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Casework in a veterans' hospital : an analytical study of referrals from doctors, Shaughnessy Hospital,… Barsky, Anastasia Nellie 1954

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CASEWORK IN A VETERANS * HOSPITAL An A n a l y t i c a l Study of Referrals from Doctors Shaughnessy Hospital, 1953-4. by ANASTASIA NELLIE BARSKY Thesis Submitted i n P a r t i a l Fulfilment of the Requirements: f o r the Degree of MASTER OF SOCIAL WORE i n the School of S o c i a l Work Accepted as conforming to the standard required f o r the degree of Master of Soc i a l Work School of Soc i a l Work 1954 The University of B r i t i s h Columbia i v Abstract There i s evidence that from the e a r l i e s t days of recorded hi s t o r y man has been aware of a s i g n i f i c a n t r e l a t i o n -ship between sound physical health and an harmonious s o c i a l en-vironment. Many physicians and h o s p i t a l administrators today recognize that a complete program of medical care includes f a c i l i t i e s f o r the treatment of patients' s o c i a l and emotional problems. The Department of Veterans' A f f a i r s has recently given recognition to t h i s p r i n c i p l e through the provision of medical s o c i a l service as part of the Treatment Services pro-gram f o r veterans. In the present study the medical s o c i a l service program at Shaughnessy Hospital i s examined i n an attempt to show how the doctors use the new service and with what r e s u l t s . At the same time, an attempt i s made to point out other potential areas of development f o r medical s o c i a l service i n t h i s hospi-t a l . The basic information f o r the study was obtained from an analysis of approximately four hundred s o c i a l service records, representing new r e f e r r a l s by doctors to the department f o r the year 1953-54. In addition, approximately t h i r t y doctors were asked, through the medium of a questionnaire and i n personal interviews, how they were using s o c i a l services to complement medical care, and what recommendations they might make f o r the f u l l e r u t i l i z a t i o n of these services. The findings from these two procedures were consis-tent. They indicated that there i s a growing demand f o r s o c i a l services i n t h i s s e t t i n g , and that the p o t e n t i a l demand i s even greater. The services most widely requested were f o r the pur-poses of enabling medical diagnosis and treatment, and a s s i s t i n g the patients i n discharge planning.. On the other hand, there i s as yet, l i t t l e recognition of s o c i a l work as a method of t r e a t -ment, complementary to the medical plan: this f i n d i n g appears both i n the c l a s s i f i c a t i o n of the services f o r which patients were referred to the Medical S o c i a l Service Department, and i n the comments and suggestions made by medical personnel. While recognizing the very r e a l l i m i t a t i o n of s t a f f shortage within the S o c i a l Service Department, t h i s study i s primarily concerned with the need f o r continuous i n t e r p r e -tation of casework services. Much can be done through the refinement of everyday practices, such as c l o s e r co-operation with the medical s t a f f , more e f f e c t i v e use of casework record-ing, and continued self-evaluation. These practices, together with the favourable attitudes toward s o c i a l - s e r v i c e already expressed by the medical s t a f f , should enable the doctors to make the optimum use of the e x i s t i n g services available through the Medical S o c i a l Service Department, to the end of improving s t i l l f u r ther the o v e r a l l program of care f o r the veteran patients. V Acknowledgements I should l i k e to convey my sincere appreciation to the members of Shaughnessy Hospital who have made t h i s study possible. In p a r t i c u l a r I should l i k e to thank Hiss C e c i l Hay-Shaw, Head of the S o c i a l Service Department, f o r the suggestions and c r i t i c i s m s which she contributed as the study progressed. Special appreciation isJdne to Dr. G. Hutton, Head of the Neuropsychiatric C l i n i c f o r h i s c r i t i -cism and guidance i n formulating the questionnaire used as the basis f o r part of this study; to Dr. K.S. Ritchie, Assistant Superintendent, f o r h i s support of the project; and to a l l the members of the medical s t a f f who p a r t i c i -pated i n the survey. I am happy to acknowledge also the help of Mrs. Helen HacCrae of the School of So c i a l Work. University of B r i t i s h Columbia, f o r evaluating the material included i n this study and f o r her int e r e s t and encouragement. F i n a l l y , I am deeply grat e f u l to Dr. Leonard C. Marsh of the School of Soc i a l Work f o r the invaluable technical assistance and f o r the support which he gave so generously throughout the planning and conduct of the study, and i n the writing of the f i n a l report. i i TABLE OP CONTENTS Chapter 1. S o c i a l Aspects of Medical Care Page Soc i a l component of i l l n e s s . The concept of "Medical Teamwork"; the s o c i a l worker*s r o l e . Four aspects of s o c i a l work i n a hospital s e t t i n g . Begin-nings of medical s o c i a l work. A national program of medical care: the Canadian Rehabilitation Program f o r Veterans. S o c i a l Service i n the Treatment Program. Development of s o c i a l service at Shaughnessy. Aims of the present project. Special character of s o c i a l work in a Veterans 1 H o s p i t a l . ................... 1 Chapter 2. Case Referral to S o c i a l Workers Referrals to s o c i a l service i n r e l a t i o n to hospi-t a l population. Trends i n r e f e r r a l s to s o c i a l s e r v i c e . The sources of r e f e r r a l . Proportion of r e f e r r a l s by medical s t a f f . The nature of these requests. C l a s s i -f i c a t i o n : Groups A, B, C, D. Study by groups. S o c i a l problems involved. Evaluation of the services rendered .,..25 Chapter 3. S o c i a l Service as Doctors See I t Use of questionnaire as a measurement. Scope of the f i e l d covered. Findings of the survey: methods of r e f e r r a l ; s o c i a l information considered most useful; services requested most frequently; suggestions f o r improvement. Other recommendations made by medical s t a f f 49 Chapter 4. Medical S o c i a l Work at Shaughnessy Hospital: Some implications Retrospect and prospect. Implications: to s o c i a l workers; to medical s t a f f ; to administration. Con-clusion • . . • e ..••.....•..» . o ........ . .67 Appendices: A. Administrative chart of the Department of Veterans A f f a i r s . B. Departmental Hospitals and I n s t i t u t i o n s . C. Table of Treatment Categories.' D. Statement of Departmental p o l i c y : "Function of Medical S o c i a l Service." E. Questionnaire used i n t h i s study. P. Excerpt from Interne's Manual: "Medical S o c i a l Service." G. Bibliography. i i i TABLES AND CHARTS IN THE TEXT (a) Tables Page Table 1. Referrals to social service in relation to patient population 2 6 Table 2. Trends in referrals to social service 27 Table 3. Sources of referral to social service 27 Table 4. Age distribution of patients referred to the social service department .............. 29 Table 5. Requests for social history and other ser-vices rendered 37 Table 6. Problems of anxiety, and services rendered . 41 Table 7. Referrals for practical services 48 Table 8. Social information requested by doctors or considered most useful 57 (b) Charts Pig. 1. Medical social services requested for patients , 3 3 Fig. 2. Social services considered most frequently requested 6 1 CASEWORK IS A VETERANS' HOSPITAL An A n a l y t i c a l Study of Referrals from Doctors Shaughnessy Hospital, 1953-4. CHAPTER 1 SOCIAL ASPECTS OF MEDICAL CARE Current conceptions of health and disease rest on a broad basis. The World Health Organization, a specialized agency of the United Nations, defines health as "a state of complete physical, mental, and social.well-being and not 1 merely the absence of disease and infirmity." This statement implies that health can be achieved and sustained only in res-ponse to many favorable influences and forces, including econ-omic, social, emotional, and physical. Medical care i s not confined to the diseased organ but takes cognizance of the total person involved, and implies planning on a community basis, because complete rehabilitation requires many services. It might be added that health in this sense i s much more than the product of physical medicine, but requires economic and social services, and the work of several professions. This concept of the interrelation of social, emo-tional, and physical factors in the etiology and treatment of disease i s not a new idea. In primitive form i t might be said to be known to ancient Greek physicians who, like Plato and Hippocrates, emphasized that mind and body are inseparable. The old prophets of the Bible must have held i t in strong belief also, for they wrote of strange miracles of healing 1 Chisholm, Brock. "Organization for World Health." Mental Hygiene. July, 1948. V. 32. pp.364-371. 2 and of the great power of prayer. The technological and chemical discoveries of the eighteenth century opened up wide channels for research and investigation. Doctors could observe the human body with greater accuracy through i t s various stages of pathology in ill n e s s . So absorbing was this new interest that, for a time, medical study was focused almost exclusively on the diseased organ. This inevitably led to great advancement in knowledge of specific diseases and to the specialization and precision which have become the tradition in the science of medicine. Ho re recently, with perfected tools of research and refined s k i l l s of treatment, new findings were brought to light, broadening the concept of disease and medical care. 1 Of particular significance are the studies made by Cannon 2 in the area of "physiological stress" and by Dunbar in the f i e l d of psychosomatic medicine, as they emphasize the con-cept of illne s s as a reaction of the whole organism to l i s environment. Currently, the investigations of such leading phy-3 sicians as Professor Hans Selye have helped to crystallize some of the thinking on the subject of the relation of mind and body in il l n e s s . Couched in c l i n i c a l terminology, the 1 Cannon, Walter B., The Wisdom of the Body. Norton: New York; 1952. Dunbar, Helen Flanders, Mind and .Body: Psychosomatic  Medicine. Random House; New York; 1947. 3 Selye, Hans, M.D. "The Adaptation Syndrome in C l i n i c a l Medicine." The Practitioner. January, 1954. V. 172. No. 1027. pp. 6-15. 3 basic ideas of "the adaptation syndrome" and "the stress concept" express the modern broad concept of disease and the significance of environmental conditions in the treatment plan. In many respects, the general practitioner of medio cine in his role of family doctor i s at an advantage over the specialist in that he observes the patient's i l l n e s s within a broad context of personal, social, and medical factors. The specialist in a large modern hospital, with i t s complex organi-zation of specialized departments and services, shares the responsibility of formulating a diagnosis and effecting a treatment plan with any number of other specialists, either of his own profession or of ancillary professions and services, such as psychiatry, nursing, dietetics, physical and occu-pational therapy, vocational counselling, and social work. The problem then becomes one of delineating the specific services and co-ordinating them into an integrated treat-ment plan. Out of such an approach has evolved the concept of "medical teamwork." The Social Worker's Role in Medical Teamwork The role of the social worker in helping the hospi-tal carry out i t s obligation of restoring the patient to maximal usefulness constitutes an integral part in a compre-hensive program of medical care. Mrs. Minna Field in a paper presented at the International Congress of Hospitals in London, May, 1953, outlines the medical social worker's role in a l l 4 1 i t s f acets. This includes four broad areas of a c t i v i t y : d i r e c t help to the i n d i v i d u a l and h i s family; i n t e r p r e t a t i o n to h o s p i t a l personnel; research; and i n t e r p r e t a t i o n to the community. In the-area of d i r e c t help to the patient and his family, the m e d i c a l s o c i a l worker, as part of the professional team, brings the- same techniques and s k i l l s that characterize s o c i a l work i n general* In essence, t h i s d i r e c t help, o r s o c i a l casework, i s directed towards preventing f u r t h e r s o c i a l break-down; restoring s o c i a l functions; making l i f e experiences more comfortable or compensating; creating opportunities f o r growth and development; and increasing the i n d i v i d u a l ' s capacity f o r 2 s e l f - d i r e c t i o n and s o c i a l contribution. I t i s based upon an understanding of the dynamics of human behaviour, upon the t r a n s l a t i o n of this understanding as i t applies to the patient, and upon s p e c i a l competence i n guiding him toward maximal adjustment i n the l i g h t of h i s i l l n e s s . The f i r s t step i n such a helping process i s a thorough understanding of the patient's inner and outer environment, f o r each, person i s unique i n h i s personality configuration, h i s s o c i a l and.economic background, and i n h i s reaction to a given s i t u a t i o n . The combination of these variables determines tee 1 F i e l d , Hinna. "Hole of the S o c i a l Worker i n a Modern Hospital.* Social Casework. November; 1953. V. 34. No. 9. pp. 398-402. 2 Hamilton, Gordon, S o c i a l Case Work. Columbia Univ e r s i t y Press; New York; 1952. p. 239. ~* 5 meaning illne s s w i l l have to the patient and the areas in which he w i l l need help. Thus, he may require assistance with con-crete problems, such as financial d i f f i c u l t y , confronting him and his family during his i l l n e s s , or he may be disturbed by deep emotional d i f f i c u l t i e s and interpersonal relationships which may react upon his medical condition. Frequently, the patient's ill n e s s creates imbalance not only within the pat-ient himself, but within the family unit. Anxiety created by il l n e s s and separation decreases the capacity of the remaining members to handle added responsibilities. In the process of gaining an understanding of the patient's problem, the social worker senses the strengths within the patient himself and within the family group, and draws on these strengths as resources. Whenever possible, she w i l l c a l l upon additional resources within the community, as this knowledge i s part of her professional equipment. Some of the ways i n which the social worker can help reduce anxiety and enable the patient and his family in a constructive handling of problems created by illness are: clarifying medical procedures, referring to an appropriate community resource, helping modify the a t t i -tudes of relatives towards the patient, preparing the family for the patient's after care. But this individualization i s only one aspect of the casework process. The manner in which the help i s given i s of even greater importance, and i t i s here that the social 6 1 worker o f f e r s a unique service to the patient. Mrs. F i e l d describes the casework approach as follows: The s o c i a l worker's approach d i f f e r s from that of the other members of the professional team, h i s r e l a -t i v e s , or his f r i e n d s . While the very nature of t h e i r functions imposes upon the other members of the profes-s i o n a l team the obliga t i o n to exercise authority, and while the attitude of the family members and friends may be colored by t h e i r own emotional reactions, the s o c i a l worker can remain free from the need to prescribe any p a r t i c u l a r l i n e of action and from emotional entangle-ment. Rather, the s o c i a l worker's approach i s gov-erned by an attempt to see the problem as the patient sees i t , to allow the patient to move at his own pace, and to make h i s own decisions toward a goal that he i s helped to set f o r himself. Such an approach can he car-r i e d out only when i t i s rooted i n a genuine apprecia-tion of the i n t r i n s i c worth and dig n i t y of the human being regardless of the stage of h i s i l l n e s s or the de-gree of the incapacity i t produces. For the patient such an approach assumes p a r t i c u l a r s i g n i f i c a n c e i n the l i g h t of an i l l n e s s that tends to undermine hi s f e e l i n g of usefulness and status. Experience has demonstrated that t h i s approach, removing as i t does the threat of cont r o l , compulsion, o r censure, tends to minimize the patient's f e e l i n g of helplessness produced by the i l l -ness. I t enables him to view h i s problems more r e a l -i s t i c a l l y and to f e e l free to ask f o r help i n i t s solution, convinced that he wants such help and that he w i l l not be forced into a l i n e of action contrary to h i s own needs and desires. In the area of int e r p r e t a t i o n to hospital personnel, the s o c i a l worker has the r e s p o n s i b i l i t y of helping the other pro-fessions gain an increasing awareness of the patient's t o t a l needs as a functioning, l i v i n g being who has an existence and concerns beyond the hospital.walls. This r e s p o n s i b i l i t y can be achieved only i f the s o c i a l service department i s included i n p o l i c y making and planning i n the h o s p i t a l . A well-rounded, program of int e r p r e t a t i o n includes u t i l i z a t i o n F i e l d , op. c i t . . p. 399. 7 of opportunity f o r day-to-day contacts with other h o s p i t a l s t a f f , supplemented by more formalized teaching. In the area of research f o r improved medical care, the s o c i a l worker can make a contribution by promoting an under-standing of the s o c i a l f a c t o r s i n i l l n e s s so that provision might be made to meet the t o t a l needs of the patient. F i n a l l y , i n the area of community in t e r p r e t a t i o n , the s o c i a l worker must assume the r e s p o n s i b i l i t y of c a l l i n g to the attention of the community the impact of substandard s o c i a l con-d i t i o n s upon health, and suggesting ways and means of provid-ing, remedies. In t h i s way channels w i l l be opened f o r broad s o c i a l p o l i c i e s designed to ameliorate and prevent such con-d i tions. Formal Beginnings of Medical S o c i a l Work Medical s o c i a l work as a s p e c i a l t y of the s o c i a l work profession can be traced to the work of lady almoners i n Eng-i l i s h h ospitals i n the 1890's. Through the influence of the London Charity Organization Society almoners came to be ap-pointed as part of the hospital s t a f f , and t h e i r function evolved from the o r i g i n a l task of checking abuse of medical c h a r i t i e s , to a growing concern f o r the admission of suitable patients and t h e i r f u rther help through s o c i a l service i n support of the doctor's, plan f o r medical care. 1 See Ida Cannon's book, On the S o c i a l F r o n t i e r of Medi-cine. Harvard University Press; Cambridge; 1952. 8 In the United States, s o c i a l service departments i n hospitals began to be established about 1905 with the growing recognition that adequate medical care must take account of 1 s o c i a l problems connected with i l l n e s s . This conviction had been emphasized by v i s i t i n g nurses who brought to the atten-tion of h o s p i t a l authorities the need to f i n d some way of improving patients* home conditions and t h e i r understanding of medical prescriptions i f treatment was to be successfully carried out. In addition, the incl u s i o n of s o c i a l work i n the medical curriculum at the Johns* Hopkins Medical School, s t a r t -ing i n 1902, emphasized the need f o r physicians to be well acquainted with the l i v i n g conditions and habits of t h e i r pat-ients, and to est a b l i s h relationships of confidence and influence with them. In retrospect, these developments can be seen as i n d i -cators of conscious e f f o r t within a changing s o c i a l order to bridge the gap between the patient's physical disturbances and his s o c i a l environment, so that he might be offered an i n t e -grated hospital service which would enable him to move toward restoration to health and p a r t i c i p a t i o n i n community l i f e . The Canadian Rehabilitation Program f o r Veterans During recent decades, the concept of national respon-s i b i l i t y f o r health planning and provision of medical services has gained wide support, as evidenced by the establishment of 1 A h i s t o r y of medical s o c i a l work i n the United States and i t s place i n the hospital i s given i n Dr. Richard Cabot 1s book, S o c i a l Service and the Art of Healing. Dodd, Mead and Co.; New York; 1928. 9 nation-wide health programs i n the countries of New Zealand, Great B r i t a i n , the United States, and others. The experience of World Wars I and II underscored the f a c t that manpower i s a nation's most valuable resource, and that unmet health needs create a heavy drain on the t o t a l economy. I t was i n the f i e l d of veterans' r e h a b i l i t a t i o n , however, that medical care pro™ grams were established on a national scale. In Canada such a program i s set up under the Department of Veterans' A f f a i r s 1 as part of the t o t a l program of r e h a b i l i t a t i o n . This program has as i t s guiding p r i n c i p l e : the d e f i n i t i o n of r e h a b i l i t a t i o n adopted o f f i c i a l l y i n 1946 at the National Conference on Rehabi l i t a t i o n in the United States: Rehabilitation i s the restoration of the- disabled to the maximum physical, mental, s o c i a l , economic and voca-t i o n a l capacity of which they are capable. While i t i s recognized that vocational t r a i n i n g , insurance and compensation provisions, and the other benefits provided under "The Veterans' Charter" are c l o s e l y related i n the r e h a b i l i t a t i o n of the veteran, f o r the purposes of this study emphasis w i l l be on the treatment program of rehabili:^ t a t i o n , as c a r r i e d out by the Treatment Services Branch of the Department, with p a r t i c u l a r reference to the work of Medical So c i a l Service. The present system of medical services and hospital f a c i l i t i e s has i t s o r i g i n i n the r e h a b i l i t a t i o n program f o r veterans as provided under the Department of So l d i e r s ' C i v i l 1 A , f u l l description of th i s program i s given i n "Canada's Rehabilitation Program" by Walter S. Woods. Department of Veterans' A f f a i r s Treatment Services B u l l e t i n , May, 1948. V. I I I . No. 5. pp.3-12. 10 Re-establishment, a special Government department created i n 1918 to deal with the demobilization of Canada's armed forces of World War I. With the near termination of the work of r e h a b i l i t a t i o n i n 1928 the program was taken over by the Depart-ment of Pensions and National Health, and i t was ca r r i e d by th i s department u n t i l 1944 when the present Department of Veterans' A f f a i r s was e s p e c i a l l y created to administer a l l mat-ters pertaining to veterans. The medical services program i s thus one part of a broad, comprehensive, co-ordinated plan designed to provide veterans the maximum benefit within the 1 l e g i s l a t i v e framework. The reorganization of the Treatment Services Branch at the end of World War II was based on long-term planning, although i t s immediate objective was to meet the tremendous task of emergency demobilization. I t was necessary to u t i l i z e as f a r as possible the e x i s t i n g hospital f a c i l i t i e s and the services of the p r a c t i c i n g physicians of the country on a part-time basis,, u n t i l the peak load of h o s p i t a l i z a t i o n was over. At the same time, however, cert a i n p r i n c i p l e s considered ess e n t i a l i n building up a treatment program of the highest standard were adopted as long-term p o l i c i e s . These included a f f i l i a t i o n with U n i v e r s i t i e s , the use of part-time s p e c i a l -i s t s and internes instead of f u l l - t i m e s a l a r i e d doctors, and the establishment of national and l o c a l advisory boards. Complementing the high q u a l i t y of medical s t a f f , the Department has b u i l t up a system of h o s p i t a l f a c i l i t i e s that 1 See Appendix A f o r administrative chart of the Depart-ment. 11 i s considered unequalled. In addition to active treatment hospitals, many types of spe c i a l treatment centres have been established to take care of spe c i a l groups of veterans. These special services include treatment f a c i l i t i e s f o r paraplegics, victims of severe p o l i o m y e l i t i s and a r t h r i t i s , and f o r the ageing veteran who f o r physical reasons i s unable to care f o r himself. Another type of i n s t i t u t i o n i s the Health and Occu-pational Centre, developed during World War II f o r the purpose of providing convalescent care to the veteran between the time he no longer needs to remain i n an active treatment hospital 1 and the time he i s ready to return to the community. The prime function of the Treatment Services Branch i s the medical care of the pensioned veteran who. i s e n t i t l e d to such care by vi r t u e of his war service. In general, the pen-sioner i s a veteran i n receipt of f i n a n c i a l allowance by reason of a service-connected d i s a b i l i t y or aggravation of a pre-v i o u s l y e x i s t i n g d i s a b i l i t y , e i t h e r of which constitutes a vocational handicap as determined by the Canadian Pensions Commission. Treatment entitlement i s also extended to non-pensioned veterans who may have a service-connected condition requiring medical treatment, and to the veteran. in r e c e i p t of War Veterans* Allowance. Besides the veteran group, a number of other groups, of persons are e l i g i b l e f o r medical care i n Departmental h o s p i t a l s , notably those f o r whom the federal government has d i r e c t r e s p o n s i b i l i t y , including members of 1 See Appendix B f o r a l i s t of Departmental Hospitals and I n s t i t u t i o n s . 12 the Royal Canadian Mounted Poli c e , Indians, Permanent Force and Active Service personnel, members of Overseas A u x i l i -1 ary units, and others. It has been estimated that hospital treatment f o r the disabled a f f e c t s l e s s than one per cent of those who served 2 i n Canada's f i g h t i n g forces. But this proportion are cared f o r by extensive f a c i l i t i e s and the amount of care per patient on the average i s comparatively high. Hospital in-patient treatment strength has fluctuated between a high of 14,500 and a low of 9,000 but i t has become s t a b i l i z e d at approximately 3 10,500. I t i s anticipated that the present hospital f a c i -l i t i e s w i l l be needed f o r many years to come to provide f o r the care of the e n t i t l e d veteran. S o c i a l Service i n the Treatment Program At the present time, there are Medical S o c i a l Service units i n f i f t e e n Departmental hospitals or D i s t r i c t O f f i c e s , comprising a t o t a l of 47 positions, one of which i s that of central advisor. Medical S o c i a l Service was established i n 1947 as part of the t o t a l treatment program. P r i o r to that, a l l s o c i a l services of the Department were under the S o c i a l Service Directorate, a section of General Welfare Services. Medical s o c i a l workers are administratively responsible to the Senior Treatment Medical O f f i c e r f o r services to patients 1 See Appendix C f o r Table of Treatment Categories. o Woods, op. c i t . . p. 10. 3 Winfield, G.A. and L. Wellwood. "A Study of In-patients, Department of Veterans A f f a i r s . " Treatment Services  B u l l e t i n . November, 1953. V. 8. No. 10. p. baa. ; 13 and to the Chief of Medicine f o r c l i n i c a l matters. For tech-n i c a l and professional guidance, the Director of Medical S o c i a l Services, Ottawa, i s consulted. The need f o r s o c i a l services within the treatment program f o r veterans was f i r s t recognized i n 1918 when a •Social Service System" was set up within the Medical units and provision was made f o r ex-service nurses to take t r a i n i n g i n Mental Hygiene i n order that they might render necessary " s o c i a l services" to certain veterans. T h e s e s e r v i c e s were seen to he such duties as follow-up of discharged veterans from h o s p i t a l ; investigation of home s i t u a t i o n to a s s i s t i n determining e l i g i b i l i t y f o r certain benefits; and family ser-1 vi c e s . A description of the services rendered by this group of s o c i a l service nurses i s given by Walter E. Segsworth, who had been f o r a time d i r e c t o r of Vocational Training under the Department of Soldiers' C i v i l Re-establishment: I t may happen that the man i s hot making proper pro-, gress i n r e t r a i n i n g , although physical o r mental examina-tion does not disclose grounds f o r lack of progress. A trained s o c i a l service worker who serves the Department i s sent to v i s i t his home, and i t may be discovered that the lack of progress i s due to f i n a n c i a l embarrassment, sickness i n the family, or various other matters. This s o c i a l service nurse should be a graduate nurse of experience who has made a spec i a l study of s o c i a l service conditions, and she i s directed to ascertain the home surroundings of the man, o f f e r kindly advice i f required, and so to attempt to d i r e c t matters that a l l worries w i l l be removed from the man's mind.2 x Canada, Department of Soldiers' C i v i l Re-establishment, Canada's Work f o r Disabled Soldiers. "The Medical Services: "•"Social Service Workers,'" King's P r i n t e r , Ottawa, 1919. p. 27. o Segsworth, Walter E., Retraining Canada's Disabled  Sol d i e r s . King's P r i n t e r ; Ottawa; 1920. ! 14 I t i s c l e a r that the government recognized the need f o r s o c i a l services within the treatment program, but the pro-fession of s o c i a l work i t s e l f was not yet recognized. More-over, i n the years following the establishment of the i n i t i a l program, there was apparently l i t t l e progress made i n building up a permanent s o c i a l service unit as an i n t e g r a l part of medi-c a l services. With the development of health and welfare pro-grams throughout the country, many of the duties formerly carried out by the Department s o c i a l service nurses were taken over by public health nurses and by p r o v i n c i a l s o c i a l welfare workers. F i n a l l y , i n the 1930's, the So c i a l Service System was merged with the Investigations Branch of the Department. The problem of veterans 1 social.needs came up again i n the Government's reconstruction program following the out-break of World War I I . In accordance with the recommendations of the General Advisory Committee on Reconstruction, plans were made f o r a broad, comprehensive program of r e h a b i l i t a -t i o n . One of the f i r s t services set up was the Casualty Rehabilitation program, designed to re-establish the disabled veteran i n c i v i l i a n l i f e . To carry out thi s work, a s t a f f of Veterans' Welfare O f f i c e r s , recruited from returned service men, and given s p e c i a l in-service t r a i n i n g , was b u i l t up to interview discharged members of the armed forces and advise them of t h e i r treatment r i g h t s and other benefits. 1 The Casualty Rehabilitation program i s described f u l l y i n the Casualty Welfare O f f i c e r s * Manual. King's P r i n t e r ; Ottawa; 1950. 15 Meanwhile, Welfare Departments had been operating within the Armed Forces. These Welfare Departments had been created to deal systematically with cases of s o c i a l d i f f i c u l t y , and were sta f f e d with professional s o c i a l workers whose chief s o c i a l work function was that of a l i a i s o n service between the 1 Armed Forces and the community s o c i a l agencies. The success of t h i s group had, no doubt, a favourable influence upon future planning f o r professional s o c i a l services to d i s -charged veterans. Professional s o c i a l workers came to be included i n the r e h a b i l i t a t i o n program i n 1945, with the establishment of the S o c i a l Service Directorate, a development a r i s i n g from the recommendations of the Director of S o c i a l Science at national Defence Head Quarters, who had been requested to make a sur-vey of the requirements of veterans f o r s o c i a l services. O r i -g i n a l l y comprising three sections, R e f e r r a l , Medical, and Investigation, the work of the S o c i a l Service Directorate was reorganized i n 1947, when the Medical section became a separate department responsible to Treatment Services. The Referral section was retained within the Welfare Services Branch, and became the present S o c i a l Service D i v i s i o n . The Investigation section was also retained as part of Welfare Services, r e s p o n s i b i l i t y being carried by Veterans* Welfare 1 An account of the services of the Armed Forces Welfare Department i s given in The S o c i a l Worker. Canadian Associa-tion of S o c i a l Workers; Ottawa. June, 1945. V. 14. No. 4. 16 O f f i c e r s . Both the S o c i a l Service D i v i s i o n , and the Medical S o c i a l Service units employ professional s o c i a l workers as 1 s t a f f . The i n c l u s i o n of three separate groups within the Department of Veterans 1 A f f a i r s , to deal with the s o c i a l wel-fare of veterans, makes i t necessary to have c l e a r l i n e s of r e s p o n s i b i l i t y and a close working r e l a t i o n s h i p , so that a co-ordinated program of services to the veteran can be pro-vided. The " d i v i s i o n of labour" and co-ordination of a c t i -v i t y among the three groups, outlined i n the p o l i c y and regu-l a t i o n s , and further developed through experience, has s e t t l e d into a d e f i n i t i v e pattern over the years. As a r e s u l t , s o c i a l work i n t h i s s e t t i n g i s of a somewhat unique character. The l i m i t s of t h i s report do not permit a precise d e f i n i t i o n of the areas of r e s p o n s i b i l i t y of the three groups concerned with the welfare of veterans, but a working d e f i n i -tion can be obtained from a broad picture of the f i e l d . The Veterans' Welfare O f f i c e r s , under the Director General of Welfare Services, have as t h e i r prime r e s p o n s i b i l i t y to ensure that every veteran i s aware of a l l his rights and benefits to which l e g i s l a t i o n and regulations may e n t i t l e him. The S o c i a l Service D i v i s i o n , under the D i r e c t o r of S o c i a l Service within 1 The accepted education f o r the profession of s o c i a l work, as outlined i n the University of B r i t i s h Columbia calendar, consists of a minimum of two u n i v e r s i t y years of graduate study including lectures, c l i n i c a l practice work in the f i e l d , and a research project or thesis, leading to the degree of Master of S o c i a l Work. 17 the Welfare Services Branch, ex i s t s primarily as a r e f e r r a l centre f o r veterans in the community to make available to veterans the same l e v e l of s o c i a l services as exist f o r a l l persons within the community* This involves l i a i s o n and a close working r e l a t i o n s h i p with community agencies so that duplication and overlapping of services i s avoided. Medical S o c i a l Service, under the Director, within the Treatment Services Branch, operates f o r h o s p i t a l i z e d or outpatient veterans when s o c i a l problems exi s t which a f f e c t t h e i r treatment. The function of Medical S o c i a l Service has been l a i d down by po l i c y , and consists of f i v e categories of service, as follows: (1) casework services to i n d i v i d u a l pate-ients as part of the medical team of which the doctor i s the leader; (2) medical s o c i a l consultation service to others giv« ing service to the veteran; (3) p a r t i c i p a t i o n i n the development of community understanding and aid to the s i c k and disabled; (4) p a r t i c i p a t i o n i n the teaching program of the h o s p i t a l ; (5) a s s i s t i n g i n research projects which have medical s o c i a l 1 implications. This review of the development of the s o c i a l services program within the broad r e h a b i l i t a t i o n scheme indicates the significance of the contribution that professional s o c i a l work can make i n a comprehensive approach to s o c i a l s e c u r i t y . A r e l a t i v e l y l a te comer to the medical treatment program, See Appendix D f o r a statement of Medical S o c i a l Service function. 18 s o c i a l work was, however, brought i n i n accordance with w e l l -l a i d plans, and with a sound, advanced p o l i c y of function. The carrying forward of t h i s p o l i c y o f f e r s a large poten-t i a l of contribution to an already e f f e c t i v e plan of medi-c a l care. S o c i a l Service at Shanehnessy Hospital Shanghnessy Hospital, located i n the c i t y of Van-couver, r e f l e c t s the Departmental p o l i c y of concentrating i t s hospitals i n the l a r g e r centres of population i n order that patients might have the benefit of the services of leading phy-si c i a n s and s p e c i a l i s t s i n a l l branches of medicine. Shaugh-nessy Hospital, Vancouver, and Veterans' Hospital, V i c t o r i a , constitute the main treatment centres f o r veterans i n the Van-couver D i s t r i c t . Treatment f a c i l i t i e s f o r service men i n t h i s area were o r i g i n a l l y established i n 1916 under the M i l i t a r y Hospi-t a l s Commission, when an eight-ward annex (250 beds) was opened f o r m i l i t a r y service patients, and administered by the Vancouver General H o s p i t a l . Under the S o l d i e r s ' C i v i l Re-establishment addit i o n a l f a c i l i t i e s were added, and the o r i g i n a l Shaughnessy Hospital was established on the present s i t e . Construction of the present modern bu i l d i n g was started i n 1939,and the b u i l d i n g was o f f i c i a l l y opened i n 1941, s h o r t l y a f t e r the begin-ning of World War II when hos p i t a l services were acutely needed f o r returning service men. The period 1941-47 witnessed a rapid development i n h o s p i t a l accommodation, with new buildings and 19 extensions being added, and old buildings being closed down. By 1947 the major reconstruction program was completed. Shaughnessy Hospital, with a t o t a l bed-capacity of about 1500 contains separate f a c i l i t i e s f o r active treatment, tuberculosis, convalescence, and domiciliary care. Active treatment i s provided i n the Main Building, a modern three-storey structure. Patients with diseases of the chest, and tuberculosis, are housed i n a separate building also located on the h o s p i t a l grounds, and known as the Jean Matheson Memorial Building, or more commonly, the Chest Unit. Convales-cent care i s provided at the George Derby Health and Occupa-1 t i o n a l Centre i n Burnaby. Domiciliary care i s available i n the Extension f o r bed-patients, while ambulatory patients requiring t h i s type of care are accommodated at the Health and Occupational Centre, and at Hycroft, formerly a private man-sion and now part of the Departmental f a c i l i t i e s . The Medical S o c i a l Service Department at Shaughnessy Hospital, established i n 1947 i n accordance.with the Govern-ment's reorganization p o l i c y of s o c i a l services f o r veterans, i s accommodated on the second f l o o r of the Main Building, within easy access of the medical s t a f f . Additional o f f i c e s are located i n the Chest Unit, and i n the Nenropsychiatric 1 The Centre was named "George Derby" f o r the Depart-ment's Western Regional Administrator. I t i s located i n a r u r a l environment, on Lake Burnaby. and consists of eight separate dwelling units ( P a v i l i o n s ) , plus two c e n t r a l b u i l d -ings which contain the administrative o f f i c e s , dining room and recreational f a c i l i t i e s . 20 C l i n i c on the ground f l o o r of the Main Building. With the exception of one worker who shares an o f f i c e , the s o c i a l service s t a f f are provided with i n d i v i d u a l o f f i c e s . The c l e r i c a l o f f i c e i s a single room f o r the three s t a f f members, and serves also as the general o f f i c e f o r f i l i n g records. In addition, there i s a large waiting room f o r the convenience of c l i e n t s and v i s i t o r s to the department. At the present time the Medical S o c i a l Service De-partment at Shaughnessy comprises a s t a f f of s i x f u l l - t i m e s o c i a l workers, one of whom i s the Head of the Department. Recently, a f t e r a lapse of one year, the department was:re-established as a fieldwork agency f o r students from the Uni-v e r s i t y of B r i t i s h Columbia School of Social Work, and during the year 1953-4 three students received t h e i r fieldwork t r a i n -ing here. Two of them trained under the interneship provision of the Department, a p o l i c y recently adopted i n l i n e with the general p o l i c y of the Government to maintain i t s medical ser-vices on a high l e v e l through a f f i l i a t i o n with U n i v e r s i t i e s . The growth of the s o c i a l service program at Shaugh-nessy p a r a l l e l s the growth of s o c i a l services i n the Depart-ment of Veterans' A f f a i r s generally, and t h i s has been reviewed. However, a number of points i n the development of the program seem to be of p a r t i c u l a r s i g n i f i c a n c e to t h i s study and w i l l be noted here. The program originated with the establishment of the S o c i a l Service System of 1919 when four " s o c i a l service nurses" had been placed i n the Vancouver D i s t r i c t . A remnant 21 of t h i s i n i t i a l program c a r r i e d through u n t i l i n the 1940's two professionally trained s o c i a l workers were taken on s t a f f to provide necessary services, c h i e f l y to the Neuropsyehiatric C l i n i c . This was the condition that obtained i n 1947 when the present department was established. The new Medical S o c i a l Service Department was expected to develop a program of s o c i a l services complementary to the ex i s t i n g medical services, and forming an i n t e g r a l part of the t o t a l h ospital care. To i n i t i a t e the new program, the Government made ample provision f o r leadership and s t a f f develop-ment, the Director of Medical S o c i a l Service, Ottawa, acted as consultant on a l l aspects of establishing the new department i n the h o s p i t a l . The School of S o c i a l Work, University of B r i t i s h Columbia, provided consultation as well as cred i t courses on medically-oriented material. The medical s t a f f of the hospi-t a l provided lectures f o r s t a f f and i n - s e r v i c e - t r a i n i n g internes. C l i n i c s , ward rounds, and evening lectures f o r medical internes were made available to the Medical S o c i a l Ser-vi c e s t a f f . However, even with a l l these provisions, the new department could not escape the d i f f i c u l t i e s of "growing pains." I t i s a recognized p r i n c i p l e that the strongest pro-grams are those which are b u i l t up, not handed down. The single concrete human s i t u a t i o n i s not to be discounted i n the development of any s o c i a l program, f o r s o c i a l work i s not a welter of a c t i v i t i e s but a professional d i s c i p l i n e based on 22 an integrative approach to meet s o c i a l need. In a h o s p i t a l s e t t i n g p a r t i c u l a r l y , the method of s o c i a l work and the con-t r i b u t i o n i t can make to the medical care of the patient can best be appreciated through i t s e f f e c t i v e use i n i n d i v i d u a l s i t u a t i o n s . At Shaughnessy, the i n i t i a l shortage of personnel to carry out and i n t e r p r e t the program proved a great handicap to the growth of the new service. More recently, with the greater a v a i l a b i l i t y of p r o f e s s i o n a l l y - q u a l i f i e d personnel generally, the s t a f f at Shaughnessy has been b u i l t up s u f f i -c i e n t l y to give the program a more secure fo o t i n g , and to pro-vide at l e a s t minimum coverage of s o c i a l services f o r the h o s p i t a l . The Medical S o c i a l Service Department i s now faced with the problem of expanding i t s services, so that a greater volume of services could be given, and so that services would be more r e a d i l y a v a i l a b l e . At the same time, however, there i s also need f o r evaluative research of the e x i s t i n g pro-cedures and services, so that expansion might r e s t on a sound basis. Purpose of the Present Study A l l medical care and practice i s aimed at returning the patient to an optimum state of health so that he can again be an e f f e c t i v e member of h i s family, and of the community generally. In t h i s sense the primary function of medical care i s a s o c i a l one. An increasing number of hospitals are including the professional services of s o c i a l workers as part 23 of the t o t a l medical service because of the advantages of con-sidering the patient as a person i n his r e l a t i o n s h i p to h i s family and h i s community. However, the r e s p o n s i b i l i t y of making s o c i a l work an e f f e c t i v e service i n the h o s p i t a l rests ultimately upon the mutual helpfulness and co-operation bet-ween the doctors and the s o c i a l work personnel. I t was an i n t e r e s t i n developing such knowledge and understanding that gave r i s e to the present inquiry. How do doctors use the Hedical S o c i a l Service Department as an a i d to medical care of patients? What s o c i a l services are given? What s o c i a l services are re-quested most frequently? What areas of medical s o c i a l work s t i l l remain to be developed i n t h i s hospital? These ques-tions set the focus of the study. Special Characteristics o f Veterans as Patients Certain s p e c i a l circumstances must, of course, be kept i n mind i n studying the nature of s o c i a l services i n a veterans' hospital and the use made of them. Veterans a r e n o t a "normal 0 group of patients, such as one would normally f i n d i n an ordinary general h o s p i t a l , so that the findings and implications of t h i s study would have only l i m i t e d a p p l i c a -tion to hospital patient groups generally. Since the primary r e s p o n s i b i l i t y of the Treatment Services Branch i s f o r the pensioned veterans, that i s , those with service-connected d i s a b i l i t i e s which constitute a voca-t i o n a l handicap, i t i s inevitable that the fac t o r s of chroni-c i t y and r e c i d i v i s m w i l l be paramount c h a r a c t e r i s t i c s of the 24 veterans 1 patient group. Those who need h o s p i t a l care need a good deal of i t . Another important c h a r a c t e r i s t i c of t h i s group of patients i s that a large proportion of them i s i n the higher age-group! n a t u r a l l y f o r them h o s p i t a l care i s com-p l i c a t e d by a l l the impairments which accompany o l d age. In such a s e t t i n g , s o c i a l work takes on a s p e c i a l character. Chronicity and recidivism i n disease make forl o n g -term and repeated h o s p i t a l i z a t i o n . Moreover, because of the provision of generous veterans' services, such as free medical care and f u l l pension rates during the period of h o s p i t a l i z a -t i o n , there i s nothing to stop the veteran patient from return-ing to the ho s p i t a l at any time. These conditions could mean long-term casework services. Another feature of s o c i a l work i n t h i s s e t t i n g i s that the s o c i a l worker i s dealing with many e l d e r l y patients, and with an older group generally. F i n a l l y , the presence of a l l these fac t o r s — o l d age, chronic i l l n e s s , free medical care and other veterans' ser-v i c e s — r a i s e s the question of dependency, and to what extent these conditions f o s t e r a pattern of dependency i n the veteran patient group. The problem f o r , s o c i a l work, as f o r any other group involved i n the treatment of these patients, i s to work towards the patient's maximum u t i l i z a t i o n of h i s own capaci-t i e s without playing into an e x i s t i n g o r po t e n t i a l pattern of dependency. CHAPTER 2 CASE REFERRAL TO SOCIAL WORKERS To get a broad picture of the nature of s o c i a l work i n t h i s s e t t i n g , a l l the nnewt> r e f e r r a l s made by doctors during the year 1953-4 were earmarked f o r the study. "New" r e f e r r a l s mean those cases not previously known to the s o c i a l service department, although the patients concerned may or may not have been previously h o s p i t a l i z e d . The cases were drawn from the entries i n the Case Registry of the Medical S o c i a l Service Department. Altogether, 371 cases were studied, representing 1 266 h o s p i t a l i z e d patients and 102 outpatients. The following f i g u r e s , showing the movement of hos-p i t a l patients and the r e f e r r a l s to s o c i a l service, provide some in d i c a t i o n of the r e l a t i v e s i z e of the two programs at Shaugh-nessy, and suggest the representative nature of the group of cases selected f o r t h i s survey. However, the two sets of figures preclude any precise comparison, since the s t a t i s t i c s f o r the s o c i a l service department include both in-patients and outpatients, while the hospital s t a t i s t i c s apply only to i n -2 patients. Nevertheless, the figures give s u f f i c i e n t d e t a i l A I t w i l l be noted that there i s some discrepancy between the number of new r e f e r r a l s l i s t e d i n the Case Registry and that given i n the Monthly S t a t i s t i c s of the s o c i a l service department. 2 S t a t i s t i c s f o r the Outpatient C l i n i c s were not available f o r t h i s study, f o r although that department i s located i n the hospital building, i t i s not a part of the h o s p i t a l i t s e l f . 26 to suggest the volume of the h o s p i t a l service required at Shaughnessy. Although a seasonal f l u c t u a t i o n i n patient population i s evident, the t o t a l picture indicates that pat-le n t movement i s l a r g e l y determined by the number of beds avai l a b l e . Some suggestion of the chronic nature of pat-i e n t s ' i l l n e s s i s indicated i n the figures of average patient-days stay. Table 1. Referrals to S o c i a l Service i n Relation to Hospital Population (Shaughnessy Hospital, 1953-4) Month Movement of Patients S o c i a l Service Cases No. Ad- No. Dis- Daily Average No. Re- So. Total mitted charged Average Pt.Days ferr e d Closed Case Strength Stav (a) Load A p r i l 564 583 926.10 44.30 97(50) 95 215 Hay 518 540 895.14 32.98 93(40) 102 217 June 484 506 882.97 39.60 112(77) 117 227 Jul y 576 552 894.70 48.13 107(52) 100 218 Aug. 554 556 877.71 45.87 107(45) 88 218 Sept. 550 552 861.23 38.59 111(53) 121 243 Oct. 587 539 908.67 38.83 116(63) 96 236 Nov. 565 529 931.39 46.03 119(59) 115 259 Dec. 512 610 895.70 49.19 109(47) 93 254 Jan. 598 488 956.93 44.34 100(48) 108 267 Feb. 556 549 968.88 54.89 107(42) 89 264 March 535 603 947.69 48.80 149(77) 135 317 Totals 6099 6617 912.28* 44.30* 1327(653) 1259 2935 Source: Compiled from the monthly s t a t i s t i c s of Shaughnessy Ho s p i t a l . (a) Figure i n brackets shows number of r e f e r r a l s by doctors. (A) Computed averages. The monthly d i s t r i b u t i o n of r e f e r r a l s to the s o c i a l service department shows a steady r i s e i n the volume of work 27 handled by t h i s department; and comparative yearly figures f o r the two previous years f o r which s t a t i s t i c s were available indicate a general upward trend i n the growth of the department. fable 2. Trends i n Referrals to S o c i a l Service ~ (Shaughnessy Hospital, 1953-41 Year Total Caseload Hew Cases Referred by Doctors No. P.C. 1951-2 1885 822 372 45.26 1952-3 2730 847 524 61.87 1953-4 2935 1327 653 49.21 Source: Compiled from the s t a t i s t i c s of the s o c i a l service department, Shaughnessy Hospital. I t i s s i g n i f i c a n t that about half of a l l the r e f e r -r a l s to the s o c i a l service department each year come from doc-tors, although requests may also come from other sources. Dur-ing the year 1953-4, the number and proportion of r e f e r r a l s from the various sources were as follows: Table 3. Sources of Referral to S o c i a l Service (Shaughnessy Hospital, 1953-4; Source of Referral New Cases Re-opened Cases t o t a l No. P.C. No. P.C. No. P.C. Doctor Other h o s p i t a l s t a f f Routine coverage Patient Relatives Community Other D.Y.A.personnel Other D.V.A. Hospital or D i s t r i c t 519 57.10 152 16.72 80 8.80 52 5.72 21 2.31 39 4.29 31 3.41 15 1.65 I l l 26.53 42 10.05 81 19.38 74 17.71 60 14.36 37 8.85 12 2.88 1 .24 630 47.48 194 14.62 161 12.13 126 9.50 81 6.10 76 5.73 43 3.24 16 1.2.0 Total 909 100.00 418 100.00 1327 100.00 Source: S t a t i s t i c s of s o c i a l service department, Shaughnessy Hospital (1953-4) 28 Without further elaboration of the s t a t i s t i c a l data, i t becomes clear that the medical staff at Shaughnessy have a substantial interest in the services offered by the Medical Social Service department, and that there has been a steady demand for services from them. The way in which these ser-vices contribute to the well-being of the patients for whom they are requested i s therefore a v i t a l issue, not only from the standpoint of the particular patient, but also i n the way social services w i l l be u t i l i z e d by medical staff i n the future. The Patients Referred The general characteristics of the veterans* patient group, as outlined earlier in this report, were found to he typical of this specially selected group. Naturally, the amount of information obtained on each of the 371 persons was limited, not only by r e a l i s t i c standards, but also because many of the case histories themselves lack certain pertinent informa-tion, notably the medical diagnosis, a record of previous hos-pitalizations and illnesses, and the outcome of the case. Within these limitations, only a rough picture can be presented, but certain basic characteristics are no less evident than i f more precise data were available. The features noted include old age, chronicity of disease (as indicated by the pension status of the veterans), and at least some indication of the economic status. 29 Of the 371 patients i n the group, there were 359 men and 12 women, ranging i n age from 18 to 89, with approximately 55 per cent of them over f i f t y years of age (Table 4). Table 4. Age D i s t r i b u t i o n of 371 Patients (Shaughnessy Hospital; 1953-4) Locale .. Number and Sex of Patients and Numb er Percen tage Age Hale Female t o t a l Male Female t o t a l Hospital Patients 256 8 2.6.6 72.5 66.6 72.4 Under 30 ~4T ~T~ "4~6" 11.6 41.6 TT7S 30 - 49 61 1 62 17.1 8.3 16.9 50 - 69 92 2 94 25.9 16.7 25.6 70 and over 64 — - 64 17.9 - 17.4 Out-Patients 48 4 102 2^.5 33.4 2t.6 Under 30 17 T " 1 ? T7! "T72* 30 - 49 35 2 37 9.9 16.7 10.1 50 - 69 36 — 36 10.1 — 9.9 70 and over 10 — 10 2.8 — 2.4 Total (a) 356 12 368 100.0 100.0 100.0 (a) Ages not grouped, 3 patients. Source: Compiled from records of s o c i a l service department. Special count. Some i n d i c a t i o n of the prevalence of chronic disease within the group was derived from an analysis of the Treatment Categories under which the veterans were receiving medical care at the time of r e f e r r a l to s o c i a l s ervice. However, since the case h i s t o r i e s on outpatients did not always have t h i s data, a complete analysis f o r the group could not be done. In the analysis of Treatment Categories f o r 254 patients, i t was found that the largest proportion, about one-third, were under Treatment Category (12), or War Veterans' Allowance 30 r e c i p i e n t s . The next group i n s i z e , about 16 per cent, were Armed Forces personnel (Treatment Category, 18). Others of sizable proportion were: pensioned d i s a b i l i t y (Section 5), 15 per cent; marginal income (Section 13), 8 per cent; and patients under medical observation (Section 28), approximately 8 per cent. A l l these persons would be e n t i t l e d to free medical care and the regular comforts allowance (about 7 d o l l a r s a month), and those under Section 5 would be drawing f u l l pension rates during t h e i r period of h o s p i t a l i z a t i o n . Additional information to suggest the nature of i l l -ness of the patients i n the group under hospital care was obtained by reference to the p a r t i c u l a r ward from which the r e f e r r a l s came. I t was estimated that approximately h a l f of the patients were under general medical care, about one-sixth on p s y c h i a t r i c wards, and the remainder dispersed among surgery and the other services. The smallest group of those referred to s o c i a l service were patients already under Departmental domiciliary care. Timing of Referrals to S o c i a l Service At what point i n the course of medical treatment are r e f e r r a l s to s o c i a l service most e f f e c t i v e i n meeting the s o c i a l and emotional needs of the patient and preventing t h e i r adverse influence on medical planning? I t i s c l e a r that the e a r l i e r the medical s o c i a l worker ar r i v e s at her e s s e n t i a l area of respon-s i b i l i t y i n collaborative medical-social planning with the physician, the more e f f i c i e n t and economical w i l l the treatment 31 plan be. Because of the l i m i t a t i o n s of the s o c i a l service records, i n that they do not usually contain information regard-ing the date of discharge from the hospital of the patient, and because i t was not within the scope of t h i s study to seek this data from other sources, no conclusive observation could be made on the question of timing of r e f e r r a l s . However, some i n d i c a -tion of timing was derived from reference to the date of patients' admission to the h o s p i t a l . Of the group of 371 r e f e r r a l s , approximately 29 per cent of the patients were referred from the Outpatient Depart-ment, that i s , p r i o r to admission to h o s p i t a l . Of the group of 266 patients referred a f t e r admission to h o s p i t a l , about 5 per cent were referred on the same day as admitted; approximately 29 per cent within one week of admission; just over 37 per cent i n the period one week to one month a f t e r admission; and about 21 per cent were referred a f t e r at l e a s t one month of hospital care. (No information was obtained on the remaining 8 percent). I t would be risky to draw any s p e c i f i c implications from these figures, without obtaining further information on the nature of the s o c i a l services requested. However, the importance of early r e f e r r a l to s o c i a l service cannot be over-emphasized. Nature of Referrals by Medical S t a f f In an attempt to a r r i v e at a working description of the m u l t i p l i c i t y of s o c i a l services requested i n the 371 cases 32 studied the focus was de l i b e r a t e l y set on the problem stated as the reason f o r r e f e r r a l . But even within these l i m i t s , the varia« t i o n i n problems was of wide range. Examination and analysis of the reasons f o r r e f e r r a l yielded four broad categories, which were adopted as a basis of c l a s s i f i c a t i o n . These four categories r e f l e c t the areas of s o c i a l work services i n t h i s s e t t i n g : A. S o c i a l information as an ai d to diagnostic and treat-* ment planning by medical s t a f f . This includes requests f o r s o c i a l h i s t o r y , both f o r p s y c h i a t r i c use and f o r use i n general medical treatment, as well as requests f o r s o c i a l assessment of the patient's home conditions f o r a better understanding of the patient. B. Direct assistance to patients with anxiety a r i s i n g from i l l n e s s , or as a resu l t of unsatisfactory home conditions, or s o c i a l r e l a t i o n s h i p s . C. S o c i a l screening of home conditions to determine the s u i t a b i l i t y of the home, and the a b i l i t y of the family i n providing convalescent or domiciliary care f o r the patient, or al t e r n a t e l y , to a s s i s t i n l o c a t i n g of suitable l i v i n g accommodation f o r the patient on his discharge from the h o s p i t a l . D. P r a c t i c a l services to patients or t h e i r r e l a t i v e s . This includes requests f o r f i n a n c i a l assistance, assistance i n finding suitable l i v i n g accommodation, job placement, information about Departmental p o l i c y and regulations, e t c . 33 MEDICAL SOCIAL SERVICES REQUESTED FOR PATIENTS So c i a l information f o r diagnosis and treatment planning Assistance with problems of anxiety a r i s i n g from i l l n e s s or as a r e s u l t of unsatisfactory s o c i a l relationships S o c i a l screening of home conditions f o r convalescent and domiciliary care P r a c t i c a l services, such as f i n a n c i a l assistance, job placement, l o c a t i n g suitable housing accommodation Figure 1. Medical S o c i a l Services Requested f o r Patients (Shaughnessy Hospital, 1943-54) 34 The differentiation between the types of services requested from caseworkers, and the grouping of these services Into the four basic categories reveals that the majority of referrals are for f a c i l i t a t i n g services: diagnostic aids, (Group A); and aids in treatment planning (Groups A and C). A small proportion of requests i s for practical services (Group D), and yet a smaller proportion for direct assistance to patients with problems of anxiety (Group B). A closer examination of these four broad categories should provide some solid material for an evaluation of the general nature of referrals, and of the services rendered by social workers. Group A: Diagnostic Aids The total referrals comprised 201 cases, of which 78 were from the Outpatient Department and 123 from the Hos« p i t a l wards. The referrals were of three main types: (a) Social history as an aid to psychiatric services (b) Social history for patients on general medicine wards . (c) Social work assessment of patient's home conditions for a better understanding of the patient About three-quarters of the requests were for psy-chiatric social history, while the remainder f e l l about equally between the other two types of service requested. The large proportion of requests for psychiatric social history points to the significance of the social worker's contribution in the area of diagnosis and treatment planning for the patient under psychiatric care. Referrals to Psychiatry from the Outpatient 35 Department are routed through the social service department as a matter of routine. Besides obtaining the required social history, social service staff are in a position to help patients accept the psychiatric service recommended. History-taking c a l l s for s k i l l i n interviewing, and a clear understanding of the purpose for which the information i s required. The emphasis should be not so much on the details required, as on the skill e d use of the worker-patient relation-ship to get the configuration of the l i f e pattern, or portion of i t , with as l i t t l e distortion as possible. The style of recording social histories i s determined by a number of fac-tors, among them the nature of the content, the purpose to which the material i s to be put, and the agency's policies. Material for social history i s usually blocked out under topics for easy access by persons using i t : but there i s clearly a danger in conforming too ri g i d l y to a preconceived pattern or outline, thereby losing the dynamic picture of the patient or client. In the records reviewed for this study, the major-i t y of social histories for Psychiatry were taken by the same worker, who i s allocated to the psychiatric ward. As a con-sequence, these histories showed the same general pattern of writing and contained the same type of information. It was noted that, in the taking of social histories, wide use was made of relatives as a primary or collaborative 36 source of information. This i s encouraging for the practice of social work in this setting, for relatives can be an important li n k between the patient in the hospital and his outside con-cerns. The extent of contact with relatives and friends in obtaining social history information i s about one in every two. (Table 5). It i s to be noted, however, that in over two-thirds of them there i s no further recorded contact with the patient or relatives beyond the i n i t i a l social history. In those cases where further contact i s recorded, there i s evidence that follow-up services were directed toward stabilizing or improv-ing the patient's social functioning, either through direct services, or by referral to an appropriate Departmental or community service. The group of social case histories reviewed here pro-vides a substantial sampling of the work done by medical social workers in this setting in contributing to medical diagnosis and treatment through preparation of social histories present-ing the patient in his social functioning. The high proportion of requests for social histories indicates the significance of the work in this area. The findings on the services given, point up the need for a greater concern on the part of social workers for a continuing participation in the treatment of the patient, i n i t i a l l y through a more dynamic interpretation of the patient's social situation as i t i s related to his i l l n e s s , and subsequently, through continuing casework services to relatives where this seems indicated. Finally, from the research point of view, at least, i t would be helpful for future 37 Table 5. Requests f o r S o c i a l History and Services Rendered (Shaughnessy Hospital, 1953-4) Services Rendered la) • -Service Requested at Referral S o c i a l History Direct Help (Patient or Relative) .Referral to Other Agencies Total 1.Social h i s t o r y as an a i d to diagnosis and treatment (Psychiatry) a. Information from patient only b. From patient and others 50 53 1 23 5 19 56 95 2.Social h i s t o r y (General Medicine) a. Information from patient only b. From patient and others 14 6 1 1 4 19 7 3.Social h i s t o r y with s p e c i a l em-phasis on home conditions as they rel a t e to patient's i l l n e s s a. Information from patient only b. From patient and others 7 10 2 1 3 1 12 12 Totals 140 29 32 201 Source: Compiled from the s o c i a l service records of Shaughnessy Hospital, 1953-4. (a) S o c i a l h i s t o r i e s are obtained i n a l l cases: the f i r s t column therefore means that f o r these patients, no other casework services were rendered. 38 evaluations of this kind, i f social service records showed the disposition of the case, Whether or not continued services were given. Group B: Direct Social Work Treatment Services This group of 40 cases comprises the requests made for direct assistance to patients and relatives with problems of anxiety arising from the patient's i l l n e s s or from unsatis-factory inter-personal relationships. This area of service represents one of the prime responsibilities that i s the medi-cal social worker's by tradition. The classification adopted for purposes of analysis shows two main types of problems in this group of requests: (a) those arising from the patient's hospitalization or illn e s s ; (b) those arising from patient's family and social relationships, and probably aggravated by his i l l n e s s . However, no classification can be so clear-cut that one category excludes the others; typically, problems of human relationship are complex. Problems arising from the patients' illness or hospitalization included such referrals as the following: a. Relatives are upset over patient's recent transfer to a closed psychiatric ward. Could social service help them accept the necessity of this move. b. Patient i s worried about lengthy separation from his family in the northern part of the province. Can social service help him? c. Patient i s to undergo surgery for gastric ulcer, and i s worried about the family's reaction to this: Medical Social Service aid requested. 39 d. Reply needed to l e t t e r from patient's daughter i n q u i r -ing about his i l l n e s s . (Patient i s on p s y c h i a t r i c ward). Referrals requesting assistance f o r patients with pro-blems of inter-personal relationships included such r e f e r r a l s as the following: a. Patient has bleeding peptic u l c e r . He has indicated that there are domestic d i f f i c u l t i e s i n the home. Can s o c i a l service help him. b. Patient i s an a l c o h o l i c . I t i s indicated that marital relationships are poor. Wife may benefit from Medical S o c i a l Service help. c. Domestic problems. Patient i s anxious to have estranged wife return. There are three young children. An analysis of the type of problems referred, and the frequency of the various services given, i s summarized i n Table 6. I t i s s i g n i f i c a n t that the highest frequency of services rendered was i n the areas of d i r e c t casework treatment and r e f e r r a l to community agencies. "Direct casework treatment," as i t i s used here, i s 1 that d e f i n i t i o n given by Gordon Hamilton, meaning therapeuting interviewing c a r r i e d on f o r the purpose of "inducing or r e i n f o r c -ing attitudes favourable to maintenance of emotional equilibrium, to making constructive decisions, and to growth or change." The extent of t h i s type of service i s d i f f i c u l t to measure i n any s e t t i n g , f o r i t requires process recording of the i n t e r -views, or at l e a s t a summary of the s o c i a l worker's active Hamilton, op. c i t . . p. 249. 40 participation in enabling the client to become keenly aware of his reality situation and of his part in i t . Direct thera-peutic treatment usually requires a series of interviews over a long period of time, for the growth process i s slow. From the records studied, i t would seem that the extent to which this type of service i s practiced in this setting i s very limited. The majority of case histories con-s i s t of only one, or at most, several, interviews. Moreover, because the general style of social work recording in this setting shows l i t t l e of the worker's participation i t i s d i f -f i c u l t to draw any precise conclusions about the nature of the relationship between worker and patient, and i t s effect on the latter. Referral to an appropriate community resource i s another important service that the social worker in a hospi-t a l setting can provide. Frequently an appropriate service can be initiated by the social worker in the hospital but i t s effectiveness would be lost i f i t were not continued on the patient's discharge. In the cases studied, referrals were frequently made to such agencies as the Family Welfare Bureau, Provincial Welfare Services, and: to social service departments in other hospitals i f the patient had to be transferred there. 41 Table 6. Problems of Anxiety Referred to S o c i a l Service (Shaughnessy Hospital; 1953-4) Problem at Referral Number of Cases (a) Services Rendered and Frequenc Direct Casework Services Referral to Other Source v Practic Practical Service 1.Anxiety a r i s i n g d i r e c t l y from patient's i l l n e s s or ho s p i t a l i zat ion a. Patient's concern over his i l l n e s s Relatives' concern about patient's i l l n e s s Family services r e -quired due to patient's separation from family b. c. 11(3) 6(1) 5(0) 2.Anxiety related to family and s o c i a l relationships (existing p r i o r to i l l n e s s ) a. M a r i t a l d i f f i c u l t i e s b. Other domestic troubles c. Alcoholism 7(0) 6(2) 5(0) 3 4 2 5 2 4 4 3 3 4 2 2 2 1 Totals 40(6) 19 19 Source: Compiled from s o c i a l service records of Shaughnessy Hospital, 1953-4. (a) Figure i n brackets represents the number of outpatients i n the group. Perhaps the most s i g n i f i c a n t finding from the analysis of these cases l i e s i n the l i m i t a t i o n s of recording, already noted. To quote Gordon Hamilton again, "the main considerations i n recording are: the need f o r s u f f i c i e n t f a c t u a l material, both s o c i a l and psychological; the worker's professional analysis 42 of the s i t u a t i o n ; the formulation of diagnostic and treatment evaluations; the preliminary outline and step by step reports of the treatment which i s made av a i l a b l e , and the f i n a l outcome of the case." I t i s recognized that case recording i s partly determined by the set t i n g and the administrative practices, according to the use made of i t . However, the question of concern here i s not contrary to administrative purposes. The effectiveness of the s o c i a l work method i s a matter of v i t a l concern to administration, and s o c i a l work stands to benefit by a c l e a r interpretation of the approach caseworkers use. Group C: Assessment of Home Conditions The patients i n t h i s group presented varied degrees of physical incapacity, and required temporary or permanent nursing care. Many had physical d i s a b i l i t y complicated by memory defects and senile deterioration, which made i t ess e n t i a l f o r them to have constant supervision. Host of the patients i n this group were older veterans whose problems were a complexity of chronic disease, i n f i r m i t y of old age, and lack of family or friends to care f o r them. The problems as stated at r e f e r r a l f e l l into two main types, according to the nature of the service requested by the medical s t a f f . (a) Those where s o c i a l screening of home conditions was required to determine decision on i n s t i t u t i o n a l care consideration (Treatment Section 29). This includes cases where application f o r i n s t i t u t i o n a l care was made by the patient or r e l a t i v e s , as well as those cases where such consideration was i n i t i a t e d by the medical s t a f f . (b) Requests f o r assistance i n discharge planning follow-ing a period of h o s p i t a l i z a t i o n , where fu r t h e r con-valescent care was required. I b i d . . p. 236. 43 Typical referrals i n this group included such requests as the following: a. Patient hemiplegic. Check capability of family to care for him at home. If not, Section 29 to be considered. b. Carcinoma terminal. Social screening i s necessary to determine family's interest and wishes in regard to interim care. c. Patient considered capable of taking insulin treatment for his diabetes. Is former boarding home suitable l i v i n g accommodation? Evaluation of applications for permanent institutional care i s a c r i t i c a l one for the applicant and for the Department. Admission practices and selection s k i l l s have to be of the high-est order to ensure that the present Departmental f a c i l i t i e s w i l l be uti l i z e d to the- best advantage. Medical staff must con-sider the patient's need for institutional care on the basis of medical, social, economic, and personality findings. In order to classify d i f f i c u l t cases with ease and efficiency, the Assessment and Rehabilitation (A & R) Unit was established within the Department. The A & R Unit represents a team approach to the patient who presents a disposal problem, and i s concerned with ensuring that the man i s functioning up to his f u l l e s t capacity. This i s determined through a total assessment of medical, psy-chological, social, and economic aspects, each of which is the special contribution of the respective member of the A & R team: medical man, psychologist, medical social worker, and Veterans' Welfare Officer. The immediate purpose i s to determine which candidates w i l l require Departmental f a c i l i t i e s , and which might better remain at home or seek other assistance in the community. 44 Prom the s o c i a l work standpoint, the decision to recommend i n s t i t u t i o n a l care i s easy i n many cases when the needs of the patient and the f a c i l i t i e s of h i s home and of the community are kept in mind. Thus, acutely disturbed or d i s -oriented i n d i v i d u a l s , and aged persons who have reached a stage of apathy so that t h e i r growing need f o r the physical aspects of care could not be served appropriately at home, are acceptable f o r i n s t i t u t i o n a l care when there are no friends or r e l a t i v e s able or w i l l i n g to care f o r them. Among those not able to care f o r themselves outside the i n s t i t u t i o n a l s e t t i n g are some whose problems l i e i n t h e i r upset psychological and emotional reactions to l i v i n g , and t h i s includes abnormal family and s o c i a l r e l a t i o n s h i p s . The s o l i -tary hermit who has always refused help from neighbors, the al c o h o l i c , the quarrelsome grandfather who makes h i s home with r e l a t i v e s of a younger generation, a l l these present problems of disposal when chronic i l l n e s s and the i n f i r m i t i e s of old age overcome them. In a l l cases where the e l d e r l y or p h y s i c a l l y incap-acitated person presents a disposal problem to the hospital s t a f f , i n order to ef f e c t a suitable plan, the man's motiva-t i o n and h i s remaining capacities must be known and considered. Has he the capacity to maintain himself i n the community? Are there suitable f a c i l i t i e s i n the community f o r his use? These are the questions about which the s o c i a l worker, as part of the hospital team, must be v i t a l l y concerned. 45 In the 82 cases reviewed, the services rendered by the Medical Social Service staff may be summarized as follows: a. Referral to Veterans* Welfare Services, or to an appropriate community service, 9 cases, or just over 10 per cent. The chief services requested were: find-ing liv i n g accommodation, housekeeping services, and budgetting assistance. b. Discharge recommended, in approximately one-third of the cases. For the majority of these patients, i t was found that relatives or friends were prepared to care for them, A smaller group seemed capable of making their own plans. Others simply planned to return home. c. Institutional care consideration recommended, in about ten per cent of the cases. These recommendations were found to be based on such reasons as: no relatives, or friends, or suitable accommodation; illness of relatives; relatives or friends unable to give patient the nursing care he requires; or a combination of these, d. Extension of hospitalization recommended, about ten per cent of the cases. This was usually as a transition to other plans, such as temporary illness of relatives, or other plans of patient's own making. e. No decision reached by social workers, just over ten per cent of the cases. Decisions were sometimes deferred because patient was placed under further medical obser-vation. In a number of other cases i t was stated that further contact with relatives was planned. In this group, as in the other groups discussed ear-l i e r , i t was found that in the majority of cases the social worker's recommendation was formulated on the basis of a very brief contact with the patient or his relatives, frequently after one interview. This i s often necessitated by a demand from the medical staff for an early report of social findings, p a r t i -cularly during periods of acute pressure for hospital accommoda-tion. An early referral to social service would give the worker a better opportunity to explore the social resources within the 46 community and to mobilize these resources on behalf of the aged or incapacitated patient. One more point deserves attention. With rare excep-tions, social service records do not show whether or not the recommendations made by the workers were carried out by medical staff. This information, i f i t were readily available, could be very valuable in evaluating the contribution of medical social work in this setting. Group D: Practical Services The administration of a practical service i s one of the oldest and best known ways of helping. In Departmental hospitals, i t i s usually the Veterans 1 Welfare Officers who administer the bulk of "practical services" in their responsibility of making veterans aware of their rights and benefits under veterans' legislation. Locally at least, Welfare Officers have also largely assumed the responsibility for helping patients in finding suit-able l i v i n g accommodation, job placement, etc. However, a f a i r proportion of referrals to social service are for this type of services. The appropriate use of a practical resource in serv-ing the need of the patient may be one of the most valuable con-tributions. From the social work point of view, the worker's professional responsibility goes beyond doing things or giving  things to the client or for him; the social worker has a pro-fessional obligation to determine the best source of help and to enable the client to use i t constructively. Granting the destitute man an emergency loan may be v i t a l to the man's 47 immediate need, but, i n i t s e l f , i t may not be the most e f f e c t i v e way of meeting his basic need. The use of p r a c t i c a l resources should not be an end i n i t s e l f . The person seeking help must be i n d i v i d u a l i z e d , the nature of his need c l a r i f i e d , and the prac-t i c a l resource, i f i t i s to be used, must be so employed as to motivate s e l f - h e l p , self-awareness, and r e s p o n s i b i l i t y i n the c l i e n t , so that he can mobilize his own capacities and resources i n the solution of his problems. The d i s p o s i t i o n of the 48 cases referred to Medical S o c i a l Service f o r p r a c t i c a l services i s summarized i n Table 7. Prom the analysis of the cases i n t h i s group, the significance of the Medical S o c i a l Service Department as a r e f e r r a l and l i a i s o n centre f o r veterans' patients becomes very cl e a r . Another feature of importance i s the large proportion of outpatients who are being referred to s o c i a l service. In many of the case h i s t o r i e s i t was indicated that veterans coming to the Outpatient C l i n i c are frequently more i n need of p r a c t i c a l services than of medical attention. This condition suggests that a greater a v a i l a b i l i t y of s o c i a l work services i n the Outpatient C l i n i c s would be not only desirable, but v i t a l l y important as an addition to the e x i s t i n g Departmental services. 48 Table 7. Referrals f o r P r a c t i c a l Services (Shaughnessy Hospital; 1953-4) Service Requested No. of Frequency of Services Rendered Patient able to Cases (a) At Source On Referral to Community (b) do own planning 1.Financial assistance 14(8) 15(8) = 2.Help i n finding l i v i n g accommodation 8(2) 2 5(1) 2 3.Job placement 7(2) - 5(1) 1 4.Referral to com-munity resource or service 9(5) - 8(1) 1 5 .Miscellaneous (Housekeeping ser-v i c e s , clothing, etc.) 10(3) 7 3(2) 3 Totals 48(20) 12 36(13) 7 Source: Compiled from s o c i a l service records, Shaughnessy Hospital. (a) Figure i n brackets refers to number of outpatients i n each group. (b) Figure i n brackets indicates number of r e f e r r a l s to Veterans 1 Welfare O f f i c e r s . Note: Patients discharged before any services given by Medical Social Service, 2. CHAPTER 3 SOCIAL SERVICE AS DOCTORS SEE IT To obtain information abont the degree of p a r t i c i p a -tion of the medical s t a f f i n the s o c i a l service program of the h o s p i t a l , and to get some material from the personal exper-iences of doctors i n u t i l i z i n g s o c i a l services as an a i d to medical treatment, a questionnaire was formulated. I t covered four aspects of hospital s o c i a l service: the method of r e f e r r a l preferred by doctors; the kinds of s o c i a l information found to be most useful by medical s t a f f ; the kinds of s o c i a l service most frequently requested by doctors; and, suggestions f o r improving the work of the s o c i a l service department. Each question contained a check l i s t of possible answers, and there was a space provided f o r a l t e r n a t i v e s . The purpose of the project was outlined i n the opening paragraph of the question sheet, and i t was also explained i n further d e t a i l where i t was f e a s i b l e to see each doctor personally. Doctors answering the questionnaire were not required to i d e n t i f y themselves on the form sheet, but a number of them d i d so. In t h i s part of the study, several factors had to be kept i n mind, not the lea s t being that the questionnaire would have to be b r i e f , concise, and p r a c t i c a l , i n order to get the f u l l e s t co-operation from the medical s t a f f , who have a great deal of "paper work" i n the ordinary course of t h e i r work. Another point of importance was that, since t h i s was the f i r s t 50 time such a project had been car r i e d out, the questionnaire was so constructed that i t might also contribute to the in t e r p r e t a -tion of hospital s o c i a l services, rather than simply surveying the uses that medical s t a f f are making of them i n thi s s e t t i n g . For t h i s reason, only those things which would normally f a l l within the function of a medical s o c i a l service department were included, although provision was made f o r additional or alternative suggestions, to be offered by the doctors them-1 selves. In in t e r p r e t i n g the r e s u l t s , i t i s relevant to remem-ber that the inquiry was carried out at the end of the tr a i n i n g year f o r the medical internes, who have most of the d i r e c t r e s p o n s i b i l i t y , i n consultation with resident s t a f f and part-time s p e c i a l i s t s , f o r the actual services to the patient. Since the internes had had a year's opportunity to become acquainted with the work of the s o c i a l service department, they would pro-bably have a wider appreciation of i t than a group of internes 2 just beginning t h e i r t r a i n i n g period. Altogether, approximately 80 per cent of the doctors who were requested to pa r t i c i p a t e i n the survey completed and returned the question forms. The discussion of t h e i r responses below i s not intended to provide a comprehensive review of how 1 I t would be worth while f o r the reader, at t h i s point, to turn to Appendix E and see the questionnaire used i n the study. 2 Appendix F contains a tran s c r i p t of the information on the Medical S o c i a l Service Department from the Interne's Manual. 51 doctors use the s o c i a l service department i n t h i s h o s p i t a l , nor of what the p o t e n t i a l i t i e s of the department might be from the point of view of the medical s t a f f . The 25 questionnaires reviewed here serve to bring out enough of the doctors* exper-ience and thinking to suggest what aspects of s o c i a l work are already accepted and u t i l i z e d , and what areas require further development. Method of Referral to S o c i a l Service The majority of doctors who answered the questionnaire stated that they did not f i n d the practice of w r i t i n g r e q u i s i -tions a convenient method of r e f e r r a l to Medical S o c i a l Service. A c t u a l l y , the written r e q u i s i t i o n , although a requirement, i s l i t t l e used, and a large number of r e f e r r a l s are simply t e l e -phoned i n by the doctor and received by the s o c i a l worker on intake duty. The written r e q u i s i t i o n , which i s the normal pro-cedure when doctors are requesting consultation or s p e c i a l tests, such as x-ray, i s desirable i n medical requests f o r s o c i a l ser-vice i n that i t f a c i l i t a t e s the work of the medical s o c i a l ser-vice department since the assignment of cases and i n i t i a t i o n of action by the s o c i a l worker can be c a r r i e d out more r e a d i l y when the patient's s o c i a l problem i s indicated and his medical condi-tion i s made known. These doctors who did not approve of w r i t -ten r e f e r r a l s were ready i n every instance to suggest al t e r n a -t i v e s , e i t h e r the ones l i s t e d on the form, or others of t h e i r own. The method of r e f e r r a l most widely favoured by these doctors was a preliminary r e f e r r a l by telephone, followed by 52 discussion with the worker who would be taking the case. One doctor stated that sending the patient to the social service office, after a telephone referral might be satisfactory in some cases. Another suggested the use of a modified form of written requisition, requiring only the basic identifying information about the patient. This could be written by the nurse or ward clerk, and forwarded to the department. The case could then be assigned, and the worker in charge could discuss i t in detail with the doctor. This particular doctor stated this type of requisition would be less time-consuming than the regular con-sultation form, and that the social problem could be defined in conference with the social worker. Actually, this could be done, and i s being done, even with the present form of written requisition, which i s not a ri g i d requirement, and which allows the doctor to give only as much information as he thinks i s necessary at the time. In every instance where the doctors did not approve of the written requisition, the main reason given was that i t was time-consuming, and that a duplication of work was involved, since the doctor usually discusses the case with the worker anyway. Of those doctors who considered the written requisition a convenient method of referral, two indicated no alternatives; three specified that i t should be supplemented by discussion with the social worker in charge of the case; and four simply checked discussion with the worker as an alternative, without making any comment. 53 It would seem from the doctors' overall responses and from their comments that, as a group, they are well aware of the need for a close working relationship with the social ser-vice staff; and that they are desirous of an early conference on the case, either as a supplement or as an alternative to the i n i t i a l requisition for social service, and prior to the social worker's contact with the patient. Such a discussion could serve two main purposes!:, c l a r i f i c a t i o n by the doctor of the reason for the referral, which would include the patient's medical condition and his response to the treatment plan; and, cl a r i f i c a t i o n by the worker of her role in the case, so that an integrated plan of treatment could be assured. The need for close co-operation with the medical staff i s , of course, recognized by the Medical Social Service staff, and i s part of this department's policy. However, in view of the doctors' emphasis on the need for close co-operation, and since social service records do not always show the extent of such co-opera-tion, i t would seem desirable to investigate this area further through closer examination. Social Information Because social information i s so complex and may easily follow in many directions, medical social workers in any setting have to discipline themselves in the selection and con-densation of social information which they make available for the use of medical staff. Another point of considerable rele-vance i s that many doctors, accustomed to medical abbreviations, 54 w i l l not take the time to examine long s o c i a l e n t r i e s , even i f they were desirable. The question of what information workers should place on the medical f i l e , i n thi s s e t t i n g , i s therefore a very important one. In the present survey the items included as s o c i a l information were as follows: patient's family and s o c i a l r e l a -tionships; employment his t o r y ; economic status; patient's plan on discharge; h i s reaction to his i l l n e s s ; and, home and com-munity resources f o r his use. The re s u l t s indicate that the doctors, as a group, were discriminate i n t h e i r r a t i n g of the comparative value of the d i f f e r e n t items. Out of the 25 doctors who answered t h i s section of the questionnaire, only three checked a l l the items, and two of them marked the items by numbers, i n the order i n which they found the information most u s e f u l . The majority checked two or three items; three checked only one item; only one did not check any. (Table 8). The item of s o c i a l information most frequently checked was information on the patient's family and s o c i a l r e l a t i o n s h i p s , with 21 out of 25 doctors st a t i n g t h i s as one of the most useful areas which they look f o r i n s o c i a l service reports. Second i n frequency on the l i s t was information on home and community resources available f o r the patient's use, with 17 out of 25 doctors marking t h i s as one of the areas they consider most us e f u l . The items l e a s t frequently checked 55 were employment hi s t o r y , and patient's plan on discharge. Items i n the range of "middle frequency" were, the patient's reaction to h i s i l l n e s s , and his economic status. I f economic status could be considered as part of the patient's home resources, and patient's plan on discharge as part of the t o t a l r e h a b i l i t a t i o n plan, then the item on patient's i l l n e s s emerges as the area of information doctors ask f o r least frequently. This i s referred to further, below. Other items s p e c i f i c a l l y added by the doctors, and the frequency of requests f o r them, were as follows: a. Family's reaction to patient's i l l n e s s (2) b. Wife's attitude towards helping patient, and her a b i l i t y to do so (1) c. Friends' or neighbors' opinion of the patient (1) d. Patient's motivation f o r r e h a b i l i t a t i o n (1) e. E a r l y developmental hi s t o r y (1) f . The supportive value of s o c i a l worker's i n t e r e s t , and the patient's response to such help (1) A number of doctors stated i n additional comments that the item "patient's reaction to h i s i l l n e s s " was not a s o c i a l problem, but a medical one, and therefore i t was p r i -marily the doctor's r e s p o n s i b i l i t y to obtain t h i s information from the patient. On the other hand, the additional sugges-tions received from the doctors point c l e a r l y to the same area of information; f o r example, the patient's motivation f o r r e h a b i l i t a t i o n would surely imply taking into account his reaction to h i s i l l n e s s . S i m i l a r l y , early developmental h i s -56 tory, family reactions to the patient's i l l n e s s , and the.other areas mentioned, cannot well be i s o l a t e d and considered apart from the patient's reaction to his present d i f f i c u l t i e s . On the whole, these responses suggest that there i s a wide v a r i a t i o n as to the kind of information about patients which doctors expect to get from s o c i a l workers. Some f e e l a keen r e s p o n s i b i l i t y f o r obtaining the information themselves; others see the s o c i a l worker as a valuable resource i n t h e i r medical planning f o r the patient. In future research i t would be well to explore this area more inte n s i v e l y . Reason f o r Referral The reasons f o r which doctors most frequently make r e f e r r a l s to Medical Social Service were also developed i n a c a r e f u l l y considered l i s t ; with provision f o r other comments. The l i s t contained seven types of services usually performed by medical s o c i a l workers i n a hospital s e t t i n g : a. obtaining s o c i a l h i s t o r y b. assistance i n planning convalescent care c. helping r e l a t i v e s towards a better understand-ing of the patient's i l l n e s s and his needs d. helping ameliorate patient's anxieties and fears e. helping patient towards r e h a b i l i t a t i o n planning f. a s s i s t i n g patient with f i n a n c i a l d i f f i c u l t i e s g. helping patient modify unfavourable attitudes 57 Table 8. S o c i a l Information Considered Most Usefal (Analysis of 25 questionnaires, May 1954) Number of Items Number of Information Req (Frequency) uested Total Items Checked Doctors a b c d e f ft h l ,1 k 1 Requested A l l 3 3 3 3 3 3 3 1 18 One 4 3 - 1 - - - - 1 i 1 = 7 Two 5 3 2 - mm 2 3 mm mm. mm - - - 10 Three 10 11 1 6 1 5 9 1 - 2 - - 36 Pour 1 1 - 1 1 - 1 mm mm mm - - - 4 Five 1 1 1 1 1 - 1 5 Total (a) (25) 22 7 12 6 10 17 1 1 2 I 1 1 81 (a) One doctor only l i s t e d no items as required. a - f . Items l i s t e d on questionnaire: a. patient's family and s o c i a l relationships b. employment his t o r y c. economic status d. patient's plan on discharge e. his reaction to h i s i l l n e s s f. home and community resources f o r his use g « 1 . Additional items l i s t e d by doctors: g. early developmental h i s t o r y h. patient's motivation f o r r e h a b i l i t a t i o n i . family's reaction to patient's i l l n e s s j . friends* or neighbors' opinion of patient k. wife's attitude towards helping patient, and her a b i l i t y to do so 1. the supportive value of s o c i a l worker's in t e r e s t , and the patient's response to such help 58 There was a wide v a r i a t i o n i n the responses i n t h i s section of the questionnaire, both i n the number of items checked by doctors as well as i n the p a r t i c u l a r items checked. This v a r i a t i o n seems to indicate that t h i s group of doctors use the Medical S o c i a l Service Department f o r a v a r i e t y of services; also, that i n d i v i d u a l doctors make r e f e r r a l s f o r d i f f e r e n t services. The doctors were se l e c t i v e i n specifying the reasons f o r which they referred patients to Medical Social Service; only one doctor checked a l l the items l i s t e d , and he marked them in the order of frequency i n which he used them as the basis of r e f e r r a l . In t h i s p a r t i c u l a r l i s t , the item " s o c i a l h i s t o r y " came f i r s t . The majority of doctors s p e c i f i e d two, three, or four reasons. In addition, several doctors offered other rea-sons, not l i s t e d on the question form, namely, casework with family, supportive therapy, and job placement. The highest frequency among the reasons f o r r e f e r r a l was i n the area of discharge planning and convalescent care, with items (e) and (b) most frequently checked. The use of medical s o c i a l services as a means of f a c i l i t a t i n g diagnostic and treatment planning was r e f l e c t e d i n the frequency of item (a), which came second. I t i s s i g n i f i c a n t that t h i s area also came f i r s t i n the analysis of the case records (Chapter 2), with over 50 per cent of the r e f e r r a l s requesting s o c i a l h i s -tory. The s l i g h t discrepancy may be explained i n part by the fa c t that most of the r e f e r r a l s f o r s o c i a l h i s t o r y come from the p s y c h i a t r i c ward, where the number of doctors i s com-59 paratively small; the r e s u l t s obtained from the analyses of case records and of the questionnaire would not necessarily be the same, since no weighting was given to the responses from the d i f f e r e n t Medical Departments. It i s s i g n i f i c a n t that items ( c ) , (d), and (g), which together might be considered representative of " d i r e c t s o c i a l work treatment," as contrasted to " f a c i l i t a t i n g " service, rated a comparatively low frequency. At the same time, a number of doctors commented on these items, the general opinion expressed being that t h i s area i s primarily the r e s p o n s i b i l i t y of the physician, or that i t i s best done by the doctor. A few stated that the services l i s t e d i n these items were d e f i n i t e l y not the r e s p o n s i b i l i t y of the s o c i a l worker. One doctor s p e c i f i e d that some d i r e c t service to patients on the p s y c h i a t r i c ward might be appropriately done by the s o c i a l worker, but on the general medicine wards t h i s i s primarily the doctor's r e s p o n s i b i l i t y . Because t h i s p a r t i c u l a r section of the questionnaire evoked considerable comment, there i s some question as to the meaning that the statements might have implied; that i s , was the d i s -t i n c t i o n between giving treatment, and aiding the giving of treatment made s u f f i c i e n t l y c l e a r by the question, and was i t f u l l y understood by the medical s t a f f . The area of p r a c t i c a l services was probably not given s u f f i c i e n t consideration i n the formulation of the ques-tions; only one item, ( f ) , can be said to be exclusively i n t h i s area. However, the frequency r a t i n g f o r i t was approxi-60 mately 17 per cent. In addition, one doctor l i s t e d as another reason f o r r e f e r r a l , helping the patient to obtain suitable employment. I t should be emphasized again that s o c i a l work i n t h i s s e t t i n g i s i n some ways unique. The d i v i s i o n of labour between Veterans' Welfare O f f i c e r s and Medical S o c i a l Workers almost i n e v i t a b l y places much of the r e s p o n s i b i l i t y f o r p r a c t i -c a l services to patients upon the welfare o f f i c e r s . In mental hospitals, and i n general h o s p i t a l s , t h i s r e s p o n s i b i l i t y f o r helping patients with housing accommodation, f i n d i n g jobs or t r a i n i n g f o r them, f i n a n c i a l assistance, and so f o r t h , would f a l l l a r g e l y on s o c i a l workers. From the o v e r a l l responses obtained i n t h i s question, i t would appear that doctors are keenly aware of the c o n t r i -bution that the s o c i a l service department can make i n the area of diagnostic and f a c i l i t a t i n g services, such as obtaining s o c i a l h i s t o r i e s , assessing home conditions to determine t h e i r s u i t a b i l i t y f o r the patient's convalescence, and generally a s s i s t i n g the patient i n r e h a b i l i t a t i o n planning. In the area of i n t e r p r e t i n g i l l n e s s to the patient and r e l a t i v e s , however, the doctors show s u r p r i s i n g l y l i t t l e i n c l i n a t i o n to request t h i s service from the s o c i a l service department. Again, the question i s raised as to whether the d i s t i n c t i o n between giving treatmentj and aiding the giving of treatment has been made s u f f i c i e n t l y c l e a r . 61 SOCIAL SERVICES REQUESTED BY DOCTORS (Frequency of Reasons f o r Which Referral made to Social Service Department: 25 doctors) 10 15 20 25 DIAGNOSTIC AID Soci a l h i s t o r y FACILITATING SERVICES As s i s t i n planning f o r convalescent care Help patient towards r e h a b i l i t a t i o n planning (PRACTICAL SERVICES Fin a n c i a l assistance Job placement DIRECT TREATMENT SERVICES Help ameliorate patient's anxieties and fears Help patient modify unfavourable attitudes j Case work with family j Supportive therapy L i s t e d items (questionnaire) Additional items l i s t e d 10 15 20 25 Figure 2. So c i a l services requested by doctors. 62 Suggestions f o r Improvement Five p o s s i b i l i t i e s f o r changes i n the present est-ablishment of the s o c i a l service department were l i s t e d as considerations towards making the work of the department more eff e c t i v e from the point of view of the medical s t a f f . These suggestions were based on observation of the e x i s t i n g methods of organization and functioning of the Medical Social Service Department at Shaughnessy and comparison with the practices of comparable departments i n other hospitals. The aspects included only those changes which might be i n the realm of p o s s i b i l i t y , so to speak, f o r the p a r t i c u l a r s e t t i n g . Is there a need f o r more information available about the services of the department among medical staff? Do the medical s t a f f see a need f o r a closer working rela t i o n s h i p between the two services? Would i t be desirable to have a s o c i a l worker allocated to each hospital ward f o r greater a v a i l a b i l i t y of s o c i a l service? Is i t desirable to have a s o c i a l worker available i n the Out-patient Department? Should s o c i a l workers pa r t i c i p a t e i n d a i l y ward rounds? These were the s p e c i f i c suggestions l i s t e d f o r consideration. About half of the doctors included i n the survey indicated that the a v a i l a b i l i t y of a s o c i a l worker i n the Out-patient Department would be a p r a c t i c a l improvement from the medical standpoint. In the Outpatient service of the Neuro-psychiatric C l i n i c t h i s service already e x i s t s , and the medi-ca l s t a f f from this Department were a l e r t to point t h i s out. Second highest i n acceptance was the suggestion about closer 63 co-operation between Medical Social Service s t a f f and doctors, just over one-third of the doctors checking t h i s item. While i t i s recognized that there are variations i n the degree of co-operation between the s o c i a l service s t a f f and doctors on the i n d i v i d u a l doctor-worker r e l a t i o n s h i p basis, i t i s s i g n i f i c a n t that the doctors, as a group, are asking f o r c l o s e r co-operation between the two services. (This request was also made i n the area of methods of r e f e r r a l , above, where the medical s t a f f requested discussion with the worker following r e f e r r a l of the case). Two other suggestions which gained wide support from the medical s t a f f were: making more information available about the services of the Medical S o c i a l Service department, p a r t i c u * l a r l y i n the f i r s t week of the medical internes* t r a i n i n g program (t h i s aspect was not included on the questionnaire, but was men-tioned i n the additional comments offered by doctors); and the a l l o c a t i o n of a s o c i a l worker to each ward. I t i s s i g n i f i c a n t that the f i r s t point should have gained such wide support, since the survey was done at the end of the internes 1 t r a i n i n g period when they had already had some opportunity to learn about the work of the s o c i a l service department. I t i s well to remember, however, that the only "formalized" orientation these doctors receive concerning the work of the Medical S o c i a l Service Department i s the information contained i n the Interne's Manual, referred to e a r l i e r , above. The Interne's Manual, compiled i n 1950, contains a section on the work of the Medical Social Ser-vice Department. This b r i e f account i s directed mainly at giving 64 some guidance to the beginning doctor i n recognizing s u p e r f i c i a l signs of anxiety i n the patient, and stresses the importance of early r e f e r r a l of such patients to s o c i a l service. In view of the growth and development of the Medical S o c i a l Service Depart-ment i n recent years, i t would seem desirable that t h i s section of the Interne's Manual be revised and brought up-to-date to give a more adequate interpretation of medical s o c i a l work. The idea of a s o c i a l worker allocated to each ward was seen by some doctors as a d e f i n i t e improvement, i n that the worker would be more r e a d i l y available to the doctor on the ward; also, because i t would be the same worker at a l l times, she could have a greater opportunity of i n t e r p r e t i n g the service of the department oh the wards f o r which she was responsible. On the other hand, some doctors stated that t h i s would be a d e f i n i t e l i a b i l i t y to the medical service, since certain s o c i a l workers appear to have a better approach to certain types of patients and use should be made of t h i s rather than use of one s o c i a l worker f o r a l l the patients on the ward. Again, there i s room f o r more research which would int e r p r e t the various applications of these ideas. Doctors, generally, disapproved of the idea of s o c i a l workers p a r t i c i p a t i n g i n d a i l y ward rounds, and only two i n d i -cated this as a possible means of improving the work of the department. From personal conference with a number of doctors who did not approve the suggestion, i t was learned that the main reason f o r this i s that these rounds are already attended 65 by a number of medical personnel, and the in c l u s i o n of the s o c i a l worker would probably only add to the patient's anxiety and bewilderment at such a "grand parade." A number of i n d i v i d u a l recommendations to improve the work of the Medical S o c i a l Service Department were made by the medical s t a f f . One of these was that s o c i a l service reports to doctors should be made at more frequent i n t e r v a l s when deal-ing with a case, rather than reporting when the case i s closed. Another suggestion was a request f o r s o c i a l service weekly con-ferences available to medical s t a f f , and p a r t i c u l a r l y to the doctor i n charge of the case to be discussed. Case conferences i n the s o c i a l service department are already a regular feature of the weekly s t a f f meetings, but t h i s i s not generally known among medical s t a f f , as indicated i n t h i s survey. The i n c l u -sion of medical s t a f f i n these discussions i s a feature worthy of consideration by the administration of the Medical S o c i a l Service Department, and by Hospital administration generally. Yet another recommendation made was i n the area of helping r e l a t i v e s take greater r e s p o n s i b i l i t y f o r the care of the patient, p a r t i c u l a r l y wives caring f o r t h e i r husbands at home, when the period of active treatment was completed and further hospital care was not indicated. The doctor stressed the invaluable service the s o c i a l worker could give i n help-ing the patient's r e l a t i v e s — p a r t i c u l a r l y the closest ones to gain a sense of appreciation of the patient's need to be 66 part of the family, and his sense of rej e c t i o n at being "abandoned" by his family i f he i s merely l e f t i n the h o s p i t a l . The other f a c t o r stressed was that convalescent f a c i l i t i e s f o r the chr o n i c a l l y i l l are so l i m i t e d even with the ample provisions of the Department of Veterans* A f f a i r s ; consequently, the s o c i a l worker by helping the family accept the patient at home could make the f a c i l i t i e s of the Hospital more available f o r the active convalescent patients and f o r those patients who require i n s t i t u t i o n a l care on medical grounds. CHAPTER 4 RETROSPECT AND PROSPECT: SOME IMPLICATIONS In the preceding chapters of this study an attempt has been made to examine the character of s o c i a l work at Shaughnessy Hospital against the background of developmental history. At the same time, considerable interpretation of , medical s o c i a l work method and function, as i t has developed i n the broader f i e l d , has been given. Throughout the study, those areas of s o c i a l work that are extensively u t i l i z e d i n th i s s e t t i n g have been pointed out through an examination and analysis of case records, and through a survey of doctors' opinions of the e x i s t i n g program of s o c i a l service; at the same time, potential areas f o r fur t h e r development of the program have been c i t e d . I t would be neither p r a c t i c a l nor appropriate to recapitulate the findings: they have been pre-sented p r e c i s e l y and elaborately, i f somewhat c r i t i c a l l y . But there are some obvious implications a r i s i n g from the f i n d -ings, with s p e c i f i c i n t e r e s t f o r the three groups of personnel most d i r e c t l y concerned with an e f f e c t i v e medical s o c i a l work program: s o c i a l work p r a c t i t i o n e r s , medical s t a f f , and admin-i s t r a t i o n . Implications f o r S o c i a l Workers The immediate r e s p o n s i b i l i t y of the s o c i a l worker, as a p r a c t i t i o n e r , l i e s i n bringing to the patient group the 68 most e f f e c t i v e service possible, even within the e x i s t i n g l i m i -tations, of which he may be well aware. The lack of adequate numbers of personnel does not preclude the professional o b l i g a -tion of continuous evaluation of ex i s t i n g procedures and prac-t i c e s , and the refinement of these practices to the end of serving the patient group in an ever-increasingly e f f e c t i v e manner. S p e c i f i c areas f o r desired improvement have been sug-gested by the findings presented i n thi s study. The recom-mendations below are based on these findings, and bear d i r e c t l y on the very core of s o c i a l work: (a) There i s a need f o r improvement of recording techniques i n t h i s s e t t i n g . This includes more dynamic case h i s t o r i e s which show the worker's active p a r t i c i p a t i o n , his diagnostic assessment of the s i t u a t i o n , and the plan of treatment. A systematic reviewing of case records by the i n d i v i d u a l worker can serve a useful purpose i n checking the need f o r continuous services and follow-up of recommendations made to medical s t a f f . F i n a l l y , the value of recording the d i s p o s i t i o n of the case cannot be too strongly emphasized: whether continued casework services can be given or not, i t i s the s o c i a l worker's pro-fessi o n a l r e s p o n s i b i l i t y to record t h i s i n the f i l e with the reasons f o r his decision c l e a r l y indicated. (b) Closer co-operation with medical s t a f f i s encouraged. This recommendation arises primarily from the suggestions made by medical s t a f f , since the degree of co-operation which already exists could not e a s i l y be determined from an analysis of case 69 records, and since i t was not the central focus of t h i s inquiry. (c) I f s o c i a l workers are not to r e s t r i c t t h e i r services to an environmental l e v e l , and to go beyond the s p e c i f i c request made by the doctor at r e f e r r a l , increased i n t e r p r e t a -tion to the medical s t a f f of medical s o c i a l service w i l l be necessary. The patients' problems being what they are, as shown by some of the material assembled i n previous chapters, i t i s c l e a r that some patients need extensive or continued help, and much could be done on the i n d i v i d u a l doctor-worker basis to gain a wider appreciation of such needs. Implications f o r Medical Staff The recent i n c l u s i o n of s o c i a l service programs i n Departmental hospitals i s intended to improve further the quality of medical care f o r veterans, by r e l a t i n g s o c i a l f a c -tors to the i l l n e s s , and by treatment of p a r t i c u l a r s o c i a l problems connected with medical care. While i t i s recognized that the work of making the p a r t i c u l a r services of the Medical S o c i a l Service Department known to the hospital s t a f f i s p r i -marily the r e s p o n s i b i l i t y of administration and of the s o c i a l service s t a f f , the extent to which these services are u t i l i z e d i n behalf of patients depends d i r e c t l y upon the medical s t a f f , who have o v e r a l l r e s p o n s i b i l i t y f o r treatment. At least one point of importance emerges from the material presented i n t h i s study: there appears to be some question as to whether s o c i a l workers i n hospitals concern them-selves with the giving of treatment, or aiding i n the givi n g of 70 treatment. There i s surely no doubt about who i s giving, or di r e c t i n g , the treatment. But, from the s o c i a l work standpoint, i t i s important that doctors, i n t h e i r treatment plans f o r patients, make the f u l l e s t use of available s o c i a l work services to the maximum benefit of the patient, who i s , a f t e r a l l , not merely "a white male1* with a diseased organ, but a human being --an anxious father whose i l l n e s s imposes economic dependency on his family, an e i d e r l y hermit Whose pattern of s e l f - s u f f i c i e n c y i s threatened by i n f i r m i t i e s of old age, a young s a i l o r who has found the d i s c i p l i n e of service l i f e too great a s t r a i n and who has sought escape by se l f - d e s t r u c t i o n . These problems are not l e f t behind when the hospital doors close upon the "patient," as doctors are well aware. Social workers cannot solve a l l such problems, but they can a s s i s t i n solving those that are brought to t h e i r attention, by a careful i n v e s t i g a t i o n of the s o c i a l and personality factors in the p a r t i c u l a r s i t u a t i o n , by an application of special s k i l l s and knowledge of the dynamics of human behaviour, and the appropriate use of available com-munity resources. A second, and more s p e c i f i c recommendation, l i e s i n the area of timing r e f e r r a l s to the s o c i a l service department. I f s o c i a l work services are to be most e f f e c t i v e , r e f e r r a l s must be made as early as possible by the doctor i n charge of treatment, so that the s o c i a l plan may be made on a sound basis, and so that i t might be integrated With the t o t a l treatment plan. 71 Implications for Administration The greatest impetus to the development of the medi-cal social service program within the Treatment Services Branch of the Department of Veterans* Affairs was the recognition of the service at top levels of administration; i t i s ultimately at this level that further improvements can be implemented. In the course of this report many lines of direction have been in d i -cated for the overall future development of the medical social service program at Shaughnessy Hospital. Some of them deserve special emphasis: (a) Continued support of the program for staff development. (b) Extension of social service to the Outpatient Depart-ment on a full-time basis, as soon as there are sufficient per-sonnel • (c) Inclusion of social service staff in the orientation program of medical internes, so that they might be helped to become more aware of what social workers are doing and what they can do. (d) Revision of the section on Medical Social Service i n the Interne's Manual. (e) Support and encouragement of experimentation and pilot research, particularly in the areas of more dynamic recording, and in the allocation of social work personnel. (f) Continued support of close working relationships bet-ween the social service personnel and doctors, and among the various professional bodies and services in the hospital gen-erally: at the same time, there i s a need for closer examination 72 of the possibilities for greater co-ordination of efforts of the treatment team. Conclusion The social service department at Shaughnessy Hospital has maintained a continued program of medical social casework services through i t s early years of development, and has made steady progress in the expansion of services to a l l parts of the hospital* This progress has been made possible through the com-bined efforts of administration, and medical and social service staff. The medical staff at Shaughnessy show a continuing i n -terest in the new service, and are using i t to complement the medical care of patients when they recognize the existence of social problems as obstacles to the medical treatment. Because of the special characteristics of the veterans' patient group, some types of service of the department are used more widely than others, and social work has developed in these areas of service to a greater extent. The greatest use that has been made of social service to the present time, i s as a diagnostic aid and as a f a c i l i t a t i n g service to medical treatment, but there i s much room for the development of social work as a direct treatment service. It would obviously be desirable to have the medical social service department used in a l l capacities. This i s being gradually realized as the staff of the department i s increased to make services more available generally, and as there i s greater interpretation of the existing and potential services that medical social workers can give. But there i s plenty of 73 room for further interpretation, sharing in planning, possible research or experimentation projects for the development of new areas of social services in this hospital, and research which w i l l further c l a r i f y some of the pros and cons of existing ser-vices and the opinions of the various professions and practi-tioners in the veterans' hospital teams. It i s reasonable to hope that some of these areas and possibilities have been opened up by the present study. A P P E N D I X APPENDIX A: LINES OF PROFESSIONAL RESPONSIBILITY TREATMENT SERVICES BRANCH, DEPARTMENT OF VETERANS AFFAIRS Minister Department of Veterans* A f f a i r s Deputy Minister Director General Treatment Services Director Medical Soc-i a l Services O T T A W A iLaaaaaaBai S H A U G H N E S S Y H O S P I T A L B a a a a a a a a a a a a a a a B Hospital Administrator Senior Treatment Medical O f f i c e r (Hospital Superintendent) Education" Research Assistant Superintendent A u x i l i a r y Services C L I N I C A L S E R V I C E S I h i e s -Medicine T Surgery Radiology Dentistry pathology thesia Eye, Ear, Nose and Throat Services Internal Medicine T Int. Med. (T.B.) T Derma-tology T Neuro-logy Psychiatry physical edicine i . I i e d i c a l Social Service APPENDIX B: D.V.A. HOSPITALS AND INSTITUTIONS Type of Hospital and Location Operating Social Work Capacity Staff (a) 1. Active Treatment Hospitals 9082 Camp H i l l Hospital, Halifax, N.B. ~T%0 Lancaster Hospital, P a i r v i l l e , N.B. 450 Veterans* Hospital, Quebec, P. Q. 275 Queen Mary Veterans* Hospital, Montreal, P.Q. 700 Ste. Anne*s Hospital, Ste. Anne de Bellevue, P.Q. 1135 Sunnybrook Hospital, Toronto, Ont. 1650 Westminster Hospital, London, Ont. 1522 Deer Lodge Hospital, Winnipeg, Man. 850 Veterans* Hospital, Saskatoon, Sask. 125 Colonel Belcher Hospital, Calgary, Alta. 425 Shaughnessy Hospital, Vancouver, B.C. 1100 Veterans' Hospital, Victoria, B. C. 300 2. Active Convalescent F a c i l i t i e s RIdgewood H & O Centre,an saint,John, N.B. (Lancaster) Veterans' H & 0 Centre, Senneville, P.Q. (Ste. Anne»s) Rideau H & 0 Centre, Ottawa? Ont. Divadale H & 0 Centre, Leaside, Ont. (Sunnybrook) Veterans' Convalescent Hospital, , Calgary, Alta. (Colonel Belcher) George Derby H & 0 Centre, Burnaby, B. C. 3.Special Institutions Veterans' Hospital, St. Hyacinthe, P.Q. Western Counties Veterans* Lodge, London, Ont. (Westminster) 4.Institutions Designed Primarily for Veterans' Care Cases , The Red Chevron, Toronto , Ont. 1 Bellvue Veterans* Home, London, Ont. Veterans' Home, Winnipeg, Man. (Deer Lodge) Veterans' Home, Regina, Sask. Veterans* Home, Edmonton, Alta. Hycroft, Vancouver, B.C. (Shaughnessy) A A 215 200 200 A 327 30 A 62 70 A 40(7) 1 2 8(1) 4 7 4(3) 3(1) 1 7(1) 1 2 ( 1 ) 2 T T T (a) Vacancies at this date shown in brackets A The Operating Capacity for these institutions i s included in the figures for the Hospital shown in brackets AA H & 0: Health and Occupational Centre Source: Compiled from D.V.A. Head Office Monthly Statistics Reports. APPENDIX C. D.V.A. TREATMENT CATEGORIES (As at A p r i l , 1953) Section D e f i n i t i o n 5 5 6 6 6 6 6 6 6 6 7a 7b 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Pensionable D i s a b i l i t y - Active Treatment Sequelae of Pension - Venereal Disease North West F i e l d Force - 1885 Pension Section 48 or 49 of the Pension Act Pensionable D i s a b i l i t y - Newfoundland Merchant Seamen, A u x i l i a r y Service Personnel, F i r e Fighters (Overseas), A i r Raid Wardens, Voluntary Aid Detachment Personnel, C i v i l i a n Government Employees (Wartime) Special Operator (Overseas A i r Crew) Injured on F l i g h t Duty Red Cross and Welfare Workers in the Far East Non-Permanent Active M i l i t i a and Reserve Army Personnel Newfoundland Special awards Permanent Force and R.C.M.P. f o r Poor Condition H o s p i t a l i z a t i o n f o r Pensioner i n J a i l Treatment within 30 days of Discharge: D i s a b i l i t y e x i s t i n g at that time Trainees Permanent Force: D i s a b i l i t y e x i s t i n g at time of Discharge War Veterans' Allowance Cases requiring active remedial treatment Veteran earning less than $900 ( s i n g l e ) ; $1800 (married) For Psychiatry I n s t i t u t i o n a l or Custodial Care of non-pensionable Venereal Disease Pensioner when uncertainty e x i s t s on Diagnosis Staff - Infectious Disease Case Persons referred by the Department of National Defence Persons referred by the Royal Canadian Mounted Police On request by f i n a n c i a l l y responsible authority On request of any department of the Government of Canada At the request of Imperial or other A l l i e d Government Under P r o v i n c i a l Hospital Insurance (Veterans only) Too i l l to turn away. Admitted and charged. In h o s p i t a l . Diagnosis changed to non-eligible condition H o s p i t a l i z a t i o n f o r Research Purposes Pensions Medical Examination - f o r observation Quarters and Rations f o r Pensions Medical Examination; f o r D.V.A. examination i n reference to prosthetic appliance; f o r examination required by War Veterans 1 Allowance Board; f o r examination of Prisoner of War I n s t i t u t i o n a l Care Source: Compiled from D.V.A. Treatment Regulations as contained i n The Veterans Charter and Amendments. APPENDIX D. FUNCTION OF MEDICAL SOCIAL SERVICE IN D.V.A. HOSPITALS (As stated i n D.V.A. Treatment Instruction Letter No. 1 - 1949) (A) i ) To provide s o c i a l casework services to in d i v i d u a l patients as part of the medical team of which the doctor i s the leader. i i ) To provide medical s o c i a l consultation services to others giving service to the veteran. i i i ) To a s s i s t i n the development of community understanding and aid to the sick and disabled. i v ) To partic i p a t e i n the teaching program of the h o s p i t a l . v) To a s s i s t research programs which have medical s o c i a l implications. (B) Because of the d i v e r s i t y of the services within the department i t seems advisable at t h i s time to outline s p e c i f i c a l l y to whom and under what circumstances such casework service may be given. (C) Individualized service, (including casework with the patient and/or his family, preparation of s o c i a l h i s t o r i e s , securing of other pertinent information, r e f e r r a l to the community f o r service) may be given, under medical d i r e c t i o n , to the following; i ) any patient, veteran or non-veteran, under departmental medical care i n hosp i t a l or as an outpatient whose personal or s o c i a l problems are related to his i l l n e s s or d i s a b i l i t y . i i ) any person referred to Treatment Services f o r medical assessment, diagnosis or treatment, where the doctor desires s o c i a l information or where he requests that casework ser-vice be provided. i i i ) patients discharged from Hospital or Outpatient care where requested service has not been completed or where, i n the opinion of the doctor concerned, continued service w i l l add to the e f f i c a c y of the treatment given, or materially lessen the l i k e l i h o o d of recurring i l l n e s s . i v ) veterans where the follow-up care, or securing of medical s o c i a l data, i s requested by Treatment Services i n connec-tion with some special study or research project. (D) I t i s understood that the medical s o c i a l worker w i l l c a l l on the assistance of other departmental and community services i n meeting the needs of the patient and his doctor, when, i n the opinion of the doctor concerned, i ) the value of the requested service w i l l not be materially lessened by channeling through someone else, and i i ) the service requested i s i n l i n e with the po l i c y and func-tion of the department or community service to whom the request i s made. APPENDIX E: QUESTIONNAIRE USE OF MEDICAL SOCIAL WORK SERVICES SHAUGHNESSY HOSPITAL In co-operation with the Medical S o c i a l Service s t a f f I am study-in g a group of cases! i n which s o c i a l services were requested as an aid to the medical care of patients. I t would be very h e l p f u l to have some suggestions from the medi-c a l s t a f f as to what aspects of s o c i a l services are most useful i n f a c i l i t a t i n g medical care. Your answers to the following questions and any other comments you might make w i l l provide a valuable source of reference f o r my study. A.N. Barsky U.B.C. School of S o c i a l Work 1. Do you f i n d the w r i t i n g of r e q u i s i t i o n s a convenient method of r e f e r r a l to Medical S o c i a l Service? Yes No As an a l t e r n a t i v e , do you prefer any of the following? telephone t m m_ m discussion with the s o c i a l worker m m m m m sending patient to the S o c i a l Service o f f i c e Other 2 . What kinds of s o c i a l information do you f i n d most useful? m m m m patient's family and s o c i a l r e l a t i o n s h i p s m m m m m employment h i s t o r y m m m m m economic status _ _ patient's plans on discharge m m m m m his reaction to his i l l n e s s m m m m m home and community resources f o r his use Other, 3. For what reasons do you most frequently make r e f e r r a l s to Medical S o c i a l Service? m m m m m s o c i a l history _j assistance i n planning convalescent care helping r e l a t i v e s towards a better understanding of the patient's i l l n e s s and his needs _ _ to help ameliorate patient's anxieties and fears m m m m helping patient towards r e h a b i l i t a t i o n planning m m m m m i f o r f i n a n c i a l assistance .m helping patient modify unfavorable attitudes towards the community on his return hone. Other •, 4. What suggestions would you make to improve the work of the Medical S o c i a l Service Department? — m o r e information available about the services of MSS , closer co-operation between MSS s t a f f and doctors w m m m m m m a s o c i a l worker allocated to each ward 9  m m m m m a s o c i a l worker available i n O.P.D, p a r t i c i p a t i o n by s o c i a l worker i n d a i l y ward rounds Other.•, ••••••••••••••••;•••••••••;•••»••••••. Other Comosnts (Please use reverse side i f necessary)............. APPENDIX P: SOCIAL SERVICE INFORMATION FOR MEDICAL INTERNES (As given i n the Interne's Manual. Shaughnessy Hospital, 1950). Medical S o c i a l Workers a s s i s t patients and t h e i r fami-l i e s to develop and use t h e i r personal capacities to deal with problems i n t h e i r s o c i a l environment. They work as part of the treatment team with the physician as i t s leader. Referrals to our Department may be i n s t i t u t e d by anyone but medical s o c i a l case work service i s never commenced p r i o r to consultation with the doctor i n charge of the patient. Our Department i s primarily concerned with what the patient's i l l n e s s and i t s implications means to him and h i s family and ways i n which they may be helped to work through t h e i r f e e l -ings about i t . The following are a few examples of patients e x h i b i t i n g types of behaviour which could be referred: (1) The tense, anxious, bewildered or even the "good" patient, who i s not responding to treatment. Such people may be disturbed about — t h e i r own p a r t i c u l a r illness...home worries...prolonged h o s p i t a l i z a t i o n with a l l i t s i m p l i c a t i o n s . . . c r i p p l i n g or disfigurement...surgery...their fam-i l y ' s or the community's attitude toward them with t h e i r i l l n e s s . . . f e a r of leaving the protective environment of the hospital...death. (2) . The b e l l i g e r e n t patient who p e r s i s t s i n going A.W.L., indulges excessively i n alcohol...refuses to co-operate... disregards r e g u l a t i o n s . . . w i l l not adhere to his d i e t . Referrals may be made by completing a blue form located on a l l wards, the 514A, or, i n case of emergency, a telephone c a l l to our o f f i c e s . An early r e f e r r a l i s appreciated i n order that we with you, and possibly one of the community agencies, may a s s i s t the patient to work through h i s anxieties to the point where he once again may accept and benefit from medical services provided f o r hi s treatment and convalescence. BIBLIOGRAPHY Books B a r t l e t t , H a r r i e t M., Some Aspects of S o c i a l Casework i n a  Medical Setting. The Committee on Functions, American Association of Medical S o c i a l Workers, Chicago, I l l i n o i s , 1942. Binger, C a r l , The Doctor's Job. Morton, New York, 1945. Cabot, Richard, S o c i a l Service and the Art of Healing. Dodd. Mead, New York, 1923. 6 Cannon, Ida M., On the S o c i a l F r o n t i e r of Medicine. Harvard University Press, Cambridge, 1952. . S o c i a l Work i n Hospitals. Russell Sage Founda-t i o n , New York, 192T. Cannon, Walter B., The Wisdom of the Body. Norton, New York, 1952. Dunbar, Flanders, Emotions and Bodily Changes. Columbia Univ e r s i t y Press, New York, 1946. „ Mind and Body; Psychosomatic Medicine. Random House, New York, 1942. English & Weiss, Psychosomatic Medicine. W.B. Saunders Co., PhiladelphlaTTSBn Fink, Arthur E., The F i e l d of S o c i a l Work. Henry Holt and Co.. New York, 194?: Hamilton, Gordon. Theory and Practice of S o c i a l Case Work. Columbia University Press, New York, 1952. P r i n c i p l e s of S o c i a l Case Recording. Columbia University Press, New York, 1946. Psychotherapy and Casework. Symposium of the Boston Psychoanalytic Society and I n s t i t u t i o n Incorporated. S o c i a l Casework. June, 1946. Richardson, Henry B., Patients Have Families. Commonwealth Fund. New York, 1945. Robinson, George C , The Patient as a Person. Commonwealth Fund. New York, 1939. Segsworth. Walter E., Retraining Canada's Disabled Sold iers. King's P r i n t e r , Ottawa, 1920. Upham, Francis, A Dynamic Approach to I l l n e s s . New York Family Service Association of America, New York, 1949. A r t i c l e s . Documents, Publications, etc. American Association of Medical S o c i a l Work, BA Statement of  Standards to be met by S o c i a l Service Departments In  Hospitals and C l i n i c s . w June, 1949. Canada, Department of Veterans' A f f a i r s , Treatment Instruction L e t t e r No.14-49: Co-operation Between Medical S o c i a l Service  and S o c i a l Service D i v i s i o n . 1949. , Treatment Instruction  L e t t e r No.1-49: P o l i c y of Medical~Social Service. 1949. . Casualty Welfare O f f i -cers' Manual. King's P r i n t e r , Ottawa, Revised 1950. Canada, Department of S o l d i e r s ' C i v i l Re-establishment. Canada * s  Work f o r Disabled S o l d i e r s . "The Medical Services: 'Social Service Workers. 1" King's P r i n t e r , Ottawa, 1919. C o c k e r i l l , Eleanor, "New Emphasis on an Old Concept of Medicine," Journal of Social Casework. January, 1949. Clarke, Mary A., "Social Work i n Uniform," The Social Worker. Canadian Association of So c i a l Workers, Ottawa, June, F 9 4 5 . Chisholm, Brock, "Organization f o r World Health," Mental Hygiene. July, 1948. C o l l i e r , Elizabeth A., The Social Service Department of Vancouver  General Hos p i t a l . 1950 M.5.W., U.B.C. Emery, Charlotte E., "Case Work i n the Navy," The S o c i a l Worker. Canadian Association of So c i a l Workers, Ottawa, June, 1945. Pahrni, Brock M. et a l , "The Functioning of an Assessment and Rehabilitation Unit." Department of Veterans' A f f a i r s  Treatment Services B u l l e t i n . Ottawa. July-August. 1953. F i e l d , Minna, "Role of the So c i a l Worker i n a Modern Hosp i t a l . " S o c i a l Casework. November, 1953. H i l l , Ruth, "Focusing Attention on Older People's Needs." Soc i a l Casework. V o l . 30, 1949. Laycock, J.E., "Developments i n Army Soc i a l Service." The S o c i a l  Worker. Canadian Association of S o c i a l Workers, Ottawa, June, "1945. Margolis, J.M., "The Biodynamic Point of View i n Medicine." Journal of S o c i a l Casework. January, 1949. Selye, Hans, M.D., "The Adaptation Syndrome i n C l i n i c a l Medicine." The P r a c t i t i o n e r . January, 1954. Shedlov, Abraham et a l , "Medical-Social Screening of Applicants to a Domiciliary Unit." S o c i a l Casework. January, 1954. Warner, W. P., "Relationship Between Government Medical Services and the Canadian Medical Profession." Department of Veterans' A f f a i r s Treatment Services B u l l e t i n . December. 19W. Woods, W a l t e r s . , "Canada's Rehabilitation Program." Department of Veterans' A f f a i r s . Treatment Services B u l l e t i n . May. 1948. 

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