The Policy Implementation Challenges of Individual Plans for Preschool Children with Disabilities.

This article presents findings from an investigation in southern Norway that sought to provide insight into diverse forms of collaboration on behalf of children with severe disabilities in preschool. The use of individual plans (IP) for preschool-age children is relatively new in Norway, and is being widely promoted as a tool for facilitating collaboration and support from multiple sectors. We employed a case study approach involving observations and semi-structured interviews with 5 members of the IP team supporting a 5 year-old girl with a severe disability. Using qualitative content analysis we determined relevant themes from transcribed interviews and field notes. Participants included the child's mother and father, preschool teacher, special educator, and the municipal public health nurse who also acted as the IP coordinator. We conclude that in its current form the IP in this case had little relevance for participants and did little to contribute to providing this child with the individually adapted support that the policy was intended to facilitate.


Introduction.
Norway has for many years had a wellestablished, extensive and integrated system of public education and health services for children and their families.For children between the ages of birth to 6 years, preschools play a key role in this system.The considerable and increasing relevance of early childhood education in the lives of young children and their families in Norway has grown substantially in recent years.One need only consider the fact that the population of children attending preschool increased from 60% in 2001 to 87% in 2008 (SSB, 2008).Over half of all preschools in Norway are publicly owned and cater to approximately 60% of children in this age group (OECD, 2001).Although the remaining preschools are privately operated, the services provided are largely equivalent, and both private and public preschools receive between 30% and 40% of their budget from government subsidies Correspondence concerning this article should be addressed to David L. Cameron, e-mail: david.l.cameron@uia.no(OECD).All preschools are required to collaborate with health and social service providers for supporting children and their families if the need arises.In the following section we provide a brief description of the Norwegian context with respect to the participation and support provided to children with disabilities who attend preschool.

Inclusive Ideals.
Preschool in Norway today is a natural part of ordinary life, a reflection of the values of the culture, and an essential means of maintaining and cultivating those values.These ideals are reflected in the guiding national policy for the operation of preschool (Rammeplan), wherein the following foundational principle is articulated, "Preschools shall promote fundamental values such as a sense of community, care for others and joint responsibility, and shall represent an environment that supports respect for human worth and the right to be different" (NMER, 2006, p. 7).This focus on the social aspect of childhood, the collective nature of society, and the recognition and acceptance of diversity is further emphasized via the promotion of what is often referred to as an 'ideology of inclusion' (Flem & Keller, 2001).While perhaps existing to a greater extent in policy than in practice, this ideology is espoused across all levels of education and social services.With respect to preschool, inclusion is named as an explicit educational objective in the national policy in accordance with the principle that education shall be individually adapted and equally accessible for all children, including children with special needs.Today there are approximately 3500 children (1.7%) in Norwegian preschools that receive special educational support (Solli, 2008).
Closely tied to the ideology of inclusion is the belief that preschools have an important responsibility to engage in a collaborative and supportive relationship with parents.This relationship is particularly emphasized where children with special needs are concerned.As the national curriculum for the operation of preschool states: "for these children, it may be necessary to provide individually adapted support.Adaptations may comprise social, educational and/or physical accommodations in the preschool.Parents and necessary support services around the child are important collaborative partners for the preschool" (NMER, 2006, p. 18).However, research suggests that everyday life in Norwegian preschool is often characterized by time pressures and strains on collaboration (Borg, Kristiansen & Backe-Hansen, 2008).Given these pressures, in recent years efforts have been made to promote the use of individual plans (IP) to facilitate collaboration on the part of children with special needs in preschool.
The Policy of Individual Plans.Many individuals with disabilities receive support from an assortment of professionals and agencies from a wide range of fields within their lifetimes.For young children with disabilities in Norway, the preschool period coincides with the family's introduction to a complex system of services, resources, and the laws and policies that sustain access to them.The use of individual plans (IP) is intended to facilitate this process by offering a tool for coordinating the multidisciplinary support that these children require.As a national policy, the right to an IP is guaranteed for "persons in need of long-term, coordinated support" (NDHSA, 2005, p. 11).The IP is intended to: (a) provide a holistic and individually adapted means of support, (b) specify the particular needs of the client and how these needs will be met, and (c) ensure that all services are evaluated on an on-going basis (NDHSA 2005).In Norwegian, the term 'responsibility group' (ansvarsgruppe) is used to refer to the members of the group (IP team) who together develop and implement the IP.Although this term is used in other contexts as well, it is particularly appropriate with respect to the IP, given the role of the IP team in identifying the persons responsible for important aspects of support and care.
As in many other countries, Norway also incorporates the use of individual education plans (IEP) for children receiving special education.Whereas the IEP is directed primarily at educational needs and is established in the Norwegian Education Act (NMER, 2009), the IP is anchored in laws pertaining to the health and social welfare sectors (e.g., NMHCS, 1999) and, as noted above, has an emphasis on the coordination of services across domains such as employment, health, education, social and family life.The legal distinction between these two policies demonstrates the importance that the healthcare system is intended to play with respect to the IP.Also in contrast to the IEP, the IP is not limited to use with children and adolescents.Yet, in recent years individual plans are increasingly being used as a policy-rooted instrument for supporting young children with extensive needs.Not surprisingly, for children under the age of 6, preschools play a central role with respect to the IP team's activities and the development and maintenance of the IP itself.

Rationale for the study.
Although the role of preschool in the lives of children with disabilities is a growing field of study on the international horizon, there is currently scant research concerning Norwegian preschools' work with children with special needs and their families (Hopperstad, Hellem & Kjørholt, 2005).In our review of the literature, we have found no previous investigations that have considered the use of individual plans for young children with special needs in Norway.As concerns have been raised regarding the use of individual plans in other contexts (Trefjord & Hatling, 2004), there is clearly a need for research in this field.This is particularly evident when one considers that this group of children is especially vulnerable: the decisions made on their behalf can have life-long consequences and the children themselves have little capacity to participate in the decision-making process.Moreover, as this period comprises families' introduction to the extensive social services system that they will be required to navigate for many years to come, it is important to find ways to deal with potential hindrances to future collaboration before they arise.
In contrast to research in the area of individual plans for preschool-age children, collaboration in general is a vast field of study.Some of the challenges to collaboration that have been documented in human services fields include differences in disciplinary approaches; tensions over different values, norms and motivations; and struggles over professional responsibilities, expertise, and standards of practice (Huxam & Vangen, 2000;Sandfort, 1999).Many of these problems will, of course, also be found where collaboration on behalf of children with disabilities in preschool is concerned.Whereas efforts to document and find solutions for these conflicts is an important area of research, a broader perspective that considers the local and national contexts of policy implementation is also necessary.This broader, macro-perspective is far less prevalent in the research literature (Sandfort, 1999).
The current study is part of a research project focusing on collaboration around children with disabilities in preschool in which we followed 6 families and their children over the course of an entire year.In this study, we present findings surrounding the meaning and use of the IP for participants in one of these six cases.The goal of the project is to gain knowledge about how preschools can contribute to developing positive forms of collaboration with the public health and welfare systems, and the child's home.As the IP is intended to be a holistic, interdisciplinary means of facilitating collaboration, we have chosen to apply a case study approach to examining the IP as a formal apparatus for creating and maintaining this type of support.

Theoretical Foundations of the Study.
Given that Norwegian law establishes the right to an IP and stipulates the goals and procedures inherent in that right, it is clear that an IP can be understood as a policy for which collaboration is a primary goal.It has been argued that policies to promote human service collaboration are largely symbolic and are adopted for political reasons rather than practical ones (Weiss, 1981).This sort of pessimism is perhaps warranted.The IP team that is formed during the implementation of the IP policy consists of a mixture of professionals from diverse fields, family members and, of course, the child whom the collaboration is intended to benefit.This new 'structure' gives rise to a need for the participants to negotiate their various roles, divide tasks, and establish jurisdiction over their particular fields of knowledge and expertise (Abbott, 1988;Willumsen & Skivenes, 2005).Although this new structure is constrained by several external forces (e.g., laws, resources, time), there is also a great deal of flexibility in arriving at decisions and in the actions that follow.Thus, the idea that this complexity can be facilitated through the use of a national policy is ambitious to say the least.
As a theoretical framework for this study, we apply Lipsky's (1980) conceptualization of streetlevel bureaucracy, which deals with the manner in which public policy is interpreted and implemented by the individual on the frontline of human service provision (i.e., street-level bureaucrats).The environment that frontline professionals occupy is, as Lipsky writes, "structured by common conditions that give rise to common patterns of practice and affect the direction these patterns take.At base it is the shared situational context of street-level work that permits generalization about these critical generic political and social roles and the operational policies to which they give rise" (1980, p. 27).To supplement this perspective, we consider two different interpretations of the patterns of collaboration, known as productoriented and integrated collaborations (John-Steiner, Weber, & Minnis, 1996) in our analysis of the meaning of the IP for participants.Our observations of the conditions and experiences of participants in this case have led us to consider these theoretical perspectives as both appropriate and fruitful means of explaining at least some of the many challenges that this particular IP team faced.

Case study.
We employed a case study approach involving semi-structured interviews and observation of 5 participants who have key roles in the life of a 5 year-old girl with a severe disability.Participants included the child's mother and father, preschool teacher, special educator, and the municipal health-nurse.The child was purposefully sampled (Patton, 2002) because of her need for long-term support from the social welfare system and her having an IP.As noted above, the case study we present in this article was selected from a larger project comprising six case studies.The goal of the project was to examine collaboration on behalf of children with special needs in six preschools across two municipalities in southern Norway.Families were invited to participate via the division of the local education agency that is responsible for coordinating special education services for this age group.Ethical guidelines were followed throughout the investigation, consent forms were signed by all participants beginning with the child's parents, and all identifying information was changed to protect their anonymity.The child herself was not directly observed and did not participate in interviews.
Anne, the 5 year old girl at the centre of this case, lives together with her parents and an older sister who is developing as expected for her age.Her mother has recently returned to work after several years being at home.Anne's father works in an industry where he spends several weeks away and then returns home for an extended leave.Anne experienced a number of health problems that required medical treatment as an infant.However, other than her disability her parents report that she is generally in good physical health today.She attends regular checkups with the public health nurse for the municipality, who is also the coordinator of Anne's IP.These check-ups occur at the same intervals as are provided to typically developing children of the same age.Anne began preschool at age 2 and attends for 6-7 hours a day, five days a week.Anne's preschool teacher and special educator work closely with Anne on a daily basis.

Interviews.
The interviews were semi-structured, comprising open-ended questions about broad themes.We developed an interview guide to ensure that the most important themes were covered during the interviews.Themes included: (a) the actors' different interpretations of the problems they faced, (b) challenges in maintaining positive collaboration, (c) relevance of informal as well as formal relationships, and (d) the preschools role in guiding this support.These themes were derived from a review of previous research and the researchers' professional experience working within the educational and psychological counselling services, preschools, and schools.We developed the interview guide over the course of several meetings.We discussed similar studies, examined possible theoretical models, and paid close attention to the goals of the project.
Epstein's (2001) model of collaboration was another important source of information in this endeavour.Once the first interview was conducted, we met again to discuss the content of the interview guide and revised our themes to ensure that we covered as many of the areas of interest as possible.It was also possible for the participants and researchers to explore themes not outlined in the interview guide.The overall aim of the interview process was to gain access to the participants' perspectives and to offer a chance for reflection, expansion and spontaneity.The IP team was observed during a one-hour meeting prior to the interviews.Much of the interview data reflected discussion surrounding this meeting.In addition, we maintained contact with participants throughout the study.In this manner, we were able to confirm our findings as they developed and clarify the issues that were of greatest concern for participants.

Analysis.
Interviews were audio-recorded and transcribed.Transcripts from interviews were analyzed using a computer based qualitative dataanalysis program (NVivo 7).For this study, we chose to analyze data across interview themes while focusing on aspects pertaining to participants' use and interpretation of the IP.First, an open coding process was conducted by the second author.Sequences of texts offering insights about collaboration with regard to the IP were identified and collated based on general events or ideas that were discussed during interviews.For example, groups of statements included information about starting work with the IP, the coordinator's role, and the IP meetings.Based on these groupings, the next step was a more detailed study of the text-sequences by clustering these into new, superior categories (Miles & Huberman, 1994).This portion of analysis was conducted by the first author.We then discussed these refined categories until we came to agreement on the meaning of themes and reorganized excerpts from the interviews accordingly.During the entire analysis process, we made an effort to focus on the quality of the statements made by participants, rather than the quantity of ideas presented (Patton, 2002).As is often the case in qualitative research, the puzzle became not what to include but what to exclude from the findings.Guiding these decisions was an effort to focus on information that could have the most practical relevance for participants and others going through similar experiences.
As argued by Kvale and Brinkmann (2009), the validity and reliability of an interview study rests on the quality of the researchers' craftsmanship throughout the investigation and on continuously checking, questioning and theorizing interpretations.In this study, we believe that the quality of our interpretations is strengthened by the fact that the design, analysis, interpretation, and discussion of data have been conducted by multiple researchers in collaboration.

Presentation and Discussion of Findings.
Three major themes relating to the use of the IP emerged from our analysis: (a) meaning of the IP, (b) coping with policy, and (c) shifting responsibility.In the following section we describe and interpret each of these themes in light of the theoretical framework described above.The first theme, 'meaning of the IP' was derived in large part from participants' responses to questions about the IP itself and collaboration in general.In the second section, 'coping with policy', we discuss findings related to the processes and frustrations surrounding creating, managing and putting the IP policy to use.In the final section, we examine the issue of 'shifting responsibility', which dealt with one particularly important aspect of the process of coping with the IP policy.That is, team members' apparent unwillingness to take ownership of certain tasks and their attempts to transfer responsibility to others or diminish the relevance of the task altogether.

Meaning of the IP.
When the IP coordinator was asked how she would describe successful collaboration, she replied, "It's certainly not what happens in relation to the IP."When asked specifically about the IP, she described it as a 'sleeping document', arguing, "I feel that for these small children, the IP is probably not so very important."The following excerpt from an interview with the coordinator further illustrates her attitude towards the use of individual plans for preschool children.

Coordinator: … I can see that it could be very useful when she is a little older.
Interviewer: How?
Coordinator: With the thought that one day she will go to life skills training, and could eventually have her own place to live.Just to function.Then, maybe … Interviewer: Mhm.
Coordinator: Because then it will be a whole new situation.
Interviewer: Yes, I see.
Coordinator: Then there'll be no one to watch her.But now she has a mother and father who can look after her.
This sentiment was also clearly communicated to the parents."She [the coordinator] thought that we shouldn't get it underway before Anne started school," recalled Anne's father, and continued, "She still has that opinion today... that we've pressured the municipality to start something that was totally unnecessary."The parents on the other hand, argued that they were hopeful that the IP could be of benefit, and believed that the impact of committing to the IP process now would be rewarded at a later date.However, they also indicated that the IP today was perhaps of limited relevance for Anne's development and the support that she received.
The father made this argument about the purpose of the IP: "It's there to put the wheels in motion, so that they are ready when she needs it."It is interesting that the parents and the coordinator, who had rather different opinions about the original need for the IP, drew similar conclusions about its value today.For example, whereas the coordinator stated, "I don't know ... had it been an IP that had been used," Anne's mother complained, "A plan is probably a good tool if it is used actively."However, the degree to which this particular plan was "used" seems fairly limited.As Anne's preschool teacher pointed out, "I looked at the IP at the meeting.It hasn't been updated in two years."Thus, while some participants believed that the IP could someday be of potential benefit to Anne if it were used, others failed to see the value in having an IP at all.In fact, all of the participants seemed to agree that it was of little relevance in its current state.Although there are many possible reasons as to why this might have been the case, a logical assumption is that for an IP to function well there should be a common belief among participants that it is needed in the first place.
Though comparatively few, participants in this study also saw some positive aspects of the IP process.For example, most team members agreed that the meetings that were held every 6 months were worthwhile.If and when progress was made, it was as a result of these meetings.Anne's special education teacher had this to say about the meetings, "How one feels after a meeting really comes down to the relationship one has with the parents... how well you work together with them, I think." John-Steiner, Weber, and Minnis (1996) describe two different patterns of collaboration: (a) product-oriented and (b) integrated collaborations.Whereas integrated collaboration focuses on process, dialogue, flexible roles and shared power among members; in productoriented collaboration participants roles are welldelineated and efficiency is a primary goal (John-Steiner, Weber, & Minnis).It seems that these meetings offered a sense of collaboration that is consistent with an integrated pattern of collaboration that is open to dialogue and shared roles.Indeed, as the public health nurse stated, "We can 'think together' there."However, while these integrated aspects of the collaboration were seen as positive by many in the group, not all team members were equally satisfied.
Anne's father argued, "Collaboration with other people doesn't have to be all that great... just as long as the results are what you want."In contrast to other participants' views about the meetings, this perspective could imply a productoriented pattern (John-Steiner, Weber, & Minnis, 1996).Anne's teacher offered a similar, though perhaps more nuanced conclusion, "Good collaboration, yeah... that you have a shared goal... that one is working from different sides towards the same goal.That is very important."In this particular case, this may have been an appropriate compromise.It is not merely agreement with respect to the child's needs and goals that was the ideal, rather it was a shared responsibility for reaching these goals while respecting that everyone is approaching this objective from "different sides".
Coping with policies.On the one hand, an IP is intended to be a tool for the collaborative, multidisciplinary provision of support to a person in need.On the other hand, it is an individual right specified in Norwegian law that is manifested in the form of a policy document.As with any social policy, it contains predetermined standards and procedures for use that may or may not be consistent with the goals and/or values of its users.Yet, it is the actual users at the frontline of practice (Lipsky, 1980), who are ultimately responsible for implementing the IP based on their own interpretations.These interpretations are naturally influenced by their individual goals and beliefs as well as the inherent constraints of the given circumstances.Often such "street-level bureaucrats" (Lipsky) knowingly take actions that are inconsistent with the goals or standards of the policy.Rather than simply following the policy of the IP when faced with constraints that were inconsistent with their beliefs, the participants in this study took one of the following actions: (a) adapted the policy to fit their interpretations, (b) directly ignored it, or (c) reluctantly accepted it -at times with visible frustration over the powerlessness they experienced in being unable to control its application.
There were several examples of how policy was adapted that came forth in the responses of participants.For example, whereas the legal guidelines for the IP state: "Development of the plan shall occur through a collaboration between different service providers and agencies" (NDHSA, 2005, p. 6), the coordinator confessed that she writes the actual IPs herself and then "sends them around for approval."The special educator made a similar comment with regard to Anne's IEP, "I'm the one who writes that.It says that I'm supposed to write it together with the educational and psychological services and the parents.I never do that."Oddly, this conclusion was not entirely accurate.Although IEPs are often used in preschool, Norwegian law does not guarantee preschool children with special needs the "right" to an IEP.Nonetheless, the special educator demonstrated with this statement that she was quite comfortable with adapting the policy to suit her individual and professional needs.A similar example was described by Anne's mother when the person in the municipality who was responsible for administering IP teams attended the meeting that we observed, "She showed up because of the project.She was there to show the ideal world."This finding, of course, also suggests a potential limitation with regard to our research affecting the actual IP team practice.
Beyond attending the meetings, there was also the expectation that participants would "know the child" better than they actually did -an assumption inherent in the objectives of the IP policy.For example, the guidelines for the individual plan state, "Collaboration between the service recipient and the coordinator contributes to at least one representative from the welfare system having a better and more complete understanding of the person's needs" (NDHSA, 2005, p. 23).Thus, it is assumed that the coordinator should have a holistic understanding of the child and his or her needs.The coordinator, for one, felt that this goal was unrealistic, "As a public health nurse, I have so many other tasks, that to go to the preschool to see how others work with her.I just don't have time for that."In this circumstance, the legal requirements are vague and it is the intention of the IP that seems to be violated, rather than the law itself.In other circumstances, the participants deliberately chose not to follow the legislative requirement.
In contrast to these situations, there were other instances in which the policy could not be easily adapted.Under these circumstances the participants' frustration with the loss of power they experienced was palpable and long-lasting.The most striking example of this involved an ongoing discussion about who should have held the role of coordinator for the IP.Although it is typically someone from the health or social services sectors that is given this role, the guidelines for implementation of the IP state, "the person for whom the plan is developed should be able to influence the choice of their own coordinator" (NDHSA, 2005, p. 23).Anne's parents felt that the IP process should have been led by someone from the preschool and, therefore, applied to the municipality for an exemption from the regular procedures placing this position in the hands of the public health nurse.Their application was denied, as the municipality was either unwilling or unable to redistribute the resources from one sector to another.The parents' frustration with this situation can be seen in their response to questions about the coordinator role and Anne's future transition to school.

Interviewer: How do you think it might have been different if the IP coordinator had been someone from the preschool? And when she begins with school? Do you have any thoughts about how that might be followed up?
Father: I'm really glad that you asked that!Of course we have our dreams.One issue is that there could have been a person that could have followed her up... someone who could be a help and support with the transition from preschool to the school system.That is the ideal world!Mother: But that's not the case.Father: It's not too much to hope for, though.
To complicate matters, the coordinator in this case was also aware that the parents had wanted someone from the preschool in the role of IP coordinator.Yet, it seems that while she was also frustrated by the situation, she had learned to passively accept it.
Interviewer: If you were to give any advice to others in your position, what do you think you would say to them?
Coordinator: Um… I think something about who the coordinator should be.When the preschool has most to do with the child, I think someone there should be the coordinator.
[…] Because it's easier for the parents to relate to them.They meet these people daily and I think if there's a problem then it's easier for them to deal with it.I think it's harder for the parents to call over here… and so what often happens is that things go on between the parents and the preschool and we sit on the sidelines.The important stuff happens between them.But for me, that's fine.I just deal with it.Lipsky (1980) concludes, "The decisions of street-level bureaucrats, the routines they establish, and the devices they invent to cope with uncertainties and work pressures, effectively become the public policies they carry out" (p.xii).When confronted with an inability to "invent devices," Anne's parents were left with no choice but to cope with the realities they faced.Although Anne's parents cannot be considered street-level bureaucrats in the same sense that frontline professionals like teachers or nurses might, the ideal of the IP policy is that they function as active participants in directing the provision of services for their daughter.However, when they were not able to control the manner in which the policy was implemented, they were forced to accept it.Similarly, the coordinator's reluctant acceptance of the situation suggests that she had also learned to cope with her role 'on the sidelines'.

Shifting Responsability.
The IP team, or as it is called in Norwegian, the 'responsibility group' has the important task of identifying specific persons or agencies responsible for providing support and ensuring that this support is provided appropriately.Our observations of this particular IP team revealed a frequent 'shifting' of responsibility that limited the degree to which tasks were completed or undertaken in the first place.For example, participants often talked about activities that they themselves were not involved in and therefore saw their own role as being of little importance.In addition, on several occasions participants described tasks as being minor concerns which could therefore be postponed to a later date.Discussions about the child's transition to school were frequently grouped in this category.In connection with the two previous sections, we found that the purposes and goals of this collaboration -and in large part the IP itself -were so ambiguous that participants found it difficult to translate them into achievable objectives, resulting in a general diffusion of the group's sense of responsibility and purpose.Each of these processes can be seen as both a means of 'coping with policy' as described above, and a reasonable question about one's ethical and professional responsibility towards the child and her family.
These processes represent a dilution or shifting of responsibility achieved in three basic ways: (a) shifting responsibility from one individual or group to another, (b) shifting responsibility to an indeterminate future, and (c) shifting responsibility from measurable objectives towards abstract goals or ideals.This last category is the most difficult to explain succinctly, partially because it comprises a less active process than the former two.It may help to consider that the movement towards 'abstraction' could alternatively be described as a failure to define goals as concrete and manageable objectives, which in turn would also be subject to the other two challenges of shifting responsibility.Although the reasons behind these processes are not immediately clear, it is helpful to consider this dilemma from the perspective of the frontline professional's challenge of interpreting and implementing public policy in practice.Lipsky (1980) suggests that the roles of streetlevel bureaucrats are "built upon two interrelated facets of their positions: relatively high degrees of discretion and relative autonomy from organizational authority" (p.13).Participants' substantial discretion and autonomy is certainly evident among the professionals involved in this study.However, not every decision they make is equally flexible and discretionary.Indeed, it is clear that many public service activities are 'programmatic' or conducted with little bureaucratic discretion.With respect to the IP, programmatic tasks include the group's regular meetings (twice per year), that there is a physical IP document that is written and maintained, that applications for resources follow a common set of procedures (NDHSA, 2005), and so forth.Interestingly, it is one of these non-discretionary activities (i.e., meetings) with which participants were most satisfied.Nonetheless, despite these and other examples, considerable discretion regarding how the IP was coordinated, as well as how programmatic tasks such as these were actually carried out, created a situation where the division of labour and distribution of responsibility was not entirely clear.One interpretation of this finding centres on a conflict of interest between the organization (i.e., the policy's administrative advocates) and the professional at the streetlevel.
Autonomy from authority creates difficulty when the interests of professionals differ from the higher levels of the organization: when workers do not consider their tasks "legitimate" they may choose any number of ways of resisting them, such as not working and/or holding negative attitudes such as apathy (Lipsky, 1980, p. 17).As findings described in the previous section indicate, we observed high levels of resistance on the part of the coordinator with respect to her responsibility for leading the IP team.
Coordinator: I see the plan as something more for the parents […] we haven't seen that there is so much we can do.
Interviewer: Mhm.Coordinator: …that they are... they are, of course, the client.It's the client's plan, if you want to put it that way.So, maybe the mother has been a bit interested in how it's set up and such.There are different formats for plans, and so they might all look a bit different.
When asked how she saw her own role as coordinator, she continued, "I'm not comfortable in the role at all.I feel a little like … had it been something in relation to health, then it would be different.But it's the preschool where most stuff happens."As described above, the coordinator agreed with the parents that it would have made more sense had someone from the preschool coordinated the IP team, "I don't understand why it has to be health services who should be the coordinators for the different children … if she had had lots of medications, or training or other things.I mean, if she had been sick..." The coordinator went on to stress her role with respect to the child's health, which included regular checkups, vaccines and care "as if she were any other child."Beyond these "health-related" tasks, she did not see her role as particularly important.
We interpret these and similar statements from the IP coordinator as indicating that she identified her professional role as being principally tied to health or medical concerns, and despite the fact that Anne had a disability, the challenges that she and her family faced were largely outside of the public health nurse's area of responsibility.From the coordinator's point of view, if Anne had only been more "sick" her professional interests would have been met.This conflict of interest was further exacerbated by the feeling that the role of coordinator had been forced upon the public health nurse in this case."Yes, we have to accept that we will have to take on some of this.But then it is also up to the municipality to accommodate with time to do it," she concluded.Thus, in this case it seems that there is a clear conflict of interest between those steering the IP policy (i.e., the municipality) and the workers responsible for implementing it.Given the complexities of multidisciplinary collaboration and the coordinator's high degree of individual discretion and autonomy, we conclude that these conflicts resulted in an unwillingness to engage in professional responsibilities connected to the IP and a subsequent stagnation of the collaborative process.
In a similar situation, Anne's mother expressed her frustration with what she perceived as an attempt to shift responsibility from one support organization to another.When asked about her feelings after the observed meeting, she stated, "I feel a little frustrated sometimes … that the health centre doesn't know whose responsibility it is.If it is the rehabilitation services [at the hospital] or if it is them."She continued, "The law is perfectly clear… and when the nurse and the doctor sit there and debate whether it is their responsibility, then I have to question the whole program."At another point in the interview she commented, "it seems like they just want to push everything uncomfortable over onto the rehabilitation centre."It is impossible for us to determine from the interviews whether actors in these different agencies were, in fact, attempting to transfer responsibility over to others.However, the parents' perception that those involved were unwilling to take responsibility for the tasks assigned them, was clearly just as damaging to the collaboration as any 'real' failure to fulfil their professional obligations.Lipsky (1980) points out that while discretion and autonomy may contribute to these types of conflicts, they are also important and necessary.This is because many situations are too complicated for simple programmatic solutions and workers must respond to many human dimensions of their jobs that require a great deal of flexibility."Street-level discretion promotes workers' self-regard and encourages clients to believe that workers hold the key to their wellbeing" (Lipsky, 1980, p. 15).In this case, Anne's parents did indeed appear to perceive the health service workers as 'holding the key' to Anne's well-being.In addition, these findings illustrate what happens when the client is unable to access the supports they believe they should be receiving.Anne's parents found themselves frustrated and blaming the 'key-holders' for not fulfilling their professional responsibilities.
A final issue regarding the theme of shifting responsibility concerns postponing action to a later date.This was most evident with regard to Anne's long-term goal of transition to school.Although many of the participants noted the importance of establishing early collaboration between the parents, the preschool and Anne's new school, it was common for participants to state their belief that this would eventually fall into place."I imagine next year … then we'll work more with the IP when it comes to school.That's when things start to happen", stated Anne's preschool teacher.The coordinator also noted: "So, when the parents have figured out what school she will go to … they'll contact the school so that the school will be clear that they are going to get a child who needs help and that will be followed up with a visit from the preschool," adding, "some of that will be taken care of by the educational psychological services."We can see from these responses a belief that the IP would someday become important.However, in the view of many participants, that time had not yet to come.Thus, they saw neither the necessity in taking a more active collaborative role, nor in assuming a greater responsibility for supporting this child.

Implications for Practice.
The guidelines for use of individual plans from the Directorate of Health state: "The plan document is not a goal in itself, but a tool for creating an adapted service" (2005, p. 28).Whereas all of the participants in this study would probably agree that the IP document was not the goal of their collaboration, there was considerable disagreement about what that goal actually was.In its current form, the IP in this case appeared to have little relevance for participants and, therefore, did not contribute a great deal to providing this 5 year-old child with the "adapted service" that it was intended to create.However, despite clear dissatisfaction with the manner in which the IP was used, there were aspects of the collaboration with which participants were satisfied.
For example, each of the participants noted the valuable exchange of information that the IP meetings generated.These meetings might therefore be a good starting point to improve the IP process and the relevance of the IP itself.Evidence suggests that improved communication can strengthen partnerships among families, teachers and communities (Swick, 2003).Thus, we wish to point out several themes that could be discussed within the context of IP meetings to improve collaboration among participants.First, it is important to note that discussions such as these require a clear understanding of how various themes are approached.One such process of communication is proposed by Habermas (1996) using the concept of deliberation.According to Habermas, the following components are necessary for the deliberative process: (a) all participants are recognized as equal contributors, (b) there is no coercion between actors, and (c) the discussion is a rational, argumentative process oriented towards consensus (p.305).Interactions in such a context represent a democratic process through which real-world practical conclusions can be reached and collaborative partnerships formed (Tveit & Walseth, 2011).
The results of this study suggest several themes that the IP team could seek to improve upon provided that the components listed above are in place.For example, our findings indicate that participants' belief in the utility of the IP is a major concern.For the IP process to function as it is intended, each of the team participants should ideally regard the IP as a meaningful tool for providing multi-disciplinary support.However, as Lipsky (1980) points out, frontline professionals do not always have faith in the quality of the policies that they are required to implement.In such instances, a first step may be to attempt to replace those members who have little faith in the prospects of the policy.Indeed, that is exactly what the parents in this study attempted to do with respect to the IP coordinator.However, when that effort was not successful, the family and other participants resigned themselves to a level of collaboration that can at best be described as 'procedural'.We propose that the potential of the IP team can be improved if the meaning and use of the IP itself is made the subject of deliberation in the early stages of the IP process.Although it may not be possible to reach consensus concerning the value of the IP, the actors may be able to reach consensus about their professional and personal obligations with respect to this process.
Second, when the implementation of a given policy is dramatically inconsistent with the policy itself -or even in complete discord with the legal rights of the parents -the discrepancy between policy and practice must be taken seriously by the professionals involved.Such a situation may even be avoided in the first place if routines are established within the IP team meetings for professionals to stipulate and clarify the parental rights in an open forum.Participants would then have an agreed upon starting point for cooperation as well as an extra mechanism for ensuring that the legal and policy guidelines are followed.
Our third recommendation concerns the issue of shifting responsibility from one actor or agency to another.Perhaps the most essential function that the IP is meant to serve is the coordination of the unique efforts of individuals with different knowledge, skills and expertise.Therefore, we recommend that themes discussed in the IP team meetings be transformed into explicit goals and objectives, rather than broad 'dreams' or 'visions' that are difficult to assess.Moreover, if the IP is to be used as an effective policy tool, it must clearly state who is responsible for following up each specific measure.The IP team meeting is certainly the place for determining these goals and objectives through the process of deliberation described above.
In this study, we observed participants who invented a range of devices for coping with the IP policy, which allowed them to avoid the task of truly working together.At the same time, when the parents were unable to influence the support provided to their daughter through the IP process, they experienced a loss of control, increased frustration, and their motivation to actively work towards better collaboration subsided.In summary, this case represents an IP that was more symbolic than substantive; where lack of use made it largely irrelevant, and where its subsequent lack of relevance meant that it was not likely to be used.