child protection or professional self-preservation by the baby nurses? public health nurses and...

Pergamon 0277-9536(95)00378-9

Soc. Sci. Med. Vol. 43, No. 3, pp. 303-314, 1996 Copyright © 1996 Elsevier Science Ltd

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CHILD PROTECTION OR PROFESSIONAL SELF-PRESERVATION BY THE BABY NURSES? PUBLIC

HEALTH NURSES AND CHILD PROTECTION IN IRELAND

SHANE BUTLER Department of Social Studies, Trinity College, Dublin 2, Ireland

A~tract--An exploratory, focus group methodology was used to elicit the views of public health nurses (PHNs) on the topic of child welfare and protection in the context of new legislation and evolving child care policy in Ireland. The nurses' views were considerably at variance with the officially stated commitment to inter-disciplinary collaboration and coordination within the Community Care Pro- grammes of Ireland's regional health boards. The PHNs feared that involvement in child care proceedings of a social control or adversarial nature would compromise them in terms of their traditional curative and preventive health roles, and, on this basis, argued that social workers should retain the bulk, if not all, of the responsibility for such child care activity. The nurses also defined their work roles in terms of their own traditional, professional commitment to individuals, families and communities, and felt less bound by or even aware of the corporate responsibility of their employing health board. It is concluded that the enactment of new legislation and allocation of additional resources do not resolve the issues of inter-disciplinary collaboration in this area.

Key words--public health nurses, community care, child protection, social workers, child welfare

INTRODUCTION

Child protection and community care

The enactment of the Child Care Act 1991 in the Republic of Ireland may be seen as the culmination of a long campaign by child welfare activists to replace the outdated Children Act 1908 with a more modern and comprehensive statute. The new act, which is being implemented on a phased basis, gives explicit powers and duties in relation to child welfare and protection to the country's eight regional health boards, bringing clarity to what was previously a confused legal and bureaucratic situation [l].

Given the recurring conclusion of British child abuse inquiries that serious injury or death might have been avoided if there were better inter-agency collaboration [2, 3], it might appear that the Irish health boards, with their integration of health and social services within a single bureaucracy, constitute the ideal basis for a coordinated, inter-disciplinary approach to this problem. This impression would certainly be fostered by a superficial examination of the structure of the Community Care Programmes of the health boards (Fig. l), as it would by an uncritical reading of the rhetoric of community care; such rhetoric, with its emphasis on inter-disciplinary liaison and cooperation in primary health care teams, is particularly exemplified in the report of McKinsey and Company [4] upon which these administrative structures were based.

The experience of community care services in Ire-

land since the establishment of the health boards by the Health Act 1970 has not, however, generally reflected the smooth, consensual pattern envisaged in this organizational blueprint. It should be noted that general medical practitioners (GPs), who are of paramount importance in the primary health care system, are, as depicted in Fig. l, out on an administrative limb; they operate as independent contractors rather than as health board employees, as a conse- quence of which there is considerable ambiguity concerning their reporting relationship to the Direc- tor of Community Care and their working relationships with other members of the multidisciplinary team.

While social workers are employed directly by health boards, they have persistently expressed dis- satisfaction with an administrative arrangement in which top-level decision-making in what they perceive to be their professional domain remains the prerogative of the Director of Community Care, a public health medicine official. During the 1980s there was a protracted but ultimately unsuccessful campaign by social workers to establish a separate administrative programme; this was aimed at distinguishing personal social services from community health services, thereby granting social workers a degree of professional autonomy which they had not previously enjoyed [5]. Furthermore, a comprehensive review of community care services within the health board system, which was completed in 1987 by the National Economic and Social Council (NESC), concluded

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304 Shane Butler

that existing structures had failed to "achieve the forging together of health and welfare services originally envisaged" [6] (p. 123).

Public health nurses (PHNs) are key figures in the health care system in Ireland; their role has evolved over many decades, and they are in numerical terms the largest professional grouping within community care. The research reported here was aimed specifically at exploring their attitudes towards child welfare and protection, particularly in the context of the new Child Care Act. The sociological literature on child abuse and neglect has tended to conceptualize this problem--and related attempts to prevent its occur- rence or moderate its effects---as being a contested area [7]. This means that there continue to be fundamental disputes as to the nature and definition of this phenomenon, its causal factors, and most impor- tantly in terms of teamwork in community care, the appropriate roles of the various professional groupings called upon to deal with it.

Ferguson [8] in a recent study of the Kilkenny

Incest Investigation [9], Ireland's first child abuse inquiry, has traced the evolution of Irish policy and practice in this area over the past twenty years, comparing the Irish experience with that of Britain. The British have had about fifty child abuse inquiries, as opposed to the single Irish inquiry, as a result of which, British child care policy and practice have become centrally concerned with ensuring that children are protected from abuse, sexual or otherwise, whether by their parents, other family members or indeed by anybody else. While Irish policy and practice may not be as clearly articulated or as administratively streamlined as that of Britain, it has nonetheless tended to follow a similar ideological pathway; this has been reflected in the publication of Department of Health guidelines, the establishment of bureaucratic procedures for the proper management of child abuse cases and, above all, in the enactment of the new legislation. The overall thrust of these developments is not to provide therapy for parents deemed to be negligent or abusive, but rather

I

Minister for Health

I I Department of Health

community care division

I 8 health boards

health board chief executive officer

Programme manager general hospital care

Regional programme manager

community care

Area directors of community care medical officers of health

l

Administrator

i l

Senior Senior dental public health officer nurse

I

Senior social worker

Programme manager special hospital care

I I Senior Senior

health community welfare

inspector officer

I G.P.s I I I

i Dentists ; I I

I I I Rehabilitation I I staff I I I

Fig. 1. The administrative structure of community care. Units between the broken fine are part of the local administrative structure of Community Care. Source: NESC, 1987 [6].

Child protection in Ireland 305

to protect children from 'dangerous' parents through a well-coordinated set of procedures which extends from monitoring of children in their own lt0tme to removal from their home by court order.

If, as was pointed out above, social workers are unhappy with existing community care structures, which they see as drawing them against their wishes into the medical sphere of influence, it should also be borne in mind that public health nurses (PHNs) may not be entirely comfortable with the implications of the evolving child protection system for their own professional role. In particular, what needs to be considered--and what has not previously been considered either at a research or policy making level in Ireland--is that PHNs may perceive new child care policy and practice, with its emphasis on surveillance of families, its explicit use of authority and its tendency towards adversarial relationships with clients, as being at variance with their traditional image of the nursing role.

Public health nurses in the Irish health care system

PHNs are the single largest professional grouping in community care. At the time of the NESC review [6] in 1987 there were 1153 PHNs employed in the country's eight regional health boards, as opposed to 309 social workers. The role of the PHN, as already mentioned, has evolved over many decades, but current policy on public health nursing is largely derived from a 1966 ministerial circular [10] which, among other things, stipulated that PHNs should undergo specific professional training, having previously qualified in general nursing and midwifery. The requirement that prospective PHNs should have a midwifery qualification has effectively resulted in the exclusion of men from public health nursing because, to date at least, male nurses in Ireland have not become midwives. Until 1987 the professional training of PHNs was provided directly by An Bord Altranais (the Irish Nursing Board), but since then this function has been carried out by the National University of Ireland, which offers a one-year Diploma in Public Health Nursing. This university- based programme, which favours the concept of 'education' rather than 'training' [11], may well lead to radical changes in PHNs' perception and perform- ance of their roles, although it is too soon to be definitive on this issue and the implications of this new system of professional socialization have yet to be researched.

The tasks and functions of the public health nursing service in Ireland are conventionally [12] divided into curative activities, which include home nursing of the elderly, the disabled and the terminally ill, and a range of other activities which are preventive or health promotional in nature. These latter activities include the routine visiting of mothers and their new-born babies as soon as possible after discharge from maternity hospital, followed by regular visiting for the first three years of the infants' lives. Thus the

PHN is closely involved with practically all famihes with young children, providing advice on infant feeding and nutrition, encouraging the take-up of various immunizations and, in conjunction with the public health doctors who work within the Commu- nity Care Programmes, monitoring the growth and general development of these children.

In summary, the public health nursing service is a universal service which involves the PHN in a wide range of professional activities with a wide range of clients. The majority of clients visited at home by the PHN are obviously not deviant or, in psychosocial terms, dysfunctional, and there is no popular stigma attached to families which are recipients of this service. Impressionistically, PHNs have a good image amidst the general public and this benign perception of their role appears to be particularly related to their child health functions. Lavan [13], in a study of wider social service provision, found that in a sample of 251 mothers, 210 (84%) could recall contact with a PHN. These 210 mothers were then asked the open-ended question, "Did you feel that her visits helped you in looking after the baby?" and their answers were subsequently broken down into six categories; 109 (52%) responses were in the most positive category, "very helpful", 32 (15%) were in the next category, "helpful" and only 36 (17%) of respondents were categorized as describing the PHN's visit as "not helpful". In many areas, such is the popular perception of her role, the PHN is referred to colloquially as the "baby nurse".

By contrast, the provision of a social work service within the public health system in Ireland is of recent origin, having been gradually developed within the Community Care Programmes of the health boards following the Health Act 1970. Although the rhetoric of community care suggests that social workers have a wide role, involving a diverse range of communal, personal and familial difficulties, the reality appears to be that social work activity within community care is almost exclusively confined to child care. There has been no empirical research into the case-loads of community care social workers in Ireland, but this equation of social work with child care would appear to be the norm. The Committee on Social Work, a Department of Health committee which reported in 1985, commented in summary

Ideally, a social work service with a community base should provide a wide range of service, encompassing the elderly, the disabled and the young. However, in most areas the service is confined to families and child care. Indeed, in some areas this focus has been further concentrated on families with children at risk [14] (p. 59).

The implications for social work of this exclusive concern with child care will be considered more fully throughout the remainder of this paper; one of the most obvious possibilities, however, is that other professional groups within community care might choose to interpret this situation as indicating that, because social workers are exclusively concerned with

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306 Shane Butler

child care, child care is therefore not a primary prof.egsional responsibility of their own profession (whet~er the professionals in question are public health nurses, family doctors, area medical officers or whatever they might be).

Public health nursing and child protection--theoretical perspectives

In considering the ideological openness of public health nurses to newly emergent policy on child protection and its institutionalization within the teamwork structure of community care in Ireland, there are a few main themes from the social science literature on health care and nursing which may be drawn upon to provide a theoretical context for this study. Without doubt, the dominant relevant theme in this literature has been the equation of nursing with femininity or womanhood, the implication being that nurses are primarily involved in the provision of a caring service [15, 16]. The caring role of nurses is considered to be affective in nature, thus contrasting sharply with that of doctors which is considered to be instrumental or technical in nature and, in gender terms, to be predominantly male. A dilemma for nursing as a profession, which has been succinctly presented by Reverby [16], is that caring and altruism can appear irreconcilable with professional autonomy and assertiveness. In other words, by emphasiz- ing and retaining this affective component of their professional role nurses are likely to remain deferen- tial to patients, doctors, administrators--in fact to all within their role set.

When one applies these concepts to public health nursing and current child care policy in Ireland, it becomes apparent that PHNs are to some extent placed in an occupational double-bind. If they were to acquiesce fully with these new policies and practices, the surveillance, evidence-gathering and use of legal authority which this entails might conflict sharply with their traditional caring role; on the other hand, if they were to openly and explicitly challenge or repudiate the child protection function currently being imposed upon them, this might appear as an act of insubordination which would equally constitute a deviation from the nursing ethos of service and deference. To conclude this reference to the gender issues which are commonly associated with nursing, it is worth pointing out that from the end of the nineteenth century to the Health Act 1970 a limited child protection function was exercised by the Irish Society for the Prevention of Cruelty to Children; the inspectors employed by this body were invariably male, wore uniforms and were popularly known, in individual terms, as "the cruelty man" [17]. It may well be that it is not just public health nurses but society in general which finds it culturally difficult to subsume the functions of the 'cruelty man' into those of the 'baby nurse'.

It has already been pointed out that the ideals of inter-disciplinary collaboration or teamwork which

are suggested or envisaged by Fig. 1 have not generally been found to be realized in practice, and there is no reason to expect that matters would be different specifically in relation to child protection. In fact, given the complexity and social sensitivity of the issues involved, one might reasonably expect that child protection activity would generate even more contention than is normal within community care. It is useful in this context to recall the classic study of the social organization of a psychiatric hospital by Strauss and his colleagues [18], which analyzes the hospital in interactionist terms and concludes that order or structure is 'negotiated'. What this means is that in a complex arena, where professionals with differing ideological backgrounds interact, the social or organizational order which emerges is not formally imposed or given, but is created and sus- tained through the interaction and negotiation of all concerned; if one accepts this model as valid, it stands to reason that the formal blueprint con- tained in Fig. 1 cannot be regarded as a realistic or accurate depiction of what happens in day-to-day practice.

While it would be beyond the scope of the study reported here to reach definitive answers as to how all those involved in community care negotiate an organizational order around child protection, it may at least provide a detailed account of how PHNs negotiate from their own standpoint in what is a new and ideologically difficult situation.

Aims of this research project

Against this background, the aims of the research reported here were to explore the following questions

• How familiar are PHNs with the new legislation, the Child Care Act 19917

• What are the attitudes of PHNs towards the formal procedures for the management of child care problems, such as the use of Department of Health guidelines, participation in case conferences and inter-disciplinary work generally?

• How, specifically, do PHNs view the role of social work and their own collaboration with social workers?

• Do PHNs consider that child care (as opposed to child health) is a function which can be readily assimilated into their nursing role or do they consider it to be inimical to the traditional nursing role?

Methodology

The methodology which was used in this study of PHNs and child care was a qualitative one, con.qisting of a single two-hour focus group discussion with 12 nurses from three community care areas of an Irish health board. The discussion was moderated by the author, 90 minutes of it were audiO-ml~! and this tape was then transcribed for analysis and


interpretation, The group interview or discussion was semi-structured in the sense that the researcher had a number of key questions---roughly corresponding to those set out in the above alms--which he wished to have discussed; all of these questions were in fact discussed, although the order in which issues were dealt with, the amount of time devoted to them and the depth of discussion was largely dictated by group members rather than by the researcher in his role as modera tor

This research into the attitudes and beliefs of PHNs in relation to child protection was, it should be explained, part of a much larger research project on child care needs and services which had been commis- sioned by a health board; this author, as part of the research team, suggested that some attention should be paid to the role of the PHN and, on this basis, three Superintendent Public Health Nurses agreed to make four nurses from each of their areas available for a focus group discussion. It was suggested that the participants be randomly selected rather than selected on the basis of a particular interest in child care, and it was emphasized--without going into any detail with the superintendents--that the object of the exercise was to gain an understanding of how PHNs viewed these issues rather than to test whether they would give 'right' or 'wrong' answers to the questions raised.

In attempting retrospectively to determine whether in fact the participants had been randomly selected, the researcher was most persuaded that this had been the case by the content of the discussion. If participants had been specifically selected or tutored by their superintendents, one might expect that the viewpoints they expressed would generally reflect a 'party line' demonstrating a detailed appreciation and acceptance of the new policy and their new role by PHNs; such, as will be seen below, was not the case.

Focus groups as a form of qualitative research methodology are commonly used in the sociology of health and illness [19, 20], either on their own or in conjunction with other methodologies. In this in- stance it was hoped that a single focus group discussion might provide detailed rich data, which would go some way towards answering the research questions and throwing some light on the researcher's basic hypothesis that PHNs would experience serious role conflict were they to fully embrace the child protection role envisaged in the new policy situation. Morgan, in a comment on the advantages of this methodology, said

Substantively, the strength of focus groups comes from the opportunity to collect data from group interaction. The point is not, of course, to tape-record just any interaction, but interaction that concentrates on topics of interest to the researcher. When all goes well, focusing the group discussion on a single topic brings forth material that would not come out in either the participants' own casual conver- sations or in response to the researcher's preconceived questions [21] (p. 21).

The research questions, as set out above, had the potential to show up participants as being poor team players or, more emotively, as failing to maximize the safety of children at risk. One could therefore expect that if they were dealing solely with the researcher, participants might be evasive or guarded in their expression of their opinions; the advantage of the focus group methodology was that the dynamic became interactive, with participants raising issues for one another and communicating primarily with one another rather than with the researcher. Once the discussion ' took off', the researcher as group moder- ator had relatively little involvement in its content and the nurses were almost certainly more spontaneous and unguarded in expressing themselves than if they were communicating primarily with the researcher.

The researcher indicated to the participants during the preliminary discussion that he was a lecturer in a university social work department, although he also made it clear that he was concerned in this meeting to get the views of PHNs and not to act as a spokesperson for social work. He was successful in this ambition in that participants did not treat him as a social worker but rather accepted his role as being facilitative and, as aimed at, fostering group interaction. The PHNs, as already indicated, were enthusiastic, spontaneous and uninhibited in their contributions. While all participants spoke, some were more vociferous than others and, in citing directly from the transcript, the researcher has selec- tively drawn upon those comments which are succinct and which directly address the themes identified in the Introduction.

FINDINGS

The new legislation

The nurses who attended the focus group were aware that this was part of a larger research enter- prise which was being carried out in the context of the Child Care Act 1991; it seemed logical therefore that the first issue raised by the researcher was the new legislation and its implications for PHNs. However, this proved to be the only part of the group discussion which failed to generate enthusiastic participation. What emerged from the relatively brief time devoted to this subject was that the nurses all expressed great vagueness about the new legislation and its implications for public health nursing within community care. None of the PHNs had read the new act, a summary of it or a commentary on it, although it was pointed out that the Institute of Community Health Nursing planned to hold a seminar on it. Rather than labouring this point, it is perhaps sufficient to note that none of the participants were aware that the legislation imposed a duty on health boards to promote the welfare of children not receiving adequate care and protection. It was suggested by a few

308 Shane Butler

participants that this duty was explicitly laid upon social workers, while others thought that this legal responsibility was imposed upon Directors of Com- munity Care. None of the nurses described it as what it legally is, a corporate responsibility.

There was little or no interaction between participants on this topic, and the researcher quickly passed on to other issues lest the discussion degenerate into one in which he was excessively heavily involved and one which appeared to be testing the knowledge of the participants.

Is child care a nursing function?

Section 3.1 of the Child Care Act 1991 requires each health board to "promote the welfare of children in its area who are not receiving adequate care and protection". The legislation spells out in some detail how this should be done, thereby giving clear 'ownership' of such problems as child abuse and child neglect to health authorities. In discussing this topic with PHNs, the aim was to discover to what extent this function was seen by them as compatible with their other duties or whether, regardless of the corporate duty of their health board in this regard, they saw it as inappropriate to their nursing role. In simplistic terms, the aim was to see whether PHNs were aware in their day-to-day activities of the potential role conflict which may arise where the 'social control' elements of their child care duties--such as, surveillance of families, evidence-gathering and seek- ing court orders---might sit uncomfortably with their ionglestablished 'social care' role.

In preparing for the discussion, the researchcr was aware of the risk of asking leading questions, or imposing his own perceptions on the participants; the intention was to introduce questions on whether child care was a nursing function in a neutral, low-key way after some initial discussion of the new legislation. However, quite early in the discussion one participant cut across a colleague who was describing a difficult family situation which had resulted in a court appear- ance when the health board sought a court order. The tone of this intervention and its subsequent support by other participants made it clear that the PHNs were acutely aware of these issues. Part of this intervention went as follows

I feel we're trained and we're skilled in detection and observing the child. I really feel that should be our main role and when we observe something that we're not totally happy with we should be able to refer it on to the social worker, to the psychologist or whatever the problem--for the alco- holies AA or whatever it is--refer. I don't think [that] should be our role----going i n at 12 o'clock at night getting evidence. We're nurses, we are health care profemionals; and we are not a policing force, we are not a social worker, and we are not a psychologist, and we're not an alcoholic analyst rolled into one. And I think this is where our problem is: we take on too many people's roles . . . . Now if I'm associated with taking a child from any family in the area [into care], I feel I have destroyed some of the confidence the people have in me; I really don't think people would be open with me after that . . . [PHN, No. 4].

This topic was explored more fully further into the discussion, and it became clear that while PHNs saw themselves as having unique access to families where there were babies and young children, they felt considerable discomfort at the prospect of becoming involved in formal child protection activity where this might involve an element of confrontation of parents or the use of legal sanctions. They sought to distance themselves from such child protection activity by labelling it as being clearly outside their domain and as having little to do with their routine work in the child development/health area. Earlier in the group there had been mixed views as to whether PHNs, in discussion amongst themselves, used any specific phrase or phrases to describe difficulties which were not obviously in the health care area, and while one participant had said that she found "the term 'social problem' very nebulous", another simply said

I find we use it as distinct from a 'nursing problem': we have a 'nursing problem' or a 'social problem'. [PHN, No. 3].

This certainly appeared to be borne out by the subsequent discussion which clearly reflected the participants' concern to avoid having their professional identity spoilt by too close an association with the health board's management of these 'social problems'. For example, the nurse who had earlier argued that she and her colleagues used the phrase 'social problem' spoke as follows

I would say our role is in child health and if we come across a problem that we are worried about we should be able to refer it. Let them do the observation, and still allow us to have a relationship with the family and go in and do our routine checks or development checks--still with the idea of health, child health. [PHN, No. 3].

Refer to who? [Researcher].

To other disciplines, such as the social worker if its a social problem. That once you refer them on, that's their responsibility and we still go in on the child health role, doing all the checks that we should ordinarily do. [PHN, No. 3].

There was considerable agreement with this view- point, but one nurse argued that neither in conceptual nor practical terms could such categorical distinctions be made

I don't think they can separate the two--child care and child health--because we must go in looking at both, and we can't ignore child care. And I don't think it's possible to separate them in our work. [PHN, No. 5].

However, once the question of court appearances in child care cases was raised, the participants reverted to the unequivocal position that whatever the necessity for such action on the part of the health board--or specifically on the part of its social workers---it was professionally inappropriate for PHNs. The main objection raised was that appear- ance in court cases, which was a relatively rare event and which involved only a tiny minority of families, might undermine the future capacity of the PHN to work both with the family concerned and with other


families in that community. It was emphasized that the nurse was very closely identified with her area and that she was usually seen in a positive light as representing the health board in her area; it was argued that court appearances could ruin this arrangement. A sample of comments on this issue follows

I hate it, absolutely. I was in court last year with a family. The children were being taken from them; they were neg- lected. I think its a terrible situation having the parents and grandparents standing there looking at you and you going into the house the next day. [PHN, No. 11].

The social worker isn't living in the area. You're living and working [in it]. It puts an awful strain on the confidence of the whole community over going back into working again. • . . But I can really feel the social workers should be the ones and as well as that really none of us has ever stood in a courtroom. It's a very harrowing and stressful experience and we're no way educated or geared [for it]. We're not legally-minded normally. We're trained to be caring and conscientious . . . We work within our nursing vocation. [PHN, No. 4].

I don't think we should even be asked to go to court. I think it's absolutely dreadful, and I think once we have passed on our evidence, whatever we suspect, it should be taken up by a social worker or whoever deals with these specific problems. I don't think we should have to go into court because first of all it puts--there is a stigma straight away and you're labelled from the day you enter court. The whole community have something about you--"That's the lady that took so and so to court and her kids were taken away from her". So I don't think we should have to do it, I think it's dreadful. [PHN, No. 8].

Collaboration with social workers

A number o f issues were raised concerning working relationships between PHNs and community care social workers. It appeared that the participants would not refer a family to the social worker, except in a crisis, without first informing their superintendents. When the researcher asked whether PHNs would always tell the family that they were being referred to the social worker, there was a surprising spectrum of responses and opinions on this subject. The common feature of all these responses was that referral to a social worker was not comparable to referral to any other member of the community care team; instead, as indicated in the previous section, it was seen as inevitably introducing a note of social control and stigma, association with which could easily damage the reputation of the PHN.

One participant spoke at length of how the whole question o f referral to a social worker could be handled

It just doesn't happen on a twenty-minute visit. It's a relationship that's built up; it takes a lot of our time• You'd say to them, "There's people that deal with that"---say the psychologist, ff you want them referred. - "I think maybe you'd find it an advantage". •. I 'm not saying you deceive them, but you do it in a very diplomatic, explaining, informative way and I find that works for me anyhow• [PHN, No. 4].

Other participants, however, were insistent that families being referred to social workers either did not have to be told that such a referral was being made or that they did not have to be told immediately or in clear, explicit terms what the aim of the referral was

I find I don't at the initial stages, because sometimes I find I don't want the family to know that I sent the social worker. I'd have worries because my relationship with the family is right and I might be stopped from going in. So I say [to the social worker], "Don't mention me at all; go and make your own observation and see what you see or f ind. . . but don't give my name". [PHN, No. 5].

If I came across something that I'm not too happy about, I would find another excuse to bring in the social worker. [PHN, No. l l].

Can you explain that? [Researcher].

To see how they were coping financially, assuming that if they were a little short of clothes or something . . . I think it would be very difficult to turn around to a parent and say, "I 'm a bit worried about this. I'm bringing in a social worker". [PHN, No. I 1].

Two of the nurses argued in a principled way that families had a right to know what PHNs were planning and doing and, furthermore, that any kind of deceit or subterfuge could backfire and prove counterproductive for future P H N involvement. No participant referred to possible difficulties which social workers might encounter in taking referrals under these circumstances, nor did anybody comment on the fact that no protocol or procedure had been agreed to cover this situation.

On the wider subject of contact with social workers, only one participant spoke in uniformly positive terms of having good communicat ion with social workers• One of the critical comments made concerned the failure of social workers to keep PHNs informed of what they were doing

I find that in my experience the social workers get all the information from me and I get very poor feedback from them . . . and if you do ask them they're kind of snooty enough about it! [PHN, No. 11].

They could let us know what's happening. Like if we refer someone to a speech therapist we get a letter back saying what's being done, but we never hear from the social worker about what is actually being done. [PHN, No. 6].

A further criticism was that social workers failed to see situations as crises when this was the PHNs ' perception o f them and also that they failed to respond quickly to these situations. An example was given by one P H N

I had a case actually where I referred a family that I was concerned about. They were an alcoholic family and I referred them to the social worker and she said, "I 'm not going to be able to make it for a week or ten days". And that particular weekend a crisis arose, and the woman was beaten up. So far as I was concerned it was urgent. I saw it was urgent, but somehow or other they seem to have a different perception of situations than we have . . . I wonder are they on the same planet sometimes. [PHN, No. 11].

310 Shane Buffer

This point of view was later confirmed by another participant who concluded that "what can seem major and crucial to us is often trivialized by the social worker" [PHN, No. 1].

This clash of professional cultures was discussed at some length by one participant, who argued plausibly that the differing yardsticks reflected the differing work structures of the two groups: "mostly their [the social workers'] work is dealing with the abnormal, whereas ours', thankfully, is mostly dealing with the normal". What was even more puzzling for this PHN, however, was what she perceived as a defensive and legalistic style of social work which did not appear to offer support or therapy of a traditional kind to clients

I wonder sometimes what advantage it is leaving a social worker into the home. I really don't see any advantage in it. They visit and they talk, but there's never anything constructive done; it's recorded in very nice print and it's kept on file and all that, but there's nothing constructive done when they visit the home . . . and when you phone them to ask their advice, you feel that they are recording things and it will be held in evidence against them [the parents]. They're so legally minded it's frightening. [PHN, No. 6].

In general, the picture painted of collaboration with social workers in pursuit of common child care objectives revealed many clashes of professional culture and many administrative grey areas. Perhaps the most fundamental point to emerge from this discussion, as in the last section, concerns the almost obsessive concern of PHNs to distance themselves from the social control aspect of child protection, so as to protect their caring image in the community. The result is that social workers appear to be uniquely burdened with this unenviable task for the health board.

Formal management of child care

Despite the overwhelming consensus that they would prefer to see the more difficult child care issues dealt with by other disciplines, particularly social work, PHNs accepted that they had to be involved to some extent in the formal handling of child abuse cases. During the discussion, two specific elements of PHNs' formal involvement with child abuse, their adherence to the Department of Health Child Abuse Guidelines and their involvement in case conferences, were discussed.

On the question of the Child Abuse Guidelines, attitudes were mixed. It did not appear as though participants saw them as particularly helpful or relevant. One nurse commented briefly "No I don't refer to them regularly. I have read them, but I wouldn't refer to them regularly. I didn't find them that helpful" [PHN, No. 8]. The most positive comment on these guidelines came from a participant who said that they "were at the back of my head all the time, more so in the last twelve months with the media and hype" [PHN, No. 4].

The manifest function of the case conference in child care cases, and particularly in cases of suspected or actual child abuse, is to create a forum for the exchange of information between all the relevant professionals and to facilitate decision-making for the future management of the case. It is common at these case conferences for One worker to be designated the 'key worker' with the case, although this is never intended to indicate that other members of the multidisciplinary team are abdicating responsibility for the case. During this discussion with the PHNs, however, considerable scepticism about the value of case conferences was expressed, with only one participant expressing any positive view--and this was a mixed view

I found both.. I've had both experiences. I had one that was very good, and great to have everybody around the table, all the disciplines saying what they believed . . . and action was taken. But I've had the opposite experience. [PHN, No. 6].

With the exception of this comment, perceptions of case conferences were uniformly negative: it was suggested that they were poorly chaired, that clear decisions rarely emanated from them, that they wasted PHNs' time and that, as often as not, responsibility for future management of the case would be allocated solely to the PHN. A sample of these negative views follows

I have only had experience of about three case conferences, and I must say from the three of them I went back out to my area, hack into the family, with very little knowledge and I was very disillusioned. I still had to do the work and do the advisory and nobody to help me . . . . I didn't find them [the case conferences] any help. [PHN, No. 5].

I would have the same experience my--and--. I've been at quite a few case conferences and it all ended up in a way with half the morning gone with a lot of people blowing their own trumpets. But when it all came down in the end it was left to the PHN. The social workers were at the end of their tether and someone else was at the end of their tether; but the PHN's tether had to go on, so that really I never found them helpful. [PHN, No. 11].

I've had a very recent experience of being at a case conference and, like the rest of the gifts here, it went on all morning. I had to come out into my area to do my day's work. Now at the end of that there was absolutely nothing and I blame the chairperson . . . . Now everybody came out of that case conference with nothing. [PHN, No. 8].

Finally, it is worth noting that several participants spoke positively of involving the local G.P. where there was evidence of child abuse or neglect. Follow- ing on from a colleague, who had suggested that the G.P. was the first "port of call", one participant said

I find the G.P. is the key person, really, with myself, and I would always refer to the G.P. first before I do anything. That's the way I function and it works for me that way because I had a few cases where I did suspect there was injury, non-accidental injury, and it worked very well. Because the G.P. was in on it from the very beginning and he got the child into hospital and things were sorted out in a diplomatic way. {PHN, No. 8].


This nurse appeared to be suggesting that the G.P.s 'diplomatic way' of dealing with child abuse or neglect was a valid alternative to the formal system of reporting such incidents in conformity with the guidelines and standard procedure. However, it was acknowledged by a number of nurses that G.P.s varied in their willingness to become actively involved, depending largely, it was stated, on their age, and one participant spoke of the potentially risky activity of a G.P. who was "very much into protect- ing the family--leave them as they are and things will work out" [PHN, No. 3].

see child protection activity as fitting comfortably with either their current curative or preventive roles, and argued that, so as not to jeopardize these mainstream functions, they should distance themselves from direct involvement with such activity. They were also relatively uninformed about and disinterested in the new legislation and the Child Abuse Guidelines, and tended to the view that the ease conference, rather than being a rational management tool for inter-disciplinary coordination, was merely an arena where the various professionals jockeyed to avoid being dumped with primary responsibility for intractable child care cases.

DISCUSSION

The Kilkenny incest investigation

Within a few days of the group discussion which forms the basis of this paper, the 'media and the hype' referred to by one of the participants reached previously unparalleled levels with the publication of the Report of the Kilkenny Incest Investigation [9]. The detailed account of the sexual and physical abuse of a child/young woman by her father, including the fact that she was impregnated by him and had his child when she was 15, was naturally shocking for the Irish public. Perhaps what was equally scandalous was the knowledge that over the 16 years--from age 10 to age 26---that this abuse was taking place the victim had sought and received help on numerous occasions from hospital doctors, public health doctors, family doctors, social workers and public health nurses, yet none of these had identified the full extent of the problem or initiated a decisive and satisfactory intervention. Predictably, the investigating team at- tributed this failure to poor coordination among the health care professionals and social service workers involved, and recommended that child protection practice should be strengthened and developed within community care by closer adherence to the existing procedures and guidelines--and also by the full implementation of the new legislation.

Almost certainly, if the group discussion had taken place a week later than it did, the PHNs would have been more guarded in their comments and perhaps would have expressed less reluctance concerning their role in child protection. However, it would be naive to assume that the publication of this report, with all its attendant publicity, had any lasting impact on the attitudes, beliefs and work practices of PHNs. It is probably more reasonable to assume that, once the immediate sense of moral panic had died down, the PHNs involved in this group discussion--and perhaps PHNs generally--reverted to the position expressed here.

In summary, the participants in this focus group discussion expressed views on the coordination of child protection activity which were radically at variance with the rhetoric of community care in the Irish public health and social service system. They did not

Dirty work

Whenever the details of a particular case of child abuse become public, as in the ease of the Kitkenny Incest Investigation or the many inquiries which have taken place in Britain, there is understandable revul- sion; it appears at such moments as though both public opinion and public policy are unambiguously committed to ensuring that such abuse will be either prevented or, falling this, responded to as quickly and as effectively as possible. In between these moments of unambiguous commitment, however, the task of providing a child protection service is characterized by enormous ambiguity and social complexity. Blyth and Milner [22] have suggested that the concept of 'dirty work' (originally devised by Hughes [23] in a study of the sociology of work) is analytically helpful in this context. Hughes suggests that "dirty work includes those activities which have to be done but are nevertheless distasteful in the doing and those which ought not to be done but unfortunately seem unavoidable" [23] (p. 49).

Perhaps the major difficulty which arises in relation to child protection work is that it is unavoidably linked to the surveillance of families by the state and, consequently, suffers from all the ambivalence which this type of activity generates. British social workers have been pilloried both for their failure to intervene and for what is seen as an excessive tendency to intervene. There is a burgeoning literature on the negative impact which this criticism, has both on social work as a whole and on individual practitioners. Valentine [24], in a recent paper, argues from a Kleinian psychoanalytic perspective that the public in Britain projects its negative feelings on the subject of child abuse on to social workers; in turn, the social workers introject or internalize these feelings until the individual worker comes to see herself as being quite similar to the abusing parent--in Kleinian terms as a 'bad object'.

Irish social workers are not given the same, explicit, statutory responsibility for child care as their British counterparts, yet informally what may be happening is that other community care personnel are avoiding what they view as a form of 'dirty work'. The PHN cited above who said that, "We're trained to be caring and conscientious . . . We work within our

312 Shane Butler

nursing vocation", was obviously suggesting that nurses from this kind of background and possessing these attributes could not be expected to perform the distasteful duties inherent in the child protection function. By implication perhaps, she was suggesting that social workers who routinely carry out these duties do not possess these attributes!

Finally, in this context, it may be that child protection work in Ireland has the potential to become even 'dirtier' than it is in Britain. British sociological perspectives on social work and the management of the family by the state, such as those of Parton [25, 26], cannot be applied uncritically to the Irish situation which is socially and culturally quite different. The family in Ireland is given a privileged position in the Irish Constitution (a position which the Report of the Kilkenny Incest Investigation suggested may take from the rights of children) and in general cultural terms [27] is an exalted institution, deferred to and protected more than in most western societies. Memories of the infamous 'mother and child scheme' of 1950/51 (an incident which involved a concerted and successful rejection by the Roman Catholic bishops and the medical profession of a Government proposal to introduce health care for mothers and their babies--on the grounds that this represented an unwarranted intrusion into and attack upon the integrity of the family) are still fresh [28], and public health policy has always had to tread its way cautiously and to avoid what is seen by tradi- tionalists as the 'liberal agenda'. Thus, even more than in Britain, there is ambivalence about state intrusion into the family and a greater likelihood of opprobrium attaching to those who are professionally called upon to police or regulate parenting or other aspects of family life.

Agency function and professional roles

Howe [29, 30] has suggested that within British social work the preoccupation with child protection has in recent years radically altered the way in which social workers exercise power over their day-to-day activities. He argues that dealings with clients are not primarily influenced by what front-line practitioners themselves think is professionally appropriate, nor are they significantly influenced by teachers and researchers; instead, he concludes that the nature of social work practice is now dictated by administrators, whose task it is to ensure that the 'agency function' of child protection is carried out efficiently and effectively. This, according to Howe, has resulted in a bureaucratization of social work, a process which involves an ever-increasing conformity to guidelines and procedures and a considerable diminution in the number of professional, discretionary judgements made by social workers.

While this process may not be as advanced among community care social workers in Ireland, Howe's analysis is still helpful in considering their role; they are a relatively newly-established profession and their

sole raison d'etre in community csre is child protection. By contrast, the PHNs who were the focus of this research defined their professional roles in a more traditional way, which owed little or nothing to bureaucracy. They saw it as important that they should help people and that they should be perceived by individuals, families and communities as being helpful. They had no concept of 'agency function', as it is understood by social workers and administrators, and the concept of a 'vocation'--with what seem like quaint theological overtones---was invoked to justify their continued adherence to caring or therapeutic work practices, as opposed to social control work practices. Not only were they unaware of the precise legal responsibility which their employing agency bore in relation to child care, but, in a manner which would horrify administrators, they regarded the Child Abuse Guidelines as optional or discretionary rather than in an absolutist bureaucratic way. It is unlikely, for example, that any community care social worker would say of these guidelines "I have read them, but I wouldn't refer to them regularly. I didn't find them that helpful". And, finally in this context, the nurses who took part in the focus group appeared to be puzzled by and dismissive of social workers who conformed to procedures: record-keeping and more general adherence to the guidelines on child abuse did not evoke any praise or understanding on the part of the nurses, who saw it as a substitute for being helpful.

CONCLUSION

Undoubtedly, the first point to be made in conclusion concerns the methodology which was used in this study. The focus group methodology was successful in that it was acceptable to participants and allowed for a free-flowing discussion which, at least in a preliminary way, answered the questions posed at the outset. Further research which might seek to validate these findings could either apply the focus group methodology on a wider scale or, alternatively, could utilize a conventional survey research methodology.

From an administrative point of view, the findings of this study are unwelcome since they confirm that health and social services are not happy bedfellows within the Irish health board system. Images of administrative clarity and inter-disciplinary cooperation which are suggested in the organizational blueprint (Fig. 1) appear largely illusory in relation to child protection; the conventional wisdom suggests that a lack of consensus and inter-discipfinary coordination can have disastrous consequences for children in 'dangerous' families and, if one accepts this, these findings are particularly disquieting.

A dilemma or double-bind was identified from the theoretical literature on nursing and on the centrality of caring within the nursing role: the dilemma was that by taking on the new child protection function


nurses appeared to be deviating from their traditional caring ethos, while any overt repudiation of this new role would equally appear to be an unprecedented deviation from their traditional compliance with and deference to authority. Faced with this intractable difficulty, the nurses who were participants in this study compromised by attempting to opt out of the new scheme, defining it as worthy and necessary but not a suitable task for themselves. In doing this, however, they did not in any way present an overt or political challenge to current child care policy or the health board system; and there was no suggestion that such a challenge was imminent. One could speculate that if public health nursing were to be opened up to men, the profession might respond in a more militant style to this dilemma.

It may also be that as increasing numbers of public health nurses (and nurses generally) are graduates of new university-based educational programmes, this will alter the culture and ethos of public health nursing in Ireland. Where the university rather than the hospital ward is the favoured locale for nurse education, it is reasonable to expect that discourse will become more abstract and reflective and more politically assertive. Already, for example, the nursing literature on caring [31, 32] has become more academically sophisticated and has moved far beyond the simple pieties of the stereotype of the nurse as handmaiden.

While the type of role which PHNs appear to negotiate for themselves in relation to child protection may not be pleasing to policy makers or administrators, it certainly gives the lie to the notion that nurses are totally compliant with authority. It could be argued that they have a stronger sense of self-preservation than their social work colleagues, and their ideological rejection of child protection, where this is seen to jeopardize their mainstream curative and health promotional functions, is presented logically and compellingly. The merit of the focus group methodology used in this study was that it helped to make overt the ideological objections to child protection practice, which are not customarily expressed as openly or as frankly as they were here; the researcher was in the position of being a privileged eavesdropper on an internal conversation. Ultimately, if policy makers and administrators are to improve the organizational capacity of community care to protect children as envisaged in the new legislation, they must acknowledge and address the ideological distaste of PHNs which has been identified here.

Acknowledgements--The author wishes to acknowledge the cooperation of the public health nurses who took part in this project and their superintendents who facilitated this. Help- ful advice was offered by Jean Clarke of the Department of Nursinfg University College Dublin, and Robbie Gilligan, Department of Social Studies, Trinity College Dublin. Also thanks to Pam Imacson for secretarial assistance.

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