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Social Work in Health Care

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Oncology Social Worker Competencies and Implications for Education and

Training

Brad Zebrack a; Katherine Walsh b; Mary Ann Burg c; Peter Maramaldi d; Jung-won Lim e

a University of Michigan School of Social Work, Ann Arbor, Michigan b Springfield College School of

Social Work, Springfield, Massachusetts c Community Health & Family Medicine, University of

Florida, Gainesville, Florida d Simmons School of Social Work, Boston, Massachusetts e Division of

Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California

To cite this Article Zebrack, Brad, Walsh, Katherine, Burg, Mary Ann, Maramaldi, Peter and Lim, Jung-won(2008) 'Oncology Social Worker Competencies and Implications for Education and Training', Social Work in Health Care, 47: 4, 355 — 375

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doi:10.1080/00981380802173954 355

Implications for Education and Training

Zebrack et al. SOCIAL WORK IN HEALTH CARE

Brad Zebrack, PhD, MSW, MPH

Katherine Walsh, PhD, MSW

Mary Ann Burg, PhD

Peter Maramaldi, PhD, MPH

Jung-won Lim, PhD, MSW

ABSTRACT. A mailed and online survey of 622 members of the

Associ-ation of Oncology Social Workers (AOSW) indicated their proportion of time committed to certain aspects of practice and to certain population groups, and the extent to which they feel competent in various practice areas. Respondents indicated high levels of competence in 17 topic areas, including promotion of patient coping skills, end-of-life issues, and group work. Topic areas in which at least one third of respondents indicated little Brad Zebrack is affiliated with the University of Michigan School of Social Work, Ann Arbor, Michigan.

Katherine Walsh is Professor, Springfield College School of Social Work, Springfield, Massachusetts.

Mary Ann Burg is Associate Professor, Community Health & Family Medicine, University of Florida, Gainesville, Florida.

Peter Maramaldi is Associate Professor and Hartford Faculty Scholar, Simmons School of Social Work, Boston, Massachusetts.

Jung-won Lim is affiliated with the Division of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California.

On behalf of the Association of Oncology Social Workers, the authors express appreciation to The Leukemia and Lymphoma Society for their partial support of the member survey. Thank you also to Kimberly Lawson and Kathryn Smolinski for their support and review of this effort.

Address correspondence to: Brad Zebrack, University of Michigan School of Social Work, 1080 S. University, Ann Arbor, MI 48109-1106 (E-mail: [email protected]).

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356 SOCIAL WORK IN HEALTH CARE

to no competence included pain assessment and management, cognitive behavioral therapy, complementary and alternative practices, and political advocacy. Although respondents indicated that they spend approximately 10% of their time with non-English-speaking populations, 50% of the sam-ple indicated that they have little to no competence working with this pop-ulation. Differences in levels of competence by years of experience and work setting were noted across many areas. Findings from this survey may be useful in the development of curriculum for preparing oncology social workers for practice in today’s changing health care environment.

KEYWORDS. Cancer, oncology, clinical social work, education, training

Each year, approximately 1.4 million people in the United States are diagnosed with cancer (Jemal et al., 2005; excluding non-melanoma skin cancers.). In only 11% of instances will patients obtain primarily outpa-tient cancer care at a hospital or comprehensive cancer center; most (89%) will receive care through a community-based physician’s office or group practice (Institute of Medicine, 2007). Over the next 40 years, the number of people diagnosed with cancer is expected to expand with the aging of the baby boom population. From 2000 to 2050, the absolute number of people aged 65 and older diagnosed with cancer is expected to double, thereby putting greater demand on service providers and systems of care (Edwards et al., 2002). With mortality and survival rates having improved over the past 25 years in the United States, we can anticipate greater numbers of people living with, through, and beyond cancer. How-ever, these improvements have not been experienced as such by individuals who are poor or members of medically underserved groups (Jemal et al., 2005; Singh, Miller, Hankey, & Edwards, 2003).

“Oncology social workers are [now] the primary providers of psycho-social services in major oncology treatment centers and community health care settings throughout the world, both because of their knowledge about cancer and its psychosocial impact, and because of their practice versatility” (Smith, Walsh-Burke, & Cruzan, 1998). Oncology social workers participate on multidisciplinary teams in cancer centers and community hospitals, and sometimes in oncology group practices. Some obligate all their time to oncology services, others rotate through oncology as well as other medical services. Others provide direct services through social service agencies like the American Cancer Society, the Leukemia and Lymphoma Society, and The Wellness Community. In most ambulatory fee-for-service

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or managed care institutional settings, oncology social workers receive a set salary, and their work is included as part of a cost center reimburse-ment formula. Except for some who maintain private practices, few oncology social workers charge a fee for services rendered. For those in private practice who provide psychotherapy, reimbursement rates vary by insurer.

Although a considerable body of literature has been disseminated regarding the practice of oncology social work (Lauria, Clark, Hermann, & Stearns, 2000), the literature on education and training of oncology social workers is relatively sparse. Smith and colleagues (1998) noted that “[T]he complexity and variability of psychosocial issues associated with cancer has created the demand for highly skilled practitioners who are trained to provide multilevel assessment and intervention throughout the [continuum of care]” (1061). These authors go on to identify the direct service tasks carried out by oncology social workers as being (1) screening and psychosocial assessment; (2) facilitating adjustment to illness; (3) provision of counseling and individual, family, and group psychotherapy; (4) discharge planning; (5) referral; and (6) advocacy. In other work, Walsh (2005) identifies points along a continuum of care, from diagnosis through treatment and on into off-treatment survivorship or end-of-life, at which these tasks are required. Recent recommendation set forth by the Institute of Medicine to enhance psychosocial care for cancer patients are clearly aligned with the mission of oncology social work (Institute of Medicine, 2007).

The Association of Oncology Social Workers (AOSW) has established a Scope of Practice and Standards of Practice for the profession (see www.AOSW.org); however, neither a standard set of competencies nor a formalized professional training program in oncology social work has been established in the practice or education sectors of the social work profession. Competencies have been established in related areas of social work practice, such as end-of-life care (Taylor-Brown, Altilio, Blacker, Christ, & Walsh-Burke, 2001), which can serve as models for the field of oncology. Thus, the Association of Oncology Social Work (AOSW) set out to formally assess oncology social workers’ roles, functions, scope of practice, and level of competence in key areas of practice, as well as their perceptions of professional development and training needs. Combined with the works of Smith and colleagues (1998) and Walsh (2005), find-ings reported here may be useful in the development and targeting of cur-riculum and training programs that will prepare oncology social workers for practice in the context of today’s changing health care environment.

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METHOD

To accomplish goals set forth in its “Strategic Plan: Focus 2008,” the Association of Oncology Social Work commissioned the Social Workers in Oncology Research Group (SWORG, an AOSW Special Interest Group) and an outside consultant to develop a survey of its membership. Working in tandem, the SWORG and AOSW Board of Directors created a comprehensive workforce assessment. The survey assessed oncology social workers’ practice roles and their perceptions of their levels of com-petency across different areas of practice, types of clients, and social work content areas. We hypothesized that higher levels of perceived compe-tence would be associated with more years of experience in oncology social work. We also explored differences in competencies based on whether respondents reported working in the community or in larger health care systems.

E-mail announcements about the online member survey were sent to 844 of the 999 AOSW members with e-mail addresses registered with the organization. The remaining 155 members received a notice via U.S. mail. Two reminder e-mails and reminder postcards were sent to all members during the period of data collection, December 2005 through May 2006. Although the response rate by online survey (63.4%) was slightly higher than that by U.S. mail (56.1%) there were no significant differences in overall findings.

The survey included the following demographic characteristics: most advanced degree (BSW/other Bachelors degree, MSW/other Masters degree, PhD/DSW/other doctoral degree); licensure status (yes/no), and, geographic location (urban, suburban, rural). The survey also assessed years in oncology, work-status (full-time or part-time), and work setting (academic/university-affiliated institution, community-based treatment facility, or community-based service/advocacy agency).

To assess education and training needs, the survey asked respondents to indicate the percent of time they spend in nine areas of practice (direct services, administration, patient education, program development and/or evaluation, social work education, research, providing clinical supervision, community organizing, and grant-writing) and with eight different popu-lation groups (children, adolescents, and young adults age 15–39, middle-age adults age 40–64, older adults age 65–79, oldest adults 80 years and over, low income populations, non-English-speaking populations, and other). The survey also asked respondents to indicate their level of competence (not at all, a little, somewhat, very) in these various practice areas and

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with client population groups, as well as in 33 specific oncology social work topic areas. A single question asked respondents how often they engage patients or family members in discussions about clinical trials (never, 1%–25% of the time, 26%–50% of the time, 51%–75% of the time, 76%–100% of the time). Finally, an open-ended question asked respondents what they thought AOSW could do to enhance their skills and abilities to provide quality care services to patients and families.

Analyses of data involved examination of frequency distributions for all demographic items, work-related items, and all self-reported compe-tency items for the total sample. Next, contingency tables and Chi-square tests were used to examine differences in competency outcomes by respondents’ years in oncology social work (<5 years, 5 or more years) and work setting. Although somewhat arbitrary, five years in practice is considered here to be a symbolic threshold at which point a practitioner may be considered “seasoned” or “experienced.” With regard to work setting, academic/university-affiliated institutions included large university hospitals and government-sponsored institutions (i.e., Veteran’s Affairs facilities, National Cancer Institute–designated comprehensive cancer centers). Community-based treatment facilities included out-patient centers, free-standing treatment facilities (e.g., outout-patient radiation oncology, out-patient surgical centers), free-standing hospice, private medical groups, and private practice. Community-based agencies consisted of national or local foundations or service organizations pro-viding direct services such as patient education, resources, or support groups.

RESULTS

Table 1 describes the sample in terms of employment and demographic characteristics. A total of 622 AOSW members (62.3% of total AOSW membership) completed the survey. On average, respondents have been in oncology social work for 11 years (SD = 7.93 years, range 0–50 years), with 25% of respondents (n = 152) having worked in oncology for less than 5 years. The majority of respondents worked in community-based treatment facilities (69%), whereas others worked in university-affiliated cancer treatment facilities (17%) or in community-based agencies (12%). Most respondents had Masters-level social work training (79%) and were state-licensed (84%). Respondents worked in urban (56%), suburban (29%), and rural (13%) areas.

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The large majority of respondents are practitioners involved in patient contact. On average, respondents reported having 103 (SD = 91.6) patient or family contacts per month, with number of contacts ranging from zero to 800. Only 41 respondents (6.5%) indicated having 10 or fewer patient/ family contacts per month, of which 27 (4%) reported no patient/family contact at all. No data were collected to distinguish self-identified clini-cians from administrators or academics; however, 5% of respondents indicated that they spend the majority of their time in administration and 5% of respondents possess doctoral degrees.

The percentage of time respondents allocate to various activities and patient groups is summarized in Table 2. On average, respondents spend 64.2% of their time conducting direct service, which includes psychoso-cial assessment, counseling for individuals, couples, groups, and families, as well as case management and discharge planning. Other areas in which

TABLE 1. Sample characteristics

Frequency (%) Work setting

University-affiliated institution/comprehensive cancer center

103 (17)

Community-based treatment facility 428 (69)

Community-based agency 75 (12)

Most advanced degree

BSW or other Bachelors degree1 _{38 (6)}

MSW or other Masters degree2 _{492 (79)}

BSW and MSW 57 (9)

PhD/DSW/other Doctoral degree 30 (5)

State-licensed 520 (84) Geographic location Urban 350 (56) Suburban 177 (29) Rural 80 (13) Work status Full-time 423 (68) Part-time 176 (28)

Years in oncology social work, n = 614 Mean: 11.1 yrs

(SD 7.9 yrs) Median: 10 yrs Percentages do not total 100% due to missing data.

1_{Nine respondents indicated Bachelors degree other than BSW.}

2_{Twelve respondents indicated Masters degree other than MSW.}

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members allot their time include administration (13.7% of time), patient education (12.0% of time), program development and/or evaluation (11.3%), social work education activities like teaching or training (9.0%), clinical supervision (5.4%), research (6.1%), community organizing (4.9%), and grant-writing (2.7%).

On average, respondents reportedly spend most of their time with adults age 40–64 (39.2% of time) and age 65–79 (32.1% of time). They report spending 12.3% of time, on average, with adults 80 years of age and older, 15.3% of time with adolescents and young adults, and 3.0% of time with children. Almost 40% of respondents’ time is spent with low-income clients, and 9.8% of time is spent with non-English-speaking clients.

Practice Competencies

Table 3 reports the extent to which respondents feel competent work-ing in specific areas of practice. Ninety-five percent of members indicated

TABLE 2. Average percentage of time allocated to areas of practice and types of clients

Areas of practice Average percentage

of time spent in area of practice (SD)

Direct services 64.2 (26.7)

Administration 13.7 (19.1)

Patient education 12.0 (13.3)

Program development and/or evaluation 11.3 (12.4)

Social work education (e.g., teaching, training) 9.0 (13.2)

Research 6.1 (14.2)

Providing clinical supervision 5.4 (8.5)

Community organizing 4.9 (8.3)

Grant-writing 2.7 (4.6)

Type of clients

Middle age adults (40–64 years) 39.2 (18.2)

Older age adults (65–79 years) 32.1 (17.4)

Oldest age adults (80 years +) 12.3 (11.9)

Adolescents/young adults (age 15–39) 15.3 (12.0)

Children (0–14 years old) 3.0 (7.6)

Low income populations 39.2 (26.4)

Non-English-speaking populations 9.8 (12.4)

Other1 _{6.8 (18.3)}

1_{Other includes “gay and lesbian”; “substance abuse/addiction”; “hearing}

impaired”; “homeless”; “minorities”; “veterans.”

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362 TABLE 3. Self -r epo rt ed l e vels o f comp et en ce wo rking in spe c ific ar eas of pra c tice A reas of practice n a Level of comp etence , n (% ) A ssociat ed varia b les c 2 N one A little S ome A lot # Years in oncology soci al work b Wor k setting c Direct service s 51 4 1 (0.2) 1 (0.2 ) 26 (5.1) 286 (94 .6) 27.97*** 6.07 P a tient e ducat ion 4 1 8 7 (1.7) 30 (7.2 ) 119 (28.5) 262 (62 .7) 6.40 7.26 S o cial w o rk educatio n (e.g., t eac hing, train ing) 39 1 16 (4.1) 39 (10. 0) 133 (34.0) 203 (51 .9) 16.51** 17.22** P rogram development and/or evaluation 3 7 8 23 (6.1) 37 (9.8 ) 155 (41.0) 163 (43 .1) 23.23*** 13.42* A d ministration 35 4 32 (9.0) 58 (16. 4) 114 (32.2) 150 (42 .4) 6.14 14.30* Grant writing 3 1 8 96 (30.2) 135 (42. 5) 66 (20.8) 21 (6.6 ) 7 .13 26.06*** Community organizing 31 6 52 (16.5) 130 (41. 1) 82 (25.9) 52 (16 .5) 4.92 15.50* P

roviding clinical supervision

31 3 60 (19.2) 34 (10. 9) 87 (27.8) 132 (42 .2) 37.64*** 9.66 Rese arch 27 8 64 (23.0) 111 (39. 9) 70 (25.2) 33 (11 .9) 4.26 27.44*** *p < .0 5, ** p < .0 1, ** *p < .00 1 . aIn

dicates number of respondent

s wh o provid ed data. bR e spo n se catego rie s are <5 ye ars, 5 or mo re years. cRe sponse cate gories are University-affiliated or comprehe nsive cancer center, C o mmunity-base d treat ment cente r, C o mmunity-base d agency.

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a high level of competence in direct practice oncology social work. Respondents also expressed relatively high levels of competence in the areas of patient education (62.7%) and social work education (51.9%). Several areas of practice generated lower self-reported levels of compe-tence. Twenty-five percent of the 354 members who allot some of their time to administration indicated they have little to no competence in this area. Among 313 members providing clinical supervision, 30% indicated little to no competence. For the approximately 300 members involved in research, community organizing, and grant-writing, 63%, 58%, and 73%, respectively, report little to no competence in these areas.

Competence levels in some areas of practice were associated with years of experience and work setting. A significantly larger proportion of respondents with less than 5 years of experience in oncology indicated less competence in provision of direct services, social work education and training, program development/evaluation, and provision of clinical supervision. Significantly larger proportions of respondents working in community-based treatment facilities indicated less competence in research, administration, and involvement in social work education. Sig-nificantly larger proportions of respondents working in community-based service agencies reported higher levels of competence in community organizing, grant-writing, and program development (Table 3).

With regard to clinical trials, almost three-quarters of all respondents indicated that they engage patients and family members in discussion about clinical trials less than 25% of the time. Of these, 135 respondents (32%) indicated that they never discuss clinical trials with patients or family members. Social workers with less than 5 years experience were significantly less likely than those with more experience to discuss clini-cal trials (c2 = 16.78, p = .000). Twenty-seven percent of social workers in community-based treatment facilities reported never discussing clinical trials with patients, and an additional 63% indicated that they discussed clinical trials with patients less than half the time. These proportions were significantly less when compared to social workers working in university-affiliated centers and from those working in community-based agencies (c2 = 16.90, p = .002) (Table 4).

Population Competencies

Table 5 reports the extent to which respondents feel competent working with specific client groups. Overall, 72% to 89% of respondents indicated high levels of competence working with patients aged 40 and over.

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dence level ratings were lower for work with adolescents/young adults and children. With respect to non-English-speaking populations, 50% of members indicated that their level of competence in working with these populations was little to none. As for low-income populations, almost all respondents (94%) indicated some to a lot of competence.

A significantly larger proportion of respondents with less than five years experience reported less competence in working with middle age (40–64 years) and older age (65–79 years) adults. When compared to social workers in university affiliated/comprehensive cancer centers, a sig-nificantly larger proportion of those working in community-based treat-ment sites and community-based service agencies indicated significantly less competence in working with children, non-English-speaking patients, older adults (age 65–79 years), and oldest adults (age 80 and above).

Topic Competencies

Respondents’ levels of competence across 33 topical areas are summa-rized in Table 6. A majority of members reported high competence in 17 areas, including promoting patient coping skills, end-of-life issues, self-advocacy (decision-making and problem-solving), advanced directives, caregiving, and conducting psycho-educational and support groups. Areas in which sizeable proportions (more than 40%) indicated little to no competence included organizational development, cognitive-behavioral therapy (CBT), creative/expressive therapies, business skills for human service professionals, and political/legislative advocacy.

A significantly larger proportion of social workers with less than 5 years’ experience indicated less competence in 27 of the 33 topic areas, as noted in Table 6. In particular, the most significant differences by years of experience (p ≤ .001) related to: complementary/alternative practices, depression/anxiety treatment, survivorship, conducting psycho-educational

TABLE 4. Frequency by which social workers discuss clinical trials, by work setting University-affiliated or comprehensive cancer center Community-based treatment facility Community-based service agency Never 19 (19%) 109 (27%) 5 (8%) 1–50% of time 64 (65%) 257 (63%) 48 (43%)

More than 50% of time 16 (16%) 40 (10%) 13 (20%)

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365 T A BL E 5 . Self -r e por ted levels of co mpe te n ce work ing with spec ific types of clients P o pulation n a Level of compe tence, n (% ) A ssociated variables c 2 None A little S ome A lot # Years in o n cology so ci al work b Wor k setting Middle adults (40–64 ) 475 1 (0.2) 2 (0.4) 47 (9.9) 425 (89.5) 19.26*** 5.89 Older a dults (65 –79) 466 1 (0.2) 6 (1.3) 50 (10.7 ) 409 (87.8) 11.92** 28.95***

Oldest adults (80 and over)

397 5 (1.3) 16 (4.0) 87 (21.9 ) 289 (72.8) 6.86 20.00** A d

olescents & young a

dults (1 5–39) 425 13 (3.1) 37 (8.7) 152 (35.8) 223 (52.5) 4.40 7.67 Children (0–14 years o ld) 277 59 (21.3) 73 (26.4) 89 (32.1 ) 56 (20.2) 3.29 16.45* Low income populations 430 6 (1.4) 18 (4.2) 101 (23.5) 305 (70.9) 1.76 12.47 Non-English speakin g populatio ns 363 39 (10. 7) 142 (39. 1) 126 (34.7) 56 (15.4) 4.12 34.69*** Other d 30 16 (53.3) 1 (3.3) 3 (10) 10 (33.3) 3.96 18.36** *p < .0 5, ** p < .0 1, ** *p < .00 1 . aIn

dicates number of responden

ts wh o provid ed data. bR e spo n se catego rie s are <5 ye ars, 5 or mo re years. cRe sponse categories a re University-affiliat ed or compre

hensive cancer center,

C

o

mmuni

ty-b

ased treatment center, Commun

ity-based

agency. dOther includes “gay and lesbi

an”; “substance abuse/addict

ion”; “hearing impaired”; “home

less”; “minoritie

s”; “veterans.”

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366 TABLE 6. T he d egr ee o f comp et en ce m e mb er s f eel with reg a rd t o to pics Topics Not at all A little S omew hat Very Associated variables ( χ 2) Years of expe rience a Wor k setting b P

romoting patient coping

skills 1 (0.2 %) 8 (1. 4 %) 131 (22.5%) 4 43 (76% ) 31.17*** 16.46* E n d of life issues 1 (0.2 %) 15 (2. 6 %) 114 (19.7%) 4 50 (77.6 % ) 21.38*** 16.49** P

romoting patient

self-advocacy (e.g., d e cision making, p roblem solvin g) 1 (0.2 %) 15 (2. 6 %) 130 (22.4%) 4 34 (74.8 % ) 22.39*** 6.65 A d vanced directives 3 (0.5 %) 37 (6. 4 %) 117 (20.2%) 4 22 (72.9 % ) 17.13** 56.61***

Grief and bereavement for adult

pat ients & families 1 (0.2 %) 11 (1. 9 %) 164 (28.3%) 4 03 (69.6 % ) 45.45*** 16.64** Caregiving 1 (0.2 %) 22 (3. 8 %) 179 (30.7%) 3 81 (65.4 % ) 19.78*** 11.58 Family issues 0 (0.0 %) 15 (2. 6 %) 184 (31.8%) 3 80 (65.6 % ) 17.54*** 7.39 P sycho -educational g roups 2 (0.3 %) 41 (7. 0 %) 183 (31.4%) 3 56 (61.2 % ) 46.39*** 2.32 S tress mana gement 0 (0.0 %) 26 (4. 5 %) 206 (35.4%) 3 50 (60.1 % ) 12.71** 4 .59 S u pport groups 7 (1.2 %) 54 (9. 3 %) 175 (30.1%) 3 46 (59.5 % ) 17.59** 13.96* P a tient d epression/anxiety 2 (0.3 %) 21 (3. 6 %) 220 (37.8%) 3 39 (58.2 % ) 16.95** 11.69

Financial distress and assistance

7 (1.2 %) 55 (9. 5 %) 189 (32.6%) 3 28 (56.6 % ) 4 .58 17.99** S u rvivorship issues 5 (0.9 %) 33 (5. 7 %) 218 (37.6%) 3 24 (55.9 % ) 65.78*** 14.97* Discharge care/plan n ing 29 (5.1 %) 85 (14 .9%) 145 (25.4%) 3 12 (54.6 % ) 11.25* 24.67*** E th ics 3 (0.5 %) 35 (6. 0 %) 237 (40.9%) 3 04 (52.5 % ) 8 .55* 13.09*

Home health care

5 (0.9 %) 94 (16 .2%) 182 (31.4%) 2 98 (51.5 % ) 11.26* 23.74** Interdisciplinary team leade rship 12 (2.1 %) 65 (11 .4%) 204 (35.7%) 2 90 (50.8 % ) 16.30** 12.79* Y o ur country’s hea lth care syst em 8 (1.4 %) 67 (11 .6%) 289 (49.8%) 2 16 (37.2 % ) 8 .86* 8.15

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367

Use

of humor in clinical pra

c tice 23 (4.0 %) 122 (21 .0%) 222 (38.3%) 213 (36.7 % ) 6 .20 Cultu ral comp etence /diversity 2 (0.3 %) 66 (11 .4%) 300 (51.7%) 212 (36.6 % ) 2 .87 P a tient n a vigation 39 (6.8 %) 111 (19 .5%) 212 (37.2%) 208 (36.5 % ) 4 .67

Children whose pare

n ts h a ve cancer 20 (3.5 %) 143 (24 .8%) 230 (39.9%) 184 (31.9 % ) 23.40*** Workp

lace and emp

loyment issues 6 (1.0 %) 112 (19 .3%) 304 (52.3%) 159 (27.4 % ) 22.84*** S e xuality 7 (1.2 %) 118 (20 .3%) 312 (53.8%) 143 (24.7%) 13.66** Organizational developme n t (non-profit or fo r-pr o fit) 61 (10. 5%) 181 (31 .1%) 214 (36.8%) 126 (21.6%) 5 .62

Cognitive behavioral thera

p y (CBT) 68 (11. 8% ) 189 (32 .8%) 194 (33.6%) 126 (21.8%) 4 .39 P a in assessment and management 32 (5.5 %) 164 (28 .2%) 269 (46.3%) 116 (20.0%) 31.26***

Complementary and Alterna

tive pra c tice s 42 (7.2 %) 177 (30 .4%) 251 (43.1%) 113 (19.4%) 21.54*** Grief an d bereavement f o

r pediatric patients &

families 126 (21. 8%) 185 (32 .1%) 174 (30.2%) 92 (15.9%) 15.99** Creative/exp

ressive therapies (i.e

., art , music, etc.) 95 (16. 5%) 226 (39 .2%) 188 (32.6%) 68 (11.8%) 11.99** B u

siness skills for

human service professionals 173 (29. 9%) 206 (35 .6%) 149 (25.8%) 50 (8.7%) 10.46* P o litical/legislative advoc acy 66 (11. 4%) 247 (42 .8%) 217 (37.6%) 47 (8.1%) 7.72 B u ilding a priva te health practice 294 (51. 3% ) 156 (27 .2%) 78 (13.6%) 45 (7.9%) 20.78*** *p < .0 5, ** p < .0 1, ** *p < .00 1 . aR e spo n se catego rie s are <5 ye ars, 5 or mo re years. bR e spo n se catego rie s are University-a

ffiliated cancer center, Co

mmunity-based treatment c

enter, Community-based

agency.

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groups, caregiving, promoting patient coping skills, self-advocacy (decision making, problem solving), support groups, pain assessment and manage-ment, grief and bereavemanage-ment, employment issues, family issues, children whose parents have cancer, end-of-life issues, advanced directives, building a private practice, and interdisciplinary team leadership.

When compared to all others, a significantly larger proportion of social workers in community-based agencies indicated less competence in clini-cally relevant topic areas such as end-of-life, advanced directives, grief and bereavement, and discharge care (Table 6). In contrast, a significantly larger proportion of respondents working in community-based agencies reported higher levels of competence with regard to promoting patient self-advocacy (e.g., decision making and problem solving), organiza-tional development, and building a private practice.

Qualitative Findings: Recommendations for Advancing Skills

The mission of the Association of Oncology Social Work is to advance excellence in the psychosocial care of persons with cancer, their families, and caregivers through networking, education, advocacy, research, and resource development. Consistent with the mission, members recom-mended actions for AOSW having to do with advancing professional edu-cation and resource development. In eduedu-cation, members suggested that AOSW enhance offerings with regard to:

• Training on psycho-educational and other clinical interventions.

• Training in supervision, leadership development, grant-writing, and management skills.

• Regionalized trainings, intensive trainings, local conferences, tele-conferences, and online training.

With regard to resource development, members requested that AOSW:

• Coordinate and make resource literature (e.g., newsletters, books, journals, tapes, contact numbers with agencies) easier to access (net-working of resources).

• Conduct research and publish more social work–related articles (e.g., evidence-based research, experiences of oncology social workers).

• Provide authoritative guidelines about oncology social work (e.g., staffing guidelines/requirements, salary ranges, specific role of oncology social workers).

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• Develop and distribute materials (e.g., handouts) for patients and families.

• Compile and post on the AOSW website an ongoing list of various conferences, educational opportunities, or better outcomes for patients who receive psychosocial support.

• Enhance availability of these materials and resources to members who cannot attend conferences.

Members suggested that these recommendations could be carried out through partnerships with other organizations that share the goal of qual-ity care for all persons affected by cancer and include the Council on Social Work Education, National Association of Social Workers, the National Cancer Institute, the Leukemia and Lymphoma Society, and the American Cancer Society.

DISCUSSION

Results of this member survey indicate that AOSW social workers’ perceived competencies and strengths revolve around delivery of direct services and patient education, and that they practice these skills in large health systems as well as in community-based medical centers, group practices, and human service agencies. As could be expected, higher levels of self-reported competencies existed among veteran oncology social workers; however, respondents’ reported competencies also often varied depending on their work setting. Thus, competencies may be associated with the skills necessary to function in a particular setting. For example, social workers in human service agencies are often involved in program planning, development, and implementation, and indeed reported higher levels of competence around these tasks in which they are more likely to be involved. Similarly, social workers in large health systems reported greater levels of competence in administration and research, where the likelihood of being exposed to these activities is greater than it would be in community-based treatment facilities or ser-vice agencies. Based on these findings, content for skill building can be targeted to match the needs of different social work audiences based on where they work.

Three fourths of the survey respondents indicated that they rarely if ever engage patients in discussions about clinical trials. Cancer clinical trials portend significant advances in cancer treatment and reductions in

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the burden of cancer, but only 3% of adults diagnosed with cancer are recruited to clinical trials (National Cancer Institute, 2002). Often times, and particularly for racial and ethnic minority groups in the United States, psychosocial factors are largely responsible for resistance to clinical trials recruitment. Social workers could be specifically trained and positioned to improve recruitment of patients into clinical trials (Wells & Zebrack, 2008). For example, social workers can play a critical role in educating patients as to the purposes and specific protocols of clinical trials and in reinforcing the value of clinical trials as a method of expanding patients’ range of options for cancer treatment.

Although the survey results confirm that oncology social workers have developed skills to competently assist patients and their caregivers, cer-tain subpopulations most in need may not have adequate access to these skilled professionals. Persons over the age of 65 comprise approximately 67% of all people diagnosed with cancer (Jemal et al., 2005); yet, the oncology social workers surveyed here indicated that just 44% of their work time is devoted to older and elderly adults. These findings recall earlier research suggesting that oncology social work practice may not be adequately meeting the needs of this large segment of the cancer patient population (Rohan, Berkman, Walker, & Holmes, 1994).

Maramaldi and Lee (2006) have documented that older adults have multiple needs for assistance with managing a variety of acute and/or chronic conditions, loss of social support, caretaking needs, interactive effects of pharmacological interventions, and potential complications from age-related cognitive impairment. However, a limited knowledge base on evidence-based psychosocial practice models with older adults with cancer makes it challenging for oncology social workers to replicate or develop and implement appropriate and relevant services for older adults. Future research is required to focus closely on the unique needs of older cancer patients in order to develop social work competencies and advocacy for improving care for this portion of the population.

Similarly, there is increasing emphasis in social work education and standards on cultural competence, particularly with regard to multiethnic groups speaking myriad languages. There is a growing need for educating and training social workers with diverse backgrounds and languages themselves to address diverse clients in all fields of social work practice, including oncology. The findings reported here suggest that there are too few oncology social workers prepared to meet the needs of multiethnic groups of cancer patients. For example, half of the sample reported little

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to no competence in working with non-English speaking populations, pre-sumably because they do not speak the language of these patients. This lack of competence may explain why oncology social workers allot just 10% of their time to non-English speaking populations in a country where 18% of the entire population does not speak English (Shin & Bruno, 2003). Furthermore, for some cities and regions the percentage is higher, often nearing or exceeding 50% (US Census Bureau, 2006). In order to meet the needs of an increasingly diverse patient population, the social work profession will have to look at better ways to recruit new social workers from various ethnic and language groups and prepare new and seasoned social workers to conduct psychosocial assessments and imple-ment supportive interventions within patients’ own cultural context and language.

Implications for Social Work Education

How can social workers with expertise and specialty training in oncol-ogy better serve cancer patients where they are being treated and fol-lowed? On the one hand, the challenge to bridge this gap in cancer care can be approached by doing a better job preparing social workers in MSW training programs. Students need the knowledge and skills to provide cul-turally competent assessment and assistance to cancer survivors and care-givers who deal with common psychosocial problems imposed by cancer, such as adjustment to illness, bereavement, and financial stress. This is important because social workers in mental health, education, child welfare, and health care settings are all likely to encounter clients who are affected by cancer. Curriculum infusion methods and model syllabi for elective course offerings similar to those used for training social workers in gerontology (Damron-Rodriguez & Corley, 2002) or end-of- life care (Cskai & Jones, 2007) could be adopted by BSW and MSW programs. In the continuing education arena, NASW has developed a model curricu-lum to equip community-based mental health practitioners to assist with cancer-related issues and this training program could be more widely disseminated.

Yet, the set of knowledge and skills required for the specialty prac-tice of oncology social work is most often acquired through a combina-tion of specialized internships, on-the-job training and specialized continuing education programs held at annual conferences for both adult and pediatric oncology social workers. These training opportunities need to be offered in community settings (and in diverse communities), and

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not just in university-affiliated comprehensive cancer centers. Indeed, new training as well as employment opportunities for social workers are emerging in community-based patient education and support agencies as patients are spending less time in hospitals and looking to the com-munity to meet their informational and psychosocial needs (Blum et al., 2006).

Education and training efforts to strengthen skills such as grant-writing, fundraising, new language acquisition, program development, and com-munity organization may facilitate the integration and movement of social workers into communities where the patients live, work, and seek ser-vices. Also, there is undoubtedly a need to work on macro/policy levels to advocate for reimbursement for social work services across the cancer care continuum, and to work with national organizations such as the American Cancer Society, the National Institutes of Health, the Centers for Disease Control and Prevention, and physician specialty organizations to develop evidence-based practice guidelines reinforcing the value of oncology social work.

Although well representative of social workers who are self-selected members of their professional association, the data presented here do not reflect the experiences or needs of the unknown number of social workers practicing in oncology who are not AOSW members. Although both online and hard copy surveys were available to all AOSW members, 38% of AOSW members did not complete the survey. Yet, the distribution of respondents by work settings, licensure, educational degrees, and years in oncology closely approximate the entire membership. Although the data from this self-selected sample may not be generalizable to all those prac-ticing in the field, the information obtained from this group of specialists dedicated to providing psychosocial care in oncology is valuable in iden-tifying some very specific areas of need for education and training in the future.

CONCLUSION

As a specialty area of practice, oncology social work has a history of approximately 50 years, emerging in the United States in the second half of the twentieth century with the employment of social workers in major comprehensive cancer treatment centers such as the [Sidney] Dana-Farber Cancer Center in Boston and Memorial Sloan-Kettering Cancer Center in New York. This specialized field of practice expanded following President

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Richard Nixon’s “War on Cancer” effort, which directed funds specifi-cally for cancer prevention and control. Formal professional development and networking programs were subsequently initiated with the formation of the National Association of Oncology Social Work (later renamed the Association of Oncology Social Workers) in 1984 when the first annual conference was held in New York City and sponsored by the American Cancer Society.

Today, oncology social workers must be knowledgeable about the myriad factors that influence the delivery and receipt of cancer care in the United States and around the world. They also must intervene to address psychosocial needs where they are most acute and be proactive in the innovation, creation, and delivery of relevant and appropriate services to socioeconomically, culturally, and ethnically diverse populations. This often requires not only the development of programs and treatment models but also simultaneous implementation and evaluation studies to determine which programs and interventions are most effective for which clients and client populations.

The societal benefits of social work interventions with cancer patients will be expansive if evidence-informed interventions are accessible to all survivors and their caregivers. To remain viable, the profession must provide basic training and continuous professional development opportunities that prepare workers to effectively deliver quality care in the twenty-first century. Much of this effort needs to be provided in the context of community-based care as the health care con-tinuum continues to shift from acute care settings to outpatient settings, including people’s own homes. As the community increasingly becomes the setting for provision of services, culturally competent social workers and social workers with diverse backgrounds must be prepared to work effectively with the populations residing in diverse communities. Con-comitantly, knowledge and skills to address the psychosocial needs of older adults (who constitute the highest proportion of cancer patients) must be a continuing focus of BSW, MSW, and continuing education programs. The oncology social work profession is contributing to the development of this body of knowledge and skills. The challenge now is to translate and expand this knowledge base to thus impact a wider pop-ulation of survivors over an entire continuum of care. This report serves as a frame of reference, an evidence-driven guide for the investment of resources to prepare, train, and advance oncology social workers in their pursuit of maximizing outcomes and achieving excellence in psychoso-cial oncology.

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REFERENCES

Blum, D., Clark, E.J., Jacobsen, P.B., Holland, J., Monahan, M.J., & Duquette, P.D. (2006). Building community-based short-term psychosocial counseling capacity for cancer patients and their families: The Individual Cancer Assistance Network (ICAN) Model. Social Work in Health Care, 43(4), 71–83.

Cskai, E., & Jones, B. (2007). Teaching resources for end-of-life and palliative care

courses. Chicago: Lyceum Press.

Damron-Rodriguez, J. A., & Corley, C. (2002). Social work education for interdisciplinary practice with older adults and their families. Journal of Gerontological Social Work,

39(1/2) 37–55.

Edwards, B.K., Howe, H.L., Ries, L.A.G., Thun, M., Rosenberg, H.M., Yancik, R., Wingo, P.A., Jemal, A., & Feigal, E.G. (2002). Annual report to the nation on the status of cancer, 1973–1999, featuring implications of age and aging on the US cancer burden. Cancer, 94(10), 2766–2792.

Institute of Medicine (IOM). (2007). Cancer care for the whole patient: Meeting

psycho-social health needs. Washington, DC: National Academies Press.

Jemal, A., Murray, T., Ward, E., Samuels, A., Tiwari, R.C., Ghafoor, A., Feuer, E.J., & Thun, M.J. (2005). Cancer statistics, 2005. CA: A Cancer Journal for Clinicians, 55(1), 10–30. Lauria, M.M., Clark, E., Hermann, J.F., & Stearns, N. (2000). Social work in oncology.

Atlanta, GA: American Cancer Society.

Maramaldi, P., & Lee, J. (2006). Older adults with cancer. In B. Berkman & S. D’Ambruso (eds.), The Oxford handbook of social work in aging. New York: Oxford University Press.

National Cancer Institute. (2002). Cancer clinical trials: The basic workbook. Bethesda, MD: National Cancer Institute. Retrieved from: http://www.cancer.gov/clinicaltrials/ resources/basicworkbook/

Rohan, E.A., Berkman, B., Walker, S., & Holmes, W. (1994). The geriatric oncology patient: Ageism in social work practice. Journal of Gerontological Social Work, 23(1/2), 201–221.

Shin, H.G., & Bruno, R. (2003). Language use and English speaking ability: 2000, Census

2000 Brief. US Department of Commerce, Economics and Statistics Administration,

US Census Bureau.

Singh, G.K., Miller, B.A., Hankey, B.F., & Edwards, B.K. (2003). Area socioeconomic

variations in US cancer incidence, mortality, stage, treatment, and survival, 1975–1999, National Cancer Institute Cancer Surveillance Monograph Series, No. 4. Bethesda,

MD: National Cancer Institute.

Smith, E., Walsh-Burke, K., & Cruzan, C. (1998). Principles of training social workers in oncology. In J. Holland (ed.), Psycho-oncology (pp. 1061–1068). New York: Oxford University Press.

Taylor-Brown, S., Altilio, T., Blacker, S., Christ, G., & Walsh-Burke, K. (2001). Best practices

in end-of-life care. Philadelphia: Society for Leadership in Social Work and Health Care.

US Census Bureau. (2006). 2004 American community survey: Nativity by language spoken

at home by ability to speak English for the population age 5 years and over. US

Depart-ment of Commerce, Economics and Statistics Administration, US Census Bureau.

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Walsh, K. (2005). Oncology social work roles and functions across the continuum of care. Washington, DC: National Patient Advocate Foundation.

Wells, A.A., & Zebrack, B.J. (2008). Psychosocial barriers contributing to the under-representation of racial/ethnic minorities in cancer clinical trials. Social Work in

Health Care, 46(2), 1–14.

DATE RECEIVED: July 13, 2007

ACCEPTED FOR PUBLICATION: January 8, 2008