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.     

Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

Assessing social work and nursing students’ intentions to work with dying patients

This study assessed social work and nursing students’ intentions to provide end-of-life care, based on the Theory of Planned Behavior. A total of 181 social work and nursing students completed a questionnaire examining intentions to provide end-of-life care, attitudes, subjective norms, perceived control, death anxiety, subjective knowledge, and sociodemographic characteristics. Students manifested a moderate level of intentions to provide end-of-life care, with nursing students indicating higher levels of intentions than social work students. Multiple regression analyses revealed that attitudes, subjective norms, and previous experience were the main predictors of intentions to provide end-of-life care. Recommendations for academic programs are discussed.     

Tracing disorder across theories of autism,empathy, and mental health care

Abstract

Categories of mental disorders are generally understood through a biomedical paradigm of clinical research, diagnosis, and intervention. Here, diagnoses operate as professional tools, facilitating care organization and information exchange across diverse social contexts. In this article, I focus on how the diagnosis of autism-spectrum disorder operates in this manner. Autism conceived as a biomedical disorder is then contrasted with proposals by the neurodiversity movement, who understand core qualities of autism as alternative expressions of otherwise normal processes of brain development. Finally, I supplement these conversations with insights from Gerald Edelman’s theory of neural plasticity and Felix Guattari’s paradigm of ethico-aesthetic care. Understood together, these allow mental disorders and community care generally to be reconceived in terms of networks of expressive, embodied, and dynamically embedded rhythms that transcend individual persons. This serves, additionally, to illustrate a concept of empathy that traverses neurological, psychological, and sociocultural domains.     

‘We are actually,after all,just children’: caring societies and South African infantilisation of adults with intellectual disability

This article comments on infantilisation by attending to South African adult intellectual disability (ID) care through an intersubjective ethics of care lens, and shows how such an ethic can shine light on shifting our responses towards ID. Care performance data were gathered from three sources within two South African specialist ID care sites – from 10 adult residents, 16 nurses as spatiotemporal carers, and three wards as ethnographic sites. Deeply embedded and interwoven throughout various care practices is the disabling of adults with intellectual impairment when literally referred to as ‘children’. These adult-unmaking processes constitute practices that fall short of Tronto and Kittay’s caring societies ethic. Care exchanges generate relational and intersubjective spaces in which people are understood as never meeting full criteria for personhood. Infantilising care dynamics require urgent attention if we wish to change ways in which ID is viewed and responded to in South Africa.     

Care Diamonds and Welfare Regimes in East and South-East Asian Societies: Bridging Family and Welfare Sociology

This paper tries to bridge the micro-level analyses of social networks for "care" provision which have been conducted in the field of family sociology, and the macro-level framework on welfare mix which has been developed in the area of welfare sociology, because the options for creating social networks are given to individuals by society. A group of Asian researchers including the author have conducted comparative research on social networks for childcare and elderly care in six Asian societies, namely Korea, China, Taiwan, Thailand, Singapore, and Japan. To reexamine the results, the author draws diagrams of the care diamonds in each society for each type of care (childcare or elderly care) to show the balance between four sectors (the state, market, family and relatives, and the community) which determines the pattern of welfare mix. The most prevalent pattern in Asian societies today is the pattern with a large family and relatives sector and a large market sector. We can interpret it as a familistic welfare regime combined with liberalism. However, Japan alone shows a pattern close to pure familism because the development of the market sector is restricted by immigration policies prohibiting the employment of foreign domestic workers. Unlike other Asian societies which were exposed to the global market before the family could become a closed organization and marketization of care work took place easily, in Japan, where the modern family system had been established, both socialization and marketization of care work have stagnated.     

Family involvement in the institutional eldercare context. Towards a new understanding

This article focuses on family involvement and its various patterns and expressions in the context of end-of-life care in a nursing home. Based on analyses from an ethnographic study carried out at a nursing home ward, the aim is to describe and analyze the conditions of aging and dying for the old residents, as well as effects on their visiting families and relatives. As in similar research findings, it became clear from the study that families continue to visit and contribute to the care of the old resident throughout the years, from the time of placement to their demise, but that this involvement might vary both in content and in extent. However, it was found that families' involvement (as well as their changing relationships and roles) is particularly shaped by the very process of dying and lingering aura of death on the ward. The analysis presented in the article evinces the difficult — and in many ways impossible — role of the family in the institutional end-of-life setting, and discloses the various patterns and manifestations of family involvement in this environment. Different meanings and implications of family involvement are discussed and highlighted.     

Children’s Psychosocial Rehabilitation: Clinical Outcomes for Youth with Serious Emotional Disturbance Living in Foster Care

Children living in foster care are an especially vulnerable population who often come to the attention of Medicaid mental health providers. These children experience a high incidence of emotional and behavioral disorders and may have specialized treatment needs related to their living arrangement status. This study assessed whether Children’s Psychosocial Rehabilitation could effectively treat youth with severe emotional and behavioral disorders who live in foster care. Analysis of data from an open trial of 218 clinically-impaired youth, aged 3–18 years, revealed no reliable differences in treatment outcome between foster versus non-foster children, with a trend toward more favorable outcomes for foster youth. Findings justify further study of the effectiveness of this Medicaid-funded service for the treatment of youth in care.     

Family Therapy for Kids Without Families: Working Systemically With Children and Young People in Residential Care

A significant proportion (4%, Australian Institute of Health and Welfare, 2008) of children and young people in Australia live in some form of residential care, usually in small group‐homes staffed by residential care workers in shifts. However, as Hawkins‐Rodgers (2007) points out, these placements are often not resourced to heal the effects of trauma and multiple attachment disruptions in their residents. The lack of an archetypal ‘family’ has led in the past to family therapists considering that there is little work to be done with such clients. This leaves such placements to be supported most frequently by clinicians who specialise in behaviour management and other linearly founded models of practice. The Alternate Care Clinic (ACC) is the first mental health service in New South Wales dedicated entirely to children and young people in out of home care with a high level of complex needs. This article examines the systemic therapeutic model the clinic has developed in the last two years. In particular, the article seeks to explore the importance of ‘meaning making’ in a diffuse parental system, particularly with regards to the term ‘family’. The complexities of working in this area and possible ways forward are illustrated with a closely worked case study.