S c h o l a r l y A r t i c l e T h e S t r a t e g ic D e v e l o p m e n t o f P h y s i o t h e r a p y in S o u t h A f r ic a P a p e r 1: S o m e T h e o r e t ic a l C o n c e p t s W h ic h R e l a t e t o O r g a n i s a t i o n a l C h a n g e A B S T R A C T : This is the fir s t o f two papers which examine the relationship between professional organisations and organisational change. Different theoretical paradigm s f o r change are outlined against the historical development o f the physiotherapy profession in South Africa. An evolu­ tionary approach using an open systems fram ew ork emphasises the need fo r constant interaction by the physiotherapy profession with the external environment. Some o f the responses by the physiotherapy profession to the changing events and shifts in the external environment are discussed and some strategic recommendations f o r the continuing sustainability o f the profession are made. KEYWORDS: PRO FESSIONAL ORGANISATIONS; PHYSIOTHERAPY; TRANSFORMATION; THEORIES OF ORGANISATIONAL CHANGE. BOWERBANK P, MCSP, MBL BA(Hons)'; 1Department of Physiotherapy, University o f C a p e Town INTRODUCTION Organisations form one o f the most fundam ental characteristics o f modern society. They are founded as a conse­ q u e n c e o f h is to ric a l n e c e ssity and resource availab ilty (A ldrich 1999). T hrough organisations people pursue activities too broad in scope to be accom ­ plished by individuals. M ajor tasks, such as health care, are addressed not by a single organisation, but by sets o f inter­ dependent organisations which include nursing, physiotherapy, m edicine etc. This is the first o f two papers which seek insights into the ways the phy­ siotherapy profession in South Africa evolved, m anaged and sustained itself as a sm all professional organisation throughout the last 30 years. This first paper introduces m odern sociological theories w hich underpin our understanding o f professional orga­ nisations, o rg anisational change and transformation processes. The evolution o f the,physiotherapy profession in South Africa will be used as an example. CORRESPONDENCE: Associate Professor Pat B ow erbank Physiotherapy Departm ent Faculty o f Health Sciences University o f Cape Town Observatory The second paper will relate how the profession changed over time and the course o f the profession in contem po­ rary society will be charted over the period 1970 - 1999. Chronologically, the decisions and actions that shaped the profession’s history will be tracked, as well as the related trends and events which took place in the environm ent and impacted on the profession. The second paper also investigates the strategies em ployed by physiothera­ pists in South Africa for professional growth and survival; and, draw ing on the theoretical concepts discussed in the first paper will propose a physiotherapy paradigm for m anaging the health care environm ent in South Africa. No formal theory has been developed which contains a physiotherapy para­ digm for understanding and managing the health care environm ent. A num ber o f recen t authors (P aartero , 1982; Tynne-Lenne, 1991; Richardson, 1993; Grant, 1995) have challenged physio­ therapy organisatio n s w orld -w id e to question their profession and its place and role in health care. They have sug­ gested that the use o f a paradigm as a th eoretical concept could fram e the questions which would help to establish an organisational identity and definition for the profession. Paradigm proliferation in organisational studies has given us a wealth o f perspectives in w hich to view organisations and organisational change. THEORIES OF ORGANISATIONS & ORGANISATIONAL CHANGE The physiotherapy organisation is not self sufficient, depending on interchanges with its environm ent in order to be sus­ tained. Under the influence o f m odem social scientists we now recognise that organisations, such as physiotherapy, are strongly em bedded in environm ents and environm ental influences penetrate organisations in many ways. There is an abundance o f theoretical inquiry and research on the relationship betw een organisations and their societal contexts; organisation-environm ent rela­ tions; and conceptual models of organi- sation-environm ent relations (D iM aggio and Powell, 1983; A llm endinger and Hackm an, 1996; Hannan and Freeman, 1977, 1989) This paper adopts an evolutionary approach which assum es that organisa­ tions do not follow a fixed path of developm ent, instead, external events in teract w ith an o rg a n isa tio n ’s ow n actions to drive the pace, pattern, and direction o f change (Aldrich, 1999) - o rg an isatio n s reform , transform and renew them selves to fit the environment. All transform ations are tim e-dependent historical pro cesses, g en eralisatio n s 4 SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) made about the physiotherapy organi­ sation must therefore be historically grounded and limited to the dom ain o f the profession. As the environm ents o f organisations change and as the needs or dem ands o f clientele change, organisations must, if they are to persist, be able to change. Organisations are always changing and generally change typically takes the form o f episodes, distinct periods in which some shift takes place - such shifts may be in the external environ­ ment such as technology, governm ent policy or laws, consum er dem ands or by changes in the internal context - struc­ ture, norms, and values. A physiotherapy paradigm requires that the profession think o f itself in terms o f what it does, how it does it and how it identifies itself in terms o f pro­ fessional values. The notion o f a paradigm has the potential to help clarify, express and ev alu ate fundam ental beliefs w hich underpin phy sio th erap y organisation (Richardson, 1993). This process of critical self reflection and self identifica­ tion helps to determ ine what is given attention, what interpretations are made and what behaviours are elicited. Kuhn (1970) used the term paradigm to express unique thinking, acting and m ethods o f solving problem s of a parti­ cular group o f people.' PHYSIOTHERAPY AS A PROFESSIONAL ORGANISATION All professions cam e into being to fulfil a specific social function and they are found in the division o f labour which prevails with the times. Within health care, professions delineated their own sphere o f activities into specialist areas as they sought to define their fields into specific occupations and to em phasise their own status. In 1970 a greater propo rtio n o f physio th erap ists w ere em ployed by the state in bureaucratic institutions, either hospitals or clinics, which were perceived at that tim e to be the main em ploying bodies. The classic perspective on bureaucracy was pro­ posed by Weber (1947) and had, as one o f its main characteristics, a hierarchical structure and em ploym ent based on length o f service and merit. This posed many problem s to the aspirations and developm ent o f physiotherapists and to the profession itself and lead to a move, by m any physiotherapists, towards the more independent private sector. Goode (1969:275) states “ ... m any aspiring occupations and semi professionals will never becom e professionals in the usual sense; they will never reach the levels o f knowledge and dedication to service that society considers necessary for a profession.” He goes on to say that even if they do reach professional level they will always be less professional ( than eg medical doctors) in such traits as cohe­ sion, com m itm ents to norms o f service and control over professional violations. O rganisations that seek recognition m ust change them selves and be able to engage in transactions which include power, prestige and income. Professional status for physiothera­ pists in South A frica has been an on going ambition for some tim e and since 1972 there has been considerable recog­ nition o f a structured body o f knowledge, a regulating body with a code o f practice, and recognition o f autonom y o f practice. Physiotherapists w orking in the private sector have been able.Jo negotiate with appropriate bodies over fee structures and to establish their own incomes. M intzberg (1979:175) defines a pro­ fessional as “som eone in w hom the capacity to carry out some complex, specialised w ork has been internalised through extensive training.” and describes the function and structure o f profes­ sional organisations as follows: 1. relying for co-ordination o f function on the standardisation o f skills and its associated training and indoctrination; 2 . having c o n sid erab le control over their own w ork but w ork.closely with the clients served, the social system within the profession is collegial; 3. standards are m aintained by the self governing professional associations which sets their own occupational and ethical guidelines; 4. professional associations set universal standards which emphasis the power o f expertise and licensing system; 5. the structure o f the professional orga­ nisation becom es at the sam e tim e both functional and market-based; 6 . and (also) the activity is connected to some value the com m unity considers important. In a sense professionalism can be seen as an ideology w ith certain c ru ­ cial characteristics associated with it (Paatero, 1981), and the position and location o f physiotherapy is along a con­ tinuum o f professionalisation - shifting as conditions change. An organisation is “a social structure deliberately created and m aintained to get work done” (Etzioni, 1964:195), “goal d ire c te d , b o u n d a ry -m a in ta in in g and socially constructed” (Aldrich, 1999:2). Physiotherapists, as part o f such a social structure, occupy three main employment roles in South Africa, the role o f state em ployee which involves making phy­ siotherapy skills available to the public sector; the role o f educator involving the training and education o f under graduate and, m ore recently, post graduate stu­ dents; and thirdly the role o f private practitioner which includes contracting an individual’s skills directly to indi­ vidual patients or specific organisations. T he most im m ediate difference in the nature o f the three roles is the degree to which the holder may define the role. THE PROFESSIONAL ASSOCIATION T he professio n al asso ciatio n has to balance the diverse needs expressed by the different coalition groups am ongst its mem bership in order to m aintain a legi­ timate presence both internally and to the outside com m unity o f stakeholders. M ichaels (1976) describes an asso­ ciation as “a collection o f people who agree to com e together and govern them selves by certain rules in order to accom plish things w hich as isolated individuals they could not accom plish.” T he South African Society o f P hysio­ therapy (SASP) in the form o f a volun­ tary association cam e into being in 1925, it has gone through several stages o f internal restructuring and currently has approxim ately 3000 members. The function o f professional associa­ tions is to exert an influence on state regulators; prom ote collective good o f the mem bers through information shar­ ing; obtain econom ic advantage; reduce legislative or com petitive uncertainty through the efforts to standardise the SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) services o f members; and to enhance the im age o f the profession and its m embers O liver (1990). Professional associations m ust be orientated towards the needs of their m em bers by pursuing objectives which enhance the well-being, status, recognition and quality o f the profession (Benveniste, 1987); through these broad objectives the association represents, controls and sets policy for the entire profession, ensuring the know ledge base is relevant to its task and thus legiti­ mising the profession. Thus the professional association plays a central role in defining and defending its boundaries and m aintaining its rela­ tionship with the external environm ent, influencing and inform ing stakeholders and preventing encroachm ent from other professionals. However, the current shift in health care policy firstly away from disease orientated m edicine tow ards a more participative client based system whereby clients take more responsibility for their own health; and secondly, encom passing a m ore com prehensive, m ultidisciplinary approach means the profession’s boundaries are likely to becom e m ore blurry with a greater over­ lapping and sharing o f com m on skills. This presents new challenges to the pro­ fession which has- spent considerable time and effort over the past 20 years protecting its skills and scope o f prac­ tice. New generic skills, broader defini­ tion o f the scope o f practice and a more pragm atic understanding o f the task domain whilst retaining the skills w hich define physiotherapy are all issues fac­ ing m odem physiotherapists. The scope o f practice for physiothe­ rapy, w hich is prescribed and changes from time to time in line with acquired technologies and patient needs, lays down specific goals and unam biguous criteria for understanding the activity o f physiotherapy; as such it legalises and legitim ises the activity. H ow ever the scope o f practice is likely to becom e m ore am biguous in the future as more disciplines allied to physiotherapy such as m asseurs, biokineticians and exercise therapists jo in the m ulti-disciplinary ranks. This could pose as either a threat o r an opportunity to the physiotherapy profession depending on the strategic approach that is utilised. CONCEPTS OF ENVIRONMENT & THEORIES OF ORGANISATIONAL CHANGE This paper adopts an open system per­ spective and as such views organisations as a com prehensive structure o f coalition o f interests and netw orks o f interdepen­ dent activities. T hese are dependent on resources, inform ation and technology from the outside environm ent w hich shapes the structure and supports the organisation. O rganisations in an open- system fram ew ork interact w ith their external environm ent which, in this con­ text, may be defined as being com posed o f those institutions or forces that affect the perform ance o f the organisation but over which the organisation has little or no direct control. G enerally speaking these forces may be seen as follows; political events and changes in regimes; legal and regulatory policy change; shifts in societal norm s and values; changes in resource availability. In order to develop, organisations have to be capable o f detecting trends, events, com petitors, m arkets and tech­ nological developm ents in the external environm ent which are relevant to their survival and to w hich they have to adapt. Thus the physiotherapy profes­ sion has had to respond to events in the environm ent, developing a unique, deci­ sion m aking process which is set in a historical context. C ycles o f transform a­ tion have resulted changing the course o f the profession. Transform ation in this context refers to a m ajor change in the (physiotherapy) organisation involving a break with existing routines and a shift to new kinds o f com petencies that chal­ lenge professional know ledge resulting in changes to goals, boundaries, and activities (Aldrich, 1999). CHANGE AND OPPORTUNITY Barbara Richardson (1999) writes “ the aim now is to em pow er patients to m anage their own health needs and it is proposed that this will be best supported through m ulti-disciplinary and inter­ disciplinary team w ork ... for physio­ therapists, collaboration in a socially- based, client centred model o f health care is a radical change from the treat­ m ent o f patients in large acute hospitals d o m in ated by a m edical m odel o f health care” Population ecology theory (Hannan and Freem an, 1989) explores how popu­ lations (eg physiotherapy profession) are transform ed by environm ental changes. C hange fo r a p a rtic u la r pop u latio n occurs through an evolutionary process, those better suited or w hich fit best to their environm ent survive and those that do not fit - die. New organisations are then created or evolve that em body the new needs o f the environm ent. Health care organisations are closely linked to external forces o f both political and social nature and as such are largely dependent on those institutions to confer legitim acy and resources - both essential for their survival and fitness with the environm ent. M uch o f the change affecting the cur­ rent health care reform s in South Africa, and, for that m atter in other parts o f the world, is being driven by both econom ic reality and the need to express ideolo­ gical com m itm ent. One distinguishing feature o f the private sector reform s is their focus which basically aims through a m arket m echanism to alter the core purpose o f purchasers; whereas ideolo­ gical underpinning can be seen in the public sector by a m ove away from essentially line m anaged, “high tech” curative m edicine tow ards more com ­ prehensive community based health care. T he com plexity o f the external envi­ ronm ent and the dem ands and con­ straints w hich this places on the phy­ siotherapy pro fessio n requires m uch effort and visionary thinking from the profession in order to sustain the growth it has experience in recent years. At the same time it offers an opportunity to m ove forward on m any fronts challeng­ ing the decisio n m aking ability o f physiotherapists to m ake responsible choices. Their ability to do this will depend, in part, firstly on their profes­ sional adaptability and confidence and secondly on their desire for the sustain­ ability o f the profession. CONCLUSION T he physiotherapy profession in South A frica has evolved from a small begin­ ning in 1925 to an established contem ­ porary health care organisation in 2000. This paper has drawn on a variety o f sociological theories and perspectives to 6 SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) explain the pattern o f change which has taken place in the professional organisa­ tion over the past 30 years. R eference is m ade to ev o lu tio n ary theory w hich em phasises the need for legitim acy in the developm ent o f technology, norm a­ tive and legal standards necessary for professional sustainability w ithin the external environment. W hilst review ing material for this paper it appeared to the author that the p h y siotherapy p ro fessio n in South A frica worked hard over the past 30 years to achieve true professional status, in so doing it concentrated on the first fo u r professional ch aracteristics as suggested by M intzberg, 1979 (above). Now it has an opportunity to consolidate these characteristics into professional skills and must look to developing the fifth and sixth characteristics - thus making the profession both functional and m arket based w hilst connecting the activity to som ething o f value to the community. REFERENCES Aldrich, H.E. 1999. Organisations Evolving, Sage Publications, London Allmendinger, J., & Hackman, J.H. 1996. O rganisations in Changing Environm ents. Administrative Scien ce Quarterly 4 1, 337-369. Benveniste, G. 1987. P rofessionalising the Organisation, Jossey-B ass, San Francisco D iM aggio, P.J.,& Pow ell, W.W. 1983. The Iron Cage Revisited.Am erican Sociological R eview (48), 146-160 E tzion i, A . 1964. M odern O rganisations, Prentice Hall, Englew ood-C liffs. G oode, W.J. 1969. The Theoretical Limits o f Professionalisation. In: The Semi Professio­ nals and Their Organisation, ed Etzioni,A. First Press, U S A , 266-309. Grant, R. 1995. The pursuit o f E xcellence in the Face o f Constant Change. Physiotherapy 81(6), 338-344. Hannan, M.J.,& Freeman, J.H. 1977. The Population E cology o f Organisations. A m eri­ can Journal o f S o c io lo g y (82), 929-964. Hannan, M .J.,& Freem an, J.H. 1989. O rganisational E c ology. C am bridge M A. Harvard University Press. Kuhn, T.S. 1970. The Structure o f Scientific R evolutions. University o f C hicago Press. M ichaels, M. 1976. W CPT Address Eighth International Congress. South African Journal o f Physiotherapy 32(2), 16. M intzberg, H. 1979. The Structuring o f Organisations. Prentice-Hall, Englewood-Cliffs. Oliver, C. 1990. Determinants o f Interorga- nisational Relationships. Academ y M anage­ ment R eview 15(2), 241-265. Paatero, H. 1982. Physiotherapy in Perspective. Congress proceedings, W CPT Ninth Inter­ national Congress, 868-876. Richardson, B. 1993. Practice, Research and Education - What is the link? Physiotherapy 7 9(5), 317-322. Richardson,B. 1999. Professional D evelop ­ ment. Physiotherapy, 85(9), 4 6 7-473 Tynne-Lenne, R.A. 1991. Towards a Physio­ therapy Paradigm. In: Congress proceedings, Eleventh W CPT International C on gress, 238-240. Weber,M. 1947. The Theory o f Social and Econom ic Organisations (Translated), Oxford University Press, N ew York. N e w M i l l e n n i u m T i m e t o t h i n k o f a c h a n g e ? Quality Locums are looking for quality personnel in all grades and specialities for work in the UK. Eligibility for a visa or work permit would be an advantage, but even if you are not eligible we would stiJL like to hear from you as we may be able help. Quality Locums are the largest independent Medical, Care and Education Agency in the UK and we have branches in South Africa and Australia. We need Medical Staff of all specialities, Social Workers and Teachers urgently to fill full and part time positions throughout Great Britain and Ireland. We are experts at helping you to take advantage of the opportunities in the UK. Why not call one of our managers today for an informal discussion. S o n ja L e w is Quality Locums Cape Town Tel: 021 4625357 Fax: 021 4625390 Email: QualityLocums@W orldonline.co.za Matt W a gn e r Quality Locums Durban Tel: 031 4692098 Email Wagner@yebo.co.za , O v e r s e a s W O R K L I N E “Part o f The Recruitment Solutions Group” One simple phonecall, will open the door to hundreds of opportunities in the UK. rorirthe moment you pick up the phone, you'll know you made the right decision. As a South African Physiotherapist your skills are in high demand throughout the United Kingdom. By talking direct to our friendly and knowledgeable staff you can be assured that all of your working holiday arrangements will be dealt with in a seamless and stress-free manner. You will receive up to the minute information about the many career options available to you in the United Kingdom. We also provide: ■ A meet and greet service ■ Help with accommodation arrangements ■ Bank Accounts arrangements ■ Help with travel arrangements ■ Tax efficient employment packages ■ Great pay rates ■ Visit our web-site at wwwjeauitmentsolutions.co.uk for more details. To take advantage call Angela, Alison, Baski, Nigel or Manny. ' Committed to equal opportunities" The Chambers, 728/730 Eastern Avenue, Newbury Part, Ilford, Essex IG2 4PE. (UK) Toll-free on: 0800 99 1062 or f a x u s your C V on + 4 4 1 8 1 9 2 4 2 0 6 5 or e-m ail u s on: p w litre c ru itn ie n t so lu tio n s .c o .u k SA J o u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 3 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:QualityLocums@Worldonline.co.za mailto:Wagner@yebo.co.za