Nugus Peter, Ranmuthugala Geetha, Lamothe Josianne, Greenfield David, Travaglia Joanne, Kolne Kendall, Kryluk Julia, Braithwaite Jeffrey
McGill University , Montreal, Canada.
University of New England , Armidale, Australia.
J Health Organ Manag. 2018 Sep 17;32(6):809-824. doi: 10.1108/JHOM-09-2017-0239. Epub 2018 Oct 3.
Health service effectiveness continues to be limited by misaligned objectives between policy makers and frontline clinicians. While capturing the discretion workers inevitably exercise, the concept of "street-level bureaucracy" has tended to artificially separate policy makers and workers. The purpose of this paper is to understand the role of social-organizational context in aligning policy with practice.
DESIGN/METHODOLOGY/APPROACH: This mixed-method participatory study focuses on a locally developed tool to implement an Australia-wide strategy to engage and respond to mental health services for parents with mental illness. Researchers: completed 69 client file audits; administered 64 staff surveys; conducted 24 interviews and focus groups (64 participants) with staff and a consumer representative; and observed eight staff meetings, in an acute and sub-acute mental health unit. Data were analyzed using content analysis, thematic analysis and descriptive statistics.
Based on successes and shortcomings of the implementation (assessment completed for only 30 percent of clients), a model of integration is presented, distinguishing "assimilist" from "externalist" positions. These depend on the degree to which, and how, the work environment affords clinicians the setting to coordinate efforts to take account of clients' personal and social needs. This was particularly so for allied health clinicians and nurses undertaking sub-acute rehabilitative-transitional work.
ORIGINALITY/VALUE: A new conceptualization of street-level bureaucracy is offered. Rather than as disconnected, it is a process of mutual influence among interdependent actors. This positioning can serve as a framework to evaluate how and under what circumstances discretion is appropriate, and to be supported by managers and policy makers to optimize client-defined needs.
卫生服务的有效性仍然受到政策制定者与一线临床医生目标不一致的限制。虽然“街头官僚主义”概念考虑到了工作人员不可避免地行使的自由裁量权，但往往人为地将政策制定者与工作人员区分开来。本文旨在探讨社会组织背景在使政策与实践保持一致方面所起的作用。
设计/方法/途径：这项混合方法参与式研究聚焦于一种当地开发的工具，该工具用于实施一项全澳大利亚范围的战略，以参与并回应为患有精神疾病的父母提供的心理健康服务。研究人员：完成了69份客户档案审计；进行了64次员工调查；与员工和一位消费者代表进行了24次访谈和焦点小组讨论（64名参与者）；并在一个急性和亚急性心理健康单元观察了8次员工会议。使用内容分析、主题分析和描述性统计对数据进行了分析。
基于实施过程中的成功与不足（仅对30%的客户完成了评估），提出了一个整合模型，区分了“同化主义者”和“外部主义者”立场。这些立场取决于工作环境在多大程度上以及如何为临床医生提供条件，使其能够协调工作，以考虑客户的个人和社会需求。对于从事亚急性康复过渡工作的专职医疗临床医生和护士来说尤其如此。
原创性/价值：提出了一种对街头官僚主义的新的概念化理解。它并非是脱节的，而是相互依存的行为者之间相互影响的过程。这种定位可作为一个框架，用于评估自由裁量权在何种方式和情况下是合适的，以及如何得到管理者和政策制定者的支持，以优化由客户界定的需求。
