Differences and similarities between social work and nurse discharge planners.
For more than a century discharge planning has been a part of the practice of social work as well as nursing. Historically, both disciplines recognized the need for formalized services that reflect discharge planning and have often worked together to provide subsequent aftercare activities. To date, studies have looked at the differences between social work and nursing and the overlap of activities (Egan & Kadushin, 1995; Kulys & Davis, 1987; Sheppard, 1992). This role sharing has been noted as prospective payment systems have assigned discharge planning activities increased status and overlapping and convergence of social work and nursing tasks has led to turf battles. This article examines the similarities and differences between social work and nurse discharge planners. To highlight this relationship, we identify the tasks that consist of the essential components of discharge planning among social workers and nurses and compare demographic characteristics of discharge planners, work setting variables, and specialization differences.
THE ROLES AND TASKS OF THE DISCHARGE PLANNER
The overlap and sharing between the two disciplines of social worker and nurse has led to the question of the exact role of each. To answer this question, Egan and Kadushin (1995) surveyed social workers and nurses to ascertain what generic hospital social services tasks should be done by social workers, nurses, or both. Both social workers and nurses agreed that social workers were better qualified to provide concrete services such as setting up home equipment, arranging nursing home placement, and helping patients understand insurance and finances. However, social workers and nurses saw themselves as qualified to perform the tasks of supportive counseling.
In addition, there have been studies focusing on systematic differences between the two groups. For example, Sheppard (1992) studied the communication styles of social workers and nurses during their interactions with physicians. Sheppard found that nurses contacted physicians more frequently than social workers and the reason for contact often differed. Nurses generally contacted physicians about the patient's condition and treatment. Social workers contacted physicians about the case's outcome, the final treatment plan, or family issues.
Bennett and Beckerman (1986) believed that the 1970s brought a change of status regarding the professionals who performed discharge planning. These authors pointed out that the "drudges of yesteryear" (that is, social workers who did not avoid assignments to medical and surgical services) had been transformed into major players. Carlton (1989) and Ross (1993) commended social workers for their ability to work with elaborate systems and claimed that social workers were the best-qualified professionals to do discharge planning. Cox (1996) in a study of discharge planning with patients suffering from dementia found that social workers were the team members most involved and influential with discharge decisions and nursing home placements. Atkatz (1995) found that social workers were commonly involved in discharges of homeless people because of the problematic placement issues with this group. Social workers were also frequently involved in cases of discharge planning with HIV/ AIDS patients (Fahs & Wade, 1996; Marder & Linsk, 1995), people with mental illnesses (Gantt, Cohen, & Sainz, 1999; Tuzman, 1993), and infants with special care needs (Gentry, 1993). These studies support the importance of including social workers in discharge planning, especially when multiproblem cases occur and there is a lack of available community resources.
Several sources have claimed that nurses are the most qualified discharge planners because their medical training allows them to complete physical assessments, provide medical information with referrals, and assess the quality of health care resources and facilities (Lusis, 1996; McWilliams & Wong, 1993; "Nurse specialists make discharge planning pay," 1994; Steun & Monk, 1990; Thoms & Mott, 1978; Worth, 1987).
McHugh (1994) and Spataro (1995) agreed that although discharge planning remains a priority in nursing the perceptions of what this requires vary. Some nursing professionals believe that nurses involved in discharge planning should take more of an administrative role, and others see nurses' role as teaching patients and families complex postdischarge treatments, such as breathing treatments, decubitus and skin care, feeding tubes, and home injections (Lusis, 1996; Penrod, Kane, & Kane, 2000).
The primary debate on discharge planning focuses on who should be doing it and what should be done. Turf battles between social work and nursing have increased over the past decade, as health care resources have become more limited. Despite the continuous debates about who should perform discharge planning, there is no empirical evidence that one group is more qualified than the other. Kulys and Davis (1987) concluded that despite role conflict and overlap both social workers and nurses can make unique and substantial contributions in health care. The study discussed in this article explored the differences between social work and nurse discharge planners and their approaches to their work.
To gather as representative a sample as possible, we compiled a list of all the hospitals in Alabama that were members of the Alabama Hospital Association (AHA). This list consisted of 124 hospitals that were actively operating. An introductory letter and reply card were sent to these hospitals. The mailing labels for the letter and reply card were addressed to the attention of "Discharge Planner" as an attempt to reach discharge planners in all disciplines. The introductory letter explained the study, and the reply card requested that the respondent designate a contact person for the research. Information to be returned included the number of discharge planners employed by the hospital and demographic information about the hospital, such as auspice and hospital size.
Of the 124 hospitals initially contacted, 89 returned cards, a hospital response rate of 72 percent. Based on information supplied by each hospital representative, it was estimated that there were approximately 500 individuals that performed discharge planning functions. The number of surveys that each hospital requested, rounded up to the next highest number requested was sent to the hospital contact person. A stamped, addressed return envelope was included with each survey for the individual discharge planner to mail the survey directly to the researchers. One hundred and eighty-one surveys were returned from 58 hospitals, a hospital response rate of approximately 65 percent (58/89); the response rate for the discharge planners was 36 percent (181/500). Of the completed surveys 178 were usable for data analysis.
The respondent discharge planners in the present study were surveyed using a self-report task analysis instrument developed by the authors and called the Discharge Planning Activity Inventory (DPAI). Originally, concepts identified in this instrument were modified to fit the specific terminology and tasks of discharge planning from the Social Work Activity Inventory (SWAI) by Teare and Sheafor (1995). The SWAI, along with Kadushin's (1989) dissertation on social workers' views of discharge planners with elderly patients in acute care hospitals, were used as a guide. The resulting instrument was pilot tested for face validity at the annual meeting of the Alabama Society of Health Care Social Workers, where several members were given a draft of the instrument and asked for feedback as to how it could best fit the work of social work discharge planners. Additional feedback from several individuals with the Alabama Organization of Nurse Executives and the University of Alabama School of Nursing also was obtained for a nursing perspective of discharge planning. Emphasis was given to be sure that the tasks identified were relevant to both nurses and social workers and any other professions involved in discharge planning. Demographic information included hospital demographic items and respondents' age, gender, race, educational background, and professional field of practice. Responses to open-ended questions, as well as to Likert-based responses on the type and frequency of the work, were analyzed. The final instrument, DPAI, contained 69 task items. Tasks were rated on how often they were performed using a five-point scale, ranging from 5 = almost always done to 1 = not done. (Copies of the instrument are available from the first author.)
Demographic information gathered from the 178 respondents revealed that the majority of the sample (66 percent, n = 117) were social workers, 53 (30 percent) were nurses, and eight (5 percent) were other professionals. Thirty-four of the social workers held BSWs, and 85 held MSWs. Five of the nurses had a certificate or diploma, 15 had associate degrees, 21 had a bachelor's degree in nursing, and 12 had a master's degree in nursing. Of the social worker and nurse respondents (n = 170), 149 (88 percent) were women and 21 (12 percent) were men. Ninety-four percent (n = 167) of the social workers reported their race; 143 (86 percent) stated that they were white, and 24 (14 percent) reported their race as African American. The mean age for social workers and nurses was 39 years. There were no significant differences among social workers and nurses for the demographic variables of gender, race, and age.
The median salaries underscored substantial differences between social workers and nurses (Table 1). Nurses with lower education levels (that is, certificate or diploma only) made more money than social workers with graduate degrees. With the exception of the nursing certificate/diploma nurses, income was associated with level of education among social work and nurse discharge planners.
Work Setting Differences
Comparisons were made between the employment settings of social workers and nurses by region of the state where social workers and nurses were employed, hospital auspice, and hospital bed size. There were no significant differences in the regions of the state of Alabama that employed social work and nurse discharge planners. However, there were significant differences in hospitals that employed social workers and nurses by hospital auspice and bed size. Private hospitals were more likely to employ nurse discharge planners, whereas federal and state hospitals were more likely to employ social work discharge planners (p < .01). Also, hospitals with fewer than 250 beds were more likely to employ nurse discharge planners, and hospitals with more than 250 beds more often hired social work discharge planners (p <.01).
This study defined specialization in discharge planning as the case in which a worker had a caseload of at least 60 percent of a certain patient population. Most (88 percent, n = 157) of the discharge planners had specialized caseloads.
Specializations fell into four areas: geriatric, psychiatric, pediatric, and HIV/AIDS. Geriatric specialists dealt primarily with patients over age 60. Psychiatric specialists had a predominance of patients with psychiatric disorders, substance abuse diagnoses, or mental retardation. Pediatric specialists worked with individuals who were age 20 or younger. The AIDS specialists worked primarily with individuals who were HIV positive or who had AIDS (Table 2).
Task Differences between Social Workers and Nurses
A task analysis described how often the discharge planner performed a task. To present the tasks in an ordered and more meaningful way, a core group of tasks was identified. These core tasks were defined as duties that a high percentage of respondents did frequently or almost always. Table 3 lists the 10 tasks that 85 percent of all the discharge planners, both social workers and nurses, did frequently or almost always.
In identifying differences, some tasks were identified as exclusively completed by nurses (Table 4).
And in a limited number of cases, the converse was true.
In an open-ended question, respondents were asked to list job responsibilities they had in addition to discharge planning. One hundred sixty-six (92 percent) of the 178 discharge planners stated that they had additional job responsibilities and these responsibilities varied somewhat by profession.
In an open-ended question about the skills and training required to perform discharge planning, some planners believed that their professional education made them qualified discharge planners. Twelve (22.6 percent) of the 53 nurse respondents stated that it was their background and knowledge of medicine, diagnosis, treatment, and statistics and research that made them better discharge planners than social workers. By contrast, only seven (6 percent) of the 117 social workers stated that social workers were the most qualified discharge planners, although, their responses tended to be more general than the comments of nurses. Overall, many commented on how the social worker's ability to look at the patient in the environment helped them to better prepare to help the clients they served.
Social workers and nurses continue to be important providers in discharge planning. There are similarities and differences between social work and nurse discharge planners. For the demographic variables of gender, race, and age there were no significant differences between the social work and nurse discharge planners. Our demographic findings are similar to those of Teare and Sheafor's (1995) national studies, in which their social worker respondents were mostly women, white, and between ages 32 and 44.
Other similarities of social work and nurse discharge planners were that over 45 percent of both the social work and nurse discharge planners had specialty caseloads of patients over age 60 and that social workers and nurses did similar work tasks. The 10 tasks that 85 percent of the social work and nurse discharge planners did frequently or almost always included tasks such as coordination of services, assessment, supportive counseling, documentation, and treatment team participation. Tasks for social work and nurse discharge planners in addition to discharge planning were associated with management and supervision, coordinating programs and in-service education, documentation and quality assurance. Again, these findings were supported by Teare and Sheafor (1995), who found that a substantial number of social workers served people over age 60 and performed generalist and advanced generalist social work tasks similar to the 10 tasks identified in this study.
One major difference noted between social work and nurse discharge planners was in regard to the work setting. Social workers were more likely to work in larger hospitals with more than 250 beds and often worked in federal and state hospitals. Private hospitals and hospitals with 250 or fewer beds were more likely to employ nurse discharge planners. It appeared that employment work setting differences were related to professional, administrative, and funding differences across hospitals. An exact explanation of this finding is an area for future research.
Significantly more social workers specialized in working with psychiatric patients than their counterparts in nursing. In addition, the four discharge planners who specialized in serving individuals with HIV/AIDS were all social workers. These findings are similar to those of earlier studies (Atkatz, 1995; Fahs & Wade, 1996; Marder & Linsk, 1995; Tuzman, 1993) that reported social workers were commonly involved in discharge planning with psychiatric, homeless, and HIV/AIDS patients.
This study also found that comparable nurses tended to specialize more often than social workers in pediatric discharge planning. One potential reason postulated for this difference is related to the complex medical needs of high-risk infants and children (Gentry, 1993).
In looking at the tasks exclusive to nurse discharge planners, we noted roles related to service standards such as providing physical care and ensuring quality management functions, such as insurance verification, auditing records, preparing reports, and looking at outcome measures. By contrast, social work discharge planners stressed the importance of providing comprehensive mental health assessment and caregiver support and education. Social workers included supplemental tasks, such as assisting with advance directive initiation and implementation; child or elder abuse screening; substance abuse intervention; home visits; and individual, family, and group therapy.
Overall, both disciplines felt well-trained to perform their jobs. Social work discharge planners reported a clear connection between recognizing the importance of each patient and his or her situation, highlighting the "person-in-environment" stance. Social work has always considered assessment of the environment as critical to successful discharge planning.
Nurse discharge planners commented on their background in medicine, diagnosis, treatment, and statistics and research as key to their effectiveness as discharge planners. Although social workers are trained in practice and program evaluation, this was not evident in their responses to the survey. The reason for this response is unknown, but more emphasis on research and outcome measures by social work discharge planners could increase service recognition and measurement of practice effectiveness.
Ozawa and Law (1993) looked at income differences among social workers, nurses, and teachers and found that social workers had the lowest salaries of the three. This also appeared to be the case in this discharge planning study. When social worker salaries were compared with nurses with similar education and experience, the certificate/ diploma-only nurses made more money than graduate degree social workers. These higher salaries for nurses may be related to how the nursing profession traditionally has been considered an essential member of the medical team and has always had stronger involvement in hospital organization and unions than social workers (Dziegielewski, 1998). Open involvement of social workers in hospital administration and their advocacy for higher salaries has only been visible in the past two decades (Falck, 1997). Social workers, when compared with nurses, still have minimal involvement in unions. Therefore, greater involvement in hospital administration and participation in professional advocacy groups and unions may be beneficial for social workers in terms of professional hiring preferences and salary negotiations.
We compared Alabama social work and nurse discharge planners. Looking specifically at the similarities and differences between the two disciplines, nurses participated in physical care activities such as wound care, diet instruction, and medication instruction more frequently than social workers. Furthermore, nurses were more involved in quality management functions such as insurance verification, auditing records, preparing reports, and looking at outcome measures.
On the other hand, social workers were more often involved in mental health assessment, counseling, caregiver support and education, and community activities. In addition, the social workers in this study often worked with selected populations such as elderly people, psychiatric patients, and people with HIV/AIDS. These individuals can be viewed as vulnerable and may need additional continued care and attention for successful return to the community.
In today's era of managed care, all activities performed by discharge planners are essential; yet, the ones nurses concentrated on tended to be more related to activities such as physical care and quality management. These types of activities, considered concrete and identifiable, are often considered of greater "value" by the hospital than the generalist and advanced generalist activities that social workers often perform. Furthermore, the higher salaries for nurses who serve as discharge planners may also be related to this easily quantifiable and reimbursable service factor.
Work setting, salary, and several task differences, demographic characteristics and the major tasks performed in discharge planning remained similar for social workers and nurses. Of the 10 tasks identified as the core of discharge planning, the majority of the social work and nurse discharge planners were assigned and completed these tasks with similar frequency. For social workers, advocacy must stress the similarities between what social workers and nurses do. In addition, social workers have a unique and necessary role in the hospital, especially in the areas of mental health assessment and therapy, as a liaison between the hospital and the community, and as providers of support and education for caregivers. These functions traditionally have not been the focus of outcome assessment, yet they can be--they are critical indicators of service success by preventing recidivism and containing costs. By using their practice expertise and making other professionals aware of it, in conjunction with policy and research activities, social workers can better demonstrate their effectiveness as discharge planners.
Table 1. Median Annual Salaries for Discharge Planners Social Workers BSW MSW Social Workers (n=34) (n = 83) (n = 117) $32,359 $35,351 $32,585 Nurses Certificate/Diploma AA BSN MSN All Nurses (n=5) (n = 15) (n = 21) (n = 12) (n = 53) $36,248 $35,624 $43,398 $50,832 $41,388 All Discharge Planners (n = 173) $34,436 NOTE: AA = associate degree; BSN = bachelor's degree in nursing; MSN = master's degree in nursing. Table 2. Specialization and Caseload Variables Discharge Planners with Caseloads that Contain at Least 60 Percent of a Certain Patient Population Total Sample Social Workers Nurses (N = 178) (n = 117) (n = 53) Specialized Caseloads (N = 156) n % n % n % Geriatrics * 88 56 63 7 25 28 Psychiatric * 38 24 36 95 2 5 Pediatric * 26 15 12 46 14 54 HIV/AIDS * 4 2 4 2 0 0 * Differences between social workers and nurses Table 3. Tasks of All Discharge Planners Ten Tasks That 85 Percent of the Discharge Planners Performed Frequently or Almost Always % That Performed the Task Task Frequently or Almost Always Coordinate services and patient discharge 96.0 Interview caregivers for assessment 95.0 Make contacts for referrals 92.2 Review record prior to contact 91.6 Reassure, support, and reduce anxiety 91.5 Establish rapport 90.4 Perform documentation 89.9 Review workload to set priorities 86.0 Perform treatment team responsibilities 85.4 Discuss discharge/treatment options with patient/caregivers 85.4 Tasks Exclusive to Social Work and Nursing Tasks performed frequently or almost always by 60 percent of discharge planners Performed by social workers % Assess to see if mental health services are needed 63.3 Provide support to unpaid caregivers 63.3 Performed by nurses 75.4 Review records to ensure standards are met 75.4 Assess treatment plans and quality of care and service effectiveness 64.1 Know current rules/policies 62.3 Gather, enter, and compile data for reports 62.2 Verify eligibility and insurance status 60.4 Educate patients about medical symptoms 60.3 Table 4. Comparison of Responsibilities in Addition to Discharge Planning Performed by Social Workers and Nurses By Social Workers Only Psychosocial assessments Initiation and implemention of advance directives Child/elder abuse screening High-risk screening Substance abuse intervention Crisis intervention Individual/family therapy Group therapy Grief therapy Employee assistance programs Home visits By Nurses Only Patient/family education Insurance verification Infection control Employee health Quality management Pharmacy inventory Critical pathways Teaching professionals Research Performed by Both Social Workers and Nurses Attendance at meetings Documentation Treatment team responsibilities In-service training for staff Supervision Outpatient responsibilities Fundraising Preparation for audits Organ donation coordination Budgeting
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ABOUT THE AUTHORS
Diane Holliman, PhD, is assistant professor, Division of Social Work, Valdosta State University, Valdosta, GA 31636; e-mail: firstname.lastname@example.org.
Sophia E Dziegielewski, PhD, LCSW, is professor, School of Social Work, University of Central Florida, Orlando;
Robert Teare, PhD, is professor emeritus of social work, School of Social Work, University of Alabama, Tuscaloosa. Direct all correspondence to Dr. Diane Holliman.
Original manuscript received December 14, 1999 Final revision received November 2, 2000 Accepted December 18, 2000