Changing Best Practice - Centralize O&M Innovation?
By Dona Sauerburger, COMS
In a profession such as Orientation and Mobility (O&M), which deals with life-and-death situations, strategies for critical tasks such as avoiding injury and crossing streets should include only those strategies that are reliable and effective. To prepare consumers to travel safely in the world as we find it today, our profession should:
- study problems: Whenever consumers or O&M practitioners encounter problems with traditional O&M strategies, those problems should be studied thoroughly.
- evaluate strategies before implementing: The solutions and strategies that are developed to address those problems should be carefully evaluated before they are used.
- widely adopt strategies / solutions: As soon as it is feasible, those solutions / strategies that are proven to be effective should be widely adopted by O&M practitioners and the university programs that train them.
How well is our profession meeting its responsibility?
Study problems: In 1988, when Dick and Lorraine Evensen were killed crossing a street with no traffic control, we became aware of a problem with our traditional strategy of "cross when quiet." However, more than 17 years passed after their deaths before this problem was studied seriously (Wall Emerson and Sauerburger, 2008).
Even today, more than 22 years after the tragedy alerted us to the problem, some graduates of O&M university programs still report that they were not taught how to prepare their students to assess and cross streets with no traffic control.
Evaluate strategies before implementing: More than 40 years ago, a strategy which involved crossing with a vehicle from the stop sign beside you was developed for crossing streets that have no traffic control. Some university programs and practitioners are still teaching it today. However, the reliability and effectiveness of this strategy were never evaluated before adopting it. Ann McLaughlin, P.E. and I are researching it now, and are dismayed to find that aspects of it are very unreliable (see poster), and other aspects have never been studied to verify their reliability.
Widely adopt strategies / solutions: In 1964, it was thought that remaining vision would be harmed by using it, and O&M training for children with functional vision was done with blindfolds (Audrey Smith, personal correspondence, March 2010). Natalie Barraga's research showed that vision utilization can be increased by a carefully designed program (Barraga, 1964). Although this changed our paradigm, it was not until 1972 that a course in the use of low vision was required by one of the university O&M programs, and 4 years later Apple and Blasch (1976) called on O&M specialists to develop a more systematic body of knowledge to serve people with low vision (Geruschat and Smith, 1997).
So it seems that some O&M problems, even those that have caused fatalities, are not studied until many years after the problem was noticed. Our profession develops strategies that people's lives depend on, and uses them for decades without seriously questioning their effectiveness and reliability. And sometimes when research reveals that a change in paradigm is indicated, our O&M profession takes many years to adopt it.
What can we do to facilitate a faster change of best practice when safety requires it? How can we avoid adopting and teaching strategies that are not proven to be effective even though our consumers' lives depend on them? How can we be assured that problems that are raised by consumers and practitioners are addressed quickly?
The way that people adopt new ideas and change the way they do things has been studied for many years in every kind of organization or society - from illiterate villagers in remote jungles to American doctors to farmers in Iowa (Rogers, 2003). Surprisingly, all the societies and organizations that were studied followed similar patterns when developing and evaluating innovations to solve problems, and making decisions to adopt them.
Research showed that in every society, it is especially difficult to get people to adopt innovations whose benefits are preventative, uncertain, or invisible. This would include innovations that address safety in O&M. For example, the benefits of teaching students to recognize situations of uncertainty at uncontrolled crossings are preventative (avoiding more tragedies like that of the Evensens), uncertain (we can't be sure that teaching these skills will prevent other deaths), and invisible (we don't usually notice that our students are still alive because we taught them well). Innovations such as these require extraordinary efforts to get them accepted into the society or profession.
And people resist adopting innovations which are contrary to their experience or beliefs, such as our former beliefs about vision and our experience with street-crossing strategies. People also have difficulty accepting innovations which are complex - even if they decide to adopt a complex innovation, they are likely to ultimately reject it if they don't understand it completely. These principles may explain why there are still O&M specialists who do not teach their students to assess situations at streets with no traffic control -- the concepts involved are very complex and contrary to O&M traditions, and in order to be adopted, complex innovations require sufficient education for O&M specialists to understand them.
Given that important changes needed in O&M are inherently difficult to get adopted by the profession, how can we facilitate more efficient changes in best practice when warranted? One way might be to centralize our profession's system for evaluating and adopting new ideas.
According to Rogers (2003), in each society or profession or village, the system for adopting new ideas and innovations (called "diffusion systems") tends to be centralized or decentralized. In systems that tend to be centralized, decisions about what innovations to adopt tend to be made by a central entity. In decentralized systems, it is individuals who evaluate innovations and decide whether to adopt them.
One of the most successful centralized diffusion systems is the U.S. agricultural extension program, which is supported with government funding to increase food production. Although individual farmers ultimately make the decision about what agricultural practice to follow, research is interpreted and innovations are evaluated by state extension specialists who decide which are good enough to introduce to farmers and encourage them to adopt.
Our O&M profession's diffusion system tends to be decentralized. Individual instructors or their employers evaluate new ideas and decide whether to adopt changes in best practice. The advantages of decentralized systems are that innovations fit more closely to users' needs, and users feel in control and participate in decisions.
But the disadvantages of our profession's decentralized system of diffusion are profound, and explain why it takes so long for us to change best practice. The disadvantages are that with decentralized diffusion systems:
- it is very difficult to evaluate innovations with technical expertise;
- there is a lack of quality control;
- users who develop innovations are not expert in how to share new ideas and convince others to adopt them; and
- there is an overload on the innovator / agency when others want to learn about it.
This is what happened when O&M was developed at the Hines VA hospital - those agencies that wanted to provide O&M to their consumers had no choice but to send instructors to Hines for training, some of whom stayed only for a few days. This not only overloaded the staff at Hines, it backfired when some instructors didn't learn enough to be competent and their agencies concluded that O&M was not effective. A result of this failed attempt to spread O&M to agencies outside of the VA was the decision to establish university programs to train O&M specialists.
Centralize our O&M profession's infusion system?
When looking at the disadvantages of decentralized diffusion systems such as our O&M profession, it is easy to understand why it can take several decades to adopt badly-needed changes in best practice. And with decentralized diffusion systems being associated with a lack of quality control and difficulty having technical expertise to evaluate innovations, it is easy to understand why an unproven and unreliable strategy for crossing streets could continue to be taught for 40 years.
Our profession needs - and the people we serve deserve - a more centralized system to help identify O&M problems, encourage the development and evaluation of innovations to address those problems, and disperse the ideas and innovations that are worthy and proven to be reliable. Who or what should be given this responsibility? Should it be the universities that prepare O&M specialists? The organization that certifies us (ACVREP)? Our professional organization (AER)?
Apple, L.E. & Blasch, B.B. (1976). Workshop on Low Vision. Bulletin of Prosthetics Research, 10-26, 46-138. Department of Medicine and Surgery. Washington, DC: VA
Barraga, Natalie (1964). Increased Visual Behavior in Low Vision Children. New York: American Foundation for the Blind.
Geruschat, D. & Smith, A.J. (1997). Low Vision and Mobility, in B.B. Blasch, W.R. Wiener, and R.L. Welsh (Eds.), Foundations of Orientation and Mobility, Second Edition
(pp. 60-103). New York: AFB Press.
Rogers, Everett M. (2003). Diffusion of Innovations. Glencoe: Free Press
Wall Emerson, Robert & Sauerburger, Dona (2008). "Detecting approaching vehicles at streets with no traffic control." Journal of Visual Impairment and Blindness, AFB Press, Volume 102, Number 12, pp. 747-760
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