Introduction
Social workers are recognized as core members of the hospice and palliative care team, supporting patients and families throughout the course of serious illness and following the patient's death (Institute of Medicine, 2014). Their services may include care/case management, behavioral health counseling and psychotherapy, support groups, advance care planning, consulting services, participation on ethics committees, concrete services, and grief and bereavement counseling (Altilio & Otis-Green, Reference Altilio and Otis-Green2011; Meier & Beresford, Reference Meier and Beresford2008; National Association of Social Workers, 2018) and are a required component of the Medicare Hospice Benefit. The need for palliative care will increase with the growing aging population; the number of people age 65+ is projected to increase from 13.7% of the US population in 2012 to 20.3% by 2030 (Ortman et al., Reference Ortman, Velkoff and Hogan2014), which will be accompanied by an increase in patients with chronic and advanced serious illness. The current shortage of trained social work professionals to meet the needs of hospice and long-term care, as well as hospital- and community-based palliative care programs, will be even more pronounced as these services expand to meet the need (Center to Advance Palliative Care, 2015; Coalition to Transform Advanced Care, 2018; Institute of Medicine, 2008).
Palliative social workers have taken important steps to increase the numbers of social workers trained and competent to deliver effective psychosocial care. 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). In addition, the National Consensus Project to Establish Care Competencies for Generalist-Level Social Work released a report in 2018 on the palliative care competencies necessary for social work practice (Glajchen et al., Reference Glajchen, Berkman and Otis-Green2018). Although a credential for advanced certification has been established based on continuing education and experience in hospice and palliative care (National Association of Social Workers, 2018), the Hospice and Palliative Care Certification Project expects to inaugurate a new specialty certification for palliative social workers in 2019 based on a comprehensive examination of the significant activities, skills, and knowledge base for specialty practice (Head, Reference Head and Peters2018).
In spite of these professional developments, social work education in palliative care has been inadequate to meet service needs. A 2015 survey of healthcare social workers found that less than one-half (46%) felt adequately prepared by their social work education for palliative care practice. Most reported learning palliative care skills from interprofessional collaboration (81%) and from social work colleagues (74%) (Sumser et al., Reference Sumser, Remke and Leimena2015). This finding was corroborated by the current authors in their 2017 survey of masters of social work (MSW) programs in the United States and Canada. Of 105 participating social work programs, only 10 had courses dedicated to palliative care and only a few had plans to develop a dedicated course. More favorably, there were 106 courses in 63 MSW programs with some palliative care content, although the majority had <25% of course content, and few had at least 50% of course content related to palliative care (Berkman & Stein, Reference Berkman and Stein2018).
The purpose of this study was to determine the type and extent of content areas included in MSW courses dedicated to palliative care and in courses with palliative care content. This report presents a content analysis of the 106 courses with some palliative care content from 63 MSW programs in the United States and Canada, as previously reported by Berkman and Stein (Reference Berkman and Stein2018).
Methods
Study design
A cross-sectional study was conducted to determine the number of dedicated courses on palliative care in MSW programs, as well as courses that included content on palliative care. In addition to completing an online survey, study participants were asked to submit the syllabus or syllabi for the courses that they reported on in the survey. The research protocol was approved by the institutional review boards at Yeshiva and Fordham Universities.
Sample
All accredited and preaccredited MSW programs, as of January 5, 2015, in the United States (n = 248) (Council on Social Work Education, 2015a) and Canada (n = 32) (Canadian Association for Social Work Education, 2015) were selected to participate in the study. An invitation letter was sent via US mail to the director of the MSW Program, or, if this position was not listed, to the dean/director of the program. An email with the survey link was sent one week later. A follow-up email was sent one month later either to the original recipient or, based on information on the school website, to a faculty member who taught a course related to palliative care or who had an interest in this or a related area. Respondents were offered anonymity, although most provided identifying information.
There were 105 MSW programs that participated survey. Respondents were first asked to provide information about courses with content on working with seriously ill or dying persons. Next, they were asked about courses on death, dying, grief, loss or bereavement. They were asked to submit the syllabus for the courses on which they reported. Seventy of the syllabi by 42 programs met the inclusion criterion of having a course outline with dates for each class session and the topics and readings for each date.
Materials and measures
The content that was used for data analysis was the description of the class sessions. Information in other parts of the syllabus was not included. Within the class sessions, the content that was used included: description of the topic for that session, in-class exercises, required class trips, and required readings. All of the readings that were used for data analysis were examined by the authors. Virtually all of the journal articles and most of the textbooks assigned were available to the authors. When an article was not available, the abstract for the article was used. When a chapter was not available, the chapter title was used, if it was sufficiently specific. The following were not included in data analysis: text from parts of the syllabus other than the class sessions; optional readings; assignments; optional activities outside of class; and anything with insufficient information to code.
Data analysis
The primary purpose of data analysis was to identify the topics covered in the syllabi and to quantify the number of weeks for each topic. A secondary purpose was to identify the focus for that topic. Each of the authors independently read the syllabi. Initial codes were created based on agreement of the topics covered in the syllabi. A grounded theory approach with constant comparison analysis was used to code the data (Charmaz, Reference Charmaz2014). New codes were created during the initial coding. Multiple codes were often assigned to the same course topic. The researchers jointly reviewed the first-level codes to eliminate redundancy and achieve consensus on assigning the initial codes to the text. As new codes were created, they were sometimes assigned to syllabi that had already been coded. The researchers then worked together to combine the initial codes into 29 main topic categories. In addition to assigning a content area to text, we indicated whether the content was in the realm of clinical practice, administration, policy, or ethics. A summary sheet was created for each course that recorded the course name; university name; number of weeks and credits for the course; for each topic, the total number of weeks it appeared in the course; and the number of weeks that topic appeared in each realm of practice. Each of the syllabi was assigned to a primary course topic based on the course name.
A very narrow approach was taken in assigning codes. Unless there was reasonable assurance that a topic was included, it was not coded. Coding decisions were documented and applied to all subsequent syllabi to be coded, as well as checking already coded syllabi. General topics on health and aging, disability, chronic illness, or caregiving were not coded unless they were specific to palliative and end-of-life care, advanced illness, death, dying, grief, loss, or bereavement.
The first 20 syllabi were coded by all three authors. The next 20 syllabi were coded by the first two authors to further establish the degree of consistency in coding. Given the extremely high rate of agreement, the second author coded the remaining syllabi, conferring with the first author and reaching consensus for any codes that were in doubt.
Results
There were 29 topic areas created during data analysis. The mean and median number of weeks for each topic, across all 70 syllabi, are shown in Table 1. The topic with the longest mean duration was grief, loss, and bereavement. This was expected, given the large representation of syllabi on this topic. Behavioral issues had the next highest mean, followed closely by supporting family, friends, and community caregivers. Cultural issues and advance care planning were are relatively common topics. The large discrepancy between the mean and median number of weeks each topic is covered, and the big SDs, are due to the great range of coverage of topics across different types of courses.
Table 1. Topics and number of weeks covered in all courses (n = 70)
LGBT, lesbian, gay, bisexual, transgender; POLST, Physician Orders for Life-Sustaining Treatment.
Figure 1 presents the most common topics for the 70 syllabi by course category. For each of the seven course categories, the top eight topics by number of weeks of coverage, or topics that were included for at least one week of the course, are shown. When there was a tie in the number of weeks among the last of the eight categories, all topics for that number of weeks were included. The largest number (n = 19) of syllabi were on courses on grief, loss, and bereavement. The most common topic in these courses was behavioral issues, supporting family, and cultural issues. There was considerable overlap with the death and dying courses, although these courses specifically referred to grief rather than behavioral issues. Slightly more than double the amount of time is spent on spirituality and on comfort with death in death and dying courses as compared with grief, loss, and bereavement courses. More time is also devoted to other end-of-life topics, such as advance care planning, illness trajectory, and traumatic death in the death and dying courses.
Fig. 1. Mean number of weeks of topics by course (n = 70).
There are noticeable differences in the most common topics in palliative and end-of-life care courses compared with the two previous categories. Supporting family is the most common topic, followed closely by interprofessional work and advance care planning. Behavioral issues, cultural issues, and communication skills were in the top six topics in palliative and end-of-life courses.
Other courses in the curriculum, both required and elective, that were submitted as having some content on palliative or end-of-life care or on grief, loss, and bereavement, had very little palliative care content. These included courses related to health, aging, human behavior in the social environment, and practice with individuals and families. None of these courses had more than a week on advance care planning, supporting family, grief, behavioral issues, or other courses directly related to palliative and end-of-life care.
Discussion
Greater opportunities are needed to provide entry-level professional social workers with the knowledge, skills, and values for palliative care practice, whether as specialists in hospice, long-term care, or hospital- or community-based palliative care settings, or as generalists practicing in an array of healthcare settings. Our findings based on the limited number of dedicated palliative care courses provide evidence of useful models for curriculum development. The greater number of courses on death, dying, grief, loss, and bereavement also include some palliative care content. Finally, there is occasional integration of palliative care content into courses on healthcare social work, aging, family systems, and trauma practice.
What's in a name? Does it matter if courses are classified as palliative and end-of-life care or death and dying; or grief, loss, and bereavement? The analysis of course content displayed in Figure 1 demonstrates considerable overlap of topics across the course categories. Palliative care courses have a strong interprofessional context that is absent from the other courses focused on grief or death and dying. Courses focused on grief or death and dying have a much stronger emphasis on behavioral issues. Content in courses focused on grief have much less content on the illness trajectory before death, the timespan at the core of palliative care. Moreover, grief is discussed in the context of behavioral/mental healthcare; causes of grief and loss other than serious illness and death are considered.
The opportunities for leadership in palliative social work education are many. The challenges of infusing additional material into the generalist social work education are well-known. Content on palliative care competes for limited time in required and elective courses with other equally important knowledge and skill areas. Accreditation standards do not specify content in specialty practice areas (Council on Social Work Education, 2015b) and MSW programs choose such content based on faculty experience and interest and student preferences. In its favor, palliative care includes practice, policy, and research across practice settings, diverse cultural communities, and the lifespan. With the aging of the US population and concomitant increases in chronic and advanced serious illness, MSW programs must prepare its generalists to address advanced illness needs across health and behavioral healthcare settings. The previously noted Generalist-Level Palliative Social Work project provides guidance for MSW programs on competency areas that should be infused into generalist education. Failure to do so may further increase opportunities for nurses at the expense of healthcare social work. Although our recommendations are made within the context of social work education, they equally apply to all professions that comprise the palliative care team, including chaplains, nurses, physicians, and physician assistants.
There are challenges to introducing palliative care content into MSW programs. Faculty qualified to teach this content may be scarce. There are many competing electives on equally compelling practice areas. Introducing palliative care content into existing required and elective courses with other important content and skills is difficult. Smaller social work programs may be challenged to develop a dedicated course on palliative care; however, the low number of dedicated palliative care courses (Berkman & Stein, Reference Berkman and Stein2018) suggest opportunities across MSW programs. Most regions around the United States have hospice and/or hospital- or community-based palliative care programs that may be tapped for expert adjunct faculty and for fieldwork. Other creative strategies, including intensive, summer, online, or hybrid courses, can be developed. Preparing cases that are relevant to palliative care, with an accompanying teaching guide, that may be used in required courses in the curriculum, may be a way to introduce this content. Smaller programs may consider collaborating with each other or larger programs to offer an online palliative social work course. Faculty interested in adding dedicated courses or content on palliative care in their MSW program may need to educate administrators and faculty colleagues on the need for all social workers to have a minimum level of competence in palliative care, particularly given the aging of the population and longer lifespans for people with serious illness. They may find it effective to suggest that offering a palliative care elective, along with field placements in palliative and hospice care, may assist in recruiting students to their MSW students. With the exponential increase in palliative care services across the United States (Center to Advance Palliative Care, 2015), the time is ripe to increase opportunities for specialty coursework in palliative care and to develop innovative centers for excellence in programs with strong commitment to this field.
Limitations and strengths
There were some important study limitations. The syllabi varied in the degree of detail included. Some syllabi had minimal information and did not provide the depth of information necessary for describing all of the topics covered, the realm of practice, or how the topics were taught. This undoubtedly resulted in undercounting some topics. It also does not allow us to provide detail on teaching methods used.
Only 105, or 37.5%, of all MSW in the United States and Canada participated, and of those, only 42 programs submitted syllabi. Based on our examination of program websites, however, it appears that there were only a few programs with a palliative care elective that did not participate in the study (Berkman & Stein, Reference Berkman and Stein2018).
This analysis is based on what was written in the syllabi, which may not always represent what was actually covered in a class session. Instructors may not have time to cover all of the content or may have introduced different content. Students may not always complete the required readings.
Study strengths include this being the only study of which we are aware that has examined syllabi of courses on palliative and end-of-life care and death, dying, grief, loss and bereavement. The sample was large and from programs that were diverse by region of the United States, size, and auspices (public, private nonsecular, and private secular), and included 10 syllabi on courses that were dedicated to palliative and end-of-life care.
Future research
Existing curricula and models of teaching, both in MSW programs and continuing education and training programs, should be evaluated to determine the ways in which they are successfully preparing emerging social work professionals and social workers in the field for palliative care practice. Program elements that are effective should be replicated. Greater collaboration across MSW programs and continuing education and training programs may lead to the development of more effective and efficient ways to prepare social workers for generalist and specialist-level palliative care. Data should be collected from course instructors to obtain the information not available in syllabi.
Following the development of Generalist-Level and Specialist-Level Competencies, there will be a need to develop curricula for MSW programs, and continuing education and training for social workers in the field.
Conclusion
Palliative social work is a relatively new field. There are few MSW programs with specializations in palliative care and there are challenges to developing and maintaining these programs; however, anecdotal evidence suggests that these programs attract a small number of highly qualified students who seek a career in this field. Electives on this topic are popular with a wider range of students who want to gain skills in this practice area. Introducing the specialization into more MSW programs, particularly in regions of the United States where they are scarce, would be beneficial in building the specialty-level workforce. Adding dedicated courses on palliative care and introducing palliative care content into existing required and elective courses might contribute to building capacity necessary for providing palliative care services earlier in the course of illness. All social workers in healthcare, social service, and other settings will encounter clients or their family members who are dealing with serious illness and they need generalist-level palliative care skills to respond competently.
