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SOCIAL WORK IN HEALTH SETTINGS Martin Nacman DSW
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Director, Social Work Division, Strong Memorial Hospital, Rochester, New York 14642 Published online: 26 Oct 2008.
To cite this article: Martin Nacman DSW (1977) SOCIAL WORK IN HEALTH SETTINGS, Social Work in Health Care, 2:4, 407-418, DOI: 10.1300/J010v02n04_05 To link to this article: http://dx.doi.org/10.1300/J010v02n04_05
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SOCIAL WORK IN HEALTH SETTINGS: A HISTORICAL REVIEW
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Martin Nacman, DSW
ABSTRACT. A retrospective account of the beginnings ofsocial work in health care giues perspective to current concerns, challenges, mandates, prospects, and problems faced by health care practitioners and administrators.
CREATION OF HOSPITALS During the early period of the settlement of this country, those who were sick were cared for a t home. Temporary facilities were built, primarily in seaport towns, to confine those with contagious diseases during epidemics. The forerunner of the hospital as a community institution was the almshouse. Established for the containment of the destitute, the sick, orphans, criminals, and the mentally ill, many who entered were ill, and those who entered healthy were exposed to contagious diseases. In 1713 in Philadelphia, William Penn founded the first almshouse. In 1736 Bellevue Hospital was established a s a n almshouse in New York for the "poor aged, insane and disreputable." Saint John's Hospital, founded in New Orleans in 1737 a s a n almshouse, also accepted some paying patients. In 1815 a separate unit for children was established. This almshouse later became the County Hospital of New Orleans.' By the middle of the eighteenth century, services for the sick were beginning to be separated from the almshouse. Middle-class urban Americans wanted better care and were willing to pay for services. This led to the construction of voluntary hospitals which were generally started with the help of philanthropic gifts. Eleven hospitals were founded between 1751 and 1840. Benjamin Franklin, in his autobiography, recalled that in 1751 a friend of his, Dr. Thomas Bond, conceived the idea of establishing a hospital in Philadelphia 'Tor the reception and cure of poor sick persons, whether inhabitants of the province or strangers." Franklin not only subscribed to the project himself but procured subscriptions from others and promoted a bill through the Assembly in support of this propos i t i ~ nDuring .~ the Revolutionary War, New York Hospital, founded as a Dr. Nacman is Director, Social Work Division, Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New York 14642. This article was adapted from a presentation made at the ffiieth-anniversary celebration of the Sodal Work Division of the Strong Memorial Hospital, Febmaty 2 6 2 7 , 1976 Soeinl Work in Health Care.Vol. 2(4), Summer 1977 @ 1977 by The Haworth Reas. All right8 reserved.
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Revolutionary War military hospital, was the first hospital to provide systematized instruction to medical students. Massachusetts General Hospital was opened in 1821, funded more by the state than private philanthropy. The Georgia Infirmary, founded in 1832 in Savannah, and the Lincoln Hospital, founded in 1840 in New York City, served aged and disabled b l a c b 3 By 1840 some hospitals had become specialized and provided care for certain populations or for particular diseases. But the almshouse, in which conditions were appalling, continued to be the primary care facility for the poor. To save the "deserving" poor from the almshouse and to emphasize moral aid over material relief, Robert M. Hartley, in 1841, founded the New York Association for Improving the Condition of the Boor. The movement of children from the almshouses to orphanages and foster homes was pioneered through the New York Children's Aid Society founded in 1853 by Charles Loring Brace.4 Also in 1841, Dorothea Lynde Dix started to crusade for reforms in the treatment of the insane. Her efforts resulted in new and improved facilities for the insane in many states. She persuaded Congress to pass a bill that would have granted public lands to the states on which to locate facilities for the insane, but the bill was vetoed by President Pierce. This action was used as precedent for denying social welfare aid to the states until the 1 9 3 0 ~ . ~ The expansion of industrialization and urbanization following the Civil War added to the growth of poverty and slums. To cope with these problems organizations opposing public relief but providing individual assistance to "deserving" applicants were set up; a State Board of Charities and Corrections in Massachusetts was established in 1863, and by 1867 similar boards existed in sixteen of the thirty-six states. In addition, the Charity Organization came into being, and by 1877 programs were operating in ninety-two cities. THE EMERGENCE OF THE PROFESSIONAL WORKER The ancestry of the contemporary medical social worker may be traced to England where in 1875 Charles Loch was chosen as secretary of the London Charity Organization Society (LCOS). Loch worked with medical practitioners to foster referrals of patients from hospitals and clinics to branch offices of the LCOS for investigation. In 1891 when he testified before the Select Committee appointed by the House of Lards, he suggested that hospitals were operating for the convenience of doctors and not a s needed by the community. But it was not until 1895 that the Royal Free Hospital in London agreed to a threemonth demonstration of the use of an "almoner." The LCOS loaned a staff member for the demonstration. Although the demonstration was considered successful, the hospital did not institutionalize the program, and the
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almoner was withdrawn. The almoner was later returned when two physicians agreed to match funds provided by the LCOS. Within the next decade seven other hospitals appointed almoner^.^ Ida Cannon identified Dr. Elizabeth Blackwell as the forerunner of the development of social work for the sick in the United States7In 1853 Dr. Blackwell established a dispensary known a s the New York Infirmary for Women and Children. In 1866 Dr. Blackwell appointed Dr. Rebecca Cole, a black physician, a s "sanitary visitor" for home visiting. Although this appointment was later dropped, in 1890 a gift prov.ided for the employment of a home visitor. In 1874 Dr. Susan Dumock of the New England Hospital reported on volunteer services to deserted wives and unmarried mothers. In 1890 Dr. Dwight Chapin of the New York Postgraduate Hospital secured volunteers to visit children in their homes to report on home conditions and to interpret his instructions to the mother. In 1894 he appointed a female physician to perform this work but later concluded that a trained nurse with "instincts for social service" was neededs In 1889 the Johns Hopkins Hospital and University was opened in Baltimore to provide free services to all, regardless of race or religion. Dr. William Osler, chief of that hospital, established a home visiting program in which medical students learned about the living conditions and personal problems of patients. Dr. Charles P. Emerson, a resident physician of the Baltimore Charity Organization Society (COS) organized a "student b o a r d a t COS. These students visited the homes of COS clients. Historically the two organizations were closely tied since President Gilman of Johns Hopkins had been instrumental in the creation of the Baltimore COS.g In 1903 Dr. Richard Cabot, chief of medicine at the Massachusetts General Hospital in Boston, became acquainted with Dr. Emerson's student program while visiting Johns Hopkins Hospital. Deeply convinced of the importance of social factors, Dr. Cabot set out to introduce a social worker into his clinic. He concluded that a patient's personal difficulties may prove to be the cause and not the result of that person's illness. Miss Garnet Isabel Pelton, who had previously completed nursing training, was appointed to the new position. She was to report to the doctors on the domestic and social conditions of patients, to help patients fulfill doctors' orders, and to provide a linkage between the hospital and community agencies and organizations. In 1906 Ida Cannon succeeded Mrs. Pelton.l0 As a result of these efforts, Dr.T. S. Armstrong, the general medical superintendent of Bellevue and Allied Hospitals in New York City, started a similar program. Mary E. Wadley, a former Bellevue and school nurse, was appointed director of that social service program.ll In 1907 a social work program was established a t Johns Hopkins Hospital. The first social worker to be employed was Helen B. Pendleton, previously a district secretary in the Charity Organization Society. At that time the wards were controlled by the nurses, and the social worker
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was not allowed on the wards. Miss Pendleton resigned after eight months, and for four months the social work program was i n limbo. From August 1908 to August 1909 Helen S. Wilmer Athey, daughter of one of the hospital trustees and a graduate of the Hopkins Training School for Nurses, was employed in the social work position. Miss Athey had previously worked a t COS and at the Henry Street Settlement House in New York City. Margaret S. Brogen, also a graduate of the Hopkins Training School for Nurses, took charge of the program when Miss Athey left the staff. Miss Brogen described the hospital of 1909 as a "small one-story dispensary building with its foul odors, rooms dark and badly ventilated, used by one clinic in the morning and by another in the afternoon, with only one nurse in the whole General Dispensary."12 She went on to recall that records were sparse and could not be sent with the patient from one unit to another. Records were kept in rooms separate from the patient areas. When records were needed by medical or nursing personnel they had to be obtained through the social worker, who was responsible for their safe return. All free medical care had to be approved by the social worker. Confidentiality was not respected. The social worker shared a room that was also used as a storage area for surgical supplies. Social work was begun in hospital settings in the preprofessional era. Nurses were employed in social work positions because they were familiar with hospital organizations and community resources. The role of the hospital social worker was modeled after that of the "friendly visitor," sympathetic to the plight of the patients, but paternalistic and moralistic. Caseworkers were a t first not concerned with the meaning of their participation in the "transaction of giving and imposing."13 Briar concludes that two conflicting ideologies were present a t that time, one representing the intent to alleviate social ills and the other to use social work to protect against changes in the status quo.14 Grinker et al., in discussing the evaluation of the volunteer charity worker, known as the "friendly visitor," note that such social and cultural gaps existed between giver and receiver that often both were frustrated. The giver was frustrated because of the lack of appreciation and the absence of expected results, the recipient because of the lack of opportunity for self-expression and the unwillingness to accept the stipulations required in order to receive what was being given.15By the beginning of the twentieth century i t had become apparent that the dispersing of "charity" by "well-meaning individuals" was not working out well. Leaders of the field concluded that workers required training in the understanding of social problems in order to achieve more discrimination in dispersing charitable funds. While the School of Philanthropy was founded in 1898 to provide formal training for the emerging profession, it was not until 1932 that the American Association of Schools of Social Work adopted a specific social work curriculum policy. In 1917 the National Social Workers Exchange
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was created with specific concern for the establishment of professional standards, the same year Mary Richmond published her book Social Diagnosis.16 This material marked a shift in casework orientation. Richmond's "Concepts of Social Study and Social Diagnosis" emphasized the need for a systematic study of the patient and careful collection of social data. In 1918 Jarrett offered the opinion that many casework situations involved psychiatric problems." In 1922 Richmond redefined casework as being concerned with the conscious development of the individual's personality a s a result of adjustments between the individual and the environment, a definition representing a n assimilation of emerging psychiatric principles and dynamics into casework practice.le' Pollak, in his discussion of cultural factors in social work practice, "~~ speaks of social work operating "in the house of another p r ~ f e s s i o n . Ida Cannon suggests that the ambivalence with which the social work program was approached by hospital authorities a t Massachusetts General Hospital was evidenced in the fact that the program was referred to a s a n "unofficial department" in the hospital's annual report of 1906. Funds for its support were solicited from the personal friends of Dr. Cabot and later from other contributors who heard about the program.*O In 1914 the hospital officially recognized social work activities on the wards, and Ida Cannon was given the title "chief of social services."21But not until 1919 was it possible to provide continuity of social work service from outpatient to inpatient unit. On October 14, 1919 the trustees voted to make the Social Services Department an integral part of the hospital. In 1918 in Kansas City the American Association of Medical Social Workers was formed, signifying the nationwide expansion of social work into health settings. In the same year the American College of Surgeons initiated the first National Hospital Standardization Program. In 1920 the American Hospital A ~ s o c i a t i osponsored ~ the first formal survey of hospital social services, making recommendations that led to the formation of a committee on Training for Hospital Social Workers. Antoinette Cannon, the executive secretary of that committee, formulated the original statement of essentials of medical social work and recommended full education for this group. She had been director of social work a t the University Hospital in Philadelphia from 1910 to 1921, when she joined the faculty of the New York School of Social Work.22 From 1920 to 1930 social work programs were started in the army, navy, and Veterans Administration. The Federal Emergency Relief Act of 1933 and the Federal Security Act of 1935 created a demand for medical social workers. Social work services were also included as part of the Federal Crippled Children's Services. In 1925 Dr. Faxon, when opening the Strong Memorial HospitaL University of Rochester School of Medicine and Dentistry, also started a social work program under the direction of Mrs. Ruth T. Boretti. Mrs. Boretti was formerly on the staff of Massachusetts General HospitaLZ3 At the First International Conference of Social Work held in Paris in
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1928, Dr. Cabot presented a comprehensive report on medical social services throughout the world.24 In that same year minimum standards for social service departments were included in the standards for hospitals published by the American College of surgeon^.^^
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THE FOCUS OF SOCIAL WORKERS IN HEALTH SETTINGS Early social workers were caught up in the antituberculosis effort of the early 1900s. They tried to cope with the psychological problems and negative effects of the patient's separation from family for prolonged physical rest that was the prescription of the day. The deplorable condition of factories and workshops led workers to assist in studies to identify hazardous working conditions. Social workers also focused on the problem of syphilis during the time when treatment was required for a prolonged period and social taboos were extreme. Another area of concern was the unmarried pregnant woman. While many social workers shared the moralistic attitude of the time toward this group, some pioneered in the development of an instructive program for these women and worked with community agencies to expand resources. Another concern was children impaired by polio. Strongly influenced by psychiatric theory, Virginia Robinson in 1930 described the social worker as psychotherapist and the therapeutic relationship as the primary casework tool.26The Rankian group led by the faculty of the Pennsylvania School of Social Work advocated "relationship therapy." Although the followers of the diagnostic (Freudian) orientation and those of the functional (Rankian) schools vigorously opposed each other's views and techniques, in retrospect the dispute was not critical to the future of the profession. During the forties, leaders such as Florence Hollis and Gordon Hamilton elaborated on the psychiatric theme with greater appreciation of family dynamics and the influence of one member on another. The goal of casework was to help educate the client in order for that person to take action that was judged by the social worker as advantageous to the client. As in the earlier days the social worker continued to obtain psychosocial information from the patient and family, but by this time the data were used to establish diagnosis and treatment plans. By the forties psychoanalysis was given considerable status by social workers in all settings. Dynamic formulations replaced the labeling of patients in rigid terms. But social workers were so eager to follow this model that the "essential and nuclear role of the caseworker was sometimes lost to the detriment of the field." The psychiatrist became the "ego ideal" for many social workers.27Social, cultural, and environmental factors were considered as secondary to repressed fears and unresolved frustrations. To listen and allow for self-determination was considered pro-
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ductive a s a technique for allowing patients to release feelings. This approach was labeled "dynamic passivity." To some it appeared that the field was doing nothing. In the forties the ultimate aspiration of many psychiatric social workers was to practice "analytically oriented" therapy. Within many general hospitals psychiatric and medical social work programs became divided. Psychiatric social workers proclaimed that their "therapeutic" role was unique. Some were reluctant to be associated with workers assigned to medical-surgical units who, in their opinion, were unsophisticated and engaged only in instrumental tasks. In reality the roles of the social worker in both settings were quite similar. Briar concluded that "the commitment to an essentially psychiatrically oriented casework served to undermine the caseworker's interest in and ability to contribute to change in the social order."*8 In the postwar era social workers such a s Helen Harris Perlman departed from the traditional psychiatric orientation and incorporated social science concepts into casework theo~-y.29Perlman reoriented the worker to the patient's role in society and identified society's contribution to the problems of people. The establishment of the community mental health movement in the fifties also placed greater emphasis on the importance of social and cultural factors in the diagnosis and treatment of psychiatric patients. Social workers trained as community organizers were added to some of these programs, and attempts were made to influence social change.30 A factor that fostered change in psychiatric institutions was the introduction of Maxwell Jones's concept of "milieu therapy."31 Unfortunately, this concept has been slow to take hold in nonpsychiatric hospital settings. Beginning in the fifties and extending into the sixties, group services also became part of the offerings of the hospital social work program. While this development was most apparent in psychiatric settings, there was expansion for medical-surgical patients as well. In pediatric units staff began to work with groups of hospitalized children, and in specialty clinics both children and parents sharing similar problems, usually related to chronic illness, were treated a s a group. In both psychiatric and medical settings family therapy was slowly expanded.32 The fifties represented a period of expansion of casework service into new areas. Tuberculosis and polio were coming under control. Medical care of acute and chronic problems was being infused with the concepts of rehabilitation, particularly for amputees, those with spinal cord injury, and stroke victims. Procedures for heart surgery and transplant surgery were developed, with some recognition of the impact of these procedures on the psychosocial adjustment of patients. Heart disease and cancer were becoming the focal point of national attention. Chemotherapy had been added to the treatment regime of psychiatric patients, and without
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complete awareness of consequences, we had begun a massive emptying of psychiatric hospitals. In the sixties the civil rights and welfare movements emphasized the inequalities that society had produced. We became more aware of the deprivations suffered by some segments of the community and the conspiracy of health and welfare bureaucracies to maintain status quo and control applicant^.^^ During this period many social workers were reawakened to the union of cause and function that had previously concerned Mary Richmond, Ida Cannon, and others. Was social work contributing to the maintenance of the status quo and the pathologies of society? Was casework encouraging clients to accept "realities" that were destructive and could be changed? Cloward, Kahn, Rein, and others challenged us to look a t our practices, to consider a n expanded role directed toward influencing social policy and becoming involved in social action.34 As social workers with graduate training came into the field, professional prerogatives were identified. Social workers no longer waited for referrals but more assertively identified patients and families in need. This approach recognized the importance of initiating social work contact early in hospitalization in order to have time to provide adequate services. Greater emphasis was placed on the establishment of continuity of service between inpatient and outpatient services. But the lack of funding for outpatient care often blocked the achievement of continuity. The advent of titles XVIII and X M of the Social Security Act created even greated demand for social work coverage in hospitals. Medicare (Title XVIII) health insurance for persons over sixty-five years of age brought millions of these individuals into hospitals, and then into extended care facilities. Medicaid (Title XM) provided medical care for the medically indigent under twenty-one and for the permanently and totally disabled, and medically indigent, between twenty-one and sixty-five. The medically indigent over sixty-five were also covered by Medicaid. Social workers played a vital role in working with these populations. WHERE ARE WE NOW? Social workers in the seventies practice a variety of therapeutic techniques including behavior modification, transactional therapy, analytic therapy, ego psychology techniques, crises intervention, and various family treatment models. More emphasis is being placed on preventive programs a s in genetic counseling, family planning, prenatal counseling, sex counseling, and prehospital orientation programs. Expansion of social work coverage into hospital emergency programs has enabled social workers to triage patients into appropriate health and welfare programs within the hospital or the community. Provision of social work services a t the point of crisis has created oppor-
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tunities for intervention a t a time when the situation maximizes the patients' and/or families' potential for involvement in a treatment relationship. The social worker's role a s advocate has done much to protect the rights of patients both within the hospital and in referral to services that they are entitled to in the community. The establishment of a Patients' Bill of Rights has helped to specify what prerogatives patients have within a health setting and what rights the staff must protect. The Patients' Bill of Rights sanctions the advocacy role of the social worker. However, we still have a long way to go in reorganizing the structure and policies of hospitals to protect these rights. Patient and family reactions to complicated procedures such a s transplant surgery, combined chemo-radiation therapy, as well as the potential of death or serious physical or mental disability have opened new avenues for social work practice. Whether in the burn or intensive care unit or the oncology or birth defect clinic, the social worker may provide valuable assistance to staff, patients, and families who face difficult problems and decisions about life and death. In the early part of the twentieth century medical leaders of the stature of Dr. Cabot of Massachusetts General Hospital and Dr. Faxon of Strong Memorial Hospital had been deeply concerned about the complexity of the hospital organization and the medical care system. They believed that these systems lacked individualization and failed to provide humane treatment. Both Dr. Cabot and Dr. Faxon looked to social workers for solutions. Today, some fifty years later, these systems have reached a degree of complexity that would stagger our predecessors. However, we face many of the same problems and threats to humane care that confronted Ida Cannon and Ruth Boretti. We have increased our technological knowledge and created new specialities, but we have failed to achieve continuity of care. Our commitment to treatment after the presence of pathology has distracted from the development of preventive programs. Indifference to patients' psychosocial needs has produced an alienated clientele and the demand for ombudsmen, advocates, and special representatives. In many respects the conservative and reactionary attitudes expressed by politicians, medical groups, and other members of the community represent a reversion back to social Darwinsim. Historically, social Darwinism was used to buttress attacks on social reform and resulted in blind support of the so-called natural law that the "strongest and best" survive.35Unfortunately, in the face of rising costs and limited resources, some politicians, physicians, and hospital administrators have begun to look a t the health care institutions as if they were production systems handling inanimate objects. Many have forgotten or perhaps never recognized the impact of psychosocial factors a s related to the precipitation
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and exacerbation of illness. The system is beset by dehumanizing factors. It has become a constant struggle to preserve the humanism essential to proper patient care. Rhetoric touts the "total treatment" of patients, but psychosocial interventions are often given low priority in federal and state legislation and the programs of health institutions. Too often hospital and medical administrators discount the importance of these factors and thereby establish a negative role model for politicians and the general community. While the need for more precise accountability in relation to cost and quality of care is long overdue, regressive political and social forces must not diminish the humane achievements of Cabot and Cannon. Social workers may abhor statistics and audits, but more precision in accounting for what we purport to accomplish is essential to the future of our profession and our impact on health care. Although the field of social work has been concerned with quality review for many years, relatively few evaluative programs have been formulated and carried out. With the advent of the Professional Standards Review Organization (PSRO), a program created by federal legislation, hospitals are now required to establish Utilization Review to make explicit the necessity for hospitalization and Medical Audit to determine the quality of hospital care rendered. These developments have accelerated the need for developing a methodology for assessing social work performance. PSRO allows social work to establish peer evaluation of our professional performance. If social work does not develop these protocols, less relevant criteria will be imposed by others. In order to ensure that the criteria established by local PSROs recognize psychosocial influences, social workers must become active in these organizations or form coalitions with other nonmedical practitioners capable of putting pressure on these groups. Another major issue confronting social work is the development of programs for the licensure of social work, a means for assuring at least minimal standards for practice and potential for securing reimbursement for services rendered. In the health arena we are experiencing increasing pressure by insurance companies and government to supply assurance as to the qualifications of nonmedical practitioners. Certification and licensure offers these assurances to payers. The development of a more stringent program by the Academy of Certified Social Workers as has been recently under way offers one possibility for solving this licensure problem. Finally, social work must concern itself with the language of proposed national health insurance programs. Unless the role and function of social workers are explicitly established it may become difficult to receive payment for social work services rendered within health organizations and in private practice. Thus far, proposed legislation is either vague or silent about social work.
Martin Nacrnan
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CONCLUSIONS In spite of the initial resistance to the inclusion of social workers a s members of the hospital team in the early 1900s, social work has made enormous progress during the intervening years. Social workers have helped to break down barriers that separated the physical aspects of patient care from psychosocial factors. Social workers have gained access to the political forces that determine hospital policy and have helped to modify programs and policies so that they reflect the needs and rights of patients. Supported by the policy of the National Association of Social Workers, hospital social workers have advocated on behalf of patients and their families. They have assertively challenged the restrictive practices of community organizations that have limited continuity of care. They have helped their patients obtain services to which they are entitled. The late sixties and early seventies have represented periods in which social workers in health settings have ventured into new programs and have expanded the scope of their operations. They have moved into new areas of health care. They have joined research teams and have engaged in research of their own.36 They have protested inequities. They have challenged abuses. They have helped create more responsive environments. Social workers have expanded their therapeutic repertoires. Fiscal problems of federal, state, and local governments will have their impact on the profession. Rising hospital deficits will dictate the availability of funds to support social work staff just as they will have their impact on other staff. Nevertheless, the pressure being placed on hospitals to create effective discharge programs and to justify the reasons for continued stay should increase medical and administrative reliance on social work practice. Although discharge planning is by no means the only area of social work proficiency, it represents a n important contribution to the patient's welfare and the hospital program. I t is a n area requiring sensitive therapeutic techniques. I t often requires a strong advocacy role in order to facilitate the completion of adequate discharge plans. Casework treatment is a n integral part of this process. Consumer pressure, the need to maintain high bed occupancy, and increased litigation are pressing hospital administrations to create programs that are capable of increasing patient satisfaction. Patient satisfaction is linked to patient knowledge, patient understanding, as well a s the preservation of patients' rights. These are areas in which social work staff can make positive contributions. REFERENCES 1. Rubin O'Connor, "American Hospitals: The First 200 Years," Hospitals, Journal of the American Hospitnl Assmiation 50 (January 1. 1976k62-72. 2. Margaret K.Soifer, ed., The Autobiography of Benjamin Franklin (New York: Macmillan Co., 19671, pp. 132-34.
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3. 4. 5. 6.
O'Connor, "American Hospitals." Charles Loring Brace, The Children's Aid Society ofNew York (New York: CAS, 18%). Encvclooedia of Social Work. Dorothea Lvnde Dix. DD. 254-56. B. E. Ltburv.' "Hosoital ~ l m o n i n v :HOG I t All ~ G- a n.. " The Almoner 1, no. 6 ( S ~ D tember, 1948j.' 7. Ida M. Cannon, On the Social Frontier of Medicine (Cambridge: Harvard University Press, 1952). 8. Ibid., p. 273. 9. Ibid., pp. 30-33. 10. Ibid., pp. 48-49. 11. Ibid., pp. 49-50. 12. Margaret S. Brogen, "The Johns Hopkins Hospital Department of Social Service, 19071931." Social Service Reuiew 39 (March 1964):8%98. 13. Roy R. Grinker e t al., "The Early Years of Psychiatric Social Work," Social Service ~ e & w35, no. 2 (June 1961):111126. 14. Scott Briar, "Social Case Work and Social Group Work: Historical Foundations," Encyclo~ediaof Social Work 11. no. 16 (1971k1237-45. . . 15. ~ k n k e er t al., "Early y e a i s of Psychiatric Social Work." 16. Mary E. Richmond, Social Diagnosis (New York: Russell Sage Foundation, 1922). 17. Mary Jarrett, "The Psychiatric Thread Running through All Social Case Work" (Proceedings of National Conference of Social Work, Chicago, 1919), pp. 587-93. 18. Mary E. Richmond, What Is Social Case Work? An Introductory Description (New York: Russell Sage Foundation, 1922). 19. Otto Pollak, "Cultural Factors in Medical Social Work Practice," Journal ofthe American Association of Medical Social Workers 3 (July 1954):81-152. 20. Cannon, Social Frontier of Medicine, pp. 64-66. 21. Ibid., p. 88. 22. Encyclopedia of Social Work, Mary Antionette Cannon (1884-1962), vol. 1 (National Association of Social Workers, 1971), pp. 91-92. 23. The Quarter Century, 1925-1950 (Rochester: University of Rochester, 1950), pp. 32-33. 24. Richard C. Cabot, "Hospital and Dispensary Social Work," Hospital Social Seruice 17 (1928):269-320. 25. Cannon, Social Frontier of Medicine, p. 149. 26. Virginia P. Robinson, A Changing Psychology in Social Work (Chapel Hill: University of North Carolina Press, 1930). 27. Grinker et al., "Early Years of Psychiatric Social Work." 28. Briar, "Social Case Work." 29. Helen H a n i s Perlman, "Social Components of Case Work Practice," in The Social Welfare Forum (New York: Columbia University Press, 19531, p. 12. 30. National Commission on Community Health Services, Health I s a Community Affair (Cambridge: H a n a r d University Press, 1966). 31. Maxwell Jones, The Therapeutic Community (New York: Basic Books, 1953). 32. Nathan W. Ackerman, The Psychodynamics ofFamily Life: Diagnosis a n d Treatment of Family Relationships (New York: Basic Books, 1958). 33. Richard A. Cloward and Frances F. Piven, "The Professional Bureaucracies: Benefit Systems as Influence Systems," in Community Organization Practice, ed. Ralph W. Kramer and H a n y Specht (Englewood Cliffs, N.J.: Prentice-Hall, 1969), pp. 359-72. 34. Ibid.; Alfred Kahn, Issues in American Social Work (New York: Columbia University Press, 1959); Martin Rein, "Social Work in Search of a Radical Profession," Social Work Journal 12, no. 2 (April 1970):13-29. 35. Richard Hofstadter, Social Darwinism in American Thought (Boston: Beacon Press, 19621, pp. 13-66. 36. M. J. Phillippus and M. Nacman, "A Psychosocial and Vocational Follow-up Study of Previously Hospitalized Asthmatic patients," Psychotherapy a n d ~ s ~ c h o s & n a t i c14 s~ (1966) 171-79, Helen Rehr, ' Qunhty and Quantity Assurance Issuer for Socral Serv~ces in Health" (Proceedlnes of Bualrtv Assurance rn Socrol Serurces in Health Prorrnms., Pittsburgh, 'March 31-lpril b, 19j5).
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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
SOCIAL WORK IN HEALTH SETTINGS Martin Nacman DSW
a
a
Director, Social Work Division, Strong Memorial Hospital, Rochester, New York 14642 Published online: 26 Oct 2008.
To cite this article: Martin Nacman DSW (1977) SOCIAL WORK IN HEALTH SETTINGS, Social Work in Health Care, 2:4, 407-418, DOI: 10.1300/J010v02n04_05 To link to this article: http://dx.doi.org/10.1300/J010v02n04_05
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SOCIAL WORK IN HEALTH SETTINGS: A HISTORICAL REVIEW
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Martin Nacman, DSW
ABSTRACT. A retrospective account of the beginnings ofsocial work in health care giues perspective to current concerns, challenges, mandates, prospects, and problems faced by health care practitioners and administrators.
CREATION OF HOSPITALS During the early period of the settlement of this country, those who were sick were cared for a t home. Temporary facilities were built, primarily in seaport towns, to confine those with contagious diseases during epidemics. The forerunner of the hospital as a community institution was the almshouse. Established for the containment of the destitute, the sick, orphans, criminals, and the mentally ill, many who entered were ill, and those who entered healthy were exposed to contagious diseases. In 1713 in Philadelphia, William Penn founded the first almshouse. In 1736 Bellevue Hospital was established a s a n almshouse in New York for the "poor aged, insane and disreputable." Saint John's Hospital, founded in New Orleans in 1737 a s a n almshouse, also accepted some paying patients. In 1815 a separate unit for children was established. This almshouse later became the County Hospital of New Orleans.' By the middle of the eighteenth century, services for the sick were beginning to be separated from the almshouse. Middle-class urban Americans wanted better care and were willing to pay for services. This led to the construction of voluntary hospitals which were generally started with the help of philanthropic gifts. Eleven hospitals were founded between 1751 and 1840. Benjamin Franklin, in his autobiography, recalled that in 1751 a friend of his, Dr. Thomas Bond, conceived the idea of establishing a hospital in Philadelphia 'Tor the reception and cure of poor sick persons, whether inhabitants of the province or strangers." Franklin not only subscribed to the project himself but procured subscriptions from others and promoted a bill through the Assembly in support of this propos i t i ~ nDuring .~ the Revolutionary War, New York Hospital, founded as a Dr. Nacman is Director, Social Work Division, Strong Memorial Hospital, 260 Crittenden Boulevard, Rochester, New York 14642. This article was adapted from a presentation made at the ffiieth-anniversary celebration of the Sodal Work Division of the Strong Memorial Hospital, Febmaty 2 6 2 7 , 1976 Soeinl Work in Health Care.Vol. 2(4), Summer 1977 @ 1977 by The Haworth Reas. All right8 reserved.
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Revolutionary War military hospital, was the first hospital to provide systematized instruction to medical students. Massachusetts General Hospital was opened in 1821, funded more by the state than private philanthropy. The Georgia Infirmary, founded in 1832 in Savannah, and the Lincoln Hospital, founded in 1840 in New York City, served aged and disabled b l a c b 3 By 1840 some hospitals had become specialized and provided care for certain populations or for particular diseases. But the almshouse, in which conditions were appalling, continued to be the primary care facility for the poor. To save the "deserving" poor from the almshouse and to emphasize moral aid over material relief, Robert M. Hartley, in 1841, founded the New York Association for Improving the Condition of the Boor. The movement of children from the almshouses to orphanages and foster homes was pioneered through the New York Children's Aid Society founded in 1853 by Charles Loring Brace.4 Also in 1841, Dorothea Lynde Dix started to crusade for reforms in the treatment of the insane. Her efforts resulted in new and improved facilities for the insane in many states. She persuaded Congress to pass a bill that would have granted public lands to the states on which to locate facilities for the insane, but the bill was vetoed by President Pierce. This action was used as precedent for denying social welfare aid to the states until the 1 9 3 0 ~ . ~ The expansion of industrialization and urbanization following the Civil War added to the growth of poverty and slums. To cope with these problems organizations opposing public relief but providing individual assistance to "deserving" applicants were set up; a State Board of Charities and Corrections in Massachusetts was established in 1863, and by 1867 similar boards existed in sixteen of the thirty-six states. In addition, the Charity Organization came into being, and by 1877 programs were operating in ninety-two cities. THE EMERGENCE OF THE PROFESSIONAL WORKER The ancestry of the contemporary medical social worker may be traced to England where in 1875 Charles Loch was chosen as secretary of the London Charity Organization Society (LCOS). Loch worked with medical practitioners to foster referrals of patients from hospitals and clinics to branch offices of the LCOS for investigation. In 1891 when he testified before the Select Committee appointed by the House of Lards, he suggested that hospitals were operating for the convenience of doctors and not a s needed by the community. But it was not until 1895 that the Royal Free Hospital in London agreed to a threemonth demonstration of the use of an "almoner." The LCOS loaned a staff member for the demonstration. Although the demonstration was considered successful, the hospital did not institutionalize the program, and the
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almoner was withdrawn. The almoner was later returned when two physicians agreed to match funds provided by the LCOS. Within the next decade seven other hospitals appointed almoner^.^ Ida Cannon identified Dr. Elizabeth Blackwell as the forerunner of the development of social work for the sick in the United States7In 1853 Dr. Blackwell established a dispensary known a s the New York Infirmary for Women and Children. In 1866 Dr. Blackwell appointed Dr. Rebecca Cole, a black physician, a s "sanitary visitor" for home visiting. Although this appointment was later dropped, in 1890 a gift prov.ided for the employment of a home visitor. In 1874 Dr. Susan Dumock of the New England Hospital reported on volunteer services to deserted wives and unmarried mothers. In 1890 Dr. Dwight Chapin of the New York Postgraduate Hospital secured volunteers to visit children in their homes to report on home conditions and to interpret his instructions to the mother. In 1894 he appointed a female physician to perform this work but later concluded that a trained nurse with "instincts for social service" was neededs In 1889 the Johns Hopkins Hospital and University was opened in Baltimore to provide free services to all, regardless of race or religion. Dr. William Osler, chief of that hospital, established a home visiting program in which medical students learned about the living conditions and personal problems of patients. Dr. Charles P. Emerson, a resident physician of the Baltimore Charity Organization Society (COS) organized a "student b o a r d a t COS. These students visited the homes of COS clients. Historically the two organizations were closely tied since President Gilman of Johns Hopkins had been instrumental in the creation of the Baltimore COS.g In 1903 Dr. Richard Cabot, chief of medicine at the Massachusetts General Hospital in Boston, became acquainted with Dr. Emerson's student program while visiting Johns Hopkins Hospital. Deeply convinced of the importance of social factors, Dr. Cabot set out to introduce a social worker into his clinic. He concluded that a patient's personal difficulties may prove to be the cause and not the result of that person's illness. Miss Garnet Isabel Pelton, who had previously completed nursing training, was appointed to the new position. She was to report to the doctors on the domestic and social conditions of patients, to help patients fulfill doctors' orders, and to provide a linkage between the hospital and community agencies and organizations. In 1906 Ida Cannon succeeded Mrs. Pelton.l0 As a result of these efforts, Dr.T. S. Armstrong, the general medical superintendent of Bellevue and Allied Hospitals in New York City, started a similar program. Mary E. Wadley, a former Bellevue and school nurse, was appointed director of that social service program.ll In 1907 a social work program was established a t Johns Hopkins Hospital. The first social worker to be employed was Helen B. Pendleton, previously a district secretary in the Charity Organization Society. At that time the wards were controlled by the nurses, and the social worker
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was not allowed on the wards. Miss Pendleton resigned after eight months, and for four months the social work program was i n limbo. From August 1908 to August 1909 Helen S. Wilmer Athey, daughter of one of the hospital trustees and a graduate of the Hopkins Training School for Nurses, was employed in the social work position. Miss Athey had previously worked a t COS and at the Henry Street Settlement House in New York City. Margaret S. Brogen, also a graduate of the Hopkins Training School for Nurses, took charge of the program when Miss Athey left the staff. Miss Brogen described the hospital of 1909 as a "small one-story dispensary building with its foul odors, rooms dark and badly ventilated, used by one clinic in the morning and by another in the afternoon, with only one nurse in the whole General Dispensary."12 She went on to recall that records were sparse and could not be sent with the patient from one unit to another. Records were kept in rooms separate from the patient areas. When records were needed by medical or nursing personnel they had to be obtained through the social worker, who was responsible for their safe return. All free medical care had to be approved by the social worker. Confidentiality was not respected. The social worker shared a room that was also used as a storage area for surgical supplies. Social work was begun in hospital settings in the preprofessional era. Nurses were employed in social work positions because they were familiar with hospital organizations and community resources. The role of the hospital social worker was modeled after that of the "friendly visitor," sympathetic to the plight of the patients, but paternalistic and moralistic. Caseworkers were a t first not concerned with the meaning of their participation in the "transaction of giving and imposing."13 Briar concludes that two conflicting ideologies were present a t that time, one representing the intent to alleviate social ills and the other to use social work to protect against changes in the status quo.14 Grinker et al., in discussing the evaluation of the volunteer charity worker, known as the "friendly visitor," note that such social and cultural gaps existed between giver and receiver that often both were frustrated. The giver was frustrated because of the lack of appreciation and the absence of expected results, the recipient because of the lack of opportunity for self-expression and the unwillingness to accept the stipulations required in order to receive what was being given.15By the beginning of the twentieth century i t had become apparent that the dispersing of "charity" by "well-meaning individuals" was not working out well. Leaders of the field concluded that workers required training in the understanding of social problems in order to achieve more discrimination in dispersing charitable funds. While the School of Philanthropy was founded in 1898 to provide formal training for the emerging profession, it was not until 1932 that the American Association of Schools of Social Work adopted a specific social work curriculum policy. In 1917 the National Social Workers Exchange
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was created with specific concern for the establishment of professional standards, the same year Mary Richmond published her book Social Diagnosis.16 This material marked a shift in casework orientation. Richmond's "Concepts of Social Study and Social Diagnosis" emphasized the need for a systematic study of the patient and careful collection of social data. In 1918 Jarrett offered the opinion that many casework situations involved psychiatric problems." In 1922 Richmond redefined casework as being concerned with the conscious development of the individual's personality a s a result of adjustments between the individual and the environment, a definition representing a n assimilation of emerging psychiatric principles and dynamics into casework practice.le' Pollak, in his discussion of cultural factors in social work practice, "~~ speaks of social work operating "in the house of another p r ~ f e s s i o n . Ida Cannon suggests that the ambivalence with which the social work program was approached by hospital authorities a t Massachusetts General Hospital was evidenced in the fact that the program was referred to a s a n "unofficial department" in the hospital's annual report of 1906. Funds for its support were solicited from the personal friends of Dr. Cabot and later from other contributors who heard about the program.*O In 1914 the hospital officially recognized social work activities on the wards, and Ida Cannon was given the title "chief of social services."21But not until 1919 was it possible to provide continuity of social work service from outpatient to inpatient unit. On October 14, 1919 the trustees voted to make the Social Services Department an integral part of the hospital. In 1918 in Kansas City the American Association of Medical Social Workers was formed, signifying the nationwide expansion of social work into health settings. In the same year the American College of Surgeons initiated the first National Hospital Standardization Program. In 1920 the American Hospital A ~ s o c i a t i osponsored ~ the first formal survey of hospital social services, making recommendations that led to the formation of a committee on Training for Hospital Social Workers. Antoinette Cannon, the executive secretary of that committee, formulated the original statement of essentials of medical social work and recommended full education for this group. She had been director of social work a t the University Hospital in Philadelphia from 1910 to 1921, when she joined the faculty of the New York School of Social Work.22 From 1920 to 1930 social work programs were started in the army, navy, and Veterans Administration. The Federal Emergency Relief Act of 1933 and the Federal Security Act of 1935 created a demand for medical social workers. Social work services were also included as part of the Federal Crippled Children's Services. In 1925 Dr. Faxon, when opening the Strong Memorial HospitaL University of Rochester School of Medicine and Dentistry, also started a social work program under the direction of Mrs. Ruth T. Boretti. Mrs. Boretti was formerly on the staff of Massachusetts General HospitaLZ3 At the First International Conference of Social Work held in Paris in
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1928, Dr. Cabot presented a comprehensive report on medical social services throughout the world.24 In that same year minimum standards for social service departments were included in the standards for hospitals published by the American College of surgeon^.^^
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THE FOCUS OF SOCIAL WORKERS IN HEALTH SETTINGS Early social workers were caught up in the antituberculosis effort of the early 1900s. They tried to cope with the psychological problems and negative effects of the patient's separation from family for prolonged physical rest that was the prescription of the day. The deplorable condition of factories and workshops led workers to assist in studies to identify hazardous working conditions. Social workers also focused on the problem of syphilis during the time when treatment was required for a prolonged period and social taboos were extreme. Another area of concern was the unmarried pregnant woman. While many social workers shared the moralistic attitude of the time toward this group, some pioneered in the development of an instructive program for these women and worked with community agencies to expand resources. Another concern was children impaired by polio. Strongly influenced by psychiatric theory, Virginia Robinson in 1930 described the social worker as psychotherapist and the therapeutic relationship as the primary casework tool.26The Rankian group led by the faculty of the Pennsylvania School of Social Work advocated "relationship therapy." Although the followers of the diagnostic (Freudian) orientation and those of the functional (Rankian) schools vigorously opposed each other's views and techniques, in retrospect the dispute was not critical to the future of the profession. During the forties, leaders such as Florence Hollis and Gordon Hamilton elaborated on the psychiatric theme with greater appreciation of family dynamics and the influence of one member on another. The goal of casework was to help educate the client in order for that person to take action that was judged by the social worker as advantageous to the client. As in the earlier days the social worker continued to obtain psychosocial information from the patient and family, but by this time the data were used to establish diagnosis and treatment plans. By the forties psychoanalysis was given considerable status by social workers in all settings. Dynamic formulations replaced the labeling of patients in rigid terms. But social workers were so eager to follow this model that the "essential and nuclear role of the caseworker was sometimes lost to the detriment of the field." The psychiatrist became the "ego ideal" for many social workers.27Social, cultural, and environmental factors were considered as secondary to repressed fears and unresolved frustrations. To listen and allow for self-determination was considered pro-
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ductive a s a technique for allowing patients to release feelings. This approach was labeled "dynamic passivity." To some it appeared that the field was doing nothing. In the forties the ultimate aspiration of many psychiatric social workers was to practice "analytically oriented" therapy. Within many general hospitals psychiatric and medical social work programs became divided. Psychiatric social workers proclaimed that their "therapeutic" role was unique. Some were reluctant to be associated with workers assigned to medical-surgical units who, in their opinion, were unsophisticated and engaged only in instrumental tasks. In reality the roles of the social worker in both settings were quite similar. Briar concluded that "the commitment to an essentially psychiatrically oriented casework served to undermine the caseworker's interest in and ability to contribute to change in the social order."*8 In the postwar era social workers such a s Helen Harris Perlman departed from the traditional psychiatric orientation and incorporated social science concepts into casework theo~-y.29Perlman reoriented the worker to the patient's role in society and identified society's contribution to the problems of people. The establishment of the community mental health movement in the fifties also placed greater emphasis on the importance of social and cultural factors in the diagnosis and treatment of psychiatric patients. Social workers trained as community organizers were added to some of these programs, and attempts were made to influence social change.30 A factor that fostered change in psychiatric institutions was the introduction of Maxwell Jones's concept of "milieu therapy."31 Unfortunately, this concept has been slow to take hold in nonpsychiatric hospital settings. Beginning in the fifties and extending into the sixties, group services also became part of the offerings of the hospital social work program. While this development was most apparent in psychiatric settings, there was expansion for medical-surgical patients as well. In pediatric units staff began to work with groups of hospitalized children, and in specialty clinics both children and parents sharing similar problems, usually related to chronic illness, were treated a s a group. In both psychiatric and medical settings family therapy was slowly expanded.32 The fifties represented a period of expansion of casework service into new areas. Tuberculosis and polio were coming under control. Medical care of acute and chronic problems was being infused with the concepts of rehabilitation, particularly for amputees, those with spinal cord injury, and stroke victims. Procedures for heart surgery and transplant surgery were developed, with some recognition of the impact of these procedures on the psychosocial adjustment of patients. Heart disease and cancer were becoming the focal point of national attention. Chemotherapy had been added to the treatment regime of psychiatric patients, and without
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complete awareness of consequences, we had begun a massive emptying of psychiatric hospitals. In the sixties the civil rights and welfare movements emphasized the inequalities that society had produced. We became more aware of the deprivations suffered by some segments of the community and the conspiracy of health and welfare bureaucracies to maintain status quo and control applicant^.^^ During this period many social workers were reawakened to the union of cause and function that had previously concerned Mary Richmond, Ida Cannon, and others. Was social work contributing to the maintenance of the status quo and the pathologies of society? Was casework encouraging clients to accept "realities" that were destructive and could be changed? Cloward, Kahn, Rein, and others challenged us to look a t our practices, to consider a n expanded role directed toward influencing social policy and becoming involved in social action.34 As social workers with graduate training came into the field, professional prerogatives were identified. Social workers no longer waited for referrals but more assertively identified patients and families in need. This approach recognized the importance of initiating social work contact early in hospitalization in order to have time to provide adequate services. Greater emphasis was placed on the establishment of continuity of service between inpatient and outpatient services. But the lack of funding for outpatient care often blocked the achievement of continuity. The advent of titles XVIII and X M of the Social Security Act created even greated demand for social work coverage in hospitals. Medicare (Title XVIII) health insurance for persons over sixty-five years of age brought millions of these individuals into hospitals, and then into extended care facilities. Medicaid (Title XM) provided medical care for the medically indigent under twenty-one and for the permanently and totally disabled, and medically indigent, between twenty-one and sixty-five. The medically indigent over sixty-five were also covered by Medicaid. Social workers played a vital role in working with these populations. WHERE ARE WE NOW? Social workers in the seventies practice a variety of therapeutic techniques including behavior modification, transactional therapy, analytic therapy, ego psychology techniques, crises intervention, and various family treatment models. More emphasis is being placed on preventive programs a s in genetic counseling, family planning, prenatal counseling, sex counseling, and prehospital orientation programs. Expansion of social work coverage into hospital emergency programs has enabled social workers to triage patients into appropriate health and welfare programs within the hospital or the community. Provision of social work services a t the point of crisis has created oppor-
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tunities for intervention a t a time when the situation maximizes the patients' and/or families' potential for involvement in a treatment relationship. The social worker's role a s advocate has done much to protect the rights of patients both within the hospital and in referral to services that they are entitled to in the community. The establishment of a Patients' Bill of Rights has helped to specify what prerogatives patients have within a health setting and what rights the staff must protect. The Patients' Bill of Rights sanctions the advocacy role of the social worker. However, we still have a long way to go in reorganizing the structure and policies of hospitals to protect these rights. Patient and family reactions to complicated procedures such a s transplant surgery, combined chemo-radiation therapy, as well as the potential of death or serious physical or mental disability have opened new avenues for social work practice. Whether in the burn or intensive care unit or the oncology or birth defect clinic, the social worker may provide valuable assistance to staff, patients, and families who face difficult problems and decisions about life and death. In the early part of the twentieth century medical leaders of the stature of Dr. Cabot of Massachusetts General Hospital and Dr. Faxon of Strong Memorial Hospital had been deeply concerned about the complexity of the hospital organization and the medical care system. They believed that these systems lacked individualization and failed to provide humane treatment. Both Dr. Cabot and Dr. Faxon looked to social workers for solutions. Today, some fifty years later, these systems have reached a degree of complexity that would stagger our predecessors. However, we face many of the same problems and threats to humane care that confronted Ida Cannon and Ruth Boretti. We have increased our technological knowledge and created new specialities, but we have failed to achieve continuity of care. Our commitment to treatment after the presence of pathology has distracted from the development of preventive programs. Indifference to patients' psychosocial needs has produced an alienated clientele and the demand for ombudsmen, advocates, and special representatives. In many respects the conservative and reactionary attitudes expressed by politicians, medical groups, and other members of the community represent a reversion back to social Darwinsim. Historically, social Darwinism was used to buttress attacks on social reform and resulted in blind support of the so-called natural law that the "strongest and best" survive.35Unfortunately, in the face of rising costs and limited resources, some politicians, physicians, and hospital administrators have begun to look a t the health care institutions as if they were production systems handling inanimate objects. Many have forgotten or perhaps never recognized the impact of psychosocial factors a s related to the precipitation
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and exacerbation of illness. The system is beset by dehumanizing factors. It has become a constant struggle to preserve the humanism essential to proper patient care. Rhetoric touts the "total treatment" of patients, but psychosocial interventions are often given low priority in federal and state legislation and the programs of health institutions. Too often hospital and medical administrators discount the importance of these factors and thereby establish a negative role model for politicians and the general community. While the need for more precise accountability in relation to cost and quality of care is long overdue, regressive political and social forces must not diminish the humane achievements of Cabot and Cannon. Social workers may abhor statistics and audits, but more precision in accounting for what we purport to accomplish is essential to the future of our profession and our impact on health care. Although the field of social work has been concerned with quality review for many years, relatively few evaluative programs have been formulated and carried out. With the advent of the Professional Standards Review Organization (PSRO), a program created by federal legislation, hospitals are now required to establish Utilization Review to make explicit the necessity for hospitalization and Medical Audit to determine the quality of hospital care rendered. These developments have accelerated the need for developing a methodology for assessing social work performance. PSRO allows social work to establish peer evaluation of our professional performance. If social work does not develop these protocols, less relevant criteria will be imposed by others. In order to ensure that the criteria established by local PSROs recognize psychosocial influences, social workers must become active in these organizations or form coalitions with other nonmedical practitioners capable of putting pressure on these groups. Another major issue confronting social work is the development of programs for the licensure of social work, a means for assuring at least minimal standards for practice and potential for securing reimbursement for services rendered. In the health arena we are experiencing increasing pressure by insurance companies and government to supply assurance as to the qualifications of nonmedical practitioners. Certification and licensure offers these assurances to payers. The development of a more stringent program by the Academy of Certified Social Workers as has been recently under way offers one possibility for solving this licensure problem. Finally, social work must concern itself with the language of proposed national health insurance programs. Unless the role and function of social workers are explicitly established it may become difficult to receive payment for social work services rendered within health organizations and in private practice. Thus far, proposed legislation is either vague or silent about social work.
Martin Nacrnan
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CONCLUSIONS In spite of the initial resistance to the inclusion of social workers a s members of the hospital team in the early 1900s, social work has made enormous progress during the intervening years. Social workers have helped to break down barriers that separated the physical aspects of patient care from psychosocial factors. Social workers have gained access to the political forces that determine hospital policy and have helped to modify programs and policies so that they reflect the needs and rights of patients. Supported by the policy of the National Association of Social Workers, hospital social workers have advocated on behalf of patients and their families. They have assertively challenged the restrictive practices of community organizations that have limited continuity of care. They have helped their patients obtain services to which they are entitled. The late sixties and early seventies have represented periods in which social workers in health settings have ventured into new programs and have expanded the scope of their operations. They have moved into new areas of health care. They have joined research teams and have engaged in research of their own.36 They have protested inequities. They have challenged abuses. They have helped create more responsive environments. Social workers have expanded their therapeutic repertoires. Fiscal problems of federal, state, and local governments will have their impact on the profession. Rising hospital deficits will dictate the availability of funds to support social work staff just as they will have their impact on other staff. Nevertheless, the pressure being placed on hospitals to create effective discharge programs and to justify the reasons for continued stay should increase medical and administrative reliance on social work practice. Although discharge planning is by no means the only area of social work proficiency, it represents a n important contribution to the patient's welfare and the hospital program. I t is a n area requiring sensitive therapeutic techniques. I t often requires a strong advocacy role in order to facilitate the completion of adequate discharge plans. Casework treatment is a n integral part of this process. Consumer pressure, the need to maintain high bed occupancy, and increased litigation are pressing hospital administrations to create programs that are capable of increasing patient satisfaction. Patient satisfaction is linked to patient knowledge, patient understanding, as well a s the preservation of patients' rights. These are areas in which social work staff can make positive contributions. REFERENCES 1. Rubin O'Connor, "American Hospitals: The First 200 Years," Hospitals, Journal of the American Hospitnl Assmiation 50 (January 1. 1976k62-72. 2. Margaret K.Soifer, ed., The Autobiography of Benjamin Franklin (New York: Macmillan Co., 19671, pp. 132-34.
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3. 4. 5. 6.
O'Connor, "American Hospitals." Charles Loring Brace, The Children's Aid Society ofNew York (New York: CAS, 18%). Encvclooedia of Social Work. Dorothea Lvnde Dix. DD. 254-56. B. E. Ltburv.' "Hosoital ~ l m o n i n v :HOG I t All ~ G- a n.. " The Almoner 1, no. 6 ( S ~ D tember, 1948j.' 7. Ida M. Cannon, On the Social Frontier of Medicine (Cambridge: Harvard University Press, 1952). 8. Ibid., p. 273. 9. Ibid., pp. 30-33. 10. Ibid., pp. 48-49. 11. Ibid., pp. 49-50. 12. Margaret S. Brogen, "The Johns Hopkins Hospital Department of Social Service, 19071931." Social Service Reuiew 39 (March 1964):8%98. 13. Roy R. Grinker e t al., "The Early Years of Psychiatric Social Work," Social Service ~ e & w35, no. 2 (June 1961):111126. 14. Scott Briar, "Social Case Work and Social Group Work: Historical Foundations," Encyclo~ediaof Social Work 11. no. 16 (1971k1237-45. . . 15. ~ k n k e er t al., "Early y e a i s of Psychiatric Social Work." 16. Mary E. Richmond, Social Diagnosis (New York: Russell Sage Foundation, 1922). 17. Mary Jarrett, "The Psychiatric Thread Running through All Social Case Work" (Proceedings of National Conference of Social Work, Chicago, 1919), pp. 587-93. 18. Mary E. Richmond, What Is Social Case Work? An Introductory Description (New York: Russell Sage Foundation, 1922). 19. Otto Pollak, "Cultural Factors in Medical Social Work Practice," Journal ofthe American Association of Medical Social Workers 3 (July 1954):81-152. 20. Cannon, Social Frontier of Medicine, pp. 64-66. 21. Ibid., p. 88. 22. Encyclopedia of Social Work, Mary Antionette Cannon (1884-1962), vol. 1 (National Association of Social Workers, 1971), pp. 91-92. 23. The Quarter Century, 1925-1950 (Rochester: University of Rochester, 1950), pp. 32-33. 24. Richard C. Cabot, "Hospital and Dispensary Social Work," Hospital Social Seruice 17 (1928):269-320. 25. Cannon, Social Frontier of Medicine, p. 149. 26. Virginia P. Robinson, A Changing Psychology in Social Work (Chapel Hill: University of North Carolina Press, 1930). 27. Grinker et al., "Early Years of Psychiatric Social Work." 28. Briar, "Social Case Work." 29. Helen H a n i s Perlman, "Social Components of Case Work Practice," in The Social Welfare Forum (New York: Columbia University Press, 19531, p. 12. 30. National Commission on Community Health Services, Health I s a Community Affair (Cambridge: H a n a r d University Press, 1966). 31. Maxwell Jones, The Therapeutic Community (New York: Basic Books, 1953). 32. Nathan W. Ackerman, The Psychodynamics ofFamily Life: Diagnosis a n d Treatment of Family Relationships (New York: Basic Books, 1958). 33. Richard A. Cloward and Frances F. Piven, "The Professional Bureaucracies: Benefit Systems as Influence Systems," in Community Organization Practice, ed. Ralph W. Kramer and H a n y Specht (Englewood Cliffs, N.J.: Prentice-Hall, 1969), pp. 359-72. 34. Ibid.; Alfred Kahn, Issues in American Social Work (New York: Columbia University Press, 1959); Martin Rein, "Social Work in Search of a Radical Profession," Social Work Journal 12, no. 2 (April 1970):13-29. 35. Richard Hofstadter, Social Darwinism in American Thought (Boston: Beacon Press, 19621, pp. 13-66. 36. M. J. Phillippus and M. Nacman, "A Psychosocial and Vocational Follow-up Study of Previously Hospitalized Asthmatic patients," Psychotherapy a n d ~ s ~ c h o s & n a t i c14 s~ (1966) 171-79, Helen Rehr, ' Qunhty and Quantity Assurance Issuer for Socral Serv~ces in Health" (Proceedlnes of Bualrtv Assurance rn Socrol Serurces in Health Prorrnms., Pittsburgh, 'March 31-lpril b, 19j5).
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