“We Ask Because We Care”: Lived Experience of Social Determinants of Health Screening Among Social Workers and Nurse Case Managers

Abstract

Introduction/Objectives

SDOH screening is increasingly required, yet is often operationalized as EHR documentation. The objective of this project was to explore how social workers and nurse case managers experience SDOH screening and how care settings shape its meaning and practice.

Methods

We conducted semi-structured interviews with 10 staff members (6 social workers, 4 nurse case managers) across inpatient and outpatient follow-up contexts in a large academic health system and analyzed transcripts using Colaizzi’s phenomenological method.

Results

Five themes emerged: negotiating patient autonomy, conversational personalization, technological and systemic frustrations, staff expertise, and interprofessional collaboration. Participants reported time pressure, emotional labor, and moral distress when needs were identified without reliable pathways to assistance, and they described contrasting inpatient urgency and outpatient continuity that influenced disclosure, trust, and follow-up.

Conclusions

SDOH screening was experienced as relationship-centered work that depends on supportive workflows and response capacity; implementation should pair screening mandates with training, streamlined documentation, and closed-loop referral processes.

Introduction

Social determinants of health (SDOH) are major drivers of health outcomes and inequities and are increasingly recognized as critical components of clinical care. ¹ Health systems are now implementing SDOH screening to identify social needs and connect patients to resources, often in response to policy, accreditation, or quality-reporting expectations. ² In practice, screening is frequently implemented as completion of standardized questions documented in the electronic health record (EHR), with success defined by completion rates and discrete data capture rather than by whether screening is respectful, disclosures are accurate, or needs are addressed.^3,4 When screening becomes compliance work, it can shift the focus from care to documentation.

Hospitalization is commonly unplanned and time-compressed. Due to reasons for admission and treatments, patients may be in pain, cognitively overloaded or impaired, or focused on immediate medical concerns.^5,6 Screening may occur during acute evaluation, perioperative care, or discharge planning, when the capacity to discuss housing, food, or financial hardship is limited.^5,6 Inpatient care is also temporally distributed: inpatient urgency narrows the window for meaningful conversation, ⁵ whereas outpatient follow-up may allow needs to surface over time but is shaped by delayed, fragmented, or inconsistent community resources.^6,7

Screening without a reliable response capacity can potentially create harm. Patients may experience questions as intrusive, stigmatizing, or irrelevant when the purpose and follow-through are unclear, and clinicians may learn to ask superficially to reduce discomfort.^3,4,8 Staff tasked with sensitive screening may experience emotional labor and moral distress when urgent needs are disclosed and the system cannot respond, eroding trust and reducing future disclosure.^3,5,8,9

Prior qualitative work has examined acceptability and implementation barriers, but fewer studies examine the lived experiences of staff who conduct screening and manage its relational and practical consequences.^3,8,10 The objective of this project was to explore how social workers and nurse case managers experience SDOH screening in clinical care and to examine how care settings shape the meaning, ethical dimensions, and practical implementation of screening. By treating screening as a relational encounter rather than a documentation event, the project offers implications for program implementation that are clinically useful, equitable, and emotionally sustainable.

Methods

We used a qualitative phenomenological approach to understand the lived experiences of social workers and nurse case managers conducting SDOH screening during clinical care. Phenomenology was selected because the research question sought to understand how clinicians experience, interpret, and make meaning of screening encounters within real-world clinical contexts, rather than to evaluate implementation outcomes or quantify screening practices. This approach allowed the project to examine the relational, ethical, and emotional dimensions of screening as experienced by staff.^11-13 Interviews were conducted by a two-person team in partnership with the health system leaders overseeing Care Management Department professionals, including Nurse Case Management and Social Work. Case management is defined by nationally recognized accrediting organizations (ACMA and CCMC) as a collaborative, dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates care to improve outcomes, patient experience, and value, with particular emphasis on addressing social determinants of health, facilitating access to resources, and supporting safe care transitions. ¹⁴ The project lead (DrPH, MPH; female) served as the primary interviewer and had no prior relationship with participants. The co-lead (PhD; female) served as the secondary interviewer and works within the same institution as a colleague to the clinical teams. Participants were informed that the project aimed to understand their experiences of screening patients for SDOH in care settings. Given institutional proximity, the team attended to positionality and power dynamics; reflexivity included journaling and analytic memoing to bracket assumptions and prioritize participants’ meanings. The work was supported by iterative coding to ensure that participant language, rather than institutional expectations, guided the analysis.

Participants were social workers and nurse case managers whose roles included screening, resource navigation, and discharge planning across inpatient services and outpatient follow-up in a large academic health system. In the care setting examined in this project, conducted at a large academic medical and level 1 trauma center, SDOH screening is incorporated into routine clinical assessments in response to Centers for Medicare & Medicaid Services (CMS) requirements to document patient social needs across key domains. Screening questions were drawn from the CMS Accountable Health Communities (AHC) screening tool, which includes domains such as food insecurity, housing stability, transportation needs, utility difficulties, interpersonal safety, and financial resource strain. Screening is incorporated into initial inpatient assessments conducted by social workers and nurse case managers, with the timing and duration of the conversation varying depending on clinical circumstances and how patient responses shape the discussion. When social needs are identified, clinicians use a community resource platform integrated into the electronic health record (Epic) to generate referrals and provide patients with relevant resources through their After Visit Summary. This approach reflects a common implementation model in which standardized screening questions are embedded within clinical workflows while referral pathways rely on community resource navigation systems.

Eligible participants were invited through an email invitation distributed to social workers and nurse case managers working within the health system. Recruitment occurred between November 2024 and March 2025. Purposive sampling sought variation by role and practice setting to capture perspectives across inpatient and outpatient contexts. Recruitment continued until thematic saturation was reached, defined as the point at which additional interviews did not yield new themes or meaningfully expand existing thematic categories.

Semi-structured individual interviews were conducted by the project lead, with the co-lead serving as a secondary interviewer. Interviews were conducted between February and March 2025 either in person in a private room on the hospital campus or via secure video conferencing, depending on participant preference and scheduling availability. Semi-structured interviews were used to allow participants to describe experiences in their own words while enabling the interviewer to probe for meaning, context, and interpretation consistent with phenomenological inquiry. Interviews followed a guide focused on concrete screening encounters (introductions, readiness, responses to discomfort, and situations in which needs were identified without clear pathways to assistance) and on perceived personal and professional impacts. Interviews occurred once per participant and lasted between 30 minutes and 1 hour. No non-participants were present. Audio files and transcripts were stored in a secure, access-controlled system for the duration of the project and deleted at project completion. Transcripts were not returned to participants for review. Recruitment continued until thematic saturation was reached (i.e.,no new themes emerged). Participants were labeled based on their practice environment (outpatient – OP or inpatient – IP), their role (social worker – SW or nurse case manager – NCM), and their order of participation.

Transcripts were analyzed using Colaizzi’s phenomenological method, which emphasizes identifying significant statements, formulating meanings grounded in participant language, and synthesizing these meanings into thematic structures that capture the essence of the lived experience. ¹³ Following Colaizzi’s analytic steps, transcripts were first reviewed to identify significant statements related to clinicians’ experiences conducting SDOH screening. These statements were then interpreted to formulate meanings grounded in participants’ language and clinical context. Related meanings were grouped into preliminary codes, which were iteratively refined as additional transcripts were analyzed. Codes were subsequently organized into a hierarchical coding tree that represented relationships among codes and categories and supported the development of broader thematic structures. This iterative process allowed patterns across interviews to be identified while preserving the contextual meaning of participant narratives.

The project lead conducted coding and qualitative analysis using Delve software. ¹⁵ Findings were shared with participants, and feedback was invited; no feedback was received. Findings were further reviewed with health system leaders with significant expertise in case management. These leaders confirmed that the findings aligned with their experience. A coding tree and theme development summary are provided as supplementary material to illustrate the analytic pathway from codes to themes. An audit trail and reflexive memos supported analytic transparency. The credibility of the analysis was further supported by iterative review of transcripts and themes, allowing the research team to confirm that thematic interpretations remained grounded in participant narratives. Reporting followed COREQ; the completed checklist is provided as a supplement. ¹⁶

The project was reviewed by the institutional review board and determined to qualify as Quality Improvement.

Results

As shown in Table 1, of the approximately 50 staff members invited via the email survey, 10 participated, including six clinicians working primarily in inpatient care and four working in outpatient follow-up settings. Participants described SDOH screening as extending beyond completion of standardized EHR questions and instead as a relational interaction shaped by clinical timing, patient readiness, and system constraints. Across interviews, staff emphasized that screening often involved navigating sensitive conversations with patients while managing competing clinical priorities and documentation requirements. Participants frequently described balancing the need to obtain accurate information with the importance of maintaining patient trust and dignity during vulnerable moments in care. Many also noted that time pressure and institutional workflows shaped how screening conversations unfolded and influenced the accuracy and completeness of documentation.

Table 1.

Participant Roles and Practice Contexts (n=10)

Role	Outpatient	Inpatient	Total
Social Worker	3	3	6
Nurse Case Manager	1	3	4
Total	4	6	10

Patient Autonomy

Negotiating patient autonomy was experienced as a moment-by-moment ethical practice. Participants described a continual balancing act: honoring a patient’s choice to decline questions while also recognizing that incomplete information could limit support and complicate care coordination. Several participants described patients who were surprised, offended, or fatigued by screening and needed reassurance that participation was optional. This was described as particularly pronounced in outpatient follow-up, where repeated screening across appointments could heighten frustration and resistance when patients did not see why the questions mattered, underscoring the importance of explaining why the questions were being asked and reaffirming choice. The emphasis on autonomy was not purely procedural; it functioned as a relational strategy to reduce defensiveness and preserve dignity. At the same time, participants were attuned to the practical stakes of accuracy, particularly when time constraints or rushed interactions increased the likelihood of incomplete or inaccurate documentation. One participant summarized the stakes succinctly: “I need it to be correct information because if it’s not, then it doesn’t help anyone” (OPSW1).

Conversational Personalization

Conversational personalization refers to the deliberate effort to make standardized questions feel purposeful, nonjudgmental, and responsive to the patient’s situation. Participants adjusted language, sequencing, and timing to align with the clinical moment and the patient’s perceived readiness. Some described prefacing screening with a brief rationale for why the team asks these questions and how the information could be used to provide support. Others described adapting the conversation to focus on what felt most immediately relevant for discharge or recovery.

Personalization was also used to protect emotional safety: participants described softening phrasing, pausing when patients appeared overwhelmed, and returning later if the timing felt wrong. As one participant explained, “You have to really understand what you’re looking for and why… Otherwise, you’re just checking boxes, and the patient can tell” (IPSW2).

Participants also described personalization as a strategy for translating screening into the patient’s own words and priorities. When needs were raised organically by patients or by other clinicians, screening felt less intrusive and more like a natural extension of care. One participant contrasted routine questioning with moments when patients initiated the topic: “When the patient says, ‘Hey… can I get some help with my rent?’ then it feels less intrusive” (IPNCM3). In these accounts, the perceived legitimacy of screening depended on the alignment between the question and the patient’s lived concern as well as whether the team could respond concretely.

Technological and Systemic Frustrations

Technological and systemic frustrations shaped screening as both a workflow burden and a moral dilemma. Participants described shifting documentation requirements, EHR misalignment, and duplication across systems. These issues were not minor inefficiencies; they affected the time available for conversation and staff confidence that screening would yield meaningful assistance. One participant reflected on the broader arc of change: “It’s always changing but not always improving” (OPSW2). Others described resource scarcity and uncertainty about whether referrals translated into timely services, which undermined confidence and increased emotional burden. As one participant noted, “We’ve been trying to figure out how long it takes for a referral… to actually result in services, and it’s just not consistent” (IPSW1). Another described a growing sense of frustration as resources tightened: “I get more frustrated as the years go on because when I first started… there was a lot of funding and resources, and now it’s getting even worse” (OPSW1).

These frustrations interacted with autonomy and personalization. Participants described that when they could not see outcomes, it was harder to explain why questions mattered or to encourage disclosure. Several described feelings caught between institutional requirements and their own professional commitment to offer meaningful support. Over time, this mismatch contributed to fatigue and moral distress, particularly when patients disclosed urgent needs that could not be addressed within the constraints of available resources.

The Importance of Staff Expertise

The importance of staff expertise was described as the practical skill of doing sensitive screening well. Participants emphasized that effective screening required confidence, judgment, and the ability to read patient cues. Expertise included knowing what to ask, when to ask it, and how to respond when answers revealed acute hardship, safety risk, or crisis. Participants described learning to tailor their approach based on patient affect, clinical acuity, family presence, and cultural considerations. They also described navigating the boundary between supportive conversation and the documentation demands that structure the interaction. A participant captured this as embodied competence: “I think it’s experience, it’s confidence, and knowing what questions to ask and when to ask them” (OPNCM1). Another emphasized that a professional perspective shaped how they navigated constraints: “We come at it from a unique perspective because we know how to work around things” (OPSW2).

Interprofessional Collaboration

Interprofessional collaboration was experienced as essential but uneven. Participants described coordinating with physicians, nurses and other care team members to align expectations and avoid implying that social needs would be resolved automatically. Some participants described supportive teamwork that made screening feel integrated and shared. Others described situations in which clinicians were uncomfortable asking sensitive questions, which shifted responsibility to social work and case management and sometimes led to inconsistent messaging. One participant observed: “You can tell that some of the doctors or nurses aren’t comfortable with these questions… they’re just hoping that [the patient] says ‘no’” (OPSW2). Participants emphasized that collaboration shaped not only workload but also patient expectations, particularly when patients interpreted any mention of social needs as a promise of immediate resources.

Across settings, emotional labor was pervasive. Participants described moral distress when they were required to ask about needs without having reliable options to offer, particularly when patients disclosed hardships that were difficult to address. One participant summarized this tension directly: “There’s a moral distress component, knowing that we’re asking, and sometimes there’s nothing we can do” (IPNCM1). Another articulated the reciprocal nature of their commitment: “We ask these questions because we care – we just need the system to care for us too, so we can keep doing it” (IPSW2).

Figure 1 presents a thematic map that visually summarizes how participants described the five themes as interconnected rather than discrete. The figure is included to help the reader see the patterning across interviews, particularly the way staff expertise sits at the center of the screening experience and is described as shaping how clinicians navigate autonomy, personalization, collaboration, and system constraints in practice. The arrows depict interpretive linkages among themes, illustrating how participants discussed certain themes as reinforcing or depending on one another within real-world workflows, while not implying causal relationships.

Figure 1.

Thematic map of major themes of staff experience of SDOH screening

Themes were consistent across interviews, but participants emphasized a clear inpatient–outpatient divide: inpatient screening unfolded under crisis conditions and time pressure, while outpatient follow-up allowed trust-building over time but brought greater inconsistency in screening processes and more patient fatigue with repeated questions. Setting shaped the temporal experience of screening and follow-up. In inpatient care, urgency and competing priorities limited time to build rapport. Participants described “racing against discharge” (IPNCM1, IPNCM3, IPSW2) and trying to complete screening alongside complex medical tasks. One participant captured this constraint: “It’s a time thing… we don’t have time to build that rapport before we ask the questions” (IPSW1). In outpatient follow-up, continuity could support deeper disclosure and allow the relationship to develop, but delays in services and fragmented community resources often reduced perceived actionability. Participants described the challenge of sustaining patient hope when referrals moved slowly or unpredictably, and the difficulty of re-asking screening questions when patients had already disclosed needs without seeing results. Participants also noted role-linked emphases, with nurse case managers orienting screening toward discharge coordination and social workers emphasizing relational engagement and longitudinal resource navigation.

Discussion

This phenomenological analysis positions SDOH screening as relational, ethical, and temporal work rather than a discrete documentation task.^5,6 Taken together, the themes describe how screening providers navigate tensions between institutional screening requirements and the relational realities of clinical care, illustrating how documentation mandates, time pressures, and resource limitations shape both the meaning and effectiveness of screening encounters. Participants described screening quality as grounded in how purpose was introduced, how vulnerability was handled, and whether the system could respond in ways that felt credible to patients.^5,6,8,17

Respect for autonomy reframes “non-disclosure” as ethically meaningful rather than merely missing data. Participants described stopping, deferring, or narrowing questions to preserve agency when medical issues, pain, or uncertainty limited their capacity to engage. This matters operationally because programs that prioritize completion may elicit low-fidelity answers offered under pressure, undermining care planning and data integrity.

Participants also described additional ways in which patient autonomy shaped screening encounters beyond the decision to decline specific questions. In practice, patients sometimes disclosed social needs outside the structure of standardized screening prompts, highlighting the importance of allowing conversations to evolve beyond scripted questions. Screening providers also described adapting the timing and pacing of screening to patient readiness, particularly in inpatient care settings where patients may be overwhelmed by competing medical concerns. These observations suggest that autonomy in SDOH screening involves not only respecting a patient’s right to decline participation but also creating space for patients to disclose needs in their own terms. At the same time, participants noted that repeated screening across multiple encounters could frustrate patients, particularly when needs had already been discussed. This tension raises important questions about how screening protocols might be adapted to balance documentation requirements with patient experience, including opportunities to improve perceived usefulness and satisfaction with the screening process.

Conversational personalization emerged as the mechanism through which standardized questions became tolerable and interpretable. Participants described translating scripted items, adapting tone, and explaining purpose to reduce defensiveness and stigma. In practice, the screening tool can exist in the EHR while the relational conditions required for disclosure remain absent; participants emphasized that patients could detect when screening was performative, shaping willingness to engage and the credibility of the offer of help. ¹⁰

Technological and systemic frustrations highlight the gap between screening mandates and response capacity. Changing requirements, misaligned workflows, and unclear follow-through constrained time for conversation and weakened staff confidence that disclosure would lead to meaningful help. These conditions can normalize “checkbox work,” producing low-quality data and increasing moral distress when urgent needs are disclosed without reliable pathways to assistance.

Staff expertise underscores that screening cannot be reduced to scripts or tools alone. Participants described judgment and embodied skill in reading cues, timing questions, and responding to disclosure while maintaining dignity. Supporting this expertise is especially important in inpatient and urgent care, where cognitive load and rapid transitions shape what patients can absorb and what will be remembered.

The findings also raise questions about whether the relational expertise described by participants can be intentionally developed through training or mentorship. Many clinicians described learning how to navigate sensitive conversations about social needs through experience rather than formal preparation. These relational skills included recognizing when patients were ready to engage, responding to discomfort, and balancing standardized screening requirements with individualized care. While such expertise often develops over time, training approaches that emphasize communication skills and reflective practice may help prepare clinicians to conduct SDOH screening in ways that maintain trust while still meeting documentation requirements. Mentorship and peer learning may also support the transfer of these skills by allowing less experienced clinicians to observe how experienced staff navigate complex screening encounters.

Interprofessional collaboration shaped whether screening felt coherent or fragmented. When screening was displaced with social work and case management alone, emotional labor was concentrated, and patients received mixed messages about whether social needs were legitimate clinical priorities. Screening programs, therefore, require shared accountability, role clarity, and consistent communication across the care team.

Taken together, these themes sharpen the ethical stakes of screening without response. Participants did not describe frustration only because resources were limited; they described distress because the act of asking can raise hopes, expose vulnerabilities, and deepen feelings of stigma if the system cannot respond. Screening can raise hopes and expose vulnerabilities; without visible follow-through, it risks deepening stigma and skepticism. A paired-intervention framing is essential: screening plus response, including time for relationship-building, clear escalation pathways for urgent social risks, and closed-loop referral processes.^5,6 Without these elements, screening can become an ethically fraught practice that asks patients to disclose hardship without demonstrating the health system’s willingness or ability to act.

These findings also have implications for measurement. Completion rates are straightforward to report, but they are poor proxies for quality. Health systems could pair documentation metrics with indicators that reflect whether screening functions as intended, such as timeliness of response, referral completion, and patient-perceived helpfulness. Even modest measures, including time from identified need to first outreach or confirmation that an offer of support was received, may better reflect whether screening is generating real-world benefit rather than merely producing structured data.

This project has limitations, including a small purposive sample from a single health system, which may limit generalizability to other settings. However, phenomenological methods prioritize depth and meaning, and the themes offer transferable insights for programs implemented under similar documentation burden, time pressure, and resource constraints. In addition, the secondary interviewer worked within the same institution as the clinical teams, which may have influenced participant responses; however, this proximity may also have supported rapport and contextual understanding during interviews.

Future work should examine patient experiences of these encounters and compare patient narratives, staff intent, and documentation artifacts to identify where programs deviate from their intended purpose and which design features promote trust, disclosure, and follow-through.

Conclusions

SDOH screening as a part of clinical care was experienced by social workers and nurse case managers as consequential relationship work shaped by time, workflow, and resource constraints. Implementation approaches that treat screening as a checklist risk undermining trust, lowering data quality, and increasing staff moral distress. Programs are most likely to be effective and sustainable when screening requirements are paired with training, usable workflows, shared interprofessional accountability, and reliable closed-loop pathways to assistance.

Supplemental Material

Supplemental Material - “We Ask Because We Care”: Lived Experience of Social Determinants of Health Screening Among Social Workers and Nurse Case Managers

Supplemental Material for “We Ask Because We Care”: Lived Experience of Social Determinants of Health Screening Among Social Workers and Nurse Case Managers by Melissa L. Habrat, Shani Cabrera Smith, Anna Ninneman, David Nelson, and Lindsay D. Nelson in Journal of Primary Care & Community Health.