September/October 2001 Table of Contents
In this Article
It would have been a lot easier without the budget cuts
Living and growing as an occupational therapist under program management
By Nathalie Cyr, Geneviève Arturi, Manon Séguin and Mary Egan
Increasingly, institutionally-based occupational therapists are undergoing the change to program management. While the potential benefits and disadvantages for occupational therapy have been discussed (Baker, 1993; Baptiste, 1993; Swinamer, 1993), little has been written regarding the actual realities of occupational therapists experiencing this change. As their final year synthesis project at the University of Ottawa, the first three authors examined the lived experience of therapists as they moved from a traditional management structure.
From known contacts, three female occupational therapists from the Ottawa-Carleton region who had experienced the change to program management within the last two years were asked to participate. These therapists worked in a variety of hospital settings. They included a discipline leader, a senior therapist and a staff therapist.
Participants were interviewed between December 1997 and March 1998 using a series of open-ended questions. Two interviews were carried out in English and one was carried out in French. Interviews were tape-recorded and later transcribed verbatim. Each participant was asked to read her transcript to ensure that it was a veritable reflection of her experience. The interviews were content analyzed and four major themes emerged: it's been a tough change, it would have been a lot easier without the budget cuts, doing my own administration, and living and growing as an occupational therapist under program management. Quotations were translated from the original French where necessary.
It's been a tough change
The transition was not an easy one. While preparation offered before the changes was perceived as helpful, many of the implications of the change were unpredictable to both staff and senior administration. Reporting relationships appeared to be especially difficult to discern as they were particular to each facility and seemed to differ from team to team within a facility. One year after the change to program management one therapist noted ongoing confusion.
"Some people are still operating in the old system, some people are operating in the new system. Some reporting relationships are not clear yet and so people are still trying to figure out the rules and figure out how things go."
Within facilities, discrepancies between teams existed in such things as funding for continuing education and access to team leaders. This led to dissatisfaction among therapists. Older, established teams were viewed as providing better care for patients and being much more gratifying for members. These teams had a clearer vision of both their work and the relationships among team members.
The change to program management was perceived as particularly difficult when the requirement to fit all services into distinct programs resulted in teams that resembled Procrustean beds, constructed to accommodate the needs of the administrative structure rather than those of the clients or staff.
"...we have a surgery program and a medical program and an ICU program...it doesn't work that simply [for clients] because most of the clients we see have multiple issues and so they might be part way in medicine, part way in surgery, part way in nose and throat..."
Additionally, the requirement to work within a number of small programs proved challenging. Lack of continuous contact with other teams members made it difficult to establish and maintain a professional role, and to build relationships with other team members necessary for successful teamwork.
It would have been a lot easier without the budget cuts
For all of the informants, the change to program management took place against a backdrop of substantial budget cuts. The transition was consequently accompanied by increased caseloads and stress regarding job security. While program management was often seen as having positive implications for clients, decreased services due to shrinking budgets were viewed as having a negative impact.
"There is less money, less services, so there is less for the client. And I think that's where the client is missing out. From the program management point of view, I think the clients have more gains than losses."
Concurrently, as department secretaries were laid off or re-assigned during the change to program management, therapists also found themselves responsible for a number of clerical duties. These duties included photocopying and ensuring that someone was present to greet clients when they arrived for treatment sessions.
Doing my own administration
Absence of middle level management left therapists with decisions that had to be made between occupational therapists, or among team members, without the help of a supervisor.
"About equipment, we have to decide more. Clinically we have to be more aware of our needs. To express our ideas we have to make up a proposal to our boss who manages all the other disciplines. So sometimes we have to deal with priorities. So if we have to talk about any expenses we have to be in line with the others..."
A certain pride of accomplishment could be seen regarding this decision-making, especially since part of the process involved determining who needed to be part of the decision and what could be done without the approval of a supervisor. The latter was important because the decisions involved, while crucial to the therapists' day to day work, were relatively lower priorities for senior administrators. Therapists perceived that such decisions would eventually need to be approved by a senior manager but knew such approval could take some time.
"For example, occupational therapists in our program expressed the need to have an OT aide assigned to our program only. To have an OT aide assigned to [our program], it has to go to the administrative level, which makes it a very complicated and difficult route. While they were debating,… the occupational therapists decided on their own to use the resources we had. We re-organized the workload of an OT aide we already had. When administration comes up with their decision, it's going to be already in place. We know what we want and we are already doing it. That the assistant's salary will come from [our program's] budget or [another program's] budget, that will be up to them to figure it out..."
Also, from an administrative point of view, two of the therapists felt that they were now personally responsible for keeping informed of important changes in the hospital's mandate, functioning and management priorities. Without the occupational therapy supervisor, they felt they had lost their liaison between staff and senior management. It was perceived that senior therapists and discipline leaders passed along all the information that they had. However, it was felt that these workers had less contact with senior hospital management than the department supervisors had had. Consequently, there was less information to pass along to therapists.
"There's a bigger gap with program management I find between administration and front line staff...We don't know what's going on always…, we hear about it late. I guess there's a lot more red tape right now. We don't have a voice in the same way..."
Two therapists perceived opportunities to become more involved in the direction of their facilities by participating on hospital-wide committees. This was also seen as a way to deal with the stress of continuing changes within the hospitals' structures and to keep informed regarding the priorities of senior management. However, involvement in such committees often required the therapists to volunteer their time, time already thinly stretched by the larger client caseloads mandated by budget cuts.
Living and growing as an occupational therapist under program management
The demands for more independent decision-making and greater awareness of the overall workings of the hospital spurred on the therapists to grow as professionals. However, other aspects of the change to program management were seen as threatening to the therapists' development as occupational therapists. These aspects included decreased interaction with other occupational therapists and difficulty accessing education budgets for occupational therapy-specific learning.
At one facility, it was difficult to recruit therapists for necessary discipline-specific duties such as preparing for fieldwork accreditation. At another facility, transdisciplinary roles had developed among team members, making it difficult for therapists to clearly identify their particular occupational therapy skills and contributions.
"Pretty much all over the hospital, there's a new role of case co-ordination that everybody does, that makes the roles more mixed up. In certain programs it's clear, I think I can say that [the roles] are specific...[In another program] we are all do the same thing. It's harder."
The opportunities for personal and professional growth which were predicted to accompany the change to program management (Baptiste, 1993) were in evidence. Whether or not these opportunities can be used to their full advantage, appears to be dependent upon both therapist-specific and facility-specific factors. Therapists reported being more personally responsible for day to day decision-making, awareness of changing institutional goals and professional development. Specific skills were required in such areas as workload management, collaboration, navigation of working relationships, and understanding, and perhaps influencing, institutional objectives.
We hope that the results of this study will assist other occupational therapists to normalize stresses experienced during the change to program management or prepare for such a change.
Acknowledgments
The authors extend their thanks to the occupational therapist participants who generously shared their time and experience. A poster based on this project was presented at the TriJoint 2000 Conference held in Toronto, Ontario.
Baker, B.R. (1993). The implication of program management for professional and managerial roles. Physiotherapy Canada, 45, 221-224.
Baptiste, S. (1993). Clinical program management: a model of promise? Canadian Journal of Occupational Therapy, 60, 200-205.
Swinamer, J. (1993). Application of a program management model in rehabilitation services in an acute care facility. Physiotherapy Canada, 45, 229-230.
Nathalie Cyr, B.Sc.(OT), Geneviève Arturi, B.Sc.(OT), Manon Séguin, B.Sc.(OT) were exploring this issue as their final year synthesis project at the University of Ottawa. Mary Egan, Ph.D., OT(C) is an assistant professor at the University of Ottawa.
September/October 2001 Table of Contents
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