Social Work - Theses
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ItemHow do early childhood intervention professionals reflect on their practice?( 2014)While reflective practice is commonly considered to be an essential part of being an effective practitioner in many professions, individuals’ experiences and understandings of reflection have not commonly been explored. Most research pertaining to reflective practice has tended to focus on theoretical understandings of reflection, or in regard to pragmatic applications, on pre-service practitioners. Thus, the ways in which professionals reflect on their practice, and the strategies they use, have received only limited attention in the literature. The overall aim of this study was to explore and describe the experiences that Early Childhood Intervention (ECI) professionals had with regard to reflective practice within the Australian context. In the state of Victoria in 2009, an overarching educational framework was introduced, emphasising reflection as a core competency for practitioners in the early childhood field. Furthermore, in the same year, another document specifically for ECI professionals was published, and this also determined reflection to be fundamental. Hence the primary target group for this study was practitioners who were working in ECI in Victoria. The key areas examined in this study were the strategies ECI professionals used to reflect on their practice, the reasons why they engaged in reflection, and the barriers they faced in doing so. The research design incorporated a web-based survey of 131 Victorian ECI practitioners recruited through an ECI managers’ network. The findings indicate that there is considerable variation in how this group of practitioners understand and implement reflective practice. In this way, the study confirms the literature that suggests reflection is a contested term lacking both definitional and operational clarity. Furthermore, practitioners experienced multiple barriers in their attempts to engage in reflective practice, most notably that of time. The majority of respondents commented on the value of particular strategies, such as debriefing, supervision, and mentoring, but there was very little indication that the use of these strategies went beyond a practical or descriptive level of reflection. The role of technology in reflection is an emerging theme from this study, as is the need for time to be regularly allocated for reflection and thus for reflective practice to be embedded into respondents’ working lives. A particular contribution of this study is the greater understanding of the strategies ECI professionals use to reflect on their practice, the potential barriers they face in engaging in reflection, and directions for future research.
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ItemEvaluation of a goal-based intervention to reduce depression post-stroke( 2014)The main contentions of this thesis revolve around the multi-factorial concept of recovery after stroke. Stroke is a focal cerebrovascular event that remains a worldwide leading cause of death and permanent disability. Although the incidence of stroke is reducing, its overall prevalence is increasing due to an ageing demographic. Also, despite improvements in acute care management (resulting in reduced mortality rates and less severe levels of impairments), the event of a stroke still often results in complex sequelae, which may present across the spectrum of enduring body structure and function changes, activity limitations, and participation restrictions. The majority of people who have had a stroke will return to reside in the community, however, many of these people will continue to have a level of disability that necessitates ongoing assistance from their families, social networks, and formal community services in order to achieve daily tasks and engage in valued activities. Historically, post-stroke rehabilitation programs have essentially focussed on the amelioration of basic mobility and self-care deficits, with the subsequent published literature abundantly reporting these outcomes. However, over recent decades there has also been greater emergence of publications reporting more ‘holistic’ post-stroke outcomes, demonstrating that the event of a stroke may also frequently result in mood disorders, reduced participation status, gradual functional decline, a diminished quality of life, adverse carer outcomes, and lifestyle adjustment issues. In particular, about one third of people who have had a stroke will also have symptoms of depression, which may impede the recovery process and adversely affect post-stroke outcomes, including failure to resume previous activities. Many of these post-stroke complications and adverse sequelae may be potentially modifiable by targeted interventions. There are many theoretical models and frameworks that exist to try to inform rehabilitation practice. Within these models it is espoused that goal setting is a key component. However, to date, relatively little research has investigated the effectiveness of facilitating the pursuit of individualised goals on the ‘holistic’ outcomes. The first area of work in this thesis assessed the published body of literature that pertained to the effectiveness of community-based rehabilitation programmes on the specific post-stroke outcomes of interest - depression, participation status, and perception of health-related quality of life. Overall, there was evidence to support some community-based interventions in affecting the outcomes of participation and health-related quality of life post-stroke, especially when incorporating management strategies that specifically target participation and leisure domains. In addition, certain exercise programs were shown to have been of benefit in the reduction of post-stroke depressive symptoms The second area of work in this thesis aimed to investigate the effectiveness of a person-centred, integrated approach to facilitating goal achievement and recovery in the community in the first year post-stroke – via a randomised controlled trial. This main study incorporated a multi-modal protocol that used resources that were predominantly available within the existing community-based rehabilitation framework. The intervention included collaborative goal setting, review of goal achievement levels, written information provision, and further referral to relevant health services as required. Intermittent telephone contacts and face-to-face reviews via home visits enabled the clinical researcher to screen for the occurrence of adverse post-stroke sequelae and monitor the participants’ progress throughout the first year after the event – and implement further management options as required With respect to the study’s primary outcome variable, there was a significant difference between the two groups regarding the rates of depression at twelve months post-stroke – with the rate of depression in the intervention group being significantly lower than the rate of depression in the control group. Additionally, the intervention group achieved a higher level of attainment of the collaborative goals that were devised at discharge from inpatient rehabilitation – in both total number of goals, and goals rated to be in the participation domain. No significant group differences were identified for the quality of life outcomes, but interestingly, there was a difference identified between the groups for self-care self-efficacy - perhaps indicating that the intervention may have also altered the participants’ perception of their ability to adopt sufficient coping mechanisms, manage their stress, and deal with arising situations post-stroke. In addition, these results further support the contention that mood status may have an association with self-care self-efficacy after stroke. Learnings from the studies in this thesis suggest that positive effects can be achieved in the more ‘holistic’ post-stroke outcomes when they are specifically targeted. The interventions utilised in this study are readily applicable to community-based clinical practice, and the next challenge lies in how to successfully translate this evidence into routine post-stroke management strategies.
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ItemFamily caregiving and neonatal surgery: an exploration of parents' experience of caregiving following neonatal surgery for non-cardiac congenital anomalies( 2014)The neonatal evidence base has grown considerably in respect to understanding the acute, and longer-term, impact on families of premature birth and the admission of a newborn to neonatal intensive care (NICU). Less research attention has been paid to newborns that have required neonatal surgery for non-cardiac congenital anomalies, and the social and emotional experience of families that care for them. In particular, there have been no qualitative studies of this relatively under-explored population. The aim of this study was to explore the experience of families who were caring for an infant who had neonatal surgery for non-cardiac congenital anomalies, with particular reference to the manner in which parents experience caregiving that may result from these conditions. This thesis sought to explore this issue, and answer the research question: How do parents experience caregiving for an infant who has had neonatal surgery for a non-cardiac congenital anomaly? This qualitative study was designed using constructivist methodology. A descriptive qualitative research design was undertaken, using individual, face-to-face, in-depth interviews. Twenty-one parents of twelve newborns that underwent neonatal surgery at The Royal Children’s Hospital, Melbourne, Australia, for a non-cardiac congenital anomaly were interviewed between three to six months after discharge from hospital. Using thematic qualitative analysis, details of health-related caregiving demands, coping strategies, and social support used by families emerged. The results of this research indicate that parents performed many health-related caregiving tasks to maintain their infants’ health three to six months after leaving hospital, and that they did so with little practical support from external resources. A significant finding was parents’ descriptions of managing life threatening events at home. The results of this study also provide an understanding of parents’ uncertain journey throughout pregnancy, admission to NICU, and recovery from neonatal surgery. Normal and uncertainty emerged as two major themes that represented parents’ constructions of this family caregiving experience. Parents adapted to the challenges that they experienced, by moderating the uncertainty they felt, and altering their definition and perception of the caregiving experience to one of normalcy. From the findings, five core understandings were developed from parents’ perception of how their family adapted to this caregiving experience. Parents adapted by: 1. moderating the negative emotions that resulted from the perinatal journey 2. managing the pile-up of demands resulting from the health –related caregiving tasks 3. drawing upon existing approaches, and developing new, coping strategies 4. obtaining new sources of social support from the health system, however relying on the parenting couple as their primary resource. 5. altering their definition and perception of the caregiving experience. This is the first qualitative study to explore parents’ perspectives of family caregiving for infants with non-cardiac neonatal surgical conditions in Australia, and one of the few studies that has focussed on parents’ experience after coming home from NICU. This study provides a unique insight into family strengths and family adaptation in this caregiving situation. The findings of this study suggest the need for continuity of care for families after neonatal surgery for non-cardiac congenital anomalies. The results have implications for post-acute psychosocial support for families, and education of neonatal health care professionals. They also suggest that paying greater attention to the experience of parents with newborns who have undergone neonatal surgery for non-cardiac congenital anomalies is a worthwhile avenue for future neonatal research.
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ItemFostering health: an Australian health policy and systems study of health assessment for children and young people in out-of-home care( 2014)This thesis reports on the first multi-centre health policy and systems study of the complex problem of health assessment for children and young people in Out-of-Home Care (OOHC) in Australia. The study has been conducted within a context of poor uptake of routine health assessment recommended by medical colleges. Analysis of the research literature around OOHC in Australia revealed that the implementation of routine health assessment had not been investigated in any systematic way. A national symposium held as part of this study confirmed the knowledge gap and identified a community of interest who supported research in this area. RESEARCH AIM: The study aimed to identify systemic and policy factors which enabled or inhibited the work of health professionals in health assessment for children in OOHC. METHODOLOGY: Guided by soft systems methodology I developed a series of conceptual models in which I imagined the elements of systems for each key step of care and then used these models as tools for comparison with experiences in the social or real world. Each of the models was built on a discrete theoretical purpose related to health assessment. The five purposes were to: I. Collect and maintain child health histories; II. Provide initial or preliminary health assessments at entry to OOHC; III. Provide comprehensive health assessments; IV. Develop individual child health management plans; V. Monitor the provision of assessment and treatment services and child health outcomes. In order to explore experiences in the social world, I undertook an embedded case-study to collect data from 9 organisations (incorporating 12 geographical sites) across two states of Australia with large OOHC populations. Case study data comprised my analysis of policy and procedural documents from state jurisdictions and local sites, observations from site visits and analysis of recordings from 47 semi-structured interviews with health professionals and policy advisors spanning 10 disciplines. RESULTS: The outcomes demonstrated that a lack of agreement about central concepts, such as how health is defined hampered consistency of assessment processes. Similarly I uncovered disparate ideas about the purpose of health assessment in OOHC, underpinned to some extent, by variable appreciation of child abuse and neglect as health determinants. At a systemic level, I found a synergy between conceptual models of systems of care associated with health assessment and the steps which health professionals both value and strive to implement in everyday practice. The results provide a compelling illustration of systemic complexity and interconnectedness. Across all steps of care the study results show that much hinges on the efficacy and effectiveness of the first step of collecting and sharing child health histories. In this step health professionals find themselves in a dependent relationship with staff from the child protection sector whose roles include gate-keeper, referrer, family liaison officer, child case manager and corporate parent. This dependence exemplifies a recurring theme in the everyday experiences of health professionals: the contrast between usual processes of patient care and the greater complexity of health assessment steps in OOHC. I argue for rethinking health policies which have been premised on minimalist approaches involving either usual, universal health care or “tweaking” usual health care processes. Minimalist interventions, such as giving children in OOHC priority in the queue for assessment cannot by themselves bring about the extent of systemic changes desired by health professionals. Of critical need are permanent and accessible health records for children who have experienced maltreatment. This thesis demonstrated that the health policy and system approach has broad utility in improving our understanding of what has been problematic about health assessment in OOHC in Australia and what changes are desirable in assessment approaches. A key strength of the study was that multi-centre and multi-disciplinary recruitment across two legislative jurisdictions enabled me to capture health professionals’ views and experiences from multiple contexts. This added richness to the data and rigour to the generalizability of the study results. IMPLICATIONS: As a result of this study I formed a view that professional purposes, judgement and volition among health professionals are individual matters, more influenced by peers, training and clinical experience than by public policy. Not only do doctors have a unique role to play in clinical governance in OOHC but their knowledge and skills, their professional roles and identity and their beliefs about the consequences of their work are important influences in bringing about quality improvement in health care. Messages from research and the recommendations of medical colleges in Australia, U.S. and U.K. were clear that health professionals believed individualized, systematic health assessment was warranted in OOHC, notwithstanding the cost. Furthermore, doctors in this study demonstrated sufficient power and professional autonomy to stop, start, block, enhance or lead initiatives to improve health assessment in OOHC. Analysis of the steps of care associated with health assessment in OOHC revealed a deeply complex web of inter-connected activities which rest on sophisticated clinical decision making by doctors. The results of this thesis indicate that health professionals are aided in their work when governments and child protection agencies appreciate this complexity and sophistication. The results of this study suggest areas where change is desirable in order to break the impasse of poor implementation of health assessment. A more congruent common understanding of the concept of health in OOHC is essential i.e. what is being assessed. Alongside this a more careful alignment of theoretical and practical purposes in health assessment is needed. I argue that in the context of Australia’s moral and civic obligations under the 1989 United Nations Convention on the Rights of the Child, purposes of health assessment must be more coherently aligned around reparative health care, and responsive to the impacts of child maltreatment on life-course health outcomes. More widespread appreciation of maltreatment as a health determinant is required in order for policy advisors and health practitioners to better align health assessment policies and practices.
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ItemA longitudinal study of the health and wellbeing of a population based sample of caregivers of people with psychosis: influences of patients’ clinical factors and carer characteristics( 2014)Background: Few studies have examined the experiences of carers of people with psychosis within a prevalence framework. Aiming to obtain generalisable results concerning carers, this carer study was conducted utilising the recruitment of people with psychosis within the Second Australian prevalence study of psychotic disorders: the Survey of High Impact Psychosis (SHIP). The study examined the social connectedness, psychological health, feelings of grief, quality of life and caregiving consequences of carers of people with psychosis. The main hypothesis was that carers’ psychological health, social connectedness, quality of life, level of grief and caregiving consequences would deteriorate over time. A second hypothesis was that the predictors of carers’ psychological health, quality of life, grief, social connectedness and caregiving consequences were a combination of patients’ clinical factors and carer characteristics. Methods: The study recruited 98 caregivers of SHIP participants in Victoria at baseline. The carers completed questionnaires consisting of validated instruments to measure psychological health, quality of life, grief, social connectedness and caregiving consequences. A follow-up interview one year later was conducted to evaluate changes in carers’ health and wellbeing and to evaluate predictive factors contributing to the consequences of caregiving over time. The study re-interviewed 78 carers at follow-up. Clinical (patient-related) factors were extracted from the SHIP database. Using both clinical and carer variables, descriptive, correlation, regression and cross-lagged statistical analyses were conducted. Results: A significant percentage of the carers experienced social isolation, psychological distress, prominent grief, poor quality of life and negative caregiving consequences. There were no statistically significant changes between baseline and follow-up scores for almost all the carers’ health and wellbeing variables. The exception was that carers had poorer perception of their quality of life regarding their physical health after one year. Regression analyses showed that the predictors of carers’ psychological health, quality of life, grief, social connectedness and caregiving consequences were a combination of clinical factors and carer characteristics. The clinical factors found to predict these outcomes were: course of mental disorder, cognitive functioning and functioning level. Carer characteristics found to predict these outcomes were: baseline caregiving outcome scores, age, gender and education level. Cross-lagged analysis suggested that higher functioning level of the person with psychosis as perceived by the caregiver at baseline led to better carer social connection, less grief and higher satisfaction in psychological health over time. Conclusion: Due to the sampling frame of SHIP participants, results of this study are likely to be representative of carers of people with psychosis. Caregivers’ perception of the functioning levels of people with psychosis was found to be crucial in determining their own health and wellbeing. As carers’ health and wellbeing remained consistently poor over time, it is important to review the practice implications within the recovery framework and delivery of psychosocial rehabilitation services to support recovery for both carers and their relatives with psychosis. Specifically, there is a need to provide interventions that address carers’ physical health as they perceived their physical health to have deteriorated after one year.
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ItemSchool social work in the state of Victoria, Australia: 65 years of student wellbeing and learning support( 2014)School social work is one of the earliest fields of professional social work practice in Australia. Despite the lack of accessible literature to document it, successive Victorian practitioners have perpetuated an unbroken tradition of practice, supporting students to achieve their potential through education. The research used professional narratives and documents retrieved from private and public archives to consider the organisational, theoretical and practice developments of school social work in the State of Victoria. The findings represent the first broad picture over 65 years of school social work as professional practice. State education department school social workers, employed within multidisciplinary teams delivering visiting services, have frequently experienced organisational reconfiguration, often associated with newly elected State governments, changing social and educational policies, and the restructuring of successive departments of education. In particular eras, a much smaller number of school social workers has been appointed by individual schools as members of staff. Since the 1973 publication of an Australian Government report into schooling, Commonwealth and Victorian State Government policies have increasingly focussed on concepts such access, equity and excellence for all students, inclusive of individual difference, socio-economic background and cultural diversity. Professional identity was found to be based on dynamic school social worker interaction with the changing context of practice, but fundamentally founded on values, knowledge and methods for intervention. School social work was embedded within the ethical base of social work, with particular emphases that identified it as specialist practice. School social workers were driven to focus particularly on the student in the learning environment, in order to facilitate children’s rights to education, and support social justice outcomes. School social work was integrated into the policies, practices and programmes of the school as host setting, with the purpose of improving student potential, through minimising the effects of inequities and removing impediments to best learning outcomes. School social workers primarily used an ecological-systems approach, and an eclectic repertoire of theories and methods, to work at the interface of multiple environments around the student. While prevention and early intervention were the preferred levels of practice, most time has been allocated to more complex casework intervention. School social workers needed generalist and school-specific expertise including: counselling and supporting children, young people and their families; teacher consultation and professional development; small group and whole class work; facilitating school policy and practice change; and building school-family-community relationships. It was by way of the acquisition of specialist knowledge and skills for school-specific methods of practice that practitioners were able to narrate school social worker professional identity at individual and communal levels. The research proposes that “the tradition of practice” is the stream of continuity of shared professional identity, where meaningful connections are made with past, current and imagined future narratives essential to the profession. Finally, the study proposes multiple areas for further consideration and research into school social work in Australia, including its effectiveness in facilitating school engagement and learning, the impediments faced by students and young people, and comparative studies with international settings.