The British Journal of Social Work

Keddell,, Emily;Hyslop,, Ian

doi: 10.1093/bjsw/bcz131pmid: N/A

Abstract Families are significantly affected by decisions made in the child protection context, yet decision outcomes differ even when cases are similar. Understanding the concepts, practices and processes of differentiation that push some cases over the threshold of key decision points, but not other similar cases, is crucial. Drawing on interviews and focus groups with child protection social workers from three site offices in Aotearoa New Zealand (interviews, n = 26; focus groups, n = 25) and using thematic analysis, this study identified the case, internal organisational, inter-site organisational and external elements that contributed to threshold decisions. Case factors such as children’s age, abuse type and chronicity recorded family history and perceptions of family compliance interacted with internal organisational processes and practices, social negotiations and hierarchical power differences to produce decision outcomes. Inter-site differences in decision thresholds resulted from differences in site managers’ perceptions of acceptable case type, site workloads, resources, size and cultural commitment to family preservation. External demographic inequalities were perceived as causing differing levels of site workload. This ‘networked decision-making’ process is theorised drawing on an extended version of the decision-making ecology (DME), by using qualitative methods to examine interactions between the DME elements and their relationship with risk regimes. child protection, decision-making ecology, decision-making thresholds, organisations, risk Introduction Understanding how child protection social workers make choices between the courses of action available to them is important for several reasons. Decisions to increase or reduce statutory intervention in family life have long-lasting consequences for both children and parents and should be undertaken in ways that consistently and fairly protect both children’s and parent’s rights (Keddell, 2014). Decision pathways involve complex choices. At important decision thresholds that result in families progressing further into or out of the child protection system, cases arise that are on the ‘cusp’, that is, the specific situation is considered to be in close proximity to the threshold for further intervention. To decide if these cases should proceed, a process of categorisation and differentiation is required. This process is influenced by many factors across the decision-making ecology (DME; Baumann et al., 2011; Fluke et al., 2014). This linear account of decision-making belies the intense social context that shapes decision outcomes. The reasoning of individual social workers is enmeshed within a complex social and institutional context focussed on managing risk in modern child protection systems (Beddoe, 2010; Parton, 2014). Decisions result from intense social negotiations with key players such as colleagues and managers, and are shaped by relationships with families, moral and ethical considerations, the assessment tools used, how key events and behaviour are interpreted, the legal context, organisational culture and processes, and issues of service supply and demand (Bywaters, 2015; Platt and Turney, 2014; Doherty, 2016). Understanding how this confluence of elements plays out in a given context is important, as it is key to understanding empirically how decisions are made in practice, and if they are fair. Examining how social workers make fine-grained distinctions between similar or uncertain cases may help to illuminate processes contributing to differences in outcomes. This article reports on a study examining practitioner perceptions of the factors that push cases over the threshold of two key decisions: to hold a family group conference (FGC) and remove children from their parents’ care. Understanding thresholds from a decision-making ecology perspective The DME conceptualises decisions as more than just the result of a single practitioner finding out information and determining a course of action (Baumann et al., 2011). Decision outcomes are perceived to occur within a spectrum of interlocking influences, including case variables, external factors, organisational factors and decision-maker characteristics. External factors include macro influences such as inequalities in system contact, service supply and demand, neighborhood variables such as social cohesion, and differing policy orientations (Gilbert et al., 2011; Bywaters et al., 2015; Barnhart and Maguire-Jack, 2016). Organisational factors are elements such as institutional cultures and processes that result in localised sense-making, while decision-maker factors include the values of the social worker and their personal biases, knowledge bases, preferences and levels of experience (Platt and Turney, 2014; Benbenishty et al., 2016; Fluke et al., 2016). Case factors are those characteristics relating to the family (Baumann et al., 2011). Infused with all these elements are concepts relating to risk, considered a ‘first order’ construct in child protection: one within which others are organised (Houston and Griffiths, 2000). Indeed, regimes of risk management focused on future predictions and managerialist/rationalist organisational arrangements dominate the child protection project, despite the tensions this provokes with strengths and safety-oriented practice philosophies, and conflictual policy orientations (Turnell and Edwards, 1999; Webb, 2006; Gilbert et al., 2011). A focus on key points in the decision-making continuum helps understand how variability occurs. The concept of a continuum refers to how cases are processed through the child protection system, from notification to investigation and possible intervention (Fluke et al., 2014). At any of these points or thresholds, families may either exit the system or enter further into the child protection system. Drawing on the concept of naturalistic decision-making, Platt and Turney (2014) propose that a threshold decision is not a technical–rational objective barrier, but is instead the product of organisational-specific sense-making practices ‘mediated through various sense-making strategies at the local level’ (Platt and Turney, 2014, p. 1472). They argue that identification of the heuristics which function in a specific pressurised working environment leads to a nuanced understanding of how thresholds are operationalised in child protection settings (p. 1472). Sense-making processes develop over time in naturalistic environments, and are fundamentally shaped by organisational norms and culture (Klein and Hoffman, 2008). Institutional norms, in turn, are influenced by formal mechanisms, such as laws, assessment tools and practice guidance, and informal factors such as cultural norms, organisational values (for example, whether family preservation or child safety is prioritised) and how decision pathways are structured (Fluke et al., 2016). The institutional context means that decisions are intersubjective, negotiated and shared between team members and this process is unavoidably influenced by power dynamics between team members, and concepts relating to risk. Decision-making may be supported by colleagues and managers through cooperative, group decision-making fora or imposed from above within a rigid managerial hierarchy focused on risk aversion (Falconer and Shardlow, 2018). Within most anglophone countries, the child protection system has narrowed to focus on identifying risk and managing it instrumentally through other services and family plans, requiring family compliance if risk is to be considered reduced (Parton, 2014). It also responsibilises practitioners for managing risks in a context of uncertainty within managerialist environments focused on accountability, and this creates anxiety for practitioners (Leigh and Laing, 2018). Perceptions of parental responsibility and their response to child protection services may also affect decisions. Stronger interventions may result where parents are viewed as exclusively accountable for maltreatment, as ‘disengaged’ in the practice relationship, or showing ‘disguised compliance’ (Platt, 2006; Leigh et al., 2019). Thresholds can also be affected by resource factors relating to service demand and supply (Bywaters, 2015). For example, in high workload environments, alternatives can become constricted, resulting in ‘… tunnel vision, in which the worker considers only a narrow range of options to save time and effort’ (Font and Maguire-Jack, 2015, p. 73). In general, where caseloads are high there is a lower likelihood of child removal, and demand management occurs to manage case acceptance by the agency (McLaughlin and Jonson-Reid, 2017; Hood et al., 2019). There is reduced time to complete the relevant relational and document preparation work required for removal. This summary shows that the common instrumental workflow image of the rational pathway neatly diverging at clearly defined points is misleading. Thresholds are better conceived as fuzzy junctures. The situations and responses of families coalesce with socially interpreted definitions of risk, enacted within organisational contexts which are shaped in turn by organisational norms, processes, available resources and other external factors. The Aotearoa New Zealand child protection decision-making context In Aotearoa New Zealand, child welfare services are divided into statutory and non-governmental service provision. The statutory service’s primary role is to assess families to decide whether legal interventions should be pursued, while preventive or support work is undertaken within the NGO sector, in a similar way to other nations with a child protection orientation (Gilbert et al., 2011). Despite efforts to develop a child welfare orientation, particularly in response to Indigenous Māori concerns relating to disproportionality, the policy orientation remains broadly protectionist (Keddell, 2017a). Within the statutory pathway, families are notified and if accepted by the statutory agency, Oranga Tamariki (OT) ‘report of concern’ is recorded. After this, family situations are assigned an urgency rating, before being assessed for either partnered (differential) response, or accepted into the statutory system where they are further bifurcated into either a child and family assessment, or an investigation status where there is greater immediate concern (Oranga Tamariki, 2019b). Possible outcomes are either a Family-whanau agreement (a voluntary plan), other types of less formal family meetings (a hui ā whānau) or referral for an FGC. If an FGC is held, either a plan will be written and reviewed via the FGC process, or mandated intervention, including orders concerning children’s custody may be applied for through the Family Court. If orders are the aim, an FGC is mandatory. Referral for an FGC requires a social worker to have ‘formed a belief’ that the child requires care or protection on the basis of one or more of the grounds specified in section 14(1) of the Oranga Tamariki Act 1989 (NZ Government, 1989). Court orders flow from a formal legal declaration to this effect (section 67). The decision to take a matter to FGC therefore reflects a legally mandated escalation of concern. Accordingly, it represents a key point within the decision-making continuum. OT employs various practice approaches that affect decision-making, including the use of a ‘case consult’ tool (Oranga Tamariki, 2019a). Loosely modelled on the Signs of Safety approach (Turnell and Edwards 1999), this tool contains sections on danger/harm, risk statements, safety, strengths/protective factors, complicating factors and next steps, as well as a risk and safety scale (Oranga Tamariki, 2019a). This is usually used before going to FGC, if orders are to be applied for, or if a case is to be closed, but its use is not mandated. Research questions This article reports on a study examining the reasoning at two key decision points: deciding to pursue an FGC and applications for removal orders. The research questions reported here using qualitative data from the second phase of this study (explained below) are: (1) What are practitioner perceptions of the influences on ‘cusp’ decision thresholds relating to FGC decisions, and decisions to remove children? (2) How do these perceptions relate to the DME, specifically case, decision-maker and organisational and external factors? (3) How do these perceptions relate to decision variability? Methods This research was conducted in two phases. Phase one employed a mixed-methods survey to explore practitioner responses to a vignette, examining factors such as differences in risk perceptions, information depth, role type and ethnic bias as sources of variability (Keddell and Hyslop, 2016; 2018; 2019; Keddell 2017b). Findings from phase one (n = 67) were that respondents perceived decision variability to be a significant problem, with 55 per cent stating the problem was ‘quite severe’ or ‘fairly severe’ and 44 per cent stating it was ‘moderate’. Practitioner perceptions of causes of variability in phase one were in response to a single open-ended question: what, in your view, causes decision variability? The four primary themes from inductive coding were: social worker values, beliefs and theoretical standpoint; workload; skill level and experience; and differences in perceptions of risk, harm and abuse (Keddell and Hyslop, 2016). Phase two built on phase one by interviewing twenty-five social workers, supervisors and team leaders, and holding six focus groups at three statutory child protection agency site offices (out of a total of fifty-nine offices nationwide). Phase two aimed to explore phase one findings further through qualitative interviews and focus groups. The sites were selected for demographic and spatial variation as follows: Site 1: Urban, low-deprivation area, mostly Pākeha staff, Pākeha plus ethnically diverse clients. Site 2: Urban, mid-high-deprivation area, mostly Māori and Pacific clients and staff. Site 3: Semi-rural site spread across several small mid-high-deprivation towns, mostly Pākeha staff and clients. At each site, staff were invited to participate in interviews and focus groups, which were organised by team. Two focus groups occurred at each site, (three focus groups, n = 25) and twenty-six practitioners agreed to be interviewed individually following reading the information sheet and consent form. Materials Practitioners were asked questions from a semi-structured interview schedule relating to decision-making processes and decision content, with a particular focus on key decision thresholds. Several interview questions related directly to cusp or threshold decisions: (1) When a case is ‘on the cusp’ between going to an FGC or not, what factors, to you, would mean it should or shouldn’t go? Give examples. (2) What are the significant aspects of a case that would mean children would definitely be removed? Give examples. (3) When compared to other offices, how does your threshold for different decision points compare? Why do you think this is? (4) Are there any unwritten rules at this office? (5) Any particularly difficult or exceptional cases? All of these questions elicited answers that related directly to threshold decisions, although data included for this article are also drawn from answers to other questions that focused on the process of making key decisions, what decisions were perceived as simple or difficult, and how they collaborate with others to reach decision outcomes. Focus group questions were related to a vignette, but covered similar topics relating to thresholds. Procedures and analysis Participants were accessed via the national office of OT. Prior to arrival, staff at selected offices were sent information sheets explaining the research and then researchers met with each staff group to answer questions and invite participation. Consent processes were explained so participants understood that they did not have to take part as a condition of their employment, could withdraw at any time, and their responses would be anonymised. Ethical approval was obtained from the University of Otago Ethics committee, the Ngāi Tahu Research consultation committee and the Research Access Committee of the Ministry of Social Development. Individual and team focus group interviews were recorded and transcribed. The data were analysed following both deductive and inductive coding processes. First, all interviews were read and re-read to understand patterns in the data. Codes were developed inductively that arose from the data initially, and developed into domain descriptions. In this iterative process, any response could be coded as relating to thresholds, even if not elicited in direct response to the questions listed above. Codes were then categorised deductively into the organising theoretical framework of the DME categories. These descriptions were then developed into more theoretical themes, with some axial coding to show connections within the data, especially to trace the interactions between case, organisational and external factors (Braun et al., 2015). Results Particpants in the study were drawn from three sites and comprised a mixture of front-line social workers, senior practitioners, supervisors, practice leaders and FGC coordinators, as illustrated in Table 1. Social workers and senior practitioners are in front-line roles with families. Supervisors are responsible for their team of social workers and senior practitioners. Practice leaders consult on difficult cases, and are positioned above supervisors. They report in line management to the site manager, while FGC coordinators facilitate FGCs. Each site office has a single site manager, and most have multiple teams within them. Table 1 Demographics of phase two participants n (interviews) % n (six focus groups) % Total 26 25 Gender Gender Female 21 81 Female 20 80 Male 5 19 Male 5 20 Ethnicity Ethnicity Pakeha 18 69 Pakeha 20 80 Maori 4 15 Maori 3 12 Pasifika 1 4 Pasifika Asian 2 8 Asian 1 4 Other 1 4 Other 1 4 Experience 1–30 years Role Sites Group composition (n group 1, n group 2, role) Social worker 14 54 Site 1 9 4, 5, 3SW, 1SUP; 4SW, 1SUP Senior practitioners 2 8 Site 2 9 5, 4, 5SW; 3SW, 1SUP Supervisor 6 23 Site 3 7 4, 3, 2SW, 1SSW, 1SUP; 2SW, 1SUP FGC coordinators 3 12 Practice leader 1 4 n (interviews) % n (six focus groups) % Total 26 25 Gender Gender Female 21 81 Female 20 80 Male 5 19 Male 5 20 Ethnicity Ethnicity Pakeha 18 69 Pakeha 20 80 Maori 4 15 Maori 3 12 Pasifika 1 4 Pasifika Asian 2 8 Asian 1 4 Other 1 4 Other 1 4 Experience 1–30 years Role Sites Group composition (n group 1, n group 2, role) Social worker 14 54 Site 1 9 4, 5, 3SW, 1SUP; 4SW, 1SUP Senior practitioners 2 8 Site 2 9 5, 4, 5SW; 3SW, 1SUP Supervisor 6 23 Site 3 7 4, 3, 2SW, 1SSW, 1SUP; 2SW, 1SUP FGC coordinators 3 12 Practice leader 1 4 Open in new tab Table 1 Demographics of phase two participants n (interviews) % n (six focus groups) % Total 26 25 Gender Gender Female 21 81 Female 20 80 Male 5 19 Male 5 20 Ethnicity Ethnicity Pakeha 18 69 Pakeha 20 80 Maori 4 15 Maori 3 12 Pasifika 1 4 Pasifika Asian 2 8 Asian 1 4 Other 1 4 Other 1 4 Experience 1–30 years Role Sites Group composition (n group 1, n group 2, role) Social worker 14 54 Site 1 9 4, 5, 3SW, 1SUP; 4SW, 1SUP Senior practitioners 2 8 Site 2 9 5, 4, 5SW; 3SW, 1SUP Supervisor 6 23 Site 3 7 4, 3, 2SW, 1SSW, 1SUP; 2SW, 1SUP FGC coordinators 3 12 Practice leader 1 4 n (interviews) % n (six focus groups) % Total 26 25 Gender Gender Female 21 81 Female 20 80 Male 5 19 Male 5 20 Ethnicity Ethnicity Pakeha 18 69 Pakeha 20 80 Maori 4 15 Maori 3 12 Pasifika 1 4 Pasifika Asian 2 8 Asian 1 4 Other 1 4 Other 1 4 Experience 1–30 years Role Sites Group composition (n group 1, n group 2, role) Social worker 14 54 Site 1 9 4, 5, 3SW, 1SUP; 4SW, 1SUP Senior practitioners 2 8 Site 2 9 5, 4, 5SW; 3SW, 1SUP Supervisor 6 23 Site 3 7 4, 3, 2SW, 1SSW, 1SUP; 2SW, 1SUP FGC coordinators 3 12 Practice leader 1 4 Open in new tab The DME categories of case factors, organisational factors and external factors are used to describe broad themes for both FGC and removal decision thresholds. Subthemes and interactions between themes are discussed to build up a rich networked description of decision-making thresholds. Case factors affecting cusp decisions Case factors invoked in the narratives of participants when discussing the decision to go to an FGC or seek removal included children’s age and development, and the seriousness of the abuse. But equally powerful when it came to decision thresholds was the perceived response and recorded history of the family. Where the family was seen as not complying with earlier, less intrusive interventions, this was key to crossing the next decision threshold. Children’s age and developmental timeframes Practitioners emphasised the child’s age, timeframes and community connections, with older children perceived as less likely to be taken into care than younger ones. This respondent explained: The age of the children as well, their own ability to you know if they are 12/13 year olds and that is where they have lived all their lives you are not going to easily go in … I am talking about removal. (Site 3, Supervisor 1) And also taking into account the age of the kids as well, working within their timeframes … one of them I’ve been working with the family (since) the child had only just been born, so I mean like that’s his entire life … we’d given his parents the opportunity to make those changes and they just hadn’t. (Site 1, Social Worker 4) Family response: history and compliance Recorded family history and perceived parental response to allegations were key themes of both FGC and removal decisions. If there was an extensive history with the child protection agency, together with a perception of lack of engagement or change from parents, then these factors could push a case over the cusp: Family whanau agreement, the thing that really dictates whether or not I feel it fits family whanau is the family’s willingness to engage in a safety plan … if I feel this family is capable of coming up with a plan and sticking to it with minor monitoring, easy. They need to know that we’re watching, and they need to actually make some changes … And I know that I can always go to FGC if that doesn’t work out. (Site 1, Social Worker 2) History again is just something that keeps coming back, you know if the child’s getting exposed to the same thing over and over again it’s like actually no, we’re going to a family group conference. You know it’s a higher level, it’s a bigger stick so to speak … Hey actually look guys this is serious, it needs to stop. (Site 1, Social Worker 4) In these instances, a decision to hold an FGC could be justified by both protective purposes ‘exposed over and over’ and disciplinary purposes ‘need to know we are serious’. Similarly, the perceived family response was pivotal to removal decision thresholds. Where there was perceived non-compliance with the FGC plan, no sign of change despite significant input, then removal would follow. Support and surveillance Another strong case factor theme affecting FGC threshold decisions was the perception of levels of support and potential surveillance, which were often conflated. Differing levels of support and monitoring can be the clincher in the decision-making process about cases that may appear similar in other ways: Say I’ve got two exact same situations, but one of them’s got just say one grandma involved and maybe a kindy, but the other ones got four grandparents, several aunts and uncles, kindy, school, GP, community agency then I’m more likely to just close that and walk away because actually there’s enough eyes in there to see what’s going on. (Site 1, Social Worker 4) Organisational factors affecting cusp decisions In addition to these case and family factors, there was a range of organisational elements affecting decisions to refer the family for an FGC or for removal. These can be further categorised as internal site factors and inter-site factors. Internal to each office site, decisions were affected by processes of social negotiation within a managerial hierarchy. These processes were shaped by group case consult tools, the relative power of more and less experienced workers, and whether an individual or collaborative approach to ‘forming a belief’ was used. Differences between sites included site culture, specifically the level of commitment to family engagement and preservation, along with differences relating to decision process pathways and site size. Social negotiation, case consults and managerial hierarchy Many social, as opposed to individual processes that occur in the organisational setting contribute to threshold decisions. Many respondents emphasised that ‘no decisions are made alone’ and that various consultations with others in their team and site office are held before going to an FGC. Supervisors were powerful in this process, as without convincing one’s supervisor, neither an FGC nor removal could occur. The use of a ‘consult tool’ to guide group consultations was also prevalent, although responses were varied over how often this was done. The tool, derived from the signs of safety assessment framework, has a set structure (see Aotearoa New Zealand decision-making context) (Turnell and Edwards, 1999). It is not designed as an individual decision-making instrument and necessitates input from a group of practitioners: Generally in collaboration with your supervisor, having a case consult—so bringing in not just your other workers in the office but key parties that are involved with the family … Twice usually, once at the initial onset to make decisions and then once again past FGC … there should be consultations so that it’s a—yeah, collaborative thinking. Two people can’t decide yes that child needs to come into care, it takes more than that. (Site 3 Social Worker 2) When discussing the removal decision, the socially negotiated process of gaining approval from managers was intensified due to the more serious nature of the decision. For example, many respondents stated that removal applications would only be made after multiple consultations with members of the whole team, and could only be approved by those in managerial positions: Ah well yeah, that kids don’t come into care without the practice leader and the manger being involved and your understanding why you’re doing that … that’s the rule … because it’s not something that we do lightly and it’s abusive in itself and you bloody well better be able to offer those kids way better than what you’re taking them from if you’re gonna do that to them. (Site 2, Social Worker 1) Experience, power and risk As the theme above alludes to, the use of hierarchical power between senior practitioners and the front-line social workers was evident. Front-line decisions were negotiated between supervisors and managers with supervisors having the final say. This hierarchical structure shapes how risk perceptions are translated into front-line decisions. For example, the role of more senior practitioners could reduce the risk anxieties of newer practitioners, and this could result in deciding not to pursue an FGC: When I first started this job I tended to look ahead and what if this happens, and what if that, but (team leader) is really good at bringing you back and saying well you’ve the here and now, you can’t predict the future so. Which is really important but yeah, hard to do … (because) that’s what the media wants us to do, you know the public. (Site 1, Social Worker 1) Others found that more senior practitioners could exercise their power in ways that were more risk-averse. This was attributed to them being less familiar with strengths-based approaches taught in current Social Work education, and more concerned about risk to the organisational reputation rather than the child. This use of power could then be transferred into the FGC environment with the family, which was perceived as diminishing the family participation imperatives of the legislation (Oranga Tamariki Act 1989): … with FGC you’ve got consults and you’ve got some pretty clear directives from management, practice leaders, and supervisors. And you might be getting some fairly strong directives about where this case is expected to go - CYFs already know, we already have got an agenda about where we want this to go. And a lot of families will pick up on this and they’ll say you’ve already made up your minds anyway what you’re going to do. (Site 2, Social Worker 9) Intersite differences: collaboration or adversarial decision-making process? In addition to these intra-site factors, respondents also perceived differences between different sites within the child protection service that affected the threshold for an FGC or removal. One of these was variability in site processes employed by social workers to reach the point of ‘forming a belief’ children are in need of protection—a key legal requirement to pursue an FGC. Some reported that they had to come to that decision themselves, then pitch it to convince their supervisor, while others came to that decision as a group, with others challenging and engaging in a critical discussion about their perceptions. This social worker describes these key differences: and then I justified it to my supervisor, convince her that this needs to go to FGC and then ok, if that is your belief and then prepare all the, you know the Tuituia [assessment tool], make the FGC referral and that will go to the FGC and then when you go to the consult you’re justifying why it needs to go to FGC so … you’re defending your views … whereas, on the other side, on my other process which I prefer, you will make the decision as a team, where your supervisor is there, a group of senior practitioners, FGC co-ordinator and the social worker … you will make a decision as a group so you’re not deciding in isolation about yourself, but here you need to defend … it’s totally different. Researcher: What would be the obstacles to having that system here? Time. (Site 2, Social Worker 3) Inter-site differences: site culture Another key theme relating to site differences concerned the cultural norms and values of each site office. For example, some reported their site had more commitment to family engagement and preservation than others, and this was especially highlighted when co-working across sites occurred. As this social worker reports: I think there’s probably a bit more trust in this site in family’s abilities than in other sites. And they probably try to work … harder with the family to get buy-in I think. Like … when I was working in (another regional city), there were cases that had gone to FGC and there hadn’t really been much engagement at all really … with the family. Whereas I know that wouldn’t happen here … we’ve got engagement with the family … we’ve got a bit more trust. (Site 3, Social Worker 3) Differences in site cultures relating to family preservation and attitudes to engagement were also reported by respondents as a key element affecting the removal decision. This respondent stated the conviction that their site office made particular efforts to retain children with their family compared to others: Researcher: … Is it fair to say that there’s quite a lot of effort made in the office here to keep kids in families … if it can be done? Yes…we do get professionals questioning … that we’re not doing our job properly because we should be removing the kids from family … but I think that’s one of the biggest challenges that our social workers have had for years is just the different perspectives but (our) site does have the lowest amount of children in care and the majority of children that we do have in care are with whanau …. (Site 2, Supervisor 1) This respondent links this commitment to family preservation, with a view that the culture of her site office held a shared perception that their role is not to ‘fix’ problem families. They connect this to the fact that most of the site workers lived in the community they served, and felt responsible for it: … some sites … are more notorious for placing children in care rather than trying to make a plan with the family … and I think for us, we really try to make things work with the family. Researcher: Why do you think that is? Part of it is the community that we work with and we have at site, we really acknowledge that we can’t just solve families’ problems …sometimes taking the children out makes it more difficult … we want to work with them rather than really damaging that relationship right away… I don’t live in this community but most of the other social workers here do … so it’s their home and they want to take care of … their community, yeah. (Site 2, Social Worker 3) Intersite differences: site size and process pathways A further inter-site organisational factor affecting the FGC decision was site size and the effect this had on how families referred to them were handled. For example, this respondent suggested that smaller sites were able to do more ‘pre-work’, that is, work to manage a case before it is accepted into the office, and this ‘heads off’ the case from being accepted by the site: No I think possibly in a small office when you get a lot of intakes you look at things at intake … sometimes on a bigger site it’ll just automatically get rolled into our child and family assessment and allocated to a social worker …. So having the ability to do things at intake which we maybe have as a smaller site more capacity than big-city towns where they get multiple intakes in a day. (Site 3, Social Worker 2) External factors Between-site differences bled into what could be considered external factors, for example, the more time-consuming collaborative decision-making processes as discussed above related to available time, and therefore site staff resourcing. Staff resources and the availability of foster carers interacted with organisational factors such as managers’ conceptualisations of acceptable ‘types’ of cases to affect site thresholds. In turn, outside of the site context, demographic inequalities affected workload, with sites in high-deprivation urban areas perceived as having higher thresholds for an FGC due to more notifications relating to ‘obvious neglect and abuse’ rather than ‘psychological abuse’. Managerial preferences and site capacity Differences between sites were linked to personal threshold differences between managers, and this was perceived as interacting with site workload capacity. Where there was high workload, less work could be accepted at the front door of the agency, especially for nebulous cases where the concerns are ambiguous or not perceived as high risk. As this worker reports: … from all across all three sites I’ve worked at I get to the same decision through the same pathway using the same set of things that have influenced me .. It’s more about the different supervisors, different practice leaders, different managers, across the sites as to whether or not that’s something they would accept within their site … down in the (different) office … some ongoing low-level family violence … the team down there would have more time and capacity, .. and it’s just like okay let’s have a family whānau agreement, or let’s have an FGC … That probably wouldn’t be the decision that would be made here … Send it off to FGC here, okay why are you sending it to FGC, what you think the outcome should be? It’s just like why are you creating more work? (Site 1, Social Worker 4) The level of workload held by a site was a prominent theme perceived to generate differences between sites relating to FGC decisions. For example: Researcher: do you think you’re roughly the same as other sites or do you think there are some differences in decision points? … I’d have to say that you know it’s dependent on how much work comes through the door … and so some of our organisations, they will be very reactive so you will find that there might be inconsistencies in this threshold because they’re needing to kind of stop the workload coming in, so then you get kind of risk management issues. (Site 1, Social Worker 7) Finally, the availability of foster care, especially long-term care, was also a site resource that was particularly scarce at some sites, affecting the decision to remove threshold. Clearly, this could affect site differences in thresholds if some sites had care available while others did not. Fostercare availability affected the ‘weighing up’ of relative risks and benefits to children, especially in chronic as opposed to immediate risk situations: … I’m not bringing these [children] into care because the placement that I can offer them isn’t a family home, and that’s not going to be any better than where they are right now. Or we just don’t have placements, we just don’t have any. We literally have no placements really … We’d be able to place them in a transitional placement but that would mean multiple moves. (Site 1, Social worker 2) Population inequalities and workload Perceptions of the type, level and prevalence of abuse reported and admitted to specific sites were also related to demographic population factors, particularly levels of need and relative deprivation. Respondents identified sites in areas with a high level of population need with a higher level of notifications and, consequently, a threshold for decisions: P1: but different sites would have different tolerance levels like what we discussed yesterday … P4: I don’t think [different urban office in highly deprived area] would have the urgency maybe as it is here, ‘cause it’d be more of a regular kind of report of concern to get in that area … And same with [different urban office] as well, because of – because there is just so much coming through the front door there – and the neglect and the abuse there is very obvious neglect and abuse, where we’ve got a lot of psychological stuff. (Site 1 Focus Group) Discussion and conclusion This study had several limitations. Interviews and focus groups were undertaken at three sites of the child protection agency that has fifty-nine sites around the country, so participants’ perceptions may not be representative. While most had worked at other offices, their perceptions of the causes of inter-site decision differences reflect their own experiences. Clients and other professionals affect decision outcomes, but their perceptions of decision thresholds are not reported in this study. The findings of this study can be framed using the DME to describe a multi-factor, nation-specific example of the interactions between case, organisational and external factors in threshold decisions. Extending the DME, this study explores qualitatively how elements in each category interact, showing how material resources, group decision-making tools, site decision-making processes, hierarchies of power, risk management and perceptions of family responses combine to produce decision outcomes. Case factors that were particularly relied upon by social workers were the seriousness of the abuse, the child’s age and their developmental stage. But to get over the threshold for holding an FGC, unless the abuse was very severe, these factors had to be bolstered with an extensive recorded family history, a perception of non-compliance by the family with the child protection agency or plan, and low levels of informal support and surveillance. These cases were much more likely to be pushed over ‘the cusp’ threshold and perceived as requiring an FGC. In terms of organisational factors, within each site, negotiations with colleagues and superiors within the managerial hierarchy shaped perceptions of risk, along with the use of group consult tools and site decision pathway processes. One of these processes, for example, meant that at some sites, there was an individual ‘pitching’ to supervisors by social workers to justify the basis of their ‘belief’, in an adversarial type process. Others had more collaborative—but time-consuming—processes where a critical conversation with colleagues was used to arrive at the ‘belief’ that children are in need of care and protection, crucial for escalating cases over the FGC threshold. Some used the more collaborative case consult tool than others. These differences meant that some decisions had more people involved in a group structured decision-making process than others, and did not rely on an individual practitioner’s view. Power differences between front-line workers and managers were further organisational factors shaping decisions. The influence of supervisors and managers was significant, and reflected the hierarchical organisational control of thresholds around risk, but could function to either increase or reduce risk aversion. Less experienced front-line workers were sometimes socialised into a less risk-averse stance by managers, and this dampened risk anxieties and tempered intrusive practice decisions. Some practitioners, however, felt dictated to and that managers were more risk-averse than they were, due to different educational experiences, and that this power from above overly controlled both social worker’s discretion and the relative power of families in the FGC decision-making forum (Falconer and Shardlow, 2018). Indeed, these ‘pre-decisions’ generally did not include family members. Together, these internal site factors combined with case factors to produce site-specific ‘institutional sense-making’ that affected when or if cases were pushed over the cusp of a decision threshold (Platt and Turney, 2014). For example, if a family were perceived as non-compliant and had an extensive family history, and struck a risk-averse supervisor at a site where the practitioner had to pitch their belief, the family may be perceived as high risk, there may be fewer opportunities for family participation or the participation of a wider range of practitioners to produce a more balanced account of the family. This points to issues of both decision consistency—families may get different decisions if these factors do not align, even if their situation is similar—and decision quality or fairness—decisions overly—weighted on recorded history and constructed with an emphasis on risk may not encourage family participation and an evenhanded construction of both risks and strengths. The opposite—or some mix of factors—could also occur, leading to variability. Decisions were affected not only by these case and internal site factors but also by inter-site differences and external factors. Sites were perceived as having differing levels of demand relating to population demographics. High-deprivation areas were perceived as heightening the entry threshold to focus only on direct physical abuse. This workload factor was perceived as shaping threshold decisions about certain types of cases. This may especially affect those types of cases whose definitions have little societal or professional consensus. For example, ‘low level’ domestic violence generated different reactions in offices depending on whether the manager regarded it as being within of the remit of the agency, as well as if there was capacity to respond. Domestic violence tends to generate a confused response from child protection services, as its reconstruction as a type of child abuse does not lead to clear child protection responses (Hester, 2011). This suggests that external factors relating to inequalities and the demand and supply of services may affect variability in responses to families, but only where the cases are of a particular type that elicit differences among managers’ perceptions of admittance criteria (Bywaters, 2015; McLaughlin and Jonson-Reid, 2017). Site culture also influenced thresholds. Some sites had cultures that emphasised family preservation and engagement more than others (Fluke et al., 2016). They placed more emphasis on building rapport with families, which led to more ‘trust’ in families, and contributed to less intensive interventions. This was reported as existing where most social workers lived in the community where the site office was located. This latter factor may contribute to a sense of community investment or accountability that shapes site culture. However, site cultures interacted with site workloads and family factors in divergent ways. Perceptions of family engagement were instrumental in pushing cases over thresholds. In sites where there was either less time (capacity) or organisational cultural preference for engaging with families, they may be perceived as resistant and this combination may lead to more interventionist, risk-averse stances (Leigh and Laing, 2018). On the other hand, sites with limited capacity could respond differently. The emphasis on family preservation, for example, occurred at the site where local deprivation and notifications were high. The combined emphasis on family maintenance with high workload in that instance could also help with demand management, reducing intervention through a commitment to family preservation. Overall, this study shows that decisions are shaped by complex sense-making that occurs within a networked web of social processes and material constraints, both within and between site offices (Platt and Turney, 2014). This qualitative approach extends the DME, providing a rich description of how family factors and perceptions of their responses interact with organisational processes and available resources. It also highlights how inter-site differences can occur even when sites are part of the same national agency. These findings have implications for practice. More careful matching of supply and demand for services is needed to ensure that threshold differences between offices relating to demographic demand are reduced. Creating a greater consensus about what types of cases should reach entry thresholds across the whole organisation also appears important. Differences in site processes and cultures (adversarial versus collaborative, the use of consults, ‘pre-work’ done at intake, differences in the type of case accepted into the site and variations in site cultures) also need examination to ensure that these differences do not result in lack of consistency, compromising just outcomes for children and their families. The role of family compliance on perceptions of risk requires critical examination. A recruitment strategy for foster carers is needed to ensure that lack of care provision does not result in removal decisions unrelated to child need. Further critical examination of the dynamic influences identified should focus on balancing the individual responsiveness needed for specific children and families, with the need to ensure that the level of intervention is justly applied across the population. Acknowledgement We would like to thank the social workers who kindly agreed to be interviewed for this project, and the Office of the Chief Social Worker at OT who helped facilitate it. Funding This study was funded by a University of Otago Research Grant, 2016. Conflict of interest statement. None declared. References Barnhart S. , Maguire-Jack K. ( 2016 ) ‘ Single mothers in their communities: The mediating role of parenting stress and depression between social cohesion, social control and child maltreatment ’, Children and Youth Services Review , 70 , pp. 37 – 45 . Google Scholar Crossref Search ADS WorldCat Baumann D. J. , Dalgleish L. , Fluke J. , Kern H. ( 2011 ) The Decision-making Ecology , Washington, DC , American Humane Association . Google Preview WorldCat COPAC Beddoe L. ( 2010 ) ‘ Surveillance or reflection: Professional supervision in “the risk society” ’, The British Journal of Social Work , 40 ( 4 ), pp. 1279 – 96 . Google Scholar Crossref Search ADS WorldCat Benbenishty R. , Davidson-Arad B. , López M. , Devaney J. , Spratt T. , Koopmans C. , Knorth E. J. , Witteman C. L. M. , Del Valle J. F. , Hayes D. ( 2016 ) ‘ Decision making in child protection: An international comparative study on maltreatment substantiation, risk assessment and interventions recommendations, and the role of professionals’ child welfare attitudes ’, Child Abuse & Neglect , 49 , pp. 63 – 75 . Google Scholar Crossref Search ADS WorldCat Braun V. , Clarke V. , Terry G. ( 2015 ) ‘Thematic Analysis’, in Rohleder P. , Lyons A. (eds), Qualitative Research in Clinical and Health Psychology , Basingstoke , Palgrave McMillan . Google Preview WorldCat COPAC Bywaters P. ( 2015 ) ‘ Inequalities in child welfare: Towards a new policy, research and action agenda ’, The British Journal of Social Work , 45 ( 1 ), pp. 6 – 23 . Google Scholar Crossref Search ADS WorldCat Bywaters P. , Brady G. , Sparks T. , Bos E. , Bunting L. , Daniel B. , Featherstone B. , Morris K. , Scourfield J. ( 2015 ) ‘ Exploring inequities in child welfare and child protection services: Explaining the “inverse intervention law” ’, Children and Youth Services Review , 57 , pp. 98 – 105 . Google Scholar Crossref Search ADS WorldCat Doherty P. ( 2016 ) ‘Child protection threshold talk and ambivalent case formulations in ‘borderline’ care proceedings cases’, Qualitative Social Work , 16 ( 5 ), pp. 1 – 19 . doi: 10.1177/1473325016640062. WorldCat Falconer R. , Shardlow S. M. ( 2018 ) ‘ Comparing child protection decision-making in England and Finland: Supervised or supported judgement? ’, Journal of Social Work Practice , 32 ( 2 ), pp. 111 – 24 . Google Scholar Crossref Search ADS WorldCat Fluke J. , Baumann D. , Dalgleish L. , Kern H. D. ( 2014 ) ‘Decisions to protect children: A decision-making ecology’, in Korbin J. E. , Krugman R. D. (eds), Handbook of Child Maltreatment , Berlin , Springer , pp. 463 – 76 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Fluke J. D. , Corwin T. W. , Hollinshead D. M. , Maher E. J. ( 2016 ) ‘ Family preservation or child safety? Associations between child welfare workers' experience, position, and perspectives ’, Children and Youth Services Review , 69 , pp. 210 – 8 . Google Scholar Crossref Search ADS WorldCat Font S. A. , Maguire-Jack K. ( 2015 ) ‘ Decision-Making in Child Protective Services: Influences at Multiple Levels of the Social Ecology’, Child Abuse & Neglect 47 , 70 – 82 . Google Scholar Crossref Search ADS PubMed WorldCat Gilbert N. , Parton N. , Skivenes M. ( 2011 ) Child Protection Systems: International Trends and Orientations , Oxford , Oxford University Press . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Hester M. ( 2011 ) ‘ The three planet model: Towards an understanding of contradictions in approaches to women and children’s safety in contexts of domestic violence', British Journal of Social Work , 41 ( 5 ), pp. 837 – 53 . Google Scholar Crossref Search ADS WorldCat Hood R. , Goldacre A. , Gorin S. , Bywaters P. ( 2019 ) ‘ Screen, ration and churn: Demand management and the crisis in children’s social care ’, The British Journal of Social Work Advance Access published April 10, 2019, 10.1093/bjsw/bcz035. WorldCat Houston S. , Griffiths H. ( 2000 ) ‘Reflections on risk in child protection: is it time for a shift in paradigms?’ , Child and Family Social Work , 5 , pp. 1 – 10 . Google Scholar Crossref Search ADS WorldCat Keddell E. ( 2014 ) ‘ Current debates on variability in child welfare decision-making: A selected literature review ’, Social Sciences , 3 ( 4 ), pp. 916 – 40 . Google Scholar Crossref Search ADS WorldCat Keddell E. ( 2017a ) The Child Youth and Family Review: A Commentary on Prevention , Auckland , The Policy Observatory, AUT , available online at: https://thepolicyobservatory.aut.ac.nz/. Google Preview WorldCat COPAC Keddell E. ( 2017b ) ‘ Comparing risk-averse and risk-friendly practitioners in child welfare decision-making: A mixed methods study ’, Journal of Social Work Practice , 31 ( 4 ), pp. 411 – 29 . Google Scholar Crossref Search ADS WorldCat Keddell E. , Hyslop I. ( 2016 ) First Findings from Phase One of the Child Welfare Decision-Making Variability Project: Research Briefing Paper , Dunedin , University of Otago , available online at: http://hdl.handle.net/10523/8101. Google Preview WorldCat COPAC Keddell E. , Hyslop I. ( 2018 ) ‘ Role type, risk perceptions and judgements in child welfare: A mixed methods vignette study ’, Children and Youth Services Review , 87 , pp. 130 – 9 . Google Scholar Crossref Search ADS WorldCat Keddell E. , Hyslop I. ( 2019 ) ‘ Ethnic inequalities in child welfare: The role of practitioner risk perceptions ’, Child & Family Social Work , pp. 1 – 12 . Advance Access published January 15, 2019, doi: 10.1111/cfs.12620. WorldCat Leigh J. T. , Laing J. ( 2018 ) Thinking about Child Protection Practice , Bristol , Policy Press . Google Preview WorldCat COPAC Leigh J. T. , Beddoe E. , Keddell E. ( 2019 ) ‘ Disguised compliance or undisguised nonsense? A critical discourse analysis of compliance and resistance in social work practice ’, Families, Relationships and Societies Advance Access published May 28, 2019, 10.1332/204674319X15536730156921. WorldCat Klein G. , Hoffman R. R. ( 2008 ) ‘Macrocognition, mental models and cognitive task analysis’, in Schraagen J. M. , Millitello L. , Ormerod T. , Lipschitz R. (eds), Naturalistic Decision Making and Macrocognition , Hampshire , Ashgate . Google Preview WorldCat COPAC McLaughlin M. , Jonson-Reid M. ( 2017 ) ‘ The relationship between child welfare financing, screening, and substantiation ’, Children and Youth Services Review , 82 , pp. 407 – 12 . Google Scholar Crossref Search ADS WorldCat NZ Government. ( 1989 ) Oranga Tamariki Act. NZ Government. New Zealand, Parliamentary Counsel Office. Retrieved from http://www.legislation.govt.nz/act/public/1989/0024/latest/whole.html (accessed September 18, 2019). Oranga Tamariki ( 2019a ) ‘Practice Centre’, Oranga Tamariki, Ministry for Children, available online at: https://practice.orangatamariki.govt.nz/ (accessed August 1, 2019). Oranga Tamariki ( 2019b ) ‘Service pathways’, available online at: https://practice.orangatamariki.govt.nz/service-pathways/care-and-protection/care-and-protection-service-pathway-guidelines/ (accessed August 1, 2019). Parton N. ( 2014 ) The Politics of Child Protection: Contemporary Developments and Future Directions , Basingstoke , Palgrave Macmillan . Google Preview WorldCat COPAC Platt D. ( 2006 ) ‘ Threshold Decisions: How Social Workers Prioritise Referrals of Child Concern’, Child Abuse Review 15 ( 1 ), pp. 4 – 18 . Google Scholar Crossref Search ADS WorldCat Platt D. , Turney D. ( 2014 ) ‘ Making threshold decisions in child protection: A conceptual analysis ’, The British Journal of Social Work , 44 ( 6 ), pp. 1472 – 90 . Google Scholar Crossref Search ADS WorldCat Turnell A. , Edwards S. ( 1999 ) Signs of Safety: A Solution and Safety Oriented Approach to Child Protection Casework , London , W.W. Norton and Company . Google Preview WorldCat COPAC Webb S. ( 2006 ) Social Work in a Risk Society: Social and Political Perspectives , Basingstoke , Palgrave Macmillan . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC © The Author(s) 2019. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. 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