From April 2002 NASW NEWS
Copyright 2002, National Association of Social Workers, Inc.

Inappropriate Tasks, Lax Enforcement, High Turnover

Nursing Home Social Work in Doldrums

Nursing Home Social Work in Doldrums
Illustration: John Michael Yanson

Many administrators see social workers as "the odd spoke in the wheel."

By John V. O'Neill, MSW, NEWS Staff

Social workers are finding it increasingly difficult to provide services to the vulnerable residents of the nation's 17,000 nursing homes, say nursing home social workers and consultants who supervise them.

The 1987 Nursing Home Reform Act requires that facilities "must provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident," but actual delivery of psychosocial services to the nation's 1.6 million nursing home residents is, in effect, optional for owners since there is minimal enforcement of, and little will to abide by, the federal statutes, say consultants.

While there are good nursing homes that attempt to provide comprehensive services for their residents, many facilities—especially those in the for-profit sector—choose to provide few services and resist compliance with federal standards.

The condition is the result of a system failure, with plenty of blame to spread around, consultants say. Congress has cut back on Medicare and Medicaid reimbursements, which make up more than half of revenues, so nursing home operators are squeezed. Administrators are often focused on the bottom line and have little knowledge of psychosocial needs or appreciation of the value of social work. Regulators pay little attention to psychosocial needs of nursing home residents, seldom naming social workers to inspection teams. Many homes hire unqualified people, and the federal government doesn't keep track of credentials of those who fill social work roles.

Consultants say the consequences are disheartening for social workers and for residents and their family members.

Nursing homes are medical facilities that make decisions based on medical necessity, says Frank Baskin of Lowell, Mass., a nursing home consultant for more than 20 years. Many administrators see social workers as "the odd spoke in the wheel" who are a drain on profits. There is not a great deal of research to demonstrate social work's value, and many times the social workers administrators hire lack the knowledge, experience and self-confidence to refuse inappropriate work or to teach administrators and staff what social workers should be doing.

The result is that administrators or nursing staff end up assigning social workers inappropriate jobs. Even though federal law and regulations outline what a social worker's functions should be, Baskin says some nursing home personnel refer to social work as the "garbage can—for anything others don't want to do."

Some of the tasks social workers report to Baskin include buying cloths for residents, helping them move from one room to another, putting names on laundry and possessions, passing out mail, moving cable television and telephones and searching for lost eyeglasses and dentures. Pat Gleason Wynn of Dallas/Ft. Worth, a part-time nursing home social worker and gerontological educator and consultant for more than 20 years, said social workers have reported being asked to monitor people smoking or to transport people in their own vehicles. They often get the work nobody else in the facility has time for, said Mary Edwards, a 20-plus-years consultant and volunteer ombudsman in Montgomery County, Md.

"Almost all the social workers I know have a list of tasks they are doing that they feel are inappropriate and take them away from work they should be doing," said Baskin.

The biggest drains on social workers' time are paperwork and administrative functions, consultants report. Often there is no admissions director, and social workers get involved in filling beds or doing paperwork and billing, said Edwards.

Baskin, Wynn and Edwards said all those jobs are important. Dentures need to be located and laundry labeled, and beds filled and billing completed so homes can operate, but these tasks draw social workers away from what they have been educated and trained to do. If social workers are looking for missing glasses, they are unable to handle end-of-life issues, to work with medical doctors to monitor patients receiving psychotropic medications, to mediate between residents in rooms, to do one-on-one therapy or conduct groups, to help people adjust to nursing home life and reduced functioning, to follow up when patients are sent to the hospital, to help solve behavior problems, to educate the nursing staff, and other medically related social work functions, said Edwards. "In very few facilities are the things required by the Nursing Home Reform Act being done," she said.

The upshot is frustration, burnout and high turnover. "[Social workers] see the great need residents and families have for social work, and unable to do their jobs, they leave," said Edwards. "In most areas of the country, other jobs pay more and allow social workers to do social work."

One social worker reported to Baskin being so busy with admissions as to never again see patients after they were admitted.

Kelsey Simons, a research assistant who is a doctoral student at the University of Maryland, said she worked in a 180-bed, not-for-profit facility in New York with four social workers and liked the work. After she moved to the Washington, D.C., area, she worked at two for-profit facilities where her work was more administrative than clinical. "I was fulfilling a role that was not necessarily social work," she said. She got "burned out" and moved on.

A social worker doing admissions "is not advocating on behalf of residents, but on behalf of the nursing home to accommodate new admissions," said Baskin.

Another serious problem is the higher level of illness of residents in recent years, creating more work than social workers can handle, consultants say. Older residents are frailer and sicker than in years past, and many facilities set up special units for rehabilitation, brain injury, kidney disease, muscular dystrophy and others to increase reimbursements from Medicare. Patients in some of these units are often sicker, and turnover is high, requiring much more work for social workers. "There may be the same number of beds as 10 years ago, but a lot more work," Baskin said.

Federal law requires at least one full-time social worker in facilities with more than 120 beds, but the number of beds should be reduced to 80 because of this, he said. Another deficiency in the law is that nursing homes with 240 or even 360 beds could meet the minimum requirement with one full-time social worker. The number of social workers should be prorated to the number of beds, said Baskin.

"I love the elderly population; that's my niche," said Phoebe Moore, a Dallas-area social worker who recently quit a nursing home job after three years even though she had the support of the owners and respect for them. "It was frustrating to me to work in a situation where I couldn't possibly do what I needed to do," she said.

Washington, D.C., nursing home consultant Laurie Prusty, a 30-year veteran, said turnover is high not just for social workers but for administrators and others, creating instability and no incentive to do good work.

The restrictions on social workers' ability to do their jobs create a downward spiral, consultants say. Facilities usually hire bachelor's-level people with no specialized training or experience because they are cheaper, and then misuse them, leading to high turnover, said Edwards. The upshot in many areas of the country is a shortage of social workers willing to work in nursing homes, say Edwards and other consultants. "Administrative staff and other department heads don't know the value of social work because they so rarely see it," Edwards said.

The worker shortages lead administrators to hire unqualified people. Already many of the nation's nursing homes hire social work "designees," those without education and training for the job. The Office of Inspector General at the Department of Health and Human Services is looking into that practice, as well as the broader issue of delivery of psychosocial services and enforcement of federal law. The study is scheduled for completion in the summer.

While action by federal and state regulators is needed if nursing home residents and families are to get the psychosocial services the law mandates, there are things that social workers can do to help themselves, residents and families, say consultants.

"I really think social workers need to be responsible for themselves and the kind of practice they do," said Edwards. "Instead of always saying, 'The administrator told me to that this,' or, 'That's just the way it is here,' and then leaving, they should educate the staff and refuse to do work that isn't social work, advocate for themselves and do direct-service social work."

Social workers should review the literature of best practices, talk to peers, organize, and develop practice guidelines for nursing homes, Edwards said.

NASW has available its Standards for Social Work Services in Long-Term Care Facilities. Also, the U.S. Department of Veterans Affairs has developed a list of social work functions in long-term care that it considers essential for delivery of adequate psychosocial services in nursing homes where it places veterans [September 2001 News].

In addition, the Nursing Home Committee of NASW's Massachusetts Chapter met with the trade association of not-for-profit and for-profit nursing homes in an effort to hammer out voluntary standards for social work in nursing homes. Facilities that met the standards would be recognized in consumer literature.

Wynn also advocated educating administrators about what social workers do in long-term care, educating social work students about nursing home work and ensuring good continuing education.

Edwards referred to a list of advocacy issues she presented at NASW's 2000 national conference in Baltimore. According to Edwards, nursing home social workers need to push for:

  • Increased staffing.
  • Partnerships between local ombudsmen and social workers for family council formation, ethics committee formation, advocacy staff training and best-practice information advice.
  • Area-wide nursing home social work peer groups.
  • Networking with citizens' advocacy groups.
  • Seeking mentors from NASW's Section on Aging, university professors and other seasoned professionals.
  • Lobbying for social workers on state inspection teams.

Models other than the medical model are found in the literature, and social workers should be advocating them, said Edwards and Baskin. Both mentioned the resident-focused care in models promoted by the Pioneer Network. Social workers, as change agents, should organize and push for adoption of new methods of care, they said.

Despite the headaches, "for people who are flexible and like to be challenged, every day in a nursing home is different," Wynn said. "That's one of the things I like best."

For NASW standards: For V.A. functions list: (202) 273-8549.

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