Understanding how hospital-based social work practice operates
Deirdre Heenan and Derek Birell discuss their research on the complex and multi-faceted professional life of the hospital-based social worker.
Hospital-based social work practice has been in existence in the UK since the late 19th century, when social care professionals were required to assess whether or not people were deserving of treatment. Despite this long historical tradition, their contributions to the sector have long received scant attention. Hospital social workers have multiple roles across a range of domains including education, policy, advocacy and counselling. They provide crucial support to those who are often frail and vulnerable, and take a holistic approach to a person’s needs, by understanding the wishes of the service user and their families.
In the last decade, discharge planning has emerged as a major professional function in hospital settings and represents an integral part of practice. Inefficient and inappropriate hospital discharges are a major policy issue for the design and delivery of health services, yet the contribution of the hospital social worker to this process remains poorly understood. Our research outlined the main roles of hospital-based social workers and identified the key challenges they face working in inter-disciplinary healthcare teams. It concluded that the emphasis on discharge planning and targets has impacted on other more traditional aspects of their role and working in an inter-disciplinary context may have implications for models of social work education. Reducing delayed discharge from hospitals has moved up the policy agenda in the UK. The rationale for this is that a considerable body of evidence suggests that hospital discharge is characterised by poor patient experience, inadequate communication, insufficient collaboration, delay, and inefficiencies.
Whilst this is the case across all user groups, it is particularly true for older people who are major users of health and social services. Longer stays in hospital have a disproportionately negative effect on older people as they quickly lose their strength and mobility. As well as the human cost, this represents poor value for money and places more financial pressures on the NHS. In the UK, social workers are usually identified as the lead professionals in discharge planning. As such, they are charged with supporting the integration of healthcare professionals, overseeing the planning process, and addressing emergent issues in a responsive manner. They take the lead in terms of co-ordinating the process, mitigating the complexity of the system and are responsible for both in-reach within the system and out-reach to other services. Importantly, they are the primary point of contact for service users from admission to discharge. It is generally accepted that although social workers have the ability to bring a unique perspective to inter-disciplinary teams, the dominance of the medical model in this clinical setting can create a number of challenges. Social workers must be professionally assertive to protect their values, identity, and expertise. Inter-disciplinary collaboration in healthcare presents both challenges and rewards for social workers.
Some of the difficulties experienced by social workers working in the healthcare setting relate to retaining their own values, ethics and professional identity. Social workers are also acutely aware of the consequences of austerity and how spending cuts impact their ability to deliver services and interventions. Employers ostensibly look for social workers who are committed to maximising the scarce resources available, rather than ones apparently overtly concerned with social justice. Implementing strategies and protocols aimed at rationing resources and managing budgets can lead to ethical challenges. The social workers involved in our research described their roles as difficult to define as they were wide, and varied. They managed complex family dynamics, usually at a point of crisis whilst working to achieve the best outcomes for their clients. It was described as a balancing act, an attempt to achieve the best outcomes for all concerned. Acting as an advocate for service users and their families was identified as one of their key functions. Respondents stressed that many of the older patients were frightened by the decision-making process and were frequently surrounded by people giving conflicting information and advice. In this context, it was essential to have someone ensuring that service users were fully informed and empowered to make decisions. There was a general agreement that co-ordinating timely hospital discharge plans was a pivotal aspect of the social work role. This involved the development and implementation of a safe discharge plan that ensured the well-being of the patient. Whilst this was an inter-disciplinary activity, social workers were the designated professionals who assumed the primary responsibility for co-ordinating this service.
During our research, it emerged that whilst this hospital-based role was rewarding, it also presented a number of challenges, particularly around discharge processes and inter-disciplinary working. There was a broad agreement that developing and implementing discharge plans had become the overwhelming focus of hospital social work and that this had negatively impacted on other, more traditional aspects of their work. There was often tension between discharge management and what could be described as a more traditional therapeutic role. There was also some frustration at the amount of time spent on the associated bureaucratic and administrative tasks. It was suggested that this was a poor use of resources and the extensive time spent on paperwork negatively impacted on the perception of their role. Overall, inter-disciplinary working was described as successful and there was a recognition from the health care professionals that social workers brought a unique perspective to the team. There was, however, a lack of clarity about their professional identity. Whilst they were described by healthcare colleagues as “the glue” of the inter-disciplinary team, there were also concerns that their skills and expertise were poorly understood.
Hospital social workers remain highly valued by their healthcare colleagues, however in a system under pressure, tensions between the staff could quickly emerge. Complex psychosocial assessments can be time-consuming and result in delays to the discharge process, which put the working relationship under strain. A key theme was the need for joint training and increasing opportunities for health and social care professionals to gain a better understanding of how their skills contributed to a complete systems approach. Differing ideologies between health and social care professionals does sometimes cause unnecessary conflict and friction. Against a backdrop of austerity, and a focus on reducing the length of hospital stays, discharge planning has become the focus with less time available for the psychosocial aspects of health and illness. Little research has been undertaken to assess the roles of hospital-based social workers in this process and what factors enhance or impede their ability to work effectively. Whilst there was a general agreement that this work was rewarding and fulfilling, it could also be emotionally draining.
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Deirdre Heenan & Derek Birell are both Professors of Social Policy at the University of Ulster.