Managing Risk in Community Care of Older People: Perspectives from the Frontline

Abstract

Since the mid-1980s, Australian governments have focused on expanding community and home-based services for older people. This has led to increased levels of dependency, vulnerability, and complexity to be managed in the community. Consequently, aged care services have had to develop mechanisms for regulating and managing these increased risks, and risk management has become more central to the practices of professional workers in this field. This paper reports on some findings from a large-scale study that explores the way risk management policies have been translated into practice by community-based services in Victoria, Australia. Drawing on interviews with 18 frontline and management professionals employed in community aged care, we found that these workers were wrestling with a diverse and new range of institutional risks beyond those encountered in the actual delivery of frontline care. We found that these workers experienced “risk” in four different contexts, which often created demands for contradictory or conflicting responses. Here we examine these “contexts of risk practice”: professional workers' relationships with their clients, relationships with other service providers, the unregulated nature of the home as a work environment, and community expectations about the management of risk. Despite tensions that frequently arose, workers expressed strong professional commitments to their clients and were motivated to find positive resolutions amid competing interests. We conclude that tensions experienced by workers were embedded in the structural dimensions of institutional relationships and the systematic absence of shared understandings of “acceptable” risks in the community care of older people, rather than in the failure of professional agency.     

Joint Assessment in Inter‐professional Education: A Consideration of Some of the Difficulties

This paper examines one effort to jointly assess nurses and social workers where professional as well as academic qualifications were at stake. It chronicles an attempt in a Scottish university to integrate assessment of a multi‐disciplinary academic course with assessment within the existing post qualifying framework for social work. In setting up a new course the assessment strategy was designed to meet both the course learning outcomes and the requirements of the Post Qualifying Award for social work. In looking at the tensions between different academic disciplines it is, perhaps, not surprising that this attempt at assessment across professional boundaries ran into difficulties. The context of the assessment issue and the different mechanisms used in repeated attempts to resolve the problems are examined. The tentative conclusion is that, while the inter‐professional education process is highly valued by students, there are tensions between the academic and practice assessment requirements, between different academic traditions and between understandings of reflection and how it is assessed. Mutual trust and understanding are essential to the development of inter‐professional education, including an accreditation system which is flexible enough to meet a range of needs.     

Change and Tensions in Non-profit Organizations: Beyond the Isomorphism Trajectory

Research on the relationship between non-profit organizations (NPOs) and the public sector has been dominated by predictions of isomorphism where change and tensions in NPOs are attributed an imposing institutional setting. This article argues that research represents a selective perspective on organizational life due to its portrayal of organizational change as synonymous with an isomorphic, linear trajectory. The purpose of this article is to illustrate different sources and characteristics of change and tension. The article presents an analytical framework comprising of four components: evolving change, episodic change, inherent dilemmas, and conflicting logics, facilitating an understanding of the organization as movement. The analysis of a case study organization suggests that by identifying different dimensions of changes and tensions we can gain a richer understanding of the complexity of processes underpinning the organization as movement. The analysis reveals how multiple, parallel processes related to change and tensions generate reflections that drive integrity and identity formation at individual and organizational levels.     

Mutual Benefits: Developing Relational Service Approaches Within Centrelink

Abstract

The machinery of income support can have considerable influence in people's lives, creating opportunities for social work but also tensions: access to vulnerable people, but not always on their terms. This paper argues that the challenge to social work is about more than holding on to professional discretion. It considers how social workers can influence service delivery approaches to work more relationally, pursuing a more equal involvement of clients, and recognising the complex interactive context of social and community life. The authors trace the development of such an approach within the Australian Government human services delivery agency Centrelink in Logan, Queensland, and briefly consider a parallel innovation in Newcastle, New South Wales. The authors suggest that grounding a large institutional social service agency in the realities of client and community experiences has mutual benefits, creating a more humanising, cooperative space, and displacing inefficient and sometimes tragic cycles of misunderstanding, confrontation, and disconnection.     

The political economy of financial inclusion: tailoring donor policy to fit

Financial inclusion has recently become a globally acclaimed policy objective. This provokes the need to review policy in this sector, particularly in light of the tensions that arise between donor approaches founded on market modernism and governments with more activist leanings. This is done here in the context of efforts to move donor development policy beyond ‘best practice’ institutional blue‐prints to those which are ‘good enough’, which seek to understand underlying political economy dynamics in order to find space to engage with governments. In doing so, it is argued that there is scope for ‘working with the grain’ and harnessing the political economy of government policy in order to produce financial inclusion outcomes.     

Singapore's economic internationalization and its effects on work and family

There are tensions between Singapore's economic strategy of internationalization and the emphasis on family life. Frequent travelers, unaccompanied expatriates, and their families experience these tensions. The frequent or extended absences of frequent travelers and expatriates make it difficult for them to fulfill their family roles and obligations, and may lead to estrangement from their families. Families who are left behind may face role conflict and role strain, but actually draw closer in their efforts to cope with the absence of their absent members. Researchers, policy-makers, and employers can contribute towards reducing the tensions between internationalization and family togetherness.     

Contextualizing critical junctures: what post-Soviet Russia tells us about ideas and institutions

The present article asks what lessons the empirical case of institutional change in post-Soviet Russia yields for the recent research on ideas and institutions. Its main point is that in post-Soviet Russia a clash between imported foreground ideas and deep domestic background ideas led to an ideational division among the elite of the country that became a main obstacle to the provision of coherent economic reforms. This story stands in some contrast to much of the newer literature on ideas and institutions, which tends to see critical junctures as leading from one equilibrium to another. I argue that tensions between imported foreground ideas and deep domestic backgrounds are likely to occur in other cases of far-reaching processes of institutional change based on Western ideas but taking place beyond the realm of Western, industrialized countries. Therefore, I argue, some general lessons on the interplay between ideas and institutions might be drawn from this case study.     

Disorganization,disidentification and ideological fragmentation: Verbal and pictorial evidence from a British business school

Rather than focusing on organizing dimensions of society, one may conceptualize disorganization processes, where ideological values incongruence leads to disidentification and ideological fragmentation. Integrating discourse analysis and critical social psychology, I focus on professional organizations facing ideological, managerialist change to develop a typology of multiple‐identity organizations (MIOs) incorporating various degrees of disorganization, rather than the traditional ideographic–holographic dualism. I then apply a creative, visual method to explore how wider ideological tensions between managerial (utilitarian) and professional (normative) values shape lived experiences in a major British business school. Longitudinal verbal and pictorial discursive analysis shows a cacophony of images competing to construct and deconstruct organizational identity over a decade and a half. The organization tends towards disorganization, but somehow retains a sufficient sense of (multiple) identity to survive, suggesting it is myopic to ignore processes and structures that mark and contribute to the ideological fragmentation of MIOs.     

Effort on Display: Unemployment and the Interactional Management of Moral Accountability

In this study of moral accountability in vocational guidance conversations at a public employment office in Sweden, I adopt a combination of approaches to explore implicit accounts as intrinsic to institutional activities. In this setting, participants managed moral accountability by normalizing a person's conduct, preempting potential critique, and marking transgression. Clients were never held accountable for lack of competence, knowledge, or skill or for failing to get a job. A critical element in sustaining oneself as a morally accountable client in this setting is to successfully display one's efforts properly in situ as well as through the institutional record.     

Child neglect and the law: catapults,thresholds and Delay

This paper discusses the dilemmas and challenges that arise when child neglect cases reach such a level of severity that court proceedings become necessary. It identifies the complexities of determining the appropriate social work and legal responses to child neglect, and of squaring these with wider organisational priorities and social policy imperatives. The paper draws on data from a series of interviews with local authority social work and legal staff. It highlights the ‘threshold criteria’ for the court's intervention, barriers to crossing them in neglect cases and the frequent need for a decisive event (a ‘catapult’) to do so. It shows the conflicts and tensions of reconciling social work and legal approaches, but also the overlaps and inter‐dependency between them. Despite the difficulties, the way forward lies in the interaction of different professional perspectives and skills, in ways that are both critical and supportive. Copyright © 2007 John Wiley & Sons, Ltd.     

The Islamic Soccer League in Israel: Setting Moral Boundaries by Taming the Wild

This article strives to use the institutional and discursive strategies employed by the Islamic Movement in Israel in the soccer sphere to illustrate wider theoretical arguments about setting boundaries of inclusion and exclusion in the public sphere. The Islamic Movement uses an isolationist strategy, by creating the independent Islamic Soccer League. In contrast, social agents who strive to promote integration in Israeli society or, alternatively, Arab-Palestinian national pride encourage the involvement of Arab teams and players in the Israeli Football Association. The article argues that the isolationist strategy is inherent in the attempts of a religious movement to articulate a definition of collective identity that is based on a sacred moral code. Then, relying mainly on the contents of the sports sections of the Islamic press, the article analyzes the inevitable tensions stemming from the use of an institution with a strong secular orientation for the purpose of reproducing religious identity.     

Multistakeholder initiatives in global production networks: naturalizing specific understandings of sustainability through the Better Cotton Initiative

In recent years, various academics, consultants, companies and NGOs have advocated a move towards more cooperative approaches to private sustainability standards to address the widely identified shortcomings of the compliance paradigm. However, is it possible to address these limitations by moving towards stakeholder inclusion and capacity building while at the same time catering to the demands of lead firms supplying the mainstream market? In this article, we analyse how the Better Cotton Initiative (BCI) seeks to do just that, in the process identifying three key tensions and competing policy concerns with which standard‐setters have had to grapple – (a) stakeholder inclusion vs process‐control/efficiency; (b) stringency of the standard vs scale of production; and (c) capacity building vs auditing. Combining theoretical considerations about governance in global production networks (GPNs) with a convention theory perspective, we explore these inherent tensions and show that due to pre‐existing power relations in the cotton GPN, it is hard to develop more cooperative approaches because market and industrial values tend to win out despite efforts to follow current best practice on sustainability standard‐setting.     

Meeting the mental health needs of elderly clients

1. Older individuals in both community and institutional settings have traditionally underused mental health services. Providers of such care devote a minimum of their professional time to those over 65 years of age. 2. Ageism and difficulty with diagnosis are the most frequent explanations for inadequate mental health care to the elderly. This study found that lack of referrals and failure of the aged to seek services partially accounted for underuse. 3. Legislative changes mandating that aged persons be screened for and receive appropriate mental health services will increase the demand for qualified providers. 4. Nursing's approach to care of the older adult, which focuses on both physiological and psychological needs, can facilitate the delivery of comprehensive effective mental health interventions in and out of the institutional setting.     

To Cut and Control: Institutional Preservation and the Sterilization of Mentally Retarded People in the United States, 1892–1947

Abstract Between 1892 and 1947, American institutional superintendents argued three distinct, though overlapping, cases for sterilizing mentally retarded people: sterilization to maintain institutional order, sterilization for eugenic control, and sterilization for controlling the growth of institutional populations. Departing from recent critics who see sterilization as a debate between 'segregation or sterilization' and who link this debate principally to the eugenics movement, I argue that superintendents drew on the above rationales to preserve their institutions in the face of several external factors, not merely eugenics. As such, sterilization became a 'medical' procedure constructed not so much for its explicit purpose - stopping procreation, but to maintain institutional stability and preserve professional prerogative.     

Social work training in Central and Eastern Europe: Experiences in Bulgaria and Slovakia

The authors draw on their experiences as members of EU-funded projects for training social workers in post-communist countries to reflect on developments in social work education there and in the United Kingdom. They argued that the emergence of social work in Central and Eastern Europe has a double agenda—to improve professional skills and values in the public services, and to contribute to the strengthening of a democratic and participatory civil society. Hence it is concerned both with changing the organizational culture and practices of the official social services, and with promoting voluntary organizations, community associations and service-user groups. Training in partnership, negotiation, networking and empowerment is as relevant as the teaching and learning of professional competences. This double agenda leads to tensions, both within universities and in various parts of the organizational systems in which social workers are employed. But these issues are not fundamentally different from the ones still being struggled over in the UK context. Similar issues over the respective roles of official social control and the authoritative enforcement of responsibilities, and empowerment and participation among excluded and deprived communities, are central to British social work education also.     

Institutional legacies in TNCs and their management through training academies: the case of transnational law firms in Italy

In this article we highlight the effects of heterogeneous institutional contexts on transnational professional service firms, a relatively poorly studied issue. Specifically, we provide empirical analysis of how the specificities of the Italian institutional context affect the activities of English legal professional service firms in Milan. This reveals the intimate connection between a variety of capitalism, place specific workplace cultures and practices, and the institution‐related challenges transnational professional service firms and all transnational corporations (TNCs) face. We also reveal the way institutionally generated differences at the level of work practices are managed in transnational law firms through worldwide training programmes designed to ‘govern’ the practices of workers in different parts of the TNC's network. This emphasizes the importance of studying attempts to manage institutional heterogeneity at the level of workplace practices, something often missed in existing mesoscale studies of TNC governance structures. Consequently, we highlight detailed empirical archaeologies that explore the direct links between institutions and practices as an important component of future research on the effects of institutions on TNCs.     

Ethical Actions: A Comparison of Individual and Group Recommendations

In order to examine the way ethical decisions are made, we asked ethicists, regulatory officials, and experienced researchers to review a set of scenarios that depict important ethical tensions in research. The method employed was “protocol analysis,” a talk-aloud technique pioneered by cognitive scientists. Each individual was asked to make recommendations for courses of action. Later, we held a focus group of university faculty and staff with either institutional review board experience or research ethics training. They too were asked to recommend actions. The results show there are areas where the two data collection approaches agree, as well as areas of considerable difference. Implications for training in the responsible conduct of research are discussed.     

Agency and capabilities to achieve a work-life balance: a comparison of Sweden and Hungary

This study develops a conceptual framework with a capabilities and agency approach for analyzing work–life balance (WLB) applied in two societies (Hungary and Sweden), which have different working time regimes, levels of precarious employment, and gender equality discourses and norms. Inspired by Amartya Sen, we present a model illustrating how agency freedom for WLB depends on multiple resources at the individual, work organizational, institutional, and normative/societal levels. Using a unique qualitative survey conducted in two cities, Budapest and Stockholm, we analyze how mothers and fathers subjectively experience the tensions between family and work demands, and their possibilities for alternative choices (agency freedom). We find similarities in these tensions involving time pressure and time poverty, cutting across gender and education. Our Hungarian parents, nevertheless, experience greater agency inequalities for WLB, which reflect weaker institutional resources (conversion factors) as well as cultural/societal norms that act as constraints for WLB claims in the workplace and household. Our study reveals that Swedish parents, both men and women, express a strong sense of entitlement to exercise rights to care.     

Continuing professional development after qualification--partnerships,pitfalls and potential

Social work educators, employers and policy-makers have increasingly recognised the importance of continuing professional development. The UK social work qualification (DipSW) provides a broad base of practice skills, knowledge and values. However, increasingly complex work, frequent legislative and policy changes, research findings and challenges of working in a societal context of increasing change and diversity all contribute to the necessity of developing strategies for continuing professional development which adequately equip social workers. Such education cannot be alienated from social workers' employment context, and thus needs to remain mindful of employers' needs while concurrently maintaining academic rigour. This paper explores the development and delivery of a year-long post-qualifying training course run collaboratively between West Sussex Social and Caring Services and University College Chichester. It places some of the experiences of tutors, candidates and Training and Development Officers within the wider context of social work education, training and the delivery of social care. In exploring some of the contradictions and tensions experienced it seeks to further understand the challenge of delivering effective training in an increasingly complex and fragmented arena. Finally, it considers possible future developments, mindful of future changes in UK social work education.     

Dying in jail: The phenomenon of adolescent suicide in correctional facilities

Adolescent suicide is increasing in the United States and the incidence of suicide gestures and attempts in juvenile correctional facilities is high. The attitudes of correctional staff toward adolescents and toward suicidal behavior may contribute to the increase. Suicide is often the outcome of a progression of problems that have isolated the adolescent from meaningful social relationships. Correctional staff must be aware of the phenomenon of adolescent suicide and be given training to deal with it effectively within the institution. Institutional staff have commonly seen suicide gestures or attempts as acting out behavior rather than a symptom of low self-esteem or inability to cope with institutional placement. This discussion examines the phenomenon of adolescent suicide and the impact the juvenile justice system has on its occurrence. It will also include an examination of interdisciplinary interventive strategies which can be used in an institutional setting.