Welfare Professions as the Overlooked Actors of Welfare States

This blog is based on an article in the Journal of Social Policy by Kathrine Carstensen, Viola Burau, Hanne Marlene Dahl and Andreas Nielsen Hald. Click here to access the article.

The predominant view of welfare professions like social workers, nurses and teachers is that they are often on the receiving end of welfare reforms: they have to cope with changes in which they have little ownership. We fundamentally challenge this view in our newly published article.

We argue that welfare professions are central to welfare governance, understood as different ways of coordinating often complex and fragmented welfare services. Coordination is about ensuring that citizens receive the right welfare services when needed. This can be challenging when a range of welfare professions are involved, who work across different provider organisations and sectors. The welfare professions contribute to welfare governance by combining formal and informal coordination and by adjusting their coordination practices to the specific situations and needs at hand. Here, welfare professions draw on a unique set of resources grounded in their strong commitment to providing public services and to advancing professional development. 

The background to our study is that welfare governance in elderly care has undergone significant changes in recent decades. This reflects successive public management reforms inspired by New Public Management, with a focus on decentralisation, output controls and performance standards. And more recently New Public Governance, with a focus on collaboration, networking and co-production. The existing literature has tended to focus on mapping out governance arrangements and their effects on organisation of elder care services. However, we know little about how welfare professions themselves contribute to welfare governance.  

This is the springboard for our case study of elderly care in Denmark. Based on interviews and observations we analyse how welfare professions like nurses, physiotherapists, occupational therapists and care assistants contribute to welfare governance with the help of their professional practice. The case study is about the introduction of a care pathway in elderly care in the second largest municipality in Denmark, Aarhus. The Care Pathway standardises care into different packages with distinct milestones and builds on closer collaboration among professions across home care services, nursing homes and health care units.

Contributing to welfare governance is a highly complex task. Welfare professions have to translate the Care Pathway into everyday practice and coordinate the delivery of elderly care within the framework of the Care Pathway. This emerges as a skilful interplay between formal and informal coordination practices. Formal coordination practices relate to the structure of the Care Pathway and already existing platforms for communication such as meetings and their documentation system. For example, professionals emphasise how the case conferences built into the Care Pathway provide a space to create and follow up on care plans of elder people, and to coordinate on-going care activities. Likewise, professionals stress how the documentation system enables them to keep up to date with progress on individual care pathways and facilitates coordination among professionals.

Welfare professions supplement the formal practices with informal coordination practices in some situations. This is where the formal milestones of the Care Pathway require further support or where shortcomings occur. For example, professionals arrange informal meetings before and after case conferences to prepare for or evaluate the conferences. Professionals also sometimes put up posters in the office to supplement information in the documentation system and ensure follow up. Our analysis clearly shows that the ways in which the professions use informal practices strongly reflects their ability to vary and adjust routine actions according to specific circumstances or situations.

This ability rests on a set of unique resources welfare professions bring into play. Nurses, physio- and occupational therapists, care assistants and home helpers refer to a strong commitment to elder care as a public service. Examples include increased possibilities for ensuring continuity in individual care pathways and better opportunities for inter-professional working. This co-exists with an equally strong commitment to professional development. This centres around doing something for and working with the elder person, according to the distinct expertise of the specific professional group. For example, nurses stress that they contribute with a health professional perspective concerned with wound care, care plans and coordination of different tests.  

Across welfare services, welfare governance is marred with wicked problems that require building bridges across organisations and sectors. If welfare professions indeed are the overlooked actors of the welfare state as our study suggests, we need more research. This includes studies of welfare professions across a broader range of welfare services and countries. Future research also needs to examine the challenges welfare professions experience. Working with welfare governance is about handling highly complex demands and mediating between conflicting demands. As feminist scholars remind us, this work has a strongly gendered character. Research needs to consider how their gendered position in welfare states influences the conditions for welfare professions to contribute to welfare governance.  

About the authors

Kathrine Carstensen is PhD student at DEFACTUM, Public Health and Health Services Research and Aarhus University, Department of Public Health, Denmark. Her areas of research expertise are: Quality improvement in healthcare; implementation and organisation of healthcare services, reforms and policies; healthcare professions; and qualitative research. 

Viola Burau is Associate Professor at Aarhus University, Department of Public Health and Department of Political Science, Denmark. Her areas of research expertise are: health services organisation and change; healthcare professions, health governance, policy and reform; and cross-country comparison.

Hanne Marlene Dahl is Professor at Roskilde University, Department of Social Science and Business, Denmark. Her areas of research expertise are: Nordic welfare regimes and care, the governance of care, the relationship between welfare professions and the state – all from a gender perspective.  

Andreas Nielsen Hald is a PhD student at Aarhus University, Department of Public Health, Denmark. His areas of research expertise are: Organizational Sociology, Sociology of the Professions, implementation and sustainment of interventions in Integrated Care, and mixed-methods research.


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