Social change and institutions: Implications for recreationists
Hutchison, Peggy
Over the past several decades, parents, advocates, professionals, and people with disabilities have been working on deinstitutionalization and inclusion in all aspects of community life (Blaney & Freud, 1994; O’Brien & O’Brien, 1991; Schleien & Ray, 1991; Schwartz, 1992). Despite these integration efforts, there continue to be thousands of persons who are disabled and elderly who live in institutional settings due to current social policy and budget constraints (Peck, 1991; Taylor & Racino, 1991). This situation is unlikely to change for some time because the appropriate community support systems for people with severe disabilities and chronic health problems are not yet in place (Trainer, Pomeroy, & Pape, 1993).
Although the research has not always been clear about the possible usefulness of institutions or facilities in our society, there is little argument about the importance of quality of life, both for those who remain in institutions and those living in the community (Carling, 1995; Rosenfield, 1992). In fact, concern about quality of life has been the main impetus behind deinstitutionalization and the community living movement (Pedlar, 1990). At the same time, some professionals working in chronic care and institutions have been trying to create changes in their settings that will result in better quality of life for residents (Flynn, La Pointe, Wolfensberger, & Thomas, 1991). Strong social networks, integration, preparation for returning to the community, and empowerment are all seen as being important contributors to enhancing quality of life (Church, 1992; Gardner, 1992; Rosenfield, 1992; Taylor & Racino, 1991). Many recreation and leisure professionals are aware of these contributors to quality of life and believe that leisure has a particularly important role to play in enhancing quality of life (Hawkins, 1997; Howe-Murphy & Charboneau, 1988; McGuire, Boyd, & Tedrick, 1996).
In reality, however, many families, community members and institutional workers have experienced significant constraints when trying to make changes that might improve the quality of life of people living in institutions (Lord & Hearn, 1987; MelbergSchwier, 1992; Peck, 1991). Those knowledgeable about change are aware that addressing issues of this magnitude requires more than organizational change or what is sometimes called first order change. What is deemed necessary is social change or second order change, which involves fundamental change to the basic assumptions and rules of the broader system within which institutions function (Bennett, 1987; Etzioni, 1991; Lauer, 1991). However, social change is often more controversial, partly because of its complexity and time consuming nature, but also because it challenges the status quo and traditional power structures (Forester, 1989; Zimmerman, 1993).
Many young recreation professionals and other professionals enthusiastically begin working in chronic care hospitals and institutions hoping to “change the world.” Whether they find they can effectively contribute to social change when working within an institution is an important question. Historically, there has been criticism of workers in facilities becoming “institutionalized” and/or conforming to the status quo, resulting in an inability to promote or accept change (Rothman, 1981). A study which would examine the source of change and the role of front line professionals is needed. As well, since recreationists are often seen as having less power and credibility compared to other professionals in institutional settings, it would be helpful to determine whether they have less influence in the social change process (McGill & Hutchison, 1991). Based on these issues, the purpose of the study was to learn about the process of social change within institutional settings. The specific objectives of this research were to determine:
1. What social change issues were being addressed by people working in institutions.
2. The source of the impetus for social change.
3. Whether recreationists and other front line professionals were able to initiate and implement social change affecting their institutions.
4. What constraints, if any, were there to social change.
5. What strategies, if any, were used to overcome these constraints to social change.
For the purposes of this study, the term recreationist was used to describe any professional hired by the recreation department to plan and co-ordinate recreation and leisure activities and opportunities for residents in any one of the three facilities that participated in the study. Other front line professionals were referred to as non-administrative staff (e.g., ward workers, nurses, physiotherapists, occupational therapists). The title administration was reserved for directors or administrators of the facilities and their immediate supervisory staff (e.g., assistant director).
Review of Literature
One of the main forces behind deinstitutionalization has been concerns about the quality of life experienced by people living in a variety of institutional settings (Melberg-Schwier, 1990; Pedlar, 1990). Concems about institutional life have been diverse. Many residents appear to lack basic rights, as indicated by abuse and the use of aversive punishments (Roeher Institute, 1994). A “blaming the victim” mentality often requires residents to acquire certain skills before they are allowed to participate in the community (Wieck & Strully, 1991). Lack of understanding and disagreements between residents and professionals can occur (Petryshen & Essex-Sorlie, 1990; Spencely, 1990). A lack of self-determination, control, autonomy, freedom and choice is pervasive (Shary & Iso-Ahola, 1989). Finally, recreationists spend most of their time on the traditional programmer role and do not provide enough indirect services such as advocacy and social network building (Hutchison & McGill, 1992; Rancourt, 1989).
Many people within and outside institutional settings have attempted to make changes that would improve the quality of life for people who continue to live there. Several current trends have challenged the traditional medical and rehabilitation paradigm underlying most institutions (Carling, 1995; Jongbloed & Crichton, 1990; McKnight, 1995). Most proponents of normalization, valued social roles, community integration, deinstitutionalization and independent living believe that institutions are not the best way to serve people (Hutchison & McGill, 1992; Kwan & Sulzberger, 1994; Peck, 1991; Pedlar, 1990, 1991; Schwartz, 1992; Wieck & Strully, 1991). Rights, empowerment, and self-determination (Blaney & Freud, 1994; Brown, Bayer, & Brown, 1992; Bullock & Mahon, 1992; Hawkins, 1997; McGuire et al., 1996; Rancourt, 1989) also challenge traditional attitudes and practices.
In addition to understanding the above trends, knowledge of social change theory and principles is seen as an important basis for creating effective change. Social change, also known as second order change, refers to “changing the assumptions, values, structural relations, and rules governing the system” (Bennett, 1987, p. 13). The magnitude of the concerns about institutional life necessitates significant social change. Some believe this change is best made from outside institutional structures by means of legislative changes or advocacy by concerned citizens and parents’ groups (Carling, 1995; Heller, Bond & Braddock, 1988; Racino & Heumann, 1992). Researchers and practitioners argue that staff working inside the institutional system have too many constraints. Instead of being active in promoting change, staff usually conform to the status quo and minimum health requirements (Sylvester, 1989). Job uncertainty makes professionals unwilling to take risks and professional interests are often put ahead of client interests (Lord, Hutchison, & Vanderbeck, 1991; Potschaske, 1988; Schillinger, 1988; Triemstra & Murdock, 1993; Witt, 1985). Certain professions, like recreation, have less power, credibility, and status than others, making it difficult to contribute to change (Smith, Perry, Neumayer, Potter, & Smeal, 1992).
Others believe change can come from both internal and external structures, but that leadership is a key issue. Rather than leaders taking a top down approach as in traditional organizational change theory (Wright, 1989; Zimmerman, 1993), leaders need to be facilitators of change, utilizing “bottom-up” processes that encourage participatory decisionmaking (Carling, 1995; Rappaport, 1987). In this sense, leadership can come from administrators of facilities, advocacy groups in the community, or recreationists working in institutions. Good leadership is comfortable with this process and open to innovation and breaking free of the conventional way of thinking and operating (Covey, 1991; Etzioni, 1991; Gardner, 1992; Senge, 1990).
Most people believe that social change is a complex process, requiring change at many levels (Forester, 1989). While the public and governments in general consider change as a threat, social change theorists define change as something normal which occurs in various directions, rates, and levels (Boudon, 1986; Lauer,1991; Zimmerman, 1993). People tend to resist change when the status quo is threatened, especially when there is economic risk or no guarantee of improving the situation (Vago, 1989). As described in chaos theory (Wheatley, 1992; Zimmerman, 1993), a degree of uncertainty and unpredictability about social contexts is natural. In fact, while theories about planned social change are important to consider, some believe that a certain amount of change will occur regardless of planning (Mintzberg, 1994).
This study examined the social change process in a variety of institutions. Social change theory provided the theoretical framework for the study (Bennett, 1987; Zimmerman, 1993). In addition, the literature review provided a rationale for focusing on quality of life issues that relate to institutional change including deinstitutionalization, empowerment, and inclusion (Friedmann, 1992; Taylor & Racino, 1991).
Method
A qualitative approach was used in this study for three reasons. First, little was known about this topic, so an open-ended, inductive approach was needed. Second, the lived experience of people can be tapped and best understood in their naturally occurring state (Alar, 1990; Henderson, 1991). Finally, a qualitative approach is useful when the anticipated available sample is small (Patton, 1990).
Selection of Sites and Subjects
Recent legislation and policy changes in one selected province in Canada have resulted in pressure being exerted on publicly funded institutions (e.g., long term care hospitals, psychiatric hospitals) to begin a process of change. At the same time, current trends such as inclusion, deinstitutionalization, and consumer directed approaches have been embraced to varying degrees by institutions throughout the province. This study focused on a few selected institutions that were attempting to initiate changes in these areas.
Three provincially run institutions were selected for this study: a psychiatric hospital, an institution for people with developmental disabilities, and a chronic care hospital serving mostly older persons. A panel of experts in the field of disabilities and social change was invited to assist in the identification of the sites and the key informants. The decision to select such seemingly diverse settings was based on the assumption that, given the unique nature of the research questions, it would be most beneficial to study change in a range of settings. At the same time, all three types of institutions were affected by similar provincial legislation and policies, economic climates, and political agendas. Finally, even if the researchers only wanted to select institutions in one area (e.g., psychiatric), it would not have been possible because of the difficulty in finding settings that met the study criteria. The panel of six experts were given the following criteria:
Consider all public institutions/facilities in the province.
Choose one site in each of the three areas, using criterion-based purposive sampling (Patton, 1990): psychiatric/mental health. developmental disabilities. long term care for people who are older.
Only consider facilities where there is least one staff member who was well known to be working on social change issues such as inclusion, deinstitutionalization, empowerment, consumer directed approaches, and quality of life (i.e., doing more than first order change); this person will be the key informant.
Select initial key informants who are knowledgeable about the overall facility and the change process that is underway.
Select the most qualified person, regardless of whether he or she is a recreationist.
The panel clearly identified two settings that best met the criteria and a third that technically met the criteria but was not as far along in the change process; however, inclusion of this latter site in the study was recommended because of the notoriety of the recreation department.
Key informants were approached by the researchers and invited to participate in the study. They also were asked to use the snowball technique (Patton, 1990) and identify two others in their respective settings who could provide the best insight on the topic of change. If the key informant was not a recreationist, then at least one of those selected from the site had to be a recreationist. Therefore, each setting varied in terms of who was interviewed (see site descriptions). Including individuals from a range of disciplines, wherever possible, was seen as strengthening triangulation of sources (Patton, 1990). A total of 9 participants were selected.
Residents were not interviewed. Preliminary discussions between the researchers, panel, and key informants indicated that some staff and/or administrators in each setting would be wary of the topic of social change, making it uncomfortable to request resident interviews. With the exception of social activities, none of the settings had resident councils that were actively involved in resident education and decision-making. One of the settings had only a handful of residents remaining. Finally, the study was more concerned with the process of social change than its outcomes.
Site descriptions. The details of each facility can be found in Table 1. Facility A was a large provincially run institution for people with developmental disabilities which was on the verge of closing. For this study, the Closure Manager was the initial key informant. This person then identified the Service Coordinator, who in turn selected the Recreation Manager, because he was the only recreationist remaining.
Facility B was a large psychiatric hospital in the initial stages of a change process resulting from a government report aimed at the development of a community focused, integrated mental health care system. The key informant from this facility was the Director of Rehabilitation, who in turn identified two people, the Head of Active Treatment and the Recreation Manager.
Facility C was a large chronic care facility. The Recreation Manager was selected as the key informant. The two others identified by this person included the Recreation Supervisor and a Recreation Therapist. Nonrecreation staff were not selected, as the initial key informant was adamant that no others met the criteria for the study. The administration was in the very early stages of the process of change and, therefore, did not wish to participate.
Data Collection and Analysis
When selected individuals were contacted by mail to formalize their participation in the study, they were asked to complete the “Informed Consent Form.” The accompanying letter described the study and its purpose. Finally, the letter outlined how the researchers would ensure confidentialityno names or any identifying information would be used in any report and all tapes would be destroyed at the end of the research.
Several data collection and data analysis strategies were used to ensure trustworthiness (Lincoln & Guba, 1989). One researcher spent one to two days in each setting observing, examining relevant documents, recording field notes and conducting individual interviews based on an interview guide. The interview questions were general in nature and focused on the concept of change. This enabled the questions to be used in interviews with people in any discipline, rather than being specific to any one discipline (e.g., recreation). A few examples of questions from the interview guide were: (a) related to your institution, from where would you say the impetus for change has come; (b) what are you trying to change; (c) what are the barriers to creating this kind of change; and (d) how are you going about implementing these changes?
All individual interviews were conducted at the person’s work place (except for one that was done at the home of a former staff member). The interviews lasted between I 1/2 to 2 hours. Following the interview, the researcher spent time touring the facility, observing programs and wards in operation, examining documents, and asking any further clarifying questions. Reflections on this aspect were recorded in the field notes. Focus groups, which would have strengthened triangulation, were not considered possible because of political constraints-the controversial nature of the topic and the need for confidentiality (Patton, 1990). The interviews were taped and later transcribed, along with the field notes that contained detailed and concrete descriptions of what had been observed; as well, researcher insights and interpretations of the events were noted (Denzin & Lincoln, 1994).
The transcriptions of the interviews were organized and interpreted in accordance with the stages for inductive analysis described by Patton (1990). Two types of analysis were conducted: within case and between cases, followed by a brief comparison of both. The initial stage for both analyses involved detailed multiple content coding of all transcripts and field notes by two researchers, including intercoder reliability checks. This was followed by the development of a hierarchical system of categories that was closely linked to the original research questions, but also was sufficiently open-ended to identify and incorporate unsolicited information. During the next phase, general trends or common themes were identified. Next, as patterns and themes were clarified and refined, themes were confirmed. By returning to the data to search for further examples that might support or refute an interpretation, credibility of the data is increased (Kirk & Miller, 1986; Miles & Huberman, 1994). Comparing observational data with interview data further strengthened the analysis (Patton, 1990). Finally, the data in the form of a written report was returned to the informants for confirmation of findings. Sites were asked to return the document with any changes or contact the researcher to discuss concerns. When no one responded, each site was contacted by telephone to confirm the findings and bring closure to the process. At this time, the key informants also provided a brief update of changes since the data collection period.
Results
Within Case Analysis
The major themes and patterns that emerged from an analysis of each site based on individual interviews and field notes will be presented in this section. While many other ideas emerged, only the key ideas which had agreement amongst the study participants at each site will be included. Some or all of the following four themes were apparent in the sites:
Social change was happening.
The impetus for the social change that was happening had multiple sources, with recreationists playing a relatively minor role in initiating change.
The constraints to social change were significant.
Concrete strategies were necessary to bring about social change.
During follow-up with this site to confirm the findings, the study participants agreed that the way the four main themes were articulated and interpreted in the report reflected what was happening at this site at the time of the interviews. At the time of confirmation of findings, the key informant also provided a brief update of changes which had occurred since the data collection period. This was not an intentional part of the study. Key informants were willing to confirm the research themes, but seemed uncomfortable not being able to mention the changes which occurred since the interviews. Given the state of transition in which all the facilities were finding themselves, this information was included at the end of each site description under a section called “Follow-up.”
Facility A
Social change was happening. Facility A was a large provincially run institution located on the edge of a small town with a population of less than 10,000. At one time housing several hundred people with developmental disabilities, this facility now had only 15 residents remaining. The facility was in the final stages of closing. Significant social change was happening at this facility. There were several main thrusts. Deinstitutionalization and the closure of the institution were a primary focus at this facility. All efforts were focused towards this end. For example, interdisciplinary teams were in place to plan and co-ordinate community placements for all residents. The fact that the closure actually occurred was clearly identified as a positive outcome by study participants. The Recreation Manager reflected on the closure:
I think it worked better than a lot of folks thought it would. A lot of people were just horrified at the thought of these people leaving the supports that the facility can offer. The reality of it was, they left and they never looked back and are quite happy where they are now.
Second, concerns about the quality of life of residents was the main rationale for the closure. Interestingly, during the closure process, staff became more concerned about quality of life issues, utilizing more of a transitional/rehabilitative model and individualized programming than a diversionary model. Residents had more of a voice, particularly pertaining to their future. Residents were more connected with their families and families became stronger advocates. As residents were seen as being more capable, there was a greater focus on community recreation.
Finally, an important part of planning for this closure involved trying to access the necessary community resources. The Manager of Community Services made an interesting comment:
The closure is one step towards community living, but it doesn’t end by putting people back into their communities-because of the way community services are. They are like institutions, smaller though, but still institutions. I think there needs to be another whole change process to deinstitutionalize group homes. I rationalize that it is still better to get rid of this place, because this place represents something that prevents people from meeting a disabled person.
The impetus for the social change that was happening had multiple sources, with recreationists playing a relatively minor role in initiating change. According to the study participants, parents and voluntary associations at the local, provincial, and national levels had been advocating for some time for the closure because of concerns about the overall quality of life of residents. The Recreation Manager said:
Anybody who has a reasonable goal or reasonable dream and works towards it, I’m sure could change the facility. Twenty years ago, nobody thought parent groups would be able to challenge government institutions and the medical model and do the changes that they have.
Study participants indicated that the Administrator of this facility played an important role in the process. The Administrator supported the changes, primarily because the changes were mandated by the government’s Multi-Year Plan. To assist the government in completing the closure, the Administrator took the notable step of hiring an advocate of social change as Closure Manager. This Manager explained:
It was just such a treat to have the government actually announce that it agreed with me and that it would hire someone like me, who is quite a strong advocate for change and community, that now I would be welcome to work with the government to create change.
She worked with local agencies, managed three service co-ordinators and five social workers, and was responsible for more advanced planning with the Ministry. The social workers were the front line people on the interdisciplinary teams responsible for arranging community placements. The primary focus of the change was to get all residents into community placements and to find alternative employment for staff. This required a great deal of effort on everyone’s part to meet the Ministry’s time lines. Individual program plans were completed by an interdisciplinary team to ensure a smooth transition to the community and better quality of life for each resident.
According to study participants, only rarely did recreationists play an important part in these interdisciplinary placement team decisions. The Recreation Manager did not feel recreationists needed to be part of the placement teams; he seemed resigned that placement was the focal point and it was rarely affected by recreation issues such as available community recreation resources. However, for the most part, the recreationists were supportive of the placement decisions. The Recreation Manager commented:
I shouldn’t be stopping placements because there are not sufficient recreational supports. The priority is for the person to have a home suitable to his or her needs. I didn’t stop a placement because they like to play Bingo and the town hasn’t got a bingo hall. Generally, we would go along with the recommendations of the rest of the team. We didn’t stop too many placements, unless it was something really specific, like a person who likes neighbours and likes to chat and is being put into a very isolated environment. That specific incident came up. We protested that and ended up getting the placement changed because of that.
In general, recreationists played a relatively minor role in the change process. For example, the Recreation Manager did not feel that people with severe disabilities could be fully integrated in the community because of their poor skill levels. This comment by the Closure Manager made it possible to see that, in many ways, this Manager was “carrying the torch”, but others were reluctant followers:
. . . seeing the value base that anybody could live in the community if the planning was appropriate is not there. It’s the value base and people here didn’t have that. They’ve always been told that the community can’t deal with these people.
With the focus on residents moving back to the community, the role of the few remaining staff had changed from a custodial to a more transitional/rehabilitative approach. The emphasis had changed from recreation being primarily diversionary, to encouraging community participation and using therapeutic recreation as a tool for working on, for example, behavior. For the handful of residents still remaining, individualized programs were provided. This was in contrast to earlier years when large numbers of residents made it impossible to do anything but group programming due to the large numbers. Recreation activities such as social events, on-site camping, and community outings for residents with low support needs were the main focus.
The constraints to social change were significant. Significant constraints to social change were identified by the study participants. Generally, the democratic process was an issue. While slowing the entire process, some considered it essential for effective change. Over time, staff and others became somewhat less resistant as they became more involved in the process. On the other hand, some believed a more top down approach was necessary because of all the barriers. For example, staff were upset about job uncertainty, role changes, wage differentials between community and institutional workers. Given these constraints, the Recreation Manager was convinced that authority and a more dictatorial approach was necessary to close this facility:
I don’t think it should be done in a democratic way. If a facility has to close, at some point in time it has to close. If you try to get the general populist to change from the bottom-up, you’re not going to see that happen. They’re going to spend their time stalling and telling you what’s wrong with the project. At some point in time, you have to say “this is what’s going to happen. What can you do to help it happen?” Give them a part in the process but make sure they know what the end result is going to be.
Several study participants also indicated concern about the input that other stakeholders were having. For example, study participants found staff to be cynical about resident input in decision-making, feeling it was little more than tokenism because of the severity of people’s disabilities. Study participants also felt parents were not easily able to accept that their children were now capable of community living after so many years of being told the opposite; as well, some parents did not feel the community understood their concerns and worried about losing the ‘recreation center’, the only fun place. Despite wanting to move, residents did not fully understand alternatives that were presented to them, according to study participants. Decisions about placements were based more on “available beds” than residents’ or families’ preferences related to friends. Finally, community agencies often ignored the input of the facility workers and offered only large group homes with an institutional mentality. This comment reflects the Recreation Manager’s concerns about lack of input and follow-up by institutional staff:
Once the residents leave, we don’t have a whole lot of follow-up with them, because when they are gone, they’ve got other people to look after them now. You go to town and you see former residents in the community. I guess you can see what they are doing and if they are acting appropriately and look like they’re doing well.
Finally, there was a concern about the severity of handicaps of the residents. Many staff, including one of the study participants, believed a significant number of residents did not have the skills to participate in activities in the community, let alone live there. This belief was expressed by the Recreation Manager:
The level of the people we were dealing with, the supports they would need to get into community programs, it was too much. Like a person has to have a basic skill level to get into town and join the ceramic group, and if that person just doesn’t have the basic skill level, then it’s never going to work. We do therapeutic recreation, trying to change something about a patient, whether it’s behavior or physically through recreation.
Closely related, front line staff blamed government for cutting community dollars and criticized the community for its lack of resources for supporting people with high needs. According to study participants, some front line staff even went so far as to question the financial motives of community associations (x dollars received for each person taken into their particular agency).
Concrete strategies were necessary to bring about social change. Legislation alone will not guarantee that a major policy change occurs. This comment from the Recreation Manager reflects the need for having a range of concrete strategies which can increase the effectiveness of the change process:
It has to come from within. You can put in all the legislation you want, but it’s got to come from within to deal with these motivational problems and all the other stuff. Even with legislation changes, if staff does not stand behind it, change will not be successful. You’ve got to win over the loyalty, the trust, and the cooperation of the staff members for sure.
Several important social change strategies were mentioned by the study participants: (a) encouraging an air of openness and flexibility around getting people back to the community; (b) using good communication, particularly sensitive and non-threatening language; (c) implementing a genuine individual program planning process; (d) respecting residents’ and families’ preferences; (e) choosing smaller communities and smaller residences; (f) ensuring residents experience the community beforehand to assist with the transition; (g) offering staff retraining and relocation opportunities; and (h) providing staff opportunities to vent concerns and make decisions. While it is not possible to provide quotes for each of these strategies, this comment from the Manager of Community Services reflects on (h), the final strategy:
We supported the staff by saying, “nothing will be done without you being involved; no social worker or administrator will make the final decision on discharge or placement.” That helped a lot. The person’s life had been totally dependent on institutional staff, so we assumed they did know the person best. They know what’s going to work, when you’re off the mark, and when you’re OK. They are the ones who are going to have to do the work.
Follow-up. During follow-up with this site, the key informant indicated that the building was now empty and community housing had been found for all residents through transfer payment agencies (e.g., in Canada, the Association for Community Living is the largest transfer payment agency). The building had been sold to a private company, supposedly for development into an international private school related to entrepreneurialism. Several residents had returned on various occasions, just to be sure no one was still living there and to celebrate.
A few residents had died since leaving, but the sense was that they hadn’t left the institution in very good health and at least their last days were spent in more positive circumstances. Some residents who were considered medically fragile and spent most of their on the ward in bed, went on to more active lives in the community. This included getting dressed, sitting up, listening to music, and getting out to such activities as national baseball games and advocacy conferences.
Most of the community agencies were getting very large, as a result of all the placements. The majority of individuals were placed in traditional group home situations, with little more than a bed and day program. There was concern that fiscal restraints may impact on day programs, which would have serious repercussions for many former residents of facilities. Person centered planning was mentioned, but little was being done to make it a reality. Finally, there was no suggestion that anyone needed to go to other institutional placements as the result of community failures.
Facility B
Social change was happening. Facility B was a large psychiatric hospital in a metropolitan area. The study participants from this facility all agreed on the major thrusts being addressed. Deinstitutionalization and community living was an important part of the overall, long-term plan. People were spending less time in the hospital, and with the support of their active treatment division in particular, most people were getting support in the community with a combination of facility staff and community programs.
There had been some talk of amalgamation with another nearby psychiatric hospital. As part of this process, efforts on several fronts were being made to create a more comprehensive, coordinated, communitybased mental health system. Meetings were held with a range of community services to begin to heal the wounds caused by separation. Possible partnerships, where staff and residents could be out in the community instead of in the hospital, were negotiated. For example, as part of their efforts to encourage employment of residents, a staff member went with residents to work in a community agency.
Finally, study participants identified the importance of a paradigm shift, from patient/ client to citizen, and from services/professionals to strong networks and friendships. While much still had to be done in this area, they had begun to meet with community mental health groups and consumer self-help groups to learn how to do this more effectively. This statement by the Head of Active Treatment reflected the direction this was all supposed to be going:
In all of these models that involve community care and client-centered care, and that’s what all these things out of the Graham Report are about, there is a whole shift in mentality required to be client-driven, client focused, very different than system focused and agency focused.
The impetus for the social change had multiple sources, with recreationists playing a relatively minor role in initiating change. According to the study participants, the facility was in the initial stages of a change process resulting from two related government initiatives, the Graham Report and Mental Health Reform, both of which addressed the need for a more community focused, integrated mental health care system. The Director of Rehabilitation noted:
Everybody has to change. We impact on a lot of people and a lot of people impact on us. We have to be going in the same direction for this to work. So I think that second order change has to be done. The mental health reform and those policies are out there to make sure the second order change is happening.
The amalgamation of two previously separate government departments, Community Mental Health and Facilities Branch, was a step in this direction. The changes occurring in the hospital at this time also were a result of several decades of influence by U.S. and Canadian consumer movements regarding greater control and empowerment of individuals with mental health problems and the availability of improved medications. As the Director of Rehabilitation pointed out:
I think there is larger trend for consumerism. Handicapped people are getting more powerful as groups-the groups are organizing. Family groups are another area which has been organizing quite strongly. I think the government is going to respond to these trends and I think they listen to them more closely than everything else.
A combination of escalating health care costs and fiscal restraint had escalated the government’s timetable for change. The administration hired external people to assist in implementing broader system changes. The Director of Rehabilitation stated:
If you want to change a whole culture in a hospital, shifting a paradigm, then it’s almost better to have an external person come in, someone who has that broad scope. For changing little parts of the puzzle, an internal person can do it.
The majority of recreationists did not initiate change at this level but got involved when directed by the administration. This comment by the Recreation Manager reflected this dilemma:
If there was a set guideline or time frame to implement community programs in two years, you could work on it and start implementing. But if we don’t hear of any change, we are more inclined to stay set, until we know what changes to make. If change took place, staff would adapt. We are not resistant to change. When the time comes to change I will change with it.
The constraints to social change were significant. The constraints to change in this setting were extensive, according to all study participants. At the broadest level, there had been little prevention or coordination in the mental health field in the recent past. Now they were finally beginning to move. The Director of Rehabilitation acknowledged the importance of a new piece of legislation in keeping the whole process moving in a forward direction:
Recently the Mental Health Reform came out, a follow-up document based on the Graham Report that goes a little further. It talks about looking at all services being part of a system and being coordinated, balancing funding and power between institutions and the community; putting consumers and families as part of the service system. So that report came out and it will continue some of the processes that we’ve begun.
The Administration was beginning to implement changes which would address these concerns, but had a bit of “institutional inertia” and was moving at a slow pace. The Recreation Manager pointed out:
It’s hard to get a big place like this moving. It’s something I call institutional inertia, and that is, things have been a certain way for a certain length of time and people like it that way. So when you say, “it’s time to change”, there is an insecurity there and it’s a fear. So people will entrench and say, “No, why should we change? Things are fine the way they are.” I think that’s natural.
Attempts to make a hospital client driven were token. Residents had strong viewsthey preferred living in the community because of fewer rules, but were cautious about community jobs and were critical of the follow-up from the hospital. Families were often at odds with patient self-help groups and found community supports threatening. Genuine collaborative efforts with residents were only just beginning and jargon, rhetoric, and power struggles aggravated the situation. The Head of Active Treatment criticized this process:
People are talking about all the same things and using different terms, or talking about different things and using the same term. People talk about programs and they sound new and different but they are not. They are just using different labels. It’s been a wonderful way to not change but say you’ve changed. . . . When a consumer is on a committee, I know what happens. They get left in the dust. Most of the semantics and the phrases, they don’t know what you’re talking about. . . . So we’ve done tokenism in terms of including them at the planning level. It’s not real.
The medical model dominated, with doctors and nurses making most decisions. Recreationists attempted to increase their profile and influence through interdisciplinary teams, however there was always a sense that recreation was not as valued as other services. This comment by the Head of Active Treatment illustrated the constraints of the medical model facing recreation and other departments such as his:
The nurses are attached to doctors who have a bunch of patients under them. The way care is delivered is conceptualized from a medical nucleus. We are set up entirely differently. We have patients who come to us. We are centered around patients and have social workers who are not attached to doctors. . . . We go right down and look at patients and their needs and then plan from that. . . . But the truth is the recreation department and other departments that are closest to patients are the least powerful.. . . You would think that the staff closest to the people’s needs would drive the system, be the ones of greatest input. . . . But their opinions aren’t normally welcome.
According to the study participants, this situation may have been aggravated by the fact that the role of recreation in the hospital was primarily focused on programs, social events, and the snack bar. There were approximately 320 inpatients and only 5 recreation staff. The recreation staff tried to educate other staff that recreation was more than for fun. But regular community participation was limited by a poor staff-to-resident ratio and a lack of structured community programs and social opportunities such as the Clubhouse Model (a drop-in center for people with mental health problems that involves social activities, employment training, and peer counselling). The Recreation Manager explained:
Recreation outings are limited by numbers, because of regulations. A certain number of staff has to be present for a certain number of people to take out. Since our staff number is very small and work has to done here too, it is difficult to engage patients in community activities.
Conflict between community agencies and the hospital staff was ongoing. These new reforms require greater co-operation and partnerships between the hospital and community services, to ensure people spend less time in hospital and get the supports they need in the community. But they have had a long history of separation, resulting in distrust of each other. For example, hospital staff were concerned that the community was simply not prepared to support people with such high needs. As well, the differences in size, structure, and policies created barriers to co-operation. The Director of Rehabilitation commented:
Community agencies can be a barrier. Most of the community agencies we deal with are small. They’re informal; they don’t have as many rules and regulations as we have. The biggest thing is that a lot of them make less money than we do. So when you tell them that one of our staff is going to show up doing the same job as them, they will say: “Why do we make so much less than them?”
Concrete strategies were necessary to bring about social change. The study participants had numerous suggestions for concrete strategies for creating change. While government policies were the impetus for change, greater co-ordination and monitoring by the government and District Health Councils were needed to ensure that the changes were in fact happening. The Head of Active Treatment made this suggestion:
The whole Graham implementation has been channelled down to the District Health Councils. Meanwhile, strategic planning has somehow been going on within each branch moving right along without any dialogue or coordination between the two impulses. Each hospital developed a strategic plan, the branch has a strategic planning committee, community mental health has its own strategic planning committee as well, which doesn’t talk to our strategic planning committee. That needs to happen.
Working closely with front line staff was essential because “they know where it’s at.” A big part of the “cheerleader” role in this process revolved around good communication. This might have included being well prepared, being honest, making people feel secure, and making people feel part of the change. The Director of Rehabilitation felt very strongly about the importance of communication in bringing about change:
I think one of the biggest ones I try and do is communication. As much as possible we have to let people know what’s going on and be really truthful about it. You have to spend a lot of time communicating with people, listening, and building that relationship. Communicating with people why we’re going to do that, how is it working, and where we have to go. You do it through meetings, memos, and newsletters. Or you do it through personal contact, so they have an opportunity to respond and to raise their concerns. People always think that communication is one of the most important things, but it is one of the hardest also.
Networking with as many community agencies as possible was an important strategy. Building relationships and partnerships through pilot projects, for example, were a good beginning. The Director of Rehabilitation pointed out:
One of our goals is to work with community agencies. And sometimes you get the feedback from them, “who are you” or “don’t even bother, we are doing our own thing, and you’ve never been there in the past.” Our hospital was seen as the `last resort’, or the asylum kind of image, where the patients came in and never came out.
Finally, finding ways of working more directly with people with mental health problems, both patients in the hospital and consumer survivors in the community, are important strategies. The Director of Rehabilitation pointed out:
Working with consumers in terms of planning and evaluation is a new thing for a hospital. We’ve been doing it for about a year and it is a learning process for both of us. It is a learning process for the consumer to know who we are. In the past there was a power inequity. Now we’re trying to make us equal in the partnership.
Follow-up. During the follow-up with this site, details of the latest government initiative affecting the facility were shared. This hospital was being amalgamated with another nearby psychiatric hospital-the result of yet another government initiative called the Hospital Restructuring Commission. Their total number of patients was going to be significantly reduced by transferring beds to two distance municipalities, thus contributing to a more community based mental health system. One positive outcome was that there would be less differentiation between acute and chronic care, and in-patient and out-patient services, resulting in greater consistency not only for patients, but all stakeholders. A major concern of this initiative was that housing would be the responsibility of municipalities which had traditionally not seen housing for people with mental health problems as a priority. As a result, there was a significant danger that, once again, people would be “dumped” back into the community. In this sense, the economic climate, not mental health reform, was driving the change.
Facility C
Social change was in the early stages. Facility C was a large chronic care hospital located in a large city that offered rehabilitation, continuing care, and palliative care through inpatient and outreach community programs. It served approximately 600 older adults, as well as a small number of younger persons with chronic illnesses and disabilities. According to study participants, despite having the Long-Term Care Act that favored community-based and integrated services over clinical options, the emphasis on coordination, deinstitutionalization, and community living by the facility itself was in the relatively early stages. According to the study participants, there had been little leadership from the administration to ensure that the facility paralleled community initiatives related to long term care. Instead, the impetus for change was coming from other sources.
The impetus for the social change had multiple sources, with recreationists playing a relatively minor role in initiating change. The Long-Term Care Act was the main impetus behind changes at this facility. The Long-Term Care Act was supposed to ensure that more dollars and support were available in the community for services such as Homecare and Meal-on-Wheels. Community based services were seen as being more economical and humane and delayed persons who were older and had chronic illnesses from going into institutional settings. As a result of this legislation, the individuals who eventually moved to this facility had higher support needs. The facility was in the process of waiting for the outcome of an important study that would determine whether it would become a chronic care facility (more rehabilitation), long term care, or a combination of the two.
The Administrator who had been there for almost 30 years recently retired. A new person was just beginning-bringing hope for change, according to study participants. The Board of Directors specifically hired an Administrator who could begin to systematically make the changes that were consistent with the Long Term Care Act. Recreationists and other front line staff generally had a relatively minor role behind the change process. The Recreation Supervisor explained why:
Front-line workers are powerless and I think it’s hard for people who are in low level health care jobs, even recreation staff who are probably just one step up from the care-givers. What are they going to do, where are they going to work? It’s hard for people in those kinds of positions to have a vision. Plus their training confirms their existence as nurses or as aids. I think that that’s a difficult place to start change.
As a way of concluding this discussion on where the impetus for change comes from, the Recreation Manager had an important message. She believed that a major stakeholder was missing from the picture, particularly if significant changes were to happen:
The broader changes have to come from society. I could never put my grandmother or mother in place like this. Well, your mother might say, “I don’t want to live at your house, I want to live in my own house” . . . I think that change has to come from everyone in the way they see themselves in the world and in the way they see other people. I guess that’s the whole point. It’s not from anywhere specifically but from everywhere generally.
The constraints to social change were significant. The constraints to change in this facility were extensive. Any changes that were made were slow and a small drop in the bucket. According to the study participants, staff repeatedly pointed out that they were not against community involvement, but they had several restrictions. Staff felt that adequate resources were not available yet in the community and they were concerned about dumping people in the community and/or families being left to cope. The Recreation Supervisor clarified their position:
We have lots of people here who could live independently on their own in the community with some support. But we all know those supports aren’t there yet. Those community resources have to be in place before they jump into that.
According to study participants, staffing problems were paramount, for several reasons. There was generally low staff morale, as a result of having a staff that had been there for too long, including the Administrator. The facility was top heavy with doctors and nurses. A recent accreditation process recommended more weekend and evening opportunities for residents, but recreationists said the nursing staff wouldn’t co-operate. And there was a power struggle going on between the different professions. The Recreation Supervisor raised concerns:
. .it’s very frustrating for therapists who are trying to work towards making the patients more independent, and you got this nursing staff on the other hand who want to make them more dependent because it’s easier to care for them when they are in bed. So you got these forces pulling in there, there’s so much tension in there between therapists and nursing.
Study participants reported that quality time with residents was very difficult to find. The staff-to-resident ratio was poor. Staff spent a significant amount of time sitting on committees, detracting from time with residents. Accountability in recreation was primarily according to numbers attending group programs, making individualized experiences with very many people impossible. As a result, a significant proportion of residents were inactive and had lost hope. According to the Recreation Supervisor:
Most people resign themselves to the fact that they were old and disabled and they just say, “I can’t possibly do that.” Because once you’re in [a chronic care hospital] it’s very demoralizing and it looks so hopeless and it’s such a big system. Plus family run away once their parents are looked after.
Concrete strategies were necessary to bring about social change. Despite this overall dismal picture, the recreation department was attempting to make a difference and contribute to the social change process. This facility was included in the study because it illustrated what recreation staff can do, and not do, to create change in a chilly environment. When the Recreation Manager first began working at the facility, medical care, therapy, and programs had been the focus for many years. Initially there was little awareness of the potential of the recreation department to build on the community initiatives by contributing to residents’ quality of life through empowerment, community participation, and relationship building. The Recreation Manager was, however, in a position to influence her staff in these areas:
There were things they had never thought about. A lot of the staff people had been traditionally trained. So they consequently had never thought about the impact that they had or that recreation had. They saw themselves as being providers, so they provided programming for people who lived there. . . . I had worked in institutions for a long time and then I went to university. As a direct result of that, I had to recognize that the things I had been doing [while working in institutions] were not good.
The recreation department made a decision many years ago to focus on a small number of residents, mostly those considered long term, and provide individualized and small group opportunities. To facilitate this process, the recreation department participated in a multi-disciplinary team and family contact was encouraged. Age appropriate activities replaced child like group activities. Leisure programs, recreation therapy, and music therapy were provided. The recreation division consisted of few staff and had limited office and programming space. People in the community were brought in, such as high school students, volunteers, and entertainers. Since recreation was the only place people had any control over their lives, this became an important theme in the department for the small number of people involved. The Recreation Supervisor commented:
I used to talk about recreation as the only thing that people who live here have control over, because in the medical model and in an institutional model they can’t control when they eat, they can’t control when they have their bowel treatments. So consequently I talked about at least giving people some sense of responsibility around leisure. . . . We started doing things that adults would typically do in their leisure time. We tried to give people the opportunity to go shopping by themselves, with the support they needed. I thought that was the thing that most people wanted to do and hadn’t been able to do since they came to the hospital. And that was something that really did happen.
A further example from the Recreation Supervisor illustrates the direction in which the department was moving on this issue of control. It was a gradual process of educating others in the facility that how they have been treating residents was not OK. One concrete example was that residents could begin to have a say in decisions that affect their lives and that vehicles for that to happen had to be put in place:
Once they realize what they are doing is hurtful to other people, they want to change, because I think that people are particularly motivated to do what they believe is best for the person that they are caring for…. Some of the events were planned by the residents’ recreation committee. We do most of the actual running around, but the decisions are made through them. But they are not recognized as a true hospital committee in this facility. We’re working on it.
A final strategy was to take advantage of recreation’s unique position in the facility to create change. The Recreation Manager talked about taking advantage of her lower professional status, in comparison to the medical profession, in positioning herself and the recreation department for creating change:
Recreation was the only thing that was non-health care related and so consequently the doctors didn’t give a darn what we did. So there was no medical control over us. . . . I saw that as a positive thing for us, because then you can take advantage of that. Recreation is really the only thing in an institutional setting the medical profession hasn’t embraced.
This meant that the recreation department had a great deal of freedom to pursue its goals. One of the most important things they worked on was having recreation more respected because of the important role it played in residents’ lives. They wanted to encourage a sense of professionalism, but didn’t want the kind of professionalism that focused on them being seen as experts, or accountability in terms of numbers and check lists when people reached their goals.
Follow-up. During follow-up with this site, the Recreation Supervisor reported that dramatic changes were occurring under the leadership of the new Administrator. Despite the general downsizing which affected mostly nurses, there was a sense of change and progress. There had been a strategic planning process, identifying quality of care, community partnerships, and facility development as key in the change process. In order to make these things happen, several things were suggested (a) utilization of a program management model, (b) hiring outside people to bring vision, (c) opening up of communication and supporting everyone to try new things, (d) conducting regular town hall forums for staff, (e) recruiting a new board of directors, and (f) encouraging an upward flow of information and decisionmaking. They received distinction on a recent accreditation, had a new commitment to education (e.g., status as a teaching hospital, high school and university co-op students), and had a technological revolution.
People are generally happier and having more stimulation as the result of a new patient focus, ward reorganization (i.e., according to people with similar needs), and renovations. The Residents’ Advisory Council was now part of the day-to-day operation of the hospital. Community outreach was key to improving their image regarding diversity (i.e., ethnicity), palliative care, dialysis, support of AIDS patients, and being a key partner in integrated health care. The initiatives started by the Recreation Department during the interview phase of the study now had more widespread support, particularly one-to-one support, leisure education, and assessments for people going back to the community. Several wards requested a full time recreationist in lieu of other staff, which opened up new possibilities.
Still other changes were looming as a result of the most recent Hospital Restructuring Commission and the Complex Chronic Care Report. If the facility was to lose their rehabilitation beds and focus largely on complex chronic care, there would be huge implications-currently, the facility is largely staffed with people trained in rehabilitation services (e.g., physical, occupational, speech therapy), not chronic care. As well, community partners identified the need for more psychiatric geriatric services, which also would require quite a different staffing arrangement.
Cross Case Analysis
The four major themes that emerged from a cross case analysis will be presented. This analysis will show that most of the themes and patterns presented in the cross case analysis also were evident in the within case analysis. While the unique aspects of each site certainly became evident during the within case analysis and reaffirmed the need for this kind of analysis, the cross case analysis confirmed individual site findings and pointed to important common themes.
Focus of Change was Similar
All study participants identified social change efforts in their facilities. The three main areas mentioned that were reflective of social change included: deinstitutionalization, enhanced quality of life, and access to community resources.
At each of the sites, all of the study participants described deinstitutionalization and community living issues that were being addressed, albeit to varying degrees. For example, Facility A was closing and had only a few residents remaining. At Facility B, several psychiatric out-patient and community aftercare programs were in place to reduce the amount of time people spent in the hospital. The least emphasis was at Facility C, although there were community initiated services that delayed persons from going into the chronic care hospital.
The second area identified by the study participants fits under the phrase quality of life. Examples of things that were being done to enhance quality of life included: clientcentered approaches, choice and control over experiences, age appropriate activities, and respect for residents as contributors rather than patients. At Facility A, as part of residents’ transition plans for moving back to the community, quality of life issues were identified. For example, utilizing more of a transitional/rehabilitative model than a diversionary model and moving towards more individualized approaches were seen as crucial. At Facility B, the study participants reported that some staff were attempting to create quality of life changes for residents, but the medical model was still dominant. Similarly, at Facility C, medical care, therapy, and programs were the focus, and there was little awareness of the importance of addressing issues such as community participation and relationship building.
The last area being worked on was access to community resources. Most of the study participants identified some or all of these issues as being important: co-operation with community services, community participation, relationships, and work opportunities for residents. It was clear from the study participants, however, that these issues were not actively pursued on a broad basis by institutional staff. Instead, most staff focused on skill development, rather than connecting residents with places and people in the community. Most study participants claimed that most staff did not think community participation was possible for people with severe disabilities and chronic health problems as the result of low skill levels and inadequate community resources. Many of the participants said improving access to community resources was not enough of a priority.
The Impetus for Change had Multiple Sources, With Recreationists Playing a Relatively Minor Role in Initiating Change
Study participants indicated that the impetus for social change in these three institutions came from multiple sources. Legislation and/or policy was an important facilitating factor at all sites. The downsizing and eventual closure of Facility A was brought about by government legislation. A government report and policy aimed at the development of a community focused, integrated mental health care system was driving the changes at Facility B. The Long-Term Care Act, legislation that favored communitybased and integrated services over clinical options, was influencing change at Facility C.
Another impetus for change came from consumer and/or parent associations. Many study participants said consumer and/or parent associations were the driving force behind pressuring the government to develop policies and legislation to bring about change in institutions. Related to this idea, some study participants believed that society was responsible for its institutional systems, not just the administration and staff who worked there. Finally, most study participants felt that, at some point, it was necessary to “dictate” changes through the use of authority such the administration of the facility or a change-oriented person in a leadership position in the setting.
Most study participants indicated that the majority of recreationists and front-line staff did not initiate change. Most staff got involved, however, when directed by the administration. This often made it difficult to determine whether these individuals believed in the changes or merely followed orders. While the role of recreationists and other staff in the change process was generally seen as limited by most study participants, the Recreation Manager from Facility C felt the recreation department’s low profile was used to advantage for creating change. Since most other staff basically ignored the recreation department, they could do a lot of things and get away with them.
The Constraints to Social Change Were Significant
The overwhelming message from study participants was that there were extensive barriers to social change. All study participants were clear that resistance to change in the three institutions came from all major stakeholders at one time or another. For example, despite legislation which was supposed to be driving the change, there were inadequate resources allocated by government for implementation. Resistance also came from the administration at all facilities at different points. For example, the lack of administrative leadership in encouraging innovation was a barrier. A few study participants mentioned that staff also displayed negative attitudes towards residents, were afraid of losing their jobs, and were uncertain whether the focus on community-based client-driven services might mean loss of staff control. Most study participants expressed the concern that all of the major stakeholders involved in their change process use more rhetoric than action. For example, the language of resident control/involvement in decision-making was sometimes used, but was rarely more than token. A few study participants noted that individuals using the rhetoric often lacked a strong social change value base, especially those who had been working at a facility for many years.
There were several things that contributed to the slow process of change. According to most study participants, the institutional hierarchy and bureaucracy made change slow. For example, recreationists seemed to be struggling for power and influence in systems where their profession was seen of less value than medical services. As a result, it was not surprising that only one progressive recreationist tried to support the empowerment process in a system where residents had little control.
The polarization of communities and institutions also made the process of change slow, according to some participants. There was inadequate dialogue, mutual planning, or co-ordination of services. This often resulted in misconceptions, prejudice, over sensitivity, and resentment because of wage gaps and different value bases. Similarly, some long time residents, who had lives that were highly structured and routinized, felt lost with the changes and did not fully understand the difference between the community and institution.
Despite recognizing the need to work together, most study participants believed that the democratic process slowed the change process. Change in institutions often happened in small steps that were difficult to see. A few recreationists felt that a democratic process was important, but that was interpreted as requiring committee work, which meant less time for their residents. Involving stakeholders (e.g., residents, families, staff, and community members) took time, since everyone had different ideas, and action was slow to follow.
Personal Qualities and Concrete Strategies Were Necessary to Bring About Social Change
Most study participants identified certain personal qualities as being essential for individuals trying to overcome constraints to social change. Good communication with the community, residents, administration, and other staff was mentioned by most study participants. Examples of good communication included listening, showing empathy, and responding to people’s needs. Having a positive attitude towards change also was seen as important. Individuals trying to create change had to continuously monitor and motivate themselves in order to keep the change process going and to stay enthusiastic. Being flexible and open to new ideas also was identified as an important characteristic. This meant constantly working on a trial and error basis, being open to learning from successes and failures, taking risks, and being innovative.
Some study participants also emphasized the importance of having a range of conscious, concrete strategies. Being strategic was viewed as important because of the complex and diverse nature of change. Being strategic included forming a plan of action, including how to present the plan in a convincing and reasonable way, and involving stakeholders in the planning and decisionmaking process. Stakeholders included people with disabilities, consumer organizations, community agencies, families, and institutional staff. Educational opportunities on social change issues and strategies were seen as an important strategy to involve key players in the change process and to keep resistance to a minimum. Finally, determining whether to hire external people who were knowledgeable and capable of providing the necessary leadership for change was seen as important by a few study participants.
Discussion and Conclusions
This study examined the process for social change in institutions. The first objective of the study was to determine the nature of the social change issues being addressed in institutions. The study participants identified three main areas of change: deinstitutionalization, enhanced quality of life, and access to community resources. These areas also have had a great deal of attention in the human service literature, an indication of their importance to social change (Pedlar, 1990; Schwartz, 1992; Wieck & Strully, 1991). Despite these findings, the researchers were left with the sense that, for many workers in the facilities studied, making these changes was not their first choice or a freely chosen direction.
Although most study participants seemed supportive of the need for change, they identified significant constraints to the social change process. The government failed to provide adequate community supports as part of deinstitutionalization. This study made it clear that there were still many people working in institutions who do not believe that people with severe disabilities can live in the community, despite extensive documentation to the contrary (Kwan & Sulzberger. 1994; Peck, 1991; Taylor & Racino, 1991). Finally, change was generally a slow process due to (a) bureaucracy, (b) lack of commitment and openness to change at different points by some administration and front line staff, (c) the polarization of institutions from the community, and occasionally (d) the democratic process.
Many of these constraints are confirmed by the social change literature. Resistance is an expected part of any change process (Boudon, 1986; Vago, 1989). Breaking free of the conventional way of thinking is not always easy (Etzioni, 1991). A certain degree of uncertainty, while necessary, is uncomfortable (Wheatley, 1992; Zimmerman, 1993). The democratic process, despite its importance, is often seen as slowing down social change (Lauer, 1991). A strong value base reflecting a shared vision is sometimes lacking, resulting in staff members resisting change or failing to move in the similar directions (Covey, 1991; Rappaport, 1987; Senge, 1990). Finally, workers often become “institutionalized”, resulting in an inability to promote or accept change (Rothman, 1981).
In response to the second objective of this research, the results of the study showed that the impetus for social change came from three sources: legislation, community based consumer/parent associations, and administrators of institutions. On one hand, these findings are not dissimilar to the literature that reports that social change is complex, requiring change at many different levels (Forester, 1989). Legislation, advocacy by the public sector, and leaders with initiative in organizations are examples of “top down” and “bottom up” strategies, as well as “internal” and “external” strategiesall of which can be important for social change (Carling, 1995; Racino & Heumann, 1992; Wright, 1989).
On the other hand, while the data certainly indicated the presence of some “internal” social change initiatives, it may be more accurate to say they were extremely limited relative to more powerful “external” influences. In this sense, talking about institutions taking initiative for social change may be a bit of an oxymoron. Would any significant social changes have occurred without political lobbying and government legislation? Probably not, especially institutional closures and other changes of that magnitude. Would there be incremental improvements in conditions in institutions? Probably yes, as institutions, like all human services, have been gradually influenced by several social change movements over the past few decades-human rights, normalization, social role valorization, demedicalization, consumerism, self-advocacy, and community living, to name a few (Blaney & Freud, 1994; Hutchison & McGill, 1992; Peck, 1991; Rancourt, 1989). As well, some change theorists believe that a certain amount of change will occur regardless of planning (Mintzberg, 1994).
Regardless of this pessimism regarding the potential of “internally” initiated social change, this study clearly pointed to the importance of people at all levels of the institution supporting the mandated changes. The majority of recreationists and front line workers did not initiate social change, but got involved when directed by legislation or administration. Several strategies were identified by study participants for maximizing the potential of institutional workers contributing to social change, several of which also were mentioned in the literature: communicating well (Lauer, 1991); involving stakeholders in the planning and decision-making process (Covey, 1991; Forester, 1989; Senge, 1990); being open to new ideas and willing to take risks (Potschaske, 1988); and offering educational opportunities. Generally, literature pertaining directly to social change and institutions is extremely limited, and even more so when it came to recreation issues.
While this study indicated that recreationists and other front line workers did not normally take a leadership role in the change process, a case also can be made for the contrary in the future. In theory, bottom-up change is possible, with anyone initiating change by taking on a leadership role (Carling, 1995; O’Brien, 1989; Rappaport, 1987). Chaos theory provides an explanation based on the “butterfly effect.” In periods of change, there is chaos, turbulence, and uncertainty, making it possible for a person or small group concerned about changing a particular pattern, to effect change (Wheatley, 1992; Zimmerman, 1993). This theory of social change implies that recreationists can and must play an important role in the change process, despite the perception that they have less power and credibility compared to other professionals (McGill & Hutchison, 1991; Smith et al., 1992). While they may not be the major initiators behind fundamental change to the basic assumptions and rules of the broader system within which institutions function (Bennett, 1987), they certainly can make a significant difference to the way change processes are played out in institutional settings.
Recommendations
The results of this study suggest implications that enhance understanding of the roles and actions that can be adopted by administrators, recreationists, and other workers to facilitate the change process in institutional settings:
1. Change the philosophy, roles, and goals of recreation and other departments in institutions by:
having social change as a main agenda
shifting the paradigm, from the medical model, to a citizen and community based model
educating all main stakeholders about social change issues including valued social roles, inclusion, deinstitutionalization, independent living, rights, empowerment, and self-determination
beginning the educational process early by adding to the curriculum for colleges and universities knowledge, skills, and strategies related to social change.
2. Recognize that the impetus for change is complex, but that recreationists and others working in institutions can play an important role in supporting “bottom up” social change by:
valuing and supporting a change process that is community and societal driven rather than only institution driven
networking with other concerned individuals both within and outside the institution.
3. Strengthen relationships with a variety of people as a basis for building a common social change agenda by:
building partnerships with key stakeholders including government, community agencies, activist disability advocacy groups, and professional recreation organizations
identifying insiders who may potentially be influential in the change process
using the stakeholder approach to ensure that the philosophy, language, and direction of social change is inclusive and consumer driven
ensuring the full participation of residents as equal partners during all stages of the change process
anticipating potential sources of resistance from the different stakeholders and providing opportunities for having more control and making a contribution in the process of change.
4. Promote action research that will provide answers to some important questions which remain unanswered such as:
what are the views of residents towards social change, particularly in settings where residents are actively involved in decision-making
what information would an intensive case study approach to researching this topic provide compared to this more thematic approach
how can the initial theory building started here related to social change, institutions, and recreation be expanded to other contexts, such as the community
how can research reflect a shifting paradigm and contribute to empowerment by having people with disabilities as partners during the research process.
Copyright National Recreation and Park Association Second Quarter 1998
Provided by ProQuest Information and Learning Company. All rights Reserved.
