A Longitudinal Look at Social Work Leadership in Hospitals: The Impact of a Changing Health Care System

A growing emphasis on market-driven cost-containment strategies causes changes in the auspices, structure, and delivery of services in the health care system (Lee & Alexander, 1999; Miller, 2000). Most hospitals have restructured to achieve flatter organizational frameworks by eliminating professionally defined departments such as social work, nursing, and physical therapy. Many have moved to a more service line approach or to more integrative structures (Berger et al, 1996; Berger, Robbins, Lewis, Mizrahi, & Fleit, 2003; Edwards, Cooke, & Reid, 1996; Ginzberg & Keys, 1995; Globerman & Bogo, 1995; Globerman, White, Mullings, & Davies, 2003; Rosenberg & Weissman, 1995). Hospital management focuses as much, if not more, on fiscal accountability than on clinical indicators or quality improvement. In addition, many hospital systems have seen a significant reduction of inpatient beds, the separation of profit-making specialty centers such as renal dialysis from the overall hospital structure, and a shift to ambulatory care. In 1994 the Society of Social Work Administrators in Health Care and the National Association of Social Workers commissioned a national study to examine the effect of changes in the health care arena on hospital social work roles, structure, and practice. It was designed to identify critical issues facing social work leaders in those systems over that decade, specifically, the mechanisms and strategies they used and anticipated using to respond to actual and anticipated changes. We reported on findings in 1996 based on responses from the first cohort of hospital social work leaders (that is, managers, administrators, and directors), who reflected on the years 1992-1994 (Berger et al., 1996; Mizrahi & Berger, 2001). This article presents longitudinal data on two additional social work administrator cohorts. It answers the following questions: How have hospital social work leaders viewed their roles over the decade? How have changes in the larger hospital environment affected their roles and functions? Are they optimistic or pessimistic about the opportunities for hospital-based social work in the future? LITERATURE REVIEW Leadership in the social work profession has taken on greater importance in response to social, cultural, economic, and political forces that shape social services provision (Gabel 2001; Menefee, 1997; Rank & Hutchison, 2000). Gellis (2001) explored clinical social workers' perceptions of the leadership behavior of their social work director or leader, by drawing the distinction between transactional and transformational leadership (Bass, 1985; Burns, 1978). Transactional leadership promotes exchanges between leaders and followers; transformational leadership facilitates organizational change toward a new vision of the future. The latter places the emphasis on inspiring and motivating followers to work toward a common organizational goal that may supersede individual interests. To the extent that transformational leadership can be attained in the current climate, social work leaders need to convey to their superiors and their subordinates a positive sense of accomplishments and opportunities. With organizational changes (for example, mergers, downsizing), administrators find themselves balancing an internal and an external focus simultaneously. Whereas some administrators rise above the challenges and continue to provide positive leadership, others may become overwhelmed by the chaos and pressure and turn negative. Still others may attempt to survive by accommodating and adjusting to their environment, exhibiting the traits of the transactional leader (Gellis, 2001). Kerfoot (2000) cautioned that leaders can also become overwhelmed by the day-to-day demands and lose sight of the long-range goals and objectives. She urged leaders to keep their sights on future issues and directions, while simultaneously having a pulse on daily operations (Heifetz cited in Kerfoot). …