By Kaitlin Louie
About DeEtta Barnhardt, LCSW, LICSW: DeEtta Barnhardt is a licensed clinical social worker at Lucile Packard Children’s Hospital Stanford (LPCHS), where she supports pediatric patients and their families in the medical-surgical units. Prior to joining Lucile Packard Children’s Hospital in 2008, Ms. Barnhardt worked as an Outpatient Social Worker at Gillette Children’s Specialty Healthcare, and as an On-Call Social Worker at Children’s Hospital Minneapolis.
Ms. Barnhardt has earned numerous awards and recognitions for her dedication to helping patients and their families. She has been presented with three rose awards at Lucile Packard Children’s Hospital Stanford, as well the PCARES Gold R.O.S.E (Recognition of Service Excellence) award which is an annual, organization-wide recognition of employees from each division exemplifying extraordinary internal/external service in 2013. She received this award in recognition for her work with a very challenging family over the course of a hospitalization of a child for over 500 days.
Ms. Barnhardt earned her Bachelor’s of Social Work in 1998 from the University of Mary in Bismarck, North Dakota. After earning her BSW she moved to Minneapolis, Minnesota and worked for three years with developmentally disabled adults, after which she returned to school to earn her Master’s of Social Work, which she received from the University of Minnesota, Twin Cities in 2002. She is licensed to practice clinical social work in Minnesota (as a LICSW) and California (as a LCSW).
[OnlineMSWPrograms.com] Could you please describe your current role as a Licensed Clinical Social Worker at Lucile Packard Children’s Hospital? What types of clients do you work with, and what kinds of challenges do they face? How do you support them and help them manage these challenges?
[DeEtta Barnhardt, LCSW, LICSW] I am a Clinical Social Worker at LPCHS. Our department is divided into 6 pods. I am a part of the CVICU/PICU/Medical-Surgical Pod. My primary focus is on the medical-surgical units. At LPCHS the social worker follows the patient and family throughout the hospitalization. Therefore, should the patient move to the PICU, I follow them on that unit and if they move from the PICU to the med-surg floor, I continue to work with them as their social worker. Since LPCHS is a teaching hospital, the medical teams change weekly which can be difficult for patients and families. As a social worker, I remain consistent in the lives of the patient and family which is often very important to them. If a patient discharges from the hospital and is readmitted to the hospital, I will again follow them throughout their hospitalization.
My patients are all ages. I see them as young as 2 weeks of age if they are not sick enough for the Neonatal Intensive Care Unit all the way up to 24 years of age. Transitioning young adults to adult care can be very difficult. The patient and family at times are resistant but other times, there is no adult provider available to accept the patient under their care. I am hoping to be more involved in developing standards for transition to adult care at LPCHS. My patients have a wide range of conditions from a general appendectomy or tonsillectomy to mitochondrial disorders and genetic disorders. I follow all services except oncology (I do follow initially if the patient has not received a diagnosis and transition the patient to an oncology social worker once diagnosis is confirmed), cardiology, cystic fibrosis (I do cover CF when the social worker is out of the office), and transplant patients (again – I may initially follow the patient until they have been listed for transplant).
There are many challenges in working with so many populations of patients. Medically, the patients may not receive a diagnosis. This is difficult for patients and families because there is not a specific treatment plan or prognosis. They live with great uncertainty. There is also the knowledge for some that their child has a poor prognosis and a shortened life span. Some patients have such complicated medical needs, that there are numerous specialists working with them so it is highly important that medical teams are communicating and working together on the best treatment plan for that individual patient.
Emotionally, patients and parents are often dealing with the unknown and the ongoing need to maintain hope. They are often confused by medical terminology and differing opinions on treatment plans. Sometimes parents don’t want the patient to know what diagnosis they have, to protect them, which can be difficult for the medical team to support. Other times parents tell their children too much information, causing anxiety and fear in the patient. It is difficult at times for the parents to find a middle ground, and of course if the diagnosis is terminal or life limiting–the patient and families are grieving, each in their own way.
There are many social challenges that my patients and families face daily. We are a hospital that brings patients from all over the United States. We have many transfers from Nevada, New Mexico, Hawaii, and Oregon to name a few. They come with very little support, often limited finances and no transportation. Many of the families we work with have issues related to housing, transportation, employment, financial strain, insurance issues, immigration issues, domestic violence, and lack of support to name a few.
As a social worker for these patients and families it is important that I provide support during the hospitalization. Often families are under great strain and need practical resources during the hospitalization. Many families are in crisis mode and I provide crisis intervention services which would include general support, resources, referrals to appropriate agencies or services within the hospital, specific steps to follow (like homework), suicide assessments, and even walking parents to the ED for mental health assessments if needed. At times it is important to discuss death, dying, grief and bereavement.
I work closely with many community agencies and often make referrals to organizations such as the Family Advocacy Project, Ronald McDonald House, Child Protective Services, TANF/CalWorks, WIC, Public Health Nursing, the Shelter Network, Legal Aid and Make-A-Wish to name a few. I also refer patients to services within our hospital including child life, chaplaincy, palliative care and psychology.
I work closely with the medical teams in development of treatment plans. The medical teams utilize Family Centered Rounds, Multidisciplinary Rounds, bedside meetings, care conferences and ongoing direct communication to include social workers in on treatment planning. I have direct access to medical teams through paging them or calling their ASCOM phones.
[OnlineMSWPrograms.com] You work with a wide range of medical-surgical pediatric patients across many different departments, excluding only oncology, transplant, cystic fibrosis, and cardiology. How do you spread your time across so many different medical departments? How do you tailor your services to meet the needs of so many different types of patients and their families?
[DeEtta Barnhardt, LCSW, LICSW] At LPCHS I am an inpatient social worker. We have outpatient social workers as well. I may assist a patient/family on outpatient needs if they have recently discharged but I will usually sign-out any ongoing outpatient needs to the assigned outpatient social worker. I at times assist the medical teams and parents in identifying a primary care provider/pediatrician but I do not work in a primary care clinic. I work with both acute care and intensive care patients that are admitted to the hospital. A patient may start their journey as an acute care patient and during the course of the hospitalization become an intensive care patient, and vice versa. The needs of an acute care patient are often very similar to that of an ICU patient, and the needs of their families can vary, and are not dependent on the state of the patients’ health. For example, I may have an ICU patient whose parents are coping well within normal but will have a parent with a child with pneumonia on the medical floor that is not coping, having panic attacks, and crying uncontrollably. Just because the patient is less critical does not mean that the parents are coping better than those parents in the ICU. Each case is very different and a thorough assessment is needed whether the patient is in the ICU or in the med-surg units.
There are many different types of social workers working at LPCHS. About 50% are LCSW level social workers. There are about 5 social workers with Advanced LCSW standing, meaning that they have been working in the field for an extended period of time. The other social workers are ASW level social workers. They have their Master’s Degree and are being supervised by an LCSW. They are working towards earning enough hours to test up to the LCSW level of licensure. There are also 2 MSW fellows that work in the PICU/CVICU, and 3-4 MSW interns each year. Our department is separated into 6 different work groups, called pods. They are Solid Organ Transplant, CVICU/PICU/Medical-Surgical, The Johnson Center (NICU and Maternity and Fetal Medicine), Oncology/Neuro-oncology, Outpatient, and Satellite.
Each social worker works with specific medical teams depending on their assignment. For example the liver transplant social worker works primarily with the GI team and Liver team in addition to the PICU team if their patient is in the PICU. I on the other hand follow all services except those listed above (cardiology, oncology, transplant, and CF) so I work closely with all the other medical specialists. It is very interesting to work with so many teams. I’m constantly on Google trying to learn about new conditions that I haven’t heard of before. It is a very diverse position which means that communication is very important. I utilize Family Centered Rounds, MAP rounds (Multidisciplinary Action Plan), care conferences, and direct communication through paging or phone calls to stay involved and aware of treatment plans and discharge plans. I work closely with the physicians, chaplaincy, child life, case management, psychology, financial counselors, patient experience, palliative care, and interpreters.
Since LPCHS has psychology and psychiatry available for evaluations and referrals, it has been important that our roles remain clear. We communicate often when we are both involved with patients/families. Psych places 5150’s in our organization, and case management locates psychiatric inpatient placements. The social work role is often to support clients and their loved ones during the difficult time/situation.
[OnlineMSWPrograms.com] You have also worked as an outpatient pediatric social worker at Gillette Children’s Specialty Healthcare, a hospital setting devoted specifically to treating children and adolescents suffering from disabilities and/or complex medical challenges. How was working for this organization different from working as a pediatric social worker at Lucile Packard, in terms of the patients you worked with and the responsibilities you had?
[DeEtta Barnhardt, LCSW, LICSW] When I worked at Gillette Children’s Specialty Healthcare, I was an outpatient social worker. At times I would cover inpatient if we were short-staffed but my primary role was outpatient. I worked with one other outpatient social worker and we covered all the outpatient clinics. Part of our role was social work related including support and referrals to resources; however the other part was care coordination (case management) such as ordering wheelchairs, hospital beds, and enteral supplies. It was similar to my current role at LPCHS as I had to prioritize my day, never knew what each day would hold, and there was a general quickness needed to accomplish the tasks necessary each day.
The patient population was quite similar at GCSH. I worked with Orthopedics, Neuromuscular, Neurology, Cerebral Palsy and Spina Bifida populations to name a few. The patients and families experienced similar obstacles such as housing, financial, new immigrants/language barrier, lack of support, transportation, and life limiting diagnoses. My responsibilities were similar as well. I would be paged to assess a situation, would complete an evaluation, provide appropriate resources and support, make referrals as needed and would continue to work with the patient/family on an outpatient basis.
[OnlineMSWPrograms.com] Why did you decide to become a pediatric social worker, and what have been some of your most rewarding experiences during your career?
[DeEtta Barnhardt, LCSW, LICSW] Growing up my parents were foster parents and I lived with many foster children. I began to wonder how I could help children like them. I decided to obtain my BSW with the intent of being an adoption social worker. I had two internships during my BSW program. One was working at the Center for Adolescent Development and the other was with Pathways (Treatment Foster Care). When I graduated, I moved to Minnesota and began working with developmentally disabled adults. I worked for three years and then went back to college to earn my Master’s Degree. During my Master’s Degree program, I worked at a long term care facility. Because I had my BSW, I was considered “advanced standing” and only needed to complete one year of coursework and one internship. My internship was at an adoption agency. I worked with international adoption and adoption within the county system.
Even though I thought adoption was what I wanted to do, I found that I didn’t “love it” and I wondered what else was out there. I worked at a long term care facility for three years after I graduated and began working on-call at Children’s Hospital Minneapolis. I found that I liked working in the hospital, but didn’t want to only do on-call work. The opportunity arose to interview at GCSH and I was offered the position. I loved working at GCSH and was sad to leave when my husband found a job in the Bay Area. Upon moving to the area I was hired as a relief social worker at LPCHS and at O’Connor Hospital. After working one month, I was hired full time at LPCHS as the High-Risk Infant Follow-up and Development and Behavior Clinic social worker as well as the social worker for the Sequoia Special Care Nursery. I transitioned into my current position in November of 2009 when our department was restructured.
The rewarding aspects of my job are that I am able to follow patients and families through their experience, from diagnosis to sometimes death. I am able to support them through the “roller coaster” that is pediatric illness. I sometimes watch patients improve and go home, never to return again. Other times I see patients during each admission as they transition from being “intensive care” to being “acute” and then going home, only to return again in the future. And then there are the other times, where I have developed a wonderful working relationship with a family, having seen them through many obstacles, only to be at a place that is the end. This is a very difficult time, but it means so much, to be there with a family through the last steps of hope, through the grief, the loss, and the time of bereavement, knowing that I made a difference, just from being there with them during that time.
[OnlineMSWPrograms.com] On the other hand, what have been some of the most challenging aspects of your job in pediatric social work, both in primary care and acute care settings? How would you recommend MSW students who wish to work in pediatric intensive care and/or primary care prepare for these challenges?
[DeEtta Barnhardt, LCSW, LICSW] Some of the most challenging aspects of my job include communication, meeting expectations, meeting administrative demands, and for me, when a patient dies.
Communication is challenging because I am working with interns, residents, fellows and attending physicians from multiple teams each day. At times it is difficult to know and understand what each team is doing and what the plan of care for the patient is. It is important to attend rounds when able, arrange care conferences as needed and seek out the medical teams for updates and information when appropriate. It is also very important that I communicate any psychosocial concerns or issues with the medical team as these issues can affect the discharge plan.
Meeting expectations is challenging because I am trying to meet the expectations of the patient and family while also managing the expectations of the medical team. Often parents have unrealistic expectations of what the hospitalization should look like, how communication happens, and the power that I hold among the other members of the multidisciplinary team. Medical teams, at times, expect that I can find a family community resources such as housing, transportation, and counseling, with very little notice. Every day, I communicate with medical teams and families about what I am able to provide realistically and what isn’t possible due to the lack of appropriate community resources, time and money.
As with any organization there are administrative demands that need to be considered. One of these is discharging patients when medically ready, another is following service goals and guidelines, and another is documenting within specific guidelines. LPCHS is also a CCS (California Children’s Services) centered hospital which means that as a med-surg social worker I have to see all the patient’s admitted for 3 days or more. The goal each day is to find a balance between administrative objectives and patient care.
When a patient dies, there is the challenge of offering support, providing resources and direction, and managing my own grief. It is important to set aside my grief to provide the appropriate support to the family of the patient that has died. I have to monitor my countertransference during the dying process. And when the family has left the building, I can sit with my grief and process it as needed with my co-workers.
It is important when working in a pediatric hospital setting to know yourself. Look into yourself and acknowledge what might produce countertransference or open old wounds. Remind yourself how you handle stress and determine a plan of how you would relieve stress after a challenging day. Try to remember why you wanted to be a pediatric social worker in the hospital setting.
[OnlineMSWPrograms.com] For social work students who are interested in working in pediatric social work, what advice do you have for them in terms of preparing for this field?
[DeEtta Barnhardt, LCSW, LICSW] In preparing to work in a pediatric hospital setting it is important that you have taken courses in childhood development, child abuse and neglect, domestic violence, death and dying, stages of grief, crisis intervention, motivational interviewing and strengths based therapy. Additional classes that could help are individual and family therapy, mindfulness, psychology based courses (personality disorders, bipolar, depression, etc).
I recommend that you try to find a field placement that allows you to work with pediatric patients and their families. Ideally, this would be in a hospital; however with there being few pediatric hospital internship possibilities in the area, working in an organization that has direct patient contact with children and families such as CPS, schools, homeless shelters or clinics would all be beneficial. Every hospital is different but at LPCHS some opportunities for students to get involved with would be volunteering in the Forever Young Zone, Cuddling The Babies, or even shadowing social workers in the organization.
Researching and navigating all the requirements for licensure is also something that students should devote proper time and planning to. North Dakota and Minnesota are different than California, in that you must take multiple exams to become clinically licensed. Therefore in 1998 I took my first social work exam and became an LSW (Licensed Social Worker). After I earned my Master’s Degree, I took another exam and became an LGSW (Licensed Graduate Social Worker). I worked under this license for two years while earning supervision credits. In 2004, I took the national ASWB exam and became an LICSW (Licensed Independent Clinical Social Worker) in the State of Minnesota. I moved to California in 2008. Because I already had a clinical license in Minnesota, my supervision credits transferred to California; however, I had to complete all the state coursework and pass the two LCSW exams to become licensed in California. Finally, in 2010 I was licensed as an LCSW in the State of California. I maintain my Minnesota license as it has reciprocity with most states in the union, just in case we were to move to another state.
Thank you Ms. Barnhardt for your time and insights into pediatric social work.