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.     

From ‘not a big deal’ to ‘hellish’: Experiences of older people with dementia

Research on subjective experiences of dementia has paid scant attention to social location, due to fairly homogeneous samples and an inattention to socio-cultural diversity in data analysis. This article addresses this gap by presenting findings from a grounded theory study of the relationships between the experiences of older people with dementia and the intersections of ‘race’, ethnicity, class, and gender. Data generation occurred through a series of interviews, participant observation sessions, and focus groups with eight older people with dementia whose social locations varied from multiply marginalized to multiply privileged plus over 50 members of their social worlds. Their experiences of dementia were found to be varied, ranging from ‘not a big deal’ to ‘a nuisance’ to ‘hellish’, and to be related to their social locations. Negative views of life with dementia were not nearly as universal as past literature suggests and social location was found to mediate experiences of dementia.     

‘Care is not a dirty word!’ Enacting an ethic of care in social work practice

While ‘care’ has been positioned as a core value of the social work profession since its inception, the increasing influence of neoliberal rationalities have placed care on the periphery of social work theory and practice. Social work scholars have promoted the incorporation of ethic of care theory into direct social work practice as a means of countering the effects of a context that is antithetical to caring practice. I present findings from my Australian study, providing an original contribution by presenting concrete understandings of how social workers enact care in everyday direct social work practice. The study was guided by a grounded theory approach. Fifteen social workers were interviewed using a semi-structured interview schedule. The interviews were analysed using constructivist grounded theory techniques. ‘Meeting needs’, ‘just being there for clients’, ‘building relationships with clients’, and ‘going the extra mile’ were some of the ways that participants demonstrated care in their practice. Constraints on care were challenged and resisted by ‘taking a stand’, ‘bending the rules’, ‘picking battles’, ‘justifying care’, and ‘taking risks’.     

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.     

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.     

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.     

‘Our young people are worse’: family backgrounds,educational progression and placement options in public care systems

Introducing continental European approaches to UK child welfare practice raises a problem of comparison: to what extent are the problems and issues similar to or different from one country compared to another. Social pedagogues trained in continental Europe and working in English residential care services often encountered the phrase ‘our young people are worse’ from their English colleagues, with the implication that the social pedagogic approach was not suitable for the client group. This paper examines two propositions: (1) that in the context of introducing the continental European approach of social pedagogy into children's residential care services in England, young people are ‘different’ in England compared to other European countries and (2) that the placement options and practices for young people living away from their birth parents in continental European countries differ from those in England. Using data from a five nation study of young people from public care backgrounds, the paper argues that while family backgrounds are remarkably similar there are marked differences in the child welfare systems that might account for the perception that young people in care are ‘worse’ in England.     

Interactional perspectives on the mistreatment of older and vulnerable people in long‐term care settings

This article draws on a study aimed at developing theoretical and methodological understanding of the abuse and neglect (mistreatment) of older people in long‐term care settings such as care homes and hospitals. It presents an interactionist account of mistreatment of older people in such establishments. Starting with an outline of definitional issues surrounding the topic, the allied concept of dignity is also briefly explored, and one important model described; we present dignity as the converse of mistreatment. The article argues for the potential of a positioning theory analysis of mistreatment. Positioning theory proposes that interactions are based on taking of ‘positions’, clusters of rights and duties to act in certain ways and impose particular meanings, which enable or prohibit access to certain storylines. It is argued that ‘malignant’ positioning can contribute to the creation of a climate that allows mistreatment to take place, or fails to prohibit its development. Mistreatment of people with dementia is used as an illustration, and it is argued that this is potentially generated by negative feedback loops of behaviour patterns, interpretations and malignant positioning by staff or family carers and subsequent response to these interpretations by the person with dementia. Positioning theory also allows for an explanation of the importance and impact of organizational cultures and social factors such as ageism. Individual staff members take positions, use meanings and develop storylines imbued with such factors. This understanding therefore overcomes some of the potential confusions created by concepts such as organizational or institutional abuse, removing the need to ascribe intentions and personal responsibility to such constructs. The article concludes with some suggestions for further research to develop an understanding of the kinds of cultures that allow mistreatment and consequently to inform the development of protective measures.     

Constructions of ‘vulnerability’ in comparative perspective: Scottish protection policies and the trouble with ‘adults at risk’

This paper places Scottish adult support and protection (ASP) policy in the context of debates about the nature of ‘vulnerability’ and its usefulness as a defining concept in law and social policy. It examines the construction of ‘adults at risk’ in ASP policy, using a comparison with the construction of children in Scottish child protection policy, on the one hand, and women in Scottish domestic abuse policy, on the other, to illuminate the nature of the vulnerability that ASP considers itself to be addressing. It then problematises this construction, drawing both on the social model of disability and on an ethic of care. It concludes that current ASP policy remains underpinned by unhelpful assumptions about disabled people, older people and people with mental or physical health problems. A more inclusive understanding of vulnerability would be more empowering to these people and others, in policies concerned with mistreatment and abuse.     

The contextual and social locations of older women's experiences of disability and decline

Understandings of disability and decline within health and social care seem to focus mainly on the bodies and function of older persons. However, the way that older people's experiences of disability and decline are fixed into rigid functional classifications such as ‘frailty’ are problematic. Drawing on the narratives of twelve diverse older English-speaking women in Montreal, Canada, I will argue that older women's experiences are more connected with the contexts within which they experience disability and decline, and the social locations they bring to these experiences, than the functional limitations of their bodies. Older women's stories – particularly those related to the home and the bus – reveal the clash between dominant understandings of ‘frailty’ and older women's contextual and social experiences of disability and decline; expose tensions within health and social care practices; and highlight the potential which exists in both context and social location.     

Conversation takes two: understanding interactions with people with dementia

The term ‘person-centred’ underpins dementia policy and approaches to support people with dementia. However, ‘person-centredness’ remains hazy, and words and definitions matter greatly when they are at the heart of defining what happens in people’s lives. Drawing on data from an ongoing project, this article suggests that conversations which include a person with dementia can elucidate how ‘relational’ support is enacted in practice and the implications this can have on our understanding of ‘person-centredness’. Identities are shaped in part through how we speak to people, and how they speak to us. This is particularly pertinent to the aims of ‘person-centredness’. A conversation analytic approach to dementia support may therefore move us towards seeing ‘personhood’ as jointly constructed and reconstructed through interactions with others.     

Translating case management in a service for older people in Berlin

Case management is a coordinating process designed to align service provision more closely to the identified needs of people requiring assistance in the context of complex care systems. It is an approach that has crossed the borders of different national welfare systems where it has been adopted to address ostensibly similar problems. This empirically based but primarily methodological article draws on the author's doctoral research during which he spent an extended period in Berlin investigating a citywide case management service for older people in the context of German long-term care policy and legislation. It explores the extent to which a specific case study can illuminate how case management adapts in differing national welfare systems and highlights the particular methodological challenges of ‘translation’ and ‘equivalence’ in cross-national research. The article outlines how institutional context both shaped and constrained the Berlin case management service and highlights the necessity in cross-country research for a critical contextual examination of apparently similar features. This is particularly relevant where English words and expressions are directly absorbed into the local language, an important yet rarely addressed complicating factor.     

Care for place: The contributions older people make to their communities

Older people are often positioned as passive recipients of care and dependent on resources or as overly productive and active. In this paper, we seek a more nuanced, middle ground between such stereotypes, by exploring the question: what contributions do older people make to the places they live in? Drawing on qualitative research from Aotearoa New Zealand, involving focus groups and interviews, we examine the varied and active ways many older people are involved in and contribute to their neighbourhoods and communities, or what we term ‘care for place’. In particular, we identify the different forms of older people's care for place, including volunteering, activism, advocacy, and nurturing, and consider how these efforts positively impact on older people and the communities in which they live. Whilst we caution against assumptions that all older people should be productively involved, we argue that greater understanding of older people's care for place is central to challenging stereotypes of older people as either passive and dependent, or highly active.     

Language Reversion among People with Dementia from Culturally and Linguistically Diverse Backgrounds: The Family Experience

Abstract

Culturally and linguistically diverse (CALD) older people with dementia, along with their families, face many unique challenges and have unique needs. One such challenge is language reversion, an issue that has received little research attention. This paper presents the findings of an exploratory study of the experiences of family members of people with language reversion emanating from dementia. Using a qualitative, phenomenological approach, in-depth interviews were conducted with seven participants. The study found that the presence of language reversion created additional challenges for family members of someone with dementia, particularly if the family member did not share the person's first language. Community-based aged care services have the potential to offer valuable support, but barriers of negative past experiences, lack of communication, stigma, cultural understanding, and locality need to be overcome. While further research is recommended, these findings have implications for both policy and social work practice in community-based aged care with CALD populations.     

Variations in subjective well-being when ‘aging in place’ — A matter of acceptance,predictability and control

The aim of the present study is to explore how older home-help recipients regard their life situation in terms of subjective well-being. The background is that there seem to be two counteracting forces affecting the achievement of subjective well-being among home-help recipients: on one hand, both diminished everyday competence and dependence on others' help are supposed to reduce subjective well-being, and on the other hand, living in one's own home is supposed to affect subjective well-being positively. The analysis is based on qualitative interviews with 21 home-help recipients between the ages of 78 and 93. The findings indicate that the informants' expressions of subjective well-being fall into four main categories: ‘well-being’, ‘well-being despite it all’, ‘well-being so far’, and ‘lack of well-being’. Three comprehensive core themes were identified as relevant to a deeper understanding of the informants' various expressions of well-being. These core themes are acceptance, predictability, and control. The findings point to the possibility of experiencing subjective well-being despite diminished everyday competence and dependence on help and support from others. They suggest, in short, that subjective well-being among older people who receive help and support in their everyday lives is not only related to socio-contextual factors – such as physical and mental capability, activities and/or engagement in the outside world, the spatial and social consequences of physical limitations, social and emotional relations, as well as the social support they receive – but also to how they regard and handle these matters in terms of acceptance, predictability and control.     

Strangers are friends I haven't met yet: a positive approach to young people's use of social media

This article reports on a recent research project undertaken in the UK that investigated young people's use of a range of prominent social media tools for socialising and relationship building. The research was conducted by a way of online survey. The findings suggest that this sample of British young people's socialising and relationship-building practices via the range of prominent social media tools reflect similar behavioural categories used offline. The use of these social media tools provides young people with an opportunity to manage, simultaneously, different categories of relationships in a multiplicity of ‘spaces’ created by these tools. The findings challenge the widely held belief that young people expose themselves to risk on social media as they indiscriminately befriend strangers. There is an absence of evidence of ‘unjustified’ intent to harm others. Indeed the findings indicate a strong desire to primarily support and protect those with whom relationships have been carefully established. The research suggests in fact that online engagement through social media can be positive and constructive for young people. It appears to provide them with a challenging ‘space’ to practice identity and relationship management strategies.     

Feeling special: Language in the lives of Polish people

In this article I use findings from an ESRC funded project on language and identity in the narratives of Polish people to challenge a narrow approach to language in debates about integration. I argue that decisions about learning languages are influenced by wider concerns of self and other identification rather then simply being issues of instrumental need. I show how research participants viewed speaking Polish as an important part of being Polish, that is, of their identity. They recognised that changing the language they spoke involved questioning the way they presented themselves and how they related to others. I discuss how language was used to differentiate between ‘us’ and ‘others’, including in terms of values and the ways in which these perceptions of difference influenced social interactions.     

Maintaining mastery despite age related losses. The resilience narratives of two older women in need of long-term community care

The aim of this article is to examine how older people mobilise sources of strength, often denoted under the concept of resilience, to maintain mastery over their lives in the context of significant threats to their function. Departing from a relational approach to resilience, we focus on how they cooperate and interact with significant others to achieve their personal goals. This is illustrated by the narratives of two older women. The concept of resilience helps us to reflect on their stories and to gain an in-depth understanding of the mediating sources of strength older people rely on when encountering the losses associated with old age. The narratives of the women show that what on the surface appears to be a similar burden to a life or function, turned out to be interpreted and responded to in a different way. Maintaining mastery in old age is a symbolic and interactional process, and a shared responsibility for older persons and their social environment. Important mediating sources of strength that turn out to influence positively one's sense of mastery include a positive perception of one's situation, openness about one's vulnerability and responsiveness to help. In order to promote older people's sense of mastery, significant others need to approach them in a positive way, by being aware of the way support is offered, by believing in their potential and strength and by allowing reciprocity in the relationship. When these conditions are fulfilled, it becomes possible to enter into a constructive dialogue and recommendations can be developed – in terms of treatment – that are consistent with the older persons' values and expectations.     

Living with dementia in rural and remote Scotland: Diverse experiences of people with dementia and their carers

There is a lack of research into people's experiences of using services as dementia sufferers themselves, or because they care for someone with dementia, in rural areas. This article explores their experiences in the context of rural Scotland, drawing on data gathered from both people with dementia and their carers. Our research suggests that understanding the nuanced and co-constituted experience of dementia in rural communities is a pre-requisite for improving service provision. The paper explores the way in which participants linked their experiences to their spatial location in rural areas. Our findings suggest that participants used a narrative of idealised rurality which linked together interwoven and overlapping social networks, a physical relationship with place and a sense of self sufficiency. However, the participants’ stories also highlighted the diversity in experiences as service users between places, suggesting a disjunction between the generalising narrative of the rural idyll and their particular situations. These findings extend the literature on rural mental health issues and on the experience of dementia in particular, in turn helping to inform place and person centred policies.     

Kitwood's thought and relational social work

Tom Kitwood is a key figure in the development of thought about dementia, but generally no references are made to his work outside of elderly care. This article argues that Kitwood's thought has much to offer to all the professional caregivers, regardless of the users’ category they are caring for, and to the broader field of professional social work. Some key themes from the writings of Kitwood are examined, namely the critique of the ‘standard paradigm’; the conception of malignant social psychology; the respect for otherness in the positive person work; the person with dementia as a resource for reciprocity processes; the new culture of dementia. For each of these issues similarities between Kitwood's approach and relational social work are identified. Relational social work considers the helping process and the well-being development as co-constructions, in which the contributions not only by the helper (or the caregiver, or the social worker), but also by the helpee (or by the care recipient, or by the user) are essential: both at the same time are helped and helpers, and both are empowered by this. This idea—of great value to all social work fields—is remarkably close to the Kitwood's thought about the dementia care.