EVOLVEMENT OF VOICE OF SOCIAL WORKERS AND USERS IN INTERPROFESSIONAL AND INTERAGENCY COLLABORATION

Social Group Work: Building a Professional Collective of Hospital Social Workers

Joanne Sulman, MSW, RSW
Diane Savage, MSW, RSW
Paul Vrooman, MSW, RSW
Maureen McGillivray, MSW, RSW

Social work’s professional mandate in acute care is extremely ambitious. At an emergency room pace, workers respond to the crises that patients and families experience. As health care advocates, they identify patient care issues and gaps in community services. Social workers design multi-layered micro, mezzo, and macro level interventions and spearhead action plans. In teaching hospitals they anchor the constantly changing staff on patient care teams. The mediating function inherent in social group work is one of their leading interdisciplinary practice tools. In addition, social workers are the community workers for systems whose permeable boundaries flow beyond the walls of the hospital. Research and teaching are done “in their spare time.”

IMPACT OF CHANGES IN HEALTH CARE ON HOSPITAL SOCIAL WORK

Given the complexity and weight of social work tasks and roles in acute care, professional support is crucial. Regrettably, social workers have lost vital underpinnings for practice as a result of the changes in health care that have occurred over the past ten years. Around the world, health care reform is being driven by market influence on cost and quality of care (Berkman, 1996; Canadian Institute for Health Information, 2001; The Change Foundation, 1999, 2000; Cherin, 2000; Davidson, Davidson, & Keigher, 1999; Hunter, 1996; Leatt, Pink & Guerriere, 2000; Rosenberg & Weissman, 1995). Alterations in both the structure and delivery of health care have reduced institutional budgets, increased regulatory measures, and moved care from inpatient settings to the community–whether the infrastructure is ready or not.

Hunter (1996) states that the belief that health services have suffered from being over-administered and under-managed has led to attempts to increase efficiency and accountability. Typically these efforts involve close performance monitoring of staff and an abandonment of traditional hierarchical forms of organization. Mizrahi and Berger (2001) have underscored the changes in health care brought about by these market containment strategies: “Most hospitals are restructuring to achieve flatter organizational structures by moving away from professionally defined structures, such as departments of social work, nursing and medicine, to more integrative structures” (p. 170).

In Canadian hospitals the most sweeping change has been the move to program management. The intention of program management is to place the patient rather than the provider at the center of care. The hope is that by dissolving professional departments, and by centralizing administrative functions and decision-making in teams and programs, both efficiency and quality of care will improve (Globerman, 1999; Globerman, Davies, & Walsh, 1996).

This shift to program management has had a profound impact on social work in health care (Levin & Herbert, 1997, 1999). Because hospitals are a secondary setting for social work, the deconstruction of departments has left social workers with scant professional backing. While there are clear benefits from focusing on the needs of patients rather than providers, in three Canadian reports, staff describe serious concerns about changes to social work in hospitals that have moved to new management forms (Globerman, Davies, & Walsh, 1996; Michalski, Creighton, & Jackson, 1999, Levin & Herbert, 1999). In addition to the decrease in leadership roles in social work, staff experienced a loss of control over decisions regarding professional identity and social work functions. They felt a heightened sense of isolation from social work colleagues and voiced concerns regarding professional practice standards including diminished involvement in hiring and performance appraisals. Staff cited a loss of control over professional development funds and over decisions regarding the supervision of students. In many cases individual social workers have been required to assume all responsibility for upholding professional standards of practice and for advocating for their own needs within a program.

Globerman, Davies, and Walsh urge social workers to “embrace the opportunities embodied in autonomous practice” (1996, p. 187) that occur when departments disappear. However, Levin and Herbert state:

Moreover, Michalski and his colleagues noted that as time passed, the majority of social workers whom they studied developed a more negative attitude toward program management. These authors conclude that the creation of professional practice roles and the establishment of shared governance models have been unsuccessful in meeting the clinical and academic needs of the profession in hospitals. “It seems clear from the present research that this type of mobilization of hospital social workers will not take place unless groups of social workers find opportunities to create a professional social work community within their work environment” (Michalski, Creighton & Jackson, 1999, p. 23).

Such struggles for social work are by no means confined to the health sector. A recent cross-Canada study identified the challenges to the social work profession in all settings (Stephenson, Rondeau, Michaud, & Fidler, 2000). One of the report’s recommendations is to rebuild support in the workplace using low cost measures like the development of supportive networks of occupational groups.

CONFLICTS FOR SOCIAL WORK

There are obvious conflicts for social work in applying solutions to health care delivery that have grown out of industry (Hunter, 1996; Moore, 1998). According to Redmond, “access to health care in the United States is not a right but instead a commodity to be bought and sold. If you cannot afford it, you cannot have it” (2001, p. 55). Productivity is being monitored for cost rather than quality, and will continue to be measured by profitability or cost-containment. “Doing more with less” is praised, but budget reductions bring increased workloads at a time of decreased support. In addition, it is difficult to gauge social work’s contribution in economic terms. For all these reasons we risk losing core social work values in climates driven by the bottom line (Sulman, Savage, & Way, 2001).

The lessening of the psychosocial role also represents conflict for social workers. In some cases the social work role is so pared down, there is only time to do the most urgent discharge planning. This leaves a host of unresolved issues, and compounds a sense of dissatisfaction, even failure, in the social work clinician. It also leaves the door open for professionals with a narrower skill set to “do social work.”

In program-based practice there are two potential sources of conflict: money and affiliation. When the team holds the purse strings, social workers who advocate for patients can feel vulnerable when they take controversial stands. It is the difference between being unpopular and unemployed. With regard to affiliation, there can be a strong pull to go along with the team and its leaders in order to be viewed as “a good team player.” These conflicts lead to a tension between advocacy and collaboration (Herbert & Levin, 1996) and jeopardize social work’s ability to define its own scope of practice.

THEORETICAL BASIS FOR THE GROUP MODEL

Chaos and Complexity Theory

Having reviewed the current context of social work in health care, we looked for a conceptual rationale, besides our own experience, for using groups in an organizational model. One set of assumptions that seems compatible with a social group work approach is chaos and complexity theory. This wide-ranging theory was imported into postmodern management literature (Berreby, 1996; Kauffman, 1995) and group dynamics (McClure, 1998) from the natural sciences, and views organizations as complex adaptive systems that should mainly be left to run themselves. This is accomplished by fostering a flattened hierarchy where teams and solutions emerge from the people closest to the problem (Arndt & Bigelow, 2000; Polis, 1998; Santosus, 1998). In our model, the social work group is the key in a management system that runs itself and has the capacity to generate moment-to-moment solutions for all practice issues. This is in contrast to other models that place the individual worker in a hierarchical department or in a program management-based multi-dis ciplinary team. In those models there may be group supervision or team meetings (Abramson, 1989; Brown & Bourne, 1996; Cherin, 2000; Richman, 1989), but the basis of the organization is not the professional social work group which has its roots in the radical democracy of settlement houses and the labour movement (Breton, 1990; Coyle, 1930/1979; Ephross & Vassil, 1988; Konopka, 1963; Lang, 1972, 1979; Lee, 1984; Middleman, 1968).

Social Group Work Theory

What makes the social work group different from other forms of group? To answer this question we need to look at some characteristics of groups. As Laski said in 1930: “we are all bundles of hyphens.” Groups, including dyadic sub-groups, are the arena for most social transactions. Our profession is well aware that such interactions run the gamut of behavioural extremes–from nurturing and collaborative to violent and conflictual–and that the complete range of these behaviours can be found in groups (Coser, 1956). Nevertheless, we are social beings, and to engage with each other face-to-face implies the presence of group.

What are some of the features that make the groups in our model social work groups? At the heart of the model is collective decision-making within democratic peer group structures (Lang, 1969, 1972). Democracy is an essential value of social group work (Coyle, 1947; Middleman, 1968). The term not only describes a particular way of arriving at a decision, it also implies a culture of respect. Democratic groups are tolerant of differences of opinion and of the right to express them. Consensus decision-making is the ideal. Majority rule is the fallback position.

The group facilitator is a member of the group, and leadership is shared among members (Lang, 1969, 1979). Regarding the concept of membership, Hans Falck (1979, 1988) has challenged the construct of the individual as a discrete, autonomous entity that can exist separately from others. He and his colleague, Thomas Carlton (1986), replace the individual with a single person who is a member, and see social work practice in membership management terms. The concept is non-linear and holistic, like social group work process and complexity theory. The membership paradigm even supplants individualistic approaches that incorporate linkage concepts such as environment, system, or ecology (Germain, 1977). According to Falck, “when the individual is placed in the middle of an imaginary circle and all else is designated as the environment, the individual can indeed be understood as being overwhelmed, powerless, disenfranchised and, therefore, in need of social work help” (1988, p. 16). A similar understanding might apply to social workers in program management who are isolated from professional support.

Mutual aid is another core feature of social work groups (Steinberg, 1997). Social group work methodology values reciprocity, and carries an expectation that members will move towards each other in a genuine, helpful manner. An implication of mutual aid is that members will process conflict constructively rather than sidestep issues with false-positive support. Ephross and Vassil (1988), in their examination of working groups, discuss the interrelated concepts of value, membership and authenticity:

From this solid base of group membership comes the capacity for collective action and the power to tackle social goals collectively and effectively (Breton, 1995). Moore (1987) suggests that a group’s environmental competence is the cornerstone of its ability to intervene in its own community situation. One of the mandates of the peer group in the collective model is to develop member competence in all levels of community intervention. These groups support members to intervene in their internal and external hospital communities via intergroup memberships on teams and in community networks (Shapiro, 2000).

Group Supervision

How is a social group work collective different from group supervision? In their important analysis of social work supervision, Brown and Bourne (1996) characterize group supervision as “largely uncharted territory looking for pioneers” and define it as “the use of the group setting to implement part or all of the responsibilities of supervision” (p. 144). In their view, the decision to use group as a supervisory vehicle is optional, depending upon the context. In our model, the social work group is the norm for supervision and for collective management.

WHAT THE MODEL LOOKS LIKE IN OUR SETTING

In the model we are describing, the social work group is the principal management vehicle where accountability, support, and collective decision-making occur between and among the members. The model addresses the need for a strong professional reference group that potentiates practice while transcending management forms. Features central to the model are professional accountability, support, autonomy, and collective decision-making within democratic peer group structures. The indelible values of social work and social group work infuse group process. Together the members of these groups create an available community of expertise, creativity, motivation, and practical help for each other.

Background and Evolution

How did the model originate? The model began as an experimental frontline initiative borne from crisis. Thirty years ago, when one of the authors first began practising social work, she was the only worker on the surgical service. She followed the directives of her supervisor until, in defense of a vulnerable family, she managed to raise the hackles of a prominent surgeon who let it be known to his colleagues that referring to social work was “asking for trouble.” With a much-reduced caseload, the worker had a couple of quiet months to reflect on things. She speculated that additional ideas from other front-line staff might have helped her avoid this problem. About a year later, despite the director’s misgivings, her colleagues agreed to a pilot project of group supervision. In this small department the group included all of the social workers, and this circumstance had a transforming effect on department culture. Because the supervision group was identical to the whole department, it was not only the beginning of a new supervisory process, but also the beginning of a profoundly different management structure (apparent only in hindsight). From the outset the group was infused with social work values and since the author was a group worker, she facilitated democratic process (e.g., when the director gave a strong opinion on a case, the author would simply ask, “What do other people think?”). As a result of this shift in management practice, the director was able to carry the group’s consensus with her when she met weekly with a vice president of the hospital. The group’s perspective added power to her recommendations and raised the profile of social work within the hospital. When the hospital moved to a new building five years later, the department tripled in size. Two more staff groups were added, along with a supervisors’ group who met with the director. Individual supervision was retained for a worker’s probationary period and could also be requested at any time. The group’s influence, however, was now central to the management process.

Democratizing the model has occurred gradually, and at times in the face of opposition. The current director and group leaders (a position altered from that of a hierarchical supervisor to facilitator) have had extensive experience in the model and are advocates of consensus decision-making. Group process takes more time than directive leadership, but the strength of the empowered collective is ultimately more enduring (Breton, 1994a, 1994b).

Types of Management Groups in the Collective

Three types of groups are integral to the model. Peer management groups, a coordinating group, and the total staff group all have interconnected goals and functions.

Peer Management Groups

In our setting there are three peer management groups organized around service clusters. The groupings are (1) perinatology; (2) medicine and Chinese services; and (3) psychiatry, surgery, and emergency. The total staff designed the group composition to reflect major service flow patterns in the hospital, as well as to balance the number of social workers in each group. Groups meet on a weekly basis in a regular location at a specific time. Usually the members provide refreshments for themselves.

In addition, the total staff collective chooses facilitators or group leaders for the management groups based on criteria that staff members define. These include leadership skills such as expertise in clinical practice, teaching, research and group facilitation, as well as a demonstrated commitment to collective goals. Because the facilitator has a front-line clinical job, she or he is a fully participating member in the group. The facilitator takes nominal responsibility for minding group process, collecting agenda items and taking issues to and from a coordinating group that also meets weekly. In practice, all members have responsibility for keeping the group on track, and when the group leader is away, members take turns in assuming the role.

Groups provide many layers of support such as social, emotional, clinical, administrative, and strategic. They also establish peer expectations of performance. The social group work collective is strengths-based and encourages autonomy of practice within a set of standards. If a member brings a clinical issue to the group for consultation, the rule tends to be that unless there is a legal concern, it is up to the worker to decide on a plan. Similar to the narrative therapy concept that people are “experts in their own lives” (Horwitz, 2001, para. 1), staff members themselves are usually the best judge of the likely effectiveness of an intervention for their own cases and teams. To obtain support and peer consultation on clinical and systems issues, a worker will typically bring a situation to group for discussion, as in the following brief examples.

A client with a history of cocaine use has had two of her children taken into care by the child protection agency. She is pregnant again, but is doing well in this pregnancy, and the worker believes that the client can manage this baby safely with counseling and supervision. She asks her colleagues what they think are the best options for supporting the client.

Or perhaps a worker is struggling with a new member of his patient care team who pressures patients to leave hospital before a safe plan is in place. How would other group members handle the problem?

The groups also exchange information about the hospital and community resources, and address housekeeping tasks like coverage, time off, and overload. A worker may come to the group saying, “I have 50 new cases this month, my co-worker is still off sick, and I can’t manage.” The group might talk about different ways to triage referrals, might distribute some cases among the members, ask other groups for help, or if all else fails, ask the group leader to give formal notification to the interdisciplinary team that reduced coverage is necessary.

Another function of the peer management group is the development of member competence in all levels of community intervention, networks, and teams. Groups provide an opportunity to model these skills and make them visible. At the same time, they provide support for a collaborative practice that is highly empowering for staff. Workers, individually or collectively, design initiatives that take patient care issues to an articulated level of policy proposal or program change. In meetings with interdisciplinary colleagues and hospital executives, such proposals can lead to immediate improvements in service delivery or to longer-term projects. A short-list of examples includes: delaying a discharge until safeguards are in place, implementing pre-admission discharge planning protocols, and developing patient and family support groups.

A deeper mandate of the peer management groups is to ensure accountability for high-level clinical practice to clients, colleagues, and ourselves. To ignore the fact that a co-worker is functioning inadequately represents a breach of trust with patients, families, and the hospital community. For this reason performance appraisals are done collectively in the group as part of an ongoing process: There should be no “surprises.”

When conflict occurs, one particular group norm is essential: Members expect their colleagues to take responsibility for identifying problems and for dealing directly with each other. The groups foster an atmosphere that is tolerant of differences of opinion. Members do not have to like each other, but they do have to be able to work together.

The Coordinating Group

The second type of group is the coordinating group, which includes each group leader and the director. The purpose of this group is to be a tracking system for issues raised in the peer groups. Staff’s ideas are clarified and amplified with plans for action or are returned to the peer groups for new direction.

Our setting combines program management and departments within a matrix model and has retained the position of social work director. For the hospital, the role carries a traditional, hierarchical meaning, along with full-time administrative responsibilities that in program management are redeployed to teams. In the social group work model, however, the primary role of the director is threefold:

Why is the coordinating group useful? Unless the total number of social workers is small enough to meet as a whole (e.g., 7-10 members), peer management groups are likely to fall along program lines. When this happens, groups end up competing for scarce resources in much the same way that specific programs in the hospital fight for priority. The coordinating group ensures that the inclusive values of patient care and the profession take priority over the exclusive, parochial demands of any given program or service.

Total Staff Groups

With a staff size of 27 social workers, major decisions can be made in the third type of group: the total staff group. (In our setting this term generally refers to all social workers, clerical/administrative staff, and students in the department.) For example, after a call from the vice-president, the director arranges an emergency staff meeting: “We have to cut two positions out of our budget; how are we going to do it?” For several years during the 1980s, all MSW staff decided to take a day off a month without pay rather than cut jobs. Last year after a decade of cutbacks, they felt that not enough was being done to highlight their own concerns about salaries. They did comparative research and discovered that their wages were indeed low. Staff then invited the head of human resources and the vice-president to a staff meeting where they presented compelling data in a powerful way, and won a significant increase.

The total staff group also meets for staff development programs, for research seminars, to undertake social action initiatives and, in the time-honoured tradition of social work groups, to have great parties.

Social Group Work Collective Creates Safety Net for Staff

Figure 1 is a visual description of how the collective works. The large outer circle represents the Total Staff Group. The three circles labeled Perinatology; Medicine & Chinese Outreach Program; and Surgery, Emergency, & Psychiatry are the peer management groups that meet weekly and are organized by service clusters. The circle labeled Coordinating Group is made up of the group leaders, selected by staff, who meet weekly with the director. The circle entitled Staff Development Seminar is one example of the many other types of periodic groups that make up the interactional life of the social work milieu. Other examples include social workers involved in advocacy, presentations, research projects, and committees. Because there are many opportunities for workers to exchange perspectives, these ongoing contacts help to create a safety net for staff within the wider hospital culture.

Is There Evidence That the Model Is Effective?

Ongoing peer evaluation is an important part of group process, and staff members give regular feedback about the utility of the group model. However, in order to assess the effectiveness of the model more fully, we looked at outcomes such as staff retention, quality assurance data, and feedback from other disciplines. We also looked at client satisfaction and speculate about features of the model that promote it.

FIGURE 1. Model of Social Group Work Collective

Staff Retention

Tsui and Ho (1997), in their comprehensive review of supervision, state that it “has been identified as one of the most important factors in determining job satisfaction levels of social workers” (p. 181). Moreover, when turnover is consistently low, satisfaction tends to be high (Poulin, 1994). Until three years ago, when new hiring occurred with the expansion of our “restructured” perinatology service, the average length of employment in a staff of 20 was 16 years. Currently, 16 staff have worked in the model for >15 years. Because of the move to program management and the dismantling of social work departments, Canada-wide social work retention data are currently unavailable, but it is likely that these figures compare favourably to other settings.

Qualitative Analysis of Quality Assurance Sample

In order to compare the model with other settings, a sample of four recently-hired (< 3 years) social workers with varying lengths of prior social work experience, plus one long-term staff member, were asked the following question: “Does this model differ from what you have experienced in relation to professional practice, support, and satisfaction?” Their responses clustered into five qualitative themes. The theme “professional practice” broke into three sub-themes: “patient care benefits,” “comparison with program management,” and “perceptions of social work.” For purposes of clarity, “support and satisfaction” were merged into one theme and the theme, “drawbacks of the model” was created.

Patient Care Benefits of the Model. Staff indicated that the model supports social work values and advocacy on behalf of patients: “You can hold up the patient perspective more when you have the support,” and “It gives you strength to fight battles you might not take on.” In a related comment, a worker stated:

Comparison with Program Management. Staff noted the isolation from social work colleagues that program management reinforces: “In program management you are an island.” They also observed the negative impact that this can have on professional practice: “If you only let the team define your role, you are in trouble.” Other comments included concern about the inability in program management to cover clients of workers in other programs, about having only a nurse manager as final arbiter of patient care issues, and the feeling that social work has little clout in comparison to other disciplines: “It’s disheartening to work in program management where no one gives a damn about the 1 social worker compared to 80 nurses.”

Perceptions of Social Work (e.g., Other Professions, Hospital Administration). In contrast, “social work is positively viewed in this hospital.” Staff observed that social workers had access all the way to hospital administration if needed to deal with patient care issues; e.g., “You can get things done and have relationships with people at all levels (e.g., problem-solving with nursing unit administrators and higher to deal with a child welfare case),” and “Senior management knows our work and supports the department and the profession.”

Support and Satisfaction. Perceived support is a key feature of the model: “The social work support is the most important thing here,” and “social workers supporting each other doesn’t exist in most places.” Here social workers can “get support about practice issues, which supports the profession.” Flexibility and freedom to practice were noted, as were the efficiency and effectiveness of the model in supporting practice. But primarily satisfaction related to professional collegiality: “I am here because I want to work for social workers, with social workers, to be supervised by social workers.”

Drawbacks of the Model. Drawbacks reported in this small quality assurance survey related to the need to process issues amongst colleagues: “The group model can be redundant, repetitious, but is probably important for new staff,” and “It can seem more restrictive–so many people you have to inform.” Another worker commented: “Groups aren’t easy for new staff but serve a purpose for support and consultation.” Other challenges of the model are discussed later in the article.

Client Satisfaction

Another area that relates specifically to the model’s effectiveness is its impact on clients. Benefits of the group model for clients include uninterrupted coverage of cases, regular clinical consultation to provide a broad rage of intervention options, and strong group support for social workers to act as advocates on clients’ behalf, both within the hospital system and in the community. Clients are not only viewed as being assigned to an individual worker; they are also clients of the collective. Group members provide reciprocal coverage for each other during times of social worker overload or when workers are away. In this way, social work coverage for clients transcends the boundaries of the hospital’s clinical programs.

The group model also gives strong support to the creation of programs for marginalized clients and those with special needs (e.g., parent-buddy program, sarcoma patient and family groups, Chinese community outreach program). In a quality assurance survey of 121 Chinese patients with limited English, satisfaction rates with other hospital services such as medicine, nursing, and nutrition were significantly higher when social workers were involved (Ng & Yau, 2002).

Feedback from Other Disciplines

Social workers are few in number in comparison to other major departments in the hospital (e.g., nursing, rehabilitation, nutrition, pharmacy) but have a strong voice in the organization. As seen above, new social work staff are quick to perceive the strength of social work in the hospital and link this strength to the model. Although the evidence is anecdotal, frequent unsolicited comments from interdisciplinary colleagues suggest social work’s impact:

In the context of a continually changing health care landscape, including four CEOs and five directors of social work, the social group work collective thrives. The social work department was recently named in honour of the former CEO of the hospital–at his request.

DISCUSSION

In reviewing our practice, one of the things we have discovered is the power of social group work as a management tool. Given the pervasiveness of restructuring in health care, as social workers we need to make our own paradigm shift back to social work. In order to position the profession in any organizational form, whether it be health maintenance organizations (HMOs), integrated delivery systems, regional health authorities, or reformed primary health care centres, we need to capitalize on our professional strengths while retaining social work’s patient-focused roles and values.

The social work group is the fundamental structural and functional entity in the model. Structure includes regularly scheduled meetings of specific groups to process the broadest range of issues. Pivotal to the integrity of the model is the social work mandate to deal with conflict and to assume shared responsibility for problem resolution. There is a collective accountability, delivering continuous quality improvement, that each member owns and accepts. The fact that social group work skills are uniquely the province of social work gives us good reason to use them in our social work collectives and in our organizations. Our model provides both a theoretical and practice-based framework that promotes experiential learning as a member of a social work group and develops talent to bring to multidisciplinary teams. It also promotes the acquisition of administrative skills because leadership is carried by every member of the group.

The combination of high accountability and autonomy that is present with this model provides staff with tremendous control and influence over practice. Staff in our setting stay a long time and are continually involving themselves in new and creative activities. Despite this, not everyone is at ease with the model. Some struggle with discussing their practice in their group with colleagues, in having responsibility for difficult decisions, and with the expectation of directness in interaction. The model requires a tolerance of some personal discomfort. Identified leadership roles and the boundaries between groups must be flexible in order to diminish unnecessary conflict and negative dynamics. Ultimately, the social work collective acts as a check and balance for the integrity of the system. One of the fascinating things that we have learned in scrutinizing our model is that the exercise is long overdue. We need to use this review of practice to create a guide for new staff and to enhance the social group work skills of other members.

The ongoing evolution of a social group work collective in our setting can give clues to adapting the model to other settings. The group form gained momentum, despite reservations of directors, because from the outset, total staff group meetings were a forum for forging consensus decisions about major issues. The model is implicit in social group work, but to make it operational in the face of resistance means putting concerted energy into creating the collective. Irrespective of organizational reporting structures, any social worker in any setting can form a peer group with other social workers in order to obtain professional social work consultation and support (Levin & Herbert, 1999), although the group or network may have to meet outside formal work hours. And unless social workers in hospitals create organizational vehicles that demand attention from the policy makers and administrative power structures, they will miss vital opportunities to make lasting patient care improvements in their hospitals. This is basic small group-community development practice, and the reality of how formal organizations work.

CONCLUSION

Our search for signposts to the future required us to look again at our foundations. Embedded in the rich history of social group work theory we discovered the supportive structure that enables our practice. The portable model of radical democracy discussed in this paper keeps the critical functions of value-based social work and accountability centralized within groups. It provides a home base whether there are professional departments or unit-based programs. It will be difficult to adhere to social work values in market-driven, bottom-line climates, but it can be done. What we have described is not a band-aid solution for the new challenges in health care. It is a grass roots model that, for 30 years, has created a community of professional support for staff who put their professional values on the line for clients every day.

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Joanne Sulman is Research Coordinator, Diane Savage is Director, and Paul Vrooman and Maureen McGillivray are Senior Social Workers, Department of Social Work, Mount Sinai Hospital, 600 University Avenue, Toronto, Canada M5G1X5.

The authors wish to thank Lieve Verhaeghe, MSW, RSW, for her insightful comments on the manuscript, Barbara Beveridge for her technical expertise, and the members of the Department of Social Work for their ongoing evolution of the social group work collective.

This paper was adapted from a presentation given at the Third International Conference on Social Work in Health and Mental Health, Tampere, Finland, July, 2001.

[Haworth co-indexing entry note]: “Social Group Work: Building a Professional Collective of Hospital Social Workers.” Sulman, Joanne et al. Co-published simultaneously in Social Work in Health Care (The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc.) Vol. 39, No. 3/4, 2004, pp. 287-307; and: Social Work Visions from Around the Globe: Citizens, Methods, and Approaches (ed: Anna Metteri et al.) The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2004, pp. 287-307. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].