First national study on nursing home social workers

Jan 5 2009

Social workers play a vital role in improving the quality of nursing home residents' lives.

But qualifications of nursing home social workers vary wildly in part because of low federal standards and inconsistent state laws, the first national study on nursing home social workers reveals.

Only half of nursing home social workers have a degree in social work, and 20 percent do not have a four-year degree, a University of Iowa survey of 1,071 nursing home social service directors shows.

Despite their desire to learn, two-thirds of nursing home social workers report they do not belong to a professional organization that helps to keep them up to date on nursing home social work issues, and only 38 percent are licensed in social work.

For-profit nursing homes are 31 percent less likely to hire a degreed social worker.

The numbers are concerning, given the important responsibilities nursing home social workers have, said Mercedes Bern-Klug, the assistant professor of social work in the UI College of Liberal Arts and Sciences who led the study.

Nursing home social workers advocate for residents and watch for signs of stress and depression. They connect residents and families with resources in and outside the nursing home and facilitate transitions such as hospice, a hospital stay or a return to independence. They guide families, residents and care providers through difficult conversations or conflicts.

"Nursing home social workers handle very serious emotional issues affecting residents, family members and other staff members, and they deserve to be educated on how to handle these issues," Bern-Klug said. "Everyone benefits when nursing homes hire qualified social workers."

Older adults struggle with dementia, and the highest rates of suicide are among older adults. Some are victims of physical, emotional or financial abuse.

"Still, many people in charge of social work in nursing homes aren't social workers, and the federal government doesn't require that they be social workers," Bern-Klug said.

Homes with more than 120 beds are required by federal law to employ a full-time social worker, but anyone with a bachelor's degree in any human service field -- not necessarily social work -- and one year of supervised experience in the field is considered qualified.

Seventy percent of nursing homes have less than 120 beds, and therefore are not required by federal law to employ a social worker. Most homes do employ one -- but typically only one -- which means devoting adequate time to each client is difficult, Bern-Klug said. Many times social workers' jobs involve other duties like marketing or activity planning.

"I asked 1,000 social workers, 'How many residents can you handle? Federal guidelines say you can do 120,'" Bern-Klug said. "An overwhelming majority said fewer than 60.

"We need legislation to demand well-prepared social workers and to set reasonable social worker-to-resident ratios, but unless families demand changes, it will be difficult to get them," Bern-Klug said. "Decades of research has documented the negative consequences of having too few nurses in a nursing home, and still we don't have strong laws demanding a realistic nursing ratio."

Bern-Klug examined state laws and found that 10 states don't address qualifications for nursing home social workers, and seven state codes do not appear to comply with federal standards. Twenty-one states require a social work degree, and most others require a four-year degree, but not in social work.

Iowa's guidelines for social services in nursing homes with more than 120 beds are identical to the federal guidelines. Iowa code does not address the social service credentials of the majority of its nursing homes, which have fewer than 120 beds.

The research also uncovered loopholes in state laws. In Colorado, for-profit nursing homes in rural areas don't have to hire a qualified social worker if they advertise for a week in a local paper and don't find one. In Indiana, social services can be provided by a member of the clergy who completes a 48-hour course and consults with a social worker.

"We need to standardize nursing home social worker qualifications, regardless of the number of beds, and nursing homes need to make sure their social workers have access to the training they deserve in order to do their jobs well," Bern-Klug said.

Nursing homes need to support existing social workers by providing educational and professional development opportunities, along with decent salaries and benefits, she said. Full-time salaries in some regions are as low as $15,000 per year, while others exceed $60,000, the study showed.

"Nursing homes tend to focus on physical care -- the risk of falling, the risk of bed sores or skin wounds -- which are very serious issues," Bern-Klug said. "But people need more than good physical care to thrive, and physical conditions have emotional consequences that social workers can help address. As individuals and families compare nursing home options, they should ask about the qualifications of the social worker and the number of residents under his or her care. "

The analysis of laws on nursing home social worker qualifications was published in the fall issue of the Journal of Gerontological Social Work . Results of the national survey will be published in an upcoming issue of the Journal of American Medical Directors Association .

The UI School of Social Work has started a national listserv about nursing home social work and has resources for nursing home social workers on its Web site. For more information, visit http://www.uiowa.edu/~socialwk/NursingHomeResource/index.html