Negotiating “person-centred” approaches and risk management in community care Anne-Maree Sawyer

1. Decision-making on the frontline... Negotiating “person-centred” approaches and risk management in community care Anne-Maree Sawyer

2. Frontline workers… ... have to bridge the worlds of their clients, the rules of their employing agencies, government regulations & policies, & the norms & ethics of their professions or disciplines. La Trobe University Page 2

3. Historical context Shaping influences on practice... 1. Human rights framework (deinstitutionalisation & shift to community care) >> “person-centred” care 2. New Public Management (increased demands for accountability & regulation >> “risk management”) >>> 2 distinct developments that come together in practice La Trobe University Page 3

4. 1. Person-centred care AND the freedom to live with risk She says, “Look at the end of the day, my choice is to live at home - if I have to lie on the floor for two hours in the middle of the night if I’ve fallen out of bed … that’s the risk I want to take, because I do not want to go to a nursing home at fifty.” So look, we’ll do all the checks that we can, but she put it very nicely: “That’s my choice, if I have an accident in bed … if I have to wait till the carer comes at seven in the morning, I’ll wait … there are emergency services but if people can’t come, that’s the choice I make - not to live in a place where there’s a nurse down the hall.” So it’s about agreeing on risk, and getting permission to put certain things in place to manage the risk. (Program manager, aged care/disability service) La Trobe University Page 4

5. 2. Person-centred care may mean ‘bad choices’ This is a guy who’s been in institutions his whole life and now lives independently … he has a mental health issue as well as an intellectual disability … I have had his sister on the phone, going: “Well you’ve got to stop him smoking”. The reality is he lives in his own home; every time I speak to him I mention the cigarettes and I’ve got a carer to take him walking to try and reduce his obesity and we’ve done a little bit of basic training with him around cigarettes, but … that’s all I can really do ... there’s major health risks … but he can choose [to smoke 35 cigarettes per day] and whilst he does have an intellectual disability, he does know that smoking is what caused him to go to hospital... La Trobe University Page 5

6. 2. Person-centred care may mean ‘bad choices’, cont. We are always treading this fine balance between independence and choice for the clients because that’s very much our ethos … and risk and their safety ... When you leave someone at home you’ve got this sort of uneasy feeling. (Case manager, aged care/ disability service) La Trobe University Page 6

7. 3. Person-centred care, risk taking AND the significance of professional agency Going into a house and finding that the light globe has blown, the little old lady or gentleman… don’t have any family and they’re saying “But I can’t see what I’m doing in the evenings”, and you sort of think – “Well it’s not rocket science to change a light globe”. But if you look at the risk assessments there you don’t know what the wiring is like … whether you’re potentially going to electrocute yourself. So we are not allowed to do that … In the meantime they could get up at night time… and trip over something and break a hip and they’re in hospital, so for me personally … I would change a light globe … it was something that I was able to help out with and was a five minute job, but outside the realm of my role and responsibility. But if we can’t help a fellow human being and I see it as a low, extremely low risk; then I’m prepared to take that option. (Community nurse, aged care service) La Trobe University Page 7

8. 4. Person-centred care AND balancing risk and security She was getting daily nursing visits to provide her medication, and periodically the nurse would ring me and say, “Look I can’t find the client” and I’d say, “Just go down to McDonalds.” By all accounts she was probably physically exposed to risk, but what was working was that it was a routine that she knew, she could get there and back, she didn’t have to cross a road which was the main thing, but yeah ... she could have fallen and been out of range of support - but my view with that client was that if we had tried to circumvent that, she would have tried to circumvent our efforts, so working with the strength, working with the person’s capacity - it’s something she enjoys, so you’re not going to take it away - so the nurse would go down there and give her the medication in McDonalds. (Case manager, aged care service) La Trobe University Page 8

9. 5. Person-centred care AND the client’s identity as a ‘self’ He was a very isolated individual and his dog was very important. His dog was dying… and the vet recommended putting the dog down and he asked if he could have time alone with the dog and I thought, “This is one of those times where it’s a judgment call” and I felt confident enough to say “I’m going to take the risk”. Because he had been talking about … if the dog had to die that he was going to die with the dog and I made the judgment call, but I could see that was really important for him and I drove him home to have time with the dog. I picked the dog up from the vet with him and gave him a period of time … and he brings up regularly that we did that together and he knew not many staff would have trusted him and would have given him the opportunity. (Program manager, mental health service) La Trobe University Page 9

10. References Fine, M. (2005) ‘Individualization, risk and the body: sociology and care’, Journal of Sociology, 41, 3, 249-68. Green, D. and Sawyer, A. ‘Managing risk in community care of older people: perspectives from the frontline’, Australian Social Work, 63, 4, 375-90 Green, D., Sawyer, A., Moran, A. and Brett, J. (2010) Managing risk in community services: A preliminary study of the impacts of risk management on Victorian services and clients, (Unpublished) Final Report to Industry Partners (book length). (Please contact Anne-Maree Sawyer, a.sawyer@latrobe.edu.au for copies) Munro, E. (2004) ‘The impact of audit on social work practice’, British Journal of Social Work, 34, 8, 1075-95.  Munro, E. (2010) ‘Learning to reduce risk in child protection’, British Journal of Social Work, 40, 4, 1135-51. Sawyer, A. (2009) ‘Mental health workers negotiating risk on the frontline’, Australian Social Work, 62, 4, 441-59. Sawyer, A., Green, D., Moran, A. and Brett, J. (2009) ‘Should the nurse change the light globe? Human service professionals managing risk on the frontline’, Journal of Sociology, 45, 4,1-21. Taylor, B. (2006) ‘Risk management paradigms in health and social services for professional decision making on the long-term care of older people’, British Journal of Social Work, 36, 8, 1411-29. Taylor, B. and Donnelly, M. (2006) ‘Risks to home care workers: professional perspectives’, Health, Risk & Society, 8, 3, 239-56. Titterton, M. (2005) Risk and Risk Taking in Health and Social Welfare, London: Jessica Kingsley Publishers. Yeatman, A. (2009) Individualisation and the Delivery of Welfare Services: Contestation and Complexity, New York: Palgrave Macmillan. Acknowledgements This paper is based on research conducted with the support of an Australian Research Council Linkages Grant, no. LP0667485. We wish to thank our industry partners, the (former) Victorian Department of Human Services and the Victorian Office of the Public Advocate, and our interviewees for generously taking part in the project. La Trobe University Page 10