Course:SOWK551/2021/Developing Confidence Amidst Role Stress, Role Conflict, and Role Ambiguity in Healthcare

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Short Summary

Literature review on developing confidence amidst role stress, role conflict and role ambiguity in healthcare.

Introduction

Social work has existed in the healthcare field for decades. Working in tandem or direct opposition to other systems, the field of social work has progressed over time (Spitzer & Davidson, 2013). Among other roles, social work maintains the connection between the hospital and the broader systems within which it operates (Craig & Muskat, 2013). Unfortunately, with growing tensions between role stress, role conflict, and role ambiguity, confidence in the social work role and profession is being eroded. By exploring confidence at the micro level with social workers and other healthcare professionals, we can begin to address ways to proactively mitigate these concerns.

This literature review sought to include a broad population sample and definition as the terms “social worker”, “healthcare worker”, “allied health”, “confidence”, "resilience", and “self-efficacy” were utilized. Research untaken in the last 10 years was prioritized however when appropriate, the research was expanded. Data from Canada was prioritized although, countries where social workers occupy similar roles in healthcare was also used.

Positionality of Social Work

Social work vacillates between being bold and being invisible (Cootes et al., 2020). Claiming roots in social justice and advocacy, social workers in healthcare walk the line between being of service to the people (Craig & Muskat, 2013) and service to the state (Morris et al., 2021). Social workers seek to promote the client's best interests (British Columbia College of Social Workers, 2009). Approaches like person-centered care (Spitzer & Davidson, 2013; Washburn & Grossman, 2017),  consumer-directed care (Veet et al., 2022), and service-user-led care (Choy-Brown, 2020) appear at the heart of the profession. They are shown to be the gold standard, not the exception. Social workers strive to walk alongside service users, "forming a partnership against the common foe" (Horvath et al., 1994, as cited by Ness et al., 2014).

Definition and Role of Confidence

Given social work’s positionality, it makes sense that the concept of self-confidence is a point of interest within research, organizations and amongst social workers themselves. Confidence is described by Bandura (1977) as a conviction that one can successfully accomplish a task that they set out to. Confidence levels might change depending on strength and generality (Bogo et al., 2017; Zimmerman, 2000). Instead of being a static quality or personality feature, confidence is based on one's ability to execute a task (Stankov & Lee, 2008).

The ability and longevity within a job are influenced by confidence (Bogo et al., 2017). This is shown in the research by Bogo et al. (2017), who found that the high-confidence social workers maintained attention with clients and saw their fear as challenging rather than overwhelming. In a simulation, Regher et al. (2010) were able to investigate confidence levels among social workers who were conducting risk assessments. According to Regher et al. (2010), low levels of stress were the foundation for high confidence levels. Workers who already lacked confidence were more likely to become stressed out throughout the simulation since confrontation worsened their emotional condition (Regher et al., 2010). In their investigation of healthcare providers and disaster response providers in Italy during the pandemic, Vagni et al. (2020) focused on the effects of workers' emotional states and confidence. Using self-regulation techniques, disaster response healthcare staff could prevent pandemic-related negative thoughts and emotions, allowing them to continue working with fewer side effects. Importantly, low confidence may also be present in workers who believe that their actions will do little to effect the environment around them (Bandura, 1977).

Gaining Professional Confidence

Knowledge acquisition and confidence are interrelated. In Vagni et al.'s (2020) study, healthcare workers experienced magnified stress due to the pandemic, resulting in lower confidence levels. Supported by Regher et al. (2010) study of social workers during an educational simulation, high confidence levels were ascribed to training that addressed knowledge acquisition, self-awareness and self-regulation. There are several ways to increase confidence, according to Bandura (1977), including emotional stimulation, verbal persuasion, vicarious experience, and performance successes. Desensitization over time results in emotional arousal. As they start to understand what is expected of them in the scenario and make the necessary adjustments, social workers who are under extended stress may experience a decrease in anxiety. This tactic however, does not support the worker by providing coping mechanisms and may cause the worker to experience harm in the process. Through thorough conversation, verbal persuasion can boost confidence. Similar to emotional arousal, this strategy might not directly address the need for self-regulation techniques, but it might help employees gradually become more self-aware. Shadowing is a way to engage in vicarious experiences. Although it can be highly beneficial, vicarious experience does not give the user the chance to rehearse and go through any possible feelings (Bandura, 1977; Bogo et al., 2017). Learning outcomes necessitate student participation in activities like simulation. Performance accomplishments result in the most generalizable advantages since they let the employee put abilities to use and get accustomed to potentially difficult situations (Bandura, 1977).

Role Stress

It is no secret that social work is a stressful and demanding profession. Frequently on the front lines of healthcare, social workers encounter the full breadth of human emotion. With funding shortages, higher complexity of clients, systemic barriers, and resource gaps, social workers must contend with more than ever before (Cootes et al., 2020; Craig & Muskat, 2013; Morris et al., 2021). In addition, neoliberal policy reforms have prioritized efficiency, forcing social workers to shift focus from people to administrative tasks such as documentation, reports, and meetings (Negura & Lévesque, 2022). As a result, social workers are at higher risk of stress and burnout than any other occupation, with professional retention being an average of 8 years (Curtis et al., 2010 & Lloyd et al., 2002, as cited by Negura & Lévesque, 2022). Social work is embodied work as the relational, biological, political, historical, economic, and social impacts of the people and systems around them are embedded in the workers themselves (Negura & Lévesque, 2022; Smeeton & O'Connor, 2020). Not surprisingly, social workers commonly experience embodied reactions such as moral injury, compassion fatigue, and PTSD.

Role Conflict

Social workers experience internal and external conflict within their roles as professionals. Such has been the reality of social work since its humble beginnings, with Mary Richmond representing the individual and clinical aspects of social work and Jane Addam's representing the profession's community and social justice aspects (Maylea, 2021). Social workers must balance thinking big (Cootes et al., 2020) while simultaneously addressing the immediate needs of those in front of them (Craig & Muskat, 2013). This fractured way of thinking and practicing often leaves social workers feeling that they have failed their clients and their duties (Morris et al., 2021). Some form of external role conflict has always existed in opposition to social work however, there is a "growing sense of unease within the profession at its ability to reconcile its social justice ambitions with the reality of the practice" (William & Briskman, 2015, p. 3 as cited by Maylea, 2021). With the rise of the biomedical model and the decline of social medicine, the value of social work is undermined (Cootes et al., 2020), and social workers' knowledge is often subjugated (Negura & Lévesque, 2022).

Role Ambiguity

Social work has been considered to be a “jack of all trades and master of none” (Cootes et al., 2020, p. 262) with ambiguity being both beneficial and a barrier. According to Craig and Muskat (2013), the profession's ambiguity is a particular predictor of burnout as social workers struggle to define and legitimize their own work. The social work role is vague resulting in given tasks that no other profession wants (Craig & Muskat, 2013). In a study conducted by MacAteer et al. (2016), there was a moderate negative correlation between role ambiguity and confidence amongst mental health staff which was comprised of allied health. Conversely, social workers experience unrealistic expectations placed upon them exacerbating social works distress (Negura & Lévesque, 2022). In Vancouver, social workers are tasked with finding service users housing amidst a housing crisis – an impossible task given the current climate. Within documentation it can appear that social workers are only offering practical services like application support or bus tickets when in reality, services go much deeper than that.

Gaining Confidence in the Profession

In recent years, in addition to the numerous calls to reform social work, some have called for its dissolution. Maylea (2021) has poignantly suggested that the profession is unsalvageable,  comparing social work to a "church so broad that it has no walls" (p. 6). For social workers on the front lines, in leadership positions, or at the forefront of research, this is an unhelpful suggestion. Further undermining or eroding the profession will only push social workers to reject the value of their epistemic contribution and confidence (Cootes et al., 2020). Interestingly, this was the case in Staniforth et al.'s research (2016, as cited by Garrett, 2021), as social workers held a more critical view of the profession than the public did when surveyed. In response to Maylea's call to action (2021), Garrett (2021) reminded us that "prisons are also constructed with walls" (p. 1139). A nod to Bentham's panopticon, this suggests that social workers are, in essence, surveilling themselves. No profession can successfully evolve without criticism or reflexivity; however, with ambiguity also comes freedom. Autonomy was felt to be crucial in promoting resilience, a derivative of confidence (Rose & Palattiyil, 2020).

Application to Practice

A two-pronged approach must be taken to promote confidence in healthcare social workers, as unilaterally addressing this issue is inadequate. Beginning with social workers themselves, we must remember that to be valued in healthcare, we must first value own our knowledge and experience; this can be done through documentation. By articulating skills and concepts that rarely permeate the walls of healthcare institutions, emancipatory language can finally coexist with that of the biomedical. Additionally, it is recommended that social workers actively counter isolation and the subjugation of their knowledge by seeking out community within healthcare. Communities of practice advance connection and prioritize social work values, ethics, and policy concerns.

Advancing confidence amongst social work practitioners from an organizational standpoint requires a robust response. Adequate supervision must be prioritized as it positively impacts outcomes for social workers and service users (Sewell et al., 2021). Finally, and perhaps the most imperative, is the provision of ongoing training that considers the aspect of emotional dysregulation and mindfulness. When emotions are dysregulated, the mind shuts down. Mindfulness techniques like those utilized by emergency healthcare workers during Covid-19 (Vagni et al., 2020) integrated with performance accomplishment training as proposed by Bandura (1977) are required within healthcare organizations and educational institutions to promote sustained confidence. Recommended research should encompass the integration of this model within educational institutions and healthcare facilities.

Conclusion

Gaining confidence in the field of social work is like swimming upstream as it requires active resistance and response. There is however, no better time than now for social workers to reassert themselves in healthcare. Developing confidence amongst social workers requires a response on micro and meso levels with an emphasis on tapping into and strengthening the qualities that social workers already possess. Doing so will decrease poor outcomes for social workers and service users alike.

References

• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215.
• Bogo, M., Regehr, C., Baird, S., Paterson, J., & LeBlanc, V. R. (2017). Cognitive and affective elements of practice confidence in social work students and practitioners. The British Journal of Social Work, 47(3), 701-718. https://doi.org/10.1093/bjsw/bcw026
• British Columbia College of Social Workers (2009). Code of ethics and standards of practice. https://bccsw.ca/wp-content/uploads/2016/09/BCCSW- CodeOfEthicsStandardsApprvd.pdf
• Choy-Brown,M., Stanhope, V., Williams, N., & Bond, L. (2020). Delivering person-centered care in community mental health programs. Research on Social Work Practice, 30(8), 907-917. https://doi.org/10.1177/1049731520944568
• Cootes, H., Heinsch, M., & Brosnan, C. (2022). 'Jack of All Trades and Master of None’? Exploring Social Work’s Epistemic Contribution to Team-Based Health Care, The British Journal of Social Work, 52 (1), 256–273, https://doi.org/10.1093/bjsw/bcaa229
• Kane, A., Yarker, J., & Lewis, R. (2021). Measuring self-confidence in workplace settings: A conceptual and methodological review of measures of self-confidence, self-efficacy and self-esteem. International Coaching Psychology Review, 16(1), 67-89.
• MacAteer, A., Manktelow, R., & Fitzsimons, L. (2016). Mental health workers' perception of role self-efficacy and the organisational climate regarding the ethos of recovery. The British Journal of Social Work, 46(3), 737-755. https://doi.org/10.1093/bjsw/bcv054
• Maylea, C. (2021). The end of social work. The British Journal of Social Work, 51(2), 772- 789. https://doi.org/10.1093/bjsw/bcaa203
• Mensinga, J., & Pyles, L. (2021). Embodiment: A key to social workers' wellbeing and attainment of social justice. Australian Social Work, 74(2), 131-133. https://doi.org/10.1080/0312407X.2021.1858472
• Garrett, M. (2021). ‘A world to win’: In defence of (dissenting) social Work—A response to Chris Maylea. The British Journal of Social Work, 51(4), 1131-1149. https://doi.org/10.1093/bjsw/bcab009
• Negura, L., & Lévesque, M. (2022). Understanding professional distress through social representations: Investigating the shared experience of healthcare social workers in Canada. International Social Work, 65(6), 1184-1200. https://doi.org/10.1177/0020872820967428
• Ness, O., Borg, M., Semb, R., & Karlsson, B. (2014). "Walking alongside:" collaborative practices in mental health and substance use care. International journal of mental health systems, 8(1), 55. https://doi.org/10.1186/1752-4458-8-55
• Regehr, C., Bogo, M., Shlonsky, A., & LeBlanc, V. (2010). Confidence and professional judgment in assessing children’s risk of abuse. Research on Social Work Practice, 20(6), 621-628. https://doi.org/10.1177/1049731510368050
• Rose, S., & Palattiyil, G. (2020). Surviving or thriving? Enhancing the emotional resilience of social workers in their organisational settings. Journal of Social Work, 20(1), 23–42. https://doi.org/10.1177/1468017318793614
• Smeeton, J., & O’Connor, P. (2020). Embodied social work practice within risk society. Journal of Social Work : JSW, 20(5), 673-691. https://doi.org/10.1177/1468017319860800
• Spitzer, W. J., & Davidson, K. W. (2013). Future trends in health and health care: Implications for social work practice in an aging society. Social Work in Health Care, 52(10), 959-986. https://doi.org/10.1080/00981389.2013.834028
• Stankov, L., & Lee, J. (2008). Confidence and cognitive test performance. Journal of Educational Psychology, 100(4), 961-976. https://doi.org/10.1037/a0012546
• Vagni, M., Maiorano, T., Giostra, V., & Pajardi, D. (2020). Coping with COVID-19: Emergency stress, secondary trauma and self-efficacy in healthcare and emergency workers in Italy. Frontiers in Psychology, 11, 566912-566912. https://doi.org/10.3389/fpsyg.2020.566912
• Veet, C. A., Winger, M. E., & Kinsky, S. M. (2022). Professional agency vs consumer directed care workers: Outcomes in managed care. Health & Social Care in the Community, 30(4), 1562-1567. https://doi.org/10.1111/hsc.13488
• Washburn, A. M., & Grossman, M. (2017). Being with a person in our care: Person-centered social work practice that is authentically person-centered. Journal of Gerontological Social Work, 60(5), 408-423. https://doi.org/10.1080/01634372.2017.1348419
• Zimmerman, B. J. (2000). Self-efficacy: An essential motive to learn. Contemporary Educational Psychology, 25(1), 82-91. https://doi.org/10.1006/ceps.1999.1016