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dissertation entitled

Ethical Problem Encountered by Hospital Social Workers

presented by

Jerry L. Clark

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ETHICAL PROBLEMS ENCOUNTERED
BY HOSPITAL SOCIAL WORKERS

bY

Jerry L. Clark

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

College of Social Science

1994

ABSTRACT

ETHICAL PROBLEMS ENCOUNTERED
BY HOSPITAL SOCIAL WORKERS

BY

Jerry L. Clark

The focus of this study was the nature of ethical
problems encountered by hospital social workers. A
naturalistic research design (Lincoln & Guba, 1985) was
used. Six key informants, four directors of hospital social
work departments, two members of the academic community, as
well as twenty informants, all staff hospital social
workers, participated in the study. The sample included
social workers from large, more than 250 beds, small,
between 100 and 249 beds, and very small, fewer than 100
beds, hospitals.

This study identifies the types of ethical problems
encountered by hospital social workers, the individuals and
groups involved in these problems, and the guides used by
hospital social workers in the resolution of these problems.

The hospital social workers encountered a wide range of
ethical problems in their practice. There were several
individuals and groups inside and outside the hospital
involved in these problems. Social workers identified their
own values, the mission of the hospital, and the National
Association of Social Workers code of ethics as guides in

the resolution of these problems.

ACKNOWLEDGEMENTS

I am pleased to thank many people who made the
completion of this dissertation possible. I am grateful to
Dr. John Herrick who chaired this dissertation committee.
His assistance and scholarly guidance were invaluable. I
thank Dr. Janet Bell for assisting in this project in spite
of her own demanding schedule. I am grateful to Dr. Peter
Manning for his scholarly insight, suggestions, and
encouragement. I thank Dr. Linda Nelson. Her close
guidance, criticism, and suggestions were essential for the
completion of this project.

I thank Dr. Diane Levande, Dr. Margaret Bubolz, and Dr.
Gil Green for their assistance, support, and guidance. I
also thank the key informants and the informants who
participated in this study.

I owe a special debt of gratitude to Dr. Jacqueline
Scherer, a scholar, colleague, and very dear friend.
Finally, this project absolutely could not have been
completed without the companionship, encouragement, and

assistance of Penny Clark.

iii

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS .................................... iii

LIST OF TABLES.... .................................. vi

LIST OF FIGURES ..................................... vii
CHAPTER

1 STATEMENT OF THE PROBLEM ..................... 1

Introduction ................................. 1

Focus of This Study .......................... 3

The Need for This Study. ..................... 4

Purpose of This Study... ..................... 8

Definition of Terms.......... ................ 9

Ethical Problems and Dilemmas ........... ..... 9

Hospital Social Worker.......... ..... . ....... 11

Discharge Planning Process...... .......... ... 13

Reflective Practice....... ................... 15

Symbolic Interactionism ...................... 19

2 REVIEW OF THE LITERATURE ..................... 21

Introduction ............. .................... 21

Social Work Ethics and Ethical Problems...... 27

Hospital Social Work....... .................. 32

Discharge Planning ............. ..... ........ 38

The Epistemology Debate in Social Work ....... 42

Symbolic Interactionism ......... . ..... . ...... 46

3 RESEARCH DESIGN ................. . ............ 50

Introduction ....... ..... .................... 50

Elements of the Research Design .............. 53

Focus of Inquiry ............. .... ............ S4

Fit of Paradigm to Focus. .................... 54

Fit of Paradigm to Theory..... ............... 55

Data Collection. ...... ........ ........... .... 56

Successive Phases of Inquiry.. ............... 59

Consent and Confidentiality ..... ..... ........ 60

Instrumentation ............ . ............... 60

Data Collection and Recording ................ 63

iv

Data Analysis Procedure ......................
REPORT OF FINDINGS ...........................

Phase One Findings ...........................
Recognition of Ethical Problems ..............
Recognition of Participants ..................
Who Addresses Ethical Problems? ..............
Guides to Practice ...........................
Very Small Hospitals .........................
Related Ideas That Emerged ...................

Phase Two Findings ............. . .............
Do Hospital Social Workers Encounter

Ethical Problems? ............................
The Range of Ethical Problems Encountered....
Misidentification of Problems ................
The Magnitude of Ethical Problems ............
Who Are Involved? ............................
Addressing Ethical Problems ..................
Guide to Handling Ethical Problems ...........
Personal Values as a Guide ....... . ...........
Intuition as a Guide .........................
National Association of Social Workers

Code of Ethics as a Guide ....................
Professional Training as a Guide ............
Reflective Practice ..........................
Very Small Hospitals .........................

Phase Three Findings .........................
SUMMARY AND CONCLUSIONS ......................
Summary ......................................

Conclusions ..................................
Recommendations ..............................

APPENDICES. ..... . ....................................

LIST OF

Appendix A: National Association of
Social Workers Code of Ethics....
Appendix B: Letter to Hospital Social Work
Directors ........................
Appendix C: Consent ..........................
Appendix D: Letter of Introduction ...........
Appendix E: Interview Protocol ...............

REFERENCES ...................................

63
65

65
65
68
70
70
73
74

79

81
82
88
90
91
93
96
97
98

99
100
104
109

113
114
119
123
125

126

126

135
136
137
138

139

LIST OF TABLES

Table

1 Social Work Area of Responsibility

2 Stated Frequency of Ethical Problems ..........

vi

LIST OF FIGURES

Figure

1 Categories and Subcategories of Data

vii

CHAPTER 1

STATEMENT OF THE PROBLEM

Let us criticize and reform ourselves before
some less gentle and appreciative body takes
us by the shoulders and pushes us into the

streets.
—- R.C. Cabot

(1931, p. 24)
Introduction

Though given over a half-century ago, Richard Cabot's
frank advice to social workers would be relevant if offered
today. It remains true that one of the many obligations
incumbent upon a profession is to monitor and police its
practice and practitioners. Such is the responsibility of
social work.

There are many difficult issues facing contemporary
social work, some of which pose especially serious threats
to the profession. One such area is ethical problems that
arise in the course of practice. Ethical problems are
situations in which a disagreement exists concerning the
right thing to do in a certain situation. Left unaddressed,
or addressed improperly, such ethical problems can result in
the loss of public confidence in the profession -- what,
Specht (1988, p. 9) refers to as social work's "community
sanction." A loss of public confidence would seriously

undermine the professional authority of social work, as well

2

as the profession's ability to respond effectively to social
problems and provide services to its clients.

Nearly all social work practice takes place in a "host
setting," i.e., in settings such as schools, courts and
hospitals, where the primary activity is not the provision
of social work services. They are therefore vulnerable to
that "less gentle and appreciative body" which Cabot tells
us may see social work as an irrelevant activity.

Statement of the Problem

Throughout the history of social work, research on the
profession's knowledge, skills, and values has guided
efforts to enhance its quality and effectiveness. Attention
to its continually expanding knowledge base, its use of a
variety of different practice methods, and its ongoing
epistemology debates are examples of social work's efforts
to become more effective.

Reamer (1993, p. 39) has noted that it is social work's
"persistent embrace of values and a distinctive ethical
framework" which distinguishes it from other helping
professions. The values and distinctive ethical framework
referred to by Reamer are reflected in the National
Association of Social Workers Code of Ethics (Appendix A).

The topic of applied ethics, comprising ethics, ethical
problems, and their role in informing social work practice,

has been a major area of interest and research in social

3
work since the early 19805. The present study developed out
of this interest.
Focus of This Study

The focus of this study is an examination of ethical
problems encountered in social work practice. Specifically,
what is the nature of ethical problems encountered by
hospital social workers?

The identification and resolution of ethical problems
requires a rigorous approach to practice. Reflective
practice is a part of such an approach and will be defined
in this study.

Major contributors to the ethical problems faced by
hospital social workers include rapid technological advances
in the areas of reproductive and neonatal medicine, the
aging patient population, and the increasing number of
people without health insurance. These developments have
created a difficult and complicated practice environment.

In particular, the current problems of providing as well
as paying for health care have highlighted one important
area of hospital social work: discharge planning. Discharge
planning accounts for a substantial segment of social work
practice in contemporary hospitals Volland, 1989).

Discharge planning, refers to the process of planning for
and facilitating the movement of hospital patients through
the hospital system and into an appropriate post-hospital

setting. The result is great pressure on hospital social

4
workers to "make professional decisions in the midst of
complex, urgent and often conflicting demandS" (Kugelman,
1992, p. 59).

In this study several questions will be explored.
First, do hospital social workers in fact experience ethical
problems? Second, who are the individuals involved in
creating ethical problems? Finally, is there an ethical
base or foundation that guides or informs hospital social
workers' practice?

Need for This Study

Throughout the history of the social work profession,
the growing complexity of the practice environment has
brought with it increasingly complex ethical problems. Each
succeeding decade has presented new and different
possibilities for ethical conflict. This is particularly
true in hospital social work for a number of reasons.

First, advances in medical technology have made it
possible to maintain the life of a patient indefinitely.
This has resulted in profound complications in deciding to
withdraw or forego life sustaining treatment, in developing
guidelines for actions to be taken by health care providers
in the event of a patient's cardiac or respiratory arrest,
and in deciding precisely what and how complex medical
information will be provided to patients and families.

Second, financially strained institutions grapple daily

with the issue of uninsured patients. What level and type

5
of care and services for this population are needed,
appropriate, and ethical?

Further complications arise from advances in
reproductive medicine, increasing numbers of hospital ethics
committees, limited resources for organ transplants, and
possible restrictions on access to treatments such as kidney
dialysis.

Hospital social workers are involved in each of these
areas. They work directly with physicians and other members
of the health care team, and with patients and families in
confronting these difficult and complex issues.

Today, the interaction between client and social worker
remains a "fertile ground for unethical conduct by the
social worker" (Levy, 1976, p. 50). Certainly social
workers want to be ethical in the conduct of their practice,
but, as Levy has noted, "they sometimes do not know how" (9.
18). The concern with ethics in social work has shifted
from the morality of the client to the ethics of the social
worker (Reamer, 1980; Trattner, 1974). Because of this
shift, and the competing ethical responsibilities of the
social worker, it is more critical than ever to examine
practice and explore the role of professional ethics,
ethical problems and dilemmas, and the ways in which such
problems are addressed (National Association of Social

Workers, 1990). Reamer notes, "There is significant concern

6

among social workers about the ethical aspects of their
professional conduct" (Reamer, 1980, p. 531).

Because of the diverse nature of hospital social work
practice and the multifaceted problems faced, it is
important that care be taken to ensure appropriate responses
to ethical problems. It is such vigilance, combined with
research about practice, that can yield valuable information
and insight regarding ways to improve the training and
performance of practitioners.

Our contemporary health care delivery system is large,
complex, and expensive. Ethical problems exist within the
system at many levels. These problems have been discussed
in detail by Bogdanich (1991), Rothman (1991), Stevens
(1989), and Wohl (1984). The present study acknowledges
this. The focus of the present study, however, deals with
only one part of this much larger issue.

The implications of this research are substantial and
far-reaching, relating to the fundamental way hospital
social workers are educated, trained, supervised, and
regulated. There are implications, as well, for how they
continue to develop as practitioners.

Research that yields, identifies, or improves effective
and appropriate practice methods is always needed.
Professionals conduct practice research not out of fear of
some less gentle and appreciative body, as Cabot (1931, p.

24) suggests, but because the professional relationship is

7
based upon a commitment to clients, practitioners, and the
organization alike.

Such research cannot be conducted without sensitivity to
epistemology and theory. Both epistemology, the study of
the origin and nature of knowledge, and theory, the
systematic statement of principles involved in an activity,
interface with practice. Epistemology, theory, and practice
interface and overlap. Each influences and is influenced by
the other.

Attention must be given not only to the epistemology of
practice, but to which epistemology serves social work
practice best (Kondrat, 1992). This notion is reflected in
recent calls for a "broader epistemology" in social work
(Imre, 1984) and for attention to "local knowledge"
(Hartman, 1992) and the "many ways of knowing" (Hartman,
1990) which exist in contemporary social work practice. The
conceptual framework for practice research must also be
sensitive to these ideas.

The conceptual and theoretical framework of this
research is based upon a synthesis of reflective practice
and symbolic interactionism -- or more correctly -- an
application of the symbolic interaction perspective through
reflective practice. Reflective practice is an approach
which views each situation as unique, which assumes that
more is unknown about a situation than is known, and which

assumes that the meaning of a problem and its solution

8
involves both the client and the social worker (schon,
1983). Symbolic interaction refers to the branch of social
psychological thought that holds that man is a symbol
creating animal, that through social interaction symbols are
defined and redefined, i.e., given meaning, and that
language serves to convey the meanings of symbols. Key
conceptualizations which have shaped this study are those of
Blumer (1969), Reamer (1979, 1980, 1990, 1993), and Schon
(1983).
Purpose of This Study
The purpose of this study is to examine the self-
reported practice of hospital social workers. There are
three goals. The first is to determine if hospital social
workers encounter ethical problems in their practice.
Hospital social workers encounter a wide variety of problems
in the course of their daily work. These problems may be
characterized in a number of ways such as, administrative,
legal, or logistical difficulties. The focus here is on
those problems the social workers characterize as ethical.
Information about the recognition, nature, and
reconciliation of such problems will be sought.

A valuable sociological perspective with which to
examine the meaning of ethical problems is that of symbolic
interactionism. It is based on the assumption that human
beings seek meaning and create, maintain, and change reality

through social interaction. By examining the meaning of

9
practice decisions from a symbolic interactionism
perspective, it is possible to understand how ethical
problems are identified, interpreted, and reconciled.

The second goal is to determine who are the individuals
that are involved in the ethical problems encountered by
hospital social workers. There are many people involved in
the care of a patient during a hospitalization. Some, such
as physicians and nurses, are directly involved in patient
care. Others, such as hospital administrators and "risk
managers," are often involved in patient care but their
involvement is much less obvious.

The third goal is to identify the ideals or principles
that guide social workers or inform their practice as they
deal with these ethical problems. While the National
Association of Social Work code of ethics is intended as an
aid in this regard, a number of other factors could also
influence practice.

Definition of Terms

There are five concepts that require definition and
some elaboration: (a) ethical problems, (b) hospital social
worker, (c) the discharge planning process, (d) reflective
practice, and (e) symbolic interactionism.
Wm

Ethics in social work are social work values in
operation. Ethics are concerned with what should be done in

practice, and as such "transcend good work and good

10

practice" (Levy, 1976, p. 14). Often, in hospital social
work, what should be done in a particular situation is not

clear. An ethical problem exists when there are a number of
things that should be done and some conflict with others.
Ethical problems center around the right thing to do in a
given practice situation (Loewenberg and Dolgoff, 1992, p.
7).

An ethical dilemma is said to exist when mutually
exclusive moral actions or choices are equally binding. A
frequent ethical dilemma is discussed at length by Bailey
and Brake (1975). It concerns the difficulty practitioners
sometimes have in discerning if an organization hires social
workers to meet the needs of the clients it serves, or to
meet the needs of the organization itself.

The issues of "creation, maintenance, or termination of
life, or the quality of life to be experienced by an
individual" (Reamer, 1985, p. 273) are examples of
situations fraught with the possibility of ethical problems
for the hospital social worker. A problem may be fairly
minor, such as how a hospital social worker addresses an
elderly patient, or as complex as the same patient's desire
to forego life-sustaining treatment. Ethical problems are
thought to be an inherent part of social work practice,
since the social worker must often balance the interests of
client and agency, client and social worker, and even social

worker and social worker.

11
Such problems are rarely obvious and often go
unrecognized. Recognizing the ethical problem is only the
first difficulty. Addressing it is usually more difficult.

The practice arena of the present study, the hospital,
presents substantial opportunities for ethical problems. It
has been argued that an ethicist should be included on the
staffs of teaching hospitals (Walker, 1993, p. 38).
Ideally, the interests of the organization, (e.g. hospital,
third party payers, practicing professionals (e.g.
physicians, nurses, and social workers), and client
(patient) are appropriately and ethically reconciled. This
often is not the case, however, and the resultant problems
pose substantial difficulty for the hospital social worker.
W

Social work in health care has a long history (Bracht,
1978; Hubschman, 1983; Kerson, 1982). Hospital social work
traces its origin to Boston and the Massachusetts General
Hospital at the turn of the century (Cannon, 1923).

In addition to hospitals, there are social work
practitioners in a number of health care settings including
nursing homes, health maintenance organizations, mental
health clinics, dialysis and chemotherapy centers, and home
health care organizations. Such practice diversity led to
the broader concept of medical social worker (Goldstein,
1954). While the concept of medical social worker would

include hospital social workers, it also includes

12
practitioners in the hospital-related arenas noted above.
For the purpose of this study, the more narrow concept of
hospital social worker provides greater precision in
delineating a segment of practice for analysis.

A hospital social worker, as this study defines it,
refers to a social worker who possesses a Master of Social
Work degree and practices within a general hospital setting.
Practitioners in such settings function with physicians,
nurses, and specialists such as physical therapists and
dieticians as members of the health care team. Most often
they engage in generic social work activities such as
patient and family counselling and the coordination of
community resources. Most recently, a significant
responsibility of hospital social workers has been in
addressing special needs related to patient discharge
planning.

The practice of hospital social work was chosen for
examination for three reasons. First, such practice
represents a significant number of practitioners. In 1988
there were 18,685 medical social workers in community
hospitals. This number compares to 13,915 in 1981 (Rakich,
Longest, & Darr, 1992, p. 46). Second, the activities these
practitioners engage in are representative of the
complexities faced by social work practitioners in general.

Finally, hospital social workers constitute a clearly

l3
discernible segment of the larger population of
practitioners.
W

In the past patients came to the hospital when they

were sick and, hopefully, left when they were well.
Hospital length of stay was the concern of very few. Today,
however, for a variety of reasons, the selection of patients
to be admitted to the hospital and the determination of who
will remain have become concerns to many.

Today the average length of stay for patients
(approximately 6 days) is nearly half that of five years ago
(approximately 10 days), and projections are for it to be
nearly half of what it is today five years from now
(Volland, 1989). The level of acuteness of today's hospital
patients has never been higher. Because of stringent
hospital admission criteria, contemporary patients are
sicker upon admission, and sicker upon discharge, than at
any time before. Planning for the orderly and appropriate
movement of patients from entry to exit from the hospital
system presents a difficult task for hospital social
workers.

Discharge planning refers to the process that
facilitates the movement of a patient through the hospital
system and into appropriate post-hospital care. This is the

central focus of many of today's hospital social workers

14

(Beckerman, 1991, p.2). In some hospitals it includes a
broader range of activities than in others. For example, in

some hospitals the discharge planning process is presumed
to begin with planning a patient's testing and diagnostic
workup prior to admission to the hospital. In other
hospitals, discharge planning begins the day the patient is
identified, usually by the physician, as ready for
discharge. At this point, attention is focused on the needs
the patient will have after leaving the hospital
(Schlesinger, 1985). Examples of such needs are durable
medical equipment such as a hospital bed, a bedside commode,
or a walker, and home care, such as a visiting nurse or home
physical therapy.

It should be noted that discharge planning is not the
exclusive domain of social workers. In some hospitals these
activities are performed by nurses, registered nurses, and
licensed practical nurses, and managed most often by a
Utilization Review Department. Another approach to
discharge planning is multidisciplinary. In this approach a
number of different disciplines work together, usually
within a single department, in the discharge planning
process to aid patients and their families in developing a
feasible post hospital plan of care (Volland, 1989).
Regardless of the particular configuration of the discharge
planning process, there is sufficient complexity to afford

the opportunity for reflective practice.

15
MW

Reflective practice, as used in this study, is defined
as follows: An approach to social work intervention guided
not only by the values, skills, and knowledge acquired
through professional education and training, but also by
evaluation and reevaluation of one's practice decisions. A
fundamental assumption of reflective practice is that
social workers do not know more than he or she knows about a
given problem. Social work practice requires precision, but
also flexibility; information, but also inquisitiveness;
clarity, but also reflection. Harrison notes, "Social work
should deliberately examine further and emphasize reflective
processes in its practitioners and students" (1987, p. 403).

Reflective practice represents an approach to practice
articulated by Schon (1983). As with most theories or
methodologies, it is an outgrowth of the work of many
scholars. Argyris & Schon (1974), Boud, Keogh, and Walker
(1985), Colaizzi (1973), and Polanyi (1966) are
representative of these.

Schon (1983) suggests reflective practice is both a
form of practice and an alternative epistemology. As
Opposed to the "technical rationality" of traditional
professional education and training, reflective practice
presumes every problem is unique, fraught with "complexity,
uncertainty, instability, uniqueness, and value conflicts"

(Schon, p. 39). The positivist approach, or a practice

16

template approach, works well in such fields as mathematics
and physics where rationality and laws apply. The role of
technical rationality is more in the "high, hard ground" of
the professional practice topography. The practice arena of
social work lies in the "swampy lowland where situations are
confusing messes" (Schon, 1983, p. 43, emphasis in the
original). Reflective practice is sensitive to such an
environment.

In addition to social work, several fields have adopted
some form of reflective practice. Among them are nursing
(Powell, 1989; Wellington, 1991), education (Kottkamp, 1990,
Osterman, 1990a; Osterman, 1990b), physical therapy (Shepard
& Jensen, 1990), home economics (Vaines, Badir, & Kieren,
1988), medicine (Hewson, 1991), and philosophy (Walker,
1993).

Obviously, since humans are cognitive beings, there is
a certain amount of reflection in all forms of human
behavior. The present discussion assumes this. However,
with regard to social work practice, reflective practice
refers to activity substantially beyond the minimal
reflection involved in usual human behavior.

Reflective practice refers to a questioning approach to
problem solving, rather than approaching problems with
predetermined solutions or answers. Conventional wisdom
views social workers as having solutions to problems and

answers to questions. They are often viewed as "social

l7
mechanics" who have answers and solutions in the event of
"social" breakdown (Rein & White, 1981, p. 7).

There are several elements of reflective practice. It
acknowledges that each problem situation is unique. Persons
whom social workers seek to help have unique life
experiences which necessitate a unique interpretation of
their life circumstances and their problems.

Reflective practice incorporates the client's own
interpretation of the problem and formulation of a response
or solution. Hartman (1992) has noted, "We must enter into
a collaborative search for meaning with our clients and
listen to their voices, narratives, and their constructions
of reality" (p. 484). When the client is present and active
in the intervention, "clientizing" and "imposing a well-
meaning but externally generated set of ideas" (Harrison,
1987, p. 399) are much less likely to occur.

Reflective practice acknowledges that during the process
of intervention, the practitioner may influence and be
influenced by the phenomena with which she or he is working.
Such interaction is unavoidable as problems and solutions
are defined and redefined. It is also highly desirable,
since it aids in the development of "a philosophy of knowing
capable of encompassing all that is human" (Imre, 1984, p.
44).

Reflective practice ultimately results in the

identification of options and choices for the client. The

18
extent to which practice has been reflective may be
indicated in the number and creativity of options
articulated.

Finally, reflective practice acknowledges that there
are times when practitioners will not be able to develop
good solutions to problems, or perhaps no solutions at all.
Given variation in the human condition, sound and enduring
solutions may never be developed. From a reflective
practice perspective, however, there is rarely a situation
in which "nothing can be done." Guidance and direction may
be provided in the absence of solving a specific problem.

In the absence of reflective practice, the patient may
be viewed as irrelevant for both the identification of the
problem and for formulation of a solution. Criticizing
mental health practitioners, sociologist Erving Goffman
(1961) observed that ideally in many hospitals, patients
would leave their social selves at home and send their
physical container in to be repaired.

Reflective practice then, is an approach to practice
that combines the values, skills, and knowledge of
professional training with the experience of the
practitioner. It holds that practice situations, while
sharing certain elements, are fundamentally unique and call
for unique intervention. And finally, it holds that the
problem being addressed those addressing the problem are

influenced, each by the other.

19

There are problems associated with disregarding the
patient's interpretation of his or her situation. When
hospital social workers disregard input from the patient,
dehumanization or "objectification" occurs. Patients come
to be referred to as hospital room numbers or as specific
diagnoses. Worse yet, they are often labelled by such
degrading nicknames as "F.L.K.'s," of Funny Looking Kids"
(i.e. children born with birth defects or some other visible
imperfection), "Gomers" (Get Out of My Emergency Room),
"Frequent Flyers," (homeless or indigent patients who
repeatedly come to emergency rooms for what is often routine
medical care), or even "A head in a bed" (neurosurgery slang
for a paralyzed patient) (Belkin, 1993, p. 32).
Waist

Symbolic interactionism rests on three premises, all of
which have much to do with meaning: first, humans act based
on the meaning things have for them; second, meaning is
derived from social interaction; and, third, meaning is
modified based on things that are encountered (Blumer,
1969, p. 2). Reflective practice is a perspective that fits
well within this framework.

In writing about total institutions, in which all
aspects of one's social functioning are rigidly controlled,
Goffman notes that clients "...typically have statuses and
relationships in the outside world that must be taken into

consideration" (Goffman, 1961, p. 61). General hospitals do

20

not meet the criteria of a total institution, since patients
are free to exercise many choices regarding aspects of their
care. Most basically, they are free to choose whether they
wish to remain hospitalized or not. However, the process of
discharge planning is one during which dehumanization could
easily occur.

Several chapters follow. Chapter two presents a review
of literature relevant to the present study. Chapter three
presents a discussion of the research design. Chapter four
will present the findings of the study. Chapter five
presents a summary of the findings and conclusions, a review
of the problem statement, and suggestions for further

research.

CHAPTER 2

REVIEW OF THE LITERATURE

Introduction

Before the substantive areas of the literature review
are presented, it is necessaryflto understand the contexti
within which contemporary social work practice occurs,
including its vast range of activities and complex nature.
It is precisely this complexity that gives rise to ethical
dilemmas, the mai n focus of this study.

The practice of social workhas never been more
complicated and difficult than it is in contemporary_m
American society. Social problems arevexing and the
configurations of resource systems more tenuous than ever;
Historically, the failure of informal resource systems gave

rise to contemporary socia l_w9rk. Today, the capacity of

formally trained professionals and of institutions to

..-

.....,

respond constructively to social needs is being strained.

_,._ ....._._ ‘_ . L
n .....— h-qa—fl‘m_ ‘7

The environment in which the contemporary social worker
functions derives from a number of interrelated developments
within both the profession and society at large. Following
are brief discussions of some of the major developments.

Wrens:- The early domain of
social work was the settlement house and charity

organization. Today, social work is practiced in every

21

22
segment of our society. In addition to traditional arenas
such as child welfare, mental health, and social service
organizations, it can be found in political, educational,
correctional, and health care institutions. In only a few
decades the focus of social work has broadened from concerns
with charity, pacifism, and suffrage to such complicated
projects as working with women prisoners, the homeless,
hospital bioethics committees, and counselling patients with
the AIDS virus. Another recent expansion of social work
activities is in the area of critical incident response
teams. These are teams of mental health professionals that
respond to crises such as airplane crashes and school
shootings by providing on-the-scene and follow—up services
for those affected by the trauma of such events.

Hospital social work, the focus of this study, is a
particular area of social work that has undergone dramatic
transformation during a period ofsubstantial growth and.
development in the past seventy-five years.‘ ~~“

Hospital social work began in 1905 when,Dr. Richard_C.
Cabot, the Chief of Medicine-at Massachusetts General”

Hospital in Boston, began to employ social workers in_his

outpatient clinic.” A motivating factor for the use of.
social workers was hisbelief that a patient'siflsickness,
fear, worry, and poverty were found inextricably mingled"
(Bartlett, 1975). The early focus of services was on

patients' "domestic and social conditions," their compliance

23

with the physician's orders, and the coordination of patient
needs with community resources (Shevlin, 1983).

Later, medical social workers began to practice inqsuch
health-related arenas as the general hospital, outpatient
mental health facilities, and home health care. Most*
recently, medical social work practice has been established

in health maintenance organizations, employee assistance_

__.‘ ____......~

programs, and independent private_practice.

Wm. It was
recognized that the desire to help and the opportunity to do
so are not the only ingredients for successful social work
practice. As social work entered different arenas and
witnessed unfamiliar phenomena, more had to be learned.
Effective practice therefore required expansion of the
breadth and depth of social work's knowledge and skill base.

In order to maintain its sanction and relevance, the
mission and conceptualization of social work practice has
been altered and refined throughout its history. Social
workers “have produced multiple, shifting images of the
nature of their practice" (Schon, 1983, p. 17), but the pace
of change and breadth of knowledge needed at the end of the
20th century dwarf the knowledge required of social work
pioneers.

The logical outgrowth of an expanded knowledge base is
an expansion of practice skills. Schools of social work

have undergone a metamorphosis in the last half century.

24
Curricula have been reorganized, obsolete courses and
programs dropped, and new and innovative programs added. A
prominent social work text notes thirteen "recognized fields
of practice" (Bloom, 1990, p. 289). Today, however, it is
possible to obtain a specialty or concentration in virtually
any aspect of social work practice.

WW- There are more
social work practitioners today than at any point in the
history of the profession. The United States Department of
Labor reports that in 1990 there were 438,000 social workers
in the United States (United States Department of Labor,
1992, p. 18). In 1983 the number was 407,000 (Bureau of the
Census, 1990, p. 395). While the number of practitioners is
not a major issue in and of itself, numbers can be important
in ensuring a reasonable level of oversight, supervision,
and competence, along with the maintenance of an appropriate
practice environment.

Efforts to regulate practice have resulted in a
hodgepodge of certification, registration, and licensure
measures at the state level. In Michigan this has resulted
in three levels of certification, "certified social worker,"
"social worker," and "social work technician." In addition,
various forms of accreditation within the profession have
evolved, such as, "Diplomate" and "Academy of Certified

Social Workers."

25
W- The service sector

of contemporary society is now confronting the demand

for quality from consumers that the manufacturing sector has
faced for many years. Programs such as Continuous Quality
Improvement, Total Quality Management, and Quality Assurance
are designed to meet heightened expectations for both
quality and efficiency. These programs are in wide use in
hospitals and other practice arenas today.

Continuous Quality Improvement and Total Quality
Management are programs adopted from industry (Rakich,
Longest, and Darr, 1992, pp. 407-442). Such programs
represent a view of quality achievement which is markedly
different from the traditional approach that sought a
certain "standard” or "level" of quality. According to the
traditional approach, once such a standard is achieved, an
acceptable level of quality has been attained. Neither
Continuous Quality Improvement nor Total Quality Management
accepts such a view. In both, the basic assumption is that
the quality of a good or service can always be improved.
When poor quality exists, it is the fault of systems or
processes, not people, since all of those involved in the
production of a good or service want to do a good job
(Oakland, 1989; Walton, 1986).

Quality Assurance programs differ somewhat. These are
programs which comprise "activities designed to assess the

services systematically, to determine whether they comply

26

with what is believed to be adequate services, and to
correct any observed deficiencies" (Coulton, 1979, p. 10).

Demand_fgr_cgst_effectiyeness, Social work services
are often costly. Third-party payers, host settings, and
policy makers alike have a strong interest in social work
practice being as cost effective as possible. There is a
constant demand for social work practice to be fully
productive and not duplicate other services.

T131ning_and_§1tles. Social work practitioners vary
greatly in their level of education and training. Some have
less than a bachelor's degree in any field, while others
have doctoral degrees of one kind or another. Social
workers have a variety of titles, as well. ’While some are
referred to as counselors or psychotherapists, others are
referred to as social service workers, community social
workers, caseworkers, or medical social workers (Levy,
1976).

In addition to these fairly specific issues, there are
a number of broad social problems that contribute to the
difficulty and complexity of social work practice. For
example, the current health care crisis is a national
concern. This is exacerbated by an absence of a public
family policy and a high divorce rate. At the same time,
traditional unemployment persists, with increases resulting
from corporate retrenchment. Add to these conditions the

continuing problems of poverty, racism, decaying inner

27
cities, and an aging society, and it is clear that the
physical and mental well-being of thousands are at risk.
These issues contribute to what Levy (1976) refers to
as the "diffusiveness of the social work profession and the
diversity of its practitioners and their practices" (p. 16).
This complex environment requires all the guidance, support,
and assistance the profession can muster. Ethical
guidelines are a central feature of such support.
Categories of Literature Reviewed
Five categories of literature are reviewed in this

chapter. They are: (a) social work ethics and ethical
dilemmas in social work, (b) the history and development of
hospital social work, (c) the evolution of discharge
planning in hospital social work, (d) the epistemology
debate in social work, its history and current status, and
(e) symbolic interactionism, which aids in the examination
of construction of meaning.
S9Q1a1_H9Ik_EIh19S_ind_E§h1§a1_£LQD1ema

Commitment to a core of values has always been a central
element in the social work profession. In the profession's

formative years, discussions of ethics revolved around the _

_ L _. .L.._,_..V

morality of the earliest clients of social work -- namely,

pauperSI Nearly a century later, in contemporary social_

work, the focus has shifted to_fthe EQESAEFXFQE

...l - —-—WL
..uh-.._ "'

practitioners and debate about the moral nature gfwthem

profession's aims" (Reamer, 1993, p. 39). The years in

28

between saw the development and_ evolution of the Code of

w-. ...—...e... _.

Ethics of the National Association of SocialIWorkerE;

From the mid- 19603 Ito the 19703 there was a significant

effort within the profession to pull together the fairly

at _. ht. D“,—.- u-o. m-

 

wide ranging thinking about social onrk ethics. Among the

”.__— —..——.v~————__' ""'-..__ .

._'-—-~

many contributions to this effort, two are particularly

- .— _.-...——-..~——-

noteworthy.

The first was the establishment of an Ethics Task Force

by the National Association of Social Workers and its 1962

--— ...... --.

development of a brief code of ethics. ThisIcode hasI

'H-r—qfih-

undergone minor revisions a number of times, withImajor_

_ _ _,__ M.
4— --—-.-—-'

revisions in 1967 and 1979. The current edition serves as

«- ~~...__. -me. - -,.- ,c-

"a guide to the everyday conduct of members of the social
work profession" (Nationai Association of Social Workers,
1990, p.Liii).

The second was Charles Levy's (1976) comprehensive book,

fig;ial_flg1&_§tn1g§,, a pioneering examination of how ethics

influence practice. Levy distinguished between ethics in

general and social work ethics, and argued that the social

work profession needed a code o_f ethics to guide practice.

....

His book served as a Ireference and guide for most scholarsI

\ .— H I

who discussed and wrote about social work ethics after his_

N.“

contribution and is still cited often.

_.1 A.“

Interest in applied ethics in health care and hospital

, . ___-r..;— -——-—~___h.._-w __‘

social work grew in the 19803 and 19903. At the same time,

29
interest grew in the subject of ethical problems inIsgciai
“02:1;- 6

Interest in applied ethics, for example, is represented
by Coulton (1990), who researched decision making regarding
life-sustaining and long-termfcare."she described the
elements of such decision making, such as recognition that a
decision is needed, articulation of alternatives, and she ’
showed how this process differs from a "rational" decision-
making model. She also, noted the very short time frame in
which critical decision making takes place (pp. 65-66).
Today's hospital social workers are very much involved in
such decision making.

Abramson (1990) examined the impact of technological
advances on both social work ethics and practice. She notes
three areas that are particularly affected: life support for
terminally ill and elderly patients, reproductive
technologies, and the severely impaired newborn (p. S).

Roberts (1989) examined conflicts arising between the
values of social work and those of medicine. Five areas
where conflict arises were identified. They are: (a) saving
life versus quality of life, (b) patient autonomy, (c)
objective and subjective data, (d) patients with emotional
problems, and (e) interdisciplinary team roles.

Mizrahi and Abramson (1985) also looked at ethical
conflicts by comparing the values of medicine and social

work in relation to: (a) training, (b) perspectives on

30
patient care, illness, and the role of the health care
professional, (c) attitudes toward knowledge and data, (d)
preparation for teamwork, (e) the role of the patient, and
(f) social work's function.

Goldmeier (1984) assessed difficulties of ethical
decisions in health care settings. He described three
different "styles of decision making," or "ethical
orientations": (a) legalistic, (b) antinomian, and (c)
normative (p. 45). The legalistic style is one which
provides the practitioner with "structure, boundary, and
rules" (p. 52). The antinomian style represents the
opposite of the legalistic, in that this approach is
"basically lawless and unprincipled" (p. 54). The normative
style represents an approach between "legalistic" and
"antinomian" styles.

Ethics in social work are reflected in the work of
Reamer (1979, 1980, 1985, 1990, 1993), Rhodes (1986), and
Kugelman (1990). Reamer has written several books and
articles related to different philosophical issues in social
work. His 1993 book, Ine_2h1lgsonhigal_£gnndatigns_of_
Social_flgrk, describes how philosophy, logic, epistemology,
and aesthetics relate to contemporary social work practice.

Reamer's 1990 study, WW,
examined ethical dilemmas in a wide variety of social work
practice situations. It addressed such issues as truth-

telling, informed consent, whistle-blowing, confidentiality,

31

and the limits of professional obligation. Rhodes (1986)
also dealt with ethical dilemmas. He addressed specific
issues such as confidentiality, coercion, bureaucracy, and
empathy. Kugelman (1990) dealt with ethical decision making
by social workers in agency settings. Wells and Masch
(1991) addressed both applied ethics in social work and
resultant ethical dilemmas.

Loewenberg and Dolgoff (1992) discussed ethical
decisions and ethical dilemmas in social work practice,
including problems of ethical choices, guidelines for
ethical decision making, ethical dilemmas in private
practice, and professional codes of ethics.

Despite considerable discussion of ethical dilemmas in
social work, there has been relatively little discussion of
ethical problems faced by hospital social workers.
Dissertations by Beckerman (1991) and Levin (1986) and an
article by Blumenfield and Lowe (1987) are notable.
Beckerman's work focused on three issues: the nature of
ethical dilemmas faced by hospital social workers, where
social workers turned when they encountered an ethical
dilemma, and how the dilemmas were resolved. Additionally,
she examined the concept of truth—telling. Levin's work was
more narrowly focused on specific ethical dilemmas regarding
the care and treatment of newborns. Blumenfield and Lowe
proposed a template for analyzing ethical dilemmas that

arise in the process of discharge planning.

32

The present study will contribute to this emerging
literature by focusing on some of the issues previously
examined and expanding understanding of how hospital social
workers deal with ethical problems. It will focus on those
broader ethical problems which do not meet the narrow
definition of a dilemma. Second, it will seek to identify
the ethical base which guides hospital social work.
82W

Hospital social work was one of the earliest specialized
fields to develop in the social work profession as it
emerged at the turn of the century. There is a significant
literature related to this development including Cannon
(1923), Goldstine (1954),

Bartlett (1975), Nacman (1977), Bracht (1978), Kerson (1982)
and Shevlin (1983).

The precise origins of hospital social work are unclear.
Several hospitals and departments claim to have been
pioneers. Massachusetts General Hospital, Bellevue
Hospital, and Johns Hopkins Hospital had hospital social
service components prior to 1910. Massachusetts General
Hospital is most widely credited with establishing and
expanding the role and function of hospital social work.

Richard C. Cabot, a physician and Chief of Staff at the
Massachusetts General Hospital, and Ida M. Cannon, both a
nurse and social worker by training, began social services

at the Massachusetts General Hospital in Boston. Cabot had

33

long recognized the need to address "the whole person" and
not simply their medical condition. He established a
project in his clinics where social services were provided
from 1905 to 1907.

Early in the 20th century Cannon had seen the benefit
of social services during her experience as a home care
nurse. She attended a talk by Jane Addams and was moved to
enter social work. She completed her social work training
and was appointed by Cabot as the "head worker" in 1908
(Bartlett, 1975). They set up shop in a little used
corridor of the clinic, and space was divided using bed
sheets. Social work in the hospital had begun in earnest.

While there were some supporters of social work in the
hospital, most took a wait-and-see attitude toward this
hospital "interloper." It would take years, but strong
allies emerged both within and outside the hospital. In
1919 the Massachusetts General Hospital Board of Trustees
agreed to fund the new Social Services Department. The
social work function would no longer be the financial
responsibility of Cabot, but of the hospital. Social
services became an integral part of the institution.

Over the next 10 to 15 years both Cannon and Cabot
traveled extensively in the United States and abroad to
advocate for programs such as the one they had developed
(Cannon, 1923). During the same period, many visitors came

to Massachusetts General Hospital to see the program.

34

Historically, this was a time of great expansion of
hospitals in the United States. Social services in
hospitals developed at the same pace. Programs and
departments were founded in several cities and universities
soon after the one in Boston. Social work departments were
established at the University of Chicago clinics in 1918 and
at Washington University in St. Louis in 1923 (Bracht,
1978).

As other programs began to emerge across the country,
and in fact around the world, i.e. St. Thomas Hospital in
England, the role and function of hospital social work
evolved. These early developments paved the way for
contemporary hospital social work practice.

One consequence of evolving hospital social work was
that hospital social workers began seeing patients "on the
wards." In the very early days, social workers were
restricted to seeing patients in their own offices. Access
to social work services was limited to the motivated and
ambulatory patient. As restrictions on hospital social
workers' activities were relaxed, social workers would
venture onto the hospital wards in cases when patients were
referred by their physician. Eventually, full access to the
hospital wards signaled a broader acceptance of the role of
social work and allowed for further refinement of duties.

As social workers became active on hospital wards, they

were much more visible and accessible to patients, nurses,

fis-

35
and physicians. By the mid-19303, social workers were
accepted in "teams," along with physicians of different
specialties and other hospital specialists such as
dietitians. The physician served as mentor and leader of
the team (Shevlin, 1983).

Soon social workers were allowed to enter "social
summaries" in the patient's medical chart. By this
documentation, the social worker could identify social
problems contributing to the patient's circumstances and
offer recommendations for their solution (Bartlett, 1975, p.
222).

Early in the 20th century, hospital social workers
began to organize professional groups. The American
Association of Medical Social Workers was established in
1908. At the same time, social work conferences in the
United States, as well as in England, Germany and other
countries, began to discuss this growing segment of the
profession. Education and training requirements for
hospital social work were formalized. Hospital social
workers moved into such arenas as education and research.

The role of the early hospital social worker was modeled
after the "friendly visitor," but was much less
paternalistic and moralistic (Nacman, 1977). In the late-
19th century, Charity Organization Society friendly visitors
would "...investigate appeals for assistance, distinguish

between the worthy and unworthy poor, and above all provide

36
the needy with the proper amount of moral exhortation"
(Trattner, 1979, p. 83). Over the entire development of
hospital social work, its central focus has remained the
patient and his or her social circumstances.

During the 19403, largely because of the influence of
psychoanalysis, two distinct social work departments were
developed in some hospitals. One focused on medical
patients and the other on psychiatric patients. There was a
perception that the skill and training of the medical social
workers were less than that of psychiatric social workers.
The perception is not based on reality since training is
very similar for both groups, but the notion exists in some
settings even today (Shevlin, 1983).

Hospital social work was strongly influenced by forces
within the profession and in society at large during the
19503 and 19603. In 1955 the American Association of
Medical Social Workers combined with other professional
social work to form the National Association of Social
Workers. The consolidation of professional organizations
and the continuing psychiatric and psychoanalytic influence
resulted in hospital social work remaining somewhat adrift
within the larger profession. Perhaps this was due to the
perception that while the roles, goals, and purposes of the
profession in general were becoming clear, those of hospital

social work remained less defined.

37

Changes were taking place in society during this time,
as well. Medicare and Medicaid came into existence with the
passage of the Social Security act and a new population of
patients entered the nation's hospitals. Social casework
was also gaining in popularity and strength. Hospital
social work was influenced by professional debates
concerning such issues as which methods of practice were
most appropriate and the professionalization of social work.

The 19703 and 19803 found hospital social workers
practicing in many varied settings. They began to work with
patients being treated by medical specialists in different
hospitals. They also worked with traditional geriatric and
psychiatric patients. In addition, cardiac, neurological,
oncological, and nephrology patients became part of their
caseloads.

Beyond work with specific patients, hospital social
workers established support groups to assist patients and
their families. These groups included cancer support
groups, psychiatric education groups, and groups that worked
with families who recently experienced the loss of a newborn
or infant. Social workers also saw patients in clinics,
such as pediatric and out-patient clinics.

Finally, besides working in new arenas and increasing in
number, hospital social workers moved into supervision and

hospital administration positions that ultimately led to

38
involvement on hospital committees and related "political"
activities.

These expansions of the hospital social work role and
function introduced a new issue. Social work could and,
some argued, should do everything. This notion was
critically reexamined when the financial crisis of the late
19803 and early 19903 became more apparent. Hospital social
work services, after all, had to be paid for.

The need to preserve professional ethics and goals,
while simultaneously honoring economic reality, is of vital
importance to contemporary hospital social work. The task
facing both hospital social work leaders and hospital
administrators is to craft a role for hospital social work
that is socially responsible, consistent with professional
standards, and economically viable. One arena in which
social work has an important role is in discharge planning.
Discharss_nlannins

Millions of people are discharged from more than 5,000
hospitals in the United States each year (Rakich, Longest,
and Darr, 1992, p. 262). Because hospital discharge is so
common, it is widely believed to be a simple and
straightforward event. It is neither. As Inlander and
Weiner (1991) have noted, "Like everything else associated
with hospitals, [a patient's] leaving is no simple matter"

(p. 165).

39

The literature on discharge planning is substantial.
There are a number of works that address its history (Cabot,
1919; Bracht, 1978; Volland, 1989), current status (Coulton,
Dunkle and Good, 1982, Hubschman, 1983; Volland, 1989),
models for implementation (Reichelt, 1982), and appropriate
domain (Barker, Williams and Zimmer, 1985; Shine, 1983;
Simmons, 1986). In addition a number of periodicals focus
on discharge planning. An example is Qisgha;gg_filanning
(1mm.

Prior to the establishment of social services in the
outpatient department at the Massachusetts General Hospital,
there were activities at that hospital and in hospitals in
England that would today be included under the rubric of
discharge planning. Both Cabot (1919) and Cannon (1923)
would later write about these activities.

Around the turn of the century English mental hospitals
attended to the aftercare needs of their discharged mental
patients. There were also "lady almoners" whose focus was
to "investigate the finances of hospital patients in order
to prevent the hospital from being imposed upon by persons
who were able to pay" (Cabot, 1919, p. xxvi). Visiting
nurses both in America and abroad paid much attention not
only to their patients' physical problems, but additionally
to their "economic, mental, and moral difficulties" (Cabot,

1919, p. xxvii).

40

During the first half of this century, activities that
have become known as "discharge planning" were chiefly the
responsibility of social workers and nurses. Little
attention was paid to discharge planning needs during these
years for a number of reasons. One was that such activities
were not held in very high esteem. At the same time, the
role of nursing was greatly expanding. Then, too, social
work was becoming enamored with the psychoanalytic movement
with the result that attention shifted to various therapies
used in the mental health field and away from discharge
planning.

Attention became strongly focused on discharge planning
in 1965 with the passage of Medicare and Medicaid
legislation. One consequence of these acts was that a
significant number of frail elderly patients were admitted
to the nation's hospitals. Such patients present a number
of problems for the health care system with respect to the
levels of care they should be given. Hospital length of
stay for this population rose and initially, little concern
was expressed.

During the 19703, as health care costs began to mount,
efforts were made which in effect drew attention to the need
for discharge planning. With the Social Security Amendments
of 1972 (PL 92-603), Professional Standards Review
Organization (PSRO) programs were implemented. These were

regional boards staffed with physicians and registered

41

nurses to monitor admissions and care of patients. They
emphasized both prompt treatment and discharge of patients
and post-hospital care. There were some sanctions of
hospitals and physicians included in this in this
legislation. For example, care which required longer
hospitalization than the PSRO deemed necessary was viewed as
poor-quality care, and "quality letters" could be sent to
physicians and hospitals. A certain number of such letters
could eventually bring the physician and hospital under
closer scrutiny. Predictably, such programs had little
effect either on prompt discharge or, by extension, health
care costs.

As a part of the Tax Equity and Fiscal Responsibility
Act of 1982, a Prospective Payment System was enacted
covering Medicare patients. It did away with PSRO programs
in favor of Peer Review Organizations (PRO), and instituted
the Diagnostic Related Groupings (DRG) system. Prospective
payment meant that hospitals would be paid a
predetermined amount for a specific diagnosis made at the
time of a patient's admission, regardless of the actual
length of hospitalization or treatment required. The DRG
system, through which a number of very similar diagnoses are
grouped into a single classification for payment purposes,
was at the heart of the prospective payment program. The
establishment of PROs meant that physicians external to the

hospital could authorize denial of payment for care that was

42
determined to be out of line with established standards of
care (Volland, 1989).

Additionally, hospitals were required to have a
discharge planning component to receive Medicare
reimbursement. In 1984 the Joint Commission on
Accreditation of Hospitals (JCAH), currently the Joint
Commission on Accreditation of Health Care Organizations,
issued guidelines identifying discharge planning as a part
of high quality hospital services. The combination of these
events resulted in discharge planning becoming a hospital
priority.

There is considerable debate regarding the provision of
discharge planning which revolves around two major issues.
The first is which discipline, nursing or social work,
should be responsible for discharge planning. The second is
the extent to which discharge planning activities conflict
or coincide with social work's professional ethics?

As these issues continue to be debated, one fact is
clear: discharge planning, primarily conducted by social
workers, is a prominent feature of contemporary health care.

d t w r

It was noted earlier that a discussion of professional
practice is incomplete unless it includes epistemology.

This is especially true for social work and it is linked to

reflective practice. Social work's epistemological debate

43

has been long and intense and it continues to this day.
What follows is a summary of that debate.

Reamer provided an excellent articulation of the
philosophical foundations of contemporary social work
(Reamer, 1993). He noted that the debate concerning "the
nature, creation, and control" of knowledge within the
profession (Reamer, 1993, p. 120) has often been bitter.
This debate, present from the early years, has intensified
substantially since the early 19803.

While use of the scientific method was not unknown
during the charity organization movement, the best known
early evidence of it can be found in Richmond's Social
Diagnnsis (1917). Abandoning the term "investigation,"
Richmond used "social diagnosis" to signal a more formal,
organized (i.e. scientific) approach to intervention. It
also had "the advantage that from the first step it fixes
the mind of the caseworker on the end in view" (p. 26). The
use by caseworkers of scientific problem solving resulted in
"social diagnosis."

Richmond's approach was scientific and it was heavily
embedded in the medical model. She sought the "etiology"
(p. 442) of social problems. She stressed the importance of
"experiment" (p. 284) and social worker training in the use
of "social evidence" (p. 39). The practice of social
diagnosis, Richmond believed, would become an "adjunct" to

the field of medicine (p. 26). This, one might argue, is

44
the situation in which hospital social work finds itself
today. Richmond's ideas continue to serve as'a foundation
for contemporary social casework.

The use of scientific methods by Richmond and those in
the social survey movement of the early 20th century
contributed significantly to the ability of social work to
do research and bring scientific methods to bear on social
problems. The profession, however, relied on research
training and education based on social science texts, most
notably those of sociology and psychology, until the late
19705 and early 19805.

Commentary within the profession about the nature of
social work research began in earnest with the introduction
of an article by Gordon: "Knowledge and Value: Their
Distinction and Relationship in Clarifying Social Work
Practice" (1965). Discussion of the nature of social work
research and knowledge continued through the 1970s, 19803
and 19903.

Heineman raised serious questions about the research
model used by social work which she found to be based on
logical positivism (Heineman, 1981). Social work, she
argued, had embraced a scientific imperative which was being
abandoned by philosophers of science and social scientists.
This held that fundamental practice-related concepts could
be empirically and quantitatively measured. According to

Heineman, the empirical and quantitative focus resulted in

45

"an overly restrictive paradigm of research." As a result,
"important questions and valuable data go unresearched" (p.
371). Heineman's call for "less restrictive approaches to
research" touched off a protracted, often intense, debate.
While the intensity has diminished, the debate continues.

In response to the assault on logical positivism,
several attempts were made to counter Heineman. Perhaps the
most ambitious response came from Hudson (1982), who
elaborated on his earlier "axioms" that "If you cannot
measure the client's problem, it does not exist" and "If you
cannot measure the client's problem, you cannot treat it"
(Hudson, 1978).

Fischer (1981) also advocated practice strategies which
could be validated empirically. He envisioned a practice
revolution in which practitioners would move toward
empiricism rather than away. He wrote of a "agnentifigallx
based_nractice" (Fischer, p. 200; emphasis in the original)

and a "new breed of social worker" that "systematically
monitors and evaluates progress...grounds practice in
empirically based knowledge...and keeps learning and seeking
more effective approaches to intervention" (9. 205).

The debate during the 19803 consisted of different
positions on which scientific imperative was most
appropriate for social work (Brekke, 1986; Epstein, 1986;
Haworth, 1984; Imre, 1984: Karger, 1983; Peile, 1988).

Logical positivism and empiricism remained at the center of

46
the debate. There was, however, no serious call to abandon
empiricism completely.

What emerged and currently exists is a call for a
"synthesis" of these various approaches (Peile, 1988). The
result would be an approach that retains the best features
of empiricism and incorporates sensitivity to the utility
and benefit of qualitative methods. This results in an
approach to research that values quantifiable phenomena but
recognizes the importance of elements of social work
practice which are not amenable to quantification, such as
its "languages" (Bloom, Wood, & Chambon, 1991). It is an
approach that admits to the "many ways of knowing" (Hartman,
1990) which are in operation in contemporary social work.
The epistemological debate in social work has given rise to
a conceptualization of reflective practice that can serve as
a model for practice as well as research (Harrison, 1987;
Kondrat, 1992; Schon, 1983).
Win

Interest in "individual-group relationships" (Hoult,
1969, p. 302) has been the central focus of symbolic
interactionism. This paradigm evolved through the work of
many scholars, and generated considerable interest between
1920 and 1950 because of the work of a number of
sociologists at the University of Chicago. Between 1950 and
1970, interest in symbolic interactionism diminished as

structural functionalism became the prevailing paradigm of

47
American sociology. During the last two decades, however,
interest in symbolic interactionism has reemerged and grown.

While the major philosophical root of symbolic
interactionism has been traced to the Scottish Moral
Philosophers (Stryker, 1981, p. S), the invention of the
concept has been widely credited to Herbert Blumer. Blumer
is said to have been heavily influenced by the writings of
George Herbert Mead and, in particular, by the ideas Mead
presented in nind1_§§1f_and_figci§tx.(1934). Head's ideas,
especially his conceptualizations embodied in terms such as
"mind," "self," "generalized other," and "significant
other," serve as part of the cornerstone of contemporary
symbolic interactionism.

Head's thoughts developed along with those of Charles
Cooley and William I. Thomas. Other important contributions
include Park's concept of role (Park & Burgess, 1921),
Cooley's notion that society and person are two sides of the
same coin of communication (Cooley, 1962); and Thomas'
assertion that if humans define a situation as real, it is
real in its consequence (Thomas & Thomas, 1928, pp. 565-
567). Taken together, these ideas provide an overview of
symbolic interactionism.

Blumer claimed that "There has been no clear
formulation of symbolic interactionism, and above all, a
reasoned statement of the methodological position of this

approach is lacking" (Blumer, 1969, p. 1). Stryker (1981)

48
has also noted that, "there is no symbolic interactionist
orthodoxy, no single vision of what the framework means" (p.
26).

This does not mean, however, that certain ideas of
symbolic interactionism are not useful in the analysis of
social interaction. Symbolic interactionism represents a
theory, although sometimes a vague and unsystematic one,
that is helpful in analyzing the ways in which people engage
in activities together. A central feature of symbolic
interactionism is the notion of meaning development.
Symbolic interactionism holds that meaning arises in the
process of social interaction and that meanings are, in
fact, social products derived through the activities of
people (Blumer, 1969).

According to Blumer (1969), "The premises of symbolic
interactionism are simple. I think they can be readily
tested and validated merely by observing what goes on in
social life under one's nose" (p. 50). This is no doubt an
overstatement of the ease with which symbolic interactionism
and its features can be isolated and examined. However,
there are elements of symbolic interactionism which may have
utility in the present study. Meaning, self ("1" and "me"),
interpretation, and role are examples of such elements. The
concept of meaning, perhaps the fundamental element of
symbolic interactionism, is of particular interest because

of its relationship to behavior.

49

For example, as social workers go about their discharge
planning activities, as they facilitate the movement of
patients through a complex system, the cooperation of the
patient is essential. In order for such cooperation to
develop, the patient needs to have or develop an
understanding of the meaning of the process.

Similarly, the meaning of an ethical problem is derived
through social interaction. It is possible that when two
hospital social workers confront the same situation, one may
interpret it as an ethical problem, while the other does
not. The same situation has different meanings for each of
the social workers in this example. Symbolic interactionism
can aid in the understanding of meaning formulation in such
situations.

According to symbolic interactionism, "meaning is not
rigidly predetermined" (Vernon, 1978). It occurs, in this
instance, through interaction between the social worker and
patient. This meaning construction often goes unrecognized
and unacknowledged.

This specific inquiry represents a relatively small
part of the overall study and, as such, is necessarily
narrow in focus. In spite of this, the concept of meaning
and how it is developed is one element of symbolic
interactionism that can be a key to better understanding
hospital social work practice and ethical problems

encountered by hospital social workers.

CHAPTER 3

RESEARCH DESIGN

Introduction

Before this study could begin, it was necessary to
obtain approval from the University Committee on Research
Involving Human Subjects (UCRIHS). Approval was granted by
UCRIHS on November 1, 1993 and the study began immediately.

The focus of this study, ethical problems encountered by
hospital social workers, lies in what Schon refers to as the
"swampy lowland" of social work practice topography (Schon,
1983, p. 42). Because the positivist paradigm works best
with phenomena in the "high, hard ground," a naturalistic,
rather than positivist, approach will be used in this study.
The naturalistic paradigm, or "naturalistic inquiry," as
articulated by Lincoln and Cuba (1985) will serve as the
model for this study. Naturalistic inquiry is carried out
in a natural setting. It demands a human instrument that
builds on his or her "tacit knowledge," knowledge that is
intuitive or felt, in addition to "propositional knowledge,"
(Lincoln & Guba, p. 40) or knowledge that can be expressed
in language form. It uses methods of data collection and
analysis that are "appropriate to humanly implemented

inquiry" (Lincoln & Guba, p. 187) such as interviews and

observations.

natural_setting. The term natural setting refers to the
50

 

 

51

context within which a phenomenon occurs. The setting is
important in the analysis of a phenomenon in that all
phenomena "take their meaning as much from their context as
they do from themselves" (Lincoln & Guba, 1985, p. 189).

A_hnman_as_instrnment. The phenomenon under study in a
naturalistic inquiry is indeterminate. The human
"instrument" provides responsiveness and adaptability that
other instruments, such as questionnaires, scales or other
quantitative measures, do not. The human is capable of
functioning simultaneously in the domains of both
propositional and tacit knowledge. With the human
instrument there is also the capacity for clarification,
summarization and the opportunity to explore responses
(Lincoln & Guba, 1985, pp. 193-194).

There are four elements of naturalistic inquiry: (a)
purposive sampling, (b) inductive analysis of data, (c)
development of grounded theory based on the analysis of
data, and (d) projection of next steps in a constantly
emergent design (Lincoln & Guba, 1985, pp. 187-188). Upon
completion of a naturalistic inquiry study, results are
disseminated in the form of a case report.

Enrngsixe_sampling. All sampling is done with some
purpose in mind, such as representativeness and
generalizability. In addition to random sampling, the
preferred type of the positivist paradigm, there are several

types which serve purposes other than facilitating

52
generalization. The sampling mode of choice for
naturalistic inquiry is maximum variation design. The
object of such a sample "is not to focus on similarities
that develop into generalizations, but to detail the many
specifics that give the context its unique flavor" (Lincoln
& Guba, 1985, p. 200). Additionally, "It is based on
informational, not statistical considerations. Its purpose
is to maximize information, not facilitate generalizability"

(Lincoln & Guba, pp. 201-202).
Wate- The inverse of deductive

data analysis, which is used in conventional investigations,
inductive analysis does not begin with a theory or
definitions before analysis or investigation but rather with
units of information that are to be analyzed. These units
of information will subsequently be organized into
categories by a process of coding. There are several
sources of data for a naturalistic study. This study
utilizes data from observational notes, notes made during
the interviews, notes made during transcription, and the
interview transcriptions.

QgyglgQmgnt_gf_g;ggndgfi_§hggry, "Grounded theory, that
is, theory that follows from data rather than preceding them
(as in conventional inquiry) is a necessary consequence of
the naturalistic paradigm" (Lincoln & Guba, 1985, pp. 204-
205). "A grounded theory is one that is inductively derived

from the study of the phenomenon it represents" (Strauss &

53

Corbin, 1990, p. 23). Collection and subsequent analysis of
data pertaining to a particular phenomenon permit the
building of a theory regarding that particular phenomenon.
Grounded theory allows one to begin with a phenomenon to be
studied and "...what is relevant to that area is allowed to
emerge" (Strauss & Corbin, 1990, p. 23). Lincoln and Cuba
(1985) note that "...utilization of grounded theory is
absolutely essential to the concept of emergent design" (p.
208).

Emergent_design, Naturalistic inquiry assumes that
the meaning of phenomena is, to a great extent, contextually
determined. The existence of multiple
realities prevents the development of a design based on only
one (the investigator's) interpretation of reality.
Therefore, the design changes and emerges during the course
of data collection.

The investigator does not, however, "begin empty-handed
and certainly not empty-headed" (Lincoln & Guba, 1985, p.
209). The investigator may well possess much tacit
knowledge about the phenomenon under study which provides
some necessary structure. "As the inquiry proceeds, it
becomes more and more focused; salient elements begin to
emerge, insights grow, and theory begins to be grounded in
the data obtained" (Lincoln & Guba, p. 209).

Elements of the Research Design

There are several elements of a naturalistic research

54
design. These are defined as: (a) determining a focus for
the inquiry, (b) determining fit of paradigm to focus, (c)
determining the fit of the inquiry paradigm to the theory
selected to guide the inquiry, (d) determining where and
from whom data will be collected, (e) determining successive
phases of the inquiry, (f) determining instrumentation, (g)
planning data collection and recording modes, and (h)
planning data analysis procedures (Lincoln & Guba, 1985, pp.

226-249).
Eggn§_gfi_1ngniry. Determining the focus of an

inquiry serves both to establish boundaries for study and to
establish the criteria by which information, i.e. data, will
be included or excluded. Both boundaries and criteria may
be altered at some point during the inquiry (Lincoln & Guba,
1985, pp. 227-228). The focus of the present study is the
nature of ethical problems encountered by hospital social
workers.

Eit_gf_paradigm_;g_figgn§. There is no claim here that
the positivist paradigm is not appropriate for inquiry into
the focus of this study. The important question here is
which approach is most appropriate for this study.

The naturalistic paradigm provides a better fit for the
processes to be examined. There are several reasons for
this. First, the phenomenon under study is represented by a
number of complex and interrelated concepts. Second, this

paradigm allows for investigator-phenomenon interaction.

55

This investigator-respondent—phenomenon interaction allows
the investigator to shift and shift again the focus of
questions as information is gathered, as data collection
evolves. Third, there is a high degree of "context
dependence" associated with the present study. The
phenomena under study may be examined in a number of
settings, such as a classroom or panel discussion. However,
it is the context within which these particular phenomena
occurs that provides the most insight and meaning. Fourth,
the phenomena under study are ones about which respondents
may not be forthcoming. The naturalistic paradigm, in large
measure due to its demand for engagement and observation,
allows the investigator to uncover and evaluate half-truths,
utterances, and even falsehoods obtained during data
collection (Lincoln & Guba, 1985, pp. 229-231).

EL;_g£_p§;§digm_tg_thegry, The theoretical
underpinning for this study, as was noted earlier, is a
synthesis of the theory of reflective practice and symbolic
interactionism. The theory behind both reflective practice
and symbolic interactionism meshes well with the
naturalistic paradigm for two major reasons.

First, reflective practice theory evolved because of a
perceived inadequacy of the positivist paradigm. In fact,
Schon (1983) presents reflective practice as not only an
alternative theory of practice but as an alternative

epistemology of practice as well (p. viii). At times the

56

concept of reflective practice is viewed as only an approach
to practice when, in reality, it is a more complex and
inclusive concept. It represents both a theory of practice,
or "how professionals do what they do," as well as an
epistemology, or "how they come to know what they know"
(Schon, p. viii). Reflective practice, as used in this
study, refers to the broader interpretation of the concept.

Second, a basic tenet of symbolic interactionism is that
meaning is socially constructed and modified. Symbolic
interactionism emphasizes the role of reflection in the
analysis of phenomena and that phenomena are defined and
redefined over time.

Q§;§_lelggtign. It was noted earlier that for the
naturalistic approach, a maximum variation sample is most
useful. Maximum variation sampling results in a sample that
will provide the broadest range of information. Maximum
variation sample is selected and "...expanded until
redundancy with respect to information is reached, at which
point sampling is terminated" (Lincoln & Guba, 1985, pp. 33-
234).

The sample for the present study was somewhat more
purposive. It was selected to insure maximum variation and
included large, small, and very small hospitals. There are
several ways to distinguish between large, small, and very
small hospitals (i.e. number of beds, patient days, number

of employees). For the purpose of this study a large

57
hospital refers to a hospital with 250 or more beds, a small
hospital refers to a hospital with between 100 and 249 beds,
and a very small hospital refers to hospitals with fewer
than 100 beds (Lemrow, Adams, Coffey & Farley, 1990, p.
106).

The American Hospital Association identifies four types
of hospitals: (a) general, (b) special, (c) rehabilitation
and chronic disease, and (e) psychiatric (American Hospital
Association, 1992, p. A5). Respondents were selected from
hospital social workers working in the fifteen general
medical surgical hospitals within the Detroit, Michigan
Primary Metropolitan Statistical Area (American Hospital
Association, 1992).

The practice of hospital social work within general,
medical and surgical hospitals is representative of hospital
social work practice as it is defined in this study. For
that reason special, rehabilitation and psychiatric
hospitals were excluded.

While sample size for a naturalistic study is somewhat
relative, Lincoln & Cuba (1985) have noted "...it is usual
to find that a dozen or so interviews, if properly selected,
will exhaust most available information; to include as many
as twenty will surely reach well beyond the point of
redundancy" (p. 235). The sample for this study comprised
twenty informants. There are eight informants from large

hospitals, eight informants from small hospitals, and four

58
informants from very small hospitals.

In addition, five key informants, such as hospital
social work directors and members of the academic community
with an interest in this area, each with several years of
experience, will aid in the development of an interview
protocol. These key informants offer "familiarity with the
social terrain of interactions, roles, and relationships"
(Walker, 1993, p. 37) that provides fertile ground for the
development of ethical problems.

This required several steps. First, a list of hospital
social work directors in the area was obtained from the
Michigan Chapter of the Society of Hospital Social Work
Directors. From this list four directors from the Detroit
metropolitan area, i.e. the counties of Wayne, Oakland, and
Macomb, were selected and interviewed in the first phase of
the inquiry. Effort was taken to insure the hospitals
selected were representative of the metropolitan area
hospitals. The group included an inner-city hospital and
three geographically varied suburban hospitals. Names of
members of the academic community emerged during interviews
of these directors. As the review of the literature
indicates there is much interest in this area of study.
Members of the academic community added to the diversity of
key informants.

Second, large and small hospitals in the Detroit,

Michigan metropolitan area, i.e., the counties of Wayne,

59
Oakland, and Macomb, were identified and a letter of
introduction (Appendix A) was sent to the director of social
work in these hospitals seeking their participation in this
study. This letter: (a) informed the directors of the focus
of the study, (b) conveyed a sensitivity to how busy they
and their staffs are, and (c) in exchange for their
participation offered to conduct an educational inservice
program for them and their staffs about the results of the
study.

Third, follow-up telephone contact was made to
directors. The purpose of this contact was to solicit
participation, answer questions, and schedule interviews.

W- The present study
consists of three phases of inquiry. They are characterized
as: (a) the orientation phase, (b) the exploration phase,
and (c) the validation phase (Lincoln and Guba, 1985, pp.
235—236).

The orientation phase consisted of interviews of
five key informants. The major purpose of this phase was to
identify what it is that we need to know about the
phenomenon under study. Toward this end six key informants
were consulted. Four of these key informants were directors
of hospital social work departments, representing large and
small hospitals, and two were members of the academic
community with an interest in this area.

Each was given a general overview of the study to date.

60
The starting point for each interview was a single question,
"If you wanted to study ethical problems encountered by
hospital social workers, what information would be important
for you to know?"

At the conclusion of each interview key informants were
asked to recommend another person whom they thought would
have ideas and relevant experience as well as a willingness
to participate. Two key informants were identified in this
manner.

Each key informant was very supportive, shared their
thoughts freely and offered substantial insight. The key
informants' genuine interest in this topic is reflected in
the useful themes that emerged from their interviews. These
interviews were not audio-taped.

Phase two, the exploration phase, consisted of twenty
interviews, eight informants from large hospitals, eight
informants from small hospitals, and four informants from
very small hospitals. These interviews were structured,
used open-ended questions, were audio-taped, and
transcribed. It was during this phase that data concerning
the nature of ethical problems encountered by hospital
social workers and how these problems are reconciled was
obtained. Following phase two, an analysis of the data
obtained was conducted and a preliminary report developed.

Phase three, the validation phase, consisted of

returning to the informants and sharing the preliminary

61

report with them. This phase had two purposes. The first
was to insure that the report had accurately captured the
data provided by the informants and to correct or amend it
as necessary. The second purpose was to validate the report
as being a true and accurate reflection of the informant's
practice experience. At the conclusion of phase three, a
final report was developed.

ggn5gnt_§nfi_ggnjldgnttallty, Consent (Appendix B) was
obtained from each informant. Each respondents was also
given a written introduction (Appendix C). The investigator
transcribed the audio tapes and was the only person to have
access to them. No names, of either informants or
hospitals, were used in the preliminary or final report.
Confidentiality was insured by these processes. The audio
tapes were secured at all times in a locked container. The
audio tapes will be erased and transcripts shredded three
months after acceptance of the dissertation.

Insttnmgntgttgn. Instrumentation in a naturalistic
inquiry is very different than for the positivist paradigm.
Naturalistic inquiry uses the human, i.e., investigator as
the "initial and continuing mainstay" of instrumentation
(Lincoln & Guba, 1985, p. 236). The investigator possesses
"theoretical sensitivity" (Glaser, 1978; Glaser & Strauss,
1967, pp. 46-47; Strauss & Corbin, 1990, pp. 41-47). This
refers to sensitivity to the issue under study as well as

the multiplicity of issues, concepts, and behaviors that may

62
or may not be relevant to the inquiry.

The investigator for this study has fifteen years of
social work practice experience, eleven of which were in the
healthcare field. The benefit of such experience is noted
by Strauss and Corbin (1990): "This knowledge, even if
implicit, is taken into the research situation and helps you
to understand events and actions seen and heard, and to do
so more quickly than if you did not bring this background
into the research." (p. 42). Most recently, he was director
of the department of social work, with a twenty social
worker staff, in large metropolitan hospital. This
experience affords a base of experience and a perspective
from which to explore the issues under study here.

An interview protocol was developed following the
completion of phase one of the inquiry. This protocol
consisted of broad, interactional questions. Specific,
probing questions emerged as the study progressed. Due to
the nature of "emerging design," neither the structure nor
the content of the interview protocol is known prior to
inquiry. The opening question for all informants was, "Do
you encounter ethical problems in your practice?"

The present study consisted of one investigator, the
author. While Lincoln and Guba recommend that a team be
used for naturalistic inquiry, exceptions are made "where
resources simply cannot be stretched" to include several

investigators (Lincoln & Guba, 1985 p. 237). This is the

case with the present study.
W- The interviews were

conducted on site, that is in the hospitals where the social
workers practice during November and December, 1993. Care
was taken to insure that the interviews are conducted in an
area that was private and free from excess noise and
distractions.

The main consideration of recording data is its
fidelity. Fidelity refers to the ability of the
investigator to reproduce exactly the data obtained in the
field. Audio recordings do this best and were used in the
present study. While field notes offer less fidelity, they
are less threatening to respondents and help keep the
investigator attuned to the data as they are being offered.
For these two reasons, field notes were used during the
recording and transcription of data in addition to audio
tapes.

Qata_analysls_ptgggdgtg§, Lincoln and Guba (1985)
noted that "Not very much can be said about data analysis in
advance of study" (p. 241). In a naturalistic inquiry
analysis of data, or coding, is conducted using the
"constant comparative method" (Glaser & Strauss, 1967).

The constant comparative method, which was used in
this study, consists of three levels of coding: open coding,
axial coding, and selective coding (Strauss & Corbin, 1990,

pp. 61-142). These levels of coding guide the analysis of

 

flat

as

if.

"'1

64
data. They are sequential and increasingly rigorous as well
as increasingly abstract.

Open coding refers to the initial phase of data
analysis in which data are broken down, examined, compared
and placed into broad categories. Axial coding refers to
the process of putting data back together and making
connections between and among categories. It is during this
process that the categories are more clearly defined and
subcategories are identified. Selective coding refers to a
multi-step process by which data are arranged in "core
categories" systematically related to other categories.

Category relationships were validated against data.

Finally, categories were refined and further developed.

 

CHAPTER 4

REPORT OF FINDINGS

There are lots of things we don't know

about these problems.
(Key Informant #5)

There were three phases of inquiry in this study.
Findings will be presented and discussed for each phase.
Phase One Findings

There were five major findings in this phase of
inquiry. First, it is not clear if social workers recognize
or identify ethical problems when they are encountered.
Second, it is not known, at this stage, who the participants
in these problems are. Third, the approaches to
reconciliation or addressing these problems and the level of
success obtained appears to vary substantially. Fourth, it
was not clear what social workers use for a guide in dealing
with these problems. These findings substantially guided
subsequent phases of inquiry. Phase one culminated in the
development of an interview protocol (Appendix F) to be used
in phase two. The major findings, as well as some related
ideas, are presented and discussed here.

RecQgn1t19n_gt_Eth1gal_Etgtlgms. All of the directors
had considerable staff hospital social work experience. The

general consensus, based on their experience, was that

65

66

hospital social workers do encounter ethical problems in
their practice on a fairly routine basis.

At the same time however, they acknowledged having
little current first hand knowledge of their social workers'
experiences with such problems. Further, they were not
completely comfortable with the knowledge they did have.
Except for those ethical problems brought to their attention
by staff social workers, the directors had little knowledge
of the day-to-day ethical problems their staffs encountered.

They expressed considerable uneasiness about this. One
stated, "I just think I should be in better touch with them
(staff social workers) on this than I am" (Key Informant
36). Another said, "Not only do I get paid to be on top of
these things, I owe it to staff to be closer to it than I
am” (Key Informant #1).

The director's lack of involvement, in the handling of
ethical problems by their staff, was not seen as an ethical
problem in itself. The directors were concerned about the
implications of their lack of involvement for the staff, the
patient, and the organization.

All had spent time "on the floors" with staff as part of
their supervisory responsibilities. As they reflected on
this, they shared some observations. A concern mentioned by
one was that, "Staff social workers often act out of their
own personal ethics rather than professional ethics" (Key

Informant #1). Another said, "Supervisors and managers get

67
involved in ethical problems so line staff do not have to"
(Key Informant #2). One said that as she observed her staff
at work, she recognized, "Lots of ethical problems that the
staff does not identify" (Key Informant #5). Finally, one
stated that in working with her staff, she saw ethical
problems "every day" that the staff did not identify. She
also stated that, "Social workers don't have enough ethics
training" (Key Informant #4).

A related concern, which further illustrates the
complexity of the issue under study, was that hospital
social workers might not recognize problems as being of an
ethical nature. A director noted, "With ethical problems
the direct issue is seldom raised" (Key Informant #1).
Another noted that with ethical problems, "We almost never
see anything happen straightforwardly" (Key Informant #4).

While the social workers might correctly identify
ethical problems, two other interpretations could occur as
well. The social workers might identify problems which were
fundamentally administrative, financial, or logistical, for
example, as being ethical. Or, they might identify
fundamentally ethical problems as being of another nature.

Two steps were taken in response to this finding.
First, the initial question of the interview protocol was
designed in such a way as to elicit information about the
types of problems the social workers encountered. The first

question was, "Have you encountered ethical problems in your

68
practice within the past six months?" Whether answered in
the affirmative or negative, a follow-up question was, "Can
you give me examples of the problems you encounter?"

The responses to these questions provided important
information about the nature and types of problems
encountered. They permitted an assessment of the extent to
which ethical problems are encountered or identified as
such.

A second step was to provide respondents with an
introduction to the study (Appendix E). The purposes of the
introduction were to explain the general focus of the study
to the informants and to explain what an ethical problem is
and provide an example. It was read by the informant prior
to the interview.

ReQQgn1tign_9f_the_£artiginants. Another finding was
that there was little agreement among the key informants as
to who the individuals involved in ethical problems are.
They did agree that at a minimum such problems would involve
the social worker and either a physician, a nurse, another
social worker, or a patient. Other individuals mentioned as
possible participants were other members of the health care
team (e.g. physical therapist), hospital administrators,
hospital attorneys, and patients' family members.

In addition to individuals, some key informants stated
that certain groups might also be a part of ethical

problems. For example, hospital ethics committees and

69
hospital boards such as the board of trustees and the board
of directors were mentioned.

One key informant (#5) stated that "Ethical problems
arise at professional junctures." Professional junctures,
she explained, were "those points at which professionals
disagreed about what the right thing to do is." It is
precisely at this juncture that the divergence of views and
differences of opinion are addressed, confusion is cleared,
and order is negotiated.

This observation brought into focus an issue of concern
throughout the discussion regarding who was involved in
ethical problems. During this discussion key informants
listed the individuals they thought were involved, and all
but one mentioned the patient at or near the end of their
list or did not mention the patient at all. When asked
specifically about the patient as a participant, key
informants responded "of course," and "obviously" the
patient was involved. Thus, it was not so obvious that the
patient was either involved, or perceived by the key
informants to be involved, in ethical problems.

When the patient is mentioned or thought of last, or
not at all by the hospital social worker, does this reveal
anything about the perceived importance or significance of
the patient in a situation with possible ethical dimensions?
To pursue this idea, the second question in the interview

protocol was, "Who are the individuals involved in the

70

ethical problems you encounter?" More specific follow—up
questions explored each individual informant's perception of

the role of the patient, if any, in these situations.

W The notion evolved
from key informants that there is a hierarchy of severity
with respect to the ethical problems they encountered. That
is, some are "routine" (Key Informants #2 & #3), "pretty
common sense stuff" (Key Informant #4), or "a nuisance" (Key
Informant #2). Others are "serious" (Key Informant #3) or
"major" (Key Informant #6). Further, these problems are
addressed at different levels within the hospital based on
their severity. As one key informant (Key Informant #2)
stated, "Routine ethical problems are solved at a low
level." Another noted, "Responsible parties manage more
serious ethical problems" (Key Informant #3).

In order to explore this notion further in phase two,
the third question in the interview protocol was, "Are you
successful in addressing the ethical problems you
encounter?" Follow-up questions were asked to determine if
social workers seek assistance in dealing with these
problems and, if they do, what sources were used. Other
follow-up questions were asked to explore the notion of a
hierarchy of severity.

Gnides_tg_£tattite. All but one of the directors had a
copy of the National Association of Social Workers Code of

Ethics hanging on the wall in their office. The code of

71
ethics, as stated in the preamble, "is intended to serve as
a guide to the everyday conduct of members of the social
work profession" (National Association of Social Workers,
1990, p.11).

As the key informants shared their thoughts about how
social workers addressed the ethical problems they
encounter, another suggestion emerged. The key informants
spoke about how ethical problem solving is often intuitive.
One noted that at times social workers are "acting out of
their gut feelings" (Key Informant #2). Another said that
she often tells her more experienced social workers to
"listen to those gut feelings" (Key Informant #6). Another
observed, "sometimes things just don't feel right" (Key
Informant #1).

All key informants were asked about his or her thoughts
on the role of the National Association of Social Workers
Code of Ethics in their practice and in the practice of
their social workers. One said, "All the code of ethics
does for me is focus the values I already had" (Key
Informant #1). Another said, "The code of ethics is
meaningless" (Key Informant #2). One responded, "There is
nothing in the code of ethics that wasn't taught to me in my
upbringing" (Key Informant #4). These sentiments reflect
the views of some that there are many written, as well as
unwritten, codes that influence or guide human and

professional behavior (Rakich, et al., 1992, pp. 99-143).

72
The general idea emerged that the code of ethics may in fact
play a small role as a guide in dealing with ethical
problems.

Assuming that the code of ethics may not play a
substantial role in guiding social workers as they manage
ethical problems, the key informants were asked what they
thought guided these efforts. Two sources were articulated.

First, "hospital culture" was identified as a strong
influence. This notion of hospital culture is very complex.
One key informant summed it up as follows:

The accepted way of conducting business whether
business is heart surgery or social work.

The mission statement is only the written part,.
there are lots of unwritten rules. Things get done

certain ways, certain things are tolerated and other

things are not tolerated. Community values are a

part of it. Every hospital is different. It's hard

to explain (Key Informant #1).

Responding to this idea another stated, "All the
directors know the mission and values of the hospital."
Further, "Organizational values supersede personal or
professional values...the hospital code takes precedence"
(Key Informant #2).

Second, hospital quality programs (i.e. Total Quality
Management, Continuous Quality Improvement) were identified
as substantial guides to practice. One reason for this,
according to one key informant, was "CQI offers very clear,
very easily understood standards, unlike the code of ethics

that tries to be all things to all people" (Key Informant
#6). She did, however, acknowledge some difficulty thinking

73
of and referring to the patient as a customer. Another
reason that quality programs may guide practice was the
perceived strong organizational support for these programs.
Within the quality discussion, one key informant made the
observation, "good ethics is good business" (Key Informant
#1).

In order to explore this idea further in phase two, a
fourth broad question in the interview protocol was, "What
guides you as you address ethical problems?" Follow-up
questions, as indicated, explored more specific factors
which may guide practice, for example, the law, individual
moral philosophy, or the National Association of Social
Workers Code of Ethics.

There is virtually no limit to the questions that could
have been asked in the study of ethical problems encountered
by hospital social workers. Because of the scope,
resources, and timetable of this study, limits were
required. Based on the information provided by the key
informants, the four broad questions in the interview
protocol and specific follow-up questions provided
substantial information about the focus of inquiry.

Egtx_§m§ll_figstttals. Two key informants noted that
while the distinction between large and small hospitals was
important for this study, another distinction might also be
useful. They proposed including very small (100 or fewer

beds) rural hospitals in the sample.

74

There were two main reasons for the inclusion of very
small hospitals. The first, and most important, was that
the experience of social workers in these hospitals could be
very different from those in the large and small urban

hospitals. Second, inclusion of such hospitals enhanced the

variation in the sample.

W- In addition to the major

findings listed above, other ideas emerged during this phase
of inquiry. One such idea emerged during a discussion about
how health care professionals in general and social workers
in particular approach problems.

We. When the
discussion turned to differences in approaches, one key
informant thought there was a major difference in the
general approach to problems taken by social workers versus
the approach taken by nurses. Her thought was, "Nurses
correct problems, social workers explain them" (Key
Informant #6).

She offered as an example a recent situation she had
observed while on one of the floors working on an unrelated
matter. The situation was one in which a physician had not
met or talked with a patient and family about the results of
an exploratory surgery that he had performed. The patient
and family approached, at different times, a social worker

and a nurse with this problem.

75

According to the key informant the social worker
explained to the patient and family that this physician was
one of only two physicians in the hospital that did these
procedures and was very busy. Further, the physician had a
lot of patients and families to meet with and should be
meeting with them soon. A few minutes later the nurse was
approached. She paged the physician on his beeper. When
the physician returned his call, about five minutes later,
the nurse informed him of the problem. The physician
responded that he had been busy but he had forgotten about
this patient. He informed the nurse that he would be up in
a few minutes to meet with the patient and family.

This key informant noted several of the values that, in
her view, were intended to guide social work practice. She
identified: (a) primacy of clients' interest, (b) respect,
and (c) self-determination. In the approach she described,
some of these values are often not included.

She acknowledged that this problem was not of an
ethical nature and was perhaps minor. It did, however, help
illustrate her idea of how problems are approached.

WWW;- Another
idea was presented by key informant #1. He talked about the
idea of "ethical behavior in an unethical environment." He
noted that today many hospitals are in reality large
corporations. He was certain, based on his experience, that

some high level corporate officials engaged in unethical

76
practices. He spoke of how, "business types are running the
hospitals" and that, "the focus has shifted from taking care
of patients to making money."

These ideas are very similar to those expressed by some
in the field of applied ethics who indicate that a shift in
the balance of power has occurred in today's hospitals.
Power and authority are exercised more by administrators and
less by physicians. Administrators are making decisions
about moral problems that have been traditionally made by
physicians and nurses (Fleck, 1989, p. 3).

To illustrate his idea, the key informant talked of how
some hospitals "buy a certificate of need." When a hospital
plans to provide a new service, such as heart surgery,
obtain a major new piece of equipment, such as a computed
tomography (CT) scanner or magnetic resonance imaging (MRI),
or add to its physical plant, a certificate of need (CON) is
generally required. A CON is issued by the state once it
has been established that there is a need in a given
locality for a given service or equipment. The process is
highly bureaucratic and often takes many months to complete.
The key informant thought that, on occasion, some hospital
representatives influence the process, by financial or other
means, to obtain a CON sooner than is customary or to obtain
one when it would not otherwise be issued.

He also told about hospitals who own their own home

health care organizations, durable medical equipment

77
company, pharmacy, ambulance company and so on. He believed
that it is not necessarily unethical for the hospital to own
these components but that hospital administrators
"encourage" employees, including physicians, nurses, and
social workers to utilize the services offered by the parent
hospital exclusively.

This notion posed an interesting question. What are
the ethical considerations when social workers assist
patients to appropriately access services (i.e. nursing
home, home healthcare, and so on) which may have been
obtained or be operated in an unethical or illegal manner?
This relates to an idea presented earlier. In chapter 1 it
was noted that ethical problems exist within the health care
delivery system at many different levels and that this study
focuses on a very specific segment of this large arena.

Eatlgnt_g§ngmantz§tign. An idea emerged related to
patient dehumanization that was different than the examples
presented in the earlier discussion of the topic. The idea
was articulated that, "the chart becomes the patient" (Key
Informant #5). As this notion was explored this with other
key informants it was noted that, "probably more attention,
care, and certainly human touch is given the chart than the
patient" (Key Informant #6). Another, emphasizing the
practical importance of the patient chart, stated, "the
chart is a documented record of the hospital experience, if

it's not charted, it didn't happen" (Key Informant #2).

78

While not a focus of this study, sensitivity to this idea
was maintained during phase two.

Another idea emerged that combined staffing levels and
workloads. The directors thought that, in general, their
staffing levels were appropriate. When asked specifically
if all the patients referred for social work services
received services, it was found that some did not. The
reasons for this varied; low staffing levels from time to
time and patients being in the hospital for very short
periods of time were mentioned. A number of questions arise
out of these situations. Perhaps most relevant is what are
the ethical implications of social workers not seeing all
patients referred for services? Again, this is not the
focus of this study but it merits attention.

WW1):- The key informants
were both forthcoming and candid in their interviews.
However, there was some concern as to whether informants
would be willing to talk about such a personal topic as
ethical problems they had encountered. The general
consensus, as reflected in a statement by key informant #1
was, "If they trust you." This is consistent with the
naturalistic inquiry idea that informants will be both
candid and forthcoming if they trust the inquirer (Lincoln
and Guba, 1985, p. 256).

The major findings of phase one were incorporated in

the interview protocol. The protocol served as the main

79
guide during subsequent phases of inquiry. The other ideas
discussed above served as part of the broader theoretical

sensitivity that was maintained as the study proceeds.

Phase Two Findings

Twenty informants participated in phase two of this
study. There are two characteristics of the informants that
are noteworthy and should be pointed out before a
substantive discussions of the findings is presented.
First, in total, the informants in this study identified
virtually every unit of the hospital as their major area of
responsibility. The social workers in the small and large
hospitals reported they had responsibility for more than one
unit (See Table 1).

Table 1
WWW

 

Unit Number

 

General medical and surgical
Emergency room

Psychiatry

Geriatrics

Adult intensive care
Oncology

Neonatal intensive care
Child protection team
transplant team

HIV & AIDS

Discharge planning coordinator
Home care

Orthopedics

Dialysis

Hrdhapraraprakamrooaucn

 

80

The social workers in the very small hospitals reported
they were responsible for social work services for the

entire hospital. The social workers worked, for the most
part, in the hospital. However, three reported they also
conducted home visits to patients. These were social
workers working in hospital home care or hospice services.
Second, the minimum hospital social work experience

required for participation in this study was one year. Only
one informant had this minimum amount of experience; most
had several years, some in several different hospitals. The
years of experience ranged from one to twenty years. The

mean was 5.5 years.

 

 

Figure 1
Categories and Sub-Categories of Data
1. PROBLEMS ENCOUNTERED 2. THOSE INVOLVED
a. presence/absence a. professionals
b. range b. family/patient
c. misidentification c. groups
d. magnitude d. hierarchy
3. ADDRESSING THE PROBLEM 4. GUIDES TO PRACTICE
a. approach a. code of ethics
b. responsible parties b. intuition
c. dissatisfaction c. personal values
d. training
e. supervision
f. experience
9. hospital mission
h. quality programs
5. REFLECTIVE PRACTICE 6. INTERACTIONISM
a. situation uniqueness a. framing of issues

b. intuition b. meaning construction

 

81

The first two levels of coding resulted in the
development of categories and sub-categories of data. These
are presented in figure 1.

The third level of coding aids in understanding the
relationship between and among the categories and
subcategories. These relationships will be discussed more
toward the end of the data analysis.

The informants were asked if they had encountered
ethical problems in their practice. Whether their answer
was "yes" or "no" they were asked to give examples of the
problems they encountered in their practice.

We're very pressured in the hospital today in

terms of code status, length of stay, and DRG's.

It puts pressure on everyone in a lot of ways and

I think it brings up ethical problems more than
ever before. (Informant #12)

Whammy
When asked if they encountered ethical problems in their
practice every informant in the study reported that they
did.

WWW. Follow-up
questions about the frequency of encountering ethical
problems yielded a wide range of responses (See Table 2).
Informants said they encountered ethical problems "not
often" (Informant #2), and "somewhat" (Informant #4).
Others said, "they don't happen that frequently" (Informant
#3), and "it doesn't happen that often" (Informant #6).

Still others said they encountered ethical problems

82

"routinely" (Informant #11), "quite frequently" (Informant
#15), "on a somewhat regular basis" (Informant #20), and
"often" (Informants #5 and #12). And, others said,
"frequently" (Informant #13) and "at least weekly"

(Informant #8). Finally, an exchange with one informant

went as follows:

investigator: Do you encounter ethical problems in
your practice?
informant: All the time.
investigator: All the time?
informant: All the time.
(Informant #9)

Table 2

WW5.

 

 

 

Mm Number

often

all the time

not often

somewhat

they don't happen that frequently
it doesn't happen that often
routinely

quite frequently

on a somewhat regular basis
frequently

at least weekly

rahewrekudreHrehan

 

Regardless of the reported frequency of occurrence of
ethical problems, informants were asked to give examples of
ethical problems they had encountered.

Range of ethical problems encountered. The informants
were asked for examples of the types of ethical problems

they had encountered. The range of problems presented was

83
substantial. There were a number of ethical problems
presented as examples. Two clusters of problems emerged.
The first cluster related to the flow of information and a
second related to issues of withholding or withdrawing of
treatment. In addition there were ethical problems not
related to these clusters.

There were several problems related to the flow of
information. This type of problem was characterized by one
informant as "who gets what information" (Informant #6). In
one instance these problems concerned a family member
insisting on withholding information from a patient. "A
family member doesn't want the patient told about the
gravity of his disease" (Informant #11). Or, "Do you tell a
teenager that they are terminally ill if the parents don't
want the child to know?" (Informant #3) A variation on this
theme was told by one informant who worked with a physician,
an oncologist, who often withholds information about the
diagnosis "unless the patient asks" (Informant #11). Citing
a similar situation one informant told of a patient who died
without being told her diagnosis "She was never told of her
diagnosis at the family's request" (Informant #18).

There were other ethical problems related to
information. One informant stated, "I have seen patients be
transferred to a nursing home and not be told until they
arrive there" (Informant #19). Another said, "A lot of

times the family doesn't want the patient to know they are

84
going to a nursing home until the very last day before they
go. Then the family tells the patient, 'You're are going to
another hospital'" (Informant #13).

A final group of ethical problems related to the flow of
information was reported. Informants expressed concern
about not telling "the whole truth" (Informant #11). One
situation has to do with the pain management of a terminally
ill patient. In some cases, a physician tells a family that
because a patient has expressed to him that he did not want
to be in pain, he will increase pain medication as needed.
He informed the family that this will result in the possible
loss of consciousness by the patient. According to one
informant,

What he doesn't tell the family is that the

increase in medication will result in reduction in

cardiac and pulmonary function and the patient will

die. Now the family may not have a problem with

the death, but I have a problem with it not being

fully discussed. (Informant #11)
Related to this "whole truth" concept is the problem one
informant had regarding the obtaining of informed consent.
She said that oftentimes the test, procedure, or treatment
being signed for had not been thoroughly explained. She
reported, "Sometimes this notion of informed consent, a
signature at the bottom of a form, is sort of a joke. I
wonder how informed these people really are. I see that a
lot" (Informant #11).

There were also many examples of ethical problems

related to the withholding or withdrawing of treatment.

85
These problems center either around the treatment staff
desiring to withhold or provide treatment against the wishes
of the patient or family or on the patient or family
desiring to receive or discontinue treatment against the
wishes of the professional staff.

As one informant phrased it, "Sometimes the doctors
don't want to give up, sometimes the families don't want to
give up, and there's a lot of ethical questions about us
continuing treatment" (#12). Another noted, "Sometimes
there are problems between services. For instance,
intensive care staff versus neurology or immunology. One
set of doctors want to keep treating and another set of
doctors want the treatment stopped" (Informant #3).

One informant gave an example that could be considered
typical of this type of ethical problem. She recalled,

A 38-year old patient with multiple sclerosis.

She was married, had two kids, and was in a chronic

vegetative state. The ethical problem centered

around whether or not to surgically insert a

feeding tube. There was a disagreement among the

family as to how to proceed. There was some

disagreement among the treating physicians as to what

to do. (Informant #13)

Similar problems emerged in a situation that involved a
multiple handicapped child and the issue of whether or not
dialysis treatment should be started (Informant #2).

Another informant provided an example of a different
situation:

I've been involved with a dialysis and a cancer

patient who decided to stop treatment. In both
cases the doctors strongly encouraged them to

86

continue. Neither one did. They were both young,
I think that's why the docs wanted to keep trying.
(Informant #19)

In a similar problem, the wishes of the family and not
the patient prevailed. A patient wanted to discontinue
treatment for cancer and go home to die. The family wanted
treatment continued. "The family talked the doctor into
continuing treatment and the patient died in the hospital a
week later" (Informant #12).

One informant reflected on the ethical issues related
to a patient who refused treatment. The patient did not
want to come to the emergency room in the first place but a
neighbor had coerced her. After several hours she left
against medical advice. In trying to isolate the ethical
issues involved in this situation the informant observed,
"We were so focused on healing and helping that we didn't
hear what she was saying" (Informant #19). Another told of
a child being maintained on life support so it could
continue to be in a research project (Informant #1).

A final example related to withholding or withdrawing
treatment involved an infant who was born addicted to crack
cocaine. The child had been raised by a foster parent since
birth. The child became gravely ill as a result of the
problems at birth and the issue of withdrawing treatment
came up. The birth parents were called on to help make the

decision. The informant asked, "What do you do when the

87
foster parent, who loves this baby dearly, has no say in the
decision?" (Informant #3)

Informants also reported encountering ethical problems
that were not related to the issues of information or
treatment. One such situation involved what the informant
called "a gift telephone." A child was to be discharged
home on a lot of monitors and other equipment. One
stipulation of the discharge was that there be a telephone
in the home. When the social worker went out to the home
for a predischarge visit she was informed that no one in the
home could afford a telephone so the mother had a telephone
installed in the name of one of the children. She could not
pay the bill and the phone would be disconnected. She would
have the telephone installed again in another child's name.
The informant said,

The doctors told the Mom that the baby had an apnea

monitor and she had to have a phone in the home.

The mother did what she had to do to have a phone

in the home. I think she was afraid that if she

couldn't provide for the child it would be taken

away by Protective Services. Sometimes you just look

the other way. (Informant #5)

Another informant discovered a parent had continued to
carry one of her children on AFDC (Aid to Families with
Dependent Children) after the child had died. She said,
"This mother had been carrying her dead baby on her ADC card

for over a year. She needed the extra money for survival"

(Informant #6).

88
Ethical problems also involved prejudiced and bigoted

treatment of family members. An informant said she had
heard hospital staff deny a family medication at no cost
because, "She's wearing gold. She's got gold on her neck
and she's begging. Sometimes family members wear gold or
carry beepers" (Informant #5). A similar problem was
encountered by another informant who reported, "Sometimes
the patients and their behavior don't fit the standards of
the staff. You know, maybe white, clean, pleasant, and
cooperative" (Informant #18). Finally, one informant noted,

There is a lot of talk about the ethical problems

connected to sending patients home too early, what

about the ones that we keep too long. I have a
patient right now that we were going to transfer

out to a nursing home about a week and a half ago,

she was doing fine. The family talked the doctor

into keeping her here for a couple of days. The

patient developed a staph infection in the blood

and is doing a lot worse. (Informant #12)

There were several other examples given by informants.
The ones presented here serve to convey the range of ethical
problems reported.

WW. There were three
findings regarding misidentification of problems. First,
social workers tended to characterize most complex,
emotionally charged problems as ethical. During discussion
of these problems they frequently changed their
characterizations. It is significant, however, that these

problems were first identified as ethical. Half way through

the interviews one informant was asked about social workers'

89
identification of ethical problems. When asked if she
thought social workers identified ethical problems she
replied, "Sometimes" (Informant #10). She was correct.
Sometimes they did, but sometimes they did not.

One problem identified as ethical was related to a
family meeting between the treatment team and a family about
a patient's diagnosis and prognosis. As it turns out, five
minutes into his explanation, the doctor discovered he had
been talking about the wrong patient. The informant
characterized this mistake as "totally unethical" (Informant
#13).

Another spoke of how unethical it was to discharge a
competent adult, homeless patient "back to the street. We
wanted him to go to a shelter" (Informant #14). Other
informants, when disagreeing with a doctor's medical
decision to discharge a patient, would characterize such
decisions as unethical.

Second, whether the problems were of an ethical nature
or not, the social worker had substantial difficulty
articulating the ethical tenets involved. When asked how
she knew she was involved in an ethical problem, one
informant said, "When I'm at a loss as to what to do. When
I feel discomfort with a situation. When I'm uncomfortable"
(Informant #7).

Third, informants often used the terms ethical problem

and ethical dilemma interchangeably. The best example of

90

this was presented during a discussion about release of
information. The informant said, "We've had ethical

problems around releasing information which is always an
ethical dilemma" (Informant #19).

We. The focus of this
study is the nature of ethical problems encountered by
hospital social workers and not merely the presence or
absence of them. The idea emerged that the informants view
some ethical problems as being more important than others.
This notion was not articulated but it is reflected in a
number of characterizations used in the discussion of
ethical problems.

When asked to give an example of an ethical problem she
had encountered one informant said, "Oh yes, I can tell you
about a real problem" (Informant #9). Another, reflecting
on a problem she had just remembered, observed, "That's a
real ethical problem" (Informant #12). Referring to an
ethical problem, another stated, " ...it's truly an ethical
problem" (Informant #4). One social worker reported that
the ethical problems she encountered, "..tend to be less
severe, not serious" (Informant #6). Another said, "If it's
a major ethical problem it will be brought to the ethics
committee" (Informant #12). The last example of this was
provided by a social worker who reported, "major ethical

problems, like with our HIV patients" (Informant #2).

91
Few informants could articulate reasons for their
determination of ethical problems as major or minor. One
however, had an idea:
investigator: What makes an ethical problem big or
or little?
informant: What makes it a big deal, from my

experience, is if the hospital is
likely to be sued.

MW? In any
environment ethical problems rarely involve only two
parties. This is certainly true for the hospital setting.
The data in this study indicate that there are usually three
groups involved: health care professionals, patients and
their families, and any of a number of groups within or
outside of the hospital.

Etgtgsslgnals, Professionals, variously referred to as
"the care team," "staff," and "hospital types" are always
involved in ethical problems. One informant said these
problems involved,

The patient or family member, depending on the

problem, the physician, the nurse coordinator, and

myself. Those would be the players. That is how,

on my team, how it gets handled. (Informant #4)

Others reported, "Physicians, the nurse, whoever is defining
the ethical problem, the patient, and me" (Informant #10),
and, "Usually physicians and nurses because they're the most
hands on, the people who interact most with the patient and

family" (Informant #1). One informant, stressing the role

of the patient and family reported, "A lot of patients and

92

family members talk to the doctor and come to some
conclusion" (Informant #12).

919325. The use of the term groups here refers to
committees, departments, and boards within the hospital as
well as agencies in the community. Informants reported that
these ethical problems sometimes involve the ethics
committee (Informants #1, #2, #3, #12, #16, and #20), the
discharge planning committee (Informants #9, #11, and #12),
the utilization review committee (Informants #7 and #16),
the risk management department (Informant #18), and
"administration" (Informants #6 and #19).

In addition to groups within the hospital, on occasion
community groups are involved. Those identified by
informants were Community Mental Health (Informants #5, #18
and #20) and the local Michigan Department Social Services
office (Informants #5 and #19). In addition, one informant
reported an ethical problem related to withdrawing treatment
and "A local right to life group became quite involved"
(Informant #17).

A_hietattny_gt_1nyglygmgnt. In the analysis of the
data related to those involved in ethical problems, an idea
emerged related to the major versus minor ethical problem
idea discussed earlier. That is, there are different levels
at which ethical problems are addressed. According to the
informants, most ethical problems are dealt with at the

staff level. However, dealing with some problems involved

93
the risk management department (usually attorneys), the
chiefs of different medical services, and the highest levels
of administration. One informant reported, "When it becomes
a real hot and heavy ethical issue, it involves the top

doctors and hospital types" (Informant #2).

W. The focus here is on
how social workers deal with the ethical problems they

encounter.

W. The data indicate a number

of approaches in dealing with these ethical problems. Some
are relatively simple and straightforward and involve few
people and a short process. Others are much more complex,
involve many individuals and groups, and require a long
process for resolution.

Whatever the approach, the central player in the
reconciliation of these problems appears to be the
physician. It does not appear that the physician always
decides how a given ethical problem will be addressed.
However, the physician is almost always involved and has
considerable influence in the approach to resolution.

An example of this was reported by an informant who was in
the process of arranging a family meeting to discuss
termination of treatment of a patient. When the informant
talked with the physician about this the physician said,
"The docs will get together on this. I'll let you know what

we'll do tomorrow" (Informant #8).

94

In other instances, the approach is the result of
negotiations among a number of individuals, usually the
social worker, nurse, and physician. Social workers appear
to be rather comfortable in these negotiations. Commenting
on this one informant reported, "It takes some courage, some
confidence, and some credibility to have an impact"
(Informant #12).

Respgnsible parties. After problems are initially
identified as being ethical in nature and attempts to
reconcile are begun, the issue may be redefined. For
example, it may be determined that the problem is actually a
legal problem. One informant reports,

Sometimes you get involved in solving these

problems and you find yourself out of your

element. You have to remember that there are

certain individuals in the hospital whose

responsibility it is to deal with certain

specific kinds of issues. If it turns out to

be a legal problem, it's the lawyer's

responsibility. If it's a medical issue, it's

the doctor's responsibility." (Informant #16)
According to another, "If you come to find out you are
dealing with a medical issue rather than an ethical issue,
which happens, the bottom line is the physician is going to
decide what happens to the patient. Always!" (Informant
#19).

In most cases the informants report being satisfied
with the resolution of these problems. This is true whether

the problems are ethical or are defined at a later point as

being of another nature. An informant reported that, "Most

95

of the time these problems are resolved appropriately"
(Informant #5). Others reported, "I say in the large
majority of the time they are resolved appropriately
(Informant #8), and, "For the most part the ethical problems
are resolved before the patient leaves the hospital.
Ethical problems arise, there may even be some
confrontation, but for the most part they are resolved"
(Informant #14). Another noted that ethical problems were
resolved, "Nearly all of the time" (Informant #6). Finally,
one informant said this was the case, "Well, not 100%, but
most of the time" (Informant #4). Satisfaction with
resolution appears to be best when the ethical problem is
specific to social work. This idea is reflected in
informant reports such as, "When it deals with social work,
these things tend to get ironed out" (Informant #20) and, "I
would say (long pause) if it has to do with social work, I'm
very successful and satisfied" (Informant #3). While these
responses were typical, satisfactory resolution was not
always the outcome.

WWW.
Occasionally, informants report being unsatisfied with the
resolution of the ethical problem or thinking the problem
was not dealt with or managed appropriately. As one
informant reported, "In several cases I was not comfortable

with the way they were handled. That's a real frustrating

96

spot to be in" (#18). Another reported a somewhat

philosophical view,

You accept that you did what you thought was

right. Sometimes these problems don't get

solved the way you want. You suck it up and go

on. There's nothing more you can do. The

hospital may get sued, I won't. (Informant #9)

When social workers are dissatisfied with the
reconciliation of these problems they are, for the most
part, reluctant to register strong opposition. The reasons
for this are not apparent. One informant reported that she
does voice her dissatisfaction although it is not always
well received: "Some people say I'm a little forward, but
that's okay" (Informant #8).

William.

Kugelman (1992) states, "The critical document defining
the standards for social work practice is the National
Association of Social Workers Code of Ethics" (p. 62). This
study indicates that the Code of Ethics is not a significant
guide to practice.

Investigator: Have you had training in ethics since

graduate school?
Informant: No.
Investigator: Did you have ethics training during
your social work training? -
Informant: No.
Investigator: Do you think you are prepared to deal
with the ethical problems you encounter?
Informant: Oh yes. I do feel prepared.
As social workers encounter and deal with these often

very complex ethical problems, what informs or guides their

practice? The reaction to this question was different from

97

any other question asked. Informants reported that they
found this question intriguing (Informant #14), very
interesting (Informant #9), and thought provoking (Informant
#11). One reported, "I've never been asked that question
before" (Informant #18) and another said, "I know there are
things that guide me, but I don't know if I can say what
they are (Informant #7). There was often a long pause
before responding to this question. The responses varied
and indicate that there are a number of factors involved.

Egt§Qn§l_ygltg§_a§_§_gntgg, The most frequently
articulated guide to dealing with ethical problems was
personal values. When asked what guided her in dealing with
such complex ethical issues one informant reported, "I guess
the first thing that comes to mind is my own values. That's
probably number one" (Informant #16). Another was more
certain as she reported, "My own belief system, my own
faith" (Informant #1). One informant reported that her
guide was, "My philosophy on things" (Informant #6).
Another stated it a bit differently but reported, "The way I
was brought up, being a Christian. My values are what I
call gospel values" (Informant #11). Another reported, "I
do what I believe in to be the right thing to do, my values"
(Informant #13). Another was not quite sure but reported,
"Maybe it's just based on my value system. Maybe my
religious beliefs. It's just my own judgment, my own

opinion, how I feel" (Informant #12).

98

other informants articulated their own personal values
as a guide to practice but suggested other influences. One
reported, "I think my personal values guide me but my values
are under the umbrella of social work values" (Informant
#6). Another reported, "I went into social work because I
had these beliefs and values to begin with. Social work
supports a lot of them" (Informant #1).

One informant reported a situation in which her personal
values were guiding her and a patient recognized this. The
social worker was counseling a patient about a possible
abortion. The social worker was opposed to abortion. The
patient said, "You don't want me to have this abortion, do
you?" The informant reported, "It must have been the
expression on my face or something. I realized that somehow
I had conveyed my personal values to her. She picked up on
that" (Informant #3). In a similar vein an informant
reported, "A lot of us have missions and carry torches"
(Informant #4). However, one informant reported, "Your job
is to be a social worker, not a person's judge or jury"
(Informant #5).

Intuittgn, Several informants reported that they were
guided by intuition. They reported this in a number of
different ways. One informant stated she was guided by,
"Things from the heart. You know, you have this intuition.
I think we should get tuned in to those gut feelings. In

most cases they're right" (Informant #12). Another

99
reported, "I always trust what I'm feeling inside. That
inner voice, whatever it is" (Informant #13). Others
reported, "I depend a lot on my instincts, intuition"
(Informant #7), "You get a sense" (Informant #6), and,
"Sometimes it's just a gut feeling. I think I am a very
intuitive person. I don't have another explanation for it"
(Informant #19). Finally, one informant reported, "There is
something spiritual. I'm not a religious person but you go
into the patient's room or hold their hand, you can feel
things" (Informant #12).

,- 5. .1. ;--. 1 .1 ., . fr Wo,. oq* . , —.
Though identified by several informants as a guide to
practice, the NASW Code of Ethics was seldom the first guide
articulated. Informants that identified the Code of Ethics
first reported, "I think the Code of social work, the
Ethics, my ethical beliefs as a social worker" (Informant
#11), "I have a copy of the NASW Code of Ethics in my office
that I refer to from time to time" (Informant #8), "My
professional ethics" (Informant #14), and "I guess it sounds
too obvious, but the ethics of the profession" (Informant
#16). Finally, one informant reported, "Well, I know the
ethical standards pretty well. The guidelines of what
social workers are supposed to do" (Informant #19).

Two informants spoke of the NASW Code of Ethics in
combination with other factors as being the guide to

practice. For example, "A balance between the Code of

100
Ethics and my own values in working with people" (Informant
#5) and "The ethics of my profession along with the goals of
the hospital" (Informant #14).

Some informants reported that the Code of Ethics was
not a guide at all. One reported, "I don't even know what
the Code of Ethics is. I think I have it in my department
manual" (Informant #17). Another, when asked if the code of
ethics was a guide reported, "You would hope, but I don't
think it's that way at all" (Informant #13).

W. When informants
noted professional training as a guide they usually included
their formal education in this as well. Some informants
stated this guide in very simple terms, "My training"
(Informant #15), and, "The social work training I had"
(Informant #10). Another informant reported, "I think my
training and education are a major part" (Informant #17).
Finally, another reported her professional training,
"Especially the clinical assessment skills" (Informant #1).

There were other informants, however, that minimized
their training and education as a guide. When asked
specifically if training was a guide to dealing with ethical
problems one informant reported, "For me, I can't say it is"
(Informant #12). Another reported, "Not so much my
professional training but the individuals I encountered
during my training, priests and some colleagues" (Informant

#13).

101

fittgty1§19n_§§_a_ggtdg. Supervision either from
supervisors or peer supervisors and consultation with
colleagues was identified as "a strong guide" (Informant
#14). Others reported that they frequently go to their
supervisors for help and guidance in dealing with ethical
issues. As one informant phrased it, "I process it with my
supervisor" (Informant #6). Another informant reported,
"The supervisor may suggest something or they may have to

intervene" (Informant #8).

Expettgnge_as_a_gtidg, When informants identified

experience as a guide in dealing with ethical problems most
referred to a blending of personal and professional
experience. One informant reported, "I think my main guide
is my own professional and personal life experience. This
teaches you what is worth getting upset about" (Informant
#3). Another simply reported, "Probably my personal
experience" (Informant #18). Finally, one informant
reported, "I have been in hospital social work for ten
years. My experience guides me with these problems. I've
seen a lot" (Informant #7).
WWW- Early in the data
collection the idea of hospital mission and hospital
philosophy emerged as a guide to management of ethical
problems. Informants noted, "The philosophy of the team I
work with is..." (Informant #1) and, "Our hospital mission

is..." (Informant #2). When questioned further regarding

102

the significance of the hospital mission as a guide, one
informant reported that compliance with the hospital mission
was, "...a condition of continued employment" (Informant
#2). This was noted later in data collection as well.
Another informant reported, "We are being told a lot about
the importance of the hospital mission. I know when I get
stuck in one of these ethical issues, I'm sensitive to the
mission and how this problem should play out" (Informant
#14). Finally, after some reflection one informant noted,
"I guess hospital mission does influence me in these
problems because there have been times that I have felt
compromised because I had to go along with the mission. I
would have said no without first thinking about it"
(Informant #17).

WW. During data
collection there was substantial discussion about new and
developing "Quality" programs. Quality programs are
discussed in detail in Chapter Two. Some informants
identified these programs as guides in dealing with ethical
problems.

One informant reported, "TOM operationalizes things for
you. The code of ethics is very abstract, very etherial.
TQM brings it right down to home for you" (Informant #20).
Another reported that their department mission was "a

synthesis of TQM and the code of ethics" (Informant #12).

103

In addition to these subcategories there were other
factors occasionally identified as guides in dealing with
ethical problems. Informants reported that "the law" was a
guide (Informants #3, #6, and #19). Others reported,
"Length of stay is always a guide in these problems"
(Informant #20), and, "I know what my job is. It's to
create timely discharges. The bottom line is money"
(Informant #14).

Two informants noted that the community surrounding
their institutions influenced ethical problem solving. One
reported, "You know what I think guides it? The community.
If you're a community hospital, you are very influenced by
the community. The community supports us financially"
(Informant #17). This informant could not provide an
example of this. Another reported, "One thing that guides
me is being downriver. We have our own personality, our own
way of doing things. I think each community has its own
standards" (Informant #16).

Two other influences were identified. One informant
reported, "I guess I'd have to say the institution itself.
There are certain traditions within the hospital. Sometimes
we don't question why we address these problems in a certain
way, we just do it" (Informant #16). Finally, one informant
reported, "At my social work cubicle I have this little card
with 'Values to Live By.‘ That helps guide me" (Informant

#9).

104

Reflective practice. The concept of reflective
practice was presented in Chapter One. It was noted that
because of the complex nature of hospital social work,
reflective practice, as a part of an overall practice
strategy, would enable the social worker to better navigate
the "swampy lowlands of professional practice topography"
(Schon, 1983, p. 42).

As the data were collected, hospital social workers
recounted their efforts to convert problematic situations
into manageable problems and to reconcile ethical problems.
These data were analyzed for evidence of reflective
practice. Some informants reported that they were
"rational" (Informant #6), relied on "clinical skills"
(Informant #14), "policy and procedures" (Informant #12),
and the law (Informants #3 and #19) for guidance. They
stated they were very clear about their "defined roles"
(Informant #9) and the bureaucratic avenues available to
them for ethical problem solving.

There were times, however, when formal training and
rational thinking did not help with ethical problems. One
informant told of how colleagues had become frustrated with
complex problems and situations and observed, "Sometimes
doing social work 101 doesn't work" (Informant #5). Related
to this another reported, "If it isn't in the book, we don't

know what to do" (Informant #16).

105

One informant spoke of how, after a few years of
experience, hospital social workers may tend to focus on the
similarities among patients and their illnesses, diseases,
and circumstances rather than their uniqueness. This view
often results in a "template approach" to working with
patients and their problems. This is sometimes the case in
working with ethical problems.

Another informant spoke of an ethical problem related
to "another 'failure to thrive' baby" (Informant #2). It is
important to focus here not on the ethical problem, but on
the social worker's characterization of the patient and his
or her situation. "Failure to thrive" syndrome is a
characterization used to describe a situation in which an
infant, for a variety of reasons, does not bond with the
mother, gain weight, and grow and develop properly. There
are many variables, including physical, emotional, and
social issues, that can contribute to this syndrome.

To refer to a situation as "another" anything connotes
a preconceived approach to a situation on the part of the
social worker. This may not be based on accurate
information or knowledge about a situation. Nevertheless,
this approach may be used to guide initial social work
intervention. Unfortunately, this represents a way of
dealing with complex problems which does not use reflective
practice. Among some informants there was much evidence of

reflective practice.

106

Situatign_nnigneness. One informant reported, "I
believe it is important for me to treat the patient as a
unique individual" (Informant #11). Another noted, "You
can't write a policy or procedure for every situation you
will encounter" (Informant #8). In addition, there were
many responses of "that depends" and "depending on the
particular situation" to questions asked.

An oncology social worker reported, "I know there are
no two cancer patients alike. All these patients and
families and life circumstances are very different, even
unique" (Informant #9).

In understanding a situation as unique, much discussion
of and interaction with the situation takes place. During
"reflective conversations with the situation" (Schon, 1983,
pp. 76-104), one informant reported, "You learn to read what
the patient or family is saying underneath what they
actually say" (Informant #16). Anothen informant called it,
"Listening to what is unsaid as well as what is said"
(Informant #20). Imbedded in these two observations is the
use of intuition.

LntnLtLQn. Intuition results from a combination of
experience and reflection. Reflective practice is based not
on the mere presence of intuition but on its use in
practice. The earlier discussion of intuition as a guide in
dealing with ethical problems is adequate to indicate the

presence of intuition in hospital social work practice as

 

107
well as social workers' recognition and utilization of it in
their practice.

fixmhflll£_inifza££19nlsm, The findings indicate that
interactionist ideas are used in two ways. First, they are
used in the analysis and definition of problems. Second,
they are also used in the construction of meaning.

Etamtng_lssues. Both Schon (1983), and Goffman (1974)
discuss the practice of framing and reframing social
behavior. Framing refers to a view of an event or social
behavior, that includes both the objective elements of the
behavior and the viewer's subjective involvement in it.

An informant reported, "As a social worker, I bring
something different to the ethical problem. I think I have
a way of looking at the situation" (Informant #14). What a
social worker brings to the ethical problem is his or her
framing of the problem. It represents a perspective on the
problem and his or her role in both the definition and
reconciliation of the problem.

Another informant reported, "If you were in the room
with a physician, a psychologist, a social worker, a nurse
and a chaplain, you would get five different perspectives on
the problem. Each person has a different view and does
something different" (Informant #4). Represented in this
idea are the viewing of the objective aspects of a situation
and the subjective involvement of the different

participants.

108

The idea of reframing was also identified. An ethical
problem developed related to the placement of‘a patient with
Alzheimer's disease in a nursing home. There was a
considerable amount of disagreement among family members
about the appropriate thing to do. The social worker
discussed the situation with a colleague. The colleague was
not sensitive to the complexity of the situation. The
social worker then said, "Look at the big picture. This
isn't just about placing an old senile man in a home.
There's more to it. This man is a husband and a father.
What we decide to do impacts them too" (Informant #9).

The social worker was saying that one way of viewing
the situation, i.e., framing, is to see just the patient and
what needs to be done for him. When you "look at the big
picture," i.e., reframe, the situation is different.

At times framing and reframing takes place as problems
are identified. This is the case when the social worker
initially identifies a situation as an ethical problem but
after consultation with colleagues or other members of the
care team the problem is seen differently.

uganinnggngttggtlgn, An idea that is closely related
to framing is meaning construction. In the interactionist
perspective all meaning is socially constructed.

Fundamental to meaning construction is consensus. The right
thing to do, which is at issue in all ethical problems, is

socially constructed as well.

109

One informant served on what she referred to as the
"mega-claims committee" (Informant #5). This was a
committee in the hospital that reviewed the situation of
patients whose hospital bill had exceeded $50,000.

In one instance a patient's case came before this
committee for discussion and recommendations. The
patient's attending physician made a presentation and there
was much discussion. The hospital chaplain's assessment
was, "What this means is we have a terrible ethical problem
on our hands." Also in attendance was the hospital vice
president for finance. His interpretation was, "What this
means is we have a financial problem." Finally, a consensus
was reached. It was decided that the situation was a
financial problem. Until consensus could be reached, no
meaning could be attached to the situation.

As informants identified and misidentified ethical
problems, they also reported that negotiations over meaning
were a part of this process. While they did not recognize

it as such, these negotiations led to meaning construction.

 

Level one and two coding resulted in the development of the
categories and subcategories presented. Level three coding
resulted in the identification of links between

subcategories of data. There were three major findings in

this regard.

110

First, the idea of a "magnitude of problems" is related
to that of "hierarchy." These are related in that it
appears that the "bigger" the ethical problem (magnitude),
the higher up in the hospital bureaucracy (hierarchy) one
must go to identify the appropriate person to resolve it.

Second, the idea of "intuition" is related to both the
category of reflective practice and the category of guide to
handling ethical problem. The meaning of the term is the
same in both instances. However, at different times the
idea was presented in reference to distinct categories.

Third, there is a link between "responsible parties"
and "meaning construction." It appears that before
reconciliation of ethical problems can occur, responsible
parties must bring about consensus regarding the nature of
the problem.

Vgty_small_hgspitals. Hospital social work in very
small hospitals (fewer than 100 beds) is different than in
larger hospitals in a number of ways. Some were easy to
identify, others were more difficult.

First, the patient populations of these very small
hospitals are very homogenous. They tend to be white and
elderly. Informants reported, "This is a rural, white
community. There are very few minorities" (Informant #18),
and "Because we are a very small rural hospital we deal with
a lot of the elderly. Our average patient age is in the

high 705" (Informant #17).

111

Second, these hospitals have much smaller staffs and
small organizational structures. This accounts for a number
of differences. Problem solving and decision making
regarding ethical problems tend to happen fairly quickly and
without fanfare. One informant reported, "We have a
biomedical ethics committee but, it met only once last year
and hasn't met this year either" (Informant #19). One
informant reported that the social worker had substantial
influence in reconciling ethical problems. She reported,
"In the larger hospitals the doctors seem to make the final
decisions in these ethical matters. It's different in this
hospital. I would say the majority of the times, it's my
decision" (Informant #17).

The relationships among staff members were characterized
as "good" and "strong." One informant reported, "It's easy
to develop a good relationship with the staff. We have ten
docs and I know them all well, personally. In this
hospital, whenever I write a note in the chart, whoever
reads it knows me personally" (Informant #17).

There may be a negative side to these outcomes. In the
very small hospitals the doctors have generally known their
patients for many years. One informant reported,

The dying issue is real difficult for some of our
physicians to deal with. This is because the
doctors here know many of the patients and have a

lot of ties to them. I think there are a lot of
those ties. (Informant #18)

112

Third, there is a "fishbowl" existence for both staff
and patients in very small hospitals. As one informant
reported,

Everybody sees what you do. Everybody knows who

you are. You can bet an hour from now people on the

other side of the building will say, "Who was that

man in your office?" It's a fishbowl kind of

existence in a small place. (Informant #17)

During the interview the this informant spoke of an
incident of unethical behavior she had witnessed. She made
the observation that at one time she believed that in a very
small hospital there would be a lot of pressure to behave in
an ethical manner. She was stuck by how much pressure there
also was to leave unethical behavior unaddressed, "I guess
you could call it peer pressure. You know, to go along and
not rock the boat" (Informant #17).

One informant told of an interesting way of paying a
hospital bill that is probably unique to very small
hospitals. She reported,

We have in this area a lot of rural farmers. We

have people who don't put their money in the banks.

For many of our patients their method of paying
hospital bills is selling acreage or livestock, or
digging it up out of the backyard.

(Informant #18)

One informant reported that the community had some

"right to life groups" that became involved in an ethical
issue. The hospital was opposed to surgically inserting a

feeding tube into a young, mentally retarded, terminally ill

patient.

113

Finally, one informant made a general observation about
very small hospitals and ethical problems. She noted, "We
never saw these problems ten years ago, or even five years
ago. Now this happens a lot" (Informant #17). She was
referring specifically to the ethical issues related to the
withdrawal of treatment.

Phase Three Findings

Eh§§§_1ht§§;_1§lig§tign. In this "member check"
(Lincoln & Guba, 1985, p. 236) phase, a provisional report
is presented to the informants. This phase is not primarily
a data gathering phase. Its purpose is to obtain
confirmation that the report has captured the data reported
by the informants. Corrections, amendments, and extensions
are made if indicated.

The investigator met with Informants from the small and
large hospitals in the conference room of their hospitals.
Other members of the department were not present.

Informants from the very small hospitals were contacted by
phone. The discussions with the social workers from very
small hospitals were very brief. In anticipation of this
phase, each informant was given feedback following the
interview during phase two.

The informants were eager to hear the provisional
report. The report, an oral presentation of tentative
findings, took about an hour. The informants indicated that

the report was very consistent with the information they had

 

114

provided. one informant quipped, "It should have been easy

with the tape recorder."

There was a brief discussion about the concept of
"reframing." This was a new concept for most of them. One
informant said he thought reframing was "a fancy word for
second guessing yourself." We discussed this in some
detail.

Some informants were upset by the idea presented by a
key informant that "Nurses solve problems, social workers
explain them." One informant commented, "We don't give just
pills or untangle IV tubing." Another said, "We call
doctors and have them talk with families too." It was
explained that there was no support for this notion in the
data.

Two informants, recognizing their quotes, raised the
issue of confidentiality. The steps taken to preserve
confidentiality were explained once again and no objections
were raised.

Some of the informants reported that they had thought
about their interviews for days afterward. For some it was
the first time they had given this aspect of their practice
any thought. They were positive about the experience.

A summary of these findings is presented in the next
chapter. Also presented are conclusions and areas for

further research.

CHAPTER 5

Summary and Conclusions

The investigator for this study had fifteen years of
social work experience. The last five years were in
hospital social work, most recently as director of a
department of social work in a large hospital. The seed for
this study was planted three years ago. The following
anecdote illustrates this.

One day the investigator received an urgent call to
attend a special meeting that was currently underway. Also
in attendance at this meeting were the Vice President for
Nursing, the Chief Counsel from the hospital's legal
department, the Director of Physical Therapy, assorted
nursing and support staff, and a very upset and determined
Chief of Surgery.

A patient had been admitted to\the emergency room
following an injury to his right hand. He had been drinking
and playing cards with friends and became involved in a
fight. During the fight the patient broke through a window
with his fist, cutting himself severely. He was brought to
the hospital emergency room.

The Chief of Surgery was called to the emergency room
to perform micro-surgery on the patient's hand. The hand
was saved but several days of noncompliance with

115

116
post—surgery instructions, refusing to keep the injured hand
elevated, and demanding to be discharged, reSulted, in the
opinion of the Chief of Surgery, in the risk of loss of
function in the hand.

The Chief or Surgery demanded that someone go to court,
petition the court to involuntarily confine the patient to
the hospital. His hand would be elevated, proper care
provided, and adequate healing would take place. This would
take about a month.

The Chief of surgery was a very influential physician
in the hospital and well known for his gruff nature and
propensity for verbal outbursts. The small meeting room was
filled with hustle and bustle as those in attendance
discussed how they could comply with the demands of the
physician.

The Vice President for Nursing thought that adequate
nursing care could be provided. The Director of Physical
Therapy agreed that her therapists could manage the patient
as well. The Head Nurse for the floor had no problems the
plan. The attorney noted that this would involve going to
Probate Court and reckoned that was a job for Social Work.
All of this happened in a matter of minutes.

The investigator took the position that this could not
be done, not just because it was insensitive and perhaps
illegal, but because it was not right. This stance was not

well received. As the investigator articulated the ethical

117
issues involved, emotions cooled and it was decided not to
go to court and petition the patient as incompetent, but
instead, to talk with the patient about the care he needed
and either seek his cooperation or discharge him as he
requested, but against medical advice.

Besides the investigator, none of these intelligent,
competent, and influential individuals considered the
ethical dimensions of the problem at hand. Do hospital
social workers encounter ethical problems? How are they

resolved? What guides this process?

This study was guided by a single broad question: What
is the nature of ethical problems encountered by hospital
social workers?

This was a qualitative study focusing on ethical
problems encountered by hospital social workers. The
theoretical guide for this study was a synthesis of the
sociological perspective of symbolic interactionism and
Schon's (1983) theory of reflective practice. The method
used to conduct this study was based on Lincoln and Egon
Guba's (1985) naturalistic inquiry method.

The focus of this study was the nature of ethical
problems encountered by hospital social workers. Four
related areas were examined. First, do hospital social
workers, in fact, encounter ethical problems in their
practice? Second, who is involved in the definition and

resolution of these ethical problems? Third, how successful

118
are social workers in resolving these problems. Finally,
what guides social workers as they deal with these ethical
problems?

There were five key informants and twenty informants
involved in this study. The key informants were Directors
of Hospital Social Work Departments and members of the
academic community with interest in this topic.

The informants were hospital social workers from very

I" A.
1‘

small hospitals, those with fewer than 100 beds, small
hospitals, those with between 100 and 249 beds, and large
hospitals, those with more than 250 beds. The informants in
this study had an MSW degree and a minimum of one year
hospital social work experience. Most informants had
several years of hospital social work experience. They
represented nearly every unit found in contemporary

hospitals.

 

Initially there was concern about the informants
willingness to talk about these sensitive issues. However,
it was found that they were eager to discuss their issues
and many stated that they benefitted from having
participating in the study.

This study consisted of three phases of inquiry. In
the first phase, the orientation phase, key informants were
interviewed. The result of this phase was an interview
protocol to be used in the next phase of inquiry. In the

second phase, the exploration phase, twenty informants were

119

interviewed. The focus of this phase was the four questions
presented above. Following this phase a preliminary report
was developed. In the third phase, the validation phase,
the preliminary report was presented to the informants. The
purposes of this phase was to insure that the report had
accurately captured the data provided by the informants and
to correct and amend it as necessary, and to validate the
report as being a true and accurate reflection of the

informants practice experience.

Summagy of Findings. This study found that hospital

social workers encountered ethical problems in their
practice. The frequency of these problems varied from
social worker to social worker. Some social workers
encountered ethical problems very frequently; other social
workers seldom encountered ethical problems.

Ethical problems were generally recognized and dealt
with. However, at times hospital social workers identified
problems as being ethical when they were not. A related
finding was that hospital social workers often used the
terms ethical dilemma and ethical problem interchangably.
An ethical dilemma exists in a situation whereby following
one ethical tenet another is violated. An ethical problem
exists when one ethical tenet conflicts with another.

Ethical dilemmas constitute a sub—category of ethical

problems.

120

Most of the ethical problems encountered by hospital
social workers fell into two categories. The first were

ethical problems related to the withholding, withdrawing, or
refusing medical treatment. The second were ethical
problems related to the flow of information.

In addition to these two main categories of ethical
problems, hospital social workers also encountered a range
of ethical problems that were not easily recognized.
Examples were: 1) a physician noting in a patient's chart
that he had performed a service he had actually not
performed; 2) a patient's family obtaining electrical
service in an unscrupulous manner; and 3) a patient's family
obtaining telephone service in an unscrupulous manner.

Hospital social workers haddifficulty articulating the
ethical tenets involved in the ethical problems they
recounted. This was true even when the ethical problems
they recounted involved fairly clear ethical issues.

Hospital social workers viewed some ethical problems as
more serious than others. The seriousness of a given
ethical problem usually dictated who was involved in dealing
with it. This study indicates that most routine ethical
problems encountered by hospital social workers were dealt
with at the staff level involving few individuals in a short
time frame.

In addition to hospital social workers, physicians and

nurses were usually involved in resolving these problems.

121
It is not clear, from this study, what the level of
involvement of the patient or his or her family was in
dealing with ethical problems.

Besides the individuals mentioned above, various groups
became involved in resolving ethical problems. These
included groups within the hospital such as ethics
committees, discharge planning committees and groups outside
the hospital such as community service agencies and
political or social action groups.

Occasionally ethical problems were resolved and the
social worker was not in agreement with the outcome. In
those cases the social worker was either unwilling or unable
to pursue the matter further. This was mainly because of
the custom that the physician usually has the last word in
cases where there is significant disagreement over what

should be done.

 

Primarily, hospital social workers relied on their
individual values as guides in dealing with ethical
problems. They also relied on their own intuition. The
National Association of Social Workers Code of Ethics was
not identified often as a guide. Professional training and
education, individual experience, supervision, hospital
culture, hospital quality programs, and legal regulations
also guided social workers.

Hospital social workers had little training in ethics

during and after their professional education. However,

122

they believed they were prepared to deal with ethical

problems they encountered.

Hospital social work practice in very small hospitals
was different from that in large and small hospitals. In
very small hospitals there was a great deal of familiarity
among staff and between staff and patients. Informants in
the very small hospitals referred to their "fishbowl
environment." They reported that this level of familiarity
and the fishbowl environment encouraged ethical practice.

Patient populations in very small hospitals was very
homogeneous. The patient population was also older than in
the large and small hospitals.

The practice of most of the hospital social workers in
this study can be characterized as objective and rational.
Some, however, exhibited significant reflection in their
practice. They acknowledged that each patient's
circumstances were unique, leading to very different kinds
of ethical problems. This was demonstrated by creativity in
ethical problem solving and by help-seeking behavior.

In the process of dealing with ethical problems
hospital social workers defined and re—defined problems and
sought alternative views as they framed and re-framed
situations in seeking solutions.

There was very little evidence of patient
dehumanization reported. The most frequent example cited

was that patients were referred to by their room number or

123

diagnosis. Some patients that were referred for social work
services did not receive it because of staffing shortages or
short lengths of stay.

anclusiogs. One function of social work research is
to inform social work practice. This study has provided
information about and understanding of the nature of ethical
problems encountered by hospital social workers.

In hospital social work professional status enabled the

r”
i

social worker to practice alongside of physicians, nurses,
and other health professionals in the provision of services
to patients. Because most hospital social workers have
earned a master of social work (MSW) degree, hospital
departments of social work have been referred to as, "the
second most educated department in the hospital."

The provision of social work services in the complex

practice arena of the hospital requires the use of

 

professional skills and knowledge and the ability to
delineate ethical problems. Ethical problems in hospital
social work often involve contentious situations and
substantial disagreement among social workers, physicians,
nurses, patients and their families. As these problems are
dealt with, not only is the correct ethical solution at
issue, so, too, are the competence and credibility of the
professionals involved. When ethical problems are
identified incorrectly or not recognized at all, the

competence of the hospital social worker may be questioned

124

and the ability to provide services to patients may be

impaired.

From a professional social work perspective, it is
critical that during ethical problem solving hospital social
workers be guided by the ethical tenets of the profession.
This is a function of the National Association of Social
Workers Code of Ethics. This study indicates that the NASW
Code of Ethics is only a minor guide to hospital social
workers as they deal with ethical problems. They rely more
on their individual moral philosophy and intuition than on
the Code for guidance.

This study suggests two questions. First, to what

extent should the NASW Code of Ethics guide hospital social

 

work practice in the resolution of ethical problems? Should
the NASW Code of Ethics be "a" guide to practice or "the"
guide to practice?

Second, how well are schools of social work preparing
practitioners to deal with ethical problems? This study
indicates that hospital social workers recall little
training in ethics during their MSW program. This is
reflected in mis-identification of problems as ethical and
an inability to understand the ethical dimensions of the

problems they encounter.

Etttngt_t§§g§tgn, Studies such as this contribute to

the understanding of ethical problems encountered by

hospital social workers. However, research that is focused

125
less on the broad nature of such problems and more focused
on particular elements of these problems is needed.

A number of suggestions for further research emerged
from this study.

First, the findings of this study reflect "one reality"
of hospital social work practice, the practitioners'
perceptions. Further research involving observation of
practitioners may identify still other "realities." Such
research could provide valuable information about processes
involved in the identification and mis-identification of
ethical problems.

Second, research is needed to determine the extent to
which ethics are taught in schools of social work. This
would aid in determining if ethics training in schools of
social work is adequate.

Finally, the extent to which the NASW code of ethics
does or should serve as a guide to practice should be
explored. This should include further examination of

hospital social work and other practice arenas as well.

APPENDICES

APPENDIX A

NATIONAL ASSOCIATION OF SOCIAL WORKERS
CODE OF ETHICS

 

APPENDIX A

National Association of Social Workers
Code of Ethics

 

126

1227

NASW PROFESSIONAL STANDARDS
Code of Ethics

Standards for the Classification of Social Work Practice
Standards for Continuing Professional Education
Standards for the Practice of Clinical Social Work
Standards of Practice for Social Work Mediators
Standards for School Social Work Services

Standards for Social Work Case Management
Standards for Social Work in Health Care Settings
Standards for Social Work Personnel Practices
Standards for Social Work Practice in Child Protection
Standards for Social Work Services in Long-Tenn

Care Facilities

NASW CLINICAL INDICATORS

Clinical Indicators for Social Work and Psychosocial
Services in the Acute Psychiatric Hospital

Clinical Indicators for Social Work and Psychosocial
Services in the Acute Care Medical Hospital

Bylaws of the National Association of Social Workers

A single copy of these standards is available free of charge.
Standards also may be ordered in bulk for a fee. Contact
NASW Distribution Center
PC. Box 431
Annapolis JCT. MD 20701
1-800-22'7-3590

JPP-801 F

Code of Ethics

of the

National Association
of Social Workers

As adopted by the 1979 NASW Delegate Assembly
and revised by the 1990 NASW Delegate Assembly.

“NASW

National Association of Social Workers
750 First Street. NE. Suite 700
Washington, DC 20002-4241
(202) 408-8600

 

128

Contents
Preamble ................................. iii
Summary at Major Principles ................. 1
Code oi Ethics ............................. 3
I. The Social Worker’s Conduct and

Compartment as a Social Worker .......... 3
II. The Social Worker’s Ethical Responsibility

to Clients ............................. 4
III. The Social Worker’s Ethical Responsibility

to Colleagues .......................... 6
IV. The Social Worker's Ethical Responsibility

to Employers and Employing

Organizations .......................... 7
V. The Social Worker’s Ethical Responsibility

to the Social Work Profession ............. 8
Vi. The Social Worker’s Ethical Responsibility

to Society ............................. 9

129

Preamble

This code is intended to serve as a guide to the everyday
conduct of members of the social work profession and
as a basis for the adjudication of issues in ethics when
the conduct of social workers is alleged to deviate from
the standards expressed or implied in this code. It
represents standards of ethical behavior for social
workers in professional relationships with those served,
with colleagues. with employers. with other individuals
and professions. and with the community and society as
a whole. it also embodies standards oi ethical behavior
governing individual conduct to the extent that such con-
duct-is associated with an individual's status and identity
as a social worker.

This code is based on the fundamental values of the
social work profession that include the worth. dignity,
and uniqueness of all persons as well as their rights and
opportunities. It is also based on the nature of social
work, which fosters conditions that promote these
values.

In subscribing to and abiding by this code, the social
worker is expected to view ethical responsibility in as
inclusive a context as each situation demands and
within which ethical judgement is required. The social
worker is expected to take into consideration all the prin-
ciples in this code that have a bearing upon any situation
in which ethical judgement is to be exercised and pro-
fessional intervention or conduct is planned. The course
of action that the social worker chooses is expected to
be consistent with the spirit as well as the letter of this
code.

In itself. this code does not represent a set of rules that
will prescribe all the behaviors of social workers in all
the complexities of professional life. Rather. it offers
general principles to guide conduct. and the judicious
appraisal of conduct. in situations that have ethical
implications. It provides the bass for making
judgements about ethical actions before and after they
occur. Frequently, the particular situation determines
the ethical principles that apply and the manner of their
application. In such cases. not only the particular ethical
principles are taken into immediate consideration. but
also the entire code and its spirit. Specific applications
of ethical principles must be judged within the context in
which they are being considered. Ethical behavior in a
given situation must satisfy not only the judgement of
the individual social worker. but also the judgement of
an unbiased jury of professional peers.

This code should not be used as an instrument to
deprive any social worker of the opportunity or freedom
to practice with complete pfOleSSlOl'lal integrity; nor
should any disciplinary action be taken on the basis of
this code without maximum provrsion for safeguarding
the rights of the socral worker affected.

The ethical behavior of social workers results not from
edict. but from a personal commitment of the individual.
This code is offered to affirm the will and zeal of all
social workers to be ethical and to act ethically in all that
they do as social workers.

The following codified ethical principles should gurde
socral workers in the various roles and relationships and
at the various levels of responsrbility in which they func-
tion profess:onally. These principles also serve as a
basrs for the adjudication by the National Assocration of
Socral Workers of issues in ethics.

In subscribing to this code. social workers are required
to cooperate in its implementation and abide by any
discrplinary rulings based on it. They should also take
adequate measures to discourage. prevent. expose. and
correct the unethical conduct of colleagues. Finally,
social workers should be equally ready to defend and
assist colleagues unjustly charged with unethical
conduct

130

Summary of Major Principles

l. The Social Worker’s Conduct and
Comportment as a Social Worker

A. Propriety.The Social worker should maintain
high standards of personal conduct in the
capacrty or identity as social worker.

B. Competence and Professional Develop
ment. The social worker should strive to
become and remain proficient in professional
practice and the performance of professronal
functions.

C. Service. The social worker should regard as
primary the serwce obligation of the socral
work profeSSion.

D. Integrity. The soc:al worker should act in
accordance wrth the highest standards of pro-
fessional integrity.

E. Scholarship and Research. The social
worker engaged in study and research should
be gurded by the conventions of scholarly
inquiry.

II. The Social Worker’s Ethical
Responsibility to Clients

F. Primacy of Clients’ Interests. The social
worker's primary responsibility is to clients.

G. Rights and Prerogatives of Clients. The
social worker should make every effort to
foster maximum self-determination on the part
of clients.

H. Confidentiality and Privacy. The social
worker should respect the privacy of clients
and hold in confidence all information obtained
in the course of professional service.

I. Fees. When setting fees. the social worker
should ensure that they are fair, reasonable,
considerate. and commensurate with the
service performed and with due regard for the
clients' ability to pay.

Ill. The Social Worker’s Ethical
Responsibility to Colleagues

J. Respect. Fairness, and Courtesy. The seeial
worker Should treat colleagues with respect.
coortesy. fairness. and good faith.

K. Dealing with Colleagues’ Clients. The social
worker has the responsibility to relate to the
clients of colleagues with full professional
conSrderation

IV. The Social Worker’s Ethical

Responsibility to Employers and
Employing Organizations

L. Commitments to Employing Organizations.
The social worker should adhere to
commitments made to the employing
organizations.

. The Social Worker’s Ethical
Responsibility to the Social Work
Profession

M. Maintaining the Integrity of the Profession.
The social worker should uphold and advance
the values. ethics. knowledge. and mission of
the profession.

N. Community Service. The social worker
should assist the profession in making spoial
services available to the general public.

0. Development of Knowledge. The social
worker should take responsibility for identity-
ing. developing. and fully utilizing knowledge
for professional practice.

VI. The Social Worker’s Ethical

Responsibility to Society

P. Promoting the General Welfare. The social
worker should promote the general welfare of
society.

131

The NASW Code of Ethics

I. The Social Worker’s Conduct and

Comportment as a Social Worker

A. Propriety—The Social worker should main-
tain high standards of personal conduct in
the capacity or identity as social worker.

1. The private conduct of the social worker is a
personal matter to the same degree as is any
other person's. except when such conduct
compromises the fulfillment of professronal
responsibilities.

2. The somal worker should not participate in.
condone. or be assoaated wrth dishonesty.
fraud. deceit. or misrepresentation.

3. The somal worker should distinguish clearly
between statements and actions made as a
private individual and as a representative of
the social work profession or an organization
or gr0up.

B. Competence and Professional Develop
ment—The social worker should strive to
become and remain proficient in profes-
sional practice and the performance of
professional functions.

1. The social worker should accept responsibility
or employment only on the basis of existing
competence or the intention to acquire the
necessary competence.

2. The social worker should not misrepresent
professional qualifications. education. ex.
perience. or affiliations.

C. Service —The social worker should regard
as primary the service obligation of the
social work profession.

I. The social worker should retain ultimate
responSibiIity for the quality and extent of the
service that individual assumes. assigns. or
performs.

2. The social worker should act to prevent prac-
tices that are inhumane or discriminatory
against any person or group of persons.

D. Integrity -The social worker should act in
accordance with the highest standards of
professional integrity and impartiality.

l. The SOCial worker should be alert to and reSist
the influences and pressures that interfere
with the exercise of proteSSional discretion
and impartial judgement required for the per-
formance of profeSSional functions.

2. The social worker should not exploit profes-
sional relationships for personal gain.

3

 

 

consent. only for compelling professronal
reasons.

The socral worker should inform clients fully
about the limits of confidentiality in a given
Situation. the purposes for which information
is obtained. and how it may be used.

The SOCIal worker should afford clients
reasonable access to any official socral work
records concerning them.

When providing clients with access to
records. the sooal worker should take due
care to protect the confidences of others con-
tained in those records.

The somaf worker should obtain informed con-
sent of clients before taping. recording. or per-
mitting third party observation of their
activities.

Fees —When setting fees. the social
worker should ensure that they are fair,
reasonable. considerate. and commen-
surate with the service performed and with
due regard for the clients’ ability to pay.

. The social worker should not accept anything

of value for making a referral.

Ill. The Social Worker’s Ethical
Responsibility to Colleagues

J.

Respect, Fairness. and Courtesy —The
social worker should treat colleagues with
respect courtesy. fairness. and good faith.

. The social worker should cooperate with col-

leagues to promote proteSSional interests and
concerns.

The social worker should respect confidences
shared by colleagues in the course of their
professronal relationships and transactions.
The SOCIaI worker should create and maintain
conditions of practice that facilitate ethical
and competent profe55ional performance by
colleagues.

The somal worker should treat with respect.
and represent accurately and fairly. the
qualifications. Views. and findings of
colleagues and use appropriate channels to
express Judgements on these matters.

The socral worker who replaces or is replaced
by a colleague in professronal practice should
act With consideration for the interest.
character. and reputation of that coHeague.
The socral worker should not explOit a dispute
between a colleague and employers to obtain

0

132

11.

a position or otherwise advance the score
worker's interest.

The socral worker sho’uld seek arbitration o
mediation when conflicts with colleague:
reqUire resomtion for compelling professona
reasons.

The social worker should extend to colleagues
of other professions the same respect anc
c00peration that is extended to somal worl
colleagues.

The socral worker who serves as an employer
supervisor. or mentor to colleagues shoulc
make orderly and explicit arrangements
regarding the conditions of their continuing
prof885ionai relationship.

The spoial worker who has the responsibility
for employing and evaluating the performance
of other staff members. should fulfill such
responsibility in a fair. consrderate. and
equitable manner. on the basis of clearly
enunciated criteria.

The socral worker who has the responsibility
for evaluating the performance of employees.
supervisees. or students should share evalua-
tions With them.

Dealing with Colleagues’ Clients —The
social worker has the responsibility to
relate to the clients of colleagues with full
professional consideration.

The social worker should not assume profes-
sional responsibility for the clients of another
agency or a colleague without appropriate
communication With that agency or colleague.
The social worker who serves the clients of
colleagues. during a temporary absence or
emergency. should serve those clients with
the same conSideration as that afforded any
client.

IV. The Social Worker’s Ethical

Responsibility to Employers and
Employing Organizations

L. Commitments to Employing Organiza-

tion —The social worker should adhere to
commitments made to the employing
organization.

The SOClal worker should work to improve the
employing agency's policies and procedures.
and the efficiency and effectiveness of its
services.

Scholarship and Research —The social
worker engaged in study and research
should be guided by the conventions of
scholarly inquiry.

. The social worker engaged in research should

consrder carefully its possible consequences
for human beings.

The social worker engaged in research should
ascertain that the consent of partiCipants in
the research is voluntary and informed.
Without any implied deprivation or penalty for
refusal to particrpate. and With due regard l0r
partiCipants' privacy and dignity

The socral worker engaged in research should
protect participants from unwarranted
physical or mental discomfort. distress. harm.
danger. or deprivation.

The social worker who engages in the evalua-
tion of services or cases should discuss them
only for the professional purposes and only
with persons directly and proteSSionally con-
cerned with them.

Information obtained about participants in
research should be treated as confidential.
The social worker should take credit only for
work actually done in connection with scholar-
ly and research endeavors and credit con-
tributions made by others.

If. The Social Worker’s Ethical
Responsibility to Clients

F.

Primacy of Clients’ Interests—The social
worker’s primary responsibility is to
clients.

. The social worker should serve clients with

devotion. loyalty. determination. and the
maximum application of professional skill and
competence.

The social worker should not exploit relation-

Ships with clients for personal advantage.
The somai worker sh0uld not practice. con-
done. facrlitate or coHaborate With any form of
discrimination on the baSlS of race. color. sex.
sexual orientation. age. religion. national origin.
marital status. political belief. mental or
phVSical handicap. or any other preference or
personal Characteristic. condition or status.
The socral worker shOuld av0id relationships
or commitments that conflict With the
interests of clients.

133

10.

11.

The social worker should under no Cir-
cumstances engage in sexual activities with
clients.

The social worker should provide clients with
accurate and complete information regarding
the extent and nature of the services available
to them.

The social worker should apprise clients of
their risks. rights. opportunities. and obliga-
tions associated with socral service to them
The spoial worker should seek adVice and
counsel of colleagues and superVisors
whenever such consultation is in the best
interest of clients.

The somal worker should terminate serwce to
clients. and professronal relationships with
them. when such service and relationships
are no longer required or no longer serve the
clients’ needs or interests.

The somal worker should Withdraw services
preCIpitously only under unusual Cir-
cumstances. giving careful consrderation to
all factors in the situation and taking care to
minimize possible adverse effects.

The social worker who anticipates the ter-
mination or interruption of service to clients
should notify clients promptly and seek the
transfer. referral. or continuation of service in
relation to the clients' needs and preferences.

Rights and Prerogatives of Clients-The
social worker should make every effort to
foster maximum self-determination on the
part of clients.

When the social worker must act on behalf of
a client who has been adjudged legally in-
competent. the social worker should
safeguard the interests and rights of that
client.

When another individual has been legally
authorized to act in behalf of a client. the
somal worker should deal with that person
alwavs with the client‘s best interest in mind.
The socral worker should not engage in any
action that violates or diminishes the Civil or
legal rights of clients.

Confidentiality and Privacy —The social
worker should respect the privacy of
clients and hold in confidence all informa—
tion obtained in the course of professional
service.

The social worker should share with others
confidences revealed by clients. WithOut their

:3

2.

3.

The social worker should not accept employ-
ment or arrange student field placements in
an organization which is currently under
public sanction by NASW for violating person—
nel standards. or imposing limitations on or
penalties for professronal actions on behalf of
clients.

The social worker should act to prevent and
eliminate discrimination in the employing
organization's work assignments and in its
employment policres and practices.

. The social worker should use With scrupulous

regard. and only for the purpose for which
they are intended. the resources of the
employing organization.

V. The Social Worker’s Ethical
Responsibility to the Social
Work Profession

M.

Maintaining the Integrity of the Profes~
sion—The social worker should uphold
and advance the values, ethics,
knowledge, and mission of the profession.

. The social worker should protect and enhance

the dignity and integrity of the profession and
should be responsible and vigorous in discus-
sion and criticism of the profession.

The social worker should take action through
appropriate channels against unethical con
duct by any other member of the profession.
The social worker should act to prevent the
unauthorized and unqualified practice of
social work.

. The social worker should make no misrepre-

sentation in advertising as to qualifica-
tions. competence. service. or results to be
achieved.

Community Service—The social worker
should assist the profession in making
social services available to the general
public.

. The social worker should contribute time and

professional expertise to activities that pro-
mote respect for the utility, the integrity. and
the competence of the somal work profession.
The soc;ial worker should support the formula-
tion. development. enactment and implemen-
tation of social policies of concern to the
profession.

134

Development of Knowledge—The social
worker should take responsibility for iden-
tifying, developing, and fully utilizing
knowledge for professional practice.

. The social worker should base practice upon

recognized knowledge relevant to social work.
The somal worker should critically examine.
and keep current with emerging knowledge
relevant to socral work.

The sooal worker should contribute to the
knowledge base of social work and share
researcn knowledge and practice Wisdom
With colleagues.

VI. The Social Worker’s Ethical
Responsibility to Society

P.

Promoting the General Welfare—The
social worker should promote the general
welfare of society.

. The social worker should act to prevent and

eliminate discrimination against any person or
group on the basis of race. color. sex. sexual
orientation. age. religion. national origin.
marital status. political belief. mental or
physrcal handicap. or any other preference or
personal characteristic. condition. or status.
The social worker should act to ensure that all
persons have access to the resources. ser-
vices. and opportunities which they require.
The somal worker should act to expand choice
and opportunity for all persons. with special
regard for disadvantaged or oppressed groups
and persons.

The somal worker should promote conditions
that encourage respect for the diversity of
cultures which constitute American society.

. The social worker should provide appropriate

professional services in public emergencies.
The social worker should advocate changes in
policy and legislation to improve social condi-
tions and to promote seeial justice.

. The somal worker should encourage informed

participation by the public in shaping soaal
policies and institutions.

LPPERDIX B

LETTER TO HOSPITAL SOCIAL WORK DIRECTORS

APPENDIX B

Letter to Hospital Social Work Directors

XXXXXXX, 1993

Xxxxxxxxxx Xxxxxxxx

Director, Department of Social Work
Xxxxxxxxxxx Hospital

Xxxxxxxxxxx Street

Xxxxxxxxxxx, Michigan xxxxx

Dear XXXXXXXXXXXX,

My name is Jerry Clark. As you may recall, I was Director of
Social Work at Xxxxxxxxx Hospital for the past two years. I
resigned that position earlier this year.

I am currently a doctoral student at Michigan State University
and am in the process of writing my dissertation. That is the
reason for this letter.

My dissertation topic has to do with hospital social workers. I
am conducting interviews with social workers in this area and
would like to ask your assistance. Would it be possible to
interview social workers in your department for this purpose?

I am very aware of how busy hospital social workers are. I am
also aware of their commitment to scholarship and practice
excellence.

I will contact you within the next two weeks to talk with you
further. Please consider this request.

Sincerely,

 

Jerry L. Clark

135

APPENDIX C

CONSENT

APPENDIX C

Consent

Ethical Problems Faced By Hospital Social Workers
To Participants in this study:

I am a graduate student at Michigan State University in
East Lansing. The subject of my doctoral research is the
practice of social work in a hospital setting. I am
interviewing hospital social workers in the metropolitan
area. You are one of approximately thirty participants.

As part of this study, you are being asked to
participate in an interview. The interview should last
approximately one hour. In the interview you will be asked
to discuss your experience with ethical problems you have
encountered in your practice. Your responses will be
audiotaped and transcribed. The audio tapes will be erased
and transcriptions shredded three months following defense
of this dissertation. There will be no fee paid for your
participation.

I am interested in objective details of your practice.
I will not use your name, the names of people you mention,
or the name of your hospital. Your confidentiality will be
strictly preserved. You may withdraw from the interview at
any time without penalty.

In signing this form, you are assuring me that your
participation is voluntary.

I have read the above
statement and agree to participate as an interviewee under
the conditions stated above.

 

Signature of participant

 

 

Signature of interviewer Date

136

APPENDIX D

LETTER OF INTRODUCTION

APPENDIX D
Introduction

My name is Jerry Clark and I am a graduate student at
Michigan State University in East Lansing. The subject of
my doctoral research is the practice of social work in a
hospital setting. I am interviewing hospital social workers
in the metropolitan area. You are one of approximately
thirty participants.

Specifically, I want to talk with you about ethical
problems you have encountered in your practice. I am
interested in the nature of these problems. An ethical
problem exists when your professional values conflict with
those of someone else. Ethical problems may develop between
you and another professional or between you and an
individual with whom you are working.

An example of an ethical problem would be when the
members of a health care team know a patient is terminally
ill and the physician does not inform the patient of this.
In this example the ethical problem is between the
physician's value that to inform the patient would do him or
her more harm than good and the social work values of the
right to know and the right to selfedetermination.

There are three main questions I would like to discuss
with you. First, have you encountered such problems in the
course of your practice? Second, what individuals were
involved? Finally, how did you reconcile the problem.

If at any time you become uncomfortable and wish to
withdraw from the interview, you may do so. Thank you very
much for your time and consideration.

Jerry Clark

137

APPENDIX E

INTERVIEW PROTOCOL

APPENDIX E

Interview Protocol

The purpose of this interview is to talk with you about
ethical problems you have encountered in the course of your
professional practice. Ethics represent values in
operation. An ethical problem exists when your professional
values conflict with those of a colleague or with those of
an individual with whom you are working. Do you have any
questions?

I would like to ask you about four broad areas that
concern ethical problems in your practice.

1. Have you experienced ethical problems in your
practice within the last six months?

If yes: Would you please tell me about it (them)?

If no: What types of problems do you encounter in
your practice?

2. Who are the idividuals are involved in these
problems?

3. How successful are you in addressing these
problems? Please elaborate.

What obstacles do you encounter in your efforts to
address these problems?

4. As you deal with these problems, what guides you?
(e.g. own moral philoSophy, code of ethics)

During the course of the interview other questions may be
asked to probe responses or elicit elaboration.

138

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