Introduction:the Social Work Role
Social Work looks at complex interactions between individuals as patients, their environment outside of the hospital, and the treatment process within the hospital setting.
Social Work recognises that illness and admission to hospital involves adjustment within the individual and within his/her relationships with is outside world.
It also recognises that in the process of admission and treatment in hospital the patient experiences a degree of loss of control and independence,
It is in this context that we take a central role in the hospital goal of fostering the psychological, emotional and social well-being of hospital patients.
We do this by providing a service to the patient and to the organisation.
Our service to patients is in identifying and dealing with psychosocial problems that arise as a result of, or that are contributing to problems in adjusting to the crisis of illness, treatment and hospitalisation. We call this aspect of our service "crisis intervention."
Our service to the organisation is in identifying and dealing with psychosocial problems that hinder the smooth transition of patients through the hospital treatment system. We call this aspect of our service "consultation".
We recognise that these two aspects of our service work together toward the paramount goal of patient well-being. If pychosocial problems are resolved then a smooth transition is facilitated, and conversely, a smooth transition will enhance the patients emotional and social well-being.
When do social workers become involved?
Patients and their families experience the crisis of illness to varying degrees. In responding to this crisis patients experience a range of normal healthy emotional reactions. They draw upon the coping patterns that they have developed through their life experiences, and the internal and external resources that they have available to them. In most cases, these are sufficient to help them to cope and even grow emotionally through their illness experience.
This can be aided by the creation of a hospital environment that enhances patients' ability to maintain control of their own lives, and deal with the situation in their own ways. Social Workers can help the organisation to create this environment by offering information and advice on psychosocial issues.
Sometimes, for a variety of reasons there is a breakdown in the patient's ability to cope with their situation. Psychosocial problems may manifest as interferences to the normal healthy reactions and coping patterns of patients or to the resources available to them. They may also manifest as "blockages" or "hindrances" in effective treatment or discharge, causing delays and various management problems in the ward. Social Workers educate staff to be able to identify where these problems exist so that patients can be appropriately referred for Social Work intervention.
Social Work expertise is in understanding the relationships among the various parts that make up the individual and his/her environment. The exploration of these relationships is called the:
Psychocial Assessment
The Social Worker looks at:
- which parts have problems
- which interaction between the parts have problems
- Which of the problems are the ones which are interfering with our current goals
- what strategies are needed to deal with only the problems which are interfering.
The psychosocial assessment, therefore, involves not only gathering information, but being able to make skilled judgements at each of these stages of the process, as to what further assessment or interventionis required.
The Social Worker will explore any problems related to the
- individual- the patient's emotional reactions and coping patterns and how appropriate and adequate they are for the current crisis.
- environment- the patient's resources and supports, and whether there are problems related to heir family, housing, work, finances, childcare etc.
- organisation- whether there are factors in the hospital treatment process which re resulting in psychosocial problems for the patient eg. where an interpreter is needed but has not been used.
Which interactions between the parts have problems?
Along with their personal effects, patients bring with them into hospital baggage which cannot be seen, which is their own way of seeing things, reactions, behaviour, patterns of relating to their family and others, and issues happening in their homelife. These things may then be played out in the ward, and are further complicated by all the issues of being in hospital- the treatment process, the relationships with staff, the ward environment an so on. The ward experience becomes a part of the patient's world but must somehow incorporate all of the baggage that rhe patient is unable to just leave at the entrance door.
The experience for staff is that they can become somehow unknowingly caught up in all of this baggage without understanding what is happening or how to respond to it.
Staff also need to be aware of their own "baggage" that they bring to work with them, as we are all people who have emotional and social lives outside of he hospital setting.
Which of the problems are the ones interfering with our current goals?
In a hospital setting the goals of the social work role relate to the patients' emotional and social well-being in so far as it impacts on their:
- health and recovery
- treatment plans
- management within the ward
- discharge
The Social Worker will explore how psychosocial issues and the related stress have contribute to the person's illness and ability to recover. In some cases the illness may have a psychological or social basis, and the psychosocial assessment may provide information to help the medical team in formulating a diagnosis.
Information on psychosocial issues may help the medical team in deciding on treatment plans that are appropriate to the person's situation eg. with treatment that requires certain resources such as family support, transport, finances etc. the Social Worker can assess whether these are available.
The Social Worker will explore whether the treatment may result in problems in the patient's family and/or work situation.
The Social Worker may explore situations where patients have not complied with treatment to assess whether there are psychosocial issues contributing to their non-compliance.
Some examples of how information gained in a psychosocial assessment has helped in the management of patients in the ward are:
- A young man post surgery on his jaw was asking for excessive amounts of pethidine. He was referred to Social Work to assess if he had a prior narcotic abuse problem. The Social Worker discovered that on the day of his surgery he had received news of his mother's sudden death, and assessed that his low pain tolerance level was a result of his grief and distress.
- The father of a young child in hospital became aggressive with the medical officer, insisting that the child be discharged, although it was not medically advisable. His wife disagreed with him and an explosive argument developed between them on the ward. The Social Worker was able to establish from the father that within the next two hours he was required to see his mortgager to pay an amount of arrears or the family eould be evicted from the home, and that he felt unable to leave thew child in distress to attend to this. The Social worker was able to negotiate with the mortgager to have the deadline extended.
- A man of Arabic origin was continually insisting in an aggressive manner that he be given a "gatepass" prior to his heart surgery, although this was medically dangerous. The Social Worker was able to reveal that according to his religion there were preparations he needed to carry out in case of his death during surgery, which involved the need for his wife to assist him in shaving his genital area. The ward was then able to arrange for the couple to be given the privacy to carry out these preparations in the hospital, negating the need for a gatepass.
The focus for the Social Worker, and the hospital, is the need for patients to return to their home environment with optimal functioning, and so that readmission is prevented or minimised. Social Workers assist in this by identifying and resolving psychosocial problems that may interfere with the patient's capacity to cope at home, and arranging alternatives for care when necessary.
The psychosocial assessment may reveal problems that do not directly relate to the current goals. These are dealt with by referring to appropriate agencies within the community so that they can be followed up after discharge.
What strategies are needed to deal with only the problems which are interfering with our current goals?
Social Workers within the hospital setting intervene at various levels working with:
- Individual and his/her relationship with family and outside world
- individual staff and teams
- the organisation in the are of policy and procedures
affecting broader numbers of patients.
What do Social Workers do?
Social Workers use a range of types of interventions, including:
1)Individuals and Families
- Psychosocial assessment
- Information and resources
- Referral to services
- Liaison with community services
- Advocacy
- Counselling
- Patient Education
- Groupwork
These "direct service interventions are provided within a model of "crisis intervention". This means that the intervention is in response to an identified crisis in the person's life through which we are helping them to cope and to emerge from the crisis having grown emotionally through increasing their internal and external resources and ability to cope in the future.
It means that there needs to be a clearly identified problem or "crisis" for Social Work to intervene.
Our intervention is brief- we aim to have the maximum effect with the minimum amount of intervention.
The goal of promoting the patient's independence underlies all our work.
2)Individual staff and teams within the hospital
- psychosocial assessment and consultation to assist in the formulation of treatment/discharge plans
- consultation regarding patient management problems
Sometimes providing care for a patient on the ward can be like putting together a jigsaw with some of the pieces missing- some patients just don't seem to fit with the normal ward procedures and ways of doing things. This is often because of all that extra baggage they carry in the form of psychosocial problems. The Social Worker can help to provide the missing pieces by identifying the information that helps the ward to make sense of what is happening. The Social Worker may help the ward to put the "jigsaw" together, by helping staff develop new ways of responding within their own role to that particular patient on the ward.
An example of this was when the mother of a terminally ill child was reacting to nursing staff in a hostle way and complaining about many aspects of the child's care. The Social Worker was able to reassure nursing staff that this was her way of expressing her anger in grief, and the feeling of being out of control, and was not a personal attack on them. The Social Worker worked with the staff to help them to work out more effective ways of responding to the mother's anger such as encouraging her to take on some aspects of her son's care (eg. bathing him), so that she would feel more in control of the process. The Social Worker was also able to provide Nursing Administration with a psychosocial assessment so that any complaints about staff could be considered in an appropriate context.
- staff debriefing
staff debriefing is particularly relevant in wards that are frequently dealing with death and grief, but can also be useful when working with families with particularly complex problems. It recognises that staff are often confronted with their own feelings in regard to particular people and situations.
It recognises that if staff are given an opportunity for these feelings to have a healthy outlet, they will be able to respond to the patient in a way that is more effective. Regular debriefing sessions also give the opportunity for staff to begin to look at patterns that may have develpoed on the ward in response to certain situations, and to explore different ways of dealing with patients. It enables all the staff on the ward to provide input on how the ward copes with patients. It has a positive effect on patients indirectly in that it can help the staff to create an environment that promotes patients' well-being.
- Staff Education
Social Workers can provide staff development sessions on psychosocial issues related to patient care.
Social Workers have input into policy and procedures related to psychosocial issues.
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