High quality resident care increases likelihood that nursing home social service directors report thriving at work.

Nursing homes contend with high staff turnover. Resources invested in employees are lost when an employee leaves. However, if employees are thriving in their job, turnover is less a concern. How can employers promote thriving in employees? Using an adaptation of Spreitzer et al. (2005)'s Social Embeddedness Model of Thriving at Work as a conceptual framework, we performed a logistic regression on the responses of 836 nursing home social service directors in the 2019 National Nursing Home Social Service Director Survey to determine factors that contribute to thriving. The model explained 39% of the variation. Seven variables contributed the most to distinguishing social service directors who report thriving at work from those who do not. Having greater influence on social service functions, having time to support residents, not having to do things others could do, and the facility providing quality care were all associated with greater thriving. Those who reported the administrator and/or attending physicians engage the expertise of social services were more likely to report thriving at work. Working in nursing home social services is demanding; retaining a good social worker is important. These findings suggest ways in which administrators can support social service directors thriving at work.

Social Workers Critical to Honoring Commitments to Residents and Families in Long-Term Care.

Social workers have been at the forefront of research and advocacy to improve nursing home care for several decades. However, United States (U.S.) regulations have not kept pace with professional standards, as nursing home social services workers are still not required to have a degree in social work and many are assigned caseloads that are untenable for providing quality psychosocial and behavioral health care. The National Academies of Sciences, Engineering, and Medicine (NASEM)'s recently published interdisciplinary consensus report, The National Imperative to Improve Nursing Home Quality: Honoring our Commitment to Residents, Families, and Staff (NASEM, 2022) makes recommendations for changing these regulations, reflecting years of social work scholarship and policy advocacy. In this commentary, we highlight the NASEM report recommendations for social work and chart a course for continuing scholarship and policy advocacy to improve resident outcomes.

High Interest in Pursuing Trauma-Informed Care in Nursing Home Social Services Directors.

This study explored nursing home social services directors' interest in pursuing trauma-informed care (TIC) training, and individual and organizational characteristics associated with their interest. Data from the 2019 National Nursing Home Social Services Directors Survey, a national cross-sectional survey, were used. Measures sought information on participants' interest in TIC training, sociodemographic characteristics, and characteristics of employing nursing homes. Descriptive statistics and multivariate binary logistic regression analyses were used. Of the 924 respondents, 880 (95.2%) were included in the analysis. Most (71.7%) expressed high interest in TIC training. Younger age, fewer years of nursing home social services experience, being degreed and licensed in social work, and being a person of color were associated with greater odds of high interest in TIC training. Neither nursing home ownership nor social services staffing ratio was significantly associated with interest in TIC training. As policy requires TIC in nursing homes, these findings present a first step towards understanding implementation.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes.

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

Dementia Care Involvement and Training Needs of Social Services Directors in U.S. Nursing Homes.

This study describes social services directors' involvement in dementia care in U.S. nursing homes, focusing on interest in and needs for dementia care training. Respondents were 924 social service directors from U.S. nursing homes. We found that 87% of social service departments engaged in cognitive assessment; 59% of social services directors were strongly interested in dementia care training, and 23% would need up to 10 hours of preparation time or would not be able to train staff on dementia-related care. Multinomial logistic regression analysis (n = 836) revealed that, in comparison to having no interest in dementia training, age, years of experience in nursing homes, outside mental health contracting, barriers to staffing, and hours needed to prepare dementia training predicted varying interest in dementia care training. These findings demonstrate social services directors' active involvement in dementia care and need for training.

Structural Characteristics of Nursing Homes and Social Service Directors that Influence Their Engagement in Disaster Preparedness Processes.

Nursing home residents are an at-risk population during disaster situations, and nursing homes face unique challenges in managing disasters. Nursing home social service departments can support their nursing homes in meeting the needs of residents during disasters, yet there is little research exploring their involvement. To address this gap, we use secondary data from the 2019 National Nursing Home Social Service Directors' study to explore social service directors' and their departments' involvement in disaster preparedness and response, and personal- and nursing home-level characteristics that predict involvement. Results show that nursing home social service directors and their staffs are predominantly involved; 61.9% (n = 562) of respondents stated always participating, and an additional 20.3% (n = 184) usually participating in disaster planning. The age of the director significantly predicted involvement, with older directors being most likely to always be involved. Further research is needed to understand why some nursing homes involve their social service directors in disaster planning and others do not, what roles those directors play, and to identify strategies to increase involvement within this role.

Barriers to Psychosocial Care in Nursing Homes as Reported by Social Services Directors.

This study identifies social services directors' perceptions of major barriers to psychosocial care and examines the structural factors associated with these barriers. Data were merged from the 2019 National Nursing Home Social Services Directors Survey and CMS's Nursing Home Compare. A hierarchical linear regression predicts overall barriers. Nine binary logistic regressions predict specific barriers. Common major barriers include "insufficient number of nurse aide staff" (31%), and "having to do things other people could do" (30%). Overall barriers to psychosocial care decreased as directors' years of experience increased, the number of staff members in social services increased, and less time was spent on short-stay residents. Departments with one staff member (compared to 3+) have a 300% greater likelihood of perceiving a major barrier in social services staffing, pressured discharge of short-stay residents, and residents' socioemotional needs are treated as less important than medical/nursing needs. Directors had a 59%-239% greater likelihood of perceiving a major barrier across six of the nine barriers when 50% or more of social services staffing is devoted to short-stay residents. To improve psychosocial care, federal guidelines should ensure adequate staffing levels differentiated by resident needs across short- and long-term care.

Social Services Involvement in Care Transitions and Admissions in Nursing Homes.

Care transitions (CT) are critical junctures in the healthcare delivery process. Effective transitions reduce the need for subsequent transfers between healthcare settings, including nursing homes. Understanding social services (SS) involvement in these processes in nursing homes is important from a quality and holistic care perspective. Using logistic regression, this study examines structural and relational factors identified with higher involvement of SS in care transitions and admissions. SS directors from 924 nursing homes were evaluated in relation to SS involvement in care transitions and admissions processes. Results suggest the level of SS involvement in care transitions and admissions are associated with structural factors such as size of facility, geographical location, ratio of FTE's to beds, ownership status, and standalone SS departments, as well as relational factors, including perceptions and utilization of SS staff by facility leadership, coworkers, and family. Additionally, SS staff with higher levels of expertise and with social work degrees are less involved in admissions tasks.

Dementia Tops Training Needs of Nursing Home Social Services Directors; Discharge Responsibilities Are Common Core Functions of the Department.

This report address two key questions: what are common core functions of nursing home social services departments and what are top training needs. Cross-sectional survey data collected in 2019 from a nationally representative sample of 924 social services directors reveal 33 responsibilities that at least two-thirds of respondents reported their department was usually or always involved in. We document strong and consistent interest in more training related to dementia and in common mental health and psychosocial challenges residents face. Findings reveal that training specific to social services is difficult to find. Online training opportunities were endorsed and 96% felt training targeted to new social services directors would be useful.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors.

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.

About a Third of Nursing Home Social Services Directors Have Earned a Social Work Degree and License.

Nursing home (NH) residents have high psychosocial needs related to illness, disability, and changing life circumstances. The staff member with the most expertise in addressing psychosocial needs is the social worker. However, federal regulations indicate that only NHs with 120+ beds need hire a social services staff member and that a "qualified social worker" need not have a social work degree. Therefore, two-thirds of NHs are not required to employ a social services staff member and none are required to hire a degreed social worker. This is in stark contrast to NASW professional standards. Reporting findings from this nationally representative sample of 924 social services directors, we describe the NH social services workforce and document that most NHs do hire social services staff, although 42% of social services directors are not social work educated. 37% of NHs have a degreed and licensed social worker at the helm of social services. The odds of hiring a degreed and licensed social workers are higher for larger NHs, especially if not-for-profit and not part of a chain. NH residents deserve psychosocial care planned by staff with such expertise. Quality of psychosocial care impacts quality of life.

Prospect Theory Concepts Applied to Family Members of Nursing Home Residents with Cancer: A Good Ending Is a Gain.

Family members are often involved in medical decision-making on behalf of a nursing home resident. Prospect theory provides a framework for understanding how people weigh decisions. In the current study, prospect theory concepts are used to build understanding about how family members weigh medical decisions for an NH resident diagnosed with cancer. This is a secondary analysis of qualitative interview data from 24 family members of nursing home residents. Prospect theory concepts of gain, loss, risk, and reference point were used deductively in qualitative content analysis. Themes were developed by comparing content related to these four concepts, across the transcripts from the 24 participants. Three themes comprise the main findings, including "Don't prolong this," "A good ending is a gain," and "Experience can facilitate seeing the big picture." Prospect theory concepts applied to decisions faced by family members were useful in building an understanding of what participants considered as gains, losses, risks, and reference points. Many participants framed the medical decisions within the larger context of the resident's life and concluded that jeopardizing the chance for a peaceful dying process was too high a risk. Medical interventions were selected or avoided because of the impact on a comfortable dying process; considered a gain. Advance care planning discussions and goals of care discussions can benefit by directly addressing what residents/patients, families, and health practitioners consider outcomes worth pursuing and avoiding.

Defining Core Competencies for Generalist-Level Palliative Social Work.

CONTEXT: Care provided to seriously ill patients by frontline social workers is a component of generalist-level palliative care. The core competencies for high-quality generalist-level palliative social work are necessary to promote training curricula and best practices but have not yet been defined in the U.S. OBJECTIVE: The objective of this study was to develop consensus-derived core competencies for generalist-level palliative social work. METHODS: Fifty-five proposed social work competencies were categorized by the eight domains of palliative care identified by the National Consensus Project for Quality Palliative Care. The competencies were rated by 41 regionally dispersed, Master's level social workers selected through purposive and snowball sampling using a Delphi method. Each was rated as essential for generalist-level palliative social work, acceptable with modifications, or rejected based on the judgment that it was not essential for generalist-level palliative social work or was outside the scope of practice. Consensus was defined as >70% agreement to accept or reject a competency. Three review rounds were needed to achieve consensus on all competencies. RESULTS: Two competencies were added to the original list. Of the 57 proposed competencies, 41 were accepted (19 after modification) and 16 were rejected. Competencies in the social, spiritual, cultural, and ethical/legal aspects of care domains were relatively more likely to be accepted compared with those in structure and processes of care, physical care, psychological care, and care of patient at the end of life. CONCLUSION: The 41 consensus-derived competencies for generalist-level palliative social work may inform the development of training curricula and standards for high-quality care.

Nursing Home Residents' Legal Access to Onsite Professional Psychosocial Care: Federal and State Regulations Do Not Meet Minimum Professional Social Work Standards.

Background and Objective: The federal government holds nursing homes (NHs) responsible for assessing and addressing resident psychosocial needs. The staff person most responsible for psychosocial care planning is the social worker. However, the federal government requires only NHs with 120+ beds to employ one full-time social worker, and that person need not hold a social work degree. We compare/contrast state laws against federal laws and professional standards in terms of the minimum qualifications of NH social workers to determine in which states NH residents are legally entitled to receive services from a professional social work staff member. Research Design and Methods: Qualitative content analysis of language regarding NH social worker qualifications in state (and DC) administrative codes. Results: Twelve states do not address NH social worker qualifications. Up to 25 states appear to be out of federal compliance. Only Maine appears to meet the NASW professional standards. Other states approaching the standards include: Alaska, Arkansas, Connecticut, Illinois, Massachusetts, Minnesota, and West Virginia. Discussion: The vast majority of the 3 million residents a year served by U.S. NHs are not entitled to social work staff who meet minimum professional standards, despite new federal regulations calling for trauma-informed and culturally competent care planning and the recognition that the needs of residents (including psychosocial needs) have continued to increase over past decades. Changes in federal regulations are recommended so that all NH residents have access to professional psychosocial services provided by a staff person who has earned at least a bachelor's degree in social work and who carries a reasonable caseload.