Amy Colver, LCSW
Melody Griffith, MSW, LMSW, OSW-C
AOSW Communications Director
Jeanice Hansen, LCSW, OSW-C
To submit a story or information for inclusion in a future issue of AOSW Newsletter, contact Amy Colver or Melody Griffith on the list above.
Consult Etiquette and the Social Work Role in Health Care: Challenging Entrenched Culture
Since the advent of diagnosis-related groups (DRGs) under Medicare, health care has become increasingly regulated. Competition for health care dollars drives the focus on throughput. Health care organizations have flattened their structures, collapsing social work departments into care coordination departments. Departments have been decentralized and later merged with Utilization Review Nurses, and then Nurse Case Managers. Social workers often work alongside nurses, and may also report directly to nursing leadership. The social work voice at the level of hospital administration may be more likely to represent Case Management, with emphasis on the discharge role.
These changes have pushed health care professionals to work within tighter time constraints at the expense of communication and professional consultation etiquette (Rogers, 2010). Social workers have faced the additional challenge of role confusion and role blurring with nurses, patient navigators and even volunteers on the case management side, and with counselors and psychologists in behavioral health settings. Other clinicians may have a limited understanding of our training, and social workers’ schedules and caseloads may not be conducive to offer continuity of care for patients needing ongoing services.
As an example of this confusion about social work roles, the American Counseling Association (ACA) recently retracted a “fact sheet” that mischaracterized the roles of social workers (P. Clark, personal communication, August 22, 2016). The document attempted to differentiate professional counseling from other professions that provide mental health services. Applying Maslow’s Hierarchy of Needs as a model for defining professional jurisdiction, the ACA suggested that counselors and other mental health professionals provide assistance for needs related to love and belonging, self-esteem and self-actualization. Social workers, on the other hand, essentially addressed basic biological needs like access to food and water and needs for shelter. There have been internal struggles over the practice of clinical case management, long held as the standard for social work (Carlton, 1984; Walsh & Manuel, 2015).
Consult etiquette refers to a collection of commonly accepted norms and courtesies guiding the process of consultation. Its premise is that referring clinicians respect the value of the consultant’s expertise, and honor the patient’s relationship with established providers in order to promote continuity of care and reduce duplication in services. While social work may not share the same status as a provider, the concepts are applicable. Reducing the disruption of service in transitions of care from one provider to another promotes continuity of care and quality of care and reduces liability and risk.
Yet another matter to consider from a patient perspective, and perhaps the most important of all, is “telling my story.” This is an important experience for patients, one to be respected and regarded. In some cases, patients share with us accounts of their experiences that are difficult and require courage. We are honored as clinicians by the personal stories patients share with us, and both the telling and the listening are important to the therapeutic process. But there's a caveat: "Telling my story" repeatedly to new listeners is fatiguing and some say even causes harm. We may inadvertently cause a negative experience for a patient when they have told us their story, and later are referred to a different mental health professional and the patient has to tell their story again. One way we reduce harm for patients is through the preservation of established relationships, unless a change is initiated by the patient.
It is possible that few referring providers are really cognizant of that inadvertent and negative outcome of fragmentation in care. In their minds, and in their language, referring for counseling is a positive activity—”It's a good thing, something I can do for my patient.”
There is merit in maintaining a distinct place as practitioners of a role with dual functions that distinguishes social work from other professions, yet how does one consistently define the role within the health care system and gain the understanding of the interdisciplinary team as to the use and scope of this role? Social work itself is not yet united on this concept. Social work positions may vary in their scope; employing institutions may also offer varied challenges and opportunities for social work to address this issue.
Social workers have options to work to change culture and gain acceptance of the roles we inhabit or to accept the culture and allow others to define us. If we are seen as technicians and not clinicians with specialized knowledge, then we are not offered the consult etiquette given to other professionals. Our work with clients is sometimes defined by the concrete tasks over advanced knowledge and expertise.
Social work needs to participate in all of the professional activities of other disciplines. This includes research, teaching, clinical practice and more. Social workers may advocate for this through astute organizational knowledge (Spitzer, Silverman & Allen, 2015). They may collaborate to produce a united definition of services. A shared professional identity can advance the practice of individual social workers who can perceive themselves to be censured when asserting the value of their role in the medical culture. They can also support the professional development and mentorship of less experienced social workers who may find it easier to adapt to institutional dynamics than to productively navigate interprofessional tensions. Group process can also be a vehicle for sharing information that can be compromised due to decentralization of staff and by lack of inclusion in process/program planning as a result of role confusion.
Social workers with voices in leadership and administration are essential to communicate the expertise we offer to patients and all members of the clinical team. We are encouraged to adopt professional development tools as available to other disciplines (e.g., a clinical ladder for advancement) (Blosser, Cadet & Downs, 2010). Social work grand rounds may be a vehicle toward demonstration of clinical competence. Journal clubs where books or articles and role in-services can be discussed is another option.
Individual social workers can actively develop professional relationships with other disciplines and conduct in-services for their teams. Identification of allies in other disciplines—doctors, nurses, and other allied health professionals—is helpful in advancing evidence-based practice. Collaboration with the professionals who share roles with social work is ideal, but requires mutual respect and commitment. Mentors who are seasoned clinicians and have already built strong interdisciplinary relationships can promote the best quality and continuity of care to patients.