Determinantes sociais condicionantes das altas clínicas dos utentes da rede nas UCCI: um estudo de caso

Introdução: O adiamento das altas clínicas nas Unidades de Cuidados Continuados Integrados (UCCI) por motivos sociais é actualmente considerado um dos principais motivos que impedem a integração atempada de novos clientes na Rede Nacional de Cuidados Continuados, RNCC, daqui em diante designada como a REDE. Este atraso tem impacto ao nível da recuperação e estabilização dos utentes, bem como ao nível de eficiência e eficácia da UCCI, não podendo deixar de se considerarem os aspectos sociais e económicos. Objectivo Geral: Identificar os determinantes que influenciam as altas clínicas em UCCI. Métodos e População do Estudo: Este é um estudo de caso colectivo, em que os dados observacionais, transversais, são recolhidos por meio de questionário de auto-relato (por cada área de intervenção directa) e por análise dos processos de consulta de pacientes. O objecto desta pesquisa abrange dois grupos: o grupo de amostra composto por 70 profissionais de saúde que lidam directamente com os utentes e o grupo amostra composto de utentes internados na UCCI L Nostrum, com alta clínica entre 1/1/2011 e 31/12/2012, e que foram integrados através da REDE. Foram recolhidos os dados de 293 utentes sendo objecto de estudo os casos de 83 utentes integrados através da REDE e com prolongamento de internamento por motivos sociais. Resultados: Na percepção dos profissionais de saúde, as respostas institucionais apresentam-se como a condicionante mais indicada, tanto para os utentes em geral, com 22 indicações (88%) como para os utentes da REDE, com 10 indicações (40%). Relativamente aos motivos familiares há referência de 76% para os utentes em geral e de 36% para os utentes da REDE. Os motivos económicos também apresentam, para os profissionais inquiridos, um valor expressivo (68%) nos utentes em geral, estando nos da REDE este factor condicionante a par com os motivos familiares (36%). Os motivos estruturais têm menor expressão tanto nos utentes em geral (32%) como nos utentes da REDE (16%). “Outros” para os utentes em geral, refere-se a dependência funcional (4%). Nos motivos familiares, para os utentes em geral, 23 (92%) foi mais vezes indicada a insuficiência de suporte familiar, para os utentes da REDE, 13 (52%). A ausência de suporte familiar, para os utentes em geral, representa 48% das respostas, seguindo-se o suporte inadequado (28%) e a ausência de cuidadores (24%). Para os utentes da REDE, o suporte inadequado apresenta-se como segundo motivo (7%), seguindo-se a ausência de suporte familiar (16%). Na percepção dos profissionais, os utentes da REDE estão também condicionados pela distância geográfica (8%) da sua área residencial. Em termos estruturais, os motivos mais assinalados pelos profissionais para a generalidade dos utentes foram as barreiras físicas à mobilidade (80%) e a habitação sem condições básicas de habitabilidade (78%). Os mesmos motivos foram assinalados para os utentes da REDE, barreiras físicas à mobilidade (40%) e habitação sem condições de habitabilidade (28%). No entanto, relativamente aos utentes em geral, a ausência de habitação (29%) e a distância geográfica (4%) também foram motivos assinalados. Dos motivos económicos percebidos pelos profissionais, a insuficiência de rendimentos é o factor mais assinalado pela generalidade dos utentes (84%) e pelos da REDE (68%), seguida da percepção da capacidade de reposta limitada das instituições, 64% para a generalidade dos utentes e 28% para os da REDE e por fim os tipos de respostas insuficientes para as necessidades individuais dos utentes (20% dos utentes em geral e 12% da REDE). No total dos dois anos, 2011 e 2012, verificaram-se na UCCI L Nostrum 293 prorrogações (100%) das quais 210 (71,6%) foram consideradas dentro do prazo e justificadas com motivos clínicos, enquanto 83 (28,3%) foram efectivamente protelamentos por motivos sociais, tendo em conta que nestes casos os utentes já não tinham critérios clínicos que justificassem a sua permanência na UCCI. Das 210 prorrogações consideradas dentro do prazo e justificadas com motivos clínicos, 93 (44,3%) foram-no por tempo de espera para transferência de UCCI. Em 2011, dos 146 utentes com alta protelada (100%), 50 utentes (34,2%) permaneceram na UCCI por motivos sociais, enquanto em 2012 houve registo de 33 casos de protelamento (22,4%) em 147 (100%) altas prorrogadas. Conclusões: Dos factores identificados como motivo de protelamento nos 83 utentes, estritamente por motivos sociais, destaca-se o protelamento de alta por espera de integração em equipamento/resposta adequada, nomeadamente lar ou serviços de apoio domiciliário (79,5%), seguindo-se a insuficiência de rendimentos do utente/familiares para contratação de serviços ou resposta institucional (74,7%), a inexistência de condições habitacionais para regresso ao domicílio (63,9%) e a insuficiência de suporte familiar (54,2%). Regista-se também a inadequação do suporte familiar (31,3%), a inexistência de suporte familiar (28,9%) e, em menor percentagem, a ausência de condições estruturais (13,3%). A ausência de domicílio (sem abrigo) (8,4%) e a ausência de rendimentos (4,8%) também foram factores inibidores da alta clínica. Dos 293 utentes identificados que tiveram protelamento da alta por motivos sociais verificou-se que 144 (49,1%) dos utentes permaneceram unicamente pela existência de condicionantes institucionais e familiares/estruturais. Aspectos éticos: ao longo deste estudo, foram assegurados e respeitados, todos os procedimentos de garantia da confidencialidade e rigor na recolha dos dados, e a não interferência nas dinâmicas da instituição, dos utentes e dos profissionais.

Agricultural adaptation to climate change: insights from a farming community in Sri Lanka

The vulnerability of smallholder farmers to climate change and variability is increasingly rising. As agriculture is the only source of income for most of them, agricultural adaptation with respect to climate change is vital for their sustenance and to ensure food security. In order to develop appropriate strategies and institutional responses, it is necessary to have a clear understanding of the farmers’ perception of climate change, actual adaptations at farm-level and what factors drive and constrain their decision to adapt. Thus, this study investigates the farm-level adaptation to climate change based on the case of a farming community in Sri Lanka. The findings revealed that farmers’ perceived the ongoing climate change based on their experiences. Majority of them adopted measures to address climate change and variability. These adaptation measures can be categorised into five groups, such as crop management, land management, irrigation management, income diversification, and rituals. The results showed that management of non-climatic factors was an important strategy to enhance farmers’ adaptation, particularly in a resource-constrained smallholder farming context. The results of regression analysis indicated that human cognition was an important determinant of climate change adaptation. Social networks were also found to significantly influence adaptation. The study also revealed that social barriers, such as cognitive and normative factors, are equally important as other economic barriers to adaptation. While formulating and implementing the adaptation strategies, this study underscored the importance of understanding socio-economic, cognitive and normative aspects of the local communities.

On climate change and cultural geography: farming on the Lizard Peninsula, Cornwall, UK

Climate change as a global problem has moved relatively swiftly into high profile political debates over the last 20 years or so, with a concomitant diffusion from the natural sciences into the social sciences. The study of the human dimensions of climate change has been growing in momentum through research which attempts to describe, evaluate, quantify and model perceptions of climate change, understand more about risk and assess the construction of policy. Cultural geographers’ concerns with the construction of knowledge, the workings of social relations in space and the politics and poetics of place-based identities provide a lens through which personal, collective and institutional responses to climate change can be evaluated using critical and interpretative methodologies. Adopting a cultural geography approach, this paper examines how climate change as a particular environmental discourse is constructed through memory, observation and conversation, as well as materialised in farming practices on the Lizard Peninsula, Cornwall, UK

Os serviços de acolhimento institucional para crianças e adolescentes: os desafios e o trabalho com a rede proteção social

O presente artigo tem como objetivo discutir como é realizado o trabalho dos serviços de acolhimento institucional, abordando o Estatuto da Criança e do Adolescente e as normativas estabelecidas para os abrigos - Plano Nacional de Convivência Familiar e Comunitária e as Orientações Técnicas para os serviços de acolhimento para Crianças e Adolescentes. Apresenta também os principais desafios enfrentados, como a adequação das práticas institucionais às legislações e parâmetros técnicos vigentes, a necessidade de empreender respostas institucionais que atendam as demandas dos acolhidos e o permanente trabalho articulado e intersetorial com a rede de proteção social. Apesar dos desafios, os abrigos tendem a caminhar em direção da nova ação pública, que supera as fronteiras da setorialização e permite aglutinar diversificados serviços, programas, atores e instituições.

Estrutura e desafios de financiamento do programa Abrigos Solidários: Liga Solidária

A prestação do serviço de acolhimento institucional para crianças e adolescentes ainda é um grande desafio para as organizações que realizam este trabalho, não só pelas atuais mudanças do perfil dos abrigados, que passa a exigir novas respostas institucionais, com pela fragilidade da estrutura de financiamento público. Desse modo, o presente trabalho tem como propósito identificar as principais fragilidades da estrutura de financiamento público desse serviço, a partir do estudo de caso do Programa Abrigos Solidárias da Liga Solidária, organização social sem fins lucrativos que mantém três abrigos via convênio firmado com a Secretaria Municipal de Assistência e Desenvolvimento Social de São Paulo (SMADS). Para tanto, foi realizada pesquisa qualitativa baseada em entrevistas semi estruturadas junto a gestores e técnicos da Liga Solidária, bem como uma revisão bibliográfica sobre os principais marcos da Política Nacional de Assistência Social, referências sobre a Reforma Gerencial do Estado e o funcionamento básico do Sistema Único de Saúde (SUS). Com base nos dados encontrados na pesquisa, foi possível realizar um diagnóstico da atual estrutura de financiamento público e complementar que subsidiou a elaboração de uma proposta integrada de aperfeiçoamento da estrutura de financiamento desse serviço respaldado por uma análise comparativa com o SUS e resgatando as propostas de contratualização previstas na Reforma Gerencial do Estado de 1995.

Towards a model of the institutional logics of climate change

The proliferation of innovative schemes to address climate change at international, national and local levels signals a fundamental shift in the priority and role of the natural environment to society, organizations and individuals. This shift in shared priorities invites academics and practitioners to consider the role of institutions in shaping and constraining responses to climate change at multiple levels of organisations and society. Institutional theory provides an approach to conceptualising and addressing climate change challenges by focusing on the central logics that guide society, organizations and individuals and their material and symbolic relationship to the environment. For example, framing a response to climate change in the form of an emission trading scheme evidences a practice informed by a capitalist market logic (Friedland and Alford 1991). However, not all responses need necessarily align with a market logic. Indeed, Thornton (2004) identifies six broad societal sectors each with its own logic (markets, corporations, professions, states, families, religions). Hence, understanding the logics that underpin successful –and unsuccessful– climate change initiatives contributes to revealing how institutions shape and constrain practices, and provides valuable insights for policy makers and organizations. This paper develops models and propositions to consider the construction of, and challenges to, climate change initiatives based on institutional logics (Thornton and Ocasio 2008). We propose that the challenge of understanding and explaining how climate change initiatives are successfully adopted be examined in terms of their institutional logics, and how these logics evolve over time. To achieve this, a multi-level framework of analysis that encompasses society, organizations and individuals is necessary (Friedland and Alford 1991). However, to date most extant studies of institutional logics have tended to emphasize one level over the others (Thornton and Ocasio 2008: 104). In addition, existing studies related to climate change initiatives have largely been descriptive (e.g. Braun 2008) or prescriptive (e.g. Boiral 2006) in terms of the suitability of particular practices. This paper contributes to the literature on logics by examining multiple levels: the proliferation of the climate change agenda provides a site in which to study how institutional logics are played out across multiple, yet embedded levels within society through institutional forums in which change takes place. Secondly, the paper specifically examines how institutional logics provide society with organising principles –material practices and symbolic constructions– which enable and constrain their actions and help define their motives and identity. Based on this model, we develop a series of propositions of the conditions required for the successful introduction of climate change initiatives. The paper proceeds as follows. We present a review of literature related to institutional logics and develop a generic model of the process of the operation of institutional logics. We then consider how this is applied to key initiatives related to climate change. Finally, we develop a series of propositions which might guide insights into the successful implementation of climate change practices.

A critical appraisal of responses to Maori offending

This article critically analyses the role that criminological theory and specific policy formulations of culture play in the New Zealand state’s response to the over-representation of Māori in the criminal justice system. Part one provides an overview of the changing criminological explanations of, and responses to, Māori offending in New Zealand from the 1980s onwards and how these understandings extended colonialist approaches to Māori and crime into the neo-colonial context. In particular, we chart the shift in policy development from theorising Māori offending as attributable to loss of cultural identity to a focus on socio-economic and institutional antecedents and, finally, through the risk factors, assessment, and criminogenic needs approaches that have gained prominence in the current policy context. In part two, the focus moves to the strategies employed by members of the academy to elevate their own epistemological constructions of Māori social reality within the policy development process. In particular, the critique scrutinises recent attempts to portray Indigenous responses to social harm as “unscientific” and, in part, responsible for the continuing over-representation of Māori in New Zealand’s criminal justice system. The purpose of this analysis is to focus the critical, criminological gaze firmly on the activities of policy makers and administrative criminologists, to examine how their policies and approaches impact on Māori as an Indigenous people.

Responding to a transformative stressor : climate change and the institutional governance of Australian cities

This paper understands climate change as a transformative stressor that will prompt responses from institutional governance frameworks in Australian cities. A transformative stressor is characterised as a chronic large-scale phenomenon which triggers a process of institutional change whereby institutions seek to reorientate their activities to better manage the social, economic and environmental impacts created by the transformative dynamic. It is posited that institutional change will be required as Australian metropolitan institutional governance frameworks seek to manage climate change effects in urban environments. It is argued that improved operationalisation of adaptation is required as part of a comprehensive urban response to the transformative stresses climate change and its effects are predicted to create in Australian cities. The operationalisation of adaptation refers to adaptation becoming incorporated, codified and implemented as a central principle of metro-regional planning governance. This paper has three key purposes. First, it examines theoretical and conceptual understandings of the role of transformative stressors in compelling institutional change within urban settings. Second, it establishes a conceptual approach that understands climate change as a transformative stressor requiring institutional change within the metropolitan planning frameworks of Australia's cities. Third, it offers early results and conclusions from an empirical investigation into the current prospects for operationalisation of climate adaptation in planning programs within Southeast Queensland (SEQ) via changes to institutional governance. A significant emerging conclusion is that early climate stresses appear not to be leading to episodic institutional change in the metropolitan planning frameworks of SEQ.

Effective responses to offenders with intellectual disabilities : generalist and specialist services working together

Despite policies of deinstitutionalisation, many people with intellectual disabilities in developed western countries continue to live in mainstream institutional settings, such as correctional facilities, rather than in the community with support from disability services. This paper reports on the life stories of 10 people with intellectual disabilities, who had been imprisoned in adult correctional facilities in Queensland. The pathways taken by these 10 people into and out of prison are marked by significant abuse, neglect, and poverty. Significant disparity and disconnection is also displayed between the policies and service approaches, particularly between the disability, mental health, and correctional systems in Queensland. Based on these findings, a framework for practice, which spans both generic and specialist services, is suggested.

Planning for climate change adaptation in a neoliberal context: Influences and responses

This thesis explores how planning policy and practice is responding to the challenge of climate change, particularly in contexts where neoliberal rationales and practices frame decision making. It documents patterns of devolving government responsibilities and experiences of market based mechanisms before reporting on institutional and professional responses to these conditions. The research centred on a qualitative case study and involved thematic content analysis of policy documents and informant interviews. The contribution of the research and thesis is to establish the outlook for climate change adaptation under neoliberal conditions, and to introduce strategies for planners operating within these conditions.

Child sexual abuse: Raising awareness and empathy is essential to promote new public health responses

Child sexual abuse is a major global public health concern, affecting one in eight children and causing massive costs including depression, unwanted pregnancy and HIV. The gravity of this global issue is reflected by the United Nations’ new effort to respond to sexual abuse in the 2015 Sustainable Development Goals. The fundamental policy aims are to improve prevention, identification and optimal responses to sexual abuse. However, as shown in our literature review, policymakers face difficult challenges because child sexual abuse is hidden, psychologically complex, and socially sensitive. This article contributes significant new ideas for international progress. Insights about required strategies are informed by an innovative multidisciplinary analysis of research from public health, medicine, social science, psychology, and neurology. Using an ecological model comprising individual, institutional and societal dimensions, we propose that two preconditions for progress are the enhancement of awareness of child sexual abuse, and of empathic responses towards its victims.

When innovation fails: An institutional perspective of the (non)adoption of boundary spanning IT innovation

We combine the concepts of legitimacy, institutional (mis)alignments, strategic responses and organizing visions to develop a conceptual framework to analyse the adoption of innovations that span organisational fields. We apply the framework to examine a telehealth innovation connecting a public sector hospital-based eye clinic with private sector optometry practices. We find that while compromise strategies were successful in encouraging adoption within each field, the innovation ultimately failed as fields developed different organising visions which could not be reconciled. The findings suggest that institutional misalignments within and between fields interact to amplify their overall effect on the adoption of hybrid innovations.

Trade union responses to ageing workforces in the UK and Germany

Ageing workforces are placing conflicting pressures on European trade unions in order to, on the one hand, protect pensions and early retirement routes, and, on the other, promote human resource management (HRM) policies geared towards enabling their older members to extend working life. Using interviews from German and United Kingdom (UK) trade unions, we discuss how unions are both constrained and enabled by pre-existing institutional structures in advocating approaches to age management. In Germany, some unions use their strong institutional role to affect public policy and industrial change at national and sectoral levels. UK unions have taken a more defensive approach, focused on protecting pension rights. The contrasting varieties of capitalism, welfare systems and trade unions’ own orientations are creating different pressures and
mechanisms to which unions need to respond. While the German inclusive system is providing unions with mechanisms for negotiating collectively at the national level, UK unions’ activism remains localized.