Introduction: a weekly review meeting
The weekly review meeting in a child psychiatric unit is taking place. About twenty people are present, mainly nursing staff who are the direct care providers in this setting. They are discussing Tommy whose difficult behaviour has been disrupting the unit all week. The plumber has had to be called three times to unblock the toilets after Tommy had put things down them “mostly other children's possessions. The staff now have to watch him all the time, even in the toilet. As there are usually two staff on duty with Tommy’s group, this means one is with Tommy while the remaining worker is with the other five boys – provided Tommy’s behaviour is not requiring two staff to deal with it, and as long as neither of them needs to take a tea break, answer the phone, or see to visitors! The staff are angry that the other children are getting little or no attention beyond basic care. They are also frustrated at being unable to get beyond supervision of Tommy to do any more positive work with him.
Staff also find Tommy’s parents most peculiar and difficult to deal with. The staff are not making any progress at getting to know Tommy’s parents and do not know if the social worker is making progress either. They are certain that Tommy’s behaviour will not improve unless there is also some change in his parents.
Tommy is the responsibility of a consultant psychiatrist who requested his admission to the unit. A social worker sees his family and a psychologist is devising a treatment programme for him. None of these three people is present at the meeting. Care staff do not feel they can make any plans for coping with the situation without the agreement of one or more of the “outside” professionals. Debate about what can be done to help Tommy gets mixed up with what can be done about the “outside” workers. Will they agree with any plans made? Will they come to the next meeting? Should the care staff send a deputation?
Feelings of desperation and despondency settle on the meeting. Some are saying keeping Tommy in the unit is not doing him any good, and the other children are being prevented from making the progress of which they are thought capable. Though not said explicitly, discharge is definitely in people’s minds (discharge in this unit is the only decision that care staff are empowered to take unilaterally). Nothing is settled but time is running out. The other children are discussed hurriedly in the remaining time.
Later in the week a case conference is held on Tommy. This is one of a series of regular meetings to review progress and make plans. The care staff repeatedly answer the door to admit people who have come for the conference. Most are people they do not know well and some they have never seen before. Most of the care staff will not be able to attend because they are minding the children. One of the care staff, Mrs Forbes, gives a report about Tommy’s behaviour in the unit since the last meeting. In the formal atmosphere this report is phrased in the neutral terms of professional jargon. Tommy is said to have been “acting out” and “needing limits to be set”. There is no flavour of the chaos that Tommy has been causing, the staff’s exasperation or the other children's outrage about their lost belongings (the other children are not mentioned because the meeting is only about Tommy). With so many strangers present, Mrs Forbes feels overawed and unable to assert her point of view. The discussion gets very theoretical as people suggest psychodynamic reasons for Tommy’s behaviour. No attempt is made to discuss the practical difficulties of coping with Tommy and five other children. The psychiatrist suggests that the care staff should try talking to Tommy when he is being difficult. He does not explain how they are to do this while separating a roomful of fighting boys. Mrs Forbes feels insulted: does the psychiatrist really think that care staff do not talk to the children?
Let us consider these two meetings in terms of the obstacles and difficulties that prevent those involved from working together more effectively. The most obvious problem concerns the number of people involved with this one child, both within the agency and from other agencies. In any residential setting many staff are needed to give 168 hours per week coverage. In many units like this one, the staff can never meet together all at the same time because of shift working and because the children must be supervised. All too often agency roles are clearly distinguished by profession and status within each profession, so that the tasks to be done are allocated to a number of different people. For instance, care of the child and decision-making may become separated, with the latter resting with workers who are “attached” to the unit but whose main working base lies outside. In addition to tasks that are directly concerned with the child, there are also tasks related to management of the unit and supervision of staff which may involve yet more people.
A child like Tommy, whose behaviour causes chaos wherever he goes, has already attracted the attention of a number of other agencies before arriving at this unit. These other agencies may include school, special educational services, the local social work department, the juvenile court system, the school health service, and others. They all have a legitimate continuing interest, and need to be kept involved if the best use is to be made of available resources for Tommy’s future. Therefore their representatives may also be invited to meetings.
These “outsiders” and also some of the attached workers from within the agency, may only come to the unit to attend meetings. The geographical separation of the unit from the rest of the agency is partly responsible for this. Thus, there may be no informal contact between “outsiders” and unit staff. Any difficulties which arise have to be dealt with via the formal machinery of the organization, and this can be very cumbersome and ineffective at times.
Systems and boundaries
One can see that many of the difficulties described above have to do with the organizational structure of the agency, as noted earlier in this volume by Maier, particularly those difficulties related to processes of planning and decision-making. Others are associated with role differentiation and the nature of communications between workers.
In order to analyse the nature of problems encountered and to suggest ways of tackling them, it is helpful to view the unit, its parent agency, and its contacts with the outside from a systems perspective (Miller and Rice 1967). This perspective incorporates ideas about individuals as organisms interacting with their environment. Studies on the functioning of groups have shown that groups have characteristics which are more than the sum of the individuals that form it, and in this respect a group may be seen as a living organism (Monane 1967). Systems perspectives have been used to examine natural groupings in society including families, peer groups, institutions, neighbourhoods, and communities (Emery 1969).
A systems orientation seeks to make explicit the idea that groups or systems have boundaries and that there are interactions across boundaries with the external environment or the world outside. No change can take place within a living system without exchanges taking place with its environment. A system may, therefore, be examined in terms of its inputs, its conversion process, and its outputs. The larger organization of which it is a part may be evaluated as a system also. Every system is, from this perspective, part of a larger system, and every system has smaller groups within it which are sub-systems. Every system except the largest has an environment and every system except the smallest is an environment (Hearn 1969).
Perhaps the real value of systems thinking is that it highlights ways in which, to understand or change an individual’s behaviour or attitudes, one must take account of their environment. This involves the relationships, stresses, and expectations that influence behaviour. Such a notion applies to ourselves as workers, our colleagues, and our work organizations, as much as to the children with whom we work.
If we regard a group care unit as a system, as suggested by Polsky and Claster (1968), then we need to examine the dynamics within it, the functioning of the staff group as a team (Fulcher 1981); and interactions with the outside world, which may be referred to as transactions across the boundary. The important boundaries are those around the unit and around the agency. Some staff are clearly inside the unit and others outside it, but some may have an ambiguous position. They may be seen as inside or outside depending on the viewpoint of the observer. For instance, an outside agency or the child's parents may regard a social worker as being a member of the unit, and thereby inside the boundary. On the other hand, unit care staff and the children may regard this person as a visitor or an outsider.
In reality there is a multitude of boundaries that have differing degrees of permeability to different people. Many of the staff both inside and outside the unit become involved in tasks which mean crossing boundaries. The allocation of these boundary tasks to particular workers depends on the organizational structure of the agency, and assumptions about the roles appropriate to particular professions and ranks. The need for particular tasks and their relative importance will also depend on these, as well as on the individual needs of each child and family.
What are the tasks of a boundary worker?
One task is improving patterns of communication: to assist the sharing of information about work undertaken by the team with or on behalf of the child, and to ensure that decisions and plans are known to all affected by them. In addition to just passing on information in various directions, there is a process of co-ordinating and drawing together the different views. Another important element is that of support for staff, particularly those working in the somewhat enclosed and often intensive atmosphere of the living unit.
This sounds all very purposeful and organized! In reality, of course, such situations are so beset with opportunities for failure of communication and conflict over decisions, that a large part of the work of the boundary worker involves trying to patch up the gaps. It involves providing an outlet for the frustration, anger, and sadness of care staff who may feel that their opinions go unheard as well as supporting decision-makers who find resources inadequate to meet a particular child's needs. In an inter-disciplinary setting, it is also unlikely that the many workers with different training backgrounds, experience, and methods of practice will find themselves in total agreement. Boundary workers may often find it necessary to balance conflicting views or wishes, and carry the resulting confusion and uncertainty. Several other boundary tasks will be discussed in more detail later, but firstly consideration of the relationship between organizational structures and the need for boundary workers is necessary.
The hospital child psychiatric setting is perhaps the ultimate illustration of organizational complexity and division of labour. Not only are many professions involved in the inter-disciplinary department, but fairly rigid hierarchies also exist within some of these professions, notably nursing. Isobel Menzies’s classic study (1970), for example, showed how the nursing profession's hierarchical structure serves to reduce the anxiety of basic care staff by passing responsibility to a higher level in that structure. The tradition of training and the nature of the work in general nursing has not in the main encouraged care staff who come from that background to use personal initiative or step outside their assigned physical care tasks. Certainly in some in-patient units where nurses are the care workers, the tradition still exists that care involves physical needs only and that the daily or weekly clinical session with a “therapist” is the major agent for change. This is in spite of evidence to the contrary (Polsky 1962; Trieschman, Whittaker, and Brendtro 1969).
In such a setting it is invariably easier (although not desirable) for individual workers if they keep to their established territory: nurses provide physical care, psychologists make assessments, teachers teach, doctors provide therapy, and social workers give support to the family. In this way of working it is of course traditionally the medical consultant who co-ordinates all the various efforts.
However, increasingly things are changing and all disciplines are more ready to share or exchange tasks as the common basis of work with children is understood. This helps workers to see the links between all the separate tasks and to view the child, family, and social environment as a total system. The increased understanding of each other’s work that this promotes also helps to improve staff relationships and offers a firm base for further inter-disciplinary co-operation. It provides for more flexibility in the provision of services to children, and also offers greater opportunities for professional development amongst all the workers. Yet at the same time, such role sharing must be carefully managed if confusion is to be avoided.
In the psychiatric hospital setting, some boundary tasks are normally tackled by use of formal structures. For example, out-patient team meetings and group meetings within disciplines offer opportunities for co-ordination as well as professional support, even though this latter issue may not be an overt aim. In the inpatient unit, Kardex meetings and case conferences are also set up to facilitate communication and provide arenas for decision-making.
The “within-profession” structure referred to above does of course pre-date the coming together of the different professions in the inter-disciplinary setting of a hospital. In many cases, however, the cross-profession structure that true inter-disciplinary work implies has yet to evolve. The stages in creating such an inter-disciplinary team are, however, usefully described by VanderVen (1979). Fortunately, collaborative practice generally moves ahead of the formal structures needed to contain this. As a consequence, in many hospital settings, the authority remains clearly defined in regard to each professional group. Competing professional hierarchies continue to cloud the issue of team accountability and the degree of individual autonomy as exercised by key professions in inter-disciplinary teams.
In many public service areas, attempts have been made to deal with this kind of difficulty by structural re-organization with the ultimate idea of developing corporate management approaches. Thus local government in Britain underwent changes between 1957 and 1974, which re-organized the tiers and boundaries of local government and the management system operating within them (Cockburn 1977). A particular example is seen in the reorganization of social services in Scotland in 1968, in which the previously separate, specialist services for different client groups were integrated into one Social Work Department. In the Health Service, similar ideas were less fully implemented. The overall structure of the services has been re-organized, with the separate General Practitioners, Hospitals, and Community Services being brought together under one Area Health Board. However, the power held by some clinicians has made it difficult to move towards principles of corporate management, principles which are viewed as antipathetic to the exercise of individual clinical judgements. Moreover within a health care setting some workers (for instance social workers and teachers) are employed by a different system altogether, being seconded to hospital settings and lacking accountability to any corporately structured management group.
The formal system of management is then very diffuse, and it is not surprising that contradictions and difficulties often emerge. It is indeed remarkable that the system works at all! As stated clearly by Whittaker:
“The structural implications of the infusion of psychoanalytic treatment into the therapeutic milieu have been particularly unfortunate... Since the therapist was isolated from the actual behaviour in the ward, his view of the child was derived from information collected in the artificial environment of the 50minute therapy hour. To compound the problem, the individual therapist was often the person responsible for directing the child's total treatment plan.... Small wonder that the forces actually governing the course of a child's progress in residential treatment often had less to do with the formal structure of treatment authority and more to do with informal, covert systems.” (1981: 100)
In spite of this situation the formal system of management does provide a framework within which the overall work of any child psychiatric unit takes place. The smooth running of the system and the effectiveness of the work may however depend upon informal systems that workers create and boundary workers are frequently key people in making these systems work. The balance between formal and informal structures will of course vary with the size and complexity of the organization. Roberts (1982) has noted how theoretical approaches to understanding organizations emphasize structure or personal interactions to differing degrees.
Where formally prescribed tasks can be delineated in job descriptions, and where specific actions are performed by someone under the direct supervision of a line manager, then the informal aspects of work depend upon close personal relationships, the development of trust, and a mutual working out of tasks. Strangers cannot work an informal system. Group care, with its demand for constant care and close involvement in the life in the unit, leaves little time to cultivate contacts with all the outsiders concerned. One can see, therefore, the importance of a boundary worker who can bridge the gap, getting to know as far as possible both insiders and outsiders.
Various tasks that a boundary worker may take on as part of the informal system are discussed below. The possibilities are extensive, and obviously no one worker can attempt to cover more than a few of the tasks involved. Each worker will select according to the needs of his or her particular situation: the kind of formal structure in operation and the needs it creates; the tasks taken on by other workers; and the particular skills and preferences found amongst the members of an inter-disciplinary team.
Some boundary tasks in group care practice
In an inter-disciplinary hospital setting the formal management system normally lies within the different professional organizations. In Britain, for instance, junior doctors are accountable to a consultant; nurses have a hierarchical system whose upper strata may be outside a particular unit and located in another part of the main hospital; domestic staff have their own supervisory hierarchy within the hospital but one that is separate from the nurses; social workers are accountable through their departmental organization to a Local Government Regional Authority; teachers are the responsibility of another department in the same authority; clinical psychologists have their own department and hierarchy within the Health Board.
The decisions that individual workers can take are clearly laid out in regard to the different professions. In practice, individuals may feel they can make all but major decisions themselves, particularly where they have good relationships within their own department’s supervisory system and that they can expect that sensible decisions will be backed. Where this expectation does not exist, and where workers are inexperienced, they may feel they have to defer decisions to others higher up in the departmental structure. Workers who have the support of colleagues and a chance to make use of others' ideas and experience in joint discussion are likely to have more confidence in making their own decisions. They are less likely to feel free to make decisions in situations where there is distrust or disagreement with other workers.
Though the formal hospital structure may be clear, it is not always easy to resolve difficult issues, particularly where there is conflict between professional groups that have separate systems of accountability. Equally, the medical profession may claim that theirs is the overall responsibility in a hospital setting, and in any question of treatment for individual children, it usually is. Yet few doctors have managed to influence a determined nursing hierarchy that persists, for example, in the view that nurses in a psychiatric unit must wear uniforms, including caps! Equally if a child is suspected of being the victim of non-accidental injury, a social worker may argue that the legal duty to take action is more important than a doctor’s view that this would be detrimental to the treatment plan.
The informal aspects of management, then, are divorced from the power and authority to make decisions for others. These informal aspects involve creating working situations and relationships wherein individual staff can feel supported in making their own decisions at an appropriate level. Obviously no one person can do this, but each person can contribute. The boundary worker, or “outsider” in the context of the unit, has a special contribution to make in validating the right of “inside” workers to make decisions about those issues which are primarily “inside” concerns. The boundary worker may be the person best placed to bring “outside” issues into the unit; to try and balance discussion about details of daily life in the unit with reminders of the situation outside, so that these issues are also given due consideration. This applies to general issues of policy, working methods and such like, as well as to work with individual children.
The formal system for staff support is generally found within professional groups, and varies considerably from one group to another. Some support systems exist across professional boundaries, as found within the inter-disciplinary team. At its best and most trusting, such a team offers a very supportive environment in which members can learn from each other, share tasks, and expand their own views within the wider perspective of different approaches. However, many inter-disciplinary teams are such in name only. As VanderVen points out, some teams are merely collections of people from separate departments, and, because the power balance is unequal, some impose the views of one or more professions on the others (VanderVen 1979). It is most commonly the care staff whose views are discounted. Working in a living situation with disturbed and difficult children produces a tremendous amount of stress. Add to this the frustration of not being in a position to make decisions about plans for the children, other than on a superficial level associated with daily routines, and the dissatisfactions can be overwhelming. The need for support is therefore immense.
In a hierarchical system such as health care, it is flying in the face of tradition and training for senior staff to accept or look for support from junior staff or even from peers. A boundary worker who is outside this hierarchy may be in a good position to give support to senior personnel, who cannot ask for support from below, nor get it from above. Support from above may not be available because the higher ranks are removed from the unit, have no relevant training or experience, and because they are not felt to be in touch with the nature of the difficulties. The boundary worker can also help in staff support groups, by bringing in a rather more detached viewpoint to problems arising from intensive involvement, or by bringing in an expectation that difficulties can be shared with mutual benefit “perhaps by bringing his or her own difficulties to the group.
The most important aspect of support is availability. This is not always as easy as it sounds! In addition to the practical difficulties of finding sufficient time in the midst of a busy working schedule, there is the difficulty of establishing reasons for being in a unit and overcoming the suspicion of inside staff towards all outsiders. Initially when visiting an unfamiliar unit, it helps to have a specific task in mind as a focus for the visit. Just “dropping in” raises all sorts of anxieties when the visitor is an unknown quantity. As time passes and friendliness and interest are established, it becomes possible to extend visits beyond the ostensible task, and then to visit without a task at all. Finding out when staff take a coffee break is a great help in this, especially as much useful communication takes place over coffee!
Flexibility is needed, along with the ability to respond when someone wants to talk about something that is bothering them. Too tight a schedule, with just time for an interview or meeting, does not help. In this middle stage, staff can speak with an available person, but will not actively seek someone out, perhaps because they are not sure that their needs are valid. Later on workers may become able to initiate contact, asking when the boundary worker would have time, or phoning up for a chat. Depending on other factors – the general atmosphere in a unit or the training and experience of staff – it may also be possible to set aside times specifically for support purposes for individuals or groups with or without a boundary worker or outsider as third party.
As well as establishing one’s presence, one has to establish some credibility as a worker, and also indicate some sort of allegiance to the unit. Support can be offered by anyone, but it may only be taken up from certain people. Credibility can be difficult to establish as a boundary worker, since it usually depends on work done, and seen to be done. The boundary worker is not often involved in direct work in a unit, or at least not in the “real” work of caring for children. If boundary workers are directly involved, as therapist or as key worker, then they obviously have a means of establishing their credibility, provided their influence is seen as positive, and as long as they can steer clear of rivalries. The worker who is seeing a family may also display the results of his/her efforts for inspection, but here there are possible difficulties when staff see the parents as causing the child's problems, and the worker as allied with the parents. A boundary worker whose involvement is via teaching or supervising students has a further difficulty, since practice teaching is usually not considered to be real work! Other ways of establishing credibility are through assiduously following procedures, for instance in relation to recording in the notes what the worker has been doing, or by making sure that everyone who should be is provided with all relevant information and consulted about decisions. Those who enter purely as consultants, with no working links with the unit, will depend for credibility on their work elsewhere and their reputation. Hopefully, such people will have been invited in the first place because their credibility is good.
Allegiance to the unit is both difficult to define and difficult to establish. It may have something to do with valuing the aims of and the work done in the unit, and seeing the positive aspects of group care and treatment. Those who think any group care setting is institutional and should be avoided at all costs, or used only as a last resort, will not find it easy to give positive messages to care staff. Any group care setting that caters for disturbed children is likely to be an uncomfortable place at times. A worker must be able to accept the less agreeable aspects of the place without fearing the worst, and remain able to see that stress and crisis are often an accompaniment to growth and change. Indeed these influences may be a necessary part of development for some people!
Allegiance is also about valuing the staff who work in the unit. Indeed valuing other workers is often the most important element in being a boundary worker. This includes those who work both inside and outside of a unit, are members of various professional groups in a multi-disciplinary department, or workers from separate agencies. Each group has its own tasks to perform and its own skills to contribute, and each is needed to achieve a total service. Even within one professional group, individuals have their different personalities and interests, and the total service is richer for this variety. If some allegiance is felt on both sides, then mistakes and omissions on the part of a boundary worker are likely to be viewed as such, and can then be mentioned to the person concerned, dealt with, and forgiven. Otherwise, deficiencies may be viewed as being either signs of incompetence in the worker or deliberate insults.
Another aspect of staff support for the boundary worker is in sharing the burden of responsibility and holding some of the anxiety that goes with it. This is achieved primarily by listening to staff when they express worries and frustrations. Sometimes worries such as these are not so much about whether actions were appropriate or effective, but whether others will approve. The boundary worker may need to stand alongside the inside worker to defend a decision or to negotiate with outsiders. Quite often the best response is to do nothing, thereby giving implicit approval and permission for inside workers to take the initiative. Doing nothing can be very difficult since it goes against all our expectations of how to be helpful. When staff come with worries about the way things are going, the immediate response may well be to offer advice or directions. But often the staff member knows how to handle the situation, and merely wants to share the anxiety and frustration about how to manage it. It may be precisely because the boundary worker is not part of the chain of authority that these anxieties are brought to him or her, since advice or action are not wanted.
Anxieties and frustration may be dealt with as we have seen, either by passing responsibility for decisions up the professional hierarchy, or by sharing within a supportive group or with particular individuals. Another way such feelings are dealt with is to put blame for failure or difficulties onto a scapegoat. Because staff in a group care unit develop close inward-looking relationships and tend to be suspicious of relatively unknown outsiders, and because it is much more comfortable to place such blame outside the unit, the chosen scapegoat is usually someone with peripheral contact with the unit. Boundary workers may well find themselves in this position, particularly in the early stages when they have a formal role but have not yet developed informal links. It is an uncomfortable position, and one that makes it difficult to achieve any of the other, more positive tasks of a boundary role. It is also a position that tends to be self-perpetuating, because of the mutual distrust and anger that is engendered. Frequently, such a worker can do nothing right: action is seen as interference and inaction as disinterest or worse. For all of these reasons, the boundary worker will need to have his or her own source of support to help hold these anxieties. For similar reasons, this may need to be outside both the care system in which they arise and outside the system of responsibility for decisions.
Co-ordination of work with individual children
Work with a child in group care may well be split up into a number of small specialized contributions, making it easy to forget that the child is a whole person. It is important when planning for a child to be aware of all the influences which impinge on him within his environment. If this is not done, then it may be that some factors are working to maintain the status quo, however hard one tries to achieve changes in a particular area. In deciding how to intervene, it is important to assess what changes would be possible within the child's total situation, or what changes to other aspects of that situation would also need consideration. This said, it is common practice to work in fairly limited areas, and very often small changes in one aspect will create a knock-on effect to create wider changes in the situation.
In a group care centre, and particularly in a hospital setting where there are workers from different professions and specialties, a child's problems are approached on a number of different fronts. One worker may be helping the child to improve social skills, another may be setting limits on his behaviour, while a third may be encouraging him to consider difficult relationships at home. In addition, the child himself will select, from among the staff available, particular relationships which will be used to meet his needs.
There are some who think that the only way a number of people can work efficiently together is if they share the same philosophy and method of working. This may be possible in a small, close-knit unit dealing with a limited range of difficulties and where external resources are not required. It is not always possible in settings that are part of large bureaucratic organizations and is particularly difficult in a multi-disciplinary hospital setting. Children are rarely confused by the differences in people; it is after all something that we all have to cope with in daily life! Sheltering children from obstacles or inconsistencies may be unhelpful in the long run. Helping children cope with activities or people that they dislike or find difficult may also be part of the whole therapeutic process.
A boundary worker needs to be able to accept and value every contribution without feeling a need to improve on it, or fit it into a neat pigeon hole. This comes perhaps with a basic acceptance of one’s own particular skills and limitations. One of the great satisfactions of boundary work comes from seeing effective work being done without having to feel responsibility for doing it all! Results are possible that one worker could never hope to achieve alone.
The training of social workers may particularly fit them for boundary tasks in that such training has traditionally covered a wide view of society and of different working ideologies. The social worker is encouraged to be aware of social and economic conditions, cultural influences, family and group dynamics, community institutions and resources, as well as intra-psychic processes. This background may help social workers in taking on liaison tasks. However, social workers do not have a monopoly on boundary tasks and many do not wish to act in this role, feeling their interests and skills lie elsewhere. Many colleagues in other professions will, from interest and experience, have an equal ability to see a wider perspective. In any one setting, it would be an enormous expectation for a single worker to perform the boundary tasks in respect of all children in the unit. The need to share these tasks is no doubt one reason for the growing practice of allocating a key worker to each child.
In many group care settings the key worker is one of the care staff, that is she/he is working directly with the child.3 The primary task of a key worker is to be a special person in the eyes of a child and to be responsible for liaison with others on behalf of that child. As the person who has most information about the child and his situation, she/he will be responsible for overall plans and will therefore need to have authority to make decisions.
In a setting where decision-making lies outside the immediate living situation, this role of co-ordination may fall on a boundary worker rather than a member of the unit staff. In the particular instance of a hospital psychiatric setting, the responsibility for long-term plans for a child is likely to rest with the medical consultant and the out-patient team. Every member of this team is potentially a boundary worker, in the sense of coming between the in-patient unit and the outside world. As therapist for the child or worker with the family, she/he also carries the out-patient team’s authority to take decisions, into the in-patient unit. Many team members find this a difficult task, for the reasons outlined at the end of the previous section: they readily fall into the trap of becoming a scapegoat. Their boundary role is allocated on the basis of membership in an outside group and not on the basis of their attachment to the inside setting. Thus, their allegiance is suspect. They easily become the focus for all the frustrations engendered by a system that removes authority from the care workers.
Even in a setting where the formal structure is less complex and the care workers are directly involved in planning, there is still a need for some one person to take the role of co-ordinator. If the psychiatric hospital setting is at one end of the spectrum of organizational size and complexity, then one might find at the other extreme the example of a small hostel for young adults working their way from institutional care towards independence. Sponsored by a voluntary agency, and staffed by five or six workers, this hostel operated according to a democratic philosophy. All the workers were of the same profession and status, and a clear division of labour was not much in evidence. Indeed the absence of other kinds of worker (cook or secretary) and the absence of hierarchy resulted in a certain amount of inefficiency when it came to carrying out some tasks. There was always some uncertainty about who would cook dinner, and what would happen to telephone messages! Task sharing was based more on time (shifts) than on individual roles, and any worker could be expected to perform a range of tasks when they were on duty. Such an arrangement required a close-knit group of staff, where information and work was shared closely. However, it soon became apparent that some kind of key worker system was necessary, since every staff member could not maintain a special interest in every resident nor keep a hold on the large amount of information available about all the residents. If the five or six workers found it confusing to try and be all things to all residents, then the confusion was further compounded in communications across the boundary with families, other workers, and agencies.
In some ways communication is simply an aspect of the co-ordination required in group care practice since it provides the means through which service co-ordination takes place. It merits separate consideration, however, because of its importance to all who are involved with children, and because the manner (as opposed to the content) of communication is not always given sufficient attention. Boundary workers may be used as channels of communication even when they have little or no involvement with a particular child, simply because they happen to be present. This means passing information in two or more directions, and not just collecting it for oneself. Such a go-between role is difficult to fulfill in that it is not always easy to pass on the full flavour of a communication at second hand. A significant part of any communication is implicit, that is non-verbal, and – though recognized – may not be sufficiently clear as to be passed on to others.
In such cases communication is clearly different from coordination since it is entirely separate from responsibility for work or decisions. This type of communication without authority is particularly evident in working on the boundary between separate agencies, since each agency will be autonomous in decision-making within their own sphere. It may also apply between different professional groups, particularly where professional roles are clearly and rigidly demarcated.
The formal communication system consists largely of meetings and written reports. In any group care setting there are likely to be daily change-of-shift meetings, and regular review meetings for longer-term planning, to which outsiders may be invited. Written records may also be organized for daily, weekly, and longer-term reports, and for inside and outside use. It is difficult, however, to ensure that the formal system meets all communication needs. People miss meetings (perhaps because they are minding the children!) and fail to read reports. Reports tend to be factual and often do not contain impressions or “intuitive” understanding. Moreover, communication is not just about information, it is about relationships, trust, and support. When emotional aspects of communication are blocked, workers are left feeling unheard or misunderstood and a frequent result is that distrust arises. Any lapse in factual communication is then magnified, and attempts may be made to change the formal system to ensure fuller discussion and agreement. What is more often needed are better informal opportunities for talk in a relaxed atmosphere where feelings can be more freely expressed.
Communication is about understanding. If the formal content of communication is divorced from the relationship between communicators, then misunderstandings are all too frequent. To an extent, one hears what one expects to hear. Expectations are set up by one’s attitude towards the other person, by one’s previous experiences of working with him or her, and by the pressures one is under at the time. Words are an inadequate medium to convey the richness and complexity of our thoughts and feelings. Understanding is only achieved through the medium of non-verbal signals, openness, freedom from anxiety, and shared experience. Otherwise what one says may reach the other person with a changed meaning. The story is told of an old lady who played the bugle. Her favourite saying, when accused of playing out-of-tune, was that “it was all right when it left me”. Perhaps the lesson to be learned from this is that if one wishes to be understood, one needs to have, as well as an idea of what one wants to say, an awareness of the other’s point of view.
Working with families
In some group care settings, particularly those provided by social services, children may be there because they have no effective home base, and contact with parents may be minimal or nonexistent. In a psychiatric setting children are likely to have their own or substitute families, who have frequent contact with their children while in the unit, and usually these children return home afterwards. In this case the work being done with the families outside the unit parallels that done with the child inside the unit, and is likely to be just as important to the eventual outcome.
The boundary worker’s role with a family includes of course keeping unit staff informed about what is happening within the family, and the family informed about what is happening with their child in the unit. More important is the process of engaging the family to work alongside the staff towards mutual goals. Initially the parents may feel a lot of anger and guilt towards care staff, at having failed to cope with their own child and because the staff seem able to cope so much better. Parents need to be reassured that the staff also find their child difficult at times. Staff have the added advantage of having other people available to help, of having a time-limited commitment with the certainty of leaving at the end of a shift, and are able to work with no other distracting tasks which must be carried out simultaneously, such as housework. Given such reassurances, staff may then be able to help parents observe and try out alternative ways of managing their child's difficult behaviour, as suggested by Conte elsewhere in this volume.
Group care staff may also come to feel quite angry towards parents, because the parents are seen as being the root cause of the child's problems. This is particularly the case with parents who seem rejecting, who fail to visit or keep promises, or who criticize and undermine their child when they do visit. Staff see the effect of this behaviour on the child, and it often stirs up deep-rooted fears and anxieties of their own. The family’s worker is likely to suffer the same emotional reaction, but being less closely involved with the child, she/he may be able to remain detached enough as to try and understand the reasons for the parents' difficulties.
Many boundary workers may also have a formal teaching role with staff in a group care unit, since most in-service training tends to be provided within professional groups. Boundary workers may sometimes have a role supervising students who are working temporarily in or around a unit. Informal teaching occurs through a process of mutual learning which is one of the great benefits found in working closely with members of different professions. A liaison worker’s contribution to the unit team is to bring in information about a child's family, environment, and contributions of workers outside the unit, so that the child's behaviour can be better understood. The worker may also be able to promote sharing of tasks and the emergence of inside workers into the outside arena. Many group care staff are becoming more and more involved with, for instance, work with families, and are beginning to participate in family therapy and home visits. Since work of this nature involves the blurring of roles and the taking on of tasks previously regarded as belonging to other professions, performance is initially accompanied by diffidence and uncertainty.
Care staff in particular may feel ill-equipped for such work because of the narrowness or inappropriateness of their earlier training. Nurses working in psychiatric settings, for example, may not have had any suitable specialist training. For instance in Scotland there is no training course for nurses in child psychiatry, and elsewhere such courses are usually limited to a few centres. It is therefore not unusual for nurses to have a weighting of general training, with its emphasis on physical care, regular routines, and close supervision from senior staff. Inevitably, therefore, nurses working in child psychiatric in-patient settings have to learn many of the skills they need on the job, by observing others at work, by working alongside a more experienced staff member, and by “trial and error”. As well as senior nurses, members of all the other professions involved have a useful part to play in this. Where the other professions are organizationally separated from the group care unit, then such involvement becomes a boundary task.
Group care is one of a range of services and facilities available for helping troubled children. It is often seen as undesirable, harmful, to be avoided at all costs, and only used when other measures have failed. This is particularly the case at present given the drive away from institutional care towards community-based services. Group care offers an experience that is different from other forms of professional intervention because of its intensity and its all-embracing nature. At its best, group care provides considerable impetus for change in a setting which is safe and controlled, and which offers a choice and flexibility of means through the number and varied skills of a staff team. It also provides opportunities for the development of a much more comprehensive picture of a child and his or her problems. Group care can also have a considerable influence on children and their problems because of the close relationships which can be formed there.
One of the most important tasks of a boundary worker is to “sell” this more positive view of the potential of residential treatment to those outside. “Outside” includes colleagues working in, say, the out-patient department of a hospital as well as those from other agencies, since acquaintance with and responsibility for a unit does not necessarily mean that it is favourably regarded. Indeed influencing the views of colleagues on an out-patient team or in an external agency can be paramount, since it is they who decide whether to ask for admission to a unit for any particular child. The group care unit may refuse admission on the grounds of inability to cope with a particular child or because of an unbalanced mix of children currently in the group, but they cannot make a positive choice. And yet successful outcomes, and consequently work satisfaction for the staff, depend upon the suitability of children referred to a unit and their ability to respond to the experiences which can be offered to them there.
It has been argued throughout this chapter that much of the role of a boundary worker consists of establishing and encouraging informal mechanisms to carry out the tasks of communication, co-ordination of work, and so on; and that the need for this informal system arises from the complexity and inbuilt conflicts contained in the formal system of management operating in many group care centres. The smaller the organization and the less cumbersome its formal structure, the less need there is for some boundary roles. There will always be a need for communication and liaison with the community and agencies outside the group care setting. But tasks inside the setting, in particular support and sharing of anxiety and frustration, may be minimized if the formal structure is one in which authority is clearly delegated, where there is frequent and open discussion of work, and where relationships are characterized by trust and valuation between members of staff.
Two questions can be said to have arisen out of direct experience of work in a boundary role. The first question involves whether it is possible to sit right in the middle of the boundary without moving to one side or the other. It can be a very uncomfortable place, attracting maximum blame and minimum satisfaction. One is not closely enough involved in the direct work of the unit to share the pleasure of seeing children improve and one can sometimes feel loaded with all the problems. One alternative is to look for satisfaction in work outside the unit (for example, with families) and see the boundary tasks as a necessary but onerous duty. The other is to become more involved with the staff and children in the unit, and see oneself as something of an ambassador, rather than a neutral negotiator.
The second question is whether it is necessary to have actually
practised as a care worker, inside a group care unit, in order to
perform boundary tasks adequately. It is very helpful in relating to
care staff to have some idea of the kind of stresses their work imposes.
Group care practice is non-stop and can be exhausting. The pace is quite
different from that of planned appointments, and much of the time it is
a matter of responding to the constant demands of others. There may only
be a small number of children, but relationships with them are likely to
be close and sometimes intensive. The world “outside” can seem far away
and not very relevant to the task at hand. It is thus easy to develop a
certain distrust of strangers and outsiders. One is dealing with a group
of children, not just one individual, and this can multiply any
problems. If a boundary worker is not aware of all this, she/he may not
hear when staff complain of feeling stressed and thereby not respond
helpfully. It is of course possible to understand what group care work
is like without having direct experience of it. However, without the
experience, it is not possible to know whether one could cope oneself in
that situation! Descriptions of a day in the life of a unit can
sometimes sound quite horrendous. The inexperienced boundary worker may
react with panic
measures: suggest discharging a child or send in the experts. Such a
reaction is not necessarily helpful to staff and may have disastrous
consequences for children. Helping staff to tolerate crises and even to
use such experiences is far more convincing if one has been able to do
the same oneself on previous occasions.
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