Educating Social Workers in Palliative and End-of-Life Care: Development and Implementation of a New National Training Program

Abstract

Background:

Educating Social Workers in Palliative and End-of-Life Care (ESPEC) is a nationally scalable continuing education program designed to improve the knowledge and skills of frontline health social workers caring for patients with serious illness.

Objectives:

This article describes ESPEC's rationale, development, and initial implementation.

Design:

Following the creation of consensus-derived core primary palliative care competencies for health primary care social workers based on the eight domains of palliative care outlined in the National Consensus Project Guidelines for Quality Palliative Care, an evidence-based curriculum was developed. This was used to develop a hybrid training model with a self-study component, synchronous instructor-led skills-based training, leadership training, and mentorship. The interactive curriculum incorporates patient scenarios highlighting the health social work role. Training targets high-impact skills—the biopsychosocial-spiritual assessment, advance care planning, family meetings, and interprofessional communication—and professional development.

Settings/Subjects:

ESPEC was launched in the United States in collaboration with the National Association of Social Workers (NASW) and the Social Work Hospice and Palliative Care Network (SWHPN).

Results:

The preliminary launch demonstrated high user acceptability, positive ratings for content and format, and gains in knowledge and competence.

Conclusions:

Data suggest that ESPEC can increase health social workers' knowledge and confidence as providers of palliative care interventions. National dissemination is ongoing.

Introduction

Palliative care is a model for the delivery of comprehensive, person-centered, family-focused, culturally congruent, goal-concordant quality care appropriate for all people with serious illness. Treatment plans aligned with the principles of palliative care support the patient's and family's values and preferences and provide interventions designed to prevent or relieve illness-related distress and burden from the time of diagnosis and through the illness trajectory.¹ These interventions are routinely provided by clinicians, including social workers, whose scope of practice includes interventions that may mitigate the burden of illness and improve the quality of life. This frontline care is known as either generalist-level or primary palliative care.²

Primary palliative care is distinguished from the specialist palliative care provided by clinicians with advanced training and experience, typically working as a dedicated interprofessional team. Social workers are core members of specialist teams, performing comprehensive biopsychosocial-spiritual assessments and other challenging tasks, such as navigating difficult conversations with vulnerable patients and families, facilitating decision-making and advance care planning in the context of progressing illness, managing complex psychosocial issues, promoting interprofessional communication, attending to the social determinants of care, and offering leadership in training and research.³

Patients with serious illness and their families who encounter specialists in palliative care usually do so for relatively brief periods of time, typically when disease is advanced and the patient is hospitalized or enrolling in hospice. Most care is provided by clinicians who are not palliative care specialists. For the frontline health social worker whose scope of practice is expected to include the management of problems associated with serious illness, the care is often complex and accompanied by concerns about competence. Research suggests that moral distress may be experienced as social workers perceive that they are not fully prepared to provide primary palliative care to people with serious illness, when they are presumed to have the competencies required.^4–6

Although competency-based education in palliative care has long been advocated for health social workers,^7–10 there have been limited opportunities for comprehensive continuing education in this area. In contrast to national training programs for physicians (Education in Palliative and End-of-Life Care [EPEC^®]), interprofessional staff (Education in Palliative and End-of-Life Care-Pediatrics [EPEC-Peds]), The Interprofessional Education Exchange [iPEX]), and nurses (End-of-Life-Care Nursing Education Consortium [ELNEC]),^2,11–13 equivalent programs for health social workers have been lacking.

Educating Social Workers in Palliative and End-of-Life Care (ESPEC) was conceptualized as an accessible continuing education program for health social workers to integrate the principles, knowledge, and skills of primary palliative social work into frontline practice. In this study, we describe the program's development and preliminary implementation.

ESPEC Program Development

To develop ESPEC, the project directors (M.G. and S.O.-G.) empaneled a group of advisors who were experts in palliative social work and/or social work education and initiated collaborations with the National Association for Social Workers (NASW) and the Social Work Hospice and Palliative Care Network (SWHPN). The vision of the project was widely embraced—to develop and disseminate a nationally scalable continuing education program that would parallel those available for other professional groups, cover the core competencies and principles of primary palliative social work, and employ a pedagogy with capacity to improve the knowledge and skills of health social workers in any setting.

A training curriculum for ESPEC was developed to teach core competencies in primary palliative social work. These core competencies were developed previously based on review of the literature,^14–16 selection of a framework proposed by U.S. and Canadian experts,^17,18 recommendations in the National Consensus Project Guidelines for Quality Palliative Care (NCP) developed by the National Coalition for Hospice and Palliative Care,¹ and a formal consensus-development process involving national experts in palliative social work. The consensus-derived competency framework for primary palliative social work, organized on the basis of the eight domains of palliative care recommended in the guidelines, was published in 2018 (Table 1).¹⁹ Translation of this competency framework into the training curriculum was developed through iterative discussions with the ESPEC advisors.

Table 1.

Application of the National Consensus Project Domains to Social Work Practice in Educating Social Workers in Palliative and End-of-Life Care

National consensus project domain	Social work competency
Structure and processes of care	Promote standardized care planning; establish standardized protocol for screening and biopsychosocial-spiritual assessment
Physical aspects of care	Address physical concerns to improve function and quality of life
Psychological and psychiatric aspects of care	Promote adjustment to illness; improve coping
Social aspects of care	Address impact of unmet social determinants of health; facilitate family meetings
Spiritual, religious, and existential aspects of care	Promote the integration of patient's/family's religious, spiritual, and existential beliefs into care
Cultural aspects of care	Promote delivery of culturally congruent care
Care of the patient nearing the end of life	Promote shared decision-making to support goal-concordant care; advance care planning; provide grief/bereavement support
Legal and ethical aspects of care	Address the ethical, legal, and regulatory issues commonly impacting care

The worldwide COVID-19 pandemic highlighted the urgency to improve skills in palliative care among health social workers, who participated in the care of seriously ill patients and struggled to adapt to the rapidly changing health care landscape.^20–22 ESPEC development continued as the pandemic worsened and the pedagogy was changed to provide an opportunity for training in the context of reduced travel and in-person meetings. A hybrid model of continuing social work education was ultimately selected, consisting of both self-study and synchronous components. The self-study components were created as an online course that included recorded modules that may be viewed at any time. Synchronous components were live sessions with faculty and learners interacting and could be conducted in-person or online. The self-study modules provide broad coverage of the curriculum, and the synchronous component focuses on specific high-impact practice skills to deepen the learning and reinforce the concepts.

ESPEC online modules

All online components of ESPEC, including the self-study modules and the option of a Virtual Instructor-Led Training (VILT) and Virtual Leadership Training, are integrated into the learning management system maintained by the NASW. The NASW is the provider of continuing education credit and supports registration and tracking, scheduling of ESPEC components, and access to an ESPEC Resource Hub containing full-text articles, tools, course slides, and four original Best Practice Guides (Comprehensive Biopsychosocial-Spiritual Assessment, The Family Meeting, Advance Care Planning, Interprofessional Communication) developed for ESPEC.

The self-study component of ESPEC comprises modules that respectively focus on each of the domains of palliative care. Modules follow a clinical scenario—a middle-aged woman with ovarian cancer whose illness trajectory includes diagnosis, treatment, recurrence, hospice, end-of-life care, and bereavement support—to capture the goals, objectives, and social work competencies to be covered. The curriculum includes didactic information and skills-based training focused on important practices, such as the management of psychosocial distress and the psychosocial components of illness-related pain, and the identification of patients' strengths-based coping mechanisms. The content in each module is presented with interactive elements using multiple modalities, such as video, animation, music, and voiceovers, to enhance engagement and learning. Each of the self-study modules underwent alpha and beta testing by a minimum of five experienced social workers, whose feedback informed iterative modifications to improve the content and ease of use.

ESPEC synchronous instructor-led sessions

The instructor-led components of ESPEC include a skills-based component and Leadership training. The in-person training has the same content as the VILT and Virtual leadership training. The skills-based session provides 2.5 hours of continuing education credit focused on building high-impact skills emphasized in the literature (Table 2),^23–26 including the biopsychosocial-spiritual assessment, advance care planning, facilitating a family meeting, and promoting interprofessional communication. The patient scenarios in the session provide opportunities for rehearsal and problem-solving with coaching by the faculty. The faculty encourages collaboration, team building, learner interaction, and critical reflection of their own practice.

Table 2.

Educating Social Workers in Palliative and End-of-Life Care Instructor-Led Training

Best social work practice	Theory, rationale, and practice
Biopsychosocial-spiritual assessment	Comprehensive, culturally informed assessment Standardized approach to case finding Implicit bias Sharing findings Open notes
Advance care planning	Patient self-determination Serious illness communication Mediation and conflict resolution Resolving ethical dilemmas Conducting goals of care conversations
The family meeting	Person-in-situation perspective Role theory; systems theory Indications for meetings Promote understanding and consensus Leadership role for social work
Interprofessional communication	Teamwork Team hierarchy Pre-planning meeting Post-meeting debrief

The Leadership Training offers 4.0 hours of continuing education credit and focuses on enhancing the confidence of social workers when interacting with other members of health care teams and improving the ability to navigate complex systems. Learners construct a personal mission statement and practice strategies for becoming a more effective change agent, communicating the value-added proposition of social work and strengthening their advocacy skills. Coaching by the expert faculty is intended to enhance professionalism, problem-solving, effective collaboration, and advocacy on behalf of patients and their care partners (Table 3).²⁷

Table 3.

Educating Social Workers in Palliative and End-of-Life Care Leadership Course

Leadership activity	Theory, rationale, and practice
Define your brand	Leadership vs. leadership Become a more effective change agent Become an influencer Construct a personal “mission statement”
Refine your message	Market your skill set Tailor your message for different audiences Define your value proposition Develop an elevator pitch for stakeholders
Enhance interprofessional communication skills	Teamwork definitions Teamwork benefits, challenges, dynamics Team functioning Team-building strategies
Professional development plan	Make a commitment to lifelong learning Develop your professional development plan Identify three action steps Identify accelerators and barriers Reflect upon what success will look like

Following completion of the ESPEC self-study component and synchronous instructor-led skills-building training, learners also have the opportunity to participate in free monthly group mentorship with a palliative social work specialist, which focuses on challenges learners may be facing regarding their implementation of the ESPEC skills and concepts, role modeling, and professional development. Mentorship was implemented during the preliminary launch of ESPEC using an invitation for monthly online “drop-in” sessions.

ESPEC implementation

IRB approval was obtained from the Salus IRB. A preliminary launch of ESPEC's self-study and synchronous sessions was conducted between February and December 2022. To provide access to the instructor-led components, social workers with expertise in palliative care were recruited through the SWHPN and 31 members were selected to participate in the training. This group of trainers became the first to join an increasing pool that would be a resource for ESPEC training sessions going forward.

During the preliminary launch, 134 social workers completed the self-study ESPEC course, 85 of these individuals participated in the VILT, 55 completed the Leadership sessions, and 50 participated in mentorship sessions. The social workers who participated came from 35 states. Many lived in urban or suburban settings (75%), were practicing clinicians (79%), and worked in hospitals or hospice agencies (57%); 10% were supervisors or administrators, fewer than 2% were in academic or research positions, and the rest were in “other” positions. Two-thirds had previously taken continuing education related to palliative care.

Among the social workers completing the post-module assessments provided with the self-study component, and those completing the post-session evaluation following the VILT, ratings of self-assessed knowledge were uniformly high both before and after the trainings. This finding was expected given the high interest in palliative care among these initial participants. Comments offered by the participants were highly positive (Table 4).

Table 4.

Selected Comments: Relevance of Educating Social Workers in Palliative and End-of-Life Care Training: Clinical Skills

“The practical side of the training is what makes this different and excellent … real life experiences”
“I appreciated the vignettes. I truly felt like the actress and family were going through the disease process. It sparked empathy and helped me understand a better holistic picture”
“That the training was built around the tenets of social work, especially how to approach issues with cultural consideration”
“Materials that are shareable will aid in future training of new staff”
“I enjoyed the videos as it gave me real life terminology to use with patients and families”
“Fill in the gaps in my knowledge of the eight domains of palliative care, and to have resources that I could have easy access to.”
“Goal was to fully experience the training and then to identify ways to enroll my team to increase skills/delivery of care. Working on this for 2023.”
“Help providers on the interprofessional team (IDT) more fully understand the important role of the social worker—leading the Biopsychosocial-spiritual assessment, having family meetings, advance care planning conversations and follow-up and interprofessional coordination.”
“Implemented the domains into my template when assessing patients—helped to ensure I've addressed them.”
“All of the content I found to be excellent and when thinking about a course one would design … this is the content.”
“I found very useful the extensive literature for review and independent study provided during each module of ESPEC. The trainee has the opportunity to access and review information at any time.”

ESPEC, Educating Social Workers in Palliative and End-of-Life Care.

The social workers who attended the Leadership Training also expressed high satisfaction. The most popular exercise was the Elevator Pitch, through which learners had to develop and present a 60-second overview about their value proposition as social workers. All leadership session learners also reported an increase in their level of confidence after the course, particularly in promoting the role of social work within their settings and being more proactive in providing feedback to colleagues during clinical encounters. Comments from learners identified specific leadership skills that could be applied in practice (Table 5).

Table 5.

Selected Comments: Relevance of Educating Social Workers in Palliative and End-of-Life Care Training: Leadership Skills

“I identified a void in leadership for family meetings and solidified my role coordinating and leading”
“The course gave me the confidence in knowing I am a valued team member and my job is important. I'm less hesitant to speak my mind”
“The training program provided me with energy and confidence to pursue what I consider to be very meaningful work”
“Engaging with more confidence as an expert among our providers in the area of advance care planning and serious illness conversations.”
“I wanted to engage in training other social workers. The program helped give me the confidence to share my knowledge.”
“The leaders who developed this training were so generous with their knowledge, experience, time and insight. I am so grateful.”

The 134 social workers who participated in the preliminary launch were sent a survey three to six months after completing the program, which requested a global rating of the training and information about whether the social worker had implemented a professional development goal, integrated palliative care principles into practice, or used ESPEC training to enhance leadership. Responses were extremely positive. Specifically, 97% of ESPEC graduates rated the faculty as knowledgeable, 99% rated the course as organized and clearly structured, 100% found the presentations and course material congruent, 98% found the presentation delivery format of slides, video, and audio appropriate, and 89% indicated that they would recommend the course to others.

Knowledge in the eight domains of palliative care was measured both pre- and post-training and showed gains across the board, with the largest increases in these NCP domains: the physical aspects of care, cultural aspects of care, and ethical and legal aspects of care. ESPEC graduates were asked to rate their level of confidence in their skills pre- and post- the ESPEC VILT, and gains were reported in the core social work skills highlighted in each part of the course. Of note, the social workers' confidence increased by more than 40% in these areas: interprofessional communication, conducting the biopsychosocial-spiritual assessment, applying action steps to change practice, and applying best social work practices in advance care planning.

The gains in clinical competence were sustained in the six-month follow-up survey. ESPEC graduates reported implementation of leadership activities to improve advocacy, enhance their professional development, and participate in both quality improvement and policy activities. A fuller analysis of the quantitative ESPEC data will be shared in a subsequent article as the sample size grows.

Discussion

The ESPEC program offers 14.5 continuing education credits for health social workers seeking to build knowledge and skills in primary palliative social work. All components of the training can now be accessed through the ESPEC pages of the NASW website (https://www.socialworkers.org/ESPEC). The positive results observed during the preliminary launch suggest that the program is impactful and ready for further dissemination.

ESPEC has the potential to improve the quality of care for individuals with serious illness and their families. Like EPEC and ELNEC, the national training programs for physicians and nurses, respectively, ESPEC was designed to improve knowledge and skills in primary palliative care among the health social workers who provide the care needed by patients with serious illness, their families, and care partners. It focuses on the types of tasks that are within the social work scope of practice and incorporates social work theory and adult learning principles into the curriculum's pedagogy to enhance engagement and learning.

By increasing social work confidence and skills, ESPEC training also may reduce the risk of social work workforce shortages due to job avoidance and burnout. A study of oncology social workers during the COVID-19 pandemic noted that work-related and personal distress, including moral injury and burnout, are at unprecedented levels for health care providers, including social workers,²² and suggests that the pandemic has changed professional roles and increased responsibilities. Accessible and effective training could potentially support social work practice in complex clinical populations and difficult times.^21,22

As with any new program of this scope, challenges have been experienced during development and implementation. Limited resources constrained our ability to conduct outreach, marketing, and data collection during the preliminary launch. National dissemination requires greater focus on all these aspects. Despite our efforts to raise funds for training scholarships and keep costs as affordable as possible, registration costs were a barrier for social workers whose employers did not provide support for continuing education.

Although ESPEC was originally conceptualized to include a major in-person training component, pandemic lockdowns, moratoriums on travel, and organizations' reprioritization of discretionary funds necessitated versatility and adaptability. Accordingly, the program was converted to allow learners to access all components online. This flexibility should contribute to the program's success by reducing the travel time and expense necessary to attend the training, making the program more accessible to a wider economic and geographic range of participants. Efforts are underway to ensure the sustainability of the ESPEC program and expand its reach. A new curriculum for social workers in safety net hospitals was developed and successfully implemented as a one-day in-person meeting for 75 participants in New York City.

This enhanced curriculum has a strong focus on best social work practices in advocacy, leadership, cultural awareness, and system changes to promote health equity and antiracist approaches to serious illness care. This new content has been integrated into ESPEC. The ESPEC team is currently working, in collaboration with the Association of Oncology Social Workers (AOSW), to focus on best social work practices in palliative care for oncology social workers. Work is in progress to increase partnerships with other professional groups, promote the training more effectively, market the program more rigorously, and further adapting the curriculum to highlight the social worker's role in mitigating the impact of social drivers of health and to address health disparities. The importance of developing a cadre of health social workers capable of more effectively serving those with serious illness could not be more urgently needed at this time.²⁸

Footnotes

Acknowledgments

The ESPEC Project Directors gratefully acknowledges the expertise and guidance of the ESPEC Advisory Board: Cathy Berkman, PhD; Darla Coffey, PhD, MSW; Penny Damaskos, PhD, MSW; Carrie Dorn, MPA, LMSW; Louise Knight, MSW, LCSW-C, OSW-C, FNAP; Ken Meeker, LCSW, APHSW-C; Abby Nathanson, DSW, LCSW, APHSW-C, ACS; Laura Radensky, LCSW; Tara Schapmire, PhD, MSSW, OSW-C, FAOSW; Tom Sedgwick, LCSW; Jennifer Silva, LCSW-S; Gary Stein, JD, MSW; Raffaele Vitelli, CAE; Christine Wilkins, PhD, LCSW. The ESPEC Project Director is indebted to these colleagues whose generosity and support were instrumental in developing this new training program for social workers: Betty Ferrell, PhD, Stacey Remke, LCSW, and Stefan Friedrichsdorf, MD.

Funding Information

The ESPEC team is deeply appreciative of the generous support of these funders who made the work possible: The New York Community Trust (P18-00237; P22-000928), The United States Cancer Pain Relief Committee, The Y.C. Ho/Helen & Michael Chiang Foundation, the Hearst Foundations (GR-000019801), and The Fan Fox and Leslie R. Samuels Foundation.

Author Disclosure Statement

No competing financial interests exist.

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