SOCW 6070 wk 8 Assignment: Journal: Supervising Others

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The Clinical Supervisor

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Models and Methods in Hospital Social Work Supervision

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

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

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

Published online: 10 Nov 2009.

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Models and Methods in Hospital Social Work Supervision

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

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

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

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

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

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

INTRODUCTION

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

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

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

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

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

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

LITERATURE REVIEW

Hospital Reorganization: Impact on Social Work Hospital Supervision

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

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

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

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

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

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

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

Models of Social Work Supervision

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

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

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

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

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

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

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

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

METHODOLOGY

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

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

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

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

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

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

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

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

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

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

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

FINDINGS

Sample Characteristics

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

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

Organizational Context and Sanction for Social Work Supervision

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Administrative sanction is poignantly captured in the following scenario. Although supervisory staff existed, they were unwilling to provide clinical supervision to non-licensed workers. This finding suggests that the organiza- tion has no commitment to making these resources available to ensure their workers achieve licensure.

[The participant] . . . as for licensure, that’s pretty frustrating . . . we have a couple of people who are licensed who are not willing to provide one-on-one supervision . . . . (Cathy)

The lack of commitment to licensure is also captured in the following two quotes. The first participant describes how she chose to leave the organization after the clinical supervisor position was not replaced. While some chose to seek their supervisory hours outside of the organization, many accepted positions that included available supervision. The provision of supervision could have a significant impact on a health care setting’s ability to recruit and retain competent social work practitioners.

And when she [the supervisor] left, that was actually the reason I left. When she left, they didn’t make an effort to get a new clinical super- visor . . . I was losing about 30 hours a week of supervised hours [toward licensure]. (Barb)

Will reported another example of sanction. He stated that after the elimination of the social work manager=supervisor positions in his hospital, the social work staff advocated for the provision of clinical supervision. The organization agreed to have a consultant come to provide the supervision but did not make it a requirement for all staff to obtain licensure. Will reported that not all non-licensed staff took advantage of the clinical supervisor. Again, this finding supports the concern that without administrative sanction, the quality of social work services and the skill development of the staff can be compromised, particularly in situations where supervision may be provided by non-social workers.

And for the clinical supervision it’s an LCSW, I believe PhD, from outside who really is just volunteering, it’s not, an LCSW is definitely not needed for our position. It’s really just something that if you personally want to take the time to help yourself out then that person is volunteering to do that.

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The system-driven nature of individual social work supervision was also reflected in workers’ statements about the emphasis of their work on discharge planning, length of stay, and cost control, and how this emphasis shaped their supervision. However, workers who were seeking licensure, in particular, and some of the licensed workers, mentioned wanting more clinical insight from their supervision.

It’s getting everybody, no matter what your background is, it’s focused on shortening length of stay and identifying discharge barriers early on . . . it takes up a lot of everybody’s space and time, it is the top priority and so all the energy is being spent in that direction and what gets left over you might . . . be able to squeeze in some clinical. It’s just a matter of space and time. (Abigail)

I could benefit from more clinical supervision. The work has a psychosocial component but there is too much emphasis on concrete services and supervision that is task-focused to get the job done. The current emphasis is on length of stay and discharge planning. There is more focus in supervision on these issues than clinical content. (Judy)

The presence of organizational sanction set the tone for the types of supervisory models apparent within the organization. Both licensed and unlicensed workers reported receiving scheduled clinical, face-to-face social work supervision and administrative supervision on both a formal, scheduled basis and as-needed basis. Commonly cited concerns were lack of physical access to an off-site supervisor and lack of access to supervisors within the institution. The absence of recent clinical practice experience among super- visors was also mentioned as a barrier to supervision by workers. Scheduled in-person meetings with the supervisee were initiated at the request of the supervisee, formal meetings that the supervisor scheduled on a monthly basis or less frequently, or formal meetings with the supervisor that were sched- uled on a weekly basis for both licensed and unlicensed workers. The major- ity of respondents reported contact with their supervisors on an ‘‘as-needed’’ basis using e-mail, phone, or pager. This latter function of supervision was primarily administrative supervision.

Changing Models of Supervision: Multiple Modalities

INDIVIDUAL SUPERVISION MODEL

In contrast to the literature that identifies formal clinical supervision as the most widely used model (Bogo & McKnight, 2005; Kadushin & Harkness, 2002; Tsui, 2005), these focus group participants mentioned a variety of supervision models for different functions. Individual clinical formal supervi- sion was infrequent. For those who did report its use, the experience varied. Elizabeth and Abigail, licensed workers, describe their access to formal clinical supervision.

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I have access to clinical supervision as needed. Basically if I’m meeting with my supervisor for individual it’s probably 80% clinical. (Elizabeth)

I meet with my supervisor once a month. The focus is mostly on admin- istrative, not clinical issues. But we have access to this supervisor daily, almost instantly. So, I never have the feeling that I ever need help and it’s not available. (Abigail)

Will, Kathryn, and Cathy, unlicensed workers, describe a similar picture, only on a more frequent basis.

I meet with my director weekly. I would say the majority of . . . probably upwards of 80% of my time is spent, my clinical supervision is spent on clinical concerns. (Kathryn)

The actual clinical supervision is by someone (a PhD consultant with no formal authority in the institution) affiliated with another hospital that we just were supported in the sense that we can take an hour during the workweek to be with that person. (Will)

I have been at my job about six years and there was no formal clinical supervision whatsoever up until about a few months ago. It is very hard to get licensed. And I meet primarily informally with my personal super- visor [unlicensed social worker in that state] and with the lead [licensed social work manager] assigned to me. That’s very informal also . . .. It is so limited. I am going to have to pay for outside supervision so that I can be licensed. (Cathy)

In addition to a primary supervisor, some workers also had access to team leaders or managers, some with administrative authority, for clinical supervision. Workers expressed skepticism about the clinical competence of the primary supervisor when he or she carried no clinical caseload. These secondary supervisors were perceived as being more knowledgeable and skilled in regard to clinical issues:

The distance from day-to-day clinical practice for the director in provid- ing supervision can also be somewhat of a challenge in terms of just the day-to-day practice of what we do. My team leader [licensed clinical social worker] is often more accessible than the director; her office is right across the hall from mine and she’s always just checking in on an informal basis is [there] anything I need, how’s everything going. So it is helpful. (Kathryn)

We have a director, a manager, and then we have supervisors. There are four line workers who are more experienced social workers [who] do clinical work and are clinical supervisors as well. The strength with non-management clinical supervisors is that they are still on the floor. So they know, they are in the trenches kind of with us. And that helps.

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That’s a good thing. The weaknesses with having the director in particular being the clinical supervisor is that she does no clinical work at all any- more, so she’s very, very removed from the clinical setting. (Barb)

GROUP WORK MODEL

Formal group supervision (on a weekly or monthly basis) substituted for individual clinical supervision for some workers.

Individual supervision is, it varies in term of clinical content depending on what makes sense but I have group supervision every two weeks. Group supervision is probably 100% clinical but if someone has an issue that is going to potentially impact their work and it’s not a clinical issue they are free to bring it in, but typically we talk about clinical issues. (Tracy)

I have not brought clinical cases to my individual supervision as much as to my group supervision; since I meet with them more regularly I can get in more depth with cases clinically and that is the part about meeting with them regularly is that you are bringing that kind of stuff to the table whereas even though you can call on your supervisor about things and I do. It is just lately there hasn’t been a need for that. (Elizabeth)

What my boss did, was she has an MSW from another state from a long time ago and had not been licensed yet in the state where I live. And so. So she appointed four of the most experienced people in the department and they are kind of in a lead role to help her kind of manage all these people. So, one of those women is licensed and has been providing group supervision on a monthly basis that is focused on clinical content about half of the time. (Cathy)

In other cases, groups were a supplement to individual clinical supervision.

I meet with my supervisor on an as-needed basis and those meetings are probably 80% clinical. And then in terms of the group supervision that is scheduled weekly and that’s pretty much 100%, maybe you could say 99% clinical. (Barb)

TEAMWORK MODEL

Formally scheduled team supervision (monthly or weekly) was the least frequently mentioned source of supervision. Team supervision included both administrative and clinical supervisory functions. Lucille, a licensed social worker who received clinical and administrative supervision on an as-needed basis, accessed clinical supervision in a formally scheduled team meeting.

I don’t have any one-on-one clinical supervision. We do have weekly team meetings where we talk about cases. The team I work for also meets

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regularly and sometimes it’s administrative and sometimes it’s clinical. It varies; it’s probably about 30% clinical. (Lucille)

Kathryn, an unlicensed social worker who received individual clinical supervision, discussed the additional clinical supervision she received in the team setting.

The team meets twice a month formally as a group for an hour and that’s probably on average maybe 50% administrative=50% sort of clinical in terms of our practice. (Kathryn)

PEER CONSULTATION

Informal peer consultation was frequently cited as a source of clinical guidance and support. These contacts occurred over lunch, in offices, by phone, through text messaging, pager, and e-mail. This variety of mod- alities reflects the creativity of workers in arranging for clinical and sup- portive peer consultation. With one or two exceptions, these collectives appeared to form on a spontaneous ad hoc basis. This form of peer con- sultation is differentiated from peer group supervision, which is formally scheduled and institutionalized as a format for supervision in the agency. Workers, both licensed and unlicensed, accessed peers informally for clin- ical guidance.

I work with a population that requires a great deal of psychosocial inter- ventions; generally my supervision time entails talking about do you know what the hospital can pay for that kind of thing. But when we have a tough case I use my peers at work to talk about these cases. (Judy)

There’s two social workers in my setting and we lean on each other pretty heavily. The other social worker and I get together, yeah, as a peer and that has . . . that is very helpful. I am hooked up with, on the Internet, with a group of area social workers in health care and we get information . . . I get information that way. (Jan)

In a few instances, workers stated they received peer group supervision. Barb, a licensed social worker, discussed her oncology section peer group.

We have an oncology section. It’s a peer group. We meet once a month for an hour all oncology social workers and we discuss system issues, research issues, a really difficult case, and we also do a lot of continuity of care type issues at that setting too. (Barb)

Will, an unlicensed worker, mentioned supervision in a peer group that developed after the social work supervisor was demoted and the department decentralized.

194 G. Kadushin et al.

We developed our own social work council that met monthly just to kind of be a support group and a place to have input and have our voice heard. And we actually were able to get a pay raise and a compromise. We still report directly to a nurse but we now have a social work manager on their same level as a consultant that adds a dotted line person that we can talk to and we are still meeting.

In the previous quote of Will’s and in the following statement made by Barb, the peer group was also perceived as a source of support in a challenging hospital environment.

The oncology section group makes us have a presence in the hospital which is so important as a group, as a section because they realize, people realize that we have an oncology section, a group of designated oncology social workers. And that’s important I think because it’s a specialty in a way just like a lot of other practices are. (Barb)

NO SOCIAL WORK SUPERVISION

A minority of licensed workers and two of the five unlicensed workers reported that they received no social work supervision. These workers were supervised by RNs or BSNs. All of the unlicensed workers who did not receive social work supervision relied on peer consultation for clinical guidance and support. One worker contracted to pay for private supervision for licensure. Among unlicensed workers, the nurse supervisor was perceived as unqualified and an obstacle to professional development and licensure.

I mean I think for a nurse who’s gone from direct nursing to management without getting any kind of management degree and then being told to supervise and evaluate a social worker based on I don’t know exactly what. I think there’s been some talk about whether or not that’s such a great idea but that’s just kind of the way it is. (Will)

Non–social work supervision was also viewed as representing a lack of valuation of social work as a profession in the organization.

In our setting too, a lot of the staff don’t really understand what we do. I think it is very much related to lack of social work supervision. My super- visor is a registered nurse over the case management department. I do have a problem with having a nurse as a supervisor because she doesn’t understand, I think, what the social workers really need to do their job, and how long things take and what it takes . . .. I would like a little more clinical focus. Now there is a much bigger focus on length of stay, and discharge planning. (Jan)

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AUTONOMOUS SOCIAL WORKER PRACTICE

The most frequently mentioned model of supervision for licensed social work- ers was clinical supervision on an as-needed basis. Licensed workers contacted their supervisors through pager, e-mail, text messaging, or phone when they made a clinical, ethical, or legal judgment on a situation that required input from a supervisor. This model of supervision was more frequent when the pri- mary social work supervisor was a corporate level employee off-site or a hos- pital administrator at a high level in the bureaucracy. Generally, these licensed workers frequently evaluated this mode of supervision positively. For exam- ple, Abigail, a licensed clinical social worker, noted,

My supervisor is off-site but she is available if something comes up by e-mail. I see our relationship as a form of guidance, not supervision. It is very hands off but I don’t want more clinical contact [so] I am satisfied with this arrangement. (Abigail)

Judy, another licensed social worker, noted that her autonomy conveyed her supervisor’s confidence and respect.

I think that the supervisor respects my clinical competency. They do check our electronic notes. So, they always access, she always has access to what we’re doing. They refer to us here as having our own practices. So, that should tell you a lot. (Judy)

However, workers also wanted to maintain access to formal clinical supervision and regarded the absence or presence of this option as an indication of the hospitals’ support for the profession.

Most of my supervision is on an as-needed basis. I think that the super- visor respects my clinical competency. But I do think that just because you are licensed does not mean you cannot benefit from supervision. I think I could benefit from more clinical supervision but it is not available because the emphasis in this hospital is on concrete services and cost control. (Judy)

IMPLICATIONS FOR EDUCATION, PRACTICE, AND RESEARCH

Generalizability from this pilot study to the larger population of hospital social work supervisees is not warranted because this was not a representa- tive sample. Other limitations are the small convenience sample; the homo- geneity of the sample in regard to licensure status; the potential for bias introduced by using supervisors in the recruitment of subjects; and any unknown characteristics of the sample that may have influenced the findings. Recognizing that this was only a sample for a qualitative pilot study, a

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strength of the methodology was that we had participants who represented geographic regions throughout the country, providing information that was not limited by working in a specific geographic area.

The findings of this study provide new information about worker perceptions of the significance of the hospital’s sanction and valuation of social work as a profession in supporting social work supervision as an organizational responsibility. Supervision was shaped by the ‘‘order of the day’’ (Bogo & McKnight, 2005, p. 56). The supervisees’ perceptions were that their supervisors’ primary commitment was to the corporation or the hospital bureaucracy and that the supervision they received was not systematically matched to their needs. While workers with and without clinical licenses had access to formal one-on-one supervision, the focus was predominantly on administrative issues.

Access to educational=clinical social work supervision was regarded by these subjects as secondary to the constraints of the hospital or corporation to monitor costs through length of stay and discharge planning. These atti- tudes are reflected in statements that there ‘‘were bigger problems out there than my professional development’’ and the frequent observation that the supervisor was out of touch or distant from social work practice. These find- ings are consistent with previous research on the function of supervision in an environment influenced by managed care organizations or principles (Kadushin & Harkness, 2002). The supervisees’ perceptions of a supervisor preoccupied with administrative responsibilities and lacking clinical credibil- ity also confirm the apprehension about the sustainability of the resource- intensive model of clinical supervision in the profit-conscious hospital.

In place of formal individual clinical supervision as the most frequent model, these supervisees mentioned a variety of supervisory models includ- ing seeking out secondary on-site supervisors (team leaders, senior workers, or leads) and participation in group, team, and autonomous supervision models. Workers also relied on peer consultation and, less frequently, peer group supervision for clinical and supportive supervisory functions. These findings may suggest that social workers are responding to organizational constraints on the labor-intensive individual supervision model by develop- ing alternative sources for supervision.

While this may be interpreted as a positive development by suggesting that models of hospital supervision are evolving to adapt to leaner manage- ment structures and cost constraints, we find no evidence of a thoughtful, systematic process of planning and implementation or mechanisms for evaluation or accountability in the findings. In particular, it is unclear how the supervisory functions of administration, education, and support were provided to those workers without social work supervision who relied on peer consultation for clinical guidance and support.

Organizations such as the Society for Social Work Leadership in Health Care and National Association of Social Workers are appropriate professional

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leaders to assume responsibility for the systematic development and evalua- tion of cost-effective, sustainable supervision models that produce positive outcomes for workers and clients (Berger & Mizrahi, 2001; Sulman et al., 2004).

Schools of social work may need to be aware of the health care context and revise their fieldwork and classroom curricula to prepare students with skills in advocacy, program planning, group work, and teamwork to be successful in accessing a variety of supervision models to support their professional development.

Future research is suggested to provide an evidence-based approach to practice which documents the association of appropriate hospital supervi- sion models, worker competence, positive patient outcomes, and reduced consumption of health care resources.

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