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EDITORIAL
JUDITH W. ROSS
DECISION MAKING AND SOCIAL WORK:
ANOTHER LOOK
With the inauguration of a new administra-
tion that promises change, social workers have
high hopes that the wrenching economic and
social problems this country faces will be hon-
estly confronted and ameliorated. These prob-
lems willchallenge President Bill Clinton's abil-
ity to lead courageously and engage in
considered decision making.
During the seemin?ly interminable election
campaign, we were t~yated to a veritable circus,
replete with three rings, endless side shows, and
bravura performances. A plethora of debates,
talkathons, and infomercials exposed the pub-
lic to substantive ideas and hot-headed opin-
ions, considered analysesand hasty conclusions,
real and make-believe issues. The time isat hand:
Decisions must now replace conjecture, and
deeds must replace rhetoric.
The process of leading is fraught with deci-
sions. Some decisions are routine. Others are
extraordinary. Some willhave limited impact on
events or circumstances. Others will have pro-
found effects. How will our leaders approach
the decision-making tasks necessary to address
the shortcomings in our health care system?
When addressing health care issues, President
Clinton will face the same decision-making cli-
mate social workers in health care experience
every day. Because the decisions he makes will
alter that climate, an examination of models of
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decision making that dominate health care is
in order.
MAKING LEADERSHIP DECISIONS
Whether they are presidents, corporate ex-
ecutives, or heads of social work departments,
leaders are held responsible for their decisions;
the decision maker is considered accountable
not only for the actual decision but also for the
process by which it is made. It is possible to
analyze an individual's decision process, that is,
to evaluate the course of action or idea he or she
selects from possible alternatives.
In reality, however,the environment surround-
ing decision makers (the system) and its values
detract from strictly individual choice (Koontz,
1979). For example, a social work department,
hospital, or government agency may be viewed
as a social system that structures, regulates, and
influences the options exercised by individuals
in specific instances.
The effectiveness of a particular leader de-
pends partly on his or her skill in handling the
intellectual tasks involved in making decisions.
These tasksare affected by the leader's cognitive
ability, time available for deliberation, and re-
sources for gathering information. Imagination
and critical thinking are necessary, for solving
most policy problems often requires a creative
3
new alternative, notjust choosing among givens
Qanis, 1989).
A flow of meaningful information is essential
to the decision process (Katz & Kahn, 1987). A
leader's inability or refusal to modify percep-
tions and behavior based on new data results in
flawed decisions. For instance, some past presi-
dents were so insulated by subordinates or advis-
ers they did not receive critical facts or disre-
garded information that did not cohere with
their preferred views. To expedite enormous
workloads and effectivelymanage time, busy ex-
ecutives often screen out unessential contacts
and nonvital information. But flexibility is an
important key to good decision making (Katz &
Kahn, 1987), and the quality, relevance, and
timing of information received may be more
important than the amount of information
Qanis, 1989).
Policy decisions are especially critical and
differ from routine decisions in that they are
highly consequential for the organization's vital
interests and goals. These decisions are strategic
because they create a new situation that influ-
ences subsequent decisions. Using shortcuts to
make policy decisions can be dangerous. Presi-
dent Ronald Reagan, known for his delegating
style of management, frequently relied on
nutshell briefings; they save time when a
complicated policy problem is faced. But a
leader who relies exclusivelyon a single nutshell
briefing, which is usually biased in favor of one
course of action, and who does not raise incisive
questions to ascertain the pros and cons of alter-
native options is in effect delegating the deci-
sion (janis, 1989).
DECISION-MAKING MODELS
Rational Model
The rational model presumes that there is a
unified purpose or set of preferences character-
izing the entity taking action. An agency's stated
mission, goals, and objectives offer purpose, val-
ues, and directions for specific programs and
actions. Rational decision making involves search-
ing for alternatives, assessing consequences, es-
timating risk or uncertainty, determining the
4 HEALTH & SOCIAL WORK / VOLUME 18, NUMBER 1 / FEBRUARY 1993
value of consequences, and selecting the action
that maximizes attainment of the desired objec-
tive Qanis, 1989; Pfeffer, 1987).
Bureaucratic Model
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Rather than to maximize values, in a bureau-
cracy choices are made and actions are taken
according to rules, procedures, and processes
that have worked and been acceptable in the
past (Pfeffer, 1987). The bureaucratic model,
which relies on habitual ways of doing things, is
considered best for decisions that are unimpor-
tant and uncontested. However, "rules, norms
and procedures have implications for the distri-
bution of power and authority in organizations
and therefore for how contested decisions should
be resolved" (Pfeffer, 1987, p. 331). Changes in
relative power and decision-making rules can
lead to a change in the organization.
Political Model
In a political or power model, decision out-
comes are related to measures of power rather
than to goals (rational model) or precedence
(bureaucratic model). Whereas rational models
may disregard the diversityof interests and goals
within an organization, political models view
organizations as pluralistic and divided into vari-
ous interests, subunits, or subcultures. Conflict
is viewed as normal, or at least customary. Deci-
sions seldom perfectly reflect the preferences of
any group or subunit within a political organiza-
tion; action results from bargaining and com-
promise among players who hold different views
of issues and of preferred outcomes (Pfeffer,
1987). Subunits or individuals within the orga-
nization who possess the greatest power receive
the greatest rewards.
To understand organizations from a political
model perspective, "it is necessary to understand
who participates in decision making, what deter-
mines each player's stand on the issues, what
determines each actor's relative power, and how
the decision process arrives at a decision; in other
words, how the various preferences become com-
bined" (Pfeffer, 1987, p. 330). Thus, in power
models, the decision does notnecessarilyadvance
the attainment of goals. Power and politics char-
acterize so many organizations that the phrase
"lawof political entropy" wascoined, which states
that, given the opportunity, an organization will
tend to seek and maintain a political character.
Once politics is introduced into a system, it is
difficult to restore rationality. Once concensus is
lost, it is difficult to restore shared perspectives
and solidarity (Pfeffer, 1987).
DECISION MAKING IN HEALTH CARE
Policy Level
Rational decision making for national health
policy might go a long way toward solving the
overarching problems currently before us. Yet it
would be foolish to disregard the prevalence of
bureaucratic elements and the influence of
power that flavor decision making throughout
health care. Changes in national health policy
may not ultimately affect the micromanagement
culture of particular organizational entities. How-
ever, national policies, regulations, and laws
guide institutional behavior and decisions. For
example, the recently enacted disability legisla-
tion may require renovation of physical plants
and changes in interview questions posed to
prospective employees. Advance directives legis-
lation has already altered hospital admission
procedures. Laws and regulations alsoaffect clini-
cal practice and decisions. A social worker may
not choose to work with children who have been
sexuallyabused, but he or she must explore and
report instances of suspected abuse that are re-
vealed in practice.
Practice Level
Whether in clinical work, administration, re-
search, or policy formation, health care social
workers are engaged in and subject to decision
making. Social work clinicians seek information
based on a presenting problem or situation.
Clients' needs, goals, and unique circumstances
are organized, interpreted, and applied accord-
ing to the practitioner's theoretical orientation
to understanding human behavior and the ef-
fects of environment and other factors. Profes-
EDITORIAL
sional principles and the social worker's duties
and functions within a particular setting estab-
lish an important framework for practice. The
purpose and outcome of this process is a treat-
ment plan based on an evaluation of critical
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factors and decision choices.
In health care settings, particularly in hospi-
tals or large, multipurpose agencies, social work
managers may not feel or actually be in control
over many of the decisions that affect their op-
erations. Budget, number, and even assignment
of staff; purchase of equipment or services; and
numerous other dominions affecting socialwork
activitiesoften are not determined bysocialwork-
ers. The dominant style of decision making is
reflected in the allocation of resources, the way
a leader responds to a new approach to an issue
or to problem resolution, how information sub-
mitted is used, the willingness of decision mak-
ers to receive an unpopular or contrasting opin-
ion, and the field of acceptable reporters and
confidants. If the institutional culture is essen-
tially bureaucratic or political, resources may be
allocated to social work based on its relative
power or place in the hierarchic structure and
in its traditional or assigned significance. Find-
ing a wayto operate effectively within a complex
organization is difficult; understanding the de-
cision process is essential.
FOR FURTHER CONSIDERATION
How do clinicians know when sufficient infor-
mation has been obtained? How do individual
and societal values, the profession's codes and
standards, and other elements affect choice of
treatment plan and mode of intervention? Clini-
cal decision making should be client-eentered,
unbiased and uninfluenced by organizational
expediency and personal interests or preferences
of the social worker, but is this possible?To what
extent can clinical interactions be disengaged
from institutional constraints and obligations?
Agency or organizationally based social workers
are not free agents. Even in the roles of client
and family advocates, social workers are sanc-
tioned by and functionally obligated to their.
organization. Their work is also affected by bu-
reaucratic structures and political milieu.
5
 Within social work's domain, a fertile climate
and supportive structure for rational decision
making can be created that minimizes the nega-
tive features of bureaucratic and political mod-
els. It behooves social workers to reflect on their
Ott (Eds.), Classics oforganizational theory, (pp.
250-263). Chicago: Dorsey Press.
Koontz, H. (1978). The management theory
jungle. In W. Natemeyer (Ed.), Classics in orga-
nizational behavior (pp. 19-31). Oak Park, IL:

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own styles of decision making. For example, are
important policy decisions given appropriate
consideration? Are they delegated to others? Is
information from subordinates valued? Can in-
formation that does not agree with preferred
viewpoints be received and utilized? Does power
playa role in the decision process? Further analy-
sis of decision making from the perspective of
social work is warranted to expand the scholarly
literature that supports social work administra-
tive practice in health.
References
Janis, I. 1. (1989). Crucial decisions: Leadership and
policy making in crisis management. New York:
Free Press.
Katz, D., & Kahn, R. 1. (1987). Organizations
and the system concept. In]. M. Shafritz &]. S.
Moore.
Pfeffer,]. (1987). Understanding the role of power
in decision-making. In]. M. Shafritz &]. Steven
Ott (Eds.), Classics of organizational theory (pp.
309-335). Chicago: Dorsey Press.
This issue notes changes in the editorial board. I am
pleased thatSharon Milligan hasagreed to remain for
another term and thattwo consulting editors, Carleton
Pilsecker and Rita Beck Black, havebecome editorial
board members. Their longtime support of the journal
has been extremely valuable. As members of the eduo-
rial board they willparticipate in policy formation. I
am pleased also to welcome Peter Vaughan as a new-
comer to the editorial board and the journal. Changes
in consulting editors have also occurred as terms have
expired. New consulting editors are currently being
appointed.

In Memoriam
Thomas Owen Carlton, who was editor-in-chief of Health &' Social Work from
1986 to 1990, died December 15, 1992 in Richmond, Virginia. Editing the
journal was one of Tom's many services to the profession. He resigned as one of
the original members of the NASW Health/Mental Health Commission to
become editor. A frequent contributor to literature in social work and in health,
he was professor and associate dean at Virginia Commonwealth University
School of Social Work. The Society for Hospital Social Work Directors
conferred the Hyman J. Weiner award upon him, and NASW invited him to
deliver the first KneelWittman Lecture in Mental Health.

In addition to being a fine writer and scholar, Tom was a warm and caring man.
His many friends will miss him greatly.

6 HEALTH & SOCIAL WORK I VOLUME 18, NUMBER 1 I FEBRUARY 1993