INTRODUCTION
Palliative care is intended to improve quality of life by preventing or alleviating the suffering associated with serious illness (World Health Organization, 2016). In the present work, we use “palliative care” to refer to the continuum of services that range from diagnosis to the end of life. Social workers provide vital psychosocial care as core members of palliative care interdisciplinary teams. They support patients and their families throughout the course of illness and following the patient's death. The important role of social workers on palliative care teams is well-recognized (Altilio & Otis-Green, Reference Altilio and Otis-Green2011; Institute of Medicine, 2014; Meier & Beresford, Reference Meier and Beresford2008) and is a required element of the Medicare Hospice Benefit. Yet, there is a shortage of trained social work professionals to meet the needs of hospice, long-term care, and community-based programs, and for expanding hospital-based palliative care. (Center to Advance Palliative Care, 2015; Institute of Medicine, 2008) This shortage may worsen as persons aged 65+ increase from 13.7% of the U.S. population in 2012 to an expected 20.3% by 2030 (Ortman et al., Reference Ortman, Velkoff and Hogan2014), coupled with medical advances that enable chronically and seriously ill persons to live longer. As the benefits of providing palliative care simultaneously with curative care (Temel et al., Reference Temel, Greer and Muzikansky2010) are more widely adopted and reimbursed, this will further add to the need for social workers who are competent in providing palliative care.
In addition to educating social workers to have specialized palliative care expertise, it is important that social workers in a wide range of health care and other settings have basic palliative care competence. Comprehensive evidence-based standards for palliative social work have been developed (Bosma et al., Reference Bosma, Johnston and Cadell2010; Gwyther et al., Reference Gwyther, Altilio and Blacker2005; National Association of Social Workers, 2004), and a credential for advanced certification has been established (National Association of Social Workers, 2015). Many important components of these competencies have not been integrated into social work curricula, and previous studies have noted the lack of content related to palliative care in Master of Social Work (MSW) programs (Christ & Sormanti, Reference Christ and Sormanti1999; Csikai & Jones, Reference Csikai, Jones, Altilio and Otis-Green2011; Csikai & Raymer, Reference Csikai and Raymer2005; Dickinson, Reference Dickinson2013; Kovacs & Bronstein, Reference Kovacs and Bronstein1999; Kramer et al., Reference Kramer, Howland-Scafe and Pacourek2003; Walsh-Burke & Csikai, Reference Walsh-Burke, Csikai and Blacker2005b). A 2015 survey of health care social workers found that most reported learning palliative care skills from interprofessional team collaboration (81%) and from social work colleagues (74%). Only 46% felt adequately prepared by their social work education (Sumser et al., Reference Sumser, Remke and Leimena2015).
The purpose of the present study was to describe the inclusion of content on palliative care in MSW programs in the United States and Canada. Our aims were to: (1) determine the number of programs with either a dedicated course on palliative care or a course with palliative care content; (2) describe the characteristics of these courses and programs; and (3) determine the number of programs that are planning to develop a dedicated palliative care course.
METHODS
Study Design
A cross-sectional study design was used, with data collected via an online questionnaire. Publicly available information from the websites of MSW programs was also recorded. The research protocol was approved by the institutional review boards at Fordham and Yeshiva.
Sample
All MSW programs in the United States (N = 248, including four in Puerto Rico) listed on the Council on Social Work Education website (Council on Social Work Education, 2015) and 32 programs listed on the Canadian Association for Social Work Education website (Canadian Association for Social Work Education, 2015) as accredited or pre-accredited as of 5 January 2015 were included. A letter of invitation was sent via the U.S. Postal Service to the Director of the MSW Program, or, if this position was not listed on the website, to the dean/director of the program. An email with a survey link was sent one week later.
A follow-up email was sent one month later. The second mailing was sent, when possible, to someone who might be more familiar with courses on the topics of interest who would be both more invested in this research and be the best reporter for that program. This included, in order of priority: a faculty member listed as teaching a course on palliative care, death, dying, grief, loss, or bereavement; a faculty member teaching a course on health care, oncology, disability, or a closely related topic; and a faculty member involved in clinical practice or research in this area.
Respondents were offered anonymity, although most provided identifying information. Information about which programs had participated was used only to send second mailings and to obtain basic information.
Measures
Questions were asked about courses dedicated to and courses with some content on: (1) working with seriously ill or dying persons; and (2) death, dying, and/or grief and bereavement. Respondents were asked about up to two courses in each category. They were asked why the dedicated palliative care course was developed, and, if no dedicated course was reported, whether one was planned. Participants were asked to submit the syllabus for the courses they reported.
Respondents were asked whether field placements were available in hospital-based palliative care programs or a hospice setting and whether they were part of a specialization. The characteristics of MSW programs included: number of students; if they had a concentration in health care or gerontology; the auspices of the school; the geographic region; if there was a medical, nursing, or theology school at the university; and whether a reported dedicated course was developed in collaboration with these schools. Respondents were also asked to provide their job titles. Open-ended comments were elicited.
Information on Nonparticipants
Information extracted from the websites of all eligible MSW programs included: (1) course names that included palliative care, end-of-life care, oncology, or a closely related topic; (2) course names that included death, dying, grief, loss, or bereavement; (3) faculty members who reported experience or interest in palliative care, end-of-life care, oncology, or a closely related field; and (4) faculty members who reported experience or interest in death, dying, grief, loss, or bereavement. This information was used to assess the degree to which we might be underestimating the inclusion of content on palliative and end-of-life care in MSW curricula.
Data Analysis
Descriptive statistics, including frequencies and measures of central tendency and variability, are reported. Due to small numbers, only frequencies are reported in some instances. Chi-square tests are not valid due to the number of cells with small expected counts.
There were too few responses to open-ended questions to warrant qualitative data analysis. We therefore report some of the pertinent comments.
RESULTS
Sample Description
There were 105 participating MSW programs. The response rate was 37.5%, which was higher for the United States (39.1%) than for Canada (25%). Table 1 shows that programs were from all regions of the United States. A majority were from a public university. Respondents were most commonly Director of the MSW program and full-time faculty. Program size varied from 10 to 1,400 students (median = 133).
Table 1. Sample characteristics (N = 105)
MSW = masters of social work; SD = standard deviation.
Courses dedicated primarily to palliative care are described first, followed by those that only contained some palliative care content.
Courses Dedicated to Palliative Care
There were 29 respondents who reported 36 courses dedicated to palliative care. Most were offered during the previous academic year. Mean enrollment was 21.1 (SD = 15.6).
The question about offering a dedicated course on palliative care was worded as follows: “Are there any specific courses in your MSW program dedicated primarily to working with seriously ill or dying persons? This does not include courses on death and dying or grief and bereavement. We will ask you about that later in the survey.” However, as shown in Table 2, only 10 of the course names reported appear on their face to be dedicated to palliative care. Eleven courses appear to be dedicated to death, dying, loss, grief, and/or bereavement. The remaining course names were related to medical social work, aging, long-term care, and/or family caregiving. A review of many syllabi submitted by respondents confirmed that courses with these names were not dedicated to palliative care. Some of the courses with death or dying in the name had some content on palliative care. Those with medical, aging, or long-term care in their name had very little.
Table 2. Description of courses reported as dedicated to palliative care
SD = standard deviation.
Part of Specialization or Certificate Program
Nine of the courses reported as dedicated to palliative care were part of a specialization or certificate program, including all five of the courses with “palliative” or “end-of-life care” in their name. As shown in Table 3, the most common specialization was gerontology.
Table 3. Course focus by course name category
1 More than one course focus could be selected.
Course Focus
Table 4 shows the focus of courses listed as dedicated to palliative or end-of-life care. Most focused on clinical practice skills and on ethical issues. History or context of palliative care, spirituality, and legal issues and/or legislation related to palliative care were also the focus of most of the courses with palliative or end-of-life in the course name. Most of the courses with death, dying, grief, loss and/or bereavement in their name were reported as having a clinical practice focus.
Table 4. Description of courses with some content on palliative care
1 The names of these four courses are: “Death and Dying,” “Grief and Loss,” “Interprofessional Psychosocial Oncology,” and “Relational Practice with Families.”
2 This was a seminar which included topics that were not on palliative care, based on the course syllabus.
Collaboration with Medical or Nursing Schools
Of the 10 courses with a name indicating that they were dedicated to palliative care, 7 were at a university with a medical school, 3 of which were designed or implemented in collaboration with the medical school. Seven of these courses were at a university with a nursing program, and two of these were designed or implemented in collaboration with that program.
Reasons for and Challenges in Developing the Dedicated Course
Courses with names indicating that they are dedicated to palliative care were developed due to the program's focus on health, behavioral health, as part of a specialization, or having a specialist on the faculty. Respondents reported no challenges in implementing the dedicated palliative care course, stating that faculty members were supportive and that the course was popular with students.
Plans to Offer Dedicated Courses
Of the 24 programs answering the question about whether they were planning to develop a dedicated course on palliative or end-of-life care, only 2 responded affirmatively, 2 stated that they were planning a course with substantial content, and 4 were considering developing a course with moderate (n = 1) or a little (n = 3) palliative care content. The reasons given for developing a palliative care course were: faculty interest; lack of sufficient content, including clinical skills, in an existing course on death and dying; a supportive dean; commitment by the university to participate in a palliative care institute; having field placements in palliative care or medical facilities; expanding a gerontology certificate program; and student interest in working with older adults, particularly related to medical and palliative social work.
Courses with Content on Palliative Care
There were 106 courses in 63 MSW programs with at least some content on palliative care. Of the 83 courses for which the amount of content on palliative care was reported, three-fifths had less than 25% of the content on palliative care, and less than 7% had at least half of their content on this topic. The majority of courses with palliative care content were offered at least once a year, and almost all were currently offered.
Of the 98 courses for which information was provided, 17 were part of a specialization in gerontology and/or health care. Of the 30 courses that were required: 11 were a practice with individuals and/or a families course; 7 were Human Behavior in the Social Environment; 6 were on health, illness, or medical issues; 4 were on aging; and 2 were on another topic.
Field Placements
Most programs (n = 83, 79.0%) offered field placements in a hospital-based palliative care program or in a hospice program. Of these, 21 (25.3%) were part of a specialization in palliative care.
Open-Ended Comments
Respondents were invited to comment on teaching MSW students about working with seriously ill or dying individuals. Some remarked that the content on this topic should be required in the MSW curriculum and that an elective on this topic should be offered. One respondent from a smaller program reported having to cancel a palliative care elective due to insufficient enrollment, and another mentioned not having time to cover this content in their advanced generalist curriculum. One respondent pointed out the difficulty in finding qualified faculty to teach the course. Some stated that they teach a palliative care course and find it to be very rewarding and reported that most students “loved” the class and found it to be valuable for their professional development.
Nonparticipating Programs
Given the modest response rate, we attempted to understand the degree of selection bias. Table 5 shows that, among nonparticipating programs, the information available on school websites indicated only 4 programs with a dedicated palliative care course and 15 programs with a dedicated course on death, dying, loss, grief, and/or bereavement. We examined information for all faculty at each nonparticipating school. This was done to ascertain the extent to which there might be courses offered by these faculty on the topics of interest in our study, even if the course was not listed on the school website. We found only 11 nonparticipating schools that did not list a dedicated course and at which at least one faculty member listed palliative or end-of-life care as an area of interest. Similarly, there were only 13 faculty at nonparticipating schools where at least one faculty member listed death, dying, grief, or bereavement as an area of interest.
Table 5. Response rate and information on nonrespondents
1 Categories are mutually exclusive, with classification hierarchy starting on left and descending to the right.
DISCUSSION
Content on palliative and end-of-life care is extremely limited in most MSW programs. Few programs offer a dedicated palliative care course, or even one with substantial palliative care content. There is more content in the curriculum on death, dying, and bereavement, though these courses tend to focus on historical, psychosocial, cultural, legal, policy, ethical, and spiritual areas, with little, if any, content on palliative care practice. A recent study reported 18 dedicated palliative care courses, but given that the course names were not reported, it may be that, as in our study, some of these are not actually dedicated courses (Dickinson, Reference Dickinson2013). On a positive note, there are MSW programs leading the way by developing curricula to educate the next generation of social workers for palliative and hospice care practice. These courses are usually part of a specialization, concentration, or certificate program in gerontology or health, including one in psychosocial oncology.
We were surprised to find that 25% of the many programs that reported having field placements in palliative care or hospice also reported that the field placement was part of a specialization in palliative or end-of-life care. The small number of dedicated palliative care courses and the very small number of programs reporting that these courses were part of a palliative care specialization cast doubt on this finding. It seems more likely that the question was misunderstood than that there are so many programs with a palliative care specialization that do not offer a dedicated course on the topic.
Implications
Social workers in all practice settings will encounter clients with serious and life-limiting illness and their families. In addition to the relatively small number of social workers who will be employed in palliative care or hospice settings, social workers in the wide range of health care settings should have basic competence in palliative care due to the need for palliative care services early in the course of illness. Even if there is eventually an adequate number of specialty hospice and palliative care social workers, not all patients will require or be referred to such services. Competence to deliver basic palliative care should be required of all health care professionals, including social workers. Social workers in other settings will also encounter clients who would benefit from assessment of palliative care needs, treatment for less complicated issues, and referral to specialty palliative care. For these reasons, regardless of whether a dedicated palliative care course is offered, adding palliative care content to required courses is recommended.
Curricula are needed for palliative social work. While there are competencies for specialty palliative social work practice, a recommended core curriculum does not exist. The recent report by the Center to Advance Palliative Care recommended that states fund palliative care curriculum development in medicine, nursing, and social work that would be integrated into courses (Center to Advance Palliative Care, 2015). Discussion and consensus on basic palliative care knowledge and skills for all, or most, MSW graduates are recommended, which could then lead to curriculum development.
Different models of delivering specialty palliative care education to MSW students may increase the opportunities for reaching more students. Descriptions of different models exist, including some that report outcome data (Agnew & Duffy, Reference Agnew and Duffy2010; Supiano & Berry, Reference Supiano and Berry2013; Turner et al., Reference Turner, Kuyini and Agustine2015). Competing electives among course offerings and finding faculty qualified to teach a specialty palliative care course may be challenging. Intensive courses scheduled during the summer or semester breaks, as well as online and hybrid courses, could expand the opportunity for offering specialty electives. Smaller programs might offer joint courses with other programs, making it feasible to find qualified teachers and enroll a sufficient number of students. Video conferencing could be used to connect remote campuses. The data from the current study suggest that specialty and certificate programs in related areas—such as aging or health—may provide opportunities for developing specialty courses in palliative care.
When a dedicated course is not feasible, palliative care practice content could be added to existing electives on death and dying, health care, disability, or aging. Better integration of didactic education in field placements in inpatient, hospice, long-term, and community-based care, complementary to or instead of coursework, should be explored. Resources to assist in this effort are available (Csikai & Jones, Reference Csikai and Jones2007; Walsh-Burke & Csikai, Reference Walsh-Burke and Csikai2005a; 2005b), and more are needed.
Introducing basic palliative care content in required courses also presents challenges and will require innovation. Such content could be introduced during the generalist and/or specialist years—ideally both. Generalist and clinical practice courses are recommended for introducing clinical skills in basic palliative care. Human Behavior in the Social Environment and required policy courses also present opportunities for including palliative care content. Case examples and readings relevant to palliative care could be included in any of the required courses in MSW curricula. These would serve the dual purpose of illustrating a concept in the class and infusing palliative care content.
The National Consensus Project to Establish Core Competencies for Generalist-Level Palliative Social Work, a project of the MJHS Institute for Innovation in Palliative Care in New York City, was launched in March, 2016. Input from social work educators and practitioners from a wide range of practice settings nationwide will be used to develop a set of palliative care competencies for generalist-level practice. Members of the board of directors of the Social Work Hospice and Palliative Care Network, including the study authors, are on the board of the National Consensus Project, ensuring close coordination between this project and one of the leading professional organizations for palliative social work. The core competencies proposed by the National Consensus Project will be used to guide curriculum development and teaching materials in basic and specialty palliative care.
Limitations and Strengths
The low response rate in this study limits the generalizability of our findings. However, available information on nonresponding programs suggests that few of these offer courses on palliative care. Even allowing for incomplete and outdated information on websites, the number of programs with courses that contain more than a small amount of content on palliative care appears to be extremely small. There were also few faculty members who reported an interest in or expertise in these topics, suggesting that content on palliative care is not being infused into other courses.
The majority of respondents were not the instructor for the course. Reports of whether the course was dedicated to palliative care, the percentage of the course with content on the topic, and the course focus may not be accurate. In addition, the measure of palliative care field placements was very cursory.
Our study had several important strengths. This is the first study to examine courses on palliative and end-of-life care that attempted to include all accredited MSW programs in the United States and Canada. The survey included measures on content in dedicated and other courses, as well as information about these courses. To minimize the possibility of misconceptions about palliative and end-of-life care, we did not use these terms in the questions, but rather asked about content about working with seriously ill or dying persons.
Future Research
Future research should closely examine the palliative care content in both dedicated and other courses. Evaluation of different curricula and models of teaching MSW students about generalist and advanced palliative care should be evaluated for how well the content, focus, and teaching modality prepare students. Similarly, field placements in palliative or hospice care settings should be evaluated to understand how to better prepare emerging social work professionals.
Building on earlier courses that focused on death, dying, and bereavement, newer course models have incorporated a broader palliative approach to care for those facing serious, chronic, and advanced illness, as well as their families. These educational models—whether full-semester courses, mini-courses, modules integrated into aging or health care courses, special workshops, conferences, or other time-limited programs—will need to be examined for their effectiveness in preparing students for palliative care practice.
CONCLUSIONS
Palliative social work is a relatively new field. Social work graduate education is beginning to respond to the growth of palliative care services and has begun to develop practice competencies for specialty practitioners. The introduction of palliative care services earlier in the course of an illness requires all social workers in health care settings to have basic palliative care competencies. Finally, social workers in other settings can better assist clients if they too have basic knowledge and skills in this area. It is time for palliative social work educators, practitioners, and policy leaders to reach a new consensus on the minimum competencies necessary for both generalist health care social workers and those specializing in hospice and palliative care practice, and to develop curricula for them.
ACKNOWLEDGMENTS
This work was supported by the Faculty Research Development Fund at the Fordham University Graduate School of Social Service. The authors gratefully acknowledge the contributions of Ellen Csikai and Iris Cohen Fineberg, who provided feedback on the survey instrument, and to Elizabeth Ige for her assistance in conducting the research.
DISCLOSURES
The authors hereby declare that they have no conflicts of interest to disclose.
