S C H O L A R L Y P A P E R 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 io t h e r a p y in S o u t h A f r ic a Pa p e r 2: M a p p i n g S t r a t e g y - C r it ic a l C h o ic e s o v e r 3 0 Y e a r s ABSTRACT: This p a p e r dem onstrates an unusual approach to trace decision m a k e r s ’ interpretations o ver tim e as they a ttem pt to understand environm ental events. The p a p e r adopts an evolutionary p ersp ective and m ethodologically, dem onstrates a w ay o f tracing changes in cause m a ps o ver tim e fr o m available docum ents a n d statem ents. A rgu m ents are offered f o r the usage o f such data to infer cognitive processes. The South A frica n Society o f P hysiotherapy is the su b ject o f study. BOWERBANK P, MCSP, MBL, BA (Hons)1 1 Emeritus Professor, Faculty Health Sciences, University of C a p e Town The author conducted this research as part of a study for a PhD degree. “I have been very privileged to be your Chairman at the most exciting point in our Society’s history. In April o f this year the election took place fo r the first Professional Board fo r Physiotherapy- it was a very proud moment fo r us all. ” Chairman’s report SASP council minutes 1973. The South African Society o f Physio­ therapy is committed to being a dynamic, united, innovative and professional organisation; effectively representing its members and playing an active role in the formulation and implementation o f health care policy in South Africa. PhysioForum Sept 2000. W hy are some organisations able to adjust to changing circum stances while others fail to respond to environm ental changes that threaten their long-term viability? To w hat ex ten t are pro fessional organisations shaped by their environ­ ment, that is, by the network of indivi­ duals, groups, agencies and institutions with w hom they m ust interact? Are there org an isatio n al ch aracteristics such as strategies, structures, processes - w hich work for one environm ent or p eriod o f tim e but w hich m ay fail in another? Are there linkages across these characteristics w hich determ ine organisational success? PURPOSE The purpose o f this paper is firstly to reveal a m ethod for conducting longi­ tudinal field research on change in a professional organisation. Specifically the research task is to link the content, context and processes o f change and transform ation in the South A frican Physiotherapy profession over 30 years, from 1971 -2 0 0 0 . Secondly the purpose o f the research reported here is to gain insight into how interpretations, made by decision m akers in the physiotherapy profession, change over tim e to accom ­ m odate u n fam iliar co n cep ts and to reconceptualise fam iliar ones and to link this interpretation process to the tim ing and content o f strategic change. How do the decision-m akers in the p h y sio th erap y p ro fessio n view th eir environm ent? How does this affect the co u rse o f action they p re scrib e for the profession? H ow do they revise these conceptions? Professional service o rg an isatio n s d iffe r from industrial o rg anisations, they are characterised by a high degree o f self-m anagem ent and collegial control, since only other professionals are held responsible to evaluate their peers (Botha and Orkin, 1993). The physiotherapy profession in South A frica is represented by its pro­ fessional association, a non-statutory body which relies on voluntary m em ber­ ship from the student and qualified physiotherapists in that country. The professional association plays an im por­ tant function and role in the developm ent o f the profession (Bow erbank, 2000; Richardson, 1999). In order to m aintain enduring m em bership it has to actively pursue the com m on mutual beneficial goals and interests o f its m em bers. Broadly speaking these goals include: to exert influence on state regulators; to prom ote the collective good of the m em bers; to obtain econom ic advan­ tage; and to enhance the im age o f the profession. As such, and as the principal decision making body for the physio­ therapy p ro fessio n in S outh A frica, the professional association the South African Society o f Physiotherapy (SASP) presents the ideal subject for the purpose o f the research outlined above. CONCEPTUAL UNDERPINNINGS The strategy literature stresses the need to be concerned w ith understanding how organisations adapt to their changing CORRESPONDENCE TO: P Bow erbank No 7, A lbion Road R ondebosch 7700 South A frica Tel: (021) 685-6314 E-m ail: pbow erbk@ iafrica.com SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 3 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. ) mailto:pbowerbk@iafrica.com e n v iro n m e n ts an d the re la tio n s h ip betw een an o rg anisation’s long term success, even survival, and its ability to m aintain strategic alliance w ith its environm ent, (Barr, 1998). The im por­ tance o f strategy hinges on the assumption that organisations can and do adapt to changes in their environm ent. There is an explicit recognition that change is m ultifaceted involving poli­ tical, cultural, increm ental, environm en­ tal, and structural as well as national dim ensions (Pettigrew, 1990). W hereas transform ation is change, not all change is transform ation; transform ation is a m ajor change in an organisation involv­ ing a break with existing routines and a shift to new kinds o f com petencies that c h allen g e o rg an isatio n al k now ledge, it involves changes in goals, boundaries and activities (Aldrich, 1999). Research linking cognition to strategy sug gests that o rg an isatio n action is based upon beliefs that decision m akers hold regarding how the organisation can best succeed in its current environm ent (Daft and Weick, 1984). This belief system is developed over tim e and is based on tim e and events presenting a useful “m ap” for understanding organi­ sational action. A ldrich (1999) suggests that transform ation only takes place following an event in the environm ent, the nature o f the response to these events is shaped by the interpretation processes w hich eventually define that particular event. A contextual analysis o f a process such as change draws on phenom ena at vertical and horizontal levels o f analyses and the interconnections between those levels through time. An exam ple of this is the effect o f regulatory context on the features o f professional organisation and interest group behaviour over a time period, eg the increm ental change in the ethical ruling for medical referral and its effect on professional developm ent, special interest groups, education and econom ic advantage. C ognitive processes m ay represent an im p o rtan t m echanism by w hich organisations adapt to their environm ent. N arayanan and Fahey (1990) argue for a cognitive view o f strategy form ulation by build in g th eir arg um en ts on the concept o f causal maps. Causal maps allow the m apm aker to focus on action - how the respondent explains the current situation in term s o f previous events (H u ff, 1990). This view o f strategic fo r­ m ulation is therefor m ore explanatory and is com plem entary to m any o f the causal assertions prevalent in the stra­ tegic m anagem ent literature. Research on causal attributions is related to stu­ dies o f interpretation o f specific events and relates this to strategic action. METHODOLOGY Interp retation is a cognitive process and a key difficulty in any research that attem pts to identify cognitive processes is that they cannot be m easured directly (Barr, 1998). G iven the re se a rc h e r’s inability to directly m easure the con­ struct o f interest, the results o f cognitive processes such as w ritten archival attri­ butes m ust be used as indirect reflections o f the cognitive processes that generate them. The key considerations in selecting statem ents for analysis are; (1) W hose statem ents to analyse? (2) W hat type o f statem ents is o f interest? (3) H ow to elicit the inform ation? M uch o f the literature on interpre­ tation in p ro fessio n a l o rg an isatio n s suggests that rather than one individual guiding the actions o f the organisation there is a constellation o f jo in tly held, co n sen su al u n d erstan d in g s betw een groups and in d iv id u als w ithin the organisation (G ioia and Sims, 1986). H ow ever the interpretations o f chairm en are also seen to be m ost closely related to and reflective o f changes in strategic action (N orbum and Birley, 1988). The m ajor task in the research was to extract relevant data from the consid­ erable am ount o f available inform ation in order to construct revealed causal maps (RCM s). In a longitudinal study interview s becom e difficult for two rea­ sons: first the organisation chairpersons may not be available or be difficult to access and secondly even w hen acces­ sible their m em ories m ay have dim m ed or be faulty. A m ethod o f generating interpreta­ tions for longitudinal studies is content analysis o f docum ents w ritten during the period o f interest. The assum ption m ade is that the issues discussed by d ecisio n -m ak ers in these d ocum ents reflect im portant concerns o f that time. C ause m apping is a form o f content an aly sis that iso la tes the assertio n s w ithin a d o cu m en t that deals w ith causality or categorisation. A ssertions can be m apped to gain a larger picture of changing beliefs and both m ap structure and in d iv id u al statem en ts can be exam ined for changes over tim e ( Barr, Stim pert and Huff, 1992). CONTEXT AND STUDY PERIOD T he research therefor focuses on the m inutes o f the council m eetings held by the SA SP from the period 1971 - 1999. T he view adopted in this research is that the rep orts by the chairm an o f the professional association and the deci­ sions, in the form o f m otions, passed by the national council are m ost likely to closely relate to strategic action taken by the p h y sio th erap y p ro fessio n in South Africa. W hilst statem ents made by chairpersons in their report are con­ cerned w ith the past, the m otions passed at the m eetings are concerned with the future. T hese statem ents serve as an im p o rtan t forum in w hich in te rp re ­ tations are a rtic u lated and they are a particularily rich source o f causal' statem ents about the environm ent and professional strategic action. T he source o f data is taken from the m inutes o f all the Council m eetings held by the SASP betw een 1971 - 1999, m eetings w ere held every two years (except for the later 5 years in the 1990s) - 15 m eetings in total. Eight different chairm en held office during this period. REVEALED CAUSAL MAPS C ausal maps are revealed to the public by decision m akers during the process of public discourse - revealed causal maps are assertions o f causality w hich deci­ sion makers choose to reveal to the world around them. Since decision m akers em ploy different w ords their assertions cannot be com pared, consequently their “m a p s” h av e to be p re sen ted in a way w hich will serve theoretical ends. A graphic schem e for depicting these assertions is presented in Figure 1 and is anchored on strategic m anagem ent literature. The schem e is based on that o f N arayanan and Fahey (1990), it is built up on three blocks or hierarchies - 4 SA J o u r n a l o f Physiotherapy 2001 V o l 57 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. ) Figure 1: Conceptual Scheme for Organising Revealed Causal Maps E N V IR O N M E N T M ACRO ENVIRO NM ENT HEALTH CARE INDUSTRY E c o n o m ic r e g u la t o r y te c h n o lo g ic p o lit ic a l s o c io / c u l t u r c 1 g r o w t h c o m p e t it io n p o lic y c u s to m e r s s u p p lie r s STRATEGY O BJECTIV ES \ \ 1 . Q U A L IT Y S ER VIC E M a r k e t in g S e r v ic e \ E x p e r tis e R e s e a rc h p u b lic s e c to r \ & & p r iv a t e s e c to r \ S k ills E d u c a tio n e d u c a tio n P ro fe s s io n a l 2 . E C O N O M I C A D V A N T A G E d e v e lo p m e n t 3 . P R O F E S S IO N A L I M A G E /I D E N T IT Y Figure 2: Summary Map of Chairman's Reports 1971 - 1975 1 9 7 6 - 1985 1 9 8 6 - 1991 1992 - 200 0 m a r k e tin g 2 4 0 1 2 s e rv ic e d e liv e r y 6 1 4 1 9 1 3 p r o fe s s io n a l d e v e lo p m e n t 1 6 1 4 . 8 1 4 e x p e rtis e 7 2 3 3 e d u c a tio n 7 1 0 5 7 g r o w t h 3 4 5 0 c o m p e titio n 3 6 0 4 p o lic y 1 1 5 9 c u s to m e rs 2 2 7 3 s u p p lie rs 2 3 0 4 m acro-environm ent and industry, func­ tional strategy, and objectives. The schem e show n here is adapted for professional health care organisations. DERIVING REVEALED CAUSAL MAPS Chairman's report Stage 1 T he m ethod suggested by (A xelrod, 1976) was adopted for deriving “raw ” revealed council m aps (RCM s). Only the chairm an’s reports were used for this part o f the research. All the statements in the form o f concepts and cause-effect re la tio n sh ip s w ere cap tu red in the language o f d ecisio n -m ak ers. Only statem ents that referred to the external environm ent and strategic developm ent or action w ere used. Statem ents refer­ ring to internal professional m atters were discarded. For each report the statem ents were aggregated in network charts (Appendix 1). Stage 2 The “raw ” maps were translated into RC M s using the scheme presented in Figure 1. T he concepts w ere sorted into one o f the theoretical categories. A rrow s depict the direction o f causal linkages. (Appendix 2) Stage 3 The RCM s constructed on an annual basis were aggregated over the eras by com bining all the causal maps o f that era. (Figure 2) Decisions taken by Council Stage 1 All the m otions passed by each council were extracted, only those, which require strategic action connecting w ith the external environm ent, were categorised. Stage 2 The scheme presented in Figure 1 was used to translate these statem ents into theoretical concepts. SA J o u r n a l o f Physiotherapy 2001 V o l 57 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. ) Figure 3: Summary map decisions by council 1971 - 1975 1976 - 1985 1 9 8 6 -1 9 9 1 1992 - 200 0 FUNCTIONAL STRATEGY m a r k e tin g 2 7 1 3 3 s e rv ic e d e liv e r y 5 11 1 5 8 p r o fe s s io n a l d e v e lo p m e n t 6 7 7 4 e x p e r tis e 2 0 2 1 e d u c a tio n 1 8 4 5 OBJECTIVES q u a lit y s e r v ic e / p r iv a t e / p u b li c / e d u c a t io n 6 1 2 1 4 1 5 e c o n o m ic a d v a n t a g e / s a la r ie s / f e e s 6 7 6 0 p r o fe s s io n a l i m a g e / id e n t i t y 5 1 5 21 6 Figure 4: Summary External Events and Organisation Adaption 1971 - 1975 EXTERNAL EVENTS STRATEGIC ACTION * M e d ic a l A i d S c h e m e s A c t * M e d ic a l, d e n ta l a n d p h a r m a c y a c t * s c o p e o f p r a c t ic e * lim ite d r e g is t r a tio n * D e v e lo p m e n t o f M a it la n d m o b ilis in g te c h n iq u e s - v is it b y M a it la n d to S A * L a ck o f p a r it y s a la rie s * N a t io n a l a th le tic s m e e tin g * F o r m a tio n p r iv a t e p r a c t itio n e r s g r o u p * E le c tio n p r o fe s s io n a l b o a r d * F o r m a tio n O M T g r o u p * M e m o a n d m e e tin g w ith a u th o r it ie s - * P h y s io p r o v id e d r o u n d c lo c k s e rv ic e 1 9 7 7 - 1983 * R e m u n e r a tio n c o m m is s io n e s ta b lis h e d * S h o r ta g e o f p h y s io s in N W h o s p ita ls * F irs t lin e p r a c t it io n e r sta tu s in A u s t r a lia f o r p a tie n t r e fe r r a l * S A M D C a g r e e s to 4 y e a r d e g r e e f o r a ll p h y s io t h e r a p y u n d e r g r a d tr a in in g * PPA fo rm s a ta r if fs c o m m itte e * T r a in in g f o r p h y s io t h e r a p y a s s is ta n ts * R e c o m m e n d a tio n to S A M D C f o r c h a n g e in S A e th ic a l r u le * P re s su re o n u n iv e rs itie s w ith d ip lo m a to c o m p ly * M o d e r n k n o w le d g e & s k ills to r e p la c e o ld s y lla b u s 1985 -1991 * M a j o r te c h n o lo g ic a l a d v a n c e s in t e r t ia r y h e a lth c a r e * In c re a s e in p o s t g r a d u a t e c o u rs e s * C o lle g e p h y s io p r o p o s e d * Q A p r o g r a m m e s in tr o d u c e d * F irs t lin e p r a c t it io n e r sta tu s g r a n te d * P o litic a l p re s s u re fr o m w o r ld b o d y (W C P T ) * P ro fe s s io n a lis a tio n in s p o rt * In c re a s e in p r o fe s s io n a l m a r k e tin g * A ll t r a in in g 4 y e a r d e g r e e * P riv a te p r a c t ic e p r o life r a te s * S A S P re je c ts a p a r t h e id p o lic ie s - p re s e n ts p o lic y to W C P T * M S c in s p o rts p h y s io - p h y s io a p p o in t e d to n a tio n a l s p o rts te a m s * B a c k w e e k in t r o d u c e d 1993 - 1999 C h a n g e in g o v e r n m e n t & h e a lth c a r e p o lic y a n d e m p h a s is o n PHC * R e c o g n itio n f o r d if fe r e n t le v e ls o f h e a lth c a r e w o r k e r * E s ta b lis h m e n t o f TRC * M a n a g e d h e a lth c a r e in p r iv a t e s e c to r * E s ta b lis h m e n t e th ic s c o m m itte e * A c c r e d it a t io n o f p r a c tic e s * P o lic y s ta te m e n ts c o m p ile d o n a ll p r o p o s e d p h y s io s e rv ic e s * E ffo rts to d e v e lo p C BR p r o g r a m m e s * S A S P m a k e s a s u b m is s io n to TRC * PPA c h a n g e s to P h y s io F o c u s & in tro d u c e s P h y s io N e tW o r k s 6 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 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. ) Causal linkages were m ade between the functional strategy category and o bjectives for each council m eeting (Appendix 3) Stage 3 The RCM constructed for each council was aggregated over the eras. (Figure 3) DATA REPESENTATION AND INTERPRETATION The task o f presenting the data from the causa] maps is not an easy one. In this report I have adopted a descriptive stance and do not address the issues relating to predictive validity o f the maps. Identifying Eras This research assum es an evolutionary approach to organisational change, it takes the stance described by Aldrich (1999) that organisational transformations occur within historical and geographical contexts. Transform ation often follows an external event, which takes place in the external environm ent. In this case specific “events” were identified which lead to significant change in the South African Physiotherapy profession. These events divided the period under research into four eras. (All quotes in italics are those o f the chairperson at that time). 1971 -1977 Three events characterise this era. The amendment to the South African Medical, Dental and Pharmacy act 1971 heralded the electio n , in 1973, o f the first Professional Board o f Physiotherapy - a statutory body which greatly increased the au tonom y o f the ph y sio th erap y profession. As shown at the beginning o f this article the chairm an described this as “the most exciting point o f our society’s history". A second event during this period was the first visit to South A frica by M r G eoff M aitland who was invited to run a course on the mobilising techniques, which bore his name. His visit was described as “an unparalleled success ” and was to change much o f the way p h y sio th erap ists p ractised. The third event was the prescription, in 1976, o f certain m agisterial districts (in fact m ost o f the old ap arth eid era South Africa) whereby only registered physiotherapists could practise in those areas “a fulfillment o f a long awaited dream - the culmination o f many many years o f dogged determination by those who served this society so faithfully’’. 1977 - 1985 In 1979 at a meeting o f the world body (W CPT) the A ustralian Physiotherapy A ssociation presented the concept o f first line practitioner status for physio­ therapists. Following this, in 1981, the South African Society o f Physiotherapy (SASP) sent a com prehensive m em o to the South A frican Medical and Dental C ouncil (SA M D C ) recom m ending a change in the ethical rule for patient referral “the acceptance will have fa r reaching implications - a major shift in professional status, responsibility and accountability”. This was accepted and prom ulgated in 1985. M em ber countries o f W C PT m ounted increasing po litical p ressu re on the SA SP because o f the apartheid policies held in the country “we are under fire from certain countries regarding accept­ able policies in this country - we will have to convince the international body that we as a society do not necessarily subscribe to those view s”. 1985 - 1991 This era was characterised by increasing pressures from health activists for the recognition o f different levels o f health w orker “there is a need to distribute rehabilitation services throughout the community - the future structure must include the facility fo r entry into the profession at several levels”. This pres­ sure was coupled with declining health budgets in state health and radical cuts in public health expenditure “the fra g ­ mentation o f the health service has made availability o f health care to all people even more difficult”. 1991 - 1999 T he single m ost sp e ctacu lar event, which took place in this era, was the release from prison o f N elson M andela and the subsequent change in govern­ ment and political pow er “never before has council met at such an auspicious tim e”. Health care policy changed from support for curative tertiary care to that o f p re v en tativ e p rim ary health care (PHC) “perceptions o f how the desired health care o f the future is to be, vary grea tly”. T he priv ate sec to r h ealth care m oved from a fee for service policy to that o f m anaged health care “we attended a negotiating forum on managed health care - the minefield in privatised health ”. DISCUSSION Figure 4 sum m arises the events which took place in the environm ent, and the resultant changes in the physiothe­ rapy profession. Significant actions took place due to the change in legislation firstly, the form ation o f the professional board for physiotherapy and secondly, the eventual prom ulgation o f the ethical rules allow ing physiotherapists the free­ dom to practice without a patient referral from a medical practitioner. Selection o f this change in legisla­ tion, as one o f the focal events, led to the period o f interest for this study being 1971 - 1999. Starting the time ju st prior to the change in legislation provided a baseline for identifying change in interpretation and strategic action. Porter (1985) describes the 1970s as one o f com petition - com petition am ongst occupations - we are separate - we m ust com pete. All professional o rg an isatio n s w ere c o m p etin g and m aking dem ands on money, prestige and power markets. C om petition was shaped by econom ic supply and dem and and resulted in: i) m onopoly o f tasks and market, ii) very strict pro fessional entrance requirem ents; and iii) shifts in consum er needs. In order to m aintain the position gained in the 1970s several actions had to take place in the 1980 - the com petence o f the entrants to the profession had to be raised; quality controls were imposed over members work; m echanism s had to be developed for im proving profes­ sional skills and techniques; and m arket­ ing strategies had to be developed. These actions becam e a source o f social change within the physiotherapy profes­ sion and developed the foundation for true professionalism - it lead to: i) new privileges eg PPA negotiated their own tariffs, ii) graduate education; and SA J o u r n a l o f Physiotherapy 2001 V o l 57 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. ) Figure 5: Threats and Opportunities Facing the SASP THREATS/OPPORTUNITIES STRATEGIES/SOLUTIONS * R e -o r ie n ta tio n o f th e p u b lic s e c to r - re c o u rc e s & fu n d in g to P H D * R e -o r ie n ta tio n o f r e h a b ilit a t io n s e rv ic e s * In c re a s e d p u b lic / p r iv a t e c o - o p e r a tio n — * M u lt i- d is c ip lin a r y c o - o p e r a tio n * In te g r a tio n o f h e a lth s e rv ic e s - c o s t e ffe c tiv e s e rv ic e s __ * C o n tr a c ts b e tw e e n p r o v id e r & g r o u p s & fu n d e r s * N e w r o le p la y e r s in h e a lth c a r e a r e n a * A llia n c e s & jo in t v e n tu re s * In c re a s e d c o m p e tit io n fr o m o th e r a llie d h e a lth p r o fe s s io n a ls _ * C lin ic a l g u id e lin e s & o u tc o m e s d a ta * C h a n g in g p a tie n t p r o file s & r e fe r r a l p a tte rn s * L ic e n s in g & a c c r e d ita t io n o f p r a c tic e s * In c re a s e in c o n s u m e ris m — * T e c h n o lo g y f o r c o m m u n ic a tio n * In c re a s e d lit ig a tio n * T e c h n o lo g y fo r d a ta c a p tu r e & in f o r m a tio n * In c re a s e d c h a lle n g e o f e th ic a l p a r a m e tr e s __ iii) it directed leg islatio n to pro tect the profession eg who may or not register. Perusal o f Figures 2 and 3 shows how the interpretation by chairm an o f these eras is focused on service delivery and professional developm ent and the deci­ sions taken by the council are directed at achieving quality service and im proving the professional image. The 1990s saw a com plete turn around - com petition, usually a pow erful force for both quality enhancem ent and cost reduction appears to be driving costs through the ceiling (Teisburg and Porter, 1994). This resulted in the skewed developm ent o f high tech, curative ser­ vices being halted; closure o f hospitals and services in the public sector; em pha­ sis on prim ary health care and a move tow ards m anaged health care in the public sector. Physiotherapists them ­ selves w ere deeply affected by these dram atic changes and a flurry o f policy statem ents and a redirecting o f service strategies resulted. IMPLICATIONS Institutional constituents, including the state, professions and interest groups im pose a variety o f laws, regulators and expectations on professional bodies. T he maps (Figures 2 and 3) show that the m ajority o f stimulus/cause for organi­ sational change cam e from the m acro environm ent and m ost particularily the regulatory and financial context. This is not surprising, institutional theorists have em phasised the survival value o f conform ity with the institutional envi­ ronm ent and the value o f adhering to external rules and norms (Oliver, 1990). Organisations will expect to acquiesce m ore readily to pressures that do not co n strain su b sta n tiv e o rg an isatio n al decisions. However, in 1989, following the c o n sid e ra b le p re ssu re from the w orld body (W CPT) w hich was threat­ ening expulsion o f South A frica from its m em bership, the SASP took unpre­ cedented steps to defy and challenge the apartheid policy o f the governm ent - issuing a strongly w orded policy docu­ ment. The likelihood o f resistance to institutional pressure is predictable if the organisation is dependent on the constituent who is exerting the pressure. In this case the SASP w ould have suf­ fered considerably if it w ere expelled from the w orld body. A few years later the SASP was able to m ake a virtue o f its insurrection by subm itting a docu­ m ent to the TRC acknow ledging its faults and om issions o f previous years. In S ep tem b er 2000 the SA SP published a new proposed vision and the rea lities facing the p h y sio th erap y profession in South A frica (FORUM Septem ber 2000). I printed the vision at the beginning o f this article. I have reorganised the realities into threats/ opportunities and solutions/strategies - Figure 5. The threats/opportunities have been categorised into a suitable variable according to Figure 1. You will notice that they fall into - supplier, com p etitio n , co n su m e r and policy contexts - none o f these variables has figured to any great degree over the past 30 years. L ikew ise the solutions are all relatively new concepts. Perhaps the physiotherapy profession is on the threshold o f a new transform ation. A professional organisation’s survival is enhanced if it conform s to social norms o f a c c ep tab le behav iour, these self serving advantages result in a variety o f rew ards for exam ple, increased prestige, stability, legitim acy, so cial support, interna] and external support, access to resources, attraction o f personnel, acceptance to other professions (Oliver, 1990). T he research described in this article has shown som e o f the interpretations and decisions m ade by the physiotherapy profession in South A frica over the past 30 years. M any o f these decisions have resulted in action, w hich have been well rew arded by society as described above. T hough the focus o f this research was on identifying specific events and pat­ terns o f interpretation across the physio­ therapy profession several interesting results suggest that it is not ju st the interpretation o f isolated events that are im portant to strategic change but also linkages across events. The efforts over the years to have physiotherapy assistants officially recognised and the concept o f p h y sio th erap y stu d en ts doing an internship-year after qualifying w ere all thwarted until new policies w ere adopted by governm ent introducing mandatory continuing education and the concept o f life lo n g le a rn in g a n d s e a m le ss 8 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 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. ) education. The im plications being that successful o utcom es are linked to changes in the environm ent and that key activities change over tim e as they adapt to the environm ent. FURTHER RESEARCH This research has several implications for further research. The relationship between the health industry and physio­ therapy organisational context and the developm ent o f interpretations relating to strategic adaptations remain to be identified. Secondly the relationship b etw een industry and org anisational context o f the special interests groups of the SA SP requires further investigation. ACKNOWLEDGMENTS The author is indebted to P rofessor Frank H orw itz o f the Graduate School o f Business, University o f Cape Town for all his support during this research and to the adm inistrative staff at SASP headquarters who allow ed me to sift through all their archives. REFERENCES A ld ric h H E 1999 O rg a n is a tio n s E v o lv in g , S ag e p u b lic a tio n s, L o n d o n A x e lr o d R 1976 S tru c tu r e o f D e c is io n , P rin c eto n U n iv e rsity P re ss, P rin c e to n , N ew J ersey B a rr P S 1998 A d a p tin g to U n f a m ilia r E n v ir o n m e n ta l E v e n ts : A L o o k a t th e E v o lu tio n o f I n te rp re ta tio n a n d its R o le in S tra te g ic C h a n g e . 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In: T h e T h in k in g O rg an isatio n , S im s H an d G io ia D (e d ito rs). J o s se y B ass, S an F ra n sisco H u f f S E 1990 M a p p in g S tra te g ic T h o u g h t. Jo h n W iley, N ew York N a ra y a n V K , F ah ey L 1990 E v o lu tio n o f R ev ea le d C a u sa l M a p s d u rin g d e c lin e . In: M a p p in g S tre g ic T h o u g h t. H u ff S E (ed ito r). Jo h n W iley, N ew York N o rb u rn D , B irley S 1988 T op M a n a g e m e n t Team . S trategic M a nagem en t Journal: 225 - 237 O liv e r C 1990 D eterm in a n ts o f In te ro rg an i- s a tio n a l R e la tio n sh ip s. A ca d e m y m a n a g e m e n t R ev ie w 15(2): 241 - 265 P ettig re w A 1990 L o n g itu d in a l F ie ld R esearch o n C h a n g e . O r g a n is a tio n a l S c ie n c e 1(3): 267 - 292 P o rte r M E 1985 C o m p e titiv e A d v a n ta g e , F ree p ress, L o n d o n R ic h a rd so n B 1999 P ro fe ss io n a l D e v e lo p ­ m en t. P h y sio th e ra p y 8 5 (9 ): 4 6 7 - 473 T eisb u rg E O , P o rte r M E, B ro w n G B 1994 M a k in g C o m p e titio n in H ea lth C are W ork. H arvard B u sin ess R ev iew , J u ly /A u g u s l Appendix 1: An Example of Raw Revealed Causal Map CHAIRMAN'S REPORT 1987 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 9 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. ) Appendix 2: An Example of Reconstructed Causal Map Appendix 3: Constructed Causal Map REQUIRED STRATEGY OBJECTIVE DECISIONS 1987 T h a t th e s o c ie ty in v e s tig a te th e p o s s ib ility o f o b t a in in g d e m o g r a p h ic d a ta fo r m a ll PTs a n n u a lly w h e n th e y p a y th e ir r e g is t r a tio n fe e s to S A M D C PD PROF N o t to u n d e r ta k e th e tr e a tm e n t o f a n y p a tie n t ... e x c e p t in a n e m e r g e n c y o r in c lo s e c o lla b o r a t io n w it h a re g is te r e d m e d ic a l SD SER V A m e m b e r m a y e n te r in to a s s o c ia tio n w ith a re g is te r e d m e m b e r o f a n o th e r s u p p le m e n ta r y h e a lth s e rv ic e s p r o fe s s io n w ith th e a p p r o v a l o f th e P ro f b o a r d SD SER V T h a t th e s o c ie ty in v e s tig a te s th e re s p e c tiv e ro le s o f th e u n iv e r s ity le c tu r e r & th e h o s p ita l PT in th e c lin ic a l in s tr u c tio n o f th e PT s tu d e n t ED SER V T h a t th e S A S P m a k e s r e p re s e n ta tio n to P ro v in c ia l a n d s ta te a u th o r itie s to d is c o n tin u e th e use o f th e te rm p a r a m e d ic a l w h e n r e fe r r in g c o lle c tiv e ly to su ch p r o fe s s io n s a s PT, O T PD P RO F 1 T h a t th e S A S P w r it e to th e u n iv e rs itie s to stress th e n e e d f o r h ig h e r d e g r e e s f o r r e g is t r a tio n in m a ip t h e r a p y ED S ER V ED T h a t N E C re q u e s t th e P ro f B o a r d to in v e s tig a te m e a n s o f e n s u rin g th a t PTs a r e n o t a llo w e d to o p e n s o lu s p r a c t ic e w it h o u t o n e y e a r s c lin ic a l p r a c tic e in a n a p p r o v e d in s titu tio n S D SER V 10 SA J o u r n a l o f P hysiothera py 2001 V o l 57 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. )