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Chapter 1
INTRODUCTION
Medical social work is one of the largest areas of practice for social workers.
Medical and public health social workers held about 124,000 jobs in 2006. Only
child, family and school social workers held more jobs. Medical and public health
social work jobs are projected to increase by 24 percent to 154,000 in 2016 (Bureau of
Labor Statistics, 2008). Social work is currently established in various health care
settings, particularly hospitals. For example, 86 percent of general acute care hospitals
reported having social work services in 2000 (Fort Cowles, 2003). There is growing
recognition among medical professionals regarding the importance of various
psychosocial issues and problems for health. Social work is unique in health care
settings in that it primarily focuses on psychosocial issues and problems.
Nevertheless, social work departments in health care settings increasingly encounter
challenges, primarily as a result of recent developments and changes in health care.
Social work is struggling, more than ever, to maintain its identity in a changing health
care environment.
Health care settings are secondary or “host” settings for social work. Social
services are secondary to medicine. The value of social work services is often unclear
to health care administrators or even other health care professionals. Social workers
do not directly treat health problems as other health care professionals do. In addition,
contemporary trends and developments in health care delivery, particularly the
emergence of managed care, have profoundly influenced medical social work. These
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trends and developments present new challenges to the field of medical social work,
particularly adapting to the changing health care environment while preserving its
identity. Social work values and purpose may not be consistent with the culture and
policies of health care organizations in today’s evolving managed care environment.
The roles and functions of medical social workers are changing to reflect and respond
to the changing health care arena although, unfortunately, it is increasingly
challenging for medical social workers to remain essential in health care.
Background of the Problem
Social workers have worked in hospitals and, later, other health care settings
since the early twentieth century. The role of early medical social workers was to
assist medical staff, primarily physicians, in reaching out to patients in the community
and provide knowledge of patients in the context of their home environment (Fort
Cowles, 2003). Their role has continued to evolve since these beginnings. Roles of
medical social workers today typically include psychosocial assessment, counseling,
provision of resources, advocating for patients and families, and discharge planning
(Fort Cowles, 2003; Gregorian, 2005). Medical social work roles vary in the context
of health care settings. Roles and functions of social workers in hospitals, for
example, may be different from roles and functions of social workers in home health
care or in nursing homes.
Social work practice in professional organizations such as hospitals and other
health care organizations is typically different from social work practice in
bureaucratic organizations such as most social services organizations and agencies.
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Roles are not as firmly defined in professional organizations but must be “negotiated”
with other professionals. As a result, some professionals may perceive some of the
roles and functions typically assigned to other professionals as part of their own roles
and functions. For example, roles and functions of social workers in health care
settings often are not very well defined. Other health care professionals increasingly
perceive some of the “traditional” social work roles and functions including
psychosocial issues and problems of patients as part of their own domain (Fort
Cowles, 2003). There is some research on the role overlap and conflict social workers
experience with other health care professionals (Holliman, Dziegielewski, & Teare,
2003; Reese & Sontag, 2001; Wittenberg-Lyles, Oliver, Demiris, Baldwin, & Regehr,
2008).
Statement of the Research Problem
Increasingly medical social workers have experienced role overlap and conflict
with other medical professionals. Better understanding of factors that influence
medical social work roles and contribute to role overlap and conflict could provide
guidelines to address this role confusion and conflict. A review of current literature
reveals the need for additional studies.
Purpose of the Study
The purpose of this study is to explore the roles of medical social workers,
specifically hospital social workers, from their own point of view. It is logical and
even essential to get a better understanding of the views of hospital social work
practitioners on their work within the hospital environment to begin to address some
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of the challenges and barriers to hospital social work. This study will focus on the
views of hospital social workers on one of the major challenges and barriers identified
– role overlap and conflict. In addition, this study will explore their views on the
factors that may contribute to role overlap and conflict and their perspectives on how
to address the issues.
Major Questions
There are two major questions this study attempts to explore. The first is how
social workers in a large teaching hospital perceive their roles. The second is if and
how they experience role overlap and conflict.
Theoretical Framework
The ecological systems model is useful in conceptualizing and understanding
the problem this study focuses on. A description of the ecological systems model is
given next. A description of how the model can be applied to this research is given as
well.
The Ecological Systems Model
The ecological systems model is an eclectic approach in assessing and
understanding an individual or community. It was influenced by multiple theoretical
approaches such as ecology, ego psychology, and general systems theory.
Psychodynamic approaches, largely influenced by Freud, primarily dominated from
the 1920s until the 1960s. Beginning in the 1960s and 1970s, understanding of
environmental factors and how an individual interacts with their environment was
given increasing emphasis. The ecological systems model emphasizes the importance
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of the relationship between an individual and their environment. According to the
model, an individual and their environment influence one another. An individual
exists within the context of multiple systems. The most important concept is that
people need to be understood within the context of their environment (Hepworth,
Rooney, Rooney, Strom-Gottfried, & Larsen, 2006).
According to the ecological systems model, assessment focuses on the
transactions between an individual and his or her physical and social environment, or
the “goodness of fit” between the two. Assessment of an individual’s needs and the
availability of essential resources and opportunities within their environment is
important. Adequacy of various aspects of the environment to meet an individual’s
needs influences “goodness of fit.” Plans of interventions may consider assisting
people to adapt to their environments, altering environments to meet the needs of
individuals more adequately, or a combination of the two (Hepworth, Rooney,
Rooney, Strom-Gottfried, & Larsen, 2006). Assessment and interventions may look at
various levels: microsystem, mesosystem, exosystem, and macrosystem levels. The
microsystem level encompasses the individual and all groups and structures with
which the individual has direct contact. The mesosystem level includes relationships
between the groups and structures of the individual’s microsystem. The exosystem
level encompasses community level systems that may not relate directly to the
individual but that affect the individual. The macrosystem level includes societal
factors such as societal attitudes and values. It is ultimately important to understand
personal and environmental systems and factors.
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Application of the Ecological Systems Model
Social work in health care settings exists within the context of multiple
systems. On the microsystem and mesosystem levels, social work in health care
settings exists within individual social work departments in health care organizations.
Social workers are part of medical interdisciplinary teams with other health care
professionals. In addition, social workers are part of health care organizations and
facilities in which they work. On the exosystem and macrosystem levels, they are part
of the social work profession and also professional social work organizations such as
the National Association of Social Workers (NASW). In addition, social work in
health care settings exists within the ever changing health care environment. Social
work ultimately needs to be understood within the context of these different systems.
It is also useful to describe the challenges of medical social work within these
different contexts.
Role overlap and conflict and a lack of a clear professional identity, potential
challenges of medical social work, may be understood and analyzed as practice
(microsystem) and policy (macrosystem) issues. On the practice or microsystem
level, understanding social work professionals’ attitudes and views in regard to their
professional identity and roles and professional relationships is important. On the
policy or macrosystem level, understanding relevant health care policies that govern
health care financing and delivery, particularly as they affect social services, is
important. Ultimately, however, both practice and policy issues should be explored as
well as potential relationships between the two. Conceptually, the major questions
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this study attempts to explore are practice issues. However, policy issues related to
the questions will be explored in the review of the literature.
Justification
Despite the fact that, for example, 86 percent of general acute care hospitals
reported having social work services in 2000 (Fort Cowles, 2003), there is, on the
whole, little research on social work in health care settings. There is particularly little
research on the views of medical social workers on their work and roles and the
challenges of medical social work, particularly within the managed care environment.
It is the hope of this author that this research study will contribute to the body
of knowledge in regard to medical social work, specifically hospital social work. As
social workers and medical professionals develop a better understanding of
contributions of hospital social workers in regard to what they do and challenges to
their professional identity and roles, they may be able to more effectively address the
challenges and identify the unique contributions of social work. Social work in
hospitals is struggling to maintain its identity and its very existence. Further research
will hopefully lead to greater integration of social work in hospitals and other health
care settings.
Summary
Chapter One included an introduction and background of the problem, a
statement of the research problem, the purpose of the study, the major questions and
the theoretical framework. Chapter Two is a review of the relevant literature. Chapter
Three will describe the methodology used in the study. Chapter Four will describe the
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results of the study. Chapter Five is a summary of the findings and limitations and
implications are discussed.
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Chapter 2
REVIEW OF THE LITERATURE
Introduction
This literature review will be organized into the following sections. The first
section will provide a historical background of social work in health care. The second
will describe the roles of medical social workers and the role overlap and conflict
medical social workers experience. The third will examine the factors that influence
medical social work roles. The fourth will explore how medical social work can
survive in a changing health care environment. These themes were chosen to provide
a foundation for understanding social work in health.
Historical Background of Social Work in Health Care
Social work in health care began in 1905. Richard Cabot, a physician at
Massachusetts General Hospital, appointed a nurse to the first hospital social worker
position. Two years later, social workers were placed in the Neurology Clinic at
Massachusetts General Hospital. A distinction between medical and psychiatric social
work was not made at the time, however. Dr. Cabot and other physicians saw the
potential of social workers to provide observations and knowledge of the home and
social environments and conditions of patients. Differences in expectations and views
of the role and function of social workers in health care emerged early in the
development of the field. Social workers believed and expected that their role should
include treatment of social and psychological problems. In contrast, physicians and
other medical practitioners saw social workers primarily as a liaison between the
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hospital and the social environment and community of the patient (Fort Cowles,
2003).
The medical social work field grew fairly rapidly. By 1913, 100 hospitals in
the United States had social work services and 400 by 1923. Social work in the health
field was the first specialty area of social work although a distinction between medical
and psychiatric social work had not been made. In 1918, hospital social workers
founded the American Association of Hospital Social Workers (AAHSW). In 1955,
the AAHSW merged with other social work organizations to become the National
Association of Social Workers (NASW). Currently, the national health social work
organization is the Society for Social Work Leadership in Health Care, founded in
1965, as the Society for Social Work Administrators in Health Care (Fort Cowles,
2003).
From its beginnings in the early twentieth century, social work in health care
has been influenced by a variety of historical developments and changes. Freudian
psychoanalytic theory emerged in the 1920s and contributed to the division between
medical and psychiatric social work. Freudian theory emerged and became popular at
a time when social workers sought professional status as it was asserted that social
work did not have a body of knowledge rooted in science. This period marked the
beginning of a focus on person-centered problems rather than social and
environmental conditions. In addition to Freudian psychoanalytic theory, World War I
influenced early social work in health care. Many servicemen returned with physical
and psychological injuries such as “shell shock,” or post-traumatic stress disorder,
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which resulted in the rapid expansion of VA hospitals and job opportunities for
medical and psychiatric social workers. The deinstitutionalization movement in the
1950s and the discovery of psychotropic drugs resulted in the transfer of patients from
mental institutions to community –based care and the development of community
mental health centers. This also increased opportunities for social workers, especially
for psychiatric social workers (Fort Cowles, 2003).
The need for social workers and the variety of work settings for social workers
in health care increased after World War II and the passage of the Social Security Act
and Medicare and Medicaid. For example, the number of social workers in health care
nearly doubled between 1960 and 1970. Social workers were increasingly employed
in a variety of health care settings such as in extended-care facilities, home health
agencies and in state and local health departments. Social workers added knowledge
and techniques and interventions which emerged based on new theories in social work
as well as other disciplines (Gehlert & Browne, 2006). The changes in the delivery of
health care in the late twentieth century have affected social work in health care as
profoundly as any other changes or developments. It is important to discuss these
changes as they have posed challenges to the field of social work as well as the
populations that social workers work with most closely.
An important development in the delivery of health care has been the
emergence of managed care. The impact of managed care on social workers in health
and mental health care as well as their clientele has been great. The traditional
rationale behind the emergence of managed care as the means of health care financing
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and delivery has been to contain costs and monitor services. Health care has overall
become increasingly controlled by larger systems and increasingly market driven.
Since the early examples of HMOs such as Kaiser Permanente which emerged in
California in 1939, there have been many societal changes affecting the efficiency and
quality of health care delivery in the managed care environment. For example, the
population has aged and more people are living with chronic conditions. Medical
technology and health insurance have become much more expensive. As part of this
trend, the delivery of health care through managed care seems increasingly
withholding and insensitive. Patients and providers have less and less decision
making ability regarding health care decisions. The most vulnerable populations are
often most affected by the restrictions of managed care. The changes and challenges
are increasingly felt by social workers in the health field as they most often work with
vulnerable populations. Social workers that work in mental health care have
especially been affected as there have been great drops in insurance payments for
psychiatric care. It is increasingly important for social workers to help clients to
negotiate the managed care environment. The advocacy function of social work in the
health field is growing (Kerson, 2002).
Finally, the emergence of interdisciplinary teamwork in health care has
affected the field of social work. Interdisciplinary teamwork means various
professions or disciplines are working together to provide services to the patient or
client. Interdisciplinary health care teams first emerged in community mental health
centers and then expanded to hospitals and other settings. Several factors contributed
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to the emergence of interdisciplinary teams in health care such as increased
specialization and division of labor which resulted in multiple staff members involved
in patient care and a recognition that a patient’s problems are often interdependent.
Ideal outcomes of interdisciplinary teamwork include comprehensive and coordinated
service delivery, improved quality of patient care and cost savings by reducing gaps
and overlap in services. In other words, everyone should ultimately benefit from
interprofessional collaboration (Fort Cowles, 2003).
Although there are a variety of benefits of interdisciplinary and
interprofessional teamwork, there are potential problems or issues interdisciplinary
teams may encounter. For example, the following common problems in
interdisciplinary team functioning have been identified in the literature: turf
protection; different values and perceptions of the problems and needs; selfpromotion; prestige and status discrepancies that impair open communication; lack of
understanding of one another’s language, skills, and knowledge areas, and differences
in the problem-solving process (Fort Cowles, 2003). As interdisciplinary teamwork is
one of the most important contemporary features of various health care settings, it
becomes important to develop an understanding of such issues that social workers in
health care may encounter. As a result, the issues of social work role clarity within
health care interdisciplinary teams are explored next.
Medical Social Work Roles
The roles of medical social workers are primarily dependent on the health care
settings in which they work. Social workers work in various health care settings such
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as primary care, hospitals, home health care, hospice, and nursing homes. However,
social workers in all health care settings traditionally practice from the perspective of
the biopsychosocial model. The biopsychosocial model is a perspective for
understanding all the factors that influence a person and contribute to changes in the
person’s health and mental health. In the biopsychosocial model, physical,
psychological, and social conditions of patients are linked. In contrast to the
biopsychosocial model, the medical model focuses on physical or mental disease in
the individual, while social and environmental factors and conditions are not taken
into account for the most part.
Although they may vary by settings, social work functions in health care
settings include: assessment of the need for social work services; preadmission
planning and discharge planning; direct services and treatment to individuals, families,
and groups; case-finding and outreach; information and referral; client advocacy
within and outside the organization; protection of clients’ rights and entitlement; short
and long term planning (Fort Cowles, 2003). Social work roles and functions often
are not firmly defined in health care settings. For example, psychosocial problems and
discharge planning are traditionally part of the domain of social work yet physicians
and nurses increasingly perceive these functions as part of their own domains (Fort
Cowles, 2003). Examples of role conflict and blurring in social work practice in
health care are explored later.
There is very little research on how social workers perceive their identity and
roles in different medical settings. Gregorian (2005) explored the identity and roles of
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hospital social workers as well as important personal and professional qualities social
workers should possess to survive in the hospital environment. Gregorian lists the
following main roles and functions of social workers in an academic hospital setting:
1. Assessing the family’s social situation, dynamics, and capacity to cope with
the illness, treatment and hospitalization.
2. Consulting with multidisciplinary team members about how to interact most
effectively with the patient and family system.
3. Identifying or diagnosing the psychological, emotional or social barriers that
interfere with treatment, positive outcomes, or discharge planning.
4. Clarifying and addressing conflicts that might arise between providers and the
patient. Advocating for patients and families.
5. Providing medical crisis counseling and emotional support to patients and
families.
6. Counseling around end-of-life, grief and bereavement issues.
7. Consulting around suspected child abuse, elder abuse and domestic violence.
In pediatrics, social workers may also be involved with divorce, custody and
adoption cases.
8. Addressing substance abuse issues.
9. Performing mental health evaluations and crisis intervention.
10. Writing, teaching and research, especially in academic medical centers (p. 4).
Some of the professional skills that Gregorian identified as important for
hospital social workers include skills such as a good understanding of baseline
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functioning, the basics of a patient’s disease, the course of the illness and the types of
treatment offered as well as assessment and treatment skills such as psychiatric
evaluations, crisis intervention, medical crisis counseling and supportive
psychotherapy. In addition, hospital social workers need to understand hospital
“politics” and be able to cultivate relationships at all levels within the hospital. The
personal qualities that hospital social workers should possess include good “customer
relations” skills, taking a proactive approach and creativity (Gregorian, 2005). Even
though primary roles and skills of hospital social workers have been identified in the
literature, there is a lack of literature on how medical social workers perceive their
roles and also role conflict.
The roles and tasks of medical social workers historically overlap with the
roles and tasks of nurses. The overlap and sharing of roles between medical social
workers and nurses occur especially in the area of aftercare and discharge planning, an
increasingly important area in contemporary delivery of health care. There is no
empirical evidence that social workers or nurses are more qualified than the other to
perform aftercare and discharge planning although studies have noted differences
between social work and nurse discharge planners. One study (Holliman,
Dziegielewski, & Teare, 2003) compared social work and nurse discharge planners
based on demographic data, work setting, caseloads, and tasks, using surveys. The
study found that although there were no significant differences for the demographic
variables, there were differences for income, work setting, specialization, and tasks.
Nurses made significantly more money than social workers. Private hospitals were
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more likely to employ nurse discharge planners, and federal and state hospitals were
more likely to employ social work discharge planners. Social workers were
significantly more likely to specialize in psychiatric discharge planning and nurses
were significantly more likely to specialize in pediatric discharge planning. Nurse
discharge planners were more likely to perform tasks related to physical care and
quality management although social workers and nurses performed similar major tasks
in discharge planning (Holliman, Dziegielewski, & Teare, 2003).
Other research explored the professional identities and relations of medical
social workers and nurses (King & Ross, 2003). The authors noted that professional
identities are dependent on historically and culturally embedded values and
expectations which are adopted through professional socialization. Using focus
groups and individual interviews, the goal of the study was to examine how nurses and
medical social workers construct their professional identities and the implications for
the effectiveness of joint working practice, particularly in community and primary
care. The findings reflected that medical social workers experienced a move towards
less “hands-on” involvement with clients and a move towards a case management role.
Social workers and nurses reported that they experienced shifting boundaries and
changing roles which commonly left them with a sense of ambiguity about what was
expected of them. Moreover, as the authors point out, individuals construe their
professional identity and roles in different ways although their perceptions are
influenced by social context (King & Ross, 2003).
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King and Ross’s (2003) study found that, on the whole, nurses were more
likely to emphasize a traditional interpretation of roles, identities and boundaries,
while social workers were more likely to emphasize the need for flexibility. Social
workers were more flexible when defining boundaries in joint working and they
tended to be less critical of the nurses than vice versa. The findings suggest that social
workers have a less rigid professional identity and roles. The quality of
communications and relationships between professionals is important as professional
identities are largely constructed through interaction. For example, lack of effective
communication and relationships resulted in somewhat negative stereotypical views of
social workers, making health professionals less likely to embrace collaborative work.
In contrast, good communication and relationships resulted in flexible attitudes,
making health professionals more likely to embrace collaborative work. There is a
lack of literature about how medical social workers perceive their role in medical
interdisciplinary teams.
In addition to nurses, medical social workers experienced role conflict with
chaplains, primarily within the interdisciplinary team process. One study explored
how hospice chaplains perceive their role in interdisciplinary teams, using a purposive
sampling strategy with a semistructured phone survey. Professional and group roles of
chaplains within the interdisciplinary team were explored. The results revealed that
when chaplains experienced role conflict, it predominantly occurred with social
workers, followed by nurses. However, the majority of chaplains reported close
working relationships with social workers despite the role conflict. Group roles of
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chaplains that emerged included the role of conflict manager and the role of providing
spiritual care for team members. Findings from this study demonstrated that the role
of the chaplain is not clear within the interdisciplinary team. Chaplains reported that
other team members often do not understand their role which may be a result of the
similarity in roles with other team members such as social workers (Wittenberg-Lyles,
Oliver, Demiris, Baldwin, & Regehr, 2008).
Role conflict and blurring were identified as barriers to the use of all
disciplines, but particularly social workers, on the hospice team by Reese and Sontag
(2001). Role conflict and blurring may result in competition between professions and
decreased quality of services. A potential solution is the development of procedures
that indicates an automatic referral to a certain member of the team in certain case
situations. However, other research has indicated that roles must be flexible and
services geared to the individual case. Other related and interdependent barriers to the
use of all disciplines on the hospice team identified by the authors include lack of
knowledge of the expertise of other professions and conflicts arising from differences
in values and theory. Because health care professionals are trained in isolation from
each other, members of each profession may ultimately lack awareness and
understanding of what the other professions can contribute. For example, other
professionals tend to consider the social work role as provision of concrete services.
In addition, members of interdisciplinary teams may lack awareness of each other’s
values and theoretical approaches. For example, social work values patient self-
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determination but medical practitioners are traditionally oriented toward an
authoritarian stance (Reese & Sontag, 2001).
In addition to other health care professionals’ lack of awareness of social work
roles and services, patients often lack awareness of social work roles and services in
health care settings. For example, O’Brien and Stewart (2009) point out that the role
of medical social workers is often unclear to people seeking medical treatment.
Medical social workers practice in a “host” setting. Patients in medical settings are
seeking assistance with medical concerns, not social work services. Social work
referral mechanisms in health care settings consist of case finding or referral from the
medical team, whereas in other social service settings, a person typically either seeks
out the referral for assistance or is court ordered. The nature of the contacts is agreed
on by the client and the social worker in many social service organizations, whereas
social workers typically have very limited time with patients within the hospital
setting. Medical social workers are frequently pressured to provide clear outcomes
such as discharging patients quickly from the hospital. O’Brien and Stewart point out
that medical social workers need to ensure that patients are satisfied with social work
services.
Factors Affecting the Identity and Roles of Medical Social Workers
The factors that contribute to a lack of a clear professional identity for social
workers in health care have not been explored adequately in the literature. In an
exploratory study that explored one factor that contributes to a lack of a clear
professional identity, it was found that organizational reengineering and restructuring
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in hospitals, an increasingly common process designed to increase efficiency,
profoundly influenced professional identity, job satisfaction and morale of hospital
social workers (Neuman, 2003). Neuman used a survey and follow up focus group
interviews to explore how social workers’ job functions changed and whether the
changes were consistent with social workers’ professional identities and academic
preparation. Restructuring in hospitals particularly threatens non-revenue generating
and non-mandated services such as social work. “Traditional” social work roles
combined counseling and discharge planning services while restructuring involves
combining or separating existing roles and functions. The study found that the
changes in tasks and workloads resulted in decreased job satisfaction for all workers
but particularly staff in combined roles. Staff in combined roles were also more likely
to feel that the changes were inconsistent with their academic preparation and
professional identity and that reengineering would negatively impact patient care.
Social workers that retained traditional functions ultimately had the highest
satisfaction levels and morale (Neuman, 2003).
Related health care changes have affected the field of medical social work and
the professional identity and roles of medical social workers. The continuing shift to
managed care has had major implications for medical social work. Dziegielewski and
Holliman (2001) noted that social workers, like other health care professionals, have
been affected by cost containment policies such as declining hospital admissions,
reduced lengths of stay, and other restrictions and methods of cost containment. It is
essential that social workers link social work roles and services with associated cost
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savings. For example, the provision of hospital discharge planning should emphasize
cost savings in the prospective payment reimbursement system. In addition,
Dziegielewski and Holliman point out that self-marketing, with clients and other team
members, is increasingly important for medical social workers.
Sulman, Savage and Way (2002) also explored the impact of managed care on
the delivery of social work services in acute care hospitals. The authors asserted that
social work in acute care hospitals is struggling to survive as social work departments
disappear and other professions compete for roles in counseling, discharge planning
and community liaison. Social work budgets cuts are commonplace, social workers
are being replaced by nonprofessional staff and other disciplines are taking on key
social work functions and roles. In addition, practice with clients and client
populations is increasingly shorter term, focused, solution-based and episodic. The
authors suggest that social workers should identify roles that demonstrate its unique
value to the multidisciplinary team. This and other research suggests that hospital
social workers need to evaluate their practice in the managed care environment.
In addition to hospital social workers, social workers in other health care
settings such as home health care have been affected by changes in health care. Lee
and Rock (2005) studied how The Balanced Budget Act of 1997 and the new
prospective payment system (PPS) changed home health care and social work in home
health care. Under PPS, agencies are reimbursed a flat rate per patient under
Medicare. This change marked the beginning of an increased focus on service
outcomes. Medicare home health care serves homebound individuals who need acute
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medical care. Services include medical social services in addition to part-time or
intermittent skilled nursing and home health aide services. Social workers provide
direct patient services such as counseling and indirect patient services such as referrals
to other community services. Emerging roles for social workers include working with
managed care organizations. Medicare requires that social work services be justified
for reimbursement. The authors noted that social workers must demonstrate their
efficiency and effectiveness in improving patient outcomes as improving patient
outcomes results in increased revenue for the agency. Lee and Rock conclude
defining social work roles in home health care and developing a screening instrument
for identifying need for social work services is important. Existing research and
literature such as the research and literature identified in this literature review suggest
that the changing health care system has profoundly influenced the professional
identity and roles of medical social workers, particularly as social workers are
increasingly expected to contribute to the ultimate goal of contemporary health care
systems – cutting costs.
The perspective of social work leaders is important. A longitudinal study of
social work leadership in hospitals explored the impact of a changing health care
system on social work departments (Mizrahi & Berger, 2005). Social work
administrators reported, from 1992 to 2000, the major accomplishments and obstacles
of their departments and also the changes occurring throughout their hospitals. The
findings reflected that the percentage of social work administrators reporting one or
more of seven areas of accomplishment declined (new programs, preservation of
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professional social work, participation in system reorganization, expanded or
reclaimed social work settings/populations, new social work roles/responsibilities,
increased social work positions/coverage, increased social work influence) although
there were variations in successes in the different areas. On the other hand, the type
and number of perceived negative factors increased overall (increasing pressure on
social work, devaluation or non-recognition of social work, external threats with
negative consequences, decreasing quality of patient care, elimination or deprofessionalization of social work, problems within social work). Mizrahi and Berger
identified two primary challenges for social work leaders and their departments:
preserving social work mission and values while adapting to the changing health care
system, and innovation, particularly reconfiguring traditional roles and
responsibilities.
How Medical Social Work Can Survive
There is some literature on how social work can survive in a changing health
care environment, particularly in regard to changing or taking on new roles or
functions. It has been suggested in the literature that medical social workers need to
develop power to remain essential in their organizations (Rizzo & Abrams, 2000).
Rizzo and Abrams suggested one of the ways in which medical social workers can
gain power is to embrace new or nontraditional roles and functions such as utilization
review. Utilization review is the process to determine that a recommended medical
treatment or procedure is medically necessary. The goal of utilization review is to
decrease medical costs while providing quality medical care. One of the concerns that
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arises as a result of social workers taking on such roles is that it may create conflict for
the social worker in the dual roles of client advocate and system representative. Rizzo
and Abrams finally conclude that, in reality, social workers practicing in other settings
play dual roles and social workers are well-equipped to effectively resolve conflicts
created by these dual roles as they arise.
Other research suggests that rather than taking on new or nontraditional roles
to remain essential in their organizations, social workers in health care settings should
emphasize the contributions they make in their existing roles. For example, one study
monitored social work discharge services and compared outcome with non-social
work discharges in a medical/surgical hospital unit (Auerbach, Mason, & LaPorte,
2007). The authors noted that social workers in hospitals are often subjected to the
dual roles of both serving patients and keeping hospital costs down. The profession’s
basic values such as client advocacy can conflict with a hospital’s priority of
discharging patients quickly. The study found that patients receiving social work
services had higher lengths of stay compared with non-social work patients. Cases
assigned to social work, such as the elderly and high risk groups, are complex and
require multiple services and resources. Social workers are trained in the
biopsychosocial model and so they are well suited to resolving these complex
discharge issues. The authors suggest that departments of social work need to develop
computerized tracking systems to provide empirical data about their contributions to
their organizations (Auerbach, Mason, & LaPorte, 2007).
26
Lechman and Duder (2009) also studied the importance of social workers in
hospital discharge planning and the important role that social services can potentially
play in controlling hospital costs. They point out that social workers link the patient,
the institution, and the community. The study sample was made up of all inpatients
referred to social services who had been discharged from an acute care university
teaching facility from June 2006 to October 2006. The findings revealed that, similar
to the Auerbach, Mason, and LaPorte study, the average length of stay was greater for
older patients than for younger and for patients with more severe psychosocial
problems. The authors noted that social work role in discharge planning increasingly
includes community consultation and collaboration. There is increasingly more
emphasis on care in the community. Social workers in hospitals can have a significant
role as a specialized knowledge resource – a link between the hospital and the
community. Lechman and Duder point out that future study is needed to enhance the
case for social work services in hospitals, particularly to get a better appreciation of
what is unique to social work compared to other medical professionals.
Other research suggests that social workers should expand their roles within
hospital multidisciplinary teams. Kitchen and Brook (2005) proposed a facilitative
role for social workers within the medical team in teaching hospital settings. They
designed a project to provide patients and medical staff access to social work services
upon admission rather than discharge. The project was designed to use social workers
as team coordinators to improve communication and coordination of the admission
and discharge processes. The project was evaluated using descriptive statistics and
27
qualitative interviews and questionnaires of different multidisciplinary professionals
involved in patient care. Several benefits emerged as a result of the project including
more comprehensive patient care, high risk social or medical conditions identified
earlier and more orderly discharge planning process. The implications are that
medical multidisciplinary teams with social workers as coordinators can function more
efficiently, which demonstrates strong support for the social worker role as team
coordinator (Kitchen & Brook, 2005). The literature suggests that medical social
workers can demonstrate their unique value to their organizations through new and
enhanced roles and functions.
The perspective of physicians and nurses, the most important professions in
health care settings, is potentially very important to get a better understanding of how
social work can survive in health care. Keefe, Geron and Enguidanos (2009) used
focus groups with primary care physicians and nurses to examine their perspectives
about the potential roles, challenges, and benefits of integrating social workers into
primary care teams. In general, most physicians and nurses had positive perceptions
of social workers and their potential roles. Physicians were more likely to see the
social work role as providing community-based services and resources, whereas
nurses were overall more likely to see the social work role as a broader array of tasks.
Both physicians and nurses felt that social workers could provide care coordination
and support for patients. Both felt that having social workers would result in
improved, more comprehensive, patient care and outcomes (Keefe, Geron, &
Enguidanos, 2009). Based on such research, other health care professionals see the
28
potential benefits of having social workers in health care settings which bodes well for
the future of medical social work.
Summary
This chapter reviewed some of the relevant literature in regard to medical
social work. It discussed the history of medical social work, the roles of medical
social workers, the factors that influence medical social work roles and, finally, how
medical social work can survive in a changing health care environment. The overall
goal was to provide a better understanding of social work in health care settings. The
next chapter will describe the methods used to conduct the study.
29
Chapter 3
METHODOLOGY
Introduction
The methodology used to conduct this study is described in this chapter.
Included are sections on the research questions, research design, participants,
instrumentation, data gathering procedures and, finally, protection of human subjects.
Research Questions
There are two major questions this study attempts to explore. The first is how
social workers in a large teaching hospital perceive their roles. The second is if and
how they experience role overlap and conflict.
Research Design
This study has dimensions of both exploratory and descriptive research. The
purpose of exploratory research is to explore a new topic. The purpose of descriptive
research is to describe a social phenomenon. Studies may have multiple purposes
such as, especially, both to explore and to describe. In fact, descriptive and
exploratory research very often blur together in practice (Kreuger & Neuman, 2006).
This study aims to both explore how hospital social workers perceive their roles and
role overlap and conflict and describe the context in which role overlap and conflict
may occur. There is a general lack of research on medical social work roles and, as a
result, taking an exploratory stance is appropriate. However, role overlap and conflict
have been identified in the literature as potential challenges of medical social work
30
and, as a result, it is appropriate to begin to formulate a more detailed picture of these
issues which is the descriptive aspects of this study.
Exploratory research primarily uses qualitative methods. In contrast,
descriptive research uses qualitative or quantitative methods. Qualitative and
quantitative research differs in many ways. However, they complement each other as
well. Quantitative research attempts to measure objective facts. Qualitative research
attempts to construct social reality. Quantitative research is independent of context
while qualitative research is situationally constrained. Quantitative research primarily
uses statistical analysis while qualitative research uses thematic analysis (Kreuger &
Neuman, 2006). This study has aspects of both.
The specific technique used for this study is a survey. The survey is the most
widely used data-gathering technique in social work and many other fields as well.
Surveys are appropriate for research questions about behavior, attitudes,
characteristics, expectations, self-classification or knowledge. Surveys can be
questionnaires or interviews (Kreuger & Neuman, 2006). This study uses a
questionnaire that consists of open-ended and closed-ended questions. Open-ended
questions are unstructured questions to which respondents can give any answer.
Closed-ended questions give respondents fixed responses from which to choose
(Kreuger & Neuman, 2006). This researcher’s choice to use a survey in the form of a
questionnaire was influenced by the purpose and the practical limitations of this
research study.
31
Participants
The study population for this study consisted of social workers in the
Department of Clinical Social Services at University of California Davis Medical
Center (UCDMC). UC Davis Medical Center is a large teaching hospital in
Sacramento, California. It is affiliated with University of California, Davis.
According to its website, “UC Davis Medical Center is a leading referral center for the
most seriously injured or ill patients, and the most medically complex cases in a
region, covering 33 counties, more than 65,000 square miles and 6 million residents.”
All social workers at UC Davis Medical Center have a Master’s in Social
Work (MSW). Most are Licensed Clinical Social Workers (LCSW). They work in
four general units: adult, crisis, pediatrics and perinatal. There are at least two social
workers in each of the units. This researcher held an internship in UC Davis Medical
Center’s Department of Clinical Social Services at the time of this study. The
researcher had the opportunities to conduct this study there.
Instrumentation
A questionnaire was developed by this researcher and utilized for this study
(see Appendix A). The questionnaire consisted of open-ended and closed-ended
questions. The questions were influenced by the purpose of the study and review of
the relevant literature. The purpose of the study was to explore the roles of hospital
social workers and one of the major challenges to hospital social work identified in the
literature. For example, some of the questions were utilized to construct the context in
which role overlap and conflict may occur. In addition, some questions were utilized
32
to explore the views of the participants on the factors that may contribute to role
overlap and conflict and how to address these issues. Current literature and the
purpose of this study guide the development of this questionnaire and to ensure its
validity. The questionnaire’s formal validity and reliability were not statistically
established.
Data Gathering Procedures
Prior to data collection, this researcher obtained approval to conduct this study
from the manager of the UC Davis Medical Center Department of Clinical Social
Services. The researcher handed out the informed consent forms and questionnaires in
the mailboxes of the social workers in the department. Upon completion, the social
workers were asked to return their signed informed consent forms and completed
questionnaires directly to the researcher or in the researcher’s mailbox. The signed
informed consent forms and completed questionnaires were numbered. The researcher
identified and then analyzed common themes and concepts after the data collection
was complete. Statistical analysis was used in the context of some responses.
Protection of Human Subjects
Prior to data collection, Protocol for the Protection of Human Subjects was
submitted and approved by California State University, Sacramento, Division of
Social Work Committee for the Protection of Human Subjects. The study was
approved as a “no risk” study, with an approval number of 09-10-022.
Participation in the study was voluntary. All information was confidential. An
informed consent form was used and explained the voluntary and confidential nature
33
of the questionnaire. The participants were informed they had a right to decline
participation or any questions. No names or other identifying information was used.
Upon completion, the informed consent forms and questionnaires were stored in a
secure location. Only the researcher had access to the data. Upon the completion of
this thesis research project, all data were destroyed.
Summary
This chapter described the methodology used to conduct this study. A
description of the research design, the research participants, the instrumentation and
the data gathering procedures was provided. In addition, this chapter explained the
methods for protecting the research participants. In the next chapter, the results of the
study will be described and analyzed.
34
Chapter 4
ANALYSIS OF DATA
Introduction
Thirteen social workers from the UC Davis Medical Center (UCDMC)
Department of Clinical Social Services returned completed questionnaires to the
researcher. Eight participants work in crisis services, two work in the adult inpatient
units, one works in pediatrics, one works in the intensive care units (ICUs), and one
works in both the adult inpatient units and the ICUs. All participants are LCSWs.
The average number of years that the participants have worked as medical social
workers is 15. The number of years ranges from 3 to 36. The average number of
years that the participants have worked at UC Davis Medical Center as social workers
is 14. The number of years ranges from 3 to 36. The purpose of the study was to
investigate the roles of hospital social workers and if and how hospital social workers
experience role confusion and overlap that occur with members of other disciplines
within the hospital. Themes were developed around the questions included in the
questionnaire utilized which were influenced by the purpose of the study and review
of the relevant literature.
Roles of UC Davis Medical Center Social Workers
Roles of UC Davis Medical Center social workers vary in the context of the
hospital unit in which they work – crisis services, the adult inpatient units or
pediatrics. Crisis services social workers reported that their primary roles include
“identify trauma patients, notify family,” “supportive counseling for patients and
35
family members,” “death notification, support, facilitate viewing of deceased, contact
coroner,” “psychiatric evaluations for safety, 5150 status and effective transfer to
appropriate psychiatric facilities,” “abuse assessments and reporting,” “referrals for
counseling, substance abuse, homeless resources etc.” Adult inpatient social workers
reported that their primary roles include “psychosocial assessment,” “emotional
support,” “information and referral,” “evaluate safety issues of patient.” Intensive
care social work roles include “assess needs and provide supportive as well as
concrete services to patients and families in the adult ICUs,” “consult with staff in
regard to complicated patient care issues,” “locate next of kin,” “collaborate with
hospital personnel in regard to patient financial and funding issues.” Pediatrics social
work roles include “assess biopsychosocial needs of patients and families,” “advocate
and enable patients to get optimum medical care and services by assisting with
resources,” “protect infants and children from being discharged to unsafe environment
where abuse or medical neglect may occur.” Although they vary by hospital unit, all
participants reported that their primary roles include psychosocial assessment,
counseling, provision of resources, and advocating for patients and families – roles
that have been identified in the literature (Fort Cowles, 2003; Gregorian, 2005).
Most participants reported that there is not a significant difference between
expected and actual roles and functions. One crisis social worker asserted “My role is
crisis team social worker and, as such, I am expected to take on a wide range of
assignments as needed.” Another crisis social worker had a different point of view,
specifically in regard to taking on non-typical roles and functions, and noted “At times
36
social workers are asked to assist in anything that doesn’t clearly fit in someone else’s
area of expertise. It is necessary to set limits and know your scope of practice.”
Another crisis social worker similarly noted “Social workers are often beseeched with
broad requests for services that are outside our common role.” However, for the most
part, participants did not report differences between expected and actual roles and
functions.
Role Confusion and Overlap
All participants reported that they experienced role confusion and overlap with
other disciplines within the hospital one time or another. They reported they are clear
about their own roles and functions but others are often not clear about roles and
functions of social workers. One social worker indicated that “I’m not confused with
my role, but other disciplines, patients and families are. The most often confused are
social worker vs. discharge planner and social worker vs. financial counselors.” One
social worker noted that “The confusion is more on the part of some patients, families
and staff who do not understand the roles of the case managers (discharge planners),
the financial counselors and Medi-Cal workers” and another said “Occasionally
inpatient patients and units confuse me with a discharge planner.” As the literature
suggests (Fort Cowles, 2003; Holliman, Dziegielewski, & Teare, 2003; O’Brien and
Stewart, 2009), it seems roles and functions of social workers in hospitals are often not
clear to other staff, to patients and to families, particularly when they are not clear in
regard to roles and functions of some other disciplines such as discharge planners.
37
One social worker offered the following when asked if they experienced role
confusion and overlap:
Yes, many, many times. This frequently depends on the personality of the
individual in other disciplines. The most frequent examples are nurses and
chaplains who, while also addressing certain psychosocial aspects of the
patient’s life, get in a little over their heads in terms of their education,
experience, and job responsibilities.
Other responses included “Sometimes it occurs with the chaplain interns in the type of
support given to families,” “Yes, occasionally roles overlap with psychiatry, discharge
planning and chaplains, as well as some of the medical interns,” “Yes, particularly
with financial counselors and private and public insurance eligibility workers,
sometimes with discharge planners,” and “There has been some expectation of a social
worker to do or provide something that another discipline should handle.” While it is
very clear that role confusion and overlap occur at least sometimes, it is less clear if
members of other disciplines are taking on social work roles and functions, as the first
social worker suggested, or if social workers are taking on non-typical roles and
functions. Based on the responses and literature, it seems it is most likely a
combination of both.
Table 1 reflects the percentage and number of participants that reported
experiencing role confusion and overlap in terms of intensity. Role confusion and
overlap most commonly occur with discharge planners who are typically nurses at
UCDMC. Eleven of thirteen participants (84%) reported that they experience at least
38
“a little” role confusion and overlap with discharge planners while one participant
(7%) reported that they experience “a lot.” Participants reported that role confusion
and overlap occur with nurses as well. Five participants (38%) reported at least some
role confusion and overlap with nurses while one participant (7%) reported “a lot.” In
addition, five participants (38%) reported at least some role confusion and overlap
with chaplains and seven (53%) reported at least some with physicians. However,
most participants reported that role confusion and overlap occur only “rarely if ever”
in terms of frequency. Table 2 reflects the percentage and number of participants that
reported experiencing role confusion and overlap in terms of frequency. “Other”
disciplines that participants reported experiencing role confusion and overlap with
included “eligibility workers,” “financial counselors,” “police department,”
“psychiatrist,” and “team coordinator.” One participant reported that they experience
“a lot” with eligibility workers while another reported that they experience “a lot” with
financial counselors.
39
Table 1
Percentage and Number of Participants Experiencing Role Confusion and Overlap in
Terms of Intensity
Disciplines
None
A little
A lot
Discharge planners
15% (2)
76% (10)
7% (1)
Nurses
61% (8)
30% (4)
7% (1)
Chaplains
61% (8)
30% (4)
7% (1)
Physicians
46% (6)
53% (7)
0% (0)
Other
61% (8)
23% (3)
15% (2)
Table 2
Percentage and Number of Participants Experiencing Role Confusion and Overlap in
Terms of Frequency
Disciplines
Rarely if ever
At least weekly
At least daily
Discharge planners
53% (7)
46% (6)
0% (0)
Nurses
84% (11)
7% (1)
7% (1)
Chaplains
84% (11)
15% (2)
0% (0)
Physicians
100% (13)
0% (0)
0% (0)
Other
69% (9)
23% (3)
7% (1)
All participants but one reported experiencing role confusion and overlap in at
least one of the roles and contexts given (see Table 3): “collection of patient
40
psychosocial information,” “provision of services and resources to address patient
psychosocial concerns,” “arrange for services at patient discharge,” and “act as the
primary liaison between hospital and patient’s family.” In regard to “collection of
patient psychosocial information,” five of thirteen participants reported experiencing
role confusion and overlap with at least one of the given disciplines (four with
discharge planners, two with nurses, four with chaplains, two with physicians, one
with “other”). In regard to “provision of services and resources to address patient
psychosocial concerns,” seven participants reported experiencing role confusion and
overlap with at least one of the given disciplines (six with discharge planners, one with
nurses, five with chaplains, one with physicians, one with “other”). For “arrange for
services at patient discharge,” eight participants reported experiencing role confusion
and overlap with at least one of the given disciplines (six with discharge planners, one
with nurses, one with physicians, one with “other”). For “act as the primary liaison
between hospital and patient’s family,” eight participants reported experiencing role
confusion and overlap with at least one of the given disciplines (three with discharge
planners, four with nurses, two with chaplains, three with physicians, one with
“other”).
Thus, the roles and disciplines in which participants reported experiencing role
confusion and overlap most commonly are “provision of services and resources to
address patient psychosocial concerns” and “arrange for services at patient discharge”
– both with discharge planners. Study data reflect that most of the role confusion and
overlap were with the discharge planners (n=19), followed by the chaplains (12).
41
Table 3
Number of Participants Experiencing Role Confusion and Overlap within Each Given
Role
Disciplines
Arrange for
services at
patient
discharge
Total
4
Act as the
primary
liaison
between
hospital and
patient’s
family
3
6
19
5
4
3
0
12
Nurses
1
2
4
1
8
Physicians
1
2
2
1
6
Other
1
1
1
1
4
Total
14
13
13
9
Discharge
planners
Chaplains
Provision of
services and
resources to
address
patient
psychosocial
concerns
6
Collection of
patient
psychosocial
information
Factors That Contribute to Role Confusion and Overlap
When asked to name the primary factors that contribute to role confusion and
overlap, participants identified various factors. Lack of effective communication was
suggested by several social workers. For example, one social worker offered the
following:
There are a lot of players in a patient’s medical care which can be confusing to
the family. Lots of layers and the right person being difficult to locate.
Another team player may say they do not do something but then not give
adequate info about who can provide the service.
42
Another social worker similarly mentioned “Lack of communication as to who has
done what” while another mentioned “Unit supervisor not clearly communicating our
role.”
Other participants suggested that social work roles and functions often are not
firmly defined and other disciplines (as well as patients) often do not understand social
work roles and functions. It seems it is an issue particularly as there is similarity in
roles with other disciplines such as discharge planners. For example, participants had
the following responses when asked to name the primary factors that contribute to role
confusion and overlap they experienced: “Patients and referral sources assuming that
social workers do discharge planning duties or eligibility for insurance,” “Lack of
clarity about who should be doing what” and “Lack of information by staff.” In
addition, one social worker wrote
Lack of awareness by doctors and nurses regarding the differing roles of social
workers vs. the other disciplines such as discharge planning. Other times I
don’t think they are so much confused, but we are more available on
weekends, after hours. They are just hoping we can assist them and they won’t
have to wait for a discharge planner or financial counselor.
The last response highlights another factor participants identified contributes to
role confusion and overlap – “expediency” – as one participant put it. It seems social
workers take on (or at times are expected to take on) various roles or assignments for
some shared purpose. One social worker wrote “I think that once you start to work
43
with a patient and/or family, one thing leads to another and get caught up with helping
them even if it’s outside of your role.” Another similarly wrote
Sometimes I will respond to requests for services more appropriately directed
to one of the staff named above because 1) it can be easily and quickly handled
2) it’s not something outside my scope of service and no one else is readily
available 3) there is an established relationship with the patient or family.
Another social worker suggested other disciplines step in as well to assist with some
shared purpose. They wrote
Some roles naturally overlap depending on the patient circumstances and who
is available to help them at the time. Social workers are in short supply, so
sometimes staff try to give us a break by “filling in” and saving us for the more
complex cases.
Participants’ Recommendations to Reduce Role Confusion and Overlap
Participants were asked how role confusion and overlap they experience is
typically resolved. All participants but one, who did not answer, suggested that it is
primarily resolved directly and situationally. The participants’ responses included
“Educate referral source and/or patient that I don’t handle certain functions,” “Talking
with the coworker,” “By communication, direction, giving pager or phone numbers of
appropriate people.” One social worker wrote
Talking and clarifying what the social worker does, what the other disciplines
do. Giving them the phone numbers, process to access those disciplines. It
44
takes knowing your role and others to redirect them without them getting angry
and feeling you aren’t willing to help them.
Another social worker wrote
If two disciplines are working on the same thing, I talk about it with them and
determine who really needs to help the patient based on what their needs will
be and we agree what our tasks and goals will be.
Several participants reported that they occasionally consult supervisors to get
an issue resolved. One social worker wrote “Appropriately assertive communication
among team members has been the most effective method” but added “With chaplains,
I have found it necessary to go to their supervisor over the years for clarification of
their role.” Other participants wrote “Educate staff as appropriate … If I am confused,
I consult with supervisor or legal affairs, if needed” and “I personally clarify if it’s a
discharge planning function over my own scope. If I have concerns about another
disciplines involvement I may speak with them directly or talk with their supervisor.”
Participants were asked if they were aware of any attempts to reduce role
confusion and overlap. Many reported that they were not. Several participants,
however, mentioned that there is some education provided to staff (and patients).
Participants mentioned “Some of our social workers are taking it upon themselves to
do in-services in their units and for certain groups of professionals (e.g. pediatric
residents),” “In-service training to new residents and staff, info given to
patients/families explaining services and role of social worker in the hospital,” and “At
times social services has put out the types of referrals we will take … Social workers
45
speak to the incoming chaplain interns each year.” One social worker added “We
have had committees make recommendations to social services manager about
clarifying role of social worker.”
Participants’ recommendations to reduce role confusion and overlap primarily
involved better communication and education. One social worker suggested “Annual
presentations by social workers to each of the patient care areas that addresses
particular aspects of social workers’ education/training, as well as education on the
role of social workers and what they can offer patients/families at UCDMC.” Another
suggested “Better training of new residents on what each service does and how to
secure the assistance they need. Some teaching about the limited resources available
so expectations are more realistic.”
This chapter discussed the data from the study. Various themes were
presented. The next chapter will present a summary of the findings and conclusions.
The limitations of this study and implications for social work practice and policy are
also discussed in the next chapter.
46
Chapter 5
CONCLUSIONS
Data and results from the study were presented in the previous chapter. Major
findings will be presented in this section. The study sought to investigate the roles of
hospital social workers and their experiences with role confusion and overlap.
Participants were first asked to identify their primary roles and functions. Participants
reported a wide range of roles and functions. However, all participants reported that
they do psychosocial assessments, provide support and counseling, provide resources,
and advocate for patients and families. Fort Cowles (2003) identified the following
roles and functions of hospital social workers: screening and case finding, crisis
intervention, psychosocial assessment and intervention planning, brief counseling,
bereavement services, and discharge planning. UC Davis Medical Center social
workers do not do discharge planning and, in fact, they experience role confusion and
overlap primarily with discharge planners.
All participants reported that they experience role confusion and overlap at
times. Participants most commonly experience role confusion and overlap with
discharge planners who are typically nurses but specifically provide discharge
planning services. They experience some with nurses, chaplains, physicians and other
disciplines as well. However, most participants reported that they experience a little
role confusion and overlap and that it occurs only rarely in terms of frequency, even
with discharge planners. The statistics derived from the study suggest that role
confusion and overlap occur but ultimately not to a significant extent. Nevertheless,
47
participants’ comments suggest that although role confusion and overlap occur rarely,
they regard it as a more significant issue than the statistics suggest.
In regard to roles in which participants experience role confusion and overlap,
the role in which participants reported experiencing role confusion and overlap most
commonly was provision of services and resources to address patient psychosocial
concerns, particularly with discharge planners and chaplains. Social workers are more
likely to experience role confusion and overlap with discharge planners and chaplains
than with nurses and physicians because discharge planners and chaplains primarily
deal with psychosocial issues whereas nurses and physicians primarily deal with
medical issues. Similarity in roles with discharge planners and chaplains has been
suggested in the literature (Holliman, Dziegielewski, & Teare, 2003; WittenbergLyles, Oliver, Demiris, Baldwin, & Regehr, 2008). Fort Cowles (2003) suggested that
even nurses and physicians who traditionally focus on medical issues increasingly
perceive psychosocial issues as part of their own domains which participants
suggested to some extent as well.
Participants were asked to identify the primary factors that contribute to role
confusion and overlap and provide recommendations to reduce role confusion and
overlap. Lack of communication and lack of awareness by other disciplines as well as
patients in regard to social work roles were identified as factors. In addition, several
social workers reported they sometimes step in to assist other staff or patients even if it
is outside of their role. They do not regard it as a problem necessarily, however.
Participants’ comments suggest that hospital social workers feel that roles should be
48
flexible at times. King and Ross (2003) found that medical social workers were likely
to emphasize the need for flexibility in roles whereas nurses were likely to emphasize
a traditional interpretation of roles. Participants’ recommendations to reduce role
confusion and overlap primarily involved better communication and education. In
fact, it seems there is some education provided to staff and patients in regard to
explaining services and roles of social workers in the hospital, as well as what the
other disciplines do.
Limitations
The most significant limitations of this study are the sample size and the datagathering technique used. Only thirteen participants took part in the study. The low
number of participants limited input regarding the issue. In addition, all participants
work in the same hospital and department, UC Davis Medical Center Department of
Clinical Social Services. Their experiences and perceptions may not necessarily
represent the experiences and perceptions of hospital social workers in general. The
data-gathering technique used for this study was a questionnaire. The researcher feels
that they likely may have been able to gain greater insight if they used interviews. It
was, however, not practical to conduct interviews specifically with the study
population for this study.
Implications
Based on the results of this study, it is clear that hospital social workers
experience role confusion and overlap to some extent. Professional role confusion and
overlap have practice and policy implications, particularly as they are practice and
49
policy issues. On the practice level, role confusion and overlap may affect the
effectiveness of joint working practice and even the quality of relationships between
professionals. In addition, it may result in lack of coordinated service delivery and
decreased quality of services. This researcher feels that more research is needed in
regard to social work practice in hospitals. Understanding social work professionals’
practice issues such as role confusion and overlap, researchers and practitioners may
be able to more effectively address the issues, particularly as there are significant
implications to not addressing them.
Professional role confusion and overlap have policy implications as well.
Hospital social workers practice in a host setting. The value of social work services is
very commonly unclear to others. Social work in hospitals is increasingly struggling
to survive as well as to maintain its identity. Elimination of social work departments
and social work budget cuts are commonplace in hospitals. Hospital social workers
should demonstrate their unique value and contributions to their hospital teams and
organizations. Social work researchers have identified a need for social workers to
evaluate their practice and skills and knowledge in a changing health care
environment. Further research and knowledge will hopefully lead to greater
integration of social work in hospitals and other health care settings.
50
APPENDIX A
Study Questionnaire
51
Roles of UC Davis Medical Center Social Workers
The purpose of this questionnaire is to examine the various roles of UC Davis Medical Center social
workers. The questionnaire will take about 20 minutes of your time. Your participation is voluntary.
No identifying information will be used.
1.
What are your primary roles and functions as a UC Davis Medical Center social worker?
2.
Is there a difference between your expected and actual roles and functions as a UC Davis
Medical Center social worker? If so, how do they differ?
3.
Have you ever experienced role confusion with other disciplines as a UC Davis Medical Center
social worker?
52
4.
Which disciplines have you experienced role confusion with or with which disciplines do you
see the potential for role confusion? Please indicate the intensity and frequency with which
you have experienced role confusion with each of the disciplines.
INTENSITY
DISCIPLINES
None
A little
FREQUENCY
A lot
Rarely if ever
At least weekly
At least daily
Discharge
Planners
Nurses
Chaplains
Physicians
Other (please
specify)
5.
In which roles or contexts have you experienced role confusion or in which roles or contexts
do you see the potential for role confusion? Please indicate the disciplines with which you
have experienced role confusion in each of the roles or contexts.
Collection of
Provision of
Arrange for
Act as the
Other (please
DISCIPLINES
patient
psychosocial
information
services and
resources to
address patient
psychosocial
concerns
services at
patient discharge
primary liaison
between hospital
and patient’s
family
specify)
Discharge Planners
Nurses
Chaplains
Physicians
Other (please
specify)
6.
What are the primary factors that contribute to role confusion experienced by UC Davis
Medical Center social workers?
53
7.
How is the role confusion that you experience typically resolved?
8.
What are your recommendations to reduce role confusion for UC Davis Medical Center social
workers?
9.
Are you aware of any attempts or ideas to reduce role confusion and their outcomes?
Are you a MSW or LCSW?
What hospital unit do you currently work in?
How long have you worked as a medical social worker?
How long have you worked at UC Davis Medical Center as a social worker?
THANK YOU! Your participation is appreciated.
54
APPENDIX B
The Informed Consent Form
55
Roles of UC Davis Medical Center Social Workers
Research Study Consent Form
I____________________have been asked to participate in a research study under
the direction of Aleksandra Baksa, Sacramento State Social Work Graduate Student,
whose phone number is (916) 844-4798. The advisor for this research is Professor
Francis Yuen, whose phone number is (916) 278-6943.
Purpose: I understand that the purpose of this study is to examine the roles of UC
Davis Medical Center social workers and any role confusion and overlap that occur
with members of other disciplines within the hospital.
Duration: I understand that the study will take about 20 minutes.
Procedures: I will be asked to answer questions about my roles as a UC Davis
Medical Center social worker and any role confusion and overlap that I experience
with members of other disciplines in the format of a questionnaire.
Risks: There is little risk of discomforts or harm involved in the study.
Benefits: I understand participating in this study may help researchers and
practitioners in medical settings better understand the roles of medical social
workers.
Confidentiality: I understand my name and other identifying information will not be
directly associated with any information obtained from me. When results of this
study are published, my name or other identifying information will not be used.
Signatures: I have read this entire consent form and understand my rights as a
potential research subject. I understand my participation is voluntary and I may
decline questions or withdraw at any time.
__________________________
Signature of Research Subject
__________________________
Date
56
REFERENCES
Auerbach, C., Mason, S., & LaPorte, H. (2007). Evidence that Supports the Value of
Social Work in Hospitals. Social Work in Health Care, 44(4), 17-32.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook
Handbook, 2008-2009 Edition. Retrieved from http://www.bls.gov/oco/.
Dziegielewski, S., & Holliman, D. (2001). Managed Care and Social Work: Practice
Implications in an Era of Change. Journal of Sociology & Social Welfare,
28(2), 125.
Fort Cowles, L. A. (2003). Social work in the health field (2nd Ed.). NY: Haworth
Press.
Gehlert, S., & Browne, T. A. (2006). Handbook of health social work. Hoboken, N. J.:
Wiley.
Gregorian, C. (2005). A Career in Hospital Social Work: Do You Have What It
Takes? Social Work in Health Care, 40(3), 1-14.
Hepworth, D. H., Rooney, R. H., Rooney, G. D., Strom-Gottfried, K., & Larsen, J. A.
(2006). Direct social work practice: Theory and skills (7th Ed.). Belmont, CA:
Thomson/Brooks/Cole.
Holliman, D., Dziegielewski, S., & Teare, R. (2003, August). Differences and
Similarities Between Social Work and Nurse Discharge Planners. Health &
Social Work, 28(3), 224-231.
57
Keefe, B., Geron, S., & Enguidanos, S. (2009). Integrating Social Workers into
Primary Care: Physician and Nurse Perceptions of Roles, Benefits, and
Challenges. Social Work in Health Care, 48(6), 579-596.
Kerson, T. S. (2002). Boundary spanning: An ecological reinterpretation of social
work practice in health and mental health systems. New York: Columbia
University Press.
King, N., & Ross, A. (2003). Professional Identities and Interprofessional Relations:
Evaluation of Collaborative Community Schemes. Social Work in Health
Care, 38(2), 51-72.
Kitchen, A., & Brook, J. (2005). Social Work at the Heart of the Medical Team. Social
Work in Health Care, 40(4), 1-18.
Kreuger, L. W., & Neuman, W. L. (2006). Social work research methods: Qualitative
and quantitative applications. Boston: Pearson Publications Inc.
Lechman, C., & Duder, S. (2009). Hospital Length of Stay: Social Work Services as
an Important Factor. Social Work in Health Care, 48(5), 495-504.
Lee, J., & Rock, B. (2005). Challenges in the New Prospective Payment System:
Action Steps for Social Work in Home Health Care. Health & Social Work,
30(1), 48-55.
Mizrahi, T., & Berger, C. (2005). A Longitudinal Look at Social Work Leadership in
Hospitals: The Impact of a Changing Health Care System. Health & Social
Work, 30(2), 155-165.
58
Neuman, K. (2003). The Effect of Organizational Reengineering on Job Satisfaction
for Staff in Hospital Social Work Departments. Social Work in Health Care,
36(4), 19-34.
O’Brien, M., & Stewart, S. (2009). Measuring Satisfaction with Social Work Services.
Social Work in Health Care, 48(2), 105-118.
Reese, D., & Sontag, M. (2001, August). Successful Interprofessional Collaboration
On The Hospice Team. Health & Social Work, 26(3), 167.
Rizzo, V., & Abrams, A. (2000). Utilization Review: A Powerful Social Work Role in
Health Care Settings. Health & Social Work, 25(4), 264.
Sulman, J., Savage, D., & Way, S. (2002). Retooling Social Work Practice for High
Volume, Short Stay. Social Work in Health Care, 34(3/4), 315-332.
Wittenberg-Lyles, E., Oliver, D., Demiris, G., Baldwin, P., & Regehr, K. (2008,
December). Communication Dynamics in Hospice Teams: Understanding the
Role of the Chaplain in Interdisciplinary Team Collaboration. Journal of
Palliative Medicine, 11(10), 1330-1335.