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Week96351HowSocialWorkersCopewithManagedCare.pdf
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Administration in Social Work
ISSN: 0364-3107 (Print) 1544-4376 (Online) Journal homepage: https://www.tandfonline.com/loi/wasw20
How Social Workers Cope with Managed Care
Gila M. Acker
To cite this article: Gila M. Acker (2010) How Social Workers Cope with Managed Care, Administration in Social Work, 34:5, 405-422, DOI: 10.1080/03643107.2010.518125
To link to this article: https://doi.org/10.1080/03643107.2010.518125
Published online: 09 Nov 2010.
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Administration in Social Work, 34:405–422, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0364-3107 print/1544-4376 online DOI: 10.1080/03643107.2010.518125
How Social Workers Cope with Managed Care
GILA M. ACKER Department of Social Sciences, York College of The City University of New York,
Jamaica, New York, USA
The study reported in this paper examined the relationships between social workers’ experiences when interfacing with man- aged care organizations, coping strategies, burnout, and somatic symptoms associated with stress. A sample of 591 social work- ers completed questionnaires that included demographic questions and measures of perceived competence in the context of man- aged care, coping strategies, burnout, and somatic symptoms. Multiple regression analyses revealed that coping had statistically significant correlations with several burnout dimensions and with workers’ perceived competence in the context of managed care. As coping provided the most comprehensive influence on workers’ psychological and somatic reactions associated with burnout, the author suggests that agencies provide social workers with adequate training to promote workers’ use of effective coping styles that are appropriate when interfacing with managed care organizations.
KEYWORDS managed care, emotional exhaustion, depersonal- ization, personal accomplishment, somatic symptoms, perceived competence in the context of managed care, coping strategies
INTRODUCTION
Social workers, along with other human service workers, have shown to be vulnerable to work stresses characteristic of those occupations that involve ongoing contacts with people. External and internal pressures includ- ing role conflict, overload, economic problems of the health and mental health systems, and increased accountability to managed care organizations,
Address correspondence to Gila M. Acker, Department of Social Sciences, York College of The City University of New York, Jamaica, NY 11451, USA. E-mail: [email protected]
405
406 G. M. Acker
have created new pressures for service providers, including social work- ers (Cohen, 2003; Daniels, 2001; Hall & Keefe, 2000; Keefe & Hall, 1998). Job stress is thought to be largely a function of conflicts within the work envi- ronment, such as when workers feel that they cannot master organizational and work demands, and that their job activities are inappropriate and incon- gruent with their training and expertise (Acker, 2004; Al-Garni, 2003; Arches, 1997; Cohen, 2003; Hall & Keefe, 2000; Lambert, Pasupuleti, Cluse-Tolar, Jennings & Baker, 2006; Lloyd, King & Chenoweth, 2002). Prolonged stress is associated with chronic anxiety, psychosomatic illness, emotional fatigue, frustration, irritability, and a variety of other emotional problems (Lloyd, King & Chenoweth, 2002). Burnout is a syndrome composed of three dimensions including emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach, Jackson & Leiter, 1996). Burnout has serious implications for both the worker and the organization including poor job performance, absenteeism, psychosomatic illnesses, and turnover (Montes- Berges & Augusto, 2007; Thoresen, Kaplan, Barsky, Warren & Chermont, 2003).
Addressing burnout can increase employees’ efficiency and effective- ness in today’s increasingly cost-prohibitive world of care. Although the empirical literature has emphasized that the ways that workers cope with job stressors may be more important than the amount of stress itself (Gellis, 2002; Latack, 1992), insufficient attention has been paid to how social work- ers cope with the new culture of mental health care (Cohen, 2003; Feldman, 2001; Gellis, 2002; Hall & Keefe, 2000). In this study, the negative out- comes of job stress, including the psychological and the psychosomatic disturbances of social workers, were explored in relation to workers’ coping strategies.
BURNOUT
Burnout is defined as a negative psychological experience that is a reac- tion of workers to job-related stress such as challenging organizational demands, lack of autonomy, unsupportive work environment, and large caseload size (Acker, 2003, 2004; Arches, 1997; Gellis, 2002; Maslach, Jackson & Leiter, 1996; Pines, 1983; Rosenbaum, 1992). Burnout refers to a cluster of physical and emotional symptoms, including emotional exhaustion, a lacking sense of personal accomplishment, and deperson- alization of clients. Burnout symptoms can also include common colds, flu-like symptoms, gastroenteritis, headaches, fatigue, poor self-esteem, dif- ficulty in interpersonal relationships, and substance abuse (Maslach, 1982; Maslach, Jackson & Leiter, 1996; Mohren, Swaen, Kant, Van Schayck & Galama, 2005). It is critical to recognize that social workers confronted by the complex needs of clients and the organizational demands of cost
How Social Workers Cope with Managed Care 407
containment are at risk to experience the negative symptoms associated with burnout.
Job resources like supervision and other supportive mechanisms directed toward workers have been diminishing with the lack of funding associated with social services (Acker, 2003, 2004; Adams, 2001; Pumariega, Winters, & Huffine, 2003). Lack of social support is known to be another stressor associated with burnout, as workers who feel professionally unsup- ported are more likely to develop negative attitudes toward their job (Acker, 2003; Pines, 1983; Um & Harrison, 1998; Winnbust, 1993).
MANAGED CARE
During the past two decades, managed care has become the new approach and organizing theme for the delivery of mental health care services in the United States. It strives to provide efficient quality care at a lower cost than that offered in the fee-for-service professional community. The emer- gence of managed care has created a new source of stress for social workers and other helping professionals. Managed care’s cost containment approach, which includes limited access to necessary services, strict practice guidelines, reduced autonomy, and increased accountability, has created new challenges for social workers, who used to enjoy much more profes- sional freedom and opportunities for decision making (Cohen, 2003; Egan & Kadushin, 2007; Feldman, 2001; Keefe & Hall, 1998; Lu, Miller & Chen, 2002; Mechanic, 2007).
The increased involvement of managed care has had vast implications for the role of social workers in the mental health care field. Social work- ers who perform the largest portion of mental health work in the United States have been required to alter their role from serving as clients’ advo- cates to balancing clients’ needs against the need for cost control. In their new roles as gatekeepers and treatment providers, social workers must learn new strategies and skills to reduce considerable cost-savings expenditures when providing services to clients (Cohen, 2003). Skills that social workers need in the managed care environment involve computers and technology, documentation and paperwork, empirical validation of treatment methods, knowledge of brief treatment methods, and a business orientation in man- aging services in a profitable way (Bolen & Hall, 2007; Feldman, 2001; Lu, Miller & Chen, 2002). Building on the concept of competence, which describes feelings of confidence about one’s abilities to master organiza- tional and work demands (Hall & Keefe, 2000; Wagner & Morse, 1975; White, 1967), several theorists argue that a person’s belief that he or she can- not perform well professionally increases their risk of becoming burned out (Bandura, 1989; Cherniss, 1993; Harrison, 1980). Participating in managed care is complicated, and those who are not apprised about the managed
408 G. M. Acker
care world are likely to suffer stress and anxiety concerning their ability to provide effective services in the context of managed care (Hall and Keefe, 2000; Spevack, 2009).
COPING STRATEGIES
Coping strategies are defined as the cognitive and behavioral efforts that people use to manage external and/or internal demands appraised as tax- ing or exceeding the person’s resources (Lazarus, 1993; Lazarus & Folkman, 1984; Sears, Urizar & Evans, 2000; Shikai, et al., 2007). Lazarus and Folkman (1984) describe two major strategies for coping with stress: problem-focused coping and emotion-focused coping. Problem-focused coping consists of active behaviors and deliberate efforts to solve the situation, and the use of social support, including collaborative efforts to educate and support each other at the workplace (Brooks & Riley, 1996; Jenaro, Flores & Arias, 2007). Emotion-focused coping, on the other hand, is directed at regulating emotional responses to a problem, such as using alcohol, drugs, exces- sive sleep, and denial and disengagement behaviors (Lazarus & Folkman, 1984; Jenaro, Flores & Arias, 2007; Shikai, et al., 2007). Previous studies have found problem-focused coping to be effective for reducing stress in the workplace (Gellis, 2002; Jenaro, Flores & Arias, 2007; Koeske, Kirk & Koeske, 1993; Riolli, 2003). On the other hand, previous studies have found emotion-focused coping to be related to negative psychological outcomes such as higher levels of occupational stress (Gellis, 2002; Jenaro, Flores & Arias, 2007; Thornton, 1992; Koeske, Kirk & Koeske, 1993).
A growing body of literature is stressing that personal resources (cop- ing strategies) may help workers adjust to job demands, and diminish the stress associated with a difficult and demanding job environment (Gellis, 2002; Jenaro, Flores & Arias, 2007; Latack, 1992). With the impact of man- aged care on the professional lives of social workers, such as increased demands for new management activities and paperwork, cost containment, and ongoing demonstration that continued treatment is needed (Rupert & Baird, 2004), it is important to understand how workers cope with these job situations. Types of coping strategies that workers use when interfac- ing with managed care are important to explore as they are likely to affect work outcomes of social workers (i.e., burnout). Although managed care has not suffered from any lack of attention from both the public and the professional media, there is limited data to support the notion that social workers feel that they are not competent and/or able to master the orga- nizational demands associated with managed care (Feldman, 2001; Cohen, 2003; Hall & Keefe, 2000; Keefe & Hall, 1998; Shera, 1996; Stone, 1995). There is also scarce data about how social workers cope when interfac- ing with managed care, and the impact of managed care on negative job
How Social Workers Cope with Managed Care 409
outcomes such as burnout (Feldman, 2001; Cohen, 2003; Rupert & Baird, 2004).
The aim of the present study was to explore in more depth the pro- fessional lives of social workers heavily involved in managed care, and to identify the coping strategies they find most useful in helping them to deal more effectively with the job demands associated with managed care and in reducing negative work outcomes. This study will add to the knowl- edge of how managed care impacts social workers, and how social workers respond to the new demands and challenges associated with managed care. The hypotheses of the study include:
1. Social workers who use problem-focused coping are more likely to feel more competent in the context of managed care.
2. Social workers who use emotion-focused coping strategies are less likely to feel competent in the context of managed care.
3. Social workers who use problem-focused coping strategies are less likely to suffer from burnout, including emotional exhaustion, depersonaliza- tion, reduced personal accomplishment, and somatic symptoms.
4. Social workers who use emotion-focused coping strategies are more likely to suffer from burnout, including emotional exhaustion, depersonaliza- tion, reduced personal accomplishment, and somatic symptoms.
MATERIALS AND METHODS
Procedure
The sample of this study, which was obtained from a professional list of social workers practicing in New York State, consisted of 591 social work- ers. Self-administered and anonymous questionnaire packets were mailed to 1,000 randomly selected individuals from this list. The overall response rate was 58%. The institutional review board of the university where the author is employed approved the study.
Sample
Educational levels of respondents included 89% with master degrees in social work, and 5% with doctoral degrees. The respondents were primarily females (80%). The mean age was 51, ranging from 21 to 80. Seventy-one percent were married or involved in long-term relationship with a partner; 28% were not married. The respondents were predominantly White (86%); 5% were African American or Black, 7% were Latino, and 1% were Asian. The mean for years of experience in social work was 22 years, ranging from 2 to 50 years of employment. The median for client contact hour per week was 25. Forty-three percent were employed in outpatient mental health
410 G. M. Acker
settings, 13% in community support systems, 23 % in private practice, 7% in substance abuse rehabilitation settings, 8% in inpatient psychiatric settings, and 6% in schools.
Measures
PERCEIVED COMPETENCE IN THE CONTEXT OF MANAGED CARE (CMC)
In this study, perceived competence in the context of managed care was defined as workers’ feelings of confidence about their abilities in mas- tering organizational and work demands associated with managed care. The CMC developed by Hall and Keefe (2000) included 16 items ranging from “1 = strongly disagree” to “4 = strongly agree.” Higher scores indi- cated a perception of greater competence in the context of managed care. Example of items included: “Managed care allows me enough direction to be effective in treating clients”; “Coordinating care under managed care con- ditions is easy once you understand the various managed care company requirements”; and, “Managed care allows me enough freedom to be effec- tive in treating clients.” Hall and Keefe (2000) demonstrated that the CMC had adequate validity and reliability. In this study, the Cronbach’s alpha for the CMC was .86.
PROBLEM-FOCUSED COPING STRATEGIES (PFCS)
Problem-focused coping strategies described assertive efforts of the indi- vidual to alter stressful situations. PFCS were measured by a 10-item scale developed by Folkman and Lazarus (1988). Examples of items are: “Stood my ground and fought for what I wanted”; “I expressed anger to the per- son(s) who caused the problem”; and, “Talked to someone who could do something concrete about the problem.” Respondents were asked to rate each item on a 4-point Likert-type scale for the extent to which they used each strategy during stressful job encounters in the past (0 = did not use; 1 = used somewhat; 2 = used quite a bit; 3 = used a great deal). PFCS are known to have both good reliability and validity (Carver, Scheier & Weintraub, 1989; Folkman, Lazarus, Dunkel-Schetter, DeLongis & Gruen, 1986). Cronbach’s alpha for this study sample was .84.
EMOTION-FOCUSED COPING STRATEGIES (EFCS)
This 9-item scale (Folkman & Lazarus, 1988) described wishful thinking and efforts to escape or avoid stressful job related situations. Examples of items were: “wished that the situation would go away or somehow be over with,” “didn’t let it get to me; refused to think about it too much,” and “tried to make myself feel better by eating, drinking, smoking, using drugs,
How Social Workers Cope with Managed Care 411
or medications.” Respondents were asked to rate each item on a 4-point Likert-type scale as described before. EFCS are known to have both good reliability and validity (Carver, Scheier & Weintraub, 1989; Folkman et al., 1986). Cronbach’s alpha for this study sample was .76.
SOCIAL SUPPORT AT THE WORKPLACE
This scale was adapted from the social support from supervisor and social support from co-workers scales (Caplan, Cobb, French, van Harrison, & Pinneau, 1980). The new scale comprised eight questions about the extent to which people around the worker (the worker’s supervisor and co-workers) provided support by listening and by being persons that the worker can rely on for help. Examples of questions are: “How much does your super- visor go out of the way to do things to make your life easier?” and “How much are other people at work willing to listen to your personal problems?” Cronbach’s alpha for this study sample was .88.
BURNOUT
Emotional exhaustion (EE), depersonalization (DP), and personal accom- plishment (PA) were measured by a slightly modified version of the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996). The EE subscale com- prised nine items reflecting feelings of being emotionally overextended, exhausted, physical exhaustion, and emptiness. Examples of items included: “Working with people all day is really a strain for me” and “I feel frus- trated by my job.” The four items of the DP subscale described an unfeeling and impersonal response toward clients of one’s service. It included such items as “I feel I treat some as if they were impersonal objects” and “I don’t really care what happens to some clients.” The PA subscale consisted of six items that describe feelings of competence and successful achieve- ment in one’s work. Examples of items included: “accomplishing worthwhile things at work” and “positively influencing my clients’ lives through work.” Respondents were asked to rate each statement on a 7-point Likert-type scale for frequency of agreement (0 = never, 1 = a few times a year or less; 2 = once a month or less; 3 = a few times a month; 4 = once a week; 5 = a few times a week; 6 = every day). Cronbach’s alpha coef- ficient for this study’s sample included .92 for EE, .78 for DP, and .77 for PA.
SOMATIC SYMPTOMS
This measure included two scales based on previous research done by Mohren and colleagues (2005) and Nakao, Tamiya and Yano (2005). The first scale (12 items) measured flu-like symptoms (e.g., colds, sore throat, cough,
412 G. M. Acker
and fever). The second scale (3 items) measured symptoms of gastroenteritis (GA). Respondents were asked to rate each item on a 7-point Likert-type scale in terms of how often they have been experiencing each of those symptoms for the past six months (0 = never, 1 = rarely; 2 = sometimes; 3 = fairly often; 4 = often; 5 = very often; and, 6 = all or most of the time). Cronbach’s alpha coefficient for this study’s sample included .85 for common colds and flu-like symptoms, and .75 for symptoms of gastroenteritis.
DATA ANALYSIS
Pearson product-moment correlation coefficient was used to investigate the research hypotheses and other relationships among the study’s variables. A correlation matrix was computed for all the study’s variables. To fur- ther explore how coping strategies contributed to the burnout measures above and beyond work-related variables (i.e., competence in the context of managed care, social support, caseload size, satisfaction with the salary, and years of experience practicing social work), as well as workers’ socio- demographic variables (i.e., age, race, and gender), hierarchical regression analyses were used. Data analyses utilized SPSS computer software.
Nominal variables such as gender and race (people of color or Whites) were included in the regression analysis by coding them as dummy variables.
RESULTS
The analysis began with the investigation of the relationships among the variables included in the study’s hypotheses and the other variables of the study. As shown in Table 1, problem-focused coping was found to have statistically significant low positive correlations with emotional exhaustion (EE), depersonalization (DP), flu-like symptoms, and symptoms of gastroen- teritis (GA); and low negative correlations with perceived competence in the context of managed care (CMC) and age. Emotion-focused coping was found to have statistically significant low to medium positive correlations with CMC, EE, DP, reduced personal accomplishment (PA), flu-like symp- toms and GA; and low negative correlations with age and work experience. EE had low negative correlations with CMC, satisfaction with the salary, and social support, and positive low correlation with size of caseload. DP was found to have statistically significant medium positive correlation with emotion-focused coping, and statistically significant low negative correla- tions with age and work experience. PA had statistically significant low negative correlation with emotion-focused coping and low positive cor- relations with age and work experience. CMC had statistically significant
T A
B L E
1 In
te rc
o rr
e la
ti o n s
A m
o n g
St u d y
V ar
ia b le
s (N
= 5 9 1 )
E E
D P
PA F LS
G A
P F C S
E F C S
SS P
R ac
e C as
e lo
ad Sa
la ry
E X
P. A
g e
G e n d e r
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2 3
4 5
6 7
8 9
1 0
1 1
1 2
1 3
1 4
1 5
1 . C M
C −.
1 7
∗∗ −.
0 7
.0 2
−. 1 4
∗∗ −.
0 5
−1 9
∗∗ .1
4 ∗∗
.1 2
∗∗ −.
1 3
∗∗ .0
1 −.
1 1
∗ −.
0 9
−. 0 7
−. 0 1
2 . E E
.5 0
∗∗ −.
2 9
∗∗ .3
2 ∗∗
.2 9
∗∗ .2
6 ∗∗
.4 1
∗∗ −.
1 4
∗∗ .0
9 ∗
.1 4
∗∗ −.
1 8
∗∗ −.
0 9
∗ −.
1 0
∗ .0
1 3 . D
P −.
3 7
∗∗ .2
6 ∗∗
.2 2
∗∗ .2
0 ∗∗
.4 4
∗∗ −.
0 2
.1 1
∗∗ .0
2 −.
0 5
−. 1 4
∗∗ −.
1 5
∗∗ −.
1 0
∗
4 . PA
−. 1 3
∗∗ −.
1 3
∗∗ −.
0 5
−. 1 9
∗ .0
3 −.
0 0
.0 3
.0 8
∗ .1
2 ∗∗
.1 7
∗∗ .0
4 5 . F lu
-l ik
e sy
m p to
m s
.4 0
∗∗ .1
5 ∗∗
.2 5
∗∗ −.
1 0
∗ 0 7
−. 0 3
−. 0 6
−. 0 6
−. 0 8
−. 0 8
6 . G
as tr o -
e n te
ri ti s
.1 6
∗∗ .2
8 ∗∗
−. 0 7
.1 4
∗∗ −.
0 1
−. 0 7
−. 0 4
−. 0 6
.0 4
7 . P ro
b le
m -
F o cu
se d
.5 3
∗∗ −.
0 1
−. 0 5
.0 8
.0 3
−. 0 8
−. 1 6
∗∗ .0
6
8 . E m
o ti o n -
fo cu
se d
.0 2
.1 0
∗ −.
0 3
−. 0 3
−. 1 7
∗∗ −.
2 8
∗∗ .0
0
9 . So
ci al
su p p o rt
−. 0 1
.0 2
.0 6
−. 0 1
−. 0 5
−. 0 6
1 0 . R ac
e .0
1 .0
6 −.
0 3
−. 0 3
−. 0 4
1 1 . C as
e lo
ad si
ze .0
7 .0
7 .0
1 −.
0 3
1 2 . Sa
la ry
.0 7
−. 0 4
−. 0 5
1 3 . W
o rk
e x p e ri e n ce
.5 8
∗∗ −.
1 8
∗∗
1 4 . A
g e
−. 9
∗∗
∗ p <
.0 5 ,
∗∗ p
< .0
1 .
413
414 G. M. Acker
low positive correlation with social support, and statistically significant low negative correlation with flu-like symptoms. Both coping styles had low pos- itive correlations with flu-like symptoms and GA. Positive correlation means that the two variables move in the same direction, and negative correla- tion means that the two variables move in opposite directions—that is, as one increases, the other one decreases. White workers reported higher lev- els of DP and GA than non-White workers and also felt less competent in the context of managed care than the non-White workers. The results also indicate that the power of the correlations between the primary variables including EE, DP, PA, flu-like symptoms, and gastroenteritis are sufficiently independent to be examined separately.
Multiple regression analyses provided information on the influence of the different coping mechanisms on burnout symptoms including EE, DP, PA, flu-like symptoms, and gastroenteritis above and beyond the work-related variables (i.e., CMC, social support, caseload size, satisfaction with the salary, and work experience), and workers’ socio-demographic variables includ- ing age, gender, and race. Problem-focused coping was entered first into the regression equation. The second step included the variable emotion- focused coping. Then, in the third step, the work variables were added to the regression to examine whether there was an increase in predictabil- ity above and beyond the information provided by the coping strategies variables. The fourth step included workers’ socio-demographic variables to examine if those variables also contributed significantly to the outcome variables (Table 2). To reduce the problem of finding significance that’s actually produced by chance when multiple correlations are made with mul- tiple regression analysis, the Bonferroni procedure calls for the researcher to divide the .05 probability level by the number of statistical tests to be con- ducted, which in this case included 10 tests. This resulted in a new p value, p = .005 (.05/10)(Montcalm & Royse, 2002).
The first analysis for predicting EE, which included the variable problem- focused coping in the first step, resulted in significant relationship: R2 = .05, F (1, 378) = 20.86, p < .001. Step two, which included the variable emotion- focused coping, was also significant: R2 change = .12, F (1, 377) = 53.07, p < .001. The third step, which included work variables (social support, CMC, caseload size, satisfaction with salary, and years of experience practicing social work), was not significant: R2 change = .03, F (5, 372) = 3.02, p < .011. The fourth step with the socio-demographic variables (age, race, and gender) was not significant, R2 change = .00, F (3, 369) =.537, p < .657. The first step of the second analysis with problem-focused coping as the predictor of DP was significant: R2 = .03, F (1, 378) = 11.36, p < .001. The second equation, which included emotion-focused coping, was also significant: R2
change = .16, F (1, 377) = 76.70, p < .001. The third step, which included the work variables, was not significant: R2 change = .02, F (5, 372) = 2.10,
T A
B L E
2 R e su
lt s
fr o m
H ie
ra rc
h ic
al R e g re
ss io
n A
n al
y se
s P re
d ic
ti n g
O u tc
o m
e V ar
ia b le
s (E
E , D
P, PA
, fl u -l ik
e sy
m p to
m s
an d
G A
)
E E
D P
PA F lu
– li k e
sy m
p to
m s
G A
V ar
ia b le
β t
p β
t p
β t
p β
t p
β t
p
S te
p 1
: P ro
b le
m -F
o cu
se d
.2 3
4 .5
6 8
∗∗ .1
7 3 .3
7 6
∗∗ −.
0 4
−. 8 4 6
∗∗ .1
6 −3
.1 3 0
∗∗ .1
7 3 .4
3 4
∗∗
R 2
.0 5
∗∗ .0
3 ∗∗
.0 0
.0 3
∗∗ .0
3 ∗∗
F 2 0 .8
6 1 1 .4
0 .7
2 9 .8
0 1 1 .8
0
S te
p 2
: E m
o ti o n -F
o cu
se d
.5 4
7 .2
8 5
∗∗ .4
7 8 .7
5 8
∗∗ −.
2 3
−3 .8
9 8
∗∗ .2
0 3 .5
0 8
.2 6
4 .5
0 5
∗∗
R 2
.1 7
∗∗ .1
9 ∗∗
.0 4
∗∗ .0
6 ∗∗
.0 8
∗∗
F 5 3 .0
7 7 6 .7
0 1 5 .1
9 1 2 .3
1 2 0 .2
9
S te
p 3
: C M
C .1
3 2 .8
6 7
∗ .1
3 2 .9
4 2
∗ −.
0 1
−. 1 9 0 4
.0 6
1 .2
2 5
.0 1
.1 2 4
So ci
al su
p p o rt
−. 0 6
−1 .1
4 1
.0 2
.3 6 7
−. 0 2
−. 3 0 8
−. 1 1
−2 .2
2 5
−. 0 5
−. 8 9 5
C as
e lo
ad −.
0 2
.5 2 0
.0 1
.1 3 6
−. 0 6
−1 .1
6 8
.0 2
.3 3 1
.0 3
.6 3 8
Sa la
ry −.
0 8
−1 .7
7 4
.0 0
−. 0 0 5
.0 8
1 .4
8 6
−. 0 8
−1 .6
1 6
−. 0 5
−1 .0
1 8
e x p e ri e n ce
.0 2
.4 2 2
−. 0 7
−1 .4
3 1
.0 9
1 .6
4 4
−. 0 2
−. 4 3 9
.0 2
.3 1 6
R 2
.2 0
.2 2
.0 7
.0 8
.0 9
F 3 .0
3 2 .1
0 2 .1
0 2 .0
.4 7
S te
p 4
: A
g e
.0 7
1 .1
2 4
−. 0 7
−1 .4
3 1
.1 5
2 .3
2 0
.0 5
.7 8 7
.0 4
.5 8 5
G e n d e r
.0 3
.5 4 9
−. 0 8
−1 .6
7 4
.0 9
1 .8
2 0
.0 3
.6 3 0
.0 6
1 .1
6 1
R ac
e .0
2 .3
6 3
.0 4
.9 2 5
.0 9
1 .8
1 9
−. 0 2
−. 3 0 7
.0 1
.2 4 0
R 2
.2 1
.2 3
.1 0
.0 8
.0 9
F .5
4 1 .5
7 3 .7
6 −.
3 5
.5 4
∗ p <
.0 0 5 ,
∗∗ p
< .0
0 1 .
415
416 G. M. Acker
p < .064. The fourth step with the socio-demographic variables was not significant: R2 change = .01, F (3, 369) = 1.20, p < .197.
The first step of the third analysis for predicting PA was not significant: R2 = .00, F (1, 378) = .716, p < .398). The second equation, which included emotion-focused coping, was significant: R2 change = .04, F (1, 377) = 15.19, p < .001. The third step which included the work variables, was not sig- nificant: R2 change = .03, F (5, 372) = 2.10, p < .065. The fourth step with the socio-demographic variables was not significant: R2 change = .03, F (3, 369) = 3.76, p < .011.
The analysis for predicting flu-like symptoms resulted in significant rela- tionship for the first step: R2 = .03, F (1, 377) = 9.80, p < .002. The second equation was also significant: R2 change = .03, F (5, 376) = 12.31, p < .001. The third step, which included the work variables, was not significant R2
change = .03, F (5, 371) = 2.00, p < .077. The fourth step with the socio- demographic variables was not significant: R2 change = .00, F (3, 368) = .35, p < .790. The last analysis for predicting gastroenteritis resulted in a signif- icant relationship for the first step: R2 = .03, F (1, 377) = 11.80, p < .001. The second equation was also significant: R2 change = .05, F (1, 376) = 20.29, p < .001. The third step including the work variables was not significant: R2 change = .01, F (5, 371= .47, p < .800). The fourth step with the socio- demographic variables was not significant: R2 change = .00, F (3, 368) = .54, p < .653.
Based on the results of the multiple regression analyses, EE, DP, and the somatic symptoms were predicted by problem-focused coping and emotion- focused coping when controlling for the work and the socio-demographic variables. PA was predicted only by emotion-focused coping when con- trolling for the work and the socio-demographic variables. The sets of the work variables and the socio-demographic variables offered little additional predictive power beyond that contributed by problem-focused coping and emotion-focused coping.
DISCUSSION
The results of this study suggest significant relationships between compe- tence in the context of managed care, coping, emotional exhaustion, somatic symptoms, social support, and several demographic variables such as race, age, and work experience. The data suggested that social workers that felt competent in working with managed care organizations did not rely on problem-focused coping. It is possible that, because of their good relation- ship and comfort working with managed care organizations, they did not need to assert themselves with managed care staff and/or direct their energy and efforts toward actions and activities that would eliminate problems. This confirms previous research, which suggests that stressful work situations
How Social Workers Cope with Managed Care 417
elicit those behaviors directly aimed at altering or managing the problematic situation (Gellis, 2002; Lazarus & Folkman, 1984; Shikai, et al., 2007).
On the other hand, those who did not feel competent in working with managed care organizations relied on emotion-focused coping and used escape-avoidance behaviors. The study also found that competence in the context of managed care did contribute negatively to emotional exhaustion and flu-like symptoms. These findings are consistent with other researchers (Bandura, 1989; Cherniss, 1993; Hall & Keefe, 2000; Harrison, 1980; Wagner & Morse, 1975; White, 1967).
The findings of this study are in accordance with the coping strategies literature, which suggests that the mere existence of stress is less important than how individuals appraise and cope with stress (Aldwin & Revenson, 1987; Antonovski, 1979; Gellis, 2002; Lazarus, 1981). When controlling for all the other variables in the hierarchical regression analyses, coping strate- gies had statistically significant relationships with all the burnout variables, indicating that the internal psychological resources available to people are the key component of how people deal with work stress. Contrary to the burnout literature (Arches, 1997; Maslach, 1978; Maslach, Jackson & Leiter, 1996; Pines, 1983; Rosenbaum, 1992), in this study work-related stressors, such as those associated with lower levels of competence in the context of managed care, social support, and caseload size, were not as important in predicting burnout as the ways that people cope with those stressors.
As some theorists state, the relationship between problem-focused cop- ing and emotion-focused coping is not as simple, as people tend to use both coping styles when dealing with the same source of stress. When dealing with stressful encounters, people do not necessarily use either problem- focused coping or emotion-focused coping. They may wait for a while until they react directly to the stressful encounter by first using emotional-coping style. When people feel that they have not handled the stressful situation well, they will expand the effort to reduce the impact of the stressful event; one possibility is to switch to more effective coping styles such as those that deal directly with the problem and are more likely to reduce the impact of the stressful event (Carver, Scheier & Weintraub, 1989). In this study, both problem-focused coping and emotion-focused coping had statistically significant positive correlations with the burnout dimensions; however, the power of the correlations between emotion-focused coping and the burnout variables were stronger than the power of the correlations between problem- focused coping and the burnout variables. These results suggest that workers probably use both coping styles; however, those that use more emotion- focused coping are more likely to experience burnout. These results support other studies that show that emotion-focused coping has substantial posi- tive association with distress, and that problem-focused is not necessarily effective in lowering it (Ben-Zur, 2005).
418 G. M. Acker
The results of this study also exhibited that several demographic vari- ables such as race, age, and work experience were related to competence in the context of managed care and several burnout variables. These find- ings are consistent with early studies of burnout, which claimed that older workers with more life and job experience are at a lower risk for burnout compared to those who are young and have less job experience. Non-White workers, according to the early theory of burnout, do not burn out as much, as they have a more realistic perspective about life and are thus better prepared to cope with stress (Farber, 1983; Maslach, 1982).
Although competence in the context of managed care had statistically significant correlations with coping and several of the burnout symptoms, those relationships were not evident in the multiple regression analyses. These findings support the empirical coping literature, which has empha- sized that the ways that workers cope with job stressors may be more important than the amount of stress itself (Aldwin & Revenson, 1987; Antonovski, 1979; Gellis, 2002; Latack, 1992; Lazarus, 1981). Thus, it appears that it is more important to focus on how social workers deal with the new challenges and requirements associated with managed mental health care rather than on the stressors themselves.
STUDY LIMITATIONS
The convenience sample of social workers and the voluntary nature of participation limit the generalizability of the study’s findings. Because of the respondents’ advanced age and work experience, as well as their higher level of education, they may be more competent and better pre- pared in dealing effectively with the challenges and demands associated with managed care practices. Younger and less educated workers may be at a disadvantage when negotiating and intervening with managed care organizations in comparison to the more experienced and skilled workers. Another limitation is the response set of subjects when respond- ing to self-report measures, which is inclusive for this type of research design. A similar response set to different scales that measure respon- dents’ feelings and perceptions about their job could be a result of a temporary mood of respondents at the time of responding to those measures, as well as it can be related to a social desirability factor. The non-response bias is another problem, as those who choose not to participate may be different than those who participate. Although the findings included several statistically significant correlations, most of them would not be significant with a Bonferroni correction. Thus, with this type of research design, a cautious interpretation of the findings is suggested.
How Social Workers Cope with Managed Care 419
CONCLUSIONS
The coping strategies provided the most comprehensive influence on work- ers’ both psychological and somatic reactions associated with burnout. Although this study provided a preliminary understanding of how social workers cope in this current mental health care environment, there are still many more unanswered questions. Future research should use more diverse samples with workers who are younger and who represent more diverse ethnic and racial backgrounds. Future studies should also attempt to answer what the most effective strategies are for social workers dealing with the external pressures associated with the current mental health care environment. Coping skills can be improved by providing social workers— especially those just entering the field—with training that can promote the use of effective coping styles appropriate for dealing with challenges such as those associated with managed care organizations.
Agencies may consider workshops and peer group discussions that focus on how to deal with work stressors and work demands not suffi- ciently discussed in professional programs and academic institutions (Bolen & Hall, 2007; Keefe & Hall, 1998). Creating a supportive environment for workers is another consideration that could help reduce the negative impact of potential work stressors and alter workers’ negative perceptions of their work.
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