A Cross-Sectional National Survey of Social Workers: Focusing on Attitudes, Knowledge, and Practice Behaviors for Educating Patients About Advance Directives

Background Healthcare social workers play a critical role in working with individuals and families who are managing a seriously illness and needing assistance with advance care planning (ACP) including advance directives (ADs). As clinical providers, social workers are tasked with addressing patients’ health and behavioral health care needs, especially for patients and families facing the end of life. Objective The primary aims of this study were to: (1) examine social workers’ perspectives and attitudes about educating patients in documenting an AD, and (2) test whether certain factors such as perceived barriers and perceived importance of ACP influences the frequency of social workers educating patients about ADs. Methods Using a cross-sectional study design, we surveyed 142 social workers on their knowledge, attitudes, and behaviors related to ADs. Using exploratory factor analyses, we identified two provider practice attitudes factors, three perceived barriers factors, and two perceived importance of AD factors. We then used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for each of the factors in association with the frequency with which the social workers reported educating patients about ADs. Results While various positive and negative attitudes and barriers towards educating patients are important factors to consider, social workers’ perceptions of the importance of engaging patients in ACP education was the most important factor that influenced their behaviors. The odds of always/often (vs. sometimes/rarely/never) educating patients about ADs in their practice were greater for those social workers who reported they see the importance of AD decision-making (OR=3.21, 95%CI=1.83-5.62) and confirming goals-of-care (OR=1.76, 95%CI=1.03-3.01). Conclusion Social workers’ knowledge about ACP and experiencing benefits to educating patients about ACP are important to advancing upstream conversations before patients

need end-of-life care or before a crisis ensues. Social workers are uniquely qualified to engage patients in ACP and have skills to help patients develop a comprehensive care plan. More education is needed to impact providers views about the importance of education patients about ACP.

Background
Healthcare social workers play a critical role in working with seriously ill individuals and their families in managing chronic medical conditions. One such role for social workers involves educating patients about their rights towards end-of-life (EOL) care with advance care planning (ACP). 1 As healthcare providers, clinical social workers are tasked with addressing the health and behavioral health care needs of patients and to assist with removing barriers, 2 such as addressing miscommunication, linking patients to psychological services when needed, and supporting individualized and family decisionmaking, that if not addressed can hinder the most effective patient care which is especially important for early planning for future death. 3 Social work providers have unique opportunities to prepare patients and their families to engage them in ACP conversations that address end-of-life care before a crisis arises.
More importantly, all health organizations and healthcare providers need to understand the various roles that social workers engage in, conducting routine assessments and assisting patients by developing EOL care plans for those with serious illness. 2 Social workers are trained in a person in environment and strengths based perspectives, 4 and have specified skills to help individuals and families develop comprehensive patient care plans. 5,6 This care can include but is not limited to provision of supportive counseling to address emotional distress and family conflict. Social workers also work on interprofessional teams 7 and consult with other providers to make referrals on behalf of patients and their families to address end-of-life care. Best practices for ACP integrate social workers within transdisciplinary teams that work together with medical providers (e.g., physicians and nurses) and other team members (e.g., psychologists and chaplains) to provide holistic care. Collaboration and joint discussions among providers transcends traditional boundaries and reduces work done in silos by sharing knowledge, skills, and decision-making regarding patient care. 8 Such care involves ACP, an important process supporting EOL care discussions and helps patients to complete an advance directive (AD). The ACP process involves assisting patients with documenting treatment decisions and enables them to express their wishes for EOL care on an AD. Patients are also encouraged to discuss their ACP with physicians and other providers so they can receive support with such decision-making.

Methods
We used a cross-sectional study design, 142 social workers were recruited through a broad recruitment approach using snowball sampling methods. Participants were eligible if they were a clinical social worker working in a variety of healthcare settings. To examine the aims, social workers completed a one-time online survey. The recruitment approach included sending survey links through social media targeting listservs frequented by social workers promoting the survey through Facebook, Twitter, and Linkedin. In addition, various organizations emailed the survey request and link to their members. Participants were not provided incentives for their participation. This study was approved by the Institutional Review Board.

Survey Instrument
As reported in a previous article, 11 we developed a survey questionnaire through a review of the literature on ADs and by involving three healthcare providers who were a part of a stakeholder group (a nurse, physician, and social worker). Some items were adapted from a survey that providers completed about their attitudes on the use of ACP in palliative care units. 11 Additionally, the survey was pilot tested with two providers who reviewed the survey items for readability and clarity. The questions assessed social workers' (n=142) knowledge, attitudes, and practice behaviors for educating seriously ill patients about ADs. At the beginning of the survey, social workers were given a brief definition about ADs legal documents used in patient care to document patients' wishes for medical treatment and the appointment of someone as a durable power of attorney for healthcare decision making. Completing the survey took approximately 20 to 25 minutes.

Key Variables
The following variables were assessed in the study: Perceived knowledge, attitudes about ADs, importance of ADs, and barriers to educating patients on ADs. Perceived knowledge about advance directives was assessed by asking social workers, "How knowledgeable are you with educating patients about advance directives?" This item was measured using a 2-point scale with either "very knowledgeable" or "somewhat knowledgeable". Ten items were used to assess social workers' attitudes about AD's asking, "how much do you agree with the following questions?", which were related to the purpose of using ADs in patient care.
Attitudes about advance directives were adapted from Nakazawa and colleagues (2014) 12 and were measured using a 4-point scale indicating whether social workers "strongly agree" to "strongly disagree" with the questions. Social workers were asked how strongly to you agree with the following: Educating patients about advance directives helps to improve patient-provider communication; Educating patients about advance directives reduces their emotional distress; Completing an advance directive is an effective way for patients to influence their medical treatment options; Educating patients about advance directives reduces family discord about medical treatment options; I have difficulty asking terminally ill patients about their treatment preferences for an advance directive; I am concerned that talking with patients about advance directives will upset or overwhelm them; Patients' cultural values and beliefs make it difficult to educate them about advance directives; and Patients will worry less about unwanted treatment after documenting an advance directive. We also asked social workers if they experienced benefits to educating patients about ADs, measured yes/no. Social workers were also asked about the importance of educating patients on ADs which was measured using 10 items scored on a 4-point scale from "not at all important" to "extremely important". Behaviors for engaging in patient education for ADs was measured by two questions: (1) Do you personally educate patients about advance directives in your practice? (yes/no) and (2) In your practice, how frequently do you educate patients about advance directives (Always/Often or Sometimes/Rarely/Never).
Barriers influence educating patients about ADs were measured using 15 items scored on a 5-point Likert scale from "not at all a barrier" to "extremely a barrier" with higher Information about work environment was collected indicating degree, primary work setting, and years of practice.

Statistical Analysis
Univariate analyses were used for describing participant characteristics, demographics, level of knowledge, attitudes, and practice behaviors related to AD education with patients. In preparation for conducting a logistic regression analysis to examine predictors on frequency of educating patients practice, we conducted three exploratory factor analyses 13 (FA): (a) on the 10 items related to attitudes for educating patients about ADs; (b) on the 15 items related to the barriers; and (c) on the 10 items which indicated the importance of educating patients on ADs. Factors were identified by examining factor loading coefficients. Factor loadings ≥0.5 on only one factor and <0.5 on the other factors were used to generate factor scores to create subscales for subsequent analyses, these were the regression scores that were saved from the exploratory factor analysis. For each subscale, we computed Cronbach's alphas to assess internal reliability of the items in each factor. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for each of the identified factors in association with the frequency with which social workers reported educating patients about ADs in their practice (yes/no). We considered a number of potential confounders, but selected the most parsimonious model given the small sample size. 14 Analyses were conducted using IBM SPSS Statistics Version 25.0 (IBM Corp., Armonk, NY). 15

Results
The social workers who participated in this study (n=142) reported working in various inpatient hospital and out-patient medical settings. A response rate was not obtained due to multiple recruitment methods including snowball sampling. As shown in Table 1, most participants were female (84.5%), non-Hispanic White (86.6%) and had a broad range of experience working as healthcare provider, mostly in hospital, in-patient settings (57.7%).
Knowledge, Attitudes, and Behavior towards Advance Directive Education

Attitude Scale
An exploratory FA on ten items related to social workers' attitudes generated two factors with three items. Those items that did not fall on either factors were dropped. The six items remaining related to social workers' attitudes and represented positive benefits and negative concerns about educating patients on ADs. These factors were retained using a cutoff eigenvalue score greater than 1.0 and accounted for 57.9% of the common variance. Notably, there is often a low to moderate shared variance found in social science research. The Kaiser-Meyer-Olkin (KMO) was .578 adequate for FA and Bartlett's test of sphericity was 144.65 (df 15, p=.001) indicating the suitability to support a FA. Table 3 shows a theoretically relevant scale of attitudes on educating patients.

Importance of Advance Directives
An exploratory FA was conducted on 10 items associated with perceived importance of educating patients about ADs which generated two factors. These factors were retained using a cutoff value greater than 1.0, accounting for 72.62% of the common variance. The Kaiser-Meyer-Olkin (KMO) .891 was adequate for conducting a FA with this data. The Bartlett's test of sphericity was 839.86 (df 36, p = .001) indicating the suitability to support a FA. The two theoretically relevant scales represent the importance of advance directive documentation in decision making as well as the importance of advance directives to confirm the goals of care. The first relevant scale (Table 5)

Logistic Regression Analysis
We used logistic regression to examine factors associated with the frequency for which social workers reported educating patients about ADs, while controlling for demographic factors ( Table 6) Similar to another study, 6 social workers in this study indicated they were knowledgeable about ACP and experienced benefits to educating patients. However, missed opportunities for engaging in ACP conversations continue to persist. 16 These gaps are in part due to the lack of skills for beginning or initiating complex conversations involving multiple methods for talking about the possibility of dying while documenting individualize medical plan of care for future death. The complexity of ACP conversations also involve an understanding of how and when to engage patients and their families, which is more difficult when patients are in pain or may not feel well, experiencing mental distress. 17 Notably, social workers were overwhelmingly positive towards educating patients about ADs, while also embracing barriers like having concerns when educating patients. It is important to note that the three questions scaled for negative barriers had low internal consistency indicating that it may not be a reliable measure for experiencing negative barriers.
However, research suggests these types of barriers are important factors for understanding provider engagement in ACP EOL care conversations. 6,18 Perhaps social work providers who participated in the study held a particular interest in this topic or had extensive experience educating patients about ADs, particularly because they selfselected to participate in this study. While there was a range of experience indicated across the sample of social work participants, number of years worked was not a significant predictor of frequently (always/often) educating patients about ADs. Also, of interest was the fact that this was a highly educated sample suggesting that they should have received education in this area in school. However, there may be a disconnect about learning about having discussions about ADS and actually doing them. Increasingly social worker trainees are participating in simulated experiences alone or with other professional disciplines to help decrease the disconnect between learning and experiencing. 19 There may be an opportunity to create simulated experiences for social work trainees in engaging and talking with patients about AD particularly because there is a process for engaging patients in this area.
Knowledge about this topic is often learned through provider training involving a process for engaging patients in asking certain types of questions for EOL care planning. First, providers need to ask their patient whether or not they have completed an advance directive. This question should indicate a baseline understanding from the patient's view about ADs. If they say they have completed one, then it would be important to obtain a copy of the AD document for their medical chart. However, medical charts may have inconsistent information about a patient's AD because after completing an AD the patients must return to their provider and give them a copy to be placed in their medical chart, which may not always happen. Therefore, it is important for providers to ask about obtaining a copy for the medical chart. Social workers are often advocating for patients' rights which involves getting updated information to support quality patient care.

Limitations
There are several limitations to this study worth noting. First is the sampling method. A snowball approach was utilized to recruit participants. These participants self-selected to participate in the survey which potentially suggest bias. Second, because of the crosssectional design, there was not a comparison group to better understand the responses and results. Finally, the sample largely represented social workers who worked in-patient hospitals. There are social workers in other settings with adults who may need ADs that may have differing perspectives on educating patients about ADs.

Conclusions
Despite the limitations, this study contributes to a growing literature base on the role of social workers and ADs. As the populations continues to demographically grow older and manage multiple chronic illnesses, the need for patients to be engaged and educated on the purpose and meaning of AD is critical. Having these discussion will potentially minimize difficult conversations for other members of the health care team as social workers can and should take lead in these discussions. Ethics approval and consent to participate -This study was approved by the Institutional Review Board at New Mexico State University. Online consent was provided anonymously as participants self-selected for the study.

Consent for Publication -Not applicable
Declaration Competing Interests -The authors declare that they have no competing interests.