Afraid to care; unable to care: A critical ethnography within a long-term care home

This paper describes the findings of a critical ethnographic research study conducted in an urban long-term care home. While our intention was to learn more about the culture of care, specifically as it relates to mental health care provision, the participants in the study consistently spoke with us about (what we have labeled as) a culture of compliance. In a context where new long-term care legislation is being implemented along with new, standardized resident assessment instruments, gaining a deeper understanding of the (un)intended consequences of government's efforts to ensure a high quality of care is of paramount importance. This research demonstrates how policy-driven structural mechanisms can (re)produce conditions that result in frontline staff being afraid and unable to care, and thus contributes to a better understanding of the lived experience of frontline long-term care staff who find that their caregiving responsibilities are displaced by caregiving accountabilities.     

Changing the narrative: the role of frontline worker attitudes and beliefs in shaping dementia-friendly services in England

Applying the main principles of the social model of disability as a guide, this article argues that the attitudes and beliefs of staff and volunteers employed in frontline service delivery can play an important role in the achievement of dementia-friendly communities, particularly through influencing the types of services offered. This position is supported by findings from an evaluation of an awareness-raising intervention run by Age UK, aimed at organisations which provide services for people living with dementia in England. The article contributes to an understanding of the cultural climate within frontline service delivery, which is often neglected in favour of discussions around meeting more immediate care and support needs. More specifically, the article reflects on whether there is a need for an additional conceptualisation within the discourse around dementia-friendly communities which ensures inclusion of the cultural environment.     

A gender-based incidence study of workplace violence in psychiatric and forensic settings

Limited data exist analyzing the role of gender in workplace violence in health care settings. This study examined whether different types of threatening incidents with patients (physical, verbal, sexual, or posturing) were salient to male versus female staff across psychiatric settings (inpatient forensic, inpatient acute/chronic psychiatric, and outpatient psychiatric). Results indicated that although women disproportionately experienced sexualized threats, they were not more likely to report such incidents as salient and threatening. The study also assessed the extent to which situational variables contributed to staff's feelings of threat. Results showed that rapport with the patient, quality of relationships with coworkers, and presence of coworkers in the area were not significantly related to how threatened staff felt in a recent threatening incident. Findings are discussed within the context of staff training and organizational benefits.     

Use of data to assess performance and promote outcome achievement by public and private child welfare agency staff

Despite the emphasis on evidence-based practice in the literature, little is known about the extent to which child welfare workers routinely use data to assess the effectiveness of their practice, or consider an array of evidence informed practices such as peer record review, supervisory sessions or program evaluation as useful in improving their performance. This study, conducted as a part of the planning phase for a larger research and demonstration project measured frontline staff perceptions in both the public and private sectors in one state regarding these and other outcome-focused activities. Statistically significant differences were noted between public and private agency staff. In addition, the relationship between staff's use of data and their assessment of their own skill and the support provided by their agency for an array of out-of-home care practice activities are described. Implications for building the use of evidence-informed practice in child welfare are discussed.     

The Atascadero State Hospital experience. Engaging patients in violence prevention.

When it comes to caring for the forensic psychiatric inpatient, there is no "how to" book. In the forensic hospital environment, the commingling of severe and persistent mental illness with criminality poses vexing clinical challenges and complex moral dilemmas not faced in either general psychiatric or correctional environments. While providing evaluation and treatment in our maximum security forensic environment, we continually strive to create and maintain a therapeutic milieu as we fulfill our social mandate to protect the public from the dangerous "criminally insane." Few studies guide us. We do know that within the forensic population there is a spectrum of psychopathology to manage, some of which responds to traditional psychotherapeutic techniques and some of which does not. For example, patients with psychopathic traits may not respond well to traditional treatment methods (Rice, 1997). As forensic psychiatric staff, we sometimes feel as if we are making it up as we go, adapting and blending psychiatric theory with knowledge from penology and criminal justice science to provide a safe environment conducive to growth for patients, the majority of whom may be considered "violence-prone" persons (Toch, 1969). Change is a characteristic of public-sector settings (Smoyak, 1991). Forensic hospitals must continually strive to monitor, refine, and improve their organizational systems as they respond and adapt to constant change. Despite the inherent challenges posed when collaborating with forensic patients, the VAC has achieved some notable successes. Staff and patients have been encouraged to work together to create and maintain a milieu where violence is neither assumed nor condoned. An active collaboration and partnership with our forensic patients has been one component of the hospital's successful violence reduction program. We trust that ASH's successful effort to collaborate with patients on the issue of violence reduction may be of use to other forensic hospitals faced with similar challenges.     

Working with Dave. Application of Peplau's interpersonal nursing theory in the correctional environment.

Achieving therapeutic relationships with forensic patients is dependent upon nurses' awareness of personal needs, reactions to the patient, recognition of their participation in the pattern, the effects of this participation on others, and the changes they needed to make. Nurses have more extensive contact with the forensic patients than other health care professionals. Consequently, the potential exists for nurses--through interpersonal relationship--to have the greatest therapeutic impact or to engage in patterns that replicate pathology-producing situations (Peplau, 1978). The goal is not that nurses be perfect, but that they be aware of imperfections and capable of exploring them.     

Re-visioning nurses' punitive attitudes within forensic psychiatric and correctional nursing: the significance of ethical sophistication

1. Development is an essential lifelong process if we are to compassionately care for patients in forensic and correctional nursing. 2. Many of us are blocked in our ability to understand and to care; we will need to grow to meet the challenges and to bear the shocks of forensic and correctional nursing. 3. Concepts that correspond to Kegan's levels of consciousness imply a progression from punitive attitudes toward more positive attitudes.     

Performative identity regulation in rehabilitative home care work: an analysis of how experts’ embodied mediation of the managerial ideology ‘activates’ new frontline identities

ABSTRACT

This article explores how therapists when introduced as new so-called frontline ‘experts’ in home care work, become both discursive and embodied mediators for the managerial ideology of rehabilitation, and how their presence regulates the care aides’ subjectivities at work. We show how the managerial discourse of rehabilitation mobilizes the care aides to transform their identity from traditional nurturing to rehabilitation, as a result of promoting the latter as more professional. While the traditional managers/nurses promote the identity transfer through more classic discursive regulation at a distance from ‘the office’, the therapists do so through what we label performative regulation. Performative regulation is exercised by the therapists performing the desired role at the frontline and thus embodies the ideal and transfers it by embodied practices, not directives. With this notion of performative regulation, the article emphasizes the material, physical, embodied and performative dimensions of professional identity regulation.     

A proposal for change to achieve competence in long-term psychosocial nursing care

Psychiatric nursing in a large institutional setting presents challenges to the nursing staff, who must remain competent in the specialized areas of psychiatric and medical nursing. Chronically mentally ill individuals present complex and continuing nursing care needs that must be addressed using a holistic approach to nursing assessment and care. The complex needs of nursing staff and patients in an institutional setting have been described. Methods of assisting the nurse to achieve competence using education and experience have been implemented and described with the goal of improving holistic nursing care to chronically institutionalized individuals.     

Slaps,Punches, Pinches—But not Violence: Boundary‐Work in Nursing Homes for the Elderly

This article presents an analysis of boundary work in the context of care for the elderly, where violence appears to be widespread but is still relatively unacknowledged. Talk about aggressive patients was formulated in a particular way among workers in a nursing home. Nursing home staff described how the elderly residents sometimes slapped, pinched, or hit them. Although staff members could describe these acts as intentional, although they could hold patients responsible, and although this violence could end in injuries, demarcations were made such that aggressive acts were constructed as somehow not really “violence.” As “violent” is an inherently exclusionary label, this downplaying can be seen as an effort to avoid pushing persons outside the boundary of normalcy and of continued acceptance. Placing the elderly's violence outside the boundaries of violence means that the elderly remain “care takers,” the staff “caregivers,” and the nursing home a “caring context.”     

Users' involvement in their care. A follow-up study

1. User involvement in both care planning and staff development helped staff and residents at a community rehabilitation unit in terms of attitudes and care delivery. 2. Undertaking follow-up work shows progress in care management for staff and in social skills development for residents. 3. The results of this study provide clear indications of positive progress and identify a few areas where work still need to be done to improve care.     

Transforming the culture of caring

Direct care staff struggle with the decision of when to physically intervene with patients. There is a widely held belief that they are expected to place themselves in danger of harm to prevent patients from hurting themselves or others. In this acute mental health care setting, an educational program was developed, using principles of adult and transformational learning, to dispel the idea that getting hurt is part of the job. The Staying Safe program strongly discourages staff from physically intervening alone and promotes staff getting enough help and having a plan. Staff are encouraged to interact with patients in helpful ways and to respond to patient requests in ways that do not increase frustration or evoke anger. There has been a positive response to the training program, evidenced by changes in the way staff think about their jobs and a reduction in the number of assaults and injuries to staff.     

Competing demands,competing solutions,differing constructions of the problem of recruitment and retention of frontline rural child protection staff

Abstract

This article reports on a study conducted in rural Victoria. It examines the problem of recruitment and retention of frontline staff in the Victorian Child Protection program. The article delineates those factors identified by managers and supervisors as influencing workers to enter, stay and leave the program. Managers and supervisors have collective responsibility for recruiting and retaining staff. It is for this reason that their viewpoints are considered crucial in responding to the problem. What this study found was that, while managers and supervisors recognise that the problem is complex, they differ in the emphasis placed on facets of the problem, thus their approaches to solving it. As solutions are contested the problem is exacerbated. The argument advanced is that any response should recognise the complexity of the problem and solutions be considered in a coordinated way.     

Sacred time: Ensuring the provision of excellent supervision

In this study, the authors explore the beliefs and attitudes regarding what constitutes “excellent supervision” from the perspectives of frontline workers and supervisors employed by one voluntary services organization in Northern Ireland. Several themes emerged from focus group narratives, regardless of participants’ agency position, and a concept map provides an understanding of the relationships of the identified themes. This study reflects the important role of organizational context and culture in relation to staff’s ability to provide excellent supervision, as well as in sustaining organizational change efforts regardless of organizational setting. The potential of peer and/or group supervision to address improving staff support with limited resources is also suggested.     

Child Abuse on the Internet: Ending the Silence

The Melbourne Health (MH) Social Work Residential Care Team (RCT) was established in 2002 as a new and innovative approach to aged care. The service employs three full-time social workers and an Allied Health assistant with previous experience in aged care. The RCT works across the MH continuum of care with inpatients recommended for residential care. The service is predominantly patient- and family-focused, but is also consultative to meet the education needs of MH staff and the community. This paper discusses the MH Social Work Residential Care model, reviews data collected since RCT implementation and the benefits shown for patients, their families and interdisciplinary staff. This paper discusses pressures and factors that impinge on the ability to discharge patients to residential care and explores recommendations for ongoing clinical practice as well as recommendations that the RCT has submitted to management for further consideration.     

Enclosed versus open nursing stations in adult acute care psychiatric settings: does the design affect the therapeutic milieu?

Specific efforts by hospital accreditation organizations encourage renovation of nursing stations, so nurses can better see, attend, and care for their patients. The purpose of this study was to examine the effect of nursing station design on the therapeutic milieu in an adult acute care psychiatric unit. A repeated cross-sectional, pretest-posttest design was used. Data were collected from a convenience sample of 81 patients and 25 nursing staff members who completed the Ward Atmosphere Scale. Pretest data were collected when the unit had an enclosed nursing station, and posttest data were collected after renovations to the unit created an open nursing station. No statistically significant differences were found in patient or staff perceptions of the therapeutic milieu. No increase in aggression toward staff was found, given patients' ease of access to the nursing station. More research is needed about the impact of unit design in acute care psychiatric settings.     

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.     

Framing nursing practice within a forensic outpatient service

The role of the outpatient forensic nurse is evolving as a specialized area of nursing practice in the community. Nurses must have comprehensive knowledge of the patients, keen intuition, and sound judgment in the continuous clinical assessment of the criminogenic factors that help determine the patients' level of risk. In addition, it is crucial to know and understand the court system, the process of the ORB, and the implications of the disposition order. The comprehensive, client-centered care provided by the Forensic Outpatient Service encompasses multifunctional and complex roles and responsibilities and clearly demonstrates the importance of the forensic outpatient nurse in working with this group of patients.     

Professionals without a profession? Redesigning case management in Dutch local welfare agencies

This article explores the new roles of frontline workers in Dutch local welfare agencies against the background of recent active welfare state reforms, with a specific focus on frontline workers involved in activating social assistance recipients. The results presented in the article come from case studies in four local welfare agencies. The article investigates how active welfare state reforms have influenced the room for discretion of frontline workers, how discretion is managed in local welfare agencies, and how frontline workers cope with discretion. The article argues that the discretion of activation by frontline workers has increased significantly. The research results show a clear though not unambiguous shift from a bureaucratic towards a more professional treatment of frontline workers, combined with attempts to introduce a more performance oriented style of management. However, given the low level of institutionalisation of the profession of activation work, activation frontline workers still seem to be professionals without a profession. This not only makes activation work a rather individual project, it also entails risks for clients for whom activation services may become unpredictable and lacking in transparency.