Understanding Complex Challenges and Creative Solutions in Rural Hospice Social Work

Background and Purpose: America's aging population, advances in life prolonging medical technologies, and rising health care costs are timely and critical issues. Therefore, policy-makers, practitioners, and researchers are becoming increasingly aware of the challenges associated with meeting the complex social service, health care, and end-of-life care needs of rural dwellers (National Rural Health Association, 2001). Literature exists on social work practice in rural areas and social work practice related to end-of-life care, but little research focuses specifically on both. The aims of this study were to investigate the complex factors involved in providing services, approaches to evaluating practice, and how to build capacity of local communities in rural settings.

Methods: A national cross-sectional survey was administered through a web-based survey. Hospice social workers were invited to participate through state and hospice and palliative care networks. A total of 339 (N=339) respondents participated in the survey, 61% of whom practiced in a very to somewhat rural setting and the years of experience ranged from five to 28 years (M=6.86, SD=5.26). Ninety-six percent of respondents possessed a masters or bachelors degree from a CSWE accredited school and 86% reported having social work licensure. The 93 item survey contained multiple choice questions including likert subscales. Additionally, participants were invited to answer many open-ended questions to explore the domains of interest.

The quantitative data was analyzed in SPSS. Respondents' answers were analyzed to determine the strongest responses. Correlations between items anticipated to be related were performed. Group differences were also tested between social workers who served more rural settings and those who worked more in urban settings. T-tests were used to determine differences of perceptions as well as professional and demographic information. Each open-ended survey question was examined using a line by line analysis and open coding process frequently employed in qualitative research (Boyatzis, 1998). Related themes were subsequently grouped together into higher order variables, and data excerpts were documented to verify each theme. Peer debriefing, a co-coding process involving ongoing comparative analysis and discussion of intersubjective agreement between the two principal investigators took place (Padgett, 1998; Lincoln & Guba, 1985).

Results: The results of analysis of both the quantitative and qualitative data can be grouped under three major domains of perceived challenges, approaches to overcoming those challenges, and perceived strengths of rural communities. Perceived challenges related to geographic distance, multiple roles, resources, hospice use, and practice specific challenges. For example, 57% of the participants were performing multiple roles and this challenge was statistically significantly higher for those who served in more rural settings. Over 45% of participants provided detailed commentary on multiple opened-ended questions.

Conclusions and Implications: The results of this national survey of hospice social workers revealed challenges and creative solutions for practice in rural areas. New contributions to the understanding of challenges and opportunities were identified. Findings can be used to inform future efforts to build on individual social work and community assets in order to improve the quality of life of terminally ill and chronically ill patients and their families.