Professional discretion and length of work experience: what findings from focus groups with care managers in elder care suggest

ABSTRACT

Research has explored how care managers in elder care – who often function as ‘street-level bureaucrats’ – regard professional discretion. The way in which length of work experience affects care managers’ use of professional discretion remains, however, unexplored. This article present findings from 12 focus groups with 60 care managers. By bringing attention to how care managers experience the needs assessment process, this article sheds light on how these ‘street-level bureaucrats’ struggle when they try to balance their clients’ needs against institutional frameworks and local guidelines. Length of work experience seems to play a role in how care managers claim to use professional discretion. Experienced care managers describe how they deviate from the guidelines at times in order to create an increased scope of action in their decision-making process. Those with less time in the profession describe greater difficulties in this respect. Findings suggest that research should explore if length of work experience plays a role in the actual way in which care managers assess needs and make decisions. As such, they contribute to our understanding of how needs assessment processes are navigated by professionals while also pointing towards the nature of professional discretion in gerontological social work.     

The politics of joking: narratives of humour and joking among adults with Asperger’s syndrome

The purpose of this article is to analyse how humour and narratives about humour are used in a natural group of adults with Asperger’s syndrome. Narratives about humour and use of humour in the group are analysed from a discursive psychological perspective, informed by insights from both disability studies and critical autism studies. The setting of the research is ethnographic fieldwork in an educational setting in Sweden. In the paper, I show the use of three storylines among a natural group of people with autism (PWA) when talking about humour: the storyline of humourless PWA that dominates within Swedish society; and two alternatives, a storyline of alternative humour among PWA and another storyline in line with the social model of disability, of neurotypical humour or disabling humour. When invoking these two alternative storylines, PWA challenge both the humourlessness storyline and the lack of social accessibility within mainstream neurotypical settings.     

Interprofessional collaboration in Swedish health and social care from a care manager's perspective

The aim of this study was to study interprofessional collaboration in health and social care for older people and persons with disabilities from a care manager's perspective. The empirical data was collected at a workshop held during a national conference for care managers and through focus group interviews in two Swedish municipalities. The results showed that the care managers collaborated in different ways with many different professionals from different organisations. The care and discharge planning meetings emerged as the most typical situation where care managers collaborated with different health care professionals. Interprofessional collaboration was seen as a means for care managers to fulfil their assignment and carry out their work. The care manager role encompassed role strain, a relatively weak professional identity, and differences in professional status among those involved in interprofessional collaboration.     

Health care,social care or both? A qualitative explorative study of different focuses in long-term care of older people in France,Portugal and Sweden

Challenges with an ageing population are increasingly becoming a reality in the Western world. Since cognitive impairment increases with age, we can expect an increasing number of older people in need of care. The aim of this article is to describe, analyse and compare different focuses on care of older people with dementia, using examples from France, Portugal and Sweden. The questions are principally focused on the participants’ view about their tasks, the organisation of work, the professional role and cooperation with other professions. Everyday care was studied through observations and participant observations and the staff's opinion was explored by means of interviews. Twenty-two care settings for older people were included. The findings showed that France provided mainly ‘health care’, Sweden ‘social care’ and Portugal an integrated ‘health care and social care’. In a comparative perspective the Portuguese general care of older people, which focuses on integration of health care, social care and social work, also seems to provide care for older people suffering from dementia which best corresponds to the previously developed group living model.     

Belonging to the library: humanising the space for social work education

Abstract

This article describes the running of four Living Libraries on a UK postgraduate social work course. A Living Library is a metaphoric remodelling of a conventional library where people, as authors of their experiences, provide specialist knowledge based on authorial areas of expertise. In the Living Libraries discussed here, ‘Living Books’ carried stories of social work—their narratives were of lived experiences as people using social care services; as carers in personal relationships with others who use social care services; or, as social work practitioners. The focus of this article is on those Living Libraries involving the participation of the first two of these groups. Drawing on social psychology, phenomenology and human geography, we propose that a Living Library can act as a connective space within social work education by engendering a discursive forum where all participants—people with experiences of services, students, practitioners and social work educators—are given both the freedom and obligation to talk openly about their differential experiences, fears and hopes for social work. Through this process, opportunities are created to consider how improvements that meet all stakeholders’ interests may be achieved.     

Governance,Accountability, and Organizational Development: Eldercare Unit Managers’ and Local Politicians’ Experiences of and Responses to State Supervision of Swedish Eldercare

This article explores how local politicians and care unit managers in Swedish eldercare experience and respond to state supervision (SSV). Twelve politicians and twelve managers in 15 previously inspected municipalities were interviewed about their experiences of and reactions to SSV in relation to their views of care quality and routines in eldercare practice. The findings indicate that local managers and political chairs perceived SSV in eldercare positively at a superficial level but were critical of and disappointed with specific aspects of it. In terms of (a) governance, chairs and managers said SSV strengthened implementation of national policies via local actors, but they were critical of SSV’s narrow focus on control and flaws in eldercare practice. With regard to (b) accountability, SSV was seen as limited to accountability for finances and systemic performance, and regarding (c) organizational development, SSV was seen as limited to improving routines and compliance with legislation, while local definitions of quality are broader than that. In general, local actors regarded SSV as improving administrative aspects and routines in practice but ignoring the relational content of eldercare quality.     

Assessment for home care: Negotiating solutions for individual needs

This article explores care management as an activity that regulates the distribution of society's resources for home care. It focuses on interaction in assessment meetings, which are part of the planning of services and care for old people in Sweden. The aim was to acquire an understanding of how old people, as applicants, account for their needs for care, and how these accounts are negotiated and positioned in talk. Twenty home care assessments were audio-taped and the data were analyzed using discursive analysis. It was found that the assessment meetings had an institutional structure within, which old people, as applicants and with individual needs for care, were assessed within fixed institutional categories. Furthermore, analysis showed how interaction during assessment meetings functioned as formal problem-solving, in which applicants' accounts of their health issues were negotiated, contributing to the construction of their identity as home care receivers.     

The care manager’s dilemma: balancing human rights with risk management under the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003

In New Zealand, the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003 provides diversion for persons with an intellectual disability who have been charged with, or convicted of, a criminal offence. This unique Act moves the responsibility for such ‘care recipients’ from the criminal justice system to a disability sector that values a social model of disability and philosophies of autonomy, choice and normalisation. This research identified dilemmas faced by care managers legally responsible for care recipients. Care managers experienced: tension between imperatives of risk management, rehabilitation and human rights; role ambiguity between ‘custodian’ or ‘therapist’; philosophical incongruity within their services; and ethical dilemmas over decisions to lengthen care orders. The changing care recipient population has intensified these dilemmas: services must now adapt to the needs of young, street-wise people with alcohol and drug problems and histories of criminal behaviour. The article makes recommendations about how these dilemmas can be addressed.     

The knowledge,skills and qualities needed for social work in a major paediatric teaching hospital

Abstract

The place of aged care in social work has long been ambiguous, if not marginal. Social work (as do other comparable professions) often displays a reluctance to place practice in this field within the core of the profession that embodies aspects of ageism in contemporary society. Working with older people is frequently characterised as ‘mundane’, ‘routine’ and even ‘not “real” social work’. This paper examines the practice implications of the current policy context. Forms of ‘indirect’ practice are identified as central to social work in aged care, and the implications of this for the standing of aged care social work in the wider profession are discussed. It is argued that ‘indirect’ practices are core to the development of the profession and so should be seen as ‘real’ social work. In conclusion, it is suggested that unless social work affirms practice with older people and their families we will fail to be congruent with our own values.     

The utility of positioning theory to the study of ageing: Examples from research with childless older people

Growing older is hard to make sense of. Opposing perspectives are presented on everything from individual to population ageing, and there is widespread ambivalence towards many aspects of ageing. Positioning theory is a research approach that can tolerate such ambiguity and provides a clear, useful framework to make sense of research data, while doing justice to its complexity. It is starting to be used in gerontology; the aim of this paper is to give gerontologists the tools and impetus to use it more. The positioning triad is outlined, comprising positions (how we position ourselves and others within a single conversation or across a lifetime), storylines (the individual and social narratives which furnish those positions), and the speech acts (and acts of research) through which storylines and positions are enacted. In addition, considering the rights and duties associated with different positions and storylines can usefully illuminate some of the tensions around competing positions on ageing. Worked examples from a qualitative study on childless older people (38 participants aged 63 to 93) in terms of their positioning of childlessness, views on residential care, and positioning of emotional support show how the complexity of such diverse topics can be usefully studied using a positioning theory framework.     

The desire for control: Negotiating the arrangement of help for older people in Sweden

The interface between formal (public) and informal help for older people is unclear and subject to change in many welfare states. Our aim in this study was to contribute to increased understanding of the experiences of older people, their next of kin, and the care managers from the municipalities in the process of negotiating help in the everyday lives of older people who can no longer manage on their own. We took a qualitative approach, using qualitative interviews as the main data collection method. The results revealed that the different actors had contrary interests that made it difficult for all parties to be content with the outcome of the negotiations. The everyday lives of dependent older people and their next of kin are strongly affected by the conditions of formal eldercare.     

Informal caregiving for elders in Sweden: an analysis of current policy developments

In Sweden, care of elderly people is a public responsibility. There are comprehensive public policies and programs providing health care, social services, pensions, and other forms of social insurance. Even so, families are still the major providers of care for older people. In the 1990s, the family was "rediscovered" regarding eldercare in Sweden. New policies and legislative changes were promoted to support family caregivers. The development of services and support for caregivers at the municipal level has been stimulated through the use of national grants. As a result, family caregivers have received more recognition and are now more visible. However, the "Swedish model" of publicly financed services and universal care has difficulty addressing caregivers. Reductions in institutional care and cutbacks in public services have had negative repercussions for caregivers and may explain why research shows that family caregiving is expanding. At the same time, a growing "caregivers movement" is lobbying local and national governments to provide more easily accessible, flexible, and tailored support. In 2009, the Swedish Parliament passed a new law that states: "Municipalities are obliged to offer support to persons caring for people with chronic illnesses, elderly people, or people with functional disabilities." The question is whether the new legislation represents a paradigm shift from a welfare system focused on the individual to a more family-oriented system. If so, what are the driving forces, motives, and consequences of this development for the different stakeholders? This will be the starting point for a policy analysis of current developments in family caregiving of elderly people in Sweden.     

Substance Use Training Experiences and Needs: Findings From a National Survey of Social Care Professionals in England

For more than 30 years there have been calls in the UK to improve training for social workers in relation to substance use. Yet very little research has explored what training practitioners have received or what their training needs are. This study sought to establish practitioners' experiences of previous training in substance use and identify their current training needs. An online survey was disseminated to 3,164 practitioners in adults' (AS) and children's (CS) social care and 12 vignette-based focus groups were also held. Of the final sample of 597, more than a third of social workers had not received any training and a further fifth only received between one and four hours. Other social care staff fared worse. Overwhelmingly, respondents said that substance use knowledge and skills were very important to their practice but their professional education had not prepared them well. They identified a number of training needs including ‘how to talk to people about substance use’ and ‘the types of intervention and treatment available’. Most social care professionals report not being adequately prepared for working with substance use, particularly basic knowledge and skills which would help them to conduct assessments and signpost people to specialist substance services.     

Young people's views of children's rights and advocacy services: a case for ‘caring’ advocacy?

This paper looks at some preliminary findings from research with young people in foster and residential care in the UK who have received advocacy services from a range of local authority and voluntary agencies. The study also includes the views of professionals, from both children's rights and social services. The initial findings highlight the importance to young people of their relationship with rights professionals. They speak about the value to them of care and respect, aspects not always seen as fundamental to rights work. Caring, in its various guises is seen by young people as a vital component of their relationship with children's rights workers. They also see this as important within advocacy work itself since caring about the outcome is often key. A pure individual rights focus with an emphasis on challenge and ‘being heard’ may not take account of the complexity of their situation and may pose difficult dilemmas for young people, especially in dealings with their carers. This ‘caring’ advocacy is not the paternalistic approach of a professional who ‘knows what's best for you’ but is a model based on a strong awareness of ways that young people are excluded and oppressed. It is also about placing a positive value on their contribution as citizens and links to a view of society that gives importance to an ethic of inter‐relationship and care as well as an ethic of individual rights. Copyright © 2007 John Wiley & Sons, Ltd.     

Emergency department social work in the UK and Sweden: evaluation by older frequent emergency department attenders Kuratorsarbete på akutmottagning i förenade kungadömet Storbritannien och Sverige: en utvärdering utifrån brukarperspektivet hos äldre mångbesökare på akutmottagningen

Social work based in hospital emergency departments (EDs) in Sweden and the UK reflects a wider European social/health care policy trend. A key focus is on diverting older frequent ED attenders from ‘inappropriate’ hospital re-attendance or emergency admission, because of social care problems. However, previously there has been no evaluation of the significance of ED social work for health and well-being, from the standpoint of older frequent ED attenders themselves. In a preliminary way, our paper provides this through drawing on a small scale Swedish/UK study. Its comparative account of service user feedback underscores the importance of ED social work as a facet of European social work. It indicates that ED social work contributes to the quality of care within emergency departments, acts as a key access point to social services, and can promote both short and longer-term health. At the same time, some serious shortcomings emerge. These include under-developed referral systems, and limitations to community based services following ED social work assessment, which reflect the under-resourcing of social care provision in both countries. Moreover, service users’ experience in both Sweden and the UK reveals the risk of ED social work with older frequent ED attenders being used as a substitute for follow-up medical/nursing care when that is also required.     

The ‘ordinary’ family as a resource for single parents—on the Swedish contact family service

This article reports on some important results from a qualitative study, which mainly focused on the topics of family notions and notions of ‘good parenthood’, and their impact on the Swedish ‘contact family service’. The service is provided to help mostly single mothers—with scarce social networks that lack the ability to provide support—to get relief from constant care-giving for one or two weekends a month. The three parties—client families, contact families and the social workers that handled the cases—have been interviewed (a total of 54 interviews) about their experience of their own parenthood and family life as well as their notions in general, for example of a ‘normal’ and an ‘ideal’ family. The interaction and influence of these notions on shaping the contact family service were studied. The article comes to the conclusion that the design of the contact family service needs further consideration on the family ideals that are reproduced in the service. With the nuclear family as the norm, the burden of a lone parenthood will increase.     

Working with Older People with Alcohol Problems: Insight from Specialist Substance Misuse Professionals and their Service Users

Significant numbers of older people worldwide have a drinking level or pattern which places them at risk of harm. In England, older people are more likely to be admitted to hospital for an alcohol-related condition than younger people and levels of alcohol-related harm are increasing fastest in this population. Whilst alcohol problems in older people are highly treatable, they frequently go undetected or ignored. The aim of this study was to develop guidelines for health and social care workers on what intervention strategies are likely to work best with older drinkers. Insight from alcohol practitioners who specialise in working with older people and the perspectives of older people receiving alcohol treatment were gained through focus groups and individual interviews. This paper reports some of the key findings including a perception that health and social care workers often did not intervene when alcohol misuse was suspected because of ageist attitudes and false beliefs about older people's drinking. Participants however acknowledged that social workers faced difficult choices in relation to the ‘right’ of older people with alcohol problems to continue to drink and the ‘risk’ associated with them doing so. The implications for social work education and training are discussed.     

‘Stuck In The Middle With You’: Towards Enabling Social Work with Disabled People

This article explores progress to date in embedding enabling social work understandings and practices with disabled people by reviewing the UK social work curriculum. Based on these observations and the ideas from UK disability studies, it will offer possible solutions or at least better pathways to enabling practice with disabled people. As Meekosha has pointed out in a global context, to date social work has been experienced as an ambivalent practice [Meekosha, H. & Dowse, L. (2007) ‘Integrating critical disability studies into social work education and practice: an Australian perspective’, Practice, vol. 19, no. 3, pp. 59–72], often both enabling and disabling; an intervention that can both lock and unlock resources, and challenge and reaffirm traditional notions of the ‘disability problem’ [Finkelstein, V. (1993) ‘Disability: A Social Challenge or an Administrative Responsibility?’, in Disabiling Barriers ‐ Enabling Environments, eds J. Swain, V. Finkelstein, S. French and M. Oliver, Sage Publications in association with the Open University, London]. Social work also has the potential to both challenge, but also be an (inadvertent) apologist for contemporary social support and welfare systems. Indeed it is clear that social work as a profession and social care as a policy area have been the poor relations of healthcare and health professions [King's Fund (2011) Social Care Funding and the NHS: An Impending Crisis?, King's Fund, London]. Viewed anthropologically, social work remains a largely non-disabled workforce ‘ministering’ to disabled clients (BCODP, 1997). This might reinforce the perception of ‘us and them’ in some social work encounters. As Paul Longmore questioned, can we begin to go ‘beyond affliction’ (2003) in our work with disabled people? Can social work help support the collective struggles of disabled people or is their role inevitably to reinforce that of individual(ised) clients?

The development of the personalisation agenda and self-directed support is clearly welcome in this context [DoH (2006) Our Health, Our Care, Our Say: A New Direction for Community Services, Department of Health, London; DoH (2007) Independence, Choice and Risk: A Guide to Best Practice in Supported Decision-Making, Department of Health, London; DoH (2009) Personalisation of Social Care Services, Department of Health, London]. Such developments reflect the changing service user–professional relationship. The temptation to see these developments as the icing on the social support cake needs, however, to be resisted. Arguably, with the increased rationing of social support, the continued role of social workers in assessment and monitoring of support could be seen to require a yet more reflexive and enabling professional education and training in an age of austerity, one where previously supported disabled people are being told that their needs can no longer be met.