Anna Olaison

Handling the Dilemma of Self-Determination and Dementia: A Study of Case Managers’ Discursive Strategies in Assessment Meetings

In assessment meetings concerning care services for people with dementia, Swedish case managers face a dilemma. On the one hand, according to the law, the right to self-determination of every adult citizen must be respected, but on the other hand cognitive disabilities make it difficult to fulfill obligations of being a full-fledged citizen. In this article, we examine 15 assessment meetings to identify discursive strategies used by case managers to handle this dilemma. We also examine how these affect the participation of persons with dementia, and indicate implications of our study for social work practice and research.

Creating Images of Old People as Home Care Receivers Categorizations of Needs in Social Work Case Files

Central to the assessment process in case management is how older people’s needs are constructed through documentation and case files. This article examines how older people’s needs are categorized in written documentation. Sixteen case files from three social work districts in Sweden were studied using discourse analysis. The results identified two general types of case files; the fact-oriented (using objective language) and event-oriented case file (using more personal language) — which depicted the older individuals quite differently. All case files employed several need categories; though social needs were important in describing living conditions, it was medical and physical needs that impinged on home care decisions. This raises questions about how case documentation depicts older people through society’s eyes and about the discourses prevailing in gerontological social work.

Orally Positioning Older People in Assessment Meetings

It has been demonstrated that persons with dementia may be positioned as less competent than participants of the same age without dementia, and that persons with dementia possibly also are positioned as less competent than other older persons without dementia. In the present study, we aim to explore this further by analyzing Swedish assessment meetings in which needs and preferences are investigated for older persons without dementia. The material consists five audio-recorded assessment meetings, where there were at least two conversational partners present (a spouse and/or a child) and where the older person applying for social services was not diagnosed with dementia. The ages of the older persons ranged from 81 to 88, while the age of the relatives ranged from 46 to 93. The results of the present study demonstrate that older persons without dementia mainly are positioned as competent. However, it may be related to the degree of frailty, because the frailest person in the present study appears to be positioned as less competent than the other participants. The present paper adds to existing knowledge on how professionals in assessment meetings contribute to the positioning of older persons as competent and capable of making decisions. The results of the present article may be useful to promote development of education and training of communication skills for care mangers in assessments. Such training would further ensure that older persons with and without cognitive impairments can be actively involved in the creation and interpretation of their applications for social services.

Processing older persons as clients in elderly care: A study of the micro-processes of care management practice

ABSTRACT Elder care has undergone a marketization in recent years in which various models for care management have been introduced with the aim of making assessments efficient. This article investigates the effects the care management model has on resource allocation for home care when handling the requests of older persons in the needs assessment process. Sixteen tape-recorded assessment conversations with associated case-file texts were analyzed through discourse analysis. The results show that a managerialist thinking has had a partial impact on the assessment process where the documentation requirements have entailed bureaucratization in terms of the transfer that occurs from talk to text. The findings from the study nevertheless indicate that the assessment conversations have clear elements of an individual-centred perspective in which there is room for a care rational dialogue. This constitutes a welfare policy dilemma today. Providing for older people’s requests should be on the basis of quality and an individual-centred perspective and care management has had a contrary effect in which focus is directed instead towards needs assessment and bureaucratic processes.

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.

What is yet to come? Couples living with dementia orienting themselves towards an uncertain future:

Dementia is a chronic illness that not only has substantial effects on the life as well as future for the individuals diagnosed, but also affects those with whom these individuals have relationships. This has implications that need to be addressed by professional practice, not least since social work research has shown that the support available for couples managing dementia is insufficient. There are few studies today of how couples jointly talk about their future with dementia and how they adapt to it as a couple and as individuals. Therefore, this article explores how couples in which one of the spouses has a diagnosis of dementia jointly talk about an uncertain future with dementia. The study benefits from using the conversation analytic method when studying video-recorded interactions among 15 couples living with dementia. The results show that either or both spouses can actively request knowledge about the progression of dementia, but at the same time, the spouses without dementia express awareness of the uncertainty that is connected to a future with dementia. Moreover, either or both spouses may also express contentment with “not knowing.” In all examples, one or several of the participants alternate between taking epistemic stances of knowing and unknowing as well as ascribing stances to others, and spouses can display similar or oppositional stances. The findings suggest a need for developing communicative practice for couples to jointly talk about dementia, as well as a need for social workers to find ways of providing emotional support.