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Empirical analysis of professional-patient role asymmetry in two rehabilitation centres : evidence of… Palmer, Carla Ruth 1984

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EMPIRICAL ANALYSIS OF'PROFESSIONAL-PATIENT ROLE ASYMMETRY IN TWO REHABILITATION CENTRES: EVIDENCE OF A LAG BETWEEN SOCIETAL TRENDS AND PROFESSIONAL RESPONSE By CARLA RUTH PALMER B.Sc. ( P h y s i o t h e r a p y ) , U n i v e r s i t y of Toronto 1979 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Hea l th S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n ) i n THE FACULTY OF GRADUATE STUDIES (Department of Hea l t h Care and Ep idemio logy) We accept t h i s t h e s i s as conforming to the r e q u i r e d s tandard THE UNIVERSITY OF BRITISH COLUMBIA October 1984 © C a r l a Ruth Pa lmer , 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department Of Health Care and Epidemiology The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date October 3. 1984 ABSTRACT Demographic s h i f t s and changes i n s o c i e t y ' s b e l i e f s and va lues are c h a l l e n g i n g the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p i n r e h a b i l i t a t i o n , where p ro fe s s i ona l dominance i s entrenched i n the i n s t i t u t i o n . S i nce t h i s i n t e r a c t i o n unde r l i e s much of the u t i l i z a t i o n of hea l th s e r v i c e s , w i t h the ensuing cos t s and b e n e f i t s of concern to the p r o f e s s i o n a l , p a t i e n t and t h i r d p a r t i e s , such as p a t i e n t s ' f a m i l i e s and governments as the b i l l - p a y e r s , i t undergoes ongoing s c r u t i n y by both the p u b l i c and governments. I t i s important then to assess the p r o f e s s i o n a l ' s response to the cha l l enge . With the f u t u r e d i r e c t i o n s of the c ha l l e n g e , and the lagg ing response, unknown, the i m p l i c a t i o n s o f the response are obscured. The p r o f e s s i o n a l ' s response to the p a t i e n t ' s cha l l enge to p r o f e s s i o n a l a u t h o r i t y was examined through r o l e i n t e r a c t i o n between the p r o f e s s i o n a l and p a t i e n t . Whereas, t r a d i t i o n a l l y , p r o f e s s i ona l s b e l i e v e they make h e a l t h d e c i s i o n s through the a p p l i c a t i o n of t h e i r e x p e r t i s e , i t was hypothes ized t h a t how the p ro fe s s i ona l e x p l a i n e d , descr ibed and d e a l t w i th the p a t i e n t was p r e d i c t e d to be dependent on the i n t e r a c t i o n between p r o f e s s i o n a l r o l e and p a t i e n t r o l e when the d e c i s i o n concerned the r e s p o n s i b i l i t y f o r making d e c i s i o n s . Quest ionna i res and i n t e r v i ews were g iven to t h i r t y - n i n e p r o f e s s i o n a l s - -p h y s i c i a n s , p h y s i o t h e r a p i s t s , occupat iona l t h e r a p i s t s , nurses , and s o c i a l workers — at G.F. Strong and Holy Family H o s p i t a l s . The que s t i onna i r e measured the p r o f e s s i o n a l ' s r o l e as a ' c o n t r o l l e r ' ( be l i e ve s t ha t the p r o f e s s i o n a l should i i assume the r e s p o n s i b i l i t y f o r h ea l t h d e c i s i o n s ) or 'accomrnodator' ( b e l i e v e s t h a t the p a t i e n t should assume r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s ) . The p a t i e n t ' s r o l e , p resented to these p r o f e s s i o n a l s i n the i n t e r v i e w , was f a b r i c a t e d i n two case s t u d i e s i n which the p a t i e n t ' s behav io r was c o n s i s t e n t w i t h t h a t of a 'consumer ' (wishes t o assume the r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s ) or a ' t r a d i t i o n a l dependent ' p a t i e n t (wishes the p r o f e s s i o n a l t o assume r e s p o n s i -b i l i t y f o r h e a l t h d e c i s i o n s ) . In the i n t e r a c t i o n between the p r o f e s s i o n a l and each o f the p a t i e n t r o l e s , the p a t i e n t was r epo r t ed t o d i s ag ree w i t h the p r o -f e s s i o n a l ' s d e c i s i o n . In t h i s c o n t e x t , the p r o f e s s i o n a l was asked t o e x p l a i n , de s c r i be and deal w i t h the p a t i e n t ' s behav i o r . The i n t e r a c t i o n between p r o f e s s i o n a l r o l e and p a t i e n t r o l e was assessed by two-way a n a l y s i s o f v a r i a n c e . The hypothes i s was supported f o r the dimensions o f d e s c r i b i n g and d e a l i n g but not f o r e x p l a i n i n g . I t was conc luded t h a t t h i s p r ov i ded p r e l i m i n a r y ev idence t h a t r o l e i n t e r a c t i o n s y s t e m a t i c a l l y e x p l a i n e d , i n p a r t , the p r o f e s s i o n a l ' s response to cha l l enge to the t r a d i t i o n a l p r o f e s s i o n a l -p a t i e n t r e l a t i o n s h i p . The t r a d i t i o n a l p r o f e s s i o n a l r o l e was con s ide red as ev idence of r e s i s t a n c e t o the c h a l l e n g e . The i m p l i c a t i o n s o f the r e s i s t a n c e were con s i de red i n terms o f f ou r s c ena r i o s which combined 1) the f u t u r e d i r e c t i o n of the t r end of ' c h a l l e n g e ' , t h a t i s t o i n c r e a s e or decrease , and 2) the d i r e c t i o n o f the p ro -f e s s i o n a l ' s r e s i s t a n c e , t h a t i s to i n c r ea se or decrease. The opt i on s f o l l o w i n g from the i n t e r a c t i o n between d i r e c t i o n s i n c l u d e d 1) r e t u r n t o the s t a t u s quo, t h a t i s p r o f e s s i o n a l dominance i n the i n s t i t u t i o n ; 2) accommodation of the c h a l l e n g e , t h a t i s , p a t i e n t dominance; and c o n f l i c t when, 3) p r o f e s s i o n a l and i i i p a t i e n t f i g h t to determine who i s i n charge, and 4) n e i t h e r the p r o f e s s i ona l nor p a t i e n t take charge. I t was recommended t ha t 1) researchers develop a d d i t i o n a l s tud ie s to f u r t h e r de f ine the s i t u a t i o n and to monitor the d i r e c t i o n of the t rends ; and 2) t ha t p r o f e s s i o n a l s and the i n s t i t u t i o n , a) r ede f i ne the t r a d i t i o n a l concepts such as ' team ' and the o b l i g a t i o n s and r e s p o n s i b i l i t i e s of the p r o f e s s i ona l and p a t i e n t , and b) d i s cu s s , i n a p u b l i c forum, the d i r e c t i o n i n which the t rends should go, and the i n t e r v e n t i o n s t h a t would best d i r e c t them. i v TABLE OF CONTENTS Page Ab s t r a c t i i L i s t of Tables v i L i s t of F i gu re s v i i i Acknowledgement x I I n t r oduc t i on : The Chal lenge to Profes s iona l -Dominant 1 Role Asymmetry i n the R e h a b i l i t a t i o n S e t t i n g II Theory: Modes of I n t e r a c t i o n between the P ro fe s s i ona l 13 and P a t i e n t Roles I I I Methods 28 IV F ind ings 61 V D i s cu s s i on : I m p l i c a t i o n s : A Lag between S o c i e t a l 80 Trends and P ro f e s s i ona l Response B ib l i o g raphy 91 Appendices: 1 In terv iew 96 2 Quest ionna i re 107 3 D i s t r i b u t i o n of Fac to r Score 115 4 R e l a t i o n of Fac to r s to P r o f e s s i ona l A t t r i b u t e s 116 v LIST OF TABLES Page I De M i g u e l ' s P o l i c y A n a l y s i s Framework 7 II Study Sample Acco rd i ng to S p e c i a l t y 31 I I I V a r i a b l e s r e f l e c t i n g the c i rcumstances o f the p a t i e n t case s t u d i e s 36 IV (A) F a c t o r 1. The p a t i e n t ' s r o l e as a team member (B) A l t e r n a t e P e r c e p t i o n s o f the P r o f e s s i o n a l ' s Ro le Regard ing the P a t i e n t ' s Ro le as a Team Member 50 51 V F a c t o r 2 . Judg ing P a t i e n t We l fa re 52 VI F a c t o r 3. G i v i n g and F o l l o w i n g Adv i ce 53 VI I F a c t o r 4. P a t i e n t F a i t h i n P r o f e s s i o n a l Adv i ce 54 V I I I F a c t o r 5. U t i l i z a t i o n o f the Cent re 55 IX F a c t o r 6 . Who Should Assume R e s p o n s i b i l i t y f o r Hea l th D e c i s i o n s 56 X D i f f e r e n c e s i n Range i n F a c t o r Scores Between F a c t o r s 57 XI E x p l a i n i n g the Consumer i s t P a t i e n t ' s Behav i o r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r F a c t o r 6 and Country o f T r a i n i n g With Con t ro l f o r Other V a r i a b l e s 71 XII E x p l a i n i n g the Dependent P a t i e n t ' s Behav io r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r age and a t t i t u d e to a u t h o r i t y i n general w i t h c o n t r o l f o r o the r v a r i a b l e s 72 X I I I D e s c r i b i n g the P a t i e n t ' s Behav io r : 2-way ANOVA between F a c t o r 1 and P a t i e n t Case Study 74 XIV D e s c r i b i n g the Dependent P a t i e n t ' s Behav io r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r F a c t o r 6 and number o f yea r s a t the f a c i l i t y , c o n t r o l l i n g f o r the i n f l u e n c e o f o the r v a r i a b l e s 75 XV D e a l i n g w i t h the P a t i e n t ' s Behav io r : 2-way ANOVA between F a c t o r 6 and P a t i e n t Case Study 77 XVI D e a l i n g w i t h the P a t i e n t ' s Behav io r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r Country o f T r a i n i n g 78 XVII K u r t o s i s and Skewness va lues o f f a c t o r s 1 to 6 v i 115 Page XVI I I E x p l a i n i n g the d i s t r i b u t i o n o f f a c t o r s co re s : 116 Pearson R. c o r r e l a t i o n s f o r age, yea r s a t the f a c i l i t y and a t t i t u d e to a u t h o r i t y XIX One-way a n a l y s i s o f v a r i a n ce between f a c t o r scores 117 and s p e c i a l t y , G.F. S t rong and Holy Fami l y combined XX One-way a n a l y s i s o f v a r i a n ce between f a c t o r scores 118 and count ry o f t r a i n i n g v i i LIST OF FIGURES Page 1. B loom ' s model o f the P r o f e s s i o n a l - P a t i e n t R e l a t i o n s h i p 18 2. The P r o f e s s i o n a l ' s C i r c l e of I n t e r e s t s 19 3. Modes o f I n t e r a c t i o n between the P r o f e s s i o n a l 22 and P a t i e n t 4 . How P r o f e s s i o n a l r o l e , p a t i e n t r o l e and e x p l a i n i n g 25 the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d 5. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and d e s c r i b i n g 26 the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d 6. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e , and d e a l i n g w i t h 27 the p a t i e n t ' s behav io r a re p r e d i c t e d to be r e l a t e d 7. A Framework I n t e g r a t i n g the assumption o f the a l t e r n a t e 43 p r o f e s s i o n a l r o l e s , the c a t e g o r i e s o f responses, and the a c tua l responses p r e d i c t e d t o emanate from i n t e r a c t i o n w i t h each o f the p a t i e n t r o l e s 8 . P r o f e s s i o n a l Responses t o P a t i e n t Ro les P re sented i n 58 the I n t e r v i e w 9. Modes o f I n t e r a c t i o n Between the P r o f e s s i o n a l and P a t i e n t 61 10. E x p l a i n i n g the P a t i e n t ' s Behav i o r : P a t t e r n o f Responses, 63 G.F. S t rong and Holy Fami l y H o s p i t a l s Combined 11. D e s c r i b i n g the P a t i e n t ' s Behav io r : P a t t e r n o f Responses, 64 G.F. S t rong and Holy Fami ly H o s p i t a l s Combined 12. D e a l i n g w i t h the P a t i e n t ' s Behav io r : P a t t e r n o f Responses, 65 G.F. S t rong 13. E v a l u a t i n g the I m p l i c a t i o n s o f the P a t i e n t ' s Behav io r f o r 67 t he E f f e c t i v e n e s s o f R e h a b i l i t a t i o n : P a t t e r n o f Responses, G.F. S t rong 14. How p r o f e s s i o n a l r o l e , D a t i e n t r o l e and e x p l a i n i n g the 69 p a t i e n t ' s behav io r are p r e d i t e d t o be r e l a t e d 15. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and d e s c r i b i n g the 73 p a t i e n t ' s behav io r are p r e d i c t e d t o be r e l a t e d v i i i Page 16. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and d e a l i n g w i t h 76 the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d 17. The Contex t and Approach t o Study o f the P r o f e s s i o n a l ' s 81 Response to Cha l l enge to the T r a d i t i o n a l P r o f e s s i o n a l -P a t i e n t R e l a t i o n s h i p 18. D i f f e r i n g P e r s p e c t i v e s o f the P r o f e s s i o n a l , P a t i e n t and 84 T h i r d P a r t y o f the Cost s and B e n e f i t s o f D i s cha rge D e c i s i o n s F o l l o w i n g from P ro fe s s i ona l -Dom inan t and Pa t i en t -Dominant Asymmetry 19. The I n t e r a c t i o n between A l t e r n a t e D i r e c t i o n s of the t r end 88 o f c h a l l e n g i n g behav io r and the degree o f p r o f e s s i o n a l r e s i s t a n c e i x ACKNOWLEDGEMENT I g r a t e f u l l y acknowledge the a s s i s t a n c e p rov ided by many persons and o r g a n i z a t i o n s . In p a r t i c u l a r , I would l i k e to r ecogn i ze my a d v i s o r , Dr. Nancy Waxier M o r r i s o n , f o r her unwavering support and d i r e c t i o n . In a d d i t i o n , my committee members, Dr s . Anne C r i c h t o n and Lyn Jongb l oed , made v a l u a b l e c o n t r i -bu t i on s to my unders tand ing o f the con tex t and development of the s tudy. S p e c i a l mention must be made o f the a d m i n i s t r a t i v e and c l i n i c a l s t a f f of the f a c i l i t i e s which agreed t o p a r t i c i p a t e i n 1) the p i l o t s tudy , Vancouver General H o s p i t a l , and i n 2) the a c t ua l s tudy , G.F. S t rong and Holy Fami ly H o s p i t a l s . Many of my c o l l e a g u e s , w i t h i n the School o f R e h a b i l i t a t i o n Med i c ine and the M.Sc. H e a l t h S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n Program, U.B.C., a s s i s t e d w i t h the p r e p a r a t i o n o f the s tudy. And, f o r s t a t i s t i c s and computer a n a l y s i s , the d i r e c t i o n o f Ronnie S i z t o and Wayne Jones i s a l s o a p p r e c i a t e d . F i n a l l y , to my husband, Bob, who took t ime from h i s own work to p r ov i de e d i t o r i a l a s s i s t a n c e , belongs the most c r e d i t f o r the c l a r i t y and con s i s t ency of the p r e s e n t a t i o n of i d e a s . x INTRODUCTION The acceptance of the i n s t i t u t i o n as an e f f e c t i v e and e f f i c i e n t s e t t i n g f o r the p r o v i s i o n o f h ea l t h s e r v i c e s i s l o n g s t and i n g . The i n s t i t u t i o n i s c o n s i -dered e f f e c t i v e , s i n c e m u l t i - d i s c i p l i n a r y and t e c h n i c a l i n pu t i s on hand and ready f o r s e r v i c e , and e f f i c i e n t , s i n ce these s e r v i c e s are a l l o c a t e d by p r o f e s s i o n a l s who, by over see ing p a t i e n t need, demand, and supp l y , can d i s t r i b u t e s e r v i c e s to serve the common good. T h i s , a t l e a s t , i s the ph i lo sophy of the t r a d i t i o n a l p e r s p e c t i v e . F r e i d s on (1972) and o ther s ( f o r example Roth and Eddy, 1967) have debated t h i s p o i n t o f v iew. They que s t i on the p r o f e s s i o n a l ' s competence i n t h i s t r a d i -t i o n a l r o l e and p o i n t to the u n d e s i r a b l e , i n d i r e c t e f f e c t s o f the i n s t i t u t i o n , independent o f i t s s t a t e d g o a l . The i n t e n t o f t h i s t h e s i s i s t o look a t t h i s debate i n g r ea te r d e t a i l , from the p e r s p e c t i v e of the i n t e r a c t i o n between p ro -f e s s i o n a l s and p a t i e n t s . The p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p forms an i n t e g r a l p a r t o f the h e a l t h ca re system. The terms of t h i s r e l a t i o n s h i p are con s i de red by many to u n d e r l i e the u t i l i z a t i o n o f h e a l t h s e r v i c e s . 1 The subsequent co s t s and b e n e f i t s p o t e n t i a l l y concern v a r i ou s t h i r d p a r t i e s such as p a t i e n t s ' f a m i l i e s and governments. As examples, a f a m i l y c ou l d be concerned about the a v a i l a b i l i t y o f d i s cha rge o p t i o n s , and the government about who w i l l pay f o r them. Consequent ly , the r e l a t i o n s h i p undergoes ongoing s c r u t i n y by the p u b l i c and governments. 1 Rad i c a l views such as those of Navarro (1977) and I l l i c h (1976) suggest t h a t the r e l a t i o n s h i p i s i n s i g n i f i c a n t i n the con tex t o f l a r g e r s o c i a l systems such as economics. Th i s v iew w i l l not be d i s cu s sed f u r t h e r but does put a pe r -s p e c t i v e on the scope o f t h i s t reatment of the t o p i c . 1 Wi th i n s o c i e t y , t h e i n t e r e s t s of the p r o f e s s i o n a l , p a t i e n t and va r i ou s t h i r d p a r t i e s are r e l a t e d and ba lanced. The t r a d i t i o n a l r e l a t i o n s h i p i s pa t te rned a f t e r r o l e asymmetry i n which the p r o f e s s i o n a l i s the dominant pa r t ne r i n the i n t e r a c t i o n . That i s , the p r o f e s s i o n a l assumes r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s . P r e s e n t l y , however, a s h i f t i n these f o r c e s i s o c c u r r i n g i n a number of ways, one o f them appear ing i n the form of i n c r e a s i n g p a t i e n t consumerism. As t h i s s h i f t i s c h a l l e n g i n g the t r a d i t i o n a l r e l a t i o n s h i p , e v a l u a t i o n o f the ensu ing p r o f e s s i o n a l response i s impor tan t . The nature o f the t r a d i t i o n a l r e l a t i o n s h i p , the cha l l enge to i t i n the c l i n i c a l env i ronment, and the i m p l i c a t i o n s o f both can be de s c r i bed d i f f e r e n t l y depending on the focus o f one ' s p e r s p e c t i v e . The economist, p h i l o s o p h e r , p o l i c y a n a l y s t , s o c i o l o g i s t , and hea l t h a d m i n i s t r a t o r w i l l each i n t e r p r e t the cha l l enge d i f f e r e n t l y . Th i s t h e s i s c on s i de r s these i n t e r p r e t a t i o n s of the i m p l i c i t and e x p l i c i t p o l i c i e s t h a t ba lance competing i n t e r e s t s i n the r e h a b i l i t a t i o n s e t t i n g . An a c tua l case w i l l be presented i n t h i s chapte r and then assessed u s i ng the d i f f e r e n t v iews , w i t h the p o l i c y a n a l y s t p r o v i d i n g the con tex t f o r an e m p i r i c a l assessment o f the s i t u a t i o n . The second chapte r o u t l i n e s the s o c i o -l o g i c a l p e r s p e c t i v e which w i l l p rov i de the c o n d i t i o n s f o r the c o l l e c t i o n of da ta . The t h i r d and f o u r t h chapte r s de s c r i be the methods and f i n d i n g s of the s tudy. And the f i f t h c hap te r , through the p e r s p e c t i v e o f the p r o f e s s i o n a l s and i n s t i t u t i o n , c on s i de r s the i m p l i c a t i o n s , e s p e c i a l l y those i n f l u e n c i n g the o r g a n i z a t i o n o f h e a l t h s e r v i c e s . A l s o i n chapter f i v e , requ i rements f o r f u r t h e r research w i l l be c o n s i d e r e d , and recommendations r e s u l t i n g from the study w i l l be d i r e c t e d t o the p r o f e s s i o n a l s and i n s t i t u t i o n . 2 The scope of t h i s t h e s i s i s r e s t r i c t e d to the c o n s i d e r a t i o n of the p r o f e s -s i o n a l - p a t i e n t r e l a t i o n s h i p i n the s p e c i a l t y o f r e h a b i l i t a t i o n . There are a number of reasons f o r s e l e c t i n g t h i s d i s c i p l i n e . One, i n p a r t i c u l a r , i s t h a t r e h a b i l i t a t i o n i s a s p e c i a l t y which e x p l i c i t l y se t s the terms o f the i n t e r a c t i o n between the p r o f e s s i o n a l and p a t i e n t . Though r e h a b i l i t a t i o n p r o f e s s i o n a l s o r gan i ze as a team, each i s expected to e s t a b l i s h a one-to-one r e l a t i o n s h i p w i t h the p a t i e n t . A l a t e r examinat ion of p r o f e s s i o n a l and p a t i e n t r o l e s i n c l u d e s c o n s i d e r a t i o n o f the team approach, but i t i s the i n t e r a c t i o n between i n d i v i d u a l p r o f e s s i o n a l s and p a t i e n t s t h a t w i l l be the b a s i s of measurement i n t h i s t h e s i s . Based i n a r e h a b i l i t a t i o n s e t t i n g , the f o l l o w i n g p a t i e n t case study p rov ide s a focus f o r the d i s c u s s i o n o f a l t e r n a t e p e r s p e c t i v e s of r o l e asymmetry. Case Study 2 A l i c e Smith i s a 32 yea r o l d woman admit ted to a general h o s p i t a l w i t h an acute e xace rba t i on o f m u l t i p l e s c l e r o s i s . She was assessed and t r e a t e d by a comprehensive r e h a b i l i t a t i o n team. F o l l o w i n g medical s t a b i l i z a t i o n she was l e f t w i t h r e s i d u a l d e f i c i t s which s eve re l y l i m i t e d her p h y s i c a l f u n c t i o n a l a b i l i t y . D i scharge p l ann i ng had been an ongoing process and presented the f o l l o w i n g c i r cums tance s : 1) the p a t i e n t had from the beg inn ing vo i ced her i n t e n t i o n o f r e t u r n i n g home alone to l i v e i ndependent l y , 2) her f a m i l y l i v e d i n the M a r i t i m e s ; she was p r e s e n t l y l i v i n g i n Toronto and wished t o stay t h e r e , 3) she had a b o y f r i e n d o f t h ree months d u r a t i o n , and 4) she l i v e d on d i s a b i l i t y b e n e f i t s . F u r t h e r , a h o s p i t a l p h y s i o t h e r a p i s t assessed the p a t i e n t ' s p h y s i c a l 2 Th i s i s a pseudonym and not her r ea l name. 3 f u n c t i o n i n g and a f t e r no response to t reatment d i s c o n t i n u e d the p a t i e n t from therapy; the occupa t i ona l t h e r a p i s t assessed the home s i t u a t i o n and presented the c o s t s r e q u i r e d f o r a t tendent he lp and f o r renovat ion s n e c e s s i t a t e d by a w h e e l c h a i r ; and f i n a l l y , a s o c i a l worker presented a number o f d i s cha rge opt i on s rang ing from home through semi - t o f u l l - i n s t i t u t i o n a l c a r e . 3 The nu r s i n g department c o - o r d i n a t e d the team meeting w i t h the end of s e l e c t i n g from the d i scharge o p t i o n s . Two po les of op i n i on emerged. The f i r s t cons idered the p a t i e n t to be d i f f i c u l t , and to have l i m i t e d i n s i g h t i n t o her d i s a b i l i t y , thus i n c r e a s i n g the r i s k o f s e r i ou s i n j u r y i f sent home. I t r e -commended p r o t e c t i v e c a r e . The second op i n i on suggested t h a t the p a t i e n t had ' g u t s ' , t h a t her view was d i f f e r e n t from t h a t o f the team ' s but j u s t i f i e d , and t h a t her d e c i s i o n t o go home should be r e spec ted . R e f l e c t e d i n these two v iews, where the co s t s and b e n e f i t s to the r e s p e c t i v e p a r t i e s d i f f e r w i d e l y between outcomes, are d i f f e r e n c e s i n how the p r o f e s s i o n a l s have d e s c r i b e d , e x p l a i n e d and d e a l t w i t h a p a t i e n t . The f o l l o w i n g examinat ion o f d i f f e r e n t p e r s p e c t i v e s w i l l e x p l a i n the p ro -f e s s i o n a l s ' v a r y i n g responses to the s i t u a t i o n i n the case s tudy. The ac tua l outcome o f t h i s case, however, w i l l be con s ide red i n the f i n a l c hap te r , d i s c u s s i o n o f i m p l i c a t i o n s and recommendations. 3 P a t i e n t s a t t h i s c en t r e do not a t t end r e g u l a r team meet ings . P h y s i c i a n s a l s o do not g e n e r a l l y a t tend but g i ve t a c i t approval to d i s cha rge p lans by t h e i r s i g na tu re on the r e q u i r e d forms. 4 V a r y i n g Views of Asymmetry i n the P r o f e s s i o n a l - P a t i e n t  R e l a t i o n s h i p : The Economi s t ' s P e r s p e c t i v e ' 4 The economist models the p r o f e s s i o n a l - p a t i e n t i n t e r a c t i o n as an a g e n t - c l i e n t r e l a t i o n s h i p . The c l i e n t seeks the exper t adv i ce o f the p r o f e s -s i o n a l i n o rder t o r e s o l v e the problem, t h a t i s , t o get b e t t e r i f p o s s i b l e . But the c l i e n t ' s r e l i a n c e on c au t i on ( p a t i e n t beware) as a consumer, i s compromised i n t h i s i n t e r a c t i o n . Role asymmetry e x i s t s i n t h i s r e l a t i o n s h i p by v i r t u e of the f a c t t h a t the p r o f e s s i o n a l ' s range o f t e c h n i c a l knowledge i s not r e a d i l y a c c e s s i b l e t o the p a t i e n t . In t h i s way p r o f e s s i o n a l s makes the ' b e s t ' d e c i s i o n about the k i n d of h e a l t h ca re r e q u i r e d t o improve t h e i r p a t i e n t s ' h e a l t h s t a t u s , w h i l e s t i l l a l l o w i n g the p a t i e n t s t o i n t e r p r e t the persona l va lue of t h e i r r e s u l t i n g ' h e a l t h s t a t u s ' . In M i s s . S m i t h ' s ca se , she would have con s ide red her r e s i d u a l r i s k l e v e l and l i m i t e d f u n c t i o n a l a b i l i t y i n c ompe t i t i o n w i t h o ther e n t i t i e s or va lues such as independence. I f p r o f e s s i o n a l s . w e r e p e r f e c t agents , or complete advocates of p a t i e n t s , they would make d e c i s i o n s f o r p a t i e n t s as i f they were the p a t i e n t s themse lves . But p r o f e s s i o n a l s have o the r i n t e r e s t s to c o n s i d e r , such as p r e s t i g e , and o the r o b l i g a t i o n s to a t tend t o , such as mon i t o r i n g the use of the h e a l t h system. These may not c o i n c i d e w i t h a p a t i e n t ' s pe r cep t i on o f needs, nor w i t h the most e f f i c i e n t or c o s t - e f f e c t i v e use of the system. Thus the p r o f e s s i o n a l , p a t i e n t and, even, t h i r d p a r t i e s have i n t e r e s t s e x t e r na l to the medical problem of the p a t i e n t . 4 Th i s p e r s p e c t i v e i s de s c r i bed from the l e c t u r e notes o f D r . Robert Evans from the cou r s e , Hea l t h Economics, U n i v e r s i t y of B r i t i s h Co lumbia , 1983. 5 The P h i l o s o p h e r ' s P e r s p e c t i v e The ph i l o s phe r con s i de r s the c i rcumstances under which the v a r i ou s p r o f e s -s i o n a l s ' and p a t i e n t s ' terms of i n t e r a c t i o n are j u s t i f i e d , and, i n e f f e c t , when asymmetry can r i g h t f u l l y e x i s t . C a r l t o n (1978) p re sen t s a continuum of j u s t i -f i c a t i o n rang ing from the c l i n i c a l , through the l e g a l , t o the moral p e r s p e c t i v e . Dec i s i o n s are made a t each o f these l e v e l s as to what i s ' r i g h t ' o r ' w r o n g ' , ' a c c e p t a b l e ' or ' u n a c c e p t a b l e ' , ' p e r m i s s a b l e ' or ' f o r g i v a b l e ' , ' o b l i g a t o r y ' o r ' o p t i o n a l ' . T h i s p e r s p e c t i v e of cou r se , may change over t im e , p l a ce or a c t o r as s o c i e t y ' s va lues and b e l i e f s change. Ba s s f o rd (1982) p rov i de s the example o f a j u d g e ' s d e c i s i o n t h a t i l l u s t r a t e s the t r a d i t i o n a l view f a v o u r i n g p r o f e s s i ona l - dom inan t asymmetry, " In response to the que s t i on o f who i s to dec ide 'what c o n s t i t u t e s the p a t i e n t ' s w e l f a r e ' , he [ L o r d Denning] answers, ' t h e p h y s i c i a n . . . , by the very nature o f h i s p o s i t i o n , i s the bes t a r b i t e r o f t h i s que s t i on when i t concerns a p a t i e n t ' . . . i n summing up to the j u r y , [he a l s o ] suggested t h a t any que s t i on o f the p a t i e n t ' s w e l f a r e i s a medica l one, which i s to be s e t t l e d by expe r t medical t e s t i m o n y . " (Pg. 733) Ba s s f o rd concludes t h a t , a t p re sen t , p a t e r n a l i s m i s j u s t i f i e d on ly when the s u b j e c t o f p a t e r n a l i s m i s not f u l l y competent. In the case o f M i s s . Smi th , the f i r s t view r e f l e c t e d a c l i n i c a l l e v e l judgment o f incompetence p resent i n the s tatement, ' l a c k o f i n s i g h t i n t o d i s a b i l i t y ' , when the p a t i e n t ' s mental s t a t e was assessed w i t hou t ev idence independent o f the s u b j e c t i v e ob se r va t i on o f what the p a t i e n t c ou l d (would?) and c ou l d not (would not?) do on r eque s t . The r a t i o n a l e f o r the judgment i s not c l e a r . And, i f o the r than an exp re s s i on of e x p e r t i s e , i t t r e spa s se s on the p a t i e n t ' s r i g h t s . 6 The Context o f Examining the P r o f e s s i o n a l - P a t i e n t  R e l a t i o n s h i p : The P o l i c y A n a l y s t ' s P e r s p e c t i v e The h e a l t h - p o l i c y a n a l y s t attempts to understand the ' c o n t e n t and process o f dec i s i on -mak ing which may have i m p l i c a t i o n s f o r peop le s ' h ea l t h and the p r o -v i s i o n of h e a l t h s e r v i c e s ' ( C r i c h t o n 1981, p. 3 ) . To f u r t h e r d e f i n e the dec i s i on -mak ing a r e a , boundar ies he lp to assess the items t h a t shou ld , and should not be, i n c l u d e d . De M i g u e l s ' (1975) framework f o r the a n a l y s i s of p o l i c y has been s e l e c t e d here f o r i t s p o t e n t i a l to i n c r ea s e unders tand ing o f h ea l t h systems and t h e i r r e l a t i o n s to the process o f change i n s o c i e t y . In t h i s framework the h e a l t h system i s d i v i d e d i n t o f ou r subsystems which progress on a mic ro to macro s c a l e . These, i n o r d e r , are r e l a t e d to 1) i n d i v i d u a l s , 2) i n s t i t u t i o n s , 3) s o c i e t y and 4) l a r g e r systems. Tab le I l i s t s the s p e c i f i c f a c t o r s composing each o f the subsystem a reas . Tab le I De M i g u e l ' s P o l i c y A n a l y s i s Framework Subsystem Fac t o r s I n d i v i d u a l : A l Hea l th S ta tu s A2 B i o -med i ca l F a c t o r s A3 P s y c h o l o g i c a l F a c t o r s I n s t i t u t i o n s : B l Hea l t h S e r v i c e s B2 Hea l th O r g a n i z a t i o n B3 Hea l th P l a n n i n g S o c i e t y : CI S o c i o - c u l t u r a l P a t t e r n s C2 P o l i t i c a l S t r u c t u r e C3 Economic Development C4 Demographic S t r u c t u r e La rge r System: Dl Environments (From De Miguel 1975, c i t e d i n C r i c h t o n 1981, p. 4) 7 W i t h i n t h i s framework, the scope o f t h i s d i s c u s s i o n i s r e s t r i c t e d to the i n s t i t u t i o n s and subsystems of s o c i e t y . The p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p i s an element w i t h i n each f a c t o r i n the i n s t i t u t i o n subsystem, but the cha l l enge to the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p , such as w i t h the case o f M i s s Sm i th , emanates from the components o f the s o c i e t y subsystem. Two o f these w i l l be h i g h l i g h t e d f o r t h i s i n v e s t i g a t i o n : s o c i o - c u l t u r a l p a t t e r n s and demographic s t r u c t u r e . F i r s t , however, i t i s necessary to e x p l o r e , i n the h i s t o r i c a l c o n t e x t , how dec i s i on -mak ing l e d to the t r a d i t i o n a l ba lance o f i n t e r e s t s , and t h e n , i n a c u r r e n t c o n t e x t , how changes i n the s o c i o - c u l t u r a l and demographic f a c t o r s are c h a l l e n g i n g these t r a d i t i o n a l p o l i c i e s . H i s t o r i c a l Contex t The major growth o f Canadian r e h a b i l i t a t i o n s e r v i c e s surged forward i n the l i g h t o f pos t Wor ld War II s o c i a l concern f o r w a r - i n j u r e d veterans and c r i p p l e d c h i l d r e n (Canada 1960). I n i t i a l l y , p r o v i n c i a l and f e d e r a l fund ing schemes supported the e f f o r t s of v a r i ou s v o l un ta r y agencies which served the i n t e r e s t s of s p e c i f i c d i s a b i l i t y groups. But the emphasis g r a d u a l l y changed to the support o f p r o f e s s i o n a l groups i n i n s t i t u t i o n s , as medic ine e v e n t u a l l y assumed o v e r a l l r e s p o n s i b i l i t y f o r r e h a b i l i t a t i o n and c u s t o d i a l ca re o f the c h r o n i c a l l y i l l and d i s a b l e d (Wessen 1965). In t h i s way, a r e h a b i l i t a t i o n ph i l o sophy emerged w i t h i n the c o n s t r a i n t s of the medica l model, p r o v i d i n g th ree main com-ponents of the h e a l t h p r o f e s s i o n a l ' s view o f d i s a b i l i t y and p a t i e n t need: 1) Problems are o rgan i c and/or p h y s i c a l and bes t c a t e g o r i z e d acco rd ing to d i s ea se ; 2) Problems are cen t red i n the i n d i v i d u a l ; and 3) The i n s t i t u t i o n i s the e f f e c t i v e s e t t i n g f o r the p r o v i s i o n o f s e r v i c e s . 8 The r e h a b i l i t a t i o n f a c i l i t y , as the cen t r e of the p r o f e s s i o n a l ' s work, was des igned t o c o - o r d i n a t e phy s i c a l f a c i l i t i e s and resources o f community agenc ie s . But r e h a b i l i t a t i o n , though con s ide red a component o f a comprehensive range of h e a l t h s e r v i c e s , was regarded as a lower p r i o r i t y among s p e c i a l t i e s s e r v i n g m o r t a l i t y and emergency needs. To upgrade i t s s t a t u s i n the medical f i e l d , r e h a b i l i t a t i o n p r a c t i t i o n e r s have ac ted toward i n c r e a s i n g p r o f e s s i o n a l i z a t i o n , s p e c i a l i z a t i o n and o b j e c t i v i t y . These f o r c e s f a c i l i t a t e d and enhanced the development o f r e h a b i l i t a t i o n s e r v i c e s but ac ted a ga i n s t the i n t e g r a t i o n o f s e r v i c e s across d i sea se and i n s t i t u t i o n a l c a t e g o r i e s . Th i s t r end was o f f s e t as r e h a b i l i t a t i o n p r o f e s s i o n a l s began to d i r e c t p a t i e n t t reatment as a team, r e s u l t i n g i n the development o f v a r i ou s o r g a n i z a t i o n a l techn iques such as team meetings and medical r e c o r d s . Today, w i t h i n t h a t s e t t i n g , the p r o f e s s i o n a l con t i nues to d i r e c t p a t i e n t t reatment by w r i t i n g medical o rder s and by over -see ing admiss ion and d i scharge d e c i s i o n s . These f a c t o r s , a n d the f a c t t h a t t reatment i s o rgan i zed acco rd ing to f a c i l i t y s chedu le , have i n s t i t u t i o n a l i z e d the p r o f e s s i o n a l ' s dominant r o l e . Over the t ime o f the development o f these s e r v i c e s another important f a c t o r emerged: government f i n a n c i n g changed to n a t i o n a l h ea l t h i n su r ance . As such, hea l t h d e c i s i o n s became, i n p a r t , a component o f the p o l i t i c a l agenda, where, i n western s o c i e t y , government r o l e i s seen as one o f med ia t ion and c r i s i s manage-ment (Renaud 1981). Th i s has had the e f f e c t o f i n t r o d u c i n g the i n t e r e s t s of a t h i r d p a r t y , as w e l l as an impor tant s o c i a l l e v e r , i n t o the system. Though the o r g a n i z a t i o n of s e r v i c e s s t i l l tends to support the p r o f e s s i o n a l ' s dominant r o l e i n an asymmetr ical r e l a t i o n s h i p w i t h the p a t i e n t , the government, as the fund ing body, has the p o t e n t i a l to mon i tor the a l l o c a t i o n o f r e sou r ce s . 9 Current Context of Change Demographic and s o c i o - c u l t u r a l t rends are c h a l l e n g i n g the t r a d i t i o n a l o r g a n i z a t i o n of s e r v i c e s . Demographic t rends i n c l u d e an i n c r e a s i n g aged popu-l a t i o n , concur rent expansion of the medical needs of the c h r o n i c a l l y i l l and changing f a m i l y s t r u c t u r e . The inadequacy o f present s e r v i c e s t o meet changing s o c i e t a l needs has been wel l -documented (Brown 1977; Canada 1982; Mar sha l l 1980; Shap i ro and Roos 1981). S t raus (1965) has i l l u s t r a t e d one aspect of t h i s c l e a r l y . He de sc r i bed i n d i v i d u a l s who predominant ly r e q u i r e long term care as hav ing the c h a r a c t e r -i s t i c s of a ' c l u s t e r of p a t h o l o g i e s ' ; t h a t i s , a number of problems of which i l l n e s s i s on ly one. Some d i s a b l e d p a t i e n t s , and aged p a t i e n t s , i n p a r t i c u l a r , are admit ted i n c r i s i s t o an acute care or r e h a b i l i t a t i o n f a c i l i t y w i t h o ther problems such as pove r t y , inadequate s o c i a l support and phy s i c a l impairment. P r o f e s s i o n a l s are then presented w i t h non-medical problems ou t s i de t h e i r areas of e x p e r t i s e , and thus have a l i m i t e d set of op t i on s a v a i l a b l e i n the i n s t i t u t i o n a l s e t t i n g . The s o c i a l worker i s q u a l i f i e d t o ac t as an agent f o r the p a t i e n t i n these o the r c o n t e x t s , bu t , a g a i n , a l s o r e t a i n s o ther i n t e r e s t s which compromise the s t a t u s of ' p e r f e c t a g e n t 1 , such as an o b l i g a t i o n to f o l l o w f a c i l i t y p o l i c y on d i s cha rge p rocedures . The demographic change has c rea ted an inadequacy i n the p r o f e s s i o n a l ' s e x p e r t i s e t o deal w i t h problems p r e sen t i n g i n the p r o f e s s i o n a l - p a t i e n t i n t e r a c t i o n . S o c i o - c u l t u r a l changes are i n d i c a t e d by an assessment of events over t i m e , p l ace and per son. To pe r ce i v e a s h i f t i n b e l i e f s and va lues one might look to a comparison of views presented i n t e l e v i s i o n and the media. There i s ev idence 10 from each of these t h a t i n d i c a t e a s h i f t from p u b l i c acceptance to p u b l i c q u e s t i o n i n g of p r o f e s s i o n a l a u t h o r i t y . Examples o f acceptance of the t r a d i -t i o n a l p e r s p e c t i v e are the t e l e v i s i o n shows, Dr. K i l d a r e or Marcus Wei by, M.D., p r e s e n t i n g p h y s i c i a n s as complete advocates o f p a t i e n t s . Though t h i s view s t i l l e x i s t s , the s h i f t i s r e f l e c t e d i n P a t i e n t Beware, r e c e n t l y w r i t t e n by C yn th i a Carver (1984), a general p r a c t i t i o n e r from Toronto . There are a l s o r e p o r t s of the i n c r e a s i n g i n c i d e n c e of both d i scharges from h o s p i t a l a ga i n s t medica l a d v i c e , and charges l a i d f o r m a l p r a c t i c e . These are examples o f d a i l y events t h a t f u r t h e r suggest a q u e s t i o n i n g , and even r e j e c t i o n , o f medica l a u t h o r i t y . De Miguel (1975) hypothes i ze s t h a t the i m p l i c a t i o n s o f the demographic and s o c i o - c u l t u r a l s h i f t s are h e l d l a t e n t i n a l a g t h a t e x i s t s i n r e a c t i o n s between s u b d i v i s i o n s of h i s framework; i n t h i s ca se , between s o c i e t a l t rends and i n s t i t u t i o n a l response. The e x i s t e n c e o f t h i s l a g i s the con tex t o f the study developed f o r t h i s t h e s i s . Th i s i n v o l v e s , s p e c i f i c a l l y , the p r o f e s s i o n a l s ' response to c ha l l e n ge t o p r o f e s s i o n a l e x p e r t i s e and a u t h o r i t y . Thus, w i t h De M i g u e l ' s h ypo the s i s , the p o l i c y a n a l y s t has s e t the con tex t i n t h i s paper f o r measuring the response o f the p r o f e s s i o n a l to cha l l enge s to the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p i n which p r o f e s s i o n a l dominant asymmetry i s entrenched i n the o r g a n i z a t i o n o f h e a l t h s e r v i c e s . In r e c a l l i n g the example of the case o f M i s s . Smi th , she presented problems and behav io r which cha l l enged the t r a d i t i o n a l terms of the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p , terms i l l u s t r a t e d by the v i ewpo in t s o f economists and ph i l o sopher s 5 Th i s book a l e r t s the p u b l i c t o the terms o f the p h y s i c i a n t h a t - a r e not always i n the p a t i e n t ' s bes t i n t e r e s t . 11 as w e l l as by the h i s t o r i c a l p e r s p e c t i v e . Some of the p r o f e s s i o n a l s agreed and some d i sag reed w i t h M i s s . S m i t h ' s e v a l u a t i o n of her w e l f a r e . T h e i r d i s cha rge d e c i s i o n s d i f f e r e d a c c o r d i n g l y . Obv i ou s l y , the c o s t s and b e n e f i t s to these p a r t i e s , as w e l l as to s o c i e t y as the t h i r d pa r t y pay ing the b i l l , d i f f e r w ide l y between the d e c i s i o n s . However, f u r t h e r t o the economic dimension o f p a t i e n t beware,and the p h i l o s o p h i c dimension o f r i g h t s , i t i s a que s t i on o f e f f e c t i v e -ness and e f f i c i e n c y o f the o r g a n i z a t i o n of h ea l t h s e r v i c e s . Impor tant l y t hen , how are p r o f e s s i o n a l s responding to the cha l l enge to the t r a d i t i o n a l o r g a n i z a t i o n of t h e i r s e r v i c e s ? In the next c hap te r , w i t h f u r t h e r use o f the case s tudy, hypotheses are developed from s o c i o l o g i c a l theory t o measure the p r o f e s s i o n a l ' s response t o t h i s c ha l l enge t o the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . 12 THEORY The ba l anc i n g o f p r o f e s s i o n a l s ' and p a t i e n t s ' i n t e r e s t s may be understood through an i n v e s t i g a t i o n of human r e l a t i o n s h i p s . More e x p l i c i t l y , the s o c i o l o -g i s t models human i n t e r a c t i o n i n terms o f the r o l e s t h a t i n d i v i d u a l s assume w i t h i n the broader p e r s p e c t i v e o f s o c i a l norms. B i d d l e and Thomas (1966) d e f i n e the r o l e p e r s p e c t i v e as ' a p a r t i c u l a r v i ewpo in t rega rd ing [1 ] those f a c t o r s presumed to be i n f l u e n t i a l i n govern ing human behav iour [and 2] the ac tua l p e r -formance [ t h a t ] r e s u l t s from the s o c i a l p r e s c r i p t i o n s and behav io r of o t h e r s . ' (P.4) In the e v o l u t i o n o f s o c i o l o g i c a l models, the c e n t r e p i e c e o f the p r o f e s -s i o n a l - p a t i e n t r e l a t i o n s h i p has been the concept o f ' s o c i a l system' (Bloom and Summey 1976). In t h i s t h e s i s , the term r e f e r s to the i n t e r d e p e n d e n c e s o f r o l e s i n the form o f r e l a t i o n s h i p s . Bloom (1976;1979) has t w i c e t r a c e d the development o f t h i s concept . From h i s overv iew, two fundamental r a t i o n a l e s emerge to account f o r the d i f f e r e n t a p p l i c a t i o n s o f ' s y s t em ' t o the t o p i c o f the p r o f e s s i o n a l - D a t i e n t r e l a t i o n s h i p . The f i r s t i n t e r p r e t a t i o n , ' f u n c t i o n a l i s m ' , u n d e r l i e s Pa r son s ' S i ck Ro le Model (1951) , and the second, ' s t r u c t u r a l i s m ' , u n d e r l i e s arguments based by F r e i d s on (1961) on premises opposed t o Pa r sons ' model. J n the f u n c t i o n a l i s t p e r s p e c t i v e , s o c i e t a l i n t e r e s t s are ba lanced w i t h i n a s i n g l e s o c i a l system through complimentary f o r ce s d i r e c t e d to the shared va lue of a c h i e v i n g an o p t i m a l l y p r o d u c t i v e s o c i e t y . The s t r u c t u r a l i s t p e r s p e c t i v e , on the o the r hand, pe r ce i ve s a ba lance o f i n t e r e s t s through competing f o r c e s , each 13 d i r e c t e d to a c h i e v i n g i t s own opt imal l e v e l w i t h i n c o n s t r a i n t s se t by the meet ing o f separate s o c i a l systems. These i n t e r p r e t a t i o n s w i l l be d i s cu s sed r e s p e c t i v e l y as the t r a d i t i o n a l and c h a l l e n g i n g views of the p r o f e s s i o n a l -p a t i e n t r e l a t i o n s h i p . Pa r sons ' model and the l i m i t a t i o n s o f i t s a p p l i c a t i o n i n the r e h a b i l i t a t i o n s e t t i n g , as w e l l as i n the l a r g e r p o l i c y forum, w i l l be p re sented f i r s t w i t h ob se r va t i on s from Nagi (1965) , Bloom (1976) and o t h e r s . These rep re sen t the t r a d i t i o n a l v iew. F r i e d s o n ' s model se t s the stage f o r the p r e s e n t a t i o n o f the c h a l l e n g i n g v iew. Through the s t r u c t u r e o f competing s o c i a l systems, the p a t i e n t ' s p a r t i -c u l a r i n t e r e s t s are a l l owed to emerge. Haug and L a v i n ' s (1981) i n v e s t i g a t i o n of t h i s new concept o f n e g o t i a t i o n between p r o f e s s i o n a l and p a t i e n t i s then p re sented . De J o n g ' s (1979) model o f p a t i e n t dominant asymmetry f o l l o w s , t a k i n g the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p f u l l c i r c l e t o a s i n g l e s o c i a l - s y s t e m network w i t h the asymmetry o f the p r o f e s s i o n a l and p a t i e n t r o l e s r e ve r s ed . These views are then i n t e g r a t e d to form a b a s i s from which to measure the p r o f e s s i o n a l s ' response to c h a l l e n g e to the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . Parsons ' S i ck Ro le Model Parsons model led the p r o f e s s i o n a l - p a t i e n t r o l e s i n terms of complimentary f o r c e s . Such a ba lance was deemed neces sa ry , f o r how w e l l s o c i e t y f u n c t i o n e d was con s i de red to be d i r e c t l y r e l a t e d to l e v e l s of h e a l t h . Too low a general l e v e l o f h e a l t h and too h igh an i n c i d e n c e of i l l n e s s would be d i s r u p t i v e . Cont ro l was t h e r e f o r e necessary to keep members of s o c i e t y from t a k i n g advantage 14 of secondary ga in w h i l e i l l and unnece s s a r i l y p ro long ing d i s a b i l i t y . Th i s k ind of c o n t r o l has taken p l a ce i n the form of p r o f e s s i o n a l dominant asymmetry i n the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . The r e l a t i o n s h i p i s arranged t o guarantee t h a t a f u n c t i o n a l ba lance of hea l t h and i l l n e s s i s ma in ta i ned . The asymmetry i s assumed to be en fo rced or l e g i t i m a t e d through the support of s o c i o - c u l t u r a l e xpec t a t i on s pa t te rned i n s o c i e t y , s i n ce w i t h i n a s i n g l e s o c i a l system, the p r o f e s s i o n a l and p a t i e n t share the same va lues and i n t e r e s t s . To serve t h i s f u n c t i o n , the p r o f e s s i o n a l and p a t i e n t have o b l i g a t i o n s and p r i v i l e g e s . E n t a i l e d i n the p r o f e s s i o n a l ' s r o l e i s an o b l i g a t i o n to the p a t i e n t t o a i d r ecove r y , and, t o the s o c i e t y , t o ensure the p a t i e n t ' s r e t u r n , once deemed w e l l , t o normal r e s p o n s i b i l i t i e s . In r e t u r n , the p r o f e s s i o n a l , i n p a r -t i c u l a r , the p h y s i c i a n , i s accorded h igh s t a t u s and esteem. As i l l n e s s i s r e -cogn ized as unavo idab le , the p a t i e n t has the p r i v i l e g e of excuse from normal d u t i e s . But prolonged i l l n e s s i s a l s o d i s r u p t i v e t o s o c i e t y and the p a t i e n t i s o b l i g e d to comply w i t h the p r o f e s s i o n a l ' s d i r e c t i o n i n o rder t o get w e l l . Thus, p a t i e n t s assume the ' s i c k r o l e ' which i s cons ide red a form of tem-porary s o c i a l dev iance from which they s t r i v e t o r ecove r . P r o f e s s i o n a l s are t e c h n i c a l exper t s who l e g i t i m i z e p a t i e n t s ' c l a ims t o i l l n e s s and are r e spon s i b l e f o r r e t u r n i n g them t o t h e i r normal r o l e s i n s o c i e t y . The p r o f e s s i o n a l r o l e i s dominant and c o n t r o l l i n g and the p a t i e n t ' s r o l e i s compl iant and p a s s i v e . This asymmetry between the p r o f e s s i o n a l and p a t i e n t i s l e g i t i m i z e d so t h a t p a t i e n t s are ' c o n t r o l l e d ' l e s t they take advantage of the p r i v i l e g e s of the ' s i c k r o l e ' and pro long dependency. 15 One i s o r i e n t e d t o such a r e l a t i o n s h i p from c h i l d h o o d , f o r example, when needing a note from one ' s doc to r to r e t u r n to school f o l l o w i n g a lengthy i l l n e s s . The p a r t i c u l a r terms of asymmetry i n the r e l a t i o n s h i p are f u r t h e r emphasized i n comparison t o one ' s r e l a t i o n s h i p w i t h a d e n t i s t . In t h i s s i t u a t i o n , i l l n e s s i s not u s u a l l y as d i s r u p t i v e and the d e n t i s t does not u s u a l l y a t t a i n the p h y s i c i a n ' s s t a t u s as an agent o f s o c i e t y . A long the same l i n e s , the p h y s i c i a n ' s h igh s t a t u s i s awarded i n r e spec t o f t e c h n i c a l e x p e r t i s e when com-pa red , f o r example, w i t h another agent o f s o c i a l c o n t r o l , the p o l i c e o f f i c e r . Pa r sons ' model i s obv i ou s l y d i r e c t e d to a type of i l l n e s s wh i ch , however acute or seve re , i s temporary. G a l l a g h e r (1976) and Kassebaum and Baumann (1965) have commented on the inadequacy of Pa r son s ' model t o accommodate ch r on i c i l l n e s s . C h a r a c t e r i s t i c s such as i n d e f i n i t e d u r a t i o n of d i s e a s e 9 and u n c e r t a i n t y rega rd ing r e t u r n t o normal h e a l t h and s o c i a l p a r t i c i p a t i o n , c o n f l i c t w i t h the expec ta t i on s o f Pa r son s ' model. Szasz and H o l l a n d e r (1956) developed a t h r e e f o l d typo logy o f p r o f e s s i o n a l -p a t i e n t r e l a t i o n s h i p s t h a t d i s t i n g u i s h e d the i m p l i c a t i o n s of d i f f e r e n t d i sea se t ype s . A c t i v i t y - p a s s i v i t y i s o r i e n t e d to emergency s i t u a t i o n s . The p h y s i c i a n assumes complete c o n t r o l and the p a t i e n t remains p a s s i v e . Fo r s i t u a t i o n s l e s s extreme but s t i l l a cu te , gu i dance - co - ope ra t i on i s the management model. The p a t i e n t seeks the p r o f e s s i o n a l ' s e xpe r t he lp and the p r o f e s s i o n a l guides the p a t i e n t back to r e cove r y . L a s t l y , those w i t h c h r o n i c i l l n e s s a re be s t managed i n a m u t u a l - p a r t i c i p a t i o n r e l a t i o n s h i p ; the p r o f e s s i o n a l ' s r o l e i s to he lp p a t i e n t s he lp themselves . The p a t i e n t manages most o f the t reatment r o u t i n e w i t h o cca s i ona l i n t e r v e n t i o n by the p r o f e s s i o n a l . The a u t h o r i t y o f the p r o f e s -16 s i o n a l , c o - o p e r a t i o n of the p a t i e n t , and asymmetry i n the r e l a t i o n s h i p are r e t a i n e d as l e g i t i m a t e . The premises unde r l y i n g Pa r sons ' model are ma in ta i ned . N e v e r t h e l e s s , t h i s ex ten s i on of Pa r son s ' model f a c i l i t a t e s i t s a p p l i c a t i o n to the s p e c i a l t y o f r e h a b i l i t a t i o n . I t a l l ows one to d i s t i n g u i s h between d i f -f e r e n t stages o f i l l n e s s as would be r e q u i r e d i n r e c u r r e n t ep i sodes of c h r o n i c i l l n e s s . And i t a l s o a l l ows one t o d i s t i n g u i s h between a l t e r n a t e r o l e e xpec t a -t i o n s t h a t an i n d i v i d u a l s u f f e r i n g from an impairment would encounter when a p a t i e n t i n a r e h a b i l i t a t i o n f a c i l i t y . The p a t i e n t s ' r o l e i n s o c i e t y , w i t h i n the f a m i l y and employment may be m o d i f i e d through c o n d i t i o n s o f i l l n e s s or impairment, but Nagi (1965) c au t i on s a ga i n s t the i n d i v i d u a l assuming, as a r o l e , the c h a r a c t e r i s t i c s o f these c o n d i -t i o n s . ^ That i s , though p a t i e n t s do approach t h i s s t a t u s when i n a r e -h a b i l i t a t i o n s e t t i n g , these r o l e s e x i s t ' i n dependen t l y o f the person who may occupy them and [ i ndependen t l y ] o f any o the r r e l a t i o n s h i p s these persons may have to the sys tem. ' (P.106) I t i s these o the r r e l a t i o n s h i p s t h a t B loom's model makes e x p l i c i t by l i n k -i n g them to the system. The premises unde r l y i n g t h i s model are the same as the S ick Ro le Model, but the model overcomes the l i m i t a t i o n s imposed by Pa r son s ' narrow f o cu s , by expanding s o c i e t y ' s i n t e r e s t s i n t o a game w i t h more than two p l a y e r s . F i g u r e 1 p resent s t h i s model. 6 For an example, r e f e r to Robert A. S c o t t , The Making of B l i n d Men, R u s s e l l Sage Foundat ion , New York , N.Y., 1969. 17 F igure 1 Bloom's model o f the P r o f e s s i o n a l - P a t i e n t R e l a t i o n s h i p (From 'The To ta l T r a n s a c t i o n a l S y s t em ' , Bloom, S.W. (1963, P.256) c i t e d i n Ga l l a ghe r (1976)) 18 As e v i den t i n the f i g u r e , the game i s expanded to i n c l u d e the major r e l a t i o n -sh ip s t h a t the p r o f e s s i o n a l and p a t i e n t ma in ta i n e x t e r n a l to the p r o f e s s i o n a l -p a t i e n t encounter . However, i t i s the i n t e r a c t i o n between the p r o f e s s i o n a l and p a t i e n t t h a t s t i l l occup ies the c e n t r a l f ocu s . A c l e a r e r p i c t u r e o f the i n f l u e n c e of the e x t e r n a l demands on the p r o f e s s i o n a l i s d ep i c t ed i n F i g u r e 2. Here, the s i g n i f i c a n t f a c t o r s occupy a s i n g l e c i r c l e . F i g u r e 2 The P r o f e s s i o n a l ' s C i r c l e of I n t e r e s t s Each o f the c i r c l e ' s components are f a c t o r s which i n f l u e n c e the r o l e o f the p r o f e s s i o n a l . The s i z e o f each p o r t i o n i s a r b i t r a r y i n t h i s diagram and, i n r e a l i t y , are probably m o d i f i e d acco rd i ng to the c i r cums tance s . T r a d i t i o n a l l y these have o r i e n t e d the p r o f e s s i o n a l to be dominant and i n c o n t r o l o f the p a t i e n t . 19 The Cha l l enge to the S i n g l e S o c i a l System The q u e s t i o n i n g of p r o f e s s i o n a l e x p e r t i s e and a u t h o r i t y has been a c h a r a c t e r i s t i c o f a number o f r e cen t s o c i a l movements. Two examples o f these are consumerism, i n which p a t i e n t s r e l y on t h e i r own judgment, and s e l f h e l p , i n which p a t i e n t s take on the r e s p o n s i b i l i t y f o r h ea l t h d e c i s i o n s . These movements i n d i c a t e a s h i f t from the t r a d i t i o n a l p e r s p e c t i v e i n which the p r o f e s s i o n a l assumes r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s and the p a t i e n t i s expected to r e l y on the p r o f e s s i o n a l ' s a d v i c e . F r e i d s o n ' s C o n f l i c t o f Terms F r e i d s on has ques t ioned the t r a d i t i o n a l p e r s p e c t i v e of the exchange of ob-l i g a t i o n s and p r i v i l e g e s between the p r o f e s s i o n a l and p a t i e n t . H i s argument r e s t s a ga i n s t the b a s i c premises o f Pa r son s ' model which has behav io r dependent on e xpec t a t i o n s c o n s i s t e n t w i t h s o c i o - c u l t u r a l norms. F r e i d s o n ma in ta in s t h a t i n f l u e n c e i s drawn c h i e f l y from the p o s i t i o n o f the person h o l d i n g the expec ta -t i o n s . Thus, s t r u c t u r a l r a t h e r than f u n c t i o n a l determinants o f the s i t u a t i o n i n f l u e n c e behav iour . Th i s can be con s i de red a long w i t h F r e i d s o n ' s o the r premise t h a t s o c i e t y i s comprised o f a number o f s o c i a l systems and not j u s t one as i n Pa r son s ' model. In t h i s way the p r o f e s s i o n a l and p a t i e n t are each presented as separate s o c i a l systems w i t h d i f f e r i n g i n t e r e s t s and e x p e c t a t i o n s . In comb ina t i on , the two f a c t o r s o f (1) r e s p e c t i v e p o s i t i o n of the person and (2) separate s o c i a l systems i n t e r a c t . In t h a t people i n c e r t a i n p o s i t i o n s have c e r t a i n i n t e r e s t s , i t i s t h e i r i n t e r e s t s t h a t c o n f l i c t . 20 The c h a l l e n g e , as F r e i d son s t a t e s i n h i s argument aga i n s t p r o f e s s i o n a l dominant asymmetry (keeping i n mind the case of A l i c e Smith and the d i f f e r e n c e of op i n i on amongst p r o f e s s i o n a l s r ega rd ing her d i s cha rge outcome), i s t h a t such e v a l u a t i o n i s normative i n c h a r a c t e r and i s not so e s o t e r i c as to j u s t i f y i t s r e s t r i c t i o n to e x p e r t s . Where laymen are exc luded from such e v a l u a t i o n , t r u e e x p e r t i s e i s not a t i s s ue but r a t h e r the s o c i a l and p o l i t i c a l power of the e x p e r t . (1970, P.336) From De J o n g ' s (1979) view o f the power r e l a t i o n s h i p , s o c i e t a l t r e n d s , as de s c r i bed i n the p rev i ou s c hap te r , are c h a l l e n g i n g the terms t r a d i t i o n a l l y presented by the p r o f e s s i o n a l i n favour o f the i n t e r e s t s o f the p a t i e n t . And i t i s the p a t i e n t i n the consumer i s t s tance t h a t u n d e r l i e s h i s model of independent l i v i n g . A l though he argues t h a t h i s model r e f l e c t s a r e v o l u t i o n a r y re sea rch paradigm, i t a c t u a l l y ba lances the p r o f e s s i o n a l ' s and p a t i e n t ' s r o l e s a f t e r Par sons ' model, excep t , i n t h i s c a se , the asymmetry i s r e ve r s ed . In t h i s way p r o f e s s i o n a l s and p a t i e n t s , aga in as a s i n g l e s o c i a l system, r e t a i n the same i n t e r e s t s and v a l ue s . He argues t h a t a s h i f t i n s o c i o - c u l t u r a l e x p e c t a t i o n s l e g i t i m i z e s the reve r sed r o l e s o f asymmetry. Thus i n both the t r a d i t i o n a l and c h a l l e n g i n g v iews, the terms o f the p ro -f e s s i o n a l - p a t i e n t i n t e r a c t i o n can be congruent w i t h ' a c c e p t e d ' asymmetry, i n the f i r s t case w i t h the p r o f e s s i o n a l as dominant, and i n the second case w i t h the p a t i e n t as dominant. A l t e r n a t i v e l y , the terms may c o n f l i c t as i n F r i e d s o n ' s model. As a measure o f the d i s t a n c e between the t r a d i t i o n a l and c h a l l e n g i n g p e r s p e c t i v e s , one can look t o Haug and L a v i n ' s (1981) i n v e s t i g a t i o n o f whether or not p a t i e n t s were c h a l l e n g i n g p r o f e s s i o n a l a u t h o r i t y , and, i f they were, the ex ten t to which p r o f e s s i o n a l s r e j e c t e d or accommodated such behav i o r . Responses 21 to ques t i on ing i n d i c a t e d cha l l eng i n g behavior amongst p a t i en t s and accommodating behav ior amongst ph y s i c i a n s . The causes of the s h i f t have been hypothes ized to i nc lude f a c t o r s ranging from the be t t e r educat ion of the young (Haug and Lav in 1981), to a new r e s i s t ance aga ins t the encroachment of a u t h o r i t i e s i n t o areas un re la ted to t h e i r c la imed e x p e r t i s e (Haug and Sussman 1979). Far from accept ing the asymmetry as g i ven , the i n t e r a c t i o n i s opened to n e g o t i a t i o n , as i n S t r au s s ' (1978) terms, i n an arena. Haug and Lav in suggested, i n conc lu s i on po s s i b l e dimensions along which p ro fe s s i ona l and p a t i e n t r o l e s can be arranged, s p e c i f i c a l l y , the p ro fe s s i ona l as e i t h e r c o n t r o l l e r or accommodator, and the p a t i e n t as e i t h e r consumerist or dependent i n the det reminat ion of 'who ' s i n c h a r g e ' . The range of i n t e r a c t i o n of terms i s suggested by Haug and L a v i n ' s set of c r o s s - r e l a t i o n s h i p s . F igure 3 i n d i c a t e s the po s s i b l e i n t e r a c t i o n modes accord ing to the s p e c i f i c combinations of r o l e s assumed by the p r o f e s s i ona l and p a t i e n t . F i gu re 3 Modes of I n t e r a c t i o n Between the P r o f e s s i ona l and the P a t i e n t P r o f e s s i o n a l O r i e n t a t i o n Consumerist P a t i e n t O r i e n t a t i o n Dependent C o h f l i c t of Terms Asymmetry unaccepted by the p ro fe s s i ona l or p a t i e n t 1 Congruence o f Terms Asymmetry Leg i t imate P a t i e n t 2 Dominant Congruence of Terms 3 Asymmetry Leg i t imate P r o f e s s i ona l Dominant ^ C o n f l i c t o f Terms Asymmetry unaccepted by the p r o f e s s i ona l or p a t i e n t 22 These terms can be i l l u s t r a t e d u s ing the example of the case of Miss Smith i n which d i f f e r e n c e s of op i n i on e x i s t e d rega rd ing d i s cha rge outcome. In one case the p r o f e s s i o n a l ' s and p a t i e n t ' s terms agreed and i n the o ther they d i f f e r e d . The con ten t o f the d e c i s i o n and i t s outcome concerned the p a t i e n t ' s w e l f a r e , the de te rm ina t i on of which i s a p i v o t a l p o i n t i n the t r a d i t i o n a l versus c h a l l e n g i n g p e r s p e c t i v e s o f p r o f e s s i o n a l s ' and p a t i e n t s ' r o l e s . How the p r o -f e s s i o n a l d e s c r i b e d , e xp l a i ned and d e a l t w i t h the p a t i e n t d i f f e r e d a c c o r d i n g l y . Pa r son s ' model u n d e r l i e s the i n t e r a c t i o n expected i n c e l l 3 . The r e l a t i o n s h i p i s p r o f e s s i o n a l dominant and the p r o f e s s i o n a l ' s d e c i s i o n o f p r o t e c t i v e ca re would be f o l l o w e d whatever the ensu ing b e n e f i t s and c o s t s . De J o n g ' s model i s p resented i n c e l l 2 . The asymmetry i s p a t i e n t dominant and Mi s s S m i t h ' s d e c i s i o n t o go home would be f o l l o w e d whatever the ensuing b e n e f i t s and c o s t s . C e l l s 1 and 4 r e f l e c t i n t e r a c t i o n between p r o f e s s i o n a l and p a t i e n t when t h e i r r o l e s c o n f l i c t . In C e l l 1 both the p r o f e s s i o n a l and p a t i e n t expect t o be dominant and r e s p o n s i b l e f o r h e a l t h d e c i s i o n s , and i n C e l l 4 n e i t h e r the p ro -f e s s i o n a l nor the p a t i e n t wishes t o be dominant o r r e s p o n s i b l e f o r h e a l t h d e c i s i o n s . In these cases the process o f dete rmin ing outcomes i s not c l e a r . Examples of the p r o f e s s i o n a l s ' responses c o n s i s t e n t w i t h c e l l s 1 ( the p r o f e s -s i o n a l as dominant) and 2 ( the p r o f e s s i o n a l as accommodator) were p r e v i o u s l y de s c r i bed i n the case of M i s s Smith who presented i n a consumer i s t s t ance . The p r o f e s s i o n a l s e x p l a i n e d , de s c r i bed and d e a l t w i t h the M i s s S m i t h ' s behav io r i n d i f f e r e n t ways. In r e v i ew , M i s s S m i t h ' s behav io r was de s c r i bed ' d i f f i c u l t ' by one group and ' g u t s y ' by the o t h e r . The f i r s t group e xp l a i ned her behav io r as ' l i m i t e d 23 i n s i g h t i n t o her d i s a b i l i t y ' i n c on t r a s t t o the second groups ' statement of the l e g i t i m a c y of her views though d i f f e r e n t from t h e i r own. One group wished t o r e t a i n c o n t r o l over the d i s cha rge d e c i s i o n by recommending p r o t e c t i v e c a r e , w h i l e the o the r accommodated the p a t i e n t ' s d e c i s i o n t o go home. These v a r i a -t i o n s i n responses can be cons idered i n the context of the cha l l enge t o the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p e n t a i l e d i n t r a d i t i o n a l and c h a l l e n g i n g p e r s p e c t i v e s of what the p r o f e s s i o n a l ' s and p a t i e n t ' s r o l e s should be rega rd ing the e v a l u a t i o n of p a t i e n t w e l f a r e . P r o f e s s i o n a l r e c o g n i t i o n of the cha l l enge i s i n d i c a t e d through the e x p l a n a t i o n of the p a t i e n t ' s behav io r . The response t o the cha l l enge i s i l l u s t r a t e d by how the p r o f e s s i o n a l de s c r i be s and dea l s w i t h the p a t i e n t ' s behav i o r . E x p l a i n i n g the P a t i e n t ' s Behav ior In the t r a d i t i o n a l v iew, i l l n e s s i s pe r ce i ved as an o b j e c t i v e e n t i t y and i s seen as a problem of the p a t i e n t . Views beyond the medical model, on the o the r hand, s t a t e t h a t i l l n e s s can a l s o be de f i ned through the i n d i v i d u a l ' s i n t e r -a c t i o n w i t h the env i ronment; t h a t i s , i n f l u e n c e s e x t e r na l t o the p a t i e n t and the d i sea se can a l s o shape the problem. In the f i r s t p e r s p e c t i v e the p a t i e n t ' s behav io r would be a t t r i b u t e d t o p a t i e n t v a r i a b l e s such as p e r s o n a l i t y , a d j u s t -ment to the d i sea se or e f f e c t of the d i s e a s e . Conve r se l y , those who are s e n s i -t i v e t o the e x t e r na l i n f l u e n c e s would be more l i k e l y t o e x p l a i n the behav ior w i th r e fe rence t o the terms the p r o f e s s i o n a l and p a t i e n t have brought t o t h e i r encounter . In t h i s l i g h t , the con sumer i s t ' s and dependent p a t i e n t ' s behav ior would be pe rce i ved as a congruence or c o n f l i c t i n te rms. The dynamics of t h i s 24 i n t e r a c t i o n are s c h e m a t i c a l l y p resented i n F i g u r e 4 below. P r o f e s s i o n a l Ro le P a t i e n t Ro le c o n t r o l l e r accommodator Consumer ist p a t i ent c o n f l i c t of a t t r i b u t e terms Dependent p a t i e n t c o n f l i c t o f a t t r i b u t e terms F i g u r e 4. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and e x p l a i n i n g the p a t i e n t ' s behav io r a re p r e d i c t e d to be r e l a t e d D e s c r i b i n g the P a t i e n t ' s Behav io r The p r o f e s s i o n a l ' s d e s c r i p t i o n of the p a t i e n t ' s behav io r can be argued to f o l l o w from the p r o f e s s i o n a l ' s e xpec t a t i o n s o f the p a t i e n t ' s r o l e . In the t r a -d i t i o n a l view the p a t i e n t should be pa s s i ve and compl iant w i t h the p r o f e s -s i o n a l ' s a d v i c e . T h i s view i s somewhat mod i f i e d i n r e h a b i l i t a t i o n where the p a t i e n t i s expected to c o n t r i b u t e to t reatment d e c i s i o n s . H o s p i t a l r o u t i n e , however, tends to favour the o r g a n i z a t i o n o f p r o f e s s i o n a l s ' s e r v i c e s a t the co s t o f e n f o r c i n g p a s s i v i t y and dependency i n p a t i e n t s who are expected to f o l l o w the f a c i l i t y s chedu le . The ' good ' p a t i e n t i s the one who w i l l i n g l y submits to the regimen. And the ' d i f f i c u l t ' p a t i e n t i s one who r e s i s t s the e x t e r na l c o n t r o l on i n d i v i d u a l op t i on s and does not f i t i n t o the f a c i l i t y s chedu le . 25 In the c h a l l e n g i n g p e r s p e c t i v e , on the o the r hand, p a t i e n t s are expected to r e l y on t h e i r own judgment and make t h e i r own d e c i s i o n s . As the e xpec t a t i o n s of the p a t i e n t ' s r o l e are reve r sed so too are the d e s c r i p t i o n s . The consumer i s t p a t i e n t would then be con s i de red as ' g ood ' and the dependent p a t i e n t as ' d i f f i c u l t ' . The dynamics o f t h i s i n t e r a c t i o n are s c h e m a t i c a l l y d e p i c t e d i n F i g u r e 5 . P r o f e s s i o n a l Ro le c o n t r o l l e r accommodator P a t i e n t Ro le Consumerist Dependent d i f f i c u l t good good d i f f i c u l t F i g u r e 5 . How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and d e s c r i b i n g the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d . D e a l i n g w i t h the P a t i e n t ' s Behav io r The p r o f e s s i o n a l i s t r a d i t i o n a l l y pe r ce i ved as be ing r e s p o n s i b l e f o r the d i r e c t i o n o f p a t i e n t c a r e . And the p a t i e n t s are supposed to p a s s i v e l y accept t h i s d i r e c t i o n and understand i t to be i n t h e i r be s t i n t e r e s t . I f the p a t i e n t dev i a t e s from t h i s r o l e the p r o f e s s i o n a l i s encouraged to s anc t i on the p a t i e n t ' s behav io r and w i l l t h e r e f o r e take measures t h a t r e j e c t or c o n t r o l the p a t i e n t . So f o r both the consumer i s t and dependent p a t i e n t s , the p r o f e s s i o n a l w i l l deal w i t h the p a t i e n t by be ing i n charge. In the a l t e r n a t e i n t e r a c t i o n , where the p a t i e n t ' s dominance i s accepted , the p r o f e s s i o n a l w i l l accommodate the consu-26 m e r i s t p a t i e n t ' s behav io r and wish to i n s p i r e the dependent p a t i e n t to take c o n t r o l . The dynamics of t h i s i n t e r a c t i o n are presented i n F i g u r e 6. P r o f e s s i o n a l Ro le C o n t r o l 1 e r Accommodator Consumerist c o n t r o l or accommodate r e j e c t P a t i e n t Ro le Dependent c o n t r o l or i n s p i r e p r o t e c t F i g u r e 6. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e , and d e a l i n g w i t h the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d . In sum, t h i s t h e s i s hypothes i zes t h a t the p r o f e s s i o n a l ' s response to the p a t i e n t ' s behav io r i s dependent on the s p e c i f i c i n t e r a c t i o n of the p r o f e s s i o n a l r o l e and p a t i e n t r o l e , when the content o f the d e c i s i o n i n v o l v e s the e v a l u a t i o n of the p a t i e n t ' s w e l f a r e . The models of Pa r sons , Bloom, F re i d son and De Jong , among o t h e r s , have t r a c e d the development and r e l a t i o n s h i p of these r o l e s and have h i g h l i g h t e d the p o s s i b l e areas o f congruence and c o n f l i c t t h a t p r e d i c t the ways t h a t p r o f e s s i o n a l s w i l l e x p l a i n , de s c r i be and deal w i t h the p a t i e n t ' s behav i o r . The next chapte r on methods de s c r i be s the measures dev i sed to assess i f the p r o f e s s i o n a l w i l l respond as p r e d i c t e d . 27 METHODS In t h i s t h e s i s , v a r i ou s techn iques were developed t o assess the p r o f e s s i o n a l ' s response to cha l l enge t o the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . As the hypotheses s t a t e t h a t how the p r o f e s s i o n a l e x p l a i n s , de sc r i be s and dea l s w i t h the p a t i e n t i s dependent on the s p e c i f i c combinat ion of 1) p r o f e s s i o n a l r o l e , 2) p a t i e n t r o l e and 3) d e c i s i o n c on ten t , these th ree form the independent v a r i a b l e s . To measure the p r o f e s s i o n a l ' s r o l e , as e i t h e r ' c o n t r o l l e r ' or ' accommodator ' , a q u e s t i o n n a i r e was g i ven t o a sample o f p r o f e s s i o n a l s — p h y s i c i a n s , p h y s i o t h e r a p i s t s , o ccupa t i ona l t h e r a p i s t s , nurses and s o c i a l workers - - i n two r e h a b i l i t a t i o n s e t t i n g s . The p a t i e n t s ' r o l e s were f a b r i c a t e d . These were presented to the p r o f e s -s i o n a l s i n i n t e r v i e w s , i n two case s t u d i e s i n which the p a t i e n t ' s behav io r was c o n s i s t e n t w i t h e i t h e r the ' c o n s u m e r i s t ' o r ' dependent ' r o l e . The t h i r d independent v a r i a b l e o f d e c i s i o n con ten t was f a b r i c a t e d a l s o as p a r t of the case study and presented c i r cumstances i n which the p r o f e s s i o n a l and p a t i e n t d i s a -greed about the ' b e s t * d i s cha rge o p t i o n . The p r o f e s s i o n a l ' s response to each o f the p a t i e n t r o l e s was measured i n the i n t e r v i e w i n which the p r o f e s s i o n a l was asked t o e x p l a i n , de s c r i be and deal w i t h the p a t i e n t ' s behav io r as presented i n each o f the case s t u d i e s . These responses were then ana lyzed i n terms of the s p e c i f i c hypotheses. Th i s a n a l y s i s i s p resented i n the next c hap te r . What f o l l o w s , de s c r i be s and e x p l a i n s the methods and study techn iques i n more d e t a i l . 28 Design The study employed a mix o f e x p l o r a t o r y and d e s c r i p t i v e c o n d i t i o n s f o r the c o l l e c t i o n and a n a l y s i s o f the data r e l e v a n t t o the p r o f e s s i o n a l - p a t i e n t i n t e r a c t i o n . The v a s t amount of theory r e l a t e d to the t o p i c , and the s p e c i f i c hypotheses o f the i n v e s t i g a t o r suggested a d e s c r i p t i v e study as the most appro-p r i a t e means by which t o document p r o f e s s i o n a l response to cha l l enge s to the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . Moreover, the study f o l l o w e d on the work by Haug and L a v i n (1981) who i n v e s t i g a t e d t h i s p a r t i c u l a r phenomenon among general p r a c t i t i o n e r s and the p u b l i c . But the s h i f t i n s e t t i n g s , from the community to the i n s t i t u t i o n and from genera l p r a c t i t i o n e r s to a range of r e h a b i l i t a t i o n p r o f e s s i o n a l s , c au t i oned a ga i n s t an unmodi f ied approach. For t h i s reason an e x p l o r a t o r y approach was necessary to a l l o w the r e sea r che r the f l e x i b i l i t y to respond to unexpected or unp red i c ted d i r e c t i o n s o r c o n d i t i o n s . W i t h i n these c o n f i n e s the most accu ra te way by which to measure p r o f e s -s i o n a l response to cha l l enge s t o the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p would have been through s y s temat i c ob se r va t i on o f a determined sample o f these i n t e r -a c t i o n s . But t h i s e f f o r t was beyond the scope o f t h i s t h e s i s and a l t e r n a t e methods of g a the r i ng data were developed. Thus, the f i n d i n g s from t h i s study can be o f f e r e d on ly as p r e l i m i n a r y ev idence o f 1) r e h a b i l i t a t i o n p r o f e s -s i o n a l s ' p e r cep t i on s of the r o l e s the p r o f e s s i o n a l and p a t i e n t assume du r i ng t h e i r i n t e r a c t i o n and 2) the dynamics o f the p r o f e s s i o n a l s ' response to the p a t i e n t . 29 Sample P a r t i c i p a n t s were r e c r u i t e d from two s e t t i n g s i n Vancouver, G.F. St rong R e h a b i l i t a t i o n Cent re and Holy Fami l y H o s p i t a l . G.F. S t rong R e h a b i l i t a t i o n Centre i s a 150 bed i n - p a t i e n t and 270 c l i e n t s per day o u t - p a t i e n t f a c i l i t y . Treatment i s d i r e c t e d toward severe p h y s i c a l d i s a b i l i t y . Holy Fami l y H o s p i t a l has an 80 bed r e h a b i l i t a t i o n u n i t w i t h i n a chjronic h o s p i t a l s e t t i n g . Only those p r o f e s s i o n a l s work ing w i t h an a d u l t p o p u l a t i o n were approached. Vo l un tee r s from the p r o f e s s i o n s of med i c i ne , phy s i o the rapy , occupa t i ona l t he rapy , nu r s i ng and s o c i a l work were asked to p a r t i c i p a t e . The c r i t e r i o n f o r i n c l u s i o n was a p r o f e s s i o n a l s t and i n g . Diploma o r degree t r a i n i n g was accepted. For nurses , a r e g i s t e r e d nu r s i ng s t a t u s was r e q u i r e d . Of the e l i g i b l e s t a f f , 37 o f 80 a t G.F. St rong and 17 o f 30 from Holy Fami l y H o s p i t a l expressed an i n t e r e s t i n p a r t i c i p a t i n g . Of the 37 cand ida te s a t G.F. S t r ong , 10 were from med i c i ne , 9 from phy s i o the rapy , 6 from occupa t i ona l t he r apy , 9 from n u r s i n g , and 2 from s o c i a l work. Of t h i s group, 6 i n d i v i d u a l s d i d not complete the study f o r a v a r i e t y o f reasons such as 1) f a i l u r e to r e t u r n the q u e s t i o n n a i r e (N=2), 2) d i f f i c u l t y i n s chedu l i n g t ime f o r the study (N=2), 3) not f i t t i n g the c r i t e r i a f o r i n c l u s i o n (N=l ) , and 4) the s i g na tu re was i l l e g i b l e and consent cou l d not be acknowledged (N=l ) . Of those who d i d not complete the study 1 was from med i c i ne , 1 from phy s i o the rapy , 3 from nu r s i ng and 1 unknown. 30 Of the 17 cand ida te s a t Holy Fami l y H o s p i t a l , 3 were from med ic ine , 4 from phy s i o t he r apy , 4 from occupa t i ona l the rapy , 5 from nu r s i ng and 1 from s o c i a l work. Of these i n d i v i d u a l s , 3 d i d not complete the s tudy. The reasons were 1) f a i l u r e to r e t u r n the q u e s t i o n n a i r e (N= l ) , and 2) f a i l u r e to complete the q u e s t i o n n a i r e (N=2). Those who d i d not complete the study i n c l u d e d 1 from med i c i ne , 1 from nu r s i ng and the 1 p a r t i c i p a n t from s o c i a l work. Tab le II l i s t s the f i n a l sample o f the study acco rd ing to s p e c i a l t y . Tab le I I Study Sample Acco rd ing to S p e c i a l t y S p e c i a l t y G.F. S t rong Holy Fami ly Combined Med ic ine 9 2 11 Phy s i o the rapy 8 4 12 Occupat iona l Therapy 6 4 10 Nur s ing 6 4 10 S o c i a l Work 2 0 2 T o t a l 31 14 45 The p r o f e s s i o n a l s were compared on a number o f a t t r i b u t e s such as age, number o f yea r s exper ience a t the f a c i l i t y , country of t r a i n i n g and a t t i t u d e . Because of t h e i r smal l number, the two s o c i a l workers were l e f t out of the compar ison. 31 Sex d i f f e r e n c e s e x i s t e d on ly amongst medical s t a f f . At G.F. S t r ong , 2 o f the 9 p h y s i c i a n s who p a r t i c i p a t e d i n the study were female. A t Holy Fami l y both p h y s i c i a n s were male. The r e s t of the sample was w i t h o u t excep t i on female. The average age i n the f a c i l i t i e s was 38 yea r s a t G.F. S t rong and 36 yea r s a t Holy F a m i l y . In both f a c i l i t i e s , the average age o f the medical and nu r s i n g s t a f f was i n the mid f o r t i e s , whereas t h a t o f the p h y s i c a l and occupa t i ona l therapy s t a f f was i n the low 3 0 ' s . Average l eng th o f exper ience a t the f a c i l i t y ranged from 2 to 8 y e a r s . In both f a c i l i t i e s p h y s i o t h e r a p i s t s s tayed the l owes t number of y e a r s , 2 y ea r s a t Holy Fami ly and 3 yea r s a t G.F. S t rong . P h y s i c i a n s a t both f a c i l i t i e s s tayed l onge r on the average, 8 yea r s a t G.F. S t rong and 7 yea r s a t Holy F a m i l y . Occupat iona l t h e r a p i s t s a n d - r e g i s t e r e d nurses were i n the midd le range a t 5 yea r s f o r both a t G.F. S t r ong , and a t Holy F a m i l y , 4 y ea r s f o r o ccupa t i ona l t h e r a p i s t s and 5 f o r r e g i s t e r e d nurses . The s i t e o f p r o f e s s i o n a l t r a i n i n g r e f e r s to country o f t r a i n i n g . The d i v i s i o n s were 1) t r a i n e d i n Canada, 2) t r a i n e d o u t s i d e o f Canada ( a l l but one from the Un i t ed Kingdom) and 3) t r a i n e d i n both s e t t i n g s . A lmost 60 per cent of p r o f e s s i o n a l s a t G.F. S t rong and 80 per cent of p r o f e s s i o n a l s a t Holy Fami l y had t r a i n e d i n Canada o n l y . Of the 5 p r o f e s s i o n a l s who had t r a i n e d i n the U n i t e d Kingdom o n l y , 2 were p h y s i o t h e r a p i s t s , 2 were nurses and 1 was an occupa t i ona l t h e r a p i s t . Of 11 p r o f e s s i o n a l s who had t r a i n i n g i n both env i ronments, 4 were p h y s i c i a n s , 4 were p h y s i o t h e r a p i s t s and 3 were occupa t i ona l t h e r a p i s t s . Though not o v e r t l y r e f l e c t e d i n the sample c h a r a c t e r i s t i c s , t he re i s a l s o a v a r i ance i n a t t i t u d e to c o n s i d e r . Haug and L a v i n ' s study (1981) i d e n t i f i e d an 32 ' a t t i t u d e to a u t h o r i t y i n g e n e r a l ' as the only a t t r i b u t e of p h y s i c i a n s s i g n i f i -c a n t l y i n f l u e n c i n g t h e i r r e a c t i o n t o p a t i e n t cha l l enge s to t h e i r a u t h o r i t y . T h e r e f o r e , t h i s dimension f o r a l l p r o f e s s i o n s w i l l be cons ide red i n the s tudy. In sum, t he re appears to be enough v a r i a t i o n i n the sample c h a r a c t e r i s t i c s to warrant assessment o f the i n f l u e n c e o f d i f f e r e n c e s i n f a c i l i t y , s p e c i a l t y , age, l eng th o f exper ience a t the f a c i l i t y , country of t r a i n i n g , and a t t i t u d e t o a u t h o r i t y i n g e n e r a l , on the p r o f e s s i o n a l ' s response t o the p a t i e n t ' s behav i o r . F u r t h e r a n a l y s i s t o compare the sample c h a r a c t e r i s t i c s w i t h the p r o f e s s i o n a l popu l a t i on w i t h i n or ou t s i de each f a c i l i t y was f e l t t o be beyond the scope of t h i s t h e s i s . A l s o , as random sampl ing was not f e a s i b l e , t h e r e i s a p o t e n t i a l b i a s r e s u l t i n g from s e l f - s e l e c t i o n . Consequent ly , though the summary c h a r a c t e r i s t i c s are not s u r p r i s i n g o r unexpected, one cannot say w i t h con f i dence t h a t the sample a c c u r a t e l y r e f l e c t s the p o p u l a t i o n o f p r o f e s s i o n a l s i n the f a c i l i t y or the p o p u l a t i o n o f r e h a b i l i t a t i o n p r o f e s s i o n a l s i n t o t a l . Thus the study f i n d i n g s cannot be g e n e r a l i z e d i n s i d e o r ou t s i de the two f a c i l i t i e s . N e v e r t h e l e s s , the o b j e c t i v e o f g a the r i n g p r e l i m i n a r y ev idence s t i l l ho lds t r ue even i f c au t i on i s war ranted when c o n s i d e r i n g the i m p l i c a t i o n s o f the r e s u l t s . Measures There a re two s e c t i o n s d i s c u s s i n g the measurements used i n t h i s t h e s i s . The f i r s t concerns the i n t e r v i e w ; i t s development, a d m i n i s t r a t i o n and a n a l y s i s . Here the dependent v a r i a b l e s ( r e p r e s e n t i n g how the p r o f e s s i o n a l e x p l a i n s , de sc r i be s and dea l s w i t h the p a t i e n t ) and the independent v a r i a b l e s ( r e p r e s e n t -33 i n g ' p a t i e n t r o l e ' and ' d e c i s i o n c o n t e n t ' ) are d i scus sed. Fu r the r to t h i s , two a d d i t i o n a l dimensions were assessed i n the i n t e r v i e w . The f i r s t cons idered the p r o f e s s i o n a l ' s pe rcept ion of the ' i m p l i c a t i o n s ' o f the p a t i e n t ' s behavior f o r the achievement of r e h a b i l i t a t i o n goa l s . Th i s i s i n c l uded i n order to he lp i n t e r p r e t the p r o f e s s i o n a l s ' responses and the i m p l i c a t i o n s of the f i n d i n g s . The second was the i n t e r v i e w e r ' s ' i m p r e s s i o n ' of the r o l e the p r o f e s s i ona l a c t u a l l y assumed dur ing the i n t e r a c t i o n w i th each o f the f a b r i c a t e d p a t i e n t r o l e s . Th i s measure i s d i scussed as a check on the v a l i d i t y of the measurement of the p r o f e s s i o na l r o l e i n the que s t i onna i r e . I t i s cons idered i n the second s e c t i o n . Foremost i n the second s e c t i on i s the development, a d m i n i s t r a t i o n and a n a l y s i s of the que s t i onna i r e . P r i m a r i l y , t h i s cons ide r s the independent v a r i a b l e , p r o f e s s i ona l r o l e . Other p r o f e s s i o na l a t t r i b u t e s tha t p o t e n t i a l l y account f o r the pa t t e rn of the p r o f e s s i o n a l s ' responses are a l s o d i scussed here. The I n t e r v i e w 1 Development The i n t e r v i e w was designed to e l i c i t the p r o f e s s i o n a l ' s responses as they v a r i e d between the p a t i e n t ' s r o l e as consumer and dependent, when the dec i s i o n content addressed the o b l i g a t i o n s and r e s p o n s i b i l i t i e s o f the p r o f e s s i o n a l ' s and p a t i e n t ' s r o l e s concerning dec i s i on s about the p a t i e n t ' s w e l f a r e . The p a t i e n t ' s r o l e was i m p l i c i t i n a f a b r i c a t e d p a t i e n t case study i n which the p a t i e n t ' s behavior was c o n s i s t e n t w i t h the consumerist or dependent r o l e s . 1 An actua l i n t e r v i ew i s presented i n Appendix 1. 34 In t h i s r e ga rd , the consumer i s t p a t i e n t ques t ioned the f a c i l i t y ' s program, d i d not f i t w e l l i n t o the f a c i l i t y s chedu le , and asked f o r second op i n i on s on m e d i c a t i o n . Conve r s e l y , the dependent p a t i e n t f o l l o w e d the p r o f e s s i o n a l ' s d i r e c t i o n s w i t hou t q u e s t i o n , f i t w e l l i n t o the f a c i l i t y s chedu le , and agreed to be p resented a t c l i n i c a l rounds even though embarrassed. The a c tua l d e s c r i p t i o n o f the behav io r i s p resented w i t h i n the ac tua l case study i n Appendix 1. The f a b r i c a t e d s t u d i e s p resented i n f o r m a t i o n t h a t was matched on e s s e n t i a l v a r i a b l e s o the r than behav io r . The o b j e c t i v e was t h a t the d i f f e r e n c e s i n p ro -f e s s i o n a l s ' p e r c e p t i o n s and responses to the p a t i e n t ' s behav io r c ou l d be a t t r i -buted to the v a r i ance i n ' p a t i e n t r o l e ' , r a t h e r than t o o the r p a t i e n t a t t r i b u t e s such as d i s e a s e , age or sex. The i n f o r m a t i o n con ta i ned i n the case s t u d i e s was a l s o des igned t o p resent c i r cumstances r e l e v a n t t o who shou ld make the u l t i m a t e d e c i s i o n s r ega rd i ng the w e l l - b e i n g o f the p a t i e n t . These c i rcumstances were developed to i n v o l v e th ree d imens ions: 1) c l u s t e r of pa tho logy , 2) r i s k , and 3) disagreement between the p a t i e n t and p r o f e s s i o n a l r ega rd ing ' b e s t d i s cha rge outcome ' . ' C l u s t e r of pa tho logy ' i s a c h a r a c t e r i s t i c o f c h r o n i c i l l n e s s . In g e n e r a l , c h r o n i c a l l y i l l p a t i e n t s have many problems o f which medica l s t a t u s i s only one. L i m i t e d f i n ance s and l a ck of s o c i a l support a re two examples of c o n t r i b u t o r y problems. The second d imens ion, ' r i s k ' , r e s u l t s when the r e s i d u a l d e f i c i t from the i l l n e s s combines w i t h the o the r problems i n the ' c l u s t e r ' t o p resent the p a t i e n t w i t h the p o t e n t i a l o f s e r i ou s i n j u r y . T h i s r i s k can be i n c rea sed or decreased, dependent on the d i s cha rge o p t i o n chosen. The t h i r d d imens ion, ' d i s a g r e e m e n t ' , i n v o l v e s the p a t i e n t choos ing an op t i on t h a t i s d i f f e r e n t f rom, and i n vo l ve s 35 more r i s k than , the op t i on s e l e c t e d by the p r o f e s s i o n a l . To c o n s i d e r a comprehensive range o f v a r i a b l e s to r e f l e c t these th ree d imens ions , f ou r c a t e g o r i e s were con s i de red : 1) i n d i v i d u a l a t t r i b u t e s , 2) medica l s t a t u s , 3) s o c i a l s t a t u s , and 4) c i r cums tance s . T a b l e I I I l i s t s the v a r i a b l e s con s i de red w i t h i n these c a t e g o r i e s . The matching and exp re s s i on of the v a r i a b l e s i n the p a t i e n t case study are d i s cu s sed i n the i n t e r v i e w example i n Appendix 1. Tab l e I I I V a r i a b l e s r e f l e c t i n g the c i r cumstances of the p a t i e n t case s t u d i e s I n d i v i d u a l a t t r i b u t e s Age Sex Med ica l s t a t u s P a s t medical h i s t o r y Mental s t a t u s Res idua l d e f i c i t P rognos i s D i agnos i s S o c i a l S t a t u s M a r i t a l s t a t u s C h i l d r e n Educat ion Employment F inances Accommodation C i rcumstances R i sk 36 The con ten t of these f a c t o r s was d r a f t e d i n t o two p a t i e n t case s t u d i e s i n a form resembl ing a r e p o r t from a medica l r e co rd summarizing the p a t i e n t ' s s t a y . A rev iew of the medica l records of the two f a c i l i t i e s p a r t i c i p a t i n g i n the study he lped the i n v e s t i g a t o r t o match the termino logy used i n the s t u d i e s w i t h t h a t f a m i l i a r to the p r o f e s s i o n a l s . The c r e d i b i l i t y o f the case s t u d i e s , t h e i r exp re s s i on i n a l u c i d manner, and the v a l i d i t y o f the matching o f the v a r i a b l e s were assessed through a number o f p r e - t e s t s . The p r e - t e s t i n g was done by the i n v e s t i g a t o r ' s c o l l e ague s whose range of expe r i ence i n c l u d e d n u r s i n g , phy s i o the rapy , occupa t i ona l t he rapy , and med ic ine . I n te r v i ew S t ra tegy 2 The i n t e r v i e w e r used open-ended ques t i on s and p rob ing s t r a t e g i e s to e l i c i t the p r o f e s s i o n a l s ' responses t o the behav io r of each of the p a t i e n t s . Quest ions were d i r e c t e d s p e c i f i c a l l y t o how the p r o f e s s i o n a l s s t a t e d they would e x p l a i n , d e s c r i b e and deal w i t h the p a t i e n t ' s behav i o r . In a d d i t i o n , the p r o f e s s i o n a l s were asked to e va l ua te the i m p l i c a t i o n s of the p a t i e n t ' s behav io r f o r the achievement o f r e h a b i l i t a t i o n goa l s . S t anda rd i zed open-ended q u e s t i o n s , c o n s t r u c t e d i n advance, began each i n t e r v i e w . P r o b i n g was then used t o d i r e c t the p r o f e s s i o n a l s to the r e l e -vant d imens ions . Th i s approach was used t o guard a ga i n s t the i n t e r v i e w e r o v e r l y b i a s i n g the d i r e c t i o n o f the i n t e r v i e w . The p rob ing then kept the i n t e r v i e w focused but a l l owed f o r the emergence o f i n d i v i d u a l p e r s p e c t i v e s . 2 Examples of these ques t ions are i n c l u d e d i n the i n t e r v i e w presented i n Appendix 1. 37 Three p a r t i c u l a r techn iques of p rob ing were employed. The f i r s t was an approach t h a t pushed the case study c i rcumstances and the ensu ing responses to t h e i r extreme. For example, a t one p o i n t , one of the p r o f e s s i o n a l s s t a t e d , ' t h e p a t i e n t ' s d i s cha rge d e c i s i o n shou ld be f o l l o w e d i f a p p r o p r i a t e . 1 F u r t h e r i n -fo rmat ion was then p rov ided to 1) i n d i c a t e disagreement between the p r o f e s -s i o n a l and p a t i e n t as t o the p r e f e r r e d outcome, 2) i n d i c a t e t h a t g r ea te r r i s k was i n v o l v e d i n t h e - p a t i e n t ' s c h o i c e , and 3) s t r e s s t h a t a d e c i s i o n had to be made. The p r o f e s s i o n a l was then asked t o d e f i n e the term ' a p p r o p r i a t e ' as i t was meant. F o l l o w i n g t h i s e x e r c i s e , the p r o f e s s i o n a l s t a t e d , 'You mean, who shou ld make the u l t i m a t e d e c i s i o n . ' The second techn ique o f a sk i ng f o r d e f i n i t i o n s o f terms and the t h i r d of a s k i ng the same que s t i on i n d i f f e r e n t ways he lped t o c l a r i f y the meaning and check the v a l i d i t y of the p r o f e s s i o n a l ' s s tatements . In t h i s way, f o r example, the d e s c r i p t i o n of the p a t i e n t as ' c o m p l i a n t ' was d i f f e r e n t i a t e d to mean, i n one case, ' r e s p o n s i v e ' and, i n the o t h e r , ' p a s s i v e ' . The new connota t i on s o f the word f a c i l i t a t e d the i n t e r v i e w e r ' s i n t e r p r e t a t i o n o f the s tatement. These techn iques were p r e - t e s t e d i n f o r m a l l y w i t h the i n v e s t i g a t o r ' s c o l l e ague s and, f o r m a l l y , i n p i l o t s t ud i e s conducted at Vancouver Genera l and Holy Fami l y H o s p i t a l s . T h i s he lped t o develop the i n t e r v i e w e r ' s a b i l i t y to conduct an i n t e r v i e w i n a competent, r e l a x e d manner i n o rde r t o s t i m u l a t e su f -f i c i e n t exp re s s i on o f the p r o f e s s i o n a l s ' v iews. Though not a l l responses were a s c e r t a i n e d , p a r t i c u l a r l y i n the i n i t i a l i n t e r v i e w s o f the s tudy , the i n t e r v i e w e r ' s s k i l l developed f u r t h e r t o min imize the l o s s o f i n f o r m a t i o n . 38 A d m i n i s t r a t i o n The i n t e r v i e w was conducted i n h a l f hour se s s i on s a t a t ime and p l a ce con-ven i en t to the p r o f e s s i o n a l . A room was re se rved f o r each i n t e r v i e w i n o rder to f a c i l i t a t e an u n i n t e r r u p t e d d i s c u s s i o n . The p r e s e n t a t i o n of each p a t i e n t case study f o l l o w e d the same r o u t i n e . F i r s t , a page l ong case study o f the consumer i s t p a t i e n t was g iven t o the p r o f e s s i o n a l t o read. When the p r o f e s s i o n a l i n d i c a t e d the complet ion o f the r e a d i n g , the i n t e r v i e w e r f o l l o w e d , 'Now I would l i k e to t e l l you a l i t t l e more about Mr. C ' s s tay a t the C e n t r e . ' A t t h i s t ime , the i n t e r v i e w e r read the paragraph d e s c r i b i n g the p a t i e n t ' s behav io r . The p r o f e s s i o n a l then r e t a i n e d both p i e ce s of i n f o r m a t i o n f o r ongoing r e f e r e n c e . The ques t i on se s s i on f o r each p a t i e n t case began, 'What i s your general impre s s i on of Mr. ' s C C f o r consumer i s t , ' D ' f o r dependent) stay a t the c e n t r e . ' The ensu ing responses were p r i m a r i l y d i r e c t e d t o the dimensions o f ' d e s c r i b i n g ' , ' e x p l a i n i n g ' , and ' d e a l i n g ' w i t h the p a t i e n t ' s behav i o r . The next stage o f the q u e s t i o n i n g was d i r e c t e d a ga i n , p r i m a r i l y , to ' d e a l i n g ' , as w e l l as to the dimension o f the i m p l i c a t i o n s f o r a c h i e v i n g r e h a b i l i t a t i o n goa l s . F i r s t the p r o f e s s i o n a l was asked: 'What do you see as the bes t d i s charge o p t i o n f o r Mr. ' ' . Then f u r t h e r i n f o r m a t i o n of the p a t i e n t ' s s i t u a t i o n rega rd ing d i s cha rge was p r o v i d e d , i n i t i a t e d by the s t a t e -ment: 'Now I would l i k e t o t e l l you a l i t t l e more about Mr. ' s d i s c h a r g e . ' The c i r cumstances su r round ing the p a t i e n t ' s d i s cha rge op t i on s h i g h l i g h t e d the aspects of a ' c r i s i s ' s i t u a t i o n . The d i s cha rge op t i on s were compromised through 1) f a m i l y r e f u s a l to assume r e s p o n s i b i l i t y f o r support ( the f am i l y 39 r e f u se s the p a t i e n t ' s request to l i v e w i t h them) and 2) the p a t i e n t ' s v u l n e r a b i l i t y , when the p a t i e n t s ' o p t i o n i s s a i d t o i n c l u d e more r i s k than t h a t of the p r o f e s s i o n a l . Though both cases p resented the p a t i e n t ' s opt ions as be ing que s t i o nab l e i n these terms, they d i f f e r e d i n p r e s e n t a t i o n i n o rder to ma in ta i n con s i s t ency w i t h p a t i e n t r o l e . Whereas the consumer i s t p a t i e n t openly p resented h i s op t i on to the p r a c t i t i o n e r s ( 'Mr . C. s t a t e d t h a t he wished t o . . . . ' ) , the dependent p a t i e n t ' s p re fe rence was s t a t e d through h i s f am i l y ( 'The Cent re heard from Mr. D. ' s daughter who s a i d she had spoke w i t h him on the p h o n e . . . ' ) . The i n t e r v i e w e r f r e e l y recorded the statements of the p r o f e s s i o n a l du r i ng the i n t e r v i e w . Four o f the f i r s t ten i n t e r v i e w s were taped w i t h the consent of the p r o f e s s i o n a l . In t h i s way the i n t e r v i e w e r cou ld assess the p r e s e n t a t i o n and q u e s t i o n i n g t e chn i que s . A n a l y s i s The p r o f e s s i o n a l s ' responses to each p a t i e n t r o l e were measured a long a continuum rang ing between the c o n t r o l l e r ' s and accommodator 's p e r s p e c t i v e s as p r e d i c t e d from the dynamics of the s p e c i f i c combinat ion o f p a t i e n t r o l e and p r o f e s s i o n a l r o l e . Each response was then taken to the c l o s e r extreme of the continuum and coded on a 2 -po int s c a l e . To a s s i s t t h e i r i n t e r p r e t a t i o n , the responses were i n i t i a l l y examined i n two ways; f i r s t , f o r each p r o f e s s i o n a l , comparing the response to each p a t i e n t r o l e and second, f o r each p a t i e n t r o l e , comparing the responses o f the p r o f e s -s i o n a l s . In t h i s e x e r c i s e , the s i m i l a r i t i e s and d i f f e r e n c e s between responses were i l l u m i n a t e d . 40 Examples from the c a t e g o r i e s of p r o f e s s i o n a l s ' responses w i l l he lp to c l a r i f y the cod ing of the terms. P r o f e s s i o n a l s cou ld e x p l a i n the p a t i e n t ' s behav io r on a continuum rang ing from a ' p a t i e n t a t t r i b u t e 1 t o a ' c o n f l i c t of t e r m s ' . An example of the f i r s t f o r the dependent p a t i e n t i s , " t h e p a t i e n t goes a long because t h e y ' r e t h a t s o r t of p e r s o n " , as opposed to the second, "may not have p a r t i c u l a r o b j e c t i v e s t h a t c o n f l i c t w i t h s t a f f " . For the consumer i s t p a t i e n t , an example o f ' c o n t r o l l i n g ' , " d i f f i c u l t y cop ing w i t h h i s d e t e r i -o r a ted f u n c t i o n " , and of ' accommodat ing ' , "needs t h a t have occu r red to him might be a t odds w i t h those o f s t a f f . " The p a t i e n t s ' behav io r cou l d be de s c r i bed a long a continuum rang ing from ' good ' t o ' d i f f i c u l t ' . An example o f ' g ood ' f o r the dependent p a t i e n t was, " m o t i v a t e d p a t i e n t - wants to s tay out o f h o s p i t a l s " , and o f ' d i f f i c u l t ' , " o v e r - c o m p l i a n t - l a c k s i n i t i a t v e " . An example of ' g ood ' f o r the consumer p a t i e n t , " good m o t i v a t i o n - l i k e l y to s ucceed " , and o f ' d i f f i c u l t ' , " b e h a v i n g l i k e a teenage - a c t i n g ou t , de l ud i ng h i m s e l f * . When the p a t i e n t ' s behav io r was con s ide red to be due t o a ' l a c k of judgment ' , the p a t i e n t was not he ld re spon-s i b l e and the behav io r was not e va l ua ted i n terms of ' good ' and ' d i f f i c u l t ' , f o r example, f o r the dependent p a t i e n t , " p r o b a b l y a l i k e d compl iant p a t i e n t , o r h i s judgment i s dec rea sed " . The p a t i e n t ' s behav io r cou ld be d e a l t w i t h on a continuum rang ing from ' c o n t r o l l i n g ' t o 'accommodating ' w i t h ' c o n t r o l l i n g ' i n c l u d i n g the dimension o f ' r e j e c t i o n ' f o r the consumer i s t p a t i e n t , and the 'accommodating ' p e r s p e c t i v e i n c l u d i n g the dimension of ' i n s p i r a t i o n ' f o r dependent p a t i e n t . For the con -sumer i s t p a t i e n t an example o f ' c o n t r o l ' i s , " educa te him f o r h i s r e s p o n s i -b i l i t y , the reason he i s he re . Why does he t h i n k h e ' s a t the C e n t r e ? " , 41 and an example o f ' r e j e c t i o n ' , " h e i s not ready f o r r e h a b i l i t a t i o n a t t h i s t ime , t h a t i s not w i l l i n g to p a r t i c i p a t e , c o - ope ra te , be m o t i v a t e d . " An example of 'accommodating ' the consumer i s t p a t i e n t i s , " h e does not have the same expec ta t i on s - f r u s t r a t i n g f o r the s t a f f but r e a l l y up t o the pe r s on " . Fo r the dependent p a t i e n t , an example o f ' c o n t r o l l i n g ' , ''We must modify h i s t reatment program, s h o r t e r s e s s i o n s " , and ' i n s p i r i n g ' , "Withdraw the c l o s e s u p e r v i s i o n so he w i l l take on more r e s p o n s i b i l i t y ' 1 . The i n v e s t i g a t o r i n t e r p r e t e d and coded these responses w i t h the a s s i s t a n c e o f a framework ( F i gu re 7 ) . I f the p r o f e s s i o n a l e x p l a i n e d t h e i r responses i n terms o f t h e i r assumptions or o the r arguments t h a t u n d e r l i n e d t h e i r e v a l u a t i o n these were assessed a ga i n s t the assumptions and arguments made e x p l i c i t i n the framework. Once the responses were coded, the i n v e s t i g a t o r checked the r e l i a b i l i t y o f the cod ing i n t h r ee ways: 1) recod ing by the same i n d i v i d u a l was done a t a 90% c o r r e c t r a t e ; 2) the framework was i n f o r m a l l y assessed by a c o l l e a gue who was s a t i s f i e d t h a t the con ten t , the arguments, and the assumptions had f ace v a l i d i t y and were c o n s i s t e n t ; 3) a c o l l e a gue was asked to code randomly s e l e c t e d s tatements . These was then compared w i t h the i n v e s t i g a t o r ' s . Seven o f ten d e c i s i o n s were the same. In r e a l i t y , o f cou r se , p r o f e s s i o n a l s do not c on s c i ou s l y t h i n k i n terms of c a t e g o r i z i n g t h e i r responses i n t o ' e x p l a i n i n g ' , ' d e s c r i b i n g ' or ' d e a l i n g ' w i t h the p a t i e n t ' s behav io r . The i n t e r v i e w e r probed i n these d i r e c t i o n s but recog -n i z ed the need t o i n c o r p o r a t e the c a t e g o r i e s or responses w i t h the ' r a t i o n a l e ' t h a t connected them.- The framework was developed to i n t e g r a t e the assumptions 42 PROFESSIONAL AS CONTROLLER PROFESSIONAL AS ACCOMMODATOR "Professional should assume responsibility for health decisions." "Patient should rely on the professional's expertise." "PROFESSIONAL DOMINANT ASYMMETRY LEGITIMATE" CONSUMERIST PATIENT TRADITIONAL PATIENT "Patients should assume-responsibility for health decisions." "Patients should rely on their own judgment." "PATIENT DOMINANT ASYMMETRY LEGITIMATE" CONSUMERIST PATIENT TRADITIONAL PATIENT 4* CO BEHAVIOR explained AS "PATIENT ATTRIBUTE" BEHAVIOR DISRUPTIVE described "DIFFICULT" BEHAVIOR explained AS "CONFLICT" OF TERMS" CONFLICT NOT VALID described "DIFFICULT1 y deal CONTROL OR REJECT BEHAVIOR explained AS "PATIENT ATTRIBUTE" y x PATIENT MOTIVATED described "GOOD" \ LACK OF JUDGMENT not described patient not held responsible deal CONTROL BEHAVIOR explalned AS "PATIENT ATTRIBUTE" BEHAVIOR BENEFICIAL described "GOOD" BEHAVIOR explained AS "CONFLICT OF TERMS" CONFLICT VALID described "GOOD" deal ACCOMMODATE BEHAVIOR explained AS "PATIENT ATTRIBUTE" BEHAVIOR DISRUPTIVE described "DIFFICULT" BEHAVIOR explained AS "CONFLICT OF TERMS" CONFLICT NOT VALID described "DIFFICULT" F t ^ - ^ d e a T ' ^  SUftrtOllHTABLTf | INSURMOUNTABLY" I I INSPIRE t REVERT TO CONTROL Figure 7. A Framework Integrating the assumption of the alternate professional roles, the categories of responses, and the actual responses predicted to emanate from Interaction with each of the patient roles. of the a l t e r n a t e p r o f e s s i o n a l r o l e s , the c a t e g o r i e s of responses, and the a c tua l responses p r e d i c t e d to emanate from i n t e r a c t i o n w i t h each o f the p a t i e n t r o l e s . In sum, the i n t e r v i e w e r presented two p a t i e n t case s t ud i e s which,though d i f f e r e n t i n c o n t e n t , v a r i e d on ly i n terms o f p a t i e n t r o l e . In both ca se s , the i n f o r m a t i o n presented c i rcumstances which n e c e s s i t a t e d c o n s i d e r a t i o n o f making d e c i s i o n s about the p a t i e n t ' s w e l l - b e i n g . To he ighten the dimension of p r o f e s -s i o n a l ' s and p a t i e n t ' s r o l e r e s p o n s i b i l i t i e s i n making such a d e c i s i o n , the p r o f e s s i o n a l and p a t i e n t were r epo r t ed to d i sag ree about the bes t d i s charge o p t i o n . The p r o f e s s i o n a l s were asked how they would e x p l a i n , d e s c r i b e , and deal w i t h the p a t i e n t ' s behav i o r . A number o f s teps were taken t o enhance the i n t e r v i e w ' s a b i l i t y t o measure what i t was in tended to measure. The Que s t i o nna i r e Devel opment The independent v a r i a b l e s were s e l e c t e d as p o s s i b l e e xp l ana t i on s o f the p a t t e r n of responses of the dependent v a r i a b l e s . The hypothes i s p r e d i c t s t h a t p r o f e s s i o n a l o r i e n t a t i o n t o r o l e e xpec t a t i o n s should u n d e r l i e much o f the v a r i a n c e . 3 A q u e s t i o n n a i r e was dev i sed to measure p r o f e s s i o n a l r o l e as e i t h e r c o n t r o l l e r o r accommodator. Twenty-seven items were adopted and r e v i s e d from the s c a l e s developed by Haug and L a v i n (1981) t o measure a t t i t u d i n a l and behav i o r a l a spects r e l a t e d to the a u t h o r i t y dimension of the d o c t o r - p a t i e n t r e l a t i o n s h i p . In cap su l e form, these dimensions r e f l e c t e d 1) a t t i t u d i n a l 3 See appendix 2. 44 cha l l e nge to p h y s i c i a n a u t h o r i t y , 2) behav i o r a l c ha l l e n ge to p h y s i c i a n a u t h o r i t y , 3) p h y s i c i a n accommodation o f p a t i e n t s ' behav i o r a l c h a l l e n g e , 4) b e l i e f i n p a t i e n t s r i g h t to i n f o r m a t i o n , 5) b e l i e f i n the p a t i e n t s ' r i g h t to make d e c i s i o n s . Haug and L a v i n ' s dimensions were presented to the p u b l i c as w e l l as to p h y s i c i a n s . They conducted i n t e r v i e w s to assess the ex ten t o f r epo r ted p u b l i c a t t i t u d e s and behav io r s t h a t c ha l l enge the p h y s i c i a n ' s t r a d i t i o n a l a u t h o r i t y , as w e l l as p h y s i c i a n ' s r epo r ted response t o such a t t i t u d e s and event s . M o d i f i c a t i o n s o f these items were done i n p r e p a r a t i o n f o r t h i s study f o r v a r i ou s reasons: 1) The study s e t t i n g changed from the community t o the i n s t i t u t i o n ; 2) The sample i n c l u d e d a range o f p r o f e s s i o n a l s i n a d d i t i o n t o the p h y s i c i a n ; 3) Some of the exp re s s i on s and termino logy used were not app rop r i a t e f o r a Canadian sample i n 1984; 4) The o r i g i n a l que s t i on s had been presented through an i n t e r v i e w and c o u l d a l l o w p r o b i n g , whereas the c u r r e n t q u e s t i o n n a i r e was t o be c i r c u l a t e d . The f i r s t change to be i n c o r p o r a t e d i n the q u e s t i o n n a i r e was the i d e n t i f i c a t i o n o f the s p e c i f i c p r o f e s s i o n as a p p r o p r i a t e . A d d i t i o n a l changes came as the r e s u l t o f p r e - t e s t i n g o f the q u e s t i o n n a i r e amongst r e h a b i l i t a t i o n s tudents and the i n v e s t i g a t o r ' s c o l l e a g u e s . They i n d i c a t e d where, f u r t h e r m o d i f i c a t i o n would be necessary to encourage comprehension and complet ion o f a l l A que s t i on s . The accepted recommendations f o l l o w : 4 For examples o f the m o d i f i c a t i o n s r e f e r t o the q u e s t i o n n a i r e i n Appendix 2. 45 1) Quest ions which were arranged as 2 - p o i n t s c a l e s , t h a t i s , s e l e c t i o n from a l t e r n a t e o p t i o n s , were changed to two separate ques t i on s arranged on 4 - p o i n t L i k e r t type s c a l e s . 2) Some of the ab so l u te terms such as 'most ' impor tant were q u a l i f i e d , f o r example, to ' v e r y ' impor tan t . S i n ce answers were g iven on L i k e r t type s c a l e s , the op t i on s o f s t r o n g l y agree or d i s ag ree were s t i l l a v a i l a b l e to r e f l e c t s t rong b i a s . 3) Quest ions which had been presented as case s t ud i e s and l e f t open-ended ( f a c i l i t a t e d by the i n t e r v i e w p r e s en t a t i o n ) w i t h the answers coded i n t o th ree c a t e g o r i e s r e p r e s e n t i n g e i t h e r ' r e j e c t ' , ' c o n t r o l ' , and 'accommodate ' , were r e p l a c e d by statements r e f l e c t i n g the t h r ee c a t e g o r i e s , each on a 4 - p o i n t L i k e r t type s c a l e . An a d d i t i o n a l two ques t i on s were i n c l u d e d t o cover the type of c ha l l e n ge l i k e l y to occur i n the i n s t i t u t i o n r a t h e r than the community as i n Haug and L a v i n ' s s tudy. The q u e s t i o n n a i r e used L i k e r t type s c a l e s on a 4 - p o i n t s c a l e . As such, no neu t r a l category was p r o v i d e d . The responses were meant to r e f l e c t c o n t r o l l i n g or accommodating o r i e n t a t i o n o f the p r o f e s s i o n a l . The responses were then coded so t h a t the numbers 1 and 2 always r e f l e c t e d the ' c o n t r o l l e r ' and 3 and 4 the 'accommodator ' o r i e n t a t i o n . In sum, the s t r u c t u r e o f the Haug and L a v i n q u e s t i o n n a i r e was changed d r a m a t i c a l l y . The content c a t e g o r i e s were r e t a i n e d and were s t i l l con s ide red as the a p r i o r i meaning o f the ques t ions to r e f l e c t 1) c ha l l enge to a u t h o r i t y , 2) b e l i e f i n p a t i e n t r i g h t t o i n f o r m a t i o n , and 3) b e l i e f i n p a t i e n t r i g h t to make d e c i s i o n s . F u r t h e r changes i n termino logy were recommended dur ing p r e - t e s t i n g and these were implemented i n o rde r t o enhance comprehension and complet ion o f the q u e s t i o n n a i r e . 46 A d m i n i s t r a t i o n 5 The que s t i o na l ' r e s , w i t h consent forms a t t a ched , were c i r c u l a t e d to a l l p r o f e s s i o n a l s i n the sample. The i d e n t i t y o f the p a r t i c i p a n t was i n d i c a t e d on the consent form and q u e s t i o n n a i r e by the same code number. The r e tu rned q u e s t i o n n a i r e c o u l d then be coded by the i n v e s t i g a t o r w i t hou t knowledge o f the s u b j e c t ' s i d e n t i t y , s i n ce t h i s knowledge p o t e n t i a l l y would have b i a sed the i n v e s t i g a t o r ' s assessment o f the p r o f e s s i o n a l ' s responses i n the i n t e r v i e w . I n te r v i ews were begun on ly a f t e r a l l q u e s t i o n n a i r e s had been r e t u r ned . Those s ub j e c t s who had not r e tu rned the q u e s t i o n n a i r e by t h i s t ime were removed from the s tudy. The s u b j e c t s were asked to r e f r a i n from d i s c u s s i n g the content of the q u e s t i o n n a i r e w i t h each o t h e r , o r w i t h t h e i r c o l l e ague s not i n v o l v e d i n the s tudy. A n a l y s i s A c o r r e l a t i o n m a t r i x o f the responses t o the q u e s t i o n n a i r e items showed t h a t 1) i tems t h a t were thought to be c o n c e p t u a l l y r e l a t e d were showing p a t t e r n s o f answers to the c o n t r a r y ; and 2) respondents c ou l d not e a s i l y be c a t e g o r i z e d as e i t h e r ' c o n t r o l l e r s ' or ' accommodators ' . There appeared to be meanings, d i f f e r e n t from the a p r i o r i assumptions o f the i n v e s t i g a t o r , t h a t determined the p a t t e r n o f p r o f e s s i o n a l s ' responses. That i s , t he re were d i f f e r e n t ways i n which the ques t i on s c o u l d be grouped, each r e f l e c t i n g a l t e r n a t e dimensions of the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p , o f which the i n v e s t i g a t o r ' s way was on ly one. 5 The consent forms are i n c l u d e d w i t h the q u e s t i o n n a i r e i n Appendix 2 . 47 A c t u a l l y , c o n t r o l l i n g and accommodating o r i e n t a t i o n s may be measured i n a number of ways. F a c t o r a n a l y s i s was s e l e c t e d as a techn ique t h a t cou l d regroup the ques t i on s a cco rd i ng to the p r o f e s s i o n a l s ' re sponses , i n a way t h a t was l a r g e l y independent o f the i n v e s t i g a t o r ' s p r e - conce i ved d e f i n i t i o n s . F a c t o r a n a l y s i s i n v o l v e s t h r ee s teps : 1) The f i r s t i s the p r e p a r a t i o n of a c o r r e l a t i o n m a t r i x which c a l c u l a t e d a p p r o p r i a t e measures o f a s s o c i a t i o n between v a r i a b l e s . Fo r the q u e s t i o n n a i r e , R-type c o r r e l a t i o n between the q u e s t i o n n a i r e i tems was sought r a t h e r than Q-type c o r r e l a t i o n between p a i r s of i n d i v i d u a l s . 2) The second step i n v o l v e s the r e d u c t i o n o f i tems i n t o new v a r i b a l e s , c a l l e d f a c t o r s , based on the i n t e r - r e l a t i o n s e x h i b i t e d i n the c o r r e l a t i o n m a t r i x . I t i s assumed t h a t these i n t e r - r e l a t i o n s f o l l o w some u n d e r l y i n g p a t t e r n ; t h a t i s , the re i s assumed to be a ' r e a s o n ' f o r some v a r i a b l e s t o be r e l a t e d and o t h e r s , not. T h e r e f o r e , i f t h e r e i s any c o r r e l a t i o n between two v a r i a b l e s , i t i s assumed t o be due to a common f a c t o r . The f a c t o r s themse lves , however, are not c o r r e l a t e d . 3) The t h i r d s tep i n v o l v e s the f i n a l s e l e c t i o n o f the f a c t o r s r e -p r e s e n t i n g the dimensions o f the independent v a r i a b l e . On the b a s i s o f the i n i t i a l f a c t o r m a t r i x , s i x f a c t o r s were r e t a i n e d , as s i x t y per cent o f the v a r i a n ce of q u e s t i o n n a i r e i tem responses was accounted f o r by t he se . A f e a t u r e o f f a c t o r a n a l y s i s i s t h a t f a c t o r s a re arranged i n o rder of t h e i r importance w i t h the f i r s t f a c t o r the most impor tant component and account ing f o r the most v a r i a n c e . Tab le s I I I t o IX de s c r i be the s i x f a c t o r s which were i s o l a t e d . W i t h i n each f a c t o r are the q u e s t i o n n a i r e i tems which were c o r r e l a t e d . P r o f e s s i o n a l s who responded to one i tem as e i t h e r ' c o n t r o l l e r ' o r 'accommodator ' tended t o respond l i k e w i s e t o a p o s i t i v e l y c o r r e l a t e d i tem or c o n t r a r i w i s e to a n e g a t i v e l y c o r r e l a t e d i t e m . 48 The con ten t o f the items f u r t h e r de f i ne s the meaning o f the f a c t o r . The s t r eng th o f the i n f l u e n c e o f each i tem on the i n t e r p r e t a t i o n o f the f a c t o r , however, i s i n d i c a t e d by i t s ' l o a d i n g ' . Through the i n s p e c t i o n o f the h i g h l y ' l o a d e d ' i tems on each f a c t o r , d i s t i n c t dimensions are i n t e r p r e t e d . On two occa s i on s , two f a c t o r s shared an i tem t h a t was ' h e a v i l y l o aded ' on each. Th i s i n d i c a t e s t h a t these i tems measure more than one t h e o r e t i c a l d imens ion. I t i s the con tex t of the o the r ' h e a v i l y l o aded ' i tems t h a t i s o l a t e s the r e l e v a n t d imens ion. The common element observed i n f a c t o r one i s the p a t i e n t ' s i n t e r a c t i o n w i t h ' t eam ' r e sou r ce s , a c t i v i t i e s and p rocedures . Med ica l records and meetings are good examples of t he se . Wh i le a l l p r o f e s s i o n a l s would s t a t e t h a t the p a t i e n t i s p a r t o f the ' t e a m ' , a l t e r n a t e responses on these i tems i n d i c a t e d i f f e r i n g p r o f e s s i o n a l s ' b e l i e f s r ega rd ing the s p e c i f i c r o l e the p a t i e n t shou ld assume. Access to the p r o f e s s i o n a l s ' team meetings and medical records i s i n que s t i on here. Item 10, i n t h i s c o n t e x t , c on s i de r s the p r o f e s s i o n a l ' s response to the p a t i e n t ' s non-compl iance w i t h the ' t e a m ' s ' d e c i s i o n . T h i s f a c t o r has been l a b e l l e d , 'The p a t i e n t ' s r o l e as a team member'. 49 The a l t e r n a t e pe r cep t i on s of the p r o f e s s i o n a l ' s r o l e become c l e a r e r when the i tems are expressed as separate groups o f statements c o n s i s t e n t w i t h the d i r e c t i o n of the c o r r e l a t i o n s . These groups are d i s t i n g u i s h e d below i n Tab le IV (A & B ) . Tab le IV (A) F a c t o r 1. The p a t i e n t ' s r o l e as a team member. Item Load ing 14 15 16 10 .917 .834 -.798 .545 -.535 Case 3. A p a t i e n t asks to a t t end a meeting t h a t was meant on ly f o r p r o f e s s i o n a l s t o d i s cu s s the p a t i e n t ' s behav io r . The p r o f e s s i o n a l c o n s i d e r s : 14 ' a l l o w him t o a t t e n d ' , 15 ' r e f u s e him permi s s ion t o a t t e n d ' , 16 ' a r r ange another meeting f o r him to a t t e n d ' . Even i f a p a t i e n t asks to read h i s own medical records he should not be a l l owed to do so. Case 1. A p a t i e n t suggests t h a t what you adv i sed was too much t r o u b l e . You d i s cu s s the reasons behind your adv i ce but he s t i l l r e fu se s to comply You, ' D i s c u s s o the r a l t e r n a t i v e s t h a t might be e a s i e r ' . 50 Tab le IV (B) F a c t o r 1. A l t e r n a t e pe r cep t i on s of the p r o f e s s i o n a l ' s r o l e r ega rd ing the p a t i e n t ' s r o l e as a team member. Group 1 Group 2 A l l o w the p a t i e n t to a t tend the m e e t i n g . 1 D o n ' t a l l ow the p a t i e n t t o a t tend the mee t i n g . ' D o n ' t r e fu se the p a t i e n t pe rm i s s i on to a t t e n d . ' Refuse the p a t i e n t permi s s ion to a t t e n d . ' D o n ' t arrange another meeting f o r h im . ' Arrange another meeting f o r h im . ' A p a t i e n t shou ld be a l l owed t o see h i s own medica l r e co rd s . A p a t i e n t shou ld not be a l l owed t o see h i s own medical r e c o r d s . ' In response to non-compl icance: Don ' t d i s cu s s o the r a l t e r n a t i v e s t h a t might be e a s i e r . ' ' D i s c u s s o the r a l t e r n a t i v e s t h a t might be e a s i e r . ' F a c t o r two (Tab le V below) i s c h a r a c t e r i z e d by i s s ue s r e l a t i n g the d e c i s i o n s p r o f e s s i o n a l s might make i n the i n t e r e s t o f the w e l f a r e of the p a t i e n t . Items 20 , 22 and 6 are c l a s s i c a l ep isodes of the ques t i on of ' l e g i t i m a t e p a t e r n a l i s m ' . Items 26 and 19 r e f l e c t some c h a r a c t e r i s t i c s of the p r o f e s s i o n a l and p a t i e n t i n t e r a c t i o n as the route through which these d e c i s i o n s a re made. T h i s f a c t o r i s l a b e l l e d ' j u d g i n g p a t i e n t w e l f a r e ' . 51 Tab le V F a c t o r 2. Judg ing P a t i e n t We l fa re Item Load ing 20 .729 The p a t i e n t i n the l a s t s tages o f a t e rm ina l i l l n e s s shou ld dec ide i f f u r t h e r treament should be con t i nued . 22 .612 Most t e r m i n a l l y i l l p a t i e n t s shou ld not be t o l d the p rognos i s even i f requested by them. 26 .610 I f p r o f e s s i o n a l s would d i s cu s s l e s s w i t h p a t i e n t s and t e l l them s t r a i g h t out what t o do everybody would be b e t t e r o f f . 6 .480 Even i f no p o t e n t i a l harm t o any o the r person i s i n v o l v e d , a p a t i e n t should not be a l l owed t o l eave the h o s p i t a l when the doc to r does not agree. 19 - .462 Case 4. A p a t i e n t has appeared unmot ivated du r i ng t r ea tment . He has r e fu sed c o u n s e l l i n g and o the r e f f o r t s to e xp l o r e the problem. The p r o f e s s i o n a l c o n s i d e r s : ' c o n t i n u e as be fo re and l e t him make the f i r s t move to 'come a r o u n d ' . ' F a c t o r th ree (Tab le VI below) con ta i n s items r e l a t i n g t o the process by which h e a l t h d e c i s i o n s might be reached. Items 4 and 21 r e f e r t o the r o l e of the p r o f e s s i o n a l g i v i n g adv i ce and i tems 1 and 11 to the r o l e of the p a t i e n t i n f o l l o w i n g a d v i c e . Th i s f a c t o r i s t h e r e f o r e l a b e l l e d , ' g i v i n g and f o l l o w i n g a d v i c e ' . Opposing views would range from the o b l i g a t i o n of the p a t i e n t to f o l l o w adv i ce t o the o b l i g a t i o n o f the p r o f e s s i o n a l to accept the p a t i e n t ' s e v a l u a t i o n o f the a d v i c e . 52 Tab l e VI F a c t o r 3. G i v i n g and Fo l l owng Adv i ce Item Load ing 4 .722 I f p r o f e s s i o n a l s would d i s cu s s matter s more w i t h p a t i e n t s be fo re a c t i n g , everybody would be b e t t e r o f f . 1 .678 I t i s very impor tant f o r p a t i e n t s to comply w i t h what p r o f e s s i o n a l s a d v i s e . 11 .603 Case 2 . A p a t i e n t suggests t h a t what you adv i sed i s not necessary f o r h i s c o n d i t i o n and asks f o r something d i f f e r e n t t h a t you f e e l i s i n e f f e c t i v e , ' h e l p him o b t a i n what he has r e q u e s t e d . ' 21 .428 When d i s c u s s i n g t reatment programmes w i t h p a t i e n t s p r o f e s s i o n a l s ought t o make the f i n a l d e c i s i o n about what the p a t i e n t should do. F a c t o r f o u r (Tab le VII below) concerns , as d i d f a c t o r t h r e e , the assessment of the p r o f e s s i o n a l ' s a d v i c e , but f ocu se s , i n items 10, 13 and 9, on the p r o f e s s i o n a l ' s r o l e as persuader . That i s , the p r o f e s s i o n a l shou ld o r shou ld not be o b l i g e d to persuade the p a t i e n t to f o l l o w t h e i r adv i ce . The o r i e n t a t i o n t o e i t h e r r o l e seems dependent on i tems 7 and 27 which concern the p a t i e n t ' s f a i t h i n the p r o f e s s i o n a l ' s adv i ce or the p a t i e n t ' s r e l i a n c e on access to i n f o r m a t i o n through q u e s t i o n i n g . T h i s f a c t o r i s t h e r e f o r e l a b e l l e d , ' p a t i e n t f a i t h i n p r o f e s s i o n a l a d v i c e ' . 53 Table VI I F a c t o r 4. P a t i e n t f a i t h i n p r o f e s s i o n a l adv i ce Item Load ing 7 .570 I t i s a l l r i g h t f o r p a t i e n t s to r a i s e ques t ions w i t h p r o f e s s i o n a l s about anyth ing they a d v i s e . 27 .512 P a t i e n t s shou ld have complete f a i t h i n p r o f e s s i o n a l s and do what they adv i se w i t h o u t a l o t o f que s t i on s . 10 .441 Case 1. A p a t i e n t suggests t h a t what you adv i sed was too much t r o u b l e . You d i s cu s s the reasons behind your adv i ce but he s t i l l r e fu se s to comply, ' d i s c u s s o the r a l t e r n a t i v e s t h a t might be e a s i e r ' . 13 .427 Case 2 . A p a t i e n t suggests t h a t what you adv i sed i s not necessary f o r h i s c o n d i t i o n and asks f o r something d i f f e r e n t t h a t you f e e l i s i n e f f e c t i v e . ' T r y t o e x p l a i n why your suggest ion i s b e t t e r than h i s ' . 2 .426 In making h e a l t h d e c i s i o n s , p r o f e s s i o n a l s ought to take the p a t i e n t ' s o p i n i on i n t o account . 9 -.391 Case 1. (as above) ' T r y t o persuade him t o g i ve i t a t r y . ' F a c t o r f i v e (Tab le V I I I below) i n c l u d e s items such as 17, 18 and 8 r e l a t i n g to d e a l i n g w i t h p a t i e n t behav io r t h a t i s a h inderance t o the ' p r o d u c t i v e ' use of the f a c i l i t y . The i n c l u s i o n o f i tem 21 c o n t r i b u t e s to the dimension t h a t i n v o l v e s n e g o t i a t i n g the u t i l i z a t i o n o f the c e n t r e . Th i s f a c t o r i s t h e r e f o r e l a b e l l e d , ' u t i l i z a t i o n of the c e n t r e ' . 54 Tab l e V I I I F a c t o r 5. U t i l i z a t i o n of the Cent re Item Loading 17 .786 Case 4. A p a t i e n t has appeared unmot ivated du r ing t r ea tment . He has r e fu sed c o u n s e l l i n g and o ther e f f o r t s to exp l o re the problem. ' D i s cha rge the p a t i e n t so t h a t the f a c i l i t y can be used more p r o d u c t i v e l y f o r someone e l s e ' . 18 .576 Case 4. (see above) ' Implement a s p e c i a l he lp program f o r the p a t i e n t . ' 8 .561 Case 1. A p a t i e n t suggests t h a t what you adv i sed was too much t r o u b l e . You d i s cu s s the reasons behind you r adv i ce and he s t i l l r e fu se s to comply. 'Go to t r e a t another p a t i e n t f e e l i n g t h a t o t h e r -w i se you are not u s i ng you r t ime p r o d u c t i v e l y . ' 21 -.415 When d i s c u s s i n g t reatment programmes w i t h p a t i e n t s p r o f e s s i o n a l s ought t o make the f i n a l d e c i s i o n about what the p a t i e n t shou ld do. F a c t o r s i x (Tab le IX below) c o n t a i n s i tem 5 which focuses the p r o f e s s i o n a l ' s a t t e n t i o n on p a t i e n t s r e f u s i n g t rea tment . F u r t h e r to t h i s , p r o f e s s i o n a l ' s 'accommodation ' ( i tem 11) or ' r e j e c t i o n ' ( i t em 12) of the p a t i e n t ' s cho i ce o f a l t e r n a t e t rea tment , and the e v a l u a t i o n i n i tem 25 o f whether p a t i e n t s should r e l y on t h e i r own judgment, tap the p r o f e s s i o n a l s ' p e r c e p t i o n o f t h e i r r o l e as an agent o f the p a t i e n t , as e i t h e r a complete advocate assuming f u l l r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s , o r as a p a r t i a l agent i n which the p a t i e n t assumes f u l l r e s p o n s i b i l i t y . 55 Tab le IX F a c t o r 6. Who should assume r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s Item Load ing 5 .748 P a t i e n t s shou ld not be a l l owed to r e fu se t rea tment . 11 -.498 Case 2 . A p a t i e n t suggests t h a t what you suggested was not necessary f o r h i s c o n d i t i o n and asks f o r something d i f f e r e n t t h a t you f e e l i s i n e f f e c t i v e . 'He lp him o b t a i n what he has r eque s t ed . ' 12 - .421- Case 2 . (see above) ' T e l l him he w i l l have to see someone e l s e to get what he has r e q u e s t e d . ' 25 .351 I t i s very important f o r p a t i e n t s to r e l y on t h e i r own judgment and make t h e i r own d e c i s i o n s about what p r o f e s s i o n a l s adv i s e . The emergence of these f a c t o r s f u r t h e r s the knowledge o f d i f f e r i n g dimen-s ions of the p r o f e s s i o n a l - p a t i e n t r o l e s . A l s o , i n d i c e s may be developed f o r each f a c t o r t o a l l o w i t s use as a measuring d e v i c e . A s c a l e was con s t r u c ted f o r each f a c t o r u s i ng the items which had ' l o a d e d ' on the f a c t o r . Respondents ' s co res on each i tem were then summed f o r each f a c t o r . The f a c t o r scores are arranged on a continuum c o n t a i n i n g oppo s i t e ends of the dimension r e f l e c t e d by the f a c t o r . As such, the mean w i t h i n each f a c t o r i s equal t o ze ro w i t h scores rang ing then t o the negat i ve and p o s i t i v e ends o f the cont inuum. The d i s t r i b u t i o n and range o f s c o r e s , however, d i f f e r between the f a c t o r s and are shown i n Tab le X below. 56 Tab le X D i f f e r e n c e s i n Range i n F a c t o r scores between f a c t o r s . F a c t o r Mean Min Max Range 1 0 -2.117 2.064 4.181 2 0 -1.985 1.658 3.644 3 0 -2.772 1.607 4.379 4 0 -1.778 1.597 3.375 5 0 -2.746 1.835 4.580 6 0 -3.011 1.635 4.646 W i t h i n each f a c t o r some p r o f e s s i o n a l s scored above and some scored below z e r o . The r e p r e s e n t a t i o n of p r o f e s s i o n a l s i n each h a l f o f the continuum though di f f e r s between f a c t o r s * . Though the f a c t o r s themselves are u n c o r r e l a t e d , they are p o t e n t i a l l y r e l a t e d to the o the r p r o f e s s i o n a l a t t r i b u t e s con s ide red i n t h i s s tudy: s p e c i a l t y , f a c i l i t y i n which l o c a t e d , age, l eng th o f exper ience a t the f a c i l i t y and a t t i t u d e t o a u t h o r i t y i n g e n e r a l . These r e l a t i o n s h i p s were assessed by the a p p r o p r i a t e s t a t i s t i c a l t e s t s of 2 a s s o c i a t i o n . Of p a r t i c u l a r i n t e r e s t from t h i s e x e r c i s e i s the f i n d i n g t h a t f a c t o r 1 shows no s i g n i f i c a n t r e l a t i o n to these o the r a t t r i b u t e s . 1 The k u r t o s i s and skewness va lues i n d i c a t i n g the shapes of the curves are l i s t e d and d i s cu s s ed i n Appendix 3. 2 The r e s u l t s and d i s c u s s i o n are presented i n Appendix 4 . 57 Thus, t h i s f a c t o r r e l a t i n g to the p r o f e s s i o n a l ' s p e r c e p t i o n o f the p a t i e n t as a team member, which as the f i r s t f a c t o r i s most r e p r e s e n t a t i v e o f the i n d e -pendent v a r i a b l e p r o f e s s i o n a l r o l e as measured through the q u e s t i o n n a i r e , i s a l s o r e p r e s e n t a t i v e of the p r o f e s s i o n a l s as a whole r ega rd l e s s o f d i f f e r e n c e s i n f a c i l i t y , s p e c i a l t y , age, l eng th of expe r i ence a t the f a c i l i t y , country of t r a i n i n g , o r a t t i t u d e t o a u t h o r i t y i n g e n e r a l . F i n a l l y , a check was made on the v a l i d i t y of the q u e s t i o n n a i r e measures of ' p r o f e s s i o n a l r o l e ' . T h i s t e s t was f e a s i b l e f o r the G.F. S t rong sample o n l y . The r o l e the p r o f e s s i o n a l assumed w i t h each o f the p a t i e n t r o l e s presented i n the i n t e r v i e w was s u b j e c t i v e l y measured by the i n t e r v i e w e r i n terms of whether the assumptions i m p l i c i t i n the p r o f e s s i o n a l ' s responses to each p a t i e n t case were c o r r e l a t e d w i t h the p r o f e s s i o n a l ' s responses to the q u e s t i o n n a i r e . Fo r the p r o f e s s i o n a l s ' responses t o the consumer i s t p a t i e n t t he re i s no c o r r e l a t i o n e v i den t between the i n t e r v i e w and q u e s t i o n n a i r e measures of o r i e n t a t i o n . F o r the dependent p a t i e n t , however, the p r o f e s s i o n a l ' s r o l e as measured by f a c t o r 1 does c o r r e l a t e s i g n i f i c a n t l y (P<.0001). The d i s t r i b u t i o n of response, to the p a t i e n t r o l e s presented i n the i n t e r v i e w i s shown i n F i g u r e 8 below. F i g u r e 8 P r o f e s s i o n a l Responses t o V a t i e n t Roles ' p resented i n the I n te r v i ew (G.F. St rong) | / / / 7 / / / / / / / / / / / / / / / / / / / / / / / K W A \ Cv| Consumer P a t i e n t Ro le 0 10 20 30 40 50 60 70 80 90 100 % y///// / / / /////•////;k\\\\\\\\\\\\ v w ^ x r Dependent P a t i e n t 0 10 20 30 40 50 60 70 80 90 100 % Ro le N=24* C o n t r o l l e r j ^ J Accommodator *These were the number o f responses a s c e r t a i n e d from a t o t a l o f 27 p r o f e s s i o n a l s i n t e r v i e w e d . 58 Whereas f o r the consumer i s t p a t i e n t 83% o f the p r o f e s s i o n a l s responded as c o n t r o l l e r s , on ly 58% of the p r o f e s s i o n a l s d i d so f o r the dependent p a t i e n t . Th i s i n d i c a t e s a g r ea te r degree o f c o n t r o l l i n g of the consumer i s t p a t i e n t not expected from the q u e s t i o n n a i r e responses. In a d d i t i o n to p r o f e s s i o n a l r o l e , o the r a t t r i b u t e s of the p r o f e s s i o n a l s t h a t were p o t e n t i a l l y r e l a t e d t o the v a r i ance i n p r o f e s s i o n a l ' s responses were i d e n t i f i e d . These were s e l e c t e d because 1) the sample c h a r a c t e r i s t i c s o f age, l e n g t h o f exper ience a t the f a c i l i t y and count ry of t r a i n i n g showed va r i ance amongst the p r o f e s s i o n a l s , 2) the sample had i n he ren t v a r i a n ce acros s s p e c i a l t i e s and f a c i l i t i e s , and 3) the c h a r a c t e r i s t i c o f a t t i t u d e to a u t h o r i t y i n general v a r i e d as a p e r s o n a l i t y t r a i t and had been shown by Haug and L a v i n (1981) t o be a s i g n i f i c a n t f a c t o r u n d e r l y i n g p r o f e s s i o n a l s ' accommodation o f p a t i e n t s ' c h a l l e n g i n g behav io r . Age and l eng th o f exper ience a t the f a c i l i t y were measured as numbers of y e a r s . Country o f t r a i n i n g , f a c i l i t y and s p e c i a l t y were measured as o r d i n a l s c a l e s i n c a t e g o r i e s as a p p r o p r i a t e . A t t i t u d e to a u t h o r i t y i n general was measured by e i g h t i tems appended to the q u e s t i o n n a i r e measuring p r o f e s s i o n a l r o l e . These items were developed and coded i n the same way as the o ther i tems i n the q u e s t i o n n a i r e . The accummulated score of the e i g h t i tems formed an i n t e r v a l s c a l e . The d i r e c t i o n o f i n f l u e n c e o f these a t t r i b u t e s was not p r e d i c t e d s i n ce they had not y e t been e m p i r i c a l l y t e s t e d i n t h i s way. 59 Thus, techn iques have been developed to measure both the independent and dependent v a r i a b l e s . F a c t o r 1, the p r o f e s s i o n a l ' s p e r c e p t i o n o f the p a t i e n t ' s r o l e as a team member, has emerged as the dimension of the independent v a r i a b l e p r o f e s s i o n a l r o l e r e p r e s e n t a t i v e o f 1) the p r o f e s s i o n a l s ' q u e s t i o n n a i r e responses , as w e l l as 2) the p r o f e s s i o n a l s as a group r e ga rd l e s s o f v a r i ance i n o the r a t t r i b u t e s . The r e l a t i o n of these v a r i a b l e s , p r e d i c t e d by the hypotheses, w i l l serve to assess the p r o f e s s i o n a l s ' response t o cha l l enge to the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . Other a t t r i b u t e s p o s s i b l y r e l a t i n g t o the p r o f e s s i o n a l ' s responses have a l s o been i d e n t i f i e d . The next chapte r assesses i f the v a r i a n ce i n the dependent v a r i a b l e s (how the p r o f e s s i o n a l e x p l a i n s , de s c r i be s and dea l s w i t h the p a t i e n t ' s behav io r ) i s dependent on the s p e c i f i c combinat ion o f the p r o f e s s i o n a l ' s r o l e (as c o n t r o l l e r o r accommodator), the p a t i e n t ' s r o l e (as consumer i s t o r dependent) and the d e c i s i o n content ( i n which the c i r cumstances focus a t t e n t i o n t o the r e s p o n s i b i l i t i e s o f the p r o f e s s i o n a l and p a t i e n t ) . 60 FINDINGS The hypothes i s developed f o r t h i s study p r e d i c t s t h a t the p r o f e s s i o n a l ' s response to the p a t i e n t ' s behav io r i s dependent on the s p e c i f i c i n t e r a c t i o n of p r o f e s s i o n a l r o l e and p a t i e n t r o l e . Th i s hypothes i s evo l ved from the r e s u l t s o f o ther s t u d i e s p e r t a i n i n g to the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p , as w e l l as from views put fo rward i n the l i t e r a t u r e . These i n d i c a t e d a range o f j ;• i n t e r a c t i o n s between the p r o f e s s i o n a l and p a t i e n t , w i t h the p r o f e s s i o n a l assuming the r o l e o f e i t h e r ' c o n t r o l l e r ' or ' accommodator ' , and the p a t i e n t , the r o l e o f e i t h e r ' c o n s u m e r i s t ' , o r ' d ependen t ' . I t has been p r e d i c t e d t h a t how the p r o f e s s i o n a l e x p l a i n s , de s c r i be s and dea l s w i t h the p a t i e n t ' s behav io r i s dependent on the v a r i ou s i n t e r a c t i o n s o f these r o l e s . F i g u r e 9 repeats an e a r l i e r F i g u r e 3 t o show the range o f i n t e r a c t i o n modes. F i g u r e 9 Modes o f I n t e r a c t i o n Between the P r o f e s s i o n a l and the P a t i e n t P r o f e s s i o n a l O r i e n t a t i o n c o n t r o l l e r accommodator C o n f l i c t o f Terms Congruence of Terms Consumeri s t Asymmetry unaccepted by the p r o f e s s i o n a l or p a t i e n t Asymmetry L e g i t i m a t e P a t i e n t Dominant P a t i e n t O r i e n t a t i o n Congruence o f Terms C o n f l i c t o f Terms Dependent Asymmetry L e g i t i m a t e P r o f e s s i o n a l Domi nant Asymmetry unaccepted by the p r o f e s s i o n a l o r p a t i e n t 61 P r o f e s s i o n a l r o l e and p a t i e n t r o l e are the independent v a r i a b l e s , and the p r o f e s s i o n a l ' s responses t o the p a t i e n t ' s behav io r are the dependent v a r i a b l e s . In a d d i t i o n , the p r o f e s s i o n a l ' s e v a l u a t i o n o f the i m p l i c a t i o n s o f the p a t i e n t ' s behav i o r , on the e f f e c t i v e n e s s of r e h a b i l i t a t i o n , was con s i de red i n o rder to a s s i s t i n i n t e r p r e t i n g the f i n d i n g s . Thus f a r , each o f these v a r i a b l e s has been measured, as de s c r i bed i n the l a s t c hap te r . Th i s chapte r now assesses whether the f i n d i n g s of t h i s study support or r e j e c t the h ypo the s i s . The f i n d i n g s w i l l be assessed i n a number o f ways. F i r s t , f o r the dependent v a r i a b l e s , the p a t t e r n s o f the p r o f e s s i o n a l s ' responses i n each category of ' e x p l a i n i n g ' , ' d e s c r i b i n g ' , and ' d e a l i n g ' , as w e l l as w i t h ' i m p l i -c a t i o n s ' , w i l l be de sc r i bed i n two ways: 1) f o r each of the p a t i e n t r o l e s , by the number o f the p r o f e s s i o n a l s responding as ' c o n t r o l l e r ' and 'accommodator ' r e s p e c t i v e l y ; and, 2) f o r each o f the p r o f e s s i o n a l r o l e s , by the v a r i a t i o n of the p r o f e s s i o n a l s ' r o l e ac ros s the p a t i e n t r o l e s . Second, the s p e c i f i c hypo-t h e s i s w i l l be t e s t e d to determine i f the va r i ance i n the p r o f e s s i o n a l s ' responses i s accounted f o r by the i n t e r a c t i o n between the p r o f e s s i o n a l r o l e and p a t i e n t r o l e . And, l a s t , the e f f e c t o f the o the r independent v a r i a b l e s — f a c i l i t y , s p e c i a l t y , age, l eng th o f exper ience a t the f a c i l i t y , country of t r a i n i n g , and a t t i t u d e t o a u t h o r i t y i n general — w i l l be a s ses sed. F i r s t , however, we s t a r t w i t h the p a t t e r n o f responses of the dependent v a r i a b l e s . 62 P a t t e r n o f Responses: Dependent V a r i a b l e s  E x p l a i n i n g the p a t i e n t s ' behav i o r . Th i s dimension assessed the p r o f e s s i o n a l ' s p e r c e p t i o n o f the p a t i e n t ' s behav i o r as e i t h e r an a t t r i b u t e o f the p a t i e n t , when c o n s i s t e n t w i t h the t r a d i -t i o n a l v iew, o r as a c o n f l i c t o f terms, when c o n s i s t e n t w i t h the c h a l l e n g i n g v iew. The consumer i s t p a t i e n t ' s behav io r was e x p l a i n e d as a p a t i e n t a t t r i b u t e by 69% o f a l l respondents and as a c o n f l i c t o f terms by 31%, G.F. S t rong and Holy Fam i l y H o s p i t a l s combined. The dependent p a t i e n t ' s behav io r was e xp l a i ned as a p a t i e n t a t t r i b u t e by 85% o f a l l respondents and as a c o n f l i c t o f terms by 15%. These f i n d i n g s a re presented i n F i g u r e 10. F i g u r e 10 E x p l a i n i n g the P a t i e n t ' s Behav io r : P a t t e r n o f Responses, G.F. S t r ong and Holy Fami l y H o s p i t a l s combined. E x p l a i n i n g the Consumer i s t P a t i e n t ' s Behav io r 69 CmbA™* V/(IW</HA/ ^ ^ ^ ^ ^ ^ F a c i l i t i e s 0 10 20 30 40 50 60 70 80 90 100 N=39* % E x p l a i n i n g the Dependent P a t i e n t ' s Behav io r 85 Y77\ " p a t i e n t a t t r i b u t e " | ^ X f " c o n f l i c t o f te rms " * These were the number of responses a s c e r t a i n e d from the t o t a l number of p r o f e s s i o n a l s i n t e r v i e w e d , 39. T h i s l eave s 6 from the o r i g i n a l sample t h a t were not i n t e r v i e w e d . T h e i r q u e s t i o n n a i r e answers, however, c o n t r i b u t e d to the c a l c u l a t i o n of F a c t o r S co re s , p resented i n the next s e c t i o n . 63 Comparison across p a t i e n t r o l e i n d i c a t e d a tendency by both p r o f e s s i o n a l r o l e s to e x p l a i n the p a t i e n t ' s behav io r as a p a t i e n t a t t r i b u t e r a t h e r than as a c o n f l i c t of te rms, w i t h t h i s o c c u r r i n g more f r e q u e n t l y w i t h the dependent p a t i e n t . D e s c r i b i n g the P a t i e n t ' s Behav io r Th i s dimension assessed the p r o f e s s i o n a l ' s responses , c o n s i s t e n t w i t h t h e i r e x p e c t a t i o n s o f the p a t i e n t ' s r o l e . The behav io r o f the consumer i s t p a t i e n t was de s c r i bed as ' good ' by 27% o f a l l respondents and as ' d i f f i c u l t ' by 73%. The behav io r of the dependent p a t i e n t was de s c r i bed as ' good ' by 36% o f a l l respon-dents and as ' d i f f i c u l t ' by 64%. These f i n d i n g s are presented i n F i g u r e 11 . F i g u r e 11 ALL ALL D e s c r i b i n g the P a t i e n t ' s Behav io r : P a t t e r n of Responses, G.F . S t rong and Holy Fami l y H o s p i t a l s Combined D e s c r i b i n g the Consumer i s t P a t i e n t ' s Behav io r 0 10 20 30 40 50 60 70 80 90 100 % D e s c r i b i n g the Dependent P a t i e n t ' s Behav io r 36 ^ 0 10 20 30 40 50 60 70 8(3 90 100 % N=22^ N=36' E3 "good" £23 " d i f f i c u l t " * These were the number o f responses a s c e r t a i n e d from the t o t a l number i n t e r v i e w e d , 39. 64 Comparison acros s p a t i e n t r o l e i n d i c a t e d a tendency to de s c r i be both p a t i e n t s ' behav io r as ' d i f f i c u l t ! though the d e s c r i p t i o n of ' g ood ' was more f requent f o r the dependent p a t i e n t . D e a l i n g w i t h the P a t i e n t ' s Behav io r Th i s dimension assessed the p r o f e s s i o n a l ' s responses , c o n s i s t e n t w i t h t h e i r e xpec t a t i on s o f the p r o f e s s i o n a l ' s r o l e . T h i s v a r i a b l e , measured on ly a t G.F. S t rong i n d i c a t e d t h a t 40% ' c o n t r o l l e d ' o r ' r e j e c t e d ' the consumer i s t p a t i e n t ' s behav i o r , w h i l e 60% accommodated i t . F o r the dependent behav i o r , 55% ' c o n t r o l l e d ' and 45% ' i n s p i r e d ' the p a t i e n t . These f i n d i n g s are p resented i n F i g u r e 12. F i g u r e 12 D e a l i n g w i t h the P a t i e n t ' s Behav io r : P a t t e r n o f Responses, G.F. S t rong D e a l i n g w i t h the consumer i s t p a t i e n t ' s behav io r N=25* % Dea l i n g w i t h the dependent p a t i e n t ' s behav io r G.F. S t rong \ / / / / / / / / y / / / / / / / / N = 2 4 * 0 10 20 30 40 50 60 70 80 90 100 % 23 " C o n t r o l " or " R e j e c t " "Accommodate" or " i nspi re" * These are the number o f responses a s c e r t a i n e d from the t o t a l number i n t e r v i e w e d , 39. 65 Comparison ac ro s s p a t i e n t r o l e i n d i c a t e d a f a i r l y even d i v i s i o n (between 40% and 60%) between ' c o n t r o l l i n g ' and 'accommodating ' responses. However, the percentage o f ' c o n t r o l ' s h i f t e d from 40% f o r the consumer p a t i e n t , t o 55%, f o r the dependent p a t i e n t . I m p l i c a t i o n s o f the P a t i e n t ' s Behav io r Th i s d imension assessed the p r o f e s s i o n a l ' s p e r cep t i on s o f the i m p l i c a t i o n s of the p a t i e n t ' s behav io r f o r the e f f e c t i v e n e s s o f r e h a b i l i t a t i o n . And, i n t h i s c o n t e x t , i f r e h a b i l i t a t i o n was f e l t to be i n e f f e c t i v e , the p r o f e s s i o n a l suggested whether the o r g a n i z a t i o n o f s e r v i c e s or the p a t i e n t was the main d i s -r u p t i v e f a c t o r . (Th i s dimension was measured a t G.F . S t rong on l y . ) Four c a t e -g o r i e s o f responses r e f l e c t e d the p r o f e s s i o n a l s ' e v a l u a t i o n o f the i m p l i c a t i o n s : 1) The e f f e c t i v e n e s s o f r e h a b i l i t a t i o n was not ques t ioned (no f r u s t r a t i o n o r s a t i s f a c t i o n expres sed ) ; 2) R e h a b i l i t a t i o n was f e l t t o be e f f e c t i v e ; 3) R e h a b i l i t a t i o n was f e l t t o be i n e f f e c t i v e and the p a t i e n t was blamed; and 4) R e h a b i l i t a t i o n was f e l t t o be i n e f f e c t i v e and the o r g a n i z a t i o n o f s e r v i c e s was blamed. The v a r i a n c e o f responses i s i n d i c a t e d i n F i g u r e 13 below. 66 F i g u r e 13 E v a l u a t i n g the I m p l i c a t i o n s of the P a t i e n t ' s Behav io r f o r the E f f e c t i v e n e s s of R e h a b i l i t a t i o n : P a t t e r n o f Responses, G.F. S t rong I m p l i c a t i o n s o f the Consumer i s t P a t i e n t ' s Behav ior G.F. S t rong |////////777 TO 20 30 f f l N=26^ % I m p l i c a t i o n s o f the Dependent P a t i e n t ' s Behav io r G.F. S t rong \////////////} / ///////////J^ 1 1 1 1 1 1 N = 2 4 * n i n o n o n /in c o cn -»n o n nt\ 1 nff oi 0 10 20 30 40 50 60 70 80 90 100 % REHABILITATION FELT INEFFECTIVE PATIENT BLAMED YZk REHABILITATION NOT QUESTIONED PTTT| REHABILITATION FELT EFFECTIVE * Number o f responses a s c e r t a i n e d from t o t a l number i n t e r v i e w e d , 39 . REHABILITATION FELT INEFFECTIVE ORGANIZATION OF SERVICES BLAMED Fo r the consumer i s t p a t i e n t , on l y one respondent ques t i oned the i n f l u e n c e o f the r e h a b i l i t a t i o n s e t t i n g . Of the remain ing 97% who d i d not que s t i on the system, 35% f e l t the system cou l d handle the cha l l enge and remain e f f e c t i v e , and about 29% f e l t r e h a b i l i t a t i o n was be ing i n e f f e c t i v e and expressed f r u s t r a t i o n w i t h the p a t i e n t . That l e f t 33% who n e i t h e r ques t ioned the s e t t i n g nor expressed s a t i s f a c t i o n o r f r u s t r a t i o n . Of the remain ing responses to the dependent p a t i e n t , 6% f e l t r e h a b i l i t a t i o n to be e f f e c t i v e , 11% f e l t r e h a b i l i t a -t i o n t o be i n e f f e c t i v e , w i t h the blame on the p a t i e n t , and 9% f e l t r e h a b i l i t a -t i o n to be i n e f f e c t i v e , w i t h the blame on the o r g a n i z a t i o n o f s e r v i c e s . Comparison across p a t i e n t r o l e s ( consumer i s t t o dependent), draws a t t e n t i o n t o the dramat ic l eap from 33% t o 74% o f p r o f e s s i o n a l s who n e i t h e r ques t ioned the r e h a b i l i t a t i o n system nor expressed s a t i s f a c t i o n or f r u s t r a t i o n . 67 Summary The p a t t e r n of responses i n a l l dimensions may be summarized i n two ways: 1) In each category o f responses f o r each p a t i e n t r o l e , t he re was va r i ance i n responses across p r o f e s s i o n a l r o l e s . The l e a s t amount of v a r i a n c e , o v e r a l l , was i n d i c a t e d i n , ' e x p l a i n i n g the p a t i e n t ' s b e h a v i o r ' , i n which case the behav i o r was most o f t e n e x p l a i n e d as a p a t i e n t a t t r i b u t e . 2) In each category o f response, v a r i ance i n responses d i f f e r e d between the p a t i e n t r o l e s . The dependent p a t i e n t ' s behav io r was more o f t e n e xp l a i ned as a p a t i e n t a t t r i b u t e , de s c r i bed as ' g o o d ' , and d e a l t w i t h by ' c o n t r o l l i n g ' . The g r e a t e s t amount o f v a r i ance between p a t i e n t r o l e s was i n d i c a t e d i n the dimension o f i m p l i c a t i o n s . In the case o f the dependent p a t i e n t , 74% o f p r o f e s s i o n a l s d i d not ques t i on the system. In the case o f consumer i s t p a t i e n t , 33% d i d not , a d i f f e r e n c e o f 41%. Hypothes i s T e s t i n g The hypothes i s p r e d i c t e d the s imultaneous e f f e c t s of p r o f e s s i o n a l and p a t i e n t r o l e on the p r o f e s s i o n a l ' s response t o the p a t i e n t ' s behav i o r . The range of i n t e r a c t i o n s between the r o l e s has aga in been de s c r i bed i n F i g u r e 9 a t the beg inn ing o f t h i s c h a p t e r . In t h i s s e c t i o n the i n t e r a c t i o n s are f u r t h e r de f i ned f o r use w i t h each o f the c a t e g o r i e s o f responses , to he lp p re sent the way i n which the p r o f e s s i o a n l s e x p l a i n e d , d e s c r i b e d , and- d e a l t w i t h the p a t i e n t ' s behav i o r s . As seen from the case s t u d i e s , v a r i ance occur red i n the p r o f e s s i o n a l ' s responses to the p a t i e n t s ' behav i o r . Va r i ou s t e chn i que s , t hen , were s e l e c t e d to examine what might account f o r t h i s v a r i a n c e . Two-way a n a l y s i s o f v a r i ance (ANOVA) was chosen as the most r i g i d measure of the h ypo the s i s . A d d i t i o n a l 68 t e s t s were a l s o done to measure the i n f l u e n c e of the o ther independent v a r i a b l e s on the v a r i ance o f responses to each of the p a t i e n t r o l e s . The e f f e c t of f a c i l i t y and s p e c i a l t y were measured by one-way a n a l y s i s of v a r i a n c e . The e f f e c t s of age, l eng th of expe r i ence a t the f a c i l i t y , country o f t r a i n i n g , and a t t i t u d e to a u t h o r i t y i n general were measured by p a r t i a l c o r r e l a t i o n s . T h i s l a t t e r techn ique p r o v i de s a s i n g l e measure o f a s s o c i a t i o n d e s c r i b i n g the r e l a t i o n s h i p between two v a r i a b l e s w h i l e a d j u s t i n g f o r the e f f e c t s o f one or more a d d i t i o n a l v a r i a b l e s . E x p l a i n i n g the P a t i e n t ' s Behav io r The hypothes i s p r e d i c t s t h a t how the p r o f e s s i o n a l e x p l a i n s the p a t i e n t ' s behav io r i s dependent on the s p e c i f i c combinat ion o f p r o f e s s i o n a l r o l e and p a t i e n t r o l e , as d e p i c t e d i n the f i g u r e below. P r o f e s s i o n a l Ro le C o n t r o l 1 e r Accommodator Consumer i s t PATIENT ROLE Dependent P a t i e n t a t t r i b u t e c o n f l i c t of terms P a t i e n t a t t r i b u t e c o n f l i c t of terms F i g u r e 14. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and e x p l a i n i n g the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d . Two-way ANOVA was observed f o r each f a c t o r w i t h repeated measures f o r reponse to p a t i e n t case . I t f a i l e d to show s i g n i f i c a n t i n t e r a c t i o n between p r o f e s s i o n a l and p a t i e n t r o l e to account f o r the ways i n which the p r o f e s s i o n a l s e xp l a i ned the p a t i e n t ' s behav i o r . For a l l f a c t o r s , however, the scores f o r responses to the dependent p a t i e n t 69 were lower than those to the consumer i s t p a t i e n t . In each case the p r o b a b i l i t y l e v e l was between 0.1 and 0.2 and approached 0.1 f o r f a c t o r s 1,2,3 and 6. The next step i n the a n a l y s i s was to measure the e f f e c t s of the other p r o -f e s s i o n a l a t t r i b u t e s . P a r t i a l c o r r e l a t i o n s were assessed f o r age, number o f yea r s o f exper ience a t the f a c i l i t y , a t t i t u d e t o a u t h o r i t y i n g e n e r a l , country o f t r a i n i n g . One-way ANOVA was done f o r s p e c i a l t y and f a c i l i t y . Those measures of these r e l a t i o n s h i p s t h a t are s i g n i f i c a n t are presented where r e l e v a n t to the d i s c u s s i o n . F a c t o r 6 and country of t r a i n i n g accounted f o r some the v a r i a n ce i n how the p r o f e s s i o n a l e x p l a i n e d the consumer i s t p a t i e n t ' s behav i o r . Both o f these r e l a t i o n a h i p s , though, were s u b j e c t t o m o d i f i c a t i o n through the i n f l u e n c e of the o the r v a r i a b l e s . Tab le XI p re sent s the range of s t rengh t s o f the r e l a t i o n s h i p s when the i n f l u e n c e o f the o the r v a r i a b l e s i s c on s i de red . 70 Tab le XI E x p l a i n i n g the consumer i s t p a t i e n t ' s behav io r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r f a c t o r 6 and country o f t r a i n i n g w i t h c o n t r o l f o r o the r v a r i a b l e s . R e l a t i o n s h i p w i t h ' E x p l a i n i n g ' F a c t o r 6 Country o f T r a i n i n g Z e r o - o r d e r -.2539 .3243 P-.l p<.05 Age -.2547 .3076 P-.l p<.07 No. y r s . a t f a c i l i t y - .2595 .3348 P-.l p<.05 A t t i t u d e t o A u t h o r i t y -.2883 .3363 p<.005 p<.05 Country o f T r a i n i n g -.2805 n/a D<.09 S p e c i a l t y -.3172 .3031 p=.05 p=.06 A l l -.3910 .2744 p<.05 P-.l Whereas f a c t o r 6 shows an i n s i g n i f i c a n t r e l a t i o n s h i p i n i t i a l l y , i t becomes s t ronge r when the i n f l u e n c e o f the o the r v a r i a b l e s , i n p a r t i c u l a r the va r i ance i n a t t i t u d e t o a u t h o r i t y , i s c o n t r o l l e d . Country of t r a i n i n g , on the o the r hand, has a s t r onge r r e l a t i o n s h i p i n i t i a l l y (p<.05), but subsequent ly d im i n -i shes when the s imultaneous i n f l u e n c e o f the o the r v a r i a b l e s i s c o n t r o l l e d . Some of the v a r i a n c e i n how the p r o f e s s i o n a l e x p l a i n s the dependent p a t i e n t ' s behav io r i s accounted f o r by the age of the p r o f e s s i o n a l and the p ro -f e s s i o n a l ' s a t t i t u d e t o a u t h o r i t y i n g e n e r a l . Tab le X I I p resent s the range of s t r e n g t h o f these r e l a t i o n s h i p s dependent on the i n f l u e n c e o f the o the r v a r i a b l e s . 1 F a c t o r 6 and Country o f T r a i n i n g were measured on an i n t e r v a l s c a l e f o r t h i s t e s t . Tab le XI I E x p l a i n i n g the dependent p a t i e n t ' s behav io r : P a r t i a l C o r r e l a t i o n C o - e f f i c i e n t s f o r age and a t t i t u d e t o a u t h o r i t y i n general w i t h c o n t r o l f o r o ther v a r i a b l e s . R e l a t i o n s h i p w i t h ' e x p l a i n i n g ' Age A t t i t u d e Ze ro -o rde r -.3555 -.2344 p<.05 p=.15 Age n/a -.4391 p<.01 No. y r s . a t f a c i l i t y -.3095 -.3322 p=.07 p<.05 A t t i t u d e -.5038 n/a p<.005 Country of t r a i n i n g -.2596 -.2718 P=.l p<.l S p e c i a l t y - -.3862 -.2547 p<.05 P=.l A l l - .4783 -.4666 p<.01 p<.01 Fo r both age and a t t i t u d e t o a u t h o r i t y i n g e n e r a l , the s t r eng th o f the r e l a t i o n s h i p ranges from P<.01, when i n f l u e n c e from a l l o the r v a r i a b l e s i s s imu la taneous l y c o n t r o l l e d , t o P=.l o r ove r , f o r the independent i n f l u e n c e o f another v a r i a b l e . In sum, f o r the dimension of e x p l a i n i n g the p a t i e n t ' s behav i o r , the f i n d i n g s do not support the hypothes i s t h a t how the p r o f e s s i o n a l e x p l a i n s the p a t i e n t ' s behav io r i s dependent on the i n t e r a c t i o n between p r o f e s s i o n a l r o l e and p a t i e n t r o l e . There was an e f f e c t o f p a t i e n t r o l e i n d i c a t e d , however, i n t h a t the dependent p a t i e n t ' s behav io r was more o f t en de s c r i bed as a p a t i e n t a t t r i -bute . As w e l l , o the r v a r i a b l e s emerged through p a r t i a l c o r r e l a t i o n s to suggest s i g n i f i c a n t r e l a t i o n s h i p s t o e x p l a i n i n g the p a t i e n t ' s behav io r . 72 D e s c r i b i n g the P a t i e n t ' s Behav io r The hypothes i s p r e d i c t s t h a t the p r o f e s s i o n a l w i l l d e s c r i be the p a t i e n t ' s behav io r as i n d i c a t e d i n the f i g u r e below. P r o f e s s i o n a l Ro le C o n t r o l l e r Accommodator Consumer i s t d i f f i c u l t good P a t i e n t Ro le Dependent good d i f f i c u l t F i g u r e 15. How P r o f e s s i o n a l r o l e , P a t i e n t r o l e and d e s c r i b i n g the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d . Two-way ANOVA showed s i g n i f i c a n t i n t e r a c t i o n e f f e c t s between p r o f e s s i o n a l r o l e as r e f l e c t e d i n f a c t o r 1 ( t he p r o f e s s i o n a l ' s p e r c e p t i o n o f the p a t i e n t ' s r o l e as a team member) and the p a t i e n t ' s r o l e as e i t h e r consumer i s t or depen-dent. Th i s i n d i c a t e s t h a t the combinat ion o f these two v a r i a b l e s un ique ly accounts f o r the v a r i ance i n how the p r o f e s s i o n a l de s c r i be s the p a t i e n t ' s behav io r . Tab le X I I I p re sent s these f i n d i n g s . 73 Tab le X I I I D e s c r i b i n g the p a t i e n t ' s behav io r : 2-way ANOVA between F a c t o r 1* and P a t i e n t case s tudy. P a t i e n t Case Study (B) Consumer i s t Dependent F a c t o r 1 (A) C o n t r o l l e r 1.83 1.17 Accommodator 1.63 1.50 E f f e c t AB P<.01 A P<.4 B P<.05 *The p a t i e n t ' s r o l e as a team member. As w e l l , the e f f e c t o f p a t i e n t case i s s i g n i f i c a n t (P<.05). In both l e v e l s o f f a c t o r 1 the responses to the consumer i s t p a t i e n t were more towards ' d i f f i c u l t ' than f o r the dependent p a t i e n t . The presence o f an i n t e r a c t i o n e f f e c t , though, s i g n a l s t h a t the d i f f e r e n c e s between the cases are more accu -r a t e l y q u a l i f i e d by s p e c i f y i n g the o r i e n t a t i o n of p r o f e s s i o n a l r o l e . By doing t h i s , one can see t h a t the d i f f e r i n g o r i e n t a t i o n s to the p a t i e n t ' s r o l e as a team member a l t e r s the magnitude of the d i f f e r e n c e s between the responses to the case s t u d i e s . As the p e r s p e c t i v e o f the p r o f e s s i o n a l d i f f e r s from c o n t r o l l i n g to accommodating, t he re i s a s h i f t i n how the p a t i e n t ' s behav io r i s d e s c r i b e d ; the consumer i s t p a t i e n t from ' d i f f i c u l t ' to ' good ' and, f o r the dependent p a t i e n t , from ' g ood ' t o ' d i f f i c u l t ' . The 2-way ANOVA r e s u l t s f o r f a c t o r s 2 to 6 were i n s i g n i f i c a n t . However the e f f e c t o f case study c o n s i s t e n t l y shows a s i g n i f i c a n c e l e v e l between .1 and .2 . P a r t i a l c o r r e l a t i o n s i n d i c a t e d t h a t number o f yea r s a t the f a c i l i t y was an a d d i t i o n a l v a r i a b l e t h a t n e g a t i v e l y r e l a t e d t o how the p r o f e s s i o n a l de s c r i be s the dependent p a t i e n t ' s behav io r . Tab l e XIV presents these f i g u r e s . 74 Tab le XIV D e s c r i b i n g the dependent p a t i e n t ' s behav io r : P a r t i a l C o r r e l a t i o n s C o - e f f i c i e n t s f o r number o f yea r s a t the f a c i l i t y c o n t r o l l i n g f o r the i n f l u e n c e of o the r v a r i a b l e s . R e l a t i o n s h i p w i t h ' D e s c r i b i n g ' No. o f yea r s a t the f a c i l i t y Zero -Order -.4716 p<.005 No. Y r s . a t the F a c i l i t y Age -.3015 p<.l n/a A t t i t u d e to A u t h o r i t y -.4727 p<.005 Country o f T r a i n i n g -.4015 p<.02 S p e c i a l t y -.4604 p<.005 A l l -.2786 Though t h i s v a r i a b l e had a s i g n i f i c a n t z e r o - o r d e r c o r r e l a t i o n , i t approached a p r o b a b i l i t y l e v e l of P<.1 when a l l o the r v a r i a b l e s are he ld c on s t an t . In p a r t i c u l a r , age has t h i s e f f e c t on the s t r eng th of number o f yea r s a t the f a c i l i t y . In sum, f o r the dimension o f d e s c r i b i n g the p a t i e n t ' s behav i o r , the f i n d i n g s support the hypothes i s t h a t how the p r o f e s s i o n a l de s c r i be s the p a t i e n t ' s behav io r i s dependent on the i n t e r a c t i o n between p r o f e s s i o n a l r o l e and p a t i e n t r o l e . Thus the p r o f e s s i o n a l who b e l i e v e s t h a t p a t i e n t s should not be granted access to medica l records and ' t eam ' meetings i s l i k e l y t o de s c r i be the consumer i s t p a t i e n t as ' d i f f i c u l t ' and the dependent p a t i e n t as ' g o o d ' . Conve r se l y , the p r o f e s s i o n a l who b e l i e v e s p a t i e n t s should have access to ' t eam ' i n f o r m a t i o n de s c r i bed the consumer i s t p a t i e n t as ' good ' and the dependent p a t i e n t as ' d i f f i c u l t ' . 75 Length of expe r i ence a t the f a c i l i t y emerged through p a r t i a l c o r r e l a t i o n s to suggest a f u r t h e r s i g n i f i c a n t r e l a t i o n s h i p to d e s c r i b i n g the dependent p a t i e n t ' s behav io r . As the number o f y ea r s a t the f a c i l i t y i n c r e a s e d , the p r o f e s s i o n a l was more l i k e l y t o de s c r i be the dependent p a t i e n t ' s behav io r as ' g o o d ' . D e a l i n g w i t h the P a t i e n t ' s Behav io r The hypothes i s p r e d i c t s t h a t the p r o f e s s i o n a l w i l l deal w i t h the p a t i e n t ' s behav io r as d e f i n e d i n the f o l l o w i n g c h a r t . P r o f e s s i o n a l Ro le C o n t r o l l e r Accommodator c o n t r o l o r accommodate Consumer ist r e j e c t P a t i e n t Ro le Dependent c o n t r o l i n s p i r e F i g u r e 16. How p r o f e s s i o n a l r o l e , p a t i e n t r o l e and d e a l i n g w i t h the p a t i e n t ' s behav io r are p r e d i c t e d to be r e l a t e d . Two-way ANOVA showed s i g n i f i c a n t e f f e c t s on the response ' d e a l i n g ' , due t o p r o f e s s i o n a l r o l e o r i e n t a t i o n r e f l e c t e d i n f a c t o r 1 (P<.05). Though not s i g n i f i c a n t below the .05 l e v e l , an i n t e r a c t i o n e f f e c t (P<.07) was p resent and w i l l c o n t r i b u t e to the d i s c u s s i o n . Tab le XV p re sent s the f i g u r e s f o r two-way ANOVA. 76 Tab le XV D e a l i n g w i t h the p a t i e n t ' s behav io r : 2-way ANOVA between F a c t o r 1* and P a t i e n t Case Study P a t i e n t Case Study (B) Consumerist Dependent F a c t o r 1 (A) C o n t r o l l e r 1.46 1.18 Accommodator 2.00 1.71 E f f e c t AB P<.07 A P<.05 B P=.70 * F a c t o r 1. The P a t i e n t ' s Ro le as a Team Member. The s h i f t i n the p r o f e s s i o n a l ' s p e r s p e c t i v e of the p a t i e n t ' s r o l e as a team member (from c o n t r o l l e r t o accommodator) i s towards an accommodator of the consumer i s t p a t i e n t and i n s p i r e r o f the dependent p a t i e n t . The s t r eng th of the i n t e r a c t i o n e f f e c t ( i n d i c a t e d by two-way ANOVA) suggests c o n s i d e r a t i o n o f the p r o f e s s i o n a l ' s r o l e w i t h the combined e f f e c t o f the p a t i e n t ' s r o l e , as presented i n the case s tudy. Though the ac tua l range o f responses between f a c t o r l e v e l s i s c o n s i s t e n t over both ca se s , the responses t o the consumer i s t p a t i e n t are h i ghe r o v e r a l l , when compared w i t h those o f the dependent p a t i e n t . The 2-way ANOVA r e s u l t s f o r f a c t o r s 2 t o 6 were i n s i g n i f i c a n t . However, nega t i ve c o r r e l a t i o n s were s i g n i f i c a n t f o r country of t r a i n i n g . Tab le XVI p re sent s the ac tua l f i g u r e s . 77 Tab le XVI D e a l i n g w i t h the Dependent P a t i e n t ' s Behav io r : P a r t i a l c o r r e l a t i o n C o - e f f i c i e n t s f o r country o f t r a i n i n g . R e l a t i o n s h i p w i t h Country o f ' d e a l i n g ' T r a i n i n g Ze ro - o rde r -.4689 p<.05 Age -.3885" p<.07 Mo. y r s . a t F a c i l i t y -.5291 p<.01 A t t i t u d e -.4775 p<.05 Country o f T r a i n i n g n/a S p e c i a l t y -.4461 p<.05 A l l -.4537 p<.05 Country of t r a i n i n g c o r r e l a t e d n e g a t i v e l y and remained s i g n i f i c a n t when o the r v a r i a b l e s were c o n t r o l l e d , though the s t r eng th of the r e l a t i o n s h i p dminished somewhat (P<.07) when the i n f l u e n c e of age was he l d c on s t an t . In sum, f o r the dimension of d e a l i n g w i t h the p a t i e n t ' s behav i o r , the f i n d i n g s suppor t , i n p a r t , the hypothes i s t h a t how the p r o f e s s i o n a l dea l s w i t h the p a t i e n t ' s behav io r i s dependent on the i n t e r a c t i o n between p r o f e s s i o n a l r o l e and p a t i e n t r o l e . Thus, the p r o f e s s i o n a l who b e l i e v e s t h a t p a t i e n t s should not be g ranted access to medica l records and ' t eam ' meetings i s l i k e l y to ' c o n t r o l ' both the consumer i s t and dependent p a t i e n t . Conve r se l y , the p r o f e s s i o n a l who b e l i e v e s p a t i e n t s should have access to ' t e am ' i n f o r m a t i o n i s l i k e l y to accom-modate the consumer i s t p a t i e n t ' s behav io r and i n s p i r e the dependent p a t i e n t ' s 78 behav io r . Country o f t r a i n i n g emerged through p a r t i a l c o r r e l a t i o n s to i n d i c a t e a s i g n i f i c a n t r e l a t i o n s h i p w i t h ' d e a l i n g w i t h the dependent p a t i e n t ' s b e h a v i o r 1 . Those who have had some or a l l of t h e i r t r a i n i n g ou t s i de Canada were more l i k e l y to ' c o n t r o l ' the dependent p a t i e n t ' s behav i o r . Summary of F i nd i n g s Th i s chapte r has 1) p resented the p a t t e r n s of the p r o f e s s i o n a l s ' responses to p a t i e n t behav io r and 2) assessed whether the f i n d i n g s have supported or r e f u t e d the h ypo the s i s . As the s p e c i f i c f i n d i n g s have been summarized a t the end o f each s e c t i o n , they w i l l not be repeated he re . G e n e r a l l y , however, f o r the dimensions o f ' d e s c r i b i n g ' and ' d e a l i n g ' w i t h the p a t i e n t ' s behav i o r , the hypothes i s has been supported. On the o the r hand, f o r the dimension o f e x p l a i n i n g , the hypothes i s has not been supported. With r e spec t to these d imens ions , o t he r v a r i a b l e s have emerged (age, country o f t r a i n i n g , e t c . ) which r e l a t e t o them, but the e x t en t of the i n f l u e n c e o f these v a r i a b l e s i s not y e t e s t a b l i s h e d . And, i n the l i g h t of the o the r f i n d i n g s t h e i r s i g n i f i c a n c e i s d im in i s hed . The Study has i n d i c a t e d t h a t the p r o f e s s i o n a l s ' response to p a t i e n t behav io r i s s y s t e m a t i c a l l y determined from the i n t e r a c t i o n o f p r o f e s s i o n a l r o l e and p a t i e n t r o l e . The next chap te r w i l l examine t h i s premise t o c on s i de r i f i t o f f e r s p r e l i m i n a r y ev idence o f a l a g between s o c i e t a l t rends and p r o f e s s i o n a l response. 79 DISCUSSION The p r e l im i na r y evidence from t h i s study i n d i c a t e s t h a t the p r o f e s s i o n a l ' s response to p a t i e n t behavior i s s y s t e m a t i c a l l y r e l a t e d to the i n t e r a c t i o n between p ro fe s s i ona l r o l e and p a t i e n t r o l e . The s i g n i f i c a n c e of t h i s f i n d i n g l i e s i n the comparison of the o l d and cha l l eng i ng pe r spec t i ve s . Whereas the t r a d i t i o n a l premise s t a te s t h a t hea l th dec i s i on s are o b j e c t i v e l y determined through the p r o f e s s i o n a l ' s a p p l i c a t i o n of e x p e r t i s e , t h i s s t udy ' s f i nd i n g s have supported the cha l l eng i n g premise tha t the r o l e s assumed by the p ro fe s s i ona l and p a t i e n t e xp l a i n how the p ro fe s s i ona l desc r ibes and deals w i th p a t i e n t s . I t was such an i n t e r a c t i o n between Miss Smith and members of the r e h a b i l i -t a t i o n team tha t was presented i n Chapter One. She had entered the t r a d i t i o n a l i n s t i t u t i o n which was recognized as an e f f e c t i v e and e f f i c i e n t s e t t i n g w i t h i n which p r o f e s s i o n a l s oversaw the p r o v i s i o n and u t i l i z a t i o n of r e h a b i l i t a t i o n s e r v i c e s . Two d i scharge opt ions emerged, where the cos t s i n both monetary and non-monetary terms v a r i ed wide ly between outcomes. Through severa l s teps , t h i s chapter assesses the i m p l i c a t i o n s of t h i s i n t e r a c t i o n i n the context o f the cha l lenge to the t r a d i t i o n a l o r gan i z a t i on of r e h a b i l i t a t i o n s e r v i c e s . F i r s t , the connect ion between the study and the t h e s i s t o p i c w i l l be c l a r i f i e d i n a framework t ha t de f ines the scope and approach of the t h e s i s . Second, the c i rcumstance of the case of Miss Smith w i l l be reviewed i n terms of the r o l e s the p ro fe s s i ona l and p a t i e n t have assumed as we l l as i n terms of the cos t s o f the d i scharge outcomes ensuing from the i n t e r a c t i o n . T h i r d , the i m p l i c a t i o n s of Miss Smi th ' s r o l e as a consumer w i l l be cons idered from the pe r spec t i ve of p r o f e s s i o n a l s who have r e s i s t e d the cha l lenge to t h e i r e xpe r t i s e and a u t h o r i t y . 80 Th i s w i l l be i l l u s t r a t e d by quotes from the p r o f e s s i o n a l s who p a r t i c i p a t e d i n the s tudy. As w e l l , t h i s r e s i s t a n c e i s proposed to be ev idence of a l a g t h a t e x i s t s between the s o c i e t a l t rends and p r o f e s s i o n a l response. F o u r t h , the i m p l i c a t i o n s o f t h i s r e s i s t a n c e , s a i d t o be he ld l a t e n t i n the l a g , w i l l be d i s cu s sed i n terms of the e f f e c t i v e n e s s and e f f i c i e n c y o f the o r g a n i z a t i o n of r e h a b i l i t a t i o n s e r v i c e s i n the i n s t i t u t i o n . And l a s t , recommendations to the p r o f e s s i o n a l s and requi rements f o r f u r t h e r re search are d i s cu s s ed . The Study i n the Contex t o f the Scope and Approach o f the The s i s Many assumptions and d e c i s i o n s a re made i n the e f f o r t to study the ' r e a l w o r l d ' through exper imenta l de s i gn . The study o f the ques t i on o f the p r o f e s -s i o n a l ' s response t o cha l l enge t o the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a -t i o n s h i p was based on r o l e i n t e r a c t i o n . Other f a c t o r s e x i s t , however, t h a t may c l o u d the connect ion between the study and the q u e s t i o n . F i g u r e 17, below, p resent s a framework t h a t p l ace s the study i n the c on tex t o f the scope and approach o f the t h e s i s . C OTHER Eg. '• FUNDING - RECOMPENSE FACTORS i - HOSPITAL POLICY . 3. LARGER SOCIAL SYSTEMS * (ECONOMICS) A l A2 A3 A4 PATIENT + PROFESSIONAL + DECISION PROFESSIONAL ROLE ROLE CONTENT ~ ~ * RESPONSE TO i i i CHALLENGE B l B2 B3 B4 D INTERVIEW QUESTIONNAIRE INTERVIEW HOW THE PROFESSIONAL <— OTHER FACTORS EXPLAINS, DESCRIBES eg.>.OBJECTIVITY AND DEALS WITH THE i.NEUTRALITY PATIENT'S BEHAVIOR 3-INDIVIDUAL DIFFERENCES F i g u r e 17 The Context and Approach t o the Study o f the P r o f e s s i o n a l ' s Response to Cha l l enge to the t r a d i t i o n a l P r o f e s s i o n a l - P a t i e n t R e l a t i o n s h i p . (Adapted from Runke l , P h i l i p J . and McGrath, Jo seph , 1972, P.160.) 81 The l e t t e r ' A ' r e f e r s to the concepts t h a t emerged i n the l i t e r a t u r e , the s y n t h e s i s of which formed the b a s i s of the hypotheses. The hypotheses are p ro -posed t o r e f l e c t what ' r e a l l y 1 o c cu r s . The l e t t e r ' B ' r e f e r s t o the measures, o f the concepts ' A ' , t h a t were dev i sed t o assess whether the hypotheses were ' t r u e ' . A number o f s teps were taken to enhance the a b i l i t y of these measures to a c t as v a l i d and r e l i a b l e r e p r e s e n t a t i o n s o f the concept s . Though the ' s u c c e s s ' o f these s teps was not r i g i d l y e v a l u a t e d , one can make the assumption ( o the rw i se known as p r e d i c t i v e v a l i d i t y ) t h a t the v a l i d i t y o f the measures i s supported by the a b i l i t y to p r e d i c t a c c u r a t e l y . Other f a c t o r s may a l s o c l o u d the development and r e s u l t s of the s tudy. These may, as i n d i c a t e d i n ' C ' , i n f l u e n c e the c e n t r a l concept ('A4'), the p r o f e s s i o n a l ' s response t o c h a l l e n g e , o r , as i n d i c a t e d by ' D ' , the measures, ('B4'), o f t h i s concept . In some ca se s , as w i t h h o s p i t a l p o l i c y o r l a r g e r s o c i a l systems, these f a c t o r s were bypassed as be ing beyond the scope o f the s tudy. The i n v e s t i g a t o r assumed t h a t these f a c t o r s d i d not d r a m a t i c a l l y change over the course o f the study and were a con s tan t e f f e c t on a l l the p r o f e s s i o n a l s . In o t he r ca se s , such as w i t h the t r a d i t i o n a l premises of o b j e c t i v i t y or i n d i v i d u a l d i f f e r e n c e s u n d e r l y i n g the p r o f e s s i o n a l ' s h e a l t h d e c i s i o n s , the f a c t o r s were c o n t r o l l e d f o r the s tudy. Fo r example, the two f a b r i c a t e d case s t u d i e s were matched on e s s e n t i a l v a r i a b l e s so t h a t the p r o f e s s i o n a l ' s response cou l d be e xp l a i ned by the va r i ance i n p a t i e n t r o l e , r a t h e r than p a t i e n t a t t r i b u t e s such as sex and age. In sum, the study has focused to the r o l e i n t e r a c t i o n i n the p r o f e s s i o n a l -p a t i e n t r e l a t i o n s h i p t o account f o r the p r o f e s s i o n a l ' s response to cha l l enge to the t r a d i t i o n a l p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . 82 The Ro les Assumed by Miss Smith and Members o f the R e h a b i l i t a t i o n Team The case study o f A l i c e Smith was presented i n Chapter One. Her behav io r c ou l d be i n t e r p r e t e d as t h a t o f the consumer: ( r e l y i n g on her own judgment and assuming the r e s p o n s i b i l i t y f o r the d e c i s i o n ) , she assessed her s i t u a t i o n and r e s o l v e d t h a t she would go home t o l i v e ' i n d e p e n d e n t l y ' . The p r o f e s s i o n a l s responded i n two ways. These two po les of p r o f e s s i o n a l o p i n i o n may be i n t e r p r e t e d as d i f f e r i n g o r i e n t a t i o n s t o the p r o f e s s i o n a l ' s r o l e . With the d e s c r i p t i o n o f M i s s Smith as ' d i f f i c u l t ' , and the recommendation o f ' c o n t r o l l i n g ' , the p r o f e s s i o n a l was assuming r e s p o n s i b i l i t y f o r the hea l t h d e c i s i o n . Conve r se l y , w i t h the d e s c r i p t i o n o f the p a t i e n t as ' h a v i n g gut s ' ( i n t e r p r e t e d as ' g o o d ' ) , and the recommendation to support her d e c i s i o n , the p r o f e s s i o n a l was accommodating the p a t i e n t ' s judgment and acknowledging the p a t i e n t ' s r e s p o n s i b i l i t y t o make h e a l t h d e c i s i o n s . In a p r o f e s s i o n a l - d o m i n a n t , asymmetr ical r e l a t i o n s h i p , the p r o f e s s i o n a l ' s d e c i s i o n o f p r o t e c t i v e ca re would be f o l l o w e d . In a p a t i en t - dom inan t , asymmetr ical r e l a t i o n s h i p , the p a t i e n t ' s d e c i s i o n to go home independent ly would be f o l l o w e d . The co s t s and b e n e f i t s to the r e s p e c t i v e p a r t i e s as w e l l as t o a t h i r d pa r t y fund ing the outcome d i f f e r w ide l y between d i s cha rge d e c i s i o n s . These are as ses sed, i n general te rms, i n the c h a r t below, from the p e r s p e c t i v e s o f each of the p r o f e s s i o n a l ' s r o l e s , the p a t i e n t , and government as the t h i r d pa r t y r e s p o n s i b l e f o r ove r see ing the fund ing o f the d i s cha rge o p t i o n s . 83 Figure 18 Differing Perspectives of the Professional, Patient and Third Party of the Costs and Benefits of discharge decisions following from professional-dominant and patient-dominant asymmetry. Perspective Professional-dominant Asymmetry Discharge decision - Protective Care Patient-dominant Asymmetry Discharge decision - Home Independently Costs Benefits Costs Benefits Professional as 'Controller' Effectiveness and Efficiency assured effectiveness and efficiency not assured Professional as 'Accommodator' Effectiveness and efficiency not assured effectiveness and efficiency assured Patient Not judged to be In own best Interest (consistent with perspective of the 'accommodator') Risk of Injury lessened Ongoing support of medical needs, (consistent with perspective of the 'controller') Increased responsibility for $ costs Increased risk of Injury Judge to be In own best Interests Government or Third Party (overseeing fund-ing of discharge decisions) Government takes on responsibility of costs Some costs assumed through disability benefits. Other costs assumed by other agen-cies and governments. For example, home renovation. Patient takes on more responsibility for day to day costs. From t h i s overv iew of the va r i ou s p e r s p e c t i v e s , the view of the p r o f e s s i o n a l w i l l be d i s cu s sed f u r t h e r i n the next s e c t i o n . I m p l i c a t i o n s of the Consumer i s t Ro le The p r o f e s s i o n a l who assumes the t r a d i t i o n a l r o l e of ' c o n t r o l l e r ' p e r ce i ve s the i n s t i t u t i o n as the e f f e c t i v e and e f f i c i e n t s e t t i n g f o r the p r o v i s i o n of s e r v i c e s . A l i c e Sm i th , i n the consumer i s t s tance , has c ha l l enged the / t r a d i t i o n a l o r g a n i z a t i o n o f s e r v i c e s . S p e c i f i c a l l y , she wished t o r e l y on her own judgment and assume the r e s p o n s i b i l i t y f o r h e a l t h d e c i s i o n s . Th i s s e c t i o n c on s i de r s the i m p l i c a t i o n of t h i s c ha l l enge from the ' c o n t r o l l e r ' p r o f e s s i o n a l ' s p e r s p e c t i v e . Examples o f t h i s p r o f e s s i o n a l ' s p e r s p e c t i v e are a v a i l a b l e from the study i n which p r o f e s s i o n a l s were asked t o e va l ua te the i m p l i c a t i o n s o f the p a t i e n t ' s behav io r f o r the achievement of r e h a b i l i t a t i o n goa l s . These w i l l be used t o h i g h l i g h t the d i s c u s s i o n . Of i n t e r e s t f i r s t , though, i s the a c t ua l outcome of A l i c e S m i t h ' s s i t u a t i o n : She r e tu rned home t o l i v e ' i n d e p e n d e n t l y ' . She arranged w i t h the a s s i s t a n c e of the s o c i a l worker to have an a t tendant to he lp w i t h her persona l ca re on a p a r t - t i m e b a s i s . Thus the p a t i e n t ' s d e c i s i o n was f o l l o w e d . From a rev iew o f F i g u r e 18, the b e n e f i t s and co s t s of t h i s outcome, from the va r i ou s p e r s p e c t i v e s , can be as ses sed. From the ' c o n t r o l l e r ' p r o f e s s i o n a l ' s pe r spec -t i v e the e f f e c t i v e n e s s and e f f i c i e n c y o f the i n s t i t u t i o n has not been a s su red, t h a t i s , the re sources w i t h i n the i n s t i t u t i o n were not u t i l i z e d t o t h e i r opt imal l e v e l . 85 In response to a s i m i l a r s i t u a t i o n i n the f a b r i c a t e d case s t u d i e s , p re sented i n the study i n t e r v i e w s , the p r o f e s s i o n a l s eva lua ted the outcome i n d i f f e r i n g ways. Only two p r o f e s s i o n a l s ques t ioned the e f f e c t i v e n e s s o f the r e h a b i l i t a t i o n s e t t i n g . As an example, a response to the consumerist. p a t i e n t , i t was s t a t e d , "When the p a t i e n t i s not p a r t i c i p a t i n g f u l l y ? I d o n ' t know, i s i t a f a u l t o f the p a t i e n t o r program? The crunch comes though when he l e a v e s . " Most p r o f e s s i o n a l s , however, d i d not que s t i on the e f f e c t i v e n e s s o f the s e t t i n g , but f o r d i f f e r e n t reasons . Some f e l t the s e t t i n g c ou l d handle the c h a l l e n g e , such as t h i s s tatement: ' [we] assume t h a t r e h a b i l i t a t i o n should be h e l p i n g people assess a b i l i t y f o r s a f e t y . A t the same t ime you have to r e spec t the i n d i v i d u a l and h i s r i g h t t o make h i s own d e c i s i o n . [We can] he lp i f he wishes to accept h e l p . ' The l a r g e r number o f p r o f e s s i o n a l who d i d not que s t i on the e f f e c t i v e n e s s of r e h a b i l i t a t i o n , though, expressed a l o t o f f r u s t r a t i o n . The f o l l o w i n g statements i l l u s t r a t e t h i s : ' [we a re ] f r u s t r a t e d - [we are] d e a l i n g i n areas where you are supposed t o be e x p e r t , bu t , d e s p i t e what you may a d v i s e , p e o p l e ' s w i l l w i l l win o u t ' , and ' i f the p a t i e n t i s not s a f e , r e h a b i l i t a t i o n has not completed i t s r e s p o n s i b i l i t i e s , [and we] have not made the p a t i e n t ' s l i f e as bes t as i t c ou l d b e . ' I t i s t h i s f i n a l group of responses t h a t seems to i n d i c a t e a r e s i s t a n c e on the p a r t o f p r o f e s s i o n a l s to the c ha l l e n ge t o t h e i r t r a d i t i o n a l r o l e . The v a l i d i t y o f the p a t i e n t s ' c h a l l e n g i n g view t o r e l y on t h e i r own judgment and to assume r e s p o n s i b i l i t y f o r t h e i r own d e c i s i o n s i s not y e t r e cogn i z ed . Y e t , these p a t i e n t s have the l e g a l r i g h t , un les s incompetence can be proved, t o make t h e i r own d e c i s i o n s . As l o ng as the v a l i d i t y o f the c h a l l e n g i n g view i s not r ecog -86 n i z e d , a gap r e s u l t s between what the p r o f e s s i o n a l s b e l i e v e i s be s t f o r p a t i e n t s and what the p a t i e n t s b e l i e v e i s bes t f o r themselves . That i s , the p r o f e s s i o n a l b e l i e v e s t h a t p a t i e n t s have the r i g h t to dec i de , but t h a t they should make t h e i r d e c i s i o n s based on the p r o f e s s i o n a l ' s e x p e r t i s e , and not r e l y on t h e i r own judgment. When t h i s does not happen, the p r o f e s s i o n a l cannot e x p l a i n the p a t i e n t ' s behav io r r a t i o n a l l y and f r u s t r a t i o n r e s u l t s . In the p o l i c y c on tex t o f the t h e s i s , t h i s gap i s proposed as a l a g t h a t e x i s t s between s o c i e t a l t rends ( the consumer i s t s tance) and p r o f e s s i o n a l response ( r e s i s t a n c e to r e c o g n i t i o n o f the v a l i d i t y of the c h a l l e n g i n g v i ew) . The i m p l i c a t i o n s o f the r e s i s t a n c e are proposed to be h e l d l a t e n t i n the l a g . IMPLICATIONS OF PROFESSIONAL RESISTANCE Four s cena r i o s are presented i n the f i g u r e below, as p o s s i b l e i n t e r a c t i o n s of the d i r e c t i o n s o f the s o c i e t a l t r ends and p r o f e s s i o n a l response. 87 F i g u r e 19 The i n t e r a c t i o n between a l t e r n a t e d i r e c t i o n s o f the t r end o f c h a l l e n g i n g behav io r and the degree o f p r o f e s s i o n a l r e s i s t a n c e . Cha l l enge to P ro fe s s i ona l -Dom inan t Asymmetry t r end T t r e n d i r e s i s t a n c e ( P r o f e s s i o n a l ] t c o n f l i c t t f r u s t r a t i o n p e f f e c t i v e n e s s • e f f i c i e n c y : W h o ' s i n Charge? 1 i c o n f l i c t I f r u s t r a t i o n r e t u r n to s t a t u s quo: P r o f e s s i o n a l 2 domi nance \ Response / no r e s i s tance 3 i c o n f l i c t i f r u s t r a t i o n r e d e f i n i t i o n of e f f e c t i v e n e s s and e f f i c i e n c y : P a t i e n t domi nance 4 t c o n f l i c t f f r u s t r a t i o n p e f f e c t i v e n e s s • and e f f i c i e n c y : W h o ' s i n Charge? I f the cha l l enge s i n c r e a s e , i n the s i t u a t i o n s where the r e s i s t a n c e i s ma i n t a i ned , one can expect more f requent occurances o f c o n f l i c t and f r u s t r a t i o n , r e s u l t i n g i n i n c r ea sed q u e s t i o n i n g , though not n e c e s s a r i l y by p r o f e s s i o n a l s , o f the e f f e c t i v e n e s s and e f f i c i e n c y of the i n s t i t u t i o n a l s e t t i n g . A decrease i n the degree o f c ha l l e n ge would r e s u l t i n a r e t u r n to the s t a t u s quo w i t h p r o f e s -s i ona l -dominan t asymmetry s t i l l entrenched i n the i n s t i t u t i o n a l s e t t i n g . I f the p r o f e s s i o n a l r e s i s t a n c e decreases , and s teps are taken t o accommodate the p a t i e n t ' s i n c r e a s i n g r e s p o n s i b i l i t y as a ' t eam ' member, f o r example through access t o medical records and team meet ings , the r o l e o f the i n s t i t u t i o n and i t s e f f e c t i v e n e s s and e f f i c i e n c y would have to be r e d e f i n e d . I f the c h a l l e n g i n g view should s imu l taneous l y decrease, however, one might expect c o n f l i c t to r e s u l t from no one t a k i n g charge. 88 With fou r p o s s i b l e s c e n a r i o s , one cannot make conc l u s i on s w i t hou t r e s e r v a -t i o n . The l a g i n r e s i s t i n g the cha l l enge may i n d i c a t e an i n e f f e c t i v e r e h a b i l i t a t i o n s e t t i n g ' n o t keep ing up w i t h the t i m e s ' , but i t a l s o may serve as a guard a ga i n s t approaching the r e a l i t i e s o f l i f e through i d e o l o g i c a l extremes. The t r a d i t i o n a l ( p r o f e s s i ona l - dom inan t ) and c h a l l e n g i n g ( pa t i en t -dominan t ) views are the two po les o f what the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p shou ld be. N e i t h e r extreme, however, seems adequate to deal w i t h the cha l l enge s o f the day, f o r the b e n e f i t s o f one are p o t e n t i a l l y a t the c o s t s of the o t h e r . One a l t e r n a t i v e i s to take charge over the d i r e c t i o n of the t r e n d s . The maintenance o f r e s i s t a n c e by the p r o f e s s i o n a l , w h i l e the c h a l l e n g e has i n c r e a s e d , has been shown to r e s u l t i n que s t i o nab l e e f f e c t i v e n e s s and e f f i c i e n c y o f the u t i l i z a t i o n o f the f a c i l i t y ' s r e s ou r ce s . The r e c o g n i t i o n o f i n p u t from a l l the p e r s p e c t i v e s - the p r o f e s s i o n a l , the p a t i e n t , government - might r e s o l v e t h i s c o n f l i c t i n t o a workable compromise. REQUIREMENTS Th i s study has been an e m p i r i c a l a n a l y s i s of r o l e asymmetry i n the i n s t i -t u t i o n a l s e t t i n g . As i t f o l l o w s on a s i m i l a r study by Haug and L a v i n (1981) i t c o n t r i b u t e s another smal l pocket of data to the r a t h e r l a r g e t o p i c of the p ro -f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . These and f u r t h e r attempts to measure aspects of the r e l a t i o n s h i p would he lp to p a i n t a more comprehensive p i c t u r e o f the dynamics o f the s i t u a t i o n . Over t im e , they a l s o he lp t o mon i tor changes i n the r e l a t i o n s h i p . 89 A second requi rement o f re search suggested by t h i s study i s t h a t of f u r t h e r a n a l y s i s o f p r o f e s s i o n a l and p a t i e n t r o l e s i n r e l a t i o n t o the dimensions of e f f e c t i v e n e s s and e f f i c i e n c y . Th i s r e l a t i o n s h i p has been assumed to e x i s t f o r t h i s t h e s i s . A focus o f f u r t h e r re search c ou l d be the i d e n t i f i c a t i o n of those i n d i c a t o r s , i n r e spec t to the measures o f e f f e c t i v e n e s s and e f f i c i e n c y , t h a t a re t h e o r e t i c a l l y o r e m p i r i c a l l y r e l a t e d t o the p r o f e s s i o n a l - p a t i e n t r e l a t i o n s h i p . 1 RECOMMENDATIONS The recommendations, to the p r o f e s s i o n a l and i n s t i t u t i o n , f o l l o w i n g from t h i s t h e s i s are t w o f o l d : 1. a) As many of the t r a d i t i o n a l d e f i n i t i o n s of concepts have been c h a l l e n g e d , i n c l u d i n g the va lues o f e f f e c t i v e n e s s , e f f i c i e n c y , and the i n d i c a t o r s t h a t measure them, and b) as the r o l e s o f p r o f e s s i o n a l s and p a t i e n t s have been que s t i oned , p a r t i c u l a r l y i n r e spec t t o the p a t i e n t ' s r o l e as a team member, i t i s recommended t h a t these concepts be r e - e v a l u a t e d by p r o f e s s i o n a l s a l one , as w e l l as i n c o n s u l t a t i o n w i t h c u r r e n t and former p a t i e n t s ; and 2. As the o b j e c t i v e s a re to a) d i s cu s s i n which d i r e c t i o n the t r end should  be s t go and b) d i s cu s s the i n t e r v e n t i o n t h a t would best d i r e c t the t r e n d , i t i s 1 For example see Dav i s and von der L i ppe (1967/8), "D i scharge from H o s p i t a l A ga i n s t Med i ca l A d v i c e : A Study o f r e c i p r o c i t y i n the d o c t o r - p a t i e n t r e l a t i o n -s h i p " . 90 recommended t h a t a p u b l i c forum be opened, t o those concerned, t o d i s cu s s a l l p e r s p e c t i v e s of the co s t s and b e n e f i t s ensuing from the u t i l i z a t i o n o f , and d i s cha rge f rom, r e h a b i l i t a t i o n f a c i l i t i e s . CONCLUSION The l a t t e r recommends a d i a l ogue between p r o f e s s i o n a l s and p a t i e n t s and t h i r d p a r t i e s t o p r ov i de a g r e a t e r p r o f e s s i o n a l - p a t i e n t under s tand ing , i f not a more e f f e c t i v e and e f f i c i e n t u t i l i z a t i o n of r e h a b i l i t a t i o n s e r v i c e s . The study p rov ided ev idence of a l a g t h a t e x i s t s i n the p r o f e s s i o n a l response t o change. How q u i c k l y change occurs depends on how one pe r ce i ve s the l a g as a f f e c t i n g the e f f e c t i v e n e s s and e f f i c i e n c y o f the i n s t i t u t i o n a l s e t t i n g . A study of t h i s k i n d , seve ra l yea r s down the road , may p r o v i de the answer. 90(a) BIBLIOGRAPHY A l b r e c h t , G.L. and H i g g i n s , P.C. (eds) H e a l t h , I l l n e s s , and Med ic ine . Rand McNal ly Co l l e ge P u b l i s h i n g Company, Chicago (1979). Arney, W i l l i a m Ray and Bergen, Bernard J . 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Jossey-Bass P u b l i s h e r s , (1978). Szasz , T .S . , and Ho l l ande r , M.H. 'A C o n t r i b u t i o n to the Ph i losophy o f Medic ine: the ba s i c models of the d o c t o r - p a t i e n t r e l a t i o n s h i p ' , AMA Arch ives  of I n t e rna l Med i c i ne , 97:585-592, (1956). Wessen, A.F. 'The Apparatus o f R e h a b i l i t a t i o n : An O rgan i za t i ona l A n a l y s i s ' i n Soc io logy and R e h a b i l i t a t i o n . Marv in B. Sussman (ed ) , American S o c i o l o g i c a l A s s o c i a t i o n , (1965). W i l l i a m s , G.H. 'The Movement f o r Independent L i v i n g : An E v a l u a t i o n and C r i t i q u e ' , S o c i a l Sc ience and Med i c ine . 17:15, pp. 1003-1010, (1983). 95 APPENDIX 1 INTERVIEW Th i s appendix conta in s the i n t e r v i ew procedure, an ac tua l i n t e r v i e w , and a b r i e f d i s cu s s i on of the matching of p a t i e n t c h a r a c t e r i s t i c s and c i rcumstances . In terv iew Procedure ( con ta i n i n g an ac tua l i n t e r v i ew from the study) The i n t e r v i e w i n vo l ve s p re sent ing to you 2 case s tud ie s of p a t i e n t s i n a r e h a b i l i t a t i o n f a c i l i t y other than t h i s one. You can cons ider the study as a t r a n s f e r l e t t e r w r i t t e n by a s t a f f member from t h a t Cent re . In l ook i ng through the medical records here I have t r i e d to modify terms to those used at t h i s f a c i l i t y , so, i f any are not c l e a r , p lease l e t me know. A f t e r you read the case I w i l l g i ve you some more i n fo rmat i on about the p a t i e n t ' s stay and then ask you some quest ions about your impress ions . 96 Case Study #1 Mr. C. i s a 70 year o l d male t r e a t e d at R e h a b i l i t a t i o n Centre f o r the l a s t 10 weeks f o r d e f i c i t s r e s u l t i n g from a b r a i n tumour which was s u r g i c a l l y removed at General H o s p i t a l . Mr. C. has had past admissions to h o s p i t a l f o r o s t e o - a r t h r i t i s which has worsened over the past 20 y e a r s . He a l s o has hypertens ion which has been med i ca l l y c o n t r o l l e d f o r the past 15 yea r s . Mr. C. i s on a treatment program f o r r e s i dua l a t a x i a of the r i g h t upper e x t r em i t y , and improvement of f u n c t i o n l i m i t e d by a r t h r i t i s i n h i s knees and l e f t shoulder. He a l s o has s u f f e red a l o s s i n hear ing , from the tumour, f o r which he has been f i t t e d w i t h a hear ing a i d . He has occas iona l d i z zy s p e l l s and has f a l l e n a couple of t imes a t the Cent re . He i s o r i en ted to person, p l ace and t ime. He p re sen t l y walks w i th a wa lker but i s p rogres s ing to 2 canes. The a t a x i a on the r i g h t s i de and OA of the l e f t shoulder have made i t d i f f i c u l t f o r Mr. C. to manage h i s own personal c a r e . Mr. C. l i v e s i n a s u i t e i n a house i n Vancouver. He i s on the main f l o o r but says he has some d i f f i c u l t y n e g o t i a t i n g a set o f s t a i r s l e ad i n g to the f r o n t ent rance. Fo l l ow ing high s c hoo l , Mr. C. worked h i s way up to foreman i n a warehouse but had to stop 10 year s ago because of i n c r e a s i n g pa in from h i s a r t h r i t i s . He r ece i ve s government a s s i s t ance and has few savings from h i s pens ions. He was marr ied f o r 42 year s and h i s w i f e d ied 8 year s ago. He has a daughter i n V i c t o r i a and one i n Mont rea l . They share the r e s p o n s i b i l i t y of c on tac t i n g him r e g u l a r l y throughout the yea r . In d i s cu s s i on s w i th the s o c i a l worker, they have s t a ted t ha t they th ink i t would be s a f e r f o r him i f he were 97 ' p l a c e d 1 . They t a l k of how the fami l y has d r i f t e d apart and how they are now h e s i t a n t to suggest he l i v e w i th e i t h e r one of them. S t a f f th ink t h a t ongoing treatment f o r h i s a r t h r i t i s would be b e n e f i c i a l but t h a t he cou ld be ready f o r d i scharge from the f a c i l i t y i n another week. * * * * * Now I would l i k e to t e l l you a l i t t l e more about Mr. C . ' s stay a t the Cen t re . Mr. C. has repeatedly quest ionned the treatment program at the Cent re . He says he has l ea rned to do h i s own personal c a r e , on h i s own, i n h i s room, but has re fused to demonstrate t h i s to the nurses and t h e r a p i s t s . Often he shows up l a t e , and sometimes not a t a l l , f o r therapy. He o f ten asks a second op in ion about whatever medicat ion i s p r e s c r i b ed . 98 I - I n te rv iewer P - P r o f e s s i o na l I What i s your general impress ion of Mr. ' C ' s ' s tay a t the Centre? P General impress ion? I Uhhuh. P I don ' t know what you mean by general impress ion. I A f t e r read ing the case study about h i s medical problems and s o c i a l problems e t c . , and w i thout f u r t h e r i n f o r m a t i o n . . . P A l l I can say i s i t looks to me t ha t h i s pe rcept ion of h i s problems and s t a f f ' s pe rcept i on of h i s problems are d i f f e r e n t . I Yes , what has i n d i c a t e d t h a t to you. P The f a c t t h a t he doesn ' t want to do the th ings t ha t s t a f f want him t o . I Why do you th ink t h a t happens, where percept ions d i f f e r ? P W e l l , I th ink t h i s i s an awful common t h i n g to happen because s t a f f some-times get too p s e u d o - s c i e n t i f i c i n t h e i r approach and they d o n ' t n e c e s s a r i l y recognize the importance of how the p a t i e n t s both pe rce i ve themselves and the remed ia t i on . I I f s t a f f were to recogn ize t ha t what would t h e i r approach be? P Then they might begin to t a c k l e problems t h a t the p a t i e n t sees as being important. I Uhhuh. P And they might make some headway. I What do you mean by headway? P They might get the p a t i e n t to be f u n c t i o n i n g i n a s l i g h t l y b e t t e r way more by i n d i r e c t than d i r e c t methods. I Uhhuh, what do you th ink a p a t i e n t would see as important t h a t would be d i f f e r e n t from a s t a f f member?...For example i n Mr. ' C ' s ' case. P W e l l , obv ious l y from what you t e l l me, he does h i s s e l f - c a r e h imse l f and he i s n ' t going to demonstrate how he does i t except I gather he appears dressed, so i f he i s ab le to dress and doesn ' t get somebody e l s e to help him, and so the methods of d r e s s i n g . . . i f t h a t ' s what s t a f f i s concerned about, I can only assume tha t from the f a c t t h a t t h e y ' r e concerned about 99 him, h i s i n a b i l i t y - h i s r e f u s a l to demonstrate to them what he ' s capable of do ing, but I wou l dn ' t l i k e you to th ink t h a t I th ink p a t i e n t s are always r i g h t and t he r e f o r e we do eve ry th ing the p a t i e n t says, but sometimes i f one works through then we can get them to respond to the t he r apeu t i c methods t ha t we th ink w i l l a l s o be of importance to them. I Uhhuh. P I o f ten have a s o r t o f c on f r on t a t i on approach. I How do you judge as to when a p a t i e n t ' s suggest ion might be r i g h t o r yours be r i g h t ? P W e l l , I th ink t ha t I can look a t p a t i e n t s and determine what t h e i r patho-l o g i c a l c ond i t i o n s are and how t h a t e f f e c t s t h e i r a b i l i t y to l i v e t h e i r l i v e s and what th ings are p o s s i b l e f o r us to do to help them l i v e t h e i r l i v e s i n a l i t t l e b e t t e r way. I Uhhuh. P Or to reduce the e f f e c t s of the pathology on the l i f e s i t u a t i o n . I Uhhuh. P But the p a t i e n t i s n ' t always n e c e s s a r i l y w i l l i n g to see i t q u i t e t ha t way and we have to be a l i t t l e i n d i r e c t i n how we approach. The same u l t ima te aims tha t we might have had but not go about ach iev ing them i n a way t h a t i s a t odds w i t h the p a t i e n t ' s pe rcept i on of h imse l f . I Uhhuh. Does i t ever happen where the percept ions do c o n f l i c t and the approach must become d i r e c t ? P Oh sometimes y e s , no th i n g ' s ab so lu te . I Uhhuh, what would you do i n t h a t case where they do c o n f l i c t and i t ' s brought i n t o the open when you haven ' t been ab le to approach i t i n d i r e c t l y . P One has to make some k i nd of accommodation, some s t a f f f i n d i t e a s i e r to accommodate, and others are much more r i g i d and c a n ' t , and t h i s i s one of the problems one sees i n i n s t i t u t i o n s such as t h i s . There are times when you c a n ' t change s t a f f when you would l i k e to change them. I Why do you th ink Mr. ' C ' has quest ioned h i s treatment? P I c o u l d n ' t answer you t h a t , I don ' t know. The re ' s no way from t h i s . . . I can j u s t say t ha t i t ' s not too uncommon nowadays. And very o f ten pa t i en t s who quest ion treatment are very unhappy about the s i t u a t i o n and themselves. I What do you th ink would be the u l t i m a t e treatment goal f o r Mr. ' C ' ? 100 P An independent l i v i n g s i t u a t i o n , prov ided t h a t he ' s able to manage, and I'm not sure from the i n fo rmat i on t h a t t h i s i s r e a l l y a p r a c t i c a l p o s s i -b i l i t y or not. I Uhhuh. With the i n fo rmat i on prov ided t he r e , cou ld you t e l l me what you th ink the optimum d i scharge op t i on would be? P That the o p t i o n , w e l l , i t says here he l i v e s i n a s u i t e on the main f l o o r , he ' s got some d i f f i c u l t y w i th nego t i a t i n g the s t a i r s . I f he can do t h a t , and there might be p o s s i b i l i t i e s t h a t he can, one doesn ' t change the way people l i v e un less t h e r e ' s a good reason to change. And i f t ha t was a reasonably s a t i s f a c t o r y s i t u a t i o n be fo re , then t h a t ' s what one would t r y -a re tu rn to t h a t l i v i n g s i t u a t i o n . I A t the Centre where he was he made i t known to the s t a f f t ha t he wished to go l i v e w i th h i s f a m i l y . How would you eva luate t h a t request? P Uh, what I would do about i t - i f he t o l d me t h a t I would po i n t out to him tha t i t may or may not be a reasonable p lan f o r him. And t h a t I ' d be very p leased to t a l k to h i s daughter. And, p a r t i c u l a r l y the daughter i n V i c t o r i a . Bu t , of cour se , he might have p lans to move to the one i n Mont rea l . I What do you mean by ' r e a s onab l e ' ? You s a i d , ' t h a t may or may not be a reasonable p l a n . P W e l l , t h a t i s my way o f l e t t i n g the daughter o f f the hook, as we l l as the p a t i e n t o f f the hook. We c a n ' t t e l l people what they must do and what they must not do. Only guide them towards a f i n a l d e c i s i o n tha t i s going to p rov ide them w i t h a l i v i n g s i t u a t i o n tha t i s compat ib le both to themselves and to other r e l a t i v e s . I I f i t d id happen, i f you t r i e d to proceed i n t h i s way and the daughter r e fu sed , and the p a t i e n t then says he wants to go home a lone. How would you deal w i th tha t ? P I f he cou ld manage i n h i s s e t t i n g a t home where he was p rev i ou s l y - t h a t would be the most app rop r i a te t h i n g to encourage. I O ' kay , t h a t ' s case study number 1. I have a second one f o r you. Th i s i s Mr. ' D ' . 101 Case Study #2 Mr. 0. i s a 66 yea r o l d man admitted to R e h a b i l i t a t i o n Centre 3 months ago on t r a n s f e r from General H o s p i t a l . He had been admitted there w i t h a r i g h t b r a i n aneurysm. Pa s t medical h i s t o r y i nc ludes adu l t onset d iabetes of 12 years du ra t i on c o n t r o l l e d by d i e t , and emphysema, f o r which he i s v i s i t e d i n t e r m i t t e n t l y by home care phys iotherapy. P r e s e n t l y , Mr. D. has l e f t - s i d e d neg lec t which i s caus ing problems because of l ack of balance when wa l k i n g . Treatment has been d i r e c t e d toward compensa-t i o n f o r the neg l ec t . Mr. D. 's speech i s d i f f i c u l t to understand due to d y s a r t h r i a and he has to repeat sentences 3 or 4 t imes before he i s understood. The speech t h e r a p i s t does not expect improvement. Otherwise, h i s comprehension i s normal and competent. He i s ambulat ing w i th a quad cane. Mr. D. p re sen t l y ren t s an apartment i n the Vancouver a rea. The foye r has m i r ro r s and shiny f l o o r s which he f i n d s d i s t u r b i n g . He i s a high school graduate. He worked as a supe rv i s o r on c o n s t r u c t i o n s i t e s u n t i l r e t i rement 5 years ago because of i n c r e a s i n g d i f f i c u l t y w i t h b rea th i ng . He has l i m i t e d f inances and app l i ed f o r government a s s i s t ance l a s t yea r . He has been widowed f o r the past 10 year s and has 2 daughters l i v i n g on the I s l a nd and a son i n W i l l i ams Lake. There i s not much communication between the c h i l d r e n though each has t r i e d to phone him r e g u l a r l y p r i o r t o , and s i n c e , h i s h o s p i t a l i z a t i o n . Each has avoided contac t w i t h the s o c i a l worker who has t r i e d to i n q u i r e about pos t -d ischarge arrangements. A t the l a s t team meeting i t was decided he would be ready f o r d i scharge i n 2 weeks t ime. 102 Now I would l i k e to g i ve you a b i t more i n fo rmat ion about Mr. D. ' s stay a t the Cent re . Mr. D. has f i t we l l i n t o the f a c i l i t y schedule and has p a r t i c i p a t e d , though a l i t t l e embarrassed, i n c l i n i c rounds when h i s case was presented. He has been f o l l o w i n g h i s treatment program r i g i d l y and s t a f f have had to superv i se c l o s e l y . Once when he was g iven a hot pack f o r 15 minutes he l e f t i t on the f u l l t ime i n s p i t e of f e e l i n g pa in from the heat. He consequently s u f f e r e d a m i l d s c a l d . In the gym, he f o l l ows through h i s d a i l y schedule even on days he i s not f e e l i n g w e l l . On occas ion he has had to be helped back to h i s room. I What i s your general impress ion of Mr. ' D ' s ' s tay a t the Centre? P He seems to have been co -ope ra t i ng w i t h the treatment s t a f f . I t ' s d i f f i -c u l t to say i f he r e a l l y b e n e f i t e d . I d i d n ' t see him when he came i n 3 months ago and how he i s now. Except i t says h e ' l l be ready f o r d i scharge i n two weeks t ime. I Why do you th ink Mr. 'D ' l e f t the hot pack on the f u l l t ime i n s p i t e of f e e l i n g the heat? P I 'd be i n t e r e s t e d to know why he ever had the hot pack on i n the f i r s t i n s t ance . I I don ' t th ink I can answer t h a t f o r you. For whatever reason they d e c i d e d . . . P Doesn ' t seem a good idea to put hot packs on to people who have sensory impairment. I I th ink you cou ld assume that whatever rou t i ne s were requ i red before p u t t i n g the hot pack on, had been done. 103 P One can only guess t ha t he ' s a r a the r r i g i d person t ha t f o l l ows the th ings t ha t he ' s t o l d . I f the t h e r a p i s t was a very f o r c e f u l p e r s o n a l i t y t h a t s a i d that t ha t had to stay f o r 15 minutes , then he j u s t accepted i t as such. And some p a t i e n t s w i l l accept t ha t from one t h e r a p i s t and not another. I What do you see as the optimum treatment goal f o r Mr. 'D ' ? P He ' s a 66 year o l d man w i th a l e f t h emap l i z i a , and very o f t en the l e f t hemaplegic has g rea te r d i f f i c u l t y i n develop ing independence and i t doesn ' t r e a l l y t e l l me too much here about how we l l he does manager. And h i s personal care - how w e l l he i s ab le to walk - i t says he used a quad cane - another f a c t o r i s i t mentions he has a d y s a r t h r i a , t h a t might mean he might be a b i l a t e r a l ce rebra l involvement and t h a t cou ld mae a b i g d i f f e r -ence i n terms o f probable outcome when i t ' s not s o l e l y a u n i l a t e r a l ce reb ra l l e s i o n . I 'A d i f f e r e n c e i n the outcome' i n what way? P That he might not do as we l l as some of the t h e r a p i s t s perce ived he would. They might have a n t i c i p a t e d tha t he would do....They d o n ' t measure i f he ' s had g reate r d i f f i c u l t i e s i n managing h i s d i abe te s . He was be fo re , s o l e l y by d i e t . I Do you th ink h i s behav ior a t the Centre - the e x t r a i n fo rmat ion prov ided -w i l l a f f e c t the treatment goals a t a l l ? P Not sure I understand what you mean h i s behav ior at the Centre a f f e c t the treatment goals? I I n f l uence , would the treatment goal have to b e . . . P Mod i f ied? I t h ink they always have to be. I t ' s no good s e t t i n g up a program and say ing , 'you damn w e l l do i t , or e l s e ! ' I t ' s not very s u c c e s s f u l . I In what way do you see the goals being mod i f i ed i n t h i s case? P W e l l , the quest ion i s whether he i s ab le to l i v e on h i s own or whether he needs a superv i sed type of l i v i n g s i t u a t i o n and the - he may w e l l need an i n te rmed ia te ca re 1 l e v e l r a t h e r than l i v i n g i n an apartment. And m i r ro r s and shiny h a l l s might be a s i g n i f i c a n t f a c t o r f o r someone w i th h i s type of pathology. I The s t a f f have heard from h i s daughter t h a t he has spoken w i t h her and t o l d her t h a t he wanted to go l i v e w i th her . And she i s h e s i t a n t to do t h a t . How would you deal w i th that ? P Th i s matter of whether r e l a t i v e s go and stay w i t h f ami l y i s very much an i n d i v i d u a l matter . One can t a l k to them about i t and they both come to a r e a l i z a t i o n of whether t h i s i s a good idea or not. Sometimes we don ' t t e l l them what to do but they make b e t t e r dec i s i on s a f t e r t a l k i n g over the pros 104 and cons w i t h the doctor and s o c i a l worker and sometimes the other s t a f f as w e l l . We know nothing about the phy s i ca l l ayout of the daughters house or the fami l y s i t u a t i o n - whether she works, or i f she ever got along w i th her f a t he r or not. Whether the f a t h e r c a n ' t stand h i s s on - i n - l aw. . .The re are so many th ings t h a t come i n . I t seems tha t t h i s i s a fami l y t h a t has been i n communication w i th each other and not t o t a l l y d r i f t e d apa r t . But s t i l l t h e y ' v e gone t h e i r separate ways. I The daughter f o l l o w e d , tha t her f a t h e r s a i d t ha t i f he c o u l d n ' t l i v e w i th her he would want to go home a lone. How would you deal w i th t h a t f o r Mr. ' D ' ? P W e l l , i f I d i d n ' t th ink he cou ld manage we would have a home v i s i t , people look to see what the home s i t u a t i o n was l i k e and a f t e r t hey ' v e done t h i s I 'd put them through the t h i r d degree to eva luate Mr. ' D ' s ' c a p a b i l i t i e s . And, between us we would come t o some conc lu s i on as to whether we would encourage him t o go home w i t h or w i thou t some a s s i s t ance or whatever community support would be a v a i l a b l e . Or whether some a l t e r n a t i v e l i v i n g arrangement should beg in. And from the i n fo rmat ion g iven I d on ' t th ink I can say what should or s h o u l d n ' t be. I Going back to a po i n t you made at the beginning about l e a v i n g the hot pack on, you mentioned how some p a t i e n t s would do t h a t f o r some t h e r a p i s t s but not f o r o the r s . What do you th ink i s the nature of t h a t k i nd of r e l a t i o n -sh ip between the p a t i e n t and the hea l th p r o f e s s i o na l ? P Some people have a very f o r c e f u l p e r s o n a l i t y . They impose i t w i thou t even attempt ing t o . Some p a t i e n t s respond one way to one p r o f e s s i ona l and a d i f f e r e n t way to another. And sometimes the very f o r c e f u l p e r s o n a l i t y , i f they apply t h e i r techniques i n an aggress ive way w i l l se t up defence mechanisms w i t h the p a t i e n t so tha t t h e y ' l l r e s i s t i n s tead of cooperate -and other t imes how the t h e r a p i s t approaches the p a t i e n t can have a great i n f l u e n c e on what the p a t i e n t does or does not do. I O 'kay, thank you very much. That concludes the i n t e r v i e w . I t would be b e n e f i c i a l to the study i f you d i d not d i s cus s w i th other s t a f f the s p e c i f i c content or quest ions of the i n t e r v i e w . A general r epo r t of the study w i l l be presented f o l l o w i n g the a n a l y s i s of the da ta , but do you have any quest ions a t t h i s time? 105 Matching P a t i e n t C h a r a c t e r i s t i c s and Circumstances Though many of the p r o f e s s i o n a l s commented on the s i m i l a r i t i e s of the problems f a c i n g the ' p a t i e n t s ' only one commented on the ' apparent ' d u p l i c a t i o n of p a t i e n t a t t r i b u t e s such as age, m a r i t a l s t a t u s , accommodation, e t c . D i f f e r e n c e s between p r o f e s s i o n a l ' s e va l ua t i on of the d i sease a l s o became ev ident . L e f t s ided d i s a b i l i t y i n d i c a t e d to many p r o f e s s i o n a l s a t Holy Family a worse out look f o r the p a t i e n t ' s response to treatment and/or f u n c t i o n a l recovery . But these f e e l i n g s d i d not cross a l l p r o f e s s i o n a l s and appeared to be r e l a t e d more to a ' s choo l of thought ' shared by those i n a common s e t t i n g . Another v a r i a b l e which had matching d i f f i c u l t y was hear ing/speak ing. Each was presented as ' d i f f i c u l t ' but the p a t i e n t r e t a i ned some capac i t y f o r e f f e c -t i v e i n t e r a c t i o n . Th i s v a r i a b l e was i nc luded to add to the dimensions of r i s k and c l u s t e r of pathology. Most p a r t i c i p a n t s chose not to comment or made pass ing comments and d i d not cons ider i t to be a c r i t i c a l v a r i a b l e . A couple though weighted dysar threa a g reate r problem than near ing d i f f i c u l t y and i n -creased the r i s k dimension of the one over the o ther . 106 APPENDIX 2 Th i s appendix conta in s a sample of the study ques t i onna i re and an example of some of the m o d i f i c a t i o n s made from Haug and Lav i n (1981). Study Ques t i onna i re " R e h a b i l i t a t i o n : P r o f e s s i o na l and P a t i e n t Behav ior " The f o l l o w i n g quest ions seek to ob ta in i n fo rmat ion from p ro f e s s i ona l s ^ concern ing t h e i r a t t i t u d e s about the way i n which p r o f e s s i o na l s ^ and p a t i e n t s should behave i n order to make hea l th dec i s i on s most e f f e c t i v e f o r p a t i e n t s . There are no ' r i g h t ' or 'wrong ' answers as one would expect p r a c t i t i o n e r s to have d i f f e r i n g op in ions about t h i s t o p i c . I t i s more b e n e f i c i a l f o r the study i f you do not d i scus s the quest ions w i th others before answering. I t i s recommended t ha t knowing more about the s i t u a t i o n s presented i n each quest ion would be d e s i r a b l e i n order to make an informed d e c i s i o n . But w i t h no f u r t h e r i n fo rmat ion prov ided p lease i n d i c a t e your agreement or disagreement wi th the f o l l o w i n g statements on a s c a l e of 1 to 4. 1. I t i s very important f o r p a t i e n t s to comply w i t h what p r o f e s s i o n a l s adv i se . 1 2 3 4 s t r ong l y agree d i sagree s t r ong l y agree d i sagree In making hea l th d e c i s i o n s , p r o f e s s i o n a l s ought to take the p a t i e n t ' s op in ion i n t o account. 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 3. Even i f a p a t i e n t asks to read h i s own medical r eco rd s , he should not be a l lowed to do so. 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 1 The ques t i onna i re s sent to each of the d i s c i p l i n e ' s had the s p e c i f i c d i s c i p l i n e ' s name s u b s t i t u t e d wherever ' p r o f e s s i o n a l ' appears, unless i n d i c a t e d otherwi se. 2 ' P r o f e s s i o n a l ' was used here f o r a l l que s t i onna i r e s . 107 4 . I f p r o f e s s i o n a l s would d i scuss matters more w i th p a t i e n t s before a c t i n g , everybody would be b e t t e r o f f . 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 5. P a t i e n t s should not be a l lowed to re fuse t reatment. 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 6. Even i f no p o t e n t i a l harm to any other person i s i n v o l v e d , a p a t i e n t should not be a l lowed to leave the h o s p i t a l when the doctor * does not agree. s t r ong l y agree 2 agree d i sagree s t rong l y d i sagree I t i s a l l r i g h t f o r p a t i e n t s to r a i s e quest ions w i th p r o f e s s i o n a l s about anything they adv i se . 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree In t h i s next s e c t i o n , 4 cases are presented i n which you can assume the p a t i e n t to be menta l l y competent. A f t e r read ing the case presented, i n d i c a t e your agreement or disagreement on a s c a l e of 1 to 4 w i th the p o s s i b l e responses t ha t f o l l o w . Case 1. A p a t i e n t suggests tha t what you advised was too much t r o u b l e . You d i s cus s the reasons behind your adv ice but he s t i l l re fuses to comply. Would you: 8. Go to t r e a t another p a t i e n t f e e l i n g t h a t otherwise you are not us ing your time p r o d u c t i v e l y ; 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 3 ' D o c t o r ' was used here f o r a l l que s t i onna i r e s . 108 9. Try to persuade him to g ive i t a t r y ; 1 2 3 4 s t rong ly agree d i sagree s t rong ly agree d i sagree 10. D iscuss other a l t e r n a t i v e s t h a t might be e a s i e r . 1 2 3 4 s t rong ly agree d isagree s t rong ly agree d i sagree Case 2. A p a t i e n t suggests t ha t what you advised i s not necessary f o r h i s c o n d i t i o n and asks f o r something d i f f e r e n t t ha t you f e e l i s i n e f f e c t i v e . Would you: 11. Help him ob ta i n what he has requested; 1 2 3 4 s t rong ly agree d i sagree s t rong ly agree d i sagree 12. T e l l him he w i l l have t o see someone e l s e to get what he has requested. 1 2 3 4 s t rong ly agree d i sagree s t rong l y agree d i sagree 13. Try to e xp l a i n why your suggest ion i s b e t t e r than h i s . 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree Case 3. A p a t i e n t asks to attend a meeting t ha t was meant only f o r p r o f e s -s i o n a l s ^ to d i scuss the p a t i e n t ' s behav ior . What do you f e e l should be done: 14. A l low him to a t tend ; 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 4 ' P r o f e s s i o n a l ' was used here f o r a l l que s t i onna i r e s . 109 15. Refuse him permiss ion to a t t end ; s t rong l y agree 2 agree d i sagree s t rong l y d i sagree 16. T e l l him you w i l l arrange another meeting f o r him to a t t end . 1 s t rong l y agree 2 agree d i sagree s t r ong l y d i sagree Case 4 . A p a t i e n t has appeared unmotivated dur ing t reatment. He has re fused c o u n s e l l i n g and other e f f o r t s to exp lo re the problem. A p a t i e n t conference, between p r o f e s s i o n a l s ^ has been c a l l e d to d i scuss how to re so l ve the problem. Would you recommend: 17. Discharge the p a t i e n t so t h a t the f a c i l i t y can be used more p r oduc t i v e l y f o r someone e l s e ; s t rong l y agree 2 agree d i sagree s t rong l y di sagree 18. Implement a s pec i a l help programme f o r the p a t i e n t ; s t rong l y agree 2 agree d i sagree 4 s t rong l y d i sagree 19. Continue as before and l e t him make the f i r s t move to 'come around' s t r ong l y agree 2 agree d i sagree s t rong l y d i sagree 5 ' P r o f e s s i o n a l ' was used here f o r a l l que s t i onna i r e s . 110 I n d i c a te you agreement or disagreement w i t h the f o l l o w i n g statements on a s ca l e o f 1 to 4. 20. The p a t i e n t i n the l a s t stages o f a te rmina l i l l n e s s , should decide i f f u r t h e r treatment should be cont inued. 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 21. When d i s cu s s i n g treatment programs w i th p a t i e n t s p r o f e s s i o n a l s ought to make the f i n a l dec i s i on about what the p a t i e n t should do. 1 . 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 22. Most t e r m i n a l l y i l l p a t i e n t s should not be t o l d the prognos is even i f requested by them. s t rong l y agree 2 agree d i sagree s t r ong l y di sagree 2 3 . 6 I f no abno rma l i t i e s show up i n p a t i e n t ' s symptoms are probably 1 2 s t r ong l y agree agree the l ab r e s u l t s or phy s i ca l exam, a psycho-somat ic. 3 4 d i sagree s t rong l y d i sagree 24. A p a t i e n t ' s d i agnos i s should always be made complete ly c l e a r to him. 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 25. I t i s very important f o r p a t i e n t s to r e l y on t h e i r own judgment and make t h e i r own dec i s i on s about what p r o f e s s i o n a l s adv i se . 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 6 The p r o f e s s i o n a l s overwhelmingly ' d i s a g r e e d ' or ' s t r o n g l y d i sag reed ' w i th t h i s statement. Because of l i m i t e d va r iance the re was no f u r t h e r con s i de ra t i on of t h i s que s t i on . I l l 26. I f p r o f e s s i o n a l s would d i s cus s l e s s w i t h p a t i e n t s and t e l l them s t r a i g h t out what to do, everybody would be b e t t e r o f f . 1 2 3 4 s t r ong l y agree d i sagree s t rong l y agree d i sagree 27. P a t i e n t s should have complete f a i t h i n p r o f e s s i o n a l s and do what they adv ise w i thout a l o t of ques t i on s . 1 2 3 4 s t rong ly agree d isagree s t rong l y agree d isagree The f o l l o w i n g quest ions seek your op in ion on r e l a t i o n s h i p s i n gene ra l . 28. In making f am i l y d e c i s i o n s , parents ought to take the op in i on o f the teenagers i n t o account. 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 29. Respect f o r a u t h o r i t y i s the most important t h i ng teenagers should l e a r n . 1 2 3 4 s t r ong l y agree d i sagree s t r ong l y agree d i sagree 30. I t ' s a l l r i g h t f o r people to r a i s e quest ions about even the most s e n s i t i v e mat te r s . 1 2 3 4 s t r ong l y agree d i sagree s t r ong l y agree d i sagree 31. For the most p a r t , i f people would t a l k l e s s and work more, everybody would be b e t t e r o f f . 1 2 3 4 s t rong l y agree d i sagree s t r ong l y agree d i sagree 112 32. Parents ought to have the main say-so i n dec id i ng what to do about a teenager ' s problems. 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 33. Everybody should have f a i t h i n some a l l - p o w e r f u l f o r ce t h a t guides de s t i ny . 1 2 3 4 s t rong l y agree d i sg ree s t rong l y agree d i sagree 34. For the most p a r t , i f everybody would d i scuss matters before a c t i n g , everybody would be b e t t e r o f f . 1 2 3 4 s t r ong l y agree d i sagree s t r ong l y agree d i sagree 35. Re l y i ng on t h e i r own judgments and making t h e i r own dec i s i on s are the most important th ings teenagers should l e a r n . 1 2 3 4 s t rong l y agree d i sagree s t rong l y agree d i sagree 113 T H E U N I V E R S I T Y OF BRITISH C O L U M B I A Faculty of Medicine Consent Form In the s p i r i t o f r e h a b i l i t a t i o n ph i losophy, p r o f e s s i o n a l s attempt to take i n t o account p a t i e n t behavior i n order to enhance treatment outcome and p a t i e n t w e l l - b e i n g . The purpose of t h i s s tudy , ' P l a n n i n g f o r P a t i e n t D i scharge: How R e h a b i l i t a t i o n P r o f e s s i o na l s View P a t i e n t B e h a v i o r ' , i s t o c o l l e c t i n fo rmat ion about how p r o f e s s i o n a l s f e e l they and p a t i e n t s should best behave i n order to make treatment plans most e f f e c t i v e and i n t h i s i n t e r e s t , how do they assess p a t i e n t behav ior ? The study forms par t of the requirements of the M.Sc. Program i n Health Se rv i ce s P lann ing and Adm in i s t r a t i on a t U.B.C. I t i s o f b e n e f i t to me i n a c q u i r i n g the s k i l l s o f research. In the f a c i l i t y ' s i n t e r e s t I have agreed to present the r e s u l t s and conc lus ions back to you at a time arranged i n June. The f a c i l i t y w i l l have ongoing access to t h i s i n f o rmat i on so t h a t you may cont inue to use i t i n d i s c u s s i o n s . The study i n vo l ve s a 15 minute ques t i onna i re and a h a l f - h o u r i n t e r -view arranged w i t h i n the f o l l o w i n g s i x weeks at a convenient t ime of the workday. P a r t i c i p a t i o n i s vo l un ta r y . You have the r i g h t to withdraw at any time or re fuse to answer any quest ion wi thout f e a r of s a n c t i o n . To make no te - t a k i n g e a s i e r wh i l e we t a l k I w i l l ask your permis s ion to record the i n t e r v i e w . This i s not an e s s e n t i a l procedure though, so i f you f e e l uncomfortable about tap ing do not h e s i t a t e to re fuse when I ask. Your s i gna tu re on t h i s form represents consent to the que s t i onna i r e and the i n t e r v i e w and to acknowledge r e c e i p t of a copy o f t h i s consent form, a t tached . P lease r e tu rn the consent form and completed que s t i onna i r e form as soon as p o s s i b l e i n the attached envelope. Thank you! Car l a Palmer Student Hea l th Se rv i ce s P lann ing and A d m i n i s t r a t i o n Program UBC S i gna tu re : Department: Date: 113a An example of the m o d i f i c a t i o n s made: A 2 - po i n t s c a l e quest ion such as s e l e c t i n g from, I t i s most important to comply w i t h what phys i c i an s adv i se or I t i s most important f o r p a t i e n t s to r e l y on t h e i r own judgment and make t h e i r own dec i s i on s about what phy s i c i an s adv ise was changed to the form shown i n quest ions 1 and 25. 114 APPENDIX 3 D i s t r i b u t i o n of F a c t o r Scores In the cha r t below the d i s t r i b u t i o n of scores f o r f a c t o r s 1 to 6 are r e f l e c t e d by Comparison of K u r t o s i s and skewness va lues . Tab le XVII K u r t o s i s and Skewness values of f a c t o r s 1 to 6 Fac to r K u r t o s i s Skewness 1 -0.631 -0.042 2 -0.099 -0.270 3 1.271 -0.859 4 -0.851 -0.008 5 1.872 -0.934 6 1.369 -0.586 Fac to r s 1 and 4 show f l a t t e r curves than a normal d i s t r i b u t i o n but have r e t a i ned a degree of symmetry. F ac to r 2 i s c l o se to a normal d i s t r i b u t i o n but c l u s t e r s somewhat to the r i g h t . Fac to r s 3 , 5 and 6 are more peaked than a normal d i s t r i b u t i o n and show a c l u s t e r i n g to the r i g h t w i t h more extreme values to the l e f t . 115 APPENDIX 4 R e l a t i o n of Fac to r s t o P r o f e s s i o n a l A t t r i b u t e s Th i s s e c t i o n d i scusses the p r o f e s s i ona l a t t r i b u t e s tha t account, i n p a r t , f o r the d i s t r i b u t i o n of f a c t o r s scores . The d i s t r i b u t i o n of f a c t o r scores i n f a c t o r s 1, 5 and 6 show no s i g n i f i c a n t r e l a t i o n to the p r o f e s s i ona l a t t r i b u t e s . However some of the var iance i n f a c t o r s 2, 3 and 4 i s exp la ined by these a t t r i b u t e s . The age of the p ro fe s -s i o n a l s c o r r e l a t e s p o s i t i v e l y w i th f a c t o r 3 (P=.01) but the r e l a t i o n w i th f a c t o r 4 (P=.06) was spur ious when other v a r i a b l e s were he ld constant . Thus i n c r ea s i n g age i n d i c a t e s h igher scores i n f a c t o r 3 ( g i v i n g and f o l l o w i n g a d v i c e ) . Table XVII E x p l a i n i n g the d i s t r i b u t i o n of f a c t o r scores : Pearson R c o r r e l a t i o n s f o r age, years a t the f a c i l i t y and a t t i t u d e to a u t h o r i t y . Fac to r Age Years a t the A t t i t u d e to F a c i l i t y Au tho r i t y 1 .07 -.12 .11 p=.67 p=.46 p=.46 2 -.25 -.04 .43 p=.12 p=.79 p<.01 3 .42 .20 • 14 p=.01* p=.18 p=.35 4 - .30 -.36 .58 p=.06* p=.02* p<.001 5 -.16 -.16 .04 p=.32 p=.29 p=.82 6 -.01 .06 .24 p=.97 p=.68 p=.12 116 Number o f yea r s exper ience a t the f a c i l i t y c o r r e l a t e s n e g a t i v e l y w i t h f a c t o r 4 (P=.02). Thus the fewer yea r s o f exper ience a t the f a c i l i t y , the h i ghe r the score on f a c t o r 4 ( P a t i e n t f a i t h i n p r o f e s s i o n a l a d v i c e ) . A t t i t u d e t o a u t h o r i t y i n general c o r r e l a t e s p o s i t i v e l y w i t h both f a c t o r s 2 (P=.003) and 4 (P<.0001). Thus the h i ghe r the score on a t t i t u d e the h i ghe r the scores a l s o on f a c t o r 2 ( Judg ing p a t i e n t w e l f a r e ) and f a c t o r 4 ( P a t i e n t f a i t h i n p r o f e s -s i ona l a d v i c e ) . A t t i t u d e a l s o c o r r e l a t e s n e g a t i v e l y w i t h age (P<.01) and w i t h yea r s a t the f a c i l i t y (P<.05). No s i g n i f i c a n t r e l a t i o n was seen between country of t r a i n i n g and a t t i t u d e i n one-way a n a l y s i s o f v a r i a n ce (P=.54). The r e l a t i o n s h i p between f a c t o r scores and s p e c i a l t y was examined through one-way a n a l y s i s of v a r i a n c e . These r e s u l t s are presented i n the t a b l e below. T a b l e XIX One-way a n a l y s i s o f v a r i ance between f a c t o r scores and s p e c i a l t y , G.F. S t rong and Holy Fami ly H o s p i t a l s Combined. F a c t o r S p e c i a l t y (Combined GFS & HFH) Phys. P.T. O.T. Nurs. N=l l N=12 N=10 N=10 1 .0538 .0642 -.1712 -.1079 P=.94 2 -.3945 .6161 -.0952 -.1485 P=.04* 3 .0645 -.7127 .0596 .4945 P<.01* 4 -.5456 .2663 .3237 -.1655 P= .07* 5 -.1370 .0179 .0506 .0237 P=.96 6 .4864 -.1285 .0479 -.4496 P=.12 F a c t o r s 1, 5 and 6 show no r e l a t i o n t o s p e c i a l t y , however, some of the va r i ance i n f a c t o r 3 (P<.01) i s accounted f o r by the d i v i s i o n i n t o s p e c i a l t i e s . The r e l a t i o n s h i p s w i t h f a c t o r s 2 and 4 were shown by p a r t i a l c o r r e l a t i o n s to be spu r i ou s . 117 D i v i s i o n of the f a c t o r scores was repea ted , t h i s t ime by r e l a t i o n w i t h two c a t e g o r i e s o f country o f t r a i n i n g . The t a b l e below p resent s these r e s u l t s . Tab le XX One-way a n a l y s i s between f a c t o r scores and country of t r a i n i n g F a c t o r Country o f T r a i n i n g Canada N=24 Combined Canada/UK* N=16 P r o b a b i l i t y 1 .1293 -.2344 p=.25 2 -.0755 .1368 p=.44 3 -.0692 .1255 p=.50 4 .1828 -.3314 p= .06* 5 .0809 -.1465 p=.43 6 -.0397 .0720 p=.69 * t h i s i n c l u d e s one a l s o from Peru F a c t o r 4 (P=.06) was the only f a c t o r t o show s i g n i f i c a n t r e l a t i o n to country o f t r a i n i n g . In t h i s c a se , those w i t h combined t r a i n i n g accounted f o r the lower s co re s . And f i n a l l y , one-way a n a l y s i s of v a r i ance between f a c t o r scores and f a c i l i t y showed no s i g n i f i c a n t r e s u l t s . 118 

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