Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
EMERGENCY DEPARTMENT SOCIAL WORK John M. Farber To cite this article: John M. Farber (1978) EMERGENCY DEPARTMENT SOCIAL WORK, Social Work in Health Care, 4:1, 7-18, DOI: 10.1300/J010v04n01_02 To link to this article: http://dx.doi.org/10.1300/J010v04n01_02
Published online: 12 Dec 2008.
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Citing articles: 4 View citing articles
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Date: 21 June 2016, At: 18:04
EMERGENCY DEPARTMENT SOCIAL WORK: A PROGRAM DESCRIPTION AND ANALYSIS
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John M. Farber
ABSTRACT. This article reports on the development of a social work component in the Emergency Department of a teaching-research hospitaL I t examines the rationale for developing the service and the objectives of the program. I t also presents a statistical analysis of the first 2 full years of sentice. Finally, some of the major problems experienced in establishing such a program are discussed and possible solutions recommended
There appears to be a growing recognition within hospitals of the need for more extensive access to the social work d e partment. Recent articles by Krell (1976),Bennett (1973),and Lindenberg (1972)are representative of this growing awareness. For example, Krell(1976)notes that "patient need and current medical and hospital practice clearly point to the necessity for extending social work coverage in order to more closely approximate the continuous hours of a hospital's operation." Bennett (1973)describes the development of social work services in the Emergency Department of Brooklyn Hospital. Briefly, that program provides 12 hours of coverage on weekdays and 8 hours of coverage on weekends. Staffing of these extended hours was accomplished by regular Social Work Department staff rotating to cover the evening and weekend shifts. The social worker who has the initial contact with the patient in Emergency usually continues to follow the patient, even if admitted. Recording is done directly into the patient's medical chart. Bennett notes that after social workers were based in Emergency, the number of referrals tripled from about 50 per year to approximately 150 per year. In 1973, the Department of Social Work at Saint Boniface General Hospital, in conjunction with the Emergency Department, began to Mr. Farber is Unit Coordinator o f Emergency and Ambulatory Care Services, Department of Social Work, Saint Boniface General Hospital, 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6, Canada. Social Work in Henlth Care. Vol. 4111. Fall 1978 0 1 9 7 8 by The Haworth Ress. AU rightareserved
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SOCIAL WORK IN HEALTH CARE
initiate extended coverage. This article describes the development and operation of that service.
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OBJECTIVES OF SOCIAL WORK SERVICE IN AN EMERGENCY DEPARTMENT The program to be described in this article follows a model different from that described by Bennett (1973) and others. Saint Boniface General Hospital is an 850-bed teaching-research hospital located just outside the downtown area of Winnipeg, Manitoba. The Emergency Department of the hospital had 42,000 patient visits during 1976,just over double that reported by Bennett. Like many hospital social work departments prior to 1973, service was provided to Emergency on a demand-referral basis. The experiences of staff responding to those referrals and two studies by Pascoe (Note 1)and Crahart (Note2) revealed a number of important issues: 1. Psychosocial crises tend to occur after 5:00 p.m., the traditional closing time for social work departments. 2. There is a distinct lack of community resources after 5:00 p.m. 3. There is a tendency for people in crisis, whether medical, social, or psychological, to expect a hospital emergency department to provide the required services. 4. People, other than the patient, may be affected when emergency treatment is required. 5. There are many situations for which social work consultation should be an essential adjunct to medical treatment. 6. I t was recognized that Emergency staff, be they nurses or physicians, are often unable to provide the level of psychosocial care required by patients andlor their families, because of the volume of patients to be seen and the acute nature of medical treatment.
These considerations and issues became the foundation for developing a list of functions and objectives for the social work component in the Emergency Department: 1. To assist medical and nursing staff in determining appropriate treatment by assessing the patients' and families' levels of psychological and social functioning. 2. To act as advocate and liaison for the patients and their families while in Emergency. 3. To provide crisis counseling to patients andlor families in acute emotionaldistress. 4. To assist with the identification, documentation, immediate
John M. Farber
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treatment, and referral of suspected cases of child abuse or neglect. 5. To provide consultations and follow-up to patients who have made suicidegestures or attempts. 6. To assist patients in locating and obtaining required community support services. 7. To provide short-term follow-up when existing community services are inappropriate or not available immediately. 8. To be as available as possible to patients during the acute phase of their distress. 9. To provide and participate in Emergency Department staff inservice programs. 10. To serve on selected Emergency Department committees. SCHEDULING OF STAFF In late 1973, a program was initiated to provide 8hour coverage on weekdays. This was expanded in mid-1974 to 11 hours of coverage 7 days a week. Finally, with the addition of a third member and a coordinator, who was also responsible for all outpatient services, coverage was further expanded in late 1974 to 14 hours on weekdays and 11hours on weekends. The current schedule of 14 hours on weekdays and 11hours on weekends has evolved over the past 3 years. The hours are distributed as follows: Monday through Friday, 8:30 a.m. to ll:00 p.m.; Saturday, 9:00 a.m. to 8:00 p.m.; and Sunday, 12:00 noon to 11:OO p.m. This close ly parallels the coverage recommended by Krell (1976) and described by Bennett (1973) and follows the patient flow of the Saint Boniface General Hospital Emergency Department. The schedule is arranged such that between noon and 5:00 p.m. on weekdays two social workers are on duty. This overlap ensures a quick response to Emergency and also allows the opportunity for uninterrupted follow-up sessions, attendance at meetings, staff development sessions, and the like. I t does, of course, require some appointment coordination to ensure that one of the two staff members is always available during the 5-hour overlap period. The 14/11schedule is maintained by one social worker having a regular 8:30 a.m. to 5:00 p.m. shift, Monday through Friday. The other two staff members alternate 4 days on and 4 days off, a t 11%hours per day. The coordinator plus an additional .2 equivalent full-timeposition are available to cover holiday time, sick leaves, and other extended a b sences as they occur. I t should be noted that with 3.2 full-time positions there is considerable coverage flexibility. The current schedule utilized by Saint Boniface General Hospital is dictated largely by patient flow and utiliza-
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SOCIAL WORK IN HEALTH CARE
tion data and coincides with the times when most ~ a t i e n t sresent to Emergency. Referral data show that about 65% of patients referred to social work staff present to the Emergency Department between 11:OO a.m. and 8:00 p.m. This is followed by the period 8:00 p.m. to 11:OO p.m. when a further 12.5% of those referred present to Emergency and 8:00 a.m. to 11: a.m. when an additional 10.2% present. These three time periods account for about 88% of the referrals. I t is noteworthy that the current schedule provides coverage for only 55% of the week (92 hours of 168 hours), yet a social worker is available when 88% of the people who are referred come to Emergency. The remaining 12% of the patients are referred during the 45% of the week when there is no social worker on duty. These patients are followed up in the morning by phone or, if required, are held in the Observation Unit overnight. Finally, it should be noted that in developing a schedule there is a time lag between the time a patient presents to Emergency and the time a referral is received by the social worker. The experience at Saint Boniface General Hospital is that on the average about 32% of the patients are referred within l hour of coming to Emergency, 56% are r e ferred within 2 hours, and 80% within 4 hours. This means that at least 2 hours and preferably 4 hours should be allowed between peak hours in Emergency and the end of the social worker shifts. RECORDING I t is essential in an emergency department that relevant information be communicated quickly and effectively to those who reqube it. To accomplish this, a combination referral and report form was designed. It is a two-page form, the second page being a carbon copy. The top part of the form has space for a descriptionof thereason(s)for referral. The bottom part has a space for the social worker's Summary Report. In addition, the second page has a space to record information that is used for statistical purposes with the Department of Social Work. The entire form remains on the Emergency chart. When the patient is discharged the original is sent to Medical Records, and the copy is retained for the social work file. CONTINUITY OF CARE The Emergency Department Social Work Program described by Bennett (1973) emphasized that patients seen in Emergency were followed by the staff member who initiated the contact, even if the patients were admitted. The extent of follow-up with patients seen in an emergency department can range from none, which is most consistent from an emergency department's philosophy, to being fairly involved and regular.
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The position taken by the Department of Social Work at Saint Boniface General Hospital is that if a patient andlor his family requires follow-up contact(& then, whenever possible, it should be provided by someone other than social work staff assigned to Emergency. The rationale for this position is that the effectiveness of a social work program in Emergency rests in large part on being able to respond quickly to referrals. Follow-up can involve substantial expenditure of time, thus impeding the ability to respond rapidly. Since an objective of the program is short responsetime, follow-up commitments must be kept to a minimum. Translating this position of limited follow-up into practice can be difficult and is done at the expense of maintaining continuity of care. It is achieved by (a) referring patients who are discharged home to appropriate community or hospital resources that are equipped to provide follow-up with subsequent verification that service is being provided and (b) transferring patients who are admitted to the hospital to the social worker assigned to the ward where the patient is placed. However, there still remains a number of patients who require some followup services either because suitable community resources do not exist or because in the social workers' opinion it would be more therapeutic for them to continue providing care themselves. In these situations, the Emergency Unit social worker provides the follow-up as required or until a referral is appropriate. STATISTICAL DESCRIPTION OF SERVICE One of the first tasks of the coordinator when appointed in 1974 was to devise a system for documenting social work services in the Emergency Department. I t seemed reasonable that the innovativeness of the program required objective information to document the utilization of the service. A basic information system was implemented in November 1974, and later revised and expanded in 1975 and 1976. A comparison of the number of visits to Emergency and the number of referrals to the Department of Social Work for 1975 and 1976 is presented in Table 1. Table 1 shows that there were approximately 950 referrals per year, or about 80 per month. Although this number of referrals keeps the social workers fairly busy, a slight increase could be tolerated. For planning purposes, each social worker could be expected to handle effectively about 35 new cases each month. A previous departmental study revealed that about 60% of new cases are closed within 1 month of opening. An additional 20% are closed after 2 months, and about 15% more are closed after 3 months. The other 5% remain open for more than 3 months. This means that of the 80 cases opened in a month about 48 of them will be closed by the end of the month, with an addi-
SOCIAL WORK IN HEALTH CARE
Vizits to Energency and Referrals to Social Work 1975
Visits/Referrals
-
1976
1975
1976
948
787
Percent change
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Number of Referrsls to Social Work from Daergcncy
t4.1196
Hean Nwbcr of Rcferrds per month to Social York
(Standard Deviation)
79.0
82.3
(16.5)
(20.6)
+&.I&%
tional16 being closed at the end of 2 months and 12 more at the end of 3 months. Table 1 also shows that the number of referrals to the Department of Social Work from the Emergency Department increased by 4.11% from 1975 to 1976,with only about 1.05% of the increase possibly b e ing attributable to the increased number of patients' visits to Emergency. The age of patients seen by social workers in Emergency by sex r e veals that the mean age for males was 46.7 years (SD = 25.3)in 1975 and 43.6 years (SD = 25.8)in 1976.The mean age for females was 43.5 years (SD = 24.0)in 1975 and 39.4 years (SD = 22.5)in 1976.The variance in age, as reflected by the standard deviation, shows that unlike some other areas of the hospital, there is considerable diversity in the ages of patients referred from Emergency. Therefore, work in Emergency requires a social worker to have considerable flexibility and experience in working with a broad range of patients. The sex distribution of patients referred in 1975 was 42.5% male and 57.5% female. In 1976 the distribution was 45.5% male and 54.5% female. These distributions reflect closely the distribution of patients coming to Emergency, suggesting that there is no particular sex bias in the referral pattern.
John M.Farber
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Table 2 provides a breakdown of the primary presenting problem d e termined by the social worker first involved with the patient. In developing a system of recording problems, the following issues were considered and limits established: 1. Only one problem can be recorded. 2. The list is roughly hierarchical, such that if a patient presents two or more of the problems listed, the problem highest on the list is the one recorded. 3. The problem "relative of patient" largely involves supportive work with the relatives of a patient taken to the resuscitation room. 4. When developing the categories, an effort was made to define the categories - in observable, behavioral terms in order to reduce the staff's inconsistency in recording. 5. The category "self-inflicted injury" includes unequivocal suicide attempts and gestures, self-inflicted injuries of undeterminable and uncertain intentionality, and a small number of clearly accidental selfinflicted injuries. However, the greatest proportion involve self-inflicted injuries of unequivocaland uncertainintentionality.
The breakdown reveals that 59.9% of the cases referred in 1976 p r e sented primary problems best described as individual or family in nature. The remaining 39.8% were problems involving living arrangements, need for community support services, or practical assistance, such as transportation or information. The distribution of the problems presented to social work staff in Emergency suggests that a fairly high degree of training and experience is required. The unique nature of crisis intervention with potentially explosive personal and family problems such as child abuse, spouse beating, or suicide attempts requires a complete, accurate, and rapid assessment of the situation coupled with practical, strategic, and effective plans for immediate treatment. The position requires a strong sense of professional confidence, and an extraordinary ability to function effectively under pressure. I t also requires staff who seek and appreciate the challenges offered by crisis work, but who can also accept the more routine and less stimulating situations.
PROGRAM PROBLEMS The process of establishing an emergency department social work service of the nature and scope as the one at Saint Boniface General Hospital is a continuing one. I t requires the cooperation and support of emergency department administration and its staff. One major initial problem, and one that periodically appears with the coming of new medical or nursing staff, is the altering of ste-
,
SOCIAL WORK IN HEALTH CARE
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reotypes about what social work can provide within an emergency d e partment. The most effective way of changing these attitudes, and of obtaining and maintaining credibility, is to establish close working relationships with medical and nursing staff. Being visible and providing feedback are essential to establishing a successful service. Emergency staff frequently seek information on how particular patients are progressing, and mechanisms for providing feedback should be included in the program. Most often this is of an informal nature; however, provisions should be made for periodic presentations a t rounds or in-services. The value of providing feedback cannot be understated. I t provides confirmation on the appropriateness of refer-
D i ~ t r i b u t i o nof P r i w r g Presenting S o c i a l u o r k Problem In the emargancg Depsrtmant
Problem
-
1976
Number
Percent
Child Abuso
20
2.0
Spouse Beating
22
2.2
W r i t e l Problem
29
2.0
Relative of Patient
54
5.5
Family Problems
Orhsr
13
1.3
Total
138
1b.0
Individual Problem. S o l f - i n f l i c t e d InJury Drug Abuse Alcohol Abuse AnrietglDepraeslon Other Total
Plscemnnrs Hospital Wspital
-
Chronic Acute
-
H o ~ p i t s l Rshnb Nuraing Homm PosterlBoarding H o ~ e
John M. Farber
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rals, establishes the value of follow-up, provides vicarious learning about methods of assessment and intervention, and maintains interest in the psychosocial implication of illness and hospitalization. The primary problem encountered in providing feedback about patients is maintaining confidentiality. A balance must be struck between sharing information and ensuring that the patients' rights to confidentiality are maintained. I t is strongly recommended that this issue be considered and guidelines established prior to the implementation of a service. Working in Emergency presents some special problems for the social workers assigned there. First, it can require some personal attitude
Table 2 Cont'd. Problem Temporary Emrgeacy Lodging Other
Toea1
co-nity
support s.,rvices
Periodic Nursing Care Child Care Housekeeping equ1pmant Other Total
Practical Alaistanca Financial Transportation Info-tton Othar
Total
Number
Percent
40
4.1
11
1.1
166
16.8
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changes about the role of social work. The norm becomes rapid assessment, strategic and sometimes unorthodox intervention, and shortterm follow-up. This may conflict with traditional beliefs about social work practice and may require close supervision. A second potential problem is adjustment to working shifts. Whereas this is routine for most other disciplines in Emergency, it can be a new experience for social work. It can require reorientation by other Social work Department staff who may o h y see the ~ m e r ~ e Denc~ partment social workers brieflv during the week. Intradepartmental conflicts can develop because oi the reduced contact, and careful monitoring is indicated. Shift work can create other unique problems. Two other problems experienced by staff are loneliness and excitement. During 52 hours of each week, after 5:00 p.m. and on weekends, the social worker in Emergency is the only social worker in the hospital. This limits their opportunity for informal contact both with their colleagues in Emergency and, as already noted, in the Department of Social Work. Related to this is that after an evening or weekend shift is over, particularly if it has been an unusually stressful one, there is little opportunity to ventilate or share it with other staff. During the day, staff use each other to help dissipate the day-to-day stresses. In the evening a q l on weekends, staff are left to their own resources to dissipate the shifts' accumulating pressures. Other problems also exist for social work staff. I t is much more difficult, if not impossible, to establish a normal working routine or maintain control over case loads in Emergency because of the variable d e rnand for service. I t is common to have scheduled plans interrupted by a call from Emergency. This can be a frustrating experience; however, it can be minimized with appropriate appointment scheduling and monitoring of cumulative referral rate data. The highly variable rate of referrals from Emergency creates other problems for social work staff. There are times when the number of referrals andlor the demands of a particular situation strain one's capacity to cope effectively. There are other periods, however. when there are few or no referrals. The latter is found to be more difficult to tolerate than the former. To reduce the discomfort created by these slow periods and to exploit a valuable opportunity, these times are utilized in a number of ways. Social work staff use these times to consult with Emergency staff about patients presently in the department iri an attempt to discover problems requiring intervention. This is particularly importatit when Emergency is busy, as data reveal that this is one time when Emergency staff are less likely to refer (Farber, Note 3). This time is also used to review the previous day's charts in order to locate patients who were not referred but perhaps should have been. Slow periods can also be used to provide feedback on the appropriate
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John M. Farber
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ness and progress of patients previously referred. Finally, it also p r e vides an opportunity to assist Emergency staff with personal problems and intradepartmental problems. Another problem encountered by work in an emergency department is maintaining a commitment to the service. Work in Emergency should be a high priority. It is often one of the first opportunities for contact with a patient. Those with psychosocial problems can beidentified early even if the reason for coming to Emergency is primarily medical. However, for such a service to be useful it must be available on a regular and consistent basis! This means havingprovision tocover when regular staff are away for holidays, illness, attendance at staff development programs, and so on. There are a number of alternatives for handling absences. The unit coordinator or another staff member can fill in for the absent social worker. This is feasible for short-term absences which are spaced relatively far apart because of the additional strain it puts on staff. Another method is to hire replacement staff on a casual or temporary basis. Although this is a more expensive alternative in absolute dollars. it may be less expensive than appears if one considers the benefits in terms of staff effectiveness and morale. The cost can be offset partially by using an on-call system, although our experience has been that an on-call system is not as effective as actually being present in Emergency. In addition, for an on-call system to be effective, it requires a well-established relationship with Emergency staff. Regardless of which alternative is adopted in order to maintain credibility, it is important to honor whatever schedule is decided upon and to avoid the "essential-by-convenience" trap. Finally, once service was established, another problem emerged. Word spread quickly through the hospital that during evenings and weekends there was a social worker available in the hospital. Suddenly there was an upsurge in requests from the wards requiring immediate attention when in the past, they would be left to the following working day. At one point the calls came so frequently that they interfered with work in Emergency. Documentation of these requests was forwarded to Nursing Service, which informed the wards that with the exception of true crisis situations, the social worker assigned to Emergency was not available to them. In anticipation of this problem it is recommended that departments considering implementing a service in Emergency consider and decide how requests from outside the area are to be handled. CONCLUSION As health care costs continue to rise, new means are r e q e e d to identify and alleviate those conditions that produce, precipitate, and perpetuate poor physical and emotional health. Early iden-
SOCIAL WORK IN HEALTH CARE
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tification of these conditions can often postpone or alleviate their deleterious effects. One way to achieve early identification and remediation is by crisis intervention, and a hospital emergency department provides one obvious setting for the initiation of this type of service. Emergency department staff are often unable to provide the level of psychosocial care required by patients andlor their families, because of the volume of patients to be seen and the acute nature of medical treatment. Hospitals are becoming increasingly aware of the need to expand social work coverage and services in emergency departments.
REFERENCE NOTES 1. Pascoe. D. Social service department research. Unpublished manuscript. 1971. (Available from the Department of Social Work. Saint Boniface General Hospital. 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6. Canada.) 2. Crahart, B. Social work student study of the emergency ward of Saint Boniface Genem1 Hospital. Unpublished manuscript, 1973. (Available from the Department of Social Work, Saint Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6. Canada.) 3. Farber. J. M. An analysis of referral rate by emergency department volume. Unpublished manuscript. 1976. (Available from the Department of Social Work, Saint Boniface General Hospital. 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6, Canada.)
REFERENCES Bennett, J. J. The social worker's role. Hospitals, 1973.47.111-118. Krell, G. I. Hospital social work schedule should be more than a 9-5 position. Hospitals. 1976,50.99-104. Lindenberg, R. E. The need for crisis intervention in hospitals. Hospitals. 1972, 46. 52-110.
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
EMERGENCY DEPARTMENT SOCIAL WORK John M. Farber To cite this article: John M. Farber (1978) EMERGENCY DEPARTMENT SOCIAL WORK, Social Work in Health Care, 4:1, 7-18, DOI: 10.1300/J010v04n01_02 To link to this article: http://dx.doi.org/10.1300/J010v04n01_02
Published online: 12 Dec 2008.
Submit your article to this journal
Article views: 51
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wshc20 Download by: [University of California, San Diego]
Date: 21 June 2016, At: 18:04
EMERGENCY DEPARTMENT SOCIAL WORK: A PROGRAM DESCRIPTION AND ANALYSIS
Downloaded by [University of California, San Diego] at 18:04 21 June 2016
John M. Farber
ABSTRACT. This article reports on the development of a social work component in the Emergency Department of a teaching-research hospitaL I t examines the rationale for developing the service and the objectives of the program. I t also presents a statistical analysis of the first 2 full years of sentice. Finally, some of the major problems experienced in establishing such a program are discussed and possible solutions recommended
There appears to be a growing recognition within hospitals of the need for more extensive access to the social work d e partment. Recent articles by Krell (1976),Bennett (1973),and Lindenberg (1972)are representative of this growing awareness. For example, Krell(1976)notes that "patient need and current medical and hospital practice clearly point to the necessity for extending social work coverage in order to more closely approximate the continuous hours of a hospital's operation." Bennett (1973)describes the development of social work services in the Emergency Department of Brooklyn Hospital. Briefly, that program provides 12 hours of coverage on weekdays and 8 hours of coverage on weekends. Staffing of these extended hours was accomplished by regular Social Work Department staff rotating to cover the evening and weekend shifts. The social worker who has the initial contact with the patient in Emergency usually continues to follow the patient, even if admitted. Recording is done directly into the patient's medical chart. Bennett notes that after social workers were based in Emergency, the number of referrals tripled from about 50 per year to approximately 150 per year. In 1973, the Department of Social Work at Saint Boniface General Hospital, in conjunction with the Emergency Department, began to Mr. Farber is Unit Coordinator o f Emergency and Ambulatory Care Services, Department of Social Work, Saint Boniface General Hospital, 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6, Canada. Social Work in Henlth Care. Vol. 4111. Fall 1978 0 1 9 7 8 by The Haworth Ress. AU rightareserved
8
SOCIAL WORK IN HEALTH CARE
initiate extended coverage. This article describes the development and operation of that service.
Downloaded by [University of California, San Diego] at 18:04 21 June 2016
OBJECTIVES OF SOCIAL WORK SERVICE IN AN EMERGENCY DEPARTMENT The program to be described in this article follows a model different from that described by Bennett (1973) and others. Saint Boniface General Hospital is an 850-bed teaching-research hospital located just outside the downtown area of Winnipeg, Manitoba. The Emergency Department of the hospital had 42,000 patient visits during 1976,just over double that reported by Bennett. Like many hospital social work departments prior to 1973, service was provided to Emergency on a demand-referral basis. The experiences of staff responding to those referrals and two studies by Pascoe (Note 1)and Crahart (Note2) revealed a number of important issues: 1. Psychosocial crises tend to occur after 5:00 p.m., the traditional closing time for social work departments. 2. There is a distinct lack of community resources after 5:00 p.m. 3. There is a tendency for people in crisis, whether medical, social, or psychological, to expect a hospital emergency department to provide the required services. 4. People, other than the patient, may be affected when emergency treatment is required. 5. There are many situations for which social work consultation should be an essential adjunct to medical treatment. 6. I t was recognized that Emergency staff, be they nurses or physicians, are often unable to provide the level of psychosocial care required by patients andlor their families, because of the volume of patients to be seen and the acute nature of medical treatment.
These considerations and issues became the foundation for developing a list of functions and objectives for the social work component in the Emergency Department: 1. To assist medical and nursing staff in determining appropriate treatment by assessing the patients' and families' levels of psychological and social functioning. 2. To act as advocate and liaison for the patients and their families while in Emergency. 3. To provide crisis counseling to patients andlor families in acute emotionaldistress. 4. To assist with the identification, documentation, immediate
John M. Farber
9
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treatment, and referral of suspected cases of child abuse or neglect. 5. To provide consultations and follow-up to patients who have made suicidegestures or attempts. 6. To assist patients in locating and obtaining required community support services. 7. To provide short-term follow-up when existing community services are inappropriate or not available immediately. 8. To be as available as possible to patients during the acute phase of their distress. 9. To provide and participate in Emergency Department staff inservice programs. 10. To serve on selected Emergency Department committees. SCHEDULING OF STAFF In late 1973, a program was initiated to provide 8hour coverage on weekdays. This was expanded in mid-1974 to 11 hours of coverage 7 days a week. Finally, with the addition of a third member and a coordinator, who was also responsible for all outpatient services, coverage was further expanded in late 1974 to 14 hours on weekdays and 11hours on weekends. The current schedule of 14 hours on weekdays and 11hours on weekends has evolved over the past 3 years. The hours are distributed as follows: Monday through Friday, 8:30 a.m. to ll:00 p.m.; Saturday, 9:00 a.m. to 8:00 p.m.; and Sunday, 12:00 noon to 11:OO p.m. This close ly parallels the coverage recommended by Krell (1976) and described by Bennett (1973) and follows the patient flow of the Saint Boniface General Hospital Emergency Department. The schedule is arranged such that between noon and 5:00 p.m. on weekdays two social workers are on duty. This overlap ensures a quick response to Emergency and also allows the opportunity for uninterrupted follow-up sessions, attendance at meetings, staff development sessions, and the like. I t does, of course, require some appointment coordination to ensure that one of the two staff members is always available during the 5-hour overlap period. The 14/11schedule is maintained by one social worker having a regular 8:30 a.m. to 5:00 p.m. shift, Monday through Friday. The other two staff members alternate 4 days on and 4 days off, a t 11%hours per day. The coordinator plus an additional .2 equivalent full-timeposition are available to cover holiday time, sick leaves, and other extended a b sences as they occur. I t should be noted that with 3.2 full-time positions there is considerable coverage flexibility. The current schedule utilized by Saint Boniface General Hospital is dictated largely by patient flow and utiliza-
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SOCIAL WORK IN HEALTH CARE
tion data and coincides with the times when most ~ a t i e n t sresent to Emergency. Referral data show that about 65% of patients referred to social work staff present to the Emergency Department between 11:OO a.m. and 8:00 p.m. This is followed by the period 8:00 p.m. to 11:OO p.m. when a further 12.5% of those referred present to Emergency and 8:00 a.m. to 11: a.m. when an additional 10.2% present. These three time periods account for about 88% of the referrals. I t is noteworthy that the current schedule provides coverage for only 55% of the week (92 hours of 168 hours), yet a social worker is available when 88% of the people who are referred come to Emergency. The remaining 12% of the patients are referred during the 45% of the week when there is no social worker on duty. These patients are followed up in the morning by phone or, if required, are held in the Observation Unit overnight. Finally, it should be noted that in developing a schedule there is a time lag between the time a patient presents to Emergency and the time a referral is received by the social worker. The experience at Saint Boniface General Hospital is that on the average about 32% of the patients are referred within l hour of coming to Emergency, 56% are r e ferred within 2 hours, and 80% within 4 hours. This means that at least 2 hours and preferably 4 hours should be allowed between peak hours in Emergency and the end of the social worker shifts. RECORDING I t is essential in an emergency department that relevant information be communicated quickly and effectively to those who reqube it. To accomplish this, a combination referral and report form was designed. It is a two-page form, the second page being a carbon copy. The top part of the form has space for a descriptionof thereason(s)for referral. The bottom part has a space for the social worker's Summary Report. In addition, the second page has a space to record information that is used for statistical purposes with the Department of Social Work. The entire form remains on the Emergency chart. When the patient is discharged the original is sent to Medical Records, and the copy is retained for the social work file. CONTINUITY OF CARE The Emergency Department Social Work Program described by Bennett (1973) emphasized that patients seen in Emergency were followed by the staff member who initiated the contact, even if the patients were admitted. The extent of follow-up with patients seen in an emergency department can range from none, which is most consistent from an emergency department's philosophy, to being fairly involved and regular.
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John M.Farber
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The position taken by the Department of Social Work at Saint Boniface General Hospital is that if a patient andlor his family requires follow-up contact(& then, whenever possible, it should be provided by someone other than social work staff assigned to Emergency. The rationale for this position is that the effectiveness of a social work program in Emergency rests in large part on being able to respond quickly to referrals. Follow-up can involve substantial expenditure of time, thus impeding the ability to respond rapidly. Since an objective of the program is short responsetime, follow-up commitments must be kept to a minimum. Translating this position of limited follow-up into practice can be difficult and is done at the expense of maintaining continuity of care. It is achieved by (a) referring patients who are discharged home to appropriate community or hospital resources that are equipped to provide follow-up with subsequent verification that service is being provided and (b) transferring patients who are admitted to the hospital to the social worker assigned to the ward where the patient is placed. However, there still remains a number of patients who require some followup services either because suitable community resources do not exist or because in the social workers' opinion it would be more therapeutic for them to continue providing care themselves. In these situations, the Emergency Unit social worker provides the follow-up as required or until a referral is appropriate. STATISTICAL DESCRIPTION OF SERVICE One of the first tasks of the coordinator when appointed in 1974 was to devise a system for documenting social work services in the Emergency Department. I t seemed reasonable that the innovativeness of the program required objective information to document the utilization of the service. A basic information system was implemented in November 1974, and later revised and expanded in 1975 and 1976. A comparison of the number of visits to Emergency and the number of referrals to the Department of Social Work for 1975 and 1976 is presented in Table 1. Table 1 shows that there were approximately 950 referrals per year, or about 80 per month. Although this number of referrals keeps the social workers fairly busy, a slight increase could be tolerated. For planning purposes, each social worker could be expected to handle effectively about 35 new cases each month. A previous departmental study revealed that about 60% of new cases are closed within 1 month of opening. An additional 20% are closed after 2 months, and about 15% more are closed after 3 months. The other 5% remain open for more than 3 months. This means that of the 80 cases opened in a month about 48 of them will be closed by the end of the month, with an addi-
SOCIAL WORK IN HEALTH CARE
Vizits to Energency and Referrals to Social Work 1975
Visits/Referrals
-
1976
1975
1976
948
787
Percent change
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Number of Referrsls to Social Work from Daergcncy
t4.1196
Hean Nwbcr of Rcferrds per month to Social York
(Standard Deviation)
79.0
82.3
(16.5)
(20.6)
+&.I&%
tional16 being closed at the end of 2 months and 12 more at the end of 3 months. Table 1 also shows that the number of referrals to the Department of Social Work from the Emergency Department increased by 4.11% from 1975 to 1976,with only about 1.05% of the increase possibly b e ing attributable to the increased number of patients' visits to Emergency. The age of patients seen by social workers in Emergency by sex r e veals that the mean age for males was 46.7 years (SD = 25.3)in 1975 and 43.6 years (SD = 25.8)in 1976.The mean age for females was 43.5 years (SD = 24.0)in 1975 and 39.4 years (SD = 22.5)in 1976.The variance in age, as reflected by the standard deviation, shows that unlike some other areas of the hospital, there is considerable diversity in the ages of patients referred from Emergency. Therefore, work in Emergency requires a social worker to have considerable flexibility and experience in working with a broad range of patients. The sex distribution of patients referred in 1975 was 42.5% male and 57.5% female. In 1976 the distribution was 45.5% male and 54.5% female. These distributions reflect closely the distribution of patients coming to Emergency, suggesting that there is no particular sex bias in the referral pattern.
John M.Farber
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Table 2 provides a breakdown of the primary presenting problem d e termined by the social worker first involved with the patient. In developing a system of recording problems, the following issues were considered and limits established: 1. Only one problem can be recorded. 2. The list is roughly hierarchical, such that if a patient presents two or more of the problems listed, the problem highest on the list is the one recorded. 3. The problem "relative of patient" largely involves supportive work with the relatives of a patient taken to the resuscitation room. 4. When developing the categories, an effort was made to define the categories - in observable, behavioral terms in order to reduce the staff's inconsistency in recording. 5. The category "self-inflicted injury" includes unequivocal suicide attempts and gestures, self-inflicted injuries of undeterminable and uncertain intentionality, and a small number of clearly accidental selfinflicted injuries. However, the greatest proportion involve self-inflicted injuries of unequivocaland uncertainintentionality.
The breakdown reveals that 59.9% of the cases referred in 1976 p r e sented primary problems best described as individual or family in nature. The remaining 39.8% were problems involving living arrangements, need for community support services, or practical assistance, such as transportation or information. The distribution of the problems presented to social work staff in Emergency suggests that a fairly high degree of training and experience is required. The unique nature of crisis intervention with potentially explosive personal and family problems such as child abuse, spouse beating, or suicide attempts requires a complete, accurate, and rapid assessment of the situation coupled with practical, strategic, and effective plans for immediate treatment. The position requires a strong sense of professional confidence, and an extraordinary ability to function effectively under pressure. I t also requires staff who seek and appreciate the challenges offered by crisis work, but who can also accept the more routine and less stimulating situations.
PROGRAM PROBLEMS The process of establishing an emergency department social work service of the nature and scope as the one at Saint Boniface General Hospital is a continuing one. I t requires the cooperation and support of emergency department administration and its staff. One major initial problem, and one that periodically appears with the coming of new medical or nursing staff, is the altering of ste-
,
SOCIAL WORK IN HEALTH CARE
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reotypes about what social work can provide within an emergency d e partment. The most effective way of changing these attitudes, and of obtaining and maintaining credibility, is to establish close working relationships with medical and nursing staff. Being visible and providing feedback are essential to establishing a successful service. Emergency staff frequently seek information on how particular patients are progressing, and mechanisms for providing feedback should be included in the program. Most often this is of an informal nature; however, provisions should be made for periodic presentations a t rounds or in-services. The value of providing feedback cannot be understated. I t provides confirmation on the appropriateness of refer-
D i ~ t r i b u t i o nof P r i w r g Presenting S o c i a l u o r k Problem In the emargancg Depsrtmant
Problem
-
1976
Number
Percent
Child Abuso
20
2.0
Spouse Beating
22
2.2
W r i t e l Problem
29
2.0
Relative of Patient
54
5.5
Family Problems
Orhsr
13
1.3
Total
138
1b.0
Individual Problem. S o l f - i n f l i c t e d InJury Drug Abuse Alcohol Abuse AnrietglDepraeslon Other Total
Plscemnnrs Hospital Wspital
-
Chronic Acute
-
H o ~ p i t s l Rshnb Nuraing Homm PosterlBoarding H o ~ e
John M. Farber
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rals, establishes the value of follow-up, provides vicarious learning about methods of assessment and intervention, and maintains interest in the psychosocial implication of illness and hospitalization. The primary problem encountered in providing feedback about patients is maintaining confidentiality. A balance must be struck between sharing information and ensuring that the patients' rights to confidentiality are maintained. I t is strongly recommended that this issue be considered and guidelines established prior to the implementation of a service. Working in Emergency presents some special problems for the social workers assigned there. First, it can require some personal attitude
Table 2 Cont'd. Problem Temporary Emrgeacy Lodging Other
Toea1
co-nity
support s.,rvices
Periodic Nursing Care Child Care Housekeeping equ1pmant Other Total
Practical Alaistanca Financial Transportation Info-tton Othar
Total
Number
Percent
40
4.1
11
1.1
166
16.8
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SOCIAL WORK IN HEALTH CARE
changes about the role of social work. The norm becomes rapid assessment, strategic and sometimes unorthodox intervention, and shortterm follow-up. This may conflict with traditional beliefs about social work practice and may require close supervision. A second potential problem is adjustment to working shifts. Whereas this is routine for most other disciplines in Emergency, it can be a new experience for social work. It can require reorientation by other Social work Department staff who may o h y see the ~ m e r ~ e Denc~ partment social workers brieflv during the week. Intradepartmental conflicts can develop because oi the reduced contact, and careful monitoring is indicated. Shift work can create other unique problems. Two other problems experienced by staff are loneliness and excitement. During 52 hours of each week, after 5:00 p.m. and on weekends, the social worker in Emergency is the only social worker in the hospital. This limits their opportunity for informal contact both with their colleagues in Emergency and, as already noted, in the Department of Social Work. Related to this is that after an evening or weekend shift is over, particularly if it has been an unusually stressful one, there is little opportunity to ventilate or share it with other staff. During the day, staff use each other to help dissipate the day-to-day stresses. In the evening a q l on weekends, staff are left to their own resources to dissipate the shifts' accumulating pressures. Other problems also exist for social work staff. I t is much more difficult, if not impossible, to establish a normal working routine or maintain control over case loads in Emergency because of the variable d e rnand for service. I t is common to have scheduled plans interrupted by a call from Emergency. This can be a frustrating experience; however, it can be minimized with appropriate appointment scheduling and monitoring of cumulative referral rate data. The highly variable rate of referrals from Emergency creates other problems for social work staff. There are times when the number of referrals andlor the demands of a particular situation strain one's capacity to cope effectively. There are other periods, however. when there are few or no referrals. The latter is found to be more difficult to tolerate than the former. To reduce the discomfort created by these slow periods and to exploit a valuable opportunity, these times are utilized in a number of ways. Social work staff use these times to consult with Emergency staff about patients presently in the department iri an attempt to discover problems requiring intervention. This is particularly importatit when Emergency is busy, as data reveal that this is one time when Emergency staff are less likely to refer (Farber, Note 3). This time is also used to review the previous day's charts in order to locate patients who were not referred but perhaps should have been. Slow periods can also be used to provide feedback on the appropriate
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John M. Farber
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ness and progress of patients previously referred. Finally, it also p r e vides an opportunity to assist Emergency staff with personal problems and intradepartmental problems. Another problem encountered by work in an emergency department is maintaining a commitment to the service. Work in Emergency should be a high priority. It is often one of the first opportunities for contact with a patient. Those with psychosocial problems can beidentified early even if the reason for coming to Emergency is primarily medical. However, for such a service to be useful it must be available on a regular and consistent basis! This means havingprovision tocover when regular staff are away for holidays, illness, attendance at staff development programs, and so on. There are a number of alternatives for handling absences. The unit coordinator or another staff member can fill in for the absent social worker. This is feasible for short-term absences which are spaced relatively far apart because of the additional strain it puts on staff. Another method is to hire replacement staff on a casual or temporary basis. Although this is a more expensive alternative in absolute dollars. it may be less expensive than appears if one considers the benefits in terms of staff effectiveness and morale. The cost can be offset partially by using an on-call system, although our experience has been that an on-call system is not as effective as actually being present in Emergency. In addition, for an on-call system to be effective, it requires a well-established relationship with Emergency staff. Regardless of which alternative is adopted in order to maintain credibility, it is important to honor whatever schedule is decided upon and to avoid the "essential-by-convenience" trap. Finally, once service was established, another problem emerged. Word spread quickly through the hospital that during evenings and weekends there was a social worker available in the hospital. Suddenly there was an upsurge in requests from the wards requiring immediate attention when in the past, they would be left to the following working day. At one point the calls came so frequently that they interfered with work in Emergency. Documentation of these requests was forwarded to Nursing Service, which informed the wards that with the exception of true crisis situations, the social worker assigned to Emergency was not available to them. In anticipation of this problem it is recommended that departments considering implementing a service in Emergency consider and decide how requests from outside the area are to be handled. CONCLUSION As health care costs continue to rise, new means are r e q e e d to identify and alleviate those conditions that produce, precipitate, and perpetuate poor physical and emotional health. Early iden-
SOCIAL WORK IN HEALTH CARE
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tification of these conditions can often postpone or alleviate their deleterious effects. One way to achieve early identification and remediation is by crisis intervention, and a hospital emergency department provides one obvious setting for the initiation of this type of service. Emergency department staff are often unable to provide the level of psychosocial care required by patients andlor their families, because of the volume of patients to be seen and the acute nature of medical treatment. Hospitals are becoming increasingly aware of the need to expand social work coverage and services in emergency departments.
REFERENCE NOTES 1. Pascoe. D. Social service department research. Unpublished manuscript. 1971. (Available from the Department of Social Work. Saint Boniface General Hospital. 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6. Canada.) 2. Crahart, B. Social work student study of the emergency ward of Saint Boniface Genem1 Hospital. Unpublished manuscript, 1973. (Available from the Department of Social Work, Saint Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6. Canada.) 3. Farber. J. M. An analysis of referral rate by emergency department volume. Unpublished manuscript. 1976. (Available from the Department of Social Work, Saint Boniface General Hospital. 409 Tache Avenue. Winnipeg, Manitoba R2H 2A6, Canada.)
REFERENCES Bennett, J. J. The social worker's role. Hospitals, 1973.47.111-118. Krell, G. I. Hospital social work schedule should be more than a 9-5 position. Hospitals. 1976,50.99-104. Lindenberg, R. E. The need for crisis intervention in hospitals. Hospitals. 1972, 46. 52-110.
