Frontline Practice Research Articles

P150 Death anxiety recognition in a palliative care setting

Death anxietyis the "feeling of dread, apprehension or solicitude (anxiety) when one thinks of the process of dying, or ceasing to ‘be’." (1)IntroductionRecognition of death anxiety is important in hospice...

Electronic Information Systems and Human Services Organisations: Avoiding the Pitfalls of Participatory Design

Recent research and evaluation of the forms of electronic information systems (IS) being used in child welfare agencies in both Australia and England and Wales have shown that, despite the many millions of dollars spent, not only are they unfit for purpose, but also they may undermine front line practice. Jurisdictions may differ in their readiness to accept and respond to these criticisms, but attention is now turning to how IS can be designed that do meet the needs of practitioners. A particular problem that has been identified is the limited involvement that practitioners have had in the design of IS and efforts are now being made to include them. Though there is a considerable amount of literature about how to include the intended users of technology in designing IS, there is a paucity of advice that is relevant to the particular circumstances of social work and social care practitioners. Drawing from an ethnographic study of an IS implementation project in a human services organisation, this article aims to begin to address this gap in the literature by articulating some of the pitfalls for social workers and other human services staff who may become involved in the design, or redesign, of IS.

Transforming New Ideas into Practice: An Activity Based Perspective on the Institutionalization of Practices

AbstractWe develop an activity‐focused process model of how new ideas can be transformed into front line practice by reviving attention to the importance of habitualization as a key component of institutionalization. In contrast to established models that explain how ideas diffuse or spread from one organization to another, we employ a micro‐level perspective to study the subsequent intra‐organizational processes through which these ideas are transformed into new workplace practices. We followed efforts to transform the organizationally accepted idea of ‘interdisciplinary teamwork’ into new everyday practices in four cases over a six year time period. We contribute to the literature by focusing on de‐habitualizing and re‐habitualizing behaviours that connect micro‐level actions with organizational level theorizing. Our model illuminates three phases that we propose are essential to creating and sustaining this connection: micro‐level theorizing, encouraging trying the new practices, and facilitating collective meaning‐making.

‘I mean, obviously you're using your discretion’: Nurses Use of Discretion in Policy Implementation

This article explores the application of Lipsky's (1980) notion of street-level bureaucracy for nursing staff. This article aims to demonstrate the importance of discretion within the day-to-day work of front-line nursing staff, which is similar to that of other public-sector workers. The findings are from an exploratory case study based within a Scottish inner-city hospital. It specifically focuses on how nurses can be seen to be street-level bureaucrats and how front-line nursing staff interpret policy. Discretion can be seen to be a significant feature within the front-line practice of nursing staff and this may have implications for the implementation of health policy.

Turned off and burned out: what will it take for "front-line" medicine to tune back in?

The United States is facing a severe shortage of physicians providing access at the front lines of care access. Specialties with provider shortages include general medicine, family medicine, and other fields providing longitudinal primary and comprehensive care.1,2 In fact, because nearly one-half of visits to subspecialists actually involve primary and general medical care services,3,4 the insufficient supply of front-line physicians to meet patient care demands may be even more extreme than current projections suggest. Despite this impending crisis, student and resident interest in these front-line longitudinal care fields has been stagnant at best in recent years and has declined drastically during the past 2 decades.5,6 For example, in 2012, only 6% of graduating medical students planned careers in family medicine.6 Additional data suggest only 2% of graduating medical students plan to practice general or primary care internal medicine,7 and only 1 in 5 internal medicine residents plans a career in general medicine after graduation.8

Implementation of pay for performance in primary care: a qualitative study 8 years after introduction

Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF). To obtain a longer term perspective on the implementation of the QOF. Qualitative study with 47 health professionals in 23 practices across England. Method Semi-structured interviews. Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients' best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences. Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care.

Provider Views of Harm Reduction Versus Abstinence Policies Within Homeless Services for Dually Diagnosed Adults

Harm reduction is considered by many to be a legitimate alternative to abstinence-based services for dually diagnosed individuals, yet there is limited understanding of how varying approaches affect front-line practice within services for homeless adults. This paper examines how front-line providers working with individuals who have experienced homelessness, serious mental illness, and addiction view policies of harm reduction versus abstinence within two different approaches to homeless services: the traditional or "treatment first" approach that requires abstinence, and the more recent housing first approach that incorporates harm reduction. As part of a federally funded qualitative study, 129 in-depth interviews conducted with 41 providers were thematically analyzed to understand how providers view harm reduction versus abstinence approaches. Themes included the following: (a) harm reduction as a welcomed alternative, (b) working with ambiguity, and (c) accommodating abstinence. Drawing on recovery principles, the authors consider the broader implications of the findings for behavioral health care with this population.

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.

Scotland's Knowledge Network: translating knowledge into action to improve quality of care

The Knowledge Network (www.knowledge.scot.nhs.uk) is Scotland's online knowledge service for health and social care. It is designed to support practitioners to apply knowledge in frontline delivery of care, helping to translate knowledge into better health-care outcomes through safe, effective, person-centred care. The Knowledge Network helps to combine the worlds of evidence-based practice and quality improvement by providing access to knowledge about the effectiveness of clinical interventions ('know-what') and knowledge about how to implement this knowledge to support individual patients in working health-care environments ('know-how'). An 'evidence and guidance' search enables clinicians to quickly access quality-assured evidence and best practice, while point of care and mobile solutions provide knowledge in actionable formats to embed in clinical workflow. This research-based knowledge is complemented by social networking services and improvement tools which support the capture and exchange of knowledge from experience, facilitating practice change and systems improvement. In these cases, the Knowledge Network supports key components of the knowledge-to-action cycle--acquiring, creating, sharing and disseminating knowledge to improve performance and innovate. It provides a vehicle for implementing the recommendations of the national Knowledge into Action review, which outlines a new national approach to embedding knowledge in frontline practice and systems improvement.

Moral agency in everyday safeguarding work: reclaiming hope in the ‘small stories’ of family support: some lessons from John Dewey

This article engages with international concerns about the negative impact of an expanding neoliberal project on the professional values of social work. Examining theoretical debates about human agency, a case is made for cultivating a moral sensibility in the practitioner workforce to resist the excesses of the neoliberal paradigm. Rejecting depictions of the practitioner as ‘institutional dope’, discussion excavates the early work of classical pragmatist John Dewey to counter assertions that institutional context simply determines practitioner beliefs and actions. A number of illustrative examples are provided from the author’s fieldwork in sites of local authority children’s services, which challenge a presumed singularity of ethical disposition. Excerpts from practitioners’ case deliberations are offered as ‘small stories’ of hope and illustrate the heterogeneity of frontline practice. The article aims to speak to readers in search of a more hopeful imaginary for social work and who are wary of monolithic accounts of practice.

A common sense approach to advance care planning: translation of theory into every day front-line practice

Advance care planning (ACP), in its most sophisticated form, is a comprehensive, ongoing, and holistic communication between a physician and his or her patient (or the patient's designated proxy) about...

Social Work in Police Stations: Challenges for Front Line Practice in India

The article discusses the need for social work practice in police stations. The first part presents the current state of the Indian Criminal Justice System (CJS). The next section situates CJS within the mandate of a welfare state. The issues related to policing and corrections in the country precede the section elucidating the role of and challenges faced by a social worker in the police station. It suggests that Social Work practice within the CJS would facilitate a tactical shift in its approach to address the domain of civil and political rights. The article concludes that while there is need for a partnership between social workers and police, the divergent cultures and mandates of the two professions makes it difficult, even though both have a commitment to protection.

What's at risk? The proliferation of risk across child and youth policy in England

The concept of risk has found increasing prominence in social policy, human services management and front-line practice in recent years. This is particularly the case in relation to children and young people, who, in the UK, have been subject to a range of interventions based on the identification of population-based risk factors. Through the analysis of UK publications (primarily covering England) relating to children and young people during the Labour Government (1997–2010), this article identifies how risk has proliferated across a wide range of youth-related fields, becoming a social, political and moral entity in itself rather than a tool for primarily criminological prediction and intervention. The article concludes that this proliferation demands further empirical study and theoretical scrutiny beyond the criminal justice sphere in which it is often contained and also questions the extent to which the construction of youth both ‘at-risk’ and ‘as-risk’ is a useful and effective way of driving policy and practice interventions.

Welfare Reform, Jobcentre Plus and the Street-Level Bureaucracy: Towards Inconsistent and Discriminatory Welfare for Severely Disadvantaged Groups?

A defining feature of UK welfare reform has been concerted moves towards greater conditionality and sanctioning which has stimulated much academic debate. However, few policy articles have sought to examine how welfare reforms are actually implemented. Lipsky (1980) has shown that the intentions of policy makers may be frustrated by the behaviour of public service workers operating in a ‘corrupted world of service’. This article draws upon the findings of the evaluation of the Jobseekers Mandatory Activity to discuss how key welfare reforms are likely to be implemented. It argues that that discretion remains a significant feature of front-line practice with potentially profound implications for severely disadvantaged groups.

Enabling risk and ensuring safety: self‐directed support and personal budgets

PurposeThis paper aims to present a digest of the main discussion points and key findings from a recent Social Care Institute for Excellence report on risk enablement and safeguarding in the context of self‐directed support and personal budgets.Design/methodology/approachThe paper explores how the personalisation agenda and adult safeguarding can work together in policy and practice and addresses some of the frontline concerns about empowerment and duty of care.FindingsEvidence on how self‐directed support and personal budgets can be used to enable people to take positive risks while staying safe and emerging practice is examined. It suggests that person‐centred working in adult safeguarding, along with the mechanism of self‐directed support planning and outcome review, can support the individual to identify the risks they want to take and those they want to avoid in order to stay safe. It is clear that if frontline practitioners are overly occupied with protecting organisations and individuals from financial abuse, this will impact on the capacity of those practitioners exercising their duty of care at the front line. This means that practitioners are less able to engage with individuals to identify safeguarding issues and enable positive risk taking. Defensive risk management strategies or risk‐averse frontline practice may then result in individuals not being adequately supported to make choices and take control and, therefore, being put at risk. Practitioners need to be supported by local authorities to incorporate safeguarding and risk enablement in their relationship‐based, person‐centred working. Good quality, consistent and trusted relationships and good communication are particularly important for self‐directed support and personal budget schemes.Originality/valueThe use of “risk enablement panels” and “personalisation and safeguarding frameworks” are two ways to address some of the issues in practice.

‘Street‐level Bureaucracy’ Revisited: The Changing Face of Frontline Discretion in Adult Social Care in England

AbstractThis reassessment of the continuing significance of Lipsky's (1980) work on ‘street‐level bureaucracy’ for frontline decision making is based on a retrospective review of the author's research on assessment practice in adult social care in England. The studies span the past two decades during which time successive governments have restructured and modernized social services departments. When these were established in 1970, they represented the high watermark of bureau‐professionalism – a mode of administration which dominated social welfare at the time Lipsky was writing. The subsequent dismantling of bureau‐professionalism calls into question the validity of his findings, and the author draws on her own research to assess conflicting views about the impact of social care reforms on the discretion which social workers exercise as street‐level bureaucrats. She concludes that the distinct types of discretion to emerge from her findings, represented in a taxonomy, are shaped by the differing micro environments of frontline practice which, in turn, affect the relative force of managerialism, professionalism and user empowerment in countering the defensive exercise of discretion described by Lipsky. Whilst her analysis affirms the continuing significance of Lipsky's analysis, it also points to the need for some revision to accommodate major shifts in welfare administration since the publication of his work. She highlights the potential relevance of these insights for investigating the next planned transformation of adult social care, personalization, as well as for the implementation literature more widely.

Trust, risk and the (mis)management of contingency and discretion through new information technologies in children’s services

• Summary: While UK social work’s core purpose in children’s services continues to invoke the ready virtues of universal care, protection from significant harm and a child rights led approach as foundational to effective intervention, there is a ‘real-world’ context of organizational practices that inevitably mediate who gets what services and why. This was ever thus. What has changed however is not so much the claims by social work to a virtuous purpose (the ethic of care offers a durable discourse from which to cast service users as worthy and our efforts as honourable) but that new risk-reduction technologies are exposing a worrying gap between the rhetoric of a humane-oriented project of care and the actionable decision-making of professionals drawing upon administrative targeting systems that seek to reduce organizational exposure to error, blame, reputational damage and unwanted external scrutiny.• Findings: The article exposes a gap between core values and risk management by examining the erosion of trust in professional social work and consequent shift towards new information technologies which intend to generate system confidence, such as the Integrated Children’s System (ICS) which seeks to provide a more accountable management of contingency. Drawing on data from our recent multi-method research of frontline practice funded by the UK Economic and Social Research Council, we challenge the view that the uncertainty and ambiguity of risk-immersed social work can be more safely moderated by computer-based technologies for reporting and decision-making.• Applications: The findings of this study suggest the need for significant reform of the ICS system. Our explorations in front line decision-making suggests that the IT workflow systems that channel and shape the way need is responded to in order to make actions and their often distributed ownership transparent and justifiable, have the unintended potential to obscure risk. We outline ways in which risk in its institutional and personal contexts in children’s services may become less evident and tractable to moderation by the ICS systems that seek this very purpose. In doing so we consider the balance between professional trust and system confidence and consider whether the time has come to shift the balance back to the former if we are to re-engage more fully with the occupation’s humane mission.

Personalization: From Story‐line to Practice

AbstractPersonalization has become a unifying theme and a dominant narrative across public services in England. Key to understanding the dominance of personalization is the recognition that it is a story that is told about public services, their history and the roles and experiences of the people who use them and work in them. Like other stories it is compelling, emotionally resonant, but also multi‐interpretable. This article identifies five key themes which are central to the personalization story‐line, noting their reliance on a combination of formal evidence, personal narratives and common sense. These are: (1) personalization works, transforming people's lives for the better; (2) person‐centred approaches reflect the way people live their lives, rather than artificial departmental boundaries; (3) personalization is applicable to everyone, not just to people with social care needs; (4) people are experts on their own lives; (5) personalization will save money. The article goes on to examine some of the complexities that audiences face in translating a story‐line into policy programmes and frontline practice. Three aspects in particular are considered: the ambiguity of personalization as a guide to action; the tensions between user empowerment and user responsibility; and the extent to which personalization is used to legitimize other reforms, in particular budget cuts.

Tuberculosis screening of migrants to low-burden nations: insights from evaluation of UK practice

Tuberculosis (TB) primarily occurs in the foreign-born in European countries, such as the UK, where increasing notifications and the high proportion of foreign-born cases has refocused attention on immigrant (new entrant) screening. We investigated how UK primary care organisations (PCOs) screen new entrants and whether this differs according to TB burden in the PCOs (incidence < 20 or ≥ 20 cases per 100,000 per annum). An anonymous, 20-point questionnaire was sent to all 192 UK PCOs asking which new entrants are screened, who is screened for active TB/latent TB infection (LTBI) and the methods used. Descriptive analyses were undertaken. Categorical responses were compared using the Chi-squared test. 177 (92.2%) out of 192 PCOs responded; all undertook screening action in response to abnormal chest radiographs, but only 107 (60.4%) screened new entrants for LTBI. Few new entrants had active TB diagnosed (median 0.0%, interquartile range (IQR) 0.0-0.5%) but more were identified with LTBI (median 7.85%, IQR 4.30-13.50%). High-burden PCOs were significantly less likely to screen new entrants for LTBI (OR 0.26, 95% CI 0.12-0.54; p<0.0001). Among PCOs screening for LTBI, there was substantial deviation from national guidance in selection of new entrant subgroups and screening method. Considerable heterogeneity and deviation from national guidance exist throughout the UK new entrant screening process, with high-burden regions undertaking the least screening. Forming an accurate picture of current front-line practice will help to inform future development of European new entrant screening policy.

The strategic leadership of complex practice: opportunities and challenges

AbstractThis paper addresses the issue of how strategic‐level partnerships, such as Local Safeguarding Children Boards, know about and learn from practice. The death of Baby Peter in Haringey exposed the dangers of reliance on numerical performance data alone to inform leaders about the true state of practice. The drivers for, and impact of, regulatory, media and political pressures on front‐line practice and partnership behaviour are discussed with reference to the rise of organisational risk management and ‘rule‐based’ responses (Munro, 2009). These are exacerbated by an overload of negative data about child protection systems which results in contagious ‘attention cascades’ which lead to over‐simplification of complex issues and the rush to quick‐fix solutions. This results in compliance‐based responses designed to avoid ‘blame’, based on individualistic analyses of complex situations. Under these conditions, ‘learning’, such as from serious case reviews, can become regressive (how to avoid future culpability) rather than progressive (how to improve knowledge skills and practice). It is argued that understanding and improving practice require strategic partnerships to have engaged with front‐line staff in order to access practice narratives as well as performance numbers, and to achieve an accurate and systemic analysis of the state of practice and how it can be improved. This calls for collective forms of knowing and reflecting and the paper concludes by describing examples. Copyright © 2010 John Wiley &amp; Sons, Ltd.