The Changing Scene of Social Work in Hospitals:A Report of a National Study by the Society for Social Work Administrators in Health Care and NASW

The need for radical change in the health care field is gaining support. Hospitals are feeling the pressure of hard economic times as decreasing reimbursements, changing service delivery patterns, and increased competition are forcing them to reduce costs while maintaining quality (Cummings & Abell, 1993; White & Simmons, 1993). As hospitals move to create more cost-effective service delivery, significant changes are occurring in the location, structure, and delivery of services. Such terms as "resizing," "rightsizing," "work redesign," "re-engineering," and "restructuring" are a part of the vocabulary in most hospital settings (Berger, 1993; Hammer & Champy, 1993). These changes offer exciting opportunities in primary care, prevention, health promotion, and delivery system innovations. Preliminary information suggests that the effects of these changes are being felt by social work departments in hospitals across the country. Anecdotal reports indicate that departments are being eliminated, decentralized, or enlarged to include other departments. Both the Society for Social Work Administrators in Health Care (SSWAHC) and NASW receive numerous requests for information and assistance in responding to these organizational changes. Although these anecdotal reports are important, there is little rigorous research to substantiate what changes are occurring and the effects of those changes on the quality of social work service delivery and professional social work standards. NASW conducted a preliminary study to explore what was happening to social work departments in hospital settings (Brennan, 1993). The results of this study led to SSWAHC and NASW joining forces to develop a systematic, comprehensive national research project to study the changes occurring in hospitals and the impact of those changes on social work. This article presents preliminary findings from the national study. METHOD An exploratory and descriptive survey design was used to study three key research questions: (1) What changes are occurring in hospital environments and, specifically, social work departments? (2) What strategies are being used to achieve these changes? and (3) What effects have these changes had on social work departments? A standardized, self-administered survey instrument was developed for this study. The instrument was composed primarily of fixed-response questions with a few open-ended questions to explore specific issues in depth. To measure change, many questions asked for comparative data from fiscal year (FY) 1992 and FY 1994. The instrument underwent multiple revisions using a variety of mechanisms to evaluate its ease of completion and content validity. There was no check on reliability conducted before use of the instrument. A stratified, random sample of 750 hospitals listing social work as a service provided within their organizations was drawn from the membership list of the American Hospital Association (3,700 hospitals met this criteria). There were two steps to the sampling strategy. First, hospitals were stratified into five study groups (Table 1). The first four groups were developed according to the degree of managed care development (group 1 = lowest stage to group 4 = highest stage) within a geographic area to study the effect of managed care on changes within the hospital and social work department. These groupings were created by a national consulting firm. A total of 751 hospitals fell within these four groups, from which half of the sample was pulled. Group 5 consisted of the remaining geographic areas not contained within the four managed care groupings (2,949 hospitals) and provided the second half of the sample. The fifth group was weighted toward small and rural hospitals (50 percent of this group) to compensate for the overrepresentation of urban areas in the first half of the sample. The second step was to stratify the study groups according to number of beds (1 to 300,301 to 600, and 601 and greater). …