Rural Challenges in Social Work Regulation

Abstract

Purpose: Social work practice and its regulation pose special challenges in rural areas. The present study reports findings from a statewide assessment of the social work labor force in a midwestern state, focusing on workforce issues in rural communities. Methods: Researchers used a mixed-methods approach to collect and analyze qualitative and quantitative data through sequenced study phases, conducting focus groups, key informant interviews, and surveys. Results: The statewide assessment identified challenges in rural communities that inform critical issues in recruiting and retaining social workers and in social work monitoring, including access to supervision, continuing education, licensure portability, and equity and justice. Conclusions: Study results suggest strategies for improving the recruitment and retention of rural social workers and areas for future research.

Keywords

rural social work social work workforce social work regulation

Social work practice and its regulation pose special challenges in rural areas. The present study reports findings from a statewide assessment of the social work labor force conducted by the University of Iowa in collaboration with the National Association of Social Workers, Iowa Chapter (NASW-IA). The study used a mixed-methods approach, collecting and analyzing both qualitative and quantitative data through sequenced components occurring in two phases (Phase I: focus groups and key informant interviews; Phase II: surveys of schools of social work, practicing social workers, and employers). A key area of focus was the needs of rural communities, driven by severe social work labor force shortages in the state's rural communities.

Studies of health and social services have identified a shortage of social workers as a significant issue in rural areas nationally (Mackie & Lips, 2010; Thomas et al., 2012; Walters, 2020). In Iowa, a particular concern that prompted the statewide assessment has been the scarcity of licensed social workers in rural areas of the state. More than two-thirds of Iowa's licensed independent social workers (LISW) lived in the eight most populated counties or out-of-state, and 29 out of Iowa's 99 counties had three or fewer LISWs. At the social work master's level licensure (LMSW), nearly 70% lived in the same eight most populated counties or out-of-state; and 34 of Iowa's 99 counties had three or fewer LMSWs (Landsman & Crandall, 2019). Moreover, nearly 90% of Iowa's counties were considered federal Mental Health Professional Shortage Areas, indicating a shortage of social workers as well as other mental health professionals. There is ample evidence that social, emotional, and behavioral problems are as prevalent in rural areas as in other settings; and although the need for social work practitioners in rural communities is clear, there is a relative paucity of social work research focused on rural populations (Slovak et al., 2011; Wright & Harmon, 2019).

Literature Review

Despite a widespread perception that social problems are concentrated in urban areas, rural communities experience rates of social, behavioral, and health problems similar to, if not higher than, other locales (Walters, 2020). These include, for example, substance use and mental health disorders (Browne et al., 2016). The opioid epidemic has taken a particularly hard toll on rural communities, with higher rates of misuse (Palombi et al., 2018), and higher death rates (Lister et al., 2020) relative to more urbanized areas. Suicide rates in rural counties are higher and have increased more over time than in urban counties (Rossen et al., 2018), with a similar pattern among populations of adolescents and young adults (Fontanella et al., 2015). Rural areas have been noted to have higher rates of depression (Carpenter-Song & Snell-Rood, 2017), persistent poverty (USDA, 2020; Walters, 2020), intimate partner violence (Edwards, 2015), and poor health and health outcomes (Bolin et al., 2015; Vohra et al., 2020). Regarding child maltreatment, some studies have found higher rates in rural areas and others in urban areas (Maguire-Jack et al., 2021). All told, the evidence shows considerable levels of distress in rural areas.

Where rural communities differ from others is in the availability of services and providers qualified to address these problems (Bolin et al., 2015; Daley, 2015; Thomas et al., 2019; Walters, 2020). Compared with other demographic-based health disparities such as race and ethnicity, research has paid little attention to health disparities based on geographic location (Young et al., 2015). However, rural social workers have long expressed concerns about service availability and client access (Allan et al., 2008; Daley, 2015; Lewis et al., 2013).

Social workers in rural areas face additional challenges such as geographical isolation and distance from professional supports (Walters et al., 2020). Rural practitioners struggle with role overload stemming from the need to be a generalist practitioner in areas where specialized services are scarce; and often need to balance dual relationships as both community members and community service providers (Humble et al., 2013; Riebschleger et al., 2015; Wright & Harmon, 2019). Recent demographic changes in rural areas include influxes of migrant and refugee populations (Bose, 2021). This increase has created additional challenges for rural social workers unfamiliar with the cultural and linguistic diversity that new populations bring, and who also lack basic knowledge about immigration (Bhuyan et al., 2012; Held et al., 2018; Wright & Harmon, 2019).

Recruitment and Retention

Population shifts toward urbanized areas have affected many helping occupations, including social work. As a result, rural areas struggle to both recruit and retain social workers (Brown et al., 2017; Mackie & Lips, 2010; Phillips et al., 2010). Some research has found that individuals who grew up in nonurban areas, who enjoy living in rural areas, or those who have other ties or attachments to a rural area, are more likely to be attracted to, return to, or stay employed in rural locations (Allan et al., 2007; Gifford et al., 2010; Mackie & Simpson, 2007; Sowl et al., 2021). When it comes to hiring staff for rural areas, there are indications that supervisors prefer to hire those familiar with rural settings because of the better fit and greater likelihood of retention (Mackie & Lips, 2010).

In child welfare, an area with a considerable amount of workforce research, Kim and Hopkins (2017) noted that child welfare agencies in rural areas have long-standing difficulties in finding qualified child welfare workers and filling vacant positions. Other studies have identified rural/urban differences related to retention, but findings are inconsistent. For example, some studies have found higher rates of turnover and intention to leave in rural areas (Fulcher & Smith, 2010; Strolin-Goltzman et al., 2007). Other studies, however, have reported lower turnover in rural areas (Griffiths et al., 2017; Yankeelov et al., 2009). One study of the child welfare workforce concluded that geographic location was not a direct predictor of intention to leave but related to other underlying factors associated with turnover intentions such as age, education, and tenure (Aguiniga et al., 2013).

Social Work Regulation

The demands of social work regulation pose special challenges for practice in rural communities. All states now require a license for clinical social work practice, and many states also require a license for nonclinical practitioners. Earning a license requires that the individual has graduated from a school of social work accredited by CSWE and passes the applicable Association of Social Work Board (ASWB) licensing exam. For licensing for independent practice, each state specifies the additional practice experience needed and the qualifications required for supervising the individual seeking the license. Additionally, license renewal requires ongoing professional education, with each state determining the number and/or category of approved continuing education (CE).

Although there should be a logical connection between graduation from an accredited school of social work and acquisition of a license to practice social work, Apgar (2021) has discussed problems posed by the competing foci of education and licensing—educational programs teaching students what social workers should do, licensure assessing knowledge directly applicable to what social workers actually do. These are not always consonant with one another, but both are challenging for social workers practicing in rural areas.

First, studies have found proportionately fewer individuals with social work degrees living in rural areas (Strolin-Goltzman et al., 2007), and this demographic situation also applies to graduate-level educated social workers (Aguiniga et al., 2013). Second, social work curricula typically do not focus on practice in rural communities, on the broad range of tasks that rural social workers perform, or on the diversity and social justice aspects of rurality (Bice-Wilgington & Morgan, 2018; Phillips et al., 2010; Riebschleger et al., 2015). The CSWE Educational and Policy Accreditation Standards do not specify competencies unique to rural practice. Some social work programs located in rural areas have developed a rural focus (i.e., Ginsberg, 2014; Riebschleger et al., 2015), but these remain the exceptions. The most significant development affecting social work education in rural communities has been the growth of distance learning, including online and hybrid programs, providing opportunities for place-based learners to obtain a social work degree (Richwine et al., 2021). Still, the effectiveness of social work education in preparing graduates for rural practice and in maintaining a rural social work labor force commensurate with need remains questionable.

Licensing for rural social workers is also challenging. First, because rural social workers play many different roles—caseworker, advocate, counselor, community practitioner, resource developer—the more clinically focused license is often perceived as unnecessary (Lightfoot et al., 2016). If licensing is intended to assess knowledge directly applicable to one's work tasks (Apgar, 2021), social work licensure examinations fall short in capturing much of the work of rural social workers. Nonetheless, even if the exam is not geared toward the breadth of tasks involved in rural practice, state laws, and policies governing reimbursement for services specify provider credentials. Second, for rural social workers inclined toward clinical practice, labor force shortages make it difficult to find the supervision required for obtaining a license for independent practice. Finally, there are areas of practice in the public sector, such as child welfare, which do not require a license (or even a social work degree) in many states, including Iowa, raising complicated issues around who may legitimately represent themselves as social workers.

The lack of attention to rural/urban disparities leaves unanswered questions about social work regulation. The home county of licensed social workers can be identified but not the geographic span to which they provide professional coverage. One cannot ascertain whether scarcities of licensed social workers in rural areas are due to fewer individuals seeking the license, difficulties obtaining supervision for licensure for independent practice, or whether rural practitioners have lower licensure pass rates. There is no research to inform whether employers in rural areas prioritize criteria other than social work credentials in making hiring decisions. Nor is there any research on whether the earnings premium identified for licensed social workers (Kim et al., 2021) holds for rural social workers, who typically earn lower salaries. There is insufficient research in all these areas.

Beyond obtaining licensure, there is the issue of maintaining it. The ethical responsibility to keep current with practice knowledge has long been an expectation for social workers, though CE as a requirement for maintaining a social work license nationwide is a more recent development that has led to an explosion of demand (Kurzman, 2016). In response, schools of social work, NASW chapters, social service organizations, and others have increased their CE offerings (Kurzman, 2016). Heretofore, rural social workers have reported less access to resources, professional development opportunities, and knowledge of evidence-based practices (Lee, 2016). However, the more recent growth in distance education and online learning has increased the options for CE access. Although there is yet no published research in this area, social workers in rural areas stand to benefit from greater access to continuing professional education through these modern technologies, which have increased during the COVID-19 pandemic.

Purpose of the Study

The purpose of this study is to identify key issues relevant to workforce and social work monitoring in rural communities that emerged from the statewide workforce assessment and to propose recommendations to address these issues. The investigators pose two key research questions: 1) What are the prevalent workforce challenges affecting the recruitment, retention, and monitoring of social workers in rural communities? and 2) What can be done to strengthen the practice and regulation of rural social work?

Methods

Study Design

The research team conducted the workforce assessment using a mixed-methods approach, collecting and analyzing both qualitative and quantitative data through sequenced components occurring in two phases from July 2018 through February 2019. In Phase I (Information Gathering), they conducted focus groups and key informant interviews. In Phase II (Survey), surveys were administered to social work programs, social workers, and employers of social workers. The study team conducted focus groups and key informant interviews first and used this information to shape the content of subsequent surveys. The team designed the breadth of activities to obtain information from varied stakeholders relevant to understanding workforce issues affecting Iowa's social workers. The Institutional Review Boards at both the lead university and NASW reviewed and approved the study protocols (up to 2500 participants) before data collection.

Focus Groups and Key Informant Interviews

The first phase consisted of five focus groups, conducted using a semistructured, qualitative format. Because the study had a particular focus on workforce issues around diversity and rurality, researchers determined focus group locations by identifying a city or town in each of the five regions of the NASW-IA that provided a good representation of diversity, child welfare involvement, aging population, and/or low local availability of licensed social workers. Four of the five focus group sites were in more rural areas relative to other towns/cities in the region.

The team used purposive sampling to identify individuals responsible for hiring social workers, identifying human services agencies serving each area through local and county resource guides and referrals from other social service professionals. Investigators sought representation from a wide range of organizations, including those covering mental health and disability, children and families, aging services and nursing homes, education, hospitals, community-based services, and corrections. In total, 23 individuals out of 59 invited participated in focus groups.

Focus groups took place in local community gathering spaces. Each took approximately 2 hours and followed a semistructured format with primarily open-ended questions for participants to respond to. With permission from participants, researchers audiotaped each focus group to provide a backup to note-taking by the co-facilitators. Following the focus groups, the team conducted stakeholder interviews with professionals familiar with statewide hiring issues in practice areas under-represented in focus groups. Investigators conducted stakeholder interviews individually by phone; the individual conducting the interview prepared a summary of responses to the interview questions.

Surveys

After transcribing and analyzing data from Phase I, researchers created and distributed web-based surveys to three groups across the state: social work education program administrators, social workers, and employers of social workers.

The surveys of both social workers and employers used the U.S. Census Bureau's urban-rural classification system to categorize the respondent's locale: urbanized area (population 50,000 or more); urban cluster (population between 2,500 and 50,000); and rural area (population less than 2,500). This system was selected because it was less complicated than other urban/rural classifications for self-report surveys, and the researchers believed the three categories would sufficiently differentiate rural settings from other locales.

Social Work Education Programs

The team contacted each of the 13 educational institutions with bachelor's and/or graduate-level CSWE-accredited social work programs in the state of Iowa and requested that they complete an electronic survey and provide CSWE survey reports for the prior three years. The intention was to begin to compile a statewide, longitudinal demographic profile of students who enrolled in and who completed bachelor's and graduate-level social work degrees in the State. This information would assist NASW-IA in identifying trends in the emergent professional workforce and noting potential shortfalls.

Social Workers

Investigators created a web-based survey for distribution to Iowa social workers. The survey asked for information about their academic degrees and licensure, demographic characteristics, employment, and related issues of organizational climate, recruitment, retention, and challenges in the field. This study component sought to obtain a broad representation of individuals with social work degrees, using multiple sampling strategies. First, the team requested that social work programs in Iowa distribute to their alumni an email message with a link to a web-based survey (if they were able to do so). Second, for those schools of social work unable to distribute the survey, investigators posted a survey link on the Iowa Social Workers Facebook page. Third, researchers administered the survey electronically through the NASW-IA's email distribution list. This list included both NASW members and nonmembers (e.g., individuals who participated in NASW's CE programs). Through these different vehicles, the team hoped to capture the perspectives of as many Iowa social workers as possible within the study's time and resource constraints.

A total of 652 respondents completed the social worker survey. Out of these, 257 (39.4% of the total respondents) participated through the distribution by schools of social work; 56 individuals (8.6% of the total) accessed the survey through the Facebook link, and 339 individuals (52% of the total) responded to the survey through their affiliation with NASW-IA. Researchers were not able to calculate response rates because the team did not have access to the complete sampling frame. Thus, the investigators are cautious in interpreting and generalizing survey findings.

Employers

The final survey component was a brief web-based survey for employers that focused primarily on employee recruitment and retention and their perspectives on hiring. Researchers found compiling a representative email list of employers quite challenging, as there was no ready source of email addresses for human services employers in various fields of practice across the state. The final email list the team created for this employer survey represents key areas of social work practice throughout the state, but smaller agencies are underrepresented in this list. Investigators received 64 responses from 370 agencies (17.3%), 48 of which were complete. As with the social worker survey, the team uses caution in interpreting these results because the extent to which the respondents represent the population of employers cannot be determined.

Data Analysis

This study used both quantitative and qualitative analytic methods. For descriptive results, frequency distributions and measures of central tendency and dispersion (means and standard deviations) are reported. To examine differences by locale (rural, urban clusters, urbanized areas) the team used a one-way analysis of variance (ANOVA), examining the statistical significance of group differences and the magnitude of the effect of locale. Survey items regarding work challenges were rated on a four-point scale (1 = not at all, 4 = very challenging); and Likert-type items about the work environment were rated on a five-point scale (1 = strongly disagree, 5 = strongly agree). For qualitative data, the investigators applied thematic analysis to detailed notes from focus groups and interviews, and open-ended responses to survey items. The team edited direct comments from respondents only for purposes of protecting confidentiality and used respondent numbers when reporting these comments.

Limitations

The use of purposive sampling for focus groups and interviews, and the inability to determine how well the samples of survey respondents represent their respective populations, present limitations to generalizing findings. Researchers designed the study to assess the social work labor force at a point in time and consider the findings exploratory rather than conclusive. Further, because the investigators conducted this study before the COVID-19 pandemic, changes in the use of technology for service provision and/or supervision are not captured in the responses.

Results

Focus group discussions and key informant interviews conducted in Phase I elicited numerous challenges in recruitment, retention, and issues related to social work monitoring prevalent in rural areas, many consistent with results reported in the literature. Surveys administered in Phase II provided further data on these issues. Findings from Phase I are presented first, organized by the key themes that emerged. Next, results from survey data are presented, organized by these same themes.

Results from Focus Groups and Interviews

Living in a Rural Area

Focus group participants remarked that it takes a “certain type of person” to be interested in working and living in rural communities. Employers were most successful in hiring those familiar with the area either because the hires originally came from that area, from a similar rural community, or had family ties there. For prospective employees coming from larger metropolitan areas, the rural community lacked sufficient entertainment and consumer choices. However, even prospective hires from rural backgrounds declined job offers due, in part, to the challenges of working in rural communities.

Participants mentioned personal attributes that affected recruitment. For example, younger applicants tended to seek jobs in communities with a variety of social and entertainment options, while those with families expressed greater interest in school district quality, good wages, and benefits. Job opportunities for spouses and housing availability affected recruitment as well. In some rural areas, participants discussed the scarcity of open and desirable housing, with long waits for planned housing under construction.

Job Qualifications, Competition, and Attributes

Participants consistently reported staff shortages and difficulties in filling positions in rural areas. Perhaps in response to this ongoing problem, many rural participants stated they prioritized work experience over educational credentials, often not differentiating a social work degree from related fields such as mental health counseling or psychology. The exceptions were if a particular job required a social work credential or license. But across different areas of practice, participants emphasized the importance of potential employees having work experience with the population served by the agency—and this experience often outweighed the degree.

Employers in rural areas close to larger population centers identified competition from these neighboring communities as a factor impeding successful recruitment. Salaries in rural agencies were often lower than comparable positions in urbanized areas. Potential hires had more options in their field of practice and compared and used salaries and benefits as a negotiating tactic. They evaluated nontangible benefits such as working outside their home community to avoid complicating personal and professional relationships, as well as driving time for commuting and client visits.

Driving distances and the amount of time spent on the road were repeatedly identified as challenges in rural areas. Some employees spend a sizable portion of their day on the road. Not only is this time not fully reimbursable, but time on the road means less time available to spend with clients and to complete documentation. Some participants offered that providing an agency car was an effective incentive for individuals with heavy driving demands, but this amenity was not widely available.

Access to Supervision

Several issues related to supervision emerged from focus group discussions and key informant interviews. Most problematic, and more pronounced in rural areas, was poor access to the supervision needed to attain licensure for independent practice. Participants noted that social work's requirement that only those holding the LISW license can provide supervision (rather than other clinicians such as Licensed Mental Health Counselors [LMHCs] or Licensed Marriage and Family Therapists [LMFTs]) was challenging in rural areas that had few clinical practitioners. For agencies that lacked the personnel to provide supervision, this situation became a barrier to recruiting new social workers and created a disincentive for potential hires to accept a position and/or limited their ability to advance professionally. (Iowa law changed in 2021; LMHCs and LMFTs may now provide clinical supervision for LMSWs.)

License Portability

The state of Iowa is bordered by six states (Minnesota, Wisconsin, Illinois, Missouri, Nebraska, and South Dakota), and many areas near these borders are rural. Participants stated that currently, lack of license portability across states is a problem for practitioners in these areas, as social workers must obtain a license to practice in each state in which they will serve clients. Focus group participants discussed the requirements and burdens of obtaining and then maintaining dual licenses. Beyond the initial investment of time, effort, and resources in applying for each license, passing the exam, and paying the licensing fees, the license must be maintained according to the specific requirements of each state. There are differences in the number and type of CE to maintain a license in good standing; as well as differences in states’ requirements for obtaining a license for independent practice. Participants trying to manage the demands of dual licenses expressed frustration with both the process and the expense.

Continuing Education and Professional Development

Requirements for ongoing professional development through CE came up during focus group discussions. Participants noted the paucity of CE opportunities for state-of-the-art knowledge and skill-building in rural areas. Some commented on the financial burden these imposed and noted that many agencies did not provide the funding for staff to attend. Others stated that many of the CE opportunities available in the community did not provide valuable information or were repetitive of previous training. The growth in distance learning has expanded the range of opportunities, but for those seeking in-person CE, the options in rural areas remain limited. There are also ongoing issues with reliable internet access, which creates frustration for those trying to use online learning.

Equity and Justice

Participants raised several points related to workforce equity and justice. Many identified having trouble attracting a diverse workforce, even at the application stage, noting that the workforce did not match their client population. The social work workforce in rural communities, as is true of the state overall, was predominantly Caucasian and female. Participants described the scarcity of males as a workforce problem, particularly in practice areas with a large male client population (i.e., chronic mental health, disabilities).

In some communities, the few bilingual staff expressed concerns about the additional demands placed on them. They reported that nonbilingual colleagues did not appreciate the level of effort required, not only in communicating in the other language but also within the parameters of the other culture, which often took more time due to building rapport and respecting cultural norms.

Finally, the scarcity of resources and inability to fill positions created problems of equal access to services for rural residents. Participants noted that social, emotional, behavioral, and health problems are no less prevalent or serious for rural residents than for others. Yet there are gaps in services and delays in receiving services, which are inherently unjust.

Results from Surveys

Living in a Rural Area

There is no existing data source from which to determine the percentage of social work students who come from rural communities. As part of the workforce assessment, researchers surveyed program administrators in the state's 13 accredited schools of social work. Pooling estimates across the state, an average of 28% of MSW students and 32% of BA/BSW students came from communities of 2,500 or fewer residents. Clearly, social work educational programs draw a proportion of students from rural areas.

Data from the web-based social worker survey provide clues about where practitioners end up living/working. Of the 652 survey respondents, 535 were currently employed in a social work position. The largest percentage (62.9%) reported working in an urbanized area; 26.7% in an urban cluster; and 10.4% in a rural area. Most respondents were living and working only in Iowa, although 32 were employed in bordering states. These data suggest that many students from rural areas do not return to practice in rural communities, yet a small percentage do. Although response rates are low, recent surveys of social work professionals and students administered by NASW-IA yield similar trends regarding rural residence.

Job Qualifications, Competition, and Attributes

Some job-related issues emerging from focus groups and interviews were verified in results from the social worker and employer surveys. From the sample of currently employed social workers, using one-way ANOVA to compare responses across the three locales, salaries were lowest for rural employees and highest in urbanized areas, F_{(2, 521)} = 4.24, p = .015. Although this difference is statistically significant and therefore not likely due to chance, the size of the effect of locale on salary is still small, η² = .016, 95% CI [.001, .041]. This means that factors other than locale are more important in explaining variation in salary. There were no differences in student loan debt by locale, but 48% of survey respondents were currently paying student loans, only 12% were receiving some form of loan forgiveness, and nearly 25% held a second job.

Although respondents’ age did not significantly differ by locale, rural practitioners had the strongest concern that people leaving the job due to retirement was problematic, F_{(2, 403)} = 6.17, p = .002, likely reflecting the difficulties in recruiting new workers to fill the positions vacated through retirements. The size of this effect was small, η² = .030, 95% CI [.004, .066], indicating that factors other than locale had a greater impact on explaining concerns about filling vacancies due to retirement. Rural practitioners were also most concerned about the increased demands for documentation characteristic of current practice, F_{(2, 403)} = 3.67, p = .026, though again the size of the effect of locale was small, η² = .018, 95% CI [.000, .048].

Two variables related to demands on time differed significantly by locale. Rural social workers agreed most strongly that they were spending more time on paperwork and documentation than they had expected to, F_{(2, 498)} = 3.18, p = .042, η² = .013, 95% CI [.000, .036] and were least likely to agree that they were spending about the right amount on job-related travel, F_{(2, 498)} = 12.22, p < .001, η² = .047, 95% CI [.016, .085]. The effect of locale on travel demands was a little larger than its effect on other variables. Still, locale explains a relatively small percent of variation in these work-related factors.

On the other hand, rural social workers were no more likely than others to think that agencies were hiring people without social work degrees for social work jobs. In fact, rural practitioners were more likely than those in urbanized areas or urban clusters to believe that their organization sought employees with social work degrees, F_{(2, 432)} = 4.24, p = .015, although the effect size was small, η² = .014, 95% CI [.000, .039]. On many questions related to work environment and job expectations, responses were statistically similar across geographic cohorts. Rural social workers expressed higher levels of overall job satisfaction than those in urbanized areas or urban clusters, F_{(2, 499)} = 3.10, p = .046, but again the size of the effect was small, η² = .012, 95% CI [.000,.036]. In sum, for most of the work-related factors discussed here, p values indicate that the differences by locale are large enough to rule out chance, but the small effect sizes suggest that factors other than locale have a greater impact on variation in these factors.

Access to Supervision

Questions on the social worker survey regarding access to supervision yielded varied responses, in part because more than half of the respondents already held the license for independent practice and thus no longer needed supervision; others were not aspiring toward independent practice. Problems with access to supervision appeared to be dependent on a variety of factors, not only the individual's career stage but also location, agency capacity, and area of practice. The most informative survey data on this topic are found in free-response comments offered by respondents, for example:

I am currently facing difficulty trying to find supervision in order to work toward LISW licensure. (Respondent 1)

Insufficient clinical supervision for clinical social workers, especially newly graduated ones due primarily to financial crunch. (Respondent 2)

I could hire more MSWs if I had more LISWs able/willing to do supervision. (Respondent 3)

My job doesn’t provide opportunity for LISW, but they said they would when I started five years ago. (Respondent 4)

It’s been rough to find a decent job. My first one was good but wanted me to work a ton of hours and then I lost my supervision. I decided to leave and found another job. (Respondent 5)

On the survey of employers, the team was not able to test differences by locale statistically because of the small numbers of rural employers.

License Portability

Because the workforce assessment did not focus on license portability, investigators did not ask specific survey questions about this. Among respondents currently living in Iowa, most (88.5%) intended to remain in the state for at least the next 3 years, about 10% were not sure; 1.5% did not intend to remain in the state. About 6% of respondents reported working with clients in one of the bordering states. An additional 2% worked in other nonbordering states and presumably would have benefitted from license portability. Thus, although license portability is not a pressing concern for most respondents, it is important for those currently or aspiring to work across state lines. The challenges for these individuals emerged in free-response comments:

I live in Iowa near the border and am licensed in (another state), at this time working toward my LISW as I practice at a clinic in (another state). Some of my clients travel from rural Iowa. I purchased a home closer to my place of work in order to reduce my commute time, however I continue to commute about 45 min each way daily from Iowa to my practice in (another state). (Respondent 6)

Lack of licensure forces some recent MSW graduates to seek employment in other fields to sustain basic needs. Moreover, the inequality established in MSW licensing forces graduates to question their competence as a social worker who fail the LMSW exam because other states allow their MSW graduates’ degrees to translate into limited or temporary licenses for immediate employment under a LISW. I have lost 18 months of employment as a therapist because I cannot pass this exam. (Respondent 7)

Investigators conducted this study before the COVID-19 pandemic. The survey did not ask questions about telehealth and how the increase in the use of telehealth might be affecting social work practice in rural areas, nor about the desire to be licensed in multiple jurisdictions due to utilizing telehealth.

Continuing Education and Professional Development

Responses to questions about professional development on the social worker survey did not detect differences between practitioners in rural, urbanized, and urban centers. Overall social workers agreed that their job offered opportunities for professional development, and investigators found no differences in the extent to which social workers expressed difficulties in staying current with new practices and skills.

Equity and Justice

Although Iowa's population is becoming more diverse in race and ethnicity, the social work workforce is still predominantly female and White. About 94% of respondents to the web-based survey of social workers were White, non-Hispanic; 2.3% were African American/Black; 1.5% Hispanic/Latino; and less than one percent identified with other races/ethnicities. About 86% of respondents identified as female. Regarding the future social work workforce, based on national data (CSWE, 2017), Iowa's schools of social work are less diverse in gender, race, and ethnicity than the national average. However, estimates of African American/Black and Hispanic/Latino students enrolling and graduating from the state's accredited programs do exceed the current percentages of these groups in the state's population, indicating that the state's future social work workforce is starting to grow more diverse (Landsman & Crandall, 2019).

Because bilingualism emerged from the focus groups as a workforce issue, researchers included questions about this in the social worker survey. The team asked whether the respondent was fluent in more than one language and noted that 25 individuals answered affirmatively. Spanish was the most common secondary language, noted by 17 individuals. Other languages included French, braille, and sign language. Investigators also asked whether their fluency led to added responsibilities at their work; 52% of those with fluency in another language (n = 13) indicated that it did.

Both the social worker survey and employer survey contained questions about recruitment challenges. Respondents to the social worker survey who have hiring responsibilities indicated that their greatest recruitment challenges centered on diversity. On a scale of 1–4, ratings on these items included: finding bilingual individuals to work with non-English-speaking clients (M = 3.4, SD = .8); recruiting individuals to work in rural communities (M = 3.1, SD = 1.1); and recruiting employees with backgrounds similar to clients in race and ethnicity (M = 3.0, SD = 1.0). In the employer survey, researchers found two of these items among their greatest recruitment challenges as well: recruiting bilingual individuals to work with non-English-speaking clients (M = 3.3, SD = .7), and recruiting employees to work in rural communities (M = 2.8, SD = 1.1).

Discussion

Findings from this statewide workforce assessment offer implications for regulating social work in rural communities, particularly regarding recruiting and retaining a workforce of social workers, providing access to supervision, licensure portability, CE, and equity for racial, ethnic, and linguistically diverse populations.

Two important caveats should be noted in interpreting study results. First, in keeping with the exploratory purpose of the workforce assessment, findings should be considered tentative rather than confirmatory. The methods did not allow for an assessment of sample representativeness. Purposive sampling was used to recruit participants for focus groups and interviews, and response rates for surveys were lower than desirable. The sequenced study phase approach strengthened the internal validity, but the study's external validity remains inconclusive. Second, because this study was conducted prior to the COVID-19 pandemic, findings do not reflect changes the pandemic may have prompted, including the expansion of telehealth, the possible use of distance approaches to supervision, or other types of online programming. Future research should examine the extent to which these changes occurred and their impacts on the rural workforce.

Agencies in rural areas often struggle to fill social work positions, facing a shortage of individuals willing to live and work in these communities, confirming findings from previous research (Mackie & Lips, 2010; Thomas et al., 2012; Walters, 2020). Yet higher levels of job satisfaction and organizational commitment among rural workers, consistent with some prior research (Griffiths et al., 2017; Kim & Hopkins, 2017), suggest that rural social work remains a desirable practice setting for some. Agencies report the most success with candidates who have familiarity or close ties with the community, and when they can offer clinical supervision hours. Schools of social work draw students from rural areas, but most graduates do not return to those small communities as practitioners. Contributing factors include competition with jobs in more urbanized areas that offer higher salaries, housing availability, job opportunities for spouses/partners, and social and entertainment options. Some of these issues require long-term community planning and development efforts to invest more resources in rural communities and are beyond the scope of what social work can take on independently.

Results from this study offer some practical strategies for addressing rural workforce challenges. Supervision for obtaining the license for independent practice poses a barrier to recruiting and retaining clinically oriented rural practitioners. Rural agencies that can provide clinical supervision for their employees as part of the employment contract are in a better position to hire and keep them. When social workers must find and finance supervision on their own, they will be looking for employers who provide this support. The shortage of licensed clinical social workers in rural areas threatens the well-being of rural residents; thus, this is a serious professional issue.

In 2021, Iowa law changed to allow qualified LMHCs and LMFTs to provide clinical supervision for LMSWs. This adjustment may be more impactful in urbanized areas than in rural communities, though. Since the workforce assessment in 2019, there has actually been a loss of social work capacity in small counties, and both LMHCs and LMFTs are concentrated in urbanized areas. In some counties, the number of LMHCs exceeds LISWs, which may provide some relief to LMSWs. Overall, though, the law's expansion of qualifications to provide social work supervision may not do much to increase the number of rural social workers. As a practical solution, agencies in rural areas would do well to forge regional collaborations to maximize the availability of supervision and to provide the best match of supervision to need. For example, LMFTs may provide excellent supervision to LMSWs working with families, while LMHCs may be well suited to provide clinical supervision for LMSWs working in mental health settings.

To address the problem of license portability, the U.S. Department of Defense has funded an effort for ASWB, NASW, and the Clinical Social Work Association to develop a legislative framework for an interstate compact for social work licensure. Individual states would have to pass this legislation to validate the compact. For Iowa, license portability would be highly valued by practitioners who serve clients in one or more of the six adjoining states. This modification could reduce the time, cost, and confusion around maintaining multiple licenses and make it easier for social workers to practice across state lines and expand their reach, particularly in an era when both clients and practitioners more readily accept mental health services provided via telehealth.

However, Interstate license portability also poses potential drawbacks for rural practitioners. Larger organizations based in major cities in other states may be able to efficiently expand their efforts into small towns and rural areas in adjoining states, leading to over-reliance on telehealth and a further exodus of social workers from rural areas. Out-of-state practitioners may not be as familiar with local resources, and the potential to further erode a social work presence may be detrimental to these communities which face many of the same social problems as larger population centers. For example, given the higher rates of suicide in rural areas, prevention requires the capacity to respond immediately and sensitively. Social workers should advocate for legislation that carefully considers these potential impacts and places some parameters around interstate practice.

Student loan burden is a workforce concern for social work. In this study, student loan burden did not differ by locale, but a sizable percentage of social workers across the state were still paying off student loans and working second jobs, and few had received any loan forgiveness. NASW-IA supported 2022 legislation that created a loan repayment assistance program for nonprescribing mental health professionals, including LISWs, LMHCs, LMFTs, and licensed psychologists. Although this program may help recruit more professionals to the federally designated mental health professional shortage areas (which are nearly all rural), the initial funding for the program would assist only 13 professionals per year. This program represents a step in the right direction, though it is insufficient to address the extent of need.

Results from this study suggest a mix of strategies to strengthen CE for rural practitioners. Continuing education is one area in which the expansion of distance learning opportunities appears to have benefitted rural social workers (Lee, 2016). Prompted by employer request (Iowa Association of Community Providers), Iowa enacted legislation before the COVID-19 epidemic that allowed social workers to earn all CE remotely. NASW-IA offered its first online CE opportunities in March 2020 because of the pandemic, and this format has been well received; thus NASW-IA will continue to offer online CE for the foreseeable future.

However, in-person events provide opportunities for networking and rejuvenation that may be especially important for rural social workers who feel isolated from colleagues (Walters et al., 2020). Study participants from rural areas noted that internet capacity was not uniformly dependable and expressed frustration with limited or repetitive programming in rural communities. Post-pandemic, weighing the pros and cons of in-person and online CE will be important. Due to the restrictive operating budgets of rural areas, when feasible agencies should consider pooling resources to support in-person learning; building employee capacity is both desirable and considerably less costly than turnover (Selden & Sowa, 2015).

Regarding equity and justice, the study team found that the current workforce does not reflect the changing demographic composition of the state's rural areas, although the social work student population is beginning to grow more racially and ethnically diverse. Linguistic competence remains a significant challenge, with few social workers having fluency in a language other than English. Most educational programs have reduced requirements for second language fluency, and social workers and employers report finding bilingual social workers one of the strongest challenges to staff recruitment. The best solution to this dilemma is for social work education programs at both undergraduate and graduate levels to make focused efforts to recruit bilingual individuals from these communities.

Rural areas are often not perceived as marginalized communities, yet they experience many of the same problems as other locales and have more limited services and supports (Daley, 2015; Walters et al., 2020). The investigators argue that the continued scarcity of social workers in rural areas places these communities at higher risk for social, emotional, and behavioral disorders. Regulating social work practice in rural communities is also more difficult in the face of constant shortages of licensed social workers and difficulty in attaining and maintaining licensure. The approach of many state legislatures across the country (including Iowa's) has been to introduce bills to eliminate licensing as a means of easing workforce shortages. While politically popular, such an approach may be a disservice to the vulnerable populations that need and deserve help from people with the knowledge and skills to provide it. Given the challenges rural communities face, these areas need both qualified generalist social workers and LISWs who provide clinical services and supervision; both are in short supply.

Many questions remain about the regulation of social work in rural communities and how this can be strengthened. Research in this area is especially challenging in a changing and politically fraught regulatory climate. The research team conducted the statewide assessment as an initial step in understanding the situation of Iowa's rural social work workforce and as noted, some legislative and regulatory changes have already occurred. Future research should examine whether or to what extent the changes in who can provide clinical supervision affect the numbers of social workers in rural areas and the quality of social work services. If license portability legislation is enacted, future research should examine both its implementation and impact on rural residents, rural practice, and the rural social work workforce.

Finally, the paucity of social work research focusing on rural areas raises important questions on issues of social justice (Young et al., 2015). Rural communities suffer from the same problems as other locales but have fewer resources at their disposal, and many communities are experiencing influxes of diverse populations without social workers who can communicate in their language and culture. In rural social work, recruitment, retention, and regulation of social workers remain interrelated challenges.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded in part by the Telligen Community Initiative to initiate and support, through research and programs, innovative and farsighted health-related projects aimed at improving the health, social well-being and educational attainment of society, where such needs are expressed (Grant #2017-02-229). The authors also acknowledge Stephanie Crandall for her work on the workforce assessment project. Finally, the authors express appreciation to the NASW Foundation for their support of the workforce project.

ORCID iD

Miriam J. Landsman

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