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by Vickie Leff (@VickieLeff)

Another year, another study proving the value of the palliative care social worker. Edmonds et al (2021) found that when a social worker was involved in a palliative care consultation, whole-person care components were more likely to be addressed, including addressing psychological (82% vs 18%) and spiritual needs (92% vs 8%) and documenting advance directives (90% vs 10%). This adds to what we already knew: involvement of social work impacts quality of care and patient satisfaction (Auerbach, 2007; O’Donnell et al., 2018).

It surprises me that despite much research and team role development, palliative care team members may not be aware of the importance of the palliative care social worker. And yet, as a Hospice Social Worker, in the year of the pandemic, I was considered non-essential. I was not the only one. Around the country, I heard stories of many palliative care and hospice social workers being sent home. Unfortunately, many articles had to be written this year arguing that the social worker is essential (Guerrero 2020; Lipe 2020; Abrams 2020; Gewirtz 2020). Still, so many of us continue to be asked: What does a palliative care social worker do?

If what you know about social workers comes from TV you would think we primarily work for child protective services. If all you know of us is what you see in your ambulatory clinic you might think a social worker is only helpful for ordering a patient oxygen or a rolling walker. These misconceptions are common. After all, the profession of Social Work is represented in many different fields of practice. Our educational training varies and there are many levels and degrees one can have to be called a social worker.

There is a wide range of variation for social work practice in the healthcare setting. Hospitals have social workers as case managers doing discharge planning; some are employed as behavioral health specialists, substance use experts and counselors, and population health managers; some clinical social workers are on Palliative Care teams providing extensive psychosocial care; and some are cognitive behavioral therapy experts in the outpatient setting. Quite a wide gamut. This broad range of practice is both a strength and a challenge for the social work profession because it can make it difficult for others to understand our value.

As March is social work month, let’s spend some time reflecting on the value of social work within the palliative care team. So here is what we do…. (this is not all inclusive!)

Broadly, we provide psychosocial care to patients and families. We are mental health providers who are trained to facilitate family meetings, manage family dynamics, and assess and treat anxiety and depression. We provide counseling to patients, children, and families. We assess for pain, spiritual needs, and advocate for a clear plan of care. We have advance care planning conversations and help to locate resources for patients and families.

We have an expert understanding of the social determinates of health and engage in cultural curiosity, often helping reframe concerns for our team members. For instance, we interpret medical information for the patient and family (think of your patients asking, “What did they just say?”). We coach surgeons prior to a “difficult” conversation, sharing our insight about family dynamics, use of language, and culture to guide them. We listen to the moral distress from bedside nurses in ICU units, offering strategies for well-being. We are often the team member who takes responsibility for team wellness and reflection, helping our colleagues identify their own reactions to difficult cases.

Palliative care social work has come a long way. Like our physician and nursing colleagues, we now have our own evidence-based certification: the APHSW-C. We have a national organization of 1,000 members – the Social Work Hospice and Palliative Network (SWHPN) and over 10 social work fellowships across the country, to train post-masters social workers in specialty level palliative care.

All palliative care team members listen with their own attention, intention, and biases. That is surely the beauty of working as a team, learning and depending on each other to provide the best care. As Rosa, et.al. suggests, we have an opportunity, right now, to become transdisciplinary teams “co-creating a unified framework for delivering palliative care that transcends disciplinary perspectives.” (Rosa et.al., 2020) This transcendent palliative care team requires that we all commit to having a shared understanding of each other’s value. While social work may be a large umbrella, our role in serious illness care is clear and rooted in data. Please stand with us and use your voice to tell others about our value: We are crucial members of the palliative care team and we are essential.

For more Pallimed posts by Vickie Leff, click here.

For more Pallimed posts about social workers, click here.

Vickie Leff, LCSW, APHSW-C is the Executive Director of the Advanced Palliative & Hospice Social Work Certification Program; she is also an Adjunct Instructor at the UNC School of Social Work, Chapel Hill. She still thinks that running a 6 hour marathon is actually a really good finish time.



References

Abrams, L. S., & Dettlaff, A. J. (2020). Voices from the Frontlines: Social Workers Confront the COVID-19 Pandemic. Social work, 65(3), 302–305. https://doi.org/10.1093/sw/swaa030

Auerbach, C. (2007). Evidence that Supports the Value of Social Work in Hospitals. Social Work in Health Care, 44(4), 17–32. https://doi.org/https://doi.org/10.1300/J010v44n04_02

Edmonds, K. et al (2021). An Exploratory Study of Demographics and outcomes for Patients Seen by Specialist Palliative Care Social Work in the Inpatient Setting at an Academic Center. Journal of Pain and Symptom Management.

Gewirtz, R. (2020) As I See It: Social Workers are Essential personnel; So, why aren’t we talking about them? Retrieved from: https://www.telegram.com/news/20200330/as-i-see-it-social-workers-essential-personnel-so-why-arent-we-talking-about-them

Guerrero, L., Avgar, A., Phillips, E., Sterling, M. (2020). They are Essential Workers now, and should continue to be: Social Workers and Home Health Care workers during COVID-19 and Beyond. Journal of Gerontological Social Work. http://doi.org/10/1080/01634372.2020.1779162

Lipe, L. (2020) Social Workers are Essential Workers. Retrieved from: https://www.socialworker.com/feature-articles/practice/social-workers-essential-workers/

O’Donnell, A. E., Schaefer, K. G., Stevenson, L. W., DeVoe, K., Walsh, K., Mehra, M. R., & Desai, A. S. (2018). Social Worker-Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial. JAMA Cardiology, 3(6), 516–519. https://doi.org/10.1001/jamacardio.2018.0589

Rosa, W. et al (2020) Coronavirus Disease 2019 as an Opportunity to Move toward Transdisciplinary Palliative Care. Journal of Palliative Medicine, 23(10), pp. 1290–1291.http://doi.org/10.1089/jpm.2020.0306

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by Vickie Leff (@VickieLeff)

As a clinical social worker, I am often approached by my medical colleagues asking for support and a listening ear around difficult cases, understanding their own reactions, team dysfunction, and moral distress. In the middle of this COVID pandemic, Social Workers, Chaplains, Nurses, Physicians, Respiratory Therapists, Child Life Specialists, etc. are all likely experiencing an increase in moral distress. This is due to the necessary change of focus from “patient-centered” to “community -based” approach, and resource allocation issues such as PPE shortage, health inequities, visitation limitations.

A few years ago I wrote another article about Moral Distress. Things have changed since then, compounded by the pandemic. I would like to take a moment to focus on how we can manage these complicated, emotionally charged situations during this incredibly stressful time in which we are challenged about ability, time, strategies to deal with moral distress. Moral Distress challenges clinicians to speak out, work together, and tolerate ambivalence. We must embrace the discomfort in order to legitimize the occurrence and find solutions, especially during this pandemic, when the focus of providers can be easily pulled in many directions. 

“You have to do everything to keep her breathing,” the father of a 15 year old dying of a brain hemorrhage, said to me as the Palliative Care Social Worker. Hearing the panic and desperation in his voice while knowing she would not survive was distressing. Relaying the conversation to the bedside nurse and Resident amplified the distress, as they said what I was thinking: “There is no way she will survive, we have to take her off life support.” Calming myself to be able to have a discussion about the ethics of the situation was challenging, but critical. I worried about whether advocating on behalf of the father would be interpreted as, “the social worker doesn’t get it,” and wondered if they would respect my opinion.

How can we help each other when faced with cases that cause us moral distress? What can our institutions do in response? How can we work as a team to deal with these issues when they arise?

We can remind ourselves that “When addressing moral distress, the aim is not to eradicate the phenomenon but rather to mitigate its negative effects, including preventing caregivers from feeling unable to provide compassionate patient-centered care, feeling withdrawn, unable to return to work or continue in their profession.”

Evidence tells us there are many strategies that can help on the individual, team, and organizational level. It will take deliberate intention, institutional support, and commitment.

Individual Strategies:

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by Vickie Leff (@VickieLeff) and Allie Shukraft (@Alifrumcally)

It has been an amazing year for those of us who are palliative care social workers. The 4th edition of National Palliative Care Guidelines, published this fall, adding several psychosocial focused domains to the list of best care practices.¹ Many of the 8 domains specifically highlight the expert skill set of social workers on the interdisciplinary team. Palliative care social workers were delighted to see these highlighted in the guidelines. Palliative Care teams work best when they allow members to practice to the top of their license. Although there is often overlap, especially in the arena of psychosocial care, social workers are usually the backbone of providing these services.

We saw the FIRST advanced practice, evidence-based certification for palliative care & hospice social workers open for testing in January 2019: a significant step for social workers in a concerted effort to be recognized and respected for our work within the field. The APHSW-C certification was the result of years of work, spearheaded by Barbara Head and the leadership of Social Work in Hospice and Palliative Network (SWHPN). Comprehensive, evidence-based standards were developed and reviewed by experts in the field.² The result is a pathway for pc and hospice social workers to validate their special skill set, which may, over time, lead not only to increased validity but more leadership and financial opportunities. Hopefully, this advanced practice certification will lead to increased financial opportunities such as pay increases for those with the certification, as well as creating the potential for inpatient palliative social workers to bill for their services, and increased opportunities outpatient billing.

While this acknowledgment and use of the social work skill set is a great step forward, we still often struggle to “prove our value” to many medical teams, some of them even our own. We cannot bill for our inpatient services, unlike other team members, and this has often led to needing to assert our skills and impact perhaps louder than others (I have a particularly “loud” reputation!). Many PC teams still don’t have a PC SW, or are understaffed by national standards.³ It’s a difficult problem, funding a position that cannot generate direct revenue. However, more and more data point the important role of psychosocial care, as evidenced by the 2018 guidelines. We know intuitively, the expertise of the social worker impacts the quality of care for our patients. Sometimes it’s harder to prove this to the folks who are responsible for the bottom line.

Another, more general, opportunity for growth for social workers in the coming year is a shift in where we see some palliative care programs “owned” within health care systems. As Palliative Care moves into the realm of population health including outpatient and home services, there will likely be more social workers in program and administration leadership positions, helping their teams and programs with these initiatives. This focus is perfect for the social work perspective of “person in environment”, first named by Mary Richmond, social worker in 1917. We see transition points in the framework of systems theory, which naturally assesses the patients’ needs in the context of where they are, meeting those needs and anticipating interventions going forward. As palliative care programs move into this home space, we encourage their use of the long-standing and well developed social work theories about how people adapt, change and cope. These skills will serve to enhance our palliative care efforts for the patients, families and our colleague providers.

Another accomplishment for palliative social work at the beginning of the year was the publication of an incredible resource for the health social worker released in 2019: Palliative Care: A Guide for Health Social Workers. Edited by B. Sumser, M. Leimena and T. Altilio, Oxford Press. The outstanding collection of authors lend their expertise to complicated theoretical frameworks, clinical interventions, case examples and a variety of overarching issues related to providing the best care to patients and families. Undoubtedly, this new book will become the teaching resource for social work academic and field work to guide health social workers when working with seriously ill and/or dying populations.

Finally, this year has seen an incredible increase in social workers in palliative care and hospice providing a variety of strategies and interventions to cope with compassion fatigue and burnout. One of the best articles came from Emily Browning on debriefings in the ICU.⁴ The debrief model has been used in social work for quite some time and translates extremely well to helping our colleagues with moral distress, increasing social support, decreasing isolation – all factors that impact one’s desire to leave the field.

For more Pallimed posts on Social Work, click here. For more posts by Vickie Leff, click here. For more posts by Allie Shukraft, click here.

Allie Shukraft, MAT, MSW, LCSWA is a reformed high school English teacher turned pediatric palliative care social worker with Carolinas Healthcare System in Charlotte, NC. She enjoys spending time with her family, trying out new recipes, and exploring the country whenever she can. You can find her on Twitter @Alifrumcally.

Vickie Leff, LCSW, BCD is the clinical social worker for Palliative Care at Duke University Hospital. She uses running and humor (not always at the same time!) as her primary coping mechanisms. You can follow her on Twitter @VickieLeff

References

1. Ferrell B, et.al. National Consensus Project Clinical Practice Guidelines for Quality Palliative Care Guidelines, 4th Edition. Journal of Palliative Medicine. 2018;2018.

2. Glajchen M, et.al. Defining Core Competencies for Generalist-Level Palliative Social Work. Journal of Pain and Symptom Management. 2018;2018.

3. Spetz J, Dudley, N., Trupin, L., Rogers, M., Merier, D., Dumanovsky, T. Few Hospital Palliative Care Programs Meet National Staffing recommendations. Health Affairs. 2016;35(9).

4. Browning E. Reflective Debriefing: A Social Work Intervention addressing Moral Distress among ICU Nurses. Journal of Social Eork in End of Life & Palliative Care. 2018;14(1).

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by Vickie Leff

Every day, we get involved in unbelievable and incredible situations. Tragedy, sadness, horrific trauma, despair, and hopelessness all wrap themselves around the cases we drop into. We step onto the stage and become part of the story.

Moral distress – the discomfort, angst, and frustration related to situations in which we think we know the “right thing” to do, but cannot due to the situation – is endemic to palliative care and hospice work. 

Some examples are:

• Aggressive chemotherapy for a dying cancer patient with days to live.
• Dumping the truth on a patient overwhelmed and alone.
• Following the treatment wishes of a family that which are incongruent with the patient who can’t speak for themselves.
• Prolonging dying because a family says they are waiting for a miracle.

It’s not the same as the stress we feel day to day about our work as palliative care clinicians. This feels different; it gets under our skin, and stays with us. What do we do with these feelings? How do we recover when our souls have been tattered? How do we suffocate the intense desire to “change the system”? How do we do this and remain present and authentic to our patients and families looking at their situation?

I scream in my head: Why is the family not letting him die peacefully? Why is the team pushing him out the door, don’t they know he’s dying? It’s a useless exercise, but it helps alleviate (momentarily!) my anxiety when dealing with these complicated, unanswerable questions. As palliative care clinicians, we calmly address these issues, advocating for our patients, hoping our perspective and expertise may provide some alternatives. Many times, we are successful in changing the conversation; sometimes we are not. And then there are the cases when we become as entangled as everyone else, and it seems like a failure. I often feel selfishly relieved when a patient dies, because the angst has ended.

Moral distress is worse for those of us who do not have as much power as others, especially among nurses¹. This makes sense; doctors can more effectively change treatment, write orders, and direct care. I spend a good deal of time speaking with bedside nurses and other colleagues about their distress over plans of care, and their frustrations with the surgeon who won’t consult palliative care because they don’t want to “give up.” Most of all, I listen every day to the struggles they have related to feeling powerless in extraordinary situations.

The “crescendo effect” of moral distress is real and dangerous. It can linger for months and years. We all have a difficult case burned into our minds. The result of moral distress, especially if we are exposed to it frequently, causes emotional exhaustion, unrealistic expectations, close-mindedness, and boundary blurring between the suffering of the patient and the family and our own ².

As a clinical social worker, I was trained on how to practice self-awareness, or how our issues, reactions, emotions are triggered by therapeutic encounters; and how these impact our work with patients and families. It’s not as easy as it sounds; this takes deliberate practice and natural curiosity. And even then, we are not immune from moral distress. Self-awareness is probably the one skill  we can learn that can build moral resilience and help us remain emotionally available to our pts/families and colleagues.

We can choose to sweep it aside, become immune and/or cynical or we can take time to examine moral distress and work toward solutions.

Identify it early on. Speak about it directly with each other and our colleagues not as failure or barrier but as an opportunity. Only then can we untangle our opinions, and the emotions that keep us frustrated and sometimes frozen.

We can also focus on resilience. While many resilience strategies are solo in practice, the more social strategies can help us most with moral distress. Informal social support, debriefings³. (See also the Pallimed article, "The Clinical Social Worker Role in Interprofessional Practice"), roundtables, case discussions, Schwartz rounds can all give voice to this distress. Learning from each other, decreasing the isolation that comes with stress, and finding creative solutions to unsolvable problems can give us the glimmer of hope we need to continue and even feel refreshed.

Challenging ourselves to see the other side of an argument or plan, remaining open minded, avoiding catastrophizing, and remaining curious (along with regularly scheduled vacations!) can ensure we continue to find meaning and occasional joy in this emotionally difficult work.

We should expect moral distress; it is part of our work. We can welcome it into our daily discussions as a way of understanding our patients, families, and ourselves.

¹ Whitehead, P. “Moral Distress Among healthcare professionals: Report of an Institution-Wide Survey”. 2014. J. of Nursing Scholarship. 47:2.
² Epstein, E., Hamric, A. “Moral Distress, Moral Residue, and the Crescendo Effect”. 2009 J. Clin. Ethics. 20(4).
³ Leff, V. “A Successful Debrief Program for House Staff. J. of SW in EOL & Pall Care. 2017 1552-4256.

Vickie Leff, LCSW, BCD is the clinical social worker for Palliative Care at Duke University Hospital. She uses running and humor (not always at the same time!) as her primary coping mechanisms.

Photo credits:
Title photo Vincent Burkhead via Unsplash
Mannequin Edu Lauton via Unsplash
Fire Amuri Am via Unsplash

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By Vickie Leff

Stand Up! was 2017’s theme for Social Work Month. As many of us know, social workers are excellent advocates; advocacy it is a core skill that is integral to our teaching, profession, and interventions. In celebration of that theme, as March concludes, I want to challenge you to spread that enthusiasm and charter across the palliative care universe this year. After all, palliative care is a team sport, defining itself not whole until a physician, nurse and social worker (at a minimum, with ideally many more disciplines involved) are members. This is not a random collection of professionals, but a calculated necessity based on evidence of how the best care can be provided.

But the world of medicine, where most of our patients live, has many silos and doesn’t often work as an interprofessional team. The administrators we work with, who are responsible for the growth of our programs, may not be accustomed to such an interprofessional collaboration and often have to account for more factors than just best evidence based care. All the more reason for all members of the team to Stand Up! for each other. It is not enough for the physician to lobby for more physician positions without the unwavering support of their nurse and social work colleagues; or a nurse practitioner without the other professionals bringing their voice to the discussion.

I worry that the long history of hierarchy in medicine may lull us into forgetting we must stand and fall as a team. I have been at the table, filled with palliative care providers including physicians and NP’s, when news has come down that an additional social work position would need to be put on hold, and everyone immediately looked at me for my reaction. I was disappointed with the news, but surprised that everyone only looked at me. I said, “this should concern everyone, not just me as the social worker”. After all, it isn’t about one professional but all of us together providing the best care, with our distinct scopes of practice and shared goals.  Our programs are only as good as each member of the team and the care each can uniquely and synergistically provide.

This is hard work we all do in the field of palliative care; it takes its toll on us emotionally. Some days we feel we make no difference at all and other days can be full of meaning and reward. Doing the work by ourselves, however, is dangerous and although necessary to get the work done, is never palliative care at its best. We must be vigilant about reminding ourselves and colleagues about this as we struggle through the day to see 11 new consults on top of the 25 already on the list. Standing up for each other is one way to remind ourselves that we are equally important, each have something vital to bring to our patients and families.

It is exhausting work, but we mustn’t let that tire us from voicing the support we all need to be the best team possible. I will stand up for our NP’s, our physicians and social workers. Without one of them, we all fail. Our patients need all of us, not just one. This is what makes palliative care so impactful to individuals and families; we tend to the whole of patient and their family. Just as we tend to our patients, we must stand up for all of us.

Vickie Leff, LCSW, ACHP-SW, BCD is the clinical social worker for Palliative Care at Duke University Hospital. She uses running and humor (not at the same time!) as her primary coping mechanisms. You can find her on Twitter at @VickieLeff.

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By Vickie Leff

Susan Blacker, et.al provided an excellent article “Advancing Hospice and Palliative Care Social Work Leadership in Interprofessional Education and Practice.” 1 The authors describe the importance of interprofessional collaboration in palliative care, and strategies to address barriers. Increasing curriculum and practice presence are essential to improving this effort.

I would like to add and highlight a practical example of interprofessional practice that can:

1. help build resilience for nurses
2. serve as a model for clinical social work perspective and problem solving
3. increase the understanding of roles between CSW and nursing.

Implementing this suggested strategy can have an immediate, long-lasting impact.

As a palliative care clinician, I work with providers across the acute care system. I’m happy to see that there are more and more programs and efforts being made to help house staff and other physicians manage the emotional impact of our work 2.

I spend a good portion of my day talking with nurses about our patients, teams, impact of care, ethical decisions, and more. Nurses at the bedside spend many hours with patients and families.They often become the most trusted partner in care, witnessing a variety of difficulties both physical and emotional 3. There is, however, surprisingly little emotional or educational support for processing this emotional impact of this charged work – aside from brief lunchtime banter.

We know from research done with physicians that having structured, institutionally supported programs that addresses  the potential burnout and compassion fatigue felt in medical practice are effective 2. How can we extend these programs n to nurses? There is no break in the day, no protected time: time set aside for a specific reason away from patient care. We must, therefore, follow one of the most basic foundations of CSW strategies--meet them where they are. CSW facilitated debriefings for bedside nurses in acute care hospitals can be challenging in design primarily due to the protected time limitations; however, they can be immediately impactful on several levels.

Suggested Program: Monthly Debriefings for Nurses

Providing monthly debriefings for nursing staff is one such strategy. A 30-45 minute facilitated opportunity  allowing nurses to give voice to the difficult nature of the work they do and how it impacts them can be immediately impactful.

Some of the things I hear at meetings are:
“I was so upset when the transplant team dangled the carrot of transplant for this woman who is clearly dying."
“I just have to compartmentalize this stuff and try and leave it here”
“I can’t talk to my husband about my day, it’s too complicated to explain. Thank goodness I can talk to my colleagues!”

Led by a CSW familiar with the culture and the staff, these meetings are supported by the unit nurse manager. Meetings are open to all nurses on the unit, voluntary and confidential. Though this is not a support group, meeting are led consistently by a facilitator who is familiar with the unit culture. We schedule the debriefings for several months in advance, letting the staff know we are committed to the process, not waiting for an incident to happen.

There are many potential outcomes these debriefings:

1. CSW and RN management work together to design the program
2. Increases understanding of the RN and CSW role
3. Provides resilience-building strategies for staff including self-awareness, availability of resources, normalization,education on burnout, compassion fatigue, and secondary trauma
4. Learning from each other, breaking down stereotypes and communication barriers

I would encourage clinical social workers in health care to take the initiative and offer the program– other providers don’t know we can do this. This is our expertise; it is what we do very well and it’s a wonderful opportunity for interprofessional development. We have been doing these at Duke Hospital for 3 years in a variety of settings: in-patient oncology, pulmonary step down unit, cardiac intensive care, medical intensive care, general surgery, pediatric ICU and more. Each has its own cultural barriers and openings. Use your clinical skills to tailor your approach for success. We can learn so much from each other.

1. Blacker SH, Barbara. Advancing Hospice and Palliative Care Social Work Leadership in Interprofessional Education and Practice. Journal of Social Work in End of Life & Palliative Care. 2016;12(4):316-330.
2. Back AL, Steinhauser KE, Kamal AH, Jackson VA. Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors. J Pain Symptom Manage. 2016.
3. Boyle D. Countering Compassion Fatigue: A Requisite Nursing Agenda. Online J Issues Nurs. 2011;16(1).

Vickie Leff, LCSW, ACHP-SW, BCD is the clinical social worker for Palliative Care at Duke University Hospital. She uses running and humor (not at the same time!) as her primary coping mechanisms. You can find her on Twitter at @VickieLeff.

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By Vickie Leff

March is Social Work Month – a great excuse to take a moment and celebrate the work that clinical social workers do in palliative care. But, hang on, perhaps we should be doing more than that. Can we adjust our lens settings and challenge ourselves to see clinical social work differently?

Palliative Care is a team sport; the standard model of practice includes an MD, NP and CSW. My challenge to all of you would be to make sure you are all equal partners in our unequal medical world. CSW’s can’t bill for in-patient visits, we can’t generate RVU’s for the hospital system, and it’s often hard to quantify data-driven results proving the impact of CSW interventions. I don’t know about you, but I work in a pretty physician-centric organization where there is a distinct pecking order. In fact, my hospital recently dissolved the CSW department in lieu of a Case Management Department. Medical social workers have been dealing with this for a long time (1920-30’s).

Much of the work done by your CSW is unseen, done in private with a patient or family member – needing to have conversations away from other providers due to the nature of the content and emotions. The work you may see us doing might look like “general support” but I can tell you it is quite deliberate and well thought out, founded in evidence based theories.

We choose our words very carefully. In fact, CSW has been having the “conversation” with patients and families for decades about goals of care, end of life and other difficult subjects. You may not know that the theory that grounds most of the communication skill and psychosocial protocols you use every day relies on the most fundamental social work tenant: start where the patient is. CSW developed the person-in-environment theory way back in the 1920’s and has served our profession well- understanding our clients in the context of their situation – which is now fundamental to all palliative care providers.

What’s the big deal, you ask? It is important to recognize the significant contribution of Clinical Social Work to Palliative Care. Communication is the heart of palliative care, without that we are nothing. Before there was SPIKES, NURSE, VitalTalk, OncoTalk there was Clinical Social Work – communicating with patients and families and other providers about these difficult subjects.

CSW also brings the concept of countertransference to the communication table. We don’t call it that when we are helping providers look at how their reactions impact the patient directly, (we call it self-awareness) but those are the theories we are using.

So, thank your team clinical social worker today; treat them as your equal in this work we do with patients and families. We might not be able to bill, or add to the financial bottom line of the hospital, but we are the backbone of the communication and psychosocial  skills you use everyday.

Vickie Leff, LCSW, ACHP-SW, is a clinical social work in Palliative Care at Duke University Hospital. She won first place in her age division of her first marathon because she was the only person in her age division (40-45) at the marathon many years ago. And she still runs...

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by Vickie Leff

Today I started my training for my eighth marathon, the Chicago Marathon in October 2015. I started running as a way of relieving stress during my first job as an oncology social worker at Beth Israel Hospital in Boston in 1984. Running along the Charles River was extremely therapeutic! I had no idea how emotionally challenging the work would be, and yet I absolutely loved it. My training as a clinical social worker taught me the most invaluable defense against burnout: self-awareness (aka dual- awareness or counter transference). This is the one learned skill that I have used every single day in my practice working with end of life and cancer patients. I don’t think about it anymore because it’s second nature to me, but I teach other providers about it every day. Self-awareness, learning about how our reactions impact our patients’ families and ourselves is, in my opinion, the most important thing you can learn to do as a clinician that will both improve your practice and protect you against compassion fatigue and burnout.

Like resilience and self-care, training for a marathon requires just a couple of things: focus on a goal, time commitment and willingness to self-examine. OK, a good pair of shoes is also required! Using that as a metaphor is how I like to think about resilience in palliative care. You could go out and run 26.2 miles, but without training you’re going to hurt yourself and may never run again. With practice, and small successes you can reach your goal and that finish line; and may have even learned something about yourself in the process.

As most marathon runners will tell you, it’s about the training. When do you need water; when should you take a walk break; what is the best gear; how do you deal with hitting a wall, what are the roughest miles for you; what should eat the night before? The only answers to these questions come from training and trial and error. I think it’s the same for assessing what you need to stay resilient throughout your career – what works for you; what should you do when you start to get “crispy”, what are the signs you take a walk break; how do you reward yourself? Of course, you can run a marathon just by increasing your mileage each week and not thinking much more about it. But in my experience, your marathon will go better and will have lots more meaning if you take stock and self-examine along the route. We all know about burnout and compassion fatigue. Thankfully there have been many wonderful studies and articles about how burnout affects providers in palliative care. I’m glad so much attention is being paid to our sanity and longevity. It’s time to adopt some strategies for a lifetime so that we can continue this work, and survive, for the long haul. I encourage all of us to think about our commitment to resilience and self-care as a marathon, not a sprint. Developing habits and insights that can carry us through to a finish line, not just the first water stop.

Take time to think about this work we do and how it impacts you and how you impact your patients and families and co-workers. This skill and knowledge will surely take you to the finish line and hopefully you won’t be last!

Vickie Leff, LCSW, ACHP-SW is a Clinical Social Worker for Palliative Care at Duke Hospital in Durham, NC. She has run (slowly) 7 marathons so far and still hasn't come in last. She and her husband live in Cary (Containment Area for Yankees) but, will soon move to Durham because their kids went off to college. You can contact her at victoria.leff - at - dm.duke.edu 

Photo Credit: Vancouver Sun Run Alain Limogenes via cc
Image Credit: Christian Sinclair for Pallimed avail via cc