Palliative social work competencies: they need to show that social work is social
January 19th, 2012 by Malcolm Payne
The glitterati of London palliative social work gathered at St Christopher¶s yesterday (naturally, I exclude myself from this description) mainly to discuss competencies in palliative social work, aided by a visit from Dr Susan Cadell, a senior academic at Wilfred Laurier University in Canada who was involved in the Canadian attempt to write social work competencies for what they call hospice palliative care. Among the arguments for creating competencies is to clarify for other professions in palliative care what exactly social workers say is special about their role. Since other professions, in particular nursing, use competencies a lot, some people think that having similar statements about palliative social work might help to establish the profession more clearly with colleagues who can¶t quite get what social work is about. Some of the audience also wanted to use them to distinguish the wonders of palliative social work from other (and by implication in some eyes, lesser) forms of social work. This objective was greeted doubtfully by others, who thought that social work in child protection, or with mentally ill people, or with frail older people (or just about anything really) also dealt with difficult emotions, was stressful and a really important contribution to social well-being (especially if it was well done).
The Canadian project
Competences are based on research into the functional analysis of work roles. This was very popular in the 1980s as a way of looking at interdisciplinary teamwork. It takes a job title and breaks it down into a detailed list of functions. These are usually researched by getting together a whole crowd of people involved and recording their discussion, so you get a detailed list of possible functions, which are then tested out in consultation with a wider range of people. And indeed, this is what the palliative social workers did in Canada: they used a research technique called Delphi, which involves getting together a whole crowd of people involved, recording their discussion and then testing the results out with a wider range of people. You can read the article here: Bosma, H. et al (2010) Creating social work competences for practice in hospice palliative care. Palliative Medicine. 24(1): 79-87. (Researchers like to give classy ± or classical ± names to doing the obvious. You may be vaguely conscious that Delphi is a place in Greece where there was a famous oracle foretelling important events through the gods possessing a series of local peasant ladies of µblameless life¶ ± if you want to know how it worked, Wikipedia is the place: http://en.wikipedia.org/wiki/Delphi. Now you know that, you want to hear one of the prophecies, don¶t you: also from Wikipedia: There are two roads, most distant from each other: the one leading to the honourable house of freedom, the other the house of slavery, which mortals must shun. It is possible to travel the one through manliness and lovely accord;
so lead your people to this path. The other they reach through hateful strife and cowardly destruction; so shun it most of all. (I¶ll leave you to think that over. Anyway, the Delphi technique, originally created to help the American armed forces decide how the Soviets where going to target them in the cold war, is now used to achieve widespread consultation among different groups to gain agreement on a complicated problem, particular in healthcare professions ± that is, according to the British Council, which publishes a useful and short description ± with citations ± of it: http://www.britishcouncil.org/eltons-delphi_technique.pdf. Deviation now over.) Of course, any attempt to get social workers to agree about anything is bound to be complicated and so it was with this Canadian study. Finally, they got down to a basic list of competencies. These were: y y y y y y y y y y y Advocacy Assessment Care delivery Care planning Decision making Evaluation Education and research Information sharing Interdisciplinary team Self-reflective practice Community capacity building
Later in the consultative process, they added t these: y Cultural competency.
Each of these is buttressed by a fairly detailed list of what is involved in each. Apparently, some of the other professions have commented that these were fairly lengthy. See for yourself: they are available on the Canadian Hospice Palliative Care Association website: http://www.chpca.net/social-work_counsellors_competencies. The aim is then to create curricula for these in specialist or qualifying social work courses. The Americans have also been at this: have a look at the NASW standards for social workers in palliative and end-of-life care: On the web: http://www.naswdc.org/practice/bereavement/standards/standards0504New.pdf
Doubts about competencies
So far so uninspiring: what¶s all the fuss about? It might seem obvious that you want people doing a professional job to have the ability to do it, so finding some way of defining what they ought to be competent at seems a reasonable thing to try to do. But, as Dr Cadell pointed out, many academics have their doubts about competences, and people who would like to
look at the British literature on social work competences might like to find the following in their libraries: O¶Hagan, K. (ed.) (2007) Competence in Social Work Practice: A Practical Guide for Students and Professionals. (2nd edn) London: Jessica Kingsley. Vass, A. A. and Harrison, B. (eds)(1996) Social Work Competences: Core Knowledge, Values and Skills. London: Sage. Of these two books, O¶Hagan is the only one now up-to-date and is written by people who are broadly sympathetic, whereas Vass and Harrison, while not totally dismissive, present the critique rather more enthusiastically. And any glance at the giant glossy American introductory texts on social work will tell you that the concept is alive and well over on the other side of the Atlantic (but not, according to Cadell, among her academic colleagues in Canada). There¶s also a lot of it here, although it¶s sometimes not called that, in the way in which social work education operates. For example, if you look at the higher education Quality Assurance Agency benchmark for social work courses, it has listings of things social workers have to be able to do, which includes listings of knowledge and skills in a variety of areas: these are in reality competencies, although the term is not actually used in the document, because UK academics have the same problems with it that Canadians do. On the web: http://www.qaa.ac.uk/Publications/InformationAndGuidance/Documents/socialwork08.pdf And also in palliative care. To see the sort of thing that is available in the UK, look at the Common Core Competences for Social Care Workers in End-of-life Care produced by Skills for Care, the National End of Life Care Programme, the Department of Health and Skills for Health. On the web at: http://www.skillsforcare.org.uk/developing_skills/endoflifecare/endoflifecare.aspx So lots of people are at it, what¶s the problem that the academics have with it? The first problem is these long lists of things that people should be able to do. It¶s complicated and detailed. All those of you who are refusing to be practice educators for students from social work qualifying courses have probably been put off it mainly by one thing. That is, the long tickbox lists of things that you have to produce evidence that the student can do, rather than people relying on your experience that in a global sense this person is OK at social work. There are practical ways of dealing with this. I get the students to write down the evidence that they would claim shows they can do this, and then I check it. Someone else refused to do it, and to get the placement the University paid one of their minions to be a µlong-arm¶ supervisor, complete the forms for the agency and shared the fee between the supervisor and the agency. One part-timer I know uses her own time just to go through the lists and put the evidence together: not everyone has this opportunity or would give up their free time to do it ± particularly because the agency usually keeps the fee, rather than handing it over to the person who does all the work. But whatever you do, it is timeconsuming, detailed, boring and repetitive. As a result, it doesn¶t encourage creative, flexible practice education focused on priorities.
On the other hand, I¶m old enough to remember when some people, asked to write a report on the student they had just supervised for six months, sent in a few handwritten lines saying what a good egg they were. As an external examiner in those days, I not infrequently had to instruct universities to upset their relationships with their placement-providing agencies by complaining to the director of social services about the professional performance of their staff doing supervision work. I used to do it that way so that I could be blamed, not the poor staff on the course, who entirely agreed with me but had the job of fixing the placements for next year. Agency participation in qualifying education was partly designed to get the agencies to take responsibility for this, although generally this just meant that they stopped doing anything about social work education. I also remember the times when some supervisor would react adversely to a student and end up by psychoanalysing them for their personal problems, rather than looking rationally and in an organised way at what they could actually do. The use of competency checklists is an ace way of dealing with both of these problems. Both the practice educator and the student know what the student is required to be able to do, and there is a clear benchmark to assess them against. The second problem is the research base: you can dignify it with research technique with a Greek classical name, but in reality all Delphi does is collect opinions. There¶s not real empirical evidence there that this is what social workers actually do. In fact, Delphi tends to tell you what experts agree about: it doesn¶t tell what actually happens on the ground. So what you have here is a list of what the competences that the people who believe in and are committed to palliative social work say is essential, but you have no idea what competencies social workers actually display. The third problem is both theoretical and researchy. Functional analysis of job roles disaggregates something that is done holistically. So you don¶t look at the job in the round and see the actions integrated into one another: instead you look at the job in little bits. It is difficult to research the distinctions between these different bits, hence the long and repetitive lists that tend to build up. And it looks at jobs in terms of µfunctions¶ assuming that jobs contribute to an existing structure of tasks in an organisation, rather than looking creatively at possible new constructions of roles. The fourth problem is that the listings start to look presumptuous. Outsiders look at it and say: µare they really claiming that they do all this and it is all essential to what they do?¶ Other professionals look at it say: µWell, we do all that, too.¶ The British Association of Social Workers once produced a report on the µsocial work task¶ based on 1970s functional research into social work (now out of print and not on the internet, so I can¶t give a link) and got roundly chastised for arrogance. The answer to this point is that all the professionals (and others) working in palliative care occupy a territory in which their roles, knowledge and skills overlap. It¶s the particular combination and emphasises of each role which defines it. But this, of course, also questions the methodology of functional analysis of job roles.
So how do you define palliative social work?
It¶s all very well for me to witter on about the problems, how can we tell people what social work is in an understandable way. Several people at the meeting had various ideas, and of course I have several publications ± I like to tell you about these occasionally. In particular,
you can see my article on the role of social workers in end-of-life care in the journal End of Life Care: On the web: http://endoflifecare.co.uk/journal/0101_colleagues.pdf and you can download excerpts from my book: What is Professional Social Work? http://lyceumbooks.com/WhatisProSW.htm But in general, I¶m a great believer in making clear that social work is about the social. Many social workers are currently keen to say that social work is not a µhealthcare¶ profession, particularly since in England it looks as though the registration of social workers will shift soon to the Health Professions Council (renamed the Health and Care Professions Council). So what is it then, the healthcare professionals all ask? To me, the objective of social work is increasing the resilience and solidarity of people in society. We work in healthcare, or with schools, or with parents and their children or wherever in order to achieve better parenting, better family care, better care for older people, disabled people and others and a better society in general. Getting involved in healthcare is only an instrument for achieving those social objectives. We don¶t ourselves improve people¶s health, we help them deal in their families and communities more effectively with the ill-health that assails them. And the social involves being concerned with the whole social context of the people that we work with: their families and communities, their workplaces and schools. So palliative social workers tend to say (accurately) that while doctors and nurses focus only on the individual patient, social workers focus on the family and wider context that affects the patient and their care. That;s why social workers deal with boundary problems when agencies disagree or services need integrating. That¶s why it¶s their job to make the system work for their clients. If you want a concrete example: here¶s the one I use. Ask a counsellor to see someone with family problems because of death, dying or bereavement. The counsellor will sit down with their identified client (and refuse to see anyone else, because they¶re focusing on their client) and help them to think through the emotional and relationship difficulties and practical problems that they are facing and identify ways of dealing with them, supporting them to do so. The social worker will get involved. For one thing, they will visit the home. If the children are distressed, they will work alongside the parents with the children. If there are relationship problems they will talk to both the husband and wife and anyone else who can help or is getting in the way. If there are money problems, they will sit down and work out what benefits can be claimed and help claim them. Show me the counsellor or clinical psychologist that will get involved in that way.