Transcript Negotiating person centred approaches and risk

Decision-making on the frontline...
Negotiating “person-centred” approaches
and risk management in community care
Anne-Maree Sawyer
Frontline workers…
... have to bridge the worlds of their clients, the rules of
their employing agencies, government regulations &
policies, & the norms & ethics of their professions or
disciplines.
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Historical context
Shaping influences on practice...
1. Human rights framework (deinstitutionalisation & shift to
community care) >> “person-centred” care
2. New Public Management (increased demands for
accountability & regulation >> “risk management”)
>>> 2 distinct developments that come together in practice
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1. Person-centred care AND the freedom to
live with risk
She says, “Look at the end of the day, my choice is to live at home if I have to lie on the floor for two hours in the middle of the night if
I’ve fallen out of bed … that’s the risk I want to take, because I do
not want to go to a nursing home at fifty.” So look, we’ll do all the
checks that we can, but she put it very nicely: “That’s my choice, if I
have an accident in bed … if I have to wait till the carer comes at
seven in the morning, I’ll wait … there are emergency services but if
people can’t come, that’s the choice I make - not to live in a place
where there’s a nurse down the hall.” So it’s about agreeing on risk,
and getting permission to put certain things in place to manage the
risk. (Program manager, aged care/disability service)
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2. Person-centred care may mean ‘bad
choices’
This is a guy who’s been in institutions his whole life and now lives
independently … he has a mental health issue as well as an
intellectual disability … I have had his sister on the phone, going:
“Well you’ve got to stop him smoking”. The reality is he lives in his
own home; every time I speak to him I mention the cigarettes and
I’ve got a carer to take him walking to try and reduce his obesity and
we’ve done a little bit of basic training with him around cigarettes,
but … that’s all I can really do ... there’s major health risks … but he
can choose [to smoke 35 cigarettes per day] and whilst he does
have an intellectual disability, he does know that smoking is what
caused him to go to hospital...
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2. Person-centred care may mean ‘bad
choices’, cont.
We are always treading this fine balance between independence
and choice for the clients because that’s very much our ethos … and
risk and their safety ... When you leave someone at home you’ve got
this sort of uneasy feeling. (Case manager, aged care/ disability
service)
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3. Person-centred care, risk taking AND the
significance of professional agency
Going into a house and finding that the light globe has blown, the
little old lady or gentleman… don’t have any family and they’re
saying “But I can’t see what I’m doing in the evenings”, and you sort
of think – “Well it’s not rocket science to change a light globe”. But if
you look at the risk assessments there you don’t know what the
wiring is like … whether you’re potentially going to electrocute
yourself. So we are not allowed to do that … In the meantime they
could get up at night time… and trip over something and break a hip
and they’re in hospital, so for me personally … I would change a
light globe … it was something that I was able to help out with and
was a five minute job, but outside the realm of my role and
responsibility. But if we can’t help a fellow human being and I see it
as a low, extremely low risk; then I’m prepared to take that option.
(Community nurse, aged care service)
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4. Person-centred care AND balancing risk
and security
She was getting daily nursing visits to provide her medication, and
periodically the nurse would ring me and say, “Look I can’t find the
client” and I’d say, “Just go down to McDonalds.” By all accounts
she was probably physically exposed to risk, but what was working
was that it was a routine that she knew, she could get there and
back, she didn’t have to cross a road which was the main thing, but
yeah ... she could have fallen and been out of range of support - but
my view with that client was that if we had tried to circumvent that,
she would have tried to circumvent our efforts, so working with the
strength, working with the person’s capacity - it’s something she
enjoys, so you’re not going to take it away - so the nurse would go
down there and give her the medication in McDonalds.
(Case manager, aged care service)
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5. Person-centred care AND the client’s
identity as a ‘self’
He was a very isolated individual and his dog was very important.
His dog was dying… and the vet recommended putting the dog
down and he asked if he could have time alone with the dog and I
thought, “This is one of those times where it’s a judgment call” and I
felt confident enough to say “I’m going to take the risk”. Because he
had been talking about … if the dog had to die that he was going to
die with the dog and I made the judgment call, but I could see that
was really important for him and I drove him home to have time with
the dog. I picked the dog up from the vet with him and gave him a
period of time … and he brings up regularly that we did that together
and he knew not many staff would have trusted him and would have
given him the opportunity. (Program manager, mental health
service)
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References
Fine, M. (2005) ‘Individualization, risk and the body: sociology and care’, Journal of Sociology, 41, 3, 249-68.
Green, D. and Sawyer, A. ‘Managing risk in community care of older people: perspectives from the frontline’, Australian Social Work, 63,
4, 375-90
Green, D., Sawyer, A., Moran, A. and Brett, J. (2010) Managing risk in community services: A preliminary study of the impacts of risk
management on Victorian services and clients, (Unpublished) Final Report to Industry Partners (book length). (Please contact
Anne-Maree Sawyer, [email protected] for copies)
Munro, E. (2004) ‘The impact of audit on social work practice’, British Journal of Social Work, 34, 8, 1075-95.
Munro, E. (2010) ‘Learning to reduce risk in child protection’, British Journal of Social Work, 40, 4, 1135-51.
Sawyer, A. (2009) ‘Mental health workers negotiating risk on the frontline’, Australian Social Work, 62, 4, 441-59.
Sawyer, A., Green, D., Moran, A. and Brett, J. (2009) ‘Should the nurse change the light globe? Human service professionals managing
risk on the frontline’, Journal of Sociology, 45, 4,1-21.
Taylor, B. (2006) ‘Risk management paradigms in health and social services for professional decision making on the long-term care of
older people’, British Journal of Social Work, 36, 8, 1411-29.
Taylor, B. and Donnelly, M. (2006) ‘Risks to home care workers: professional perspectives’, Health, Risk & Society, 8, 3, 239-56.
Titterton, M. (2005) Risk and Risk Taking in Health and Social Welfare, London: Jessica Kingsley Publishers.
Yeatman, A. (2009) Individualisation and the Delivery of Welfare Services: Contestation and Complexity, New York: Palgrave
Macmillan.
Acknowledgements
This paper is based on research conducted with the support of an Australian Research Council Linkages Grant, no. LP0667485.
We wish to thank our industry partners, the (former) Victorian Department of Human Services and the Victorian Office of the Public
Advocate, and our interviewees for generously taking part in the project.
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