Combining Practice and Classroom: Moving Out of the Ivory Tower
BPD Update Online, Winter 2003
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Moving Out of the Ivory Tower and Back into the Homes of Our Clients
by Gloria Duran Aguilar, PhD, ACSW

What does one do after the children are out of the nest?

In my case, I got myself a puppy. But I have also returned to the arena of social work practice. After teaching and serving as a BSW Director for the past 17 years, I have "run out of stories". And as we know, the case presentations in the textbooks and readers do not "really speak" to the students the same way that one's personal experience with clients can. The year 2001 brought a lot of changes in my life - my father-in-law passed away in March of that year after residing in a nursing home for more than four years. He had suffered numerous strokes and in progressive stages of Alzheimer's. My father passed away in October from a massive heart attack in his sleep - a vitally healthy man who loved life and his three grandchildren and one great grandchild and who was looking forward to seeing them grow-up. Our family also lost our family pet of nine years - a stray English Springer Spaniel who had been abandoned by her owners because she was in such bad shape. Spot developed kidney problems last year and all we could do was make her comfortable. She passed away on September 10th. And of course, there was 9/11.

All of these events seem to have led me to return to social work practice and so I now work as a Family Support Counselor at our local hospice. While my area of Florida does not have a large Hispanic population, it is growing and the neighboring county does have a large migrant population. I am working PRN and on-call and filling the void at the agency for bilingual and bicultural social workers.

"Working with Other Professionals"

The hospice agency for which I work began serving patients and families in 1983 and was certified as a Medicare provider in 1986 and as a Medicaid provider in 1987. The hospice provides physical, emotional, social, practical, and spiritual care for terminally ill patients diagnosed with a terminal illness and a prognosis of 6 months to one year. Hospice care is provided by an Interdisciplinary Team (IDT) which gives support and care during the illness, death, grief, and bereavement process, not only to the patients but also to their families and caregivers.

The IDT consists of medical, social, spiritual, and support staff and services. The medical staff and services include Attending Physicians, Medical Director, Hospice Nurses, and Home Health Aides. The Attending Physician maintains primary medical care of the patient and works with the hospice staff in directing care. The Medical Director consults with the IDT, including the patient's physician, and verifies the appropriateness of all admissions. In this agency, it is the Hospice Nurses who assess the physical needs of the patient and provide overall management of that care. They provide education and symptom control and supervise home health aides and other ancillary health care staff. The nurse also assists the family in securing all the medical equipment needed by the patient in the home as well as all expendable medical supplies needed. A hospice nurse is available 24 hours a day, 365 days a year. Finally, Home Health Aides provide personal care for the patient, include bathing, grooming, changing bed linens, and other tasks to make the patient and patient's area in the home as comfortable and neat as possible.

The social support staff and services include Hospice Family Support Counselors, Grief/Bereavement Counselors, Children's Program Counselors, and Music Therapists. Family Support Counselors assess the overall emotional, social, and spiritual needs of the patient and family. Grief/Bereavement Counselors assess the needs of the bereaved and provide supportive counseling for up to a year following the death of the patient according to the wishes of the bereaved. In addition, support groups are offered throughout the year. Children's Program Counselors provide supportive counseling and education to children and adolescents. Support services include time limited, school based grief support groups, monthly hospice based children and adolescent support groups, crisis support, and an annual one day retreat for children and adolescents each year. Music Therapists provide another means to assist patients and families/caregivers who have requested such services or for whom other IDT members feel would benefit from music therapy.

Spiritual services are provided by the Chaplains on staff. The Chaplains provide spiritual and pastoral counseling as part of the IDT and in response to the spiritual needs of the patient or family/caregiver. Hospice also provides outside referrals to religious communities as requested by the patient and family. Chaplains also lead memorial services upon request.

Working with other professionals who have the same values and goals has been a refreshing experience. In academia, many times we find ourselves "fighting" with other disciplines for resources and never really get to appreciate each other's strengths and contributions. At hospice, everyone works together to make the patient comfortable and to be there for the family. There is no atmosphere of one group being superior or more worthy of resources than another group.

"Orientation is not Just for Field Students"

How many times have we heard from our students that they want to work with clients and are tired of reading manuals, observing, and spending time in meetings at their volunteer placement or at their field placement? After all, they have taken all their social work courses and have been at their field agency for two weeks now..As a Family Support Counselor, my primary functions include education, emotional support and empowerment, supportive counseling and therapeutic interventions, crisis management, advocate, facilitator, mediator, and serving as a member of the IDT. I have held my MSW since 1979 and have practiced in various settings. But I too had to attend Orientation, read manuals, observe others, and spend time in meetings before I got to work with clients at the agency.

After two weeks of Orientation, I went out with a different member of the staff on separate days to learn first-hand what their tasks involved and to meet some of the patients. The first ride-along that I had was with one of the Chaplains. She was ordained as a Methodist minister, I was raised Catholic, and the patient that we visited was Southern Baptist. But it mattered not that we were all of different religions as the Chaplain read the patient's favorite bible passages and as we joined hands in a closing prayer. We were there for the patient who requested the specific readings and led us in prayer.

The second ride-along was with a Home Health Aide, a woman whose energy was enormous. As we visited six patients in their homes or in their facilities, it was very evident that the Home Health Aide found her work to be very personally satisfying and that her patients enjoyed her company. She visits her patients either two or three days a week, depending on the wishes of the patient. I excused myself from the room when she was ready to bathe the patient to provide them the respect and dignity they deserved. At one home, I found myself with the caregiver daughter who just seemed to need someone to talk to about her mother and the strain it was causing her family to watch her deteriorate.

Next, I spent the day with one of the Hospice Nurses as she made her visits to the nursing homes. The hospice nurse truly has to be an advocate for these patients who are in a facility with other medical personnel, to assure that they are not neglected. Turf issues were very evident and it made me acutely aware of the discrepancy of the quality of nursing care provided to the residents. While we read about this and discuss it in class, to see it first-hand is very powerful. Money did not seem to be the determining factor of quality of care because one of the most expensive facilities in town seemed to be the most neglectful.

Going out with a Family Support Counselor as she visited clients in their homes and in facilities, I became familiar with the multitude of forms and the many tasks for which the social worker holds responsibilities. We visited one patient whose health indicated that she no longer met the criteria for Hospice. She was in her 80s and lived alone in an isolated area of the county. The social worker had to inform her that hospice would no longer be visiting her but that arrangements were made so that she could continue to receive visits from a Home Health care agency. I will never forget the look on her face when she heard this.

I also spent a day at the Hospice House as part of my orientation. The Hospice House has 12 beds and is made available for those patients who need onsite 24 hour care or for patients whose caregivers need a short respite. One patient had been brought to the Hospice House directly from the hospital with a diagnosis of dementia, his spouse and caregiver remaining at the hospital for a minor stroke. This elderly man would be released as soon as his family arrived from out of town as he was not terminal. He had been admitted temporarily over the weekend since his caregiver was unable to care for him due to her hospitalization. Fortunately, a room had been available for him. In another room, I met a relatively young man who was eminent. He had the most beautiful smile and spoke about his parents and siblings and pets and how he had lived a productive life. The social worker was making arrangements to bring his cat to visit him the next day.

"Working Directly With Clients Is More Than Reading or Lecturing About It"

Being PRN and on-call is a challenge in and of itself because I find myself working briefly with patients who have a regular social worker and doing the Psychosocial Assessment for new patients whom I may not have the opportunity to work with again. For new patients, one of my first tasks is to conduct and complete a Psychosocial Assessment, which includes the patient/family history, financial assessment, an assessment of the home environment, a spiritual assessment, and a bereavement assessment. Making sure that the patient has prepared a Will and has made arrangements for Power of Attorney and funeral arrangements is the most challenging of my tasks. Hospice has a form entitled "Location of Important Papers" which helps in directing the conversation to these topics with the patient and assuring that the family/caregiver is made aware of where these papers can be found. Legal documents for our state such as Living Wills, Designation of Health Care Surrogate, and Advance Directives are reviewed with the patient and it is one of our responsibilities to make sure that the IDT is informed of these documents in the file. Getting the necessary information requires establishing rapport and trust very quickly. Informing the patient and family/caregiver that another social worker will be assigned to their case provides a challenge in establishing that rapport and trust. But I have found that just knowing services and support will be provided lifts such a burden off the patient and/or family/caregiver that they willingly give you the information you need.

For those cases which are ongoing, the major challenge is to read the file and quickly become familiar with the patient. One form that the nurse is responsible for is the DNR (Do Not Resuscitate), but as a Family Support Counselor it is part of my job to make sure this form is in the patient's file, especially when I visit patients who are residents of nursing homes or alternative living facilities. I also routinely review the file to make sure that the other legal documents are on file. If not, I make a note for the assigned social worker. Primarily, for these ongoing cases, I find myself serving in the role of listener and occasionally making a referral to the Chaplain or Music Therapist. One task that I may find myself handling as PRN and on-call is that of being the one from Hospice called out to the home or the facility at time of death. I believe that this will be the most difficult task for me, especially for those families which I have had no contact. To have a stranger come into your home at the time of death...

Making the Classroom Connection

Working at Hospice one day a week, teaching three classes, administering a BSW program and providing community service has been a major balancing act for me. But I am very glad that I am working in a local social service agency providing direct service to clients and their families. Incorporating my weekly experiences into my current classes has made a difference in my energy level and in my responses to the student's questions. Making the connection between theory and practice is more real to them now. While students have been aware of my service to NASW, seeing their professor actually working in the field seems to have made the greatest impact on their professional identification. It has also been very well received from those Family Support Counselors at the agency who have said to me that they wish more faculty would work part-time with clients instead of spending all their time with books.

Now when I discuss secondary practice settings and working in a multidisciplinary setting in the Introduction to Social Work class, I can tell them directly what that involves. I can describe first-hand the challenges of finding appropriate services for clients when none exist. In policy classes, I can describe the difficulties, frustrations, and barriers to service for many clients because they do not neatly fit the picture of diagnosis or income or age. Absolute and Relative Poverty are no longer just concepts, but going into the homes of my clients and experiencing the smells, the extreme heat or extreme cold, the clutter or emptiness of poverty has been like a rush of cold air hitting me in the facemy memory being shaken by reality.

Like many of my colleagues who teach HBSE, we find that we do not spend enough time discussing Older Adults and end-of-life issues because the semester is too short to adequately cover the entire life cycle. As a result of working with hospice, I will make a stronger effort to make sure that we adequately discuss Older Adults and end-of-life issues because I know that not every student will choose to take the elective in Death and Dying. And when I meet the new majors during Orientation and discuss the curriculum and the field placement, I can tell them that I too had to "shadow" other professionals to learn about the agency in which I currently work PRN. When I talk about professional development and that receiving the degree is not the end of our education, I can tell them how I had to get a new copy of the PDR so that I could become familiar with the current medications. I can tell them about the workshops I attend to stay current with working with the terminally ill. My hope is that they will see that I am not just standing in front of the classroom lecturing from the book and other references, but that I take my profession very seriously.that those who teach, can also practice.

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