Effect of a Changing Health Care Environment on Social Work Leaders: Obstacles and Opportunities in Hospital Social Work

Beginning of article

The health care system is undergoing dramatic change in auspice, structure, and services delivery in response to an emphasis on market-driven, cost-containment strategies. Consequently, many hospital social work directors either have lost some of their administrative responsibilities or have expanded their span of control beyond social work services. This article examines the responses of social work administrators to the breadth of changes occurring throughout their hospitals; the major accomplishments of social work services within their facilities; and the failures, frustrations, and obstacles in the delivery of social work services. As a result of examining the relationship between their actual and anticipated behavior and changes in the hospital and external environment, the authors found that social work leaders in hospitals understand the complexities and challenges of the world around them. Overall, they have exhibited commitment, competence, and confidence in shaping organizational change.

Key words: health care; hospital social work; leadership; organizational change; social work administration

An emphasis on market-driven, cost-containment strategies has brought about a dramatic change in the auspice, structure, and delivery of services in the health care system. Most hospitals are restructuring to achieve flatter organizational structures by moving away from professionally defined structures, such as departments of social work, nursing, and medicine, to more integrative structures (Globerman & Bogo, 1995; Rosenberg & Weissman, 1995b). In addition, there has been a significant downsizing of inpatient beds and, in many instances, shifts to ambulatory and community care. Consequently, many hospital social work directors have either lost at least some of their administrative responsibilities or are expanding their span of control beyond social work services (Berger et al., 1996).

How have hospital social work administrators fared in these turbulent times? What are the mechanisms and strategies they have used to respond to actual and anticipated changes? Are they optimistic or pessimistic about the opportunities for hospital-based social work in the future? This article explores the perspectives of hospital social work leadership in this uncertain environment. Although conditions external to social work are driving the drastic changes in health care delivery, the social work profession has promoted a social change role at the micro and macro levels. Indeed, the NASW Code of Ethies (1996) insists that social workers help to improve conditions in their agencies.

In 1994 the Society of Social Work Administrators in Health Care (currently known as the Society of Social Work Leaders in Health Care) and the National Association of Social Workers commissioned a national study to examine the effect of changes in the health care arena on social work structure and practice in hospitals (Berger et al., 1996). The research questions shaping this study were: What were the changes occurring in the hospital in general and the social work department in particular? What was the impact of these changes on social work roles, functions, and practice? What strategies were used in a reconfigured health care delivery system to influence the direction of hospital social work?

This article examines the responses of social work administrators to the following six open-ended questions and the relationship of those responses to other variables:

* Describe the breadth of changes occurring throughout your hospital.

* Describe the major accomplishments of social work services within your facility.

* Describe the failures, frustrations, and obstacles in the delivery of social work services.

* What changes do you anticipate within your organization and/or social work department that will affect the delivery of social work services?

* Describe the major opportunities for social work created as a result of organizational changes within your hospital.

* Describe the major threats and challenges for social work created as a result of organizational changes within your hospital.

Elsewhere, we analyzed responses to these questions (Mizrahi & Berger, 1998). This article builds on that previous work and presents further analysis of reports by social work directors on the obstacles and opportunities social work faces or expects to face in reorganized health care settings.

Literature Review

There is much in the literature about social work management and administration, but only limited attention to the topic of social work leadership. If addressed, it is usually embedded in the context of social work administration or advanced primarily in community organization practice, where social workers are viewed as change agents (Brilliant, 1986). There is an important distinction between management and leadership. Management is about getting the work done. It is the technical and operational components of the job. Leadership is about setting the direction, standards, and vision for the organization. The personal orientation of the leader, the internal--external environment, professional values, and the political and economic climate all play a role in shaping this vision. In 1987 Rosenberg and Clarke, editors for a special volume of Social Work in Health Care, devoted an entire issue to the transition to leadership for social work directors in hospitals. Mayer (1995) described this as follows: "Many di rectors were selected not necessarily because we had demonstrated superb management skills prior to our new jobs, but rather because we were. . . politically savvy or well known within our institutions for being highly responsible" (p. 70). It is this vision that then shapes the organizational priorities that will guide resource allocation, ultimately influencing the quality of services delivered (Ezell, Menefee, & Patti, 1997). Dimond and Markowitz (1995) added that in reality many people are capable of managing, but few people actually lead. In today's environment, leadership is needed more than ever to preserve as well as promote programs through these turbulent times of change.

The small body of literature on social work leadership in hospitals (Berger, 1990; Irizarry, Gameau, & Walter, 1993; Rosenberg & Weissman, 1995a; Ruster, 1995) has been primarily anecdotal or has typically used a case study method. It is useful in identifying a range of knowledge, skills, values, and attributes of social work directors who have been successful in maintaining or growing their roles during chaotic periods (Bixby, 1995; Dimond & Markowitz, 1995; Mayer, 1995; Patti, 1984; Spitzer, 1995). A major competence gleaned from this literature is an ability to balance the needs of the patient, the institution, and the staff, while coping effectively with the tensions often involved in meeting these conflicting demands. Although the literature is replete with examples of what has been accomplished, much less appears on actual strategies used to manage these inherent pressures, and there are no recently published large-scale comparative studies of social work directors across settings and communities. This article seeks to fill this gap.

Method

We used an exploratory--descriptive survey design (see Berger et al., 1996, for more detail on the methodology), drawing on a stratified random sample of 750 (of 3,700) hospitals from the member list of the American Hospital Association. We …