Despite the holistic approach inherent in the hospice philosophy, social work may be viewed in hospices as ancillary or secondary to medicine. Social work, in turn, may have a lack of training and sensitivity about other professions' expertise and values and as a result be unprepared to collaborate across the cultural boundary that exists between professions. Barriers to full use of all disciplines on the interdisciplinary team include lack of knowledge of the expertise of other professions, role blurring, conflicts arising from differences among professions in values and theoretical base, negative team norms, client stereotyping, and administrative issues. This article outlines the barriers and proposes solutions to address them.
medical social work
Spearheaded by volunteer physicians and nurses, the hospice movement always has espoused a holistic philosophy, but the medical staff provided psychosocial care until the Medicare requirement for social work services in 1983. A comment by a longtime hospice nurse--"I was doing social work before there was social work"--highlights the early resistance to the inclusion of social workers on the hospice team, a resistance that continues today on many teams despite 17 years of interdisciplinary experience.
Since 1983 hospices have used social workers on a limited basis, but a lack of understanding exists about their role in hospice, both on the part of the other disciplines on the team (Abramson & Mizrahi, 1996; Davidson, 1990; Mizrahi & Abramson, 1985) and on the part of some social workers, who often report a lack of training in issues of death and dying (Reese & Raymer, 2001; Sontag, 1996b). A recent survey by Kadushin and Egan (1997) found that only 51 percent of health courses in their sample addressed the social worker's role, and the authors concluded that the content in this area implies a lack of preparation for practice. Other authors agreed that social workers do not have adequate professional knowledge and training (Benner & Wrubel, 1989; Kovacs & Bronstein, 1999; Meyer, 1984; Sormanti, 1994). In addition, social workers may have a lack of understanding of the role of the other disciplines in hospice, and cultural differences between professions may be interpreted by social workers as personal defic its on the part of other team members (Abramson & Mizrahi, 1986).
In this article we discuss the pressures that are working against the full use of social workers on interdisciplinary teams and describe the status of social work in hospice. We identify barriers to implementation of true interdisciplinary teams and suggest ways to overcome these barriers. The conceptualization of barriers and solutions presented here is based on our own hospice social work experience, as well as a review of the literature in this area. The issues discussed and the solutions suggested are particularly focused on hospice, but may be relevant to all interdisciplinary practice groups.
PRESSURES AGAINST THE FULL USE OF SOCIAL WORK
The demand to reduce health care costs has resulted in competition among health care providers as each profession seeks to protect its turf (Sands, Stafford, & McClelland, 1990). Establishing a profession as the best or only provider of an area of service allows the profession a degree of protection from budget cuts. Social work is active in the competition among health care providers and can be seen as both encroaching on the traditional domain of other professions (Lister, 1980) and losing ground to others (Colone, 1993; Kulys & Davis, 1987). On the hospice team, social workers are in competition with nurses (Ben-Sira & Szyf, 1992; Kulys & Davis) and chaplains (Lister).
The competition between nurses and social workers is neither new nor diminishing. In 1987 Kulys and Davis found that hospice directors believed nurses were at least as qualified to perform traditional social work duties as social workers. Furthermore, nurses in the same study also believed they were equally qualified to assume psychosocial roles. Other authors reported similar results (Benner & Wrubel, 1989; Ben-Sira & Szyf, 1992; MacDonald, 1991). In a national study of hospice professionals, many social workers clearly were frustrated by what they perceived as a takeover of social work duties by nursing (Sontag, 1996a).
The increasing emphasis on spirituality in social work (Canda, 1988; Joseph, 1988; Smith, 1995) brings health care social workers into what many consider the domain of chaplains. Just as social workers may compete with nurses for provision of psychosocial services, chaplains may view social workers as encroaching on their professional turf (Lister, 1980). At the same time, chaplains provide psychosocial care, which may be viewed by social workers as better left to social work (Furman & Fry, 2000).
BARRIERS TO FULL USE OF TEAM AND PROPOSED SOLUTIONS
Lack of Knowledge of the Expertise of Other Professions
One barrier to full use of all professions on the interdisciplinary team is a lack of knowledge, on the part of each member, of the other professions' expertise, skills, training, values, and theory. This is the result of training health care professionals in isolation from each other (Lister, 1980). Nurses (Ben-Sira & Szyf, 1992; MacDonald, 1991) and physicians (Mizrahi & Abramson, 1985) tend to view the social work role as provision of concrete services, and attempts to add social work interventions that are outside this view result in conflict (MacDonald; Mizrahi & Abramson). Social workers often are equally unaware of the training and expertise of the other professions (Kovacs & Bronstein, …