Virtual Social Work Practice – Learnings and Thoughts from the CASW & Heidi Sturgeon, MSW, RSW

In keeping with my learning goals of telehealth, today I watched an informative video on virtual social work practice (telehealth) from the CASW.  Heidi Sturgeon is an RSW who holds an MSW and has vast experience of leadership and mental health work throughout her practice.  My goal is to critically explore the information presented and integrate it into my own learnings of how I will practice social work.

One of the interesting ideas brought up in the session is that electronic means of providing healthcare services are not entirely new (Sturgeon, 2020).  Used as an example are the Crisis lines and suicide prevention lines that popped up during the second half of the twentieth century.  This was an interesting perspective that I had not considered before.  I am unsure of what laws governed the practice surrounding crisis/suicide prevention lines at those times, and if volunteers and practitioners working those lines had to worry about liability in the way practitioners currently do in the current environment.  I think this would be an interesting area to explore further if one wants to back their decision-making by case law or legal precedents.  Exploring the history and back-and-forth between practice and law of these historical services can be a consideration for further exploration in the learning plan.

One of the benefits of telehealth (if a video is used) is that there are two dimensions of cues present.  Video conferencing often provides audio channels along with the video feed, allowing practitioners to have some form of access to visual non-verbal cues.  This would be an advantage over the accepted telephone practice where verbal cues are more heavily relied on for feelings and context.  Thus, video practice may provide a benefit in service provision.  If there is any literature on this, it may provide a basis in which telehealth video conferencing as an evidence-based practice.  There needs to be some caution in that assertion, however.  my interpretation of evidence-based practice would be to look at various interventions I am trained in (competency), and see if those interventions are evidence-based for delivery through digitally mediated communication (telehealth).  In essence, I see providing ethical practice as a two-pronged approach initially as the practitioner transitions into virtual service provision.

I really valued the considerations that Sturgeon (2020) brought up for telehealth services.  One of the first considerations is if the client is in the same location or a different location.  While the example of prison service provision is used, I can see a few other examples of where this could be used.  If the safest way for clients is to be in the location of the practitioner for services while Covid-19 or any other pandemic/disaster takes place, it may be useful in some cases to have a client room and practitioner room.  These can create physical distance while having the supports/supervision more directly available to the client.  Software such as VLC Media Player would be able to allow for these types of broadcasted communications to take place within a local intranet via its webcam streaming capabilities.  While the drawback of location and set up space would limit some of the setup’s practicality, an intranet (as opposed to internet) video stream would be internally controlled, and thus avoid many of the privacy concerns that are inherent to data privacy concerns on the internet.  If the client would benefit from being outside of their environment, while possibly benefiting from the disinhibition effect, this could be an area to explore further in the literature. Sturgeon (2020) categorized the same location service locations as “supervised sites.”

“Unsupervised sites” are what most telehealth practitioners are likely to encounter.  In this situation, the client is not in the same location as the practitioner.  Communication is thus mediated through digital channels such as the internet.  This has the benefit of convenience for the client and arguably allows the client to have more autonomy in the services they receive.  Any communications broadcast through the internet are vulnerable to discovery through security flaws or exploits.

With a background in Information Technology, the hardware component of considerations for practice was relatively straightforward.  Having an internet connection with sufficient upload/download speeds is essential to be able to receive and transmit video feeds and chat channels that are critical to the functions of telehealth.  If one was to look at the resolutions they have as an option for the client and practitioner to transmit at, here is a tool to roughly calculate the speeds/bandwidth needed for a meeting.  Remember that computers are binary systems so one Kbyte actually is 1024 bytes instead of 1000 bytes.  The recommendations of having no other streaming services running while in session make sense.  Another consideration, if the business model permits, would be to have a dedicated line for practice.

Another mention of hardware is a good working computer and possibly headphones with a microphone built-in.  Considerations for a computer that is dedicated to working would be to either have a personal hardware firewall protecting it (in addition to antivirus), and setting it up with full-disk encryption so that should it ever be taken, stolen, or missing, the person with the key to unlocking the drive would be able to access the device.  Most user-friendly operating systems now provide support for full-disk encryption.  If you are interested in learning about full-disk encryption, please look here.  Windows 7 and newer computers can use Microsoft’s Bitlocker software if they are utilizing a professional version of their operating system (Windows 7 Professional, Windows 8 Professional, Windows 8.1 Professional, & Windows 10 Professional).  I encourage those interested to research how it can be enabled and installed or to connect with an IT professional to set up full disk encryption on their computer.  The one drawback is if the password or key to unlock the computer is forgotten, you will be out of luck on retrieving the data.  So carefully consider this.  As a side note: This only protects data stored exclusively on the computer.  Data stored on the cloud or other wed platforms is not protected by using full disk encryption.  Mac users can alternatively explore the use of FileVault, and Ubuntu (or other Linux distribution) users have a variety of tools at their disposal such as LUKS, fscrypt, & eCryptfs.

Other security considerations were that both the client and practitioner both have antivirus software installed.  While there are many free antivirus options, the cost of antivirus software for the client is something I would generally want to consider as a piece of ethical practice – especially in circumstances where the choice to partake in face-to-face practice is removed from the client.  I do not think that it would be ethical for the social worker to recommend software (venturing beyond our scope of practice if there is no information technology education or certifications), but it may be ethical to provide examples of low-cost or free alternatives with a provision of the risks/benefits of their capabilities or role of reducing the risk of privacy breaches (such as ClamAV).  Another great point brought up by Sturgeon (2020) was the use of secured networks.  In practice, I would certainly not use open/public networks to provide services.  I would also not use wifi in general.  There is an abundance of tools that malicious parties can use to crack publically broadcasted wifi networks, such as those found on the Sectools website.  Private practice practitioners would ideally either research what encryption standards for wifi (such as WPA/WPA-2) are currently difficult to penetrate, consider hiding or disabling their broadcasting SSID (or opting to only use a physical cable for internet access – such as Cat5e/Cat6 RJ-45 cables), consider periodically changing their router and wifi passwords, and consult with their IT professionals to ensure their local networks are more difficult to penetrate.  Another security feature to consider is using telehealth platforms that require a password for clients to enter the conference room.

Sturgeon (2020) brought up several practice management platforms that are in three categories.  They are as follows:

Video

• Doxy (American Company)
• Vsec
• Zoom (health)
• Modeo
• Microsoft Teams
• Gsuite
• Skype Business

Email

• Hushmail
• Gsuite
• Prontomail

Video + Practice

• OnCall (Canadian Company)
• Noustalk
• Jane

*Note: Considerations for video platforms can include client recognizability and their preference for platforms based on familiarity with them.  Security/privacy is of greater concern though too.

*Note: Practice management platforms help process payments, receipts, consent signings, and more.

Sturgeon (2020) makes note of some very important considerations around consent by considering the context of virtual practice.  First, consent must be voluntary like face-to-face practice.  I am interested in further exploring the ethics around consent when clients are mandated and put in an involuntary position to partake in virtual services.  Clients need to be given information on the foreseeable risks and benefits of digitally-mediated services.  I interpret this to include the risks of security breaches, and the evidence-based for expected outcomes for digitally-mediated interventions as a part of evidence-based practice.  Other elements of consent to include would be the ACSW standards of practice (see the March 2019 version here).  The practitioner must also explain how the platform works (setting up technology, any downloaded software needed to operate – such as Doxy’s requirement of Firefox or Google Chrome, or Zoom’s application that needs to be downloaded).  Another consideration is the candid conversation on the limitations of confidentiality (such as subpoenaed records or data of the platform and practitioner) and agreed upon terms of no screen recording sessions by all parties (this may have particular relevance to privacy concerns for group facilitation).  Agreed upon locations that are quiet for the duration of the session and on secured networks should be agreed upon before the working alliance begins.  Other considerations include social media policy, social contracts, payment options, and policies for contacting the practitioner.

Sturgeon (2020) rightfully notes that provincial and federal legislation needs to be considered in the provision of services.  Federal legislation such as PIPEDA (you can view it here) and Alberta’s HIA (you can view it here) need to be considered.  As outlined by Alberta’s health information regulation (you can view it here), section 2.1 does not designate members of the Alberta College of Social Workers as designated custodians of health information.  This would then impact our roles and responsibilities for health data management and privacy.   I will explore this further in my overview of legislation that influences service provision (including telehealth) as of 2020 AD.  Other considerations for data storage is how PIPEDA may influence our decisions on using national vs. international service platforms.  Decisions on platforms, if influenced by country the platform and data storage originates from, should be selected based on how our code of ethics for privacy/confidentiality fits with the jurisdictional laws for the locations where servers store the data.

Another consideration in digital practice is liability coverage.  We should not practice virtually if our insurance does not cover virtual practice.  While the Canadian Association of Social Workers’ BMS plan includes coverage for virtual practice (Gomes & McKenna, 2020), while no information could be found stating the HDF plan with the ACSW provides coverage for virtual practice.  Practitioners that are insured through their agency may want to check to see if they are covered or can supplement their coverage if they are not covered for virtual practice.

I really liked the information that Sturgeon (2020) discussed in screening individuals in a virtual consult before taking them on as a client.  This goodness-of-fit allows the practitioner to see if the potential client is appropriate for telehealth, improving the argument that carrying out telehealth is an ethical practice.  Some of the considerations outlined by Sturgeon included:

• Asking for the client’s age and to have them show ID.
• Finding out where they are located, and seeing if we are registered or legally allowed to practice there
• Screening for past or present suicide ideations.  This is useful for suicide intervention or emergency planning.
• Reviewing where and how the clients will connect.  Discuss being in a distraction-free location.

As was mentioned with the screening for suicide ideation, emergency planning from the onset is also an ethical choice.  As mention by Sturgeon (2020), considerations include:

• A safety plan (while having a phone number and address of the client physically on paper in front of you)
• Considering in advance what you need to know for an emergency plan for an online client
• Having an emergency contact for the client
• A “safe word” that is negotiated for use if the client enters a dangerous situation

Some of the final pieces of wisdom brought up by Sturgeon include:

• Considering the implications of the disinhibition effect on practitioners and clients alike.
• How virtual practice can benefit or distract the goals of a session.
• How the dynamics of virtual practice may change a client’s willingness to open up.
• Normalizing unpredicted events that take place while in session
• Having a sense of humour when technology does not work as anticipated.
•  Be well-versed in how your platform works – don’t be afraid to call tech support!
• Ask clients to adjust their video if it will benefit communication.
• Allow clients pets to be included in the session.
• Take breaks between sessions!
• Ask for help when you need it!
• Screening for fit:
  • Does the client have the technical skills for virtual practice?
  • What level of comfort does the client have with digitally-mediated sessions?
  • Would it be beneficial to do a test session to acquaint the client with the platform(s)?
  • What is the speed/bandwidth of the practitioner’s and client’s internet connections (can they support video-conferencing)?
  • Is parental/guardian consent needed?
  • Is there a private space for virtual sessions?
  • Developing an emergency plan early on by assessing harm to self from consultation onward.

 

In all, this educational session provided me with an opportunity to begin thinking about virtual practice.  Keeping these pieces in mind, I will continue to look at the legislation and regulation that is relevant to practice, and continue to research the evidence base for interventions and standards for competency that will allow for a practitioner to be evidence-based and competent in virtual practice.  If you are interested in learning from Heidi Sturgeon’s presentation, I highly recommend you watch the session.  Registration for the webinars are provided in the references.

References

Province of Alberta. (2018). Health information act: Health information regulation.  Retrieved May 13, 2020, from https://www.qp.alberta.ca/documents/Regs/2001_070.pdf

Gomes, B., & McKenna, A. (2020). Current State of COVID-19: Telehealth, Liability, and Business Insurance Considerations [on24 webinar].  Retrieved May 10, 2020, from https://www.casw-acts.ca/en/webinar/current-state-covid-19-telehealth-liability-and-business-insurance-considerations

Sturgeon, H. (2020).  Telehealth & social work practice: Same ethical practice – different locations [on24 webinar].  Retrieved May 13, 2020, from https://www.casw-acts.ca/en/webinar/telehealth-social-work-practice-same-ethical-practice-–-different-locations