Six months in: COVID-19 and its impact on oncology social work practice

Abstract

The extent to which oncology social workers (OSWs) are available and adapting to disruptions in service delivery throughout the COVID-19 pandemic is unknown.

Objectives:

The purpose of this report is to outline the initial impact of COVID-19 on oncology social work practice during the first six months of the pandemic.

Methods:

As part of a nationwide investigation of workforce conditions for OSWs, three professional organizations surveyed their members to assess the effects of COVID-19 on changes to work hours, employment status, work setting, pay, and mode for patient contact (e.g., telephone or videoconference).

Findings:

Among 939 OSWs, 20% reported a reduction in work hours, and two-thirds indicated a temporary shift in work to home, with most patient contact occurring primarily via telephone or videoconference.

Implications:

Results speak to the essential nature of oncology social work and the need for evidence to inform OSW training and advocacy efforts for however long the pandemic continues.

Introduction

The COVID-19 pandemic has exposed long-standing inequities and produced unprecedented stresses on the United States health care system.^1,2 Current understanding about the pandemic suggests that we will continue to observe these inequities and stresses as regions of the country experience surges of the virus and associated competition for scarce technological and human resources.³ Cancer patients, in particular, have experienced changes and limitations with regard to care access, and are disproportionately borne by vulnerable populations, including Black, Indigenous and Persons of Color (BIPOC), and persons with co-occurring physical and mental health challenges.^4,5

Social workers comprise the largest proportion of mental health care providers in the US,⁶ with oncology social workers (OSWs) being at the front line of addressing and mitigating the psychosocial and behavioral effects of cancer and COVID-19 on patients, families, and communities. The extent to which OSWs are available and able to adapt to disruptions in care delivery throughout the COVID-19 pandemic and for however long it may continue is unknown. Thus, the purpose of this brief report is to outline the initial impact of COVID-19 on oncology social work practice during the first six months of the pandemic.

Methods

Three professional organizations – the Association of Oncology Social Work (AOSW), the Association of Pediatric Oncology Social Work (APOSW), and the Association of Community Cancer Centers (ACCC) – surveyed their members in August-September, 2020 to examine workforce conditions and delineate the role of an oncology social worker. An online questionnaire included five Likert-scale items assessing the extent to which OSWs experienced temporary or on-going reductions or changes to work hours, employment status (e.g., dismissed or furloughed), work setting (home), pay, and mode for patient contact (e.g., telephone or videoconference) as a result of COVID-19. Descriptive statistics and cross-tabulations for reporting effects by OSWs’ type of cancer program are presented. Illustrative responses to a single open-ended question asking participants to describe ways they have experienced or observed changes in their work or professional life as a result of COVID-19 are also presented.

Results

Data analytic results were derived from 939 social workers who indicated that their practice setting was within a cancer program and that their work included direct service with cancer patients (Table 1).

Table 1.

Sample description (n = 939).

	Frequency (%)
Primary role
Direct service provider	848 (90.3)
Management, supervision, administration (including program director)	91 (9.7)
Type of health system
NCI-Designated Cancer Program (NCIP)	276 (29.4)
Academic or University-affiliated Cancer Program (ACAD)	185 (19.7)
Comprehensive Community Cancer Program (CCCP)	200 (21.3)
Community Cancer Program (CCP)	137 (14.6)
Pediatric Cancer Program (PEDS)	68 (7.2)
Other Cancer Programa	73 (7.8)

^aOther Cancer Program = Veterans Affairs Cancer Program, Free-standing Cancer Program, Integrated Network Cancer Program, Hospice, Home Health Care.

The extent to which respondents reported that either temporary or on-going changes in their health system occurred as a result of COVID-19 are summarized in Table 2. Approximately one in five respondents (n = 199) indicated that they experienced a reduction in their work hours at some time during the first six months of the COVID-19 pandemic, with most of those (n = 158, 79%) indicating that the reduction in hours was temporary. Of the 93 social workers (9.9%) who were forced to stop work, 12 (13%) indicated that their work stoppage was on-going at the time of study. Among 64 social workers (6.8%) who reported a reduction in pay, 27 (42%) indicated that the pay cut was on-going.

Table 2.

Frequency (percent) of social workers reporting changes in practice as a result of COVID-19 (n = 939).

	No	Yes, but no longer (temporary)	Yes, and on-going
Reduction in work hours	717 (76.4)	158 (16.8)	41 (4.4)
Forced to stop work (e.g., furloughed, dismissed)	818 (87.1)	81 (8.6)	12 (2.9)
Reduction in pay	845 (90.0)	37 (3.9)	27 (2.9)
Work from home/telecommute	319 (34.0)	268 (28.5)	328 (34.9)
Patient contact limited to telephone or videoconference	296 (31.5)	284 (30.2)	334 (35.6)

Not all rows total 100% due to missing data.

OSW’s open-ended responses described personal distress attributable to reduction in hours and shifts of work from the cancer center to home. They also reported observations of exacerbated stress for patients and families that were linked to isolation, job and income loss, substance use, and infection control efforts that precluded family members or other caregivers from accompanying patients at scheduled appointments or visiting them while admitted to the hospital. Social workers also commented on the exacerbated stress experienced by colleagues who remained on site and witnessed patient experiences of inadequately addressed distress, loneliness, and isolation.

Two-thirds of respondents were required to work from home, with patient contact limited to telephone or videoconferencing. At the time of this study, approximately 35% of OSWs were still working from home and providing only telehealth or virtual support services. Their comments included descriptions of how working from home and communicating with most patients primarily via mobile devices resulted in a shift in the type of services rendered, with less clinical and psychotherapeutic intervention (including support groups) and more attention to addressing practical support needs as a consequence of an increased financial burden for patients. In some instances, a shift of therapeutic services (including support groups) to online/virtual settings and telehealth improved service delivery and access to services.

All of my work has become remote (telephonic visits), but that has had unexpected positive impact on patients and myself (increased privacy to speak with patients about sensitive issues, patients feel more comfortable opening up when they have chosen the day/time of initial psychosocial assessment rather than having it imposed on them during their first infusion visit (pre-COVID protocol), not having to worry about space and privacy (of which there was none in clinic).

Descriptions of benefits for some patients, however, were countered by comments about others who were unable to access virtual services due to limited cellular minutes or difficulties hearing. Some OSWs described a sense of loss in being able to have face-to-face contact, personal touch with patients, and rapport-building.

While the telephone is an effective way of interacting with patients at times, it is not appropriate for some circumstances such as meetings with newly diagnosed patients, goals of care meeting, crisis intervention, etc.

Working from home, some OSWs perceived their efforts to serve patients and also support colleagues who continued to work on-site as suboptimal, and included concerns about having to use one’s own personal electronic devices (e.g., cellphone, computer) while working from home.

I am working from home with a toddler on my own, which doesn’t lend to a therapeutic environment for phone calls.

I was very angry that the hospital insisted on me working remotely as none of the other staff in my clinic was asked to do so. I felt I wasn’t supporting my team as well as my patients.

Results of cross-tabulations suggest significant differences in the likelihood of social workers reporting COVID-19 related effects by the type of cancer program in which they worked (Figure 1(a–c)). OSWs working in NCI-Designated Cancer Programs (NCIP) and Academic or University-affiliated Cancer Programs (ACAD) were half as likely to report reductions in work hours, when compared to OSWs at Comprehensive Community Cancer Centers and Community Cancer Programs (X² = 35.9; p = .000) (Figure 1(a)). Across cancer programs, approximately one-half to three-fourths of all OSWs reported that they experienced at least a temporary shift of work to home, with a significantly greater proportion of social workers at NCIPs (76.0%) and ACAD (72.8%) programs shifting work to home and still working from home at the time of study (X² = 39.7; p = .000) (Figure 1(b)). Overall, 60–70% of OSWs indicated that patient contact had been limited to telehealth or videoconferencing, and was still occurring for 30–45% of all OSWs, with no significant differences observed across sites (X² = 6.6; p = 0.25) (Figure 1(c)). Responses to the open-ended item suggested that some face-to-face patient contact had been reinitiated but only with the most severely distressed patients, and that these contacts were mediated through, and often negatively affected by, the use of Personal Protective Equipment (PPE) as well as by masks worn by patients:

“Wearing masks makes it harder to read patient’s facial expression, and hard for patients to hear/understand me (lots of repeating).”

Figure 1.

(a) Percent of social workers reporting reduction in hours. (b) Percent of social workers reporting work from home. (c) Percent of social workers reporting patient contact limited to telephone/video.

Discussion

The findings speak to the essential nature and adaptability of oncology social work. Most OSWs returned to work on-site after temporary shifts to working from home, and most OSWs did not experience reductions in hours or pay. For those reporting reductions, the extent to which these effects were temporary are consistent with how many hospitals and health systems initially reacted to the pandemic by re-directing resources to management of COVID-19 patients in order to attenuate catastrophic circumstances (e.g., stressing systems beyond capacity), and with less attention given to the impact on non-emergent care and inequalities to care, which emerged later.⁴ Though challenges continued for some settings and systems, most OSWs adapted the delivery of psychosocial support and care to telephone or online interface, while reserving face-to-face contact for patients in the most dire or severe of circumstances, when permitted by the institution. OSWs described simultaneous and sometimes contradictory experiences of distress and benefit related to virtual delivery of psychosocial support services. Challenges, including difficulty building rapport and assuring confidentiality, were reported by those who were required to shift to working from home with the use of telephone/computer versus face-to-face connections, while benefits such as increased patient availability when not competing with busy cancer center visits were also recognized.

Most of the survey participants were employed by national organizations and large institutions. The extent to which they fully represent a universe of social workers who work with cancer patients across multiple and varied settings is unknown. Further exploration of the settings, conditions, and strategies used by OSWs to engage successfully with patients and delivery quality care is required to inform best practices as well as to build an evidence-base demonstrating efficacy of telehealth as applied to the delivery of psychosocial support services for cancer patients and their families. Research about patient experiences related to telehealth consultation and delivery of therapeutic support and intervention is also needed to determine the extent to which patients and families are differentially impacted by the shifts in OSW practice. The notion of precision medicine as applied to psychosocial care for cancer patients suggests a need to determine which patients are likely to benefit from telehealth and other virtual services such as online support groups, and which may require and be more likely to benefit from direct face-to-face contact.

These data are critically needed to support advocacy. If data support the continued use of telehealth for psychosocial care of cancer patients and their families, successful implementation will require that employers support new education and training methods to assure best practices in this expanding modality, including regard for patient privacy and secure use of electronic communication channels. Institutions will also need to assure the provision of necessary resources for virtual patient engagement (e.g., hospital-owned cell phones and computers and not providers’ own personal devices) and also advocate for legislative policies that support virtual patient interactions, such as private insurance reimbursement for telehealth/virtual OSW services. Nationally, the Centers for Medicare & Medicaid Services has expanded telehealth benefits for Medicare beneficiaries during the outbreak, a decision that will allow individuals to receive health care services without traveling to a health care facility.⁴ As reported here, OSWs are playing an essential role in the delivery of potentially reimbursable telehealth services.

The COVID-19 pandemic will have a lasting impact on health care and social work practice. Crippling financial losses due to COVID-19 threaten the viability of hospitals and practices across the US, especially those that were already financially vulnerable, including rural and safety-net providers.¹ OSWs in this study reported a shift in the type of services rendered when working from home and even after returning to their place of employment, with less time and effort spent on clinical and psychotherapeutic intervention (including support groups) and more on patient support needs related to the financial effects of cancer and COVID.

It remains to be seen whether OSWs will continue to work virtually and if in doing so they continue to experience a de-emphasis on or limited ability to deliver clinical services. Thus, it is incumbent upon social workers to plan for and sustain oncology social work practice, support colleagues, learn new skills, and contribute to future advances in delivery of quality cancer care, including the elimination of long-standing disparities that have been exposed by the COVID-19 crisis. Professional associations such as AOSW, APOSW, ACCC and others are well-positioned to promote the value and essential nature of OSW service by continuing to provide clear guidance to members about the scope of OSW service, and by continuing to educate members about effective approaches to assessment, intervention, advocacy and research.