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Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: https://www.tandfonline.com/loi/wshc20

Developing and sustaining a practice-based research infrastructure in a hospital social work department: Why is it important?

Sara Tischler, Melissa Webster, Daniela Wittmann & Kathleen Wade

To cite this article: Sara Tischler, Melissa Webster, Daniela Wittmann & Kathleen Wade (2017) Developing and sustaining a practice-based research infrastructure in a hospital social work department: Why is it important?, Social Work in Health Care, 56:1, 1-12, DOI: 10.1080/00981389.2016.1247409

To link to this article: https://doi.org/10.1080/00981389.2016.1247409

Published online: 07 Nov 2016.

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ARTICLES

Developing and sustaining a practice-based research infrastructure in a hospital social work department: Why is it important? Sara Tischler, LMSWa, Melissa Webster, LMSWa, Daniela Wittmann, PhD, LMSWb, and Kathleen Wade, PhD, MSWc

aDepartment of Social Work/Psychiatry, University of Michigan Health System, Ann Arbor, Michigan, USA; bDepartment of Social Work/Urology, University of Michigan Health System, Ann Arbor, Michigan, USA; cPatient and Family Center, University of Michigan, Ann Arbor, Michigan, USA

ABSTRACT The future of hospital social work departments depends on their ability to demonstrate their effectiveness, efficiency, and conse- quently, their value to their host organizations. In order to demonstrate and enhance social work’s contribution, research activities of various kinds must be encouraged. These include research consumption as well as production and utilization by clinicians, supervisors, managers, and administrators. The authors sought to develop a sustainable research environment in a large social work department of an academic health system. Continued work is needed to understand practice-research “best practices” within hospitals and how to ensure their sustainability within an ever changing health care environment.

ARTICLE HISTORY Received 6 June 2016 Revised 15 September 2016 Accepted 8 October 2016

KEYWORDS Health system; hospital; practice-research; social work

The need for practice-research in social work

Social workers in the United States are mandated by the National Association of Social Workers’ Code of Ethics to continually develop and enhance practice competencies (National Association of Social Workers, 1999). Within the field of social work, there has been a demand for accountability that goes beyond documentation, service delivery, and compliance with policies. The future of hospital social work is contingent upon the ability of social workers to demonstrate how they add value within the larger organization. This requires social work leadership to play a pivotal role in helping staff transition from a solely care delivery model to a research-informed intervention model.

Research that emanates from practice and is conducted by practitioner- researchers or by practitioners in collaboration with researchers can demon- strate the cost-effectiveness and overall worth of social work interventions (Davis, 2004). Thus, one of the major tasks of social work administrators and managers becomes providing opportunities and any necessary training to

CONTACT Sara Tischler, LMSW stisch@med.umich.edu Department of Social Work/Psychiatry, University of Michigan Health System, 4250 Plymouth Road, Ann Arbor, MI 48109.

SOCIAL WORK IN HEALTH CARE 2017, VOL. 56, NO. 1, 1–12 http://dx.doi.org/10.1080/00981389.2016.1247409

© 2017 Taylor & Francis

incorporate practice-based research into the daily work of staff. In this context, the need for evaluation and outcomes management has become ever more critical in the allocation of resources, training, and staffing.

According to the Substance Abuse and Mental Health Services Administration, social workers are the largest group of mental health service providers in the United States (Substance Abuse and Mental Health Service Administration, 2006). There are more health and mental health trained social workers than psychologists, psychiatrists, and psychiatric nurses combined, yet resources for many hospital social work departments are diminishing. Funders are eager to see that what they have been reimbursing is actually making a difference in the lives of patients (Palinkas & Soydan, 2012). Orme and Powell (2007) assert that, to improve professional practice and demonstrate effectiveness, research production and utilization must be encouraged, but research by whom and from where?

To answer these questions, funding institutions look to academically-based researchers. By contrast, this article will describe the development of a practice-based research program embedded in a large social work depart- ment, designed to increase social work research endeavors and provide a research infrastructure needed to sustain these intramural efforts. Overcoming professional and organizational barriers to implementation will also be addressed. Nine essential elements will be described that encom- pass the platform and how this model can be replicated.

Historical perspective on research development in hospital social work in the United States

Although practice-based research can provide a way for social work practi- tioners to disseminate and discuss their scientific questions and potential treatment interventions, research has not historically been a key priority in social work training. Yet, when social work was emerging strongly as a profession in health care during the second half of the 20th century, research activity was also beginning to develop. This was particularly evident in the field of cancer care, with the appearance of social work in published peer reviewed journals. In 1969, Reid and Shyne conducted an experiment in which the outcomes of two social work approaches were compared. A short- term, problem solving approach to treatment was found to be more effective than a long-term, open-ended, psychosocial approach. These findings had a considerable impact on the profession of social work. Based on this study, Reid and Epstein (1977) developed a task-centered approach to social work practice, meeting the demand for measurable outcomes and cost efficiency.

Practice wisdom and supervision were the traditional methodologies for the development and transfer of knowledge in social work. As a result, new discoveries could not be easily translated to other disciplines or the field of

2 S. TISCHLER ET AL.

health and mental health in general. Moreover, training in the construction of knowledge through scientific inquiry and research methods had not been typically offered in any depth in social work curricula. This posed further professional challenges and led to a shortage of tools with which to advance the visibility of its contribution to the understanding of the human experi- ence in health care. In 1991, the director of the National Institute of Mental Health, Lewis Judd, MD, in his report on the development of social work knowledge, stated: “There is a crisis in the current development of research resources in social work. Contributions of research to the knowledge base of social work practice lag far behind the dynamic growth of the profession and professional education” (National Institute of Mental Health, 1991). This was a call to action that could not be resisted.

The need to support social work practice with evidence of effectiveness, efficiency, and “fidelity” to practice guidelines was also brought about by a new development in health care. The ascendancy of the Diagnostic Related Groups (DRGs) as a method of reimbursement in the 1980s put pressure on social work to prove that its interventions made a difference. Furthering a research agenda in social work became a priority. Under the leadership of director Dr. Grace Christ, Memorial Sloan Kettering Cancer Center became a leader in this endeavor. Christ and colleagues describe the implementation of a 2-year writing seminar to assist staff in preparing research papers and presentations, followed by the development of a dedicated research unit, paid for by philanthropic funds (Christ, Siegel, & Weinstein, 1995). This allowed for the addition of a full-time research director with a track record of getting grants and being published. Emphasis was placed on independent research with some collaboration with other mental health professionals. Other medical professionals welcomed collaboration with social workers, which allowed for increased access to patient groups.

Unfortunately, the Memorial Sloan Kettering Cancer Center experience was more unique than typical. While Christ and colleagues advocated for hospital-wide projects focused on social work assessment and intervention, this methodology did not have much success. Three possible reasons were a lack of institutional support for social work research, lack of training, and likely the pressure of both direct practice and increasing bureaucratic responsibilities, which some have interpreted as an ongoing and enduring reluctance of clinicians to engage in research (Epstein, 2010).

Ideally, building a research infrastructure and culture within an agency creates opportunities for teamwork, mentoring, collaboration, and innovation. Rather than an additional burden, a research-friendly environment can empower social work practitioners. In fact, in recent years, the enthusiasm for research by practitioners has increased globally, as evidenced by the existence of conferences such as the International Conference on Practice Research and the International Conference on Social Work in Health and

SOCIAL WORK IN HEALTH CARE 3

Mental Health. As Wade and Neuman (2007) suggest, the results of research can reinforce the individual intellectual and organizational resource investment in the roles social workers perform. However, still today, regardless of the potential benefits that would be derived by the cultivation of a hospital-based research culture and infrastructure, few social work practitioners are actively engaged in research (Palinkas & Soydan, 2012).

Historically, research development has facilitated the advancement of other health care professions such as dietetics, nursing (Kilpatrick, 2008), occupational therapy, and the field of medicine as a whole. Additionally, the field of clinical psychology has historically been more research-oriented, with the terminal degree being a doctorate. Health social work will similarly benefit from an increased focus on research, and it will benefit more if there are contributions to knowledge from practice as well as to practice. In any profession, research is the foundation of successful practice. Knowledge creation, whatever its source, not only validates the efforts of practitioners, but it also promotes the well-being and empowers practitioners with tools of self-reflection and empirical enquiry. Likewise, social workers in health care must participate as full partners with each other and with other disciplines that have already cultivated research cultures.

Integrating social work practice and research

Although there is a desire to integrate research training and appreciation into graduate social work education, for most students, there are no meaningful opportunities to participate in research activities during their training, nor do they appreciate its value (Dodd & Epstein, 2012). Social work faculty members are rarely involved in health care research at a practice level and cannot provide the mentorship necessary to integrate practice and research. Therefore, newer health care social work professionals lack the ability or competency to take integrated practice frameworks into the field. Recognizing that practice and research should be a two-way street: The Council on Social Work Education (CSWE) identifies engagement in research-informed practice and practice-informed research as a “core compe- tency.” To become accredited by the CSWE, schools of social work must use the core competencies to design their curriculum (CSWE, 2008).

The CSWE Commission on Research works to promote education-based research in schools of social work. This is done by identifying and advocating for resources that advance the profession’s research agenda and identifying emerging areas of research and research methodologies in social work educa- tion. The commission encourages and promotes the development of curricu- lum tools and professional development opportunities with the goal of improving the teaching of research in schools of social work. It also works with CSWE stakeholders to advance the profession’s research agenda in higher

4 S. TISCHLER ET AL.

education, government agencies, and the public. It is concerned with helping to build databases that promote innovation in education and strengthening the link between research and practice. Progress toward these goals is reviewed annually, and goals are amended.

Recognizing the need, a few organizations have expanded their roles in promoting research, and social work researchers have achieved greater visi- bility and influence. At the Mount Sinai Department of Social Work, clinical data mining—the extraction and analysis of existing clinical data—was pio- neered and used to further practice-based research within a number of specialties in the field (Epstein & Blumenfield, 2001). Practitioner-Research projects at Mount Sinai were funded by modest amounts of endowment money, foundation money, and physician-contributed money. In June 2014, the Silberman School of Social Work at Hunter College and Mount Sinai co-sponsored and held the 3rd International Conference on Practice Research (ICPR), highlighting the integration of research into everyday social work practice throughout the world. This initiative to highlight practice research and bring together experienced and “emerging” practitioner- researchers from the United States and 21 other countries was convened by Irwin Epstein, then occupant of the Helen Rehr Chair in Applied Social Work Research at Silberman and Adjunct Professor at Mount Sinai. The Conference, held at Silberman in New York City, aimed to recognize gaps between practice organizations and research efforts, identify models for exchange, and examine strategies for building collaborations among practi- tioners and researchers. Its theme was “Building Bridges, Not Pipelines: Promoting Two-Way Traffic between Practice and Research.” Although the historical context changes as each country grapples with the integration of research into social work practice, many of the challenges remain the same, i.e., funding, time, and a lack of alignment within academic research.

The organizational setting

Cognizant of the cultural shift toward research informed practice and moti- vated to deliver high quality care, the leadership of another large, academic social work department sought to develop a sustainable research culture and infrastructure with a long-term goal of integrating research into practice. The social work department is one of the largest in the United States with over 200 social workers in an academic tertiary care health system. Given the limited research resources, it was critical to be strategic and set achievable goals through which to build several integrated, mutually supportive compo- nents. The social work department’s director took on the role of a champion of social work research by encouraging staff members who were interested in research to work together and engage in a variety of activities that gradually formed the foundation on which the first steps into the research enterprise

SOCIAL WORK IN HEALTH CARE 5

could be made. In the absence of the hospital administration’s financial support for social work research, volunteerism on the part of these self- selected individual staff members became critical start-up currency.

The effort began with highlighting already existing research activity of a few social work practitioners in a social work research symposium. All social workers in the health system were invited to attend and continuing education credits were granted. Further steps were built from this event, based on social workers’ interest and the availability of modest funds from the department of social work. A social work research committee was composed from those social workers who were inspired by the symposium to work on a common goal—to promote research activity in the department. The social work research committee continues to build an infrastructure by creating roles, building partnerships, and learning from past experience. Most of these social workers had no research experience when they began this journey.

Building the research infrastructure included nine essential components. Table 1 describes each method as a component. They are as follows: 1) the creation of venues for social work research awareness and encouragement; 2) the formation of a social work research committee composed of research activists and mentors within the department; 3) the establishment of a lead role to support this committee; 4) collaboration with an existing federally funded research training program for clinicians in the university’s medical school; 5) collaboration with school of social work faculty involved in health research; 6) identification of accessible funding resources for social workers interested in research; 7) the creation of research databases to collect psy- chosocial data from patients in a center for sexual health and across the health system as a whole; 8) the development of a social work assessment tool; and 9) the development of a career ladder that incorporates research into the highest category of clinical scholar.

Program development

Over a 6-year period, research activities were highly encouraged, and the practice-research culture began to emerge. Table 1 describes the results as both intermediate outcomes and long-term outcomes. Nine elements emerged sequentially and will be described in order below. These elements were seen as a natural progression of social workers’ meeting on a regular basis to promote research throughout the department and have maintained sustainability. 1) Symposia: The Biennial Social Work Research Symposium was first held in 2009. During 2013 and 2015, it became a regional conference and the number of attendees and presentations has nearly doubled. 2) The social work research committee: The vision of the social work research committee is “to be leaders in cultivating the promotion of hospital-based social work research.” Its mis- sion is “to support already existing social work practice in the health system

6 S. TISCHLER ET AL.

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SOCIAL WORK IN HEALTH CARE 7

with evidence and to contribute to the development and dissemination of new evidence-based social work practice in health and mental health.” Some of its regular activities include mentoring social workers who are interested in research, developing new training and research opportunities for social work- ers, and designing venues that could highlight social work practice research within and beyond the boundaries of the hospital. The committee is respon- sible for the creation of a research newsletter and website. In total, the health system has had 44 research projects, 22 investigators, and 10 new investigators in 2014, and 36 total publications to date. 3) Leadership: The appointment of a research lead led to accountability for research development and a commit- ment to an ongoing research vision and mission. 4) Research training: The research committee developed a partnership with a federally funded research training program in the university’s medical school, designed to develop clinician-scientists (Murphy, Kalpakjian, Mullan, & Clauw, 2010). 5) Partnership with the school of social work: The school of social work funds 10 MSW students each year as integrated health community scholars to participate in ongoing practice research projects under the supervision of a social work clinician-scientist. 6) Identification of funding: Medicaid matching funds have been granted for 11 projects to date. Additionally, foundation funding has been accessed. 7) The establishment of a model research database: A sexual health database was designed to collect psychosocial data from patients who have sexual problems in the context of medical conditions. 8) The development of a social work acuity tool: A methodology to measure the psychosocial acuity of patients across a health care continuum that documents social work activity and leads to resource alignment and distribution (Klett et al., 2014). 9) The development of a career ladder: Incorporates scholarly publications, significant primary role in grant writing, and completion of research training as qualifications for meeting the highest level on the ladder of clinical scholar. The career ladder provides a framework for the develop- ment, advancement, and recognition of MSWs. Financial incentives are also aligned with promotions on the career ladder.

Success in integrating practice and research

Our focus on several initiatives, including research training and collaboration with social work students, has led to an increased interest in research partici- pation and furthered the integration of research and practice. The following three examples illustrate some of the outcomes of the Social Work Department’s effort to promote the integration of practice and research.

1) The findings from a study that evaluated the impact of a one-day retreat on couples’ coping with the side-effects of prostate cancer surgery on specific outcomes (Wittmann et al., 2013) resulted in the adaptation of the findings of the study to usual care. Prostate cancer survivors and partners now attend

8 S. TISCHLER ET AL.

a pre-operative seminar that prepares them for surgery-related side-effects of rehabilitation. The effect of the seminar on patients’ and partners’ learning and expectations has also been evaluated, and the study findings are in press in a peer reviewed journal. These studies and clinical experience using the studies’ content formed preliminary data for a foundation funding award for the development and testing of a web-based intervention for couples coping with the side-effects of prostate cancer treatment (Paich et al., 2015).

2) Through a study focused on improving emotional and social function- ing of adolescents with epilepsy, 34 adolescents with epilepsy participated in a group cognitive behavioral therapy program. Baseline scores suggested that many participants had difficulties with emotions, concentration, and social functioning, with parent-reported impact scores significantly worse than adolescent-reported scores. After the intervention, adolescent-reported pro- social behavior scores significantly improved. Parent-reported scores improved significantly at follow-up in several areas of emotional and social functioning. Adolescents with lower socioeconomic status reported the great- est improvements (Carbone, Plegue, Barnes, & Shellhaas, 2014).

Finally, 3) a scale that measures the psychosocial acuity of patients and families across the health system was developed and implemented in the hospital system’s electronic medical record. All patients seen by social work receive an acuity score. The psychosocial acuity measure provides data that documents social work contributions to the care of hospital patients. It corresponds to a statistics database and can aid in the alignment of resources as well as allow social work departments to accurately convey the full scope of value to health system leadership. The biggest strength of the acuity scale is that it has already been implemented into practice. Future steps for this measure include dissemination to other health systems in the United States.

Discussion

The department of social work has been successful in creating a culture and structure which actively supports practice-based research. It has done so by adopting a multimodal approach that included forming a dedicated body of social workers, who provided encouragement to colleagues. Additionally, it developed collaboration with a training program and academic colleagues. Ultimately, a new generation of clinician-scientist social workers is emerging. It is this new generation that will continue to carry on the mission.

The department of social work has demonstrated that it is possible, despite limited resources and lack of institutional support, to reach significant outcomes, such as the establishment of scientific social work conferences that focus on social work research in health care, successful competition for internal and external funding, and completed projects and publications, all of which lead to improved practice and greater visibility of social workers’

SOCIAL WORK IN HEALTH CARE 9

contribution to the care of patients. However, the lack of resources and institutional support are significant barriers that must be overcome if social work research is to remain viable and sustained over time. Identifying creative solutions and strong partnerships will be essential to ensuring its ongoing success.

Some barriers are structural and not easily overcome. As holders of an MSW, not a PhD, social workers are unable to be faculty either in the health system, in the school of social work, or in the medical school. Their inability to hold an academic rank prevents them from being able to access research education available to junior medical and academic faculty. Without faculty status, social workers are also unable to apply for intramural and federal funding independently. Thus, structural problems have, to date, been a barrier to the department of social work’s ability to align itself with the health system’s teaching and research missions.

Given these limitations, the social work department has had to cope with unforeseen complications. In order to support social work research, the department tries to “backfill” when a social worker engages in a funded research project. Although this has not been a genuine threat, social workers worry about giving up a part of their salary for “soft funding” in case there is either no job to come back to or at least not the same job. Thus, pursuing research may inadvertently lead to job insecurity and staffing problems that become disincentives.

The question then becomes, how do social workers who engage in practice- based research demonstrate the unique value of their work to the larger organi- zation and community, and to the field of social work? Additionally, and perhaps even more importantly, how do they sustain these efforts? This question has been asked over the last 2 decades, and yet it does not seem that we are any further along in our journey. Pockets of research activity or social work cham- pions dedicated to integrating research into practice settings have not provided the long-term solution to this dilemma in the presence of institutional barriers. Structural changes that challenge traditional divisions between school of social work and health care settings (practice and research), and between health and mental health care, must take place using collaborative relationships, affording new models to emerge. Discussions about “what’s in it for me” may need to occur, especially given the barriers around the lack of alignment of health system incentives versus the academic promotion/tenure process.

It is clear that, without an approach to practice that utilizes research to substantiate the value social work brings to the proverbial table, our role within health care will flounder. As healthcare continues to be redefined and new models emerge, it is in our best interest, and perhaps survival, to work together with a shared vision and purpose to manage these challenges and create opportunities that bridge these efforts into a sustainable, competence- based best practice that becomes the true gold standard in social work.

10 S. TISCHLER ET AL.

We need to propose solutions, such as advocacy at an institutional, state, and federal level, recognize the academic role of social work, and develop funding streams specifically oriented toward social work research training and proven interventions. We have to look outside the field of social work to partner with our colleagues in medicine and nursing and advocate for the significant contributions that hospital social workers make to patients’ lives. We have to work harder to create alliances between hospital and academic social workers in developing jointly-funded collaborative research studies. In proposing research projects and searching for funding, social workers must look toward team science so that they can become an integral part of a multidisciplinary research effort, similar to the current trends in advancing interprofessional teaching occurring within health care cohorts. Our profes- sional associations require more cross fertilization and collaboration to provide the substantive conversations needed to break through these obstacles. Successful social work interventions and practice-based research will further psychosocial outcomes necessary to promote the health and mental health of our patients, as well as the larger health care community. It is critical to our field to construct a shared responsibility model that promotes these efforts across the clinical, academic, and research ranks of social work.

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