Social Work in Hospitals: A Contribution to Progressive Medicine

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Preface

IN THE winter of 19 12 I had the interesting opportunity of visiting most of the hospital social service departments in this country. At that time I was impressed by the variety of types of organization, by the diversities in the interpretations of the hospital social worker's function, and by the great need for more adequately trained workers. In every department the paid workers were women. It was interesting to note, however, that in some instances men — especially medical students — ^were being drawn into volunteer service. I was even more impressed with the widespread interest that I found among physicians, hospital authorities, and lay people, in this new conception of the hospital's social responsibilities. If hospital authorities and physicians are persuaded that social work is needed as part of thorough treatment of the sick, surely the workers, in spite of their handicaps in training, in spite of the lack of standardization in their case work and in their organization, are meeting, nevertheless, a real need. Every department I visited seemed to me pervaded by a genuine spirit of service. Eagerness for information concerning all phases of the hospital's social problems was also

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PREFACE

notable among those actually engaged in the work. This very general desire and evident need for exchange of experience and for a more conscious and consistent effort to establish standards, has made it seem worth while to present this preliminary survey of the present status of hospital social work.

Suggestions have come to me from workers in various existing departments and from an interesting personal experience. To make acknowledgment to all who are responsible for material presented in this book would be impossible. The material has come to me in some instances unconsciously, but more often with the most generous spirit of helpfulness from hospital social workers, from physicians and institution executives, and also from many other friends of social service, — afnong them the patients themselves.

1 am indebted to my sister, Cornelia James Cannon, and to Miss Elizabeth V. H. Richards, Head Worker of the Social Service Department of the Boston Dispensary, with whom many of the subjects in this little book have been discussed.

Especially am I under obligation to Dr. Richard C. Cabot, whose stimulating leadership I have enjoyed for six years. He has read the manuscript and made invaluable suggestions. I am indebted also to Miss Mary E. Richmond, without whose stimulus and interest the book would not have been attempted.

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Table Of Contents

PAOB

Preface vii

List of Forms xi

Chapter I Introductory

THE hospital social service movement aims to throw a new light on medical practice in our institutions. It seeks to understand and to treat the social coriiplicationsof disease by establishing a close relationship between the medical care of patients in hospitals or dispensaries and the services of those skilled in the profession of social work. It strives to bring to the institutionalized care of the sick such personal and individual attention to the patient's social condition that his recovery may be hastened and safeguarded.

The physician recognizes physical symptoms and seeks for the underlying causes of disease. The skilled social worker recognizes social symptoms of human distress and also seeks their underlying causes, that she may the more wisely help. Our large charity hospitals and dispensaries shelter many who need both kinds of aid. The services of doctor and social worker then become interdependent, just as the physical and social conditions of the patient himself are interrelated. This interdependence of medical and social work, not

only in treatment but also in seeking for causes of

I disease, the hospital social service movement is emphasizing. It seeks to find the common ground of medicine and sociology and to relate most effectively the functions of the doctor and the social worker.

As a cause, and also as a result of social distress, disease is a large factor in the plight of those who become dependent on public and private charity. Mr. Devine says* that inquiry into the physical condition of members of the families that ask for aid — ^without for the moment taking any other complications into account — clearly indicates that either as the chief cause or as a complication due to the effect of other causes, "physical disability is ... a very serious disabling condition at the time of application in three-fourths . . . of all the families that come under the care of the [New York] Charity Organization Society." Thus the lessening of disease is of importance not only for health and comfort, but for economic welfare and social progress. This fact makes hospital social service a particularly significant feature of constructive social work.

As hospital problems are social as well as medical, two expert professions, not one alone, are needed. Yet only in the last few years have the medical and the social worker been able to aid each other. Only within that period have they been able habitually to meet as experts, each

* Devine, Edward T.: Misery and Its Causes, p. 54. New York, The Macmillan Co., 1909.

INTRODUCTORY

teaching and each learning from the other: both united to serve the patient and the community. Both groups must recognize a common ground before they can reach a mutual understanding. So we find gradually developing this sympathetic interweaving of effort by tWo professional groups that for a time struggled separately with the problems of the sick and dependent in the community.

Since the beginning of the hospital social service movement in 1905 there have been started in the United States over one hundred social service departments in hospitals and dispensaries. Extensive as the interest has become we are not, after so short an experience, justified in dogmatizing about either the function of the hospital social worker or the proper organization of the work. We are still pioneers. Our field is only beginning to be surveyed. All the experience gathered so far must be considered as experimental material. Nevertheless, out of it we may at least develop some ideals. A few fundamenfal principles have been evolved. Not only has it been demonstrated that medical and social interests are closely interrelated, but also their technique, — neither can reach a high quality without similar excellence in the other.

* The social worker may destroy the value of a doctor's prescription by a faulty social diagnosis or treatment, and a doctor may no less effectively vitiate an excellent social diagnosis or treatment.

A patient for whom a back brace was ordered by an orthopedic surgeon was found subsequently by a social worker to be starving herself to pay for the brace. Later a general physical examination showed that she was suffering from pernicious anemia. One thing is certain: a patient with pernicious anemia does npt need to starve herself for a back brace; she Will die soon enough without that. Another patient, markedly debilitated, came to the hospital for a tonic, but received little benefit from the physician because she was struggling to care for herself and young son on the J4.50 a week provided by a relief society.

Between the two extremes there are many dangers of ineffectiveness in what is being done for the patient or with the patient, if a high standard of work is not sustained. Not every hospital can make the most effective use of the medical-social worker even though the latter be an expert. For if the social worker is to help make treatment effective^ good medical work is the prime necessity, I f medical diagnosis is vague or faulty, no social work, however expert, can compensate for it. Hospital social service, as part of efficient medical practice, can develop, therefore, only in institutions where the medical work is really and constantly of a high grade. In short, to be effective, medical-social work demands two things: constructivle medical work and constructive social work.

In the pages that follow an attempt has been made, not to present a text-book on hospital social

INTRODUCTORY

work, but to offer an interpretation of what the movement means to some of those most closely in touch with it. This is no time for dogmatic statements. The essential thing for any new movement is that its leaders, while firm in the conviction that a fundamental truth is being carried forward, should still be open-minded and plastic enough to fit it gradually into its place of greatest usefulness.

Chapter II The Beginnings Of Hospital Social

SERVICE

THE spirit of service to the sick is not new. Indeed, the care of the sick has been an unfailing expression of human kindliness since the dawn of Christianity. Early in the Christian Era, the care of the bodies as well as of the souls of men was recognized as a duty of the church. Hospitals were established and nursing orders arose as a practical expression of the religious zeal that glorifies unselfishness. Victims of sin and sufi'ering were sought in their wretchedness and served with tender, sympathetic devotion. Throughout the history of hospitals and the history of the Christian Church the spiritual welfare of the sick has claimed the attention of the clergy, and no hospital today is without their ministrations.

In our modern hospitals also there are many persons who recognize that the patient's needs are not entirely physical, and who contribute their share of cheer and comfort to the sick. Volunteer committees of women have for many years visited

patients in the wards of various institutions and extended their friendly offices. Busy doctors and nurses have done countless unrecorded acts of kindness not demanded by the requirements of their professional duties. Thus, the patient's spiritual needs and his dependence on sympathy and affectionate interest have long been recognized both in theory and in practice.

There are, however, some fundamental differences between these intramural attentions and the hospital social service which we are to consider. Formerly, neither the priest nor the friendly visitor co-operated closely and constantly with the doctor inside or with the social workers outside the hospital. It has remained for the medical-social workers of the present day to supplement the function of the unofficial visitors with a fuller consideration of the patients' needs, and with a form of service that is now accepted as an important element in thorough medical treatment.

Four important contributions have been made to the development of this new hospital social service, which, however, is quite different from any of them: first, by the society for the after care of the insane in England; second, by the lady almoners in London hospitals; third, by visiting nursing in its various forms; fourth, by the methods of social training given medical students in the Johns Hopkins Hospital.

The first of these contributions dates back to about 1880. The problem of the insane is a peculiar one, yet the principles on which the after care 2 7 of the insane was developed in England are of more than ordinary significance to general medical-social service. The object of the English organization known as the Society for After Care of Poor Persons Discharged Recovered from Insane Asylums is to arrange for the care of discharged patients, — especially those who are homeless, — and to keep friendly oversight during the process of their readjustment to community life. This was always done in close co-operation with the medical superintendent of the asylum. The excellent work of this society was the stimulus for similar work in connection with the New York state hospitals for the insane. The sub-committee on the after care of the insane, of the State Charities Aid Association of New York, was formed about the same time that the hospital social service movement started in this country. The work of this committee has been of such value that the plan has been adopted in connection with hospitals for the insane in many other states.*

The second and probably most important contribution to hospital social service comes from the reorganization of the work of the lady almoners by Mr. C. S. Loch of the London Charity Organization Society. The almoner is an old institution in many of the English hospitals. Mr. Loch saw possibilities of increased usefulness in the almoner's function and presented his suggestions for a new

* See State Charities Aid Association of New York, Fourteenth Annual Report, Nov. i, 1906. Also later reports of its Sub-committee on After Care of the Insane.

J interpretation of her work in a paper published in London in 1892.*

"People talk of medical charity as if it were a thing apart, unlike all other forms of charity, to be regulated by no principles, to be bettered by no co-operation with others. . . . What more glaring picture of charitable impotence is there than that destitute persons should constantly apply to a free dispensary for drugs which cannot benefit them if they lack the necessary food? Or that, in the same illness they should go from one out-patient department, free or even part-pay dispensary, to another without any heed being paid to their actual conditions? To be effectual, even to be equitably administered, medical charity must act in alliance with general charity. Their cause is one. Their difficulties are very similar. Each will succeed better with the help of the other."

How to prevent the abuse of medical charities by those able to pay, has long been a puzzling problem for hospital boards and social workers. Mr. Loch saw in the almoner a means of checking that abuse. But in practice the lady almoner's function soon grew to be much wider than that of mere "inquirer." The first lady almoner was appointed in 1895 at the Royal Free Hospital in London in accordance with a plan outlined by Colonel Montefiore and Mr. Loch in 1890. Their

* See Nineieentb Century, Vol. XXXII, pp. 303-304.

plan as presented to the Select Committee of the House of Lords in 1890 was as follows:

"There should be appointed in every medical charitable institution a distributer or referer of patients, who should see the patients after they have been seen by the medical officer, and who, subject to the requirements of the hospital from the point of view of medical instruction or gravity of illness, should decide as far as possible on the statements of the petitioners for relief, and also as a rule, by a reference of the case to a charity organization committee or some proper local organization."

The lady almoner was then to decide whether the patient's social condition indicated that both medical and social relief were more suitable under poor law provision, or whether he had best be cared for at the private hospital to which he had applied, or whether he ought to provide for himself by going to a private practitioner. "On this plan, each applicant at the hospital would receive relief on his first visit, if necessary; medical requirements, from the point of view of education, would be met ; the social circumstance of the patient would be taken into account, no less than the medical; and other than medical relief would be forthcoming for those that require it."

In England the hospital was conceived as a link in the chain of charitable institutions and organizations, and. the lady almoner was regarded as the

expert ready to bring to the hospital problems a knowledge of the community resources and a mind trained in the methods of social work. The lady almoner has been described by the secretary of a London hospital as "a lady who has had a period of training in social questions generally, and especially in the various organizations of charitable help. She knows all about Labor Bureaus, Emigration Societies, Sick Room Aid Societies, Prevention of Cruelty to Children Societies, Discharged Prisoners Aid Societies, Home Nursing Associations, Convalescent Homes, Societies for the Prevention of the Spread of Phthisis, Provident Dispensaries, Poor Law Infirmaries, Apprenticeship Associations and so on."* In 1905, the year in which the first social service department was established in the United States, many of the London hospitals had the services of the lady almoner.

It is difficult to measure how much the work of the visiting nurse in all her varied services has contributed to the hospital social service movement. She was an accepted part of medical care in the homes of the sick poor long before the typeof hospital social service which we are considering was established. Though trained in a hospital, she found visiting nursing so different from what she had learned in the hospital wards, that she was more and more in need of social knowledge. Her function was first conceived as distinctly medical ;

* British Medical Journal, Feb. 5, 19 10.

f but she has been forced to add much social knowledge to her medical training.

The form of service which most resembles hospital social work — though it is quite distinct in function — is that of the visiting nurse attached to a hospital and a dispensary. Sometimes the nurses visit dispensary patients or those who are discharged from the hospital, in order to extend or finish the medical work of the institution. Many general hospitals and maternity hospitals, as well as tuberculosis dispensaries and milk stations for babies, maintain visiting nurses for this type of work. Not only in connection with dispensaries and hospitals but also with social settlements has the visiting nurse found a useful field of service.

Somewhat difi^erent in its purpose is that form of visiting nursing typified by the extramural work done in connection with the nurses' training school at the Presbyterian Hospital in New York, and designed to broaden the training of the nurse. In 1904, student nurses attended by an instructor began to visit the homes of the hospital and dispensary patients and were "taught to give nursing care, to improve hygienic conditions, and to aid and encourage the patients by kindness and helpful advice." Thus, patients who leave the hospital while still needing surgical dressings are kept under supervision. Tuberculous patients, sick children, and others receive hygienic instruction and are kept in touch with the dispensary physicians. With an increasing recognition of the need for social work in connection with this medical service, a special nurse was appointed in 1907 to supervise the social aspects of this part of the nursing instruction. This course in visiting nursing is elective and the term of service is two months.

The visiting nurse during the last fifteen years has helped to demonstrate the value of extending the services of the medical institution into the home. As a result of her struggle with such problems as tuberculosis and infant mortality, she has also helped to call attention to the common field of the medical and the social worker.

The most significant contribution to the early development of hospital social service in the United States was made by Dr. Charles P. Emerson, who in 1902 organized a group of medical students for social training. He recognized that truly effective medical training must include an understanding of the background of the patients' lives and something of their standards of living. Dr. Emerson describes the development of his work as follows :*

" It was partly to aid their education that seven years ago (1902) some of the medical students of the Johns Hopkins University organized the first student board of the Charity Organization Society of Baltimore. They visit one poor family or at most two families, assigned them by this society, for weeks, months, or even for four years. They do what they can to improve conditions in those

* Emerson, C. P.: A Social Service Department of a General Hospital. National Hospital Review, Mar. 15, 1909.

households. No effort is made to select for these students, families in which there is sickness. The students learn how the poor man lives, works, and thinks; what his problems are; what burdens he must bear. They learn the intimate relationship between the ills of the physical body and the home environment. They also learn how easy it is to give very good advice which will add burdens which cannot be borne. They find out that the poor man is not always a self-convicted sinner nor a self-confessed ignoramus, and that he has his own ideas as to the necessity, and especially as to the possibility, of his following advice. The poor man loves his vices as truly as does the rich man, and will not abandon them at the off-hand suggestion of a strange doctor. The students find that to effect a much needed reform, e. g., to keep the windows open, they must win first the confidence, next the love of the poor patient, and then stick to him closer than a brother to prevent relapses.

" In five years there were on the rolls of active volunteer workers of the three students' boards over sixty students, or one-quarter of the entire enrollment of the school. They do not meet in the hospital but in the offices of the Charity Organization Society. The reason for this was that every member of the self-appointed committee which guided this work was connected with the hospital and was also a manager of the Charity Organization Society; hence no conflict between these two interests could arise. All the patients at this hospital who seemed to need special social service were referred directly to this society, but the most interesting and the best cases for the students to study are not these medical cases. This organized student work, with its purpose of training doctors in social service is, we believe, a very important department of the hospital."

Dr. Emerson's valuable work differed from the present social service in hospitals in that he was aiming to educate medical students, not primarily to serve hospital patients. His students visited many who were not sick and paid no especial attention to the clinics.

These four expressions of social interest were to be found in varying degrees in many hospitals previous to 1905. That year, however, saw the first organization of a social service department in a dispensary and the beginning of the present spread of enthusiasm for trained social work in medical institutions in the United States. It is well known that to Dr. Richard C. Cabot of Boston is due the credit for introducing the social worker as a factor in hospital and dispensary treatment. Not alone for the sake of the patient's spiritual welfare, not for the training of medical students, nor for the instruction of nurses, nor simply for the extension of medical care into the homes was this form of work created. Rather was it conceived by a physician who, in seeking the improvement of dispensary practice, found in the social worker a potent means for more accurate diagnosis and more effective treatment. Miss Garnet I. Pelton, the pioneer hospital social worker, helped to lay the foundation of the first social service department, — ^that at the Massachusetts General Hospital.

Hospital social service as we are to discuss it in this book brings into consideration a worker whose function is not distinctly medical. While she must have an understanding of the patient's physical condition, the physical condition is only one aspect of the patient of which she must take account. As the doctor sees the diseased organ not isolated but as possibly affecting and being affected by the whole body, so the hospital social worker sees the patient not merely as one unfortunate person occupying a hospital bed but as belonging to a family or community group that is altered because of the ill health of one member. The physician and nurse seek to strengthen the general physical state of the patient so that he can combat his disease. The social worker seeks to rally to the disturbed social condition the forces of reinvigoration within him and within his environment. Thus the hospital social worker finds in the hospital an opportunity for supplementing and reinforcing medical service. Wherever hospital social workers have been able, for the sake of thorough, effective treatment, to relate their efforts most closely to those of the doctors, nurses,

and hospital authorities on the one hand, and to

i6 outside social agencies on the other, they have found their greatest usefulness. They have demonstrated that there is in medicine a place for trained workers who devote themselves to the study and understanding of social disasters, which, no less than physical disease, disturb and cripple human lives.

I have said that the spirit of service to the sick is not new. Before proceeding to those practical details of medical-social work with which this book is especially concerned, it may be well to turn back to the hospital and nursing background against which all these details must be measured and without which their relation to progressive medicine cannot well be understood.

CHAPTER 111 THE HOSPITAL BACKGROUND

THE story of the Christian nursing orders, down to the organization of the Sisters of Charity under St. Vincent de Paul, is one of devotion and service to the sick which we may never hope to surpass, however much we may excel those earlier workers in scientific medical knowledge. Yet in the last quarter of the eighteenth century, John Howard, in reporting the conditions he found in the prisons and hospitals of England and France, revealed a black page in the history of medicine and nursing. His story not only disclosed the ignorance and superstition that shrouded much of the medical practice of that day but also described institutional conditions so unsanitary as to be revolting, and personal care of the sick so incompetent as to be intolerable.

The picture that he drew is in striking contrast not only with the hospital of today but also with some of the earlier types of hospitals in which the dependent as well as the sick were welcomed and treated with tenderness and skill. The reforms in medical service for which Howard pleaded and

to which the Fliedners of Kaiserswerth, and later,

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Florence Nightingale, made such valuable contributions, demanded just such vigorous measures as we see in the semi-militarism of the modern training schools for nurses.* Coincident with the reforms in nursing came marvelous changes in medical science. Out of all this has evolved the modern hospital, complex and technical, prepared to care for physical ills through the help of the specialized, scientifically trained physician and nurse.

Diverse factors have contributed to the increased mechanical efficiency and the growing popularity of hospitals. The administration of anaesthesia, the application of asepsis, the laboratory as a diagnostic factor, the larger use of such therapeutic measures as X-ray, hydrotherapy. Zander exercises, massage — all the modern refinements of medicine, surgery, and nursing and the team-work thereby necessitated — accent the economy of grouping many forms of medical treatment in an institution. The dangerously rapid enlargement of our cities, with the attendant overcrowding in wretched tenements, the poverty, weakened vitality, and accompanying disease, necessitates hospital treatment for an increasing number of people not well cared for at home. Another factor which contributes to an increasing attendance at hospitals is the diminishing prejudice against them. The public sees constant evidence

* See Nutting, M. Adelaide, and Dock, Lavinia L.: A History of Nursing, Vol. I, pp. 203, 205, 506, 508, 517, 524. Also Vol. II, Chapter I. New York, G. P. Putnam's Sons, 1907.

of the improved care of the sick. The attitude of the mother who leaves her child in the hospital is now less often one of despair than of hope. Patients who have been treated with kindness and skill have helped to establish in the community a justified confidence in the hospital. Such confidence has, of course, contributed to greater demands on the capacity of the hospitals. Again, the experience which medical students have in the wards frequently influences them, when they become physicians, to seek the advantage of institutional care for their private patients.

During the rapid material expansion of hospital accommodation, the attention of the institution officers and trustees has quite naturally been concentrated on the economic and quasi-military aspects of the organization and on the problems of properly housing and caring for the large numbers of patients applying for admission. But with the enlargement of the hospital and the increase in administrative work has come a division of function. The technique of administration developed in the business world has, in recent years, been more and more applied to medical institutions. Details of the management of a hospital, such as the investment of funds, purchase and distribution of supplies, employment and supervision of the large corps of employes, care of the plant, running of the laundry, providing of food, regulation of the dietary, and bookkeeping, have necessitated careful business organization. This has largely engaged the attention of superintendents and trustees. They have been setting their house in order and have had little time to study its environing and supporting public. The medical work of the hospital and the relation of the hospital to the actual needs of the sick applying for care have been to a great extent passed over to the physicians and nurses.

But the staff of physicians and surgeons has been organized, not for a sensitive appreciation of what the public needs, but for efficiency and consistency of technical service and for authoritative control of the medical work within the hospital. The training schools for nurses, with their rigid organization and severe discipline, have had their attention fixed upon an earnest effort to wrest from incompetence the personal care of the sick who come within the hospital walls.

The large modern hospital with all its elaborate organization has become so like a great machine that the uninitiated often see in it an uncompromising militarism. The machinery is baldly apparent, while the reason for its existence is often obscured. This obscurity is discouraging not alone to the outsider who knows nothing of hospital life and organization, but too often to those who are part of the machinery itself. Machinery is necessary; indeed, those who really understand the problems of hospital administration realize that there is need for even better and more extensive application of business principles in our institutions than at present prevails, and that not until the machinery runs efficiently and smoothly can the hospital reach its most effective medical service. Nevertheless, smooth-working machinery cannot alone produce a successful hospital, any more than an imposing edifice, beautiful chimes, cushioned pews, and a creed can produce a church.