Introduction to Soundings: Explorations of social work in a changing health care environment.

Preface

Soundings offers a series of essays about the position of social work in the continuously changing context of health care provision from the 1980’s to the early 2000’s.

The impetus to express these thoughts to colleagues in social work and the other professions derived from an urgent need to counter a growing sense of marginalization of social work in this rapidly changing practice environment. The traditional ways we have had of talking to ourselves and fellow professionals were developed in the context of a society and practice environment that was rapidly disappearing. Terms like psychosocial, person-in-context, advocate were, on the one hand, no longer unique to social work and on the other, were of seemingly little interest to the forces that were shaping this new practice environment.

For example, the conceptualization of a department of social work as an ‘agency within a host environment’ made little sense when the hospital or health care setting was no longer seen as a professional organization. The hospital, for medicine, nursing and other professions, had been traditionally seen as an instrument of practice as well as a place of practice. From a professional organization, with all that was implied for training, professional development as well as practice, the health care center was transformed into a ‘service delivery system’ – and health care was morphed into a series of services and products to be sold to a consumer – with third party payers as intermediaries. Supervisors, no longer supported in this environment by their professions’ rich traditions of mentorship and professional development were reduced to ‘product line managers’. Practice supervision for social workers, nurses and a host of other professions has been eroded in health care organizations to the point of virtual extinction.

Although the need to clearly articulate the role of social work in an interdisciplinary environment had always been important, the context of that conversation had radically changed … not only for social work, but for all the professions in the setting. It became increasingly apparent that the demands on the professions in this new environment were threatening to erode the professions’ value base in an effort to have them ‘deliver the product’ in the most ‘cost effective way’. Under the force of that pressure, the ‘product’ was being completely redefined by those who were not the practitioners. Increasingly, the ‘client’ of the entire health care delivery system became less the patient, practitioner or the organizations themselves; the ‘client’ was becoming the vested interests (stock holders, management, etc.) of the privatized third party payer systems.

As a social worker with increasing administrative responsibilities, the immediate sense of urgency focused on finding ways to help social workers articulate to themselves, clients and other professionals an understanding of social work practice that was emotionally as well as conceptually meaningful; and that could lead to flexibility in defining their role and function in ways that resisted the tendency to be reduced to narrowly defined ‘tasks’.

The series of essays in chapter I, Society Page, were originally published in the newsletter for the Metropolitan New York Chapter of the Society for Social Work Leaders in Health Care. The Society Page provided a forum that allowed one to ‘think out loud’ with peers facing the same situations and dilemmas. As noted above, there is a progression of concern from practice to more fundamental ethical challenges to professional practice in the current health care environment.

Chapter II, Tools for Professional Leadership, presents attempts to make operational the concepts developed in the Society Page essays. Discharge planning, for example, is reframed in therapeutic terms that include the function of the hospital as a key transition to recovery. As the ethical concerns mentioned above became clearer, the application of a broader psychosocial perspective to ethics in health care organizations was explored. The last essay applies the social work perspective to expand and broaden an understanding of organizational ethics in health care organizations.

Postscript

From the earliest days of our evolving profession, we have always been “in the middle”. In fact, we have taken that difficult position with a certain amount of professional pride. We are the ‘brokers’ between the ‘powers that be’ and those in our community who are insufficiently considered. We are a proud profession but one marked, by the very centrality of our position: ambiguity.

That certainly puts us ‘in the middle of things’. Paul Tillich once made the comment that life is essentially ambiguous. That, to our pleasure and pride as social workers, puts us in the center of the action. But if we are to learn the lessons of these last years in health care, it is this: be careful how you adopt the words of those who are trying to define you; terms that deny you the leverage of your ambiguity.

We may adopt terms like ‘discharge planner’ or ‘clinical’ social worker in order to establish a valid place in the current arena of play … a position that has economic as well as ‘status’ implication. However, out of the necessity of our commitment to those ‘insufficiently considered’, we have an obligation to transform the meaning of those very labels we accept. We, by professional commitment, must work to transform the meaning of those terms to include realities that, by virtue of less inclusive agenda, dismiss the value of what we do for those we represent.

The profession of social work, as an integral aspect of health care provision, is a constant reminder: a service delivery system that ignores the reality that illness and disability impose a challenge to a meaningful human life is un-therapeutic. If ‘clinical’ cannot take that reality into consideration in its method and purpose, it then becomes assaultive … and as such, no longer serving the common good.

For us, as we strive for proper recognition and reward for our services in health care, we cannot surrender the fundamental mission of our profession: to have everyone included, not only in the provision of care but in full recognition that a challenge to a meaningful life for any is a challenge for all.

For thoughts and comments, please send to: jdonnellydsw@gmail.com

South Garden Press, New York