Anna Dunér

The discretion and power of street-level bureaucrats: an example from Swedish municipal eldercare

This paper focuses on discretion in the frontline practice of social work with elderly people in Sweden. The aim is to describe and analyse how care managers in municipal eldercare use discretion and power in needs assessment and decision-making. Emanating from Lipskys concept of discretion, we identify the conditions of decision-making, which along with the concepts of structural power and intentional power constitute the theoretical framework of our analysis. Eight care managers from four Swedish municipalities were observed and interviewed. The researchers carried out 38 observations and nine in-depth interviews. The analysis led to the identification of four techniques in the decision-making process of care managers: reject, execute, transform needs and control. The consequences of these practices are discussed at the end of the paper. Denna artikel handlar om beslutsprocessen inom socialt arbete med äldre i Sverige. Syftet är att beskriva och analysera hur några biståndsbedömare inom kommunal äldreomsorg, som exempel på frontlinjebyråkrater, använder sitt handlingsutrymme och sin makt. Utifrån Lipskys begrepp handlingsutrymme, beskriver vi de villkor för beslutsfattandet som tillsammans med begreppen strukturell och intentionell makt, utgör ramen för analysen av det empiriska materialet. Åtta biståndsbedömare, från fyra svenska kommuner, har observerats och intervjuats. Sammanlagt har 38 observationer och nio djupintervjuer genomförts. I analysen framträder fyra handlingssätt i biståndsbedömarnas beslutsprocess: avvisa, expediera, omvandla behov och kontrollera. Konsekvenserna av dessa handlingssätt diskuteras avslutningsvis i artikeln. Handlingsutrymme Strukturell Och Intentionell Makt Frontlinjebyråkrater Beslutsfattande Äldreomsorg Biståndsbedömare

The roles and functions of the informal support networks of older people who receive formal support: a Swedish qualitative study

Several studies of frail older people have focused on the relationship between formal and informal care, while others have examined the character of inter-generational relationships. Yet knowledge of the significance of the informal-support networks of older people who receive formal care is still scarce. The aim of this paper was to explore how older Swedes who receive formal elder-care experienced their informal support networks. The findings presented emanate from a qualitative case study. The structural, interaction and functional dimensions of the support networks were the main analytical tools. In the study population, the size of the formal support network varied from one to 12 people (or categories of people), and the size of the informal support network varied from one to six people (or categories of people). The main results demonstrate the importance of informal support with reciprocal relationships, and the value of confidants and emotional support, both of which contribute to feelings of belonging, security and wellbeing. A well-functioning formal and informal support network allows individuals to maintain autonomy in old age, even when they have to depend on help from others.

Care planning and decision-making in teams in Swedish elderly care: A study of interprofessional collaboration and professional boundaries

In front-line practice, joint working between different professionals in health/social care and rehabilitation is regarded as a means to reach a comprehensive assessment of the needs of the older care recipients, leading to decisions on appropriate care and services. The aim of this study was to examine professional collaboration and professional boundaries in interprofessional care planning teams. Two different care planning teams were studied, one performing care planning in the homes of older individuals and the other performing care planning for older people in hospital wards. The empirical data consisted of audio-recorded care planning meetings and interviews with the professionals in the teams. The integration between the professionals involved was most noticeable in the investigation and assessment phase, while it was lower in the planning phase and almost non-existent in decision-making. The home care planning team tended to work in a more integrated manner than the discharge planning team. The importance of clarifying the roles of all professions concerned with needs assessment and care planning for older people became evident in this study.

Multi-professional and multi-dimensional group education – a key to action in elderly persons

Purpose: This study was intended to evaluate a multi-professional health-promoting and disease-preventive intervention organized as multi-professional senior group meetings, which addressed home-dwelling, independently living, cognitively intact elderly persons (80±), by exploring the participants’ experiences of the intervention. Method: The focus group methodology was used to interview a total of 20 participants. The informants had participated in four multi-professional senior group meetings at which information about the ageing process and preventive strategies for enhancing health were discussed. Results: The overall finding was that the elderly persons involved in the intervention lived in the present, but that the supportive environment together with learning a preventive approach contributed to the participants’ experiencing the senior meetings as a key to action. Conclusions: Elderly persons who are independent may have difficulty accepting information about preventing risks to health. However, group education with a multi-professional approach may be a successful model for achieving an exchange of knowledge, which may possibly empower the participants, give them role models, the opportunity to learn from each other and a sense of sharing problems with people in similar circumstances. Implications for Rehabilitation Since elderly persons these days are expected to live beyond their 80 s, there is still time for interventions aimed at health promotion and disease prevention to have an effect on functional status and the quality of life of their remaining years. Elderly persons who are independent may have difficulty accepting information about preventing risks to health. Multi-professional health promoting and disease-preventive senior meetings could motivate elderly persons to act on behalf of their own health. Multi-professional collaboration combined with the group model made the participants in our study experience the senior meeting as a key to action.

Older people's views of quality of care: a randomised controlled study of continuum of care

AIMS AND OBJECTIVES To analyse frail older peoples views of quality of care when receiving a comprehensive continuum of care intervention, compared with those of people receiving the usual care (control group). The intervention included early geriatric assessment, case management, interprofessional collaboration, support for relatives and organising of care-planning meetings in older peoples own homes. BACKGROUND Prior studies indicate that tailored/individualised care planning conducted by a case manager/coordinator often led to greater satisfaction with care planning among older people. However, there is no obvious evidence of any effects of continuum of care interventions on older peoples views of quality of care. DESIGN Randomised controlled study. METHODS Items based on a validated questionnaire were used in face-to-face interviews to assess older peoples views of quality of care at three, six and 12 months after baseline. RESULTS Older people receiving a comprehensive continuum of care intervention perceived higher quality of care on items about care planning (p ≤ 0·005), compared with those receiving the usual care. In addition, they had increased knowledge of whom to contact about care/service, after three and 12 months (p < 0·03). CONCLUSIONS The study gives evidence of the advantages of a combination of components such as organising care-planning meetings in older peoples own homes, case management and interprofessional teamwork. RELEVANCE TO CLINICAL PRACTICE The results have implications for policymakers, managers and professionals in the area of health and social care for older people to meet individual needs of frail older people.

Interprofessional collaboration in Swedish health and social care from a care manager's perspective Interprofessionell samverkan i svensk hälso- och sjukvård och social omsorg ur biståndshandläggares perspektiv

The aim of this study was to study interprofessional collaboration in health and social care for older people and persons with disabilities from a care managers perspective. The empirical data was collected at a workshop held during a national conference for care managers and through focus group interviews in two Swedish municipalities. The results showed that the care managers collaborated in different ways with many different professionals from different organisations. The care and discharge planning meetings emerged as the most typical situation where care managers collaborated with different health care professionals. Interprofessional collaboration was seen as a means for care managers to fulfil their assignment and carry out their work. The care manager role encompassed role strain, a relatively weak professional identity, and differences in professional status among those involved in interprofessional collaboration.

The impact of socioeconomic conditions, social networks, and health on frail older people’s life satisfaction: a cross-sectional study

It has been shown that frailty is associated with low levels of well-being and life satisfaction. Further exploration is needed, however, to better understand which components constitute life satisfaction for frail older people and how satisfaction is related to other life circumstances. The aim of this study was to examine relationships between frail older people’s life satisfaction and their socioeconomic conditions, social networks, and health-related conditions. A cross-sectional study was conducted (n=179). A logistic regression analysis was performed, including life satisfaction as the dependent variable and 12 items as independent variables. Four of the independent variables made statistically significant contributions: financial situation (OR 3.53), social contacts (OR 2.44), risk of depression (OR 2.26), and self-rated health (OR 2.79). This study demonstrates that financial situation, self-rated health conditions and social networks are important components for frail older people’s life satisfaction. Health and social care professionals and policy makers should consider this knowledge in the care and service for frail older people; and actions that benefit life satisfaction – such as social support – should be promoted.

Organizing integrated care for older persons: strategies in Sweden during the past decade

PURPOSE The purpose of this paper is to describe and analyse ways of organizing integrated care for older persons in Sweden during the past decade. DESIGN/METHODOLOGY/APPROACH The data consist of 62 cases of development work, described in official reports. A meta-analysis of cases was performed, including content analysis of each case. A theoretical framework comprising different forms of integration (co-ordination, contracting, co-operation and collaboration) was applied. FINDINGS Co-operation was common and collaboration, including multiprofessional teamwork, was rare in the cases. Contracting can be questioned as being a form of integration, and the introduction of consumer choice models appeared problematic in inter-organization integration. Goals stated in the cases concerned steering and designing care, rather than outcome specifications for older persons. Explicit goals to improve integration in itself could imply that the organizations adapt to strong normative expectations in society. Trends over the decade comprised development of local health care systems, introduction of consumer choice models and contracting out. RESEARCH LIMITATIONS/IMPLICATIONS Most cases were projects, but others comprised evaluations of regular organization of integrated care. These evaluations were often written normatively, but constituted the conditions for practice and were important study contributions. PRACTICAL IMPLICATIONS Guiding clinical practice to be aware of importance of setting follow-up goals. SOCIAL IMPLICATIONS Awareness of the risk that special funds may impede sustainable strategies development. ORIGINALITY/VALUE A theoretical framework of forms of integration was applied to several different strategies, which had been carried out mostly in practice. The study contributes to understanding of how different strategies have been developed and applied to organize integrated care, and highlights some relationships between integration theory and practice.

A matter of love and labour? Parents working as personal assistants for their adult disabled children

The overall aim was to explore experiences of parents working as personal assistants (PAs) for their adult disabled children, with a focus on the roles of these parents and the intersection between formal and informal support. In 1994, the right to personal assistance was introduced in Sweden. The intention was to promote disabled people’s independence and participation in society. Many users combine personal assistance from family members with non-family assistance. Employing parents of adult children as PAs has been depicted as a barrier to independence and adulthood, but can also be seen as lessening potential difficulties of having ‘strangers’ deliver support in the private sphere. Welfare policies and social work practices have a major impact on the lives of families with disabled children. Fourteen parents working as PAs for their adult children were interviewed. For the parents, pursuing an employee role outside the home was very difficult to combine with the caring role. Shortcomings in the formal support system and battles with social services to receive adequate and appropriate support were experienced as burdensome. Families with disabled members were forced into very traditional family patterns and found themselves interwoven into a complex fabric of emotional and economic interdependence.

Support networks and social support for persons with psychiatric disabilities—a Swedish mixed-methods study

The aim of this study was to explore the structure, interaction, and function of the support networks of women and men with psychiatric disabilities. The study took a mixed-methods approach, using quantitative (n=181) and qualitative (n=42) data from a region in southern Sweden. The quantitative results showed that the respondents received widespread support of different types and from many different sources. However, the qualitative interviews revealed that many of the interviewees did not perceive the received support as supportive. The respondents’ internal resources influenced both their ability to receive support and their perception of the support. The informal and formal support sources formed the external resources of the respondents. Our interviewees often experienced formal support as conditional support, while informal support from the family was experienced as unconditional. There was thus a gap between the structure and function of the social support. This article contributes important knowledge from the perspective of persons with psychiatric disabilities.