title: When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services.
abstract: The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N = 1509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N = 10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED.
authors.affiliation: School of Social Work, University of Washington, United States; Harborview Injury Prevention and Research Center, University of Washington, United States. Electronic address: mm99@uw.edu.
authors.forename: Megan
authors.initials: M
authors.lastname: Moore
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Margaret
authors.initials: M
authors.lastname: Cristofalo
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Danae
authors.initials: D
authors.lastname: Dotolo
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Nicole
authors.initials: N
authors.lastname: Torres
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Lahdya
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Leyna
authors.initials: L
authors.lastname: Ho
authors.affiliation: School of Social Work, University of Washington, United States.
authors.forename: Mia
authors.initials: M
authors.lastname: Vogel
authors.affiliation: University of Washington, Harborview Medical Center, United States.
authors.forename: Mollie
authors.initials: M
authors.lastname: Forrester
authors.affiliation: University of Washington, Harborview Medical Center, United States.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Conley
authors.affiliation: University of Washington, Harborview Medical Center, United States.
authors.forename: Susan
authors.initials: S
authors.lastname: Fouts
mesh_terms: D004636:Emergency Service, Hospital / Q000458:organization & administration; D006801:Humans; D036301:Qualitative Research; D012935:Social Justice / Q000523:psychology* / Q000639:trends; D000068217:Social Workers / Q000523:psychology*; D014193:Trauma Centers / Q000458:organization & administration; D014481:United States; D000078329:Workforce
keywords: Ecological framework; Electronic medical records; Emergency department; Social work; United States