a major change effort, it is curious that The Hospital has not extended greater energy in securing their involvement 74 in the process and commitment to the goals. They could play a key role in dealing with the emotional reactions and aligning staff in a common direction. Senior Management Reaction The Hospital's senior executives function like a high performing team. Many of these respondents echoed sentiments of being a close knit, supportive group. Some of the characteristics they attributed to themselves include patient, modest, creative, bright, fair, and good communicators. Several themes with regard to this team of leaders emerged including a common philosophical perspective, an unwritten code of ethics, a large capacity for change, and an ability to maintain perspective. Each of these themes is reviewed. First, these managers seem to have a common philosophy regarding mental health reform. They are absolutely committed to reforming the mental health system based on the principles of improving the quality of life and mental health of patients. This team has identified and is committed to a common vision. They are working to achieve a common goal. They established this commitment to each other and the vision by meeting for one half day each week to resolve problems and address new challenges. They also attend one or two day retreats together and self-facilitate these events. When they have a problem with each other they work it out by talking and negotiating. They have tremendous respect and trust for one another, which has led to strong supportive relationships. One respondent described a telling event: I remember one project that one of us was working on and the three of us got together and we decided that reality dictated that the deadline needed to be 75 changed and we had to tell [the president] this. So the three clinical VPs go there and the point man says this is what we think and [the president] goes "Are you two here for moral support?". And we killed ourselves laughing. A second theme with regard to senior managers was ethics. The senior executives also seem to have an unwritten ethical code with regards to downsizing the organization. There is pride amongst this group for no layoffs. The integrity is assumed possibly because their personal ethics have not been violated. One vice president said the following: I wouldn't be able to work in an organization that didn't have that. Basically, it's to prevent the layoffs, to create vehicles for staff at any level of the organization so people can make choices as best as can be made under the circumstances. So we have that fundamental assumption. All our HR plans flow from that. A third key theme relating to the senior managers was that these individuals have a high capacity for change. They seem to enjoy and even thrive on change, ambiguity, and uncertainty in their environment. The final theme related to the senior managers was keeping change in perspective. Humor was an important factor in this regard as it helps them maintain perspective. They also maintain outside interests for balance. These interests also allow them to pursue independence from the organization. The status quo is not appealing to these individuals. They see themselves as different from the employees in this sense: 76 I think in a Darwinian sense we're talking about a different type of person. I think The Hospital for the first 70 years hired people who were comfortable with the status quo and I think society has come along and said we want to reconfigure how we use our resources. We want them to be independent. Job security was not a major theme in our conversations. All of the executives met with the president individually to identify a personal plan for the future. This plan has likely liberated these individuals from personal job security concerns and allowed them to work towards achieving the collective goals. If personal plans were not established, worries about their future security may have hindered their ability to perform in the necessary capacity to accomplish their work. One respondent's comments on this issue were: The president is saying, now look folks, you know, nobody is going to get canned out of this organization, but I do want to know how you individually fit in. We've had one-on-one discussions. Each vice president has met with the president to gain some idea of how we think we're going to fit within the organization. Overall, this group functions as a strong cohesive team. They rely heavily on each other for support and motivation. The vice president's reverence for the president leads to the assumption that her leadership and guidance has a big part to play in this high performance functioning. The curious and troubling aspect to the situation is that no other layer in the organizational hierarchy parallels this functioning. The middle managers and staff seem to be functioning poorly with little trust, support, or respect. The leaders of this organization established and valued this rapport amongst themselves but did not recognize and foster it in other areas of the organization. Communication Communication is an important theme in managing employee downsizing. One of the biggest challenges that The Hospital faces is how to effectively communicate with its large employee population on the planning and implementation of the downsizing. Some of the issues of communication include consistency in the meaning of downsizing language, timing of communication, congruity in messages from different stakeholders, and a large employee population. To resolve some of the above issues, The Hospital hired a communication specialist to develop and carry out a detailed communication strategy for the various change initiatives at The Hospital. The Hospital now uses various oral and written media to attempt to communicate consistent, clear, and timely information to staff, patients, family members, management, unions, and the various other stakeholders. The oral types of media employed in communicating with the stakeholders included large general assemblies, information sessions delivered by senior executives, open houses, and various meetings such as with the labour relations representatives, staff, one-on-one, or middle management. The types of written media included president's bulletins, internal and external newsletters, information session packages, and union letters. The Hospital administrators also solicited feedback from employees through various surveys, an innovation reward program, and feedback questionnaires at meetings and information sessions. 78 One key message the executive has communicated is that downsizing will continue because it is government policy. For example, a President's Bulletin published in February 1995 reads as follows: The continuing discomfort of some staff with the government's policy of downsizing The Hospital is something that there is little we can do about...It is not likely that the current government, or any subsequent one, will move away from what is generally agreed as being an appropriate direction for the mental health service system. So, while we empathize with those of you who have strong negative views about this government policy, the downsizing of The Hospital will continue. Another key message communicated to employees is that it is their responsibility to make career choices with the support of the human resource initiatives at The Hospital. Staff are urged to make those choices earlier rather than later. One respondent's comments provides a typical example of responses with this issue: We're asking staff to turn their minds to making decisions, personal decisions. Do I want to go, do I think I may go because of my seniority? Then if that's my decision, then we have a number of initiatives in place to help them do that. For other staff, if you answer I want to stay, then you need to have a sense of the vision and develop a commitment to do personal things, to go with the organization. The above message strikes at the psychological contract between employer and employee that traditionally sets up the employer as a paternalistic entity who secures a job and paycheck for employees. In return, employees are loyal and hard working. The 79 new contract demands independence and, equal partnership but seems devoid of security and obligation. Human Resource Initiatives One of the four strategic thrusts at The Hospital is managing change. Eleven change management strategies were outlined in the strategic plan. These strategies described key methods of managing change including building staff knowledge and skills, providing training and mentoring to middle managers, involving key stakeholders in the change processes, ensuring staff are equipped to meet the needs of tertiary care patients, and promoting a positive work environment through support programs. Based on the strategic plan, The Hospital has implemented a series of human resource initiatives designed to effectively manage the transition to the new environment. The initiatives were developed by a committee composed of staff and management from different levels of the organization. These initiatives fall into two primary categories: labour adjustment and employee support initiatives. The labour adjustment initiatives included secondment opportunities, placements, peer counselling, training, and retraining with tuition subsidies.. These initiatives are primarily aimed at reducing headcount through means other than layoffs. Temporary formal and informal secondments have occurred to mental health centres and hospitals in the province. Secondments are temporary placements to a position in a different organization for the purpose of gaining experience and knowledge, or filling in for another worker whileion leave or assigned elsewhere. 80 Placements are where staff have successfully competed for full-time or part-time positions in other mental health organizations. These placements are sometimes obtained through restricted competition where only The Hospital staff are permitted to apply for positions. A peer counselling program was established in the second year of downsizing. This program trained 30 staff as vocational peer counsellors. A coordinator was recruited to organize and administer the program.. Training and retraining funding is available to staff who want to prepare for alternate work placements or to enhance their skills in the direction of specialized tertiary care. The retraining programs include opportunities for food service workers to work as health care workers, health care workers to train as nursing unit clerks, and staff to train as peer counsellors. Approximately 91 applications were approved during the 1994-1995 fiscal year. Part of the retraining for some positions has been accompanied by a mentorship program that provides coupling of newly trained employees with senior staff for temporary on the job training placements to gain practical experience and knowledge. Other training programs have been implemented.as well. For example, a computer skills enhancement program was offered to clerical and other targeted positions to provide personal computer training including word processing. A job search program was delivered to a group of staff that taught resume development, interviewing techniques, and hidden job market access. 81 A deinstitutionalization coordinator has also been hired to access public service vacancies on a priority placement basis for downsized staff. No information is available as to the success of this function. The employee support initiatives have been implemented to assist staff to transition through the downsizing process. The primary support initiative has been vocational counselling. Trained co-workers counsel fellow employees in making pro-active career choices related to the downsizing initiative. Approximately 229 employees have participated in this program. Management development has been directed at educating senior and middle managers in organizational transitions, planning, quality improvement, and program management. No information was available as to the success or difficulty with any of the above initiatives. Organization Redesign The Hospital is undergoing dramatic organizational redesign. Freeman and Cameron (1993) indicate that downsizing is closely linked with organizational restructuring because processes, technology, and structure can seldom remain constant after a large scale downsizing. Participants consider this aspect of the change initiative to be the redevelopment of the new facility. The initiatives that seemingly connect to this overall redesign of The Hospital including the redevelopment are program management, functional planning, customer service orientation, and technological innovation. Each of these initiatives is reviewed briefly. 82 Program Management The program management initiative restructures the method by which The Hospital admits, treats, and discharges patients. The current programs within The Hospital's clinical departments are basically organized around three phases of mental illness: acute onset (admittance), treatment, and rehabilitation. Patients move to a different clinical program when the phase of their mental illness changes. In the current model, many disciplines (e.g., social work) report centrally to one department (e.g., department of social work) but actually work in different departments or clinical programs. Difficulties exist with this type of treatment model. One key shortcoming is that the patient receives disjointed care as he/she moves to different hospital service units based on the phase of his/her mental illness. At this time, the relationships that have developed with care providers are forfeited and new ones begin. Care providers also lose the opportunity to witness patient progress to a balanced state of mental health. In contrast, a program management model provides a continuous care model for each phase of the different types of mental illness. Clinical staff are decentralized to the various programs. The clinical programs care for patients throughout the whole mental illness life cycle. Social workers no longer report to the social work department in this model but rather report directly to the program they are assigned to. In a program management organizational design, different programs are established for different types of patient populations and within each program patient service units are organized specific to each type of mental illness. The Hospital will create three programs with approximately 14 patient service units. The three clinical programs are assessment and treatment, specialized rehabilitation, and 83 psychogeriatric. See Table 4 for a list of the patient service units in each clinical program. Table 4: Clinical programs with listing of patient service units Assessment & Treatment (4 units) Specialized Rehabilitation (4 units) Psychogeriatric (5 units) Intensive Care Refractory Psychosis Geriatric Acute Assessment & Treatment STAT Neuropsych Aggressive Behaviour Rehabilitation Young Schizophrenic Mental Illness/ Mental Handicap Behaviour Stabilization Mental Illness/ Substance Abuse Rehabilitation Psychotic & Affective Disorders Extended Treatment Each program will be managed by a team of two: a physician and a clinician! A multi-disciplinary team of clinical staff will report to this management team including dietitians, nurses, social workers, physicians, occupational therapists, and others. These teams will be responsible for program planning, operations, budgeting, and human resource processes for the program. Each patient service unit will also be managed by a physician and clinician. In this model, operational functions such as overall financial operations and human resources are defined as separate divisions. A set of support services are centralized and include dentistry, hairdressing, x-ray, volunteers, laboratory, and others. The program management design developed for The Hospital restructures the entire organizational hierarchy. For example, the head nurse and clinical management positions will be eliminated. The vice-president positions will be consolidated and 84 refocused in new areas. This restructuring and role elimination has alarmed staff and raised questions about where they fit into this new structure, if at all. Some managers and staff believe that this program is financially driven because of the consolidation or elimination of many positions. However, a recent internal newsletter answered this concern as follows: The introduction of program management into The Hospital is not financially driven. Instead, some of the objectives are to decentralize decision making, establish budgeting at the program level, and enhance the multi-disciplinary team approach to patient care and rehabilitation. Functional Programming Functional programming is the planning and design of the new facility. This process involves defining the physical environment of the future hospital including space requirements, projected staff requirements, integration of programs and services, support service requirements, and layout. The Hospital has commissioned a consulting firm to facilitate the development of the functional program and plan. The consultants will work with 14 user groups, consisting of management, staff, patients, and families, who are responsible for defining the needs of individual programs and services for the new facility. The Hospital plans to produce a full report outlining the new facilities major operational policies, anticipated staff, workload requirements, and space requirements before any design work commences. The new facility will be built on the existing hospital grounds, but the current facilities will not be used as remodeling costs are too high. 85 Customer Service One of The Hospital's major strategic initiatives is to meet or exceed customer expectations. The Hospital is attempting a transition from an existing custodial model of care to one that is patient-centered and customer driven. This model places the patient at the center of all hospital planning and practices. For example, in this model, discharge planning begins upon admittance. Some of the strategies designed to transition The Hospital to a patient-centered culture are patient's charter of rights, continuous quality improvement, and continuing education programs. Each of these strategies is reviewed briefly. A Charter of Patient Rights was developed by hospital staff, lawyers, patients, family members of patients, and community advocates from 1991-1993. It was approved by the Board of Trustees at The Hospital in 1994. The charter outlines a framework of patient care with three key focuses: rights to be involved in treatment decisions; rights to be informed of reasons for detention and of the available review process; and rights to be in a safe and therapeutic environment. The Charter of Patient's Rights will be used as a framework to drive all hospital operations. It identifies norms of conduct for patient care, demonstrates commitment to patient-centered policies, and guides audits of hospital policies. A second part of the strategic movement toward customer service is to continuously improve the quality of care and service provided to the patients and their families. The Hospital administrators call this initiative continuous quality improvement orCQI. 86 One participant reported that most staff and some middle managers view the continuous quality improvement initiative as a buzz word and the meaning and purpose behind the initiative was not well understood by staff or articulated to them. In fact, some employees reportedly feel offended by the implication that they have not been delivering quality service in the past. Technological Innovation The Hospital has been exploring means of improving efficiency and effectiveness through information technology. A few examples of how The Hospital has recently employed technology are presented here. During 1993-1994, The Hospital developed an on-line patient banking system. This system manages each patient's banking needs similar to how a bank would operate a bank account. Patients can deposit and withdrawal money as they would from any bank and have their passbook updated as required. The Hospital has also invested in a workload measurement system called GRASP to assess the hours of care by patient based on the patient acuity level. Consensus criteria regarding patient acuity is monitored and recorded in the system by the nurses on the ward. This program assists The Hospital to schedule staff in response to patient clinical support requirements: The system will project for three shifts how many and what type of staff are required on each ward. The result is that resource utilization is optimized. GRASP is used in other psychiatric hospitals in North America and provides cross comparison and analysis on patient care needs and resource utilization. The Hospital 87 administrators expect their patient acuity level to rise as the less seriously mentally ill patients are downsized to the primary and secondary mental health services. GRASP will provide a mechanism for tracking acuity to rationalize budget requirements for staff. The Hospital is attempting to use advances in technology and automation to improve patient services and operational efficiency. Other examples of technology innovation are likely available; however, given the minor role technology played in this study, the above examples were the only ones provided in the interviews. Summary In summary, The Hospital is undergoing extensive change. This change incorporates not only a 41% reduction in its employee population, but also a completely new service model, culture, and facility. The process will continue for another 7 years. During the early stages of change, The Hospital lacked a vision, and therefore, the downsizing process was planned on a year-by-year basis. This lack of vision led to high levels of frustration, anger, uncertainty, and insecurity in staff and management. Over the last year and a half, The Hospital has engaged in long-term, strategic planning. This planning has led to the creation of a vision and direction for The Hospital employees. The Hospital has created numerous committees and teams to manage the various change initiatives underway. The coordination of these initiatives remains a challenge for The Hospital administrators. 88 CHAPTER VI. ANALYSIS & INTERPRETATION OF THE DATA This chapter describes an analysis and interpretation of the downsizing at The Hospital. First, Cameron's (1994) effective downsizing model is used as a basis from which to analyze The Hospital's downsizing process. Second, The Hospital environment and downsizing is reviewed from a systemic perspective to examine the context in which the downsizing occurred. A systemic review will help us understand some of the reasons why The Hospital has experienced so many challenges with this process. Effective Downsizing As stated earlier, Cameron's (1994) model identifies nine best practices for effective downsizing including approach, preparation, involvement, leadership, communication, support, cost cutting, measurement, and implementation. This model will be used to analyze The Hospital's downsizing process insofar as many of the results found in this study are reflected in Cameron's model. Therefore, his model seems to provide an appropriate perspective from which to reflect on the downsizing process at The Hospital. Cameron's first best practice relates to the approach or philosophy an organization takes with regard to the downsizing. The Hospital's approach to downsizing has been viewed as a long-term strategy. Downsizing is the strategy being employed to reform the mental health system in the province over a 10 year period. The major thrust behind the downsizing was to deinstitutionalize patients and move them closer to their families and communities. Further along in the initiative, The Hospital seized this as an 89 opportunity to improve internal patient care practices. For example, they are reevaluating what they expect from employees and restructuring their organization to improve how service is delivered to patients. Initiatives such as continuous quality improvement and redevelopment are the mechanisms being used to accomplish these improvements. One key component of the "approach" best practice is to view human resources as assets rather than liabilities. The thoughts echoed by the some of the interviewees was that some staff and middle managers are viewed more as liabilities than assets. For example, one director said the following: A number of staff here because they're institutionalized feel that custodial care is just fine. It's fine, that's the way we've done things for 20 years. We don't perceive a need to change so we don't want to change. So if you want to make a change, you make a plan for me. Give me an early retirement package or you find me a job. I am not going to listen to this other stuff, take care of me. Not all of the staff are perceived in such a light by the interviewees. However, their sentiments may not be unfounded. It would not be surprising if some staff were comfortable with continuing to service patients the same way they have for the past several decades. It is perhaps natural for humans to be content with the status quo especially with the emotional and physical investment that these employees have made at this hospital. Many employees have work experience of 20 or more years. Change can be difficult. Some employees may also be operating in what Bridges (1993) calls the neutral zone, or in other words, they have not given up the old methods and tools regardless of whether the world around them is changing. 90 It is important to value the strength these employees bring to bear on the organization. For example, front-line staff have a wealth of knowledge and experience in dealing with the patients at The Hospital. They know the ins and outs of the system and likely operate effectively within this system. Some of the players will have strong relationships with other staff and therefore influence their behaviours and feelings on issues and events, and therefore, it is important to get everyone aligned. The challenge for the leadership of an organization is to continually motivate and confront the thinking processes of employees to ensure that the organization does not get "stuck" in one mode of operation, but rather evolves through the process of critical thinking and innovative ideas. This continuous improvement philosophy is being introduced into the organization as discussed in the last chapter. The Hospital has an obligation to invest resources and time into developing a culture that is consistent with their new values. The Hospital has endeavoured to accomplish this. For example, no layoffs have occurred to date. The Hospital administrators have retrained, cross-trained, and arranged secondments for employees. A cultural transition team has been formed. The organization strives for closer ties with academia. Redesign and restructuring is occurring and will be the major driving force behind cultural change at The Hospital. The initiatives associated with the downsizing will likely bring about some form of cultural change because they reshape the basic operations of The Hospital. For example, program management revises the roles, responsibilities, and reporting structure at The Hospital. 91 Cameron's (1994) second best practice is preparation. One primary goal of preparation is to develop independent plans so that the organization views the process as an improvement rather than as loss of discretion. The Hospital did not prepare for the downsizing prior to being mandated to do so in 1992. This unprepared state is evidenced by the lack of a plan for the downsizing during the first year of the process and the surprise of many hospital employees to the actual closing of wards. The Hospital did not establish its own vision with targets, deadlines, and objectives for the downsizing. The community had not begun developing new services and facilities for the downsized patients. Planning is likely difficult in this process due to the number of stakeholders involved in the decision making. The various perspectives each stakeholder carries in the system likely polarizes their positions to some degree and further frustrates the downsizing initiative. For an example, one might consider trade unions. Morgan (1986) suggests that trade unions are developed as a check on management and are designed to balance power relations. Therefore, a polarity is often established between management and staff: Also, many of the stakeholders have specific agendas that are inconsistent with the downsizing initiative. One such agenda may be personal or organizational survival. Overall, the lack of a plan and a vision was cited by all of the interviewees as a significant problem with the downsizing initiative. This issue was also identified in the 1994 Value for Money Report as follows: Since the government announced the mental health initiative in 1990, the ministry has engaged in an extensive consultation process with mental health 92 care stakeholders. However, it does not yet have a well-documented, comprehensive long-term plan on which a shared understanding of expectations concerning the replacement of The Hospital and related patient and funding transfers can be based, or against which progress.can be evaluated. There are a number of reasons why a plan and a vision were not developed for the downsizing initiative. The Hospital administrators indicate that there was not enough information to develop a multi-year plan. Only recently has there been agreement on and approval for a 320 bed tertiary care facility to replace The Hospital. However, the initial report that many refer to as the blue print for replacing The Hospital states that there will be a need for 550 medium/long-term psychiatric inpatient beds of which 300 will be located in the same region as The Hospital. This fact is also repeated in the 1994 Value for Money Report completed by the Auditor General. A multi-year plan may not have been created because of lack of agreement on the initial blue print to replace The Hospital by the various stakeholders. It is important to note that in August 1992, a new Chief Executive Officer was appointed to The Hospital. Two months later a new, larger Board of Trustees was appointed. These changes occurred at a critical time in the downsizing process. Whose responsibility was it to develop the multi-year plan the sponsor of the change initiative or the change agents? In Conner's (1993) model, the change agents are responsible for planning and implementing the change. However, he also suggests that "successful change must have sponsorship support and follow-through (p. 117)." In 93 this case, it is unclear how much power and influence The Hospital administration had to take charge of the plan. The third best practice in Cameron's (1994) model is involvement. Initially, the downsizing at The Hospital was driven top down. However, during the second and third years of the downsizing, the senior management team attempted to involve staff by establishing committees for various change initiatives with different levels of staff participating as committee members. As well, The Hospital has involved staff in the planning and implementation of the patient downsizing. For example, The Hospital has developed a bed reduction protocol that identifies the steps that must be undertaken for a successful bed reduction. The purpose of the protocol as it reads in the document is: To ensure that a process is in place to facilitate open and continual communication at all staff levels. The principles outlined in this protocol support a collaborative and organized approach to decision making between administration and clinical staff. The process promotes a proactive approach whereby responsibilities and'expectations are stated. (May 1994) However, the issue of getting staff involved in the process poses its challenges. One director described an interesting dilemma when attempting to involve staff: The management committee on occasion has tried to have middle managers and other people get involved in the downsizing, but people don't want to. They don't necessarily understand it and a number of people don't agree with it. Therefore, it is forced to be a top down exercise. Cameron (1994) suggests that everyone should be held accountable for achieving downsizing goals. However, this idea suggests that everyone believes in the vision and 94 is working towards the same goals. The Hospital does not seem to be operating from this premise which again relates to the lack of agreement on the problem. It is difficult to discern exactly what happened at The Hospital when the government mandated the downsizing of 105 beds in 1992. It is unclear whether or not there was agreement among the various stakeholders as to the "closer to home" philosophy and deinstitutionalization. One respondent in this study suggested that the closer to home philosophy was a political reaction and not something that the family members really wanted. This interviewee said that the family's bottom line was good patient care, not having the patients closer to home. This respondent suggests that families are concerned about their relatives being moved out into the community without any kind of proper care. Again, this perspective provides further evidence of the lack of agreement and understanding of the issues at hand. It seems that the cornerstone of an effective downsizing model is to first establish a clear understanding of the problem and some agreement on the solution to the problem. One of the first and most critical steps in a downsizing process may be to establish an understanding and agreement of the problem at hand for which downsizing is intended as the solution. One of the biggest challenges The Hospital faces is that there is no agreement among the stakeholders as to what the problem is that downsizing is intended to help resolve. For example, one middle manager said the following about consensus over the problem: So there is still a sense of frustration over the fact that their concerns have not been heard. They still don't understand why the decisions were made in that 95 fashion. A lot of them obviously feel this way because they didn't know what the reason was behind it. But those who have learned of the decisions were not convinced those were the right reasons. An addition to Cameron's (1994) model for effective downsizing as a best practice might be alignment. The intent of this best practice would be to ensure that the stakeholders of a system understand the problem that demands a solution. The change agents would be responsible for articulating and obtaining agreement on the problem and working with the stakeholders to identify a solution. It would not be expected that all stakeholders agree with the problem, but rather only that they be aligned in the same direction and understand the issue itself. This best practice may be considered a cornerstone of the process, and therefore, it should be the focus at the outset of any downsizing initiative. Cameron suggests that external stakeholders such as customers and suppliers should also be involved in the downsizing process. The Hospital has involved patients, families, and others in the downsizing process. For example, one director said: We've tried to involve consumers and families in the decision making all along the way which I think is very important. And they were very helpful in clarifying points and assisting in making some evaluations for the purposes of changing and amending what we were doing. The fourth best practice is leadership. Cameron (1994) maintains that leaders must be visible, accessible, motivational, and positive. He also suggests that they should articulate the vision as a desired future state and not as a retreat from the past. The leaders at The Hospital seem to have become more visible and accessible to the staff 96 during the past 12 to 18 months of downsizing. The President and vice-presidents have been delivering information sessions to staff regarding the downsizing and redevelopment initiatives. Many senior managers are also leading various committees associated with the change initiatives at The Hospital and elsewhere. However, it is difficult to assess the level of motivation and positiveness these leaders inspire in others as a result of their visibility and accessibility. Some of their comments did not always reflect optimism. For example, the following excerpt from an interview with a senior executive does not altogether reflect a positive, empathic response to a very real concern. We went to program management [a meeting] and we had a whole large group there, all the head nurses and everything. They found out we were going to program management. And the head nurses found out they were not going to be there and [they] had a whole big reaction. And I told the group, "I'm really surprised by your reaction because as you all know we were not even sure we were going to be here in the next 7 years. But, and secondly, even if we weren't going to program management that the most we would have had was 13 head nurses and we have 29 of you now. Although, the manager's response reflects a very realistic perspective that employees need to hear, the comments do not seem to reflect any empathy for the perspective of the employee who already feels threatened, insecure, and devalued by the bombardment of downsizing and other change initiatives occurring over the past months and years. An empathic response coupled with direction and leadership may 97 provide a less defensive environment for employees to more readily accept the changes being asked of them. An important event to explore in relation to leadership is the step that the president took to develop a personal plan with each senior manager that identified potential opportunities in the new organization and other future plans for that individual. This strategy was intended to alleviate any worries these managers may have regarding job security and thus allow them to fully focus on leading the downsizing initiative. Most of the senior executives when asked about this process indicated that this had little or no bearing on their subsequent behaviour because they were self-determining individuals who appreciated and thrived on change. These individuals may be minimizing the effect that this process had on their behaviour. It seems that it would be difficult for an individual to carry out an assignment that resulted in loss of financial income and status especially if a large debt load was being carried by the individual and his/her family. On the other hand, these individuals expressed a clear satisfaction of working within change and uncertainty. It may be that these people are more highly differentiated individuals, a concept found in Bowen Theory (Kerr, 1982). A Bowen theorist'might argue that these individuals are highly differentiated. Differentiation describes the varying degrees of human adaptability. At higher levels of differentiation, individuals are less reactive to emotional forces around them, more self-determining, better able to make transitions, and can assume responsibility for themselves (Kerr, 1982). 98 The senior managers seem very capable of continuing to strive towards their vision within this highly emotive and reactive environment. They indicated several key issues that allowed them to manage within this context/First, they have a strong and supportive team. There is a great deal of trust and respect between all members of this group. Second, each team member is completely committed to the same vision of mental health reform. In other words, they are striving to achieve the same goals and objectives. Third, they feel that the way they are approaching the downsizing is ethically responsible in that they are attempting to prevent layoffs. Finally, some of the team members indicated that they strive for personal balance between work, family, and other interests. They manage to take care of their personal needs, as well as their professional ones. For example, one interviewee talked about self reward: You've got to be able to self-reward. I know what a good job is and this looks good. No one has said thank you but that's okay and maybe a few people have said no thank you. You sort of have to have your own meter ticking say, "Yep, that's good, that's bad". You know because of the stress level of staff and the resistance right now, you know, it would be easy to give up and think "Oh God, they all hate me." It is difficult to separate the individual psychological state from the context in which an individual is functioning. The senior managers are driving the downsizing process and thus have some control over how the process unfolds. These individuals have different social and psychological investments in the organization. Most of them have worked at The Hospital for only a few years as opposed to many staff who have been employed with The Hospital for their entire career. The senior managers believe in the 99 vision and were likely hired to carry it out. They have a personal career plan mapped out which alleviates most of their worries related to job security. The organizational role they fulfill has formal power and control associated with it. On the other hand, many staff and middle managers have little formal control over the process and some do not believe in the purpose and motivation for downsizing. These individuals have decades of experience and psychological and social investments associated with the organization. They are at high risk for losing their jobs. Most of them have not had a personal career plan worked out with them by their manager. The positions they hold in the organization have little formal power or control. These individuals have a great deal of personal investment at stake in the downsizing process, certainly more so than the senior managers. It is difficult to discern the level of differentiation in the middle managers and employees from this study. Given the level of anxiety present in the employees as described by interviewees, it may appear from a "Bowenian" perspective that these individuals are less differentiated. Less differentiated individuals are more likely to react emotionally to what is going on around them and require a greater degree of input from their environment to function (Kerr, 1982). The concept of differentiation cannot be applied to staff and mangers with any confidence without risk of ignoring the very important issue of their situational context as described above. However, if highly differentiated individuals do function well in an uncertain and unpredictable environments, this may be a quality to foster in employees for today's changing workplace. 100 Cameron's (1994) fifth best practice relates to communication. Communication as defined in this model indicates that everyone should be fully informed of the purpose, strategies, costs, and time frame of the downsizing in an ongoing, frequent, and honest manner. Evaluation should also be completed throughout the downsizing process, rather than just at the end. One of the challenges that has been most acutely realized by The Hospital is the need to communicate long-term downsizing targets for the process and, perhaps more importantly to communicate these targets to employees such that they can contextualize their involvement in the process and enable them to better orientate their futures and career plans. The Hospital has developed a comprehensive communication strategy that is being implemented by a communications officer. The plan includes developing and publishing at least three newsletters and a president's bulletin. The administrators recently created an information package for all staff that provide detailed information on the downsizing and redevelopment initiatives. The senior managers reviewed and discussed this information with staff during spring information sessions. A staff feedback survey was conducted recently to obtain feedback on their satisfaction with the downsizing initiative. The language used to communicate messages during periods of high anxiety is often as important as the content of the message itself. Staff with high levels of anxiety may misconstrue the meaning of various communications because of their anxiety. When an organization implements initiatives in areas related to quality or customer service, for example, the messages should be phrased such that they demonstrate 101 respect for past and present efforts of employees in this regard. These initiatives should also be implemented with the involvement of the front line staff as these are the individuals who actually do the work. The Hospital has experienced the importance of consistent and clear usage of language, empathy, and different media when communicating. For example/during their attempts to change business practices, new language was introduced into the setting. It has been important that staff understand new terminology, as well as the meaning behind new messages. Empathy is also a fundamental component of communication in the process of downsizing. Empathic responses to staff concerns may help staff feel heard by the decision makers and liberate them to listen to the new messages. Rodgers (cited in Egan, 1990) describes empathy as follows: Empathy is in itself a heaNng agent. It is one of the most potent aspects of therapy because it releases, it confirms, it brings even the most frightened client into the human race. If a person is understood, he or she belongs (p. 124). The employees at The Hospital are the long-term caregivers for The Hospital's patients. Many of them have invested tremendous amounts of energy, time, and emotion into the caring and convalescence of patients. It is not surprising that this investment coupled with minimal progress in community development has led some employees to react negatively to placing downsized patients in community facilities. It is important for the leaders to acknowledge, respect, and value staff contributions and perspectives in this process. It seems important to assume that staff 102 reactions are founded on real issues and concerns that they witness and experience. Empathic reflections of employees' concerns over the lack of community development in mental health services may help staff feel listened to and build a more cohesive environment. An analysis of the data collected in this study did not find examples of empathic responses in communication materials from senior or middle management to employees. One director commented on this issue in the following manner: What is increasingly apparent to myself at The Hospital is the push for CQI, serving the customer which is a very good thing that we are agreeing on. But in my understanding and interpretation, the customer doesn't mean only patients. Customers also mean staff that we have to govern. I sense from the general duty staff while The Hospital is pushing the staff and everyone else to recognize the patients as customers, sometimes events happen and even if the staff are present, they do not matter. Their concerns have not been addressed particularly when their concerns conflict with the patient's concerns. Their concerns have not been addressed or the patient's concerns have been addressed to the detriment of their concerns. Although, downsizing cannot be compared with therapy; pain is felt deeply by people in both cases. Empathy is simply "a form of human communication that involves both listening and understanding, and communicating understanding" to the other party (Egan, 1990, p. 123). Application of empathy in downsizing may at minimum help employees to feel understood. 103 Cameron's (1994) sixth best practice, support, relates to how employees are treated and helped before, during, and after the downsizing process. Safety nets should be provided to employees who are leaving as well as those who will remain with the organization. Preparation through training, cross-training, and retraining should be given to staff in advance of downsizing the organization. The Hospital is in the 4th year of a 10 year downsizing process. The duration of the process itself positions the organization and its employees to endure an extensive period of stress and uncertainty. However, this multi-year plan developed recently has given structure and boundaries to this change. The Hospital has invested the majority of its resources into establishing retraining programs, peer counselling, and other outplacement strategies for employees who will be leaving the organization. Safety nets such as financial benefits have not been provided since no layoffs have occurred to date. Given that The Hospital is being downsized over a 10 year period they have the ability to prepare many of their staff in advance of the downsizing. However, no preparation was provided to those who were downsized during the earlier phases of the process. The seventh best practice is cost cutting. Cost cutting involves employing a variety of cost reduction strategies rather than relying strictly on headcount reductions. Cost reductions may occur in overtime restrictions, redundancy elimination, and other excess activities that may take place within an organization. Waste reduction often occurs through work process analysis and redesign (Cameron, 1994). The Hospital has eliminated some redundancies and excess activities in work processes in parts of the organization. However, it has been done informally and 104 inconsistently throughout the organization as illustrated in the following comments made by a vice president during our first interview: One of the good things that comes out of the ugliness in the whole thing is that they start looking internally at what they are doing. All the reports that they are producing, are they necessary? We found out no they're not. They did them because that's the way it was set-up. But when you're down one person, you start looking at these reports and say are they really necessary? Although, work redesign has occurred at a high level for program management and informally for some work processes, no comprehensive, in-depth work redesign project has been or is planned to be completed at The Hospital. This type of program may benefit the organization by formally analyzing work processes for the purpose of streamlining or eliminating unnecessary steps. The eighth best practice in Cameron's (1994) model is measurement. Measurement relates to surveying the speed and time of activities, rather than just output in an organization to identify possible improvements and ultimately decrease the need for headcount reductions. In The Hospital there does not seem to be a strong emphasis on measurement, although some areas are measuring components of their operations. The human resource department recently assessed employee skills, interests, and future plans to assist in planning placements and transfers in relation to the downsizing. Information technology is also being used to measure workloads for staff. For example, a computer program called G R A S P has been implemented that identifies how many hours of care 105 each patient will require based on their level of acuity. Resource utilization can be managed and monitored more effectively using this type of technology. Implementation is the final best practice in this model. The Hospital has implemented a broad array of downsizing strategies including using auxiliary staff, transfers, restructuring, retraining, retirements, and placements. They have attempted to offer professional growth opportunities to employees in areas such as peer counselling, change management, information technology, and cardiopulmonary resuscitation (CPR). Cross-functional and cross-level teams have been formed to plan and implement the downsizing in hopes of avoiding a top down driven process. Changes have been initiated in communication and staff development. However, the fairness and equality of these strategies are not known. The most striking aspect of work force reduction at The Hospital is the commitment made by the senior management team to avoid layoffs if possible. The amount of time and resources being devoted to finding alternative reduction strategies is impressive. In three years of the process, this organization has not laid off one individual. There was one severance, but apparently it was at the individual's request. The only strategy that \ the administrators are not able to employ is early retirement packages due to government restrictions. This strategy affords a shorter transition period by reducing staff size quickly and it offers a more dignified exit for senior staff. Although, The Hospital has invested a significant amount of time and resources into alternative work force reduction strategies, very little has been invested in the emotional process related to the changes occurring. Bowen's (Kerr, 1982) concept of emotional process relates to an individual's automatic emotional reactivity to the , 106 environment. This reactivity influences our behaviour and thinking especially when anxiety is high. In The Hospital, anxiety has been one of the primary responses to the uncertainty and insecurity caused by downsizing. Kerr (1982) suggests that in work systems the emphasis should be on recognizing emotional reactivity in self and others, and learning to control one's own reactive patterns. Fineman (1993) argues that emotions have an important role in creating meaning in an organization. Emotional energy generates a sense of belonging or drives conflict. He compares emotions to social glue that divides or fuses organizational structures and events. Emotions are not meant to be bottled or masked to preserve social order, rather organizations should proceed through negotiated order where situations and events are negotiated through deals, compromises, tradeoffs, and other types of agreements. Given the significance of emotions, whether attempts are made to control them or not, it seems paramount that an organization understand the emotional systems operating in their environment and endeavour to respect and foster constructive means of recognizing emotional perspectives of all stakeholders. Systemic Analysis The Hospital system consists of both internal and external stakeholders. Internal stakeholders are individuals who function within various roles at The Hospital including senior managers, middle managers, clinical program staff, operational staff, and patients. External stakeholders interact with or influence The Hospital system and include the public, government, board of trustees, advocacy groups, trade unions, 107 families of patients, and community mental health service providers. (See Table 5 for a list of the stakeholders involved in this system.) These stakeholders represent diverse perspective and beliefs with respect to downsizing. For example, the public's perspective on mental health reform will vary, in general, from a psychiatric nurse's perspective. The variety of perspectives represented by the number of different stakeholders involved in the overall mental health system likely hinders making quick and effective decisions with respect to downsizing. A change in government alone would likely mean a shift in the policies and practices of mental health services in the province. Table 5: Key Stakeholders Internal Stakeholders External Stakeholders • Patients • Ruling Political Party • Family Members of Patients • Ministry of Mental Health • Senior Executives • The Hospital's Board of Trustees • Middle Managers • Community Mental Health Services • Staff • Community Advocate Groups • Trade Unions • The Public These various perspectives sometimes clash and create discord in one or more relationship. One senior manager stated the following with regard to the relationship between The Hospital and the community mental health service providers: And of course the government out here, was like again some other provinces, did not replenish and provide funding for the concurrent services transferred to the community. And so that built up a significant residue of hostility between the community and The Hospital. 108 Another interviewee said this with respect to internal systemic relationships: I think staff don't perceive senior management as truly caring about them. The distrust also comes from the many mixed messages that front-line staff get from middle managers. The type of relationships that may exist between the various stakeholders is illustrated in Figure 2 (McGolderick & Gerson, 1985). Relationships may be depicted as conflictual, close, or unknown. These descriptors are defined as follows. Poor or conflictual describes relationships with discord that results from opposing needs or desires. Close relationships have greater trust, are more friendly in nature,, and have less discord. Unknown is identified where limited information is available on the level of conflict or closeness between the stakeholders. These characterizations are based on information provided by the interviewees and field documents. 109 Public Government Legend Conflict = = = = = Close ~* ^ Unknown Community Mental r ^ ^ ^ Health Sr. Mgmt Board of Trustees Uiilon Mid Mgmt Clinical Clinical Clinical Program Program Program Staff Patients Families Figure 2 : Internal & External Stakeholder Relationships As the diagram illustrates, some level of conflict exists within many relationships in this system. Given this conflict and the general organizational culture as described in Chapter V, it is unlikely that all of the stakeholders will cooperate effectively in such a highly uncertain and emotional environment as downsizing. Pastin (1986) reports that high-ethics organizations are successful partly because they consider the perspective of both internal and external stakeholders in their business operations and practices. This suggests that each stakeholder's viewpoint is 110 somehow acknowledged or recognized in the solutions to ensure fairness and justice in the process. Barling and Phillips (1993) concluded from the result of their vignette research with 213 full-time Canadian students that not only fair procedures influence employees' attitudes, but also the way those procedures are implemented through interpersonal interactions influences employees' trust in management, organizational withdrawal (e.g., absenteeism or tardiness), and emotional commitment to the organization. Bridges (1993) suggests that trust is developed through experience. In this case, many employees have worked at The Hospital for decades, and therefore, have a long history of past experiences that contributes to their lack of confidence and trust in management, the community, and the government. However, over the years employees have gained a tremendous sense of loyalty to the patients, which is demonstrated by their continued employment at The Hospital despite this lack of trust. The employees loyalty and paternalism towards patients and their lack of trust in management has likely contributed to the challenge in obtaining "buy-in" from staff to downsize. Another important consideration in this analysis is to examine how each stakeholder in the system influences the downsizing process from their unique position in that system. For example, some staff have influenced the process by their lack of commitment to downsizing the organization. One interviewee described an example of how some staff are not fully cooperating in this process: You see a lot of passive-aggressive strategies being played out and being acted upon. We get people who sort of nod their heads and they say "yes, 111 that's fine," but you know like from the word go, as they say, you get the energy from them that they're not going to go anywhere close to fulfilling what they've said they would do. We've seen certain wards in the downsizing, to prevent the downsizing from being successful, we've seen substitution of patients. In very infrequent cases, this is certainly not the norm, like you will see certain wards with particular head nurses or certain clinicians including psychiatrists try and get some of the most difficult and unplaceable patients on the list for downsizing, and at the risk of sounding glib, being almost gleeful when the placement didn't work. This underlying emotional process affects the success of the downsizing effort and the day-to-day operations of the organization. One director commented on their concern about the impact of the effects of a downsizing environment on psychiatric care: "if you have staff who are concerned, anxious, worried, how the hell are they supposed to give good psychiatric care. I mean you can't hide it that well." The conflict and high emotional reactivity in the system may be caused by several factors. First, there was no clear vision or direction for The Hospital until the fourth year of the downsizing process. A vision encourages alignment, builds momentum, and commitment to common goals, and provides clarity about what you are trying to do (Senge et al., 1994). Second, there does not seem to be agreement on the "problem" that initiated the need to downsize in the first place (i.e., deinstitutionalization, closer to home philosophy). As discussed previously, selling the problem identifies a clear purpose for people to engage in the journey of change. It explains the reasons behind the initiatives, vision, and direction. 112 Third, Downsizing poses different threats or challenges to different players in the system. The various individuals and groups at The Hospital may be responding to these challenges. For example, jobs will be lost as a result of the downsizing. Job security represents a serious threat particularly to middle managers and staff. A final consideration in the systemic analysis is to understand the role each player assumes in the system. One way of examining roles in the system is to apply Conner's (1993) model which identifies four distinct roles in the change process: sponsor, agent, target, or advocate. A sponsor is the individual or group who legitimizes the change by deciding what will happen, communicating those decisions, and providing the required resources to ensure success. A change agent is an individual or group who plans and executes a change process. A target is the individual or groups who are the focus of the change effort-the people who actually must make a change. Change advocates are those who desire the change, but lack the power to invoke it. The role assumed by each player in the system may shift based on the different challenges and situations that arise in the process. The stakeholders involved in The Hospital's system are aligned with the following change roles: 113 Table 6: Change Roles of Key Stakeholders SPONSORS AGENTS Government Board of Trustees Senior Executives Middle Managers Community Mental Health Services TARGETS ADVOCATES Staff Middle Managers Patients Community Mental Health Services Advocacy Groups The Public Family Members of Patients Trade Unions The primary sponsorship of downsizing at The Hospital rests with the government and board of trustees. Evidence to this effect is found in the fact that the decision to downsize The Hospital originated with the government. Prior to 1987, the government held public forums to discuss moving patients closer to home and the process of deinstitutionalization. Furthermore, when The Hospital administrators did not begin to downsize after it had been mandated to, an inquiry into The Hospital administration's practices was ordered by the government. In fact, several times over the years, the government has ordered investigations at The Hospital. It is assumed that these investigations are initiated because of dissatisfaction with the progress made by The Hospital. The senior executive team and the community mental health system are the primary change agents in the downsizing process. These groups are responsible for planning and implementing the downsizing initiatives. Middle management also seems a likely candidate for the role of change agent in this process. The middle management group is critical to the success of the downsizing process as its members hold a tremendous amount of power in their positions. They work more 114 closely with the key targets of change and they are responsible for sharing downsizing information with staff in departmental and ward meetings. Morgan (1988) suggests that managers influence others' perceptions by controlling and filtering what information is available to them and thus shaping their view of events and situations. Morgan's statement implies that a manager's behavior is purposeful and intentional in controlling knowledge and information to advance their own ends. However, it is likely some will be conscious of these acts while others will not. Individual perception and reality is also guided by situational factors, past experiences, values, and beliefs. If the managers at The Hospital are filtering and shaping knowledge, it is likely that part of their motivation is self-preservation. Middle managers have either not been assigned the role of change agents or have chosen not to assume it. It seems that they are viewed more like targets for change rather than agents in the process. Based on the interviewees' comments, some middle managers may not be able to make the changes required for the new hospital. For example, one director indicated that many middle managers are anxious about their futures because they do not have properly developed skills for managing in the 90s and they have not been focused on their professional development. The primary targets of change are staff and patients. Deinstitutionalizing both parties is one key change that is desired. Middle managers are targets for change in this process as some middle managers are viewed as being outdated and unchangeable. For example, one director commented on middle managers in the following way: 1 1 5 Over half of our middle managers are anxious about where they're going to be because they don't have properly developed skill sets for managing in the 90s. They're just not equipped. A number of them haven't been to school in years. They're used to working in a union environment where accountability is not stressed. The community mental health providers are also change targets in this process in that they need to change their system to accommodate different types of patients and integrate more closely with The Hospital system. The advocates for change in this process are the various advocacy groups, the public, the trade unions, and the families of patients. However, it is unlikely that all individuals and groups in this category are advocating for the same end result. For example, some family members may prefer their relative, who has a mental illness, to remain at The Hospital. Also, part of the public likely has concerns about the increase in individuals with mental illness seen on the streets of their communities. In summary, an analysis of The Hospital system has yielded a greater understanding of how the downsizing initiative has been affected by the relationships, perspectives, and roles of the various players in the system. By examining the relationships, we have a greater understanding of the influence that each group yields on the downsizing process. Conclusions • In summary, the administrators of The Hospital have invested a tremendous amount of resources into downsizing the organization. They have made a strong commitment to avoid layoffs if possible and have managed to accomplish this task so 116 far. However, despite this effort, there continues to be opposition and resistance to the downsizing and other change initiatives. Downsizing, regardless of efforts taken to involve and support employees, is a difficult and formidable process. Downsizing strikes at core issues for employees such as economics, identity, and security. An organization's challenge is to minimize the pain caused through downsizing so as to maximize the benefits that can result from such efforts. The organization may have benefited from selling the problem to staff rather than the solution (Bridges, 1993). The practice of selling the problem before any planning begins on the downsizing would be a healthy addition to Cameron's (1994) effective downsizing model. The administrators philosophy regarding downsizing was to reform the mental health system and improve patient care using a long-term strategy. Their approach to downsizing was based on a strong commitment to reform the mental health system over a long time frame. The only area of concern in this regard is their view of some employees as liabilities. Currently, some staff may feel devalued. Terminology and language in both oral and written communication must be scrutinized to avoid this perception. Leaders should find ways to acknowledge and celebrate the contributions of all employees. The organization did not plan for the downsizing prior to its being mandated to do so. However, a multi-year plan was prepared during the third and fourth year of the process. This vision is critical in providing direction and setting expectations for all of the stakeholders involved. 117 the Hospital has involved staff in the planning and implementation of patient downsizing. Some staff and middle managers are also involved in many of the other transition projects including functional planning, continuous quality, and cultural transition. However, it may be that to ensure meaningful involvement of key stakeholders, there must be some agreement on the problem and solution. The senior executives benefited from exploring career and professional development opportunities with respect to their future. Some job security concerns may be laid to rest for middle managers and staff if this process was implemented with them with their manager. This plan does not require specifics but rather an exploration of future goals and desires and possible plans for achieving them. In particular, it seems crucial to secure buy-in and commitment in this process from middle managers given their positions and influence in the organization. The organization has implemented an extensive communication strategy that includes at least three newsletters, president's bulletins, information session meetings, and other oral and written mediums. They identified severalchallenges with regard to communication including consistency in language and its meaning, and the size and openness of audience. Communicating with others includes active listening and empathy. Empathic responses to employee perspectives is critical to ensuring that staff feel understood and listened to in this process. The organization has developed several support mechanisms for staff to locate alternate employment or retrain for a different position or occupation. These mechanisms support the critical needs of staff with regard to job security and economics. However, minimal support has been implemented for. the emotional process 118 that develops with downsizing. Both the practical and emotional dimensions of downsizing should be dealt with as it occurs. The organization is exploring a variety of cost cutting activities instead of relying solely on headcount reductions. However, cost savings is only part of the initiative behind downsizing, yet this issue was not a significant part of the study. The focus of the reorganization was on reforming the mental health system and improving patient care rather than strictly cost reduction. In fact, the organization does not seem to be actively attacking what Cameron (1994) refers to as organizational fat (i.e., excess information, meetings, and new programs). Instead it is initiating more meetings with staff to improve communication and there are a number of significant initiatives underway as part of the redesign process including continuous quality improvement, program management, and transition management. Minimal information was collected on measurement activities occurring at The Hospital. However, several key items were discussed including the human resource survey that collected information on interests, skills, and future plans of employees; and the implementation of technology to manage resource utilization. The organization has implemented a broad array of downsizing strategies to place patients in the community mental health system and reduce the size of the employee population. More emphasis on celebrating the successes may assist to create impetus towards achieving results rather than criticizing the downsizing process itself (Cameron, 1994). 119 CHAPTER Vll. IMPLICATIONS OF THE STUDY The purpose of this study was to describe the downsizing process employed in one organizational setting and to analyze and interpret this event/This was accomplished through ethnographic research in a psychiatric institution undergoing long-term downsizing. The limitations of the study and implications for theory, practice, and future research are described in this chapter. Limitations of the Study . There are several possible limitations related to the research design and methodology of this study that might be considered in the interpretation of its results. The current body of research concerning downsizing focuses primarily on institutions that have financial advancement as their primary purpose. Consequently, downsizing, as it has been studied, has been viewed in the scope of its effectiveness in achieving the financial betterment of its host organization. When assessing the outcome of this research project, it is important to acknowledge that The Hospital has very different downsizing objectives. The optimal convalescence and rehabilitation of the hospital's patients most certainly forms its primary organizational objectives, at least from a theoretical standpoint; Some people may speculate that the distinction of purpose between The Hospital's downsizing and other organizational downsizings would result in a significant difference in the downsizing process itself. However, although it may be important to acknowledge the distinction between The Hospital's downsizing objectives and those of other organizational downsizings, it is my position that this variance is immaterial. For 120 example, while The Hospital's primary objective emerged from the deinstitutionalization of its patients to improve mental health care, The Hospital most certainly embraced the corollary objective of maintaining an effective work environment that would efficiently employ its resources. In other words, The Hospital still attempted to achieve an efficient and effective work environment although it was not its primary reason for downsizing. In this way, it is not completely different from other organizations attempting to achieve workplace efficiency through downsizing as their sole or primary objective. Another possible limitation to this study pertains to the duration of The Hospital's downsizing process. Unlike most organizations which typically attempt to gain financial benefit in short order through a relatively brief downsizing period, this organization was studied in the middle stage of a relatively protracted and lengthy downsizing that spanned 10 years. The conclusions that have been drawn from a downsizing of this nature may not be as readily applicable to a more common downsizing where steps are taken quickly and employee positions are affected and changed with expedience. One must also consider the possible limitation of this study that arises from the fact that this organization agreed to participate in the study whereas other organization declined. The fact that The Hospital was open to an outsider's review of its processes may in and of itself reveal a predisposition to more progressive and open discourse concerning the downsizing as a whole. Organizations that are not inclined to entertain others' analyses on their downsizing may operate in a different manner than did the management of this hospital. 121 The temporal restrictions of the sampling employed for this study posed another potential limitation of the study. While the downsizing itself took place over a 10 year period. The data gathering for this study occurred over approximately a 5 month period in the midst of this process. The perspectives and experiences reported in these interviews were those that the participants recognized as being important at that particular time. To extend the conclusions drawn from this snapshot of the downsizing to the process as a whole should be done cautiously. If time were not an obstacle, the optimal research project would involve interviewing the participants over a longer time period. The unique quality of this researcher as the research instrument resulted in an individualistic and personal study of downsizing. The personal values and biases that I brought not only to the interviewing table, but also to the interpretation of the research data exposes it to the obvious challenge of critics who hold different values and biases. This research was conducted in a government organization concerning a very politically sensitive issue. Government funds were being expended on this project and its participants had a certain accountability for the project and the outcome of their actions. One cannot ignore that their responses may have been either politically or personally motivated. Again, this may not be a great distinction from other studies in that personal interests can never be far from an individual's thoughts when undergoing a downsizing when careers are at stake and advancement of an institutional objective is paramount. In summary, there are potential limitations to the findings of this research. The Hospital is different from other organizations that have been studied in a downsizing 122 setting. Although these limitations must be acknowledged, it is perhaps more impressive to note the many similarities and commonalties of the downsizing processes between organizations that do not share common purposes. Ultimately, regardless of purpose it seems logical that an organization undergoing a downsizing would want to be left after completion with a harmonious work environment that is effective in accomplishing its stated objectives whatever they might be. This downsizing differed in several significant ways from other organizations that downsize. These differences may limit the ability to generalize the results of the study beyond this organization and context. However, ethnographic studies are not aimed at generalizing the results, rather the goal is to extend our understanding of a phenomenon through a detailed description. Implications of the Study Implications of this study are explored as they relate to theory, practice, and future research of organizational downsizing. Theoretical Implications From a theoretical perspective, the results of this downsizing research may be interpreted as being both confirming in some respects and perhaps even expansive in others. While Cameron's model of nine best practices of effective downsizing was supported by the findings of this research, the very nature of the organization studied leads one to believe that perhaps Cameron's scope of inquiry was too limited in nature. Downsizing is most commonly defined and referenced in a manner which implies a financial motivation. The quest for administrative efficiency through restructuring and 123 work force reduction appears to be the focus of downsizing theory as it currently exists. This research project illuminates the fact that the primary objective of downsizing is not only unimportant in judging its success, but it is also not integral to the definition itself. In other words, downsizing is first and foremost a process. It can be motivated by any purpose and still be considered downsizing. Whether a hospital wants to change its method of delivering health care or whether a computer organization wants to eliminate costly duplication in management may not matter. What is key in assessing downsizing models and analyzing particular instances of downsizing is how effective these processes have been in accomplishing whatever goals that have been set by the host institution and how successful these institutions are in maintaining harmony in the remaining work environment and relationships. If one were to adopt the narrower definition of downsizing employed by Freeman and Cameron (1993), then it is perhaps even conceivable that what happened at The Hospital was not a downsizing at all. This would be an unfortunate result of such a limited definition insofar as the current downsizing theory applies well to the process that is taking place at The Hospital. The current theory of downsizing, and in particular, Cameron's model, for the most part were instructive and functional with respect to the downsizing process at The Hospital. Accordingly, it appears to make more sense to expand the definition of downsizing such that the unnecessary restriction of primary motive or initiative for the downsizing is no longer integral to the definition itself. In a more expansive and appropriate definition of downsizing, a downsizing may take place for any reason and still be labelled a downsizing. The models that are applicable to financially motivated downsizings may, in many respects, be equally 124 assistive in institutions such as The Hospital. In the introductory comments of this paper, it was acknowledged that we live in a society that is changing in new and different ways. We would perhaps be blind or negligent if we were to focus our attention only on that change that exists in for-profit institutions. Non-profit government organizations change. Charitable organizations change. Religious institutions similarly must change. Sometime these changes will be motivated by financial initiatives and sometimes they will not. The theoretical models that exist with respect to downsizing may be applicable to many change objectives as they are found in our society and its many varied institutions. This Hospital had a mandate to change the manner in which it delivered a health care service. Other institutions may be enfranchised with the task of improving the bottom line. Leaving employees relationships, confidence, and motivation in tact are objectives that permeate all downsizing institutions regardless of their primary motivating factor. In short, the purpose of downsizing may be many and varied, but the process will still properly be termed downsizing. The research in this project also proved to be confirming of Cameron's (1994) effective downsizing model. Not only were the nine best practices identified in his model relevant to the downsizing at The Hospital, but they also seem to be particularly accurate in the guidance that they would have provided at the outset of the downsizing. One significant modification to Cameron's model that should be considered as a result of this research pertains to the theory of alignment. Within The Hospital, the downsizing appeared to be most effective and met least resistance among those who had a common understanding of its purpose. While senior management seemed to be 125 highly in favour of the deinstitutionalization initiative, it was evident that some staff members and middle managers were not as persuaded. For example, the initiative of transferring patients to appropriate community facilities, while endorsed by senior management, met substantial resistance amongst the staff members and middle managers. At times, there appears to have been frustration within the staff that led to minor mutinies to the extent that certain patients were slotted for downsizing with the premeditated intention that they would be rejected from those facilities and returned to The Hospital. It appears that many of the staff did not concur with senior management on the strategy, and accordingly there was a breakdown in the downsizing process in this respect. This data leads one to believe that alignment of purpose amongst not only management, but all levels of an organization may be critical in achieving success in the organization's downsizing goals. If all stakeholders in the system are working towards the same goals or, at minimum, understand why they are heading in a particular direction (whether they agree with the explanation or not), then the downsizing process may operate more fluidly. The notion of alignment has been noted by many other theorists (Bridges, 1993; Conner, 1993). These writers noted that this notion is a critical element in the success of any organizational change. It is suggested that Cameron's model is deficient in omitting reference to the same. I would endorse a more comprehensive model that would add a tenth best practice to this model called "Alignment." It is also suggested that research to date underestimates the importance in addressing the emotional process in downsizing. Emotions are largely ignored in work 126 organizations. These organizations are tied to human functioning and it is undeniable that emotional stability and well-being are similarly integral to human functioning. Any comprehensive theory of downsizing must not fail to address this important component of the process. In summary, this study contributes to the knowledge of downsizing by urging a reevaluation of the current definition of the downsizing process. A more expansive approach to downsizing is encouraged that would include a process that is not necessarily motivated by financial gain or organizational efficiency. The theoretical model for effective downsizing omits reference to the important notion of alignment. Similarly, the importance of attending to the emotional process of downsizing must be more emphatically embraced in downsizing theory. Practical Implications Corporate-sponsored counselling programs like Employee Assistance Programs (EAPs) are gaining wider acceptance and are increasing in availability (Gerstein & Shullman, 1992). Healthy employees are seen by organizations as more productive and less expensive to maintain in the work place. Accordingly, it is becoming increasingly worthwhile to invest resources into improving the mental health of employees. Gerstein and Shullman (1992) report that counsellors work in a variety of capacities in all types of industries and businesses to provide training, resolve organizational and work group issues, and coach executives. For example, executive coaching is described as follows: Executive coaching involves helping high-level managers to work effectively with intact groups and preparing these persons for key leadership events. Such 127 leadership events may include critical performance appraisal and management challenges (e.g., coping with organizational downsizing, acquisition, or implementation of new services)." p. 591 As indicated above the emotional impact of an organization's internal conduct is key to the efficiency and effectiveness of that organization. Counsellors have an opportunity for direct involvement in the emotional state of an organization's employees. Consequently, it is critical for these professionals to have a working comprehension of the downsizing process and how it affects employees emotional well-being. By identifying and addressing those challenges related to a downsizing, counsellors can more effectively guide and assist employees through the process. If competently performed with a good understanding of the process, it is expected that these counsellors could actually expedite and improve the downsizing itself. Metaphorically speaking, while the management arm of an organization might properly steer a company through a downsizing, it would be the counsellors who would oil the machinery such that it would function more smoothly and with less friction. Ultimately, the operation will be more healthy, more productive, and less susceptible to breakdown with counsellors, knowledgeable in the dynamics of downsizing, involved throughout. To this point, much emphasis has been placed on counsellors roles in assisting employees. It is not to be forgotten that managers also benefit greatly from organizational counselling services. This research project focuses more than most on the management arm of downsizing insofar as all participants in the project were actually members of the management team. Counsellors would do well to reflect on this project and the data obtained when coaching managers on how to proceed through 128 a downsizing in their capacity as leaders. Counsellors can effectively assist management in appreciating and subsequently avoiding the obstacles that an organizations faces in carrying out a downsizing. Another contribution of this study to practice was identified through an analysis of the descriptive data. First, when downsizing, it is important to consider the systemic context of the organization so as to identify and prepare for obstacles in the process. It is similarly important to clarify roles and responsibilities and to anticipate how the downsizing may unfold within the system. By examining each stakeholder's perspective on the issue of downsizing, the organization may develop a solution that encompasses all perspectives and thus illicits greater cooperation in the process. It was established in this downsizing that the senior managers who had a confident and secure vision of their career path were effective in coping with the process and planning for its outcome. Regrettably, it was only the senior management level that benefited from career planning and counselling in this regard. Personal career planning with one's employees may be a worthwhile investment for managers to consider when downsizing the organization. The Hospital invested considerable time and resources into this component of the process. It also established training and retraining programs, provided peer counselling, and fostered job placement opportunities. The payoff for this investment is illustrated by the absence of any layoffs up to the fourth year of this downsizing. The underlying emotional process that employees experience such as loss, grief, and anger also requires attention. Counsellors may be particularly helpful in this aspect of the downsizing process. For example, counsellors may conduct workshops and 129 seminars in managing transitions, counsel individuals or teams, carry out closing ceremonies and other symbolic demonstrations, and coach managers on working with employees in this type of environment. Fineman (1993) argues that emotion forms and directs organizational processes. The emotional process of downsizing does not seem to be adequately addressed. The communication material reviewed during this project illustrated no empathic responses to employee's perspectives on downsizing. Most of the support effort was focused on addressing the more pragmatic consequences of downsizing such as job and financial security. For example, the majority of the transition initiatives involved job placements or retraining. Putnam and Mumby (1993) suggest that acknowledgment and expression of work feelings develops a sense of community and mutual understanding amongst people in an organization. They argue that sharing work feelings builds mutual affect, connectedness, and cohesion. This organization may have benefited from addressing both the job security related concerns and the emotional process associated with downsizing. Managers and human resource personnel should observe the recommended best practices identified in Cameron's (1994) model when planning and executing a downsizing initiative. This model provides a starting point and guide for organizational resources engaging in a downsizing. The leadership of an organization should also consider developing and fostering a supportive team environment at all levels of the organizational hierarchy, similar to how 130 the president established this at the senior level of The Hospital. Individual plans for the future should be reviewed with all employees and managers. Practitioners should consider the above factors when working in organizational systems to plan a downsizing initiative. A thorough analysis of the systemic context should assist the counsellor and organizational agents to assess the steps they need to take to achieve success in this process and minimize the negative effects of the same. Future Research Implications An ethnographic research design provides an excellent means of capturing data on downsizing within the context of the organizational setting. This research method allows the researcher to record dialogue, interactions, non-verbal cues, and observations in the context of the organizational setting. I would encourage future researchers to pursue qualitative methods to develop a grounded theory of downsizing with several cautions. Researchers should persevere in finding an organization willing to be studied. Although, the process to locate a willing participant organization is difficult and sometimes frustrating, the resulting opportunity to observe downsizing in the context of the organizational setting is invaluable. Examining the process in context is critical to developing practical and real world understanding of the phenomenon. Researchers should identify how the study will benefit the organization as a method of persuading the gatekeepers that the study is valuable. The most progressive leaders are more likely to be open to research; therefore, researchers may choose to seek out these types of leaders in search of a willing participant organization. 131 Researchers should also consider using a multi-modal data collection strategy including video tapes, formal observations, tape recordings, field diary, and document analysis. Data should be collected, if possible, from different stakeholders in the organizational system. 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The purpose of my study is to explore the relationship between an organization's culture, the approach or strategy used in downsizing and remaining employees' response to the downsizing. The research design that we will employ is based on research techniques associated with ethnographic fieldwork. The types of techniques utilized in this type of research include three to four observations of the organizational site and semi-structured individual interviews with five to ten employees and managers. It is my understanding that your organization has recently downsized. I am convinced that the opportunity to conduct a small research project within your organization will offer mutual benefits. Initially this type of request may appear somewhat intimidating or invasive as the subject matter is highly sensitive. However, the project will be structured carefully by the researcher and the organization to ensure anonymity and a safe, respectful environment for interviewees. Some of the benefits that may result for your organization are discussed briefly below. This type of project will provide your staff and management an opportunity to anonymously share their thoughts and feelings of the sometimes daunting experience of downsizing. It is suggested by several researchers and writers that downsizing will continue to be employed by organizations as a strategic method for developing more effective and efficient organizations. If this prediction is true, then it is important for organizations to understand downsizing from the employee's perspective and develop an approach to downsizing that minimizes the aftershock which plagues organizations today. These aftershocks include heightened absenteeism, increased illness, higher attrition, role ambiguity, damaged relationships, and low productivity. APPENDIX B: INTERVIEW SCHEDULE 138 Participant Interview 1 (1 hour) Interview 2 (1 hour) President/CEO (CEO) Mar 2, 1995 (pm) Aug 24, 1995 (pm) Vice President 1 (VP1) May 24, 1995 (am) Aug 24, 1995 (pm) Vice President 2 (VP2) May 26, 1995 (pm) Sept 7, 1995 (pm) Vice President 3 (VP3) May 24, 1995 (am) Sept 7, 1995 (pm) Vice President 4 (VP4) May 5, 1995 (pm) Aug 2, 1995 (pm) Vice President 5 (VP5) May 9, 1995 (pm) Aug 12, 1995 (am) Director 1 (Dir1) May 9, 1995 (pm) Aug 2, 1995 (pm) Director 2 (Dir2) July 5, 1995 (am) Aug 25, 1995 (am) Director 3 (Dir3) July 5, 1995 (am) Aug 24, 1995 (am) Director 4 (Dir4) May 10, 1995 (am) Aug 25, 1995 (am) 139 APPENDIX C: INTERVIEW QUESTIONS A. Strategy 1. What was the overall strategy used to downsize THE Hospital? - work force reduction - work redesign change in relationships with other institutions, organizations, or groups 2. What were the objectives of or driving factors behind the downsizing? 3. Did you perceive these objectives as being attainable through a downsizing? 4. What role(s) did you play and involvement did you have in the downsizing process? 5. What was the decision making process around downsizing? - What decisions were to be made? - Who made the decisions? - How were decisions made? - How were programs/wards/employees selected? - How was this process different from the existing decision making processes? B. Implementation Process 1. What was the plan for the implementation? 2. Who had access to the plan? 3. Communication - How were employees told about the downsizing? - Who told the employees? - What were employees told about the process? - When were employees told about the process? C. Understanding 1. What understanding did the employees have of the downsizing? 2. What was your understanding of the downsizing initially? 3. What is your understanding of this process now? 4. What understanding did your peers have of the downsizing initially? 5. What is their understanding of this process now? 6. What is your perception of the effect of downsizing on The Hospital? 7. Were there adjustment phase(s)? If so, what happened during these phases? 8. What other resources/information would have been helpful to you as a manager in this process? 140 D. Results 1. What results were The Hospital hoping to achieve from the downsizing? 2. Does The Hospital believe that the objectives were attained now that the downsizing is complete? 3. Do you believe these objectives have been identified? 4. Did the results of some downsizing strategies (e.g., transfers) differ from other strategies (e.g., layoffs)? 5. What other side benefits have been achieved by the downsizing? E. Demographics 1. Age 2. Gender 3. Career history - What is current position and responsibilities? - How long have been in this position? - What is career history with The Hospital? 1 4 1 APPENDIX D: THEMES AFTER 1ST INTERVIEW A. General Information 1. Type of changes 2. Reasons a. Close to home philosophy b. Institutionalization c. Medication Improvements 3. Recommendations a. Long term plan from beginning of process b. Fiscal Framework from beginning of process c. Annual Evaluations on process & numbers d. Understand that it is a difficult process despite best efforts e. Labour Adjustment plan 4. Strengths a. Ability to work well with acute patient populations B. Patient Downsizing 1. Successes a. Patient placements b. Transitional assistance program c. Agreement to accept people back d. Partnering with community 2. Challenges a. Myths and images of mental illness b. Community programs c. Skills in community care to deal with acuity of THE HOSPITAL population d. Cost of service in community e. Moving professionals to rural areas f. Special populations g. Multi-year planning -Sharing a vision h. Population versus resources I. Timing & pace j. Acuity of new HOSPITAL population k. Patient moving process I. Public perceptions of process 3. Reactions a. Community reactions b. Public reactions c. Family reactions d. Staff reactions 4. Patient downsizing strategies a. Patient transfers another program/ward in The Hospital b. Transition Assistance Program c. Placements in community 5. Involve 6. Monitor a. Reviewing Referrals 7. Communication a. Family forums b. Community forums c. Community Newsletter d. Ministry negotiation Employee Downsizing 1. Successes a. No layoffs b. Helping some staff take advantage of new opportunities c. Retraining some staff d. Improvements in planning process each year 2. Challenges (challenges) a. Workload on survivors (workload) b. Institutionalized staff c. Level of skill currency -Promoting from within d. Multi-year planning e. Staff anxiety (so can still give therapeutic care) f. Staff anxiety (so can hear messages) g. Not sterilizing existing family/caring culture h. Constraints of existing personnel system i. Size of employee population -communication -cohesiveness -team building j. Unified mid-management team 3. Reactions a. Survey b. Staff reactions -concern for job security -anger -uncertain -denial -devalued -unheard -resistant -stress -accepting -apprehension 143 -ambivalence -fear -low morale c. Middle Managers' reactions (midreact) d. Doctors' Reactions (docreact) e. Supervisor reactions (supvreact) f. Senior Managers' reactions (senreact/percepts) 4. Work Force Reduction a. Cross board b. Transfers c. Attrition d. Auxiliary Staff e. Retirements f. Skills management opportunity g. No Layoffs 5. Communication a. Communication Strategy (commstrat) b. Messages communicated (msg) c. People require information about the future (info) d. Communication Timing (commtime) e. Communication challenges -Communication should be proactive & early (proactive) -Same language -Consistent message -FTE size f. Communication types -president's bulletins -newsletters -staff meetings -committees -middle management communication -listening -HR meetings -Meeting minutes -General Assembly -VP meetings -Communication Officer -Union Communication -Open house -Individual meetings 6. Resources a. training -retraining for another job -upgrading skills b. education c. counselling -peer 144 -career d. ceremony e. resume service f. career planning g. consultants h. project management i. Secondments to community j. Transition funding 7. Plans in Process a. Fiscal framework b. Human resource plan c. Multi-Year Plan d. Hire new people with desired qualifications & skills e. Use inside people to participate in downsizing who know culture f. Develop a protocol g. Time D. Redesign 1. Vision 2. Accreditation 3. Technology 4. Work flow or business processes 5. Program management -referrals (referrals) 6. Continuous quality improvement 7. Customer service 8. Research 9. Patient rights 10. Restructuring E. Systemic 1. community development 2. community relationships 3. government relationships F. Structure 1. Decisions 2. Committees 3. Teams -Transition team 4. Unions 5. Middle Management 6. Senior Management -perceptions 7. Leadership 8. Employee type -service staff -ward staff 145 G. Culture 1. raising what is expected of subordinate managers (e.g., responsibilities)-2. empowerment 3. learning organization 4. literature 5. metaphor 6. reward 7. management training 8. risk 9. story 10. trust 11. employee contract 12. role model 13. values H. Chronology 1. All Years 2. Pre1987 3. Pre 1992 4. 1987 5. 1988 6. 87-91 7. 90-91 8. 91-92 9. 92-93 10. 95-96 11.93-94 12. 94-95 I. Tape 146 APPENDIX E: DOCUMENTS RELATED TO THE HOSPITAL Document Name Date Created By Source Bed Reduction Protocol May 94 Director Director Clinical & Human Resource Planning for the Downsizing of Psychiatric Hospitals: The Experience from The Hospital's Perspective No date Written By CEO, 2vps, Director, Student, & Unknown Other President Connections Newsletter Spring 95 Communications Officer Director Evaluation by Front Line Clinicians of the 1993-1994 Downsizing Initiative at The Hospital July 94 Contractor Director Geriatric Division Programs No date Unknown Director Human Resource Plan: The Hospital March 95 Human Resource Plan Steering Committee Vice President Letter of Approval for Study (to researcher) April 95 Vice President Vice President Letter Pending Approval of Study (to researcher) February 95 Chair of Research Advisory Board (RAC) Chair of RAC Letter outlining issues related to study December 94 Chair of Research Advisory Board (RAC) Chair of RAC Listening: A Review of The Hospital May 94 Ombudsman Vice President Managing Cultural Change at The Hospital July 94 Student President Memorandum to Participants Re: Research Study April 95 Vice President VP Administrator Mental Health Consultation Report 1987 Government Library President's Bulletin February 95 President President Spring Information Sessions April 95 Various Hospital Committees Vice President Status of the Downsizing of The Hospital No date President President Strategic Plan No date Unknown Vice President Strategic Planning Presentation (Divisional Mgrs) No date Unknown Vice President Strategies for Staff Position Reduction No date President President Value for Money Audit 1994 Government Library The Hospital Committee Structure July 94 Unknown Vice 147 President The Hospital Organization Chart July 94 Unknown Vice President The Hospital Program Management Organization July 95 Unknown Vice President The Hospital Research Advisory Board Terms of Reference 1992-1993 Unknown Director The Hospital Site Map October 91 Unknown President's Office Zig Zag Zone Newsletter July 95 Transition Management Team Vice President APPENDIX F: SENSITIZING CONCEPTS • Communication • Employee support • Involvement • Timing • Organizational culture • Organizational redesign • Resistance • Stress • Survivor reaction • Systemic relationships • Trust • Union • Vision • Work Force Reduction => attrition => auxiliary staff => layoff retirement package => transfers 149 APPENDIX G: LIST CODES WITH DESCRIPTIONS CODE BOOK for CODE1 3/24/1996 11:10 TYPE CODEWORD PARENT DEFINITION Text CHR-2001 CHRONOLOGY Reference made to the downsizing in 2001 Text CHR-92-93 CHRONOLOGY Reference made to the downsizing in 1992-1993 Text CHR-92-95 CHRONOLOGY Reference made to the downsizing in 1992-1995 Text CHR-93-94 CHRONOLOGY Reference made to the downsizing in 1993-1994 Text CHR-94-95 CHRONOLOGY Reference made to the downsizing in 1994-1995 Text CHR-95-96 CHRONOLOGY Reference made to the downsizing in 1995-1996 Text CHR-ALLYRS CHRONOLOGY Reference made to the chronology of the downsizing process over the years Text CHR-PRE87 CHRONOLOGY Reference made to the downsizing prior to 1987 Text CHR-PRE92 CHRONOLOGY Reference made to the downsizing prior to 1992 Text EMC-CHAL EMPLOYEE Communication - Communication challenges with employee downsizing Text EMC-INFO EMPLOYEE Communication - Information needs in communicating downsizing Text EMC-MSG EMPLOYEE Communication - Types of messages communicated in the various downsizing communication forums Text EMC-MTGS EMPLOYEE Communication - Staff and management meetings as a communication tool 150 Text EMC-NEWSLT EMPLOYEE Text EMC-OFFICR EMPLOYEE Text EMC-PRESB EMPLOYEE Text EMC-VPMTGS EMPLOYEE Text EMP-CHAL EMPLOYEE Text EMP-CUNION EMPLOYEE Text EMP-FUTURE EMPLOYEE Text EMP-MPLAN EMPLOYEE Text EMP-PLAN EMPLOYEE Text EMP-PROCES EMPLOYEE Text EMP-SUCCES EMPLOYEE Text EMR-CERMON EMPLOYEE Text EMR-CONSLT EMPLOYEE Text EMR-COUNSL EMPLOYEE Text EMR-CPLAN EMPLOYEE Communication - Newsletters as a type of communication Communication - Communication officer responsible for developing communication strategy and materials Communication - President's Bulletin as a communication Communication - Meetings conducted by the vice-presidents as a communication tool General challenges with employee downsizing Communicating with the unions in the employee downsizing process Vision information required for staff to feel more secure about downsizing A multi-year plan for employee and patient downsizing Planning for employee downsizing How the employee downsizing was carried out Successes in the employee downsizing process Employee resource - Closing ceremony as employee support function Employee resource - Use of consultants to aid the employee downsizing process Employee resource - Counselling offered as a support to employees Employee resource - Career planning offered as support to employees 151 Text EMR-MARKET EMPLOYEE Text EMR-RTRAIN EMPLOYEE Text EMR-SECOND EMPLOYEE Text EMR-TRAIN EMPLOYEE Text EMS-ACCEPT EMPLOYEE Text EMS-AMBIVL EMPLOYEE Text EMS-ANGER EMPLOYEE Text EMS-DENIAL EMPLOYEE Text EMS-DEVALD EMPLOYEE Text EMS-MIDACT EMPLOYEE Text EMS-PATCON EMPLOYEE Text EMS-RESIST EMPLOYEE Text EMS-SAD EMPLOYEE Text EMS-SECURE EMPLOYEE Employee resource - Hospital marketing open government agency positions to employees & setting up restricted competitions for hospital employees Employee resource - Retraining employees for new jobs Employee resources - Secondments to community or other agency for prescribed period of time Employee resources - Training employees new skills for same type of role (updating training) Employee reactions - acceptance of downsizing Employee reactions - ambivalent about employee downsizing Employee reactions - angry about employee downsizing Employee reactions - denial that employee downsizing will occur Employee reactions - feeling devalued as an employee for past services to the organization Employee reactions - middle management reactions to downsizing Employee reactions - concern for patients' well-being and safety through downsizing Employee reactions - resistance to employee downsizing Employee reactions - sadness about employee downsizing Employee reactions - concern over job security 152 Text EMS-SRACT EMPLOYEE Text EMS-STRESS EMPLOYEE Text EMW-ATTRIT EMPLOYEE Text EMW-AUX EMPLOYEE Text EMW-CROSBD EMPLOYEE Text EMW-LAYOFF EMPLOYEE Text EMW-RETIRE EMPLOYEE Text EMW-TRANSF EMPLOYEE Text GD-REASONS GENERAL Text GD-RECOMND GENERAL Text GD-SURVEY GENERAL Text GDCU-METAP GENERAL Text GDCU-MISC GENERAL Text GDCU-NEW GENERAL Text GDCU-STORY GENERAL Text GDCU-TAPE GENERAL Text GDCU-TRUST GENERAL Text GDOS-COMIT GENERAL Employee reactions - senior management's reaction to downsizing Employee reactions - stress related to downsizing Work force reduction strategies - attrition Work force reduction strategies - auxiliary staff Work force reduction strategies - cross the board cuts Work force reduction strategies - layoffs Work force reduction strategies - retirement Work force reduction strategies - transfers to another ward within hospital General description - reasons for downsizing General description - recommendations for how to downsize General description - reference to surveys conducted Cultural description - Metaphors used to describe the culture or changes Cultural description - Miscellaneous comments Cultural description - Plans for new culture Cultural description - Examples and stories about culture Cultural description - References made to being tape-recorded Cultural description - trust Organizational structure - Committee structure 153 Text GDOS-EMP GENERAL Text GDOS-MID GENERAL Text GDOS-SRMGT GENERAL Text GDOS-TEAMS GENERAL Text GDOS-UNION GENERAL Text PAT-CHAL PATIENT Text PAT-COMDEV PATIENT Text PAT-COMM PATIENT Text PAT-COMREL PATIENT Text PAT-CREACT PATIENT Text PAT-DECISN PATIENT Text PAT-FISCAL PATIENT Text PAT-FREACT PATIENT Text PAT-GOVT PATIENT Text PAT-INVOLV PATIENT Text PAT-MPLAN PATIENT Text PAT-PLAN PATIENT Organizational structure - Employee types Organizational structure - Middle Management Organizational Structure - Senior Management Organizational structure - team structure Organizational structure - Trade unions Patient downsizing - challenges with patient downsizing Patient downsizing - community development Patient downsizing - Communication regarding patient downsizing Patient downsizing - Hospital's relationship with community Patient downsizing - community reaction to patient downsizing Patient downsizing - decision making process in patient downsizing Patient downsizing - fiscal framework for funding transfers Patient downsizing - family reactions to patient downsizing Patient downsizing - Hospital's relationship with government Patient downsizing - Involvement of various stakeholders in process Patient downsizing - multi-year plan Patient downsizing - Planning for patient downsizing 154 Text PAT-PREACT PATIENT Text PAT-PROCES PATIENT Text PAT-SUCCES PATIENT Text RD-ACCRED REDESIGN Text RD-BUSPROC REDESIGN Text RD-CQI REDESIGN Text RD-CUSTSER REDESIGN Text RD-MISC REDESIGN Text RD-PROGMGT REDESIGN Text RD-TECHNOL REDESIGN Text SR-COUNSEL SENIOR MGT Text SR-INDIVID SENIOR MGT Text SR-TEAM SENIOR MGT Patient downsizing - public reaction to patient downsizing Patient downsizing - How carried out patient downsizing Patient downsizing - Successes with patient downsizing Redesign - Academic accreditation to enhance academic role of hospital Redesign - Streamline business processes (eliminate redundancy, inefficiency and unnecessary work flow) Redesign - Continuous quality improvement initiative Redesign - Transition to patient focused rather than custodial care Redesign - Miscellaneous Redesign - Program management model Redesign - Technology innovation Senior Management Experience -Counselling for senior management in downsizing Senior management experience - Individual strategies for managing the downsizing process Senior management experience - Team strategies for managing the downsizing process 


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