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ETHICAL DILEMMAS IN HOME HEALTH CARE: A Social Work Perspective.

The survey in this article examined several factors related to the frequency and difficulty of resolving four ethical conflicts in a national sample of 364 home health care social workers. Ethical conflicts regarding the assessment of mental competence, self-determination, and access to services were moderately frequent and difficult to resolve, whereas conflicts over implementing advance directives were infrequent and not difficult to resolve. Each ethical conflict involved multiple stakeholders. Multiple regression analyses revealed significant predictors of the frequency and difficulty of resolving the ethical conflicts. Implications for practice and administration in home health care and social work education are discussed.

Keywords

advance directives

ethics

high-technology home health care

home health care

Medicare

reimbursement policy

Recent changes in health care such as improved health care technology and the economic pressure of managed care have led to shortened hospital stays (O'Neil & The Pew Health Professions Commission, 1998) and a movement in the delivery of health care, induding social services, to community-based settings (Berkman & Volland,1997; Simmons, 1994). One of these community-based settings is home health care. During the 1990s home health care was one of Medicare's fastest growing benefits. Total Medicare spending on home health care rose from 3.2 percent ($3.7 billion) in 1990 to 9 percent ($17.8 billion) in 1997 (U.S. Department of Health and Human Services, 1999).

The expansion of home health care has been attributed to several factors, including liberalized government regulations regarding coverage of services, the Prospective Payment System's focus on abbreviated hospital stays, and the development of high technology for home-based care. The growing number of people over age 65, an increase in the number of HIV/AIDS patients, and children and adults with complex medical conditions, all of whom are living longer, also have contributed to the growing use of home health care (Kane, Kane, & Ladd, 1998; O'Neil & The Pew Health Professions Commission, 1998; Thomas & Payne, 1998).

The expansion of home health care offers new opportunities for social work practice (Egan & Kadushin, 1999). However, home health care also confronts workers with distinctive ethical dilemmas arising from limited community resources, restrictions on the type and amount of care funded, the challenges of chronic and acute illness, and the need to accommodate the multiple perspectives of patients, families, agencies, and reimbursement sources (Collopy, Dubler, & Zuckerman, 1990; Egan & Kadushin, 1999).

Despite the movement toward community-based care, and the potential for ethical conflicts to arise in home health care, empirically based research in this area is scarce. This study sought to provide this information by examining ethical conflicts in social work practice in home health care.

LITERATURE REVIEW

Most of the literature reviewed in this section is based on philosophical or conceptual discussions. Only four of the empirical articles that examined ethical conflicts in home health care included social workers in their samples (Clemens, Wetle, Feltes, Crabtree, & Dubitzky, 1994; Davitt & Kaye, 1996; Egan & Kadushin, 1999; Healy, 1998).

An ethical dilemma occurs when social workers must choose between two contradictory ethical principles or directives, or when every alternative would result in an undesirable outcome for one or more individuals (Loewenberg & Dolgoff, 1996). Ethical dilemmas also involve conflicts between interested parties or stakeholders who have an investment in the issue under consideration. Conflicts may arise between patients, families, agency staff, and government regulations or third-party reimbursement sources (Clemens et al., 1994; Clemens & Hayes, 1997; Foster & McLellan, 1997; Foster, Sharp, Scesny, McLellan, & Cotman, 1993; Kane & Caplan, 1993; Proctor, Morrow-Howell, & Lott, 1993).

Ethical tensions often arise in home care between the ethical commitment to the patient's autonomy or self-determination and to the patient's well-being. These conflicts are most likely to occur when client safety is in question as a result of decreased mental and physical capacity, or there is a lack of access to formal or informal resources (Clemens et al., 1994; Collopy, 1988; Collopy et al., 1990; Galambos, 1997; Healy, 1998; Hofland, 1993). Because family members provide the majority of home health care, balancing the patient's and family's right to self-determination also may create ethical conflicts for practitioners (Arras & Dubler, 1994; Collopy et al., 1990; Galambos, 1997).

The right to exercise self-determination rests on the premise that the client is mentally competent to make the choice in question (Reamer, 1998a). The assessment of mental competence in the home can be complicated by the fact that clients are seen only intermittently in contexts surrounded by family and familiar routines (Collopy et al., 1990; Reamer, 1998a). Mental competence also fluctuates and is decision specific: A client may be considered incompetent to make decisions about handling financial matters, yet competent to make a decision about living arrangements (Reamer, 1998a). Workers who experience difficulty assessing mental competence may experience an ethical dilemma in deciding whether to support patient autonomy when patient safety is an issue (Galambos, 1997; Healy, 1998; Kane & Caplan, 1993).

Since 1991 the Patient Self-Determination Act (PSDA) of the Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508) has required health care facilities receiving Medicare or Medicaid funding to inform patients of their right to make decisions about life-sustaining treatments in advance directives (Kapp, 1995; Soskis & Kerson, 1992). Social workers may encounter ethical dilemmas in implementing the PSDA if the home health agency has not developed policies and procedures regarding advance directives (Davitt & Kaye, 1996) or if there is a disagreement among health care providers, patients, and families in implementing an advance directive (U.S. Department of Health and Human Services, 1995).

Finally, social workers may experience ethical conflicts regarding access to services when government regulations, reimbursement limits of third-party payers, or agency fiscal priorities conflict with client needs for care. Under Medicare (health insurance for people age 65 and older and the disabled) patients are eligible for home health services if they are homebound, require intermittent care, have potential for rehabilitation, and need skilled medical (nursing, speech, or physical therapy) care. Clients who meet these criteria are eligible to receive medical social work services. Thus, Medicare makes eligibility for social services contingent on the receipt of skilled medical care (Binney, Estes, & Ingman, 1990). Furthermore, Medicare does not cover other social services necessary to maintain patients in the community such as homemaking, meal preparation, or shopping (Kane, 1995).

The recent Interim Payment System (IPS) implemented as part of the Balanced Budget Act of 1997 (P. L. 105-33) may have reduced access to home health care services for Medicare clients. Before the implementation of IPS, home health care agencies were paid on the basis of their costs up to a pre-established limit. This system encouraged agencies to provide a high volume of services with little consideration of cost (Anonymous, 1998). The IPS attempts to control the cost and amount of services provided to beneficiaries through the application of payment limits (U.S. Department of Health and Human Services, 1999). The IPS reduces Medicare reimbursement to home care agencies by paying agencies the lower of their reasonable costs, a reduced aggregate cost limit per visit, or a new aggregate cost limit per beneficiary based on 1994 data and adjusted for an agency-specific regional blend (U.S. Department of Health and Human Services, 1999).

Preliminary research suggests that agencies are attempting to adjust their case mix and practice patterns to conform utilization to reimbursement demands. To reduce costs agencies are refusing to provide care for the sickest and frailest beneficiaries who require the highest intensity of service--that is, more services or longer duration of service--while targeting care to relatively healthy beneficiaries (Smith, 1999).

Proprietary agencies, which prior to the implementation of IPS, provided a higher intensity of service (Ellenbecker, 1995; Williams, 1994; Williams, McKay, & Torner, 1991) may have experienced greater reductions in Medicare reimbursement under the new payment system than nonprofit agencies (Anonymous, 1998); 83 percent of agency closures between October 1997 and January 1999 were proprietary agencies (U.S. Department of Health and Human Services, 1999).

Like Medicare, Medicaid (health insurance for people who cannot afford to pay) coverage for home health care services also emphasizes skilled medical care. Although some states have Medicaid waiver programs that provide coverage for social services, access to the programs is limited by highly restrictive functional and financial eligibility requirements (Smith, 1999). Finally, private insurance usually covers skilled medical services, but not social services (Benjamin, 1993).

A recent study (Egan & Kadushin, 1999) of social workers in home health care agencies in Wisconsin and Tennessee found that ethical conflicts related to self-determination, assessment of mental competence, implementation of advance directives, and access to services occurred most frequently. Workers in proprietary agencies reported that ethical conflicts over access to services occurred significantly more often than workers in nonprofit settings. Workers with diverse caseloads reported ethical conflicts over the implementation of advance directives as significantly more frequent than workers with solely elderly caseloads, presumably because diverse caseloads contained younger clients who are typically the recipients of high-tech home care.

This review suggests that there are distinctive ethical problems encountered in home care settings, that social workers encounter certain ethical problems frequently, and that the occurrence of these problems differs in relation to agency auspice and caseload composition. However, no research has examined systematically the factors involved in the ethical dilemmas experienced by social workers in home health care. This information is important because social work in home health care is an emerging field of practice characterized by restrictive reimbursement limits and diverse caseloads, which include frail elderly people and younger patients who are the recipients of high-technology home care. Research on the factors related to ethical conflicts in this complicated practice environment is necessary to help social workers effectively resolve ethical conflicts and to provide information to social work practitioners and educators, home health agency supervisors, and administrators. The purpose of this research was to examine the frequency of ethical conflicts and difficulty of resolving ethical conflicts in home health care in relation to the characteristics of social workers, their agencies and patient caseloads, the participants (stakeholders) involved, and the resources that practitioners consulted to resolve conflicts.

METHOD

Design and Sampling Procedures

The study was implemented in fall 1998 through a survey mailed to all members of the American Network of Home Health Care Social Workers (N = 673), the only national professional organization for social workers in the field of home health care. It is estimated that network members comprise about 10 percent of the social workers employed full-time in Medicare-certified home health agencies nationally (National Association for Home Care, 1999). The mission of the network is to promote the exchange of knowledge and to offer mutual support to social workers involved in home health care" (American Network of Home Health Care Social Workers, 2000). Forty-eight additional non-network member social workers also were included in the sampling (N = 721). A total of 408 completed questionnaires were returned. Of the questionnaires returned, 44 (10.8 percent) were from practitioners who, because they were no longer in home health care practice, were ineligible. Extrapolation of the ineligible proportion to the original to tal of potentially eligible social workers resulted in a response rate of 57 percent (N = 364) of eligible participants.

Measurement

The questionnaire was developed from the relevant literature and was pilot tested with 19 social workers in home health care. Four ethical conflicts previously identified in the literature as specific to social work practice in home health care (Clemens et al., 1994; Egan & Kadushin, 1999; Healy, 1998; Kane & Caplan, 1993) were included in the questionnaire. The four conflicts were identified and operationally defined in the questionnaire as follows: access to services (defined as "a conflict arises between your agency's fiscal needs or reimbursement limits of third-party payers and patient care needs"); assessing a patient's mental competence (defined as "you are unsure whether a patient is competent enough to choose or refuse medical care or to stay at home"); self- determination (defined as "a competent patient makes a decision which in your opinion threatens his or her well-being, or a patient and his or her family disagree about care"); and implementation of advance directives (defined as "staff do not f ollow agency policy regarding implementation of advance directives, or conflict arises between involved parties concerning the implementation of advance directives").

Respondents rated on Likert scales how often each ethical conflict occurred (0 = never to 4 = very often) and how difficult each conflict was to resolve (0 = not at all difficult to 4 = extremely difficult). In respect to each ethical conflict, respondents identified which of nine types of stakeholders (for example, the patient, yourself, your supervisor, your administrator, or other staff) were typically involved and which of 10 resources (for example, social work and nursing colleagues, the agency administrator, or the code of ethics) were consulted in resolving each conflict. Furthermore, social workers rated the helpfulness of each resource they consulted for each ethical conflict (1 = not helpful to 6 = extremely helpful).

In a second section, respondents rated how often they believed they had compromised professional ethics overall (0 = never to 4 = very often) and identified the most common reason among eight possible reasons--that is, conforming to government regulations, conforming to the limits of reimbursement of third-party payers, conforming to agency policy, or decisions and requests of supervisors, physicians, nurses, patients, or patients' families--for their ethical compromise. Social workers also indicated if they had any ethics training, defined as professional ethics courses, content on ethics in other courses, workshops, or conferences. Last, workers responded to three questions concerning ethics committees. First, respondents indicated whether their agencies had ethics committees and, second, whether they participated on the committee. Third, if they participated on their agency's ethics committee, respondents rated their influence in the committee's decision making (1 = minimal influence to 5 = strong influen ce). Demographic characteristics were collected about the social workers and their caseloads and agencies.

Analysis

All data from the questionnaires was entered in SPSS 8.0. Data from workers in hospice-only agencies (n = 27) were omitted from the present analyses because of differences in policies, philosophical approaches to service delivery, and reimbursement mechanisms between hospice and home health care settings. Univariate analyses provided descriptive statistics of all variables, and bivariate and multivariate analyses were computed to examine the relationships among variables.

FINDINGS

Sample and Agency Characteristics

The majority of the sample had social work degrees (80 percent MSW and 17 percent BSW), worked in nonprofit agencies (70 percent), and had an average of nearly seven years of practice experience in home health care (M = 6.9 years, SD = 4.8 years). Although the network does not collect demographic information about its members with which to compare the sample, the sample is similar demographically to that of a previous national survey that included network members in its sampling frame (that is, 81 percent MSW; 64 percent nonprofit) (Stark, 1997). The majority of the sample had ethics training (84 percent). Nearly two-thirds (65 percent) of the respondents were in agencies with ethics committees. Although less than one half of workers in agencies with ethics committees participated on these committees (46 percent), those who participated rated themselves as fairly influential in committee decision making (M = 3.4, SD = 1.3). Although significantly more respondents in nonprofit than in proprietary agencies repo rted that their agencies had ethics committees [[chi].sup.2](1, N= 328) 28.15,p [less than] .0001], workers' participation and influence on these committees were similar in both nonprofit and proprietary settings.

Caseload size--that is, number of patients per month--was moderate (M = 26). On average, elderly patients made up large proportions of caseloads (elderly with basic psychosocial needs = 47.7 percent; elderly with complex psychosocial needs = 32.8 percent). Although comprising smaller caseload proportions, three quarters of the respondents included adults with basic (75 percent) and complex (77 percent) psychosocial needs; one-third (35 percent) included children, and one-quarter (26 percent) included HIV/AIDS patients in their caseloads. Only 12 percent of the respondents indicated caseloads consisting solely of elderly patients. Most respondents (91 percent) reported that their caseloads included patients receiving high-tech medical care. The composition of practitioners' caseloads differed by auspice only on the inclusion of children (for profit = 20 percent, nonprofit = 38 percent) [[[chi].sup.2](1, N = 306) = 9.l, p = .01].

Frequency and Difficulty of Ethical Conflicts and Variables Influencing Frequency and Difficulty

Social workers rated three ethical conflicts as similarly frequent and difficult to resolve. That is, assessing patients' mental competence, patient access to services, and patient self-determination were moderately frequent (M = 2.3, SD = 1.1; M = 2.5, SD = 1.3; M = 2.4, SD = 1.1, respectively) and difficult (M = 2.8, SD = .97; M= 2.7, SD = 1.1; M = 2.6, SD = .89, respectively), whereas conflicts over advance directives was less frequent (M = 1.1, SD = 1.0) and less difficult (M = 1.7, SD = 1.1).

Ethical conflicts over access to services were found to be significantly more difficult for workers employed in proprietary than in nonprofit settings [t(248) = 2.04, p = .04]. Workers with high-tech patients rated ethical conflicts over access as more frequent [t(276) = -2.27, p = .02], and difficult [t(232) = -2.89, p = .004], than workers without high-tech patients in their caseloads. Conflicts over advance directives also were rated as significantly more difficult to resolve by workers with high-tech patients than by workers without these patients [t(195) = -2.26, p = .03]. The frequency and difficulty of each ethical conflict was not related to workers' years of experience in home health, education, or ethics training.

Stakeholders

Data on the nine types of stakeholders were analyzed descriptively, the total types of stakeholders for each conflict were summed, and the relationship between the frequency and difficulty of each conflict and total types of stakeholders was examined (Table 1). Nearly all respondents indicated the involvement of multiple types of stakeholders in each conflict. Not surprisingly, patients, and, to a lessor extent, their families, were identified by most respondents as stakeholders in each conflict (Table 1). On average, conflicts regarding assessment of patients' mental competence involved the most stakeholders (M = 4.6, SD = 2.2), and implementation of advance directives involved the fewest (M 3.4, SD = 2.2). The total stakeholders in each ethical conflict and the frequency and difficulty of resolving that conflict were positively and significantly correlated (Table 1).

Resources for Resolving Ethical Conflicts

Data on which resources workers consulted and their ratings of the helpfulness of these resources was analyzed descriptively for each ethical conflict, the proportion of respondents using each resource was aggregated across conflicts, the mean helpfulness of each resource was aggregated across conflicts (Table 2), and the relationship between the frequency and difficulty of each conflict and the helpfulness of resources was examined (Table 3). Although the resources consulted differed among conflicts, aggregated across conflicts, most respondents identified consulting nurses (93 percent) and social workers (91 percent). Social work colleagues received the highest helpfulness ratings in each ethical conflict area and in the aggregate (M = 4.5, SD = 1.1) (Table 2). Correlation computations revealed several significant relationships among the frequency and difficulty of resolving conflicts and the helpfulness of nursing colleagues, social work colleagues, and administrators (Table 3).

Multiple Regression Analysis

Because the four ethical conflicts are distinguished by their focus and the ethical principles involved, separate regression models were generated to examine independent variable predictors of the frequency and the difficulty of each ethical conflict. Regression models were generated on the basis of the bivariate findings from this study and previous research (Egan & Kadushin, 1999; Kaye & Davitt, 1999; U.S. Department of Health and Human Services, 1999). Thus, agency auspice (1 = for profit, 0 = nonprofit) was included in the regression analyses of ethical conflicts over access to services and high-tech patients in workers' caseloads (0 = not included, 1 = included) were included in the regression analyses of both conflicts over implementation of advance directives and confficts over patient access to services. Total types of stakeholders involved in each conflict were included, as were the helpfulness ratings of resources found to be significantly correlated with ethical conflicts at the p [less than] .004 level. These criteria were set because of the number (12) of correlation analyses required for each independent variable. Multiple regression analyses with simultaneous entry of independent variables and standardized regression coefficients were computed to determine the unique contribution of each predictor to the frequency of each ethical conflict and the difficulty of resolving each ethical conflict and to provide comparison of the relative contribution of each predictor.

Regression analyses of the frequency and the difficulty of resolving conflicts over patient self-determination found that total types of stakeholders involved was a significant predictor in a model explaining 7 percent of the variance in the difficulty of resolving ethical conflicts [F(2, 275) = 11.208, p [less than] .001] over patient self determination, whereas both total types of stakeholders and the helpfulness of social work colleagues were significant predictors in explaining 7 percent of the variance of the frequency of the conflict [F(2, 290) = 11.768,p [less than] .001 (Table 4).

The total types of stakeholders was also a significant predictor in a model explaining 12 percent of the variance in the frequency [F(3, 177) = 8.909,p [less than] .001] and 14 percent of the variance in the difficulty of resolving ethical conflicts [F(3, 171) = 10.227, p [less than] .001] over advance directives. The helpfulness of nursing colleagues contributed significantly to the explanation of both the frequency and difficulty of resolving this conflict. However, high-tech patients in workers' caseloads did not contribute significantly to the explanation of variance for either the difficulty or the frequency of this conflict (Table 5).

Total stakeholders and the helpfulness of administrators were significant predictors in regressions explaining 11 percent of the frequency [F(4, 196) = 7.349,p [less than] .00 1] and 13 percent of the difficulty [F(4, 183) = 7.730,p [less than] .001] of resolving ethical conflicts over patients' access to services. High-tech patients was a significant predictor of the difficulty of resolving, but not the frequency, of ethical conflicts over access (Table 6). Auspice was not a significant predictor of either frequency or difficulty of ethical conflicts over access.

Because the frequency and difficulty of resolving ethical conflicts over assessing patient's mental competence were significantly related to only one independent variable--that is, total types of stakeholders involved--generation of a regression model for this ethical conflict was not appropriate.

Compromising Professional Ethics

On average, respondents reported that they rarely had to compromise their ethics (M = 1.3, SD = 1.0). One of five respondents (21 percent) reported that they "never" (that is, "0") compromised their professional ethics. Reimbursement limits (50 percent) and government regulations (36 percent) were identified by more respondents as the "most common reason" for compromising professional ethics than other reasons such as requests or decisions of patients or families (15 percent), physicians (10 percent), or supervisors (8 percent). Limits of reimbursement was identified as the most common reason for compromising professional ethics significantly more often by practitioners whose caseloads included elderly patients with basic, Fisher's exact [[[chi].sup.2](1, N = 280) = 4.72, p = .04], and elderly patients with complex psychosocial needs, Fisher's exact [[[chi].sup.2](1, N= 281) = 7.62, p = .007], than by workers whose caseloads did not include these patients. Neither the frequency nor reasons for compromising et hics were significantly related to the frequency and difficulty of ethical conflicts.

Ethics Training and Worker Influence on Ethics Committees

Although respondents with and without ethics training reported similar ratings of the frequency and reasons for compromising professional ethics, among participants on their agency ethics committees, those with ethics training rated their influence (M = 3.5) on those committees as significantly greater [t(106) =-2.33,p=.02] than participants without training (M = 2.6).

DISCUSSION

The findings, their interpretation, and generalization are limited by both the nonrandom sampling procedure and the cross-sectional design used in the study. Also, because there is no existing demographic information on the membership of the network, the sample obtained cannot be analyzed for representativeness. Thus, it is possible that the findings are a reflection of characteristics of the respondents that have not been detected. Lastly, because the network membership comprises only a small proportion of all social workers in the field, caution in interpretation of the findings is warranted.

The variance explained in the regression analyses of the frequency and difficulty of resolving the ethical conflicts was small. The small variance obtained in the regressions may relate to undetected characteristics of the sample or to the homogeneity of the sample in terms of education, ethics training, and agency auspice. The restricted range of the scales measuring the dependent variables (0-4) also may have contributed to the small amount of variance explained. In addition, the small explanations of variance may relate to variables that were not addressed in the study, such as the profession providing supervision to home health care social workers and the presence of clients in workers' caseloads with a diagnosis of Alzheimer's disease or dementia. With regard to the former variable, more home health care social workers receive supervision from other professions (for example, nurses or therapists) than from social workers (Stark, 1997), and this may influence their ability to recognize and resolve ethical dilemmas. With regard to the latter variable, patient confusion was identified as a significant predictor of ethical conflicts in hospital social work (Proctor et al., 1993), presumably because confused patients may not be capable of decision making, require more intensive care, and are difficult to assess. Additional variables not addressed in this study that may relate to the small explained variance obtained in the regression analysis of access to services are identified in the discussion of those findings. However, given these caveats the study does provide new empirical findings and advances knowledge about ethical conflicts in home health care. The frequency of ethical conflicts found in this study is consistent with previous research with the exception of conflicts over implementing advance directives. This difference in findings may relate to differing measurement approaches because the Egan and Kadushin (1999) survey did not provide a definition of ethical conflicts over advance directives, whereas in this study the conflict was explicitly defined in the questionnaire. It is unclear why relationships among worker demographic characteristics (level of education, ethics training, and years of experience in home health care) and the dependent variables were not found. Although the homogeneity of the sample may be a factor, this question should be addressed in future research.

The regression analyses found that total types of stakeholders involved contributed significantly to the explanation of variance in the frequency and difficulty of each ethical conflict, suggesting the importance of understanding stakeholders' perspectives in ethical conflicts in home health care. This analysis supports previous research, which found a significant relationship between the occurrence of ethical dilemmas in hospital discharge planning and the number of parties involved (Proctor et al., 1993). Similarly, findings in this study suggest that ethical conflicts may involve accommodation to the interests of many parties. That is, the interests of the patient, although a primary ethical commitment for social workers, may have to be balanced with the interests of family members, other home health agency staff or agency fiscal needs, and external reimbursement and regulatory systems (Collopy et al., 1990). Thus, the relationship between increases in the total types of stakeholders involved in an ethical conflict in home health care, and greater frequency and difficulty of resolving conflicts, may suggest a need to balance multiple and competing interests. It may also be that as more total types of stakeholders are involved in an ethical conflict, differences among various professional perspectives, or the priorities of those in various roles in the agency, are exacerbated.

It might have been anticipated that ethical conflicts over access to services would be more frequent and more difficult given the implementation of the IFS. However, the influence of IPS may be a factor in the finding that the most common reasons identified by most respondents for compromising ethics were government regulations and reimbursement limits and that practitioners with caseloads including elderly patients with complex and basic psychosocial needs identified reimbursement limits as the most common reason for ethical compromise more often than workers without these patient groups in their caseloads.

The small explanations of variance obtained in the regression analyses for access to services may relate to a variable not addressed in this study -- patients' payment sources (for example, Medicare, Medicaid, and private insurance). Previous research has identified payment source as a predictor of ethical conflicts in hospitals (Proctor et al., 1993) because patients who lack adequate insurance may experience more difficulty gaining access to resources. Because agency auspice was not a significant predictor of either the frequency or the difficulty of conflicts over access to services, it is suggested that, in addition to the variable of auspice, future research include variables such as agency case mix, agency size, agency geographic location, and whether an agency's per beneficiary costs vary from the regional average (Komisar & Feder, 1998; Lewin Group, 1998; Medicare Payment Advisory Commission, 1999) to understand the effect of the IFS on home health care agencies. Social workers also reported ethical conflicts over access to services as less frequent and less difficult with greater helpfulness of their agency administrators, suggesting that administrators maybe pivotal decision makers in these conflicts.

The significance of high-tech patients in workers' caseloads in the difficulty of resolving conflicts over access to services supports previous suggestions in the literature that as agencies attempt to control their case mix to avoid costlier patients, access to services may be restricted for high-tech patients who require a high intensity of service (Anonymous, 1998; Dombi & St. Pierre, 1998; Metzler & Peale, 1998; Smith, 1999). In addition, the exclusion of home drug infusion therapy from current Medicare coverage may limit access to services for high-tech patients (Balinsky & Mollin, 1998; Kane, 1995).

Social workers experienced ethical conflicts over advance directives as less frequent and less difficult to resolve because nursing colleagues were perceived as more helpful. Research suggests that home health care agencies delegate responsibility for the discussion of advance directives to nurses during the initial home visit (Davitt & Kaye, 1996). Therefore, nurses may encounter and resolve these ethical conflicts with clients and families without a referral to social work, thus reducing the occurrence and difficulty of these conflicts from the perspective of social work. It is also possible that because these conflicts involve biomedical and psychosocial issues they are regarded by both social workers and nurses as falling within the professional domain of nursing to a greater extent than social work, thereby curtailing social work involvement in these situations and reducing the frequency and difficulty of these conflicts for social workers (Foster, Sharp, Soesny, McLeilan, & Cotman, 1993).

The helpfulness of social work colleagues as a significant predictor of the frequency of ethical conflicts over patient self-determination may reflect the importance of this ethical principle for social workers as discussed in the professional literature (Clemens et al., 1994; Healy, 1998; Kane & Caplan, 1993; Kapp, 1995; Reamer, 1998a). Thus, social work colleagues may readily identify these conflicts and support the importance of raising them.

The relationship of training in ethics and perceived greater social worker influence on ethics committees may reflect research reporting that worker with ethics training are more skillful in communicating about ethical issues (Joseph & Conrad, 1989). Thus, skill in communication may shape the perception of more influence among workers with ethics training.

In summary, the findings suggest that ethical conflicts in home health care involve social workers in complicated negotiations in an environment affected by restrictive reimbursement policies and multiple stakeholders. In this stressful environment, social workers identified nursing and social work colleagues and agency administrators as helpful resources, suggesting the importance of skillful collaboration in negotiating ethical issues.

IMPLICATIONS FOR PRACTICE, ADMINISTRATION, AND EDUCATION

This research suggests several implications for practice, supervision, and education. With regard to practice, because reimbursement restrictions may create pressures for workers to restrict access to services or prematurely terminate care to patients who require a higher intensity of service, social workers may confront competing ethical obligations to avoid abandoning clients while honoring commitments to their employing agencies (Reamer, 1998a; Reamer, 1998b). In these situations, social workers are ethically obligated to advocate for patients in their agencies and, at a wider social level, for health care regulatory reform through the political process. In the agency, it may be helpful to target advocacy efforts to, and develop ongoing alliances with, administrators.

In resolving ethical conflicts it may be advisable for workers to focus not only on labeling the conflicting ethical principles in a situation, but also on understanding the perspectives of involved stakeholders. When there is discretion about the involvement of additional stakeholders in an ethical conflict, workers may want to weigh carefully whether the benefit of involving more parties is worth the risk arising from the possible increase in the frequency and difficulty of conflicts.

With regard to supervision and administration, supervisors and administrators may wish to examine the criteria nurses apply in referring cases involving ethical conflicts over the implementation of advance directives to social work to determine whether social workers are underused in these situations. In providing supervision, supervisors may focus not only on developing workers' understanding of conflicting ethical principles in a situation, but also on analyzing the interests of involved stakeholders. Finally, supervisors may want to monitor closely and provide support to workers with caseloads that include a high proportion of high-tech patients or elderly patients who may be negatively affected by reimbursement limits.

With regard to education, this study suggests that specific content may be considered for inclusion in the curricula of graduate schools and continuing education programs. It may be advisable to develop case studies and course content that includes the interests of involved stakeholders, as well as competing ethical principles, and emphasizes the development of skill in ethical conflict analysis and decision making. Field placements that provide opportunities for interdisciplinary collaboration may help students develop an understanding of the perspectives of other professionals who may be involved as stakeholders in ethical conflicts. The development of skills in conflict mediation, negotiation, and advocacy is suggested both through field and through classroom experiences.

To prepare social workers to participate in situations involving ethical conflicts over advance directives, educators may wish to develop course content and case studies to help students understand how to give comparative weight to the patients' prognosis, treatment options, the risks and benefits of different treatments, and the rights and interests of patients and families in making these decisions (Foster et al., 1993). It may also be advisable to help students understand their ethical obligation to avoid abandoning clients while maintaining their commitment to the agency when access to resources are restricted.

Future research should focus on enhancing the profession's knowledge of ethical conflicts in home health care by examining whether the inclusion of additional worker, client, and agency characteristics and the use of random sampling from a larger population of home health social workers results in greater explanations of variance than were found in this study.

ABOUT THE AUTHORS

Goldie Kadushin, MSW, PhD, is associate professor, School of Social Welfare, University of Wisconsin-Milwaukee, PO Box 786, Milwaukee, WI 53201; e-mail: kadushin@uwm.edu. Marcia Egan, MSW, PhD, is associate professor, College of Social Work, University of Tennessee, Memphis. An earlier version of this article was presented at the 46th Annual Program Meeting of the Council on Social Work Education, New York, February 2000, and at the 35th Annual Meeting of the Society for Social Work Leadership in Health Care, Orlando, June 2000.

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Table 1.
Stakeholders Involved in Ethical Conflicts
 Access to Advance
 Services Directives
Type of Stakeholder (%) (%)
Patient 62 56
Yourself (social worker) 65 35
Family 51 59
Your supervisor 44 15
Your administrator 48 8
Other staff in your agency 49 40
Your agency policies 52 21
Policies outside your agency 44 12
Staff in other agencies 35 13
Percent identifying multiple stakeholder 94 90
 Mental Self-
 Competence Determination
Type of Stakeholder (%) (%)
Patient 86 87
Yourself (social worker) 73 54
Family 84 87
Your supervisor 36 20
Your administrator 17 11
Other staff in your agency 70 67
Your agency policies 19 18
Policies outside your agency 26 20
Staff in other agencies 49 31
Percent identifying multiple stakeholder 95 95
 M SD M
Total stakeholders in conflict 4.4 2.6 3.4
Correlation of total stakeholders and
 frequency of ethical conflict r= .41 *** r= .37 ***
Correlation of total stakeholders and
 difficulty of ethical conflict r= .27 *** r= .40 ***
 SD M SD
Total stakeholders in conflict 2.2 4.6 2.2
Correlation of total stakeholders and
 frequency of ethical conflict r=.40 ***
Correlation of total stakeholders and
 difficulty of ethical conflict r=.41 ***
 M SD
Total stakeholders in conflict 4.0 1.8
Correlation of total stakeholders and
 frequency of ethical conflict r=.27 ***
Correlation of total stakeholders and
 difficulty of ethical conflict r=.28 ***
NOTE: Bold numbers indicate top three most frequently identified
stakeholders in each ethical conflict.
(***)p [less than] .001, two-tailed.
Table 2.
Resources Consulted and Means for Helpfulness of Resources
in Ethical Conflicts
 Ethical Conflicts
 Access
 % M
Resources Consulting Helpfulness
Social work colleagues 87 4.2
Physician colleagues 67 2.5
Nurse colleagues 89 3.4
Your agency administrator 86 3.7
Your agency supervisor 89 3.9
Your agency policies 89 3.3
Your agency ethics committee 48 3.1
Government regulations 77 2.6
Third-party payer policies 83 2.5
NASW Code of Ethics 73 3.4
 Mental Self-
 Competence Determination
 % M %
Resources Consulting Helpfulness Consulting
Social work colleagues 92 4.5 94
Physician colleagues 89 3.7 73
Nurse colleagues 98 3.8 98
Your agency administrator 78 3.1 82
Your agency supervisor 87 3.7 90
Your agency policies 77 3.0 89
Your agency ethics committee 53 3.4 57
Government regulations 75 2.9 86
Third-party payer policies 42 2.0 64
NASW Code of Ethics 77 3.7 89
 Advance
 Directives
 M % M
Resources Helpfulness Consulting Helpfulness
Social work colleagues 4.8 92 4.5
Physician colleagues 2.9 77 3.2
Nurse colleagues 3.6 85 3.6
Your agency administrator 3.3 76 3.3
Your agency supervisor 3.9 85 3.7
Your agency policies 3.2 88 3.7
Your agency ethics committee 3.6 57 3.6
Government regulations 2.7 73 3.2
Third-party payer policies 1.9 43 2.1
NASW Code of Ethics 3.9 77 3.9
 Aggregated
 % M
Resources Consulting Helpfulness
Social work colleagues 91 4.5
Physician colleagues 77 2.4
Nurse colleagues 93 3.6
Your agency administrator 81 3.4
Your agency supervisor 88 3.8
Your agency policies 87 2.3
Your agency ethics committee 54 3.3
Government regulations 78 2.8
Third-party payer policies 58 2.3
NASW Code of Ethics 79 3.9
Table 3.
Correlations of Helpfulness Ratings
of Resources Consulted
 Ethical Conflicts
 Access
Resources Frequency Difficulty
Social work colleagues .03 .01
Physician colleagues -.11 -.04
Nurse collegues -.13 -.09
Your agency administrator -.25 * -.24 *
Your agency supervisor -.19 -.17
Your agency policies -17.00 -.19
Your agency ethics committee -20.00 -.14
Government regulations .15 -.14
Third-party payer policies -.06 -.14
NASW Code of Ethics -.07 -.03
 Mental Competence
Resources Frequency Difficulty
Social work colleagues .04 -.01
Physician colleagues -.09 -.05
Nurse collegues -.07 -.01
Your agency administrator -.04 -.01
Your agency supervisor -.02 -.02
Your agency policies -.11 -.12
Your agency ethics committee -.07 .01
Government regulations -.03 -.15
Third-party payer policies -.07 .19
NASW Code of Ethics -.09 -.08
 Self-determination
Resources Frequency Difficulty
Social work colleagues .18 * .17 *
Physician colleagues -.06 -.01
Nurse collegues .06 .11
Your agency administrator .08 -.01
Your agency supervisor .15 .03
Your agency policies .08 -.07
Your agency ethics committee .14 -.03
Government regulations .05 .01
Third-party payer policies .03 -.04
NASW Code of Ethics .07 -.03
 Advance Directives
Resources Frequency Difficulty
Social work colleagues -.09 -.13
Physician colleagues -.12 -.19
Nurse collegues -.21 * -.22 *
Your agency administrator -.15 -.13
Your agency supervisor -.18 -.10
Your agency policies -.07 -.17
Your agency ethics committee -.19 -.12
Government regulations -.02 -.02
Third-party payer policies -.03 -.10
NASW Code of Ethics -.11 -.08
(*)p [less than].004, two-tailed.
Table 4.
Regression Model for Predicting Frequency and Difficulty of Ethical
Conflicts over Self-Determination
Frequency
Variable B a p
Constant 1.426 [less than].001
Stakeholders .210 [less than].001
Social work colleagues .160 .005
Adjusted [R.sup.2] = .069
F(2,290) = 11.77 p[less than].001
Frequency Difficulty
Variable Variable B a
Constant Constant 2.004
Stakeholders Stakeholders .273
Social work colleagues Social work colleagues .015
Adjusted [R.sup.2] = .069 Adjusted [R.sup.2] = .069
F(2,290) = 11.77 p[less than].001 F(2,275) = 11.21
 p[less than].001
Frequency
Variable p
Constant [less than].001
Stakeholders [less than].001
Social work colleagues NS
Adjusted [R.sup.2] = .069
F(2,290) = 11.77 p[less than].001
NOTE: NS = not significant.
(a)Standardized regression coefficient.
Table 5.
Regression Model for Predicting Frequency and Difficulty of Ethical
Conflicts over Advance Directives
Frequency
Variable B a p
Constant 1.457 .011
High tech .017 NS
Stakeholders .300 [less than].001
Nursing colleagues -.178 .013
Adjusted [R.sup.2] = .116
F(3,177) = 8.91 p [less than].001
Frequency Difficulty
Variable Variable B a
Constant Constant 1.516
High tech High tech .047
Stakeholders Stakeholders .325
Nursing colleagues Nursing colleagues -1.77
Adjusted [R.sup.2] = .116 Adjusted [R.sup.2] = .137
F(3,177) = 8.91 p [less than].001 F(3,171) = 10.23
 p[less than].001
Frequency
Variable p
Constant [less than].001
High tech NS
Stakeholders [less than].001
Nursing colleagues .014
Adjusted [R.sup.2] = .116
F(3,177) = 8.91 p [less than].001
NOTE: NS = not significant.
(a)Standardized regression coefficient.
Table 6.
Regression Model for Predicting Frequency and
Difficulty of Ethical Conflicts over Access to Services
Frequency
Variable B a p
Constant 2.419 [less than].001
Auspice .009 NS
High tech .077 NS
Stakeholders .258 [less than].001
Administrators -.234 .001
Adjusted [R.sup.2] = .113
F(4, 196) = 7.35 p [less than] .001
Frequency Difficulty
Variable Variable
Constant Constant
Auspice Auspice
High tech High tech
Stakeholders Stakeholders
Administrators Administrators
Adjusted [R.sup.2] = .113 Adjusted [R.sup.2] = .126
F(4, 196) = 7.35 p [less than] .001 F(4,183) = 7.73 p [less than].001
Frequency
Variable B a p
Constant 1.956 [less than].001
Auspice .092 NS
High tech .191 .006
Stakeholders .252 [less than].001
Administrators -.193 .005
Adjusted [R.sup.2] = .113
F(4, 196) = 7.35 p [less than] .001
NOTE: NS = not significant.
(a)Standardized regression coefficient.
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Author:Kadushin, Goldie; Egan, Marcia
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Date:Aug 1, 2001
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