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As a social worker, you interact with individuals who are at various stages of change in their lives. This may become frustrating for you when clients are struggling to achieve their goals. Thus, it is important for you to develop strategies to process your experiences so that you can maintain your compassion and professionalism. As you consider the strategies you have developed to address these issues, also consider how you might help other social workers to develop such strategies. Perhaps you consulted with your supervisors when you had difficulty processing your emotions in particular situations. As you consider assuming a supervisory role, how might you apply your learning from those experiences to helping those whom you supervise?

For this Discussion, review the Levy case study in this week’s video. Consider how you, as a social worker, might address the challenge of remaining engaged with a client while not letting your emotions affect the interaction. Also, consider how you, as a supervisor, might discuss this topic with a social worker whom you supervise.

By Day 3


a strategy that you, as the social work supervisor in the Levy case study video, might use to debrief the social worker after the session described in the video.

Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child. As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories. Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, they have slowly isolated themselves. My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). During this meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on the couch drinking beer and  watching TV or playing video games. When we discussed Jake’s options for treatment he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors. Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course of action would be for him to participate in weekly individual sessions with me and a weekly support group that was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor the effectiveness of his medications. The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma. The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal, and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him. He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told him that naming the issue or concern was often helpful in the healing process. During the first few sessions my goal was to help Jake feel safe and validate his feelings. We consistently assessed his feelings of safety, including any potential suicidal ideation. He was reluctant to attend AA at that time, so we began monitoring his drinking and his behaviors after several drinks.The Levy Family Jake Levy: father, 31 Sheri Levy: mother, 28 Myles Levy: son, 10 Levi Levy: son, 8 Jake began his individual sessions practicing techniques I had shown him to help reduce his anxiety symptoms. We used deep breathing and guided meditation to help him remain calm and in the moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal, and when he tried to dissociate or numb in reaction to these episodes. Jake slowly began to share his experiences while in combat. I helped to gently guide him through the events that seemed to haunt him the most. I explained that telling one’s story in effect helped him “own it,” and in turn it would be integrated into his life on his terms. I told him that the act of telling his story can actually change the processing of the traumatic event in his brain. I was careful through this process not to push him into talking about events that seemed too traumatic for fear of re-traumatizing him. There were many sessions in which he started to share a specific event and then stopped mid-story and had to begin his relaxation exercises. During this time he had also started participating in the veterans’ support group. Jake reported that he was uneasy during the first couple of meetings because he did not know anyone, but that the other vets were supportive. He said it was helpful to hear from others who experienced the same feelings he had since he returned home. He said he no longer felt alonenor did he feel “crazy.” Jake also shared that he had started attending AA meetings. While I did not participate in the couples’ sessions, Jake felt it was important that I hear about how these sessions were going. He told me the social worker at the local mental health clinic helped Sheri understand what he was going through by teaching her about PTSD. The social worker explained how PTSD affected not only the individual, but the whole family and, in turn, the home environment. Jake said Sheri admitted that she did not understand what he was going through but that he was not the same person when he returned home from Iraq, and this scared her. Jake said Sheri seemed to be empathetic toward him and appeared to be relieved when the social worker explained his diagnosis. Jake said he and Sheri worked together to address her main concerns. She felt he drank too much, was not communicating with her, was isolating himself from the family, and appeared to be depressed. She was particularly concerned about his lack of interaction with his sons and lack of interest in the current pregnancy. She worried that he would be uninvolved in caring for this new baby just as he was uninvolved with his boys. Jake shared that in another couples’ session, Sheri talked about wanting to be able to communicate with Jake without feeling that she was “nagging him” or fearful that she was making him withdraw. She said she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own. As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with friends and having family outings and felt isolated. Jake said just keeping his intrusive thoughts at bay took all the energy he could muster, so making small talk with friends was not something he felt he could do right now. Sheri admitted that she did not know that socializing affected him that way. He said the social worker explained that for veterans with PTSD, oftentimes crowds, loud noises, and open spaces triggered intrusive memories and caused anxiety attacks. He said that he and Sheri had developed a plan that would improve their communication. He said they were going to slowly begin planning outings that he felt he could handle, and that they also agreed that if at any time he felt uncomfortable while out that they would leave. Key to Acronyms AA: Alcoholics Anonymous PTSD: Post-Traumatic Stress Disorder VA: Veterans Affairs Health Care Center Through individual, group, and couples sessions, Jake was able to address his trauma and his PTSD symptoms abated. He realized that drinking was being used as a way to avoid his feelings and attended AA meetings regularly. He has been able to maintain his sobriety and found a sponsor who is also a veteran. Sheri gave birth to a healthy baby boy, and Jake shared pictures of his son. He continues to attend group sessions and has become involved in some mentoring with young vets here at the VA. He feels strongly in giving back and has suggested that the VA begin a program that has.

The Clinical Supervisor
ISSN: 0732-5223 (Print) 1545-231X (Online) Journal homepage: https://www.tandfonline.com/loi/wcsu20
Models and Methods in Hospital Social Work
Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin
To cite this article: Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin
(2009) Models and Methods in Hospital Social Work Supervision, The Clinical Supervisor, 28:2,
180-199, DOI: 10.1080/07325220903324660
To link to this article: https://doi.org/10.1080/07325220903324660
Published online: 10 Nov 2009.
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The Clinical Supervisor, 28:180–199, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 0732-5223 print=1545-231X online
DOI: 10.1080/07325220903324660
Models and Methods in Hospital
Social Work Supervision
University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, United States
University of Texas at El Paso, El Paso, Texas, United States
Loyola University School of Social Work, Chicago, Illinois, United States
University of Utah, Salt Lake City, Utah, United States
This is the first qualitative study of the perceptions of hospital-based
social work supervisees regarding their hospital supervision.
Seventeen social workers were recruited using a national listserv
and snowball sampling techniques. According to the perception
of the clinical social workers participating in the study, hospital
social work supervision is organizationally driven rather than
worker-focused. Implications for social work education and
research are discussed.
KEYWORDS hospital, managed care, models of supervision,
organizational re-structuring
Social work supervision has played an important but changing role in the
development of the profession. Supervisors are agency managers who
have been delegated authority to maintain the job performance of supervisees.
In assuming this responsibility, the supervisor performs educational, administrative, and supportive functions in a positive relationship with the supervisee.
Address correspondence to Goldie Kadushin, Professor, Helen Bader School of Social
Work, University of Wisconsin-Milwaukee, PO Box 786, Milwaukee, WI 53201. E-mail:
Hospital Social Work Supervision
The long-term objective of supervision is to prepare the supervisee to deliver
effective, efficient services to clients, consistent with the agency’s mandate and
professional practice standards (Kadushin & Harkness, 2002; Tsui, 2005). The
administrative function of supervision is to organize the work of the supervisees to achieve agency objectives. This is the basic supervisory function. Educational or clinical supervision improves the knowledge and skills of workers
within the mandate of the agency. Supportive supervision reduces job-related
stress and fosters worker self-awareness to cope with stress (Bogo & McKnight,
2005; Kadushin & Harkness, 2002; Tsui, 2005). These functions apply to any
supervisor in any social work agency.
This paper focuses on social work supervision in hospitals. The
sustainability of supervision in hospital settings is threatened by the elimination of middle management and supervisory positions in favor of leaner,
cost-effective structures. This reorganization reflects the influence of managed care and capitated methods of financing that are reducing the hospitals’
access to revenue (Berger & Mizrahi, 2001; Globerman, McKenzie-Davies, &
Walsh, 1996; Weissman & Rosenberg, 2002; Schmid, 2002). Consistent
with these findings, a recent survey of licensed health care social workers
reported increased job stress in the context of reduced access to supervision
(Center for Health Workforce Studies, 2006).
The influence of managed care and capitated financing systems on hospital supervision has not been examined by social work researchers since
1996, the last year of data collection in a longitudinal study conducted by Berger and her colleagues (Berger, Robbins, Lewis, Mizrahi, & Fleit, 2003; Berger
& Mizrahi, 2001; Berger et al., 1996.) The existing research is also limited by an
exclusive focus on the perceptions of supervisors. No research has examined
hospital supervision from the perspective of the supervisee. An understanding
of the supervisee’s views is necessary to inform the profession of unmet
worker needs for oversight, support, and education in the social work health
care labor force (Center for Health Workforce Studies, 2006). To begin to
address this gap in the literature, a pilot study was conducted to answer the
following question: What are the perceptions of supervisees about the current
models and functions of social work supervision in hospitals? The hospital
agency was the setting for this pilot study because previous research on supervision in health care has been hospital-based, providing a knowledge base for
the development of the study questions and instruments.
Hospital Reorganization: Impact on Social Work
Hospital Supervision
Many theories explain the relationship between the hospital and the environment (Netting, Kettner, & McMurtry, 2004) or those ‘‘external conditions
G. Kadushin et al.
that may affect the organization’’ (Schmid, 2002, p. 133). The merits of different
theories are still debated, but all theories assume environmental circumstances
influence organizational processes (Schmid, 2002). In particular, the immediate
or task environment is assumed to affect organizational strategies and structures (Schmid, 2002; Netting et al., 2004). The task environment includes
patient populations, revenues, in-kind resources, competitive institutions,
and federal and state regulators (Netting et al., 2004; Schmid, 2002).
In the early 1980s, health care delivery and funding underwent a radical
change in the United States with the introduction of a Medicare capitated
payment system for hospital care. Capitated payment is a form of managed
care. Managed care can be defined as a payment and health care delivery system that regulates, monitors, and coordinates resources to contain costs and
increase efficiency. Introduced into the United States to reduce spiraling
health care spending in the early 1980s, managed care is now the dominant
arrangement in both public and private sectors.
Because a capitated payment system transfers risk from payer to provider, the Medicare prospective payment system reduced hospital revenues.
Aware of the risk of cost-shifting, private and public third-party payers also
adopted managed care payment and delivery procedures. Hospitals were
confronted with an unstable, rapidly changing environment in which fierce
competition for scarce resources and patients existed. In this context, theories predict that organizations will revise strategies and structures to reassert
control over actors in the task environment (Schmid, 2002).
Hospitals responded by developing alliances with multi-hospital systems, merging with competitive institutions, and separating functions into
independent, decentralized programs or teams (Lee & Alexander, 1999;
Bazzoli, Dynan, Burns, & Yap, 2004; Weil, 2003). The effect of hospital reorganization was to reduce operating costs by consolidating management and
duplicative services. However, this strategy also eliminated the positions of
middle managers and social work directors who provided supervision,
decreasing institutional resources to support this function (Kadushin &
Harkness, 2002; Weissman & Rosenberg, 2002).
A government-mandated managed care program implemented in the
1990s in Canadian hospitals is suggestive of the effect of hospital restructuring
on social work supervision. The introduction of managed care was the impetus
for the dismantling of Canada’s hospital social work departments. Social work
supervision decreased in the absence of an administrative structure (e.g., social
work directors and supervisors). Canadian hospital workers organized peer
groups to provide clinical and supportive consultation but they had no
access to formal supervision (Globerman et al., 1996; Globerman, White, &
McDonald, 2002; Globerman, White, Mullings, & McKenzie-Davies, 2003;
Michalski, Creighton, & Jackson, 1999). While this research is specific to the
Canadian health care system, it is suggestive of the potential impact of managed care and hospital restructuring on worker access to formal supervision.
Hospital Social Work Supervision
Kadushin and Harkness (2002) hypothesize that clinical and supportive
supervision, which are resource-intensive, non-revenue-generating functions,
may be assigned a low priority by hospitals impacted by managed care. They
suggest, however, that because administrative supervision directly benefits
the organization, it may be the sole form of supervision recognized by hospitals within an environment of cost containment (Kadushin & Harkness, 2002).
Models of Social Work Supervision
Models of social work supervision can be differentiated by levels of agency
control. At one extreme is the ‘‘casework model’’ or scheduled one-on-one
individual social work supervision, which is based on high levels of administrative accountability. At the other extreme is the autonomous practice
model, which is characterized by professional autonomy of the supervisee.
Between these extremes on the continuum of administrative accountability
are group, team, and peer supervision models (Bogo & McKnight, 2005;
Kadushin & Harkness, 2002; Tsui, 2005).
Individual supervision is the most widely used model of supervision,
particularly for unlicensed or inexperienced (less than two to six years of
practice in the same setting) workers (Kadushin & Harkness, 2002). It is
delivered in a one-on-one tutorial session scheduled weekly for at least an
hour. The demands of time and effort required by this model may be challenging to hospital-based social work supervisors who have corporate or wideranging administrative responsibilities.
Group supervision is the second most widely adopted model of
supervision. It is characterized by the presence of a formal social work
supervisor who performs the functions of supervision—administrative,
educational, and supportive—in a group format. Group supervision is a
supplement to, not a substitute for, casework supervision.
The introduction of group supervision is ideally preceded by worker
preparation for the change and agreement by the staff. The advantages of
the group modality are conservation of time and resources; lateral peer learning; and sharing and normalization of job-related stress (Bogo & McKnight,
2005; Kadushin & Harkness, 2002; Sulman, Savage, Vrooman, & McGillivray,
2004; Tsui, 2005).
Peer supervision is supervision led by a peer group; in this situation, no
supervisory oversight or authority exists. All participants hold equal status in
terms of accountability and responsibility for their own practice. The purpose
of peer group supervision is to provide educational=clinical supervision
through case conferences and the exchange of clinical expertise and guidance.
Peer supervision is a supplement to, or a substitute for, educational=
clinical supervision (Brashears, 1995; Barretta-Herman, 1993; Hardcastle,
1991; Kadushin & Harkness, 2002; Sulman et al., 2004; Tsui, 2005). Team
supervision is led by a team leader who may or may not be a social worker.
G. Kadushin et al.
In team supervision, intradisciplinary workers may exercise autonomy,
collectively make decisions about work assignments, case dispositions, performance checks, and professional development, providing educational=clinical
guidance and oversight and allocating work assignments. The supervisor is a
team member but retains administrative accountability for team performance
(Kadushin & Harkness, 2002; Tsui, 2005). On interdisciplinary teams, the leader
may be a physician, nurse, or other medical professional who assumes supervisory authority over the other team members (Kadushin & Harkness, 2002).
The question of the prevalence of supervision models in hospital-based
social work has generally been ignored by social work research. Berger and
Mizrahi (2001) examined supervision from the perspective of supervisors in a
national sample of hospitals in 1992, 1994, and 1996. They found that in the early
to late 1990s, individual and group supervision were the most frequent models
(these models were collapsed into the category ‘‘formal supervision’’). Peer
supervision (consultation) was the second-most frequent model. The use of
non-social work supervision significantly increased over all time periods.
Health care social workers speculate that as hospitals restructure and
eliminate social work managers and departments, the resources to support
the traditional individual supervision model will decline. Workers will have
to take the initiative in finding support for supervision outside the hospital
or by creating group or peer models that use collective resources efficiently.
The caution is the need for thoughtful planning, implementation, and a
mechanism for training and evaluation to accumulate research to inform
the profession regarding the efficacy of innovative supervision models
(Berger & Mizrahi, 2001; Kadushin & Harkness, 2002).
This qualitative study was implemented using telephone focus group
interviews. Focus groups have been widely used as a data collection method
in qualitative research, and growing evidence supports the efficacy of
telephone focus groups or ‘‘telegroups’’ as an alternative to face-to-face focus
groups (Cooper, Jorgensen, & Merritt, 2003; Appleton, Fry, Rees, Rush, &
Cull, 2000). Using the Society for Social Work Leadership in Health Care
membership as a sampling frame, researchers employed purposive and
snowball sampling techniques. Social work directors=managers were
contacted by electronic mail using the organization’s listserv. The e-mail
explained the purpose and method of the study and encouraged social work
directors=managers to share the attached flyer with their staffs. Inclusion=
exclusion criteria were as follows: graduate-level social work staff (i.e.,
MSW, PhD, DSW); 50% currently employed in an inpatient or outpatient
hospital setting; one or more year working in clinical practice; at least one
year of experience in the current setting; and English-speaking.
Hospital Social Work Supervision
Eligible staff members e-mailed the Principal Investigator (PI) to indicate
their willingness to participate. The PI responded to the e-mail and screened
the subject for eligibility. If he or she qualified for the study, the PI sent an
electronic version of the consent form that was approved by the institutional
review boards (IRBs) of every member of the research team. A waiver of
signature for consent was obtained from the IRBs in order to ensure anonymity of the participants. In developing the focus groups, every attempt was
made to ensure that subjects from the same setting did not participate in
the same focus group to prevent voice identification.
The PI contacted the individuals by phone to discuss the study, answer
questions, and confirm their willingness to participate. Subjects were also
encouraged to share information about the study with their colleagues within
their own and other health care settings. Given the use of the listserv and the
snowball sampling technique, it was not possible to calculate how many
social work clinicians in health care settings were informed of the study to
produce a response rate.
The subjects were made aware of scheduled times for the focus groups
and selected a group. The subjects were asked to adopt fictitious names to
be used during the telegroup; these same names are also used in the data
presentation that follows. The intention in using fabricated names was not only
to increase the level of confidentiality, but also to ensure that each person in
the telegroup session had a distinguishable name. An e-mail was subsequently
sent to the participants confirming the time of the telegroup, the phone number that the participants called to access the focus group, the conference call
identification number to be used, and the fictitious name that they selected
for use during the telegroup and additional flyers advertising the study to share
with colleagues. This e-mail also contained the fictitious names of the other
participants and the focus group leader. A similar e-mail was sent to the group
facilitators. Focus group facilitators were aware only of the fictitious names and
geographic location of the participants; they were not given any other identifying information about the participants in their groups. The day before the telegroup, the PI sent an e-mail reminder to each participant with the same
information contained in the previous e-mail.
Once this reminder e-mail was sent, the PI erased any electronic
information required in setting up the conference calls in order to ensure
anonymity within the actual focus groups. If a participant did not call the
access number for the telegroup, it was impossible to contact him or her
since all identifying information was erased. However, most of the participants who were not able to attend their assigned focus group did contact
the PI to reschedule another time to participate. A private teleconferencing
company was used to set up the conference calls for the focus groups.
The members of the research team served as the facilitators of the focus
groups; the focus groups took about 60 minutes. Telegroup members were
instructed to use only their fictitious names in identifying themselves.
G. Kadushin et al.
A semi-structured interview schedule was finalized following a literature
review and the consensus of the four researchers who contributed both
academic knowledge and practice experience in supervision. The interview
schedule consisted of a series of six open-ended questions and accompanying
probes related to the following topics:
1. access to individual educational=clinical supervision;
2. access to different models of supervision (e.g., group, peer);
3. supervisors’ professional discipline;
4. administrative supervision and accountability for job performance;
5. use of outside supervisors; and
6. organizational changes affecting supervision.
This semi-structured interview schedule was followed in each focus
group to ensure some comparability. Major topic questions were presented
to each group separately to maintain a focus on the topic, but group leaders
had the flexibility to explore issues raised that did not coincide with the topic
questions. The topic questions were read aloud by the facilitator, who then
prompted the group for responses. Once discussion was underway, the facilitators intervened only as necessary to guide, probe, or provide support. This
procedure aided in conducting groups that were focused, without excessive
and counterproductive constraints on their interaction.
All interviews were audio-recorded and then transcribed by members of
the research team or by the teleconferencing company. The focus group
sessions began with an assignment of a study identification number. Only
the study identification numbers appeared on the transcripts. Any identifying
information on the tape (e.g., names of individuals, institutions, and locations
used in the discussion) were deleted from the transcript. Once the transcript
was checked for accuracy, the audiotapes were destroyed.
Using a grounded theory approach to data analysis, the narrative data was
pre-coded into conceptual categories. Content was then grouped into broad
categories to detect patterns and relationships. Through further coding, these
categories were reduced to reveal consistencies and inconsistencies in the data.
When codes fit well with old and new data, they were reviewed again in order to
identify focused themes to enhance understanding. This paper will focus on two
key themes that appeared to influence the participants’ perceptions of supervision: the organizational context and the multimodal approach to supervision.
Sample Characteristics
The majority of the 17 focus group participants were licensed; 5 subjects
were not licensed. In general, the participants were experienced workers;
Hospital Social Work Supervision
five had supervisory responsibilities and also carried caseloads. All
participants were employed in hospitals as social workers and, with one
exception, all were women. One participant was employed in a psychiatric
hospital; the remaining sample was employed in medical hospitals.
Organizational Context and Sanction for Social Work Supervision
One of the dominant themes related to the organizational context was the
amount of change that the practitioners were experiencing in their settings.
For some, the change had more to do with roles, while for others restructuring and resizing strategies led to the elimination of social work directors,
transfer of reporting relationships to non-social work personnel, and=or
implementation of matrix models for organizational structure. These matrix
structures retained a social worker as one of the managers, but the supervisor
could be a nurse, a social work department director, or a social worker at the
corporate level. Lisa, an unlicensed social worker in an outpatient dialysis
unit, described a matrix structure of supervision in her setting.
It’s just been a very large growth boom within this organization. So, right
now my clinical supervisor is the only director for all social work departments in the corporation. So that does limit her availability with that
change. I receive clinical supervision monthly by phone and we meet
every three months as a group. I have a direct supervisor at the center
and she is an RN. For, you know, more of the actual clinical needs with
the patients that I’m seeing day in and day out, my tasks, the issues that
come up within my actual work setting, it’s really underneath the RN
clinical manager. But the corporate director of social work and the direct
clinical manager do communicate when they need to.
Abigail, a licensed social worker in a large hospital in a corporate
system, describes a matrix organization in discussing her supervision:
I meet with my director two times a month now, and then I have a manager [nurse] here that I have access to whenever I need to talk to someone.
Other workers experienced the loss of their social work supervisor and
had to advocate for supervision by an MSW.
Previously we had a social work supervisor and there was more clinical
supervision, but she was replaced by a nurse because she did not have
the medical knowledge that the hospital wanted. There is no understanding of the social work role in this setting. (Jan)
In one hospital, the social workers acted more proactively in response to
the elimination of their social work director. The director had been demoted,
and they were then expected to report to a nurse. The social workers began
G. Kadushin et al.
meeting as a group to provide peer support and supervision, and this led to
political action. They were successful in getting the hospital to allow a licensed
social worker to be a consultant in order to provide supervision to staff.
Our previous social work supervisor was demoted and replaced by
a nurse supervisor. The new supervisor does not know much about
social work. After this happened we advocated for a social work supervisor, and the hospital hired a social worker who is a consultant for
supervision. (Will)
Organizational changes and the exponential increase in the scope of
the managers’ responsibilities made access to supervision problematic. The
participants reported that many social work supervisors carried wide-ranging
administrative responsibilities for corporate social work systems, entire
geographic areas, or several hospital departments. Even when the participants had social workers as managers or supervisors, some reported that
their ability to obtain supervision was eroded by the increased administrative
demands of their supervisor, particularly if the social work supervisor was
the department director. Many described ad hoc supervision based on the
supervisor’s availability rather than the workers’ needs. When they met with
their supervisor, the sessions were often described as shorter:
Our company was bought out by a larger company. Now it is harder to
communicate with higher people in the company . . . . Previously we had
access to social work supervision but the supervisor is less accessible
now and the quality of supervision is not as good. (Dodie)
One of the other things that might be a limitation is that we have overtaken many other centers throughout the United States and it’s just been
a very large growth boom within this organization. So, right now she [the
social work supervisor] is the only supervisor for the entire area. She is
the director of the entire department nationwide. So that does limit her
availability with that change. (Lisa)
He’s [the director] on a lot of different boards at the hospital. And the hospital is going through some changes where the person who is the head of
the hospital is going to be stepping down and they’re going into a search
committee to be looking for a new president of the hospital. He’s
involved a lot in that type of thing. So, I think that, where you don’t have
a time that’s set up, sometimes it’s difficult . . . versus if you have a supervisor who’s more accessible around the hospital. (Barb)
Others reported the presence of licensed clinical supervisors within
their work unit who provided supervision.
[Supervision] was by an RN because it was also under the offices of the
case management department. And what the social workers did, we
Hospital Social Work Supervision
actually fought to have a clinical supervisor. So, the most senior social
worker who was an LCSW took on the role of supervising us . . . . (Cathy)
Another factor that seemed to influence the frequency and mode of
supervision related to the status of the worker. In some but not all hospitals
new workers to the organization or service, or those who were preparing for
licensure, reported that they were more likely to receive scheduled, frequent
clinical supervision. This access may have been influenced by variations
between states’ licensure requirements.
The first six months on this job, I am way past licensure, we are supervised once a week. Then after six months, it is once a month . . . or as
needed. (Judy)
. . . in order to keep their licensure, they need to meet with the director of
social service once a week. (Debbie)
As supervisors assumed responsibilities for oversight of entire geographic regions or director positions over all social work departments in a
corporate system, communication technology appeared to be an essential
tool to facilitate access to supervision. Participants reported the use of cell
phones, pagers, e-mail, and the Internet as helpful tools to ensuring access
to clinical supervision or consultation.
Pretty much on a daily basis, several times a day . . . we’re on the Internet
so we have a direct e-mail access to each other all day long. I do mostly
[supervision] by phone about 20% clinical and the rest is administrative,
and we have a quarterly meeting with the supervisor every month. (Lisa)
I have access to clinical supervision as needed basically. I like the flexibility of being able to call him on a whim if I’m in the middle of something
and it’s stumping me or whatever I need to—or if something’s really bothered me that’s happened that I need to talk about . . . . I have that ability
then to page them and they’ll get back with me and so forth. (Elizabeth)
Ultimately, the strongest factor influencing the availability, frequency,
and models of supervision was organizational sanction. The participants
reported an array of scenarios ranging from complete disbanding of the
social work program with social workers reporting to non-social work leaders to centralized social work departments with social work managers
and supervisors. Organizational recognition and sanction for the importance
of social work supervision and the allocation of resources to the supervisory
function seemed to define the organizational context for supervision. Tracy,
a licensed social worker in a mental health hospital, attributed her access to
G. Kadushin et al.
supervision to the organization’s recognition of the salience of social work
The flexibility of having access to individual supervision pretty much
whenever I need it is pretty useful. Like someone who said that their
licensure doesn’t require supervision, nor does mine, but my unit
supports it, my director supports it and her director supports it.
Administrative sanction is poignantly captured in the following scenario.
Although supervisory staff existed, they were unwilling to provide clinical
supervision to non-licensed workers. This finding suggests that the organization has no commitment to making these resources available to ensure their
workers achieve licensure.
[The participant] . . . as for licensure, that’s pretty frustrating . . . we have a
couple of people who are licensed who are not willing to provide
one-on-one supervision . . . . (Cathy)
The lack of commitment to licensure is also captured in the following
two quotes. The first participant describes how she chose to leave the
organization after the clinical supervisor position was not replaced. While
some chose to seek their supervisory hours outside of the organization, many
accepted positions that included available supervision. The provision of
supervision could have a significant impact on a health care setting’s ability
to recruit and retain competent social work practitioners.
And when she [the supervisor] left, that was actually the reason I left.
When she left, they didn’t make an effort to get a new clinical supervisor . . . I was losing about 30 hours a week of supervised hours [toward
licensure]. (Barb)
Will reported another example of sanction. He stated that after the
elimination of the social work manager=supervisor positions in his hospital,
the social work staff advocated for the provision of clinical supervision. The
organization agreed to have a consultant come to provide the supervision but
did not make it a requirement for all staff to obtain licensure. Will reported
that not all non-licensed staff took advantage of the clinical supervisor.
Again, this finding supports the concern that without administrative sanction,
the quality of social work services and the skill development of the staff
can be compromised, particularly in situations where supervision may be
provided by non-social workers.
And for the clinical supervision it’s an LCSW, I believe PhD, from outside
who really is just volunteering, it’s not, an LCSW is definitely not needed for
our position. It’s really just something that if you personally want to take
the time to help yourself out then that person is volunteering to do that.
Hospital Social Work Supervision
The system-driven nature of individual social work supervision was also
reflected in workers’ statements about the emphasis of their work on
discharge planning, length of stay, and cost control, and how this emphasis
shaped their supervision. However, workers who were seeking licensure, in
particular, and some of the licensed workers, mentioned wanting more
clinical insight from their supervision.
It’s getting everybody, no matter what your background is, it’s focused on
shortening length of stay and identifying discharge barriers early on . . . it
takes up a lot of everybody’s space and time, it is the top priority and so
all the energy is being spent in that direction and what gets left over you
might . . . be able to squeeze in some clinical. It’s just a matter of space
and time. (Abigail)
I could benefit from more clinical supervision. The work has a
psychosocial component but there is too much emphasis on concrete
services and supervision that is task-focused to get the job done. The
current emphasis is on length of stay and discharge planning. There is
more focus in supervision on these issues than clinical content. (Judy)
The presence of organizational sanction set the tone for the types of
supervisory models apparent within the organization. Both licensed and
unlicensed workers reported receiving scheduled clinical, face-to-face social
work supervision and administrative supervision on both a formal, scheduled
basis and as-needed basis. Commonly cited concerns were lack of physical
access to an off-site supervisor and lack of access to supervisors within the
institution. The absence of recent clinical practice experience among supervisors was also mentioned as a barrier to supervision by workers. Scheduled
in-person meetings with the supervisee were initiated at the request of the
supervisee, formal meetings that the supervisor scheduled on a monthly basis
or less frequently, or formal meetings with the supervisor that were scheduled on a weekly basis for both licensed and unlicensed workers. The majority of respondents reported contact with their supervisors on an ‘‘as-needed’’
basis using e-mail, phone, or pager. This latter function of supervision was
primarily administrative supervision.
Changing Models of Supervision: Multiple Modalities
In contrast to the literature that identifies formal clinical supervision as the
most widely used model (Bogo & McKnight, 2005; Kadushin & Harkness,
2002; Tsui, 2005), these focus group participants mentioned a variety of
supervision models for different functions. Individual clinical formal supervision was infrequent. For those who did report its use, the experience varied.
Elizabeth and Abigail, licensed workers, describe their access to formal
clinical supervision.
G. Kadushin et al.
I have access to clinical supervision as needed. Basically if I’m meeting
with my supervisor for individual it’s probably 80% clinical. (Elizabeth)
I meet with my supervisor once a month. The focus is mostly on administrative, not clinical issues. But we have access to this supervisor daily,
almost instantly. So, I never have the feeling that I ever need help and
it’s not available. (Abigail)
Will, Kathryn, and Cathy, unlicensed workers, describe a similar picture,
only on a more frequent basis.
I meet with my director weekly. I would say the majority of . . . probably
upwards of 80% of my time is spent, my clinical supervision is spent on
clinical concerns. (Kathryn)
The actual clinical supervision is by someone (a PhD consultant with no
formal authority in the institution) affiliated with another hospital that we
just were supported in the sense that we can take an hour during the
workweek to be with that person. (Will)
I have been at my job about six years and there was no formal clinical
supervision whatsoever up until about a few months ago. It is very hard
to get licensed. And I meet primarily informally with my personal supervisor [unlicensed social worker in that state] and with the lead [licensed
social work manager] assigned to me. That’s very informal also . . .. It is
so limited. I am going to have to pay for outside supervision so that I
can be licensed. (Cathy)
In addition to a primary supervisor, some workers also had access to
team leaders or managers, some with administrative authority, for clinical
supervision. Workers expressed skepticism about the clinical competence
of the primary supervisor when he or she carried no clinical caseload. These
secondary supervisors were perceived as being more knowledgeable and
skilled in regard to clinical issues:
The distance from day-to-day clinical practice for the director in providing supervision can also be somewhat of a challenge in terms of just the
day-to-day practice of what we do. My team leader [licensed clinical
social worker] is often more accessible than the director; her office is right
across the hall from mine and she’s always just checking in on an
informal basis is [there] anything I need, how’s everything going. So it
is helpful. (Kathryn)
We have a director, a manager, and then we have supervisors. There are
four line workers who are more experienced social workers [who]
do clinical work and are clinical supervisors as well. The strength with
non-management clinical supervisors is that they are still on the floor.
So they know, they are in the trenches kind of with us. And that helps.
Hospital Social Work Supervision
That’s a good thing. The weaknesses with having the director in particular
being the clinical supervisor is that she does no clinical work at all anymore, so she’s very, very removed from the clinical setting. (Barb)
Formal group supervision (on a weekly or monthly basis) substituted for
individual clinical supervision for some workers.
Individual supervision is, it varies in term of clinical content depending on
what makes sense but I have group supervision every two weeks. Group
supervision is probably 100% clinical but if someone has an issue that is
going to potentially impact their work and it’s not a clinical issue they
are free to bring it in, but typically we talk about clinical issues. (Tracy)
I have not brought clinical cases to my individual supervision as much as
to my group supervision; since I meet with them more regularly I can get
in more depth with cases clinically and that is the part about meeting with
them regularly is that you are bringing that kind of stuff to the table
whereas even though you can call on your supervisor about things and
I do. It is just lately there hasn’t been a need for that. (Elizabeth)
What my boss did, was she has an MSW from another state from a long
time ago and had not been licensed yet in the state where I live. And so.
So she appointed four of the most experienced people in the department
and they are kind of in a lead role to help her kind of manage all these
people. So, one of those women is licensed and has been providing
group supervision on a monthly basis that is focused on clinical content
about half of the time. (Cathy)
In other cases, groups were a supplement to individual clinical
I meet with my supervisor on an as-needed basis and those meetings are
probably 80% clinical. And then in terms of the group supervision that is
scheduled weekly and that’s pretty much 100%, maybe you could say
99% clinical. (Barb)
Formally scheduled team supervision (monthly or weekly) was the least
frequently mentioned source of supervision. Team supervision included both
administrative and clinical supervisory functions. Lucille, a licensed social
worker who received clinical and administrative supervision on an as-needed
basis, accessed clinical supervision in a formally scheduled team meeting.
I don’t have any one-on-one clinical supervision. We do have weekly
team meetings where we talk about cases. The team I work for also meets
G. Kadushin et al.
regularly and sometimes it’s administrative and sometimes it’s clinical. It
varies; it’s probably about 30% clinical. (Lucille)
Kathryn, an unlicensed social worker who received individual clinical
supervision, discussed the additional clinical supervision she received in
the team setting.
The team meets twice a month formally as a group for an hour and that’s
probably on average maybe 50% administrative=50% sort of clinical in
terms of our practice. (Kathryn)
Informal peer consultation was frequently cited as a source of clinical
guidance and support. These contacts occurred over lunch, in offices,
by phone, through text messaging, pager, and e-mail. This variety of modalities reflects the creativity of workers in arranging for clinical and supportive peer consultation. With one or two exceptions, these collectives
appeared to form on a spontaneous ad hoc basis. This form of peer consultation is differentiated from peer group supervision, which is formally
scheduled and institutionalized as a format for supervision in the agency.
Workers, both licensed and unlicensed, accessed peers informally for clinical guidance.
I work with a population that requires a great deal of psychosocial interventions; generally my supervision time entails talking about do you
know what the hospital can pay for that kind of thing. But when we have
a tough case I use my peers at work to talk about these cases. (Judy)
There’s two social workers in my setting and we lean on each other
pretty heavily. The other social worker and I get together, yeah, as a peer
and that has . . . that is very helpful. I am hooked up with, on the Internet,
with a group of area social workers in health care and we get
information . . . I get information that way. (Jan)
In a few instances, workers stated they received peer group supervision.
Barb, a licensed social worker, discussed her oncology section peer group.
We have an oncology section. It’s a peer group. We meet once a month
for an hour all oncology social workers and we discuss system issues,
research issues, a really difficult case, and we also do a lot of continuity
of care type issues at that setting too. (Barb)
Will, an unlicensed worker, mentioned supervision in a peer group that
developed after the social work supervisor was demoted and the department
Hospital Social Work Supervision
We developed our own social work council that met monthly just to kind
of be a support group and a place to have input and have our voice
heard. And we actually were able to get a pay raise and a compromise.
We still report directly to a nurse but we now have a social work manager
on their same level as a consultant that adds a dotted line person that we
can talk to and we are still meeting.
In the previous quote of Will’s and in the following statement made
by Barb, the peer group was also perceived as a source of support in a
challenging hospital environment.
The oncology section group makes us have a presence in the hospital
which is so important as a group, as a section because they realize,
people realize that we have an oncology section, a group of designated
oncology social workers. And that’s important I think because it’s a
specialty in a way just like a lot of other practices are. (Barb)
A minority of licensed workers and two of the five unlicensed workers
reported that they received no social work supervision. These workers were
supervised by RNs or BSNs. All of the unlicensed workers who did not
receive social work supervision relied on peer consultation for clinical
guidance and support. One worker contracted to pay for private supervision
for licensure. Among unlicensed workers, the nurse supervisor was
perceived as unqualified and an obstacle to professional development and
I mean I think for a nurse who’s gone from direct nursing to management
without getting any kind of management degree and then being told to
supervise and evaluate a social worker based on I don’t know exactly
what. I think there’s been some talk about whether or not that’s such a
great idea but that’s just kind of the way it is. (Will)
Non–social work supervision was also viewed as representing a lack of
valuation of social work as a profession in the organization.
In our setting too, a lot of the staff don’t really understand what we do. I
think it is very much related to lack of social work supervision. My supervisor is a registered nurse over the case management department. I do
have a problem with having a nurse as a supervisor because she doesn’t
understand, I think, what the social workers really need to do their job,
and how long things take and what it takes . . .. I would like a little more
clinical focus. Now there is a much bigger focus on length of stay, and
discharge planning. (Jan)
G. Kadushin et al.
The most frequently mentioned model of supervision for licensed social workers was clinical supervision on an as-needed basis. Licensed workers contacted
their supervisors through pager, e-mail, text messaging, or phone when they
made a clinical, ethical, or legal judgment on a situation that required input
from a supervisor. This model of supervision was more frequent when the primary social work supervisor was a corporate level employee off-site or a hospital administrator at a high level in the bureaucracy. Generally, these licensed
workers frequently evaluated this mode of supervision positively. For example, Abigail, a licensed clinical social worker, noted,
My supervisor is off-site but she is available if something comes up by
e-mail. I see our relationship as a form of guidance, not supervision. It
is very hands off but I don’t want more clinical contact [so] I am satisfied
with this arrangement. (Abigail)
Judy, another licensed social worker, noted that her autonomy
conveyed her supervisor’s confidence and respect.
I think that the supervisor respects my clinical competency. They do
check our electronic notes. So, they always access, she always has access
to what we’re doing. They refer to us here as having our own practices.
So, that should tell you a lot. (Judy)
However, workers also wanted to maintain access to formal clinical
supervision and regarded the absence or presence of this option as an
indication of the hospitals’ support for the profession.
Most of my supervision is on an as-needed basis. I think that the supervisor respects my clinical competency. But I do think that just because
you are licensed does not mean you cannot benefit from supervision. I
think I could benefit from more clinical supervision but it is not available
because the emphasis in this hospital is on concrete services and cost
control. (Judy)
Generalizability from this pilot study to the larger population of hospital
social work supervisees is not warranted because this was not a representative sample. Other limitations are the small convenience sample; the homogeneity of the sample in regard to licensure status; the potential for bias
introduced by using supervisors in the recruitment of subjects; and any
unknown characteristics of the sample that may have influenced the findings.
Recognizing that this was only a sample for a qualitative pilot study, a
Hospital Social Work Supervision
strength of the methodology was that we had participants who represented
geographic regions throughout the country, providing information that was
not limited by working in a specific geographic area.
The findings of this study provide new information about worker
perceptions of the significance of the hospital’s sanction and valuation of
social work as a profession in supporting social work supervision as an
organizational responsibility. Supervision was shaped by the ‘‘order of the
day’’ (Bogo & McKnight, 2005, p. 56). The supervisees’ perceptions were that
their supervisors’ primary commitment was to the corporation or the hospital
bureaucracy and that the supervision they received was not systematically
matched to their needs. While workers with and without clinical licenses
had access to formal one-on-one supervision, the focus was predominantly
on administrative issues.
Access to educational=clinical social work supervision was regarded by
these subjects as secondary to the constraints of the hospital or corporation
to monitor costs through length of stay and discharge planning. These attitudes are reflected in statements that there ‘‘were bigger problems out there
than my professional development’’ and the frequent observation that the
supervisor was out of touch or distant from social work practice. These findings are consistent with previous research on the function of supervision in
an environment influenced by managed care organizations or principles
(Kadushin & Harkness, 2002). The supervisees’ perceptions of a supervisor
preoccupied with administrative responsibilities and lacking clinical credibility also confirm the apprehension about the sustainability of the resourceintensive model of clinical supervision in the profit-conscious hospital.
In place of formal individual clinical supervision as the most frequent
model, these supervisees mentioned a variety of supervisory models including seeking out secondary on-site supervisors (team leaders, senior workers,
or leads) and participation in group, team, and autonomous supervision
models. Workers also relied on peer consultation and, less frequently, peer
group supervision for clinical and supportive supervisory functions. These
findings may suggest that social workers are responding to organizational
constraints on the labor-intensive individual supervision model by developing alternative sources for supervision.
While this may be interpreted as a positive development by suggesting
that models of hospital supervision are evolving to adapt to leaner management structures and cost constraints, we find no evidence of a thoughtful,
systematic process of planning and implementation or mechanisms for
evaluation or accountability in the findings. In particular, it is unclear how
the supervisory functions of administration, education, and support were
provided to those workers without social work supervision who relied on
peer consultation for clinical guidance and support.
Organizations such as the Society for Social Work Leadership in Health
Care and National Association of Social Workers are appropriate professional
G. Kadushin et al.
leaders to assume responsibility for the systematic development and evaluation of cost-effective, sustainable supervision models that produce positive
outcomes for workers and clients (Berger & Mizrahi, 2001; Sulman et al., 2004).
Schools of social work may need to be aware of the health care context
and revise their fieldwork and classroom curricula to prepare students with
skills in advocacy, program planning, group work, and teamwork to be
successful in accessing a variety of supervision models to support their
professional development.
Future research is suggested to provide an evidence-based approach to
practice which documents the association of appropriate hospital supervision models, worker competence, positive patient outcomes, and reduced
consumption of health care resources.
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