What Happens at the Intersection of Policy and Practice? Examining Role Conflict and Professional Alienation of Occupational Therapy Professionals in Complex Environments By © 2016 Wendy C. Hildenbrand M.P.H., University of Kansas, 2002 B.S., University of Kansas, 1989 Submitted to the graduate degree program in Public Administration and the Graduate Faculty of the University of Kansas in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Chair: Steven Maynard-Moody Michael Fox Heather Getha-Taylor Marilu Goodyear Joseph Weir Date Defended: 08 December 2016 The dissertation committee for Wendy C. Hildenbrand certifies that this is the approved version of the following dissertation: What Happens at the Intersection of Policy and Practice? Examining Role Conflict and Professional Alienation of Occupational Therapy Professionals in Complex Environments Chair: Steven Maynard-Moody Date Approved: 08 December 2016 ii ABSTRACT To examine what happens at the intersection of policy and practice, this dissertation utilizes a three-article format to advance public administration scholarship and contribute to health system research about occupational therapy. This work creates bridging links between public administration scholarship in the areas of street-level bureaucracy and policy alienation and the occupational therapy profession. The articles combine to inform the occupational therapy community by providing empirical findings to validate role conflict and professional alienation experiences of practicing occupational therapy professionals when implementing policy in practice. The Article One thesis asserts that while policy content matters, it is vital to understand the context of policy, and by extension, the context of practice as a response to policy implementation. Drawing on institutional theory, this work offers an historical review of policy- specific critical junctures in occupational history and how policy has influenced occupational therapy practice. Article Two connects institutional theory, street-level bureaucracy scholarship, and policy alienation research to explain the experience of role conflict related to implementation of productivity standards for occupational therapy professionals. Article Three utilizes street-level bureaucracy theory and policy alienation scholarship to provide the foundation for introducing “professional alienation” as an extension of policy alienation constructs. The article examines the extent to which occupational therapy professionals feel pressured to alienate core professional values, such as client-centered care, in practice. iii Articles Two and Three present the empirical findings from this original research study, which employed online survey methodology to explore the relationship of professional profile characteristics and work context factors with the two dependent variables of interest – role conflict and professional alienation. T-tests and multiple regression analyses indicate that professional profile characteristics such as professional credential/status and direct treatment provider designation influence role conflict and professional alienation. Work context factors that contribute to role conflict and professional alienation appear related to practice parameters and policy expectations in specific practice environments such as long term care/skilled nursing facilities and pediatric practice settings. This study lends support for future research including frontline storytelling of occupational therapy professionals, exploration of context differences, and coping strategies of frontline workers. iv ACKNOWLEDGMENTS Praise be to God! – This dissertation outcome is due to God’s presence in my life…period! Opened doors, timely conversations, financial means, prayer warriors, supportive people, personal fortitude, academic capacity, drive, a crooked path made straight…thank you! The God of Angel Armies is always by my side! Dissertation Committee Steven Maynard-Moody – Thank you for being willing to serve as chair of my committee. I came to you because of shared interests in frontline workers, storytelling as a lens for hearing people’s perspectives, and your capacity to think outside the traditional public administration box. Recognizing this was part of a challenging life journey with fits and starts, I thank you for seeing me through to the end – the PhDone! Mike Fox – I would not have known about the “new” PhD in Public Administration without our Q39 lunch conversation about career/life transitions and the need for “options.” Likewise, I would not have made it through the difficult times without your words of encouragement, wisdom, and reason. I will always remember you telling me that my work was “important work” and it would make a difference in my profession. I believe you! Thank you for believing in me! Marilu Goodyear, Heather Getha-Taylor, and Joseph Weir – Thank you for taking a walk with me through new ideas and connections that might have seemed unfamiliar and disconnected at times. Admittedly, the occupational therapy/public administration merger makes some people pause or step away, but you were open to stepping into this space with me. Marilu – I appreciate your support and acknowledgement that my life position was not an easy position. Heather – I appreciate your thoughtful questions that always brought me back to core management and v public administration fundamentals. Joe – I appreciate your willingness to join my committee in the eleventh hour of the journey; you could have said no but you didn’t…and that was huge! School of Public Administration and Affairs Faculty and Staff – Over nine years, many faculty and staff have come and gone through the department’s door. All have left a mark – some more than others, some good and some not so good. I want to acknowledge those who moved me forward.  Chuck Epp – thank you for being the first professor to support my effort to connect occupational therapy and public administration in the same paper! That sounds small, but it was significant for me. Also, thank you for sharing your passion for the Constitutional foundations of PA. I never wanted to miss a class!  Dorothy Daley – thank you for providing the forum for me to consider public health and health policy. I still believe we need health impact studies attached to all forthcoming policy. I learned more about teaching by being a student in your class. Thank you for not allowing quotations in our policy papers and for acknowledging that “we all have constraints” and choices to make.  H. George Frederickson – thank you for introducing me to the world of public administration through the “canon” and by your example. Your first-hand historical accounts of public administration brought people, events, and concepts to life. Gardening as a metaphor for public leadership still sticks with me. Now, if I could only find my George bobblehead!  Diana Koslowsky – thank you for all you do! You have been a rock star throughout this dissertation journey, particularly grateful for your help in navigating “the system” and vi being supportive in the midst of last-minute crisis situations. The SPAA is lucky to have you at the helm to steer the ship. My People! – PhD Cohorts and friends While in the program, I was surrounded by fellow students who now hold faculty positions, engage in scholarship activities, and serve to pave the way for innovation public administration or citizen/community engagement. “My People” pushed me through, walked alongside, and cheered me on at every turn. To name a few – Tony Reames, you are my sustainability hero! Susan Keim, leadership becomes you! Jeannette Blackmar, you make a difference in your community every day! Erin, Robin, Alisa, Linda, Cullen, Duncan, Nate, Min, Angela, Maneekwan, Randy, Ed and others…each of you enriched my experience with the SPAA. My People! – Occupational Therapy Community Thank you to my occupational therapy students for candidly sharing their perspectives about the transition from academic preparation to the “real world” of OT practice. Our hallway conversations helped shape my research ideas for my dissertation and for future. Also, thank you for extending a little grace in those moments when I was “spinning too many plates.” Teaching you provides the professional touchpoint I need when things would get a bit hectic. Thank you to the Occupational Therapy Education Department faculty and staff for patiently (most of the time) waiting for me to complete this nine-year goal…it was a haul for all of us! Winnie Dunn – you provided the push for my decision to pursue a doctoral degree and supported my decision to earn that degree in PA. I will always remember your “pearls of wisdom” and expertise at just the right time…thank you! vii Thank you to my occupational therapy colleagues across the country for their kind words of encouragement and advice to move me forward when I wanted to stop. Simple words that are well-timed make a big difference. Robin – thank you for the “Valley of S**t”! Brent – thank you for the reminder that thinking about writing is not writing! Thank you to my Kansas occupational therapy professional community for continuing to be my professional base – “there’s no place like home”! Particularly, thank you to every occupational therapist and occupational therapy assistant who took the time to complete my survey, send an email to share their story, or hand write out their thoughts to share with me as my analysis was taking shape. Truly, I could not have done this dissertation without you and your support. “I get by with a little help from my friends!” (Beatles) I am blessed beyond measure to have meaningful, true friendship circles that were not afraid to cry, celebrate, criticize, conceptualize, and otherwise walk this dissertation journey with me. Thank you to my Martini Girls, my WOW Book Club, the “Other Mothers,” my church people, old friends who know me well, and new friends who’ve met me in the middle of this dissertation process. I look forward to returning to life and reconnecting with many of you soon! “We are family!” (Sister Sledge) To my girls – Dana and Jordan – I love you more than I can ever say or display! You have been with me through this process to cheer me on, to ask hard questions, to listen when I was frustrated, and to toast my successful defense. More than that, you walk our shared life journey with focused attention and drive to do your best for those you love and all people who enter your life. Your academic and professional success sets the bar high – you’ve been my example and role models for pushing through very difficult times to meet goals on your terms. viii Watching your compassion and caring hearts in action fills my soul. Thank you for your unconditional love – it is a constant in my life, and I would not be who I am without the gifts you share with me. Wendell – We’ve been walking this road together and will celebrate “done” for both of us soon! Persist and finish…even through the tough stuff. This "Moms" is so proud of you! Jaxon, Gaffin, and Laila – Thank you for loving your Mammo and for always wanting just a little time with me! When the load was heavy, I would see “perspective” in your sweet faces and feel the love in your hugs. I am one lucky Mammo! Sistor, the Brothers, Mom, Dad, and so many extended family people – You are my rock in this crazy world! Family is the glue when things start to fall apart. You’ve been that glue for a lifetime. Sistor – I love you! Thank you for always being there for me! Marvin – Thank you for being alongside me throughout this final dissertation push but also for simply being alongside me. Your kind, generous, supportive, loving spirit takes my breath away. Your concrete questions about time and deadlines provided necessary reality checks that I needed. Thank you for allowing me the space and time to complete my work without worry about us. I’m excited to embrace life with you post-dissertation! ix CONTENTS ABSTRACT ................................................................................................................................... iii ACKNOWLEDGMENTS ...............................................................................................................v LIST OF TABLES ....................................................................................................................... xiv Chapter 1. The Institutional Context of Practice: Reaping Benefits and Unanticipated Consequences of Policy ......................................................................................................................................1 Abstract ................................................................................................................................1 The Institutional Context of Occupational Therapy Policy and Practice ............................3 Understanding Critical Junctures in the Development of Our Profession’s Path ................6 Shaping Our Profession – Implications of Policy on Practice ...........................................10 Critical Juncture – Medicare Act of 1965 ..............................................................13 Critical Juncture – Education for All Handicapped Children Act of 1975 ............15 Critical Juncture – Community Mental Health Act of 1963 ..................................17 Another Critical Juncture – Now! ......................................................................................19 Closing Thought Piece .......................................................................................................21 2. Role Conflict on the Frontline: When Practice and Policy Collide ...........................................22 Abstract ..............................................................................................................................22 Health and Human Service Organizations as Complex Systems.......................................24 Occupational Therapy Professionals as Frontline Workers ...............................................27 Role Conflict on the Frontline ...........................................................................................28 Professional Profile Characteristics and Work Context as Factors Influencing Role Conflict ..................................................................................................31 x