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Care provided to seriously ill patients by frontline social workers is a component of generalist-level palliative care. The core competencies for high-quality generalist-level palliative social work are necessary to promote training curricula and best practices but have not yet been defined in the U.S.
Objective
The objective of this study was to develop consensus-derived core competencies for generalist-level palliative social work.
Methods
Fifty-five proposed social work competencies were categorized by the eight domains of palliative care identified by the National Consensus Project for Quality Palliative Care. The competencies were rated by 41 regionally dispersed, Master's level social workers selected through purposive and snowball sampling using a Delphi method. Each was rated as essential for generalist-level palliative social work, acceptable with modifications, or rejected based on the judgment that it was not essential for generalist-level palliative social work or was outside the scope of practice. Consensus was defined as >70% agreement to accept or reject a competency. Three review rounds were needed to achieve consensus on all competencies.
Results
Two competencies were added to the original list. Of the 57 proposed competencies, 41 were accepted (19 after modification) and 16 were rejected. Competencies in the social, spiritual, cultural, and ethical/legal aspects of care domains were relatively more likely to be accepted compared with those in structure and processes of care, physical care, psychological care, and care of patient at the end of life.
Conclusion
The 41 consensus-derived competencies for generalist-level palliative social work may inform the development of training curricula and standards for high-quality care.
In the U.S., social work is recognized as a core discipline in specialist-level palliative care. Social workers are part of the interdisciplinary team supported by the federal hospice benefit, and a comparable role was endorsed in the 2001, 2009, 2013, and 2018 versions of the clinical practice guidelines developed by the National Consensus Project for Quality Palliative Care.
Canadian Hospice and Palliative Care Association. Canadian Social Work competencies for hospice and palliative Care: A framework to guide education and practice at the generalist and specialist level.
and the efforts of U.S.-based professional groups such as the Social Work Hospice and Palliative Network, the National Association of Social Workers, and the National Hospice and Palliative Care Organization.
In some countries, professional certification is used to demonstrate the acquisition of specialist-level competencies by social workers trained in palliative care.
Although this emergence of palliative care as a specialization in social work is a very positive development, most patients living with serious chronic illness, and their families, receive palliative interventions from professionals without specialist training.
Frontline social workers in all venues of care implement diverse interventions to prevent or mitigate the suffering and illness burden experienced by the patient and family throughout the course of the illness. Collectively, these interventions may be characterized as generalist-level palliative social work. Guided by a comprehensive assessment, they may focus on the management of poorly controlled symptoms, psychological distress, caregiver burden, care fragmentation, disturbances in communication or decision making, or other concerns.
Best practices in generalist-level palliative social work require a set of explicitly defined professional competencies that contribute to successful performance of palliative interventions as well as observable and measurable skills specific to each competency. These can be used to guide the development of training curricula, evaluation tools, and practice standards used to determine the quality of care.
Initiatives to define core competencies for palliative social work have been undertaken in the U.S., Canada, and Europe.
Canadian Hospice and Palliative Care Association. Canadian Social Work competencies for hospice and palliative Care: A framework to guide education and practice at the generalist and specialist level.
The current project expanded on this prior work by focusing specifically on generalist-level palliative social work and incorporating the eight-domain framework for best practices developed by the National Consensus Project for Quality Palliative Care.
The aim was to elicit consensus about the competencies needed by frontline social workers to provide high-quality, generalist-level palliative care in any venue.
Methods
An Advisory Group of academic social workers with expertise in palliative care and health social work was empaneled to oversee item creation and the consensus development process. The project was approved by The New England Institutional Review Board, which exempted it from signed consent requirements.
Canadian Hospice and Palliative Care Association. Canadian Social Work competencies for hospice and palliative Care: A framework to guide education and practice at the generalist and specialist level.
ExCEL in social work: excellence in cancer education & leadership. An oncology social work response to the 2008 Institute of Medicine Report: Cancer care for the whole patient: meeting psychosocial health needs.
and palliative social work job descriptions obtained from Advisory Board members, 93 competencies were drafted by the first author. Each competency depicted a specific skill that a social worker may possess to contribute to the prevention or management of distress and burden experienced by the patient or family living with serious illness. The draft competencies were systematically reviewed by the Advisory Group, and proposed edits, additions, and deletions were discussed in conference and resolved by consensus. Redundant competencies and those perceived as specialist-level competencies were eliminated and many competencies were modified.
The 55 competencies remaining after this review were arranged within the framework of the eight domains of palliative care.
This categorization also was reviewed by the Advisory Group and there was unanimity in designating 15 competencies as part of Structure and Processes of Care domain; four in the Physical Aspects of Care domain; eight in Psychological and Psychiatric Aspects of Care; five in Social Aspects of Care; three in Spiritual, Religious and Existential Aspects of Care; eight in Cultural Aspects of Care; nine in the Care of Patients at the End of Life domain; and three in Ethical and Legal Aspects of Care.
Delphi Survey
The 55 competency statements, organized by domain, were subjected to an iterative Delphi method of review by a larger and diverse group of social workers.
The aim was to elicit consensus about the competencies needed by frontline social workers to provide high-quality, generalist-level palliative care in any venue. The Delphi process was completed in June 2017.
The criteria for participants in the Delphi survey were developed by the Advisory Group and included regionally dispersed in the U.S.; practicing primarily in a hospital, long-term care setting, home care or hospice; and with specific experience in the management of seriously ill patients.
Potential participants were identified using purposive and snowball sampling approaches. Each member of the Advisory Group nominated three social workers who were perceived to meet the eligibility criteria. Nominated social workers were contacted through telephone. The purpose of the project was explained and the eligibility criteria were reviewed. If eligible, the social worker was invited to participate and to nominate up to three other social workers who would be appropriate for the Delphi review. Irrespective of whether the first nominated social worker agreed to participate, the newly nominated individuals were called. This sampling approach yielded a group of 51 social workers who agreed to participate.
An online survey was used to implement the Delphi method using Qualtrics Survey Software to evaluate the 55 competencies organized by the eight domains.
Each competency had four response categories: 1) Accept as written; this is a competency for all practicing social workers; 2) Accept as a competency for all practicing social workers but with changes in the wording (text box included for suggested wording); 3) Accept as a competency only for social workers practicing at the specialized or advanced level; and 4) Reject as a competency for both generalist- and specialist-level social workers.
For the first round of the Delphi method, each of the 51 social workers who agreed to participate was sent an e-mail reminding them of the project aim with a link to the online survey. The landing page stated that the competencies were being evaluated to determine whether each was considered necessary to perform generalist-level palliative social work in a manner consistent with best practices. Participants were asked to select one of the four response categories for each competency. To profile the participants, they were also asked about degrees held and the year each was awarded, social work license(s) held, primary practice setting and location (urban, suburban, rural, or other), zip code of the primary practice setting, and whether they had taken continuing education classes in palliative care or hospice.
Reminders were sent to nonresponders at two weeks and at four weeks. The first round of the Delphi was closed two weeks after the second reminder was sent.
The responses of participants to the first Delphi round were exported to a spreadsheet. Competencies accepted by >70% of participants without requests for wording changes were considered to be endorsed and were not subjected to additional review. Similarly, competencies rejected by >70% were considered to be inappropriate for further review and were removed. Those competencies that yielded requests for wording changes and/or failed to elicit a consensus to accept or reject were retained for further review in a second round of the Delphi process. Most wording suggestions were stylistic and were implemented; several were substantive changes and were made after conferring with the Advisory Group. One survey participant in the first round of the Delphi suggested a new competency, which was evaluated by the Advisory Group and added to the next Delphi round.
The online survey program was revised for the second Delphi round and included competencies that did not yield a consensus to accept or reject, competencies with wording changes, and the one new competency suggested during the first round. A link to this survey was sent to all the Round 1 participants. Instructions were identical to the first round, but no profile information about the participant was collected. Nonresponders were sent an electronic reminder after two weeks, and if there was again no response, a second reminder was sent. The second round of the Delphi was closed two weeks after the second reminder was sent.
The responses to the second round were evaluated similar to the first round. Competencies receiving >70% acceptance or rejection were removed from further review. Those for which there was no consensus and/or a request for wording change were retained. Substantive wording changes were reviewed by the Advisory Group. Another new competency was suggested by one survey participant during the second Delphi round; this was evaluated by the Advisory Group and retained for review in the next round.
The online program was revised for a third round of the Delphi process and the link was sent to those respondents who participated in the second round. The program included only those competencies that did not yield a consensus or required wording changes and the one new competency suggested during the second round. The third and last round of the Delphi was closed two weeks after the second reminder was sent to nonresponders.
Results
Fifty-one social workers agreed to participate in the Delphi surveys; 41 participated in one or more rounds. The response rates for the first, second, and third Delphi rounds were 80%, 80%, and 73%, respectively. Respondents were from the Northeast (51%), Midwest (26%), South (10%), and West coasts (10%) of the U.S. All respondents had a Masters' Degree or higher and worked in hospital (37%), home care (24%), long-term care (20%), or hospice settings (18%).
During the first Delphi round, 28 of the 55 competencies were accepted without wording changes by >70% of participants and eight competencies were rejected by >70%. These 36 competencies were removed from the subsequent rounds.
The second Delphi round included 20 competencies: There were three that had not achieved consensus during the first round, 16 that had undergone substantive wording changes, and one that had been newly suggested during the first round. During this round, eight of these 20 competencies were accepted without wording changes by >70% of respondents and another eight were rejected by >70%. These 16 competencies were removed from the next round.
The third Delphi round included five competencies. This included the four competencies that did not achieve consensus in the second round and the one competency newly suggested in the second round. During this round, >70% of the participants accepted three of the five competencies. There was no consensus on two items, and no modifications were suggested. With concurrence of the Advisory Group, these competencies were rejected.
The three rounds of the Delphi method yielded consensus that 41 of the proposed competencies are essential to perform specific tasks as part of high-quality, generalist-level palliative social work (Fig. 1). A total of 16 competencies were rejected (Fig. 2). The extent of consensus varied among the eight domains of palliative care used to organize the competencies in the Delphi survey. There was a high rate of consensus, with few suggested wording changes, and no eliminated competencies in the Social, Spiritual, Cultural, and Ethical/Legal domains of care. Rejected competencies included items in four domains: Structure and Processes of Care, Physical Aspects, Psychological Aspects, and Care of Patient at the End of Life.
Some of the suggested changes in wording were informative. For example, the original competency, “provide support and counseling,” was modified by respondents into two separate competencies, “provide support” and “provide counseling.” In addition, the word “attention” in the competency “identify complex situations that require attention” was unclear to some participants, and a change to “utilize assessment to identify complex situations that require attention by social worker or other team members,” yielded consensus in the subsequent round.
Discussion
This work reflects the first effort to develop consensus-derived competencies for generalist-level palliative social work in the U.S. Using a well-accepted consensus development process,
a diverse group of practicing social workers agreed that frontline social workers caring for patients or families living with serious illness should possess at least 41 competencies to perform tasks consistent with generalist-level palliative social work. In the consensus development process that yielded agreement about these competencies, those items in the Social, Spiritual, Cultural, and Ethical/Legal aspects of Care domains achieved relatively higher consensus as compared with those in Structure and Processes of Care, Physical Care, Psychological Care, and Care of Patient at the End of Life.
These consensus-derived competencies focus on the need to improve training of social workers in palliative and end-of-life care and establish a framework that may be used to develop or refine social work training curricula and evaluation tools. Practicing social workers report a lack of adequate preparation for the specialized work they are expected to provide in the areas of palliative and end-of-life care and cite this as a source of stress, compassion fatigue, decreased job satisfaction, and high turnover at work.
Adler N.E. Page A.E.K. Institutes of Medicine (US) committee on psychosocial services to cancer patients and families in a community setting. Cancer care for the whole patient: Meeting psychosocial health needs. The National Academies Press (US),
Washington, DC2008
Competency-based training may reduce these outcomes. Improved training may also help address a serious workforce shortage by enhancing the quality of generalist-level care and encouraging larger numbers of social workers to seek specialist-level training and qualifications.
and postgraduate training opportunities are limited.
Agreement about core competencies also may be used to define a set of best practices and skills for generalist-level palliative social work. Standards of care, which may inform the evaluation of treatment programs and settings, can be created based on expectations for best practices.
This work expands upon previous efforts to define social work competencies. Core competencies were proposed by a Canadian group of social work practitioners and educators in 2010
Canadian Hospice and Palliative Care Association. Canadian Social Work competencies for hospice and palliative Care: A framework to guide education and practice at the generalist and specialist level.
In the U.S., standards for social work practice in palliative and end-of-life care were proposed in 2004 by the National Association of Social Workers.
The competencies described in Fig. 1 overlap with this earlier work but are broader in scope, evidence-based, and developed through a process that yielded a consensus among practitioners. For the U.S., the proposed core competencies also reflect many changes that have occurred in palliative care practice during the 15 years since practice standards were proposed.
The consensus process revealed important perspectives about the complexity of the tasks expected of social workers to ensure high-quality palliative care for diverse populations of patients and caregivers living with serious and chronic illness. Perhaps not surprisingly, the strongest consensus was observed in the domain related to social aspects of care. Facilitating access to services, assessing social networks, adapting communication based on health literacy, and respecting privacy traditionally fall within the realm of social work, and respondents in the Delphi method were consistent in viewing these tasks as essential competencies.
ExCEL in social work: excellence in cancer education & leadership. An oncology social work response to the 2008 Institute of Medicine Report: Cancer care for the whole patient: meeting psychosocial health needs.
The high consensus about competencies that address the need for cultural humility and care that is ethical and legal also is unsurprising. Cross-cultural communication is taught to practicing social workers in the field,
The consensus about competencies that address the spiritual domain of care may be explained by recent work to integrate spirituality into palliative care across disciplines.
The consensus process led to elimination of 16 competencies from the core competency list. Participants expressed concerns about tasks that were perceived as outside of their scope of practice, such as those related to the physical aspects of care, and their responses suggested discomfort with tasks for which they may have limited training. For example, participants indicated that generalist-level social work core competencies should not include discussing advance care planning, leading family meetings, addressing sexual functioning, or managing complicated bereavement.
To some extent, the latter responses may reflect role ambiguity. In a 2015 survey of 1149 health care social workers, only 46% of participants felt prepared for practice by their social work education
; lack of confidence was noted in the areas of funeral arrangements, family meetings, hospice, palliative care, and treatment options. This survey reported that most social workers receive information about these topics through on-the-job training from other team members.
Similarly, a survey of home care social workers in New York City identified knowledge and clinical deficits among frontline clinicians, with widespread confusion about palliative care terminology and the role of social workers in this field.
These consensus-derived core competencies have several important limitations. They were developed with input from Master's level social workers and the findings should be replicated for Bachelor's level social workers. The participants in the Delphi surveys were disproportionately from the Northeast and West Coast and from the hospital setting; this may also limit the generalizability of the findings. However, strengths include an extensive process for developing the list of core competencies, a relatively large number of participants, three rounds in the Delphi process, and allowing for revised wording and the addition of new competencies as part of the survey.
Conclusions
The definition of consensus-derived core competencies for generalist-level palliative social work is part of a national effort to ensure that patients and caregivers living with serious chronic illness have access to high-quality palliative care throughout the course of illness in every setting of care. These core competencies should continue to evolve as the field matures. For now, they may inform best practices and the development of standards of care that can be assessed to judge the quality of care offered by varied treatment programs and settings. This set of consensus-derived competencies provides a useful tool for the development of new training curricula, new evaluation tools, and future outcomes research.
Disclosures and Acknowledgments
This work was supported by the US Cancer Pain Relief Committee. The authors would like to thank the respondents who generously shared their time and expertise.
References
The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. 3rd edition. 2013 (Available from)
Canadian Hospice and Palliative Care Association. Canadian Social Work competencies for hospice and palliative Care: A framework to guide education and practice at the generalist and specialist level.
ExCEL in social work: excellence in cancer education & leadership. An oncology social work response to the 2008 Institute of Medicine Report: Cancer care for the whole patient: meeting psychosocial health needs.
Adler N.E. Page A.E.K. Institutes of Medicine (US) committee on psychosocial services to cancer patients and families in a community setting. Cancer care for the whole patient: Meeting psychosocial health needs. The National Academies Press (US),
Washington, DC2008 (Available from)
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