Organizational policy

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  • An explanation of organizational policy in your field education experience

NOTE: Currently intern as a social work intern at a mental health clinic

Conflict Between Professional Ethics and Practice Demands: Social Workers’ Perceptions

Nancy Gallina, Ph.D. Touro College

Journal of Social Work Values and Ethics, Volume 7, Number 2 (2010) Copyright 2010, White Hat Communications This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.

Abstract This study examined the degree to

which social workers perceived experiencing ethical conflicts in the contexts of their practice environments. A sample of 376 NASW members filled out questionnaires to report on a Likert scale the degree to which eight vignettes describing practice situations presented a value conflict, were frequent, and were inevitable. Findings indicated that respondents tended to view most situations as creating an ethical conflict and infrequent. Financially-related situations were seen as inevitable more often than others. Findings are discussed and implications for the profession are offered.

Keywords: Ethical Dilemmas, Values, Mission, Market

1. Introduction In making professional decisions,

social workers are currently caught between two conflicting sets of demands, one informed by the mission of the profession and the other by market forces. The professional commitment is guided by the NASW 1996 Code of Ethics, which describes social work’s mission as meeting

client needs and attending to environmental forces that create and contribute to their problems, and, requires that social workers place service to others above self-interest, provide access to services for all who need it, and challenge social injustice (preamble). The market forces, which have become apparent since the 1990s, include reduced funding for human services, the decrease in federal welfare provisions, delegation of service delivery to states and cities, and, tighter eligibility requirements for services (Brill, 2001).

As funding became scarce because of conservative tax policies and human services dwindled in tandem with tighter eligibility requirements, the government began to privatize its services in an effort to become more fiscally prudent (Beresford, 2005; Munger, 2006; Zullo, 2006) and practice started to be driven by funding sources such as managed care (Alegria, et al., 2001). For example, employment and foster care services, once offered by the Department of Social Services, are now being provided through individual agencies in the nonprofit sector (Zullo, 2006). The move to outsourcing of service delivery to the private sector using federal and state grants and contracts led to

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

government’s increased vigilance over funding and the demand for accountability and evidence-based practice. The push for fiscal solvency among the nonprofits has grown and requirements have become more rigid with demand for demonstrated outcomes, to the degree that some grants delay the release of funding until outcome targets have been met (Abramovitz, 2005).

The aforementioned changes in the practice environments require social work settings to augment their performance (Schneider, Hyer, & Luptak, 2000), as well as provide a growing amount of documentation relative to utilization rates, client outcomes, and capitation, while struggling to perform in the context of decreasing funding. In an effort to address these growing pressures, secure funding, satisfy performance and outcome requirements, as well as improve the appearance of service utilization, human services have developed strategies such as misreporting, inflating statistics, prolonging treatment of clients, multiple counting and double booking of clients, selecting clients based on ability to pay and potential for success, as well as terminating clients who are unable to meet fees (Abramovitz, 2005; Arches 1991; Gallina, 2007; Kane, Hamlin, & Hawkins, 2003).

Because of the increasing rigidity of eligibility criteria, decreasing resources dictated by market “philosophy” embraced by the organizations that restrict service delivery, and growing demands for spending time and energy on producing written reports, social workers’ professional obligations became hard to achieve, and their ability to provide satisfactory direct service to all who need them has shrunk (Abramovitz, 2005; Brill, 2001; Carpenter & Platt, 1997; Franklin, 2001; Galambos, 1999; Gibelman & Whiting, 1999; Mirabella & Wish, 2000;

Reisch & Lowe, 2000). Consequently, social workers have been positioned in a situation of “dual citizenship” with conflicting demands resulting from their professional and organizational affiliations. As members of the professional community, they are obliged to follow NASW Code of Ethics, whereas administratively, they need to follow the guidelines of managed care companies or their government and nonprofit agency employers. This position increasingly creates for social workers a role conflict, i.e., a situation in which societal standards, norms and expected behaviors connected to one position disagree with those ascribed by another position held by the same individual (Biddle & Thomas, 1979; Broderick, 1998; Turner, 1996). When charged by the profession to deliver services to those in need (i.e., expectations derived from the professional role) and faced with organizational policies that restrict service delivery (i.e. expectations related to employment affiliation), the potential for conflict is high. The conflict may be exacerbated by the large and growing number of untreated populations, such as the chronically mentally ill, uninsured, underinsured, and those struggling with substance-related issues (Amaro, 1999; Gibeaut, 2000; Meinert, Pardeck, & Kreuger, 2000). Furthermore, the aforementioned strategies used by agencies to alleviate the pressures may in themselves conflict with the professional ethics, further intensifying workers’ role conflict.

The resulting role conflict may lead to workers’ mounting stress and frustration (Abramovitz, 2005, Collings & Murray, 1996). The stressful nature of social work in general has been well documented (Acker, 1999; Collings & Murray, 1996; Gilbar, 1998; Himle, Jayaratne, &

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

Thyness, 1993; Jayaratne & Chess, 1986; Lloyd, King, & Chenoweth, 2002; Tidd & Friedman, 2002; Um & Harrison, 1998). Specifically, sources of stress in the current practice environment have been identified as administrative requirements, planning and meeting performance targets, challenges in resource allocation, lack of autonomy, high turnover rates, the bureaucratic nature of the environment, and, the amount of work, all of which may influence negatively on social workers’ ability to deliver quality services to clients (Abramovitz, 2005; Acker, 1999; Collings & Murray, 1996; Furman & Langer, 2006; Gummer, 1996; Himle, Jayaratne, & Thyness, 1993; Jayaratne & Chess, 1986; Lloyd, King, & Chenowth, 2002; Um & Harrison, 1998). While role conflict and role stress in social workers have been well documented separately, their relationships with being “trapped” has not been studied empirically; i.e., whether role conflict and its subsequent stress are related to the disparity between the two sets of demands that workers encounter due to their professional commitment on one hand and the organizational and administrative nature of the setting in which they practice on the other hand remained to be examined. This question is the focus of the current study. Specifically, it explored three questions relative to workers’ perception of practice situations that reflect typical issues of incompatibility between professional ethical principles and administrative expectations regarding decisions about clients. First, are the situations viewed as causing an ethical conflict; second, are they perceived as frequent; and finally, are they assessed as inevitable in today’s professional landscape. In addition, this study sought to examine associations among these three perceptions. By exploring these questions, a better understanding of the challenges

facing social workers can emerge to inform strategies for resolving or ameliorating the conflict and thus enhancing workers’ performance.

2. Method

2.1 Sample

The sample was comprised of 376 NASW members residing in a demographically diverse suburban area in the Northeast, who responded to a mailed survey (response rate was 17%). Respondents were mostly white, middle age, MSW level, experienced females who reported familiarity with the NASW Code of Ethics. About half were involved exclusively in direct client services, a third combined client services and administrative roles, and 13% were administrators. Seventy nine percent of the participants identified their employment settings, which included mental health clinics (19.2%), medical settings (17.3%), schools (7.4%), residential care (3.5%), academia (2.1%), and the legal system (1.3%). Twenty-seven percent were self employed. Most practitioners worked in either the nonprofit (41.5%) or for-profit (38.6%) private sector and 18.4% worked in the public sector. One and a half percent (1.5%) did not respond to this question.

2.2 Procedure

Research packets were mailed to potential respondents. The packet included a letter of introduction, a description of the study, a demographic questionnaire, and the instrument Perceptions of Conflict in Contemporary Practice Settings, as well as a postage paid return envelope. The letter of introduction and description of the study emphasized the voluntary nature of the study, identified inclusion criteria and

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

measures taken to protect participants’ anonymity, specified the commitment asked of participants, and described potential benefits of the study. Returning of the survey indicated proxy for consent.

2.3 Measures

Eight vignettes describing practice situations that reflect the potential ethical issues identified above were developed on the basis of the literature and personal practice experience (Abramovitz, 2005; Arches, 1991; Gallina, 2007; Kane, Hamlin, & Hawkins 2003). Participants were asked to rate on a 6-point Likert scale (ranging from 0 for strongly agree to 5 for strongly disagree) the frequency in which each of the eight situations occurs in their practice, the degree to which they view each practice situation as presenting a value conflict, and, the extent to which they find each practice situation to be inevitable in social work practice. For example, a sample item read: Please read carefully the following vignette describing a practice situation and address the questions following it. Terminating clients based on their inability to pay. Examples: Termination of a client because insurance benefits are running out or because client can no longer meet established fee. Please indicate 1) the frequency within your practice setting that social workers are faced with the above situation; 2) to what extent you find the above situation to be a value conflict; 3) to what extent you find the above situation a necessary part of contemporary practice.

3. Results

The findings indicated that with the exception of selecting clients based on their ability to pay (reported by 44.6% of

respondents, n= 166), fewer than a quarter of the participants reported occurrence of the situations described in the vignettes. The descending order of occurrence was: terminating clients based on inability to pay, misrepresenting information to meet performance/outcome requirements, selecting clients based on potential for success, inflating statistical data to satisfy reporting requirements, prolonging treatment to satisfy utilization rates or performance targets, misrepresenting information on grants proposals, and double booking clients to maintain fiscal viability (23.6%, 17.2%, 14.6%, 13.2%, 13.2%, 11.2%, 9.0% respectively).

Although the situations described in the vignettes were reported to occur with limited frequency, respondents viewed encountering all of them as creating an ethical conflict for practitioners. Viewed as causing such a conflict by the largest number of participants were situations that required them to provide false information relative to performance and outcomes or information on grants to obtain funding, along with inflated statistics to satisfy reporting requirements (79.3%, n=264; 78.8%, n=252; 78.4%, n=247, respectively). About three quarters of the participants viewed as causing an ethical conflict situations that involved direct impact on clients such as prolonging treatment to satisfy utilization rates or performance targets and terminating clients based on inability to pay (76.1%, n=268; 75.7%, n=274 respectively). Selecting clients with greatest potential for success was viewed as causing an ethical conflict by 73.1% (n=245), double booking by 71.7% (n=246) and selecting clients based on ability to pay by 67.7% (n=245).

Participants’ view of the situations described in the vignettes as inevitable varied. Financially-related situations, such

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

as selecting clients based on their ability to pay and terminating those who could not pay, were seen as inevitable by the largest number of respondents (67.7% n=245 and 61.5% n=255 respectively), followed by misrepresenting reporting information to meet performance or outcome requirements, selecting clients based on their potential for success, inflating statistical data to satisfy reporting requirements, prolonging treatment to satisfy utilization rates or performance targets, misinformation on grant documents, and double booking (32.9%, n=109; 30.7%, n=103; 28.4%, n= 90; 25.4%, n=89; 29.2, n=94; 24.3%, n=84 respectively).

A correlation analysis indicated a significant positive association between participants’ report about the frequency of all eight practice situations and the degree to which they viewed such occurrence as inevitable in contemporary social work practice; that is, those who reported common occurrence of a practice situation also viewed it as inevitable. This correlation was highest for misrepresenting performance or outcome information, followed by selecting clients based on success prospects, misrepresenting grant information, selecting clients based on ability to pay, inflating statistical data, double booking, prolonging treatment, and terminating clients based on inability to pay (.624, n=330; .492 n=334; .49,1n=321; 470, n=362; .433, n=314; 420, n=344; . 403, n=350; .20,8n=365 respectively; p≤ . 01).

However, the view of a situation as causing an ethical conflict was significantly correlated with its perceived inevitability only relative to terminating clients based on inability to pay (r=-.150 p<.001 n=360; r is negative because of scoring direction) and with its reported frequency only relative to selecting clients

based on ability to pay as being frequent did not judge it to be a conflict (.103 p<.005 n=362). Thus, respondents who saw terminating clients based on inability to pay as causing a conflict also saw it as inevitable, and those who perceived selecting clients based on ability to pay as being frequent did not judge it to be a conflict.

4. Discussion

Because the sample in this study was self selected, the generalizability of the results is limited. Furthermore, data was collected by means of a self administered questionnaire, and respondents did not have an opportunity to ask questions for clarification. Therefore, responses depend on their interpretation of the practice situations. Also, this instrument has been newly devised and was first used in the described study; thus, its psychometric characteristics have been established only to a limited degree.

In spite of these limitations, the study can offer some insight into ethical issues that social workers may face and their potential implications for practice and future research. The combination of high rates of reported inevitability and perceived value conflict confirms that social workers indeed experience being caught between their professional commitment and the market forces that guide their practice environment. Nowhere was being caught between a rock and a hard place more evident than in the finding that inevitability of terminating clients based on inability to pay and perceived value conflict were significantly negatively correlated, reflecting respondents’ belief that this practice, as well as other fiscally driven practices, breaches the mission of the profession and their feeling forced to follow it.

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

That participants reported most of the situations, which they saw as both causing ethical conflict and inevitable at least to some degree, as occurring infrequently may raise the possibility of under-reporting to avoid a cognitive dissonance, i.e., the discomfort experienced as a result of having conflicting attitudes, beliefs, or behaviors simultaneously (Festinger, 1957). Because people strive to maintain harmony among their attitudes, beliefs, and behaviors, when inconsistency (i.e., dissonance) occurs, an effort to change one of them is made. Being forced to act against their own beliefs may create such a dissonance (Festinger & Carlsmith, 1959). To address the discomfort brought on by dissonance, three strategies may be used: the behavior may be changed, the perception of the importance of the cognition re-evaluated and altered, or a new cognition may be added (Bacharach, Bamberger, & Sonnenstuhl, 1996, Greenwald et al., 2002, Greenwald, McGhee & Schwartz, 1998, Watson & Winkelman, 2005).

It is conceivable that practitioners who experience a conflict between professional values and job tasks and feel forced to practice in a way that is not consistent with their ethical values and professional identity experience a dissonance (Taylor, 2007) and struggle to reduce the resulting discomfort. Because respondents perceive situations of the type described in the vignettes as causing ethical conflict, if they saw these situations as frequent, they would have to face a reality of practicing in an unethical professional environment, thus causing dissonance. At the same time, because they view the situations as inevitable, i.e. they feel pressured to act as the practice situations suggest, admitting their frequency would force respondents to face their own powerlessness to change the

environment in which they practice and their inability to escape compromising their ethical values.

To avoid such a painful acknowledgement, participants need to reconcile their perceptions of the realities of the professional environment with their views of themselves as ethical. To achieve this goal, they could either change their evaluation of the situations or minimize the occurrence of the situations. The former route would expose them to the danger of providing socially undesirable responses. Because the situations clearly violate ethical values, participants will have to admit that they compromise these values and thus the integrity of their professional identity as practitioners in a value-based profession may be threatened. However, if they minimize the occurrence of the situations, the discrepancy between their perception of themselves as professionals and of their practice reality is decreased, protecting them from conflict and guilt.

The findings of this study agree with Abramovitz’ (2005) findings relative to the negative effects on workers of a practice environment that is perceived as unethical, such as the restrictive eligibility criteria and access to welfare, as well as high demands for outcomes and performance assessment. Abramovitz documented reports by practitioners of deliberate misreporting, as well as concealing client information from funding sources in an effort to preserve services to clients. At this juncture, the literature portrays individual workers grappling alone and making decisions unilaterally (Abramovitz, 2005). However, in the field, human service agencies have begun collaborating in the difficult task of lobbying for change, because advocating for change sometimes may become “biting the hand that feeds you.” However, as the experience of other helping professions

Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

such as nursing suggest, a promising route to resolving professional dissonance is raising awareness, creating coalitions, and advocacy for the client and the profession. Such efforts should be augmented by research relative to fiscal and market pressures and their manifestation in practice to equip the profession with better understanding of the processes as well as guidelines for developing strategies to effectively address them. The combination between organization of the professional community and developing more knowledge has the potential of developing an environment that allows professionals to perform ethically while considering relevant market forces.

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Journal of Social Work Values and Ethics, Vol. 7, No. 2, Fall 2010 http://www.socialworker.com/jswve

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