social worker role in research

The link between social work research and practice

When thinking about social work, some may consider the field to solely focus on clinical interventions with individuals or groups.

There may be a mistaken impression that research is not a part of the social work profession. This is completely false. Rather, the two have been and will continue to need to be intertwined.

This guide covers why social workers should care about research, how both social work practice and social work research influence and guide each other, how to build research skills both as a student and as a professional working in the field, and the benefits of being a social worker with strong research skills. 

A selection of social work research jobs are also discussed.  

• Social workers and research
• Evidence-based practice
• Practice and research
• Research and practice
• Build research skills
• Social worker as researcher
• Benefits of research skills
• Research jobs

Why should social workers care about research?

Sometimes it may seem as though social work practice and social work research are two separate tracks running parallel to each other – they both seek to improve the lives of clients, families and communities, but they don’t interact. This is not the way it is supposed to work.

Research and practice should be intertwined, with each affecting the other and improving processes on both ends, so that it leads to better outcomes for the population we’re serving.

Section 5 of the NASW Social Work Code of Ethics is focused on social workers’ ethical responsibilities to the social work profession. There are two areas in which research is mentioned in upholding our ethical obligations: for the integrity of the profession (section 5.01) and for evaluation and research (section 5.02). 

Some of the specific guidance provided around research and social work include:

• 5.01(b): …Social workers should protect, enhance, and improve the integrity of the profession through appropriate study and research, active discussion, and responsible criticism of the profession.
• 5.01(d): Social workers should contribute to the knowledge base of social work and share with colleagues their knowledge related to practice, research, and ethics…
• 5.02(a) Social workers should monitor and evaluate policies, the implementation of programs, and practice interventions.
• 5.02(b) Social workers should promote and facilitate evaluation and research to contribute to the development of knowledge.
• 5.02(c) Social workers should critically examine and keep current with emerging knowledge relevant to social work and fully use evaluation and research evidence in their professional practice.
• 5.02(q) Social workers should educate themselves, their students, and their colleagues about responsible research practices.

Evidence-based practice and evidence-based treatment

In order to strengthen the profession and determine that the interventions we are providing are, in fact, effective, we must conduct research. When research and practice are intertwined, this leads practitioners to develop evidence-based practice (EBP) and evidence-based treatment (EBT).

Evidence-based practice is, according to The National Association of Social Workers (NASW) , a process involving creating an answerable question based on a client or organizational need, locating the best available evidence to answer the question, evaluating the quality of the evidence as well as its applicability, applying the evidence, and evaluating the effectiveness and efficiency of the solution. 

Evidence-based treatment is any practice that has been established as effective through scientific research according to a set of explicit criteria (Drake et al., 2001). These are interventions that, when applied consistently, routinely produce improved client outcomes. 

For example, Cognitive Behavioral Therapy (CBT) was one of a variety of interventions for those with anxiety disorders. Researchers wondered if CBT was better than other intervention options in producing positive, consistent results for clients.

So research was conducted comparing multiple types of interventions, and the evidence (research results) demonstrated that CBT was the best intervention.

The anecdotal evidence from practice combined with research evidence determined that CBT should become the standard treatment for those diagnosed with anxiety. Now more social workers are getting trained in CBT methods in order to offer this as a treatment option to their clients.

How does social work practice affect research?

Social work practice provides the context and content for research. For example, agency staff was concerned about the lack of nutritional food in their service area, and heard from clients that it was too hard to get to a grocery store with a variety of foods, because they didn’t have transportation, or public transit took too long. 

So the agency applied for and received a grant to start a farmer’s market in their community, an urban area that was considered a food desert. This program accepted their state’s version of food stamps as a payment option for the items sold at the farmer’s market.

The agency used their passenger van to provide free transportation to and from the farmer’s market for those living more than four blocks from the market location.

The local university also had a booth each week at the market with nursing and medical students checking blood pressure and providing referrals to community agencies that could assist with medical needs. The agency was excited to improve the health of its clients by offering this program.

But how does the granting foundation know if this was a good use of their money? This is where research and evaluation comes in. Research could gather data to answer a number of questions. Here is but a small sample:

• How many community members visited each week and purchased fruits and vegetables? 
• How many took advantage of the transportation provided, and how many walked to the market? 
• How many took advantage of the blood pressure checks? Were improvements seen in those numbers for those having repeat blood pressure readings throughout the market season? 
• How much did the self-reported fruit and vegetable intake increase for customers? 
• What barriers did community members report in visiting and buying food from the market (prices too high? Inconvenient hours?)
• Do community members want the program to continue next year?
• Was the program cost-effective, or did it waste money by paying for a driver and for gasoline to offer free transportation that wasn’t utilized? What are areas where money could be saved without compromising the quality of the program?
• What else needs to be included in this program to help improve the health of community members?

How does research affect social work practice?

Research can guide practice to implement proven strategies. It can also ask the ‘what if’ or ‘how about’ questions that can open doors for new, innovative interventions to be developed (and then research the effectiveness of those interventions).

Engel and Schutt (2017) describe four categories of research used in social work:

• Descriptive research is research in which social phenomena are defined and described. A descriptive research question would be ‘How many homeless women with substance use disorder live in the metro area?’
• Exploratory research seeks to find out how people get along in the setting under question, what meanings they give to their actions, and what issues concern them. An example research question would be ‘What are the barriers to homeless women with substance use disorder receiving treatment services?’
• Explanatory research seeks to identify causes and effects of social phenomena. It can be used to rule out other explanations for findings and show how two events are related to each other.  An explanatory research question would be ‘Why do women with substance use disorder become homeless?’
• Evaluation research describes or identifies the impact of social programs and policies. This type of research question could be ‘How effective was XYZ treatment-first program that combined housing and required drug/alcohol abstinence in keeping women with substance use disorder in stable housing 2 years after the program ended?’

Each of the above types of research can answer important questions about the population, setting or intervention being provided. This can help practitioners determine which option is most effective or cost-efficient or that clients are most likely to adhere to. In turn, this data allows social workers to make informed choices on what to keep in their practice, and what needs changing. 

How to build research skills while in school

There are a number of ways to build research skills while a student.  BSW and MSW programs require a research course, but there are other ways to develop these skills beyond a single class:

• Volunteer to help a professor working in an area of interest. Professors are often excited to share their knowledge and receive extra assistance from students with similar interests.
• Participate in student research projects where you’re the subject. These are most often found in psychology departments. You can learn a lot about the informed consent process and how data is collected by volunteering as a research participant.  Many of these studies also pay a small amount, so it’s an easy way to earn a bit of extra money while you’re on campus. 
• Create an independent study research project as an elective and work with a professor who is an expert in an area you’re interested in.  You’d design a research study, collect the data, analyze it, and write a report or possibly even an article you can submit to an academic journal.
• Some practicum programs will have you complete a small evaluation project or assist with a larger research project as part of your field education hours. 
• In MSW programs, some professors hire students to conduct interviews or enter data on their funded research projects. This could be a good part time job while in school.
• Research assistant positions are more common in MSW programs, and these pay for some or all your tuition in exchange for working a set number of hours per week on a funded research project.

How to build research skills while working as a social worker

Social service agencies are often understaffed, with more projects to complete than there are people to complete them.

Taking the initiative to volunteer to survey clients about what they want and need, conduct an evaluation on a program, or seeing if there is data that has been previously collected but not analyzed and review that data and write up a report can help you stand out from your peers, be appreciated by management and other staff, and may even lead to a raise, a promotion, or even new job opportunities because of the skills you’ve developed.

Benefits of being a social worker with strong research skills

Social workers with strong research skills can have the opportunity to work on various projects, and at higher levels of responsibility. 

Many can be promoted into administration level positions after demonstrating they understand how to conduct, interpret and report research findings and apply those findings to improving the agency and their programs.

There’s also a level of confidence knowing you’re implementing proven strategies with your clients. 

Social work research jobs

There are a number of ways in which you can blend interests in social work and research. A quick search on Glassdoor.com and Indeed.com retrieved the following positions related to social work research:

• Research Coordinator on a clinical trial offering psychosocial supportive interventions and non-addictive pain treatments to minimize opioid use for pain.
• Senior Research Associate leading and overseeing research on a suite of projects offered in housing, mental health and corrections.
• Research Fellow in a school of social work
• Project Policy Analyst for large health organization
• Health Educator/Research Specialist to implement and evaluate cancer prevention and screening programs for a health department
• Research Interventionist providing Cognitive Behavioral Therapy for insomnia patients participating in a clinical trial
• Research Associate for Child Care and Early Education
• Social Services Data Researcher for an organization serving adults with disabilities.
• Director of Community Health Equity Research Programs evaluating health disparities.

No matter your population or area of interest, you’d likely be able to find a position that integrated research and social work. 

Social work practice and research are and should remain intertwined. This is the only way we can know what questions to ask about the programs and services we are providing, and ensure our interventions are effective. 

There are many opportunities to develop research skills while in school and while working in the field, and these skills can lead to some interesting positions that can make a real difference to clients, families and communities. 

Drake, R. E., Goldman, H., Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., et al. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services, 52(2), 179-182. 

Engel, R.J., & Schutt, R.K. (2017). The Practice of Research in Social Work. Sage.

National Association of Social Workers. (n.d). Evidence Based Practice. Retrieved from: https://www.socialworkers.org/News/Research-Data/Social-Work-Policy-Research/Evidence-Based-Practice

Social Work Research Methods That Drive the Practice

Social workers advocate for the well-being of individuals, families and communities. But how do social workers know what interventions are needed to help an individual? How do they assess whether a treatment plan is working? What do social workers use to write evidence-based policy?

Social work involves research-informed practice and practice-informed research. At every level, social workers need to know objective facts about the populations they serve, the efficacy of their interventions and the likelihood that their policies will improve lives. A variety of social work research methods make that possible.

Data-Driven Work

Data is a collection of facts used for reference and analysis. In a field as broad as social work, data comes in many forms.

Quantitative vs. Qualitative

As with any research, social work research involves both quantitative and qualitative studies.

Quantitative Research

Answers to questions like these can help social workers know about the populations they serve — or hope to serve in the future.

• How many students currently receive reduced-price school lunches in the local school district?
• How many hours per week does a specific individual consume digital media?
• How frequently did community members access a specific medical service last year?

Quantitative data — facts that can be measured and expressed numerically — are crucial for social work.

Quantitative research has advantages for social scientists. Such research can be more generalizable to large populations, as it uses specific sampling methods and lends itself to large datasets. It can provide important descriptive statistics about a specific population. Furthermore, by operationalizing variables, it can help social workers easily compare similar datasets with one another.

Qualitative Research

Qualitative data — facts that cannot be measured or expressed in terms of mere numbers or counts — offer rich insights into individuals, groups and societies. It can be collected via interviews and observations.

• What attitudes do students have toward the reduced-price school lunch program?
• What strategies do individuals use to moderate their weekly digital media consumption?
• What factors made community members more or less likely to access a specific medical service last year?

Qualitative research can thereby provide a textured view of social contexts and systems that may not have been possible with quantitative methods. Plus, it may even suggest new lines of inquiry for social work research.

Mixed Methods Research

Combining quantitative and qualitative methods into a single study is known as mixed methods research. This form of research has gained popularity in the study of social sciences, according to a 2019 report in the academic journal Theory and Society. Since quantitative and qualitative methods answer different questions, merging them into a single study can balance the limitations of each and potentially produce more in-depth findings.

However, mixed methods research is not without its drawbacks. Combining research methods increases the complexity of a study and generally requires a higher level of expertise to collect, analyze and interpret the data. It also requires a greater level of effort, time and often money.

The Importance of Research Design

Data-driven practice plays an essential role in social work. Unlike philanthropists and altruistic volunteers, social workers are obligated to operate from a scientific knowledge base.

To know whether their programs are effective, social workers must conduct research to determine results, aggregate those results into comprehensible data, analyze and interpret their findings, and use evidence to justify next steps.

Employing the proper design ensures that any evidence obtained during research enables social workers to reliably answer their research questions.

Research Methods in Social Work

The various social work research methods have specific benefits and limitations determined by context. Common research methods include surveys, program evaluations, needs assessments, randomized controlled trials, descriptive studies and single-system designs.

Surveys involve a hypothesis and a series of questions in order to test that hypothesis. Social work researchers will send out a survey, receive responses, aggregate the results, analyze the data, and form conclusions based on trends.

Surveys are one of the most common research methods social workers use — and for good reason. They tend to be relatively simple and are usually affordable. However, surveys generally require large participant groups, and self-reports from survey respondents are not always reliable.

Program Evaluations

Social workers ally with all sorts of programs: after-school programs, government initiatives, nonprofit projects and private programs, for example.

Crucially, social workers must evaluate a program’s effectiveness in order to determine whether the program is meeting its goals and what improvements can be made to better serve the program’s target population.

Evidence-based programming helps everyone save money and time, and comparing programs with one another can help social workers make decisions about how to structure new initiatives. Evaluating programs becomes complicated, however, when programs have multiple goal metrics, some of which may be vague or difficult to assess (e.g., “we aim to promote the well-being of our community”).

Needs Assessments

Social workers use needs assessments to identify services and necessities that a population lacks access to.

Common social work populations that researchers may perform needs assessments on include:

• People in a specific income group
• Everyone in a specific geographic region
• A specific ethnic group
• People in a specific age group

In the field, a social worker may use a combination of methods (e.g., surveys and descriptive studies) to learn more about a specific population or program. Social workers look for gaps between the actual context and a population’s or individual’s “wants” or desires.

For example, a social worker could conduct a needs assessment with an individual with cancer trying to navigate the complex medical-industrial system. The social worker may ask the client questions about the number of hours they spend scheduling doctor’s appointments, commuting and managing their many medications. After learning more about the specific client needs, the social worker can identify opportunities for improvements in an updated care plan.

In policy and program development, social workers conduct needs assessments to determine where and how to effect change on a much larger scale. Integral to social work at all levels, needs assessments reveal crucial information about a population’s needs to researchers, policymakers and other stakeholders. Needs assessments may fall short, however, in revealing the root causes of those needs (e.g., structural racism).

Randomized Controlled Trials

Randomized controlled trials are studies in which a randomly selected group is subjected to a variable (e.g., a specific stimulus or treatment) and a control group is not. Social workers then measure and compare the results of the randomized group with the control group in order to glean insights about the effectiveness of a particular intervention or treatment.

Randomized controlled trials are easily reproducible and highly measurable. They’re useful when results are easily quantifiable. However, this method is less helpful when results are not easily quantifiable (i.e., when rich data such as narratives and on-the-ground observations are needed).

Descriptive Studies

Descriptive studies immerse the researcher in another context or culture to study specific participant practices or ways of living. Descriptive studies, including descriptive ethnographic studies, may overlap with and include other research methods:

• Informant interviews
• Census data
• Observation

By using descriptive studies, researchers may glean a richer, deeper understanding of a nuanced culture or group on-site. The main limitations of this research method are that it tends to be time-consuming and expensive.

Single-System Designs

Unlike most medical studies, which involve testing a drug or treatment on two groups — an experimental group that receives the drug/treatment and a control group that does not — single-system designs allow researchers to study just one group (e.g., an individual or family).

Single-system designs typically entail studying a single group over a long period of time and may involve assessing the group’s response to multiple variables.

For example, consider a study on how media consumption affects a person’s mood. One way to test a hypothesis that consuming media correlates with low mood would be to observe two groups: a control group (no media) and an experimental group (two hours of media per day). When employing a single-system design, however, researchers would observe a single participant as they watch two hours of media per day for one week and then four hours per day of media the next week.

These designs allow researchers to test multiple variables over a longer period of time. However, similar to descriptive studies, single-system designs can be fairly time-consuming and costly.

Learn More About Social Work Research Methods

Social workers have the opportunity to improve the social environment by advocating for the vulnerable — including children, older adults and people with disabilities — and facilitating and developing resources and programs.

Learn more about how you can earn your  Master of Social Work online at Virginia Commonwealth University . The highest-ranking school of social work in Virginia, VCU has a wide range of courses online. That means students can earn their degrees with the flexibility of learning at home. Learn more about how you can take your career in social work further with VCU.

From M.S.W. to LCSW: Understanding Your Career Path as a Social Worker

How Palliative Care Social Workers Support Patients With Terminal Illnesses

How to Become a Social Worker in Health Care

Gov.uk, Mixed Methods Study

MVS Open Press, Foundations of Social Work Research

Open Social Work Education, Scientific Inquiry in Social Work

Open Social Work, Graduate Research Methods in Social Work: A Project-Based Approach

Routledge, Research for Social Workers: An Introduction to Methods

SAGE Publications, Research Methods for Social Work: A Problem-Based Approach

Theory and Society, Mixed Methods Research: What It Is and What It Could Be

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What is Social Work and What Do Social Workers Do?

Social work is a profession in which trained professionals are devoted to helping vulnerable people and communities work through challenges they face in everyday life. Social workers practice in a wide variety of settings, united in their commitment to advocating for and improving the lives of individuals, families, groups and societies.

On this page:

What is the role of social workers.

While there is a diverse array of settings in which social workers practice, together social workers share the commitment to:

• Promote social welfare
• Help people from all backgrounds overcome the individual challenges they are facing
• Advocate for social and economic justice for members of diverse communities
• Embody the  social work code of ethics

Who do social workers help?

Social workers work directly with, and on behalf of, a wide variety of populations. Some examples are:

• Children and adolescents
• Individuals with disabilities
• Individuals who are experiencing poverty or homelessness
• Medical patients
• LGBTQ+ individuals
• Individuals struggling with addiction
• Individuals with mental health concerns
• Refugees and immigrants
• Aging individuals
• Couples and families
• Victims of violence or trauma
• Individuals who are incarcerated or in the criminal justice system

Social workers are uniquely positioned to help our fellow members of society who are vulnerable, oppressed or marginalized.

Ask yourself: Who are you most passionate about helping? Chances are you can make a difference with that population as a social worker!

Scope of social work practice

Social workers create change in many ways — from high, systems-level change (macro practice) to the individual level (micro practice). Social workers make an impact at all levels of practice.

When most people think of social workers, they think of micro-level social workers. These are the individuals who are working with people one-on-one to help them create change in their lives. Examples of micro-level social workers include:

• School social workers who help students to cope with problems they are facing at school and at home
• Child and family case workers at a county social services department helping a variety of at-risk populations
• Legal advocates helping individuals navigate the criminal justice system
• Clinical social workers who provide counseling services (addictions, mental health, marriage and family, trauma, etc.)
• Medical social workers that provide and coordinate services for patients during and after their treatment

Social workers at the mezzo (or middle) level, tend to work with larger groups or institutions as opposed to individuals, or they may have an administrative role overseeing a program or service delivery. Some examples of mezzo social work roles include:

• Social workers who supervise a team of others who provide direct practice interventions
• Leaders of non-profit or community agencies
• Community organizers who work with community members to create change within neighborhoods, towns or regions
• Health educators who provide training to various groups about public health issues
• Faculty members at a university teaching and training new social workers

Social workers at the macro level are working to create high-level change. While they don't necessarily work with populations directly, the changes they are making in programs, policy, research and other areas trickle down to affect many. Some examples of macro-level social work include:

• Social work researchers and data analysts
• Policymakers and grant writers
• Local, state and federal representatives, lobbyists and political advocates
• Program development and evaluation specialists

Macro-level social workers less frequently have the words "social worker" in their official job title as compared to micro-level social workers, but they are still able to step into a myriad of roles as a result of their comprehensive graduate education. 

Where are social workers employed?

There are a diverse range of agencies that employ social workers, and the job descriptions for social workers vary greatly depending on where they work. Some examples of places that employ social workers are:

• Schools (all levels, including higher education)
• Hospitals and health care agencies
• Government agencies (local, state, federal), including Veteran's Affairs (VA) agencies and the military
• Community development and outreach agencies
• County, state and federal legal agencies (courts, prisons, etc.)
• Clinics and counseling agencies

Some social workers are also self-employed in private practice as licensed clinical social workers (LCSW). 

What are the education and license requirements for social work?

The  Council on Social Work Education (CSWE)  is the national accrediting body for all bachelor's and master's level social work programs.

Some entry-level social work positions only require a bachelor's degree in social work (BSW) or another related field. Many individuals find, however, that in order to expand their job opportunities and earning potential, they need a Master of Social Work degree (MSW), as individuals with MSW degrees have more in-depth training, which leads to different and higher level job responsibilities.

Many jobs may also require a social work license. Depending on the state, individuals may need to have their master's in social work (MSW) in order qualify for licensure.

Individuals do not need to have a bachelor's degree in social work (BSW) in order to obtain their master's in social work (MSW). Many MSW programs (including ours!) admit students from all kinds of undergraduate programs. Psychology, sociology, criminal justice, English and other liberal art majors are often found in MSW programs, but any bachelor's degree can prepare students well to become social workers. Read more about our MSW admissions prerequisites here.

Social work licensure varies from state to state. 

Each state licensing board determines the different kinds of licenses social workers can earn, what level of degree is required and the scope of practice (what they are allowed to do). View the licensure requirements and types of credentials for your state or province on the ASWB page . 

In New York State, social workers are only licensed at the master's level, which means they first need to earn their MSW degree. The New York State Office of the Professions is the official licensing body for a variety of licensed professions, including social work. There are a few different kinds of licenses individuals with an MSW degree can earn. 

NY Licensed Master Social Worker (LMSW)

Not all states have the equivalent of New York's LMSW, which is the initial general practice social work license individuals can earn once they complete their MSW degree from an accredited program and pass a licensure exam. Many, but not all, social work positions in New York State require an LMSW.

NY Licensed Clinical Social Worker (LCSW)

All states require a license to practice clinical social work. Clinical social workers offer therapeutic counseling to clients struggling with health, mental health, addiction, and other issues. Social workers holding clinical licensure are qualified to make diagnoses and provide clinical treatment.

In New York State, this license is the LCSW, which stands for "Licensed Clinical Social Worker." The LCSW is an advanced license for those interested in clinical practice.  Not all social workers need to get their LCSW, as it is just for individuals who want to practice this specific subset of social work.

LCSWs in New York need to have an MSW degree that includes clinical coursework and post-graduate supervised work experience in a clinical setting before they can take the licensing exam. 

Social workers with their LCSW can then work towards obtaining the additional supervised practice hours to add their "R" (which would update their license to LCSW-R). The "R" indicates that the social worker has psychotherapy privileges. 

Learn more: Reliable resources for information about the profession

The Occupational Outlook Handbook is compiled by the U.S. Bureau of Labor Statistics and includes information about all kinds of careers, including social work. In addition to information about the profession, it also has data regarding average salary and future job outlook. 

The National Association of Social Workers (NASW) is a professional organization whose membership is made up of social workers from across the country. The NASW website includes educational information about choosing the profession of social work, in addition to helpful information for social work practitioners.

The Grand Challenges for Social Work are championed by the American Academy of Social Work and Social Welfare. They call for scientific and interdisciplinary solutions to large societal issues. The Grand Challenges include some great examples of issues social workers care about and are working to mitigate. 

The inSocialWork Podcast  has been produced here in the UB School of Social Work for more than 10 years, and new episodes are released monthly. We bring in experts from across the country to discuss different social work topics and issues. Listening is a great way to explore the different populations and issues relevant to social work, as well as to learn about the variety of roles they fill in our society.

If you aren't sure where to start, here are our top five episode recommendations in no particular order (but feel free to look for other topics you are interested in!)

• Imposter Syndrome Within the Social Work Profession: Recognizing Your True Potential (Episode 237)
• Exploring the Integration of Social Workers into the Library Setting (Episode 264)
• Wanted: Social Workers on Capitol Hill (Episode 203)
• Smart Decarceration (Episode 212)
• Multisystemic Therapy: A Strengths-Based, Collaborative Approach for Working with Negative Adolescent Behaviors (Episode 201)

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• v.16(1); 2020 Aug

Language: English | French

The Role of Social Workers in Interprofessional Primary Healthcare Teams

Rôle des travailleurs sociaux dans les équipes interprofessionnelles de soins primaires.

Executive Director, Bruyère Academic Family Health Team, Ottawa, ON

Rachelle Ashcroft

Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON

Judith Belle Brown

Professor, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON

Simone Dahrouge

Scientist, Bruyère Research Institute, C.T. Lamont Primary Health Care Research Centre, University of Ottawa, Ottawa, ON

Background:

In Ontario, Canada, social workers are employed in a number of primary healthcare (PHC) settings such as Community Health Centres (CHCs) and Family Health Teams (FHTs). However, many aspects of social work practice within PHC settings are unknown.

Objectives:

The objectives of our study are to determine the amount of social work services provided in CHCs and FHTs, identify the types of services that social workers provide in CHCs and FHTs and ascertain the methods social workers use to deliver services in CHCs and FHTs.

An analysis of a cross-sectional data set obtained from a survey conducted in June 2016 in Ontario was performed.

The majority of practices (84.2%) had a social worker, although several practices also hosted other types of mental health workers. In virtually all practices with social workers, they (and individuals designated as mental healthcare providers) were also involved in practice level efforts to support mental healthcare delivery. In several practices, the care they delivered extended beyond that related directly to mental healthcare, ranging from preventive care and health promotion (64.5%) to palliative care (16.8%). In several practices, these workers also offered group appointments related to healthy behaviour (43.6%) and self-management (~33%).

Interestingly, the role of social workers in practices where they were the sole designated mental healthcare worker was not meaningfully different from practices where other mental health professionals work.

Conclusions:

In PHC, social workers deliver or support the delivery of mental healthcare, but their role extends beyond that domain to encompass a broader set of services that contribute to the individual's health and wellbeing.

En Ontario, au Canada, des travailleurs sociaux sont employés dans nombre d'organismes de soins de santé primaires (SSP) tels que les centres de santé communautaire (CSC) et les équipes Santé familiale (ESF). Toutefois, plusieurs aspects du travail social au sein des organismes de SSP demeurent inconnus.

L'objectif de notre étude est de déterminer la quantité de services en travail social proposé dans les CSC et les ESF, d'identifier le type de services offerts par les travailleurs sociaux et de connaître les méthodes employées par ceux-ci pour offrir leurs services.

Méthode:

Nous avons procédé à l'analyse d'un ensemble de données transversales obtenues au moyen d'une enquête menée en Ontario, en juin 2016.

Résultats:

Il y a un travailleur social dans la majorité des organismes (84,2 %), mais plusieurs organismes comptent aussi sur la présence d'autres types d'intervenants en santé mentale. Dans pratiquement tous les organismes qui offrent des services de travail social, ces derniers – et les personnes désignées comme prestataires de services en santé mentale – sont aussi impliqués dans les efforts de l'organisme pour appuyer la prestation de soins de santé mentale. Dans plusieurs organismes, les services qu'ils offrent débordent les soins directement liés à la santé mentale, allant d'activités de promotion de la santé et des soins préventifs (64,5 %) aux soins palliatifs (16,8 %). Dans plusieurs organismes, ces travailleurs animent aussi des groupes pour favoriser les comportements sains (43,6 %) et l'autogestion (~33 %).

Il est intéressant de constater que le rôle du travailleur social n'est pas significativement différent entre les organismes où il constitue le seul travailleur désigné pour les services de santé mentale et ceux où travaillent aussi d'autres professionnels de la santé mentale.

Conclusion:

Dans les SSP, les travailleurs sociaux offrent des services de santé mentale ou y contribuent, mais leur rôle s'étend au-delà de ce domaine et comprend un plus large éventail de services qui favorisent le bien-être et la santé des individus.

Introduction

Canada has a universal healthcare system that covers the majority of healthcare costs, such as physician costs, hospital care and tests, but that public insurance system does not include services by most non-physician healthcare professionals. This lack of insurance for services provided by non-physician healthcare professionals is especially detrimental for those with mental healthcare issues (found in 17% of the Canadian population), the costs for which are often prohibitive to those without private insurance ( Corscadden et al. 2019 ; Sunderland and Findlay 2013 ). Improving access to mental health services in primary healthcare (PHC) settings can improve care quality, coordination of care and outcomes for patients struggling with mental illnesses ( Rush 2014 ). Team-based care also improves the prevention and management of chronic diseases and is linked to lower costs ( Beaulieu et al. 2013 ; Kates et al. 2011 ; Kiran et al. 2015 ).

In Canada, Ontario has led the way in funding interprofessional PHC teams with the introduction of Family Health Teams (FHTs) in 2005 ( Brown and Ryan 2018 ) – which now serve approximately three million Ontarians (22% of the provincial population; Glazier et al. 2012 ) – and by investing in the expansion of Community Health Centres (CHCs), a PHC model established in the 1970s that serves the more vulnerable segments of the population ( Collins et al. 2014 ; Hastings 1972 ). Different PHC models are intended to serve different patient populations, community needs and provider preferences ( Ashcroft 2015 ; Glazier et al. 2012 ; Hutchison and Glazier 2013 ). In Ontario, FHTs are an example of a professional PHC model that has physicians as the main providers who hold a high level of responsibility; care is preventative, diagnostic and curative; and, historically, FHTs have little community involvement, serving a limited number of enrolled patients ( Ashcroft 2015 ). CHCs are an example of a community PHC model aimed to meet broad health needs of the population from a social determinants perspective and serve their respective neighbourhood catchments ( Collins et al. 2014 ).

Although both FHTs and CHCs are designed to meet local community needs, CHCs have distinct services that enable them to address the broad health needs of the more vulnerable segments of the population that they provide care for ( Glazier et al. 2012 ). For example, compared with FHTs, CHCs typically offer a broader range of health promotion services to address the social determinants of health faced by the disadvantaged populations that they serve and are involved in a range of community engagement activities outside of their practice organization ( Glazier et al. 2012 ). FHTs were established with the intention to improve access to comprehensive healthcare services, interdisciplinary team–based care, patient-centred care and mental health services, as well as to improve services' continuity across other parts of the healthcare system ( Ashcroft 2015 ; Aggarwal 2009 ; Brown and Ryan 2018 ). The interprofessional composition within FHTs and CHCs varies from practice to practice, but it typically comprises family physicians, nurses and nurse practitioners, as well as other allied health professionals, such as social workers, pharmacists and dietitians, who provide a range of health and mental health services without the burden of direct costs assumed by the patient ( Glazier et al. 2012 ; Gocan et al. 2014 ; Marchildon and Hutchison 2016 ).

Integration of social work in PHC

The absolute numbers of social workers practising in primary care settings across Ontario are currently unknown. Yet, the surge in the emergence of interprofessional teams since the early 2000s has significantly increased the availability of publicly funded social workers in Ontario PHC settings ( Ashcroft et al. 2018 ). For example, social workers now represent the third largest group of interprofessional health professionals in FHTs, following physicians and nurses ( Ashcroft et al. 2018 ). The number of publicly funded social workers in FHTs ranges from approximately 0.4 to 56.7 FTE ( Ashcroft et al. 2018 ), which suggests that some smaller FHTs have one part-time social worker and larger FHTs have hired multiple social workers across multiple sites ( Ashcroft et al. 2018 ). Moreover, the actual number of social workers employed in interprofessional PHC settings is even more difficult to ascertain because some social workers are hired into roles that are explicitly titled “social worker,” whereas other similarly trained social workers are employed in PHC settings as a “mental health counsellor” ( Kates et al. 2002 ).

Social work's scope of practice in PHC settings

The biopsychosocial approach, person-in-context philosophy and clinical expertise of social work align well with those of PHC ( Ashcroft et al. 2018 ; Mann et al. 2016 ; Rabovsky et al. 2017 ), particularly because patients in PHC settings are increasingly confronted with complex psychosocial and mental health problems that benefit from social work interventions ( Mitchell 2008 ; Van Hook 2003 ). Social workers assist a range of patient populations and provide services in areas including mental health conditions and addictions, chronic disease, children and youth illnesses, geriatrics illnesses, grief, trauma, parenting issues, palliative care, dementia and other neurological issues, financial stressors, housing issues and a broad range of other general psychosocial issues ( Ashcroft et al. 2018 ; McGregor et al. 2018 ; Sverker et al. 2017 ).

Patient care activities of social workers in PHC settings include providing psychosocial assessments and interventions, completing comprehensive risk assessments, providing psychotherapy as well as other types of counselling, making referrals to community resources, supporting medical provider interventions, conducting health promotion activities, engaging in systems navigation and care coordination, providing ongoing case management, improving relationships between the medical provider and the patient, assisting in team building and, at times, assisting in the education and training of other healthcare providers ( Ashcroft et al. 2018 ; Horevitz and Manoleas 2013 ; McGregor et al. 2018 ; Sverker et al. 2017 ). The typical length of appointments with social workers in PHC settings is unknown, although sessions tend to be shorter than sessions in other mental health specialty care contexts ( Horevitz and Manoleas 2013 ).

The delivery of social work services in PHC settings may take on various forms. For example, patient care may occur in-office via direct face-to-face individual, couple and/or family appointments ( Kates et al. 2002 ; Sverker et al. 2017 ). Social workers in PHC settings may conduct home visits for homebound patients as in the case of palliative and end-of-life care and other types of complex biomedical and psychosocial situations ( Reckrey et al. 2014 ; Steketee et al. 2017 ). Group services are an alternate mode of care, in which social workers in PHC settings may facilitate a range of different types of psychoeducation or therapeutic group interventions ( Ezhumalai et al. 2018 ; Kates et al. 2002 ; Steketee et al. 2017 ). Indirect interventions are also used, where the need for face-to-face contact, such as with completion of referrals and other types of documentation, is less ( Horevitz and Manoleas 2013 ). Social workers may also lead a range of activities within PHC contexts that are not direct patient care interventions such as community development and outreach, some health promotion activities, education and training, supervision and taking on various formal and informal leadership roles ( Ashcroft et al. 2018 ).

Despite the rapid increase of social work services, there is limited information and research conducted on social work in the current PHC context ( Ashcroft et al. 2018 ; Dinh and Bounajm 2013 ; Mitchell 2008 ). The purpose of this study is to determine the extent to which social work services are integrated into the current PHC context in Ontario, Canada. The research question guiding our study is as follows: What social work services currently exist in CHCs and FHTs in Ontario, Canada? The objectives of our study are to (i) determine the number of social work services in CHCs and FHTs, (ii) identify the types of services that social workers provide in CHCs and FHTs, and (iii) ascertain the methods social workers use to deliver services in CHCs and FHTs.

Design and context

An analysis of a cross-sectional data set obtained from a primary care setting survey conducted in June 2016 in Ontario, Canada, was perfomed. In Ontario, the Ontario Health Insurance Plan covers most medical care facilities for the entire population, including the primary care services provided by family physicians, but it does not cover the services provided by allied health professionals, including mental health professionals, in the non-acute out-patient setting for most Ontarians. For this reason, and to determine the extent of services provided by allied health professionals, including social workers, a survey was considered as the appropriate method to reach a large number of primary care settings across Ontario. Only patients receiving care at a CHC or FHT may have free access to the services of a social worker or psychologist or other mental healthcare worker if that practice's team comprises such a professional. Thus, our survey targeted CHCs and FHTs because of the integration of allied health professionals within these PHC models.

Participant recruitment

The survey targeted all primary care settings that provide comprehensive care (i.e., excluding specialized and walk-in clinics) in the province of Ontario. Practice sites working together under a single organization across different geographical locations were considered unique practices and a questionnaire was sent to each. The survey was promoted through the Ontario College of Family Physicians, newsletter. Local Health Integration Network primary care leads were asked to promote the survey within their network of primary care providers. The survey was promoted by the INSPIRE PHC network through their e-mail listserv. Finally, the Ontario Association of Community Health Centres (now the Alliance for Healthier Communities [AOHC]) and the Association of Family Health Teams of Ontario (AFHTO) promoted the survey among their members each by way of membership listserv. The AOHC and AFHTO sent an invitation for their members to complete the survey on three separate occasions. This study is limited to the subset of practices in these interprofessional models. At that time, there were 184 and 73 CHCs and FHTs, respectively. One organization may have a single practice site or be composed of more than one practice site working collaboratively under the same management.

Data source

The research tool we relied on was an online survey developed to capture primary care attributes that could be studied for their relationship with the quality of care delivered. The survey was largely based on the “Measuring Organizational Attributes of Primary Health Care” survey developed by the Canadian Institute for Health Information and released in 2013 and the Evolution survey used in Quebec ( Levesque et al. 2014 ; Pineault et al. 2012 ), and supplemented with additional questions to capture all required information.

Description of variables in the research tool

We assessed the practice's primary care model, team composition and services provided. For the last question, items were divided into services provided during individual appointments, group appointments and practice-level initiatives or programs. The respondent was asked to record whether that service was provided, and by whom. The options provided were doctor, registered nurse or registered nursing assistant, nurse practitioner, pharmacist, dietitian, mental health worker and other. These questions are provided in Appendix 1, available online at longwoods.com/content/26292 .

For the question that captured team composition, respondents could identify the presence of social workers and other mental health workers separately. No definition was provided for either term. The section that captured services provided six specified categories (MD, RN/RNA, Nurse Practitioner, Pharmacist, Dietitian and Mental Health Worker) and an Other category for which the respondent was asked to provide details. We created a Social Worker category to capture the sites that had identified that the service was provided by a social worker in the “Other” category. Because there was no Social Worker category available to the respondents, some practices likely recorded the work performed by these professional under the category “Mental Health Worker”. PHC practices that included social workers were identified based on the proportion of practices having reported that an activity was performed by an “other mental health worker” yet did not check “mental health workers” in their team profile. Considering the three most commonly reported services for that group, the proportion was as follows: psychosocial services, 69%; primary mental health care, 71%; and prevention and health promotion, 76%. Given that the majority of services captured under Mental Health Worker were likely performed by a social worker, we describe activities having been reported as performed by a “Mental Health Worker” or a “Social Worker” under the “Other (specify)” together for all 101 practices eligible for that analysis. As a sensitivity analysis, we also report on these activities in the subset of 68 practices having indicated that no other mental health workers or psychologists were present in the practice.

In total, 68 CHCs and 77 FHTs completed at least a portion of the survey. Of these, 10 CHCs and 14 FHTs did not complete the principal section of interest and were excluded, resulting in 58 CHCs and 63 FHTs included in the analyses. The analyses pertaining to a social worker's role are limited to 43 CHCs and 58 FHTs having reported the presence of these professionals.

We reported on proportions and averages for various professionals or of activities performed. Although we provide the data by model, because the intent was to understand these practices' features in the different models, and not to identify differences, we did not conduct statistical comparisons between models.

The survey was completed primarily by an administrative or clinical manager (57.0%) or executive directors (34.7%), although a practice physician, other managerial health professionals, or junior administrative staff were also involved (18.5%) in completing the survey.

Practice description

Of the 121 CHCs and FHTs, 53.7% were part of a multisite organization. Most respondents were from academic sites (70.0%) involved in teaching medical students or residents, situated in the community (93.4%) rather than attached to a tertiary care centre and established at least five years earlier (88%).

The staffing profile in CHCs, FHTs and others is shown in Table ​ Table1. 1 . Family physicians, nurse practitioners and nurses were the most predominant health professionals at the sites. The majority of practices (83%) reported having at least one social worker on staff, and some practices (18%) had psychologists on staff. Social workers were slightly more common in FHTs, whereas other mental health workers were more common in CHCs. Thirty-one practice sites (approximately 25%) reported having an other mental health worker, a term the survey did not define in more depth. In total, 11 (35.5%) of these 31 practices did not report having a social worker on staff.

Human resources

Full-Time Equivalent is calculated for only practices where that team member is present. Registered Nurse includes registered practical nurses.

In the 101 sites that reported having a social worker on staff, the full-time equivalent ratio of social workers to primary care providers (i.e., family physicians or nurse practitioners) was 0.24, although this ratio was considerably lower in FHTs (0.16) than in CHCs (0.34).

Services provision

We limited our analyses to practices reporting having a social worker(s) on staff ( n = 101). Among these, only 20 practices reported having Other Mental Health Worker on staff. Survey results strongly suggested that, in the absence of a Social Worker category, respondents most likely codified some activities performed by the social worker into the Other Mental Health Worker category. We show the results of the respondents that selected Mental Health Worker or specified that the activity was performed by a social worker under “Other: specify” combined. When the data set is limited to practices without any mental health professional other than the social worker ( n = 68), the activities' profile is largely unchanged (Table ​ (Table2). 2 ). These professionals are commonly involved in direct, one-on-one patient service delivery, and they influenced the programs offered at the practice level. They were less likely to deliver group services.

Services offered by social workers/mental health workers [practices with social worker(s)only]

Group appointments = group appointments for education and self-management programs.

Amount of social work in PHC practices

There is a variation in the amount of social work services integrated across CHCs and FHTs. Although more FHTs are likely to have social workers on site (92.1% vs. 74.1%); however, the FTE is somewhat higher in CHCs than FHTs (2.0 vs. 1.5 FTE). In these practices, the ratio of social worker to FTE primary care providers was 0.24. Given the existing wait-list for social work services in many FHTs and CHCs ( Ashcroft et al. 2018 ), determining the recommended ratio of social work services per family physician or nurse practitioner may help to meet patient care demands ( Keefe et al. 2009 ). Organizational features of a PHC setting have a profound effect on patient care, including the degree to which healthcare providers such as social workers are integrated into the team ( Ashcroft et al. 2018 ; Hogg et al. 2008 ). Knowing the recommended amount of social work services considered optimal to meet patient care demands in a given PHC setting, and in relation to organizational variations, will aid policy and decision-makers make evidence-based decisions about future resource allocation to meet patient care demands.

Type of services provided by social workers

Social workers provide a broad range of services, including psychosocial care, mental health care, patient education and sometimes end-of-life care, in CHCs and FHTs, with little differences across models. Given that social workers were not involved in the survey completion, we suspect that these represent underestimates of the actual numbers of the types of social work services. For example, given that all of social work services fall under the umbrella of psychosocial care, we would anticipate that psychosocial care would likely be reported at 100% if social workers completed the survey ( Ashcroft et al. 2018 ; Mann et al. 2016 ; Mitchell 2008 ; Rabovsky et al. 2017 ).

Contextual variables such as patient population characteristics, geographical setting and availability of community resources understandably influence the types of services offered in PHC settings ( Hogg et al. 2008 ), including social workers' scope of practice ( McGregor et al. 2018 ; Mitchell 2008 ; Sverker et al. 2017 ). Social workers in CHCs and FHTs are providing services to Ontarians with mental health care needs, yet the range of other types of patient populations who are recipients of social work's services such as prevention and health promotion, home visits, lifestyle counselling and chronic disease management remains unclear. Variations exist in the types of social work services provided in different PHC settings in Ontario ( Ashcroft et al. 2018 ), yet the differences that exist between northern and southern regions remain unknown. In addition, it is unknown how the scope of practice of social workers in CHCs and FHTs is developed in relation to existing resources in different communities and the mechanisms in which social workers are liaising with other health organizations.

Methods of care delivery

A range of modalities help deliver social work services in PHC settings ( Kates et al. 2002 ; Sverker et al. 2017 ). According to our data, a majority of a social work services are being provided via in-office appointments, with the emphasis more on individual appointments than on group appointments. The average length of social work appointment is unknown and was not asked in our survey. The data showed that home visits are being offered by some social workers, although the types of clinical situations and patient characteristics to benefit most from home visits by social workers in CHCs and FHTs remain unknown. Less than half of the practices having a social worker(s) reported that these professionals offered group appointments for lifestyle and healthy living, patient self-management plans and chronic disease management. There may be even more opportunities for social workers to apply their expertise in group appointments than in what currently exists ( Ashcroft et al. 2018 ). Future investigations will help determine the optimal modalities for practice in PHC settings to meet the high demands for social work services, given the increasing patient complexity ( Ashcroft et al. 2018 ; Ashcroft et al. 2019 ).

Challenges to optimizing integration of social work in PHC

The inclusion of social work in CHCs and FHTs has made a range of services available to PHC that can help improve individual and population health outcomes. However, more data are needed to help demonstrate the impact of social work services on care processes and patient outcomes ( Ashcroft et al. 2018 ). For example, research has shown that patients of FHTs experienced considerable improvement in diabetes care over time compared to patients of primary care physicians who were not a part of an interprofessional team ( Kiran et al. 2015 ); yet contributions of social work, if any, to these or other types of patient outcomes despite their involvement in providing lifestyle counselling, helping with patient self-management planning and engaging in chronic disease management activities, are unknown. One of the challenges is that it is difficult to capture social work's contributions to care in administrative databases that are used to determine the population-based impact of care. Only recently has CHC interprofessional team data, including data on social work and the patients they serve, become available. Outcome data was beyond the scope of this study, although we recommend that leaders and social workers in PHC settings integrate the collection of data within the practice setting to help highlight the impact social workers are having on patient care and health outcomes. We encourage academic FHTs and CHCs to make this integration a priority, given their capacity for research.

Policy Implications

The integration of social work in PHC has expanded substantially because of a systematic pan-Canadian PHC reform that began in the early 2000s ( Ashcroft et al. 2018 ). Considerable investments have been made, leading to the accelerated inclusion of social workers in PHC settings in Ontario and elsewhere across Canada ( Ashcroft 2015 ; Ashcroft et al. 2018 ; Hutchison et al. 2011 ). Now that social workers are flourishing in numbers in PHC settings ( Ashcroft 2015 ; Ashcroft et al. 2018 ), our study suggests that there is an opportunity for key stakeholders to determine how best to sustain the social workers currently embedded in PHC practices, to maximize their contributions in patient care. This suggestion is particularly timely, given the recent provincial policy priorities to enhance patient access to mental health services, which directly align with social workers' scope of practice in PHC settings ( The Canadian Press 2020 ).

In a previous study, social workers indicated that some leaders have a limited understanding of social workers' roles in PHC settings ( Ashcroft et al. 2018 ). Despite the limitation, we felt that it was important to carry out this study because the participants who completed our survey are the same leaders in PHC settings making influential decisions on the number of social workers to employ in a practice, the types of activities that fall within a social worker's role within their practice setting and the modes of service delivery that are permitted and encouraged. Despite the gaps of having non–social workers as respondents, our survey provides an opportunity to provide an understanding from a perspective that highly influences social work's role in PHC settings ( Ambrose-Miller and Ashcroft 2016 ; Ashcroft et al. 2018 ).

Limitations

There are two key limitations for consideration. Using a survey to answer our research question meant that the range of responses and the depth of understanding of social workers' roles are limited to categories within the survey itself. The second limitation is that the survey relied on participants who are non–social workers and who may not be able to fully articulate the amount, range or methods used to deliver social work services in PHC settings ( Ashcroft et al. 2018 ).

Recommendations

Our study raises additional recommendations for social work practitioners, educators and researchers. Role clarity is essential for team collaboration and for ensuring that social workers in PHC settings are contributing to patient care at an optimal level by providing the most effective types of services ( Ambrose-Miller and Ashcroft 2016 ). We encourage social workers to identify themselves as social workers even when not hired in the role that has the social work title (such as mental health counsellor). Doing so will help clarify the scope of practice to patients, other team members and administrators ( Ambrose-Miller and Ashcroft 2016 ). We also encourage PHC leaders to hire social workers in roles using the formal title “Social Worker” instead of the general term “Mental Health Counsellor.” Furthermore, where applicable, we advise that the job title of social worker be taken into consideration and included in collective agreements. Any person who uses the title “Social Worker” or “Registered Social Worker” is registered with a provincial social work regulatory body, which then provides some assurance for educational requirements and performance standards that guide scopes of practice ( Collins et al. 2002 ). There is substantial value in having PHC professional organizations (e.g., AFHTO and the Ontario College of Family Physicians) and social work professional organizations (e.g., Ontario Association of Social Workers) collaborate to help determine how to maximize social workers' scope of practice in PHC settings. The reason for this is because healthcare is a complex system, and by effectively nurturing the ongoing integration of social work in PHC settings, local PHC leaders will benefit from ongoing direction and supportive infrastructure at a macro level ( Corrigan et al. 2017 ; Sørensen et al. 2018 ).

Educators have a role to ensure that social workers are prepared to provide a range of services using multiple modalities that are required in comprehensive and fast-paced PHC settings ( Horevitz and Manoleas 2013 ). Academic practice sites are well-positioned to facilitate educational opportunities for social work students, given their long history of training medical students and family medicine residents ( Soklaridis et al. 2007 ). Early exposure to PHC teams, and learning in “real time” (with trainees from other disciplines), can increase the social work practice readiness in primary care settings ( de Saxe Zerden et al. 2018 ). Further embedding social work within the training provided at academic practices will better prepare students from other disciplinary backgrounds for collaborative care practices inherent to PHC ( de Saxe Zerden et al. 2018 ). When social work students are included in interprofessional training opportunities, students from other disciplinary perspectives gain a greater understanding of group process, improve communication skills for difficult conversations, feel more confident when encountering adversity and improve group decision-making abilities – which leads to better patient care outcomes ( Charles et al. 2011 ; Reeves et al. 2017 ). We encourage the academic practice sites involved in our study to also prioritize education and training of social workers.

We recommend that researchers develop surveys in a way that can capture social workers' contributions in PHC settings. Complexities exist in doing so because of the many roles assumed by social workers in PHC settings. For example, many mental health worker positions are held by a social worker. It is challenging for surveys to capture person-centred, relational and multipronged approaches of social work unless these are designed from the outset with this particular intent. Future research can help determine the most optimal types of activities, approaches and delivery modalities for social workers to use, to best address the needs of increasingly complex patient issues within the current PHC context.

Acknowledgements

We are very grateful to Jennifer Rayner (Alliance for Healthier Communities) and Carol Mulder (formerly Association of Family Health Teams of Ontario [AFHTO]) for their invaluable support in the delivery of the survey, and to Laura Belsito (AFHTO) and Drs. Rayner and Mulder for reviewing the manuscript. Thank you to the Transdisciplinary Understanding and Training on Research Primary Health Care (TUTOR-PHC) program, which supported the involvement of Vela Tadic in this research as part of her TUTOR-PHC traineeship.

Contributor Information

Vela Tadic, Executive Director, Bruyère Academic Family Health Team, Ottawa, ON.

Rachelle Ashcroft, Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON.

Judith Belle Brown, Professor, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON.

Simone Dahrouge, Scientist, Bruyère Research Institute, C.T. Lamont Primary Health Care Research Centre, University of Ottawa, Ottawa, ON.

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Social Work and Policy Practice: Understanding the Role of Social Workers

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Ankur Saxena, Sneha Chandrapal, Social Work and Policy Practice: Understanding the Role of Social Workers, The British Journal of Social Work , Volume 52, Issue 3, April 2022, Pages 1632–1642, https://doi.org/10.1093/bjsw/bcab073

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The social work profession is a practice-based profession that promotes social justice and advocacy for marginalised individuals. In spite of the fact that the policy practice is considered as crucial component of social work practice, the real participation of social workers in policy practice seems very less. It has a potentially significant influence on social work profession, both as a field of study and an area of practice. History is filled with an evidence showing that the policy practice paved the way for the development of social work profession as people used different social work skills to campaign for the formalisation of the social work profession. Social workers have been held up as exercising substantial power to influence policy being policy implementers (Schorr, A. L. (1985) ‘Professional practice as policy’, Social Service Review, 59(2), pp. 178–96; Scott, W. R. and Davis, G. F. (2007) Organisations and Organising: Rational, Natural, and Open System Perspectives, Upper Saddle River, Pearson Prentice Hall). Social workers having practice experience make them excellent advocates because they understand clearly the challenges confronted by their clients, including clients’ presenting problems, holistic environmental factors, and client strengths that can be drawn on so as to assist them. This article throws light on linkages between social work and social policy, policy practice in social work and role of social worker as a change agent in policy practice.

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Social Work Haven

What are the 10 Roles of Social Workers

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You asked, what are the 10 roles of social workers ?

While I can provide a list of 10 common roles of social workers, it’s important to note that our roles often go beyond these.

Here are 10 roles of social workers, but this list is by no means exhaustive:

• Advocate : Social workers often act as advocates for their clients, working to ensure their rights and needs are met within various systems and institutions.
• Counsellor : They provide counselling and emotional support to individuals and families facing a wide range of challenges, including mental health issues, addiction, and crisis situations.
• Case Manager : Social workers coordinate services and resources for their clients, ensuring they receive comprehensive care and support.
• Mediator : They facilitate communication and resolve conflicts between individuals or within families to promote healthy relationships.
• Educator : Social workers educate clients about resources, coping strategies, and life skills to enhance their well-being and self-sufficiency.
• Researcher : Some social workers engage in research to better understand social issues, evaluate programs, and inform policy development.
• Policy Advocate : They work to influence social policies, advocating for changes that benefit marginalised or disadvantaged populations.
• Community Organizer : Social workers may organise and mobilise communities to address social issues, promote social justice, and create positive change.
• Therapist : Clinical social workers provide therapy to individuals, couples, and families, addressing mental health and emotional challenges.
• Child Welfare Specialist : Social workers in this role focus on the safety and well-being of children, often within the context of child protective services or foster care systems.

What is the main role of a social worker?

Social workers often work in social services and they support individuals, families, and communities to recognise their strengths and address their needs.

They are dedicated to helping people develop skills, build relationships and find resources that will help them live more satisfying lives.

The role of a social worker, whether in clinical settings, correctional facilities, or private practices, plays a critical role in promoting positive change.

This is because they develop treatment plans to address mental illness and substance abuse problems, often holding supervisory roles and advocating for human rights within the criminal justice system.

Social workers have a strong educational foundation, including bachelor’s and master’s degrees.

If you are looking for more social work related content, check out the following articles:

• Why You Should Actively Listen as a Social Worker
• Social Work Values & Respect

Professionalism in Social Work

• Sample Letter of Recommendation for Social Worker
• Benefits of Being a Social Worker
• Psychologist vs Social Worker
• Social Work Haven Home Page

In the field of social work, other roles include –

Client Assessment

Assessing your client involves gaining a comprehensive understanding of their multi-dimensional context to formulate an effective strategy for positive change.

During this stage, you will gather information regarding your client’s situation within their personal, organisational, and societal frameworks.

This encompasses exploring their family and medical histories, relationships, educational and employment backgrounds, as well as the challenges they have faced within each of these systems.

The assessment process enables you to appreciate your client’s perspective on their situation, identify their priority areas for intervention, and recognize the strengths they bring to the therapeutic process.

Upon completion of the assessment, you will be better equipped to collaboratively develop a treatment plan tailored to your client’s unique needs.

Development and Implementation of Care and Treatment Plans

Following the client assessment, the next step involves creating a support or treatment plan designed to empower your client in addressing, recovering from, or adapting to their circumstances.

During this phase, active listening is paramount as you work collaboratively with your client to define their goals and establish criteria for achieving wellness.

Typical treatment plans include ongoing individual therapy sessions, aimed at helping your client progress toward their desired objectives, and may also incorporate group or family sessions tailored to address specific challenges.

Flexibility in adapting treatment plans is essential, as goals are met, new issues emerge, or crises arise.

Additionally, you may refer clients to other resources and professionals, including support groups and medical practitioners, based on their diverse needs.

Securing and Facilitating Access to Resources

The process of creating and implementing a treatment plan extends beyond therapy sessions, often involving the connection of clients to community resources and governmental agencies.

This includes linking clients with essential services such as food banks, healthcare, unemployment support, and benefit programs like food stamps.

Social workers may also facilitate referrals to medical professionals for further evaluation, guide clients to support groups specific to their concerns, assist with job placement, and provide information on childcare resources, all geared toward helping clients successfully achieve their wellness goals.

Monitoring and Evaluating Progress

Once treatment is initiated, ongoing evaluation becomes essential to assess whether clients are making progress toward their established goals and criteria.

This evaluation serves the dual purpose of determining how best to continue supporting the client and assessing the effectiveness of the current intervention methods.

Occasionally, adjustments to the treatment plan may be necessary based on new developments, goal achievement, or the emergence of crises.

Flexibility in adapting strategies is key to helping clients reach their objectives effectively.

Client Advocacy

Client advocacy is a core aspect of social work, reflecting a commitment to improving the lives of those who may face challenges in advocating for themselves.

Advocacy takes various forms, including individual, organisational, and systemic levels.

On an individual level, social workers may intervene in complex situations, such as ensuring the safety of an abused child by working with the family, law enforcement, and child protective services.

Empathy and Active Listening:

Empathetic Attitude: Social workers approach their clients with genuine empathy, recognising the emotions and experiences that clients may be going through.

They aim to understand their perspectives and feelings without judgment.

Active Listening: Social workers actively listen to their clients, giving them their full attention.

They ask open-ended questions to encourage clients to express themselves and their concerns fully.

Respect for Individuality:

Recognising Diversity: Social workers respect the uniqueness of each client.

They acknowledge cultural, ethnic, religious, and other differences, understanding that these factors can significantly influence a client’s experiences and needs.

Client Autonomy: Social workers empower clients to make their own decisions whenever possible.

They respect their clients’ autonomy and choices, even if they may not align with the social worker’s personal beliefs.

Building Trust:

Consistency and Reliability: Social workers establish trust by being consistent, reliable, and dependable.

They keep their promises and follow through on commitments.

Confidentiality: Maintaining strict confidentiality is essential.

Social workers assure clients that their personal information will be kept confidential, except in situations where disclosure is mandated by law.

Collaborative Approach:

Partnership: Social workers view the client relationship as a partnership.

They involve clients in decision-making processes and encourage them to actively participate in setting goals and developing intervention plans.

Informed Consent: Social workers get informed consent from clients before initiating any interventions or services.

This involves explaining the purpose, benefits, and potential risks of the services being provided.

Strengths-Based Perspective:

Identifying Strengths: Social workers focus on identifying and leveraging the strengths and resources of clients and their support systems.

This approach helps clients build resilience and self-efficacy.

Goal-Oriented: Social workers work with clients to establish clear, achievable goals.

They celebrate successes and milestones along the way, fostering a sense of accomplishment and motivation.

Cultural Competency:

Cultural Sensitivity: Social workers continually educate themselves about cultural competence to better serve diverse populations.

They adapt their practices to be culturally sensitive and respectful.

Avoiding Bias: Social workers are vigilant about their own biases and prejudices, ensuring they do not negatively impact their interactions with clients.

Personal Well-being: Social workers understand the importance of self-care to maintain their own well-being.

They manage stress, seek supervision and support, and maintain healthy boundaries to prevent burnout.

By embodying these principles and practices, social workers create a safe and nurturing environment for their clients.

This compassionate and understanding approach enables social workers to help clients navigate challenges, achieve their goals, and build stronger, more resilient lives.

Establishing Rapport and Building Trust :

Initial Engagement : Social workers begin by establishing a positive and trusting relationship with the individual.

This rapport-building process creates a safe space for open communication.

Comprehensive Assessment :

• Information Gathering : Social workers collect information about the individual’s history, current circumstances, and concerns.
• This may include personal interviews, family histories, and the review of relevant documents.
• Holistic Approach : Assessments consider all aspects of an individual’s life, including physical health, mental well-being, emotional stability, family dynamics, social support, and cultural factors.

Physical Needs Assessment :

• Health Status : Social workers evaluate the individual’s physical health, identifying any chronic illnesses, disabilities, or immediate health concerns that may require attention.
• Basic Needs : Assessment includes evaluating access to necessities such as food, shelter, clothing, and transportation.

Mental and Emotional Needs Assessment :

• Mental Health Evaluation : Social workers assess the individual’s mental health status, looking for symptoms of mental disorders, substance use issues, or trauma.
• Emotional Well-being : They explore the individual’s emotional well-being, including their ability to cope with stress, manage emotions, and maintain healthy relationships.

Identifying Risk and Protective Factors :

• Risk Factors : Social workers identify potential risk factors that may impact the individual’s well-being, such as substance abuse, domestic violence, or exposure to trauma.
• Protective Factors : Conversely, they identify protective factors that can support the individual’s resilience and ability to cope with challenges, including strong social support networks and personal strengths.

Cultural Competence :

• Cultural Sensitivity : Social workers take cultural factors into account, recognising that cultural backgrounds and beliefs can influence an individual’s needs and preferences for interventions.
• Language and Communication : They assess language proficiency and communication barriers to ensure effective interactions and interventions.

Assessing Client Goals and Preferences :

• Goal Setting : Social workers work collaboratively with the individual to identify their goals and aspirations.
• This helps tailor interventions to align with the individual’s objectives.
• Client Preferences : They consider the individual’s preferences and choices in the selection of interventions and services.

Documentation and Evaluation:

• Record Keeping : Social workers maintain detailed records of their assessments, including observations, findings, and recommendations.
• Ongoing Evaluation : Assessments are dynamic and may need to be updated periodically to reflect changes in the individual’s circumstances or needs.

Interdisciplinary Collaboration:

• Team Consultation : Social workers collaborate with other professionals, such as healthcare providers, counselors, and educators, to obtain a comprehensive understanding of the individual’s needs.

By conducting thorough assessments that encompass physical, mental, and emotional aspects, social workers can develop customised intervention plans that address the individual’s unique needs, strengths, and goals.

This person-centered approach enhances the likelihood of positive outcomes and improved well-being for those they serve.

What are the roles of social worker?

1. Client Assessment

2. Development and Implementation of Treatment Plans

3. Securing and Facilitating Access to Resources

4. Monitoring and Evaluating Progress

5. Client Advocacy

6. Empathy and Active Listening

7. Respect for Individuality

8. Building Trust

9. Collaborative Approach

10. Strengths-Based Perspective

11. Cultural Competency

12. Self-Care

13. Establishing Rapport and Building Trust

14. Comprehensive Assessment

15. Physical Needs Assessment

16. Mental and Emotional Needs Assessment

17. Identifying Risk and Protective Factors

18. Cultural Competence

19. Assessing Client Goals and Preferences

20. Documentation and Evaluation

21. Interdisciplinary Collaboration

What are the 7 core functions of social work?

Social work is an interdisciplinary profession that helps individuals, families, communities and groups to enhance their well-being.

To do so, social workers employ seven core functions within their practice:

• Assessments: Social workers assess the individual’s needs by evaluating physical health, mental well-being, emotional stability, family dynamics, social support networks, cultural factors and other aspects of their lives.
• Planning: By taking all relevant information into account, social workers develop comprehensive plans to help clients achieve their goals in a timely manner.
• Intervention: Social workers use evidence-based interventions and techniques such as counselling, coaching or advocacy to provide meaningful support for individuals facing complex problems.
• Monitoring and Evaluation: Social workers regularly monitor their client’s progress to ensure that goals are being met, and adjust plans as needed with input from the individual.
• Documentation: Social workers document all assessments, interventions, progress notes, and other relevant information in a timely manner.
• Advocacy: In addition to providing direct service to clients, social workers use their expertise and knowledge to advocate for policy change and increased access to services.
• Research: Social workers participate in research initiatives relevant to the profession, helping to advance evidence-based practice and identify areas of need.

What is a social worker role example?

As a social worker, one of your most important roles is to be an advocate for those in need.

This includes defending individuals’ rights and addressing issues such as poverty, mental health, domestic violence, disability rights and substance abuse.

You may also provide direct services, such as counselling or case management, to clients or their families.

Other examples of social worker roles include conducting assessments, providing crisis intervention, collaborating with other service providers, and developing community support programs.

Social workers also provide psychoeducation to clients and their families, helping them to understand the issues they are facing and develop strategies for coping.

Your role may even extend beyond direct client work, as you can educate the public on social justice issues related to your area of expertise.

What is the role of a social worker in safeguarding?

Social workers play an important role in safeguarding vulnerable adults and children.

This involves identifying potential risks, assessing the level of risk and then taking any necessary measures to protect individuals from harm or exploitation.

Social workers work with other professionals, such as healthcare providers, police officers, and teachers, to identify signs of abuse or neglect and take appropriate action.

They also provide support and counseling to individuals who have experienced abuse.

Additionally, social workers assist in developing prevention strategies and providing training on child protection procedures for other professionals.

They also conduct assessments to determine the appropriate level of care for vulnerable adults and children.

Finally, they are responsible for ensuring that policies are in place to protect those at risk, and that any existing policies are regularly reviewed and updated.

Social workers have an important role to play in safeguarding vulnerable adults and children, and their work is essential for protecting the rights of those who are most at risk.

By providing support, counseling, assessments, and policy reviews, social workers help to ensure that individuals are safe from harm or exploitation. This contributes to a safer and better society.

What are the four functions of social work?

The four functions of social work are:

• Helping individuals, families, and groups to enhance their well-being;
• Promoting the self-determination and dignity of people in need;
• Working with the community to create services and resources for those in need;
• Advocating for social change to reduce disparities in power and resources.

What are the six social work values?

The six social work values are: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence.

These core values help guide professional behavior and decision-making for social workers.

Service refers to providing assistance to people in need; social justice is aimed at eliminating inequality; dignity and worth of

What are the six objectives of social work?

The six objectives of social work are:

• To enhance the well-being of people in need;
• To empower individuals, families and groups to take control of their lives;
• To promote the self-determination and dignity of people in need;
• To reduce poverty and other forms of inequality;
• To build and maintain partnerships with other organisations;
• To foster collaboration, innovation and change in the social service sector.

What skills does a social worker need?

Social workers need a variety of skills, including the ability to empathise and connect with clients, strong communication skills, problem-solving abilities, knowledge of community resources, and an understanding of social policy.

They must also be able to manage their own stress levels while providing effective support for those in need.

Additionally, social workers should be knowledgeable about cultural diversity and able to work effectively with people from different backgrounds.

Finally, social workers should have a strong ethical code of conduct and adhere to professional standards in order to protect the welfare of their clients.

What other roles can social workers do?

Social workers also play important roles in schools, hospitals, and other public settings.

In schools, social workers provide support to improve the educational outcomes of children from diverse backgrounds and help address issues such as bullying or mental health concerns.

At hospitals, they may provide counselling to patients and their families or connect them with resources that can help support their recovery.

Other public settings may include government offices, prisons, and homeless shelters, where social workers provide assistance to those in need, such as linking them with housing or other services.

Social workers also play an important role in research and policy development, advocating for changes that can improve the lives of vulnerable populations.

In conclusion, the role of a social worker is both diverse and indispensable, encompassing a wide array of job titles and services.

Social work professionals, armed with their social work degree and clinical experience, serve as strong advocates for addressing social problems, promoting social justice, and meeting clients’ needs across the lifespan.

Whether working in healthcare settings, child abuse prevention, senior centers, or private agencies, their commitment to facilitating positive change and social cohesion remains unwavering.

With easier access to education, including online MSW programs and doctoral degrees, they are better equipped than ever to address the complex social conditions and mental health problems faced by individuals, families, and communities.

As per statistics from the U.S. Bureau of Labor Statistics and UK statistics of social workers, the median salary for social work graduates is a testament to the value placed on their practice-based profession.

Moving forward, social work professionals will continue to conduct research, advocate for the needs of children, older adults, and young people, and provide different types of services across government agencies and private organisations.

In essence, the field of social work is ever-evolving, adapting to the evolving needs of society, and remains dedicated to making a positive impact on public health and the well-being of individuals and communities alike.

Socialworkhaven.com Useful Resources

• Social Work To-Do List

Social Work To – Do List: What To Include: We sometimes struggle with managing our daily tasks as social workers. This is not because we do not have the skills. The work load, crisis and challenges we face can be overwhelming. That is why a social work to-do list may help us manage better.

• Recommended Books

Best Social Work Books Every Student Must Read is a great article full of highly recommended and engaging books. Helping student social workers to equip themselves with knowledge and skills. It is a great way to empower yourself and encourage you to read more.

• Social Work Registration

Social Work Registration: Get it done – is a useful article that walks you through the social work registration process.

• Social Work Burnout

51 Effective Ways to Fight Social Work Burnout helps practitioners explore 51 effective ways to fight Social Work Burnout. Social work burnout can affect the way we execute our role. It can cause social work stress, and a stressed social worker cannot perform their role effectively.

• Active Listening in Social Work

Why You Should Actively Listen as a Social Worker raises awareness of active listening in social work. Social work active listening involves the listener paying close attention to the speaker, making sure not to interrupt, and reflecting on what they have heard. This helps the speaker feel heard and validated, and it can also help them clarify their thoughts and feelings.

• Social Work Humour

Social Work Humour for the End of a Long Day This article explains when social work humour is important. Essential social work skills include empathy, authenticity, resilience and respect. These skills help us cope with situations and meet the needs of service users or clients. However, the best coping mechanism in social work is definitely humour.

• Social Work CV Writing

Social Work CV Writing This article is a must read – whether you are a student, newly qualified, or an experienced social worker, and looking for a new company to work for, you will find these 13 fundamental tips useful if you want to create the perfect Social Work CV/resume that will make you outshine others and get noticed.

• Social Work Values & Respect in Social Work

Social Work Values & Respect in Social Work Social work values include respect, dignity and worth of individuals, pursuit of social justice, integrity and competence. This article explores what ‘respect’ means in social work. Social work values are the beliefs and principles of social workers, which guide their practice and help them to determine the right course of action when making decisions.

• Generalist Intervention Model: Complete Guide

Generalist Intervention Model: Complete Guide The Generalist Intervention Model (GIM) is an approach to working with individuals, families, and communities that is based on a recognition of the interconnections of human systems. It emphasises building partnerships with clients and utilising their strengths to address problems and create solutions.

The model uses an ecological perspective to identify multiple levels of influence in client’s lives, including but not limited to: family, peers, school/work, community, and policy.

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Public Involvement in Social Care Research

• Published: 05 July 2021
• Version: V 1.0 July 2021
• 48 min read

The NIHR is one of the principal funders of adult social care research in England. We are committed to boosting social care research and have increased funding and capacity building opportunities across NIHR – including the now annual Research for Social Care call. The Social Care Institute for Excellence (SCIE) was commissioned by the NIHR to undertake a piece of work to identify good practice in user, carer and public involvement in social care research, explore differences between involvement in health care and in social care research, and highlight opportunities for further work. Social care research has a long history of user, carer and public involvement and we welcome this report which provides us with helpful guidance on where we can continue to develop and strengthen our partnership with service users, carers and the public in social care. Some of NIHR’s internal structures have evolved since the writing of this report. Most notably, recommendations refer to NIHR INVOLVE. From the 1st April 2020 the NIHR brought together its activities in patient and public involvement, engagement and participation (previously led by NIHR INVOLVE) with its activities in research dissemination to establish a new NIHR centre .

The work for this report was carried out in 2019 but the recommendations remain highly relevant and have influenced subsequent plans. The report identifies that NIHR needs to work differently – taking research closer to the people in the communities where they live and work, and building sustainable relationships over time. This need was starkly illustrated by the COVID-19 pandemic. COVID had a significant impact upon people using care and support services. The pandemic exposed inequalities which are yet to be fully explored, but we know that some groups of people using care and support have experienced much greater risk of illness and death (for example, people with learning disabilities), that access to essential services has been reduced or withdrawn and that there has been an increased toll and mental health impact upon carers.  It has never been more important that social care research is prioritised, designed and undertaken in partnership with users, carers and the public, so that future services can better meet the diverse needs of people and communities. The recommendations made in the report fall within four main themes. Below we lay out how the NIHR has so far been working to address them through its work to meaningfully engage with, and involve, service users, carers and the public. Our work is by no means complete - and we will continue to challenge ourselves and others to engage with the findings of the report and fully realise the recommendations made within it. We welcome the opportunity to hear your insights on the themes raised in this report. You can share these by contacting [email protected] . Jeremy Taylor NIHR National Director for Public Voice and David Abbott, NIHR School for Social Care Research Associate Director

How NIHR is working to address SCIE recommendations

Theme 1: committing to continue to embed strong public involvement and engagement in nihr social care research.

NIHR has expressed its commitment to social care research, including a new annual Research for Social Care funding call and the appointment of the Applied Research Collaborative (ARC) Kent, Surrey and Sussex as the National Lead for Social Care. There has been investment in the skills and knowledge of researchers through the NIHR Academy and five new large adult social care partnership projects have been established. The NIHR Adult Social Care (ASC) Coordination Group is ensuring a shared approach to raising awareness of, encouraging and supporting social care research across all parts of the NIHR. All social care research funded through NIHR is required to ensure appropriate opportunities for public involvement in the research, with tailored approaches to reach populations using social care services as well as carers. Public involvement is a key feature of the NIHR School for Social Care Research (SSCR) and is vital to all of its research and research capacity development activities. We will draw on the advice and extensive expertise of the SSCR in embedding effective public involvement and engagement in social care research, and we will work with the NIHR Programme Directors and Chairs, NIHR CED, the NIHR ASC Coordination Group and a broader range of stakeholders to ensure this is truly a cross-NIHR effort. We will work with the NIHR Programme Directors and Chairs to ensure that they understand what can be done to ensure our public involvement and engagement activities, for both our commissioned and research-led funding calls, promote inclusion and strive to be accessible to social care users, carers and the public.

Theme 2: Championing Equality, Diversity and Inclusion

NIHR is working to ensure that our governance and decision-making groups include a greater presence from those who use and work in adult social care. For example, public involvement is a key feature of the NIHR School for Social Care Research (SSCR) and is integral to their research and research capacity development activities. The SSCR has recently refreshed membership of their User, Carer and Practitioner Reference Group (UCPRG) and is working with them to develop a programme of activity. NIHR Schools for Social Care, Primary Care and Public Health have met to explore options for further developing inclusive public involvement and engagement across all School activities. The report highlights that universities can sometimes generate significant barriers through their finance and payment arrangements, and by providing  poor incentives for academics that want to work collaboratively with service users, including disabled people. Some of these  barriers relate to HMRC policy - or how it is interpreted - and the processes and procedures of individual universities. The NIHR CED has recently refreshed its payment guidance for researchers and payment guidance for members of the public and we are working with institutions - as a cross UK project - and those affected by payment barriers, both to encourage institutions to adopt more inclusive solutions in line with current HMRC guidance, and to influence the policy environment (in partnership with other organisations like the Health Research Authority ). Alongside the Research for Social Care call and wider NIHR Equality, Diversity and Inclusion activities, we will undertake a strategic project to improve levels of inclusion, diversity, representation and equality in social care research funding – for those developing, conducting research and taking part in it.

Theme 3: Engaging communities and supporting user-led research

We recognise the importance of community engagement and the burgeoning work in this area.  There is learning that can be shared from our Global Health Research portfolio and we will encourage all parts of NIHR to develop effective approaches to stimulate the development of relationships between communities and researchers/NIHR programmes for more inclusive research partnerships. The “Reaching Out” programme has produced a summary of learning on engaging with people from marginalised and seldom heard communities and follow up work is planned to determine next steps for NIHR. The number of SSCR-funded research studies that are in collaboration with users, carers and/or practitioners is increasing, and is attracting user-led research and career development proposals. To further aid such efforts, the SSCR is currently funding scoping work to build capacity for user-led and co-produced research, with a view to develop a proposal for a pilot scheme and will share learning across NIHR.

In 2021/2 CED and the NIHR Clinical Research network public involvement leads will work with a range of carers to identify how NIHR can best improve and advance how it engages and works with carers in shaping and delivering health and care research.

Theme 4: Providing accessible, practical and relevant resources

The report raises the importance of developing, or adapting, accessible, practical and relevant resources to support social care researchers and users involved in producing research, and disseminating them appropriately. The most used resources which INVOLVE produced have recently been reviewed, updated and republished on Learning for Involvement . CED is now responsible for curating, updating and disseminating NIHR guidance on public involvement, engagement and participation, and has committed to ensuring that new resources are inclusive of social care research and include social care examples. This approach has been taken with the most recently published resource; the final publication of the ‘Co-production in Action’ series in April 2021 . This document builds upon the NIHR’s Guidance on coproducing a research project by illustrating co-production in action in different types of NIHR funded research, and has a strong emphasis on social care research examples.   The SSCR annual conference took place virtually this year, and included live subtitled and British Sign Language interpreters, to improve the accessibility of the event. We will continue to share such learning and practice across NIHR.

Public Involvement in Social Care Research: Final report to NIHR INVOLVE

Alison Faulkner, Kate Pieroudis, Pete Fleischmann - Social Care Institute for Excellence, February 2019

Executive Summary

This report presents the results of a piece of work undertaken by SCIE for NIHR INVOLVE to explore public involvement in social care research. We interviewed 14 key people, held a workshop to discuss early findings and carried out a brief literature review. The aim of the work was to surface good practice in involvement in social care research, explore differences between involvement in health care and social care research, and identify opportunities for further work. 

This piece of work concludes that the practice of public involvement in social care research shares much in common with health care research. Many of the elements that support good practice or act as barriers to involvement are shared across the two fields. Guidelines that address public involvement in health care research can be adapted for use by social care researchers. However, we heard from many people who felt that issues of equal access (for Disabled people, people with different health conditions and people with caring responsibilities) need a greater focus in social care research, in order to ensure that research is accessible and people can be meaningfully involved.

Social care research is the poor relation of health care research, receiving less funding and less status within the research world dominated by a focus on evidence-based practice. Unlike health care, social care is not a universal service, and is largely provided by unqualified care workers employed by a range of different statutory and private social care providers. This results in a fragmented service which does not lend itself to service user and carer involvement. It also results in fewer research-active professionals overall. This means that practitioners also need to be considered as potential stakeholders in research.

Social care researchers less often use the terms 'public involvement' or PPI (patient and public involvement). They more often talk of service user or carer participation or involvement, or use terms such as inclusive or participatory research. This connects with the historical context to social care research rooted in the Disabled People's Movement. This history has created greater awareness among some social care researchers of the power relations inherent in research and has created a context for the use of participatory methods.

Some of the differences lead us to highlight the importance of making available accessible practical examples of involvement in social care research and guidance on enabling equal access for people with different disabilities and needs.

Recommendations

• INVOLVE could develop a resource to direct social care researchers towards useful resources to include, for example, those provided by SCIE; and adapt their current resources to be inclusive of social care research by (for example) reviewing the terminology used.
• INVOLVE could collate practical examples of public involvement and co-production in social care research, would help to enable both researchers and service users & carers to understand what it looks like and what is possible. This project could include the use of film and other formats to ensure accessibility to a wide range of disabled people and social care service users.
• Guidance on making research accessible: The consultation suggests a need to collate and disseminate the experience and expertise enabling equal access for all of the many different groups of disabled people and people who use social care services: how to make research genuinely accessible. For example: the use of different communication formats, managing meetings, engaging people from different communities, the use of technology, using creative methods and so on.
• Co-production: NIHR INVOLVE and SCIE could usefully explore further work together to ensure that guidance on co-production is relevant to the social care research and service user communities.
• The School for Social Care Research: would be a good partner for INVOLVE to explore ways of taking these recommendations forward.
• Community engagement: INVOLVE could explore good practice in relation to community engagement, as part of making research relevant and more widely accessible to people from marginalised and seldom heard communities.
• NIHR could set aside funding to support user-led research and DPULOs: much of the genuinely innovative social care research has been undertaken by Disabled people's and user-led organisations.
• INVOLVE membership: a greater presence of people from the social care world, researchers and service users & carers, would help to build the further presence and priority given to public involvement in social care research.
• NIHR could make a statement committing to do more in terms of social care research, and with an expectation that there must be public involvement.
• Those involved in commissioning NIHR research need training/awareness raising on the issues that are particular to social care research.  This includes the funding implications of ensuring equal access for public involvement in social care research.
• Disabling barriers presented by Universities: Both SCIE and INVOLVE could review together how best to address the disabling barriers presented by Universities - perhaps by producing a discussion paper or organising a seminar. 

This was a small scale piece of work designed for a ‘light touch’ paper: further work would enable a fuller investigation of the issues raised here as well as the development of solutions.

Glossary of acronyms

• BAME: Black, Asian and Minority Ethnic communities
• DPULO: Disabled people's and user-led organisation
• ESRC: Economic and Social Research Council
• IMHA: Independent Mental Health Advocacy
• LGBTQI: Lesbian, gay, bisexual, transgender, queer, intersex
• NHS: National Health Service
• NICE: National Institute for Health and Care Excellence
• PI: Principle Investigator
• PPI: Patient and Public Involvement
• RCT: Randomised Controlled Trial
• SCIE: Social Care Institute for Excellence
• SSRC: School for Social Care Research (part of the NIHR)
• ULO: User-led organisation

Introduction

SCIE was commissioned by National Institute for Health (NIHR) INVOLVE to produce a scoping paper to inform the development of good practice in public, patient and carer involvement in social care research. The aim of the paper was to:

• surface recent examples of good practice in involvement within social care research (ideally across the spectrum of social care provision)
• explore what good involvement looks like and is understood to be in a social care context
• explore any differences in involvement within social care compared with involvement in health research
• identify opportunities for the development of involvement (with a particular emphasis on frameworks, guidance and support to researchers, panels, members of the public, service users and carers) within social care research, by NIHR and its partners
• inform future INVOLVE/cross-NIHR work plans, frameworks and guidance from 2019 onwards

The main audience for the paper is internal to NIHR - senior NIHR managers - as part of a wider examination of what NIHR can do to further stimulate and provide the right frameworks and support for increasing effective social care research. In addition, INVOLVE will consider using some part of the report to share with external audiences in line with its mission to raise aspirations, drive up standards, provide guidance and facilitate partnerships.

Public involvement in research

INVOLVE defines public involvement in research as “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them.” (INVOLVE, 2012). It posits an active partnership between members of the public and researchers. This could include working with research funders to prioritise research, offering advice as members of a project steering group, commenting on and developing research materials and undertaking interviews with research participants. In using the term 'public involvement', INVOLVE refers to a wide range of potential research partners as members of the public:

• patients and potential patients
• people who use health and social care services
• informal (unpaid) carers
• parents/guardians
• disabled people
• members of the public who are potential recipients of health promotion programmes, public health programmes, and social service interventions
• groups asking for research because they believe they have been exposed to potentially harmful substances or products (for example pesticides or asbestos)
• organisations that represent people who use services.

This describes a broad understanding of the 'public' who might be involved in research and it is not one shared by all organisations or individuals, nor is it relevant to all areas of research. In this piece of work, which focuses on social care research, we reflect the views of those we have consulted in understanding 'public involvement' rather than necessarily retaining the INVOLVE definitions.

In the past, INVOLVE used the terms consultation, collaboration and user controlled to describe different levels of involving people in research. However, it became clear that, in practice, research projects can include a combination of these three and also that the boundaries between them are not clear cut. They now describe these terms  as approaches to involvement as there are many different ways of involving people during the various stages of the research. Other organisations inevitably use different terms and this is explored further in this report.

Social care

In order to understand social care research, it is essential to understand the complex service context in which social care is provided. Social care covers a wide range of services and activities, from child protection through to end of life care, including people with physical disabilities and people with learning disabilities, people with mental health problems, older people and people at risk of abuse. Most of the people who provide social care are care workers working for social care agencies, although this does not account for the estimated 6 million unpaid carers including family and friends. Trained social workers account for a small proportion of the overall workforce.

One of the important differences between social care and health care is that, unlike health care provided by the NHS, social care is not a universal service. There are many small private providers and social care is delivered and managed differently by local councils across the country. As the UK population gets older, the demand for social care is increasing. However, the funding for social care is far less than that for health care. In addition, the recent cuts to funding have resulted in a decline in the number of private agencies and care providers. The funding available for social care research is further limited because there is little incentive for private organisations, such as pharmaceutical companies, to become involved. 

The vast number of small private providers have little incentive to involve service users and carers in the way they work, even if the local council where they operate does so. There is little in the way of infrastructure to support the involvement of service users and carers in social care. In health care, there are networks and forums to support involvement, including Healthwatch, PALS (Patient Advice and Liaison Service) and numerous patient and carer forums in local Trusts.

Nevertheless, there is a history and tradition of involving service users and carers in the training and education of social workers - and this was made mandatory in 2002 (Department of Health, 2002). Most social workers will have been exposed to the perspectives of service users and carers during the course of their professional training. Cossar and Neil (2015) report that it was important to their research team 'that social work research should be undertaken with similar ethical standards to those governing social work practice' (p.230). According to BASW (the British Association of Social Workers), the principles of human rights and social justice are fundamental to the social work profession . In theory, this ethical context could provide a natural environment for public involvement in research to flourish.

Social care research

It should be said that there is no clear dividing line between health and social care research; just as people cross these boundaries with their needs so does the research that involves them. Certain areas in particular, such as mental health and dementia, often cross the boundaries between health and social care services and research.

There is a powerful history of emancipatory disability research dating back to the 1970s and 1980s. This means that the participation of disabled people in research and the existence of disabled researchers, is more widely understood in social care research than it has been traditionally in health care research (Beresford, 2010). There is a strong tradition of exploring the power issues in social care research with strong ethical and political imperatives to challenge the nature of research production, going back to the inception of the disabled people's movement. Peter Beresford has written of this in a number of publications (Beresford and Carr, 2018; Beresford, 2010).

Earlier in this section, we described the different approaches to public involvement as: consultation, collaboration and (service user) control. However, there are other ways in which the approach taken to involvement in research can vary. One of these lies in the underlying ethos or values. Arguably, the ethos of participatory research and of user-controlled research is to make change happen: to make visible the knowledge of marginalised people and to empower people and communities through that knowledge-making process to change their lives (Beresford and Carr, 2018; Turner and Beresford, 2005). As Beresford (2010) points out, the central purpose of emancipatory disability research and user-controlled research, is to empower service users with a focus on what research is for; the process of research and where control of the research lies. Beresford (2009) distinguishes between democratic and managerialist approaches to involvement; the former having explicitly ethical and political aims and the latter having more pragmatic goals that avoid challenging existing power relations. Participatory research is more closely associated with the democratic approach and tends to be concerned with challenging the power relations involved in research. Much of the research taking place across the broad spectrum of public involvement in research, may have more pragmatic aims in mind - such as, bringing in a different perspective to the research or, indeed, gaining funding. The involvement of service users and carers in research may be seen as providing one part of the picture, giving involvement of service users and carers a more pragmatic, if important, presence in research. However, as has been pointed out by Cossar and Neil (2015), the involvement of service users for purely policy or funding purposes is in danger of being tokenistic, as it may not be embedded in the process of research nor expected to influence the outcomes.

In truth, there is a range of political, ideological and pragmatic motivations underlying all of these approaches to research. Terms such as participatory, emancipatory research and inclusive research are used more frequently in social care research, whereas the 'public involvement' terminology has more agency in the health care context. Another term introduced more recently to the research arena is 'co-production', a theme also explored in this piece of work. Whilst the terminology might not necessarily ally itself directly with a particular ethos, it can have implications for the nature and process of involvement.

A relatively recent development in the field is the establishment of the NIHR School for Social Care Research in May 2009, to 'develop the evidence base to inform and improve adult social care practice in England by commissioning and conducting world-class research'. The NIHR SSCR is a partnership between five leading academic centres in adult social care research in England. The SSCR has a service user, carer and practitioner reference group to advise their work.

Many of the publications and guidelines that address 'public involvement in health and social care research' make little specific reference to social care research (Brett et al, 2012). This means that more work is needed if we are to understand some of the differences and similarities, which is one of the aims of this piece of work.

SCIE has extensive experience of service user and carer involvement and co-production in research, through, for example, our involvement in the NICE Collaborating Centre and the new What Works Centre for Children’s Social Care (https://www.scie.org.uk/children/what-works-centre). SCIE has good knowledge of existing practice and access to relevant networks, and is a known expert on co-production. The SCIE team adopted the following approach to this piece of work:

• A brief literature review
• Interviews with key people engaged and involved in social care research
• A workshop to review the interim findings

A total of 14 people were interviewed: eight were employed as academics (two retired/emeritus professors); six identified as service users, survivors or disabled people; three were employed by voluntary organisations in a managerial capacity. The subject areas covered by the interviewees were: mental health, social care, disability, dementia, race and racialisation, LGBTQI issues, children and families, learning disabilities, alcohol, housing. In addition, interviewees had expertise in co-production, social work practice and teaching, law, participatory research methods, funding research and involvement in research.

The topic guide used for interviews is given in Appendix A. All interviews were recorded and service user participants were paid £50 if they were not otherwise employed. The literature review has been used to inform this report.

The workshop was attended by 15 people: disabled people, people who use services and carers associated with SCIE, and a couple of academics and people from voluntary sector organisations and DPULOs. 

The programme for the workshop is attached in Appendix B. During the day, some participants were filmed talking to camera and an edited film is available as a resource from the day.

The interviews and the workshop revealed considerable passion among the academic, service users and disabled people involved in social care research. Some of the passion was for carrying out genuine participatory research; equally some of the passion originated from bad experiences of involvement or inauthentic co-production. In this report, we are assuming some prior knowledge of public involvement in research, as it is in the first instance intended for INVOLVE.

Please note: Projects included in this report as good examples of public involvement or co-production were nominated by interviewees; however, they have not been checked with other members of the relevant research teams for their views.

The findings are divided into the following sections:

• Identifying the differences
• Good practice in public involvement in social care research
• Barriers to public involvement in social care research
• Co-production

1. Identifying the differences

This piece of work confirmed that many of the practical elements of public involvement in research are common across social care and health care research - the section on good practice (page 15) reflects this. Issues such as: involving people from the start (or before the start) of a research project, ensuring good support and shared training, building in adequate time and resources, fostering relationships, are familiar themes from across the literature (INVOLVE, 2012; Rice et al, 2015; NIHR Mental Health Research Network, 2013). A few differences did emerge, however, and these are explored below. Particular thanks are due to the workshop participants who helped to draw these out.

The social, policy and funding context

As discussed in the Background section to this report, the policy and funding context for social care services is very different to the context for health care. This has implications for research practice and public involvement. There is less funding available for social care and for social care research than there is for health care. The involvement of a multiplicity of private providers in social care gives a fragmented and atomised context in which to develop service user and carer involvement.

There is a difference between health care and social care expertise in relation to care practice. Social care takes place overwhelmingly in people's own homes or residential care where practitioners are not 'experts'; whereas, health care tends to take place in clinics, surgeries and hospitals where practitioners are assumed to have some specialist expertise - or can refer the person to an expert. This potentially places the social service user in a different role in relation to the practitioners involved: at times, for example, more knowledgeable (about their own needs) but at times more at risk from people coming into their home or dependent on care home staff for their basic daily needs. Power imbalances are ever-present.

Social attitudes may affect social care service users more than (many) users of health care services. Social care covers a wide range of different people, many of whom face discrimination, stigma within society, poverty and social disadvantage. In recent times, social attitudes towards people depending on welfare benefits appear to have worsened, with people sometimes regarded as 'scroungers' and doubt cast on people's lived experience of disability. In addition, the tendency to perceive people receiving social care as vulnerable can militate against them being involved. (However, some groups within health care services and research will be equally affected by social attitudes; for example, people who use mental health services, people living with HIV and AIDS.)

Language and terminology

The language used to refer to people in social care research can be quite different to that used in health care research. Researchers less often use the terms 'public involvement' or PPI (patient and public involvement) in social care research. They more often talk of service user or carer participation or involvement, or use terms such as inclusive or participatory research. Some social care researchers have also used the term 'emancipatory research' and, more recently, co-production (see section page 19). For some people, the impression they have of 'PPI' is of a tick box exercise to meet funders' requirements: it can often represent a very low bar. (Conversely, co-production entails a more comprehensive exploration of the relationships, power and the expertise brought by all of the partners). A key problem with public involvement terminology identified by the consultation surfaces a direct challenge to the nature of public involvement. The term 'public involvement' implies inclusion of members of the public who may be 'lay' people - i.e. they do not necessarily have direct experience as recipients of social care (or, indeed, of health care). This was felt to be particularly inappropriate in a social care context. The involvement of 'lay' people (or generic PPI representatives) can open up involvement to 'well-meaning retired professionals' or representatives from voluntary organisations, who have no direct experience of what it means to use social care services. People felt that it was essential to bring the lived experience of using social care services to the research - that involvement (and co-production) is about having a particular expertise grounded in lived experience, not about having no research expertise. [See the good practice example from SCIE] Some interviewees felt that language in social care is generally less medical, not driven by or based in the medical model, as it is in health research. The social model and recognition of disabling social barriers is more prevalent and helpful. However, conversely, some disabled people/service users suggested that social care retains a significant reliance on the medical model, which tends to result in disabled people being pathologised.

Equal access and accessibility

The importance of addressing access requirements and making research accessible to people with a range of different impairments and needs, is not solely an issue for social care research. However, it is an issue of great significance to social care research, due to the wide range of people who use social care services and for whom the research might be relevant. Ensuring equal and easy access has to be a primary concern for researchers undertaking research in social care. The organisation Shaping Our Lives produced the report 'Beyond the Usual Suspects' (Beresford, 2013) which gives practical guidance on developing more inclusive involvement. They usefully distinguish between the following sources of exclusion:

• Equality issues: gender, ethnicity, culture, belief, sexuality, age, disability and class.
• Where people live: homelessness, living in residential services, in prison or secure services, travellers and gypsies.
• Communication issues: Deaf people, blind people and people with visual impairments, Deaf and blind people, people who do not communicate verbally, people for whom English is not their first language.
• The nature of impairments: people with complex and multiple impairments, people with dementia, people who are neuro-diverse.
• Unwanted voices: e.g. activists, people who are more experienced and confident in challenging the status quo.

Below, we address some of the issues that emerged from the interviews.

• The example of involving people with dementia was given, with many examples of ways in which it is possible to engage people with dementia (e.g. using cards to communicate in groups, pictures, turn-taking in groups, ways of remembering and reminding...)
• There can be a significant cost element to access and this needs proper planning and budgeting at the start of a project.
• Social class is a major issue in relation to involvement - particularly, but not exclusively, in social care research. Middle class educated people 'fit in' more easily to the academic enterprise. The use of 'lay' terminology complicates this, as it potentially opens up involvement to members of the public who do not have direct experience of social care services. Equally, if people are expected to take part without immediate (or any) payment of expenses, this creates a perverse incentive for less disadvantaged people to take part.
• Diversity has to be purposefully addressed - it cannot be left to chance. Exclusion of certain groups - particularly people from BAME (Black, Asian and Minority Ethnic) communities and people in residential facilities - remains a challenge to good involvement practice. Participants also mentioned the white middle class environment of academia as excluding people from BAME communities and working class backgrounds.
• There was some concern that some academics and academic departments have been using the same model of participatory research for a long time, involving the same people over and over again. Although this builds long term relationships, it can also become exclusionary over time and does not lead to involving new, younger or different people.
• The technology often used to aid access (e.g. Skype and its equivalents) can fail. It is vital that these aids work if people are not to feel excluded.
• Involvement needs creative methods, art, videos, not assuming everyone can talk in groups, and learn from others who have developed expertise in communicating with different groups of people.
• It is important to bear in mind those people who are not in the room and to be aware of gatekeepers in social care: people in care homes, people deemed to be too vulnerable or without capacity.
• It is also important to bear in mind that BAME community leaders may not represent their communities authentically - it is vital to reach the people with direct experience of using social care services.

Research methodology and the role of evidence

There are differences in methodology between social care and health care research. Participatory methods are more prevalent and have greater credibility in social care than in health care research. In health care, quantitative methods are more prevalent; the randomised controlled trial (RCT) is commonplace as it occupies a significant role in the formation of evidence-based health care. To obtain large grants in health care research, a clinical trial is more or less obligatory. The tendency for social care research to employ more mixed, qualitative and participatory methods, potentially opens it up more easily to public involvement. 

In conjunction with the above, the role of NICE (the National Institute for Health and Care Excellence) and its assessment of research evidence is greater in health care than in social care.

In social care research, the principle researchers are often academics but not clinicians - for example, sociologists. In health care, the researchers are more often clinical academics - leading research from a medical model and clinical perspective. In theory, this could lend social care research a broader theoretical and methodological approach. However, it also means that research is, or can be, separated from practice which has implications for the involvement of social care practitioners in research.

2. Good Practice Involvement in Social Care Research

This section does not look unlike good practice in any research context. A quick Google search reveals a plethora of guidance on public involvement in research, produced by individual NGOs in different health and social care conditions, DPULOs and Universities, as well as specialist organisations like INVOLVE. The following list reflects the responses received from the consultation; issues in bold were those most frequently mentioned.  

• Involvement from the START was identified by almost all participants as essential to good practice. Unless service users are involved from the start, much that follows can be tokenistic and people do not feel true ownership of the research. However, resources are needed to achieve this: funding that provides for engagement prior to getting funding.
• TIME is a major issue, both a need and a barrier. Good involvement takes time and research deadlines often mitigate against this.
• It is important for researchers to build up relationships of trust with people who user services, carers and disabled people.
• Recognising, acknowledging the different skills, experience and contributions people bring to research - including life experience and including the contributions of all members of the research team.
• Paying people appropriately for their time and expertise - and finding other ways of creating positive incentives for people to participate.
• Clear job or role descriptions help to clarify roles and tasks and reduce uncertainty.
• Transparency, honesty about the limits of influence: start by agreeing the terms of involvement/co-production but be honest about what is and is not in the scope of the involvement influence. Involvement is likely to fare better if the project begins with a well thought-out and negotiated strategy from the start: with clarity about the purpose of involvement, the limits of influence and where decision-making takes place.
• It is important to give space and support for people to attend to identity issues:  not just how people identify themselves but how they become identified as a result of involvement. Methods suggested included mentoring, peer support or external supervision; some people suggested finding creative ways to enable people to discuss this.
• Useful to have someone to talk to outside the project, a mentor, who is not the line manager, about difficult issues
• Endings emerged as a major issue: how to manage endings well in the context of  research contracts and funders' deadlines. It is frustrating for everyone when people who are 'involved' or on short contracts cannot be involved in writing up and disseminating. Academics can move on to another project but continue to write up when others have left.
• Funders also need awareness of the cost implications of good involvement and co-production: assessment of funding applications should include checking the budget for appropriate elements for inclusion and accessibility.
• Disabled people's organisations and service users/disabled people are often seeking practical outcomes from the research; it is important to build this in from the beginning.
• A plea was made for funders to put in place some kind of external audit after the funding has been awarded, to monitor the public involvement aspect of the research - and for researchers to monitor and write up the public involvement aspects of their research.

Example of involvement in research

' tackling disabling practices: co-production and change '. university of bristol school for policy studies, funded by esrc. nominated by pi val williams the idea and proposal came from two sources: disability rights uk and norah fry colleagues; some colleagues were also disabled people. instead of simply describing the barriers faced by disabled people, the project focused on mechanisms of change, aiming to find out what theoretical ideas have practical use. the research aimed to develop and sustain practices that are on the terms of disabled people themselves. involved disabled people from the start. disability rights uk was in control of part of the research and on the management group. it was a large project with time: 'we had the luxury of being able to think.' they had regular meetings, the group was enthusiastic, met frequently to thrash out the theories and ideas that would be useful. the project took opportunities to bring in and work with other groups, e.g. - the dementia strand. co-researchers included three disabled people who were also involved in analysing data and making the product at the end. outputs included an accessible booklet; it was important that disabled people were involved in taking the messages and using them, disseminating the findings. easy read outputs from the project can be found here . example of supporting user-led research, dementia enquirers: innovation in dementia cic, nominated by rachael litherland [text edited from website] the aim of this project is to develop a new approach to research or 'enquiry', that is led and controlled by people with dementia themselves. the big lottery fund has awarded over £700,000. the project runs from october 2018 - march 2022. innovations in dementia will support people with dementia to explore how knowledge is acquired and applied in a way that feels relevant to their own lives. dementia enquirers will support up to 20 deep groups to conduct their own small-scale research projects. many groups have been involved in research studies carried out by universities. however, this project will give people with dementia a chance to lead, and be in control, of their own research - on issues that are important to them. training, guidance, support and ideas will be available to help groups to build their own research skills and expertise. university researchers may be involved as advisers or have roles in the projects. small grants will be available for groups to get on with their own research projects. these groups will be encouraged to share their learning with the rest of the deep network. the project will also explore with people with dementia the lessons that emerge from their work, and share this learning widely. we are confident that the project can influence the prevailing approaches in research - while bringing new respect for the skills, expertise and resilience of those who are living with dementia. 3. barriers to public involvement in social care research.

As with good practice, the barriers to public involvement in social care research are not dissimilar to those encountered in other areas of research. Beresford (2013), for example, identifies the following categories of barriers to involvement in social care: physical access, organisational, attitudinal and structural. Snape et al (2014) identified perceived tokenism as a major barrier to public involvement in research, as well as time and appropriate resources, scientific jargon, attitudes of researchers, power and control. In a systematic review on the impact of older people’s involvement in health and social care research, Baldwin et al. (2018) suggest that restrictive time limitations in research projects appear to be associated with tokenistic involvement and do not allow for the dynamic nature of public involvement. The authors call for funding bodies to have less restrictive contracts and timeframes to accommodate public involvement and provision of additional funding for evaluation within projects. 

Below we examine the barriers raised during the course of this piece of work, as there are perhaps some different emphases to be found. 

• Time and resources: funders rarely allow for the additional requirements of public involvement - and researchers may not take them into account either. This can result in projects ending badly or with only those on permanent contracts left to complete the writing up and dissemination.
• A perennial barrier is paying people for involvement and the difficulties of paying people who receive welfare benefits. It is essential to make payments easy to claim and to pay people's expenses promptly, otherwise some people can be excluded or left out of pocket - leading to inequalities of access. Benefits rules make paying people difficult and potentially open to sanctions - it is important to give people up to date information and support them in their claims.
• Employment status for people employed to be involved in research tends to be variable, precarious and problematic. Some people do not have formal employment status or pay and may be on zero hours contracts. This results in significant power imbalances and uncertainty, as well as unpredictable work and pay.  
• Finance and arranging payments is a huge barrier - causing real upset on occasions, examples of projects and individuals waiting long periods for payment or a contract to be settled. One academic said that the barrier is so great that he no longer tries to involve service users in his teaching.
• The incentives that count for career progression within academia (publications, research grants) are inherently disabling: they are individualising and competitive and do not support those academics who want to work in a collaborative way with service users and disabled people. Equally, these same issues represent significant barriers to the employment of disabled people and service users.
• Precarious employment status for people involved or employed in a University setting has implications for the (lack of) power associated with this status. This also leads to difficulties in completing projects ethically, as those who remain to write up and complete when contracts and funding have finished will be the permanent employees.
• (As above) the power imbalances represented by different employment status and pay in relation to academic partners, plus the knowledge imbalance between academic researchers and people involved for their experiential knowledge.
• Power imbalance inherent in identity (as disabled person, service user, carer) can be exacerbated if it is not discussed within the team and the value of experiential knowledge made clear.
• Service users/disabled people becoming aware of their own power and status as employed in relation to service users on an advisory group getting £20 for attending.
• Power of academia and those in positions of power can limit how critical you can be particularly if you are seeking further work in the same setting.
• The advancement of certain progressive and life-limiting conditions, e.g. dementia, is a barrier in itself.
• Identity was discussed at length by some disabled people and service users. This emerged as a significant issue, particularly for people employed within an academic setting. One or two people had not fully identified themselves as 'disabled' or 'service user' until becoming involved in research. Another spoke of the challenge of being unable to escape the label of mental health service user, and its implications for how they were treated by other academics, once they were identified as a survivor researcher within an academic setting. Generally, people felt that some professionals did not understand the significance of identity within the research team and how personal it felt to bring your lived experience, your life even, into this formal workplace: "It's about disabled people generally but it's also about me." They described a significant emotional investment to involvement.

Example of co-production

Co-production of the national institute for health and care excellence (nice) guidelines, nominated by pete fleischmann, scie head of co-production the nice collaborating centre for social care (nccsc) hosted by scie developed 11 social care guidelines using nice's methods and processes. scie was able to negotiate several adjustments to nice's processes to improve user and carer involvement. the most important of these was to agree that up to four people who use services or carers could be part of the guideline committee which oversaw the production of the guideline and owned the recommendations. nice guideline committees usually include two lay members, further adjustments were that users and carers were involved in the selection of the guideline committee chair and also in the scoping phase. nccsc conducted two guidelines relating to people with learning difficulties. co-producing these guidelines with people with learning required nccsc staff and the co-production team to develop several new approaches to support everyone involved: a workshop as part of recruitment of service user and carer representatives to the committee to give candidates a full briefing about the role training to support all staff working on the guideline on sharing complex information with people with learning difficulties, from scie and people first lambeth. a facilitator to support people with learning difficulties on the guideline committees. committee members worked before each meeting with the facilitator to understand the evidence-base. they worked out what they think is important in relation to the evidence and what they think the committee should focus on when making recommendations. they then presented their ideas at each meeting and this has also helped to inspire the rest of the committee. as the work progressed some further adjustments to committee meetings were made. these have included producing meeting papers two weeks in advance, all papers and presentations being in an easy read format and having more frequent and longer breaks during meetings. the resulting guidelines can be found here: learning disabilities and behaviour that challenges: service design and delivery and care and support of people growing older with learning disabilities . 4. co-production.

We were interested to understand people's views about co-production, whether it is a term used in social care research and whether they would describe any of their research experience in these terms, rather than using the term 'public involvement'. First we explore some of the context for co-production in research.

A recent literature review (Tracey & Paylor, 2018) discussed how public involvement relates to co-production and identified the differences and similarities they share. The key differences they identified were that co-production: 

• underpins the way research is designed and conducted and is not something that can be added into the research methodology
• demands a shift in power relations and establishing an equal partnership between citizens and professionals
• focuses not on the outcomes derived from the research findings, but from the process itself and the benefits for those involved. This could include expanded social networks or the development of new skills
• involves different stakeholders in analysing the research findings, whereas, in public involvement, this can often be something that researchers control and dominate
• places an emphasis on the importance of reflecting on the knowledge production process, and the relations between participants and the research itself
• opens up possibilities of involving a wide range a stakeholders, including policymakers and practitioners.

For SCIE, there is no simple definition of co-production. They emphasise the core of co-production as being an equal partnership: 'people who use services and carers working with professionals in equal partnerships towards shared goals' (SCIE, 2015). They describe four key principles for putting co-production into action: equality, diversity, accessibility and reciprocity ( SCIE Guide 51 Co-production ).

SCIE believes that, for co-production to be transformative, people who use services need to be recognised as experts in their own right. There needs to be respect for the assets that everyone brings to the process and an emphasis on all the outcomes that people value, rather than just those, such as clinical (or in this case, research) outcomes that the organisation values. Real change is accompanied by a movement of resources to people who use services and to frontline staff.

INVOLVE also proposes a number of key principles for co-producing research:

• Sharing of power – the research is jointly owned and people work together to achieve a joint understanding
• Including all perspectives and skills – make sure the research team includes all those who can make a contribution
• Respecting and valuing the knowledge of all those working together on the research – everyone is of equal importance
• Reciprocity – everybody benefits from working together
• Building and maintaining relationships – an emphasis on relationships is key to sharing power. There needs to be joint understanding and consensus and clarity over roles and responsibilities. It is also important to value people and unlock their potential.

In guidance on co-producing a research project , (Hickey et al., 2018) notes that co-producing research will “usually build on existing public involvement frameworks in organisations...sometimes these involvement frameworks will provide firm foundations for building co-produced research while at other times these frameworks will require modification”. The guidance recognises that people may only want to co-produce parts of a research project.

The interviews for this piece of work revealed a wide range of views and experiences of co-production. There was considerable scepticism about the authenticity of co-production in a research context and some bad experiences were related. Equally, a few good examples of co-produced research were given. For several people it was seen is an aspiration rather than a reality. The power differentials frequently remained despite some degree of power-sharing as is required by co-production. For some interviewees, it was seen as similar to 'involvement' in that there could be different levels of co-production. However, many workshop participants believed that we should be careful to define co-production and emphasise its distinct identity in our final report. The following views were given during the course of the interviews:

• Service users have more thorough ownership of the research
• You cannot ignore what people are saying in co-production as you might do with a consultation: you are working with people, taking them seriously.
• There is a higher bar than for involvement or participation
• Co-production values the skills, experience, contributions of all partners - professional skills too - drawing on the skills and assets of everyone.
• The term can be used to mean partnership with any variety of partners, and certainly includes practitioners in social care research. However, this can mean that it does not always include service users or carers.
• Co-production is more common within a service context than in research.
• It is difficult to do co-production well, it is rare, it has been colonised, researchers can be bit fraudulent in their claims to be co-producing research; for example, agendas set by professional researchers, meetings spaced wide apart when most of the real work and decision making goes on in between. One participant described seeing papers written about a project they had been involved in and not recognising the project from the write-up; she felt very disillusioned.
• Co-production is inevitably compromised by the limits and constraints imposed by organisations and research funders, - e.g. employment and payment limitations in Universities.
• People have learnt to use the word to get funding; it is not as meaningful as it could be.

Examples of co-produced research

Lgbtqi+ disabled people using self-directed support, nominated by pi david abbott this project was a partnership between the university of bristol, scie, stonewall and regard (a national organisation of lgbtq people who self-identify as disabled). the research was funded by nihr sscr. david abbot was the pi for the research, but it was regard and therefore lgbtqi+ disabled people who determined the need for the project and invited him to become involved as a researcher. this meant that the researchers held less power within the partnership than in a conventional involvement model - although the pi was accountable to funders. the project was an exploration of lgbtqi+ disabled people's needs around personal assistance. da described it as a good example of co-production, led by disabled people and with authentic relationship struggles and dilemmas. the research findings are published here (.pdf) . it helped that the project partnered with scie, who could pay the service users and disabled people involved in the project and circumvent the problems presented by trying to get payments administered by the university. the outputs from the project were managed and produced by scie in collaboration with regard and stonewall; they are practical tools aimed at lgbtqi disabled people and their support workers . the right to be heard: review of independent mental health advocacy services, uclan, funded by nihr, moninated by julie ridley. text edited from the report (.pdf) this review of the quality of independent mental health advocate (imha) provision across england was commissioned by the department of health. a team of independent researches including four academics and nine co-researchers with experience of mental health services undertook the study, which lasted eighteen months from 2010. using different methods, the experiences and viewpoints of those with experience of imha, advocacy services, and health and social care professionals were explored in-depth. one of the hallmarks of this research was the partnership between academics and mental health service users. the nine co-researchers were recruited for their interest in advocacy and research, and experience of using mental health services, including detention under the mh act, and experience of secure services. co-researchers were given training and support and the team worked hard to be reflexive, to consider how prior viewpoints might have influenced the research process. "it is our view that the research has been considerably enriched by service user involvement as a consequence of deeper insight into the experience of distress and detention. furthermore, it has been strengthened by the direct accountability to service users, as most of the research team come from this background, and have consistently provided a challenge to assumptions, methods, process and analysis." p.49 an implementation project was designed with scie to produce practical outputs. the team wrote a book from the resaerch, also co-produced with the service user researchers. "independent mental health advocacy - the right to be heard: context, values and good practice", jessica kingsley, 2015. glasgow centre for independent living: evaluation, nominated by gerry zarb glasgow centre for independent living (cil) commissioned gz to develop a participatory method for them to evaluate their own services and to plan new services.the approach he took was to enable them to take a lead role in the evaluation in order that, when it was finished, they would be in a position to do it themselves in the future. the project had tow guiding principles: social model of disability: gz's role was to put his research expertise at their disposal ' do i keep my research expertise to myself or do i share it around' the evaluation had to contribute to the empowerment of disabled people - it would be of real material use to them gz set up an evaluation action group, including staff and service users. they became an extended research team - designed the evaluation together as a team and carried out the data collection themselves. gz trained people to run focus groups. they came up with some basic questions with which to interrogate the service, and then designed a focus group topic guide. the evaluation was truly collaborative at every stage; the cil knew that they anted to do it in this way, they wanted a co-production approach. 5. guidelines/guidance.

There were divergent views about the role and value of guidelines for public involvement in social care research. Many people felt there were enough guidelines in existence already; or that the principles are the same for health and social care, it is the context and language that are different - so perhaps guidelines need to be pitched differently. For some people, 'guidance is an alternative to action' and there is no need for any new guidance. Some doubt was expressed about the potential for guidelines to make any difference if they have no status or clout. Few people interviewed were actively using guidelines, other than the INVOLVE guidance on payment. Some people said that they suggest or recommend guidelines to others, often INVOLVE (INVOLVE, 2012). These are some more of the views expressed:

• Any new guidelines must themselves be co-produced
• Guidelines are often too shiny and optimistic - what is needed are need real accounts of the journey, authentic accounts of what it is like to involve/be involved
• Relationships are key - guidelines don't solve this - need to establish and maintain relationships of trust whilst also not only using the same people every time
• Several people said they had been doing it for so long, they rarely look at guidelines. A couple of people mentioned the book 'This is Survivor Research' - edited by Sweeney, Beresford, Faulkner, Nettle and Rose, PCCS Books, 2009. Mentions were also made of Peter Beresford's work and Shaping Our Lives as sources of guidance.
• There is definitely a need for more guidelines that enable researchers to think about how to involve particular groups of people, e.g. people with dementia, people with learning disabilities: understanding how to make research accessible for people with different needs.

Conclusions

This piece of work concludes that the practice of public involvement in social care research shares much in common with health care research. Many of the elements that support good practice or act as barriers to involvement are shared across the two fields. Guidelines that address public involvement in health care research can easily be used by social care researchers. However, we heard from many people who felt that issues of equal access need a greater focus in social care research, in order to ensure that research is accessible and people can be meaningfully involved.

Social care research is the poor relation of health care research, receiving less funding and less status within the research world dominated by a focus on evidence-based practice. Few social workers become active researchers, meaning that practitioners also need to be considered as potential stakeholders in research. We heard far more about service user involvement than carer involvement. Some of the differences lead us to highlight the importance of making available accessible practical examples of involvement in social care research and guidance on enabling equal access for people with different disabilities and needs.

• INVOLVE could develop a resource to direct social care researchers towards useful resources to include, for example, those provided by SCIE; and adapt their current resources to be inclusive of social care research by (for example) reviewing the terminology used. INVOLVE could collate practical examples of public involvement and co-production in social care research, would help to enable both researchers and service users & carers to understand what it looks like and what is possible. This project could include the use of film and other formats to ensure accessibility to a wide range of disabled people and social care service users.
• The School for Social Care Research: would be a good partner for INVOLVE to explore ways of taking these recommendations forward. Community engagement: INVOLVE could explore good practice in relation to community engagement, as part of making research relevant and more widely accessible to people from marginalised and seldom heard communities.
• Disabling barriers presented by Universities: Both SCIE and INVOLVE could review together how best to address the disabling barriers presented by Universities - perhaps by producing a discussion paper or organising a seminar.  

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