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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 o f T o r o n t o 1979  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning and A d m i n i s t r a t i o n ) in  THE FACULTY OF GRADUATE STUDIES (Department o f H e a l t h C a r e and E p i d e m i o l o g y ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA O c t o b e r 1984 ©  C a r l a Ruth P a l m e r , 1984  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may  be granted by the head o f  department or by h i s or her  representatives.  my  It is  understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be allowed without my  permission.  Department O f  H e a l t h Care and  The U n i v e r s i t y of B r i t i s h 1956 Main Mall Vancouver, Canada V6T  1Y3  Date  October 3.  1984  Epidemiology  Columbia  written  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 v a l u e s  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 r o f e s s i o n a l  dominance i s entrenched i n the i n s t i t u t i o n .  Since  this  i n t e r a c t i o n u n d e r l i e s much o f 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 , w i t h t h e e n s u i n g c o s t s and b e n e f i t s o f concern t o 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 ' undergoes  ongoing  f a m i l i e s and governments  s c r u t i n y by both the p u b l i c and governments.  then t o a s s e s s the p r o f e s s i o n a l ' s  response  t o the c h a l l e n g e .  d i r e c t i o n s o f the c h a l l e n g e , and the l a g g i n g o f the response  as the b i l l - p a y e r s ,  response,  It  is  it  important  With t h e f u t u r e  unknown, the i m p l i c a t i o n s  are o b s c u r e d .  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 c h a l l e n g e t o  professional  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  patient.  Whereas, t r a d i t i o n a l l y , p r o f e s s i o n a l s  decisions  through the a p p l i c a t i o n o f t h e i r e x p e r t i s e , i t was h y p o t h e s i z e d  how the p r o f e s s i o n a l  b e l i e v e they make h e a l t h that  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 was  p r e d i c t e d t o 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 decisions. Questionnaires physicians, workers —  and i n t e r v i e w s were g i v e n t o t h i r t y - n i n e p r o f e s s i o n a l s  physiotherapists,  occupational t h e r a p i s t s , nurses,  a t G.F. S t r o n g and Holy F a m i l y H o s p i t a l s .  the p r o f e s s i o n a l ' s  and s o c i a l  The q u e s t i o n n a i r e  r o l e as a ' c o n t r o l l e r ' ( b e l i e v e s t h a t t h e p r o f e s s i o n a l  ii  --  measured should  assume t h e 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 'accomrnodator'  t h e p a t i e n t s h o u l d 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 ) . r o l e , presented to these p r o f e s s i o n a l s  (believes The  that  patient's  i n t h e i n t e r v i e w , was f a b r i c a t e d i n two  c a s e s t u d i e s i n w h i c h t h e p a t i e n t ' s b e h a v i o r was c o n s i s t e n t w i t h t h a t o f a 'consumer'  ( w i s h e s t o assume t h e 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 )  'traditional bility  dependent'  p a t i e n t (wishes the p r o f e s s i o n a l  for health decisions).  t o assume  or a  responsi-  In t h e i n t e r a c t i o n between t h e p r o f e s s i o n a l  and  each o f t h e p a t i e n t r o l e s , t h e p a t i e n t was r e p o r t e d t o d i s a g r e e w i t h t h e p r o fessional's  decision.  In t h i s c o n t e x t , t h e p r o f e s s i o n a l  d e s c r i b e and d e a l w i t h t h e p a t i e n t ' s  behavior.  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 two-way a n a l y s i s o f v a r i a n c e .  was asked t o e x p l a i n ,  r o l e and p a t i e n t r o l e was a s s e s s e d by  The h y p o t h e s i s was s u p p o r t e d f o r t h e d i m e n s i o n s  o f d e s c r i b i n g and d e a l i n g b u t not f o r e x p l a i n i n g .  I t was c o n c l u d e d t h a t  this  provided p r e l i m i n a r y evidence 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 , p a r t , the p r o f e s s i o n a l ' s patient  response to challenge to the t r a d i t i o n a l  in  professional-  relationship.  The t r a d i t i o n a l p r o f e s s i o n a l to the c h a l l e n g e .  r o l e was c o n s i d e r e d as e v i d e n c e o f  The i m p l i c a t i o n s o f t h e r e s i s t a n c e were c o n s i d e r e d i n  o f f o u r s c e n a r i o s w h i c h combined 1)  the d i r e c t i o n of the pro-  r e s i s t a n c e , t h a t i s to increase or decrease.  from t h e 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) that is professional  terms  the f u t u r e d i r e c t i o n of the trend 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 o r d e c r e a s e , and 2) fessional's  resistance  The o p t i o n s  following  return to the status  quo,  dominance i n t h e i n s t i t u t i o n ; 2) accommodation o f t h e  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)  iii  professional  and  p a t i e n t f i g h t t o determine who i s i n c h a r g e , and 4) n e i t h e r the p r o f e s s i o n a l  nor  p a t i e n t take charge. I t was recommended t h a t 1)  researchers  develop a d d i t i o n a l s t u d i e s  to  f u r t h e r d e f i n e t h e s i t u a t i o n and t o m o n i t o r the d i r e c t i o n o f the t r e n d s ; and 2) that professionals  and t h e i n s t i t u t i o n , a) r e d e f i n e the t r a d i t i o n a l  concepts  such as ' t e a m ' and t h e 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  and  p a t i e n t , and b) d i s c u 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 r e n d s s h o u l d go, and t h e i n t e r v e n t i o n s t h a t would b e s t d i r e c t them.  i v  TABLE OF CONTENTS Page  I  Abstract  ii  L i s t of Tables  vi  L i s t of Figures  viii  Acknowledgement  x  Introduction:  The C h a l l e n g e t o P r o f e s s i o n a l - D o m i n a n t Role Asymmetry i n the R e h a b i l i t a t i o n Setting  II  Theory:  III  Methods  28  Findings  61  IV V  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 R o l e s  1  Discussion:  I m p l i c a t i o n s : A Lag between S o c i e t a l Trends and P r o f e s s i o n a l Response  Bibliography  13  80  91  Appendices: 1  Interview  96  2  Questionnaire  107  3  D i s t r i b u t i o n o f F a c t o r Score  115  4  R e l a t i o n of Factors to P r o f e s s i o n a l A t t r i b u t e s  116  v  LIST OF TABLES Page  I II III IV  De M i g u e l ' s  Policy Analysis  7  Framework  Study Sample A c c o r d i n g t o S p e c i a l t y  31  V a r i a b l e s r e f l e c t i n g the circumstances of the p a t i e n t case s t u d i e s  36  (A) (B)  50 51  F a c t o r 1. The p a t i e n t ' s r o l e as a team member A l t e r n a t e Perceptions of the P r o f e s s i o n a l ' s Role R e g a r d i n g t h e P a t i e n t ' s R o l e as a Team Member  V  Factor 2.  Judging P a t i e n t Welfare  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 A d v i c e  53  VII  F a c t o r 4.  Patient Faith i n Professional  VIII  F a c t o r 5.  U t i l i z a t i o n of the Centre  55  IX  Factor 6.  Who S h o u l d Assume R e s p o n s i b i l i t y f o r Health Decisions  56  X XI  XII  XIII XIV  XV  XVI  XVII  Advice  54  D i f f e r e n c e s i n Range i n F a c t o r S c o r e s Between F a c t o r s  57  E x p l a i n i n g t h e Consumerist P a t i e n t ' s Behavior: Partial 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 C o u n t r y o f T r a i n i n g With Control f o r Other V a r i a b l e s  71  E x p l a i n i n g t h e Dependent P a t i e n t ' s B e h a v i o r : Partial 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 with c o n t r o l f o r other v a r i a b l e s  72  Describing the P a t i e n t ' s Behavior: F a c t o r 1 and P a t i e n t Case Study  74  2-way ANOVA between  D e s c r i b i n g t h e Dependent P a t i e n t ' s B e h a v i o r : Partial 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 years 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 influence of other v a r i a b l e s  75  Dealing with the P a t i e n t ' s Behavior: F a c t o r 6 a n d P a t i e n t Case Study  2-way ANOVA between  77  Dealing with the P a t i e n t ' s Behavior: Partial Correlation 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  Kurtosis  and Skewness v a l u e s o f f a c t o r s 1 t o 6 vi  115  Page  XVIII  XIX  XX  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: P e a r s o n R. c o r r e l a t i o n s f o r age, y e a r s a t t h e 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  116  One-way a n a l y s i s o f v a r i a n c e between f a c t o r s c o r e s and s p e c i a l t y , G . F . S t r o n g and Holy F a m i l y combined  117  One-way a n a l y s i s o f v a r i a n c e between f a c t o r s c o r e s and c o u n t r y o f t r a i n i n g  118  vii  LIST OF FIGURES Page  1.  B l o o m ' s model o f t h e 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  19  3.  Modes o f I n t e r a c t i o n between t h e P r o f e s s i o n a l and P a t i e n t  22  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  25  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  26  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  27  7.  A Framework I n t e g r a t i n g t h e assumption o f t h e 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 , t h e c a t e g o r i e s o f r e s p o n s e s , and t h e a c t u a l r e s p o n s e s 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 t h e p a t i e n t r o l e s  43  8.  P r o f e s s i o n a l Responses t o P a t i e n t R o l e s P r e s e n t e d i n the Interview  58  9.  Modes o f I n t e r a c t i o n Between t h e 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 Behavior: P a t t e r n of Responses, G . F . S t r o n g and H o l y F a m i l y H o s p i t a l s Combined  63  11.  D e s c r i b i n g the P a t i e n t ' s Behavior: P a t t e r n o f Responses, G . F . S t r o n g and H o l y F a m i l y H o s p i t a l s Combined  64  12.  Dealing with the P a t i e n t ' s Behavior: G.F. Strong  P a t t e r n of Responses,  65  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 Behavior 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 of Responses, G.F. S t r o n g  67  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i t e d t o be r e l a t e d  69  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  73  C i r c l e of I n t e r e s t s  viii  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  76  17.  The C o n t e x t and Approach t o Study o f t h e 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 t o t h e T r a d i t i o n a l P r o f e s s i o n a l Patient Relationship  81  18.  D i f f e r i n g P e r s p e c t i v e s o f t h e 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 y o f t h e C o s t s and B e n e f i t s o f D i s c h a r g e D e c i s i o n s F o l l o w i n g from P r o f e s s i o n a l - D o m i n a n t and P a t i e n t - D o m i n a n t Asymmetry  84  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 t h e t r e n d o f c h a l l e n g i n g b e h a v i o r and t h e degree o f p r o f e s s i o n a l resistance  88  ix  ACKNOWLEDGEMENT  I  g r a t e f u l l y acknowledge t h e a s s i s t a n c e p r o v i d e d by many p e r s o n s and  organizations.  I n p a r t i c u l a r , I would l i k e t o r e c o g n i z e my a d v i s o r , D r .  W a x i e r M o r r i s o n , f o r h e r u n w a v e r i n g s u p p o r t and d i r e c t i o n . committee members, D r s .  Nancy  I n a d d i t i o n , my  Anne C r i c h t o n and L y n J o n g b l o e d , made v a l u a b l e c o n t r i -  b u t i o n s t o my u n d e r s t a n d i n g o f t h e c o n t e x t and development o f t h e s t u d y . S p e c i a l m e n t i o n must be made o f t h e a d m i n i s t r a t i v e and c l i n i c a l t h e f a c i l i t i e s w h i c h a g r e e d t o p a r t i c i p a t e i n 1) G e n e r a l H o s p i t a l , and i n 2)  s t a f f of  the p i l o t s t u d y , Vancouver  t h e a c t u a l s t u d y , G . F . S t r o n g and H o l y F a m i l y  Hospitals. Many o f my c o l l e a g u e s , w i t h i n t h e S c h o o l  o f R e h a b i l i t a t i o n M e d i c i n e and t h e  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 P r o g r a m , 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 of the study.  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 R o n n i e S i z t o and Wayne J o n e s i s a l s o a p p r e c i a t e d . F i n a l l y , t o my husband, Bob, who took t i m e from h i s own work t o p r o v i d e editorial  a s s i s t a n c e , b e l o n g s t h e most c r e d i t f o r t h e c l a r i t y and c o n s i s t e n c y  the p r e s e n t a t i o n of  ideas.  x  of  INTRODUCTION  The a c c e p t a n c e o f t h e 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 the p r o v i s i o n of health s e r v i c e s  is longstanding.  The i n s t i t u t i o n i s  for  consi-  d e r e d 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 p u 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 , professionals  who, by o v e r s e e i n g  distribute services of the t r a d i t i o n a l Freidson  tional  a r e a l l o c a t e d by  p a t i e n t need, demand, and s u p p l y ,  t o s e r v e t h e common good.  can  T h i s , a t l e a s t , i s the  philosophy  perspective.  (1972) and o t h e r s  t h i s point of view.  since these s e r v i c e s  ( f o r example Roth and Eddy, 1967)  They q u e s t i o n t h e p r o f e s s i o n a l ' s  r o l e and p o i n t t o t h e u n d e s i r a b l e ,  independent of i t s s t a t e d g o a l .  have  debated  competence i n t h i s  tradi-  i n d i r e c t e f f e c t s of the i n s t i t u t i o n ,  The i n t e n t o f t h i s t h e s i s  i s to look at  this  debate i n g r e a t e r d e t a i l , from t h e p e r s p e c t i v e o f t h e i n t e r a c t i o n between p r o fessionals  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 t h e h e a l t h c a r e system.  The terms o f t h i s r e l a t i o n s h i p a r e c o n s i d e r e d by many t o u n d e r l i e  the u t i l i z a t i o n of h e a l t h s e r v i c e s . p o t e n t i a l l y concern v a r i o u s governments.  The subsequent  1  t h i r d p a r t i e s such as p a t i e n t s '  families  and  As e x a m p l e s , a f a m i l y c o u l d be c o n c e r n e d about t h e a v a i l a b i l i t y o f  d i s c h a r g e o p t i o n s , and t h e government Consequently,  c o s t s and b e n e f i t s  about who w i l l  t h e r e l a t i o n s h i p undergoes  ongoing  pay f o r them.  s c r u t i n y by t h e p u b l i c  and  governments.  1 R a d i c a l views such as t h a t the r e l a t i o n s h i p i s such as e c o n o m i c s . This s p e c t i v e on t h e scope o f  t h o s e o f N a v a r r o (1977) and I l l i c h (1976) s u g g e s t i n s i g n i f i c a n t i n t h e c o n t e x t o f l a r g e r s o c i a l systems v i e w w i l l not be d i s c u s s e d f u r t h e r b u t does p u t a p e r t h i s treatment of the t o p i c . 1  W i t h i n s o c i e t y , t h e i n t e r e s t s o f t h e p r o f e s s i o n a l , p a t i e n t and v a r i o u s p a r t i e s a r e r e l a t e d and b a l a n c e d . a f t e r r o l e asymmetry interaction. decisions.  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  i n which the p r o f e s s i o n a l  That i s , the professional  third  patterned  i s t h e dominant p a r t n e r i n t h e  assumes r e s p o n s i b i l i t y f o r h e a l t h  P r e s e n t l y , however, a s h i f t i n t h e s e f o r c e s i s o c c u r r i n g i n a number  o f ways, one o f them a p p e a r i n g i n t h e form o f 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 t h e 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 t h e ensuing p r o f e s s i o n a l  response i s  important.  The n a t u r e o f t h e t r a d i t i o n a l r e l a t i o n s h i p , t h e c h a l l e n g e t o i t i n t h e clinical  e n v i r o n m e n t , and t h e i m p l i c a t i o n s o f both can be d e s c r i b e d d i f f e r e n t l y  depending on t h e f o c u s o f o n e ' s p e r s p e c t i v e . analyst,  sociologist,  differently.  The e c o n o m i s t , p h i l o s o p h e r ,  and h e a l t h a d m i n i s t r a t o r w i l l  This thesis  considers  policy  each i n t e r p r e t t h e c h a l l e n g e  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 balance 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 setting.  An a c t u a l c a s e w i l l  be p r e s e n t e d i n t h i s c h a p t e r and t h e n a s s e s s e d  u s i n g t h e d i f f e r e n t v i e w s , w i t h t h e p o l i c y a n a l y s t p r o v i d i n g t h e c o n t e x t f o r an empirical logical data. study.  assessment o f t h e s i t u a t i o n .  p e r s p e c t i v e which w i l l  The second c h a p t e r o u t l i n e s t h e  socio-  provide 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  The t h i r d and f o u r t h c h a p t e r s d e s c r i b e t h e methods and f i n d i n g s  of the  And t h e f i f t h c h a p t e r , through t h e p e r s p e c t i v e o f t h e p r o f e s s i o n a l s  i n s t i t u t i o n , considers  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  organization of health s e r v i c e s . research w i l l  and  Also i n chapter f i v e , requirements f o r f u r t h e r  be c o n s i d e r e d , and recommendations  be d i r e c t e d t o t h e 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  r e s u l t i n g from t h e study  will  The scope o f 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  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 of r e h a b i l i t a t i o n . number o f r e a s o n s 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 . 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 between t h e p r o f e s s i o n a l  and p a t i e n t .  profes-  There a r e a  One, i n p a r t i c u l a r , i s  that  s e t s t h e terms o f t h e i n t e r a c t i o n  Though r e h a b i l i t a t i o n  professionals  o r g a n i z e as a team, each i s e x p e c t e d t o e s t a b l i s h a o n e - t o - o n e 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 examination 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  includes  c o n s i d e r a t i o n o f t h e team a p p r o a c h , but i t i s t h e i n t e r a c t i o n between i n d i v i d u a l professionals  and p a t i e n t s t h a t w i l l  be t h e b a s i s o f measurement i n t h i s  thesis.  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 , t h e f o l l o w i n g p a t i e n t c a s e study p r o v i d e s focus f o r the d i s c u s s i o n  Case  of 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  a  asymmetry.  Study 2 A l i c e Smith  i s a 32 y e a r o l d woman a d m i t t e d t o a g e n e r a l  w i t h an a c u t e e x a c e r b a t i o n o f m u l t i p l e s c l e r o s i s .  She was a s s e s s e d 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.  l e f t with residual  d e f i c i t s w h i c h s e v e r e l y l i m i t e d her p h y s i c a l  ability.  Discharge  F o l l o w i n g m e d i c a l s t a b i l i z a t i o n she was  p l a n n i n g had been an o n g o i n g  following circumstances:  process  3)  2  This  v o i c e d her  2) h e r f a m i l y l i v e d i n  she was p r e s e n t l y l i v i n g i n T o r o n t o and w i s h e d t o s t a y  she had a b o y f r i e n d o f t h r e e months d u r a t i o n , and 4)  benefits.  functional  and p r e s e n t e d t h e  1) t h e p a t i e n t had from t h e b e g i n n i n g  i n t e n t i o n o f r e t u r n i n g home a l o n e t o l i v e i n d e p e n d e n t l y , the M a r i t i m e s ;  hospital  Further, a hospital  she l i v e d on d i s a b i l i t y  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  i s a pseudonym and not h e r r e a l  name. 3  there,  physical  f u n c t i o n i n g and a f t e r no r e s p o n s e therapy;  the occupational  the c o s t s  t o t r e a t m e n t d i s c o n t i n u e d t h e p a t i e n t from  t h e r a p i s t a s s e s s e d t h e home s i t u a t i o n and p r e s e n t e d  r e q u i r e d f o r a t t e n d e n t h e l p and f o r r e n o v a t i o n 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 w o r k e r p r e s e n t e d a number o f d i s c h a r g e ranging  options  from home through s e m i - 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 n u r s i n g  department c o - o r d i n a t e d t h e team m e e t i n g  s e l e c t i n g from t h e d i s c h a r g e o p t i o n s .  Two p o l e s o f o p i n i o n emerged.  c o n s i d e r e d t h e p a t i e n t t o be d i f f i c u l t ,  and t o have l i m i t e d i n s i g h t  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 of s e r i o u s commended p r o t e c t i v e c a r e . 'guts',  w i t h t h e end o f The f i r s t i n t o her  i n j u r y i f s e n t home.  It  re-  The second o p i n i o n s u g g e s t e d t h a t t h e p a t i e n t had  t h a t h e r view was d i f f e r e n t from t h a t o f t h e t e a m ' s b u t j u s t i f i e d ,  t h a t h e r d e c i s i o n t o go home s h o u l d be r e s p e c t e d . where t h e c o s t s outcomes,  and  R e f l e c t e d i n t h e s e two v i e w s ,  and b e n e f i t s t o t h e 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  are d i f f e r e n c e s i n how t h e 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  dealt with a patient. The f o l l o w i n g e x a m i n a t i o n 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 fessionals'  v a r y i n g responses to the s i t u a t i o n i n the case study.  outcome o f t h i s c a s e , however, w i l l discussion  e x p l a i n the pro-  o f i m p l i c a t i o n s and  be c o n s i d e r e d i n t h e f i n a l  The a c t u a l  chapter,  recommendations.  3 P a t i e n t s a t t h i s c e n t r e do not a t t e n d r e g u l a r team m e e t i n g s . Physicians a l s o do not g e n e r a l l y a t t e n d but g i v e t a c i t a p p r o v a l t o d i s c h a r g e p l a n s by t h e i r s i g n a t u r e on t h e r e q u i r e d f o r m s .  4  V a r y i n g Views o f Asymmetry i n t h e P r o f e s s i o n a l - P a t i e n t Relationship: The E c o n o m i s t ' s P e r s p e c t i v e ' 4 The e c o n o m i s t  models t h e 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  agent-client relationship. sional  The c l i e n t seeks t h e e x p e r t a d v i c e o f t h e p r o f e s -  i n order to r e s o l v e the problem, t h a t i s , to get b e t t e r i f p o s s i b l e .  t h e c l i e n t ' s r e l i a n c e on c a u t i o n ( p a t i e n t beware) as a consumer,  is  But  compromised  in this interaction. R o l e asymmetry e x i s t s professional's patient.  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 o f t h e f a c t t h a t t h e  range o f t e c h n i c a l knowledge i s n o t r e a d i l y a c c e s s i b l e t o t h e  In t h i s way p r o f e s s i o n a l s  makes t h e ' b e s t '  d e c i s i o n about t h e k i n d o f  h e a l t h c a r e r e q u i r e d t o improve t h e i r p a t i e n t s '  health status, while  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 personal  value of t h e i r r e s u l t i n g  status'. level values  still  In M i s s . S m i t h ' s c a s e , she w o u l d have c o n s i d e r e d her r e s i d u a l  'health risk  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 o m p e t i t i o n w i t h o t h e r e n t i t i e s o r such as i n d e p e n d e n c e .  If  professionals.were  a d v o c a t e s o f p a t i e n t s , they would make d e c i s i o n s the p a t i e n t s themselves.  But p r o f e s s i o n a l s  such as p r e s t i g e , and o t h e r o b l i g a t i o n s of the h e a l t h system.  p e r f e c t agents,  or complete  f o r p a t i e n t s as i f t h e y were  have o t h e r i n t e r e s t s t o  consider,  t o a t t e n d t o , such as m o n i t o r i n g t h e use  These may not c o i n c i d e w i t h a p a t i e n t ' s p e r c e p t i o n o f  needs, nor w i t h t h e most e f f i c i e n t o r c o s t - e f f e c t i v e use o f t h e s y s t e m .  Thus  t h e p r o f e s s i o n a l , p a t i e n t a n d , e v e n , 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 n a l t h e m e d i c a l problem o f t h e p a t i e n t . 4 T h i s p e r s p e c t i v e i s d e s c r i b e d from t h e l e c t u r e notes o f D r . R o b e r t Evans from t h e c o u r s e , H e a l t h E c o n o m i c s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1983. 5  to  The P h i l o s o p h e r ' s  Perspective  The p h i l o s p h e r c o n s i d e r s sionals'  and p a t i e n t s '  the c i r c u m s t a n c e s  Decisions  profes-  terms o f i n t e r a c t i o n a r e j u s t i f i e d , a n d , 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 . f i c a t i o n ranging  under w h i c h t h e v a r i o u s  C a r l t o n (1978) p r e s e n t s  a continuum o f  from t h e c l i n i c a l , t h r o u g h t h e l e g a l , t o t h e moral  a r e made a t each o f t h e s e l e v e l s as t o what i s  'right'  perspective. 'wrong',  'acceptable'  or ' u n a c c e p t a b l e ' , ' p e r m i s s a b l e '  'optional'.  T h i s p e r s p e c t i v e o f c o u r s e , may change o v e r t i m e , p l a c e o r a c t o r as  society's  v a l u e s and b e l i e f s  Bassford  or ' f o r g i v a b l e ' ,  or  justi-  'obligatory'  or  change.  (1982) p r o v i d e s t h e example o f a j u d g e ' s  t h e 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 o n a l - d o m i n a n t  decision that i l l u s t r a t e s asymmetry,  " I n r e s p o n s e t o t h e q u e s t i o n o f who i s t o d e c i d e ' w h a t c o n s t i t u t e s t h e p a t i e n t ' s w e l f a r e ' , he [ L o r d Denning] a n s w e r s , ' t h e p h y s i c i a n . . . , by t h e v e r y n a t u r e o f h i s p o s i t i o n , i s t h e b e s t a r b i t e r o f t h i s q u e s t i o n when i t c o n c e r n s a p a t i e n t ' . . . i n summing up t o t h e j u r y , [he a l s o ] s u g g e s t e d t h a t any q u e s t i o n o f t h e p a t i e n t ' s w e l f a r e i s a m e d i c a l one, w h i c h i s t o be s e t t l e d by e x p e r t m e d i c a l testimony." ( P g . 733)  Bassford  concludes  t h a t , a t p r e s e n t , p a t e r n a l i s m i s j u s t i f i e d o n l y when t h e  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. f i r s t view r e f l e c t e d a c l i n i c a l  level  In t h e c a s e o f M i s s . S m i t h , t h e  judgment o f incompetence p r e s e n t i n t h e  s t a t e m e n t , ' 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 t h e p a t i e n t ' s mental  state  was a s s e s s e d w i t h o u t e v i d e n c e i n d e p e n d e n t o f t h e s u b j e c t i v e o b s e r v a t i o n o f what t h e p a t i e n t c o u l d (would?) and c o u l d n o t (would not?) do on r e q u e s t . r a t i o n a l e f o r t h e judgment i s not c l e a r . expertise, i t trespasses  on t h e p a t i e n t ' s  6  The  And, i f o t h e r t h a n an e x p r e s s i o n rights.  of  The C o n t e x t o f E x a m i n i n g t h e P r o f e s s i o n a l - P a t i e n t Relationship: 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 a t t e m p t s t o u n d e r s t a n d t h e ' c o n t e n t and o f d e c i s i o n - m a k i n g w h i c h may have i m p l i c a t i o n s f o r p e o p l e s ' 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 1 9 8 1 , p. 3 ) .  decision-making area, boundaries should not be, i n c l u d e d .  h e a l t h and t h e p r o -  To f u r t h e r d e f i n e t h e  help to assess the items t h a t should,  De M i g u e l s '  process  (1975) framework f o r t h e a n a l y s i s  and 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 t o i n c r e a s e u n d e r s t a n d i n g h e a l t h systems and t h e i r r e l a t i o n s t o t h e p r o c e s s  o f change i n s o c i e t y .  of In  this  framework t h e h e a l t h system i s d i v i d e d i n t o f o u r subsystems w h i c h p r o g r e s s on a m i c r o t o macro s c a l e . 2)  i n s t i t u t i o n s , 3)  These,  i n o r d e r , are r e l a t e d to  s o c i e t y and 4)  l a r g e r systems.  1)  individuals,  Table 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 t h e subsystem a r e a s .  Table I  De M i g u e l ' s  Policy Analysis  Framework Factors  Subsystem Individual:  Al A2 A3  Health Status Bio-medical Factors Psychological Factors  Institutions:  Bl B2 B3  Health Services Health Organization Health Planning  Society:  CI C2 C3 C4  Socio-cultural Patterns P o l i t i c a l Structure Economic Development Demographic S t r u c t u r e  Dl  Environments  Larger  System:  (From De M i g u e l  1975, c i t e d i n C r i c h t o n 1 9 8 1 , p. 4) 7  W i t h i n t h i s framework, t h e scope o f t h i s d i s c u s s i o n i n s t i t u t i o n s and subsystems o f s o c i e t y .  i s r e s t r i c t e d to the  The p r o f e s s i o n a l - p a t i e n t  i s an element w i t h i n each f a c t o r i n t h e i n s t i t u t i o n subsystem,  relationship  but the challenge  t o t h e 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 t h e c a s e M i s s S m i t h , emanates from t h e components o f t h e s o c i e t y s u b s y s t e m . will  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 :  demographic historical  structure.  socio-cultural patterns  F i r s t , however, i t i s n e c e s s a r y  c o n t e x t , how d e c i s i o n - m a k i n g  Two o f  of these  and  to e x p l o r e , i n the  l e d to the t r a d i t i o n a l balance of  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 t h e s o c i o - c u l t u r a l demographic  Historical  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 .  Context  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 l i g h t o f p o s t W o r l d War II c h i l d r e n (Canada 1 9 6 0 ) .  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 f u n d i n g  of s p e c i f i c d i s a b i l i t y groups. support of p r o f e s s i o n a l  ill  agencies which served the  B u t t h e emphasis  gradually  interests  changed t o t h e  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 c a r e o f t h e c h r o n i c a l l y  emerged w i t h i n t h e c o n s t r a i n t s  In t h i s way, a r e h a b i l i t a t i o n  philosophy  o f t h e m e d i c a l m o d e l , p r o v i d i n g t h r e e main com-  of the h e a l t h p r o f e s s i o n a l ' s  1) Problems disease;  voluntary  schemes  groups i n i n s t i t u t i o n s , as m e d i c i n e e v e n t u a l l y assumed  and d i s a b l e d (Wessen 1 9 6 5 ) .  ponents  surged f o r w a r d i n t h e  s o c i a l c o n c e r n f o r w a r - i n j u r e d v e t e r a n s and c r i p p l e d  supported the e f f o r t s of various  overall  and  view o f d i s a b i l i t y and p a t i e n t need:  a r e o r g a n i c and/or p h y s i c a l  and b e s t c a t e g o r i z e d a c c o r d i n g t o  2) P r o b l e m s a r e c e n t r e d i n t h e i n d i v i d u a l ; and 3) The i n s t i t u t i o n  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 of  8  services.  is  The r e h a b i l i t a t i o n f a c i l i t y , designed to c o - o r d i n a t e physical  as t h e c e n t r e o f t h e p r o f e s s i o n a l ' s f a c i l i t i e s and r e s o u r c e s  w o r k , was  o f community  agencies.  But r e h a b i l i t a t i o n , though c o n s i d e r e d a component o f a comprehensive  range  h e a l t h s e r v i c e s , was r e g a r d e d as a l o w e r p r i o r i t y among s p e c i a l t i e s  serving  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  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 a c t e d toward i n c r e a s i n g 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 .  across  disease  T h i s t r e n d was o f f s e t as  began t o d i r e c t p a t i e n t t r e a t m e n t as a team,  r e s u l t i n g i n t h e development o f v a r i o u s meetings  professionalization,  but a c t e d a g a i n s t t h e i n t e g r a t i o n o f  and i n s t i t u t i o n a l c a t e g o r i e s .  rehabilitation professionals  field,  These f o r c e s f a c i l i t a t e d and enhanced t h e  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 services  and m e d i c a l r e c o r d s .  organizational  t e c h n i q u e s such as team  Today, w i t h i n t h a t s e t t i n g , t h e  professional  c o n t i n u e s t o d i r e c t p a t i e n t t r e a t m e n t by w r i t i n g m e d i c a l o r d e r s and by seeing admission  and d i s c h a r g e d e c i s i o n s .  s c h e d u l e , have i n s t i t u t i o n a l i z e d  dominant r o l e .  Over t h e t i m e o f t h e development o f t h e s e s e r v i c e s emerged:  another important f a c t o r  government f i n a n c i n g changed t o n a t i o n a l h e a l t h i n s u r a n c e .  health decisions  over-  These f a c t o r s , a n d t h e f a c t t h a t  treatment i s organized according to f a c i l i t y the p r o f e s s i o n a l ' s  of  became, i n p a r t , a component o f t h e p o l i t i c a l  As  such,  agenda, where,  w e s t e r n s o c i e t y , government r o l e i s seen as one o f m e d i a t i o n and c r i s i s  manage-  ment (Renaud 1 9 8 1 ) .  T h i s has had t h e e f f e c t o f i n t r o d u c i n g t h e i n t e r e s t s o f a  t h i r d p a r t y , as w e l l  as an i m p o r t a n t s o c i a l  o r g a n i z a t i o n of s e r v i c e s i n an a s y m m e t r i c a l  still  l e v e r , i n t o the system.  tends to support the p r o f e s s i o n a l ' s  r e l a t i o n s h i p w i t h t h e p a t i e n t , t h e government,  body, has t h e p o t e n t i a l t o m o n i t o r t h e a l l o c a t i o n o f 9  resources.  in  Though t h e dominant  as t h e  role  funding  C u r r e n t C o n t e x t o f Change Demographic  and s o c i o - c u l t u r a l t r e n d s a r e c h a l l e n g i n g t h e 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  l a t i o n , concurrent expansion  t r e n d s i n c l u d e an i n c r e a s i n g aged  popu-  o f t h e m e d i c a l needs o f t h e c h r o n i c a l l y i l l and  changing  family structure.  The inadequacy o f p r e s e n t  s e r v i c e s t o meet  changing  societal  needs has been w e l l - d o c u m e n t e d (Brown 1977; Canada 1982; M a r s h a l l  1980;  S h a p i r o and Roos 1 9 8 1 ) . Straus  (1965) has i l l u s t r a t e d one a s p e c t o f t h i s c l e a r l y .  He d e s c r i b e d  i n d i v i d u a l s who p r e d o m i n a n t l y r e q u i r e l o n g term c a r e as h a v i n g t h e 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 ' ; i l l n e s s i s only one.  t h a t i s , a number o f problems  o f which  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 ,  a r e a d m i t t e d i n c r i s i s t o an a c u t e c a r e o r 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 t h e r problems such as p o v e r t y , i n a d e q u a t e s o c i a l Professionals  s u p p o r t and p h y s i c a l  a r e then p r e s e n t e d w i t h n o n - m e d i c a l  problems o u t s i d e t h e i r  o f e x p e r t i s e , and t h u s have a l i m i t e d s e t o f o p t i o n s institutional  setting.  which compromise t h e s t a t u s p o l i c y on d i s c h a r g e  inadequacy  of  'perfect agent , 1  procedures.  in the p r o f e s s i o n a l ' s  areas  a v a i l a b l e in the  The s o c i a l worker i s q u a l i f i e d t o a c t as an agent  the p a t i e n t i n these other c o n t e x t s , but, again, a l s o  facility  impairment.  retains other  for  interests  such as an o b l i g a t i o n t o f o l l o w  The demographic  change has c r e a t e d an  e x p e r t i s e t o deal w i t h problems p r e s e n t i n g  in  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 . Socio-cultural p l a c e and p e r s o n . a comparison  changes a r e i n d i c a t e d by an assessment o f e v e n t s  over t i m e ,  To p e r c e i v e a s h i f t i n b e l i e f s and v a l u e s one might l o o k  o f views p r e s e n t e d i n t e l e v i s i o n and t h e m e d i a .  10  There i s  to  evidence  from each o f t h e s e 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 a c c e p t a n c e t o p u b l i c questioning of p r o f e s s i o n a l tional  authority.  Examples o f a c c e p t a n c e o f t h e  tradi-  p e r s p e c t i v e a r e t h e t e l e v i s i o n shows, Dr. K i l d a r e o r Marcus Wei by,  presenting physicians  as c o m p l e t e a d v o c a t e s o f p a t i e n t s .  e x i s t s , t h e 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, C y n t h i a Carver (1984), a general  Though t h i s view  r e p o r t s o f t h e i n c r e a s i n g i n c i d e n c e o f both d i s c h a r g e s  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 ,  still  r e c e n t l y w r i t t e n by  p r a c t i t i o n e r from T o r o n t o .  m e d i c a l a d v i c e , and c h a r g e s l a i d f o r m a l p r a c t i c e .  M.D.,  There a r e  from h o s p i t a l  also  against  These a r e examples o f  daily  and even r e j e c t i o n , o f m e d i c a l  authority. De M i g u e l socio-cultural subdivisions institutional  (1975) h y p o t h e s i z e s  t h a t t h e i m p l i c a t i o n s o f t h e demographic  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  of h i s  framework;  response.  i n t h i s c a s e , between s o c i e t a l t r e n d s  This involves,  response to c h a l l e n g e t o p r o f e s s i o n a l Miguel's hypothesis,  between  and  The e x i s t e n c e o f t h i s l a g i s t h e c o n t e x t o f t h e  developed f o r t h i s t h e s i s .  s p e c i f i c a l l y , the  study  professionals'  e x p e r t i s e and a u t h o r i t y .  T h u s , w i t h De  t h e p o l i c y a n a l y s t has s e t t h e c o n t e x t i n t h i s paper  measuring the response of the p r o f e s s i o n a l  to challenges  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 entrenched i n the o r g a n i z a t i o n of h e a l t h  and  for  to the t r a d i t i o n a l dominant asymmetry  is  services.  In r e c a l l i n g t h e example o f t h e c a s e o f M i s s . S m i t h , she p r e s e n t e d and b e h a v i o r w h i c h c h a l l e n g e d t h e t r a d i t i o n a l terms o f t h e  problems  professional-patient  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 t h e v i e w p o i n t s o f e c o n o m i s t s  and  philosophers  5 T h i s book a l e r t s t h e p u b l i c t o t h e terms o f t h e p h y s i c i a n t h a t - a r e not always i n t h e p a t i e n t ' s b e s t i n t e r e s t . 11  as w e l l  as by t h e h i s t o r i c a l p e r s p e c t i v e .  some d i s a g r e e d w i t h M i s s . S m i t h ' s decisions  differed accordingly.  p a r t i e s , as w e l l  Some o f t h e p r o f e s s i o n a l s  e v a l u a t i o n of her w e l f a r e . Obviously,  the costs  Their  and  discharge  and b e n e f i t s t o  as t o s o c i e t y as t h e t h i r d p a r t y p a y i n g t h e b i l l ,  between t h e d e c i s i o n s .  agreed  these  d i f f e r widely  However, f u r t h e r t o t h e economic d i m e n s i o n o f p a t i e n t  beware,and t h e p h i l o s o p h i c d i m e n s i o n o f r i g h t s ,  i t i s a question of e f f e c t i v e -  ness and e f f i c i e n c y o f t h e 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 . how a r e p r o f e s s i o n a l s  responding  o r g a n i z a t i o n of t h e i r  services?  Importantly  to the challenge to the t r a d i t i o n a l  In t h e n e x t c h a p t e r , w i t h f u r t h e r use o f t h e c a s e s t u d y , h y p o t h e s e s d e v e l o p e d from s o c i o l o g i c a l  then,  t h e o r y t o measure t h e p r o f e s s i o n a l ' s  t h i s challenge 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  12  response  relationship.  are to  THEORY  The b a l a n c i n g o f p r o f e s s i o n a l s ' through  and p a t i e n t s '  an i n v e s t i g a t i o n o f human r e l a t i o n s h i p s .  i n t e r e s t s may be  understood  More e x p l i c i t l y , t h e  sociolo-  g i s t models human i n t e r a c t i o n i n terms o f t h e 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 of s o c i a l t h e r o l e p e r s p e c t i v e as  norms.  B i d d l e and Thomas (1966)  ' a p a r t i c u l a r viewpoint regarding [1]  presumed t o be i n f l u e n t i a l  i n governing  those  define  factors  human b e h a v i o u r [and 2] t h e a c t u a l  formance [ t h a t ] r e s u l t s from t h e s o c i a l p r e s c r i p t i o n s  and b e h a v i o r o f  per-  others.'  (P.4) In t h e e v o l u t i o n o f s o c i o l o g i c a l m o d e l s , t h e c e n t r e p i e c e o f t h e 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 t h e c o n c e p t o f ' s o c i a l Summey 1 9 7 6 ) .  system'  profes(Bloom and  In t h i s t h e s i s , t h e term r e f e r s t o t h e i n t e r d e p e n d e n c e s  i n t h e form o f r e l a t i o n s h i p s . development o f t h i s c o n c e p t .  underlies Parsons' u n d e r l i e s arguments  roles  Bloom (1976;1979) has t w i c e t r a c e d the From h i s o v e r v i e w , two fundamental  emerge t o a c c o u n t f o r t h e 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 e m ' professional-Datient  of  relationship.  S i c k R o l e Model  The f i r s t  to the t o p i c of  the  interpretation, 'functional ism',  ( 1 9 5 1 ) , and t h e s e c o n d ,  based by F r e i d s o n  rationales  (1961) on p r e m i s e s  'structuralism',  opposed t o  Parsons'  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 balanced w i t h i n a single social  system t h r o u g h c o m p l i m e n t a r y f o r c e s d i r e c t e d t o t h e s h a r e d  o f 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 .  value  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  t h e o t h e r hand, p e r c e i v e s a b a l a n c e o f i n t e r e s t s t h r o u g h competing f o r c e s ,  13  each  d i r e c t e d t o a c h i e v i n g i t s own o p t i m a l l e v e l w i t h i n c o n s t r a i n t s meeting of separate s o c i a l systems.  s e t by t h e  These i n t e r p r e t a t i o n s w i l l  be  discussed  r e s p e c t i v e l y as t h e t r a d i t i o n a l and c h a l l e n g i n g views o f t h e p r o f e s s i o n a l patient relationship.  Parsons'  model and t h e 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  t h e 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 presented f i r s t with observations  as i n t h e l a r g e r p o l i c y forum, w i l l  be  from Nagi ( 1 9 6 5 ) , Bloom (1976) and o t h e r s .  These r e p r e s e n t t h e t r a d i t i o n a l v i e w . Friedson's view.  model s e t s t h e s t a g e f o r t h e p r e s e n t a t i o n o f t h e  Through t h e s t r u c t u r e o f c o m p e t i n g s o c i a l s y s t e m s ,  c u l a r i n t e r e s t s a r e a l l o w e d t o emerge.  Haug and L a v i n ' s  t h i s new c o n c e p t 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 presented.  the p a t i e n t ' s  and p a t i e n t i s  c i r c l e to a single  network w i t h t h e asymmetry o f t h e p r o f e s s i o n a l  response  follows,  taking  social-system  and p a t i e n t r o l e s  to challenge to the t r a d i t i o n a l  of  then  reversed.  These views are t h e n i n t e g r a t e d t o form a b a s i s from w h i c h t o measure professionals'  parti-  (1981) i n v e s t i g a t i o n  De J o n g ' s (1979) model o f p a t i e n t dominant asymmetry  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  challenging  the  professional-patient  relationship.  Parsons'  S i c k R o l e Model  P a r s o n s m o d e l l e d t h e 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 o f forces.  Such a b a l a n c e was deemed n e c e s s a r y ,  f o r how w e l l  was c o n s i d e r e d t o be d i r e c t l y r e l a t e d t o l e v e l s o f h e a l t h . level  complimentary  society  functioned  Too low a g e n e r a l  o f h e a l t h and t o o h i g h an i n c i d e n c e o f i l l n e s s would be d i s r u p t i v e .  C o n t r o l was t h e r e f o r e n e c e s s a r y  t o keep members o f s o c i e t y from t a k i n g  14  advantage  o f secondary  g a i n w h i l e i l l and u n n e c e s s a r i l y  prolonging  o f c o n t r o l has t a k e n p l a c e i n t h e form o f p r o f e s s i o n a l professional-patient  relationship.  disability.  dominant asymmetry  The r e l a t i o n s h i p i s a r r a n g e d t o  t h a t a f u n c t i o n a l b a l a n c e o f h e a l t h and i l l n e s s  This  i s maintained.  kind in the  guarantee  The asymmetry  is  assumed t o be e n f o r c e d o r l e g i t i m a t e d t h r o u g h t h e s u p p o r t o f s o c i o - c u l t u r a l expectations patterned in s o c i e t y , since w i t h i n a single social professional  and p a t i e n t s h a r e t h e same v a l u e s and  To s e r v e t h i s f u n c t i o n , t h e p r o f e s s i o n a l privileges.  E n t a i l e d i n the p r o f e s s i o n a l ' s  responsibilities.  the  interests.  and p a t i e n t have o b l i g a t i o n s  and  r o l e i s an o b l i g a t i o n t o t h e p a t i e n t  t o a i d r e c o v e 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 deemed w e l l , t o normal  system,  In  r e t u r n , once  r e t u r n , the p r o f e s s i o n a l , in  t i c u l a r , t h e p h y s i c i a n , i s a c c o r d e d h i g h s t a t u s and e s t e e m .  As i l l n e s s  par-  is  re-  c o g n i z e d as u n a v o i d a b l e , t h e p a t i e n t has t h e p r i v i l e g e o f excuse from normal duties.  But p r o l o n g e d 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 t h e p a t i e n t  o b l i g e d t o comply w i t h t h e p r o f e s s i o n a l ' s Thus, p a t i e n t s assume t h e porary s o c i a l technical  'sick  d i r e c t i o n i n o r d e r t o get  well.  r o l e ' w h i c h i s c o n s i d e r e d a form o f t e m -  d e v i a n c e from w h i c h t h e y s t r i v e t o r e c o v e r .  Professionals  e x p e r t s who l e g i t i m i z e p a t i e n t s ' c l a i m s t o i l l n e s s and a r e  f o r r e t u r n i n g them t o t h e i r normal  roles in society.  The p r o f e s s i o n a l  are  between t h e p r o f e s s i o n a l  and p a t i e n t i s  ' c o n t r o l l e d ' l e s t t h e y t a k e advantage  and p r o l o n g  dependency.  15  l e g i t i m i z e d so t h a t  of the p r i v i l e g e s of the  are  responsible role  dominant and c o n t r o l l i n g and t h e p a t i e n t ' s r o l e i s c o m p l i a n t and p a s s i v e . asymmetry  is  is This  patients  'sick  role'  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 n e e d i n g a note from o n e ' s d o c t o r t o r e t u r n t o s c h o o l illness.  The p a r t i c u l a r terms o f asymmetry  f o l l o w i n g a lengthy  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 o n e ' 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 . situation, illness  i s 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 physician's  high status  In  this  as d i s r u p t i v e and t h e d e n t i s t does not  s t a t u s as an agent o f s o c i e t y .  usually  A l o n g t h e same l i n e s ,  the  i s awarded i n r e s p e c t o f t e c h n i c a l e x p e r t i s e when com-  p a r e d , f o r example, w i t h a n o t h e r agent o f s o c i a l c o n t r o l , t h e p o l i c e o f f i c e r . Parsons'  model i s o b v i o u s l y  acute or severe,  i s temporary.  d i r e c t e d t o a t y p e o f i l l n e s s w h i c h , however G a l l a g h e r (1976) and Kassebaum and Baumann  (1965) have commented on t h e inadequacy illness.  of Parsons'  model t o accommodate  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 o f d i s e a s e a n d 9  chronic  uncertainty  r e g a r d i n g 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 t h e expectations of Parsons'  model.  S z a s z and H o l l a n d e r (1956) d e v e l o p e d a t h r e e f o l d t y p o l o g y  of  professional-  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 types.  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 t o emergency  situations.  assumes c o m p l e t e c o n t r o l and t h e p a t i e n t remains p a s s i v e . extreme b u t s t i l l  acute, guidance-co-operation  p a t i e n t seeks t h e p r o f e s s i o n a l ' s p a t i e n t back t o r e c o v e r y .  with occasional  physician  For situations  i s t h e management m o d e l .  e x p e r t h e l p and t h e p r o f e s s i o n a l  the p r o f e s s i o n a l ' s  less The  guides  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 are best  in a mutual-participation relationship; p a t i e n t s help themselves.  The  disease  the  managed  r o l e i s to help  The p a t i e n t manages most o f t h e t r e a t m e n t r o u t i n e  i n t e r v e n t i o n by t h e p r o f e s s i o n a l .  16  The a u t h o r i t y o f t h e p r o f e s -  s i o n a l , c o - o p e r a t i o n o f t h e p a t i e n t , and asymmetry r e t a i n e d as l e g i t i m a t e . Nevertheless,  The p r e m i s e s  underlying Parsons'  t h i s extension of Parsons'  to the s p e c i a l t y of r e h a b i l i t a t i o n .  i n the r e l a t i o n s h i p  model a r e m a i n t a i n e d .  model f a c i l i t a t e s i t s  I t a l l o w s one t o d i s t i n g u i s h  And i t a l s o a l l o w s one t o d i s t i n g u i s h  t i o n s t h a t an i n d i v i d u a l  application  between d i f -  f e r e n t s t a g e s 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 e p i s o d e s illness.  are  of  chronic  between a l t e r n a t e r o l e e x p e c t a -  s u f f e r i n g from an i m p a i r m e n t w o u l d e n c o u n t e r when a  patient in a rehabilitation 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 t h e f a m i l y and employment may be  m o d i f i e d t h r o u g h c o n d i t i o n s o f i l l n e s s o r i m p a i r m e n t , b u t Nagi (1965) against tions.^  t h e i n d i v i d u a l assuming,  as a r o l e , t h e c h a r a c t e r i s t i c s o f t h e s e c o n d i -  T h a t 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 roles e x i s t occupy them and [ i n d e p e n d e n t l y ] have t o t h e s y s t e m . ' It  ' i n d e p e n d e n t l y o f t h e p e r s o n who may  o f any o t h e r r e l a t i o n s h i p s t h e s e p e r s o n s may  (P.106)  i s t h e s e o t h e r r e l a t i o n s h i p s t h a t B l o o m ' s model makes e x p l i c i t by  i n g them t o t h e s y s t e m .  The p r e m i s e s  narrow f o c u s ,  by e x p a n d i n g s o c i e t y ' s  link-  u n d e r l y i n g t h i s model a r e t h e same as t h e  S i c k R o l e M o d e l , b u t t h e model overcomes  players.  cautions  t h e l i m i t a t i o n s imposed by  Parsons'  i n t e r e s t s i n t o a game w i t h more than two  F i g u r e 1 presents t h i s model.  6 F o r an e x a m p l e , r e f e r t o R o b e r t A. S c o t t , The Making o f B l i n d Men, R u s s e l l Sage F o u n d a t i o n , New Y o r k , N.Y., 1969.  17  Figure 1  B l o o m ' s model o f t h e P r o f e s s i o n a l - P a t i e n t  (From 'The T o t a l T r a n s a c t i o n a l S y s t e m ' , Bloom, S.W. c i t e d i n G a l l a g h e r (1976)) 18  Relationship (1963, P.256)  As e v i d e n t i n t h e f i g u r e , t h e game i s expanded t o i n c l u d e t h e m a j o r r e l a t i o n s h i p s t h a t the p r o f e s s i o n a l p a t i e n t encounter. patient that s t i l l  and p a t i e n t m a i n t a i n e x t e r n a l t o t h e p r o f e s s i o n a l -  However, i t i s t h e i n t e r a c t i o n between t h e p r o f e s s i o n a l occupies the c e n t r a l focus.  A c l e a r e r p i c t u r e of the  i n f l u e n c e o f t h e e x t e r n a l demands on t h e p r o f e s s i o n a l H e r e , t h e 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  Figure 2  The P r o f e s s i o n a l ' s  C i r c l e of  and  is depicted in Figure  2.  circle.  Interests  Each o f t h e c i r c l e ' s components a r e f a c t o r s w h i c h i n f l u e n c e t h e r o l e o f t h e professional.  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,  r e a l i t y , are probably m o d i f i e d according to the circumstances. t h e s e have o r i e n t e d t h e p r o f e s s i o n a l  Traditionally  t o be dominant and i n c o n t r o l o f t h e  patient.  19  in  The C h a l l e n g e t o 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 o f 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 c e n t s o c i a l movements. a r e consumerism,  Two examples o f  i n w h i c h 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 ,  w h i c h p a t i e n t s t a k e on t h e 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 . i n d i c a t e a s h i f t from t h e t r a d i t i o n a l p e r s p e c t i v e i n w h i c h t h e 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 on t h e p r o f e s s i o n a l ' s  Freidson's  these in  These movements professional  and t h e p a t i e n t i s e x p e c t e d t o r e l y  advice.  C o n f l i c t o f Terms  F r e i d s o n has q u e s t i o n e d t h e t r a d i t i o n a l p e r s p e c t i v e o f t h e exchange o f obl i g a t i o n s and p r i v i l e g e s between t h e p r o f e s s i o n a l rests against  the b a s i c premises  and p a t i e n t .  His  argument  o f P a r s o n s ' model w h i c h has b e h a v i o r  on e x p e c 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.  dependent  Freidson maintains  that  i n f l u e n c e i s drawn c h i e f l y from t h e p o s i t i o n o f t h e p e r s o n h o l d i n g t h e e x p e c t a tions.  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 of the s i t u a t i o n  influence  behaviour.  T h i s can be c o n s i d e r e d a l o n g w i t h F r e i d s o n ' s c o m p r i s e d o f a number o f s o c i a l In t h i s way t h e p r o f e s s i o n a l  other premise t h a t s o c i e t y  systems and not j u s t one as i n P a r s o n s '  model.  and p a t i e n t a r e each p r e s e n t e d as s e p a r a t e  social  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 c o m b i n a t i o n , t h e 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 o f t h e p e r s o n and (2) s e p a r a t e s o c i a l interact.  is  In t h a t p e o p l e i n c e r t a i n p o s i t i o n s  their interests that c o n f l i c t .  20  have c e r t a i n i n t e r e s t s , i t  systems is  The c h a l l e n g e , as F r e i d s o n s t a t e s i n h i s argument a g a i n s t dominant asymmetry  professional  ( k e e p i n g i n mind t h e c a s e o f A l i c e Smith and t h e d i f f e r e n c e  o f o p i n i o n amongst p r o f e s s i o n a l s  r e g a r d i n g h e r d i s c h a r g e outcome), i s  such e v a l u a t i o n i s n o r m a t i v e i n c h a r a c t e r e s o t e r i c as t o j u s t i f y i t s r e s t r i c t i o n t o laymen a r e e x c l u d e d from such e v a l u a t i o n , i s n o t a t i s s u e b u t r a t h e r t h e s o c i a l and of the e x p e r t . (1970, P.336)  that  and i s n o t so experts. Where true expertise p o l i t i c a l power  From De J o n g ' s (1979) view o f t h e 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  d e s c r i b e d i n t h e p r e v i o u s c h a p t e r , a r e c h a l l e n g i n g t h e terms t r a d i t i o n a l l y p r e s e n t e d by t h e p r o f e s s i o n a l  i n favour of the i n t e r e s t s of the p a t i e n t .  i s t h e p a t i e n t i n t h e c o n s u m e r i s t s t a n c e t h a t u n d e r l i e s h i s model o f living.  A l t h o u g h 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  paradigm, i t a c t u a l l y balances the p r o f e s s i o n a l ' s Parsons'  and p a t i e n t s , a g a i n as a s i n g l e s o c i a l  i n t e r e s t s and v a l u e s .  independent research  and p a t i e n t ' s r o l e s a f t e r  m o d e l , e x c e p t , i n t h i s c a s e , t h e asymmetry i s r e v e r s e d .  professionals  And i t  In t h i s way  s y s t e m , r e t a i n t h e same  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 reversed r o l e s of  asymmetry.  Thus i n b o t h t h e t r a d i t i o n a l and c h a l l e n g i n g v i e w s , t h e terms o f t h e 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 can be c o n g r u e n t w i t h ' a c c e p t e d ' asymmetry, i n t h e f i r s t case w i t h the p r o f e s s i o n a l p a t i e n t as dominant. model.  as dominant, and i n t h e second c a s e w i t h t h e  A l t e r n a t i v e l y , t h e terms may c o n f l i c t as i n  Friedson's  As a measure o f t h e d i s t a n c e between t h e 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 l o o k t o Haug and L a v i n ' s o r 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 extent to which p r o f e s s i o n a l s  (1981) i n v e s t i g a t i o n o f whether a u t h o r i t y , and, i f they w e r e , t h e  r e j e c t e d o r accommodated such b e h a v i o r . 21  Responses  t o q u e s t i o n i n g i n d i c a t e d c h a l l e n g i n g b e h a v i o r amongst p a t i e n t s and accommodating b e h a v i o r amongst p h y s i c i a n s .  The causes o f the s h i f t have been h y p o t h e s i z e d t o  i n c l u d e f a c t o r s r a n g i n g from the b e t t e r e d u c a t i o n o f the young (Haug and L a v i n 1981),  to a new r e s i s t a n c e a g a i n s t the encroachment o f a u t h o r i t i e s i n t o a r e a s  u n r e l a t e d t o t h e i r c l a i m e d e x p e r t i s e (Haug and Sussman 1979).  F a r from  a c c e p t i n g the asymmetry as g i v e n , the i n t e r a c t i o n i s opened t o n e g o t i a t i o n , as in Strauss'  (1978) t e r m s , i n an a r e n a .  Haug and L a v i n suggested,  p o s s i b l e dimensions a l o n g which p r o f e s s i o n a l 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  in conclusion  and p a t i e n t r o l e s can be a r r a n g e d ,  as e i t h e r c o n t r o l l e r o r accommodator, and the  p a t i e n t as e i t h e r c o n s u m e r i s t or dependent i n the d e t r e m i n a t i o n o f ' w h o ' s i n charge'.  The range o f i n t e r a c t i o n o f terms i s suggested by Haug and L a v i n ' s  of c r o s s - r e l a t i o n s h i p s .  F i g u r e 3 i n d i c a t e s the p o s s i b l e i n t e r a c t i o n modes  a c c o r d i n g t o the s p e c i f i c c o m b i n a t i o n s o f r o l e s assumed by the p r o f e s s i o n a l patient. Figure 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 Professional C o h f l i c t o f Terms  Consumerist  Congruence o f Terms Asymmetry Legitimate Professional Dominant  22  and the P a t i e n t  Orientation Congruence o f Terms  Asymmetry unaccepted by the p r o f e s s i o n a l or p a t i e n t  Patient Orientation Dependent  set  Asymmetry Legitimate  1  2  3  ^  Patient Dominant C o n f l i c t o f Terms Asymmetry unaccepted by the p r o f e s s i o n a l or p a t i e n t  and  These terms can be i l l u s t r a t e d u s i n g  t h e example o f t h e case o f M i s s  i n w h i c h d i f f e r e n c e s o f o p i n i o n e x i s t e d r e g a r d i n g d i s c h a r g e outcome. case the p r o f e s s i o n a l ' s differed.  In  Smith one  and p a t i e n t ' s terms agreed and i n t h e o t h e r t h e y  The c o n t e n t o f t h e d e c i s i o n and i t s outcome c o n c e r n e d t h e  patient's  w e l f a r e , the d e t e r m i n a t i o n o f w h i c h i s a p i v o t a l p o i n t i n t h e t r a d i t i o n a l challenging perspectives of p r o f e s s i o n a l s ' fessional Parsons'  and p a t i e n t s '  roles.  How t h e p r o -  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 t h e 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 . model u n d e r l i e s t h e i n t e r a c t i o n e x p e c t e d i n c e l l  is professional  dominant and t h e p r o f e s s i o n a l ' s  w o u l d be f o l l o w e d whatever t h e e n s u i n g presented i n c e l l  2.  The asymmetry  3.  The  relationship  decision of p r o t e c t i v e care  b e n e f i t s and c o s t s .  De J o n g ' s model  i s p a t i e n t dominant and M i s 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 their roles c o n f l i c t .  In C e l l  dominant and r e s p o n s i b l e fessional  for health decisions,  nor t h e p a t i e n t w i s h e s  decisions.  sional  1 both t h e p r o f e s s i o n a l  of the p r o f e s s i o n a l s '  as dominant)  and p a t i e n t e x p e c t t o be  and i n C e l l 4 n e i t h e r t h e p r o -  o f d e t e r m i n i n g outcomes  for health i s not c l e a r .  responses c o n s i s t e n t w i t h c e l l s 1 (the  and 2 ( t h e p r o f e s s i o n a l  costs.  and p a t i e n t when  t o be dominant o r r e s p o n s i b l e  In t h e s e c a s e s t h e p r o c e s s  is  Smith's  d e c i s i o n t o go home would be f o l l o w e d w h a t e v e r t h e e n s u i n g b e n e f i t s and  Examples  versus  as accommodator)  were  profes-  previously  d e s c r i b e d i n t h e c a s e o f M i s s S m i t h who p r e s e n t e d i n a c o n s u m e r i s t  stance.  The  professionals  behavior  in  different  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 t h e M i s s S m i t h ' s  ways.  In r e v i e w , M i s s S m i t h ' s 'gutsy'  by t h e o t h e r .  b e h a v i o r was d e s c r i b e d ' d i f f i c u l t '  The f i r s t group e x p l a i n e d h e r b e h a v i o r as  23  by one group and 'limited  insight  i n t o her d i s a b i l i t y ' i n c o n t r a s t t o t h e second g r o u p s '  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. r e t a i n c o n t r o l over the discharge  s t a t e m e n t of t h e  One group wished  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 t h e o t h e r accommodated t h e p a t i e n t ' s d e c i s i o n t o go home. tions  to  These v a r i a -  i n r e s p o n s e s can be c o n s i d e r e d i n t h e c o n t e x t o f t h e c h a l l e n g e t o t h e  traditional  professional-patient  challenging perspectives  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  o f what t h e p r o f e s s i o n a l ' s  be r e g a r d i n g t h e e v a l u a t i o n o f p a t i e n t w e l f a r e . challenge is  and p a t i e n t ' s  Professional  roles  should  r e c o g n i t i o n of the  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 behavior.  r e s p o n s e t o t h e c h a l l e n g e i s i l l u s t r a t e d by how t h e p r o f e s s i o n a l deals with the p a t i e n t ' s  behavior.  E x p l a i n i n g the P a t i e n t ' s  Behavior  In t h e t r a d i t i o n a l v i e w , i l l n e s s seen as a problem o f t h e p a t i e n t .  The  describes  and  i s p e r c e i v e d as an o b j e c t i v e e n t i t y and  is  Views beyond t h e m e d i c a l m o d e l , on t h e o t h e r  hand, s t a t e t h a t i l l n e s s can a l s o be d e f i n e d t h r o u g h t h e i n d i v i d u a l ' s  inter-  a c t i o n w i t h t h e e n v i r o n m e n t ; t h a t i s , i n f l u e n c e s e x t e r n a l t o t h e p a t i e n t and t h e d i s e a s e can a l s o shape t h e p r o b l e m .  In t h e f i r s t p e r s p e c t i v e t h e  patient's  b e h a v i o 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 , ment t o t h e d i s e a s e  or e f f e c t of the d i s e a s e .  adjust-  C o n v e r s e l y , t h o s e who a r e  t i v e t o t h e e x t e r n a 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 t h e  sensi-  behavior  w i t h r e f e r e n c e t o t h e terms t h e 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.  and dependent p a t i e n t ' s  In t h i s l i g h t , t h e c o n s u m e r i s t ' s  would be p e r c e i v e d as a congruence  or c o n f l i c t i n t e r m s .  24  The dynamics  behavior of  this  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 presented i n F i g u r e 4 below.  Professional controller  Role accommodator  pati ent attribute  Consumerist  c o n f l i c t of terms  P a t i e n t Role Dependent  patient attribute  conflict terms  of  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d  Describing  the P a t i e n t ' s  The p r o f e s s i o n a l ' s  Behavior d e s c r i p t i o n o f t h e p a t i e n t ' s b e h a v i o r can be argued  f o l l o w from t h e p r o f e s s i o n a l ' s  expectations of the p a t i e n t ' s r o l e .  In t h e  ditional  view t h e p a t i e n t s h o u l d be p a s s i v e and c o m p l i a n t w i t h t h e  profes-  sional's  advice.  Hospital  however, t e n d s t o f a v o u r t h e 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 ' of enforcing p a s s i v i t y schedule.  regimen. individual  tra-  T h i s view i s somewhat m o d i f i e d i n r e h a b i l i t a t i o n where t h e  p a t i e n t i s expected to c o n t r i b u t e to treatment d e c i s i o n s .  facility  to  and dependency  The ' g o o d '  And t h e ' d i f f i c u l t '  routine,  services at the  cost  i n p a t i e n t s who a r e e x p e c t e d t o f o l l o w t h e  p a t i e n t i s t h e one who w i l l i n g l y submits t o t h e p a t i e n t i s one who r e s i s t s  o p t i o n s and does not f i t i n t o t h e f a c i l i t y  25  t h e e x t e r n a l c o n t r o l on  schedule.  In t h e c h a l l e n g i n g p e r s p e c t i v e , on t h e o t h e r hand, p a t i e n t s a r e e x p e c t e d t o 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 t h e e x p e c t a t i o n s  t h e p a t i e n t ' s r o l e a r e r e v e r s e d so t o o a r e t h e d e s c r i p t i o n s . p a t i e n t w o u l d t h e n be c o n s i d e r e d as ' g o o d ' 'difficult'.  The  of  consumerist  and t h e dependent p a t i e n t as  The dynamics o f t h i s i n t e r a c t i o n a r e s c h e m a t i c a l l y d e p i c t e d i n  Figure 5. Professional  Role  controller Consumerist  accommodator  difficult  good  good  difficult  P a t i e n t Role Dependent  Figure 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 p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d .  Dealing with the P a t i e n t ' s The p r o f e s s i o n a l  Behavior  i s t r a d i t i o n a l l y p e r c e i v e d as b e i n g r e s p o n s i b l e  d i r e c t i o n of p a t i e n t care.  f o r the  And t h e p a t i e n t s a r e supposed t o p a s s i v e l y  t h i s d i r e c t i o n and u n d e r s t a n d  i t t o be i n t h e i r b e s t i n t e r e s t .  d e v i a t e s from t h i s r o l e t h e p r o f e s s i o n a l b e h a v i o r and w i l l  the  If  accept  the p a t i e n t  i s encouraged t o s a n c t i o n t h e p a t i e n t ' s  t h e r e f o r e t a k e measures t h a t r e j e c t o r c o n t r o l t h e p a t i e n t .  So f o r both t h e c o n s u m e r i s t  and dependent p a t i e n t s , t h e p r o f e s s i o n a l  w i t h t h e p a t i e n t by b e i n g i n c h a r g e .  will  deal  In t h e a l t e r n a t e i n t e r a c t i o n , where t h e  p a t i e n t ' s dominance i s a c c e p t e d , t h e p r o f e s s i o n a l  26  will  accommodate t h e c o n s u -  m e r i s t p a t i e n t ' s b e h a v i o r and w i s h t o i n s p i r e the dependent p a t i e n t t o t a k e control.  The dynamics o f t h i s i n t e r a c t i o n a r e p r e s e n t e d i n F i g u r e  Professional  6.  Role  C ontrol1er  Accommodator  Consumerist  control or reject  accommodate  Dependent  c o n t r o l or protect  P a t i e n t Role  F i g u r e 6.  inspire  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 b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d .  In sum, t h i s t h e s i s h y p o t h e s i z e 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 b e h a v i o r i s dependent on t h e s p e c i f i c i n t e r a c t i o n o f t h e 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 t h e c o n t e n t o f t h e d e c i s i o n i n v o l v e s t h e 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 o f P a r s o n s , Bloom, F r e i d s o n and De J o n g ,  among o t h e r s , have t r a c e d t h e development and r e l a t i o n s h i p o f t h e s e r o l e s  and  have h i g h l i g h t e d t h e p o s s i b l e a r e a s o f congruence and c o n f l i c t t h a t p r e d i c t t h e ways t h a t p r o f e s s i o n a l s w i l l behavior. if  e x p l a i n , d e s c r i b e and d e a l w i t h t h e p a t i e n t ' s  The n e x t c h a p t e r on methods d e s c r i b e s t h e measures d e v i s e d t o a s s e s s  the p r o f e s s i o n a l w i l l  r e s p o n d as p r e d i c t e d .  27  METHODS  I n t h i s t h e s i s , v a r i o u s t e c h n i q u e s were d e v e l o p e d t o a s s e s s t h e professional's  response to c h a l l e n g e 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  relationship.  As t h e h y p o t h e s e s s t a t e t h a t how t h e p r o f e s s i o n a l  explains,  d e s c r i b e s and d e a l s w i t h t h e p a t i e n t i s dependent on t h e s p e c i f i c c o m b i n a t i o n o f 1)  professional  r o l e , 2)  p a t i e n t r o l e and 3)  the independent v a r i a b l e s . 'controller'  To measure t h e p r o f e s s i o n a l ' s  r o l e , as e i t h e r  o r ' a c c o m m o d a t o r ' , a q u e s t i o n n a i r e was g i v e n t o a sample o f  professionals —  physicians,  and s o c i a l w o r k e r s - -  physiotherapists, occupational t h e r a p i s t s ,  nurses  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 . sionals  d e c i s i o n c o n t e n t , t h e s e t h r e e form  These were p r e s e n t e d t o t h e p r o f e s -  i n i n t e r v i e w s , i n two c a s e s t u d i e s i n w h i c h t h e p a t i e n t ' s b e h a v i o r was  c o n s i s t e n t with e i t h e r the 'consumerist'  or 'dependent'  role.  The t h i r d  i n d e p e n d e n t v a r i a b l e o f d e c i s i o n c o n t e n t was f a b r i c a t e d a l s o as p a r t o f t h e case study and p r e s e n t e d c i r c u m s t a n c e s i n w h i c h t h e p r o f e s s i o n a l g r e e d about t h e ' b e s t * The p r o f e s s i o n a l ' s  and p a t i e n t d i s a -  discharge option. r e s p o n s e t o each o f t h e p a t i e n t r o l e s was measured  in  t h e i n t e r v i e w i n w h i c h t h e p r o f e s s i o n a l was asked t o e x p l a i n , d e s c r i b e and deal w i t h t h e p a t i e n t ' s b e h a v i o r as p r e s e n t e d i n each o f t h e case s t u d i e s . r e s p o n s e s were then a n a l y z e d i n terms o f t h e s p e c i f i c h y p o t h e s e s . i s presented i n the next chapter.  This  What f o l l o w s , d e s c r i b e s and e x p l a i n s  methods and s t u d y t e c h n i q u e s i n more  detail.  28  These analysis the  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 t h e c o l l e c t i o n and a n a l y s i s interaction. hypotheses  of the data r e l e v a n t to the p r o f e s s i o n a l - p a t i e n t  The v a s t amount o f t h e o r y r e l a t e d t o t h e t o p i c , and t h e s p e c i f i c  o f t h e i n v e s t i g a t o r s u g g e s t e d a d e s c r i p t i v e s t u d y as t h e most a p p r o -  p r i a t e means by w h i c h t o document p r o f e s s i o n a l professional-patient relationship.  response t o c h a l l e n g e s t o t h e  M o r e o v e r , t h e s t u d y f o l l o w e d on t h e 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 g e n e r a l p r a c t i t i o n e r s and t h e p u b l i c .  But the s h i f t i n s e t t i n g s ,  from t h e community t o  the i n s t i t u t i o n and from g e n e r a l p r a c t i t i o n e r s t o a range o f r e h a b i l i t a t i o n professionals,  c a u t i o n e d a g a i n s t an u n m o d i f i e d a p p r o a c h .  e x p l o r a t o r y approach was n e c e s s a r y  For t h i s reason  an  to a l l o w the researcher the f l e x i b i l i t y  to  respond t o unexpected or u n p r e d i c t e d d i r e c t i o n s or c o n d i t i o n s . W i t h i n t h e s e c o n f i n e s t h e most a c c u r a t e way by w h i c h t o measure sional  response  profes-  t o c h a l l e n g e s t o t h e 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 t h r o u g h s y s t e m a t i c o b s e r v a t i o n o f a d e t e r m i n e d sample o f t h e s e i n t e r actions.  B u t t h i s e f f o r t was beyond t h e scope o f t h i s t h e s i s and a l t e r n a t e  methods o f g a t h e r i n g d a t a were d e v e l o p e d .  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 o n l y as p r e l i m i n a r y e v i d e n c e o f 1) r e h a b i l i t a t i o n p r o f e s sionals'  perceptions 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 d u r i n g  t h e i r i n t e r a c t i o n and 2) t h e dynamics o f t h e p r o f e s s i o n a l s ' patient.  29  response to the  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 R e h a b i l i t a t i o n C e n t r e and H o l y F a m i l y H o s p i t a l .  i n Vancouver, G.F. Strong  G.F. Strong R e h a b i l i t a t i o n  C e n t r e i s a 150 bed i n - p a t i e n t and 270 c l i e n t s p e r day o u t - p a t i e n t Treatment i s d i r e c t e d toward severe p h y s i c a l  disability.  Holy Family 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 professionals  w o r k i n g w i t h an a d u l t p o p u l a t i o n were  Volunteers  from t h e p r o f e s s i o n s  therapy, nursing  setting.  of medicine, physiotherapy,  standing.  For nurses, a r e g i s t e r e d nursing  Only  those  approached.  and s o c i a l work were asked t o p a r t i c i p a t e .  i n c l u s i o n was a p r o f e s s i o n a l  facility.  occupational  The c r i t e r i o n f o r  Diploma o r degree t r a i n i n g was a c c e p t e d .  s t a t u s was r e q u i r e d .  Of t h e e l i g i b l e s t a f f , 37 o f 80 a t G . F . S t r o n g and 17 o f 30 from Holy Family Hospital  e x p r e s s e d 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 t h e 37 c a n d i d a t e s a t  G . F . S t r o n g , 10 were from m e d i c i n e , 9 from p h y s i o t h e r a p y , 6 from o c c u p a t i o n a l t h e r a p y , 9 from n u r s i n g ,  and 2 from s o c i a l work.  d i d n o t c o m p l e t e t h e study the q u e s t i o n n a i r e  Of t h i s group, 6 i n d i v i d u a l s  f o r a v a r i e t y o f r e a s o n s such as 1) f a i l u r e t o r e t u r n  (N=2), 2) d i f f i c u l t y i n s c h e d u l i n g t i m e f o r t h e study  (N=2),  3) n o t f i t t i n g t h e c r i t e r i a f o r i n c l u s i o n ( N = l ) , and 4) t h e s i g n a t u r e was i l l e g i b l e and c o n s e n t c o u l d n o t be acknowledged ( N = l ) .  Of t h o s e who d i d n o t  c o m p l e t e t h e study 1 was from m e d i c i n e , 1 from p h y s i o t h e r a p y , 1  unknown.  30  3 from n u r s i n g and  Of t h e 17 c a n d i d a t e s a t Holy F a m i l y H o s p i t a l , 3 were from m e d i c i n e , 4 from p h y s i o t h e r a p y , 4 from o c c u p a t i o n a l work.  t h e r a p y , 5 from n u r s i n g  and 1 from s o c i a l  Of t h e s e i n d i v i d u a l s , 3 d i d n o t c o m p l e t e t h e s t u d y .  The r e a s o n s were  1) f a i l u r e t o r e t u r n t h e q u e s t i o n n a i r e questionnaire  (N=2).  Those who d i d n o t c o m p l e t e t h e study i n c l u d e d 1 from  m e d i c i n e , 1 from n u r s i n g T a b l e II  T a b l e II Specialty  ( N = l ) , and 2) f a i l u r e t o c o m p l e t e t h e  and t h e 1 p a r t i c i p a n t from s o c i a l  l i s t s the f i n a l  work.  sample o f t h e study a c c o r d i n g t o s p e c i a l t y .  Study Sample A c c o r d i n g t o S p e c i a l t y G.F.  Holy Family  Strong  Combined  Medicine  9  2  11  Physiotherapy  8  4  12  Occupational Therapy  6  4  10  Nursing  6  4  10  S o c i a l Work  2  0  2  31  14  45  Total  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 y e a r s e x p e r i e n c e a t t h e f a c i l i t y , c o u n t r y o f t r a i n i n g and a t t i t u d e . Because o f t h e i r s m a l l number, t h e two s o c i a l w o r k e r s were l e f t o u t o f t h e comparison. 31  Sex d i f f e r e n c e s e x i s t e d o n l y amongst m e d i c a l s t a f f .  At G.F. Strong, 2 of  t h e 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 t h e s t u d y were f e m a l e . p h y s i c i a n s were m a l e .  A t Holy F a m i l y both  The r e s t o f t h e sample was w i t h o u t e x c e p t i o n f e m a l e .  The average age i n t h e f a c i l i t i e s was 38 y e a r s a t G . F . S t r o n g and 36 at Holy F a m i l y .  In b o t h f a c i l i t i e s , t h e average age o f the m e d i c a l and  years  nursing  s t a f f was i n t h e mid f o r t i e s , whereas t h a t o f t h e p h y s i c a l and o c c u p a t i o n a l t h e r a p y s t a f f was i n t h e low  30's.  Average l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y ranged from 2 t o 8 y e a r s . 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 t a y e d t h e l o w e s t number o f y e a r s , 2 y e a r s  H o l y F a m i l y and 3 y e a r s a t G . F . S t r o n g . l o n g e r on t h e a v e r a g e , 8 y e a r s Occupational  Physicians  a t both f a c i l i t i e s  In at  stayed  a t G . F . S t r o n g and 7 y e a r s a t H o l y F a m i l y .  t h e r a p i s t s a n d - r e g i s t e r e d n u r s e s were i n t h e m i d d l e range a t 5  y e a r s f o r b o t h a t G . F . S t r o n g , and a t H o l y F a m i l y , 4 y e a r s f o r o c c u p a t i o n a 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 The s i t e o f p r o f e s s i o n a l  nurses.  t r a i n i n g r e f e r s to country of 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 t h e U n i t e d Kingdom) professionals  and 3) t r a i n e d i n both s e t t i n g s .  A l m o s t 60 per c e n t o f  a t G . F . S t r o n g and 80 p e r c e n t o f p r o f e s s i o n a l s  t r a i n e d i n Canada o n l y .  a t H o l y F a m i l y had  Of t h e 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 t h e 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 n u r s e s and 1 was an o c c u p a t i o n a l therapist.  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 b o t h e n v i r o n m e n t s , 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 o c c u p a t i o n a l  therapists.  Though not o v e r t l y r e f l e c t e d i n t h e sample c h a r a c t e r i s t i c s , t h e r e i s a l s o a variance i n a t t i t u d e to consider.  Haug and L a v i n ' s  32  study  (1981) i d e n t i f i e d an  ' a t t i t u d e to authority in general'  as the o n l y a t t r i b u t e o f p h y s i c i a n s  signifi-  cantly i n f l u e n c i n g t h e i r reaction to patient challenges 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  will  be c o n s i d e r e d i n t h e  study.  I n sum, t h e r e appears t o be enough v a r i a t i o n i n t h e sample c h a r a c t e r i s t i c s t o w a r r a n t assessment o f t h e 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 ,  specialty,  age, l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y , c o u n t r y o f 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 t h e p r o f e s s i o n a l ' s Further analysis  response t o the p a t i e n t ' s  behavior.  t o compare t h e sample c h a r a c t e r i s t i c s w i t h t h e p r o f e s s i o n a l  p o p u l a t i o n w i t h i n o r o u t s i d e each f a c i l i t y was f e l t t o be beyond t h e scope this thesis.  of  A l s o , as random s a m p l i n g was n o t 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 .  C o n s e q u e n t l y , though t h e summary  c h a r a c t e r i s t i c s a r e not s u r p r i s i n g o r u n e x p e c t e d , one c a n n o t say w i t h c o n f i d e n c e t h a t t h e sample a c c u r a t e l y r e f l e c t s t h e 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 facility  or the population 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  i n the  in total.  Thus t h e  study f i n d i n g s c a n n o t be g e n e r a l i z e d i n s i d e o r o u t s i d e t h e 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 of gathering p r e l i m i n a r y evidence s t i l l  holds  true  even i f c a u t i o n i s w a r r a n t e d when c o n s i d e r i n g t h e i m p l i c a t i o n s o f t h e r e s u l t s .  Measures  T h e r e a r e two s e c t i o n s d i s c u s s i n g  t h e measurements  used i n t h i s  thesis.  The f i r s t c o n c e r n s t h e 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 Here t h e dependent v a r i a b l e s  ( r e p r e s e n t i n g how t h e p r o f e s s i o n a l  explains,  d e s c r i b e s and d e a l s w i t h t h e p a t i e n t ) and t h e i n d e p e n d e n t v a r i a b l e s  33  analysis.  (represent-  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 ' ) a r e d i s c u s s e d . additional  dimensions were a s s e s s e d i n the i n t e r v i e w .  professional's  F u r t h e r t o t h i s , two  The f i r s t c o n s i d e r e d t h e  perception of the ' i m p l i c a t i o n s ' of the p a t i e n t ' s behavior f o r  t h e achievement o f r e h a b i l i t a t i o n g o a l s . i n t e r p r e t the p r o f e s s i o n a l s '  This i s included i n order to help  r e s p o n s e s and the i m p l i c a t i o n s o f the  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 '  findings.  of the r o l e the p r o f e s s i o n a l  a c t u a l l y assumed d u r i n g the i n t e r a c t i o n w i t h each o f t h e f a b r i c a t e d p a t i e n t roles.  T h i s measure i s d i s c u s s e d as a check on the v a l i d i t y o f t h e measurement  of t h e p r o f e s s i o n a l  r o l e i n the q u e s t i o n n a i r e .  I t i s c o n s i d e r e d i n the second  section. Foremost i n the second s e c t i o n i s t h e 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 q u e s t i o n n a i r e . variable, professional  role.  P r i m a r i l y , t h i s c o n s i d e r s the independent Other p r o f e s s i o n a l  account f o r the p a t t e r n o f t h e p r o f e s s i o n a l s '  The I n t e r v i e w  attributes that potentially  responses are a l s o d i s c u s s e d  here.  1  Development The i n t e r v i e w was designed t o e l i c i t t h e p r o f e s s i o n a l ' s  responses as they  v a r i e d between t h e p a t i e n t ' s r o l e as consumer and dependent, when t h e d e c i s i o n c o n t e n t addressed t h e 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 t h e p r o f e s s i o n a l ' s p a t i e n t ' s r o l e s c o n c e r n i n g d e c i s i o n 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 b e h a v i o r was c o n s i s t e n t w i t h the c o n s u m e r i s t or dependent r o l e s .  1  An a c t u a l i n t e r v i e w i s p r e s e n t e d i n Appendix  34  1.  and  I n t h i s r e g a r d , t h e c o n s u m e r i s t p a t i e n t q u e s t i o n e d t h e f a c i l i t y ' s program, d i d not f i t w e l l medication.  i n t o the f a c i l i t y  s c h e d u l e , and asked f o r second o p i n i o n s  C o n v e r s e l y , t h e dependent p a t i e n t f o l l o w e d t h e  directions without question, f i t well be p r e s e n t e d a t c l i n i c a l  i n t o the f a c i l i t y  rounds even though e m b a r r a s s e d .  on  professional's  s c h e d u l e , and a g r e e d t o The a c t u a l  description  o f t h e b e h a v i o r i s p r e s e n t e d w i t h i n t h e a c t u a l c a s e s t u d y i n Appendix  1.  The f a b r i c a t e d s t u d i e s p r e s e n t e d 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 other than b e h a v i o r . fessionals'  The o b j e c t i v e was t h a t t h e d i f f e r e n c e s i n p r o -  p e r c e p t i o n s and r e s p o n s e s t o t h e p a t i e n t ' s b e h a v i o r c o u l d be a t t r i -  b u t e d t o t h e v a r i a n c e i n ' p a t i e n t r o l e ' , r a t h e r than t o o t h e 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 o r  sex.  The i n f o r m a t i o n c o n t a i n e d i n t h e c a s e s t u d i e s was a l s o d e s i g n e d t o p r e s e n t c i r c u m s t a n c e s r e l e v a n t t o who s h o u l d make t h e u l t i m a t e d e c i s i o n s r e g a r d i n g w e l l - b e i n g of the p a t i e n t . dimensions:  pathology'  These c i r c u m s t a n c e s were d e v e l o p e d t o i n v o l v e t h r e e  1) c l u s t e r o f p a t h o l o g y , 2)  p a t i e n t and p r o f e s s i o n a l  regarding  r i s k , and 3) d i s a g r e e m e n t between t h e  ' b e s t discharge outcome'.  i s a c h a r a c t e r i s t i c of chronic i l l n e s s .  p a t i e n t s have many problems o f w h i c h m e d i c a l s t a t u s f i n a n c e s and l a c k o f s o c i a l  the  'Cluster  of  In g e n e r a l , c h r o n i c a l l y i l l i s o n l y one.  Limited  s u p p o r t a r e two examples o f c o n t r i b u t o r y p r o b l e m s .  The second d i m e n s i o n , ' r i s k ' ,  r e s u l t s when t h e r e s i d u a l d e f i c i t from t h e i l l n e s s  combines w i t h t h e o t h e r problems i n the ' c l u s t e r ' t o p r e s e n t t h e p a t i e n t w i t h the p o t e n t i a l of serious  injury.  T h i s r i s k can be i n c r e a s e d o r d e c r e a s e d ,  dependent on t h e d i s c h a r g e o p t i o n c h o s e n .  The t h i r d d i m e n s i o n ,  'disagreement',  i n v o l v e s t h e p a t i e n t c h o o s i n g an o p t i o n t h a t i s d i f f e r e n t f r o m , and  35  involves  more r i s k t h a n , t h e o p t i o n s e l e c t e d by t h e 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 t o r e f l e c t t h e s e t h r e e dimensions, medical  f o u r c a t e g o r i e s were c o n s i d e r e d :  1) i n d i v i d u a l a t t r i b u t e s , 2)  s t a t u s , 3) s o c i a l s t a t u s , and 4) c i r c u m s t a n c e s .  v a r i a b l e s considered w i t h i n these c a t e g o r i e s .  T a b l e III  lists  the  The m a t c h i n g and e x p r e s s i o n  of  t h e v a r i a b l e s i n t h e p a t i e n t c a s e s t u d y a r e d i s c u s s e d i n t h e i n t e r v i e w example i n Appendix  1.  Table III  V a r i a b l e s r e f l e c t i n g the circumstances of the p a t i e n t case  Individual  Medical  attributes  Age Sex  status  P a s t medical h i s t o r y Mental s t a t u s Residual d e f i c i t Prognosis Diagnosis  Social Status  Marital status Children Education Employment Finances Accommodation  Circumstances  Risk  36  studies  The c o n t e n t o f t h e s e 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 c a s e s t u d i e s  i n a form  r e s e m b l i n g a r e p o r t from a m e d i c a l r e c o r d summarizing t h e p a t i e n t ' s s t a y .  A  r e v i e w o f t h e m e d i c a l r e c o r d s o f t h e 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 t h e study h e l p e d t h e i n v e s t i g a t o r t o match t h e t e r m i n o l o g y used i n t h e 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  professionals.  The c r e d i b i l i t y o f t h e c a s e s t u d i e s , t h e i r e x p r e s s i o n  i n a l u c i d manner,  and t h e v a l i d i t y o f t h e m a t c h i n g o f t h e v a r i a b l e s were a s s e s s e d t h r o u g h a number of p r e - t e s t s .  The p r e - t e s t i n g was done by t h e i n v e s t i g a t o r ' s  c o l l e a g u e s whose  range o f e x p e r i e n c e i n c l u d e d n u r s i n g , p h y s i o t h e r a p y , o c c u p a t i o n a l t h e r a p y ,  and  medicine.  Interview  Strategy  2 The i n t e r v i e w e r used open-ended q u e s t i o n s e l i c i t the p r o f e s s i o n a l s '  and p r o b i n g s t r a t e g i e s  to  r e s p o n s e s t o t h e b e h a v i o r o f each o f t h e p a t i e n t s .  Q u e s t i o n s were d i r e c t e d s p e c i f i c a l l y t o how t h e p r o f e s s i o n a l s e x p l a i n , d e s c r i b e and deal w i t h t h e p a t i e n t ' s b e h a v i o r .  s t a t e d they would  In a d d i t i o n , the  p r o f e s s i o n a l s were a s k e d t o e v a l u a t e t h e i m p l i c a t i o n s o f t h e p a t i e n t ' s  behavior  f o r t h e achievement o f r e h a b i l i t a t i o n g o a l s . S t a n d a r d i z e d 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 interview.  P r o b i n g was then used t o d i r e c t t h e p r o f e s s i o n a l s  vant dimensions.  to the r e l e -  T h i s approach was used t o guard a g a i n s t t h e 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 of the i n t e r v i e w .  The p r o b i n g t h e n k e p t t h e i n t e r v i e w  f o c u s e d b u t a l l o w e d f o r t h e 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 o f t h e s e q u e s t i o n s Appendix 1.  are i n c l u d e d i n the i n t e r v i e w presented i n  37  T h r e e p a r t i c u l a r t e c h n i q u e s of p r o b i n g were employed.  The f i r s t was an  approach t h a t pushed t h e c a s e s t u d y c i r c u m s t a n c e s and t h e e n s u i n g r e s p o n s e s t o t h e i r extreme.  F o r example, a t one p o i n t , one o f t h e p r o f e s s i o n a l s  p a t i e n t ' s d i s c h a r g e d e c i s i o n s h o u l d be f o l l o w e d i f a p p r o p r i a t e .  1  stated,  'the  Further i n -  f o r m a t i o n was t h e n p r o v i d e d t o 1) i n d i c a t e d i s a g r e e m e n t between t h e p r o f e s sional  and p a t i e n t as t o t h e 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 e a t e r  risk  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 t o be made.  The p r o f e s s i o n a l  was meant.  was t h e n asked t o d e f i n e t h e term ' a p p r o p r i a t e ' as  F o l l o w i n g t h i s e x e r c i s e , the professional  it  s t a t e d , 'You mean, who  s h o u l d make t h e u l t i m a t e d e c i s i o n . ' The second t e c h n i q u e o f a s k i n g f o r d e f i n i t i o n s o f terms and t h e t h i r d o f a s k i n g t h e same q u e s t i o n i n d i f f e r e n t ways h e l p e d t o c l a r i f y t h e meaning and check t h e v a l i d i t y o f t h e p r o f e s s i o n a l ' s  statements.  I n t h i s way, f o r example,  t h e d e s c r i p t i o n o f t h e 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 t o mean, i n one case,  'responsive'  and, i n the o t h e r ,  'passive'.  The new c o n n o t a t i o n s o f t h e  word f a c i l i t a t e d t h e 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 t h e s t a t e m e n t . These t e c h n i q u e s were p r e - t e s t e d i n f o r m a l l y w i t h t h e  investigator's  c o l l e a g u e s and, f o r m a l l y , i n p i l o t s t u d i e s c o n d u c t e d a t V a n c o u v e r G e n e r a l Holy Family H o s p i t a l s .  and  T h i s helped t o develop the i n t e r v i e w e r ' s a b i l i t y to  c o n d u c t an i n t e r v i e w i n a c o m p e t e n t , r e l a x e d manner i n o r d e r t o s t i m u l a t e s u f f i c i e n t expression of the p r o f e s s i o n a l s '  views.  ascertained, p a r t i c u l a r l y in the i n i t i a l  interviews of the study,  interviewer's s k i l l  Though not a l l r e s p o n s e s were the  developed f u r t h e r to minimize the l o s s of i n f o r m a t i o n .  38  Administration The i n t e r v i e w was c o n d u c t e d i n h a l f hour s e s s i o n s a t a t i m e and p l a c e c o n v e n i e n t to the p r o f e s s i o n a l .  A room was r e s e r v e d f o r each i n t e r v i e w i n o r d e r t o  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 . s t u d y f o l l o w e d t h e same r o u t i n e .  The p r e s e n t a t i o n o f each p a t i e n t c a s e  F i r s t , a page l o n g c a s e s t u d y o f t h e  c o n s u m e r i s t p a t i e n t was g i v e n t o t h e p r o f e s s i o n a l professional  to read.  i n d i c a t e d the completion of 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 w o u l d l i k e t o t e l l you a l i t t l e more about Mr. C ' s A t t h i s t i m e , the i n t e r v i e w e r read the paragraph behavior.  When t h e  The p r o f e s s i o n a l  stay a t the C e n t r e . '  d e s c r i b i n g the p a t i e n t ' s  t h e n r e t a i n e d both p i e c e s o f i n f o r m a t i o n f o r  ongoing  reference. The q u e s t i o n s e s s i o n f o r each p a t i e n t case began, i m p r e s s i o n of Mr. centre.'  's  The e n s u i n g  'describing',  CC  f o r consumerist,  'D'  'What i s y o u r  f o r dependent)  general  stay at the  r e s p o n s e s were p r i m a r i l y d i r e c t e d t o t h e d i m e n s i o n s  ' e x p l a i n i n g ' , and ' d e a l i n g ' w i t h t h e p a t i e n t ' s  of  behavior.  The n e x t s t a g e o f t h e q u e s t i o n i n g was d i r e c t e d a g a i n , p r i m a r i l y , t o ' d e a l i n g ' , as w e l l  as t o t h e d i m e n s i o n o f t h e i m p l i c a t i o n s f o r  r e h a b i l i t a t i o n goals.  F i r s t the professional  t h e b e s t d i s c h a r g e o p t i o n f o r Mr.  '  '.  was a s k e d :  achieving  'What do you see  as  Then f u r t h e r i n f o r m a t i o n o f t h e  p a t i e n t ' s s i t u a t i o n r e g a r d i n g d i s c h a r g e was p r o v i d e d , i n i t i a t e d by t h e s t a t e ment:  'Now I w o u l d l i k e t o t e l l The c i r c u m s t a n c e s  the aspects through 1)  you a l i t t l e more about Mr.  surrounding  of a ' c r i s i s ' family refusal  the p a t i e n t ' s discharge  situation.  's  options  The d i s c h a r g e o p t i o n s were  t o assume r e s p o n s i b i l i t y f o r s u p p o r t  39  discharge.' highlighted compromised  (the family  r e f u s e s the p a t i e n t ' s r e q u e s t t o 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 t h e 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 t h a n t h a t of the p r o f e s s i o n a l . Though both c a s e s p r e s e n t e d t h e p a t i e n t ' s o p t i o n s as b e i n g q u e s t i o n a b l e  in  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 order to m a i n t a i n c o n s i s t e n c y w i t h patient role.  Whereas t h e c o n s u m e r i s t p a t i e n t openly p r e s e n t e d h i s o p t i o n t o  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 w i s h e d t o . . . . ' ) , t h e dependent  p a t i e n t ' s p r e f e r e n c e was s t a t e d through h i s f a m i l y ( ' T h e C e n t r e h e a r d from Mr. D.'s  d a u g h t e r who s a i d she had spoke w i t h him on t h e  phone...').  The i n t e r v i e w e r f r e e l y r e c o r d e d t h e s t a t e m e n t s o f t h e p r o f e s s i o n a l the i n t e r v i e w .  F o u r o f t h e f i r s t t e n i n t e r v i e w s were t a p e d w i t h t h e c o n s e n t  the p r o f e s s i o n a l . questioning  during of  In t h i s way t h e i n t e r v i e w e r c o u l d a s s e s s t h e p r e s e n t a t i o n and  techniques.  Analysis The p r o f e s s i o n a l s '  r e s p o n s e s t o each p a t i e n t r o l e were measured a l o n g a  continuum r a n g i n g between t h e 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 t h e dynamics o f t h e s p e c i f i c c o m b i n a t i o n o f p a t i e n t r o l e and professional  role.  Each r e s p o n s e was t h e n t a k e n t o t h e c l o s e r extreme o f t h e  continuum and coded on a 2 - p o i n t 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 , t h e r e s p o n s e s were i n i t i a l l y two ways; f i r s t ,  examined i n  f o r each p r o f e s s i o n a l , comparing t h e r e s p o n s e t o each p a t i e n t  r o l e and s e c o n d , f o r each p a t i e n t r o l e , comparing t h e r e s p o n s e s o f t h e p r o f e s sionals.  I n t h i s e x e r c i s e , t h e 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 t h e c a t e g o r i e s o f p r o f e s s i o n a l s ' c l a r i f y the coding of the terms.  Professionals  responses w i l l  could e x p l a i n the p a t i e n t ' s  b e h a v i o r on a continuum r a n g i n g from a ' p a t i e n t a t t r i b u t e terms'.  help to  to a ' c o n f l i c t of  1  An example o f t h e f i r s t f o r t h e dependent p a t i e n t i s , " t h e p a t i e n t goes  a l o n g because t h e y ' r e t h a t s o r t o f p e r s o n " , as opposed t o t h e s e c o n d , "may 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 " . 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 o r a t e d f u n c t i o n " , and o f  'accommodating',"needs  be a t odds w i t h t h o s e o f  staff."  For the  consumerist  coping with his  deteri-  t h a t have o c c u r r e d t o him might  The p a t i e n t s ' b e h a v i o r c o u l d be d e s c r i b e d a l o n g a continuum r a n g i n g 'good'  to ' d i f f i c u l t ' .  An example o f ' g o o d '  p a t i e n t , "good motivation - l i k e l y  from  f o r t h e 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 t o s t a y o u t o f h o s p i t a l s " , and o f "over-compliant - lacks i n i t i a t v e " .  not  An example o f ' g o o d '  'difficult',  f o r t h e consumer  t o s u c c e e d " , and o f ' d i f f i c u l t ' ,  l i k e a teenage - a c t i n g o u t , d e l u d i n g h i m s e l f * .  "behaving  When t h e p a t i e n t ' s b e h a v i o r was  c o n s i d e r e d t o be due t o a ' l a c k o f j u d g m e n t ' , t h e p a t i e n t was not h e l d r e s p o n s i b l e and t h e b e h a v i o r was not e v a l u a t e d i n terms o f ' g o o d '  and ' d i f f i c u l t ' ,  example, f o r t h e dependent p a t i e n t , " p r o b a b l y a l i k e d c o m p l i a n t p a t i e n t , o r judgment i s  his  decreased".  The p a t i e n t ' s b e h a v i o r c o u l d be d e a l t w i t h on a continuum r a n g i n g 'controlling' 'rejection'  for  from  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  f o r t h e c o n s u m e r i s t p a t i e n t , and t h e ' a c c o m m o d a t i n g '  i n c l u d i n g t h e d i m e n s i o n o f ' i n s p i r a t i o n ' f o r dependent p a t i e n t . s u m e r i s t p a t i e n t an example o f ' c o n t r o l ' i s , " e d u c a t e him f o r h i s b i l i t y , t h e r e a s o n he i s h e r e .  Why does he t h i n k h e ' s  41  of  perspective For the conresponsi-  at the Centre?",  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 i m e , t h a t i s not w i l l i n g t o p a r t i c i p a t e , c o - o p e r a t e , be m o t i v a t e d . " 'accommodating'  An example o f  t h e c o n s u m e r i s t p a t i e n t i s , " h e does not have t h e same  e x p e c t a t i o n s - f r u s t r a t i n g f o r t h e s t a f f but r e a l l y up t o t h e p e r s o n " . 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 m o d i f y h i s  For the  treatment  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 ' , " W i t h d r a w t h e c l o s e s u p e r v i s i o n he w i l l  so  t a k e 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 t h e s e r e s p o n s e s w i t h t h e o f a framework  (Figure 7).  terms o f t h e i r assumptions  If  the p r o f e s s i o n a l  o r o t h e r arguments  t h e s e were a s s e s s e d a g a i n s t t h e a s s u m p t i o n s framework.  assistance  e x p l a i n e d t h e i r responses i n  that underlined t h e i r  and arguments  evaluation  made e x p l i c i t i n t h e  Once t h e r e s p o n s e s were c o d e d , t h e i n v e s t i g a t o r checked t h e  r e l i a b i l i t y o f t h e c o d i n g i n t h r e e ways: 1)  r e c o d i n g by t h e 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)  t h e framework was i n f o r m a l l y a s s e s s e d by a c o l l e a g u e who was s a t i s f i e d t h a t t h e c o n t e n t , t h e arguments, had f a c e v a l i d i t y and were  3)  and t h e  assumptions  consistent;  a c o l l e a g u e was asked t o code randomly  s e l e c t e d statements.  These was t h e n compared w i t h t h e i n v e s t i g a t o r ' s .  Seven o f  t e n d e c i s i o n s were t h e same. In r e a l i t y , o f c o u r s e , p r o f e s s i o n a l s  do n o t c o n s c i o u s l y  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 ' , the p a t i e n t ' s b e h a v i o r .  'describing'  t h i n k i n terms or ' d e a l i n g '  of  with  The i n t e r v i e w e r probed i n t h e s e d i r e c t i o n s b u t r e c o g -  n i z e d t h e need t o i n c o r p o r a t e t h e c a t e g o r i e s o r r e s p o n s e s w i t h t h e ' r a t i o n a l e ' t h a t c o n n e c t e d them.- The framework was d e v e l o p e d t o i n t e g r a t e t h e 42  assumptions  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 BEHAVIOR explained AS "PATIENT ATTRIBUTE"  4*  CO  BEHAVIOR explained AS "CONFLICT" OF TERMS"  BEHAVIOR explained AS "PATIENT ATTRIBUTE"  "Patients should assume-responsibility for health decisions." "Patients should rely on their own judgment." "PATIENT DOMINANT ASYMMETRY LEGITIMATE" CONSUMERIST PATIENT TRADITIONAL PATIENT BEHAVIOR explalned AS "PATIENT ATTRIBUTE"  BEHAVIOR explained AS "CONFLICT OF TERMS"  BEHAVIOR explained AS "PATIENT ATTRIBUTE"  BEHAVIOR explained AS "CONFLICT OF TERMS"  BEHAVIOR BENEFICIAL described "GOOD"  CONFLICT VALID described "GOOD"  BEHAVIOR DISRUPTIVE described "DIFFICULT"  CONFLICT NOT VALID described "DIFFICULT"  y x BEHAVIOR DISRUPTIVE described "DIFFICULT"  CONFLICT NOT VALID described "DIFFICULT  1  y  deal CONTROL OR REJECT  PATIENT MOTIVATED described "GOOD"  \  LACK OF JUDGMENT not described patient not held responsible  deal CONTROL  deal ACCOMMODATE  Ft^-^deaT'^  SUftrtOllHTABLTf | INSURMOUNTABLY"  I  I INSPIRE t 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.  REVERT TO CONTROL  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 , t h e c a t e g o r i e s o f r e s p o n s e s , and t h e a c t u a l  r e s p o n s e s 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 t h e p a t i e n t r o l e s . In sum, t h e i n t e r v i e w e r p r e s e n t e d two p a t i e n t c a s e s t u d i e s d i f f e r e n t i n c o n t e n t , v a r i e d o n l y i n terms o f p a t i e n t r o l e .  which,though  In both c a s e s ,  the  i n f o r m a t i o n p r e s e n t e d c i r c u m s t a n c e s w h i c h 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 . sional's  profes-  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 , t h e  professional option.  To h e i g h t e n t h e d i m e n s i o n o f  and p a t i e n t were r e p o r t e d t o d i s a g r e e about t h e b e s t  discharge  The p r o f e s s i o n a l s were asked how t h e y 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 behavior.  A number o f s t e p s were t a k e n t o enhance t h e  i n t e r v i e w ' s a b i l i t y t o measure what i t was i n t e n d e d t o measure.  The Q u e s t i o n n a i r e Devel opment The i n d e p e n d e n t 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 x p l a n a t i o n s o f t h e p a t t e r n o f r e s p o n s e s o f t h e dependent v a r i a b l e s . professional  The h y p o t h e s i s  predicts that  o r i e n t a t i o n t o r o l e e x p e c t a t i o n s s h o u l d u n d e r l i e much o f t h e  variance.  3 A questionnaire  was d e v i s e d t o measure p r o f e s s i o n a l  c o n t r o l l e r o r accommodator.  Twenty-seven  r o l e as e i t h e r  i t e m s were adopted and r e v i s e d from  t h e s c a l e s d e v e l o p e d by Haug and L a v i n (1981) t o measure a t t i t u d i n a l and behavioral  aspects 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  relationship. 3  In c a p s u l e form, these dimensions  See a p p e n d i x 2 .  44  r e f l e c t e d 1) a t t i t u d i n a l  c h a l l e n g e t o p h y s i c i a n a u t h o r i t y , 2) b e h a v i o r a l  challenge to  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 ' b e l i e f i n p a t i e n t s r i g h t t o i n f o r m a t i o n , 5) make  behavioral  challenge,  b e l i e f i n the p a t i e n t s '  right  physicians.  dimensions  to  were p r e s e n t e d t o t h e p u b l i c as w e l l  as  as p h y s i c i a n ' s  t h a t challenge the p h y s i c i a n ' s  r e p o r t e d response  traditional authority,  t o such a t t i t u d e s and  as  events.  M o d i f i c a t i o n s o f t h e s e i t e m s were done i n p r e p a r a t i o n f o r t h i s study various  to  They c o n d u c t e d i n t e r v i e w s t o a s s e s s t h e e x t e n t o f r e p o r t e d p u b l i c  a t t i t u d e s and b e h a v i o r s  for  reasons:  1)  The study s e t t i n g changed from t h e community t o t h e 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  3)  Some o f t h e e x p r e s s i o n s  C a n a d i a n sample i n 4)  4)  decisions. Haug and L a v i n ' s  well  physician  and t e r m i n o l o g y  i n a d d i t i o n to the p h y s i c i a n ;  used were n o t a p p r o p r i a t e f o r a  1984;  The o r i g i n a l q u e s t i o n s  had been p r e s e n t e d t h r o u g h 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 t h e 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 t o be i n c o r p o r a t e d i n t h e q u e s t i o n n a i r e was t h e i d e n t i f i c a t i o n of the s p e c i f i c profession  as a p p r o p r i a t e .  Additional  changes  came as t h e r e s u l t o f p r e - t e s t i n g o f t h e 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 students  and t h e i n v e s t i g a t o r ' s  m o d i f i c a t i o n w o u l d be n e c e s s a r y questions.  4  colleagues.  They i n d i c a t e d where, f u r t h e r  t o encourage comprehension  The a c c e p t e d recommendations  and c o m p l e t i o n o f a l l  A  follow :  F o r examples o f t h e m o d i f i c a t i o n s r e f e r t o t h e q u e s t i o n n a i r e  45  i n Appendix  2.  1)  Q u e s t i o n s w h i c h were a r r a n g e d 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 t o two s e p a r a t e q u e s t i o n s L i k e r t type 2)  a r r a n g e d on 4 - p o i n t  scales.  Some o f t h e a b s o l u t e terms such as  example, t o ' v e r y '  important.  the options of strongly  'most'  i m p o r t a n t were q u a l i f i e d ,  S i n c e answers were g i v e n on L i k e r t t y p e  agree o r d i s a g r e e were s t i l l  for  scales,  a v a i l a b l e to r e f l e c t  strong  bias. 3)  Q u e s t i o n s w h i c h had been p r e s e n t e d as c a s e s t u d i e s and l e f t  open-ended  ( f a c i l i t a t e d by t h e i n t e r v i e w p r e s e n t a t i o n ) w i t h t h e answers coded i n t o t h r e e categories representing either ' r e j e c t ' ,  ' c o n t r o l ' , and ' a c c o m m o d a t e ' , were  r e p l a c e d by s t a t e m e n t s r e f l e c t i n g t h e t h r e e 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 q u e s t i o n s were i n c l u d e d t o c o v e r t h e t y p e o f  c h a l l e n g e l i k e l y t o o c c u r i n t h e i n s t i t u t i o n r a t h e r t h a n t h e community as Haug and L a v i n ' s  study.  The q u e s t i o n n a i r e used L i k e r t t y p e s c a l e s on a 4 - p o i n t s c a l e . neutral  in  c a t e g o r y was p r o v i d e d .  As s u c h , no  The r e s p o n s e s were meant t o r e f l e c t c o n t r o l l i n g  o r accommodating o r i e n t a t i o n o f t h e p r o f e s s i o n a l .  The r e s p o n s e s were then coded  so t h a t t h e numbers 1 and 2 always r e f l e c t e d t h e ' c o n t r o l l e r ' and 3 and 4 t h e 'accommodator'  orientation.  In sum, t h e s t r u c t u r e o f t h e Haug and L a v i n q u e s t i o n n a i r e was dramatically.  The c o n t e n t 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  t h e a p r i o r i meaning o f t h e q u e s t i o n s  changed c o n s i d e r e d as  t o r e f l e c t 1) c h a l l e n g e t o 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 t o make decisions.  F u r t h e r changes i n t e r m i n o l o g y were recommended d u r i n g p r e - t e s t i n g  and t h e s e were implemented i n o r d e r t o enhance comprehension and c o m p l e t i o n o f the q u e s t i o n n a i r e .  46  Administration The q u e s t i o n a l ' r e s , w i t h c o n s e n t forms all  professionals  i n t h e sample.  5  a t t a c h e d , were c i r c u l a t e d t o  The i d e n t i t y o f t h e p a r t i c i p a n t was i n d i c a t e d  on t h e c o n s e n t form and q u e s t i o n n a i r e by t h e same code number.  The  returned  q u e s t i o n n a i r e c o u l d t h e n be coded by t h e i n v e s t i g a t o r w i t h o u t knowledge o f t h e subject's  i d e n t i t y , s i n c e t h i s knowledge p o t e n t i a l l y would have b i a s e d  investigator's  assessment o f t h e 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 t e r v i e w s were begun o n l y a f t e r a l l q u e s t i o n n a i r e s s u b j e c t s who had n o t r e t u r n e d t h e q u e s t i o n n a i r e the study.  the  had been r e t u r n e d .  Those  by t h i s t i m e were removed from  The s u b j e c t s were asked t o r e f r a i n from d i s c u s s i n g  t h e 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 a g u e s  the content of  not i n v o l v e d i n t h e  study.  Analysis A c o r r e l a t i o n m a t r i x of 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 t e m s t h a t were t h o u g h t t o be c o n c e p t u a l l y r e l a t e d were showing o f answers t o t h e c o n t r a r y ; as e i t h e r ' c o n t r o l l e r s '  and 2) r e s p o n d e n t s  or ' a c c o m m o d a t o r s ' .  d i f f e r e n t from t h e a p r i o r i a s s u m p t i o n s pattern of professionals' which t h e q u e s t i o n s  responses.  patterns  c o u l d not e a s i l y be c a t e g o r i z e d  T h e r e appeared t o be  meanings,  o f the i n v e s t i g a t o r , t h a t determined the  T h a t i s , t h e r e were d i f f e r e n t ways i n  c o u l d be g r o u p e d , each r e f l e c t i n g a l t e r n a t e d i m e n s i o n s  t h e 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 w h i c h t h e i n v e s t i g a t o r ' s way was one.  5  The c o n s e n t forms a r e i n c l u d e d w i t h t h e q u e s t i o n n a i r e i n Appendix 47  2.  of only  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 o f ways. the questions  Factor analysis  was s e l e c t e d as a t e c h n i q u e t h a t c o u l d  according to the p r o f e s s i o n a l s '  l a r g e l y independent of the i n v e s t i g a t o r ' s Factor analysis  involves three steps:  responses,  i n a way t h a t was  pre-conceived d e f i n i t i o n s . 1)  The f i r s t i s t h e p r e p a r a t i o n o f a  c o r r e l a t i o n m a t r i x w h i c h c a l c u l a t e d a p p r o p r i a t e measures variables.  of a s s o c i a t i o n  F o r t h e q u e s t i o n n a i r e , R - t y p e c o r r e l a t i o n between t h e  i t e m s was s o u g h t r a t h e r t h a n Q - t y p e c o r r e l a t i o n between p a i r s o f 2)  regroup  between  questionnaire individuals.  The second s t e p i n v o l v e s t h e r e d u c t i o n o f i t e m s i n t o new v a r i b a l e s ,  called  f a c t o r s , based on t h e 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 t h e c o r r e l a t i o n m a t r i x .  It  i s assumed t h a t t h e s e 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  is,  t h e r e i s assumed t o be a ' r e a s o n ' not.  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 ,  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 ,  assumed t o be due t o a common f a c t o r . correlated.  3)  The t h i r d s t e p i n v o l v e s  p r e s e n t i n g the dimensions initial  The f a c t o r s t h e m s e l v e s , the f i n a l  it  is  however, a r e n o t  s e l e c t i o n of the f a c t o r s  of the independent v a r i a b l e .  re-  On t h e b a s i s o f t h e  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 p e r c e n t o f t h e  variance of q u e s t i o n n a i r e of f a c t o r a n a l y s i s  i t e m r e s p o n s e s was a c c o u n t e d f o r by t h e s e .  i s t h a t f a c t o r s are arranged i n order of t h e i r  A feature  importance  w i t h t h e f i r s t f a c t o r t h e most i m p o r t a n t component and a c c o u n t i n g f o r t h e most variance.  Tables III  t o IX  d e s c r i b e t h e s i x f a c t o r s w h i c h were i s o l a t e d .  W i t h i n each f a c t o r a r e t h e q u e s t i o n n a i r e i t e m s w h i c h were c o r r e l a t e d . Professionals  who responded t o one i t e m 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 item or c o n t r a r i w i s e to a negatively correlated item. 48  The c o n t e n t o f t h e items f u r t h e r d e f i n e s  the meaning o f t h e f a c t o r .  The  strength  o f t h e i n f l u e n c e o f each i t e m on t h e i n t e r p r e t a t i o n o f t h e f a c t o r ,  however,  is  'loaded'  i t e m s on each f a c t o r , d i s t i n c t d i m e n s i o n s  occasions,  i n d i c a t e d by i t s  'loading'.  Through t h e i n s p e c t i o n o f t h e  two f a c t o r s s h a r e d an i t e m t h a t was  are i n t e r p r e t e d .  'heavily  loaded'  highly  On two  on e a c h .  i n d i c a t e s t h a t t h e s e i t e m s measure more t h a n one t h e o r e t i c a l d i m e n s i o n . the c o n t e x t of the o t h e r  'heavily  loaded'  items t h a t i s o l a t e s  the  This It  is  relevant  dimension. The common e l e m e n t o b s e r v e d i n f a c t o r one i s 'team'  resources,  good examples  a c t i v i t i e s and p r o c e d u r e s .  of these.  the p a t i e n t ' s  Medical  While a l l professionals  records  interaction with  and meetings  are  would s t a t e t h a t t h e p a t i e n t  p a r t o f the ' t e a m ' , a l t e r n a t e r e s p o n s e s on t h e s e i t e m s i n d i c a t e d i f f e r i n g professionals'  b e l i e f s regarding  Access to the p r o f e s s i o n a l s ' here.  Item 10,  the s p e c i f i c r o l e the p a t i e n t should  team meetings  in t h i s context, considers  p a t i e n t ' s non-compliance w i t h the ' t e a m ' s ' labelled,  'The p a t i e n t ' s  and m e d i c a l r e c o r d s the p r o f e s s i o n a l ' s decision.  r o l e as a team member'.  49  is in  assume. question  response to the  T h i s f a c t o r has  been  is  The a l t e r n a t e p e r c e p t i o n s o f t h e 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  t h e i t e m s a r e e x p r e s s e d as s e p a r a t e groups o f s t a t e m e n t s c o n s i s t e n t w i t h t h e d i r e c t i o n of the c o r r e l a t i o n s . IV  (A & B ) .  T a b l e IV Item  (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.  Loading  14  .917  15  .834  16  -.798  .545 10  These groups a r e d i s t i n g u i s h e d below i n T a b l e  -.535  Case 3. A p a t i e n t asks t o a t t e n d a m e e t i n g t h a t was meant o n l y f o r p r o f e s s i o n a l s t o d i s c u s s t h e p a t i e n t ' s b e h a v i o 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 p e r m i s s i o n t o a t t e n d ' , 16 ' a r r a n g e a n o t h e r m e e t i n g f o r him t o attend'. Even i f a p a t i e n t a s k s t o r e a d h i s own m e d i c a l r e c o r d s he s h o u l d n o t be a l l o w e d t o do s o . Case 1. A p a t i e n t s u g g e s t s t h a t what you a d v i s e d was t o o much t r o u b l e . You d i s c u s s t h e r e a s o n s b e h i n d y o u r a d v i c e b u t he s t i l l r e f u s e s t o comply Y o u , ' D i s c u s s o t h e r a l t e r n a t i v e s t h a t m i g h t be easier'.  50  T a b l e IV  (B)  F a c t o r 1. regarding  Alternate perceptions the p a t i e n t ' s  of the p r o f e s s i o n a l ' s  r o l e as a team member.  Group 1 Allow the p a t i e n t to the meeting.  role  Group 2 attend  D o n ' t allow the p a t i e n t to attend the meeting.'  1  D o n ' t refuse the p a t i e n t permission to a t t e n d . '  Refuse the p a t i e n t to a t t e n d . '  D o n ' t arrange another meeting f o r him.'  Arrange another for him.'  A p a t i e n t s h o u l d be a l l o w e d t o see h i s own m e d i c a l r e c o r d s .  A p a t i e n t s h o u l d not be a l l o w e d t o see h i s own m e d i c a l r e c o r d s . '  In r e s p o n s e t o  'Discuss other a l t e r n a t i v e s t h a t m i g h t be e a s i e r . '  i s c h a r a c t e r i z e d by i s s u e s r e l a t i n g t h e  decisions  professionals  patient.  Items 2 0 , 22 and 6 a r e c l a s s i c a l  might make i n t h e i n t e r e s t o f t h e w e l f a r e o f t h e  'legitimate paternalism'. professional a r e made.  meeting  non-complicance:  Don't discuss other a l t e r n a t i v e s t h a t m i g h t be e a s i e r . '  F a c t o r two ( T a b l e V below)  permission  episodes  of the question  of  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 o f  and p a t i e n t i n t e r a c t i o n as t h e r o u t e t h r o u g h w h i c h t h e s e  This factor is labelled 'judging  51  patient welfare'.  the  decisions  Table V  F a c t o r 2.  Item  Loading  Judging P a t i e n t Welfare  20  .729  The p a t i e n t i n t h e l a s t s t a g e s o f a t e r m i n a l i l l n e s s s h o u l d d e c i d e i f f u r t h e r t r e a m e n t s h o u l d be c o n t i n u e d .  22  .612  Most t e r m i n a l l y i l l p a t i e n t s s h o u l d not be t o l d t h e p r o g n o s i s even i f r e q u e s t e d by them.  26  .610  I f p r o f e s s i o n a l s would d i s c u 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 o u t 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 t h e r p e r s o n i s i n v o l v e d , a p a t i e n t s h o u l d n o t be a l l o w e d t o l e a v e t h e h o s p i t a l when t h e d o c t o r does n o t a g r e e .  19  -.462  Case 4 . A p a t i e n t has appeared u n m o t i v a t e d d u r i n g t r e a t m e n t . He has r e f u s e d c o u n s e l l i n g and o t h e r e f f o r t s t o e x p l o r e t h e p r o b l e m . 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 b e f o r e and l e t him make t h e f i r s t move t o 'come a r o u n d ' . '  F a c t o r t h r e e ( T a b l e VI  below) c o n t a i n s  w h i c h h e a l t h d e c i s i o n s m i g h t be r e a c h e d . the p r o f e s s i o n a l  items r e l a t i n g t o the process  by  Items 4 and 21 r e f e r t o t h e r o l e o f  g i v i n g a d v i c e and i t e m s 1 and 11 t o t h e r o l e o f t h e p a t i e n t i n  following advice.  This  advice'.  v i e w s w o u l d range from t h e o b l i g a t i o n o f t h e p a t i e n t t o  Opposing  factor is therefore labelled,  f o l l o w advice to the o b l i g a t i o n of the p r o f e s s i o n a l evaluation of the advice.  52  'giving  and f o l l o w i n g  to accept the p a t i e n t ' s  T a b l e VI  F a c t o r 3.  G i v i n g and F o l l o w n g A d v i c e  Item  Loading  4  .722  I f p r o f e s s i o n a l s w o u l d d i s c u s s m a t t e r s more w i t h p a t i e n t s b e f o r e a c t i n g , everybody w o u l d be b e t t e r off.  1  .678  I t i s very i m p o r t a n t f o r p a t i e n t s t o 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 s u g g e s t s t h a t what you a d v i s e d i s not n e c e s s a r y 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 r e a t m e n t 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 t h e f i n a l d e c i s i o n about what t h e p a t i e n t s h o u l d do.  F a c t o r f o u r ( T a b l e VII of the p r o f e s s i o n a l ' s professional's  below) c o n c e r n s , as d i d f a c t o r t h r e e , t h e assessment  a d v i c e , b u t f o c u s e s , i n i t e m s 1 0 , 13 and 9 , on t h e  r o l e as p e r s u a d e r .  That i s , the p r o f e s s i o n a l  should or  not be o b l i g e d t o p e r s u a d e t h e p a t i e n t t o f o l l o w t h e i r a d v i c e .  should  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 t e m s 7 and 27 w h i c h c o n c e r n t h e 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  a d v i c e o r t h e p a t i e n t ' s r e l i a n c e on a c c e s s  i n f o r m a t i o n through q u e s t i o n i n g . faith in professional  This factor is therefore labelled,  advice'.  53  to  'patient  T a b l e VII  F a c t o r 4.  Item  Loading  Patient f a i t h in professional  advice  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 questions w i t h p r o f e s s i o n a l s about a n y t h i n g t h e y a d v i s e .  27  .512  P a t i e n t s s h o u l d have c o m p l e t e f a i t h i n p r o f e s s i o n a l s and do what they a d v i s e w i t h o u t a l o t o f q u e s t i o n s .  10  .441  Case 1 . A p a t i e n t s u g g e s t s t h a t what you a d v i s e d was t o o much t r o u b l e . You d i s c u s s t h e r e a s o n s b e h i n d y o u r a d v i c e b u t he s t i l l r e f u s e s t o comply, ' d i s c u s s o t h e 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 s u g g e s t s t h a t what you a d v i s e d i s n o t n e c e s s a r y f o r h i s c o n d i t i o n and a s k s 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 y o u r s u g g e s t i o n i s b e t t e r than h i s ' .  2  .426  9  -.391  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 take the p a t i e n t ' s opinion i n t o account. Case 1. (as above) a try.'  ought t o  ' T r y t o persuade him t o g i v e  it  F a c t o r f i v e ( T a b l e V I I I below) i n c l u d e s items such as 1 7 , 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 behavior t h a t i s a hinderance t o the ' p r o d u c t i v e ' the f a c i l i t y . involves labelled,  The i n c l u s i o n o f i t e m 21 c o n t r i b u t e s t o t h e d i m e n s i o n  n e g o t i a t i n g the u t i l i z a t i o n of the c e n t r e . ' u t i l i z a t i o n of the c e n t r e ' .  54  This  factor is  use  that therefore  of  Table VIII Item  F a c t o r 5.  U t i l i z a t i o n of the Centre  Loading  17  .786  Case 4 . A p a t i e n t has appeared u n m o t i v a t e d d u r i n g t r e a t m e n t . He has r e f u s e d c o u n s e l l i n g and o t h e r e f f o r t s to e x p l o r e the problem. ' D i s c h a r g e the p a t i e n t so t h a t t h e 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) ' I m p l e m e n t program f o r t h e p a t i e n t . '  8  .561  C a s e 1. A p a t i e n t s u g g e s t s t h a t what you a d v i s e d was t o o much t r o u b l e . You d i s c u s s t h e r e a s o n s b e h i n d y o u r a d v i c e and he s t i l l r e f u s e s t o comply. 'Go t o t r e a t a n o t h e r 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 s e you a r e n o t u s i n g y o u r t i m e 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 r e a t m e n t 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 t h e f i n a l d e c i s i o n about what t h e p a t i e n t s h o u l d do.  F a c t o r s i x ( T a b l e IX  below)  contains  a special  i t e m 5 which f o c u s e s  professional'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 r e a t m e n t .  professional's  'accommodation'  ( i t e m 11)  or ' r e j e c t i o n '  help  the  Further to ( i t e m 12)  of  this, the  p a t i e n t ' s c h o i c e o f a l t e r n a t e t r e a t m e n t , and t h e e v a l u a t i o n i n i t e m 25 whether p a t i e n t s s h o u l d r e l y on t h e i r own judgment,  tap t h e  of  professionals'  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 t h e p a t i e n t , as e i t h e r a c o m p l e t e a d v o c a t e assuming f u l l  responsibility  for health decisions,  agent i n w h i c h t h e p a t i e n t assumes f u l l  responsibility.  55  o r as a p a r t i a l  T a b l e IX  F a c t o r 6.  Item  Loading  Who s h o u l d assume r e s p o n s i b i l i t y f o r h e a l t h  decisions  5  .748  P a t i e n t s s h o u l d not be a l l o w e d t o r e f u s e t r e a t m e n t .  11  -.498  Case 2 . A p a t i e n t s u g g e s t s t h a t what you s u g g e s t e d was not n e c e s s a r y f o r h i s c o n d i t i o n and a s k s 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 . '  12  -.421-  Case 2 . ( s e e above) ' T e l l him he w i l l have t o see someone e l s e t o g e t what he has r e q u e s t e d . '  25  .351  I t i s v e r y i m p o r t a n t f o r p a t i e n t s t o 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 a d v i s e .  The emergence o f t h e s e f a c t o r s f u r t h e r s t h e knowledge o f d i f f e r i n g dimensions 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 .  Also,  each f a c t o r t o a l l o w i t s use as a measuring  i n d i c e s may be d e v e l o p e d f o r  device.  A s c a l e was c o n s t r u c t e d  each f a c t o r u s i n g t h e items w h i c h had ' l o a d e d ' on t h e f a c t o r .  for  Respondents'  s c o r e s on each i t e m were t h e n summed f o r each f a c t o r . The f a c t o r s c o r e s  a r e a r r a n g e d on a c o n t i n u u m c o n t a i n i n g o p p o s i t e ends o f  t h e d i m e n s i o n r e f l e c t e d by t h e f a c t o r . equal t o z e r o w i t h s c o r e s continuum.  As s u c h , t h e mean w i t h i n each f a c t o r  is  r a n g i n g t h e n t o t h e n e g a t i v e and p o s i t i v e ends o f t h e  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 t h e  f a c t o r s and a r e shown i n T a b l e X b e l o w .  56  Table X  Differences  i n Range i n F a c t o r s c o r e s  between f a c t o r s .  Factor  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 zero.  The r e p r e s e n t a t i o n o f p r o f e s s i o n a l s  s c o r e d above and some s c o r e d below i n each h a l f o f t h e continuum  though  d i f f e r s between f a c t o r s * . Though t h e f a c t o r s t h e m s e l v e s r e l a t e d to the other p r o f e s s i o n a l specialty, f a c i l i t y  a r e u n c o r r e l a t e d , they a r e p o t e n t i a l l y a t t r i b u t e s considered in t h i s  study:  i n w h i c h l o c a t e d , age, l e n g t h o f e x p e r i e n c e a t t h e  facility  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 a s s e s s e d by t h e 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 2 association  .  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 t h e  finding  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 t o t h e s e o t h e r a t t r i b u t e s .  1 The k u r t o s i s and skewness v a l u e s i n d i c a t i n g t h e shapes o f the c u r v e s l i s t e d and d i s c u s s e d i n Appendix 3 . 2 The r e s u l t s and d i s c u s s i o n a r e p r e s e n t e d i n A p p e n d i x 4 .  57  are  of  Thus, t h i s f a c t o r r e l a t i n g t o the p r o f e s s i o n a l ' s  perception of the patient  as a team member, w h i c h as t h e 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 t h e 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 t h e q u e s t i o n n a i r e ,  also representative of the professionals facility,  as a whole r e g a r d l e s s  is  of differences in  s p e c i a l t y , age, length of experience a t the f a c i l i t y , country of  t r a i n i n g , or attitude to authority i n general. F i n a l l y , a check was made on t h e v a l i d i t y o f t h e q u e s t i o n n a i r e measures 'professional  role'.  T h i s t e s t was f e a s i b l e f o r t h e G . F . S t r o n g  The r o l e t h e p r o f e s s i o n a l  sample  of  only.  assumed w i t h each o f t h e p a t i e n t r o l e s p r e s e n t e d i n  t h e i n t e r v i e w was s u b j e c t i v e l y measured by t h e i n t e r v i e w e r i n terms o f whether t h e 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  were c o r r e l a t e d w i t h t h e p r o f e s s i o n a l ' s professionals'  r e s p o n s e s t o each p a t i e n t c a s e  responses t o the q u e s t i o n n a i r e .  For the  r e s p o n s e s t o t h e c o n s u m e r i s t p a t i e n t t h e r e i s no c o r r e l a t i o n  e v i d e n t between t h e i n t e r v i e w and q u e s t i o n n a i r e measures t h e dependent p a t i e n t , however, t h e p r o f e s s i o n a l ' s 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).  of o r i e n t a t i o n .  For  r o l e as measured by f a c t o r 1  The d i s t r i b u t i o n o f r e s p o n s e ,  to the  p a t i e n t r o l e s p r e s e n t e d i n t h e i n t e r v i e w i s shown i n F i g u r e 8 b e l o w . Figure 8  P r o f e s s i o n a l Responses t o V a t i e n t R o l e s ' p r e s e n t e d i n the Interview (G.F. Strong)  Consumer P a t i e n t R o l e  |///7 / / / / / / / / / / / / / / / / / / / / / / 0  10  20  30  40  50  60  70  /KWA  80  y///// / / / /////•////;k\\\\\\\\\\\\ Dependent P a t i e n t Role Controller  0 j^J  10  20  30  40  50  60  70  80  Accommodator  * T h e s e were t h e number o f r e s p o n s e s a s c e r t a i n e d from a t o t a l professionals interviewed.  58  o f 27  90  \ Cv|  100  %  vw^xr 90  100 N=24*  %  Whereas  f o r the consumerist  p a t i e n t 83% o f t h e p r o f e s s i o n a l s  c o n t r o l l e r s , o n l y 58% o f t h e p r o f e s s i o n a l s  responded  as  d i d so f o r t h e dependent p a t i e n t .  T h i s i n d i c a t e s a g r e a t e r degree o f c o n t r o l l i n g o f t h e c o n s u m e r i s t p a t i e n t not e x p e c t e d from t h e q u e s t i o n n a i r e In a d d i t i o n to p r o f e s s i o n a l  responses. r o l e , other a t t r i b u t e s of the  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 t h e v a r i a n c e i n p r o f e s s i o n a l ' s  professionals r e s p o n s e s were  i d e n t i f i e d . These were s e l e c t e d because 1) t h e sample c h a r a c t e r i s t i c s o f l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y and c o u n t r y o f t r a i n i n g showed amongst t h e p r o f e s s i o n a l s , 2)  t h e sample had i n h e r e n t v a r i a n c e  age,  variance  across  s p e c i a l t i e s and f a c i l i t i e s , and 3) t h e c h a r a c t e r i s t i c o f a t t i t u d e t o 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 ' patients'  challenging  accommodation  of  behavior.  Age and l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y were measured as numbers years. scales  Country of t r a i n i n g , f a c i l i t y i n c a t e g o r i e s as a p p r o p r i a t e .  and s p e c i a l t y were measured as o r d i n a l A t t i t u d e to a u t h o r i t y i n general  measured by e i g h t i t e m s appended t o t h e q u e s t i o n n a i r e measuring role.  was  professional  These i t e m s were d e v e l o p e d and coded i n t h e same way as t h e o t h e r  i n the q u e s t i o n n a i r e . interval  of  items  The accummulated s c o r e o f t h e e i g h t i t e m s formed an  scale.  The d i r e c t i o n o f i n f l u e n c e o f t h e s e a t t r i b u t e s was not p r e d i c t e d s i n c e 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  59  way.  they  T h u s , t e c h n i q u e s have been d e v e l o p e d t o measure both t h e i n d e p e n d e n t 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  perception of the p a t i e n t ' s  r o l e as a team member, has emerged as t h e d i m e n s i o n o f t h e i n d e p e n d e n t professional  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 '  as 2)  other a t t r i b u t e s .  The r e l a t i o n o f t h e s e v a r i a b l e s , p r e d i c t e d by t h e  serve to assess the p r o f e s s i o n a l s '  professional-patient relationship. professional's  as a group r e g a r d l e s s  Other a t t r i b u t e s p o s s i b l y  r e s p o n s e s have a l s o been i d e n t i f i e d .  in  hypotheses,  r e l a t i n g t o the  The n e x t c h a p t e r a s s e s s e s  (how t h e p r o f e s s i o n a l  and d e a l s w i t h t h e p a t i e n t ' s b e h a v i o r )  combination of the p r o f e s s i o n a l ' s  of variance  response t o c h a l l e n g e to the t r a d i t i o n a l  i f t h e v a r i a n c e i n t h e dependent v a r i a b l e s describes  variable  questionnaire  r e s p o n s e s , as w e l l  will  the p r o f e s s i o n a l s  and  explains,  i s dependent on t h e s p e c i f i c  r o l e (as c o n t r o l l e r o r accommodator),  p a t i e n t ' s r o l e (as c o n s u m e r i s t o r dependent)  and t h e d e c i s i o n c o n t e n t ( i n which  the circumstances 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 of the and p a t i e n t ) .  60  the  professional  FINDINGS  The h y p o t h e s i s response  developed f o r t h i s study p r e d i c t s t h a t the  professional's  t o t h e p a t i e n t ' s b e h a v i o r i s dependent on t h e s p e c i f i c i n t e r a c t i o n o f  professional  r o l e and p a t i e n t r o l e .  This hypothesis  e v o l v e d from t h e r e s u l t s  o t h e r s t u d i e s p e r t a i n i n g t o t h e 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 from v i e w s p u t f o r w a r d i n t h e l i t e r a t u r e . i n t e r a c t i o n s between t h e p r o f e s s i o n a l  These i n d i c a t e d a range o f  and p a t i e n t , w i t h t h e  assuming t h e r o l e o f e i t h e r ' c o n t r o l l e r ' o r ' a c c o m m o d a t o r ' , r o l e of e i t h e r ' c o n s u m e r i s t ' , the professional  or 'dependent'.  explains, describes  dependent on t h e v a r i o u s  j ;•  professional and t h e p a t i e n t , t h e  and d e a l s w i t h t h e p a t i e n t ' s b e h a v i o r Figure 9 repeats  e a r l i e r F i g u r e 3 t o show t h e range o f i n t e r a c t i o n modes.  Figure 9  Modes o f I n t e r a c t i o n Between t h e P r o f e s s i o n a l Professional controller C o n f l i c t o f Terms  Consumeri s t  Asymmetry u n a c c e p t e d by the p r o f e s s i o n a l or p a t i e n t  and t h e P a t i e n t  Orientation accommodator Congruence o f Terms Asymmetry Legitimate Patient Dominant  Patient Orientation Congruence Dependent  o f Terms  Asymmetry Legitimate Professional Domi nant  61  as  I t has been p r e d i c t e d t h a t how  i n t e r a c t i o n s of these r o l e s .  of  C o n f l i c t o f Terms Asymmetry u n a c c e p t e d by the p r o f e s s i o n a l or p a t i e n t  an  is  Professional professional's  r o l e and p a t i e n t r o l e a r e t h e i n d e p e n d e n t v a r i a b l e s , and the  r e s p o n s e s t o t h e p a t i e n t ' s b e h a v i o r a r e t h e dependent  In a d d i t i o n , t h e p r o f e s s i o n a l ' s  variables.  e v a l u a t i o n of the i m p l i c a t i o n s of the p a t i e n t ' s  b e h a v i o r , on t h e 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 c o n s i d e r e d i n o r d e r t o 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 t h e s e v a r i a b l e s has  measured, as d e s c r i b e d i n t h e l a s t c h a p t e r . the f i n d i n g s  o f t h i s study  The f i n d i n g s w i l l  T h i s c h a p t e r now a s s e s s e s whether  support or r e j e c t the  hypothesis.  be a s s e s s e d i n a number o f ways.  dependent v a r i a b l e s , t h e p a t t e r n s o f t h e p r o f e s s i o n a l s ' category of ' e x p l a i n i n g ' , cations', will  t h e number o f t h e p r o f e s s i o n a l s r e s p e c t i v e l y ; and, the p r o f e s s i o n a l s ' thesis w i l l  2)  F i r s t , f o r the r e s p o n s e s i n each  ' d e s c r i b i n g ' , and ' d e a l i n g ' , as w e l l  be d e s c r i b e d i n two ways:  1)  r e s p o n d i n g as  as w i t h  ' c o n t r o l l e r ' and  f o r each o f t h e p r o f e s s i o n a l  r o l e across the p a t i e n t r o l e s .  'accommodator'  r o l e s , by t h e v a r i a t i o n o f Second, the s p e c i f i c  hypo-  professionals'  r e s p o n s e s i s a c c o u n t e d f o r by t h e i n t e r a c t i o n between t h e p r o f e s s i o n a l  facility,  'impli-  f o r each o f t h e p a t i e n t r o l e s , by  be t e s t e d t o d e t e r m i n e i f t h e v a r i a n c e i n t h e  patient role.  r o l e and  And, l a s t , the e f f e c t of the other independent v a r i a b l e s  —  s p e c i a l t y , age, l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y , c o u n t r y  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 —  will  be a s s e s s e d .  however, we s t a r t w i t h t h e p a t t e r n o f r e s p o n s e s o f t h e dependent  62  been  First,  variables.  P a t t e r n o f Responses:  Dependent  E x p l a i n i n g the p a t i e n t s '  Variables  behavior.  T h i s dimension assessed the p r o f e s s i o n a l ' s  perception of the p a t i e n t ' s  b e h a v i o r as e i t h e r an a t t r i b u t e o f t h e p a t i e n t , when c o n s i s t e n t w i t h t h e  tradi-  tional  v i e w , o r as a c o n f l i c t o f t e r m s , when c o n s i s t e n t w i t h t h e  view.  The c o n s u m e r i s t p a t i e n t ' s b e h a v i o 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 r e s p o n d e n t s Holy Family H o s p i t a l s  and as a c o n f l i c t o f terms by 3 1 % , G . F . S t r o n g  combined.  The dependent p a t i e n t ' s b e h a v i o r was  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 r e s p o n d e n t s 15%.  These f i n d i n g s  F i g u r e 10  are presented i n Figure  and  explained  and as a c o n f l i c t o f terms by  10.  E x p l a i n i n g the P a t i e n t ' s Behavior: P a t t e r n of Responses, G . F . S t r o n g and H o l y F a m i l y H o s p i t a l s combined. E x p l a i n i n g the Consumerist P a t i e n t ' s 69  A™* V/(IW</HA  Cmb  /  Facilities  challenging  0  10  20  30  40  50  ^ ^ ^ ^ ^ ^% 60  70  E x p l a i n i n g t h e Dependent P a t i e n t ' s  Y77\  "patient attribute"  |^Xf  " c o n f l i c t of  Behavior  80  90  N=39*  100  Behavior 85  terms"  * These were t h e number o f r e s p o n s e s a s c e r t a i n e d from t h e t o t a l number o f p r o f e s s i o n a l s i n t e r v i e w e d , 3 9 . T h i s l e a v e s 6 from t h e 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 t o t h e c a l c u l a t i o n of F a c t o r Scores, presented i n the next s e c t i o n .  63  Comparison a c r o s s p a t i e n t r o l e i n d i c a t e d a tendency by b o t h p r o f e s s i o n a l r o l e s t o e x p l a i n t h e p a t i e n t ' s b e h a v i o 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 t h a n as a c o n f l i c t o f t e r m s , 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 t h e dependent patient.  Describing the P a t i e n t ' s Behavior T h i s dimension assessed the p r o f e s s i o n a l ' s expectations of the p a t i e n t ' s r o l e . d e s c r i b e d as ' g o o d '  responses,  The b e h a v i o r o f t h e c o n s u m e r i s t p a t i e n t was  by 27% o f a l l r e s p o n d e n t s and as ' d i f f i c u l t '  b e h a v i o r o f t h e dependent p a t i e n t was d e s c r i b e d as ' g o o d ' dents and as ' d i f f i c u l t '  F i g u r e 11  consistent with t h e i r  by 6 4 % .  by 7 3 % .  The  by 36% o f a l l r e s p o n -  These f i n d i n g s a r e p r e s e n t e d i n F i g u r e 1 1 .  Describing the P a t i e n t ' s Behavior: P a t t e r n of Responses, G . F . S t r o n g and H o l y F a m i l y H o s p i t a l s Combined Describing the Consumerist P a t i e n t ' s Behavior N=22^  ALL 0  10  20  30  40  50  60  70  80  90  D e s c r i b i n g t h e Dependent P a t i e n t ' s B e h a v i o r 36 ALL  0  E3  "good"  £23  "difficult"  *  10  20  30  40  100 % ^ N=36'  50  60  70  8(3  90  These were t h e number o f r e s p o n s e s a s c e r t a i n e d from t h e t o t a l interviewed, 39.  64  100 %  number  Comparison a c r o s s p a t i e n t r o l e i n d i c a t e d a tendency t o d e s c r i b e b o t h patients'  b e h a v i o r as ' d i f f i c u l t ! though t h e d e s c r i p t i o n o f ' g o o d ' was more  f r e q u e n t f o r t h e dependent p a t i e n t .  Dealing with the P a t i e n t ' s Behavior This dimension assessed the p r o f e s s i o n a l ' s expectations of the p r o f e s s i o n a l ' s  role.  responses,  T h i s v a r i a b l e , measured o n l y a t G . F .  S t r o n g 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 ' b e h a v i o r , w h i l e 60% accommodated i t . 'controlled'  consistent with t h e i r  the consumerist p a t i e n t ' s  F o r t h e dependent b e h a v i o r , 55%  and 45% ' i n s p i r e d ' t h e p a t i e n t .  These f i n d i n g s a r e p r e s e n t e d i n  F i g u r e 12.  F i g u r e 12  Dealing w i t h the P a t i e n t ' s Behavior: of Responses, G.F. Strong  Pattern  D e a l i n g w i t h the consumerist p a t i e n t ' s behavior N=25*  % D e a l i n g w i t h t h e dependent p a t i e n t ' s b e h a v i o r G.F. Strong 23  0  10  \ 20/ / /30 / / 40/ / 50/ y 60/ / 70/ / 80/ / /90 / N100= %2 4 *  " C o n t r o l " or " R e j e c t " "Accommodate" o r " i n s p i r e "  *  These a r e t h e number o f r e s p o n s e s a s c e r t a i n e d from t h e t o t a l i n t e r v i e w e d , 39.  65  number  Comparison a c r o 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 40% and 60%)  between ' c o n t r o l l i n g ' and ' a c c o m m o d a t i n g '  responses.  (between  However,  p e r c e n t a g e o f ' c o n t r o l ' s h i f t e d from 40% f o r t h e consumer p a t i e n t , t o 55%,  the for  t h e dependent p a t i e n t .  I m p l i c a t i o n s of the P a t i e n t ' s  Behavior  T h i s dimension assessed the p r o f e s s i o n a l ' s  perceptions of the i m p l i c a t i o n s  of the p a t i e n t ' s behavior 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 .  And, i n  this  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 t o be i n e f f e c t i v e , t h e p r o f e s s i o n a l s u g g e s t e d whether t h e o r g a n i z a t i o n o f s e r v i c e s o r t h e p a t i e n t was t h e main d i s ruptive factor.  (This  d i m e n s i o n was measured a t G . F . S t r o n g o n l y . )  g o r i e s of responses r e f l e c t e d the p r o f e s s i o n a l s ' 1)  Four c a t e -  e v a l u a t i o n of the i m p l i c a t i o n s :  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 q u e s t i o n e d (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  expressed);  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 t h e 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 t h e o r g a n i z a t i o n s e r v i c e s was blamed.  The v a r i a n c e o f r e s p o n s e s i s i n d i c a t e d i n F i g u r e 13 b e l o w .  66  of  F i g u r e 13  Evaluating the Implications of the P a t i e n t ' s Behavior 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. Strong Implications  G.F. S t r o n g  TO  Behavior  ffl  |////////777 20 30  Implications G.F. Strong  of the Consumerist P a t i e n t ' s  o f t h e Dependent P a t i e n t ' s  N=26^  %  Behavior  \////////////} / ///////////J^ 1 1 1 1 1 1 N = 2 4 0 10 20 30 40 50 60 70 80 90 100 % n  i n  on  /in  on  co  cn  -»n  on  nt\ 1 nff  oi  YZk REHABILITATION NOT QUESTIONED  REHABILITATION FELT INEFFECTIVE PATIENT BLAMED  PTTT|  REHABILITATION FELT INEFFECTIVE ORGANIZATION OF SERVICES BLAMED  *  REHABILITATION FELT EFFECTIVE  Number o f r e s p o n s e s 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 , 3 9 .  F o r t h e c o n s u m e r i s t p a t i e n t , o n l y one r e s p o n d e n t q u e s t i o n e d t h e i n f l u e n c e of the r e h a b i l i t a t i o n s e t t i n g .  Of t h e r e m a i n i n g 97% who d i d n o t q u e s t i o n t h e  s y s t e m , 35% f e l t t h e system c o u l d h a n d l e t h e c h a l l e n g e 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 b e i n g i n e f f e c t i v e and e x p r e s s e d with the patient.  frustration  T h a t l e f t 33% who n e i t h e r q u e s t i o n e d t h e s e t t i n g n o r  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 remaining responses t o t h e  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 t o 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 t h e blame on t h e 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 t o be i n e f f e c t i v e , w i t h t h e blame on t h e o r g a n i z a t i o n o f s e r v i c e s . Comparison a c r o s s  p a t i e n t roles (consumerist  t o d e p e n d e n t ) , draws a t t e n t i o n  t o t h e d r a m a t i c l e a p 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 q u e s t i o n e d t h e  r e h a b i l i t a t i o n system n o r e x p r e s s e d 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 .  67  Summary The p a t t e r n o f r e s p o n s e s i n a l l d i m e n s i o n s may be summarized i n two ways: 1)  I n each c a t e g o r y o f r e s p o n s e s f o r each p a t i e n t r o l e , t h e r e was v a r i a n c e  responses across p r o f e s s i o n a l  roles.  in  The l e a s t amount o f 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 b e h a v 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)  I n each c a t e g o r y o f r e s p o n s e ,  patient roles.  v a r i a n c e i n r e s p o n s e s d i f f e r e d between t h e  The dependent p a t i e n t ' s b e h a v i o r was more 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 , d e s c r i b e d 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 ' .  g r e a t e s t amount o f v a r i a n c e 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 t h e of i m p l i c a t i o n s .  The  dimension  I n t h e c a s e o f t h e dependent p a t i e n t , 74% o f p r o f e s s i o n a l s  not question the system.  did  In t h e c a s e o f c o n s u m e r i s t p a t i e n t , 33% d i d n o t , a  d i f f e r e n c e o f 41%.  Hypothesis  Testing  The h y p o t h e s i s  p r e d i c t e d the simultaneous e f f e c t s of p r o f e s s i o n a l  p a t i e n t r o l e on t h e 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 behavior.  and The  range o f i n t e r a c t i o n s between t h e r o l e s has a g a i n been d e s c r i b e d i n F i g u r e 9 a t the beginning of 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  d e f i n e d f o r use w i t h each o f t h e c a t e g o r i e s o f r e s p o n s e s , way i n w h i c h t h e p r o f e s s i o a n l s patient's  t o h e l p p r e s e n t the  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 t h e  behaviors.  As seen from t h e c a s e s t u d i e s , v a r i a n c e o c c u r r e d i n t h e responses to the p a t i e n t s ' b e h a v i o r .  professional's  V a r i o u s t e c h n i q u e s , t h e n , were s e l e c t e d t o  examine what m i g h t a c c o u n t 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  (ANOVA) was chosen as t h e most r i g i d measure o f t h e h y p o t h e s i s .  68  of  variance  Additional  t e s t s were a l s o done t o measure t h e i n f l u e n c e o f t h e o t h e r i n d e p e n d e n t on t h e v a r i a n c e o f r e s p o n s e s t o each o f t h e p a t i e n t r o l e s . facility  and s p e c i a l t y were measured by one-way a n a l y s i s  variables  The e f f e c t o f  of v a r i a n c e .  The  e f f e c t s o f age, l e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y , c o u n t r y o f 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 were measured by p a r t i a l c o r r e l a t i o n s . l a t t e r t e c h n i q u e p r o v i d e 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  This  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 t h e e f f e c t s o f one o r more a d d i t i o n a l  variables.  E x p l a i n i n g the P a t i e n t ' s The h y p o t h e s i s  Behavior  p r e d i c t s t h a t how t h e p r o f e s s i o n a l  explains the  b e h a v i o r i s dependent on t h e s p e c i f i c c o m b i n a t i o n o f p r o f e s s i o n a l  patient's  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 t h e f i g u r e b e l o w .  Professional C ontrol1er  Role Accommodator  Consumerist  Patient attribute  c o n f l i c t of  terms  Dependent  Patient attribute  c o n f l i c t of  terms  PATIENT ROLE  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o be r e l a t e d .  Two-way ANOVA was o b s e r v e d f o r each f a c t o r w i t h r e p e a t e d measures f o r reponse t o p a t i e n t c a s e . professional  It  f a i l e d t o show s i g n i f i c a n t i n t e r a c t i o n between  and p a t i e n t r o l e t o a c c o u n t f o r t h e ways i n w h i c h t h e  explained the p a t i e n t ' s  professionals  behavior.  F o r a l l f a c t o r s , however,  t h e s c o r e s f o r r e s p o n s e s t o t h e dependent p a t i e n t  69  were l o w e r than t h o s e t o t h e c o n s u m e r i s t p a t i e n t . l e v e l was between 0.1  and 0.2  and approached 0.1  The n e x t s t e p i n t h e a n a l y s i s fessional  attributes.  Partial  In each c a s e t h e p r o b a b i l i t y f o r f a c t o r s 1,2,3  and 6 .  was t o measure t h e e f f e c t s o f t h e o t h e r p r o -  c o r r e l a t i o n s were a s s e s s e d f o r age, number o f  years of experience at 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 , of 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 .  of these r e l a t i o n s h i p s  country  Those measures  t h a t a r e s i g n i f i c a n t a r e p r e s e n t e d where r e l e v a n t t o t h e  discussion. F a c t o r 6 and c o u n t r y o f t r a i n i n g a c c o u n t e d f o r some t h e v a r i a n c e i n how t h e professional  explained the consumerist p a t i e n t ' s behavior.  Both of  these  r e l a t i o n a h i p s , t h o u g h , were s u b j e c t t o m o d i f i c a t i o n through t h e i n f l u e n c e o f t h e other v a r i a b l e s .  T a b l e XI  presents  t h e range o f s t r e n g h t s  when t h e i n f l u e n c e o f t h e o t h e r v a r i a b l e s i s  70  considered.  of the  relationships  T a b l e XI  Explaining the consumerist p a t i e n t ' s behavior: Partial 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 c o u n t r y o f t r a i n i n g with control f o r other v a r i a b l e s .  Relationship with 'Explaining'  Factor 6  Zero-order  -.2539  Country  .3243 p<.05 .3076 p<.07 .3348 p<.05 .3363 p<.05 n/a  P-.l -.2547 P-.l -.2595 P-.l -.2883 p<.005 -.2805 D<.09 -.3172 p=.05 -.3910 p<.05  Age No. y r s . a t f a c i l i t y Attitude to Authority Country of T r a i n i n g Specialty All  .3031 p=.06  .2744 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 , s t r o n g e r when t h e i n f l u e n c e o f t h e o t h e r v a r i a b l e s , in attitude to authority, i s controlled. hand, has a s t r o n g e r  i t becomes  i n p a r t i c u l a r the variance  C o u n t r y o f t r a i n i n g , on t h e o t h e r  relationship i n i t i a l l y  i s h e s when t h e s i m u l t a n e o u s  of Training  (p<.05), but subsequently  influence of the other variables  Some o f t h e v a r i a n c e i n how t h e p r o f e s s i o n a l  is controlled.  e x p l a i n s t h e dependent  p a t i e n t ' s b e h a v i o r i s a c c o u n t e d f o r by t h e age o f t h e p r o f e s s i o n a l fessional's  attitude to authority i n general.  strength of these r e l a t i o n s h i p s  Table XII  presents  and t h e p r o t h e range o f  dependent on t h e i n f l u e n c e o f t h e o t h e r  variables.  1 F a c t o r 6 and C o u n t r y for this test.  dimin-  o f T r a i n i n g were measured on an i n t e r v a l  scale  Table XII  E x p l a i n i n g t h e dependent p a t i e n t ' s b e h a v i o r : Partial Correlation 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 g e n e r a l w i t h control f o r other v a r i a b l e s .  Relationship with ' e x p l a i n i n g ' Zero-order Age No. y r s . a t f a c i l i t y  Attitude  -.3555 p<.05 n/a  -.2344 p=.15 -.4391 p<.01 -.3322 p<.05 n/a  -.3095 p=.07 -.5038 p<.005  Attitude Country  Age  -.2596  of t r a i n i n g  -.2718 p<.l -.2547 P=.l  P=.l -.3862 p<.05 -.4783 p<.01  Specialty All  -.4666 p<.01  F o 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 , t h e s t r e n g t h o f t h e r e l a t i o n s h i p r a n g e s from P<.01, when i n f l u e n c e from a l l o t h e r v a r i a b l e s simulataneously another  is  c o n t r o l l e d , t o P=.l o r over, f o r the independent i n f l u e n c e o f  variable.  I n sum, f o r t h e d i m e n s i o n o f e x p l a i n i n g t h e p a t i e n t ' s b e h a v i o r , t h e findings  do n o t s u p p o r t t h e h y p o t h e s i s t h a t how t h e p r o f e s s i o n a l  p a t i e n t ' s behavior patient role.  explains the  i s dependent on t h e i n t e r a c t i o n between p r o f e s s i o n a l  T h e r e 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,  t h e dependent p a t i e n t ' s b e h a v i o r was more o f t e n d e s c r i b e d as a p a t i e n t bute.  As w e l l , o t h e r v a r i a b l e s  significant relationships  emerged t h r o u g h p a r t i a l c o r r e l a t i o n s  to explaining the p a t i e n t ' s  72  behavior.  r o l e and i n that attri-  t o suggest  Describing  the P a t i e n t ' s  Behavior  The h y p o t h e s i s p r e d i c t s t h a t t h e p r o f e s s i o n a l  will  describe the  patient's  b e h a v i o r as i n d i c a t e d i n t h e f i g u r e b e l o w .  Professional Controller Consumerist  Role Accommodator good  difficult  Patient Role Dependent  F i g u r e 15.  good  difficult  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 t h e b e h a v i o r a r e p r e d i c t e d t o 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 r o l e as r e f l e c t e d i n f a c t o r 1 ( t h e p r o f e s s i o n a l ' s  patient's  professional  p e r c e p t i o n of the  patient's  r o l e as a team member) and t h e p a t i e n t ' s r o l e as e i t h e r c o n s u m e r i s t o r dependent.  T h i s i n d i c a t e s t h a t t h e c o m b i n a t i o n o f t h e s e two v a r i a b l e s  accounts behavior.  f o r t h e v a r i a n c e i n how t h e p r o f e s s i o n a l Table XIII presents  these  findings.  73  describes  the  uniquely  patient's  Describing the p a t i e n t ' s behavior: F a c t o r 1* and P a t i e n t c a s e s t u d y .  Table XIII  2-way ANOVA between  P a t i e n t Case Study (B) Consumerist Dependent Factor 1 (A) Effect  Controller  1.83  1.17  Accommodator  1.63  1.50  AB P<.01 A P<.4 B P<.05  * T h e p a t i e n t ' s r o l e as a team member.  As w e l l , t h e e f f e c t o f p a t i e n t c a s e i s  s i g n i f i c a n t (P<.05).  o f f a c t o r 1 t h e r e s p o n s e s t o t h e c o n s u m e r i s t p a t i e n t were more 'difficult'  t h a n f o r t h e dependent p a t i e n t .  e f f e c t , though, s i g n a l s  I n both  levels  towards  The p r e s e n c e o f an i n t e r a c t i o n  t h a t t h e d i f f e r e n c e s between t h e c a s e s a r e more a c c u -  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 t h e o r i e n t a t i o n o f p r o f e s s i o n a l  role.  By  doing  t h i s , one can see t h a t t h e d i f f e r i n g o r i e n t a t i o n s t o t h e p a t i e n t ' s r o l e as a team member a l t e r s t h e magnitude o f t h e d i f f e r e n c e s between t h e r e s p o n s e s t o t h e case s t u d i e s .  As t h e p e r s p e c t i v e o f t h e 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  t o accommodating, t h e r e i s a s h i f t i n how t h e p a t i e n t ' s t h e c o n s u m e r i s t p a t i e n t from ' d i f f i c u l t ' p a t i e n t , from ' g o o d '  to  to 'good'  behavior i s  and, f o r the  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 .  e f f e c t o f c a s e 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  additional  dependent  'difficult'.  The 2-way ANOVA r e s u l t s  Partial  described;  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 y e a r s  between .1 and  T a b l e XIV 74  presents  the .2.  a t t h e f a c i l i t y was an  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  t h e dependent p a t i e n t ' s b e h a v i o r .  However  these  figures.  describes  T a b l e XIV  D e s c r i b i n g t h e dependent p a t i e n t ' s b e h a v i o r : Partial 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 y e a r s a t t h e f a c i l i t y c o n t r o l l i n g f o r the influence of other v a r i a b l e s .  Relationship with 'Describing'  No. o f y e a r s a t the f a c i l i t y  Zero-Order  -.4716 p<.005 -.3015 p<.l n/a  Age No. Y r s . a t t h e F a c i l i t y Attitude to Authority  -.4727 p<.005 -.4015 p<.02 -.4604 p<.005 -.2786  Country o f T r a i n i n g Specialty All  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 constant.  o f P<.1 when a l l o t h e r v a r i a b l e s a r e h e l d  I n p a r t i c u l a r , age has t h i s e f f e c t on t h e s t r e n g t h o f number o f y e a r s  at the f a c i l i t y . I n sum, f o r t h e d i m e n s i o n o f d e s c r i b i n g t h e p a t i e n t ' s b e h a v i o r , t h e findings  support the hypothesis  t h a t how t h e p r o f e s s i o n a l  describes the  p a t i e n t ' s b e h a v i o r i s dependent on t h e i n t e r a c t i o n between p r o f e s s i o n a l patient role.  Thus t h e 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 s h o u l d n o t be  g r a n t e d a c c e s s t o m e d i c a l r e c o r d s and ' t e a m ' meetings c o n s u m e r i s t p a t i e n t as ' d i f f i c u l t ' Conversely,  the professional  is likely  and t h e dependent p a t i e n t as  to describe the 'good'.  who b e l i e v e s p a t i e n t s s h o u l d have a c c e s s t o ' t e a m '  i n f o r m a t i o n d e s c r i b e d t h e c o n s u m e r i s t p a t i e n t as ' g o o d ' p a t i e n t as  r o l e and  'difficult'. 75  and t h e dependent  L e n g t h o f e x p e r i e n c e a t t h e f a c i l i t y emerged through p a r t i a l 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 p a t i e n t ' s behavior. professional  correlations  dependent  As t h e number o f y e a r s a t t h e f a c i l i t y i n c r e a s e d ,  the  was more l i k e l y t o d e s c r i b e t h e dependent p a t i e n t ' s b e h a v i o r  as  'good'.  D e a l i n g w i t h the P a t i e n t ' s The h y p o t h e s i s  Behavior  p r e d i c t s that the p r o f e s s i o n a l  will  deal w i t h the p a t i e n t ' s  b e h a v i o r as d e f i n e d i n t h e f o l l o w i n g c h a r t .  Professional Controller Consumerist  Role Accommodator  control or reject  accommodate  control  inspire  Patient Role Dependent  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 t h e p a t i e n t ' s b e h a v i o r a r e p r e d i c t e d t o 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 t h e r e s p o n s e ' d e a l i n g ' , due t o professional  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 t h e .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 r e s e n t will  c o n t r i b u t e to the d i s c u s s i o n .  T a b l e XV p r e s e n t s  ANOVA. 76  the f i g u r e s  for  and  two-way  Dealing with the p a t i e n t ' s behavior: F a c t o r 1* and P a t i e n t Case Study  T a b l e XV  2-way ANOVA between  P a t i e n t Case Study (B) Consumerist Dependent Factor 1 (A) Effect  *  Controller  1.46  1.18  Accommodator  2.00  1.71  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 R o l e as a Team Member.  The s h i f t i n t h e p r o f e s s i o n a l ' s  p e r s p e c t i v e o f t h e 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 o f t h e  c o n s u m e r i s t p a t i e n t and i n s p i r e r o f t h e dependent p a t i e n t .  The s t r e n g t h o f t h e  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) s u g g e s t s c o n s i d e r a t i o n o f t h e professional's  r o l e w i t h t h e combined e f f e c t o f t h e p a t i e n t ' s r o l e , as p r e s e n t e d  i n the case study.  Though t h e a c t u a l range o f r e s p o n s e s  i s c o n s i s t e n t over both c a s e s , t h e responses  between f a c t o r l e v e l s  t o the consumerist p a t i e n t are  h i g h e r o v e r a l l , when compared w i t h t h o s e o f t h e 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 . n e g a t i v e 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 c o u n t r y o f t r a i n i n g . presents the actual  figures.  77  However,  T a b l e XVI  T a b l e XVI  D e a l i n g w i t h t h e Dependent P a t i e n t ' s B e h a v i o r : Partial 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 of t r a i n i n g .  Relationship with 'dealing'  Country o f Training  Zero-order  -.4689 p<.05 -.3885" p<.07 -.5291 p<.01 -.4775 p<.05 n/a  Age Mo. y r s . a t F a c i l i t y Attitude Country of T r a i n i n g  -.4461 p<.05 -.4537 p<.05  Specialty All  C o u n t r y o f 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 t h e r v a r i a b l e s were c o n t r o l l e d , though t h e s t r e n g t h o f t h e r e l a t i o n s h i p d m i n i s h e d somewhat (P<.07) when t h e i n f l u e n c e o f age was h e l d c o n s t a n t . I n sum, f o r t h e d i m e n s i o n o f d e a l i n g w i t h t h e p a t i e n t ' s b e h a v i o r , t h e findings  support,  i n p a r t , the hypothesis  t h a t how t h e p r o f e s s i o n a l  deals with  t h e p a t i e n t ' s b e h a v i o r i s dependent on t h e 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 . be g r a n t e d a c c e s s  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 s h o u l d n o t  t o m e d i c a l r e c o r d s and ' t e a m ' meetings  both t h e c o n s u m e r i s t and dependent p a t i e n t .  Conversely,  is likely  to ' c o n t r o l '  t h e 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 s h o u l d have a c c e s s t o ' t e a m ' i n f o r m a t i o n i s l i k e l y modate t h e c o n s u m e r i s t p a t i e n t ' s b e h a v i o r and i n s p i r e t h e dependent  78  role  t o accompatient's  behavior. C o u n t r y 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 t h e dependent p a t i e n t ' s  behavior . 1  Those who have had some o r a l l o f t h e i r t r a i n i n g o u t s i d e Canada were more to  ' c o n t r o l ' t h e dependent p a t i e n t ' s  Summary o f  likely  behavior.  Findings  T h i s c h a p t e r has 1)  presented the p a t t e r n s of the p r o f e s s i o n a l s '  t o p a t i e n t b e h a v i o r and 2) r e f u t e d the h y p o t h e s i s .  responses  a s s e s s e d whether t h e f i n d i n g s have s u p p o r t e d o r  As t h e s p e c i f i c f i n d i n g s  have been summarized a t t h e  end o f each s e c t i o n , t h e y w i l l  n o t be r e p e a t e d h e r e .  G e n e r a l l y , however,  for  the  and ' d e a l i n g ' w i t h t h e p a t i e n t ' s b e h a v i o r ,  the  dimensions  hypothesis  of ' d e s c r i b i n g '  has been s u p p o r t e d .  explaining, the hypothesis  On t h e o t h e r hand, f o r t h e d i m e n s i o n  has n o t been s u p p o r t e d .  of  With r e s p e c t t o t h e s e  d i m e n s i o n s , o t h e r v a r i a b l e s have emerged ( a g e , c o u n t r y o f t r a i n i n g , e t c . ) which r e l a t e t o them, b u t t h e e x t e n t o f t h e i n f l u e n c e o f t h e s e v a r i a b l e s i s not y e t established.  And, i n the l i g h t of the other 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  is  diminished. The Study has i n d i c a t e d t h a t t h e p r o f e s s i o n a l s '  response to p a t i e n t  b e h a v i o r i s s y s t e m a t i c a l l y d e t e r m i n e d from t h e 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 and p a t i e n t r o l e .  The n e x t c h a p t e r w i l l  role  examine t h i s p r e m i s e t o c o n s i d e r i f  o f f e r s p r e l i m i n a r y e v i d e n c e o f a l a g between s o c i e t a l t r e n d s and p r o f e s s i o n a l response.  79  it  DISCUSSION  The p r e l i m i n a r y e v i d e n c e from t h i s study i n d i c a t e s t h a t the  professional's  response t o p a t i e n t b e h a v i o r i s s y s t e m a t i c a l l y r e l a t e d t o t h e 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 .  The s i g n i f i c a n c e o f t h i s f i n d i n g  l i e s i n the comparison o f the o l d and c h a l l e n g i n g p e r s p e c t i v e s . traditional  Whereas the  premise s t a t e s t h a t h e a l t h d e c i s i o n 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 study's findings  have  supported the c h a l l e n g i n g premise t h a t the r o l e s assumed by the p r o f e s s i o n a l p a t i e n t e x p l a i n how the p r o f e s s i o n a l  and  d e s c r i b e s and d e a l s w i t h 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 M i s s Smith and members o f the r e h a b i l i t a t i o n team t h a t was p r e s e n t e d i n Chapter One.  She had e n t e r e d 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 r e c o g n i z e d 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 o f r e h a b i l i t a t i o n services.  Two d i s c h a r g e o p t i o n s emerged, where the c o s t s i n both monetary and  non-monetary terms v a r i e d w i d e l y between outcomes.  Through s e v e r a l s t e p s ,  this  c h a p t e r a s s e s s e s the i m p l i c a t i o n s o f t h i s i n t e r a c t i o n i n the c o n t e x t o f the c h a l l e n g e t o 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 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 c o n n e c t i o n 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 h a t d e f i n e s the scope and approach o f the t h e s i s . Second, the c i r c u m s t a n c e o f the case o f M i s s Smith w i l l the r o l e s the p r o f e s s i o n a l  be reviewed i n terms o f  and p a t i e n t have assumed as w e l l as i n terms of the  c o s t s o f the d i s c h a r g e outcomes ensuing from the i n t e r a c t i o n . i m p l i c a t i o n s o f M i s s S m i t h ' s r o l e as a consumer w i l l  T h i r d , the  be c o n s i d e r e d from t h e  p e r s p e c t i v e o f p r o f e s s i o n a l s who have r e s i s t e d the c h a l l e n g e t o t h e i r e x p e r t i s e and a u t h o r i t y . 80  This w i l l  be i l l u s t r a t e d by q u o t e s from t h e 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 study.  As w e l l , t h i s r e s i s t a n c e i s proposed t o be e v i d e n c e o f a l a g t h a t  e x i s t s between t h e s o c i e t a l t r e n d s 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 h e l d l a t e n t i n t h e l a g , w i l l discussed  i n terms o f t h 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 t h e o r g a n i z a t i o n  rehabilitation services professionals  The Study  i n the i n s t i t u t i o n .  and d e c i s i o n s a r e made i n t h e e f f o r t t o s t u d y t h e ' r e a l  response  The study o f t h e q u e s t i o n o f t h e p r o f e s -  to challenge 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  t i o n s h i p was b a s e d on r o l e i n t e r a c t i o n .  p r e s e n t s a framework t h a t p l a c e s t h e study approach o f t h e  rela-  O t h e r f a c t o r s e x i s t , however, t h a t may  c l o u d t h e c o n n e c t i o n between t h e s t u d y and t h e q u e s t i o n .  F i g u r e 17, below,  i n t h e c o n t e x t o f t h e scope and  thesis.  Al A2 A3 PATIENT + PROFESSIONAL + DECISION ROLE ROLE CONTENT i i i Bl INTERVIEW  discussed.  i n t h e C o n t e x t o f t h e Scope and Approach o f t h e T h e s i s  through experimental d e s i g n .  sional's  of  And l a s t , recommendations t o t h e  and r e q u i r e m e n t s f o r f u r t h e r r e s e a r c h a r e  Many a s s u m p t i o n s world'  be  B2 QUESTIONNAIRE  ~~*  B3 INTERVIEW  C OTHER E g . '• FUNDING - RECOMPENSE FACTORS i - HOSPITAL POLICY . 3. LARGER SOCIAL SYSTEMS * (ECONOMICS) A4 PROFESSIONAL RESPONSE TO CHALLENGE  B4 D 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 C o n t e x t and Approach t o t h e Study o f t h e 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 t o t h e t r a d i t i o n a l Professional-Patient Relationship. ( A d a p t e d from R u n k e l , P h i l i p J . and M c G r a t h , J o s e p h , 1972, P.160.) 81  The l e t t e r synthesis  'A'  r e f e r s t o t h e c o n c e p t s t h a t emerged i n t h e l i t e r a t u r e , t h e  o f which formed t h e b a s i s o f t h e h y p o t h e s e s .  posed t o r e f l e c t what ' r e a l l y of the concepts 'true'.  'A',  1  occurs.  The l e t t e r  'B'  The hypotheses r e f e r s to the  measures,  t h a t were d e v i s e d t o a s s e s s whether t h e hypotheses  A number o f s t e p s were t a k e n t o enhance t h e a b i l i t y o f t h e s e  t o 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 'success'  are pro-  of the concepts.  were measures  Though t h e  o f t h e s e s t e p s was n o t r i g i d l y e v a l u a t e d , one can make t h e  assumption  ( o t h e r w i s e known as p r e d i c t i v e v a l i d i t y ) t h a t t h e v a l i d i t y o f t h e measures  is  s u p p o r t e d by t h e a b i l i t y t o p r e d i c t a c c u r a t e l y . O t h e r f a c t o r s may a l s o c l o u d t h e development and r e s u l t s o f t h e These may, as i n d i c a t e d i n ' C ' , professional's  ('B4'), social study.  response  of t h i s concept.  systems,  i n f l u e n c e the c e n t r a l concept  ('A4'),  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 ' , In some c a s e s , as w i t h h o s p i t a l  t h e s e f a c t o r s were bypassed  study.  the  the  measures,  p o l i c y or  larger  as b e i n g beyond t h e scope o f t h e  The i n v e s t i g a t o r assumed t h a t t h e s e f a c t o r s d i d not d r a m a t i c a l l y  o v e r t h e c o u r s e o f t h e s t u d y and were a c o n s t a n t e f f e c t on a l l professionals.  In o t h e r c a s e s ,  the  such as w i t h t h e t r a d i t i o n a l p r e m i s e s  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 underlying the p r o f e s s i o n a l ' s decisions,  t h e f a c t o r s were c o n t r o l l e d f o r t h e s t u d y .  f a b r i c a t e d c a s e s t u d i e s were matched on e s s e n t i a l professional's  response  change  of  health  F o r example, t h e two  v a r i a b l e s so t h a t t h e  c o u l d be e x p l a i n e d by t h e v a r i a n c e i n p a t i e n t r o l e ,  r a t h e r t h a n p a t i e n t a t t r i b u t e s such as sex and age. In sum, t h e study has f o c u s e d t o t h e r o l e i n t e r a c t i o n i n t h e 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 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  relationship.  82  response  professional-  to challenge  to  The R o l e s Assumed by M i s s Smith and Members o f t h e R e h a b i l i t a t i o n Team The c a s e study o f A l i c e S m i t h was p r e s e n t e d i n C h a p t e r One. c o u l d be i n t e r p r e t e d as t h a t o f t h e consumer:  Her  behavior  ( r e l y i n g on h e r own judgment  and  assuming t h e r e s p o n s i b i l i t y f o r t h e d e c i s i o n ) , she a s s e s s e d h e r s i t u a t i o n and r e s o l v e d t h a t she w o u l d go home t o l i v e responded i n two ways.  'independently'.  These two p o l e s o f p r o f e s s i o n a l  The  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 t h e p r o f e s s i o n a l ' s d e s c r i p t i o n o f M i s s S m i t h as ' d i f f i c u l t ' , ' c o n t r o l l i n g ' , the professional decision.  professionals  role.  and t h e recommendation  With the of  was assuming r e s p o n s i b i l i t y f o r t h e h e a l t h  C o n v e r s e l y , w i t h t h e d e s c r i p t i o n o f t h e p a t i e n t as ' h a v i n g  ( i n t e r p r e t e d as professional  'good'),  and t h e recommendation t o s u p p o r t her d e c i s i o n , the  was accommodating t h e p a t i e n t ' s judgment and a c k n o w l e d g i n g  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 . asymmetrical be f o l l o w e d .  guts'  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  In a  r e l a t i o n s h i p , the  d e c i s i o n t o go home i n d e p e n d e n t l y would be f o l l o w e d .  w i d e l y between d i s c h a r g e  professional-dominant,  d e c i s i o n o f p r o t e c t i v e c a r e would  In a p a t i e n t - d o m i n a n t , asymmetrical  t h e r e s p e c t i v e p a r t i e s as w e l l  The c o s t s  patient's  and b e n e f i t s  as t o a t h i r d p a r t y f u n d i n g t h e outcome  decisions.  These a r e a s s e s s e d ,  i n general  funding of the discharge  as t h e t h i r d p a r t y r e s p o n s i b l e options.  83  f o r overseeing  to  differ  terms,  t h e c h a r t b e l o w , from t h e p e r s p e c t i v e s o f each o f t h e p r o f e s s i o n a l ' s p a t i e n t , and government  the  roles, the  in the  Figure 18  Perspective  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.  Professional-dominant Asymmetry Discharge decision - Protective Care Costs Benefits  Professional as 'Controller' Professional as 'Accommodator'  Patient  Government or Third Party (overseeing funding of discharge decisions)  Effectiveness and Efficiency assured  Patient-dominant Asymmetry Discharge decision - Home Independently Costs Benefits effectiveness and efficiency not assured  Effectiveness and efficiency not assured  Not judged to be In own best Interest (consistent with perspective of the 'accommodator') Government takes on responsibility of costs  effectiveness and efficiency assured  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  Some costs assumed through d i s a b i l i t y benefits. Other costs assumed by other agencies and governments. For example, home renovation.  Patient takes on more responsibility for day to day costs.  From t h i s o v e r v i e w o f t h e v a r i o u s will  be d i s c u s s e d  Implications  p e r s p e c t i v e s , t h e view o f t h e  professional  f u r t h e r i n the next s e c t i o n .  of the Consumerist  The p r o f e s s i o n a l  Role  who assumes t h e t r a d i t i o n a l r o l e o f ' c o n t r o l l e r '  perceives  t h e i n s t i t u t i o n as t h e 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 t h e p r o v i s i o n  of  services.  /  A l i c e Smith, i n the consumerist  traditional  organization of s e r v i c e s .  s t a n c e , has c h a l l e n g e d t h e  S p e c i f i c a l l y , she w i s h e d t o r e l y on h e r  own judgment and assume t h e 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 .  This  c o n s i d e r s t h e i m p l i c a t i o n o f t h i s c h a l l e n g e from t h e ' c o n t r o l l e r ' perspective. study  Examples  of t h i s p r o f e s s i o n a l ' s  i n which p r o f e s s i o n a l s  Of i n t e r e s t f i r s t , situation: assistance  professional's  p e r s p e c t i v e a r e a v a i l a b l e from t h e  were asked t o e v a l u a t e t h e i m p l i c a t i o n s o f t h e  p a t i e n t ' s b e h a v i o r f o r t h e achievement o f r e h a b i l i t a t i o n g o a l s . used t o h i g h l i g h t t h e  section  These w i l l  be  discussion. t h o u g h , i s t h e a c t u a l outcome o f A l i c e  She r e t u r n e d home t o l i v e ' i n d e p e n d e n t l y ' .  Smith's  She a r r a n g e d w i t h t h e  o f t h e s o c i a l w o r k e r t o have an a t t e n d a n t t o h e l p w i t h h e r  c a r e on a p a r t - t i m e b a s i s .  Thus t h e 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 .  r e v i e w o f F i g u r e 1 8 , t h e b e n e f i t s and c o s t s p e r s p e c t i v e s , can be a s s e s s e d .  o f t h i s outcome, from t h e  From t h e ' c o n t r o l l e r ' p r o f e s s i o n a l ' s  t i v e t h 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 t h e i n s t i t u t i o n has n o t been  personal From a various perspecassured,  t h a t i s , t h e r e s o u r c e s w i t h i n t h e 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 o p t i m a l level.  85  In r e s p o n s e  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  p r e s e n t e d i n t h e study i n t e r v i e w s , t h e p r o f e s s i o n a l s 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  rehabilitation setting.  e v a l u a t e d t h e outcome  to the consumerist. p a t i e n t ,  i t was s t a t e d , "When t h e 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 ?  Most p r o f e s s i o n a l s ,  such as t h i s s t a t e m e n t :  The c r u n c h comes though when he  is  leaves."  Some f e l t t h e s e t t i n g c o u l d h a n d l e t h e c h a l l e n g e ,  '[we]  assume t h a t r e h a b i l i t a t i o n s h o u l d 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 t h e same t i m e you have t o r e s p e c t t h e  and h i s r i g h t t o make h i s own d e c i s i o n .  to accept h e l p . '  I d o n ' t know,  however, d i d not q u e s t i o n t h e e f f e c t i v e n e s s o f t h e s e t t i n g ,  but f o r d i f f e r e n t reasons.  individual  in  questioned the e f f e c t i v e n e s s of the  As an e x a m p l e , a r e s p o n s e  i t a f a u l t o f t h e p a t i e n t o r program?  studies,  The l a r g e r number o f p r o f e s s i o n a l  [We can] h e l p i f he w i s h e s who d i d not q u e s t i o n  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 , t h o u g h , e x p r e s s e d 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 :  ' [ w e a r e ] f r u s t r a t e d - [we a r e ] d e a l i n g  a r e a s where you a r e supposed t o be e x p e r t , b u t , d e s p i t e what you may people's w i l l  in  advise,  w i l l w i n o u t ' , and ' i f t h e p a t i e n t i s n o t s a f e , r e h a b i l i t a t i o n has  not c o m p l e t e d i t s r e s p o n s i b i l i t i e s , [and we] have not made t h e p a t i e n t ' s l i f e  as  b e s t as i t c o u l d b e . ' It  is this final  group o f r e s p o n s e s t h a t seems t o 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 of p r o f e s s i o n a l s  to the challenge to t h e i r t r a d i t i o n a l r o l e .  v a l i d i t y of 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 t o  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 p a t i e n t s have t h e l e g a l r i g h t , u n l e s s own d e c i s i o n s .  i s not y e t r e c o g n i z e d .  The  Yet,  these  incompetence can be p r o v e d , t o make t h e i r  As l o n g as t h e v a l i d i t y o f t h e c h a l l e n g i n g view i s not r e c o g -  86  n i z e d , a gap r e s u l t s between what t h e p r o f e s s i o n a l s  believe i s best f o r  and what t h e p a t i e n t s b e l i e v e i s b e s t f o r t h e m s e l v e s . professional  That i s ,  patients  the  b e l i e v e s t h a t p a t i e n t s have t h e r i g h t t o d e c i d e , b u t t h a t they  s h o u l d make t h e i r d e c i s i o n s based on t h e p r o f e s s i o n a l ' s on t h e i r own judgment.  e x p e r t i s e , and not r e l y  When t h i s does not happen, t h e p r o f e s s i o n a l  e x p l a i n t h e p a t i e n t ' s b e h a v i o r r a t i o n a l l y and f r u s t r a t i o n In t h e p o l i c y c o n t e x t o f t h e t h e s i s , e x i s t s between s o c i e t a l t r e n d s  cannot  results.  t h i s gap i s proposed as a l a g  (the consumerist  stance)  and  that  professional  response ( r e s i s t a n c e to r e c o g n i t i o n of the v a l i d i t y of the c h a l l e n g i n g  view).  The i m p l i c a t i o n s o f t h e r e s i s t a n c e a r e proposed t o be h e l d l a t e n t i n t h e l a g .  IMPLICATIONS OF PROFESSIONAL RESISTANCE Four scenarios  a r e p r e s e n t e d i n t h e f i g u r e b e l o w , as p o s s i b l e  o f t h e d i r e c t i o n s o f t h e s o c i e t a l t r e n d s and p r o f e s s i o n a l  87  response.  interactions  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 t h e t r e n d o f c h a l l e n g i n g b e h a v i o r and t h e 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 . C h a l l e n g e t o P r o f e s s i o n a l - D o m i n a n t Asymmetry trendT trendi tconflict iconflict t frustration I frustration p effectiveness return to • efficiency: s t a t u s quo: Professional Who'sin Charge? 1 2 domi nance 3 4 iconfl ict tconflict i frustration ffrustration r e d e f i n i t i o n of peffectiveness effectiveness • and e f f i c i e n c y : and e f f i c i e n c y : Who'sin Patient Charge? domi nance  resistance  (Professional ] \ Response / no r e s i stance  If  the challenges  i n c r e a s e , i n t h e s i t u a t i o n s where t h e r e s i s t a n c e  is  m a i n t a i n e d , one can e x p e c t more f r e q u e n t o c c u r a n c e s 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 e a s e d q u e s t i o n i n g , though n o t 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 , t h 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 t h e i n s t i t u t i o n a l s e t t i n g .  A decrease  t h e degree o f c h a l l e n g e w o u l d r e s u l t i n a r e t u r n t o t h e s t a t u s quo w i t h sional-dominant If  asymmetry  the professional  still  entrenched i n the i n s t i t u t i o n a l  resistance decreases,  of in  profes-  setting.  and s t e p s a r e t a k e n t o  accommodate t h e 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 e a m ' member,  for  example t h r o u g h a c c e s s t o m e d i c a l r e c o r d s and team m e e t i n g s , t h e r o l e o f t h e 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 t o be r e d e f i n e d . If  t h e c h a l l e n g i n g view s h o u l d s i m u l t a n e o u s l y  e x p e c t c o n f l i c t t o r e s u l t from no one t a k i n g  88  d e c r e a s e , however, one might charge.  With four p o s s i b l e tion.  scenarios,  one c a n n o t make c o n c l u s i o n s w i t h o u t  reserva-  The l a g i n r e s i s t i n g t h e c h a l l e n g e 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 k e e p i n g up w i t h the t i m e s ' , b u t i t a l s o may s e r v e a guard a g a i n s t  approaching the r e a l i t i e s of l i f e through  The t r a d i t i o n a l ( p r o f e s s i o n a l - d o m i n a n t )  and c h a l l e n g i n g  ideological  as  extremes.  (patient-dominant)  views  a r e t h e two p o l e s o f what t h e 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 h o u l d be. N e i t h e r e x t r e m e , however, seems adequate t o deal w i t h t h e c h a l l e n g e s  o f t h e day,  f o r t h e b e n e f i t s o f one a r e p o t e n t i a l l y a t t h e c o s t s o f t h e o t h e r . One a l t e r n a t i v e i s t o t a k e charge o v e r t h e d i r e c t i o n o f t h e t r e n d s . maintenance o f r e s i s t a n c e by t h e p r o f e s s i o n a l , w h i l e t h e c h a l l e n g e  The  has  i n c r e a s e d , has been shown t o r e s u l t i n q u e s t i o n a b 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 of the u t i l i z a t i o n of the f a c i l i t y ' s resources. all  The r e c o g n i t i o n o f i n p u t from  t h e p e r s p e c t i v e s - t h e p r o f e s s i o n a l , t h e p a t i e n t , government - m i g h t  t h i s c o n f l i c t i n t o a workable  resolve  compromise.  REQUIREMENTS T h i s study has been an e m p i r i c a l a n a l y s i s tutional  setting.  o f r o l e asymmetry  in the  insti-  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)  it  c o n t r i b u t e s another small pocket of data to the r a t h e r l a r g e t o p i c of the professional-patient relationship.  These and f u r t h e r a t t e m p t s t o measure  o f t h e r e l a t i o n s h i p w o u l d h e l p t o p a i n t a more comprehensive dynamics o f t h e s i t u a t i o n .  aspects  p i c t u r e of the  Over t i m e , t h e y a l s o h e l p t o m o n i t o r changes i n t h e  relationship.  89  A second r e q u i r e m e n t o f r e s e a r c h s u g g e s t e d by t h i s study analysis  of professional  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 t h e d i m e n s i o n 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 . this thesis.  i s t h a t of  of  T h i s r e l a t i o n s h i p has been assumed t o e x i s t  A f o c u s o f f u r t h e r r e s e a r c h c o u l d be t h e i d e n t i f i c a t i o n o f  i n d i c a t o r s , i n r e s p e c t t o t h e measures  for  those  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 r e  t h e o r e t i c a l l y or e m p i r i c a l l y r e l a t e d to the relationship.  further  professional-patient  1  RECOMMENDATIONS The recommendations, this thesis 1.  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  are t w o f o l d :  a) As many o f t h e t r a d i t i o n a l d e f i n i t i o n s o f c o n c e p t s have been c h a l l e n g e d ,  i n c l u d i n g t h e v a l u e s 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 t h e i n d i c a t o r s measure them, and b) as t h e r o l e s o f p r o f e s s i o n a l s  that  and p a t i e n t s have been  q u e s t i o n e d , p a r t i c u l a r l y i n r e s p e c t t o t h e p a t i e n t ' s r o l e as a team member, i s recommended t h a t t h e s e c o n c e p t s 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 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 f o r m e r p a t i e n t s ; 2.  alone,  it as  and  As t h e o b j e c t i v e s a r e t o a) d i s c u s s i n w h i c h d i r e c t i o n t h e t r e n d  should  b e s t go and b) d i s c u s s t h e i n t e r v e n t i o n t h a t would b e s t d i r e c t t h e t r e n d , i t  is  1 F o r example see D a v i s and von d e r L i p p e ( 1 9 6 7 / 8 ) , " D i s c h a r g e from H o s p i t a l A g a i n s t M e d i c a l A d v i c e : A Study o f r e c i p r o c i t y i n t h e d o c t o r - p a t i e n t r e l a t i o n ship".  90  recommended t h a t a p u b l i c forum be opened, t o t h o s e c o n c e r n e d , t o d i s c u s s a l l p e r s p e c t i v e s o f t h e c o s t s and b e n e f i t s e n s u i n g discharge  from t h e u t i l i z a t i o n o f ,  and  from, 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 o g u e between p r o f e s s i o n a l s  and p a t i e n t s  t h i r d p a r t i e s to provide a greater p r o f e s s i o n a l - p a t i e n t understanding, 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 o f r e h a b i l i t a t i o n s e r v i c e s . provided evidence of a l a g t h a t e x i s t s  i n the professional  response  i f not a The  to  and  study  change.  How q u i c k l y change o c c u r s depends on how one p e r c e i v e s t h e l a g as a f f e c t i n g t h 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 t h e i n s t i t u t i o n a l s e t t i n g . k i n d , s e v e r a l y e a r s down t h e r o a d , may p r o v i d e t h e  90(a)  answer.  A study o f  this  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 M e d i c i n e . Rand M c N a l l y C o l l e g e P u b l i s h i n g Company, Chicago ( 1 9 7 9 ) . A r n e y , W i l l i a m Ray and B e r g e n , B e r n a r d J . and the P l a y of M e d i c a l P o w e r ' , Sociology No. 1 ( 1 9 8 3 ) .  'The Anomaly, t h e C h r o n i c P a t i e n t o f H e a l t h and I l l n e s s . Vol.5,  B a s s f o r d , H.A. 'The J u s t i f i c a t i o n o f M e d i c a l P a t e r n a l i s m ' , and M e d i c i n e . V o l . i 6 , pp. 731-739, ( 1 9 8 2 ) .  Social  Science  B e n - S i r a , Z. ' S o c i e t a l I n t e g r a t i o n o f t h e D i s a b l e d : Power S t r u g g l e o r Enhancement o f I n d i v i d u a l Coping C a p a c i t i e s ' , S o c i a l S c i e n c e and M e d i c i n e . 1 7 : 1 5 , pp. 1011-1016, ( 1 9 8 3 ) . B i d d l e , B . J . and Thomas, E . J . (eds) John W i l e y and Sons, I n c . , ( 1 9 6 6 ) . Bloom, S.W. (1963).  R o l e Theory: Concepts and R e s e a r c h .  The D o c t o r and h i s P a t i e n t ,  New York: Russel  Page F o u n d a t i o n ,  Bloom, S.W. and Sumrney, P. ' M o d e l s o f 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 : A H i s t o r y o f the S o c i a l System C o n c e p t ' i n The Changing H e a l t h Scene. Eugene G a l l a g h e r ( e d ) , U.S. Department o f H e a l t h and W e l f a r e , (1976). Bloom, S.W. and W i l s o n , R.N. 'Patient-Practitioner Relationships' in Freeman, H.E., L e v i n e , S., and Reeder, L . G . ( e d s ) , Handbook o f M e d i c a l S o c i o l o g y 3 r d e d . P r e n t i c e H a l l , I n c . , pp. 275-296, ( 1 9 7 9 ) . Brown, J o a n C. A H i t and M i s s A f f a i r : P o l i c i e s f o r D i s a b l e d P e o p l e i n Canada. Canadian C o u n c i l o f S o c i a l Development, Ottawa, ( 1 9 7 7 ) . Canada H e a l t h and W e l f a r e , R e h a b i l i t a t i o n S e r i e s , H e a l t h Care Memorandum 8 - 9 , O t t a w a , ( 1 9 6 0 ) . 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" D i s c h a r g e from h o s p i t a l a g a i n s t medical a d v i c e : a study o f r e c i p r o c i t y i n t h e 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 s " , ( T e c h n i c a l R e p o r t ) S o c i a l S c i e n c e and M e d i c i n e , V o l . 1 , pp. 336-344, (1967/8). DeJong, G. 'Independent L i v i n g : From S o c i a l Movement t o A n a l y t i c P a r a d i g m ' , A r c h i v e s of P h y s i c a l M e d i c i n e and R e h a b i l i t a t i o n . V o l . 6 0 , pp. 4 3 5 - 4 4 6 , October ( 1 9 / 9 ) . De M i g u e l , J e s u s M. ' A Framework f o r the Study o f N a t i o n a l H e a l t h S y s t e m s ' , Inquiry. Supplement t o 12, No.2, pp. 10-24, ( 1 9 7 5 ) . F r a n c i s , V . , K o r s c h , B.M., M o r r i s , M . J . 'Gaps i n D o c t o r - P a t i e n t Communication: P a t i e n t s ' Response t o M e d i c a l A d v i c e ' , The New England J o u r n a l o f M e d i c i n e . 280:10, pp. 535-540, Mar.6 ( 1 9 6 9 ) . Freemon, B., N e g r e t e , V . F . , D a v i s , M., and K o r s c h , B.M. 'Gaps i n D o c t o r - P a t i e n t Communication: D o c t o r - P a t i e n t I n t e r a c t i o n A n a l y s i s ' , P e d i a t r i c Research. 5 : 2 9 8 - 3 1 1 , (1971). F r e i d s o n , E. P a t i e n t ' s Views o f M e d i c a l P r a c t i c e . Foundation, (1961). F r e i d s o n , E.  The P r o f e s s i o n o f M e d i c i n e .  New Y o r k : R u s s e l l  New Y o r k : Dodd Mead,  F r e i d s o n , E. and L o r b e r , J . (eds) M e d i c a l Men and T h e i r Work. A t h e r t o n , C h i c a g o , New Y o r k , (1972).  92  Sage  (1970). Aldine  G a l l a g h e r , Eugene B. ' P a t i e n t s , D o c t o r s , and P o l i c i e s i n Renal D i a l y s i s : C r o s s N a t i o n a l T r e n d s ' 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 i n t h e Changing H e a l t h Scene. Eugene G a l l a g h e r ( e d ) , U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e , ( 1 9 7 6 ) .  Haug, M.R., and L a v i n , B. ' P r a c t i t i o n e r or Patient-Who's i n Charge?', J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r . V o l . 2 2 , pp. 2 1 2 - 2 2 9 , September  (1981).  Haug, M a r i e R., and Sussman, M a r v i n B. ' P r o f e s s i o n a l Autonomy and the R e v o l t o f t h e C l i e n t ' , S o c i a l P r o b l e m s . V o l . 1 7 , pp. 153-61, ( 1 9 7 9 ) . Hayes-Bautista, David ' M o d i f y i n g the Treatment: P a t i e n t C o m p l i a n c e , P a t i e n t C o n t r o l and M e d i c a l C a r e ' , S o c i a l S c i e n c e and M e d i c i n e . V o l . 1 0 , pp. 233-238, (1976)..  Hays, W i l l i a m I l l i c h , I.  Statistics.  M e d i c a l Nemesis,  H o l t , R i n e h a r t and Winston I n c . , New Y o r k : Bantam Books,  (1963).  (1977).  Ludwig, E . G . , and Davidson Adams, S. ' P a t i e n t Cooperation i n a R e h a b i l i t a t i o n C e n t e r : Assumption o f the C l i e n t R o l e ' , J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r . V o l . 9 , pp. 3 2 9 - 3 3 6 , (1968). Marshall, Victor Canada, ( 1 9 8 0 ) .  Aging i n Canada.  F i t z h e n r y and W h i t e s i d e L t d . , Don M i l l s ,  Mechanic, D. ' R o l e E x p e c t a t i o n s and Communication i n the T h e r a p i s t - P a t i e n t R e l a t i o n s h i p ' , J o u r n a l o f H e a l t h and Human B e h a v i o r . V o l . 2 , pp. 190-198, (1961). M e c h a n i c , D.  Medical Sociology.  The F r e e P r e s s , New Y o r k ,  (1968).  M i s h l e r , E . G . , AmaraSingham, L.R., Hauser, S.T., L i e m , R., O s h e r s o n , S.D., and W a x i e r , N.E. S o c i a l C o n t e x t s o f H e a l t h , I l l n e s s , and P a t i e n t C a r e . Cambridge U n i v e r s i t y P r e s s , ( 1 9 8 1 ) . N a g i , Saad Z. 'Some Conceptual I s s u e s i n D i s a b i l i t y and R e h a b i l i t a t i o n ' i n S o c i o l o g y and R e h a b i l i t a t i o n . M a r v i n B. Sussman ( e d ) , 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). 93  Navarro, Vicente  M e d i c i n e Under C a p i t a l i s m ,  P r o d i s t , New Y o r k ,  (1977).  N i e , Norman H . , H u l l , C. H a d l a i , J e n k i n s , J e a n G . , S t e i n b r e n n e r , K. and B e n t , D. S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s , 2nd e d . , M c G r a w - H i l l , (1975).  N i k l a s , D. ' M e t h o d o l o g i c a l C o n t r o v e r s i e s between S o c i a l and M e d i c a l S o c i a l S c i e n c e and M e d i c i n e . V o l . 1 6 , pp. 659-665, ( 1 9 8 2 ) .  Sciences',  O r t , R.S., F o r d , A . B . , and L i s k e , R.E. '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 as D e s c r i b e d by P h y s i c i a n s and M e d i c a l S t u d e n t s ' , J o u r n a l o f H e a l t h and Human Behavior. V o l . 5 , pp. 2 5 - 3 4 , (1964).  Parsons, T a l c o t t  The S o c i a l System.  The F r e e P r e s s , G l e n c o e , I l l i n o i s ,  (1951).  Reeder, Leo G. ' T h e P a t i e n t - C l i e n t as a Consumer: Some O b s e r v a t i o n s on the Changing P r o f e s s i o n a l - C l i e n t R e l a t i o n s h i p ' , J o u r n a l o f H e a l t h and S o c i a l Behavior. V o l . 1 3 , December ( 1 9 7 2 ) , pp. 406-4HT Renaud, Marc ' R e f o r m o r I l l u s i o n ? An A n a l y s i s o f the Quebec S t a t e I n t e r v e n t i o n i n H e a l t h ' i n Canadian S o c i o l o g i c a l P e r s p e c t i v e s . D ' A r c y , Coburn and New ( e d s ) , F i t z h e n r y and W h i t e s i d e L t d . , pp. 3 6 9 - 3 9 2 , ( 1 9 8 1 ) . 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'The G e r i a t r i c L o n g - S t a y H o s p i t a l P a t i e n t : A Canadian Case S t u d y ' , J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y and Law. V o l . 6 , N o . l , S o r i n g , (1981).  Straus, Robert ' S o c i a l Change and the R e h a b i l i t a t i o n C o n c e p t ' i n S o c i o l o g y and R e h a b i l i t a t i o n . M a r v i n B. Sussman ( e d ) , 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).  S t r a u s s , Anselm  Negotiations.  Jossey-Bass P u b l i s h e r s ,  (1978).  S z a s z , T . S . , and H o l l a n d e r , M.H. 'A C o n t r i b u t i o n to the Philosophy of M e d i c i n e : the b a s i c models o f 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 A r c h i v e s o f I n t e r n a l M e d i c i n e , 97:585-592, ( 1 9 5 6 ) . Wessen, A . F . 'The A p p a r a t u s o f R e h a b i l i t a t i o n : An O r g a n i z a t i o n a l A n a l y s i s ' i n S o c i o l o g y and R e h a b i l i t a t i o n . M a r v i n B. Sussman ( e d ) , 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 S c i e n c e and M e d i c i n e . 1 7 : 1 5 , pp. 1003-1010, ( 1 9 8 3 ) .  95  APPENDIX 1 INTERVIEW  T h i s appendix c o n t a i n s t h e i n t e r v i e w p r o c e d u r e , an a c t u a l i n t e r v i e w , and a b r i e f discussion  o f t h e matching o f 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 r c u m s t a n c e s .  I n t e r v i e w P r o c e d u r e ( c o n t a i n i n g an a c t u a l i n t e r v i e w from the  study)  The i n t e r v i e w i n v o l v e s p r e s e n t i n g t o you 2 case s t u d i e s o f 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 o t h e r than t h i s one.  You can c o n s i d e r 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 C e n t r e .  In l o o k i n g  through  the m e d i c a l r e c o r d s here I have t r i e d t o modify terms t o those used a t t h i s facility, I will  so, i f any are not c l e a r , p l e a s e l e t me know.  A f t e r you r e a d the case  g i v e you some more i n f o r m a t i o n about the p a t i e n t ' s s t a y and then ask you  some q u e s t i o n s about y o u r  impressions.  96  Case Study  #1  Mr. C. i s a 70 y e a r o l d male t r e a t e d a t  Rehabilitation  C e n t r e f o r t h e 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 a t admissions years.  General H o s p i t a l .  Mr. C. has had p a s t  t o 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 p a s t 20  He a l s o has h y p e r t e n s i o n which has been m e d i c a l l y c o n t r o l l e d f o r t h e  p a s t 15 y e a r s . Mr. C. i s on a t r e a t m e n t program f o r r e s i d u a l a t a x i a o f the r i g h t upper e x t r e m i t y , and improvement o f 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 r e d a l o s s i n h e a r i n g , from the tumour, f o r  which he has been f i t t e d w i t h a h e a r i n g a i d . has f a l l e n a c o u p l e o f t i m e s a t t h e C e n t r e . time.  He has o c c a s i o n a l  d i z z y s p e l l s and  He i s o r i e n t e d t o p e r s o n , p l a c e and  He p r e s e n t l y walks w i t h a w a l k e r but i s p r o g r e s s i n g  t o 2 canes.  The  a t a x i a on the r i g h t s i d e and OA of the l e f t s h o u l d e r have made i t d i f f i c u l t Mr. C. t o manage h i s own p e r s o n a l  for  care.  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 s e t o f s t a i r s l e a d i n g t o the f r o n t entrance.  F o l l o w i n g h i g h s c h o o l , Mr. C. worked h i s way up t o foreman i n a  warehouse but had t o stop 10 y e a r s ago because o f i n c r e a s i n g p a i n from h i s arthritis. pensions.  He r e c e i v e s government a s s i s t a n c e and has few s a v i n g s from h i s He was m a r r i e d f o r 42 y e a r s and h i s w i f e d i e d 8 y e a r s ago.  daughter i n V i c t o r i a and one i n M o n t r e a l .  He has a  They share the r e s p o n s i b i l i t y o f  c o n t a c t i n g him r e g u l a r l y throughout t h e y e a r .  In d i s c u s s i o n s  w i t h the s o c i a l  w o r k e r , they have s t a t e d t h a t they t h i n k i t would be s a f e r f o r him i f he were 97  'placed . 1  They t a l k o f how the f a m i l y has d r i f t e d a p a r t and how they are now  h e s i t a n t t o suggest he l i v e w i t h e i t h e r one o f them. S t a f f t h i n k t h a t ongoing t r e a t m e n t 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 c o u l d be ready f o r d i s c h a r g e  from the f a c i l i t y i n another week.  ***** Now I would l i k e t o t e l l you a l i t t l e more about Mr. C . ' s  s t a y a t the  Centre. Mr. C. has r e p e a t e d l y q u e s t i o n n e d the t r e a t m e n t program a t the C e n t r e . says he has l e a r n e d t o do h i s own p e r s o n a l  c a r e , on h i s own, i n h i s room, but  has r e f u s e d t o demonstrate t h i s t o t h e nurses and t h e r a p i s t s . l a t e , and sometimes not a t a l l , f o r t h e r a p y . about whatever m e d i c a t i o n i s  prescribed.  98  He  O f t e n he shows up  He o f t e n asks a second  opinion  I - Interviewer P - Professional I  What i s y o u r g e n e r a l i m p r e s s i o n o f Mr.  'C's'  s t a y a t the C e n t r e ?  P  General  I  Uhhuh.  P  I d o n ' t know what you mean by general  I  A f t e r r e a d i n g t h e case study about h i s medical problems and s o c i a l e t c . , and w i t h o u t 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 l o o k s t o me t h a t h i s p e r c e p t i o n o f h i s problems and s t a f f ' s p e r c e p t i o n o f h i s problems are d i f f e r e n t .  I  Y e s , what has i n d i c a t e d t h a t t o y o u .  P  The f a c t t h a t he d o e s n ' t want t o do the t h i n g s t h a t s t a f f want him t o .  I  Why do you t h i n k t h a t happens, where p e r c e p t i o n s  P  W e l l , I t h i n k t h i s i s an awful common t h i n g t o happen because s t a f f somet i m e s g e t t o o 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 r e c o g n i z e t h e importance o f how the p a t i e n t s both p e r c e i v e themselves and the remediation.  I  If  P  Then they might b e g i n t o t a c k l e problems t h a t t h e p a t i e n t sees as b e i n g important.  I  Uhhuh.  P  And they might make some headway.  I  What do you mean by headway?  P  They might get t h e p a t i e n t t o 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 t h i n k a p a t i e n t would see as i m p o r t a n t 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 ' c a s e .  P  W e l l , o b v i o u s l y from what you t e l l me, he does h i s s e l f - c a r e h i m s e l f and he i s n ' t g o i n g t o demonstrate how he does i t e x c e p t I g a t h e r he appears d r e s s e d , so i f he i s a b l e t o d r e s s and d o e s n ' t get somebody e l s e t o h e l p h i m , and so the methods o f 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 o n l y assume t h a t from t h e f a c t t h a t t h e y ' r e concerned about  impression?  impression. problems  differ?  s t a f f were t o r e c o g n i z e t h a t what would t h e i r approach be?  99  him, h i s i n a b i l i t y - h i s r e f u s a l t o demonstrate t o them what h e ' s c a p a b l e of d o i n g , but I w o u l d n ' t l i k e you t o t h i n k t h a t I t h i n k p a t i e n t s are always r i g h t and t h e r e f o r e we do e v e r y t h i n g the p a t i e n t s a y s , but sometimes i f one works through then we can get them t o respond t o t h e t h e r a p e u t i c methods t h a t we t h i n k w i l l a l s o be o f importance t o them. I  Uhhuh.  P  I o f t e n have a s o r t o f c o n f r o n t a t i o n approach.  I  How do you judge as t o when a p a t i e n t ' s s u g g e s t i o n might be r i g h t o r y o u r s be r i g h t ?  P  W e l l , I t h i n k t h a t I can look a t p a t i e n t s and determine what t h e i r p a t h o l o g i c a l c o n d i t i o n s a r e 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 t o l i v e t h e i r l i v e s and what t h i n g s are p o s s i b l e f o r us t o do t o h e l p 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 t o reduce t h e e f f e c t s o f t h e p a t h o l o g y 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 t o see i t q u i t e t h a t way and we have t o 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 i m a t e aims t h a t we m i g h t have had b u t not go about a c h i e v i n g them i n a way t h a t i s a t odds w i t h t h e p a t i e n t ' s p e r c e p t i o n o f h i m s e l f .  I  Uhhuh. Does i t e v e r happen where the p e r c e p t i o n s do c o n f l i c t and t h e approach must become d i r e c t ?  P  Oh sometimes y e s , n o t h i n g ' s  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 t h e open when you h a v e n ' t been a b l e t o approach i t i n d i r e c t l y .  P  One has t o make some k i n d o f accommodation, some s t a f f f i n d i t e a s i e r t o accommodate, and o t h e r s a r e much more r i g i d and c a n ' t , and t h i s i s one of t h e 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 t o change them.  I  Why do you t h i n k Mr.  P  I c o u l d n ' t answer you t h a t , I d o n ' t know. T h e r e ' s no way from t h i s . . . I can j u s t say t h a t i t ' s not too uncommon nowadays. And very o f t e n p a t i e n t s who q u e s t i o n t r e a t m e n t are very unhappy about the s i t u a t i o n and t h e m s e l v e s .  I  What do you t h i n k would be t h e u l t i m a t e t r e a t m e n t goal f o r Mr.  'C'  absolute.  has q u e s t i o n e d h i s  100  treatment?  'C'?  P  An independent l i v i n g s i t u a t i o n , p r o v i d e d t h a t h e ' s a b l e t o manage, and I'm not s u r e from t h e i n f o r m a t i o n 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 t h e i n f o r m a t i o n p r o v i d e d t h e r e , c o u l d you t e l l t h i n k t h e optimum d i s c h a r g e o p t i o n 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 , h e ' s got some d i f f i c u l t y w i t h n e g o t i a t i n g t h e s t a i r s . I f he can do t h a t , and t h e r e m i g h t be p o s s i b i l i t i e s t h a t he c a n , one d o e s n ' t change the way people l i v e u n l e s s t h e r e ' s a good reason t o change. And i f t h a 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 b e f o r e , then t h a t ' s what one would t r y a return to t h a t l i v i n g s i t u a t i o n .  I  A t t h e C e n t r e where he was he made i t known t o t h e s t a f f t h a t he wished t o go l i v e w i t h h i s f a m i l y . How would you e v a l u a t e t h a t r e q u e s t ?  P  Uh, what I would do about i t - i f he t o l d me t h a t I would p o i n t out t o him t h a t i t may o r may not be a r e a s o n a b l e p l a n f o r him. And t h a t I ' d be very p l e a s e d t o t a l k t o h i s daughter. And, p a r t i c u l a r l y t h e daughter i n V i c t o r i a . B u t , o f c o u r s e , he might have p l a n s t o move t o t h e one i n Montreal.  I  What do you mean by ' r e a s o n a b l e ' ? 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 w e l l as the p a t i e n t o f f t h e 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 t h a t i s g o i n g t o p r o v i d e them w i t h a l i v i n g s i t u a t i o n t h a t i s c o m p a t i b l e both t o themselves and t o o t h e r r e l a t i v e s .  I  I f i t d i d happen, i f you t r i e d t o proceed i n t h i s way and the r e f u s e d , and the p a t i e n t then says he wants t o go home a l o n e . you deal w i t h t h a t ?  P  I f he c o u l d manage i n h i s s e t t i n g a t home where he was p r e v i o u s l y would be t h e most a p p r o p r i a t e t h i n g t o encourage.  I  O ' k a y , t h a t ' s case study number 1. T h i s i s Mr. ' D ' .  me what you  You s a i d , ' t h a t may o r may not be a  daughter How would  I have a second one f o r y o u .  101  that  Case Study  #2  Mr. 0 . i s a 66 y e a r o l d man a d m i t t e d t o  Rehabilitation  C e n t r e 3 months ago on t r a n s f e r from  General H o s p i t a l .  been a d m i t t e d t h e r e w i t h a r i g h t b r a i n aneurysm.  P a s t medical h i s t o r y  He had includes  a d u l t o n s e t d i a b e t e s o f 12 y e a r s d u r a t i o n c o n t r o l l e d by d i e t , and emphysema, 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 c a r e  physiotherapy.  P r e s e n t l y , Mr. D. has l e f t - s i d e d n e g l e c t which i s c a u s i n g problems o f l a c k of b a l a n c e when w a l k i n g . t i o n f o r the n e g l e c t .  Mr. D.'s  speech i s d i f f i c u l t t o understand due t o  The speech t h e r a p i s t does not e x p e c t improvement.  Otherwise, his  graduate.  f l o o r s which he f i n d s d i s t u r b i n g .  He worked as a s u p e r v i s o r  comprehension  on c o n s t r u c t i o n s i t e s u n t i l  f i n a n c e s and a p p l i e d f o r government a s s i s t a n c e f o r the p a s t 10 y e a r s and has 2 daughters  The f o y e r  He i s a high  y e a r s ago because o f 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 r e a t h i n g .  Williams Lake.  understood.  He i s a m b u l a t i n g w i t h a quad cane.  Mr. D. p r e s e n t l y r e n t s an apartment i n t h e Vancouver a r e a . m i r r o r s and shiny  because  Treatment has been d i r e c t e d toward compensa-  d y s a r t h r i a and he has t o r e p e a t sentences 3 or 4 times b e f o r e he i s  i s normal and competent.  for  l a s t year.  has  school retirement 5  He has  limited  He has been widowed  l i v i n g on t h e I s l a n d and a son  in  There i s not much communication between the c h i l d r e n though  has t r i e d t o 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 . has a v o i d e d c o n t a c t w i t h the s o c i a l worker who has t r i e d t o i n q u i r e about discharge  each Each  post-  arrangements.  A t the l a s t team meeting i t was d e c i d e d he would be ready f o r d i s c h a r g e 2 weeks t i m e . 102  in  Now I would l i k e t o g i v e you a b i t more i n f o r m a t i o n about Mr. D . ' s  stay at  the Centre. Mr. D. has f i t w e l l  i n t o the f a c i l i t y  s c h e d u l e 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 p r e s e n t e d . He has been f o l l o w i n g h i s t r e a t m e n t program r i g i d l y and s t a f f have had to supervise c l o s e l y . on the f u l l  Once when he was g i v e n a hot pack f o r 15 minutes he l e f t  t i m e i n s p i t e o f f e e l i n g p a i n from the h e a t .  suffered a mild scald.  it  He c o n s e q u e n t l y  In t h e gym, he f o l l o w s through h i s d a i l y s c h e d u l e even  on days he i s not f e e l i n g w e l l .  On o c c a s i o n he has had t o be h e l p e d back to h i s  room.  I  What i s y o u r g e n e r a l i m p r e s s i o n o f Mr.  P  He seems t o have been c o - o p e r a t i n g w i t h t h e t r e a t m e n t s t a f f . I t ' s d i f f i c u l t t o 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. E x c e p t i t says h e ' l l be ready f o r d i s c h a r g e i n two weeks t i m e .  I  Why do you t h i n k Mr. f e e l i n g t h e heat?  P  I ' d be i n t e r e s t e d t o know why he e v e r had the hot pack on i n t h e instance.  I  I d o n ' t t h i n k I can answer t h a t f o r y o u . decided...  P  D o e s n ' t seem a good i d e a t o put hot packs on t o p e o p l e who have impairment.  I  I t h i n k you c o u l d assume t h a t whatever r o u t i n e s were r e q u i r e d b e f o r e p u t t i n g t h e hot pack on, had been done.  'D'  'D's'  s t a y a t the C e n t r e ?  l e f t the hot pack on the f u l l  103  time i n s p i t e o f first  F o r whatever reason they sensory  P  One can o n l y guess t h a t h e ' s a r a t h e r r i g i d person t h a t f o l l o w s t h e t h i n g s that 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 t h a t t h a t had t o s t a y f o r 15 m i n u t e s , then he j u s t a c c e p t e d i t as such. And some p a t i e n t s w i l l a c c e p t t h a t from one t h e r a p i s t and not a n o t h e r .  I  What do you see as t h e optimum t r e a t m e n t goal f o r Mr.  P  H e ' s a 66 y e a r o l d man w i t h a l e f t h e m a p l i z i a , and very o f t e n t h e l e f t hemaplegic has g r e a t e r d i f f i c u l t y i n d e v e l o p i n g independence and i t d o e s n ' t r e a l l y t e l l me too much here about how w e l l he does manager. And h i s p e r s o n a l c a r e - how w e l l he i s a b l e t o 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 c e r e b r a l i n v o l v e m e n t and t h a t c o u l d mae a b i g d i f f e r ence i n terms o f p r o b a b l e outcome when i t ' s not s o l e l y a u n i l a t e r a l cerebral 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  T h a t he might not do as w e l l as some o f t h e t h e r a p i s t s p e r c e i v e d he w o u l d . They might have a n t i c i p a t e d t h a t he would d o . . . . T h e y d o n ' t measure i f h e ' s had g r e a t e r d i f f i c u l t i e s i n managing h i s d i a b e t e s . He was b e f o r e , s o l e l y by d i e t .  I  Do you t h i n k h i s b e h a v i o r a t the C e n t r e - the e x t r a i n f o r m a t i o n p r o v i d e d w i l l a f f e c t the t r e a t m e n t g o a l s a t a l l ?  P  Not sure I understand what you mean h i s b e h a v i o r a t the C e n t r e a f f e c t the treatment goals?  I  I n f l u e n c e , would t h e t r e a t m e n t goal have t o b e . . .  P  Modified? I t h i n k they always have t o be. I t ' s no good s e t t i n g up a program and s a y i n g , ' y o u damn w e l l do i t , o r e l s e ! ' I t ' s not very successful.  I  In what way do you see the g o a l s b e i n g m o d i f i e d i n t h i s case?  P  W e l l , the q u e s t i o n i s whether he i s a b l e t o l i v e on h i s own o r whether he needs a s u p e r v i s e d t y p e o f 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 t e r m e d i a t e c a r e 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 r o r s and s h i n y 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 t h 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 t o go l i v e w i t h h e r . And she i s h e s i t a n t t o do t h a t . How would you deal w i t h t h a t ?  P  T h i s m a t t e r o f whether r e l a t i v e s go and stay w i t h f a m i l y i s very much an i n d i v i d u a l m a t t e r . One can t a l k t o them about i t and they both come t o a r e a l i z a t i o n o f whether t h i s i s a good i d e a o r n o t . Sometimes we d o n ' t t e l l them what t o do but they make b e t t e r d e c i s i o n s a f t e r t a l k i n g over the pros 104  'D'?  and cons w i t h the d o c t o r and s o c i a l worker and sometimes the o t h e r s t a f f as w e l l . We know n o t h i n g about the p h y s i c a l l a y o u t o f the daughters house or the f a m i l y s i t u a t i o n - whether she works, o r i f she e v e r got a l o n g w i t h her f a t h e r o r n o t . Whether the f a t h e r c a n ' t s t a n d h i s s o n - i n - l a w . . . T h e r e are so many t h i n g s t h a t come i n . I t seems t h a t t h i s i s a f a m i l y t h a t has been i n communication w i t h each o t h e r and not t o t a l l y d r i f t e d a p a r t . But s t i l l t h e y ' v e gone t h e i r s e p a r a t e ways. I  The daughter f o l l o w e d , t h a t her f a t h e r s a i d t h a t i f he c o u l d n ' t l i v e w i t h her he would want t o go home a l o n e . How would you deal w i t h t h a t f o r Mr. 'D'?  P  W e l l , i f I d i d n ' t t h i n k he c o u l d manage we would have a home v i s i t , people look t o 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 h e y ' v e done t h i s I ' d put them through the t h i r d degree t o e v a l u a t e Mr. ' D ' s ' c a p a b i l i t i e s . And, between us we would come t o some c o n c l u s i o n as t o whether we would encourage him t o go home w i t h o r w i t h o u t some a s s i s t a n c e o r whatever community s u p p o r t 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 s h o u l d b e g i n . And from the i n f o r m a t i o n g i v e n I d o n ' t t h i n k I can say what s h o u l d o r s h o u l d n ' t be.  I  Going back t o a p o i n t you made a t the b e g i n n i n g about l e a v i n g t h e 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 t h e r s . What do you t h i n k i s the n a t u r e o f t h a t k i n d o f r e l a t i o n s h i p between the p a t i e n t and the h e a l t h p r o f e s s i o n a l ?  P  Some p e o p l e 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 t h o u t even a t t e m p t i n g t o . Some p a t i e n t s respond one way t o one p r o f e s s i o n a l and a d i f f e r e n t way t o a n o t h e r . 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 t e c h n i q u e s i n an a g g r e s s i v e way w i l l s e t up defence mechanisms w i t h the p a t i e n t so t h a t t h e y ' l l r e s i s t i n s t e a d o f c o o p e r a t e and o t h e r t i m e s how t h e t h e r a p i s t approaches the p a t i e n t can have a g r e a t i n f l u e n c e on what the p a t i e n t does o r does not do.  I  O ' k a y , thank you very much. That c o n c l u d e s the i n t e r v i e w .  I t would be b e n e f i c i a l t o t h e study i f you  d i d not d i s c u s s w i t h o t h e r s t a f f t h e s p e c i f i c c o n t e n t o r q u e s t i o n s o f the interview.  A general r e p o r t o f the study w i l l  be p r e s e n t e d f o l l o w i n g the  a n a l y s i s o f t h e d a t a , but do you have any q u e s t i o n s a t t h i s  105  time?  M a t c h i n g 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 r c u m s t a n c e s Though many o f 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 o f the problems f a c i n g the ' p a t i e n t s ' o n l y one commented on the ' a p p a r e n t '  duplication  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 evident.  e v a l u a t i o n o f the d i s e a s e a l s o became  L e f t s i d e d d i s a b i l i t y i n d i c a t e d t o many p r o f e s s i o n a l s  a t Holy F a m i l y a  worse o u t l o o k f o r t h e p a t i e n t ' s response t o t r e a t m e n t and/or f u n c t i o n a l recovery.  But t h e s e f e e l i n g s d i d not c r o s s a l l p r o f e s s i o n a l s  r e l a t e d more t o a ' s c h o o l o f t h o u g h t '  and appeared t o be  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 h e a r i n g / s p e a k i n g . was p r e s e n t e d as tive interaction.  'difficult'  but the p a t i e n t r e t a i n e d some c a p a c i t y f o r e f f e c -  T h i s v a r i a b l e was i n c l u d e d t o add t o the dimensions o f  and c l u s t e r o f p a t h o l o g y .  Each  risk  Most p a r t i c i p a n t s chose not t o comment o r made  p a s s i n g comments and d i d not c o n s i d e r i t t o be a c r i t i c a l  variable.  A couple  though w e i g h t e d d y s a r t h r e a a g r e a t e r problem than n e a r i n g d i f f i c u l t y and i n c r e a s e d the r i s k dimension o f t h e one o v e r the o t h e r .  106  APPENDIX 2 T h i s appendix c o n t a i n s a sample o f t h e study q u e s t i o n n a i r e and an example o f some o f t h e m o d i f i c a t i o n s made from Haug and L a v i n (1981). Study Q u e s t i o n n a i r e " 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 and P a t i e n t B e h a v i o r " The f o l l o w i n g q u e s t i o n s seek t o o b t a i n i n f o r m a t i o n from p r o f e s s i o n a l s ^ c o n c e r n i n g 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 n a l s ^ and p a t i e n t s s h o u l d behave i n o r d e r t o make h e a l t h d e c i s i o n s most e f f e c t i v e f o r patients. There are no ' r i g h t ' o r ' w r o n g ' answers as one would e x p e c t p r a c t i t i o n e r s t o have d i f f e r i n g o p i n i o n s 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 s c u s s the q u e s t i o n s w i t h o t h e r s b e f o r e a n s w e r i n g . I t i s recommended t h a t knowing more about t h e s i t u a t i o n s p r e s e n t e d i n each q u e s t i o n would be d e s i r a b l e i n o r d e r t o make an i n f o r m e d d e c i s i o n . But w i t h no f u r t h e r i n f o r m a t i o n p r o v i d e d p l e a s e i n d i c a t e y o u r agreement o r disagreement w i t h the f o l l o w i n g s t a t e m e n t s on a s c a l e o f 1 t o 4 . 1.  I t i s very i m p o r t a n t f o r p a t i e n t s t o comply w i t h what p r o f e s s i o n a l s 1 strongly agree  2  3 disagree  agree  advise.  4 strongly disagree  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 t o t a k e the p a t i e n t ' s opinion i n t o account. 1 strongly agree 3.  2  3 disagree  agree  4 strongly disagree  Even i f a p a t i e n t asks t o read h i s own medical r e c o r d s , he s h o u l d not be a l l o w e d t o do so. 1 strongly agree  2  3 disagree  agree  4 strongly disagree  1 The q u e s t i o n n a i r e s s e n t t o each o f t h e d i s c i p l i n e ' s had t h e 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 ' a p p e a r s , u n l e s s 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 q u e s t i o n n a i r e s . 107  4.  I f p r o f e s s i o n a l s would d i s c u s s m a t t e r s more w i t h p a t i e n t s b e f o r e a c t i n g , everybody would be b e t t e r o f f . 1 strongly agree  5.  3 disagree  agree  4 strongly disagree  P a t i e n t s s h o u l d not be a l l o w e d t o r e f u s e t r e a t m e n t . 1 strongly agree  6.  2  2  3 disagree  agree  4 strongly disagree  Even i f no p o t e n t i a l harm t o any o t h e r person i s i n v o l v e d , a p a t i e n t s h o u l d not be a l l o w e d t o l e a v e the h o s p i t a l when t h e d o c t o r * does not a g r e e . 2 agree  strongly agree  disagree  strongly disagree  I t i s a l l r i g h t f o r patients to r a i s e questions with professionals about a n y t h i n g they a d v i s e . 1 strongly agree  2  3 disagree  agree  4 strongly disagree  In t h i s next s e c t i o n , 4 c a s e s a r e p r e s e n t e d i n which you can assume the p a t i e n t t o be m e n t a l l y competent. A f t e r r e a d i n g t h e case p r e s e n t e d , i n d i c a t e y o u r agreement or disagreement on a s c a l e o f 1 t o 4 w i t h the p o s s i b l e responses t h a t f o l l o w . Case 1. A p a t i e n t suggests t h a t what you a d v i s e d was too much t r o u b l e . You d i s c u s s the reasons behind y o u r a d v i c e but he s t i l l r e f u s e s t o comply. Would you: 8.  Go t o t r e a t a n o t h e r 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 s e you a r e not u s i n g your time p r o d u c t i v e l y ; 1 strongly agree  3  2  3 disagree  agree  ' D o c t o r ' was used here f o r a l l q u e s t i o n n a i r e s . 108  4 strongly disagree  9.  Try t o persuade him t o g i v e i t a t r y ; 1 strongly agree  10.  2  3 disagree  agree  4 strongly disagree  D i s c u s s o t h e 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 . 1 strongly agree  2  3 disagree  agree  4 strongly d i sagree  Case 2 . A p a t i e n t suggests t h a t what you a d v i s e d 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 . Would you: 11.  Help him o b t a i n what he has r e q u e s t e d ; 1 strongly agree  12.  Tell  3 disagree  agree  him he w i l l  1 strongly agree 13.  2  4 strongly disagree  have t o see someone e l s e to g e t what he has r e q u e s t e d .  2  3 disagree  agree  4 strongly disagree  Try t o e x p l a i n why y o u r s u g g e s t i o n i s b e t t e r than h i s . 1 strongly agree  2  3 disagree  agree  4 strongly disagree  Case 3. A p a t i e n t asks t o a t t e n d a meeting t h a t was meant only f o r p r o f e s s i o n a l s ^ t o d i s c u s s the p a t i e n t ' s b e h a v i o r . What do you f e e l s h o u l d be done: 14.  A l l o w him t o a t t e n d ; 1 strongly agree  4  2  3 disagree  agree  ' P r o f e s s i o n a l ' was used here f o r a l l q u e s t i o n n a i r e s . 109  4 strongly disagree  15.  Refuse him p e r m i s s i o n t o a t t e n d ; 2  strongly agree 16.  Tell  him you w i l l  1 strongly agree  agree  disagree  strongly disagree  arrange a n o t h e r meeting f o r him t o a t t e n d . 2  agree  disagree  strongly disagree  Case 4 . A p a t i e n t has appeared unmotivated d u r i n g t r e a t m e n t . He has r e f u s e d c o u n s e l l i n g and o t h e r e f f o r t s t o e x p l o r e the problem. A p a t i e n t c o n f e r e n c e , between p r o f e s s i o n a l s ^ has been c a l l e d t o d i s c u s s how t o r e s o l v e t h e p r o b l e m . Would you recommend: 17.  D i s c h a r g e the p a t i e n t so t h a t t h e 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 ; 2  strongly agree 18.  agree  disagree  Implement a s p e c i a l h e l p programme f o r the p a t i e n t ; 2  strongly agree 19.  strongly di sagree  agree  disagree  4 strongly disagree  C o n t i n u e as b e f o r e and l e t him make the f i r s t move t o 'come around' 2  strongly agree  5  agree  disagree  ' P r o f e s s i o n a l ' was used here f o r a l l q u e s t i o n n a i r e s . 110  strongly disagree  I n d i c a t e you agreement or disagreement w i t h t h e f o l l o w i n g statements on a s c a l e of 1 to 4. 20.  The p a t i e n t i n t h e l a s t s t a g e s o f a t e r m i n a l i l l n e s s , should d e c i d e i f f u r t h e r t r e a t m e n t s h o u l d be c o n t i n u e d . 1 strongly agree  21.  2 agree  22.  2 agree  2 agree  6  4 strongly disagree  disagree  strongly di sagree  I f no a b n o r m a l i t i e s show up i n the l a b r e s u l t s o r p h y s i c a l exam, a p a t i e n t ' s symptoms are p r o b a b l y p s y c h o - s o m a t i c . 1 strongly agree  2 agree  A p a t i e n t ' s diagnosis 1 strongly agree  25.  3 disagree  Most t e r m i n a l l y i l l p a t i e n t s s h o u l d not be t o l d the p r o g n o s i s even i f r e q u e s t e d by them. strongly agree  24.  4 strongly disagree  When d i s c u s s i n g t r e a t m e n t programs 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 t h e f i n a l d e c i s i o n about what the p a t i e n t s h o u l d do. 1 . strongly agree  23.  3 disagree  3 disagree  4 strongly disagree  s h o u l d always be made c o m p l e t e l y c l e a r t o him.  2 agree  3 disagree  4 strongly disagree  I t i s very i m p o r t a n t f o r p a t i e n t s t o 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 a d v i s e . 1 strongly agree  2 agree  3 disagree  4 strongly disagree  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 s a g r e e d ' w i t h t h i s s t a t e m e n t . Because o f l i m i t e d v a r i a n c e t h e r e was no f u r t h e r c o n s i d e r a t i o n of t h i s q u e s t i o n . Ill  26.  27.  I f p r o f e s s i o n a l s would d i s c u s s l e s s w i t h p a t i e n t s and t e l l o u t what t o do, everybody would be b e t t e r o f f .  them s t r a i g h t  1 strongly agree  4 strongly disagree  2  3 disagree  agree  P a t i e n t s s h o u l d 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 advise without a l o t of questions. 1 strongly agree  2  3 disagree  agree  4 strongly disagree  The f o l l o w i n g q u e s t i o n s seek y o u r o p i n i o n on r e l a t i o n s h i p s i n g e n e r a l . 28.  In making f a m i l y d e c i s i o n s , p a r e n t s ought t o t a k e t h e o p i n i o n o f the teenagers i n t o account. 1 strongly agree  29.  agree  4 strongly disagree  2  3 disagree  agree  4 strongly disagree  I t ' s a l l r i g h t f o r p e o p l e t o r a i s e q u e s t i o n s about even the most sensitive matters. 1 strongly agree  31.  3 disagree  R e s p e c t f o r a u t h o r i t y i s the most i m p o r t a n t t h i n g t e e n a g e r s s h o u l d l e a r n . 1 strongly agree  30.  2  2  3 disagree  agree  4 strongly disagree  F o r the most p a r t , i f p e o p l e 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 strongly agree  2  3 disagree  agree  112  4 strongly disagree  32.  P a r e n t s ought t o have the main s a y - s o i n d e c i d i n g what t o do about a t e e n a g e r ' s problems. 1 strongly agree  33.  2 agree  Everybody s h o u l d have f a i t h i n some a l l - p o w e r f u l 1 strongly agree  34.  2 agree  3 disgree  4 strongly disagree f o r c e t h a t guides  destiny.  4 strongly disagree  F o r t h e most p a r t , i f everybody would d i s c u s s m a t t e r s b e f o r e a c t i n g , everybody would be b e t t e r o f f . 1 strongly agree  35.  3 disagree  2  3 disagree  agree  4 strongly disagree  R e l y i n g on t h e i r own judgments and making t h e i r own d e c i s i o n s are the most i m p o r t a n t t h i n g s t e e n a g e r s s h o u l d l e a r n . 1 strongly agree  2  3 disagree  agree  113  4 strongly disagree  T H E UNIVERSITY 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 p h i l o s o p h y , p r o f e s s i o n a l s a t t e m p t t o t a k e i n t o a c c o u n t p a t i e n t b e h a v i o r i n o r d e r t o enhance t r e a t m e n t outcome and p a t i e n t w e l l - b e i n g . The purpose o f t h i s s t u d y , ' P l a n n i n g f o r P a t i e n t D i s c h a r g e : How 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 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 f o r m a t i o n about how p r o f e s s i o n a l s f e e l t h e y and p a t i e n t s s h o u l d b e s t behave i n o r d e r t o make t r e a t m e n t p l a n s 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 a s s e s s p a t i e n t b e h a v i o r ? The s t u d y forms p a r t o f the requirements o f the M.Sc. Program i n 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 a t U.B.C. It i s of benefit t o me i n a c q u i r i n g the s k i l l s o f r e s e a r c h . In the f a c i l i t y ' s i n t e r e s t I have agreed t o p r e s e n t the r e s u l t s and c o n c l u s i o n s back t o you a t a time a r r a n g e d i n June. The f a c i l i t y w i l l have ongoing access t o t h i s i n f o r m a t i o n so t h a t you may c o n t i n u e t o use i t i n d i s c u s s i o n s . The s t u d y i n v o l v e s a 15 minute q u e s t i o n n a i r e and a h a l f - h o u r i n t e r view a r r a n g e d w i t h i n the f o l l o w i n g s i x weeks a t a c o n v e n i e n t t i m e o f t h e workday. P a r t i c i p a t i o n i s v o l u n t a r y . You have the r i g h t t o w i t h d r a w a t any time o r r e f u s e t o answer any q u e s t i o n w i t h o u t f e a r o f s a n c t i o n . To make n o t e - t a k i n g e a s i e r w h i l e we t a l k I w i l l ask y o u r p e r m i s s i o n t o r e c o r d the i n t e r v i e w . T h i s i s not an e s s e n t i a l p r o c e d u r e t h o u g h , so i f you f e e l u n c o m f o r t a b l e about t a p i n g do not h e s i t a t e t o r e f u s e when I ask. Your s i g n a t u r e on t h i s form r e p r e s e n t s consent t o the q u e s t i o n n a i r e and t h e i n t e r v i e w and t o acknowledge r e c e i p t o f a copy o f t h i s consent form, attached. P l e a s e r e t u r n the consent form and completed q u e s t i o n n a i r e as soon as p o s s i b l e i n the a t t a c h e d e n v e l o p e . Thank y o u ! C a r l a Palmer Student 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 UBC  Signature: Department: Date:  113a  form  An example o f the m o d i f i c a t i o n s made:  A 2 - p o i n t s c a l e q u e s t i o n such as s e l e c t i n g f r o m , I t i s most i m p o r t a n t t o comply w i t h what p h y s i c i a n s  advise  or I t i s most i m p o r t a n t f o r p a t i e n t s t o 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 h y s i c i a n s  advise  was changed t o the form shown i n q u e s t i o n s 1 and 25.  114  APPENDIX 3 D i s t r i b u t i o n o f F a c t o r Scores  In t h e c h a r t below t h e d i s t r i b u t i o n o f s c o r e s f o r f a c t o r s 1 t o 6 a r e r e f l e c t e d by Comparison o f K u r t o s i s and skewness v a l u e s .  T a b l e XVII  Kurtosis  and Skewness v a l u e s o f f a c t o r s 1 t o 6  Factor  Kurtosis  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  F a c t o r s 1 and 4 show f l a t t e r c u r v e s than a normal d i s t r i b u t i o n but have r e t a i n e d a degree o f symmetry. somewhat t o t h e r i g h t .  F a c t o r 2 i s c l o s e t o a normal d i s t r i b u t i o n but c l u s t e r s F a c t o r s 3 , 5 and 6 a r e 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 t o t h e r i g h t w i t h more extreme v a l u e s t o t h e left.  115  APPENDIX 4 R e l a t i o n of Factors to Professional This section discusses the professional the d i s t r i b u t i o n of f a c t o r s  Attributes  a t t r i b u t e s that account, i n p a r t , f o r  scores.  The d i s t r i b u t i o n o f f a c t o r s c o r e s 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 t o the p r o f e s s i o n a l  attributes.  However some o f t h e v a r i a n c e i n  f a c t o r s 2 , 3 and 4 i s e x p l a i n e d by these a t t r i b u t e s . sionals  The age o f t h e p r o f e s -  c o r r e l a t e s p o s i t i v e l y w i t h f a c t o r 3 (P=.01) but t h e r e l a t i o n w i t h f a c t o r  4 (P=.06) was s p u r i o u s when o t h e r v a r i a b l e s were h e l d c o n s t a n t . age i n d i c a t e s h i g h e r  Table XVII  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  Thus  increasing  advice).  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, y e a r s a t t h e 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 .  Factor  Age  Years a t the Facility  Attitude to Authority  1  .07 p=.67  -.12 p=.46  .11 p=.46  2  -.25 p=.12  -.04 p=.79  .43 p<.01  3  .42 p=.01*  .20 p=.18  • 14 p=.35  4  -.30 p=.06*  -.36 p=.02*  .58 p<.001  5  -.16 p=.32  -.16 p=.29  .04 p=.82  6  -.01 p=.97  .06 p=.68  .24 p=.12  116  Number o f y e a r s e x p e r i e n c e a t t h e 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 t h e fewer y e a r s o f e x p e r i e n c e a t t h e f a c i l i t y ,  h i g h e r t h e s c o r e 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 to a u t h o r i t y i n general 4 (P<.0001).  advice).  years  Thus t h e h i g h e r t h e s c o r e on a t t i t u d e t h e h i g h e r t h e s c o r e s  advice).  (P<.05).  also  profes-  No s i g n i f i c a n t r e l a t i o n was seen between c o u n t r y  o f 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 r e l a t i o n s h i p between f a c t o r s c o r e s  T a b l e XIX  and  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  at the f a c i l i t y  analysis  Attitude  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)  on f a c t o r 2 ( J u d g i n g 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 sional  the  of v a r i a n c e .  of v a r i a n c e (P=.54).  The  and s p e c i a l t y was examined t h r o u g h  one-way  These r e s u l t s a r e p r e s e n t e d i n t h e t a b l e b e l o w .  One-way a n a l y s i s o f v a r i a n c e between f a c t o r s c o r e s and s p e c i a l t y , G . F . S t r o n g and H o l y F a m i l y H o s p i t a l s Combined.  Factor  Specialty Phys. N=ll  (Combined GFS & HFH)  P.T. N=12  O.T. N=10  Nurs. 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  6  .4864  -.1285  .0479  -.4496  P=.96 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 o f t h e v a r i a n c e i n f a c t o r 3 (P<.01) i s a c c o u n t e d f o r by t h e 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 t o be spurious. 117  Division  o f t h e f a c t o r s c o r e s was r e p e a t e d , t h i s t i m e by r e l a t i o n w i t h two  categories of country of t r a i n i n g .  T a b l e XX  One-way  analysis  The t a b l e below p r e s e n t s  these  results.  between f a c t o r s c o r e s and c o u n t r y o f t r a i n i n g  Factor  Country o f T r a i n i n g Combined Canada/UK* N=16  Canada N=24  Probability  1  .1293  -.2344  p=.25  2  -.0755  .1368  p=.44  3  -.0692  .1255  p=.50  4  .1828  -.3314  p= . 0 6 *  5  .0809  -.1465  p=.43  6  -.0397  .0720  p=.69  *this  i n c l u d e s one a l s o from P e r u  F a c t o r 4 (P=.06) was t h e o n l y 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 t o c o u n t r y o f training.  I n t h i s c a s e , t h o s e w i t h combined t r a i n i n g a c c o u n t e d f o r t h e l o w e r  scores. And f i n a l l y , one-way a n a l y s i s facility  showed no s i g n i f i c a n t  o f v a r i a n c e between f a c t o r s c o r e s and  results.  118  

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