Hospital Social Workers in the US

The article is addressed to a wide range of readers, from the public unfamiliar with the topic of social work generally to the experts who have not had a chance to know the specifi cs of hospital social work in the United States. The goal is to provide an up to date overview of the subject in the current post-presidential election climate. The article does not provide a deep analysis of social work methods. It rather analyses the selected characteristics that are important for defi ning the hospital social worker’s current and future role in the US health care system. It briefl y describes the development of the hospital social worker’s status and his or her duties since the beginning of the twentieth century, the current job characteristics, and the educational necessities. It also compares their salaries in diff erent regions in the US. The same method is used when dealing with the value of the hospital social work and the negative aspects of the job. Two research studies are introduced and the results of each are compared in order to prove and understand those issues. In the last part of the article, the current situation in the health care area is briefl y described, focusing on the consequences of the cost-cutting political eff orts for hospitals. Future demographical, cultural and racial issues in the US are brought up and the predicted fi gures are compared with the past ones. Those are put into the context with the hospital social worker’s current and expected future role in the health care area. The conclusion synthesises used data and information and put forward the crucial changes needed in the future hospital social work fi eld.


Introduction
Hospital social work has had a long tradition in the US since the beginning of the twentieth century. Th e overall economic development and social demands infl uence the form of this type of social work just like any other fi eld. Th e article introduces the hospital social worker's job in a complex way, putting together economic as well as demographical and some specifi c, internal factors. While the fi rst part of the article deals with the signifi cant changes over time, the second part faces the current hospital social worker's profi le and its relevant issues. Enough space is given to the characteristics of the hospital social worker's duties and responsibilities as well as to the necessary personal qualities and skills. Due to the fact that economic status and fi nancial security have a major importance in the US, the educational necessities and salary options will be introduced as well. For more than three decades, there has been a long-lasting eff ort to save money in the US health care system. Th is, of course, has had an impact on the whole medical fi eld. Signifi cant consequences have been taking place such as reducing numbers of social workers in hospitals, rising pressure in the workplace, and the increasing complexity of the job. Besides the cost-cutting eff orts, there are other factors infl uencing the hospital social worker's job. Th ose include multicultural and racial matters, the working environment, the size of institutional support, or the lack of evidence-based documentation proving the hospital social worker's effi ciency and necessity. All of these matters will be discussed in the relevant context in the last two parts of the article.

Th e Development of the Hospital Social Worker's Role in Time
Th e role of social work and hospital social workers themselves has been changing due to changes in American society. Th e beginning of the twentieth century brought fi nancial support into the medicinal and health care area. Th ere was a change in the status of hospitals as well. Th ey started to resemble businesses rather than charity settings and the poor became patients or, in more modern language, clients. Naturally, social work within hospitals followed this trend. 2 At fi rst social work service programmes were helping with identifying patients to relieve the overcrowding of hospitals due to civil war and setting up volunteer units for poor patients. Th e function of hospital social workers was to help patients as well as to help with organisation in the hospital setting. In a general sense, they had the same working status as nowadays. It was the 7 2017 complexity of the job which came later on. 3 In 1918, the American Association of Hospital Social Workers (AASW) was established and there was a signifi cant rise in number of hospital social work departments as well as an expansion of social workers' roles and duties. Social workers became a helping mediator between the patient and his or her doctor, and at the same time they helped patients to understand their diagnosis and the treatment they were undergoing. 4 Another important issue was to defi ne the hospital social worker's position towards doctors and hospital staff in general. Th e growing importance and prestige of physicians led to the tendencies or eff orts to treat social workers as subordinates rather than as cooperating members of the hospital teams. 5 In 1926, there was a split between the social workers who work with medical doctors and the social workers who work with psychiatrists followed by the conference of AASW in 1929 where the most important job duties of hospital social worker were expressed. Th ose included medical-social diagnosis and its interpretation, teamwork, casework, discharge planning, fi nancial solutions for the chronically ill and disabled, and several others. Psychiatric social workers later established their own organisation, the American Association of Psychiatric Social Work (AAPSW). 6 Since World War I, hospital social workers have followed the trend of forming group practices like those created by physicians. Th ese include several diff erent specialists in the fi eld and enable to work with patients in more fl exible and holistic way. 7 In the early 1950s, all national social organisations merged into the new National Association of Social Workers (NASW). Due to the specialised knowledge of the medical fi eld, it was not an easy decision for hospital social workers existing at that time under AAMSW (American Association of Medical Social Workers). Th e newly formed NASW's goals were making the social profession even more professionalised and formalised. 8 Another event that was very important in American health care history in general was the establishing of Medicare and Medicaid, which occurred in 1965. Th e founding of these federal programmes (which fi nancially ensured health care for the elderly and the poor) caused an increase in these kinds of patients in hospitals and the further development of social hospital work as well. 9 In the 1970s, hospital social work became more and more specialised, following the general trend in medicine. Th e eff orts of proving the effi ciency and productivity of social work praxis in numbers appeared. How to go about measuring social work has been a very important question, mainly because of the topic of its usefulness and either the indispensability or dispensability of social workers in hospitals. Th ese discussions arose in the 1980s and it has been this way since then. Th e main reason was due to attempts to reduce the costs of health care and these discussions have continued to last into the present. Naturally, the circumstances put more pressure on hospital social workers and have diminished their infl uence, mainly because there has been a signifi cant drop in the number of them in administrative and managerial areas. Because of this, the workload of an individual hospital worker has increased. 10 7 2017

Job Characteristics
Th e hospital social worker helps the patients and their families to address and solve the physically, socially, and economically diffi cult situation and problems connected with the patient's health condition. His or her specialisation within a hospital varies and generally correlates with the hospital departments. 11 Th eir job duties include the following areas.
• Medical-social diagnosis: Th e hospital social worker helps patients to understand their medical condition and treatment options and prepares them for the consequences of various treatments or for treatment refusal. Consequently, he or she helps them to make those necessary changes in their lifestyle. 12 • Team work: Th e hospital social worker cooperates with doctors, nurses and other health care professionals. He or she informs them and helps them to consider the eff ect of the patient's physical condition on his or her mental health or emotional state. 13 • Case work: Th is includes a follow up with patients during their case. Th e social worker should ensure himself or herself about the improvement of the patient's situation in the future. Th is duty is connected with the evaluation of services provided by hospital social workers. Th e eff ective outcomes should be ensured for a positive job status as well. 14 • Discharge planning: Th e hospital social worker prepares patients for the transition from hospital settings back to their homes, communities and (in case of serious illness or dying patients) to the alternative facilities such as hospices or specialised clinics. He or she provides for transportation, arranges for in-home medical equipment, and coordinates the follow-up treatments. He or she cooperates with the service provider agencies in order to develop a care plan for a patient if necessary. He or she gives patients and their families the information about various services such as home health care or support groups in their local community. 15 Long, chronic or serious illnesses are usually connected with high medical expenses and (even if some patients have the insurance coverage) the out-of-pocket expenses could be signifi cant. Th e hospital social worker can deal with those fi nancial problems by helping patients to apply for benefi ts provided by Medicaid or other types of government or community support. In other words, he or she should be able to arrange for resources to fi nance the medication and services which are needed. 16

Personal Skills and Qualities
Th e hospital social worker's job can be challenging and psychologically very demanding. Th e hospital social worker meets people in stressful, diffi cult situations. Th ese are oft en seriously ill and have to deal with the consequences of their health condition. To be able to successfully manage the job a hospital social worker should possess certain qualities and skills, such as: • Compassion and empathy -for understanding problems of people and the ability to develop a trustworthy relationship with them. In addition to these qualities, a hospital social worker has to be able to listen to the patients' needs. 17 • Organisational and time-management skills -the ability to help and manage caseloads. Th e medical social worker takes care not only of his or her own documents, but they oft en assist and guide the patients with their paperwork as well. Due to there usually being a large number of patients, a medical social worker must effi ciently manage his or her time in order to provide help for all of them equally and fairly. 18 • Problem-solving skills -to be able to deal with patients' problems. A hospital social worker has to be an advocate for patients and stand by them. He or she needs to fi nd an eff ective solution for many specifi c situations connected with patients' health conditions. 19

Education and Salary
Th e basic educational requirement for a job in a social work area (including the hospital social work area) is a bachelor's degree. However, for the majority of medical facilities a master's degree in social work is the best option. Th e job training includes lots of hours in praxis. Th e practical part of the studies is called a fi eld placement. 20 As soon as an individual has successfully gained his or her master's degree, he or she can become a licensed social worker. In order to obtain the license, one has to fulfi l the conditions and requirements of the state in which he or she wants to work. Th e standards for licensing vary; there is a tendency to place emphasis on communicative skills, professional ethics, and an awareness of cultural diversity. 21 Th e requirements of individual states are provided by the Association of Social Work Boards. 22 Th ese also include a specifi c number of supervised working hours and this supervision must be done by a licensed social worker. Th e license is not mandatory, though, for some hospitals or other medical facilities hire social workers who are still in the process of working on their certifi cation. 23 On the other hand, most insurance providers require the license in order to be willing to reimburse for services. 24  the US earn $67,700 (median) while their counterparts in the Midwest earn only $55,000 (median). Regarding diff erences according to practice area, the highest annual salaries are in administration ($92,000 median). Length of experience has an evident impact on hospital worker salaries as well. Th e hospital social worker with less than nine years of practice earns annually $52,000 (median) while one with more than 20 years of practice earns $64,900 (median). 26

Th e Value of Social Work in Hospitals
As health care spending has been constantly on the rise, hospital administrators oft en view social workers and their work as expendable. Th ere has been pressure to prove the cost-eff ectiveness of social work in hospitals. On the other hand, the hospital infrastructure has to allow the collaboration and utilisation of data that can support and prove the need for hospital social work. For example, tracking the successes of discharge processes could be the way of showing and proving the effi ciency of hospital social workers. 27 Charles Aurebach, Susan E. Mason and Heidi Heft La Porte did a research study to prove there to be a more quality outcome with patients being served by social workers in comparison with patients treated without social workers' help. Th eir study reviews the two-year data set documenting social work activities on medical-surgical units of a large medical centre. 28 Th e data shows that 64,722 patients were admitted to the hospital medical-surgical area within two years (2002)(2003)(2004) and 15.7% of them were served by social workers. Th e mean age of patients with social work assistance was higher (68.8) in comparison with others (53.8). Th ose patients with social work service had a signifi cantly higher length of stay (11.4 days) in comparison with those without this service (4.3 days). Th e most frequents services provided to patients were assessment (85.7%), discharge planning (80.7%), hospital staff cooperation (67.8%), health education (33.3%), individual counselling (23.7%), family counselling (33,0%), and fi nancial counselling (18.5%). 29 As the age and complexity of the social services provided show us, social workers are assigned to the most diffi cult cases. Th ose cases would be problematic to solve without eff ective social work involvement. Th us, those facts suggest that seeing hospital social workers as expendable is inadequate. Hospital social workers are trained to solve a combination of physical, mental and social issues that are out of the range of the usual diagnostic numbers and facts. 30

Negative Aspects Infl uencing Hospital the Social Worker's Job
Th e hospital social worker deals with the sick that are oft en in a very diffi cult situation suff ering physically, emotionally, or even socially on a daily basis. As was mentioned before, social workers are intensively prepared for the possible obstacles during their studies and practice. On a longterm basis or with a diff erent hospital environment, some negative working aspects might arise.

2017
and Christine Grady investigated the reference frame of several work factors (ethical climate and ethical stress, job satisfaction and the intention to leave one's job) among nurses and social workers in the United States. Questionnaires were sent to 1215 randomly selected nurses and social workers in four census regions of the United States. Th e results and following discussions can be presented within the following three parts. 31 • Ethical stress and its consequences -32.5% of respondents felt powerless and 34.7% overwhelmed with ethical issues at their workplace. Th ose frustrated were 52.8% and 40% felt fatigue when unable to solve ethical issues. Almost two thirds of respondents confi rmed that there are some ethical issues which cannot be infl uenced. 32 • Th e diff erences. Racial and cultural trends -hospital social workers expressed more ethical stress than their counterparts from other settings. Th is fact could be infl uenced by the greater size of the hospital settings, and thus by the higher number of staff and patients. Regarding racial diff erences, African-American nurses felt less satisfi ed than their white colleagues. In multicultural American society with its changing demographical trend, racial and cultural issues will have to be addressed. Th is matter will be dealt with in the last part of this article introducing future trends in hospital social work. 33 • Working environment and institutional support -the working environment contributes strongly to one's attitude toward the job. An overall positive climate and job satisfaction worked against the intention of correspondents to leave their jobs. Being a respected and valued member of the team is more infl uential than staffi ng patterns and salaries, which are oft en overestimated by traditional economic models. Institutional support correlates with ethical stress as well. Social workers are trained to recognise, address and deal with ethical stress. Sadly, with no support and respect in their workplace, their ability cannot be adequately used. On the other hand, with a supportive environment social workers are able to deal with much higher ethical stress while still being happy with their job. Consequently, overall job satisfaction has a signifi cant eff ect on care and its quality and, in this sense, on spending as well, which is crucial. 34

Th e Current Situation and Possible Trends for Hospital Social Work
In the fi nal part of this article, let me introduce the current situation of hospital social work and its possible future in general social and political contexts. Th e most infl uential seems to be the fi nancial issues, specifi cally, the long-lasting eff ort to reduce the health care spending and its impact, and the future demographical changes in the US population. Aft er the 2016 presidential elections and transition of political powers in the US government, the future of health care reform is still unclear. Th e intention to save money in the health care industry has been strong since the spending is enormous and at the highest worldwide. As already mentioned in chapter one, there have been the consequences of those cost-cutting eff orts in the hospital, for the social workers mainly in management, and the administration area. On the other hand, the workload of a single hospital social worker is increasing. One of the specifi c reasons for tight hospital budgets for social workers is reduced Medicare payments to hospitals. Medicare is 31

2017
a federal programme ensuring coverage for elderly Americans. During the processing of the 2010 health care reform, Medicare's budget was lowered in order to broaden coverage for more uninsured Americans. As elderly people represent a signifi cant part of hospital patients and social workers' clients, these Medicare cuts could have the fi nancial impact on hospital social work as well. 35 Despite the eff orts, health care spending is still on the rise and many Americans are dealing with their medical bills. Th us, the duties of a hospital social worker connected with fi nancial advising and counselling will be on the rise. As the budget limitations for hospitals have been diminishing along with the number of managerial and administrative staff , it will defi nitely increase the need for self-care and self-monitoring among social workers in practice for the future. 36 Talking about future and possible trends in US society for hospital social work, a lot of infl uence could be had by a changing demographical trend in the US population and its eff ect. While in 1980 there was 11.3% of population above 65, the expected number in 2020 is 16.3%, and 20.4% in 2040. Whereas the percentage of seniors is growing, the population of people from 0 to 19 years old is declining (from 31.9% in 1980 to 25.9% according to the prediction for 2040). Elderly people tend to need more health care. In addition, due to a longer life expectancy, the majority of those elderly will be white. Such a change could bring more intercultural and racial issues. 37 All of the duties of hospital social workers are likely to increase and become even more complex due to the social changes and budget diffi culties in the health care area. In addition, he or she will have to become more sensitive to intercultural and racial matters. All of those mentioned circumstances also bring the question of how to attract and retain staff with professional skills and personal qualities for the job. For this issue, the need for improving working conditions will arise even more intensively. Furthermore, due to the prevailing fi nancial troubles, hospital social workers will have to manage the evidence-based outcome assessment to clearly demonstrate their economic importance and value for patients, hospitals, and the whole society. 38

Conclusion
Th e future of hospital social work depends on general factors, as well as on specifi c ones. Among the general elements, the future of US health care reform and its subsequent fi nancial solutions are the most important. Whether the system will be almost completely private or some of the federal programmes like Medicare and Medicaid will stay, it is determined by the current president Trump and his administration. Th e specifi c factors for the hospital social worker's job (which are crucial) include the cooperation of the hospital social workers themselves with hospitals and relevant institutions on establishing: • the evidence-based outcome assessment -in order to prove the value and effi ciency of the job; • the professional preparation for the future demographical and culture-racial changes in the population; • the quality teamwork in the workplace among social workers, doctors, nurses and the hospital staff in general; • the educational and practical preparation of hospital social workers including the development of their independency, self-care, and self-monitoring skills; • the improvement of the working environment in order to retain staff with professional skills and high personal qualities necessary for the job, and the institutional support for social workers and nurses to be able to cope with the working stress and other negative psychological issues.

Abstract
The article is addressed to a wide range of readers, from the public unfamiliar with the topic of social work generally to the experts who have not had a chance to know the specifi cs of hospital social work in the United States. The goal is to provide an up to date overview of the subject in the current post-presidential election climate. The article does not provide a deep analysis of social work methods. It rather analyses the selected characteristics that are important for defi ning the hospital social worker's current and future role in the US health care system. It briefl y describes the development of the hospital social worker's status and his or her duties since the beginning of the twentieth century, the current job characteristics, and the educational necessities. It also compares their salaries in diff erent regions in the US. The same method is used when dealing with the value of the hospital social work and the negative aspects of the job. Two research studies are introduced and the results of each are compared in order to prove and understand those issues. In the last part of the article, the current situation in the health care area is briefl y described, focusing on the consequences of the cost-cutting political eff orts for hospitals. Future demographical, cultural and racial issues in the US are brought up and the predicted fi gures are compared with the past ones. Those are put into the context with the hospital social worker's current and expected future role in the health care area. The conclusion synthesises used data and information and put forward the crucial changes needed in the future hospital social work fi eld.