Many working in frontline health and social care will be familiar with dilemmas of “how far to go” for the people they care for.
In the current context of pandemic recovery with stretched resources and increasing demand, how workers respond may be influenced by multiple factors. These include their working environment – time pressures, targets, organisational cultures – as well as individual attitudes and values. Often, they will use their own discretion to “go the extra mile” (this link will take you away from our website) – beyond their usual role – to ensure needs are met.
The use of discretion and flexibility are prominent features of the Community Link Worker (or Practitioner) (CLW) role. CLWs generally work in primary care, supporting people to improve their health and wellbeing, often by linking them to community services and resources. In Scotland, CLWs have initially been targeted in socioeconomically deprived areas and the people they support often have complex needs. The role has been developed to be very flexible, allowing CLWs to support vulnerable people in a person-centred way. In such an open role, how do CLWs know where and when their work ends? What factors influence how far they go?
These questions were examined through qualitative interviews with seven CLWs in Glasgow in early 2020 – research conducted (this link will take you away from our website) as part of a MSc in Global Health at the University of Glasgow, and in collaboration with Health Improvement at Glasgow City HSCP. The project explored the ways that CLWs make use of flexibility and discretion, and how this may be influenced by experience and values.
Defining the CLW role and setting boundaries is a dynamic and ongoing process
The findings revealed that CLWs were dealing with a myriad of issues. There was a sense that they could help with almost anything to some extent – though this was not about being able to fix every problem, but rather being able to “take the time” to listen. There did not seem to be a clear notion of what constituted “going the extra mile” in this context. Suggested examples included visiting someone in hospital or helping someone move house.
As one CLW said, “that’s not necessarily part of our job…it’s not in the job description, but it’s not not in the job description”. Drawing the boundary was generally a matter of individual judgement or consensus opinion with colleagues. There was a strong awareness of maintaining professional boundaries in relationships with patients and avoiding creating dependency – though it was emphasised that intense support is necessary for some, and in the right context can be enabling.
Some CLWs found that their role was not fully understood among practice staff at first. One described receiving referrals for nothing but benefits enquiries initially – but this changed with time and familiarity. The absence of a formal professional status (like doctor or nurse) could be seen as an impediment in this regard, but for some in this study it was also an important asset – allowing CLWs to relate to patients on a person-to-person level.
In a world where many health and social care roles are rapidly changing, lack of role clarity is not something unique to CLWs. As such, this research underlines the importance of finding ways to maintain an understanding of each other’s work – for example, through effective communication between professionals and teams.
CLWs value flexibility and autonomy
Flexibility was considered crucial by interviewees in enabling person-centred care for vulnerable patients. Examples included offering appointments in a range of locations and keeping referrals open even if appointments had been missed. Employing organisations appeared to have set broad job descriptions to allow for flexibility in the role, and CLWs felt they had been given significant autonomy. They rarely experienced dilemmas in which their “hands were tied” by organisational protocols. Rather, as one interviewee put it, they were “free to do more or less whatever we want for people”. This contrasts with other frontline roles in health and social care, who may be more heavily burdened by performance targets (this link will take you away from our website).
CLWs’ autonomy was ultimately constrained, however, by the limited capacity of organisations that they referred to – particularly mental health, social care and housing services. It was felt that some services were only able to respond once a person was in “dire need”. The flexibility in the CLW role allowed them to provide “holding services” to fill gaps – for example, providing informal mental health support until a person could access the specialist service. This “gap-filling”could become more prominent in the context of increasing demand or further service cuts, which has implications for sustainability.
Personal experience and values are influential
CLWs in this study emphasised the importance of experience and values in their work, and of “bringing you into the role”. Diverse professional experience was considered an asset, but interviewees also emphasised the influence of personal life experience in their work. Several described how dealing with problems in their own lives helped them empathise with people. Some experienced growing up and living in socioeconomically deprived communities, which they felt amplified their concern about inequalities.
Personal values such as social justice, non-judgement and empathy were identified as influencing CLWs’ work. Similar ideals were evident in the job descriptions, suggesting an organisational culture supporting such values. Importantly, CLWs appreciated their ability to express their values in their work activity. This is something which is likely to contribute to job satisfaction and has been noted to be compromised in other frontline roles (this link will take you away from our website).
Maintaining this expression of personal values in their work appears to be an important priority for the future, as well as preserving the flexible and person-centred nature of the CLW role. Such characteristics helped CLWs to adapt to the challenges of the pandemic and could prove crucial to meeting the needs of vulnerable people as we head into the recovery period.