A Part Versus Apart: The Relationship Between Social Workers’ Political Ideology and Their Professional Affiliation

A Part Versus Apart: The Relationship Between Social Workers’ Political Ideology and Their Professional Affiliation



Mitchell Rosenwald

Binghamton University

Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)

Copyright © 2006, White Hat Communications

This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.

Key Words: Political ideology; values; professional affiliation; diversity; social workers


Abstract

This article explores the relationship between social workers’ political ideologies and their sense of professional affiliation. Using a randomly-distributed mailed survey, both quantitative and qualitative data were collected from 294 licensed social workers. Study findings are mixed on this relationship. Implications for the profession are also forwarded.

1. Introduction

The social work profession includes social workers that subscribe to a variety and range of political values. Studies of social workers’ political ideologies, whether examined as political party affiliation or political philosophy, are mixed in their findings. Overall, social workers tend to be liberal and Democrats (Abbott, 1988, 1999; Koeske & Crouse, 1981; Reeser & Epstein, 1990; Rosenwald, 2004). These beliefs reflect the “liberal” policy statements in Social Work Speaks that are the profession’s official policy statements (National Association of Social Workers, 2000); they are liberal because the content of these statements correspond to values inherent in liberal political ideology including support for a welfare state, support for civil rights, and pro-choice regarding abortion) (Brint, 1994; Lowi & Ginsberg, 1994; McKenna, 1998). The few other studies relating to political beliefs in the literature, several quite dated, found more support for social workers identifying as moderate more than liberal (Varley, 1968) or moderately liberal (Henry, Sims, & Spray, 1971, Hodge, 2003). Conservative social workers comprised from under ten to a quarter of the sample in some studies (Henry et al., 1971; Hodge, 2003; Rosenwald, 2004).

This diversity in social workers' political views is to be respected according to National Association of Social Workers (NASW) Code of Ethics (1999) and, therefore, room for all “voices” should be allowed. Yet how do social workers who subscribe to different, and often competing, political ideologies, feel about affiliating with a profession that through its largest membership organization (NASW) officially reflects liberal political ideology (NASW, 2000; O’Neill, 2003)? A discrepancy, then, may exist between the NASW’s respect for political diversity in its Code of Ethics (NASW, 1999) and its liberal policies as espoused by its policy statements. This discrepancy may even affect social workers’ sense of affiliation with the profession, and social workers who are more liberal might feel more professional affiliation than those who are not. Because the existing literature did not examine this aspect, this article expands on the literature by exploring: “How do social workers’ political ideologies affect their professional affiliation?” It is important to note that NASW policy statements represent social work policy within the United States and may have limited application for social work policy in other countries where other issues may take precedence (NASW, 2000).

2. Political Ideology and Professional Affiliation

Political ideology refers to a group’s views on how policy decisions ought to be made in response to the economic, moral, and social concerns of society and can be conceptualized among a complex, multi-layered continuum from “radical left” and “liberal” to “moderate, “conservative,” and “radical right” (Brint, 1994; Knight, 1999; Lowi & Ginsberg, 1994; O’Connors & Sabato, 2000). This continuum is depicted in Figure 1.

Figure 1: Continuum of Political Ideology

<=====================================================================>

Radical Left Liberal Moderate Conservative Radical Right

“Radical left” political ideology emphasizes that the solution for social problems, such as class and other conflicts, lies in some form of societal conversion to socialism (Longres, 1996; Wagner, 1990). The “liberal” perspective emphasizes governmental protection of the disenfranchised, separation of church and state, and institutionally-based change (Brint, 1994; Dolgoff & Feldstein, 2003; Lowi & Ginsberg, 1994; McKenna, 1998). “Moderate” political ideology combines conservative and liberal ideologies depending on the particular issue and emphasizes planned incremental change (Berman & Murphy, 1999; McKenna, 1998). “Conservative” ideology stresses for-profit and voluntary sectors’ abilities to address social problems, maintenance of the status quo, and typical favoring of socially traditional values (e.g., pro-life stance, anti-gay rights) (Dolgoff & Feldstein, 2003; Lowi & Ginsberg, 1994). Finally, “radical right” political ideology draws on biblical literalism, the moral defense of capitalism, and the “pro-family” movement (Diamond, 1989; Hyde, 1991).

How, then, might the range of social workers’ political ideologies correlate with their feelings about the profession? Differences in political ideology manifest in all professions. Although professions attempt to create a “seeming unity” to the public (Bucher & Strauss, 1966), such unity is “not necessarily evidence of internal homogeneity and consensus but rather of the power of certain groups: established associations become battlegrounds as different emerging segments compete for control” (Greenwood, 1966, p.192). These segments, represented by different professional associations with different political ideologies, compete with each other. These differences also have implications; for example, the professional association that holds the most power (NASW) emerges as the dominant “expert” professional voice (Derber, Schwartz & Magrass, 1990) and can restrict alternative political ideologies from gaining power.

Therefore, examining professional affiliation can be helpful in understanding their perspectives. On the mezzo level, professional affiliation is the degree to which professions are successful in maintaining commitment among their members; on the micro level, it is the degree to which a professional feels a sense of belonging to her or his profession. One way to explore this relationship between political diversity and professional affiliation is by examining the role of professional membership associations (Vollmer & Mills, 1966). Considering the professional affiliation of its members is important to a profession because a profession’s legitimacy and strength critically depend on the support (through continued membership and pride) of its members via formal membership organizations (Greenwood, 1966; Dolgoff & Feldstein, 2003).

For social work, NASW is the largest professional organization; aspects of its liberal policy statements may strongly resonate with some members, yet may be construed as too conservative or too liberal by others. Examples of these policy statements include support for a minimum wage, support for pro-choice options regarding abortion, opposition to the death penalty, and reluctance to report “welfare fraud” (Abbott, 1988). For those expressing a radical left critique of liberalism, their subscription to an alternative Code of Ethics, challenge to the capitalist system, and deconstruction of the hierarchical power arrangement in the client/social worker relationship, are reasons they may feel excluded from the liberal social work mainstream as represented by NASW (Longres, 1996; Wagner, 1990). Parallel and yet in contrast, social workers who espouse a more conservative or radical right political ideology may also not feel aligned with NASW based on political differences. For example, addressing the moral context of conservative political ideology, Hodge (2002, p. 406) argues that traditional religious values’ importance to social work are compromised and even superseded by the profession’s “ideologically inspired drive to control the parameters of the debate by excluding divergent voices.” Additionally, Rubin (1999) discourages the profession’s pervasive liberal political ideology when it is not supported by research. In summary, the degree of social workers’ professional affiliation may depend on their particular political views.

3. Method

The study’s guiding research question is: “How do social workers’ political ideologies affect their professional affiliation?” This question, part of a larger study conducted by the author, was explored quantitatively with supplemental qualitative analysis.

3.1. Measures

The exploratory variable of professional affiliation was partially derived from Epstein (1969), Evans and Jarvis (1986), and Keyton’s (1991) scales on, respectively, professional participation, group membership, and group satisfaction. The four questions that address professional affiliation are: 1) How strongly do you feel a part of the profession? 2) How strongly do you feel that the National Association of Social Workers (NASW) represents you? 3) How strongly do you believe in the National Association of Social Workers’ (NASW) Code of Ethics? and 4) How strongly do you believe that the social work profession should only accept social workers with a liberal political ideology? Questions one and two directly relate to the mezzo-operational definition of professional affiliation. Questions three and four assess professional affiliation by the micro-operational definition of professional affiliation provided with respect to commitment to NASW’s Code of Ethics and political ideology. The response categories are four-point Likert scale items with “1” being “Very Strong,” “2” being “Somewhat Strong,” “3” being “A Little Strong,” and “4” being “Not Strong At All.” Each question also provided a section for participants to write comments, which served as the basis for a qualitative data analysis.

The independent variable of political ideology was principally measured by the 40-item Professional Opinion Scale (POS) (Abbott, 1988, 1999, 2003) which is a comprehensive and reliable scale that examines social workers’ values. It is divided into four value dimension subscales: Respect for Basic Rights (BRSS), Commitment to Individual Freedom (IFSS), Sense of Social Responsibility (SRSS), and Support of Self-Determination (SDSS) (Abbott, 1988). These subscales reflect both economic and social components of political ideology (Abbott, 2003; Brint, 1994; Lowi & Ginsberg, 1994). Specifically, Abbott’s four POS subscales reflect the following:

Basic rights encompasses the concepts of equality and respect for individual rights…Social responsibility incorporates the concept that society has a responsibility to develop legislation, funding and programs which promote and improve the well-being of its members…Individual freedom includes a measure of approval (or disapproval) of the use of punishment or rules as a means for promoting desired behavior…. Self-determination refers to respect for individuals’ abilities to make their own decisions regarding life’s alternatives. (1999, p. 457-8).

Based on a five-point Likert scale with ‘1’ corresponding with more conservative views and ‘5’ reflecting more liberal views, the POS’s higher scores correspond with greater liberalness (Abbott, 1988, 1999). To compensate for three contemporary policies not addressed in the POS (Abbott), the author created a Professional Opinion Scale Plus Three (POS+3) with the addition of the following three items: 1) “Faith-based delivery of social service is an effective method of helping people in need,” 2) “Special laws for the protection of lesbians’ and gay men’s equal rights are not necessary,” and 3) “Social services should be provided to illegal immigrants.” These three items used the same five-point response categories and increased the POS’ Cronbach’s alpha of 0.85 from this study to 0.86, suggesting continued good internal consistency reliability.

A second single-item measure of political ideology, commonly used in the literature (Knight, 1999), asked participants to identify their political ideology (Self-Ranked Political Ideology [SRPI]) on a seven-point Likert scale: Radical left (1); Very liberal (2); Liberal (3); Moderate (4); Conservative (5); Very conservative (6); Radical right (7). Participants were also surveyed on demographic characteristics (e.g., gender, age) and professional characteristics (e.g., primary work setting, primary social work function).

3.2. Data Collection and Analysis

A pilot test completed by ten practicing social workers revealed no substantive problems (Dillman, 2000). The sample was collected from the 2003 membership list of one mid-Atlantic state’s social work licensing board. Proportional random sampling was employed to ensure licensed social workers from all four licensure levels were represented (Rubin & Babbie, 2001). Five hundred and fifty eight participants received a cover letter, questionnaire, self-addressed stamped envelope, and a dollar bill as an incentive. They also received a follow-up reminder postcard a short time later (Dillman, 2000). Data from 294 questionnaires was analyzed; this resulted in a 52.6% response rate, which is considered a fairly good response rate for mailed questionnaires (Rubin & Babbie, 2001).

The four professional affiliation items were independently analyzed with descriptive statistics (means, standard deviations, frequencies, and percentages) and the Spearman correlation statistic. These four items had a low Cronbach’s alpha, which precluded their combined use as a scale (Rubin & Babbie, 2001). The participants’ written comments were analyzed using “analytic induction” (Huberman & Miles, 1994). This method incorporates an iterative process by which themes from the data are inductively and repeatedly identified and verified (Huberman & Miles, 1994). Additionally, themes were identified if at least twenty percent of participants addressed each theme. This author analyzed the data with the assistance of the co-chair of his dissertation committee.

4. Quantitative Results

The sample was largely white (80.1%), female (85.6%), 35-46 years old (M = 45), Protestant (36.1%), and somewhat to strongly religious/ spiritually affiliated (72.2%). In addition, participants averaged an income range between $40,000 and $49,999; were mostly Democrats (78.1%) and heterosexual (93.7%). The majority of participants possessed master's degrees in social work (83.6%), worked full time (72.9%), and held their state’s advanced clinical social work license (59.8%). Participants tended to work in public settings (36.6%), as well as non-profit settings (35.5%). They had about 13 years of licensed experience and a slight majority (52.6%) worked in clinical/direct social work practice. Finally, with respect to political ideology, the participants self-identified as (in descending percent): liberal (40.6%), moderate (34.4%), very liberal (12.5%), conservative (9.7%), radical left (2.1%), very conservative (0.7%), and radical right (0.0%).

4.1. Range of Professional Affiliation

The distribution for professional affiliation is presented in Table 1. Many participants felt somewhat strongly (38.1%) or very strongly (35.7%) about being a part of the profession. Participants felt differently about NASW’s representation; their responses tended to fall into approximate thirds-- 33.7% felt somewhat strong, 31.5% felt a little strong, and 30.0% felt not strong at all. The vast majority of participants (91.9%) believed in the NASW Code of Ethics, with over two-thirds (65.0%) stating they strongly believed in the Code. Finally, a majority of participants (82.3%) did not think that the profession should limit entrance based on a social worker’s liberal political ideology. However, a minority (17.7%) felt at least a little supportive that the social work profession should exclude those with non-liberal political ideologies.

Table 1: Frequency Distribution, Means and Standard Deviations of Professional Affiliation

__________________________________________________________________________
Item N
Percentage
Feel part of the profession

Very strong
104
35.7%
Somewhat strong
111
38.1%
A little strong
55
18.9%
Not strong at all
21
7.2%
Feel represented by NASW

Very strong
13
4.8%
Somewhat strong
91
33.7%
A little strong
85
31.5%
Not strong at all
81
30.0%
Believe in the NASW Code of Ethics

Very strong
184
65.0%
Somewhat strong
76
26.9%
A little strong
19
6.7%
Not strong at all
4
1.4%
Believe in liberal political ideology req.

Very strong
4
1.4%
Somewhat strong
15
5.3%
A little strong
31
11.0%
Not strong at all
233
82.3%



4.2. Relationship between Political Ideology and Professional Affiliation

Table 2 provides the correlation of professional affiliation with the seven measures of political ideology. Aside from self-ranked political ideology, participants’ feeling part of the social work profession was significantly correlated with every political ideology measure, suggesting that being more liberal leads to feeling more a part of the profession, whereas being more conservative corresponds to feeling slightly marginalized from the profession. Participants’ sense of feeling represented by NASW was related to Self Ranked Political Ideology (rs = .208, p = .001) and the Commitment to Individual Freedom (rs = -.146, p = .024). More conservative thought was slightly associated with feeling less represented by NASW. Participants’ belief in the NASW Code of Ethics was significantly correlated with every political ideology measure except Commitment to Individual Freedom. More conservative political ideologies were associated with a weaker belief in the code. Finally, participants’ belief in requiring a liberal ideology for social workers to be accepted into the profession was significantly correlated with the Professional Opinion Scale, Professional Opinion Scale+3, Support of Self-Determination, Sense of Social Responsibility and Self-Ranked Political Ideology. The results suggest that those with a more conservative political ideology did not favor such a requirement.

Table 2: Spearman Correlations of Professional Affiliation and Political Ideology

_________________________________________________________________________
Professional Affil. Item
SRPI
BRSS
IFSS
SDSS
SRSS
POS
POS+3
Part of Profession
.122
-.178b
-.169b
-.204b
-.178b
-.261c
.279c
N
(287)
(275)
(255)
(266)
(260)
(227)
(225)
Represented by NASW
.208b
.017
-.146a
-.056
-.083
-.060
-.087
N
(266)
(255)
(239)
(248)
(245)
(213)
(211)
Believe in Code of Ethics
.151a
-.258c
-.110
-.186b
-.184b
-.197b
-.204b
N
(279)
(266)
(248)
(259)
(253)
(219)
(217)
Believe in Liberal Requirement
.215c
-.008
-.109
-.139a
-.177b
-.177b
-.183b
N
(278)
(269)
(251)
(259)
(253)
(222)
(220)

a p < .05 (2-tailed)

b p < .01 (2-tailed)

c p < .001 (2-tailed)

5. Qualitative Results

The four questions used in the quantitative data analysis were also used in the qualitative data analysis by asking participants to “please comment on your answer.” The variation in the quantitative findings echoed within the themes from the qualitative data. The themes of diversity and representation emerged from the professional affiliation items. Participants’ self-ranked political ideology and their corresponding questionnaire numbers are incorporated into their comments.

5.1. Diversity

The majority of participants who responded believed that a broad range of political ideologies should be reflected in social work. With respect to diversity, one participant [moderate, 103] stated, “I believe there is room in the profession for people of various ideologies – [it] keeps us all on our toes” and another [liberal, 148] felt, “There should be no ideological litmus test.” Anchored in the ethical standards, one participant [liberal, 111] reported, “As long as Code of Ethics are followed, political ideology shouldn’t matter.” Within this theme of diversity, some participants believed that identifying with more moderate and conservative political ideologies was still compatible within social work’s political ideological range. One participant [moderate, 119] stated, “We need diversity of opinions. I find it highly objectionable when the profession asserts we should all be liberal thinkers!” Recognizing her own ideological shift, another [moderate, 84] said, “With age, I have moved from liberal bleeding heart to moderate. I still serve our profession well,” whereas a third [liberal, 82], reflected “I find myself leaning more to the right (becoming somewhat more conservative) as time passes.”

Some participants appeared to favor one ideology over another within this goal of diversity. A number of participants were comfortable with social workers subscribing to a liberal political ideology. For example, one [moderate, 39] suggested that, “Based on the tradition of social work, I am more comfortable with the idea of more liberal thinking people in the profession…” A second [very liberal, 290] participant believed, “By learning about social policy and inequalities that exist in society, an intelligent person may find it difficult to avoid becoming liberal.” Finally, one [liberal, 165] wrote, “I think liberals are sufficiently unselfish to be social workers.”

Paralleling this favoring of liberal political ideology by some within the profession was skepticism of the compatibility between conservative political ideology and the social work profession. Specifically, some participants questioned the match between the inclusion of conservative ideology and the profession’s demand to exhibit empathy and respect. One participant [moderate, 82] stated, “It helps to have empathy [working in social work]. If one is too far to the right, there goes the empathy.” A second participant [liberal, 156] believed, “If a social worker has a conservative ideology, he or she needs to be sensitive to and respectful of – and even value the differences of others so that they do not wrongly impose their beliefs on others.” Another [very liberal, 132] explicitly remarked, “I don’t think conservatives have social work values.” Finally, with slightly more subtlety, one participant [moderate, 237] believed that although “even conservative people may have something beneficial to contribute to the profession…It doesn’t mean that a conservative person has to inflict his values on the client.”

A few participants disagreed with this liberal critique of conservatives and professionalism. One participant [moderate, 16] believed aspects of liberal ideology may have dire consequences in practice, stating, “Many ‘liberal’ views work against client empowerment and personal responsibility. Certain views assist clients to remain dependent and weak.” A second participant [moderate, 114] stated, “The assumption is that a ‘good’ social worker holds to/ supports the ‘liberal’ ideology,” whereas a third [moderate, 227] said, “I am disappointed in most social workers and agencies. Social workers tend to reject anyone not ultra liberal.” Finally, a fourth [conservative, 280] succinctly opined, “You don’t have to be liberal to care.”

5.2. Representation

Beyond diversity, the importance of representation was important to participants. This theme examined social workers’ feelings of being personally represented by their profession with respect to their political ideologies.

Participants held mixed views about the congruence between their own political ideologies and NASW’s. One participant [very liberal, 107] responded, “I am pleased with the NASW’s efforts to strengthen the profession and advocate for legislation that supports social work values.” A second participant [moderate, 84] depended “on it to represent our basic core values and ethics” and a third [liberal, 152] believed that “NASW does fairly well in matching [my] political agenda.” Other participants questioned NASW’s careful representation of its members’ political ideologies and referenced general disaffection with the organization’s overall political stance, as well as disagreement with specific policies. For example, for some, NASW’s bias was seen as problematic. One [moderate, 227] stated, NASW is “too liberal and political – excludes moderate views and conservative views.” Another [moderate, 100] reported, “I am a moderate in my opinion and NASW in my mind is more liberal, politically motivated.” Interestingly, coming from two opposing political ideologies, which recalls this study’s guiding research question, two participants shared their extreme dissatisfaction with NASW. One [very conservative, 57] wrote, “I dropped my membership [in] NASW due to lack of variety of members and agenda – seems to be far left,” whereas the other [very liberal, 239] said, “I dropped my membership last year. [NASW n]eeds to be a more radical [left] organization [and] inspire more activism among its members.”

Participants, particularly from more moderate and conservative perspectives, also disagreed with NASW’s specific policy positions, with respect to both economic and social issues. One participant [conservative, 281] stated NASW is “not an effective organization – politically liberal and advocates for the government to provide more and more – what about personal responsibility? No room for discussion/differing views.” Another participant [moderate, 168] stated, “NASW’s political agenda is much too liberal and has shifted away from the original mission to represent the poor and disenfranchised.” With respect to moral issues, one participant [conservative, 6] felt, “NASW is very liberal in its platform ideology (e.g. abortion, women’s right to choose); my religious convictions are counter to the spirit of NASW…I don’t believe any discrimination is right; however, I see homosexuality as a choice – which is a sin in God’s eyes. NASW seems to validate a homosexual lifestyle as okay, one not to be discriminated against – I have a problem with this.”

Other participants did not feel represented by NASW because the organization was too conservative in its ideologies and believed it needed to play a larger role in addressing inequality and correcting economic and social injustices. One participant [moderate, 178] stated that "NASW is too conservative in its focus. It does not promote [the] plight [of] the disenfranchised within the USA.” A second [radical left, 86] said, “My beliefs, particularly around economic justice/ the need for redistribution of wealth, ‘narrowing the gap’ aren’t addressed in the more radical manner I hold them.” Echoing this sentiment, a third participant [moderate, 16] believed, “Social work needs to focus more on income inequality stemming from government bail-outs; estate, capital gains, and other benefits that protect the wealthy; and subsidies to farmers and others to not produce. Too much emphasis is placed on the poor without getting at the root causes of poverty and income disparities.”

6. Discussion

From an organizational perspective, as the social work profession continues “to rise within the professional hierarchy, so that it, too, might enjoy maximum prestige, authority, and monopoly” (Greenwood, 1966, p. 19), NASW provides a prevailing political ideology that attempts to unify and rally the professional workers. This seeming united front, espoused by NASW in its policy statements and legislative agenda (National Association of Social Workers, 2000; O’Neill, 2003), directs the profession in terms of practice, education, policy, and research. Yet, as Bucher and Strauss (1966) observe, this unity is “spurious” and, therefore, does not reflect the complexity of social workers’ political ideologies that can affect their sense of professional affiliation. Social workers who embrace different political ideologies may experience varying levels of professional affiliation based on the degree to which their respective political ideologies resonate with the official liberal ideology of the profession.

This exploratory study’s findings showcase the complexity of political ideology’s relationship to professional affiliation. On one hand, the descriptive statistics and some of the participants’ comments suggest that political diversity is welcomed. Indeed, incorporating political diversity reflects the natural growth of a profession as competing ideological fragments (competing political ideologies) are created (Bucher & Strauss, 1966; Greenwood, 1966). Many social workers agree with the liberal components of social work’s policy statements (National Association of Social Workers, 2000) and tend to support the profession’s stances on welfare state, basic system commitments, civil rights, civil liberties, and moral issues (Brint, 1994). For them, their private political ideology mirrors NASW’s political ideology. Additionally, most believe that incorporating political diversity strengthens the profession. On the other hand, the Spearman correlations and other participants’ comments indicate that more liberal social workers have somewhat greater political affiliation. Further, the findings suggest that participants, who are more liberal with respect to social policies, are slightly more connected to the profession, to NASW and its Code of Ethics, and slightly favor a liberal political ideology requirement for social workers.

The finding that 17.7% of participants believed that social workers should be excluded, to some extent, from the profession if they subscribe to a non-liberal political ideology is interesting. Although these sentiments were not strongly held beliefs, their mere existence suggests that despite the inclusion of diversity of political beliefs in the NASW Code of Ethics (National Association of Social Workers, 1999), a significant minority of the participants were reluctant to embrace social workers of a larger range of political beliefs. This leads to the question: Is prejudice against non-liberal social workers an acceptable prejudice for social workers to hold? This is a significant question when considering that hardly any social worker would a belief that admit that the profession should only admit women or individuals who are white. This prejudice, by some, was particularly directed toward social workers with conservative political ideology. This attitude may be somewhat attributable to the skepticism about whether more conservative social workers are able to truly care and empathize with their clients. Thinking specifically of the extreme conservatism (“radical right”) of social workers who espouse fundamentalism, Dinerman (2003) asks social workers, “Can truly fundamentalist social workers maintain the needed separation between their own beliefs, strongly held, that they know what is true and right yet respect and accept a client with sharply different beliefs to help the client to find his or her own goals and beliefs?” (p. 250).

Some of the more moderate and conservative social workers refuted that sentiment, based on the qualitative data, stating that they subscribed to professional standards and ethics, and were skilled in professional caring and empathy. In addition, these social workers believed liberal social workers disservice their clients because their ideologies promote financial dependency instead of empowerment, and immorality on some social issues. This critique reflects disagreement with NASW’s position on welfare state, as well as its stances on civil rights (i.e., pro-lesbian and gay rights) and moral issues (i.e., pro-choice).

Conversely, a few social workers who subscribed to more liberal and radical left political ideologies found the profession’s “liberal” yet status quo views on basic system commitments and the welfare state reducing their professional affiliation. This split in political ideology is understood as social workers balance their stated mission of helping clients, organizations and communities with working within the capitalist structure (Ehrenreich & Ehrenreich, 1977) and pursuing professional prestige (Greenwood, 1966).

Therefore, these findings provide a beginning framework to discuss how agreement with the different components of the profession’s political ideology affects social workers’ professional affiliation. This discussion also highlights the need to move beyond the “conservative-liberal” debate and provide attention to what a “moderate” social worker is. Those with moderate ideologies, who represented over a third of the sample, aligned at times with both conservative and liberal political ideologies.

7. Study Limitations

Several study limitations exist. The limit to external validity prevents generalizability beyond licensed social workers in one particular state (Rubin & Babbie, 2001). Although these participants’ reflections on the profession and NASW are important, it is equally important to understand this key limitation. Additionally, an overrepresentation of social workers who are interested in the topic of political ideology may have responded to the questionnaire and biased the results (Dillman, 2000). Social desirability may have existed in situations in which participants wanted to appear more “open” to political diversity than they really were (Rubin & Babbie). An additional question addressing the exclusion of non-conservative social workers would have balanced the professional affiliation question asking about excluding non-liberal social workers. Finally, the low internal reliability of the professional affiliation “scale” suggests a need for further scale development, which would include a confirmatory factor analysis.

8. Implications

This study suggests that, whereas many support the profession and NASW, those who are more moderate and conservative may feel more marginalized from the profession, because they feel that NASW does not represent them. Similarly, a few of the participants’ comments suggest that those “left” of liberal might also feel marginalized based on a parallel reasoning of feeling excluded when participant political ideology does not fully match NASW’s policy statements. In addition, some stereotypes of what it means to be “conservative” or “liberal,” for example, shape social workers’ view of their own efficacy and the professionalism of their peers. Therefore, creating a discussion around the diversity of social workers’ political ideology would perhaps assist the state chapter of NASW, in this particular state, in more fully meeting the needs of its members (The author did write a column on key findings from the larger study for this state’s NASW newsletter.) Specifically, the NASW chapter could sponsor a forum on political ideology that explicitly addresses the relationship between social workers’ political ideology and their perceptions of how different policies and laws should be. Finally, this discussion can extend into political ideology’s impact on practice (Rosenwald & Hyde, 2006).

Although immediate implications are confined to the particular state of focus, this study provides food for thought on what implications might occur for NASW and the profession at large. A national forum on political ideology, at a conference for example, along with editorials on the diversity of social workers’ political ideology, might be useful to explicate the debate that occurs every three years within the Delegate Assembly as Social Work Speaks policy statements are established and modified. The creation of such a forum honors the spirit of the respect for diversity of colleagues’ political belief in the NASW Code of Ethics (1999) and might result in moving beyond superficial sound bites of the “other” to greater understanding of those along the political spectrum without fear of instant dismissal or reprisal.

This inclusion of voices, representing the full range of political views, could increase NASW’s membership. As more social workers feel increasingly a part of both the profession and NASW, they may be more inclined to support the profession’s mission and ethics. Consequently, the profession’s occupational legitimacy, as measured by member support, could be strengthened (Vollmer & Mills, 1966).

9. Conclusion

It turns out that the stereotypes of social workers, as identified by Dolgoff & Feldstein (2003, p. 301), as “‘bleeding hearts,’ radicals, captives of and apologists for ‘the establishment,’ organizers of the poor, and servers of the middle class” are held not only by the public but by social workers about each other. These stereotypes originate, in part, from the varied political ideologies held by social workers, as detailed in the data, and their conceptions of what a social worker should be. They also provide a foundation upon which social workers make judgments about themselves and one another regarding the degree of fit between political ideology and the profession.

This study expands on others (Abbott, 1988, 1999; Koeske & Crouse, 1981; Reeser & Epstein, 1990) that examined political ideology by exploring the relationship of political ideology with professional affiliation in social work. Understanding the economic, social, and moral dimensions of political ideology (Brint 1994; Lowi & Ginsberg, 1994) provides insight into how some members’ political ideologies are accorded dominant status in the profession, whereas other members might feel their ideologies are a basis upon which they are excluded.

Professional affiliation depends, in part, on the congruence of social work’s espoused political ideology with the political views of the profession’s members. But this political ideology is not monolithic; put more succinctly, does political diversity “threaten” the profession in terms of its cohesion? It is within this context that the social work profession and NASW need to weigh the alleged benefits and risks of incorporating political diversity and to decide how explicitly supportive a climate for such diversity it desires to create. This article is an initial step in that conversation.
_____________________________________________________________________________________
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Teaching Ethics through Self-Reflective Journaling

Teaching Ethics through Self-Reflective Journaling
Marian L. Swindell and Joshua Watson
Mississippi State University

Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)



Copyright © 2006, White Hat Communications

This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.

Key Words: Self-reflective journaling; social work; ethics; SRJ

Abstract

This article introduces and explores the usefulness of Self-Reflective Journaling (SRJ) as a means of actively engaging social work students in the learning process of ethical resolution. After a brief review of the literature on self-reflective writing, the article outlines the approach adopted by a second-year assistant professor at a small, rural, undergraduate program. Passages from students’ reflective writing assignments for this course are provided to illustrate how they approached the assignments and their overall view of the course experience. The article concludes that this approach to teaching ethics and moral philosophy is beneficial from both an instructor and a student perspective, because it encourages active student participation, critical thought and application, and writing skills development.
1. Introduction
Social work courses focus on preparing students for the field practicum experience and, ultimately, for professional practice. Infused in these courses are content areas on values, ethics, spirituality, research, policy, human behavior, theory, and practice skills. Implicit in the development of practice skills and ethical responsiveness is a degree of self-awareness. Social work students, academicians, and practitioners must be aware of their ethical code, moral boundaries, attitudes, and value system so that they may effectively work with diverse populations. The social work curriculum is structured to enhance and encourage this self-awareness. Students are expected to develop the ability to reflect on their value systems, models of practice, theoretical frameworks leading their practice, and their own moral struggles.
The social work profession is built upon an ethical code that sets forth a standard of practice. The Code of Ethics of the National Association of Social Workers (NASW) (2000) focuses primarily on ethical practice within our profession at the micro, macro, mezzo, and international levels. As such, this Code guides the professionalism of our practitioners. According to Marsh (2003), our “profession is defined by the tasks we accomplish; the problems we solve; as well as the knowledge, skills, and values we bring to bear to solve those problems” (p. 5). Reamer (1998) points out that “ethical issues have always been at the foreground of social work practice and that throughout our historical development we have been concerned with matters of right and wrong and matters of duty and obligation” (p. 489). Advances in technology and information dissemination have also fostered an evolution of the profession’s Code (Reamer, 2001). As a result, the educational experience addressing such ethical issues as client confidentiality, Internet messaging, e-mail retrieval and submission, and fax machine usage, is also evolving. A review of the literature shows that social work ethics curricula focus on preparing our students to identify ethical dilemmas, apply appropriate theoretical frameworks, and protect themselves as practitioners from complaints and legal recourse (Dickson, 1998; Loewenberg, Dolgoff, & Harrington, 2005; Madden, 2003; NASW, 2000; Osman & Perlin, 1994; Reamer, 1999, 2001a, 2005; Stein, 2004). Black, Congress, and Strom-Gottfried (2002) have also published a curriculum resource guide on various approaches for including ethics content in the curriculum, course assignments, classroom exercises, handouts, and reading lists. In addition, NASW (1998) also provides a book with examples of ethical controversies and considerations in resolving them. These available resources provide educators with a variety of models of ethical decision-making methods from which to choose to engage the student (Congress, 1998; Joseph, 1985; Lowenberg & Dolgoff, 1996; Mattison, 2000; Reamer, 1993).

Sadly, though, even with these available resources, there remains a great divide between the conventional and the creative lecturers regarding ways to enhance the learning experience. The conventional method of instruction is the “I lecture-you listen” approach. The creative method of instruction incorporates a multitude of approaches: modified lecture format, problem-based learning, case vignettes, writing assignments, small group discussion, journaling, role-playing, student-led presentations, and critical debate. To be honest, however, the mode of information delivery is useless unless the student actively engages in the learning process. What is useful is how the instructor utilizes those available resources to engage the student to achieve the learning objectives. According to the research, social work academicians are not utilizing these resources to the best of their ability. Boland-Prom and Anderson (2005) point out that “while progress has been made in social work education and training on ethics, more effort is needed” (p. 495). Dodd and Jansson’s (2004) research also points out two pivotal findings in their review of ethics curricula in social work programs: 1) whereas social work practitioners are trained in how to recognize ethical dilemmas and become involved in their resolution, they are not fully invited to participate in the process as equals, and 2) the training they received did relate to their awareness and desire to participate in the ethical resolution process, but they had not been trained in how to engage themselves in the resolution process.

To train students in how to engage themselves in the resolution process, we must train them first in the classroom. One effective method that actively and responsibly engages students in the learning process is the Learning-Centered Paradigm (McManus, 2001). This method has proven effective in situating students at the center of the learning experience, motivating and empowering students to assume responsibility for their own learning. The instructor also takes responsibility by adopting teaching techniques specifically designed to encourage students to see themselves as active thinkers and problem-solvers. Clinchy (1995, p. 100) posits that in conventional pedagogy (I lecture, you listen) students are often pressured to “defend their knowledge rather than exhibit their thinking.” King (1995) contends that students need to learn how to think critically by constantly questioning, analyzing, and reviewing the world and environment around them. Seeler, Turnwall, & Bull (1994) encourage academicians to integrate innovative teaching techniques in the classroom that take students out of the passive role and place them in an active, thinking mode during their learning experience. One way to achieve active learning is through the use of SRJ.
2. Self-Reflective Journaling Defined
Dewey (1933) defines reflective thought as “an active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” (p. 9). Dewey contends that the purpose of this type of thinking is to achieve a goal and that the thought process is active and purposeful. An important and implicit element in learning is the capacity to be reflective. Studies show that learning is likely to be deeper or more connected to practice when it includes reflection, the ability to connect new information with personal meaning or past experience (Smith, 2005). Johns (1995) considers reflective writing part of the learning process, and both Andrews (1996) and Durgahee (1996) posit that reflective writing encourages critical thought and application. Gardner’s (2001) research also found that reflective writing is indeed effective with social work students, increasing their ability to recognize and articulate their own values and attitudes and exposing them to new ideas, new knowledge, new avenues of critical thought, and new ways to critically problem solve. Tsang (2003) also found that self-reflective journaling as a coursework assignment fostered critical reflectivity over time and promoted understanding of theory.

Self-reflective journaling (SRJ) compels the student to actively think about a feeling, event, behavior, emotion, or action and to record those thoughts. SRJ writing focuses on the process of learning rather than the product of learning, providing valuable educational benefits (Conner-Green, 2000; Croxton & Berger, 2001; Hyers, 2001). This method of writing increases student awareness of both what they are learning and how they are learning (Voss, 1988). Dart, Boulton-Lewis, Brlwolee, and McCrindle (1998) found that as students practiced introspective writing, their reflection and insight become more analytical and the quality of their writing also improved.

Benefits of SRJ include presenting students with an opportunity to make sense of their own personal histories, stories, and life events (Hedlund, Furst, & Foley (1989), and the increased ability to remember concepts they have learned in the classroom for a longer period (Croxton & Berger, 2001). Additional benefits included improved exam and research paper scores (Connor-Greene, 2000; Hyers, 2001), increased awareness and knowledge of critical analysis and application (Hettich, 1990), increased levels of student-teacher trust (Lohman & Schwalbe, 1996), and increased cognitive development and affect (Lohman & Schwalbe, 1996).

Paul and Elder (2005) propose that in order for reflective writing to be effective, guidelines must be followed and students must be disciplined in their efforts. They state, “if students are to learn, they must write” (p. 40). They suggest that instructors provide a brief overview of the foundations of substantive writing, explain the idea of self-reflection, provide examples to the students of entries written by the instructor, and discuss appropriate topic areas for the writing assignment. They also stress that a student cannot be both “a skilled thinker and a poor writer” (p.40) and that it is the instructor’s responsibility to help the student transition from the perspective of learning to write to the perspective of writing to learn.
3. Self-Reflective Journaling in the Profession
In many areas of practice, clinicians ask clients to keep logs and journals, preparing narrative accounts of their activities, thoughts, emotions, and feelings. Clients find that keeping a journal or log helps them “increase their understanding and awareness of the factors contributing to their presenting problem” (Berlin & Marsh, 1993, p. 99). The same is true for the social work student. CSWE (2003) mandates graduates of social work programs be able to:

1) apply critical thinking skills within the context of professional practice;
2) understand the value base of the profession and its ethical standards and practice accordingly;
3) become aware of their own personal values and possess the ability to analyze ethical dilemmas and the ways in which they affect practice, services, and clients (pp. 33-34).

In many programs of study, students are required to keep a journal or daily log during their field practicum experience. This student journal serves the same purpose as the client journal: to increase understanding and awareness through critical and reflective thought on events, thoughts, feelings, and emotions.
4. Case Study
The purpose of the integration of SRJ in a social work core course was threefold: 1) to help students learn the process of ethical problem solving, 2) to help students explore the dimension of ethical dilemmas and how personal biases are related to the problem solving process, and 3) to provide a safe environment for students to explore ethical issues. Upon Institutional Review Board Approval, the course selected to integrate SRJ was Social Work with At-Risk Populations in the fall of 2004, with 24 students enrolling (17 social work majors, 3 business majors, 2 education majors, and 2 interdisciplinary studies majors). The course focused on cultural competence and ethical practice with diverse populations, discrimination, prejudice, oppression, social and economic justice, distributive justice, and theory. Key objectives spelled out in the Learning Outcomes (see Table I) encouraged students to become actively involved in this classroom experience, rather than passively reacting to the information at exam and research paper time. The content of the course, examination of different approaches, perspectives, and ideologies, also made the SRJ approach possible. The teaching/learning pedagogy adopted for this class was based on lectures as the key mode of delivery and a structured bibliography. Lectures were prepared and delivered using PowerPoint presentations, and WEBCT was used to support the course.

TABLE I. Learning Outcomes of the Course.

On successful completion of this course, students should have:
1. “Knowledge and understanding of the main ingredients of ethical, strengths-based, generalist approaches to social work practice,
2. Understanding of the value base of the profession and its ethical standards and principles,
3. Knowledge of practice methods which do not discriminate,
4. Respect, knowledge, and practice skills related to clients' age, class, color, culture, disability, ethnicity, family structure, gender, marital status, national origin, race, religion, sex, and sexual orientation,
5. Ability to use communication skills differently across client populations,
6. Awareness of personal values and ability to develop, demonstrate, and promote values of the profession,
7. Knowledge of methods to analyze ethical dilemmas and the ways in which these affect practice, service, and clients,
8. Understanding, affirmation, and respect for people from diverse backgrounds,
9. Ability to recognize diversity within and between groups,
10. Knowledge of methods to identify ways group membership influences access to resources,
11. Understanding of distributive justice, human and civil rights, and the global connectedness of oppression” (CSWE, 2003, p. 33-34).

Students were instructed to process through self-reflective writing: 1) feelings and emotions, 2) thoughts, 3) behaviors leading to and following the incident, 4) their personal value system, 5) approaches they would utilize now to work toward resolving the ethical dilemma, and 6) an overall analysis of the incident, drawing from their classroom discussion, a review of the Code of Ethics, and their increased level of knowledge and/or maturity since the incident. This process usually took about 45 minutes. The journals were then submitted to the instructor for review, with the understanding that grading was to be based on critical thought and application, not technical presentation.

The purpose of this course was to focus the students on studying material throughout the semester, rather than reading for exam purposes only. Each week, they were to work through an ethical dilemma which focused on the population-at-risk we had just discussed. After students had prepared for classroom discussion through readings and participated in class discussion and activities, they were then provided with a case vignette on an ethical challenge related to the population we had just discussed. Class was then dismissed, usually about 30-45 minutes early, and they were instructed to go to the computer lab on campus and write for about 45 minutes on 1) their reactions to the case vignette (thoughts, feelings, ideas), 2) applicable standards in the NASW Code of Ethics that would be helpful in working toward resolution of the problem, and 3) reflections on how they synthesized the information from the readings, the lecture, the case vignette, and the Code of Ethics to help them become more effective and ethical students for field practicum.
4.1 Writing Assignment Structure
At the beginning of the semester, students were told that each week they should be able to complete this assignment independently of other students and that each entry should be no less than one typed page. Students were also provided with a writing assessment rubric to help them understand the content that would be assessed in this writing assignment. See Table II.

TABLE II. Reflective Writing Evaluation Descriptors

Mark (%) Comment

80–100 This assignment shows an outstanding ability to take information from the readings, lecture, class discussion, and class activities and apply it appropriately when working toward the resolution of an ethical dilemma. Your ability to identify appropriate ethical standards of practice found in the NASW Code of Ethics and apply them to a case vignette is exceptionally strong. Your reflective writing exhibits a high level of insightfulness and introspection, explaining how you will use this information (readings, lecture material, class discussion, and Code of Ethics) to enhance your professionalism in social work. Wonderful work! I am glad you are learning!

50-79 This assignment shows a strong ability to take information from the readings, lecturer, class discussion, and class activities and apply them appropriately toward the resolution of an ethical dilemma. Your ability to identify appropriate ethical standards of practice found in the NASW Code of Ethics is adequate at best. There is room for improvement if you and I work together outside of class. Your reflective writing skills exhibit a limited level of insightfulness and introspection and do not adequately explain how you will use this information (readings, lecture material, class discussion, and Code of Ethics) to enhance your professionalism in social work. I know this is not your best work! Let’s meet after this class to find out what areas we should work on.

20-49 This assignment shows a weak ability to take information from the readings, lecturer, class discussion, and class activities, and apply them appropriately toward the resolution of an ethical dilemma. Your ability to identify appropriate ethical standards of practice found in the NASW Code of Ethics is weak at best. There is room for improvement if you and I work together outside of class. Your reflective writing skills exhibit a serious deficiency in your level of insightfulness and introspection, and do not adequately explain how you will use this information (readings, lecture material, class discussion, and Code of Ethics) to enhance your professionalism in social work. A referral to the writing center has been made, and we need to schedule a meeting outside of the class to discuss these matters further.

0 – 19 This assignment shows a lack of understanding of the assignment. This assignment shows an inability to take information from the readings, lecturer, class discussion, and class activities and apply them appropriately toward the resolution of an ethical dilemma. Your ability to identify appropriate ethical standards of practice found in the NASW Code of Ethics is lacking. The writing assignment you have completed lacks substance, introspection, and insightfulness. There is no material that is relevant to the topic. The NASW Code of Ethics was not reviewed nor was it applied correctly, if at all. A referral has been made to the writing lab on your behalf. No further reflective writing assignments can be submitted until this one is revised and resubmitted. We need to schedule a meeting outside of class to discuss these matters further.

Students were provided with a sample reflective writing assignment that the instructor had developed in order to help them understand how they might set about writing the document.
4.2 Student Approach
Most students went to the computer lab directly after class to type their assignments. Students were instructed to use current APA format on the assignment, but the content, style, and approach were left to the discretion of the student. The typical assignment length of entry was about two full pages, double-spaced, and there was no obvious association between quality and length, although the assignments with more introspection were lengthier than those that provided minimal requirements for the assignment.
Each student had his or her own writing style. Some students began their entries with an integration of lecture and reading learned, while others wrote directly about the case vignette. Other students began their entries focusing on the case vignette and then drawing on lecture and reading material to work toward resolution, and then concluded with reflections on the overall experience. From the instructor perspective, reading the different student writing styles was both frustrating and refreshing, but free-style writing also encourages students to express what is most important for them in their learning experience.
Students also varied the style format, as they had varied both content and structure. The majority of assignments were written in present tense, active voice, placing the student in the here and now. Students were reminded throughout the semester that they were able to write in any style, on any content areas, and with whichever structure they felt most comfortable. Very few students deviated from their original assignment style, unless encouraged to do so by me as a result of their low performance.
4.3 Content
Students were given great freedom in their choice of what content they thought most appropriate to write about from the lecture, readings, and class discussions. Some students wrote about what they found interesting in the lecture or the readings, while others wrote more information on the ethical standards of practice. Many students wrote about their struggles to work toward resolution of the ethical problem, as they were now more aware of populations-at-risk and becoming culturally competent. Many students wrote that they felt unprepared and unqualified to apply ethical standards to problems, but this mindset quickly changed as the course progressed. Students were encouraged to write about the content areas they had the most problems with and explain why they found that content difficult to master. These entries proved insightful to the instructor in that a review of material, along with additional readings and examples, was then placed on WEBCT for further study. Students also wrote honestly about particular client populations with whom they would feel uncomfortable practicing (gays, transgenders, disabled). For example, Student A wrote, “I could never work with gays or lesbians, because I don’t believe it is a moral lifestyle.” This provided me with an opportunity to review cultural competence and values of the profession.

Students also wrote honestly about challenges with other students. For example, Student B wrote, “I don’t understand some of the things that Student ABC says in class…she definitely has a chip on her shoulder about men. She male-bashes all the time. I hope she doesn’t have to work with any men in her job or have any male clients.” Students also wrote about difficulties with stressful events they themselves had experienced pertaining to ethical decision making. Student C wrote, “About a month ago, I really needed money to fix my car, and there it was, $180 in the petty cash drawer at my office. We are supposed to use that money to buy clothes and things for the children at the shelter...but there it was...right there in front of me.” These entries also allowed me to visit the values of the profession and address these issues in the next class meeting. From this perspective, reflective writing offered an opportunity for further self-examination. Students were able to write about the event, reflect on their actions, and move past them.
4.4 Self-Reflective Writing Excerpts
The writing assignments themselves provided an in-depth explanation of: 1) approaches to writing tasks, 2) ability to assimilate course content, 3) ability to critically apply course content to ethical problem solving, and 4) reflection on the learning process. The following writing assignment excerpts provide an overview of student reactions to the course, the case vignettes, and their overall learning experience.

As this course was an open elective, and some students had no prior experience with reflective writing, some were able to grasp the concept of reflective writing more quickly than others. Social work majors and education majors were familiar with this type of writing assignment, as it is often used within their profession (client logs, journaling). Business majors, however, struggled diligently throughout the first weeks of the semester.

Students were often frustrated in the beginning, because learning how to write their thoughts and feelings down in an academic manner (meaning that there had to be clarity, conciseness, and cohesiveness to the thought process just so that it would make sense to the reader) was a learning process itself. As one student (D) suggested, “Self-reflective writing is hard work---I had to learn how to write down my thoughts so they would make sense to someone other than me.” Students explained that during class discussions, self-reflection was difficult because primarily they had to figure themselves out to begin the assignment. The most interesting assignments I read were those written by students who were working through frustration of learning who they were and who they were becoming. Their transformation was happening on paper. Student E wrote, “My next door neighbor asked me to tell her some ‘gossip’ about a client of mine at DHS. I didn’t really know what to say and so I lied and told her I didn’t know anything. Now I understand that the ethical code protects my clients, and now I can explain that. It’s like I have my profession backing me up. Now I feel like I can protect my clients.”

Students initially reacted to the weekly reflective writing assignment with both fear and excitement. Most students explained that they had kept journals in courses before, but nothing quite this structured. Many students asked for specific directions on how to set up the assignment so that the format would be correct from the very beginning of the course. Over the course of the semester, the majority of students developed their own unique writing style, usually very effectively.

Initial discomfort was voiced in a number of ways. Sometimes it reflected uncertainty about what was required—Student G, for example, wrote on his first assignment, “I am unsure exactly what I should be writing. I just know I am supposed to be focusing on my readings, class lecture, and this case vignette---and exactly how honest am I supposed to be? What if I thought the lecture was boring…do I actually write that?” Student H wrote, “I think I know what I am supposed to be doing….writing about how the lecture and the readings help me understand how to resolve the ethical problem in the case study. I think I can do this.” After the first assignments were graded and returned to the students, apprehension decreased considerably. Student I wrote, “I am now able to understand how the discussions in our class help me see the discrimination other cultures experience and how an ethical problem needs to be looked at with cultural consideration.” Student I also provided a more in-depth analysis. “Now I know what I need to be doing….taking what I read before class, apply that to the lecture, then apply all that information to understanding why the ethical dilemma is a dilemma and using the Code to help me resolve the issue. Then I am supposed to reflect back on the entire experience of this week. It actually brings everything I have learned together in my mind. I enjoy it now--it’s like a pre-study guide.”

The instructor also encouraged students at mid-term time to sit down and review all their assignments, making sure that they were learning what they felt they should be learning, reflecting on the experience of education itself, and determining if they were more comfortable with ethical challenges and methods used to resolve them. This reflection on their assignments was also to be graded. Student F recorded, in a mid-term reflection on her assignments, “Now I know that I do have knowledge and I can go to the Code to help me solve ethical problems. I think I started out not really knowing what to do, but now I feel like I’m an expert. I have learned how to take information that I have learned in this class (as well as my other social work courses) and bring it all together in my mind and see how it applies to social work!” At the end of the semester, the same student wrote, “Now I have all this information that makes more sense to me in my mind and I feel more prepared to go into field. Before these assignments, all the classes would get mixed up in my mind. Now, I think I understand how it all fits together.”
4.5 Overall Feedback from Students
Completing this type of weekly assignment was a new experience for the majority of students in this course. Many explained at the end of the course that the overall experience was painful but productive. Typical student responses that were written on end-of-the year evaluations were: “I dreaded this type of weekly assignment because it really did entail me preparing for class and paying attention” (Student J). Student K wrote, “I think this is a good thing to do in the class because it really made me read and then think about how to apply everything I was learning. It did take a lot of time, though, a lot more than 45 minutes reading the book. It’s a lot of work but in the end it really helped me learn.” Some students had mixed reviews of the assignment structure. For example, at the end of her learning journal, Student L wrote, “This assignment allowed me to vent about the frustration of some of the lectures--especially when a construct was hard for me to grasp. It was also nice in that you then addressed student concerns in the next lecture. Most instructors don’t care. They would have just continued on with the schedule.” The majority of students documented that the assignments required a lot of work, but that their learning experience was enhanced as a result of having to keep track every week. Others reported that being dismissed from class 30-45 minutes early was really nice, so they put extra effort into completing the assignment.

The last day of class, students were asked to write an anonymous review of the course (outside of completing the end-of-the year evaluation) and to focus specifically on the learning outcomes that had been specified in the syllabus. Students documented again that the learning outcomes, according to them, had been met. Student M wrote, “When I first read through the learning outcomes, I thought I would never be able to complete those in one semester. But with the reflective writing, I was able to target which outcomes I was not working on and then focus some of my studying on those areas which would help me learn or master that outcome.” Student M also wrote, “This type of reflective writing has helped me learn not only about my class but also how to organize my thoughts a lot better.” On the end-of-the year course evaluations, most students reflected back on the assignment and gave very good feedback. See Table III.

TABLE III. Year-End Course Evaluation Student Comments.

“The reflective writing was interesting.”
“The once a week writing assignments were sometimes boring but helped me learn.”
“The writing assignment really helped me apply all the information in the course and helped
me do better on exams.”
“Writing every week on a case vignette really helped me understand the NASW Code of
Ethics.”
“The cases on ethical problems were interesting and scary---especially when I found out
these were real cases.”
“The writing assignment comments from you were really good and helped me pass the
course. I wouldn’t want to do them all over again but I learned.”
“The writing assignments took up too much time--I have 4 other classes to do work in.”
“I will use reflective writing in my other courses to help me bring all the information
together.”
“Ethics I now understand----but only because every week I had to write about them.”
“I never knew about the NASW Code but now I know it front to back.”
“If I never see that green Code of Ethics book again, I’ll be happy.”
“Now I understand about how to solve a problem from a professional standpoint, not from a value/judgment standpoint.”
“I never knew social workers had all these ethical problems to deal with--the reflective writing assignment really helped me see how social workers solve these problems.”
“The writing assignment--it was helpful but I’m glad it’s over!”


4.6 Case Vignette and Student Application Example
The following case vignette was assigned the seventh week of class, after discussing confidentiality, rights of partners, and the Tarasoff case.

You staff a support group for HIV-positive adults. During one of the group meetings, Gary Damian relates that he continues to engage in unprotected sexual relations with his wife. When challenged by a group member, he admitted that he was not being fair to his wife but that he was afraid she would leave him if she found out he was HIV-positive (Lowenberg, Dolgoff, & Harrington, 2000, p. 228).

Student I wrote in response to this vignette:
After getting through the emotion of anger on behalf of the wife, I tried to look at the situation from the perspective of the social worker, the male group member, and the wife. In the lecture we learned that as social workers we must “start where the client is” and also about the Tarasoff case. Obviously, this client needs help in working through his HIV-related issues. He is worried that if he tells his wife he has HIV, she will leave him and he will have to be alone while struggling with HIV. He has already practiced in his mind telling his wife. But in order to be an ethical social worker, I have to figure out what is more important--telling the wife about the danger of having unprotected sex with her husband who has HIV, or respecting the wishes of the client and allowing the dangerous acts of unprotected sex to continue. Personally, I would say, “Of course tell the wife,” but professionally I have an obligation to my client. The NASW Code of Ethics, (2000, p. 10), Ethical Standard, 1.07.c requires that the social worker break client confidentiality in cases of “serious, foreseeable, and imminent harm” is unpreventable to an identified person (p.10). The Code also points out in Social Workers Ethical Responsibilities to Clients, Ethical Standard 1.01, that we also have an obligation not only to our clients but to the larger society, and this obligation may supersede the loyalty owed to clients and that we should explain this obligation to our clients (NASW, 2000, p. 7). When I first read the vignette, I got mad and thought that the wife needed to know-this reaction came from emotions. The Code of Ethics then showed me that the dilemma is really not an emotional one, but one of education, obligation to see the bigger picture, and ultimately to help the client see and understand the larger picture. I think I would be able to explain to this client that 1) I understand his hesitation to tell his wife, 2) the importance of confidentiality, 3) instances when confidentiality may be broken, and 4) the assistance I could provide in helping him talk with his wife about his HIV status.

In this self-reflective journal exercise, the student obviously struggled with personal feelings and emotions versus professional obligations, a common occurrence within this course. Evidenced in this excerpt, the student was able to successfully integrate lecture material, personal reflection, the NASW Code of Ethics, and was able to provide sound resolution decisions based on this information. Many students often experience an emotional first reaction and then transition into a more professional reaction once they begin researching the case in the NASW Code of Ethics. It is obvious that this student wavers back and forth between emotion and professional, but ultimately defers to the Code, the information learned from the readings and the lecture, to help her further understand the most ethical way to critically analyze the ethical dilemma.
5. Limitations and Strengths
There are several limitations to integrating this approach. The first limitation is the deficiency in writing skills possessed by students, which leads to frustration in the journaling assignment. Instructors considering using these methods in their classrooms may experience frustration with the lack of writing skills possessed by their students. This can be a vicious cycle that detracts from the original learning objectives. One method used to circumvent this frustration is the explanation that journal entries are not graded on technical presentation but solely on critical thought and application. A second limitation is that the experience is labor intensive on the front-end, with in-depth explanations and instructions often being repeated throughout the class. Learning a new way to “learn” or a different teaching approach other than “I lecture-you listen,” may increase student insecurity, which results in requests for validation and assuredness throughout each stage of the assignment. A third limitation in integrating this approach in the classroom was the lack of empirically driven data to support the claims that SRJ is beneficial and that students became more skilled in the integration of classroom materials and readings to case vignettes. Our conclusions are based solely on excerpts from the SRJ and anonymous feedback that was provided. These excerpts indicate that the students' perceptions are that they became more skilled in the SRJ process, but no other data are used to support this claim, as this was the instructor's first endeavor in using SRJ. Further research in this area showing a correlation between test scores and SRJ would be most useful.

Strengths, however, outweigh the limitations. Students actively participate in these processes and report that they have a more thorough understanding of ethical application at the conclusion of the assignment than they have from any other assignment. End-of-semester student evaluations are also consistently positive, with students reporting that these exercises helped them appreciate the struggles that social workers often encounter on a daily basis.
6. Conclusion
According to Reamer (2001), most social work students receive a basic introduction to ethical issues. Improving the classroom environment by providing a more competent and comprehensive approach to ethical decision making is pivotal to social work education, with both CSWE and NASW charging academia to integrate ethics throughout the curriculum. Educators have many models of ethical decision making from which to choose (Congress, 1998; Joseph, 1985; Lowenberg & Dolgoff, 1996; Mattison, 2000; Reamer, 1993). Building on this professional mandate as well as existing models, the authors integrated SRJ in an attempt to stimulate student learning.

The use of SRJ in Social Work with At-Risk Populations was beneficial, and the instructor will continue to use this approach in future courses. The case vignettes may be modified, as ethical dilemmas continue to change and evolve over time. The instructor hopes to use more WEBCT and interactive on-line activities to stimulate student competency with computer applications, and plans to form writing groups, so students can help each other with critical thought and applications through reflective writing, hopefully also increasing the cohesiveness of the students. The instructor also tried to have social work guest speakers visit the class to discuss ethical problems within their agencies, but, as this class meets during normal working hours (at 4:00 p.m.), has been unsuccessful with this venture. Providing students with exposure to an actual practitioner early on in the course could help them become more involved in the reflective writing process. Also, by providing a real-world practitioner to the class, students would receive firsthand knowledge of current ethical challenges within the profession. A guest speaker would also provide a different point of reference for the students and an opportunity to discover different approaches practitioners take in resolving ethical problems. This teaching methodology worked well for this instructor, and the course evaluations are positive. The most rewarding aspect of this approach is that students document that they actually learn throughout the course, enjoy the experience, and, for some, will continue to use this approach in other courses.

The information collected from this one-semester course in the form of this case study does show support for the integration of self-reflective writing in the ethics curriculum. The excerpts indicate that 1) students actively engaged in the learning process, 2) students became more skilled in the integration of classroom materials and readings to case vignettes, and 3) students were able to effectively synthesize the information through reflective writing. Students reported that, overall, the reflective writing assignments were enjoyable. It is important to note, however, that a few students did not find the assignment enjoyable. These students were also passive throughout the course, refusing to take notes during lecture presentation, showing up late for class, and handing in assignments past the due date.

This approach encouraged students to actively engage in the learning process and take responsibility for their classroom experience. From an instructor perspective, this approach to the teaching of ethics and moral philosophy provides valuable feedback on student learning methods, study habits, integration of material, critical thought, and application. According to students, this assignment also improved writing skills. The challenge for the instructor, however, is the time it takes to read and provide feedback on these assignments. For an instructor considering integrating this type of assignment, the time evaluating and responding to the weekly assignments must be considered.

The intent of this article is not to criticize any one teaching method used in social work to enhance student interest in a topic area, but to provide an example of innovative approaches that have proven successful with undergraduate students in a rural two-year program. It is hoped that this article will motivate academicians to identify creative teaching techniques that will enhance the learning experience for social work students.
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NASW Standards for Social Work Practice in Palliative and End of Life Care

NASW Standards for Social Work Practice in Palliative and End of Life Care

©2011 National Association of Social Workers. All Rights Reserved.

Gary Bailey, MSW
NASW President (2003-2004)


Palliative and End of Life Care Expert Steering Committee

* Susan Blacker, BSW, MSW, RSW, Volunteer Leader
* Iraida V. Carrion, LCSW
* Yvette Colón, ACSW, BCD
* Pamela M. Jackson, MEd
* Stuart Kaufer, CSW, ACSW
* Patricia O' Donnell, DSW, LICSW, CCM
* Mary Raymer, ACSW
* Sherri Roff, CSW, PhD Candidate
* Elizabeth Smart, MA
* Sharon Hines Smith, PhD, QCSW, MSW
* Mila Ruiz Tecala, ACSW, DCSW, LICSW
* Katherine Walsh-Burke, DSW

NASW Staff:

* Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director
* Toby Weismiller, ACSW
* Tracy Whitaker, ACSW
* Karyn Walsh, ACSW, LCSW

Contents

* Introduction
* Definitions
* Background
* Guiding Principles
* Standards for Professional Practice
* Standards for Professional Preparation and Development
* References
* Resources
* Acknowledgements

NASW Standards for Social Work Practice in Palliative and End of Life Care
Introduction

All social workers, regardless of practice settings, will inevitably work with clients facing acute or long-term situations involving life-limiting illness, dying, death, grief, and bereavement. Using their expertise in working with populations from varying cultures, ages, socioeconomic status, and nontraditional families, social workers help families across the life span in coping with trauma, suicide, and death, and must be prepared to assess such needs and intervene appropriately.

Social work practice settings addressing palliative and end of life care include health and mental health agencies, hospitals, hospices, home care, nursing homes, day care and senior centers, schools, courts, child welfare and family service agencies, correctional systems, agencies serving immigrants and refugees, substance abuse programs, and employee assistance programs. Thus, social work is a broadly based profession that can meet the needs of individuals and families affected by life-limiting illness and end of life issues.

Social workers are challenged to provide expertise and skill in direct services to clients and their families. At the same time, they have the opportunity to influence a range of professionals, consumers, and laypersons regarding life-limiting illness, care of the dying, and the bereaved. The need for social workers trained and skilled in working with palliative and end of life care situations has increased, because of advancements in medical technology, rising rates of chronic illness, increasing number of elderly people, and longer life spans.

Palliative and end of life care is a growing area of practice, and social workers may feel unprepared to deal with the complex issues it encompasses (Csikai & Raymer 2003; Christ & Sormanti, 1999). These standards are designed to enhance social workers' awareness of the skills, knowledge, values, methods, and sensitivities needed to work effectively with clients, families, health care providers, and the community when working in end of life situations.
Definitions
1. End of Life Care

End of Life Care refers to multidimensional assessment and interventions provided to assist individuals and their families as they approach end of life. Whether sudden or expected, the end of a person’s life is a unique experience that has a great impact on the person, his or her family system, and the family legacy.

End of life decisions encompass a broad range of medical and psychosocial determinations that each individual may make before the end of his or her life. No person has to make decisions; one can delegate, with or without an advance directive, depending on one’s capacity to do so. Individuals may address such decisions through advance planning, or in emergencies, when careful consideration is not possible, they may leave the difficult decisions to be made by family members and friends who may be ill prepared to decide what their loved ones might have wanted. Such decisions can include where one plans to spend the final months before death and the degree of self-sufficiency one wishes at that time. The use of personal, family, and societal resources to attain these decisions may change, depending on the course of a particular illness, and are among some of the most important decisions individuals and family members may face.

Health care and end of life decision making crosses ethical, religious, cultural, emotional, legal, and policy areas. The complexity of issues includes aspects such as weighing risk and benefit; allocation of individual, family, and societal resources; and the recognition of changing goals of care. It concerns individuals’ deepest and most dearly held fears, values, and beliefs. Palliative and end of life issues are often delicate and controversial and require skilled, insightful interdisciplinary care.

There is increasing agreement that attending to needs along the continuum of illness, coming to terms with end of life issues, making informed decisions and ensuring society honors them, are vital life tasks. It is with just such a constellation of responsibilities that social work’s values and skills can make a significant contribution
(Kaplan, 1995).
2. Palliative Care

Palliative care is an approach that improves quality of life for patients and their families facing the problems associated with life-limiting illness. This is accomplished through the prevention and relief of suffering by means of early identification and comprehensive assessment and treatment of pain and other physical, psychosocial, and spiritual problems. Palliative care:

* provides relief from pain and other distressing symptoms;
* affirms life and regards dying as a normal process;
* intends neither to hasten nor to postpone death;
* integrates the psychological and spiritual aspects of patient care;
* offers a support system to help patients live as actively as possible until death;
* offers a support system to help the family cope during the patient's illness and in their own bereavement;
* uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;
* enhances quality of life and may also positively influence the course of illness; and
* is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications (World Health Organization, 2003).

3. Hospice and Palliative Care

Considered the model for quality, compassionate care for people facing life-limiting illnesses or injuries, hospice and palliative care involve a team-oriented approach to expert medical care, aggressive pain and symptom management, and emotional and spiritual support expressly tailored to the patient's needs and wishes. Support is also provided to the patient's loved ones. At the center of hospice and palliative care is the belief that each of us has the right to live and die free of pain, with dignity, and that our families should receive the necessary support to allow us to do so.

Hospice focuses on caring, not curing and, in most cases, care is provided in the patient's home. Care also is provided in freestanding hospice centers, hospitals, and nursing homes, and other long-term care facilities. Services are available to patients of any age, religion, race, or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations.

Palliative care extends the principles of hospice care to a broader population that could benefit from receiving this type of care earlier in their illness or disease process. No specific therapy is excluded from consideration. An individual's needs are continually assessed, and treatment options should be explored and evaluated in the context of the individual's values, symptoms, and changing goals. Palliative care may segue into hospice care if the illness progresses (National Hospice and Palliative Care Organization, 2003).

NASW endorses the Last Acts Precepts for Palliative Care. (The precepts can be obtained from http://www.lastacts.org)
4. Bereavement

Bereavement has been defined by several experts as the objective situation of a person who has experienced the loss of a significant person or other attachment figure.
5. Grief

Grief is a reaction to loss, and, for each person who has sustained a loss, is an individual experience. Certain losses affect entire group systems such as families, communities, cultures, and countries. Grief affects people from every standpoint, including physical, emotional, behavioral, cognitive, and spiritual.
Background

During the past decade, consumer advocacy groups, health professional organizations, and government agencies have paid increased attention to the quality and accessibility of care along the continuum of illness and at the end of life. As a result, health care professions are focused on their own ability to train members of their respective disciplines and to contribute to the building of a knowledge base for excellence in care. Social work is no exception.

A 2002 Social Work Leadership Summit on End of Life and Palliative Care addressed the need for a formalized collaborative effort in the social work profession that focuses on palliative and end of life care. During this meeting, participants designed an agenda for the profession to improve care and to elevate social work's role and contributions in this arena (Project on Death in America , 2002).

Building on this foundation, the National Association of Social Workers (NASW) has developed Standards for Social Work Practice in Palliative and End of Life Care, a useful practice tool for social workers. The standards reflect core elements of social work functions in palliative and end of life care and professional social work practice, and are targeted toward social workers practicing in various settings dealing with these issues. For many practicing social workers in palliative and end of life care, these standards reinforce current practices. For others, they provide an objective to achieve and guidelines to assist in practice.
Guiding Principles

Social workers have unique, in-depth knowledge of and expertise in working with ethnic, cultural, and economic diversity; family and support networks; multidimensional symptom management; bereavement; trauma and disaster relief; interdisciplinary practice; interventions across the life cycle; and systems interventions that address the fragmentation, gaps, and insufficiency in health care. These are critical areas for implementing change in palliative and end of life care.

Social workers also have expertise in analyzing, influencing, and implementing policy change and development at local, state, and federal levels that can be used to make important improvements in the care of patients living with life-limiting illness and the dying. Social work research in the care of the dying is also developing and addressing many previously overlooked areas of end of life care, such as issues concerning ethnic, cultural, and economic diversity, substance abuse, incarceration, interventions at different life cycle stages, problem-solving interventions, and intervention in community contexts.

Social workers are concerned with enhancing quality of life and promoting well-being for individuals, families (defined broadly), and caregivers. When confronting issues related to palliative and end of life care, social workers have a multidimensional role as clinicians, educators, researchers, advocates, and community leaders. When confronting ethical dilemmas in palliative and end of life care, social workers can draw on the principle of client self-determination in matters where clients or their proxies are faced with such issues (National Association of Social Workers, 2003).

The scope of social work in palliative and end of life care extends across many practice settings and populations, and requires intervention at the individual, family, group, community, and organizational levels. The standards may be regarded as a basic tool for social work practice in palliative and end of life care, although practice priorities may vary among settings.
STANDARDS
Standards for Professional Practice
Standard 1. Ethics and Values

The values, ethics, and standards of both the profession and contemporary bioethics shall guide social workers practicing in palliative and end of life care. The NASW Code of Ethics (NASW, 2000) is one of several essential guides to ethical decision making and practice.

Interpretation:

Social workers who practice in palliative and end of life care must be prepared for challenges that encompass evaluation of ethical dilemmas and value conflicts and consider questions related to religion, spirituality, and the meaning of life. To be an effective practitioner in this area, specialized training in palliative and end of life care is preferred.

The minimal knowledge base needed for work in this practice area includes an understanding of the following basic ethical principles:

* Justice: the duty to treat all fairly, distributing the risks and benefits equally
* Beneficence: the duty to do good, both for individuals and for all
* Nonmaleficence : the duty to cause no harm, both for individuals and for all
* Understanding/Tolerance: the duty to understand and to accept other viewpoints, if reason dictates that doing so is warranted
* Publicity: the duty to take actions based on ethical standards that must be known and recognized by all that are involved
* Respect for the person: the duty to honor others, their rights, and their responsibilities, as showing respect for others implies that we do not treat them as a mere means to our end
* Universality : the duty to take actions that hold for everyone, regardless of time, place, or people involved
* Veracity : the duty to tell the truth
* Autonomy: the duty to maximize the individual's right to make his or her own decisions
* Confidentiality: the duty to respect privacy of information and action
* Equality: the duty to view all people as moral equals
* Finality: the duty to take action that may override the demands of law, religion, and social customs

In addition, the social workers working in palliative and end of life care are expected to be familiar with the common and complex bioethical considerations and legal issues such as the right to refuse treatment; proxy decision-making; withdrawal or withholding of treatment, including termination of ventilator support and withdrawal of fluids and nutrition; and physician aid in dying. End of life issues are recognized as controversial, because they reflect the varied value systems of different groups. Consequently, NASW does not take a position concerning the morality of end of life decisions, but affirms the right of the individual to determine the level of his or her care. Particular consideration should be given to special populations, such as people with mental illness, with developmental disability, individuals whose capacity or competence is questioned, children, and other groups who are vulnerable to coercion or who lack decisional capacity.
Standard 2. Knowledge

Social workers in palliative and end of life care shall demonstrate a working knowledge of the theoretical and biopsychosocial factors essential to effectively practice with clients and professionals.

Interpretation:

The social worker possesses knowledge about navigating the medical and social systems that frequently present barriers to clients. Social workers have expertise in communication, both within families and between clients/families and health care or interdisciplinary teams. Drawing on knowledge of family systems and interpersonal dynamics, the social worker is able to examine the family's experience in a unique way, to conduct a comprehensive assessment, and to assist the team to integrate biopsychosocial, spiritual factors into their deliberations, planning, and interactions.

Social work's view includes an appreciation of the socioeconomic, cultural, and spiritual dimensions of the family's life. As experts in helping individuals and families maximize coping in crisis ¾ and at addressing the psychosocial domains of symptoms, suffering, grief, and loss ¾ social workers are able to provide intensive counseling as well as practical services for those confronted by life-limiting illnesses and assist with complex problems.

Essential areas of knowledge and understanding about palliative and end of life care include:

* the multifaceted roles and functions of social worker clinicians
* the physical and multidimensional stages of the dying process
* the physical, psychological, and spiritual manifestations of pain
* the range of psychosocial interventions that can alleviate discomfort
* the biopsychosocial needs of clients and their family members;
* the impact of ethnic, religious, and cultural differences
* illness-related issues such as decision making, relationship with health care providers, dying and death
* the range of settings for palliative and end of life care, including home care, nursing homes, and hospice settings
* the available community resources and how to gain access to them
* the impact of financial resources on family decision making along the continuum of illness and at the end of life
* the development, use, support, and revision of advance directives throughout the progression of the illness
* disparities across cultures in gaining access to palliative and end of life care
* the accreditation and regulatory standards governing settings providing palliative and end of life care
* the needs faced by members of special populations and their families, such as children; those with physical, developmental, mental, or emotional disabilities; and those in institutionalized settings such as nursing homes and nonmedical settings such as correctional facilities.

Standard 3. Assessment

Social workers shall assess clients and include comprehensive information to develop interventions and treatment planning.

Interpretation:

Assessment is the foundation of practice. Social workers plan interventions with their clients based on assessments and must be prepared to constantly reassess and revise treatment plans in response to newly identified needs and altered goals of care. Comprehensive and culturally competent social work assessment in the context of palliative and end of life care includes considering relevant biopsychosocial factors and the needs of the individual client and the family (as defined by the client).

Areas for consideration in the comprehensive assessment include:

* relevant past and current health situation (including the impact of problems such as pain, depression, anxiety, delirium, decreased mobility)
* family structure and roles
* patterns/style of communication and decision making in the family
* stage in the life cycle, relevant developmental issues
* spirituality/faith
* cultural values and beliefs
* client's/family's language preference and available translation services
* client's/family's goals in palliative and end of life treatment
* social supports, including support systems, informal and formal caregivers involved, resources available, and barriers to access
* past experience with illness, disability, death, and loss
* mental health functioning including history, coping style, crisis management skills
* and risk of suicide/homocide
* unique needs and issues relevant to special populations such as refugees and immigrants, children, individuals with severe and persistent mental illness, and homeless people communicating the client's/family's psychosocial needs to the interdisciplinary team.

Standard 4. Intervention/Treatment Planning

Social workers shall incorporate assessments in developing and implementing intervention plans that enhance the clients' abilities and decisions in palliative and end of life care.

Interpretation:

Social workers in all practice areas use various theoretical perspectives and skills in delivering interventions and developing treatment plans. I nitial assessments and team input inform and guide plans of care. Social workers must be able to adapt techniques to work effectively with individuals from different age groups, ethnicities, cultures, religions, socioeconomic and educational backgrounds, lifestyles, and differing states of mental health and disability, and in diverse nonmedical care settings.

Essential skills for effective palliative and end of life care include:

* the ability to recognize signs and symptoms of impending death and prepare family members in a manner that is guided by clinical assessment
* competence in facilitating communication among clients, family members, and members of the care team
* competence in integrating grief theories into practice
* competence in determining appropriate interventions based on the assessment
* competence in advocating for clients, family members, and caregivers for needed services, including pain management
* competence in navigating a complex network of resources and making appropriate linkages for clients and family members
* competence in supporting clients, families, and caregivers including anticipatory mourning, grief, bereavement, and follow-up services.

Interventions commonly provided in palliative and end of life care include:

* individual counseling and psychotherapy (including addressing the cognitive behavioral interventions)
* family counseling
* family-team conferencing
* crisis counseling
* information and education
* multidimensional interventions regarding symptom management
* support groups, bereavement groups
* case management and discharge planning
* decision making and the implications of various treatment alternatives
* resource counseling (including caregiving resources; alternate level of care options such as long term care or hospice care; financial and legal needs; advance directives; and permanency planning for dependants)
* client advocacy/navigation of systems.

Standard 5. Attitude/Self-Awareness

Social workers in palliative and end of life care shall demonstrate an attitude of compassion and sensitivity to clients, respecting clients' rights to self-determination and dignity. Social workers shall be aware of their own beliefs, values, and feelings and how their personal self may influence their practice.

Interpretation:

To practice effectively, social workers in palliative and end of life care must demonstrate empathy and sensitivity in responding to the pain, suffering, and distress of others. Specific social work attitudes and responses that encompass compassion and sensitivity in caring for clients shall include, but not necessarily be limited to, the following:

* flexibility and adaptability on a daily basis, to be able to confront human suffering
* consistent individualization of client/client system needs as the primary care unit
* facilitative interactions with clients/client systems
* ability to communicate and work collaboratively as an interdisciplinary team member to achieve care goals
* willingness to advocate for holding the focus in palliative and end of life care on client/client system choices, preferences, values, and beliefs
* awareness of compassion fatigue and the ethical responsibility to mitigate this condition
* confidence and competence in professional identify and in empowering the profession in its vital role in palliative and end of life care.

Standard 6. Empowerment and Advocacy

The social worker shall advocate for the needs, decisions, and rights of clients in palliative and end of life care. The social worker shall engage in social and political action that seeks to ensure that people have equal access to resources to meet their biopsychosocial needs in palliative and end of life care.

Interpretation:

In advocacy efforts, social work provides unique and essential skills and perspectives such as a rich understanding of the person-in-environment, communication skills, expertise in group process and systems, a social justice commitment, a strong background in values and ethics, and a broad psychosocial and spiritual knowledge base. Among the crucial components of effective empowerment and advocacy are identifying and defining needs from the client's perspective, including cultural and spiritual beliefs, and communicating the concerns and needs of the client to decision makers and providers of care. Advocacy and empowerment come into practice at both the micro and macro level.

Practice examples include linking clients with resources, identifying and supporting the family of choice, assisting individuals and families negotiate their goals of care, navigating through systems of care, monitoring pain and symptom management, addressing quality-of life issues, team conferencing, consulting, and providing caregiver support. Broader examples of advocacy include advocacy with special populations, institutions, and communities, as well as the health care policy arenas where efforts need to integrate cultural and ethnic variation. It is essential to identify barriers to effective palliative and end of life care at the macro level by addressing issues of financial inequities, lack of culturally competent services, and other access issues and to address those barriers so that individuals experience the highest quality of life possible to the end of life.
Standard 7. Documentation

Social workers shall document all practice with clients in either the client record or in the medical chart. These may be written or electronic records.

Interpretation:

Ongoing documentation of social work service should reflect the assessment, issues addressed, treatment offered, and plan of care, and must assure continuity of care between all settings (for example, hospital to hospice, nursing home to hospital).

The transfer of medical records must be conducted in compliance with current federal and state law with an emphasis on confidentiality/privacy of medical information. Compliance with agency policy, particularly regarding the transfer of electronic records, is essential.
Standard 8. Interdisciplinary Teamwork

Social workers should be part of an interdisciplinary effort for the comprehensive delivery of palliative and end of life services. Social workers shall strive to collaborate with team members and advocate for clients' needs with objectivity and respect to reinforce relationships with providers who have cared for the patient along the continuum of illness.

Interpretation:

Interdisciplinary teamwork is an essential component in palliative and end of life care. Social workers are integral members of a health care team. Social workers should advocate for the views and needs of individuals and families in palliative and end of life care within the team, and should encourage and assist clients in communicating with team members. Often, clients, families, and team members rely on the expertise of the social worker in problem solving concerns and conflict resolution.

Teamwork requires collaboration, and an ability to empower and advocate when necessary. The psychosocial expertise of the social worker assists the interdisciplinary team to enhance understanding, form interventions and decisions, and formulate treatment plans. In addition, the social worker identifies resources, provides counseling, support services, and practical interventions.
Standard 9. Cultural Competence

Social workers shall have, and shall continue to develop, specialized knowledge and understanding about history, traditions, values, and family systems as they relate to palliative and end of life care within different groups. Social workers shall be knowledgeable about, and act in accordance with, the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001).

Interpretation:

Social workers respect and integrate knowledge about how individuals and families are influenced by their ethnicity, culture, values, religion- and health-related beliefs, and economic situations. Social workers should understand systems of oppression and how these systems affect client access to, and utilization of, palliative and end of life care. Many cultures maintain their own values and traditions in the areas of palliative and end of life care.

Culture influences individuals' and families' experience as well as the experience of the practitioner and institution. Social workers should consider culture in practice settings involving palliative and end of life care. Each cultural group has its own views about palliative and end of life practices and these need to be understood as they affect individuals' response to dying, death, illness, loss, and pain.

Social workers who understand how culture affects the illness and end of life experience of an individual and family will be better able to individualize care and intervene in the psychosocial impact of illness, pain, dying, and death. Therefore, social workers should be familiar with the practices and beliefs of the cultural groups with whom they practice to deliver culturally sensitive services.
Standards for Professional Preparation and Development
Standard 10. Continuing Education

Social workers shall assume personal responsibility for their continued professional development in accordance with the NASW Standards for Continuing Professional Education (NASW, 2002) and state requirements.

Interpretation:

Social workers must continue to grow in their knowledge of theories and practices in palliative and end of life care to effectively work with individuals and families. Palliative and end of life care is a rapidly expanding and changing field, which crosses all practice settings. In addition to clinical competence, social workers need to enhance their skills and understanding by keeping abreast of research, so their practice reflects the most current knowledge.

Numerous opportunities in professional development are available through NASW and other professional organizations, institutions, coalitions, and service agencies at local, state, and national levels. Social workers should participate in and contribute to professional conferences and training activities on a regular and consistent basis to provide the highest possible level of care. Social workers should also assist in identifying palliative and end of life professional development needs by participating in research and encouraging organizations and institutions to collaborate, advocate, and provide appropriate education for the field.
Standard 11. Supervision, Leadership, and Training

Social workers with expertise in palliative and end of life care should lead educational, supervisory, administrative, and research efforts with individuals, groups, and organizations.

Interpretation:

Social workers shall offer their expertise to individuals, groups, and organizations as well as offering training and mentoring opportunities to beginning social workers or those transitioning into palliative and end of life care. When able, skilled social workers shall work in conjunction with schools of social work to advocate for programs in palliative and end of life care and enhance and encourage interest in this specialization.

Social workers shall offer supervision to practicing social workers, interns, and students to provide a guiding expertise to clinicians in this area. Social workers shall contribute to research initiatives not only to demonstrate the efficacy of the social work profession and social work interventions, but also to advance the recognition among colleagues in other professions of the essential need to address psychosocial needs of individuals and their families.
References


Christ, G., & Sormanti, M. (1999). Advancing social work practice in end-of- life care. Social Work in Health Care, 30 (2) , 81- 99.


Csikai, E. L., & Raymer, M. (2003). The Social Work End of Life Care Education Project: An assessment of educational needs. Insights. Retrieved October 6, 2003 , from http://www.nhpco.org/files/public/InsightsIssue2_2003Social_Worker_pp8-9.pdf .
Field, M. J., & Behrman, R. E. (Eds.). (2002). When children die: Improving palliative and end of life care for children and their families . Washington , DC : National Academy of Sciences, Institute of Medicine , Committee on Palliative and End of Life Care for Children.

Field, M. J., & Cassel , C. K. (Eds.). (1997). Approaching death: Improving care at the end of life. Washington , DC : National Academy of Sciences , Institute of Medicine .

Kaplan, K. O. (1995). End of Life decisions. In R. L. Edwards (Ed.-in-Chief), Encyclopedia of social work (19th ed., Vol. 1, pp. 856–868). Washington , DC : NASW Press.

National Association of Social Workers. (2003). Client self-determination in end of life decisions. Social work speaks: National Association of Social Workers policy statements, 2003 – 2006 (6 th ed., pp. 46 – 49). Washington , DC : NASW Press.

National Association of Social Workers. (1999). NASW code of ethics . Washington , DC : NASW Press.

National Association of Social Workers. (2000). Code of ethics of the National Association of Social Workers. Washington , DC : Author.
National Association of Social Workers. (2001). NASW standards for cultural competence in social work practice. Washington , DC : NASW Press.

National Hospice and Palliative Care Organization. (2001). Competency-based education for social workers . Arlington, VA: Author .

National Hospice and Palliative Care Organization. (2003). Hospice and palliative care . Retrieved September 3, 2003 , from http://www.nhpco.org/i4a/pages/index.cfm?pageid=3281 .
Project on Death in America . (2002). Social Work Summit on End of Life and Palliative Care. (Press release). Retrieved from http://www.swlda.org/Summit.htm on October 6, 2003 .

Project on Death in America . (2002). Social Work Summit on End of Life and Palliative Care. (Press release). Retrieved October 6, 2003 , from http://www.swlda.org/Summit.htm .

World Health Organization. (2003). WHO definition of palliative care . Retrieved September 23, 2003 , from http://www.who.int/cancer/palliative/definition/en/ .

Resources

NASW has developed several policy statements, which are published in Social Work Speaks: National Association of Social Workers Policy Statements, 2003 – 2006 (6th ed.), related to palliative and end of life care. These statements are listed below:

* Client Self-Determination in End of Life Decisions
* Health Care
* Hospice Care
* Long-Term Care
* Managed Care

Acknowledgements

NASW would like to acknowledge the work of the following individuals for their contributions to the "Social Work Scope of Practice and Competencies Essential to Palliative Care, End of Life Care and Grief Work" (as yet unpublished), as part of the National Social Work Leadership Summit on Palliative and End of Life Care, in conjunction with the Last Acts Provider Education Committee, the Duke Institute on Care at the End of Life, and the Soros Foundation's Project on Death in America: Lisa P. Gwyther, Terry Altilio, Susan Blacker, Grace Christ, Ellen Csikai, Nancy Hooyman, Betty Kramer, Julie M. Linton, Mary Raymer, and Judy Howe.

The work of the aforementioned authors provided the foundation of the NASW Standards for Practice for Social Workers in Palliative and End of life Care.

NASW would also like to acknowledge and thank Project on Death in America for the grant to fund the development of practice standards for social workers in palliative and end of life care.