patient focused care: theory and practice

THERAPEUTIC RECREATION JOURNAL Vol. 35, No. 1, 15-30, 2001

Patient Focused Care:Theory and Practice

Alison Pedlar,* Taflyn Hornibrook, and Bernice Haasen

Therapeutic recreation is often conceptualized as inherently person-centered. However, therehave been virtually no examples of what person focused TR practice actually looks like. Thepresent study attempted to fill this gap. The study was carried out in response to the desire oftherapeutic recreationists at a major Canadian health care facility to better understand then-practice. Of particular interest was the initial encounter between patient and therapist, anencounter that traditionally has been called "assessment." As a part of this action researchproject, the co-researcher/practitioners engaged in a reflective process that allowed them gain adeeper understanding of themselves and their practice. This they did by looking beyondtherapeutic recreation to another discipline, nursing, where they found Parse's theory of humanbecoming. The findings of this study demonstrate an approach that fosters the emergence of moreauthentic relationships between patients and therapists, and enables therapeutic recreation tomore nearly fulfil its potential in the practice of patient focused care.

KEY WORDS: Patient Focused Care, Theory of Human Becoming, Reflective Practice

Individuals admitted to institutionalized wide range of allied health care disciplinessettings often experience a loss of control (Law, Baptise, & Mills, 1995; Lohman, 1980).(Fawcett, Stonner, & Zepelin, 1980). Feelings At the same time, research has indicated that aof frustration and loss of identity among newly sense of control is critical to both physical andadmitted patients have been documented by a psychological health (Deci & Ryan, 1987;

* Please address correspondence to Alison Pedlar, Ph.D., Department of Recreation andLeisure Studies, University of Waterloo, Waterloo, ON, N2L 3G1; Taflyn Hornibrook, M.A.,Department of Recreation and Leisure Studies, University of Waterloo; Bernice Haasen,M.A., Professional Practice Leader, Recreation Therapy and Creative Arts, Sunnybrook andWomen's College Health Sciences Centre, North York, ON.

First Quarter 2001 15

Langer & Rodin, 1976; Rodin & Langer,1977; Searle, Mahon, Iso-Ahola, Adrolias, &Dyke, 1995). Patients and patients' advocatesare now voicing dissatisfaction with ap-proaches to care that tend to exacerbate theexperience of loss of control (Stewart, Brown,Weston, McWhinney, McWilliam, & Free-man, 1995). In response, concerned health carepractitioners are suggesting a revised, patientfocused model. Central to this model is the aimto "create a caring, dignified and empoweringenvironment in which patients truly direct thecourse of their care and call upon their innerresources to speed the healing process"(Mathes-Kraft, George, Olinger, & York,1990, p. 128). The paradigm shift towardspatient focused care has become a priority formany institutions, including one of Canada'smajor health care facilities, Sunnybrook andWomen's College Health Sciences Centre(SWCHSC), a 1,300 bed teaching hospital inToronto, Ontario. There, the move toward pa-tient focused care was spearheaded by nursing,guided by Parse's theory of human becoming(Mitchell, 1993).

The shift to a patient focused philosophy inhealth care is occurring simultaneously with aphilosophical debate within therapeutic recre-ation. Important arguments have been pre-sented within the literature (Sylvester, 1996)in relation to patient autonomy and self-deter-mination, and while the therapeutic recreationliterature has not specifically discussed patientfocused care, it has addressed practices thatrelate directly to that approach. An underlyingcritical theme within this literature is therapeu-tic recreation's adoption of the medical modeland a concomitant "treatment-outcome" phi-losophy. Focussing on treatment-outcomes hastended to diminish many of the beneficialcharacteristics of leisure (Hemingway, 1986;Lahey, 1996; Mobily, 1996; Sylvester, 1998).This result is because leisure experience in-volves spontaneity and internal motivation. Assuch, leisure is essentially person focused(Coleman & Iso-Ahola, 1993). However, ifpatients' activities are prescribed and they areuninterested in engaging in them, as is all too

often the case when the treatment-outcomesapproach is followed, it is unlikely that leisurewill be experienced.

Purpose and Rationaleof the Study

Despite efforts to adopt a treatment-out-come approach to practice, therapeutic recre-ation is often conceptualized as inherently per-son-centered (Bullock & Mahon, 1997;Halberg & Howe-Murphy, 1985; Howe-Mur-phy & Charboneau, 1987). However, therehave been virtually no examples of what per-son focused therapeutic recreation practice ac-tually looks like. In the present study we at-tempted to fill this gap. The study was carriedout in response to the desire of the RecreationTherapy1 professional group at SWCHSC tobetter understand its practice in relation to thetenets of patient focused care and the theory ofhuman becoming. It, thus, became an actionresearch project initiated by the recreationtherapists at SWCHSC who approached theresearchers to undertake a collaborative studyof their practice (Haasen, Hornibrook, & Ped-lar, 1998) in relation to the initial encounterbetween patient and therapist, an encounterwhich traditionally has been called "assess-ment." The purpose of the study was to under-stand the initial encounter or assessment pro-cess from two perspectives, that of the patientand that of the therapist, and to discover theways in which the assessment process wascongruent with Parse's theory of human be-coming.

Parse's Theory of HumanBecoming

Nursing has been a leading discipline in themove toward patient focused care. Nurseshave provided this type of care by committingto and living Parse's (1981, 1992, 1994, 1998)theory of human becoming. Human becoming

1 When referring to the professional practicegroup as SWCHSC, the language used in this paperfollows that in use at the hospital.

16 Therapeutic Recreation Journal

is an ongoing changing process, grounded inthe idea of living paradox, wherein paradox isnot a problem, but a natural rhythm of life.Living paradox is "a rhythmical shifting ofviews, the awareness of which arises throughexperiencing the contradiction of opposites inthe day-to-day relating of value prioritieswhile journeying to the not-yet" (Mitchell,1993, p. 44). Three principles explicate theideas behind the notion of living paradox andhuman becoming:

Principle #1: "Structuring meaning multi-dimensionally is cocreating reality through thelanguage of valuing and imaging" (Parse,1998, p. 35). This recognition of the fluidity ofa person's reality and the many realms of whatwas, is, and shall be for that person illuminatesmeaning. As an individual speaks out loudabout a concern or life event the meaning oftenchanges as articulating thought sheds newlight on the event. Similarly, if something isimagined, a person may see it in a differentlight. For example, Parse (1995) described theexperience of an older man who was terrifiedof telling his wife he had cancer. Imagininghow she would react and how he would sup-port her gave him strength to move forward.

Principle #2: "Cocreating rhythmical pat-terns of relating is living the paradoxical unityof revealing-concealing and enabling-limitingwhile connecting-separating" (Parse, 1998, p.42). Revealing, enabling, and connecting de-pend upon their apparent opposites—conceal-ing, limiting, and separating (Kelley, 1995).For example, while choice can be enabling, itis also limiting. Thus, an older adult with ahealth issue decides to no longer drive, achoice which is enabling with respect to healthbut limiting with respect to mobility. There isone dimension at the fore, but another in thebackground. The rhythm of these dimensionsis synchronized and may ultimately realizechange.

Principle #3: "Cotranscending with thepossibles is powering unique ways of originat-ing in the process of transforming" (Parse,1998, p. 46). Examining and imagining future

options allows for mobilizing transcendence.For example, people who have lost a leg maythink of all the things they can no longer do.By doing so they are seeing their future anddespite the negativity that may accompanytheir thoughts, they may accept their situationand move forward. In fact, in thinking aboutthe "impossibles," the possibles are also oftenconsidered; individuals may begin to see hopein what they can do, once they have acceptedwhat they can not.

At the root of patient focused care is therecognition that such care is not a techniquebut a way of thinking. It is not just used incertain circumstances but is a guide to every-day interaction with patients. In practice, then,the theory of human becoming acts as a guideto interacting with people. The values andbeliefs that make up the theory are committedto and integrated into the lives of those whowish to practice it (Mitchell, 1993). Nursesusing Parse's theory relinquish the roles oftelling, advising, managing, and controllingand instead become listeners, explorers, par-ticipators, and clarifiers for patients. Patientsare encouraged to become the directors of theirown care and ultimately of their health.

Integral to the successful implementationof this theory is the practitioner's ability to betruly present with others, enabling those othersto focus on their becoming as individuals.Mitchell (1993) described true presence as "anintentional way of 'being with' that honors theother's intersubjective relationship with theworld" (p. 69). By "being with" patients,nurses have reported several things happeningin the nurse-person relationship. First, by dis-cussing with patients the meaning of theirpersonal situation, that meaning often changes,resulting in the patient seeing things in a newlight. As well, the nurse's true presence mayresult in the "synchronizing of rhythms," asthe patient discusses fears, hopes, questions,alternatives, and dreams (Mitchell, 1993). Un-der the guidance of the Parse theory, nurses"travel" with patients in that they go with thepatient to each considered choice and conse-quence. This type of interaction often results in


the patient saying that their nurse made apositive difference by not attempting to con-trol their thoughts and feelings (Mitchell,1993).

Rationale for the Chosen ResearchMethods: The Beginning of Action

The aim of this phenomenological inquiry(Moustakas, 1994) was to understand and re-construct the realities that both recreation ther-apists and patients confront in the recreationassessment experience. Accordingly, the re-searchers and the therapists as co-researchersemployed a theoretical framework that wouldassist in their comprehending the perceptionsand meanings of these experiences (Patton,1990). The research adopted a constructivistparadigm, described by Guba and Lincoln(1994) as a wide ranging framework whichassumes that people construct their own real-ity. Inquiry begins with the issues and con-cerns of participants and unfolds through a"dialectic" of iteration, analysis, critique, reit-eration, reanalysis, and so on that leads even-tually to a joint (inquirers and respondents)construction of a case (i.e., findings or out-comes; Guba & Lincoln, 1994, p. 179). Al-though individuals construct their own reality,this construct is or can be jointly determined.

Consistent with the dialectic character ofthe constructivist paradigm, an action researchbased strategy was used. In the past, therapistshave often felt excluded from the researchprocess (Miller & Crabtree, 1994; Sneegas,1989). This study sought to remove, or at thevery least reduce, the separation between ther-apists and researchers through the use of aparticipatory action research strategy in whichthe research process was guided by therapistsand researchers as co-investigators (Pedlar,1995). This strategy has been described as an"approach to social research that involves theresearcher trying to change the system while atthe same time generating critical knowledgeabout it" (Small, 1995, p. 942). Specifically,within this inquiry, action research consistedof active participation of both the researchers

and the recreation therapists at SWCHSC inevery stage of the research and action process,including inception, design, data collection,interpretation, and implementation of change.In order to begin to capture the complexity anddiversity of the assessment experience, quali-tative methods were used (Howe, 1993; Kirby& McKenna, 1989; Patton, 1990).

Study ParticipantsA primary selection of participants (Morse,

1994) was made possible by SWCHSC's in-volvement in the study. There were three cri-teria: (a) the patient had to have been involvedwith the therapeutic recreation department forless than one week, so as to capture their firstencounter; (b) the patient was well enough toparticipate in the interview process; and (c) thepatient had to be "typical" to that unit bydiagnosis.

Residents were selected in order to "iden-tify critical incidents that may be generalizedto other situations" (Morse, 1994, p. 229).Participants included three patients from phys-ical rehabilitation and two patients from eachof the following units: mental health, physicalsupport, and acute care. One recreation thera-pist from each unit participated in the inter-views and observation processes. Thus, a totalof 9 patients (4 men and 5 women) and 4recreation therapists (all women) were in-volved in data collection.

To gain a more holistic view of the assess-ment experience, observations of the actualassessments, as well as semi-structured inter-views with both therapists and patients wereused. All stages of the procedures used in thedesign and data collection were finalized col-laboratively between the primary and therapistco-researchers. The interviews addressed theassessment experience since this was the focusof the inquiry. The observations and inter-views all took place in SWCHSC.

The interviews with the patients took up to60 minutes, averaging 45 minutes each. Inaddition to providing an understanding of thepatient's overall assessment experience, theinterview questions were used to understand


the patient's perception of the role of thetherapist. The interviews with the therapists,which took place immediately after the patienthad been interviewed, averaged 40 to 60 min-utes. Similar to the patient interview questions,the recreation therapists were asked questionsthat attempted to gain an understanding of theassessment experience from their perspective.A journal detailing conversations, meetings,and personal reflections was kept by the pri-mary researcher throughout the entire researchprocess.

Data Analysis and InterpretationThe researcher interwove data gathering

and data analysis as suggested by Miles andHuberman (1994) in order to "cycle back andforth between thinking about the existing dataand generating strategies for collecting new,and often, better data" (p. 50). The entireprocess of data gathering and analysis wasreflective in nature (Small, 1995). This reflex-ivity extended to the therapists as their con-sciousness of the interaction between them-selves and the patients was constantly raiseddue to the iterative nature of the researchprocess.

All interviews were transcribed and obser-vation notes reflected upon immediately afterthey were conducted in order to gain an un-derstanding of the relationship between theactual assessment and the experiences of bothrecreation therapists and patients. Discrepan-cies or similarities in perceptions betweentherapists and patients also were noted andexamined for consistency and meaning. Caseswere read a number of times in order to clearlyidentify the meaning and structure of the in-formation, the key concepts, and finally therelationships between those concepts whichlater in the analysis were synthesized intothemes.

As suggested by Patton (1990), thesethemes were organized into a case record,which was designed to be accessible bothchronologically and topically. Each case con-sisted of field notes of the assessment and the

interviews with both the patient and the recre-ation therapist. Upon completion of the 9 ob-servations and 18 interviews, the transcriptswere read once again, and coded descriptivelyto denote which categories the segment repre-sented and where they could be located withinthe transcripts (Huberman & Miles, 1994).Specifically, the transcripts were analyzed lineby line in order to identify conceptual catego-ries relevant to meaning and behaviour(Strauss & Corbin, 1990).

Segments were then removed from theiroriginal context and organized by category.Any emerging relationships between catego-ries were noted in the researcher's log. At thistime, many of the categories overlapped anddifferent patterns began to emerge. Differ-ences between experiences were noted. Forinstance, when patients' perceptions of thetherapists were noted for similarities and dif-ferences, it became apparent that those patientswho had very positive impressions of the ther-apists had similar assessment experiences. Therelationships between patterns were then fur-ther examined in order to identify broadercategories or themes that emerged frequentlyin the assessment experiences. The themesfrom the case records were then used in across-case analysis of each assessment to ex-amine common themes. These themes gavethe researcher a clear idea of the qualities andcharacteristics of the assessment procedure, aswell as an idea of common or inconsistentpatient/therapist perceptions of their assess-ment experience.

Given the collaborative nature of actionresearch, the therapists were also very in-volved in the final stages of analysis. Valida-tion of the researcher's interpretation wasachieved by including the therapists' feedbackand clarifications. Their involvement in theanalysis consisted of three meetings in whichthe primary researcher presented tentativefindings in the form of themes and patterns tothe participating therapists for review andfeedback.


FindingsDuring the observations and individual in-

terviews, many aspects and impacts of theassessment were described by the participants.Presented below are the themes that emergedfrom the analysis of these data that are partic-ularly relevant in understanding how the as-sessment experience may or may not incorpo-rate the principles of patient focused care andParse's theory of human becoming in recre-ation therapy practice. These themes are (a)sensitivity of language, (b) tools of the trade,and (c) losing sight of the self.

Sensitivity of LanguageThe recreation therapy assessment consists

almost entirely of discourse that establishes aperson's leisure interests and strengths. In de-termining these, the recreation assessmentuses no physiological tests such as blood workor a measure of flexibility. Although there issome assessment of non-verbal behaviour, theassessment is primarily based on verbal com-munication. As the study demonstrates, thiscommunication process is crucial for the qual-ity of the assessment experience. Sensitivityand responsiveness in language included theways in which the patient's experience wasvalidated. Therapists sometimes inadvertentlyinvalidated patient's contributions in their ini-tial exchange. This situation was in part aresult of the therapist feeling compelled toobtain certain information from the assess-ment. Perhaps not surprisingly, invalidating apatient's experience tended to stifle conversa-tion:

Therapist: So, Billy how long have youbeen here?

Billy: Oh about three or four weeks.Therapist: About two I think.

Similarly, therapists can invalidate a person'sexperience by seeming to almost ignore what apatient has to say:

Marjorie: He [her husband] also didpainting. We had all kinds ofpaintings around the house. Idon't know what happened tothe paintings. He died beforehe should have really. He hadcancer. But he was really look-ing forward to painting beforehe retired. He died when hewas 62. It is too bad because hewaited a long time for that.

Therapist: While you're here, whileyou're in the hospital we actu-ally have bowling, we havebowling next Monday.

Redirecting the patient without addressingwhat the patient had just said was not uncom-mon and was something therapists were awarethey were doing. In their individual interviews,they indicated that feeling hurried and con-cerned that they were not gathering the infor-mation they needed often resulted in theirredirecting the patient. Not infrequently, mis-understandings occurred, particularly aroundthe words "leisure," "recreation," and relatedconcepts such as "barrier," all of which areentirely familiar to those trained in leisure:

Therapist: O k . . . u m m . . . do you seeany barriers to your leisure in-volvement?

Bess: Do I see any what dear?Therapist: Barriers to your leisure in-

volvement.Bess: No, just that I haven't been

involved.

Clearly this sort of terminology was unfamiliarto patients, resulting in confusion. Anothertherapist asked Marjorie, "in terms of socialinteraction... how does that make you feel,interacting with someone?" Marjorie re-sponded, "What do you mean?"

Therapist: Umm, do you feel comfortabletalking and initiating conversa-tion?


Marjorie: Oh—(confused) I would talk toanybody, I do a lot of talking.That is why I miss my phone.

Therapists felt that it was expected that theassessment would provide all the informationneeded to plan for the individual being as-sessed. In every case in this study, however,the therapist felt uncomfortable with theamount and quality of information they gath-ered in the assessment. The lack of clearlyexpressed leisure goals in assessments was acause of concern for every therapist. They feltas though their assessments were incomplete,as demonstrated by one therapist's comment:"I'm having no closure here because I don'tknow what her goals are here." When anothertherapist was asked how she felt the assess-ment with a patient had gone, she replied:

It was all right, I mean it just sort ofadded to what I already knew abouthim. I mean when we're on trips I try toget to know them and like walking upthe stairs too. Like just finding out moregoals when they are here. Except thatthey don't even really know what youmean when you say goals, they don'teven want to have to think about goals.

Tools of the TradeWithin therapeutic recreation, there are

many aspects of practice that have been ac-cepted and utilized unquestioningly. The find-ings of this study give reason to question anumber of these aspects including many of thetools students have been educated to use, suchas assessment tools and the use of goals andobjectives in planning.

Various assessment tools were available tothe recreation therapists at SWCHSC. A fre-quently used tool was a leisure inventory, a listof different activities and interests that wasread to the patient and to which the patient wasasked to respond. Scales were often found tobe confusing, time consuming, and inappropri-ate:

Therapist: When you answer try to usethis scale here. It is 1 to 5; 1 isnever true, 2 is almost nevertrue, 3 is somewhat true and 4is often true and 5 is alwaystrue. So what we are going todo is put one of these numbersbeside each statement here. Ok,I likeV> read in my free time, isthat never true or always true?

Roxy: No I like to read a lot.Therapist: So is that always true or often

true?Roxy: Pardon me?

Eventually the therapist stopped using thescale and continued by asking the patient torespond to the statements. However, some ofthe statements were very ambiguous and leftRoxy wondering why she was being askedquestions such as "I like to create artisticdesigns in my free time," or "I like to workwith mechanical devices." She responded,"What do you mean? Like electrical instru-ments . . . yeah I can use a can opener." Thetherapist attempted to clarify the question byasking for a more "leisure based" response, towhich Roxy replied, "Lawnmower?" Otherleisure interest scales proved to be equallyconfusing and repetitive, as demonstrated inthe following example:

Therapist: I use my leisure to developclose relationships with others.

Roxy: Well I am not quite sure aboutthat question.

Therapist: OK that is good. The nextquestion is do you regularlycontribute to other organiza-tions or activities

Roxy: Well I never was involved, butanyone that I knew that neededanything I would definitely doit for them—my husband wasthe same—if anyone neededhelp . . . (defensive).

Therapist: I prefer leisure activities thatrequire social interaction.


This interchange suggests how not being ableto reword questions when using a scale caninhibit discussion and render a genuine ex-change impossible as the therapist forges onwith the next question.

Losing Sight of the SelfEmbedded within this theme was the un-

productive focus upon patients' past leisureinterests, which occurred in every assessment.Patients consistently decided against restartingpursuits that had once been enjoyable to them.One woman felt she "wouldn't be any good atthat any more." Many patients felt they werejust "not able" to participate. Despite constantreassurance from the therapists that activitiescould be adapted, many patients remained re-luctant to take part in activities that they onceenjoyed. For instance, during one assessment atherapist asked Mike if he would enjoy work-ing with his hands in gardening, woodwork-ing, or ceramics. Mike responded:

Mike: I like wood working but I can'tbecause I have a bad arm here.

Therapist: You know there is a creativearts department here, they havedifferent shops. I should takeyou down there one day—justbeautiful. They even have de-vices that have a piece of woodthat is secured and you don'thave to use both your hands.They make lots of things downthere and you can even sell it inthe shop and make money.

Mike laughed. But he did not say he wouldlike to try woodworking again and in a subse-quent interview with the primary researcher heindicated very clearly that he would not bepursuing woodworking again.

After each assessment, first the patient andthen the therapist were interviewed to betterunderstand their experiences and perceptionsof that initial exchange. It became apparentthat often the patient did not know what therole of the recreation therapist was. As well,

the demands of running particular programstook precedence over patients' preferences.

At least half of the patients were not awareof why the recreation therapist came to seethem or what role the therapist would play intheir lives. When Roxy was asked why shethought the recreation therapist came to seeher, she replied:

To find out more about this [illness], tofind out what they are talking about. . . And to learn more about the diseaseand to see how I was reacting to mytreatments.

Roxy did not distinguish the recreation thera-pist from the doctors or nurses. Similarly,when Marjorie was asked why she thought therecreation therapist came to see her she re-sponded:

Well she thought I was interested inwhat they were doing, I don't knowwhy she came really . . . does she turn itin?

For the therapists, the reflexive nature ofthe research gave them a chance to step backand examine their practice. They, too, began torecognize the incongruity of many of the ex-changes that took place between them and thepatients in the assessment process. In thewords of one therapist:

I have never really given much thoughtto exactly what I was saying. I amsurprised, disappointed in myself, andat the same time grateful for the insightI have gained. Wow, some of the thingsI said . . . .

Interpretation and SynthesisIn action research, the researcher involves

participants in assessing, planning, implement-ing, and evaluating action-oriented approachesto solving areas of concern (McWilliam,1992). In this case, the area of concern was the


assessment process. In keeping with an actionresearch methodology, the therapists' partici-pation in interpreting the data was also criticalto the success of project. The information wasshared through a series of seven exchangesinvolving the primary researcher and co-re-searcher recreation therapists over a 4 monthperiod in which the data were re-examined andreorganized until the team felt they genuinelyreflected the meaning of the experiences to theindividuals they represented.

During the first meeting, a decision wasmade to rename the recreation therapy "assess-ment." This decision reflected the feelings ofall team members and was based on the fol-lowing observations. Many patients describedfeelings of anxiety about the assessments thatthey had undergone and the possible implica-tions of these assessments, such as the deter-mination of their ability to return home. As-sessment implies a one way flow ofinformation from the patient to the therapist. Arecreation therapist's role is to exchange infor-mation; the information they pass on to theindividual is as important as the informationthey receive. Finally, assessment was seen as avery technical term implying measurement.For example, a physical therapist would assessan individual's flexibility and strength, or adoctor would assess an individual's blood gasor white blood cell count. However, the rec-reation therapists felt they were not measuringa clearly quantifiable, technical aspect of anindividual's life.

Based on the above observations, it wascollectively decided that the label "assess-ment" did not capture the exchange of infor-mation that was actually occurring betweenpatient and recreation therapist on their firstvisit. No decisions were made until the find-ings were taken to the recreation therapy de-partment as a whole, particularly since thisproject had directly involved only 4 of the 19therapists at SWCHSC. A summary of thefindings was subsequently presented to thewhole recreation therapy group. They re-sponded with enthusiasm, noting that theyshared many of the concerns and issues of

practice that had been flushed out through thecourse of the research project. After muchdebate and reflection, the research team work-ing with the recreation therapy departmentconcluded that the term "Personal Leisure Pro-file" best captured what they hoped to developduring the first exchange with the patient.

The Personal Leisure Profile andParse's Theory of HumanBecoming

Mishler (1984) speaks of two voices, thevoice of medicine and the voice of the life-world. The voice of medicine asks questionssuch as: "where does it hurt," "when did itstart," and "how long does it last?" Thesequestions parallel programming questions ofthe recreation therapists such as: "did youenjoy physical activities" and "do you enjoybeing around people?" As evidenced in thisstudy, questions of this nature were oftenasked in a series and were responded to with"yes" or "no," leaving the recreation therapistan idea of what patients used to do, but notwhy they participated or if they wanted to takeup that pursuit again. Indeed, the therapistswere often discouraged and surprised when thepatient refused to join a group that involved anactivity they had said they once enjoyed. Incontrast, the voice of the lifeworld consists ofquestions such as: "what are you most con-cerned about," "how does it disrupt your life,"and "what do you think it is?" In recreationtherapy, this lifevoice is reflected in questionsthat give insight into the patient's feelingsabout leisure, and how it fits into their expe-rience of illness. For example, many therapistsasked: "What do you enjoy about certain ac-tivities?" and "How do you feel about tryingthat again?" As Mishler's (1984) research sug-gests, using the voice of the lifeworld giveshealth practitioners a much better understand-ing of their patients, while helping patientsclarify their own experience of illness.

At the core of the theory of human becom-ing is the belief and recognition that paradox-ical processes are inherent in being human.


These paradoxes "are not viewed as problemsto be solved or eliminated but rather naturalrhythms of life" (Parse, 1995, p. 6). Alsocentral to this theory is the concept of humanfreedom. Parse refered to freedom as an ex-pression of human becoming and thus, ofhealth. Those living the theory of human be-coming believe that freedom and being humanare identical. Even choosing not to choose is amanifestation of freedom. Freedom is sur-prise—being able to move on, shaped by ev-eryday life. Within that life, Parse described aninherent struggle, an unpredictable journeythat includes suffering and joy, loss and dis-covery. Life may bring peace of mind or an-guish and torment. It is believed that peoplechoose the meaning of their experiences andhow to be with the universe in their own lives.

As outlined earlier, the dimensions andprocesses of Parse's theory of human becom-ing (1987) are: (a) illuminating meaning whichhappens in shedding light through explicatingthe what was, is, and will be as it is appearingnow; (b) synchronizing rhythms happens indwelling with the flow of the paradox andrhythms of human becoming; and (c) mobiliz-ing transcendence happens in moving beyondthe meaning to what is not yet. Moving be-yond is propelling with the possibilities intransforming. These processes translate into anapproach that allows a practitioner to truly bewith the patient. The next sections will exam-ine how the experiences of the patients andtherapists in this study support each of theseprocesses.

Illuminating Meaning andSynchronizing Rhythms

Parse (1995) suggested that when personsspeak of the meaning of their experience, themeaning changes. This change is because bymaking a feeling or thought explicit throughspeaking or writing, people see things in a newlight. The difference between being trulypresent with a patient and merely looking foranswers is key. Therapists who validated thepatient's experience were rewarded with valu-

able information about the patient as they feltsupported in their expression. For instance, inthe next excerpt a therapist supports Lucy asshe talks about her homeland.

Lucy: My dog I loved so much. WhenI am young my father had lotsof pets.

Therapist: Wonderful. Did you grow upon a farm then or a piece ofland?

Lucy: Near my house was a fruitfarm.

Therapist: A fruit farm.Lucy: There was always so much

flowers, so much flowers.Therapist: Oh nice, so is that where you

picked up your gardening inter-ests?

Lucy: Yes, and there we also-. . . honey bees.

Therapist: Honey bees! Lucky you.Lucy: Good for flowers.Therapist: Did you collect the honey af-

terwards?Lucy: Yes, we brought it home. My

father, my brother and I . . . wehad such a good time, so manydogs, cats . . . .

Therapist: Oh beautiful.Lucy: We used to go to the beach, so

many birds—singing birds ev-erywhere.

Lucy went on to say how much she missed herfamily and the ocean, and talking about themmade her smile. By going with the patient asshe reminisced about the past, the therapist notonly helped Lucy understand her sadness, shealso gained valuable insight about her love ofanimals, flowers, and the ocean that she woulduse in future interaction with Lucy.

True presence is also apparent in a practi-tioner's ability to go with the person as theysynchronize rhythms by dwelling with the upsand downs of the interhuman relationship(Parse, 1987). It is with this presence thatpractitioners find the most difficulty, for theyno longer try to change or control the person's


thoughts or feelings (Parse, 1995). This diffi-culty was evident in this study in the waytherapists responded to many of the patients'negative statements, such as "I am just notable" or "I am too tired and old for thatanymore." Often, a therapist would try to en-courage the patient by suggesting ways inwhich they could participate, or reassure thepatient by saying "You're not too old. Maybeyou just need some more sleep." Despite thisencouragement, patients who expressed feel-ing this way did not change their minds aboutparticipating.

According to Parse (1987), what patientsfeel is their reality, and by going with them asthey speak about their life, practitioners canhelp them find meaning in the ups and downsof their experience. By trying to change orcontrol what a patient is experiencing, a ther-apist is denying him or herself the privilege ofknowing and understanding a patient's life.

Mobilizing TranscendenceAs patients dwell upon their experience

and their feelings of the ways their life is goingto change, they are synchronizing rhythms. Asthey accept change or resist change, they movebeyond. Moving beyond is described by Parseas moving beyond the meaning of the momentto what is not yet. By thinking about plans,hopes, and dreams, people propel themselvestoward possible futures. Whether it is a desireto continue doing something they have onceenjoyed, or to accept that they will never do itagain, it is moving on and beyond in a way thatthey can commit to and plan for.

The process of mobilizing transcendencesheds light upon patients' decisions not toparticipate in activities suggested by their rec-reation therapist. The lack of interest manypatients expressed in taking up leisure pursuitsthey had once enjoyed was often due to thefact that they could no longer attain the samebenefits. For example, Mike was not excitedabout visiting the wood working shop becausehe no longer had the use of his left hand and heknew he wouldn't be able to do what he usedto. For him, pleasure came from being good at

the activity he was participating in. Mike hadthought about what it would be like to go backto wood working and he knew it was some-thing he could not see in his future. By doingso, he had moved beyond.

Parse's (1998) principles lend understand-ing to many of the feelings and desires patientsexpressed in this study. Understanding theseprocesses and being truly present with patientshas resulted in numerous outcomes for nursesliving the theory of human becoming. In gen-eral, practitioners working within the theory ofhuman becoming enhance the dignity of thepatients and families they serve. The apparentrelevancy of this approach to care to the ex-periences of the patients and therapists in rec-reation therapy resulted in Parse's theoryserving as a source of inspiration in thedevelopment of the Personal Leisure Profile atSWCHSC. The development of the PersonalLeisure Profile began with a collaborative ef-fort to understand practice and how it influ-ences the experience of the patient and thetherapist. Armed with the knowledge that ourfindings were strongly supported by currenttheories and models of patient focused care,the research team put in place a number ofprotocol recommendations to present to therecreation therapy department at SWCHSC.These are outlined below.

• Protocol Recommendation #1: Be trulypresent with individuals by listening, ac-cepting and empathizing with their real-ity.

As we moved to incorporate our findingsinto possible practice implications, it becameapparent that every word and action a therapistbrought to the exchange could influence thepatient and their experience. According toParse (1995), language is a symbolic represen-tation of the human experience. Ignoring apatient's meaningful comment, or more obvi-ously discrediting a patient's feeling or belief,presented the possibility of invalidating a pa-tient's experience. At the same time, recogniz-ing and respecting the reality that a personconstructs does not mitigate the practitioner's


responsibility to challenge that reality if itthreatens the person's health and wellbeing.As indicated above, many therapists wouldsuggest an activity or group to a patient, and acommon response was, "Oh, I couldn't dothat, I am not able." Not unlike therapeuticrecreation practice considered in earlier re-search (Caldwell, Datillo, Kleiber, & Lee,1994/95), therapists would often respond, "Ohyes you can," attempting to encourage thepatient. Believing in the importance of recon-necting with a past self through leisure (Lee,Dattilo, & Caldwell, 1996), the therapists inthe current study tried to convince patients thatthey could enjoy these activities again throughadaptations. Parse, however, would perceive apatient's decision to not revert to past leisurepursuits as a positive experience of mobilizingtranscendence, or moving beyond to what isnot yet. Protocol 6 below speaks to the thera-pists' encouragement of patients in relation tomoving beyond the present and an emergingawareness of possibilities.

• Protocol Recommendation #2: Use un-derstandable language that is familiar tothe individual.

Many studies have shown that using lan-guage or labeling that is unfamiliar and "overthe heads" of the patient is regarded as de-meaning by individuals experiencing that typeof treatment (Siefert, 1992). Therapists whoused inclusive language were more likely tohave patients interested in participation andwere often described by their patients as peo-ple who made them feel important.

Sharing understandable information is alsocrucial in patient focused care. Simply put,patients have the right to receive informationto enable them to make decisions about ther-apy services that will meet their needs. Theyexpect their values to be respected and tomaintain their dignity and integrity throughoutthe process (Polatajko, 1992). By using inclu-sive language therapists were not only convey-ing the centrality of the patients' views andpreferences to the entire process, they werealso giving them understandable information

that enabled them to make informed choicesabout participation.

• Protocol Recommendation #3: Ensurethe individual understands the purpose oftherapist questions and actions.

Rogers (1951) identified many of the coreconcepts of patient focused care. Included inthese is the need for openness and honestywithin the clinical relationship. Those thera-pists who included and informed their patientsby asking straightforward questions, and ex-plained exactly why and what they were writ-ing down during the "assessment," signifi-cantly reduced the anxiety of their patients.Many practitioners have discovered that pa-tient focused visits, in which the practitioner isopen and honest, have also resulted in thereduction of patient concern (Henbest &Fehrsen, 1992; Henbest & Stewart, 1990).Asking straightforward questions avoided mis-understandings of the motivation behind cer-tain inquiries.

• Protocol Recommendation #4: Contrib-ute personal experiences and ideas to theexchange of information.

Those therapists who offered informationabout themselves developed a more open, re-ciprocal relationship. This result was demon-strated in the information they gathered as wellas the overall atmosphere of the exchange,which was always caring and positive. Whilethere is little in the therapeutic recreation lit-erature that addresses the practitioners' contri-bution of personal information, Parse (1995)described the results of a study in whichnurses, practicing under the theory of humanbecoming, were considered to be kind, gentle,welcoming, willing to listen, willing to talk,and willing to do things the patient desired.This process does not mean divulging espe-cially personal or intimate details of one's life,but offering something of oneself is crucial topatient focused practice.

• Protocol Recommendation #5: Eliminateassessment tools in the first exchange


and focus on individuals' current leisureinterests.

Therapists generally did not use an assess-ment tool on a regular basis other than theoccasional leisure inventory list. However,even the use of the leisure inventory resultedin little discussion about a patient's interests,but rather led to the patient being faced with atorrent of questions requiring only a yes or noresponse. These leisure inventory lists or in-terest finders have "demonstrated an inabilityto reflect variation in intrinsic motivation par-ticularly the intricacies of need satisfaction"(Fain & Shank, 1986, p. 48).

• Protocol Recommendation #6: Providereal and meaningful opportunities forchoice.

Therapists who conveyed future choicewere often rewarded with enthusiasm and anincreased willingness to participate by the pa-tients. This outcome may be related to theimportance of freedom in an individual's lei-sure and adjustment to disability (Lee et al.,1996). It has been shown that the freedom oneexperiences in choosing an activity is one ofthe most critical determinants of leisure (Iso-Ahola, 1980; Mannell & Bradley, 1986; Man-nell, Larson, & Zuzanek, 1988; Mannell &Kleiber, 1997).

With these considerations and recommen-dations, the research team moved forward byenvisioning a process that would allow for theincorporation of what had been discoveredthrough the research process. The therapistsidentified those areas of information that theywould ideally gather from patients. These in-cluded: (a) past and present leisure interests,(b) details of the enjoyable aspects of thoseinterests, (c) current leisure status in terms ofwhat brought enjoyment and happiness, (d)barriers they may be facing, and (e) their hopesand dreams. Subsequently, the following fiveguiding questions that provide the basis for thePersonal Leisure Profile were determined incollaboration with the co-researchers:

1. What do you enjoy? (Past/present lei-sure interests)

2. What about that do you enjoy? (Char-acteristics of pursuits that are enjoyed)

3. Recently, what has brought enjoyment/happiness to your day? (Current leisure status)

4. What is stopping you from enjoying(or some of those activities)? (Barriers)

5. Is there something that you have alwayswanted to do? (Dreams)

These questions are now being used inpractice by most of the recreation therapists atSWCHSC. They have found that using thequestions results in more patient informationbeing gathered in less time. The team hasfurther developed a list of probes for eachquestion, which have proven helpful in prac-tice. In the words of one of the therapists afteradopting the Personal Leisure Profile in herpractice, "the first visit with the patient waslike finding out the title of a book—it can oftenbe misleading. To really find out what it meansyou must read on." In using the PersonalLeisure Profile, the process becomes suffi-ciently flexible and individualized to allow forco-discovery and co-constitution between thepatient and therapist, so that they are able toget beyond "the title."

ConclusionIn the field of therapeutic recreation, ques-

tions surrounding the effectiveness of the rec-reation therapy assessment process are notuncommon. Fain and Shank (1986) voicedtheir concerns about the individual assessmentin therapeutic recreation where they found "apaucity of evidence related to the effectivenessof this service and the applicability of existinginstruments to serve specific populations andgroups" (p. 47). Over 25 years ago, Fain(1973) argued that the concern of leisure prac-titioners with matching clients' preferenceswith existing leisure resources was misplaced,especially when those resources or programsare often designed to serve people collectively.What was missing was an understanding of


individual differences and motivations, an at-tempt to understand the needs and wants andthe why. This is what the Personal LeisureProfile aims to do.

In moving toward an increasingly patientfocused approach to learning about individualsand their leisure, the recreation therapists atSWCHSC have engaged in a reflective process(Schon, 1987), which has allowed them toaddress concerns practitioners have had formany years. The recreation therapy practice atSWCHSC continues its reflective journey;other areas of practice beyond the initial meet-ing with patients are being examined as prac-titioners consider whether and how the tenetsof patient focused care are realized in theirday-to-day involvements with patients. Whatis apparent is that these practitioners havesought a deeper understanding of themselvesand of their practice. They have done this bylooking beyond therapeutic recreation to an-other discipline, nursing, where they foundParse's theory of human becoming. In theirdiscovery they began to accept that paradox isnot a problem, but a natural rhythm of life. Thefindings of this study demonstrate that this wasnot only a natural but a necessary change inpractice, allowing for the emergence of moreauthentic relationships between patients andtherapists, and enabling therapeutic recreationto more nearly fulfil its potential in the practiceof patient focused care.

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