Children at risk? Hospital social workers’ and their colleagues’ assessment and reporting experiences

Abstract

This thesis explores factors that influence professional discretion in Swedish hospital professionals’ assessment of children who may be at risk of harm. It is based on two data samplings, interviews with fourteen hospital social workers and a questionnaire with 295 responding physicians, nurses, nurse assistants and hospital social workers. The theoretical frame consists of theories of professions, sociology of emotions and normativity. Although all professionals are mandated to report suspicions about children who may be at risk to social services, the findings show that a majority of the participants had never made a report. However, there were major differences between the professions: hospital social workers and physicians made most reports, while it was unusual for nurses and nurse assistants to report. This is explained by children at risk being everyone’s but no single profession’s responsibility within health care – which shapes an informal pattern of jurisdiction, split between physicians and hospital social workers. The professional group to which a person belongs was shown to affect how other factors influence assessment. The lower the status of the group, the less knowledge about the issue and the available organisational support its members have, and the more emotions influenced the decisions not to report. While hospital social workers are less strongly affected by emotions in decisions not to report, the deeper qualitative analysis shows that assessment tended to follow a ‘logic of normativity’ where their worries stuck to ‘warning signs’ associated with gender stereotypes or unprivileged groups of parents. Critical reflexivity could disturb this logic as well as the silence of normality, meaning that children from privileged groups may not be given enough attention. Hospital social workers were also found to take different positions in their inter-professional teams – active, reflective or passive – relating to three institutionalized norms of action – juridical, therapeutic and medical. A small number followed the medical norm, but that had the most dangerous consequences for children who sometimes were not dealt with appropriately despite severe signs of harm. The overall analysis in this thesis suggests that theories of professional discretion should take into account factors such as the context, inter-professional relations, emotions and normativity to enhance the understanding of what influences assessment and decisions.