The changing nature of therapeutic recreation: maintaining consistency in the face of change.

The field of therapeutic recreation is now faced with changes that impact both educational preparation and professional practice. In the health care arena, greater emphasis is being placed on health promotion, prevention of secondary conditions among individuals with disabilities, and community-based wellness initiatives. Given the role of leisure behavior in moderating health status and enhancing quality of life, therapeutic recreation professionals have the opportunity to respond to this emerging trend in health care. But to do so, they must possess the knowledge and skills needed to design, implement, and evaluate health programs geared at affecting lifestyle changes through leisure. Another force influencing service delivery to persons with disabilities is the change in paradigm being advocated by the disability community, which proposes a shift from being mere recipients of clinical services to becoming informed consumers who developed and work toward wellness goals in partnership with trained health professionals. Once again, therapeutic recreation practice, when rooted in the concepts of self-efficacy and locus of control, has the potential to answer the demands of its constituents. In a world of higher education, recommendations from various public and governmental sources are calling universities to revise their educational curricula to include cross-discipline training and work-force preparation. This manuscript examines the aforementioned forces and suggests the need for rethinking the way we currently operate in order to secure the future of therapeutic recreation. It also presents the reorganization recently undertaken by Temple University's therapeutic recreation curriculum as one example of a proactive attempt to respond to the challenges and opportunities confronting the discipline.

Therapeutic recreation, like most disciplines today, is surrounded by change. These changes exist in the world of health and human services, the arena in which therapeutic recreation specialists are most heavily employed, and in the world of higher education, where emerging therapeutic recreation practitioners receive "relevant" preparation for entry-level practice. Although such times can be disconcerting, adjustments are necessary for growth or, in some cases, survival. Reorganization is a reality in today's world, and that reality has enormously impacted health and human services and higher education. Organizational responses to changing conditions, however, should not preclude the need for thoughtful decisions about how such changes would affect the fundamental nature and purpose of the organization, the professional discipline, or the service provided to clients. For therapeutic recreation practitioners and educators everywhere, the current climate represents a time to reassess the fundamental tenets of our discipline. For the faculty at Temple University, the climate and subsequent reorganization has resulted in a reaffirmation that therapeutic recreation preparation, practice, and research ought to be guided by three distinct yet interrelated themes: disability, health, and leisure. This article identifies some specific change forces that are influencing practice as well as the educational preparation of therapeutic recreation students, and provides one example of how faculty are integrating these changes into the curriculum.

Change Forces Affecting Service Delivery

Reorganization, redefinition, and maximization of similarities and differences are the standards in health care today. Health care is dramatically different today than it was 10 to 20 years ago, and while the 1997 Job Analysis Report of the National Council for Therapeutic Recreation Certification may have indicated that little has changed in terms of entry-level skills required for certified therapeutic recreation specialists, the environment, pace, and focus of the agencies in which therapeutic recreation is being practiced has changed and will continue to change in the upcoming years.

An emerging trend that is gaining increasing support among health care agencies is the greater emphasis on disease prevention and health promotion. This focus is an excellent opportunity for therapeutic recreation, provided practitioners have the knowledge and skills to develop programs in this area. A few major trends can account for the greater emphasis on health and wellness programs. For instance, the national health objectives proposed in Healthy People 2000 (USDHHS, 1991) include several health targets for people with physical disabilities, including, reducing leisure-time physical inactivity; reducing negative effects from stress; and increasing the proportion of persons with disabilities who receive health education information about using community and self-help resources and managing their health conditions (p. 604-605). Furthermore, the Institute of Medicine's publication, disability in America: Toward a National Agenda for Prevention (1991), contains a number of recommendations for the provision of comprehensive prevention and health-promotion programs for persons with disabilities, including expanding research on preventive and therapeutic interventions; developing new health-service delivery strategies for people with disabilities; developing new health-promotion models for people with disabilities; and examining the longitudinal effects of these programs on health and wellness behavior.

Most recently, CARF-The Rehabilitation Accreditation Commission has developed standards for health enhancement programs in its 1997 manual. According to CARF:

Health Enhancement Programs are proactive, comprehensive, and outcome focused. They are designed to prevent health risks and to optimize function, performance, productivity, and the quality of life of the persons served. These programs assist persons to identify and accept responsibility in the management of their own health and support their efforts to gain or maintain their health through a coordinated continuum of care that has the capability to address: health, health promotion, nutrition, rehabilitation, disease/injury prevention/management, prevention of secondary conditions, lifestyle management/enhancement, wellness/fitness, quality of life (p. 223).

Likewise, the National Center for Medical Rehabilitation and Research (NIH, 1993) has also identified prevention, specifically prevention of secondary disabilities, as a primary research and funding area. And finally, numerous health care facilities have begun to operate community-based health and wellness facilities that are open for use by the general public and people will disabilities. Undoubtedly, the practice within the health care arena is and will continue to be influenced by these priorities.

Parallel to these trends in the health care arena is a movement spearheaded by the leaders of the disability community (Shapiro, 1994). Individuals with disabilities have been calling for a paradigm shift in the way they are perceived and how their needs are addressed, and are increasingly questioning the view of disability as something that needs to be "fixed." Rather, they are asking professionals to examine the environment that often presents obstacles to their efforts to live independently. Similarly, individuals with disabilities are also claiming a more active role in determining which services meet their needs. The term consumer is often used in place of patient, showing the desire to be regarded as more than passive recipients of treatment interventions. Such a paradigm shift does not ignore the need for and importance of rehabilitation as a means to achieving functional health; however, it expands the definition of health so that "health and wellness" can exist in the presence of disabling conditions. It asks service providers to put greater emphasis on helping individuals with disabilities take charge of their lifestyles, not only to prevent further losses but also to achieve physical and psychological well-being. It also invites human-services professionals to approach the individual holistically as someone who not only wishes to learn to walk or speak but as someone who yearns to work, recreate, communicate, and socialize. Finally, it also challenges practitioners to go beyond the clinical setting, to work toward community integration and participation, to help find creative solutions to environmental barriers, and to focus on quality of life.

Certified therapeutic recreation specialists should be involved in these initiatives via the development of "health enhancement" programs in all settings. Clearly, leisure is an excellent arena for coordinating lifestyle changes, especially those changes related to achieving and maintaining physical and psychological health. According to Coleman and Iso-Ahola (1993), leisure behavior is a particularly germane moderator of health status and well-being. Increased participation in physically and socially active leisure buffers the stress associated with life crises and other challenges in daily life. "Leisure-generated self-determination disposition and leisure-generated social support are the two main properties of leisure that presumably buffer against increased life stress," (Coleman & Iso-Ahola, 1993, p. 114). Other research (Brock, 1988; Green, 1989; Rancourt, 1991; Mahon & Bullock, 1992; McGuire, Boyd & James 1992; Santiago, Coyle & Kinney, 1993 Coyle, Shank, Kinney & Hutchins, 1993 Coyle & Santiago, 1995) has shown the role of leisure in enhancing quality of life, improving health, and decreasing the incidents and severity of secondary conditions among persons with disabilities. Healthy People 2000, Disability in America: Toward a National Agenda for Prevention, and the revised CARF standards have set the stage in health care for the development of services that do more than rehabilitate; the opportunity exists for programs that can promote and enhance health, wellness, and quality of life. Therapeutic recreation should be a natural service provider in this emerging arena, but it is a role where practitioners must assert and demonstrate leadership, or it will pass us by as other disciplines move their practices toward a health-enhancement model.

In addition, if therapeutic recreation hopes to maintain the support of those who consume its services, we must remain in touch with changing trends in the disability community and organize our practice accordingly. For some of us trained under the medical model, the paradigm shift discussed above may be uncomfortable and challenge our perceived role as healers. However, a brief examination of theories in which therapeutic recreation practice is rooted -- social-learning theory or attribution theory -- reveals that self-determination and self-efficacy have long been in our discourse. It appears, then, that responding to our consumer demands is possible if we are able to translate theoretical tenets into everyday practice.

Change Forces Affecting Educational Preparation

In 1995, the Pew Health Professions Commission issued a report titled "Critical Challenges: Revitalizing the Health Professions for the 21st Century." This report contained several provocative recommendations that deserve consideration by the therapeutic recreation curricula. The report calls for a broadening of the medical sciences perspective to include psychological-behavioral sciences as well as a reorientation of the health system away from treatment and towards education and prevention. With their call for greater collaboration among disciplines (and, in fact, a de-emphasis of specializations), the report urges a restructuring of education to include cross-discipline training, carried out "where it makes most sense for the lesson to be learned and is most convenient for the student." A simple interpretation and adjustment would result in more classes where therapeutic recreation students interact fully with students from allied disciplines including (but not limited to) school and community health education majors, social work majors, allied health majors, as well as those majoring in leisure services. Further interpretation of the report would result in increased use of field-based sites for instruction. The result, according to the report, will be "more active modeling of effective team integration in the delivery of effective, efficient, and quality care," (Pew Health Professions Commission, 1995, p.36).

Of course, a major dilemma facing educators today is the scope of the curriculum; just how much can undergraduate students receive in their curriculum? Obviously, hard choices will have to be made. The Pew report (1995) states:

It is simply impossible for students to learn with the same level of thoroughness all of the knowledge that is available. Instead, they should learn basic competencies and be expected to continue to learn throughout professional life. They should be provided with an educational experience that leaves them always questioning and with the skills to answer the questions they frame throughout the years of practice (p.33).

To accomplish this, they recommend that general competencies include a strong foundation in the sciences, increased critical thinking and analytical problem-solving skills, and excellent communication abilities. Such a foundation would enable students to understand systems change and ethics. These core competencies are identical to what the U.S. Department of Education and Labor's "National Health Care Skills Standards" project refers to as "employability skills" (Siri & DaVanzo, 1995).

Other forces, both from the public and the government, are causing colleges to re-examine how they do business. Declining public confidence and tough questions of accountability are raising such issues as productivity, efficiency, and cost effectiveness. Like health and human service agencies, colleges are being challenged to focus less on the process of education and more on the outcomes of education (Levine, 1997). That is, what is the quality of the student that is graduated? Much of this change has been driven by employers who are unhappy with the product of colleges because graduates are not prepared to step into a particular industry (e.g., health care) and immediately make a contribution. A report by the Education Commission of the States says that colleges need to radically reorganize to adequately prepare students for the workforce (Schmidt, 1996). Like the Pew report, it recommends combining education with the workplace to ensure student competence.

Unfortunately, universities, especially undergraduate educational curricula, have typically been slow to respond to the changing needs of the work world and society. That slowness has contributed to what now seems like massive changes in higher education. College and university reorganizations are becoming commonplace, with little commonality across the industry. Therapeutic recreation curricula must become proactive in such reorganizations or face the threat of being labeled by others on planning committees as insignificant and peripheral.

References

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Brock, B. (1988). Effects of therapeutic horseback riding on physically disabled adults. Therapeutic Recreation Journal, 22(3), 34-43.

Coyle, C.P., & Santiago, M.C. (1995). Aerobic exercise training and depressive symptomatology in adults with physical disabilities. Archives of Physical Medicine and Rehabilitation, 76, 647-652.

Coyle, C., Shank, J., Kinney, W., & Hutchins, D. (1993). Psychosocial functioning and changes in leisure lifestyle among individuals with chronic secondary health problems related to spinal cord injury. Therapeutic Recreation Journal 27(4), 239-252.

Coleman, D. & Iso-Ahola, S. (1993). Leisure and health: The role of social support and self-determination. Journal of Leisure Research, 25(2), 111-128.

Commission on Accreditation of Rehabilitation Facilities (1997). Standards Manual and Interpretative Guidelines for Medical Rehabilitation. Tucson, AZ: Commission on Accreditation of Rehabilitation Facilities.

Green, J. (1989). Effects of a water aerobic program on the blood pressure, percentage of body fat, weight, and resting pulse rate of senior citizens. Journal of Applied Gerontology, 8(1), 132-138.

Institute of Medicine. (1991). Disability in America: Toward a national agenda for prevention. Washington, DC: National Academy Press.

Levine, A. (1997). Higher education's new status as a mature industry. The Chronicle of Higher Education. January 31, A48.

Mahon, M. & Bullock, C. (1992). Teaching adolescents with mild mental retardation to make decisions in leisure through the use of self-control techniques. Therapeutic Recreation Journal, 27(1), 9-25.

McGuire, F., Boyd, R., and James, A. (1992). The Clemson humor project. Activities, Adaptation and Aging, 17(1), 31-55.

National Council for Therapeutic Recreation Certification. (1997). 1997 Job Analysis Report, New City, New York: NCTRC.

National Institutes of Health (1993). Research Plan for the National Center for Medical Rehabilitation Research. U.S. Department of Health and Human Services, NIH Publication No. 93-3509.

Pew Health Professions Commission (1995). Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century. The Third Report of the Pew Health Professions Commission. San Francisco: Center for the Health Professions, University of California San Francisco.

Rancourt, A. (1991). An exploration of the relationships among substance abuse, recreation, and leisure for women who abuse substances. Therapeutic Recreation Journal, 25(3), 9-18.

Santiago, M., Coyle, C., & Kinney, W. (1993). Aerobic exercise effect on individuals with physical disabilities. Archives of Physical Medicine and Rehabilitation, 74, 1192-1198.

Schmidt, P. (1996). Report urges reforms in job training. The Chronicle of Higher Education. August 2, A23.

Shapiro, J. (1994). No pity: People with disabilities forging a new civil rights movement New York, NY: Times Books.

Siri, A & DaVanzo, J. (1995). National Health Care Skill Standards. San Francisco, CA: West Ed.

U.S. Department of Health and Human Services (1991). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office, DHHS Publication No. (PHS). 91-50213.

RELATED ARTICLE: ONE EXAMPLE OF REORGANIZATION

Recent reorganization initiatives at Temple University have resulted in a therapeutic recreation curriculum that is more responsive to the challenges and opportunities confronting the therapeutic recreation discipline. Now housed in a newly created Department of Health Studies, the new curriculum allows students access to health-related skills and knowledge that will allow them to practice more effectively in the health-promotion arena. Therapeutic recreation students now receive a better foundation in health psychology and health behavior, and a special emphasis is placed in the curriculum on having students learn how to promote wellness and fitness through leisure behavior. This educational experience allows students to better design and deliver services that promote health and well-being. The new curriculum's philosophical foundation is rooted in the belief that play, recreation, and leisure are significant contributors to health status, functional capacity, and quality of life. In addition, students are exposed to public-health policies that shape the health and human service environments in which therapeutic recreation competes; students sit in classes along with peers majoring in social administration, community health education, and allied health. This educational experience should allow students to become more marketable and effective in these changing times. It undoubtedly allows therapeutic recreation students to articulate their role in health care to the vary colleagues with whom they will collaborate in client care, enlightening these individuals to the unique role of therapeutic recreation in promoting health, wellness, and leisure behavior among persons with disabilities. Likewise, it allows therapeutic recreation students to advocate for inclusive programs.

While this is but one example of a response to the issues and forces raised in this article, the same situation is facing -- or has already faced -- numerous other curricula. In the case of Temple University, the result has been a reorganization that will hopefully allow students to more easily find the curriculum in therapeutic recreation and more effectively prepare them to make an immediate impact on the delivery of health, wellness, and leisure services to persons with disabilities.