Social Work Practice in For-Profit and Not-For-Profit Dialysis Facilities: A Call for Action

BACKGROUND AND PURPOSE: Social workers’ caseloads, hourly wages, workload demands, and job-related emotional exhaustion can vary considerably depending on the organizational structure of their work setting.  In accordance with a Medicare mandate, a Master’s level social worker is required in every U.S. dialysis facility because of the many psychosocial barriers to optimal dialysis outcomes.  Studies in the literature indicate that high dialysis social worker caseloads are associated with lower patient satisfaction, less successful patient rehabilitation outcomes, and a decreased ability to provide clinical social work interventions (Bogatz, Colasanto, & Sweeney, 2005; Callahan, Moncrief, Wittman, & Maceda, 1998; Merighi & Ehlebracht, 2002, 2005).  In addition, high workload demands (Spector & Jex, 1998) and emotional exhaustion (Wharton, 1993) have been linked to suboptimal occupational outcomes such as job dissatisfaction, poor work performance, and limited commitment to an organization. The aim of this study is to assess variations in social workers’ practice experiences between for-profit and not-for-profit dialysis corporations.

METHODS: A cross-sectional online survey was administered to measure social workers’ caseloads, hourly rates, job-related resources, professional responsibilities, workload demands, and emotional exhaustion.  The survey contained 70, multicomponent questions and took 25 minutes to complete.  Data were gathered between January 2 and March 1, 2014 using the Council of Nephrology Social Worker (CNSW) listserv.  A sample of 617 full-time (32 hrs/wk or more) social workers was obtained from all 50 states and the Northern Mariana Islands.  The majority of respondents were female (92.6%), licensed in their state (89.2%), and White (87.0%).  Respondents had a mean age of 34.7 (9.1) years and 10.1 (9.1) years of nephrology-specific social work practice experience.

RESULTS: Overall, full-time social workers in for-profit settings (n=495) experienced greater burdens than their colleagues in not-for-profit settings (n=122).  Specifically, significant differences were found between for-profit and not-for-profit providers with regard to workload demands, emotional exhaustion, and caseloads.  In each case, employees in for-profit corporations reported higher workload demands (19.1 vs 17.1, p<.001), higher emotional exhaustion (19.2 vs. 14.8, p<.001), and higher caseloads (108.8 vs 95.0, p<.01) than employees in not-for-profit settings.  Hourly rate did not differ significantly between work settings.

CONCLUSIONS AND IMPLICATIONS: This study represents an important national effort to quantify disparities between for-profit and not-for-profit social work practice settings.  The majority of nephrology social workers in the United States are employed by large dialysis chains, and nearly 80% of dialysis patients receive their care from for-profit providers. Unfortunately, the corporate ethos of many for-profit dialysis providers has social workers performing tasks that support the financial goals of the organization. The study findings provide empirical evidence that can be used by CNSW, the National Kidney Foundation, and policy makers to lobby for more equitable work conditions so that social workers in for-profit settings experience fewer occupational burdens and dialysis patients receive optimal psychosocial care.