The Serendipitous Survey: A Look at Primary and Specialist Palliative Social Work Practice,Preparation,and Competence

Introduction

The need and evidence supporting the value of palliative care services for our aging and chronically ill populations is ever growing.^1,2 Most recently, the Institute of Medicine (IOM) report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, ³ issued a clear directive regarding the importance of high-quality palliative care for the seriously ill. The scope of IOM imperatives ranges from support for palliative care through revised and novel policies for payment, training of professionals, and essential consideration for social determinants of health. Additionally, there is a call for palliative care to become a standard of practice for elderly patients with complex illness in nursing homes. ⁴ These calls echo voices of palliative care social workers advocating the importance of this work through increased and targeted research while properly supporting programs and practitioners.^5–7

Given anticipated shortages of health care professionals, and specifically those trained in competencies of palliative care, the health care system is unprepared to meet this need. There are an estimated 141,839 health care social workers, about 40,000 of whom practice in hospital settings and 16,000 in home health care service. ⁸ To understand how the social work profession is positioned to face these challenges, the authors created a survey to investigate preparation, training, and self-assessed competence of social workers who deliver services in varied settings and specialties including palliative care. This preliminary investigation, in a climate of health care reform, is a timely addition to the existing literature regarding current and potential contributions social workers might make to person-family centered care.

Health social workers have the potential to integrate primary palliative social work skills into their practice, addressing the needs of seriously ill persons and an aging population. While there is an evolving clarity on the particular knowledge and competencies exemplifying advanced practice in health social work, much less attention has been paid to the process of acquiring these skills. The survey data presented here is of particular relevance as we consider meeting the burgeoning need for trained health care professionals at primary and specialist levels, and as we educate patients, families, and caregivers about services to expect when social work clinicians join their care team.

The IOM report highlights the importance of professional education and development and the expectation that providers interacting with the seriously ill integrate basic palliative care knowledge and skills. Social work education and training in the complement of palliative care principles and skills includes but is not limited to support for patient and family autonomy, pain and symptom management, and psychosocial interventions along the continuum of illness and at end of life. The IOM recommendations closely align with existing values, practice knowledge, and strengths of social work where whole person and family-centered care is central to practice. The important role of social workers at the primary and specialist levels comes into sharper relief with this report. The question is whether thousands of health care social workers are maximizing their contributions and assuming the opportunities for leadership this national call demands.

Birth of a Survey

In 2013, prior to the IOM report, the authors, all palliative care social workers, developed a survey with the initial goal of informing educational initiatives by capturing the views of students, practitioners, and educators related to education, training, and competency through formal and informal preparation for social work practice in health care. Questions addressed education level, professional training and preparedness, specialization, and scope of practice, asking respondents to provide narrative feedback about gaps and opportunities for training. The survey questions were informed by existing literature, published competencies, and practical experience of practitioners involved in the research.^9–13 The survey sought to gain insight into how social work practitioners across health specialties defined the essential knowledge and skills needed for practice and how these skills were learned. The researchers made an assumption that palliative social work represents a specialist, or advanced level of practice.

The survey was completed by 1149 health care social workers; 85% with master's degrees. Thirty-five percent self identified as palliative or end-of-life care social workers and 48% of practitioners were based in hospital settings. Respondents identified core skills which cohere across health care practitioners and captured areas of practice considered essential to specialist hospice and palliative care social work. This report provides a snapshot of data, beginning to inform our understanding of primary and specialist palliative care social work. The variation in respondents offers opportunity to capture the competencies and skills assumed and considered important in primary health social work, while recognizing the limits and biases often implicit in self-assessment. The collective wisdom of respondents may influence best practice recommendations for academic education and guide practice expectations at primary and specialist levels. This is an important step in documenting a developmental trajectory of the advanced social work practitioner.

Survey Findings

Social workers across specialties reported high competence in facilitating family conferences (80%), collaborating with team (94%), intervening with family and caregiver distress (87%), and addressing cultural and religious diversity needs (82%). A much smaller percentage report competence in topics integral to palliative practice such as participation in pain and symptom management, family systems interventions, and techniques for working with children as patients or family members. Perhaps it's in this area of low competency skills that this survey begins to shine a light on the contributions of the specialist practitioner. While about 75% assert competence in advance directives and decision making at end of life, respondents report reduced competence in providing anticipatory guidance (53%), legacy work (38%), and cognitive behavioral techniques (56%). These are therapeutic techniques palliative social workers frequently use to mitigate suffering and enhance the cognitive and emotional integration of the adaptations that serious illness demands.

How Social Workers Learn

This survey data shows a large percentage of health social workers express competence in areas of essential primary palliative care skills, e.g., we would expect these skills of all social workers practicing in health care. However, while 46% of respondents felt prepared by their social work education, 81% reported learning through collaboration with interprofessional teams and 74% identified ongoing skill building from social work colleagues. This haphazard model of attaining practice wisdom and skill will not suffice to meet the burgeoning need for clinicians with primary palliative skills poised to address the psychosocial needs of this population. Of additional concern is the lack of preparedness to integrate research into practice (33%), which represents a critical learning gap given the growing research evolving in palliative practice and which is essential to high-quality care.

Practicing to the “Top of One's License”

Social work is not alone in efforts to discover, mediate, and confront the realities that discourage practicing to the “top of one's license.”^14,15 These data begin to outline what it looks like for social workers to practice to the full extent of their training, where time is organized and barriers minimized, allowing clinicians to actualize core professional responsibilities. The data highlight self-assessed competencies, providing impetus for health social workers to deliver core and critical psychosocial intervention to patients and families coping with life-threatening illness. Rather than continuing to acquiesce to systems that dilute social work impact, capitalizing on the skills and knowledge of social workers strengthens patients and families' ability to navigate their health crisis and utilize health care more effectively. It is likely that primary health and specialist-level social workers will continue to expand their impact in palliative care domains and that social work educators may celebrate and integrate the essential congruence of social work and palliative care principles. The work of specialist palliative social work clinicians may then focus on complex ethics, symptom management, decision making, and patient family needs for which deeply engaged consultation is needed.

Conclusion

As with other core disciplines providing palliative care, social workers have workforce issues including a dearth of opportunities for preparation and advanced training. Formal educational programs to train social workers in specialist palliative care are developing slowly. Fellowships are rare, but advanced certificate programs continue to flourish. Many palliative programs do not include a dedicated social work practitioner, “borrowing” on the primary skill set that may be part of the referring or primary teams. As the survey data shows, increasing education and training for a primary and specialist level of palliative social work is essential, as is an enhanced coherence between education and practice demands. Most immediately, this commentary joins interprofessional advocacy for all clinicians to be empowered and expected to work “to the top of their license.” From this data it appears many practicing social work clinicians have essential skills needed to address the psychosocial determinants of health in order to ensure safe, high-quality, and reliable health care, especially for the most vulnerable populations with significant palliative care needs.