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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 (1976) A Systems Approach to the Provision of Social Work Services in Health Settings, Social Work in Health Care, 1:2, 133-143, DOI: 10.1300/J010v01n02_02 To link to this article: http://dx.doi.org/10.1300/J010v01n02_02
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 2
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Martin Nacman, DSW
ABSTRACT. In Lhe firsL par1 o f this presentation published in the lasl issue, the author offered a sociological uiew o f the hospital as an institution within the economic, political, and uulue systems o f the community. Syslems lheory is the conceptual base [orprojecling the potenliul role o f the social worker in the health setting. Part 2, in this issue, deals with impediments and barriers t o effectiue social worl? in hospitals as well as solution finding based o n systems worlz in combination with direct seruice shills.
BARRIERS TO ACHIEVEMENT In this section the position of social work within the health setting is examined in terms of a structural-functional model. This model focuses on the effect on each other of the organization and the social worker. The conditions and restraints under which the social worker participates in health organizations will be discussed. Research reveals that the social worker is viewed within a limited frame of reference by other professionals in the health area. Studies by Wollock and Russell,' as well as Phillips et al.,' report that while physicians refer sizable numbers of patients for social work services, the physician perceives the social work role as primarily encompassing concrete, instrumental services to patients. These studies indicate a fundamental difference between the social workers' view of their practice as being concerned with emotional and behavioral problems of patients (affective-expressive tasks) and the physicians' more narrow perception that social work is primarily capable of providing assistance for transportation, location of nursing homes, and the like (instrumental tasks). Dr. Nacrnan is Director, Social Work Division of the Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New York 14642. This paper is Part 2-of a two-part article. Social Work in Health Care V o l . 1(2), Winter 1975-76
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In a study of 1 2 university hospitals, Schrager3 found a fair amount of agreement among social workers, physicians, nurses, and administrators on the importance of social work involvement in tasks relating to "instrumental" service. However, there was much variance between social workers and the other professionals in relation t o "affectiveexpressive" services. In addition, physicians give little support t o social work's involvement in the training and education of medical students and physicians. While there appears to be more support on the part of physicians for clinical-type educational activities, hospital administrators do not see these activities as important for social workers to engage in. Schrager concludes that "clearly, the sanctions and obligations which social workers derive from their commitment t o their profession; its system of values and beliefs, and its ethical commitments, etc., seem to be discrepant from those provided by the 'power group' in the hospital i.e. the 'employers of social workers."" What has produced this discrepancy? Down through the years, the social worker, perhaps more than any other member of the hospital team, worked in behalf of patients' rights, and recognized the inseparability of physical, emotional, and social factors. As early as 1934 Harriet Bartlett wrote on this issue: "The medical social workers' special contribution lies in the relating of medical and social factors, and in the treatment of what we have called the social component of illnes~."~ Nevertheless, by the late '40s many hospital social workers had become cloistered within their offices. While hospital social workers became expert in individual treatment and instrumental tasks, in only a few exceptional cases is there any evidence that social workers developed their potential in the area of social action and organizational change. And t o a large extent their provision of "affective-expressive" services if present was not visible to others. Although social workers might have developed a distinctive method of practice, they followed the patterns of others, and in many instances were co-opted into the hospital bureaucracy and so lost the reform-social action spirit of earlier social work leaders. It also may be argued that social workers influenced patients and the system in ways that were not completely discernible. Without the conscious awareness of the learner, social workers may have imparted t o nurses, medical students, and other health practitioners respect for the dignity and worth of the individual, and an appreciation of the importance of environmental factors. Perhaps for patients the low visibility of the social workers' performance was the result of the subtle techniques they employed, which emphasized self-realization rather than forceful direction. W e do not have adequate empirical data t o support or deny these contentions. They may, however, account for the
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Martin Nacman
fact that other staff and even patients do not recognize all aspects of the social worker's performance. Social work performance within hospitals is influenced by the attitudes of physicians and hospital administrators, who wield a great deal of power within these organizations. To a large extent these elite have defined the prerogatives and role repertoire of the social worker and other nonmedical practitioners. Restrictions and restraints have been imposed that, in part, prevent social work from realizing its potential.4 Within health settings the social worker has been placed in an "ancillary status" that has imposed control by other professions. But, in addition, hospital social workers have done little to improve their own image and status, nor have they been assertive about their professional prerogatives and values. Berkmer and Rehrs conclude that in the past social workers frequently abdicated their right to set their own professional standards and priorities with respect to case finding, choice of therapeutic interventions, and resource allocations. Social workers also yielded their right to evaluate social work performance and became excessively dependent upon the physician and the hospital. Social workers did not develop professional boards such as were achieved in medicine and law. Thus the functions and evaluation of social work have not always remained within its own professional control. In health settings the profession is particularly vulnerable to the control of other specialties. The establishment of the Academy of Certified Social Workers and state licensure in a few instances represent beginning attempts to accredit social work as a distinct profession. Another problem that diminishes the effectiveness of social work derives from the division of the hospital into two separate systems: one with a biochemical-physical orientation and the other with a psychosocial orientation. Under these circumstances, services are delivered separately and often in a fragmented manner. In general hospitals, because priority is given to physical treatment, the psychosocial aspects of treatment to a large extent are considered of secondary importance. For example, Kutner6 in his review of the performance and perceptions of surgeons, indicates that they are more concerned with the technological aspects of surgery than with the interpersonal management of patients. With the emphasis on physical treatment in general hospitals, the role of social work is sometimes subordinated to a lowly status. And in spite of theoretical propositions extolling the virtues of "total treatment," little has been accomplished toward unifying psychiatric, social, and medical services. Not infrequently an exchange of consultants seems to be the most than can be accomplished. W e ~ s e n ,commenting ~ on the modern hospital, concludes that serious limits are placed upon the extent of integration that can be
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achieved. He identifies the tendency to isolation and the existence of different professional ideologies as the causes of strain which prevents integration. The physical and organizational separation that has been created between the psychiatric and the medical surgical services of the hospital has sometimes led t o the subdivision of social work into two separate operating units. In this system, the professional identity of the social worker becomes blurred. The dichotomization of social work weakens social work's potential for developing a systems approach. In the highly competitive hospital arena a divided profession is a vulnerable profession. Traditional boundary maintenance between medical and psychiatric departments (and even among medical units) has limited the flexible use of social workers throughout the hospital. A social worker, regardless of special expertise, is sometimes constrained t o operate on only one service because territorial rights supersede the needs of patients or the prerogatives of social work. In a divided program the professional identity of the social worker is dimmed by the pull of the unit t o which the worker is assigned. Identification with the assigned unit is highly desirable, providing the social worker is permitted t o function as a peer professional with the prerogative of exercising the authority and rights of a social work professional. All too often, with no central power base, the individual worker is forced into a dependent relationship in which the physician defines and sanctions the role, responsibilities, and degree of professional authority that will be permitted. Under these circumstances, social workers, bound by the ethics of their profession, are sometimes caught in a double bind. If they argue on behalf of a patient or for organizational change, they may come in direct conflict with other staff on whom they are totally dependent for rewards. Without a central professional social work base there may be little or no protection for the worker who wants t o engage in patient advocacy and organizational change activities. In England, in reaction to this dilemma, social workers formed a separate, government-sponsored social work organization that provides service t o hospitals and other health care organization~.~ Even the humanistic approach of the social worker may come into conflict with the orientation of other co-workers. Social workers who press for more humane, dignified treatment and the protection of patients' rights are sometimes labeled overprotective and unrealistic. Their concern for environmental and organizational change may be viewed as irrelevant and even disruptive. In time, some social workers may give up their convictions in favor of a less rejected existence. Studies of social work performance indicate that when faced with choices between the needs of clients and adherence t o agency proce-
Martin Nacman
dures, a high percentage of social workers comply with agency rulesg Too often, it becomes too difficult to try to preserve one's professional integrity. As Sheps" points out, the real issue is for different professionals to learn to act together but not necessarily to think alike.
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THE NEED FOR PROGRESS Today, hospitals are complex technological organizations consisting of a series of mazes that confound both employees and patients. They suffer the strains experienced by most large bureaucratic organizations. These strains, which reduce hospital efficiency and the establishment of continuity of care, produce much anxiety and alienation among staff particularly, because the hospital's product is human service. The need to employ patient advocates and ombudsmen attests to the fact that organizational maladies exist within our hospitals. Too often we have been inclined to define these deficiencies as individual patient crises rather than as basic organizational problems requiring basic changes in hospital structure and policies. Improvements in social and organizational programs and the delivery of services have not kept pace with the technological advances that have been made in health sciences. To a large extent, the problem of providing adequate health care is not one of inadequate technological knowledge; rather it is related to the ossification inherent in our administrative and organizational systems. The danger in health care institutions is the gradual descent into a fatalism that serves to help employees escape from accepting responsibility for organizational maladjustments." The existence of long-established patterns of social behavior and the vesting of power in a few privileged professional employees have led to failure to deal with, and toleration of, social and organizational inadequacies. For example, in many tuberculosis hospitals exaggerated programs of protective isolation and rest in bed persisted for years after research demonstrated that chemotherapy and arnbulation were a safe combination. By labeling the patient recalcitrant, the officials of these hospitals rationalized the rigidity and inadequacies of their institutions and even ignored the fact that large numbers of patients were leaving their hospitals against medical advice. Change was indeed difficult to achieve in these institutions. Will hospitals change? Not easily, but the potential for change is affected by at least three inescapable factors: (a) organizations must change in order to survive; (b) power groups external to the hospital are putting pressures on hospitals to become more responsive and respectful of patient rights as well as more efficient and effective; and (c) the internal power structure of the hospital is in a state of flux. Elling notes that the power structure of the hospital is now more fluid and
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more dispersed. He forecasts optimistically the emergence of a system based on "functional equality." Thinking along similar lines, Howard suggests that the title "Medical School" should be replaced by a broader term, "Academic Health Center." The new title recognizes that a vast array of different health practitioners are contributing to the care of the patient. Sheps" also sees the potential for change, but he stipulates that it depends upon whether professional attention focuses on patient needs rather than territorial prerogatives. Rothenberg,14 speaking about social workers, remarks: "We are only beginning to articulate a positive conception of our role in maximizing human potential and organizing the function of social institutions within which human potential can be fully realized." Fortunately, the social worker's goals of improving the hospital environment, protecting patients' rights, and achieving comprehensive care for patients comprise concerns now shared with other hospital employees and consumers. This is an important point, since the resources of the health care social worker will not be enough t o create change; support must be received from medical and lay administrators who control resources and influence policy. In the past, social work's potential for changing the system and gaining status has often been invisible because social workers have not been permitted t o participate in, or have been granted only limited access to, the policy-making structures of their institutions. Social workers are partially t o blame for not negotiating membership in these important groups. Dana" challenges social workers t o remove the limitations they have imposed upon themselves, but she also asks hospital administrators to "give social work the right and accompanying responsibility to identify and help modify those factors in the medical center environment itself, whether admission policies or the physical arrangements of beds, which add situational insult t o bio-medical injury." Social workers, in order to improve their status and obtain necessary resources t o carry out the proposed systems approach, need t o learn (a) how power is distributed within their organizations and the surrounding community and (b) how t o develop and apply power systematically. emphasizes the importance of analyzing the hospital's power structure in order to identify those who control policy and t o form pertinent alliances with the power elite in order t o influence their decisions. As parts of the system reach a critical point, the social worker, through skillful use of tension management and negotiation, within the hospital and in the community, may help administration t o resolve institutional problem^.'^ The many crises that hospitals face on a daily basis provide social workers with multiple opportunities t o put their professional skills t o productive use, and in the process develop a stronger professional role and status. The complex issues confronting
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Martin Nacman
health care organizations constrain the physician and hospital administrator to seek advice and assistance from other professionals who are identified as having expertise in organizational change strategies, and community organizational skills. The social worker practicing in the health setting is in an advantageous position to become an adviser to administration and other staff and t o assume a leadership role during the period of organizational change that inevitably lies ahead. While priority should be gven to expanding the social work role beyond the confines of casework and group work, at the same time care should be exercised to continue to provide the highest quality of casework and group work services possible. Social workers gain influence as they assist other employees in the resolution of organizational and administrative problems that are crucial to fellow health care professionals. Examples are negotiating with community groups, developing advisory committees, establishing patients' rights, setting up training programs, and advising on the establishment of counseling programs for employees. This plan requires (a) that the social worker be alert to discover new areas in which social work skills may be employed and (b) that these inputs be identified as social work contribution^.'^ A systems approach implies the ultimate establishment of continuity between inpatient and outpatient units. In hospitals the predominant focus has been on inpatient services; insurance coverage favors this model. But according to data compiled by the American Hospital Association (AHA) there has been a decisive increase in the provision of outpatient services by hospital staff. Compared to 1955, clinic visits in 1967 had increased by 4876, referred visits by 93%, and emergency visits by 230%. To quote a special AHA report dated 1969, "Hospitals were organized originally to provide in-patient care. Today, in the light of changes that have taken place in medical practice and in the delivery of health care, it is imperative that equal consideration be given t o out-patient service^."'^ The same report recommends that outpatient programs involve all of the professional and supportive resources of the hospital. Increased involvement in outpatient services offers social workers additional opportunities t o provide continuity between inpatient and outpatient units, and ultimately t o move into preventive programming. Here, again, a systems orientation is a meaningful model in devising an adequate patient treatment program. For example, in the situation involving a child with lead poisoning, the immediate medical problem requires prompt attention, as does the emotional concern of parents and child. Consideration must also be given to the recurrence of poisoning in the same child as well as the prevention of other cases of poisoning. This .goal requires action in the community. The social
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worker in conjunction with hospital, governmental, and legal authorities must establish procedures that result in the removal of the lead poisoning threat. This aim is often difficult t o achieve, since powerful external economic forces (real estate interests, etc.) may resist intervention and put up barriers t o change. The efforts of the caseworker may require supplementation by a community organizer who has the specific training and skill for a community action program. Of equal importance in considering patient care is the internal makeup of the health organization that is providing the service. Structural and attitudinal factors influence how services are rendered. Within recent years, in the mental health rehabilitation fields, the treatment milieu has received considerable attention, but this focus is late in being applied to general hospitals and outpatient clinics. For example, the recent development of special training programs for treating the alcoholic in general hospitals is in response to the lack of adequate programs and the poor treatment afforded these individuals in many hospitals throughout the country. The social worker with combined knowledge of the hospital organization and patients' physical, emotional, and social needs is in an advantageous position to diagnose organizational problems regarding staff attitudes, communications, the appropriateness of facilities and programs, and the degree of coordination and continuity of services both within and outside the specific health facility. There are usually a myriad of problems that require evaluation and creative recommendations. As noted previously, the hospital in concert with other bureaucratic organizations tends t o become rigid and often expends excessive energy defending its status quo. Often hospitals do not place sufficient emphasis on the impact of staff attitude, management procedures, and the format for delivering services ultimately received by patients. The hostility of a receptionist in the emergency room toward an alcoholic patient, the rapid and repeated transfer of a cardiac surgical patient from the point of admission through the recovery period, the lack of children's furniture and facilities in a pediatric clinic, the lack of bilingual services or the failure t o provide understandable and adequate explanations of medical and surgcal procedures are only a few examples of organizational problems that impede treatment. For the social worker these problems represent social and environmental difficulties that should be the focus of attention and action. The absence of this focus constitutes a serious limitation in social work performance. Regardless of what other competencies are achieved by a given social worker, concern and responsibility for the impact of social and environmental factors should not be lost. Increased involvement by social work in research is another evidence of professional peer status. In the past, the lack of research training and almost complete preoccupation with clinical practice limited social
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Martin Nacman
work's capacity for evaluative input. However, trained social work researchers are now operating within health settings, and are engaged in clinical and organizational research programs such as studies of patients' satisfaction, treatment outcomes, cost of service, the organization of medical units, problem recording, and attitudes of and toward social work. Furthermore, social workers are increasing their involvement in educational programs both at the informal and formal level. They are offering medical, nursing, and administrative students a better understanding of the effect of social and cultural factors on the delivery and acceptance of health care. Involvement in these educational projects offers social work an important opportunity to influence the orientation of other professionals during the formative stages of their development. The social worker also needs to gain entry into the political arena of the community, either directly or by influencing others to exercise their prerogatives to support meaningful change. The social worker is an effective liaison between the hospital and community, and can encourage dialogue between these groups. The inclusion on staff of a trained community organizer provides the necessary expertise. Hospitals are often intellectually isolated from surrounding communities and are consequently viewed by consumers with suspicion and distrust. Social work staff can provide valuable two-way community-hospital feedback. CONCLUSIONS In pursuing a systems approach, the direct service component of social work remains highly significant but must be enlarged to include organizational change and social action programs. Social work's knowledge of organizational theory, change strategies, and conflict management provides important resources to the hospital and to the patient. While direct service and specialization in method need to survive, it is essential that we strengthen the connection between direct service programs and social welfare and action programs. Within this framework, internal and external services are interlocked so as to provide those interventions that are required not only to treat existing pathologies but to enhance prevention. In order to create this system the lines of demarcation between the hospital and community, as well as those between various hospital subunits, have to be defined less rigidly. Less emphasis on traditional boundaries will allow for the flexibility that is needed to move social work staff between the hospital and the community as well as between departments within the hospital itself. The traditional team concept should be expanded to include staff from other community agencies that d e involved with a given patient or area of service. To achieve these goals social work must continue to strive t o gain
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access t o the policy-making bodies that determine the destiny of the hospitals in which they are employed. In addition to forming coalitions within hospital organization, the social worker should work t o amass considerable influence through coalitions formed in the community. In the past, social work relied mainly on its clinical competence t o develop its bargaining power, but this concept of power and professional development is too narrow. Social workers' knowledge and capacity to work with certain consumer and staff groups are potential sources of strength at a time when hospitals have become more sensitive to the needs and pressures of patients and consumers. POSTCRIPT Since this article was written, changes in the national and local political scene necessitate a brief comment. The rising costs of health care, the increased suspicion of the consumer, and the current inflationary trend have resulted in increased pressure t o reduce health care costs. Whether the humanistic aspects of health care can survive these pressures remains to be seen. The pressure t o reduce costs makes social work vulnerable t o cutbacks. Continuity of social work programs and its vital contribution t o the humanization of health care institutions rests upon our professional ability t o influence federal and state legislation and our capacity t o convince health care administrators of the importance of our contribution. As the previous article recommends, we must increase our visibility; we must provide for quality assurance; we must provide facts that clearly define what we are doing and what we are accomplishing. REFERENCES 1 . Wollock, Isabel, and Russell, Harr J. "Physicians Views and Use of Social Services." Journal of Perth Amboy General Hospital, October 1972, pp. 32-40. 2. Phillips, Beatrice; McCullough, J. W.; Brouwn, M. J.; and Hambro, N. "Social Work and Medical Practice." Hospitals, February 16, 1971, pp. 76-79. 3. Schrager, Jules. "Social Work Departments in Selected University Alliliated Hospitals." Unpublished study, University of Michigan Hospital, Ann Arbor, Michigan, September 1973. 4. March, J. G., and Simon, H. A. Organizalions. New York: John Wiley & Sons,
1961. 5. Berkmer, Barbara G., and Rehr, Helen. "Unanticipated Consequences of the Case Finding System in Hospital Social Services." Social Work 1 5 (1970): 63-68. 6. Kutner, Bernard. "Surgeons and Their Patients: A Study in Social Perceptions." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958. 7. Wessen, A. F. "Hospital Ideology and Commiinication between Ward Personnel." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958.
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8. Cooper, B. "Social Work in General Practice: The Cerby Scheme." Lancet, March 13, 1971, pp. 539-42. 9. Billingsley. "Bureaucratic and Professional Orientation Patterns in Social Casework." Social Seruice Reuiew 38 (1964): 402-3. 10. Sheps, C. G. "Developmental Perspectives on Interprofessional Education." Paper presented at the Colloquium on Interprofessional Education and Practice in the Health Field, April 18-19, 1973, at Mount Sinai Hospital, New York. 11. Haydon, A. E. "Fatalism." In Encyclopedia of the Social Sciences, vol. 6. New York: Macmillan, 1931. 12. Elling, Ray H. "The Shifting Power Structure in Health." Milbank Memorial Quarterly 46, no. 1 (1968), pt. 2. 13. Howard, Robert B. "The Academic Health Center: On the Rocks with a Twist of Dilemma." Journal of Medical Education 45 (1970): 839-46. 14. Rothenberg, Elaine. "Curriculum Implications of Educating Social Service Manpower for Health Care Services." Paper presented at the Workshop on Preparation lor Social Work Practice in the Health Field, Society for Hospital Social Work Directors, AHA, March 9-10, 1972, a t Cockeysville, Maryland. 15. Dana, Bess. "Social Work in the University Medical Center." Johns Hopkins Medical Journal 124 (1969): 277-82. 16. Wax, John. "Power Theory and Institutional Change." Social Service Reuiew 45 (1971): 274-88. 17. Lurie, Abraham, and Rosenberg, Gary. "Current Role of the Hospital Social Work Director." Paper presented a t the Seventh Annual Meeting of the Society for Hospital Social Work Directors, August 5, 1972. 18. American Hospital Association. Out-patient Health Care. Chicago: AHA, 1969.
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 (1976) A Systems Approach to the Provision of Social Work Services in Health Settings, Social Work in Health Care, 1:2, 133-143, DOI: 10.1300/J010v01n02_02 To link to this article: http://dx.doi.org/10.1300/J010v01n02_02
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 2
Downloaded by [North Carolina State University] at 00:16 28 February 2015
Martin Nacman, DSW
ABSTRACT. In Lhe firsL par1 o f this presentation published in the lasl issue, the author offered a sociological uiew o f the hospital as an institution within the economic, political, and uulue systems o f the community. Syslems lheory is the conceptual base [orprojecling the potenliul role o f the social worker in the health setting. Part 2, in this issue, deals with impediments and barriers t o effectiue social worl? in hospitals as well as solution finding based o n systems worlz in combination with direct seruice shills.
BARRIERS TO ACHIEVEMENT In this section the position of social work within the health setting is examined in terms of a structural-functional model. This model focuses on the effect on each other of the organization and the social worker. The conditions and restraints under which the social worker participates in health organizations will be discussed. Research reveals that the social worker is viewed within a limited frame of reference by other professionals in the health area. Studies by Wollock and Russell,' as well as Phillips et al.,' report that while physicians refer sizable numbers of patients for social work services, the physician perceives the social work role as primarily encompassing concrete, instrumental services to patients. These studies indicate a fundamental difference between the social workers' view of their practice as being concerned with emotional and behavioral problems of patients (affective-expressive tasks) and the physicians' more narrow perception that social work is primarily capable of providing assistance for transportation, location of nursing homes, and the like (instrumental tasks). Dr. Nacrnan is Director, Social Work Division of the Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New York 14642. This paper is Part 2-of a two-part article. Social Work in Health Care V o l . 1(2), Winter 1975-76
133
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In a study of 1 2 university hospitals, Schrager3 found a fair amount of agreement among social workers, physicians, nurses, and administrators on the importance of social work involvement in tasks relating to "instrumental" service. However, there was much variance between social workers and the other professionals in relation t o "affectiveexpressive" services. In addition, physicians give little support t o social work's involvement in the training and education of medical students and physicians. While there appears to be more support on the part of physicians for clinical-type educational activities, hospital administrators do not see these activities as important for social workers to engage in. Schrager concludes that "clearly, the sanctions and obligations which social workers derive from their commitment t o their profession; its system of values and beliefs, and its ethical commitments, etc., seem to be discrepant from those provided by the 'power group' in the hospital i.e. the 'employers of social workers."" What has produced this discrepancy? Down through the years, the social worker, perhaps more than any other member of the hospital team, worked in behalf of patients' rights, and recognized the inseparability of physical, emotional, and social factors. As early as 1934 Harriet Bartlett wrote on this issue: "The medical social workers' special contribution lies in the relating of medical and social factors, and in the treatment of what we have called the social component of illnes~."~ Nevertheless, by the late '40s many hospital social workers had become cloistered within their offices. While hospital social workers became expert in individual treatment and instrumental tasks, in only a few exceptional cases is there any evidence that social workers developed their potential in the area of social action and organizational change. And t o a large extent their provision of "affective-expressive" services if present was not visible to others. Although social workers might have developed a distinctive method of practice, they followed the patterns of others, and in many instances were co-opted into the hospital bureaucracy and so lost the reform-social action spirit of earlier social work leaders. It also may be argued that social workers influenced patients and the system in ways that were not completely discernible. Without the conscious awareness of the learner, social workers may have imparted t o nurses, medical students, and other health practitioners respect for the dignity and worth of the individual, and an appreciation of the importance of environmental factors. Perhaps for patients the low visibility of the social workers' performance was the result of the subtle techniques they employed, which emphasized self-realization rather than forceful direction. W e do not have adequate empirical data t o support or deny these contentions. They may, however, account for the
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fact that other staff and even patients do not recognize all aspects of the social worker's performance. Social work performance within hospitals is influenced by the attitudes of physicians and hospital administrators, who wield a great deal of power within these organizations. To a large extent these elite have defined the prerogatives and role repertoire of the social worker and other nonmedical practitioners. Restrictions and restraints have been imposed that, in part, prevent social work from realizing its potential.4 Within health settings the social worker has been placed in an "ancillary status" that has imposed control by other professions. But, in addition, hospital social workers have done little to improve their own image and status, nor have they been assertive about their professional prerogatives and values. Berkmer and Rehrs conclude that in the past social workers frequently abdicated their right to set their own professional standards and priorities with respect to case finding, choice of therapeutic interventions, and resource allocations. Social workers also yielded their right to evaluate social work performance and became excessively dependent upon the physician and the hospital. Social workers did not develop professional boards such as were achieved in medicine and law. Thus the functions and evaluation of social work have not always remained within its own professional control. In health settings the profession is particularly vulnerable to the control of other specialties. The establishment of the Academy of Certified Social Workers and state licensure in a few instances represent beginning attempts to accredit social work as a distinct profession. Another problem that diminishes the effectiveness of social work derives from the division of the hospital into two separate systems: one with a biochemical-physical orientation and the other with a psychosocial orientation. Under these circumstances, services are delivered separately and often in a fragmented manner. In general hospitals, because priority is given to physical treatment, the psychosocial aspects of treatment to a large extent are considered of secondary importance. For example, Kutner6 in his review of the performance and perceptions of surgeons, indicates that they are more concerned with the technological aspects of surgery than with the interpersonal management of patients. With the emphasis on physical treatment in general hospitals, the role of social work is sometimes subordinated to a lowly status. And in spite of theoretical propositions extolling the virtues of "total treatment," little has been accomplished toward unifying psychiatric, social, and medical services. Not infrequently an exchange of consultants seems to be the most than can be accomplished. W e ~ s e n ,commenting ~ on the modern hospital, concludes that serious limits are placed upon the extent of integration that can be
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achieved. He identifies the tendency to isolation and the existence of different professional ideologies as the causes of strain which prevents integration. The physical and organizational separation that has been created between the psychiatric and the medical surgical services of the hospital has sometimes led t o the subdivision of social work into two separate operating units. In this system, the professional identity of the social worker becomes blurred. The dichotomization of social work weakens social work's potential for developing a systems approach. In the highly competitive hospital arena a divided profession is a vulnerable profession. Traditional boundary maintenance between medical and psychiatric departments (and even among medical units) has limited the flexible use of social workers throughout the hospital. A social worker, regardless of special expertise, is sometimes constrained t o operate on only one service because territorial rights supersede the needs of patients or the prerogatives of social work. In a divided program the professional identity of the social worker is dimmed by the pull of the unit t o which the worker is assigned. Identification with the assigned unit is highly desirable, providing the social worker is permitted t o function as a peer professional with the prerogative of exercising the authority and rights of a social work professional. All too often, with no central power base, the individual worker is forced into a dependent relationship in which the physician defines and sanctions the role, responsibilities, and degree of professional authority that will be permitted. Under these circumstances, social workers, bound by the ethics of their profession, are sometimes caught in a double bind. If they argue on behalf of a patient or for organizational change, they may come in direct conflict with other staff on whom they are totally dependent for rewards. Without a central professional social work base there may be little or no protection for the worker who wants t o engage in patient advocacy and organizational change activities. In England, in reaction to this dilemma, social workers formed a separate, government-sponsored social work organization that provides service t o hospitals and other health care organization~.~ Even the humanistic approach of the social worker may come into conflict with the orientation of other co-workers. Social workers who press for more humane, dignified treatment and the protection of patients' rights are sometimes labeled overprotective and unrealistic. Their concern for environmental and organizational change may be viewed as irrelevant and even disruptive. In time, some social workers may give up their convictions in favor of a less rejected existence. Studies of social work performance indicate that when faced with choices between the needs of clients and adherence t o agency proce-
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dures, a high percentage of social workers comply with agency rulesg Too often, it becomes too difficult to try to preserve one's professional integrity. As Sheps" points out, the real issue is for different professionals to learn to act together but not necessarily to think alike.
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THE NEED FOR PROGRESS Today, hospitals are complex technological organizations consisting of a series of mazes that confound both employees and patients. They suffer the strains experienced by most large bureaucratic organizations. These strains, which reduce hospital efficiency and the establishment of continuity of care, produce much anxiety and alienation among staff particularly, because the hospital's product is human service. The need to employ patient advocates and ombudsmen attests to the fact that organizational maladies exist within our hospitals. Too often we have been inclined to define these deficiencies as individual patient crises rather than as basic organizational problems requiring basic changes in hospital structure and policies. Improvements in social and organizational programs and the delivery of services have not kept pace with the technological advances that have been made in health sciences. To a large extent, the problem of providing adequate health care is not one of inadequate technological knowledge; rather it is related to the ossification inherent in our administrative and organizational systems. The danger in health care institutions is the gradual descent into a fatalism that serves to help employees escape from accepting responsibility for organizational maladjustments." The existence of long-established patterns of social behavior and the vesting of power in a few privileged professional employees have led to failure to deal with, and toleration of, social and organizational inadequacies. For example, in many tuberculosis hospitals exaggerated programs of protective isolation and rest in bed persisted for years after research demonstrated that chemotherapy and arnbulation were a safe combination. By labeling the patient recalcitrant, the officials of these hospitals rationalized the rigidity and inadequacies of their institutions and even ignored the fact that large numbers of patients were leaving their hospitals against medical advice. Change was indeed difficult to achieve in these institutions. Will hospitals change? Not easily, but the potential for change is affected by at least three inescapable factors: (a) organizations must change in order to survive; (b) power groups external to the hospital are putting pressures on hospitals to become more responsive and respectful of patient rights as well as more efficient and effective; and (c) the internal power structure of the hospital is in a state of flux. Elling notes that the power structure of the hospital is now more fluid and
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more dispersed. He forecasts optimistically the emergence of a system based on "functional equality." Thinking along similar lines, Howard suggests that the title "Medical School" should be replaced by a broader term, "Academic Health Center." The new title recognizes that a vast array of different health practitioners are contributing to the care of the patient. Sheps" also sees the potential for change, but he stipulates that it depends upon whether professional attention focuses on patient needs rather than territorial prerogatives. Rothenberg,14 speaking about social workers, remarks: "We are only beginning to articulate a positive conception of our role in maximizing human potential and organizing the function of social institutions within which human potential can be fully realized." Fortunately, the social worker's goals of improving the hospital environment, protecting patients' rights, and achieving comprehensive care for patients comprise concerns now shared with other hospital employees and consumers. This is an important point, since the resources of the health care social worker will not be enough t o create change; support must be received from medical and lay administrators who control resources and influence policy. In the past, social work's potential for changing the system and gaining status has often been invisible because social workers have not been permitted t o participate in, or have been granted only limited access to, the policy-making structures of their institutions. Social workers are partially t o blame for not negotiating membership in these important groups. Dana" challenges social workers t o remove the limitations they have imposed upon themselves, but she also asks hospital administrators to "give social work the right and accompanying responsibility to identify and help modify those factors in the medical center environment itself, whether admission policies or the physical arrangements of beds, which add situational insult t o bio-medical injury." Social workers, in order to improve their status and obtain necessary resources t o carry out the proposed systems approach, need t o learn (a) how power is distributed within their organizations and the surrounding community and (b) how t o develop and apply power systematically. emphasizes the importance of analyzing the hospital's power structure in order to identify those who control policy and t o form pertinent alliances with the power elite in order t o influence their decisions. As parts of the system reach a critical point, the social worker, through skillful use of tension management and negotiation, within the hospital and in the community, may help administration t o resolve institutional problem^.'^ The many crises that hospitals face on a daily basis provide social workers with multiple opportunities t o put their professional skills t o productive use, and in the process develop a stronger professional role and status. The complex issues confronting
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health care organizations constrain the physician and hospital administrator to seek advice and assistance from other professionals who are identified as having expertise in organizational change strategies, and community organizational skills. The social worker practicing in the health setting is in an advantageous position to become an adviser to administration and other staff and t o assume a leadership role during the period of organizational change that inevitably lies ahead. While priority should be gven to expanding the social work role beyond the confines of casework and group work, at the same time care should be exercised to continue to provide the highest quality of casework and group work services possible. Social workers gain influence as they assist other employees in the resolution of organizational and administrative problems that are crucial to fellow health care professionals. Examples are negotiating with community groups, developing advisory committees, establishing patients' rights, setting up training programs, and advising on the establishment of counseling programs for employees. This plan requires (a) that the social worker be alert to discover new areas in which social work skills may be employed and (b) that these inputs be identified as social work contribution^.'^ A systems approach implies the ultimate establishment of continuity between inpatient and outpatient units. In hospitals the predominant focus has been on inpatient services; insurance coverage favors this model. But according to data compiled by the American Hospital Association (AHA) there has been a decisive increase in the provision of outpatient services by hospital staff. Compared to 1955, clinic visits in 1967 had increased by 4876, referred visits by 93%, and emergency visits by 230%. To quote a special AHA report dated 1969, "Hospitals were organized originally to provide in-patient care. Today, in the light of changes that have taken place in medical practice and in the delivery of health care, it is imperative that equal consideration be given t o out-patient service^."'^ The same report recommends that outpatient programs involve all of the professional and supportive resources of the hospital. Increased involvement in outpatient services offers social workers additional opportunities t o provide continuity between inpatient and outpatient units, and ultimately t o move into preventive programming. Here, again, a systems orientation is a meaningful model in devising an adequate patient treatment program. For example, in the situation involving a child with lead poisoning, the immediate medical problem requires prompt attention, as does the emotional concern of parents and child. Consideration must also be given to the recurrence of poisoning in the same child as well as the prevention of other cases of poisoning. This .goal requires action in the community. The social
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worker in conjunction with hospital, governmental, and legal authorities must establish procedures that result in the removal of the lead poisoning threat. This aim is often difficult t o achieve, since powerful external economic forces (real estate interests, etc.) may resist intervention and put up barriers t o change. The efforts of the caseworker may require supplementation by a community organizer who has the specific training and skill for a community action program. Of equal importance in considering patient care is the internal makeup of the health organization that is providing the service. Structural and attitudinal factors influence how services are rendered. Within recent years, in the mental health rehabilitation fields, the treatment milieu has received considerable attention, but this focus is late in being applied to general hospitals and outpatient clinics. For example, the recent development of special training programs for treating the alcoholic in general hospitals is in response to the lack of adequate programs and the poor treatment afforded these individuals in many hospitals throughout the country. The social worker with combined knowledge of the hospital organization and patients' physical, emotional, and social needs is in an advantageous position to diagnose organizational problems regarding staff attitudes, communications, the appropriateness of facilities and programs, and the degree of coordination and continuity of services both within and outside the specific health facility. There are usually a myriad of problems that require evaluation and creative recommendations. As noted previously, the hospital in concert with other bureaucratic organizations tends t o become rigid and often expends excessive energy defending its status quo. Often hospitals do not place sufficient emphasis on the impact of staff attitude, management procedures, and the format for delivering services ultimately received by patients. The hostility of a receptionist in the emergency room toward an alcoholic patient, the rapid and repeated transfer of a cardiac surgical patient from the point of admission through the recovery period, the lack of children's furniture and facilities in a pediatric clinic, the lack of bilingual services or the failure t o provide understandable and adequate explanations of medical and surgcal procedures are only a few examples of organizational problems that impede treatment. For the social worker these problems represent social and environmental difficulties that should be the focus of attention and action. The absence of this focus constitutes a serious limitation in social work performance. Regardless of what other competencies are achieved by a given social worker, concern and responsibility for the impact of social and environmental factors should not be lost. Increased involvement by social work in research is another evidence of professional peer status. In the past, the lack of research training and almost complete preoccupation with clinical practice limited social
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work's capacity for evaluative input. However, trained social work researchers are now operating within health settings, and are engaged in clinical and organizational research programs such as studies of patients' satisfaction, treatment outcomes, cost of service, the organization of medical units, problem recording, and attitudes of and toward social work. Furthermore, social workers are increasing their involvement in educational programs both at the informal and formal level. They are offering medical, nursing, and administrative students a better understanding of the effect of social and cultural factors on the delivery and acceptance of health care. Involvement in these educational projects offers social work an important opportunity to influence the orientation of other professionals during the formative stages of their development. The social worker also needs to gain entry into the political arena of the community, either directly or by influencing others to exercise their prerogatives to support meaningful change. The social worker is an effective liaison between the hospital and community, and can encourage dialogue between these groups. The inclusion on staff of a trained community organizer provides the necessary expertise. Hospitals are often intellectually isolated from surrounding communities and are consequently viewed by consumers with suspicion and distrust. Social work staff can provide valuable two-way community-hospital feedback. CONCLUSIONS In pursuing a systems approach, the direct service component of social work remains highly significant but must be enlarged to include organizational change and social action programs. Social work's knowledge of organizational theory, change strategies, and conflict management provides important resources to the hospital and to the patient. While direct service and specialization in method need to survive, it is essential that we strengthen the connection between direct service programs and social welfare and action programs. Within this framework, internal and external services are interlocked so as to provide those interventions that are required not only to treat existing pathologies but to enhance prevention. In order to create this system the lines of demarcation between the hospital and community, as well as those between various hospital subunits, have to be defined less rigidly. Less emphasis on traditional boundaries will allow for the flexibility that is needed to move social work staff between the hospital and the community as well as between departments within the hospital itself. The traditional team concept should be expanded to include staff from other community agencies that d e involved with a given patient or area of service. To achieve these goals social work must continue to strive t o gain
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access t o the policy-making bodies that determine the destiny of the hospitals in which they are employed. In addition to forming coalitions within hospital organization, the social worker should work t o amass considerable influence through coalitions formed in the community. In the past, social work relied mainly on its clinical competence t o develop its bargaining power, but this concept of power and professional development is too narrow. Social workers' knowledge and capacity to work with certain consumer and staff groups are potential sources of strength at a time when hospitals have become more sensitive to the needs and pressures of patients and consumers. POSTCRIPT Since this article was written, changes in the national and local political scene necessitate a brief comment. The rising costs of health care, the increased suspicion of the consumer, and the current inflationary trend have resulted in increased pressure t o reduce health care costs. Whether the humanistic aspects of health care can survive these pressures remains to be seen. The pressure t o reduce costs makes social work vulnerable t o cutbacks. Continuity of social work programs and its vital contribution t o the humanization of health care institutions rests upon our professional ability t o influence federal and state legislation and our capacity t o convince health care administrators of the importance of our contribution. As the previous article recommends, we must increase our visibility; we must provide for quality assurance; we must provide facts that clearly define what we are doing and what we are accomplishing. REFERENCES 1 . Wollock, Isabel, and Russell, Harr J. "Physicians Views and Use of Social Services." Journal of Perth Amboy General Hospital, October 1972, pp. 32-40. 2. Phillips, Beatrice; McCullough, J. W.; Brouwn, M. J.; and Hambro, N. "Social Work and Medical Practice." Hospitals, February 16, 1971, pp. 76-79. 3. Schrager, Jules. "Social Work Departments in Selected University Alliliated Hospitals." Unpublished study, University of Michigan Hospital, Ann Arbor, Michigan, September 1973. 4. March, J. G., and Simon, H. A. Organizalions. New York: John Wiley & Sons,
1961. 5. Berkmer, Barbara G., and Rehr, Helen. "Unanticipated Consequences of the Case Finding System in Hospital Social Services." Social Work 1 5 (1970): 63-68. 6. Kutner, Bernard. "Surgeons and Their Patients: A Study in Social Perceptions." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958. 7. Wessen, A. F. "Hospital Ideology and Commiinication between Ward Personnel." In Patients, Physicians, and Illness, edited by E. G. Jaco. New York: Free Press of Glencoe, 1958.
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8. Cooper, B. "Social Work in General Practice: The Cerby Scheme." Lancet, March 13, 1971, pp. 539-42. 9. Billingsley. "Bureaucratic and Professional Orientation Patterns in Social Casework." Social Seruice Reuiew 38 (1964): 402-3. 10. Sheps, C. G. "Developmental Perspectives on Interprofessional Education." Paper presented at the Colloquium on Interprofessional Education and Practice in the Health Field, April 18-19, 1973, at Mount Sinai Hospital, New York. 11. Haydon, A. E. "Fatalism." In Encyclopedia of the Social Sciences, vol. 6. New York: Macmillan, 1931. 12. Elling, Ray H. "The Shifting Power Structure in Health." Milbank Memorial Quarterly 46, no. 1 (1968), pt. 2. 13. Howard, Robert B. "The Academic Health Center: On the Rocks with a Twist of Dilemma." Journal of Medical Education 45 (1970): 839-46. 14. Rothenberg, Elaine. "Curriculum Implications of Educating Social Service Manpower for Health Care Services." Paper presented at the Workshop on Preparation lor Social Work Practice in the Health Field, Society for Hospital Social Work Directors, AHA, March 9-10, 1972, a t Cockeysville, Maryland. 15. Dana, Bess. "Social Work in the University Medical Center." Johns Hopkins Medical Journal 124 (1969): 277-82. 16. Wax, John. "Power Theory and Institutional Change." Social Service Reuiew 45 (1971): 274-88. 17. Lurie, Abraham, and Rosenberg, Gary. "Current Role of the Hospital Social Work Director." Paper presented a t the Seventh Annual Meeting of the Society for Hospital Social Work Directors, August 5, 1972. 18. American Hospital Association. Out-patient Health Care. Chicago: AHA, 1969.
