Eye on Ethics

Reflective Practice in Social Work — The Ethical Dimension
By Frederic G. Reamer, PhD
April 2013

Recently, I received an urgent voicemail message from a hospital social worker: “Please get back to me as soon as possible. I have a meeting tomorrow morning with our head of human resources, and I’m very nervous about it.”

Later in the day, I connected with the social worker and learned the following: He had been employed by the hospital for seven years and had never been disciplined. His current predicament began when his immediate supervisor called him in to discuss concerns about possible boundary violations and an alleged inappropriate dual relationship with a hospital patient. The social worker explained to me that in his personal life he is actively involved in a community-based group of parents who adopted children from China. The group sponsors a wide range of activities to support and enhance the children’s ethnic identity. Through this involvement, the social worker said, he and his wife had become very friendly with several other adoptive parents.

About three weeks earlier, one of the parents who had become a good friend was admitted to the social worker’s hospital for treatment of a chronic, debilitating infection. The friend did not receive social work services. During the friend’s hospital stay, the social worker occasionally stopped by his room to say hello and inquire about the friend’s health. The patient’s attending physician had collaborated professionally with the social worker in other hospital cases and was well aware of the patient’s friendship with the social worker.

One afternoon during the patient’s hospital stay, the physician contacted the social worker and explained that the patient was distraught after having just learned that he was diagnosed with bone cancer. According to the social worker, the physician asked the social worker to visit the patient and offer emotional support. The social worker visited the patient in his room and spent about an hour helping his friend process the distressing medical news.

The social worker documented this patient encounter in the hospital chart. During a random quality-control review of social workers’ chart entries, the hospital’s social work supervisor read the note and became concerned because the social worker had not been assigned to provide social work services to this patient. The supervisor learned of the social worker and patient’s friendship and notified the director of human resources, who documented this “incident” in the social worker’s personnel record and asked to meet with the social worker.

The Nature of Reflective Practice
In 1983, the late scholar Donald Schon published his influential and groundbreaking book The Reflective Practitioner: How Professionals Think in Action. Schon’s thesis, based on his extensive empirical research, was that the most skilled and effective professionals have the ability to pay critical attention to the way they conduct their work at the same time that they do their work. Schon coined the terms “knowing-in-action” and “reflection-in-action,” which suggest that some professionals can take a step back and think hard about what they are doing while they are doing it. The concepts are akin to the widely used social work concept “use of self.”

Ordinarily the concepts of knowing-in-action and reflection-in-action are applied to practitioners’ cultivation and use of technical skill, whether in surgery, architecture, town planning, engineering, dentistry, or psychotherapy. In my view, and as the above case demonstrates, social workers would do well to extend the application of these compelling concepts to their identification and management of ethical issues in the profession. Ideally, effective practitioners would have the ability to recognize and address ethical issues and challenges as they arise in the immediate context of their work, not later when someone else points them out. Put another way, social workers would have a refined “ethics radar” that increases their ability to detect and respond to ethical issues.

Of course, the most important benefit is client protection. However, an important by-product is self-protection, that is, the increased likelihood that social workers will protect themselves from ethics-related complaints.

Implementing Reflective Ethics Practice
Certainly the hospital social worker who called me with panic in his voice would have benefited from reflective ethics practice and highly sensitive ethics radar. Had he reflected on the ethical dimensions of the boundary challenges that emerged when he interacted with his friend and hospital patient, it is likely that this well-meaning practitioner would have avoided his unpleasant encounter with the human resources department. The social worker’s decision to visit his friend was not the error; that was a humane and compassionate gesture. The error, rather, was not reflecting on his role in that moment and managing the boundaries carefully, including discussing them with his friend and his supervisor.

In my experience, ethics-related reflection-in-action entails three key elements.

• Knowledge: Skillful management of many ethical dilemmas requires knowledge of core concepts and prevailing standards. Ethics concepts are addressed in professional literature and standards exist in several forms, including relevant codes of ethics, agency policies, statutes, and regulations. For example, the National Association of Social Workers’ Code of Ethics includes explicit standards pertaining to boundaries, dual relationships, and conflicts of interest (especially section 1.06). It would have been best for the hospital-based social worker to consult relevant literature and standards with regard to conflicts that can arise when a social worker encounters a friend or social acquaintance in the work setting. The hospital’s personnel policies also prohibit dual relationships that involve conflicts of interest.

In some cases, although not all, statutes and regulations address ethical issues. In the United States, both federal and state laws address various ethical issues, such as confidentiality, privileged communication, informed consent, and social workers’ ethical conduct. Such laws would not have been particularly helpful in the hospital social worker’s case, but often they are helpful and critically important, for example, when social workers must decide whether to disclose confidential information without clients’ consent to protect a third party from harm or whether parental consent is necessary to provide services to minors who seek help with substance abuse but insist that this information be withheld from their parents.

• Transparency: Reflective social workers who sense an ethical issue share their concern with supervisors, colleagues, and appropriate administrators. An effective way to protect clients and practitioners alike is to avoid any suggestion that the ethical issue is being handled “in the dark.” Such clarity demonstrates social workers’ good faith efforts to manage ethical dilemmas responsibly. When appropriate, clients should be included in the conversation.

• Process: Although some ethical decisions are clear-cut, many are not. The hospital social worker who contacted me was unsure about the best way to manage his involvement with a good friend who had become a patient. Unfortunately, the social worker did not notify his supervisor about the dilemma or seek consultation. He documented his lengthy hospital-room encounter with the patient, but doing so in the client’s hospital chart created the impression that the social worker was functioning in his professional capacity, not as a friend. My hunch is that had the social worker notified his supervisor of his friendship with the patient and made clear that any contact with the patient occurred as a friend, the social worker may have avoided any adverse personnel issues. What I have learned is that many ethical decisions are not simple events; they require a considerable, often painstaking, process.

During the course of the profession’s history, social workers have refined the art of reflective practice. Historically, these skills have been applied primarily to clinical, policy, advocacy, and administrative functions. Clearly, reflective practice should extend to ethics as well.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.