THE ROLE OF TELEPHONIC CONSULTATIONS IN CREATENG ENNGVATEON ADOPTEON IN HEALTH .. ORGAN.!ZATION Dissertatibn for the Degree at Ph. D. MlCHiGAN STATE UNEVERSiTY ESTHER GNAGA FERGUS 1973 lll mu lIIIIlllllllllllulmlllllll , ‘ 3 1293 _'.r' r." LI 3 32 R Y r‘v’iit‘ rigor}. State L- li'.'e::3itty This is to certify that the thesis entitled , THE ROLE OF TEIEPHONIC CONSULTATIONS IN CREATED INNOVATION ADOPTION IN HEALTH CHEANIZATIONS _ presented by ESTHER ONAGA' Farms g4 j t has been accepted towards fulfillment of the requirements for __E_h..gD.__ _ degree in . .. 151.0%?! .10. 2' Major professor , if; . Date. 9/14/73 ' ‘ 0-7639 We. 37 W m _fiwwl~3~ 635 o rm m . a?! w-vn 332 (J EM (3Wl8fiL W W1 D mg i, a {3&6 ABSTRACT THE ROLE OF TELEPHONIC CONSULTATIONS IN CREATING INNOVATION ADOPTION IN HEALTH ORGANIZATIONS BY Esther Onaga Fergus This study examined whether telephonic consulta- tions subsequent to a five day workshop on a geriatric program called milieu therapy affected the degree to which the adoption of the program took place in nursing homes and hospitals. The nursing homes and hospitals were rangzmly assigned to three conditions: (1) no persons receiving telephonic consultations, (2) one person receiv- ing consultation and (3) three persons receiving consul- tations. Following the workshop, five consultations were conducted, one every two weeks. Three months after the last consultation a follow-up questionnaire was obtained to examine how much adoption had occurred. Results of this study indicated that telephonic consultations did not create more information diSsemination or enhance utilization of particular forms of information dissemination. However, the consultations with three persons: (1) enhanced the inclusion of more staff in the Esther Onaga Fergus planning groups, (2) supported low social status staff in taking leadership roles and (3) included more staff from various work areas into the planning group. No significant difference could be found for the degree of actual program adoption that took place within the organizations, but there were significant differences between nursing homes and hospitals on the degree of change that took place. Cluster analyses revealed that the outcome variables were relatively independent as were various organizational dimensions. THE ROLE OF TELEPHONIC CONSULTATIONS IN CREATING INNOVATION ADOPTION IN HEALTH ORGANIZATIONS BY Esther Onaga Fergus A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1973 To Ted ii ACKNOWLEDGMENTS I wish to thank members of my committee, Dr. George Fairweather, Dr. Louis Tornatzky, Dr. Lawrence Lezotte and Dr. Raymond Frankmann for their guidance, support and direction in this research. In particular I wish to acknowledge Dr. Fairweather for his creative ideas and advice given me throughout my graduate education and Dr. Tornatzky for his insightful suggestions for the study as well as for his equally brilliant methods on how to stalk the wily brookies. I Thanks are also expressed to Dorothy Coons and her staff from the Institute of Gerontology and the milieu Staff at Ypsilanti State Hospital whose cooperation and efforts made this study possible. For financial assistance in this project, I thank the MSU Department of Psychology and the Bio Medical Fund grantors. I am grateful to several other individuals who have contributed to this research and my graduate education. First of all I thank Dr. Walter Nunokawa for introducing me to this program. I appreciate the supportiveness shown by fellow students and staff in the ecological psychology iii program. Thanks to John Lounsbury and Dr. Robert Calsyn who were most generous with their time to discuss research methods and statistics. Bob Carr and his fellow associates at the Office of Research Consultation deserves recognition for their skill and helpfulness. To Satoru and Sumie who have always been supportive and have encouraged learning, thank you. Most importantly, special thanks to my husband, Ted, for his patience, encouragement and his great sense of humor. iv TABLE OF CONTENTS LIST OF TABLES O O I O O O O O O O O O O 0 LIST OF FIGURES O O O O O O O O O O O O O . LIST OF APPENDICES . . . . . . . . . . . . Chapter I. II. INTRODUCTION 0 O C O O I O C O C 0 Five Models of Change Agentry. . Problem Solver Model (P-S) . . Social Interaction Model (S-I) Research, Development and Diffusion Model. . . . . . . Linkage Model (L). . . . . . . Experimental Social Innovation Model. . . . . . . . . . . Methods Change Agents Utilize To Promote Implementation . . . . Written Methods. . . . . . . . Personal Contacts. . . . . . . Workshops, Conferences, and Seminars . . . . . . . . . . Demonstrations . . . . . . . . Mass Media . . . . . . . . . . Experimental Hypotheses. . . . . Hypothesis Hypothesis Hypothesis Hypothesis QWNH o 0 METHODS. . . . . . . . . . . . . . Sampling Procedure . . . . . . . Treatment. . . . . . . . . . . . Page viii xi xii 10 11 11 11 12 15 15 15 16 17 18 18 20 Chapter III. IV. Data Collection Procedures. . . . . . . Instruments . . . . . .‘. . . . . . . . Description of Setting (Appendix B). . . . . . . . . . . . Physical Environment and Resources, Programing, Staff and Patient Roles, (Appendix C) . . . . . . . . Workshop Effectiveness (Appendix D). . . . . . . . . . . . Characteristics of Innovations (Appendix E). . . . . . . . . . . . Follow-up Communication Questionnaire (Appendix F). . . . . . . . . . . . Telephone Consultation (Appendix G). . . . . . . . . . . . COMPARATIVE RESULTS 0 O O O O O O O C O O 0 Testing the Experimental Hypotheses. . . . . . . . . . . . . . Information Dissemination . . . . . . Formation of a Planning Group . . . . Initiation of Change. . . . . . . . . ASSOCIATIVE RESULTS . . . . . . . . . . . . Examining Empirical Dimensions from Rationally Selected Dimensions. . . . Information Dissemination . . . . . . Planning Group Formation. . . . . . . Environmental Change. . . . . . . . . Program Change. . . . . . . . . . . . Staff Role Change . . . . . . . . . . Workshop Effectiveness and Perception of Innovations . . . . . Organization Variables. . . . . . . . Relationships Between Empirically Determined Dimensions . . . . . . . . Cluster 1. (Planning Group Outcome Measures) . . . . . . . . . Cluster 2. (Staff Involvement in Patient Treatment Decisions Outcome Measures) . . . . . . . . . vi Page 22 23 23 24 25 25 26 27 28 28 28 32 41 55 55 55 59 6O 6O 63 65 67 73 73 73 Chapter Page Cluster 3. (Organization Vari— ables and Environmental Outcome Measures) . . . . . . . . . . . . . . 74 Cluster 4. (Perception of the Innovation and Program-Staff Outcome Measures) . . . . . . . . . . 74 Cluster 5. (Staff Involvement in Teaching, Resident Treat- ment and Training Outcome Measures) . . . . . . . . . . . . . . 74 Cluster 6. (State Hospitals and Staff-Program Outcome MeasureS) O O O O O O O O O O I O O O 75 Cluster 7. (General Facility Meeting). . . . . . . . . . . . . . . 75 Cluster 8. -(Prior Contact with the Institute of Gerontology Training) 0 O O I O O O O I O O O O O 75 Cluster 9. (Implementation Difficulty) . . . . . . . . . . . . . 76 V. DISCUSSION. 0 O O C C O O O O O O O O I O O C 83 Experimental Hypotheses . . . . . . . . . . 83 Overview of the Cluster Dimensions. . . . . 89 Final Cluster Analysis for All Empirical Dimensions. . . . . . . . . . . 91 Limitations . . . . . . . . . . . . . . . . 93 Implications for Future Research. . . . . . 95 APPENDICES O O O O O O O O O O O O O O O O O O O O O O 98 LIST OF REFERENCES. . . . . . . . . . . . . . . . . . 137 vii Tables 1. 2. 10. ll. 12. l3. 14. 15. 16. LIST OF TABLES Experimental Design. . . . . . . . . . . . Comparison of the Number of Staff Receiving Information. 0 O O O O O O O O O O O O 0 Rental Of Film 0 O O O O O O O O O O I O 0 Purchase of Training Series. . . . . . . . Information Dissemination Via Written Literature 0 O O I O O O O O I O O O O 0 Information Dissemination Via a Meeting. . Information Dissemination in Conversation. Information Dissemination Through Workshops Formation of a Planning Group Number of Staff Involved in Planning Group Analysis of Variance for Mean Social Status of Staff in Group. . . . . . . . . . . . . Analysis of Variance for Leader's Social Status 0 O O O I O O O O O O Q C O O O 0 Cell Means for Social Status omeeader . . Analysis of Variance for Social Status of Original Leaders in Group . . . . . . Analysis of Variance for Social Status of Leader and Social Status of Two Other Members Selected by the Leader . . . . . Analysis of Variance for Frequency of Meetings 0 O O O O O O O O O O O O O O 0 viii Page 19 28 29 29 30 31 31 32 33 33 35 35 35 36 36 37 Tables 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. Analysis of Variance for Length of Meetings. . Analysis of Variance for Attendence of Meetings 0 O I O C C O O O C O O O I I O O 0 Analysis of Variance for Turnover. . . . . . . Analysis of Variance for Participation in Decision Making . . . . . . . . . . . . . Analysis of Variance for Number of Staff Levels 0 O O O O O O O I O O O O O O O O O 0 Cell Means for Number of Social Status Levels Involved in Planning Group . . . . . . . . . Work in Same Area. . . . . . . . . . . . . . . Informal Meetings. . . . . . . . . . . . . . . Analyses of Covariance on Change Measures. . . Means and Standard Deviations of the Ten Significant Variables. . . . . . . . . . . . The Three Clusters on Information Dissemination. O O O O O O C O O O O O O O 0 Correlations Between Oblique Cluster Domains for Information Dissemination. . . . . . . . The One Cluster on Planning Group Formation. . . . . . . . . . . . . . . . . . The One Cluster on Environmental Change Outcome Variables. . . . . . . . . . . . . . The Three Clusters on Program Change Outcome Variables. . . . . . . . . . . . . . Correlation Between Oblique Cluster Domains for Program Variables. . . . . . . . . . . . The Two Clusters on Staff Role Change Outcome Variables. . . . . . . . . . . . . . ix Page 37 38 38 38 39 39 40 41 43 53 57 58 59 60 62 63 64 Tables Page 34. Correlation Between Oblique Cluster Domains for Staff Variables. . . . . . . . . . . . . . . 65 35. The Three Clusters on Workshop Effectiveness and Perception of Innovations. . . . . . . . . . 66 36. Correlation Between Oblique Cluster Domains for Workshop Effectiveness and Perception of Innovations . . . . . . . . . . . . . . . . . 67 37. The Eight Clusters on Organizational variables. . . . . . . . . . . . . . . . . . Q . 70 38. Correlation Between Oblique Cluster Domains for Organizational Variables . . . . . . . . . . 72 39. The Nine Clusters in the Implementation StUdy . . . . . . . . . . . . . . . . . . . O . O 78 40. Correlation Between Oblique Cluster Domains for the Implementation Study . . . . . . . . . . 82 LIST OF FIGURES FIGURE 1. Pre and Post Scores for Initiation Change on Environment. . . . . . 2. Pre and Post Scores for Initiation Change on Program. . . . . . . . 3. Pre and Post Scores for Initiation Change on Staff Behavior . . . . 4. Pre and Post Scores for Initiation Change on Behavior for Specific Levels of Staff and Patient Behavior. . xi of PAGE 51 51 52 52 APPENDIX A. Participant Interaction. . . . . B. Description of Setting . . . . . C. Physical Environment and Resources, Programing, Staff and Patient Roles. . . . D. Workshop Effectiveness . . . . . E. Characteristics of Innovation. . F. Follow-up Communication Questionnaire. G. Telephonic Consultation. . . . . H. Scoring Social Status of Staff . LIST OF APPENDICES xii PAGE 99 102 110 118 121 127 133 135 CHAPTER I INTRODUCTION The ever increasing rate of innovation develOpment in the fields of health and welfare, and the prevailing gap between what is known and what is used, makes the study of how innovations are adopted exceedingly important. LaBiere (1965) clearly recognizes the difficulties involved in im- plementation of innovations. In a sense every innovation is ahead of the times and therefore at odds with the times; but whether the course of human events will catch up with a given innovation and foster its being utilized or veer off in some other direction is not determined by the innovation itself. Since the potentialities of an innovation cannot become actualized without some introduction or promotion, the change agent or advocate is a crucial person in the adoption of an innovation (LaPiere, 1965; Havelock, 1972). This study examines the effects of a change agent's efforts to implement a geriatric milieu therapy program in hospitals and nursing homes. Organizational variables which relate to implementation are also investigated. It is essential to examine the five models of change agentry as well as the studies which have been done on various methods of imple- mentation to gain some perspective about the process of implementation. Five Models of Change Agentry Four of the five models of change agentry have been discussed in Planning of Innovation by Ronald Havelock (1971). The four models include: (1) the problem solver model (P-S), (2) the social interaction model (S-I), (3) the research, development add diffusion model (RD&D), and (4) the linking model (L). The fifth model, experimental social innovation (ESI), has been developed by George Fairweather (1967, 1972). Although the change agent in the five models shares the attribute of being a champion of change in some way, each model suggests different roles for the change agent. Problem Solver Model (P-S) The term, change agent, was first introduced in the P-S perspective. Most of the practical applications of the P—S perspective have been done in organizational change work although the P—S process has often been applied in psycho- therapy on change of an individual's behavior. A major distinction of the role of the change agent in the P-S model is that he is a professional helper from the outside (Lippit, Watson and Westley; 1958). The relationship between the change agent and client begins at the client's request for help. The relationship is voluntary and temporary. The basic function of the change agent is to help the client solve a problem. Specifically the change agent (l) helps the client diagnose the problem, (2) helps assess the client's resources and capacity to change, (3) helps the client select appropriate change objectives, (4) helps the client promote change and helps the client to become inde- pendent by teaching skills for promoting self renewal. A collaborative role between the change agent and client is emphasized because it is believed that clients will support what they create (Thelen, 1967). Often the change agent in the P—S perspective carries with him some knowledge of theories and research in social science. His ability to bring this knowledge to bear on the client's problems, to a large extent, determines his effectiveness. In this respect the P-S change agent greatly differs with change agents in the other models, who advocate some tested system of product. Examples of the types of change agents using the P-S per- spective include such professionals as marriage counselors, community organizers, social workers and therapists. It should be clearly recognized that although inter- personal and group relations may improve through the change agent's efforts, change in organizational structure and pro- cedures that would affect the organization's function would not necessarily result. Argyris (1970) explictly states that the implication in the P-S perspective is that change is not a primary task of the agent; rather the agent's function is to provide information in order that the client may make a choice. Thus, it appears that although the term change agents originated from the P-S perspective, in re- ality the agents are not advocates for change in the form of adaption of a specific social innovation. The following four models, in contrast to the P-S models, define change as the adaption of an innovation that may well change the func- tion and structure of the client system. Social Interaction Model (S-I) S-I therorists concern themselves with observations of the channels of communication by which innovations diffuse through a social system. Major focus is placed on the characteristics of the user or adOpter in the context of his social interaction network. The innovation decision process developed by Rogers (1971), a major Spokesman for the S-I perspective, explains the stages of diffusion with respect to the S-I perspective. The innovation decision process includes: (1) knowledge, (2) persuasion, (3) de- cision, and (4) confirmation. The role of the change agent is not explicitly char- acterized in this perspective because the emphasis has been on the user and not the change agent per se as described in the P-S perspective. From the S-I studies available, Ronald Havelock (1971) listed the following roles that change agents played in the S-I perspective: (1) the passive observer re- lying on the natural forces of social interaction, (2) the user of opinion leaders, (3) the network builder who enlisted Opinion leaders and used group meetings, and (4) the user of multimedia. Rogers (1971) refers to the 5-1 role of change agents from two perspectives. The first perspective comes from the findings of correlative studies on the determinants for a change agent's success. The second perspective in- volves the change agent's use of communication channels for diffusion of innovations. The S-I model has perhaps made its greatest contribution regarding the characteristics of successful change agents and the effectiveness of various communication methods through its correlative studies. Research, Development and Diffusion Model The elements of the RD&D perspective were first laid out by Henry Brickell (1964) and David Clark and Egon Guba (1965), men in the field of education. The research, develop- ment and diffusion model (RD&D) supports the process of (1) basic research, (2) applied research, (3) develOpment and testing of prototypes, (4) packaging and product, and (5) mass dissemination. The writings in RD&D suggest that the theorists hope that the process is continuous and that link— ages are made between basic research, applied research, developers and the diffusers. This perspective emphasizes a rational approach to change beginning with a useable pro- duct or process demonstrated through research and development followed by packaging and dissemination. Although widely accepted by educational organizations as well as agricultural extension systems there are some weaknesses in its practical application. First there is little known continuity between the work of the basic researcher and the applied research, and there appears to be an equally large gap between the work of the applied research and the user. Although a great deal of work has been done in the research and development phases, the diffusion aspect of the model has received little attention. Like the S-I model, the change agent's role is not explicitly defined. Perhaps this lack of attention is reflected in the underlying assumption held by RD&D theorists that a passive and rational audience will accept the information when given at the right time, at the right place and in the right form (Havelock, 1971). Although not stated, the person who packages and plans for dissemination may be thought of as a change agent because he is working towards diffusion of an innovation. Two things are true of change agents in the RD&D model. First, they advocate a product or program that is tested and second, they intend to plan for a large scale diffusion, although in reality great efforts in diffusion have not been made. Linkage Model (L) The development of the linkage model (L), supported by the Center for Research on Utilization of Scientific Knowledge at the University of Michigan, was primarily pri- marily prompted by the concern that a large prOportion of innovations in American education and social practice never gets transmitted to the user. The linkage model has been created in an attempt to bridge the gap between the resource system and the user system by selecting the strongest fea- tures from the three distinct perspectives, research develop- ment and diffusion (RD&D), social interaction (S-I), and problem solving (P-S) (Havelock, 1971). The linkage process rests on creating interdependent and reciprocal relationships between user systems and re- source systems. The user system takes the model of problem solving cycle, initiating with a felt need and moving suc- cessively to diagnosis, problem statement, search, retrieval of the solution and application of the solution. The re- source system and the user system simulate the processes that occur within each system. It is hOped that if the resource system could simulate the problem solving cycle in the user system it would better understand the user's need. Likewise if the user simulated the resource system's pro- cess of research and develOpment it will be more receptive to adopt the innovation. In The Change Agent's Guide to Innovation in Educa— 2122! Ronald Havelock (1973), delineates four primary ways a change agent can act. The first type of role is that of a catalyst where the change agent prods or stimulates the client system to begin working on its problems. A second is as a solution giver. Here the change agent is knowledge- able about when and how to offer solutions to the client system. In a third role the change agent helps the client system go through the six stages of planned change as a pro: eggs helper. Finally, as a resource linker, the change agent brings resources such as finances, knowledge of solutions, skills in diagnosing problems and expertise in the change process to the client system. The organization of the linkage system suggest that change agents would be located in the interphases of the subsystems. Some focus is placed on the practice subsystem (subsystem of practitioners) for taking the linkage role between the research systems and the user system. Part of the problem of the lack of knowledge dissemination is attri- buted to the lack of practitioner's skills to interpret in- formation and to question the researcher (Lippit, 1967). Thus linkage theorists encourage training the practitioners in how to use scientific knowledge, how to adapt the find- ings, and how to use diagnostic tools to collect information. Experimental Social Innovation Model The major spokesman for the E51 model, George W. Fairweather, best expresses the underlying features unique to the E81 model in his module, Social Change: The Challenge to Survival (1972).~ The features of the E51 model include the model building and evaluation phase and the implementa- tion phase which consist of approaching, persuading, adoptin , and activating diffusion of the model. The change agent plays an important role in the implementation process which occurs only after a model has experimentally demonstrated its effectiveness. The ESI change agent (1) is supportive of humanitarian values, (2) is committed to solve a human problem, (3) approaches change with a social action orientation, (4) advocates an innova- tion that has been experimentally tested, (5) utilizes experiments with methods of change until the masses adOpt the innovation (Fairweather, 1972). Like the P-S model the change agent operates outside of the user system. However, unlike the more passive roles given the change agent in the other perspectives, the ESI change agent is described as one who is himself active and morally committed to the implementation of the particular innovation. The ESI model is unique in that it has established many of its guidelines for the role of change agent from experimental work. It gives a fairly clear picture about the general role of the change agent and relies on ongoing or future experimental research to determine what role would be most effective. Methods Change Agents Utilize to Promote Implementation Five methods commonly used for diffusion of informa- tion or innovations include: (1) dissemination of written material, (2) peOple to people contact, (3) presentation of workshops, conferences or seminars, (4) providing demonstra- tions or site visits, and (5) use of mass media. 10 Experimental studies on the efficacy of these methods for the diffusion of information or innovations are scarce and clearly need more attention. Written Methods The research findings on the effectiveness of written material indicate that they have limited value with reSpect to promoting behavioral change. For instance Halpert (1966) found that printed reports, although widely used, were not read by many practitioners. Another study found that re- cipients of the written information used the information in further verbal discussions, but not in any modification of practices (Goldin, Margolin, et al., 1969). Results of an experimental study on the diffusion of a mental health in- novation indicated that passing out of brochures on the innovation did not create any significant changes (Fairweather et al., 1973). In another study, newsletters advocated certain environmental action for consumers were found to be ineffective by themselves in creating be- havioral change, but newsletters with telephonic prods were effective in adoption of ecologically supportive behavior. (Lounsbury, 1973). A recent study by Glaser and Ross (1971) state that at best written reports stimulate interest and rarely do they create active advocacy, especially when the innovation requires considerable modification of present behavior. 11 Personal Contacts Research findings on the diffusion of information via personal contacts appear to show that they are somewhat effective. The literature indicates that many utilizers of information receive their information from face-to-face confrontations (Rogers, 1962; Coleman, Katz, et al., 1966; Roberts and Larsen, 1971). Furthermore studies indicate that practitioners learn most readily from opinion leaders in their profession (Watson, 1966; Lazarsfeld, Sewell, et al., 1968). The study by Ryan and Gross (1943) showed that salesmen were effective informers, but informal sources legitimized the information. Spooner and Thrush (1970) report that personal follow-up following an interagency con- ference enhanced the dissemination of a mental health research findings and initiating institutional change. Workshops, Conferences, and Seminars The general consensus of the effectiveness of work- shops, conferences or seminars is that they are more in- fluential than one-way reports in providing a climate for change and facilitating the use of new knowledge (Glaser, 1966; Chesler and Fox, 1967; Fairweather, et al., 1973). Demonstrations Demonstrations appear to be fairly effective in pro- viding for adopting. Visits to demonstration sites similar to the visitor's own working situation have greater transfer 12 value than when the visitor sees his own situation as basically different from that of the demonstration site (Costello and Zalkind, 1963; Brickell, 1964; Miles, 1964b; Lippit, 1965b; Wiles, 1965; Mackie and Christensen, 1967). Glaser and Ross (1971) state that site visits promoted enough advocacy so that the participant often actively Sponsored the innovation after leaving the demonstration project. Richland (1965) found that his traveling seminar introduced more innovations to schools than those schools which received no visits. In a major experimental study comparing the effectiveness of brochures, workshops and demonstrations, it was found that demonstrations followed by site visits and telephonic consultations produced a significanly higher proportion of adopters than the brochure and workshop conditions. (Fairweather et al., 1973) In a study of mental health demonstration projects, Lippitt and Butman (1969) recommend that more thought be placed on the needs of potential adopters, that evaluation of the various methods of communicating with adopters be made and that change agents become available to continue providing support in planning and implementing the new programs. Mass Media Mass media have not received much use in communicat- ing research findings. It appears that mass media are help- ful in providing for awareness of a problem to a large group, 13 but interpersonal communication is necessary to build more credibility (Rogers, 1962; Menzel, 1966; Rogers and Svenning, 1969). The literature on the various methods of communica- tion indicate that although some methods for implementation are commonly practiced they are not necessarily effective in creating change. One method may be effective in only one aspect of implementation. For example, mass media seems to be effective in providing information to a mass of people, but it is not necessarily effective in initiating change. By far demonstrations appear to be most effective in enhanc- ing change. These findings suggest the need to test more powerful methods and need to test the efficacy of a combin- ation of the methods to implement change. An examination of the five models of change indicate that the change agent's role ranges from (1) passive to active, (2) vague to explicitly defined, and (3) champion of an untested product to a champion of a product that has been experimentaly tested in a naturalistic setting. Compara- tively, the ESI model appears to have made and to provide great potential for contributing experimental evidence re— garding the processes of change. The role of the change agent is explicitly deliniated in the ESI model and provides for continuity in the implementation process. 14 A study which involved actual behavioral changes was conducted by Fairweather, Sanders and Tornatzky (1973). They compared the effectiveness of an action consultant, who made site visits to the target organizations with written in- formation from a manual, in the adOption of a mental health program for residents in mental hospitals. The results showed that implementation related prsitively with (1) active and continuous consultation during the social change process, (2) greater number of professional staff involvement in the decision to implement, (3) greater number of persons talked to and talked to more often at the time of initial contact, (4) greater personal satisfaction among staff about the decision to implement and (5) less hierarchical structure of the organization as perceived by the staff. The results of the Fairweather, Sanders, and Tornatzky (1973) study raise a number of questions con- cerning staff involvement and the degree of communication that are important for further investigation. Some of the questions it raises and explored in this study are: (1) will telephonic advocacy be as effective in promoting active adOption as the action consultant who makes site visits?, (2) will peer planning groups be formed with telephonic advocacy?, and (3) will telephonic advocacy with staff of different professional levels increase involvement of more peOple, promote peer group development and finally promote 15 actual implementation of the innovation? Observing the tenets of the ESI model, this study experimentally tested the effects of telephonic advocacy on the degree of imple- mentation of a geriatric treatment program that had been evaluated. Experimental Hypotheses Hypothesis 1 Rogers and Shoemaker (1971) indicate that informa- tion dissemination is the first step toward change. In addition the literature shows that many utilizers of in- formation receive their information from personal contacts (Rogers, 1962, Coleman, Katz et al., 1966; Roberts and Larsen, 1971). Furthermore the study by Spooner and Thrush (1970) found that personal follow-up after an interagency conference enhanced the dissemination of a mental health finding. These findings suggest that perhaps personal telephonic consultations to more than one person could stimulate more information dissemination which may follow with actual adoption of the innovation. Thus it is hypothe- sized that personal telephone contacts with more than one person over apperiod of time during the social change pro- cess will increase the dissemination of information. Hypothesis 2 In a recent finding from a national social change of hospitals study, it was found that a group of members 16 within the organization, whose goals were to actively take measures toward the adoption of innovation, was essential, in addition to information dissemination, to create change. (Fairweather et al., 1973). In essence planning groups could be considered as a mediating outcome variable before social change of a complex nature occurs. The national social change study, in addition, revealed that the visit from the action consultant contributed to creating change by enhacing group cohesiveness and giving staff some task orientation (Fairweather et al., 1973). These findings suggest that an outside consultant could act as a catalyst to establish a group of persons committed to create change. Therefore it is hypothesized that personal telephone contacts with more than one person over a period of time during the social change process will increase the formation of plann— ingpgropps. Hypothesis 3 The national social change study of hospitals also revealed that diffusion of an innovation does not occur Spontaneously but is created by use of external pressures or stimulations which are active, personal and frequent (Fairweather et al., 1973). In addition, the study found that the development of planning groups was related to active adoption of the innovation, and that more peOple talked to at the time of the initial contact related to the 17 adoption of the innovation (Fairweather et al., 1973). It appears that perhaps personal telephonic contacts to more than one person over frequent intervals may be effective in creating change. Thus it is hypothesized that personal telephone contacts with more than one person over a period of time during the social change process will increase the active adoption of the innovation. Hypothesis 4 The innovation advocated in this study was created and tested in a hospital setting. It is therefore possible that the innovation which was created is more apporpriate for hospitals than nursing homes as it was developed in the hospital setting. Thus it is hypothesized that more hospitals will adopt the innovation than nursing homes. In addition to testing the experimental hypotheses, the interrelationships between the various organizational dimensions, outcome dimensions and attitudinal measures will be examined. CHAPTER II METHODS Sampling Procedure Thirty-six health organizations served as the sam- ple for the study. Twenty-three of them were hospitals and thirteen of them were nursing homes. The thirty-six organizations were volunteer participants in five milieu therapy workshops at the Institute of Gerontology. The thirty~six health organizations were accumulated by two workshops, one in July and the other in August. The Instutute of Gerontology provided for their housing and food for the five day workshop. When more than one participant represented a par- ticular organization, the Participant Interaction (Appendix A) questionnaire was administered on the fifth day of the workshop. The questionnaire provided the following infor— mation: (1) whether the other staff members who attended the workshop, worked in the same area, (2) whether the staff who attended the workshOp with them exchanged or shared staff with him, (3) whether the staff who attended the work- shop worked with the same patients, (4) whether the staff who attended the workshop with them attended meetings with him more than once a month. If the workshop participant 18 19 answered pp to these questions he was considered a separate unit and treated as a separate organization. The twenty-three hospitals and thirteen nursing homes were then randomly assigned to the following treat- ment conditions: 1. no person receiving telephonic consultations 2. one person receiving telephonic consultations 3. three people receiving telephonic consultations This is shown in Table 1. TABLE l.-—Experimental Design. Number of Staff Receivinngonsultations Organizations 0 l 3 Nursing Homes n = 4 n = 5 n = 4 13 Hospitals n = 7 n = 8 n = 8 23 ll 13 12 36 The recipients of the telephone consultations were chosen at the end of the five day workshop. If only one person represented the organization, he automatically became the leader. If more than one person represented the organiza- tion they were asked to select a leader. The leader was then told to list two other staff members who would be interested in developing the milieu program in their work area. Thus for the one person consultation condition, the 20 leader became the contact person; for the three person contact situation, the leader and the two other staff mem- bers he listed became the contact peOple. In six situations the leader did not list two other names. When this occurred, the experimenter first contacted the leader and asked for two other names of staff who might be interested in develop- ing the milieu program. In both the one person contact situation and the three person contact situation, names were changed as the consultant was referred to call another person. (One organization, a nursing home, refused to dis- close two other names for consultation purposes and was thus eliminated from the study). Treatment The concept of milieu therapy, the innovation being advocated, is best described in the training manual, Develop- ing a Therapeutic Community, (Coons, pp 31., 1973). Milieu therapy uses the total environment- staff, program, ward life, physical setting, the patients themselves-as treatment agents. The therapeutic community must begin with STAFF; in an important sense, the milieu is therapeutic only when staff becomes actively involved with patients and learns new roles. The health spec- ialists-doctors, nurses, social workers, occupa— tional therapists, etc.-must be not only thera- pists but trainers, demonstrating and teaching ward staff the techniques and skills they need to become treatment agents. The specialist must learn to give staff the support they need to en- able them to accept change, and he must gain his satisfaction, not from maintaining his position of authority, but from helping staff grow. Ward staff must become actively involved as team members and must share in the responsibility for bringing about change. 21 The PROGRAM must be designed to meet Speci- fic treatment goals for the patient. This implies an awareness of patients needs and a willingness on the part of staff to evaluate current interventions, test new programs, and discard practices which do not prove to be therapeutic for patients. The PHYSICAL ENVIRONMENT should look attractive and be as noninstitutional as possible. It must provide chances for pri- vacy and Opportunities for patients to be self-sufficient rather than deprive them of the materials and equipment they need to care for themselves. PATIENTS thenselves must be taught new ways to function, new skills to care for themselves, and apprOpriate ways to relate to others. The consultant attended two five day workshOps and worked with the staff and patients on the ward for a week to become acquainted with the milieu therapy program. The consultant also conducted approximately five hours of role playing consultation sessions with the training staff at the Institute of Gerontology in preparation for the tele- phonic consultations. Five consultations were given to each of the organ- izations (nursing homes and hospitals) in the two experi- mental treatment conditions. These consultations were conducted by a person—to—person call to each of the recipients once every two weeks. The consultant attempted to keep the consultations at the rate of one every two weeks. However, the consultations generally spanned a longer period of time because of problems in contacting staff on vacations, meetings, and sick leave. The order of the calls was selected ramdomly for the first 22 consultation. However, leaders of the organization re- ceived their call first before the other two members in the three man condition. The content of the telephone consultation consisted of: (l) introducing oneself in association with the milieu training staff, (2) questioning what had been initiated after return from the workshop or last consultation, (3) encouraging information dissemination to other staff, (4) encouraging creating a group of interested staff, (5) suggesting that meetings be set with interested staff on a regular basis, (6) encouraging that specific tasks be delegated to begin action toward adoption, and (7) offering to answer any questions staff may have had. The length of the consultations was not limited and ranged from approx- imately 30 seconds to 30 minutes. Data Collection Procedures Data for the study was collected by written ques- tionnaires from the designated leaders of the organization at the workshop and once after the workshop. The follow-up data was gathered 12 weeks after the last consultation with the organization's leader. The follow-up date for the control group (no person receiving telephonic consultation) was determined. It was set at 12 weeks after the mean date of the last consultation for each of the July participants. A separate mean and follow-up date was established for the August participants. 23 The follow—up procedure entailed a sequential pro- cess depending on whether questionnaires were returned. Thus the first questionnaires for the follow-up were sent by air mail delivery to the leaders of each organization at the time of the last telephonic consultation along with a stamped envelope and a letter requesting that the ques- tionnaires be completed. If the questionnaire was not returned the experimenter waited for two weeks after the questionnaires had been sent before sending a second follow- up letter again requesting that the questionnaire be com- pleted and returned. If no reply was received in two weeks, the experimenter placed a person-to-person call requesting that the questionnaire be completed. In this way follow-up information was obtained on all but one organization. Instruments The variables of interest in the study were measured by administering five different questionnaires, recording information during the telephonic consultations and having the training staff record any rentals of films and purchases of training packages of the program. The questionnaires were: Description of Setting (Appendix B) This questionnaire was designed to retrieve infor- mation about the nature of the organization with respect to the type of patients, staff, characteristics of the leader 24 and organizational locale and history. This questionnaire was completed on the first day of the workshop. The vari- ables measured in the questionnaire include: (1) location of the facility, (2) length of the facility's existence, (3) type of patients (elderly, ambulatory, length of their stay), (4) staff resources, (5) staff turnover, (6) frequency of staff meetings, (7) involvement of staff in meetings, (8) involvement of the leader in training, administration, direct services, and planning of programs and the environment, (9) number of staff who attended previous workshOps or insti- tutes, (10) how the leader was first introduced to the program, (ll) the leader's training, (12) the leader's length of time spent at present job. Scoring procedures for responses concerned with staff positions are shown in Appendix H. Physical Environment and Resources, Programing, Staff and Patient Roles, (Appendix C) This questionnaire was adminstered at the workshop and twelve weeks after the last telephonic consultation. The items in the questionnaire examined the physical environment and resources of the organization, the programs, staff and patient roles. The scoring for the physical en- vironment and resources of the organization, its program and staff varaibles was done on a six point Likert type 25 scale. The staff decision making on patient treatment, staff teaching role and patient's roles were scored on a five point Likert type scale. Workshop Effectiveness (Appendix D) The workshop effectiveness questionnaire examined the following variables: (1) perception of milieu therapy as a new program, (2) effectiveness of the workshop for information dissemination, (3) degree of ease in adapting the innovation, (4) degree of personal agreement with the information presented, (5) degree to which staff in the same work area responded positively to the information presented, (6) recommendations of workshop to other staff members, (7) perception of the utility of the training series, and (8) the intent to obtain the training series and films. Items in this questionnaire were scored on a five point Likert type scale. Characteristics of Innovations (Appendix E) This questionnaire provided information about the participants' perceptions of milieu therapy with respect to: (l) the degree of role change necessary, (2) the degree to which the program was apprOpriate for their patients, and (3) the degree to which the program was easy to persuade other staff to implement. Each of the items on the four 26 dimensions were rated from 1 to 6. The mean score was then taken for each of the categories. (See appendix D for scoring). Follow-up Communication Questionnaire (Appendix F) The follow-up questionnaire examined the following types of information: (1) the extent of discussion of the program to fellow staff members, (2) the methods of commun- ication used to present the material, (3) the number of members receiving information, (4) staff reaction to the information, (5) degree of difficulty in presenting infor- mation, (6) existence of a group to try out the ideas of milieu therapy, (7) the social status of the member of the group who assumed leadership, (8) number involved in the group, (9) mean score of the social status of the people involved in the group, (10) the frequency of the group meetings, (ll) length of the meetings, (12) location of the work area, (13) degree of hierarchial decision making, (14) whether the group met in informal session, (15) extent to which conditions prevented making successful changes, (16) whether participants ordered the films from the Institute of Gerontology and (17) whether the participants ordered the training series package. 27 Telephone Consultation (Appendix G) This short questionnaire was administered to only those leaders receiving telephonic consultations. It measured whether the participant thought the consultation was helpful or not and if helpful whether the helpfulness was the result of providing information on resources, on how to initiate change, or in provision for emotional support. The total number of minutes for each organization's five consultations was recorded. Finally the order of how the telephone calls were conducted was determined by ranking each leader's consultation by who received the call first. The sum of the ranks for each organization determined the final rank for the consultation calls. CHAPTER III COMPARATIVE RESULTS Testing the Experimental Hypotheses The primary hypotheses of this study concern: (1) the amount of information dissemination, (2) the degree to which planning groups were formed, and (3) the degree to which actual initiation of change took place. After these hypotheses were tested, the relationship between these out- come measures with other organizational variables was examined. Information Dissemination The analysis to determine the degree to which infor- mation about the innovation was disseminated is shown in Table 2. A two way analysis of variance indicates that there are no significant differences between treatment groups and between institutions. TABLE 2.--Comparison of the Number of Staff Receiving Information. Source df MS F 'Institutions 1 .0075 .003 Treatment 2 .2582 .1031 I x T 2 .5488 .2191 Error 30 ’ 28 29 To further examine how the information was dissem- inated, chi-square tests were completed on (1) whether films were actually obtained and (2) whether the institute's training series were purchases. Tables 3 and 4 show that there are no significant differences between treatment groups. TABLE 3.--Rental of Film Number of Staff Receiving Organization Rented Films Telephone Consultations 0 l 3 yes 3 3 2 no 8 10 10 2 x = .34 df = 2 TABLE 4.--Purchase of Training Series Number of Staff Receiving Organization Purchased Series Telephone Consultation 0 l 3 yes 6 8 3 no 5 5 9 2 X = 3.63 df II N 30 In order to investigate the methods used in infor- mation dissemination, chi-squares were used to test: (1) whether staff passed on written literature, (2) whether staff called a meeting to disseminate information, (3) whether staff disseminated information via conversation, and (4) whether workshops were conducted. Tables 5, 6, and 8 show there were no significant differences between treatment groups. Table 7 reveals that there was a significant difference (p<.Ol) between treatment groups on information disseminated through conversation. TABLE 5.--Information Dissemination Via Written Literature Dissemination of Written Number of Staff Receiving Literature Telephone Consultations 0 l 3 yes 5 7 3 no 6 6 9 2 X = 2.17 II N df 31 TABLE 6.--Information Dissemination Via a Meeting Information Dissemination Number of Staff Receiving Via a Meeting Telephone Consultations 0 l 3 yes 5 6 7 no 6 7 5 2 x = .44 df = 2 TABLE 7.--Information Dissemination in Conversation Information Dissemination Number of Staff Receiving in Conversation Telephone Consultations 0 1 3 yes 4 11 11 no 7 2 1 2 x = 10.25* df = 2 * = p significant at .01 level 32 TABLE 8.--Information Dissemination Through Workshops Number of Staff Receiving Conducted Workshops Telephone Consultations 0 1 3 yes 0 2 2 no 11 ll 10 2 x = 2.22 df = 2 Formation of a Planning Group The second area of interest investigated was the formation of planning groups. To further explore character- istics of the planning group, the following variables were measured and tested: (1) the number of members in the planning group, (2) mean social status of the entire group, (3) social status of the leader, (4) frequency of meetings, (5) length of the meetings, (6) whether members worked in the same area, (7) attendance of meetings, (8) turnover of group membership, (9) degree of shared decision making, (10) whether the groups met informally and (11) number of staff levels involved in planning group. The chi—square test was used to examine the effects of the treatment on the formation of a planning group. Table - 9 reveals that there were no differences between treatment conditions. However, a close glance at Table 9 reveals a 33 strong trend (p< .10) towards formation of planning groups in the condition where three staff members received consul- tations. TABLE 9.—-Formation of a Planning Group _ . Number of Staff Receiving EXistence of a Planning Group Telephone Consultation 0 l 3 yes 6 7 11 no 5 6 l 2 X = 5.06 df = 2 This finding becomes significantly pronounced when the number of staff involved in the planning group was ex- amined by the median test. Table 10 shows a difference between the treatment groups obtained at the .01 level of significance. TABLE lO.--Number of Staff Involved in Planning Group Number of Staff Receiving Number Of Staff ln Group Telephone Consultation 0 1 3 less than or equal to 4 9 9 2 more than 4 2 2 4 10 x = 11.43* df = 2 34 The two way analysis of variance to test for differences between the treatments or between the types of organizations or mean social status of the entire group indicates no significance as shown in Table 11. However, the analysis of variance results as shown in Table 12 reveals that there was a significant difference between treatments for the leader's social status. Examination of the cell means shown in Table 13 indicates that the three person contact situation had a lower status leader than the other two treatment conditions for the hospital sit- uation. The one person contact situation seemed to have a higher social status leader than the no person contact situation or the three person contact situation for both hospitals and nursing homes. In order to examine whether the original leader's social status differed between the treatment conditions, an analysis of variance was done showing no difference (Table 14). In addition, whether the leader's choice of two other members differed in social position from his own was tested to determine the possibility of the original composition of social status influencing the outcome of lower social status staff involvement in leadership roles for the three person contact situation. Table 15 shows that there were no significant differeces between the original leader's social status and those social status of the two staff he chose. 35 TABLE ll.--Analysis of Variance for Mean Social Status of Staff in Group. Source df MS F Institutions 1 1.5467 .3205 Treatments 2 7.2826 1.5089 I x T 2 .8171 .1693 Error 18 TABLE 12.--Analysis of Variance for Leaders' Social Status Source df MS F Institutions 1 2.8451 .6634 Treatments 2 15.9864 3.7275* I x T 2 3.7451 .8732 Error 8 *p<.05 TABLE 13.--Cell Means for Social Status of Leadera. Number of Staff Receiving Institutions Telephonic Consultations 0 l 3 Nursing Homes 2.5 1.6 2.5 Hospitals 2.4 1.3 4.4 aSocial Status was scored 1 to 6 with higher status staff given 1. 36 TABLE 14.--Ana1ysis of Variance for Social Status of Original Leaders in Group Source df MS F Institution 1 1.8006 .7638 Treatments 2 2.5714 1.0908 I x T 2 1.8396 .7804 Error 8 TABLE 15.—-Ana1ysis of Variance for Social Status of Leader and Social Status of Two Other Members Selected by the Leader Source df MS F Institution 1 3.2552 1.3751 Leader and 1 Selected Two 1 3.0104 1.2717 I x T l .8802 .3718 Error 8 As shown in Tables 16, 17, 18, 19 and 20, the analyses of variance did not result in any significant differences between treatments and between institutions for the following variables: frequency of meetings, length of meetings, attendence of meetings, turnover of group member- ship and degree of shared decision making. Table 21 in- dicates that there was a significant difference between 37 institutions with respect to the number of staff levels involved in the planning group. Table 22 shows the cell means of the number of staff levels involved, clearly in- dicating greater number of staff levels involved in hOSpitals than nursing home planning groups. TABLE l6.--Ana1ysis of Variance for Frequency of Meetings Source df MS F Institutions 1 .4047 .1472 Treatments 2 2.7958 1.0166 I x T 2 .2500 .0909 Error 18 TABLE 17.-—Analysis of Variance for Length of Meetings Source df MS F Institutions 1 3.0773 2.1223 Treatments 2 1.9525 1.3468 I x T 2 1.0363 .7147 Error 18 38 TABLE 18.--Ana1ysis of Variance for Attendence of Meetings Source df MS F Institutions 1 6.3772 1.3367 Treatments 2 11.4628 2.4026 I x T 2 .7287 .1527 Error 18 TABLE l9.--Ana1ysis of Variance for Turnover . .— Source df MS F Institutions 1 2.3192 ' .5743 Treatments 2 9.2631 2.2937 I x T 2 .6098 .1510 Error 18 TABLE 20.--Ana1ysis of Variance for Participation in Decision Making Source df MS F Institutions 1 2.3487 .6683 Treatments 2 4.8926 1.3922 I x T 2 .5920 .1684 Error 18 39 TABLE 21.--Analysis of Variance for Number of Staff Levels Source df MS F Institutions 1 12.0401 5.0632* Treatments 2 7.4034 3.1133 I x T 2 .9068 .3814 Error 18 *p<.05 TABLE 22.—-Cell Means for Number of Social Status Levels Involved in Planning Group Number of Staff Receiving Institutions Telephonic Consultations 0 1 3 Nursing Homes 1.0 1.0 1.8 Hospitals 1.6 2.1 3.5 Chi-squares were used to test for differences in treatment effects for whether staff in the planning groups worked in the same area and whether they met informally. Table 23 reveals that there was a significant difference between treatments in whether the staff worked in the same area. The data indicates that more staff who worked in different areas were involved in the planning groups in the three person contact situation. 40 TABLE 23.-~Work in Same Area Number of Staff Receiving Work in Same Area Telephone Consultations 0 1 3 yes 6 7 4 no 0 0 7 x2 = 11.68* df = 2 *p<.01 As shown in Table 24 there were no significant differences between treatment groups with regard to whether staff met informally. Using the probability of significance for a series of statistical tests created by Sakoda and his colleagues (1954) three significant results out of a series of twelve independent tests is significant at the .05 level. Thus, those three significant results obtained for the effects of treatment on the three variables involving planning groups should be recognized. 41 TABLE 24.--Informa1 Meetings Number of Staff Receiving Met Informally Telephone Consultations 0 l 3 yes 6 5 5 no 1 1 4 2 x = 2.26 df = 2 Initiation of Change The third outcome dimension involves the actual change initiated. Pretest measures were obtained for the change variables and two-way analyses of variance were used to determine whether any significant differences were obtained between the treatment groups on these variables. Six of the sixty-five variables were signficant on the pre test measures, which according to Sakoda gt 31.'s (1954) figure does not reach the .05 level of significance for the number of significant tests in a series of such tests. Thus the experimenter was able to treat the pretest scores as a covariate (Porter, 1972). In order to test whether any changes took place in initiating change within the health organizations, analyses of covariance was used to test the sixty-five items of change and the pretest score was used as a covariate. 42 Three other variables which might have significantly affected the change score and which could not be controlled at the time of the random assignment were treated as co- variates through the use of the following scores: (1) number of participants attending the workshop, (2) number of former participants who attended previous 14 week insti- tutes, and (3) number of former participants who attended previous workshops. The results of the covariance tests on the sixty- five change variables showed that (1) no significant differences can be attributed to the treatments, (2) nursing homes and hOSpitals were significantly different on several of the variables, and (3) no significant interaction effects were found. Although five of the sixty-five variables were found to be significant at the .05 level for the test of the treatment effect, the overall test of significance using Sakoda, Cohen and Beall's figure (1954) indicates that five out of sixty-five tests does not reach significance at the .05 level. The results of the analyses of covariance are shown in Table 25. 43 homv. «chm. mm naom. mmao. om some. «Ohm. om Aeoou mom vlmv mofluoufleuop gem mpfl>oum ammo. mmnm. mm Nmnv. comm. mm movm. omma. om mumaflou so meson w muoopxz meoouaumn HMCOflusuflumcHIsos mofl>oum poxooass ammo. omoo.m mm mamm. hmma. mm Nmmm. ommm.a mm a .Ham>m xaflommu I .omw >Ho a Smm3_usms mofl>oum omxooacs hmmv. vah. mm mman. mmvm. mm mman. mmvm. mm a .HHm>m maflpmmu I .mflswo mcflsmm w mSHosmE mofl>oum neon. mvmm. mm came. voma. mm Noam. mmmH.H mm poxooas: w .HHm>m waflpmmn mamflnmumemqueooum mpfl>oum memo. mvhm.m om Name. mmmo. mm vmmm. mama. mm boxooas: w .Hflm>m maaommu I .omw mcflxooo mpfl>oum Umxooass omma. mmmm.a mm mmma. vmmo.m mm mane. nmmn. mm w .HHm>m waflommu I .omm huocsma Hmcomumm mofl>oum ER. 884 mm 88. $84 em 84m. 834 mm 39..» soon: .>.e £338 a menu.m95mflmq mcfl>oum omnm. woao.a mm wmmm. mmom. mm Hmom. ommm. mm msoouoon w mcflcflo toda>fla mxHHmeon mpfl>onm m m mp m m mp m b m6 mHQMHHm> 83335 uomfim Hmcoflfiflmfi nomwmm €95,889 m.mmnsmmm2 mmsmcu co mocoflum>ou mo mommamc¢rl.mm mammH 44 vhNH. mmmm.m mm Hmvm. mmma. mm ovmv. vmvh. mm vwma. mmmm.H mm ovmm. oomm. mm comm. mhma. mm mhmm. hoav. mm momm. mamv.a mm 0000. momm.m mm Homm. omhm.H mm «NNoo. Hmmm.HH mm mono. vmma. mm Hwflv. Nmmm. mm oooo.a oooo. mm MNMH. Hmav.m mm HNNH. mvmm.m mm mmmm. NmHo. mm Hhmv. mev. mm oomm. mono. mm boom. mmam. mm hmmm. mHmH.H mm vmmm. hth.H mm mvmm. mmno.a mm hmmm. voao. mm moav. mmmm. mm oomo. mmva.m mm vmmm. mmaa. mm oumz meow CO.QME03 w sue woman 93:30.38 med: ashamed: w Bflmmo: mo “50 mofiwoum mo®Q_cso mxma .msflnuoHo .onmmm mmoofio 600m moofl IHHHDG mmooco .xooo .COHH .mmnuoHo smm31mm>awm now 9.80 B so: mnemoflmmn £08m. anyway osmse mogoum Emsmoum mummuo most/8m mumfio 00. 33 low 8 30: m Sop .Qfi macaw .3 omucoflomdp $5 5.9 Emnooum moam>mo msflnuoao s30 mmmfiUHsm 8 353mm How mmflguuommo oak/0.3 mxmmu dammed; muoe 9898s E 88988 maggot/HQ: endgame 3mg soamfirum Imam ”593d; £03838: 9:3 8 mucmoflmmn 5H2 m m mp coflomnmufi m m MC ”68an 88030.2 m m we uomflm pathways 6395/ UOSQHMCOUII.mN mqde 45 mamm. vaH. mm Nmmv. ommm. mm vhmm. mmmm. mm Hmvm. vmmv.H mm NHNH. mHmN.N mm hmmm. mmmo. mm mNNm. Hmmm. mm mmma. omHo.N mm mvmm. MNHH. mm HHhv. Hmmm. mm «omvo. mmom.v mm mmmm. mmma. mm «moao. ovmm.m mm mmmh. bmmo. mm mmmm. mmvm. mm whoa. NHNm.H mm ommo. Hmvo.m mm «mavo. anom.m mm mamm. NomH. mm ovuv. mmmh. mm vmmm. mane. mm taboo. mmmm.m mm oamm. mmmm. mm mmmo. vmvw.m mm hvmm. NNVH.H mm maaflxm memo mamm msflsommu How Houosuumcfl mo mach mxwa muonmmamu may msflumsmcm m HHME do msflxoflm mm £05m mxmmu CH muowoflmmu m>ao>cH mmoflpome Hmsuom Mo mpflmuoo mmmwm ocoam muMOHsoeeoo hausmswmum mEHOMAGS mo omoumcfl monuoao ummnum Hows usmsummnu ucmoflwmu usonm assets conmnomu Bantam mcflmmoam m mumcsflp .mmfl>oe I mmCHuso How mooum mQH Luanda ucwflumm m moam>mm méH>HH muHQQsEHo on cusumu ou msoum msfl Iscmam pcmoflmmn m moam>mo .Emzu mmommu no umooom on mofloso m>mn m Homemomam Hosnowuom pflmfl> on mucmoflmmu soaam mmmumcu HMUHmmbm m©fl>onm .m .m .mm coeuowumucH *mNoo. vomN.HH mm mmmm. mvmv.a mm mm .m .mm powwow Ht¢0flusnflnmcH .m .m .wm nommmm namaummns 6333,. omscsncooII.mm momma 46 maee. wmee. mm mmem. omom. mm mvev. meme. mm mumuumsw moH>HH mo moons Ham on muooo xUOHsD oHeo. mvmm.m mm mmma. memH.N mm moem. emma. mm cosumuuommcmuu moo Ho moo .Hflm>m waflommu mxmz Hmvm. Hove. mm maem. Hmmm. mm omom. NmNN.H mm meswofimmu en sun moan xomcm no muoum mofl>oum mmom. ommm.a mm mmmo. mmam.m mm ommm. mmem.a mm ozone mo mm: ou mmwoom mofl>oum Hmva. memo.m mm tommo. emmm.m mm Hmea. mvmm.a mm meoou mum>flua mofl>oum memH. omme.H mm mamm. mmem. mm mmvm. mmmv.a mm mossuwma mmmum Hmasomu m>mm mama. mmme.H mm Hmom. mvao. mm mmmm. «mao. mm pomeummuu ucmoflmmu co mocmsHMCH m.mmuoz memm. HmeH. mm mmom. evoe.H mm mmvm. Homo. mm usmsummuu unmoflmmu so cosmoamsfl m.uomH>Mmgsm Hmom. «mom. mm memo. Nmoo. mm mmev. mHee. mm unmeummuu usmpflmwu so moomoHMCH m.uouooo memo. omev. mm wmem. mmom. mm mmmm. mvem.H mm mEMHmonm unmeummuu Hmdpfl>flosfl swam mmmm. eemvé mm mmam. Hommé mm mema. movam mm euHcQEBO 9? CH mmfluu uCMECHmuumucm m maammosm so monopflmmu arse m. m wit m. m Mm m m Mm cowuomnmusH uommwm HMCOHusuflwmcH uomflm ugmmfi 339$ COUCHuCOUII.mN mqméfi 47 usuaummuu unwoflmmu so ammo. memm.m mm momH. momm.m mm eevv. Hmmm. mm mucosamsfl m.meHo3 Hwfloom doom. mmmm.a mm maae. Howa. mm «mmvo. mmvm.m mm pomsummuu ucmpflmmu . so 8533 m . ”2598.qu mmem. emHo.H mm mamm. momo. mm «mow. Hmvm. mm unusummnu ucooflmmu so mucosHMCH m.moflm m.mmuoz emme. mvmm. mm mvmm. mmoo. mm mmvm. mmHH.H mm mcflnuoao mosmno m mouse on dogs psonm ooflono unmoflmmu soaam memo. ammo. mm Hmem. mooo. mm mama. mmma.m mm mucwoflmwu mo eaco mcaumflmcoo Unmon msHCHm>om pomflumm mofl>oum mmem. memo. mm *mMHo. memo.e mm meme. mmmm. mm mCHMoE.QOHmHomp How Unwoa mcflsnm>om muomoflmmu mwmum m mofl>oum wmom. vmvm.H mm mmmm. veoo. mm eamm. mmmm. mm Muos_uomuucoo nmsonnw mocmflummxm xuosvmofl>oum ammo. mmme.m mm tamoo. mmme.HH mm somvo. momm.m mm mos was ommzm .UOOm m>uwm Oh so: mm £05m maaflxm mafimmmx Immoon mucmoflmmu mafisomma m m .wlt m m mm m m Mm odomaum> _:0fluomnmuCH noommm accosuouflumsH womwmm unmeummna . GODGHuCOUII.mN mammH 48 mmmm. mmmo.H mm vaH. memv.m mm vam. mmvH. mm mmvm. HNeH. mm mmoH. mmHv.m mm eomo. mmmm.m mm meom. emmm. mm oevm. mmvv. mm VHmm. ommm.H mm mvvo. eeHm.m mm mmmH. omme.H mm mem. ommo. mm mmmN. HmmH.H mm Hmmm. mooo. mm memo. Hme. mm mmeo. mmmm.m mm mmvm. mmmo. mm memm. Hmom. mm «emoo. vmmo.HH mm moNH. Hvem.m mm mmmo. memo.m mm MHeH. Homm.H mm emmm. HmmH.H mm mHmH. mmmm.H mm mmmm. mHmm. mm mmmm. moem. mm VMHw. movm. mm ammo. meee. mm mmoe. mmmm. mm meHv. mmom. mm @888“ 5 ”256395 m LdemHmfi Renata mCHCommu CH UCmEm>Ho>CH m_umHomuwCu HMCoHumosooo mCHCommu CH qu8 Im>Ho>CH m.menoz HMHoom mfifimfi CH 68.8395 .0. L838“ mCHCommp CH que Im>Ho>CH m.mon m.mmusz mCHzomop CH quem>Ho>CH m.mmusz mCHCommu CH pCmEm>Ho>CH m.uomH>Hmmom mCHCommu CH qusm>Ho>CH m.nopooo 22583 uCopHmmH Co mocmDHMCH m Lmafimfi Bowed “Cmaummuu ucmonmH Co mOCmusCH m.umHmmnmCu HMCOHummsooo m m .wm CoHpomumuCH m m MU 6.83m 850339: m m mm 66me sinuous 6333/ COUCHUCOUII.mN mqde 49 ummu eum>w MOM om mH Romeo How sooooum mo mmummo mayo 88; mo. no utmoflflsmnm t ommm. mmmv. mm VMOH. emev.m mm eHem. HmMH. mm Nmom. emmo. mm mHNv. mmmm. mm omHm. MHom. mm mmmo. mamm.m mm mHmN. HHmm.H mm vmmm. mmmm. mm memm. mmmm. mm «meHo. memv.m mm «movo. mmmm.v mm eeHv. mmem. mm memv. mmmm. mm memm. oooo. mm mmMH. mmmm.m mm Homm. ommm. mm moeH. momm.H. mm mHmm. mmom. mm vvmo. Hmmm.m mm mmvm. mmmm. mm mmmm. vmev. mm mmmm. momH. mm emmo. HHmm.N mm meoo. oemH.m mm mmmH. oeme.H mm mmHm. Hmmv. mm mCmNHuHo mm 383mg 438 $3.... mumxmsmsoc mm 38888 $38 33m 880“ mm $8688 $38 EBm mumxuosvmm meCmonmH msoHHm mmmum HmEDmCoo mm mUCmonmH meoHHm uwmum xownoomw m>HummoC ImH w mm>Hm mmmum x0388 gnawed lo“ a mm>Hm mmmum Mom Op #Cmuxm HUM OH Hcmfixm How OH ucwpxm not 8. ease you 8. pg mm>Hwo page mm>Hmo ncmnxm mmCHuomE um oommoomHo mum memaooum wmmum usmflfl quEummHu quUHmmH mmsomHU ow mooum m mm mmCHume mmmum mo namnxm m m .ud 530333 C m me 33.5 888.33an m C W nommmm 383889 8333/ GOSCHUCOUII.mN mqm¢H 50 The experimenter graphed the distribution of pre and post test scores as shown in Figures 1, 2, 3 and 4. Figures 1, 2 and 3 display a highly skewed distribution closely resembling a J- distribution. For testing the differences between nursing homes and hospitals, however, ten of sixty-five were found to be significantly different at less than the .05 level for the overall test. These ten variables were: (1) out of hospital follow-up, (2) visit potential placement facili— ties, (3) teach housekeeping skills, (4) staff-resident governing board, (5) private room provision, (6) wearing of street clothes by staff, (7) involvement of residents in mail pickup and telephone answering, (8) physical therapist's influence on resident treatment, (9) enhancement of resi- dent's role as a friend, and (10) enhancement of resident's role as a homemaker. Table 26 shows cell means for these variables. The table indicates that hospitals scored higher than nursing homes on variables 1, 2, 4, 6, 9, and 10, while nursing homes scored higher than hospitals on Variables 3, 5, and 8. Frequen 51 7 252 ///z Pre Scores [:1 Post Scores 215 200‘ 175‘ 150 ‘ 139 125 I 121 I 100 ‘ T 123122 75‘ 53 ‘ 32 22 r 0 1’ H.52t:i_ z 7 , l 2 3 4 5 6 Do Not Intend to Intend to Have Taken Presently Presently Intend to Make it. Make it. Action to Exist for Exist for Make it Exist Exist Make it Some Staff Nearly A11 Exist within within Exist Staff 6 Months 3 Months Figure l.--Pre and Post Scores for Initiation of Change on Environment. 7 300 1 [/A Pre Scores 275 [:1 Post Scores 250 J j I 225 4. 200 j 175 a 150 a ._ —.. 9 1.25 . _____1 i Z 3‘ 100 . ' / “-1.; It: 75 . ’/ so ‘ g . ' . A "'j J’ r? 25 _‘ l 0 x' r/ 0 /I i a J A “1.1%.; A . l 2 3 4 5 6 Do Not Intend to Intend to Have Taken Presently Presently Intend to Make it Make it Action to Available Available Make it Available Available Make it for Some for Nearly Available within within Available Residents All 6 Months 3 Months Residents Figure 2.~—Pre and Post Scores for Initiation of Change on Program. 52 % Pre Scores 200. 175‘ D POSt Scores 150 g 125 J 105 3 100‘ 80 g 75‘ 2 a. so / 25 1. 27 24 /'2 I 13 4 4 12 5 12 '2; 01 533 | ZZT—1 155F—1 £23 I ”/2 1 2 3 4 S Dorkm Inhamlto Inflafilto lflue‘finmm. Imesaufly lueasmiy Inflatito Mafiait Mduiit Actflllto Enhn:far Exnn:f6r Make it mist mist Make it Sans Staff Nearly All mist within within Exist Staff Gltmmhs 3Itrmhs Figure 3.--Pre and Post Scores for Initiation of Change on Staff Behavior. 7 300 I Pre Scores 275i ‘ 2550‘ 26723.53 E] Post Scores 225< y 219. 6‘ 200‘ ¢ 197 C ‘// 184 o 175‘ /// ,xi .—— g / V’J *4 125 -133 / 130 m 4 {*m A //< /. /" / 7,— 100 ‘ I 2" ¢. / 2 fl / ; ¢ :4 2:: so / ¢ «'3' 9:: ‘ / “i f. ” if/f’ 25‘ / /1 i . r“ , .- - / / 0 l L 1’ Vz‘ 1 3 4 5 None Little Some Quite A Great A Bit Deal Figure 4.--Pre and Post Scores for Initiation of Change of Behavior for Specific Levels of Staff and Patient Behavior. 53 «Hm.H oom.v e ems. omm.m m oae.H ooo.e m mem.H 004.4 m meats maozmmHmu s mmH.~ ooo.m e eH~.~ omm.e H HHms.:H namam>Ho>aH ooo.o ooo.m e eHm.~ omm.e m emm.m mme.v m mom.~ ooe.m m mem. emm.m e Neo.~ ome.m H mmtnoHo nmmnum Geo.~ mem.m e ooo.m ooo.m m emm.m mmH.e m mm~.~ ooo.m N autos aOHmHoma mmo.~ emm.m e eHm. ooo.m H namaHmmn mmmnm Hoe. om~.m m eHm.~ om~.e m Nmm.H ome.m m ewe. oom.H m mmm. ooo.m e mam.H ome.m H thammxmmaom Hmo.~ mmH.m s eem. omm.m m mam.H mNH.e m mem. ooe.m m mmm.H NHH.~ 4 com. ome.m H maoon mnm>Hua mHm. mem.m e mam.H omm.m m mmm. ooo.m m meH.~ oom.e m HHHHHUMH awe. eHe.m e HH~.~ omm.e H ntmemoaHe HtHnamnoe nHmH> omo.H ooo.m e ooo.m ooo.m m emm.H mem.v m mom.H oom.H m mssoHHow mean vmm. mmv.m w ooo.m ooo.m H mCHmHCC m HCUHQmoC mo #30 COHUMH>wQ COHuMH>mQ . [eumeamnm cams. HHmo eumsamum came. HHmo mHanHw> mHCUHmmom mmeom mCHmusz mmHomHHm>_quonHCmHm CmB mCu mo mCOHHMH>wQ pHCUCmnm pCm mCmmer.mm mammH 54 COHemoom mumHmEoo on COHumoom 0C scum mmom m OH H scam mmmCmn muoom « mm0.H 0me.m 0 4H4.H 000.4 0 4mm. me0.m m m4m. 000.N m 000. 04H.m 4 00m. ome.m H mememao: Ho mHom H00.H mm0.m 0 0N0.H 000.0 m ome. em4.m m 000.H 000.4 m sea. 000.4 4 H00. 00m.~ H mecmHne mo mHom 0H0. mem.m 0 mmm.H 000.4 m nameummnn 00H.H 005.~ m 400.4 004.0 N ncmaHmmn co mommaHHcH H00. 4He.H 4 0mm.H 000.4 H m.umHeanmsu Haonsam COHumH>mQ COHHMH>wQ enmacmnm cam: HHmo antacmum cams. HHmo mHBHdmom 88m mfimusz mHnaHHg oosCHuCOUII.mm mammH CHAPTER IV ASSOCIATIVE RESULTS It is now important to examine the data from two perSpectives: (1) degree of fit between the rationally determined dimensions and their experimental counterparts and (2) the degree of relationship between all areas of measurement in the study. Examining Empirical Dimensions from Rationally Selected Dimensions The preceding section presented experimental com- parisons on four selected variables. It is now important to discover whether or not these rationally created dimen- sions are empirically valid. The BCTRY cluster analysis program (Tryon and Bailey, 1970) was used to determine empirical domains within the following rationally chosen dimensions: (1) information dissemination, (2) formation of planning groups, (3) initiation of change in the environ- ment, (4) initiation of change in programs, (5) initiation of change in staff variables, (6) workshop effectiveness and perception of the innovation and (7) organizational variables. Information Dissemination The first dimension of interest was information dissemination. The cluster analysis on the variables in 55 56 this dimension generated three clusters as shown in Table 27. As seen in Table 28 these clusters appear to be relatively unrelated to one another. Cluster 1: (Little Difficulty in Presenting Infor- mation).--This cluster is comprised of items relating to overall difficulty in information presentation as well as specific areas of presentation difficulty including staff role, environmental and program information. 57 TABLE 27.--The Three Clusters on Information Dissemination Cluster Loading Cluster 1.--Litt1e Difficulty in Presenting Information 1. Less difficulty presenting information to other staff . .89 2. Less difficulty presenting staff informa- tion to other staff .84 3. Less difficulty presenting program infor- mation to other staff .70 4. Less difficulty presenting environmental information to other staff .51 Cluster 2.--Use of Training Material 1. Staff actually obtained training series .91 2. Staff ordered training series .75 3. Staff ordered films .73 4. Staff actually obtained films .52 5. Staff used films and filmstrips .44 6. Greater number of people received infor- mation .41 Cluster 3.—-Information Dissemination and Positive Staff Reaction 1. Positive staff reaction to program infor- mation .80 2. Positive staff reaction to physicial environment information .70 3. Positive staff reaction to staff informa- tion .62 4. Greater extent to which information discussed .55 5. Meeting called to disseminate information .43 58 TABLE 28. --Corre1ations Between Oblique Cluster Domains for Information Dissemination l 2 3 1. Little difficulty in presenting information -.16 .17 2. Use of training material -.16 .27 3. Information dissemination and positive staff reaction .17 .27 Cluster 2: (Use of Training Material).--The degree to which staff initiated efforts to use the training series and films is descriptive of this cluster. Two types of efforts are included in the cluster. The first is whether the staff wrote out that he had ordered the film or train- ing series and the second is a record from the Institute of Gerontology of actual purchase or rental of materials. In addition the variable greater number of people receiving information was included in the cluster. Cluster 3: (Information Dissemination and Positive Staff Reaction).--Staff's positive reaction to program, staff and environmental information along with the extent the infor- mation was discussed are descriptive of this cluster. When the information dissemination dimension is viewed from a cluster analytic perspective, three relative- ly unrelated dimensions emerge. Information dissemination 59 thus does not appear to be a unitary concept, but rather comprised of three separate dimensions. Planning Group Formation The planning group variables emerged as one cluster as shown in Table 29. This finding indicates that the activities of the planning group appear to be highly inter- related. TABLE 29.--The One Cluster on Planning Group Formation Cluster Loading Cluster 1.--Planning Group Staff Involvement and Decision Making 1. More different levels of staff involvement in decision making .98 2. Higher attendance in planning group .98 3. Existence of a planning group .98 4. Little turnover of staff in planning group .97 5. Lower mean staff position in planning group .94 6. More staff work together in same area .89 7. More staff meet informally .86 8. Staff meet more often .83 9. Longer planning group meetings .81 10. Lower staff position of the group leader .79 11. Many staff involved in planning group .62 60 Environmental Change One cluster emerged from the environmental change outcome variables. An examination of the items in the cluster shows that the cluster appears to be descriptive of the access to facilities and equipment that the residents have. Thus, it appears that the environmental variables have one major dimension relating to the availability of facilities and equipment to residents. TABLE 30.--The One Cluster on Environmental Change Outcome Variables Cluster Loading Cluster 1.--Residents Access to Facilities and Equipment 1. Provision of cooking facilities .80 2. Provision of sewing and mending equipment .66 3. Provision of grooming materials .50 4. Provision of laundry facilities .50 Program Change The cluster analysis of program change variables produced three relatively unrelated clusters. The variables in each cluster are shown in Table 31 and the relationship between cluster domains are shown in Table 32. 61 Cluster 1: (Crafts and Consumer Role for the Resident).--This cluster is comprised of the variable, availability of crafts program, and the variable, provi- sion for residents to purchase their own clothing. Cluster 2: (Self Help Programs).--This cluster is descriptive of variables relating to developing self help skills and independence. The provision of music therapy is also included in this variable. Perhaps music therapy can be thought of as a method to help residents work toward self help skills. Cluster 3: (Resident Decision Making).--A formal decision making body for residents and some power to make decisions on hygiene practices of self care are descriptive in this cluster. The program change variables, unlike the environ- mental variables which formed one cluster, form three relatively unrelated concepts. Thus in examining program variables in the future, the investigator may wish to consider studying programs in these three dimensions. 62 TABLE 31.--The Three Clusters on Program Change Outcome Variables Cluster Loading Cluster l.——Crafts and Consumer Role for the Resident 1. Provision crafts program .85 2. Provision for residents to purchase own clothing .81 Cluster 2.--Self Help Programs 1. More teaching of residents in self care skills .77 2. More plans for outings .67 3. More group planning in preparation to return to community living .65 4. More programs for the disoriented .58 5. Provision of music therapy .41 Cluster 3.--Resident Decision Making . Provision of staff-patient governing board .86 . High staff involvement in out of hospital follow-up -.64 3. More choice about bathing time and change of clothing .59 4. Provision of patient governing board .48 63 TABLE 32.—-Corre1ation Between Oblique Cluster Domains for Program Variables l 2 3 1. Crafts program and provision for resident consumer role .11 .14 2. Programs oriented for self help .11 .16 3. Resident decision making .14 .16 Staff Role Change Two clusters emerged from the cluster analysis on staff variables. Table 33 describes each cluster and Table 34 provides the cluster correlation matrix. Cluster 1. (Staff Decision Making on Resident Treatment).--Cluster 1 contains variables relating to staff decision making about resident treatment and staff involve- ment in resident teaching. Cluster 2. (Support Staff Involvement with Resident Treatment).--This cluster is descriptive of the involvement staff who are not housed on the ward have with residents. It is evident that these two dimensions have been determined by the social status of the staff who are involved in the treatment of the elderly, rather than being deter— mined by Specific types of resident roles available in their institutions. Table 30 shows that these two clusters are not related. 64 TABLE 33.--The Two Clusters on Staff Role Change Outcome Variables Cluster Loading Cluster 1.—-Staff Decision Making on Resident Treatment 1. Higher involvement of attendents in decisions about resident treatment .99 2. Higher involvement of aides in decisions about resident treatment .85 3. More shared decision making by staff .74 . More regular staff meetings held .71 5. Higher involvement of teaching role by attendent .70 6. Higher staff involvement in teaching basic skills .64 7. Higher staff involvement in planning individual treatment programs .60 8. More staff take residents on shOpping trips .52 . Higher involvement in teaching role by aide .58 10. Provision of worker role for residents .50 Cluster 2.--Support Staff Involvement with Residents 1. More staff wear street clothes .81 2. More influence on resident treatment by physical therapists -.78 3. More involvement of teaching role by social worker .65 4. More influence on resident treatment by occupational therapist -.55 5. More involvement in teaching role by physical therapist -.42 65 TABLE 34.--Corre1ation Between Oblique Cluster Domains for Staff Variables Staff decision making on resident treatment .09 Support staff involvement with residents .09 Workshop Effectiveness and Perception of Innovations The cluster analysis on workshop effectiveness and perception of innovation variables generated three clusters which appear to be fairly unrelated as shown in Table 36. The variables included in each cluster are listed in Table 35. Cluster 1: (Perception of Implementation Difficulty). --This cluster includes variables which are descriptive of the leader's perception of how difficult implementation of the innovation would be with respect to degree of rule change, role change, program change and amount of persuasion necessary to initiate change. Cluster 2: (Staff Roles and Program Agreement).-- This cluster includes variables of leader's personal agree- ment about the information presented on staff and programs at the workshOp. In addition the variable concerning the intent of ordering the training series is included. 66 Cluster 3. (New Program and Agreement on Physical Environment).--This cluster contains the variable on how descriptive of a new program the information presented at the workshop was and the leader's personal agreement about the information on physical environment. TABLE 35.--The Three Clusters on Workshop Effectiveness and Perception of Innovations Cluster Loading Cluster l.--Perception of Difficulty for Implementation 1. Leader perceives lower degree of rule change required .94 2. Leader perceives lower degree of diffi- culty in persuasion of staff to accept innovation .90 3. Leader perceives lower degree of role change required .90 4. Leader perceives lower degree of program change required .60 Cluster 2.--Staff Roles and Program Agreement 1. Plan to order training series .77 2. Higher personal agreement about programs .69 3. Higher personal agreement about staff roles .50 Cluster 3.——Descriptive of New Program and Agree on Physical Environment Information 1. More descriptive of a new program .68 2. More personal agreement about physical environment .63 67 TABLE 36.-—Correlation Between Oblique Cluster Domains for Workshop Effectiveness and Perception of Innovations l 2 3 l. Perception of difficulty for implementation -.10 -.15 2. Agreement about staff roles and programs -.10 .16 3. Descriptive of new program and agree on physical environment information -.15 .16 Organizational Variables The eight clusters obtained from the cluster analy- sis of organizational variables appear on Table 37. The clusters provide specific dimensions descriptive of the organization's staffing, residents and Operations. Cluster 1: (General Facility Meeting).--This cluster is descriptive of the general facility meeting with respect to the staff who attend and attendence. Also included in this cluster is the variable on leader's involvement with staff training. This cluster appears to be relatively un- correlated with other clusters with the exception of two clusters. Cluster 5, which is descriptive of funding and focus correlates -.35 with this cluster. Cluster 7 which includes variables on prior participation in institutes correlates —.31 with this cluster. 68 Cluster 2: (Area Staff Meeting).-—This cluster is descriptive of area staff meetings and staff involvement in program planning and direct services for residents. Although this cluster correlates .39 with cluster 8, which describes staff turnover, the correlation with the other clusters is negligible. Cluster 3: (Prior Participation in 5 Day WorkshOp). --Variab1es relating to the number of former workshOp par- ticipants are included in this cluster. A longer period of stay in the work area is also included in this cluster. This cluster is highly related to the cluster on prior 14-week institute participation and is otherwise unrelated with the other clusters. Cluster 4: (Resident's Stey, Facility's Existence, and New Programs).--Cluster 4 contains variables reflecting length of resident's stay, length of facility's existence and the existence of new programs. With the exception of a .33 correlation with cluster 8, staff turnover, it is fairly unrelated with the other clusters. Cluster 5: (Facility's Funding and Focus).—-This cluster describes the facility's goals with respect to release of residents, density of elderly in the facility and how the organization is funded. It appears that private- ly funded organizations relate with higher incidence of elderly and more focus in providing a permanent residence 69 for their occupants. This cluster is correlated -.34 with cluster 7, prior 14-week institute participation. Cluster 6: (Ambulatory Residents).--This cluster generally indicates incidence of ambulatory residents in the general facility and work area. This cluster is negligibly related with other clusters in this domain. Cluster 7: (Prior Participation in l4-Week Institutes).--This cluster describes the kind and the degree of participation of staff in previous institutes and de- scribes the training accumulated by the leader. This cluster is highly related with cluster 3, prior workshOp participation. Cluster 8: (Turnover of Staff).-—This cluster is descriptive of the degree of staff turnover. This cluster correlates .39 with cluster 2, area staff meeting, and .33 with cluster 4, resident's stay and new programs. 70 TABLE 37.--The Eight Clusters on Organizational Variables Cluster Loading Cluster 1.--General Facility Meeting 1. Higher staff attendance of general meetings .96 2. Lower mean staff position for those who attend the meetings .94 3. Existence of general facility meetings .71 4. More involvement in staff training by leader .43 Cluster 2.--Area Staff Meetings 1. Lower mean staff position of those who attend work area meetings .69 2. Existence of work area staff meetings .57 3. More involvement in program planning by leader .53 4. More involvement in direct service by leader .48 5. More staff involved in program planning .48 Cluster 3.--Prior Participation in 5—day Workshops 1. Lower mean staff position of those who attended previous 5-day workshops .97 2. Sent participants to prior 5-day workshOps .88 3. More staff participated in previous 5-day workshops .83 4. Longer period of stay in work area by staff .26 Cluster 4.—-Length of Resident's Stay and Program DevelOpment l. Longer resident stay in work area .93 2. Longer resident stay in total facility .82 3. Longer existence of total facility .82 4. Existence of new programs .61 5. Leader's involvement in the new program .53 71 TABLE 37.--Continued Cluster Loading Cluster 5:--Faci1ity's Funding and Focus 1. Privately funded facility -.77 2. State funded facility .77 3. Higher incidence of elderly in total facility -.63 4. More focus on release of residents in work area .58 5. More focus on release of residents in total facility .51 6. Higher incidence of elderly in work area -.32 Cluster 6:--Ambulatory Residents 1. Higher incidence of ambulatory residents in work area .87 2. Higher incidence of ambulatory residents in total facility .81 Cluster 7:--Prior Participation in l4-Week Institute 1. Lower mean staff position of those who attended previous 14-week institutes .92 2. Higher staff attendence of previous 14—week institutes .91 3. Sent participants to previous 14-week institutes .89 4. More long term training accululated by leader .44 Cluster 8:-—Turnover of Staff 1. Less staff turnover in work area .97 2. Less staff turnover in total facility .90 72 eH. mo. mo. mm. 4H. mm. mH. wmmum mo Hm>OCHCB .m eH. mm. 4m. mm. mm. mo.I Hm.I mmusuHumCH xmszvH CH COHummHOHuHmm HoHHm .e 40.- mm. 00. 0H. em. 4H.I 4N.I mnamaHmmm mnoansnss .0 mo. 4m. mo. oH. 4H. mo. mm.I msoom oCm mCHUCsm m.euHHHomm .m mm. mm. oH. oH. mo. mH.I mm.I quEmon>mo Emumoum on Noam m.quUHmmm mo CumCmH .4 4H. 00. em. 4H. 00. H0.I 4H.I mdosmxuos mmoum CH COHummHoHuHmm HoHHm .m mm. mo.I 4H.I 00. mH.I e0.I 00. mmcHumms Hmmnm mama .m 0H. Hm.- 4H.- mm.I HN.I 4H.- 00. 0cHHmms mHHHHomm Hmsmcmo .H m e m m 4 m m H meQMHHm> HMCOHumNHCmmHO How mCHmEoo HmHmCHU msvHHQO ComBHmm COHHMH®HHOOII.mm mqmme 73 Relationships Between Empirically Determined Dimensions All variables which obtained a .40 loading or more with the cluster and variables which were labeled definers from the previous cluster analyses (Tryon and Bailey, 1970) were included in the final cluster analysis. This final cluster analysis produced nine clusters (Table 39). Cluster 1. (Planning Group Outcome Measures) The variables in this cluster are concerned with describing the planning group members and process. This cluster's relationship was negligible with other clusters with the exception of cluster 5 which is concerned with staff's teaching role. Cluster 2. (Staff Involvement in Patient Treatment Decisions Outcome Measures) This cluster is concerned with the staff's involve- ment in decision making about patient treatment. This cluster reveals that there appears to be a high relation- ship between high involvement of lower social status staff in resident treatment decisions and high shared decision making and more regularly held meetings. This cluster is highly related to cluster 5, staff involvement in teaching role. 74 Cluster 3. (Organization Vari- ables and Environmental Outcome Measures) Cluster 3 reveals a high relationship between organ- izational variables such as long term resident stay in the facility, longer existence of the facility and existence of new program with some environmental outcome variables. This cluster relates negatively with cluster 9 which involves implementation difficulty. The negative relation- ship is interpreted as organizations with long term resi- dents, longer period of existence and new programs perceive it difficult to implement the innovation. Cluster 4. (Perception of the Innovation and Program-Staff Outcome Measures) As in the previous cluster analysis items involving the leader's perception of the innovation remain highly related. The present cluster dimension now includes program and staff outcome measures with fairly high relationship to the perception of innovation items. Cluster 5. (Staff Involvement in Teaching, Resident Treat- ment and Training Outcome Measures) Items in this cluster relate to staff matters. They include staff involvement in teaching, involvement in resi— dent treatment and long term training. This cluster is relatively highly related to the other cluster involving staff decision making, cluster 2. 75 Cluster 6. (State Hospitals and Staff-Program Outcome Measures) This cluster appears to be descriptive of a state supported hospital with high staff involvement in out of hospital follow-up and social worker involvement in decision making and lesser existence of a staff patient governing board. This cluster is negatively related to cluster 7, general facility meeting. Cluster 7. (General Facility Meeting) This cluster describes the members and attendence of general facility meetings. This cluster is negligibly correlated to other clusters with the exception of cluster 6, which is descriptive of state hospitals. Cluster 8. (Prior Contact with the Institute of Gerontology Training) This cluster is descriptive of the staff's previous contact with the institute's training programs. The rela- tionship between this cluster and other clusters are negligible. This finding indicates that there is little relationship between prior training given by the institute and outcome measures of adoption. 76 Cluster 9. (Implementation Difficulty) Items in this cluster relate to the leader's perception of why actual implementation of programs and environmental changes were difficult. This cluster differs with the cluster involving leader's perception of the innovation in that the leader's perception was obtained before the leader ever tried to implement the innovation and the implementation difficulty measure was obtained in the follow-up. This cluster relates negatively with cluster 3, which is concerned with long term residents, long existence of facility, existence of new programs and some environmental outcome variables. The clusters produced from all of the empirically determined dimensions reveal several pertinent relationships and non-relationships. First of all with the exception of the planning group items which remained as one dimension, outcome measures on the environment, programs, and staff were distributed over several dimensions. This result shows the Specificity of the environment, program and staff out- come measures. Thus implementation of one aspect of the program does not imply that other features of the program would be adopted. Secondly, the analysis provided information about relationships between certain organizational variables and some outcome measures. For example, cluster 3 shows that 77 organizational variables such as length of resident stay, length of facility's existence, existence of new program relates to outcome measures such a less likely to provide for a small dormitory, provide for sewing and mending equipment, and intent to order the training series. Cluster 6, another example, provided information showing the relationship between state hospital variables and certain program and staff variables. Thirdly, the intercorrelations between clusters clearly shows that there is little relationship between outcome measures and the prior experience of training at the institute. Thus although prior training was rationally thought to be influential on the outcome measures, this though was not empirically validated. 78 TABLE 39.-~The Nine Clusters in the Implementation Study Cluster Loading Cluster l.--P1anning Group Outcome Measures 1. High staff attendence in planning group meetings .98 2. Lower turnover of staff in planning group .98 3. Lower mean staff position in planning group .96 4. Planning group meets informally .85 5. Lower staff position of the group leader .83 6. Longer planning group meetings .83 7. More staff involved in planning group .63 8. Positive staff reaction to program information .41 Cluster 2.——Staff Involvement in Patient Treatment Outcome Measures 1. High involvement of attendents in resident treatment decisions .99 2. High involvement of aide in resident treatment decision .98 3. High staff shared decision making .65 4. More regular meetings held .63 5. High resident involvement worker role .53 6. High staff involvement in taking residents on shopping trips .49 79 TABLE 39.--Continued Cluster Loading Cluster 3.--Organizationa1 Measures and Environmental Outcome Measures . Provision of a small dorm (outcome) -.55 2. Provision of sewing and mending equipment (outcome) .54 3. Plan to order training series (outcome) .50 4. Longer resident stay in work area .92 5. Longer resident stay in total facility .82 6. Longer existence of facility .79 7. Existence of new programs .65 8. Higher personal agreement about programs by the leader .52 Cluster 4.--Perception of the Innovation and Program-Staff Outcome Measures 1. Higher staff involvement in teaching basic skills (outcome) .69 2. Higher staff involvement in planning individual treatment programs (outcome) .66 3. Provision of grooming materials (outcome) .66 4. Higher resident autonomy about bathing and change of clothing (outcome) .58 5. Leader perceives lower degree of rule change required .93 6. Leader perceives lower degree of persuasion required .92 7. Leader perceives lower degree of role change required .87 8. Leader perceives lower degree of program change required .58 9. Higher agreement on effectiveness of workshop presentation -.45 10. Higher incidence of ambulatory residents in total facility .37 80 TABLE 39.--Continued Cluster Loading Cluster 5.--Staff Involvement in Teaching, Resident Treatment and Training Outcome Measures 1. Higher attendent involvement in teaching role .96 2. Higher nurse involvement in teaching role .71 3. Higher degree of long term training of leader .49 4. Higher social worker involvement in decisions about resident treatment .37 Cluster 6.--State Hospitals and Staff-Program Outcome Measures 1. Higher staff involvement in out of hospital follow-up (outcome) .74 2. Higher social worker involvement in decisions about resident treatment (outcome) .60 3. Existence of a staff patient governing board -.33 4. Privately funded facility -.88 5. State funded facility .88 Cluster 7.--General Facility Meeting 1. Lower mean staff position of those who attend general facility meetings .93 2. Higher staff attendence of general meetings .86 3. Existence of general facility meetings .77 81 TABLE 39.--Continued Cluster Loading Cluster 8.--Prior Contact with Institute of Gerontology Training 1. Higher staff attendence of previous 5-day workshOps .99 2. Higher staff attendence of previous 14-week institutes .77 3. Lower mean staff position of those who attended previous 14-week institute .72 4. Lower mean staff position of those who attended previous 5—day workshops .69 Cluster 9.--Implementation Difficulty 1. Higher degree of difficulty to implement programs because of state regulations .86 2. Higher degree of diffuculty to implement environmental change because of state regulations .85 3. Higher degree of diffuculty to implement programs because of lack of funds .78 82 0H.- 0H. 00.: 00.- 00. 04.- 00.: 0H.- mHHsoHHHHo aoHnmucmsdesH MH.I VH.I om. Hm.l mo. eH. mm.I eo.I mCHCHMHB emoHouConmo mo quuHumCH mcu CuHB uomuCou HOHHm 0H. 4H.- 04.- 00. 0H.- 4H.- 00.- eo.I mmaHumms HHHHHomm Hmnmcmu mm.I om.I mv.l mo.I mH. mo. mo.I Ho. mo.I Hm.l mo. mm.I om. mo. Hm. mm. mo. mo. eH.I mH. om. mo. mm. mm. mv.I «H.I vH.I mo. mo. mo. mH. mm. mo.I mm.I mo.I Hm. mm. mH. mm. OH.I eo.I eo.I oo. mm. mm. mm. mm. mmusmmoz mEoouso Emmmoum Immmum w HmuHmmom mumum mmusmmmz mEoouCO mCHCHmHB m quE lummHB quUHmom .mCHComoa CH quEm>Ho>CH wwmum monsmmmz mEoouCo meumIEmnmoum on CoHum> IOCCH map Ho COHpmmoumm mmusmmmz mEoo Iuoo HmquECOHH>Cm oCm mmHQmHHm> HMCoHumNHCmmHO mmusmmmz mEoouCO mConHo loo quEummHB quHumm CH quEm>Ho>CH mmmum mmusmmmz mEoopCo QCOHU mCHCCMHm modem CoHumquEmHQEH map How mCHmEOQ HmumCHo msvHHQO Comsumm COHumHDHHOUII.ov mqmde CHAPTER V DISCUSSION The results of the tests of the experimental hypoth- eses and the relationships between the dimensions involved in the implementation of the innovation will be discussed in this chapter. In addition the limitations of the study and the implications for future research will be examined. Experimental Hypotheses The three major areas of implementation which experi- mental hypotheses were tested include: (1) information dis- semination, (2) formation of planning groups and (3) the degree of actual initiation of change. Table 2 showed that there were no significant differences between treatment groups with regard to the number of staff receiving the information. Thus the number of peOple receiving the information is not significantly affected by the number of staff who received telephone con- sultations over a period of time. The additional tests on whether the treatment affected use of various methods of information dissemination showed that telephone con- sultations did not affect the use of the various techniques for information dissemination. Although conversation as a method of information dissemination was found to be 83 84 significantly affected by the treatment, it was only one significant test out of seven tests which does not provide for an overall test of significance at the .05 level (Sakoda ep 21., 1954). The second hypothesis concerned the formation of planning groups. A chi-square test on the formation of planning groups did not reach the .05 level of significance, However, a median test of the number of staff involved in the planning groups showed that there was a significant (p<.01) difference between treatment groups (Table 10). This result suggests that continuous contact with these staff members in the organization increases the number of people involved in planning groups. An examination of the data in Table 10 indicates that there appears to be little difference between the no contact group and the one contact group, but the difference lies between the three person contact situation and the other two groups. There were no significant differences between treatment groups on mean social status of staff in the planning group, the frequency of meetings, the length of meetings, attendence, turnover, participatory decision making, number of staff levels in the group and informal meetings. Table 12 shows that the analysis of variance on the leader's social status reached the significance level of .05 for the treatment effect. Examination of the data shows that the three person contact 85 treatment condition had more leaders of lower social status than the no person contact and one person contact treatment conditions. Furthermore, the one person contact treatment condition had more staff of a higher social status than the other two groups. This finding suggests that contacting more staff increases and supports the active participation of lower level staff members in leadership roles and that perhaps contacting of one staff enhances containing leader- ship at the higher social status level. The chi-square test on whether there was any difference with regard to staff working in the same area indicated a significant difference between the treatment conditions. Table 19 shows that the three person contact situation drew members from other work areas for their planning group more than in the other two treatment conditions. These three significant results out of the twelve tests run on planning group outcome variables gives an overall significance at the .05 level according to the table provided by Sakoda and his colleagues (1954). Although Table 18 shows that there I was a significant difference between institutions on the number of staff levels involved in the planning, this must be interpreted cautiously since only one out of the twelve tests does not reach .05 significance level for a series of independent tests. 86 A third hypothesis concerned the degree of actual change. The analyses of covariance to determine whether there were any significant differences between treatments as shown in Table 21 indicate that there were no significant differences between treatments for the overall test for significance. This suggests that the treatment of telephone consultations was not powerful enough to create changes although the treatment contributed to the increase in membership in the planning groups, lower social status members involved as leaders, and involvement of staff from different work areas in the planning groups. Perhaps a more direct and personal type of contact such as face-to- face site visits may be more effective in initiating complex changes. The length of time allowed before follow-up data was collected may also have influenced this result. It is possible that change could occur at some later time and the formation of planning groups could be a step toward actual initiation of change. Another possible reason for the lack of treatment effects on actual initiation of change may be attributed to the distribution of the change scores. As seen in Appendix I, many variables appear to have either a high frequency on the upper part of the scale or a high frequency on the lower part of the scale, thus producing a ceiling and/or a basement effect for change. Figures 1, 2 and 3 show show a J distri- bution with a high frequency on total adoption anda somewhat 87 high frequency on no change to be initiated. The organ- izations in the study may have already adopted many of the items of change and thus created a ceiling effect for change. This finding suggests that perhaps the training should be limited to organizations who have not already adopted major portions of the program. Complexity of the innovation may be a vital factor influencing adoption as some studies have implied. For example an implementation study involving consumer environ- mental social action found that adoption of practices which were not complex, such as placing a brick in the toilet, was significantly influenced by newsletters and telephonic prods (Lounsbury, 1973). This present study involves adoption of practices requiring role change and some change in organ- izational structure. The more complex nature of this inno- vation in comparison to the environmental action study may have been a factor in determining why telephonic consultation did not create change in the health organizations, while telephone prods with newsletters affected change in consumer behavior. A more complex innovation in contrast to the two preceding examples is the adoption of a community living program which requires considerable staff and organizational changes. The complex changes in roles and organizational structure probably influenced the high frequency of organ- izations showing the lack of initiation toward adOption. (Fairweather e; 31., 1973). With respect to the distribution 88 regarding social change, the Fairweather study (1973) showed an adoption distribution similar to the J-distribution where there was a high frequency of no adopters and a small population of complete adopters. In contrast, this parti- cular study's results displayed a J-distribution completely the opposite of the Fairweather distribution, with a high frequency of complete adOpters and a smaller frequency of non-adOpters. It is interesting to note that as Figures 1, 2 and 3 indicate the J-distribution was consistent for the environmental, staff and program change items. Table 21 shows that there was a significant differ- ence between nursing homes and hospitals. The nursing homes and hospitals varied in degree of implementation for the ten significant variables. The cell means for nursing homes and hospitals as shown in Table 22 indicate that these ten variables appear to be distinguishing variables for the two types of organizations. Out of hospital follow-up, visits to potential placements, housekeeping duties, staff's use of street clothes, and the resident's opportunities to take the role of a friend and homemaker appear to be more prevalent in hospitals than nursing homes. The cell means indicate that nursing homes have more private rooms, staff resident decision boards, involvement of residents in mail and telephone tasks and involvement of physical therapists in resident treatment. This difference appears to be 89 descriptive of different organizational patterns in these two treatment institutions. These results suggest that training should be planned with consideration to these differences. Overview of the Cluster Dimensions The information dissemination variables formed into three relatively uncorrelated clusters. The degree of difficulty for information presentation, the use of training material and the extent of information dissemination and staff reaction to the information were three separate di- mensions (Table 23). This finding suggests that research- ers need to recognize these dimensions as separate factors when examining information dissemination in future studies. The high degree of relationships between all planning items, by contrast, indicate that the planning group variables form one dimension (Table 29). The change variables produced several clusters. The environmental variables as seen in Table 30, have formed one cluster tapping the common underlying dimension, access to equipment and materials. The three clusters produced from program change variables are fairly uncorrelated. The three clusters are descriptive of (1) crafts and role of consumer, (2) self help programs and (3) resident decision making. Although, the cluster involving crafts and role of consumer 90 may be questionable as to its interpretation because it contains only two variables, the two other clusters appear to have drawn variables which can be rationally named. The staff role variables produced two rational dimensions. Cluster 1 appears to measure staff decision making for resident treatment, and cluster 2 is descriptive of the involvement of staff who are not necessarily officed on the ward, in resident treatment decisions. These empiri- cally created clusters provides dimensions which can be looked at in future studies involving initiation of change in hOSpitals and nursing home programs. The clusters generated from workshop effectiveness and perception of innovations are fairly uncorrelated. All four variables which dealt with perception of innovations fell into one cluster. This implies that the items of rule, role and program change and persuasion belong in one dimen- sion. The agreement of staff roles and programs and the intent to order the training series formed one cluster, whereas agreement on physical environment and the item descriptive of a new program fell into a separate cluster. This may indicate that the physical environment aSpect of the innovation is the basic factor which made the program appear innovative to participants. The organizational variables formed eight clusters. Of these eight clusters a few had fairly high relationships. 91 Although prior participation in 5-day workshops and insti- tutes formed two separate clusters they were correlated .67 which shows a relatively high degree of relationship between them. Other dimensions include general facility meetings, area meetings, length of resident's stay and program devel- Opment, funding and focus, ambulatory residents and staff turnover. Final Cluster Analysis for All Empirical Dimensions In order to obtain an overall picture of the rela- tionships between all the empirically created clusters, a final cluster analysis on variables selected as definers of a cluster by the cluster analysis program and all variables with a loading of at least .40 were included in the final cluster analysis. This analysis produced nine dimensions which includes: (1) planning group outcome measures, (2) Staff involvement in patient treatment decision outcome measures, (3) organizational variables and environmental outcome measures, (4) perception of the innovation and program-staff outcome measures, (5) staff involvement in teaching, resident treatment and training outcome measures, (6) state hospitals and staff-program outcome measures, (7) general facility meetings, (8) prior contact with the Institute of Gerontology training and (9) implementation difficulty. 92 The final cluster analysis on all the empirically created dimensions provided some important relationships and lack of relationships. The first cluster, planning group outcome measures, showed that planning group variables belonged in one dimension. In addition examination of the relationship between the planning group cluster and clusters containing outcome measures show a weak relationship. This finding raises some questions if the formation of planning groups is considered to be an important part of the process before adoption of an innovation takes place. Perhaps, as it is later suggested, a further experiment should be con- ducted to examine whether planning groups that had formed led in any significant way to the adoption of this innova- tion even though the time lapse before the follow—up for this study may have been too brief. The diffusion of the outcome measure involving staff, program and environment into several clusters shows that outcome items concerning these dimensions are quite inde- pendent of one another. Thus caution needs to be taken when assessing adoption of innovations as the adoption of one aspect of the innovation does not necessarily imply that all aspects retionally related to the innovation will be adopted. The high relationship between items of perception of innovation suggests that they belong in one dimension. The items in that cluster (Table 37) indicate that certain staff and program outcome measures relate to the perception 93 that adoption of the innovation would not cause need for drastic changes in the organization. It is important to note also that this perception of how difficult the innovation would be to adopt is not highly related to the formation of planning or to the actual difficulty encounter- ed when the adoption of the innovation was attempted. Perhaps the initial impression of the degree to which an innovation may be difficult to implement is not reflective of whether planning groups are formed or the degree of difficulty in implementation when it is actually attempted. Finally prior training from the institute was not related to either planning group outcome or clusters con— taining other outcome measures. It seems that prior train- ing thus has little influence over actual adoption or initiation toward adOption. Limitations The limitations of this study are numerous. Finan- cial factors placed constraints on the nature of the treat- ment. The telephone consultations were limited to five instead of the originally planned six calls. The follow-up information was retrieved through a questionnaire mailout rather than telephone interviews or a site visit for economi- cal reasons, although the latter two methods may have pro- vided more accurate and comprehensive information. The funds also limited the number of organizations which were involved in the study. 94 The lack of administrative control over the par- ticipants contributed to the limitation of the study. The experimenter could not require commitment from participants who came to the workshops in order to eliminate passive observers. Also the type of workshop conducted could not be determined by the experimenter. The demonstration model with active participation of staff in actual work situation would have been preferred over the lecture model. The number of staff and the kind of staff who attended the workshOp could not be controlled also. Thus there is no comparability over the type and number of staff who attended the workshop. There were some difficulties concerning the treatment. First, although the treatment required consultations once every two weeks, maintenance of that frequency was difficult as staff took vacations and leaves during the summer and early fall, besides being called away to meetings. A sugges- tion for future attempts of telephonic consultations is that consultations be conducted after the vacation period. With the exception of two organizations, cooperation from staff to accept telephone consultations was possible, although reception to consultations on the fourth and fifth time ranged from enthusiastic to slightly hostile for being called. The two cases where treatment was difficult or impossible were in nursing homes. In one case the Mother Superior of 95 the house refused to allow names to be released for the three staff consultation treatment. This organization was eliminated from the study. The second example involved a leader who was hesitant in giving out names for fear that staff could not handle outside input into the organization. It is important to recognize that the findings of this study are generalizable to volunteers only. The subjects volunteered first of all to come to the workshop and then those in the treatment conditions permitted the telephone consultations to continue. Implications for Future Research The results of this study have several different implications. A previous study of organizational change revealed that the use of action change agents led to organ- izational change which followed the process of information dissemination, formation of active planning groups and adOption (Fairweather e; 31., 1973). This particular study found that continuous, active telephonic advocacy created the involvement of more members in the planning groups with lower social status members taking active leadership roles and more involvement of staff from different work areas for planning. But initiation of change was BEE significantly different between the treatment groups. 96 The finding that telephonic contacts to more than one person creates planning group involvement has direct applicability in terms of providing an effective mechanism to actuate one essential link in the change process. The no treatment effect for change needs further study. In spite of the skewed distribution of pre and post scores, the degree of change created after the time of the follow— up may need to be examined in order to discuss the degree to which planning groups actuated change over a longer period of time. If no difference is found in the degree of actual change, then it is clear that initiation of change requires a stronger advocacy than this experiment attempted to test. Perhaps more action orientation and more personal contacts or another change agentry method such as economic contin- gencies need to be examined. The significant differences found between nursing homes and hospitals in actual initiation of change suggest the need to examine the nature of the organizations which will utilize the innovation being advocated. For the items which differentiate the organizations, the change agent may want to tailor his consultation to meet these differ- ences. For example, follow—up information may be in- apprOpriate to get from nursing homes and should be elimin- ated from the presentation. 97 Finally the results of this study further confirms the need to create and test new change agentry methods to provide for a humanitarian mechanism of social change. The limited effectiveness of the telephonic advocacy clearly calls for testing of new models for change on the dimensions of intensity of change agentry and target organization interaction, degree of action orientation, and frequency of contact. APPENDICES 98 APPENDIX A PARTICIPANT INTERACTION 99 Appendix A Name Name of Facility Participant Interaction These questions will help determine how closely you work with the other participants in your hospital or nursing hone who have cone with you to this workshop. 1. Do you work with any of the staff who are here at the workshop? . yes no If no, list names of the staff here who do not work with you. 2. Do you work in the sane wards with the staff who are here with you? yes no If no, list names of the staff here who do not work with you on the same ward. If you work on separate wards , do you exchange or share staff between your wards? yes no If yes, list the nanes of the staff you share or exchange staff with. 3. Do you work in entirely separate buildings with the staff who are with you here at the workshop? yes no If yes, list the names of the staff who are located in separate buildings. 4. Do you and staff here with you work with the same patients or residents? yes no If no, list the names of the staff who do not work with the same residents or patients you work with. 100 5. Do you attend the sane staff meetings with the staff who are with you at the workshop? yes no If yes, list nanes of staff who attend the sane meetings with you and how often you attend the neetings. Name How often nesting held 101 APPENDIX B DESCRIPTION OF SETTING 102 Name ' Staff Position Phone {umber (work) Area Code Name of Facility Description of Setting Please complete each of the items as best as you can. Thank you. 103 l. 2. 3.b. 4.a. 4.b. 5. what type of setting is ysur facility situated in? (check one) a. Urban b. Suburban c. Rural How long has your facility been in existence? (check one) . 0-9 years . l0-l9 years . 20-29 years . 30-39 years . 40-49 years . 50 years or more ||||| mm 9.0 0'9! What percentage of the patients in your facility are composed of the elderly? (50 years and older) (check one) a. 0-25% b. 26-50% c. 5l-7S% d. 73-]003 What percentage of the patients you work with are composed of the elderly? (50 years and older) (check one) a. 0-25% b. 26-53% c. 51-75% d. 76-l00% What percentage of the elderly in your facility are ambulatory? (check one) a. 0-25% b. 26-53% C. 5l-75% d. 76-100% What percentage of the elderly you work with are ambulatory? (check one) a. 0-25% b. 26-50% c. 5l-7S% d. 76-100% If you are from a nursing home what type of care are you involved with? (check one) a. basic care b. skilled care c. both 104 Page -2- 6.a. What is the general focus for the elderly in your facility (entire home or hospital)? (check one) a. eventual release to return into the community. b. providing a place to live throughout their lives. c. both a and b 6.b. What is the general focus with the elderly that you work with? (check one) a. eventual release to return into the community. b. providing a place to live throughout their lives. c. both a and b 7.a. What is the approximate average stay of the elderly in your total facility (entire home or hospital)? (check one) a. less than one year b. l - 5 years c. 6 - l0 years d. more than l0 years 7.b. what is the approximate average stay of the elderly that you work with? (check one) a. less than one year b. l - 5 years c. 6 - 10 years d. more than l0 years 8. List the specialist and consultant types of staff resources (ex. social worker, psychiatrist, music therapist, etc.) that are available to the elderly you work with and the percentage of their work time that they spend working with the elderly. Staff Resources % of Work Time Spent 9.a. Has there been any great turnover of staff for the elderly in your total facility (entire hospital or home) in the last two years? (check one) . a great deal . quite a bit . some . a little . nothing IQIQ‘O'OJDJ 105 Page -3- 9.b. l0.a. 10.b. Has there been any great turnover of staff for the elderly that you work with in the last two years? (check one) . a great deal . quite a bit . some ___. a little . nothing lll' (DD-DUO! Do you have general staff meetings for the whole facility (entire hospital or entire home)? (check one) Yes no If yes, how often do you have them? (check one) a. once a week b. once a month c. once a year (Indicate d. other how often) Hho attends the general meetings? (check all appropriate members) . psychiatrists . psychologists . nurses' aides . attendants . nursing supervisor . social worker . medical doctors .physical therapist Please list any ot'1er staff members wio attend the meetings. kiilflifi|mlflifi ID“ DJ Do you have staff meetings in your own area (ward, entire hospital only if you work with patients in entire hosoital)? (check one) Yes No If yes, how often do you have them? (check one) a. once a week b. once a month :c. once a year (Indicate :d. other how often) 106 Page -4- ll. 12. l3. 14. Who attends your area ( ward, entire hospital if you work with patients in entire hospital)‘meetings? (check all appropriate members) . psychiatrists . psychologists . nurses' aides . attendants . nursing supervisor physical therapist social worker h. medical doctor Please list any other staff members who attend the meetings. DJ OIU‘ m‘m‘o. L To what extent is your work involved with staff training? (check one) DJ . complete involvement . moderate involvement . some involvement . little involvement . no involvement L7 who provides most of your funding to run the facility? (check all appropriate categories) a. federal government b. state government c. local government d. individaul residents/patients e. other (please indicate) l Hho usually does the planning and deciding on new treatment programs (plans to enhance the social, physiological and mental being of the residents) for the elderly you work with? (list the staff-positions of those involved) In the past 2 years have there been new programs for the elderly you work with? (check one) Yes No If yes, briefly describe it (them): 107 Page -5- 15. 16. 17. 18. 19. Are you currently involved in this new program(s)? Yes Nb Please enclose a written description of the program if it is available. To what extent is your work involved with planning of programs for patients/ residents? (check one) complete involvement . moderate involvement . some involvement . little involvement . no involvement leJnLrlm Did any other person from your facility (entire hospital or home) attend a 5-day workshop in milieu therapy at the Institute of Gerontology at Ypsilanti State Hospital? (check one) Yes No If yes, list their positions and how many of them attended. Position Number Attended Did any other person from your facility attend the l4 week institute in milieu therapy at the Institute of Gerontology at Ypsilanti State Hospital? (check one) Yes No If yes, list their positions and how many attended. Position Number Attended How did you learn about the milieu therapy program at the Institute of Gerontblogy? (check as many as applicable) . journals or newsletters . conferences . staff in your facility . staff from another facility . former workshop or institute participant . other (Indicate how) l-bItDIOJOIUJQ} Have you visited a setting where milieu therapy with the elderly was in operation? (check one) Yes No If yes, where was it? .108 Page ~6- 20. 21. 22. 23. 24. 25. 27. Please list the types of training you have had in health care or work with the elderly? Also please list all the short term types of training you have had from workshops, institutes, etc. To what extent is your work involved in administrative tasks? 0.! CT O O. (D (check one) complete involvement . moderate involvement some involvement . little involvement no involvement To what extent is your work involved in providing direct services or health care to the elderly? O'UJD' Q. (D (check one) . complete involvement moderate involvement some involvement . little involvement . no involvement To what extent is your work involved with planning the physical environment (ordering equipment for leisure time activities, arranging furniture, etc) for the elderly you work with? C. (b How many years have you _._‘ How many years have you How many years have you (check one) . complete involvement . moderate involvement . some involvement little involvement no involvement been working at this facility (hospital or home)? held your present position at this facility? worked with the elderly? (50 years and older) Hhat would you particularly like to learn from the 5 day training program? 109 APPENDIX C PHYSICAL ENVIRONMENT AND RESOURCES, PROGRAMING, STAFF AND PATIENT ROLES 110 lJLl coo; :w 2:onc wrs:_eq ‘ J.“ ,WweDCMLS, 2: c t h2m$::m_:zw gfiumm.;u .xw-ar m meager « ,...F..w".wn..t Phi/HT.» ernyw... Upfméwmxfiq mucofiwmwm mucm—memd a. a.“ mpeepmese mprc__es. um ewe: scam Lot __< to» fLHJ. 1 in“ a... ._..4 WP rwl... Cw CCFHUc. n.w...r.r.P@>< “Fae—wd>.€ ..a.wn» > COme ya. ;» .I ear” cu ucowr» zmgfie u>cz >,.:e-vea ”a a ...MHCO,'.._MO.~ ”.11er LG» UFLflFwJ>m >_.u:0mm¢~f.: 1.”..-......... v2.3... .11. 1 Hun we m...“ Cr A \. V 4.3.1; 29m...) c MUG”? .1.” T... 4L0: 30> «Sequdmw»\wuunhfler can) we u:0c Low .H_mpr.>c men mucosa muo>wco mm ”m4afidxm .USmu? an“ we >=m “$20 was on mmmmpa .\:. _s we oc_ucm ecu :? Jew: so: m_ 050: go Pouwcmo; mewucm ms» o» memwwe lea; .th yen; nwpmzuue 3o> :u_:> cw mega man to» seoooumu mucwccogccm mg» Lava: gem: eupgu mco muo_o mucmEouaum mnu eo sumo Lou .mxw— ewes» new mason ocwmcac .mpm», woe may; go emuwuuecc new muwumweouumemsu ms» 0» meug mucmEmumum ccPEo—pow as» euw_wuma nlmsmz 112 I I l I 5l111- I 5 5 “III 1 5. 11111.. 115 11 l 11. I11 . P w P P . IIIII. a 5 III . I . 5 - .I 5 ..5III 15. . ..IIIIF. P. ..I 55 .II 5I... II II. ., I .5, 5 I. 1.. . 151. I 1 M AMY m ”X. ,I..4 ‘5 m—.5L! PP“ PP.“ VLF“? 1.... .|\.P . P P r1111 .1 151111 1 G 1 1. 1 5o 1 I I1 |1l .-1111~ IT11I?1I1!1 11.... 5 .1 .1 5 .. . 5 .. ...l1 :1 110.1111 . 5 11|1l . . I _ :c.1,.ecoucmLP ma; Lo Lee QPch-PJ>m >PP.P4 CDL ..Pccb ...UGCm LO QLCPW ..1.51.111 11.. ..+.. 11.1.. P I . . . 11! 11 I l . 1 1.1 1 T1. .1111 l .+ 11111.11 II I 5 I, 55 1551 I. a. I 1111 .I111 II 5 II 55111- . oco.:c »o c.: cP mma.u& 1-11.1.1: 511 ,1I11115lnlo. I . .5 .. .1 I .I ll I .551 111115-1111ll5.+1l11115. 1.1 .15. .1 .. II; 55. ... . 1.15 5. . . 51 I 111 .11 5|..5..l1 5.55 . ..5 5 4. . . me :P :“PP LL .II5lIII15?5-I51I r.5i. . 115.15 2f :IIII+I:III--.TIIIII---5 .3, ...;s- - ;- 5: . - . u . . _ Pee;_ cc. -wten c- N. u.=ozcv wLPL..PLPu1 PP.iw 51.55... 5- 5 .5- . -- .-III. 5-- --..I.P I I--. .- . 55 -5. --5 5.-- ,5 555-- - - 5- . . , . d P Pr:cI Lwc mvmc up wson_v ch.PeuPL.:. -ecPeP I . II.!. 5 IrI- I P siEIIIIIIIIIIIIIIIIIIIEIII m m . P.c;..t .:P mePPeu :0 mac my masoccuca PocoPusPPPch-coP P P P . 1--. III p .. ...IIPII- I +1.1 4 III: ,. IIIII I- . . u . texucPc: .ce. c.1PPPn>: >PcheP we: ac;P mmPuPPPumw cchmc: can CcPPLL LPc P . _ _ I I 11.. I o IIII I III I I 5 1 11155 P n :5151 1 Inll .«I 11. 11 IIIIII 555 I 11 I I IIIIII 111lI11 1 1111111111111 a P 1a.ucPc: xcc q.PPPPm.>« PPPtmmP etc uczu aceEszcm cchcm cc: ccmwco. 1111 IPI 15.515: :11 a I 1 It 1111...114.,11 Pr II. 5 . . 5 1l11I1111~111111il. 15' u . P P xasu:_ea Ice. ePrmPPm>m >PPucoP ego per. mPcPLmPce .ccraoo P . . _ .II _ :I -I-Il +5 I I II III I I I I-.. -..5- III III- I5I--- I IIIIIII . _ . E n ” cexucPc: use cPrcPPc>o >PPrmoL men umgu mmPuPPPUcP ocPPcoP . a - _ P. T15 w . IL. .55I,-5....-|PII5I - P , IIIII-I-I 15111.51 -5 .II P m A M H E taPucP L: :cm mPLo.PM>c >PPumoc mew Page mmPuPPPumw >Pvc2cP Pc:0mL¢P P _ l e 5 .L I -.l lfI. lIll. 5:, 5-5 i- . _ , P >P .ePncu Poo: .oPcemxw PoePu ocszeP POP PcLEQPacP P . P I55 -Plll:l.lll5” -- _ .L .: .12555.:l .5. .155l5 1.: 55;- fl . P. w P 45 . meeoecco . meooc ccPcP.: .NeoUP ccP>PP OPP. a. o: . . _ IJT . 1 11 W .1.\111fl1 I. 1.51 w 11 111111 mwuusomma oz< hzuzzcmP>zw Pap—mPIQ mcpcor o mnwcos a mPcachoa mPaoPPc>« cPrPP: cPcPP: ePcnPPc>q mucwanem PPq or axe: u—om—Pm>q ¢PQcPP¢>n uP wxc: wfiom LOP >Peou. PCP cu vcmuc_ HP cam? PP «in: cu ccPueq ancPPm>q oPnnPPo>u uox cc 0» ccwucu c. vcwucP case» ¢>~z >PuemmoLa >Puc¢uoea 113 €925 ... Ear. . eusuocn 3E5 : . .555 time B 32.: 3 3o: (P2. .35 PEPPER: €357.33 Pa) of SP: 5:523; 5 515 z -5 1.23.52“. $6 3295: 3 3:3qu .3. mpPuPStouPS «PP... ......ta. «.1 _ . Puxmnfi . .9... «auaeaneq 5: 3:52:03 Paco—ugnmlgqlr. acmm...1.:4..m III: I: 353202.... ParuWPPHmoP...mern.L .. ... ....H.....5.5 . I I. I -15..- II 9;: ccPEc..wlde.P.:e .3352 mm PPS; 322.5 .6». 9.55 PEPE»; ul......_....5P..m P L III .1 . D PEP:— mPcaPPEeu 3 53?. .8» .595 9.253 85:5 P I II m m P5534 6.65 2.» «.53 8 Pas: ”zoo... ......Pcfi “553 2:5... . . M I .-I 5Pmco5lemoIPflwmIPmmPNP whom..mc.P.cumMomI..........Ma _ h P I _ A P unPumwni. [2. Peer . _ EB 0.55.5: .... P252: :33“.on L5 bumcm 05533.“ u:¢3.€-C-m . I. ......PMPP .EPchlwmm _ .3533 3.2: .Puu 9:32P ..xu 6533 nofifox 5 >535 ......a... 1-. P .3w 59... was 323 Pups 3me 8 :2 £33 at. I 3533:3558 :02: E. 223...: 3 9533332. mqu... “ch3333: P _ .nguwoaa «5.5.. o :95: m P 3533: _ 02-221 55.: 55.: . Eon—.35 3:033”. 72 _ a. 8.5.. 03-225 35:23 P I 3.2. 2.8 L3 2.3.: .Poe P 3 3.3.: “P on»: 3 use: 3 .53: 02:23.. vPPPuPPEE . an: 8 3 23:— 3 2.3:. ii..— c>~z >553; >253...— 1.1.4 """V- D'l II. .I ...-.-I II’IIIII‘I . I. o—nu—.u>¢ I-.- Ifl:r. mgycox o c,gu_x a. as»: _ e.no,_c)¢ cu vcvuc_ an: a: a. axe: 9» new“:— +I - _ VIIIIII III4 IIII. I _ _ _ .vruZCI F :.:u_3 ¢—;a~_m>c ‘p Q‘s: c. tc¢~:_ C—Lcnmuw)1 .5_ .I. t... a“ co.b_q L (...P Q)...‘A m... ...»..U .~ mun. LLCV g3» mpgflu—rm‘zc ) gunmvw‘... .... _. .... arur~u~_......13 .......... r: . .I'Illlil tl ltti‘IlgI. I “I IIIII-II fliIl‘uIII II ., _ w . . a . _ :a_,wp .ccnnucph L.:_;;r (:1 x . .n¢:.cpg ccwrcgv I. .I‘II‘III'! . V _....——-—‘L — —~ ~ . wu:cr_mum ” PP4 _ >_gc¢: gs» ;_nm.ru>q >ch:uuLQ II‘ II. ..N 1 (Ir . .. ‘.pxw. . - .I. J u . I , . A I w.€«_uLCLC, ,(.,.. . .m.,.x,\L,((r.rn I‘IIIID‘I‘ {I‘-l.l .Iflll'll' I’ x Jr“ H IO"| II -I,’ - I - I ' II V'i . ...w .... n. 3 _ n _ ..L , “3* . ( ..p....\:.f I ‘urtmOI I uII II .I - u o -0- I III. - .I 0...», ..x; ....uub. . If, ~Hpguac r (.5. WIU . ... VJl. LT... ~U-.u 0d, ”wrkwenh bnu._1.» Q.- r.rr;«391:u 115 u w.v;:c;¢ _. fur-mu ucwwuoa floatw>wwcw Cc—a I I IIII I II I + I II I I .IIIIII IIIIo I II III! II I .II II I I. I . .I. I . I I II I I I I.II II. II I I .I I. . II. . . . >. . m . . yr , w“ CLCI C2wrglc LO _fpp.vCL r”, *3 . _ ctrmazc vLmL~ h ...xcuc. ta. ....w .I.Lr:u Lr v‘cccpmaLxuuT._nhc w4m_ .VII II I IIIII. I I I I I I III I I .o IIIIII II I.. .I Q.II II II III IIIII.II.IIII I II .I I II I, I ! .III II.IIIII II.| IIII IIIIIII . I I I I VHCQTP m3.... up... L. . . a .. 4. "km ... ....m CCwELOCu 1.3% LOHUDLujvc.» ho C.~..L m .65 , . fl III IIII I #. II I 1+1 I IIIII I III I IIIIIIII III I I . I . III I IIIIIII ’ . . @ aficnccwmw win LLrglfiqgc CL: _.nh t3 Ucrxuwc we rvbw rumcu Cw murcwumc t®>—C>C— , , ~ .0 . M . €539... .552.» *0 $3326 to: 95% 332258 32.53:: IIIITIIIIIII _ 1! IIII II I IIIIII II ‘ I .II.|.A.IIIIII I. II“ IIIIIIIIII IIIIII IIII I-IIIIIIIII H _ . 9502:: we 33%: 3.503 38.3 on: aI.-III:IIIm-II-I-II II I .--IIII--- III-IIIIIIII .- - - II ---I--IIIIIIA.quIc-mmc.wu§.Adammm:megInciflmpanucmM - _ . . . 322m 32?. 9.9% 3.85 2953.5 28383:...th co 0:221:9378 . . _ _. w m 3:386 33¢ 33.00.. “.../m: III I II I I.-. II. .. I I . _ “CF; wrhcui u m wxvccr m . _ “$3 55.2 m 55:... . ..."... _ p .33.... r So: 3:.” :5 u... ...... _ r3... 88. ...... ..,._..,.c.... on vcmucm u. ms“! »w «x»: :. :cwuuq g; Fr,«u go» I w “02 cu c. nczwr_ x. using“ c “3. c»«; m.n;w.:;I >~uLdv1Lh I I . 11.6 Staff koie For II¢H I and 2 (neck one of t2: blocks 13 the right of each staff position. ”a” much influonge do yo; tzink rdCH of the foIIouing peooIe in vour awta has In determing the p Lieut treatnent? In the soaces following the listed staff position, fill in other staff positions that you have in your work area and check the appropriate blocks. A GREAT QUITE DEAL A BIT SWHE LITTLE NONE a. doctor (psychiatrist. H.D.) b. supervisor C . nurse d. nurse's aide —- ---- _... e. attendants f. social Horker g. OCLUPdLIUhaI theranist r-.-.-—--~ .— --q ...- n. unvsital thcraoist 3,-.- -_ ....-. .---__.--....-.---- -..I .-.... -_ In. ......W..- ----..--...---.. I. _L~.II__~__.__--IL-.... I - . To ”Hat extent do the foIIuwinq staff take the teaching roIe to train residents/ patients basic sLIIIs? (usinn on0ne, making beds, washing clothes) In the swaces fnloouinq the Iisted.staff positions, fiII in other staff DOSIIIUIS tIaI vnu have in your work area and check the anpronriate blocks. A CRLAI QUITE nrnL .JEEBJ m-~_SQJE LITTLE NONE 3. III“. {UT II"$",'{.I It‘ll: I .t, 3.0.) I I... - _- .. ...... ....._.__......-...-+-- .. . ._.. .4» U supervisor ? I—_-_ _*.“,1...‘ -. ----.. .4.... .....Q_ “AF—...... ..I} I III‘ ) 1 I I . ""I‘” EL-.-" --.. .‘5 (I I 'I‘ ‘ ' I I--.-I...--.-- .. u ' .jnI- j ; ............. I- -- -.-—.---I -..- r I I 0. tr ' , I . -_. ._,_¢ . - -.. _ - L+ -.. . .-. -.. . ....41»-..4- . .---fi— T— ———»—a—--—--‘—4 I T ‘ 1I \ I C l‘ I t L -;-__- — -..”,4ev--+ -- — . I I I I ".II.,II I 6“'!‘)I. I I I r-—— - -~-———- -?—————--— .. ... D"._I --~——~— - *---’--o o--»~-—.—-I>—-—.——.ww g -P c - x at“ 0r- (.4 rim O‘cj m ..J. "3‘. a. lack of funds (check one) “ '(Jwv‘33 . ’””r b. lack of trained staff (check one) '” ) c. lack of communication between 1 staff (Check one) d. staff disagreement with the milieu therapy information ' I (check one) ' e. state regulation (check one) l f. other (describe) ' l 130 page 4 18a. List and explain the attempts you have made in establishing milieu programs. 18b. To what extent did the following conditions prevegt you from anecessfully making any changes you mentioned in 18a. +9 M s ‘e’ 2 a: s 53 a e :3 e x I: I" O 'F' O < Lu 0 co m —-I z a. lack of funds (check one) '”'”“”T"“““I‘“77”“"T“"‘“l .---.. ' l i b. lack of trained staff (check one) I If“ i . 1 i ' ‘ ’ l . -;—-*~ ~1—— -——-;~—~—---+ —-- —--~ c. lack of communication between 3 z . staff(check one) 3 , l 2 ' g l“ i Y d. staff disagreement with the E ; I E i g milieu therapy information i , i ; é (Cheek one) yw- --——--—---—-—- -~~+ .- ,L TL ..1' e. state regulation (check one) ' . -JL ~—-—.— .. f. other (describe) ; ) l g l 19a. List and explain the attempts you have made to bring about changes in staff behavior. .131 page 5 19b. 20. 21. To what extent did the following conditions prevent you from successfully making any changes you mentioned in 19a. +: m as. .. 2 L o +4 a: +’ o a“; '5‘: 3 $3 8 (LU Ca: m .—l 2 a. lack of funds (check one); i i i —l ‘ s I 5 b. lack of trained staff (check one) I {I i j l c. lack of communication between staff (check one) d. staff disagreement with the milieu therapy information e. state regulation (check one) f. other (describe) am —. -«co-d—n—u—o —- >4 -—-_-—¢—. -..4r..- —.---« -.— Have you ordered milieu therapy films from the Institute of Gerontology? yes no Have you ordered the training sereis from the Institute of Gerontology? yes no 132 APPENDIX G TELEPHONIC CONSULTATION 133 Telephonic Consultation Was the telephonic consultation helpful? yes no Please explain. Also if yes, order the following categories by assigning l to the category in which you received most help, 2_for the category in which you received some help, and §_for the category in which you received least help. ---—-providing information on resources providing information on how to initiate change providing emotional support Example: Order the following colors by assigning 1 to the color you like best, 2 to the color you somewhat like and 3 to the color you least like. 1 red 1 yellow 2 blue 134 APPENDIX H SCORING SOCIAL STATUS OF STAFF 135 Appendix H Scoring Social Status of Staff The following scores were assigned for questions involving staff positions: 1 = doctor 2 = supervisor 3 = nurse 4 = social worker 5 = occupational, physical and musical therapists 6 = attendent or aides 136 LIST OF REFERENCES 137 138 LIST OF REFERENCES Argyris, C. Intervention Theory and Method: A Behavioral Science View. Reading, Mass.: Addison-Wesley, 1970. Brickell, H. Organizing New York State for Educational Change. University of the State of New York, 1961. Brickell, H. State Organization for Education Change: A Case Study and a Proposal, In Miles, Mathew R., ed., Innovation in Education. Bureau of Publications, Teachers College, Columbia University, 1964. Carlson, R., Adoption of Educational Innovations, The Center for the Advanced Study of Educational Administration, Eugene, Oregon, 1969. Chesler, M.A. and Fox, R. "Teacher Peer Relations and Educational Change", in National Educational Assoc1ation Journal, 1967, 56(5), 25-26. Clark, D.L. and Guba, E.G. An Examination of Potential Change Roles in Education. Paper presented at the Symposium on Innovation in Planning School Curricula, Arlie House, Virginia, October, 1965. Coleman, J.S., Katz, E. and Menzel, H. Medical Innovation: A Diffusion Study. New York: Bobbs-Merrill, 1966. Coons, D., Lippitt, M., Grossman, E., Sahara, P. and Brown, C., Developing a Therapeutic Community, Audio—Visual Education Center, University of Michigan, 1972. Costello, T.W. and Zalkind, S.S. (eds.). Psychology in Administration. Englewood Cliffs, N.J.: Prentice~ Hall, 1963. Fairweather, G.W. Methods for Experimental Social Innovation. New York: Wiley, 1967. Fairweather, G.W. Social Change: The Challenge to Sur- vival. General Learning Press, 1972. 139 Fairweather, G.W., Sanders, D.H., Tornatzky, L.G. with Harris R. Creating Change in Mental Health Organizations. 1973. In press. Glaser, E.M. and Ross, H.L. "Increasing the Utilization of Applied Research Results." Final report to National Institute of Mental Health, Grant No. 5 R12 MH 09250-02. Los Angeles, California: Human Inter— action Research Institute, 1971. Goldin, G.J., Margolin, K.N. and Stotsky, B.A. The Utiliza- tion of Rehabilitation Research: Concepts, Prinprles and Research. Northeastern Studies in Vocational Rehabilitation, 1969, No. 6. Halpert, H.P. "Communications as a Basic Tool in Promoting Utilization of Research Findings." Community Mental Health Journal, 1966, 2(3), 231-236. Havelock, R.G. Planning for Innovation Through Dissemination and Utilization of Knowledge. Center for Research on Utilization of Scientific Knowledge, 1971. Havelock, R.G. Training for Change Agents. Center for Research on Utilization of Scientific Knowledge, 1972. LaPiere, R. Social Change. New York: McGraw Hill, 1965. Lazarsfeld, P.F., Sewell, W.H. and Wilensky, H.L. (eds.). The Uses of Sociology. New York: Basic Books, 1967. Lippit, R., Watson, J. and Westley, R. The Dynamics of Planned Change. New York: Harcourt, Brace and World, 1958. Lippit, R. "The Use of Social Research to Improve Social Practice", in American Journal of Ortho s chiatr 1965, 35(4), 663-669. p y y, Lippit, R. and Butman, R.W. "A Pilot Study of Research Utilization Aspects of a Sample of Demonstration Research Mental Health Projects." Final report of Contract No. PH 43651047, National Institute of Mental Health, 1969. Lounsbury, J.W., "A Community Experiment in Dissemination Models for Citizen Environmental Action", Unpub- lished doctoral dissertation, Michigan State University, 1973. 140 Mackie, R.R. and Christensen, P.R. "Translation and Application of Psychological Research." Technical Report 716-1, Goleta, Calif.: Santa Barbara Research Park, Human Factors Research, Inc., 1967. Menzel, H.A. "Scientific Communication: Five Themes from Social Science Research." American Psychologist, 1966, 21. Miles, M.B. "On Temporary Systems", in M.B. Miles (ed.). Innovation in Education, New York: Bureau of Publications, Teachers College, Columbia Univer- sity, 1964, 437-499. Porter, A.C., "Analysis Strategies for Some Common Evaluation Paradigms", Occasional Paper from the Office of Research Consultation School for Advanced Studies, College of Education, Michigan State University, February, 1973. Richland, M., "Traveling Seminar and Conference for the Implementation of Educational Innovations", Santa Monica, Calif.: System Development Corpor- ation, 1965. Technical Memorandum Series 2691. Roberts, A.O.H. and Larsen, J.K. "Effective Use of Mental Health Research Information." Final report for National Institute of Mental Health, Grant No. ROl MH 15445, Palo Alto, Calif.: American Institute for Research, January, 1971. Rogers, E. Diffusion of Innovations, New York: The Free Press of Glencoe, Inc., 1962. Rogers, E. with Shoemaker, F. Communication of Innovation, New York: The Free Press, 1971. Rogers, E. and Svenning, L., Managing Change. Washington, D.C. Operation PEP (A State - wide Project to Prepare Educational Planners for California), U.S. Office of Education, Dept. of Health, Education and Welfare, September 1969. Ryan, B. and Gross, N.C. "The Diffusion of Hybrid Seed Corn in Two Iowa Communities", Rural Sociology, 1943, 8, 15-24. 141 Sakoda, J.M., Cohen, B.H. and Beall, G., "Tests of Significance for a Series of Statistical Tests", Psychological Bulletin, 1954, 51,(2). Spooner, S.E. and Thrush, R.S. "Interagency COOperation and Institutional Change." Final report on a special Manpower project prepared under a contract with the Manpower Administration, U.S. Department of Labor. Madison, Wisconsin,: University of Wisconsin, 1970. Thelen, H.A. "Concepts for Collaborative Action Inquiry", in R.R. Leeper (ed.), Concepts for Social Change, Institute for Applied Behavioral Science, 1967. Wiles, K. "Contrasts in Strategies of Change", in R.R. Leeper (ed.), Strategy for Curriculm Change, Washington, D.C.: Association for the Supervision of Curriculm Development, 1965, 1-10. "IElllllllfllllll)(S