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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
A Systems Approach to the Provision of Social Work Services in Health Settings Martin Nacman DSW
a
a
Director, Social Work Division, Strong Memorial Hospital, Rochester, NY 14642 Published online: 26 Oct 2008.
To cite this article: Martin Nacman DSW (1975) A Systems Approach to the Provision of Social Work Services in Health Settings, Social Work in Health Care, 1:1, 47-53, DOI: 10.1300/J010v01n01_07 To link to this article: http://dx.doi.org/10.1300/J010v01n01_07
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
A SYSTEMS APPROACH TO THE PROVISION OF SOCIAL WORK SERVICES IN HEALTH SETTINGS: PART 1
Downloaded by [UQ Library] at 07:42 29 April 2015
Martin Nacman, DSW
ABSTRACT. This paper, the first of a two-part presentation, offers a sociological view o f the hospital as an institution within the economic, political, and value systems o f the community. Systems theory is ihe conceptual framework for projecting the potential role o f the social worker in the health setting. Part 2, in the next issue, will deal with impediments and barriers to effective social work in hospilals as well as solution finding based on systems work in combination with direct service skills.
THE HOSPITAL WITHIN THE LARGER COMMUNITY
Systems theory offers a conceptual framework for discussing the potential role of the social worker in the health care setting. The hospital is a social system that depends on important sectors of its external environment as well as its own internal structure to produce useful services. Along with other complex organizations, the hospital is dependent upon powerful economic and political forces and events (e.g., legislative acts, insurance company policies) as well as private benevolence for the procurement of land, labor, and capital. These resources, once provided, are the factors of production. They are mobilized by the establishment of a formal organizational structure that systematically delineates a pattern of coordination, the ordering of positions and duties, and the chain of command. This results in the integration of various specialized resources and functions.' It is crucial to note that both within and outside of the organization, policy decisions that lay down the nature of the program and the differential allocation of resources are determined by administrative, Dr. Nacman is Director, Social Work Division, Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New Y o r k 14642.This is Part 1 o f a two-part article. Social Work in Health Care,V o l . 1(1), Fall 1975
47
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
medical, and board elite. These decisions are not necessarily reached by a completely rational process; they are nearly always influenced by the value judgments and personal sentiments of these powerful figures. It should be noted, too, that once a formal organization is established the informal social structure formed within that system creates an ambience of its own, which in turn influences the formal structure. As a social system the hospital must provide appropriate inducements t o staff and patients t o obtain cooperation. To survive, the formal organization must accommodate itself t o the needs of patients and staff, who themselves have rights and prerogatives of their own. Disregard of these considerations is a source of conflict and tension within hospital organizations as well as between the organizations and the community. A break in the continued striving for adjustment between the formal and informal structure imperils the effectiveness and/or efficiency of the organization. The organization must provide a climate that will motivate both patients and staff t o participate in organizational activities and will encourage effective and efficient utilization of r e s o ~ r c e s . ~
A SYSTEMS APPROACH Within this systems theory framework both the social worker and the patient are viewed as being influenced by powerful forces operating within and outside the health organization. At the same time, but t o a lesser degree, the patient and the social worker, as well as other staff members, influence the organization and determine the effectiveness and efficiency t o be reached. But since health programs are carried out within bureaucratic organizations, the essential mode of power is exercised through a hierarchical power structure that places authority in a select elite and limits the attainable influence of lower ranked personnel. The establishment and development of a social work program within a given health organization is therefore influenced by the policies formulated by political, economic, and professional elite, both governmental and private, who influence national health policies and those who supervise and control a specific health institution. Initially, social work controls no resources and has no legal authority within the setting except in those programs where social sewice is explicitly mandated by payment sources or accreditation requirements. The number of social work department staff hired, the qualifications of these staff members, the nature and extent of the propam to be developed, and the relationship of the social work program t o other hospital programs are strongly influenced by the value judgments of lay w d medical administrators who determine the organization's basic commitment to psychosocial treatment and their acceptance of nonmedical practitioners. This state
Downloaded by [UQ Library] at 07:42 29 April 2015
of affairs has resulted in much frustration for social workers but also a serendipitous gain. It offers incentive for social workers t o acquire an understanding of the politics of the organizations in which they work and to learn how to deal with the system. The patient also is influenced by internal and external factorscommunity, family, intrapsychic, and organizational-and the dynamic interaction of these factors. The social worker is therefore compelled to consider all of these factors, and not one to the exclusion of the others. Direct casework or group work sewices with respect t o interactional aspects of the patient's situation present one entry point. But in addition, intervention with reference t o intraorganizational and interorganizational variables that impinge upon the patients' access to and utilization of health care sewices is equally important. ~ a n contends a ~ that the social worker's relationship with the client population should be viewed as a longitudinal process. Social work services should be directed toward the establishment and maintenance of conditions that produce optimum social health, as a means of preventing dysfunctioning while providing for the treatment of disease when it occurs. ~ a h embraces n ~ the same idea when he recommends that, in addition , t o clinical sewices, social work should develop input into health and welfare planning oriented toward ameliorating those institutional problems and restraints that deprive the individual of the opportunity t o achieve and maintain his maximum level of health. Kahn emphasizes that social work will perform its advocacy role more effectively when the profession establishes a leadership position at the corporate management level and participates in political and planning processes that have the potential for change and innovation. The handling of child abuse or neglect cases offers an excellent example that the social worker has t o apply a systems approach to practice that recognizes the interrelatedness of emotional, social, and physical factors and the significance of organizational procedures and policies. In situations involving child abuse or neglect the social worker is required to operate within at least four subsystems: the hospital, the family, the protective unit, and the court. Anticipatory planning is essential. In recognition of the occurrence of child abuse problems, hospital staff should devise a comprehensive plan that covers both immediate and long-range services. The social worker may serve as both catalyst and coordinator of the program. However, the formation of this program requires joint planning by hospital administration, medical, social work, and nursing staff in combination, and the delineatior? of the special roles of each participant. It is significant that in emergency room departments, where many child abuse cases are first identified, horizontal, interdepartmental working relationships are operative more frequently than elsewhere in the hospital where traditional verti-
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
cal departmental boundaries persist. Immediate services include: (a) medical care; (b) documentation of the injury; (c) casework and, if needed, psychiatric services t o help the parents and the child with their emotional responses to the situation; and, finally, (d) procedures for reporting the situation to the proper legal authorities. The establishment of a positive relationship between social worker and family is seen as an extremely important part of a long-range program t o prevent further abuse of the identified child, and other children. On the other hand, court action may be required t o safeguard the child's life. In complex situations this process may require several months of direct service in the family as well as continued collaborative effort with other community agencies. Social work involvement goes beyond the provision of direct service to the family, to encompass planning with the local protective organization, the court, and other essential community agencies. An appropriate anticipatory program includes prior arrangements with these organizations in order to coordinate and facilitate activities. When community services are inadequate or lacking, the hospital social worker becomes responsible for taking action directly or through community groups t o improve existing programs or t o help create new resources. This commitment may require the formation of coalitions with other interested parties, who share the same concerns. These may be lay and professional, in and out of the hospital. For example, in Rochester, a coalition has been formed among various agencies concerned with child protection. This group serves t o foster collaboration and advocates in behalf of the abused and neglected child. Social work is, therefore, concerned with the family, the hospital organization, home care services, the judicial and protective system of the community, because all of these elements influence the treatment of the abused child and the prevention of further abuse. And at the other end of the continuum social work services in a well-baby clinic may offer some possibility for preventing child abuse and neglect. The systems approach being described departs from the traditional casework orientation that has been the historic thrust of hospital social work. In contrast, the emphasis is on a developmental approach stressing both organizational and community change progams geared toward preventive interventions. These intra- and interorganizational change programs are directed t o w a d the elimination of physical, operational, and attitudinal pathologies. A commitment t o institutional change and social reform, in addition t o direct clinical services, offers social work a substantially greater opportunity to provide constructive assistance for the hospital and t o expand opportunities for patients. To achieve these goals social work programs should include community organization and administrative staff who can devote the necessary time LO changing outdated and obstructive health and welfare policies and rectify organ-
Downloaded by [UQ Library] at 07:42 29 April 2015
Martin Nacman
izational pathologies, since in the long run this action may at times be more relevant than direct patient services. However, Gilbert and SpechtS point out that it is unlikely that one social worker can be expert both in direct patient services and in organizational and community change strategies. Both types of expertise are necessary, but how this mix of abilities will be developed is variable depending on the size of the department, as well as skill versatility. The important theoretical point is the delineation of needed practice components. It is impractical t o assume that most caseworkers are inclined, or trained, to assume direct responsibility for community or institutional change programs. Defined in these terms, a hospital social work staff needs not only competent direct service capability but also expertise in administration, organizational theory, social planning, and community organization. These areas of expertise are currently being instilled as part of graduate and postmaster's degree programs in schools of social work. The direct service and social action efforts require close linkage so as to maximize communication and collaboration. Patient problems, identified by direct service workers, may become the potential focus for organizational and community activities which are the responsibilities of staff trained in these areas. The reverse also applies. Problems identified by administrative and community personnel may require the attention of direct service workers. The proposed model does not require that every caseworker and group worker become expert in these other methods, although some may. What is suggested is awareness of these approaches and access t o other staff and community workers with competence in these techniques. This task cannot be undertaken lightly. The clinical service worker needs the skill t o identify institutional and environmental problems that contribute to the dysfunctioning of the individual patient or family. Even if social action is alien t o the clinical social worker, that professional must be astute t o the nature of systems as well as psychic problems. He should not be content t o help clients adjust t o destructive forces that are possibly alterable. Responsibility for needed change in administrative and/or social policy must be shared by all social workers. Within recent history hospital social work has often failed to focus on social and organizational pathologies. This has seriously limited its development as a unique helping profession and its potential for helping patients and their families. The preoccupation with the intrapsychic gave the impression that social work was not interested in organizational and environmental matters, and too often the social worker has been excluded from intraorganizational power groups that are responsible for setting hospital policies and procedures. The absence of a true disciplinary peer status has resulted in vulnerability t o domination by lay and medical administration functionaries. The practice of casework became so narrowly defined as t o exclude
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
significant involvement in social and organizational change, which could have represented a unique contribution of the social work profession. Over time the hospital social worker lost relevant contact with consumers and their communities. They rationalized their lack of involvement in social intervention by pointing to their contact with a select group of other professionals who worked in community agencies. Social workers were reluctant and afraid t o enter the "power arena" of the hospital or the community. In instances in which social workers were interested in social change, they rarely focused on the organizational structure of the health institution in which they were employed. Social work along with other subgroups within the hospital system is governed by forces that counteract centrifugal pull. Inducements are provided to those who conform t o the image of the organization depicted by organizational elite. ~ i l l has s ~ pointed out that employees of large bureaucratic organizations sell not only their time and energy but their personalities and prerogatives as well. Once joined to the organization, the social worker is expected, within limits, to behave according t o orders and instructions supplied to him by the organization's elite, physicians, and lay administrators. This system produces little conflict or anxiety for the social worker, providing that the institutional mores, the ethical structure, the program orientation, and degree of autonomy sanctioned are essentially in agreement with those of the social work profession. When there is variance between the values and rules sanctioned by the profession and those allowed by the institution, the social worker is under stress. The impersonalization, and hierarchical power structure of organizations, often results in an alienated labor force. Coser's7 study of nurses in a general hospital demonstrated that they became alienated because they felt powerless t o implement significant goals. Traditionally, within health organizations the right to exercise professional judgments has been rigorously limited for anyone other than the physician. This condition restricts the professional prerogatives of the social worker as well as other professionals who practice in these settings. Major rewards, salaries, extra benefits and the availability of scarce resources, office space, and equipment may be implicitly related to the acceptance of an institutionally self-sewing role. In the event that the professional orientation of the social worker comes into conflict with the prevailing orientation of organizational elite, the worker is expected to yield his position to avoid conflict. Under these conditions it is extremely difficult for social workers to fulfill their role as advocates or engage in activities directed toward organizational change. T'itmus8 refers to the social worker as a prisoner of the collective status quo of the organization. In his study of an eastern hospital, Wessen9 found the ideology of
Martin Nacman
Downloaded by [UQ Library] at 07:42 29 April 2015
physicians to be conservative. They viewed the hospital primarily from the angle of their professional needs and tended to resist new developments and trends. The limited definition of the social work role by hospital elite and the conservatism of medical administration influence the choice of social work leadership. Recruitment may be biased in favor of a social work administrator with a conservative orientation, in an attempt to preserve the status quo of the organization. If, however, the mandate is broad enough t o permit the exercise of an expanded repertoire of skills, social work offers hospital and medical administrators additional expertise that may be utilized as part of a joint effort to improve patient services and community relations.
(To be continued in the next issue) REFERENCES 1. Parsons, Talcott. "Suggestions for a Sociological Approach t o the Theory of Organizations." In Complex Organizalions, edited by Amitai Etzioni. New York: Holt, Rinehart & Winston, 1962. 2. Coser, R. L. "Alienation and the Social Structure." In The Hospital in Modern Society, edited by E. Freidson. New York: Free Press of Glencoe, 1963. 3. Dana, Bess. "Social Work in the University Medical Center." Johns Hopkins Medical Journal 1 2 4 (1969):277-82. 4. Kahn, Alfred J. "Theory and Practice of Social Planning." New York: Russell Sage Foundation, 1969. 5. Gilbert, Neil, and Specht, Harry. "The Incomplete Profession: Commitment to Welfare." Paper read a t the Annual Meeting of the Council on Social Work Education, February 23, 1973, San Francisco, California. 6. Mills, C. W. White Collar. New York: Oxford University Press, 1951. 7. Coser, R. L. "Authority and Decision Making in a Hospital: A Comparative Analysis." American Sociological Review, no. 23 (1958), pp. 56-63. 8. Titmus, Richard. Commitment to Welfare. New York: Pantheon Books, 1968. 9. Wessen, A. F . "Hospital Ideology and Communication between Ward Personnel." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958.
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
A Systems Approach to the Provision of Social Work Services in Health Settings Martin Nacman DSW
a
a
Director, Social Work Division, Strong Memorial Hospital, Rochester, NY 14642 Published online: 26 Oct 2008.
To cite this article: Martin Nacman DSW (1975) A Systems Approach to the Provision of Social Work Services in Health Settings, Social Work in Health Care, 1:1, 47-53, DOI: 10.1300/J010v01n01_07 To link to this article: http://dx.doi.org/10.1300/J010v01n01_07
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
A SYSTEMS APPROACH TO THE PROVISION OF SOCIAL WORK SERVICES IN HEALTH SETTINGS: PART 1
Downloaded by [UQ Library] at 07:42 29 April 2015
Martin Nacman, DSW
ABSTRACT. This paper, the first of a two-part presentation, offers a sociological view o f the hospital as an institution within the economic, political, and value systems o f the community. Systems theory is ihe conceptual framework for projecting the potential role o f the social worker in the health setting. Part 2, in the next issue, will deal with impediments and barriers to effective social work in hospilals as well as solution finding based on systems work in combination with direct service skills.
THE HOSPITAL WITHIN THE LARGER COMMUNITY
Systems theory offers a conceptual framework for discussing the potential role of the social worker in the health care setting. The hospital is a social system that depends on important sectors of its external environment as well as its own internal structure to produce useful services. Along with other complex organizations, the hospital is dependent upon powerful economic and political forces and events (e.g., legislative acts, insurance company policies) as well as private benevolence for the procurement of land, labor, and capital. These resources, once provided, are the factors of production. They are mobilized by the establishment of a formal organizational structure that systematically delineates a pattern of coordination, the ordering of positions and duties, and the chain of command. This results in the integration of various specialized resources and functions.' It is crucial to note that both within and outside of the organization, policy decisions that lay down the nature of the program and the differential allocation of resources are determined by administrative, Dr. Nacman is Director, Social Work Division, Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New Y o r k 14642.This is Part 1 o f a two-part article. Social Work in Health Care,V o l . 1(1), Fall 1975
47
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
medical, and board elite. These decisions are not necessarily reached by a completely rational process; they are nearly always influenced by the value judgments and personal sentiments of these powerful figures. It should be noted, too, that once a formal organization is established the informal social structure formed within that system creates an ambience of its own, which in turn influences the formal structure. As a social system the hospital must provide appropriate inducements t o staff and patients t o obtain cooperation. To survive, the formal organization must accommodate itself t o the needs of patients and staff, who themselves have rights and prerogatives of their own. Disregard of these considerations is a source of conflict and tension within hospital organizations as well as between the organizations and the community. A break in the continued striving for adjustment between the formal and informal structure imperils the effectiveness and/or efficiency of the organization. The organization must provide a climate that will motivate both patients and staff t o participate in organizational activities and will encourage effective and efficient utilization of r e s o ~ r c e s . ~
A SYSTEMS APPROACH Within this systems theory framework both the social worker and the patient are viewed as being influenced by powerful forces operating within and outside the health organization. At the same time, but t o a lesser degree, the patient and the social worker, as well as other staff members, influence the organization and determine the effectiveness and efficiency t o be reached. But since health programs are carried out within bureaucratic organizations, the essential mode of power is exercised through a hierarchical power structure that places authority in a select elite and limits the attainable influence of lower ranked personnel. The establishment and development of a social work program within a given health organization is therefore influenced by the policies formulated by political, economic, and professional elite, both governmental and private, who influence national health policies and those who supervise and control a specific health institution. Initially, social work controls no resources and has no legal authority within the setting except in those programs where social sewice is explicitly mandated by payment sources or accreditation requirements. The number of social work department staff hired, the qualifications of these staff members, the nature and extent of the propam to be developed, and the relationship of the social work program t o other hospital programs are strongly influenced by the value judgments of lay w d medical administrators who determine the organization's basic commitment to psychosocial treatment and their acceptance of nonmedical practitioners. This state
Downloaded by [UQ Library] at 07:42 29 April 2015
of affairs has resulted in much frustration for social workers but also a serendipitous gain. It offers incentive for social workers t o acquire an understanding of the politics of the organizations in which they work and to learn how to deal with the system. The patient also is influenced by internal and external factorscommunity, family, intrapsychic, and organizational-and the dynamic interaction of these factors. The social worker is therefore compelled to consider all of these factors, and not one to the exclusion of the others. Direct casework or group work sewices with respect t o interactional aspects of the patient's situation present one entry point. But in addition, intervention with reference t o intraorganizational and interorganizational variables that impinge upon the patients' access to and utilization of health care sewices is equally important. ~ a n contends a ~ that the social worker's relationship with the client population should be viewed as a longitudinal process. Social work services should be directed toward the establishment and maintenance of conditions that produce optimum social health, as a means of preventing dysfunctioning while providing for the treatment of disease when it occurs. ~ a h embraces n ~ the same idea when he recommends that, in addition , t o clinical sewices, social work should develop input into health and welfare planning oriented toward ameliorating those institutional problems and restraints that deprive the individual of the opportunity t o achieve and maintain his maximum level of health. Kahn emphasizes that social work will perform its advocacy role more effectively when the profession establishes a leadership position at the corporate management level and participates in political and planning processes that have the potential for change and innovation. The handling of child abuse or neglect cases offers an excellent example that the social worker has t o apply a systems approach to practice that recognizes the interrelatedness of emotional, social, and physical factors and the significance of organizational procedures and policies. In situations involving child abuse or neglect the social worker is required to operate within at least four subsystems: the hospital, the family, the protective unit, and the court. Anticipatory planning is essential. In recognition of the occurrence of child abuse problems, hospital staff should devise a comprehensive plan that covers both immediate and long-range services. The social worker may serve as both catalyst and coordinator of the program. However, the formation of this program requires joint planning by hospital administration, medical, social work, and nursing staff in combination, and the delineatior? of the special roles of each participant. It is significant that in emergency room departments, where many child abuse cases are first identified, horizontal, interdepartmental working relationships are operative more frequently than elsewhere in the hospital where traditional verti-
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
cal departmental boundaries persist. Immediate services include: (a) medical care; (b) documentation of the injury; (c) casework and, if needed, psychiatric services t o help the parents and the child with their emotional responses to the situation; and, finally, (d) procedures for reporting the situation to the proper legal authorities. The establishment of a positive relationship between social worker and family is seen as an extremely important part of a long-range program t o prevent further abuse of the identified child, and other children. On the other hand, court action may be required t o safeguard the child's life. In complex situations this process may require several months of direct service in the family as well as continued collaborative effort with other community agencies. Social work involvement goes beyond the provision of direct service to the family, to encompass planning with the local protective organization, the court, and other essential community agencies. An appropriate anticipatory program includes prior arrangements with these organizations in order to coordinate and facilitate activities. When community services are inadequate or lacking, the hospital social worker becomes responsible for taking action directly or through community groups t o improve existing programs or t o help create new resources. This commitment may require the formation of coalitions with other interested parties, who share the same concerns. These may be lay and professional, in and out of the hospital. For example, in Rochester, a coalition has been formed among various agencies concerned with child protection. This group serves t o foster collaboration and advocates in behalf of the abused and neglected child. Social work is, therefore, concerned with the family, the hospital organization, home care services, the judicial and protective system of the community, because all of these elements influence the treatment of the abused child and the prevention of further abuse. And at the other end of the continuum social work services in a well-baby clinic may offer some possibility for preventing child abuse and neglect. The systems approach being described departs from the traditional casework orientation that has been the historic thrust of hospital social work. In contrast, the emphasis is on a developmental approach stressing both organizational and community change progams geared toward preventive interventions. These intra- and interorganizational change programs are directed t o w a d the elimination of physical, operational, and attitudinal pathologies. A commitment t o institutional change and social reform, in addition t o direct clinical services, offers social work a substantially greater opportunity to provide constructive assistance for the hospital and t o expand opportunities for patients. To achieve these goals social work programs should include community organization and administrative staff who can devote the necessary time LO changing outdated and obstructive health and welfare policies and rectify organ-
Downloaded by [UQ Library] at 07:42 29 April 2015
Martin Nacman
izational pathologies, since in the long run this action may at times be more relevant than direct patient services. However, Gilbert and SpechtS point out that it is unlikely that one social worker can be expert both in direct patient services and in organizational and community change strategies. Both types of expertise are necessary, but how this mix of abilities will be developed is variable depending on the size of the department, as well as skill versatility. The important theoretical point is the delineation of needed practice components. It is impractical t o assume that most caseworkers are inclined, or trained, to assume direct responsibility for community or institutional change programs. Defined in these terms, a hospital social work staff needs not only competent direct service capability but also expertise in administration, organizational theory, social planning, and community organization. These areas of expertise are currently being instilled as part of graduate and postmaster's degree programs in schools of social work. The direct service and social action efforts require close linkage so as to maximize communication and collaboration. Patient problems, identified by direct service workers, may become the potential focus for organizational and community activities which are the responsibilities of staff trained in these areas. The reverse also applies. Problems identified by administrative and community personnel may require the attention of direct service workers. The proposed model does not require that every caseworker and group worker become expert in these other methods, although some may. What is suggested is awareness of these approaches and access t o other staff and community workers with competence in these techniques. This task cannot be undertaken lightly. The clinical service worker needs the skill t o identify institutional and environmental problems that contribute to the dysfunctioning of the individual patient or family. Even if social action is alien t o the clinical social worker, that professional must be astute t o the nature of systems as well as psychic problems. He should not be content t o help clients adjust t o destructive forces that are possibly alterable. Responsibility for needed change in administrative and/or social policy must be shared by all social workers. Within recent history hospital social work has often failed to focus on social and organizational pathologies. This has seriously limited its development as a unique helping profession and its potential for helping patients and their families. The preoccupation with the intrapsychic gave the impression that social work was not interested in organizational and environmental matters, and too often the social worker has been excluded from intraorganizational power groups that are responsible for setting hospital policies and procedures. The absence of a true disciplinary peer status has resulted in vulnerability t o domination by lay and medical administration functionaries. The practice of casework became so narrowly defined as t o exclude
Downloaded by [UQ Library] at 07:42 29 April 2015
SOCIAL WORK IN HEALTH CARE
significant involvement in social and organizational change, which could have represented a unique contribution of the social work profession. Over time the hospital social worker lost relevant contact with consumers and their communities. They rationalized their lack of involvement in social intervention by pointing to their contact with a select group of other professionals who worked in community agencies. Social workers were reluctant and afraid t o enter the "power arena" of the hospital or the community. In instances in which social workers were interested in social change, they rarely focused on the organizational structure of the health institution in which they were employed. Social work along with other subgroups within the hospital system is governed by forces that counteract centrifugal pull. Inducements are provided to those who conform t o the image of the organization depicted by organizational elite. ~ i l l has s ~ pointed out that employees of large bureaucratic organizations sell not only their time and energy but their personalities and prerogatives as well. Once joined to the organization, the social worker is expected, within limits, to behave according t o orders and instructions supplied to him by the organization's elite, physicians, and lay administrators. This system produces little conflict or anxiety for the social worker, providing that the institutional mores, the ethical structure, the program orientation, and degree of autonomy sanctioned are essentially in agreement with those of the social work profession. When there is variance between the values and rules sanctioned by the profession and those allowed by the institution, the social worker is under stress. The impersonalization, and hierarchical power structure of organizations, often results in an alienated labor force. Coser's7 study of nurses in a general hospital demonstrated that they became alienated because they felt powerless t o implement significant goals. Traditionally, within health organizations the right to exercise professional judgments has been rigorously limited for anyone other than the physician. This condition restricts the professional prerogatives of the social worker as well as other professionals who practice in these settings. Major rewards, salaries, extra benefits and the availability of scarce resources, office space, and equipment may be implicitly related to the acceptance of an institutionally self-sewing role. In the event that the professional orientation of the social worker comes into conflict with the prevailing orientation of organizational elite, the worker is expected to yield his position to avoid conflict. Under these conditions it is extremely difficult for social workers to fulfill their role as advocates or engage in activities directed toward organizational change. T'itmus8 refers to the social worker as a prisoner of the collective status quo of the organization. In his study of an eastern hospital, Wessen9 found the ideology of
Martin Nacman
Downloaded by [UQ Library] at 07:42 29 April 2015
physicians to be conservative. They viewed the hospital primarily from the angle of their professional needs and tended to resist new developments and trends. The limited definition of the social work role by hospital elite and the conservatism of medical administration influence the choice of social work leadership. Recruitment may be biased in favor of a social work administrator with a conservative orientation, in an attempt to preserve the status quo of the organization. If, however, the mandate is broad enough t o permit the exercise of an expanded repertoire of skills, social work offers hospital and medical administrators additional expertise that may be utilized as part of a joint effort to improve patient services and community relations.
(To be continued in the next issue) REFERENCES 1. Parsons, Talcott. "Suggestions for a Sociological Approach t o the Theory of Organizations." In Complex Organizalions, edited by Amitai Etzioni. New York: Holt, Rinehart & Winston, 1962. 2. Coser, R. L. "Alienation and the Social Structure." In The Hospital in Modern Society, edited by E. Freidson. New York: Free Press of Glencoe, 1963. 3. Dana, Bess. "Social Work in the University Medical Center." Johns Hopkins Medical Journal 1 2 4 (1969):277-82. 4. Kahn, Alfred J. "Theory and Practice of Social Planning." New York: Russell Sage Foundation, 1969. 5. Gilbert, Neil, and Specht, Harry. "The Incomplete Profession: Commitment to Welfare." Paper read a t the Annual Meeting of the Council on Social Work Education, February 23, 1973, San Francisco, California. 6. Mills, C. W. White Collar. New York: Oxford University Press, 1951. 7. Coser, R. L. "Authority and Decision Making in a Hospital: A Comparative Analysis." American Sociological Review, no. 23 (1958), pp. 56-63. 8. Titmus, Richard. Commitment to Welfare. New York: Pantheon Books, 1968. 9. Wessen, A. F . "Hospital Ideology and Communication between Ward Personnel." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958.
