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How Welfare Professions Contribute to the Making of Welfare Governance: Professional Agency and Institutional Work in Elder Care
Abstract
Welfare governance in elder care has undergone significant changes, but we know less about the processes and actors of making welfare governance. This is problematic, as the concern for process is a key strength of the welfare governance perspective. Based on a case study of elder care in Denmark, and drawing on studies of professions, the aim is to analyse how welfare professions contribute to the making of welfare governance. Our analysis shows that welfare professions bring unique resources into play. They have strong professional agency, drawing on both broader institutional roles and more specific professional projects. The institutional work itself is highly complex and the welfare professions combine not only formal and informal coordination, but also do so in ways that are closely tailored to specific contexts. The analysis makes important empirical and theoretical contributions to the study of welfare governance in elder care.
... However, frontline workers' practices are also recognised as playing an important role in welfare service reform implementation (Carstenen et al., 2021;Lipsky, 2010). Carstensen et al. (2021) demonstrates how frontline care workers through their everyday practices contributed to welfare service governance reform aiming at holistic services to elderly in Danish municipalities. In line with their focus on frontline care workers, our study contributes with a bottom-up perspective on care work and care workers' practice following from a welfare service governance and organisational reform. ...
... Care work on the ground Care work is highly complex and contextual (Carstensen et al., 2021) and is typical of what Lipsky (2010) calls frontline work. Care workers work under constant pressure and in an everlasting gap between demands and resources. ...
... As scholars have pointed out, regardless of specific organisational arrangements, the time pressure under which home care workers perform is paramount. Several studies have emphasised the significance of time and the importance of understanding the temporal aspects of professional agency in terms of how home care work is managed and organised (Adams et al., 2012;Bergschöld, 2018;Carstensen et al., 2021;Hirvonen and Husso, 2012;Tufte, 2013). Hirvonen and Husso (2012) demonstrate how institutional demands and requirements about efficiency shape care workers' agency and how 'working on a knife's edge' may undermine the relational nature of professional care work and, as a result, ultimately damage both care workers' professionalism and their delivery of care to service users. ...
The central idea in trust-reform is to improve service delivery by granting professional autonomy and acknowledging the experiential knowledge of professionals. In this article, we study trust-reform bottom-up from the perspective of frontline care workers. Our aim is to discuss the challenges for care work and care workers who have been organised in self-managing teams, paying particular attention to the organising of the daily work in the teams. This study draws on data from four months of fieldwork in Norwegian municipal home care services for older people. The article sheds light on some problematic aspects in trust-reform regarding the relationship between frontline workers’ autonomy and responsibility on the one hand and the lack of authority and managerial support on the other hand. The study demonstrates that trust-reforms within public service delivery can be experienced as delegation of logistical tasks and enhanced responsibility instead of delegation of the authority that is necessary for professional care work to be performed. As such, trust-reforms risk obstructing rather than advancing their declared intentions of strengthening professional agency in care work, and rather than distributing management tasks, trust-reforms need to strengthen the management function in order to succeed.
... Recent working-life studies have regarded professional agency as an essential factor in fostering the development of work communities and organizations. Teachers' agency in educational settings has been widely explored in this manner (e.g., Priestley et al. 2013;Vähäsantanen 2015), and the same goes for professional agency in information technology work (Collin et al. 2017), in elderly care (Carstensen et al. 2022), in hospital organization (Collin et al. 2015), and in decision-making in child protection (Parada et al. 2007). To the author's knowledge, however, no study has similarly explored the role of professional agency in social and health care for addressing DV. ...
While the existing research on domestic violence (DV) interventions has provided substantial insights into the challenges associated with addressing DV, the factors that facilitate its intervention in social and health care remain under-researched. This study focuses on DV intervention practices that professionals have deemed successful and employs subject-centered sociocultural theories of professional agency to analyze how professional agency is manifested in these situations. To this end, 10 focus group interviews were conducted with 45 experienced social and health care professionals. The collected data were subjected to thematic content analysis. The findings illustrate how professional agency is manifested in various contexts: through understanding DV as a phenomenon and its contextual factors (epistemic agency), launching a process (processual agency), collaborating with other professionals (relational agency), and reflecting on one’s own actions and emotions (reflective agency).
... Proximity is an important factor in the creation of ties between teams [44][45][46]. Geographic proximity facilitates knowledge diffusion and information exchange through serendipitous communications between neighboring actors [47,48]. Organizational proximity, on the other hand, occurs when network actors share institutional membership, such as belonging to chains. ...
Background
We applied a longitudinal network analysis approach to assess the formation of knowledge sharing and collaboration networks among care aide-led quality improvement (QI) teams in Canadian nursing homes participating in the Safer Care for Older Persons (in residential) Environments (SCOPE) trial which aimed to support unregulated front-line staff to lead unit-based quality improvement (QI) teams in nursing homes. We hypothesized that SCOPE's communicative and participatory nature would provide opportunities for peer support, knowledge sharing, and collaboration building among teams.
Methods
Fourteen QI teams in Alberta (AB) and seventeen QI teams in British Columbia (BC) participated in the study. Communications across nursing homes occurred through a series of 4 collaborative Learning Congresses (training sessions) over a 1-year period. The senior leaders of QI teams participated in two online network surveys about the communication/collaboration between teams in their province, 1 month after the first, and 6 months later, after the fourth Learning Congress. We developed communication and collaboration network maps pertaining to three time points: before SCOPE, at 2 months, and at 9 months.
Results
Over time, teams made significantly more new connections and strengthened existing ones, within and across regions. Geographic proximity and co-membership in organizational chains were important predictors of connectivity before and during SCOPE. Teams whose members were well connected at baseline disproportionately improved connectivity over time. On the other hand, teams that did not have prior opportunities to connect appeared to use SCOPE to build new ties.
Conclusions
Our findings suggest the importance of network-altering activities to the formation of collaboration networks among QI teams across nursing homes. Active strategies could be used to better connect less connected teams and facilitate collaboration among geographically proximate teams. These findings may inform the development of interventions to leverage existing networks and provide new networking opportunities to develop and sustain organizational improvements.
... Taken together, the interprofessional collaboration happens between two well-established professional groups (nurses and therapists) that are afforded a lot of autonomy within the collaboration and PWs who enjoy a lot less autonomy. The context for the collaboration is characterized by institutional complexity in a 'broken' system; the professionals must collaborate and deliver high-quality care despite a fragmented organization, high workload, and few resources (Carstensen et al. 2022). ...
There is a growing interest in understanding when and why interprofessional collaborations are well functioning, especially within healthcare systems. However, more knowledge is needed about how professionals affect and contribute to these collaborations when they engage in them. To address this shortcoming, this study aims to contribute to professional and organizational studies of interprofessional collaboration by providing novel insights into how professionals engage in and contribute to interprofessional collaborations. It builds on a theoretical perspective of examining professionals’ everyday collaboration practices through the interplay between temporal-oriented agency and institutional work. It applies this perspective to a case study of interprofessional collaboration between personal workers (PWs), nurses, and therapists in the home care sector in Denmark. Overall, the findings show that the professionals engaged in and contributed to the interprofessional collaboration by ‘trying to patch a broken system’. All three professional groups did this primarily by ‘adopting new practices to deal with inept institutionalized practices’ to maintain collaboration. Additionally, some PWs ‘failed to enact institutionalized practices’ to disrupt the collaboration, and some nurses and therapists ‘invented and established mechanisms’ to create new arrangements for the collaboration. Based on the findings, the study demonstrates that certain dimensions of agency are associated with certain types of institutional work. Furthermore, the study suggests that the interplay between agency and institutional work varies between professional groups, influenced by their relative autonomy.
... Instead, a preceding qualitative study can help deduce the most important context conditions in a given setting. Following this approach, we analysed data from a preceding qualitative study in the case-setting [37] and identified the most important context conditions as experienced by staff and managers. Table 1 summarizes the constructed variables. ...
Introduction
Increasing demand for interprofessional collaboration in health care settings has led to a greater focus on how conditions influence the success of interprofessional collaboration, but little is known about the magnitude of the interactions between different conditions. This paper aims to examine the relationships of intervention conditions and context conditions at the professional and organisational level and examine how they influence the staff’s perceived success of the interprofessional collaboration.
Methods
The study was conducted as a multilevel cross-sectional survey in March of 2019 in the second largest municipality in Denmark, Aarhus. The study population was all frontline-staff members and managers in nursing homes, home care units and health care units. The final sample consisted of 498 staff members and 27 managers. Confirmatory path analysis was used to analyse the data.
Results
The results indicate that context conditions greatly influence intervention conditions at the professional and organisational level and that the professional and organisational levels moderately co-variate. Professional level context conditions have the biggest influence on staff’s perceived success, partly because its influence is confounded by intervention conditions.
Conclusion
Practice and research in health care settings should re-focus their attention from a broad understanding of context as unchangeable and inconsequential, to understanding context as an important condition type for interprofessional collaboration that needs to be further understood and researched.
Paperwork has always been a central part of bureaucratic work. Over the last few years, bureaucratic procedures have become increasingly standardised and digitalised. Based on interviews and ethnographic fieldwork within welfare offices in Switzerland and Belgium, we reflect on the way evidence is constructed within social policy and cases built for or against noncitizen welfare recipients in order to show how paper truths are established and challenged. The focus on digital practices within public policy implementation highlights how it contributes to enhanced control mechanisms on the implementation level and how migration law continues to guide welfare governance for noncitizens. This allows targeting of the most marginalised groups, whose rights to access state support are institutionally impeded. Through database information flows, official forms, paper reports and face-to-face meetings, we further show how a hybrid form of bureaucratic work emerges, where direct contact with the client is still key, yet highly influenced by standardisation processes.
Purpose
The purpose of this paper is to empirically explore and conceptualize how healthcare professionals and managers give shape to the increasing call for compassionate care as an alternative for system-based quality management systems. The research demonstrates how quality rebels craft deviant practices of good care and how they account for them.
Design/methodology/approach
Ethnographic research was conducted in three Dutch hospitals, studying clinical groups that were identified as deviant: a nursing ward for infectious diseases, a mother–child department and a dialysis department. The research includes over 120 h of observation, 41 semi-structured interviews and 2 focus groups.
Findings
The research shows that rebels’ quality practices are an emerging set of collaborative activities to improving healthcare and meeting (individual) patient needs. They conduct “contexting work” to achieve their quality aims by expanding their normative work to outside domains. As rebels deviate from hospital policies, they are sometimes forced to act “under the radar” causing the risk of groupthink and may undermine the aim of public accounting.
Practical implications
The research shows that in order to come to more compassionate forms of care, organizations should allow for more heterogeneity accompanied with ongoing dialogue(s) on what good care yields as this may differ between specific fields or locations.
Originality/value
This is the first study introducing quality rebels as a concept to understanding social deviance in the everyday practices of doing compassionate and good care.
Background:
The iCoach approach to case selection focuses on innovative models of community-based primary healthcare (CBPHC) and their contexts. The aim of this study was to assess the possibilities and limitations of the approach based on Denmark, which differs in significant ways from the jurisdictions initially included.
Theory and methods:
Case study research suggests the approach is an interesting attempt to standardise case selection based on literal replication. The study reviewed the national grey literature and interviewed key informants at national and local levels.
Results:
Applying the approach to Denmark required redefining selection criteria related to collaboration and context to capture its specific institutional and policy context. Selecting cases at the organisational level also required assessing how the system level contexts compared to those of the initial three jurisdictions included in iCoach.
Discussion:
The iCoach approach allows collecting broadly comparable cases of innovative models of CBPHC across jurisdictions. However, the analysis of underlying conditions of implementing innovative models requires a more interactive approach to case selection.
Conclusion:
Researchers need to be clearer about the specific purpose of the case selection. This is also highly relevant for practitioners to ensure that insights are applicable in specific local and national contexts.
Background
With its emphasis on cost-reduction and external management, New Public Management emerged as the dominant healthcare policy in many Western countries. The ability to provide comprehensive and customized patient-care is challenged by the formalized, task-oriented organization of home-care services. The aim of this study is to gain deeper understanding of how nurses and the patients they care for, relate to and deal with the organizational systems they are subjected to in Norwegian home care.
Methods
The focused ethnographic design is based on Roper and Shapira’s framework. Data collection consisted of participant observation with field notes and semi-structured interviews with ten nurses and eight patients from six home care areas located in two Norwegian municipalities.
Results
Findings indicate cultural patterns regarding nurses’ somewhat disobedient behaviors and manipulations of the organizational systems that they perceive to be based on economic as opposed to caring values. Rigid organization makes it difficult to deviate from predefined tasks and adapt nursing to patients changing needs, and manipulating the system creates some ability to tailor nursing care. The nurses’ actions are founded on assumptions regarding what aspects of nursing are most important and essential to enhance patients’ health and ensure wellbeing – individualized care, nurse-patient relationships and caring – which they perceive to be devalued by New Public Management organization. Findings show that patients share nurses’ perceptions of what constitute high quality nursing, and they adjust their behavior to ease nurses’ work, and avoid placing demands on nurses. Findings were categorized into three main areas: “Rigid organizational systems complicating nursing care at the expense of caring for patients”, “Having the patient’s health and wellbeing at heart” and “Compensating for a flawed system”.
Conclusions
Our findings indicate that, in many ways, the organizational system hampers provision of high-quality nursing, and that comprehensive care is provided in spite of - not because of - the system. The observed practices of nurses and patients are interpreted as ways of “gaming the system” for caring purposes, in order to ensure the best possible care for patients.
This article examines how social workers and managers perceive meaningful work and expertise in six care and treatment facilities in Denmark. Based on 29 interviews with social workers (n=22) and managers (n=7), the article shows how New Public Management-inspired tools such as scoring schemas align with social work values such as “client-centeredness” and working with the individual welfare recipient face-to-face. The article finds that fitting social work into organizational schemas changes the work practices of social workers and also the way members of this profession define meaningful work and expertise. In addition, the article also finds that scoring schemas cause conflicts among social workers regarding the character of expertise when values of social work (to meet a welfare recipient’s need) must be aligned with NPM-inspired values of organizations (to meet managers’ demand for documentation).
Austerity places intense pressures on labour costs in paid care. In the UK, electronic monitoring technology has been introduced to record (and materially reduce) the working time and wages of homecare workers. Based on empirical findings, we show that, in a ‘time of austerity’, care is reductively constructed as a consumption of time. Service users are constructed as needy, greedy, time-consumers and homecare workers as resource-wasting time-takers. We point to austerity as a temporal ideology aimed at persuading populations that individual deprivation in the present moment, self-sacrifice and the suppression of personal need in the here and now is a necessary requirement to underpin a more secure national future. Accordingly, women in low-waged care work are required to eschew a rights-bearing, present-tense identity and are assumed willing to suppress their entitlements to lawful wages as a sacrifice to the future. By transforming our understandings of ‘care’ into those of ‘time consumption’, and by emphasizing the virtue of present-tense deprivation, a politics of austerity appears to justify time-monitoring in care provision and the rationing of homecare workers’ pay.
Background
When functional impairment occurs, assistance to achieve self-help can lead to qualitatively more active everyday life for recipients and better use of community resources. Home-based everyday rehabilitation is a new interdisciplinary service for people living at home. Rehabilitation involves meeting the need for interprofessional services, interdisciplinary collaboration, and coordination of services. Everyday rehabilitation is a service that requires close interdisciplinary cooperation. The purpose of this study was to gain knowledge about employees’ experiences with establishing a new multidisciplinary team and developing a team-based work model.
Method
The study had a qualitative design using two focus group interviews with a newly established rehabilitation team. The sample consisted of an occupational therapist, two care workers with further education in rehabilitation, a nurse, a physiotherapist, and a project leader. Data were analyzed by thematic content analysis.
Results
The data highlight three phases: a planning phase (ten meetings over half a year), a startup phase of trials of interdisciplinary everyday rehabilitation in practice (2 months), and a third period specifying and implementing an everyday rehabilitation model (6 months). During these phases, three themes emerged: 1) team creation and design of the service, 2) targeted practical trials, and 3) equality of team members and combining interdisciplinary methods.
Conclusion
The team provided information about three processes: developing work routines and a revised team-based flow chart, developing team cooperation with integrated Trans- and interdisciplinary collaboration, and working with external exchange. There is more need for secure network solutions.
The literature on policy implementation is divided with regards to the impact of street-level bureaucrats on the implementation of public policies. In this paper, we aim to add to and nuance these debates by focusing on ‘institutional work’ – i.e. the creation, maintenance and disruption of institutions – undertaken by central authorities and street-level bureaucrats during public reform processes. On the basis of a case study of the organisational implementation of a retirement pension reform in the Norwegian Labor and Welfare Administration, we argue that institutional work is a useful heuristic device for conceptualising the variety of responses available to street-level bureaucrats during public reforms. We also argue that the responses demonstrate the impact of street-level bureaucrats in these reforms in the context of managerial control and regulation. Finally, we argue that the effectiveness of policy change is dependent on the institutional work of street-level bureaucrats and, in particular, on institutional work that supports the institutions created by politicians and public administrations.
Over the last forty years, nursing's claim to professional expertise has been expressed in terms of its care-giving function. Informed by a distinctive ‘holistic’ approach, models of nursing identify therapeutic relationships as the cornerstone of practice. While ‘knowing the patient’ has been central to clinicians' occupational identity, research reveals that nurses not only experience significant material constraints in realising these ideals, their contribution to healthcare extends far beyond direct work with patients. Amidst growing concern about healthcare quality, a body of critical commentary has emerged proposing that the contemporary nursing mandate, with its exclusive focus on care-giving, is no longer serving the interests of the profession or the public. Drawing on an ethnographic study of UK hospital nurses' ‘organising work’ and insights from practice-based approaches and actor network theory, this paper lays the foundations for a re-conceptualisation of holism within the nursing mandate centred on organisational rather than therapeutic relationships. Nurses can be understood as obligatory passage points in health systems and through myriad processes of ‘translational mobilisation’ sustain the networks through which care is organised.
Beginning with this article, our special issue advances the understanding of the role of professions in processes of institutional change and through this it proposes a retheorization of contemporary professionalism. Using institutionalist lenses in professional settings, we highlight the relationship between professionalization and broader institutionalization projects. We start by critically reviewing existing approaches in the sociology of the professions, identifying a functionalist and a conflict-based approach. Then, we build on and further elaborate an institutionalist perspective on professional work. Such a perspective affirms the importance of studying professions as institutions and connecting professionalization to broader patterns of institutionalization; it highlights the role of professions and professionals as agents in the creation, maintenance, and disruption of institutions, and recognizes the importance of accommodating contemporary patterns of professionalization within the organizational context. We also illustrate how, empirically, the eight papers in this issue advance our understanding of professional agency in contemporary change and, theoretically, contribute to the reconceptualization of the study of professionalism. Finally, we briefly summarize our contribution and identify a series of directions for further research.
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
The proximity concept is used in many different ways in the literature. These dimensions of proximity are, however, defined and measured in many different (sometimes even contradictory) ways, show large amounts of overlap, and often are under- or over-specified. The goal of this paper is to specify the different dimensions of proximity relevant in inter-organizational collaboration more precisely and to provide definitions of these dimensions. The research presented contributes to reducing the ambiguity of the proximity concept as used in the literature.
Based on the above, the following research question is addressed in this paper: ‘Which dimensions of proximity are relevant in inter-organizational collaboration and how are they defined?’ A systematic literature review is presented in order to disentangle the dimensions of the proximity concept. Based on this literature review, three dimensions of proximity relevant in inter-organizational collaboration are distinguished: geographical proximity, organizational proximity and technological proximity. Examples (case studies) from the literature are used to illustrate the current conceptual ambiguity as well as to clarify how the proposed dimensions of proximity reduce this conceptual ambiguity.
This article reflects on the process and outcomes of modernisation in adult social care in England and Wales, drawing particularly on the recently completed Modernising Adult Social Care (MASC) research programme commissioned by the Department of Health. We begin by exploring the contested status of ‘modernisation’ as a descriptor of reform. We then outline some of the distinctive features of adult social care services and suggest that these features introduce dynamics likely to shape both the experiences and outcomes of policy ambitions for modernisation. We then reflect on the evidence emerging from the MASC studies and develop a model for illuminating some of the dynamics of welfare governance. Finally, we highlight the emerging focus on individualisation and on user-directed and controlled services. We argue that the current focus of modernisation involves a reduced emphasis on structural and institutional approaches to change and an increased emphasis on changes in the behaviours and roles of adult social care service users. This focus has implications for both the future dynamics of welfare governance and for conceptions of citizenship.
Coordination among healthcare providers in intra- and inter-organizational networks is critical for the provision of seamless and efficient healthcare. Relational Coordination (RC) represents a type of coordination that enables network participants to manage interdependencies and has consistently been found to improve quality and efficiency of patient care. The majority of RC studies focuses on intra-organizational settings, while less is known about inter-organizational settings. This pilot study examined RC in relation to a collaboration between a hospital-based geriatric team and a community-based acute care team. The study focused especially on how structural challenges due to lack of technological, geographical and organizational proximity between the healthcare providers affected RC, drawing on literature on inter-organizational collaboration. We adopted a qualitative case design to gain an in-depth understanding of barriers and facilitators of interprofessional RC. Data included seven qualitative interviews with healthcare professionals and managers across the two provider teams and 16 hours of participant observations. Findings suggested that core tasks were coordinated through strong RC, while RC in non-core tasks were systematically hindered by structural challenges of the inter-organizational setting. Findings also indicated that RC in core tasks was partly dependent on formal coordination mechanisms to overcome frictions in inter-organizational structures.
Increasing pressures on social systems have spurred innovations in service delivery models. One such innovation is an increased focus on co-production-based models of care, which focus on increased personal autonomy and service-user self-determination. However, there is little empirical evidence on how co-production interacts with other social policies, such as personalisation. This paper uses data from two qualitative case studies to explore the role of co-production for personalisation in the context of recent Scottish policy initiatives. We use Osborne et al .’s (2016) [‘Co-production and the co-creation of value in public services: a suitable case for treatment?’, Public Management Review , 18, 639–653] co-production matrix to understand what forms of co-production are used in personalisation, what factors act as drivers and barriers, how co-production relates to outcomes, and how co-production theory can inform social policy and legislative reform on personalisation.
With the coordination of health care services becoming increasingly complex, the challenges of fragmentation cannot be solved by administrative restructuring alone. Attention must also be given to the coordination practices of professional groups, and, in this respect, the nursing profession is a particularly interesting case. Based on a qualitative case study of Danish nurses in hospital, municipality, and general practice, this article addresses the following question: How does the nursing profession practice formal and informal inter‐organisational coordination in complex pathways, and what is the interplay between the 2 types of coordination? The findings contribute to our knowledge of coordination at the operative level of health care by identifying specific informal practices in inter‐organisational coordination and by showing how informal coordination is activated to support formal coordination in a concurrent organisational and professional ambition of integration. The nurses studied here proved very loyal to formal inter‐organisational coordination mechanisms, prioritising them as first choices of action. When formal procedures were found insufficient, however, the nurses temporarily switched to informal coordination. This was triggered by random encounters with fragmentation, a strong professional engagement in making things work in the interest of the patient, and a constant striving to be on top of things. Informal inter‐organisational coordination is broken down into supplementary and by‐passing practices, and 4 specific by‐passing practices are identified. The discussion offers insight into how a lack of agency related to formal inter‐organisational coordination can be related to negotiated settlements, and informal coordination is considered in terms of “rule bending” within complex systems.
The professionalization of social care workers is a policy goal in many welfare states. At the same time, professionalization risks being undermined by enhanced audit. The objective of this article is to analyze whether the audit processes adopted in Swedish eldercare and childcare support or undermine the professionalization of the occupations working there, i.e., nurses, nursing assistants, preschool teachers, and preschool assistants. In particular, we investigate whether the three main forms of audit—standard-setting, inspections, and quality measurements—support or undermine the occupations’ ability to achieve professional closure and enhance their external and internal autonomy. The findings suggest that audit processes in eldercare risk undermining professionalization, while in childcare the pattern is reversed: audit appears supportive of professionalization, at least for preschool teachers. This finding suggests that audit processes do not have to be detrimental to professionalization.
Performing Governance sets out a new framework to assess the performance of partnerships and examines what these actually deliver. This is applied to three areas of New Labour’s welfare policy; child safeguarding, urban regeneration and the modernisation of health and social care. This book contributes to understanding governance under New Labour.
The objective of this article is to analyse whether the increased reliance on marketisation in the provision of social care challenges the universality of eldercare in Sweden, Denmark, Finland and Norway. The study focuses on national reforms for contracting out and user choice of provider, analysing their consequences for four universalistic dimensions: (i) equal inclusion, (ii) public funding, (iii) public provision and (iv) comprehensive usage. The findings suggest that, although need-based inclusion and public funding remain key principles in all four countries, there is an increased reliance on private provision in Sweden, Denmark and Finland. In addition, the introduction of topping-up services challenges the dimension of comprehensive usage by enabling users with economic resources to turn to the private market to increase the comprehensiveness and quality of their care.
This book has been published in three editions. The first year of publication was 2012.
The anthology focuses on the professional ‘institutional identity’ and examines the work that takes place within welfare organizations and perceives it as more than just individual-oriented work. How does the welfare state outline particular frameworks for the professionals’ jobs, and how do these frameworks affect the welfare efforts and the professionals’ self-perception – and thus the conditions for the client work as well?
The book presents a number of analyses of the many paradoxes in the daily work the professionals describe pertaining to when they are asked to implement the legislation and continue the norms celebrated by the welfare state. Examples from the social sector, the healthcare sector and the pedagogical sector are presented. The chapters of the book comprise of a broad empirical field, including professions such as addiction treatment providers, social workers, doctors, nurses, schoolteachers, pedagogues and prison officers. The analyses of the book indicate that even though these fields are very different, then there are currently certain circumstances that arguably “create one professional” in a very particular way.
The anthology is directed towards students at the socially specialized studies and the colleges of social education, students at the university institutes where there is conducted research in welfare institutions, and for the practitioners of social work.
CONTENTS: CHAPTER 1: 'Indledning: At skabe en professionel' by Margaretha Järvinen and Nanna Mik-Meyer; CHAPTER 2: 'Fra afhængighed til autonomi: At arbejde med stofbrugere' by Margaretha Järvinen; CHAPTER 3: 'Den forstående læge og evidenssøgende socialrådgiver: Rollebytte i dagens velfærdsstat' by Nanna Mik-Meyer; CHAPTER 4: 'Når personkendskab bliver professionskundskab: Aktuelle udviklinger i lærerrollen' by Helle Bjerg and Hanne Knudsen; CHAPTER 5: 'Fortællinger og fantasier om socialpædagogiske identiteter i arbejdet med unge' by Kathrine Vitus; CHAPTER 6: 'Når ansvaret overdrages til patienten: Sygeplejerskers arbejde med patientcentreret forebyggelse' by Kathrine Pii; CHAPTER 7: 'Kunsten at skabe en medfølende og engageret hospitalslæge' by Anne Roelsgaard Obling; CHAPTER 8: 'Socialrådgiverrollen under aktiveringspolitikken' by Marie Østergaard Møller; CHAPTER 9: 'Formelle og uformelle realiteter blandt fængselsfunktionærer: Om professionalisme, uklarhed, relationer og identitet' by Malene Molding Nielsen; CHAPTER 10: "Hold hænderne i lommerne": Om hjælp til selvhjælp på plejecentre' by Jens Kofod.
'This is an exhaustive text, soundly rooted in "social policy", which contains a wealth of detailed information on home care: a topic of welfare policy that is little studied... it provides an extremely useful initial analysis of home care governance in the nine countries studied and is a useful basis for further research in this area. It will be of interest to researchers and students of social policy, particularly those who are interested in undertaking comparative studies, as well as to senior managers in health and social services (national and local levels), who plan to develop and commission home care services for older people.' - Pat Chambers, International Journal of Health Planning and Management. © Viola Burau, Hildegard Theobald and Robert H. Blank 2007. All rights reserved.
This article draws on recent developments in institutional theory to better understand the managerial efforts implicated in the implementation of government-led reforms in public sector services. Based on a longitudinal study of a massive reform effort aimed at transforming the province of Quebec’s publicly-funded healthcare system, the article applies the notion of institutional work to understand how managers responsible for newly formed healthcare organizations defined and carried out their individual missions while simultaneously clarifying and operationalizing the government’s reform mandate. We identify and describe the properties of four types of work implicated in this process and suggest that structural work, conceptual work, and operational work need to be underpinned by relational work to offer chances for successful policy reform. By showing the specific processes whereby top-down reform initiatives are taken up by managers and hybridized with existing institutionalized forms and practices, this article helps us better understand both the importance of managerial agency in enacting reform, and the dynamics that lead to policy slippage in complex reform contexts.
Over the last two decades, many changes have happened to the social welfare policies of various industrial countries. Citizens have seen their pensions, unemployment benefits, and general healthcare policies shrink as “belt tightening” measures are enforced. But in contrast, long-term care has seen a general growth in public financing, an expansion of beneficiaries, and, more generally, an attempt to define larger social responsibilities and related social rights.
The aim of this book is to describe and interpret the changes introduced in long-term care policies in Western Europe. The volume argues that recent reforms have brought about an increasing convergence in LTC policies. Most of the new programs have developed a new general approach to long-term care, based on a better integration of social care and health care.
The book explores increasing public support given to family care work (in the past, the family would take care of the elderly or infirm) and increasing growth and recognition of a extended social care market (by which care has shifted from a moral obligation based on family reciprocity to a paid, professional activity). A new social care arrangement has therefore been developing in Western countries, based on a new mix of family obligations, market provision, and public support. In order to understand such changes, this analysis will take into account the social and economical impact of these reforms.
The first part of the paper argues that the care relationship is crucial to securing care quality, which has implications for the way in which quality is achieved and measured. However, for more than twenty years, governments have emphasised the part that increasing market competition and, more recently, user choice of services can play in driving up the quality of care. The second part of the paper analyses the development of social care services for older people, from the reform of 1990 to the changes following the general election of 2010. The paper goes on to examine whether competition and choice are in any case enough to result in ‘good care’, given the evidence of limitations both in the amount of choice available and in how far older people are able or willing to choose. It is argued that if ‘good care’ depends disproportionately on the quality of the care relationship, then more attention should be paid to the care workforce, which has received relatively little comment in recent government documents.
Healthy and active ageing has become an ideal in Western societies. In the Nordic countries, this ideal has been supported through a policy of help to self-help in elder care since the 1980s. However, reforms inspired by New Public Management (NPM) have introduced a new policy principle of consumer-oriented service that stresses the wishes and priorities of older people. We have studied how these two principles are applied by care workers in Denmark. Is one principle or logic replacing the other, or do they coexist? Do they create tensions between professional knowledge and the autonomy of older people? Using neo-institutional theory and feminist care theory, we analysed the articulation of the two policy principles in interviews and their logics in observations in four local authorities. We conclude that help to self-help is the dominant principle, that it is deeply entrenched in the identity of the professional care worker and that it coexists with consumer-oriented service and without major tensions in the logics identified in their practices.
Modernising health care: Reinventing professions, the state and the public is a crucial contribution to debates about the rapid modernisation of health care systems and the dynamics of changing modes of governance and citizenship. Structured around the role of the professions as mediators between state and citizens, and set against a background of tighter resources and growing demands for citizenship rights, Ellen Kuhlmann’s book offers a much-needed comparative analysis, using the German health care system as a case study. The German system, with its strongly self-regulatory medical profession, exemplifies both the capacity of professionalism to re-make itself, and the role of the state in response, highlighting the benefits and dangers of medical self-regulation, while demonstrating the potential for change beyond marketisation and managerialism. Kuhlmann critically reviews dominant models of provider control and user participation, and empirically investigates different sets of dynamics in health care, including tensions between global reform models and nation-specific conditions; interprofessional dynamics and changing gender arrangements; the role of the service-user as a new stakeholder in health care; and the rise of a new professionalism shaped by social inclusion. Modernising health care provides new approaches and a wealth of new empirical data for academics and students of health policy, medical sociology and sociology of professions, and for health policy makers and managers.
This collection seeks to reconnect two separate streams of work on professional organizations and professional occupations. In particular the articles collected here identify two key themes: (1) the challenges and opportunities that professional organizations pose for established and emerging professionalization projects and (2) the extent to which professional organizations create, institutionalize and manipulate new forms of professionalism and models of professionalization. To this effect, this collection brings together a number of articles from a broad range of disciplines (sociology, management, healthcare, accountancy, law and geography), theoretical backgrounds and national contexts which explore the complex connections between professional occupations and organizations.
Governance is now quite widely used as a frame of analysis, although not in social policy. This article elaborates some of the different roots and usages of governance and interrogates the utility of the concept for the discipline and study of social policy. Having traced the concept's diverse origins and contemporary usages, the article goes on to develop from them a framework for the analysis of developments in public policy in the UK under New Labour. This is then applied to consider in turn the nature of the public sphere, policy-making, policy implementation and societal incorporation. This leads to a discussion of the various strengths and weaknesses of governance. The former include its direct interest in policy-making, its focus on power and the state and the fact that it can connect different levels of action and analysis. On the negative side, though, one must question to what extent a governance perspective finds social policy interesting in its own right and whether its over-riding focus on state and government leads it to residualise both social policy and society.
The Swedish welfare state has, during the twentieth century, developed into the primary guarantor of health and social services as well as economic security. As the welfare state has developed, a new group of professions has emerged which can be described as welfare state professions. In this paper I will point out a few central aspects of how female‐dominated welfare state professions have emerged and developed within the framework of the Swedish welfare state's expansion. These ideas will then be demonstrated on two female‐dominated occupations, nurses and occupational therapists, which have developed in close association with the expansion of the welfare state.
The results indicate that the emergence of a centrally planned welfare state and the occupational groups' organizational resources have been of crucial importance for the professional development of female‐dominated health and care occupations in Sweden. The welfare state has opened up new professional fields and created a stable labour market, which has provided good conditions for professional organizing. The state has also been quick to establish relationships with occupational groups whose professional competence has been deemed to be suited to the welfare political context. However, the state's interests in professional matters have often been in conflict with those of the professions themselves, regarding, for example, education, sub‐specialization and certification. One conclusion that can be drawn is that the Swedish welfare state has acted both as an engine and a brake regarding professional development and status.
The professional terms for occupations that provide welfare services are changing, and here the introduction of new public management in the Nordic countries since the 1990s is indicative of wider developments. The article explores professional projects in welfare service work from both conceptual and empirical perspectives. The aim is to produce a gender-sensitive analysis of the professional projects at the lower levels of the occupational hierarchies in health care. The first part reviews the literature conceptualizing the societal and institutional embeddedness of professional projects. The institutional matrix of welfare states emerges as a key context in shaping the welfare service work performed by women-dominated professional groups. The second part examines the case of Finland and suggests that recent reforms have created new inequalities in the system of professions, in which occupational groups in welfare service work are becoming marginalized. This signals a move away from ‘democratic professionalism’ towards a revival of ‘old professionalism’.
This paper discusses four dimensions of the capitalist state's role in economic and social reproduction: its economic and social policy roles, the scales on which these roles are performed, and the modes of governance with which they are associated. It describes the typical postwar welfare regime on these dimensions, analyses the crisis in the governance of welfare that began to emerge in the late 1970s and 1980s, and characterizes the new regime that is tendentially replacing the postwar welfare state.
Hjörne E, Juhila K, van Nijnatten C. Negotiating dilemmas in the practices of street-level welfare work
Int J Soc Welfare 2010: 19: 303–309 © 2010 The Author(s), Journal compilation © 2010 Blackwell Publishing Ltd and International Journal of Social Welfare.
The theme of this mini-symposium is based on the core ideas of two influential books published about 30 years ago, namely Michael Lipsky'sStreet-Level Bureaucracy – Dilemmas of the Individual in Public Services (1980) and Jeffrey Prottas'sPeople-Processing – The Street-Level Bureaucrat in Public Service Bureaucracies (1979). In these books, three dilemmas were identified that have great importance for welfare workers' position as mediators between institutions and citizens: autonomy versus control, responsiveness versus standardisation, and demand versus supply. In this editorial, we discuss these dilemmas with regard to the present context of street-level welfare work, which is strongly influenced by managerialist policies (also called new public management). It is emphasised that in the era of managerialism, the dilemmas should be approached as empirical matters: how they are present, talked into being and negotiated in naturally occurring practices of street-level welfare work, and with what consequences.
Sygeplejersker som ‘organisatorisk lim’ i sundhedsvæsenet: interorganisatoriske, professionelle og feminine perspektiver [Nurses as ‘organisational glue’ in the healthcare system: inter-organisational professionals and feminine perspectives
- A Doessing
Doessing, A. (b), Sygeplejersker som 'organisatorisk lim' i sundhedsvaesenet: interorganisatoriske, professionelle og feminine perspektiver [Nurses as 'organisational glue' in the
healthcare system: inter-organisational professionals and feminine perspectives], Aalborg:
Aalborg Universitetsforlag.
Forløbsmodellen trin for trin
- Omsorg Sundhed Og
Sundhed og Omsorg (), Forløbsmodellen trin for trin. [The Care Pathway step by step]
Sundhed og Omsorg, Aarhus Kommune.
The formation of professions: knowledge, state and strategy
- M Bertilsson
Bertilsson, M. (), The welfare state, the professions and the citizens, in R. Torstendahl and
M. Burrage (eds.), The formation of professions: knowledge, state and strategy. London:
Sage, -.
The Routledge companion to the professions and professionalism
- V Burau
Burau, V. (), Governing through professional experts, in M. Dent, I. L. Bourgeault, J. L.
Denis and E. Kuhlmann (eds.), The Routledge companion to the professions and professionalism, London: Routledge, -.
The Routledge companion to the professions and professionalism
- J L Denis
- N Van Gestel
- A Lepage
Sociological and organisational theories of professions and professionalism
- S Ackroyd
Ackroyd, S. (), Sociological and organisational theories of professions and professionalism, in M. Dent, I. L. Bourgeault, J. L. Denis and E. Kuhlmann (eds.), The Routledge companion to the professions and professionalism, London: Routledge, -.
), Etnography: principles in practice, rd
- M Hammersley
- P Atkinson
Hammersley, M. and Atkinson, P. (), Etnography: principles in practice, rd. ed., London:
Routledge.
Four Nordic countries -four responses to the international trend of marketization
- M Szebehely
- G Meagher
Szebehely, M. and Meagher, G. (), Four Nordic countries -four responses to the international trend of marketization, in G. Meagher and M. Szebehely (eds.), Marketization in
elder care, Stockholm University: Department of Social Work.
Rehabilitering på ældreområdet. Hvad fortæller danske undersøgelser os om kommuners arbejde med rehabilitering i hjemmeplejen? [Rehabilitation in elder care: what do Danish studies tell us about the municipalities’ work with rehabilitation in home care?
- A Petersen
- L Graff
- T Rostgaard
- J Kjellberg
- P K Kjellberg
Responsive brobyggere som alternativ til regelsfølgende omsorgsgivere og incitamentsstyrede lønarbejdere [Public frontline employees: responsive bridge-builders as alternative to rules following caregivers and incentive driven employees
- E Sørensen
- J Torfing
Sørensen, E. and Torfing, J. (), Offentlige frontlinjemedarbejdere. Responsive brobyggere
som alternativ til regelsfølgende omsorgsgivere og incitamentsstyrede lønarbejdere
[Public frontline employees: responsive bridge-builders as alternative to rules following
caregivers and incentive driven employees], in Torfing, J. and Traintafillou, P. (eds.), New
public governance -på dansk, Copenhagen: Akademisk Forlag, -.
), Fra kitler til eget tøj: diskurser om professionalisme, omsorg og køn
- H M Dahl
Dahl, H. M. (), Fra kitler til eget tøj: diskurser om professionalisme, omsorg og køn, Aarhus:
Aarhus Universitet.
), Professional agency, leadership and organisational change
- J L Denis
- N Van Gestel
- A Lepage
Denis, J. L., van Gestel, N. and Lepage, A. (), Professional agency, leadership and organisational change, in Dent, M., Bourgeault, I. L., Denis, J. L. and Kuhlmann, E. (eds.), The
Routledge companion to the professions and professionalism, London: Routledge, -.