Читать книгу Interprofessional Collaboration and Service Users - Группа авторов - Страница 9
ОглавлениеKirsi Juhila, Tanja Dall, Christopher Hall and Juliet Koprowska
I walked into the room, and I was nervous as it was, because obviously you’re going into something that is like judge and jury on you. And you walk in and you look at the people and I thought to myself, I’ve got to sit here in front of all these people being judged and … Well, everyone introduced themselves, like they do, they all go round the table. You don’t take it all in, because there’s so many people, all going, ‘Hello my name is so and so’. You have to acknowledge them, but you don’t take it in … (Packman and Hall, 1998, p 222)
These words, from a parent talking about participating in an initial child protection conference, encapsulate the tension at play when service users participate in multi-agency meetings in social welfare. The number of participants alone can make the meetings hard to ‘take in’, and differences in status confer predetermined roles of judging and being judged before the meetings even begin. At the same time, however, multi-agency meetings constitute an opportunity for shared discussions that may increase both cooperation and understanding between different professionals and service users. It is this opportunity that has made meetings where professionals from different disciplines and service users are co-present become commonplace in health and social welfare in Western welfare states. This has happened as part of a larger development, where collaborative and integrated welfare is promoted as a solution to the perceived ineffectiveness of health and social services that are professional-led and dispersed (Kitto et al, 2011). Two themes in particular are presented as essential for the success of collaborative and integrated welfare: interprofessional collaboration and service user participation. This book is about how such aims are realised in multi-agency meetings. The words of the parent that open this chapter represent a service user’s reflections on a meeting after the event. By contrast, this book analyses audio- and video-recordings of the naturally occurring interactions that ‘talk the meetings into being’.
Multi-agency meetings are understood as boundary spaces where professionals from different disciplines and welfare agencies, service users and their lay representatives are brought together to work on a common task. Such an understanding brings forward the negotiated and interactional character of social welfare, casting interprofessional collaboration and service user participation as complex practices, involving work across professional and organisational boundaries, the integration of aims and perspectives, comprehensiveness in assessment and efforts, and shared goals and synergy (see Chapter 1).
The core idea of this book is to examine empirically how professional participants in the meetings collaborate with each other (or do not), and the kinds of alliances they create, as well as how service users position themselves and are positioned as participants in the information gathering, reasoning, assessing and decision making about their personal and institutional circumstances. By analysing the specific setting of multi-agency meetings across a range of social welfare fields, the book contributes to the ongoing discussion about collaborative and integrated welfare through the thematic lenses of interprofessional collaboration and service user participation. The ambition is to facilitate a deeper understanding of how collaborative and integrated welfare is brought about in meetings between professionals from different disciplines and service users, and to develop a conceptual and analytical framework that can support further examination of the doing of interprofessional collaboration and service user participation.
Doing interprofessional collaboration and service user participation in multi-agency meetings
Increasingly, multi-agency meetings are the locus for implementing the policies and procedures of interprofessional working (Blom, 2004; Julkunen and Willumsen, 2017). The meetings explored in this book have certain characteristics that differentiate them from other professional and workplace practices:
•They are multi-agency in that they include practitioners from a number of agencies – for example, social work, education, health, the police, housing, social security, employment services and third sector organisations.
•The terms and conditions of some meetings are prescribed by statute or institutional policy and procedures.
•The meetings focus on individual families or service users.
•The meetings are the place where professionals organise their work with the service user in terms of the goals set at one meeting and reviewed at the subsequent one.
•The meetings often have decision-making or reviewing functions, meaning that they result in the provision (or denial) of a service or establishment of an institutional category for an individual or family, for example child concern or adult risk.
•The service user, their family and perhaps an advocate are encouraged or required to attend.
In these – and other – ways, the practical accomplishments of multi-agency meetings in social welfare become the realisation of collaborative and integrated welfare policy. Henneman et al (1995, p 108) make the observation that collaboration is ‘a process which occurs between individuals, not institutions, and only the persons involved ultimately determine whether or not collaboration occurs’. Arguably, the same can be said of service user participation. Several studies have demonstrated that having users present at meetings does not ensure their inclusion in decision making or care planning (for example, Hall and Slembrouck, 2001; Hitzler and Messmer, 2010). When seeking to understand how policies come about in practice, then, looking at what actually happens as professionals and service users meet around a common task brings us closer to the details of ‘doing’ interprofessional collaboration and service user participation. Research in health care and business organisations has illustrated that meetings require participants to pay attention to certain conventions and constraints on what can be brought up, how and by whom (for example, Asmuβ and Svennevig, 2009; Svennevig, 2012; Halvorsen and Sarangi, 2015). The opening quote in this Introduction illustrates one small aspect of this, as participants ‘go round the table’ following a certain format in introducing themselves while the service user sits back trying to take it all in. By examining the details of how participants orient to and act out such interactional conventions and devices, this book demonstrates how the realisation of policy becomes contingent on the interactional practices of professionals and service users, situated in particular meetings.
The organisation of the book
The book revolves around two themes, alluded to earlier: (a) how professionals negotiate professional boundaries, responsibilities and hierarchies; and (b) how service users participate and are formulated as participants in their own personal matters at multi-agency meetings. These themes are closely interrelated, and especially so in multi-agency meetings where both the service user and several professionals are present. Thus, while some chapters of the book may focus on one theme more than the other, both interprofessional collaboration and service user participation are present in all chapters.
Chapters 1 and 2 make up the introductory section of the book, with the first conceptualising interprofessional collaboration and service user participation and the second, multi-agency meetings as communicative events. Chapter 1 (Juhila, Raitakari, Caswell, Dall and Wilińska) discusses collaborative and integrated welfare as a current policy trend and defines the concepts of interprofessional collaboration and service user participation. The two themes are introduced as relational and interactional activities that require and constitute relational expertise. The chapter goes on to address the potential and challenges of interprofessional collaboration and service user participation – themes that are most often presented in uncritical and idealised ways. Finally, the chapter introduces multi-agency meetings and teamwork as frontline arenas and boundary spaces to ‘do’ collaboration based on shared aims and common knowledge. Chapter 2 (Hall and Dall) moves closer into the interactional makeup of multi-agency meetings, reviewing the literature on meeting talk. The chapter outlines literature that has approached meetings as ceremony and ritual and discusses a number of key analytical concepts related to meeting talk: the structure of meetings, the role of the chair, turn-taking, topic progression and decision making. The conceptualisations and analytical concepts introduced in Chapters 1 and 2 are taken up in the empirical chapters (Chapters 3 to 8), which analyse concrete instances of interprofessional collaboration and service user participation in multi-agency meetings.
Chapters 3 to 8 draw on research in different sectors of social welfare in different countries, formulated through different legal jurisdictions. The chapters are all empirically based in multi-agency talk and preoccupied with the details of accomplishing interprofessional collaboration and service user participation, along with the interactional practices and dilemmas that follow. Depending on the practice field, literature and author preference, a variety of descriptions are used in discussing the two themes (for example, client/patient/parent and inclusion/involvement/ownership). To ensure coherence of terminology, all the chapters refer to ‘interprofessional collaboration’ and ‘service user participation’, except when referencing literature that uses other terms, for example professional–client talk.
Chapter 3 (Dall and Caswell) examines rehabilitation team meetings in Danish employment services. Meetings are led by a chairperson who represents one of the attending agencies, and the chapter analyses how chairs use the pronoun ‘we’, to include or exclude other team members and the service user in decision making. The authors find that chairs’ use of ‘we’ contributes to a practice that places ‘the team’ as a unit in a position of authority and dissuades disagreement from service user and team members. Chapter 4 (Hall and Slembrouck) examines chairs’ practices in child protection core group meetings in England. The authors draw on the concepts of ‘framing’ and ‘boundary work’ to explore how different professionals contribute to the multi-agency meeting and how the meetings emerge as arenas for competing interprofessional claims. The chapter concludes that constructing and managing professional contributions involves complex boundary work by all participants.
Chapter 5 (Raitakari, Ranta and Saario) examines multi-agency meetings in low-threshold services for people using drugs in Finland. The concept of ‘alignment’ is applied as a linguistic device that supports a cooperative flow of interaction, making visible how collaborative participation is only ever partially achieved and at risk of failing. The authors find, for example, that question–answer sequences and positioning both service users and professionals in alternating ways as ‘tellers’ and ‘recipients’ are essential alignment techniques to advance collaborative participation. Chapter 6 (Bülow and Wilińska) examines return-to-work meetings within the Swedish social insurance system and, uniquely in this book, studies video recordings, enabling the analysis of posture and gesture. The concepts of ‘sympathy’ and ‘sympathizing’ are used to explore emotions and micropolitics in multi-agency meetings concerning work ability. The authors demonstrate how sympathizing becomes an integral part of the institutional frame, with the institutional actors stepping outside their specific meeting roles to sympathize with the service user.
Chapter 7 (Juhila, Morriss and Raitakari) examines mental health meetings undertaken as part of the Care Programme Approach context in England. In this chapter the concepts of ‘epistemic status’ and ‘epistemic rights’ are used to analyse the ownership of knowledge concerning service users’ recent histories. The authors demonstrate how not only service users but professionals, too, display access to and ownership of such knowledge. They go on to find that meetings contain both collaborative practices that strengthen service user participation and practices that produce epistemic injustice for service users. Chapter 8 (Koprowska) examines interactions between chairs and service users in initial child protection conferences in two local authorities in England. The author finds that frontline practices differ between the two authorities, influencing the way the chair takes up the role. The concepts of ‘relational agency’, ‘epistemic rights’ and ‘epistemic justice’ are utilised to show that the chair’s interactional approach advances or constrains service user participation.
The book then concludes by synthesising the main findings of Chapters 3 to 8 in a discussion of how to understand multi-agency meetings in social welfare settings as interactional accomplishments. Four themes are highlighted: the role of the chair and turn-taking; information-giving and decision-making roles; different uses of ‘we’ and alignments; and owning, prioritising and producing knowledge. The Conclusion argues that multi-agency meetings have the potential to be both integration ceremonies, which make possible the creation of common knowledge, and degradation ceremonies, which devalue the knowledge and status of both service users and professionals. It ends by outlining some of the specific areas of attention that may facilitate more constructive meetings for both professionals and service users.
References
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