兒少保護服務歷程決策「失誤」？─第一線社工人員實務觀點

Abstract

近年來，重大兒少虐待事件的發生，一再挑戰兒少保護社工決策的品質，特別是當代社會工作實務界強調服務的責信，兒少保護系統所做的決策，可能影響兒少的生活福祉、家庭功能與關係，甚至威脅到兒少的生命安全，一旦「失誤」造成的結果重大，然另一方面，被指出發生「決策失誤」，同時帶給兒少保護社工難以承受之重，久而久之形成迴避與防衛的情況，更不讓人樂見，凸顯現今「決策失誤」的議題，需要由下而上地深入釐清與探討實務工作者的觀點，尋找發生「失誤」的脈絡，進一步發展解決兒少保護系統性問題的策略。 回顧1970年代以來，兒少保護服務持續朝向高度結構化的方向發展，每個重要工作階段都有對應的決策點與輔助工具，也開始從嚴重兒虐案例中摸索「決策失誤」的軌跡，不管是嘗試去定義「決策失誤」，或是從社工個人，擴展到服務資源、評估工具，以及現行組織政策與文化、服務模式等面向去分析造成「失誤」發生的因素與除錯策略，都顯示兒少保護「決策失誤」的脈絡富含系統性的思維。 為了釐清我國兒少保護「決策失誤」的脈絡，本研究採取質化分析研究取向，並以「訪談法」來蒐集相關資訊，透過兩階段個別訪談第一線兒少保護社工人員，再從個別訪談資訊中萃取可以再深入討論的議題，納入第二階段焦點團體訪談兒少保護督導，重點發現如下： 一、多數實務工作者同意「決策失誤」的存在，但認為「決策失誤」不等於「處遇失敗」，是指在當下依據能蒐集到的資訊，可以做出更好的決策；且內部組織認定的「決策失誤」，造成的影響與傷害，更甚外部機關。 二、造成兒少保護「決策失誤」的發生因素橫跨個案、組織、政策制度及社工本身因素等面向， 改善「決策失誤」的策略也應富含多面向的系統性思維。 綜整前述研究發現，研究者建議未來兒少保護服務系統應：發展兒少保護「知錯、容錯、認錯、除錯」的嶄新機制與風氣、政策發展必須圍繞核心工作職能、完善組織社工與督導的培訓與養成系統、強化兒少保護的跨系統與跨轄合作。從政策制度、組織風氣、專業訓練、人員養成等不同層面精進兒少保護工作，以降低「決策失誤」的發生，也讓「決策失誤」的經驗成為實務工作者寶貴的教材。

In recent years, the occurrence of serious child abuse incident has challenged child protection workers’ quality repeatedly. Especially contemporary social work practice emphasizes accountability of service, the decision of CPS would influence the child’s long-term welfare, the household function, relationship and even threaten the safety of child. Once “decision error” were made, it may cause serious consequences. On the other hand, being accused of happening “decision error” brings CPS workers unbearable weight. Over time, CPS workers will be starting to avoid the problem and defend their own title. It is the last thing everyone wants. Therefore, it is important to clarify and explore the error of personal and system context from the bottom to the top, seeking the crux of the occurrences of error and develop strategies to solve the systematic problems of CPS. CPS has been developing toward high-professional and structured since 1970s. Every important working stage has correspondent decision points and assistant tools. Besides, CPS field is devoted to finding the track of “decision error” from severe child abuse fatal cases. Regardless of trying to define “decision error”, or analyzing the cause and debugging strategy of “error” from the aspects of CPS worker, service resource, assessment tool, present organizational policy, culture, service model, these things display that CPS “decision error” context are filled with systematic thought. To clarify CPS “decision error” context of our country, this study adopts “grounded theory” of “qualitative research method” and collects information through “interview method.” The interview will be divided into two stages. The first stage is to interview the frontline CPS workers individually. Then, extract the issues which are worthy for further discussion. The second stage will discuss those issues in a focus group which contains senior CPS workers and supervisors. The important findings are as below: 1.Most of the practical workers agree the existence of “decision error”, but think that “decision error” doesn’t equal to “treatment with failure”. They think that “decision error” refers that it can be done better decision according to the information, and“decision error” defined by internal organization results in the influence and hurt which is more serious than external agency did. 2.The causes of “decision error” includes many aspects of case, organization, policy and CPS workers. The improvement strategies should also fill with multi-aspect systematic thought. To sum up, researcher advise CPS system should reorganize and focus on the core competency of CPS worker, create the open atmosphere of the organization to review and discuss the “error”, complete the organization training and cultivate system for CPS workers and supervisors, strengthening the multi-system and multi-jurisdiction collaboration of CPS in the future. To improve CPS work from policy system, organizational atmosphere, personnel cultivation and other different aspects, it will not only reduce “decision error” from happening but also make the experience of “decision error” become the precious teaching materials for CPS workers.