JOB SATISFACTION, BURNOUT, AND TURNOVER IN HEALTH CARE SOCIAL WORKERS KRISTINE SIEFERT, SRINIKA JAYARATNE, and WAYNE A. CHESS The findings of two consecutive surveys of job satisfaction and burnout in national samples of health care social workers are presented. Between 1979 and 1989 there were significant increases in the proportion of social workers employed in private versus public agencies, in quantitative workload, and in social workers ' perceptions of the challenges presented by their jobs. Role conflict and role ambiguity, lack of comfort and dissatisfaction with financial rewards emerged as significant predictors of depersonalization and burnout. However, a significant increase in social workers ' feelings of personal accomplishment also occurred, and high challenge emerged as a significant predictor of sense of effectiveness. 1
Job-related stress and burnout among health care social workers are topics that have received considerable attention in the health care social work literature (Beemsterboer & Baum, 1984; Borland, 1981; Kane, 1981; Taylor-Brown, Johnson, Hunter, & Rockowitz, 1981). Burnout has often been cited as a hazard of social work practice with chronically ill children and adults, with terminally ill patients, and with patients requiring emergency or intensive care (Bergman, West, & Lewiston, 1979; Koocher, 1979; Pilsecker, 1979). More recently, a number of authors have expressed concern about the impact of the sweeping changes that have occurred in the organization, financing, and delivery of health care over the past decade on social workers practicing in health settings. The rapid expansion of for-profit health care; the need to develop income-producing services; heavier caseloads
and more complex and demanding cases; the pressure to discharge patients earlier engendered by the shift to prospective payment; the declassification of social work positions and increased competition among the ancillary health professions, particularly between social work and nursing; and ethical dilemmas and value conflicts resulting from financial constraints and advances in health care technology have all been identified as potential sources of stress and burnout for social workers (Edinburg, 1988; Joseph & Conrad, 1989; Kenney, 1990; Kulys & Davis, 1987). Ortiz and Bassoff (1988) commented that "given the demands placed on social workers in hospital settings, burnout seems to be a particularly acute risk for both proprietary and nonprofit hospital social workers" (p. 120). Despite widespread concern about job-related stress among health care social workers, there is
CCC Code: 0360-7283/91 $1.00 © 1991, National Association of Social Workers, Inc.
193
little empirical research addressing this topic and none investigating changes in job-related stress and job satisfaction among health care social workers over time. This article presents the findings of two consecutive surveys of factors associated 'with job satisfaction and burnout in national samples of health care social workers. The first survey was undertaken in 1979 and the second in 1989. The conceptual framework used by the authors assumes that job satisfaction and burnout are separate but related functions of the interaction between the social worker and various aspects of his or her job. This perspective is congruent with that of other research investigating occupational stress, job satisfaction, and workers' physical and mental health (House, 1981; Kahn, 1970; LaRocco, House, & French, 1980). The research presented here is part of a larger study of job satisfaction and burnout in professional social workers, including family service workers, community mental health workers, and child welfare workers Qayaratne & Chess, 1982/1983, 1983, 1984).
VARIABLES AND MEASUREMENT Job characteristics chosen for study as correlates of job satisfaction and burnout were identified through reviews of the social work, occupational health, and organizational psychology literature. Role conflict, role ambiguity, value conflict, and workload have been associated with both job satisfaction and burnout (Harrison, 1980; Kahn, 1970; Rizzo, House, & Lirtzman, 1970). For social workers in health care settings, physician dominance, the rivalry between social work and nursing, and the need for multidisciplinary collaboration are frequently cited as sources of stress when disagreement, overlap, or competition occur and as sources of considerable satisfaction when health care team members are able to work together in an atmosphere of mutual support (Dana, 1983; Davidson, 1978; Kane, 1975; Kulys & Davis, 1987; Lister, 1980; Lowe & Herranen, 1978; Mailick & Jordan, 1977). Joseph and Conrad (1989) found that role clarity was associated positively with satisfaction with the medical social work role and that satisfaction was associated highly 194
with the ability of the social worker to influence ethical decisions. Davidson (1978), Ortiz and Bassoff (1988), and Edinburg (1988) noted the strain related to workload and professional value conflict among health care social workers. Mizrahi and Abramson (1985) described conflict over roles, values, and ethical dilemmas as a source of strain between social workers and physicians. Challenge, financial reward, opportunity for promotion, and comfort have previously been examined primarily as correlates of job satisfaction in studies of social workers in non-health care settings. However, the challenge of working with terminal cancer patients was noted by Koocher (1979) and discussed in detail by Pilsecker (1979). In the most recent literature addressing the impact of the last decade's changes in health care on social workers, challenge plays a major role. Edinburg (1988) identified seven major challenges to social workers in health care settings as a result of the proliferation of for-profit health care providers and changes in reimbursement, and Kenney (1990) noted a number of challenges to social work management in emerging multihealth systems. All of these variables have been examined as correlates of job satisfaction among a diverse sample of professional social workers, with challenge and promotional opportunities emerging as significant predictors (jayaratne & Chess, 1982/1983, 1983, 1984). The following nine job characteristics were measured: role ambiguity, role conflict, value conflict, workload, challenge, comfort, financial rewards, promotional opportunities, and job satisfaction. All job characteristics were measured using well-established indexes of demonstrated reliability and validity. All indexes are based on a Likert scale response format. Internal reliability coefficient alphas are presented where appropriate and available; all indexes have been used in large-scale surveys with a wide range of occupational groupings. Study populations do not differ significantly from those on which the scales were developed. Role ambiguity is a four-item measure of job clarity. An item example is "My work objectives are well-defined. " Its reliability is .84 (Caplan, Cobb, French, Harrison, & Pinneau, 1975).
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
Scores range from 4 to 20, with high scores indicating greater role ambiguity. Role conflict is a four-item index of the conflicts that an individual perceives as being present in his or her job. An item example is "On my job, I can't satisfy everybody at the same time." Its reliability is .62 (Quinn & Staines, 1978). Scores range from 4 to 16, with higher scores indicating higher conflict. Value conflict is a single item that asked the respondent "How often do your professional values conflict with the job?" Scores range from 1 to 5, with higher scores indicating higher conflict. This item was constructed for this study. Workload is a four-item index of quantitative workload. An item example is "How often does your job require you to work very fast?" Its reliability is .60 (Caplan et al., 1975). Scores range from 4 to 20, with higher scores indicating higher workload. Challenge is a six-item scale on the perceived challenge of the job. An item example is "The problems I am expected to solve are hard enough." Its reliability is .83 (Quinn & Shepard, 1974). Scores range from 6 to 24, with higher scores indicating greater challenge. Comfort is a seven-item index measuring the physical comfort of the work situation. An item example is' 'The physical surroundings are pleasant." Its reliability is .69 (Quinn & Shepard, 1974), and higher scoresindicate greater comfort. Financial rewards is a three-item index measuring the worker's satisfaction, pay, security, and fringe benefits. An item example is "The pay is good." Its reliability is .70 (Quinn & Shepard, 1974). Scores range from 3 to 12, with higher scores indicating greater satisfaction. Promotional opportunities is a three-item index measuring the person's perceptions about opportunities for advancement within the organization. An item example is "The chances for promotion are good." Its reliability is. 76 (Quinn & Shepard, 1974). Scores range from 3 to 12, with higher scores indicating greater satisfaction on this dimension. Job satisfaction is a single item that asked the respondent "All in all, how satisfied would you say you are with your job?" Scores range from 1 to 4, with lower scores indicating greater satisfaction (Quinn & Shepard, 1974). JOB SATISFACTION, BURNOUT, AND TURNOVER
Burnout was measured using modified versions of the depersonalization, emotional exhaustion, and sense of personal accomplishment scales developed by Maslach and Jackson (1981). The scaleswere modified to decrease the length of the questionnaire and thus minimize respondent fatigue. The item "I feel burned out from my work" was used rather than the entire emotional exhaustion scale; this particular item has a very high factor loading (.81) with the total scale and is thus an acceptable measure of emotional exhaustion. The entire depersonalization and personal accomplishment scales were used, but only the intensity dimension was measured. Within the Maslach Burnout Inventory, the betweenscale correlation is .49 (emotional exhaustion x depersonalization). This interscale correlation is comparable to that reported by Maslach and Jackson (1981) using the original scales. Job satisfaction is correlated at -.43 with depersonalization and emotional exhaustion. Clearly, these scales are measuring different but overlapping dimensions. For all the scales, Maslach's "never" category of alternatives was dropped, and a seven-point response option was presented. Higher scores indicate greater levels of depersonalization and emotional exhaustion, as wellas a higher level of feelings of accomplishment. Termination of employment is frequently cited as a potential outcome of burnout (Armstrong, 1977; Maslach, 1976). Therefore, respondents were asked to indicate the likelihood of making a genuine attempt to find a new job within the next year. Response options ranged from "very likely" to "not at all likely" on a three-point scale.
SAMPLE AND METHOD Subjects in this study were social workers who identified themselvesas working in health care settings in two national surveys drawn from the computerized membership directory of the National Associationof SocialWorkers. The sample for the first survey was drawn in 1979 and the second in 1989. In the 1979 survey, 1,173 randomly selected members were mailed questionnaires, and 853 were returned, for a response rate of 72.7 percent. In the 1989 survey, 1,500 randomly selected members were mailed questionnaires, 195
working in private health care agencies (X 2 17.52, df = 1, P = .0000).
and 882 were returned, for a response rate of 58.8 percent. The present analysis is restricted to those respondents who identified themselves as master of social work-level social workers employed in health settings and having direct client contact. Table 1 presents the demographic characteristics of the respondents for each sample. Of the 126 respondents in the 1979 sample, the majority were female (83.3 percent, n = 105), Caucasian (83.3 percent, n = 105), and married (51.6 percent, n = 65), and 23.0 percent (n = 29) had an annual personal income of more than $25,000. Of the 144 social workers in the 1989 sample, the majority of respondents also were female (88.2 percent, n = 127), Caucasian (91.7 percent, n = 132), and married (63.9 percent, n = 92), and 63.2 percent (n = 91) had an annual personal income of more than $25,000. Significantly more social workers in the 1989 sample were married than in the 1979 sample (X2 = 4.08, df = 1, P = .04). Interestingly, there was also a significant change in the proportion of social workers employed in private health care agencies as opposed to public health care agencies between 1979 and 1989. In 1979, 38.1 percent (n = 48) of the respondents worked in private agencies, whereas in 1989, 62.5 percent (n = 90) of the respondents reported
FINDINGS In 1979, 32.5 percent (n = 41) of the respondents reported that they were very satisfied and 53.2 percent (n = 67) reported that they were somewhat satisfied with their jobs. In 1989, there was very little change in workers' level of job satisfaction: 31. 9 percent (n = 46) of the respondents described themselves as very satisfied and 51. 4 percent (n = 74) described themselves as somewhat satisfied with their jobs. Similarly, 16.7 percent (n = 21) of the respondents scored higher than 16 out of 35 possible points on the depersonalization scale in 1979, and only 18.1 percent(n = 26) scored higher than 16 on the same scale in 1989. In 1979, 31.7 percent (n = 40) of the social workers in the sample rated themselves higher than 4 on a seven-point scale in response to the statement "I feel burned out from my work." In 1989, 25.7 percent (n = 37) rated themselves higher than 4 on this same scale. Thus, althoughjob satisfaction among the 1989 respondents remained high and social workers continued to report little depersonalization in their practice, one-fourth of the respondents reported feelings of emotional exhaustion.
Table 1. Demographic Characteristics of Respondents
1979 (n = 126) Factors
Mean
Age (years)
39.17
n
1989 (n = 144)
%
Mean
n
%
41.25
Sex Male Female
21 105
16.7 83.3
17 127
11.8 88.2
Race/Ethnic Group American Indian Asian Black/African American Caucasian Chicano/Mexican American Puerto Rican Other
1 6 13 105 0 0 1
0.8 4.8 10.3 83.3 0 0 0.8
1 1 5 132 3 0 2
0.7 0.7 3.5 91.7 2.1 0 1.4
65 61
51.6 48.4
92 52
63.9 36.1
Marital Status Married Not married Years in Position
196
4.12
4.69
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
However, the number of workers reporting such feelings did not increase between 1979 and 1989. The most substantial change between 1979 and 1989 occurred in social workers' ratings of their sense of personal accomplishment. In 1979,46.8 percent (n = 59) of the respondents scored 40 or more out of 56 possiblepoints on the sense of personal accomplishment scale, whereas in 1989, 70.8 percent (n = 102) scored more than 40 points on the same scale. In 1979,16.7 percent (n = 21) of the social workers surveyed described themselves as very likely to make a genuine effort to find another job within the next year, and 23.8 percent (n = 30) described themselves as somewhat likely to do the same. In 1989, 21.5 percent (n = 31) of the respondents indicated that they were very likely to attempt to find another job, whereas 25.7 percent (n = 37) reported that they were somewhat likely to do so within the next year. Thus, although the increase was not significant, in 1989 almost one-half of the health care social workers surveyed were at least considering making a serious effort to find other employment. In 1979, of the four outcome measures studied, only job
satisfaction correlated significantly with likelihood of job turnover. Higher levels of job satisfaction were associated with less likelihood of a social worker making a serious attempt to find other employment. In 1989, however, significant and substantial correlations were found between likelihood ofjob turnover and all of the outcome measures. High levels of job satisfaction and a high sense of personal accomplishment were associated with less likelihood of turnover, and depersonalization and emotional exhaustion were associated with greater likelihood that the social worker would make a genuine attempt to find another job. Mean scores on the four outcome measures and on the measures of the job characteristics identified as factors injob satisfaction and burnout were compared for the two samples. Significant differences between the 1979 respondents and the 1989 respondents were found for workload, which was higher in the 1989 sample, and for perceived challenge and sense of personal accomplishment, which were also higher for the 1989 sample (Table 2). Satisfaction with financial rewards was significantly lower for the 1989
Table 2. Factors Influencing Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment among Health Care Social Workers, 1979 and 1989
p
Factors
1979
1989
Role ambiguity Mean Variance
8.14 9.55
7.70 7.16
-1.248
Workload Mean Variance
15.72 12.85
16.75 8.05
2.627
.0091 **
Role conflict Mean Variance
10.63 8.73
10.55 7.39
-.2085
NS
Comfort Mean Variance
18.03 15.97
18.73 12.40
1.4969
NS
Challenge Mean Variance
17.61 12.84
18.67 9.88
2.5664
.0108*
9.35 3.55
8.62 3.86
- 3.0856
Financial rewards Mean Variance
NS
.0022** continued
JOB SATISFACTION, BURNOUT, AND TURNOVER
197
Table 2. (continued) Factors
1979
1989
Promotional opportunities Mean Variance
6.50 5.77
6.47 5.33
- .11354
NS
Value conflict Mean Variance
2.52 1.50
2.46 1.38
.39387
NS
Job satisfaction Mean Variance
3.17 .47
3.15 .49
.29253
NS
Emotional exhaustion Mean Variance
3.43 3.75
3.33 3.13
- .37292
NS
Depersonalization Mean Variance
11.80 34.24
11.24 26.73
-.75286
NS
Personal accomplishment Mean Variance
38.25 34.23
43.62 45.35
6.2835
.0000" •
NOTE: NS
=
P
Not significant.
'p < .05. **p < .01. ***p < .001.
respondents, despite significantly higher personal incomes. However, the effects of inflation must be considered when interpreting this response. To determine which of the eight job characteristics were the best predictors of outcome, standardized multiple regression analyses of the job characteristics associated with job satisfaction, emotional exhaustion, depersonalization, and personal accomplishment were computed for each sample (Tables 3 and 4). Marital status was used as a control variable because there was a significant difference in marital status between the 1979 and 1989 samples. In 1979, high challenge and high perceived opportunity for promotion were significant predictors of job satisfaction. Not being married was the only significant predictor of emotional exhaustion, and low challenge was the only significant predictor of depersonalization. Low role conflict was a significant predictor of sense of personal accomplishment. In 1989, high challenge, satisfaction with financial rewards, and low conflict with professional values were significant predictors of job satisfaction. Role conflict, role ambiguity, and lack of comfort were significant predictors of emotional 198
exhaustion, and high role conflict, low challenge, and low satisfaction with financial rewards were significant predictors of depersonalization. Five job characteristics were significant predictors of sense of personal accomplishment: high challenge, high workload, greater satisfaction with financial rewards, low levels of role conflict, and low levels of conflict with professional values. .
DISCUSSION Some of the changes that have occurred in health care over the past decade have had a significant impact on social workers who practice in health care settings. Between 1979 and 1989, a major shift from employment in public agencies to employment in private agencies took place, paralleling the privatization of health care. Although it is not known whether private agencies that employ social workers are for-profit organizations, the authors suspect that this is increasingly the case. Even if such agencies are not proprietary, a number of authors have expressed concern about the impact of the changing economic climate and the increased emphasis on
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
Table 3. Multiple Regression Analyses of Workers' Perceptions of Job Characteristics as Predictors of Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment, 1979 Factors Job satisfaction (R2 .53, F Marital status Role ambiguity Workload Role conflict Comfort Challenge" Financial rewards Promotional opportunities' Value conflict
8.684, P
Emotional exhaustion (R2 = .26, F Marital status' Role ambiguity Workload Role conflict Comfort Challenge Financial rewards Promotional opportunities Value conflict Depersonalization (R 2 = .19, F Marital status Role ambiguity Workload Role conflict Comfort Challenge' Financial rewards Promotional opportunities Value conflict Personal accomplishment (R2 Marital status Role ambiguity Workload Role conflict' Comfort Challenge Financial rewards Promotional opportunities Value conflict
p
Beta .0000)
2.742,
1.776, P
.18, F
P
-.80 .19 .18 - .18 - .12 .47 .91 .23 -.59
-.948 .185 1.216 - .127 - .775 3.978 .937 2.245 - .580
NS NS NS NS NS .0002 NS .0280 NS
.24 .54 .76 .34 .11 -.65 .61 - .25 -.71
2.233 .411 .411 1.917 .567 -.442 .496 - 1.922 -.551
.0287 NS NS NS NS NS NS NS NS
.89 .77 -.38 .31 .17 -.31 -.76 .79 .27
.800 .560 - .197 1.638 .864 - 2.008 -.596 .581 .201
NS NS NS NS NS .049 NS NS NS
.64 .48 .33 -.37 .71 .25 -.65 - .12 .44
.576 .351 1.717 - 1.954 .359 1.635 -.508 -.908 .331
NS NS NS .0547 NS NS NS NS NS
.0084)
.0884)
1.746, P
.0947)
NOTE: NS = Not significant. *p :S .05. * *p :S .0005.
revenue-producing social work services in health care settings (Edinburg, 1988; Kenney, 1990; Ortiz & Bassoff, 1988). The authors found that social workers' workloads rose concurrently with major cutbacks in health care services and personnel. Although challenge remained a stable predictor of job satisfaction among health care social workers, concern about financial rewards JOB SATISFACTION, BURNOUT, AND TURNOVER
and conflict with professional values emerged as significant predictors of overall satisfaction with employment. The emergence of these characteristics occurred at the same time as the implementation of stringent cost-containment measures and the appearance of increasingly complex ethical dilemmas engendered by technological advances and the need to allocate and 199
Table 4. Multiple Regression Analyses of Workers' Perceptions of Job Characteristics as Predictors of Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment, 1989
10.569, P
Job satisfaction (R 2 .49, F Marital status Role ambiguity Workload Role conflict Comfort Challenge'" Financial rewards' Promotional opportunities Value conflict'
Depersonalization (R 2 = .19, F Marital status Role ambiguity Workload Role conflict' Comfort Challenge' Financial rewards' Promotional opportunities Value conflict Personal accomplishment (R2 Marital status Role ambiguity Workload" Role conflict" Comfort Challenge'" Financial rewards" Promotional opportunities Value conflict' =
.00(0)
5.659, P
Emotional exhaustion (R2 .34, F Marital status Role ambiguity" Workload Role conflict' Comfort" , Challenge Financial rewards Promotional opportunities Value conflict
NOTE: NS 'p :5 .05.
2.678, P
.49, F
.36 - .12 - .16 - .13 .56 .41 .22 -.99 - .19
.482 - 1.314 - .159 - 1.357 .571 4.675 2.439 - .110 - 2.265
NS NS NS NS NS .0000 .0165 NS .0257
.47 -.27 -.22 .22 - .44 - .17 - .14 .15 .10
.554 -2.742 - 1.859 1.959 -3.902 -1.713 - 1.388 1.457 1.017
NS .0072 NS .0529 .0002 NS NS NS NS
.85 - .10 - .13 .24 - .32 -.23 -.24 .18 - .19
.915 -.933 -.993 1.942 -.261 -2.104 -2.142 1.598 1.829
NS NS NS .0549 NS .0379 .0346 NS NS
-.28 .96 .32 -.30 .17 .44 .25 - .15 -.21
-.382 1.092 3.068 - 3.038 1.728 5.062 2.849 - 1.648 -2.438
NS NS .0028 .0030 NS .0000 .0053 NS .0165
.00(0)
.0(79)
10.689, P
.00(0)
Not significant. :5 .01. "'p :5 .0005.
"p
a
even ration scarce health care resources oseph & Conrad, 1989). As changes in reimbursement and "remedicalization" prompted increased competition among ancillary providers (Edinburg, 1988) and as nursing asserted itself as a profession and expanded its domain (Kulys & Davis, 1987), role conflict and role ambiguity emerged as significant predictors of emotional 200
p
Beta
Factors
exhaustion among health care social workers in 1989. Interestingly, lack of physical comfort replaced being unmarried as a significant contributor to burnout. Perhaps the most striking and encouraging change occurred in health care social workers' sense of personal accomplishment: A significant increase in feelings of effectiveness occurred
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
between 1979 and 1989. Current research and social psychological theory suggest that a sense of competence and mastery is a critical element for successful coping and adaptation under stressful conditions (Bandura, 1982; Lazarus & Folkman, 1984; Rutter, 1987). This sense of competence and mastery is especially important considering the role conflicts and value conflicts that health care social workers face today (Edinburg, 1988; Kulys & Davis, 1987). Kenney (1990) observed that "the values to which professional social workers subscribe and the altruistic motives that led most of them to pursue this particular career can be challenged strenuously if service-related reductions occur when corporate ventures appear to be prospering" (p. 25)and that such a dynamic is especially likely to occur when patients are affected. He noted that the outcome can be "cynicism, blame, and blatant anger" (p. 25) toward the social worker. The findings reported here suggest that despite higher workloads and less satisfaction with financial rewards, health care social workers are maintaining a strong belief in their effectiveness as professionals. Joseph and Conrad (1989) found that social workers who were satisfied with and clear about their roles as medical social workers and who had formal preparation in ethical decision making had greater influence on ethical choices in multidisciplinary settings. Their findings and those of this study suggest the need for increased attention to conflict resolution and ethical decision making in social work practice in health settings.
About the Authors Kristine Siefert, PhD, is Associate Professor, and SrinikaJayaratne, PhD, is Professor, School of Social Work, 1065 Frieze Building, University of Michigan, Ann Arbor, MI 48109. Wayne A. Chess, PhD, is Professor, School of Social Work, University of Oklahoma, Norman, OK. This paper was supported by National Institute of Mental Health Research and Development Grant No. MH18773-03.
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Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122147. Beemsterboer,J., & Baum, B. H. (1984). Burnout: Definitions and health care management. Social Work in Health Care, 10, 97-109. Bergman, A. S., West, A., & Lewiston, N. J. (1979). Social work practice and chronic pediatric illness. Social Work in Health Care, 4, 265-274. Borland, J. J. (1981). Burnout among workers and administrators. Healthand Social Work, 6, 73-78. Caplan, R., Cobb, S., French,J.R.P., Harrison, R. V., &Pinneau, S. R. (1975).Jobdemandsand workers' health. Washington, DC: U.S. Department of Health, Education, and Welfare. Dana, B. (1983). The collaborative process. In R. Miller & H. Rehr (Eds.), Social workissues in health care (pp. 181-220). Englewood Cliffs, NJ: Prentice Hall. Davidson, K. W. (1978). Evolving social work roles in health care: The case of discharge planning. Social Work in Health Care, 4, 43-54. Edinburg, G. M. (1988). Social work in teaching hospitals and expansion of for-profit health corporations. Health and Social Work, 13, 122-129. Harrison, W. D. (1980). Role strain and burnout in child protective service workers. SocialService Review, 54, 31-44. House, J. S. (1981). Work stress and social support. Reading, MA: Addison-Wesley. Jayaratne, S., & Chess, W. A. (1982/1983). Some correlates of job satisfaction among social workers. Journal of Applied SocialScience, 7, 1-18. Jayaratne, S., & Chess, W. A. (1983). Job satisfaction and burnout in social work. In B. A. Farber (Ed.), Stress and burnout in the human service professions (pp. 129-141). New York: Pergamon Press. Jayaratne, S., & Chess, W. A. (1984). Job satisfaction, burnout, and turnover: A national study. Social Work, 29, 448-453. Joseph, M. V., & Conrad, A. P. (1989). Social work influence on interdisciplinary ethical decision making in health care settings. Health and Social Work, 14, 22-30. Kahn, R. L. (1970). Some propositions toward a researchable conceptualization of stress. In J. E. McGrath (Ed.), Social and psychological factors in stress. New York: Holt, Rinehart & Winston. Kane, R. A. (1975). The interprofessional team as a small group. Social Work in Health Care, 1, 19-32. Kane, R. A. (1981). Burnout may be a copout. Health and Social Work, 6, 2-3. Kenney, J. J. (1990). Social work management in emerging health care systems. Health and Social Work, 15, 22-31. 201
Koocher, G. P. (1979). Adjustment and coping strategies among the caretakers of cancer patients. Social Work in Health Care, 5, 145-151. Kulys, R., & Davis, M. A., Sr. (1987). Nurses and social workers: Rivals in the provision of social services? Health and Social Work, 12, 101-112. LaRocco, J. M., House, J. S., & French, J.R.P. (1980). Social support, occupational stress, and health. Journal oj Health and Social Behavior, 21, 202-218. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lister, L. (1980). Role expectations of social workers and other health professionals. Health and Social Work, 5, 41-49. Lowe, J. 1., & Herranen, M. (1978). Conflict in teamwork: Understanding roles and relationships. Social Work in Health Care, 3, 323-330. Mailick, M., &Jordan, P. (1977). A multi-model approach to collaborative practice in health settings. Social Work in Health Care, 2, 445-454. Maslach, C. (1976). Burned out. Human Behavior, 5, 16-22. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal ofOccupational Behavior, 2, 99-113. Mizrahi, T., & Abramson, J. (1985). Sources of strain between physicians and social workers:
JUST
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114-121. Pilsecker, C. (1979). Terminal cancer: A challenge for social work. Social Work in Health Care, 4, 369-380. Quinn, R. P., & Shepard, L. J. (1974). The 1972-73 quality ofemployment survey. Ann Arbor, MI: Institute for Social Research. Quinn, R. P., & Staines, G. L. (1978). The 1977 quality ofemployment survey. Ann Arbor, MI: Institute for Social Research. Rizzo, J. R., House, J. H., & Lirtzman, S. 1. (1970). Role conflict and ambiguity in complex organizations. Administrative Science Quarterly, 15, 150-163. Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316-331. Taylor-Brown, S., Johnson, K. H., Hunter, K., & Rockowitz, R. J. (1981). Stress identification for social workers in health care: A preventive approach to burnout. Social Work in Health Care, 7, 91-100. Accepted December 21, 1990
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HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
Job-related stress and burnout among health care social workers are topics that have received considerable attention in the health care social work literature (Beemsterboer & Baum, 1984; Borland, 1981; Kane, 1981; Taylor-Brown, Johnson, Hunter, & Rockowitz, 1981). Burnout has often been cited as a hazard of social work practice with chronically ill children and adults, with terminally ill patients, and with patients requiring emergency or intensive care (Bergman, West, & Lewiston, 1979; Koocher, 1979; Pilsecker, 1979). More recently, a number of authors have expressed concern about the impact of the sweeping changes that have occurred in the organization, financing, and delivery of health care over the past decade on social workers practicing in health settings. The rapid expansion of for-profit health care; the need to develop income-producing services; heavier caseloads
and more complex and demanding cases; the pressure to discharge patients earlier engendered by the shift to prospective payment; the declassification of social work positions and increased competition among the ancillary health professions, particularly between social work and nursing; and ethical dilemmas and value conflicts resulting from financial constraints and advances in health care technology have all been identified as potential sources of stress and burnout for social workers (Edinburg, 1988; Joseph & Conrad, 1989; Kenney, 1990; Kulys & Davis, 1987). Ortiz and Bassoff (1988) commented that "given the demands placed on social workers in hospital settings, burnout seems to be a particularly acute risk for both proprietary and nonprofit hospital social workers" (p. 120). Despite widespread concern about job-related stress among health care social workers, there is
CCC Code: 0360-7283/91 $1.00 © 1991, National Association of Social Workers, Inc.
193
little empirical research addressing this topic and none investigating changes in job-related stress and job satisfaction among health care social workers over time. This article presents the findings of two consecutive surveys of factors associated 'with job satisfaction and burnout in national samples of health care social workers. The first survey was undertaken in 1979 and the second in 1989. The conceptual framework used by the authors assumes that job satisfaction and burnout are separate but related functions of the interaction between the social worker and various aspects of his or her job. This perspective is congruent with that of other research investigating occupational stress, job satisfaction, and workers' physical and mental health (House, 1981; Kahn, 1970; LaRocco, House, & French, 1980). The research presented here is part of a larger study of job satisfaction and burnout in professional social workers, including family service workers, community mental health workers, and child welfare workers Qayaratne & Chess, 1982/1983, 1983, 1984).
VARIABLES AND MEASUREMENT Job characteristics chosen for study as correlates of job satisfaction and burnout were identified through reviews of the social work, occupational health, and organizational psychology literature. Role conflict, role ambiguity, value conflict, and workload have been associated with both job satisfaction and burnout (Harrison, 1980; Kahn, 1970; Rizzo, House, & Lirtzman, 1970). For social workers in health care settings, physician dominance, the rivalry between social work and nursing, and the need for multidisciplinary collaboration are frequently cited as sources of stress when disagreement, overlap, or competition occur and as sources of considerable satisfaction when health care team members are able to work together in an atmosphere of mutual support (Dana, 1983; Davidson, 1978; Kane, 1975; Kulys & Davis, 1987; Lister, 1980; Lowe & Herranen, 1978; Mailick & Jordan, 1977). Joseph and Conrad (1989) found that role clarity was associated positively with satisfaction with the medical social work role and that satisfaction was associated highly 194
with the ability of the social worker to influence ethical decisions. Davidson (1978), Ortiz and Bassoff (1988), and Edinburg (1988) noted the strain related to workload and professional value conflict among health care social workers. Mizrahi and Abramson (1985) described conflict over roles, values, and ethical dilemmas as a source of strain between social workers and physicians. Challenge, financial reward, opportunity for promotion, and comfort have previously been examined primarily as correlates of job satisfaction in studies of social workers in non-health care settings. However, the challenge of working with terminal cancer patients was noted by Koocher (1979) and discussed in detail by Pilsecker (1979). In the most recent literature addressing the impact of the last decade's changes in health care on social workers, challenge plays a major role. Edinburg (1988) identified seven major challenges to social workers in health care settings as a result of the proliferation of for-profit health care providers and changes in reimbursement, and Kenney (1990) noted a number of challenges to social work management in emerging multihealth systems. All of these variables have been examined as correlates of job satisfaction among a diverse sample of professional social workers, with challenge and promotional opportunities emerging as significant predictors (jayaratne & Chess, 1982/1983, 1983, 1984). The following nine job characteristics were measured: role ambiguity, role conflict, value conflict, workload, challenge, comfort, financial rewards, promotional opportunities, and job satisfaction. All job characteristics were measured using well-established indexes of demonstrated reliability and validity. All indexes are based on a Likert scale response format. Internal reliability coefficient alphas are presented where appropriate and available; all indexes have been used in large-scale surveys with a wide range of occupational groupings. Study populations do not differ significantly from those on which the scales were developed. Role ambiguity is a four-item measure of job clarity. An item example is "My work objectives are well-defined. " Its reliability is .84 (Caplan, Cobb, French, Harrison, & Pinneau, 1975).
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
Scores range from 4 to 20, with high scores indicating greater role ambiguity. Role conflict is a four-item index of the conflicts that an individual perceives as being present in his or her job. An item example is "On my job, I can't satisfy everybody at the same time." Its reliability is .62 (Quinn & Staines, 1978). Scores range from 4 to 16, with higher scores indicating higher conflict. Value conflict is a single item that asked the respondent "How often do your professional values conflict with the job?" Scores range from 1 to 5, with higher scores indicating higher conflict. This item was constructed for this study. Workload is a four-item index of quantitative workload. An item example is "How often does your job require you to work very fast?" Its reliability is .60 (Caplan et al., 1975). Scores range from 4 to 20, with higher scores indicating higher workload. Challenge is a six-item scale on the perceived challenge of the job. An item example is "The problems I am expected to solve are hard enough." Its reliability is .83 (Quinn & Shepard, 1974). Scores range from 6 to 24, with higher scores indicating greater challenge. Comfort is a seven-item index measuring the physical comfort of the work situation. An item example is' 'The physical surroundings are pleasant." Its reliability is .69 (Quinn & Shepard, 1974), and higher scoresindicate greater comfort. Financial rewards is a three-item index measuring the worker's satisfaction, pay, security, and fringe benefits. An item example is "The pay is good." Its reliability is .70 (Quinn & Shepard, 1974). Scores range from 3 to 12, with higher scores indicating greater satisfaction. Promotional opportunities is a three-item index measuring the person's perceptions about opportunities for advancement within the organization. An item example is "The chances for promotion are good." Its reliability is. 76 (Quinn & Shepard, 1974). Scores range from 3 to 12, with higher scores indicating greater satisfaction on this dimension. Job satisfaction is a single item that asked the respondent "All in all, how satisfied would you say you are with your job?" Scores range from 1 to 4, with lower scores indicating greater satisfaction (Quinn & Shepard, 1974). JOB SATISFACTION, BURNOUT, AND TURNOVER
Burnout was measured using modified versions of the depersonalization, emotional exhaustion, and sense of personal accomplishment scales developed by Maslach and Jackson (1981). The scaleswere modified to decrease the length of the questionnaire and thus minimize respondent fatigue. The item "I feel burned out from my work" was used rather than the entire emotional exhaustion scale; this particular item has a very high factor loading (.81) with the total scale and is thus an acceptable measure of emotional exhaustion. The entire depersonalization and personal accomplishment scales were used, but only the intensity dimension was measured. Within the Maslach Burnout Inventory, the betweenscale correlation is .49 (emotional exhaustion x depersonalization). This interscale correlation is comparable to that reported by Maslach and Jackson (1981) using the original scales. Job satisfaction is correlated at -.43 with depersonalization and emotional exhaustion. Clearly, these scales are measuring different but overlapping dimensions. For all the scales, Maslach's "never" category of alternatives was dropped, and a seven-point response option was presented. Higher scores indicate greater levels of depersonalization and emotional exhaustion, as wellas a higher level of feelings of accomplishment. Termination of employment is frequently cited as a potential outcome of burnout (Armstrong, 1977; Maslach, 1976). Therefore, respondents were asked to indicate the likelihood of making a genuine attempt to find a new job within the next year. Response options ranged from "very likely" to "not at all likely" on a three-point scale.
SAMPLE AND METHOD Subjects in this study were social workers who identified themselvesas working in health care settings in two national surveys drawn from the computerized membership directory of the National Associationof SocialWorkers. The sample for the first survey was drawn in 1979 and the second in 1989. In the 1979 survey, 1,173 randomly selected members were mailed questionnaires, and 853 were returned, for a response rate of 72.7 percent. In the 1989 survey, 1,500 randomly selected members were mailed questionnaires, 195
working in private health care agencies (X 2 17.52, df = 1, P = .0000).
and 882 were returned, for a response rate of 58.8 percent. The present analysis is restricted to those respondents who identified themselves as master of social work-level social workers employed in health settings and having direct client contact. Table 1 presents the demographic characteristics of the respondents for each sample. Of the 126 respondents in the 1979 sample, the majority were female (83.3 percent, n = 105), Caucasian (83.3 percent, n = 105), and married (51.6 percent, n = 65), and 23.0 percent (n = 29) had an annual personal income of more than $25,000. Of the 144 social workers in the 1989 sample, the majority of respondents also were female (88.2 percent, n = 127), Caucasian (91.7 percent, n = 132), and married (63.9 percent, n = 92), and 63.2 percent (n = 91) had an annual personal income of more than $25,000. Significantly more social workers in the 1989 sample were married than in the 1979 sample (X2 = 4.08, df = 1, P = .04). Interestingly, there was also a significant change in the proportion of social workers employed in private health care agencies as opposed to public health care agencies between 1979 and 1989. In 1979, 38.1 percent (n = 48) of the respondents worked in private agencies, whereas in 1989, 62.5 percent (n = 90) of the respondents reported
FINDINGS In 1979, 32.5 percent (n = 41) of the respondents reported that they were very satisfied and 53.2 percent (n = 67) reported that they were somewhat satisfied with their jobs. In 1989, there was very little change in workers' level of job satisfaction: 31. 9 percent (n = 46) of the respondents described themselves as very satisfied and 51. 4 percent (n = 74) described themselves as somewhat satisfied with their jobs. Similarly, 16.7 percent (n = 21) of the respondents scored higher than 16 out of 35 possible points on the depersonalization scale in 1979, and only 18.1 percent(n = 26) scored higher than 16 on the same scale in 1989. In 1979, 31.7 percent (n = 40) of the social workers in the sample rated themselves higher than 4 on a seven-point scale in response to the statement "I feel burned out from my work." In 1989, 25.7 percent (n = 37) rated themselves higher than 4 on this same scale. Thus, althoughjob satisfaction among the 1989 respondents remained high and social workers continued to report little depersonalization in their practice, one-fourth of the respondents reported feelings of emotional exhaustion.
Table 1. Demographic Characteristics of Respondents
1979 (n = 126) Factors
Mean
Age (years)
39.17
n
1989 (n = 144)
%
Mean
n
%
41.25
Sex Male Female
21 105
16.7 83.3
17 127
11.8 88.2
Race/Ethnic Group American Indian Asian Black/African American Caucasian Chicano/Mexican American Puerto Rican Other
1 6 13 105 0 0 1
0.8 4.8 10.3 83.3 0 0 0.8
1 1 5 132 3 0 2
0.7 0.7 3.5 91.7 2.1 0 1.4
65 61
51.6 48.4
92 52
63.9 36.1
Marital Status Married Not married Years in Position
196
4.12
4.69
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
However, the number of workers reporting such feelings did not increase between 1979 and 1989. The most substantial change between 1979 and 1989 occurred in social workers' ratings of their sense of personal accomplishment. In 1979,46.8 percent (n = 59) of the respondents scored 40 or more out of 56 possiblepoints on the sense of personal accomplishment scale, whereas in 1989, 70.8 percent (n = 102) scored more than 40 points on the same scale. In 1979,16.7 percent (n = 21) of the social workers surveyed described themselves as very likely to make a genuine effort to find another job within the next year, and 23.8 percent (n = 30) described themselves as somewhat likely to do the same. In 1989, 21.5 percent (n = 31) of the respondents indicated that they were very likely to attempt to find another job, whereas 25.7 percent (n = 37) reported that they were somewhat likely to do so within the next year. Thus, although the increase was not significant, in 1989 almost one-half of the health care social workers surveyed were at least considering making a serious effort to find other employment. In 1979, of the four outcome measures studied, only job
satisfaction correlated significantly with likelihood of job turnover. Higher levels of job satisfaction were associated with less likelihood of a social worker making a serious attempt to find other employment. In 1989, however, significant and substantial correlations were found between likelihood ofjob turnover and all of the outcome measures. High levels of job satisfaction and a high sense of personal accomplishment were associated with less likelihood of turnover, and depersonalization and emotional exhaustion were associated with greater likelihood that the social worker would make a genuine attempt to find another job. Mean scores on the four outcome measures and on the measures of the job characteristics identified as factors injob satisfaction and burnout were compared for the two samples. Significant differences between the 1979 respondents and the 1989 respondents were found for workload, which was higher in the 1989 sample, and for perceived challenge and sense of personal accomplishment, which were also higher for the 1989 sample (Table 2). Satisfaction with financial rewards was significantly lower for the 1989
Table 2. Factors Influencing Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment among Health Care Social Workers, 1979 and 1989
p
Factors
1979
1989
Role ambiguity Mean Variance
8.14 9.55
7.70 7.16
-1.248
Workload Mean Variance
15.72 12.85
16.75 8.05
2.627
.0091 **
Role conflict Mean Variance
10.63 8.73
10.55 7.39
-.2085
NS
Comfort Mean Variance
18.03 15.97
18.73 12.40
1.4969
NS
Challenge Mean Variance
17.61 12.84
18.67 9.88
2.5664
.0108*
9.35 3.55
8.62 3.86
- 3.0856
Financial rewards Mean Variance
NS
.0022** continued
JOB SATISFACTION, BURNOUT, AND TURNOVER
197
Table 2. (continued) Factors
1979
1989
Promotional opportunities Mean Variance
6.50 5.77
6.47 5.33
- .11354
NS
Value conflict Mean Variance
2.52 1.50
2.46 1.38
.39387
NS
Job satisfaction Mean Variance
3.17 .47
3.15 .49
.29253
NS
Emotional exhaustion Mean Variance
3.43 3.75
3.33 3.13
- .37292
NS
Depersonalization Mean Variance
11.80 34.24
11.24 26.73
-.75286
NS
Personal accomplishment Mean Variance
38.25 34.23
43.62 45.35
6.2835
.0000" •
NOTE: NS
=
P
Not significant.
'p < .05. **p < .01. ***p < .001.
respondents, despite significantly higher personal incomes. However, the effects of inflation must be considered when interpreting this response. To determine which of the eight job characteristics were the best predictors of outcome, standardized multiple regression analyses of the job characteristics associated with job satisfaction, emotional exhaustion, depersonalization, and personal accomplishment were computed for each sample (Tables 3 and 4). Marital status was used as a control variable because there was a significant difference in marital status between the 1979 and 1989 samples. In 1979, high challenge and high perceived opportunity for promotion were significant predictors of job satisfaction. Not being married was the only significant predictor of emotional exhaustion, and low challenge was the only significant predictor of depersonalization. Low role conflict was a significant predictor of sense of personal accomplishment. In 1989, high challenge, satisfaction with financial rewards, and low conflict with professional values were significant predictors of job satisfaction. Role conflict, role ambiguity, and lack of comfort were significant predictors of emotional 198
exhaustion, and high role conflict, low challenge, and low satisfaction with financial rewards were significant predictors of depersonalization. Five job characteristics were significant predictors of sense of personal accomplishment: high challenge, high workload, greater satisfaction with financial rewards, low levels of role conflict, and low levels of conflict with professional values. .
DISCUSSION Some of the changes that have occurred in health care over the past decade have had a significant impact on social workers who practice in health care settings. Between 1979 and 1989, a major shift from employment in public agencies to employment in private agencies took place, paralleling the privatization of health care. Although it is not known whether private agencies that employ social workers are for-profit organizations, the authors suspect that this is increasingly the case. Even if such agencies are not proprietary, a number of authors have expressed concern about the impact of the changing economic climate and the increased emphasis on
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
Table 3. Multiple Regression Analyses of Workers' Perceptions of Job Characteristics as Predictors of Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment, 1979 Factors Job satisfaction (R2 .53, F Marital status Role ambiguity Workload Role conflict Comfort Challenge" Financial rewards Promotional opportunities' Value conflict
8.684, P
Emotional exhaustion (R2 = .26, F Marital status' Role ambiguity Workload Role conflict Comfort Challenge Financial rewards Promotional opportunities Value conflict Depersonalization (R 2 = .19, F Marital status Role ambiguity Workload Role conflict Comfort Challenge' Financial rewards Promotional opportunities Value conflict Personal accomplishment (R2 Marital status Role ambiguity Workload Role conflict' Comfort Challenge Financial rewards Promotional opportunities Value conflict
p
Beta .0000)
2.742,
1.776, P
.18, F
P
-.80 .19 .18 - .18 - .12 .47 .91 .23 -.59
-.948 .185 1.216 - .127 - .775 3.978 .937 2.245 - .580
NS NS NS NS NS .0002 NS .0280 NS
.24 .54 .76 .34 .11 -.65 .61 - .25 -.71
2.233 .411 .411 1.917 .567 -.442 .496 - 1.922 -.551
.0287 NS NS NS NS NS NS NS NS
.89 .77 -.38 .31 .17 -.31 -.76 .79 .27
.800 .560 - .197 1.638 .864 - 2.008 -.596 .581 .201
NS NS NS NS NS .049 NS NS NS
.64 .48 .33 -.37 .71 .25 -.65 - .12 .44
.576 .351 1.717 - 1.954 .359 1.635 -.508 -.908 .331
NS NS NS .0547 NS NS NS NS NS
.0084)
.0884)
1.746, P
.0947)
NOTE: NS = Not significant. *p :S .05. * *p :S .0005.
revenue-producing social work services in health care settings (Edinburg, 1988; Kenney, 1990; Ortiz & Bassoff, 1988). The authors found that social workers' workloads rose concurrently with major cutbacks in health care services and personnel. Although challenge remained a stable predictor of job satisfaction among health care social workers, concern about financial rewards JOB SATISFACTION, BURNOUT, AND TURNOVER
and conflict with professional values emerged as significant predictors of overall satisfaction with employment. The emergence of these characteristics occurred at the same time as the implementation of stringent cost-containment measures and the appearance of increasingly complex ethical dilemmas engendered by technological advances and the need to allocate and 199
Table 4. Multiple Regression Analyses of Workers' Perceptions of Job Characteristics as Predictors of Job Satisfaction, Emotional Exhaustion, Depersonalization, and Personal Accomplishment, 1989
10.569, P
Job satisfaction (R 2 .49, F Marital status Role ambiguity Workload Role conflict Comfort Challenge'" Financial rewards' Promotional opportunities Value conflict'
Depersonalization (R 2 = .19, F Marital status Role ambiguity Workload Role conflict' Comfort Challenge' Financial rewards' Promotional opportunities Value conflict Personal accomplishment (R2 Marital status Role ambiguity Workload" Role conflict" Comfort Challenge'" Financial rewards" Promotional opportunities Value conflict' =
.00(0)
5.659, P
Emotional exhaustion (R2 .34, F Marital status Role ambiguity" Workload Role conflict' Comfort" , Challenge Financial rewards Promotional opportunities Value conflict
NOTE: NS 'p :5 .05.
2.678, P
.49, F
.36 - .12 - .16 - .13 .56 .41 .22 -.99 - .19
.482 - 1.314 - .159 - 1.357 .571 4.675 2.439 - .110 - 2.265
NS NS NS NS NS .0000 .0165 NS .0257
.47 -.27 -.22 .22 - .44 - .17 - .14 .15 .10
.554 -2.742 - 1.859 1.959 -3.902 -1.713 - 1.388 1.457 1.017
NS .0072 NS .0529 .0002 NS NS NS NS
.85 - .10 - .13 .24 - .32 -.23 -.24 .18 - .19
.915 -.933 -.993 1.942 -.261 -2.104 -2.142 1.598 1.829
NS NS NS .0549 NS .0379 .0346 NS NS
-.28 .96 .32 -.30 .17 .44 .25 - .15 -.21
-.382 1.092 3.068 - 3.038 1.728 5.062 2.849 - 1.648 -2.438
NS NS .0028 .0030 NS .0000 .0053 NS .0165
.00(0)
.0(79)
10.689, P
.00(0)
Not significant. :5 .01. "'p :5 .0005.
"p
a
even ration scarce health care resources oseph & Conrad, 1989). As changes in reimbursement and "remedicalization" prompted increased competition among ancillary providers (Edinburg, 1988) and as nursing asserted itself as a profession and expanded its domain (Kulys & Davis, 1987), role conflict and role ambiguity emerged as significant predictors of emotional 200
p
Beta
Factors
exhaustion among health care social workers in 1989. Interestingly, lack of physical comfort replaced being unmarried as a significant contributor to burnout. Perhaps the most striking and encouraging change occurred in health care social workers' sense of personal accomplishment: A significant increase in feelings of effectiveness occurred
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 3/AUGUST 1991
between 1979 and 1989. Current research and social psychological theory suggest that a sense of competence and mastery is a critical element for successful coping and adaptation under stressful conditions (Bandura, 1982; Lazarus & Folkman, 1984; Rutter, 1987). This sense of competence and mastery is especially important considering the role conflicts and value conflicts that health care social workers face today (Edinburg, 1988; Kulys & Davis, 1987). Kenney (1990) observed that "the values to which professional social workers subscribe and the altruistic motives that led most of them to pursue this particular career can be challenged strenuously if service-related reductions occur when corporate ventures appear to be prospering" (p. 25)and that such a dynamic is especially likely to occur when patients are affected. He noted that the outcome can be "cynicism, blame, and blatant anger" (p. 25) toward the social worker. The findings reported here suggest that despite higher workloads and less satisfaction with financial rewards, health care social workers are maintaining a strong belief in their effectiveness as professionals. Joseph and Conrad (1989) found that social workers who were satisfied with and clear about their roles as medical social workers and who had formal preparation in ethical decision making had greater influence on ethical choices in multidisciplinary settings. Their findings and those of this study suggest the need for increased attention to conflict resolution and ethical decision making in social work practice in health settings.
About the Authors Kristine Siefert, PhD, is Associate Professor, and SrinikaJayaratne, PhD, is Professor, School of Social Work, 1065 Frieze Building, University of Michigan, Ann Arbor, MI 48109. Wayne A. Chess, PhD, is Professor, School of Social Work, University of Oklahoma, Norman, OK. This paper was supported by National Institute of Mental Health Research and Development Grant No. MH18773-03.
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Koocher, G. P. (1979). Adjustment and coping strategies among the caretakers of cancer patients. Social Work in Health Care, 5, 145-151. Kulys, R., & Davis, M. A., Sr. (1987). Nurses and social workers: Rivals in the provision of social services? Health and Social Work, 12, 101-112. LaRocco, J. M., House, J. S., & French, J.R.P. (1980). Social support, occupational stress, and health. Journal oj Health and Social Behavior, 21, 202-218. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lister, L. (1980). Role expectations of social workers and other health professionals. Health and Social Work, 5, 41-49. Lowe, J. 1., & Herranen, M. (1978). Conflict in teamwork: Understanding roles and relationships. Social Work in Health Care, 3, 323-330. Mailick, M., &Jordan, P. (1977). A multi-model approach to collaborative practice in health settings. Social Work in Health Care, 2, 445-454. Maslach, C. (1976). Burned out. Human Behavior, 5, 16-22. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal ofOccupational Behavior, 2, 99-113. Mizrahi, T., & Abramson, J. (1985). Sources of strain between physicians and social workers:
JUST
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114-121. Pilsecker, C. (1979). Terminal cancer: A challenge for social work. Social Work in Health Care, 4, 369-380. Quinn, R. P., & Shepard, L. J. (1974). The 1972-73 quality ofemployment survey. Ann Arbor, MI: Institute for Social Research. Quinn, R. P., & Staines, G. L. (1978). The 1977 quality ofemployment survey. Ann Arbor, MI: Institute for Social Research. Rizzo, J. R., House, J. H., & Lirtzman, S. 1. (1970). Role conflict and ambiguity in complex organizations. Administrative Science Quarterly, 15, 150-163. Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316-331. Taylor-Brown, S., Johnson, K. H., Hunter, K., & Rockowitz, R. J. (1981). Stress identification for social workers in health care: A preventive approach to burnout. Social Work in Health Care, 7, 91-100. Accepted December 21, 1990
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