annual in therapeutic recreation - … in therapeutic recreation – volume 26 call for manuscripts...

ISBN: 978-1-57167-902-4 Copyright 2017

AMERICAN THERAPEUTIC RECREATION ASSOCIATIONhttp://www.atra-online.com

All rights reserved.

ANNUAL IN

THERAPEUTIC

RECREATION

V O L U M E 2 4, 2 0 1 7

The American Therapeutic Recreation Association’s Code of Ethics is to be used as a guide for promoting and maintaining the highest standards of ethical behavior. The Code applies to all Recreational Therapy personnel. The term Recreational Therapy personnel includes Certified Therapeutic Recre- ation Specialists (CTRS), recreational therapy assis-tants and recreational therapy students. Acceptance of membership in the American Thera-peutic Recreation Association commits a member to adherence to these principles.

PRINCIPLE 1: BENEFICENCERecreational Therapy personnel shall treat persons served in an ethical manner by actively making efforts to provide for their well-being by maximiz-ing possible benefits and relieving, lessening, or minimizing possible harm.

PRINCIPLE 2: NON-MALEFICENCERecreational Therapy personnel have an obligation to use their knowledge, skills, abilities, and judg-ment to help persons while respecting their deci-sions and protecting them from harm.

PRINCIPLE 3: AUTONOMYRecreational Therapy personnel have a duty to pre- serve and protect the right of each individual to make his/her own choices. Each individual is to be given the opportunity to determine his/her own course of action in accordance with a plan freely chosen. In the case of individuals who are unable to exercise autonomy with regard to their care, recreational therapy personnel have the duty to respect the decisions of their qualified legal repre-sentative.

PRINCIPLE 4: JUSTICERecreational Therapy personnel are responsible for ensuring that individuals are served fairly and that there is equity in the distribution of services. Indi-viduals should receive services without regard to race, color, creed, gender, sexual orientation, age, disability/disease, social and financial status.

PRINCIPLE 5: FIDELITYRecreational Therapy personnel have an obliga-tion, first and foremost, to be loyal, faithful, and meet commitments made to persons receiving services. In addition, Recreational Therapy person-

nel have a secondary obligation to colleagues, agencies, and the profession.

PRINCIPLE 6: VERACITYRecreational Therapy personnel shall be truthful and honest. Deception, by being dishonest or omitting what is true, should always be avoided.

PRINCIPLE 7: INFORMED CONSENTRecreational Therapy personnel should provide services characterized by mutual respect and shared decision making. These personnel are responsible for providing each individual receiving service with information regarding the services, benefits, outcomes, length of treatment, expected activities, risk and limitations, including the pro-fessional’s training and credentials. Informed con-sent is obtained when information needed to make a reasoned decision is provided by the professional to competent persons seeking services who then decide whether or not to accept the treatment.

PRINCIPLE 8: CONFIDENTIALITY & PRIVACY

Recreational Therapy personnel have a duty to disclose all relevant information to persons seeking services: they also have a corresponding duty not to disclose private information to third parties. If a situation arises that requires disclosure of confi-dential information about an individual (i.e.: to protect the individual’s welfare or the interest of others) the professional has the responsibility to inform the individual served of the circumstances.

PRINCIPLE 9: COMPETENCERecreational Therapy personnel have the responsibility to maintain and improve their knowledge related to the profession and demonstrate current, competent practice to persons served. In addition, personnel have an obligation to maintain their cre-dential.

PRINCIPLE 10: COMPLIANCE WITH LAWS AND REGULATIONS

Recreational Therapy personnel are responsible for complying with local, state and federal laws, regu-lations and ATRA policies governing the profession of Recreational Therapy.

ATRA CODE OF ETHICS

REVISED JULY 2009

E D I T O R S Ellen Broach, Ed.D., CTRS Alexis McKenney, Ed.D., CTRS University of South Alabama Florida International University Mobile, AL Miami, FL

A S S O C I A T E E D I T O R S

V O L U M E 24

Candy Ashton-Forester, Ph.D., LRT/CTRSUniversity of North Carolina Wilmington

Wilmington, NC

David R. Austin, Ph.D., FDRT, FALSIndiana UniversityBloomington, IN

Patricia Craig, Ph.D., CTRS/LUniversity of New Hampshire

Durham, NH

Marcia Carter, Re.D., CTRS, CPRPWestern Illinois University –QC

Moline, IL

Brandi Crow, Ph.D., CTRSUniversity of North Carolina Wilmington

Wilmington, NC

Dawn DeVries, DHA, MPA, CTRSGrand Valley State University

Grand Rapids, MI

Patricia Irvin, MPA, CTRSEastern State Hospital

Medical Lake, WA

Megan Janke, Ph.D., LRT/CTRSEast Carolina University

Greenville, NC

Elizabeth Kemeny, Ph.D., CTRS, CPGSlippery Rock University

Slippery Rock, PA

Junhyoung (J.P.) Kim, Ph.D., CTRSCentral Michigan University

Mt. Pleasant, MI

Lisa Mische Lawson, Ph.D., CTRSUniversity of Kansas Medical Center

Kansas City, KS

Tim Passmore, Ed.D., CTRS/L, FDRTOklahoma State University

Stillwater, OK

Alysha Walker, M.S., CTRS/LOklahoma State University

Stillwater, OK

Richard Williams, Ed.D., LRT/CTRSEast Carolina University

Greenville, NC

Alexis McKenney, Ed.D., CTRSTemple UniversityPhiladelphia, PA

Ellen Broach, Ed.D., CTRSUniversity of South Alabama

Mobile, AL

F O R E W O R DWelcome to Volume 24 of the ATRA Annual in Therapeutic Recreation. Please accept our sincere thanks to

all the authors and associate editors who have worked with us through our transition to a new management team and a new publisher, Sagamore-Venture. ATRA promises to keep publishing and “moving forward” as the ATRA Annual continues to be an important scholarly journal in our field. We really appreciate everyone’s interest and continuing support as we go forward to provide quality research, important new protocols, and theoretical discussions that contribute to the advancement of our practice and to “empower recreational therapists” to be best practice RT providers. Special thanks to our ATRA liaison, Jo-Ellen Ross, our CEU item writer, Pam Fleck, and again, the associate editors for their work on the Annual. This volume continues the tradition of featuring strong research papers along with several interesting practice perspective papers and conference poster abstracts. We hope readers will enjoy these fine and diverse pieces of scholarship that represent a wide variety important RT topics and issues.

This issue features four excellent research articles. The authors of the first article, “Analysis of the Status and Extent of Marketing and Promotion Strategies in the Practice of Recreation Therapy,” present a study designed to increase our understanding of the needs and strengths of marketing in the field and provide direction to future marketing efforts. The second research paper, “Leisure as a Predictor to Health and Quality of Life in Caregivers,” examines how the impact of various factors, including leisure experiences, predicts self-reported general health and quality of life of caregivers. The results provide a strong foundation for leisure as a predictor for health and quality of life. The third study is “The role of recreational therapy in the treatment of a stroke population.” The purpose of this study is to determine which therapies best predict discharge FIM™ scores while controlling for age and respective admission functional independence measure scores. The authors’ findings indicate that, for the participants, recreational therapy appears to be the only therapy that contributes to the prediction of discharge FIM™ scores. The final research article, “ATRA Code of Ethics: Impressions from the Profession,” examines the knowledge, attitudes, and behaviors of recreational therapists about the professional code of ethics and concludes that there is a continued need for ethics education.

This 24th volume also features interesting practice perspectives beginning with the manuscript “You Say ‘Recreational Therapy’ and We Say ‘Therapeutic Recreation,’” which includes an in-depth discussion related to the compatibility of academic programs in recreational therapy (RT) with departments in which they are commonly housed and a call to unite recreational therapists, therapeutic recreationists, and the field of parks and recreation. This insightful manuscript is followed by three varied and well conceptualized responses from other practitioners in our field. This section on “Practice Perspectives” is well worth taking time to read.

We are happy to include a final section that includes the 12 research abstracts and 17 research to practice abstracts that were presented at the 2016 ATRA Annual Conference. ATRA would like to thank Cari Autry, Brandi Crowe, Jasmine Townsend, and Stephen Lewis, for their hard work and dedication coordinating the submission and the peer review process for the research presentations and posters.

This issue concludes in the same fashion as all issues of each of our volumes: publishing an index for the ATRA Annual contents from Volume I to our current Volume 24. In addition, we always include the opportunity for readers to acquire CEUs for reading the manuscripts and answering the multiple choice questions for each article. Each test is worth .1 (1 hour) CEU. As always, may you continue to enjoy worthy reading that promotes quality RT practice!

Ellen Broach, Ed.D., CTRS, and Alexis McKenney, Ed.D., CTRS Editors, Volume 24

ATRA Annual in Therapeutic RecreationAnnual in Therapeutic Recreation, Vol. 24, 2017 i

Annual in Therapeutic Recreation – Volume 26

Call for Manuscripts

ii Annual in Therapeutic Recreation, Vol. 24, 2017

1. Only those manuscripts that fit the purpose of theATRA Annual in Therapeutic Recreation will bereviewed for publication.

2. Authors are required to use inclusive language,that is avoid in their manuscripts language thatcould be construed as sexist, racist, or biased inother ways. For more specific guidelines, see pages61-76 in the APA Manual (6th ed., 2010). Notechange of APA Manuals!

3. Authors should remove all identifying informationon the electronic file. For some operating systems,this can be accomplished in the “Properties” pulldown menu.

4. All pages must be double-spaced on 8.5 x 11 inches paper, with 1" (2.54 cm) margins for every page.Font sizes of 10, 11, or 12 are acceptable; TimesNew Roman is the preferred font style. Maximummanuscript length is 20-25 pages, including refer-ences and tables/figures. Manuscripts must be inEnglish.

5. All pages must be numbered consecutively in theupper right hand corner; the title page numberedpage 1, the abstract page numbered page 2, withthe text starting on page 3.

6. The title page (page 1) must include: Article title;Author(s) names, credentials, and employment

The American Therapeutic Recreation Association is pleased to invite the submission of manuscripts for the Volume 2 of the Annual in Therapeutic Recreation, the official research journal of the association. The purpose of the Annual is to further advance the body of knowledge of the therapeutic recreation profession by creating new knowledge and understandings in practice and in education. The Annual publishes a wide range of original, peer-reviewed articles such as

• Evidence-based practice/Empirical studies• Systematic reviews• Application of theories or models to practice and education• Program or service evaluations/Case studies• Methodological reviews• Current issues and trends in service delivery or education• Innovations in service delivery or education• Practice protocols

ANONYMOUS REVIEWThe Editor will accept for anonymous review unpublished manuscripts suitable for the Annual. While a manuscript is under review, it may not be submitted to another journal. Typical review time is 10 to 12 weeks. Authors must prepare manuscripts according to the Publication Manual of the American Psychological Association (6th ed.). Manuscripts not adhering to the APA Manual will be returned to the authors without review. The Instructions for Authors is attached to this Call. Manuscripts must be submitted electronically as ONE Word attachment to an email. The Editor will acknowledge receipt of manuscripts within 3 business days; authors should contact the Editor if acknowledgement has not been received within that time frame.

MANUSCRIPT PREPARATION

Deadline for Volume 2 :March 14, 201February 14, 2018


Call for Manuscripts (continued)

For further information, you may contact:

ATRA11130 Sunrise Valley Drive, Suite 350

Reston, VA 20191(703) 234-4140

(703) 435-4390 Faxwww.atra-online.com

settings. Indicate which of the author(s) is the cor-responding author, giving full contact information. Include a short biographical sketch of each au-thor, including all professional and academic cre-dentials, limiting each to 50 words.

7. The abstract page (page 2) must contain the article title and a 200-250 word abstract. No information about the authors should be included on this page.

8. The manuscript should begin on page 3.

9. All authors must follow the APA Manual (6th ed., 2010).

10. Authors must ensure and mention in their man -

uscript, approval by institutional review commit-tees and/or human subject protection boards, if appropriate.

11. Manuscripts must be submitted electronically. The Editor will acknowledge receipt of manuscripts within 3 business days; authors should contact the Editor if acknowledgement has not been received within that time frame. Authors should keep a copy of the manuscript to guard against loss.

12. Manuscripts not adhering to the APA Manual (6th ed., 2010) will be returned to the author(s) without review. Please use the checklist on the attached page PRIOR to submission.

Annual in Therapeutic Recreation, Vol. 24, 2017 iii

Important APA Style Issues:

Checklist

Please use this checklist to ensure that your manuscript adheres to the APA Manual (6th edition, 2010). Your adherence to these guidelines will greatly enhance the editorial process.

_____ Title Page: p. 23-25 (completed for all authors)_____ Abstract: p. 25-27_____ Introduction: p. 27-29_____ Method: p. 29-32_____ Results: p. 32-35_____ Discussion: p. 35-36_____ Writing Clarity: p. 61-62; 65-86_____ Mechanics of Writing: p. 87-124_____ Headings and Levels: p. 62-63_____ Seriation in Text: p. 63-65_____ Quotations in Text: p. 92, 170-174_____ Numbers/Statistics in Text: p. 116-124_____ Tables and Figures: 125-167 (See checklist for

Tables on p. 150 and checklist for figures on p. 167)

_____ Footnotes: p. 37-38 (please do not use footnotes, except for copyright permissions)

_____ Appendixes: p. 38-40 (please do not use appendixes unless absolutely necessary)

_____ Reference Citations in Text: p. 174-179_____ Reference List: p. 183-192 (especially sections

7.01 to 7.11)_____ Manuscript Preparation_____ One-inch margins_____ Double-spaced_____ 12-pt Times Roman font_____ Numbered pages_____ Running head in header, with brief title_____ Checklist for Manuscript Preparation:

p. 241-243

Below are examples of formats for a reference list; please see the APA Manual for additional examples and details.

Periodical example [include either DOI or URL]: (see APA Manual for explicit examples of other sub-types)Enders, A. (2001). Modeling and measuring the framework of independence. Rehabilitation Education, 15(4), 333-

351. Retrieved from: http://csaweb114v.csa.com.proxy2.library.uiuc.edu/ids70/results.php?SID=r2om8md5kabtrdmg1ull1719s 4&id=3

Magazine exampleSabbach, J. (2009, October). Research update: Method of eight: A contemporary planning process unfolds. Parks

and Recreation, 44(11), 28, 30, 32, 34. Retrieved from: http://www.nxtbook.com/nxtbooks/nrpa/200911/#/30. {non-continuous pagination}

Book exampleMpofu, E., & Oakland, T. (Eds.). (2010). Rehabilitation and health assessment: Applying ICF guidelines. New York:

Springer.

Book Chapter exampleScherer, M. J., & Sax, C. L. (2010). Measures of assistive technology predisposition and use. In E. Mpofu & T.

Oakland (Eds.), Rehabilitation and health assessment: Applying ICF guidelines (pp. 229-254). New York: Springer.

Dissertation exampleLong, T. D., Jr. (2001). Constructivist and didactic leisure education programs for at-risk youth: Enhancing knowl-

edge, meaning, and behavioral intentions (Unpublished doctoral dissertation). University of Utah, Salt Lake City, Utah. Accession No.: SPHS-872027.

iv Annual in Therapeutic Recreation, Vol. 24, 2017


Protocols and Evidence Based Guidelines (continued)

Assessment: describing how clients are assessed for placement in the intervention protocol.

Planning: describing how client goals were deter-mined, referrals, coordination and/or collaboration with treatment team professionals, etc.

Implementation: describing the exact sequence and execution of the intervention protocol with observations and data on each session content and process.

Evaluation: describing an appraisal of how the clients responded to the planned intervention, mea-surement of client outcomes, adaptations and revi-sions of the protocol, and observed unanticipated positive and negative outcomes of the implemented intervention protocol.

E. Author Comments This section should summarize the content with clinical or personal commentary, reflections, cri-tique, and/or ideas for the future by providing new or unusual insights, sound integration with practice, or logical argument, and concluding with real life implications for recreational therapy practice.

F. References All references cited in the manuscript should be appropriately referenced according to APA style (6th edition). References may include published literature sources, personal interviews or communication, observations, or unpublished material relevant to the article.

TABLES AND FIGURESAs part of some protocol interventions, tables or figures might illustrate theory or practice application. Tables and figures are camera-ready submissions formatted in APA style.

QUALITY OF PRESENTATIONThe writing should convey clearly, adequately, and precisely the purpose of the manuscript. Graphics should be appropriately used, basic data be presented, and without discrepancies in writing. Grammatical aspects should be correct and sequence of thought adequate. Manuscripts must adhere to APA (6th ed., 2010) style guidelines.

USEFUL REFERENCESBuettner, L. L., & Fitzsimmons, S. (2006). Introduction

to evidence-based recreation therapy. Annual in Therapeutic Recreation, 15, 10 19.

Stumbo, N. J., & Peterson, C. A. (2009). Therapeutic recrea tion program design: Principles and pro-ce dures (5th ed.). San Francisco : Benjamin Cummings.

PUBLISHED EXAMPLEGongora, E. L., McKenney, A., & Godinez, C. (2005).

A multidisciplinary approach to teaching anger coping after sustaining a traumatic brain injury: A case report. Therapeutic Recreation Journal, 39(3), 229 240.

(continued)

Annual in Therapeutic Recreation, Vol. 24, 2017 v

Annual in Therapeutic Recreation, Vol. 24, 2017 vii

V O L U M E 24

T A B L E O F C O N T E N T SForeword ................................................................................................................................................................... i

Call for Papers, Volume 26 ................................................................................................................................... ii

Analysis of the Status and Extent of Marketing and Promotion Strategies in the Practice of Recreation Therapy ................................................................................................................ 1 Leandra A. Bedini, Ph.D., LRT/CTRS

Leisure as a Predictor to Health and Quality of Life in Caregivers ...........................................................14 Nancy J. Gladwell, Re.D., CPRP; Leandra A. Bedini, Ph.D., LRT/CTRS; and Erick T. Byrd, Ph.D.

The Role of Recreational Therapy in the Treatment of a Stroke Population ............................................26Melissa L. Zahl, Ph.D., CTRS/L; Greg Horneber, CTRS/L; Jennifer A. Piatt, Ph.D., CTRS; and Mwarumba Mwavita, Ph.D.

ATRA Code of Ethics: Impressions from the Profession ............................................................................ 38Melissa L. Zahl, Ph.D., CTRS/L; Dawn DeVries, D.H.A., CTRS; Wayne Pollock, Ph.D., CTRS, FDRT; and Mwarumba Mwavita, Ph.D.

SPECIAL SUBMISSIONS ON PRACTICE PERSPECTIVES

Editorial: You Say “Recreational Therapy” and We Say “Therapeutic Recreation” ................................51Daniel L. Dustin, Ph.D. and Keri A. Schwab, Ph.D.

Rejoinder #1: You Say Recreational Therapy or Therapeutic Recreation: We Say Recreational Therapy and Leisure Facilitation ...............................................................................59David R. Austin, Ph.D., FDRT, FALS; Bryan P. McCormick, Ph.D., CTRS, FDRT, FALS;Marieke Van Puymbroeck, Ph.D., CTRS, FDRT

Rejoinder #2: “We Know What We Are, But Know Not What We Might Be”: A Response to Dustin and Schwab’s Words of Caution for the Recreational Therapy Profession............................ 69Alexis McKenney, Ed.D., CTRS

Rejoinder #3: And I Say Recreation ................................................................................................................ 76Charles Sylvester, Ph.D.

ATRA Annual in Therapeutic Recreation Contents, Volumes 1–24 ........................................................ 85Continuing Education Units (CEU) Correspondence Program ............................................................... 97Abstracts from the 2016 ATRA Research Institute .................................................................................... 105Abstracts from the 2016 ATRA Research Institute Poster Session ......................................................... 131

Annual in Therapeutic Recreation, Vol. 24, 2017 1

Analysis of the Status and Extent of Marketing and Promotion Strategies in the Practice of Recreation Therapy

Leandra A. Bedini, Ph.D., LRT/CTRSProfessor and Director of Therapeutic Recreation

Department of Community and Therapeutic RecreationUniversity of North Carolina at Greensboro

(336) 334-3260 • [email protected]

AbstractThe field of recreation therapy (RT) still struggles with occupational prestige and professional acknowledgment as a viable and effective treatment service. Thorn (1984) emphasized the need for a marketing strategy for the field of RT, noting the importance of identifying recreational therapists’ professional image. Unfortunately, little has been done to identify and implement a comprehensive marketing strategy for the field. The purpose of this study was to examine current status and extent of RT marketing as perceived by practicing Certified Therapeutic Recreation Specialists (CTRSs) in the United States and Canada. This study was designed to understand the needs and strengths of marketing in the field that subsequently may give direction to future marketing efforts. Using the Social Marketing Theory (SMT) (Morris & Clarkson, 2009) as well as marketing literature as a framework, a 53-item electronic questionnaire was designed and emailed to 6,500 active CTRSs through the National Council on Therapeutic Recreation Certification (National Council for Therapeutic Recreation Certification). Respondents (n = 1,116) represent broad demographics in terms of geography, setting, population, and professional experiences. Results showed that overall the status of marketing by CTRSs is inconsistent and moderate at best. Particular concerns included CTRSs’ lack of awareness and use of available marketing resources and techniques. Recommendations address suggestions for future research as well as local (agency) and global (organizational) initiatives to improve the status of marketing in the field of RT.

Since its inception, the field of recreation therapy/therapeutic recreation (recreation therapy) has grown in number and professional reputation; however, in many ways, it is still one of health care’s “best-kept secrets.” The unfamiliarity of recreation therapy (RT) services among the general public and within the health care arena is an often repeated concern among professionals in the field. The field of RT has long struggled in terms of occupational prestige and professional acknowledgment as a legitimate therapeutic service, especially when compared to related treatment services such as occupational and physical therapies (Harkins, 2010; Harkins & Bedini,

2013; Hinton, 2000; Smith, Perry, Neumayer, Potter, & Smeal, 1992). Furthermore, in addition to lower salaries offered when compared to those of related therapies (Bureau of Labor Statistics, 2016–2017), recreation therapy programs are also challenged within their own agencies for recognition, often experiencing omission from websites, marketing materials, and other marketing outlets (Bedini & Petrarca, 2013).

Over the last several decades, national professional organizations in the field (i.e., American Therapeutic Recreation Association [ATRA], National Therapeutic Recreation Society [NTRS],

2 Annual in Therapeutic Recreation, Vol. 24, 2017

STATUS OF MARKETING IN RECREATION THERAPY

and the National Council for Therapeutic Recreation Certification [NCTRC]) have made efforts to market recreation therapy through the use of marketing teams, printed materials, promotional items, RT Month (and previously TR Week) celebrations, publications such as the Promoting Therapeutic Recreation: The Marketing Guide, and brochures such as Why Hire a CTRS and Why Become a CTRS. Although these efforts have served to inform and advance the visibility and understanding of RT overall, the field still lacks marketing skills and knowledge needed to consistently and effectively demonstrate RT’s impact as a credible therapy.

In 1984, Thorn emphasized the importance of a marketing strategy for the RT field, noting the importance of identifying recreational therapists’ professional image and proposing that the field seek to understand the “discrepancies between the desired image and the actual image” (p. 44). Thirty-two years later, however, little research exists that specifically addresses needs, barriers, and/or strategies for RT marketing (e.g., Harkins, 2010; Harkins & Bedini, 2013; Hinton, 2000; Smith et al., 1992). To address the problems of visibility, credibility, and occupational prestige, the field of RT needs to go beyond informational marketing and move toward establishing a unified, targeted, and comprehensive marketing strategy for the field. Therefore, this study was designed to gather input directly from practicing CTRSs regarding their experiences, insights, obstacles, and suggestions about marketing in an effort to begin the discussion of designing and implementing a model that may allow for a consistent, widespread marketing of RT.

Background and Need

Although the field of RT is considered young when compared to nursing, occupational therapy (OT), physical therapy (PT), and speech and language pathology (SLP), it can be said that RT lags behind them in terms of public awareness and occupational prestige. For example, occupational prestige is founded on “high pay, high social value with the greatest training” (Rosoff & Leone, 1991, p. 322). According to the Bureau of Labor’s Occupational Outlook Handbook ([BLS] 2016-2017), the field of RT holds fewer jobs, has lower educational requirements

(BS degree) to practice, and on average, offers lower salaries than PT, OT, and SLP. In addition, it can be said that RT has lower social value since it is absent from many General Social Surveys that collect national data evaluating occupational prestige (Hinton, 2010). Occupational prestige is also an issue from within our own ranks. For example, internally, of the 18,600 RT practitioners identified as practicing in the field (BLS, 2014), just under 2200 (11.5%) are members of the national professional organization, ATRA. Other disciplines like OT report that 50,000 (43.5%) of their 114,600 practicing therapists are members of their national organization (AOTA, 2016).

Another obstacle to public recognition and prestige of RT is a lack of understanding by health care administrators. Harkins and Bedini (2013) reported a study of over 400 health care administrators in North Carolina, where results revealed that the majority of respondents from various settings (i.e., hospital, long-term care, behavioral health) were generally unfamiliar with RT services. For example, many administrators did not know that to practice in RT, one is required have specific training/education (56%). Nor did they know that RT was medically prescribed (43%), with 30% thinking that RT did not function as part of an interdisciplinary team. Perceptions also included that RT was “fun activities during downtime” for clients (60%), not really beneficial (55%), not permitted due to budget (70%), and not needed (40%) in their agency. In fact, a large majority of administrators perceived overlap between RT and activity professionals (79%), and 45% of the respondents also saw overlap with OT services. In addition, over 85% of the administrators reported awareness of physician referrals for PT, whereas only 19% noted physician referrals for RT.

The current study was designed based on tenets of the Social Marketing Theory (SMT) (Morris & Clarkson, 2009), as well as from marketing literature in six other disciplines (i.e., business, nursing, PT, OT, public health, higher education). The SMT offers six guiding principles: (a) goals for the target market behavior, (b) insight into customer decision processes, (c) segmentation and targeting, (d) competition, (e) exchange, and (f) marketing and intervention mix. Applying these principles



to the potential target markets for our field (i.e., health care administrators, physicians, related therapies, community advocates, potential clients/families) provides a strong foundation for marketing initiatives. These “markets,” while different from each other, all hold the ability to “choose” RT as a service, either through prescription, hire, or request and thus, should be considered in a comprehensive plan.

The first two principles of the SMT address the importance of changing knowledge and attitudes of our target markets in order to achieve actual behavioral changes (Morris & Clarkson, 2009, p. 137). These changes are dependent on insight of consumers to make these changes happen. Thus, it is essential to understand the motivation underlying customer choices. To this end, RT practitioners need to explore what influences and restricts potential consumers (i.e., administrators, physicians, therapists, clients) and then design methods that can affect their knowledge and attitudes to create desired behaviors (i.e., choosing our services, hiring RTs onto staff, and actively promoting RT services).

Within each of the major target markets in RT (i.e., health care administrators, physicians, therapists, consumers), there are sub-markets (segments) that should also be identified (e.g., different disability groups, settings, systems). The third principle of segmentation emphasizes the importance to matching strategies with different needs and perspectives of each of these sub-groups. Next, SMT addresses getting a field’s competition (e.g., who or what stands in the way of getting the target markets) to value the commodity. As noted earlier, RT struggles to articulate an identity that separates RT from AP as well as other related therapists (i.e., OTs, PTs, SLPs). Establishing RT’s value, as well as its unique contribution to achieving client outcomes, should underlie these efforts.

Successful marketing is dependent on an attractive exchange between parties. For RT, the benefit of a service to our consumer (e.g., administrator, physician, therapist, client) must exceed costs (real and perceived) for the exchange to be worthwhile. According to Morris and Clarkson (2009), cost can be more than financial, including “…emotional, social, loss of preferred behaviors, or time cost of learning

new practices” (pp. 137–138). From this perspective, a challenge before the field of RT is to demonstrate how RT, conducted by a CTRS, provides therapeutic benefits that offset these and other costs.

The final principle of the SMT is the marketing and intervention mix, commonly known as the four “Ps” (product, price, place, promotion). As Jacobs (2012) suggested, RT professionals must be careful to avoid assumptions that our beliefs are known or shared by a particular audience. Thoughtfully analyzing and assessing our target markets will lead to accurate and effective marketing efforts for the field.

Purpose

The purpose of this study was to examine the current status and extent of RT marketing across the United States and Canada. In addition, this study sought to identify specific needs and barriers that prevent successful marketing of RT programs and services, as well as successful strategies used by CTRSs to implement effective RT marketing.

Methods

Instrumentation A 53-item electronic Qualtrics questionnaire

was designed to solicit information on the status and extent of effective marketing strategies and techniques used to promote RT programs and departments. Questions were developed based on professional marketing literature and input from RT practitioners. The questionnaire was formatted using three conceptual categories of marketing (Bedini & Kelly, 2013). The intra-departmental questions (5 items) inquired about activities conducted within the RT department to prepare staff and interns to market RT. Questions regarding inter-departmental marketing (13 items) asked about activities RT department conduct to market themselves within their agency to administration, physicians, and therapists, and clients/families as well as within the community. Questions about extra-departmental efforts (22 items) addressed the establishment of systems for continuous marketing of RT, such as branding, points of contact, media, and signage. Cronbach reliability coefficients for each of the



three areas were intra-departmental ( = .78), inter-departmental ( = .89), and extra-departmental (= .92).

Four open-ended questions were designed to solicit responses about marketing needs, marketing strengths, strategies used to market RT, and general comments and concerns about marketing in RT overall. In addition, four questions asked about the existence and use of an RT marketing plan. Finally, demographic questions (5 items) were designed using the categories of the NCTRC 2014 Job Analysis Report on current position in RT department/program, primary employment sector, client population, primary age group, and years working as a CTRS.

Sample and Procedures An anonymous and confidential Qualtrics

online questionnaire (IRB approved) was emailed to 6,500 active CTRSs through the National Council on Therapeutic Recreation Certification (NCTRC). The sample was delimited to include only full-time practicing CTRSs. Thus, part-time CTRSs, CTRAs, RT educators, and CTRSs who were not currently practicing in the field were excluded. An email describing the purpose of the study and all IRB conditions and protections along with a link to the online questionnaire was sent electronically using mailing “labels” provided by NCTRC. One week after the initial email, NCTRC sent a reminder email with the survey link to all potential participants asking those who had not participated to complete the survey. The survey was closed one week from that date.

Analysis All data received from the Qualtrics

questionnaires were downloaded into the SPSS v. 22 statistical analysis program. Statistical analysis comprised descriptive analysis using frequencies and percentages and discriminatory analyses such as independent t-tests and analyses of variance (ANOVA). Content analysis was employed to determine patterns and themes from the open-ended questions.

Results

DemographicsResponses were received from 1,373 CTRSs

(response rate of 21.1%). Subsequently incomplete surveys were removed, yielding a usable sample of 1,116 respondents. Respondents represented 48 states, the District of Columbia, and six Canadian provinces.

Demographically, the majority of respondents identified as therapists (48%) with administrators, supervisors, and recreation therapy leader/programmers distributed afterward. The largest employment sector was hospital (37.4%), followed by skilled nursing facilities/long-term care. The most common populations groups with whom the respondents worked were behavioral health (38%), geriatrics/long-term care (24.2%), physical medicine and physical disability (17.9%), and developmental/intellectual disabilities (7%). The majority of respondents (74%) worked with adults and/or older adults. The number of years practiced as CTRSs was distributed equally across all categories. The largest categories of respondents were those who practiced as a CTRS for more than 25 years (24.7%) and those practiced for 5 or fewer years (20%) (see Table 1).

Overall Status of Marketing in RTResults indicated that the overall status

of marketing in the field of RT was generally inconsistent and at best, moderately utilized. Of the 40 items within the three conceptual areas (intra, inter, extra-departmental), only 13 items showed positive responses (often/always) by 50% or more of the responses. For example, three of the five intra-departmental items indicated that 59% to 69% of the respondents “never” or “occasionally/rarely” conducted these marketing activities within the RT department. Similarly, for the inter-departmental marketing category, 56% to 85% of the respondents rarely/never engaged in the majority (9 of 13) of these marketing activities noted. Finally, results showed that the majority of respondents pursued 15 of the 22 extra-departmental activities.

In addition, several questions addressed the presence and use of either a marketing plan and/



or connecting with agency marketing specialist. Less than 10% of the respondents reported having a formal marketing plan for the RT department, with only 6% doing any periodic refinement of the plan. Twenty-five percent of the respondents reported that someone employed in the RT department was specifically responsible for marketing RT. In addition, 22% had someone in RT department working directly with the agency marketing specialist (see Table 2). It is important to note that comparative t-test analyses demonstrated that CTRSs who used any of the three strategies noted above were consistently more likely to utilize the marketing techniques noted in the questions in all three categories: intra-departmental, inter-departmental, and extra-departmental.

TABLE 1RESPONDENT PROFILE

DEMOGRAPHIC PROFILE N %

Client Population Served by CTRS

Behavioral Health 294 38.1DD/ID 55 7.1Geriatric Long-Term Care 187 24.2Physical Medicine and Physical Disability 138 17.9Other 98 12.7Total 772 100.0

Current Position

Administrator 36 4.6Therapist 371 47.7Therapist/Administrator 53 6.0Therapist/Supervisor 191 24.6TR Leader/Programmer 40 5.1TR Leader/Supervisor 43 5.5Other 43 5.5Total 777 100.0

Primary Employment Sector

Adult Day Care 31 4.0Community Parks & Recreation 39 5.0Correctional Facility 28 3.6Disability Organization 9 1.2Hospital 291 37.4Human Services 6 .8Outpatient Day Program 23 3.0Residential/Transitional 70 9.0School 6 .8Skilled Nursing Facility 146 18.8Other 129 11.6Total 778 100.0

Age Group Served

Older Adult 131 16.8Adult/Older Adult 282 36.2Adult 161 20.7Adolescent 34 4.4Pediatric/Adolescent 45 5.8Pediatric 5 .6All Age Groups 120 15.4Total 778 100.0

Years Worked as CTRS

0-5 147 18.96-10 127 16.311-15 118 15.216-20 103 13.220-25 91 11.7Over 25 192 24.7Total 778 100.0

Finally, for the most part, no differences were found within any demographic variable with the exception of “Client Population Served.” Overall, CTRSs who worked with clients in physical medicine and physical disability (PM/PD) were more likely to conduct marketing efforts in all three categories: intra-departmental, inter-departmental , and extra-departmental, while CTRSs who worked in behavioral health were least likely in comparison.

TABLE 2OVERALL STATUS OF MARKETING

N %

Formal Recreation Therapy Marketing Plan

Yes 106 9.5No 1010 90.5Total 1116 100.0

Yes 69 6.2No 34 3.0Total 103 100.0

Yes 194 25.3No 573 74.7Total 767 100.0

Works with Agency Marketing Specialist

Yes 167 21.7No 603 78.3Total 770 100.0



TABLE 3INTRA-PROFESSIONAL

N %

Gives Recreation Therapy Marketing at

Never 345 31.0Occasionally/Rarely 389 34.9Often 219 19.7Always 161 14.5Total 1114 100.0

Trains Interns on Value or Recreation Therapy


Compiles Stats on Recreation Therapy as Non-pharm Treatment


Compiles Stats on Recreation Therapy &


Speak Up in Meetings to Describe Recreation Therapy


Intra-Departmental MarketingFive questions addressed marketing efforts

conducted within an RT department. Although approximately 65% of the respondents indicated that they trained interns to provide examples of how RT is a goal-directed service, results showed that only 34% included how to market RT in staff orientation. In terms of gathering data to demonstrate the value of the field, 31% compiled statistics regarding RT being non-pharmacological or being effective in increasing quality of life and well-being (41%). Interestingly, 87% of the respondents indicated that their staff was competent in describing the impact of RT services in staff, team, and treatment meetings (see Table 3).

Inter-Departmental Marketing Thirteen items addressed marketing efforts

conducted between the RT department and facets within an agency. Results showed that only four items in this category were conducted by a majority of respondents. The remaining nine items garnered less than 44% positive responses. Positive responses indicated that over 77% of the respondents reported marketing directly to clients within an agency. Similarly, 69% stated that they co-treat with other services. Just over half of the respondents routinely shared important data, statistics, or current research about the positive outcomes of RT with agency decision-makers; specifically 58% about RT’s non-pharmacological nature and 56% about positive effect on quality of life. The remaining nine items, however, showed only 15% to 44% use. The least conducted activities related to in-services/workshops on RT within and outside of the agency, ranging from only 15% to 25% depending on the audience. Other weak areas involved research involvement whereby only 29% sought to keep administrators up to date with latest evidence-based practice literature related to RT, and 35% sought to conduct/collaborate on research or grant projects. Similarly, only 44% shared RT patient satisfaction data with administrators/decision-makers. The last item in this section addressed using testimonials from current or former clients/families through agency or media outlets with only 27% using this technique (see Table 4).

Extra-Departmental MarketingTwenty-two items addressed extra-departmental

marketing efforts that reached out beyond the department and agency including community at large. These items represented four categories of extra-departmental marketing: contacts, signage, media, and branding. Results showed that all but seven of these items were conducted “often” or “always” by the majority of the respondents. In the sub-area of contacts, however, only 24% of the respondents reported that their RT program/department was “always” findable within four clicks (maximum effective number) on the agency webpage. Also, although 80% noted that the person who answers the phone can direct caller to RT staff, only 41% noted that this person can articulate what RT is to a caller/visitor.



TABLE 4 (continued)INTER-PROFESSIONAL

N %

Markets Recreation Therapy Directly to Patients





Collaborates on RT-Related Research


Posts Testimonials


TABLE 4INTER-PROFESSIONAL

N %

Shares with Decision-Makers Recreation Therapy as Nonpharmacological Treatment










Less than two-thirds of the respondents reported that RT is represented in signage within their agency. Just over half noted that RT was identified in the main directory, 64% had RT appropriate signage at their department office, and just 60% stated that the RT signage is consistent with that of other therapies. Of note, however, is that 48% of the respondents stated that they did not display their personal CTRS credential.

In terms of utilizing media for marketing RT, just over a third of the respondents reported being visible in agency marketing efforts and 29% participated in any media collaboration with agency, departmental, or outside (newspaper/TV) opportunities. Similarly, only 18.5% had any active RT departmental social media systems.

For the last area of extra-departmental marketing, less than half of the respondents participated in any branding efforts with 17% using a tagline, 11% using branded clothing, and 20% with RT brochures. Twenty-five percent of the respondents did not have RT nametags, and 43% did not have RT business cards (see Table 5).

TABLE 5EXTRA-PROFESSIONAL

N %

Findable in Four “Clicks” on Computer


Person Answering Phone Can Direct Callers


Person Answering Phone Can Articulate Recreation Therapy


TABLE 5 (continued)EXTRA-PROFESSIONAL

N %

Directory


Signage in Main Directory





Visible in Agency Marketing


Active Social Media





N %



Presence in Public Places





N %




Seeks Collaboration with PR/Marketing





Open-Ended QuestionsContent analysis was conducted on the four

open-ended questions to determine patterns and topical themes. Responses to the question asking for general comments were primarily about the survey itself; however a number of comments shared concerns about restrictions marketing due to HIPAA (Health Insurance Portability and Accountability Act). The remaining three open-ended questions that asked respondents to share greatest marketing needs, greatest marketing



strengths, and successful strategies about marketing in the field.

Greatest RT Marketing Needs Analysis of the open-ended responses about

marketing needs data revealed seven broad topical themes. All of the themes were related to need for increased recognition in some way. The largest category addressed the need for more awareness of RT by other services, administrators, and consumers. Comments about lack of awareness by target markets also included the need for education of what RT is within the agency as well as in community. A related theme addressed the need for potential consumers as well as administrators to distinguish between RT and AP specifically. Also, the need for RT to be recognized as a legitimate service that is equal to other therapies was commonly cited. Other categories included the need for effective marketing materials (e.g., brochures, DVDs, social media, and websites), research to prove evidence-based practice, and support from management for RT marketing in particular. Of note, a significant number of respondents stated that they had no marketing needs because they did not market RT.

Greatest RT Marketing Strengths Open-ended responses regarding marketing

strengths yielded six themes, although not all actually addressed strengths, per se. Many respondents indicated that a marketing strength came from securing a presence in interdisciplinary and collaborative relationships on administrative and treatment teams and committees. In particular, working with the agency marketing committee/department was identified as a marketing strength. A second theme dealt with partnering and community involvement and outreach. A related theme noted the importance of educating decision-makers about the impact of RT. Another identified strength addressed the importance of skilled and knowledgeable RT staff suggesting that the investment in a good hire paid off as a marketing strength later on.

Two other themes emerged from this question that will be addressed in more detail in the discussion. First, a large number of respondents stated that “word of mouth” was a marketing strength. Most of

these comments had no additional information or qualifiers. The second theme that presents a concern was the significant number of respondents who noted that they had “no” marketing strengths. Again, these responses offered little to no explanation.

Successful Strategies for RT Marketing Responses to this open-ended question yielded

conceptual suggestions as well as specific techniques for successfully marketing RT. This question requested information that was similar to strengths, but while strengths addressed opportunities that existed, strategies sought specific techniques that they were using that worked to marketing RT in their agency. In addition to generalized recommendations for characteristics of target audiences, respondents detailed examples in areas of types of events, unique promotion approaches, specialized communication with families, as well as particulars in terms of signage, timing, and products. Several categories of successful marketing strategies emerged from the data.

Similar to marketing strengths, respondents stressed the overall importance of visibility within the agency through membership on committees as well as partnering with other disciplines. Respondents also noted the importance of community engagement and aiding others in understanding the potential impact of RT as a treatment service. This included techniques such as hosting special events and public speaking. Another theme regarding strategies suggested a consistent presence in media output. Comments noted that exposure through brochures/newsletters, social media, videos, as well as television coverage, facilitated exposure, and communication about the benefits of RT services. A related theme addressed strong branding of RT through printed and electronic materials. Many of the respondents stressed the effectiveness of using client/patient testimonials in these outlets.

From a provision perspective, comments about the importance of quality of the RT programs as well as of RT staff emphasized the need for high standards and expectations in effective marketing of the field. The last strategy group suggested was the use of “hard” data in the form of statistics and patient satisfaction data, in promoting the effects and



benefits of RT service. Once again, there were a large number of respondents who noted that they did not utilize any marketing strategies in their agency.

Limitations

Some limitations should be noted when examining the results of this study. First, this was a self-designed survey. Although it was based on professional literature about marketing and the three conceptual area had strong reliabilities, it is important to note that it lacks some psychometric data. Second, the intent of this study was to attain a baseline of information regarding the status and extent of marketing in the field of RT. Therefore, the survey design and use of open-ended questions served primarily exploratory purposes. Further analysis based on the results that would focus on questions that emerged from this analysis should be considered in future research. Third, sampling was not stratified to strengthen representation from respondent groups that might have lower numbers of practitioners than others. Thus, CTRSs from less represented settings might not have had substantial presence in the data.

Discussion and Implications

The results of this study suggest that marketing in the field of RT is inconsistent and ranges from active to non-existent efforts. Reasons for this wide differential are not clear but suggest that the field may benefit from a comprehensive strategy. CTRSs surveyed were only moderately, at best, conducting marketing activities in their programs. Results indicated that while some CTRSs were implementing successful marketing strategies, others felt inadequately prepared or restricted with regards to developing and/or implementing marketing efforts. In addition, there appeared to be no consistent patterns among settings, population, or therapist experience.

Several concerns arose from the data. First, a significant number of respondents stated that they had no marketing needs, strengths, and/or strategies because they did not market RT in their agency. This response alone raises the possibility that CTRSs do not know the importance marketing or that they perceived they do not have the skills or opportunities to do so.

A second concern was the result showing that seemingly easy-to-achieve techniques for marketing RT within one’s agency were pursued by relatively low numbers of respondents. For example, just over half of the respondents reported that they displayed their own CTRS credential for public view. The lack of posting one’s CTRS credential not only deprives clients, allied therapists, and administrators the opportunity to identify a CTRS as a vetted and trained practitioner (prestige), but also potentially communicates lack of occupational pride, or unimportance of the certification by the CTRS. Whether these results indicate apathy or perhaps a sense of learned helplessness on the part of these CTRSs is unclear. In another example, results showed that almost half of CTRSs do not share RT patient satisfaction data with administration/decision-makes. This could be due to the fact that they do not collect these data or that they do not share data they have.

Third, data indicated contradictory results re-garding CTRSs’ ability to explain the value of RT to others. For example, a vast majority of the respon-dents identified themselves as able to articulate ben-efits of the RT field, but most also noted they do not gather current data/statistics on the benefits of RT. In addition, a slight majority reported that they routinely shared data with agency decision-makers that RT is a non-pharmacological treatment (58%) and that it increases outcomes related to quali-ty of life (56%), however, less than 41% noted that they collected these data/facts. Also, for each of the open-ended questions (needs, strengths, strategies), very few respondents (4%, 7%, 5% respectively) sug-gested evidence-based practice/outcomes/research as important in these areas. These results raise the question of what information they are sharing and indicate a potential need for education and training directed at CTRSs for how to market the therapeutic benefits of the field of RT.

Last, the category of “word of mouth” was by far the most often cited “strength” as well as “marketing strategy” by the respondents. Although word of mouth can be a powerful tool, it is not clear that the effectiveness of this technique has been established. Without rigor or protocols to assure that what is shared by families and clients communicates



the important elements of RT as a goal-directed, effective therapy, word of mouth has little impact in marketing. In addition, CTRSs might be relying on word of mouth as their only marketing strategy, thus, omitting opportunities to increase occupational prestige and recognition as a valid therapy.

Recommendations

Although many of the results of this study indicated concerns regarding the efforts as well as awareness of marketing needs in the field of RT, they also illustrated many specific areas of successful marketing by CTRSs. Therefore, the results can be used as a baseline to begin to design a strategic marketing plan that would serve as a template to assist CTRSs in increasing visibility, understanding, and occupational prestige for their programs and subsequently, for the field of RT. Data suggest that there are significant barriers that should be addressed on local levels (agencies) as well as through broad and global efforts (organizational) to address the perceived and actual lack of knowledge and/or opportunity to design and implement functional marketing strategies.

Recommendations for PracticeRecommendations for practice span both short-

term and long-term agendas as well as local and global foci. First, as noted above, results indicated that some CTRSs are not marketing RT services. In addition, for a segment of those who are marketing, results showed that there is a lack of knowledge of specific techniques for how to market in the field. Therefore, it seems important to incorporate education and training about how to market the field into RT curricula on the college/university level. Unfortunately, there is little emphasis from the field to include these skills in RT curricula. For example, NCTRC’s 2014 Job Analysis Report’s Knowledge areas include only one item that addresses marketing (under Advancement of the Profession which is only 7% of the exam). Academic programs should take the initiative to expand training on how to market RT. This in turn might increase marketing efforts in RT practice and eventually affect the tasks identified within the field in the future to include broader marketing skills.

Second, CTRSs should be careful not to confuse specific marketing strategies with merely “spreading the word.” Reliance on word of mouth alone is not sufficient to market our services effectively. As noted earlier, occupational prestige is hinged on training and high social value (Rosoff & Leone, 1991). In this context, training does not necessarily mean additional years in school, but can be interpreted as more skills in the practitioner skill set. Similarly, high social value addresses recognition as a practice that works to meet its goals. With this said, focus should be on addressing the fact that the field of RT lacks recognition as an evidence-based, non-pharmacological, goal-driven therapy. As noted, very few respondents (4%–7%) used evidence-based practice (EBP)/outcomes/research as a marketing tool. Clearly, these results highlight the level of need for education and training directed at CTRSs on how to collect and use data in their practice and then use these data to market the field of RT. Practitioners who implement these practices should take initiative to provide training and strategies to other CTRSs, state, regional, and national. Lastly, additional organized efforts from national leadership such as ATRA and the NCTRC should be employed. As national organizations, these groups have the potential to design and distribute materials that may inform and direct practicing CTRSs in strategic marketing techniques within their respective practices.

Recommendations for Research Several recommendations exist for future

research on this topic. First, to facilitate consistency and reduce variability among the questionnaire items in future research, a factor analysis should be conducted on the three main sections (Intra, Inter, Extra) to eliminate possible conceptual redundancies among the variables. This analysis would potentially strengthen the sections and eliminate items that might distract from the interpretation of the results.

Second, examining respondents’ constraints (real and perceived) as well as facilitators to marketing identified by CTRSs may contribute to understanding unique marketing needs and abilities. For example, some of the respondents suggested specific barriers to designing and conducting marketing activities. Analysis indicated, however, that some of these



barriers were perceived rather than real. Further research should explore what perceptions might be keeping CTRSs from pursuing marketing efforts that are available and possible to achieve. Similarly, it will be important to identify specific characteristics of the settings, support systems, and techniques of the CTRSs that are conducting successful marketing strategies in order to develop models for other to utilize in designing and improving their own marketing efforts. Finally, surveying college and university RT programs about the level and extent of curriculum content on marketing is taught to RT students could help give a perspective of what needs to be developed on the curricular level for the field.

In conclusion, results from this study provide a baseline understanding of the knowledge and experiences of CTRSs regarding marketing in the field of RT. An effort to gain more specific understanding about conditions of identified marketing constraints, as well as details about successful techniques, is warranted. As these elements are identified and understood, the foundation of a comprehensive and strategic marketing model can be built.

References

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Author Note

This study was funded in part by the North Carolina Recreation Therapy Association.

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