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Original Article
Creating social work competencies for
practice in hospice palliative care
Palliative Medicine
24(1) 79–87
! The Author(s), 2010.
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DOI: 10.1177/0269216309346596
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Harvey Bosma School of Social Work, University of British Columbia, Vancouver, BC, Canada
Meaghen Johnston School of Social Work, University of British Columbia, Vancouver, BC, Canada
Susan Cadell Lyle S Hallman Faculty of Social Work, Wilfrid Laurier University, Kitchener, ON, Canada
Wendy Wainwright Victoria Hospice, Victoria, BC, Canada
Ngaire Abernethy Mental Health Services for the Elderly, Brandon Regional Health Authority, Brandon, MB, Canada
Andrew Feron Parkwood Hospital, St Joseph’s Health Care, London, ON, Canada
Mary Lou Kelley School of Social Work & Northern Ontario School of Medicine, Lakehead University, Thunder Bay, ON, Canada
Fred Nelson Palliative Care Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
Abstract
Social workers play an important role in the delivery of Hospice Palliative Care in many diverse settings. The profession
brings a unique perspective to end-of-life care that reflects and supports the holistic philosophy of Hospice Palliative
Care. Despite the prominent and longstanding position of social work in this area, the role and functions of social
workers had not been clearly defined. A Canadian task group of social work practitioners and educators utilized a
modified Delphi process to consult front line clinicians nationally, and thereby achieved consensus regarding the identification and description of eleven core competencies in Hospice Palliative Care. These competencies are relevant for
social workers at different experience levels across care settings. They can be used to inform social work practice, as
well as professional development and educational curricula in this area.
Keywords
social work competencies, social work practice, palliative care, end-of-life care, Delphi technique
Introduction
Social workers play an important role in the delivery of
Hospice Palliative Care (HPC). In time, most social
work practitioners will encounter adults, children, and
families who are facing progressive life limiting illness,
dying, death, or bereavement. Such social work interactions occur not only in health care settings, but in all
locations where social workers practice. These include
hospitals, hospices, nursing homes, adult daycare, and
senior centers as well as non-health-care sites such as
child and family services agencies, income assistance
programs, schools, courts, and employee assistance
services.1
The profession of social work brings a unique perspective to end-of-life care that reflects and supports the
holistic philosophy of HPC. It draws on an ecological
approach to problem-solving that considers the multidimensional impact of individual, family, and sociocultural influences in our daily experiences.2 This
approach fits well with the focus of palliative care,
which aims to alleviate suffering and improve the quality of living and dying by addressing physical, psychological, social, spiritual, and practical concerns.3 Both
palliative care and social work reflect philosophies of
caring that consider individuals in the full context of
their lives.4–7
As such, HPC is most effectively delivered by an
interprofessional team with relevant expertise in each
discipline.8 For social workers, the focus of practice
within this collaborative approach is centered primarily
on psychosocial needs at end of life and during bereavement.9,10 They bring to the team an expertise regarding
Corresponding author:
Harvey Bosma, School of Social Work, University of British Columbia, 2080 West Mall, Vancouver, BC, Canada V6T 1Z3. Email: bosmah@shaw.ca
80
health and social systems, individual and family
dynamics, cultural diversity, grief and loss, communication, advocacy, ethics, and interdisciplinary practice.1,8,11–13 As Brandsen11 points out, ‘social workers
are integral participants in developing and delivering
end-of-life care, and have been for quite some time’
(p. 58).
Despite the prominent and long-standing position of
social work in HPC, the role and functions of social
workers have not been clearly defined. In
Brandsen’s11 literature review of the social work profession’s involvement in end-of-life care, she found that
empirical documentation of social workers’ roles and
responsibilities was weak. This gap was also identified
in pediatric palliative and end-of-life care.14 The lack of
a clearly defined identity has contributed to other professionals’ confusion about what social workers actually do in HPC, and, consequently, other professions
often have inadequate knowledge about the complexity
and value of social work practice in this area.5,10,15 The
resulting ambiguity has contributed to boundary and
role issues between social workers and other health care
professionals, particularly nurses and physicians.12,16
Furthermore, without a clearly articulated role, social
workers have questioned their adequacy and competence to provide professional care to individuals and
families during the dying process and after death.15
Therefore, it is crucial for the social work profession
to coherently identify and outline its roles and competencies so that social work practice can be advanced in
HPC, and adequate education and training be developed and offered to current practitioners and new students. Recently, efforts have been made to address this
gap. For example, in the United States, an outcome of a
social work leadership summit on end-of-life and palliative care was a description of competencies for social
work practice in HPC, which became the source for
national standards for social work practice in palliative
and end-of-life care in America.1,17,18 Jones14 also produced a report of best social work practices for care of
children and their families at end of life based on a
survey of over 100 pediatric oncology social workers.
Until now, similar endeavors have not occurred in
Canada, although the Canadian Senate Committee for
Palliative and End of Life Care has underlined the
importance of national standards and competency in
end-of-life care, and the need for specific training for
all professions to achieve these.19,20 The call to develop
evidence-based norms and standards of professional
practices in HPC was strongly reiterated by the
Quality End-of-Life Care Coalition21 in light of the
prediction that the number of deaths in Canada is
expected to increase 33% by the year 2020. In response
to this call, a national task group of social work practitioners and educators came together to identify
Palliative Medicine 24(1)
competencies that are essential to social work practice
in HPC (Appendix 1). The group members recognized
that a clear description of basic practice competencies
was imperative to the development of professional
practice standards and social work education in this
area. This need was further underlined by the fact
that other disciplines involved in HPC had already
established descriptions of professional competencies.22,23 Therefore, the task group successfully applied
for funding through Health Canada to accomplish this
project.
Methods
The task group adopted a Delphi technique to identify
and describe the competencies required for social work
practice in HPC. The Delphi technique is a structured
method that has been broadly used in the health
sciences.24 Its aim is to synthesize a diverse range of
expert opinions about a particular topic, until a consensus is achieved. The Delphi technique is an iterative
process that typically comprises two to three rounds of
anonymous questionnaires. Information is collected
from a panel of experts (people who are able to offer
credible opinions) during each round. Responses are
then analyzed and refined into a new questionnaire
for the subsequent round with the same panel.25
Panel sizes usually range from 15 to 35 members with
the expectation that 35–75% invitees will actually
participate.26
Originally a postal method, the Delphi technique has
been adapted to electronic mail. Consequently, experts
from a large geographical area can easily participate.
Another advantage of this technique is that it provides
an opportunity for participants to confidentially present and respond to ideas without reacting to the
group dynamics that sometimes impede face-to-face
interactions. Moreover, it allows time for reflective consideration of the questions at hand.
There are differing forms of the Delphi technique
and few researchers use a uniform method.27,28 The
task group developed a modified Delphi process to
meet the goals of this project. Instead of starting the
first round of the process with a set of open-ended
questions, the task group identified and described a
number of competencies (Table 1) themselves, which
they then presented to a panel of national experts for
feedback. Because the Delphi technique can generate
large volumes of data, the presentation of pre-existing
information based on previous literature reviews or
focus group data is an efficient way of using a technique
that can be very time consuming otherwise.28–30
The template for the competencies was modeled on
the Canadian Hospice Palliative Care Association’s31
Norms of Practice and a related conceptual framework
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H Bosma et al.
Table 1. Task group competencies
Advocacy
Assessment
Care delivery
Care planning
Community capacity building
Decision making
Evaluation
Education and research
Information sharing
Interdisciplinary team
Self-reflective practice
regarding levels of competency developed by the
Victoria Hospice.31 The initial description of the competencies was based on a combination of the knowledge
and skills of the task group members and a review of
publications and websites of various HPC and oncology organizations in Canada and the United States
regarding current practice standards.33–38
The task group members worked in pairs to develop
a description of each competency. When a version of a
competency was completed, it was circulated to two
other members for further review and input. The resulting framework of each competency provided specific
details that included an overall description of the core
competency, and the required attitudes and values,
knowledge, and skills most pertinent to it.
The task group then identified and invited social
work practitioners and educators across the country
to review these competencies through two rounds of
questionnaires. The goal was to establish consensus
regarding the relevance and description of each competency, and to identify any other core competencies that
should be added and developed. In the initial stage of
recruitment for the panel, the task group sent out a
general call to the British Columbia and the Canadian
Social Work/Counseling HPC Interest Groups for participants for this project. They also identified a number
of social workers and counselors currently working in
the area of HPC. Two research assistants (RAs: HB
and MJ) sent each social worker a letter of invitation,
which was followed by a phone call as needed to determine whether or not the individual was able to participate. Completion of the initial request served as consent
for Phase One and also for agreement to participate in
the second round of the Delphi process.
Several of these respondents also suggested other
individuals for the panel, who were then contacted as
well. The use of both purposive and snowball sampling
techniques ensured a panel with diverse experience and
expertise in social work practice in the context of HPC.
A deliberate effort was made to include participants
from different practice settings and all regions of
Canada. Thus, participants on this panel worked in a
variety of locations such as hospitals, hospices, longterm care facilities, cancer care centers, community
agencies, and universities in British Columbia,
Alberta, Manitoba, Ontario, Newfoundland, Nova
Scotia, and the Yukon.
Data collection was done by email. This approach
had both positive and negative aspects. Certainly, the
electronic transmission of information and questionnaires facilitated efficient communication with panel
members during each round of the study. However,
difficulties occurred during the first round when the
questionnaire was transferred into an Adobe format.
Specifically, some participants did not have the computer software to enter responses directly into the document, and they were only able to access the document
as a ‘read-only’ version. This required the participant to
print out and manually complete the document, and
then fax or mail the completed questionnaire to the
research office. To address this problem, the Adobe
format was discontinued in Round Two and the questionnaire was reformatted as a Word document, permitting easy data entry and electronic transmission.
The task group employed several strategies of data
generation consistent with the consensus building process of the Delphi methodology. Task group members
identified and developed the first version of the 11 core
competencies. This was followed by a peer review process whereby all competencies were reviewed by two
other members. The RAs read all the final comments
and incorporated the edits for each competency for this
initial process and the subsequent panel rounds; they
consulted with two members of the task group (SC and
WW) as needed. The RAs, who were doctoral students
and research trainees with two CIHR New Emerging
Teams (NETs): Transitions in Pediatric and End of Life
Care and Palliative Care in a Cross-Cultural Context,
also had relevant clinical social work experience in
HPC. The study extended over a period of 10 months
and involved two phases of data collection and
analyses.
Results
Round One
A response rate of 66% (20/30) was achieved in the first
round of this research study. One emailed questionnaire
was not received and was designated as missing data.
In Round One, 16 participants (80%) agreed that all 11
competencies listed are essential to social work practice
in HPC. Two of the competencies were listed as nonessential by three participants: one participant identified community capacity building as non-essential, and
two participants identified education and research as
non-essential.
Six additional competencies were suggested as essential to social work practice in HPC. Cultural competency was suggested twice as essential and the
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Palliative Medicine 24(1)
following five new competencies were suggested once:
(1) competency in understanding the multidimensional
nature of health and wellness; (2) competency in understanding the social determinants of health; (3) adaptability to work environment; (4) spirituality of self, team, and
others; (5) counseling and treatment planning (Table 2).
Round Two
All responses were carefully reviewed by the RAs and
compiled into a new questionnaire and emailed to the
20 respondents of Round One. The Round Two questionnaire included a list of the original competencies as
well as all of the changes suggested in Round One
regarding their descriptions. All changes were highlighted in red within the body of the 11 competencies.
The list of additional competencies that were suggested
by some panelists for further development was also
included.
The participants were asked to complete three tasks
for Round Two: (1) to state whether they agreed with
the suggested changes to the competencies; (2) to indicate how essential each competency was to social work
practice in HPC; (3) to indicate whether the six new
competencies should be developed further. Panelists
indicated their responses by clicking on an appropriate
answer from a drop down menu as described below.
They also had opportunities to enter additional
remarks in comment boxes along the way.
Nineteen responses (95%) were received via email
and fax. In the final analysis of the data, the total
number of respondents fluctuates for several competencies as a result of missing data. Inclusion of missing
data as part of the total sample translates statistically
to assuming that the response was ‘no.’ After careful
consideration by the task group as a whole, it was
determined that the management of missing data
according to the purpose of consensus building
deemed it appropriate to have a fluctuating sample.
Table 3 displays the consensus levels for the description
of each aspect of each competency.
In the Round Two analysis, the RAs incorporated
content changes to the competencies when the majority
Table 2. Suggested competencies for future development
Cultural competencya
Supporting spiritual needs
of self, team and othersb
Understanding social
determinants of healthb
a
Suggested twice.
Suggested once.
b
Adapting to work environmentb
Counselling
and
treatment
planningb
Understanding multi-dimensional
aspects of health and wellnessb
of participants agreed with the proposed recommendations. For some competencies, a minority of participants suggested changes. The RAs incorporated these
suggestions when such changes did not alter the overall
meaning of a particular point, and, from their perspective, helped to clarify the point. For example, under
the interdisciplinary care competency, the RAs agreed
with the suggestion to remove the qualifier ‘good’ from
‘good psychosocial care’ as it was deemed that in
the context of core competencies, ‘good’ care is implicit
to ‘psychosocial care.’ The reviewers did not incorporate minority suggestions that significantly altered
the meaning of a point. To include such changes
would warrant a third round to provide an opportunity
to all participants to respond to the recommended
change.
In addition to reviewing the suggested changes,
participants were asked to rate how essential each competency was according to a six-point Likert scale:
absolutely essential, very essential, essential, somewhat
essential, not essential, and unsure (Table 4).
Participants were also asked whether the new competencies that had been suggested in Round One should
be developed further as stand-alone competencies.
Participants were asked to consider whether or not
each competency should be added, whether it was
already included in an existing competency, or whether
they were unsure about the suggested competency
(Table 5).
Discussion
The Delphi method has facilitated an effective process
to establish consensus among social work clinicians and
academics across Canada regarding core competencies
Table 3. Achieved consensus for descriptions of competency
domains
Competency
Attitudes/
values
Knowledge
Skills
Advocacy
Assessment
Care delivery
Care planning
Community capacity building
Evaluation
Decision making
Education
Research
Information sharing
Interdisciplinary team
Self-reflective practice
83%
82%
100%
82%
94%
100%
93%
82%
94%
77%
100%
88%
83%
72%
83%
83%
94%
94%
94%
100%
94%
100%
100%
100%
78%
72%
94%
94%
94%
82%
94%
69%
75%
88%
88%
88%
83
H Bosma et al.
Table 4. Scale rating results of 11 competencies
Competency
Absolutely
essential
Very
essential
Essential
Advocacy
Assessment
Care delivery
Care planning
Community capacity building
Confirmation
Decision making
Education and researcha
Information sharing
Interdisciplinary team
Self-reflective practice
50%
69%
56%
62%
13%
50%
50%
13%
56%
62%
62%
31%
6%
19%
19%
37%
6%
25%
33%
25%
19%
13%
13%
25%
19%
19%
31%
44%
25%
40%
19%
19%
25%
Somewhat
essential
Not
essential
Unsure
6%
6%
6%
13%
7%
7%
a
One person rated ‘education’ (essential) and ‘research’ (not essential) separately.
Table 5. Response rating of adding suggested competencies
Competency
Add
Do not add
Already included
Unsure
Cultural competency
Multi-dimensional nature of health/wellness
Social determinants of health
Adaptability to work environment
Spirituality of self, team, and others
Counseling and treatment planning
50%
19%
31%
6%
6%
6%
6%
13%
6%
31%
13%
6%
38%
62%
44%
44%
75%
75%
6%
6%
19%
19%
6%
13%
for social work practice in HPC. Round One results
demonstrate strong agreement among the participants
regarding 11 specific competencies as essential to social
work practice in end of life care. Round Two results
reflect the consensus established among the panel of
experts regarding the descriptions of each competency.
Furthermore, several additional competencies have
been identified in this process and suggested as also
essential to social work practice in HPC. As expected,
differences among panel member perspectives also
emerged during this process, which are also valuable
data. The following discussion addresses additional
information received that is relevant for further
consideration.
comment section whereby participants questioned the
need to specify theories. Questions were raised about
why knowledge of specific theories is deemed a core
skill in some areas but not others. The task group
reviewed these comments and determined that the purpose of developing core competencies was not to outline a specific set of theories. However, the inclusion of
some theories pertinent to particular competencies was
deemed necessary by the panel and consensus was
established. Therefore, mindful of the fact that the
competencies do not include an exhaustive list of theories, it was determined that keeping the theories as
part of the competencies may be helpful in informing
practice and future curriculum.
Specificity of theories
Language
In the first round, specific theories were identified as
required knowledge for several of the competencies.
For example, for the competencies of advocacy, care
delivery and interdisciplinary team, theories pertaining
to communication and mediation, evaluation, systems,
and group work were specifically included, although
this level of detail does not occur in all possible
instances. This prompted a discussion within the
Several participants voiced concern regarding use of the
word ‘power.’ However, in adhering to the principles of
the Delphi process, we did not remove the word, as the
majority of participants did not comment on it, or seek
removal of it, during the Round Two data collection.
We underline this point because the reaction to the use
of this word seemed quite strong, and failure to mention the specific comments surrounding this term and
84
merely dismissing this concern would not be appropriate. Upon closer review, the main concern appears to
be related to the actual use of the word within a specific
context. For example, a participant questioned whether
‘power differentials’ fits with the competency care planning. Furthermore, a request was made to remove the
word ‘power’ from a bullet referencing ‘spirituality’ as
the participant deemed it inappropriate to link these
two terms together. Due to the reaction to this specific
word, the task group discussed the inclusion or removal
of the word and decided to leave the word as part of the
document.
In addition, the majority of respondents preferred
use of the term ‘evaluation’ rather than ‘confirmation’
as the name for that competency. Those participants
who advocated the ongoing use of the word ‘confirmation’ explained that this was the term used by the
Canadian Hospice Palliative Care Association in its
description of norms of practice. To maintain the integrity of the consensus building process, the competency
was changed from ‘confirmation’ to ‘evaluation.’
Core skills and level of education
The education and research competency generated the
greatest amount of discussion and debate, which
accounts for a lower level of consensus regarding the
‘skills’ domain of this competency (education 69%;
research 75%). Specifically, respondents voiced concern
that identification of research as a core competency
would limit the scope of HPC practice to Masters prepared social workers. Similarly, inclusion of supervision as a core skill within this competency was viewed
in the same way. This raises a larger question regarding
differences between Bachelor and Masters prepared
practitioners, and how those differences are apparent
along a continuum of knowledge and skills.
These responses also represent the various perceptions among social workers regarding the appropriate
scope of practice for each of these levels of education.
They reflect a long-standing discussion in the profession regarding generalist versus specialist training for
social workers in health care settings.39 Many generalist
social work skills regarding counseling, family systems,
community resources, and psychosocial assessments
are relevant to working with patients and families
with terminal illness.12 However, practitioners and
educators have underlined the benefit of a combined
generalist and specialist training for social workers
who work primarily with dying individuals and
families.18,39
From the outset, the task group recognized that
social work core competencies in HPC may not have
direct application across all settings and for all practitioners. This perspective reflects the reality of different
Palliative Medicine 24(1)
resource levels that exist across care sites and geographic locations in Canada. Therefore, the task
group emphasized that the final competencies should
not be presented for use as an inflexible or uniform
template of knowledge, values, and skills for all social
workers who provide HPC. Rather the competencies
are meant to be used as a recommended framework
outlining desired social work practice components
in end-of-life care. This echoes the Quality Endof-Life Care Coalition’s (2005) recommendation
that best practices be flexible enough to respond to
different service programs and settings, but substantial enough to provide clear guidelines for appropriate
care.
Additional competencies
As indicated above, six additional competencies were
identified as important to social work practice in HPC.
Although the majority of panel members indicated that
several of these competencies, such as the multidimensional nature of health and wellness, spirituality of self,
team, and others, and counseling and treatment planning
were already included in the original 11 competencies, a
significant number of respondents (50%) recommended
that cultural competence should be developed as a
stand-alone competency.
Implications
In the end, this information will be helpful to social
workers to articulate their role and activities to other
professionals, and serve as a basis to develop and evaluate outcomes of social work practice in HPC.
Furthermore, the competencies can be used to inform
social work professional development and educational
curricula in this area. As Lawson9 emphasizes, we must
develop and demonstrate our knowledge and skills so
that we can contribute effectively ‘to the shared responsibility of excellence in palliative and end-of-life care’
(p. 17).
The building of consensus around these competencies has resulted in a comprehensive, descriptive document outlining 11 core competencies for social work
practice in HPC.40 These competencies can be used to
facilitate the development of consistent practice goals
and guidelines for social workers entering the field as
well as those currently practicing in it. They are relevant across a range of practice locations and populations. Furthermore, social workers can draw on these
competencies to clearly articulate their role and activities within interprofessional care teams, and to evaluate their contributions.
An important next step is to incorporate these competencies into social work education curricula at both
H Bosma et al.
the undergraduate and graduate levels. Social workers
report that they are inadequately prepared to work with
dying and grieving clients.14,15,18,39,41 This assessment is
reiterated by social work educators, who share the perspective that students receive little course content on
care of the dying and bereaved.15 Insufficient educational preparation has been identified as a barrier to
effective and ethical practice in end-of-life care.11
These competencies can be used to build relevant
curricula for Bachelor of Social Work (BSW) and
Master of Social Work (MSW) courses as well as
professional development and training programs.
The incorporation of this knowledge into discipline curricula is one way to address this significant educational
gap and enhance the contributions of social work to
meaningful and effective end-of-life care.
Next steps
This project is currently being expanded into a subsequent phase of data generation through a national consultation process.a The aim of this second initiative is to
validate these 11 competencies, to explore how cultural
competence can be integrated into them or established
on its own, and to create a strategic plan for implementation into education and practice settings. This broad
consultation process will engage social work practitioners, educators, and professional organizations, as
well as individuals and families who are receiving
end-of-life care. With an expanded representation of
members involved in this next phase, these activities
will address the limitations related to the small panel
involved in the first project.
Acknowledgements
The authors acknowledge the support of Health Canada and
two CIHR-funded New Emerging Teams (NETs): Palliative
Care in a Cross-Cultural Context: A NET for equitable and
quality cancer care for culturally diverse populations and
Transitions in Pediatric Palliative and End-of-Life Care.
Note
a National Consultation for Implementation of Social Work
Competencies in Palliative Care Education Project.
Canadian Partnership Against Cancer Rebalance Focus
Education Subcommittee.
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