Dignity, not Dismissal

Social work in a hospital setting is a dynamic field in itself. The role of a social worker within a hospital looks very different depending on the unit; Each unit requires a different balance of emotional support, discharge planning, groups, crisis intervention, program-planning, etc. 

While in graduate school, I spent a year as a social work intern in an inpatient hospital setting on the general medicine unit. I worked with patients exhibiting a wide range of concerns. One of my main responsibilities was to create a safe discharge plan with the patient since they would likely need a bridge in their care to get stronger before heading home. We worked primarily with older adults as our floor of the hospital had many joint-replacement cases. I was excited to work with this population but I soon realized that older patients did not always experience the dignity and autonomy that was rightfully theirs.

Before we’d work with a patient, we’d ask a few questions to determine how alert and oriented the patient was at the time. If the patient was alert and oriented, we were able to work directly with the patient. If they were not, we’d speak with a family member to make decisions regarding discharge planning and to find appropriate resources. I found that even when an older patient was completely alert and oriented, professionals would often go straight to a family member to get information. It was common to see professionals engage the family more than the patient and unknowingly dismiss the patient throughout the encounter. Sometimes, the professional was so engaged in their conversation with the family member that they didn’t notice the older patient trying to share something. I can’t imagine what it’s like to lay in a hospital bed, away from home, and being ignored when you know the most about what you’re experiencing. How much worse this must be as the aging individual grapples with the complexities of aging and may not be able to hear the conversations being spoken.

For the professional, this shift in dynamic may result from pressure to get through a case load and speed up discharges. Avoiding the patient and opting for family can be an easy way to get necessary information fast. I feel strongly that professionals are not necessarily experiencing a lack of care, rather, they could be facing what’s known as the “obligation dilemma” (Lev & Ayalon, 2014). The professional is pulled to abide by the patient, the family, and the hospital, which often leads to picking the most efficient option rather than the necessary one. 

This disorientation when working with older adults may be exacerbated by the social worker’s versatility in tending to a wide range of concerns. Social workers are uniquely positioned to serve the patient, the family, the healthcare team, the hospital, and the community. When trying to serve everyone effectively, we may not realize the bias we have when determining the order of significance.

Beyond the multiple loyalties, there are larger social issues at play. Dr. Louise Aronson, a geriatrician and professor, puts it well in her book Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life stating, “Our health system penalizes hospitals if they don’t fix people and quickly send them home, designates just fifteen to twenty minutes for clinic appointments, and doesn’t provide most nursing facility staff with the time, training, or both to help people in ways appropriate to their life stage. This sets up a vicious circle, as age-blind systems lead to bad outcomes for old people, which in turn reinforce people’s sense that they are not worth treating.”

Quick discharges are important because it ensures the patient isn’t paying for more than they have to, that hospital beds are available for patients in need, that patient’s aren’t exposed to risks longer than they have to, and the timely discharges are also a reflection of hospital success. How can we adhere to our social work values in a hospital setting while also prioritizing the hospital needs of tending to a caseload and being accountable to a team? How can we break the norm while also remaining efficient? How can we respect our patient’s autonomy even when they are not alert or oriented?

Well, I think it begins with a few small steps:

  1. Connect: Enter every patient room by first connecting with the patient. Even if the patient is confused or nonverbal, starting the encounter by making eye contact with and acknowledging the patient not only affirms the dignity and respect that is deserved but also sets the tone to ourselves that we are here to give the best care possible to the patient.
  2. Elevate skills: While the encounters within an inpatient hospital setting are short, remember that this doesn’t make our work any less important. Being able to acutely listen to a patient in such a small amount of time will make a difference in the overall experience of the patient, the family, and the health care team so fine tune those clinical social work skills! Having a shorter span of time to engage means we have the nudge to upgrade our skills and knowledge.
  3. Set an example: Role model the patient-centered behavior in your work to show the team that it is possible to remain productive while realigning the attention – even if in small ways. 
  4. Expand competence: Actively engage in trainings and conferences to learn about the impacted population. Use this expanded competence to educate the team you’re on and the organization you work in to slowly break down what has been calcified over years. 

The dismissive treatment of older adults is so socially ingrained that the action may seem inadvertent. It is not limited to medical settings. In the New York Times article titled, “Talk to Me, Not to My Daughter,” Fran Hawthorne describes the numerous settings in which older adults are ignored from their own care – from the barbershop to the bank. One older adult stated, “As the elderly, we lose our identity [to] a work-oriented society” and further states, “When people say they’re retired, they’re no longer a person of interest.”

 I encourage you, regardless of the setting you work in, to find the most commonly disregarded client and think of ways to better serve them. Which population popped into your mind first? What can be done better?