Nurse social work practitioner: a new professional for health care settings.
Subject: Health services administration (Research)
Social workers (Practice)
Interdisciplinary approach in education (Evaluation)
Social work education (Study and teaching)
Authors: Schneiderman, Janet U.
Waugaman, Wynne R.
Flynn, Marilyn S.
Pub Date: 05/01/2008
Publication: Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2008 National Association of Social Workers ISSN: 0360-7283
Issue: Date: May, 2008 Source Volume: 33 Source Issue: 2
Topic: Event Code: 310 Science & research; 200 Management dynamics
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 179158818
Full Text: Hospital systems are merging, cutting back, and dismantling as a result of the shift in delivery of care to ambulatory settings and the continuing shift to managed care (Berkman, 1996; Pecukonis, Cornelius, & Parrish, 2003). Cutbacks and downsizing are occurring at a greater rate than hospital social work leaders predicted (Mizrahi & Berger, 2005). Social workers are often frustrated and challenged by increasing demands of a health care system in crisis. As a result of the market-driven cost-containment strategy that hospitals are adopting, many social workers are forced to either adapt or leave their jobs. The social workers who remain must do more with less, with an eye on the bottom line. Even field education of social work students in hospitals has been compromised by these changes (Globerman & Bogo, 2002).

Along with the threats to social work has come a call for a more integrated health care workforce, with fewer silos of practice and an emphasis on how the patient (consumer) experiences the system (Institute of Medicine of the National Academies, 2003; O'Neil, 2005). The present silo system is burdened with a multitude of differing scopes of practice and responsibilities for delivery of patient care. The integration of the varied health care professions, including social work, is made more difficult by the early discharge of patients from acute care facilities requiring coordination with continuing care settings such as nursing homes, and the increasing use of outpatient departments and surgicenters for serious and extensive surgeries that used to require inpatient days both before and after surgery.

The traditional roles of social work within health care settings are at risk of becoming obsolescent unless social work adapts to the changing health care settings. Increasingly, patients do not suffer from acute simple diseases that require short-stay hospitalization, but from multiple, chronic health problems that require predictable episodic need for care (Berkman, 1996). Social workers can meet the challenges of the "new patient" by restructuring their scope of practice to include more emphasis on community care and case management services to help patients access the myriad of health and social services, as well as by helping patients deal with the accompanying psychological and social issues and empowering patients to make knowledgeable choices (Cowles, 2003).

The University of Southern California's (USC) School of Social Work has developed a transdisciplinary educational option, the nurse social work practitioner (NSWP) that will meet the demand of the new health care service system. USC is currently the only school of social work with this option. We define transdisciplinary, as the fusion of knowledge and practice techniques from multiple disciplines. This transdisciplinary role is client focused rather than provider focused and differs, therefore, from interdisciplinary education and practice wherein connections are made but each provider retains his or her own distinct disciplinary approach (Massey, 2001). The NSWP option was developed in 2004 to recruit registered nurses (RN) with baccalaureate degrees as students in the Master's of Social Work (MSW) program. Thus Far, we have admitted 11 students, three of whom graduated in May 2006. The program was designed to meet a community need and not to increase the numbers of MSW applicants, because it is anticipated that the number of RNs applying for this program will remain low. An integrated case management curriculum was created to bridge the health and social welfare worlds to holistically meet the needs of patients, families, and communities. Community health care agencies helped shape the educational program, develop the practice roles, and design the curriculum.

THE CHANGING ROLE OF SOCIAL WORKERS IN HEALTH CARE SETTINGS

The Society for Social Work Administrators in Health Care and NASW commissioned a study in 1994 to look at the changes that were occurring in hospital social work departments (Berger et al., 1996).The study found that changes in social work departments mirrored changes in the hospital environment as a whole: downsizing, decentralization, and a decrease in administrative positions. Although social work clinical activity was slowly moving to outpatient sites, this activity was outpaced by the significant exodus of patients to outpatient and community-based programs. A longitudinal follow-up study of hospital social work leaders conducted by Mizrahi and Berger (2005) found that these leaders had mixed and negative perspectives on their future. These leaders strove to maintain hospital social work departments by increasing coverage to seven days a week and by adding specialized services, for example, emergency room services. The leaders did not find a significant reduction in the number of social work employees, but did find a significant reduction in administrative social work staff. Although some respondents could delineate multiple accomplishments within their hospital, an increasing number reported that their ability to begin new programs and to expand or reclaim social work functions was unlikely.

Health social workers need to expand their practice settings to include private physician's offices, community-based health centers, and individual advocacy for patients navigating the health care system, to increase their effectiveness and to better reach the changing health care population. Patient advocacy is progressively being recognized as necessary and has even been developed as a separate career path (Foreman, 2006). Claiborne and Vandenburgh (2001) proposed a new role for social workers in disease management, a proactive coordination approach that would follow patients with chronic diseases over time and through multiple settings, such as inpatient, outpatient, and community-based settings. This approach is founded on evidence-based medical outcomes that are measured by real health and quality-of-life improvements, including a reduction in the number and duration of disease episodes and an increase in targeted treatment and self-management. Social work's emphasis on a person-in-environment approach seems well suited for managing patients over the long term. It is accepted that disease is often related to lifestyle choices (for example, sedentary lifestyle, obesity, and smoking), and good health is related to making healthy choices. Social workers have expertise in behavior change (Pecukonis et al., 2003), which is a critical element in disease management.

Case management in health care is an increasingly vital component in the delivery of health services. This intervention modality can vary in terms of the role of the social worker. The case manager enables linkages to services, advocates for care, monitors patient activities, and provides direct therapy to patients (Kerson, 1997). Hospitals are including case management functions in the hospital social work role to meet cost-control mandates by preventing rehospitalization. Case management programs are inherently interdisciplinary and include consideration of the patients' needs both in the hospital and in the community (Cowles, 2003).

The NSWP option at the USC School of Social Work responds to the changes in health care and the challenges social workers face in hospital practice. This transdisciplinary professional can address the health, medical, and social needs of patients dealing with chronic illness and shortened hospital stays. This new role is ideal for disease management over the long term and for the fluid movement of patients from inpatient to community-based to home-based settings.

HISTORICAL DEVELOPMENT OF THE NSWP

In 2000, the dean of the USC School of Social Work convened a group of faculty from social work and the Department of Nursing to explore collaborative research interests. Social work and nursing found a strong alliance and through this collaborative partnership began a dialogue to develop this new transdisciplinary provider. Because of academic changes within the university, three nursing faculty members were invited to join the faculty in the School of Social Work (Waugaman & Schneiderman, 2004). After approximately one year of investigative inquiry with a wide variety of potential employers and recruitment sources, the School of Social Work determined a need for a transdisciplinary professional who would combine the professions of social work and nursing. The discussions with community agencies entailed the dean of the School of Social Work and the former chair of the Nursing Department visiting many different types of health care agencies to explore the following: What type of professional could meet the health and social needs of their clients, how a combined nurse social work professional could fit into their existing organizational structure, and whether they would hire a transdisciplinary health care provider. All agencies committed to hiring our graduates at competitive salaries similar to advanced practice nurses, such as nurse practitioners. The Los Angeles County child welfare and mental health departments, for example, have already agreed on a NSWP salary range that tops out at $88,900.

The discussions with agencies included both public and private health and social welfare settings. We visited three large medical centers, the largest HMO in Southern California, the Veterans Health Care System, and the county hospital system. We also visited the county mental health department, county HIV/AIDS services, skilled nursing facilities, and three home health agencies. After discussions with social workers, nurses, administrators, and physicians in these settings as well as the Los Angeles school district, in nearly every circumstance, the agency leaders noted that both a nurse and a social worker are required to manage individual client cases because each professional in his or her own discipline does not possess the expertise to coordinate and oversee the myriad of case management care required by clients served.

The USC faculty envisioned a new professional, a "nurse social work practitioner" (NSWP), who would bring unique talents to facilitate patient care across disciplinary borders. Disciplinary borders can present serious roadblocks to the efficient navigation of the health care system, particularly in the public sector, where clients are managed by their diagnoses in a silo-type system. One unmet need consistently identified by agencies, for example, was the challenge of managing clients with "dual diagnoses." Many times these diagnoses are both psychological and physical and only one of the diagnoses is addressed by the professional caregiver. Health care agencies also noted that the increasing population of older clients who often experience a combination of medical, social, and mental health needs could greatly benefit from services of a transdisciplinary provider. Although the faculty designed the NSWP program with clients' needs at the center of the educational endeavor, the economic pressures within the health care environment were also an important element. It is anticipated that this transdisciplinary provider could meet the multiple needs of the increasingly complicated clients in a more cost-efficient manner.

CHALLENGES TO DEVELOPING THE TRANSDISCIPLINARY ROLE AND EDUCATIONAL PROGRAM

Some social work and nursing professionals have had difficultly accepting and embracing this transdisciplinary role. Boundaries dividing professional groups are similar to the division between "us and them," which colors the lens through which each profession views an issue (McCroskey, 1998). Altshuler (2003) studied child welfare and public school collaboration and found that adversarial relationships were frequent even with common approaches. Although discussions with employers noted that both professionals were underused, especially in the case management arena, some social work and nursing leaders expressed anxiety about the role fusion. A few nursing administrators raised concerns that not giving a nursing graduate degree would be a potential deterrent to student recruitment, but we assured them that receiving an MSW with a specialization in case management would not be a disadvantage to nurses entering the program because the graduates will be prepared to take a national certifying examination in case management such as the one offered by the American Nurses Association and the American Case Management Association. Other nursing leaders expressed fear about losing nurses to social work. Some social workers expressed concerns that nurses would take some of their jobs. This overlapping of roles, ambiguity of professional values, and competition between social workers and nurses has been identified in hospice team care (Reese & Sontag, 2001). Social work prides itself on tension and discussion as a way to move the profession forward (McLaughlin, 2002). Cowger (2003) concluded that the social work profession's idealism of inclusiveness in society does not apply to protecting their own jobs. Therefore, conflict concerning role turf on both sides (social work and nursing) may be a necessary evil to develop this transdisciplinary education and practice and does not preclude its success.

Even though social work and nursing are accustomed to practicing with other professions in the health care setting, there are clear delineations in the systems of practice for both professions. These delineations present yet another challenge. Unions and human resources departments identify social workers and nurses by job titles specific to each profession. No provisions are currently available for a provider with a blended identity whose practice spans the boundaries of two professions. Another issue is the pay scale for NSWPs. Although agencies agree to pay salaries commensurate with advanced practice nurses, if the job description is under a social work category, the pay rate may not be sufficient to compensate the blended professional. In some hospitals, social workers and nurses may even be represented by two different unions. The challenge is identifying a niche for this transdisciplinary provider and developing an organizationally appropriate job description that encompasses the client-centered work focus rather than the provider-centered focus.

Recruitment of nurses to pioneer this newly developed educational opportunity and to develop the transdisciplinary role has also proven challenging. Because nursing jobs are currently plentiful and salaries are lucrative, many nurses are not considering graduate school options. This program requires outreach to a particular type of nurse, one who has a passion for providing "holistic" care for the client; one who is concerned beyond the health care needs to the needs of managing home life, work, and other activities of daily living that contribute to improving the quality of life. Nurses who currently work in public health or other clinic-type settings, such as HIV or drug counseling, would seem to find movement into this graduate program a natural extension of their current work environment, building and expanding on their current strengths and professional knowledge. School nurses and nurses who work in child care would find this type of graduate education a valuable asset. It requires nurses to think outside of a typical nursing graduate degree track into how their practice might be enhanced in the current health and social welfare environment. We recognize that becoming an NSWP is not the career goal for every nurse. It requires the ability to relinquish singular professional identity for broader dual identity and the creativity to join ideas in new ways.

PILOT PROGRAM

Nurses who were accepted into the pilot program described this program as the "ideal graduate program. "A common theme emerging from students and applicants is that they "want to know more about their clients/patients than just what happens when they take care of them in the hospital." Their curiosity extends beyond the traditional nursing care role; they want to know how clients will manage at home after discharge. Several of the nurses' work with clients in their current positions requires not only nursing expertise but also numerous social referrals, such as transportation assistance, meals, and other similar types of services. The nurses described a lack of knowledge regarding public policy that negatively affects their ability to provide holistic care for their clients. The pilot NSWP students noted that combining social work with nursing rather than replacing one with the other will provide the professional with the knowledge and skills necessary to care for the "whole" client. Initial recruitment for the pilot program centered primarily on former graduates of the USC nursing school. Of the 11 students accepted thus far, five are part-time and six are full-time students. Five are USC nursing graduates. Full-time enrollment is most desirable because early exposure to field experiences fosters professional socialization that is essential in the creation of a new discipline (Waugaman, 1988). Admission criteria are the same as non-NSWP applicants. Fifty percent of the students who applied were accepted. NSWP applicants were not considering nursing graduate programs and did not want to give up being a nurse to become a social worker but were interested in pioneering a new provider role. The NSWP option is different from dual degrees (for example, JD, MBA, MD plus an MSW), wherein there is relatively superficial integration between professional programs; this NSWP option is an MSW educational program that integrates content and professional role development across the disciplines.

The nonnursing social work faculty members have readily accepted the new NSWP students. They have noted that these students enrich the classroom with their real-life experiences from their respective hospital setting, such as the intensive care unit, the burn unit, or the research unit at a county hospital. Dietz (2000) commented that each individual student is unique in his or her values and process of learning in social work. Therefore, it is difficult to talk about the NSWP students as a separate group because they are really a part of the entire social work student cohort. The nurses have been able to fit in with all the other social work students yet bring their own health care philosophy ideas to the classroom discussions and field experiences.

Although the NSWP student sits in the same classes with other MSW students, he or she also takes additional coursework focusing on case management of special populations and advanced coursework in incorporating information technology into practice, social policy, and financial management in health care (see Table 1). Both years of field placement for these students are supervised jointly by a social work field instructor and a nurse faculty member, to facilitate socialization into the new professional role. Nursing and social work faculty meet regularly with the NSWP students for field integration seminars, ,all with the goal of actualizing the new professional role and promoting camaraderie. These students bring more biological content to their social work training, which enriches their integration of social work theory and health care.

CONCLUSION AND NEXT STEPS

Cowger (2003) called on schools of social work housed in research universities to open boundaries and engage in more interdisciplinary education and research. The opportunity of including nurses as faculty members and nurses as students will enable USC's School of Social Work to lead in this effort to expand the traditional boundaries of academia and engage in testing new ideas to meet the diverse needs of clients. Both a community need for this new NSWP professional and a pool of applicants have been identified. The Hearst Foundation ("Hearst Foundation Funds Scholarship," 2006) has recognized the value of the NSWP educational program by awarding scholarship money to help defray the educational costs for these students. We are presently evaluating this program by researching the acculturation, socialization, and learning styles of NSWP students as they progress through the program. As more NSWPs graduate, we plan to evaluate organizational and client outcomes.

Original manuscript received June 15. 2006

Final revision received February 26, 2007

Accepted April 23, 2007

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Janet U. Schneiderman, PhD, is assistant professor, University of Southern California School of Social Work, 669 West 34th Street, Los Angeles, CA 90089-0411; e-mail: juschnei@usc.edu. Wynne R. Waugaman, PhD, RN, FAAN, is professor, and Marilyn S. Flynn, PhD, MSW, is dean and professor, University of Southern California School of Social Work, Los Angeles.
Table 1: Nurse Social Work Practitioner Case Management
Curriculum

Name of Course                    Description of Course

Policy in the Health Care   Analysis of behavioral, practice, and
Sector                      research considerations in addressing
                            a range of health problems and the
                            policy-snaking process

Case Management as a        Case management as a service model for
Service Model               increasing cost-effectiveness and
                            quality of care for diverse populations,
                            including transitional planning,
                            utilization management, and resource
                            utilization

Information Technology      Information technology as a resource
for Human Services          for quality health and human services

                            Implications for interagency
                            collaboration, empowerment of clients
                            and professionals, evidence-based
                            practice, education, and ethics
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