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How to demonstrate that nephrology social work is effective
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As mandated members of interdisciplinary teams, Masters-level social workers providing care for dialysis and kidney transplant patients play an important role in improving patient outcomes. As outlined in Stephanie Johnstone’s article in this issue, there is a wide array of interventions that nephrology social workers can implement to fulfill this goal. These include ameliorating psychosocial barriers to care outcomes such as adjustment and coping, depression and anxiety, pain and palliative care, social role changes, quality of life, body image, sexuality, and reproduction. They can also include medication and treatment self-management as well as helping patients get kidney transplants.1
Nephrology social workers are the experts in dialysis and transplant settings related to psychosocial outcomes and interventions. The best way to remind your interdisciplinary colleagues of this is to document your efforts and demonstrate the value of your clinical expertise. These evaluations can be showcased at your clinic’s Quality Assurance and Performance Improvement meeting, written up and submitted to this publications or the Journal of Nephrology Social Work, or be the basis for abstracts or making presentations at conferences such as the National Kidney Foundation’s Spring Clinical Meeting or the American Society of Nephrology’s Kidney Week.
For most nephrology practitioners, the thought of “evaluation” might be a daunting enterprise, and invoke bad memories from your college research courses. Fear not! Today there are terrific resources and examples to make simple practice evaluation less intimidating for nephrology social workers (see Table 1). These include open-access journals where you can find relevant literature. You can also ask your interdisciplinary colleagues to read copies of their journals to stay informed about state of the art nephrology research.
Getting to work
For most social workers, using a Microsoft Excel spreadsheet is probably the easiest way to evaluate your data. In Excel, you can track information about the patients you work with (such as their age) and the indicator(s) you choose to determine if your intervention is a success (for example, their depression screening or Quality of Life scores). There are some great resources to walk you through using Excel for these purposes, including websites like www.utdallas.edu/~serfling/3332/Biology_statistics_made_simple_using_Excel.pdfand http://annkemery.com/excel/, or a book such as Don't Fear the Spreadsheet: A Beginner's Guide to Overcoming Excel's Frustrations by Nash, Jelen, Jones and Urtis.
Very simply, you are looking to see if patients do better after your intervention compared to before your intervention. You might also be able to use your clinic’s data management system to track these outcomes.
There are many different examples of nephrology social work evaluation in the literature to use as an example or motivation for your practice assessment. These examples highlight ways that social work intervention can improve patient outcomes, particularly those that are very important to a clinic’s bottom line and that impact patient quality of life. These include areas such as helping patients take their dialysis or transplant medications as prescribed, promoting the use of fistulas, and decreasing missed or shortened treatments.
For example, Lindber and colleagues 2 found that a team approach to patient education about vascular accesses, that included a social worker, was more successful than a single-disciplinary approach. Beder discovered that nephrology social work counseling and cognitive behavioral education interventions significantly lower patient depression. 3 Cabness determined that a cognitive behavioral education group led by social workers is significantly linked to lower depression. 4 Roberts and Johnstone noted that in one analysis, 76% of dialysis patients indicate that they prefer to seek counseling for depression from the nephrology social worker on their treatment team, rather than pursue care from an outside mental health practitioner. 5
Rita-An Kiely and her social work colleagues counseled patients on the importance of attending all hemodialysis treatments, tracked attendance, and provided ongoing encouragement for adhering to the treatment regime. As a result of this social work education and counseling, there was a 50% decrease in missed hemodialysis treatments. 6 Auslander and Buchs 7 and Root (2005) have shown that social work counseling and education led to reduced fluid weight gains in patients. Johnstone and Halshaw 8 found that social work education and encouragement were associated with a 47% improvement in fluid restriction adherence. Yusack found that patient education provided by social workers about advance directives led to a 51% increase in the use of such documents. 9
Beder, Mason, Johnstone, Callahan, and LeSage conducted an experimental research study to determine the effect of cognitive behavioral social work services. They found that patient education and counseling by nephrology social workers was significantly associated with increased medication compliance. This study also determined that such interventions improved patients’ blood pressure.10 Several researchers have determined that nephrology social work counseling significantly improves dialysis and transplant patient quality of life. 11-13 Recently, Dr. Ebony Boulware and colleagues discovered that a social work-delivered intervention significantly improves the likelihood that patients will pursue kidney transplantation.14 Finally, Melissa McCool and her colleagues have shown that symptom-targeted intervention (STI) can be used in brief intervals with patients while they are receiving dialysis treatments to help reduce depressive symptoms and improve quality of life. 15
Collaboration with renal professionals
Nephrology social workers can partner with their colleagues in their clinics to conduct evaluation research. For example, you can collaborate with your dietitian to try an intervention that will reduce patient interdialytic weight gains, or with your nurse to improve the use of fistulas in your unit. Be sure to track your outcomes, and present them to your entire team. Also, you can explore partnering with a local social work professor who is interested in health or medical social work to work on a publication about the work you do with your patients.
Research demonstrates, verifies our value
It is essential to remember that demonstrating the value of social work interventions is critically important for several reasons. Primarily, we need to know that what we are doing works and helps patients and their families. Practice evaluation also allows us to modify our interventions appropriately. It is also important to share the findings of our intervention efficacy with our colleagues and employers. This promotes interdisciplinary team work, and highlights the value of clinical social work. Finally, our code of ethics reminds us that “social workers should monitor and evaluate policies, the implementation of programs, and practice interventions.” 16 Accordingly, nephrology social workers must evaluate their practice, and with the resources in this article may find that mandate less daunting. -by Terri Browne, PhD, MSW, NSW-C
References
1. Browne T. (2011). Nephrology social work. In S. Gehlert, and T. Browne (Eds.), Handbook of Health Social Work, 2nd Edition. (pp. 468-497). NY, NY: John Wiley & Sons.
2. Lindber JS, Husserl FE, Ross, JL, Jackson D, Scarlata D, Nussbam J. et al. (2005). Impact of multidisciplinary early renal education on vascular access placement. Nephrology News and Issues, 19(3), 35-43.
3. Beder J. (1999). Evaluation research on the effectiveness of social work intervention on dialysis patients: The first 3 months. Social Work in Health Care, 30(1), 15–30.
4. Cabness J. (2005). National Kidney Foundation second quarter research progress report. New York: National Kidney Foundation.
5. Roberts J, Johnstone S. (2006). Screening and treating depression: Patient preferences and implications for social workers. Nephrology News & Issues. 20(13):43, 47-49.
6. Medical Education Institute. (2004). Social work project reduces missed treatments. Control, 1(3), S2, S8.
7. Auslander, GK, Buchs A.(2002). Evaluating an activity intervention with hemodialysis patients in Israel. Social Work in Health Care, 35(1/2), 407–423.
8. Johnstone S, Halshaw D. (2003). Making peace with fluid: Social workers lead cognitive-behavioral intervention to reduce health-risk behavior. Nephrology News and Issues, 17(13), 20–27, 31.
9. Yusack, CM.(1999). The effectiveness of a structured education program on the completion of advance directives among hemodialysis patients. Journal of Nephrology Social Work, 19, 51–56.
10. Beder J, Mason S, Johnstone S, Callahan MB, LeSage L. (2003). Effectiveness of a social work psychoeductional program in improving adherence behavior associated with risk of CVD in ESRD patients. Journal of Nephrology Social Work, 22, 12–22.
11. Chang, CF, Winsett RP, Gaber AO, Hathaway DK (2004). Cost-effectiveness of post-transplantation quality of life intervention among kidney recipients. Clinical Transplantation, 18(4), 407-415.
12. Frank A, Auslander GK, Weissgarten J. (2003). Quality of life of patients with end-stage renal disease at various stages of the illness. Social Work in Health Care, 38(2), 1–27.
13. Johnstone S. (2003). Evaluating the impact of a physical rehabilitation program for dialysis patients. Journal of Nephrology Social Work, 22, 28–30.
14. Boulware, LE, Hill-Briggs F, Kraus, ES, Melancon JK, Falcone B, Ephraim PL, et al. (2013). Effectiveness of educational and social worker interventions to activate patients’ discussion and pursuit of preemptive live kidney transplantation: A randomized controlled trial. American Journal of Kidney Diseases, 61(3), 476-486.
15. McCool M, Johnstone S, et al. (2011). The promise of symptom-targeted intervention to manage depression in dialysis patients. Nephrology News & Issues, 25(6), 32-33.
16. National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Washington, D.C. NASW Press.