Communicator

Amputee Coalition of America - National Limb Loss Information Center
900 E. Hill Avenue, Suite 205, Knoxville, TN 37915 · 888-AMP-KNOW (267-5669)
Richard Mooney, editor; e-mail: matlmgr@jps.net - Becky Bruce, coordinator; e-mail: rbruce@amputee-coalition.org

ACA News and Views
New CEO and COO Announced
Anaheim - Support Group leaders' Workshop
Regional Rep Chat - Meet your Regional Representative

The Amputee Coalition of America is pleased to announce that, effective March 15, 2002, Paddy Rossbach, RN, was appointed President and CEO; and Patricia Isenberg, MS, assumed the role of Chief Operating Officer (COO).

Paddy Rossbach, who was designated interim President & CEO after the resignation of John Miller in September 2001, was unanimously appointed to the position of President & CEO by the ACA Board of Directors because of her experience and proven track record in the field of limb loss. A registered nurse and an amputee, Paddy has been involved in the education and training of people living with limb loss since 1984-most notably in the area of sports and recreational activities for young amputees. Paddy will maintain her legal residence in Connecticut, and as a national spokesperson for the organization's mission and goals, will be responsible for the overall management of the organization. In accepting the position, Paddy said, "We're in for some very exciting times and we're particularly enthusiastic about the new membership drive. I am delighted that Pat Isenberg has accepted the position of COO."

Pat Isenberg, formerly ACA's Program Manager for Training & Outreach, holds Master of Science degrees in Education and Psychology and brings more than 26 years of experience in nonprofit management to the COO position,Based at the Knoxville office, she will be responsible for assuring the effective day-to-day operation of the ACA's national headquarters, including its financial stability and its various programs. Pat had this to say regarding her new role as COO: "I am honored and excited by this opportunity. I appreciate Paddy's support and confidence and look forward to enhancing relationships with support groups throughout the country."

Once again, a support group leaders' workshop will be held in Anaheim at the ACA annual meeting on July 18, 2002. This year the workshop will be divided into three main topics. The topics and times are as follows:

Each session will be divided into two groups. One group will be for beginners--those who are new to support group facilitation and have recently started local amputee support groups--and a second group for those who are seeking advanced information related to the session topics. We hope that by tailoring the sessions to the needs of attendees, we can provide useful information that can be more readily applied to your group and its members.

The ACA will be sending a letter to all member support groups to give them an opportunity to nominate presenters who have experience in the three session topics listed. If you or any members of your group would like to present at this workshop, in either the advanced or beginner sessions, please fill out the form that will accompany the letter and mail it back to the ACA office by the specified date. The letters will be mailed out by April 5, 2002.

Finding your regional representative in a sea of annual meeting attendees can be easier said than done. Every year there are those who hoped to meet their representative but never could find the opportunity or the right name on a badge. This year, the ACA is planning a " Regional Rep Chat" on Sunday, July 21, from 3:00 to 5:00 p.m. We're going to corral all the representatives into one room and give any of you who need a few minutes to chat with your representative an easy way to do so. No more wandering around checking name badges, asking others if they've seen your representative, or sitting patiently in the lobby hoping to be lucky enough to have them sit down next to you!

The " Regional Rep Chat" will be listed in the conference program with the time and room location. All you need to do is show up! For those of you who would like to leave a message for your representative during the annual meeting, there will be a message board located near the ACA registration desk for doing just that. Each representative will have a clearly marked envelope on the board for you to put your message in. We've tried to make it foolproof and easy for you to meet your representative. Leave the eye straining badge reading to others. Be there Sunday afternoon from 3:00 to 5:00, introduce yourself and your group to your regional representative, and enjoy the opportunity to get to know each other.

One of our readers, Elisabeth Szanto, sent us a topic suggestion with some pretty specific questions about prosthesis materials and socket design. Since The Communicator is not a technical publication we can't address her specific questions here but we can suggest that she--and any other readers who are interested--go to the ACA's "NLLIC Library Catalog" where scores of articles on the subject of prosthetics can be found.

Leadership Skills
Leader or Manager? Which Are You? Which Should You Be?
The Case for Being Well-Rounded

As I wrote this, I found it difficult to keep terms straight. On the one hand I wanted to discuss the practice of "leadership," referring, in an academic sense, to those who practice leadership as "leaders." Similarly, I wanted to discuss the practice of "management," referring, in an academic sense, to those who practice management as "managers." But on the other hand, I also needed to refer to us as support group "leaders," which is, after all, what we call ourselves. So you see the problem; I had to find a way to keep "leader" separate from "leader!" The method I decided on is the following: Whenever I refer to "leader," "leadership," "manager," or "management," I will be referring to the academic meaning of those terms. When I refer to us and what we call ourselves, I will generally use the term "SGL."

"What's in a name?" We are typically referred to, and refer to ourselves, as SGLs, but as anyone who regularly reads this newsletter knows, I am always urging SGLs to be better managers. This suggests that leaders and managers are different animals. Which should we be, or should we be a combination? What are the differences between leaders and managers and what proportion of each role should we adopt as our personal style? I may have unwittingly confused this issue by continually writing about "leadership skills" in this publication, even when many of the things I have written about are actually management skills.

Maybe an even more basic question is, why is this even necessary to discuss? I believe it's necessary and this is my reasoning: As SGLs, we are responsible for putting to best use the human and material resources at our disposal. The ways in which we do that determine whether or not the missions and goals that have been set for our groups will be successfully achieved. The ways in which we put to use those human and material resources are determined by the mental image we have of our leadership role.

When we say to ourselves and others, "I am an SGL," we must have some mental image in our minds of what that means--what we do that defines our SGL role. Whatever is our mental image of "leader" in the title we use tends to make us act in ways that are consistent with that mental image. If our mental image is appropriate, we will tend to act in ways that are good for our groups, and vice versa.

The purpose of this article is to motivate us to think deeply about the mental image we have of our role as SGLs, to question the appropriateness of that role, and to change it if, and as, necessary to a role that may be more appropriate. The better we understand our management and leadership roles, the better we will perform and the better we will "lead" our groups to provide the services our constituents need and expect.

If one were systematically to read what many "authorities" have written about leadership and management, the first thing one would notice is that writers often have widely different, and sometimes conflicting, views about the two. In general, people who favor and write about leadership tend to disparage management traits as cold, unfeeling, and excessively logical. They say such things as, "managers see work as something that must be done or tolerated," "management focuses attention on procedure," and "management sees the world as relatively black and white."

On the flip side, people who favor and write about management tend to describe leadership traits as wishy washy and touchy feely. They say such things as, "leadership involves an intuitive, mystical understanding of what needs to be done," "leaders innovate through flashes of insight or intuition," and "leaders influence people through altering moods, evoking images and expectations." In my judgment, both of these polar views are equally extreme and equally wrong.

I must add that nowhere can one find an informed opinion that management and leadership are the same. So if the polar views are extreme and wrong, and if there aren't any views that the two are the same, then the "truth" must lie somewhere in between. So let's pay special attention to the "middle of the road" viewpoints.

As an example, William Wallace (who most of us Anglos know as "Braveheart") would have been completely ineffective leading the Scots to victory over the English if he were to have used only management skills. Conversely, the proprietor of a financial management business would probably relate to her clients well but wouldn't make much money for them if she were to use only leadership skills.

Carter McNamara, MBA, PhD, wrote that leadership is a facet of management. He wrote, "Leadership is just one of the many assets a successful manager must possess. Care must be taken in distinguishing between the two concepts. The main aim of a manager is to maximize the output of the organization through administrative implementation. To achieve this, managers must undertake the following functions:

If effective management requires us to practice good management skills and effective leadership requires us to practice good leadership skills, and both are needed to do our jobs as SGLs well; then first we need an understanding of what effective management and leadership skills are, and then we must understand how we can combine them to make us successful as SGLs.

Rather than extend this unnecessarily, I will provide only the most common and universally accepted definitions.

Management is the process of attaining organizational goals in an effective and efficient manner through planning, organizing, controlling, and directing organizational resources.

Leadership is the process of exercizing the influence between a leader and his/her followers that is necessary to attain group, organizational, and social goals.

Note that both processes involve the attainment of organizational goals, but each involves different kinds of functions.

As mentioned earlier in several places, the commonly listed functions of management are planning, organizing, controlling, and directing human efforts.

Planning - On a strategic level, the planning function includes the development of organizational mission statements, goals, and objectives. In other words, on a strategic level, planning defines where the organization should be going. On a tactical level, the planning function involves the development of such tools as action plans and budgets. In other words, on a tactical level, planning defines how the organization will get to it's desired destination. Indeed, any forward thinking with the goal of preventing problems, surprises, and obstacles is planning. Crisis management is fire fighting. Planning is fire prevention.

In the support group arena, for example, defining the "correct" mission for the group, identifying the services the group will provide to its members, and deciding how needed resources--both financial and human--will be acquired and allocated are parts of the planning function. Also, all the subsidiary decisions that are required to support these kinds of plans are part of the planning function. For example, if it's decided that one of the services that should be provided is a newsletter, one must also define what the newsletter's objectives will be, who will be on the mailing list, how much will the newsletter cost and what can we afford to spend, how can the newsletter be funded, how should space in the newsletter be budgeted, who should be responsible for the newsletter's production, and on, and on, and on.

Organizing - After defining the operational needs of the organization (which is planning) the organizing function involves grouping operating positions in an optimum way. After defining the needs of each job (which is also planning) the organizing function involves placing people in the jobs for which their skills, knowledge, and abilities are the best match. This is sometimes called "staffing," which many consider to be part of the organizing function. The organizing function includes defining superior/subordinate relationships, chains of command, relationships between people and functions, and how the staff will work in groups or teams to assure goals are met.

In the support group context, for example, the organizing function would include defining volunteer needs and recruiting them, and staffing a board of directors. Again, there are many subsidiary steps to be taken, such as determining how many board members there should be, should non-amputees be allowed on the board, how will the board perpetuate itself, how frequently should the board meet, and so on.

Controlling - The control function means constantly checking to assure that the way things are within the organization is how they should be--that is, under control. Budgeting is a planning function but checking to see that funds are being spent as the budget indicates they should be is a control function. Developing procedures for the annual dues solicitation is planning, but checking to make sure that those procedures are being followed is a control function. Getting periodic reports from the peer visitation coordinator, sample audits of visits, and feedback from visitees are all parts of the control function.

Directing - All activities involving human effort within the organization fall within the directing function. Training, supervising, delegating, team building, rewarding are all directing functions. Because no products are produced by support groups and there are few material resources to manage, a lot of the SGL's activity will be in the directing area.

Broadly put, the function of leader is to persuade others to follow. In the organizational context, as mentioned above, training, supervising, delegating, team building, rewarding are all leadership functions. So are active and empathetic listening, evaluating performance, maintaining effective interpersonal relations, and counseling when mistakes are made.

An important leadership function is exercising power and influence to motivate staff members to do what they are supposed to. As pointed out in my other article in this issue that covers power and influence, SGLs, as a practical matter, have very little power to make staff members perform as they should. Therefore, as one writer describes it, leadership is utilizing "the incremental influence that a person has beyond his or her formal authority."

Effective managers must be analytical, and skilled in problem-solving and decision making. They must have both vision and organizational awareness--vision to determine the correct directions for the organization and organizational awareness to constantly monitor whether or not what is conforms to what should be. And they must have the energy, determination, frustration tolerance, and tough-mindedness to bring the two into conformance, resolve problems, and mediate conflicts.

Effective managers must be skilled communicators. They must be articulate in communicating the organization's goals and objectives, they must send clear signals about what must be done, and they must listen well when others disagree or have different ideas.

Managers must know the difference between efficiency and effectiveness and must constantly strive to improve both.

Sandra Larson, former executive director of "The Management Assistance Program for Nonprofits" developed the following list of qualities needed by a leader.

Passion - A leader has a passion for a cause that is larger then they are, a dream for how the world can be better and the part they can play--and rally others to join--in making their dream a reality.

Vision - Vision gives direction to, and is needed to breathe life into, a passionate dream. Vision answers the question, what is versus what can be?

Holder of Values - Leaders have values that legitimize an organization and characterize the organization's culture--values like respect for others, caring about people, and in the case of support groups, empathy for those who need support and encouragement.

Creativity - Leaders think outside the box. They are not afraid to try solutions that are new or different.

Intellectual Drive and Knowledge - Leaders are perpetual students of their craft. They read, they learn, and they get ideas from others.

Confidence and Humility - Leaders have confidence that their vision is correct, yet they are humble enough to accept better ideas from other people.

Communicator - Leaders speak and write in ways that encourage others to follow.

Interpersonal Skills - Leaders have the ability to listen well, delegate well, resolve interpersonal conflicts, and keep everyone moving along in the same direction.

We can see from the foregoing that there is a great deal of overlap in roles and skills. We can see that management skills and leadership skills are something like conjoined twins; they may be separate entities but often they overlap and frequently cannot be separated one from the other.

What we have seen is that it is not enough to be only an effective manager or only an effective leader. One way to put it is that management and leadership are symbiotic. Management brings order and structure to leadership and leadership "actualizes" management by effectively rallying the entire team to put their shoulders to the wheel. Without both being present, this symbiosis cannot occur. To be an effective SGL, therefore, a person must be skilled in both areas.

Management skills are necessary to create a structure from within which the organization's mission can be accomplished, but leadership skills are needed to supply the passion and vision necessary to define the mission appropriately.

Management skills are necessary to develop goals and action plans but leadership skills are needed to communicate, persuade, encourage, and motivate others to follow the plans and strive to meet those goals.

Management skills are needed to design an organizational structure that is optimum for accomplishing the group's mission, but leadership skills are needed to persuade others to join the organization, to train them, to supervise them, and to reward them when they perform well.

As J. P. Kotter wrote in his 1991 "The Best of the Harvard Business Review" article, What Leaders Really Do:

"Leadership is different from management, but not for the reason most people think. Leadership isn't mystical and mysterious. It has nothing to do with having charisma or other exotic personality traits. It's not the province of a chosen few. Nor is leadership necessarily better than management or a replacement for it. Rather, leadership and management are two distinctive and complementary activities. Both are necessary for success in an increasingly complex and volatile business environment"

. . . . And, I can add with confidence, in the support group environment, as well!

Peer Visitation Corner
Gaining Respect and Recognition for you Peer Visitation Program
Peer Visitation Retraining Clarification
2002 Peer Visitation Training Schedule
Peer Visitation Q and A Forum

There are many approaches to developing a successful visitation program--somewhat like the old adage--there's more than one way to skin a cat. Well, maybe that is no longer a politically correct statement, but the idea behind the cliché can be appropriately applied to "growing" a peer visitation program--just ask Liz Zemke, RN, ACA Regional Representative (Region K), and below-knee amputee.

In response to a Communicator staff request to share information for the Peer Visitation Corner, Liz has contributed a few success tidbits that I believe have value for everyone involved with or planning a peer visitation program. But, before we consider Liz's comments, let me provide some history on the seven-year seasoned program with which Liz is associated; the Central California Amputee Education and Support Group (CCAESG) Peer Visitation Program.

In the November/December, 2000, issue of inMotion magazine, author Zahra Maghani penned the following excerpt about Liz and the CCAESG in an article titled "Different Strokes."

Zemke, a nurse case-manager, used her professional knowledge of the health care system to convince various area hospitals to collaborate with CCAESG's peer visitation program. This was no easy task.

The first hospital Zemke approached rejected her overtures contending that it didn't perform enough amputation surgeries each year to warrant a formal alliance with CCAESG. Rather than taking their word for it, Zemke asked the hospital to back up its claim with actual numbers. Tabulation of the statistical incidence of amputation surgeries revealed that the hospital was averaging as many as two or three amputation surgeries each week. "Of course, then the hospital's CEO jumped at the chance to get CCAESG's pre- and post-amputation support services for its annual load of 120 amputee patients," Zemke said.

Encouraged by the creation of the first alliance, Liz approached various other area hospitals with a proposal to formally collaborate with CCAESG. "How could they turn us down?" Zemke asks. "This was a win-win situation--their patients would benefit from this free service and the hospital's reputation for quality patient services would soar."

Now, whenever an area hospital patient is about to undergo amputation surgery, the hospital's patient services department notifies CCAESG's peer visitor program coordinator. Depending on the circumstances and kind of amputation, a peer visitor is selected to visit with the patient. "Seeing someone who has a similar amputation but is active and doing well in life can bring so much hope to the new amputee," Zemke notes.

Because first impressions matter so much, the program coordinator usually arranges for a peer visitor close in age to the new amputee. "A teenager who has just lost his leg might find it easier to communicate with a peer visitor who is closer to his age than someone much older," Zemke notes. With this concern in mind, CCAESG's Peer Visitation Program has recruited peer visitors of various ages, including teens.

To appropriately address the needs and concerns of the new amputee, the program coordinator must respect the emotional limitations of the amputee peer visitors. Because some peer visitors find it difficult to visit with people who have lost a limb because of complications from diabetes and other peer visitors have a hard time counseling trauma amputees, the peer visitor program coordinator takes a great deal of care in matching up new amputees with the "right" peer visitor. "It is really not in the patient's best interest to have a peer visitor who finds the circumstances of the patient's amputation, say cancer, depressing. That peer visitor is not going to be able to offer much support or hope to the new amputee," Zemke stresses.

The care, thoughtfulness, and hard work that has gone into the CCAESG peer visitation program has earned it and its partner hospitals accolades from the Joint Commission on Accreditation of Healthcare Organizations and other reviewing bodies. Zemke points out that, although a formal study on the program's impact on new amputee recovery rates has not yet been done, she believes that the program and support group activities make a significant contribution to the amputees' post-amputation adjustment and general sense of well-being.

Zemke's insights on the needs of new amputees stem from her personal experience. Five (now seven) years ago, when her right leg was amputated below the knee, there was no amputee peer visitor program in place to reach out to for comfort and direction. "It would have made all the difference in my recovery if I had had the kind of support, understanding and information that only amputees can provide to each other," she says.

Along the journey of the past years, Liz has developed a few techniques that have served the CCAESG program particularly well.

The CCAESG program is good example of how a peer visitation program can grow with time, organization, persistence, and dedication. With the assistance of a few CCAESG volunteers, Liz visits five to ten new amputees per week and also contacts the same number by email, telephone, and regular mail. And, all indications show that the program is growing by leaps and bounds.

Thanks Liz for sharing some of your success stories. Hopefully, other peer visitation programs will benefit from your proven techniques, and aspiring program coordinators will be encouraged by your results.

In a Peer Visitation Corner article published in the February, 2002, edition of the Communicator entitled "Peer Visitation Training Program Gets New Look," I reported on the necessity to "retrain individuals who are currently on the trainer roles (emphasis added), along with anyone else not previously trained." This statement seems to have created some confusion regarding exactly who needs to be trained again. One reader asked if it would be necessary to retrain all peer visitors now on the role call.

I apologize for the confusion that may have occurred and would like to emphasize that my article referred to the retraining of current and future trainers only.

To further clarify this, Pat Isenberg, ACA's new COO and training coordinator, was contacted. She explained that ACA "will not require that trained and experienced peer visitors be retrained. Obviously, since the material is new, they may want to be, or they may feel that they need a refresher course. We have more than 600 peer visitors in our database; but are unsure how many of these are active." Pat continues, "What I hope we will be able to do at future annual conferences is provide sessions for seasoned peer visitors to deal with more advanced issues. And, I hope some of them will be interested in becoming certified trainers. As we proceed through certification of trainers, I plan to have additional training sessions at annual conferences to enhance the skills of certified trainers (so, each year we would certify new trainers and provide continuing education for those certified previously)."

Sounds to me like the NPN's Peer Visitation Program is a work in progress with many exciting improvements to come in the months and years ahead. And that can only mean bigger and better things ahead for amputees, their families and friends, and the professionals who serve them.

My question concerns home visits. What do you do when you find out, once you've arrived at the amputee's home, that due to tension between family members and/or a stressful situation involving an issue that a peer visitor isn't supposed to address, you find yourself unable to conduct a "normal" visit?

Your question correctly suggests that there can potentially be a number of situations that must be resolved before a "normal" visit is possible. Let's look at some of these individually, together with some of the options open to a visitor. Incidentally, as you will recognize, several of these same situations could also occur during a hospital visit.

The situations to which I am referring involve safety issues, comfort level issues, and inappropriate questions, including combinations of these.

Safety Issues - In general, any situation that causes a visitor to be concerned about his or her personal safety must be dealt with immediately and affirmatively by terminating the visit and leaving the venue. These could involve such things as potentially violent displays of temper, out-of-control arguing among family members, inappropriate or threatening advances by anyone present toward the visitor, evidence of uncontrolled drunkenness or drug use, etc. Fortunately, these kinds of situations are rare, but the visitor must still be prepared to deal with them.

Visitors should always remember that 1) their duty to protect themselves transcends any duty they might feel they have toward the visitee, and 2) that their own level of discomfort is the barometer that should tell them when to excuse themselves as politely as possible and leave the home. In other words, you don't have to be able to prove the threat exists; simply feeling the threat is enough to justify taking your leave. The most recent ACA guidelines, found in the new peer visitor training manual, support you in this. They state: "Terminate the visit if anything about the setting or behavior of anyone in the home makes you feel unsafe or uncomfortable."

Should this happen, reporting the terminated visit to the peer visitation coordinator or referral source would be an important, logical, and necessary next step. Should this occur during a hospital visit, it should also be reported to the charge nurse or social worker.

Comfort Level Issues - There are many possible situations that might make a visitor uncomfortable but which would not normally warrant termination of the visit. In general, these are the kinds of things that the visitor is usually able to control or motivate others present to bring under control. They might include distractions such as from a television or children running noisily through the room, or a family member or other third party who interferes with your conversation with the amputee.

Most distractions can be reduced one way or another; for example, the visitor might ask that the television be turned off or that the children play elsewhere. Or one can suggest moving to a different room.

In the case of family members who interrupt or dominate the conversation, it's okay to explain diplomatically that you are there to speak privately with the amputee. It would also be appropriate, at your option, to suggest meeting separately or at another time with the family or other support individuals.

Naturally, if the visitor's discomfort level becomes sufficiently extreme, if the distractions or interruptions can't be controlled, or if anyone's behavior becomes too much of a problem, even though the visitor might not have personal safety concerns, he or she can still decide to terminate the visit.

A different kind of comfort level issue involves questions from the visitee that are entirely appropriate but that embarrass the visitor or offend the visitor's sensibilities sufficiently that he or she would be reluctant to answer. An example might be a question concerning the potential for continued sexual relations after amputation. In dealing with these, the visitor should admit to being uncomfortable with responding and then offer to help find another visitor or professional person who would be more comfortable with the subject matter.

Inappropriate Questions - One category of questions that are inappropriate for a visitor to answer involve subjects outside the visitor's purview, such as medical questions or questions about the competence of a particular prosthetist. Equally inappropriate are personal questions, such as "Could you arrange for your prosthetist to contact me?" "Would you be interested in dating me?" etc.

Obviously, the visitor should not answer inappropriate questions and the amputee should be told why. Care should be taken, however, to differentiate these kinds of questions from questions that are simply beyond the visitor's competence to answer. In these cases, explaining that you have no knowledge of the subject matter or a simple "I don't know but I'll find out" should suffice, provided that you actually do get back with an answer.

Rule No. 1 is protect yourself at all times and terminate any visit you feel jeopardizes your personal safety;
Rule No. 2 is attempt to control distractions, interruptions, or other inappropriate behaviors but terminate any visit during which these cannot be controlled;
Rule No. 3 is do not answer inappropriate questions; and
Rule No. 4 is that you have the option of not answering questions that you find too embarrassing or discomforting.

If other support group leaders or peer visitation coordinators have information, advice and/or questions to share, please forward them by email directly to Kathy Spozio at mermaid@usachoice.net.

This year's ACA Annual Educational Conference promises to be the biggest and best ever! With more than three months to go, it's time to begin raising funds for your support group members to attend. (Remember to register early for the conference to take advantage of the discount).

Fundraising can be as simple as writing solicitation letters to key supporters in the community:

Leadership Skills
Some Thoughts About Power and Influence . . .
. . . and how to get your support group's volunteers to do what you want them to do.

"Diabetes is a major contributor to heart disease, kidney disease and blindness. So when you support the American Diabetes Association, you fight some of the worst diseases of our time. We need your help."
~American Diabetes Association

One of the problems support group leaders experience (and, for that matter, everyone else who supervises other people) is how to get those within the organization--in our case, volunteers--to do what they need to do to uphold their responsibilities. Sometimes we feel powerless to do so and tend to take whatever comes along as the best work we can get from them. But we aren't entirely powerless, provided that we understand power and influence and know how to use those tools effectively.

If the practice of leadership involves (at least in part) accomplishing organizational goals through others, then the ability to get others to do what is necessary to reach those goals is an extremely important leadership skill. There are a wide variety of ways to get others to do our bidding, ranging from persuasion to coercion--from the soft sell to the hard sell--as illustrated by the two quotations above. The hard sell involves primarily force, and the soft sell involves what we'll call "influence." Clearly, the hard sell is one of the tools not available to us and we probably wouldn't want to use it even if it were. The hard sell is a tool chiefly available to managers in a conventional business setting and it involves the ability to punish or reward subordinates in ways that motivate them to do the boss's bidding; something like, "You are free to do any job you want but I have to make clear to you that the only one that pays any money is the one I want you to do."

So, since we have no formal, direct authority and no ability to "control" subordinates by exercising the right to command, including the right to impose painful sanctions for non-compliance, we must look to "influence" as our principal tool to get others within the group to do what we need them to do.

In Chapter 10 of his book, Social Psychology, Professor Bertram Raven discusses interpersonal influence, and identifies six basic kinds of social power, which he defines as the potential ability to change another person's beliefs, attitudes, behaviors, or emotions (i.e., to influence them). These power bases are Informational, Reward, Coercion, Expert, Referent, and Legitimate.

Dependent Influence - influence that depends on continued intervention by the influencing agent

Independent Influence - influence that continues without further intervention by the influencing agent

Surveillance - the supervision that the influencing agent exerts on the target

In the examples I use in the following paragraphs, the support group leader is the influencing agent and the peer visitation coordinator is the target.

Informational Power - For its strength, informational power relies on learning, which in turn, results in a change in understanding or viewpoint on the part of the target. What's more, the change is independent of the influencing agent and requires no surveillance. In communications designed to exert informational power, then, it's the persuasive content of the message that's important. To be persuasive, a message requires not only information, but it must be presented in a logical, believable, and compelling way. An example of the use of informational power is when a support group leader explains in clear detail to the coordinator of the peer visitation program who has a habit of using untrained people as visitors exactly why this is not a good practice. The explanation is even more persuasive if it is made clear, for example, that an untrained visitor once got the group in hot water by "selling" her own prosthetist to the new amputee. As it turned out, the prosthetist didn't do a satisfactory job and the amputee held the visitor and the group responsible. Once the visitation coordinator understands this, and understands the correct way that visitors should be selected, his or her behavior changes without further intervention by the support group leader.

Reward Power - For its power, reward relies on the promise of, and ability to deliver a reward in return for desired behavior. Rewards that are institutional, like raises, days off, perquisites, or promotions aren't available to us. That leaves us with personal rewards, like approval, attention, or agreement.

An example of reward power is when a support group leader tells the peer visitation coordinator who has a habit of using untrained people as visitors that some valuable right or advantage, like the ability to attend the ACA annual meeting at group expense, will be granted when it can be demonstrated that the coordinator is consistently using only trained visitors.

Coercive Power - Conversely, coercive power relies on the threat of punishment (plus the target's understanding that the influencing agent can, and if necessary will, deliver it). Again, punishments that are institutional in nature, like disciplinary action, loss of support, or removal of perquisites; are not available to us. That leaves us with personal coercive power, like disapproval or disagreement.

An example of personal coercive power is when the support group leader explains to the peer visitation coordinator that some valuable right or advantage will be taken away if he or she persists in using untrained visitors. I can't imagine what valuable right or advantage could be taken away from the visitation coordinator for non-compliance but I can visualize that the leader could "counsel" the visitation coordinator in strong terms and express "extreme disappointment" in his or her performance. These could be considered milder forms of coercion.

There are a couple of important limitations to reward and coercion, the most important being that they're both highly dependent on the influencing agent. Also, surveillance is absolutely necessary with each, because the influencing agent must keep tabs on the target and apply rewards and punishments as needed to keep the target's behavior "in line." With reward power, surveillance is easier because targets are usually motivated to make sure that the influencing agent knows they've complied. With coercion, on the other hand, use of surveillance is made more difficult because coercion tends to force the target away from the influencing agent and drive the target's behavior underground. Coercion also tends to make the target feel negatively about the situation and the influencing agent. Likewise, the negative motivational aspects of surveillance are troublesome.

Expert Power - To be effective, expert power does not involve rewards, punishments, or surveillance; but instead, it's highly dependent on the influencing agent having specialized knowledge, training, and/or experience which the target recognizes, respects, and is willing to be influenced by. The target must also respect the influencing agent's motives, for if they're seen as selfish or purely manipulative, they'll lose their power to influence.

An example of expert power is where a support group leader explains to the visitation coordinator that she has been an amputee support group leader for 25 years, is a member of the ACA, has attended six ACA support group leaders' workshops, has attended ACA's peer visitation training twice, and is certified by the ACA as a visitor and can assure the visitation coordinator unequivocally that using untrained visitors is a poor strategy. That's not quite the same kind of expert power a doctor uses when he tells you to stop smoking or you're going to die, but it's probably the best we can do in the support group setting.

Referent Power - Referent power relies on the target's personal identification with the influencing agent and wanting to follow his or her example. The target typically admires and respects the influencing agent. The potential for personal satisfaction or gratification motivates the target to be influenced in this case. This method is highly dependent on the influencing agent, but surveillance isn't required. The multitudes of famous people (carefully chosen because they're thought to be highly admired by the targets) who are seen on television endorsing consumer products is dramatic testimony of the potential power of this technique.

Legitimate Power - Legitimate power is like the formal authority that we've already observed flows down the chain of command to specific positions in business organization . Those who are influenced by legitimate power reason, "Well, she is the leader and has a right to ask me to use only trained visitors, so I think I'll go along with her request." As with referent power, legitimate power is highly dependent on the influencing agent, but surveillance isn't required.

Now that we have a nodding acquaintance with these power classifications, we're tempted to ask the question, which is best? The right answer probably is that each has its own strengths and there are situations in which it would be more effective to use one than another. As with most alternative methods of dealing with people, the best bet is to have the widest possible repertoire and be able to use the right tools in the right places.

It can be correctly said, however, that some of these influence bases have fewer inherent problems than others, and that, therefore, those may tend to be generally more effective. Earlier, when we defined terms, we observed that we could qualify each influence type according to two factors; surveillance and dependence. We observed that, with each, effective influence either did or did not require continued intervention (surveillance), and it was either dependent or independent of the influencing agent. If we can agree that it's much better if we don't have to continually intervene, and when influence can be effective without being dependent on the unique identity and qualifications of the influencing agent, then we can see that there's only one power base that is independent and requires no surveillance; informational power. The following chart will illustrate this.

Surveillance			Role of Influencing Agent
	Required	Not Required	Dependent	Independent
Informational		X		X
Reward	X		X
Coercion	X		X
Expert		X	X
Referent		X	X
Legitimate		X	X

For us as support group leaders, if there's any important lesson to be learned from this brief survey of social power and influence, it's that facts, information, and knowledge presented in the right way are persuasive; and the best way to influence the behavior of our colleagues, especially when we have no direct authority over them in our setting, is to convince them through appealing to their intellectual values and to their need to understand the logic and rationale behind our requests.

Today is the first anniversary of my amputation surgery and I'm really bummed out. It took a couple years after my injury before I decided to go ahead with the amputation. I thought all these feelings were behind me. What's wrong with me?

Well, first of all, let me tell you that nothing is "wrong" with you; you are very normal. The feelings that go with an amputation are intense and individual. In most cases it feels like a death in the family. Something near and dear is gone, not to return in this life.

It has been said that it takes two years just to start to get over a death of someone dear. In truth, we really never do "get over" the death of someone precious, nor do we truly ever get over the loss of part of our body. Fortunately, for most of us, the feelings of grief diminish over time. We move on and a new life develops. But our senses will often remind us of our loss:

These changes at first can be highly annoying if not overwhelming. We may be constantly comparing ourselves to others or how we used to be. The grief can and, perhaps, should be intense in the beginning. After months, and finally years, pass, the nuisances of this life as an amputee may only bring up brief twinges of emotion. A brief twinge when we see shoes or clothes that just don't work well with this new body. An ache when we see someone move effortlessly on the dance floor, the ice skating rink, or in the gym. A sentimental sad thought when we realize that today is the tenth anniversary of our amputation. We usually don't go farther than a brief pain because we've learned that there is nothing to be accomplished by dwelling on it. And, truly, it really doesn't hurt that much after a while; it's just the way our new life is.

Do you have a question you would like Dee to address? If so, we invite you to ask Dee directly at deemalco@mindspring.com.

Dee Malchow, MN, RN, is a nurse case manager who is self employed and specializes in the care of amputations. She experienced a right below knee amputation at age 19 from a boating accident.

Over the past 37 years she has come into close contact with over 2500 amputees through organized skiing and soccer, mission work in Sierra Leone, research for Seattle Foot, and her position as a Clinical Nurse Specialist at the Harborview Medical Center in Seattle, a Level I Trauma Center. In 2001, she retired from Harborview after 34 years. Dee served as the facilitator for the weekly Harborview Amputee Support Group for 22 years and has taught several peer visitor training classes. She has written several related articles and is currently working on a book about the emotional impact of limb loss.

(This is the first of three articles that will present different aspects of "Selecting a Wheelchair." In the next issue we will consider wheelchair use and some of the options available that will make your chair more user friendly.)

Independence, the ability to move from place to place on one's own, is a basic human need, desire, something that motivates us. We see this in the lengths taken by a young couple choosing a stroller for their first child, by a child working hard to be worthy of his/her first bike, by the adolescent striving to meet the requirements of a driver's license and earning the right to drive the family car, or a young adult saving his/her hard earned money to buy "wheels" whether it be a car, a motorcycle, or . . . . .These are recognized rights of passage in society as we know and have experienced it. "Wheels" are both fascinating and liberating. They mark the transitions between infancy and childhood, childhood and adolescence, adolescence and adulthood in a society where more formal, ceremonial transitions generally do not exist. They are signs of our maturing, being ready and able to accept new and added responsibilities. "Wheels" are a part of who we are.

As we mature, there comes a time when we are faced with a decision about another set of wheels, wheels which markedly change how we see others, move from place to place, and are viewed by the public. That decision often is not of our choosing, but one forced upon us by circumstances we did not intend. It is the decision to stop struggling to walk, choosing instead to use a wheelchair. Certainly, it is not what we planned, but it is something that permits a level of independence. Note: I will not use the phrase "confined to a wheelchair" or the term "wheelchair bound." A wheelchair is an enabling, not a confining, piece of Durable Medical Equipment (DME).

That said, when faced with a decision to obtain a wheelchair, where should you start? A magazine? A catalog? A showroom? A hospital? A rehabilitation center? Another person who is a wheelchair user? A healthcare professional?

When asked to address the issues surrounding Selecting a Wheelchair a few years ago, I accepted without question having been involved in buying a number of wheelchairs during the past twenty-plus years. However, as I began to research the topic I found that my experience was the exception. I knew what was wanted/needed and where to buy it. For the inexperienced, Selecting a Wheelchair can be a complicated series of decisions.

To begin with, you as a person who will come to depend on it must have a clear idea about how you intend to use a wheelchair. What do you want to accomplish that will be done more easily from a wheelchair? Equally important, what obstacles do you foresee if a wheelchair is part of your life?

Determining how you will use a wheelchair starts with the prescription process. A physician must sign a prescription authorizing your purchase of a wheelchair. Ideally, however, that prescription should be the work of a team of healthcare professionals, including one or more of the following: physical therapist, occupational therapist, seating specialist, and rehabilitation engineer. Each of these professionals will examine you. In the process, they should ask a lot of questions as together you and they work to determine the best type of wheelchair for you.

At the same time, you must find out about the limits of your insurance coverage in relation to the purchase of a wheelchair. As an aside, if you know what you need in a wheelchair, you must become your own advocate to make sure your needs are met--don't let the bureaucracy increase your disability.

The most important decision comes next as you set out to choose where you will buy your wheelchair. Your insurance company will likely refer you to a supplier that's a Preferred Provider. You will want to visit that company, but you should also obtain a list of all of the companies that are on your insurance company's approved list so you can make an informed choice.

As you visit different suppliers, recognize that those who sell wheelchairs, unlike the other healthcare professionals who have worked with you, are not required to meet educational or experience standards--in other words, anyone can open a business and begin selling wheelchairs. This is of particular concern in a competitive market where price is often the determining factor in what your insurance company will approve. What follows are some questions you should find answers to when deciding about doing business with a specific supplier:

1. Does the supplier have a presence in the community that indicates stability and permanence? Not only should the facility be well kept, wheelchairs should be a prominent part of the business, not a sideline. Also, is the supplier a member of the local Chamber of Commerce and the owner/manager a member of one of the local service clubs, i.e., Rotary, Lions, Kiwanis, etc.? Answers to these questions will not assure competence, but do indicate a measure of credibility.

2. Do members of the supplier's staff have experience with wheelchairs and have they completed formal training in fitting and servicing wheelchairs? Ask about the specific training and years of experience staff members have had in wheelchair design, options, fitting, and servicing. Also, look for certificates on display that indicate the type and recency of the staff's training. Above all, does the person who will work with you give you a feeling of confidence and competence. Use that sixth sense--intuition.

3. Is the supplier a member of AAH (the American Association for Homecare) and/or its local affiliate; in California that is either the California Association of Medical Product Suppliers or the California Association for Health Services at Home? This is a sign of the company's commitment to the field. However, membership in these organizations does not indicate that a standard of competence or excellence has been met. Keep in mind the stated purpose of AAHomecare is "to support the passage of essential legislative and regulatory policy, that creates a fair economic environment for providers."

4. Does the supplier have equipment in stock--an inventory--and will he allow you to try out different chairs, even bring them to your home to determine which one best meets your needs? Take your time--selecting the right wheelchair is every bit as important as selecting an automobile and every car dealer I know will allow you to take a test drive.

5. Is the supplier able to service and repair wheelchairs on the premises and are "loaner" chairs available if yours is out of service? Since you must depend on your wheelchair to accomplish day-to-day activities, you cannot be without your chair if and when it breaks down. Therefore, the ability to repair a wheelchair locally is essential as is the availability of a "loaner" in case of an emergency. Also, an in-house service department is another indication of the stability and commitment of the supplier to the community.

6. Does the supplier represent more than one manufacturer? In making a selection, you are looking for choices. This includes not only the variety of designs and options offered by one manufacturer, but also variations made available by competing manufacturers. A supplier who represents only one manufacturer usually does not have the variety of chairs you should have to choose from.

7. Does the supplier listen to what it is that you, the consumer, want/need in a wheelchair? Yes, you have a prescription for a wheelchair, but you must decide which wheelchair best meets your needs. The supplier should be your guide in making this choice. A major part of such guidance is answering questions and listening to your concerns. The decision you make will affect the quality of your life for years to come. The emphasis is on listening!

8. In what ways will the supplier stand behind the products he sells? What about warrantees? Watch out for verbal promises and only rely on what is written. In saying this, make sure you read the small print and do not sign anything you do not understand!

Interestingly, in visiting three suppliers to check the accuracy of information in this article, I found, to my surprise, that none of them provided more than a bill of sale and an "Owner's Operator and Maintenance Manual." The manual included both a "Safety Summary" and a "Limited Warrantee." Both should be read carefully before accepting (signing for) delivery of your wheelchair.

There are three statements I have found in contracts that make me uncomfortable. They are:

Do not sign a contract containing this statement unless you have been thoroughly trained in the care and use of the wheelchair in question.

Do not sign a contact containing this statement as any accessory you add to your wheelchair that is not in the manufacturer's catalog may cancel your limited warrantee.

Do not sign a contract containing this statement as it absolves the local supplier from any responsibility for the wheelchair he is selling you.

Finally, if you are offered a deal that sounds too good to be true, it probably is!

(This article is an updated version of one first printed in Meeting the Challenge Quarterly, (Volume 8, Number 3), Winter 1999, published by the Partnership to Preserve Independent Living for Seniors and Persons with Disabilities, Riverside County, CA)

Send address changes and membership requests to the Amputee Coalition of America (ACA), 900 East Hill Avenue, Suite 205, Knoxville, TN 37915-2566. ACA membership is $25 per year for individuals and $75 per year for Support Group Membership. The opinions and editorial viewpoints expressed in the Communicator are those of the authors and do not necessarily reflect those of the Amputee Coalition of America. This publication is partially supported by Grant No. US59/CCU41-4287-03 from the Centers for Disease Control & Prevention (CDC). Its contents do not necessarily represent the official views of the CDC. ©2000 by ACA; all rights reserved. Articles may be reprinted with proper acknowledgements unless otherwise specified by author.

NEWSLETTER FOR AMPUTEE SUPPORT GROUP LEADERS