Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
Enhancing Patient Participation Julie S. Abramson ACSW, PhD To cite this article: Julie S. Abramson ACSW, PhD (1990) Enhancing Patient Participation, Social Work in Health Care, 14:4, 53-71, DOI: 10.1300/J010v14n04_06 To link to this article: http://dx.doi.org/10.1300/J010v14n04_06
Published online: 26 Oct 2008.
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Enhancing Patient Participation: Clinical Strategies in the Discharge Planning Process
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Julie S. Abramson, A C S W , PhD
ABSTRACT. Social workers are in an excellent position to develop
clinical interventions to enhance patient control over decision rnaking about post hospital care. Participation in decision making has been identified in many studies as influencing well-being, health status and even mortality rates for elderly individuals facing relocation. Some of the practice patterns that support patient autonomy include: (1) involving the patient when working with families; (2) reaching for underlying conflict; (3) creating a sense of choice within existing parameters; (4) preparing patients for discharge; and (5) educating families and hospital caretakers to assist in this process.
Since 1905, social workers have assisted hospitalized individuals and their families to make decisions about post hospital care (Kerson, 1985). The shift to a prospective payment reimbursement structure for acute care hospitalizations (DRGs) has rcduced length of stay and therefore affected the process of engaging patients and families in discharge planning. The financial penalty aspccts of this policy have contributed to increasing pressures to discharge patients quickly (Coulton, 1988; Peterson, 1986187). Consequently, patients must begin to consider alternative post discharge plans while Julie S. Abramson is Assistant Professor, School of Social WelPare, State University of New York at Albany, 135 Western Avenue, Albany, NY 12222. The author wishes to acknowledge that several of the case examples were adapted from those provided by Susan Streeter, MSW, of Emerson Hospital, Concord, MA. Social Work in Health Care, Vol. 14(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved. 53
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still adapting to the impact of their illness or impairment (Blumenfield & Rosenberg, 1988). These time constraints exacerbate the impact of other factors that may disrupt patient participation in planning for discharge. Among these are: the nature of patienttfamily relationships; patient physical and mental condition; the absence of appropriate optiolis; and professional and institutional attitudes toward paticnt participation. Social work commitment to client self-determination is an essential value of the profession and is utilized as a therapeutic strategy as well (Bendor, 1987). However, the current regulatory climate puts this value at risk as social workers face pressures for rapid discharge of patients (Walsh, 1987). This article suggests approaches social workers can use to enhance patient control over the planning process. Interventions are identified that can be implemented within the parameters of a typical hospital stay. Examples are drawn from the literature and from clinical experience with elderly patients who required transfer to another institution. The principles identified here are applicable as well to individuals returning home and to those of all ages whose impairment or illness has decreased their autonomy. SIGNIFICANCE OF CONTROL OVER DECISION MAKING
People are defined as having control when they can bring about a desired outcome through their own actions. The degree of control individuals experience over decisions affecting their physical and social environment influences their health status, utilization of medical care, activity levels, feelings of well being and mortality rates (Coulton, Dunkle, Chow, Haug & Vielhaber, 1988; Ferrari, 1963; Pohl & Fuller, 1980; Rodin, 1986; Slivinske & Fitch, 1987). Even modest interventions to enhance perceived control have significant impact on individual well-being and physical status. For example, Langer, Janis and Wolfer (1975) were able to induce perceptions of control for patients having surgery by providing information about the operation and by teaching the patients to distract themselves. These techniques reduced anxiety and resulted in a better recovery, including lower doses of medications for pain. Other interventions aimed at enhancing perceived control have included
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giving nursing home residents responsibility for caring for a plant (Langer & Rodin, 1976; Mercer & Kane, 1979), allowing nursing home residents to predict or control visits by volunteers (Schulz, 1976) and educating residents of a retirement community in techniques for mastery of their environment (Slivinske & Fitch, 1987). In each study, these simple interventions rcsulted in general improvement in health status, and some also led to increased activity levels, better psychosocial functioning and reduced need for medical care. These findings suggest that increasing patient control of decision making in discharge planning would facilitate positive post discharge outcomes. However, studies specifically related to discharge planning found that patients had lower levels of influence over the planning process and outcome than did family members or most professional staff (Abramson, 1988; Coulton, Dunkle, Goode, & Macintosh, 1982; Townsend, 1986; York & Caslyn, 1977). Some studies found that social workers spent more time with families than with patients (Gambel, Heilbronn, & Reamer, 1980; Levey, 1980). In one study, family members made decisions for a substantial group of patients who appeared able to make their own, although patients in poor mental and physical condition were found to participate less (Abramson, 1988). However, depression and mild dcmentia did not inhibit participation (Abramson, 1988). Participation in making decisions has been identified as a critical factor in the adjustment of those elderly individuals who relocate from one setting to another (i.e., home or hospital to nursing home or from nursing home to nursing home) (Mirotznik & Ruskin, 1984; Schulz & Brenncr, 1977). Increased mortality rates and physical deterioration have been identified repeatedly as an outcome of relocating the elderly (Ferraro, 1982; Lieberman & Tobin, 1983). However, the negative consequences of relocation have been mediated by interventions that are consistent with the literature cited on the significance of control. For examplc, simulated models were uscd in one study to prepare individuals for relocation (Hunt & Hunt, 1983) while site visits were used in another (Pastalan & Bourestom, 1975). Both studies found much lowcr post relocation mortality rates for the prepared group as compared to the control group. Other studies found that patients and families did not consider many op-
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tions in making decisions about long term care (Van Meter & Johnson, 1985; York & Caslyn, 1977), but that consideration of more choices facilitated adjustment for individuals who were relocating (Beaver, 1979).
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SOCLAL WORK ROLE IN DISCHARGE PLANNING
In their role as coordinators of the planning process, social workers can promote patient control over decision making. In this capacity, they negotiate with key participants to develop a plan that meets various needs, usually including those of: (1)the patient; (2) family members; (3) health care providers; (4) the institution; (5) reimbursement sources; and (6) referral resources (Caputi, 1982). These negotiations are often complex and may present ethical dilemmas for the social worker, especially where resources are scarce and client, family or organizational interests at odds (Abramson, 1981). In some circumstances, social workers may find themselves compromising patient interests and giving priority to family and organizational concerns (Abramson, 1988; Blumenfield & Rosenberg, 1988; Fields, 1978). Yet, given the benefits of perceived control and autonomy, it is important that social workers make conscious and sustained efforts to emphasize patient control over making decisions about discharge. CLINICAL STRATEGIES TO ENHANCE PATIENT CONTROL
Social workers who assist patients with decisions about post discharge care can overcome the constraints of shorter hospital stays by developing practice patterns that enhance patient control, including: (1) involving the patient when working with families; (2) reaching for underlying conflict; (3) providing a sense of choice within existing parameters; (4) preparing patients for discharge; and (5) enlisting families and hospital caretakers to assist in these processes. It is important, however, to identify the obstacles to active participation in decision making which hospitalized patients face. Patients have difficulty influencing medical decisions or the hospital
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environment because of the depleting impact of illness, their sick role status and, for older patients, discounting attitudes toward the elderly (Marshall, 1981; Strauss, 1972; Tagliocozzo & Mauksch, 1979; Coe, 1986). Many physicians take a prescriptive and paternalistic stance toward patients which minimizes patient involvement in making decisions (Breslau, 1981). It is commonplace in current medical practice to discuss the patient's condition and treatment with family members rather than with the patient, thus compromising the patient's right to information and influence. Rosow (1981, p. 144) notes that for elderly patients, a physician/adult child coalition can occur which, while not necessarily malicious, is "at best, patronizing and at worst, depersonalizing and dismissive. The parent may seldom be accorded the courtesy of significant choices that are well within his competence." Working Jointly with Patients and Families
Social workers can be consistent in recommending that patients be included in meetings that physicians hold with families. It is important that this be the standard when the social worker is present. In this way, social workers can model for the physician, patient and family an including rather than excluding way oPworking. This principle should carry over to social work contacts with patients and families. Yet social workers in acute care hospitals routinely see patients and families apart from one another. Although such an approach may be more expedient at times, it is suggested that this be the exception rather than the rule. Through joint meetings, the patient's concerns remain center stage and are less likely to be circumvented due to conscious or unconscious social workerlfamily alliances. Patient-centered discharge planning is essential if the consequences of loss of control are to be avoided. Of course, the focus on the patient does not eliminate the social worker's responsibility to address the needs of family members as well. Social workers find the process of balancing competing needs of families and patients particularly challenging in those cases where family members ask that they be seen separately from the patient. These requests suggest the existence of family conflict and should alert the social worker to the need to include the patient in work
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with the family unit in order to protect patient autonomy. If an adult child, while discussing the placement of a parent in a nursing home, indicates that (s)he does not wish the parent to know of this plan, the social worker should recommend a joint patientlfamily meeting. The dangers inherent in leaving the parent out of the process should be explained and reassurance offered that the social worker will help family members deal with their own needs and with any conflicts that ensue. When patients are cognitively impaired, it may not be possible to include them in making those decisions that require substantial exercise of judgment. However, plans can still be shared and reactions sought in a joint meeting. Patient capacity for making decisions varies according to the type of decision and may wax and wane with variations in patient condition (Zuckerman, 1988). The social worker can make use of the patient's more lucid moments to get input, thus avoiding, where possible, "substitute decision making" (Kapp, 1988). One elderly man, quite confused and forgetful at times, understood enough about the decisions being made while his relatives were meeting with the social worker to send one of his grandchildren in to the meeting room to announce that he did not want his house sold. Strategies for maximizing control for impaired patients are discussed later in this article. Reaching for Underlying Conflict
Questions may arise as to the feasibility of working out conflicts within the time frame typically available for discharge planning. In many cases, however, obstacles to a timely discharge will develop unless the conflict is addressed directly (Proctor & Morrow-Howell, 1990). Careful clinical assessment can differentiate between those patients and families who are likely to have difficulties in planning and those where joint planning can take place without impediments. A few questions about the nature of family relationships asked in the first contact with the patient or with any family member are pivotal to the social worker's assessment. The patient who requests that the social worker contact one daughter but not another, or the family member who impugns the care provided to the patient by another member signals the social worker to anticipate possible
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problems in the process of planning for patient care after discharge. A request to withhold information from the patient or any family member is another indicator of possible conflict. Sometimes efforts to avoid conflict can lead a patient or family members to select less desirable options.
A 79 year old woman requested nursing home placement because she was having increased difficulty in caring for her daily needs. She lived with a single daughter who, though ernployed, had a history of periodic depressive episodes which required short psychiatric hospitalizations. Communication between them had been poor. The mother was angry at the daughter for not helping her more. After exploration of the situation with the patient, the social worker met jointly with the patient and her daughter. The patient was encouraged to present her feelings and needs to her daughter. The social worker provided information about services that could help maintain the mother at home and relieve the daughter of some of the responsibilities for caring for the patient. Ultimately, the patient was able to return home with some of these services. The relationship with her daughter .was somewhat improved, and most important, a plan was developed that was in tune with the patient's situation. Had the social worker pursued placement without further exploration, it is likcly that the patient would have refused to enter the nursing home when the time came. In some cases, a patient may be dissatisfied with the recommendations of the physician or other professional caretakers. If the patient is not helped to address the issues directly with caretakers, (s)he might act out these feelings, becoming depressed or agitated. In one situation, the social worker asked the patient, an independent 93 year old man, why he seemed so unhappy about having the visiting nurse come to his home to help him with dressing changes for leg ulcers. The patient had been superficially compliant with this plan but had cut the social worker off whenever she tried to discuss it with him. She then discovered that he was embarrassed about his
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living conditions and that, in fact, he needed more extensive help than he had initially requested. Where conflict exists, social workers help by bringing underlying issues into the open early in the planning process. This gives paticnts and families opportunities to deal with the guilt, sadness and hostility so often connected to decisions about caring for the impaired member (Mailick, 1979; Parsons & Cox, 1989; Stewart, 1984; Townsend, Deimling, Noelker & Bass, 1986). Open discussion of family or individual issues, however brief, can lead to the level of resolution necessary to arrive at a decision. This also facilitates better adjustment for both patient and family after discharge (Solomon, 1983) and may, in fact, contribute to a more timely discharge. Creating a Sense of Choice Some interventions suggested in this article may appear obvious or superficial in the degree of choice they provide for patients. Yet these seemingly modest interventions do enhance perceived control and have been well documented as having an impact on various barometers of patient well-being. Consistent efforts by social workers to provide patients a sense of choice are clearly indicated. One of the most effective means for engaging patients in planning is the discussion of available options (Abramson, 1988). Social workers can encourage patients and families to consider more than one option in making decisions about post hospital care. It is often difficult for a social worker to present a variety of options if those available seem undesirable. Yet, within any given set of options, no matter how limited, it is still possible to locate areas for enhancing patient control. A well-oriented 82 year old man was reluctant to accept placement in a nursing home with a high proportion of demented patients. This nursing home was the only one that his elderly sisters could visit by public transportation. The social worker and the patient talked about his reactions to the proposed placement. The patient acknowledged that he was very frightened of "losing his marbles" someday and thought that being around confused people would upset him. He felt, how-
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ever, that he should not refuse the placement because he very much wanted to stay in close touch with his sisters. The social worker tried to help him work out ways that he might be more comfortable in this setting. She asked his sisters to meet with her and the patient. At the meeting, the sisters decided to work out a regular schedule of visits for themselves, other members of the extended family and church volunteers so that the patient would have continued stimulation. They asked the social worker to arrange for the patient to return weekly to the community center he had previously attended so that he could maintain his membership in a chess club. Weekend visits by the patient to family members were also set up. The patient and his family were encouraged to present his concerns to the nursing home's director of admissions in the hope that the staff there might suggest additional strategies such as assuring the patient a well-oriented roommate. Several months after the patient's discharge, the social worker received a call from one of the patient's sisters who noted that the patient was sometimes depressed and telephoned them often. She also reported that the patient was involved with a small group of men who talked about politics, and that he was helping the nurses a little now that he was ambulating better. She said the visits home and to the community center had gone well. Strategies such as those described here can succeed in supporting the patient's sense of autonomy only if the priorities are set by the patient and the plans carried out or at least directed by the patient to the extent possible. Self determination has to be redefined for those patients with mental impairment due to their reduced capacity to exercise judgment. However, choices can be developed that are appropriate for the patient's level of functioning (Kapp, 1988). Patients with moderate dementia, for example, may be unable to adequately evaluate their self care abilities but can be involved in choosing personal possessions to take to a nursing home. These patients can also choose the clothing to wear on discharge, the hour of discharge or
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for some nursing homes, whether to have a roommate or live in a single room. It may be possible to engage patients in identifying preferred nursing homes, depending on the level of impairment and the availability of resources. If patients are unable to gather needed documents, they can be encouraged to delegate authority to others formally. For patients with mild impairment of memory, the social worker can reinforce a patient's sense of autonomy by adhering, wherever possible, to an interview schedule and agenda set by the patient (Blumenfield, 1983). Efforts can be made to help the patient obtain preferred modifications in the hospital routine. T o assist forgetful patients in maintaining control over an interview, the social worker can make a brief outline of the discussion in a notebook kept in the patient's possession. The patient then can refer to it in the social worker's absence, or they can review it together at the beginning of the next interview. The notes of the interview should reflect the patient's point of view and any decisions made during the interview. One social worker described note taking to patients as "taking dictation" and would read back the points as a means of summarizing the session. An alert social worker can develop other creative micro-interventions that increase a sense of control for patients whose capacities for decision making are impaired. Many of the approaches noted here may be adapted well in working with unimpaired patients.
Preparing Patients for Discharge Preparing patients for coping with the circumstances of post hospital life is another means for supporting their autonomy. A patient who knows what to expect from a new setting and who is emotionally prepared to deal with the impending changes is more likely to feel a sense of control over the environment. Preparation can take place through: (1) discussing the possible negative consequences of the decisions made; (2) eliciting feelings about the change; and (3) providing information about the chosen plan. Janis and Mann (1977) point out that certain patterns of making decisions under stress can lead to satisfaction with a decision independent of whether or not its implementation leads to good or bad
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consequences. They note that the most effective decision making pattern is one of vigilant information seeking. This pattern is best supported by adequate time to explore options and by awareness of the risks associated with a given decision. Janis and Mann's notion of emotional inoculation (p. 155) provides a theoretical explanation for the importance of participation in decision making. This concept suggests that through the availability of information about a choice, its consequences and the consequences of other alternatives, individuals prepare themselves to cope with these consequences, especially the negative ones. As social workers engage patients in a consideration of alternatives for care after discharge, the review of possible negative consequences can help patients in developing cognitive strategies to assist them with future difficulties. Facing the negative aspects of a plan is helpful to patients even in those situations where the available options appear undesirable. The literature indicates that helping a patient to decide which of the unsatisfactory alternatives is most acceptable still enhances the individual's sense of control (Janis & Mann, 1977). Even satisfactory choices usually involve changes for the patient and family and thus evoke anxiety or other feelings. Reaching for feelings about the transition is essential to helping the patient begin the adaptation process. It also begins the necessary process of terminating the relationship with the social worker and the hospital setting. Although social workers do not usually control the date for discharge, they still can take the initiative to engage patients in a review of their work together in anticipation of discharge. It is helpful to identify the patient's contribution to the outcome and to reflect on the decision making process. Discussion of the working relationship between the social worker and the patient and of the significance of its ending also can help to prepare the patient to move on (Fortune, 1989). Finally, helping patients obtain information about the settings to which they were relocating has been shown to influence post discharge adjustment (Hunt & Hunt, 1983; Pastalan & Bourestom, 1975). Although it is not always possible to predict which nursing home will have an available bed for the patient, each department of social work can develop a file of brochures and photographs (espe-
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cially of patient rooms and dining rooms) of those institutions most often used for referral. Daily patient schedules can be obtained with listings of activities and menus. These materials can be used by social workers and family members to help prepare patients for the everyday realities of the new setting. They also can serve to reorient patients with dementia about the impending change. Wherever possible, arrangements should be made for the patient to visit the nursing home prior to the transfer.
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Educating Others to Enhance Control
Social workers can also help patients by involving others in using the strategies outlined. Nurses, aides, physical and occupational therapists, family members and volunteers can be helped to understand the significance of control for patients (Aroskar, Urv-Wong & Kane, 1990). They too can utilize intervention strategies such as orienting and reorienting patients to the new setting through use of photos, menus and schedules. Family members can take photos of the nursing home if no others are available. Volunteers can be involved in gathering information about frequently used facilities for a department file. A volunteer corps can be developed to visit patients awaiting placement (especially those without family). The volunteers can implement strategies worked out with the social worker, such as helping a patient pack for the move. Social workers on units where many patients are facing relocation can sensitize nursing staff to the importance of enhancing control for patients and of preparing them for transfer. It may be possible through teamwork efforts to create a patient care climate that can significantly influence post discharge adjustment for many patients. ILLUSTRATIONS
Mrs. Hopper, 82, was admitted to the hospital with a fracture of the shoulder. A widow for 15 years, she lived alone and had used a walker for the past few years. Her niece told the admitting nurse that the patient had become forgetful recently. She had been having difficulty managing her affairs and had received an eviction notice for nonpayment of rent.
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Since then, the niece and her husband had been managing the patient's finances. The patient seemed confused in some of her talks with the social worker. At other times, she seemed aware of her situation. Usually, she remembered the fall which led to her admission and admitted to being fearful about being alone at home. When asked if she wished to go to a nursing home, she said that she did not know, and that the social worker should speak with her niece instead. The social worker requested an assessment by the home care department to see if it was feasible for the patient to return home. The home care evaluation indicated that the patient could no longer. ambulate with a walker. .Home care services were not recommended since available care would not be adequate for this patient. With Mrs. Hopper's permission, the social worker asked the niece and her husband to come in for a joint meeting with the patient, stating that the patient seemed to want the niece to make the decisions. Over the telephone, the social worker explored the niece's feelings about this and indicated her concern about the patient's abdication of the right to make her own decisions. The social worker and the niece agreed that the patient's competency for making decisions was compromised by confusion, but that she could still participate to some extent. Noting that, in her experience, patients did much better after placement when they were involved in planning, the social worker proposed that the niece ask her aunt's permission to carry out needed activities on her behalf. In the joint patienttfamily meeting, the patient agreed that she could not take care of herself anymore and said she would go to a nursing home. Since there were many things to be taken care of, the niece's husband suggested that they make a list that the patient could sign, delegating the tasks that family members needed to do on her behalf. At first, the patient seemed to feel that wasn't necessary, but subsequently she got involved in telling the others what she wanted done. When the social worker interviewed the patient alone the next day, Mrs. Hopper seemed rather vague about the decision
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to go to a nursing home. The social worker explored her knowledge about local facilities and found that Mrs. Hopper's poor recent memory did not impede her ability to recall what she knew about several nursing homes in the community. In fact, she knew some residents at one home and had negative impressions of another. The social worker used this information to guide her efforts to arrange placement. She continued to meet with the patient regularly for the rest of her stay to review the plans and to prepare Mrs. Hopper for the impending change. She asked the niece to get brochures, photos and schedules from the nursing homes most likely to admit Mrs. Hopper. The niece then shared these with the patient. The niece and the patient also discussed which personal possessions Mrs. Hopper wanted to take with her. This case is typical of many seen by hospital social workers. In fact, it might be seen as fairly uncomplicated because Mrs. Hopper passively accepted the need for placement. Her shifting mental status was another common complication that social workers face when they help the elderly to make discharge planning decisions. Yet the social worker did not let Mrs. Hopper's confusion deter her from working with the patient's feelings about the upcoming transfer. She thus discovered that the Mrs. Hopper could communicate with her on an affective level despite memory loss. In another similar situation, an elderly man with fairly severe dementia commented, when told he would be going to a specific nursing home, "Oh, that place is OK, but it is a little too close to the funeral parlor." His impairment did not obstruct the efforts of the social worker to communicate with him on a more symbolic level about the meaning of this event for him. Problems often arise when there is conflict between the patient and family and with the health care providers. Mrs. Otis, a 78 year old widow, was hospitalized for a serious fracture of the femur. She required complex surgery, involving a non-ambulatory period of six weeks followed by a long convalescence. The physician emphasized that the patient would need an extended rehabilitation period in order to walk
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well again. In her first interview with Mrs. Otis, the social worker offered to help the patient find the right place to get this care. The patient, who previously had been somewhat guarded, refused to speak further with the social worker and asked her to leave the room. The patient's daughter contacted the social worker the next day to ask for help in planning for her mother's care. The social worker asked the daughter to let her mother know that she was meeting with the social worker and for what purpose. The daughter described the patient as an independent, imperious woman who was suspicious of others. She told of much conflict with her mother who had continually tried to run her life. The social worker reviewed with the daughter the options available for the patient's convalescence. The daughter emphatically stated that she could not take her mother into her own home during the rehabilitation period, nor did she feel that her mother could return to her own home without rehabilitation. At this point, the social worker set up a family meeting. At the joint meeting, the patient kept her back turned after saying to her daughter, "What are you doing here!" Initially she was an angry non-participant. The social worker acknowledged that the patient was being presented with choices that she did not find acceptable and explained once more the consequences of not receiving rehabilitation services. When Mrs. Otis did not respond, the social worker sympathized with the patient's predicament, all the while directing her comments to Mrs. Otis' back. The social worker then asked the daughter to explain why she could not bring her mother to her home. At this point, the patient responded with hurt and anger, expressing a torrent of feelings about those meddling in her affairs and about a daughter who didn't want to take care of her own mother. In support of this patient's traditionally active approach to problem solving, the social worker noted that others would need to make decisions that were rightfully hers unless she took charge. The patient ultimately accepted the need for a temporary stay in a nursing home with a good rehabilitation program.
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A careful assessment of family dynamics and the patient's past modes of problem solving was critical in this example. In light of Mrs. Otis' history, her current behavior was not the norm for her and needed to be understood for resolution to occur. Exploration of family history can bring insights that will direct further intervention and facilitate engagement of both the patient and family. In this situation, the patient's perception that her daughter was unwilling or unable to care for her was fueling her anger and resistance to planning. Joint work with the patient and her daughter was necessary, even in the face of resistance from either. Working with family conflict within the family system dilutes the pernicious impact of family secrets and assures that the patient's needs and feelings are not circumvented. It also facilitates face to face problem solving by direct confrontation of those interpersonal factors which are likely to interfere with an effective as well as timely discharge plan. CONCLUSION
Social workers in acute care hospitals are in a unique position to implement interventions that enhance patient control over decision making. They meet patients and families at critical junctures when the decisions made will have far reaching consequences. Strategies have been described which have the potential to mediate the inevitable impact of relocation and the stress of changed circumstances. However, social workers face some impediments to utilizing this approach. The long standing tendency within the field to devalue planning for post hospital care as a "non clinical" function reduces motivation to articulate appropriate clinical interventions (Bailis, 1985). Also, the current regulatory climate has shortened the time frame within which decision making takes place and has increased pressures on social workers to expedite discharges. It is suggested here that despite the well known constraints facing those who help patients and families with planning, many opportunities exist for clinical interventions to enhance control for patients. To maximize them, a social worker must be conceptually clear about the significance of these interventions, creative about developing them and committed to their implementation. A parallel process can develop: as the patient is provided a greater sense of con-
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trol, the social worker makes a contribution in an arena which is under the worker's control; namely, the engagement of the patient and family in decision making. Additionally, such an approach facilitates timely discharges by anticipating and resolving the interpersonal issues that so easily obstruct planning.
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Ferraro, K. (1982). The health consequences of relocation among the aged in the community. Journal of Gerontology, 38(1), 90-96. Fields, Grace. (1978). The anatomy of discharge planning. [Editorial.] Social Work in Health Care, 4(1), 5-6. Fortune, A.E. (1989). Improving durability of therapeutic gain: Practitioner's use of maintenance interventions. Unpublished manuscript. Gambel, J., Heilbronn, M. & Reamer, F. (1980). Hospital social workers become "decision makers" in nursing home placement. Journal of the American Health Care Association, 6 , 19-23. Hunt, M. & Hunt, G . (1983). Simulated site visits in the relocation of older people. Health & Social Work, 8(1), 5-14. Janis, 1. & Mann, L. (1977). Decision making: A psychological onalysis of conflict, choice and commitntent. NY: The Free Press. Kapp, M. (1988). Forcing services on at-risk older adults: When doing good is not so good. Social Work in Health Care, 13(4), 1-13. Kerson, T. (1985). Responsiveness to need: Social work's impact on health care. Health & Social Work, 10(4), 300-307. Langer, J., Janis, I. & Wolfer, J. (1975). Reduction of psychological stress in . surgical patients. Journal of Erperimental Psychology, 11, 155-165. Langer, J. & Rodin, J. (1976). The effects of choice and enhanced personal responsibility for the aged. Journal of Personality and Social psycho lo^, 34, 191-198. Levey, S. (1980). Study of hospital discharges for patients 65 and over. New York: Greater New York Hospital Association. Lieberman, M. & Tobin, S. (1983). Theexperience ofold age. NY: Basic Books. Mailick, M. (1979). The impact of severe illness on the individual and the family: An overview. Social Work in Health Care, 5(2), 117-128. Marshall, V. (1981). Physician characterislics and relationships with older patients. In M. Haug (Ed.), Elderlypatients and their doctors (pp. 94-1 18). NY: Springer. Mercer, S. & Kane, R. (1979). Helplessness and hopelessness among the institutionalized aged: An experiment. Health and Social Work, 4(1), 91-1 15. Mirotznik, J. & Ruskin, A. (1984). Inter-institutional relocation and its effects on health. The Gerontologist, 24(3), 286-291. Parsons, R. & Cox, E. (1989). Family mediation in elder caregiving decisions: An empowerment intervention. Social Work, 34(2), 122-126. Pastalan, L. & Bourestom, N. (1975). Forced relocation: Setting, staff and potient effects. Report to Mental Health Services Development Branch, NIMH, Ann Arbor: University o f Michigan. Peterson, K . (1986187). Changing needs of patients and families in long term care facilities: Implications for social work practice. Social Work in Health Care, 12(2), 37-49. Pohl, J. & Fuller, S. (1980). Perceived choice, social interaction and dimensions of morale of residents in a home for the aged. Research in Nursing and Health, 3. 147-157. -
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Proctor, E. & Morrow-Howell, N. (1990). Complications in discharge planning with Medicare patients. Health & Social Work. 15(1), 45-54. Rodin, J. (1986). Aging and health: Effects of the sense of control. Science, 233, 1271-1276. Rosow, 1. (1981). Coalitions in geriatric medicine. In M. Haug (Ed.), Elderly patients and their doctors (pp. 137-146). NY:Springer. Schulz, R. (1976). Effects of control and predictability on the psychological well being of the institutionalized aged. Journal of Personality and Social Psychology, 33, 563-573. Schulz, R. & Brenner, G. (1977). Relocation of the aged: A review and theoretical analysis. Journal of Gerontology. 32. 323-333. Slivinske, L. & Fitch, V. (1987). The effect of control enhancing interventions on the well being of elderly individuals living in retirement communities. The Gerontologist, 27, 176-181. Solomon, R. (1983). Serving families of the institutionalized aged: The four crises. In G. Getzel & J. Mellor (Eds.), Gerontological social work practice in long tenn care (pp. 83-97). NY: The Haworth Press. Strauss, R. (1972). Hospital organization from the viewpoint of patient-centered goals. In B. Georgopoulos (Ed.), Organizational research on health institutions (pp. 203-222). Ann Arbor: University of Michigan Institute for Social Research. Stewart, R. (1984). Building an alliance between the family and the institution. Social Work, 29(4), 386-390. Tagliacozzo, D. & Mauksch, H. (1979). The patient's view of the patient's role. In E. Gartly Jaco (Ed.), Patients, physiciam and illness. (3rd ed.) (pp. 185201). NY: The Free Press. Townsend, A. (1986). Family caregivers' perspectives on institutionalization decisions. Memphis: The University of Tennessee, Center for Health Sciences and Department of Medicine. (ERIC Document Reproduction Service NO. CG 020 923.) Townsend, A., Deimling, G., Noelker, L. & Bass, D. (1986). Ethical dilemmas in placement decisions: Family caregivers decisions. Paper presented at the 39th Annual Scientific Meeting of the Gerontological Society of America, Chicago, l l . Van Meter, M. & Johnson, P. (1985). Family decision making and long term care for the elderly: Part 11: A review. Journal of Religion and Aging, 1 , 59-72. Walsh, A. (1987). Impact of DRG reimbursement: implications for intervention. Social Work in Health Care, 13(2), 15-23. York. J. & Caslvn, R. (1977). Family involvement in nursing - homes. The Gerontologist, 17,300-505. ' Zuckerman, C. (1988). Ethical and legal issues. In P. Volland (Ed.). Discharge planning: An interdisciplinary approach to continuity of care (pp. 317-336). Owings Mills, MD: National Health Publishing.
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
Enhancing Patient Participation Julie S. Abramson ACSW, PhD To cite this article: Julie S. Abramson ACSW, PhD (1990) Enhancing Patient Participation, Social Work in Health Care, 14:4, 53-71, DOI: 10.1300/J010v14n04_06 To link to this article: http://dx.doi.org/10.1300/J010v14n04_06
Published online: 26 Oct 2008.
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Enhancing Patient Participation: Clinical Strategies in the Discharge Planning Process
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Julie S. Abramson, A C S W , PhD
ABSTRACT. Social workers are in an excellent position to develop
clinical interventions to enhance patient control over decision rnaking about post hospital care. Participation in decision making has been identified in many studies as influencing well-being, health status and even mortality rates for elderly individuals facing relocation. Some of the practice patterns that support patient autonomy include: (1) involving the patient when working with families; (2) reaching for underlying conflict; (3) creating a sense of choice within existing parameters; (4) preparing patients for discharge; and (5) educating families and hospital caretakers to assist in this process.
Since 1905, social workers have assisted hospitalized individuals and their families to make decisions about post hospital care (Kerson, 1985). The shift to a prospective payment reimbursement structure for acute care hospitalizations (DRGs) has rcduced length of stay and therefore affected the process of engaging patients and families in discharge planning. The financial penalty aspccts of this policy have contributed to increasing pressures to discharge patients quickly (Coulton, 1988; Peterson, 1986187). Consequently, patients must begin to consider alternative post discharge plans while Julie S. Abramson is Assistant Professor, School of Social WelPare, State University of New York at Albany, 135 Western Avenue, Albany, NY 12222. The author wishes to acknowledge that several of the case examples were adapted from those provided by Susan Streeter, MSW, of Emerson Hospital, Concord, MA. Social Work in Health Care, Vol. 14(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved. 53
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still adapting to the impact of their illness or impairment (Blumenfield & Rosenberg, 1988). These time constraints exacerbate the impact of other factors that may disrupt patient participation in planning for discharge. Among these are: the nature of patienttfamily relationships; patient physical and mental condition; the absence of appropriate optiolis; and professional and institutional attitudes toward paticnt participation. Social work commitment to client self-determination is an essential value of the profession and is utilized as a therapeutic strategy as well (Bendor, 1987). However, the current regulatory climate puts this value at risk as social workers face pressures for rapid discharge of patients (Walsh, 1987). This article suggests approaches social workers can use to enhance patient control over the planning process. Interventions are identified that can be implemented within the parameters of a typical hospital stay. Examples are drawn from the literature and from clinical experience with elderly patients who required transfer to another institution. The principles identified here are applicable as well to individuals returning home and to those of all ages whose impairment or illness has decreased their autonomy. SIGNIFICANCE OF CONTROL OVER DECISION MAKING
People are defined as having control when they can bring about a desired outcome through their own actions. The degree of control individuals experience over decisions affecting their physical and social environment influences their health status, utilization of medical care, activity levels, feelings of well being and mortality rates (Coulton, Dunkle, Chow, Haug & Vielhaber, 1988; Ferrari, 1963; Pohl & Fuller, 1980; Rodin, 1986; Slivinske & Fitch, 1987). Even modest interventions to enhance perceived control have significant impact on individual well-being and physical status. For example, Langer, Janis and Wolfer (1975) were able to induce perceptions of control for patients having surgery by providing information about the operation and by teaching the patients to distract themselves. These techniques reduced anxiety and resulted in a better recovery, including lower doses of medications for pain. Other interventions aimed at enhancing perceived control have included
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giving nursing home residents responsibility for caring for a plant (Langer & Rodin, 1976; Mercer & Kane, 1979), allowing nursing home residents to predict or control visits by volunteers (Schulz, 1976) and educating residents of a retirement community in techniques for mastery of their environment (Slivinske & Fitch, 1987). In each study, these simple interventions rcsulted in general improvement in health status, and some also led to increased activity levels, better psychosocial functioning and reduced need for medical care. These findings suggest that increasing patient control of decision making in discharge planning would facilitate positive post discharge outcomes. However, studies specifically related to discharge planning found that patients had lower levels of influence over the planning process and outcome than did family members or most professional staff (Abramson, 1988; Coulton, Dunkle, Goode, & Macintosh, 1982; Townsend, 1986; York & Caslyn, 1977). Some studies found that social workers spent more time with families than with patients (Gambel, Heilbronn, & Reamer, 1980; Levey, 1980). In one study, family members made decisions for a substantial group of patients who appeared able to make their own, although patients in poor mental and physical condition were found to participate less (Abramson, 1988). However, depression and mild dcmentia did not inhibit participation (Abramson, 1988). Participation in making decisions has been identified as a critical factor in the adjustment of those elderly individuals who relocate from one setting to another (i.e., home or hospital to nursing home or from nursing home to nursing home) (Mirotznik & Ruskin, 1984; Schulz & Brenncr, 1977). Increased mortality rates and physical deterioration have been identified repeatedly as an outcome of relocating the elderly (Ferraro, 1982; Lieberman & Tobin, 1983). However, the negative consequences of relocation have been mediated by interventions that are consistent with the literature cited on the significance of control. For examplc, simulated models were uscd in one study to prepare individuals for relocation (Hunt & Hunt, 1983) while site visits were used in another (Pastalan & Bourestom, 1975). Both studies found much lowcr post relocation mortality rates for the prepared group as compared to the control group. Other studies found that patients and families did not consider many op-
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tions in making decisions about long term care (Van Meter & Johnson, 1985; York & Caslyn, 1977), but that consideration of more choices facilitated adjustment for individuals who were relocating (Beaver, 1979).
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SOCLAL WORK ROLE IN DISCHARGE PLANNING
In their role as coordinators of the planning process, social workers can promote patient control over decision making. In this capacity, they negotiate with key participants to develop a plan that meets various needs, usually including those of: (1)the patient; (2) family members; (3) health care providers; (4) the institution; (5) reimbursement sources; and (6) referral resources (Caputi, 1982). These negotiations are often complex and may present ethical dilemmas for the social worker, especially where resources are scarce and client, family or organizational interests at odds (Abramson, 1981). In some circumstances, social workers may find themselves compromising patient interests and giving priority to family and organizational concerns (Abramson, 1988; Blumenfield & Rosenberg, 1988; Fields, 1978). Yet, given the benefits of perceived control and autonomy, it is important that social workers make conscious and sustained efforts to emphasize patient control over making decisions about discharge. CLINICAL STRATEGIES TO ENHANCE PATIENT CONTROL
Social workers who assist patients with decisions about post discharge care can overcome the constraints of shorter hospital stays by developing practice patterns that enhance patient control, including: (1) involving the patient when working with families; (2) reaching for underlying conflict; (3) providing a sense of choice within existing parameters; (4) preparing patients for discharge; and (5) enlisting families and hospital caretakers to assist in these processes. It is important, however, to identify the obstacles to active participation in decision making which hospitalized patients face. Patients have difficulty influencing medical decisions or the hospital
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environment because of the depleting impact of illness, their sick role status and, for older patients, discounting attitudes toward the elderly (Marshall, 1981; Strauss, 1972; Tagliocozzo & Mauksch, 1979; Coe, 1986). Many physicians take a prescriptive and paternalistic stance toward patients which minimizes patient involvement in making decisions (Breslau, 1981). It is commonplace in current medical practice to discuss the patient's condition and treatment with family members rather than with the patient, thus compromising the patient's right to information and influence. Rosow (1981, p. 144) notes that for elderly patients, a physician/adult child coalition can occur which, while not necessarily malicious, is "at best, patronizing and at worst, depersonalizing and dismissive. The parent may seldom be accorded the courtesy of significant choices that are well within his competence." Working Jointly with Patients and Families
Social workers can be consistent in recommending that patients be included in meetings that physicians hold with families. It is important that this be the standard when the social worker is present. In this way, social workers can model for the physician, patient and family an including rather than excluding way oPworking. This principle should carry over to social work contacts with patients and families. Yet social workers in acute care hospitals routinely see patients and families apart from one another. Although such an approach may be more expedient at times, it is suggested that this be the exception rather than the rule. Through joint meetings, the patient's concerns remain center stage and are less likely to be circumvented due to conscious or unconscious social workerlfamily alliances. Patient-centered discharge planning is essential if the consequences of loss of control are to be avoided. Of course, the focus on the patient does not eliminate the social worker's responsibility to address the needs of family members as well. Social workers find the process of balancing competing needs of families and patients particularly challenging in those cases where family members ask that they be seen separately from the patient. These requests suggest the existence of family conflict and should alert the social worker to the need to include the patient in work
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with the family unit in order to protect patient autonomy. If an adult child, while discussing the placement of a parent in a nursing home, indicates that (s)he does not wish the parent to know of this plan, the social worker should recommend a joint patientlfamily meeting. The dangers inherent in leaving the parent out of the process should be explained and reassurance offered that the social worker will help family members deal with their own needs and with any conflicts that ensue. When patients are cognitively impaired, it may not be possible to include them in making those decisions that require substantial exercise of judgment. However, plans can still be shared and reactions sought in a joint meeting. Patient capacity for making decisions varies according to the type of decision and may wax and wane with variations in patient condition (Zuckerman, 1988). The social worker can make use of the patient's more lucid moments to get input, thus avoiding, where possible, "substitute decision making" (Kapp, 1988). One elderly man, quite confused and forgetful at times, understood enough about the decisions being made while his relatives were meeting with the social worker to send one of his grandchildren in to the meeting room to announce that he did not want his house sold. Strategies for maximizing control for impaired patients are discussed later in this article. Reaching for Underlying Conflict
Questions may arise as to the feasibility of working out conflicts within the time frame typically available for discharge planning. In many cases, however, obstacles to a timely discharge will develop unless the conflict is addressed directly (Proctor & Morrow-Howell, 1990). Careful clinical assessment can differentiate between those patients and families who are likely to have difficulties in planning and those where joint planning can take place without impediments. A few questions about the nature of family relationships asked in the first contact with the patient or with any family member are pivotal to the social worker's assessment. The patient who requests that the social worker contact one daughter but not another, or the family member who impugns the care provided to the patient by another member signals the social worker to anticipate possible
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problems in the process of planning for patient care after discharge. A request to withhold information from the patient or any family member is another indicator of possible conflict. Sometimes efforts to avoid conflict can lead a patient or family members to select less desirable options.
A 79 year old woman requested nursing home placement because she was having increased difficulty in caring for her daily needs. She lived with a single daughter who, though ernployed, had a history of periodic depressive episodes which required short psychiatric hospitalizations. Communication between them had been poor. The mother was angry at the daughter for not helping her more. After exploration of the situation with the patient, the social worker met jointly with the patient and her daughter. The patient was encouraged to present her feelings and needs to her daughter. The social worker provided information about services that could help maintain the mother at home and relieve the daughter of some of the responsibilities for caring for the patient. Ultimately, the patient was able to return home with some of these services. The relationship with her daughter .was somewhat improved, and most important, a plan was developed that was in tune with the patient's situation. Had the social worker pursued placement without further exploration, it is likcly that the patient would have refused to enter the nursing home when the time came. In some cases, a patient may be dissatisfied with the recommendations of the physician or other professional caretakers. If the patient is not helped to address the issues directly with caretakers, (s)he might act out these feelings, becoming depressed or agitated. In one situation, the social worker asked the patient, an independent 93 year old man, why he seemed so unhappy about having the visiting nurse come to his home to help him with dressing changes for leg ulcers. The patient had been superficially compliant with this plan but had cut the social worker off whenever she tried to discuss it with him. She then discovered that he was embarrassed about his
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living conditions and that, in fact, he needed more extensive help than he had initially requested. Where conflict exists, social workers help by bringing underlying issues into the open early in the planning process. This gives paticnts and families opportunities to deal with the guilt, sadness and hostility so often connected to decisions about caring for the impaired member (Mailick, 1979; Parsons & Cox, 1989; Stewart, 1984; Townsend, Deimling, Noelker & Bass, 1986). Open discussion of family or individual issues, however brief, can lead to the level of resolution necessary to arrive at a decision. This also facilitates better adjustment for both patient and family after discharge (Solomon, 1983) and may, in fact, contribute to a more timely discharge. Creating a Sense of Choice Some interventions suggested in this article may appear obvious or superficial in the degree of choice they provide for patients. Yet these seemingly modest interventions do enhance perceived control and have been well documented as having an impact on various barometers of patient well-being. Consistent efforts by social workers to provide patients a sense of choice are clearly indicated. One of the most effective means for engaging patients in planning is the discussion of available options (Abramson, 1988). Social workers can encourage patients and families to consider more than one option in making decisions about post hospital care. It is often difficult for a social worker to present a variety of options if those available seem undesirable. Yet, within any given set of options, no matter how limited, it is still possible to locate areas for enhancing patient control. A well-oriented 82 year old man was reluctant to accept placement in a nursing home with a high proportion of demented patients. This nursing home was the only one that his elderly sisters could visit by public transportation. The social worker and the patient talked about his reactions to the proposed placement. The patient acknowledged that he was very frightened of "losing his marbles" someday and thought that being around confused people would upset him. He felt, how-
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ever, that he should not refuse the placement because he very much wanted to stay in close touch with his sisters. The social worker tried to help him work out ways that he might be more comfortable in this setting. She asked his sisters to meet with her and the patient. At the meeting, the sisters decided to work out a regular schedule of visits for themselves, other members of the extended family and church volunteers so that the patient would have continued stimulation. They asked the social worker to arrange for the patient to return weekly to the community center he had previously attended so that he could maintain his membership in a chess club. Weekend visits by the patient to family members were also set up. The patient and his family were encouraged to present his concerns to the nursing home's director of admissions in the hope that the staff there might suggest additional strategies such as assuring the patient a well-oriented roommate. Several months after the patient's discharge, the social worker received a call from one of the patient's sisters who noted that the patient was sometimes depressed and telephoned them often. She also reported that the patient was involved with a small group of men who talked about politics, and that he was helping the nurses a little now that he was ambulating better. She said the visits home and to the community center had gone well. Strategies such as those described here can succeed in supporting the patient's sense of autonomy only if the priorities are set by the patient and the plans carried out or at least directed by the patient to the extent possible. Self determination has to be redefined for those patients with mental impairment due to their reduced capacity to exercise judgment. However, choices can be developed that are appropriate for the patient's level of functioning (Kapp, 1988). Patients with moderate dementia, for example, may be unable to adequately evaluate their self care abilities but can be involved in choosing personal possessions to take to a nursing home. These patients can also choose the clothing to wear on discharge, the hour of discharge or
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for some nursing homes, whether to have a roommate or live in a single room. It may be possible to engage patients in identifying preferred nursing homes, depending on the level of impairment and the availability of resources. If patients are unable to gather needed documents, they can be encouraged to delegate authority to others formally. For patients with mild impairment of memory, the social worker can reinforce a patient's sense of autonomy by adhering, wherever possible, to an interview schedule and agenda set by the patient (Blumenfield, 1983). Efforts can be made to help the patient obtain preferred modifications in the hospital routine. T o assist forgetful patients in maintaining control over an interview, the social worker can make a brief outline of the discussion in a notebook kept in the patient's possession. The patient then can refer to it in the social worker's absence, or they can review it together at the beginning of the next interview. The notes of the interview should reflect the patient's point of view and any decisions made during the interview. One social worker described note taking to patients as "taking dictation" and would read back the points as a means of summarizing the session. An alert social worker can develop other creative micro-interventions that increase a sense of control for patients whose capacities for decision making are impaired. Many of the approaches noted here may be adapted well in working with unimpaired patients.
Preparing Patients for Discharge Preparing patients for coping with the circumstances of post hospital life is another means for supporting their autonomy. A patient who knows what to expect from a new setting and who is emotionally prepared to deal with the impending changes is more likely to feel a sense of control over the environment. Preparation can take place through: (1) discussing the possible negative consequences of the decisions made; (2) eliciting feelings about the change; and (3) providing information about the chosen plan. Janis and Mann (1977) point out that certain patterns of making decisions under stress can lead to satisfaction with a decision independent of whether or not its implementation leads to good or bad
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consequences. They note that the most effective decision making pattern is one of vigilant information seeking. This pattern is best supported by adequate time to explore options and by awareness of the risks associated with a given decision. Janis and Mann's notion of emotional inoculation (p. 155) provides a theoretical explanation for the importance of participation in decision making. This concept suggests that through the availability of information about a choice, its consequences and the consequences of other alternatives, individuals prepare themselves to cope with these consequences, especially the negative ones. As social workers engage patients in a consideration of alternatives for care after discharge, the review of possible negative consequences can help patients in developing cognitive strategies to assist them with future difficulties. Facing the negative aspects of a plan is helpful to patients even in those situations where the available options appear undesirable. The literature indicates that helping a patient to decide which of the unsatisfactory alternatives is most acceptable still enhances the individual's sense of control (Janis & Mann, 1977). Even satisfactory choices usually involve changes for the patient and family and thus evoke anxiety or other feelings. Reaching for feelings about the transition is essential to helping the patient begin the adaptation process. It also begins the necessary process of terminating the relationship with the social worker and the hospital setting. Although social workers do not usually control the date for discharge, they still can take the initiative to engage patients in a review of their work together in anticipation of discharge. It is helpful to identify the patient's contribution to the outcome and to reflect on the decision making process. Discussion of the working relationship between the social worker and the patient and of the significance of its ending also can help to prepare the patient to move on (Fortune, 1989). Finally, helping patients obtain information about the settings to which they were relocating has been shown to influence post discharge adjustment (Hunt & Hunt, 1983; Pastalan & Bourestom, 1975). Although it is not always possible to predict which nursing home will have an available bed for the patient, each department of social work can develop a file of brochures and photographs (espe-
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cially of patient rooms and dining rooms) of those institutions most often used for referral. Daily patient schedules can be obtained with listings of activities and menus. These materials can be used by social workers and family members to help prepare patients for the everyday realities of the new setting. They also can serve to reorient patients with dementia about the impending change. Wherever possible, arrangements should be made for the patient to visit the nursing home prior to the transfer.
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Educating Others to Enhance Control
Social workers can also help patients by involving others in using the strategies outlined. Nurses, aides, physical and occupational therapists, family members and volunteers can be helped to understand the significance of control for patients (Aroskar, Urv-Wong & Kane, 1990). They too can utilize intervention strategies such as orienting and reorienting patients to the new setting through use of photos, menus and schedules. Family members can take photos of the nursing home if no others are available. Volunteers can be involved in gathering information about frequently used facilities for a department file. A volunteer corps can be developed to visit patients awaiting placement (especially those without family). The volunteers can implement strategies worked out with the social worker, such as helping a patient pack for the move. Social workers on units where many patients are facing relocation can sensitize nursing staff to the importance of enhancing control for patients and of preparing them for transfer. It may be possible through teamwork efforts to create a patient care climate that can significantly influence post discharge adjustment for many patients. ILLUSTRATIONS
Mrs. Hopper, 82, was admitted to the hospital with a fracture of the shoulder. A widow for 15 years, she lived alone and had used a walker for the past few years. Her niece told the admitting nurse that the patient had become forgetful recently. She had been having difficulty managing her affairs and had received an eviction notice for nonpayment of rent.
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Since then, the niece and her husband had been managing the patient's finances. The patient seemed confused in some of her talks with the social worker. At other times, she seemed aware of her situation. Usually, she remembered the fall which led to her admission and admitted to being fearful about being alone at home. When asked if she wished to go to a nursing home, she said that she did not know, and that the social worker should speak with her niece instead. The social worker requested an assessment by the home care department to see if it was feasible for the patient to return home. The home care evaluation indicated that the patient could no longer. ambulate with a walker. .Home care services were not recommended since available care would not be adequate for this patient. With Mrs. Hopper's permission, the social worker asked the niece and her husband to come in for a joint meeting with the patient, stating that the patient seemed to want the niece to make the decisions. Over the telephone, the social worker explored the niece's feelings about this and indicated her concern about the patient's abdication of the right to make her own decisions. The social worker and the niece agreed that the patient's competency for making decisions was compromised by confusion, but that she could still participate to some extent. Noting that, in her experience, patients did much better after placement when they were involved in planning, the social worker proposed that the niece ask her aunt's permission to carry out needed activities on her behalf. In the joint patienttfamily meeting, the patient agreed that she could not take care of herself anymore and said she would go to a nursing home. Since there were many things to be taken care of, the niece's husband suggested that they make a list that the patient could sign, delegating the tasks that family members needed to do on her behalf. At first, the patient seemed to feel that wasn't necessary, but subsequently she got involved in telling the others what she wanted done. When the social worker interviewed the patient alone the next day, Mrs. Hopper seemed rather vague about the decision
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to go to a nursing home. The social worker explored her knowledge about local facilities and found that Mrs. Hopper's poor recent memory did not impede her ability to recall what she knew about several nursing homes in the community. In fact, she knew some residents at one home and had negative impressions of another. The social worker used this information to guide her efforts to arrange placement. She continued to meet with the patient regularly for the rest of her stay to review the plans and to prepare Mrs. Hopper for the impending change. She asked the niece to get brochures, photos and schedules from the nursing homes most likely to admit Mrs. Hopper. The niece then shared these with the patient. The niece and the patient also discussed which personal possessions Mrs. Hopper wanted to take with her. This case is typical of many seen by hospital social workers. In fact, it might be seen as fairly uncomplicated because Mrs. Hopper passively accepted the need for placement. Her shifting mental status was another common complication that social workers face when they help the elderly to make discharge planning decisions. Yet the social worker did not let Mrs. Hopper's confusion deter her from working with the patient's feelings about the upcoming transfer. She thus discovered that the Mrs. Hopper could communicate with her on an affective level despite memory loss. In another similar situation, an elderly man with fairly severe dementia commented, when told he would be going to a specific nursing home, "Oh, that place is OK, but it is a little too close to the funeral parlor." His impairment did not obstruct the efforts of the social worker to communicate with him on a more symbolic level about the meaning of this event for him. Problems often arise when there is conflict between the patient and family and with the health care providers. Mrs. Otis, a 78 year old widow, was hospitalized for a serious fracture of the femur. She required complex surgery, involving a non-ambulatory period of six weeks followed by a long convalescence. The physician emphasized that the patient would need an extended rehabilitation period in order to walk
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well again. In her first interview with Mrs. Otis, the social worker offered to help the patient find the right place to get this care. The patient, who previously had been somewhat guarded, refused to speak further with the social worker and asked her to leave the room. The patient's daughter contacted the social worker the next day to ask for help in planning for her mother's care. The social worker asked the daughter to let her mother know that she was meeting with the social worker and for what purpose. The daughter described the patient as an independent, imperious woman who was suspicious of others. She told of much conflict with her mother who had continually tried to run her life. The social worker reviewed with the daughter the options available for the patient's convalescence. The daughter emphatically stated that she could not take her mother into her own home during the rehabilitation period, nor did she feel that her mother could return to her own home without rehabilitation. At this point, the social worker set up a family meeting. At the joint meeting, the patient kept her back turned after saying to her daughter, "What are you doing here!" Initially she was an angry non-participant. The social worker acknowledged that the patient was being presented with choices that she did not find acceptable and explained once more the consequences of not receiving rehabilitation services. When Mrs. Otis did not respond, the social worker sympathized with the patient's predicament, all the while directing her comments to Mrs. Otis' back. The social worker then asked the daughter to explain why she could not bring her mother to her home. At this point, the patient responded with hurt and anger, expressing a torrent of feelings about those meddling in her affairs and about a daughter who didn't want to take care of her own mother. In support of this patient's traditionally active approach to problem solving, the social worker noted that others would need to make decisions that were rightfully hers unless she took charge. The patient ultimately accepted the need for a temporary stay in a nursing home with a good rehabilitation program.
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A careful assessment of family dynamics and the patient's past modes of problem solving was critical in this example. In light of Mrs. Otis' history, her current behavior was not the norm for her and needed to be understood for resolution to occur. Exploration of family history can bring insights that will direct further intervention and facilitate engagement of both the patient and family. In this situation, the patient's perception that her daughter was unwilling or unable to care for her was fueling her anger and resistance to planning. Joint work with the patient and her daughter was necessary, even in the face of resistance from either. Working with family conflict within the family system dilutes the pernicious impact of family secrets and assures that the patient's needs and feelings are not circumvented. It also facilitates face to face problem solving by direct confrontation of those interpersonal factors which are likely to interfere with an effective as well as timely discharge plan. CONCLUSION
Social workers in acute care hospitals are in a unique position to implement interventions that enhance patient control over decision making. They meet patients and families at critical junctures when the decisions made will have far reaching consequences. Strategies have been described which have the potential to mediate the inevitable impact of relocation and the stress of changed circumstances. However, social workers face some impediments to utilizing this approach. The long standing tendency within the field to devalue planning for post hospital care as a "non clinical" function reduces motivation to articulate appropriate clinical interventions (Bailis, 1985). Also, the current regulatory climate has shortened the time frame within which decision making takes place and has increased pressures on social workers to expedite discharges. It is suggested here that despite the well known constraints facing those who help patients and families with planning, many opportunities exist for clinical interventions to enhance control for patients. To maximize them, a social worker must be conceptually clear about the significance of these interventions, creative about developing them and committed to their implementation. A parallel process can develop: as the patient is provided a greater sense of con-
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trol, the social worker makes a contribution in an arena which is under the worker's control; namely, the engagement of the patient and family in decision making. Additionally, such an approach facilitates timely discharges by anticipating and resolving the interpersonal issues that so easily obstruct planning.
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