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Some limits to the hospital as a negotiated order
Sot.
SCL
Printed
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in Great
Vol. 18. No. 3. pp. 243-249. Brltaln
0277-9536/X4 $3.00 + 0.00 Pergamon Press Ltd
1984
SOME LIMITS TO THE HOSPITAL A NEGOTIATED ORDER THOMAS
Department
of Sociology,
Acadia
G.
University,
AS
REGAN
Wolfville,
Nova
Scotia,
Canada
BOP 1X0
Abstract-This paper examines issues of freedom and constraint by employing the negotiated order perspective in an analysis of a merger of three health care institutions. The findings give support to the importance of negotiated order considerations in understanding the social organization of health care, for they suggest that there are some limits to negotiations which take place within medically dominated settings.
INTRODUCI’ION
THE DELIVERY OF MENTAL HEALTH CARE IN EASTERN PROVINCE 19X1-1976
order perspective to analyze a merger involving three health care institutions. During the past 20 years this perspective has moved from a general theoretical stance within symbolic interactionism to a more focused and paradigmatic framework [l]. A central contention is that all social orders are negotiated orders, i.e. negotiations are not just another interesting topic of research but rather essential aspects of social organization [2]. Critics of the perspective argue that it ignores the real issues of social structures [3]. They point to a failure to address the importance of power and resources in negotiations; an overemphasis on the freedom of certain persons or groups to bargain; and an avoidance of the relationship of a given negotiated order to the political economy of the larger social world. While these critics acknowledge that negotiated order researches do not ignore structural and other limits, they feel that such limits are only viewed This
paper
uses
a negotiated
as parameters which define the boundaries of analysis. In response to these criticisms, Strauss states that an understanding of negotiation processes might provide important insights regarding questions of freedom vs constraint in social life: Structural process considerations suggest quite clearly that what someone takes as limits to negotiation-in any given situation-may not really constitute limits. . what were previously taken as probably nonnegotiable may in fact be negotiable in some sense, some way, some degree. Whether or not that is so has to be discovered.. exploration [4].
the.limits
During the third quarter of this century the provision of mental health care in Eastern Province reflected the patterns of regionalization and decentralization found elsewhere in Canada. A full decade before the publication of More for Ihe Mind [5] the government of Eastern Province had joined with the Canadian Mental Health Association in the formation of community-based care for the mentally ill. By the mid-sixties nine community mental health centres had been established. They were designed to provide outpatient and preventive services to a defined catchment area and functioned under the aegis of local community boards of directors. Longterm, palliative and custodial care to the mentally disabled were available at municipal hospitals. During this period the number of municipal hospitals was reduced to four. Those requiring acute or specialized services were admitted to the Provincial Hospital. Prompted by a desire to further benefit from federal-provincial cost-sharing arrangements, the provincial government in 1976 announced a policy change with respect to the financing and delivery of mental health services. The new policy had three components. Patients who no longer required active psychiatric treatment were transferred to residential facilities funded by the Ministry of Social Services. Two of the municipal hospital were transferred to Social Services and redesignated as residential and rehabilitation centres. All mental health centres were directed to merge with general hospitals.
require
This paper does such an exploration. It describes and analyzes the response of three health care institutions to a governmental directive to merge. The study is grounded in an examination of documents and 5 years of participant observation and interviewing. Before proceeding with the analysis some background information is provided.
Parts of this paper were first presented at the Canadian Ethnology Society annual meetings. Hamilton, Ontario, 7 May. 1983. 243
RESPONSES OF THE MENTAL HEALTH CENTRES AND GENERAL HOSPITALS TO THE GOVERNMENTAL DIRECTIVE
The decision to merge mental health centres with general hospitals was made without prior consultation with the institutions affected. Their board chairpersons and senior executives officers were hastily summoned to a meeting at which they were told that the Ministry wanted the regional hospitals to assume responsibility for the delivery of mental health services. In accordance with this new policy, each hospital and mental health centre would negotiate an agreement whereby the centre would become
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a department of the hospital. At this meeting the Ministry also set a deadline and issued guidelines for the accomplishment of these amalgamations. Following this meeting the Ministry issued a series of letters reminding these boards of the urgency of the directive. While each region was allowed to work out the particulars for its area, it was understood that these were to be completed forthwith and under terms acceptable to the Ministry. The governmental directive implied that amalgamation was a condition of continued funding of mental health services. These hospitals and centres were technically private corporations directed by boards comprised of local citizens. Nonetheless, the government was the principal source of funds. Of the seven mental health centres which were directed to merge with regional hospitals, three met the deadline. Within a year, five amalgamations and one financial merger were completed [6]. The preambles to these merger agreements clearly indicate that these boards viewed the directive as a nonnegotiable command. The following statement is a typical, initial sentence in these documents: As directed by the Ministry of Health, Western Counties Mental Health Cenlre is amalgamated as a department of Western Regional Hospital, effective May 1, 1976. In only one region of the province did the response take a different form. The negotiations extended over 7 years and included *explorations of options to a straightforward merger and tests of the limits of the mental health division of labour. From the beginning the Ministry of Health foresaw that this merger would be more difficult than in the other regions. On the one hand it was more complex. Elsewhere the negotiators consisted of representatives of a hospital board and a centre board, in this case the board of a municipal psychiatric hospital was also involved. Elsewhere a merger did not involve a physical relocation of staff for the mental health centres rented space from the hospital. In this case, a physical relocation was involved for the three institutions were located in different communities. On the other hand, these agencies were proud of their programmes and jealous of their identity and autonomy. The policy change had been a particular blow to the two mental health facilities. With three psychiatrists, two psychologists, four social workers, one nurse and three secretaries, Tideways Mental Health Centre was the largest in the province. During its 25 year history it had developed a good reputation based on a community orientation and a fairly egalitarian division of labour. It initially viewed a hospital merger as being antithetical to its ideology of care. The implications of the policy shift for Cornwallis County Hospital were two-fold. It was one of the municipal hospitals which was redesignated a rehabilitation centre. Accordingly, it was being asked to negotiate a transfer of its psychiatric programmes to the regional hospital and assume a new service mission in the area of social services. Both requests were hard to swallow for the municipality had devoted ten years to the recruitment of psychiatric staff with an aim to becoming the regional psychiatric centre for the southwestern region of the province. Glooscap District Hospital was prepared to assume responsibility for the provision of mental health
REGAN
care. Since the mid-sixties it had been slowly building its professional staff in order to meet its responsibilities as a regional hospital. Its board hopes to develop a full range of services for the residents of Glooscap District and aspires to be the premier regional hospital in the province. This amalgamation is another step in that direction. However, Glooscap’s officers also had a wideawake appreciation of the rivalry and conflicting ideologies of the two mental health facilities. The merger discussions have combined many subprocesses of negotiation (e.g. bargaining from extremes, trading off, exploring legitimate boundaries, territorial claiming, compromising towards the middle and progressive building of agreements) with alternatives to bargaining such as manipulation of events, false negotiation, education and persuasion. As others have noted negotiations among professionals tend to be overt [7]. These transactions were very visible. Not only were virtually all negotiations overt but efforts were taken to assure clarity about every step in the process. Additionally, talks between only two parties were informal because neither party wished to give the impression that it had initiated action in the absence of the others. During the course of 7 years, these negotiations were marked with distinctive phases in which some issues were resolved and others arose. In analysing how a service model emerged as a negotiated compromise, this paper focuses on only two of these periods. In so doing, it shows how a microscopic analysis of the interaction among the parties who negotiated this merger-an analysis that does not ignore the effects of structural conditions on negotiation processesadvances our understanding of the structural limits to negotiation and how they are tested and reset. THE STRUCTURAL
CONTEXT
In an extended presentation of the negotiated orders’ paradigm, Strauss identifies two levels of structural properties within which negotiations, and their subprocesses, take place, viz. negotiation contexts and structural contexts. The latter refers specifically to those structural properties of the larger social world within which negotiations occur. These structural properties often have a direct bearing on both the negotiation context of a given negotiation and the negotiations, per se. While it is plausible that negotiations could alter a structural context, individual negotiations are less likely to affect these structural properties, “except as they are repeated or combined with other negotiations and with other modes of action and so perhaps have a cumulative impact” [8]. In the broadest sense the structural context of the merger process under examination inclues the political economy of health care in Canada, especially in respect to the government’s distribution of resources and its relationship to health care institutions and providers. The decision of Eastern Province to relocate mental health services in general hospitals was certainly rooted in fiscal considerations. It was also a reaction to some of the inadequacies of community mental health centres and an acceptance of the counter-movement in other provinces to narrow the
Some limits to the hospital as a negotiated order range of mental health services by integrating them with the physical and personnel resources of the rest of medicine. This transition of mental health care into general hospitals places this merger process within the structural context of Canadian medical care. This context contains such structural properties as the status of psychiatry as a medical subspecialty, specialization among the caring professions and the divisions of labour in health care settings. Of particular relevance for this study is the presence of the professional dominance of medicine as a structural property which limits the influence of non-medical ideologies on the structuring of work in medical settings [9]. While some argue that physician dominance is beginning to wane, Blishen’s observation that professional control over the conditions of work is the most persistent concern of the medical profession in Canada remains the central structural feature of the power relationships in Canadian health care [lo]. Some significant features of the structural context are also visible at the intra- and interorganizational levels. The government instructed the directors of these health care organizations to work out the terms of amalgamation. These individuals are entrusted with the responsibility to plan and oversee the services provided by their respective institutions. While these boards have the final say in what is negotiated, their members typically play nominal or reactive roles to the decisions made by others. Major decisions are usually made by a small group composed of a few highly committed trustees and executive officers. These features of the governance of health care, educational and social services agencies underlie the importance of interpersonal relationships as structural properties [1 11. It is interpersonal relations qua structural properties which countenances physician dominance. Accordingly, one should look to this level for the origins of structural metamorphosis. THE NEGOTIATION
CONTEXT
A negotiation context consists of those structural properties which constitute the immediate conditions of a given negotiation. These contextual attributes form the bases of a mesostructure in which both the properties of structure and the subprocesses of negotiation are enacted [ 121. For this reason, negotiation contexts are malleable with the lines of impact running in either direction. The negotiation context of this amalgamation was characterized by a mixture of stable and variable properties. Included among the former were the novelty and complexity of the issues involved in marrying the principles of community psychiatry to the realties of inpatient psychiatry in a general hospital setting. Underlying most of these issues were questions of legitimacy: What constitutes clinical expertise? What work might members of each agency or occupational group legitimately do? The resolution of these issues was further complicated by other attributes of the negotiation context. Firstly, each party had the common stakes of appearing to comply with the governmental directive and the mutually exclusive stakes of controlling the direction and philosophy of the proposed amalgamated
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programme. Each of the mental health facilities wish to implant its respective and very different ideology of care into the structure and programmes of the proposed service. The district hospital could accept either philosophy as long as its board exercised ultimate control over the programme. Secondly, the parties met jointly with each agency represented by a small group of directors and senior staff. Initially they met in a series of encounters with the only option being the blocking of an agreement. After an agreement-in-principle was achieved, the context shifted to a sequential and linked format with the senior staff regularly meeting to develop the service model and determine the specifications of the new inpatient unit. The presence of staff as negotiators joined the working out of working relationships among these individuals to the building of a merger agreement. The settlement of these working relations became a necessary condition for the resolution of the major legitimacy issues, and hence the achievement of an amalgamation agreement. The negotiation of working relations was itself contingent on two additional contextual properties, viz. differential theories of negotiation and the evolving personal relations among the negotiators. Each party adhered to different theories of negotiation. The board and staff were quite unified in their support of Tideways’ approach to mental health care. Since merger meant the eventual disolution of its board of directors, this centre was determined to see its approach if not its name continued. In pursuit of this mission, Tideways’ representatives spoke with the assurance that their statements had the endorsement of their board and staff. They were typically well prepared and aggressive though not unwilling to make compromises. Their concern for a fine-tuning of the terms of the agreement in order to safeguard their philosophy lead to an emphasis on the negotiation of working relationships as a mechanism for establishing control over programming. Cornwallis County Hospital would have liked to have remained a regional psychiatric hospital. Accepting amalgamation as inevitable, it concentrated on transfering the responsibility for mental health care to the district hospital. Many of. its staff were unaffected by the merger. They would continue to be employees of the hospital as it entered into a new era as a rehabilitation centre. Given these circumstances, the Comwallis Board did not become systematically involved in bargaining about working relationships. It wished to see its psychiatric staff well treated but generally regarded those concerns as the responsibility of Glooscap as the operator of the new service. The passive stance of this Board placed its staff-negotiators at a disadvantage in their negotiations over working relations. This disadvantage was further aggravated by a lack of unity among the staff which was affected by the merger. Lacking a cohesive negotiative strategy, these staff-negotiators frequently found themselves simply reacting to initiatives advanced by Tideways or Glooscap. Glooscap Hospital saw the merger as an opportunity to develop a more comprehensive set of services than the Ministry had initially intended, thus enhancing its posture as a regional hospital. Its
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negotiators adopted a theory of reconciliation. They were prepared to make concessions to each party in order to convince them that they would continue to have a say in the day to day operation of the proposed unit. If it could not accomodate both parties, Glooscap was prepared to side with the one which would promote its goal of housing a viable mental health programme. Finally, these negotiations often hinged on the dynamics of interpersonal relationships. Initially these persons were relatively inexperienced negotiators. Over time they became more acquainted with one another’s styles and theories of negotiation. The more decisive and organized approaches of Glooscap and Tideways fostered an affinity between these two groups. This evolution of personal relationships shifted the balance of power in favour of the Tideways’ philosophy. The contextual properties of this merger process became structured in a manner which gave ascendancy to Tideways’ open-system and egalitarian resolutions of issues related to questions of legitimacy. Since these solutions challenged the hegemony of psychiatry in the delivery of mental health services, a segment of the psychiatrists intervened to contest the agreement and reset the limits of this negotiated order. Having situated the process within these two levels of structure, we shall now examine the efforts to build a cooperative structure and the psychiatrists’ resetting the limits of that structure. BUILDING A COOPERATIVE STRUCTURE
In the months immediately following the issuance of the directive, the two mental health facilities sought ways to avoid full compliance. Eventually they agreed to Glooscap’s suggestion that they jointly construct a ‘shopping list’ of services and facilities which could make the merger acceptable and, perhaps, even desirable. In July, 1976 the parties submitted their list of sixteen items. At a time when some mergers had already occured these negotiators tactfully placed leverage on the Ministry to accept other than financial reasons for the merger. In a letter accompanying the shopping list they state: One of the principles that has been accepted by all parties is that the overall objective is to achieve an integrated Mental Health Service. While the financial considerations for merger are compelling and important, nevertheless the overriding consideration must be. the perservation of existing levels of service and potential for future improvement. To carry out the proposed mergers for financial reasons alone would surely, in the long run, tend to compromise the services and lead to a lower standard of care. . It has been decided that no further action will be taken on the amalgamation until the Ministry has had an opportunity to review this document. It is strongly felt that the overriding consideration must be the unity of action of all parties, including government, if these mergers are to be accomplished successfully and with the acceptance of the local community.
The Minister of Health informed the parties that his Ministry fully supported their proposed programme but fiscal considerations prevented him from approving any additional services in their 1977-1978 budgets. During the year long hiatus that ensued a principle reason for the merger ceased to be a factor.
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On 31 March 1977 the federal-provincial arrangement which was the source of the funds for these hospital-based programmes was discontinued. During this period the Ministry informed the parties that it would fund items on their shopping list on a piecemeal basis. Between December 1977 and March 1979 Glooscap District Hospital inaugurated alcoholism and partial hospitalization programmes and established a department of psychiatry. Having made tangible responses to their original requests. the Ministry now asked the parties to consummate the merger. However, some unintended consequences of amalgamations elsewhere in the province emerged as unforeseen contingencies affecting the renewal of this negotiation. Before the first anniversary of its merger the board of one regional hospital unilaterally restructured its mental health service in a manner inconsistent with the Ministry’s guidelines for these new units. Worried by these events and wary of Glooscap’s Board overturning the terms of its agreement, Tideways sought ways to maintain its autonomy. At a series of bargaining sessions Tideways countered with alternatives to a full-fledged merger. The other parties dismissed these extreme positions. Eventually, Glooscap’s negotiators accepted Tideway’s preconditions of merger: acceptance of the principle that all mental health professionals share many clinical skills, including psychotherapy; recognition of a multidisciplinary team as the basic delivery unit; abolition of the hospital’s department of psychiatry; establishment of an effective mental health advisory body; and pursuit of the unrealized items on the original shopping list. Faced with this alliance between Glooscap and Tideways, the constant urging of the Ministry to conclude the negotiations, and dissatisfaction among its own staff, the Cornwallis Board requested a meeting to iron out residual disagreements “before the proposed amalgamation agreement goes any further”. In October and November 1980 the staffs of the three institutions met in joint sessions. They unanimously accepted in principle the service model outlined in the proposed agreement and struck a committee to fully specify the principles involved in that model. The planning committee met regularly from November 1980 to July 1981. A complete set of minutes was maintained which indicates that a great deal of time was spent discussing ‘next steps’ to difficult topics, reviewing ‘past steps’, reflecting on current accomplishments or grappling with present difficulties. Contentions regarding the administrative and clinical organization of the proposed service centred on such issues as the ‘latent authority of authority of the nonpsychiatry’, professional medical disciplines, the role of the general practitioner, involvement of private psychiatry, the team concept and the parameters of decision-making. Resolution of these legitimacy issues was achieved by combining persuasion with the negotiation subprocesses of trading off, balancing favours, compromising and restricting the items which could be placed on the agenda. For example, it was agreed that the general practitioner would be the primary caretaker but that the psychiatrists must have responsibility for the patient within the minimal guide-
Some limits to the hospital as a negotiated order
lines of the Hospitals Act. It was agreed that the psychiatrist does have ‘latent authority’ but that all mental health professionals are therapists. The abolition of the department of psychiatry was accompanied by the creation of professional councils for the purposes of peer review, accountability and the maintenance of standards. The position of Director of Medical Consultation Services was created to balance that of Medical Director. The committee also dismissed some lines of argument by reminding the participants that its purpose was to develop the “model as stated in the proposed amalgamation document. . not to look at another service model”. The intensity and regularity of these meeting fostered the evolution of personal relationships and the perception of common interests in the broad principles of the merger. As one member noted, “In general, people are beginning to own the ideas presented, and indeed this is a very positive step”. Additionally, the alliance between Glooscap and Tideways strengthened as their respective different stakes were replaced by shared ones. Their overriding concern became the building of this cooperative structure. However, a segment of the Cornwallis staff, especially its medical staff, only partially adhered to this overriding concern and continued to resist Tideways’ approach. This segment concluded that “Ideas disagreed with by Tideways were pushed aside”. These feelings of frustration also inhibited the formation of strong working and personal relationships with their future colleagues. Since the building of cooperative structures depends on expedient relationships and a willingness to make sacrifices, the continual refusal of this segment to make concessions and its frequent attempts to reopen previously agreed upon items, further excluded it from effective negotiation with not only the other two parties but also the rest of the Cornwallis staff. This group reluctantly accepted the others’ resolution of the outstanding areas of disagreement on the condition that a clause be written into the agreement allowing for changes in the service model in the event that the proposed model did not work. In May the staff of all three institutions unanimously accepted the merger agreement. This unanimity was, in part, a reflection of low morale and a hope that moving forward to implementation would help relieve the tensions and anxieties resulting from this lengthy negotiation. Following review and positive action by the three boards and the Ministry, a formal signing was scheduled for November 1981.
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at the Cornwallis County Hospital, he began to assume an active role in the negotiations. Being very critical of Tideways’ ideology he advocated for greater leadership by the psychiatrists in the negotiation process. Accordingly he distributed his ‘position paper’ which contained some “principles of a rational no-nonsense psychiatric service”. His tenets were: The diagnosis and treatment of mental illness is the responsibility of that specialty of medicine called psychiatry. Psychiatrists are required by law, fitted by training and recognized by society as best able to perform that function. The responsibility placed on the psychiatric profession includes the responsibility to design programs and provide leadership in the public sector of psychiatry, to train and supervise staff and to collaborate with other professionals recognized as having substantial skills to contribute to the service. These have been traditionally psychology, social work and psychiatric nursing.
Meanwhile one of the psychiatrists at Tideways began having reservations about the proposed model. As these issues were debated within the recently established department of psychiatry, these two physicians allied themselves with that segment of the Comwallis staff which was opposed to Tideways’ ideology. This coalition included the majority of Glooscap’s department of psychiatry. The minority consisted of the two full-time psychiatrists at Tideways. At an emotionally charged meeting with the planning committee, these psychiatrists withdrew their opposition and unanimously agreed: That the Department of Psychiatry accepts the need immediate implementation of the concept outlined document and schedules of amalgamation, with the standing that sufficient flexibility will be maintained the system to allow for future change.
for the in the underwithin
They had adopted
this position believing that they had received assurances the proposed service would reflect a public health model, i.e. the acknowledgement of medical direction. Their perception of the model changed drastically between the adoption of the above resolution in May and the issuance of their manifesto in November. In the latter they declared: (We) have every reason now to believe that we were seriously misled as to the philosophy and model of the service about to be formed. Specifically, we understood that a public health service model with medical direction, responsibility and authority was to be implemented, but the evidence since has mounted that the plan proposed is basically a social systems model or one in which medical
responsibility and authority is seriously diluted. RESETTING
THE LIMITS
The formal signing was cancelled. An eleventh hour intervention by the majority of the local psychiatrists changed the course of these negotiations. The origin of this intervention coincides with the solidification of the GlooscapTideways alliance. The planning committee resolved the difficult topics of team structure, therapeutic community, the role of private psychiatry etc. by accepting egalitarianism and open-systems as fundamental principles of mental health service delivery. When the only psychiatrist in full-time private practice in the district accepted a part-time position
Two entwined events underlie this change. Firstly, in June the parties to this agreement hosted the annual workshop of the province’s mental health staffs. A noted psychiatrist and advocate of an opensystems approach to mental health care gave the workshop. His visit had the unintended consequences of solidifying opposition to Tideways’ approach and convincing the psychiatric coalition that their notion of medical direction was not truly imbedded in the model. As one of them expressed it to me: If those (planning committee.) minutes had have been more accurate, much of the confusion and hostility which developed later could have been avoided.
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Secondly. at least two of these physicians feared that they might be squeezed out of private practice. At a meeting between the visiting psychiatrist and the planning committee, the ‘problem of psychiatry’ was discussed at some length. With consensus that the Ministry would not support a programme which did not include a viable psychiatric component, they questioned their ability to hold the support and cooperation of the psychiatrists. This debate concluded when the group expressed concurrence with this statement made by a Glooscap negotiator: We must go with what we have. If we find that additional psychiatrists are needed to make the programme work then we will recruit them. The local psychiatrists may not wish to be part of the public system but they have no basis for inhibiting other psychiatrists from joining. They won’t like the competition but that’s not our problem. This statement and information that informal recruitment was in progress deeply disturbed the psychiatric coalition. In July, Glooscap’s department of psychiatry adopted a resolution recommending that a complement of six psychiatrists be set for the service “with the understanding that the private and public sectors of psychiatry would cooperate in a comprehensive mental health service”. While the intent of this motion was to ask the Glooscap Board for some guarantee that all six local psychiatrists could participate in the proposed programme, it was interpreted as a request to regulate medical manpower. The Board rejected the recommendation. The Board’s action pushed the psychiatrists to change their tactics. Increasingly frustrated by their inability to negotiate successfully with the official parties to the agreement, they sought and obtained support from the Medical Society and widely circulated their November manifesto. The responses to these activities were mixed. The reaction of the non-medical mental health professionals leaned towards the position expressed by one of Cornwallis’ staff: As a clinical psychologists who has spent ten years in the formal study of human behaviour, treatment methodology, and diagnosis. I feel rather like the concentration camp victim who recently had to obtain a court ruling to substantiate the fact that The Holocaust had indeed taken place. If anything, the papers of (the four psychiatrists) beautifully exemplify the restricted vision that results when any one discipline alone directs the focus of mental health/‘illness’ service delivery. Glooscap’s medical staff met with a spokesperson for the psychiatrists and heard the proposed merger described as “the most radical attempt yet by paraprofessionals to take over a recognized medical priority”. In an effort to mediate the dispute the medical staff recommended the augmentation of psychiatry’s authority. The Cornwallis Board also scheduled a meeting to listen to the psychiatrists. Despite a tentative agreement being reached during that meeting, the Board voted to defer the signing until it had further clarified the future role of its facility. Glooscap’s executive director informed his Board of the nature of the dispute and of his understanding that the assurances demanded by the psychiatrists were “already part of the Agreement, although language”. This phrased in more general
G.
RE0~i-d
staff-negotiator also recommended that .’ if we do reach an agreement on future mental health services it must be made clear that the four psychiatrists will not dictate the terms”. This Board voted to finalize the merger and accepted the recommendations of its medical staff, “to the extent that agreement could be reached with Tideways on this matter”. The executive committee of Tideways initially discounted the demands but later accepted Glooscap’s offer to amend the agreement, “provided that it is consistent with the philosophy of this centre”. Charging that these provisos bypassed and effectively ignored their concerns, the psychiatrists rejected a revised draft and circulated their own proposal for a medically oriented service model. This move towards an extreme position following five and a half years of negotiation elicited a strong response. Glooscap’s Board viewed it as a retrograde step, based on “misrepresentation and distortion of the facts”, which could “cause the area to lose the services of some very competent professionals in other disciplines”. Its medical staff accused these psychiatrists of “attempting a perverse manipulation” and urged them to resolve the impasse as quickly as possible. In mid-December the psychiatrists withdrew their proposal and accepted some modifications to the revised agreement which they had previously rejected. These changes gave the medical director, a psychiatrist, responsibility for assuring that each patient had a treatment plan and provided a mechanism for the appointment of psychiatrists as medical heads of service. The revisions specified that psychiatrists hold ultimate responsibility for admission and discharge and for “all other situations in which medical judgement is required”. Finally, the psychiatrists were granted a structural link with the medical staff organization of the hospital: thus reaffirming that they constitute a medical department of the hospital. A second, year-long hiatus followed this accord with the psychiatrists. During 1982 the provincial government faced a serious financial situation. As part of its restraint measures it announced a moratorium on hospital construction. An agreement among the three agencies required unequivocal assurances that a new mental health facility would be constructed and the County would continue to receive funds for the maximal usage of its former municipal hospital. In November the government signalled its willingness to give these assurances and in December the Minister of Health made it clear that he fully intended to execute the amalgamation in the current year. DISCUSSION In her study of nurse-midwives Maurin distinguishes two levels of negotiation: ‘around rules’ and ‘about rules’. The former are common attributes of the informal organization of working relations. The latter “occur at a level which results in policymaking and institutionalization” [ 131.The bargaining about the clinical and administrative organization of the proposed unit involved both of these levels. The intensity and centrality of these negotiations attest to
Some limits to the hospital as a negotiated order
the importance of negotiated order considerations in understanding this amalgamation process. Tideways and Cornwallis initially opposed the change required by the governmental directive. Eventually Tideways seized the merger process as a means to negotiate about the division of labour in mental health care. The psychiatrists opposed the service model which emerged. These reactions are consistent with the findings of research on resistance to change, viz. opposition arises among those who have the least to gain or the most to lose from the change [14]. In the present case, any consideration of relative gains or losses must take into account the very different stakes which each group had. Each wished to control the direction and philosophy of the proposed service. Given the contextual properties of these negotiations, Tideways’ determination and staging of its negotiations [IS] account for both the alliance with Glooscap and the restriction of the range of topics subject to negotiation [16]. However, the implicit acceptance of the structural property of medical dominance prevented the Tideways-Glosscap alliance from pushing its negotiations ‘about the rules’ into policy. The division of labour, authority and responsibility outlined in the service model challenged psychiatry’s privileged position. A majority of the psychiatrists faced this challenge by using claims to superior knowledge and skills as a means of social control. Friedson [17] argues that such claims function as ideologies and can be evaluated independently of their validity for their part in gaining public support for one’s interests. These physicians intervented to protect their power and status in their professional communities by limiting negotiations about the rules defining the division of labour in medical settings; in their words: As doctors and psychiatrists our only unalterable needs are for freedom to practice our profession as best we can with reasonable remuneration and in acceptable circumstances. All else is negotiable. Concessions were made to the psychiatrists because, with few exceptions, the directors and staff were not prepared to deny their assertions. Indeed,
they have consistently acquiesced in the notion that the psychiatrists have latent authority. During their negotiations with these physicians, the architects of the service model argued that most of their wishes were implicitly recognized in the agreement. However, they tried to avoid making an explicit admission of the hegemony of medicine in mental health care, for to do so would-in the words of one negotiator“upset the other professional staff ‘. The psychiatrists on the other hand were quite prepared to negotiate around the rules, as long as the rules, per se, were not affected. These finding suggest that there are some limits to the hospital as a negotiated order. The professional dominance of physicians allows them to effectively exercise control over the conditions of their work and
249
hence inhibit the formal restructuring of medical settings. Unless the directors of hospitals and their non-medical staffs discount medical arguments for physician control of health care, there appears to be little leverage for significant change in these medically dominated settings. In exploring the limits to negotiation in settings dominated by one profession, we should seek to identify the conditions which foster a potent challenge to such dominance. wish to express my appreciation to those about whom I have written for their tolerance of my presence and their willingness to explain their perspectives. I also wish to thank my colleagues in the Department of Behavioural Science, University of Toronto for their comments on this material. Acknowledgements-l
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(Edited by Roth J. A.), p. 303. JAI Press, San Francisco, 1980. 14. Whisler T. L. Information, Technology and Organizational Change. Wadsworth, 1970. Rothman R. A.. Schwartzbaum A. M. and McGrath J. H. Physicians and a hospital merger: patterns of resistance to organizational change. J. Hlrh sot. Behao. 12,46-55. 1971. 15. Levy J. A. The staging of negotiations between hospice and medical institutions. Urban Lifp 11, 305, 1982. 16. Busch L. History, negotiation, and structure in agricultural research. Urban Life 11, 381, 1982. 17. Friedson E. The Professions and Their Prospects, p. 30. Sage, Beverly Hills, 1973.
SCL
Printed
Med.
in Great
Vol. 18. No. 3. pp. 243-249. Brltaln
0277-9536/X4 $3.00 + 0.00 Pergamon Press Ltd
1984
SOME LIMITS TO THE HOSPITAL A NEGOTIATED ORDER THOMAS
Department
of Sociology,
Acadia
G.
University,
AS
REGAN
Wolfville,
Nova
Scotia,
Canada
BOP 1X0
Abstract-This paper examines issues of freedom and constraint by employing the negotiated order perspective in an analysis of a merger of three health care institutions. The findings give support to the importance of negotiated order considerations in understanding the social organization of health care, for they suggest that there are some limits to negotiations which take place within medically dominated settings.
INTRODUCI’ION
THE DELIVERY OF MENTAL HEALTH CARE IN EASTERN PROVINCE 19X1-1976
order perspective to analyze a merger involving three health care institutions. During the past 20 years this perspective has moved from a general theoretical stance within symbolic interactionism to a more focused and paradigmatic framework [l]. A central contention is that all social orders are negotiated orders, i.e. negotiations are not just another interesting topic of research but rather essential aspects of social organization [2]. Critics of the perspective argue that it ignores the real issues of social structures [3]. They point to a failure to address the importance of power and resources in negotiations; an overemphasis on the freedom of certain persons or groups to bargain; and an avoidance of the relationship of a given negotiated order to the political economy of the larger social world. While these critics acknowledge that negotiated order researches do not ignore structural and other limits, they feel that such limits are only viewed This
paper
uses
a negotiated
as parameters which define the boundaries of analysis. In response to these criticisms, Strauss states that an understanding of negotiation processes might provide important insights regarding questions of freedom vs constraint in social life: Structural process considerations suggest quite clearly that what someone takes as limits to negotiation-in any given situation-may not really constitute limits. . what were previously taken as probably nonnegotiable may in fact be negotiable in some sense, some way, some degree. Whether or not that is so has to be discovered.. exploration [4].
the.limits
During the third quarter of this century the provision of mental health care in Eastern Province reflected the patterns of regionalization and decentralization found elsewhere in Canada. A full decade before the publication of More for Ihe Mind [5] the government of Eastern Province had joined with the Canadian Mental Health Association in the formation of community-based care for the mentally ill. By the mid-sixties nine community mental health centres had been established. They were designed to provide outpatient and preventive services to a defined catchment area and functioned under the aegis of local community boards of directors. Longterm, palliative and custodial care to the mentally disabled were available at municipal hospitals. During this period the number of municipal hospitals was reduced to four. Those requiring acute or specialized services were admitted to the Provincial Hospital. Prompted by a desire to further benefit from federal-provincial cost-sharing arrangements, the provincial government in 1976 announced a policy change with respect to the financing and delivery of mental health services. The new policy had three components. Patients who no longer required active psychiatric treatment were transferred to residential facilities funded by the Ministry of Social Services. Two of the municipal hospital were transferred to Social Services and redesignated as residential and rehabilitation centres. All mental health centres were directed to merge with general hospitals.
require
This paper does such an exploration. It describes and analyzes the response of three health care institutions to a governmental directive to merge. The study is grounded in an examination of documents and 5 years of participant observation and interviewing. Before proceeding with the analysis some background information is provided.
Parts of this paper were first presented at the Canadian Ethnology Society annual meetings. Hamilton, Ontario, 7 May. 1983. 243
RESPONSES OF THE MENTAL HEALTH CENTRES AND GENERAL HOSPITALS TO THE GOVERNMENTAL DIRECTIVE
The decision to merge mental health centres with general hospitals was made without prior consultation with the institutions affected. Their board chairpersons and senior executives officers were hastily summoned to a meeting at which they were told that the Ministry wanted the regional hospitals to assume responsibility for the delivery of mental health services. In accordance with this new policy, each hospital and mental health centre would negotiate an agreement whereby the centre would become
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a department of the hospital. At this meeting the Ministry also set a deadline and issued guidelines for the accomplishment of these amalgamations. Following this meeting the Ministry issued a series of letters reminding these boards of the urgency of the directive. While each region was allowed to work out the particulars for its area, it was understood that these were to be completed forthwith and under terms acceptable to the Ministry. The governmental directive implied that amalgamation was a condition of continued funding of mental health services. These hospitals and centres were technically private corporations directed by boards comprised of local citizens. Nonetheless, the government was the principal source of funds. Of the seven mental health centres which were directed to merge with regional hospitals, three met the deadline. Within a year, five amalgamations and one financial merger were completed [6]. The preambles to these merger agreements clearly indicate that these boards viewed the directive as a nonnegotiable command. The following statement is a typical, initial sentence in these documents: As directed by the Ministry of Health, Western Counties Mental Health Cenlre is amalgamated as a department of Western Regional Hospital, effective May 1, 1976. In only one region of the province did the response take a different form. The negotiations extended over 7 years and included *explorations of options to a straightforward merger and tests of the limits of the mental health division of labour. From the beginning the Ministry of Health foresaw that this merger would be more difficult than in the other regions. On the one hand it was more complex. Elsewhere the negotiators consisted of representatives of a hospital board and a centre board, in this case the board of a municipal psychiatric hospital was also involved. Elsewhere a merger did not involve a physical relocation of staff for the mental health centres rented space from the hospital. In this case, a physical relocation was involved for the three institutions were located in different communities. On the other hand, these agencies were proud of their programmes and jealous of their identity and autonomy. The policy change had been a particular blow to the two mental health facilities. With three psychiatrists, two psychologists, four social workers, one nurse and three secretaries, Tideways Mental Health Centre was the largest in the province. During its 25 year history it had developed a good reputation based on a community orientation and a fairly egalitarian division of labour. It initially viewed a hospital merger as being antithetical to its ideology of care. The implications of the policy shift for Cornwallis County Hospital were two-fold. It was one of the municipal hospitals which was redesignated a rehabilitation centre. Accordingly, it was being asked to negotiate a transfer of its psychiatric programmes to the regional hospital and assume a new service mission in the area of social services. Both requests were hard to swallow for the municipality had devoted ten years to the recruitment of psychiatric staff with an aim to becoming the regional psychiatric centre for the southwestern region of the province. Glooscap District Hospital was prepared to assume responsibility for the provision of mental health
REGAN
care. Since the mid-sixties it had been slowly building its professional staff in order to meet its responsibilities as a regional hospital. Its board hopes to develop a full range of services for the residents of Glooscap District and aspires to be the premier regional hospital in the province. This amalgamation is another step in that direction. However, Glooscap’s officers also had a wideawake appreciation of the rivalry and conflicting ideologies of the two mental health facilities. The merger discussions have combined many subprocesses of negotiation (e.g. bargaining from extremes, trading off, exploring legitimate boundaries, territorial claiming, compromising towards the middle and progressive building of agreements) with alternatives to bargaining such as manipulation of events, false negotiation, education and persuasion. As others have noted negotiations among professionals tend to be overt [7]. These transactions were very visible. Not only were virtually all negotiations overt but efforts were taken to assure clarity about every step in the process. Additionally, talks between only two parties were informal because neither party wished to give the impression that it had initiated action in the absence of the others. During the course of 7 years, these negotiations were marked with distinctive phases in which some issues were resolved and others arose. In analysing how a service model emerged as a negotiated compromise, this paper focuses on only two of these periods. In so doing, it shows how a microscopic analysis of the interaction among the parties who negotiated this merger-an analysis that does not ignore the effects of structural conditions on negotiation processesadvances our understanding of the structural limits to negotiation and how they are tested and reset. THE STRUCTURAL
CONTEXT
In an extended presentation of the negotiated orders’ paradigm, Strauss identifies two levels of structural properties within which negotiations, and their subprocesses, take place, viz. negotiation contexts and structural contexts. The latter refers specifically to those structural properties of the larger social world within which negotiations occur. These structural properties often have a direct bearing on both the negotiation context of a given negotiation and the negotiations, per se. While it is plausible that negotiations could alter a structural context, individual negotiations are less likely to affect these structural properties, “except as they are repeated or combined with other negotiations and with other modes of action and so perhaps have a cumulative impact” [8]. In the broadest sense the structural context of the merger process under examination inclues the political economy of health care in Canada, especially in respect to the government’s distribution of resources and its relationship to health care institutions and providers. The decision of Eastern Province to relocate mental health services in general hospitals was certainly rooted in fiscal considerations. It was also a reaction to some of the inadequacies of community mental health centres and an acceptance of the counter-movement in other provinces to narrow the
Some limits to the hospital as a negotiated order range of mental health services by integrating them with the physical and personnel resources of the rest of medicine. This transition of mental health care into general hospitals places this merger process within the structural context of Canadian medical care. This context contains such structural properties as the status of psychiatry as a medical subspecialty, specialization among the caring professions and the divisions of labour in health care settings. Of particular relevance for this study is the presence of the professional dominance of medicine as a structural property which limits the influence of non-medical ideologies on the structuring of work in medical settings [9]. While some argue that physician dominance is beginning to wane, Blishen’s observation that professional control over the conditions of work is the most persistent concern of the medical profession in Canada remains the central structural feature of the power relationships in Canadian health care [lo]. Some significant features of the structural context are also visible at the intra- and interorganizational levels. The government instructed the directors of these health care organizations to work out the terms of amalgamation. These individuals are entrusted with the responsibility to plan and oversee the services provided by their respective institutions. While these boards have the final say in what is negotiated, their members typically play nominal or reactive roles to the decisions made by others. Major decisions are usually made by a small group composed of a few highly committed trustees and executive officers. These features of the governance of health care, educational and social services agencies underlie the importance of interpersonal relationships as structural properties [1 11. It is interpersonal relations qua structural properties which countenances physician dominance. Accordingly, one should look to this level for the origins of structural metamorphosis. THE NEGOTIATION
CONTEXT
A negotiation context consists of those structural properties which constitute the immediate conditions of a given negotiation. These contextual attributes form the bases of a mesostructure in which both the properties of structure and the subprocesses of negotiation are enacted [ 121. For this reason, negotiation contexts are malleable with the lines of impact running in either direction. The negotiation context of this amalgamation was characterized by a mixture of stable and variable properties. Included among the former were the novelty and complexity of the issues involved in marrying the principles of community psychiatry to the realties of inpatient psychiatry in a general hospital setting. Underlying most of these issues were questions of legitimacy: What constitutes clinical expertise? What work might members of each agency or occupational group legitimately do? The resolution of these issues was further complicated by other attributes of the negotiation context. Firstly, each party had the common stakes of appearing to comply with the governmental directive and the mutually exclusive stakes of controlling the direction and philosophy of the proposed amalgamated
245
programme. Each of the mental health facilities wish to implant its respective and very different ideology of care into the structure and programmes of the proposed service. The district hospital could accept either philosophy as long as its board exercised ultimate control over the programme. Secondly, the parties met jointly with each agency represented by a small group of directors and senior staff. Initially they met in a series of encounters with the only option being the blocking of an agreement. After an agreement-in-principle was achieved, the context shifted to a sequential and linked format with the senior staff regularly meeting to develop the service model and determine the specifications of the new inpatient unit. The presence of staff as negotiators joined the working out of working relationships among these individuals to the building of a merger agreement. The settlement of these working relations became a necessary condition for the resolution of the major legitimacy issues, and hence the achievement of an amalgamation agreement. The negotiation of working relations was itself contingent on two additional contextual properties, viz. differential theories of negotiation and the evolving personal relations among the negotiators. Each party adhered to different theories of negotiation. The board and staff were quite unified in their support of Tideways’ approach to mental health care. Since merger meant the eventual disolution of its board of directors, this centre was determined to see its approach if not its name continued. In pursuit of this mission, Tideways’ representatives spoke with the assurance that their statements had the endorsement of their board and staff. They were typically well prepared and aggressive though not unwilling to make compromises. Their concern for a fine-tuning of the terms of the agreement in order to safeguard their philosophy lead to an emphasis on the negotiation of working relationships as a mechanism for establishing control over programming. Cornwallis County Hospital would have liked to have remained a regional psychiatric hospital. Accepting amalgamation as inevitable, it concentrated on transfering the responsibility for mental health care to the district hospital. Many of. its staff were unaffected by the merger. They would continue to be employees of the hospital as it entered into a new era as a rehabilitation centre. Given these circumstances, the Comwallis Board did not become systematically involved in bargaining about working relationships. It wished to see its psychiatric staff well treated but generally regarded those concerns as the responsibility of Glooscap as the operator of the new service. The passive stance of this Board placed its staff-negotiators at a disadvantage in their negotiations over working relations. This disadvantage was further aggravated by a lack of unity among the staff which was affected by the merger. Lacking a cohesive negotiative strategy, these staff-negotiators frequently found themselves simply reacting to initiatives advanced by Tideways or Glooscap. Glooscap Hospital saw the merger as an opportunity to develop a more comprehensive set of services than the Ministry had initially intended, thus enhancing its posture as a regional hospital. Its
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negotiators adopted a theory of reconciliation. They were prepared to make concessions to each party in order to convince them that they would continue to have a say in the day to day operation of the proposed unit. If it could not accomodate both parties, Glooscap was prepared to side with the one which would promote its goal of housing a viable mental health programme. Finally, these negotiations often hinged on the dynamics of interpersonal relationships. Initially these persons were relatively inexperienced negotiators. Over time they became more acquainted with one another’s styles and theories of negotiation. The more decisive and organized approaches of Glooscap and Tideways fostered an affinity between these two groups. This evolution of personal relationships shifted the balance of power in favour of the Tideways’ philosophy. The contextual properties of this merger process became structured in a manner which gave ascendancy to Tideways’ open-system and egalitarian resolutions of issues related to questions of legitimacy. Since these solutions challenged the hegemony of psychiatry in the delivery of mental health services, a segment of the psychiatrists intervened to contest the agreement and reset the limits of this negotiated order. Having situated the process within these two levels of structure, we shall now examine the efforts to build a cooperative structure and the psychiatrists’ resetting the limits of that structure. BUILDING A COOPERATIVE STRUCTURE
In the months immediately following the issuance of the directive, the two mental health facilities sought ways to avoid full compliance. Eventually they agreed to Glooscap’s suggestion that they jointly construct a ‘shopping list’ of services and facilities which could make the merger acceptable and, perhaps, even desirable. In July, 1976 the parties submitted their list of sixteen items. At a time when some mergers had already occured these negotiators tactfully placed leverage on the Ministry to accept other than financial reasons for the merger. In a letter accompanying the shopping list they state: One of the principles that has been accepted by all parties is that the overall objective is to achieve an integrated Mental Health Service. While the financial considerations for merger are compelling and important, nevertheless the overriding consideration must be. the perservation of existing levels of service and potential for future improvement. To carry out the proposed mergers for financial reasons alone would surely, in the long run, tend to compromise the services and lead to a lower standard of care. . It has been decided that no further action will be taken on the amalgamation until the Ministry has had an opportunity to review this document. It is strongly felt that the overriding consideration must be the unity of action of all parties, including government, if these mergers are to be accomplished successfully and with the acceptance of the local community.
The Minister of Health informed the parties that his Ministry fully supported their proposed programme but fiscal considerations prevented him from approving any additional services in their 1977-1978 budgets. During the year long hiatus that ensued a principle reason for the merger ceased to be a factor.
REGAN
On 31 March 1977 the federal-provincial arrangement which was the source of the funds for these hospital-based programmes was discontinued. During this period the Ministry informed the parties that it would fund items on their shopping list on a piecemeal basis. Between December 1977 and March 1979 Glooscap District Hospital inaugurated alcoholism and partial hospitalization programmes and established a department of psychiatry. Having made tangible responses to their original requests. the Ministry now asked the parties to consummate the merger. However, some unintended consequences of amalgamations elsewhere in the province emerged as unforeseen contingencies affecting the renewal of this negotiation. Before the first anniversary of its merger the board of one regional hospital unilaterally restructured its mental health service in a manner inconsistent with the Ministry’s guidelines for these new units. Worried by these events and wary of Glooscap’s Board overturning the terms of its agreement, Tideways sought ways to maintain its autonomy. At a series of bargaining sessions Tideways countered with alternatives to a full-fledged merger. The other parties dismissed these extreme positions. Eventually, Glooscap’s negotiators accepted Tideway’s preconditions of merger: acceptance of the principle that all mental health professionals share many clinical skills, including psychotherapy; recognition of a multidisciplinary team as the basic delivery unit; abolition of the hospital’s department of psychiatry; establishment of an effective mental health advisory body; and pursuit of the unrealized items on the original shopping list. Faced with this alliance between Glooscap and Tideways, the constant urging of the Ministry to conclude the negotiations, and dissatisfaction among its own staff, the Cornwallis Board requested a meeting to iron out residual disagreements “before the proposed amalgamation agreement goes any further”. In October and November 1980 the staffs of the three institutions met in joint sessions. They unanimously accepted in principle the service model outlined in the proposed agreement and struck a committee to fully specify the principles involved in that model. The planning committee met regularly from November 1980 to July 1981. A complete set of minutes was maintained which indicates that a great deal of time was spent discussing ‘next steps’ to difficult topics, reviewing ‘past steps’, reflecting on current accomplishments or grappling with present difficulties. Contentions regarding the administrative and clinical organization of the proposed service centred on such issues as the ‘latent authority of authority of the nonpsychiatry’, professional medical disciplines, the role of the general practitioner, involvement of private psychiatry, the team concept and the parameters of decision-making. Resolution of these legitimacy issues was achieved by combining persuasion with the negotiation subprocesses of trading off, balancing favours, compromising and restricting the items which could be placed on the agenda. For example, it was agreed that the general practitioner would be the primary caretaker but that the psychiatrists must have responsibility for the patient within the minimal guide-
Some limits to the hospital as a negotiated order
lines of the Hospitals Act. It was agreed that the psychiatrist does have ‘latent authority’ but that all mental health professionals are therapists. The abolition of the department of psychiatry was accompanied by the creation of professional councils for the purposes of peer review, accountability and the maintenance of standards. The position of Director of Medical Consultation Services was created to balance that of Medical Director. The committee also dismissed some lines of argument by reminding the participants that its purpose was to develop the “model as stated in the proposed amalgamation document. . not to look at another service model”. The intensity and regularity of these meeting fostered the evolution of personal relationships and the perception of common interests in the broad principles of the merger. As one member noted, “In general, people are beginning to own the ideas presented, and indeed this is a very positive step”. Additionally, the alliance between Glooscap and Tideways strengthened as their respective different stakes were replaced by shared ones. Their overriding concern became the building of this cooperative structure. However, a segment of the Cornwallis staff, especially its medical staff, only partially adhered to this overriding concern and continued to resist Tideways’ approach. This segment concluded that “Ideas disagreed with by Tideways were pushed aside”. These feelings of frustration also inhibited the formation of strong working and personal relationships with their future colleagues. Since the building of cooperative structures depends on expedient relationships and a willingness to make sacrifices, the continual refusal of this segment to make concessions and its frequent attempts to reopen previously agreed upon items, further excluded it from effective negotiation with not only the other two parties but also the rest of the Cornwallis staff. This group reluctantly accepted the others’ resolution of the outstanding areas of disagreement on the condition that a clause be written into the agreement allowing for changes in the service model in the event that the proposed model did not work. In May the staff of all three institutions unanimously accepted the merger agreement. This unanimity was, in part, a reflection of low morale and a hope that moving forward to implementation would help relieve the tensions and anxieties resulting from this lengthy negotiation. Following review and positive action by the three boards and the Ministry, a formal signing was scheduled for November 1981.
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at the Cornwallis County Hospital, he began to assume an active role in the negotiations. Being very critical of Tideways’ ideology he advocated for greater leadership by the psychiatrists in the negotiation process. Accordingly he distributed his ‘position paper’ which contained some “principles of a rational no-nonsense psychiatric service”. His tenets were: The diagnosis and treatment of mental illness is the responsibility of that specialty of medicine called psychiatry. Psychiatrists are required by law, fitted by training and recognized by society as best able to perform that function. The responsibility placed on the psychiatric profession includes the responsibility to design programs and provide leadership in the public sector of psychiatry, to train and supervise staff and to collaborate with other professionals recognized as having substantial skills to contribute to the service. These have been traditionally psychology, social work and psychiatric nursing.
Meanwhile one of the psychiatrists at Tideways began having reservations about the proposed model. As these issues were debated within the recently established department of psychiatry, these two physicians allied themselves with that segment of the Comwallis staff which was opposed to Tideways’ ideology. This coalition included the majority of Glooscap’s department of psychiatry. The minority consisted of the two full-time psychiatrists at Tideways. At an emotionally charged meeting with the planning committee, these psychiatrists withdrew their opposition and unanimously agreed: That the Department of Psychiatry accepts the need immediate implementation of the concept outlined document and schedules of amalgamation, with the standing that sufficient flexibility will be maintained the system to allow for future change.
for the in the underwithin
They had adopted
this position believing that they had received assurances the proposed service would reflect a public health model, i.e. the acknowledgement of medical direction. Their perception of the model changed drastically between the adoption of the above resolution in May and the issuance of their manifesto in November. In the latter they declared: (We) have every reason now to believe that we were seriously misled as to the philosophy and model of the service about to be formed. Specifically, we understood that a public health service model with medical direction, responsibility and authority was to be implemented, but the evidence since has mounted that the plan proposed is basically a social systems model or one in which medical
responsibility and authority is seriously diluted. RESETTING
THE LIMITS
The formal signing was cancelled. An eleventh hour intervention by the majority of the local psychiatrists changed the course of these negotiations. The origin of this intervention coincides with the solidification of the GlooscapTideways alliance. The planning committee resolved the difficult topics of team structure, therapeutic community, the role of private psychiatry etc. by accepting egalitarianism and open-systems as fundamental principles of mental health service delivery. When the only psychiatrist in full-time private practice in the district accepted a part-time position
Two entwined events underlie this change. Firstly, in June the parties to this agreement hosted the annual workshop of the province’s mental health staffs. A noted psychiatrist and advocate of an opensystems approach to mental health care gave the workshop. His visit had the unintended consequences of solidifying opposition to Tideways’ approach and convincing the psychiatric coalition that their notion of medical direction was not truly imbedded in the model. As one of them expressed it to me: If those (planning committee.) minutes had have been more accurate, much of the confusion and hostility which developed later could have been avoided.
248
TH0hf~s
Secondly. at least two of these physicians feared that they might be squeezed out of private practice. At a meeting between the visiting psychiatrist and the planning committee, the ‘problem of psychiatry’ was discussed at some length. With consensus that the Ministry would not support a programme which did not include a viable psychiatric component, they questioned their ability to hold the support and cooperation of the psychiatrists. This debate concluded when the group expressed concurrence with this statement made by a Glooscap negotiator: We must go with what we have. If we find that additional psychiatrists are needed to make the programme work then we will recruit them. The local psychiatrists may not wish to be part of the public system but they have no basis for inhibiting other psychiatrists from joining. They won’t like the competition but that’s not our problem. This statement and information that informal recruitment was in progress deeply disturbed the psychiatric coalition. In July, Glooscap’s department of psychiatry adopted a resolution recommending that a complement of six psychiatrists be set for the service “with the understanding that the private and public sectors of psychiatry would cooperate in a comprehensive mental health service”. While the intent of this motion was to ask the Glooscap Board for some guarantee that all six local psychiatrists could participate in the proposed programme, it was interpreted as a request to regulate medical manpower. The Board rejected the recommendation. The Board’s action pushed the psychiatrists to change their tactics. Increasingly frustrated by their inability to negotiate successfully with the official parties to the agreement, they sought and obtained support from the Medical Society and widely circulated their November manifesto. The responses to these activities were mixed. The reaction of the non-medical mental health professionals leaned towards the position expressed by one of Cornwallis’ staff: As a clinical psychologists who has spent ten years in the formal study of human behaviour, treatment methodology, and diagnosis. I feel rather like the concentration camp victim who recently had to obtain a court ruling to substantiate the fact that The Holocaust had indeed taken place. If anything, the papers of (the four psychiatrists) beautifully exemplify the restricted vision that results when any one discipline alone directs the focus of mental health/‘illness’ service delivery. Glooscap’s medical staff met with a spokesperson for the psychiatrists and heard the proposed merger described as “the most radical attempt yet by paraprofessionals to take over a recognized medical priority”. In an effort to mediate the dispute the medical staff recommended the augmentation of psychiatry’s authority. The Cornwallis Board also scheduled a meeting to listen to the psychiatrists. Despite a tentative agreement being reached during that meeting, the Board voted to defer the signing until it had further clarified the future role of its facility. Glooscap’s executive director informed his Board of the nature of the dispute and of his understanding that the assurances demanded by the psychiatrists were “already part of the Agreement, although language”. This phrased in more general
G.
RE0~i-d
staff-negotiator also recommended that .’ if we do reach an agreement on future mental health services it must be made clear that the four psychiatrists will not dictate the terms”. This Board voted to finalize the merger and accepted the recommendations of its medical staff, “to the extent that agreement could be reached with Tideways on this matter”. The executive committee of Tideways initially discounted the demands but later accepted Glooscap’s offer to amend the agreement, “provided that it is consistent with the philosophy of this centre”. Charging that these provisos bypassed and effectively ignored their concerns, the psychiatrists rejected a revised draft and circulated their own proposal for a medically oriented service model. This move towards an extreme position following five and a half years of negotiation elicited a strong response. Glooscap’s Board viewed it as a retrograde step, based on “misrepresentation and distortion of the facts”, which could “cause the area to lose the services of some very competent professionals in other disciplines”. Its medical staff accused these psychiatrists of “attempting a perverse manipulation” and urged them to resolve the impasse as quickly as possible. In mid-December the psychiatrists withdrew their proposal and accepted some modifications to the revised agreement which they had previously rejected. These changes gave the medical director, a psychiatrist, responsibility for assuring that each patient had a treatment plan and provided a mechanism for the appointment of psychiatrists as medical heads of service. The revisions specified that psychiatrists hold ultimate responsibility for admission and discharge and for “all other situations in which medical judgement is required”. Finally, the psychiatrists were granted a structural link with the medical staff organization of the hospital: thus reaffirming that they constitute a medical department of the hospital. A second, year-long hiatus followed this accord with the psychiatrists. During 1982 the provincial government faced a serious financial situation. As part of its restraint measures it announced a moratorium on hospital construction. An agreement among the three agencies required unequivocal assurances that a new mental health facility would be constructed and the County would continue to receive funds for the maximal usage of its former municipal hospital. In November the government signalled its willingness to give these assurances and in December the Minister of Health made it clear that he fully intended to execute the amalgamation in the current year. DISCUSSION In her study of nurse-midwives Maurin distinguishes two levels of negotiation: ‘around rules’ and ‘about rules’. The former are common attributes of the informal organization of working relations. The latter “occur at a level which results in policymaking and institutionalization” [ 131.The bargaining about the clinical and administrative organization of the proposed unit involved both of these levels. The intensity and centrality of these negotiations attest to
Some limits to the hospital as a negotiated order
the importance of negotiated order considerations in understanding this amalgamation process. Tideways and Cornwallis initially opposed the change required by the governmental directive. Eventually Tideways seized the merger process as a means to negotiate about the division of labour in mental health care. The psychiatrists opposed the service model which emerged. These reactions are consistent with the findings of research on resistance to change, viz. opposition arises among those who have the least to gain or the most to lose from the change [14]. In the present case, any consideration of relative gains or losses must take into account the very different stakes which each group had. Each wished to control the direction and philosophy of the proposed service. Given the contextual properties of these negotiations, Tideways’ determination and staging of its negotiations [IS] account for both the alliance with Glooscap and the restriction of the range of topics subject to negotiation [16]. However, the implicit acceptance of the structural property of medical dominance prevented the Tideways-Glosscap alliance from pushing its negotiations ‘about the rules’ into policy. The division of labour, authority and responsibility outlined in the service model challenged psychiatry’s privileged position. A majority of the psychiatrists faced this challenge by using claims to superior knowledge and skills as a means of social control. Friedson [17] argues that such claims function as ideologies and can be evaluated independently of their validity for their part in gaining public support for one’s interests. These physicians intervented to protect their power and status in their professional communities by limiting negotiations about the rules defining the division of labour in medical settings; in their words: As doctors and psychiatrists our only unalterable needs are for freedom to practice our profession as best we can with reasonable remuneration and in acceptable circumstances. All else is negotiable. Concessions were made to the psychiatrists because, with few exceptions, the directors and staff were not prepared to deny their assertions. Indeed,
they have consistently acquiesced in the notion that the psychiatrists have latent authority. During their negotiations with these physicians, the architects of the service model argued that most of their wishes were implicitly recognized in the agreement. However, they tried to avoid making an explicit admission of the hegemony of medicine in mental health care, for to do so would-in the words of one negotiator“upset the other professional staff ‘. The psychiatrists on the other hand were quite prepared to negotiate around the rules, as long as the rules, per se, were not affected. These finding suggest that there are some limits to the hospital as a negotiated order. The professional dominance of physicians allows them to effectively exercise control over the conditions of their work and
249
hence inhibit the formal restructuring of medical settings. Unless the directors of hospitals and their non-medical staffs discount medical arguments for physician control of health care, there appears to be little leverage for significant change in these medically dominated settings. In exploring the limits to negotiation in settings dominated by one profession, we should seek to identify the conditions which foster a potent challenge to such dominance. wish to express my appreciation to those about whom I have written for their tolerance of my presence and their willingness to explain their perspectives. I also wish to thank my colleagues in the Department of Behavioural Science, University of Toronto for their comments on this material. Acknowledgements-l
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