Social Work Accomplishments and Opportunities
The frequency of responses to the various categories for accomplishments and opportunities, describing both their present situation and future expectations in order of frequency of occurrence are displayed in Table 1. Although there is some overlap, the directors do articulate distinct types of achievement. One of the most interesting findings is the creativity with which social work leaders defined accomplishments and opportunities, as well as the scope and extensiveness of their efforts. For many administrators, the social work role was deepened and expanded at the clinical, planning and development, and management levels. Each category is elaborated on further to illustrate the richness of the activities described.
New Programs. About 39 percent of the respondents identified one or more such accomplishments, either through their own direct activities or indirectly through the activities of staff and students. They described a variety of new planning and development activities, including programs such as rape crisis services, support groups, hospice care, protocols and clinical standards, research projects, student initiatives, and consultation inside and outside the hospital. Funded externally through grants and contracts, many of the new initiatives were accomplished through collaboration with other disciplines or services outside the social work department.
We added clinical social work services in children's and adult ERs, and on call social work 12 midnight to 8 A.M.; developed a centralized patient prescription program for indigent patients under Department of Clinical Social Work. We developed a computerized database for child abuse, elderly abuse, and domestic violence cases.
[We] expanded EAP services; created critical incident stress debriefing teams; collaborated with the American Cancer Society to increase services to oncology patients, including support groups; developed our OB program; initiated an NICU parent education/support group; and initiated new concise documentation forms. More emphasis on self-directed teams under the three SW coordinators; more emphasis on outpatient (clinic) environment with social work staff; development of social work drug assistance programs which will provide more treatment to needy patients.
Of concern, however, is the projected decrease in these activities. Fewer than 5 percent of the respondents anticipated creating new programs in the future.
Preservation of Social Work. Respondents also identified the preservation of social work's position within the organization as an accomplishment. About 27 percent of the respondents asserted the importance of "holding our own":
We are surviving drastic reorganization and still providing compassionate social work services to patients and families.
This perspective often goes beyond a minimalist stance where directors declare that "it could have been worse." Rather, some specifically noted that they were retaining or recapturing the basic social work function, which several defined as including the clinical or basic professional social work role.
The professional staff may have more time to spend on the higher level function with patients/families if we get rid of the nonprofessional tasks.
* * *
We are able to employ degreed professionals and implementation of basic social work practice (that is, psychosocial assessment).
Nevertheless, it is interesting that fewer respondents (8.1 percent) foresaw this as a task for themselves in the future.
Participation in System Reorganization. Active leadership in administration, management, and coordination characterized this category. Slightly more than one-quarter of the social workers identified accomplishments related to system interventions and outcome evaluations as contributing to system reorganization of the hospital. Many believed that through these activities, they increased the value of social work to the institution. Contributions to the reorganization of discharge planning loomed large; also prominent were active roles in quality assurance. Other examples included activities related to decreasing length of stay, prescreening programs, and money-saving strategies for the hospital (for example, productivity programs). However, when looking to the future, these types of activities were expected to decrease (9.9 percent).
Social workers picked up the utilization function of monitoring length of stay and negotiating with insurance due to elimination of an admissions position. Within some programs there is also an increase in preadmission involvement due to program requirements and decreased admission department involvement.
* * *
We redefined the department as primarily responsible for discharge planning. We have refocused our efforts to positively impact the length of stay and to achieve timely, as well as safe discharges. Programs and physicians within our facility have identified the need for services to enhance the care of patients.
* * *
[Social work has] responsibilities for preadmission assessment for discharge options. We are continuing to decrease length of stay especially in psychiatry from 22 to 10 days.
Expanding or Reclaiming Social Work Functions and Settings. Almost 24 percent of the social work directors described positively a variety of organizations and groups with whom they worked. Enhancements during this period expanded the places and populations for social work intervention, as well as the reclaiming of former settings. For several directors, this meant a return for the social work profession to traditional community work. Directors also highlighted related roles in community organizing, planning, and collaboration with other health and human services agencies. Many were located in new settings or began working with additional patient populations both inside and outside the hospital. Some also assumed new clinical responsibilities, whereas others moved or anticipated moving into physicians' offices, outpatient settings, and primary health care centers. Different from those departments that maintained or expanded the basic hospital social work roles noted below, expanding ambulatory and community s ettings were two areas in which social workers saw the most opportunities, with almost one-third describing them in future terms:
We have] increased recognition as self-determination experts and increased counseling opportunities in ambulatory services.
[There are] opportunities to provide outpatient services, expand case management opportunities, increase home visits; opportunity to review our values and redesign our roles, proactive approaches.
New Social Work Roles and Responsibilities. The assumption or creation of new roles for social workers in a reconfigured hospital system was somewhat separate from the accomplishments mentioned above. These accomplishments included new models and ways of working with and without an official social work title. Almost 24 percent specified the new areas into which social work was moving--case management, patient care teamwork, and collaboration. These departments also were active in cross-training initiatives that, from their perspective, enhanced the status of social work. They also identified these arenas as holding promise for increasing social work practice in a redesigned health care delivery system, with almost one-quarter of the respondents noting the opportunities in the future for social workers to become case managers and an integral part of interdisciplinary teams.
We now have the opportunity to work with the UR nurses as a team. The departmentalized view can be so detrimental to the process of meeting the patient's needs. With this new freedom of being linked to UR, we have some exciting opportunities to expand our functioning within the hospital.
[We can] demonstrate the value of our social worker--case manager role. Possible development of broader continuum of care and need for expanded social work involvement with greater resources available, and greater possibilities for program expansion.
Perhaps the opportunity for social work managers lies in our ability to support the case management team, to facilitate team work, to redefine discharge planning as a system and not a function "controlled" by just a single discipline. Increased Social Work Positions. Despite the general trend toward downsizing, more than one-fifth of the directors had been able to add new lines or expand the social work coverage on additional services. In contrast to the two areas discussed earlier, this category included the expansion of traditional hospital social work roles, usually on inpatient services. Although the above changes in social work functions and system reorganization assumed a reconfiguration of the existing positions, this category is limited to the departments that actually increased in size. Not surprisingly, however, very few respondents (5.8 percent) anticipated that they would be able to continue to increase the basic social work function within the institution.
We added a seven-day week of social work coverage in the emergency department. Increasing staff and maintaining productivity at 150 percent [was another accomplishment]. [There was an] increase in percentage of inpatient census followed by social work. We expanded the social work lines of the hospital's EAP service.
Social work is a highly valued and respected function within this organization. Administration is committed to enhancing and increasing social work staffing as the organization grows.
Increased Social Work Influence. Although it can be inferred that the social work respondents exercised their influence to achieve these results, almost 23 percent specifically described positioning themselves for power as an accomplishment in its own right (Mizrahi & Berger, 1998). Respondents emphasized the importance of increasing one's visibility, effectiveness, and persuasiveness within the organization. They assumed leadership positions, took risks, were there "at the table" when decisions were made, led teams, collaborated with other professionals and administrators, and consistently behaved in a proactive manner. Whereas only 7 percent of directors used the specific word "leadership" in accounting for their successful outcomes, more were clearly exercising leadership and anticipated continuing to do so (16.9 percent).
Director of social work has opportunity to move up the organization and can strengthen social services.
[We have] continued responsibility for team staffing, facilitation, and coordination.
We have assumed the leadership of the ethics committee in conjunction with the physician chair.
Some social work directors highlighted their competence or expertise as an important source for gaining influence in the health care system:
We have participated on the hospital redesign team. [As a result of] initiation of discharge planning rounds on all units using a multidisciplinary approach, we are now coordinating a multidisciplinary discharge review team. Our social worker was named "employee of the year.
Inclusion on all committees that impact sound work services. We are viewed as an integral part of hospital operations and valued for the services we provide to patients and hospital operations. We have been able to fill vacancies when outside hiring freezes were not imposed.
We have recently affiliated in a network with four other hospitals. A social worker from my staff was asked to lead a task force for collaborative programming for arthritis patients. The affiliation may lead to other such opportunities. Our physician support is high, and there is possible provision of social work services in the MD's office.
Nevertheless, these social work directors by no means painted a one-sided, rosy picture of their experiences in the field. These social work administrators often described a more balanced view of their situations, articulating failure, threats, and challenges along with their positive experiences. Even the ones who projected an optimistic view of present and future circumstances listed many obstacles and challenges that they routinely faced.
Social Work Failures and Challenges
Most administrators reported some failures, threats, or, at the very least, challenges to social work. We classified these as pressure on social work, devaluation or nonrecognition of the profession, external threats with negative consequences, decreasing quality of care, threats from within social work, and changes in departmental restructuring and reporting. The following responses encompass the range of problems that others encountered:
Though efforts to network are successful, mundane tasks have been taxing. Lack of an interdisciplinary approach to discharge planning remains a problem. Expectations/demands/needs of the community are overwhelming. There is not enough self-help activity here; few established resources for remaining staff; lack of understanding of the expertise of an MSW [master's of social work]; neither has time nor opportunities to specialize.
Continued calls for cost reduction may further impact staffing, and salary increases may be low; staff turnover due to increased demands and overall health care environment; reduction in support staff; less clinical/more technical skills will affect quality of social work services; it will be a challenge to provide them, given emphasis on "bottom line." Staff providing the service sees us losing our social work perspective, vision, and concern for the "person" who is the "patient." Competition for positions will increase.
Table 2 displays the frequency with which respondents in rank order identified these various challenges.
Pressure on Social Work. By far, the frustration reported most extensively (by one-third of respondents) was heavy or unrealistic demands to provide social work services and to fulfill social work roles. Examples included the inability to recruit or retain social workers, increasing caseloads and responsibilities--often with fewer staff, low morale and burnout, and a lessening of the psychosocial or clinical component of social work activities. Perhaps more ominous was the feeling that an otherwise proactive director expressed, "[I'm] often too busy to have any time to think/plan ahead, vision.
We've lost virtually all funds for staff education. Director has had to take on substantial direct service tasks, resulting on less time to plan, direct activities, and to support staff.
[There is a] lack of adequate time to spend with patients and families, and very little ability to deal with problems in outpatient areas. No pool of resources internally to "cover" for extended illness, etc. Insufficient clerical help! Too much time in copying and faxing.
[We are facing] a decrease in financial resources; "and downsizing" of staffing, while simultaneously being expected to provide increased services for increased outpatient volume.
Identifying these pressures as the most significant problem in the present environment, only 15.3 percent of respondents foresaw this type of stress in the future.
Devaluation or Nonrecognition of Social Work. Almost one-quarter of the social work leaders discussed a more insidious change--the devaluation of social work--as reflected in decreasing respect and appreciation for social work roles, functions, and contributions to the organization and patient care. Limiting social work's ability to gain influence within the organization, this devaluation manifested itself in turf battles with nurses and, to a lesser degree, with physicians and administrators. An organizational climate of tension, confusion, or competition often resulted. Respondents suggested that this lack of understanding produced barriers to quality patient care, as well as inhibited social work's contribution to the overall success of the organization:
Hospital continues to require physician orders [for social work] to intervene with the acute patient. Nurses reluctance/inability to recognize psychosocial issues so that social work staff could intervene in a timely manner [is a problem].
Nursing surplus presents threats to the autonomy and size of social work staff in competitive environment.
Administration has difficulty understanding the importance of social services in the overall delivery of quality patient care.
However, fewer directors (13.1 percent) saw this problem continuing into the future in any significant way.
External Threats with Negative Consequences. About 18 percent of the respondents depicted a variety of external circumstances that adversely affected their department and would continue to do so in the future (16 percent). These problems appeared to emanate from factors related to changes in the larger health care system, including the political and economic conservatism of national leadership as expressed in social and health policy. Among the pressures that directors cited were the Joint Commission on the Accreditation of Healthcare Organizations, ethical issues, changes in the demographics and diseases of patients, economic factors such as increased competition by other hospitals, and decreased hospital lengths of stay.
[There are] institutional barriers to establishing fee-for-service and private contractual support for clinical social work services in hospital systems.
Frustration in the continued lack of community-based resources [that is, SNFs, HCFs, and so forth] prevents us from effectively moving patients out of the hospital. Very few choices for patients exist.
Decreasing Quality of Care. This category captures the directors' regrets about their departments' inability to meet patients' needs and expectations now (8.9 percent), as well as to remain the patients' advocate in the future (6.7 percent). Beyond the general devaluation of social work, this category includes responses in which the administrators directly articulated their identification with or empathy for patients.
The inability to obtain additional staffing to adequately provide services to patients at primary care centers [is a problem].
[There is] lack of adequate time to spend with patients and families.
Eliminating or Deprofessionalizing Social Work.
The elimination or redesign of hospital social work positions and functions due to structural downsizing was commonly reported. We coded responses into this category when the directors identified the actual elimination of social work positions, the downgrading of social work positions from MSW to BSW requirements, and the assumption of social work functions or the department by another department or discipline. Considering the extent of devaluation reported, one might expect to see many social work positions eliminated or roles deprofessionalized. However, although most respondents did not report this as a major concern in the present (8.6 percent), they clearly perceived it as a major threat in the future (28.8 percent).
[There is a] lack of open discussion about case management and its future; unclear about its impact on social services. If nursing gets too strong and is perceived as capable of replacing social workers, there could be a loss of positions. If the new CEO does not value social workers, there could be downsizing and reorganization that is detrimental to social work.
Emergence of case managers who are interested in taking on some social work function [is a problem].
Emergence of case managers who have relatively small caseloads and luxury of time to spend with patients, and who see themselves as capable of counseling and discharge planning.
Problems from within the Social Work Community. A small (5.4 percent) but important set of negative responses were targeted at either the profession of social work or the social work staff in the department. When directed at the profession as a whole, these responses described frustrations related to social work's poor position of influence within the health care arena. For example, several criticized social work's inability to articulate social work's contributions to health care or the hospital, particularly in cost savings or cost-benefit terms. Conversely, a few directors lamented their inability to adhere to social work values in this "bottom line" climate.
Simultaneously, many respondents expressed frustration at their own staffs for their unwillingness or inability to adapt and change. And more than double the number of directors (13.4 percent) anticipated that this problem would grow in the future.
As a profession, social work does not market its services well. Medical social work surely has not. I did not put a dollar sign figure on the cost-effectiveness of our program, and now that is what case management does. Social work was forced to become unit based with the advent of patient-focused care.
Patient-focused care could lead to dissolving of the department with an impact on social work values, and so forth.
Our challenge is to define our role in case management without significantly changing the way we practice.
My staff has been resistant to change. They only see the downside and no opportunities.
Impact of Department Restructuring and Reporting. It is interesting that only 3.8 percent of respondents expressed a specific concern about the restructuring occurring within social work departments. The perception by social workers of departments being eliminated and positions lost was a major impetus for this study. The data suggest that although social work departments are experiencing many changes, these types of changes were rarely identified as failures and frustrations and were not expected to be significant in the future (8.3 percent):
We've gone from decentralized to unit based with no leadership, support, or influence. We probably will integrate general social work with rehabilitation and psychosocial services departments. We'll most likely need to discontinue social work services in outpatient areas. Most likely [they] will either discontinue the manager's and supervisor's positions, and that person will become a full-time worker in the department.
Appointment of a non--social worker to director creates some threat to the identity of the group, possibly affecting clinical--professional development of staff.
Major Issues Presented by Social Work Directors
We searched the transcripts for key words or concepts that have been identified as critical concerns in the social work community. These terms included case management, managed care, primary care, physicians, and nurses, among others. These were then classified as neutral, positive, or negative, depending on their usage and context.
By far, the most commonly mentioned term was "case management," with 127 entries. This role was positively or neutrally stated--that is, most of the social work administrators viewed case management as an opportunity rather than an obstacle to social work. The second most frequently identified term was "nurses," and, by contrast and not surprisingly, most (74) of the 117 citings were negative; only 16 were positive. Conversely, references to "physicians," although referred to much less frequently (25), divided equally into positive and negative terms. "Primary care" was noted 109 times, and mostly presented in a positive context. It depicted a direction for their hospital or for the social work department. "Managed care" was not mentioned as frequently as anticipated and, surprisingly, almost all notations were neutral (27) or positive (11), not negative (3).
Relationship between Social Work Leaders' Perspectives and Changes in Their Environment
Did the changes that occurred to their department, in the hospital, or in the external environment play a part in determining the positive, negative, or mixed outlook of these directors? Was their status and background related to how they viewed the work world around them?
We compared their reported data on actual changes that occurred with their overall perspective. The overwhelming result was that there were only a few significant differences between outlook and environmental changes. Outlook, for the most part, did not appear to depend on any of the following: major administrative or structural changes in the hospital; changes in the delivery of social work services, in the number of personnel, or in the activities performed by social workers on the inpatient units; whether social work had merged with or was in charge of other departments; and the type of discharge planning structure. In other words, there were many positive social work directors who experienced one or more of the changes and still presented evidence of past or expected successes.
Significant differences were found in the following chi squares. (All the following items were significant, regardless of whether the social work leader's perspective was classified as a trichotomous (positive, negative, mixed) or dichotomous (positive versus negative and mixed) variable. The significance levels reported are when environmental changes are run against perspective as a trichotomous variable.) More positive social work directors reported actual increases in social work personnel [[[chi].sup.2](4, N = 302) = 16.885, p = .002] and in social work administrative levels [[[chi].sup.2](4, N = 281) = 12.200, p = .016], although all the social workers, regardless of their outlook, reported more decreases than increases in both staffing categories. Furthermore, although all groups experienced more increases than decreases in ambulatory clinical activity, the positive social workers reported the most increases [[[chi].sup.2](4, N = 279) = 13.466, p = .009].
With respect to professional background, the only significant difference was that positively oriented social workers were more likely to have an MSW degree [[[chi].sup.2](2, N = 292) = 4.629, p = .031). There were no differences among the few who held a BSW or other degree.
Discussion
Given the "doom and gloom" that the corporatism of health care services has aroused, we were surprised at the quality and quantity of the directors' accomplishments. Regardless of how optimistic or pessimistic they were, almost all of the respondents documented meaningful contributions to patient care. Furthermore, most of the respondents recognized a variety of places, settings, and roles in which social work could thrive in the future. Still, it is also clear that roles and responsibilities are changing to include working collaboratively with others in the hospitals--not as autonomously as they had in the past. They projected fewer new social work positions and new programs.
Although they identified factors in the larger environment that did and would affect them, these changes were not directly related to their perceptions about the current and future status of social work. The disjuncture suggests that there are real possibilities for promoting a proactive role among social work leaders in health care. For the most part, the directors neither personalized the problems that their departments were experiencing nor expressed victimization. Instead, by maintaining a systems perspective, the overwhelming majority of them solved problems and positioned themselves to take advantage of a range of opportunities on the horizon.
Despite the whirlwind changes around them--much of it framed in opposition to social work and the patients--most of the social work respondents were challenged rather than defeated. Active, creative, committed, and competent, they appeared to be key participants in shaping both health care and social work services for the future. Typically, they emphasized the importance of influence and positioning within the hospital environment to help steer the process of change, rather than merely reacting to it. As these leaders project, they and other social work leaders of the future will require even more political acumen, knowing when to resist, when to acquiesce, and when to adapt or cope. Only by mobilizing their own power can the resources be obtained to achieve their goals (Berger, 1990).
In analyzing failures, a large group of social workers refrained their frustrations as challenges, demonstrating the importance of a positive, proactive stance. Nevertheless, three areas had large increases in the numbers of directors who anticipated challenges, and these must be addressed. Clearly, social work will be restructured, and positions eliminated or drastically altered. Professional relationships are being reconfigured and threatened. Reversing a historical trend, nurses are more often viewed as adversaries than allies; the converse appears to be true of physicians. The pressures of the work environment create morale problems for staff and management, eroding the strengths that fundamentally reside in both the profession of social work and the institution. As always, social work has to manage the persistent tension between advocacy and collaboration (Mailick & Ashley, 1981), between loyalty to the patient and to the organization. The ability of the social work manager to find an effective balance between optimism and pessimism, and activity and passivity (Berger, 1993) also remains a major concern.
It is not enough to be a good manager; one must also be an exceptional leader. Leadership entails passion, a sense of optimism, political acumen, an ability to look into the future in shaping priorities, tenacity, and a joy for adventure (Blumenfield, 1995; Drucker, 1996; Mayer, 1995; Peters & Austin, 1985; Rosenberg, 1987; Spitzer, 1995). Positive change needs to be guided rather than forced. A leader must create a vision and position an organization for the future (Austin, 1989). This requires a leader to be skillful in managing interpersonal conflict, and to support an environment of positive morale (Bixby, 1995; Dimond & Markowitz, 1995). Leaders also need an attitude about failures or setbacks as nondeterrents toward goal achievement (Bixby). Ultimately, leadership is about unleashing the creative energy within organizations to develop innovative and new approaches to services delivery. It is about helping staff to streamline processes by driving out redundancy and unnecessary work, rather than merely " doing more with less" (Hammer & Champy, 1993; Rosenberg & Weissman, 1995a, 1995b). Five specific skills are necessary for this leadership: (1) accurately reading the environment; (2) reengineering your own department (or others will do it for you); (3) maintaining your strengths in your environment by focusing on programs that are highly valued, recognized, and effective; (4) innovating, experimenting, and creating new, more effective, and efficient programs, and funding these through new revenue sources such as grant writing; and (5) creating community partnerships, based on social epidemiologic information, by building on social work's strong relationships within the community (Rosenberg & Weissman, 1995a, 1995b).
This research demonstrates that social work leaders in hospitals understand the complexities and challenges of the world around them. In the aggregate they have exhibited commitment, competence, and confidence that they can contribute to the direction of change. What may not be as clear is the importance of being "up front and center" to be "at the table." Those who have not fared as well, or who view their world more pessimistically, might benefit from the skills, strategies, and support of their peers in the practice, research, and academic communities.
More research is needed to understand the issues, attributes, and attitudes of successful leadership in this changing health care arena. It remains to be seen as to whether knowledge, skills, and values alone will be sufficient to shape the future direction of social work. A follow-up national study to the same group in 1998 and again in 2000 has been completed. A comparison of cohort perspectives over three time frames will provide the social work community with unique longitudinal data. This study will contribute to the research, policy, and practice agenda of social work in health care in the 21st century.
Terry Mizrahi, PhD, is professor, School of Social Work, Hunter College.
Candyce S. Berger, PhD, is associate professor, School of Social Welfare, Health Sciences Center, State University of New York at Stony Brook.
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