A Study of Social Work in General Hospitals in Iran and Designing a Model for Social Work Services

1. Background

Desirable improvement of health in a society depends on improving health and treatment services of its people. Health is an issue which has been viewed from different biological, psychological and social points; therefore, all of these aspects must be taken into consideration so that an optimal status can be achieved (1). Social work is an occupation that - along with different methods of individual, group, and social support - can be effective in improving health of the states. In health and treatment system of developed countries, a special attention is given to social work. Its performance is highly important in three levels including prevention, treatment, and rehabilitation (2).

Presence of social workers in the country’s health, treatment, and hygiene system dates back to several decades ago. In most hospitals, public ones specially, there has been and still is a ward called “social work” (3). Social work services have witnessed many ups and downs in Iran and social workers have played different roles. At the present time, social work services have been merely limited to giving financial support or referral services. It is worth mentioning that limiting social work services to such works as giving financial support or referral services prevents the visitors from overcoming their problems, and fails to prevent social vulnerabilities. Eghlima (1390) in audit plan of social work, has studied social workers’ demographic status and performance in agencies and organizations and shown that the social workers’ performance is less specialized and more concentrated on solving financial problems. At the same study, he has also stated that most of the social workers in different wards do not hold academic degrees on social work. Mirmohseni (1382) has also mentioned the weak and unspecialized performance of social workers in hospitals (3). Therefore, in this study we seek to evaluate the exact performance of social workers and analyze the existing problems of social workers in hospitals.

The growing trend of social pathologies and complications caused by urban population has created increasing problems which, in addition to environmental problems of individuals, has lead to psychological and social problems (4). In other words, in order to solve the problems of visitors, not only do we need to look at the problem from biological aspect, but also we have to consider psychological, social, and family issues as well. In order to solve this problem, one should work comprehensively, and as a team. Fulfilling their professional roles, social workers -as one of the leading members of the treatment team- can be effective in treating their visitors and solving their problems. Their role is focused on social work of individuals, groups, and communities (5). But it seems that problems in the area of recruitment of qualified social workers and limiting social workers’ activities to financial affairs as well as lack of duty descriptions consistent with their academic and professional abilities have inflicted serious damages to social workers’ roles and services. Due to the problems arising from these issues, the study of social workers’ services in hospitals is necessary.

2. Objectives

This study aims at knowing the status of social work services in public hospitals of Iran and offering a model for providing social work services in public hospitals

3. Materials and Methods

This study has been conducted both quantitatively (using survey) and qualitatively (using case-study and Delphi). The population of this study, in the quantitative part, included all social workers employed in hospitals. The inclusion criteria of this study were employment in the social work ward of hospitals, and at least one year of experience in the related field. The exclusion criteria included having less than a year experience in social work services, and altered questionnaire.

In the qualitative part, which was conducted via interview, the participants were social workers and patients of the hospitals. In the quantitative part, which was done by full enumeration method, the questionnaires were sent to all social workers employed in hospitals. The number of questionnaires sent was 552, of which 260 have been completed and returned. Case sampling method was employed in the qualitative part and seven hospitals were selected as the cases under consideration. The selection of hospitals was based on the division made by department of public health in ministry of health. This selection was such that the universities with public hospitals were randomly selected in terms of deprivation and enjoyment of social work ward with regard to their geographical distribution: Group 1 (Good): Tehran and Shiraz, Group 2 (Mediocre): Semnan and Hormozgan, Group 3 ( Weak) Zahedan, Northern Khorasan, and Lorestan. Social work wards of these hospitals were observed and evaluated based on case-study. The instrument in the qualitative part was a structured interview. In the quantitative part, a questionnaire on executive and staff support status of social workers in Iranian public hospitals was used. This questionnaire consisted of three parts. The first part included some questions on demographic status of the respondents such as academic major or discipline, organizational position, work experience, employment status, marital status, age, gender, and educational level. The second part of the questionnaire included 36 Likert-scale questions; and in the third part, 6 open questions were included. Reliability of the questionnaire was calculated using Alpha Cronbach 75% and the content validity of the questions was evaluated by three university professors specialized on social work. In the qualitative part, the data were collected using interview and observation instruments. To investigate the validity of research findings, the sample population was re-interviewed with presence of a social-worker. In order to offer the model, data collection was done in two phases. In the first phase, parameters of a social work model were determined in hospitals. In this phase, Delphi technique was used. A series of survey or questionnaire rounds were employed for collecting the data. With regard to primary continuum question, the questions used were either focused or broad (usually broad and open response). In the second phase, the social work model was designed and evaluated. In this technique, a graphical design of hierarchy of indicators was given to decision makers. In fact, an analytical picture was given to the population sample for decision-making. Descriptive statistics were used for data processing. In order to analyze the qualitative data, an interpretive analysis was used such that the research findings were dived into structures, categories, and patterns; and the results are given in analytical reports for every case. This report includes comprehensive description and explanation of findings which clarify the events and processes used in the research. Then, inter-case analysis is done across all cases in order to determine the consistency and inconsistency between structures, patterns, and themes.

4. Results

The research findings in demographic information indicate that the number of social workers, in proportion to the population seeking health services, is very low. While only 25% of the social workers have earned the relevant academic degree in the field of social work; 75% have studied other disciplines like psychology, social sciences, radiology, computer, nursing, medicine, medical services management, environmental health, education sciences, family studies, educational services, cooperation, labor-knowledge, communications, administrative services, anesthesiology, math, exceptional Children, literature, research studies, administrative management, state management and Speech therapy. Findings show that 87% of social workers, who are employed in the country's public hospitals, are BSc holders, 7% high school diploma holders, and only 6% MSc holders. Statistical data indicates that more than half of the people who work in social work profession hold positions other than social work and only half of them are officially employed.

Frequency Chart and Frequency Percentage of social workers in Ministry of Health based on academic discipline

Blue: Social Work Discipline, Red: Other academic disciplines

Figure 1.

Frequency Chart and Frequency Percentage of social workers in Ministry of Health based on academic discipline

Findings show that less than 40% of respondents have agreed on an active and effective role of staff centers in introducing social work as a specialized profession in the health-care system. Less than 40% of respondents have agreed on positive performance of staff units in communicating with scientific communities. Only 15% of the respondents have agreed that staff centers have taken advantage of social workers' opinions in administrative units. More than 50% of respondents have disagreed that staff centers run adequate and effective courses for scientific and academic promotion of social workers. Only 25% of respondents have agreed that duty description of social workers, in hospitals, meet the needs of visitors. And only 30% of them have agreed on conformity of social workers' duties with scientific and professional principles of social work. Only 12% of social workers believed in the support of staff units in case of legal obstacles or disease. 10% of respondents have agreed that staff units support them in case of legal problems or diseases. 6% of respondents have agreed that the staff units support them in case of economic problems. 22% of respondents believe that staff units adequately monitor their work.

Open-ended questions were designed to obtain information on 4 categories including: a) Current roles of social workers in the hospitals b) Possible roles which can be played by social workers in the hospitals c) Deficiencies which social workers are facing in their profession in executive units d) Suggestions of social workers for improving their work. In response to the first question, social workers have stated that there is no role for them in the hospitals; they have no special position in the hospitals and they play major role in economic, cultural, administrative, and counseling affairs and also as coordinators. In response to the second question and the possible roles social workers can play, the following fields have been listed: healthcare, assessment, referral, economic, supportive, training, guidance, research, communicative, and legal roles. According to the views of social workers, shortcomings of their work can be summarized in 12 categories that include:

1) Ambiguity in the role of social workers in hospitals

2) Weakness in inter-sectoral collaboration

3) Low level of knowledge, skills, and motivation of social workers

4) Lack of public knowledge about the role of social workers

5) Inefficient bureaucracy and policy-making of social workers

6) Lack of attention to the role of social workers

7) Lack of facilities

8) Shortages in skilled manpower

9) Lack of job security

10) Inefficient and inadequate in-service training

11) Inefficient insurance system

12) Inadequate supervision of the work of social workers.

Research findings in the field of social work suggestions can be summarized in terms of the following categories:

1) Promotion of scientific ability of social workers

2) Giving an exact, dynamic, and comprehensive definition of social work profession in hospitals

3) Directing the work of social workers towards treatment and prevention practices

4) Forming a comprehensive data bank on social work services

5) Increasing and improving the facilities in social work sectors

6) Improving and modifying the structure of social work profession

7) Raising the level of public knowledge about social work through increased public relations.

5. Discussion

5.1. Discussion on Research Findings and Model of Social Work in Public Hospitals

Disease is a multi-dimensional issue. During treatment process of diseases, in addition to biological dimension, we have to consider mental, social, economical and spiritual dimensions as well. Treatment procedure, which follows five-dimensional principle of health, has also taken into consideration the biological, psychological and social dimensions. It goes without saying that a comprehensive treatment is achieved and promoted through teamwork. If any of the dimensions of health is ignored in the treatment process, the treatment circle would be incomplete and health goals will not be achieved. Undoubtedly, in order to consider psychological and social dimensions, professional and capable experts are needed in the field of treatment. Today, in developed countries, training the clinical social workers in the healthcare system is an essential goal of education. Meeting the quantitative and qualitative standards in the provision of health-care services, including social work, is essential. Examining the history of social workers' performance in the health-care system of the country shows that the need for professional social workers in the health-care domain, in order to complete the treatment circle, has never been recognized as a necessity. As a result, this specialized major has never been taken seriously in the hospitals.

Difference in social work services in different units of hospitals indicates that there is no single definition of the social workers' performance in hospitals. Difference and conflict in the performance of social workers is a proof of this issue. Lack of precise and coherent definition of duties of professional social work services in hospitals has caused different and personalized approaches toward social work. This, in turn, has led to employing nonprofessional staffs, lack of standards for assessing social workers' performance in hospitals, and lack of quantitative standards for measuring the effects of their presence in the hospitals. As the results of this study shows, only 25% of the people who have work as social workers in the health-care system hold the relevant degrees in the field. There is no standard for defining the number of social workers in the hospitals. For example, in Zahedan hospital with large number of patients and acute psychiatric problems, there is only one social worker at work. While in a different hospital in Shiraz, with the same number of patients and difficulties, there are 12 social workers at work. Professional performance of social workers in hospitals is not recorded and patients have no records of social work. Process of helping the patients is based on trial-and-error and certain services are purely financial. Engaging social workers in hospitals with solely doing charity and finance affairs, writing accidents reports, surveying the clients respect, writing financial documents, and attracting public participation indicates that this major is not regarded as a specialized subject and there is no specific definition of the work. This has caused the reduction in specialized tasks of the social workers and increase in the ordinary tasks which require no specialization on the part of social workers.

According to the findings of this research, only 36% of respondents agree that the staff units have the true and correct knowledge about social workers' performance. Low and insufficient knowledge of staff units about social work major has caused a major damage to the entire system of social work in the nation's healthcare system. This issue has made difficulties in planning duties and roles of social workers, monitoring their performance, and informing the community of the roles of social workers. It seems that some shortcomings like assigning social workers in non-specialized tasks in the treatment process, offering inaccurate picture of social work discipline to the professional and public community, and confusion and multiplicity of tasks all originate from this issue.

Linear programs in social work processes indicate the necessity to reassess the profession and performance of social workers. Proper functioning of the system requires revision and correction of the performance. Such a system needs to assess the views of the staff and clients of the profession so that it can revise the procedures and plans. Work programs of the social workers have been designed based on an outdated and inefficient tasks and this has undermined the overall efficacy of the discipline.

Work programs of social work are different in different hospitals. These programs are developed according to the views of directors and heads of hospitals and have a pyramid structure. The views of social workers are not taken into consideration in their own profession and they have no sufficient authority in performing their roles. This has resulted in demotivation of social workers followed by conflicts and unrest in the workplace.

Social workers have undefined and difficult conditions in the hospitals. Job dissatisfaction is greatly seen among social workers of hospitals. Difficulty of work has involved them in legal problems and physical illnesses, and unfortunately they consider the performance of staff units as very weak and inefficient in giving treatment, economical, legal, and welfare supports. Undoubtedly, such circumstances are negatively effective in the way of working and providing services by social workers and dissatisfaction of clients and raising conflicts in the workplace. It is worth mentioning that social workers' involvement in providing financial supports for the patients, and lack of financial resources have all fueled the consequent conflicts between clients and social workers. This has greatly damaged the social work values. As mentioned earlier, there is no specific framework for social work services in the hospitals. Lack of clear definition of social work and the responsibility of social workers for discharge of indigent patients has lead the social workers to act against their professional responsibilities and humanitarian will and discharge these patients at the expense of emptying the hospital beds. In fact, mandatory discharge of indigent patients damages their health-care rights and future safety. Therefore, lack of a comprehensive model encompassing social workers' duties is a problem that adversely affects the functioning and job positions of social workers in the hospitals.

5.2. Model of Social Work Services in Public Hospitals

Model of social work in hospitals has been developed based on the proposals and roles offered by the relevant experts and policymakers of the field and social workers employed in the hospitals. The assigned roles for social workers are divided into different categories such as treatment, referral, economic, supportive, evaluation, training, research, communication, and legal.

In the structure of social work model, tasks of social workers in hospitals are divided into 4 major parts including clinical social work, social services, social work supervision, and social work education. Clinical social work includes health-care services and social workers' duties fall under three categories including psycho-social health, psychosocial treatment, and psychosocial rehabilitation. Social work, in the domain of social services, is based on the social services given by a social worker, using facilities of the relevant institute, to his/her client for the client's welfare. In the work model of social work, social services are divided into 5 categories including communication, referral tasks, guidance, economy, and support. In supervisory and policy-making parts, organizational and legal supervision are the focus of attention.

Pie Chart of Social Work Services in the Country's Public Hospitals

Figure 2.

Pie Chart of Social Work Services in the Country's Public Hospitals

5.2.1. Clinical Social Work Services in Public Hospitals

Clinical social work is a specialized field of social work that focuses on scientific areas, social work theories (individual, group, and societal) and applies psychosocial treatment solutions so that it can lead the individual to psycho-social adaptation and guide the community toward social health (6). Clinical social work in public hospitals is carried out in three areas of health, treatment, and rehabilitation.

5.2.1.1. Psycho-Social Health

Clinical social work in the health field is focused on psycho-social prevention. To achieve psycho-social prevention-based goals, application of community work methods is highly important. Community work begins with a work of a community to solve the problems which are effective on a community or small communities. In line with social support, official and unofficial communication networks are empowered, established, and utilized for solving social problems (7). In community work, the goal is to collectively enable individuals, stimulate their sentiments, enable and unite the community to overcome their problems (8).

The first step in community work is to identify the social problem and set the goal. The goal often encompasses different aspects of change in a society and the mechanisms to achieve that goal. Change in community is made by community work through two processes: A) Analysis of community conditions, B) Formation of social networks and development of relations between different groups in order to achieve desired changes and offer intervention plan. Analyzing social conditions of the patients of an area and examining the diseases incidence and prevalence over time, social workers manage to identify biological, psychological, and social issues resulting in the incidence and prevalence of a disease in a particular area or at a specific time limit (9). Having identified the underlying cause of disease, social workers take steps toward overcoming the problem using social planning, local development, and social empowerment methods.

5.2.1.2. Psychosocial Treatment

Clinical social work in the field of psycho-social treatment is based on phenomenono logical perspective. The major strategy in this approach focuses on the paradigms which are concentrated on enabling the patient and his/her family, and establishing compatibility between the patient and his/her family. The objectives of this approach are focused on histological reconstruction, roles improvement, achieving sovereignty and independence, improving the framework for relations (10), overcoming the suppressive forces, increasing the level of confidence, strengthening problem-solving and decision-making skills, and critical analysis of interpersonal communication (11). Treatment practices with psychosocial approach in hospitals are focused on the following: giving medical advices with diagnostic, functional, client-oriented, cognitive, behavioral, and problem-solving approach to the patients needing these services; applying social group-work with therapeutic approaches using diagnostic, functional and problem-solving views, providing medical advices aimed at reducing stress in patients (12), giving counseling and intervention services for creating favorable conditions with the aim of returning the patients to the community, making psychosocial interventions and giving medical advices to the patients with post-traumatic stress syndrome, Giving counseling services and psychosocial interventions who attempted suicide, detection and identification of root causes of domestic violence, giving psychosocial counseling services ,and social and family interventions to prevent domestic violence and organizing the status of those who have been abused psycho-socially (13), identifying the addicted patients and giving medical ,supportive and referral services to these patients, identifying patients who are suffering from mental disorders and giving treatment, supportive and referral services to these patients (12), identifying elderly patients, careful assessment of their psychosocial status and giving psychosocially medical, supportive and referral services to these patients, identifying patients who are undergoing long treatment and assessing their psychosocial status, and giving supportive, psychological and social services to these patients, identifying patients who are suffering from mental confusion and impairment of performance due to treatments such as radiotherapy, chemotherapy, and difficult surgeries and giving medical care and psycho-social counseling to these patients, identifying patients such as runaway girls, rough-sleepers, the homeless, AIDS-infected patients and giving psychosocial and supportive services to them, identifying children and adolescents who are hospitalized and psycho-socially need medical and supportive advices and providing such services for them (12), identifying children , adolescents and individuals who are subject to loss of their loved ones and providing supportive and counseling services to these people to help them accept the reality, identifying the patients who are suffering from incurable and terminating diseases and giving supportive, spiritual, medical services to these patients and making interventions in their families, identifying patients who are mentally ill and giving counseling services to them and making psychological intervention, giving family therapy and family training services to the people who have certain patients at home, giving supportive-training and referral services to the families of the mentally ill (12), informing the patient and his/her family of the type of the disease , the resulting problems, and applying counseling and intervention solutions to prevent the emergence of dysfunction in the patient and his/her family, temporarily or permanently returning the disabled patients to the society and normalizing their functions, crisis intervention, and finally making the necessary coordination for discharge of the patients and continuing the treatment programs for the patient and his/her family at various situations including inpatient, outpatient, family, and community.

5.2.1.3. Psychosocial Rehabilitation

Rehabilitation is done about the people for whom the medical services have been performed, but they have lost their ability to cope with the community due to their disability and weaknesses (14). These services in the area of health-care workers can be seen as follows: giving counseling services to the patients, who have suffered organ defects, to accept their new condition and helping them through critical stage resulting from defects, counseling with the family of the patients with organ defects to accept the new conditions of the patient and making them understand how to properly treat the patients, giving advice and support to the families in which disabled children are born and giving rehabilitation-based services, giving referral services to the patients who need rehabilitation services, giving supervision services and solutions to hospital administrators for making the hospital a better place for the use of the disabled, giving follow-up treatment to patients who need rehabilitation services, providing medical prostheses and rehabilitation facilities for patients who need these services, using group work methods for improving psychosocial status of disabled patients and their families, environmental intervention in the living place and workplace of the patients with disabilities and improving the conditions of such places for the patients (15).

5.2.2. Social Services in Public Hospitals

Social services are the services which are provided to solve the financial, treatment, and supportive requirements of patients (16). These services are divided into two categories namely support and communication. Support services include providing advice to the patient, referring the patient to various organizations and institutions with the aim to overcome the patient's problems and support him/her financially. Patients are supported financially either by financial facilities available at the hospital and at social worker's disposal, or through social workers' consultations for attracting public participation. In insurance support part, social workers take the necessary steps to get the patients' insurance cards, communicate with insurance agencies, and guide the patients for using various insurances. As mentioned earlier, the other part of social workers' duty, in the field of social services, is communication services. In the area of communication services, the social workers communicate with members of treatment team, health-care organizations, as well as supportive and charity institutions so that a better condition can be provided for treatment of patients and solving their psychological , social and financial problems.

Model of Social Services in the Country's Public Hospitals

Figure 3.

Model of Social Services in the Country's Public Hospitals

5.2.3. Social Work Education-Research

Education-research services have been added to this model for the purpose of applying continuous training for enhancing knowledge level of social workers on the one hand, and giving educational services to patients in the area of psycho-social issues on the other hand. The purpose of providing this service to the patients is to increase abilities of the patients and their families to deal with problems and live a better psycho-social life. These trainings include the following: Running classes and courses which can help sustain the treatment, Subjects which are effective in improving psycho-social status of patients such as training in the field of stress management, life skills, showing emotions in an appropriate manner, running training courses for families with the aim to familiarize them with the diseases and how to better communicate with the patient, how to coordinate with different medical sectors, Identifying training needs of patients and running training classes for them by inviting different groups of experts, Identifying social issues affecting the disease of patients through conducting quantitative and qualitative researches and providing the relevant solution, training the community in the field of welfare and identifying diseases, training the hospital staffs regarding mental patients' issues, and active involvement in research to expand the knowledge base.

5.2.4. Supervisory and Policy-Making Social-Work

The purpose of supervisory social-work is to restore the patients' rights and offer comments and complaints for better provision of facilities needed for the welfare of the patients and their families. These goals include the following: decision-makings related to policy-making and planning for offering more humane services, defending patients' rights and health-care at the macro-level of the society and politics, participating in policy-making processes at hospitals, preparing plans for preventing accidents and diseases especially the diseases which are caused by major social and economic problems, preparing educational, health-care, and recreational programs to help patients, following up on the visitors' complaints of the medical team, familiarizing the patients with their individual and social rights, defending patients' rights and preventing violation of their rights. Social worker acts as the main supportive force of patients in the hospitals.

5.3. Recommendations

Recommendations arising from the study are summarized in seven categories including promoting social workers' knowledge base, offering an accurate, dynamic and comprehensive definition of social work service, guiding the social work profession toward treatment and prevention, establishing a comprehensive data bank consisting of social work services, increasing and improving social work facilities, raising the level of public understanding about social work profession through increasing public relation.

5.4. Study Limitations

• Lack of scientific and research work in the field of social work

• Alteration of some questionnaires and not answering them, which reduced the number of samples

• Making the observations and interviews at specified times which undoubtedly affected social and political situation of the hospitals positively.