RECREATION THERAPY PROGRAMMING: A PROTOCOL APPROACH TO ...

Global Therapeutic Recreation III

Selected papers from the 3rd International Symposium on Therapeutic Recreation

© Curators University of Missouri 1994

RECREATION THERAPY PROGRAMMING: A PROTOCOL APPROACH TO
TREATMENT EVALUATION FOR QUALITY ASSURANCE

Roy H. Olsson, Jr., Ph.D., CTRS, RTCR

Professor of Recreation Therapy
University of Toledo
Toledo, Ohio

Bruce Groves, M.Ed.

Instructor of Recreation & Leisure Education
University of Toledo
Toledo, Ohio

Shari Perkins, Ph.D. CTRS, RTCR

Assistant Prof. of Recreation Therapy
University of Toledo
Toledo, Ohio

Introduction
In the eighties an increased emphasis was placed on accountability through
efficiency, effectiveness and cost containment (Olsson, 1986; Donovan, 1987; Riley, 1987;
Halberg & Olsson, 1989). The decade of the nineties will continue to place an increasing
emphasis on accountability issues and survival of this decade will be linked with efficacy of
services (West, 1987). Steve Wright (1987) suggested the challenge for Therapeutic
Recreation (TR) is ... "to conceptualize, develop and implement Quality Assurance systems
which would reflect state-of-the-art practice."
The practice of TR has been conceptualized several ways. The National Therapeutic
Recreation Society (1982) suggested that TR is a continuum of services which include:
Therapy, the use of recreation to improve functional behaviors as a necessary prerequisite
to meaningful leisure involvement; Leisure Education, providing opportunities to acquire
leisure awareness, values, attitudes and skills as they relate to leisure involvement; and
Recreation Participation, to allow for voluntary leisure involvement. The American
Therapeutic Recreation Association (1986) conceptualized a definition of TR as follows .
. . "is the provision of Treatment Services and the provision of Recreation Services to
persons with illness or disabling conditions. The primary purpose of Treatment Services
which is often referred to as Recreation Therapy (RT), is to restore, remediate or
rehabilitate in order to improve functioning and independence as well as reduce or
eliminate the effects of illness or disability. The primary purpose of Recreation Services is
to provide recreation resources and opportunities in order to improve health and well-being.
TR is provided by professionals who are trained and certified, registered or licensed to
provide TR." Regardless of the conceptualization, it is clear that TR provides several types
of services: those that are an end unto themselves - leisure behavior (i.e., Leisure Education

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and Recreation); and those that are a means to an end - treatment (i.e., RT) (Mobily, 1985;
Olsson, 1986).

Accountability of these services demand monitoring programs, therapists, and
interventions to determine their effectiveness and their ability to produce a reasonable
expectation that the desired patient outcomes will occur (Connolly, 1984; Mobily, 1985b).
One approach to monitoring effectiveness of the RT (treatment) component is to
incorporate an evaluation process based on individualized patient goal attainment (Kiresuk
& Sherman, 1968; Davis, 1973; Katsinas, 1986). The purpose of this article is to introduce
the reader to programming design using a protocol and goal attainment approach. The
article will present an evaluation method, and administrative and ethical implications for
using this protocol design method of programming.

Utilizing Csikszentmihalyi's Theory of Flow in the
Development of Client Performance Standards

The establishment of appropriate objectives for clients requires a therapist to
evaluate several factors related to both individual clients and the activities being utilized in
treatment. Each client will possess skills and abilities that may be different from other
clients. Similarly, each potential therapeutic treatment activity provides different
opportunities for activity and participation. An examination of: (1) individual skills and
abilities and (2) the opportunities for action and challenge in a given activity will provide
information necessary to develop appropriate client objectives.

Individual skills and abilities vary greatly. Numerous physical (i.e. coordination,
strength), mental (knowledge, awareness), social (relationships, communication) and
psychological (motivation, self-esteem) factors must be assessed. Ultimately, a
determination will be made evaluating each clients abilities which may range from low to
high.

Activities available to the therapist for treatment also vary greatly. Sedentary quiet
conversation, attending a concert, or playing competitive volleyball each require action and
provide challenges from simple to complex.

In a research study of the psychology of mountain climbers, Csikszentmihalyi (1990)
identified the concept of "Flow"; a holistic sensation that people feel when they act with
total involvement in a given activity in which they have total control of the action and
environment; resulting in a sense of loss of ego involvement. When "flow occurs" factors
such as motivation, self-esteem, attention span, ability to follow directions are improved.

Csikszentmihalyi (1975) determined that there is a direct correlation between the
skills and abilities of an individual and the action and challenge required in an activity in
which the person is participating. For example, when an individual with low ability/skill
participates in an activity that has correspondingly low action/challenge demands, flow
occurs. Similarly, when an individual with high ability/skill participates in an activity that has
correspondingly high action challenge demands, flow occurs.

Significant problems can occur, however, when there is an imbalance between the
action/ability level (of an individual client):

48 • GLOBAL THERAPEUTIC RECREATION III Olsson, Groves & Perkins

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(1) When the task or activity has a higher action challenge demand than the client's
skills and abilities, the undesirable outcome will result in high rates of client
anxiety.

(2) When the client has higher skills and abilities than the task or activity requires,
the undesirable outcome will result in high rates of client boredom.

Client anxiety and boredom create severely negative environments which are to be
avoided. When "flow" occurs, however, clients can experience numerous benefits, such as
improved concentration, motivation, satisfaction and self-esteem.

Therefore, when determining client objectives and setting performance standards, it
is the responsibility of the therapist to strive to accurately balance the skills and abilities of
a client with the actions and challenges of an activity in order to avoid negative outcomes
and to achieve positive outcomes.

Program Protocol Development
This part of the article is devoted to the process needed to design and implement
protocol as a basis for RT programs. The process is divided into five steps: (1) listing
problems associated with diagnosis; (2) developing program groupings; (3) writing the
program protocol; (4) operationalizing the program protocol; and (5) evaluating outcomes.

Step 1: Listing Problems Associated With Diagnosis
In this first step, the Recreation Therapist (RT) makes a list of the diagnostic groups

which are admitted onto the unit. For example, a rehabilitation unit might admit individuals
diagnosed as traumatic brain injured (TBI), spinal cord injured, cerebrovascular accident
(CVA) and hip fracture. Once the major diagnostic groups are listed, a subdivision of these
groups may be appropriate. For example, spinal cord injuries could be divided into
paraplegic and quadriplegic (Stolov & Glowers, 1981) or CVA could be divided into right
brain damage [left hemiplegic] and left brain damage [right hemiplegic]. After the diagnostic
groups are listed and/or divided, the RT should list the associated problems under each of
the diagnostic groups. In the case of a patient diagnosed as CVA (left hemiplegic) the
patient may have difficulty with: ability to judge distance, size, position, rate of movement,
how parts relate to whole; poor judgement of his/her abilities, impulsive behaviors;
understanding visual cues; picking up body language; expressing his/her own words and
feelings, one-side neglect; and memory performance.

Step 2: Developing Program Groupings
The second step allows for the development of program titles, by grouping problems

associated with the diagnosis into program areas. For example, the therapist may group
difficulties with memory performance (e.g., attention span), ability to judge distance, ability
to judge size, ability to judge position, ability to judge how parts relate to whole, poor
judgement of one's own abilities and understanding visual cues into a program area entitled
Cognitive Retraining. Whereas, difficulties with picking up body language, expressing words
and feelings and poor judgement of one's own abilities might be categorized in a program
area entitled Community Reintegration: Communication Skills. It should be noted, when

Olsson, Groves & Perkins GLOBAL THERAPEUTIC RECREATION III • 49

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developing the program groupings, that the RT may include a problem associated with
diagnosis within more than one program area.

Step 3: Writing the Program Protocol
During this step the RT will write a protocol using an outline containing the

following information sections: program title, purpose, problem areas, referral criteria,
contraindicated criteria, evaluation, outcome expected, recreation therapy intervention
activities, approved by ???, and date (see Appendix A).

Program Title: The name the program is given (e.g., Cognitive Retraining CVA Left
Hemiplegic [Group]; Community Reintegration: Communication Skill TBI [Group]; or
Cognitive Retraining CVA Right Hemiplegic [Individual]).

Purpose: The purpose section of the written outline should define the global
intentions for which the program was designed and if applicable, the minimum and
maximum number of patients the program can accommodate. For example, the purpose of
this program is to improve skill areas found deficient in the cognitive process areas. The
number of patients within this program should range from 2 to 4.

Problem Areas: In this section, the problems associated with diagnosis which were
identified within the program grouping section (Step 2) are listed and may need to be
further specified. For example, memory performance could be divided into specific problems
such as poor attention span, poor long-term memory, poor short-term verbal memory, and
poor problem solving skills. The problem area section should be written as follows:

poor attention span
poor short-term verbal memory
poor problem solving skills.

Referral Criteria: In this section, the program should list what type of abilities or
status a patient should have to demonstrate in order to enter the program. For example, in
a group cognitive retraining program, a patient might need to possess the ability to stay on
task for 10 minutes, and/or the ability to function when others are present.

Contraindicated Criteria: This section should describe under what circumstances a
patient should be removed from the program. For example, the patient becomes combative,
or the patient's behavior is extreme to the level that other patients cannot work on their
goals and objectives. Safety concerns should be a consideration listed within this section.
For example, a program entitled Community Reintegration: Cognitive Skills—Left Hemiplegic
[Group] may list in the contraindicated criteria . . . patient's impulsive behavior becomes
to extreme to insure safety within a community group format.

Evaluation: This section should include a statement of when the program is to be
evaluated. For example, an evaluation report of this program will be written quarterly and
yearly as part of the on-going quality assurance.

Outcome Expected: In this section the RT lists the outcome goals which a patient
may expect to achieve based on participation within the program. To accomplish this task,
the RT restates the problems listed from the previous problem area section in a positive
direction outcome goal statement format. For example, the problem area section listed poor

50 • GLOBAL THERAPEUTIC RECREATION III Olsson, Groves & Perkins

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attention span as a potential problem. The outcome goal would be written as follows:
increase attention span. Likewise, if the problem area listed an inability to determine how
parts relate to a whole, the outcome goal might read increase ability to recognize how parts
relate to whole.

RT Intervention Activities: This section directly relates to each outcome goal
individually. It is the RT activity(ies) which will be used to obtain the expected outcome.
See example in figure 1 that follows:

Figure 1. Expected Outcomes from RT Intervention Activities

Outcome Expected RT Intervention Activities

increase attention span Board Games
Wood Crafts
Cards

increase ability to recognize how Puzzles
parts relate to whole Board Games

increase ability to control stress Physical Sports
Isometric Squeeze
Thematic Imagery
Yogaform Stretching

Approval: This final section is designed to allow a signature for
approval of the program by administration. It should be written as follows:

Approved By: ____________________________ Date: _____________________

Step 4: Operationalizing the Program Protocols
To operationalize the treatment program, the RT must collect information and write

measurable objectives. The collection of information which would later allow for the
evaluation of the protocol, therapist, intervention activity and department (based on the
patient's outcome goal attainment percentiles) is extremely important to the overall success
of the treatment program protocol process. Therefore, the collection process requires a
systematic tool to collect information and to write measurable objectives. The Patient
Outcome Goal Performance Sheet (Appendix B) was designed to collect information in a
systematic format. The Patient Outcome Goal Performance Sheet contains both (A) the
general information needed (i.e., patient's name, department's name, program's title, the
title of the recreational therapy intervention activity, and (B) the starting/finishing dates)
and the objective information needed. The objective information needed should include:
(1) a condition, information relating to when and/or under what circumstances the patient's

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performance behavior is expected to be exhibited (e.g., when asked, while engaged in ?
, during the Community Reintegration Program,); (2) the outcome goal, the expected
consequence of the patient's participation in the designed program (e.g., increase attention
span, decrease frustration tolerance); (3) the performance behavior, what specifically you
expect the patient to do (e.g., as characterized by the patient staying on task, as exhibited
by the patient identifying a penny, nickel, dime and quarter; (4) the criterion, the numerical
value attached to the performance behavior, this could be represented by: a number (e.g.,
the patient will maintain eye contact for 3 minutes), a number relationship (e.g., the patient
will restate 2 out of 4 instructional details), a percentage (e.g., the patient will make her
own decision without seeking therapist's approval 50% of the time), or a combination (e.g.,
the patient will maintain eye contact for 3 minutes 75% of the time); and (5) the name of
the RT who is responsible for the patient's goal/objective (Peterson & Gunn, 1984).

The criterion is the portion of the measurable objective that changes to allow for the
calculation of the goal attainment percentile. The calculation process requires that the RT
project five different levels of outcomes based on five distinct criterion. The first level (0%)
is considered the most unfavorable outcome likely and represents the current status of the
patient. The second level (50%) is considered less than expected success, with the third
(100%) considered the expected level of success, followed by the fourth (150%) more than
expected success and finally, the fifth (200%) best anticipated success (Kiresuk & Sherman,
1968; Davis, 1973; Katsinas, 1986). The following is an example of a written objective:

1. While in the Cognitive Retraining program, the patient will increase her
attention span as characterized by staying on task between 5 and 10
minutes as judged correct by the RT.

2. While in the Cognitive Retraining program, the patient will increase her
attention span as characterized by staying on task between 10 and 15
minutes as judged correct by the RT.

3. While in the Cognitive Retraining program, the patient will increase her
attention span as characterized by staying on task between 15 and 20
minutes as judged correct by the RT.

4. While in the Cognitive Retraining program, the patient will increase her
attention span as characterized by staying on task between 20 and 25
minutes as judged correct by the RT.

5. While in the Cognitive Retraining program, the patient will increase her
attention span as characterized by staying on task over 25 minutes as
judged correct by the RT.

• Note, the only change in objectives 1 through 5 is the number of
minutes (criterion) the patient is expected to stay on task.

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All of the information needed for a good written objective is included on the Patient
Outcome Goal Performance Sheet, however, the outcome goal, RT staff (therapist) and
condition are listed separately to allow the RT to calculate the goal attainment for the
outcome goal and RT staff expediently. Consequently, the RT should only include the
performance behavior and the criterion within the boxed areas on the Patient Outcome
Performance Sheet.

Step 5: Evaluating Outcomes
The final step in the protocol programming process is to evaluate the success of: (1)

an individual patient participating in the RT program(s); (2) an individual program in
meeting its stated outcome goals; (3) an individual RT in predicting and helping a patient
reach his/her outcome goal(s); (4) the RT intervention activity(ies) in producing the
expected outcome goal(s); and (5) the department in meeting its stated outcome goals
through its programs.

All five evaluation areas (i.e., patient, program, RT intervention activity, RT staff and
department) are calculated using the following instruction rules:

1. assign a 0 to the level which represents the most unfavorable outcome likely;
2. assign a 5 to the level which represents less than expected success;
3. assign a 10 to the level which represents the expected level of success;
4. assign a 15 to the level which represents more than expected success;
5. assign a 20 to the level which represents the best anticipated success.
6. to obtain goal attainment percentile multiply the assigned number by 10 (e.g.,

if the assigned number is 10, the goal attainment would equal 100%).

Patient Goal Attainment
To calculate individual patient goal attainment the therapist should:
1. Separate all completed Patient Outcome Goal Performance Sheets by
outcome goal and record (note: one Patient's Outcome Goal Performance
Sheet may have as many as three completed records).
2. Add the raw score numbers for each record representing the same outcome
goal record and then divide that number by the total number of records with the
same outcome goal to obtain the individual and patient outcome goal
attainment percentile.
Example, using Sample Form 3, pages 30 and 31, for problem solving: Problem
solving is listed as a goal for Jan Doe on page 30 with a score of 5 and on page 31
with a score of 10. Five (5) + 10 = 15 divided by 2 records = 7.5, therefore, using
rule #6, page 9, the goal attainment for problem solving is equal to 75% (10 x 7.5).

3. To produce an overall patient goal attainment percentile, sum the raw score
numbers for all outcome goal records completed, divide that number by the
total number of outcome goal records and then multiply the result by 10.

Example, using Sample Form 3, pages 30 to 31. There are three goals:
(a) increase attention span, 2 records with scores of 5 & 15;

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(b) increase problem solving, 2 records with scores of 5 & 10; and
(c) increase interaction skill, 1 record with a score of 15). Therefore, the total
number of completed records is equal to 5 with a combined score of 50. Fifty (50)
divided by 5 equals 10, therefore, using rule #6, page 9, the overall goal attainment
rating for this patient is equal to 100%).

4. Write a summary of the results. Figure 2 is an example using Appendix B-l
and B-2.

Figure 2. Example of Appendix B-l and B-2

Patient: Jan Doe

Total # of Objective Records Completed 5
Raw Total Score 50
Total Outcome Goal % 100%

Treatment Outcome Goals # of patient % of goal
objective records attainment

completed

increase attention span 2 100%
increase problem solving ability 2 75%
increase interaction skills 1 150%

The Patient Outcome Goal Performance Sheet should parallel the writing of the
progress note. If a progress note is written weekly, then the Patient Outcome Goal
Performance Sheet should be completed weekly. Consequently, the Patient Outcome Goal
Performance Sheet should serve as the informational basis for the progress note.

Goal Attainment for Therapist, Program, and Activity
To calculate the goal attainment for a therapist (Appendix C), and/or a protocol

program (Appendix D), an individual Outcome Goal Performance Sheet should be used.
When employing the Outcome Goal Performance Sheet to produce program outcome
percentiles the RT should:

1. List the outcome goals on the sheet individually by numbers 1-15.
2. Transfer each objective record's score that is completed for any patient from the

Patient Outcome Goal Performance Sheet to the Program Outcome Performance
Sheet by recording an X over the number (0, 5, 10, 15, or 20) that represents the
goal attainment level the patient achieved (each sheet contains 10 objective
boxes, therefore, to save time and duplication in writing, it is suggested that the

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RT write the name of the program on the sheet with all the possible outcome
goals and then xerox copies of that sheet as needed).
3. At the end of a quarter, sum all the numbers in the boxes representing an outcome
goal, divide that number by the number of objective records representing
that outcome goal and then multiply the result by 10 to obtain goal attainment.
Example, using the Appendix D. The goal attainment percentile for attention span
would be equal to 105% (95 divided by 9 and then multiplied by 10).
4. To produce an overall program goal percentage rating the RT should sum all the
raw numbers from each objective category, dividing that number by the total
number of all objective records completed and then multiply that number by 10.
Example using Appendix D. There are four goals: (a) increase attention span, 9
records with scores of 5, 10, 15, 10, 10, 5, 15, 15, and 10; (b) increase short-term
verbal memory, 4 records with scores of 10, 5, 10, and 10; (c) increase ability to
following directions, 5 records with scores of 15, 10,10, 10, and 10; (d) increase short-
term visual memory, 7 records with scores of 5, 5,10, 10, 10,10, & 10). Therefore, the
total number of completed records is equal to 25 with a combined score of 240. Two-
hundred and forty (240) divided by 25 equals 96, therefore, using rule #6, page 9, the
overall goal attainment rating for this protocol program is equal to 96%.
5. Write a summary of the results. Example using Appendix _ (see Figure 3 that
follows).

Figure 3. Summary of Results

Program: Cognitive Retraining LCVA (Group)

Total # of Objective Records Completed 25
Raw Total Score 240
Total Outcome Goal %
96%

Treatment Outcome Goals # of patient % of goal
objective attainment
increase attention span records
increase problem solving ability completed 105%
increase interaction skills 87%
increase short-term visual memory 9
4 110%
5 86%
7

Therapist and RT intervention activity are calculated and reported using the same
protocol as listed above for Program.

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Department goal attainment is calculated by: (1) summing all the raw total scores
from each program; (2) summing all the total number of objective records from each
program; (3) dividing the answer in number 1 by number 2; and (4) multiplying the answer
in number 3 by 10.

A yearly report can be obtained by summing all information from each quarterly
report following the same steps for each category (e.g., therapist, department).

Interpretation of Results
The goal attainment percentile results for an individual: patient, program, therapist,

RT intervention activity and/or department could range from 0 percent to 200 percent. An
individual might believe that the higher the score the better, not true according to
Csikszentimhalyi (1975). Csikszentmihalyi believed that if a goal was so hard that an
individual (in this case a patient) could not master (achieve) it, that the individual would
become anxious, lack motivation and quit, whereas, if the goal was so easy that an individual
did not have to put much effort into mastering (achieving) it, that the individual would
become bored, lack motivation and quit. Therefore, the object of goal/objective writing is
to design goals/objectives that are obtainable, but at the same time provide a constant
challenge. In the Protocol Programming Process the ideal percentile would be 100. The
range based on a normal curve and a standard deviation of 15 (Figure 4) follows:

Figure 4. Interpretation of Percentiles

86 - 115 Acceptable Range
71 - 85 or 116 - 130 Slight Revision(s) Required
65 - 70 or 131 - 145 Moderate Revision(s) Required

0 - 55 or 146 - 200 Major Revision(s) Required.

When reviewing the goal attainment percentile data, the RT should first consider that
the staff member is not accurately predicting the criterion outcome of the objective. With
constant feedback (charting objective records in the Patient Outcome Goal Performance
Sheet and the quarterly therapist report), the RT should be able to increase his/her ability
to predict the criterion for the expected level of success on the Patient Outcome Goal
Performance Sheet. This prediction ability is essential to the goal attainment process in that
all evaluations (program, RT intervention activity, patient, therapist, and department) are
directly linked to the patient's level of success in mastering (achieving) his/her objective.

A second area of concern might be the RT Intervention Activity. Is the activity
selected the most beneficial given the diagnosis and the problem associated with the
diagnosis? The system's approach to evaluation presented within this paper should give the
RT the ability to rank order the Intervention Activities based on goal attainment
percentiles. Therefore, the activities which are most beneficial should rise to the top.

When evaluation is made for goal attainment of a program, therapist, department,
and/or RT intervention activity, the RT must consider the following factors.

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1. The number of records for any one outcome goal. If a low number (below 15)
exists, interpretation and subsequent changes should be made cautiously.

2. The number of quarters for any one outcome goal which is being evaluated. It is
recommended that interpretation and changes be made cautiously until a pattern is
determined. Patterns are determined by reviewing percentile scores on a specific outcome
goal across four quarters. For example, a therapist might have scored 72 percent for an
outcome goal of increasing attention span during the first quarter. During the subsequent
quarters the therapist scored 84 percent, 86 percent, and 88 percent with an annual
percentile of 82. The interpretation based on Figure 1, page 15, would be: Therapist has
improved his/her ability to predict the expected level of success of patient's needing to
increase attention span and is therefore, operating in an acceptable range. Rather than
(based only on the annual number of 82%); Therapist needs to make slight revisions in the
prediction level of success in outcome goals involving increasing attention span.

In general, there are many reasons for less or more levels of success when
evaluating outcome goals for a program, therapist, RT intervention activity and/or
department. This system provides some information which should prove beneficial in
discovering those reasons. However, it should not be used as the sole provider of
information, rather, as one part of quality assurance monitoring.

Administrative and Ethical Implications
of This Protocol Design

The goal of the administrator is similar to the goal of the RT. The RT is trying to
provide the client with an environment that will encourage a persistent effort toward a
desired outcome. The administrator is trying to provide a similar environment for the RT
with similar results. This is usually referred to as motivation. The RT, with the cooperation
of the client, sets measurable goals and develops strategies to accomplish these goals.
Once accomplished, new goals can be developed. The result is growth toward optimizing
one's potential. This same strategy with similar results can be developed between a manager
and the RT. This approach may sound appropriate when applied to the client but when
applied to the RT it sounds much like management by objectives (MBO). Actually, when
Peter Drucker developed the concept of MBO in "The Practice of Management" (1954), it
was far from the current bureaucratic interpretation. Drucker never capitalized the words and
he did not use them alone. He spoke of management by objective and self-control; that is,
nonbureaucratic self-management was the avowed purpose. According to Drucker (1954),
objectives, like outcome goals, should be (1) simple, (2) focused on what's important, (3)
genuinely created from the bottom up (the objectives are drafted by the person who must live
up to them with no constraining guides) and (4) a living contract not a front driven exercise.

There are some who say that MBO should be eliminated. Number 11 of Deming's
(1982) 14 points states that work standards, (quotas) and MBO should be eliminated. This
is based on the bureaucratic view of MBO (in caps) not Drucker's intention of management
by objective and self-control. The Protocol Design is an example of how management by
objective and self-control can be used to create optimal performance of RT's.

Olsson, Groves & Perkins GLOBAL THERAPEUTIC RECREATION III • 57

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
should show your appreciation by providing credit to the originator of the document. You must
not sell the document or make a profit from reproducing it. You must not copy, extract,
summarize or distribute downloaded documents outside of your own organization in a manner
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RJ. Schermerhorn (1986) defined performance as Ability x Support x Effort. Performance
begins with ability so managers must choose and train their employees well. Performance
also requires support in the form of appropriate tools, equipment and facilities. Support
includes proper goal setting, freedom from unnecessary work constraints, and proper
recognition for a job well done.

Performance is additionally linked to effort on the employees part. The decision to
do so rests entirely on the individual RTs. All the effective manager can do is provide
conditions with which the employee will want to work (a motivating environment).
According to Schermerhorn (1986), the best way for a manager to provide this environment
is to give the RT a feeling of competence. Psychologists call this the effective motive. It is
gained when one feels some sense of mastery over one's environment. Competence is a
natural motivator in this sense.

The Protocol Design provides accurate, timely, and useful information on the
competency of the RT. Competency comes from the feeling that one's skills and aptitudes
match the task at hand. Competency also comes from support; from a feeling that the
working environment helps rather than hinders successful completion of the task at hand.
This protocol design can assist the manager and RT in developing both skills, and the
support necessary for optimal performance or flow on the part of the RT.

Refereneces
American Therapeutic Recreation Association. (1987). Definition statement for therapeutic

recreation. Hattiesburg, MS: Author.
Connolly, P. (1984). Analyzing program cause as well as effect: A method for program

analysis. Therapeutic Recreation Journal, 18(1), 31-39.
Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York:

Harper & Row.
Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. Washington, DC: Jossey-Bass.
Davis, H. (1973). Four ways to goal attainment: An overview. Evaluation,1(2), 43-48.
Deming, W. (1982). Quality productivity and competitive position. Cambridge, MA:

Massachusetts Institute of Technology Center for Advanced Engineering Study.
Donovan, G. (1987). You want me to do what?--Regulatory standards in therapeutic

recreation. In B. Riley (Ed.), Evaluation of Therapeutic Recreation Through Quality
Assurance, (pp. 25-35). State College, PA: Venture.
Drucker, P. (1954). The practice of management. New York: Harper & Row.
Halberg, K., & Olsson, R. (1989). An evaluation of an automated leisure assessment system
for institutionalized mentally ill adolescents. Therapeutic Recreation Journal, 23(4),
73-79.
Katsinas, R. (1986). Goal attainment scaling as program evaluation for individualized leisure
services. Journal of Expanding Horizons in Therapeutic Recreation, 1, 28-37.
Kiresuk, T., & Sherman, R. (1968). Goal attainment scaling: A general method for
evaluating comprehensive community mental health programs. Community Mental
Health Journal, 4, 443-453.

58 • GLOBAL THERAPEUTIC RECREATION III Olsson, Groves & Perkins

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
should show your appreciation by providing credit to the originator of the document. You must
not sell the document or make a profit from reproducing it. You must not copy, extract,
summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure
Information Network (LIN). http://www.lin.ca

Mobily, K. (1985a). A philosophical analysis of therapeutic recreation: What does it mean
to say "we can be therapeutic?" Part I. Therapeutic Recreation Journal, 19(1), 14-26.

Mobily, K. (1985b). A philosophical analysis of therapeutic recreation: What does it mean
to say "we can be therapeutic?" Part II. Therapeutic Recreation Journal, 19(2), 7-14.

National Therapeutic Recreation Society. (1980). Standards of practice for therapeutic
recreation service. Alexandria, VA: Author.

Olsson, R. (1986). Managing your documentation: A systems approach. Activities.
Adaptation & Aging, 9(1), 93-100.

Peterson, C., & Gunn, S. (1984). Therapeutic recreation program design: Principles and
procedures (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall.

Riley, B. (1987). Preface. In B. Riley (Ed.), Evaluation of Therapeutic Recreation Through
Quality Assurance. State College, PA: Venture.

Schermerhorn, J. (1986). Team development for high performance management. Training
and Development Journal, 11, 38-41.

Stolov, W., & Clowers, M. (1981). Handbook of severe disability. Washington, DC: U.S.
Government Printing Office.

West, R. (1987). The role of quality assurance in the professionalization of therapeutic
recreation. In B. Riley (Ed.), Evaluation of Therapeutic Recreation Through Quality
Assurance, (pp. 1-5). State College, PA: Venture.

Wright, S. (1987). Quality assurance: Practical approaches in therapeutic recreation. In B.
Riley (Ed.), Evaluation of Therapeutic Recreation Through Quality Assurance, (pp.
55-66). State College, PA: Venture.

Olsson, Groves & Perkins GLOBAL THERAPEUTIC RECREATION III • 59

Global Therapeutic Recreation III

Selected papers from the 3rd International Symposium on Therapeutic Recreation

© Curators University of Missouri 1994

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summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure Information
Network (LIN). http://www.lin.ca

Appendix A
PROTOCOL OUTLINE

Program Title:

Purpose of Program:

Problem Areas:

Referral Criteria:

Contraindicated Criteria:

Evaluation:

Outcome Expected RT Intervention Activities

Approved By: __________________________________ Date: xx

xxxxx Olsson, Groves & Perkins

60 • GLOBAL THERAPEUTIC RECREATION III

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Appendix B-1

Olsson, Groves & Perkins GLOBAL THERAPEUTIC RECREATION III • 61

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
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summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure Information
Network (LIN). http://www.lin.ca

Appendix B-2

Patient name GLOBAL THERAPEUTIC RECREATION III • 62
Olsson, Groves & Perkins

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
should show your appreciation by providing credit to the originator of the document. You must
not sell the document or make a profit from reproducing it. You must not copy, extract,
summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure Information
Network (LIN). http://www.lin.ca

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
should show your appreciation by providing credit to the originator of the document. You must
not sell the document or make a profit from reproducing it. You must not copy, extract,
summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure
Information Network (LIN). http://www.lin.ca

Global Therapeutic Recreation III

Selected papers from the 3rd International Symposium on Therapeutic Recreation

© Curators University of Missouri 1994

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only).
You are free to edit the documents you download and use them for your own projects, but you
should show your appreciation by providing credit to the originator of the document. You must
not sell the document or make a profit from reproducing it. You must not copy, extract,
summarize or distribute downloaded documents outside of your own organization in a manner
which competes with or substitutes for the distribution of the database by the Leisure
Information Network (LIN). http://www.lin.ca