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A study of Vancouver-Richmond meals-on-wheels McKinnon, Mona Claire 1985

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A STUDY OF VANCOUVER-RICHMOND MEALS-ON-WHEELS By MONA CLAIRE MCKINNON B.Sc, The University of Manitoba, 1952 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES HEALTH SERVICES PLANNING AND ADMINISTRATION We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1985 (g) Mona Claire McKinnon, 1985 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Health Care and Epidemiology The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date June 18, 1985 A STUDY OF VANCOUVER-RICHMOND MEALS-ON-WHEELS ABSTRACT L i t t l e i s known about Meals-on-Wheels organizations, though they exist in many western countries. The purpose of t h i s study i s to examine the Vancouver-Richmond Meals-on-Wheels service as an organization and from that examination to provide information about c l i e n t s , volunteers, s t a f f , and organizational management. The l i t e r a t u r e was searched for guidance on the concept of Meals-on-Wheels. Was there any d e f i n i t i o n of an i d e a l organization? S i m i l a r l y , discussions with government o f f i c i a l s i n the Province of B r i t i s h Columbia were conducted to determine what they thought t h i s organization might contribute to the province's s o c i a l support services. The prescriptions were vague and i t was found that many assumptions were made. It seemed that organization theory might help to expose the gaps i n these p r e s c r i p t i o n s . An examination of the organization by observation, interviews, use of secondary data for c l i e n t p r o f i l e s , questionnaires for volunteers, and i n t e r -views of present c l i e n t s led to the development of a d e s c r i p t i v e account which was arranged using a model developed by Donabedian to assess the quality of patient care, namely, inputs, process, structure, and outcomes. It became c l e a r that organizational theory might a s s i s t in diagnosis of some managerial problems as the findings showed that c l i e n t turnover was high. Analysis of available data had shown the c l i e n t s to be in the category of "old, o l d , " f a i r l y evenly d i s t r i b u t e d throughout the area, and s e l f - r e f e r r e d . Those volunteers who I i i responded to a questiononaire were long-term, reasonably satisfied, and strongly committed. The clients interviewed were unstinting in their praise for the volunteers and appreciative of the service. They were dissatisfied with certain aspects of the food and their lack of opportunity for input into this aspect of Meals-on-Wheels. The employees found i t d i f f i c u l t to communicate with the investigator and with other important community representatives. Internal and external relationships seemed to be tense. It seemed that by developing a prescription for "best practices" for a Meals-on-Wheels organization working in this context, comparisons of the existing organization with this prescription might assist with the diagnosis of managerial problems and lead to identification of possible remedies. This course was followed. iv TABLE OF CONTENTS PAGE CHAPTER 1: AN OVERVIEW 1 I n t r o d u c t i o n 1 Ques t ions Which Were I n v e s t i g a t e d 3 Reasons f o r S tudying Vancouver-Richmond Meals -on-Wheels 3 P o s s i b l e Uses o f the Study 4 Research Methods 5 O b s e r v a t i o n 5 C l i e n t P r o f i l e 7 V o l u n t e e r Q u e s t i o n n a i r e 7 C l i e n t I n t e r v i e w 7 Review o f the L i t e r a t u r e 8 Development o f Models 8 Chapter O r g a n i z a t i o n 10 CHAPTER 2 : A MODEL OF MEALS-ON-WHEELS ORGANIZATIONS TO FIT THE B . C . CONCEPT 13 I n t r o d u c t i o n 13 L i t e r a t u r e Review 13 N u t r i t i o n f o r the E l d e r l y 13 Geronto logy 15 The E l d e r l y as a H e a l t h Care R e s p o n s i b i l i t y i n B . C . 17 V o l u n t e e r i s m 19 Meals -on-Wheels 23 H i s t o r i c a l Overview 24 O r i g i n s o f Meals -on-Wheels i n England 24 O r i g i n s o f Meals -on-Wheels i n N o r t h America 25 Sponsorsh ip 25 Search f o r a Model 25 E x p e c t a t i o n s o f S t r a t e g i c C o n s t i t u e n c i e s 27 O r i g i n s o f Vancouver-Richmond Meals -on-Wheels 27 Present Sponsorship 28 Long Term Care Program i n B . C . 30 The M i n i s t r y o f H e a l t h ' s Reviews 33 Vancouver H e a l t h Department 33 Richmond Long Term Care 35 PAGE Lack o f a C l e a r Model Known to S t r a t e g i c C o n s t i t u e n c i e s 36 i n B . C . A v a i l a b i l i t y o f Another Source o f Guidance : O r g a n i z a t i o n 37 Theory Inputs 39 Process 39 S t r u c t u r e 40 Outcome 40 CHAPTER 3 : FROM RHETORIC TO REALITY: A DESCRIPTION OF THE VANCOUVER-RICHMOND MEALS-ON-WHEELS ORGANIZATION 41 I n t r o d u c t i o n 41 Inputs 41 C l i e n t s 41 Food 44 V o l u n t e e r s 46 Screeners 46 PWA D r i v e r s 47 A r e a Chairmen 48 Day C a p t a i n s 50 D r i v e r s and S e r v e r s 50 Funding 51 Goals 54 Process 57 C l i e n t s 57 Food 57 Meal Supply 57 Depots 58 V o l u n t e e r R e c r u i t i n g and O r i e n t a t i o n 59 C o n t i n u i t y 60 F inance 60 O f f i c e Procedures 60 Communication 62 Other Procedures 63 Changes i n Process P r e s e n t l y O c c u r r i n g 63 v i PAGE Structure 64 VON Board of Directors 65 Meals-on-Wheels Advisory Committee 65 Director of Vancouver-Richmond VON 65 Coordinator of Vancouver-Richmond Meals-on-Wheels 66 Office Staff 67 Consultants 68 Consultant Dietitian/Nutritionist 68 Consultant Accountant 69 Organization of Work Outside the Head Office 70 Strategic Constituencies 74 Client Pool 75 Volunteer Pool 76 Other Organizations 76 Government Organizations 77 Duplication of Services 79 Outcome 80 Volunteer Meal Output 80 CHAPTER 4: THE VOLUNTEERS' POINT OF VIEW 82 Introduction 82 Method 83 Design 83 Sample 83 Distribution 84 Collection 84 Instrument 84 Coding 85 Analytical Approach 86 Ethics 86 Results and Discussion 87 Degree of Commitment 87 Length of Service 88 Hours worked per month 88 Days worked per week 88 v i i PAGE Reasons f o r V o l u n t e e r i n g 89 L e v e l o f S a t i s f a c t i o n 89 S a t i s f a c t i o n 92 F r u s t r a t i o n s 93 Good f e a t u r e s 93 Improvements Needed 93 Recommendations to o t h e r s to j o i n 94 Type o f t r a i n i n g r e c e i v e d 94 Support from s t a f f 95 Work r e c o g n i t i o n 95 Degree o f t r u s t 96 I n f o r m a t i o n r e c e i v e d 96 L e v e l o f S o c i a l i z a t i o n 97 Minutes spent w i t h c l i e n t s 97 P e r c e i v e d prime f u n c t i o n s 98 Method o f Recrui tment 98 P r i n c i p a l A c t i v i t y 99 P e r c e i v e d Goals o f Meals -on-Wheels 99 Comments 102 A n a l y s i s 102 L i m i t a t i o n s to the Responses 107 G e n e r a l i z a b i l i t y 107 Summary 108 CHAPTER 5 : THE CLIENTS' POINT OF VIEW 109 I n t r o d u c t i o n 109 Method 110 Des ign 110 S amp 1ing 111 Sample s i z e 111 Instrument 112 E t h i c s 113 D i s t r i b u t i o n of Q u e s t i o n n a i r e s 114 I n t e r v i e w s 114 v i i i PAGE Results and Discussion 115 Variety 116 Price 116 Serving size 117 Temperature 118 Appearance 119 Food consumption 119 Food preferences 120 Rating of meals 123 Waiting time for acceptance 123 Socialization with volunteers 124 Change 126 Location 127 Comments 128 Limitations of the Study 131 Generalizability 132 Summary. 132 rER 6: CAN ORGANIZATIONAL THEORY HELP TO PROVIDE A BETTER MODEL OF ORGANIZATION? 134 Introduction 134 Best Practices 136 Inputs 137 Human resources 137 Motivation 137 Materials 138 Financial resources 139 Management systems 139 Goals 139 ix PAGE Process 140 Materials Flow 140 Power 141 Leadership 142 Conflict 143 Groups 144 Communication 144 Change 145 Defense mechanisms 146 Structure 146 Differentiation 147 Integration 148 Balance 148 Controls 149 Outcome 149 Quality of service 150 Commitment 150 Satisfaction 150 Effectiveness 151 Summary 151 CHAPTER 7: A COMPARATIVE ANALYSIS OF ACTUAL PRACTICE AND BEST PRACTICE 152 Introduction 152 Actual Practice 158 Inputs 158 Human resource 158 Motivation 159 Materials 160 Financial resources 160 Management systems 161 Goals 161 X PAGE Process 162 Materials flow 162 Power 162 Leadership 162 Conflict 163 Groups 163 Communication 163 Change 164 Defense mechanisms 164 Structure 164 Differentiation 165 Integration 165 Balance 165 Controls 165 Outcome 166 Quality of service 166 Commitment 166 Satisfaction 167 Effectiveness 167 Summary 168 CHAPTER 8: MAJOR DIFFERENCES IN THEORY AND PRACTICE 169 Major differences 169 Inputs 169 Human resources 169 Materials 170 Financial resources 171 Management systems 171 Goals 171 Process 172 Material flow 172 Power 172 Leadership 172 Conflict 173 Communication 173 Change 174 Defense Mechanisms 174 xi PAGE Structure 174 Integration 175 Outcomes 175 Quality of service 175 Satisfaction 176 Effectiveness 176 CHAPTER 9: A DIAGNOSIS: WHY DIFFERENCES SEEM TO OCCUR 177 Introduction 177 Why Differences Occur 178 Inputs 178 Human Resources 178 Materials 179 Management systems 179 Goals 179 Process 180 Power 180 Leadership 180 Conflict 180 Communication 181 Change 181 Structure 181 Integration 181 Outcomes 182 Quality of service 182 Effectiveness 182 CHAPTER 10: RECOMMENDATIONS TO THE AGENCY 183 Overview of Gordon's Model 183 Inputs 183 Process 184 x i i PAGE Structure 184 Outcomes 185 Pos s i b i l i t i e s for Improvement 185 Inputs 185 Human Resources 185 Materials 186 Finance 187 Goals 188 Process 188 Conflict 188 Structure 189 Outcome 190 CHAPTER 11: FURTHER COMMENTS AND RECOMMENDATIONS 192 Areas Where Theory Needs Improvement 192 Areas for Future Investigation 193 Advantages of Pluralism in Society 193 Questions Answered 195 Summary 199 BIBLIOGRAPHY 200 LIST OF TABLES x i i i LIST OF FIGURES xiv LIST OF APPENDICES xv x i i i LIST OF TABLES PAGE I Frequencies for Each Variable for Past and Present Clients 42 II Indicators of Degree of Commitment 87 III VoLunteer Satisfaction - f i r s t Answers 91 IV Volunteer Satisfaction - second Answers 92 V Prime Function as Perceived by Volunteers 100 VI Volunteers' Goals 101 VII Opinion re Training/Type of Training 104 VIII Cross-Tabulation of Method of Recruitment by 105 Length of Service IX Cross-Tabulation of Prime Function - 1st Answer 105 by Minutes Spent with Each Client X Cross-Tabulation of Hours per Month by Work Recognition 106 XI Descriptive Statistics for Reheating of Food 119 XII Rating of Meals 123 XIII Suggestions for Improvement 126 XIV Comments 128 XV Comparative Analysis 154 xiv LIST OF FIGURES PAGE 1. Organizational Chart as Perceived by VON Director 71 2. O f f i c i a l Organizational Chart, Meals-on-Wheels 72 3. Organizational Chart as Perceived by Task Force 73 4. Organizational Chart as Perceived by Investigator 74 5. Meals-on-Wheels Boundaries 75 6. Organizational Chart for Health Units 78 XV LIST OF APPENDICES PAGE B e h a v i o u r a l Sc iences Screening Committee f o r Research C e r t i f i c a t e of A p p r o v a l 211 L e t t e r o f P e r m i s s i o n from VON 212 A Community Feeding f o r S e n i o r s Task Force Report R e s u l t s 216 B R e c i p i e n t s o f Program, J u l y 1, 1981 - June 30, 1982 219 C Data s u p p l i e d by B . Kaminsky , September, 1982 223 D Methodology f o r C l i e n t Data i n Chapter 3 226 E S c r e e n e r s ' Job D e s c r i p t i o n 233 F D i s t r i c t Chairmen Job D e s c r i p t i o n s 234 G Meals -on-Wheels Monthly F i n a n c i a l Report 235 H Day C a p t a i n s ' Job D e s c r i p t i o n 236 I VON Fact Sheet 237 J VON f o r Canada Statement o f P h i l o s o p h y 240 K Food Order Form 241 L Job D e s c r i p t i o n — Meals -on-Wheels C o o r d i n a t o r 242 M Job D e s c r i p t i o n — Meals -on-Wheels Food S u p e r v i s o r 243 N Map o f D i s t r i c t s 244 0 V o l u n t e e r Q u e s t i o n n a i r e and Accompanying L e t t e r 245 P Coding System f o r Q u e s t i o n n a i r e 249 Q N a t i o n a l Centre on V o l u n t e e r i s m S c o r i n g Method 254 R I n t e r v i e w s w i t h C l i e n t s 256 S I n t e r v i e w Coding 258 T C l i e n t I n t e r v i e w Consent Form 263 xva APPENDICES E, F, H, J , and L NOT FILMED; QUALITY TOO POOR (LEAVES 2 3 3 , 2 3 4 , 2 3 6 , 240 & 2 4 2 ) . CHAPTER 1: AN OVERVIEW Introduction The number of volunteer man-hours of delivery and the paid hours of prepa-ration and administration make Meals-on-Wheels a considerable resource in a community. It appears to f i l l a psychological need for the volunteers (Francies, 1982) and both a psychological and a physiological need for the recipients. Sherwood states, "It is considered that proper nutrition can contribute to prolonging self-sufficiency of many elderly people and enable them to stay in their homes." Poor nutrition in the elderly is a complex subject, including such factors as eating habits, economics, over-medication, reduced metabolism and absorption, dental status, pathological factors, and social and psychological factors such as isolation, diminishing physical and mental a b i l i t i e s , loneliness, and apathy toward food preparation. The general problem underlying this study is that no comprehensive evalua-tion of a Meals-on-Wheels program has been conducted. The literature is fragmented and is concerned primarily with specific problems in individual programs (dimming, 1970; Karlson, 1974). It covers such topics as history, present organization (DHEW Publications, 1971), and specific problems of funding, delivery, and supply (Balanzo, 1980; Jephcott et a l . , 1977). There is ample research on nutrition-related topics (Harrison et a l . , 1982; Turne, 1981; Schlettwein-Gsell, 1971; Davies et a l . , 1981; Boiler & Moot, 1973). There is copious literature concerning volunteer organizations in general. To date the investigator has not been able to locate, by computer search, any literature that deals with the overall functioning of any Meals-on-Wheels organization. - 2 -The lack of information regarding the characteristics of the recipients and the perception of the service by both volunteers and clients make i t d i f f i c u l t to delineate the program. The pressures of increasing size and demand may eventually require changes in scope, funding, and organization. With the aging of the population and the increase in the number of disabled who are able to l i v e r e l a t i v e l y independently, the prospect exists that Meals-on-Wheels w i l l become a larger service, progressively acquiring more cl i e n t s . The scope of the organization may also change to include more categories of individuals (e.g., short-stay post-partum cases, post-day surgery, etc.) Funding should be based on factual data. If i t is determined by future studies that health promotion activities/preventive medicine such as Meals-on-Wheels reduces i n s t i t u t i o n a l i z a t i o n (a very costly and not always desirable form of health care) then funds might be increased for such services as Meals-on-Wheels. Cost-benefit and cost-effectiveness analyses are well defined by many economists (Scheffer & Paringer, 1980). It is not within the scope of this study to determine whether community services reduce i n s t i t u t i o n a l i z a t i o n , but this study may provide a base for future studies of this nature. Need, demand, and want a l l indicate a trend toward increased size. If the size does increase, i t may necessitate organizational change. This study w i l l provide some information on which to base the direction of change. Research data are required on which to base these decisions and also to assess this service for the elderly and the disabled in the community. - 3 -Questions Which Were Investigated The purpose of t h i s t hesis i s to provide information on c l i e n t s and volun-teers and to compare the functioning of Vancouver-Richmond Meals-on-Wheels with best p r a c t i c e s i n o r g a n i z a t i o n a l management theory as i t r e l a t e s to a p a r t i c u l a r c l a s s of volunteer o r g a n i z a t i o n . The s p e c i f i c questions to which answers were sought are: Who are the c l i e n t s ? Have they changed over the years? Are they s a t i s f i e d with the food and the service? Are the volunteers s a t i s f i e d ? How can recruitment of volunteers be increased? How can volunteers be retained? Who are the s t a f f ? Are they a good f i t for the organization and i t s purposes? What are the goals of Vancouver-Richmond Meals-on-Wheels? Do c l i e n t s , volunteers, management, re l a t e d agencies, and government view Meals-on-Wheels d i f f e r e n t l y ? Is i t an e f f e c t i v e organization? How does Meals-on-Wheels compare with recognized o r g a n i z a t i o n a l management theory? Is improvement needed, and i f so, what? Reasons For Studying Vancouver-Richmond Meals-on-Wheels Vancouver-Richmond Meals-on-Wheels i s one of several Meals-on-Wheels organizations s u i t a b l e f o r study and located within a reasonable distance. It was selected because i t i s the largest one in the area and the d i f f i c u l t i e s a r i s i n g out of siz e would be more apparent than in the smaller organizations i n the v i c i n i t y . It i s a t y p i c a l of the majority of Meals-on-Wheels programs in Canada only by s i z e . It appears to be t y p i c a l of Meals-on-Wheels programs in large c i t i e s and of Meals-on-Wheels programs across Canada, in general, in that i t i s sponsored by a philanthropic organization; i t i s only p a r t i a l l y funded (25%) by sources other than payment for the meals by the r e c i p i e n t s ; i t - A -provides a meal service; and i t does not discriminate against those above the poverty line. External constraints imposed on the study caused some limitations. These constraints resulted in the necessity to include anecdotal information in Chapter 3 in order to provide a reasonable basis for the discussion presented in Chapter 7. However, they were not so great as to destroy the efficacy of studying this particular organization. Results could s t i l l be useful to the organization and those who had an interest in i t , and to Meals-on-Wheels organizations generally. Possible Uses of the Study It is argued that: If more knowledge existed about the client, the volunteers, and the orga-nization, this could be advantageous. Meals-on-Wheels could use this knowledge to advantage in providing meals better suited to the tastes of the recipients, for recruiting and keeping volunteers (now a major problem), and for planning. It would be useful in setting goals. The Vancouver-Richmond Meals-on-Wheels is a viable service. No one questions the value of the service, but there is always room for improvement in any organization. Studies such as this one may help the planner dig out the facts, c l a r i f y the values, and develop future expectations. The Vancouver Metropolitan Health Department provides Home Care and Home-maker Service. A clear view of who receives Meals-on-Wheels, and why, would f a c i l i t a t e better planning and might reduce duplication of service. - 5 -The provincial government is in a period of restraint; therefore, knowledge about Meals-on-Wheels would be useful in justifying the allocation of funds to meet Meals-on-Wheels goals. Although the clients had nothing but praise and appreciation for the volun-teers, the volunteers who do the work might find the information in the study useful in better meeting the needs of the clients. "Gray power" is increasing in numbers and strength. This segment of the population is starting to demand answers. Information such as that found in this study may be of assistance to the elderly when planning their future l i f e -styles. Meals-on-Wheels exists in most of the developed countries. Hence, this study may be of international interest among those concerned with the provision of social services in their communities. Research Methods The five methods of research originally intended to be used were: 1. Non-participative observation of the organization, 2. Use of existing data to obtain a profile of the client, 3. Questionnaire for volunteers to determine commitment, satisfaction, future sources, and their perception of the organization, 4 . Interview with the client re: satisfaction with the meals and social contact with the volunteer, 5. Review of the literature. Observ ation The observation was originally intended to be passive. However i t pro-gressed from passive to active and the investigator became a participant - 6 -observer and actually delivered meals. Working as a server, even for a limited time, provided insights that would never have occurred otherwise. The observation in the office remained non-participant for the most part, except for the occasional answering of the phone. The observation at the food production centers progressed to counting completed meals for the PWA drivers. The observation at the depots included washing boxes. The observation of the drivers remained non-participant but the investigator was allowed to act as a server and thereby enter cl i e n t s ' homes and deliver meals. In addition to Meals-on-Wheels organizations, the investigator visited other institutions, and observed and interviewed staff. These included Long Term Care F a c i l i t i e s in Vancouver (e.g., Dogwood Lodge, Carlsbad Private Hospital, Blenheim Lodge), the offices of the Vancouver Health Department, the Richmond Health Unit, the United Way, and the Vancouver Volunteer Center. The generosity of these latter two organizations in allowing unlimited use of their li b r a r i e s was deeply appreciated. Interviews were conducted with a number of people, some only once, some many times. Approximately one-third were structured interviews. The volunteers' names have purposely not been li s t e d because some were reluctant to have their names cited. The literature has provided some information about Meals-on-Wheels programs in other countries (Kewley, 1973; Stuckey, 1984). In addition, the investigator corresponded and obtained information from Meals-on-Wheels programs in England and the United States, and visited a limited number in England and Scotland. She also consulted with the coordinators of the programs in the immediate v i c i n i t y — Burnaby, North Shore, Delta, New Westminster, and North Surrey. - 7 -Client Profile The client profile was based on existing data for 202 past clients and 88 present clients. The existing data contained information on 13 variables. The sample size of present clients (16%) was deemed adequate. The sample size of past recipients was small (3%). This was due to time constraints and lack of information available oh the size of the past client population. Volunteer Questionnaire The questionnaire for the volunteers was intended to determine commitment, satisfaction, degree of socialization with the cl i e n t , perceived prime function, goals of the organization, and needs of the volunteer. Random selection of volunteers was not possible because there was no master l i s t of volunteers. The questionnaires were delivered to the coordinator on January 17th for distribution. Replies were received as late as March 19th, 1985. The collection of these questionnaires was such that i t was not possible to determine the exact number distributed. Therefore, the percentage of questionnaires returned was impossible to determine. Client Interview The client interview was intended to provide information on meal satisfaction and social contact with the volunteers, as well as comments on the overall service. Direct mail tends to result in a small response (less than 35%). This would be expected to be even less in a population who may have d i f f i c u l t y in reading, writing, and mailing. i anticipated. - 8 -Fortunately, the response (51%) was higher than Review of the Literature The literature review included Meals-on-Wheels, volunteerism, and organi-zational management theory. Three other disciplines were also investigated. The raw material of Meals-on-Wheels is food. Nutrition literature provided an understanding of materials flow and outcomes. The history of health care in Canada was included because Meals-on-Wheels provides social support as well as food. To be effective, an organization should know i t s clientele. Gerontology literature was essential to an understanding of the market. The background literature is concentrated on those subjects pertinent to the organization, the volunteer, and the c l i e n t . A more detailed discussion i s presented in Chapter 2. Development of Models Lee and Jones (1933), as quoted in Donabedian (1966), stated that "patient care, like morale, cannot be considered a unitary concept. It seems li k e l y that there w i l l never be a single comprehensive criterion by which to measure the quality of patient care" (p.167). The study began by looking at services to clients and the way in which these were organized. Donabedian's model of input, process, structure, outcome was used in order to sort out the information collected. Donabedian asserts that although outcome is the easiest to measure, i t has severe limitations. He propounds the advantages of either process or structure as a measure. - 9 -Process focuses on appropriateness, completeness, redundancy, coordination and continuity, and acceptability to the patient ( c l i e n t ) . Quality judgments are made on the care provided, the actual care perceived, and the capacity of the providers to provide care. Assessment of structure involves information on f a c i l i t i e s , equipment, organization, f i s c a l policies, and administration. Donabedian suggests three methods for obtaining information: 1. C l i n i c a l records, because of their a v a i l a b i l i t y , accuracy, completeness, veracity, and v a l i d i t y . 2. Direct observation by a qualified person, which has value despite the fact that i t is never free of bias. 3. Study of behaviors and opinions.-He concluded that people are pretty good judges of the effectiveness of their organization. He recognized the limitations of quality assessments in that "best care" for the individual may not be "best care" for the community. Donabedian provided an appropriate model for provision of best patient (client) care by an organization. However, i t was not sufficiently compre-hensive in the area of organizational management best practice. Consequently, i t was necessary to find a model that could be superimposed upon Donabedian's so that the focus could be changed from service to the clients to the functioning of the organization for providing i t . This was done to improve analysis of the data. Gordon provided a comprehensive discussion of theoretical best practice in organizational management. The discussion in chapters 7 and 8 is based on this model. Wherever possible, other authors have been used to substantiate Gordon's - 10 -m o d e l f o r d i a g n o s i s a n d p r e s c r i p t i o n f o r b e t t e r o r g a n i z a t i o n a l m a n a g e m e n t . T h i s h a s b e e n t e m p e r e d by t h e b o u n d e d r a t i o n a l i t i e s o f v o l u n t e e r o r g a n i z a t i o n s w h e r e a p p l i c a b l e . D o n a b e d i a n u s e d i n p u t s , p r o c e s s , s t r u c t u r e , a n d o u t c o m e . G o r d o n u s e d g o a l s , p r o c e s s , s t r u c t u r e , a n d o u t c o m e . T h e t w o m o d e l s a p p e a r e d t o b e c o m p a t i b l e . G o r d o n ' s g o a l s w e r e now d e v e l o p e d i n t o " i n p u t s . " C h a p t e r O r g a n i z a t i o n T h e t h e s i s i s d i v i d e d i n t o e l e v e n c h a p t e r s . C h a p t e r s 1 a n d 2 p r o v i d e an i n t r o d u c t i o n a n d b a c k g r o u n d m a t e r i a l . C h a p t e r s 3 t h r o u g h 5 a r e i n f o r m a t i o n -c o l l e c t i o n c h a p t e r s . T h e y a r e b o t h q u a l i t a t i v e and q u a n t i t a t i v e . R e s u l t s a n d a n a l y s i s o f d a t a a r e i n c l u d e d . T h e y a n s w e r t h e f i r s t s i x q u e s t i o n s ( p . 3 ) . C h a p t e r 6 i s a d i s c u s s i o n o f o r g a n i z a t i o n a l t h e o r y . C h a p t e r 7 i s a c o m p a r i s o n o f b e s t p r a c t i c e s w i t h a c t u a l p r a c t i c e . T h e e i g h t h a n d n i n t h c h a p t e r c o n s i s t o f a d i s c u s s i o n o f m a j o r d i f f e r e n c e s a n d why t h e y o c c u r . C h a p t e r 10 a n d 11 c o n s i s t o f r e c o m m e n d a t i o n s . A m o r e d e t a i l e d d e s c r i p t i o n o f e a c h c h a p t e r f o l l o w s . C h a p t e r 1 i s i n t e n d e d t o be a map f o r t h e r e a d e r . I t d e a l s w i t h t h e r e a s o n s f o r t h e s t u d y ; why V a n c o u v e r - R i c h m o n d M e a l s - o n - W h e e l s was s e l e c t e d . Q u e s t i o n s f o r w h i c h a n s w e r s w e r e s o u g h t , a n d a d e s c r i p t i o n o f t h e r e s e a r c h m e t h o d s u s e d a r e a l s o i n c l u d e d i n t h i s o v e r v i e w . T h e s e c o n d c h a p t e r p r o v i d e s a d i s c u s s i o n o f t h e l i t e r a t u r e a n d b a c k g r o u n d m a t e r i a l o n t h e o r i g i n a n d h i s t o r y o f t h e o r g a n i z a t i o n . T h i s was n e c e s s a r y t o e s t a b l i s h a b a s i s f o r s t r u c t u r e d a n a l y s i s o f V a n c o u v e r - R i c h m o n d M e a l s - o n - W h e e l s . I t a l s o p r o v i d e s i n f o r m a t i o n e s s e n t i a l t o t h e c o m p a r i s o n o f a c t u a l p r a c t i c e w i t h b e s t p r a c t i c e s . I t e x p l a i n s t h e o r g a n i z a t i o n ' s s t a g e o f d e v e l o p m e n t a n d r e l a t i o n s h i p t o i t s e n v i r o n m e n t . I t t h r o w s some l i g h t o n V a n c o u v e r - R i c h m o n d - 11 -Meals-on-Wheels' defensive attitude toward its constellation organizations. It explains the choice of model used in Chapter 3. Donabedian's model of inputs, process, structure, outcome, is used to organize the material in Chapter 3. This information was obtained from observation, interviews, and documents. It was essential to the analysis in later chapters. Chapter 4 is also an information-gathering chapter, with three purposes. It reduces ambiguity about the inputs by the volunteers. It provides data on the processes of meal delivery, socialization with the client, reasons for volunteering, and sources of possible recruitment. The data provides outcomes on commitment and satisfaction. The volunteers' goals and perception of their function are important because volunteers comprise the bulk of the work force. Unfortunately the degree of validity, re l iabi l i ty , and bias, of this information makes this chapter more qualitative than quantitative. Quantitative data is provided in Chapter 5 . It corroborates previous data about volunteer inputs and process, e.g. , type of service. It deals mainly with materials input ( i . e . , food) and outcomes, and provides data for recommendations for Chapter 10. Organizational theory as i t relates to volunteer organizations is contrasted with actual practices in Chapters 6 and 7. Gordon's model of theoretical best practice is used to weave the threads of the story together in these chapters. Major differences between organizational management theory and actual practice in Vancouver-Richmond Meals-on-Wheels are examined in Chapter 8. Chapter 9 is diagnostic. It offers possible reasons why differences occur between theoretical best practice as i t relates to volunteer organizations and actual practice in Vancouver-Richmond Meals-on-Wheels. Chapter 10 contains recommendations; primarily for Vancouver-Richmond Meals-on-Wheels. They offer suggested areas where improvement may be needed. Suggested p o s s i b i l i t i e s for improvement are specific to the organization. Chapter 11 contains further recommendations, areas for possible future investigation, and a short discussion of the advantages of pluralism in our society. Answers to the questions posed in Chapter 1 are summarized. - 13 -CHAPTER 2: A MODEL OF MEALS-ON-WHEELS ORGANIZATIONS TO FIT THE B.C. CONCEPT Introduction What are Meals-on-Wheels organizations expected to do? They exist in many western developed countries and the general impression is that they provide support to the sick and elderly in their own homes. By so doing they may delay or prevent institutionalization. It was decided to begin by reviewing the literature in order to provide a background for the study, to determine whether there was an ideal Meals-on-Wheels organization, br at least a clear concept of Meals-on-Wheels goals. How did such an organization f i t into social support provision generally? Was it expected to provide nutrition primarily or social contact or both? The Literature Review Background reading was concentrated in five major areas: gerontology, history of health care, volunteerism, Meals-on-Wheels, and organizational management. Previous reading in the area of nutrition had been extensive and is summarized here. Nutrition for the Elderly Nutrition for the elderly was originally considered to be no different from that required by al l individuals (children and pregnant and lactating females excepted). Over the years this has gradually changed to an understanding that with reduced caloric intake due to reduced activity and poorer utilization of nutrients ingested, the elderly have specific nutritional needs. Recommended - 14 -protein intake is now 8% over the normal one gram per kilogram of body weight recommended for the general population. Fat intake recommendations are age-specific because, on the average, blood cholesterol and triglycerides increase by 5-10% per decade until after the age of seventy and then drop after the age of eighty. Reduced calcium absorption requires a daily calcium intake of more than a gram per day. Fluid intake is recommended at a minimum of two l i t r e s per day (Hull, 1985), and this at an age when incontinence is increasing. As well as a l l the biological aspects of aging (Baubier 1980; Von Mering 1969, Weiss 1981), there is an increasing awareness of the sociological and psychological factors that affect the older individual. Eating habits are entrenched and are not easily modified (Davies & Purvis 1981). Economics is recognized as a major factor in poor nutrition (Statistics Canada Survey of Consumer Data, 1983). In 1981, the average income for unattached males was $10,900; and for unattached females, $8,800 (Fact Book on Aging in Canada, 1983). Over half the women age 65 and older are widows (No Cause For Rejoicing, 1983). Lack of knowledge of how to obtain the best nutritive value for money spent may be almost as important a factor as low income when attempting to improve the nutrition of the elderly. Medication affects metabolism and absorption at a l l ages. The over-medication of so many elderly people creates a severe nutrition problem. Reduced metabolism and absorption exist for many reasons. There is a decrease in hydrochloric acid and digestive enzymes, the volume of gastric juice secreted, and the concentration of pepsin. Production of pancreatic enzymes such as amylase and protease is lower. Intestinal muscles and mucous membranes deteriorate. It is estimated that metabolism is slowed by as much as 30% after - 15 -the age of seventy due to diminished c e l l function, blood circulation, and heart flow (Davidson et a l . , 1979). Dental status is an important factor in nutrition at any age. As dental status declines, food intake either lessens or becomes less nutritious as easily chewed carbohydrates replace meat, f r u i t , and vegetables. Sociological and psychological factors such as isolation, loneliness, and apathy take their t o l l on food preparation and nutritive intake. One half of women over the age of 65 are widows and 10% have never married or are divorced. 80% of women over the age of 85 are widows (Task Force on Older Women in Canada, 1983). Physical impairment ( e . g . v i s u a l , hearing) contribute to social isolation and hence to the poor nutrition that results from isolation. Formal nutritional assessment of the elderly may be unwelcome, but a quick inventory of the food in the kitchen by an experienced nutritionist would provide a great deal of information on the dietary habits of the individual. A quick rule of thumb is that less than three cooking utensils indicates poor nutrition. Gerontology There is ample literature from which to select in the fi e l d of gerontology. Areas perused were anthropology, sociology, and social issues as they relate to gerontology. Anthropological literature was used in the hope of finding some common factor in aging that might be applicable to a l l the cultures where Meals-on-Wheels exists. - 16 -Weiss (1981), Amos and Harrell (1981), Cowgill and Homes (1972), Fry (1980), Hochschild (1973), and Myerhoff (1978), provided an anthropological approach to gerontology that encompassed the panhuman, the evolutionary, and the comparative. If there are any generalizations to be gleaned from anthropological gerontology i t is that old men want power and authority and old women want their own domain of power in the form of their own cooking hearths. Thus, Meals-on-Wheels is a viable concept in i t s attempt to provide acceptable assistance in keeping individuals in their own homes. Sociological literature was examined in search of factors that are considered to contribute to the quality of l i f e in the elderly. Hendricks and Henricks (1977), Atchley and Seltzer (1976), Whitbourne and Weinstock (1978), Marshall (1980), and Dowd (1980) provide sociological and social-psychological approaches to the subject of gerontology. The most important factor in l i f e satisfaction for the elderly would appear to be rate and degree of change (Palmore, 1981). Again the value of acceptable alternatives to institutionalization is readily apparent. Social issues literature, as i t relates to gerontology, was searched to find a description of the situation as i t exists in Canada today. Canada has the highest rate (7.7%) of institutionalization of the old. Most developed countries have a rate slightly in excess of 4%. These figures are misleading because there is no breakdown of the st a t i s t i c s by age group. In B.C., less than 4% of those 65-69, but nearly 45% of those over 90, are in institutions (Annual Report, Ministry of Health, Province of B.C. 1981, 1982). Levi (1983), Dulude (1978), Thompson and Thomas (1983), the Canadian Senate Report of 1979 (1979), the New Democratic Party Task Force Report (1983), - 17 -National Advisory Council on Aging Report (1983), Second Canadian Conference on Aging (1983), and the Canadian Government Report on Aging (1982) draw attention to the relative aging of the Canadian population, the isolation, loneliness, health, and other social and psychological problems of people in their later years. There is an increasing demand by the elderly for provision of services they want, not what others perceive them to need (Marshall, 1980). The Elderly as a Health Care Responsibility in B.C. At the time of Canada's inception, the care of the elderly was the respon-s i b i l i t y of the family. The neighbourhood community and the church provided the safety net for those without family. By the turn of the century, Canada had most of the philanthropic organizations that existed in the United Kingdom with only a fraction of the population. Along with these, most Canadian towns and c i t i e s boasted an assortment of religious denominations and fraternal organi-zations. What legislation existed followed the British philosophy of the Elizabethan Poor Laws. The status of older persons in society is related to the value of their contribution and their numbers in relation to the rest of the population. With technological advancement, the old are no longer as essential to the survival of society. The percentage of the population over 65 has increased rapidly. It is estimated that by the year 2001 more than 12% of the population of Canada w i l l be 65 years of age and older. By 2001 that figure will have risen to 16.8% (Fact Book on Aging in Canada, 1983). McKeown (1975) attributes this to behavioural influences (decreased infant mortality and hence decreased birth - 18 -rate due to changes in reproductive practices) and environmental influences (better nutrition and removal of environmental hazards). There is ample literature from which to select material on health care in Canada. Taylor (1978), Meilicke and Storch (1980), Van Loon (1980), Health and Welfare Canada Annual Report (1980-81), and Crichton (1981) show the evolution of health care in Canada and demonstrate that although health care and social services have not yet been entirely integrated, the trend towards this integration does exist. Services for the elderly are very medically orientated in B.C. In 1980-81, the Province of B.C. spent $1,764.7 million on Hospital Programs, Medical Services Commission, and direct care; and $150.8 million, on "other" health services. Of this, only $39.7 million or 2.07% was spent on preventive services (Ministry of Health Annual Report, 1981). In 1982-83, 44% of hospital days were used by patients 65 years old and older (Home Care/Long Term Care, 1983). Health insurance in Canada evolved in such a manner that hospital care was insured by the government before physician care. When the federal government put the last matching grant program in place (Medical Care Act, 1966), questions about the effect of the programs began to surface. There i s a bias towards illness care in institutions. Since 1969, (Task Force on the Cost of Health Services, 1969) efforts have been made to turn the system around. One effort has been concerned with health promotion, another with improving outpatient care. Laframboise (1973) lai d the foundation for the Lalonde Report (1974), which proposed prevention in four areas: l i f e s t y l e , environment, health care, and human biology. The Foulkes Report (1974) also stressed prevention. - 19 -The public is showing increasing concern for preventive medicine as evidenced by participation in keep-fit programs, the proliferation of weight reduction businesses, anti-smoking by-laws, sale of air and water purifiers, demand for s t r i c t e r enforcement of air pollution laws and regulations, and to some extent, citizens' committees against water pollution from sewage. Block grants and capitation for extended care focussed attention on development of Long Term Care programs, which were as concerned with out of hospital care as institutional services. The Ministry of Health established the Long Term Care Program in B.C. in 1978. It was intended to provide support to assist individuals to remain in their own familiar surroundings as long as possible. Placement in a residential f a c i l i t y was provided when this was no longer possible. The goal was to delay or prevent institutionalization. The demand that materialized for these services far outstripped the government's expectations. The need for Long Term Care, like the need for Meals-on-Wheels, caused both services to grow rapidly. Meals-on-Wheels "need" is more in the nature of demand because the client pays for a larger percentage of the service. Another major difference is that Meals-on-Wheels is a volunteer organization. Supply is limited by the number of volunteers available for this service. Meals-on-Wheels is regarded by the government as suitable for operation by volunteers. Therefore, a view of the volunteer literatured seemed appropriate. Volunteerism Volunteerism is well covered in the literature. There are on general volunteerism, "how to" literature, specific problems books and papers of volunteerism, - 20 -characteristics of voLunteers, history analysis and trends in volunteer organi-zations, assessment techniques, and p o l i t i c a l and sociological works. The Volunteer Readership Catalog 1984-85 (The National Center, Arlington, Virginia 1985) i s a good bibliography which covers topics of volunteer management, fund-raising, management and organization, board development, issues, trends, philosophy, and personal development. This catalog contains numerous works on church volunteers, volunteers for children, and volunteers for the handicapped. There is a dearth of literature on Meals-on-Wheels volunteers. The literature on specific problems in volunteerism include volunteer needs, motivation, and turnover (Francies, 1983) and client satisfaction (Parkum, 1982; Davis, 1983). The characteristics of Canadian volunteers are well documented by Anderson and Moore (1974) and by Carter (1975). They are primarily people who have worked in a paying position (89%); 39% are s t i l l working full-time. They are better educated than the average Canadian. Their average length of volunteerism in the present agencies is 3 1/2 years. Cities between 100,000 and 500,000 produce a larger percentage of volunteers than small towns. The average number of hours devoted to volunteer work varies from less than 4 hours per week (44%) to more than 80 hours per month (6%); the median is 1/2 day per week. Over 50% of Canadians are active volunteers, 44.7% of these volunteers are men. 56% have been involved for more than 7 years. The most frequent motive is a mixture of altruism and self-interest. The most frequent channels of entry into volunteer-ism are church, youth work, and fundraising. Participation by youth, especially young males, is increasing. No longer can volunteering be condescendingly - 21 -viewed as an activity of the bored upper-middle-class housewife with time on her hands and a zealous desire to do good. History, analysis, trends, and the future of volunteer organizations are perhaps best dealt with by such classics as the reports by Lord Eeveridge (1948) and Lord Wolfenden (1978). The Beveridge study categorizes volunteer action into mutual aid societies and philanthropic organizations. It expounds on the need for continued philanthropic volunteer organizations, their unique charac-t e r i s t i c s , and the value of them for the future. The Wolfenden study deals with the relationships between voluntary organizations and other systems of meeting social need - informal, statutory, and governmental. It strongly recommends pluralism for both the present and the future, that is the principle that the state and the voluntary sector should be partners. It envisions trends toward the informal (family, friends, neighbours) as changing but not diminishing; the statutory (pressure groups, complementary, and sole provider) as increasing but possibly decentralizing; the commercial, increasing; and the volunteer segment growing, becoming more specialized, more secular than evangelistic, and more ethnic. Authors who deal with trends in Canada (Bellamy & Wells, 1974; Carter, 1974) foresee changes in government funding, board .structures, increased admini-strative staffing, improved channels of communication, and better decision-making with the beginning of priority setting. Assessment techniques for volunteers are general in nature but much is applicable to Meals-on-Wheels. Bellamy and Wells (1974) provide questionnaires for the organization and for the volunteers re: the organization. The British Columbia Dietitians' and Nutritionists' Association has developed audit tools - 22 -for quality assurance in food service in the areas of food safety, time and temperature audit, tray audit and a meal service acceptance questionnaire. These tools are used to measure outcomes, not process. They are effective in identifying problems in food service. Reigel and M i l l e r have developed an extensive questionnaire for volunteer organizations. It includes questionnaires for the coordinator, the staff, and the volunteer. The accompanying scorecards ensure r e l i a b i l i t y of data. Not a l l questions are applicable to Meals-on-Wheels. No discussion of the literature would be complete without at least one example of p o l i t i c a l and/or sociological viewpoint on volunteerism. Piven and Cloward (1971) claim that relief-giving i s c y c l i c a l and not due to altruism or social conscience. They state that relief-giving arises from the need to stem p o l i t i c a l disorder during periods of mass unemployment and to enforce low-wage work during periods of economic and p o l i t i c a l s t a b i l i t y . They regard i t not as a charity but as a means of regulating the poor and preserving the class system. Cumming (1968) examines the sociology of volunteer organization. She defines support as having the diffusely positive quality of encouragement or reward; and control, as always having at least the overtones of punishment. She argues that the client is in control when the organization seeks the cl i e n t , and the client pays a fee; and that the agency is in control when the client is seeking something scarce and/or supplying a specialized service not available elsewhere. Meals-on-Wheels seeks to approach symmetry of control between client and agent, a desirable state. It is supportive more than controlling and, - 23 -therefore, there i s no loss of individuality. Control of in-referral is becoming more limited. There is l i t t l e or no control of out-referral ( i . e . , Meals-on-Wheels is not a sorting and screening agency). Cumming (1968) c l a s s i f i e s Meals-on-Wheels as "a client-oriented protective-controlling agency although they f a l l somewhere between a social service and a business, depending upon the fees charged" (p. 192). Meals-on-Wheels Although these kinds of questions were raised by Cummings (1968) in the volunteer literature, they do not seem to have been picked up in the Meals-on-Wheels literature. A computer search of the literature did not provide any overall view of Meals-on-Wheels programs. The literature on Meals-on-Wheels did not net much pertinent information. A Demonstration Project of Developing New Options in Home Delivered Meals (Posner et a l . , 1983) was interesting but did not provide much insight into the operation of a functioning Meals-on-Wheels organization. Evaluation of Disinfectants in the Domestic Environment Under In Use Conditions (Scott et a l . , 1984) dealt with one specific problem. Nutrition and Catering:  Some Options in the Delivery of Meals-on-Wheels (Armstrong, 1984) was more applicable to Great Britain. A Longitudinal Study (Davies & Purves, 1981) provided insight into nutritional surveys for both men and women, but again i t did not address the answers to: How does a Meals-on-wheels operate? Who does it serve? Is i t meeting the needs of the recipients? Is i t meeting the needs of the volunteers? - 24 -Vancouver-Richmond Meals-on-Wheels has a very limited library. The most recent book on the development of volunteer activities is The Royal Commission  on Health Services (1965). There are however, numerous pamphlets for volunteers. The lack of questioning of goals of Meals-on-Wheels meant that there was no examination of the assumptions that exist about its activities. There was no prescription here against which Vancouver-Richmond Meals-on-Wheels could be measured. These were questions which one might have hoped to have answered or at least it was thought that an historical overview of Meals-on-Wheels might provide insight into the reasons for present organizational management practice and structure and perhaps a model might be found. Historical Overview Origin of Meals-on-Wheels in England Meals-on-Wheels began in England in 1905 as "the delivery by community volunteers of nutritious meals to the homes of elderly, blind, and disabled persons." It was known as the Invalids' Kitchens of London. The program remained small in scope until the late 1930*s. At this time the Women's Voluntary Service began to deliver meals to invalids and others who could not prepare meals themselves. It mushroomed in size. During the Second World War it became a means of providing nutrition to the thousands who had lost their means of preparing meals. At some time during this period of growth it became known as "Meals-on-Wheels." The program spread throughout Britain and Europe. Today, Meals-on-Wheels programs are operated in Australia, Canada, England, Denmark, Germany, New Zealand, Norway, Scotland, Switzerland, Wales, and the - 25 -U n i t e d S t a t e s . I t was n e a r l y f i f t y years before North America fol lowed t h i s t r e n d . Most of these programs e x i s t as independent o r g a n i z a t i o n s without a f f i l i a t i o n . O r i g i n s of Meals-on-Wheels i n North America The f i r s t s e r v i c e i n North America began i n 1954 in P h i l a d e l p h i a and grew to s i x t e e n such s e r v i c e s i n the U n i t e d States by 1965. The f i r s t M e a l s - o n -Wheels i n Canada was s t a r t e d i n B r a n t f o r d , O n t a r i o i n 1963. In 1966, Saanich became the f i r s t community to i n i t i a t e the s e r v i c e i n B . C . By 1979, there were 55 separate Meals-on-Wheels o r g a n i z a t i o n s i n the Province of B r i t i s h Columbia (McNamara, 1979). These o r g a n i z a t i o n s were sponsored by almost as many groups. Sponsorship The o r i g i n a t o r s of the s e r v i c e were such d i v e r s e groups as c h a r i t a b l e o r g a n i z a t i o n s , s e r v i c e c l u b s , r e l i g i o u s b o d i e s , and governments. M e a l s - o n -Wheels i s sponsored by a v a r i e t y of o r g a n i z a t i o n s . In B . C . these i n c l u d e Long Term C a r e , the c i t y , the ""community, the U n i t e d Way, the Red C r o s s , one h o s p i t a l , t h r i f t shops, the U n i t e d Church of Canada, and such s e r v i c e o r i e n t a t e d o r g a n i z a t i o n s as Rotary , L i o n s ' , Women's I n s t i t u t e , V i c t o r i a n Order of Nurses , S o r o p t i m i s t s , K i w a n i s , and the I . O . O . E . Search f o r a Model Is there a problem of n o u r i s h i n g some e l d e r l y i n western s o c i e t i e s which they cannot so lve themselves? In summary, the l i t e r a t u r e r e v e a l s that good n u t r i t i o n i s c r u c i a l to good h e a l t h . I n s u f f i c i e n t s o c i a l support c o n t r i b u t e s to poor nutrition. Therefore, i t can be assumed that Meals-on-Wheels delays or prevents institutionalization by improving nutrition and providing social support. The Literature does not provide an answer to which one of these is more important. Research in Chapters 4 and 5 may provide some insight. Possibly the views of the clients, the volunteers, and the government may not coincide. If the service is needed, how should i t be provided? The literature revealed that quality of l i f e in the elderly is greatly enhanced by reducing rate and degree of change. People are happiest when l i v i n g in their own homes. Documentation is sparse, but i f Meals-on-Wheels is assumed to prevent institutionalization, then i t is needed to enhance quality of l i f e s t y l e . Pluralism is accepted in western societies. Volunteer organizations have unique characteristics which make them a valuable part of society. The government encourages volunteerism by providing grants to many volunteer organizations. Canadians are willing volunteers. Individual attention to personal circumstances can best be provided by volunteers. Therefore, i t would seem logical that this type of support service be provided by the volunteer sector. What are the goals of Meals-on-Wheels? They are presumed to be to provide food, improve nutrition, supplement social support, and prevent i n s t u t i o n a l i -zation. They are also assumed to enhance quality of l i f e . The goals were not clearly stated. What is the best model of Meals-on-Wheels organization? What type of organization should sponsor i t ? Who should supply the food? There did not appear to be any correlation between quality of service nor effectiveness of the - 27 -organization and either sponsor or supplier. A prescriptive model for type of sponsorship and source of food supply was not found. Expectations of Strategic Constituencies As a next step i t was decided to review the expectations of Vancouver-Richmond Meals-on-Wheels held by important judges of i t s work in the Province of British Columbia. These were: i t s sponsorship body, the VON; the Long Term Care Program in B.C.; the Ministry of Health of B.C.; the Vancouver Public Health Service; and, the Richmond Long Term Care Service. Before doing so, however, i t seemed important to examine i t s origins. Origins of Vancouver-Richmond Meals-on-Wheels Vancouver-Richmond Meals-on-Wheels had i t s origins in a 1967 centennial project. A survey to determine the need for the service was undertaken. The pilot project began i t s operation on February 16, 1968 when volunteers delivered 5 meals in Kitsilano. The meals were obtained from Carlsbad Private Hospital. The cost to the recipient was 60 cents. The Dunbar-Point Grey Meals-on-Wheels, which began on November 4, 1968 with the delivery of 6 meals, was supplied by Deans Restaurant. On November 11, 1968 the West End Meals-on-Wheels commenced service. Kerrisdale Meals-on-Wheels followed shortly in March of 1969. Richmond and Marpole Meals- on-Wheels came into existence in November of 1969. By the end of 1970, twelve independent Meals-on-Wheels organizations were operating in the area. The Burrard chapter was established in 1973 to reduce the pressure on Strathcona and the West End, thus bringing the number of chapters to the present 13. - 28 -In January, 1969 a steering committee was set up to study the f e a s i b i l i t y of a single coordinated Meals-on-Wheels organization for Vancouver and Richmond. The VON was approached and requested to accept responsibility for administering the program. This had numerous advantages — VON had experience with home care, housing both v i s i t i n g nurse service and Meals-on-Wheels under one roof was expected to be advantageous, space was available in the VON offices, and i t did not necessitate establishing a separate new agency. The agency agreed to a 16-month demonstration project. At that time, a committee was farmed from representatives from the Health Department and from the Lower Mainland. The main constraint was the number of volunteers who served on this Advisory Committee who were opposed to change. Discussion occurred as to the advisability of integrating Meals-on-Wheels with the health care system and the possible risk of loss of feelings of commitment on the part of those who are in contact with the recipient. The VON, at that time, was providing home care and day care and i t was expected to continue with these services — participation with Meals-on-Wheels was expected to be nearly n i l . On January 1, 1972, Meals-on-Wheels in Vancouver and Richmond became a permanent VON service. By 1972 most chapters had undergone the change from three to five days per week delivery. Since the inception of the coordinated program there have been four coordinators. Present Sponsorship Vancouver-Richmond Meals-on-Wheels is under the auspices of the Vancouver-Richmond Victorian Order of Nurses. In order to understand how this came about, i t would be helpful to understand the history of the sponsoring body. - 29 -The Victorian Order of Nurses has a history of originating demonstration projects in the health care f i e l d . These projects have met a real need. Most have been legitimized by governments — federal, provincial, or municipal. The purpose of the organization is to expand the work of the Order into new fields where no medical or nursing f a c i l i t i e s are available to the sick, poor, and to care for current d e f i c i t s . It must be remembered that health care in Canada l e f t a great deal to be desired, even as late as the middle of the twentieth century (Taylor, 1979). VON was founded in 1897 in Ontario (Gibbon, 1947) as a d i s t r i c t v i s i t i n g nurse service. Within five years i t began funding cottage hospitals for the North West Territories and wherever else they were needed. In 1908 i t founded the Grenfell Mission in Labrador. It provided assistance in the influenza epidemic of 1918-19 and the Halifax disaster during World War II. It has been a pioneer in conducting surveys and in the preparation of advisory papers on nursing. By 1939 there were 90 branches with 354 nurses and one d i s t r i c t superintendent for each 15 branches in Canada. It is a philanthropic organization. Funding has traditionally been by fund raising. In 1921 the Red Cross donated $50,000.00. The central office of the VON is located in Ottawa. Traditionally, the presidents have been men; the honorary presidents, the wives of the Governors General; and, the superintendents, female nurses. The organization has undergone a power struggle not unlike that which Meals-on-Wheels is undergoing at the present time. In 1930, Dr. Grant Flemming's recommendations included the following: - 30 -"The National Organization is made up of the Local Associations: i t cannot control the local organizations without their consent. If the Local Organizations would view the p o s s i b i l i t i e s of the Order, they would see the need for placing more power in their own National Office." (Gibbons 1947, p. 94). The structure of the organization changed slowly until i t assumed i t s present format with a Regional Director for each province. There are 79 branches at present. The Regional Director in each province i s part of the national office staff. In addition, the president of the Board of Directors is also a member of the National Office Board of Directors. The situation of the VON in B.C. is different from that of other provinces in that the B.C. Long Term Care Plan, which came into being in 1978, usurped the original function of the VON - home nursing care. At this time, the provincial government commenced provision of both institutional services for the elderly (personal, intermediate, and extended care f a c i l i t i e s ) and in-home services to maintain the elderly in their own homes. This latter included both health care support, provided by nurses and therapists, and general home li v i n g support, which includes Homemaker and Housekeeping Service. VON's v i s i t i n g nurse service had been legitimized. Long Term Care Program in B.C. Long Term Care i s a constellation group of both VON and Meals-on-Wheels. The Long Term Care Program was established by the Provincial Government on January 1, 1978. It was intended to supplement the support provided by family and friends by providing services and care for those who cannot live independ-ently without help. The primary aim is to allow people to remain in their own homes, among their families, for as long as possible. Placement in a residen-t i a l f a c i l i t y is provided when this is no longer possible. It is available to any individual in B.C. over the age of 18 who needs i t . A Citizen's Guide to Long Term Care in B.C. states: The government created this program with the following intentions: a) to make services available to persons who want to live at home but need help to do so b) to supply basic services and care with an emphasis on health need c) to improve the quality of services and f a c i l i t i e s d) to coordinate many of the previously separate services." (Berman, 1981, p. 4) Care can be provided in the recipient's home, in a residential f a c i l i t y , or in an extended care hospital. Services provided in the home are three in number: home care, homemaker services, and handyman service. Home Care is provided on the referral of a physician, by nurses, physiotherapists, occupational and rehabilitation therapists, and speech therapists. There is no charge for home care. Homemaker Service provides assistance with bathing, grooming, cooking, laundry, housecleaning, shopping, and general hygiene. Handyman Services, although not available in a l l parts of B.C., provides services such as garden maintenance, minor repairs, and window-washing. Recipients must f i r s t be assessed to determine need for both homemaker and handyman services. There is no user charge for Homemaker Service providing the recipient's income does not exceed a certain level ($395 per month in 1981), or i f the recipient i s already receiving G.I.S. (Guaranteed Income Supplement), G.A.I.N. (Guaranteed Available Income for Need), or War Veteran's Allowance. A l l others are assessed charges according to a b i l i t y to pay. Charges are - 32 -related to family income. They are calculated by a rather loose formula with room for discretional judgment. A Citizen's Guide to Long Term Care also states: Some of these do not come directly under the Long Term Care Program at this time, but are important in enabling families or individuals to live independently-. Meals-on-Wheels which deliver complete hot meals regularly. Telephone contacts, Red Cross (free) Loan Service, Kinsmen Rehabilitation Service, Friendly Visitation services. (Berman, 1981, p.7) Other community services provided in certain locations included stroke clubs, day care centers for adults, senior citizen counsellors, mobile library service, senior centres, special transportation, and New Horizons projects for seniors. The scope of this government undertaking can be illu s t r a t e d by the 1982-83 expenditures which were $394,000,000 for 25,290 clients in the three types of institutions and $80,000,000 for 78,000 clients in the home support services (HC/LTC Division, 1983). This represents an outlay of $15,580 per client and $1,025 per clie n t , respectively. These figures do not include a l l the other inputs provided by the government and/or the private sector such as the fee charged to the residents of these institutions, income supplements (GAIN, GIS, SAFER), pharmacare, transportation subsidies, Meals-on-Wheels, Red Cross sick-room loan services, reduced prices for banking, theatres, haircuts, etc., and the entire safety net for those over 65. Although Meals-on-Wheels is not under the Long Term Care umbrella, i t does receive grants from both provincial and municipal governments. Both regard i t as an important aid to maintaining the elderly in their own homes. - 33 -The Ministry of Health's Reviews In 1979 the Ministry of Health of the Province of B.C. published a book entitled Long Term Care Meals on Wheels (McNamara, 1979). It provides a history of the formation of each of the Meals-on-Wheels organizations in the province along with the name and address of each coordinator. There are only three pages of data. These provide the name of the program, the year started, the number of meals delivered in 1978, the number of days per week the service operated, the cost per meal charged to the cl i e n t , the source of the funding, the number of volunteers, and the number of paid staff. Information i s missing in one of these categories for 13 programs. There i s no compilation of the data. There is no analysis of the data. Vancouver Health Department The Community Feeding for Seniors Task Force Report (Jones, 1981) is a study of the amount and type of food-related services available by health d i s t r i c t . It shows a breakdown by health d i s t r i c t s into approximate number of Meals-on-Wheels delivered, delivery of Meals-on-Wheels to people in seniors' buildings, seniors' building meal programs, adult day care centers, Long Term Care f a c i l i t i e s , stroke clubs, shopping, transportation, organizations, community centers, and senior residences/apartments with potential for congregate meal program investigation. The figures pertaining to Meals-on-Wheels are organized in such a manner that there is considerable overlap. If a Meals-on-Wheels d i s t r i c t is even partially located within the health d i s t r i c t i t is l i s t e d . Most Meals-on-Wheels d i s t r i c t s are mentioned more than once. - 34 -Although this report offers recommendations, i t is not concerned solely with Meals-on-Wheels. It is primarily a catalogue of food related services by health d i s t r i c t s . (Appendix A) Five years ago, the head Dietitian/Nutritionist for the city of Vancouver, attempted to do a nutritional status study of Meals-on-Wheels recipients but was not allowed to select the sample randomly. The sample recipients were selected for her by Meals-on-Wheels, thus invalidating the study and resulting in i t s abandonment. A former coordinator of Meals-on-Wheels compiled s t a t i s t i c s on the source of referrals in 1982, in a report entitled, Recipients of Program from July 1,  1981 to June 30, 1982 (Appendix B). This appears to include only two d i s t r i c t s - Kitsilano and Kerrisdale. More may exist but were not available. There are 115 clients included in this study. The information includes name, address, source of referral under three categories, and whether clients are receiving Home Care and Services and/or Homemaker Service. There i s no summation of the results, but a simple tabulation reveals: Referred by self Referred by family, friends and others Referred by LTC 37 6"5 12 32.17% 57.39% 10.44% Receiving Home Care Receiving Homemaker Services 5 6 4.34% 5.21% - 35 -Richmond Long Term Care The Administrator of Richmond Long Term Care provided a set of figures (Appendix C) compiled in September of 1982 which show the following for each Meals-on-Wheels organization in the province: number of days per week average number of meals per month number of volunteers 1981-82 average number of persons served per month projected number of meals 1981-82 1981-82 subsidy per meal actual number of meals 1981-82 1981- 82 subsidy projected number of meals 1982-83 1982- 83 requested subsidy 1982-83 recommended subsidy 1982-83 subsidy per meal provides to Home Care There is no compilation of the data and no s t a t i s t i c a l analysis. Tabula-tion shows 42 programs. The subsidy received varies from 28 cents in Nanaimo to $1.00 in James Bay Community School Society. Duncan and Hope did not receive subsidies. The mean subsidy was 58.7 cents (55 cents, i f Duncan and Hope are included) as compared with Vancouver-Richmond's subsidy of 59 cents. The ratio of meals served to volunteers has l i t t l e significance for compar-ison because the number of volunteers i s the total who worked during the entire year. It is not corrected for turnover. A Plan for Long Term Care Services (Kaminsky, 1983) states, "There is no formal planning link between the Meals-on-Wheels program and Long Term Care and detailed s t a t i s t i c s are not available regarding Meals-on-Wheels u t i l i z a t i o n patterns in the province"(p.17). The data provided in this report are as follows: Richmond Long Term Care Meals-on-Wheels U t i l i z a t i o n Statistics for the Month of July, 1982 Total number of Meals-on-Wheels recipients 57 Number of Meal3-on-Wheels recipients who were LTC Assessed 44 Number of Meals-on-Wheels recipients who were LTC Assessed and receiving Homemaker Service 43 Age Distribution of Meals-on-Wheels Recipients Who are LTC Assessed Age Number of clients Richmond 1981 Population U t i l i z a t i o n Rate Under 65 years 3 89,254 65-74 years 9 4,855 0.19% 75-84 years 16 1,790 0.89% 85+ years 16 475 3.37% TOTAL 44 96,374 0.62% The only available data pertaining to Meals-on-Wheels is the Richmond Long  Term Care Home Support Survey by Sharon Brothers and Pauline Mullaney in April 1980. It states that Meals-on-Wheels service was requested by 10.1% of the respondents, while 6.7% were receiving i t . Lack of a Clear Model Known to Strategic Constituencies in B.C. A l l of the above reports are suited to the purpose for which they were designed. However they do not provide any data on the volunteers and only minimal data on the recipients. There is no profile of the recipients a v a i l -able; nor has there been any attempt to determine what Meals-on-Wheels clients want. There has been no evaluation attempted of either process or outcome. - 37 -Some of the long-term area chairmen and former coordinator made reference to the existence of such documents as "Draft of Constitution", "Terms of Reference", and "Meals-on-Wheels Policies and Procedures". Neither the Meals-on-Wheels coordinator, the VON director, nor the consultant accountant had any knowledge of their existence. The accountant suggested that i f any did exist they would probably be so outdated as to be of l i t t l e or no value. Av a i l a b i l i t y of Another Source of Guidance: Organization Theory Organizational literature that is specific to Meals-on-Wheels is primarily of the "how to" variety. There is literature on how various organizations have coped with specific problems (Balzano, 1980; Ranii, 1980; Henderson, 1979; Bild & Havighurst, 1976). The organizational management literature on volunteer organizations is primarily how to start and how to operate volunteer organizations (Volunteer Readership Catalog 1984-85, 1985). Organizational theory was consulted as another source that might provide insight into Meals-on-Wheels. A lifetime would not be sufficient to read the available literature on organizational management in general. This review en-compasses only that which i s relevant to Meals-on-Wheels in the B.C. context. Szilagyi (1981) is a comprehensive basic text. Mintzberg (1979) views the orga-nization as a paradigm and offers analysis of the factors that determine the structure of organizations. Culbert and McDonough (1980) provide a very sensi-tive discussion on the degree of alignment between the individual and the organization. Perrow (1963) analyzes power structures and postulates that an organization w i l l be controlled by those individuals or groups who perform the most d i f f i c u l t - 38 -and c r i t i c a l t a s k s . E t z i o n i (1974) a l so v i e w s o r g a n i z a t i o n s as power s t r u c -t u r e s . Wie ld ing a u t h o r i t y does not ensure compl iance . Power can be l e g i t i m a t e o r n o n - l e g i t i m a t e . Power can be c o e r c i v e , r e m u n e r a t i v e , o r n o r m a t i v e . Bacharh and L a w l e r (1980) v i e w power from the b a s i s o f i n t e r n a l p o l i t i c s . T h e o r i e s o f o r g a n i z a t i o n abound. P f e f f e r (1982) equates o r g a n i z a t i o n a l theory w i t h o r g a n i z a t i o n a l b e h a v i o u r . He s t a t e s that o r g a n i z a t i o n a l theory i s not too w e l l d e v e l o p e d . Some are h o l i s t i c , some g i v e a t t e n t i o n to o n l y a part o f the whole ( e . g . r o l e t h e o r y ) . He c a t e g o r i z e s o r g a n i z a t i o n a l theory i n t o s i x main types w i t h s u b - c a t e g o r i e s i n each t y p e , w i t h examples and r e f e r e n c e s . T o s i (1975) d i v i d e s o r g a n i z a t i o n a l theory i n t o two types — the s u b d i v i s i o n o f work and work r e l a t i o n s h i p s i n t o manageable u n i t s and the examinat ion and a n a l y s i s o f complex s t r u c t u r a l behaviour systems. He d i v i d e s the c h a r a c t e r i s -t i c s o f an o r g a n i z a t i o n i n t o s i z e , f o r m a l i z a t i o n , r a t i o n a l i t y (goa l f a c t o r i n g ) , h i e r a r c h i c a l s t r u c t u r e , and s p e c i a l i z a t i o n . H i s three c a t e g o r i e s or o r g a n i z a t i o n a l theory are c l a s s i c a l ( i . e . the anatomy), n e o c l a s s i c a l or i n d i v i d u a l b e h a v i o u r , and modern theory which he d e f i n e s as a systems p e r s p e c t i v e . Examples of the c l a s s i c a l are D a v i s (1975) and Myers (1965) i n which management i s regarded as p l a n n i n g , o r g a n i z a t i o n , and c o n t r o l . An example o f s o c i a l exchange systems theory i s B a r n a r d ' s (1975) i n which the elements o f the o r g a n i z a t i o n are d i v i d e d i n t o communicat ion, w i l l i n g n e s s to s e r v e , and purpose . March and Simon (1975) use the d e c i s i o n s approach to o r g a n i z a t i o n s and hence emphasize the importance o f g o a l s . O r g a n i z a t i o n a l change., i n n o v a t i o n , and a d a p t a t i o n are analysed by K a l u z n y and Hernandez (1983) , Todd and Murray (1982) and Kaluzny et a l . (1982) . - 39 -It would appear that the wider the range of reading, the greater the number of theories. Many overlap, many deal with only a portion of an organization, but most have valid points. Many of these theories have been used as a basis for Gordon's description of best practice in organizational management. She goes one step further and offers diagnosis of symptoms, reasons for their existence, and prescriptions for remedying the problem. Gordon's prescriptions for best practice were well defined under four headings. Inputs Human resource management theory recommends that recruitment be through employee referrals, where possible, because their source provides the best employees. It advocates a policy of encouraging upward mobility and exposure to significant others. Turnover reduction is facilitated by suitable training, realistic job previews, and matching the job to the employee. Motivation requires a planned process for satisfying unmet needs and directing behaviour. Strategies include performance evaluation and rewards. Materials should be appropriate for the organization and competitive in the marketplace. Planning should be by knowledgeable people and include sufficient research. Most of the emphasis on inputs in Gordon's model is on goals. She states that we diagnose the appropriateness of an organization's structure by its goals. As in so much of the literature, there is emphasis on the importance of clear and concise priorized achievable goals. Process In process the emphasis is on communication, groups, leadership, and power. Communications are analyzed from the receiver's perception, the structure of the organization, and the interpersonal relationships between the sender and the receiver. Considerable attention is focussed on prescriptions - 40 -for improving communication accuracy. Group behaviour is discussed in de t a i l . Intergroup behaviour and conflict is analysed and modes of handling this conflict are presented. Gordon cited Kurt Lewin's experiment which shows that participation in group discussion is ten times more effective than a lecture. Gordon shows how role conflict contributes to stress. She provides a discussion of symptoms for diagnosing them and offers a prescription for reducing i t . Her discussion of power parallels that of most authors (e.g., Bacharh & Lawler, 1980). Structure Gordon shows that the type of structure an organization should — and does — develop is influenced by the environment and the s t a b i l i t y of the organization's technology. She suggests various design responses to the environment (e.g., reducing demands by external elements by reducing dependence on those elements). She shows that as an organization ages, communication no longer occurs primarily through mutual adjustment. With age, structure becomes more mechanized and bureaucratic. She recommends Lorsch and Lawler's (1970) theories as a prescription for improving the appropriateness and effectiveness of structure. Outcome Outcomes is diagnosed in a methodical manner by use of a check-list. Effectiveness measurements are provided. In this study, the use of Gordon's theories has been tempered by applying Lindblom's concept of bounded rationality. Gordon's model for theoretical best practice, superimposed on Donabedian's model of best patient care, appeared to be appropriate for conducting this study of a volunteer organization, the Vancouver-Richmond Meals-on-Wheels program. - 41 -CHAPTER 3: FROM RHETORIC TO REALITY: A DESCRIPTION OF THE VANCOUVER-RICHMOND MEALS-ON-WHEELS ORGANIZATION Introduction Having studied the literature and discussed the perceptions of the experts of what a Meals-on-Wheels service for Vancouver-Richmond in the province of B.C. should be trying to achieve, the next step was to examine the operation of the service i t s e l f by direct observation. As discussed in chapter one, i t was decided in the f i r s t instance to regard the Vancouver-Richmond Meals-on-Wheels as an organization whose goals were client service. Hence, in this chapter, Donabedian's model of analysis and method for obtaining information are used to examine the act i v i t i e s of Meals-on-wheels. Donabedian's model of input, process, structure, and outcome uses three methods for obtaining information: c l i n i c a l records, direct observation, and the study of behaviour and opinion. Research methods used in this study were: observation, use of existing data, volunteer questionnaire, and client interview. Inputs There are five basic components of a Meals-on-Wheels program: the client, the food, the volunteer, the funding, and the organization. Clients The coordinator estimated the number of past clients (1971-1984) as 5,000. The actual number was 6,397 (unless there were some husbands and wives recorded - 42 -on the same card, in which case there might be a few more). She estimated the number of present clients as 600. In a recent newspaper a r t i c l e * , this was estimated at 800. At the time of this study, there were 538 clients. Information about the clients was obtained from an examination of 202 past and 88 present recipients of the service. Data were available for 13 variables, and are summarized in Table 1. A detailed explanation of method used is produced in Appendix D. Table I Frequencies for Each Variable for Past and Present Clients PAST PRESENT CLIENTS CLIENTS Tot al 202 88 Sex male 82 32 female 120 56 missing data 0 0 Type of accommodation house 72 33 apartment 84 48 hotel 10 1 rooming house 10 1 duplex or townhouse 9 0 other 7 0 missing data 10 5 Age Mean 74 80 Mode 83 84 Range 24-96 56-98 Marital status married 47 15 widowed 25 42 single 25 12 divorced 2 0 missing data 83 19 Referred by self 32 16 family 47 9 agency 55 16 hospital 29 6 physician 5 7 Bayley, Chuck: Meal Rounds Never Missed, The Vancouver Sun, Tuesday, May 14, 1985. Section B., p.4, col.5. - 43 -PAST PRESENT CLIENTS CLIENTS f r i e n d 5 0 c l e r g y 3 1 o t h e r 5 3 m i s s i n g data 21 30 Reason f o r r e f e r r a l post h o s p i t a l i z a t i o n 38 13 s p e c i f i c i l l n e s s 24 20 d i e t a r y r e l a t e d 25 9 f r a c t u r e 16 10 i l l h e a l t h o r aged 62 21 mental c o n d i t i o n 13 3 w i f e i l l 16 8 o ther 6 1 m i s s i n g data 2 3 Reasons f o r d i scharge improved h e a l t h (can manage) 42 admitted to h o s p i t a l 26 admitted to LTC f a c i l i t y 12 c a n c e l l e d by c l i e n t 25 n / a c a n c e l l e d by Meals -on-Wheals 12 deceased 5 unable to a f f o r d 6 o t h e r 31 m i s s i n g d a t a 43 s t i l l r e c e i v i n g s e r v i c e 0 Length of s e r v i c e Me an 103 630 ( i n days) Median 28 61 Range 1-1401 4-3081 Number of t imes 1 160 77 on s e r v i c e 2 29 7 3 8 4 4 2 0 5 2 0 6 1 0 m i s s i n g data 0 0 Number o f meals 1 1 0 per week 2 5 0 3 76 41 4 2 1 5 111 46 m i s s i n g data 5 0 - 44 -Distr i c t Burrard 11 6 Cedar Cottage 14 7 Dunbar 14 9 Fraserview 16 8 Grandview 15 4 Kerrisdale 19 11 Ritsilano 16 4 Marpole 12 9 Mount Pleasant 12 4 Richmond 12 7 Riley Park 15 9 Strathcona 21 6 West End 22 4 missing data 3 0 Homemaker Service not applicable 95 0 yes 14 22 no 2 11 missing data 91 55 Food The suppliers of food for Meals-on-Wheels varied greatly in the province. The most common sources were hospitals, catering firms, and restaurants. North Shore Meals-on-Wheels obtains i t s meals from Rally Point Catering, formerly called D.W. Foods. Burnaby Meals-on-Wheels purchases i t s meals from Pacific Vocational Institute. Formerly i t s supplier was Simpson Sears. New Westminster Meals-on-Wheels obtains meals from Woodwards, while Delta Meals-on-Wheels obtains i t s from Westshore-Ley land, a retirement center in Langley. In Vancouver-Richmond Meals-on-Wheels, Strathcona D i s t r i c t s ' are purchased from Shaughnessy Hospital (approximately 50-60 meals) and the remainder of the meals are supplied from Eagle Catering at the Vancouver Airport (approximately 500-550 meals). This s p l i t resulted from the fact that Eagle Catering had - 45 -reached the maximum number that they were willing to supply at one time. The cost of the meals was: Food Trays Juice $2.36 Fo i l covers Containers and lid s for dessert and soup Total .14 .15 .03 .06 $2.74 The cost of the styrofoam container is $6.25. It lasts for about one year. The client is charged $3.00 for each meal. Including administration and other costs, the meal is estimated to cost $4.00. It would be much higher were i t not for donations such as the entire set of Meals-on-Wheels food carts used at Eagle The meals are large. The Food Service Supervisor at Shaughnessy Hospital stated that she purposely gives large enough servings so that the food can be reheated for a second meal. The head chef at Eagle Catering did not mention this, but the meals are equally large. The menu is prepared on the basis of a four-week cycle. The meal consists of soup, crackers, juice, dessert, and a main entree of meat, fish or fowl, vegetables, and potatoes or a substitute. The soup and dessert are packaged in styrofoam containers with l i d s , the crackers are portion packed in clear plastic, the juice i s portion packed in the standard plastic container with f o i l l i d , and the main course is in an aluminum three-part TV tray with f o i l overwrap. A l l items are placed in a custom designed compartmentalized styrofoam container. The l i d is also recessed to insure each item is heat insulated. A wide elastic band is then placed around the container to keep i t shut. Catering, which were donated by Amhurst Lions Club. - 46 -Vancouver-Richmond Meals-on-Wheels delivery boxes were designed by an interested volunteer, who originally made a l l the boxes. Vancouver-Richmond Meals-on-Wheels owns the mold for these boxes. They are manufactured in the U.S.A. Vancouver-Richmond Meals-on-Wheels sells them to other Meals-on-Wheels throughout the province as a service. These carrying boxes are clearly marked and covered with white lids (instead of blue) for special diets in order to reduce the possibility of error. Colour coded lids are also used for the alternate entrees. Most days there is an alternate entree. For example, when fish was being served, veal was sent to those clients who do not like f i s h . Volunteers The volunteers' satisfaction and commitment to their jobs has far-reaching effects both in terms of cost and quality of the service. There was no record of how many volunteers were working. There are approximately 650 volunteers, although the exact number is not known because the central office does not have a master l i s t of volunteers. There was no data on which of the reasons for volunteering were the most prevalent ones in volunteering for Meals-on-Wheels. There was no data on which sources provided the greatest numbers, the most committed, or the longest term volunteer. Each volunteer is expected to work one day per week. There were six categories of volunteers — screeners, PWA drivers, area or d i s t r i c t chairmen, day captains, drivers and servers. Screeners Screeners are volunteers, preferably with training in social work or - 47 -nursing, who visit applicants and interview them. These volunteers determine whether Meals-on-Wheels is the appropriate service, explain the details to the prospective recipient and collect necessary information. They make follow-up visits on request when any problem arises. They do not make follow-up visits to clients who leave the service. Screeners are under the direction of the coordinator. There are six in number. Originally their function was to screen applicants as to their suitability and ability to pay for the service (Appendix E) and to act as an ongoing liaison with the client. The criterion for entry into the program is satisfied by anyone who., by reason of age, physical or mental handicap, or illness, is temporarily or permanently unable to prepare one nourishing meal a day. Very few requests are refused by the central office. The present function of the screener is to interview the client in order to inform the client how Meals-on-Wheels functions and to ascertain that the clients understand their obligation to pay for the meals, be at home to receive them, and cancel in advance any meal that will not be required. When the referral is not from an agency, physician, or hospital, the screener is expected to assess the client's e l ig ibi l i ty on the criterion of need for the service. The ability to pay is not a criterion. Obvious affluence is not a deterrent. PWA Drivers PWA Drivers are the volunteers who pick up meals at the kitchens in Richmond and at Shaughnessy and deliver them to the local chapter depots. Some transport over 100 meals. - 48 -The PWA drivers, (so called because originally Pacific Western Airlines supplied the food), deliver the meals to the thirteen depots, and then return the empty containers and elastic bands from the previous day to Eagle Catering and Shaughnessy Hospital. Their route is from home, to Eagle Catering, to depot, to Eagle Catering, to home. HOME ^_ ^~ EAGLE CATERING DEPOT" ~~~~2Z-^:- E A G L E CATERING HOME They are under the direction of the coordinator. She thinks there are about 30 drivers. The plan of operation allows for one driver each day for each d i s t r i c t (5 X 13). The PWA drivers are paid mileage. There are never enough drivers. Some drivers deliver to more than one d i s t r i c t . Some drivers are called to work a second day per week. The day captain in Dunbar acts as a PWA driver three days per week. The day captain in Marpole acts as a PWA driver one day per week. The office workers often act as PWA drivers. The office staff who double as PWA drivers use the Meals-on-Wheels station wagon which was recently donated to the organization. Area Chairman There are 13 d i s t r i c t s . In theory, each d i s t r i c t has an area chairman. These volunteers are key people. They are the volunteers responsible for the area or chapter. The t i t l e " D i s t r i c t Chairman" is used interchangeably - 49 -with "Area Chairman". In actuality, five of the d i s t r i c t s are without area chairmen. Richmond and Kerrisdale both had a turnover in chairmen within the last two years. Riley Park has not had a chairman for three or four years. West End has been without one for nearly three years. When a d i s t r i c t i s without a chairman, i t is operated from the central office with paid office c l e r i c a l workers performing the work of the volunteer chairman, and often acting as day captain and/or PWA driver as well. Strathcona does not have a d i s t r i c t chairman. This d i s t r i c t is unable to supply sufficient volunteers for i t s own needs. Mount Pleasant, Marpole, and Grandview s t i l l have their original chairmen. The chairman in Dunbar has been there for thirteen years. The job description for the d i s t r i c t chairmen (Appendix F) is s t i l l f a i r l y accurate after a l l this time. The area or d i s t r i c t chairmen are very capable individuals who are responsible for the organization and operation of their d i s t r i c t s on a f a i r l y autonomous basis. The ones observed fostered a remarkable team s p i r i t . Each d i s t r i c t chairman decides on the degree of delegation, type of client folder used, method of record keeping, day of collection, method of volunteer replacement. This is no mean feat as a d i s t r i c t needs, plus or minus, 40 active volunteers per week. The area chairmen offer support to the day captains, keep records and are responsible for the money collected. They submit a monthly report to the coordinator (Appendix G). The most prevalent attitude is " i f i t ' s good for the client, do i t . " One chairman is adamant in her belief that i f people received the meals at an earlier stage of their deterioration there would not be so many ending up in hospital. Commitment and altruism are evident among a l l volun-- 50 -teers, but the number of man-hours given by the area chairmen is truly astonishing. Day Captains The day captain is the person who, under the direction of the district chairman, is in charge of one day's activity. They are responsible on a given day for seeing that the meals get to the recipients. They may also be responsible for calling in substitute volunteers. In essence, they are the "team leader" for the day. Day captains are responsible for one day's operation of the Meals-on- wheels service in their distr ict . This includes responsibility for the team of volunteers. In addition, the day captains often double as driver, server, or PWA driver. Their duties include providing written instructions for drivers (e.g., use lane, number on gate, client slow to answer door, etc.) and providing written comments on each client where applicable (e.g., husband's surgery not too successful, client worried about granddaughter, client recovering from a cold, etc.) . (Appendix H) Drivers and Servers Theoretically, a server goes out with each driver to deliver the meal. Actually, most drivers also act as servers, except in the areas where parking is so difficult that double parking is the norm. The term driver and server are therefore used interchangeably. These dedicated volunteers deliver meals at least one day per week. Meals are delivered five days a week, even on statutory holidays, including Christmas and New Year's. - 51 -The drivers arrive at the depot at 11 a.m. They pick up the l i s t of deliveries prepared by the day captain plus a card for each client. The number of clients per driver depends on the number of drivers available on that particular day. The l i s t of clients is in order of location. If a client requires a special diet, this is clearly noted, as is other pertinent informa-tion. The drivers deliver the meal, remove the food from the containers and place i t on the table, chat for a few minutes with the c l i e n t , and then leave. The drivers/servers are a varied group. Many are retired — an example of the "young, old" helping the "old, old" (Uhlenberg 1979). Many volunteers are temporarily unemployed. Somehow most seem to get a job within two or three months after becoming a volunteer. Funding The consulting accountant to VON, who provided information about funding, made i t very clear that VON and Meals-on-Wheels are two separate organizations. The original resolution by VON was to sponsor Meals-on-Wheels. VON accepts responsibility for the appointment of the Meals-on-Wheels coordinator, prepares applications for grants from the provincial government and the City of Vancouver, and applies VON policy to the utlization of and benefits for the paid staff of Meals-on-Wheels. VON handles the money and holds the purse strings. The Meals-on-Wheels Advisory Committee deals with Meals-on-Wheels on a general basis. The committee's prime function is to act as a means of linking the administration of Meals-on-Wheels with the volunteers. The program revolves around the coordinator. The coordinator of Meals-on-Wheels makes the executive - 52 -decisions. The purpose of the Advisory Committee is to act as a liaison body between those who run the organization and those who perform the services. Originally, each individual organization was responsible for providing its own funding. The main source was receipts from meals and, to a lesser extent, private donations. The City of Vancouver rejected any pleas for funds on the grounds that the service was not city-wide, which of course i t was not as long as each area remained autonomous. With the amalgamation of the various organizations in 1972, this changed. In 1977, the United Way cancelled its annual contribution of $35,000 on the grounds that it was a government responsibility. In 1978 the Ministry of Human Resources contributed 15% of the overall budget. The responsibility for this grant was later assumed by the B.C. Ministry of Health. In October, 1978, the fee charged to the recipients was increased to $1.75. By 1984, it had increased to $3.00. The clients are also subsidized by private donations. Either the area chairmen or the coordinator assess each client's ability to pay. There are very few who are unable to pay $3.00 per meal. Three-quarters of the financing is derived from receipts for meals and the remaining one-quarter from other sources. The VON objective is that the receipts from meals pay the cost of the meals and the other funding pays the cost of administration. The source of funds for the quarter ending December 31, 1984 were: Payments for meals 71% Provincial and municipal grants 23% Private donations 6% - 53 -Private donations include those from individuals, service clubs, clients, and bequests from former clients. The current expenditures for that same quarter were: Cost of meals 71% Transport, volunteer recognition, styrofoam boxes, etc. 6% Administrative costs (salaries, phone, etc.) 23% Less than .05% of the meal receipts are unpaid, or paid by NSF cheques. The Vancouver Health Department and LTC pay the charges directly to Meals-on-Wheels for those clients who are subsidized by them as part of their Home Care programs. On the fifteenth of each month, Meals-on-Wheels receives a b i l l for meals for approximately $25,000, depending on the number of meals delivered that month. Therefore, a small surplus is required to operate e f f i c i e n t l y . Meal prices increase about every six months. The increased cost is not passed on to the client u n t i l the cumulative increase is sufficient to merit a change. When this becomes necessary the meal price charged to clients is increased more than the meal cost increase in order to recoup what has been a de f i c i t in the previous months. With this system, the balance between cost and charge varies at any given time. VON feels that what they lose on the swing, they gain on the roundabout. A major problem is that grants from the provincial government and City of Vancouver are not determined by zero based budgeting, but are predicated on present outlay. If the meals are being sold at a d e f i c i t , the cost to the client is raised. When applications are made for grants the following year, the - 54 -charge to the client is the base and other funding is not increased. The accountant was of the opinion that VON might advance funds or even partially support the service in an emergency but that i t would not support the service on an ongoing basis i f i t was insolvent. The quarterly statements prepared by the accountant for the VON Board show a breakdown of costs per meal and income per meals so that there are current records on which to make adjustments. The grants are a static predetermined amount for the year. If costs escalate a d e f i c i t could occur. Income from meals is a variable factor but income from grants i s not. The principal variant is the number of meals delivered. The Meals-on-wheels budgets must satisfy both municipal and provincial governments. The inconvenience in so doing is increased by the existing situation of two different year-ends; December 31 for the city,, and March 31 for the province. Goals The organization is concerned with putting a l l the inputs together. To do so effectively, i t establishes goals. Process and structure are required to reach these goals. We shall now consider how i t sets out (or f a i l s to set out) i t s goals. Vancouver-Richmond Meals-on-Wheels does not have any o f f i c i a l written goals. The closest thing to a written goal appeared in a document supplied by an area chairman (Appendix I ) . This document was unsigned and undated, but i t was - 55 -probably written about 1972, certainly before 1975, when Meals-on-Wheels began delivering five days per week. It states: The Program VON Meals-on-Wheels is a voluntary community service providing one hot nutritious noon-meal delivered three days each week on Monday, Wednesday and Friday. The People During 1971, 1132 people have availed themselves of Meals-on-Wheels. Anyone may receive this service who, by reason of age, physical or mental handicap, or i l l n e s s , is temporarily or permanently unable to prepare meals. Service may be given on a long or short term basis. The majority of clients are elderly people liv i n g on a moderate or low income who are able to maintain themselves with some help in their own home. Many are convalescing after i l l n e s s or injury or are chronically i l l . Approximately 14% of the clients are younger handicapped or convalescent persons. (Fact Sheet, n.d., p . l ) . Lack of o f f i c i a l goals does not imply lack of operational goals. The operational goals appeared to be to provide food, improve nutrition, supplement social support, and prevent institutionalization. The operational goals were perceived differently by each segment of the organization. The Regional Director for the Province and Director of Vancouver-Richmond Branch Victorian Order of Nurses, defined the Vancouver-Richmond Meals-on-Wheels' goals as being those of the VON, which are clearly stated in the VON for Canada Statement of Policy (Appendix J). Meals-on-Wheels i s only one of five programs for which she was responsible. She firmly believed that Meals-on-Wheels meets a very great social need. - 56 -The Meals-on-Wheels coordinator verbally defined the organization's goals as "Everyone who needs our service gets i t . " When asked to define need, she replied: v "The i l l , the aged, the handicapped, whether short term or long term, who are unable to prepare at least one nourishing meal per day. Inability to pay i s not a consideration. Ab i l i t y to pay is not a consideration. There i s NO delving into financial status." The implied goal was to keep people out of institutions and to help them remain independent within their own homes. She stated that she is "constantly beating the bushes for more volunteers." She has expressed, repeatedly, her goal of getting on with the administrative aspects of the job and her frustration in never having enough time because she is performing work that should be done by the office staff and/or volunteers. The reported goals of the office staff were to provide meals to anyone who needed one on the specific day they were working, to keep accurate records, to minimize waste by ordering the correct numbers and types of meals from the caterers, and to keep the system operating without interruption. The area chairmen had a variety of goals in addition to those identified by the organization for their area. One chairman's explicit goal was to get clients into the system earlier in order to keep them in good health. Another chairman's goal was to make certain a l l clients "are treated as people, not just names on a page." Drivers' and servers' goals varied greatly. "If i t is good for the cl i e n t , do i t " was a prevalent attitude that resulted in such diverse goals as deliver-ing the meal hot, making certain the client w i l l eat the food (e.g., cutting his - 57 -meat for him), providing social contact, ensuring that the other social service needs of the client are being met, and prodding Homemakers into doing more for the cl i e n t . Chapter 5 provides a further l i s t i n g of the goals of volunteers and the frequency with which the more common goals were stated by the volunteers. Process Clients The process by which individuals become clients was perceived by the coordinator to be mainly a referral system from agencies. Empirical research showed that an equal number of clients (27.6%) were referred by " s e l f " and "agency." "Family" was the next most frequent source (15.5%), followed by "physicians" (7%), and "hospital" (6%). In the randomly selected sample, one client was referred by either a clergyman, hotel manager, physiotherapist, or die t i t i a n . The most frequent reason for referral was " i l l or aged." The second, was a more specific diagnosis of illnesses, such as diabetes, a r t h r i t i s , cancer, glaucoma, etc. It was interesting that while 8% of the referrals were because the wife was i l l , there were no referrals because the husband was i l l . Nearly-one half of the present clients received only three meals per week. Food Meal Supply As previously stated, the menu was varied. The meals were large, attractively served, temperature controlled, and the food varied in texture, flavour, aroma, temperature, and colour. This variety does not guarantee that - 58 -i t w i l l suit the c l i e n t . The clients were not asked for suggestions regarding the menu nor has there been any formal evaluation of their perception of the meals. Associations with and attitudes towards food are emotional, not rational, among most individuals. An undertaking of this magnitude might be beyond the resources of Meals-on-Wheels, however the City of Vancouver's Department of Health has personnel with the expertise to conduct such an evaluation. One meal was taken back to the office each day to check quality and quantity. This was usually a simple special diet such as low fat or the alternate to the main entree. No written standards were used, so that this value judgment is based on the opinion of the coordinator and the office staff. Depots Each of the 13 d i s t r i c t s has one depot. They are usually the kitchens in a church or community center. The PWA drivers deliver the meals to the depots and the drivers are usually waiting so that meals are picked up directly outside the building. Each driver is responsible for picking up the number and kind lis t e d on the daily sheets prepared by the day captain. • When the drivers return to the depots, they wipe out the styrofoam delivery boxes with water containing bleach. Some depots add soap. The drivers/servers return the clients' cards and provide the day captain with any pertinent information about the c l i e n t . The service at each depot is characterized by a loose structure that fosters a relaxed atmosphere and allows f l e x i b i l i t y in a group that is cohesive and united in purpose. - 59 -Volunteer Recruiting and Orientation There is a constant shortage of volunteers. There are two perceptions of how volunteers are recruited. Both occur but only detailed analysis of data in Chapter 4 w i l l determine which system i s more prevalent. The coordinator directs a great deal of time and effort into recruiting volunteers. She uses every source at her disposal. She writes to newspapers, appears on Channel 10 television, and appeals to churches, the Vancouver Volunteer Center, and any organization she thinks might be a source of volunteers. One member of the office staff has been delegated the responsibility for volunteer orientation. The orientation observed was gentle, folksy, and geared to the individuals present. A l l PWA drivers are trained by the office staff. The new volunteers come to the office for orientation. The coordinator said that many of the chairmen bring in volunteers who are friends of theirs so that the office does not have a record of who they are. Once in awhile the chairmen w i l l phone the office when they are stuck. The coordinator believes that many, i f not most, of the volunteers are orientated and trained by the office staff. The area chairman perceived recruitment differently. Most chairmen were convinced that they obtain their own volunteers and only rarely do they find the office to be a source of volunteers. Volunteers bring in spouses, neighbours, bowling and golfing acquaintances, and personal friends as new volunteers. If volunteers are unable to work on a particular day, they are expected to provide a replacement. Chairmen double up when a day captain is not available. The captain w i l l double as a driver when short of volunteers. Volunteers can attend an orientation meeting at the central o f f i c e . Many do not bother to go. One - 60 -seasoned driver attended out of curiosity but fe l t she was not given any information that she did not already know. The orientation is concerned primarily with procedural measures. Continuity Continuity in Meals-on-Wheels does not exist in the sense of the same volunteer for the same client every day. The program is designed to retain volunteers by asking them to work only one day each week. Thus, even perfect continuity would mean five different volunteers per cl i e n t . With the perpetual shortage of volunteers, volunteer i l l n e s s and vacations, and volunteer change-over, even this type of continuity is not possible. Under these circumstances Meals-on-Wheels does not regard continuity as a goal. Whether or not i t is desirable is of l i t t l e significance i f i t i s not achievable. Instead, continuity i s perceived as continuity of senior positions in the volunteer hierarchy, especially area chairmen. This goal has been achieved to quite an extent. Finance Most decisions regarding finances are made at the VON Board of Directors meetings. Applications for grants are made by the VON Board. Expert advice, in the form of a paid consultant accountant, is well u t i l i z e d . VON holds the purse strings for Meals-on-Wheels. Office Procedures The office staff are flexible in their accommodation to unusual and - 61 -unpredictable situations. Their willingness to perform each others' duties is outstanding. There are no job descriptions. The coordinator said she tries to use each staff member in the work she does best. The forms used in the office are well thought out. The order form and the form used for the Food Supervisor (Appendix K) is colour coded for PWA drivers' ease in checking the number and types of special diets picked up. The d i s t r i c t s are ordered so that the one farthest from Eagle Catering receives the meals f i r s t . There is an answering machine on which clients may leave a message when the office i s closed overnight. It is the policy of the organization not to give phone numbers of area chairmen or day captains to the client s , but to take messages for them only. Changes are accepted up until 11 a.m. Again, colour coding i s used to minimize errors caused by changes. A universal problem is that meals are not cancelled by the clients for dental appointments, a lunch with daughter, etc. and the meal changes, both diet and preference, are not f i l t e r e d through. Servers are encouraged not to take the messages themselves but to assist the client in telephoning the office to make any changes in their meal delivery. The position of food supervisor, which has been held by a food service technician and a part-time d i e t i t i a n , is now f i l l e d by office c l e r i c a l staff. The coordinator made this change because she is of the opinion that the food supervisor is not supervising food, but drivers, and therefore there i s no need for a food service technician or di e t i t i a n . She perceives no need to supervise the food component. On Christmas Day, 1984, despite prior arrangements, turkey - 62 -r o l l i n s t e a d o f r o a s t t u r k e y was served and the c r a n b e r r y sauce was o m i t t e d . The o f f i c e personne l are not a u t h o r i z e d to d e a l w i t h an e r r o r o f t h i s n a t u r e . Had they phoned the c o o r d i n a t o r at home she would have had t h i s r e c t i f i e d . The g r e a t e s t s t r e s s o c c u r s i n the o f f i c e p r i o r to C h r i s t m a s . O c c a s i o n a l l y , c h a r i t a b l e o r g a n i z a t i o n s g i v e f a v o u r s d i r e c t l y to a d i s t r i c t f o r a s p e c i a l d a y . More o f t e n G i r l G u i d e s , B r o w n i e s , church g r o u p s , s e r v i c e c l u b s , and i n d i v i d u a l s g i v e g i f t s f o r d i s t r i b u t i o n to the o f f i c e . At t h i s time of year the o f f i c e i s inundated w i t h items f o r d i s t r i b u t i o n . One anonymous lady d e l i v e r s 200 wrapped and r i b b o n - t i e d bags o f o r a n g e s , home-made candy, f r u i t c a k e , e t c . a n n u a l l y . The problem i s compounded by the f a c t that c l i e n t numbers i n c r e a s e i n w i n t e r ; and, a v a i l a b l e v o l u n t e e r s d e c r e a s e . N o n e t h e l e s s , the d o n a t i o n s are a l l d i s t r i b u t e d . Communication Meal changes pose a problem i n communicat ion, even i n a t i g h t l y s t r u c t u r e d i n s t i t u t i o n . In Meals -on-Wheels the problem i s m a g n i f i e d by the number o f v o l u n t e e r s and the type o f c l i e n t . The answering machine i n the o f f i c e i s a v a i l a b l e from 4 p .m. to 8 a.m. but i s not u t i l i z e d as much as i t c o u l d be . Many p e o p l e , p a r t i c u l a r l y those who grew up before the p r o l i f e r a t i o n o f t e c h n o l o g i c a l d e v i c e s , are r e l u c t a n t to use a te lephone answering machine. The c l i e n t s are predominant ly o f an age where f o r g e t f u l n e s s may be more common than among a younger g r o u p . Perhaps the c l i e n t s f a i l to understand the importance o f n o t i f y i n g the o f f i c e i f a meal i s to be c a n c e l l e d . Perhaps the problem i s no worse than i n any o t h e r food system. A newsletter, begun by a former coordinator i s no longer being published. Chapter 5 provides data to c l a r i f y whether or not the volunteers want more information regarding the o r g a n i z a t i o n . Communication between government agencies i s perceived as a major problem by the coordinator. She i s encouraged by the prospect of a possible computer hook-up with LTC and the health u n i t s . Information regarding the c l i e n t would then be a v a i l a b l e upon r e f e r r a l . Other Procedures There are no data on the c l i e n t s ' preferences or s a t i s f a c t i o n s , although r e c i p i e n t s would seem to be the best source of information on how to improve t h e i r own s a t i s f a c t i o n . Changes in Process Presently Occurring Formerly the Advisory Committee met every month. It now meets every two months. The area chairman i n K e r r i s d a l e i s chairman of t h i s committee. In t h i s capacity, she i s also a member of the Board of D i r e c t o r s of VON. The Board sends one delegate to the Advisory Committee. O r i g i n a l l y t h i s committee was comprised of the area chairmen but i t has been expanded to include the screeners as w e l l . The VON d i r e c t o r also attends these committee meetings. Another change i s the coordinator's attempt to enforce the r a r e l y followed p o l i c y of two weeks as the minimum service allowed new c l i e n t s . One of the changes to which there i s strong resistance i s method of payment. O r i g i n a l l y payment was d a i l y . At present about h a l f the c l i e n t s pay on Monday for one week in advance. Almost as many pay d a i l y , on a d i f f e r e n t day, monthly, - 64 -or sporadically. One d i s t r i c t gives receipts for four week payments only. Others vary in their record keeping. Most t r i p l e enter payments. Each chairman uses a different system of bookkeeping, records, and payments, but a l l submit the money with the same monthly report form. The coordinator wants the clients to pay one month in advance. The objections offered by the volunteers appear to have some merit, although some appear to be simply an expression of resistance to change and potential loss of autonomy. Volunteers mentioned the problem of refunds when so many clients were short-term, some suggested i t would present d i f f i c u l t i e s i f the f i r s t of a month f e l l on a Tuesday or a Thursday when fewer clients receive meals and fewer volunteers function as drivers and/or servers. One interesting comment was that the money should be collected daily, not even weekly, and certainly not monthly, because i f a client is forgetful and insists he/she has paid when he/she has not, $15 is too much for volunteers to reach into their own pockets for. Central control i s perceived by the area chairman to be increasing. There i s a lack of information on policy regarding subsidies for clients in need. Perhaps this is because the coordinator has a mandate from the Board to make this decision on an individual basis when the need arises. Structure Vancouver-Richmond Meals-on-Wheels i s sponsored by the Vancouver-Richmond Branch of the Victorian Order of Nurses. The offices of VON are located at 1645 West 10th Avenue. Meals-on-Wheels occupies approximately half the office space on the main floor. The paid staff consists of a full-time coordinator, two full-time office staff (35 hours per week), and two part-time office staff. - 65 -There are two governing bodies. The one with the decision-making power is the VON Board of Directors. The Meals-on-Wheels Advisory Committee is responsible to the VON Board of Directors. VON Board of Directors The VON Board of Directors consists of 14 members. They are elected at a general meeting of the VON society. One member of the Board of Directors is the Board's representative to the Meals-on-Wheels Advisory Committee. She acts as liaison and is responsible for communication from the Board to the Committee. The Board of VON does not deal with Meals-on-Wheels in d e t a i l . Meals-on-Wheels Advisory Committee The Meals-on-Wheels Advisory Committee is comprised of the 13 area chairmen, 6 Screeners, the Meals-on-Wheels coordinator, the Director of VON, and one representative from the VON Board. The Meals-on-Wheels Advisory Committee is responsible to the VON Board of Directors for recommendations regarding policy, administration, long-range planning, publicity, public relations, and coordina-tion of the program. The emphasis here is on "recommendations" because, in actual practice, the coordinator i s regarded by the VON Board as the decision-maker for the operation of the service. The chairman of the Meals-on-Wheels Advisory Committee is the Committee's representative to the VON Board. Director of Vancouver-Richmond VON The Regional Director for the Province of British Columbia for VON is also Director of Vancouver-Richmond Branch VON. She perceives herself as being - 66 -professionally responsible to the National Director of VON and administratively responsible to the Vancouver-Richmond Branch VON. Her responsibilities include two adult day care centers; Meals-on-Wheels; a training program for VON nurses across Canada on how to start adult day care centers; and, the administrative function of identifying need, planning projects, starting demonstration pilot projects, and finding the funds to get them started. She does not regard Meals-on-Wheels as one of her most pressing responsibilities. She attends Board meetings but does not have a vote. Coordinator of Vancouver-Richmond Meals-on-Wheels The present coordinator assumed this position in May, 1983. Her education and experience do not meet the requirements identified in the job description (Appendix L). If the coordinator's salary i s in the range alluded to, i t would appear unlikely that an individual with the required education and experience w i l l be forthcoming. Her span of authority is perceived differently by different individuals. She attends Board meetings for the purpose of delivering the Meals-on-Wheels report and is not expected to stay for the rest of the meeting. The original letter requesting permission to undertake this study was addressed to the Board. The coordinator asked that i t be addressed to her, yet when her request was complied with, she was unable to grant this permission without the addition of the VON director's signature. There appeared to be some ambiguity concerning delegation of authority. One of the coordinator's main p r i o r i t i e s appears to be promotion of the program by contact with community groups and general public relations. She provided a copy of the August 1984 Richmond News in which her picture appeared - 6 7 -a l o n g w i t h a n a r t i c l e p u b l i c i z i n g t h e s e r v i c e p r o v i d e d b y M e a l s - o n - W h e e l s . S h e h a s a p p e a r e d o n t h e l o c a l c o m m u n i t y s p o n s o r e d t e l e v i s i o n s t a t i o n , C h a n n e l 10, a n d h a s b e e n i n t e r v i e w e d o n r a d i o . T h e c o o r d i n a t o r h a s a d i f f i c u l t r o l e i n t h a t h e r m a n d a t e f r o m VON i s t o a s s u m e e x e c u t i v e r e s p o n s i b i l i t y f o r t h e M e a l s - o n - W h e e l s o r g a n i z a t i o n , a s i t u a t i o n made d i f f i c u l t b y t h e p e r c e i v e d o w n e r s h i p o f t h e v o l u n t e e r s , p a r t i c u l a r l y t h o s e who h a v e b e e n w i t h M e a l s - o n - W h e e l s b e f o r e VON a s s u m e d s p o n s o r s h i p . S h e i s v e r y s e n s i t i v e i n h e r a v o i d a n c e o f h a v i n g VON s t a m p e d a l l o v e r " t h e i r " v o l u n t e e r o r g a n i z a t i o n . T h e c o o r d i n a t o r a p p e a r s t o b e c a u g h t i n a s q u e e z e b e t w e e n t h e l o n g - t e r m a r e a c h a i r m e n whom s h e s e e s a s a d v e r s a r i e s a n d VON w h i c h h a s c o n t r o l o f t h e m o n e y , h e r p o s i t i o n , a n d t h e o r g a n i z a t i o n . O f f i c e S t a f f I n a d d i t i o n t o t h e c o o r d i n a t o r , t h e r e a r e f o u r p e o p l e w o r k i n g i n t h e g e n e r a l o f f i c e . N o n e h a v e b e e n t h e r e m o r e t h a n a y e a r a n d a h a l f . One h a s b e e n t h e r e o n l y a f e w m o n t h s . I t i s d i f f i c u l t t o e s t i m a t e p a i d m a n - h o u r s w o r k e d a s t h e r e d o n o t a p p e a r t o b e a n y r e c o r d s a v a i l a b l e , a n d a l t h o u g h t w o o f t h e f o u r w e r e h i r e d a s p a r t - t i m e s t a f f , t h e y a r e w o r k i n g a l m o s t f u l l - t i m e ( i . e . , 35 h o u r s / w e e k ) . I t i s n e c e s s a r y f o r t h e o p e r a t i o n o f t h e o r g a n i z a t i o n t h a t t h e n u m b e r o f h o u r s w o r k e d by b o t h o f t h e p a r t - t i m e o f f i c e p e r s o n n e l r e m a i n f l e x i b l e . T h e w o r k l o a d v a r i e s g r e a t l y f r o m d a y t o d a y . I t v a r i e s a l m o s t d i r e c t l y w i t h t h e c l i e n t l o a d , b u t i s a l s o a f f e c t e d by s t a f f o f f s i c k , n u m b e r o f v o l u n t e e r s - 68 -available on a given day, and number of clients commencing or discontinuing service. The office staff perform a variety of tasks including answering phones, typing, completing forms, accounting, making changes in the l i s t of clients receiving meals, preparing the daily meal order sheets (Appendix P), and generally providing attention to the details without which the daily operation of the organization would not occur. There are no job descriptions for any of them except the Food Supervisor (Appendix M). The coordinator decided a person with these qualifications was not needed, so one member of the office staff now goes to Eagle Catering daily to perform this function. In addition to the paid office staff there are three people from H.I.P. (Handicapped I n i t i a t i v e Program) who act as servers in the Strathcona D i s t r i c t . The government pays them $50 for twenty hours of volunteer work per month. Meals-on-Wheels qualifies for five. Consultants Consultant Dietitian/Nutritionist The chief Dietitian/Nutritionist for the Vancouver Department of Health provides the technical expertise for the program. The city nutritionist set up the original guidelines for the part of the service involving the food. When the coordinator wished to change the menus last year, the Vancouver Health Department d i e t i t i a n advised her on a number of issues and provided a computer analysis of the nutritive value of the meals on the revised menu. The method used by the coordinator to effect these changes, which were implemented on June 1, 1984, was to go over the present menu and count the number of times each item appeared in the cycle (e.g. roast beef, mashed potatoes) and even this out to an equal number of each, without regard for the popularity of the item. She eliminated items for which frequent complaints had been received such as ham and sausages. She was of the opinion that ham is hard to digest. This does not coincide with the accepted body of knowledge (Province  of British Columbia Diet Manual, 1985). These decisions reduced variety and eliminate some clients' favourites. A better solution might be to reduce the frequency of these items. There was no u t i l i z a t i o n of available food service data. Food Service and Hospitality magazine publishes biannually those foods most popular in a l l food outlets in the U.S.A. This shows trends such as salad, soup, and eggs increasing in popularity and fried chicken and ice cream decreasing. The most reliable source of information as to cl i e n t s ' preferences are the clients themselves. There was no formal input sought from the cli e n t s . The Health Department's regular input includes only routine inspections such as regular inspections of Shaughnessy Hospital and Eagle Catering, which would occur even i f they were not supplying Meals-on-Wheels, annual inspections of the thirteen depots, and annual evaluation of the food for temperature-control only. This i s not for aesthetic reasons, rather for reasons of sanitation. Consultant Accountant The consultant accountant to the VON Board of Directors is paid a fee for his work. He attends the Board meetings but has no vote. At these meetings he has a voice by tacit consent only. He prepares and submits quarterly statements, assists with business matters, and advises on investments. - 70 -Organization of Work Outside the Head Office Vancouver-Richmond is comprised of thirteen d i s t r i c t s (Appendix N). They are: Burrard Cedar Cottage Dunbar Fraserview Grandview Kerrisdale Kitsilano Mar pole Mount Pleasant Richmond Riley Park Strathcona West End Kerrisdale, Dunbar, and probably Kitsilano are the more affluent d i s t r i c t s . Marpole and Richmond cut across a l l levels of affluence. Strathcona is probably the area with the greatest number of underprivileged clients. Meals-on-Wheel s is a loosely—knit decentralized structure which is slowly undergoing change to greater centralization. It emerged from a number of small autonomous individualistic organizations joining to form one organization. To a large extent, these original organizations determined the geographical boundaries of their respective d i s t r i c t s . The volunteers and their organization and a c t i v i t i e s has already been discussed. It seemed to be necessary to try to develop some kind of organization chart to sort out lines of authority. Figure 1 shows the VON organizational structure as i t relates to Vancouver-Richmond Meals-on-Wheels. - 71 -Figure 1. Organization Chart as Perceived by VON Director Board of Directors VON Director Adult Day Care Centres (2) Training Program for VON Nurses MOW Coordinator Area (13) Chairmen PWA Driver Servers Day Captains (5) Drivers & Servers Planning Identifying need planning project starting demon-stration project, finding money to get i t going Office Staff The VON Director's comments were that what works for Meals-on-Wheels in one area (e.g., Strathcona) does not necessarily work in another (e.g. West End). It is essential that there be sufficient freedom for the area chairmen to use their own systems. She believed the service peaked in 1981 and w i l l now continue at about i t s present demand. She said Wheels-to-Meals is now in the planning stage and thinks i t w i l l increase. The o f f i c a l Meals-on-Wheels organizational chart is presented in Figure 2. It was supplied by the coordinator of Meals-on-Wheels. Figure 3 is the F i g u r e 2 . OFFICIAL ORGANIZATIONAL CHART MEALS-ON-WHEELS (Vancouv er-Richmond) December, 1983 VICTORIAN ORDER NURSES BOARD OF DIRECTORS Meals on Wheels C o o r d i n a t o r ( M r s . ) P . K i r k l a n d V o l u n t e e r s PWA D r i v e r s Shaughnessy D r i v e r s Meals on Wheels Committee R e g i o n a l D i r e c t o r ' 1 ( M r s . ) D. N e l l e s O f f i c e S t a f f Volunteer R e c r u i t e r Bookkeeper C l e r i c a l A s s i s tant Adul,t Day Care Centres Food Order C l e r k K i t c h e n S u p e r v i s o r Chairmen 13 Chapters Day C a p t a i n s D r i v e r s & Servers 11 ni nm nu 1 each day 4 - 1 2 Source : C o o r d i n a t o r , Vancouver-Richmond Meals-on-Wheels - 73 -organizational chart as produced in the Community Feeding Task Force Report. Figure 4 is the investigator's view of the organizational structure of the Vancouver-Richmond Meals-on-Wheels. Figure 3. Organizational Chart as Perceived by Task Force V.O.N. Board (approximately 15 members) | Dist r i c t Advisory Committee (Chairmen and Screeners) V.O.N. Co-ordinator Food Supervisor C l e r i c a l Asst. Cleri c a l r e l i e f and Full-time Secretarial Asst. PWA Drivers Meals to Depots Shaughnessy Drivers Meals to Depots Dis t r i c t (13 Distri c t s ) - Chairman - Screener I - , Day Captain (one for each day of the week) Volunteer Group (different each day of the week) - collect fees, banking, s t e r i l i z i n g boxes for delivery, driving, delivery of meals, friendly v i s i t s , daily contacts, reporting health concerns. - 74 -Figure 4, Organization Chart as Perceived by Investigator VON Board of Directors VON Director Meals-on-Wheels Coordinator Meals-on-Wheels Advisory Committee Screeners Consultant Area Chairmen I Day Captains Office Staff PWA Drivers Drivers Servers Unsolicited comments from the volunteers on the structure were few in number. One driver remarked that the loose structure, characterized by few controls, was good for the drivers, the servers, and the clients. One area chairman remarked that central control was increasing. A day captain said that the present structure f a c i l i t a t e s personal contact, nourishing, and the psychological association of food with the idea of nourishing. Strategic Constituencies Figure 5 provides a model of Vancouver-Richmond Meals-on-Wheels structure in relation to i t s strategic constituencies. The question of how Meals-on-Wheels related to these constellation groups is perhaps best worded as how much does i t need to relate to these groups. - 75 -Figure 5, Meals-on-Wheels Boundaries Client Pool Volunteer Pool Vancouver Health Department Richmond Health Unit x \ / Provincial Government Government Organizations /""~~----.^  Vancouver Volunteer Centre VON Other Organizations Client Pool The client pool could be immense. The population is aging. Statistics Canada data are available for age s t r a t i f i c a t i o n information on a d i s t r i c t by d i s t r i c t basis. Other categories of need may exist (e.g. post-partum, post day-surgery, group homes). Meals-on-Wheels has not availed i t s e l f of any outside sources that might indicate the extent of the client pool. The organization was not seeking clients. Meals-on-Wheels did not appear to be concerned with the potential client pool, nor with input from those who are presently i t s clients. Clients, on the other hand, expressed a strong desire to have input into the organization. - 76 -Volunteer Pool The potential volunteer pool is a large one. Canadians are willing volunteers. Meals-on-Wheels does not have a l i s t of the day captains, drivers, or servers. Management had no information prior to this study of sources for recruitment nor degree of satisfaction of the volunteers. There were no data on which to base an estimate of volunteer turnover. Management did not s o l i c i t input from volunteers. The interaction between Meals-on-Wheels and the volunteer pool was far less than i t could have been. Other Organizations Vancouver-Richmond Meals-on-Wheels u t i l i z e d as many facets of the media as i t could in order to publicize the organization. Management regarded the media as a recruitment tool for obtaining volunteers. The media has been very cooperative. The coordinator has interacted extremely well with this boundary group. The Vancouver Volunteer Centre provided an estimated 10% of the volunteers. There were no data to confirm this. The Volunteer Centre has not been u t i l i z e d to recruit specific categories of volunteers such as volunteer diet i t i a n s , social workers, and evaluators. Interaction between Vancouver-Richmond Meals-on-Wheels and the Volunteer Centre has not reached i t s f u l l potential. The VON had a great deal of input into Meals-on-Wheels. Policy decisions, financial control, and staffing were a l l controlled by VON. Government Organizations The Vancouver Health Department interacted with Vancouver-Richmond Meals-on-Wheels by providing expertise. They analyzed nutrient content of menus, inspected area depots, and checked food temperature. Management of Meals-on-Wheels has not availed i t s e l f of a l l the technological and expert services available (at no cost) from this source. Long Term Care homemakers are a boundary group but neither the government, the health units, nor Meals-on-Wheels i t s e l f appeared to be particularly concerned about any aspect, except perhaps duplication of service — a concern which was only given l i p service. The general attitude was that they are two different services with the same goal of keeping the elderly in their own homes. Perhaps this i s so, for certainly those receiving Homemaker Service one day per week could not use this as a substitute for five meals per week. On the other hand, meal preparation was not excluded from the l i s t of functions performed by the Homemakers. The person responsible for Meals-on-Wheels programs in the Ministry of Health said that provincial government funding was provided for approximately 2/3 of the Meals-on-Wheels programs in the province. Funding was based on the actual meals delivered the previous year. Funding required a signed grant application from the non-profit Board of Directors responsible for the operation. It was granted only after the Long Term Care Home Support Coordinator in the d i s t r i c t had made written comment on the efficiency of the program. She said there was nothing published regarding funding or accounting. When asked what type and degree of accountability was required, she replied that i t was threefold. The sponsoring Board of Directors must submit a copy of - 78 -t h e i r c o n s t i t u t i o n and b y - l a w s , the executive must s i g n the a p p l i c a t i o n g r a n t , and the Board must f i l e an annual statement under the S o c i e t i e s A c t . She could not see any need f o r more a c c o u n t a b i l i t y than t h a t . When pressed f o r government pressures or c o n t r o l s that c o u l d be a p p l i e d she s a i d a l e t t e r was sent to any Meals-on-Wheels o r g a n i z a t i o n reminding them i f they f a i l e d to submit an annual statement. The A d m i n i s t r a t o r of Richmond Long Term Care s u p p l i e d the f o l l o w i n g o r g a n i z a t i o n a l c h a r t . F i g u r e 6. O r g a n i z a t i o n a l Chart f o r Heal th U n i t s HEALTH UNIT  E x e c u t i v e D i r e c t o r ( M . H . O . ) PREVENTION ENVIRONMENT LONG TERM CARE HEALTH CARE MANAGER MANAGER MANAGER MANAGER ASSESSORS (CASE MANAGERS) Long Term Care F a c i l i t i e s Homemaker S e r v i c e Home Care (nurs ing and physiotherapy) A d u l t Day Care Group Homes Meals-on-WheeIs She pointed out that Long Term Care met need, not demand. She estimated that the percentage of the p o p u l a t i o n r e c e i v i n g some form of support was: - 79 -5% of the population age 65-74 years 20% " " " " 75-84 years 50% " " " " 85 years and older. She said Long Term Care planning was based on an h i s t o r i c a l base (i . e . , the status quo), wait-l i s t or u t i l i z a t i o n data, population or age adjusted per capita base, and surveys of community needs. Long Term Care refers people to Meals-on-Wheels. Meals-on-Wheels can refuse the ref e r r a l , but never does. There is no formal planning link between the Meals-on-Wheels program and LTC. The boundary between Long Term Care in the health units and Meals-on-Wheels appeared to be a shifting one. If Meals-on-Wheels perceives a threatened invasion of i t s t e r r i t o r i a l imperative (e.g. LTC wanted to assume responsibility for assessing the perspective client) then Meals-on-Wheels defends i t s territory (in this instance, f a i r l y successfully). One method of defence appears to be the reluctance of supplying the constellation group with any useful information. When asked what liaison existed between Vancouver-Richmond Meals-on-Wheels and other Meals-on-Wheels program i n B.C., Canada, and throughout the world, the VON director replied that i t was by informal networking. Home Support Service in Victoria has a start-up k i t . Duplication of Services The coordinator perceived a duplication of services between Home Care, LTC, and Meals-on-Wheels. The consultant dietitian's attitude was that duplication of service was to be avoided and i f the volunteer observed such, i t should be - 80 -reported. The investigator observed instances in which a Home Care worker was not performing any observable function except giving companionship. Perhaps shopping or meal preparation by a Home Care worker would reduce the need for Meals-on-Wheels or else improve the other meals of the client. The data from the existing c l i e n t s ' f i l e s on whether or not the client i s receiving other services, such as Home Care or Long Term Care services, was predominantly "missing." No investigation has been conducted to account for the recent drop in number of meals served (117,484 in 1984 as opposed to 140,332 in 1982). The cost to the client in Vancouver-Richmond Meals-on-Wheels was $3.00 per meal. The volunteer/client ratio was roughly 1:1. There was no hard data on the number of volunteers available, however, the estimated number is approximately 650. The number of meals served per day varied because some clients received only three meals per week, but i t was estimated at approximately 600. This compared favourably with similar organizations. Outcome Volunteer Meal Output The number of meals served over recent years is as follows: 1978 1979 1980 1981 1982 1983 1984 112,915 122,630 131,882 138,685 140,332 129,201 117,484 - 81 -Burnaby North Shore Delta New Westminster Estimated average number 110-120 100 18 25-30 of meals served per day Number of meals served 16,182 14,600 4,800 6,689 in 1984 Estimated number of 100 100-200 30 55 volunteers Charge per meal $2.75 $3.00 $2.50 $2.75 (cost is @ $2.90) . - 82 -CHAPTER 4: THE VOLUNTEERS' POINT OF VIEW Introduction The literature on Meals-on-Wheels organizations i s sparse. Descriptive accounts of such organizations are available, however, any evaluation of Meals-on-Wheels as a voluntary organization in Canada is non-existent. To date, no evaluation has been undertakn on the Vancouver-Richmond Meals-on Wheels volunteers. Hence, this study i s the f i r s t of i t s kind to examine and evaluate the volunteers associated with the Vancouver-Richmond Meals-on-Wheels. There i s , however, ample literature about volunteers in general (Schwartz, 1984; Pifer, 1982; Beveridge, 1948); volunteer-oriented journals (Voluntary  Action Leadership, Volunteering, Exchange Networks); volunteers in Canada (Carter, 1975; Bellamy & Wells, 1974; Anderson & Moore 1974); and, specific aspects of volunteering such as the needs of volunteers (Francies, 1983) and volunteer satisfaction (Parkum, 1982). It soon became apparent that a shortage of volunteers posed a perpetual problem for the Vancouver-Richmond Meals-on-Wheels organization. Information was required on which to base strategies for reducing the shortage of volunteers. Since no study of volunteers in this organization has been undertaken, some v i t a l questions remain outstanding: Who are they? How are they recruited? How are they kept? Why are they lost? Prior to data collection, i t was anticipated that the information gleaned from the results of the survey would be more qualitative than quantitative in nature. The purpose of this chapter is to present information about Vancouver-Richmond Meals-on-Wheels volunteers in the areas of commitment, satisfaction, - 83 -socialization with the recipient, sources for future recruitment, and the volunteers' perception of Vancouver-Richmond Meals-on-Wheels. Method Design A questionnaire, with an accompanying explanatory letter (Appendix 0) was used to obtain information directly from the volunteers as regards length of service, time devoted to this program, entry, perception of goals, training, support, and their prime function in relation to the program's recipients. Those surveyed were a l l active volunteers in Vancouver-Richmond Meals-on-Wheels operation. Sample A random selection of volunteers was not possible because there was no master l i s t of volunteers to use as a basis for selection. The only randomization possible was to select a date randomly and distribute the questionnaires to a l l volunteers working on that particular day. If there are 650 volunteers, i t would appear highly unlikely that there would be more than 130 working on any one day. The actual number could be anticipated to be far less because there were not 13 area chairmen nor were there 13 PWA drivers available on any given day. Many volunteers doubled up as area chairmen/day captains, day captains/PWA drivers, and drivers/servers. If Tuesday or Thursday was the day randomly selected then this number would be greatly reduced because fewer meals were delivered on these days. - 84 -Distribution The coordinator agreed to distribute the questionnaires accompanied by a letter from the investigator. She saw to i t that the questionnaires were distributed through the PWA drivers to the area chairmen or day captains, who in turn, distributed them to the drivers and servers. The questionnaires and accompanying letters were delivered to the coordinator on January 17, 1985 for distribution at her discretion. Collection The sequence of collecting the questionnaires was from the volunteer, to the day captain and/or the coordinator, and f i n a l l y to the investigator. Since i t was impossible to determine the exact number of questionnaires distributed, calculation of the percentage returned was likewise impossible. Questionnaires continued to be returned up to and including March 19, 1985. A total of 65 questionnaires were returned. Instrument The questionnaire consisted of 26 questions. Questions 1, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 23, 25, and 26 were taken from the Basic Feedback System  National Information Center on Volunteerism, Boulder, Colorado, (1977). The remainder were peculiar to Vancouver-Richmond Meals-on-Wheels and had no outside source. The information obtained provided data on 25 variables. The last question was a request for comments. The variables for which data were obtained included: - 85 -Variables Chosen Used to: Measure Volunteers: Length of service. > Number of days worked per week. > Number of meals delivered per day. > Reasons for volunteering. Satisfactions. > Good features. > Improvement needed. > Frustrations. > Recommendations to others to jo i n . > Type of training received. > Adequacy of training received. > Support from staff. > Work recognition. > Degree of trust. > Adequate information received. > Minutes spent with each c l i e n t . > Perceived prime functions. > Frustrations. > Method of recruitment. Principal activity. Perceived goals of the organization. Degree of Commitment Reasons for volunteering Level of Satisfaction Level of Socialization Method of Recruitment Principal Activity Perceived Goals of the Organization Comments Volunteers' Perceptions Coding The questionnaire was tested on a non-random sample of eight volunteers. Coding was tested for r e l i a b i l i t y by a non-random duplicate coding by a fellow graduate student. The coding system is shown in Appendix P. The length of service was coded numerically in years to one decimal point to record those working less than one year (e.g., 3 months = 0.2, 4 months = 0.3, 5 months = 0.4). If the second digit after the decimal point was less than 5, the lesser numbers were used. - 86 -Number of days worked per week, number of meals delivered per day, and time spent with client were a l l recorded numerically. If a range was given, the lesser of the midpoint was used. The newspaper advertisements alluded to in this category appeared to be those placed by the Vancouver Volunteer Bureau. Where multiple answers were given for prime function and satisfaction, the answers given f i r s t and second were recorded. Only the f i r s t answers given were recorded for least important function, frustrations, good features, needed improvements, and principal activity. Analytical Approach Some of the variables (listed on p.85) chosen to assess the volunteer's evaluation of the Vancouver-Richmond Meals-on-Wheels organization were grouped for analytical and discussion purposes. For example, the variables "length of service," "number of days worked per week," and "number of hours worked per month" were measured on an interval scale and each is examined to assess the level of volunteer "commitment." However, a few variables such as "method of recruitment" are assessed under the heading "method of recruitment," because questions relating to this topic were open-ended. A number of discrete responses were given under this general open-ended question( e.g., influenced by friends, relatives, advertisements, news reports, etc.). Ethics Since the primary instrument used in this investigation was a questionnaire involving human subjects, approval was sought and obtained from the University - 87 -of British Columbia's Behavioural Sciences Screening Committee for graduate research. Results and Discussion The results of the questionnaire survey are presented below. As noted above, the variables used to assess the Vancouver-Richmond Meals-on-Wheels organization were grouped into discrete categories for discussion purposes. Degree of Commitment Volunteer commitment, in this study, was measured on the basis of the volunteer's length of service, the number of days worked per week, and the number of hours worked per month. The s t a t i s t i c a l summary of these variables i s produced in Table II. Table II Indicators of Degree of Commitment Variable Mean Median Mode Range Missing cases Length of service in years 6.6 5 2 0 1 - 1 8 2 Days worked/week 1.2 1 1 1 - 5 0 Hours worked/month 11.9 8 8 >1 - 60 8 Number: 65 The division of hours worked per month into hours with clients, paid staff, at meetings, and doing paperwork had a range of 38.5% to 44.6% missing cases and, therefore, was of l i t t l e value. Only 25% of those answering spent any time in contact with paid staff. Only 16.2% of volunteers who responded spent any time at meetings; 75% spent no time on paperwork. Length of Service. Length of service was expected to be the most decisive of the questions used to e l i c i t information on volunteer commitment. Length of service data (Table II) showed that the average length of time volunteers had worked with Vancouver-Richmond Meals-on-Wheels was just over 6 1/2 years. Anderson and Moore's (1974) B.C. study showed the average time spent by volunteers with the present agency to be 3 1/2 years. Using their data as means of comparison, Vancouver-Richmond Meals-on-Wheels volunteers showed far greater commitment than the average volunteer in Canada. Hours Worked Per Month. Anderson and Moore (1974) showed that 44% of volunteers worked less than 4 hours per week and 6% worked more than 80 hours per month. The average number of hours worked per month by Vancouver-Richmond Meals-on-Wheels volunteers (Table II) was 11.9 or 2.7 hours per week (11.86 - 4.3). There was only one individual who worked 80 hours per month. Conversations with Vancouver-Richmond Meals-on-Wheels volunteers indicated that many performed other volunteer work as well, so that the total number of volunteer hours worked per week may well exceed the national average. Certainly i f Meals-on-Wheels is not their only form of volunteerism, they are devoting a very large portion of their time to Meals-on-Wheels. Days Worked Per Week. Meals-on-Wheels is structured so that the average volunteer is required to work only 2 hours one day each week. There were 9 individuals (13.1%) in the sample (Table II) who worked more than 1 day per week. Fourteen did multiple jobs (e.g., driver and day captain, PWA driver, and driver/server, etc.). There did not appear to be any standard of comparison in - 89 -Meals-on-Wheels organizations i n Canada by which to measure this, but multiple jobs were considered an indication of commitment. Further data on volunteer commitment is shown from the client interview data presented in Chapter 5. Reasons for Volunteering The reasons given for volunteering were: To help others 25.8% Asked by friend or volunteer 14^5% Meals-on-Wheels a worthwhile program 19.4% Needed interesting & useful leisure time 16.1% Answered a c a l l for help 11.3% Duty 4.8% Other 8.1% There were 3 missing cases. "Others" included: "Meals-on-Wheels helped my husband when I was away"; "My aunt in Ontario set a good example"; "I joined after my Mother's death"; "I enjoy working with seniors"; "Someday I may need the service and i t must be there"; and "It interested me more than other a c t i v i t i e s . " Level of Satisfaction Walster et a l . (1978) showed volunteerism not to be altruism in i t s absolute form (acting without any reward, internal or external, real or psychological). Kennett (1980) defined i t as quasi-altruistic behaviour, which appears to be a l t r u i s t i c but has hidden motives (peer recognition, status, etc.). Francies (1983) concluded that satisfactions for volunteers are similar - 90 -to those for paid workers but, aside from social aspects of the work, they are ranked differently. Francies (1983) defined these needs-motivations as the need: For experience. To express feelings of social responsibility. For. social contact. To respond to the expectations of others. For social approval. For future rewards. To achieve. The Meals-on-Wheels volunteers who answered the questions did not appear to perceive their reasons for volunteering in this light. Some of Francies' (1983) categories would have had only 1 answer (e.g., need for future rewards or need for social approval). However, their answers to the question on satisfaction did f i t this model to some extent. Need for social contact was further divided into "contact with c l i e n t " and "contact with other volunteers". The need to express feelings of social responsibility was also divided into "helping others", "seeing clients improve", and "satisfying a community need". "Need for future rewards" was not included because there was only one answer in this category. Although the categories differed, the underlying reasons were retained. The answers that were used to determine satisfaction were the replies to those questions concerning satisfaction, frustrations, good features, improve-ment needed, recommended joining, opinion re: training, support from staff, opinion re: work recognition, degree of trust and information required. - 91 -Table III Volunteer Satisfaction - 1st Answers Value Label Value Frequency Percent Valid Percent Help Others 1 23 35.4 39.7 Client Appreciation 2 11 16.9 19.0 Client Contact 3 9 13.8 15.5 See Client Improve 4 2 3.1 3.4 Community Need 5 4 6.2 6.9 Avoid Institution-alization 6 4 6.2 6.9 Volunteer Contact 7 1 1.5 1.7 Accomplishment 8 3 4.6 5.2 Other 9 1 1.5 1.7 0 7 10.8 Missing TOTAL 65 100.0 100.0 Valid Cases 58 Missing Cases 7 Mode 1 - 9 2 -T a b l e I V V o l u n t e e r S a t i s f a c t i o n - 2 n d A n s w e r s V a l u e L a b e l V a l u e F r e q u e n c y P e r c e n t V a l i d P e r c e n t H e l p O t h e r s 1 5 7.7 18.5 C l i e n t A p p r e c i a t i o n 2 7 10.8 25.9 C l i e n t C o n t a c t 3 3 4.6 11.1 S e e C l i e n t I m p r o v e 4 1 1.5 3.7 C o m m u n i t y N e e d 5 1 1.5 3.7 A v o i d I n s t i t u t i o n -a l i z a t i o n 6 1 1.5 3.7 V o l u n t e e r C o n t a c t 7 3 4.6 11.1 A c c o m p l i s h m e n t 8 3 4.6 11.1 O t h e r 9 3 4.6 11.1 0 38 5 8 . 5 M i s s i n g TOTAL 65 100.0 100.0 V a l i d C a s e s 27 M i s s s i n g C a s e s 38 Mode 2 S a t i s f a c t i o n T a b l e s I I I and I V show t h e f i r s t and s e c o n d a n s w e r s g i v e n t o t h e q u e s t i o n : "What a r e some o f t h e m a i n s a t i s f a c t i o n s y o u a r e g e t t i n g f r o m y o u r v o l u n t e e r w o r k now?" The o n e " o t h e r " a n s w e r i n f i r s t a n s w e r s was " a somewhat c l e a r e r c o n s c i e n c e . " 8 4 . 5 % o f f i r s t a n s w e r s ( T a b l e I I I ) and 5 9 . 2 % o f s e c o n d a n s w e r s ( T a b l e I V ) w e r e c l i e n t - o r i e n t e d . T h e p o s i t i v e a n s w e r s , t h e m u l t i p l e a n s w e r s (some v o l u n t e e r s d i d n o t h a v e e n o u g h s p a c e t o l i s t t h e m a l l and made an a r r o w t o t h e b o t t o m o f t h e p a g e ) , and t h e e n t h u s i a s m e x p r e s s e d a l l i n d i c a t e a h i g h d e g r e e o f s a t i s f a c t i o n . _ 93 -F r u s t r a t i o n s . Over 1/4 of the respondents r e p l i e d that they had no f r u s t r a t i o n s with the Meals-on-Wheels o r g a n i z a t i o n . The most frequent reply from those who d i d have f r u s t r a t i o n s were r e l a t e d to f a c t o r s beyond the c o n t r o l of the o r g a n i z a t i o n . "Weather , " " t r a f f i c , " and " p a r k i n g - r e l a t e d " were c i t e d as second most f r u s t r a t i n g elements of the o r g a n i z a t i o n . T h i r d l y , was " c o l l e c t i o n -r e l a t e d " problems at 15.1%. " C l i e n t not home" (9.4%) and "not t o l d of changes" (7.5%) were next , r e s p e c t i v e l y . "Food r e l a t e d " and "Lack of time with c l i e n t " were low at 5.7% each . Other f r u s t r a t i o n s were: " O f t e n get c l i e n t s too la te to help them," "shortage of spare v o l u n t e e r s , " and "when no one answers the door o r phone i t ' s a worry wondering what happened." Good F e a t u r e s . Good features mentioned were p r i m a r i l y " f o o d r e l a t e d , " " s o c i a l s u p p o r t , " and " p r e v e n t i o n of i n s t i t u t i o n a l i z a t i o n . " Others i n c l u d e d a v a r i e t y of answers: " H e l p i n g e l d e r l y couples stay t o g e t h e r ; " " h e l p i n g to maintain d i g n i t y and independence;" " the meal i s a n e c e s s i t y f o r many;" " f o r some a v i s i t would appear to be almost e q u a l l y i m p o r t a n t ; " " i t g ives the c l i e n t something to look forward t o ; " and "keeps a check on t h e i r h e a l t h problems . " Improvements Needed. An i n d i c a t i o n of the high degree of s a t i s f a c t i o n experienced by v o l u n t e e r s was that 19.5% stated that no improvement was needed; while 3 4 . 1 perceived a need f o r improvement i n the q u a l i t y of the food. Less than h a l f saw any room for improvement i n the o r g a n i z a t i o n or the s e r v i c e . Improvements perceived as being needed were f i r s t : " F o o d - r e l a t e d ; " second, " o t h e r ; " and t h i r d , "none needed." " O t h e r " answers appeared to f o l l o w no - 94 -pattern. They covered sanitation, communication, philosophy, policy, and administration. They were as follows: Directions in finding the streets. More volunteers. Becoming too business oriented and getting away from the personal touch. We should remember we are dealing with people (not always alert or well) not figures on a page. Follow up. We never know where our clients are or how they are progressing when meals are cancelled due to hospitalization, etc. Appreciation shown by the clients. Better communication with staff. Not my business. Adequate reporting on cards e.g. "off today" instead of "cancelled". Maybe contacting other authorities i f a recipient needs help in other ways. This is outside Meals-on-Wheels' role but sometimes a word in another direction might help. Some plan to clean the empty (styrofoam containers) more eff i c i e n t l y , but i f administration is satisfied, I am. Sometimes I would like fuller cooperation from someone at head office. Feel area chairmen should be informed more fully on what is going on and volunteers given more chance to participate in new regulations and change policy. Recommendations to Others to Join. The overwhelming number that expressed satisfaction by recommending to others that they too become Meals-on-Wheels volunteers is perhaps the strongest indication of satisfaction expressed. To the question: "Have you ever recommended joining this volunteer program to an of your friends or family?", 42 replied "yes, definitely," 17 replied "general mention," and 6 replied "no, not really." There were no missing cases. Type of Training Received. Satisfaction with respect to training was not as high. The mean was about mid-way between average and good. Room for improve-ment exists here. The level of sustaining and corresponding intervention is o - 95 -an informal, neighbourly (family, friend, neighbour) type. Implications for training are that intervention training (e.g., social work, dietetics) would not be appropriate in this non-case-finding organization. However, further or different training of Meals-on-Wheels volunteers might increase volunteer satisfaction. 60.9% were trained on the job by other volunteers. 15.4% received no training; and 12% were trained at a central office orientation program. Other methods of training were verbal instruction, observation, common sense, and by working in other volunteer programs. More than 2/3 thought the training was "average or good;" 7.7% replied "excellent;" and 4.6% claimed training as " f a i r to poor." There were 12 missing cases. Support from staff. Again, high satisfaction was expressed regarding staff support. 52.7% responded "good;" 23.6% "average;" 21.8% "excellent;" and, 1.8% " f a i r to poor." There were 10 missing cases. Some specified that the volunteers were very supportive but that there was no contact with paid staff. Work Recognition. Work recognition again showed high satisfaction. The mean was half way between good and excellent. Even those who replied that there was none, did not mark their opinion of this as poor or f a i r . The unexpected replies were the source of recognition. Only 9.6% perceived i t as being from administration. Apparently the recognition from recipients and fellow volunteers was sufficient for most volunteers. - 96 -In rank, work recognition was good (54.8%), average, excellent, f a i r and poor. Work recognition was perceived to be by "clients" (34.6%), "by other volunteers" (19.2%), "none" (17.3%), "don't know" (9.2%), "by administration" (7.7%). "Other" included: I don't look for recognition. I receive (there is) a free lunch every Monday. Newspaper, radio, word of mouth. I don't want recognition but i t would be nice to have a pat on the back once in a while. My church knows and a bulletin i s posted and mention made from the pulpit. By volunteer week. Degree of Trust. Although there were 21 missing cases, of those who answered, most were of the opinion they were trusted. The negative and other answers indicated considerable dissatisfaction. The majority appeared to be very pleased with the degree of trust placed in them. 88.6% responded "yes" to the question: "Are you trusted to do important things?" 9.1% answered "no." In addition to the 21 missing cases there were two unrelated answers of "not interested;" and "have been but new regulations are curtailing trust and responsibility of volunteers with relation to clients." The respondent did not specify what new regulations. Information Received. Satisfaction with the amount of information received was positive. Over half replied that they did not want further information. Those who did were usually specific in their requests or they were very c r i t i c a l . - 97 -72.5% replied "no" to the question: "Would you like more information about the organizations?" 27.5% replied "yes." There were 14 missing cases. Level of Socialization Questions that related to time spent with each client, perceived prime function, and frustrations were an attempt to e l i c i t information on the degree of socialization with the client. Parkum (1982) argued that volunteers can make a contribution toward alleviating feelings of helplessness and that the contribution volunteers can make is substantially different from the services of health care professionals. Granovetter (1973) argued that "weak ties" are important, contrary to "received wisdom" which takes for granted the primacy of close intimate relationships and regards more distant ties as alienating. Granovetter 91973) pointed to the indispensable role of weak ties in providing individual access to community integration and to a wide range of socially distant opinion and information. More recently, others have looked at the significance of these weak ties in the extended network and their role in identity formation (Hirsch, 1979). Minutes Spent with Clients. Time spent with clients may or may not be important. Quality of time spent with clients appeared to be very good. The volunteers expressed contact with clients as a considerable source of satisfaction. Contact by telephone was not included in the question, due to the policy of Meals-on-Wheels, but one suspects that i t existed. The time spent with clients will be compared form the clients' and volunteers' points of view in Chapter 5. - 98 -Perceived Prime Functions. Although volunteers perceived their prme function to be "food-related," their second most important function was perceived as "social support." It was anticipated that lack of time with recipients would have rated higher on the l i s t of frustrations than i t did. The overall data indicated that contact did exist on more than a "deliver the meal only" basis and that this basis was beneficial to both clients and volunteers. Only 23 volunteers answered the question "Least important function." Of these, 11 gave answers categorized as "other." The remaining 12 answers were fa i r l y evenly divided among "food-related," "social support," and "remove f o i l plate." "Other" included the following replies: F i l l i n g out unnecessary forms. (3) Washing up containers when returned to the kitchen. (2) Talking about their ailments too much. Everything I do is important. (2) Nothing, Nothing, Nothing. Method of Recruitment Why and how an individual became a Vancouver-Richmond Meals-on-Wheels volunteer was detailed and had few missing cases. This type of information could be acted upon immediately for recruitment. There is l i t t l e sense in wasting great effort on sources that do not yield much result (e.g., TV, radio, posters, and pamphlets) when newspaper advertisements and churches both yield double the number. Additional data are required to determine which, i f any, sources of recruitment yielded the most lik e l y sources of long-term volunteers. - 99 -The most frequent method of recruitment was unsolicited volunteerism. Variations on "I just phoned in and offered" were given by 20 volunteers. The next most frequent, at 14, was that they were asked by a friend, neighbour, or relative. Asked to help by active Meals-on-Wheels volunteers was third with a frequency of 9. Church associations and answering an advertisement in the paper both occurred 6 times. Advertisements on T.V., radio, posters, and pamphlets accounted for only 4. There were 5 missing cases. Principal Activity Driver, server, or both comprised 78.5% of the volunteers who replied. 10.8% were day captains, 6.2% area chairmen, and 4.6% PWA drivers. It should be noted that screeners were frequently also drivers, and/or servers, hence, those li s t e d as drivers and servers f i r s t were recorded as being in the category. Thus, there were no screeners recorded, even though there were 4 screeners who answered the questionnaire. Perceived Goals of Meals-on-Wheels The data from the questions re: prime function, least important function, good features, improvements needed, method of training, how work was recognized*, and goals provided an overview of how the volunteer perceived Meals-on-Wheels. Table V shows the volunteers' perception of their prime function in answer to the question: "What is the most important thing you do for your client?" Other answers included "getting to know them;" "understanding and relating to their handicaps;" "whatever I can do within my power;" "calling on them twice - 100 -a week;" "helping with the shopping;" "mailing letters and running errands;" "perhaps you should ask the clients;" and, "I don't know, ask the c l i e n t . " The volunteers perceived their prime function to be 62% food-related and 25% social support in the f i r s t answer, and 21% food-related and 67% social support in their second answer (Table V). It was apparent that their perception of Meals- on-Wheels was a social-support-related food service. The number who cited "prevention of institutionalization" and the "performing of unrelated tasks" reinforced this notion. Table V Prime Function as Perceived by Volunteers Most Important Next Most Important Prime Function Frequency Valid Percent Frequency Valid Percent Food-related 37 61.7 5 20.8 Social support 15 25.0 16 66.7 Prevent i n s t i t u t i o n a l i -zation 1 1.7 0 Perform unrelated tasks 4 6.7 3 12.5 Other 3 5.0 0 Missing data 5 41 Number: 65 Their perception of the good features of Meals-on-Wheels were 38% "food-related," 22% "social support," and 21% "prevention of institutionalization" which, in i t s e l f , is a form of "social support." Their perception of their least important function was in the category of "other" which included "everything is important". "Food-related" functions and "social support" were only 4% and 3% respectively. - 101 -Their concepts of needed improvements were f i r s t in the area of food; secondly, a firm statement that none were needed; and, thirdly, a recommendation for increased social support a c t i v i t i e s . Only 9.4% of volunteers were trained by the central office. The volunteers appeared to be satisfied with this system and comments such as "as i t should be" indicated that they regard their d i s t r i c t as an autonomous unit. Recognition by administration was only 9%, yet the volunteers thought this was "very satisfactory." The goals of the organization were not clearly defined. They varied among individuals and among categories of workers. "Food-related" goals were only 29% while "prevention of institutionalization" and "helping others" were each 22.7% (Table VI). Table VI Volunteers' Goals Value Label Value Frequency Percent Valid Percent Help Others 1 14 21.5 22.6 Food Related 2 18 27.7 29.0 Social Support 3 6 9.2 9.7 Prevent Institution-alization 4 14 21.5 22.6 Don't Know 5 2 3.1 3.2 Good, Fine, Etc. 6 3 4.6 4.8 Meet a Need 7 3 4.6 4.8 Other 8 2 3.1 3.2 9 3 4.6 Missing TOTAL 65 100.0 100.0 Valid Cases 62 Missing Cases 3 Mode 2 - 102 -Comments The comments were not precoded. A l l comments were recorded without regard to o r d e r i n g f o r m u l t i p l e answers. They were as f o l l o w s : More v o l u n t e e r s needed. (7) E x c e l l e n t program. ( 6 ) Poor communication from o f f i c e . (4) F r i e n d l y v o l u n t e e r s . (3) Enjoy i t . (3) C l i e n t s apprec ia te i t . (2) Need recrui tment from the media. (2) Need younger v o l u n t e e r s . (2) V i s i t i s important . (2) And ONE each of the f o l l o w i n g : A pleasure not a chore . A p r i v i l e g e not an o b l i g a t i o n . Keep i t p e o p l e - o r i e n t e d . Nice o f f i c e s t a f f . Not much h e l p from o f f i c e . Clean up c o l l e c t i o n system. Volunteers need a thank you . Wish I could do more. Invaluable s e r v i c e . S o c i a l get togethers are very enjoyable and allow a marvellous o p p o r t u n i t y to become acquainted with other workers . T h i s i s always a p l u s . Does anyone show a p p r e c i a t i o n f o r the use of church k i t c h e n s ? A complete survey of c l i e n t s needed. When we take i n i t i a t i v e from people we are not h e l p i n g them. I found the Christmas card to be o f f e n s i v e . Who wants to be reminded of being f r u s t r a t e d , e t c . None of us are g e t t i n g any younger. Suggest that someone from the o f f i c e v i s i t the v a r i o u s Meals-on-Wheels groups to get to know the v o l u n t e e r s , hear t h e i r concerns and suggestions to perhaps make the system work b e t t e r . A n a l y s i s A f t e r the data were perused and c l e a n e d , SPSS c o n d e s c r i p t i o n f o r a l l v a r i a b l e s provided the b a s i c d e s c r i p t i v e s t a t i s t i c s of frequency, modes, mean, median, and standard d e v i a t i o n . Cross t a b u l a t i o n s were performed f o r four sets of v a r i a b l e s for which p o s i t i v e c o r r e l a t i o n s were expected: - 103 -Type of training and opinion re: training Source of recruitment and length of service-Perceived prime function and time spent with client. Volunteer hours/month and work recognition. The sample size was 65. Therefore, in order to achieve a reasonable number in each c e l l , the data were collapsed in the following manner: Source of recruitment was collapsed to three categories: friend, neighbour, relative or volunteer; just offered; and, a l l remainder. Length of service was collapsed to: 0 - 2 years, 2.1 - 5.5 years, 5.6 - 10 years, 10.1 - 18 years. Perceived prime function was collapsed to: food-related, social support, and a l l remainder. Time spent with each client was collapsed to 1 - 4 minutes, 5 minutes, and 6-12 minutes. Volunteer hours per month was collapsed to 0 - 8 and 9 - 60. Work recognition was collapsed to: none by client, by other volunteers, a l l remaining categories. Type of training was collapsed to: none, on the job by volunteers, and a l l remaining categories. Opinion regarding training was collapsed into one category for f a i r and poor because there were only 3 answers in the two categories. In each instance continuous variables (interval scales) were bracketed to provide categories of nearly equal number. Nominal scales were bracketed to maintain the most relevant categories. It was assumed that on the job training by other volunteers would be the most r e a l i s t i c and, therefore, receive a higher rating by the volunteers. Those receiving no training were expected to show marked dissatisfaction. The data did not confirm this (Table VII). - 104 -Table VII Opinion Re Training/Type of Training Opinion Re: Training Excellent Good Av erage Fair & Poor Type of Training Count Row Pet None On Job By A l l remain- Row Col Pet Volunteers der Total 1 4 1 5 80.0 20.0 9.8 11.8 9.1 2 1 15 f 5 21 4.8 71.4 23.8 41.2 16.7 44.1 45.5 3 4 14 5 23 17.4 60.9 21.7 45.1 66.7 41.2 45.5 4 1 1 2 50.0 50.0 3.9 16.7 2.9 : O L U M N 6 34 11 51 TOTAL 11.8 66.7 21.6 100.0 Chi-Square 5.45812 D.F. Significance 0.4865 Min E.F. Cells with E.F. < 5 10 of 12 (83.3%) 0.235 Number of Missing Observations = 14 It was expected that volunteers recruited by their peers would remain longer with the organization. This was not proven. There was a borderline trend toward greater length of service by unsolicited volunteers (Table VIII). It was anticipated that volunteers who perceived the service as primarily social support would spend more time with clients than those who perceived i t as food related. The data may show this as a slight trend, but does not prove i t (Table IX). - 105 -Table VIII Cross-Tabulation of Method of Recruitment by Length of Service Length o f Service Count Row Pet Col Pet 0-2 2 .1-5.5 5.6-10 10.1-18 ROW Method of 1 2 3 4 TOTAL Recruitment 1 6 i l 3 3 23 Friend, Neighbor, 26.1 47.8 • 13.0 13.0 38.3 Relative or Volunteer 37.5 57.9 21.4 27.3 2 6 2 8 4 20 Just Offered 30.0 10.0 40.0 20.0 33.3 37.5 10.5 57.1 36.4 3 4 6 3 4 17 A l l Other Categories 23.5 35.3 17.6 23.5 28.3 25.0 31.6 21.4 36.4 COLUMN 16 19 14 11 60 TOTAL 26.7 31.7 23.3 18.3 100.0 Chi-Square D.F. Significance Min E.F Cells with E.F 9.37306 6 0. 1537 3.117 6 of 12 (50.05 Number of Missing Observations = 5 Table IX Cross-Tabulation of Prime Function — 1st Answer by Minutes Spent with Each Client Count Time spent with client in minutes Row Pet Col Pet 0-4 5 6-12 ROW 1 2 3 TOTAL Prime Function 1 id 10 9 37 Food Related 48.6 27.0 24.3 61.7 66.7 66.7 50.0 2 5 4 6 15 Social Support 33.3 26.7 40.0 25.0 18.5 26.7 33.3 3 4 1 3 8 A l l Others 50.0 12.5 37.5 13.3 14.8 6.7 16.7 COLUMN 27 15 18 60 TOTAL 45.0 25.0 30.0 100.0 Chi-Square 2.23238 D.F. Significance Min E.F. 4 0.6931 2.000 Cells with E.F. < 5 T o l 9 (55.6%) Number of Missing Observations = 5 - 106 -It was expected that work recognition from administration would result in longer hours worked. Source of work recognition did not appear to be a factor in amount of time worked (Table X). Table X Cross-Tabulation of Hours Per Month by Work Recognition Work recognition Hours per Count Row Pet Col Pet None 1 By Client 2 By Other Volunteers 3 A l l Others 4 ROW TOTAL Month I 0-8 5 20.8 55.6 9 37.5 50.0 4 16.7 40.0 6 25.0 40.0 24 46.2 2 9-60 _ 4 14.3 44.4 9 32.1 50.0 6 21.4 60.0 9 32.1 60.0 28 53.8 COLUMN TOTAL 9 17.3 18" 34.6 10 19.2 15 28.8 52 100.0 Chi-Square D.F. Significance Min E.F. Cells with E.F. < 0.80820 3 0. 8475 4.154 3 of 8 (37.5%) Number of Missing Observations = 13 Chi-square analysis showed no significance in any case. The data are, therefore, not sufficiently robust to show significant correlation between any of these four sets of variables. The National Center on Volunteerism Scoring Method (Appendix Q) was used for those questions selected from this data gathering tool to be included in the volunteer questionnaire. The scoring system used was graded by percentage of volunteer organizations that the score exceeds. Aggregate answers given by Meals-on-Wheels volunteers were higher than 75% of volunteer programs. - 107 -Limitations to the Responses Although the sample size was probably adequate (10%) the fact that i t was a non-randomized sample, and the method of distribution and collection, made i t impossible to state with any certainty that the study had r e l i a b i l i t y or v a l i d i t y , or was unbiased. The sample distribution was f a i r l y representative of the distribution of volunteers in the various categories working on a given day. Doubt was cast on the probability that they were a l l volunteers working on a Monday when one questionnaire was returned with the reply to the question, "How many days do you work per week" as "1 day — Wedneday." A further problem with the replies was that there was no consistency in the answers. The answers to goals, good features, and prime functions did not produce similar percentages of answers in each category. One proof of sincerity of answers was that, although the questionnaire was designed to provide anonymity, many of the respondents signed their names. Generalizability Given the limitations of the study, the results can be stated to be repre-sentative of the entire population of Vancouver-Richmond Meals-on-Wheels volunteers only i f qualified by r e l i a b i l i t y and v a l i d i t y limitations. It was not within the scope of this study to determine profile, turnover, etc. A data base would be required for this type of analytical study. None exists at present. - 108 -Summary As anticipated, the results were more qualitative than quantitative. Certain facts were stressed repeatedly. The volunteers were dedicated, concerned, caring individuals. Their satisfaction came from knowing they were providing a worthwhile and badly needed service. Commitment was strong. Meals-on-Wheels is far broader than just a nutritional service. It is a valuable social service and one that contributes to the maintenance of the individual in his or her own environment. It bears out Carter's (1975) theory that volunteer services have many advantages over private or government services. These are: the freedom to c r i t i c i z e , advocacy role on behalf of particular groups, involvement, f l e x i b i l i t y , and the a b i l i t y to individualize need. A l l these merits were expressed by the volunteers in this study. - 109 -CHAPTER 5: THE CLIENTS' POINT OF VIEW Introduction There has been no previous attempt to assess client satisfaction in Vancouver-Richmond Meals-on-Wheels. The organization has not attempted any formal assessment of the recipients' perception of the service. Evaluation of food by the general public is totally subjective. "Good food" is food that satisfies emotional, local, cohort group, ethnic preconceived conceptions, and ingrained habits of eating. There was ample literature for assessing patient and/or client satisfaction under the general theme of volunteerism (Bellamy & Wells, 1974; National Information Center on Volunteerism, 1977; Parkum, 1982). Tested instruments for meal satisfaction were those designed primarily for hospitals. B.C.H.A. has a detailed food satisfaction questionnaire which has been available for several years. Its programmed computer analysis is simple enough to be understood by anyone. In addition, dietetic departments in most hospitals have tray audit forms for department use and patient satisfaction questionnaires. Each provincial dietetic association has developed some standard forms for quality assurance. There does not appear to be any tested instrument available in Canada for assessing Meals-on-Wheels client satisfaction. The only evaluation of Vancouver-Richmond Meals-on-Wheels was that performed by Vancouver Health Department dietitians for nutritive content. Previous studies of Vancouver-Richmond Meals-on-Wheels have not been con-cerned with client satisfaction or any aspects of food quality. The one study that was intended to be nutrition status-oriented was not allowed to proceed. - 110 -No one can better determine the needs of the recipients than the recipients themselves. The data in the client interview presented in this chapter provides information on meal satisfaction and social interaction with the volunteer, as well as comments on the clients' perception of the overall service. Method Design This was a descriptive cross-sectional study to determine recipients' attitudes towards the food, the volunteers, and general satisfaction with Vancouver-Richmond Meals-on-Wheels. It was anticipated that this study would be more descriptive than analytical. The decision to use interviews, rather than questionnaires, was based on the physical limitations of many of the subjects. Questionnaires require less time, but are better suited to individuals who are not physically impaired. Many of the subjects in this study have impaired eyesight, some degree of mental confusion, and/or poor coordination for writing. Given these constraints, i t seemed more li k e l y that an interview would be less threatening than a questionnaire and, therefore, more li k e l y to yield a reply. Eight non-randomly selected recipients were asked their preference. Two said they would try but f e l t they would be unable to answer a questionnaire. A l l eight said they would enjoy an interview i f their names were selected. The sample population chosen were a l l recipients of Vancouver-Richmond Meals-on-Wheels who were receiving meals between January 14, 1985 and January 24, 1985. Cessation of service between this date and the time of the interview did not preclude anyone. The sample comprised 100 randomly selected subjects. The interviews took place between March 18, 1985 and April 1, 1985 in each recipient's home. Sampling The coordinator estimated the population to be 600. Previous sampling of this population for profile data had revealed a population of 528 at that time. It was, therefore, assumed that the population would more closely approximate the latter. Using the f i r s t three digits from a table of random numbers, the f i r s t random number was selected blind. Random numbers were then recorded in order, discarding those over 530, until 100 numbers were obtained. These numbers were then rearranged in numerical order. The client cards were f i l e d in alphabetical order. They were assumed to be numbered in the order f i l e d . Cards were pulled in accordance with the random numbers. Sample Size In the data from the past client profile, i t was determined that the mode for length of service was 5 days and the median was 28 days. Cancellation of service was not deemed to disqualify any interviews but many cancellations were due to hospitalization and admission to Long Term Care f a c i l i t i e s . Therefore, i t was desirable to obtain names and addresses in as short a time period as possible in order not to lose subjects. A sample size of 100 (19%) was obtained during the period from January 14 to January 24, 1985. A total of 39 interviews were completed. No follow-up of those not replying was contemplated. If the client had mislaid the consent form (and confusion and poor memory are not uncommon in this type of sample); i f they were unable to walk to a mail box; or, i f they were unable to read, write, or understand the form, follow-up cards would not be of any great value in increasing replies and, furthermore, they could cause stress to the recipient. If the recipient were deceased, follow-up could prove distressing to the family. Instrument The interview form consisted of 17 questions (Appendix R). Questions 1, 2, 3, 4, 6, 7, and 8 were extracted from the Dniversity of Alberta Hospital Dietary Department Patient Meal Satisfaction Questionnaire, 1984. This instrument was selected because of a l l the dietary department food satisfaction questionnaires perused, i t contained the most simply worded questions. Questions 12, 13, 14, 15, and 17 were from the Basic Feedback System, National Information Center on Volunteerism, Boulder, Colorado, 1977. These questions were chosen to s o l i c i t answers on degree of satisfaction and social contact with volunteers. Questions 5, 9, 10, 11, and 16 were peculiar to Meals-on-Wheels and had no outside source. Less than half the questions were open-ended. These provided data on 19 variables: Serving size. Temperature of hot food. Temperature of cold food. Appearance. Left overs reheated. Satisfaction with delivery times. Foods liked best. Foods liked least. Rating of meals. Length of wait. - 113 -P r i c e . L e n g t h o f v o l u n t e e r s ' v i s i t . G o o d t h i n g s d o n e by v o l u n t e e r . L e s s h e l p f u l t h i n g s d o n e b y v o l u n t e e r s . New t h i n g s v o l u n t e e r c o u l d d o . S u g g e s t i o n s . P r e f e r e n c e r e : l o c a t i o n . Comment s. T h e i n t e r v i e w was t e s t e d o n f e l l o w s t u d e n t s a n d d i e t i t i a n s f o r c l a r i t y , e a s e o f a n s w e r i n g , a n d t i m e r e q u i r e d . I n t e r v i e w c o d i n g i s s h o w n i n A p p e n d i x S. Where p o s s i b l e , a L i k e r t s c a l e was u s e d f o r m e a s u r e m e n t . I t w a s a n t i c i p a t e d t h a t some s u b j e c t s w o u l d h a v e a s p o u s e a l s o r e c e i v i n g M e a l s - o n - W h e e l s . D e s p i t e t h e t e m p t a t i o n t o i n c r e a s e t h e s a m p l e s i z e , i t was d e c i d e d t h a t o n l y t h e i n d i v i d u a l s e l e c t e d w o u l d be i n t e r -v i e w e d i n o r d e r t o e n s u r e c o m p l e t e r a n d o m i z a t i o n . I n t h e c o d i n g , t h e t e r m " s t a r c h " was u s e d t o i n c l u d e p o t a t o , d e s p i t e t h e f a c t t h a t i t i s a v e g e t a b l e i n t h e t u b e r c l a s s . E x p e r i e n c e i n w o r k i n g w i t h t h e l a y p u b l i c i s s u c h t h a t s t a r c h i s a m o r e r e a d i l y a c c e p t e d t e r m f o r p o t a t o e s — d e s p i t e t h e f a c t t h a t t h e p u b l i c c l a s s i f i e s r i c e p u d d i n g a s a d e s s e r t . C a r b o -h y d r a t e w o u l d h a v e b e e n t o o e n c o m p a s s i n g b e c a u s e i t w o u l d h a v e i n c l u d e d g r a i n s , v e g e t a b l e s , a n d f r u i t s . T h e t e r m s t a r c h was deemed a p p r o p r i a t e f o r a c o h o r t g r o u p t h a t g r e w up a t a t i m e when t h e w o r d was i n common u s e . E t h i c s The i n s t r u m e n t o f m e a s u r e m e n t was a n i n t e r v i e w t e c h n i q u e i n v o l v i n g human s u b j e c t s . T h e r e f o r e , a p p r o v a l f o r t h i s r e s e a r c h was s o u g h t a n d o b t a i n e d f r o m t h e 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 ' s B e h a v i o u r a l S c i e n c e s S c r e e n i n g C o m m i t t e e . - 114 -Distribution of Questionnaires Letters and consent forms were mailed on February 13, 1985. Only 98 of the original 100 were mailed because the office staff requested two people be deleted, one because she had been admitted to hospital, and one because, although he did receive one box lunch per week, he was primarily a volunteer who delivered meals. Three clients phoned and refused. One client's son phoned and explained that his Mother did not speak English and that she wished to convey her regrets. He f e l t the language barrier was such a problem that an interview would not be feasible even with an interpreter. Three letters were returned, unopened, and marked: "No longer at this address." 42 written replies were received. One read "no thank you." The other 41 gave signed consent. One included a written note which read: "I am 92 1/2 years old but although very deaf I s t i l l have my Scottish accent, mind, and I can be outspoken when necessary." During the course of the interviews, two of the recipients cancelled, one because he was just out of hospital and was too i l l , and one because she had shingles and "didn't feel up to i t . " In a l l , 51 of the sample were accounted for and 39 interviews were completed. The overwhelming positive response was far greater than expected. Interviews The interviews were completed by three unpaid interviewers between March 18 and April 1, 1985. Each interviewer was trained by the investigator. Each was given a letter of introduction for the clients and a copy of the precoded - 115 -a n s w e r s i n o r d e r t o a s s u r e r e l i a b i l i t y . T h e i n t e r v i e w e r s p h o n e d e a c h c l i e n t a n d a r r a n g e d a n a p p o i n t m e n t p r i o r t o t h e i n t e r v i e w . E a c h i n t e r v i e w e r c o n s u l t e d w i t h t h e i n v e s t i g a t o r a f t e r t h e f i r s t t w o i n t e r v i e w s w e r e c o m p l e t e d . A s a l l t h r e e w e r e c o m p e t e n t a n d e x p e r i e n c e d , n o d i f f i c u l t i e s w e r e e n c o u n t e r e d d u r i n g t h e i n t e r v i e w s . T h e c l i e n t s s o e n j o y e d t h e v i s i t s f r o m t h e i n t e r v i e w e r s t h a t many i n t e r v i e w s w e r e l o n g e r t h a n a n t i c i p a t e d . R e l i a b i l i t y o f c o d i n g was e n s u r e d b y h a v i n g a f e l l o w g r a d u a t e s t u d e n t c o d e f i v e r e t u r n e d i n t e r v i e w s . T h e y a g r e e d w i t h t h a t d o n e by t h e i n v e s t i g a t o r . R e s u l t s a n d D i s c u s s i o n T h e r e c i p i e n t s i n t e r v i e w e d w e r e a v a r i e d g r o u p . F o u r w e r e i n t h e i r m i d -n i n e t i e s . Many r e c e i v e d Homemaker S e r v i c e a s w e l l a s M e a l s - o n - W h e e l s . T h i s v a r i e d f r o m 1 d a y e v e r y t w o w e e k s t o f i v e d a y s / w e e k . One r e c i p i e n t was a r e t i r e d p h y s i c i a n who l i v e d w i t h h e r h u s b a n d . One g e n t l e m a n was d e a f a n d m u t e . One g e n t l e m a n was a r e t i r e d c a t e r e r ; o n e l a d y h a d w o r k e d i n f o o d s a l l h e r l i f e . One c o u p l e s h a r e d o n e m e a l a t n o o n a n d r e h e a t e d a n d s h a r e d t h e o t h e r m e a l a t n i g h t . Two r e c i p i e n t s w e r e j u s t b a c k f r o m v a c a t i o n . One 92 y e a r o l d , who h a s a r t h r i t i s , h a d n o t b e e n o u t o f h e r s e n i o r c i t i z e n h o u s i n g a p a r t m e n t f o r o v e r a y e a r a n d a h a l f . One l a d y h a d a c a r w h i c h h a d b e e n i n h e r g a r a g e f o r t h r e e y e a r s b e c a u s e s h e was no l o n g e r a b l e t o d r i v e . One l a d y l i v e d i n h e r k i t c h e n w i t h a b e d i n i t , b e c a u s e s h e was c o n f i n e d t o a w h e e l c h a i r . T h i s d i d n o t s t o p h e r f r o m t a k i n g a t r i p a r o u n d t h e w o r l d l a s t y e a r . One h a d c a n c e l l e d M e a l s - o n - W h e e l s s e r v i c e . O f t h e 39 i n t e r v i e w e d , s i x r e p r e s e n t e d o n e o f a m a r r i e d c o u p l e , b o t h o f whom r e c e i v e d M e a l s - o n - W h e e l s . E v e n t h e i r c o n s t r u c t i v e - 116 -cri t i c i s m of the service was understanding. It was usually sandwiched between statements of appreciation and praise. They were not quite so enthusiastic about the food i t s e l f . Criticism of food was mainly constructive c r i t i c i s m of specific items. Variety Considerable concern was expressed by those who f e l t there was insufficient variety in food served. Yet 48.7% said there was "always" sufficient variety and 23.1% replied "usually". Sometimes was 5.1%, "rarely" 10.3%, and "never" 12.8%. None of the recipients interviewed were without an opinion on variety. These data are somewhat confusing. 71.8% were satisfied "usually or always" with the variety, and yet the open-ended question re: comments (Table XIV) resulted primarily in suggestions that would add variety to the menu. In addition, six people answered "more variety." Possibly the nine responders of "rarely" and "never" were particularly concerned with this aspect of the food service, and the others offering menu suggestions were merely expressing food preferences. Further information gathering from a larger sample of recipients might serve to c l a r i f y this. Price Price was deemed to be " a l l right" by 64.1% of the respondents. 10.3% considered i t "too high", 10.3% considered i t "too low", and 12.8% volunteered the information that they would be willing to pay more for better quality food, - 117 -better choice, and/or more variety. There were no missing cases. The comments included: If I was a cook my $15 could do better. Not worth i t . High for quality of food. Too expensive for value delivered. Would be willing to pay 50$ more for better quality. If food was good i t would be alright. Generally price too high for quality of food delivered. Good quality for the price. Couldn't get i t by myself for that price. The price appeared to be satisfactory (64.1%) but many clients were not satisfied with the quality received for the price. It is unlikely they were unaware of the rise in cost of food because they purchase food for their other meals (11 - 18 out of 21 meals per week). Some said they would be willing to pay more for better quality food. This may have a great deal to do with the rapid turnover of clients but, without further data, this remains speculative. Pearson correlation coefficients were performed for rating of meals and variety and rating of meals and price. As anticipated, there was a high corre-lation between how the meals were rated and how variety was rated. Pearson r = .6411. There was far less correlation between how the meals were rated by the recipients and price. (Pearson r = -.3699). Serving Size Serving size was satisfactory to 31 (79.5%) respondents. One replied "a l i t t l e too large"; three, "a l i t t l e too small"; and four, "much too small". Again, there was no missing data. - 118 -Thus serving size appeared to be very satisfactory. Since 35% reheat leftovers to some degree i t would appear that the large servings provided are consumed — even i f i t is at two separate meals. There is no way to check returns ( i . e . , food not consumed) in a service such as this, nor would i t be desirable to do so. Thus, size of serving evaluation i s dependent on the recipient's satisfaction and cost. Temperature The temperature of the cold food was "satisfactory" to 88.2%. There was room for improvement in temperature control for hot foods. Only 69% replied that the temperature of the hot food was "satisfactory", yet 41% "reheated the food" (Table XI). This did not include those who reheated the entire meals for use as an evening meal. The Vancouver Health Department checks food temperatures only infrequently as is to be expected with their workload. Food temperature can be easily and quickly tested with a temperature probe designed for this purpose. Meals-on-Wheels does not employ any individuals whose training has been food- or nutrition-oriented. Eagle Catering does attempt to provide hot food of the correct temperature. However, i t is a service geared to the chill/freeze system of delivery. Part of the problem may be in the closure of the styrofoam carrying boxes. A nutritionist could easily rectify the problem and, in a l l probability, would have prevented i t by monitoring temperature at point of service and point of delivery. - 119 -Appearance "Appearance" did not receive as high a rating as "variety". Equal numbers (11) replied "acceptable" and "good"; 8 replied "excellent"; 1, " f a i r " ; and 7, "poor". There was 1 missing case. One person replied "yes, except for white f i s h . " Overall appearance was "acceptable", "good", or "excellent" to 75% of those receiving the meals. The importance of appearance in food service cannot be overemphasized in relation to satisfaction. If even 1 client in 4 found the appearance to be only " f a i r " or "poor" then careful evaluation of colour combinations, visual shapes, and spillage should be conducted. Food Consumption Heating of leftovers revealed an interesting pattern of consumption of food: TABLE XI Descriptive Statistics for Reheating of Food VALUE LABEL VALUE FREQUENCY PERCENT VALID PERCENT CUM PER( Always 1 8 20.5 20.5 20.5 Sometimes 3 4 10.3 10.3 30.8 Rarely 4 2 5.1 5.1 35.9 Never 5 11 28.2 28.2 64.1 Entire Meal Reheated 6 4 10.3 10.3 74.4 Reheated for Later Consumption 7 10 25.6 25.6 100.0 TOTAL 39 100.0 100.0 VALID CASES 39 MISSING CASES 0 MODE 5.000 Over 1/4 consumed the food as an evening meal. One in five recipients always consumed the food as two meals. The 10.3% who reheated the entire meal - 120 -(Table XI) was a further indication that the temperature of the hot food was not satisfactory. Mealtime was "satisfactory" to 86.5%. The one answer categorized as "other" was "no preferences". Two other comments were added to this answer. One was "garbage disposal i s a problem with chicken leg" and the other was "good nourishing meal for people who can't get around". The reason mealtimes were so satisfactory may be that some clients use the meal for both lunch and dinner and prefer to eat the food on the day i t is prepared, rather than keeping i t until noon the next day. It may also be because some clients keep the entire meal refrigerated and eat i t for their evening meal. It was not indicated s p e c i f i c a l l y , but the concern for, and appreciation of, the volunteers that was expressed repeatedly may also be a factor. Many recipients were aware of the d i f f i c u l t i e s of driving in 5 o'clock t r a f f i c and the likelihood that some volunteers would be unable or unwilling to deliver meals when they were expected to be preparing dinner at home. Food Preferences Foods "liked best" and foods "liked least" f e l l primarily in the "entree class" (71.8% and 51.4%), although "starch" was mentioned by 21.6% as a food "liked least". The following shows a breakdown of categories into actual food preferences: - 121 -Foods liked best Foods liked least Chicken 19 Chicken a l a king 1 Fish 9 Fish with white sauce Fish sticks with tartar sauce 4 Meat 1 Roast beef 3 Hamburger 4 Meatloaf 2 Meatballs 2 Shepherd's pie 3 Rolled braised beef 4 Stew 3 Stroganoff Pork 0 Macaroni & cheese 1 Gravy -1 1 12 4 7 (tough) (too dry, too tough) 2 (tough) 1 1 (poor quality) Vegetables Vegetables Carrots Peas Yellow beans Hot tomatoes Mixed vegetables Salad Green beans Zucchini 5 3 2 1 1 1 1 (served too often) 2 1 1 2 1 1 1 Starch Pasta (no sauce) Potatoes Mashed potatoes Baked potatoes Bare boiled potato Esealloped potato Rice 4 3 1 14 1 2 1 (dried out) - 122 -E . Desserts Foods liked best Foods liked least Desserts A l l desserts with raisins Cream desserts Jel l o Fruit j e l l o Canned fru i t Mixed f r u i t Brown betty Apple pie Chocolate pudding Dream whip Bread pudding 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 The recipients were not hesitant to state food preferences, nor were they lacking in imagination and sound nutritional concepts. Pasta headed their dislikes. This was to be expected in a cohort group that grew up with bread and potatoes as their most common starch intakes. Since no one li s t e d plain pasta as a food liked best, i t would appear that i t should either be removed from the menu or served infrequently. In the l i s t of foods disliked, white fish with white sauce was a close second to pasta. Fish i s recognized as a controversial food by anyone knowledgeable about food. There were almost equal numbers pro and con for f i s h . Therefore, i t would seem desirable to provide an alternate when fish i s served. Theoretically, this is done, yet two people interviewed said they had asked Meals-on-Wheels for an alternate when fish was on the menu and were told they could not have this. There were no missing cases for the variable "food liked best." This i s a strong indication that the recipients know what they like and are eager to state their preferences. There do not appear to be any contradictions to asking the clients what they want, providing a l l clients understand that the fi n a l decision rests on majority preference. - 123 -Cost is easily balanced by menu adjustment of expensive items to a slightly lower frequency. The general rating of meals only served to emphasize that satisfactory food is food that the clients liked. Rating of Meals General rating of meals was "Good": 50%, with remaining answers f a i r l y evenly distributed. Table XI shows the distribution for this variable. TABLE XII Rating of Meals VALUE LABEL VALUE FREQUENCY PERCENT VALID PERCENT CUM PERCENT Excellent 1 4 10.3 10.5 10.5 Good 2 19 48.7 50.0 60.5 Acceptable 3 4 10.3 10.5 71.1 Fair 4 5 12.8 13.2 84.2 Poor 5 6 15.4 15.8 100.0 9 1 2.6 MISSING TOTAL 39 100.0 100.0 MEAN 2.737 STANDARD 1.288 MINIMUM 1.000 MAXIMUM 5.000 DEVIATION VALID CASES 38 MISSING CASES 1 Waiting Time for Acceptance Length of waiting period before acceptance by Meals-on-Wheels showed: "right away", 13; "few days", 10; "1-3 weeks", 9; "can't remember", 2; "other", 3; and missing cases, 2. One of the other answers was 6 months and two did not give an answer relevant to the question (e.g. fine). These data on length of waiting period before being accepted by Meals-on-Wheels relied on respondents' memory and, therefore, may not be as valid as the answer to other questions. For everyday events, accuracy of r e c a l l tends to - 124 -vary inversely with distance in time from the event. Data for this variable would be more accurate i f i t were obtained by observation over a given period. This was not within the scope of this study. The length of the volunteers' v i s i t in minutes was reported as having a mean of 3.0, a median of 2, and a mode of 2. The data from the volunteers' questionnaire in answer to this question showed a mean of 5.6, a median of 5, and a mode of 5. The actual length of volunteers' v i s i t s was not anticipated to agree with that reported in the volunteers' questionnaires. It is common wisdom that pleasurable experiences often are perceived as shorter in duration than they actually are. A comparison of the perceptions of the volunteers and the clients i s : Socialization with Volunteers Volunteers' Report Clients' Report Mean Median Mode Minimum Maximum Standard Deviation Valid Cases Missing Cases 5.6 2.2 5 5 1 2 2 1 8 12 2.6 1.9 47 18 38 1 The responses to the question: "What are some of the good things your volunteer does that helps you?" varied from none (18), to praise of the - 125 -volunteer (8), to specific answers. The following were some of the most frequent comments: Volunteers are A - l , always a smile. Nice people, courteous, very pleasant. Service good, meals good. A wonderful service, wonderful people. The "angels" are very pleasant and cooperative. Bring meal. Will store food in appropriate place i f not home. Visited with spouse. Send Valentine cards. Flowers on Thanksgiving and other occasions. Find telephone numbers. Xmas goodies, cakes, etc. Brings odd g i f t . Brings reading material. Posts l e t t e r s . Goes to bank for me. Gifts at different seasons. Stayed with me un t i l ambulance arrived. Less helpful things done by volunteers were "none": 87.5%, "food spillage": 9.4%, and "use of aluminum plate": 3.1%. New things the volunteer could do that would help resulted in an answer of "nothing required" by almost a l l the clients (valid percent equalled 81.3) Many added comments such as: Would interfere with meal delivery to others. Too much to ask of the volunteers. None. They don't have to because they have a delivery schedule to keep. Only three suggestions were given: "mailing", "cut food when necessary", and "might inquire whether meal brought the previous day was alright". - 126 -Change Suggestions for change were as shown in Table XIII. TABLE XIII Suggestions for Improvement VALUE LABEL VALUE FREQUENCY PERCENT VALID PERCENT CUM PERCENT Nothing needed Satisfied as is Less food spillage Better food Specific item Other 1 2 4 5 6 8 9 10 2 1 16 1 5 4 25.6 5.1 2.6 41.0 2.6 12.8 10.3 28.6 5.7 2.9 45.7 2.9 14.3 28.6 34.3 37.1 82.9 85.7 100.0 TOTAL 39 100.0 MISSING 100.0 MODE VALID CASES 5.000 35 MISSING CASES 4 Other included: Previous caterer was better (2). Meals better now (2). Does salt free have to be diabetic? Would appreciate extra food or meal on weekend. Better quality for meats. Improved packaging to lessen spillage. Would appreciate improvement of the meals (3). Food too bland. More variety in desserts. Nothing more was required of the volunteers. Improvement in "quality of food", "prevention of spillage", and "dislike of the aluminum plates" was expressed. The latter problem may be due to the fact that volunteers were asked to collect used aluminum plates for recycling and some clients expressed unfounded apprehension that the collection might be for reuse. The questions re: "good things", "less helpful things", and "possible new things" done by volunteers resulted in effusive and enthusiastic praise of the volunteers, understanding of the needs of other clients, appreciation of the - 127 -basic tasks and a l l the extra things done by the volunteers, and an unwillingness to ask for more from those who so generously give of their time. Location Preference of location was overwhelmingly "at home". A l l 39 recipients answered. Twenty-nine preferred to eat "at home", 4 replied they had no option because they were unable to go out, and 5 replied they would like to eat out (some stipulated only occasionally). One answered he much preferred to eat at home but would enjoy an outing but not to eat out. The investigator knows the advantages of socialization. The literature bears this out. The client does not want socialization in a group setting at mealtime. Once again, needs are in danger of becoming confused with wants. The prevention is simple: consult the user. One lady mentioned that poor sight resulted in spotted clothing and eating in a group would be embarrassing. One gentleman said occasional incontinence would force him to cancel Meals-on-Wheels i f he were forced to eat in a group setting because he didn't always "smell too good." Another gentleman said his manners were not f i t to eat in a group — he had been eating alone too long and, besides, his dentures didn't f i t too well. Some clients said they had no choice because they were unable to go out due to physical d i s a b i l i t i e s . There was general agreement that socialization should not be associated with mealtimes. - 128 -Comments The comments were primarily food-related, although praise for volunteers and praise for Meals-on-Wheels were also expressed repeatedly. Table XIV shows the comments. TABLE XIV Comments VALUE LABEL VALUE FREQUENCY PERCENT VALID PERCENT CUM PE! Food related 1 15 38.5 48.4 48.4 Praise for volunteer 2 6 15.4 19.4 67.7 Praise for service 3 8 20.5 25.8 93.5 Other 8 2 5.1 6.5 100.0 9 8 20.5 MISSING TOTAL 39 100.0 100.0 MODE 1.000 VALID CASES 31 MISSING CASES 8 The food-related comments (Table XIV) were mainly menu improvement suggestions. They were as follows: A. Soups More soups (2) B. Entrees Stuffing with roast pork Same meats too often Stew is tough Serve pineapple s l i c e with ham Sausages please (2) Meat pie Ham back on menu C. Vegetables Salad (10) Turnips and carrots mashed together (3) Lettuce with dressing (2) More greens Beet root (pickled beets) (2) - 129 -Parsnips (3) Carrots overused (2) Coleslaw (2) More tender green beans Cut salads fine D. Starch Potatoes instead of macaroni (2) Improve baked potatoes (2) E. Desserts Rice pudding with lots of raisins (5) Bread pudding with raisins (4) Fewer jell o s (4) Sago pudding Banana loaf (3) Fresh fru i t (3) Pie Prune whip English muffins Carrot cake Bread pudding Raisin pie Al l desserts with raisins Fresh f r u i t salad White cake Custard Apple turnover Less chocolate pudding More creamed desserts Rice pudding F. Other menu suggestions More variety (6) Substitute tartar sauce for white sauce with fish Pickles Strong cheese Improve the gravy More orange juice Other comments were: Same foods Monday/Wednesday/Friday - may cancel. People are fortunate to have this service. Volunteers are absolutely great. Foods are tasty. Delightful. Prefer Meals-on-Wheels to food provided by my own children. Swanson TV dinners are a better deal but.I can't manage f o i l , l i f t i n g , oven. - 130 -Not happy with meals but not readily mobile. Meals are second grade. Use Meals-on-Wheels because TV dinners contain MSG which I cannot have. Not able to get a hold of nutritionist at Meals-on-Wheels despite repeated c a l l s . Volunteers are wonderful people. Flat noodles are d i f f i c u l t to manipulate; shells are impossible with fork because of o i l . Meals-on-Wheels should ask clients about food needs, especially diabetics. Never asked by Meals-on-Wheels about this. Shouldn't o i l vegetables. When pasta a main course - protein not adequate. Prefer 4 meatballs (they recently reduced this number). Would like potato with roast beef. Would like to have fru i t not puddings, because of diabetes. Service great. The meals are good. Delighted to have them but they could be a l i t t l e more tailored to the receivers' tastes. Appetite has improved with Meals-on-Wheels. Pleased the service is available so we can stay in our own environment. Homemaker service i s not frequent enough to substitute for Meals-on-Wheels. Have a flashlight to make sure oven temperature is right for reheating (blind except for peripheral vision). Quit drinking tea and coffee - up too much in the night. Have one drink with lunch and one with dinner. Couldn't get along without Meals-on-Wheels. I understand you cannot cater to individual preferences, but couldn't you consult the group? I think i t ' s excellent and am very happy to have i t because I feel so much better. The suggestions regarding menu improvement were reasonable and most could be implemented without increased cost. Desserts requested were, for the most part, nutritionally sound. There is no excuse for j e l l o on a menu for this clientele. Sausages are not expensive as a main entree. However, pickles and cheese are additions that would increase cost. They require no preparation and, therefore, should be provided by the clients themselves, although cheese and crackers for dessert might be economically feasible. - 131 -The other suggestions g iven or i m p l i e d are a lso sound. They i n c l u d e c o n s u l t a t i o n of the u s e r , a v a i l a b i l i t y of n u t r i t i o n a d v i c e , and more p r a i s e f o r the v o l u n t e e r s and the o r g a n i z a t i o n . The u n s o l i c i t e d comments i n p r a i s e of the volunteers and a l l the n i c e l i t t l e extras that the c l i e n t s mentioned, served to r e i n f o r c e the c o n c l u s i o n that the v o l u n t e e r s are committed beyond the norm for v o l u n t a r y o r g a n i z a t i o n s . L i m i t a t i o n s of the Study R e l i a b i l i t y was increased by p r e c o d i n g , t r a i n i n g of i n t e r v i e w e r s so that they a l l asked the same quest ion i n the same way and i n the same o r d e r , and recoding of 5 i n t e r v i e w s by another s tudent . I n d i c a t i o n s of r e l i a b i l i t y were i d e n t i c a l r e s u l t s i n the recoding and the s i m i l a r i t y of answers r e c e i v e d by a l l three i n t e r v i e w e r s . Interviewer b i a s was reduced by c a r e f u l s e l e c t i o n of i n t e r v i e w e r s , t r a i n -i n g , and the use of three people i n s t e a d of one. As soon as one gets i n t o v e r b a l d a t a , the quest ion of v a l i d i t y a r i s e s . Three f a c t o r s that a f f e c t v a l i d i t y i n an i n t e r v i e w are a c c e s s i b i l i t y , c o g n i t i o n , and m o t i v a t i o n . The respondents had the i n f o r m a t i o n and the experience of Meals-on-Wheels s e r v i c e was an ongoing one. They c e r t a i n l y were not l a c k i n g i n o p i n i o n . C o g n i t i o n was enhanced by us ing p r e v i o u s l y tes ted questions s e l e c t e d from two sources . M o t i v a t i o n was r e a f f i r m e d by i n i t i a l d e c i s i o n to cooperate ( s i g n i n g of consent form) and the subsequent d e c i s i o n to continue (grant ing of i n t e r v i e w ) . The knowledge that the i n t e r v i e w e r s and the i n v e s t i g a t o r were engaging i n an e d u c a t i o n a l research projec t and were not c o l l e c t i n g data f o r Meals-on-Wheels should have d i m i n i s h e d any d e s i r e to i n g r a t i a t e . The a d d i t i o n a l - 132 -unsolicited comments and the fact that there were only 43 missing cases for 741 responses (39 x 19) is indicative of their lack of fear, suspicion, embarrass-ment, or d i s l i k e . Validity should be assured by random sampling, pretested questions, and precoding, as well as consideration of the foregoing factors. The limitations of the study were that the analysis of correlation between "rating of meals" and "variety" and "rating of meals" and "price" was based on a rather small number for Pearson correlation coefficients. Possibly the size of the sample may also be a limitation. Generalizability The findings should be representative of the entire population receiving Meals-on-Wheels in Vancouver and Richmond. However, the food preferences were so individual in nature that a similar study with a larger sample would probably be of even greater use in determining user preference of clients in Vancouver-Richmond Meals-on-Wheels. Summary Four things were repeated over and over again in the comments and the answers. Appreciation of the service and the volunteers was far greater than anticipated. Most recipients were unstinting in their praise for the volunteers. The second was an acceptance and understanding of the volunteers' problems and time constraints. The third was a forgiving attitude toward any shortcomings in Meals-on-Wheels service. The fourth was a mild disappointment in the actual food and an eagerness to offer suggestions for improving i t . Quality was a subjective value judgment based primarily on preferences, although - 133 -a few c l i e n t s were conversant with food s e r v i c e and o f f e r e d some c o n s t r u c t i v e - s u g g e s t i o n s based on knowledge of l i m i t a t i o n s of t ime, d i s t a n c e , and c o s t . The areas where s a t i s f a c t i o n was p a r t i c u l a r l y high were with s e r v i n g s i z e s , temperature of c o l d f o o d , meal t imes , promptness of acceptance on M e a l s - o n -Wheels s e r v i c e , c o s t , and of course , contact with v o l u n t e e r s . Areas where there was room f o r improvement were v a r i e t y , appearance, temperature of hot f o o d , lack of o p p o r t u n i t y f o r c l i e n t i n p u t , and to some degree, a w i s t f u l comment that i t would be n i c e i f the v o l u n t e e r s had more time f o r s o c i a l i z i n g when the meal was d e l i v e r e d . The one area where improvement i s s o r e l y needed i s f a i l u r e to consul t the u s e r . The c l i e n t s welcomed both the s o c i a l aspects of the i n t e r v i e w and the oppor tuni ty to p a r t i c i p a t e i n e v a l u a t i o n of the s e r v i c e . C l i e n t input should be an ongoing p r o c e s s . I t i s not d i f f i c u l t . The c l i e n t s were eager to cooperate . Assessment t o o l s are a v a i l a b l e f o r food s a t i s f a c t i o n which c o u l d r e a d i l y be adjusted to be s u i t a b l e f o r Meals -on-Wheels . Perhaps the i n t e r v i e w form used i n t h i s study could serve as a model f o r o b t a i n i n g c l i e n t i n p u t . The a t t i t u d e of the v o l u n t e e r s expressed i n Chapter 4 and the obvious rapport between c l i e n t s and v o l u n t e e r s , i n d i c a t e d that i t would be f e a s i b l e to d i s t r i b u t e q u e s t i o n n a i r e s through the v o l u n t e e r s . I f t h i s were not s u i t a b l e , i n a l l p r o b a b i l i t y the Volunteer Center c o u l d f i n d i n d i v i d u a l s capable and w i l l i n g to conduct i n t e r v i e w s . The i m p l i c a t i o n s of t h i s data are t w o - f o l d . F i r s t , i t could be used as a source of i n f o r m a t i o n f o r use i n making improvements r i g h t now. Secondly , the f i n d i n g s could be used as a data base f o r future e v a l u a t i o n s of Meals-on-Wheels c l i e n t s a t i s f a c t i o n . - 134 -CHAPTER 6: CAN ORGANIZATION THEORY HELP TO PROVIDE A BETTER MODEL OF ORGANIZATION? Introduction There i s a lack of information on Meals-on-Wheels organizations in the literature. It was not possible to find a model there against which to measure Vancouver-Richmond Meals-on-Wheels organization. Furthermore, the concept of Meals-on-Wheels organization has not been worked out by other important constituents in B.C. who might have helped with the definition of role and function. This study was not concerned with cl a r i f y i n g the assumptions about the social support role of Meals-on-Wheels. It was taken for granted that such a role was socially approved, though lacking in c l a r i t y . Possibly there could be further studies on Meals-on-Wheel's contribution to domiciliary care of the elderly, i t s cost effectiveness, and so on, but these issues were not dealt with here. The main focus was upon internal organization and management of immediate boundary problems, not on these broader p o l i t i c a l issues. The questions which were of concern to the investigator were list e d in Chapter 1 as follows: Who are the clients? Have they changed over the years? Are they satisfied with the food and the service? Are the volunteers satisfied? How can recruitment of volunteers be increased? How can volunteers be retained? Who are the staff? Are they a good f i t for the organization and i t s purposes? - 135 -What are the goals of Vancouver-Richmond Meals-on-Wheels? Do clients, volunteers, management, related agencies, and government view Meals-on-Wheels differently? Is i t an effective organization? How does Meals-on-Wheels compare with recognized best practice organizational management theory? Is improvement needed, and i f so, what? Two questions were added after observing the workings of the organization: Why does i t work even with deficiencies in management (i.e. planning, implementation, control, and evaluation)? Are deficiencies due to lack of expertise or fear of change? Chapter 5 showed that the clients were relatively satisfied, with the exception of certain foods, so i t was decided to move from a client model to an organizational management model in order to provide a basis for diagnosis of Meals-on-Wheels. It was thought that help in diagnosis of organizational problems might be found in the organization and management literature and so this was consulted. There is a considerable volume of organization theory literature, so i t was decided to be very selective in using i t , focusing only upon the areas identified in Chapter 3, assuming these to be most relevant to an organization in this class, namely a voluntary organization delivering food to peoples' homes. It was hoped to identify "best practices" by aligning Gordon's (1983) diagnostic model with that of Donabedian (1966), but to draw on volunteer literature as well. - 136 -Best Practices Gordon is not preoccupied with models, but her book is clearly written and i t was not d i f f i c u l t to pull out a model from i t that was consistent with her writing and useful for diagnosis of Vancouver-Richmond Meals-on-Wheels. Most of the organization theory literature is concerned with manufacturing organizations, though some books discuss service industries. Thus, the concept that clients are inputs would not be considered in these terms except in specific publications about volunteer organizations (reviewed in Chapter 2). In organization theory, service to clients i s part of the output and they would be considered at that end of the continuum, rather than as inputs. Gordon's model, as interpreted by the investigator i s : Inputs Human Resources Motivation Materials Finance Management systems Goals Process Materials flow Power Leadership Conflict Groups Communication Change Defense mechanisms Structure Differentiation Integration Balance Controls Outcome Quality of service Commitment - 137 -Satisfaction Effectiveness Gordon, and those quoted by Gordon, appeared to provide a relevant model for diagnosis. Volunteer literature was included in order to increase this relevance to Vancouver-Richmond Meals-on-Wheels. Inputs In Chapter 3, inputs were discussed under a series of subheadings namely: clients, volunteers, food, financing, and the organization. In Gordon's model, inputs are comprised of human resources, motivation, materials, finance, management systems, and goals. Human Resources The four principles of s c i e n t i f i c management are workers' selection, training, task analysis, and motivation. The importance of exposure to significant others and opportunity for upward mobility are common wisdom in human resource management. Gordon (1983) indicates that internal sources of recruitment, particularly employee referrals, are the most satisfactory source of personnel. Turnover is related to recruitment. Three recognized best practices for reducing turnover are r e a l i s t i c job previews, suitable training, and matching the job to the employee. Motivation Motivation influences the priorization of goals. Beveridge (1948) concludes that the prime motive in volunteerism is a specialist motive. It is a desire to make l i f e happier for others by one's personal action. Carter (1974) - 138 -states that the most frequent motive in volunteerism is a mixture of altruism and self-interest. Briggs (1982) states: Volunteers then, are d i s t i n c t l y different from paid workers, in that they value different aspects of a job assignment. People who are prospective volunteers arrive at the program's door, for the most part, not with overflowing a l t r u i s t i c motives, but with real needs for self-growth, for work experience, for building self-esteem, for enjoyment, for building relationships with others, for contributing to valued goals, for a f f i l i a t i n g with an organization or i t s staff, and so on. (p. 4) Francies (1983) categorizes volunteers' needs under seven headings: 1. The need for experience. 2. The need to express feelings of social responsibility. 3. The need for social contact. 4. The need to responds to the expectations of others. 5. The need for social approval. 6. The need for future rewards. 7. The need to achieve. Motivation is a complex process. Gordon (1983) cited best practice as planned process which satisfies unmet needs, directs behaviour, evaluates performance, and provides rewards. Materials Materials should be appropriate for the organization. They should result in a product that is competitive in the marketplace. Best practice involves careful planning by knowledgeable personnel. Part of this knowledge should be acquired by ongoing research. - 139 -Financial Resources A l l organizations require planning as part of their financial policy. Add-on budgeting is not recognized as proper planning. Program Planned Budgeting System is too complex for an organization with only one program. Zero Based Budgeting would be the most appropriate practice for Meals-on-Wheels. Economic efficiency i s the relationship between inputs and outputs. Best practice i s the production of a given output at least cost. Volunteer literature emphasizes the importance of funding that does not destroy the freedom of the volunteer agency. Management Systems Management systems should be consistent with (1) the demand of the organizational task, (2) external environment or technology, and (3) needs of the members of the organization. Goals A l l organizations have goals, whether stated or implied. Goals are multiple. Every organization and every individual within the organization has more than one goal. Thus, priorization of goals is essential for communi-cation as well as measured outcome and evaluation. Management by Objectives is an organizational management theory that has remained in vogue longer that most. Goals are essential for planning, management, and evaluation. Szilagyi (1981) l i s t s the four c r i t e r i a for good goals as cla r i t y and specificity, tim-ing, consistency, and achieveability. Goals should be clear and specific to al members of the organization concerning desired outcomes. In order to achieve the desired outcome, goals should specify a time frame so that a l l members of - 140 -the organization have similar expectations. Goals should be ordered by time frame, but much more importantly, by order of importance. Gordon (1983) adds to this that goals should be consistent with the boundaries imposed by the internal resources and the external environment. Goals should not be so d i f f i c u l t that they cause frustration, but they should be sufficiently d i f f i c u l t to stimulate improved performance. They should be worded in such a way that degree of attainment of the goals can be measured. Conflicting goals may result in goal displacement. Best practice is a planned strategy for avoiding goal displacement. The more heterogenous the goals, the more complex the structure required to respond to them. Removal of uncertainty as to o f f i c i a l and operative goals reduces goal displacement. Inputs w i l l not result in goal achievement unless appropriately u t i l i z e d . Process Process is the way inputs are transformed into outcomes. The investigator concentrated on those processes relevant to volunteer organizations such as Meals-on-Wheels. Process encompasses many facets of the organization. The discussion in this study w i l l be limited to materials flow, power, leadership, role c o n f l i c t , groups, communication, change, and defence mechanisms. Materials Flow With the advent of the computer, tools and techniques for flow of materials have changed. The tenets have remained the same. Production should be integrated into the system, not tacked-on. Area managers should be consulted regularly. Observation must be ongoing. Feedback is essential to - 141 -effective production. Production must be appropriate for the environment (e.g., type of work force). Power Under power, Gordon discussed a number of ideas about relationships which seemed particularly pertinent. Many theorists use the term power to describe social relationships or mutual dependence or influence. Power can be coercive, remunerative, or normative. It has three dimensions: weight, domain (number of persons affected), and scope (range of behaviour determined). Sources of power vary. They are often multiple. Bacharah and Lawler (1980) identify five bases of power. Legitimate power derives from the individual's position in the organization. Expert power occurs because the individual possesses special knowledge. It can be formal (e.g., the physician) or informal (e.g., the indispensible secretary). Referrent power arises when an individual aligns with a powerful person. Reward power stems from an individual's control over rewards (salary, work assignments, promotions). Coercive power occurs when the individual has sufficient authority to arouse fear in others. Bacharah and Lawler's (1980) description of bases of power was almost identical to Gordon's (1983). Perrow (1963) claims an organization will be controlled by those individuals who perform the most d i f f i c u l t tasks. The characteristics of this dominant group will determine major operating policies, and thus organizational goals. Sometimes two or more groups share power. Cumming (1968) regards best practice as symmetry of control between the client and the agency. The client has the balance of power when the organization seeks the client, the wait for service is short, the client is - 142 -screened individually instead of in a group, the client has the freedom to quit the agency, pays for the service, and is served by a supportive (rather than a controlling) agency. The agency has the balance of power when in-referral has a long scalar configuration, the client is seeking something scarce, the client seeks the agency, the agency controls entrance, the wait for service i s long, and the agency i s supplying a specialized service not available elsewhere. Kotter (1983) suggests best practice to be the reduction of job-related dependence so that managers do not feel the need to spend great energy and vast quantities of time on gaining, maintaining, or using power. Leadership Some theorists believe certain personality t r a i t s predict effective leadership. This t r a i t theory has not proven to be very reliable. Some theorists propound behavioural theory. This can be viewed as production-oriented versus employee-oriented. It can also be categorized by leadership style. Is the leader's style authoritarian, democratic, or laissez-faire? Theories of single best leadership style do not stand up well to empirical research. The contingency theory, which Gordon advocates as best practice, postulates that appropriate behaviour depends on the circumstances at a given time. Multiple leadership is not regarded as ideal, but i f i t does exist there are theories of best practice for this contingency. Perrow (1963) discusses multiple leadership in volunteer organizations. This tends to occur when goals are m u l t i p l i s t i c , lack precise c r i t e r i a for achievement, and allow considerable tolerance with regard to achievement. Other situations that foster the emer-gence of multiple leadership concern groups. If the interests of the group - 143 -diverge, or i f each group has the power to protect i t s own interests, then multiple leadership may occur. If this multiple leadership exists, i t requires f a c i l i t a t i n g leadership. Best practice in this situation is someone who w i l l keep explosive issues from erupting and can maintain easy relationships among the groups. These are f a c i l i t a t e d by maintaining an open door policy, s o c i a l -izing with the workers, and keeping communication channels open. Multiple leadership relies on accommodation. It requires that those involved put a premium on harmony. Conflict Role conflict or confusion is a source of stress. It stems from a number of situations. It can result from inappropriate structure. It can occur when there is conflict in the expectations of the authoritative body. It occurs when different people have different expectations of the leader. It occurs frequently when the leader has conflicting roles. Personal role conflict results when a leader is expected to violate personal values. Conflict can result when a leader is expected to f i l l too many roles. Role ambiguity and the role of integrator with too many facets often contribute to leadership stress. Individuals occupying positions at the organization's boundaries are potentially susceptible to c o n f l i c t . Best practice is to reduce stress by reducing or eliminating as many of the foregoing causes as are feasible. Conflict within the organization can be lessened, i f not resolved. Lawrence and Lorsch (1968) offer three prescriptions for resolving c o n f l i c t . They present confrontation as the best practice. The discussion of differences and working u n t i l a solution is found are far more effective than using power to - 144 -win a point or smoothing over differences. They also recommend an effective system of organization — one in which decision-making is at those levels where the knowledge about the factors affecting decisions are located. The use of integrators is an effective way of resolving conflict. Allan (1967) offers two additional solutions. He suggests that improving upwards and downwards communications flow and rapid response to divisional requests reduce conflict. Groups Group interdependence can be pooled, sequential, or reciprocal. Groups have different perceptions. They tend to have different goals and social orientations. Individuals within the groups differ . L i t t le wonder that conflict exists. Members of cohesive groups are more capable of dealing with stressful situations than members of loosely structured groups. Competition, forcing, and avoidance have limited effectiveness, and then only under certain circumstances. Compromise may result in sharing positions, but it does not maximize satisfaction of any group. Collaborating and accommodating appear to be the best practice under most conditions. Communication Communication accuracy is often poor. Receivers f i l ter information through their personal perceptual and attributional processes. Lower status members in an organization tend to suppress the upward flow of unfavourable information. Interpersonal relationship between sender and receiver affect accuracy of communication. Gordon's (1983) concept of best practices of communication are: 1. Use descriptive, not evaluative speech. Do no imply that the receiver needs to change. - 145 -2. Do not try to control the listener. Use a problem-oriented approach. 3. Be honest and spontaneous. Do not try to conceal strategy or true purpose. 4. Show empathy for the listener. Acknowledge the legitimacy of the listener's problem. 5. Express equality rather than dominance. 6. Avoid being dogmatic. Be open to change. Change Particular attention was paid to the volunteer literature on change. Wolfenden (1978) believes the voluntary movement is a liv i n g thing; changing, some being born, some dying. Carter (1974) envisages volunteer organizations changing and improving in administration, decision-making, priority-setting, and communication. Mintzberg's (1979) theory i l l u s t r a t e s that change is essential to survival. Change is inevitable. Forces for change are both external and internal. Change is rarely a welcome process. It is usually resisted because i t is inconvenient, disrupts social interactions, and generates fear of the unknown. Best practices include accepting the i n e v i t a b i l i t y of change, identifying the causal elements, and planning the implementation of i t . Evaluation provides the tool for corrections during the process. Kaluzy and Hernandez (1983) suggest best practice to be to identify the type of change as rational, resource dependency, or population ecology. The nature of the task, internal resources, structure, and values w i l l affect the responses to change. Increased knowledge about the type of change w i l l determine the combinations of strategy. They suggest best practice to be re-education, persuasion, f a c i l i t a t i n g , and coercion. - 146 -Defence Mechanisms Gordon (1983) suggests that demand by external elements can be reduced by reducing dependence on those elements. Carter recommends s e l f -evaluation. Beveridge (1948) i l l u s t r a t e d the efficicacy of showing a social need for the organization. Strong statements such as his, "We need philanthropy to make and keep something other than personal gain as the dominant force in society" or the media's "We need to increase health care in B.C." are believed by some of the people some of the time — veracity notwithstanding. Perrow (1963) shows that avoidance of goal setting i s a defence mechanism. He states that one of the consequences of the accommodation of group interests under multiple leadership i s the avoidance of long-range planning. By avoiding the question of what is i t s distinctive competence and i t s responsibility, the organization i s no longer a means for achieving goals that are rationally established and publicly offered for community inspection and support. Defence mechanisms are seldom discussed in the literature from the viewpoint of ju s t i f i c a t i o n . Structure Most volunteer organizations have complex structures. There are a number of ways to analyze structure. Some theorists place more emphasis on structure than others. The type of structure the organization develops i s influenced by the environment and the organization's technology. Some theorists believe diagnosis of appropriateness of an organization's structure is by i t s goals. There are reliab l e theories of structure to be found in a l l four schools of management thought: c l a s s i c a l , behavioural, s c i e n t i f i c , and contingency. Most use diagrams to explain structure. - 147 -Mintzberg (1979) provides five, and possibly six, paradigms by which to analyze structure. He divides the organization into five basic parts: operating core, middle line, strategic apex, technostructure, and support staff. He shows the relationship to each of these parts of coordinating mechanism design parameters, key part, and contingency factors. Best practice in this model is appropriate structure for size, age, environment, technology, specialization, complexity, markets, etc. His organization paradigms show the extent and manner in which division of labour occurs and the nature of formal coordinating mechanisms. As far as volunteer organizations such as Meals-on-Wheels is concerned, Mintzberg (197 9) would recommend the divisionalized form of structure. However, this type of analysis has limitations for volunteer organizations, so other models for analyzing structure were sought. Some of the organization theory is mainly concerned with internal response to boundary situations. Lawrence and Lorsch (1967) present structure as relationship to environment. They show that market information, s c i e n t i f i c information, and technology have different degrees of certainty, rates of change, and time span of feedback. They view best practice as syngerism balance between differentiation and integration. Gordon (1983) supports Lawrence and Lorsch's (1967) theory. Differentiation Potential for conflict is related to the degree of organiza-tional differentiation. People work together but have different ideas about problems. Differentiation can be measured by formalization of structure, goal - 148 -orientation, time orientation, and interpersonal orientation. Formal rules and regulations accompany a tight span of control. Goals can be oriented towards different parts of the environment. They may be concerned with markets or science, or they may be concerned with internal factors of cost quality efficiency. Time orientation may be short- or long-term. Interpersonal relationships are a measure of differentation. Emphasis can be on work i t s e l f or i t can focus on relationships with others. Lorsch and Lawrence state that orientation should be consistent with the organization's task environment. Differentation is important so that management can deal effectively with other parts of the organization. Integration The nature of volunteer organization is to be free and independent. Enterprise comes before coordination. Volunteer agencies find integration d i f f i c u l t . Beveridge (1948) claims that no central body should be established to break or weaken the connection between volunteer agencies and government departments which wish to use them. Coordination and consultation must be free, not forced. Integration is achieved by rules and procedures, mutual adjustment, face to face contact, and the use of individual integrators. If a division of an organization is doing well, management feels less need for integration. Balance There is an inverse relationship between differentiation and integra-tion. How can synergy be achieved? Best practice indicates three c r i t e r i a for this. The whole should be greater than the parts. The structure should be appropriate. Behaviour for managing conflict should be appropriate. Mechanis-t i c management systems have characteristics similar to those described in the - 149 -s c i e n t i f i c and clas s i c a l management tradition. Mechanistic management is appropriate for stable conditions. Organic management systems are more flex i b l e . They are loosely structured. They allow more employee influence over decisions than mechanistic systems. They are appropriate for changing conditions. Best practice in organizational structure is consistent with the demands of the organizational task, consistent with i t s external environment or technology, and consistent with the needs of the members. Controls Both external and internal controls exist. Cunming (1968) states: Support has the diffusely positive quality of encouragement or reward...control always has at least the overtones of punishment, (p. 6) She claims best practice occurs when external informal controls are symmetrical. The degree of internal control associated with Japanese business organiza-tions appears to be the ideal. The theorists have not found a satisfactory means of reconciling this with North American culture. Best practice would appear to be alignment of goals between the organization and the individual (Cubert & McDonough, 1980). This should be achieved by support rather than by control. Outcome Outcomes are the end product of inputs, process, and structure. According to Gordon, they encompass quality of service, commitment, satisfaction, and effectiveness. - 150 -Quality of Service In order to survive, an organization must produce an outcome that is acceptable in the marketplace, in a reasonable time frame, at a price and quality that are competitive. There are two models of supply and demand. One is the market model in which demand is consumer-induced. The other is the medical model in which demand is par t i a l l y supplier-induced and third party payment exists. In the latter model, demand expands to f i l l supply. The market model is best practice in organizational theory because resources are f i n i t e . Donabedian (1966) base measurement of quality of service on actual care provided, actual care perceived, and capacity of providers to provide care. He cautions that best care for an individual may not be best care for the community. Commitment There is a dearth of literature on the subject of commitment. This may be because i t is assumed volunteers are committed. It may be because i t is common wisdom that a high degree of commitment of the personnel i s fundamental to a high degree of success of the organization. Satisfaction Satisfaction is the degree of feeling of contentment fel t by a person toward his organizational role or job. It is the degree to which i n d i -viduals perceive they are equitably rewarded by various aspects of their job situation and the organization to which they belong. Theorists relate satis-faction to meeting needs. Early work relating to needs was pioneered by Maslow and also by Drucker. Francies (1983) related the needs-satisfaction theory to volunteer organizations. Satisfaction occurs when unresolved needs are met and recognition of contributions are f u l f i l l i n g . Empirical experiments show high - 151 -satisfaction to be directly related to high productivity. Best practice strives for a high degree of satisfaction. Measurements used in this study were designed to provide information on satisfaction for both the volunteer and the cl i e n t . Effectiveness Organizations pride themselves on their effectiveness. Pondy (1977) argues that effectiveness cannot be measured accurately. Gordon states common measurements in use today are productivity, efficiency, adaptation to change, s t a b i l i t y , goal attainment, turnover, motivation, employee satisfaction, client satisfaction, profit, growth, etc. Perhaps the best measurement of effectiveness is survival. Summary It would appear that organizational management theories can be useful in achieving a better understanding of the Meals-on-Wheels volunteer organization. Inputs, process, structure, and outcome are a l l interrelated. The foregoing categories w i l l be used to analyze these components of Vancouver-Richmond Meals-on-Wheels. This model w i l l be used to examine actual practices as they presently exist. - 152 -CHAPTER 7: A COMPARATIVE ANALYSIS OF ACTUAL PRACTICE AND BEST PRACTICE Introduction It was concern that the management systems in Vancouver-Richmond Meals-on-Wheels were deviating from "best practices" in organization theory that led to this analysis. While structure was of some concern, meeting a l l members' needs seemed to be a greater problem. Members are taken to be clients, volunteers, staff, and sponsors. Since voluntary organizations are a variant on most of the organizations studied by theorists, particular attention was paid to the incorporation of ideas from the voluntary organization literature where appropriate volunteer organizational theory is similar to organizational management theory in general. One major difference is that volunteer organizations are dependent on free labour. Obtaining and keeping this free labour i s a major preoccupation of a l l volunteer organizations. Much of management's energy is directed toward keeping the public's goodwill by creating a good public image. Behind this nice front often l i e s organizational chaos. Most volunteer organizations are slow to do anything to resolve this mess. This is easily understood when the goal of survival, which is such a high priority in a l l organizations, is dependent on perception by outside organizations, government, and volunteers. This difference in dependency is frequently overlooked and may explain why volunteer organizations appear constrained to prove continually the legitimacy of the organization. Another major difference between business organizations and volunteer organizations is perceived ownership. In a business organization, ownership is defined and the degree fel t by an individual is to a great extent dependent of - 153 -his defined role rather than his assumed role. In a volunteer organization, ownership is certainly perceived, but by a l l manner of individuals. The area chairmen and drivers feel a great deal more ownership than a corresponding middle manager in business or a direct care giver in a hospital. Their place in the organizational structure has far less influence on their degree of perceived ownership and hence on their perceived authority to set goals. Although major differences exist, the simil a r i t i e s far outnumber the differences between volunteer and other organizations. Actual practices in Vancouver-Richmond Meals-on-Wheels are now compared with organizational management theory best practices as they relate to volunteer organizations. Table XV provides a summary of the findings. Actual practice, as i t occurs in Vancouver-Richmond Meals-on-Wheels, w i l l be discussed in detail following Table XV. Similarities and differences w i l l be discussed in Chapter 8. TABLE XV COMPARATIVE ANALYSIS CATEGORIES PRESCRIPTIONS FOR ORGANIZATIONAL THEORY RELATING TO VOLUNTEER ORGANIZATIONS ACTUAL PRACTICE IN VANCOUVER-RICHMOND MEALS-ON-WHEELS Inputs Human Resources Employee referrals Suitable training Exposure to significant others Opportunity for upward mobility Realistic job previews Job matched to employee 15% haphazard yes encouraged selected categories only yes Motivation Satisfy unmet needs Planned process for satisfaction Direct behaviour Evaluate performance Provide rewards ye 8 no no no some Materials Appropriate for the organization Competitive in the marketplace Planning by knowledgeable people Research yes yes not well u t i l i z e d no Financial Resources Zero Based Budgeting Least cost for meals Autonomy maintained Add-on-budgeting Yes Yes Management Systems Consistent with organizational task Consistent with external environment Consistent with needs of members no yes unknown Goals Written Clear and specific Priorized Consistent with boundaries Achievable Certain no no no yes unknown, presumed yes no TABLE XV (continued) COMPARATIVE ANALYSIS CATEGORIES PRESCRIPTIONS FOR ORGANIZATIONAL THEORY RELATING TO VOLUNTEER ORGANIZATIONS ACTUAL PRACTICE IN VANCOUVER-RICHMOND MEALS-ON-WHEELS Process i Materials Flow Integrated into the system Area managers consulted On-going observation Feed-back Production suitable to work force yes partially ye 8 poor yes Power Symmetry of control Reduce job-related dependence ideal no Leadership Facilitating multiple types Open door policy Socialize with workers Keep communication channels open Emphasize harmony confrontational reduced no Low priority no observable attempt Conflict Reduce causes Confrontation Decision-making at level of knowledge Use integrator Communications Respond promptly to area requests no within groups partially insufficient by coordinator requires improvement partially Groups Collaborate and accommodate not enough Communication Non-control Ling Non-accusing Open and honest no yes partially Change Re-education Persuasion Facilitating Coercion no no l i t t l e yes TABLE XV (continued) COMPARATIVE ANALYSIS CATEGORIES PRESCRIPTIONS FOR ORGANIZATIONAL THEORY RELATING TO VOLUNTEER ORGANIZATIONS ACTUAL PRACTICE IN VANCOUVER-RICHMOND MEALS-ON-WHEELS Defence Mechanisms Self-evaluation Low dependence on external elements Show a "need" Avoid goal setting no yes yes yes Differentiation Structure Degree of formalization Goal orientation Interpersonal orientation low people-oriented ye 8 Integration Rules and regulations Face-to-face contact Individual integrators increased attempts l i t t l e area chairmen — yes coordinator — insufficient Balance Task Environment Needs of the members partially yes no Controls Symmetry of informal controls Support versus control excellent insufficient Quality of Service Outcome Acceptable in the marketplace Reasonable time frame Competitive price Competitive quality Market model Care provided Care perceived Capacity to provide care f a i r l y yes yes yes but could be improved yes outstanding very good under ut i l i z e d TABLE XV (continued) COMPARATIVE ANALYSIS CATEGORIES PRESCRIPTIONS FOR ORGANIZATIONAL THEORY RELATING TO VOLUNTEER ORGANIZATIONS ACTUAL PRACTICE IN VANCOUVER-RICHMOND MEALS-ON-WHEELS Commitment The higher the better high Satisfaction Planned process to promote satisfaction none E ffectiveness Productivity not known Growth decline Turnover not known Motivation high Goal attainment presumed Volunteer satisfaction work - yes; organization -probably Client's satisfaction moderately high - 158 -Actual Practices Inputs The five categories of human resources, motivation, materials, management systems, and goals w i l l be used to recount actual inputs in Vancouver-Richmond Meals-on-Wheels. Human Resources Human resources includes clients and employees, as well as volunteers. Subsidies give the organization a price-advantage in the marketplace. The social support aspect makes i t a unique service not available elsewhere. However, the existence of the organization is dependent on there being clients to serve. Clients have the option of leaving the service. Unless clients are regarded as being a valuable source of input, satisfaction could be such that client members decrease. Meals-on-Wheels subsidies and c r i t e r i a for entry to the service make Meals-on-Wheels less than a pure market-model. Under these circumstances, process should include input from the clients. Recruitment of paid employees does not apear to be by internal r e f e r r a l . Lack of job descriptions for paid office staff decreases the probability of r e a l i s t i c job previews. Recruitment in a volunteer organization such as Vancouver- Richmond Meals-on-Wheels is primarily non-selective. Publicity is aimed at the type of volunteers the organization is seeking. However, none are rejected and few are deliberately discouraged from becoming active volunteers. The area depots foster close association with significant others. The shortage of area chairmen and day captains provides constant opportunity for upward mobility. The organization encourages this progression from server to driver, to day captain, to area chairman. - 159 -Only 15% of the volunteers were obtained by volunteer referrals. One-third just offered their services. The remainder were channelled through outside sources. The job was matched to the volunteer insofar as the volunteer was able to choose the type of position he wished to f i l l . Realistic job previews were rare, except for screeners and PWA drivers. Training was haphazard. No data were kept on turnover. Motivation Francies 1 (1983) seven categories of needs appear to be met by the nature of the work. In the present situation of high unemployment, many young people use volunteerism as a learning experience. Quite often i t resulted in breaking into the job market after two to three months. The need to express feelings of social responsibility ( i . e . , altruism) was evident over and over again. There were repeated instances of home baking, cards, flowers, minor repairs, and social v i s i t s . The goal of social contact was not so evident. Most volunteers were busy people. Many were retired, however, but they were predominantly the active retired. Many expressed regret that they were not able to spend more time in this particular form of volunteerism. Less than 2% replied that their prime source of satisfaction was contact with other volunteers. The need to respond to the expectations of others was typified by those who replied they joined in answer to a c a l l for help. The need for social approval was more d i f f i c u l t to observe. It was typified by the volunteer who found need satisfaction in the recognition of her work from the pulpit. The need for future rewards became evident in the number who joked that i t was "their turn" next. The need to achieve, or goal orientation, was expressed by those who found doing a job well to be their prime satisfaction. - 160 -The task i t s e l f provided satisfaction. Helping others and client appreciation were the main sources of satisfaction. Meals-on-Wheels does not place much emphasis on motivation. Management is not concerned with planned processes which satisfy unmet needs, perhaps because most of these needs are being met. It does not attempt to direct behaviour by motivation. There is no evaluation of performance. Rewards are minimal. Volunteer week was instituted by an outside agency. Ten-year pins are a tangible reward, but ten years is a long time to remain motivated before recognition by the organization. Materials The food is wholesome and nutritionally correct. The quantity is good. It is appropriate for the organization. Management has not conducted any evaluation to determine i f i t is appropriate for the clientele. The price is competitive. It would be impossible to purchase a TV dinner, soup, juice, and dessert for three dollars. The organization is deficient in personnel trained in food. It relies solely on outside sources for food production and special diets. It does not use these sources as effectively as i t could. Best practices of planning by knowledgeable personnel and ongoing research are considered unnecessary by Meals-on-Wheels. Financial Resources One of the major reasons for area group coalition was to obtain government funding. When Vancouver-Richmond Meals-on-Wheels received i t s f i r s t grant from the government in 1977, i t relinquished i t s fund raising rights. This did not prohibit the organization from accepting g i f t s , donations, or bequests. Autonomy has been maintained by spreading funding sources over three areas — municipal, provincial, and private — and thus decreasing dependency upon any one external element. In addition, grants allow less external control than other forms of government funding. The charge to the client i s highly competitive. The clients' payments of three quarters of the cost is a major factor in the good balance of control between agency and client that Cumming (1968) recommends as best practice. The major hurdle to obtaining an increase in grants and, thereby, cost containment for the cl i e n t , appears to be Meals-on-Wheels system of budgeting. Requests for funding are based on add-on budgeting rather than Zero Based Budgeting. Management Systems The management system used is not necessarily the most appropriate for the demands of the organizational task. Decision-making should be at those levels where the knowledge about the factors affecting decisions are located. The area chairmen have this knowledge but their input into decision-making has been reduced. Meals-on-Wheels is consistent with i t s environment. It employs successful defence mechanisms to prevent encroachment. There is no attempt to ascertain whether i t is consistent with the needs of the members. Clients wanted input and were eager to cooperate in any evaluation. Goals Goals are not written. They are not priorized. The volunteers are un-certain about the goals of the organization. Since they are not clear or precise, no one knows i f they are achieved. This ambiguity is a prime defence mechanism of management. The goals do appear to be consistent with boundaries. - 162 -Process Materials Flow Production is integrated into the system. The process for de-termining numbers and types of meals, movement of meals, and delivery is well thought out and carefully followed. Meals are produced and delivered on time. Production is suitable to the workforce. Area managers are not consulted as regularly as best practice dictates. Observation is ongoing. Feedback is poor. Power There is symmetry of external control between the agency and the c l i e n t . The client seeks the agency, but other agencies seek the client and refer them. Meals-on-Wheels has control over entrance, but exercises this control loosely. Threat of expulsion is low. Wait for service is short. The clients are interviewed individually and the hierarchy for gaining entrance is f l a t . The client has total control over exit from the service. Meals-on-Wheels is not a sorting and screening agency. The client pays a fee. Meals-on-Wheels does have a monopoly on this type of service. Internal control by the coordinator is not as ideal. VON keeps her job-related dependence high. The structure fosters multiple leadership. Leadership Lack of goal s p e c i f i c i t y has resulted in multiple leadership. The groups are able to protect their own interests because volunteers can quit when they wish. Area chairmen have considerable power because i t is d i f f i c u l t to f i l l these positions. Given this existing structure, f a c i l i t a t i n g leadership is best practice. This philosophy is not evidenced by observation. The coordi-nator does not keep an open-door policy. She does not v i s i t the area depots. She rarely comes in contact with the volunteers, either in the work situation - 163 -or in planned social situations. Communication with volunteers is low prior i t y . Harmony is not an expressed goal. Conflict The coordinator's role conflict has multiple causes. She perceives herself to suffer from role overload, which may be only role ambiguity. VON does not provide clear signals regarding i t s expectations. It has not made clear to the volunteers the extent of the coordinator's authority and decision-making role. These causes can be almost eliminated. This would leave only the stress of the integration role, which could then withstand increase. The coordinator does not u t i l i z e collaboration and accommodation as the main practice in dealing with the various groups. Groups Conflict resolution within the area group is by discussion of d i f f e r -ences and working until a solution is found. Conflict is minimal within any given group. This type of confrontation is used between area groups. It is not employed to lessen conflict between the groups and the coordinator. Decision-making is coming more under the jursidiction of the coordinator, although much decision-making s t i l l occurs at the level of contact with the c l i e n t . The attempt to wrest this power from the area groups is causing conflict. Area chairmen do not perceive rapid response to their requests. Communication is poor — especially upwards communication. The coordinator does not make the most of her integrator role in dealing with the groups. Communication The monthly newpaper has been discontinued. The coordinator has reduced the number of Advisory Committee meetings. Information is not forth-- 164 -coming to the area chairmen about client subsidies, nor about amounts and sources of donations. No one acknowledges the legitimacy of their request for this information. Over a quarter of the other volunteers wanted more informa-tion about the organization. There is no follow-up to provide them with information on clients lost from the system. Change Change is resisted by the organization. Data collection is not deemed necessary. Re-education, persuasion, and f a c i l i t a t i o n are not common practice. When change does occur i t is usually by coercion — and that is usually not successful (e.g., payment one month in advance). Defence Mechanisms Dependence on external elements is kept to a minimum. The services of the Vancouver Health Department are under-utilized. Investigations and studies of Meals-on-Wheels are discouraged. As previously discussed, goal-setting is avoided. The "need" is shown by frequent public relations events. Self-evaluation i s rejected, despite the fact that established instruments 2 exist. Structure Lorsch and Lawrence's (1970) theory of differentiation — integration w i l l be used as a model to discuss the structure of Vancouver-Richmond Meals-on-Wheels. ^Volunteers Feedback forms for volunteer motivation profile, staff reaction, self-assessment for volunteer coordinators and directors. - 165 -Differentiation There is sufficient differentiation for management to deal effectively with the volunteer portion of the organization. Differentiation among the paid office personnel i s so low that ambiguity of task assignments has resulted. Differentiations in the entire organization is very low i f measured by degree of formalization. Formal rules and regulations are sparse. The span of control is loose. Goal orientation is client-oriented. Integration The coordinator perceives need for improvement. This is evidenced in her attempt to increase integration. She is attempting to impose rules and regulations (e.g., minimum two weeks service). The use of area chairmen as integrators i s inherent in the structure of the organization. This role could be greatly improved. The coordinator has l i t t l e , i f any, face-to-face contact with other volunteers. The coordinator's integrator role is primarily with the media. Balance The structure is reasonably consistent with the external environment. The demands of the organizational task require greater differentiation in the main office in order to be consistent with the organizational task. Behaviour of management is not consistent with the needs of the members of the organization. Controls Using Cumming's (1968) analysis, Vancouver-Richmond Meals-on-Wheels can be c l a s s i f i e d as a client-oriented protective-controlling agency. Symmetrical external controls exist between the organization and the client. - 166 -Internal controls are, of necessity, low. Volunteers can leave the organization and give their volunteer time elsewhere. Meals-on-Wheels management does not place sufficient emphasis on support for volunteers. Outcome Quality of Service The service is f a i r l y acceptable in the marketplace. Meals-on-Wheels has survived for fourteen years in Vancouver-Richmond. The numbers of clients increased steadily until 1982. Since then, i t has declined. In 1984 i t was below the 1979 level. This i s not consistent with an environment in which the age of the population i s increasing annually. The acceptability problem is one of food preferences, not of volunteers' inputs. The time of delivery is acceptable to the clie n t s . The price is considered very f a i r by those receiving the meals. The quality of the food i s rated as good to excellent by less than two-thirds of the clients. The market model of supply and demand is s t i l l in existence. Money received as grants results in lower control and accountability than other types of government funding. The care provided i s outstanding. The care perceived requires more suitable food. The volunteers are capable of providing more than that required of them. Commitment The commitment of the volunteers i s extremely high. They are more committed to the clients and their area group than to the organization as a whole. - 167 -Satisfaction The volunteers f e l t a high degree of satisfaction towards their roles. Less than ten percent perceived recognition from management. Recogni-tion was primarily from clients and other volunteers. The clients expressed extremely high satisfaction with the volunteers and the service in general. They were not as satisfied with the food. There was no planned program by management for promotion of satisfaction for either group. This study is the f i r s t evaluation to determine whether or not either group is satisf i e d . No regular follow-up i s attempted when clients quit the service to determine whether or not satisfaction was a factor in their decision to stop receiving me al s. Effectiveness Productivity, i f measured by ratio of volunteer to cli e n t , is not out of line with the rest of the province. Productivity, i f measured by clie n t s ' perception of the quality of contact with volunteers, was outstanding. It is impossible to measure productivity without goals. Productivity i s assumed by management to be good because a l l the meals are delivered on time every day. This i s a questionable measure. Vancouver-Richmond Meals-on-Wheels i s not growing. It has declined for the past two years. Turnover of volunteers i s not known, nor is i t a concern of management. Management is not concerned with increasing motivation. Management assumes the implied goals are met. Goal attainment cannot be measured unless goals are defined. Volunteer satisfaction is high. This is not due to management planning. Client satisfaction i s high. This i s due to the volunteers more than the food. - 168 -Summary The f i e l d of organizational theory is so vast that a discussion of a l l aspects would not be within the scope of this study. Therefore, using the Gordon model as a guide, only important segments applicable to Meals-on-Wheels were selected for discussion. In some instances there are sound reasons for departing from best practices. Areas where paradox or weakness exist w i l l be discussed in Chapter 8. - 169 -CHAPTER 8: MAJOR DIFFERENCES IN THEORY AND PRACTICE Major Differences This chapter examines the major differences between Vancouver-Richmond Meals-on-Wheels actual practice and organizational theory best practice and offers some reasons why these differences occur. The major differences that occur between Vancouver-Richmond Meals-on-Wheels and organizational theory best practice as i t relates to volunteer organizations w i l l be organized by Gordon's (1983) model of inputs, process, structure, and outcome. Those headings under which major differences do not occur w i l l be  omi 11 ed. Inputs Major differences existed in certain aspects of human resources, materials, finance, management systems, and goals. Human Resources Only 15% of the volunteers who replied to the questionnaire had been recruited by volunteer r e f e r r a l . Best practice indicated employee referral provides the most satisfactory personnel. Until this study was completed there was no data to indicate sources of volunteers. The coordinator had no knowledge of how many active volunteers there were in the organization. It is d i f f i c u l t to imagine an organization that does not have a l i s t of i t s workers. There was no planned program of training for paid office staff, area chairmen, day captains, drivers, or servers. The area chairmen have not received instruction or equipment for training other volunteers. Written information for volunteers was sketchy and out-of-date. Meals-on-Wheels pamphlets emphasized the program, - 170 -rather than volunteers ' tasks. Job previews for screeners and PWA drivers were r e a l i s t i c . For other categories of volunteers, job previews appeared to be limited to individual opinions of those referring them, i f thay occurred at a l l . With the exception of those referred by the Vancouver Volunteer Centre (an estimated 10%), formal job previews did not exist for four categories of volunteers. There was no planned process in Vancouver-Richmond Meals-on-Wheels for increasing volunteer satisfaction. Most organizations expend considerable effort to meet their members needs. Vancouver-Richmond Meals-on-Wheels did not attempt to direct the behaviour of the volunteers, except, perhaps, that the area chairmen did so when there was a clash of opinions between them and the coordinator. Meals-on-Wheels did not attempt to evaluate performance. Thus, the basic tool for determining the need for directing behaviour was non-existent. Materials Planning by knowledgeable people was not well u t i l i z e d . The Vancouver Health Department has dietitians with the expertise to assist in menu planning, temperature control, assessment of quality of food, assessment of c l i -ent satisfaction, and nutritional status of the clien t s . The service is readily available to Meals-on-Wheels. Dietitians are very generous with their time and expertise. There are numerous retired dietitians in Vancouver, yet no attempt has been made to recruit this category of volunteer. Dial-a-Dietitian is a local service without any charge. The coordinator has not consulted i t even on specific problems; nor has she referred those clients who have questions about their special diets. Free expert advice i s usually eagerly sought, as many an - 171 -accountant w i l l confirm. Best practice proposes u t i l i z a t i o n of expert advice. Research on food services and nutrition is available. Books, journals and maga-zines pertaining to these subjects were absent from the library on the premises. Financial Resources. The major difference between best practice in organizational theory and actual practice in Meals-on-Wheels was the system of budgeting. Add-on budgeting, as practiced by Meals-on-Wheels, does not provide as much c r e d i b i l i t y as Zero Based Budgeting when seeking increased grants from government sources. Management Systems The organization did not know who i t s members were, let alone their needs. Therefore, i t is impossible to state whether or not the management system is consistent with the needs of the members. Areas of decision-making were i l l - d e f i n e d . It i s expedient for members of even volunteer organizations to have some type of mandate regarding the areas in which they are responsible for making decisions. The area chairmen appeared to lack this mandate. The considerable knowledge of the area chairmen was not consistent with their reduced decision-making role. Goals Clear, precise, priorized, written goals were lacking in Meals-on-Wheels. Organizational theory best practice is adamant about the importance of goals. O f f i c i a l goals were uncertain. Operational goals were to provide food, improve nutrition, supplement social support, and prevent institutionalization. No one was certain which goal was the most important. These operational goals were sufficiently consistent with boundary organizations to avoid open conflict - 172 -and Cake-over attempts. Whether or not they prevent duplication of service does not appear to be a concern of the Vancouver Health Department or Long Term Care. Pr.ocess Materials Flow External power and defence mechanisms were the portions of process that most closely resembled organizational theory best practice. There were major differences in internal power, leadership, c o n f l i c t , communications, and change. Power Balance of external controls between client and organization approached the ideal. Internal power did not. The coordinator's job-related dependence was high. Her base of power narrow. She lccked remunerative power. What rewards existed were universal. She had very l i t t l e expert power. She had no training in dietetics, social work; or nursing. Many area chairmen f e l t they had equal expertise in management. Her coercive power was limited to the paid office personnel. The volunteers had nothing to fear. Some referrent power was derived from her association with the director of VON. She did have legitimate power because of her position, but even this was diluted because area chairmen performed the most d i f f i c u l t task. Much energy was wasted in attempts to gain or use power. Leadership The history of Meals-on-Wheels offered an explanation of how and why the structure evolved into one of multiple leadership. Goal uncertainty contributed to this structure. Organizational theory indicates that f a c i l i t a -ting leadership is best practice in multiple leadership structures. The leader-ship in Meals-on-Wheels appeared to be more adversarial. The techniques of f a c i l i t a t i n g leadership — communication channels — - 173 -open-door p o l i c y , s o c i a l i z i n g were not in evidence. with workers, and open C o n f l i c t Role c o n f l i c t was high for the coordinator. Expectations of VON were unclear. Area chairmen and VON had d i f f e r i n g expectations of the c o o r d i - nator. Accurate communications could reduce c o n f l i c t from both these causes. The r o l e of i n t e g r a t o r was s t r e s s f u l . The coordinator viewed her i n t e g r a t o r role as p r i m a r i l y with the media and other external boundaries. L i t t l e emphasis was placed on an i n t e r n a l i n t e g r a t i o n r o l e . VON encouraged the external i n t e -grator r o l e . S h i f t in p r i o r i t y of areas of int e g r a t o r r o l e would increase leadership e f f e c t i v e n e s s without increasing r o l e c o n f l i c t . C o l l a b o r a t i o n and accommodation between groups has not improved with the reduction in the number of Advisory Committee meetings. The coordinator did not u t i l i z e her i n t e g r a t o r r o l e to promote c o l l a b o r a t i o n and accommodation among the groups nor between management and the area groups. Needed improvement in communication, and better methods of non-aggressive confrontation for resolving c o n f l i c t , have been discussed e a r l i e r . D e c i s i o n -making was not assigned to those l e v e l s where the knowledge for t h i s d e c i s i o n -making e x i s t e d . The coordinator could upgrade in t e g r a t o r s k i l l s for i n t e r n a l c o n f l i c t r e s o l u t i o n s . C o n f l i c t remained higher than that prescribed in o r g a n i z a t i o n a l theory best p r a c t i c e . Communication Best p r a c t i c e in o r g a n i z a t i o n a l theory prescribes open, honest, n o n - c o n t r o l l i n g , and non-accusing communication. Communication between the volunteers in the area depots i s e x c e l l e n t . Communication between the volunteers and the coordinator and between the volunteers and the o f f i c e s t a f f - 174 -had considerable room for improvement. Gordon's (1983) precepts of best practice for accurate communication were not followed by the coordinator. Feedback was the area in which actual practice differed most from best practice. It is essential to effective production. The area chairmen were formally consulted only once very two months. This study was the f i r s t time clients have ever been formally asked for feedback. Change Best practices for coping with change are accepting, identifying cause and type, planning, and evaluation. Meals-on-Wheels resists both internal and external change, thereby negating the use of good coping techniques. VON did not encourage continuing education for the coordinator. The coordinator did not promote continuing education for the paid office personnel or the volunteers. Persuasion and f a c i l i t a t i n g were employed less often than coercion. Defence Mechanisms Although Meals-on-Wheels avoided goal setting, showed a "need," and maintained low independence on external elements, i t has made no attempt at self-evaluation, despite the fact that the latter i s recommended as best practice in organizational theory. Structure A differentiation-integration model was used for comparison between organizational theory and actual practice. The structure of Meals-on-Wheels exhibited a multiple group leadership pattern. It had an informal structure with low controls and few formal rules and regulations. The goal orientation appeared to be totally people-oriented. This can only be assumed because no - 175 -formal goals were documented. The span of control was loose. The volunteers priorized interpersonal relationships. The coordinator priorized internal work factors. The degree of differentiation was low, but sufficient to accomplish the task, except, perhaps, in the of f i c e . This is nearly as prescribed by best practice theory. Balance and control also showed tolerable differences between theory and actual practice. The only major difference was in integration. Integration The coordinator perceived the need for more integration. More face-to-face contact between the coordinator and the volunteers would improve the organizational structure. Improvement in the coordinator's integrator role with the area chairmen is desirable to improve integration. The use of area chairmen as integrators is inherent in the structure and did not appear to be in need of enhancement. With the two foregoing improvements in the coordinator's role, the structural balance would be acceptably synergistic. The structure is relatively consistent with i t s external environment, i t s organizational task, and possibly the needs of i t s members. Without evaluation, the latter cannot be determined accurately. Outcomes The outcomes were not as close to theoretical best practice as anticipated. Effectiveness was much lower than anticipated. Satisfaction and quality of service l e f t room for improvement. Quality of, Service Quality of service was generally good. Originally there was l i t t l e with which to compete. With the advent of palatable pre-prepared - 176 -food of good nutritional content and wide variety, competition has arisen. The clients have choice in frozen foods to suit individual preferences. Meals-on-Wheels did not seem to recognize this. No attempt has been made to determine client preferences in what has become a highly competitive market in regard to quality. Meals-on-Wheels relied on price differential to combat competition in the marketplace. The care provided was what distinguished Meals-on-Wheels from other food services (e.g. grocery delivery does not provide sufficient assis-tance for severely impaired clients). Another difference between theory and practice is under-utilization of the volunteers' capacity to provide care. Satisfaction The major difference between theory and practice was that there was no planned process to meet unmet needs and thus improve satisfaction. Effectiveness Best practice dictated that productivity, motivation, goal attainment, and satisfaction be high; turnover, low; and, growth, accelerating. These require measurement to determine outcome. In Vancouver-Richmond Meals-on-Wheels, productivity and turnover were not known. Goal attainment was only presumed. Rate of growth was not just declining; the entire organization was decreasing in size. The potential number of clients would appear to be increas-ing with an aging population and stalled expansion of institutional f a c i l i t i e s . Meals-on-Wheels delivered 11,131 fewer meals in 1983 than in 1982 and 11,717 fewer meals in 1984 than in 1983. The rate of decline is increasing. Perhaps frequency of Home Care service is increasing. Possibly care by family members is increasing with higher unemployment. Perhaps the reason li e s within the organization. - 177 -CHAPTER 9: A DIAGNOSIS: WHY DIFFERENCES SEEM TO OCCUR Introduction Vancouver-Richmond Meals-on-Wheels is at present a viable body with many strengths. However, this chapter w i l l be concerned mainly with identifying i t s weaknesses. It w i l l focus on the differences between best practice and actual practice and thus w i l l emphasize the negative aspects of the organization. The next chapter w i l l try to balance strengths and weaknesses in suggesting a plan for moving forward. It is not certain whether either the VON director or the Meals-on-Wheels coordinator has had any formal organizational management training and could therefore be expected to know about theoretical best practices and managerial strategies which could be applied. The organization may not expect such training in i t s personnel. Certainly the job advertisement indicated that training and experience were of lesser priority than commitment to a l t r u i s t i c service. If the desire to help others is the t r a i t considered most important in hiring, then management training may not receive much emphasis. There were some indications that salaries may not be competitive. If the administrative portion of the budget is underfunded, then Meals-on-Wheels can more easily hire well motivated individuals than experts in management organization. Data showed that the volunteers and clients f e l t a great deal of satisfac-tion with the service. Good motivation and dedication on the part of the coordinator and the paid office staff deserve credit for much of this. Addi-tional strengths of the organization w i l l be discussed more ful l y in Chapter 10. - 178 -The same structure of analysis w i l l be used in this chapter to identify what would appear to be the reasons for failure to adopt "best practices". It i s recognized that this i s , to a large extent, a subjective view based on one  person's observations. Why Differences Occur There are so many compounding variables in each category of organizational inputs, process, structure, and outcome that i t is impossible to account for them a l l . However, an examination of some of the more important variables that affect these differences may shed light on why they occur. Inputs Human Resources Efforts at recruitment seem to have been misdirected because of lack of information which is available only from data. Again, training appears to have been haphazard because management had no information about turnover. Job previews were given low p r i o r i t y . Perhaps this was because management assumed the supply of volunteers was inexhaustable or else because management was unaware of the value of job previews. Management has delegated i t s responsibility here. It relied on the volunteers to arrive at the door fully motivated or else i t relied on the area chairmen to provide motivation — a task they performed exceedingly well. Evaluation of individual performance would not be appropriate in this volunteer organization where social contact is as important as number of meals delivered. Recognition as a reward was not u t i l i z e d as well as i t might be. Again, the - 179 -l a c k o f a c t i o n o n t h e p a r t o f t h e c o o r d i n a t o r may b e b a s e d o n l a c k o f k n o w l e d g e o r a d e c i s i o n t o l e a v e t h a t t e r r i t o r y t o t h e v o l u n t e e r s . M a t e r i a l s R e f u s a l t o u t i l i z e a v a i l a b l e e x p e r t a d v i c e may h a v e b e e n a d e f e n c e m e c h a n i s m . T h e c o o r d i n a t o r d i d n o t d e t e r m i n e w h e t h e r o r n o t i t was a t h r e a t t o a u t o n o m y . H e r l a c k o f e x p e r t p o w e r may make i t d i f f i c u l t f o r h e r t o e v a l u a t e t h e d e g r e e o f t h r e a t . I f t h e s p o n s o r i n g o r g a n i z a t i o n c l e a r l y d e l i n e a t e d h e r a r e a o f r e s p o n s i b i l i t y , h e r l e g i t i m a t e p o w e r m i g h t t h e n b e s u f f i c i e n t t o a l l o w h e r t o a c c e p t t h e a d v a n t a g e s o f u t i l i z i n g e x t e r n a l e x p e r t a d v i c e o r r e c r u i t i n g v o l u n t e e r s w i t h t h i s e x p e r t a d v i c e , o r e v e n h i r i n g p a r t - t i m e p e r s o n n e l who w e r e k n o w l e d g e a b l e i n f o o d p r o d u c t i o n a n d n u t r i t i o n . M a n a g e m e n t s y s t e m s T h e a m b i g u i t y o f who h a d t h e l e g i t i m a t e d e c i s i o n - m a k i n g a u t h o r i t y was t h e r e s u l t o f l a c k o f m a n d a t e b y t h e s p o n s o r i n g b o d y o r t h e VON d i r e c t o r . I t may a l s o h a v e b e e n l a c k o f c o m m u n i c a t i o n t o t h e m e m b e r s , i f t h i s m a n d a t e h a s b e e n g i v e n . G o a l s T h e r e a s o n s M e a l s - o n - W h e e l s d i f f e r e d s o m a r k e d l y f r o m o r g a n i z a t i o n a l t h e o r y i n g o a l s w a s b e c a u s e a v o i d a n c e o f g o a l s e t t i n g a p p e a r s t o h a v e b e e n i t s p r i m e d e f e n c e m e c h a n i s m . I f no g o a l s a r e s e t , n o o n e c a n l e v y a c c u s a t i o n s o f p o o r g o a l a t t a i n m e n t . S e l f - e v a l u a t i o n i s r e c o g n i z e d i n t h e l i t e r a t u r e a s a m o r e d e s i r a b l e f o r m o f s e l f - d e f e n c e . T o t a l l a c k o f e v a l u a t i o n a t t e m p t s make a v o i d -a n c e o f g o a l - s e t t i n g t h e n e x t m o s t e f f e c t i v e d e f e n c e m e c h a n i s m . - 180 -Process Again, lack of evaluation was a reason for failure to improve alignment between actual practice and theoretical best practice. Interdependence of the categories that make up process tend to make departures from best practice a vicious c i r c l e . Power Both internal and external factors contributed to the coordinator's lack of power. The internal factors were her narrow base of power, lack of expert power, the degree of ownership f e l t by the volunteers, and the multiple leadership structure of the organization. External factors were dependency on outside organizations (e.g., area depots in churches), government, and volunteers. The use of unpaid labour reduced management power. VON usurped some of her legitimate power. Leadership The reasons why organizational theory of f a c i l i t a t i n g leadership in multiple leadership structures was not practiced may have had i t s roots in power balances and leadership style. Conflict The coordinator's role conflict resulted from inappropriate structure, poor communication, lack of c l a r i t y of expectations of VON, and operation at the organization's boundaries. Perhaps lack of direction expressed by VON may be a defence mechanism. Perhaps VON overemphasized the importance of her operating at the organization's boundaries. Conflict appeared to have i t s base in unequal power in multiple leadership. The power of the coordinator should at least equal that of the group leaders. - 181 -VON was reluctant, or else unaware, that responsibility without authority is not theoretical best practice. Communication Communication may d i f f e r from theoretical best practice because internal power was not defined or because the coordinator's power was diluted by VON. Change Lack of managerial training in diagnostic approaches to organizational change may have contributed to management's reluctance to change. Structure The structure was determined by the organization's internal environment. Historical factors set i t up. Circumstances maintained i t . Goal ambiguity and the d i f f i c u l t y of the task performed by area chairmen reinforced i t . Although multiple leadership may not be best practice under ideal circumstances, i t seems to be appropriate for the task and environment of Vancouver-Richmond Meals-on-Wheels. Improvement to align structure with best practice in multiple leadership would be more appropriate than radical change to a structure inappropriate for the organization. The discrepancies between organizational theory and actual practice in multiple leaderships were most evident in integration. Integration This major difference may have resulted from too l i t t l e face-to-face contact between management and workers, attempted control instead of - 182 -support for group leaders, or insufficient emphasis on the internal integrator role of the coordinator. The cause of these symptoms may have been inappropriate power distribution between VON and the coordinator. Outcomes The basis of major differences between organizational theory, best practice, and actual practice l i e s in lack of information. Until this study was completed, no one knew what most of the outcomes actually were. Failure to evaluate outcomes may be a faulty defence mechanism or i t may be management's failure to recognize evaluation as an important part of good management. Quality of Service Management refused to recognize that the market is becoming more competitive. They ignored the need to satisfy the clientele in the mistaken belief that input equaled outcome, regardless of process or structure. It did not even recognize the advantages of scrutinizing outcomes as a tool for improvement. Effectiveness Effectiveness was not as good as i t should be because there was no evaluation to determine effectiveness. A lack of recognition for the need for improvement precludes planned improvement in the areas where i t is required. - 183 -CHAPTER 10: RECOMMENDATIONS TO THE AGENCY Overview of Gordon's Model Gordon's model as the prescription for best practice has been described. Certain variations from this practice have been identified. This chapter w i l l be concerned with making recommendations to the organization in areas which concern Vancouver-Richmond Meals-on-Wheels. It w i l l begin with an overview of best practice under the four headings of inputs, process, structure, and outcome. Inputs Human resource management theory recommends that recruitment be through employee referrals, where possible, because their source provides the best employees. It advocates a policy of encouraging upward mobility and exposure t significant others. Turnover reduction is f a c i l i t a t e d by suitable training, r e a l i s t i c job previews, and matching the job to the employee. Motivation requires a planned process for satisfying unmet needs and directing behaviour. Strategies include performance evaluation and rewards. Materials should be appropriate for the organization and competitive in the marketplace. Planning should be by knowledgeable people and include sufficient research. Most of the emphasis on inputs in Gordon's (1983) model is on goals. She states that we diagnose the appropriateness of an organization's structure by i t s goals. As i so much of the literature, there is emphasis on the importance of clear and concise priorized achievable goals. - 184 -Process In process, the emphasis is on communication, groups, leadership, and power. Communications are analysed from the receivers' perception, the structure of the organization, and the interpersonal relationship between the sender and the receiver. Considerable attention is focussed on prescriptions for improving communication accuracy. Group behavior is discussed in detail . Intergroup behaviour and conflict is analyzed and modes of handling this conflict are presented. Gordon cites Kurt Lewin's experiment which shows that participation in group discussion is ten times more effective than a lecture. Gordon (1983) shows how role conflict contributes to stress. She provides a discussion of symptoms for diagnosing them and offers a prescription for reducing i t . Her discussion of power parallels that of most authors (e.g., Bacharh & Lawler, 1980). Structure Gordon shows that the type of structure an organization should — and does — develop is influenced by the environment and the stability of the organization's technology. She suggests various design responses to the environment (e.g., reducing demands by exte'rnal elements by reducing dependence on those elements). She shows that as an organization ages, communication no longer occurs primarily through mutual adjustment. With age, structure becomes more mechanized and bureaucratic. She recommends Lorsch and Lawler's (1970) theories as a prescription for improving the appropriateness and effectiveness of structure. - 185 -Outcome Gordon's outcomes are diagnosed in a methodical manner by use of a checklist. Effectiveness measurements are provided. In this study, Gordon's (1983) theories have been tempered by the bounded rationality of volunteer organizations. Gordon's model for theoretical best practice, superimposed on Donabedian's (1966) model of best patient care appeared to be appropriate for making this study of Vancouver-Richmond Meals-on-Wheels. Po s s i b i l i t i e s for Improvement This diagnostic analysis conducted by an outsider may be regarded as a consultant's paper prepared for the beginning of a series of discussions to be instituted by the organization i f i t intends to change more towards best practice. Inputs Human resources The number of clients receiving the service has declined steadily for two years. Whether this i s due to client turnover or lack of demand is not known. There was no evaluation to determine this. There was insufficient recognition of the correlation between client input and satisfaction. Emphasis was not placed on the clients' perceptions of the food. The clients were eager and willing to provide input. The organization could determine the reasons for declining clientele and probably reduce the turnover factor by evaluation and input from the clients. The volunteers comprise the bulk of the workforce. The number of clients - 186 -served by the organization i s limited by the a v a i l a b i l i t y of active volunteers. The existing shortage of volunteers requires data to determine whether the cause is recruitment or turnover. If the cause is turnover, then the f i r s t step is to consult the volunteers to determine why. This data gathering should include those who quit the Vancouver-Richmond Meals-on-Wheels to determine organiza-tional weaknesses and those who remain to determine organizational strengths. This information is v i t a l to meet the needs of the volunteers. Once this is determined, planned processes for improvements should reduce turnover. In the interim, a short-range plan to reduce turnover could include a concerted attempt to encourage each active volunteer to recruit one person, because internal referral reduces turnover. Another method of reducing turnover is to provide r e a l i s t i c job previews for every volunteer. Better training might also reduce turnover. Long-range planning to reduce turnover requires a data base to determine cause. Insufficient recruitment is another factor responsible for the shortage of volunteers. If the data shows this to be a cause, then the remedy is at hand. This study shows the most likely sources of recruitment for this particular volunteer agency. Meals-on-Wheels should stop wasting time and effort on non-productive sources and concentrate on encouraging the most profitable sources. The Vancouver Volunteer Centre could assist with strategies to accomplish these objectives. The value of recruitment by active volunteers should not be neglected. Materials Better u t i l i z a t i o n of expert advice would improve the service. The material is food. Therefore, i t would seem advisable that one paid employee, - 187 -even i f only part-time, be knowledgeable about food. I f lack of funds preclude a d i e t i t i a n — and t h i s seems u n l i k e l y since a d i e t i t i a n was formerly employed part-time — then a q u a l i f i e d Food Service Technician should be h i r e d as part of the paid personnel. The food depots require ongoing observation to prevent mix-ups (such as the one that occurred l a s t Christmas) and ensure q u a l i t y c o n t r o l (e.g., c o r r e c t temperature of hot food). The s e r v i c e s of a consultant d i e t i t i a n are necessary to ensure s u i t a b l e menus and optimum s p e c i a l d i e t s and to answer questions posed by those r e c e i v i n g t h i s form of treatment. The Vancouver Health Department i s w i l l i n g to provide t h i s expertise. A r e t i r e d d i e t i t i a n could probably be r e c r u i t e d as a regular consultant volunteer. A d i e t i t i a n could be h i r e d as a part-time consultant. The expertise i s there. Vancouver-Richmond Meals-on-Wheels should a v a i l i t s e l f of t h i s e x p ertise. Better cooperation with non-intrusive people wishing to study the o r g a n i -zation might benefit the c l i e n t s , the volunteers, and the management, at no cost to the organization. Meals-on-Wheels should a v a i l i t s e l f of free outside help. Finance F i n a n c i a l resources are f a i r l y consistent with t h e o r e t i c a l best p r a c t i c e , except i n the area of budgeting. Improvement i n funding could probably be increased i f Zero Based Budgeting were to replace the present add-on system. I f t h i s i s not f e a s i b l e , i t might be worthwhile to try for add-on from the beginning, not the end, of the f i s c a l year. Dependency on external elements precludes the e f f i c a c y of a large funding increase, but care should be taken not to allow the meal to be p r i c e d out of the market. - 188 -Goals The avoidance of goal-setting, as a defence mechanism, should be reduced and self-evaluation used to replace part of this form of defence of boundaries. If formal goals are considered risky by the organization, then perhaps Management by Objectives could be used by VON to direct the coordinator and reduce her role ambiguity. Short-term internal goals such as reduction of client turnover from 10% per month to 8% per month may not be perceived as high risk. Process Conflict The coordinator i s under stress from role ambiguity. If VON were to give the coordinator a clear mandate from the Board of Directors with a statement of the Board's goals, policies, and p r i o r i t i e s , the coordinator's role ambiguity would be lessened considerably. In the future, care should be taken to make this part of a r e a l i s t i c job preview. If VON defined the coordinator's task to include more power, specific areas of decision-making, and mutually agreed objectives, i t s authority could become more supportive and less controlling. If the coordinator's power were legitimized in this manner, and VON encouraged her to pursue knowledge and increase managerial s k i l l s , she might then modify her managerial style to include greater emphasis on an integrator role with the area chairmen. Two further suggestions for possible improvement are: increased contact with the volunteers and continuing education. Increased face-to-face contact with the volunteers could be accomplished by regular informal v i s i t s by the coordinator to each depot. This would encourage feedback from volunteers and improve two-way communication. Volunteers could be - 189 -encouraged to submit letters and a r t i c l e s , thus making reinstatement of the monthly newpaper relatively simple. It would also provide a first-hand observation of those volunteers who might have potential and willingness ts f i l l the vacant area chairmen positions. Education should be ongoing. Face-to-face contact might provide an indication of the direction this should take for d i f f e r e n t categories of volunteers. VON should encourage the coordinator to attend volunteers' conferences and to upgrade her communication s k i l l s , possibly by financial assistance for continuing education courses. Structure The structure of Vancouver-Richmond Meals-on-Wheels is appropriate for the organization. Modification of differentiation and integration might improve i t . The main area where there is room for improvement in differentiation is with the paid personnel. Ambiguity of task responsibility provides f l e x i b i l i t y and promotes cooperation, but i t also creates duplication of effort. Job descrip-tions which allowed f l e x i b i l i t y but defined areas of responsibility would provide sufficient differentiation to increase efficiency and effectiveness of these members of the organization. It would also reduce the stress of role ambiguity for them. Integration i s often a problem in multiple leadership. If the coordinator were allowed by VON to exercise more power, she might be willing to delegate more authority for decision-making at the area chairman level. This could be accomplished without loss of control. An example would be to delegate the authority for decisions on client subsidy to the area chairmen. At the same time, i t would be necessary to set a global limit on funds for each area, with a - 190 -l a r g e degree of l a t i t u d e f o r n e g o t i a t i o n of t r a n s f e r between g r o u p s . .The c o o r d i n a t o r ' s i n t e g r a t o r r o l e should be enhanced to f a c i l i t a t e b e t t e r i n t e g r a -t i o n . A f i r s t s tep i n t h i s d i r e c t i o n would be to r e i n s t a t e monthly meetings o f the A d v i s o r y C o u n c i l wi thout the added presence of the s c r e e n e r s , except perhaps on an o c c a s i o n a l b a s i s . Outcome Nowhere i s the need f o r e v a l u a t i o n more e v i d e n t than i n l a c k of knowledge of the outcomes. The best e v a l u a t i o n i s s e l f - e v a l u a t i o n . I t p r o v i d e s the i n f o r m a t i o n on which to p l a n , implement, and c o n t r o l . I t i s a l so an e x c e l l e n t form o f s e l f - d e f e n c e f o r the o r g a n i z a t i o n . E v a l u a t i o n i s r e q u i r e d i n a l l aspects o f the Vancouver-Richmond M e a l s - o n - W h e e l s . T h i s study i s o n l y a b e g i n n i n g . E v a l u a t i o n i s needed i n a l l i n d i c a t o r s o f e f f e c t i v e n e s s . I t i s r e q u i r e d f o r those who leave the o r g a n i z a t i o n — both c l i e n t s and v o l u n t e e r s . E v a l u a t i o n must be ongoing f o r maximum e f f e c t i v e n e s s . The importance o f e v a l u a t i o n cannot be o v e r - s t r e s s e d . Data are r e q u i r e d on v o l u n t e e r s to reduce t u r n o v e r , i n c r e a s e r e c r u i t m e n t , improve s a t i s f a c t i o n . Data are r e q u i r e d on the c l i e n t s i n o r d e r to understand the market , i n c r e a s e s a t i s f a c t i o n , and reduce t u r n o v e r . I n f o r m a t i o n i s r e q u i r e d on which to base s t r a t e g i e s f o r b e t t e r u t i l i z a t i o n of the v o l u n t e e r s ' c a p a c i t y to p r o v i d e c a r e . For example, c l i e n t contac t c o u l d be encouraged by a l l o w i n g each v o l u n t e e r to " a d o p t " a c l i e n t and s o c i a l i z e w i t h h i m / h e r . The most b a s i c e v a l u a t i o n r e q u i r e d i s to c o n s u l t the r e c i p i e n t . There i s no way o f checking food r e t u r n s . Thus, the o n l y e v a l u a t i o n of c l i e n t s a t i s f a c t i o n w i t h food i s a s u b j e c t i v e r e p o r t by the c l i e n t . T h i s study has shown that the c l i e n t s know what they want. Menu changes c o u l d be - 191 -implemented on the basis of this study. A program of ongoing evaluation is essential when clientele turn-around is less than one year. P o s s i b i l i t i e s for improvement exist in a l l organizations. It is hoped that any suggestions offered w i l l be accepted as constructive and not accusative. They are offered by an investigator whose respect and admiration for Meals-on-Wheels has increased as the study progressed. Vancouver-Richmond Meals-on-Wheels i s , at present, a viable organization. It performs a much needed and highly appreciated service. It has a large body of committed volunteers. It has sufficient grants to make the cost to the recipients competitive. It has the sponsorship of an established, experienced organization which provides i t with office space, accounting and managerial support, and a highly respected reputation. The satisfaction of the volunteers and the clients i s higher than in most volunteer organizations. It has access to excellent cooperative sources of supply for meals. It has managed to keep a l l i t s boundary constituencies at bay, thereby retaining i t s autonomy. The volunteers are caring, generous people. It has a l l the strengths of philan-thropic volunteerism in a p l u r a l i s t i c society. - 192 -CHAPTER 11: FURTHER COMMENTS AND RECOMMENDATIONS Areas Where Theory Needs Improvement More theory is needed in three areas: commitment, volunteer pr o f i l e , and volunteer management theory. Organizational theory does not place much emphasis on commitment. Most volunteers are committed to volunteerism, but there is l i t t l e information on their degree of commitment to the particular agency to which they devote their time. Knowledge about transferability of volunteers from one agency to another is essential to studies of efficiency. It is not efficient for society to eliminate an inefficient volunteer service i f those volunteers are going to be lost to society. The profile of the volunteer is changing. Carter (1975) and Anderson and Moore (1974) provided a comprehensive picture of the Canadian volunteer. In order to develop theory on how volunteerism i s changing, a more up-to-date profile is required. Glaser and Strauss (1967) in their discussion of grounded theory, view theory as a process; an ever-developing entity. It is not a perfected product or one to be just modified. Theory must be grounded in data. New data are needed to contrast with the old. The model exists. The third area where more theory would be advantageous i s the organiza-tional management theory as i t relates to volunteer organizations. There has been l i t t l e major work in this f i e l d for nearly a decade. - 193 -Areas for Future Investigation Immediate investigation is required on volunteers and outcomes. Ongoing investigation should be planned for c l i e n t s ' food preferences, client satisfaction and volunteer satisfaction. Data are required to answer questions about volunteers. Who are the volunteers? Does their profile d i f f e r from that in other voluntary organiza-tions? How committed are they? How do you keep them? Why do you lose them? Strategies for recruiting and retaining volunteers should be based on empirical grounds. Outcome evaluation is needed now to reverse the trend of a decreasing number of clients being served. Productivity, volunteer turnover, and client turnover require data for assessment. Effective remedies can be planned only i f the facts are known. Advantages of Pluralism in Society The social safety net i n Canada is provided by four sectors: 1. Statutory ( i . e . , social services provided by local or central government), 2. The commercial or private market place, 3. Voluntary agencies, 4. Informal network of support by family, friends, and neighbours. Pluralism i s the principle that the government and the voluntary sector should be partners. Voluntary organizations interact in a p l u r a l i s t i c setting. They are intended as a supplement, not a substitute for state-provided services, because there are many levels of need where social services are inadequate. - 194 -Volunteer organizations extend existing services, improve the quality of government provision, offer services where l i t t l e or nothing i s available, and help meet the needs created in society by a changing environment. Extension of the scope of existing provisions is accomplished by innova-tion, expansion, and providing complementary or supplementary services which allow the citizen to choose between government and non-government services. Volunteerism also extends the absolute amount available. It can provide direct o support to statuatory services as occurs in Meals-on-Wheels. Volunteer agencies improve the quality of government provision by offering alternatives which prevent a monopoly. Sometimes this is accomplished by the volunteer agency's advocacy role on behalf of particular groups. Volunteer organizations are free to c r i t i c i z e or champion. Volunteerism can make contributions to society that would be lacking in government social services. The volunteer can provide what the helping profes-sional cannot: time and attention to personal circumstances. The f l e x i b i l i t y of volunteer agencies allow them to offer personalized service delivery because they have the a b i l i t y to individualize need. Volunteerism benefits society. It satisfies unmet needs of volunteers and provides training in social responsibility. It helps to meet social needs created by a changing social environment where income and leisure distribution are changing, church influence i s declining, and modern l i f e i s becoming more complex. Volunteerism f i l l s needs that remain even in a social service state. More programs are started than terminated. Beveridge (1948) stated: Vigour and abundance of voluntary action outside the citizen's home, both individually and in association - 195 -with others for bettering his own and his fellows' lives are the distinguishing marks of a truly free society.... must put their hands into their pockets and their hearts into their leisure, (p. 121) Questions Answered Answers have been sought to the questions posed i n Chapter 1. Some have been provided as the study progressed. The answers arising in this study are now summarized. Who are the clients? The clients are "old, old." Two-thirds are female. The percentage of males was higher than the corresponding percentage in this age-group of the population. Referrals come equally from agencies and the clients themselves. Nearly half receive only three meals per week. Many receive Homemaker Service as well. A more detailed analysis of the profile data i s provided in Chapter 4. Have they changed over the years? The clients have remained similar over the years. Significant changes occurred only in age, number of times on service, and length of service. Data on changes in clientele are provided in Chapter 4. Are they satisfied with the food and the service? The clients are delighted with the service. Most have nothing but praise and appreciation for the volunteers. They expressed less enthusiasm for the - 196 -food. Chapter 6 provides data and detailed answers to the question of client satisfaction. Are the volunteers satisfied? The degree of satisfaction of those volunteers who replied was high. The data indicated some dissatisfaction with recognition from management. The method of distribution of the volunteer questionnaires precluded follow-up of lost cases. Non-randomization casts doubt on v a l i d i t y . Volunteers who have left the organization could not be contacted. It can be stated with certainty only that those volunteers who were retained were satisfied. How can recruitment of volunteers be increased? Volunteer recruitment can be increased by encouraging internal sources of recruitment and concentrating effort on those sources which have provided the most volunteers. Chapter 5 provides detailed answers to this question. How can volunteers be retrained? This i s uncertain. Some p o s s i b i l i t i e s can be inferred from the data in Chapter 5, but valid reliable answers can be obtained only by further evaluation. More research is required. A record of present and past volunteers is essential to accurate data gathering. Who are the staff? Are they a good f i t for the organization and i t s purposes? The staff are caring individuals dedicated to helping others. They are perhaps not as expert in management s k i l l s as theoretical best practice - 197 -recommends. Rather than lose the altruism and commitment of these employees by replacing them with management-oriented staff, VON might consider a planned course of s k i l l upgrading by continuing education. In this way, the organzation could have the best of both worlds. What are the goals of Vancouver-Richmond Meals-on-Wheels? Deficiencies exist in goal-setting and priorization. The formal goals are ambiguous. The operational goals are to provide food, improve nutrition, supplement social support, and prevent institutionalization. As self-evaluation replaces avoidance of goal-setting as the prime defence mechansism, fear of setting clear, concise, priorized goals should decrease. Do clients, volunteers, management, related agencies, and government view Meals-on-Wheels differently? Yes. The clients view i t as primarily a food-related service. The volunteers view i t as a food-related service in which the social support aspects are almost as important as the food. Management views i t more as a people-oriented business. Related agencies appear to be pleased i t exists and are content to leave i t alone. Occasionally an ambitious individual in a related agency in i t i a t e s take-over behaviour. Meals- on-Wheels usually protects i t s t e r r i t o r i a l imperative by non-cooperation and secretiveness about the operation of the organization. Governments view Meals-on-Wheels as a support to statutory services and a means of preventing institutionalization. It does not 198 -appear to be of concern to government that Meals-on-Wheels' goals are ill - d e f i n e d . Is i t an effective organization? Vancouver-Richmond Meals-on-Wheels is not as effective as anticipated. Its service i s declining, not expanding. Productivity and turnover of volunteers are not known, and turnover of clients is only estimated. Remedial action is not currently planned. How does Meals-on-Wheels compare with recognized best practice organization management theory? Vancouver-Richmond Meals-on-Wheels compares favourably with recognized best practice management theory only in certain areas. Chapter 7 and 8 provide a detailed analysis of differences and offer reasons why they may exist. The organization continues to work, even with deficiencies in planning, implementation, control, and evaluation because of the dedication of the volun-teers and because i t provides a unique service not available elsewhere. Deficiencies in process and structure are due to lack of expertise (e.g., management is unaware of the need for s t a t i s t i c a l information, rather than guesswork, on which to base planning). Goal deficiencies are due to fear of change. Is improvement needed, and i f so, what? Improvement is needed. Vancouver-Richmond Meals-on-Wheels is perceived as a necessary service by over 500 people in the community who receive i t . It is - 199 -one of the few services for the elderly that is not geared primarily to the "have-nots." 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Delivery to Seniors' Buildings: none Seniors' Building Meal Program: n i l III. MID-MAIN HEALTH UNIT - Population over 65: 9,102 Meals-on-Wheels Marpole D i s t r i c t - 40 to 50 meals Riley Park D i s t r i c t - 45 to 50 meals + wait l i s t . No Thursday delivery. Delivery to Seniors' Buildings: South Van Manor - 6 meals Southwynd - 2 meals Kiwanis Manor - 2 meals IV. NORTH HEALTH UNIT - Population over 65: 11,675 Meals-on-Wheels Grandview D i s t r i c t - 40 to 50 meals + wait l i s t Burrard D i s t r i c t - 40 to 50 meals + wait l i s t Strathcona D i s t r i c t - 50 to 60 meals + wait l i s t - 217 -Delivery to Seniors' Buildings: Beulah Gardens - 7 meals Skeena Terrace - 3 to 4 meals MacLean Park - 7 meals Antionette Lodge - 6 to 7 meals Roddan Lodge - 4 meals Oppenheimer - 5 to 6 meals Seniors' Building Meal Programs Grandview Terrace - 30 meals, 3 times per week Thunderbird/Skeena Terrace - 25 to 30 meals, Tuesdays only Raymur Park - 13 to 16 meals, twice a week V. ROBSON HEALTH UNIT - Population over 65: 8,000 Meals-on-Wheels West End D i s t r i c t - 70 to 80 meals - at capacity. Burrard D i s t r i c t - 40 to 50 meals + wait l i s t Delivery to Seniors' Buildings: Twin Arms - 8 to 10 meals Nicholson Towers - 8 to 12 meals Sunset Towers - 12 to 15 meals West Sea - 4 to 6 meals Haro Park - 4 to 6 meals Seniors' Building Meal Programs: Sunset Towers - 20 meals/day, 7 days/week Nicholson Towers - in the planning stage VI. SOUTH HEALTH UNIT - Population over 65: 7,199 Meals-on-Wheels Fairview D i s t r i c t - 40 to 50 meals (seasonal wait l i s t ) Marpole Di s t r i c t - 40 to 50 meals Delivery to Seniors' Buildings: Fairhaven - 2 to 3 meals German Canadian - 1 meal Finnish Canadian - 1 meal Menno Court - 8 meals Killarney Gardens - 8 meals - 218 -Seniors' Building Meal Program: n i l VII. WEST HEALTH UNIT - Population over 65: 11,896 Meals-on-Wheels Kerrisdale D i s t r i c t - 75 to 80 meals - at capacity Dunbar Di s t r i c t - 70 to 80 meals Delivery to Seniors' Buildings: Steeves Manor - 10 meals King Edward Court - 5 to 6 meals Parkdale Manor - 9 meals Seniors' Building Meal Programs: Steeves Manor - meal program attempted. Residents voted against acceptance and project abandoned. It should be noted that some Meals-on-Wheels d i s t r i c t s are cited more than once. APPENDIX B RECIPIENTS ON PROGRAM FROM JULY 1, 1981 TO JUNE 30, 1962 JHi A:> CHAPTER Rr :EI\ :C RECEIVIN REFERRED BY REFERRED BY FAMILY, REFERRED BY ]•:, • , j. HOMEMAKE S E L F FRIENDS OR OTHER L .T.C. 8E..VIC...I SERVICES i ro I II II II R E C I P I E N T S ON PROGRAM FROM JULY 1, 1981 TO JUNE 30, 1982 — — RE:EIV..:G R E C E I V I N G REFERRED BY REFERRED BY FAMILY, REFERRED BY HO.. 2 C- :E HOMEMAKER S E L F FRIENDS OR OTHER L.T.C. S E R V I C E S S E R V I C E S it _ II _ it _ _ - — " _ II _ - — " _ n _ _ it _ _ _ i' H _ - _ 'i n _ n _ - - _ _ II - — _ _ II - '' - - _ - " _ _ _ - " - - _ _ ti RECIPIENTS ON PROGRAM FROM JULY 1, 1981 TO JUNE 30, 19C2 .U. i'Jl.E CHAPTER n ~ RH av; .G RECEIVING REFERRED BY REFERRED BY FAMILY, REFERRED BY HOEE C, !E HOMEMAKER SELF; FRIENDS OR OTHER L/T. C. SERVICZZ SERVICES T I RECIPIENTS ON PROGRAM FROM JULY 1, 1981 TO JUNE 30, 1982 RECEIVING RECEIVING REFERRED BY REFERRED BY FAMILY, REFERRED BY HOV.E CARE HOMEMAKER SELF FRIENDS OR OTHER L.T.C. SERVICES SERVICES II n - 223 -APPENDIX C Data Supplied by 8. Kaminsky, September, 1982 MEALS ON WHEELS PROGRAM 1982-83 45 139 1,447 280 260 754 129 209 167 550 180 not prov. 100 18 12 150 18 60 1,566 6 25 44 30 12 21 6 .66 540 1,000 1,092 1,000 612 .50 1,665 1,375 2,000 2,296 1,120 .50 19,100 11.567 21,000 13,159 11.750 .47 3,328 1,440 3,500 2,450 2,450 .66 3,116 2,318 3,120 2,343 2.343 .56 9,264 5,339 9,000 6,875 6,875 ,70 1.560 1,310 1,600 2.200 1.248 .47 2.503 1,038 3.000 1,401 1,401 ,70 1.999 2,240 2,100 3,000 1.638 20 25 not prov n/a 2.000 n/a n/a nil .60 2,100 1,200 950 13 n/a .50 366 n/a n/a 475 nil 7.000 2.700 2.700 2,400 1,200 1.200 500 728 280 2,000 1,000 1.000 .56 yes .56 no # of av.0 of projected 1981/82 actual projected 1982/83 1982/83 1982/83 provides § of aV. # volunteers persons § meals subsidy § meals 1981/82 § of meals requested recom. subsidy to home PROGRAM days/wk. meals/mo. 1981/82 served/mo. 1981/82 per meal 1981/82 subsidy 1982/83 subsidy subsidy per meal care Agassiz-Harrison Community Services Society 3 Armstrong -Spallumcheen Comm. Service Centre 5 Burnaby Meals On Wheels 3 Cair.pholl i!i '••j,- L Jisl, Meals On Wheels 6 Castlegar & Oist. Homemaker Ser. Assoc. 3 Chilliwack Comm. Service Society 5 Cranbrook Homemaker Service 3 Creston Valley Homemaker Service 3 Dist. 69 Society (Parksville) 3 -Duncan Meals On Wheels 6 Fernie & District Homemakers Society 7 Golden & District Homemakers Society 3 -Hope Comm. Chimo Serv. 3 8 1,500 11 2,750 90 22.714 30 3,025 20 3,500 51 9,480 120 1.872 25 2,200 13 3,200 .70 no .75 no .76 yes .78 no .46 yes .78 yes .38 yes .50 no .56 no >>n ><o<-- 224 -* ot av.tf of projected 1981/82 actual projected 1982/03 W>/B3 1982/83 provid $ of av.0 volunteers persons 0 meals subsidy t meals 19 82 § of meals requested rt i . subsidy to hom, PROGRAM days/wk. meals/mo. 1981/82 served/mo. 1981/82 perineal 1981/82 subsidy 1982/83 subsidy subsidy perineal care James Bay Comm. School Society 4 24 12 1,240 11 ,000 Kamloops Meals On Wheels 3 345 85 32 4.100 Kimberley & Dist. Homemakers Services 3 120 17 10 1,700 Kiwanls Ladies Aux. 6 739 71 not prov. 8,550 Langley Community Services 3 300 35 27 6,000 Lr. Similkameen Comm. Services Society 3 94 10 18 2,800 Maple R1dge-Pitt Meadows Comm. Serv. 6 342 75 22 3,210 Matsqui-Abbotsford Community Services 5 410 25 50 5,000 Mission Community Services Society 3 140 20 — 1,900 Nakusp Dist. Homemaker Services 3 103 24 12 1,560 tlanalmo Meals On Wheels Program 6 1.114 101 61 14,000 Nelson & D i s t r i c t Homemakers Service 5 374 20 25 5,680 Hew Denver Silverton & Dist. Homemakers 2 125 14 10 1,248 Nicola Valley Reg. Nurses Assoc. 3 111 36 13 2,000 o th Shore Meals On W eel  Society 1,44 7 350 1 ,239 1 8, 00 1.00 13,020 11,000 ' 15,500 11,000 11,000 .36 4,276 1,500 .70 1,400 1,190 .50 8,871 4.275 .70 4,262 4.100 .50 1,034 1 ,4-10 .70 4,100 2,247 .70 4,980 3,500 .50 1,671 .50 1.211 .70 950 780 (est.) .28 12,076 4,000 .50 4.500 2,850 785 874 .50 1,460 1,000 5,500 2,500 2,500 1 ,400 1,200 1 .092 8,900 6,000 6,000 4,500 6,584 3.510 2.000 -1 ,445 1,440 4,200 5,413 3,276 5,500 4,500 4,290 1,800 1,500 1,008 1,560 2,592 930 1,327 874 14.000 5,000 5,000 5,000 2,500 2,500 521 2,520 1,600 1,400 .47 17,365 8,500 18,000 9,000 9,000 .70 no .45 yes .78 yes .67 yes .78 yes .63 !.: .78 yes .78 yes .56 yes .56 no .35 yes .50 yes .56 no .56 yes .50 yes - 225 -8 of av.tf of projected 1981/82 actual projected 1982/83 19r '63 1982/83 provides # of av.0 volunteers persons ti meals subsidy i meals 19b.. 82 ti of meals requested rei....<. subsidy to home PROGRAM days/wk. meals.mo. 1981/82 served/mo. 1981/82 per meal 1981/82 subsidy 1982/83 subsidy subsidy per meals care North Surrey Meals On Wheels 3 Port Alberni Meals On Wheels 6 St. James Social Service Society 5 Salt Spring Island Meals On Wheels 3 Si lver Threads Serv. 5 Snnrwood 8 HI:ford iiomemakers Service 3 Spencer-Pr. Rupert Homemakers Service 3 Sunshine Coast Comm. Services Soc. 3 Terrace & Dist. Comm. Serv. Society 3 Tra i l & D1st. Homemakers Rossland 3 Tra i l 3 Vernon & Dist. Homemaker Society 5 V.O.N. Rmd./Van, 5 Western Society for Senior Services 5 641 380 330 278 4,030 72 66 175 245 78 12 520 11,664 711 94 30 not prov. 17 124 B 8 15 9 72 16 180 630 53 46 23 300 18 266 7 7 15 166 7 152 34 800 711 5,700 4,100 3,960 3,000 56,000 1,200 780 ' 3,000 3,500 1,000 2,080 8,800 143,520 11,450 3B8,oi«) .66 4,722 3,800 8.050 3,960 3,960 .47 4,566 1,956 4,800 2,400 2.400 .95 5,500 3,772 not .70 prov. 2,100 .55 48,893 31,000 .70 859 .50 941 840 .33 795 260 .70 1 ,687 2,100 Jest.) .70 2,777 2,450 500 .70 .1,820 1,456 .50 6,209 4,400 .59 139,967 85,045 (est.) .50 8,601 5 , 725 353. m 221,qi2 4.000 1,200 6,996 3,120 2,505 2.200 1,954 51,500 41,000 40.170 840 825 3.150 3,500 3,841 B40 270 270 2,520 1,764 2.730 1.000 550 550 2,080 1,959 1.622 7.000 6.505 5.460 148.106 93,500 91.351 9.550 6,400 5,348 39b .9 b& 21S,ye<l 249,557 .49 yes .50 yes .78 no .78 no .78 yes .70 no .32 yes .56 yes .78 yes .55 yes .78 yes .78 yes .63 yes .56 yes - 226 -APPENDIX D Methodology for Client Data in Chapter 3 The objectives, policy, and process of Meals-on-Wheels organizations have remained f a i r l y static over the eighty years of operation since i t s inception. Meals-on-Wheels has been in operation in the Vancouver area since 1967. Records we're available from 1971, when i t became the Vancouver-Richmond Meals-on-Wheels under the auspices of the Victorian Order of Nurses. A computer search has not revealed information on the profi l e of the Meals-on-Wheels recipient in Canada. Five previous studies or attempted studies of Vancouver-Richmond Meals-on-Wheels have not produced a profile of the recipient. Improvements in client satisfaction, volunteer recruitment, and organizational management w i l l l i k e l y require a data base. The profile w i l l answer the basic unknowns of who receives Meals-on-Wheels and why* It may also provide sufficient information on other variables on which to base decision-making, goal setting, and priorization. It i s assumed that the findings would be similar to those for the entire population receiving Meals-on-Wheels in Vancouver-Richmond. This data base w i l l be useful as a basis for further studies of Meals-on-Wheels and perhaps for the future studies of this age group receiving other social services. This appendix w i l l provide a profile of the present recipients, show the similarities and differences between present and past recipients, and highlight any significant changes in the recipients of this service. - 227 -Appendix D continued. Method Design The study of the past recipients was a retrospective examination of av a i l -able data on 200 past recipients of Vancouver-Richmond Meals-on-Wheels for a period of 14 years, and 100 recipients who were receiving Meals-on-Wheels from December 10, 1984 to January 8, 1985. Trained volunteers (screeners) v i s i t each applicant and f i l l in an inter-view form. When the applicant is accepted this information is transferred to a f i l e card by salaried office staff. R e l i a b i l i t y was checked by the investiga-tor, who cross-checked the non-random sample of interview forms against f i l e cards for accuracy in the transfer of information. Completed interview forms were available for 1981 and 1982 only. Since i t was mostly straightforward background data with no threatening questions, the data should have face v a l i d i t y . Sampling The population can be divided into two parts: past and present. Past The population was those clients who have ceased meal service during the period January 1, 1971 to December 31, 1984. The sample was a random selection of 200 cards from those on f i l e . The actual sample size was 202 because 2 cards contained information on a husband and wife, both of whom had received Meals-on-Wheels. - 228 -Appendix D continued. Meals-on-Wheels estimated the number of past clients (1971-1984) at 5,000. The actual number was 6,397, unless of course there are more instances of two people on one card. The cards were in chronological order of discharge, except for the 1984 cards which are f i l e d in alphabetical order at the end. The cards were assumed to be numbered in the order in which they were f i l e d . Using the last four digits of a table of random numbers, the f i r s t number selected was by blind selection. The next numbers were then recorded in order, discarding any numbers over 6400 until 200 numbers had been recorded. These numbers were then arranged in numerical order. Cards were pulled to correspond with these numbers. The data were collected on the premises of Vancouver-Richmond Meals-on-Wheels between May 1, 1984 and December 9, 1984. Present The identical method was used for the selection of the sample of 100 present recipients, using the current 600 client cards. A sample of 10% might have been adequate, but because of the missing data encountered in the past recipient records, a size of 15% was considered desirable. The actual sample size was slightly above this. 100 random numbers were listed between 1 and 600. The actual popu- lation was 528. The random numbers between 1 and 528 were 88 in number. Thus, the sample size was 88 or 16.6% of the population. The higher number estimated by Meals-on-Wheels may have been due to the fact that in some instances husband and wife were on the same card. It may have been due to the fact that at any given point in time cards had been temporarily removed from the - 229 -Appendix D continued. f i l e because the client may not have required a meal on that particular day. Or, i t may have been due to an erroneous estimate on the part of the coordinator, although a meal count i s kept by both the office staff and the caterers for purposes of accounting. The data were collected on the premises of Vancouver-Richmond Meals-on-Wheels between December 10, 1984 and January 8, 1985. Instrument The advantages of using available data are i t s economy and time series analysis potential. It shows trends over time. It does not require the cooperation of the individual about whom information is being sought. The measurement procedure does not have any effect on the behaviour of the subjects being studied. On the other hand, there are many disadvantages* Available data may not contain a l l the information required. Differing definitions over time can create ambiguity and inaccuracy. The decision to use existing data were influenced by three factors — many of the present subjects would not remember the exact date service commenced, who referred them, or the reason for the r e f e r r a l . There was no other choice for past recipients. Many have been admitted to LTC, hospital, or died. In order to achieve any relevance between the two samples i t was essential that the method of sampling be the same. One difference did exist. Time constraints, due to limited accessibility to the - 230 -Appendix D continued. f i l e s , necessitated collecting the data over a one month period, instead of one week as originally planned. Hence, some of the short-term clients may have been lost. Meals-on-Wheels estimated the number of drop-outs at 60 per month. The sample size was 16.6%, thus the number lost could be as high as 10. Since approximately the same number (60) enter the service each month, i t i s possible that one compensates for the other. Pretesting was done by pulling 20 cards non-randomly and recording the information on a code sheet to ascertain that the data were obtainable and reasonably complete. Data were available for 13 variables: Age Sex Type of accommodation Marital status By whom referred Reason for referral Reason for discharge Date started Date stopped Number of times on service Number of meals per week Dis t r i c t Whether or not receiving Homemaker service Method of payment was originally included but was abandoned when i t became apparent that there was not sufficient information available for i t to be of any significance. The reason for this was that almost a l l recipients paid for the meals themselves. At any given time there were 4-5 paid for by the government as a hospital replacement cost. This i s usually for a period of one week only. Approximately 8-10 recipients paid directly to the off i c e . An additional 6-8 - 231 -Appendix D c o n t i n u e d . were paid by t h e i r f a m i l y , t h e i r a t t o r n e y , or t h e i r t r u s t e e . In a sample of 202 past r e c i p i e n t s , i n f o r m a t i o n with respect to method of payment was a v a i l a b l e i n only s i x i n s t a n c e s . Data on sex of c l i e n t was obtained by n o t i n g " M r . " , " M r s . " , or " M i s s . " Where these p r e f i x e s to the name were m i s s i n g i t was obtained by reading the comments and n o t i n g whether "he" or "she" was u s e d . Age recorded was at commencement of s e r v i c e . Where age was m i s s i n g , date of b i r t h was u s u a l l y i n c l u d e d which allowed c a l c u l a t i o n of age by s u b t r a c t i n g date of b i r t h from date s t a r t e d . R e f e r r a l by agencies i n c l u d e d those c l i e n t s r e f e r r e d by Long Term Care , Home C a r e , VON, D . V . A . , Community Heal th A s s o c i a t i o n s , and s p e c i f i c d i s e a s e -r e l a t e d s o c i e t i e s ( e . g . , D i a b e t i c A s s o c i a t i o n , Cancer I n s t i t u t e , e t c . ) . In order to achieve n u m e r i c a l l y c o r r e c t ( i . e . , v a l i d ) l e n g t h of s e r v i c e d a t a , i t was necessary to a d j u s t the " d a t e - s t o p p e d " v a r i a b l e when s e r v i c e was provided more than once. T h e r e f o r e , t o t a l l e n g t h of s e r v i c e i n days was c a l c u l a t e d . T h i s number was then added to date s t a r t e d to a r r i v e at the adjus ted ( f i c t i o n a l ) date s topped. T h i s number was then entered as the date s e r v i c e s topped. - 232 -Appendix D continued. The following example uses Identification #019: Actual dates of service were July 7, 1975 - August 6, 1976 and August 8, 1977 - August 11, 1977 '76, 08, 06 75, 07, 04 365 + 3 1 + 0 2 77, 08, 11 77, 08, 08 0 + 0 + 3 365 31 02 03 401 75,07,04 + 401 = 76,08,09 .. number entered was 76,08,09 Ethics A letter of permission was obtained from Vancouver-Richmond Meals-on-Wheels. Since there were no personal interviews or questionnaires directly involving the sample selected, i t was not necessary to obtain consent other than from the agency, nor was i t necessary to request approval from the UBC Behavioural Sciences Screening Committee. APPENDIX E. - 233 - November 1978 SCREENERS JOB DESCRIPTION Duties I n t e r p r e t a t i o n of Meals on Wheels service to p o t e n t i a l or a c t u a l r e c i p i e n t s i n the designated area; assessment of s u i t a b i l i t y of applicants to program and t h e i r a b i l i t y to pay f o r meals and recommend the amount; f o l i c ; ; up v i s i t s re problems reported by volunteers; f o l l o w up on any d i f f i c u l t y i n service d e l i v e r y encountered by volunteers; i n t e r p r e t a t i o n of problems of r e c i p i e n t s to the D i s t r i c t Chairman e i t h e r d i r e c t l y or through the ]v!eals on Wheels o f f i c e . Communi c a t i on Re f e r r a l s w i l l come through the Meals on Wheels o f f i c e . A f t e r the v i s i t has been made a request f o r commencement of service and information about the r e c i p i e n t should be given to the Meals on Wheels o f f i c e , and w i l l be relayed t o the area Chairman. » > APPENDIX F - 234 -November 1978 DISTRICT CHAIRMAN JOB DESCRIPTION The D i s t r i c t Chairman i s the key pa-rso» i n each chapter or area . He or she -should have good o r g a n i z a t i o n a l a b i l i t y , have a pleasing p e r s o n a l i t y and r e l a t e w e l l to both volunteers and r e c i p i e n t s . The D i s t r i c t Chairman's p o s i t i o n should be held by a volunteer, p r e f e r a b l y from the l o c a l community. (Terms oi Reference, February 1970) TEE ROLE The D i s t r i c t Chairman's chief role , i s that of coordinator i n the area.. It is his or her r e s p o n s i b i l i t y tc see that the zsrvice i s c a r r i e d cut in accordance with the accepted p r a c t i c e and p o l i c y of the orga.nizat ion so that r e c i p i e n t s are given the care and consideration they need. I t i s also the D i s t r i c t Chairman's r e s p o n s i b i l i t y to f o s t e r good r e l a t i o n s h i p s between a l l those involved i n Meals-on-Wheels to the b e n e f i t of the r e c i p i c : SPECIFIC RESPONSIBILITIES The D i s t r i c t Chairman i s responsible for the day to day organization of her chapter. However some aspects of the job may be delegated to Day Captains and other responsible volunteers. The r e s p o n s i b i l i t i e s are as f o l l o w s : a) On a. d a i l y b a s i s : 1. Keeping up to date records on r e c i p i e n t s . 2. D a i l y arrangement of volunteer schedules. 3- Checking l i s t of r e c i p i e n t s and meals required with the tfffice s t a f f 4. I n s t r u c t i n g the Day Captains ( i n c l u d i n g g i v i n g information regarding changes i n r e c i p i e n t or volunteer l i s t s , s p e c i f i c needs or problems) and r e c e i v i n g a report back a f t e r a l l meals have been d e l i v e r e d . 5- Referring s p e c i f i c problems r e q u i r i n g follow-up to the coordinator f o r appropriate a.ction. b) On a continuing b a s i s : 1. Orientation, and t r a i n i n g of new voiunt-ec-r J . 2. Knowledge of resources for the hoaiebound person i n the community. 3- Support of and assistance to volunteers. k. rioting s p e c i a l events such as bir thdayr , anniversaries, Christmas, Easter etc. so that volunteers may mark the occa.sion i n some s p e c i a l w a y . 5- Communication with s t a f f regarding the needs of r e c i p i e n t s and r - ; ^ ^ -of the chapter. 6. Monthly reports. 7- Regular checking of r e c i p i e n t s cards end records. 8. A t i -.:ndance at monthly V . O . N . MeaIs-on-WhesIs Committee meeting? . - 235 -MEALS ON WHEELS - MONTHLY FINANCIAL REPORT  MONTH meals g $ meals @ meals 9 meals office to b i l l - specify no charge to chapter meals no charge - specify no charge to chapter TOTAL MEALS SENT TO CHAPTER TOTAL CF AMOUNTS SHOWN $ AID: ANY AMOUNT TO BE REFUNDED TO RECITIENT SPECIFY ADD: ANY AMOUNT COLLECTED FOR OFFICE BILLINGS SPECIFY ADD: BANK INTEREST ADD: DONATIONS TOTAL ANY PREVIOUS CREDIT BALANCE ANY PREVIOUS OVTSRPAYMENT SPECIFY BANK CHARGES PETTY CASH SPECIFY TOTAL OF SUBTRACTIONS TOTAL AMOUNT DUE TO OFFICE AMOUNT SUBMITTED CREDIT OR DEBIT BALANCE TO CHAPTER BANK BALANCE AFTER PAYMENT DATE APPENDIX G CHAPTER SUBTRACT: SUBTRACT: SUBTRACT: SUBTRACT: A P P E N D I X H-- 236 -November 1978 Day Captains:- JOB DESCRIPTION The Day Captain i s responsible f o r the d i s t r i b u t i o n of meals on a designated day. Ea r l y on the day of service the Day Captain w i l l r e c e i v e up-to-date information from the D i s t r i c t Chairman i n r e g a r d to the number of meals required and changes i n r e c i p i e n t s or voIur:te-_rr. The Day Captain w i l l a r r i v e i n good time at t h ~ r.lace (at l e a s t 15 minutes ahead of the other volunteers), check r e c i p i e n t s ' cards and await the a r r i v a l of the meals. When the meals a r r i v e w i l l c a r e f u l l y check the numbers before the dr i v e r leaves, when the volunteers a r r i v e w i l l give them d e l i v e r y i n s t r u c t i o n s , cards with information p e r t a i n i n g to the c l i e n t s and the appropriate number of meals. The Captain w i l l remain u n t i l the volunteers return with the payments f o r the meals and the "route cerds ;', ' - i l l check that everything i s i n order and w i l l supervise the washing of the boxes. As each area has t h e i r own way of banking monies;. the Day Captain w i l l attend to t h i s i n the way arranged f o r the area. The Day Captain w i l l ensure a f u l l s l a t e of volunteers - i f someone i s to be absent w i l l attempt t o f i n d s u b s t i t u t e s from a l i s t of vo"5 "nte^etrs a v a i l a b l e from the Chairman. APPENDIX I - 237 -VICTORIAN ORDER OF NURSES MEALS-ON-WHEELS FACT SHEET THE PROGRAM V.O.N. Meals-on-Wheels is a voluntary community service providing one hot nutritious noon-meal delivered, three days each week on Monday, Wednesday and Friday. THE PEQPT.iS! During 1971, 1132 people have availed themselves of Meals-on-Wheels. Anyone may receive this service who, "by reason of age, physical or mental handicap, or illness, is temporarily or permanently unable to prepare meals. Service may be given on a long or short term basis. The majority of clients are elderly people living on a moderate or low in-come who are able to maintain themselves with some help in their own home. Many are convalescing after illness or injury or are chronically i l l . Ap-proximately 14$ of the clients are younger handicapped or convalescent persons. THE VOLUNTEERS Volunteers are drawn from many segments of the community. Over 750 men, women and high school students give at least an hour and a half once a we*»> to deliver meals and visit clients. Twelve local districts in Vancouver and Richmond each have a chairman and three day captains to coordinate activities. TTTK MEAL 39*88°" meals were served during 1971- A uniform minimum standard was set up with advice from the city nutritionists and periodic spot checks are made to see that these standards are maintained. Menu variations and limit-ations are suggested to the caterers. In addition, the requirement of an annual permit from the City Health Department involves an inspection of a l l aspects of the program. Catering for Meals-on-Wheels are Pacific Western Airlines, The Tartan Restaurant, Carlsbad Private Hospital and The Bay in Richmond. - 238 -- 2 DIETS A l i m i t e d v a r i e t y o f s i m p l e t h e r a p e u t i c d i e t s i s a v a i l a b l e t o t h o s e who need them i n a r e a s s e r v e d b y P a c i f i c W e s t e r n A i r l i n e s F l i g h t K i t c h e n and some v a r i a t i o n c a n b e made i n e x c e p t i o n a l c i r c u m s t a n c e s i n t h e m e a l p a t t e r n * A t p r e s e n t 20f> o f t h e m e a l s s e r v e d a r e l n t h i s c a t e g o r y . However due t o l a c k o f p r o p e r d i e t e t i c f a c i l i t i e s we a r e n o t a b l e t o e n c o u r a g e c l i e n t s t o h a v e s p e c i a l m e a l s . FINANCE A maximum o f $1 p e r m e a l i s c h a r g e d when t h e c l i e n t c a n a f f o r d t o p a y , othep* w i s e m e a l s a r e s u b s i d i z e d a s n e c e s s a r y . Most c l i e n t s p r e f e r t o p a y t h e v o L u n t e e r d a i l y f o r t h e i r m e a l b u t m o n t h l y b i l l i n g a r r a n g e m e n t s may b e made w i t h t h e o f f i c e . T h e f e e i s d i s c u s s e d w i t h e a c h c l i e n t b e f o r e b e o r she i s a d m i t t e d t o t h e p r o g r a m . F e e s p r o v i d e t h e main s o u r c e o f income f o r t h e p r o g r a m and t h e r e m a i n i n g 26^ o f t h e b u d g e t h a s b e e n p r o v i d e d b y g r a n t s f r o m t h e C i t y o f V a n c o u v e r and t h e V a n c o u v e r F o u n d a t i o n and d o n a t i o n s f r o m c h u r c h e s , s e r v i c e c l u b s and i n d i v i d u a l s . REFERRALS C l i e n t s may b e r e f e r r e d b y s t a f f o f h o s p i t a l s and a l l h e a l t h and w e l f a r e a g e n c i e s o r t h e y may r e q u e s t t h e s e r v i c e t h e m s e l v e s . When recommended b y p r o f e s s i o n a l s t a f f o f a r e c o g n i z e d a g e n c y , c l i e n t s a r e a c c e p t e d i m m e d i a t e l y and a v i s i t may b e made f o r c l a r i f i c a t i o n i f n e c e s s a r y . S e l f - r e f e r r e d c l i e n t s o r t h o s e recommended b y f a m i l y o r f r i e n d s a r e v i s i t e d b y a r e p r e s e n t a t i v e o f M e a l s - o n - W h e e l s . M e a l s - o n - W h e e l s s t a f f and a g r o u p o f v o l u n t e e r s w i t h p r o f e s s i o n a l s k i l l s ( n u r s i n g , s o c i a l w o r k e t c . ) under t h e s u p e r v i s i o n o f t h e c o o r d i n a t o r c a r r y out a l l s u c h s c r e e n i n g v i s i t s . C l i e n t s a r e u s u a l l y a d m i t t e d t o t h e p r o g r a m w i t h i n two d a y s o f t h e r e f e r r a l and i n an e m e r -g e n c y can b e a d m i t t e d u n t i l 9 a . m . on a m e a l d a y . t o make a r e f e r r a l , ' ADMINISTBATION The p r o g r a m i s a d m i n i s t e r e d b y t h e V i c t o r i a n O r d e r o f N u r s e s . A M e a l s - o n -W h e e l s Commit tee o f t h e V . O . N . B o a r d o f Management h a s r e p r e s e n t a t i o n f r o m a l l d i s t r i c t s and r e s o u r c e p e o p l e f r o m s e v e r a l a g e n c i e s . The C h a i r m a n o f t h i s Commit tee s i t s on t h e B o a r d . — ~ -A s t a f f o f t w o , t h e c o o r d i n a t o r and a c l e r i c a l a s s i s t a n t , work f r o m an o f f i c e a t 16U5 West 10th Avenue and a r e r e s p o n s i b l e t o t h e D i s t r i c t D i r e c t o r o f t h e V . O . N . - 239 -- 3 -FOOD STANDARDS 1. protein food, at least 3 ounces (before cooking) "boneless meat, fish or poultry. 2. vegetables - i serving cooked - \ cup or one #12 commercial disher or scoop* - 1 serving other vegetable - cooked, salad, or k f l . ounces juice or soup. 3- potato or rice or macaroni products - \ cup. h. dessert - milk or fruit pudding or fruit pie ox tart, | cup or 1+ ounces. 5* beverage and bread - optional. soup, salad and juice should be provided in rotation once each week. - 240 -A P P E N D I X J VON FOR C A N A D A STATEMENT OF PHILOSOPHY VON for Canada, a national voluntary health agency, believes chat: • a l l people have a right to comprehensive, coordinated, compassionate health care and that, whenever possible, care should be provide:: ir. the famijiar surroundings of the home; • individuals and families should be encouraged and assisted to be as independent as possible in nee ting their health care needs; • programs emphasizing the promotion and maintenance of health, the prevention of injury'and disease, the care and restoration of the sick and disabled and the comfort of the dying should be available to help individuals and families; • nursing and other community care services needed co main-tain individuals at hor.;e are v i t a l components of the health care system and should be of the highest standard; • continuing educational preparation for staff is essential to meet changing community needs; • volunteers should play an active role in promoting, planning and providing health care services at the l o c a l , provincial and national le v e l . V O N As adopted by tlu- Board of Management of the Victorian Order o: Nurses for Canada, November 23, 19 79 - 241 -APPENDIX K Food Order Form EAGLE CATERING LTD DATE MEAL #273 U38 " D r i v e r CHAPTER R E G . D I A B . #2 N . P . P . #3 BLAND H SOFT U TOTAL I #5 | DIETS E NoFISH #10 SUPP. PAC. ] TOTAL :j MEALS BUHHATU3 1 K i. 1 CEDARCOTTAG] • rj DUNBAR i 1 < i FRASERVIEVV I H ! GRANDVIEW % [i if K! Si M KERRISDALE j j H t i i ; KITSILANO i ' j;. iv MT.PLEASANT 1 i i i MARPOLE i RICHMOND " ~ 1 1 RILEY PARK 7 WEST END I 1 1 OFFICE j i TOTALS 1 CHANGES B U R R A R D K E R R I S D A I 3 T CEDAR COTTAGE MAF.POLE DUNBAR MT. PLEASANT FRASERVli.'.'.' RICHMOND' GRANDVIEiV RILL"; PAR}; KITSILANO '.VIST END j APPENDIX L - 242 -JOB DESCRIPTION - MEALS ON WHEELS COORDINATOR  Role or Function: Coordination and support of a l l aspects of the Meals on Wheels Program, including a c t i v i t i e s of volunteers and volunteer groups; responsible to the D i s t r i c t Director for the administration, promotion, planning and delivery of the service. Duties: The Coordinator i s responsible for the following: 1. Recruitment, orientation, training and placement of volunteers. 2. Routine administrative procedures i n regard to record keeping, budgeting, service delivery, information and r e f e r r a l . 3. Promotion of the program by contact w i t h community groups (churches, service clubs, etc) and by use of the media. 4. Liason with health, social service ana related agencies in.regard to the u t i l -ization of the Meals on Wheels Program. 5. A b i l i t y to negotiate with caterers f o r the provision of meals to meet standards determined by the program. 6. Keeping abreast of developments i n the f i e l d of health and soc i a l services and making recommendations to the Meals on Wheels Committee, and D i s t r i c t Director for necessary changes i n the Meals on Wheels program. 7. Supervision and evaluation of Meals on Wheels staff. 8. Assessment of e l i g i b i l i t y of potential clients and determination of length and extent of service needed. Experience and Qualifications: Extensive experience i n working with volunteers and community groups; an understanding of the physical, psychological and so c i a l needs of the elderly and homebound; basic knowledge of special n u t r i t i o n a l needs of the elderly; an a b i l i t y to communicate with volunteers, professionals and community agencies using the service; administrative a b i l i t y . Professional t r a i n i n g i n n u r s i n g , s o c i a l work or d i a t e t i c s or e x t e n s i v e experience i n running a Meals on Wheels program i s desirable. Special S k i l l s or Needs: An a b i l i t y to work with a variety of people i n i n f o r m a l o r fo r m a l situations; an enthusiastic and warm personality; a commitment t o the principles and policies developed by the VON Meals on Wheels Program: ccmmunication s k i l l s . APPENDIX M- - 243 -JOB DESCRIPTION - MEALS ON WHEELS FOOD SUPERVISOR P/T 4 h r s . d a i l y Job D e s c r i p t i o n : S u p e r v i s i o n o f a p p l i c a t i o n and standards o f menu, working w i t h the C o o r d i n a t o r and c a t e r e r i n p l a n n i n g of s u i t a b l e menus and s e e i n g t h a t the meals meet the standards r e q u i r e d f o r the program; r e s p o n s i b l e f o r the s e r v i n g , packaging and d i s p e r s a l of meals from c a t e r e r t o depots. Person w i t h t r a i n i n g and experience i n food s e r v i c e and n u t r i t i o n , p r e f e r a b l y w i t h some knowledge o f the s p e c i a l requirements f o r t h e r a p e u t i c d i e t s ; must have .an understanding of the s p e c i a l r o l e of the v o l u n t e e r i n the d e l i v e r y of t h i s type of s e r v i c e . APPENDIX N .Bu"--^ MVQBIY Ml UNIVIKSITY W-VO» • iwvasni »i sc. ,0UEENf,. .,, EUZABETH WEST ' , ; •» w *,5p£; # QUEEN OWWBVONV IHIMIMII j IISIUKQ if W « UlLCHfM fSHS* • POINT HI I CAW • ELEMENTARY SCHOOL 0 COMPREHENSIVE COMMUNITY. SCh A PRIMARY SCHOOL » PRIMARY ANNEX • SECONDARY SCHOOL , f ALTERNATIVE SCHOOL . * SPECIAL SCHOOL . H VANCOUVER COMMUNITY COLLEGE West/oast street or avenue addresses start with their unit b locks at Ontar io Street (one block weal of Main Street). * 0 1 M LOlOlt L I W I N C S T O t M MMMMIf I HENDERSON ' « PA TECUMSEH M FUMING E A S T , v BF^CONSFKUJ} ncpOSIUNEJ RENFREW mm. 1M0MPS0H • MfHRiy mSt MARINE I lu«l.»i , OPFENHEIMER WITH AREA GROUPINGS l<ef •Li^l^U ' S t i n a r ^ (\r>^i^h - 2 H q b V l ^ e<vS qw\"t- - l^oo** PU*<ia*-t Cc«^»vv A.Vxi Qe otre-31 (>/-OKLar'»'St, o • ^ J ~ • 7" KINGSFORO- 3 » k J JE CHMVUM Communications Services 1981-1SB2 U 4 0 < ^ A APPENDIX 0 - 245 -VOLUNTEER QUESTIONNAIRE 1. How long have you been in this volunteer program? 2. How many days per week do you deliver aeals? 3. How many meals per day do you deliver? 4. How long do you spend with each client? 5. Why did you become a Meals-on-Wheels volunteer? 6. How did you become a Meals-on-Wheels volunteer? 7. Please describe briefly your volunteer job(s) in this volunteer program (driver, server, day captain, etc.) 8. Where does your volunteer time go in an average month? (Please f i l l in a l l the lines as best you can.) Hours per month Hours with clients, or otherwise on the job, per month Hours consulting with regular staff per month Hours in various volunteer meetings per month Hours f i l l i n g out reports, paperwork (not part of the job i t s e l f ) 9. What is the most important thing you do for your client? 10. What is the least important? •  11. What are some the main satisfactions you're getting from your volunteer work now? - 2 46 -12. What are some of the main f r u s t r a t i o n s ? 13. What do you see as some o f the good t h i n g s about t h i s v o l u n t e e r program now? • 14. What do you see as some of the t h i n g s that c o u l d be improved? 15. Has anyone i n the o r g a n i z a t i o n ever asked you b e f o r e what you thought of t h i s v o l u n t e e r program? ( P l e a s e check the c l o s e s t t o r i g h t f o r you) No, never d i r e c t l y Once or t w i c e , maybe Many t imes 16. Have you ever recommended j o i n i n g t h i s v o l u n t e e r program to any of your f r i e n d s or f a m i l y ? Y e s , d e f i n i t e l y Genera l m e n t i o n , might not have been s t r o n g recommendation No, not r e a l l y 17. How were you t r a i n e d ? 18. What do you t h i n k about t h a t ? - 247 -19. What support do you r e c e i v e from s t a f f and o t h e r v o l u n t e e r s ? 20 . What do you t h i n k about tha t? 21 . How i s your work b e i n g r ecog n ized? 22 . What do you t h i n k about t h a t ? 23 . Are you t r u s t e d to do important t h i n g s ? 24. What do you t h i n k are the g o a l s of Meals -on-Wheels? 25 . Would you l i k e more i n f o r m a t i o n about the o r g a n i z a t i o n ? 26. Any o ther comments y o u ' d care t o make would be a p p r e c i a t e d . - 248 -I am requesting your assistance in part of a study. I would appreciate your participation in this project. I realize you already give generously of your time. Would you take another twenty minutes to answer this questionnaire? If you complete the questionnaire it will be assumed that consent has been given. If you do not, it will in no way affect your standing as a valued volunteer. A l l answers will remain confidential. Please give me the benefit of your frank opinion on these questions. Your answers are important. They will be generalized as representative for the whole group. Would you please return the questionnaire to your Day Captain or Area Chairman as soon as possible. Thank you for your help. Mona C. McKinnon APPENDIX P - 249 -CODING - VOLUNTEER QUESTIONNAIRES I d e n t i t y number Length of s e r v i c e Number of days worked/week Number of meals d e l i v e r e d per day Time spent w i t h each c l i e n t Reasons f o r v o l u n t e e r i n g Method of r e c r u i t m e n t P r i n c i p a l a c t i v i t y n u m e r i c a l l y m i s s i n g d a t a n u m e r i c a l l y i n years w i t h one d e c i m a l p o i n t m i s s i n g d a t a n u m e r i c a l l y m i s s i n g d a t a n u m e r i c a l l y m i s s i n g d a t a n u m e r i c a l l y i n minutes m i s s i n g d a t a to h e l p o t h e r s asked by f r i e n d or v o l u n t e e r Meals -on-Whee ls w o r t h w i l e program needed i n t e r e s t i n g and u s e f u l l e i s u r e t ime answered c a l l f o r h e l p duty o t h e r m i s s i n g d a t a f r i e n d , n e i g h b o u r , r e l a t i v e asked by a c t i v e v o l u n t e e r j u s t phoned i n & o f f e r e d church advert i sement i n newspaper ad on T V , r a d i o , p o s t e r pamphlet o t h e r m i s s i n g d a t a d r i v e r s e r v e r d r i v e r & s e r v e r PWA d r i v e r Day c a p t a i n 00 00 00 00 00 1 2 4 5 6 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 1,2 3 ,4 ,5 ,6 8,9 10,11 12 13 14 - 250 -Hours per month Hours with clients Hours with paid staff Hours at meetings Hours paperwork Prime function - f i r s t answer Prime function - second answer Least important function Area chairman 6 screener 7 other 8 missing data 9 numerically 15,16 none 00 missing data 99 numerically 17,18 none 00 missing data 99 numerically 19,20 none 00 missing data 99 numerically 21,22 none 00 missing data 99 numerically 23,24 none 00 missing data 99 food related 1 25 social support 2 prevent institutionalization 3 performing unrelated tasks 4 helping or serving 5 other 6 missing data 9 food related 1 26 social support 2 prevent institutionalization 3 performing unrelated tasks 4 helping or serving 5 other 6 missing data 9 food related 1 27 social support 2 prevent institutionalization 3 performing unrelated tasks 4 helping or serving 5 other 6 remove f o i l plate 7 missing data 9 - 251 -S a t i s f a c t i o n -F i r s t answer S a t i s f a c t i o n -Second answer F r u s t r a t i o n s Good Features Improvement needed h e l p i n g others 1 28 a p p r e c i a t i o n from the c l i e n t 2 enjoy contact with c l i e n t 3 seeing c l i e n t s improve 4 s a t i s f y i n g a community need 5 avoiding i n s t i t u t i o n a l i z a s t i o n 6 contact with other v o l u n t e e r s 7 sense of accomplishment 8 other 9 miss ing data 0 h e l p i n g others 1 29 a p p r e c i a t i o n from the c l i e n t 2 enjoy contact with c l i e n t 3 seeing c l i e n t s improve 4 s a t i s f y i n g a community need 5 avoiding i n s t i t u t i o n a l i z a t i o n 6 contact with other v o l u n t e e r s 7 sense of accomplishment 8 other 9 miss ing data 0 none 1 30 i n s u f f i c i e n t time with c l i e n t 2 c o l l e c t i o n r e l a t e d 3 not n o t i f i e d of changes 4 c l i e n t not home 5 weather & t r a f f i c & parking 6 food r e l a t e d 7 other 8 miss ing data 9 prevents i n s t i t u t i o n a l i z a t i o n 1 31 food r e l a t e d , e . g . improves n u t r i t i o n 2 meeting a need 3 s o c i a l support 4 h e a l t h r e l a t e d 5 enjoy s o c i a l contacts 6 makes me f e e l good 7 other 8 miss ing data 9 not needed 1 32 food r e l a t e d 2 more s o c i a l support 3 more volunteers 4 c o l l e c t i o n r e l a t e d 5 other 8 miss ing data 9 - 252 -Previous evaluation Recommended joining Training Opinion re: training Support from staff Work recognition no, never directly 1 33 once or twice, maybe 2 many times 3 other 4 missing data 9 yes, definitely 1 34 general mention 2 no 3 other 4 missing data 9 none or very l i t t l e 1 35 on the job by other volunteers 2 told what to do 3 common sense 4 office Orientation 5 observation 6 literature 7 other 8 missing data 9 excellent 1 36 good 2 average (satisfactory) 3 fair 4 poor 5 other 7 missing data 9 excellent 1 37 good 2 average (acceptable) 3 f a i r 4 poor 5 other 8 missing data 9 none 1 38 by clients 2 by other volunteers 3 by administration 4 don't know 5 other 8 missing data 9 - 253 -O p i n i o n r e : r e c o g n i t i o n Degree of t r u s t Goals Information V o l u n t e e r s e x c e l l e n t 1 39 good 2 acceptable (average) 3 f a i r 4 poor 5 other 8 miss ing data 9 yes 1 40 no 2 not a p p l i c a b l e 3 other 8 miss ing data 9 help others 1 41 food r e l a t e d 2 s o c i a l support 3 prevent i n s t i t u t i o n a l i z a t i o n 4 don ' t know 5 good, f i n e , e t c . 6 meeting a need 7 other 8 miss ing data 9 yes 1 42 no 2 other 8 miss ing data 9 yes 3 43 - 254 -APPENDIX Q National Centre on Volunteerism Scoring Method A. VOLUNTEER FEEDBACK FORM The Volunteer Feedback Form is designed for any active volunteer, and i t attempts to assess volunteers' satisfactions, frustrations, and effectiveness of time investment. The exact definition of the index is not clear, but additional elements include volunteer dependability and perseverance, and the volunteers' perception of program leadership. The form should be administered to a sampling of volunteers every three or four months. Volunteer inservice meetings are an excellent forum for completing the forms and subsequent group discussion. The results can be useful for redesigning job descriptions, volunteer training, and general program management. Also, volunteers who have recently resigned from the program can provide important feedback. B. SCORING It is important to note that a great deal of useful information is not included in the scoring index below. Question 1: 0-3 mos. = 0 points; 4-6 mos. = 1; 7-12 mos. =2; 13-23 mos. = 5; 2-5 yrs. = 8 points; more than 5 yrs. = 10. 2: One job only = 0 points; 2 jobs =5; 3 or more = 10. 3: Total hours less than 2 = 0 points; 3-5 hrs. = 2; 6-10 hrs. = 5; 11 or more total hours = 7. If ratio for total hours/"hours f i l l i n g out reports" is more than 5 to 1, add 3 points. *6: 3 or more frustrations = 0 points, 2 frustrations = 3; only 1 frustration = 6; no frustrations or "none" = 10. 7: No good things listed or "none" = 0 points; 1 good thing = 3; 2 good things listed = 6; 3 good things =8; 4 or more good things = 10. 10: (a) = 0 points; (b) = 5 points; (c) = 10 points. 11: (a) = 10 points; (b) = 0 points; (c) = 5 points. *Count of separate units will be somewhat judgmental here. - 255 -12: (a) = 10 points; (b) = 5 points; (c) = 0 po ints . 13: Add to ta l of points c i r c l ed in a l l four items. Ranges from 0 - 2 0 . Total number of points (raw score) C. NORMS The norms for the Volunteer Feedback Form are based on responses from a to ta l of 187 volunteers. The volunteers are from a wide range of programs: hospi ta l a u x i l i a r i e s , publ ic schools, Red Cross, cr iminal j u s t i c e agencies, RSVP, YMCA, and youth serv ice organizat ions. Raw scores range theo re t i c a l l y from 0 to 100. However, p r a c t i c a l l y speaking, i t i s almost impossible to get a volunteer feedback score of less than 20 to 25; these are v i r t u a l l y free po ints . NORMS FOR VOLUNTEER FEEDBACK FORM If your Volunteer Feedback raw score i s : You are higher than approximately: 0 -41 -44 -48 -51 -54 -57 -59 -61 -63 -65 -67 68 69 -71 -74 -76 -78 -82 -88 -40 43 47 50 53 56 58 60 62 64 66 5% of programs 70 73 75 77 81 87 100 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% You are in the top 5% APPENDIX R 2 5 6 INTERVIEWS WITH CLIENTS 1. Is there enough v a r i e t y i n the menu s e l e c t i o n ? 2. Are the s e r v i n g s i z e s s u i t a b l e to you? 3. Was the temperature of the hot food s a t i s f a c t o r y ? The c o l d food? 4. Does the food look a p p e t i z i n g when you r e c e i v e i t ' 5. Do you reheat any l e f t over food? 6. Do you f i n d the present meal times s a t i s f a c t o r y ' 7. Which of the foods you r e c e i v e d d i d you l i k e best? The l e a s t ? 8. In g e n e r a l , how would you ra te the meals? 9. How long d i d you wait to be accepted f o r Meals-on-Wheels? 10. How do you f e e l about the p r i c e of the meals? 11. How long does your v o l u n t e e r spend with you when he/she d e l i v e r s the meal? - 257 -12'. What a r e some o f t h e g o o d t h i n g s y o u r v o l u n t e e r d o e s t h a t h e l p y o u ? 13. What a r e some o f t h e t h i n g s y o u r v o l u n t e e r d o e s t h a t maybe d o n ' t h e l p as much? 14. What a r e some new t h i n g s y o u r v o l u n t e e r c o u l d t o t h a t w o u l d be g o o d ? 15. Do y o u h a v e a n y s u g g e s t i o n s how M e a l s - o n - W h e e l s m i g h t b e c h a n g e d ? 16. I f y o u h a v e a c h o i c e , w o u l d y o u p r e f e r t o e a t y o u r n o o n m e a l a t home o r i n a g r o u p s e t t i n g away f r o m home? 17. A n y o t h e r c o m m e n t s y o u ' d c a r e t o make w o u l d be a p p r e c i a t e d . A P P E N D I X S - 258 -INTERVIEW CODING I d e n t i f i c a t i o n number V a r i e t y Serving s i z e s Hot food - hot? Cold food - cold? 001 - 100 Always U s u a l l y Sometimes R a r e l y Never Other M i s s i n g data Far too much 1 2 3 4 5 8 9 1 A l i t t l e too much 2 Just r i g h t 3 L i t t l e too small 4 Too l i t t l e 5 Other 8 M i s s i n g data 9 Yes 1 No 2 Other 8 M i s s i n g data 9 Yes 1 No 2 Other 8 M i s s i n g data 9 COLUMN 1,2 3 - 259 -Appearance L e f t o v e r s reheated Meal times Foods l i k e d best E x c e l l e n t 1 Good 2 Acceptable 3 F a i r 4 Poor 5 Other 8 M i s s i n g data 9 Always 1 U s u a l l y 2 Sometimes 3 Rarely 4 Never 5 E n t i r e meal r e -heated 6 E n t i r e meal r e -heated f o r c o n -sumption at a l a t e r time 7 Other 8 M i s s i n g data 9 Yes 1 No 2 Other 8 M i s s i n g data 9 Soup 1 Entree 2 Vegetable 3 Starch 4 10 - 260 -Dessert 5 Liked a l l 6 Liked none 7 Other 8 Missing data 9 Foods liked least Soup 1 11 Entree 2 Vegetable 3 Starch 4 Dessert 5 Liked a l l or liked none 6 Other 8 Missing data 9 Rating of meals Excellent 1 12 Good 2 Acceptable 3 Fair 4 Poor 5 Other 8 Missing data 9 Length of wait Right away 1 13 A few days 2 1-3 weeks 3 Can't remember 4 Other 8 Missing data 9 - 261 -Price Much too high 1 14 A l i t t l e too high 2 A l l r i g h t 3 A l i t t l e too low 4 Much too low 5 Fair, but d i f -f i c u l t to afford 6 Would be willing to pay more for better variety and/or quality 7 Other 8 Missing data 9 Length of volunteer's v i s i t Numerically in minutes 15,16 Good things (open-ended) None 1 17 Cheerful, pleasant > helpful volunteer 2 - Specific item 3 Other 8 Missing data 9 Not helpful things (open-ended) Nothing further required 1 18 Food spillage 2 Specific item 3 Dislikes aluminum plate 4 Other 8 Missing data 9 - 262 -New things (open-ended) Suggestions (open-ended) Preferrence of location Comments (open-ended) Nothing more required 1 Reduction in food spillage 2 More socialization 3 Specific items 4 Other 8 Missing data 9 Nothing more needed 1 Very satisfied as is 2 Reduced food spillage 4 Better food and/or variety 5 Specific item 6 Other 8 Missing data 9 Home 1 Away from home 2 No option due to physical d i s a b i l i t y 3 Other 8 Missing data 9 Food related 1 Praise for volunteers 2 Praise for service 3 At home but would like to go out on occasion 4 Other 8 Missing data 919 20 21 22 APPENDIX T - 2 6 3 -Dear I am requesting your assistance in answering questions regarding your opinion of Meals-on-Wheels. If you would be willing to be interviewed in your own home, you w i l l be contacted by telephone during the next four weeks to arrange a time suitable to you. The interview w i l l take approximately th i r t y - f i v e minutes. A l l information collected w i l l remain confidential. Upon completion of analysis, a l l data containing any names w i l l be destroyed. It should be clearly understood that you may withdraw from the study at any time you wish and that neither your answers nor your refusal to participate w i l l affect in any way your receipt of Meals-on-Wheels. If you would be willing to assist in this study would you please sign the attached consent form and return i t to your volunteer. Thank you for your help in this project. Yours truly, Mona C. McKinnon CONSENT FORM I, , agree to be part of this study. (Name, please print) I understand that i t involves one interview in my own home at my convenience and that the interviewer w i l l maintain confidentiality. I realize I am free to withdraw from the study at any time. Dated this __________ d a v °f , 1984. Signed ^ ^ ^ ^ Phone Number _______________ 

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