Ep.87 How an Aged Care Social Worker uses Dignifying Practice as Covert Resistance
Keywords
social worker, hospital, family, work, placement, people, dementia, system, patient, pressure, support, practice, resistance.
Speakers
J S
Justin Stech
0:05
Welcome to Social Work stories, a podcast exploring social work practice through stories and critical reflection. This podcast is recorded on Aboriginal country which was never ceded. We acknowledge the traditional custodians and cultural knowledge holders of these lands, and pay our respects to Aboriginal elders past, present and emerging. We offer a warm welcome to any indigenous listeners who are part of our podcast community around the world. If you have thoughts or feedback for our team, or just want to find our whole back catalogue of episodes, check out our website Socialworkstories.com. But for now, on with the Episode.
LM
Lis Murphy
0:56
Hello, and welcome to the Social Work stories podcast. My name is Lis Murphy. And Hello, Dr. Mim Fox.
MF
Mim Fox
1:04
Hi, Lis. Hello, everyone, how you doing?
LM
Lis Murphy
1:08
Let's just say both Mim and I are a little bit excited, because we're actually in the same room using the same microphone. This never happenes It never happens. And look, I just wanted to start off by saying we're very excited. And I hope we bring that excitement to this recording.
MF
Mim Fox
1:27
Do you remember this when we first started doing this podcast and we always needed to be in the same room.
LM
Lis Murphy
1:32
We had to be.
MF
Mim Fox
1:32
Yeah. and then COVID threw us and got us into a habit of not being in the same room. But this is always so much better. Right?
LM
Lis Murphy
1:40
So much better. And I know that Dr. Ben Joseph will be also thankful because it makes editing just that much easier Mim.
MF
Mim Fox
1:47
Magic behind the curtains people and he really does help with the production process. I love it. This is a good episode today.
LM
Lis Murphy
1:55
Look I'm I'm calling it I think sometimes we call a recording a classic practice piece.
MF
Mim Fox
2:03
A classic. Yeah, it really is actually, it feels like you know how there's social work that's kind of an everyday social work. It feels like one of those Everyday Stories, which actually, when you delve deeper, you start to see the magic that's happening.
LM
Lis Murphy
2:20
I think early you'd said to me, you love the layering that goes on in this story. And so just I'll just let you know, listeners that this is a hospital social worker who's working in a clinical area, with mostly older people as the patients. And she tells a story about her work with a man called John, who has come into the hospital. And he basically requires a residential aged care placement. And so what the social worker does is talk through methodically that process, but inter woven in that are some of her reflections on not only what she's done, but the tensions that have occurred as a result of a stance she takes in supporting John and his family to await a particular placement result. So I guess Mim for me. If I could actually ask listeners to listen to the reflections, especially at the end, because I imagine they'd be wonderful ones to come into supervision with and I bet your social workers have come into supervision with these tensions.
MF
Mim Fox
3:33
Oh, absolutely. The other thing I would say while you're listening to this is when I listen to it, I fell into a bit of a trap at the beginning Lis of thinking, Oh, this is just everyday social work, that there's not something interesting or exciting happening here. I'm going to challenge you listeners to keep going and get to the end. Because really, the reflection brings out a philosophical debate I think that is fundamental to our practice. So I really want to talk about that afterwards as well.
LM
Lis Murphy
4:02
And finally, listen to the humanity that this social worker weaves through her practice. It's a very, very dignifying way in which she works. And I think that should also be mentioned at the outset. So have a listen. And then of course, we're going to come back and share our 10 cents worth why not, maybe more. Enjoy.
SW
Social Worker
4:35
I am a social worker working within an aged care ward in a small hospital within a large regional health district. Today I will be sharing the story of a man named John and his family who I supported through the process of entering a residential aged care facility. To describe this process. I'll be using the term "placement" and also the abbreviation RACF when referring to a "residential aged care facility."
SW
Social Worker
5:04
John was an elderly man who had been living with dementia for some time. Prior to John's presentation to hospital, he was managing okay at home with his wife. Although required a lot of her support, and overtime had become increasingly more confused. A particular episode of deterioration in John's cognition resulted in some aggressive behaviors, which led his concerned family to seek medical attention. John spent some time at a larger acute hospital before being transferred to a sub acute aged care hospital where I was working at the time. The medical team had treated and ruled out any ongoing reasons for his deterioration, and had determined that this was likely his new baseline and progression of the dementia.
SW
Social Worker
5:53
Hospital social workers are often referred to for discussions about placement with older persons in their families, depending on any concern that may be raised from the about the person's ability to manage at home. Before John was transferred to my hospital, the treating team at the acute hospital felt that his care needs and behaviors were so challenging that home would be unsuitable. The social worker had commenced conversations with John and his family, and John's decision making capacity had been explored by the multidisciplinary team and a geriatrician. As people living with dementia may have cognitive impairment in some areas, there are many areas in which they may still be functioning quite well and can be capable of making appropriate decisions. Although John had a diagnosis of dementia, and was found to have an untreatable progression of this illness, John's capacity needed to be formally explored further, and the recommendation of RACF presented to him.
SW
Social Worker
6:58
A neuro psychologist or a geriatrician can assess for decision making capacity. And after several reviews with John, it was found that he did not have decision making capacity in regards to his accommodation. He did not engage in conversation around this and did not show a response when prompted. From here, the Aged Care Assessment Team assess John for residential placement, and a referral to the hospital placement service was generated. A team that refers inpatients to relevant RACFs.
SW
Social Worker
7:33
As this journey had already commenced at the other hospital, when John arrived on to my ward and after I had received a handover from the social worker. I immediately met with John as to gather an understanding further of who he was and his and his ability to understand his situation. Immediately upon meeting John, I was struck by his word finding difficulty, I introduced myself but was unable to converse in depth. I could not make sense of his sentences, although there were some words within that I could identify such as his wife's name and where he lived. As I tried to speak with him, John was distractible, pacing around the room and sorting objects. I mentioned the topic of RACF placement, but John did not engage with this, nor did he seem to follow. And although I had been handed this over, I found it important to have had a face to face interaction from the get go, particularly when beginning to first work with someone no matter where they may be in their journey through hospital.
SW
Social Worker
8:42
And from this interaction, it was apparent to me that I was best to speak directly with John's family moving forward. I had sourced copies of John's enduring Guardian appointment, a person or persons that have been legally appointed to make decisions for someone in the event they can no longer do so themselves due to the nature of John's situation. From here I spoke directly with his daughter and son who were the joint Enduring Guardians. I had met with John's wife the next day when she came to visit and she was visibly frightened of John and opted to sit near the door of his room and had asked a nurse to stay nearby. Upon speaking with her, it was clear that what we were observing in John was a huge change to what his family knew him as, and that due to the incidents that led to his admission, his wife was quite frightened of his unpredictability and had said that she felt as though he was someone else.
SW
Social Worker
9:45
As I sat sat with John's wife, she detailed their life together, John's career, their family, his hobbies, and what the last several months had been like for her caring for him with his declining cognition. John's wife expressed feeling that she could not have John return home as she was elderly herself and could not provide the level of support that he needed. John's wife was very upset with this decision, but held on to hope that what was happening for him was reversible. During this time, I provided the family with Centrelink forms and information on the placement process from hospital. John was also due to commence receiving a hospital fee for his time as a medically stable patient. This hospital thing is often referred to as a nursing home type fee within health, and occurs after someone has been in hospital for a while and is no longer receiving acute care. The patient is billed if they are medically stable and awaiting an RACF and the fee is for their daily cost of care. This was a great source of stress for his family as John and his wife were both aged pensioners. I assisted the family to complete a financial hardship application, submitting it to hospital executive advocating for a reduction. Navigating this fee can be a very uncomfortable aspect of supporting families on this journey through hospital, as many are unaware of such a fee within a public health system, and it understandably elicits some strong reactions.
SW
Social Worker
11:28
From the get go, John's family were very hopeful in having him placed locally. But in the aftermath of the COVID pandemic, our RACFs vacancies were few and very little had spots available in their dementia specific units. Several RACF 's were referred to and after several months, there were no offers of placement for John. I spent a lot of time with John who often required one on one nursing support due to his wandering and assistance like for things like eating and supervision as well as he was a high falls risk due to being impulsive.
SW
Social Worker
12:07
During this time, we were experiencing another COVID outbreak so visiting had ceased at the hospital. And without the visits and support of his family John was distressed or needing more support. Whenever I could spare a moment, I would take some time to sit with John and go through his photo book that his family had made for him. I would often set him up for his meals and sit next to him while I completed my case notes on a laptop as he had his lunch. And although communication was challenging, I had grown to know a lot about John, and we were able to discuss certain things like his dog and his love for cooking.
SW
Social Worker
12:47
Due to the impact of COVID the hospital system was under great strain resulting in not enough beds for people presenting with serious issues, and the ramping of ambulances outside of emergency departments. There was an internal pressure felt to house people awaiting RACF placements across the district as soon as possible. And as I mentioned, vacancies for our RACF 's were extremely scarce. So safely discharging people felt like an impossible task at the time. It was challenging as these patients were deemed medically stable, yet due to their conditions were not suitable to return home safely. As a social worker, I was asked to provide weekly updates to hospital management on the process of placement for these patients on my ward and asked to explore other options such as out of area placements with families. At times, I began to feel pulled away from my main purpose as a social worker here having to shift focus to quick fixes and discharge planning, rather than supporting families through a vulnerable time.
SW
Social Worker
14:00
As John had been in hospital for several months, pressure began to mount on the family to consider a placement out of area. I had remained transparent with John's family about the hospital pressures and the dire opportunities for placement locally from early on. John's family wanted him placed close due to his wife's restricted license, meaning she could only travel to visit him locally. One facility had guaranteed John a bed but were unable to confirm when that bed would be available. This facility had a reputable dementia specific unit so his family were very happy about this. Management at the hospital had asked that I still suggest placement out of area with the family due to no confirmed date of entry for John. I had discussed this earlier with John's daughter who was strongly opposed to this due to the inability of her mother and siblings being able to visit him And so after much consideration, I opted not to suggest this to the family again acknowledging that this would mean that John would be without his supports if placed out of area. And I was already seeing what the impact that no visitors was having on him whilst in hospital. I also acknowledged that John had been accepted to an RACF that the family were happy with, just without a clear indication of when he may be moving there. I found this challenging as I understood the bed pressures being felt across our health district. But I was also sensitive as to not penalize John's family for wanting the very best care for him. As I had pushed back on asking the family to reconsider placement out of area, the nursing unit manager opted to call the family instead who went on to decline the suggestion.
SW
Social Worker
15:57
Across these months, I had weekly phone calls with John's daughter providing her updates on how he was traveling. These phone calls turned into both an update and emotional support and counseling for his daughter. In light of her feeling as though she'd lost the father she once had, and how the progression of dementia had impacted the whole family. John's daughter lived hours away and was planning to visit her family but due to the hospital's visiting restrictions she could not visit John. This was a great source of distress for his daughter, who felt that if she were not to see John soon, she may not ever see him again. I advocated to hospital management to arrange a one time visit for John's daughter which they approved. And with the appropriate PPE on a strict timeframe. John's daughter was granted entry into the ward to visit him.
SW
Social Worker
16:52
And so finally, the day came where John was discharged to the preferred RACF where he was met with his wife waiting with him with their pet dog on his arrival. The family later sent us through a photo of John in his new accommodation. As I reflect on John's story, there are two main things that are at the forefront of my experience as a social worker in this setting. Firstly, how grief and loss can be inherent to the placement pathway, and how holding space for patients and families is such a privilege during this time. While I was not able to gain John's perspective, I was able to recognize the feelings of grief and loss that his family were experiencing. Grief for the person John once was and who they have always known, grief for how life once was and will never be again, and a lot of grief around the decision to enter care. And as a result, the guilt that is felt around this. There was also some bargaining at times and often the family expressed wondering if John would come out of what was happening for him. I think often in a hospital setting, it may be established that an older person's discharged destination is RACF. And once all the necessary processes have commenced, it can be forgotten how big of a life event this is for the person and their network. The reality is that this decision to enter care often becomes often comes at a time where there has already been a lot of loss, a loss of mobility of good health of memory of a spouse, and with it comes further loss around having to leave their home to go somewhere where they are very likely to spend the rest of their life. Many people never enter hospital thinking they will never return home. And this is where the importance of social work comes in. To not only help with those practical processes of entering care, but also acknowledging and supporting people through what is a huge life transition, particularly in a system that is under a lot of pressure and perhaps often feels at odds with holding space for people at such a challenging time.
SW
Social Worker
19:13
And this leads me to my other main reflection on John's story. The ethical and organizational challenges at play for a hospital social worker within this age care space. At times, I found the top down pressure incredibly challenging to my practice. It felt confusing to be employed for the very system that I felt was challenging my values. I understood the bed pressures across the health district in the sense that I knew there is a direct role on effect to those awaiting admission from emergency in need of medical treatment. I also understand that a hospital is not an appropriate long term accommodation and that the risks and an extended stay can have on patients can be quite serious. such as hospital acquired illnesses. But I can also understand the challenges felt within the community of limited RACF beds, and families wanting the best care for their loved ones. And I think if I was in that position, I'd want the same if it was a loved one of mine.
SW
Social Worker
20:18
At times, it felt like the system becomes impatient with families who may be said no to a potential RACF or who may be approved or on a waitlist for an RACF Yes. But there's no idea of knowing when they will be moving there, which in in fact, then leads to less movement in the hospital. But I can also see that an older person is in hospital for a reason, meaning that their care is unattainable at home. This pressure can almost feel like we are punishing families for being challenging, or not being able to care for their loved ones. This is where the support of Social Work comes in to be an advocate and guide through this pathway. It can be ethically challenging, but it can be equally rewarding being there alongside families experiencing this journey.
LM
Lis Murphy
21:17
You know Mim. I'm curious. I want you to go first, what what comes up for you as a result of listening to the story?
MF
Mim Fox
21:25
Like I said, at the beginning of the episode, Lis I, I got lulled at the beginning, thinking that this is just an everyday case, right? Because I think that's what happens in hospital social work is that sometimes you can be working on some of those aged care wards, those medical wards, surgical wards, and you know, they call them the general medical wards the catch all of everything. And, and discharge planning becomes just a part of your every day, right? And then what happens is, when you're doing it, over a period of time, you can start to forget why you as the social worker are actually doing this role, especially when you might be working alongside a nursing discharge planner, right? The nuance of the roles can get a bit blurry. But I think this story really reminded me how important it is for social work to be involved in discharge planning. The it was such a challenging scenario for the social worker but again, that challenge is an everyday challenge. So that was that was those are my initial responses. What about you? Where were you coming from?
LM
Lis Murphy
22:32
Well, my initial response was, here is a social worker that brings heart to her practice. And by that I mean, this is someone who went the extra mile. And so from the get go, there was an amazing attention to the centering of John. So even down to she could have, she could have actually read those medical notes and seen that John had been diagnosed with dementia and gone "right, going straight to the family." No, no, not this social worker, she spent time with John and got a sense of his abilities. I mean, she got enough out of him to know that he enjoyed cooking, and he had a dog. And so they were connecting points that she was able to locate. And then beyond that, she then commenced a relationship with the family to get a sense of what what they were wanting, and what they were needing and what they wanted for John. And once she was clear about that, she was steadfast in supporting them around that. And Mim as you were talking, I was also thinking about for those of you don't know, Australian hospitals at the moment, or actually, for the last few years, this thing called bed ramping. That is this ongoing pressure for anyone who works in hospitals, where your daily reminded about the bed ramping that's going on. And by that it means down in emergency department, there are people waiting in stretches in corridors, unable to actually get to the wards. So I raised that because it's important you understand the pressure that's constantly on a social worker, including this one. But despite all that, she brings it back and she starts to remind us who is the person that she's centering her practice around. And that to me was just the moment where I thought this is this is what it's about. This is what social work brings to this particular form of hospital social work.
MF
Mim Fox
24:43
It's so true, Lis, you know what, I was just thinking about listening to you. I was thinking how often students will come in to study social work, and they'll say, "Why do I have to do a general social work degree? I want to be a child protection worker, or I want to be a hospital social worker, why can't my entire degree focus on that practice field, right." And in Australia, we all have general social work degrees, we don't specialise, right. And the reason for that is because of this basis to social work, which actually cuts across the sectors. And I was thinking about how, if you train just in one system, you can actually become a part of the system, you can actually become part of that bed ramping. And that philosophy or that discourse, which says that that's more important than the person, that actually getting someone in and out of those beds in a quick, timely fashion is actually more important than this patient's experience and or their family's experience, right. And that's the inherent challenge in social work, I think, working within a system like this, and you could hear it in the social workers voice, right? You could hear and she said, she was so challenged by that discourse, that the family now becomes a "difficult family," the family becomes the thing, stopping the beast from working, when actually the beast works for that person, for that patient and for that family. So it's really up to the social worker to stand stand tall within that system.
MF
Mim Fox
26:19
What I loved about the story was hearing the ways she did that, right. So there's COVID happening in the hospital, there's all of this pressure where this patient is isolated from their family isn't able to see anyone, and she takes her notes, and she goes next to that patient and writes her notes, while spending time with him while getting to know him. And I think that's the humanity. You referred to earlier, Lis, right? It's that, how is she going to enact I don't think it's just about her skills, I don't think it's just about her empathy. I also think it's about a silent rebellion, a silent protest.
LM
Lis Murphy
26:56
That is so true. And I want to pick up on that because a friend recently, like last week sent me an article and it was called "Social Work activism resistance at the frontier," by McAuliffe, we can actually link it in the notes. But what it actually talks about is the covert resistance that social workers can practice in the everyday practice of their social work. And with that lens, if you then step through what the social worker did. So as you mentioned, she would bring a beautiful companioning into the space with John because his family was unable to be there. She was providing support to the daughter that was just grieving, there was intense, disenfranchised grief of losing her dad through the dementia, but also through distance, then there was that resistance to the pressure that the management of that hospital would have been applying to her into saying to that family, you need to place your dad in an out of area, nursing home, essentially. Now, just as a little aside, we know that the prognosis of someone that is put in a nursing home, that has not got the ability for family to come and support is three to six months, it's something ridiculous. So in fact, she would have known that pressure to that John would have been absolutely he would have deteriorated in a matter of months, and possibly even his family if they weren't able to have access to him. So in that resistance, that quiet resistance, remember, she said something like, I chose not to mention it again to the family, despite the fact and we've all had that where the nurse management is putting a lot of pressure on social work. But that beautiful resistance to that, and the family will never know that, that she actually prevented. Well, her contribution to it. I think the nurse manager did have a crack at them. But that, you know, as a good family does sometimes just go "No, I'm not taking my dad out of the hospital. He's staying put until the appropriate bed comes." So I think that sometimes we overlook some of those small acts of resistance. And I really thank the authors of that particular article because it's helped me to actually see Yeah, it's beyond just the heat the dignifying humanity that she brings to that it's quiet resistance to a system. That and and also a reminder that her work is patient centered. That's That was her attention. Who am I working for? And I could imagine her going into her supervision session. I'm confused. I feel like I should be working for the passion. Don't we get pressure to as you say work for the beast work for the system.
MF
Mim Fox
29:56
And I think that's actually the crux of it here. Right? Is that often, you know, when social workers burnout, it's often because they haven't found that source of satisfaction. They've gotten sucked into the system that they're working with. And, you know, they've now been doing this job for however many years and it cannot find the source of joy anymore. And I think it's that it's getting lost in the pressures and the discourse that's happening that's swirling around the patient in the family in the in the organization, without being able to have that critical reflection on what's actually happening. That sense of reflexivity about who am I in that discourse? What is my role within this organizational context and environment and being able to stand up to that? Now, whether you do that in that discussion with the NUM, whether you do that in that quiet resistance, that silent protest way? I don't think that matters, right?
MF
Mim Fox
30:54
I wanted to say something else leads just what you were saying about the prognosis of three to six months post discharge, when someone doesn't have a support system. And you took me back to a memory, actually, of working in the hospital system. And when someone would die fairly soon after being discharged to a nursing home, it was treated as absolutely normal and not surprising. And that's because it would happen so often. The move in itself would be the the trigger the thing, right. And I think we lose sight of the impact of these decisions on people's lives. And this social worker says it actually in her story, that in her reflection that when you're part of the system, you think that this moment in time is just as small a moment as every other moment that you've had in your day or in your week or your month, right. But for this person, and for this family, this is enormous. And to really pay respect to that, to really be humble in our role in people's lives and the power that we hold in those in those relationships with people. I think it really it will serve us well to remember that, that actually how important this is for that person, and take your ego out of it. That it's not how important are you in this moment, it's how important is this moment to these people. And you owe it to them, we all do to actually give that that quiet, humble humility, and to be able to then enact our resistance in whatever ways work for us right and work for the family.
LM
Lis Murphy
32:32
I think less is more with this one. I think I think I think our reflections. I couldn't add to it. And I couldn't add any more to this story. So what but apart from, I think this is a piece that I would really encourage people to listen to, especially those social workers working in the Gen Med, the aged care space. And I'm hopeful that you see that this is a piece for you. And to honor the work that you're doing, because I think this social worker is very representative of the quiet work that goes on. And often your efforts aren't really sung high praises, it's not the sexy social work, they start with the machines that go ping, let's be honest. But it's actually one of those practices that many of us work in over the course of our career, the reality is our population is getting older. And I think this social worker, really does pose a wonderful example of how it can look. And some of the reflections will I hope some of our reflections can help you to honor the work you do. And also to bring some more, I guess, to actually do exactly what she's doing is to quietly resist some of the temptations that may occur within our health system.
MF
Mim Fox
33:58
You know, Lis I'd love for any listeners out there who this rings true for them to really contact us and let us know, right? Like, I'd love to hear firstly, whether this is your everyday, whether it makes sense to you. And you've experienced these moments, but also any examples that you have where you've also quietly resisted by bringing humanity to a situation by bringing that extra depth of empathy. And also, what was it philosophically that jarred with you, that challenged you, because of different contexts, as I said before, you know, these are just generic social skills. So for different contexts, this will play out in different ways, right? So I would be really keen to hear what's happening with other people out there. I really thank the social worker for this story. It's a beautiful, quiet story that actually like we said at the beginning, the layers in it, it just, it's a sort of story you can listen to a few times and get the different layers.
LM
Lis Murphy
35:01
And on that note, my friend, I think we shall bid adieu.
MF
Mim Fox
35:07
Thank you so much, everyone, we hope you're all doing well out there and get in touch. And Lis has been going crazy doing recordings.
LM
Lis Murphy
35:15
Big thank you to those social workers who have contacted me and we've had great conversations and I have my mic and I am traveling with it.
MF
Mim Fox
35:22
She literally is traveling folks. So if you want the Lis wagon to come your way, then get in touch and let us know if you've got a story to share. We are so keen to hear how everyone is and what incredible practice just keeps going on every single day. Thank you so much, everyone.
LM
Lis Murphy
35:39
Thank you, everyone. Bye for now.
JS
J S
36:01
Thanks for listening to the Social Work Stories podcast. All of the stories we share are de identified to respect and protect the people involved. We create this podcast because we're passionate about building the Global Social Work community and strengthening our practice no matter the context. If you want to help us grow the podcast tribe, and continue the work we do, we would love it if you can subscribe or follow the podcast in your favorite podcast app. That way, you'll be sure to get every episode as soon as it's released. While you're in your podcast app. If you can leave us a five star rating and write a review it would mean so much to us. You can connect with us on Instagram, Twitter, Facebook and LinkedIn where you can share our posts with your friends to help spread the word. And you can always find us at our home on the web, social work stories.com The Social Work stories podcast is made by Lis Murphy, Dr. Mim Fox, Justin Stech, Dr. Ben Joseph and Maddy Stratton. Thanks so much for listening.