Top of the license practice or out of our scope? A qualitative analysis of social workers’ role in cultivating prognostic awareness on hospital palliative care teams

Prognostic awareness, defined as patients’ understanding of their illness trajectory and likely prognosis, is an essential component of informed decision-making, values-based care planning, and high-quality palliative care. Although discussing prognosis is traditionally viewed as a physician-led task, palliative social workers (PSWs) are often involved in interventions that require prognostic understanding. Little is known, however, about the role social workers play in cultivating prognostic awareness, the professional boundaries surrounding prognostic discussions, and how PSWs’ engagement in this work is understood within interprofessional palliative care teams. This qualitative study used Interpretive Description, an applied analytic approach designed to generate practice-relevant understanding grounded in participants’ experiential accounts. Semi-structured interviews were conducted with 17 advanced-practice (APHSW-certified) palliative social workers and 16 palliative physicians practicing in U.S. hospital settings. Inductive thematic analytic techniques were used to identify patterned understandings across participants’ accounts. Role theory was used as a sensitizing framework to support interpretation of interprofessional expectations, boundaries, and dynamics related to cultivating prognostic awareness. Across professions, participants described cultivating prognostic awareness as an iterative, team-based process within inpatient palliative care. PSWs were described as extending and deepening physician-initiated conversations by reinforcing prognostic information, exploring lived experience, and supporting emotional processing. Clear professional boundaries were articulated around prognostic formulation, initial time-based disclosure, and medically complex decision-making, which were widely viewed as physician led. Role tensions emerged when workflow pressures, clinical urgency, or team expectations pushed PSWs toward medically focused conversations, or when primary teams assumed PSWs could independently deliver prognostic information. Interprofessional trust, communication, and team alignment shaped whether PSWs were supported to engage fully in this work. Engagement in cultivating prognostic awareness is widely viewed as top-of-license practice for specialty-trained PSWs when grounded in their psychosocial expertise, communication skills, and collaboration with physicians. Role agreement, organizational support, and interprofessional trust are essential for enabling PSWs to practice within their scope while maximizing their unique contributions to patient and family prognostic understanding.