Social provision in the United States is highly decentralized. Significant federal and state funding flows to local organizational actors, who are granted discretion over how to allocate resources to people in need. In welfare states where many programs are underfunded and decoupled from local need, how does decentralization shape who gets what? This article identifies forces that shape how local actors classify help-seekers when they ration scarce resources, focusing on the case of prioritization in the Housing Choice Voucher Program. We use network methods to represent and analyze 1,398 local prioritization policies. Our results reveal two patterns that challenge expectations from past literature. First, we observe classificatory restraint, or many organizations choosing not to draw fine distinctions between applicants to prioritize. Second, when organizations do institute priority categories, policies often advantage applicants who are formally institutionally connected to the local community. Interviews with officials, in turn, reveal how prioritization schemes reflect housing agencies’ position within a matrix of intra-organizational, inter-organizational, and vertical forces that structure the meaning and cost of classifying help-seekers. These findings illustrate how local organizations’ use of classification to solve on-the-ground organizational problems and manage scarce resources can generate additional forms of exclusion.
OBJECTIVES:
There is little current research comparing stress, burnout, and resilience in pediatric and adult intensive care practitioners. This article analyzes data derived from a 2018 qualitative study of burnout and resilience among ICU providers to explore differences that may exist between the pediatric and adult domains of practice.
DESIGN:
This study represents a thematic subanalysis of textual data derived from a larger qualitative study of ICU provider burnout and resilience.
SETTING:
Six international critical care units (Australia, Israel, United States).
SUBJECTS:
Physicians working at the above sites who had been practicing as intensivists for a minimum period of 4 years.
INTERVENTIONS:
None.
MEASUREMENTS AND MAIN RESULTS:
Data were collected using a semistructured interview process, and resulting transcripts were analyzed using postpositivist framework analysis. A secondary analysis was then performed separately on pediatric and adult datasets using the initial coding framework as a template. Three themes related to perceived differences were noted: differences in the patient characteristics within both cohorts, differences in the relationships between staff and family, and personal biases of individual intensivists. Pediatric and adult practitioners differed in their perceptions of the patient’s perceived responsibility for their illness. Emotional responses to the stressor of child abuse (particularly as they related to clinician-family relationships) also differed. The stress of dealing with family expectations of patient survival even in dire circumstances was unique to the pediatric environment. Both pediatric and adult practitioners commented on the perceived difficulty of assuming the opposite role. Differences in life expectancy and mortality rate were significant factors in this.
CONCLUSIONS:
Although similar stressors exist within each group, meaningful differences in how these are perceived and personally processed by individual clinicians exist. Better understanding of these differences will assist attempts to enhance the resilience and provide career guidance to aspiring intensive care clinicians.
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