When the Physical Therapist Serves as a Consultant

When the Physical Therapist

ALLAN KATCHER, Ph.D. Serves as a Consultant

The consultant and the consultative process are described, and the problems of introducing change are considered. Understanding, patience, tact, and a sense of timing are related to each step in the process of consultation. Interpersonal skills are as essential for a consultant as are technical and professional skills. Factors leading to success in the role of the consultant are delineated.

ncreasingly, members of the health sciences professions are called upon to serve as consultants to a variety of agencies. For some, the term consultant is merely a more elegant title for employee, but for others it implies a new concept of relationship to one's employer—one that is professional in its own right. This article is intended for the person who is interested in becoming a full-time consultant, or one who already functions that way but who wants to look self-consciously at how he operates in his new role.

Consultation is not a science; it is an art, blending the best of wisdom and experience with the right touch of understanding and patience. It is, therefore, a challenging, frustrating, demanding, exciting, and rewarding

Dr. Katcher is Consultant to Management, Atkins-Katcher Associates, Inc., 8383 Wilshire Boulevard, Beverly Hills, California 90048.

This article is based on material prepared in connection with Contract PH 110-68-164 between the Public Health Service, Department of Health, Education, and Welfare, and the California Nurses' Association.

This article appears in response to the impetus initiated by the Committee on Continuing Education which sponsored an Institute on Administration, Supervision, and Consultation in Oklahoma in October 1969.

experience. Understandably, every consultant is faced with certain dilemmas which he must resolve in order to perform effectively. In fact, one of his first dilemmas probably will stem from the ambiguity of the term consultant.

THE CONSULTANT

Who is a consultant? Despite the variety of functions a consultant may perform, there is a distinctive concept of the term that can be useful: A consultant is someone (usually professionally trained and qualified) who works with other persons, organizations, or groups to assist them in working through problems which they have encountered. This concept has been further defined:

Consultation is a helping relationship which is initiated when the consultee brings a problem to the attention of the consultant and requests his help in solving it ... . Freedom to accept or reject the advice, assistance, or opinion is inherent in the process.1

The consultant has certain obligations to orient his helping concerns and behavior to the needs of the client. He must develop, in addition to his professional and technical skills,

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the interpersonal ones necessary to relate sensitively and effectively with people. The negative aspect of this point was revealed by one consulting physician who emphasized his medical rank and prestige so much that he was soon ignored by everyone with whom he worked. His recommendations were generally not followed by members of the staff and the consulting relationship was soon terminated.

These interpersonal skills become especially valuable when the consultant is faced with one or more of the following on-the-job dilemmas:

Consultant or Employee?

Assume, for example, that an extended-care facility (ECF) has asked you to develop a program of physical therapy for its patients. As an expert in this field, it may be necessary for you to tell the local staff exactly what needs to be done, e.g., how patients should be handled, what motions would be most beneficial, what exercise procedures are best recommended for particular types of patients. In doing this, however, you may alienate the nursing staff, or cause them to rely on you unduly. An alternative might be to work with the existing staff, try to educate them to concepts of sound physical therapy, get them involved in thinking about the individual needs and requirements of patients, and develop in them a sense of responsibility which will commit them to providing good care. In this way, you would act as a resource rather than an expert. Yet the best expert advice may never get used if the consultant defines himself too narrowly.

At times a consultant may be asked by the health care facility administrator to run an activity or to supervise the work of others even though he may not be a part of the permanent staff. Or he may be asked to serve as an assistant to someone who is in a supervisory capacity. In either case, these are situations that should be considered carefully before being agreed to. The existing staff may not desire to cooperate with the consultant. Jealousies may be aroused by the consultant's behavior. Acting as an assistant, the consultant may all too often adopt the posture of an employee and be blocked from expressing the opinions and advice which would be of most service to his client.

One of the unique values of a consultant is his third-party objectivity. He is often

independent of the rules, fears, and concerns that constrict the freedoms of most employees. Usually, he is freed of the responsibility of working through channels, and often has direct access to key supervisors and to the administrator himself. Consequently, the moment he begins to assume the posture and attitudes of an employee, he is less likely to benefit the facility he is serving.

The consultant, however, needs to work smoothly with institutional personnel. He must, therefore, try to protect his professional role, and to make others feel that he respects their roles.

Further distinctions which help clarify the role the consultant performs may be seen in Table 1. The table, itself, goes beyond the immediate discussion, but does point out clearly the difference between functioning as a supervisory employee and functioning as a consultant.

Confidante or Spy?

In another circumstance, an administrator may ask the consultant to reveal information that he has gained in connection with visits, interviews, and observations. The consultant, by virtue of his prestige and outside identification, often becomes a confidante of employees who assume that he will respect their confidences. He is then put in a position of wanting to transmit some essential facts to management, but is faced with the ethical dilemma of his right to reveal information given in confidence.

Similarly, employees soon learn that the consultant is a convenient vehicle with which to get management's attention. A consultant may unwillingly serve to undermine the existing supervisor-employee relationship.

Idealist or Realist?

A professional consultant, whether he is a dietitian, occupational therapist, physical therapist, management consultant, physician, pharmacist, or nurse, has developed a core of experiences, principles, and knowledge which makes him distinctive in the institution. As a professional, certain things may be going on of which he does not approve, which he feels have harmful effects, and which he feels really ought to be changed to fall in line with accepted practice and procedure. Yet, the fact that he is

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TABLE 1 Distinctions between Consultation and Supervision

(From an article by graduate student (234-B), University of California, April 1959.)

Consultation

1. The purpose of consultation is to help the consultee work through a problem that is of concern to him.

2. Consultation is a discontinuous process which may or may not be present in the work relationships of two or more people.

3. Consultation is offered.

4. Consultation is an educational process.

5. Consultation is a two-way process; both persons give and receive, both learn.

6. The essential characteristic of consultation is permissiveness.

7. The consultee has the power to initiate, refuse, interrupt, or terminate the process.

8. The consultee is free to reject the advice, opinion, information, or service offered by the consultant.

9. The consultant can withhold consultation.

10. To be effective, the consultant must possess technical knowledge and skills that are valued by the consultee.

11. The consultant must establish rapport with the consultee. To do this, he must have insight into his own feelings about giving consultation and about the consultee, and be sensitive to how the consultee feels.

12. To utilize consultation, the consultee must possess some degree of technical or professional competence. His competence may be equal, even superior, to that of the consultant.

13. All people at some time, and some people most of the time, are incapable of inviting and accepting consultation.

14. A certain degree of self-confidence is necessary to give and receive consultation.

15. Consultation is worker-oriented, adapted to the needs of the consultee.

Supervision

1. The purpose of supervision is to develop staff competency to meet the demands of the job.

2. Supervision is a continuous process inherent in the work relationships of two or more people.

3. Supervision is given.

4. Supervision is an educational process.

5. Supervision is a two-way process; both persons give and receive, both learn.

6. The essential characteristics of supervision are responsibility and control.

7. The process starts when the work relationship is established. The recipient does not have the power to refuse, interrupt, or terminate the process as long as the work relationship exists.

8. The recipient has limited freedom to reject the advice, opinion, information, or service given by the supervisor.

9. The supervisor cannot withhold supervision.

10. To be effective, the supervisor must possess technical knowledge and skills that are valued by the recipient.

11. The supervisor must establish rapport with the recipient. To do this, he must have insight into his own feelings about giving supervision and about the recipient, and be sensitive to how the recipient feels.

12. The recipient does not need to possess technical or professional competence in order to utilize supervision.

13. All people at some time, and some people most of the time, are incapable of accepting supervision.

14. A certain degree of self-confidence is necessary to give and receive supervision.

15. Supervision is work-oriented. The extent to which the needs of the recipient can be met are limited by the demands of the job.


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employed and receiving money for his services may sometimes throw him into conflict. He may be reluctant to reveal all he knows.

If he is too professional in his attitude, he may overlook the practical and economic limitations of the facility's budget, and, therefore, find that recommendations will be flatly rejected.

The consultant must be able to consider each side of this dilemma, and to decide how to deal with it. He should be aware of the impact of either extreme on the people he will meet and work with. In an extended care facility, he will work with other professionals, nonprofessional staff members, and patients. Skill in handling group discussions and flexibility in adapting to different people are also essential to successful consultation.

Types of Consultant

Becoming accustomed to offering only services requested and overlooking other possibilities for consultation which might have

broader and more meaningful consequences for patient care are all too easy. The novice consultant, in particular, may be too prone to offer only patient-centered consultation and ignore the program and administration-centered consultation described in Table 2.

When is a Consultant Needed?

Consultants are often needed whenever services cannot be provided by the available staff, or when qualified professionals are not present. In some cases (as with Medicare), facilities must either carry such professionals on their staff or assure that current services are under the supervision of a professional. Thus, when a facility cannot afford a full-time person, consultants will be required. Existing surveys or the administrator's own awareness of deficiencies may foster the establishment of a more comprehensive and improved program of services through the use of a consultant.

The potential consultant must assess whether he is really needed for his professional ability.

TABLE 2 The Varieties of Consultation Services and Their Associated Methods

Patient-Centered Program-Centered Administration-Centered Consultee-Centered Consultation Consultation Consultation Consultation

1. Evaluates patient's abilities and potentials, and performs diagnostic and prognostic tests to assist the physician in his determination.

2. Develops, confirms, or challenges total care or physical therapy treatment plan.

3. Makes suggestions and recommendations based on findings.

a Reference 1, pp 4-5.

1. Evaluates design, purpose, procedures, and policies related to the operation; reviews or determines needs and available resources.

2. Develops suggestions based on assessment of present program strengths and weaknesses and community services. Program review may concern direct service, education, research, and coordination with other professions, agencies, and facilities.

1. Determines role of the physical therapist under existing or proposed organizational and administrative structure.

2. Evolves, retains, or alters structure, and related matters, e.g., job descriptions, personnel policies, fee schedules, staffing (numbers and types of personnel), table of organization, and budget.

3. Provides recommendations based on present need and estimated growth.

1. Assesses background, preparation, and orientation for the job.

2. Identifies new approaches, changes, and satisfactory solutions in interpersonal and interprofessional relationships, and self-evaluation in relation to job performance, and reaction to work situation.

3. Submits recommendations on individual or group basis.


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For example, someone may desire only a token program to satisfy statutory requirements. An administrator may not realize the amount of support needed to establish a successful program; he may intend to use the consultant as another employee instead of as someone to provide guidelines, or to supervise care rendered by less qualified personnel. The consultant must have confidence in his ability to evaluate the situation and to be aware of the difference between asking for relevant information and being wholly dependent, lest he experience failure. I recall one consultant who was so unsure about her recommendations that she constantly asked the administrator for advice. Finally he told her: "Madam, if I have to answer those questions, I really don't need you as a consultant."

How Does a Consultant Get Started?

Many clients are available for even the neophyte consultant. Often, professional associations maintain agencies or bureaus and are contacted by extended care facility administrators for prospective consultants. In this way, the new consultant has an easy entry into an ECF, for he comes with the backing of the professional association.

Some well-established consultants have overflow business and seek relationships with consultants as associates. This eliminates the hard work of making contacts and building a practice. For many professionals who do not find it comfortable to meet strangers and to start conversations readily, such a path offers a ready solution to the problem of getting started. In the process of association, one can learn a good deal from more experienced consultants, even though one naturally relinquishes more of the rewards that are commensurate with the risk of independent functioning.

Frequently, those who have used the consultant's services are in the best position to recommend him to other agencies. Sometimes this is not done simply because the consultant has never told his clients that he would appreciate their help in this regard. A letter or a call to the effect that you would appreciate their help is sometimes all that is needed to motivate an old client to recommend you to someone else. After the consultant has con

cluded a program of treatment or service, he can sit down with the client to evaluate the services which have been performed. If the administrator is pleased, the consultant may mention that he would be happy to talk with anyone who needs similar services.

Telephone calls are the most difficult way in which to get clients, especially if the consultant tends to be shy, modest, or hesitant in approaching strange people. The need for and appreciation of consultant services is growing, however, and clients are often there for the asking.

A series of calls to ECF and other institutional administrators stating who you are and inquiring if they currently use consultant services can provide an introduction. You may simply ask administrators if they could spare some time to tell you a little about what their institution is doing to provide treatment in your field.

The main intent of such calls is to arrange for a chance to meet with the administrator to discuss the possibilities for consultation. Naturally, it helps to be forearmed with a referral from someone who already knows you. In either case, the objectives are the same: 1) to provide an opportunity for getting acquainted, 2) to demonstrate possible benefits- from consultant services, 3) to determine the exact requirements for consultant services, and 4) to have an opportunity to develop a proposal.

In introducing yourself, mention the fact that you are a member of the appropriate professional group. A few credentials may enhance the possibilities of being received well by the administrator.

The Initial Interview

The consultant and the administrator should assess and discuss, before the consultant begins, the role the consultant will play in the organization, the relationship and support that will be required, and the expectations that will be mutually held. This is best done in the initial interview in which questions such as the following can be raised: Has the facility ever employed consultants before? What has the experience been? What have people become accustomed to? What does the administrator want the consultant to do? In what way can the


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consultant help him? Are policies available concerning the programs of treatment that are considered? Are they in writing? Where are they located? Who are the auxiliary staff? What training experience and supervision have they had?

The answers to these questions not only help the consultant to identify the needs involved, they will also provide information valuable in establishing the relationship with the administrator. The kinds of questions the consultant asks projects his own professional image. Questions such as these, if asked with the tone of a prosecuting attorney, are guaranteed to alienate the relationship from the start; if asked from the standpoint of a curious and friendly helper, the relationship is usually off to a fine start. These questions also tell the administrator something of a consultant's abilities to define a problem properly before recommending solutions, and to work with an administrator in a spirit of mutual problem-solving that has meaning to him and is more likely to commit him to supporting and carrying out the policies that are recommended.

At the same time, in the absence of well-defined policies and criteria, the consultant can make suggestions about things that can be done, and determine from the administrator's reactions the type of cooperation he would be likely to receive.

In a sense, a consultant is really needed when the administrator feels the need, or is made to appreciate the need for his services. One of the consultant's first major responsibilities is to convince the administrator of the value of his services. From a strictly parochial view, this may not be necessary, but, in the long run, it is essential to building the kind of administrator-consultant relationship that will result in support and follow-up of consultant recommendations.

The consultant will find it helpful to arrange for periodic reports to the administrator (or key person who will supervise his work), both to apprise the administrator of the progress that has been achieved and to afford an opportunity to deal with problems as they arise. The administrator usually expects recommendations for action, as well as suggestions for ways in which the administrator can provide assistance (best stated in request form).

What an Administrator Expects

The administrator may expect recommendations with a minimum amount of fuss. He may also expect the consultant to appreciate such factors as limited financial resources, existing schedules, and the qualifications of existing staff. The administrator may expect complete subservience, or he may be more informal and establish the relationship of a colleague. The consultant, however, must know what the administrator does expect, and he must know what he himself desires, is accustomed to, and can work well with.

If the consultant senses difficulty or does not believe he can work within the limitations of

the relationship or needs additional informa

tion, he should settle any questions before he

starts work. It is easy to avoid this step, or to hope that the administrator will come around

to your point of view, but to avoid it invites difficulties in the future, from lack of coopera

tion and poorly carried out programs to failure to pay fees.

Preparing the Proposal

After acquiring the basic information during the initial interview (and other information-gathering sessions, if necessary), the consultant prepares a proposal. The necessary information includes organizational, technical, and emotional factors, types and conditions of patients, the institution's philosophy and resources, time factors, and the consultant's ability to provide necessary services.

In this evaluative process, the consultant formulates the ideal program of services apparently needed, then modifies it through the process of trading off in light of constraints introduced by other factors in the situation. Essentially, this is an attempt to maximize the services to be provided by anticipating the constraints imposed by existing factors.

Because of possibly insufficient information in one or another area, the consultant will need to make assumptions-to arrive at decisions during the preparation of the proposal. The consultant needs to remember that he is making these assumptions, and that they might be wrong.

These educated guesses may enable the


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consultant to come up with one major plan of action—a goal which has implications for motivating the administrator. The introduction of major alternate plans invites unnecessary complications; difficulty is encountered in providing meaningful discriminations between alternatives to the administrator, and they may

invite indecision and inaction. This is particu

larly true if variations in costs are also involved.

The administrator can rightfully expect the

consultant to propose the one best solution

under the existing conditions. In fact, the

administrator tends to favor the consultant who

presents a plan with confidence and conviction. The amount of fee may be the basis for an

administrator's decision to accept one consultant over another, but it is often not the only one. Rather, the administrator—once convinced he requires a particular service—is more apt to select an individual or firm on the basis of the capability and reputation demonstrated during the initial interview, the nature of the approach contained in the proposal, and the actual presentation.

Presentation of the Proposal

As with the initial interview, the presentation of the proposal and confirming interview is most effective when it follows a sequence designed to attend to the administrator's needs and tensions, to check his acceptance at various stages of the presentation, and to build up his full acceptance of the total proposal—including the fee.

The following outline for a proposal has proven successful: 1. Set up goals for the services—as stated

initially by the administrator and as reformulated by the consultant.

2. Define the present conditions—to gain acknowledgment that they exist and to trace probable causes for these conditions.

3. Outline the services proposed. 4. Specify the benefits of the program in terms

of the problems involved and the goals desired and with respect to consequences resulting from inaction (harm from neglect).

5. State limitations of the program, expectations or goals which cannot be fulfilled, and inconveniences which may be experienced during implementation and execution.

6. Establish administrator (or institutional) participation—through utilization of administrator (or institutional) resources (other than financial), defining expectations and extent of administrator (or institutional) responsibilities in program execution, preparing the staff to assist the consultant and to make use of the consultant's assistance, as well as to conscientiously review the consultant's data, interpretations, and recommendations, in order to meet the objectives of the consultation.

Throughout the presentation of the proposal to the administrator, thus far, no mention has been made of the fee required for the services. It is much more important during these stages to achieve agreement between the consultant and the administrator, and acceptance by the administrator, in each of the following areas: 1) what the goals of the administrator are or should be, 2) what the problem is and what the basic causes were, and 3) what can be done to resolve the problem, noting both benefits and limitations of the plan of action and the respective responsibilities of both the consultant and the administrator in its execution.

In presenting each stage, the potential con

sultant has to be alert to cues offered by the

administrator: Does he question a particular statement or proposal at any length? Does he

attempt to minimize an existing condition or the need for a particular step in the program?

Does he begin to make statements such as: "When do we get started?"; "Will it be done

by.. . ?"; "I think it will be possible to set aside X hours of time." Unless the doubts and

hesitancies are resolved at each step and acceptance secured of a statement or of

successive parts of the proposal, continuing to the next phase of the presentation would be unwise. If the client has expressed concurrence at each of the preceding steps, it is possible to enter the closure phase which includes the following steps: 1. Evaluate the presentation. Summarize what

appears to have been agreed upon, note whatever hesitancies still remain to specific portions of the summary, and deal with these hesitancies.

2. Present the fee. Provide an overall fee for the services proposed; be prepared to discuss all


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or parts of the fee in light of administrator reaction; modify the proposal in terms of time if this does not affect the best interests of the administrator (but in no way enter into a bargaining relationship to reduce the cost for the same services).

3. Arrange for implementation. Set starting dates and schedules; work out other details, e.g., personnel, interim evaluations, and reports.

Follow-up Procedures

Although the continuing relationships with the administrator go beyond the immediate topic, follow-up procedures are as important as the initial sets of interviews. Too often, they are neglected, especially with respect to remaining au courant with administrator needs and tensions above and beyond the agreed-upon technical execution of a program. This neglect could lead to cancellation, especially if the administrator is led to expect the attention to his needs which he experienced in the initial contacts.

Discussing Fees

Properly, fees or their basis should be presented and discussed with the administrator before services are rendered. Most instances of failure to receive payment occur because of the consultant's reluctance to discuss this matter in advance, or because the administrator has not appreciated the value of the services to be rendered.

Assuming that the administrator wants the services and believes they are valuable, the consultant should outline what will be done by way of summarizing his understanding, and should state his fee. Generally, a fee for a total program of services should be cited; however, prevailing practices may have accustomed a facility to pay for services on a per patient, per diem, or per monthly basis. A fee can be presented which combines both aspects (as a mythical example, $500.00 for the program, which amounts to a per patient cost of $5.00 or a per diem cost of $100.00). Make sure that the administrator accepts the fee basis without reservation, and that reservations, if any, are discussed before services are rendered. You should mention how you will be billing the

administrator at the same time. Most consultants find it wise to follow up this discussion with a written statement to the administrator, detailing the services to be rendered, the fee, and the billing schedule. Be sure to mention any additional items such as travel time, equipment, or materials which will also be included.

Many consultants are not sure what to charge. Frequently, professional associations will have determined some reasonable guidelines, and if they seem acceptable, the standard fee can be presented with assurance that it will be readily agreed to by the administrator. Naturally, consultants with extensive experience can and will charge more. How much more depends upon the consultant's own expenses and sense of self-worth. It is difficult to adequately present a fee with which you feel uncomfortable, or that represents more than you feel your services are worth. In determining his expenses, the consultant should recognize that he has to finance his own business generation and planning time, so his fees should cover these as well.

Frequently, fees are not paid promptly. Failure to pay may be caused by many reasons. Often, it may indicate some reaction to the consultant's performance. If this is suspected, a frank and open discussion with the administrator is imperative. The discussion may begin, "I'm concerned about the fact that I haven't received my fee for so long, and I would like to know why. Is there something that concerns you about my services?" If there isn't a plan for payment with definite dates, one should be established. Vague promises and excuses, if accepted, will often mean that the consultant will continue to be paid late.

Never raise a fee or change a fee basis without notifying an administrator in advance. He has every right to feel deceived unless this is done. In fact, such a change is equivalent to a contract renegotiation and must be justified, or the relationship can be seriously alienated.

THE CONSULTANT'S TOOLS

Listening and Understanding

In addition to the consultant's technical and professional expertise, he must utilize skills basic for establishing good interpersonal rela-


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tions. Too many professional people find it easy to provide the right advice, but forget that others will have to accept and follow it. Most relationships require some attention to an inclusion phase before proceeding to task aspects. The inclusion phase is one in which two people become acquainted, define their relationship to each other, and learn to like and trust one another. The consultant should spend some time in an informal way to get to know the key employees with whom he will be working. Who are they? What are their special interests? How long have they been employed? How do they feel about their jobs? What are their customary procedures for providing patient care? What should you keep in mind when working there? The questions which are best to use express interest in the person and his activities, reflect curiosity and a desire to know, are focused on the other person, and seem natural and straightforward. Helping the other person to understand who you are and what you are hoping to do will also be appreciated. Another useful rule of thumb is to make demands gradually, and then only if requests fail.

Perhaps the most powerful tool the consultant has is his ability to listen to other people. There is no substitute for being able to fully pick up the nuances of feelings and thoughts which are the essence of the messages we receive. Such habits as thinking ahead of the person to complete his thoughts, mentally judging the individual and his motivations, mentally prescribing for his problems—in short, any kind of listening other than full conscious attention to the person and what he is saying—interfere with the ability to fully understand what the person means. The best attitude is one of thinking with the person.

Offering advice is easy, but make sure you fully understand the problem and have obtained a complete description of what is involved. And, after providing some acknowledgment of what you have been told, then proceed to agree, disagree, or offer advice.

The consultant's questions are also powerful tools, especially those which make the other person think. "What did you hope to accomplish when you did that?" "How do you think it could be done?" "What might be another way to do that?" Questions such as these stimulate thought, create involvement,

stimulate the desire to know. They help develop the staff, and similarly, help establish you as someone interested in them, who can guide, coach, and teach people to do a better job.

Surveying

Surveys are extremely useful devices to help people recognize the need for changing practices. At times, staff members can assist the consultant to prepare some criteria for evaluating treatment care, and then they can apply these to current practices. This has the advantage of 1) identifying needs that have to be taken care of, 2) educating staff members to emphasize appropriate behavior, and 3) developing evaluative yardsticks for the future. This technique encourages more acknowledgment of institutional lacks and needs because it comes from self-study and recognition rather than from "expert" analysis. It also creates less anxiety and defensiveness, thus leading to better motivation for change. The purpose of any survey, however, is not to be an instrument for blame, but an indicator for future improvement—a guidepost for solving problems.

In addition, other techniques which the consultant is advised to consider using include special questionnaires and tests, conference leadership techniques, demonstration techniques, coaching and guidance skills, and control devices to ensure follow-up.

INTRODUCING CHANGE

Everyone is eager to make changes rapidly, particularly if one is the instigator of change— and the consultant is no exception. Yet, the desire to hurry change can boomerang. Policy statements can be written and warnings issued, but the staff can still fail to make the desired changes. Why?

The answer is simple, if you analyze yourself and others. Who would rush home tonight and drastically alter the routines of a household? Very few would, for obvious reasons; we have developed habits, preferences, and attitudes which make us feel comfortable and which seem to work well enough.

Similarly, it takes time for attendants, orderlies, nurses, and patients to unlearn old


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habits and attitudes, and to divest themselves of the emotional attachment and comfort associated with them, unless: 1. They feel sufficient discomfort and anxiety

about their current behavior. 2. They have developed a new way to do things,

or have participated in plans for change. 3. They know in advance what changes are

desired and why they have to be made. 4. The changes are easy to make. 5. The benefits from the changes are easy to

observe. 6. They receive some encouragement, praise, or

benefit by changing. 7. They like the person who is asking them to

change. 8. They fear the person who is asking them to

change. Who introduces change is often as important

as what and how. A stranger may not have earned the right to offer changes unless people know him and know that he has become familiar with their customs, methods, and practices. The boss may sometimes be the best person to introduce change; sometimes, an influential, well-liked employee may be the best person. Enabling people to get credit for introducing change can also assist in getting changes made since it is difficult to reject one's own brainchild. The group may be able to suggest change. Use help whenever you can; you should not be the only one who is introducing change.

Some changes are not worth making. It is good to be able to acknowledge that and back off from the change if, after a fair evaluation, that appears to be the case. Too many changes at once may make it impossible to change because the competition for time and effort is too great.

Try not to start a new relationship by insisting upon change. Demonstrations can provide a model for change, especially when people are helped to learn painlessly, without criticism or blame. Do not make the mistake of attacking the sacred cows of old practices and beliefs. Make your points by acknowledging their values and conveniences before introducing the additional benefits which may be gained.

Finally, have patience. In many facilities, skill and experience levels may be low. Give people time to change and provide encourage

ment, help, and compliments along the way. Don't stand aloof on your professional critic's viewpoint. To get people to change some simple habits may take months. Learning to look at long-range goals and results may make the waiting a little easier.

Meeting Opposition

At some time, every consultant meets a stumbling block in the form of people's reactions. Becoming emotional and arguing in the face of strong vocal disagreement or abuse is common. These tactics often generate more resistance. A more effective strategy, not only from the standpoint of winning the argument but also of inducing commitment to your point of view would be to 1) listen fully to the other person, 2) try to identify the feelings and beliefs behind his point of view, 3) find out why he thinks the way he does, 4) acknowledge the value of his point of view, and 5) try to present your reasons and feelings, taking into account his point of view. This strategy is easier to apply if you believe that you do not always have to be right and if you do not take absolute stands.- The willingness to acknowledge mistakes and to be receptive to other people's ideas helps to win approval and acceptance from others. Most people are willing to be reasonable, if they are given reasons, if they understand them, and if they agree with them. Try to create the kind of atmosphere that encourages questioning, discussion, and disagreement, that invites and gets openness from others. When someone blocks you, find out why before you take action.

WHEN TO TERMINATE A RELATIONSHIP

A time may come when a consultant feels he is no longer needed. Formalize the termination of a relationship; don't wait for it to conclude. Termination may occur when appropriate professional staff have been added to the facility, the level of performance meets or exceeds standards for good patient care, the consultant feels the existing staff is independent and fully capable, or too many difficulties have been encountered and too little support has been given.

The first three instances call for some kind of termination; however, the consultant is advised


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to review with the administrator the original goals of the program, the accomplishments to date, and the expected progress for the future. In addition, the administrator should be asked for his evaluation. Assuming a mutually satisfying situation exists, little more than goodbyes may be called for, with a willingness expressed to be called again if help is required. (Call periodically to fmd out how things are going, and to renew old ties.)

Some circumstances necessarily bring about changed relationships, e.g., when the consultant is moving, or, for other reasons, cannot continue to provide existing services. He has an obligation, however, to notify the administrator in advance, to offer assistance in finding a suitable replacement, and to introduce and orient the new person before leaving. In this way, changes in consultants can be made most acceptable to the facility.

In the fourth instance, the consultant should try to confront the administrator with the difficulties he is experiencing as soon as they occur, with the spirit of wanting to improve the situation rather than blaming or fault finding. Failure to do this early is one of the major reasons why consultative relationships fail. Signs of poor support are often early warning notices that something is amiss, e.g., the program may have been too expensive or the consultant may have alienated someone. The consultant is responsible for determining the reason and finding some way to solve the problem, if possible. At times, a statement that the consultant desires to cancel the contract may be all that is needed to remedy a bad situation. The consultant should also have some specific recommendations to make to the administrator at that time.

For the technically oriented therapist, this exposition may indeed create much awe and

trepidation. The problems of physical therapy themselves are tangible and familiar and, for the person considering the possibilities of consulting, fairly well manageable. To suddenly consider all the dimensions that might be involved in relationships and to have to develop the interpersonal skills in a self-conscious and focused way may seem !<ke a formidable task. It would be, if we were all beginning at once. But what is contained here is pressed out of the distillate of personal and social relationships that is part and parcel of all of our human experience. It may seem complicated, but that is only because it has been exploded into a larger relief for the sake of making apparent those factors which have to be considered.

REFERENCE

1. The California Chapters, American Physical Therapy Association: Professional Guidelines for the Physical Therapist. Guidelines for Physical Therapy Consultation. Sacramento, CA, The California Chapters, 1967

THE AUTHOR

*' Allan Katcher, Ph.D., is President •If of Atkins-Katcher Associates,

Inc., 8383 Wilshire Blvd., Beverly jr""I* Hills, California, a firm of man-

•HKmm age men t consultants. He received B9r / his Ph.D. in psychology at the

University of California and has taught at the University of Washington, University of Chicago, University of California at Los

Angeles, and California Institute of Technology. He is professionally involved in organizational development, team development, life style management, and also in the training of professionals in consulting skills and practice management.


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When the Physical Therapist Serves as a Consultant

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Transcript of When the Physical Therapist Serves as a Consultant