The impact of COVID-19 on the professional and personal lives of pediatric oncology social workers

Abstract

Purpose:

Describe the impact of the COVID-19 pandemic on the work structure, daily care provided, personal lives, and practice models for pediatric oncology social workers (POSW).

Research Approach:

Cross-sectional online survey on APOSW professional listserv from 10/5/2020 to 11/20/2020.

Sample:

101 surveys were completed by POSW from 31 states and the District of Columbia.

Methods:

Data were summarized descriptively and with semantic content analyses.

Findings:

Surveys were completed by social workers from diverse work settings. Seventy-five percent of social workers were deemed “essential,” and 45% reported working primarily from home. Most (56%) adopted a form of telehealth for patient care, although 71% did not receive telehealth training and 87% perceived lesser quality of care with telehealth. Nearly 80% of respondents reported not being able to provide optimum psychosocial care. Notable stressors on social work practice included worry about exposure to COVID-19, limited resources, lack of contact with and increased emotional needs of patients and families, managing patient and family concerns about COVID-19, and isolation from colleagues. Inequity and social justice issues were identified. Despite challenges, over 60% of POSW endorsed positive changes to their work life resulting from the pandemic.

Conclusions/Interpretation:

As the COVID-19 pandemic persists, POSW have adapted to a changing work environment, different modes of service provision, and stark health inequities to meet the needs of patients and families in a crisis.

Implications for Psychosocial Providers:

COVID-19 vastly impacted the personal and professional lives of POSW, warranting attentiveness to lessons learned and future directions.

Introduction

In January 2020, the World Health Organization (WHO) declared a public health emergency due to the discovery of COVID-19, a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). By March 2020, it was deemed a worldwide pandemic.¹ While the numbers of infections and deaths change daily, on February 8^th, 2021 the Johns Hopkins University COVID Resource Center reported that 106,228,180 people had contracted the virus and global deaths reached 2,318,763.² Due to underreporting, it is very probable that this number may be an underrepresentation of actual cases.

These staggering numbers are not mere statistics; they represent individual human beings with families, livelihoods, and life stories. Healthcare workers worldwide have worked tirelessly to contain the spread of the virus as well as attempt to meet the growing emotional, psychological, and physical needs of individuals infected with COVID-19 and their families.

Among other healthcare disciplines, social workers have been designated “essential workers” by the U.S. Department of Health and Human Services and the U.S. Department of Homeland Security.³ Pediatric oncology social workers, the focus of this work, are essential workers and in fact, 90% of pediatric oncology programs employ social workers.^4,5

Children appear to be less vulnerable and susceptible to COVID-19 and recent reports suggest that children with cancer and other hematologic illnesses are not at as great a risk as first speculated.^6,7 However, these children and their parents represent a high-risk population in terms of their physical, psychological and emotional fragility which pediatric oncology social workers are expected to respond to and address. Emerging literature highlights the numerous challenges faced by children with cancer and their families during the pandemic including significant anxiety, posttraumatic distress symptoms, fear of delayed or canceled treatments, changes to medical and psychosocial care, limited visitation policies, increased isolation and risks associated with contracting the virus.^8–10

Since the start of the COVID-19 pandemic, and throughout previous infectious outbreaks, hospital social workers, including pediatric oncology social workers have experienced significant practice changes as they attempt to maintain professional integrity and provide ethical care in the face of challenging obstacles.^11–16 Adapting to rapidly evolving organizational policies, being mandated to work remotely, facing job insecurity, reducing team cohesion due to lengthy periods of isolation from team members and other colleagues, establishing safe forms of communication from digital platforms, and accessing appropriate IT equipment all contribute to the professional challenges faced.¹⁷

The social work profession is centered on beliefs, values, and ethics focused on respect for the dignity of all people and equitable access to supports and resources that enhance a person’s life. Changes in practice models resulting from the pandemic have highlighted the existing inequities in access to critical resources and emotional support causing social workers to experience moral distress associated with delivering psychosocial care that does not feel optimal or even acceptable.^18–21

How the COVID-19 pandemic has impacted pediatric oncology social workers or social work teams is yet unknown. Like all healthcare providers, pediatric oncology social workers are at risk of Covid-19 infection and are cognizant of the risks to their families. While pediatric oncology social workers advocate for patients and families, their own personal self-care and physical and emotional replenishment are also essential. Whether or how social workers are sustaining themselves is also unknown. Developing resilience in the face of adversity requires finding creative solutions that allow for a balanced approach in personal and work lives.^22–25

Amidst the challenges the pandemic has unleashed on pediatric oncology social work practice, it may also have given birth to positive changes in working practices and new ways of reducing psychosocial care barriers even beyond the end of the pandemic.¹⁴ The primary objectives of this current survey were to determine the work structure, daily psychosocial care provided, practice model changes of pediatric oncology social workers and the impact to their personal and family lives during the COVID-19 pandemic.

Methods

Design and sample

Pediatric oncology social workers were invited to participate in an anonymous survey which was posted on the Association of Pediatric Oncology Social Workers (APOSW) listserv. For further chain-referral sampling, the social workers were encouraged to share the survey with their pediatric oncology social work colleagues. The listserv posted one announcement with two follow-up reminders, spaced 14 days after the initial announcement from October 5th through November 20, 2020.

Measures

Survey questions were originally designed by a collaborative, interprofessional palliative care study team according to the Tailored Method of Survey Design and later adapted to address issues specific to COVID-19.^26,27 We further adapted the survey instrument based on issues specific to pediatric oncology social workers. The survey includes COVID exposure questions adapted from the CoRonavIruS Health Impact Survey (CRISIS) V0.3 Adult Self-Report Baseline Current Form.²⁸ The final survey instrument [Appendix I] consisted of 57 multiple choice questions, several with an option to describe their choice and three free-text questions organized for administration on Survey Monkey.

Data collection and analysis

The Office of Human Subjects Research Protections at the National Institutes of Health determined that the survey format and content qualified as exempt from full Institutional Review Board review. A SurveyMonkey© questionnaire format was utilized for online data collection. The analyses were descriptive and univariate in nature. The study team utilized counts for categorical variable responses. For missing responses, the number of responders was used as the denominator (actual n). Frequencies and percentages are presented.

Qualitative analyses were conducted on free-text narrative responses. Free-text responses were analyzed by two authors (LW, AF) to identify common themes. The authors met interactively to refine themes and develop codes for qualitative analysis.²⁹ Free-text responses were coded in parallel and differences were resolved through discussion.³⁰

Results

Demographics

One hundred and forty pediatric oncology social workers opened the online survey, with 136 answering the first question, asking whether they are a member of APOSW. One hundred and four respondents (77%) were APOSW members. As the study did not include any force responses, the denominator varied between questions. One hundred and one pediatric oncology social workers answered all of the closed item responses. Respondents were from 31 states and the District of Columbia, representative of 36% from northeastern, 19% southeastern, 6% southwestern, 19% midwestern, and 19% western states as defined by National Geographic criteria (Figure 1).

Figure 1.

Geographic distribution of survey respondents.

Work setting during COVID

The pediatric hematology/oncology programs remained ‘open as usual’ for 75% of respondents. Twenty three percent reported a decrease in the daily inpatient status. Less than 20% of pediatric patients were reported as having COVID-19 at the time the survey was completed, with 60% having less than 10 pediatric oncology patients having been diagnosed with COVID-19 at some point during the pandemic. COVID testing varied between sites, with 84% of all patients being routinely tested prior to an admission or before any procedure requiring sedation. See Table 1 for additional demographic and work setting information.

Table 1.

Sample characteristics.

Geographic region (N = 129)*	n (%)
Northeast	47 (36%)
Midwest	25 (19%)
West	25 (19%)
Southeast	24 (19%)
Southwest	8 (6%)
Primary work setting (N = 136)
Hospital based inpatient and outpatient cancer care program	86 (64%)
Hospital based outpatient cancer care program	27 (20%)
Hospital based inpatient cancer care program	5 (4%)
Not for profit agency (patient service or advocacy)	9 (7%)
Federal, state, local or governmental hospital	2 (2%)
Private hospital	1 (1%)
For profit agency (patient service or advocacy)	1 (0.1%)
Other	4 (3%)
Primary role (N = 135)
Clinical (inpatient and outpatient)	84 (62%)
Clinical (outpatient)	29 (22%)
Clinical/Administration (both)	8 (6%)
Clinical (community based)	6 (4%)
Clinical (inpatient)	6 (4%)
Other	2 (2%)
Years as a Pediatric Hem/Onc Social Worker (N = 119)
Less than 2 years	21 (18%)
2–5 years	29 (24%)
6–10 years	30 (25%)
11–20 years	19 (16%)
More than 20 years	20 (17%)
Number of social workers in program (N = 119)	(mean)
Hematology/Oncology	5
Transplant	2
Survivorship	1
Palliative care	1
Other	1
Annual number of patients (N = 117)
Less than 30	2 (2%)
30–60	6 (5%)
61–80	12 (10%)
81–100	14 (12%)
101–120	15 (13%)
More than 120	68 (58%)
Change in daily inpatient status (N = 111)
Not changed	44 (40%)
Decreased	26 (23%)
Unchanged, but not seeing as many patients regularly	19 (17%)
Not applicable	13 (12%)
Increased	9 (8%)
Current status of Pediatric Hem/Onc Program (N = 110)
Open as usual	82 (75%)
Reduced clinic hours/visits	9 (8%)
Majority telehealth	6 (6%)
Closed to outpatient visits	1 (1%)
Other	12 (11%)
Changes experienced due to COVID-19 (N = 117)
Patient contact has been limited to calls/videoconferencing	71 (61%)
Working primarily from home (remote)	53 (45%)
Took on greater leadership	17 (15%)
Reduction in salary	4 (3%)
Forced to stop working (laid off, furloughed)	4 (3%)
Lost position due to changes in system	1 (1%)
Other	27 (23%)
I have not experienced any of these	20 (5%)

^*Not all participants answered every question; N is given for the total number of responses per question.

Social work care provided

The majority of respondents (79%) endorsed feeling concerned that they were not able to provide what they considered to be the best psychosocial care for the families they work with. Mostly, communication changes were reported, with 83% of respondents noting that there were fewer extended relatives present to work with and 67% reporting that communication had become more complex due to severity of illness and restrictions imposed by the pandemic.

Visitation policies

Significant changes with visitation policies were noted since the pandemic began with 98% of respondents stating that the nuclear family (parents, siblings) and extended family were able to visit the child with cancer prior to the pandemic compared to only 3% at the time of survey completion. At this time, 44% were allowed one parent and 53% were allowed two parents (no siblings). An exception to this policy was made for the majority (92%) of families if the child was at the end of life. Thirty free text responses similarly illustrated how variable the decision can be for who is allowed to visit, even right before death.

Nuclear family members allowed—however unit nurse manager must approve the visitors, the visit is time limited and we have to do the visits discretely (so other families do not see there are multiple family members bedside).

Free text responses also noted the imposed stress of visitation restrictions for social workers who were put in the position of making or implementing these decisions.

Social workers spend hours each day fielding complaints by families about the tight restrictions, and some MDs and RNs bend the rules which create even more challenges for social workers—who then appears as the “bad guy”—as our hospital administration has deemed the social work the staff to allow exceptions, but we must follow a strict protocol that many medical teams don’t agree with.

SW is called on to explain, mediate, and problem-solve which takes time away from clinical issues. We are the “face” of the restrictions even though management is approving/disapproving them. Very stressful!

Social work practice changes

The majority of respondents (75%) reported that they had been deemed “essential” personnel at their cancer center. Twenty-eight percent reported that pediatric oncology social workers within their institution have been asked to cover duties outside the hematology/oncology practice. While 21% of respondents did not report any change to their social work practice due to COVID-19, 76% of respondents reported a moderate to severe impact on their practice. This impact included patient contact being limited to phone calls and/or telehealth (61%), working primarily from home (45%), taking on greater leadership roles (15%), reduction in work hours (12%), reduction in pay (3%), and being forced to stop working (being laid off or furloughed) (3%). Twenty-seven respondents provided free text comments about this impact. The majority described a hybrid work situation (inconsistent work arrangements with some days at the hospital and some at home). Respondents described loss of benefits, being forced to take or use PTO, and significant stress due to working additional hours to cover for coworkers who were working remotely or quarantining due to COVID-19 exposure. Additional COVID-19 related stresses impacting pediatric oncology social workers’ practices are shown in Figure 2.

Figure 2.

Causes of stress during COVID-19 on pediatric oncology social work practice.

Utilization of telehealth for the social worker and families

One of the most noted changes to practice has been the use of telehealth with 56% of social workers using telehealth with both their inpatient and outpatient caseloads. Only 14% of respondents used telehealth prior to the COVID-19 pandemic. For 71% of respondents, no training on telehealth had been provided and 49% said sufficient equipment was not available for them to provide care via virtual or telehealth. Eighty-seven percent of respondents perceived quality of care with telehealth to be less effective than in-person care and 13% perceived it to be equal to in-person care. No respondents endorsed quality of care with telehealth as being better than in-person care.

Respondents were able to endorse other barriers to using telehealth. Frequently endorsed barriers included patients not having reliable Internet or an appropriate device (57%), patients/caregivers being uncomfortable with video technology (43%), and patients/caregivers not being as forthcoming over the phone/video as in-person (36%). When offered the opportunity to expand on these issues, 23 open text responses illustrated additional challenges and experiences with telehealth that were not offered in the choices provided.

Not appropriate for sessions with young children or with children, teens or young adults who are undergoing a medical crisis or who are in the ICU. It works well for some outpatients and there are some benefits of seeing them in their own home and not being interrupted by others walking into their hospital room or demanding their time in the clinic setting.

We do not have cell phones issued by our medical institution and therefore choose not to use our personal cell phones for work.

Access to telehealth was one manifestation of broader healthcare inequities and social injustice. Half (50%) of respondents reported having identified issues of inequity in providing/receiving telehealth services for patients/families. Optional open-text responses elicited further concerns of inequities (n = 48) that focused on a lack of technology competency, lack of resources, particularly for Native American families and others from rural areas who do not have access to internet and for those who need an interpreter. The following quotes illustrate these points.

Socioeconomics obviously play a role–the family with access to the necessary technology (computer, tablet, smart phone), including a Wi-Fi connection are able to access telehealth more easily. The families that lack these resources typically end up not having access to this resource that would likely financially benefit them because they would save on the cost of transportation to the clinic. So, in the midst of the pandemic, the people who really need this resource can’t always access it.

Some families are uncomfortable with their homes being viewed on video, some do not have reliable internet, language barriers. We haven’t found a way to combine our interpreter service with a video visit. So non-English speakers have to do telephone visits.

Team cohesion

When respondents were asked whether cohesion within their oncology team has been affected since the pandemic began, 58% responded that their team felt more distant, 18% perceived their team to be closer, and 24% reported this to be unchanged. When asked the same question pertaining to their pediatric psychosocial team, the results were similar (50%, 21%, and 29% respectively). Almost half (49%) of the respondents noted that they are able to meet their social work colleagues in person, while practicing safe distancing and with the use of personal protective equipment (PPE).

Impact of COVID-19 on staff

Forty-one percent of the respondents noted that their team had to adapt because one or more staff members were personally impacted by COVID-19. Of these, 44 open text responses reflected adaptation due to staff quarantine after a COVID-19 exposure or positive test. Other cases requiring adaptation included staff personal leave due to family illness or death, working remotely due to being considered “high-risk,” and layoffs and furloughs.

To address support provided to pediatric oncology social workers since the beginning of the pandemic, 29% reported an increase in professional counseling services offered, 22% an increase in team care (team building or team resiliency services), and 42% an increase in special topics such as communication, self-care, and ethics. The majority of respondents (89%) had participated in online programs for professional development during the pandemic with the most helpful education pertaining to COVID-19 in the areas of social justice, stress and wellness, and general professional/licensure trainings. Considering the perceived inequities reported, appreciation for increased trainings on the impact of racism on health outcomes were noted.

Given that COVID and the George Floyd murder occurred within a similar time frame I’ve been doing quite a bit of reading and online training about systemic oppression and racial injustices.

Additional imbalances were also noted.

The trainings on self-care and burn out continue to address what the employee can do instead of what an institution can do to support them. This continues to be disheartening as there are only so many walks and self-care activities one can do without the systemic issue of social workers being overworked and underpaid continues to be ignored.

Thirty-nine percent of respondents reported that their program had been doing some things better since the beginning of the pandemic. Each of these respondents provided free text responses which included being able to check in with families more frequently, reaching more families through telehealth, implementing creativity in care, adapting to COVID-19 safety measures, and enhancing communication with the team and with families.

Impact of COVID-19 infection on personal and family health

Ten percent of participants endorsed having symptoms associated with COVID-19, but none had a diagnosis by a physician in the past 2 weeks. Thirty-five percent endorsed being exposed to someone likely to have COVID-19 during the past 2 weeks. Forty-four percent of respondents reported being moderately to extremely worried about their own risk of COVID-19. Respondents also endorsed moderate to extreme worry for their mental/emotional health (61%).

Within this time period, 4% had a member in their household and 10% had a non-household member diagnosed with COVID-19. Fifty-five percent were moderately to extremely worried about a family member becoming infected. Respondents reported 45% had a family member quarantine, 28% suffered from mental health concerns/issues, 25% had reduced ability to earn money, 11% lost their job or were laid off, 9% were reported to have “fallen ill” and 4% of respondents had family members who died.

Positive changes

Many respondents (71%) reported positive changes due to COVID-19. These included more flexibility and work-life balance that remote work provided, increased communication and cohesion with coworkers, increased time with family, more virtual professional opportunities, and increased ability to reach patients virtually. When asked whether the COVID-19 crisis had led to any positive work changes, 64% of respondents endorsed at least a few positive changes. Responses included pride in the way that social workers have been able to adapt to constantly changing policies, and new appreciation of patients, families, colleagues, and becoming comfortable with Personal Protective Equipment (PPE).

Discussion

Early 2020 saw the emergence of a global COVID-19 pandemic that at the time of this writing has resulted in 27 million Americans contracting the disease and over 463,000 deaths. While we still have more to learn about the risks of COVID-19 for children with cancer and their families, this study describes the impact of COVID-19 on the professional and personal lives of pediatric oncology social workers caring for them.

Our study participants described having to rapidly adapt to a different and constantly evolving work environment to meet the needs of the children and families they serve. They also reported considerable personal stressors that they needed to manage simultaneously while providing mental health support to patients, families, and colleagues. Although few social workers reported a high prevalence of children with cancer being treated for COVID-19, work settings and responsibilities did change dramatically to adhere to COVID-19 restrictions and guidelines.

Most social workers transitioned from working at their hospital center to either working from home or to a hybrid of home and in-person settings, while providing many psychosocial services virtually. In prior work, pediatric oncology social workers have indicated that what provides meaning and sustains them in their work is their relationships with children and families.³¹ Practicing via telehealth decreases pediatric oncology social workers’ face-to-face time with children and families. While some participants described the flexibility that remote interventions can provide, others described a sense that they are providing less optimal care and are less connected to patients and families. This may be due to the reduction in the relational aspects of the work for the child, family and social worker, and the emergence of obstacles related to technological competency and access for others. Issues of access and licensing for social workers to provide cross-state telehealth will continue to be relevant as telehealth is expored in a post-pandemic world.

Social workers also described feeling distanced from their interprofessional colleagues and missing the informal and formal debriefing which is known to both improve care and sustain professionals. Furthermore, over 40% of social workers reported an increase in the number of their colleagues with mental health or emotional support needs. Over time, the combination of patient and family stressors as well as the mental health needs of colleagues has the potential to increase distress and compassion fatigue for social workers. The extended nature of the pandemic, without a reasonable end in sight, can cause further anxiety, depression and distress.

As many treatment centers reduced the number of staff onsite, pediatric oncology social workers experienced lack of clarity around whether they had been designated as “essential” or not. Despite U.S. Departments of HHS and Homeland Security designating social workers as essential, that status can vary from location to location and can impact the provision of service in multiple ways. Essential workers are typically expected to provide in-person services and have been prioritized for access to vaccines as providers.³² While providing essential mental health services alongside their interprofessional colleagues that were deemed “essential,” a sense of demoralization and a challenge to professional identity was reported for those that were not considered essential. At the time these data was collected, 25% of social workers were still exclusively working from home and had not been designated as essential on-site staff by their administration.

Many social workers shared mixed feelings about returning to the work-place. The return to in-service provision brings fear for oneself and one’s family due to increased risk of exposure to COVID-19. Almost half of respondents reported worrying about their own exposure to the virus and being concerned about managing their patient/family concerns. Pediatric oncology social workers reported carrying the concurrent tensions of providing comprehensive psychosocial care, remaining a vital part of their teams, and trying to keep themselves and their families safe and healthy.

Changes to palliative and end-of-life care carry additional considerations for social work, as these patients and families are experiencing isolation that may have a significant impact on bereavement. Many families are forced to be alone, without typical supports, as they face their child dying, and attending to their child’s funeral or other rituals. This lack of traditional support has the potential to create complicated and extended bereavement for those denied the critical support of friends and family at a time of extreme loss. While we do not fully know the impact of the global COVID-19 outbreak on mental health due to enforced isolation, social workers need to pay special attention to those who were already at risk for poor mental health as data suggest that they have remained at risk throughout the pandemic.³³ Targeted mental health support to address the impacts of social isolation and COVID-related psychological distress are needed as the pandemic continues.³⁴ Future research is needed to understand how isolation at end of life and delayed post death rituals impact grief.

Pediatric oncology social workers also recognized inequities in care warranting special attention for marginalized communities. The economic fallout from the pandemic has been widespread and disproportionately prevalent among Black, Latino, Indigenous, and immigrant households. Data from several sources show a dramatic increase in the number of households struggling to put enough food on the table.^35,36

In addition to a dire economic situation, social workers are witnessing heightened awareness around issues of inequities in education, employment, housing, and healthcare, all compounded by the pandemic. Indeed, training focused on inequities in healthcare, systemic racism, political unrest and increased violence in communities were considered to be highly meaningful by survey respondents. Pediatric oncology social workers may have increased moral distress as they witness but cannot fully address the concurrent pandemic and its impact on inequity which is so central to social work practice and ethics.³⁷

As the pandemic continues, it is important to assess the impact of sustained trauma for children, families, and healthcare providers. Pediatric oncology social workers are in a unique position to provide leadership, education and support to families as they endeavor to survive this difficult time. Furthermore, as our knowledge of social work during the pandemic evolves, it will be helpful to assess lessons learned, helpfulness of certain interventions, and impacts of changes in care for providers and families at multiple time points. In the face of adversity, developing resilience requires finding creative solutions that allow for a balanced approach, both in our personal and professional lives.^38,39 Despite continued challenges, many of the respondents noted positive changes and opportunities to identify resilience and growth during the pandemic. True to the social work framework, pediatric oncology social workers have been developing innovative approaches to meet the needs of their patients, families and colleagues in a time of ongoing crisis with a strengths-based and social justice framework.

Although our findings illuminate social workers’ experiences with patient care, professional and personal challenges during COVID-19, several limitations are worth noting. We are unable to determine how many members of the APOS listserv received the email invitation to participate in this survey and thus are prevented from calculating a true response rate. Those who responded may have been more greatly impacted by COVID-19. Next, the survey captures a snapshot of the pandemic’s impact on POSW during the fall of 2020. Numerous shifts have occurred since that timeframe, including changes in U.S. political leadership, launching of a vaccination campaign, and rising numbers of COVID-19. Each of these factors could impact the generalizability of the results.

Implications for psychosocial oncology

This study highlights the essential nature of pediatric oncology social work throughout the first 9 months of the pandemic, particularly as the needs of patients, families, and interprofessional team members are being addressed There is a tremendous challenge in caring for children and families and one’s team while facing one’s own sense of depletion and fear. Healthcare systems and institutions hold a dual obligation to support the well-being of patients and of staff.

Even during a pandemic, pediatric oncology social workers can advocate for children and families to have access to as many resources as possible. While in-person visitation may be limited, social workers can help create meaningful interactions and communication using video and electronic tools. Pre-pandemic models of social work service delivery may be forever changed, and new, innovative interventions may prove to be more sustainable and effective. Social workers must embrace this opportunity to evaluate their individual practices.

Social workers can also utilize their understanding of social justice and health inequity to advocate for equitable care for all. They can educate the wider treatment team on how racism, inequity and poverty impacts families’ adjustment to and coping with cancer and the importance of incorporating these issues as part of a holistic assessment. Pediatric oncology social workers can avail themselves of training in telehealth, crisis intervention, complicated bereavement, disaster response, health inequities, and trauma stewardship to meet the growing challenges of this pandemic and its impact on children with cancer and their families.

Despite the unending challenges of this pandemic, pediatric oncology social workers are demonstrating considerable resilience, creativity, compassion and ingenuity as they meet the needs of their patients, families, teams and themselves. Continued study and support of pediatric oncology social work is warranted. Their work is essential to the provision of the highest level of psychosocial oncology services.