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The Clinical Supervisor

ISSN: 0732-5223 (Print) 1545-231X (Online) Journal homepage: https://www.tandfonline.com/loi/wcsu20

Models and Methods in Hospital Social Work Supervision

Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin

To cite this article: Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin (2009) Models and Methods in Hospital Social Work Supervision, The Clinical Supervisor, 28:2, 180-199, DOI: 10.1080/07325220903324660

To link to this article: https://doi.org/10.1080/07325220903324660

Published online: 10 Nov 2009.

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Models and Methods in Hospital Social Work Supervision

GOLDIE KADUSHIN University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, United States

CANDYCE BERGER University of Texas at El Paso, El Paso, Texas, United States

CARLEAN GILBERT Loyola University School of Social Work, Chicago, Illinois, United States

MARK DE ST. AUBIN University of Utah, Salt Lake City, Utah, United States

This is the first qualitative study of the perceptions of hospital-based social work supervisees regarding their hospital supervision. Seventeen social workers were recruited using a national listserv and snowball sampling techniques. According to the perception of the clinical social workers participating in the study, hospital social work supervision is organizationally driven rather than worker-focused. Implications for social work education and research are discussed.

KEYWORDS hospital, managed care, models of supervision, organizational re-structuring

INTRODUCTION

Social work supervision has played an important but changing role in the development of the profession. Supervisors are agency managers who have been delegated authority to maintain the job performance of supervisees. In assuming this responsibility, the supervisor performs educational, adminis- trative, and supportive functions in a positive relationship with the supervisee.

Address correspondence to Goldie Kadushin, Professor, Helen Bader School of Social Work, University of Wisconsin-Milwaukee, PO Box 786, Milwaukee, WI 53201. E-mail: [email protected]

The Clinical Supervisor, 28:180–199, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 0732-5223 print=1545-231X online DOI: 10.1080/07325220903324660

180

The long-term objective of supervision is to prepare the supervisee to deliver effective, efficient services to clients, consistent with the agency’s mandate and professional practice standards (Kadushin & Harkness, 2002; Tsui, 2005). The administrative function of supervision is to organize the work of the supervi- sees to achieve agency objectives. This is the basic supervisory function. Edu- cational or clinical supervision improves the knowledge and skills of workers within the mandate of the agency. Supportive supervision reduces job-related stress and fosters worker self-awareness to cope with stress (Bogo & McKnight, 2005; Kadushin & Harkness, 2002; Tsui, 2005). These functions apply to any supervisor in any social work agency.

This paper focuses on social work supervision in hospitals. The sustainability of supervision in hospital settings is threatened by the elimina- tion of middle management and supervisory positions in favor of leaner, cost-effective structures. This reorganization reflects the influence of mana- ged care and capitated methods of financing that are reducing the hospitals’ access to revenue (Berger & Mizrahi, 2001; Globerman, McKenzie-Davies, & Walsh, 1996; Weissman & Rosenberg, 2002; Schmid, 2002). Consistent with these findings, a recent survey of licensed health care social workers reported increased job stress in the context of reduced access to supervision (Center for Health Workforce Studies, 2006).

The influence of managed care and capitated financing systems on hos- pital supervision has not been examined by social work researchers since 1996, the last year of data collection in a longitudinal study conducted by Ber- ger and her colleagues (Berger, Robbins, Lewis, Mizrahi, & Fleit, 2003; Berger & Mizrahi, 2001; Berger et al., 1996.) The existing research is also limited by an exclusive focus on the perceptions of supervisors. No research has examined hospital supervision from the perspective of the supervisee. An understanding of the supervisee’s views is necessary to inform the profession of unmet worker needs for oversight, support, and education in the social work health care labor force (Center for Health Workforce Studies, 2006). To begin to address this gap in the literature, a pilot study was conducted to answer the following question: What are the perceptions of supervisees about the current models and functions of social work supervision in hospitals? The hospital agency was the setting for this pilot study because previous research on super- vision in health care has been hospital-based, providing a knowledge base for the development of the study questions and instruments.

LITERATURE REVIEW

Hospital Reorganization: Impact on Social Work Hospital Supervision

Many theories explain the relationship between the hospital and the environ- ment (Netting, Kettner, & McMurtry, 2004) or those ‘‘external conditions

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that may affect the organization’’ (Schmid, 2002, p. 133). The merits of different theories are still debated, but all theories assume environmental circumstances influence organizational processes (Schmid, 2002). In particular, the immediate or task environment is assumed to affect organizational strategies and struc- tures (Schmid, 2002; Netting et al., 2004). The task environment includes patient populations, revenues, in-kind resources, competitive institutions, and federal and state regulators (Netting et al., 2004; Schmid, 2002).

In the early 1980s, health care delivery and funding underwent a radical change in the United States with the introduction of a Medicare capitated payment system for hospital care. Capitated payment is a form of managed care. Managed care can be defined as a payment and health care delivery sys- tem that regulates, monitors, and coordinates resources to contain costs and increase efficiency. Introduced into the United States to reduce spiraling health care spending in the early 1980s, managed care is now the dominant arrangement in both public and private sectors.

Because a capitated payment system transfers risk from payer to provi- der, the Medicare prospective payment system reduced hospital revenues. Aware of the risk of cost-shifting, private and public third-party payers also adopted managed care payment and delivery procedures. Hospitals were confronted with an unstable, rapidly changing environment in which fierce competition for scarce resources and patients existed. In this context, the- ories predict that organizations will revise strategies and structures to reassert control over actors in the task environment (Schmid, 2002).

Hospitals responded by developing alliances with multi-hospital sys- tems, merging with competitive institutions, and separating functions into independent, decentralized programs or teams (Lee & Alexander, 1999; Bazzoli, Dynan, Burns, & Yap, 2004; Weil, 2003). The effect of hospital reor- ganization was to reduce operating costs by consolidating management and duplicative services. However, this strategy also eliminated the positions of middle managers and social work directors who provided supervision, decreasing institutional resources to support this function (Kadushin & Harkness, 2002; Weissman & Rosenberg, 2002).

A government-mandated managed care program implemented in the 1990s in Canadian hospitals is suggestive of the effect of hospital restructuring on social work supervision. The introduction of managed care was the impetus for the dismantling of Canada’s hospital social work departments. Social work supervision decreased in the absence of an administrative structure (e.g., social work directors and supervisors). Canadian hospital workers organized peer groups to provide clinical and supportive consultation but they had no access to formal supervision (Globerman et al., 1996; Globerman, White, & McDonald, 2002; Globerman, White, Mullings, & McKenzie-Davies, 2003; Michalski, Creighton, & Jackson, 1999). While this research is specific to the Canadian health care system, it is suggestive of the potential impact of mana- ged care and hospital restructuring on worker access to formal supervision.

182 G. Kadushin et al.

Kadushin and Harkness (2002) hypothesize that clinical and supportive supervision, which are resource-intensive, non-revenue-generating functions, may be assigned a low priority by hospitals impacted by managed care. They suggest, however, that because administrative supervision directly benefits the organization, it may be the sole form of supervision recognized by hospi- tals within an environment of cost containment (Kadushin & Harkness, 2002).

Models of Social Work Supervision

Models of social work supervision can be differentiated by levels of agency control. At one extreme is the ‘‘casework model’’ or scheduled one-on-one individual social work supervision, which is based on high levels of admin- istrative accountability. At the other extreme is the autonomous practice model, which is characterized by professional autonomy of the supervisee. Between these extremes on the continuum of administrative accountability are group, team, and peer supervision models (Bogo & McKnight, 2005; Kadushin & Harkness, 2002; Tsui, 2005).

Individual supervision is the most widely used model of supervision, particularly for unlicensed or inexperienced (less than two to six years of practice in the same setting) workers (Kadushin & Harkness, 2002). It is delivered in a one-on-one tutorial session scheduled weekly for at least an hour. The demands of time and effort required by this model may be challen- ging to hospital-based social work supervisors who have corporate or wide- ranging administrative responsibilities.

Group supervision is the second most widely adopted model of supervision. It is characterized by the presence of a formal social work supervisor who performs the functions of supervision—administrative, educational, and supportive—in a group format. Group supervision is a supplement to, not a substitute for, casework supervision.

The introduction of group supervision is ideally preceded by worker preparation for the change and agreement by the staff. The advantages of the group modality are conservation of time and resources; lateral peer learn- ing; and sharing and normalization of job-related stress (Bogo & McKnight, 2005; Kadushin & Harkness, 2002; Sulman, Savage, Vrooman, & McGillivray, 2004; Tsui, 2005).

Peer supervision is supervision led by a peer group; in this situation, no supervisory oversight or authority exists. All participants hold equal status in terms of accountability and responsibility for their own practice. The purpose of peer group supervision is to provide educational=clinical supervision through case conferences and the exchange of clinical expertise and guidance. Peer supervision is a supplement to, or a substitute for, educational= clinical supervision (Brashears, 1995; Barretta-Herman, 1993; Hardcastle, 1991; Kadushin & Harkness, 2002; Sulman et al., 2004; Tsui, 2005). Team supervision is led by a team leader who may or may not be a social worker.

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In team supervision, intradisciplinary workers may exercise autonomy, collectively make decisions about work assignments, case dispositions, perfor- mance checks, and professional development, providing educational=clinical guidance and oversight and allocating work assignments. The supervisor is a team member but retains administrative accountability for team performance (Kadushin &Harkness, 2002; Tsui, 2005). On interdisciplinary teams, the leader may be a physician, nurse, or other medical professional who assumes super- visory authority over the other team members (Kadushin & Harkness, 2002).

The question of the prevalence of supervision models in hospital-based social work has generally been ignored by social work research. Berger and Mizrahi (2001) examined supervision from the perspective of supervisors in a national sample of hospitals in 1992, 1994, and 1996. They found that in the early to late 1990s, individual and group supervision were the most frequent models (these models were collapsed into the category ‘‘formal supervision’’). Peer supervision (consultation) was the second-most frequent model. The use of non-social work supervision significantly increased over all time periods.

Health care social workers speculate that as hospitals restructure and eliminate social work managers and departments, the resources to support the traditional individual supervision model will decline. Workers will have to take the initiative in finding support for supervision outside the hospital or by creating group or peer models that use collective resources efficiently. The caution is the need for thoughtful planning, implementation, and a mechanism for training and evaluation to accumulate research to inform the profession regarding the efficacy of innovative supervision models (Berger & Mizrahi, 2001; Kadushin & Harkness, 2002).

METHODOLOGY

This qualitative study was implemented using telephone focus group interviews. Focus groups have been widely used as a data collection method in qualitative research, and growing evidence supports the efficacy of telephone focus groups or ‘‘telegroups’’ as an alternative to face-to-face focus groups (Cooper, Jorgensen, & Merritt, 2003; Appleton, Fry, Rees, Rush, & Cull, 2000). Using the Society for Social Work Leadership in Health Care membership as a sampling frame, researchers employed purposive and snowball sampling techniques. Social work directors=managers were contacted by electronic mail using the organization’s listserv. The e-mail explained the purpose and method of the study and encouraged social work directors=managers to share the attached flyer with their staffs. Inclusion= exclusion criteria were as follows: graduate-level social work staff (i.e., MSW, PhD, DSW); 50% currently employed in an inpatient or outpatient hospital setting; one or more year working in clinical practice; at least one year of experience in the current setting; and English-speaking.

184 G. Kadushin et al.

Eligible staff members e-mailed the Principal Investigator (PI) to indicate their willingness to participate. The PI responded to the e-mail and screened the subject for eligibility. If he or she qualified for the study, the PI sent an electronic version of the consent form that was approved by the institutional review boards (IRBs) of every member of the research team. A waiver of signature for consent was obtained from the IRBs in order to ensure anonym- ity of the participants. In developing the focus groups, every attempt was made to ensure that subjects from the same setting did not participate in the same focus group to prevent voice identification.

The PI contacted the individuals by phone to discuss the study, answer questions, and confirm their willingness to participate. Subjects were also encouraged to share information about the study with their colleagues within their own and other health care settings. Given the use of the listserv and the snowball sampling technique, it was not possible to calculate how many social work clinicians in health care settings were informed of the study to produce a response rate.

The subjects were made aware of scheduled times for the focus groups and selected a group. The subjects were asked to adopt fictitious names to be used during the telegroup; these same names are also used in the data presentation that follows. The intention in using fabricated names was not only to increase the level of confidentiality, but also to ensure that each person in the telegroup session had a distinguishable name. An e-mail was subsequently sent to the participants confirming the time of the telegroup, the phone num- ber that the participants called to access the focus group, the conference call identification number to be used, and the fictitious name that they selected for use during the telegroup and additional flyers advertising the study to share with colleagues. This e-mail also contained the fictitious names of the other participants and the focus group leader. A similar e-mail was sent to the group facilitators. Focus group facilitators were aware only of the fictitious names and geographic location of the participants; they were not given any other identify- ing information about the participants in their groups. The day before the tele- group, the PI sent an e-mail reminder to each participant with the same information contained in the previous e-mail.

Once this reminder e-mail was sent, the PI erased any electronic information required in setting up the conference calls in order to ensure anonymity within the actual focus groups. If a participant did not call the access number for the telegroup, it was impossible to contact him or her since all identifying information was erased. However, most of the partici- pants who were not able to attend their assigned focus group did contact the PI to reschedule another time to participate. A private teleconferencing company was used to set up the conference calls for the focus groups.

The members of the research team served as the facilitators of the focus groups; the focus groups took about 60 minutes. Telegroup members were instructed to use only their fictitious names in identifying themselves.

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A semi-structured interview schedule was finalized following a literature review and the consensus of the four researchers who contributed both academic knowledge and practice experience in supervision. The interview schedule consisted of a series of six open-ended questions and accompanying probes related to the following topics:

1. access to individual educational=clinical supervision; 2. access to different models of supervision (e.g., group, peer); 3. supervisors’ professional discipline; 4. administrative supervision and accountability for job performance; 5. use of outside supervisors; and 6. organizational changes affecting supervision.

This semi-structured interview schedule was followed in each focus group to ensure some comparability. Major topic questions were presented to each group separately to maintain a focus on the topic, but group leaders had the flexibility to explore issues raised that did not coincide with the topic questions. The topic questions were read aloud by the facilitator, who then prompted the group for responses. Once discussion was underway, the facil- itators intervened only as necessary to guide, probe, or provide support. This procedure aided in conducting groups that were focused, without excessive and counterproductive constraints on their interaction.

All interviews were audio-recorded and then transcribed by members of the research team or by the teleconferencing company. The focus group sessions began with an assignment of a study identification number. Only the study identification numbers appeared on the transcripts. Any identifying information on the tape (e.g., names of individuals, institutions, and locations used in the discussion) were deleted from the transcript. Once the transcript was checked for accuracy, the audiotapes were destroyed.

Using a grounded theory approach to data analysis, the narrative data was pre-coded into conceptual categories. Content was then grouped into broad categories to detect patterns and relationships. Through further coding, these categories were reduced to reveal consistencies and inconsistencies in the data. When codes fit wellwith old and newdata, theywere reviewed again in order to identify focused themes to enhance understanding. This paperwill focus on two key themes that appeared to influence the participants’ perceptions of supervi- sion: the organizational context and the multimodal approach to supervision.

FINDINGS

Sample Characteristics

The majority of the 17 focus group participants were licensed; 5 subjects were not licensed. In general, the participants were experienced workers;

186 G. Kadushin et al.

five had supervisory responsibilities and also carried caseloads. All participants were employed in hospitals as social workers and, with one exception, all were women. One participant was employed in a psychiatric hospital; the remaining sample was employed in medical hospitals.

Organizational Context and Sanction for Social Work Supervision

One of the dominant themes related to the organizational context was the amount of change that the practitioners were experiencing in their settings. For some, the change had more to do with roles, while for others restructur- ing and resizing strategies led to the elimination of social work directors, transfer of reporting relationships to non-social work personnel, and=or implementation of matrix models for organizational structure. These matrix structures retained a social worker as one of the managers, but the supervisor could be a nurse, a social work department director, or a social worker at the corporate level. Lisa, an unlicensed social worker in an outpatient dialysis unit, described a matrix structure of supervision in her setting.

It’s just been a very large growth boom within this organization. So, right now my clinical supervisor is the only director for all social work depart- ments in the corporation. So that does limit her availability with that change. I receive clinical supervision monthly by phone and we meet every three months as a group. I have a direct supervisor at the center and she is an RN. For, you know, more of the actual clinical needs with the patients that I’m seeing day in and day out, my tasks, the issues that come up within my actual work setting, it’s really underneath the RN clinical manager. But the corporate director of social work and the direct clinical manager do communicate when they need to.

Abigail, a licensed social worker in a large hospital in a corporate system, describes a matrix organization in discussing her supervision:

I meet with my director two times a month now, and then I have a man- ager [nurse] here that I have access to whenever I need to talk to someone.

Other workers experienced the loss of their social work supervisor and had to advocate for supervision by an MSW.

Previously we had a social work supervisor and there was more clinical supervision, but she was replaced by a nurse because she did not have the medical knowledge that the hospital wanted. There is no understand- ing of the social work role in this setting. (Jan)

In one hospital, the social workers acted more proactively in response to the elimination of their social work director. The director had been demoted, and they were then expected to report to a nurse. The social workers began

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meeting as a group to provide peer support and supervision, and this led to political action. They were successful in getting the hospital to allow a licensed social worker to be a consultant in order to provide supervision to staff.

Our previous social work supervisor was demoted and replaced by a nurse supervisor. The new supervisor does not know much about social work. After this happened we advocated for a social work super- visor, and the hospital hired a social worker who is a consultant for supervision. (Will)

Organizational changes and the exponential increase in the scope of the managers’ responsibilities made access to supervision problematic. The participants reported that many social work supervisors carried wide-ranging administrative responsibilities for corporate social work systems, entire geographic areas, or several hospital departments. Even when the partici- pants had social workers as managers or supervisors, some reported that their ability to obtain supervision was eroded by the increased administrative demands of their supervisor, particularly if the social work supervisor was the department director. Many described ad hoc supervision based on the supervisor’s availability rather than the workers’ needs. When they met with their supervisor, the sessions were often described as shorter:

Our company was bought out by a larger company. Now it is harder to communicate with higher people in the company . . . . Previously we had access to social work supervision but the supervisor is less accessible now and the quality of supervision is not as good. (Dodie)

One of the other things that might be a limitation is that we have over- taken many other centers throughout the United States and it’s just been a very large growth boom within this organization. So, right now she [the social work supervisor] is the only supervisor for the entire area. She is the director of the entire department nationwide. So that does limit her availability with that change. (Lisa)

He’s [the director] on a lot of different boards at the hospital. And the hos- pital is going through some changes where the person who is the head of the hospital is going to be stepping down and they’re going into a search committee to be looking for a new president of the hospital. He’s involved a lot in that type of thing. So, I think that, where you don’t have a time that’s set up, sometimes it’s difficult . . . versus if you have a super- visor who’s more accessible around the hospital. (Barb)

Others reported the presence of licensed clinical supervisors within their work unit who provided supervision.

[Supervision] was by an RN because it was also under the offices of the case management department. And what the social workers did, we

188 G. Kadushin et al.

actually fought to have a clinical supervisor. So, the most senior social worker who was an LCSW took on the role of supervising us . . . . (Cathy)

Another factor that seemed to influence the frequency and mode of supervision related to the status of the worker. In some but not all hospitals new workers to the organization or service, or those who were preparing for licensure, reported that they were more likely to receive scheduled, frequent clinical supervision. This access may have been influenced by variations between states’ licensure requirements.

The first six months on this job, I am way past licensure, we are super- vised once a week. Then after six months, it is once a month . . .or as needed. (Judy)

. . . in order to keep their licensure, they need to meet with the director of social service once a week. (Debbie)

As supervisors assumed responsibilities for oversight of entire geo- graphic regions or director positions over all social work departments in a corporate system, communication technology appeared to be an essential tool to facilitate access to supervision. Participants reported the use of cell phones, pagers, e-mail, and the Internet as helpful tools to ensuring access to clinical supervision or consultation.

Pretty much on a daily basis, several times a day . . .we’re on the Internet so we have a direct e-mail access to each other all day long. I do mostly [supervision] by phone about 20% clinical and the rest is administrative, and we have a quarterly meeting with the supervisor every month. (Lisa)

I have access to clinical supervision as needed basically. I like the flexibil- ity of being able to call him on a whim if I’m in the middle of something and it’s stumping me or whatever I need to—or if something’s really both- ered me that’s happened that I need to talk about . . . . I have that ability then to page them and they’ll get back with me and so forth. (Elizabeth)

Ultimately, the strongest factor influencing the availability, frequency, and models of supervision was organizational sanction. The participants reported an array of scenarios ranging from complete disbanding of the social work program with social workers reporting to non-social work lea- ders to centralized social work departments with social work managers and supervisors. Organizational recognition and sanction for the importance of social work supervision and the allocation of resources to the supervisory function seemed to define the organizational context for supervision. Tracy, a licensed social worker in a mental health hospital, attributed her access to

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supervision to the organization’s recognition of the salience of social work supervision.

The flexibility of having access to individual supervision pretty much whenever I need it is pretty useful. Like someone who said that their licensure doesn’t require supervision, nor does mine, but my unit supports it, my director supports it and her director supports it.

Administrative sanction is poignantly captured in the following scenario. Although supervisory staff existed, they were unwilling to provide clinical supervision to non-licensed workers.

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