By 2020, health care social workers are projected to make up 25 percent of the entire number of professional social workers in the United States. At the University of Southern California, the number of graduate students selecting the health social work concentration has increased exponentially over the last five years. Although there are no published findings to indicate that other schools of social work are experiencing a similar trend, the Bureau of Labor Sta tistics has reported that, nationally, the number of social workers employed in health care has increased and is projected to continue increasing over the next decade. The purpose of this study was to identify decision-making determinants of MSW students pursuing a specific vocational interest in health care settings. The study used a questionnaire to gather quantita tive and qualitative data from a population of MSW students. The findings suggest that grad uate students select the health concentration based on self-knowledge (abilities and interests) and vocational knowledge (job demands and labor market). This article concludes with a discussion of the implications of these findings for health social work curriculums, practice, research, policy, and the integral role social workers play in health care reform in the present and will play in the future.
KEY WORDS: health care reform; health education; health labor force; health policy analysis
Nationally and internationally social workers practice in an array o f settings, including health care, nonprofit organizations, consulting groups, and schools, to name a few. This article focuses on social workers interested in prac ticing in health care settings and provides a discus sion o f the impact social workers can have in health care in the U nited States with specific regards to policy, research, and curriculum.
The overall numberofsocial workers in theUnited States is projected to increase gradually over the next decade. In contrast, the percentage o f social workers employed through health facilities is pro jected to experience a more dramatic increase of 19.5 percent between 2008 and 2018 (U.S. Depart ment o f Labor, Bureau of Labor Statistics [DOL, BLS], n.d.-a). To date, no research has been con ducted to examine reasons for this increase. This study aims to identify determinants of health concentration selection among MSW students at the University of Southern California (USC). Since 2007, the num ber of students that select the health concentration has experienced exponential growth, from 21 stu dents in 2006 to 110 in 2012 (see Figure 1).
LITERATURE REVIEW Health social work is a growing field. In 2008 social workers represented 1.4 percent o f the total health care workforce (DOL, BLS, n.d.-a). The DOL pre dicts that by 2020, the number of health care social workers will increase by 34 percent and will make up 25 percent o f the entire number of professional social workers (DOL, BLS, 2012). Understanding why graduate students select social work with a spe cific specialization in health care as a vocation can aid in national efforts to educate and attract more social workers to health care— although this con centration is already gaining in popularity, im proving these efforts will ensure that there will be an adequate supply o f social workers with health care training to meet the needs o f an additional 32 million patients insured under the Patient Pro tection and the Affordable Care Act of 2010 (P.L. 111—148), commonly abbreviated as the ACA (DeParle, 2010). Identifying potential reasons for the increase in popularity is not only of interest, but also necessary. As of this writing, no research was found that provides reasons for the increase in health care social workers. However, Kerson, McCoyd,
doi: 10.1093/hsw/hlu033 © 2014 National Association o f Social Workers 230
Figure 1: Number of University of Southern California MSW Students Selecting Health
and Associates (2010) have offered specific cases exemplifying the multifaceted role social workers play in health settings. Researchers have also noted that changes in health care places additional requirements on social workers to focus on clinical interventions, research, cultural competency, and the ability to work with complex cases (Browne, Smith, Ewalt, & Walker, 1996).
WORKING HYPOTHESES This study posed the following four research ques tions: (1) Do personal experiences influence MSW students’ selection o f the health care concentration? (2) Do MSW students select the health concentra tion because of the growing older adult population? (3) Do MSW students select the health concentra tion for job and financial security? (4) Do MSW students select the health concentration because of interest in the ACA or health care reform in general? These questions were formulated to improve our understanding o f why there has been an increase in the number of MSW students seeking a vocation as health care social workers and of the implications of how health social workers may affect health care in the present and future.
Personal Experience The first hypothesis proposes that personal experi ences may influence vocational selection o f social workers in health care settings. Parson’s Career Development Theory suggests that individual voca tional decision making is rationally informed by identifying a match between both self-knowledge (abilities and interest) and vocational knowledge (job demands and labor market) (National Guid ance Research Forum, 2012). Therefore, graduate students may select health social work as a vocation
because o f a match between personal interests and abilities and the knowledge o f the labor market and job specification. The social work profession has a unique set o f ideals detailed in NASW’s Code of Ethics that emphasize service, social justice, dig nity and worth o f the person, importance of human relationships, integrity, and competence (NASW, 2008). Consequently, a match between values from the Code of Ethics with personal knowledge may also inform vocational decision making, resulting in a propensity and passion to work with individuals in health settings. Self-knowledge for health care interest may be informed by personal experiences that may include, but are not limited to, a previous experience of being a medical patient or o f having a family member with health issues. This study seeks to understand the role o f self-knowledge (abilities, personal experiences, and interests) in graduate student selection of social work in health care as a vocation.
Growing Older Adult Population The second hypothesis offers the increase in geriat ric patients as one explanation for the projected growth in social workers over the next decade. This hypothesis relates to vocational knowledge inherent in Parson’s Career Development Theory (National Guidance Research Forum, 2012). Grad uate students who have a self-knowledge match for social work may select health care as a specialty in light o f understanding the labor market and subse quent health care needs o f a growing aging popula tion (National Guidance Research Forum, 2012). It is hypothesized that an increase in the number of older adults may lead to an increase in social workers who desire to work in health care. Older adults are projected to make up 19 percent o f the population by 2030 (U.S. Department o f Health and Human Services, 2012). W ith an increase in older adults, social workers practicing in health-related fields must become adept in palliative care, hospice care, and care o f chronic illnesses (Berkman, Gardner, Zodikoff, & Harootyan, 2006). The increase in the number of older adults suggests that more jobs will be available to social workers in health settings (DOL, BLS, n.d.-a). Furthermore, Berkman, Gard ner, Zodikoff, and Harootyan (2005) emphasized that the social work perspective can ensure that health care providers do not solely categorize older adults under the field of gerontology. An integrated approach using a framework o f “biological, psy chological, socioenvironmental, cultural, political,
M itchell and Joosten / Determinants o f Health Concentration Selection among University o f Southern California M S W Students 231
and economic contexts” (Berkman et al., 2006, p. 204) must be used when assessing and treating older adults.
Job an d F in an c ia l S ecu rity The third hypothesis for the increase in the number of social workers is the desire for job and financial security. Returning to Parson’s Career Develop ment Theory, graduate students with a match be tween self-knowledge (interest in social work and health) and vocational knowledge (awareness of labor market) may base their vocational decision making on the proj ected job growth for social work ers in the health care sector. Job security and finan cial security do not mean the same thing; however, they are related. Job security refers to the ability to find and retain employment, whereas financial security describes how financial resources contribute to the maintenance of one’s lifestyle. Although they are diiferent, they both can directly affect one’s finances. Students may be selecting the health con centration because o f the perception that employ ment in a health setting is more secure. According to the U.S. News (2013), the most secure jobs are in the field o f health care. One of the main areas affected by the recent Great Recession and subse quent economic downturn has been employment. As of March 2012, the unemployment rate for the United States was 8.2 percent (DOL, BLS, n.d.-b). The mean annual salary for individuals with at least a BSW was $42,480 in 2010, which was lower than the mean annual salary for BSW health social work ers at $45,582. The minimum requirement for social workers is a BSW; however, qualification require ments vary by agency, and according to the DOL, BLS (2014) an MSW is often required. In addition, some organizations require licensure for employ ment in health settings that vary by state. In 2010, the mean annual salary for health social workers employed specifically in hospitals was $53,400. This salary was 25 percent higher than the mean annual salary for all social workers (DOL, BLS, 2014). Therefore, the desire for job and financial security may play a role in a social work student’s choice to work in health care.
In te re s t in H e a lth Care R e fo rm The fourth and final hypothesis suggests that the recent health care reform may have influenced MSW students’ selection of the health concentra tion. Health care social workers provide assistance to
individuals and families during their most vulnera ble moments with services such as crisis intervention, needs assessments, palliative care, hospice care, and dealing with grief and loss (Berkman, 1996). Fur thermore, with the changing face of health care pol icy in the United States, health social workers will be included in the continuum o f patient care from a political perspective as well (Gehlert & Brown, 2011). Social workers are not simply affected by health reform—they affect it as well. Zabora (2011) suggested that social workers must proactively en gage in preventing illness through the adoption of evidence-based practices as well as creating and im plementing interventions that decrease health care costs.
The passage of the ACA is projected to reduce the number of uninsured by 32 million (DeParle, 2010). Provisions within the ACA increase access to preventive health care and aim to decrease health disparities through cultural competence training to providers in health care settings, increasing diversity within the health care workforce and improving research and data collection (White House, n.d.). Social workers aim to provide services to and advo cacy for underserved and vulnerable population groups. Graduate social work training emphasizes the needs for cultural competency. W ith the pas sage o f the ACA and improved access to health care for patients from diverse backgrounds, social workers will be an integral part of health care in the United States in capacities ranging from social services, curriculum, research, and policy (Gorin, Gehlert, & Washington, 2010). W ith expertise and training in cultural competence, social workers in health care settings are in a unique position to provide leadership to ensure that cultural compe tence trainings and workshops lead to improved delivery of culturally competent care.
PURPOSE STATEMENT The objective o f this study was to identify determi nants o f concentration selection among MSW stu dents at the USC School o f Social Work. The USC School of Work curriculum offers a variety of con centrations including health, mental health, families and children, work and life, and community orga nizing planning and administration. In recent years, the number of students selecting the health con centration increased dramatically. This study used mixed methods to identify determinants o f con centration selection. As suggested by R ubin and
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Babbie (2013), mixed methods help determine how quantitative and qualitative data apply to par ticular studies.
R ecru itm ent o f Participants Health concentration faculty members at the USC School of Social W ork were contacted prior to administering the survey to ask for permission to visit classrooms to recruit study participants.
Students were recruited in two ways. The first m ethod included the distribution o f a paper questionnaire, w hich was designed for the pur poses o f this study, to MSW students enrolled in five sections o f the Program Planning and Evaluation in Health Care course. These students had already been enrolled in the health concen tration for one semester. Among 96 health con centration second-year students, 76 completed the questionnaire.
Because some o f the students interested in the health care concentration were not yet enrolled in any health concentration courses, a faculty advisor for the health concentration agreed to forward the questionnaire to them by e-mail (the e-mail con tained a link to the electronic version of the ques tionnaire). O f the 110 students who were not yet enrolled in the health concentration, but would start the following semester, 35 students completed the questionnaire.
In fo rm ed Consent Participants in this study were invited to complete a questionnaire after receiving a consent form for nonmedical research previously approved by the USC institutional review board. No signatures were required to participate in this voluntary research study.
Sam pling The sample size for this study included 111 MSW students. Two different sampling strategies were used for this study. The first sampling strategy was availability or convenience sampling. W hen the researchers visited the classrooms to distribute the written questionnaire, students who were present and consented to the survey were provided a ques tionnaire. For the electronic version o f the ques tionnaire, students had the opportunity to view the consent form, and if they chose to participate, they were able to access the survey. All o f the
questionnaires completed in the classrooms and online are included in the study.
M easurem ents The self-administered questionnaires were com posed o f five closed-ended Likert-scale questions and eight open-ended short essay questions. The Likert-scale items were measured from 1 to 4 (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree). These items asked students to iden tify their preference from 1 to 4 for each question. All o f the questions covered topics such as personal experiences, older adults, health care reform, job security, and financial security. Students were allowed to choose what they most identified with through the Likert-scale items and had the oppor tunity to expand on their choices in the open- ended question responses.
Q u an tita tive Questions Descriptive statistics were generated using Excel. The closed-ended questions for each survey were entered into an Excel file. For each question, fre quencies and percentages were calculated for stu dents who strongly disagreed, disagreed, agreed, or strongly agreed with each question item. The data were organized into frequency tables to categorize the numbers and percentages o f the responses.
Q ualita tive Data Qualitative data analysis was done using the rapid approach, a strategy used when speed is a factor in generating results in a study with few questions and a clear focus (Krueger & Casey, 2000). Qualitative software analysis programs can be cosdy and require timely training. Given the short time frame of one month to generate results from the time data were collected, using such a program was not feasible. After systematically random sampling every ninth survey, 12 surveys were used to identify qualitative themes. Two raters analyzed each of the 12 surveys open-ended questions independently and identi fied the most common themes for each question. Items o f agreement between the two raters were used to create categories for the most common themes. The other surveys were then examined to determine if the same themes were present. Themes were coded 1 = present on survey, 0 = not present on survey and were recorded usingExcel. Descriptive sta tistics were generated in Excel to report frequencies
M itchell and Joosten / Determinants o f Health Concentration Selection among University o f Southern California M S W Students 2 3 3
and percentages for themes present for each open- ended question.
RESULTS Quantitative Findings Responses to the five closed-ended questions com prise the quantitative data. For the breakdown of the findings, see Table 1.
Personal Experiences. This question was formu lated to find out w hether personal experiences affected their decision to choose the health concen tration. The results indicated that the majority of the students (73 percent) either agreed or strongly agreed that personal experiences played a role in their decision.
Working with Older Adults. This question was formulated to find out whether respondents wished to work with older adults. O f the 110 respondents, 51 percent did not select the health concentration to work with older adults; the other 49 percent showed interest in working with older adults.
Job and Financial Security. These questions were formulated to find out if respondents chose the health concentration because of perceived job security and financial security, and findings showed that this was a case for the majority of the students: 72 percent either agreed or strongly agreed that per ceived job security informed their decision to select the health concentration. Similarly, 71 percent of the respondents either agreed or strongly agreed that perceived financial security influenced their selection o f the health concentration.
Health Care Reform and theACA. This question was formulated to elicit whether the ACA or inter est in the health care reform affected the students’ choice of concentration. O f the 110 students who responded to this question, the majority (69 percent)
strongly disagreed or disagreed that the ACA or health care reform influenced their decision.
Qualitative Findings Systematic random sampling was used to select 12 out o f the 111 questionnaires at random: Every ninth questionnaire was selected. The most common themes were established based on the responses to open-ended questions in these 12 questionnaires. For each of the open-ended questions, at least two themes were identified. Five of the questions (ones discovered to provide valuable themes) are pre sented in Table 2.
Overall, the data include various qualitative themes, indicative of a diversity in responses. However, the three themes with the highest percentages were the desire to work in a medical settings (48.4 percent), personal experiences (41.2 percent), and financial or job security (48.3 percent). The desire to work in a medical setting relates to Parson’s Career Develop ment Theory with respect to one’s interest in working in the medical field. Furthermore, these results sup port the hypothesis that personal experiences and job and financial security influenced concentration selection among the students in the study sample.
DISCUSSION Interpretation of Findings This study demonstrates, as suggested by Parson’s Career Development Theory, that graduate students at the USC School of Social Work selected the health concentration for various personal (abilities and inter est) and vocational (job demands and labor market) reasons (National Guidance Research Forum, 2012). The quantitative results support the hypothesis that decision making was determined by personal experi ence, job security, and financial security.
aOne student d id no t respond to this question. b14 students d id no t respond to this question.
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T a b le 2: S tu d e n t D e te r m in a n ts o f H e a lth
C o n c e n tr a t io n S e le c t io n R e s p o n s e s t o C lo s e d -e n d e d Q u e s t io n s (/V = 1 1 1 )
O p e n -e n d e d Q u e s tio n a n d E m e rg e n t T h e m e s n (%) What influenced you to select the health
concentration? 111 Desire to work in a medical setting 47 (48.4) Financial security 11 (11.3) Personal experience 40 (41.2)
Are you interested in working with older adults (ages 65+)? Explain. 97 Gaps in service/needs 18 (18.5) Increasing population 12 (12.3)
In what ways has health care reform in the United States influenced your choice of the health concentration? 89 Desire to educate public 10 (11.2) More services and large impacts 19 (21.3) Job opportunities 11 (12.3)
What role did job security or financial security play in your decision to choose the health concentration? 93 Minor role 17 (18.2) Moderate role 14(15.0) Major role 45 (48.3)
Please list or describe any other reasons for choosing the health concentration? 67 Multidisciplinary team 5 (7.4) Growing older population 3 (4.4) Policy implications 5 (7.4)
A large proportion o f MSW students reported that personal experiences influenced their choice for selecting the health concentration to pursue a career in the health care sector. For the purposes of this study, the term “personal experience” relates to the concept o f self-knowledge outlined by Par son (National Guidance Research Forum, 2012). The results o f this study demonstrate that self- knowledge influences vocational decision making for graduate students to select health care as a spe cialization for social work practice.
Most graduate students also reported that job and financial security influenced their vocational deci sion making. Vocational decision making relates to another idea put forth by Parson, called vocational knowledge. This type o f knowledge is a reflection of the labor and financial markets. As discussed earlier, job security and financial security are not completely independent concepts. Contextual factors to consider when interpreting these results include both tuition and unemployment. This study surveyed graduate
students whose tuition ranged from $40,000 to $50,000 annually. About 90 percent of these stu dents receive financial aid in the form o f student loans, scholarships, work-study, and stipends (USC School o f Social Work, 2012). The pressure of repaying student loans is cause for students to seek a job that is financially secure and stable. It is worth noting that the survey for this study was adminis tered in February 2012 when the unemployment rate in California was 10.9 percent, significantly greater than the national average o f 8.3 percent (DOL, BLS, n.d.-b). These numbers serve as another motive for students to choose a profession that has better chances of yielding a job. Overall, it is understandable that students pursuing graduate degrees were concerned about job security and financial security.
The qualitative, open-ended items revealed that determinants o f concentration selection for these students varied; however, there were similarities to the quantitative results. The main themes included the desire to work in a medical setting; personal experiences; job and financial security; and the idea that, after ACA was to go into effect, more ser vices could result in larger impacts. As previously mentioned, the ACA is expected to increase access to health care for millions of individuals and fami lies. To increase access to health care, health social workers will play an integral role in helping patients to understand the health care system; they will also advocate for patients to receive the health care ser vices available to them (Jansson, 2011). Students who state that health care reform influenced their selection of the health concentration cited not only job opportunities, but also the chance to educate the public and provide more services. These aspirations will affect the nature of health care in this country. As proposed by Parson (National Guidance Research Forum, 2012), the results suggest that vocational deci sion making is indeed influenced by a match between self-knowledge and vocational knowledge.
L im ita t io n s a n d Im p lic a t io n s f o r F u tu re R es ea rc h
This study was conducted at one graduate school of social work in southern California. Therefore, the results may not be generalizable to graduate students at other universities in various geographical areas. Because this study did not collect demographic data on the students it is unknown whether responses varied by gender, age, or socioeconomic status.
M itchell and Joosten / Determinants ofHealth Concentration Selection among University of Southern California MSW Students 235
Future research should survey graduate students from various demographic and geographical areas at multi ple academic institutions to determine whether they report similar self-knowledge and vocational knowl edge influences when choosing a career in the health care sector. In addition, future studies can examine the vocational motivations of social workers already employed in health settings to provide insight into their vocational decision making and their role in a changing health care system.
Collection of personal demographic information such as race, gender, and age could help researchers to examine whether personal demographics influ ence vocational decision making for health concen tration selection. The sample size for this study was small, and descriptive statistics were used to report all data. The methods used to distribute the survey are one reason for the smaller sample size. The distribu tion of surveys directly in the classrooms presented as more effective because 76 students participated in the study, whereas only 35 students (a small percent age o f those contacted) participated in the online version. Future research should have a larger sample and use bivariate and multivariate analyses.
Im p lic a t io n s f o r C u r r ic u lu m , P ra c tic e , a n d P o lic y Because of the significant increase in social workers entering health settings, our research suggests that it is important for academic institutions to provide curriculums to students to develop the necessary skills to become effective practitioners in health set tings. Over 20 years ago, Marshack, Davidson, and Mizrahi (1988) conducted a study demonstrating the gap between what was learned in school and what was practiced in the field. This study was fol lowed by work from Kadushin and Egan (1997), which further determined that much of what was taught in social work schools did not match what was occurring in health care settings. The concept o f health concentration in schools o f social works has been evolving since its inception (Caroff & Mailik, 1985). Flowever, with an ever-changing health care system in the United States and future health social workers to train, it is imperative that curriculums meet the needs of students and profes sionals, which directly affect the needs of patients. Presently, literature calls for courses geared toward the preparation o f MSW students for practicing in environments where health disparities exist (Mitch ell, 2012). In addition, a partnership between the
Council on Social W ork Education (CSWE) and the National Association o f Deans and Directors of Schools of Social W ork is developing a curricu lum for training MSW students for clinical practice, policy, and health services to meet the needs of individuals in health settings (CSWE, n.d.).
Following the completion of our study, faculty in the health concentration made curriculum modifi cations to the health policy course. The curriculum now ensured that student competencies reflected policy relevant to direct practice in health settings through a myriad of federal-, state-, and county- level policies. The curriculum emphasizes health care access, disparities, quality and safety, preventive care, mental health, ethics, professional standards, social service programs and eligibility criteria, safety net services, and health care reform. It also provides education on home and community-based services for lesbian, gay, bisexual, transgender, questioning; minority; female; child; older adult; homeless; and veteran populations. The modified curriculum reinforces NASW’s Code of Ethics, with its emphasis on training health social work students to serve individuals and families from various backgrounds (NASW, 2008). Effective social work practice in health settings requires social workers to engage in practice informed by theory, evidence, and policy.
Furthermore, with the passage of the ACA, social workers have the opportunity to become health policy advocates for older adults, uninsured patients, members of minority groups, undocumented im migrants, and other vulnerable populations. These groups are often underserved and do not receive the necessary treatments they deserve. According to Jansson (2011), social workers as case advocates can work in health care settings to address and advocate for policy changes at organizational, com munity, and legislative levels when they observe any o f the following seven warning signs that health care consumers face when working with their patients: (1) inability to finance medical care, (2) poor-quality medical care, (3) ethical rights that are violated, (4) medical care that lacks cultural competence, (5) lack of access to preventive care, (6) untreated mental health needs, and (7) lack of linkage to home and community-based services by health care providers. With the projected increase in the labor market for social workers in health care settings, social workers will continue to be key members of multidisciplinary teams in health care settings. W ith specialized training as case advocates,
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policy advocates, and clinicians, MSW social workers trained through health concentration programs and health courses will play an important role as health care reform continues its implementation. Social workers will be key advocates involved in reducing health disparities. They will improve access to preventive care, health insurance, social programs, and home and community-based pro grams. Social workers will ensure that patients’ eth ical rights are not violated, and they will strive to enhance the quality o f life and well-being o f their patients. I5MVJ
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Keyon R. Mitchell, M SW , is a first-year medical student, V C Davis School o f Medicine, and member of the tailored clinical track: Transforming Education and Community Health
for Medical Students (TEACH-M S), 3962 1st Avenue, Sacramento, CA 95817; e-mail: email@example.com. Daum Marie Joosten, LCSW , PhD, is clinical associate pro fessor, School of Social Work, University of Southern California, Los Angeles.
O riginal manuscript received December 10, 2012 Final revision received February 6, 2013 Accepted February 13, 2013 Advance Access Publication September 9, 2014
Mitchell and Joosten / Determinants o f Health Concentration Selection among University o f Southern California M S W Students 237
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