Hospital Social Work

The Interface of Medicine and Caring

Joan Beder

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135421311
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Hospital Social Work introduces the reader to the world of medicine and social work as seen through the eyes of actual social workers. An essential reference for both students and professionals.

Over 100 social workers in dozens of hospitals were interviewed to provide the reader with first-hand experiences and discussions of practice principles, policy considerations, and theoretical treatments to provide each chapter with a unique blend of theory and practice.

Joan Beder, a professor of social work and a practicing social worker, recently noted an apparent lack of empirical discussion of the actual role and day-to-day functioning of the medical social worker. Hospital Social Work is the result, a unique supplemental text for both studying and practicing medical social workers.

1
ABOUT MEDICAL SOCIAL WORK

 

 

This chapter introduces the reader to various aspects of the social work profession as it has developed in hospitals. It explores the history of medical social work, the theoretical perspectives that guide social work practice in the medical setting, the nature of collaboration with other health care professionals within the hospital, and the meaning and impact of managed care on the delivery of social work services.

HISTORY OF MEDICAL SOCIAL WORK

Social work in health care began in the United States at Massachusetts General Hospital (MGH) in the early 1900s. At the turn of the century, a steady progression away from home care for the sick had begun; hospitals were slowly replacing the home as the locus of medical treatment in the United States. Concurrent with this shifting venue of care, physicians were beginning to realize that the living conditions and personal problems of patients were a factor in their illness and recovery. In 1889, the Johns Hopkins Hospital, for example, had begun a home visiting program for medical students to learn about their patients and how they live. However, it took the forward vision of Dr. Richard C. Cabot, chief of medicine at MGH, to see the necessity of creating the position of social worker.

Part of the motivation to initiate social work services at the turn of the century was the proliferation of certain medical conditions in the United States. Tuberculosis was prevalent in many cities, fueled by the deplorable conditions in factories and workshops. Syphilis was also quite common. Both conditions required long hospitalizations and aftercare with extended separation from the patient's family. Polio and the pregnancies of unmarried women were also concerns of these early health care workers. Dr. Cabot conceived the idea of introducing a nonmedical presence into the hospital. As a physician, Cabot realized that he and his colleagues were cut off from direct observation of patients and were unable to assess the impact of their home life, their family relationships, and their work as factors in their illness. “As a physician caring for clinic patients at the MGH, Cabot became increasingly concerned that his patients were blocked in carrying out medical treatment by their many individual and family problems. … He decided to bring social workers into the MGH to work with physicians on the patients' social problems as related to the medical treatment” (Bartlett, 1975, p. 212). Cabot also envisioned that social workers would help patients adjust to their hospitalization by having social workers provide information and reassurance to patients and their family members. It would be the task of the social worker to explain the impact of the illness and detail what the hospital stay would entail.

In 1905, Cabot appointed Garnet I. Pelton, a nurse, to fill the first hospital social work position in the United States. She was to report to the doctors on the domestic and social conditions of the patients, help patients fulfill doctors' orders, and provide a link between the hospital and community agencies and organizations. In 1906, Ida Cannon succeeded Mrs. Pelton. Within a few years, social work positions had been established at Bellevue Hospital and Johns Hopkins, and other hospitals had begun exploring the possibility of establishing such a position (Nacman, 1990).

Ida Cannon was well suited for medical social work. She had years of nursing experience and had studied psychology and sociology as part of her university training. She had worked for years doing home visits with poor families in Minnesota and had developed a first-hand understanding of the relationship between social problems and illness. Initially, the hospital's board of trustees was ambivalent about establishing a social work program, as evidenced by the fact that the program was not considered an official department of the hospital and funds to support the department were solicited from personal friends of Dr. Cabot and later from other contributors. But, by 1914, the hospital officially recognized social work activity on the wards, and Ida Cannon was given the title “chief of social services.” And in 1919 the trustees of MGH voted to make the Social Services Department an integral part of the hospital (Nacman, 1990).

Cannon became a spokesperson for social workers in hospitals. Her leadership in the profession rested on three essential ideas: (1) she kept the individual patient and his or her needs in central focus; (2) she identified and continually interpreted the basic concept of the social aspects of illness and of good patient care; and (3) she emphasized the teamwork of the professions — medicine, nursing, social work, and others (Bartlett, 1975). In short, Cabot expected the role of the social worker to revolve around bridging the gap between the hospital environment and the patients' usual social environment in order to remove barriers to effective medical treatment. Social workers were also expected to work toward modifying any social, environmental, or emotional problems that could impact the patients' health condition (Cowles, 2000).

The implication of the shift from using volunteers to assist families outside of the hospital to employing social workers to perform this function meant that professional schools of social work began to grow as the need for trained social work staff took hold. It also signaled the beginning of collaboration, albeit tentatively in the beginning, among social workers, nurses, and physicians.

It was from these beginnings that social work became established in hospitals and has grown over the decades to become a vital and necessary part of how hospitals care for patients. From one social worker in 1905, social work departments had begun in 100 hospitals in 1913 and 400 hospitals in 1923. In 2002, more than one quarter of the 477,000 social workers in the United States were working in and for hospitals (Cowles, 2003). Although a number of changes have occurred over the years, the basic orientation to the work, as envisioned by Dr. Cabot and articulated by Ida Cannon and others, has endured. What remains of their pioneer work is the need to see the patients as part of interlocking systems that include their immediate family and widen to include their community and the larger political community, which dictates care and entitlements. What has changed is that social workers are no longer seen as handmaidens of the doctors. “Theirs is a new relationship within the institution and with other health care providers as they initiate and implement social-health services. They emphasize their professional independence while they enter into sound collaborative and team relationships” (Rehr, 1998, p. 18).

SOCIAL WORK PRACTICE IN HOSPITALS — THEORETICAL PERSPECTIVES

Today, the role of the social worker is clearly established; social workers are found in every area of the health care delivery system (Dziegielewski, 2004). Although practice venues differ (small or large hospital, urban or rural setting) and organizational constraints pull social workers one way or another, core concepts bind the practice of social work in all hospitals. These concepts serve as the foundation upon which social work services are based. “The unifying theoretical perspective … is the view that people can best be understood and helped in the context of the conditions and resources of their social environment. Social environment refers to the quality and characteristics of one's life situation, including interpersonal relationships, resources for one's needs, and one's position, roles, and participation in society” (Cowles, 2000, p. 10). This orientation, known as the person-in-environment, was what motivated Dr. Cabot and Ida Cannon to establish social work in their hospital, so that the physicians could enhance their healing potential by having a greater understanding of what their patients had to deal with when they left the hospital. Did patients have people in their immediate environment who could care for them? What supports existed and what needed to be enhanced? Were there community resources that could be brought to patients to help them recover? The centrality of understanding people as they relate to their environment, and the reciprocal relationship of people to their environment, goes beyond medical and hospital social work and is the core of all social work practice.

Specific to the hospital social worker is the biopsychosocial approach to practice. “Social work's biopsychosocial approach provides a carefully balanced perspective, which takes into account the entire person in his or her environment and helps social workers in screening and assessing the needs of an individual from a multidimensional point of view” (Berkman & Volland, 1997, p. 143). The biopsychosocial approach considers three overlapping aspects of the patient's functioning: “bio” refers to the biological and medical aspects of the patient's health and well-being; “psycho” refers to the patient's self-worth, self-esteem, and emotional resources as they relate to the medical condition; and “social” refers to the social environment that surrounds and influences the patient. It behooves the social worker to assess each of these domains to gain a full understanding of the patient (Rock, 2002). This view of practice is also referred to as a holistic view because it seeks to encompass the whole picture of the individual and places the individual in a context that informs social work intervention.

To best serve their patients, social workers need special skills and levels of knowledge. Consistent with and within the context of the person-in-environment and biopsychosocial orientations to practice, schools of social work prepare social workers, stressing the need for the medical social worker to understand the patient population and their health problems, the organizational setting, the community, intervention modalities, and methods of research and program evaluation.

Understanding the patient population and health problems includes being familiar with the usual path, treatment, and management of a particular illness. This knowledge facilitates the engagement, assessment, planning, cooperation, and overall communication with the patient and family members. In addition, it allows the social worker to knowledgeably interact with the other health care professionals with whom it is necessary to communicate on behalf of the patient. An understanding of the organizational setting facilitates interdisciplinary teamwork and informal advocacy on behalf of the patient. Knowledge of the community allows the social worker ease in linking patients to resources and facilitating referrals to other health-related programs that will aid the patient. Understanding of specific treatment modalities and intervention approaches allows the social worker to meaningfully interact with patients and family members in the role of counselor and confidante. This skill enables the social worker to connect with the patient or family member to address emotional concerns and help the patient resolve problems as they relate to the medical condition. Social workers are trained to be able to do research in any work setting. The social worker's ability to design and conduct research keeps social work vital and responsive to patient needs while documenting new areas of knowledge and understanding. Research on existing programs, especially those that reinforce interdisciplinary cooperation, is vital to serving patients' and family members' needs (Cowles, 2000).

COLLABORATION: THE INTERDISCIPLINARY TEAM

Collaboration is a complex and dynamic process that occurs when two or more health care providers cooperate and assist one another in the service of a patient or family member. Collaboration takes place between and among the various components of the health care team, also called the interdisciplinary team. The rationale for collaboration and interdisciplinary teamwork is that multiple kinds of knowledge and skill need to be involved and applied to best service the patient and family.

Members of the interdisciplinary team can include physicians, nurses, social workers, physical therapists, psychiatrists, nutritionists, and others who may be providing care to the patient. The particular unit or service within the hospital dictates the exact makeup of the interdisciplinary team. The functions of such teams include shared assessment of patient problems and needs, exchange of relevant information, team teaching of staff, development of intervention plans, ethical decision making, delegation of tasks and responsibilities, and evaluation of outcome (Cowles, 2000).

Collaboration of this type requires a high degree of cooperation to be successful, with each participant knowing that he or she has something to contribute and that the contribution will be recognized in the decision making about the patient. Collaboration has the potential to work well on a medical unit, but it is not without potential difficulties. Because the goal is to bring together different professions to address the needs of one patient, it is acknowledged that different professions bring different attitudes, values, skills, and service orientations to the deliberations regarding what may be best for the patient (Rehr, Blumenfield, & Rosenberg, 1998).

The social workers interviewed for this volume were asked whether their unit worked collaboratively and whether they felt valued as part of their unit's interdisciplinary team. Almost every social worker functioned as part of a team; a large percentage of these workers felt they were a valued member of their team. In some settings, social workers were less valued than some of the other professionals on the team, but generally, collaboration of the various disciplines was supported.

MANAGED CARE

In the latter part of the 1980s it became clear that the cost of health care delivery had skyrocketed to crisis proportions in the United States. The causes for this are many, including the aging population, the ascendancy of the “baby boomers,” remarkable advances in technology, and the rise in the cost of services. In addition, the insurance industry had been faltering and hospital costs were escalating, causing smaller hospitals to either close or merge in order to be sustained. Managed care was born out of the need to control the costs of health and mental health care; managed care has become the main mechanism for cost containment in the last decade or so. Managed care may be seen as a market-driven arrangement for health services that is pervasive in the United States (Rock, 2002). It is important to note, “Managed care is not about the consumer (patient). It is not about quality. It is, however, about cost and the perceived need on the part of government and the insurance industry to control it” (Gibelman, 2002, p. 17).

Managed care involves the administration and oversight of health and mental health services by someone other than the patient and provider. The goal of managed care is control over the service delivery system of health care as well as regulation of the actual services, all efforts focused on cost containment (Corcoran, 1997). Managed care plans are designed to reduce medical costs by discouraging unnecessary services, by setting limits of duration and types of service, and by providing market inducements for providers to limit the services made available to patients (Edinburg & Cottler, 1997). This is accomplished through a mix of health insurance, government assistance, and payment programs that seek to retain quality and access while controlling the cost of services (Lohmann, 1997).

Within the health care arena, managed care has affected the practice of social workers in numerous ways. It has provoked ethical issues, has changed the nature of practice, and has moved the focus of social work services to greater accountability with a focus on evidence-based practice. In the area of ethical issues, when managed care companies demand access to client records or detailed information related to the patient and the treatment, they potentially compromise patient confidentiality, a primary arena for ethical violation. In addition, managed care companies can place limits on treatment that may well run counter to professional assessment, creating an ethical dilemma for the social worker. This is seen especially in hospitals when patients are discharged before the social worker believes they are ready for and capable of managing outside of the hospital. The nature of practice has also been deeply eroded in that managed care companies now dictate the limits on reimbursable care, duration of treatment, and some medication choices. Finally, managed care has refocused service with high demands on accountability and the need to document outcomes. The social worker is required to document that services provided result in achievement of the goals of their stated service plan. Vigilance in creating a service plan as well as conscientious tracking are now demanded of the social worker (Gibelman, 2002).

Not all the changes wrought by managed care are seen as negative. Many people support the tighter control of costs and treatment initiated by the managed care organizations. The accountability demanded by managed care has strengthened some services within the medical and hospital arena. For social workers, it has shifted many of them away from bedside relationships with patients; paperwork demands and shortened stays have decreased the interpersonal nature of their work. Physicians have their own distress with managed care, more focused on fee structures and permissible procedures as well as length of stays, and so forth. It behooves social workers to find their niche within the managed care structure and maximize their relationships with colleagues and with patients and their families.

SUMMARY

The practice of hospital social work in the 21st century dates to the turn of the last century when Dr. Richard Cabot and Ida Cannon gave voice and form to a new type of social work, one in which the social worker became an active participant in the management and care of sick people. Working with the hospital physicians, the social workers were able to add dimension and breadth to the understanding of the “surround” of the patient as it influenced health outcomes. This partnership has expanded over the many decades since the pioneering work of Ida Cannon at Massachusetts General Hospital.

The current hospital social worker works from a biopsychosocial approach, taking into consideration the person-in-environment. This sound theoretical base facilitates the efforts of the social worker who participates in an interdisciplinary environment to best meet the needs of the patient with a broad-based understanding of the family and community influences. Modern hospital social work is practiced in an environment of managed care, which has shaped medical and mental health services in the United States for the last decade. Managed care has brought to the practice of social work and medicine sweeping changes, some welcomed and seen as improvements over non-managed care and some that have been described as severely limiting. Regardless of the views about managed care, it likely will dominate and dictate medical treatment, in some form or another, for years to come. Hospital social workers have and will continue to adapt and function in this milieu and offer fully professional services to those who are ill.

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GENERAL MEDICAL SOCIAL WORK

WHAT SERVICES ARE INCLUDED?

Modern hospitals offer medical care on numerous units, sometimes delineated by floors. The units this chapter will focus on include orthopedics, obstetrics/gynecology, neurology, surgery,...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Dedication
• Contents
• Foreword
• About the Author
• Chapter 1 About Medical Social Work
• Chapter 2 General Medical Social Work
• Chapter 3 The Renal Social Worker
• Chapter 4 The Cardiac Care Social Worker
• Chapter 5 The Hospice Social Worker
• Chapter 6 Organ Transplant Social Work
• Chapter 7 Pediatric Oncology Social Work
• Chapter 8 Oncology Social Work with Adults
• Chapter 9 The HIV/AIDS Social Worker
• Chapter 10 Social Work in the Rehabilitation Unit
• Chapter 11 The Social Worker in the Burn Unit
• Chapter 12 Social Work in the Emergency Room
• Chapter 13 Rural Hospital Social Work
• Chapter 14 Social Work on the Psychiatric Unit
• Chapter 15 Social Work in the Pediatric Unit
• Chapter 16 The Interface of Medicine and Social Work
• References
• Index