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Exploration of the role of nurses in caring for children in foster care

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Exploration of the role of nurses in caring for children in foster care

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Content EXPLORATION OF THE ROLE OF NURSES IN
CARING FOR CHILDREN IN FOSTER CARE
by
Janet U. Schneiderman
A Dissertation Presented to the
FACULTY OF THE ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
August 2003
Copyright 2003 Janet U. Schneiderman
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UM I Number: 3116783
Copyright 2003 by
Schneiderman, Janet U.
All rights reserved.
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, written by
Janet. U. Schneiderm an,
under the direction o f h e x dissertation committee, and
approved by all its members, has been presented to and
accepted by the Director o f Graduate and Professional
Programs, in partial fulfillment o f the requirements for the
degree o f
DOCTOR OF PHILOSOPHY
Director
jyate August 1 2 , 2003
Dissertation Committee
Chair
^ ___ _
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ACKNOWLEDGMENTS
I wish to extend my deepest appreciation for the guidance, inspiration, and
friendship of my dissertation committee chair, Dr. David Marsh. I would also like to
thank my committee members, Drs. Madeleine Stoner and Nelly Stromquist, for
their positive suggestions and ideas. I have had significant encouragement from my
colleagues at the USC Department of Nursing. I especially want to thank Dr. Wynne
Waugaman for her patience and motivation. I also want to acknowledge Dr.
Maryalice Jordan-Marsh for listening to my ideas and reading with a critical eye. I
have had tremendous support at home from my family and friends. My best
supporter has been my husband, Matthew Schneiderman. He has helped me in every
way possible, and even proofread the entire dissertation. I want to thank each of my
children, Mark, Ellen and Andrew. Their love and encouragement have meant the
world to me. I appreciate my sister Marcia Arnold’s support and love. Finally I want
to thank my friend, Linda Levinson, for being there to listen to me complain and
always saying how proud she was of my accomplishments.
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iii
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS
LIST OF FIGURES
ABSTRACT
CHAPTER
OVERVIEW OF THE STUDY 1
Introduction 1
Statement of the Problem 10
Purpose of the Study 11
The Importance of the Study 12
LITERATURE REVIEW 20
Health of Children Living in Foster Care 21
Foster Care Population 21
Recommendations and Policies Regarding
Health Care Needs 31
Nature of the Health Needs 34
Social Ecological Model of Health 38
Provision of Health Services in Foster Care 40
Types of Services Provided 41
Obstacles to Provision of Care 42
Interface Between Health Care, Child
Welfare and Justice System 46
Financing of Health Care 49
Developments in Coordination of Services 52
Organization Model 57
Roles of Community Health Nurses in Foster Care 59
History of Involvement of PHNs 60
Current Roles of PHNs 63
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iv
CHAPTER Page
School Nurses’ Role 66
Public Health Nursing and Community
Health Nursing 70
Interdisciplinary Work 72
Future Roles of Foster Care Nurse 73
Model to Evaluate the Foster Care Public
Health Nurse and School Nurse 76
3 RESEARCH METHOLOGY 80
Introduction 80
Sample and Population 85
Instrumentation 87
4 FINDINGS 103
Introduction 103
Discussion 166
5 SUMMARY, CONCLUSIONS, AND IMPLICATIONS 174
Summary 174
Selected Findings 179
Conclusions 185
Implications 188
REFERENCES 197
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LIST OF FIGURES
Figure Page
1 Relationship of research question to instrumentation 91
2 Public Health Interventions Relationship to
Social Ecological Model 93
3 Public Health Interventions II 95
4 Interview Guide for Research Question #3 based on
Bolman-Deal Organization Model 96
5 Intervention Results from Survey 121
6 Observation of Interventions Carried out by School
Nurses and Child Welfare Nurses 124
7 Comparison of Survey to Observations 127
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ABSTRACT
This is a descriptive qualitative study of nurses working with school-age
children in foster care in two organizational settings, school and child welfare. This
study describes what nurses want to do for this population, what they are actually
doing, the nurses’ view of their organization, and how the organization affects their
role. The study investigates whether the nurses adopt of the Social Ecological Model
of Health. The nurses’ practice is viewed in terms of the Minnesota Public Health
Intervention Model (PHI), which operationalizes the Ecological Health Model for
community nurses. The Bolman/Deal Organizational Framework provided the lens
to view the organizations by dividing them into four frames: structural, political,
human resource and symbolic.
The primary data source was interviews with nurses working in child welfare
and schools. Data about the actual practice of the nurses included a survey of the
PHI interventions and observations of nurses performing their jobs. Data was
analyzed using guidelines for phenomenological research. Four themes were derived
from the data. The first theme was all nurses lacked physical access to the population
of foster children. The second theme was differing views on the cause of poor health
of foster children. Child welfare nurses adopted the broad determinants of health in
the Social Ecological Model and wanted to do upstream and downstream
interventions. School nurses felt that the foster child’s health issues resulted from
being in the “system” and wanted to give standard care. Nurses had different
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approaches to practice; child welfare nurses wanted a team while school nurses
wanted independent practice. Finally, both groups had little political influence in
their organizations and were unable to improve care for foster children.
In conclusion, nurses who work with children in foster care need more
organizational support to provide comprehensive care. It was clear that the
organizations had significant influence on what nurses wanted or were able to do.
Since nurses increasingly are working in non-health settings and in host
environments, nursing faculty need to educate students about how to understand
organizations and create effective work environments.
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CHAPTER 1
OVERVIEW OF THE STUDY
Introduction
The foster care system in the United States has evolved over the last 150
years to become a complex patchwork of federal and state agencies that control the
fate of children living out of their homes and reared by adults other than their
parents. The child welfare system is responsible for the education, health and
welfare of over 500,000 children in the United States, with California having 20% of
the foster care population (Leslie et al., 2000). The exponential increase of children
in foster care is the result of a myriad of circumstances, most notably poverty among
families, drug and alcohol abuse in the home, identification of child abuse as a
causative factor for removal of children from the home, and the inability of parents
to care for “special needs” children. The demands on the child welfare system are far
greater than previously because of the increase in the foster care population, the
decreasing age of the children when they enter foster care, and the types of children
entering the system.
There is consistent and overwhelming evidence to support the idea that foster
care children have higher than expected rates of chronic illness (Barton, 1999; Schor,
1988; Stein, Evans, Mazumdar & Rae-Grant, 1996). Most children entering the
system have not had their physical, emotional, or medical needs met (O’Hara,
Church & Blatt, 1998). Research into the health and emotional needs of this
population has been consistently overlooked. Even foster children in kinship care
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(foster care provided by relatives) receive inadequate health care follow-up,
including immunizations, and had more rehospitalizations than children in general
(Gennaro, York & Dunphy, 1998). Often the health needs of foster children are the
result of prenatal drug exposure and/or neglect and compound the already chaotic
life of the foster child.
The child welfare system has been overburdened in caring for this increased
population of sick children. The child welfare system has failed to take charge of the
health and welfare of foster children, partly due to the disorganization within the
system and partly due to the lack of coordination between health, school and child
welfare systems. The lack of comprehensive, preventive medical care for foster
children has resulted from a multitude of factors including: foster care providers with
poor preparation to maneuver within a fragmented system, social workers
overburdened with high caseloads and lack of health training, and an uncoordinated
medical record system resulting in errors in immunization and under-treatment for
chronic conditions. Physicians have documented the poor health and inadequate
health care of these children and have tried to alert policymakers about possible
solutions (Chemoff, Combs-Orme, Risley-Curtiss & Heisler, 1994; Halfon, English,
Allen & DeWoody, 1994; Simms, 1991).
The solutions differ, but primarily call for system-wide improvement of
identification, treatment, and follow-up for children with physical, developmental,
and emotional problems. One solution that seems to be the most widely documented
and utilized in the United States is the health passport, an individual record for each
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foster child of health problems, treatments, health plan of care, and educational
information (Lindsay et al., 1993). The American Academy of Pediatrics (1994)
published standards for health care services for foster children, but these standards
are not met universally because of the lack of coordination both within the health
care system and between health care, child welfare and the schools. The frequent
movement of foster children from one foster home to another has also impeded
continuity of care (Institute for Research on Women and Families, 1998).
With all the attention drawn to the health of foster care children, California is
especially vital to improving the health of foster care. California has 10% of the
nation’s population but has 20% of the children in foster care (Leslie et al., 2000).
Therefore, California provides a showcase for the problems that these children and
their families endure. There is a lack of a statewide system in California for
provision of health care to foster children (The Institute for Research on Women and
Families, 1998). The long-term effort on the part of child advocates all over the
country to both increase society’s and the health care system’s awareness of health
care needs of foster children and their families has led to increased allocations of
funds, specifically for nurses. California has appropriated money, matched on a
federal level, to hire public health nurses to help implement a better-coordinated and
responsive system. (Almquist, Cambaliza, Johnson & Ward, 2001).
The difficulties meeting the health care needs of foster care children and the
proposed solutions call for a new way at looking at health and health care. Viewing
health issues from a Social Ecological Model accounts for both the causes of illness
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and proposes new ways to promote holistic health, prevent illness, and treat
patients. The emphasis is caring for individuals, families and communities prior to
their descent into illness. This model takes into account age, gender, race, ethnicity
and socioeconomic differences that affect how individuals function and grow, and
therefore directly and indirectly influence heath risks and resources (Institute of
Medicine, 2000). These demographic and societal issues are some of the same
causes of the burgeoning population of foster care children.
The Social Ecological Model’s emphasis on identifying what factors are
causing people to be ill is conceptualized as treating people upstream rather than
downstream. The goal of health care using this model is to identify and intervene on
a primary prevention (upstream) level to increase the health and welfare of
individuals. This is far different that the current child welfare and health care
systems’ emphasis on tertiary treatment (downstream interventions). An example of
this upstream emphasis is spending health care dollars on decreasing teenage
smoking rather than paying for lung transplants. The social ecological model
identifies those groups that are at most risk for injury and disease and recommends
special attention be given to at-risk groups. The foster care children certainly fall
into special needs, high-risk population.
The environment (social, political and economic) is an important part of the
equation is determining health in the Social Ecological Model (Lomas, 1998).
Research studies on the causes of foster care, the increasing health needs of foster
care children, and the inability to meet those health care needs mirrors the
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importance the Social Ecological Model places on environment. Poverty and a
deinvestment of social capital, more specifically social trust and social cohesion, are
related to poor health, mortality and the increased need for tertiary, acute care health
(Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997). These same variables are
related to the poor health and health care of foster care children. Treating the
environmental factors in health will greatly increase the likelihood of less attention
and money spent on downstream interventions.
The Public Health Interventions (PHI) Model described by the Minnesota
Department of Health (2000) operationalizes the Social Ecology Model for
community health nurses, including the new foster care nurses and school nurses.
This intervention model focuses on the broad determinants of health (e.g., income,
social status, housing, food security, social support networks, education,
neighborhood safety, cultural customs, and community capacity of support family)
and on prevention. The social, political and economic environments of the Social
Ecological Health Model are the same as the broad determinants of health in the PHI
Model. The model emphasizes the focus on population-level interventions,
identification of the at-risk groups, and assessment of health status to determine
health needs. The practice arena of the nursing interventions includes individual and
family, community, and system-wide.
The PHI Model specifies 17 interventions that are independent functions of
the nurse. The primary emphasis of the interventions is the role of the nurse in
health teaching and counseling as well as case management. The model has specific
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interventions that emphasize health promotion, identification of clients at risk,
screening for health problems, and early treatment of health issues. These activities
reflect the Social Ecological Model of Health’s emphasis on upstream interventions.
The specific interventions are organized in a wheel format with five related
categories. Case finding is part of the interventions of surveillance, disease and
health event investigation, outreach and screening. Case management is related to
referral and follow-up, and delegated functions. The third category groups health
teaching, counseling and consultation. Community focused interventions included
collaboration, coalition building and community organization. The fifth category of
system-focused interventions include advocacy, social marketing and policy
development and enforcement (Minnesota Department of Health, 2000).
The Social Ecological Model and the Minnesota Public Health Interventions
are incorporated in the job descriptions of the new cadre of public health nurses
(foster care nurses) employed by the Health Care Program for Children in Foster
Care (HCPCFC), administered by Child Health and Disability Program (CHDP)
(Department of Social Services, 1999b). The HCPCFC nurses in Los Angeles
supplement the Los Angeles County Department of Children and Family Services,
which employs a small number of nurses who had been working in child welfare
prior to this new statewide program. These foster care nurses join the school nurses
in providing health care to school-age foster children in Los Angeles County, which
has 65,000 of the more than 110,000 children in foster care in California (Institute
for Research on Women and Families, 1998).
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The role of public health nurses historically in child protective services has
been to work in concert with the social worker, the legally mandated case manager
(Smart, 1999). The role has been somewhat limited and often problematic because
of the large numbers of cases and the PHN’s propensity for hands-on interventions
rather than the case management approach needed to work within the child
protective services milieu. Nurses have been looking for ways to meet the health
care needs of this population. Advanced practice nurses have identified the foster
care population as needing their care, but have yet to find access to these children
(Carlson, 1996). There is the real potential for dramatically improving the health
care of foster children with the addition of these foster care nurses. The child to
nurse ratio in Los Angeles County Child Welfare System will go from 2,500 children
per nurse to a much more manageable ratio of 250-500 children per nurse (Almquist,
Cambaliza, Johnson & Ward, 2001)
School nurses are an integral part of the health system for school age foster
care children. The school nursing role has expanded from primarily health screening
and primary prevention in the 1970’s to include problem management, physical and
psychological health, and environmental health (Kozlak, 1992; Parsons & Felton,
1992). Nurse practitioners, advance practice nurses, are increasingly being
employed by schools to provide primary care for children in school-based health
centers (Brindis, Sanghvi, Melinkowvich, Kaplan, Ahlstrand, & Phibbs, 1998).The
physical and psychological health of children directly impacts the ability to succeed
academically and socially in the school environment (Passarelli, 1994). School-age
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foster care children are continually connected to the school system even when there
are changes in family placement. Therefore, the ability of the school nurse to
advocate for the child, provide case management for health issues, and teach health
promotion to the foster child and his family is important to increase the health of
foster care children.
Both school nurses and foster care nurses practice community health nursing.
Community health nursing practice is a philosophy of providing care to individuals,
families, and groups wherever they are located. The emphasis is on community as a
location and includes the idea of partnerships with clients (Alexander, 2001). Public
health nursing is a specific type of community health nursing that includes more than
just the site of practice (e.g., school) and includes the emphasis on type of practice
and level of intervention (systems, community and individual/family) (Minnesota
Department of Health, 2000). School nurses in California are baccalaureate prepared
and practice public health nursing in schools (Clark, 1999). Therefore both school
nurses and child welfare nurses have the same type of education and training.
The new foster care nurses and the school nurses have the opportunity to
address some of the concerns raised in reports lambasting the existing system of
health care delivery to foster care children within both Los Angeles and California
(County of Los Angeles, 1992; Department of Health Services: Little Hoover
Commission Report, 1999; Institute for Research on Women and Families, 1998).
The nurses’ ability to meet the health care needs of this vulnerable population will
depend on their ability to function in their case management role, chose applicable
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interventions, and function within the child welfare system and school systems.
The Social Ecological Model of Health and the PHI Model provide a powerful
framework for nurses to deliver care to school-age foster children.
Improvement of the health care of foster children in California can be
impacted by the work of nurses. The foster care nurses and school nurses need to
collaborate with each other and will have to work closely with the social worker in
the child welfare system, an organization with its own set of issues and problems.
The popular literature and newspapers are witnesses to the result of the inability of
the child welfare system to function effectively and protect their charges, the foster
children. The health problems of foster children even spill over into the justice
system and immigration system (League of Women Voters of California, 1998).
Some of the problems in the health care arena stem from the social workers lack of
health training and the shortage of social workers to do the job (National Association
of Social Workers, 2001). The foster care nurses and school nurses have the task of
working in systems (school and child welfare) that historically have been unable to
coordinate the delivery of health services and have no systematic way of interfacing
with the health care delivery system (League of Women Voters, 1998).
The new foster care public health nurses must navigate their way in an
organization, the Child Welfare System, steeped in tradition and suffering from
overworked employees and poor outcomes. The school nurses must coordinate the
mandated preventive care, work with parents and teachers to insure health
promotion, and provide illness care in an organization, the schools, with its own set
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of difficulties. School organizations are complex systems with unique political
and governance structures that affect how the nurses’ function in their roles
(Passarelli, 1994). The organizational climate of the setting in which nurses work
will influence their ability to affect change and function fully in their roles.
The Bolman and Deal (1997) framework for organizations will provide a lens
to look at how nurses function within the child welfare system and the schools. The
structural, human resource, political and symbolic frameworks will allow the
researcher to explore the nurses’ experience working within the child welfare system
and the schools. An analysis of the frameworks can identify the prominent
framework of the organization and whether the frameworks of the organization
enhance or detract from the ability of the nurse to function fully in their roles.
Statement of the Problem
The application of the Social Ecological Model of Health by foster care
nurses and school nurses has the potential to dramatically affect the health and health
care of school-age foster care children. This health model holds promise for
directing interventions more upstream and improving the health promotion of this
population of children. The effectiveness of community health nurses working with
school-age foster care children and their families will depend on the nurses’ ability to
provide appropriate interventions (as specified in the Minnesota PHI Model) within
the context of the child welfare system and the school system. The organizational
context of practice will provide a backdrop for adoption of a health promotion
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philosophy. Nursing educators will need to prepare nurses to work in
organizational settings such as schools and child welfare where the nursing
workforce is not dominate.
It is unknown what the nurses working with foster care school-age children
intend or want to accomplish with their interventions. It is unclear whether school
nurses and foster care nurses’ intentions mirror the Social Ecological Model of
Health. It is also unknown what exactly these nurses are doing (what interventions
they are practicing) in their roles in caring for foster care school-age children. It is
unknown whether the similarities or differences between the organizational context
(Child Welfare vs. School) in which the nurses’ work affect their ability to assume
their role. Finally it is unclear whether the organizational context affects the actual
practice of the nurses in terms of their choices of interventions, types of clients
(cases), and communication.
Purpose of the Study
In light of the research, it is important to analyze the experiences of the
nurses working with school-age foster care children. The purpose of the study is to
investigate whether nurses adopt the theoretical framework of Social Ecological
Model of Health and whether their practice is theory-based. The study will look at
this potential for theory-based practice in two organizational contexts, the Child
Welfare System and the School. The study will investigate whether the
organizational context buffers or enhances the ability of the nurse to carry out his/her
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role and whether the organization affects communication, case finding and choices
of actual interventions.
Research Questions:
1 . What do nurses want/intend their role to be in providing health
promotion/education for foster care children and their families and how are
these role perceptions similar or different between the school setting and the
child welfare setting?
2. What strategies and interventions do nurses actually use in their role of
providing health promotion/education for foster care children and their
families?
3. What similarities or differences of the organizational structure of schools and
the child welfare system affect nurses’ role in the health of foster care
children and their families?
4. How does the organizational context of the school and the child welfare
system affect the nurses’ choices of services, clients and communication?
The Importance of the Study
The Study will give a better insight to how a theoretical framework is
implemented in very different organizational contexts. This study may have
implications for policy by viewing how the success or failure of adoption of a
theoretical framework can depend on both the views of the implementers (nurses)
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and the organizational context in which they work. The sample population of
nurses who provide health care for school-age foster care children is especially
useful since the complexity of the problem and the proposed solution mirror many
other policy issues and solutions. The findings will help provide an explanation of
what frameworks or parts of an organization enhance the nurse’s role and what
frameworks hinder adoption of the role.
The Social Ecological view of health is a powerful model for health care for
foster care children. This model reflects many of the findings of the research into
how to “solve” the health problems of foster care children. Political and health
policymakers profess the need for a greater emphasis on upstream interventions for
this patient population. The study will evaluate whether the practitioners (nurses) are
grounded in the concepts of the model and whether their actual practice mirrors this
model.
Nurse educators are another important audience for the study. Community
health faculty members teach the theoretical concepts of primary prevention (a
hallmark of the Social Ecological Model) to nursing students. It is important to
evaluate whether this concept is accepted by practicing nurses and actually used in
the practice setting. Nursing education, especially on the baccalaureate level, has an
emphasis on holistic health and the social determinants of health. The sample
population of nurses all has a baccalaureate education and, therefore, nurses’ views
on their role and their practices are relevant to evaluate if practice reflects
educational content.
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There are specific implications for the actual organizations studied and the
nurses themselves. The nurses will be able to identify those individual cases or
aggregates that they feel benefit most from their work with school-age foster
children. This will allow the nurse better prioritization of interventions. Other
members of the organizations will better understand the nurses’ role within the team
and be able to work in concert with them. This study will give the leaders of the
organizations a clearer picture of what nurses want to do and what they are actually
doing. Nurses and organizational leaders will also have a better idea how their
organizational structure helps or hinders the nurses’ work.
There are no studies evaluating this new role for foster care nursing,
especially in its reincarnation (from the 2000 funding of HPCPFC) with reduced
foster child to nurse ratios. The study may identify new ways for the social workers,
foster care nurses and school nurses to work cooperatively. Social workers have not
been successful in the identification of health care needs nor making sure the
children obtain the health care to meet those needs. The employment of nurses in the
foster care system can alleviate some of the strains on the child welfare agencies if
the social workers and nurses work together. School nurses are mandated by state
law to provide specific preventive services for school children. This study can
suggest how the foster care nurses and school nurses and social workers are working
together and how they can better work together in the future.
The administrators of both Child Health and Disability Program, Department
of Child and Family Services and school district can benefit from this study. The
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State of California currently has guidelines in which the foster care nurses are to
function. School nurses have job descriptions that detail their role responsibilities.
Looking at these guidelines in the light of the experience of foster care nurses and
school nurses may result in changes and amendments to these guidelines. In
addition, the study can help the organizations better refine job descriptions,
understandings between departments, and evaluation criteria for the nurses.
Limitations:
The importance nurses play in improving the health care of foster children
may be incorrect. The study will only investigate nurse’s perception of his/her effect
on the health care delivery to foster children. It will not consider the role of
physicians or other health care team members. The study will analyze the
organization only from the nurses’ viewpoint. Although a social worker will be
interviewed in terms of their perception of the nurses’ role, their participation in the
health care delivery of foster children will not be studied. The size of the sample is
small and may limit generalizability of the study. Limitations of the descriptive
qualitative format are inherent in this study.
Delimitations:
The investigation will use one county, Los Angeles, to investigate the
questions, which may limit the generalizability to other locales. Although a
longitudinal study would provide more in-depth information, time restraints to
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conduct the study prohibit this approach. Not all nurses in the child welfare
system or school district will be interviewed. A purposive sample of key and general
informants will be selected.
Assumptions:
This study assumes that nurse subjects in the study were knowledgeable
about their job responsibilities. The subjects of the study were assumed to respond
honestly to face-to-face interviews. Nurses who work in different agencies, CHDP
and DCFS, are assumed to have similar role responsibilities. The supervisors of the
nurses are assumed to be knowledgeable about the nurse’s job descriptions, role
responsibilities and their relationship to the organization in which they work. It is
also assumed that data collection techniques such as interviews, observations and
survey would provide valid and adequate data for the purposes of this study. Finally,
even though the nurses working in Child Welfare and Schools are assumed to have
similar education and training, the nurses’ choices about work settings may reflect
differences in personalities.
Definitions:
The following terms are presented to provide consistent definitions and
operationalize their meaning for the study:
Advanced practice nurses: Registered Nurses with a master’s degree education in a
specialty area of nursing (e.g., pediatrics, psychiatric nursing, anesthesia, midwifery
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family nurse practitioner). Some specialty training programs require licensure
exams either at a state or national level.
Bolman-Deal organizational model: a theoretical framework to view organizations.
Data are divided into four frames: structural, human resource, political, and
symbolic.
Case management: activities aimed at assisting a child and their family access and
delivery of appropriate, individualized health care across many settings in a cost
effective manner. The purpose of case management is to increase the quality of life.
Child Welfare System: governmental agencies that assume responsibility for the
protection of children’s welfare. Activities include supporting and preserving
families, investigating reports of abuse or neglect, protecting victimized children,
and assisting children temporarily or permanently removed from their parents’
homes. In Los Angeles County, the County Child Welfare service program is called
Department of Children and Family Services (DCFS).
Child Protective Services: the services provided by the Child Welfare System.
Downstream interventions: Social Ecological Model health care interventions for
individuals, families and communities once health problems have occurred. Includes
tertiary acute care health delivery.
Foster care: out of home placement in temporary residential care provided to a minor
child as a result of neglect or dependency hearing; residence care can include care by
a non-biological foster family, kinship care, group care, residential care, or
institutional care.
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Kinship care: children in the foster care system living with relatives other than
their parents.
Health Care System: organization of health care delivery to individuals, families, and
communities over the entire spectrum of health from wellness to illness
Primary prevention: interventions aimed at health promotion and disease prevention
Public Health Interventions Model: community health intervention model developed
by the Minnesota Department of Health. Lists 17 specific interventions public health
nurses practice in caring for individuals and families, communities, and systems.
Public health nurse: (In California) Registered Nurse with state-issued certificate as a
public health nurse and a Baccalaureate degree in Nursing. The PHN’s educational
program needs to include community concepts, home visiting, epidemiology, family
theory, and child abuse information.
School nurse: Registered Nurse who works in the school to provide health care and
health education to school children and their families for the purpose of increasing
wellness, preventing disease, and promoting health and safety.
Social Ecological Health Model: Framework to look at health and health care in
terms of importance of holistic health, social/political/economic environment as the
determinant of health, and emphasis on treating patients before they become ill.
Social worker: individual with a Baccalaureate Degree with the professional
responsibility to enhance the well being of children, families and communities. In
DCFS, the social workers are called Child Social Worker (CSW). In DCFS the
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CSWs are not required to have a social work education, i.e. do not have a master’s
degree in social work.
Upstream interventions: health care policy recommendations in the Social
Ecological Health model that encourages health interventions prior to individuals,
families or communities suffer from health issues or problems.
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CHAPTER 2
LITERATURE REVIEW
The use of nurses as members of the team of professionals supervising the
care of foster children in the United States is relatively recent. Nurses have come on
board to help solve the health care issues plaguing the population of children now in
foster care. The children’s needs are well documented, but the effectiveness of
nurses in the foster care field is relatively unexplored. This chapter will provide
background information by reviewing the health issues of foster children, the
provision of health care services for this population, and the role of community
health nurses in the schools and the Child Welfare System, the system legally
responsible for the organization and supervision of children in out-of-home
placements.
Foster care is the temporary, planned placement of children away from their
parents to strengthen families and improve the quality of life of the child. Child
Welfare agencies take responsibility for the health, education and well being of the
child while providing counseling and support for the parents, with the final goal of
family reunification. If it is determined after an investigation that it is in the child’s
best interest not to reunite with their parents, parental rights are terminated and
adoption is considered. When reunion or adoption is not possible, some children
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remain permanently in the foster care system until they reach adulthood (Schor,
1988).
Health of Children Living in Foster Care
The increase in population of foster children in the United States is a result of
changing demographics, legal and monetary incentives for foster care, stress placed
on indigent families, the lack of political support for legislation to support families,
and the recognition of child abuse and prenatal drug use as causative factors for entry
into foster care. The health care needs of children in foster care are increasing
because the population is expanding, and because the children who are placed into
foster care are more acutely sick at the time of placement and suffer from more
physical and emotional chronic illnesses. The reasons for the poor health of foster
children are varied, but the Child Welfare System and health care system does not
have a workable solution to prevent health problems from occurring or to treat those
problems that children bring with them when they enter foster care. Viewing these
health issues of foster children through a social-ecological lens allows for a better
understanding of the causes of poor health within the environment (psychological,
economic, and physical) of the child, the family, and the community.
Foster Care Population
History
Children have lived out of the home and have been reared by adults other
than their parents throughout American history. In colonial times, children from all
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classes of families were indentured for the purpose of learning a trade as well as
for the provision of care for children of impoverished families. In the 1850’s,
“placing-out” of children was begun to primarily move children from poor urban
centers to rural areas, fueled by anti-immigrant and anti-urban fever. By the 1880’s,
some agencies (e.g., Boston’s Temporary Home for the Destitute) began paying
adults to provide care for children with special needs. This system of boarding out
evolved into the modem system of foster care as government became more involved
in protecting the welfare of children (Hacsi, 1995).
During the 20th century, the role of the United States government in terms of
child welfare grew and evolved. The system of boarding-out began to be known as
foster care and was tied to the growth in the juvenile court system (Hasci, 1995).
Hasci wrote that even though the courts professed to favor maintaining families, they
were prone to remove children rather than provide financial aid to mothers in the
early 1900s. A White House Conference in 1909 on Care of Dependent Children
concluded that poverty alone was not a reason to take a child from his/her parents,
and recommended that carefully chosen foster care families be selected rather than
the use of orphanages or the shipping the children westward via the railroads
(Rosenfeld et al., 1997). The 1935 Social Security Act provided financial aid to
indigent families and allowed poor families to keep their dependent children. Title
IV-A, Aid to Dependent Children, was a component of the Social Security Act and
eventually was amended to include assistance to certain relatives as well as the
parent and was changed to its current name, Aid to Families with Dependent
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Children (AFDC) (Schor, 1988). The governmental financial support of families
as well as the prosperity following World War II kept the numbers of children in out-
of-home placement stable at approximately 250,000 until the 1960’s (Rosenfield et
al„ 1997).
The publishing of the “The Battered Child Syndrome” in 1962 began the
dramatic increase in the number of child abuse reports and abused and neglected
children were moved out of the home against their parents’ wishes (Rosenfeld et ah,
1997). Foster care moved from a primarily voluntary system to a non-voluntary
system. Along with child abuse reporting, came a change in the structure of the
family. More children who lived with only their mothers and fathers were absent
from the home. The number of AFDC-supported children increased from 3.6 to 8.1
million from 1967 to 1976 (Schor, 1988). Also an amendment to the Social Security
Act, Titles IV-B and XX, made federal money available to foster care (Hasci, 1995).
More children were removed from the home and the foster care population exploded.
By 1971, the number of children in AFDC foster care jumped to over 100,000
(Hasci, 1995).
The rise in the population of children in foster care in the 1960’s was
accompanied by changes in the housing location and length of stay. The increased
involvement of the government led to less institutional care and more boarding with
families. By 1950, more children were in homes than institutions and by 1960, twice
as many were in foster care than in institutions (Hasci, 1995). But removing children
from institutions did not solve children’s problems, especially for those who were
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removed due to child abuse. Rather than a temporary solution, the length of foster
placement increased and there was a lack of permanency in the placement (children
often moved from home to home) (Rosenfeld et al., 1997). The Adoption and
Assistance and Child Welfare Act of 1980 mandated increased efforts to keep
children in their own homes, but this legislation has not proved effective (Leslie et
al., 2000).
The numbers of children in foster care have increased exponentially. From
1982 to 1995, it is estimated that there was a 60% increase to 480,000 children.
Current national estimates are over 500,000 children. California, with 10% of the
national population, has 20% of the foster care population (Leslie et al., 2000). The
numbers of children in and out of home placement in California are especially
alarming. From 1984 to 1993, the number of children in foster care increased from
37,306 to 85,000, and the average age at placement decreased from 10.3 years to 6.7
years (Halfon, Mendonca & Berkowitz, 1995). Racial and ethnicity disparities exist
between the foster population and the general population. By 1990, 61% of the
foster children were African-American, Native American and Latino even though the
non-white population was only 19% of the general population (Rosenfeld et al.,
1997).
The governmental role in child placing has contributed to this dramatic
increase in foster care. The political nature of the United States government has led
to a patchwork system of support for at-risk families and partisan influence in AFDC
and Social Security funding. The nature of political ideology about families,
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children and the proper role of government changes with elections but there is the
constant that family autonomy should be upheld. This belief in the nature of family
is reflected in the over-arching policy of reunification, temporary placement, and
safety of the child. Adoption is often postponed or never offered to try to keep
families together. Also, the government has not stepped up to the plate to address
problems that lead to inadequate childcare in the home; e.g., child-care for working
moms, making the single-parent family even more at risk for the need of foster care.
Kinship Care
Large numbers of children today reside in legal placements with relatives
other than their parents. Prior to the 1980’s, foster parents were not related to their
foster children, yet in the 1990’s almost 50% of foster care take place in a relative’s
home (Rosenfeld et al., 1997). In California, it is estimated that two-thirds of the
increase in foster care placements from 1984 to 1992 can be attributed to the increase
of children placed in relative’s homes (Tyler, Howard, Espinosa, & Doakes, 1997).
This type of placement is referred to as relative foster care, relative family care, or
kinship care.
Kinship care is now often preferred by the legal system. Although relatives
do not have any obligation to care for extended family members, they are
increasingly more likely to assume that responsibility. In some states, relatives must
go through the required training and licensure to be considered as foster parents for
the child, but in California this training is not required. There is some evidence that
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kinship foster homes in California provide less than adequate care. Child welfare
workers noted that approximately one-third of the kinship homes fell below the
standards in the average foster family home (Berrick, 1998). Children in kinship care
have longer placements, are less likely to receive needed health care, and allow for
more unsupervised contact with the parent who may be abusive or neglectful
(Rosenfeld et al., 1997).
Some of the kinship caretakers are grandparents. The near doubling of life
th
expectancy over the 20 century has left the United States with a large cadre of
grandparents. Vem Bengtson, a professor of gerontology and sociology at The
University of Southern California, has done a 30-year study on multigenerational
bonds. He has found that more grandparents than ever are raising their
grandchildren and estimates that the current number is 5 million. He writes, “The
most striking case I know of is a grandmother who’s raising all 13 of her
grandchildren. Both daughters are in jail and her son is abusive, so all of her
grandkids have ended up in this woman’s household” (Blakeslee, 2001, p. 11).
Kinship care has been informally used by parents for a long time. The
formalization of kinship care has gained favor because of changes in the laws,
financing of foster care, and the increased numbers of children needing care. There
is a shrinking number of available foster homes due to changes in American family
structure (single-parent families), increase in working women and divorces, and the
rising cost of child rearing. Child welfare workers have changed their attitude from
distrust in kinship care based on the belief that maltreatment and poor parenting were
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familial, to the recognition that connections to the birth family and cultural milieu
are important to a child’s upbringing (Rosenfeld et al., 1997). Probably the most
relevant change has been the ability to provide federal funding for kinship care. In
1979, the U.S. Supreme Court ruled that kinship foster parents should be eligible for
payments the same as non-kin foster parents. Each state has interpreted this ruling
differently, but California has a very similar payment scale for both groups of foster
parents. The AFDC payments are lower for poor families than the subsidies for
foster parents (Berrick, 1998).
Social-Economic-Health Causes o f Increased Foster Care
Experts agree that family poverty is highly related to the placement of
children in foster care (American Academy of Pediatrics, 1994; Rosenfeld et al.,
1997; Shor, 1988). Catalano, Lind, Rosenblatt and Attkinsson (1999) found there
was an inverted U relationship between monthly increases in the unemployment rate
and changes in the prevalence of foster home placements in California from 1984 to
1996. This means that as the unemployment rate goes up so does the foster care
population. The researchers propose that “provocation,” (unemployment provoking
behavior that is corrosive to family life, e.g., abuse and neglect of children) is seen
when unemployment rises. Conversely, “inhibition,” (violence and alcohol abuse
decrease among a person who are employed in stable jobs) is more likely when
unemployment is low.
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The cycle of poverty and foster care has a relationship to homelessness.
Since the mid-1980’s, homeless women and their children have become one of the
major growing factions in the homeless population (Bassuk, Dawson, & Perloff,
1997). Bassuk et al. (1997) researched female-headed families becoming homeless
and found that a woman’s childhood experience of foster care was a risk factor for
adult homelessness. The researchers hypothesized that foster care might interfere
with the formulation of secure attachments and might not provide the skills and
supports for becoming a self-sufficient adult. Also children who enter the foster care
system due to homelessness are more likely to have siblings in the system than other
foster children (Zlotnick, Kronstadt, & Klee, 1998). There seems to be an
intergenerational cycle between homelessness and foster care.
Drug and alcohol abuse is another factor in removal of children from the
home. In many California counties, 70% of the foster care cases involved prenatal
drug exposure or parental drug or alcohol abuse (Halfon et al., 1995). It is estimated
that nearly 5% of the 4 million women who gave birth in 1992 used illegal drugs
while they were pregnant (Bums, 1997). In a study conducted in Los Angeles
between 1989-1991, the researchers noted that the population demographics of
women using drugs during pregnancy differed significantly than those non-users
(Lewis, Leake, Giovannoni, Rogers, & Monahan, 1995). The women were more
likely African-American, raised in a single-parent (mother only) household, and
homeless. They were more likely to have been in jail, engage in prostitution, and
have multiple sexual partners. The connection of homelessness, substance abuse and
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subsequent neglect was confirmed by Zlotnick et al. (1998) in their descriptive
study of foster children in Oakland, California. This epidemic has serious
repercussions both on the health of the fetus and placement of the child. Prenatal
drug exposure harms the health of children and brings them into foster care earlier in
their life.
Child abuse and neglect has increasingly become the primary reason that
children are removed from the home and placed in foster care (Halfon, Berkowitz &
Klee, 1992). Child abuse and neglect is often combined with poverty, homelessness,
and drug use. In a research study of mothers who were substance abusers by Tyler,
Howard, Espinosa and Doakes (1997), the researchers noted that there were more
reports of suspected child abuse and neglect during the first 6 months of life in those
babies who remained with their mother than those who were put in kinship foster
care. The birth mothers had a comprehensive home and center-based treatment
protocol in effect. Chemoff, Combs-Orme, Risley-Curtiss, & Heisler (1994) studied
a large cohort of children (2,419) entering foster care in a mid-size city (Baltimore,
MD) and found that neglect contributed to placement of about one-half of the
children and physical abuse was cited for one-fourth of the children. Although these
statistics are very alarming, for more than 46% of the children, more than one reason
was given for their entrance into foster care. This high prevalence of abuse as a cause
for foster care is confirmed in England and Wales where 80% of the surveyed
children from 1990-1995 were abused prior to entering foster care (Hobbs, Hobbs, &
Wynne, 1999). Takayama, Wolfe and Coulter (1998) found that child neglect or
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abandonment was also related to parental psychiatric illness and incarceration as
well as substance abuse.
Health problems in children can also be a contributing factor to their entrance
into foster care. “Special needs” children require additional attention from a
caregiver and close monitoring from health professionals (Chemoff et al., 1994).
Sometimes parents whose lives are stressed anyway find caring for these children
impossible. The risk factors of developmental delays overlap with many of the
causes of foster care; e.g., prenatal drug exposure and neglect. Children who are
severely delayed may further frustrate the already financially, socially, and
emotionally stressed parent. Takayama, Wolfe, and Coulter (1998) found an
association between behavioral and emotional problems and the reason for foster
placement. The increased need for foster care homes for children with developmental
disabilities was the direct result of the deinstitutionalization movement of the 1960’s
(Rodriguez & Jones, 1996). The emergence of a specific health problem, acquired
immune deficiency syndrome (AIDS), is associated with an increased need for foster
care placement (American Academy of Pediatric, 1995; Carlson, 1996; Leslie et al.,
2000; Schor, 1988). The presence of AIDS among women and young children has
exacerbated foster care needs, but possibly the advent of new drugs, e.g., protease
inhibitors, may decrease that need over the next decade.
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Recommendations and Policies Regarding Health Care Needs
As the population of foster children has undergone a tremendous escalation
over the past 20 years, the health care needs of that population have also grown. The
existing patchwork Child Welfare System and health care system has not kept up
with meeting those needs. Various private and public organizations have
investigated the health care needs of foster children and provided a “call to arms” of
forces involved in foster care. The calls have been loud and forceful, but not always
heard by the powers of government or leaders within the health care systems.
The Los Angeles Department of Children’s Service (DCS) began in the
1980’s to recognize the unmet health needs of foster children. They noted a dearth
of private physicians willing to see foster children. To respond to that need, the DCS
published a roster of private providers who had agreed to provide care for foster
children either utilizing MediCal Child Health and Disability Prevention (CHDP) or
for free. In 1991, DCS launched an educational initiative to assure a complete
physical assessment within 30 days of placement in foster care and periodic medical
examination, and began to develop a revised system for medical record keeping
increasing continuity of care (County of Los Angeles, 1992).
The County of Los Angeles (1992) submitted recommendations to the Robert
Wood Johnson Foundation, Kaiser Family Foundation and Stuart Foundations for
reorganization of the child protective system in Los Angeles. The proposal, in
reference to health care, was designed to improve the physical and mental health,
decrease impairments, and control the cost of health care of foster children. They
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32
noted that health care needed to be coordinated into a community-based, family-
oriented, culturally sensitive system that was responsive to the needs of the high-risk
child. The proposal called for an interdisciplinary approach with an initial
comprehensive assessment with intermittent reassessments and communication with
the primary care provider. The model of health care included public health nurses
(PHNs) as the case managers serving from 200-300 children each. The authors
envisioned a public-private partnership to coordinate the entire health system. This
proposal included an extensive piloting period, timetables for complete
implementation, and system to coordinate services between the DCS, Department of
Health Services, and the Department of Mental Health. According to Jeanne Smart,
a senior policy analyst for Los Angeles County, this reorganization plan was never
accepted or implemented (Personal Communication, February, 2001).
In 1994, the American Academy of Pediatrics issued standards for health care
services for foster children. The Academy had consulted with the Child Welfare
League of America in 1988 to develop initial health standards for foster children.
The tremendous increase in foster care along with the increase in the complexity of
the health needs necessitated more comprehensive and prescriptive policies. The
components of the standards included initial health screening, comprehensive health
assessment, developmental and mental health evaluation, monitoring children’s
health status while in placement, and the transfer of medical information. The
Academy recognized that pediatricians who provide care for foster children need
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33
more time for the visits, must coordinate the care with social workers and foster
parents, and may not have health histories to guide the care.
The Institute for Research on Women and Families (1998) located at
California State University, Sacramento issued a Code Blue (severe medical
emergency) for the health services for children in foster care. They determined that
the health care system for foster children did not exist in California and urged the
State Legislature and Governor to plan such a system. The Code Blue document
reiterated many of the same recommendations first proposed in 1992 by Los Angeles
County, but went farther in prescribing how such a system could work on both the
state and local level. Again they called for PHN’s to coordinate the children’s
physical, dental, mental and developmental health. The primary goals of the plan
were to: increase Medi-Cal eligibility, increase the pool of providers, educate foster
care providers, improve local coordination and delivery of services, and hire foster
care PHNs.
Soon after the release of the Code Blue document, the Little Hoover
Commission, an independent state oversight agency, released a report entitled, “Now
in our hands: Caring for California’s abused and neglected children” (Department of
Health Services: Little Hoover Commission Report, 1999). The report noted that
more effort was being put into removing children after abuse occurred into foster
homes rather than preventing the abuse from occurring. Many foster homes did not
provide the refuge these fragile children needed. The report urged that the
Undersecretary of the Health and Human Services Agency refocus attention on
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coordination of services in foster care and reorganization of funding streams for
foster children.
The pressure to “do something” about the health care of foster children
resulted in legislation that directed the State Department of Social Services to
establish public health nursing in child welfare. The enacted legislation was
Assembly Bill 1111 Education: Budget Trailer. Sharon Leahy, the Program
Specialist in the County of Los Angeles Department of Children and Family Services
(DCFS), explained that the Budget Act of 1999 appropriated a total of 2.48 million
dollars from the state general fund ( Personal Communication, April, 2000). The
money was put in the California Department of Social Services Budget and funding
began on January 1,2000. The Health Care Program for Children in Foster Care
(HCPCFC) is being administered by CHDP but housed in DCFS offices and the
probation department. The current funding for fiscal 2000-2001 consists of state
funds of $1,963,269 and federal (Title XIX) funding of $4,674,420 (Almquist,
Cambaliza, Johnson, & Ward, 2001). (Please note that the Department of Children
Services, DCS, is now called the Department of Children and Family Services,
DCFS.)
Nature of the Health Needs
As the factors associated with entry into foster care have changed and
increased, so have the health problems of foster children entering the system. The
complexity and magnitude of these health needs were part of the driving force to
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35
change policy, fund health care initiatives, and to involve a larger health care
team. There is consistent and overwhelming evidence to support the idea that foster
care children have higher than expected rates of chronic illness (Barton, 1999; Schor,
1988; Stein, Evans, Mazumdar & Rae-Grant, 1996). These health care needs include
physical, developmental, and mental health disorders. Many of the health care needs
are related to prenatal factors and the family social circumstances during
preplacement. Most children entering the system have not had their physical,
emotional or medical needs met (O’Hara, Church & Blatt, 1998).
Physical Health Needs
Physical health needs include both minor and major illness and conditions.
Minor conditions that are common in foster children include skin problems often a
result of current and past infections, impetigo, and diaper rash (Chemoff et al.,
1994). Health care screening and primary prevention is less often up-to-date in
children entering foster care. Dubowitz, Feigelman & Zuravin (1993) found that
children in foster care are often not adequately immunized and have problems
receiving adequate vision and hearing screening and dental care. Chemoff et al.
(1994) confirmed that 30.8 percent of the foster children under six years had delayed
immunizations. Even foster youth in shelters have poor compliance with
immunizations, with only 10.7% of the youth with up-to-date immunization records
(Ensign, 2001).
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Prenatal factors that predispose infants to physical health problems
primarily include drug abuse and physical abuse. Halfon et al. (1995) performed
health assessment on a cohort of foster children, with 94% having prenatal drug
exposure. Twenty percent of these children had a growth abnormality. Eighty-five
percent had at least one major medical problem; infections/parasites, respiratory
disorders and injuries were the top three problems. Infants had the greatest number
of chronic conditions (averaging 2.6) and asthma was diagnosed in 16% of all the
children. Simms and Halfon (1994) noted that their clinical experience suggested
that multiple medical problems increased the reason for a child moving from one
foster home to another, especially when the foster family did not receive enough
monetary assistance to care adequately for the child.
Developmental Health Needs
Developmental disabilities or developmental delays are often a predisposing
factor to a child entering the foster care system. They are also a common medical
condition seen on entrance into the foster care system (Gitlitz & Kuehne, 1997). It is
estimated that between 35% and 53 % of these children come into the system with
developmental delays (Horwitz, Simms & Farrington, 1994; O’Hara et al., 1998).
Often developmental delays have not been detected prior to foster care placement.
O’Hara et al. (1998) postulated that undiagnosed developmental delays might be due
to living with addicted caregivers or living in poverty without frequent contact with
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37
the health care system. O’Hara et al. also noted that the lack of secure attachments
might inhibit proper cognitive, language and physical development.
Some of these developmental disabilities seen are cerebral palsy, autism,
seizure disorders, and hearing impairments (Rodriguez & Jones, 1996). In O’Hara et
al.’s research, they documented a high incidence of abnormal muscle tone (1998).
Children under the age of 6 months demonstrated more abnormalities in muscle tone
than children over the age of 6 months. Developmental delays also are related to
length of time in foster care. Horwitz et al. (1994) found that those children who
were older at entry into care, were non-white, and had developmental delays were
1.93 times more likely to remain in foster care.
Mental Health Needs
Behavioral and emotional difficulties are more prevalent in foster children,
and have become increasingly so over the 1990’s (Halfon et al., 1995; Stein et al.,
1996). Chemoff et al. (1994) found that 75 % of children entering foster care were
at risk for mental health problems due to family history of mental illness and/or drug
or alcohol abuse. They screened 77% of these at risk children above 3 years old, and
found that 15% either admitted to or were suspected of having suicidal ideation and
7% of homicidal ideation. These statistics show the severity of the mental health
risks of foster care population and the need for comprehensive and timely mental
health services.
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In a study comparing foster children and children who are being seen in a
mental health center to the general population, it was noted that the foster children
have similar risk factors but fewer symptoms than the children being seen in the
center (Stein et al., 1996). Both groups had significantly more symptoms than the
community norms. Even children in kinship care have high levels of unmet mental
health needs, especially if they do not have a single source of health care (Feigelman
et al., 1995). Stein et al. (1996) noted that receipt of social assistance most
consistently correlated with psychiatric disorders. Poverty is related to entrance into
foster care as well as mental health issues.
Social Ecological Model of Health
The social ecological model of health focuses on the interaction between
biology, behavior and the environment; the interaction takes place over the lifespan
for individuals, families and communities. This model takes into account age,
gender, race, ethnicity and socioeconomic differences that affect how individuals
function and grow, and therefore directly and indirectly influence heath risks and
resources. The demographic factors of health need to come into play when
designing, implementing and evaluating health care interventions (Institute of
Medicine, 2000).
The social ecology model uses the visual imagery of a stream and identifies
illness as downstream and wellness as upstream. Rather than treating the people in
the water downstream, health professionals should aim at rescuing people from the
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39
water and look at what is “pushing” them into dangerous waters (Lundy & Janes,
2000). Societal level environmental interventions are recommended assure health to
all individuals, with special attention to population groups that are at risk for injury
or disease (Institute of Medicine, 2000). Health care systems in the United States
have not been successful in providing adequate provision of services downstream
(McKinlay, 1979). Political, social and health systems would influence health to a
greater degree if their emphasis were on upstream interventions. Looking at health
systems from a bottom down approach, with health promotion and health protection
at the top and medical specialists and acute care hospitals at the bottom, allows us to
envision health care within a social ecological model. This model looks like a
triangle with the hypotenuse (health promotion) on the top (Lundy & Janes, 2000).
More emphasis on health promotion would leave less need for tertiary care health
systems.
Using the ecological approach to health, researchers looked at the
relationship of social capital, income and mortality (Kawachi, Kennedy, Lochner, &
Prothrow-Stith, 1997). They found that poverty is significantly related to increased
mortality and a deinvestment of social capital in terms of social trust and social
cohesion. This view of the relationship between a decrease in health and lack of
social trust is evident in families who have children in foster care. Whether the lack
of social trust came before or after their experience with the child welfare system, it
is definitely part of the equation of foster care. The health consequences of poverty
are evident in the poor health of foster children. Support of social systems, building
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40
of social capital and community interventions are even more successful in
decreasing heart disease in a community than interventions aimed at decreasing an
individual’s risk of a heart attack (e.g., stopping smoking, exercise, and decreasing
obesity) (Lomas, 1998). This model of community upstream interventions is
applicable in supporting families to decrease the need for foster care.
This model encompasses a holistic view of health and the determinants of
wellness and illness. It looks at the environment (social, political and economic) both
as it affects health as well as it affects the way to change health status. The
environment is definitely as major player in the health of foster children. Family
poverty affects the child in utero in the type of prenatal care the mother receives as
well as the support the family has to access health care. Poverty is strongly
associated with entrance into foster care. The political and social environment
influences how society supports families or helps break them apart. Health
interventions in foster care are so extremely downstream, it is as if the child has
already floated over many cliffs and is barely able to keep his/her head above the
water. Nurses and other health care professionals need to do resuscitation of the
child as well as the system.
Provision of Health Services in Foster Care
The provision of health services to children in foster care is affected by the
constant mobility of these children and the lack of a systematic way to track health
needs and services (League of Women Voters of California, 1998). The present
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41
health care system is not able to service the children in a timely manner and can
not comprehensively meet their health care needs. The causes of the lack of health
care for foster care children are diverse but must be viewed in the context of the
child welfare organization and the health care delivery system within the United
States. It is essential to explore the type of health care provided to foster care
children in relation to the governmental systems and policies that affect the delivery
of care.
Types of Services Provided
The American Academy of Pediatrics (1994) developed standards for
services to meet the health care of children in foster care. They included a complete
screening upon entrance into the system and a comprehensive health assessment
within one month of placement. The assessment should include biological parent
involvement if recommended by the child welfare system, and should take into
account the types of problems associated with the population: sexually acquired
infections including HIV and hepatitis, immunizations, and developmental or school
progress. A separate recommendation for thorough developmental and mental health
evaluation is included in the standards along with monitoring throughout the foster
care placement. The American Academy of Pediatrics included the need for a
“medical passport” (paragraph 16) to help keep track of the information from all
health care professionals involved.
The provision of the needed services is highly complex. The system needs to
include: comprehensive gathering of health information from biological parents, past
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health care providers, foster parents, social workers, and schools; assessing the
interplay between medical, emotional, and developmental needs; and providing case
management to coordinate care among multiple providers (Halfon, English, Allen &
DeWoody, 1994). Chemoff, Combs-Orme, Risley-Curtiss and Heisler (1994) also
recommend that all children entering foster care be provided with mental health
services. They state that short-term group therapy can be used for supportive
purposes during the transition into foster care and can help identify those children
who need further diagnostic work and more intensive mental health services.
The physician is the most likely health care provider to be involved in
providing health care services to the child in foster care. The physician’s role
includes primary care, medical consultation to the social service agency, and
consultation to the state. As the primary care provider, the physician needs to take a
holistic view and assess physical, psychosocial and developmental issues as well as
provide referrals as necessary. Physicians may also work jointly with the child
welfare agency to provide input on difficult cases, identify sub-specialists that are
needed, and review medical records. Physicians can also be involved in policy
issues, programmatic evaluation, and legislation (Simms, 1991).
Obstacles to Provision of Gare
Although the need for preventive and consistent services is recognized, there
are many barriers to the health care services needed for the foster care population.
These obstacles are attributable to the nature of the placement, the role of social
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43
workers, the governmental funding issues, and the health care delivery system.
These obstacles are interwoven and have made for the systematic failure in
delivering comprehensive care to a highly at-risk population of children. The
League of Women Voters of California concludes that the foster care health system
is not really a system at all, but a patchwork, piecemeal and disjointed set of
departments that rarely communicate to each other (1998).
The constant mobility of foster children impedes continuity of care. The
Institute for Research on Women and Families (1998) note that 25% of children
move as many as three to four times a year, and county social welfare workers in
California must look for out-of-county homes for 30% of their children in foster
care. Health care records are often not up-to-date and may not accompany the child
to their next home. Confidentiality issues, bureaucratic regulations, and limited
knowledge by parents or caregivers compound the lack of useful health records or
mental health histories (Institute for Research on Women and Families, 1998).
Lindsay, Chadwick, Landsverk and Pierce (1993) noted that in San Diego county,
health problems were identified in only 14% of children in out-of-home care
compared to 25% of low-income children during routine health screening exams.
The public health nurses that Lindsay et al. spoke with felt that the low problem
identification was due to difficulty locating health care records, lack of previous
health care, inability to communicate with previous health care providers, and the
length of time that physicians need to identify health problems. Since the exams
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were performed in the first 30 days of placement, the foster parent did not know
the child well enough to be particularly helpful.
Social workers are mandated to provide case management to the children but
often do not have the expertise to understand their complex health care needs
(Carlson, 1996) or even the time. The social worker can not effectively oversee the
amount or quality of the health care administered, and the foster care parent is often
left alone to sort out the health problems of those children left in their care (Simms,
Freundlich, Battistelli & Kaufman, 1999). Social workers’ first priority is to meet
the child’s safety and welfare needs and often find the task of coordinating health
care services overwhelming (Smart, Russell & Custodio, 1998). Social workers also
have difficulty obtaining essential health history even when it is available from the
natural parent because of lack of knowledge of what questions to ask and lack of the
necessary skills to collect the data (Simms, 1991).
Most children are eligible for Medicaid (Title XIX), yet the delay in the time
the child is removed from the home and the time that the petition is filed to make the
child a ward of the state, often delays Medicaid eligibility. Many providers are
discouraged by the low reimbursement rate for the complex services needed by the
foster child and may choose not to provide care for this population (Halfon et al.,
1994; Simms et al., 1999). Counties differ in their requirement for Medicaid (called
Medi-Cal in California) enrolled foster children to be part of managed care. The
managed care companies are structured to serve children and families that stay in one
place so the mobility of foster children inhibits their use of this health care system
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(Institute for Research on Women and Families, 1998). Despite Medi-Cal’s
limitations, it remains the single most important source of care for children in out-of
home placement (Simms et al., 1999).
Along with Medicaid, there are many federal programs that can support the
health care needs that these children frequently require. Some of these programs
include: Education for the Handicapped Act, Maternal and Child Health Programs,
Birth to Three Early Intervention Programs, Head Start, Child Nutrition Act (WIC),
Juvenile Justice and Delinquency Prevention Programs, and Child and Adolescent
System Programs. Although these are very useful, they were developed for specific
issues and lack coordination between them. The forty separate federally funded
programs under Title IV-B and IV-E of the Social Security Act are the primary
sources of funding specifically allocated for child welfare services (Geen et al.,
1999). Title IV-E supplies most of the monies since it is an open-ended entitlement
that matches state funding. It has very specific eligibility requirements based on
income and is only used for one-half of children in foster care (Geen et al., 1999).
These programs are also optional for states and may not be available for foster
children who need them (Simms & Halfon, 1994).
The lack of access to care is also caused by the fragmented and under
financed health care delivery system. The current health care system has inadequate
service capacity to meet the high-risk child with multiple problems. The system is
especially unable to meet the mental health and developments services required by
this population (Halfon et al., 1994). The complicated health care needs of foster
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46
children coupled with poor utilization of the present health care delivery system
results in a lack of comprehensive health delivery to this population (Lindsay et al.,
1993). Feigelman et al. (1995) found that for children in kinship care, having a
single source of health care was important to meeting health needs. But even those
who had a single provider, half of the foster children had unmet medical health
services needs and one-third needed mental health care.
Interface Between Health Care, Child Welfare and Justice System
The foster care system has failed to care for society’s children and has often
increased the health care problems of this population. Schor (1988) writes that Child
Welfare agencies have compounded the health problems of children by inadequately
selecting, licensing, training, and supervising foster parents. The agencies have
failed to provide adequate homes and adequate medical, psychological and
educational services by assigning caseloads that are excessive and unmanageable to
child care workers (Rosenfeld et al., 1997). The lack of coordination between the
child welfare and health care systems have left social workers, foster parents and
other caregivers unable to provide adequate health care because of fragmentation,
lack of continuity and inadequate availability and capacity of services (Halfon et al.,
1994).
The interface of systems even begins before a child enters the foster care
system. A parent in prison is often the catalyst for a child placement in foster care.
It is estimated that there are 90,000 women currently incarcerated, with 145,000
minor children. About 75-80% of the women have an average of two children and
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are often single parents raising the children without a father. The picture of these
incarcerated women speaks to the cycle of foster care. One out of five women
prisoners came from a foster home or a foster group care facility and 40% report
sexual or physical abuse, most often before the age of 18. Men in prison have
similar backgrounds with one in six raised out of the home and 12% reporting sexual
or physical abuse. The children of these incarcerated parents are mostly in kinship
care but 5-10% are in unrelated foster care and live apart from their brothers and
sisters (League of Women Voters, 1998).
Dependents in the Child Welfare System also interface with the Immigration
and Naturalization Service (INS) and Juvenile Justice. In 1998, there were 800
undocumented wards of DCFS. INS has ruled that the permanency planning process
needs to be started before these children can apply for a green card or citizenship.
Even though these children in foster care are in the United States illegally, they did
not enter by their own choice and often do not know their country of origin.
Families of undocumented foster children often do not cooperate with family
preservation and the children are faced with deportation upon emancipation at age
18. Foster care children are also high risk for becoming juvenile delinquents. Social
workers in Los Angeles County are working to provide specialized, intensive case
management services to youth exhibiting delinquent behaviors to prevent them from
entering the probation system (League of Women Voters, 1998).
Child Welfare Agencies have team approaches that try to meet the health
needs of the child. The team may consist of, but not limited to, social workers,
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public health nurses, mental health professions, substance abuse counselors,
physicians, home visitors, clinic staff, foster care providers, regional centers,
parenting programs, and school nurses. (California Department of Health Services,
1999). California Child Welfare Services has four mandates: emergency response to
abuse allegations; family maintenance services for families in which children remain
with their parents; family preservation and support services which provide intensive
services for families whose children might be taken out of the home or remain in out-
of-home placements for longer periods; and family reunification services which
provide services to children in foster care who are temporarily removed from the
home to facilitate possible reunification (League of Women Voters, 1998). Family
reunification is the mandate that deals with the health care of children in foster care.
Foster care children with Medi-Cal are eligible for the Early and Periodic,
Screening, Diagnosis, and Treatment (EPSDT) Program. Social workers have the
responsibility to inform foster care providers about the EPSDT eligibility, access to
these services and the importance of prevention. The California Child Health and
Disability Prevention (CHDP) programs (which administer EPSDT benefits) receive
referrals from social workers to provide assistance in locating necessary services;
these services prove especially valuable when children are in out-of-county foster
care placements. California has 61 local health departments that have agreements
with CHDP programs (California Department of Health Services, 1999).
Trying to match the existing health care system to the needs of foster care
children has been impossible. The flexibility, resources and expertise to deal with
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the complex nature of the foster child’s health care needs are missing from the
patchwork system. There is no state agency or department that has the authority to
make the proactive changes that will make a workable system. The Child Welfare
Department has the ultimate responsibility to assure the medical, developmental,
dental and mental health of children in foster care, yet they do not have the authority
to recommend changes in the health care systems to accommodate this population’s
needs. Even though the state needs to create a coordinate health care system, each of
California’s 58 Counties have a unique take on what needs to be done and how
(League of Women Voters, 1998).
Financing of Health Care
Two important movements have changed the financing and subsequent
delivery of health care to foster children: welfare reform and health care reform. The
social welfare system has shifted from providing continuous income and service to
poor individuals and families to encouraging and eventually requiring independence
for those able to provide for themselves (or at least those thought to be able to
provide for themselves). Funding for health care has shifted to state control. These
two reforms raise questions as to whether health care for foster children will be
better served or will suffer.
Changes in family policy have had the effect of decreasing the safety net for
families and therefore the children of those families. The allocations for Aid for
Families with Dependent Children (AFDC) have been restructured on a federal level
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with responsibility shifting to the states. This change is coupled with changes in
the Supplemental Security Income (SSI) programs for children with disabilities.
These funding changes have resulted from the passage of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), more commonly
known as welfare reform. The combination of these changes has decreased
previously guaranteed benefits for poor families and children and has negatively
affected the health of children in general and especially, those in out-of-home
placements (Simms et al., 1999). Welfare reform will likely place many more
children in poverty and subsequently into out-of-home placements (Klee, Kronstadt
& Zlotnick, 1997). Welfare reform has been a negative force in health care of foster
children.
States now have more of the fiscal responsibility for provision of health care
services. Federal legislation has increased states’ flexibility in financing social
services, including child welfare services and other programs, such as Temporary
Assistance for Needy Families (TANF) (Geen, Boots, & Tumlin, 1999). These
reforms are aimed at saving money by anticipated streamlining at the state level
(Klee et al., 1997). Whether states with large numbers of foster children will direct
more funds for the health care of these children is still unanswered.
More health care dollars are spent on those children in foster care than on
other children living in poverty. Takayama, Bergman and Connell (1994) studied
health care expenditure and utilization of children in foster care in the State of
Washington. They found that in 1990, the mean health care expenditure for children
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in foster care was $3075 compared with $543 spent on children in families
receiving Aid to Families with Dependent Children (AFDC). The increased monies
were spent on mental health, hospitalization, supportive care, and medical
equipment. The difference in expenditures were significant with a P<.001. While
much of this expenditure was directed towards a small number of high-cost children
with chronic diseases, most of those children with expenses over $10,000 were foster
children. Eight percent of the foster children met the high level expenditure while
only 0.4% of the AFDC children met this level.
Although it is known that health care expenditures for foster care children are
high, it is not known how much money is being spent on child welfare in total.
Estimates range from $6.0 billion to $11.2 billion. The Urban Institute surveyed 49
states to determine the correct figures and found that states spent $12.7 billion with
the federal government’s share at 44%, state funds at 44% and local sources at 13%.
Total welfare spending per child in 1996 ranged from $100 in Mississippi to over
$500 in the District of Columbia. Many states billed Medicaid or non-traditional
funding streams rather than Title IV-E for therapeutic services because the
reimbursement rates were higher. California had the 6th highest federal funding rate
for Child Welfare services. The Urban Institute concluded that child welfare
spending is greater than previously thought, there are significant differences between
states, and there was very little funding for prevention (Geen et al., 1999).
California has developed a comprehensive legislative agenda to try to fix the
foster care system, both from a child welfare viewpoint and a health viewpoint.
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There had been 13 bills, accounting for 300 million dollars, introduced in 2001 to
provide child welfare agencies with more resources and hold them more accountable
for results. These bills range from decreasing social worker caseloads to finding and
retaining foster parents. The foster child population is on the radar of California
legislators, especially Democrats (Bustillo, 2001). It remains to be seen if these bills
pass and are funded and how they affect the health and welfare of California’s
burgeoning foster care population.
Developments in Coordination of Services
Attention has been focused on how to better coordinate comprehensive health
care services for children in foster care. This attention has come from lawmakers,
health care reformers, child welfare activists, and even from novelists. The book on
the cover of the New York Times Book Review section from Sunday, March 25,
2001 was entitled, The Lost Children of Wilder by Nina Bernstein (Luhrmann,
2001). This non-fiction book details the life of Shirley Wilder who entered the foster
care system at age 13. The author recounts the 26-year history of the legal case that
followed the abusive treatment by New York’s foster care system of Shirley, her
child, and her grandchildren. By the time the case was settled, in Shirley’s favor, she
had died.
Reorganization of the entire system seems to be the real answer to assure
proper health care for this population. Unfortunately, such a drastic upheaval is not
on the horizon; therefore small, incremental steps have been undertaken to help solve
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this lack of coordination. Special programs for children with specific problems
are one of the ways to help with needed coordination. For children with emotional
problems, child welfare agencies have created foster care treatment programs that
provide intensive services to disturbed children. These therapeutic programs are
connected with community-based mental health services and can provide cost-
effective alternatives to hospitals and residential treatment centers (Rosenfeld et al.,
1997).
The increasing influence of managed care will likely change the coordination
of health care services for foster children. The organization of services and the
emphasis on prevention would seem to offer more comprehensive services to this
population. Rosenfeld et al. (1997) questions the ability of managed care to provide
complete services due to the monetary pressures on the system. They write that
some child psychiatric inpatients are being discharged too early. Rosenfeld et al.
also suggest that communication between private managed care companies and the
public foster care need to include precise agreements about expectations and
obligations regarding health care.
Thirty of California’s top experts on foster care developed a model system of
health care for children in foster care and wrote “Code Blue: Health Services for
Children in Foster Care” (Institute for Research on Women and Families, 1998).
This model was developed to both correct problems in the current system and
propose solutions to meet the all the health care needs of this population, including
physical mental, developmental dental care. The recommendations include:
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*Develop a system of health care for children in foster care.
* Provide a comprehensive benefit package and ensure timely screens and
assessments for foster children.
*Improve coordination and delivery of services in counties.
*Hire foster care public health nurses.
*Cut red-tape in the Medi-Cal eligibility process.
*Increase the pool of providers by reducing barriers to participation.
*Increase training and education for foster and health care providers (p. 3).
Almquist et al. (2001) identify the Code Blue Report as the stimulus for the hiring of
public health nurses to serve in the Health Care Program for Children in Foster Care
in Los Angeles county.
Wraparound services delivery models were developed in the Child Welfare
System in California to identify, individualize and coordinate services for the most
disturbed children. The core of this model is coordination of services that are
community based and collaborative in nature. One model currently in existence is
the Program Uplift between Santa Clara County and Eastfield Ming Quong, a group
home. Other Wraparound projects have been developed using the Uplift model as a
result of Senate Bill 163 Solis in 1997. This bill allocated monies for 5-year pilot
projects in all California counties for Wraparound services for teens (League of
Women Voters, 1998).
A comprehensive, continuous, and multidisciplinary medical record is
consistently recommended for foster children to increase continuity of care
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(American Academy of Pediatrics, 1994; Chemoff et al., 1994; Clark, 1996;
Simms & Halfon, 1994; Takayama, Wolfe & Coulter, 1998). Lindsay et al. (1993)
described the history of legislative attempts to rectify the lack of a “medical
passport” (p. 583) for foster children. The federal government passed the Federal
Omnibus Budget Reconciliation Act (OBRA) in 1989 that mandated that the foster
child’s case plan include health and education records. In California in 1990, Senate
Bill 615 specified exactly what is needed to be included as well as the requirement
for updating the record for each change of placement. Lindsay et al. (1993)
described a computerized record for the County of San Diego that is compiled by
public health nurses working in CHDP offices. The authors’ analysis of the 431
records found that there was lack of standardization and validity checks in the mental
and emotional health assessments. They recommended national standards be
developed to coordinate the collection of behavioral/emotional health information
and to deal with matters of privacy, ethics, and quality assurance. Ensign (1991)
reviewed health passports for foster youths in emergency shelters. She found that
13.1% had met the identified criteria for a significant delay in recommended follow-
up care. Therefore, the passport itself is not an assurance that health care will be
timely or comprehensive.
Los Angeles County has also adopted a computerized health record system
for children in protective services. Smart et al. (1998) describe the system that
enabled Public Health Nurses (PHNs) to work in collaboration with the Department
of Children and Family Services’ (DCFS) social workers to assist in compiling
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56
health information on over 60,000 children under the care of Los Angeles County.
This enormous task was undertaken with the help of the Management Information
Division, which designed the computer programs to change the existing system (used
only for social worker case management) to a comprehensive health passport. Los
Angeles County used the San Diego model as a starting point, but modified it to
accommodate a much larger population. Unfortunately the small number of PHNs
could not complete the health record for all the foster children and selected those
children who were more high-risk due to their health conditions or young age. Smart
et al. noted that “secondary health care record system to maintain health care records
for disciplines outside the traditional health care environment” (p. 350) was a vital
component of a complete medical passport.
All of these attempts to rectify the disorganization and lack of coordination of
health care for foster care children look like a band-aid on a hemorrhaging wound.
Each attempt has helped fill a gap but the wound is still bleeding. It will take an
examination of the various systems from the point of view of the child and his health
care needs to really restructure the health care delivery to children in foster care.
Significantly more money and effort needs to go into prevention (both of disease and
the social ills that predispose a child to enter the child welfare system) to truly make
a difference in the health of foster children.
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Organization Model
It is important to use an organizational model to examine the delivery of
health services to children in foster care. The primary system responsible for health
of foster children in Los Angeles County is DCFS, but many other organizations
(including schools) interface in the complex dance of health care delivery. The
organizational model proposed by Bolman and Deal (1997) will allow the researcher
to structure the discussion around how nurses affect the health of foster care and
where they fit into the complex, chaotic system that has historically been unable to
provide comprehensive and timely health services. The Bolman and Deal model
divides organizations into four frameworks: structural, human resource, political, and
symbolic.
The structural framework examines authority/rules/policies and evaluates for
clarity and efficiency in the organization. The best organizations have a balance
between loose structure and rigidity. In this framework, one looks at the focus on
goals to accomplish and planning to meet those goals. One must evaluate who has
the responsibilities and whether those individuals are held accountable for those
responsibilities. The structure of an organization operates in a specific environment
and when that environment changes, the structure also has to change. If the structure
does not work, the people within the organization can sabotage the organization, give
up and leave the organization, or restructure the organization.
The human resource framework operates on assumptions about human
behavior and needs. These assumptions include that all people have needs and will
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have poor morale if the needs are not met, and that if there is a match between the
organizational goals and people’s needs then both will grow and prosper. Managers
often need to become counselors to meet human needs. A successful human resource
organization is one that adopts Theory Y, that everyone wants to do a good job, and
does not adopt Theory X, that everyone is lazy with no ambition and needs to be
externally driven to perform. An open, responsive organization must open decisions
to all, and needs be implemented from the top. The optimal human resource
organization needs to meet lower human needs as well as more sophisticated needs
as represented by Maslow’s hierarchy.
The human resources framework is often on the different end of the structural
framework but does not need to conflict. These two are often the most dominant
lenses to look at an organization. The structure needs to put people in defined roles
and the human resources need to train people to meet their roles are complementary.
The nature of the task to be done will dictate the structure, but unhappy people can
not perform in an organization even with a good structure.
The political perspective looks at where authority lies and who has the
power; these answers are often different. In assessing the political arena, one must
look at coalitions, personal charisma, informal groups, coercive forces, access to
influence, and sources of power such as education, expertise, age, and control of
rewards. Conflict within organizations and between organizations is natural. When
the players within the organization work through conflict, the organization grows
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stronger, but when the players smooth it over without dealing with it, the
organization suffers and weakens.
The final lens to view an organization is the symbolic framework. This is
often the most powerful frame. The symbolic framework embodies the value system
of an organization, a commitment to something bigger or mythical. Symbols give a
sense of shared purpose and meaning as well as bring people together. Most
organizations have rituals that help give direction and meaning to the people working
within the organization. The culture of the organization is created by the people but
then helps shape the people themselves.
This organizational model will be applied to the delivery of health care to
children in foster care. Specifically, it will be applied to how nurses work between
the child welfare system, school and health care delivery system to improve the
health care of this high-risk population. The organizations that interface to provide
health care and affect health care in foster children have been historically
disorganized with poor outcomes. It will be interesting to use the Bolman-Deal
model to analyze the organization and identify the dominant frame and how the
different frames interact.
Roles of Community Health Nurses in Foster Care
Public Health Nurses (PHNs) are new additional participants in the work
within Child Welfare Services. These PHNs join school nurses in providing health
care to school-age foster care children. The PHNs have been employed to meet the
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demand for better and more comprehensive health care for the expanding
population of increasingly medically and psychosocially fragile foster care children.
Child Welfare Agencies and public health departments have specifically identified
that the PHNs’ clinical and organizational skills and knowledge of the community
will help make the American Academy of Pediatrics’ recommendations become a
reality (California Department of Health Services, 1999). It is unclear whether the
addition of PHNs to the school nurses and social welfare team will actually be able
to make a significant improvement in the health of children in foster care since only
recently has the number of PHNs increased and PHN responsibilities expanded
significantly. Favorable political and social forces within the Child Welfare System
and within the State government are needed to support the work of the PHNs, make
sure that there are sufficient numbers of nurses to meet the demand for health case
management, and allow them to function fully in their complex interdisciplinary role.
History of Involvement of PHNs
Public Health Nurses (PHNs) in California began being recognized for their
work with foster care children and their families in the mid 1990’s when Nurse
Week, a biweekly publication sent to all Registered Nurses, ran an article about these
nurses. Gray (1994) explained that PHNs were used to assist foster caregivers and
Children’s Social Workers (CSWs) in obtaining health services by assuming case
management roles. Smart (1999) noted that the Child Welfare Offices began
employing PHNs when funding through the federal Early Periodic Screening,
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Diagnosis, and Treatment (DPSDT) program, administered by Child Health and
Disability Prevention (CHDP) program in California, became available. This
EPSDT-CHDP program ensured comprehensive health care services for Medi-Cal
eligible children and those children 200% below the federal poverty level. Most
foster children qualified for these services. The EPSDT-CHDP program provided 75
% of the funding for PHN case management (Smart, 1999).
In July of 1993, the Los Angeles County, Department of Children and Family
Services (DCFS) signed a Memorandum of Understanding with the Department of
Health Services (DHS) to hire 20 PHNs to provide health case management to work
in concert with the 1,400 CSWs in 18 DCFS offices. The PHNs’ job description was
somewhat vague but fit the narrowly defined health case management role as
specified by EPSDT funding. A study of the PHN activities of case consultation,
educational services, data management, and resource development found that the
majority of PHN time was spent in consultation activities. A breakdown of these
consultation services included: 23% of their time reviewing and assessing cases to
determine a child’s health needs and assisting the CSW with development of a health
case plan; 13% of their time trying to obtain accurate and complete health
information; 14% of their time following cases to see if care was received for
identified health problems; 11% of their time interpreting medical terminology for
the CSW or caregiver; and 8% of their time notifying health care providers, CSWs,
or caregivers when the child was due for basic health care (Smart, 1999).
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Smart (1999) also noted that the PHNs in DCFS made a significant impact
on CSW practice, reimbursement for medically fragile children, and the
computerized medical record. The PHNs routinely offered classes to the Social
Workers that helped CSWs incorporate health issues into their practice. The PHNs
also developed a form for the social workers that allowed them to obtain needed
health information prior to placement changes. Smart (1999) wrote about the
difficulties nurses had in adjusting to the culture of DCFS. These difficulties
included orientation to the jargon of child protective services, realization that legal
mandates needed to be considered sometimes even before health issues were
addressed, and provision of health and psychosocial services to their social worker
colleagues. The most difficult adaptation seemed to be the realization that social
workers were the primary case manager.
Southern and Northern California foster care nurses joined together to form
an organization for those nurses practicing in child welfare. They produced a roster
in January of 1997 of those nurses who practice in child protective services (Leahy,
1997). Each county in the state of California identified their program name, nursing
director, county population, number of children in foster placement, number of social
workers and PHNs, funding source, and program summary. The majority of the
funds for PHNs came from EPSDT/CHDP and the various County Health
Departments. Los Angeles County had identified the largest number of PHNs, 30
budgeted positions. This organization, called Foster Care Nurses Network, had a
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conference in 1997 to help educate their members in many of the issues that both
face their clients and themselves in the practice arena.
Current Roles of PHNs
Foster care nurses in Los Angeles County today are employed by both the
Child Health and Disability Prevention (CHDP) and the Department of Children and
Family Services (DCFS). The CHDP nurses work in the Health Care Program for
Children in Foster Care (HCPCFC) and the DCFS nurses work in the Public Health
Nursing program. Both groups of nurses function similarly, as “part of a
multidisciplinary team attempting to ensure children receive timely, comprehensive
health care services” according to Sharon Leahy, RN, MS, Program Specialist for the
DCFS Public Health Nursing (personal communication, April, 2000). There are
approximately 30 Public Health Nurses (PHNs) working for DCFS and 86 PHNs
budgeted for CHDP (Almquist, Cambaliza, Johnson, & Ward, 2001). The budgeted
positions in CHDP include 79 PHNs, 6 PHN supervisors, and 1 PHN Program
Specialist.
The funds for the new foster care PHN program (HCPCFC) in County
Welfare Departments became available January 1, 2000. A total of $2.48 million
State General Funds were appropriated and augmented by matching federal funds to
provide a total of $9.9 million to counties statewide. The new CHDP PHNs are
funded to provide health care oversight for the physical, dental, behavioral and
developmental needs of children in foster care. It is specified that the PHNs were to
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provide services to all children who receive Aid to Families with Dependent
Children, regardless of a child’s legal status. The PHNs are to be located at county
welfare offices and work with welfare and probation department staff. No direct
services are allowed under this funding (Department of Social Services, 1999b).
Subsequent to the announcement of the new foster care PHN program
(HCPCFC), the Department of Health Services (1999) sent a program letter to CHDP
Directors detailing the requirements to implement this program. The Program Letter
No. 99-6 included a model Memorandum of Understanding between local Child
Welfare Agencies and local CHDP programs, scope of work guidelines to meet the
objectives of the program, a description of how state money was to be allocated, and
PHN budget and staffing guidelines. Los Angeles County was allocated $923,913 of
the $2,480,00 in the state budget and had 48,077 of the 129,050 children in out-of
home placements. The numbers of nurses and children illustrate the importance of
Los Angeles County to the success of this program. The scope of work was
modified in May of 2000 (Department of Health Services, 2000a). The four goals of
the program remained the same: the health needs of children in protective services
custody will be identified and addressed in a timely manner; a comprehensive health
plan will be developed, documented and updated; a pool of qualified providers will
be available to provide needed health care in a timely manner; and child’s health
record will include the information to determine health needs and health status
throughout his/her time in foster care.
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Los Angeles County defined areas of responsibility for HCPCFC in terms
of CHDP, Foster Care PHNs, Local Child Welfare Service and Social
Worker/Probation Officers (Department of Health Services, 2000b). The services
provided by the entire team included accessing resources, health care planning and
coordination, training/education, policy/procedure development, and transition from
foster care. This document outlines the many disciplines that PHNs need to work
with to accomplish the goals of the program. The PHN role includes interpretation
of health care reports, developing health plans, referrals for needed care, and
evaluation of placements in light of health care needs. The PHNs will also educate
other disciplines regarding the health care needs of children in foster care and
provide consultation with DCFS/Probation Departments regarding policy.
The HCPCFC program now serves 48,000 of the 65,000 children in foster
care-3.4 % (1,686 foster children) are in probation. Although the state goal was 1
PHN per 200 foster children, in reality there is 1 PHN per 500+ foster children. This
ratio includes both the HCPCFC nurses and the DCFS nurses. The HCPCFC PHNs
are located in the 19 DCFS offices and in 3 probation offices. These statistics
foreshadow the possibility that the goals of this program can not be achieved unless
there are sufficient resources and people to meet those goals. Two outcome
indicators identified by HCPCFC are that children receive follow-up for diagnosed
problems within 60 days of initial diagnosis (goal is 95%) and that children are
referred to mental health care providers for a screening evaluation (goal is 100%).
The present goals for the HCPCFC program include more home visiting,
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independent home visiting by PHNs, emergency response visits, court visits with
biological parents, consultation with youths emancipating from supervision,
consultation with families in family maintenance program, and better use of clerical
staff to complete the Health Education Passport (Almquist, Cambaliza, Johnson, &
Ward, February, 2001).
School Nurses’ Role
School nurses have had an increasing role in the health care of school
children over the last century. School nursing in America began in 1902 when
Lillian Wald and her Henry Street Settlement nurses began to meet the needs of the
schoolchildren in New York City. School nursing evolved from the public health
nursing practice among tenement dwellers in large, urban cities. Lina Rogers (one of
Wald’s public health nurses) began treating 10,000 children in four New York City
Schools who suffered from infectious diseases and soon developed protocols for
these conditions. The school nurses visited the homes of schoolchildren sent home
ill and children who failed to attend schools. By 1903, Rogers employed 25 nurses
and served 100 schools. This New York experiment was repeated in other urban
cities, e.g., Los Angeles (1903), Baltimore (1905) and Boston (1906) (Hawkins,
Hayes, & Corliss, 1994).
School nursing has spread throughout the United States. Societal issues of
family poverty and single-parent families, and increasing morbidity of children have
affected the role expectations and responsibilities of school nurses of today. Healthy
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People 2010 has specific objectives that apply to school-age children and
encourages school-linked or school-based health services to prevent, detect and treat
health problems (Office of Disease Prevention and Health Promotion, 2001). The
new morbidity of school children include depression, drug and alcohol abuse,
nutritional insufficiencies and teen-age pregnancy (Miller, 1990). Increasingly
school nurses must give direct services to children with disabilities. Therefore, the
school nurse’s role, education and practice has changed to meet the demand of the
school community. These new responsibilities have led to legal imperatives for safe
practice. Harrison, Faircloth and Yaryan (1995) view the new school nurse as
having both a reactive role and a proactive role to meet legal mandates. The reactive
role is provision of direct services as well as scheduled general health screenings and
maintenance of school records. The proactive role includes more primary prevention
including health promotion and disease prevention activities and case management.
The professional preparation of school nurses has also evolved. In the 1923
Goldmark report, school nurses were recommended to have postgraduate work
beyond that of a general public health nurse (Hawkins, Hayes & Corliss, 1994). The
National Association of School Nurses define the school nurse as a licensed,
professional nurse or a Registered Nurse (RN) (Proctor, Lordi & Zaiger, 1993).
States have differing requirements for school nurses. Miller (1990) recommends a
minimum of a baccalaureate level of education of school nurses. Some states require
both a baccalaureate degree and advanced education for a certificate in school
nursing (Paladino, 2000). Harrison, Faircloth and Yaryan (1995) warns that the use
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of Licensed Vocational Nurses (LVN’s) may be appropriate for some screening
and documentation needs with the school, but RNs need to supervise the LVNs and
these RNs should hold a baccalaureate degree.
The role of school nurses is influenced by professional standards. The
National Association of School Nurses published comprehensive standards for
school-based, school-linked and collaborative school health programs (Proctor,
Lordi, & Zaiger, 1993). These standards were based on the American Nurses
Association Standards of Clinical Practice. They defined the school nurse as
practicing with students (up to age 21) and their families and school community.
The school nurse is viewed as a specialized focus of community health nursing and
is especially related to public health and occupational health. The central themes in
these standards of the school nurse’s role are collaboration, use of the nursing
process (problem-solving), meeting the needs of special education children,
communication, and health education.
The role responsibilities as defined by the profession do not always match
practice. Zimmerman, Wagoner and Kelly (1996) studied school nurses in
Pennsylvania to identify if role ambiguity and role strain are consequences of this
renewed emphasis on schools and school-nurses to meet the health care needs of this
population. Zimmerman et al. found that teaching was the prominent aspect of the
respondents’ role. The school nurses noted that diagnosis and treatment, mandated
activities, health assessment and case finding were also important interventions. The
researchers found that state-mandated tasks were far narrower and less wholistic
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(less influenced by the Socio-Ecological view of health) than what the nursing
profession acknowledges the role of the school nurses to be. This study concluded
that school nurses suffered from role ambiguity and resulting role strain since the
state mandated vision of their role (with a primary emphasis on screening and
administering first aid) left little time to do what the nurses saw as their primary role,
as health teacher. Nurses also noted the increasing need for counseling of students.
School nurses today have many challenges with the new emphasis on
comprehensive health services in the schools. Professional standards are often in
conflict with school district policies about the school nurse’s role. School nurse’s
skills are not always fully utilized and role definitions are somewhat fuzzy (Kozlak,
1992). Kozlak (1992) calls for school nurses to become more effective
administrators and managers, sharpen their diagnostic and technical skills, and
develop additional teaching skills to operationalize comprehensive school health
programs. Brindis, Sanghvi, Melinkovich, Kaplan, Ahlstrand and Phibbs (1998)
recommend redesigning the school health workforce by educating school nurses to
become nurse practitioners, an advanced practice nurse. Brindis et al. write that this
new workforce will provide a efficient point of delivery of community-based
primary care. With the recent terrorist attacks on America, the community-based
role with include emergency preparedness (Hohenhaus, 2001).
School nursing influences both the health of the school child and his/her
learning. The health services that school nurses provide support the main purpose of
schools, education. It is widely recognized that health status and learning are
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intertwined in that optimal learning requires good health (Paladino, 2000). The
school culture supports nurses and health care in order to meet the central mission of
education. The school support has escalated with the mandates for children with
varying degrees of disabilities to be in regular school settings. This legal mandate
has increased the need for school nurses in classrooms and the technical
requirements of the school nurse’s role (Committee on School Health, 1987).
Multidisciplinary teams including the school nurse are necessary to evaluate
chronically-ill children health care needs within the classroom and design special
education plans for the disabled child (Repetto & Hoeman, 1991).
Public Health Nursing and Community Health Nursing
Both school nurses and public health foster care nurses provide community
health services to foster children. Community health nursing practice is a philosophy
of providing care to individuals, families, and groups wherever they are located. The
emphasis is on community as a location and includes the idea of partnerships with
clients. With this philosophy, practitioners can provide both primary care and acute
care services in community settings, such as health education classes, prenatal clinics
in high schools, and outpatient surgery (Alexander, 2001). Both school nurses and
foster care nurses practice community health nursing.
Public health nursing is community health nursing with specific emphasis on
promoting and protecting the health of populations using knowledge from nursing,
social and public health sciences. The goal of such practice is prevention of disease
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and disability for all people through promotion of healthy behaviors. “Public
health nursing is population-focused, community-oriented nursing practice” (Quad
Council of Public Health Nursing Organizations, 1999, p. 2). Some of the tenets of
public health nursing include: assessment is population-based, policy development
and assurance processes are systematic and comprehensive; primary prevention is
given priority; interventions are selected to create healthy environmental, social, and
economic conditions; dominant concern is for the greater good of all the people; and
allocation of available resources supports the maximum population health benefit
gain (Quad Council of Public Health Nursing Organizations, 1999).
Traditionally public health nursing was an advocacy model that included both
social and environmental factors in the nurses’ scope of practice. The role of public
health nurses in local health departments is tailored to the needs of the community
and often includes ambulatory care, family-based home visits, school nursing, and
surveillance of communicable diseases. In recent years the service delivery
functions of PHNs have been curtailed due to economic issues and some feel that
public health nursing is an endangered species (Dienemann, Campbell & Agnew,
2001).
Foster care programs specifically call for Public Health Nurses. The
minimum qualifications include a valid California Registered Nurse (RN) license,
PHN certificate, California driver’s license and personal car for transportation. In
the state of California, a RN needs a baccalaureate degree to qualify to apply for the
public health nurse certificate. Experience in maternal-child health, health teaching,
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and field experience (e.g., home visiting) as well as knowledge of growth and
development of infants, children and adolescents are desired for foster care PHNs
(Department of Health Services, 1999).
Interdisciplinary Work
PHNs have traditionally been key members of multidisciplinary teams
working to protect and promote health and prevent disease and injury (Association of
State and Territorial Directors of Nursing, 2000). The interdisciplinary role of the
PHNs’ work in child welfare is detailed in the California Statewide Guidelines for
Public Health Nursing (California Department of Health Services, 1999). Most child
welfare agencies adopt a team approach which includes social workers, public health
nurses, mental health professionals, physicians, substance abuse counselors, clinic
staff, foster care providers, counselors, parenting programs, regional centers, school
nurses, and home visitors. The PHN works specifically in collaboration with the
child’s social worker.
The California Statewide Guidelines for Public Health Nursing in Child
Welfare Services (California Department of Health Services, 1999) identified those
skills needed by the PHN to successfully collaborate and work within the
multidisciplinary model. These skills included flexibility, clear communication,
ability to prioritize, understanding of the health and social services systems both at
the county and state levels, and role clarity. The multidisciplinary role
responsibilities are both focused at the individual child level and at the foster care
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system in general. These responsibilities are based on the nursing process model
of problem-solving. This process includes assessing strengths needs and identifying
problems, developing solutions and a plan of action, implementing the plan, and
finally evaluating the plan.
Future Roles of Foster Care Nurse
The role of the PHN as case manager for foster care children has received
endorsements from national organizations, studies on the health problems of children
in foster care, and political organizations (California Department of Health Services,
1999; County of Los Angeles, 1992; Department of Health Services: Little Hoover
Commission Report, 1999; Institute for Research on Women and Families, 1998;
League of Women Voters of California, 1998). There are some slight differences
between how the case management role is envisioned by each of these organizations
or recommendations. Znotnick, Kronstadt and Klee (1999) examined a group of 130
children under age four who were newly placed in foster care. Specific services the
required the most case manager effort for these children and their caregivers
included counseling and parent education. Those families that needed moderate
intensity of case management were advised to utilize foster parent support groups. It
is important to note that services aimed at foster care parents, rather than the foster
care children, required the most labor-intensive case management. This finding is
not reflected in the job responsibilities for PHNs in either CHDP or DCFS.
Advanced practice nurses, specifically those with advanced skills in pediatric
nursing, are needed to fulfill some of the case management responsibilities for
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comprehensive care of children in foster care (Carlson, 1996). Pothier (1990) also
recognized the role of psychiatric nurses to ameliorate the effects of out-of-home
placements, parental abuses and prenatal exposure to alcohol and drugs for children
in foster care. She concluded that even though psychiatric nurses had the expertise
to impact the health of these children, the nurses had neither the sanction nor access.
Pothier, in her editorial in the Archives of Psychiatric Nursing, called upon nurses to
work within their local and national communities through political processes to bring
attention to the health needs of children in out-of-home placement and to the
possibilities of psychiatric nursing to make a difference in children’s lives.
Home visiting for young children in foster care is recommended. O’Hara,
Church and Blatt (1998) investigated home visiting for developmental screening in
children in foster care. The use of such screening tools as the Denver Developmental
Screening Test-II, Early Language Milestone Scale-2, and the Infant Neurological
International Battery allowed the nurse to detect developmental delays early. O’Hara
et al. noted that these tools were instrumental in detecting problems for foster
children from birth to 18 months. They strongly recommend comprehensive
developmental testing and an expansion of foster parent education regarding growth
and development. The anticipatory guidance for foster parents should focus on age-
appropriate expectations, nutrition and injury prevention (Gitlitz & Kuehne, 1997).
Rodriguez and Jones (1996) noted that counseling of foster parents about specific
warning signs that require interventions, especially when the foster child has
developmental disabilities, reduce some of the emotional stress associated with
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parenting responsibilities. Home visiting taken to the extreme can be considered
Medical Foster Care. In this model, Registered Nurses provide temporary medical
treatment in their own homes for significantly medically fragile children in foster
care (Foster, Davis & Whitworth, 1982). Home visiting has just begun for the
present day foster care PHNs. When there were just the 30 PHNs in DFCS, the ratio
of nurse to foster care population was 1/2000. That kind of caseload would not
allow for anything but crisis intervention (Personal Communication, April, 2000).
Public Health Foster Care Nurses need to be integrated into the existing
structure of Child Welfare Services and need to be an integral player within the
political activities of organizations that direct and influence the care of foster
children. The Child Welfare Services Stakeholders’ Group established by Assembly
Bill 1740 in 2000 does not have a single nurse on its 60-member roster dated 1/25/01
(Personal Communication, March, 2001). There are many social workers and
physicians on the roster. This stakeholder group’s purpose is to examine the current
processes and outcomes of the Child Welfare Services System in California and
make recommendations for future directions. Nurses need to join these types of
groups to make their voices heard in order to affect change in the health of children
in foster care as well as to influence the evolution of their role in the child welfare
system.
Nursing students today are not being exposed to the foster care population or
this new nursing role. In California, fewer Baccalaureate Degree Nurses are being
educated and, therefore, there are fewer public health nurses (Coffman, Spetz, Seago,
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Rosenoff, & O’Neil, 2001). County health departments are searching to fill these
foster care nursing positions. The author of this paper received several unsolicited
mailings from both Los Angeles County and San Bernardino County to advertise
these jobs. The University of Southern California Department of Nursing is trying to
educate students about this nursing role by offering clinical rotations with foster care
families. They have developed a partnership with the Westside Children’s Center to
facilitate this exposure. Nursing students have felt this clinical rotation significantly
increased their interest and knowledge in this population of patients (Alaniz, 2001).
Model to Evaluate the Foster Care Public Health Nurse and School Nurse
It is important to look the role of Foster Care PHNs and school nurses in
terms of a model of public health nursing in general. Keller, Strohschein, Lia-
Hoagberg and Schaffer (1998) describe a Public Health Nursing Interventions (PHI)
Model developed by the Minnesota Department of Health that helps define more
clearly what public health nurses (including both the foster care nurses and school
nurses) do at both the community and systems level. The model identified 17
interventions with examples at both the systems, community and individual/family
level. Margaret Avila, Los Angeles County Public Health Nursing Director, has
adopted this model for all 500 PHNs that work for the county, including the Foster
Care PHNs (Personal Communication, February, 2001).
The Minnesota Department of Health (2000) developed a manual to
disseminate their work on the PHI Model. The interventions include: surveillance,
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disease and health threat investigation, outreach, screening, referral and follow-up,
case management, delegated functions, health teaching, counseling, consultation,
collaboration, coalition building, community organizing, advocacy, social marketing,
and policy development and enforcement. Case finding is separate from these 16
interventions as it is a one-to-one intervention because it only operates on the
individual/family level. This model is pictured as a wheel divided into slices of a pie
with the interventions on the outside of the slice. The inside of the pie slice includes
the focus of the group to which the intervention is aimed, e.g., individual,
community or system.
The PHI model is based on three concepts: population-based interventions,
practice at multiple levels, and independent nursing function. The population
concept includes a focus on community needs as determined by health assessment,
identification of those at risk, and interventions that are preventive and include all
determinants of health. The determinants of health are broad-based and feature such
factors as income and social status, housing, food security, social support networks,
education, physical environment, coping skills, cultural customs and values, and
violence. This way of looking at health is similar to the ecological health model, in
which health is viewed as holistic and affected by psychosocial, environmental and
physical conditions. The second concept of multiple-practice levels, individual and
family, community, and systems, identifies that almost all interventions need to be
practiced on all levels simultaneously. The independent nature of nursing
interventions refers to the authority of the states’ nurse practice act to authorize these
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functions for registered nurses. There does not have to be a physician’s order for
PHNs to practice the interventions noted in this model.
The Minnesota Model is an excellent framework for examining the work of
foster care nurses and school nurses. For example, the collaboration intervention is
part of the interdisciplinary nature of the PHNs’ work. The collaborative
relationship is defined as “...a commitment on the part of two or more persons or
organizations to enhance the capacity of one or more of the members for mutual
benefit and to achieve a common goal” (Minnesota Department of Health, 2000,
page 1 of Collaboration Section). Collaboration is the highest level of collective
action and can be practiced at both an individual/family and community level.
Collective action does the greatest good and creates a process that results in an
outcome that is likely more innovative, successful and comprehensive than if acting
alone. This is the incentive for the role of the PHN in foster care, to have outcomes
better than could be reached with just a social worker in charge of the welfare of
foster children.
All the interventions in the Minnesota Model are applicable to work of the
foster care PHN and the school nurse. The manual provides specific examples for
each intervention category at all levels of care (individual/family, community and
system). The manual also provides steps to do the intervention, best practices or how
to do the intervention with excellence, the relationships between interventions, and
theoretical and research evidence for the best practice. The foster care PHNs and
school nurses are working in complicated, multidisciplinary and often dysfunctional
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systems. This model can provide a structure for the PHN work and for research
into exactly what the nurses are doing, with whom, and for whom.
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CHAPTER 3
RESEARCH METHODOLOGY
Introduction
This chapter describes the research methodology used for the study, including
sample selection, instrumentation, data collection, and framework for data analysis.
This study analyzed the experiences of the nurses working with school-age foster
care children. The purpose of the study was to investigate whether nurses adopt the
theoretical framework of Social Ecological Model of Health and whether their
practice was theory-based. The study looked at this potential for theory-based
practice in two organizational contexts, the Child Welfare System and the School.
The study investigated whether the organizational context buffered or enhanced the
ability of the nurse to carry out his/her role and whether the organization affected
communication, case finding and choices of actual interventions.
Research Questions:
1. What do nurses want/intend their role to be in providing health
promotion/education for foster care children and their families and how are
these role perceptions similar or different between the school setting and the
child welfare setting?
2. What strategies and interventions do nurses actually use in their role of
providing health promotion/education for foster care children and their
families?
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3. What similarities or differences of the organizational structure of schools
and the child welfare system affect nurses’ role in the health of foster care
children and their families?
4. How does the organizational context of the school and the child welfare
system affect the nurses’ choices of services, clients and communication?
Methodology
The research methods for this study are qualitative in nature. In-depth
interviews of foster care nurses and school nurses provided the primary basis for
analysis for this study. A foster care social worker was also interviewed. The taped
interviews explored the organizational structure of the Child Welfare System and
School organization in relation to the role of nurses working with school-age foster
care children. The interviews also explored the nurses beliefs about what they want
or intend to practice to care for the population of school-age foster care children.
All subjects participating in the interviews were assured anonymity. Each
interviewee signed a consent form. A survey of the interventions practiced by the
school nurses and child welfare nurses was completed. The researcher also observed
the nurses working in their environment.
A qualitative study was appropriate for the research questions because there
has been a lack of previous research or theory. The goal of the research lent itself to
inductive logic in which answers to the research questions emerge from the
informants. Field research, observation in natural setting, is frequently used in
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answering questions using inductive logic (Babbie, 1995). In qualitative field
research, the researcher is able to go directly to the phenomenon under study,
observe it as completely as possible and develop a comprehensive perspective of the
problem. This is especially useful when the research topic appears to defy simple
quantification (Babbie, 1995). These qualitative methods provide context-bound
information that will lead to patterns that help explain the phenomena (Creswell,
1994). The research questions for this study were not easily quantified and lent
themselves to qualitative methods.
The phenomenon being researched was the congruence between what the
nurses believed about health care for the foster care population (in terms of adoption
of the philosophy of the Social Ecological Model) and their actual practice (in terms
of the Minnesota Public Health Interventions). This congruence was analyzed in
terms of organizational context, the Child welfare System and the School
organization. This study used applied qualitative research, a technique that tries to
generate potential solutions to a human and societal problem (Patton, 1990).
The goal of the study was to learn about the phenomenon from the
perspective of those working in the field. The phenomenological perspective derives
from the disciplinary roots of philosophy and focuses on what people experience and
how they interpret their world (Patton, 1990). The participants’ viewpoint is referred
to as the emic perspective. From the emic perspective, the researcher asked questions
that explore how the nurses made meaning of their experience in the Child Welfare
System and the School setting. The researcher attempted to understand this
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perspective through observation and interviews. At the same time, the researcher
maintained her own perspective as an outsider, which is called the etic perspective.
The researcher was able to make conceptual and theoretical sense of the data
obtained from the case studies.
The multi-method (triangulation) qualitative approach was used to conduct
this research. Triangulation is the process of using multiple data-collection methods,
data sources, analysts, or theories to check the validity of the case study findings
(Gall, Borg & Gall, 1996). This method helped eliminate some of the biases that
might result from the use of only one source, data collection method, analyst or
theory. This study utilized interviews, observations, and a survey in order to
triangulate the results. The researcher described her observations of the subject’s
non-verbal communication during the interview process and her observations of the
nurses doing their daily work. Interviewing and observation are mutually reinforcing
techniques in qualitative research (Patton, 1990). A Social Worker was interviewed
to triangulate the perceptions of the nurses in terms of organizational structure and
the cooperation between the two professions.
Nurses completed a survey of the types of interventions they engaged in and the
frequency of these interventions. The researcher observed the nurses working in their
environment for a four-hour time period. The survey and observations answered
research question number two about the actual practice of nurses.
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84
Researcher’s Role
The researcher has past experiences providing familiarity with the topic. The
researcher has a background in pediatric nursing, a Nursing Master’s Degree in
Maternal-Child health and clinical experience in providing care to children. She has
taught community health for the past 7 years to baccalaureate nursing students and
provided clinical supervision in public health settings in both Los Angeles and
Ventura Counties. The researcher supervised students in a private, non-profit agency
contracted to provide foster care. She supervised students on their home visits to
foster families. During these home visits, the researcher developed an interest in
how nurses are caring for this population. The researcher interviewed administrative
staff in both CHDP and DCFS for an article about this new nursing role for an article
in Nurseweek. a bimonthly newsmagazine mailed to all active registered nurses in
California. The researcher is quoted in the Nurseweek article about preparing
students for their role in foster care. The researcher, the preceptor at the private
foster care agency, and a student who experienced this clinical rotation wrote a
manuscript published by the peer-reviewed journal, Nurse Educator, in June 2002 on
preparing students for this role.
The researcher admits to the bias of wanting the foster care nurses to be
successful in their roles within the Child Welfare System. The researcher has former
students who are working in this role as a foster care nurse. The researcher has
supervised students in their clinical experience with school nurses. The researcher
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85
also has a bias that the theoretical framework of Social Ecology Model of Health
is important to improve the health of foster care children.
Sample and Population
A purposive population was used for this study. Informative-rich cases are
studied to depth to learn a great deal about the issues relevant to the research
questions. The researcher selected the purposive that she believed would yield the
most comprehensive understanding of the subject of the study, based on her intuitive
feel for the study questions and her observations (Babbie, 1995). Critical case
sampling is used to identify cases that are particularly important in the scheme of
things (Patton, 1990). Patton suggests that logical generalizations can be made using
the weight of evidence produced from studying critical cases. The critical cases are
chosen from the population to provide rich information to answer the research
questions. The critical cases must be representative of the total population to allow
some generalization (Babbie, 1995).
The population for the study was the foster care nurses working in Child
Welfare System (CHDP and DCFS) and school nurses working in the Pasadena
School District. Interviews were conducted with both key informants and general
informants. The three key informants who were critical in looking at the research
questions were an administrative nurse supervisor in CHDP and DCFS (Child
Welfare) and an administrative nurse supervisor in the School. These administrative
people were chosen because of their intimate knowledge of the organization in which
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86
they work, the functions of the nurses, and the interactions between the Child
Welfare System, School and health care systems.
The nurse general informants were purposively chosen from the nurses
working in CHDP and DCFS and the School. The researcher asked the Child
Welfare nurses supervisors to select nurses who were knowledgeable about their role
and represent different geographical areas within Los Angeles County. From these
lists, the researcher chose 3 DCFS foster care nurses and 3 CHDP foster care nurses
to act as general informants for the study. There are approximately 30 nurses
working for DCFS and 86 nurses working for CHDP, 79 of whom are PHNs and 6
supervisors. The DCFS research department requested that the researcher interview
the same number of nurses in DCFS as those working for CHDP. It was critical to
interview nurses who have worked in foster care for a longer time so the researcher
could ask questions about the changes that have occurred since the beginning of the
Health Care Program for Children in Foster Care (HCPCFC). This experienced
group of informants came from the DCFS sample. The nurse subjects in CHDP
offered expertise about their orientation to their role and how they were able to
function. In order to get a complete picture from these subjects, they needed to work
for CHDP for at least one year. The requirements for one year of employment did
not cause difficulty in recruiting subjects since the HCPCFC program has been
functioning since January, 2000. The foster care nurse supervisors were able to
provide an overview of the role of the foster care nurse.
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87
The three general informant School Nurses were chosen from nurses
working at the Pasadena School District. The critical case sampling included the
nurses working at school with the largest percentages of foster care children. This
school district was chosen because the student population has the greatest percentage
of foster care children than any other local school district.
The general informant social worker was identified to provide more
information about the organizational structure of the Child Welfare System and the
relationship between foster care nurses and the social worker. Since the foster care
nurse functions in concert with the mandated case manager, the social worker, the
interactions between nurses and social workers were important to understanding how
nurses function within the system. A social worker from DCFS was chosen by their
supervisor to provide an interview for the study. The social worker had to have
worked with foster care nurses. The researcher asked the DCFS nurse supervisor if
the selected social worker was a knowledgeable and representative subject for the
study.
Instrumentation
Frameworks for Instrument Design
The framework for the instrument design stems from the conceptual models
that generated the research questions. These conceptual models include the Social
Ecological Model of Health, the Minnesota Public Health Intervention Model and
the Bolman-Deal Organizational Model. The philosophy of health care delivered by
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88
nurses caring for foster children is a product of the Social Ecological view of
health determinants and health interventions. This model defines health in terms of
the interaction between biology, behavior and the environment. The emphasis for
health care is on upstream interventions of health promotion and disease prevention.
The social, political and economic environment affects health for the individual,
family and community aggregate.
The Minnesota Public Health Intervention Model operationalizes this model
of health for community health nurses. The PHI model is based on three concepts,
population-based interventions, practice at multiple levels (individual, family,
community and system) and independent nursing functions. This model organizes
community health nursing interventions into 17 categories, which define the actions
of the foster care and school nurses. The emphasis is the health teaching to provide
upstream primary prevention.
The care of the school-age foster care population occurs in two different
organizational contexts. The Bolman-Deal Organizational Model will help the
researcher view the organizations in which the nurses work. This model employs
four frameworks, structural, human resource, political and symbolic, to analyze the
organizational philosophy. These frameworks provide a lens to view the rules, power
issues, human side and culture of the organization.
Figure 1 describes the relationship of the research questions to the data needs,
data sources and instrumentation. For question 1, the nurses’ intentions were
analyzed in terms of their relationship to the Social Ecological Model of Health. For
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89
question 2, the actual practice of the nurses was viewed using the Public Health
Interventions Model. For question 3, the organizational structure was analyzed in
terms of the Bolman-Deal Frameworks. Question 4 was answered by analyzing the
organizational information from question 3 and the practice information from
question 2.
Development of Tools:
Interview guides were developed with input from experts in the field. These
experts included public health/community health nursing faculty and practicing
foster care and school nurses. Los Angeles County Department of Health Services
Public Health Nursing Education staff reviewed mapping criteria using the PHI
model. These educators have developed the Los Angeles Public Health Nursing
Model.
Interview guides and mapping criteria were field-tested in the school and
Child Welfare System to assure that the questions and criteria were understandable
and usable. Suggestions from sample general informants were incorporated into the
tools. The interview guides evolved with the experience of the researcher and the
findings of the interviews.
Instruments:
The researcher designed the interview guides to answer research questions
one, three and four. The interview guides were based on the theoretical foundations
of the study, the Social Ecological Model of Health, Minnesota Public Health
Interventions, and the Bolman-Deal Organizational model. Separate interview tools
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90
were designed for each of the population groups: foster care nurses, school nurses
and social workers.
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Figure 1. Relationship of research question to instrumentation:
Research Questions Data Needs Data Sources Instrumentation
1. What do nurses want
(intend?) their role to be in
providing health
promotion/education for
foster care children and their
families and how are these
role perceptions similar or
different between the school
setting and the child welfare
setting?
* Nurses' perceptions of their
role
■ Job description
■ Interviews with nurses working
in schools and in child welfare
■ Documents containing job
descriptions
■ Interview guides
2. What strategies and
interventions do nurses
actually use in their role of
providing health
promotion/education for
foster care children and their
families?
■ Description of actual practice
in each setting
■ Observations of nurses’ work in
each setting
■ Survey of types and frequency of
interventions
■ Mapping criteria for
activities
■ Survey listing the 17 PHI
interventions and their
definitions
3. What similarities or
differences o f the
organizational structure of
schools and the child welfare
system affect nurses’ role in
the health of foster care
children and their families?
■ Description of the structural,
human resource, political and
symbolic frameworks in
reference to nurses' work in
schools and the Child Welfare
system
■ Interviews with nurses,
administrators, and a social
worker
■ Interview guides
4. How does the organizational
context of the school and the
child welfare system affect
the nurses’ choices of
services, clients and
communication?
* Data from questions 2 and 3
* Interviews with nurses
■ After data collection and
analysis of questions 2 and 3,
interviews with nurses will need
to be done to clarify researcher’s
findings
■ Interview guides
92
Although the researcher had a clear idea of questions that need to be asked to
answer the research questions, the interview guides were modified through the
interviews. The answers evoked by initial questions shaped subsequent ones. The
interview guide was reviewed after each interview to incorporate some of these vital
follow-up questions that yielded useful data. This required the interviewer to ask a
question, hear an answer, interpret its meaning, and frame another question to either
dig into the meaning for redirect the person’s attention to an area more relevant to
the research (Babbie, 1995).
Observations of nurses performing their role required mapping criteria based
on the 17 distinct nursing interventions described in the Minnesota Public Health
Interventions Model. The mapping criteria included definitions of the interventions,
examples of the interventions, and instructions for coding. The observations were
compared to the subjects’ answers to the written survey they completed. The
nurses’ actual practice (as evidenced by survey and observations) was analyzed in
relation to the tenets of the Social Ecological Model. The observations and survey
allowed better triangulation of data to answer research question number two. Figure
2 illustrates how PHI interventions relate to the Social Ecological Model.
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93
Intervention Category
Disease and health event
investigation
(actual or potential)
Health Teaching
Case Management
Figure 2
Public Health Interventions
Relationship to Social Ecological Model
Example of Intervention
Identify at-risk pre-school foster children for lead
poisoning (lower socio-economic status, living in
old housing stock) and instruct foster families on
ways to prevent lead exposure.
Nurse reviews lead testing documentation for
lead poisoned foster child.
Nurse instructs pre-teenage foster child/ family
about risk of tobacco use.
Nurse advises a smoking foster care teen of anti
smoking programs.
Nurse makes sure that the new foster family
continues to see the primary care provider for
routine preventive care.
Nurse identifies that the foster child has not
continued the seizure medication and does not
have a health provider. Nurse connects foster
parents to appropriate health services.
Relationship to
Social Ecological
Model
Upstream - meets
tenets of model
Downstream - less
reflective of model
Upstream - meets
tenets of model
Downstream - less
reflective of model
Upstream - Meets
tenets of model
Downstream - less
reflective of model
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94
The Public Health Intervention Model has specific definitions of each
intervention and examples of each intervention for different populations (e.g.,
community, systems, and individual/family). These definitions were used to assure
reliability in the mapping of the nurses’ actual practice. Also, to further assure
reliability, two independent raters were employed. Figure 3 is an illustration of the
Minnesota Public Health Intervention Model.
The interviews and analysis of job descriptions provided the data for describing
the organizations. The analysis of the organizational model included dominant
frame, organizational strengths and weaknesses, and how the organizational structure
affects the nurses role and their performance of the needed interventions. Figure 4
illustrates examples of interview questions for each organizational frame and
analysis ideas to assess the frameworks.
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95
Figure 3
Public Health Interventions I I
Examples from Public Health Nursing
June 2000
L *.! " U * ' A I M in n eso ta D ep artm en t of H ealth
D ivision of C om m unity H ealth S e rv ic e s
ID E PA BlMtHtorHiftUHl
P u b lic H ealth N ursing S ectio n
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96
Figure 4
Interview Guide for Research Question # 3 based on Bolman-Deal
Organization Model
Organizational Frame Sample Questions/Document Review Goals Analysis Requirements
Structural
(Analysis highlighting issues
o f control)
Human Resources
(Analysis focusing on
attention to commitment)
Political
(Analysis focusing on
“influence” aspects of
organization)
Symbolic
(Analysis on organization’s
cultural patterns)
Adapted from EDPA 599 class notes, Leadership and Organizational Behavior, Summer 1999
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What are the stated goals o f the
organization?
How are activities coordinated?
How are decisions typically made?
What types o f interdependencies (e.g.,
between social workers and nurses, between
teachers and nurses) exist?
How are these interdependencies managed?
How do people relate to each other?
Do people feel able to influence their work
and larger organizational issues?
Do people listen to one another?
How people work
together.
Hierarchy of authority.
Ways to coordinate
activity.
Levels o f trust between
employees.
Informal relationships.
Are there coalitions between groups?
Do nurses have access to those people in
power?
What is the relationship between power and
authority?
Do nurses have discretion in that
relationship?
Which individuals or
groups have power,
sources o f power.
How active is the informal network?
How cohesive is the group o f nurses?
Do nurses share a core set o f values about
their work?
Core values o f
organization.
How committed people
are to the place.
97
Data Collection
Arranging for the Study
The researcher contacted the Director of Public Health Nursing, Margaret
Avila, RN/NP, MSN, MS, to propose the need for the study. Ms. Avila was very
positive about the study and shared with the researcher the new Public Health
Nursing Model that she and her colleagues have worked on. This model included the
Minnesota Public Health Nursing Interventions as part of the four-prong approach
based on the nursing process. The four parts to the model are assessment, diagnosis,
intervention and evaluation. This model has gone through numerous revisions over
the past year, but has always included the Minnesota Public Health Interventions
Model, one of the frameworks for the study. All public health nurses in Los Angeles
County have or will be inserviced on this model by the nursing education group
within the public health department.
The researcher approached both Bridget Ward, MS, RN, PHN, Nursing
Director of Public Health Programs, CHDP and Sharon Marie Leahy, RN, MS,
Program Specialist of DCFS with the idea of researching the nurses who work in
public health. Both of the administrative nurses were enthusiastic about the
proposed research. CHDP and DCFS supervisors used their staff meetings to
introduce the research objectives to the staff.
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9S
The researcher met with the Director of Nursing for the Pasadena School
District. The Chair of the Dissertation committee helped facilitate the introduction
of the researcher to the appropriate administrative people within the school district.
The researcher completed the necessary human subjects review for the
Rossier School of Education. The USC approval for the research were submitted to
DCFS, CHDP and the Pasadena School District. The researcher complied with all
additional institutional review required for the Child Welfare Department, Los
Angeles County Department of Health and the Pasadena School District. .
Procedures for Data Collection
All 13 interviews were face-to-face. Interviewing in person allowed the
researcher control over questioning and also allowed for questions about historical
data (evolution of the role). Interviews were semi-structured and open-ended, and
were recorded with an audiotape. All interviews were transcribed. The purpose of
the research was to view their nurses’ role and organization through the nurses’ eyes.
Creswell (1994) describes guidelines to structure interviews. The researcher
has adopted these guidelines to include:
1. Heading for interview form includes a space for the category of the
interviewee (key informant, general informant, social worker); place of
employment (DCFS or CHDP or school); demographic information
including date, time and place of interview; interviewee data including
length of working in the foster care.
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2. Instructions for the interviewer’s opening statements include who the
interviewer is and the purpose of the research. The researcher conducted
all interviews for the study.
3. Key research questions to be asked (as identified in the Instrumentation
section), probes to follow key questions and transition messages for the
interviewer
4. Space for recording the interviewer’s comments including reflective
notes.
Observations usedthe mapping criteria based the PHI Model. Each distinct
action will be identified as an intervention. Each action could have one PHI
attached to it.
Data Analysis
The process of data analysis required that themes be synthesized, conclusions
drawn, and recommendations made for further investigations. Patterns of data were
examined to identify principle ideas that ran throughout the data, based on the four
research questions which, in turn, addressed the purpose of the study. Major
thematic statements were then formulated from the patterns of data to substantiate
the findings. Following careful consideration of the research findings, conclusions
were reported and recommendations made in relation to policy, education, practice,
and research in Chapter 5.
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The analysis of the interview data followed the guidelines for
phenomenological research. Each interview was broken into segments and the
researcher looked for meaning units and themes in the segments. Then the meaning
units and themes were compared across interviews and finally the findings were
synthesized and validated by checking with the participants. The researcher used
structural descriptions. The structural descriptions take into account regularities of
thought, judgments and recollection that underlie the experience of the phenomenon
of nurses working in foster care and give meaning to it (Gall, Borg & Gall, 1996).
The interpretational analysis of the data followed the following sequence:
identifying meaningful segments or analysis units, developing categories, coding
segments, grouping category segments, and drawing conclusions. The interview data
was broken up into segments. The segments consisted of text that contains individual
items of information that are comprehensible outside of the entire text. Next,
categories were drawn from the data and from the research questions. A category is
a construct that refers to a certain type of phenomenon mentioned in the database.
All interviews were typed to allow analysis. The researcher did the analysis by hand
without using a computer program.
The segments were coded and grouped by categories. For these categories,
the researcher defined the concept, gave it a label, and specified guidelines for
determining whether a segment in the database was or was not an instance of the
category. The researcher used constant comparison to continually review the
segments within and across categories (Gall, Borg & Gall, 1996). After an
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exhaustive review of the coding, the individual categories, and the relationship
between the categories, a complete picture of the phenomena of nurses working in
foster care emerged. From the picture, the researcher developed themes or
characteristic features. Since this study used multiple interviews, the researcher was
able to check the generalizability of constructs and themes across subjects.
Differences and similarities between cases based on organizational context helped
answer research questions 3 and 4.
Each questions called for specific categories of information. Question 1
looked at the nurse’s perceptions of their role and their actual job descriptions. The
Researcher evaluated the perceptions in relation to the Social Ecological Health
Model and the PHI Model. Categories were derived from the data and the theoretical
frameworks. Question 2 looked at actual practice. The observations and survey
followed the guidelines for the categories in the PHI model. Question 3 reviewed the
data from interviews and written job descriptions in regards the four structural
frameworks in the Bolman-Deal Model for the two organizations studied, Child
Welfare System and the School. Research question 4 required analysis of data from
questions two and three. The Researcher’s findings were member checked with the
interviewees
Verification of the internal validity of the Study occurs by triangulation of
data as well as member checking and clarification of researcher bias. The researcher
had an ongoing dialogue with the key informants about her analysis of data. If
further clarification of the data was needed, repeated interviews were done. The
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researcher’s role description articulates the researcher’s bias and experiences in
the field being studied. The researcher detailed the analysis process to counteract
any possible bias she might hold.
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103
CHAPTER 4
FINDINGS
Introduction
This qualitative study is based on interviews, observations, and a survey. The
primary focus of data collection is interviews with 12 nurses working in the child
welfare system and the school district and one interview with a CSW. The
researcher used these interviews to derive the phenomenological perspective of the
nurses working with children in foster care in terms of what they wanted to do for
this population of children and their perception of the organizational structure of
their workplace. The analysis of the differences and similarities between the nurses’
perceptions of the two settings, school and child welfare, relates to their ability to
function within their role. A survey of the frequency of interventions and detailed
observations of nurses working in their jobs provided the data to analyze the actual
practice of the nurses.
The presentation of the findings gives detailed descriptions of (a) what
nurses want to do for foster children and their families in the school and child
welfare settings, (b) what interventions nurses practice in caring for foster care
children and their families, (c) the similarities and differences between the structure
of the child welfare system and schools and (d) how the organizational context of the
schools and children welfare affect nurses’ choices of services, clients and
communication.
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104
Research Question One: Nurses’ Intentions in Providing Care and
Similarities/Differences between School and Child Welfare Setting
Framework for Research Question One
The interviews were the primary sources of data to answer this question. The
data was grouped into the categories of goals of care, purpose of care, restraints to
meeting goals, methods, timing, interventions, and perceived causes of health
problems. A comparison of the school nurses to child welfare nurses found both
differences and similarities within the categories. The CHDP nurses and the DCFS
nurses were grouped together as child welfare nurses since analysis of their job
descriptions found their role was almost identical. Even though they report to two
different organizations, the nurses have the same job responsibilities within the child
welfare system and work physically in the same location, DCFS offices. Finally
there is a summary comparing the themes of school nurses to child welfare nurses.
Nurses ’ Intentions in Providing Care
Goals o f Care
Nurses in both settings identified the need to provide holistic, preventive
health care to children in foster care. The health care should include the whole
child’s needs: physical, psychological, and developmental.
..sensitive to the needs of this special population.. .think about the
emotional, social and physical aspects that are special to them
(School Supervisor)
...mental health, dental health, physical health needs,
developmental ...everything (CHDP Supervisor)
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105
Prevention of illness included identifying problems, clarifying the health needs,
meeting those needs, and returning the child to good health. All nurses wanted to
identify health needs early to prevent poor health.
What we should be doing on a daily basis is assuring that all the
health care needs of these children are being identified, they have
been addressed, and we follow up with them.. .(CHDP Supervisor)
..monitoring the health status of all the children within our system..
(DCFS Nurse #2)
..more than anything else do preventative kinds of teaching and
care..(School Nurse #3)
Purpose o f Care
The purpose of meeting the goal of providing preventive, holistic health care
depended on where the nurses worked. The institutional (school and child welfare)
mandates provided a basis for why the nurses wanted to meet the goal. The school
nurse’s goal was to keep the foster child in school so the child had a chance to learn.
The child welfare nurses’ purpose was to ensure the safety of the child by making
sure health needs were being met.
Restraints from Providing Care
Both groups of nurses identified that lack of time as a significant restraint in
meeting their goals. School nurses felt they have too many schools to have enough
time at any one school to make a difference. A health aide staff the health office in
each school five days a week, but the school nurse is only there a few days of the
week depending on the size of the school.
..a nurse available 5 days a week for the child, which is not in the
budget because I think again, needs arise, unforeseen needs, that to
have this person available while the school is in session, I think is
really important. (School supervisor)
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106
..but there are 760 kids here and I am only here two days and I am in
another school. That is not enough for healthy kids. (School #2)
Child welfare nurses have high caseloads which did not allow them enough time to
properly service the population.
...our caseload is 1 nurse to almost 600 children and the ideal is 1
to 200 (CHDP Supervisor)
If we had a good number of families we could really case manage
the health of the children the way it should be done. (DCFS #2)
I’m responsible for 4 different units and each of those units has
about 8 CSWs underneath a supervisor and each CSW has 30-45
cases. That’s probably 1000 kids they want each PHN in this office
to handle, which is a lot. We need more nurses. (CHDP #3)
Along with lack of time, both groups of nurses identified that lack of access
to the population resulting from organizational limitations restricted their ability to
service this population. All school nurses noted that nursing care needed to be the
same for the foster child as any other child in the school, making the foster care
population difficult to reach.
..I don’t want to use the word invisible, but they really do blend
in.. .we don’t have a single program that specifically targets the
foster kids. (School Nurse #2)
..care that is provided for foster care students should be no
different than the care that is provided for the regular population.
(School Nurse #1)
..care should be uniform across the board for children..(School
Nurse #3)
The difficulty accessing children for the child welfare nurses resulted from
their restricted role as a consultant and their inability to actually obtain the medical
records needed to do their job. The nurses’ job description identifies the nurses’
health case management responsibilities, but the CSW is the legal case manager for
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107
all foster children. Therefore, CSW’s often acted as “gatekeepers” to reaching
the foster children who need services.
With some social workers we work in that capacity and we are
involved from the beginning. We know the kids and we follow up
individually with their health. With other social workers we only
become involved if there is a problem, so it is variable what we do.
(DCFS #1)
Actually in my unit my supervisor, at one point, had a worker walk
around the whole unit to get those medical files out to give them to
the PHN because she wasn’t getting them for some reason. (CSW)
Not only did the child welfare nurses not have access to the foster child’s
DCFS files, they were unable to obtain medical records from health care providers.
Basically much of their job was a paper chase trying to assemble a clear picture of
the health care of the child. This paper chase has been complicated by the federal
government’s Health Insurance Portability and Accountability Act (HIPPA)
guidelines, which will soon make access to medical records more difficult.
We will contact physicians, we will try to make referrals. With the
new HIPPA guidelines, we will have no more electronic
communication and a lot of our social workers rely on receiving
information from the doctors that way. (DCFS #2)
So tracking down the medical records, which is essential to my
job, becomes actually the most time-consuming part of my job.
(CHDP #2)
The child welfare nurses identified more restraints than the school nurses.
The child welfare nurses expressed that their job description restrictions did not
allow them to fully utilize their capabilities in meeting the health care goals of this
population. Since they were health case managers, they were unable to “lay hands”
on the child. This is contrary to their educational training as RNs and was different
than any of their previous jobs.
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108
Our MOUs, (Memorandum of Understanding), we can’t physically
touch a child, which is difficult for us. We are used to getting in
there and doing full head to toe assessments, disrobing the patients
and things like that. Just doing something as simple as lung
sounds with a stethoscope. (DCFS #2)
...do assessments in the home...basically it is all visual and history
taking.. .1 know there are other public health programs where the
nurses go in a do weight; they do everything with the baby. I think
that would be good. (CHDP #3)
Another restraint for child welfare nurses was the difficulty working within a
health care system that is really a non-system. The lack of communication between
providers and the inadequate numbers of specific specialty providers made the
nurses’ job harder. The foster child suffered from being cared for by a health care
delivery system that was viewed as disorganized and unable to meet the needs of a
high-risk population.
Some of these children with asthma and other pulmonary problems
do not see a pulmonary specialist (CHDP#1)
I had a child who actually upon reviewing his chart suffered from
extraordinary polypharmacy as a result of having seven physicians.
It came to our attention actually through the hotline because
somebody in the school system reported that this child was in a
stupor every single day, every hour of the day. (CHDP #1)
It is sort of embarrassing to look at how the medical profession has
just become a factory. Each physician does his thing and does not
talk to another doc. (DCFS #2)
The lack of continuity within the health care system made the nurses frustrated and
angry and further restricted their ability to meet the health care goals of the foster
care population.
Methods
The school nurses and child welfare nurses agreed that multidimensional
health care was needed to meet the goal of holistic health. This type of health care
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109
included frequent physical exams by qualified health care providers. Since all
foster children are considered “high risk,” yearly CHDP exams are available to all
children on MediCal. The most pressing issue for these kids was the need for
continuous, available mental health care. Both groups of nurses identified mental
health issues as the top priority for comprehensive health care.
..having negative behaviors because, for example, there is one girl
who is twelve years old and has been shifted to 11 foster homes.
Mentally that is devastating. (School #3)
I remember a social worker coming to me who brought a whole
bag and this child was on 6 or 7 psychotropic medications....He
did have some psychiatric problems, but it was due to the
medications themselves. Our mental health system is just in poor
shape, especially in the Antelope Valley. (DCFS #2)
The mental health aspect is the one key that really needs to be
addressed for all theses kids right now. The mental health
resources are stretched so thin, we target only the neediest of the
kids. (CHDP Supervisor)
The school nurses expressed that with more time availability that their job
description allowed them to meet the necessary health care needs of the foster
children within the schools. The difficulties in meeting the school mandated health
care needs were primarily with locating health records due to the constant movement
of these children. The foster parents were often unable to provide a picture of the
health history and the required immunization record.
Once they entered the (school) system, if there was some way to
get this information so as they moved from place to place, the
fam ilies w ould have an idea o f what is going on. (S ch ool #3)
..the foster parent doesn’t have information in terms of the health
of the foster child. The social worker would provide us the
immunization records ...those immunizations are also incomplete.
(School #2)
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110
The lack of health records can keep the foster child from attending school. The
school nurse supervisor noted that the requirements for health records, specifically
immunizations, is contrary to the United States President’s “no child left behind”
dictum. There may be some policy changes in the future in which foster children are
categorized as homeless so the health requirement can be waived.
..when a foster child is admitted to school, he necessarily needs to
show his immunization records and to show his health records.
Homeless children don’t. And while that sometimes can be a
problem especially if the child does have special health concerns,
we want to make sure the child is in school and learning as much
as they can. (School Supervisor)
I have just learned from one of our educational liaisons that foster
children are going to have the legal status of homeless and the
reason for that is that the schools are being really obnoxious
sometimes about letting kids into school without immunizations.
(DCFS supervisor)
The child welfare nurses expressed the need to use a team approach in which
they worked more closely with the CSWs, foster parents or birth parents, and health
care providers to manage health care needs. The nurses strongly felt that their role
within child welfare should be an integral part of the multidisciplinary team.
We’re a team that needs to work together to get the child through.
We’re not working together really as a team at this time. (CHDP
Supervisor)
Definitely my strongest thing is between the PHN and the CSW to
get this information to the caregiver.... Some of these caregivers
will sit without a push. (CSW)
These kids will get what they need when the foster parents discuss
health recom m endations w ith the nurse. Social workers are not
focusing on health needs so ... .we need to work as a team and we
can’t do it all ourselves. (CHDP Supervisor)
The team approach was supposed to be increased by having the child welfare nurses
(specifically the DCFS nurses) involved in the orientation of CSWs and foster
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I l l
parents, but some nurses felt that more exposure was needed to really make the
team idea work.
Need more involvement in the training of social workers.. .DCFS
is doing training now but somehow it does not translate into the
role that they are supposed to do. Something’s missing. (CHDP
Supervisor)
In order to become a foster parent or even a relative foster parent,
there are classes that are offered that are required and the nurses
take part in offering those classes. (DCFS Supervisor)
Timing o f Care
The timing of the nursing care depended on the institutional setting. School
nurses felt that they had easy access to the population of foster children, therefore
they wanted their interventions to be ongoing. School nurses did not feel that
teachers acted in any way as “gatekeepers” for their students. Child welfare nurses
on the other hand wanted access from the beginning of the child’s entrance into the
system, but primarily provided care upon referral from the CSW. These referrals
were sometimes ongoing or only during crisis situations depending on the particular
CSW.
..every time the social worker has a concern, goes to the house,
something doesn’t seem right or they get the feeling that the foster
parent is unable to produce any paperwork that they’ve been to a
physician of any kind and then they ask us to follow up. (CHDP
# 1)
We are constantly putting out fires. (DCFS #2)
The best way is when the child enters the system and that’s what
the state said when we started out.. .But LA’s DCFS office had
trouble targeting the ones entering the system.. .so we ended up
focusing on the kids that they brought to us and those might not
have been the kids that were the neediest and the highest risk.
(CHDP Supervisor)
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112
The child welfare nurses recognized that true primary prevention needed to
actually occur prior to the child’s entrance into the system, when the family was
stressed and an investigation was occurring
I believe that by being proactive at the beginning we can actually
keep some of these kids out of the system by referring them to the
appropriate resources and helping the family get plugged into what
they need. (DCFS #3)
There’s a lot of urgency in that unit (emergency response unit)
from the standpoint of a court date is pending, the court needs to
know the medical issues and we interpret them in English so the
court clearly understands what is going on with the child. (CHDP
#2)
The importance of early involvement of the nurse was especially critical
when a child had physical or mental problems. Removal from the home could
disrupt care and potentially cause significant harm to the child who did not have their
medical equipment or medications. Child welfare nurses felt they could be
instrumental in assuring continuity of care during a significant time of stress. The
nurses identified that changing homes and hospitalization was a pivotal time for their
involvement.
The kids are often detained from the home, let’s say a child is
asthmatic and would normally be using a nebulizer and taking
medication of some kind.. .People are upset, parents are upset and
maybe the police are involved. The child is taken from the home
and the equipment is left behind. Nobody is even aware that the
child has asthma. (DCFS #1)
The social worker would be the primary contact for social
issues...in the hospital they don’t or may not understand what
they’re told and I think it is real important that we have team of
nurses.. .as the contact person to clarify information. (DCFS#2)
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113
Interventions
School nurses intervened in the health of foster child primarily to enable the
child to stay in school. The interventions included providing continuity in health
care by using referrals, therapeutic use of self, and providing standard health
education. The child welfare nurses intervened to help the foster child meet his or
her full potential, a more life long goal. This goal required more comprehensive
interventions, including complete health management and education. Both groups of
nurses noted that the inadequacies of the foster parents were detrimental to their
ability to intervene successfully. The child welfare nurses included difficulties with
complete records (health passports) as restraining factors to successful interventions.
School nurses identified the foster care children as high risk, but felt that the
health care management was primarily done within the child welfare system. They
were able to make referrals when specific health needs were noted, yet this was not a
priority for school nurses.
We do have connections that allow us to provide referrals or actual
hands on help. (School #1)
They get medical and there are physicians who will take care of
them within the community. We make referrals if need be.
(School #3)
The psychiatric nursing intervention of “use of self’ to provide comfort, caring and
emotional support to foster children was stressed by the school nurses. Their daily
contact with students and their desire for more time in each school could make this
intervention a powerful tool in caring for foster children.
I think that because the home placement is so iffy... to have a
relationship with somebody that means something is very
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114
important. It could be a teacher, it could be the nurse at the school.
(School Supervisor)
You need about 50 % more hug time for the foster children.
(School #1)
Child welfare nurses identified the need for more complete health case
management for foster children in their caseloads. This case management included
both preventive services like yearly physical exams and specialty services to meet
identified health care problems. The child welfare nurses wanted to know their
children’s needs intimately so they could make appropriate and needed
recommendations. They also wanted to assure that the caregivers would follow
through on the care needed, and the social workers would take their
recommendations seriously.
We would know our kids, we would know if they were due for a
follow up for a specialty problem. We would communicate with
all the various health care professionals involved with the
child.(DCFS#l)
It’s up to the CSW to do something about it because they’re the
case managers. We can’t go and put them in a headlock and make
them do what we feel is really necessary and appropriate. (CHDP
#3)
I don’t have medical orientation and my only source is my PHN.
Even if I were to talk to the doctor.. .1 need the nurse to read what
the doctor writes. (CSW)
Part of the complete case management included better access to the foster
children. Child welfare nurses wanted more home visiting with the foster children
and foster families. Presently nurses do home visiting infrequently and only upon
the request of the CSW.
I would encourage nurses to do a lot more home visitation than
they do.. .We go with the social worker; we don’t go on our own
because the social worker knows a lot of other stuff that’s going
on. (DCFS Supervisor)
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115
Some of the other smaller counties, that have a smaller foster care
program, the nurses are able to go out and make more home visits.
I think Orange and San Bemadino counties, the nurses will go out
on practically all emergency responses. (DCFS #2)
School nurses felt foster children’s health educational needs were similar to
those of any other school child. This was consistent with the idea that foster children
are not singled out by the school district. One school nurse noted that hygiene issues
were important to target immediately for this population.
Child welfare nurses recognized the need for comprehensive health education
for the foster parent. The nurses noted varied educational needs including the initial
training to become a foster parent, specialized training for caring for the “medically
fragile” foster child, utilizing the IEP (Individualized Education Plan) process in the
schools, and dealing with the health care delivery system to receive both preventive
and health problem services. The child welfare nurses realized that the better the
caregiver is, the better the child will be cared for.
We have so many kids that need IEPs and have ADHD (Attention
Deficit Hyperactivity Disorder) and can’t sit still and are having a
bunch of school problems. Medical and educational teaching is
right up there equally important. (CHDP#3)
There’s a lot of education on well child.. .immunizations.. .1 think
we are doing a much better job today trying to get copies of those
immunization records. (DCFS#3)
Specific health issues needs included anemia, head lice and especially asthma.
I keep on return back to asthma. I’ve had kids on the ambulance
weekly and we don’t know what’s wrong with them. We don’t
know what is triggering it. (CSW)
Both school nurses and child welfare nurses identified the foster families as a
problem in terms of supporting interventions. Although some foster parents were
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116
eager to care for their charges, the nurses noted many were incompetent,
uninformed or poor caregivers.
Families don’t have a clue to what has already occurred with the
youngster (School #3)
Many times these kids are dumped into a foster parent’s lap
without any information and these parents have to deal with what
is given to them in the dark. (School #2)
(Foster) mom brought the child in for a (DCFS) office visit and
this is a child who is having seizures and needs two anticonvulsive
medications and I asked her to show me how to draw up the
syringe and she did not have a clue. (CHDP #2)
Child welfare nurses were especially wary of kinship care. They found that relative
caregivers hindered their ability to intervene in health care issues.
I know it’s a lot of people’s opinion in the office that relative
caregivers can be a worse case scenario than if it was just a non-
relative caregiver. (CHDP#2)
People who are taking care of our children are their relatives and
sometimes the apple doesn’t fall far from the tree, and so even
though its grandma or auntie they may also be operating much
more in a crisis mode. (DCFS Supervisor)
A large portion of child welfare nurses’ time was spent updating and
completing the Health and Education Passport. The nurses felt the passport could be
a powerful tool in assuring continuity of care for each foster child. The passport has
information about the medical problems of the child, health care provider visits,
immunization record, and summary statements about health issues. Unfortunately
many of the passports were incomplete, out of date, or poorly done. Caregivers
should have a copy of the passport so they are aware of all the child’s needs, but
CSWs did not consistently give these documents to foster parents and foster parents
often did not share the passports with the child’s physician.
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117
I think it would be beneficial to the doctors although I have yet to
receive a call from a doctor to say “hey this thing really helped me
out.” (CHDP #1)
The black binder with all the health information in it, including the
health passport. It goes with the child to the new caregiver. I
would say that only a relatively small percentage of passports are
complete and up to date. That is a big push now. (DCFS#1)
Causes o f Poor Health
School nurses and child welfare nurses differed considerably in their
perceptions of what causes health issues for foster children. School nurses viewed
the child welfare system as the cause of poor health. Child welfare nurses
recognized the broad determinants of health including poverty, socio-cultural issues,
historical health care problems, as well as the issues brought on by entering the
“system” and living within the “system.”
School nurses saw the child welfare system’s impact on the health of foster
children was caused by the constant, frequent change of placements. The foster
parents were uninformed about the children and their health care records were
incomplete since the records did not seem to move with the child. The changes in
foster homes caused the foster child to have less continuity in their health care.
Child welfare nurses agreed that this is a part of the problem.
When a child sees the same medical provider there is a
relationship... .instead of these children are going from different
clinic to different clinic. They don’t know that the child m ight
have had 4 or 5 ear infections last year. (School Supervisor)
A lot of these kids are bounced from one foster care home to
another, so they are always behind. (DCFS#2)
The child welfare nurses included a broad expanse of reasons for the poor
health of the foster child. The socio-cultural issues associated with poverty included
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118
low nutritional status, lack of prenatal care, and poor living environment. These
nurses saw the whole picture of why these children come into the “system” at a
disadvantage.
A lot of parents have other priorities (other than health care)
sometimes even food, shelter, clothing and (health care) doesn’t
happen, and when it happens it is the minimum. (DCFS
Supervisor)
A lot of these kids have a very bad start in life, whatever the reason
is. Compound that with poor living situation, inadequate nutrition,
and add on the layers of all the bad things that can happen in life.
(D C FS #1)
The nurses recognized that the removal from the child’s family home as a result or
neglect or abuse compounded the already chaotic life of these children. The abuse
could be physical, related to prenatal or postnatal alcohol/drug use, or multiple
neglect. The foster child’s health issues resulted from this varied assault.
..removal of the child from the house in itself is traumatic so these
kids, besides what type of birth problems they are bom with,... are
more needy and at risk. (CHDP Supervisor)
It is sad but we see a lot of the children have been prenatally
exposed to some type of drug.. ...bom with a lot of complications.
(CDHP #3)
One child welfare nurse told of a particular birth mother who used the
“system” to her advantage. Her socioeconomic conditions were such that she had no
other choice than give her child up to assure that his health needs were met. This
story recognized the complexity of the situation when parents do not have the
personal resources and the community does not support parents.
The mother had 5 or 6 children and one child was extremely sick
and it was more that she could manage. She didn’t want to give
the child up, but at the time knew she could not meet his medical
needs.. .the medical benefits for the child are far greater (in the
system) So, I don’t know if it is selfish or selfless. (CHDP #1)
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119
Summary o f Themes
The central goal for all nurses was providing holistic, preventive health care
to foster children. The purpose of the care depended on the organization’s vision.
School nurses wanted to ensure school attendance and thereby a chance for the child
to learn and child welfare nurses wanted to ensure the safety of the child by meeting
their health needs. Both groups of nurses identified the restraints of time and access
to the population. Child welfare nurses added the difficulties working within the
health care delivery system and within their limited job description as further
restraints.
School nurses and child welfare nurses felt that providing multidimensional
health care with an emphasis on mental health would meet the goal. School nurses
expressed that they could meet this goal within their job responsibilities. The child
welfare nurses felt they needed to be part of a multidisciplinary team to meet the
goals. The timing of the interventions was ongoing for school nurses but early
(even before the child entered the “system”) for child welfare nurses. Interventions
differed for the two groups of nurses. School nurses felt that case management
should be provided by the child welfare system and the school nurses’ role was to
make occasional referrals and provide standard (the same as other students) health
education and care. The child welfare nurses identified the need for a broader role of
complete health case management with documentation of the health picture in the
Passport, and provision of comprehensive health education to the entire family. The
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120
poor quality of the foster parents made the interventions more difficult for both
groups of nurses.
Finally, the school nurses and child welfare viewed the causes of poor health
for foster children differently. The school nurses viewed the problems of the child
welfare system as the cause of poor health. Child welfare nurses acknowledged the
role being in the “system” plays, but also identified socio-cultural issues associated
with poverty and the health issues resulting from lack prenatal care to drug exposure
during birth as important factors in these children’s poor health.
Research Question Two: Interventions used by nurses in their roles
Framework for Research Question Two
The survey questionnaire and observations were the primary sources of data
used to answer this question. The list of the 17 interventions was derived from the
Minnesota Public Health Intervention Model. The data is organized into four
sections: reported interventions, observed interventions, comparison of reported to
observed interventions, and summary. The observations were coded by the
researcher, and then separately coded by two independent coders. The first coder
agreed with the researcher 77% of the time and the second coder agreed with the
researcher 84% of the time. The researcher decided to use her own codes since she
actually observed the nurses. Also the independent coders did not agree with each
other when they disagreed with the researcher. Since the researcher observed three
school nurses and six child welfare nurses, the observations and survey results were
weighted to allow for comparison of reported to observed interventions.
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121
Reported Interventions by Survey
Figure 1, Intervention Results from Survey, displays the frequency that
school nurses and child welfare nurses reported they employed the 17 Minnesota
Public Health Interventions. The interventions were identified as being completed
either daily, weekly, monthly, occasionally, never or not applicable to their job.
Figure 1 compares surveys completed by the school nurses to the child welfare
nurses. There is no weighting of results; each nurses’ response is included in Figure
5.
Figure 5
Intervention Results from Survey
Possible
Interventions
Daily Weekly Monthly Occasionally Never N/A to job
description
Surveillance s, S2 S3
c, c 3 c 4
C5 C6
c 2
Disease and Health
Event Investigation
S2 s3 c 3
C4
C6 S iC 2 c, c 5
Outreach C4 S, c, c 3 S2 c 6 C5 c 2 s3
Case Finding c, c 3 c 4
C5
s, c 6 c 2 s2 s3
Screening s2 s3 c 3
C4
c, c 2 c 6
s,
c 5
Referral and
Follow-Up
s, s 2 s3
c, c 2 c 3
c 4 c 5 c 6
Case Management s3 c, c 2
c 3 c 4 c 5
s, s2 c 6
Delegated
Functions
S, s2 s3
C5 c 6
C2 C4 c 3 C,
Health Teaching S3 c, c 3
c 4 c 5 c 6
S2 c 2 S,
Counseling s,s 2 c 3 s, s 3 c6
c, c2
C4 c 5
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122
Consultation S, C, C3
C4 C5 C6
S2c 2
S3
Collaboration s3 c 3 c 4
C5 C6
s2c, S,c 2
Coalition Building
C5
S3C6 s ,s 2c,
C2 c 3
S3C4
Community
Organizing
S,s2c,
c6
c 2 c 3 c 4 c 5
S3
Advocacy s2 S3 c,
c 3 c 4 c 5
c 6
c 2 S,
Social Marketing C .S C6 S, S2 C4C1 c 2 c 3 S3
Policy
Development and
Enforcement
c, C2 C3C4 c 5 C6 S2 Si S3
Ci = Child Welfare Nurse 1 C4 = Child Welfare Nurse 4 Si = School Nurse 1
C2 = Child Welfare Nurse 2 C5 = Child Welfare Nurse 5 S2 = School Nurse 2
C3 = Child Welfare Nurse 3 C6 = Child Welfare Nurse 6 S3 = School Nurse 3
All school nurses reported doing surveillance, referral and follow-up and
delegation daily. They said they did screening and counseling daily or weekly. Two
out of three school nurses reported advocacy and disease and health event
investigation daily. The nurses reported that collaboration and health teaching were
done daily, weekly or monthly. Coalition building was done either monthly or
occasionally. Policy development and enforcement was not done or not considered
part of the school nurses’ job description.
Five out of six child welfare nurses reported to do surveillance, case
management, health teaching, advocacy and consultation daily. Collaboration and
case finding was reported daily by a majority of the child welfare nurses. Five out of
six nurses did screening daily or weekly. All nurses did community organizing
either monthly or occasionally.
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123
The majority of school nurses and child welfare nurses reported to do
surveillance, referral and follow-up, and advocacy daily. School nurses reported that
they do delegation more often than child welfare nurses since all school nurses
reported doing delegated functions daily but only two out of six child welfare nurses
do this intervention daily. Health teaching was reported more frequently by child
welfare nurses as five out of the six child welfare nurses but only one out of three
school nurses ranked health teaching daily. Child welfare nurses did policy
development weekly, monthly or occasionally but school nurses did not do it at all.
The interventions that at least 7 out of the 9 nurses reported as doing daily
were surveillance, referral and follow-up, and advocacy. The interventions that at
least 6 out of 9 nurses reported as doing daily were case management, health
teaching and consultation. Case finding, screening, counseling and collaboration
were done daily or weekly by 7 out of 9 nurses. Coalition building and community
organizing were done monthly or occasionally by 6 of 9 nurses. Social marketing
and policy development were not done or done occasionally by 7 of 9 nurses.
Observed Interventions
Figure 6, Observation of Interventions Carried Out by School Nurses and
Child Welfare Nurses, illustrates the frequency that interventions were observed by
the researcher. The researcher recorded the nurses’ activities over a 4-hour period.
These observations were coded as one of the 17 Minnesota PHI that most fit the
action the nurse performed. Figure 6 illustrates these coded observations comparing
the frequency of interventions seen performed by child welfare nurses to school
nurses and the percentage of each intervention for each group of nurses.
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124
For school nurses, health teaching was observed most frequently and
accounted for 15.2 % of all interventions. Surveillance, disease investigation,
screening, referral and follow-up, and collaboration were observed second most
frequently at 10.9 % followed closely by delegation at 8.7%. School nurses did
some case finding and case management. They did very little coalition building,
advocacy, and social marketing; each of these interventions accounted for only 2.2%
of all interventions observed. There were no observations of
outreach, consultation, community organizing or policy development and
enforcement.
Figure 6
Observation of Interventions Carried out by School Nurses and
Child Welfare Nurses
School Child Welfare
Number o f
Interventions
Percent o f
Total
Interventions
Number o f
Interventions
Percent o f Total
Interventions
Surveillance 5 10.9 15 13.9
Disease and Health
Event Investigation
5 10.9 1 0.9
Outreach 0 0 0 0
Case Finding 2 4.3 6 5.6
Screening 5 10.9 2 1.9
Referral and Follow-Up 5 10.9 13 12.9
Case Management 2 4.3 11 10.2
Delegated Functions 4 8.7 1 0.9
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25
Health Teaching : 7 15.2 10 10
Counseling 3 6.5 0 0
Consultation 0 0 7 6.5
Collaboration 5 10.9 37 34.3
Coalition Building 1 2.2 0 0
Community Organizing 0 0 0 0
Advocacy 1 2.2 4 3.7
Social Marketing 1 2.2 1 0.9
Policy Development and
Enforcement
0 0 0 0
Collaboration was done considerably more often than any other intervention
by child welfare nurses and accounted for 34.2 % of all interventions.
They did surveillance, referral and follow-up, case management and health teaching
frequently; each of these interventions accounted for between 9% and 13% of the
total number of interventions. They did some case finding, consultation and
advocacy. They did very little disease and health event investigation, screening,
delegated functions, and social marketing with each of these interventions equating
to about 1% of their time. They did not do outreach, counseling, coalition building,
and community organizing.
The largest difference between school nurses and child welfare nurses in
number of observations was in collaboration. Child welfare nurses were observed
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126
collaborating 34% of the time while school nurses were only observed
collaborating 10.9% of the time. School nurses were observed doing disease and
health event investigation, screening, delegated functions, and counseling more
frequently than child welfare nurses. Child welfare nurses were observed doing case
management, consultation, and collaboration a higher percentage of the time than
school nurses.
The greatest percentage of time of interventions observed all nurses were
surveillance, referral and follow-up, health teaching, and collaboration. Both groups
of nurses did very little or no outreach, coalition building, community organizing,
social marketing, or policy development and enforcement.
Comparison o f Reported to Observed Interventions
Figure 7, Comparison of Survey to Observations, illustrates both a
comparison of the survey results to observations and a comparison of school nurses
to child welfare nurses. Figure 7 groups the survey into categories of the frequency
nurses reported doing the 17 interventions. Daily or weekly is defined as very
frequently, monthly or occasionally is defined as sometimes, and never of not
applicable is defined as never. Figure 7 groups the observations into categories of
frequency based on number of observed interventions.
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127
Figure 7
Comparison o f Survey to Observations
Interventions School Child Welfare
Survey Observations Survey Observations
Frequently Sometimes Never Code Number Frequently Sometimes Never Code Number
1. Surveillance xxxxxx F 1 0 Xxxxx X F 15
2. Disease &
Health Event
Investigation
xxxx XX F 1 0 Xx X X XX I 1
3. Outreach XX XX Xx No 0 Xxx xxx No 0
4. Case Finding XX XXXX I 4 Xxxxx
x
M 6
5. Screening XX X X X X F 1 0 Xxxxx X I 2
6. Referral and
Follow-Up
XX X X XX F 10 Xxxxx
X
F 13
7. Case
Management
X X X X XX I 4 Xxxxx X F 11
8. Delegated
Functions
xxxx XX M 8 Xxx XX I 1
9. Health
Teaching
xxxxxx F 14 Xxxxx
X
F 1 0
10. Counseling xxxxxx M 6 Xxxx XX No 0
11. Consultation xxxx Xx No 0 Xxxxx
X
M 7
12. Collaboration xxxx XX F 10 Xxxxx X F+ 37
13. Coalition
Building
XX xxxx I 2 Xx xxxx I 2
14. Community
Organizing
xxxx Xx No 0 xxxxx
X
No 0
15. Advocacy xxxx XX 1 2 Xxxxx
X
M 6
16. Social
Marketing
xxxx Xx I 2 x xxx X X I 3
17. Policy
Development &
Enforcement
Xxxx
XX
No 0 XX X X X No 0
Survey
Frequently = daily or weekly
Sometimes = Monthly or occasionally
Never = Never or N/A
(School nurse data weighted)
Observations Coding
15 Very frequently =F+
10-15 Frequently = F
5-9 Moderately = M
1-4 infrequently = ]
0 not observed = No
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Som e observations follow ed clo sely the reports o f the school nurses. For
school nurses, surveillance, screening, and health teaching w ere reported as
occurring frequently and were observed frequently. D isease and health event
investigation, referral and follow -up and collaboration were reported frequently or
som etim es and w ere observed frequently. D elegated functions were reported
frequently or som etim es and it w as observed m oderately.
Other observations differed from the frequency reported by school nurses.
Although school nurses reported that they do counseling frequently, it w as only
observed m oderately. School nurses reported case finding, case m anagem ent,
coalition building and advocacy frequently or som etim es, but it w as observed
infrequently. T w o o f the school nurses reported consultation frequently w hile one
nurse reported it never, and it w as never observed.
For child w elfare nurses, there w as less congruence betw een the observations
and the reported frequency o f interventions. For som e interventions, there w as
agreement. A ll child w elfare nurses stated that they do referral and follow -up and
health teaching frequently and these interventions w ere observed frequently. Five
out o f the six nurses rated surveillance and collaboration frequently and they were
observed frequently, w ith collaboration by child w elfare nurses observed more
frequently that any other intervention.
M any o f the interventions w ere over estim ated in frequency by survey
com pared to observations o f child w elfare nurses. A lthough child w elfare nurses
rated case finding, advocacy and consultation frequently, they w ere observed
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129
m oderately. T hese nurses rated collaboration and outreach either as frequent or
som etim es and collaboration was observed infrequently and outreach never. There
w as no com m unity organizing or p olicy developm ent and enforcem ent, even though
the nurses rated them as som etim es. There also w as no cou n seling seen, although
the child w elfare nurses rated it as frequent or som etim es. Finally five out o f the six
nurses rated screening as frequent, and it w as only observed infrequently.
This overestim ation o f the interventions by child w elfare nurses m ay be a
result o f the child w elfare nurses’ desire to do m ore than w hat is spelled out in their
job description and their difficulty actually getting access to the foster children’s
charts. The child w elfare nurses want to provide m ore com prehensive case
m anagem ent yet their actual role in DCFS is som ew hat lim ited, therefore the survey
results m ay reflect what they want to do w h ile the observational data reflects what
they are actually doing.
Summary
T he greatest differences betw een the type o f interventions practiced by
school nurses and child w elfare nurses are related to the independent or dependent
nature o f the intervention. The three interventions reported m ost frequently and
observed m ost frequently w ith school nurses w ere screening, health teaching, and
surveillance. T hese interventions can be and w ere observed to be practiced
independent o f other practitioners such as teachers, parents, or even the school
nursing aides. The interventions reported and m ost frequently observed with child
w elfare nurses w ere consultation, referral and follow -up, surveillance and case
m anagem ent. A ll but surveillance need other m em bers o f the team to be effective.
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130
These interventions w ere observed in conjunction with C SW s, physicians, and
foster parents.
Both groups o f nurses overestim ated the frequency that they practice
advocacy, consultation, and counseling. A dvocacy requires acting on so m eo n e’s
b eh alf w ith a focus on developing that person to becom e their ow n advocate.
Consultation is interactive problem solving w ith a client so the client can select the
best solution. C ounseling is having an interpersonal relationship that increases the
client’s capacity for self-care and coping. A ll these interventions require interaction
with a client that increases the clien t’s ability to m ake healthy ch oices, advocate for
them selves or perform self-care. These interventions require the nurse to let go o f
the process and let the client do for him self. The process is in educating, exploring
solutions, and allow ing freedom for the client to use the inform ation to make
choices. M ost o f the observations reflected the nurse intervening on b eh alf o f the
client and not involving the client in the process or choices.
Q uestion number three: Sim ilarities and D ifferences in O rganizational Structure
Framework for Research Question Number Three
The B olm an-D eal Organizational M odel provided the fram ework to capture
the nurses’ assessm ent o f how the organization w orks, where they fit within the
organization and h ow the organization affects their role. This m odel allow s the
researcher to use the four frameworks o f organizational structure, sym bols, politics
and hum an resource as a lens to develop a picture o f the nurses’ v iew o f their
organization. B y capturing the organizational influence on the nurses’ work, the
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researcher is able to analyze how the organization affects what they want and can
do in their roles.
The interview s with nurses in schools and in child w elfare and observations
about w ork setting provided the data to answer this question. The data are organized
into three categories: school, child w elfare, and com parison o f school organization to
child w elfare organization. W ithin each category, the organizational structure is
divided into four sections: sym bolic frame, political frame, human resource frame,
and structural frame. The descriptions o f the organizations are derived from the
nurses’ view point. The social worker interview is integrated into the description o f
the child w elfare system frames.
School Organization
Symbolic Frame
The sym bolic frame for the school looks at the nurses’ perceptions o f the core
values o f the school district, the school in w hich they work, and the school-w ide
nursing department. The interview s included questions about their com m itm ent to
their work, the culture o f the schools, informal relationships, rituals o f their jobs, and
the leadership w ithin their department and the school district.
The organizational com m itm ent to children w as evident to all the school
nurses. The school district valued children and their capacity for learning.
Our core values are that w e value children. Our principal has the
attitude that all kids are capable o f learning. (School #3)
W ell, they have a m ission and they have the goals that (each child)
can “clim b the m ountain.” (School Supervisor)
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The school nurses rejected the persistent, all-encom passing em phasis on raising
test scores. They realized that som e o f the em phasis on test scores cam e from their
ow n com m unity, but felt that this single-m inded approach adversely affected other
types o f learning, such as health education.
It’s all about test scores and increasing the test scores o f the
students, and personally I think it’s got to be more than test scores.
It’s got to be the w ellness and overall being o f the child. (School
Supervisor)
W e are a low -test school. They want every school to improve.
(S ch ool #2)
The sch ool nurses recognized the importance o f the com m unity focus o f the
school district.
B ut I find the m ost effective m eetings are the com m unity w ide
health m eetings. (School Supervisor)
The core value o f this particular school is com m unity involvem ent.
(S ch ool #1)
The school nurses also noted the strong leadership o f the school administration, and
how the head o f the school district promoted change in response to com m unity
needs.
I think that the superintendent is visionary. H e definitely is
changing the district and it needed change. (School #2)
I think his (School Superintendent) w hole approach to the district
has been so positive and upbeat and he is available to talk to
people. (S ch ool #3)
The school nurses felt that they had an important role to play in helping the
organization achieve its goals. They saw value in what they w ere doing.
The sch o o l’s primary goal is to increase academ ics. I see m y role
is to support that. I do believe w e do. W e try to m ake sure that
children are healthy enough to sit in their seat and learn. (School
#2)
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The goal is to have these kids in an environm ent to learn. M y goal
correlates w ith that, it is to keep the kids healthy. (School #1)
Although the nurses accepted the sym bolic values and goals o f the school district,
the nurses’ ow n value cam e primarily from w ithin their group. The m onthly nurse
m eetings provided support and reassurance o f their importance o f their role. They
also attended m onthly m eetings at each o f their school sites.
W e have ritual sta ff parties, w hich I think is really helpful because
I think that is a tim e w hen you can socialize and it is not about
work. It’s about our team. (School Supervisor)
The m ost important m eetings to m e are the nursing m eetings.
(S ch ool #1)
The strength o f the nursing group w as also noted by their support o f each other.
I think w e are coh esive in that w e support each other, but there is
not enough tim e for that. (School #2)
I think the camaraderie o f being nurses really brings us together.
(School #1)
Overview. The nurses view ed the school system as having the focused core
value o f the importance o f educating children. There w as no m ention o f educating
healthy children. The nurses did not buy into the w ay the schools evaluated the
achievem ent o f that core value, primarily by standardized test scores. The nurses felt
com m itted to their role w ithin the organization and had a clear v iew o f the need for
health to be a part o f education focus. A s a group, the nurses w ere m ore aligned with
their nursing department w ithin the school district, than the entire school
organization or the particular school in w hich they worked. T hey saw the head o f
the school district as visionary. The nurses recognized the sym bolic value and
connection o f the school to the com m unity at large.
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Political Frame
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The political frame view s the political nature o f the organization through the
eyes o f the school nurses. The nurses discussed their influence w ithin the individual
school, the district and the nursing department. This frame looks at power: w ho has
it, w ho uses it and w ho wants it. This frame also includes perceptions o f conflict
w ithin the organization.
The school nurses felt the school board and superintendent w ere the power
groups w ithin the school district. The pow er w as at the top o f the organization and
even the principals w ere low er on the pow er hierarchy.
The school board is a recognized power. (School Supervisor)
P olitically, definitely the superintendent (has the pow er.) I used to
b elieve the principal has a lot o f power, but in the last few years I
think the principals have less pow er politically. It is really has
been centralized. (School #2)
In the School District, the school board. I w ill occasionally attend
the board m eetings. (School #3)
N urses did not want to get involved w ith coalitions within their school sites. They
rem oved them selves from the politics w ithin their schools
I am not the m ost political savvy person in the world to know
about all the coalitions.
(School Supervisor)
There m ay be cliques going on, but as long as they d on ’t affect m e
and m y job and what I am doing for the children, I just try not to
becom e a part o f it. (School #3)
N u rses felt they have som e access to p o w e r b u t did n o t b eco m e p olitically
involved. In fact, the nurses wanted to stay aw ay from politics.
N urses tend to shy away from political agendas and from , and I
know all m y professors at U C L A are just like kicking m e under the
table, but I think there is som ething about our nurturing type o f
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personality that w e tend not to want to be real political and real in your
face. (S ch ool Supervisor)
I k now there are a lot o f political issues, but I am not too exposed
to them . B eing here in school w e are kind o f isolated from a lot o f
it. (S ch ool #2)
It is so easy to get caught up in the politics. I try to stay neutral.
(S ch ool #3)
Nurses found their pow er cam e from getting results in the school. They felt they
needed to sh ow administration that they were valuable by being visible.
(Pow er) com e from your track record and what kinds o f thing you
have d o n e .. .1 think that is very important that you are available
and that you are visible and they know what w e are doing. (School
Supervisor)
The influence is based on results. (S ch ool #2)
The nurses’ health offices w ere definitely not visible. They w ere tucked aw ay in two
o f the three sch ools the researcher visited. It w as alm ost im possible to even find the
offices. In all three schools, the health office w as slated to be located next to the
administration o ffice, w hich w ill definitely increase visibility o f the nurses.
Overview. The school nurses w ere alm ost apolitical. T hey w ere insular,
caring m ostly about their ow n job and responsibilities, and even though they wanted
change to occur, they did not really want to becom e change agents. The school
nurses felt they w ere not pow erful with the school system , although they thought
they had som e access to people in power. The location o f their health offices within
the sch ools w as temporary since all three schools visited w ere undergoing major
renovation.
Human Resource Frame
The human resource frame looks at the school organization in terms o f how
the organizations m eets the needs o f it em ployees. T hese needs include the nurses’
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satisfaction with their work, educational preparation, personal needs, and their
ability to com m unicate. The nurses view ed the human resource fram e’s strength as a
source o f com m itm ent to their work.
A ll the school nurses enjoyed their job, both because it offered autonom y and
a chance to learn new things. T hey did not find their role boring, and liked the
variety o f responsibilities and clients.
It has taken m e four years to really understand the role and now I
have a better grasp o f the sch ool nurse role, I love it. I find I have a
lot more autonom y.(School #2)
I feel that this is a fabulous job. I love it. I love that I work in
elem entary and high school. I have every grade except for sixth
grade. (School #1).
Part o f what the school nurses liked w as that they could care for w ell children and
hopefully intervene early to prom ote healthy lifestyles.
I think that as a nurse, w e all go into nursing for the reason that w e
care about people. W e care about, in m y particular case, I care a
lot about children. (School Supervisor)
I realize that i f w e can start w ith them young and early in helping
them w ith their health, that it w ill hopefully carry over to them
being healthy adults. (School #3)
The school nurses’ good feelings about their job were a result o f the support
by the nursing supervisor and their cow orkers. W ithin the invisible w alls o f the
health department, the nurses w ere secure and happy in their jobs.
It is a very supportive atm osphere. I think that this school nursing
setting is the m ost supportive setting you can possibly be in. I have
worked for over 20 years in nursing. (School #1)
The nurses w ho have been here for a long time really love their job
and it is infectious. I love getting together with them. (N urse #2)
The support was also evident in the em phasis on continuing the nurses’ education.
The m onthly staff m eetings often had an educational portion as part o f them.
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W e have m oney set aside for staff developm ent and I send nurses to the
State School nursing conferences. If a nurse w ould approach m e
w ith a particular area that she wanted to get special education in,
then w e w ould m ake that happen. (School Supervisor)
W e are encouraged to go to conferences. W e get tim e o ff to do
that. T hey have paid slots, and i f w e don’t get one o f those paid
slots w e pay for it ourselves. (School #3)
One o f the school nurses felt that more education w ould help her in her work.
She blam ed the School D istrict for their lack o f support.
I don’t b elieve that the district gives us enough tim e to go to
conferences because they don’t think o f health. (S ch ool #2)
The sch ool nurses expressed that they had a voice, but it w as up to the their
supervisor to m ake sure their vo ice w as heard.
I think m y boss has the pow er to make things change, but I also
benefit from that.
(S ch ool #2)
That’s one thing about nurses, everybody’s opinion is valued.
(S ch ool #3)
The nurses’ v o ices w ere not as strong as the powerful chorus o f the com m unity.
N urses felt that health issues w ere vital for the school system , but u nless other voices
echoed their concerns, their ideas w ould not be heard by the School Board.
I think the students and the parents have the pow er to m ake things
happen because ultim ately, w e alw ays report to the School Board,
w hich is the group the parents voted in. (School Supervisor)
Y ou have com m unity people w ho are very pow erful, not for any
other reason other than visibility and politics. The pow er com es
w hen they support your cause. (School #1)
Overview. School nurses had warm feelings about their work and w ere
m otivated to help children. They definitely “felt good ” about what they w ere doing
and i f tim e perm itted w ould like to do more for school children. The school nurses
felt supported by their supervisor and found they w ere prepared educationally to
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function in their role. W ithin the nurses’ ow n world, w hich consists primarily o f
the health department, their ideas w ere heard and valued. N urses felt that
com m unity support for their ideas w ould make changes more likely.
Structural Frame
The structural frame looks at the school nurses’ v iew o f how their work is
controlled. This frame includes the organization’s goals, roles, hierarchy, formal
com m unication and coordination o f activities. This frame helps the researcher
understand the nurses’ v iew o f the formal work arrangements in the school
organization.
The school nurses’ saw their goal as supportive and sim ilar to the goal o f the
school. B y supporting the teachers, providing health education, m aking sure that
students w ere physically able to learn, the nurses w ere serving the sch o o l’s purpose.
Our goal is to assist the teachers in providing the best environm ent
for the students. W e are concerned with their health because
w ithout them being healthy, they cannot learn. (School #3)
I see m y role is to support the education. M y goal is to keep these
kids healthy and to intervene early enough to keep them healthy so
they can be in school to learn. (School #2)
The school nurses m et their goal w ith clear, w ell-defined role responsibilities. The
nurse supervisor is n ew to her role so her job responsibilities w ere less clear than the
on-site school nurses.
A t th is p o in t in tim e, I w o u ld say it is am biguous b ecau se I h a v e n ’t
b een here a full y ear term y et to k n o w w h a t’s all going to co m e up.
(School Supervisor)
W e have job description that is very clear. The number o f things
that w e do as nurses is probably about 25-30. Then there is a
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clearly defined role for the health clerks. Through the years, w e have
m ade sure that w e have put everything into writing. (S ch ool #3)
I think m y role is w ell-defined. (School #2)
The nursing supervisor allocated workload depending on the number o f
children per school. The nurses coordinated their ow n activities w ithin their
mandated job responsibilities and role.
There are certain decisions that are already made. It is already set
in regards to what needs to be done in terms o f the tim ing o f w hen
they need to be done, that is on our own. (Nurse #2)
There are som e things that are specific as to protocol, but
otherw ise you m ust rely on your ow n personal planning skills to
plan ahead and prepare for what m ight com e. (N urse #1)
School nurses m ade their ow n goals and their evaluations w ere based on
achievem ent o f those goals.
I f there w ere conflicts betw een nurses and others in the school site, the nurses
tried to w ork out those conflicts are the low est level as p ossible. Therefore the
nurses used their com m unication skills to talk w ith the parents, teachers or principals
to reach a com prom ise i f possible. The nurses w ould only in volve their supervisor if
they could not m ediate a solution to a conflict.
A t the school site, the nurses are responsible for m aking decisions.
I f w e need to consult w ith the (Nursing) coordinator, w e do.
A b ove all w e com m unicate w ith the principal. (S ch ool #2)
W hen personalities collide or principals w ant particular things or
dow ntow n administration want particular things, I kind o f have to
say “Is that in the best interest o f the student?” (S ch ool Supervisor)
B ecause the principals each have their ow n ideas o f the w ay they
want things to happen at their school, usually it is som ething the
nurse can work with. (School Supervisor)
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The nurses realized that they role was dependent on that o f the teachers
and administrator at the school site. They worked to make sure that their goals were
part o f the goal o f their school and their coworkers.
I have found som e principals and administrators are more
interested in providing health information for fam ilies and the
students than others. (School # 1)
I take that a little further and at the beginning o f the year, I provide
health inform ation for the teachers because they need to be
healthy. (S ch ool #1)
I w ill leave the job description in the faulty lounge. The teachers
w ho have been around a long time basically understand. Som e o f
the new er teachers m ay not alw ays understand. (School #3)
School nurses acknow ledged that they need to work interdependently with teachers.
The coordination o f services som etim es worked but som etim es it w as difficult. The
lack o f acceptance o f the importance o f health as part o f the school goal for students
made the nurses’ relationships with teachers and administrators less satisfying.
I think that it is extrem ely important for the nurse to be a vital team
player at the school site. They have to be visible and they have to
be in com m unication w ith the principal and teachers about w hat
are all the needs and issues going on with the students. (School
Supervisor)
L ooking at the system in place in terms o f teachers and health, it is
very loose and informal. They know h ow I function and how they
function. I think I do a lot more interactions with them than they
do w ith m e. (School #2)
Overview. The Structural frame was view ed as the strongest part o f the
school organization but also the part that caused the m ost difficulty for the nurses.
The school nurses took com fort in the clarity o f their role functions and their ability
to m eet their goals. T hey relished in the fact that coordination o f their duties could
be their ow n responsibility. The nurses had som e am bivalence about the need for
interdependence w ith teachers in order to actually m eet their goals and
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responsibilities. The nurses belonged to the district-wide health department but
also to the structure o f the individual school. The nurses used their clear goals to
settle any conflicts w ithin their individual schools. The school structure provided
total support to the goal o f education and academ ic achievem ent and not necessarily
to the school nurses’ com plem entary goal o f health and w ell being o f children.
Child Welfare Organization
Symbolic Frame
The sym bolic frame as seen by the child w elfare nurses includes the values,
sym bols, stories and rituals o f the organization. The nurses’ v iew o f the leadership
o f D C FS was influenced by the frequent changes o f in the top position, the
relationship o f D C FS to Los A ngeles County, and their ow n nursing supervisors.
The nurses readily accepted the core values o f the child w elfare system but
included health as part o f safety. They com pared the child w elfare values to that o f
physicians and their dictum to “do no harm.” The nurses saw the terrible harm that
had been done to the children and w anted to correct this.
Y ou want the child to be safe. That is number one. Y ou also want
to m ake sure that the m edical needs w ere m et and I think that
th ey’d probably want the sam e things that w e w ould want. (CHDP
# 1)
For this department w e need to do no harm. N o matter w hat w e do
w e cause harm, by either actions or no actions. (D C FS #2)
The core values o f the child welfare system is child safety and I
w as think this w eek o f do no harm. Som etim es you get the feeling
that it just better to let things run the courses and that’s not alw ays
the best for the child. (DC FS #3)
In order to m eet the goal o f the child w elfare system , nurses felt that they needed to
be an advocate both for the child and for the system , itself.
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In this job there is not a single child in the system because o f what that
child has done them selves. It’s the environm ent that they cam e out
o f so this is a population that needs advocacy like nobody else. So
it’s actually a pleasure for m e to know that w hen I step up to the
bat I’m giving voice to a child w ho needs to have a voice. (C H DP
#2)
B ein g honest about what th ey’re doing and not taking advantage o f
a system , w hich w ould be easy to take advantage of, and things
like that. B ein g com m itted to their work. (DC FS Supervisor)
The leadership o f the child welfare system has had so m any changes over the
past five years, that the DCFS nurses w ho have worked under the present interim
director are hoping for som e perm anency. The child w elfare nurses did not find
vision in the leadership o f the system . E ven the leadership o f the L os A ngeles
County Board o f Supervisors, w ho have authority over the child w elfare director,
w as found lacking.
W e have had three directors in the last several years. I d on ’t know
enough about her (the current director) to say. (D C FS #1)
I don’t know the person, it’s a fem ale. I know that w hen y o u ’re an
interim, it’s very hard to maintain and to impact because you know
y o u ’re not staying and so do all your support people. (CH DP #1)
But she cam e in and started to get the department focused in the
right direction. But w hen you are m icrom anaged by the County
board o f Supervisors, it conflicts with what their goals are and their
vision. (D C FS #2)
The child w elfare nurses valued the ritual o f their m eetings w ithin the nursing
departments. T hey wanted m ore m eetings betw een the D C FS and CH DP nurses.
They felt that nursing m eetings helped them function w ithin their job and liked to
share inform ation w ith nurses w ho are doing the sam e thing that they are. This
included statew ide nursing m eetings o f child w elfare nurses.
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The m ost important m eeting I do have is our once a month nursing
m eeting. (DC FS #3)
Just about every m eeting a PH N says, w ell I have this case. I d on ’t
know w hich w ay to go. I need som e help and w e all learn.
Som ebody m ay have a resource that they just found last w eek or a
w ay o f getting around that roadblock, so w e do share a lot o f
inform ation w ith each other. (D C FS #2)
I think m eetings w ith DCFS supervisors are important because
they are in a different organization and things are happening all the
tim e they can share with us and w e can share with them what w e
are seeing. (CH D P Supervisor)
N urses did not feel the sam e w ay about their m eetings with social workers w ithin
their buildings. Som e child w elfare nurses found these m eetings problematic.
I w ent to one and it was awful and it w as probably about a year
ago. W e were in a room full o f social workers and social worker
supervisors and they w ere unhappy that the process w a sn ’t going, I
guess, as fast as it should. It was a free for all attack (against the
nurses). (C H D P #1)
W e really felt it w as som ew hat a w aste o f our tim e because the
only reason w hy they w ere m eetings w as to determine w here they
w ere going to put these kids. (CH DP #3)
Other nurses found that w ith persistent work they could accom plish som e o f their
goals at the unit m eetings w ith social workers.
I go to unit m eetings because that’s the level that y o u ’re
functioning. D irect face to face w ith the social workers. I m ean
literally just last w eek a worker that I’ve been dealing w ith for two
years finally got the point o f the H ealth Education Passport and the
questions stopped. (CH DP #2)
The social workers have regular unit m eetings and w e can attend if
w e have som ething to discuss. I d on’t go that often. I work more
individually w ith the social workers. (DC FS #1)
The nurses felt coh esive because o f the nursing m eetings but w ould like even
more tim e to network. The tw o groups o f nurses, CHDP and D C FS, work clo sely on
the unit level. Their status as the minority w ithin the child w elfare system added to
the coh esive nature o f the nurses.
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I think there gets to be turf issues som etim es that w e have to work out.
But one thing really unifies that is that th ey’re all nurses. Y ou
know bottom line, hey, w e ’re all nurses and this is what nurses do
and w e ’re not social workers. (DC FS Supervisor)
I d on’t feel as coh esive right now because w e d on ’t have the
opportunity to network or the opportunity. (C H D P #2)
I think the nurses are cohesive. I think the fact that w e are all
doing the sam e work generally is helpful. (DC FS #1)
Overview. The child w elfare nurses accepted the core values o f the
organization but felt that m eeting the m edical needs o f foster children must be a part
o f their safety. T hey felt that it is their role to stand up for the children in the system
and m ake sure that others do not take advantage o f the system . The leadership o f the
child w elfare system w as not view ed as stable and did not inspire the nurses. The
nurses valued their m eetings am ong the nursing groups but not the m eetings with
social workers. The nurses felt like a coh esive group even though they report to two
different organizations, D C FS and CHDP.
Political Frame
The political frame explores the nurses’ v iew o f pow er w ithin the Child
W elfare Organization. This frame includes the nurses’ ability to gain or exercise
pow er and the ability to influence or manipulate others in the organization and
outside the organization.
The child w elfare organization is legally mandated to care for children who
can n o t p ro tect them selves. I f the org an izatio n fails to p ro tect th eir charges, the
political clim ate is tense. Therefore, anxiety pervades the system .
There used to be a lot o f fear and I think som e peop le still think
there is som e. (DC FS Supervisor)
I didn’t realize that D C FS w as an animal in itself. I had no idea
w hat I w as getting into. (Social Worker)
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T he system , w ith the social workers, can be a vindictive system . If
som ething happens, the social worker can be penalized.
Som ething happened and there w ould be an audit. I f som ething
happened, there w ould be a new form that the social workers have
to fill out. (D C FS #1)
The largest group o f workers, the social workers, held the pow er w ithin the
organization. T hey are the mandated case managers and have the legal responsibility
for the children w ithin the system . The managers protected their social workers.
T hey (the social worker) stick together. I see that because I had a
case where I wanted to do a hom e visit because there w as so m uch
confusion about w hat w as going on with this kid. W e couldn’t get
in touch w ith the social worker and w e w ere telling the supervisor.
The supervisor social worker defended her social worker and I
m ean the social worker w a sn ’t responding to us. But they stick
together. (CH DP #3)
I w as told by one o f the social workers that they have the pow er
because they can rem ove kids so they feel like they have a lot o f
power. T hey can use it or abuse it and som e o f them , I hear, som e
o f them do abuse it. (CH DP #3)
N o, I don’t think the nurses have a lot o f power. T hey need to be
represented more. (Social Worker)
The nurses wanted to have access to pow er and since they are by far the
m inority, they thought that they needed to gain access by providing valued services
to the social workers. The nurses’ pow er cam e from expertise and som ew hat from
persuasion that what they were doing w ould help the social workers do their job
better. They wanted to work within the system to make changes.
A ll you have to have are one, tw o or three really significant
m edical cases and the social workers realize what an asset you
have been in problem solving and then they are your best allies.
(CH DP #2)
Y ou know I don’t know whether I gained it or it ju st w as offered to
m e because I think that the A R A (A rea R egional Administrator) is
very approachable. (CH DP #1)
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I didn’t com e in trying to change the system . I cam e in to do a job and
to survive in the system , you have to know how it works. (CHDP
#3)
L ongevity in the system and know ing the system m ade a person more
pow erful in a large organization like the child welfare. Unfortunately, the recent
retirement o f the head o f DCFS nursing decreased nursing’s ability to w ield power
within the organization. H istorically nursing has had little power anyway.
The former head o f nursing had a lot o f experience. She had been
w ith the county all o f her career. She knew how to read people,
w ho to m assage, w ho to go straight at. (DC FS #2)
(D C FS N ursing) has been at least a year w ithout that leadership so
that’s been hard that n ow w ere w orking together as a group and w e
had to put it on hold. (CH D P Supervisor)
This is the first tim e in alm ost 10 years w e ’ve been here and the
first director seem ed to listen to us sort of, but since then not
really. (D C FS Supervisor)
The researcher observed D C FS nurses and CH DP nurses working side by side
am icably but som e o f the nurses reported that there w as som e difficulty betw een the
tw o groups. The job responsibilities are sim ilar but the CH DP nurses report to
Children’s M edical Services, under the L os A n geles County Department o f Health.
There is a m edical director in charge o f C hildren’s M edical Services but not for
D CFS.
I don’t think there is a need (for a m edical director). W hen w e
w ere under CH DP, w e did have a m edical director and it’s more o f
a political administrative situation and it really had very little to do
w ith what w e are about day to day. (D C FS #3)
There is a chasm betw een D C FS nursing and CHDP nursing.
Som e o f the offices there is som e anim osity betw een the two. In
this office, w e ’re are sm all and w e get along fine. (DC FS #2)
Overview. The nurses sensed a political culture o f mistrust w ithin the child
w elfare system . W orkers felt that the system w as not supportive and was punitive.
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The social workers held the pow er within the organization. The nurses wanted
som e pow er but felt it w as difficult to exercise pow er within their local offices.
Personal relationships with administrators and social workers allow ed nurses to
exercise a sm all amount o f influence. Nurses noted that pow er cam e from longevity
with the organization. The nursing leadership w ithin D C FS and C H D P had recently
changed and that lessened the nurses’ ability to affect change. There w as som e
political infighting betw een the tw o nursing groups, D C FS and CHDP.
Human Resource Frame
T he hum an resource frame looks at the com m itm ent o f the nurses w orking in
the C hild W elfare Organization. This kind o f organizational com m itm ent is affected
by relationships w ith other workers, ability to handle conflict, and the capacity to
grow in the w ork environm ent. This framework is esp ecially affected by the nurses’
relationships w ith social workers.
A ll the nurses enjoyed their work environm ent and felt happy in their job.
Som etim es the w ork w as frustrating because o f the large num bers o f cases and the
feeling that they could never do enough. They got their rewards in the importance o f
their work.
It’s not one feeling, som e days great and it’s fabulous w hen you
put som ething together and you get it all organized and you have
this m om ent o f elation. Then you turn around and you see m y
desk and you realize it’s n ev er ending. The job has no com pletion.
(C H D P #1)
I could retire i f I wanted to, but I’m still here. So I guess that says
som ething. I really feel that what w e ’re trying to do is really
important. (D C FS Supervisor)
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The nurses felt their work w as important because their clients are children. The
nurses felt that helping children w as their calling.
Kids have been m y passion all m y life. (D C FS Supervisor)
I think that what m otivates m e is I like children and I just like to
see children cared for. (CH DP #3)
I basically love this job. I think it is a perfect job for me. I enjoy
w orking w ith the kids and I enjoy the w hole idea o f trying to help
kids that m aybe don’t have the best start in life (D C FS #1)
A lthough the child w elfare nurses liked their work, som e saw that they are not being
used appropriately. The nurses w ho w ork under CHDP felt this w ay more than the
D C FS nurses.
So from that standpoint I like it, but sitting here and doing data
entry form s all d a y .. .1 think the best thing w e can do is hire people
w ho understand m edical conditions and do data entry like m aybe a
unit clerk w h o ’s been trained in som e type o f m edical
understanding. (CH DP #2)
I keep getting dumped on. I know the ideal nurse ratio and what
they w ant us to do is really fo llo w these kids so each nurse should
probably have no more than tw o (social work) supervisors. (CH DP
#3)
The office culture w as friendly and the nurses saw them selves increasing
fitting into their local w orkplaces. The nurses worked w ell with each other and were
trying to form relationships with the social workers.
I like w orking w ith social workers (D C FS #1)
The social workers are com ing m ore to the nurses and th ey’re
relying on their expertise and then asking them w ill to go to the
hospital w ith them. (C H DP Supervisor)
The nurses saw im provem ent in their relationship with social workers, but w hen the
social worker w as interview ed she admitted that m any social workers do not use the
nurses. The process o f getting the nurses integrated into the social worker culture
and part o f the team w as going slow ly.
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I had a m eeting tw o w eeks ago and I think it was the Torrance office or
L akew ood office. The workers said w e d on ’t have PH Ns in our
office and probably the C SW s d oesn ’t know (about the PH Ns).
(S ocial Worker)
I remem ber that I was going through the m edical folders trying to
separate and get them cleaned up and in chronological order, and
one o f the social workers cam e up and asked if I w as auditing
th em ...I told her that and she said, oh. I made separate folders for
each child. But she still thought I w as auditing. It took them
aw hile to trust me. (DC FS #2)
The nurses had m ixed feelings about working in the child w elfare system in
terms o f h ow they could impact change. T hey saw them selves dealing with a system
that is large in size and belongs to the “County.”
G enerally within D C FS, the nurses do not have a lot o f clout
because w e are a sm all unit w ithin an organization., On the other
hand I think w e are view ed p ositively and I think the
administration sees us as valuable. (D C FS #1)
I m ean this is the county you know , I m ean you can ’t just hire and
fire at w ill and I think it’s really important to know w ho the people
are that you can go to w hen you need som ething. (DCFS
Supervisor)
Som e nurses wanted to use the strong hierarchy w ithin D C FS to their advantage.
I’ve been w ith the county long tim e and I find that if you go
outside the role, you don’t get the support that you need w hen you
really need it. M ost o f these people w ho work in these positions
are in them because they’re actually pretty good at them and what
they do. (CH DP #1)
I b elieve each one o f us has the pow er to m ake things happen.
T here’s alw ays a hierarchy and I think nurses need to be aware o f
it and know how it works. (DC FS #3)
O th er nurses found that th ey ju s t felt fru strated by w h at th ey saw as large, u n m oving
force that keeps the status quo.
The nurses feel that they want to m ake changes and are trying
sm all w ays to impact the system . T hey are frustrated in their
attempts. (DC FS #3)
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So a lot o f talk and but nothing is happening because w e ’re not going
back and review ing what w e said w e w ere going to do. (C H D P #3)
The nurses felt fairly satisfied w ith the amount o f education they have
received. The CH DP nurses received extensive orientation w hen they began. This
orientation w as necessary to make sure the nurses were able to integrate with the
existing D C FS nurses.
W e w ere still new and w e w ere concerned that w e w ou ld n ’t retain
the nurses. So w e had to work real fast to be sure that the other
needs w ere m et and get feedback from them to see what they
expected and what they w ere seeing out there. (CH DP Supervisor)
W e had an extensive training orientation. (CH DP #2)
The Interim U niversity Consortium offers us about four different
trainings a year. The nurses actually m eet and decide the topics
and even som e o f the speakers are expensive but because it’s the
consortium , they can pull that together. So they do giv e us som e
good training. (D C FS Supervisor)
N ot all nurses appreciate the training sessions they are receiving presently. T hey felt
som e o f the tim e w as wasted. The DC FS nurses wanted the sam e educational
benefits as the C SW s receive.
T hey d on ’t do what they do for the social workers because o f I
guess it’s a union thing and they have a certain amount o f m oney
every year, like 300 or som ething dollars, and they can just spend
to go to conferences. (DCFS Supervisor)
It’s so basic or it’s ju st like I don’t really know m y job or
som ething. Som etim es w hen you do to an all-day training and
y o u ’re sitting there falling asleep the w h ole day but th ey ’re really
cracking down on training and there is very little anym ore that w e
go to. (C H D P#2)
W ell it is good som etim es. I honestly feel like th ey’re w asting our
tim e because som e o f it is suppose to be collaborative trainings
w ith the nurses and the social workers .. ..and it w asn ’t useful.
(C H D P #3)
E ven w ith the frustrations about working in a large system w ith social
workers w ho m ay not appreciate them , the nurses were still trying to get their ideas
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heard. T hey w ere trying to stress the fact that they are valuable as a w ay to be
heard. The nurses used the system , in terms o f talking to their ow n supervisors, to
v o ice their opinions.
The idea o f being heard once in a w h ile but how far does it goes.
(C H D P #2)
Ideas are definitely heard by our supervisors and they try to make
the ideas heard by administration. (D C FS #1)
The department (D C FS) know s h ow important the nursing
department is. W e are valuable. But its being able to get the work
up the chain because w ithout Sharon Leahy, w ho was able to w alk
into the offices o f the director. (D C FS #2)
Overview. The child w elfare nurses felt that their work w as important and
they w ere trying to make a difference in the lives o f foster children. They wanted to
fit into the organization, and were trying to use their ability to form relationships as
their entree into the organization to im prove teamwork. T hey felt they had good
ideas but the system was too big and unw ieldy to impact. Som e nurses wanted to
work through the system and som e w ere frustrated by it. T hey w ere happy w ith the
support o f their nursing supervisors and their ability to have educational
opportunities although som e o f the recent training sessions w ere not useful. Som e
nurses said they w ould feel m ore satisfied in their work i f they could use their full
potential. The nurses since wanted their job to feel good, but found that the system
m ade that difficult
Structural Frame
The structural frame includes how work is controlled though job
responsibilities, com m unication betw een workers, and decision-m aking. Both the
DC FS and CH DP nurses functioned under the sam e guidelines and structure within a
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com plicated and crisis-driven organization. This frame exam ines h ow the nurses
understood the rules and worked to change rules that did not support their work.
The nurses accepted the D C FS goal o f child safety but included health as part
o f safety. T hey felt they w ere able to assure safety by connecting children to the
m edical services they needed. They realized this w as more difficult than it seem ed.
W ell I think the goal is the m ission statement, really is just to
provide the best possible outcom es for the children. I’m talking
outcom es being m edical psychological, safety, education, all o f
those. (CH DP #2)
It’s a lot more difficult to attain. It sounds very sim ple but I think
by shear volum e it’s difficult to attain. But not im possible and I
think w e w ill im prove over time. (CH DP #1)
The nurses w ere assigned by number o f children per office but w ithin each office
they distributed the workload them selves. T hese decisions w ere m ade fairly easily
am ong the nurses.
B ecau se m edical placem ent is heavy, you w ouldn’t giv e it to tw o
people. So w e divided it am ong four and A sian P acific is light, but
w e have m any o f them . H ow did w e decide it, w e just, you know ,
it w as an am icable decision, w e just decided just to split it up.
(C H D P #1)
In this building the nurses them selves divide the workload
according to the different fields o f interest o f nurses. Som e nurses
love the ER. (DC FS #1)
Specific guidelines and procedures defined the nurses’ job duties. The nurses
found com fort in know ing exactly what w as expected o f them. T hey appreciated
th at th eir resp o n sib ilities w ere fairly w ell spelled out.
W ithin certain parameters o f m y role, I’m not here to say, rem ove
a child. I’m here to review the m edical, psych ological, behavioral
inform ation, looking at the w hole w ell being o f the child and help
identify the red flags in a situation. (D C FS #3)
I think m y role is fairly w ell defined, but since w e have the
addition o f a lot more nurses it keeps changing, for the better I
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think. W hen I first cam e here I w as the only nurse for this office so at
that point, it w as a little more am biguous. (DCFS #1)
B ecause o f the political, punitive nature o f the child welfare system , the nurses
wanted and needed the structured guidelines to protect them. The nurses felt
protected by the guidelines o f their job responsibilities and found any freedom
frightening.
T hey tell you use your professional judgem ent and in this system
your professional judgem ent can get you in trouble.. .(C H D P #3)
Our administration had som e thoughts about our role too, w hich
w ere different and w e w ent through that to see exactly the danger
that w as out there. The nurse w alks a thin line in D C FS. I f the
child dies or som ething happens to a child, you are scrutinized and
the papers, the newspaper reporters are m erciless. They condem n
you w ith tw isted facts and it w as nightmare. W e were originally
going to do independent hom e visits, but I just felt so scared for
those nurses out there by them selves, it took a w hile to see that it is
m eant for joint hom e visit since you have a social worker with you.
(CH DP Supervisor)
W ithin their job guidelines, nurses w ere able to m ake decisions about how , w hen and
what to do. T hey enjoyed have this type o f autonom y to organize their work
according to their ow n schedules.
W ell you know you get a routine, you open a chart, you go through
the w h ole thing, you look for your information and you check if
there’s anything and i f not you just begin. (CHDP #1)
I ’m not having to say at 9 o ’clock I do this at 10 o ’clock I do that
unless I want to do that. (D C FS #3)
Although the nurses understood their role, the social workers w ere not sure
about what nurses could or could not do. This definitely m ade the nurses frustrated
with the work environment.
W e are constantly trying to update the social workers on what w e
are here for, because a lot o f them still have no idea w h y w e are
here. This program has been going on since ‘92 or ‘93, but they
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still don’t understand our role. They think we should be able to go out
there and give shots and things like that. (DCFS #2)
It’s fairly well defined but others I work with, social workers,
haven’t a clue why we are here.. .I’m sure there are people in this
office who don’t know the Health Education Passport even though
they’re suppose to be reporting to the supervisors how many we
give out in a month. (CHDP #2)
The child welfare nurses realized that they are in an interdependent role and
saw themselves as supportive to the CSWs. They understood that the CSW has a
difficult job and a huge responsibility. They wanted to be a part of the puzzle and fit
into the structure.
The nurses are integral consultants to the social workers. The
social worker is the case manager for the kid and they are really
different than us nurses. We are a supporting role and we still
need to get the information back and forth.. .It is a very interactive
role between the social worker and the nurse. (DCFS #1)
I depend on my social worker to be my eyes. When my social
worker comes back to me and says, “you know it just looks funny,
something isn’t right.” They have a gut feeling and they try to
explain it to me and then they give me the chart and I will go
through the chart and you know, a couple of time they’ve been
dead on, dead on. (CHDP #1)
Just because the nurses wanted to be a part of the team, the structure was not in place
to assure this would happen. Nurses did not even have input in how DCFS policies
were written.
The CSW and the nurse have to be a team however not all CSWs
function the same. If you don’t give the PHN her work and this is
your work you need. You ask her to please provide me with a
guidance here .. .There is not, if you’re asking me, in the
organization, DCFS has that structure. I don’t think so because
CSWs are not mandated, not required, we don’t have to give the
medical file to the nurse. And maybe somewhere up there, there is
a policy, I don’t know. (Social Worker)
The policies within DCFS are written by social workers and they
put nurses in it but there is not necessarily involved in writing the
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policy. At the time they get to review it later if they know its occurring.
(DCFS Supervisor)
The nurses were frustrated by the fact that the structure of DCFS does not
support their work. They felt shut out of the process and unable to work to their
fullest capacity. The nursing workforce felt unappreciated.
We have often thought of ourselves as foster children or
stepchildren because that is how it has been. (DCFS Supervisor)
We’re actually third class citizens in a social workers’
environment. Social workers are first, DCFS/PHNs are second and
were the third. (CHDP Supervisor)
The nurses were trying to understand the organizational structure of DCFS.
They worked to fit into the hierarchical structure of DCFS.
Whenever DCFS makes up decision and it is a very bureaucratic
organization.. .It is more difficult to work within (than the Los
Angeles County Department of Health Services) and you have to
remember that is a social worker organization and their guidelines
are social worker policies. Many of them are linked mandates and
have to be done. (DCFS Supervisor)
There is a chain of command and a social worker has a supervisor
and the nurse has a supervisor. (CHDP Supervisor)
Nurses tried to avoid conflict and tried to solve problems at the lowest level possible.
They only employed the chain of command when it is in the best interest of a child.
I find myself acquiescing most of the time or going around it
quietly. Ethical conflicts, I don’t compromise, I can’t. How can I?
(CHDP #1)
I think they would probably be resolved with the social worker and
the nurse. Or if they couldn’t be resolved, then between
supervisors. (DCFS #1)
To tell you the truth, I know about six nurses in the office. I find
them all very friendly, very social, very amicable, very caring,
nurturing and I don’t even think that they would confront
somebody. (Social Worker)
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Their nursing supervisors evaluated the child welfare nurses’ work. It
was difficult to identify good outcome measures, so much of their work evaluation
was done by logs.
So right now we’re kind of counting widgets, but nurses do have a
regular report that they prepare every month on how many of this
and how many of that. (DCFS Supervisor)
We’ve got a log every month and we write down the child’s name,
date of birth, the social worker, and then there are numerous
columns that we’re checking. What we did to that particular file
and there is a place where you can make notes. (CHDP #2)
The nurses would prefer to have better methods that really measure how they made a
difference in the foster child’s health and well being.
You know it’s really based on productivity. Unfortunately, it’s not
based on the outcomes of the child’s health and they don’t ever
speak to the social workers and say, “How is it working with
Mary? What do you think?” (CHDP #1)
We don’t have real good outcome measures yet. We’re working
on that. It’s hard to say that because you didn’t do something it
got better. You know the preventative thing, that’s always hard to
measure. (DCFS Supervisor)
Overview. The nurses viewed the child welfare system as highly structured
but felt they are outside of that structure. They accepted the organizational goals and
realized that meeting them was very difficult. Their own job descriptions were
clearly defined and helped protect the nurses from the punitive nature of the
organization. Unfortunately, the rest of DCFS did not seem to understand the
n u rse s’ role. T h ey w ere able to co o rd in ate th eir ow n activities and deriv ed p leasu re
in this autonomy. They saw DCFS as a social work driven system and they were
trying to break in to the structure. They wanted to be an integral part of the team but
there was no structure to make this happen. The nurses wanted to use their personal
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relationships to try to integrate themselves into the DCFS organization and avoid
conflicts. Evaluation was structured by counting activities because meeting DCFS
goals were hard to measure.
Comparison o f School Organization to Child Welfare Organization
Symbolic Frame
Both school nurses and child welfare nurses accepted and agreed with the
core values of the organizations in which they work. They would like the core value
to include more emphasis on health of children. The school nurses recognized the
influence that the community played in setting the organization’s goals. Both groups
of nurses were committed to their own role in helping reach the goals of their
organizations. The nurses in both organizations were more aligned to their fellow
nurses than their non-nursing coworkers, teachers and social workers. They derived
satisfaction from the ritual meetings with their nursing colleagues. The school nurses
viewed the head of the school organization as visionary and a strong leader. The
child welfare nurses were not convinced that the head of the child welfare
organization was strong, partly due to the frequent changes in the leadership
position.
Political Frame
School nurses were not involved in the political nature of the school
organization. Even though they wanted some changes to occur, they did not want to
become involved in making those changes. Child welfare nurses, on the other hand,
were committed to affecting change but the political climate of their organization did
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158
not allow them to be change agents. The child welfare nurses were acutely aware
of the punitive nature of their organization. Both groups of nurses felt that their
power was limited. All nurses used their supervisors to voice their concerns while
child welfare nurses also used their personal relationships with social workers to
affect change. The child welfare nurses recognized that the power was held by social
workers. Child welfare nurses took as active a part in the political side of their
organization as they could, within the boundaries of the recognized hierarchy and
recent changes in the nursing leadership. School nurses basically preferred keeping
to themselves and doing their job.
Human Resource Frame
Both school nurses and child welfare nurses liked what they did, got personal
rewards from their work, and were motivated by their love of children. Both groups
of nurses felt supported by their supervisors and enriched by the educational
opportunities provided by their organizations. The school nurses’ insular nature
allowed them to feel appreciated and valued by the other school nurses. The child
welfare nurses wanted to become part of the larger organization because they highly
valued teamwork. The child welfare nurses felt less valued because their ideas were
not heard loudly in such an unwieldy, large organization. Both groups of nurses
wanted to do more in their jobs so they could feel more satisfied in their work.
Structural Frame
Child welfare nurses and school nurses wanted and required a structured
environment, but the structure of their organizations made it difficult to do their job.
The structure of the organizations supported the organizations’ primary goals but not
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the complementary goal of health. Nurses in both organizations took comfort in
the clear job descriptions and responsibilities as well as the autonomy that allowed
them to organize their work independently. The greatest difference between the
nurse groups was in the need for interdependence with other disciplines. School
nurses had ambivalence about their dependence on teachers and wanted to primarily
work independently. Child welfare nurses were clear in their desire to be part of the
team with social workers but the organization’s structure was ambivalent. There was
no mandate for the legal case manager, the social worker, to include nurses as part of
their routine work with the foster families. The child welfare nurses worked within
the system to make themselves noticed, valuable, and used. Both groups of nurses
wanted to avoid conflict and utilized their knowledge of their responsibilities to
settle disagreements.
Question Number Four: Organizational Influence on Nurses’ Choice in Clients,
Services and Communication
Framework for Research Question Four
The interviews with school nurses, child welfare nurses and the social worker
provided data to answer this question. The findings from question three were
integrated into the interviewee’s responses to assess how the organizational context
influenced the nurses’ choices. This question is divided into communication choices
and clients/services choices. The communication section is further divided into
communication between organizations and within their own organization.
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Communication Choices Between Organizations
Communication between child welfare nurses and nurses in the school
organization was successful when it occurred. Although there was no formal
structure for this communication to take place/child welfare nurses occasionally
sought help from school nurses. This type of communication is supported by the fact
that nurses were aligned personally and professionally with other nurses as seen in
the symbolic organizational frame. Also child welfare nurses valued teamwork.
I got one of these physical exam forms from CHDP and it was that
the child needed a vision exam. It was a school-aged child. I tried
and tried to get a hold of the family. They didn’t seem to be
available so I found out where the child went to school and talked
to the school nurse because I used to be a school nurse. I know
they do vision screening and such. She was also having the same
kind of problem and so between the two of us, we really worked
hard to get this child to get a vision exam and get the glasses he
needed. (DCFS Supervisor)
I have talked to the school nurses or the schools themselves
because they will constantly make referrals to the child abuse
hotline. They are a good source of eyes and ears for us because a
lot of time the children will divulge information to the teacher
about abuse. (DCFS #2)
There was no structure in place to connect schools to the child welfare
department. Besides the nurse to nurse communication initiated by child welfare
nurses, communication between schools and child welfare was rare. It is unlikely
that school n u rses w o u ld seek access to child w elfare d ep artm en t since school nurses
shy away from interdependence and would not politically seek the power to change
the relationship between schools and child welfare. Child welfare nurses did not
routinely seek non-nursing contacts in the schools.
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The only time I really encounter the social workers is if they come to
school or if they come to the meetings that we have. Other than
that I am not in contact with the social workers because I just deal
directly with the foster parents.. .They don’t necessarily come to
the IEP (Individualized Educational Plan) meeting. (School #3)
I don’t think I’ve ever talked to a teacher. Occupational therapy,
PT yes, but not teachers. (CHDP #1)
Child welfare nurses and social workers identified ways in which
communication could be improved between their organization and the schools.
Making school nurses aware of foster children with medical problems and getting
health records for children new to the “system” would help Child Welfare do better
case management. Increased communication between these organizations would
make teamwork more of a reality.
So we scramble to find immunization records and I have to say the
school system, if you Can find out, and if the child is already in
school. If you can find out where the child is going to school and
that is generally in the chart, you can get the immunization records
and a little bit of background. And that is a beautiful thing.
(CHDP #1)
I spoke to the school nurse and I bring the child to the office to
ensure that she at least sees him one time. So if they ever come in
with the problem she will remember that this kid is under DCFS
and for her to call me. (Social Worker)
Communication Choices Within Own Organization
Although child welfare nurses had clear job description and responsibilities,
that clarity did not extend to the Passport. The Health and Education Passport is the
p rim ary w ay to d o cu m en t and share info rm atio n ab o u t th e h ealth and education
issues about the foster child and significantly helps the nurse do her job. The
structure of the child welfare system promoted but did not require the use of the
Passport by social workers. It is unlikely that social workers would systematically
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update, use and distribute the Passports unless there was some type of mandate
with negative consequences for failing to following through.
I know for a fact on one particular case that the child was taking
psychotropic medications and she was suicidal and depressed. She
just got out of the psychiatric hospital and there was no medical
information on the Passport. It’s not the nurse who’s responsible
for that thing to be updated . However if the CSW doesn’t see the
nurse.. .1 mean I really don’t know how if we don’t give her the
information how is she going to know. (Social Worker)
The health education Passports that social workers used at the
kinship meeting had 4 or 5 kids in one folder and sometimes
mistakes would be made. (CHDP #2)
Child welfare nurses wanted to increase communication with social workers.
They wanted a true team environment. The researcher observed the nurses talking
frequently to social workers, asking if they could help in any way, and responding to
CSW requests quickly and completely. The human resource frame suggests that the
nurses’ need to be valued and to be part of the team.
At least we’re sitting amongst them and so there’s more
opportunities to call me or get up and walk over to me than if I was
in a nursing station. I think they tend to open up a little more.
(CHDP #2)
They’re right here. They come. They talk to you. They fill out
these little forms. They tell you what they want. (CHDP #1)
The school nurses felt that their communication within the school
organization was adequate. Since they are insular, they do not seek to increase
communication outside their nursing group. They used the appropriate memos or
interaction when they need to communicate about a student.
There may be memos sent to teachers or other staff about thing that
they need to know. We definitely maintain right to privacy but we
do give customary information about how to deal with the
children. (School #1)
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There is not a problem with me communicating with the teacher or the
parent. (School #2)
Clients/Services Choices
The school organization’s emphasis on academic achievement rather than the
whole child education affected services for foster children. The symbolic
organization frame does not support special services for this population since
according to the school district all children should receive the same service level of
care and the main health goal is to keep children in school.
Again I think about foster students and I think about all their needs
besides just the reading, writing and arithmetic. And I think that to
have a district that is supportive of health needs, you have on that
is supportive of the needs of these special children. And I see
some roadblocks, certain issues. (School Supervisor)
I think there is not such an emphasis from above on the foster
child, not just at the school site. There is not enough recognition
of the needs of the foster care child in terms of attendance. The
focus isn’t there. If focus was given to this child from above, then
time would be allocated. (School #2)
In the school organization, foster children were not identified for the school
nurses. School nurses did not know when a child was a foster child unless they
asked or a teacher or principal told them. This lack of identification is part of the
structure of the organization. Therefore nurses have no choice in clients.
We don’t know the kind of kid, until we decide to call the family
and then we discover this is a foster child. I like it the way it is. If
there are any concerns the teachers will let us know. If there is
anything that is super unusual, the principals will let us know.
(School #3)
The foster care is only indicated in a chart, but not always. Some
of the history may indicate that they are foster, but sometimes I
don’t even know. (School #2)
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The type of services depended on the nurses’ interpretation of their job
descriptions. Although both child welfare and school nurses wanted to do more for
children than they presently can, school nurses felt that given the time their job
description would allow them to do what they wanted to do. Child welfare nurses
wanted and accepted the clarity of their job descriptions, yet they wanted to do more
than what is on the piece of paper. They felt that the services they would give foster
children were restricted by their job description.
Some of the nurses think they should be going out to the homes
like a regular field public health nurses might do without being
forced by having to go with a social worker. They want to be able
to take their little black bag and listen to breath sounds and heaven
knows what. And our funding absolutely doesn’t allow that.
(CHDP Supervisor)
Child welfare nurses were dependent on referrals from social workers for the
type of clients they can see. There were no clear guidelines within the organization
about what foster children should be referred to the nurses. The structural
framework is weak in making the nurses’ part of the day to day flow of work.
Some of these kids have been in the system for a while and some
things that have needed attention have not had attention. We don’t
find them until, it is hit or miss that we got to them. There just
isn’t a mechanism of identifying those kids easily to pull them out.
(CHDP Supervisor)
I have three units, in one unit I get almost every case, in the second
unit I get the problematic cases, and in my third unit the social
workers would prefer to do it. I have three different styles of units.
(DCFS #1)
The lack of specific guidance brought up paranoid issues for both social workers and
nurses. The social worker noted that the system does not protect her. The nurse
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noted since she is just the consultant and not the decision-maker, the system
actually will more likely protect her.
If we only select certain cases, maybe the one case we did not
select might be the case that in the future will come back and be a
failure. Maybe that’s the child who’s being neglected by the
caregiver and who’s liable for that? (Social Worker)
Because we work in a system in which you are the consultant.
Frustrating sometimes, and other times it’s relieving because
there’s some decisions that you know have to be made and we
don’t have to make them. (CHDP #1)
Child welfare nurses had other methods of choosing clients. The nurse
reviewed files to identify those foster children who need further attention. Children
came to the nurses’ attention by their CHDP physical exam forms or by an
organizational focus. This method of getting referrals is part of the structure of
DCFS but is not as helpful as referrals from their case manager, the CSW.
I always have to laugh when I spot that the child is a nine year old
and the child weighs 200 pounds and the doctor write down well
child. Well, to me that is not a well child. Nutritionally there is
something wrong and look at the hemoglobin and the child is
anemic. A well child, no. (DCFS #2)
Well the squeaky wheel gets the grease. They are other ways we
get referrals and partly one of the ways is though these little yellow
pieces of paper, which are the physical exam forms. They also
have problems listed on them. Sometimes the social worker
doesn’t even know about these problems. (DCFS Supervisor)
Legal restrictions (in terms of the structural frame) make serving clients also
difficult for the child welfare nurses. One nurse reported that the legal guardian
system ties her hands in terms of advocating for the child. Nurses want to work
within the laws to make sure that they can intervene on behalf of children.
I see the case and I see there’s problems. I can’t tell a social
worker what to do. But I’d rather go up to a judge and say you
need to take away this legal guardianship. There’s something
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funny going on and I can’t get records. You can take them out of legal
guardianship.. .The judge will then order that this child has to be
evaluated by this specialist.. .In one of my guardian cases this child
is on total psych meds, seeing a psychiatrist and these medicines
are all prescribed by the physician. The primary care physician
won’t give me any information because it’s a legal guardian non
court case. The caregivers are also seen by the same physicians
and are also on psych medications per the social worker. So I
think there is a conflict here. (CHDP #1)
We have to manipulate our practices here to what the laws are like. (DCFS #2)
Discussion
Theme Number One: Structural Barriers to Client Access
The nurses’ access to the population of foster children was not supported by
either the school or child welfare organizations. The lack of access to the target
population limited the nurses’ ability to provide adequate health care and frustrated
them in their jobs. Schools limited the nurses’ access by not identifying the
population and by promoting equal services for all children. The school nurses
recognized that foster children were a less healthy and more needy population. Equal
services for a population with unequal needs does not equate to equal health
outcomes. The child welfare organization limited access by not requiring social
workers to consult nurses about their cases. There was no structure in place for child
welfare nurses to identify which foster children needed nursing case management
and the ex ten t of th at case m anagem ent.
The nurses’ integration into their organizations and their strengths within the
organizations did not support their ability to overcome the access limitations and
care for foster children. For the nurses to treat foster children, their roles and
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responsibilities in terms of foster children needed to be realigned to fit the
necessary tasks and environment. School nurses needed more time and effort for this
population to meet their recognized health issues, including emotional health. Child
welfare nurses desired the organizational structure to allow them to access charts,
prioritize cases and give services. According to the Bolman and Deal (1997), the
structural frame of the organization needs to be reorganized to encourage the
necessary realignment, as in providing nurses’ access to foster children
The organizational strengths’ of the nurses lay in the human resource and
symbolic frames. The nurses showed their commitment and motivation for
successful integration into their organizations. Bolman and Deal (1997) noted that
for different situations, a particular perspective might be more helpful than another.
In the nurses’ cases, their perspectives primarily focused on their participation, effort
and skill to be effective in the organization. But in the case of needing the
organization’s approval to access foster children, the nurses required better strategies
to set their objectives and to coordinate their resources. These strategies are part of a
strong, supportive structural frame.
The school nurses had a job description that would allow them to give foster
children care but they could not control their resources or the coordination of that
care. The School’s goals of every child having the same care did not support the
foster child’s needs. Even though child welfare nurses had a clear job description,
they wanted be able to use strategies not delineated in their job description to give
optimum care. The child welfare nurses did not have the ability to control the
resources since the structure of the organization did not allow them. Therefore, both
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nurse groups needed a stronger organizational structure frame that supported
their work in providing health care to foster children.
Theme number two: Divergent Views on Determinates of Health
Child welfare nurses and school nurses had different views of the cause of the
poor health of foster children. The child welfare nurses identified the broad
determinants of health representative in the Social Ecological Model of Health but
school nurses primarily recognized the child’s placement in the foster care system as
the cause of health problems. When differences in level of health are determined by
the interaction between biology, behavior and environment, (as in the Social
Ecological Model) interventions will likely take into account of the special needs of
the target group and address both downstream and upstream phenomena (McKinlay,
1995). The child welfare nurses who adopted a more ecological approach to health
also adopted more comprehensive interventions, with more upstream and
downstream prevention. The child welfare nurses even wanted to provide primary
prevention to keep children from being part of the foster care system.
The child welfare nurses noted that the foster child was a product of their
poor environmental condition, abuse, lack of preventive health care, poverty, etc.
Foster children had little if any social capital since social capital is the product of
long standing social relationships (Kawachi, Kennedy, Lochner & Prothrow-Smith
1997). The lack of social capital leads to poor health outcomes. The school nurses
primarily blamed the foster child’s poor health on the result of being in the child
welfare system. The school nurses noted that the foster child’s frequent movement
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and poor providers were the cause of their lack of good health. The school
nurses’ lack of awareness of the total effects of the child’s physical, psychological,
social and economic situation, including the lack of social capital, limited their
ability to provide more comprehensive care. The PHI Model defines that
interventions need to focus on the clients broad determinants of health to be effective
(Minnesota Department of Health, 2000).
The health of individuals is influenced not just by their present environment
but by genetics, ethnicity, social and family relationships, broader social and
economic trends, and the society in general (The Institute of Medicine, 2000).
Based on acceptance of the broad view of health determinants by the child welfare
nurses, interventions for health promotion should include multiple approaches
(education, social support, laws), address multiple levels of influence (individuals,
families, communities) and take a long view on achievement of health outcomes.
School nurses’ identified interventions that would help students stay in
school. They encouraged prevention through screening but primarily met immediate
needs to keep the child healthy enough to learn. The school nurses were not
involved in the long-term outcomes, multiple approaches, or multiple levels of
influence. Child welfare nurses felt limited in their job descriptions but had goals
that included many of the Social Ecological Model’s recommendations. The child
welfare nurses wanted to manipulate the legal system in order to protect children,
provide social support, look at long-term results, and influence the family as well as
the individual. The child welfare nurses saw reaching the child’s life-long potential
as their own work goals. Adoption of the ecological view of health by child welfare
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nurses correlated with their interest in providing comprehensive health care,
including more emphasis on upstream interventions. The child welfare nurses’
desire for more upstream interventions extended to trying to keep children “out of
the system.” Therefore since child welfare nurses’ views showed a more complete
adoption of the tenets of the Social Ecological Model of Health, their intended
interventions were also more reflective of the model.
Theme number three: Philosophical Practice Differences
School nurses and child welfare nurses differed in how they wanted to
practice the PHI interventions. School nurses preferred to practice independently
whereas child welfare nurses wanted to be part of a team. The survey results and
observations confirmed the nurses’ intent. The school nurses had physical access to
schoolchildren and could give services such as screening and health teaching. The
child welfare nurses’ job descriptions identified their role as case managers and their
practice reflected their role. The child welfare nurses primarily practiced
consultation, referral and follow-up and case management. These interventions are
interdependent.
The type of practice relates to the PHI Model levels of practice. Public health
interventions can be practiced at three levels, and should be implemented at multiple-
practice levels, either simultaneously or sometime sequentially (Minnesota
Department of Health, 2000). The three levels are individual and family,
community and systems. In order to successfully practice at the system-focused
level, the interventions need to be multidisciplinary. These type of interventions are
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generally longer lasting and a way to impact more clients. System interventions
include changing organizations, policies and laws. The child welfare nurses
identified that they wanted to practice the PHI intervention of Policy development
and enforcement, although this intervention was not observed. The child welfare
nurses were not satisfied with the system they worked in and were definitely trying
to make changes. Unfortunately they did not have enough of a power base to make
significant changes.
Both school nurses and child welfare nurses work in agencies in which they
are not the primary providers of care. In both situations, the nurse supports the work
of the teacher or the social worker. Alliances with the primary practitioner would
enhance the nurses’ ability to improve the health status. Coalitions with the majority
players help give nurses’ power to have their ideas heard. Team interventions in
general are more powerful way to affect change in individuals, communities and
systems. Independent interventions can affect individuals and families but they are
not likely to affect communities and systems.
Theme number four: Lack of Political Influence
Both school nurses and child welfare nurses lacked the political power to
assure that what they wanted to do for foster children could be done. The school
nurses’ lack of political influence resulted from their apathy and fear of involvement.
Child welfare nurses did not possess political power because their lack of longevity,
the hierarchical nature of DCFS, and the reluctance to surrender power to nurses on
the part of the social workers.
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Bolman and Deal (1997) identified that there needs to be a redistribution
of power and formation of new coalitions for structural reorganization to occur.
Restructuring is an option only for those in authority. In both organizations, the
nurses were not in authority. Unfortunately the nurses in authority, the nurse
supervisors, were both new to their positions so even they were not in power
positions. In both organizations, the nurses did not have the political power to make
such a reorganization happen. The nurses within the schools did not want the power
and in fact, shied away from involvement in the political frame of the organization.
The nurses in the child welfare organization wanted political power but found that all
the power was in the hands of the social workers. Even though they desired stronger
coalitions with social workers, the coalitions were inconsistent and not solid. The
political climate within the child welfare organization was one of mistrust and
suspicion, which did not help in the nurses’ cause.
Therefore because the nurses did not have or did not desire the political
power, they were not able to promote their desire for better care and outcomes for
foster children. Bolman and Deal (1997) propose that change can occur from the
bottom up, if the change agents (partisans) find other bases of power. The child
welfare nurses looked to the social workers to join them in promoting their role and
the health of foster children. The nurses had some intermittent success, with specific
social workers, but had an uphill battle. The school nurses recognized the power of
the community to promote ideas in the school system. The school nurses did not
reach out to the community for political support nor did they form alliances with
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teachers to get their ideas heard. Therefore structural change in the organizations
will be more difficult without the political power to affect change.
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CHAPTER 5
SUMMARY, CONCLUSIONS, AND IMPLICATIONS
Summary
Background
The child welfare system is responsible for the education, health and welfare
of over 500,000 children in the United States, with California having 20% of the
foster care population (Leslie et ah, 2000). There is consistent and overwhelming
evidence to support the idea that foster care children have higher than expected rates
of chronic illness (Barton, 1999; Schor, 1988; Stein, Evans, Mazumdar & Rae-Grant,
1996). The child welfare system has been overburdened in caring for this increased
population of sick children. The solutions differ, but primarily call for system-wide
improvement of identification, treatment, and follow-up for children with physical,
developmental, and emotional problems. In California, there is a lack of a
systematic, statewide system for provision of health care to foster children (The
Institute for Research on Women and Families, 1998). California has appropriated
money, matched on a federal level, to hire public health nurses to help implement a
better-coordinated and responsive system. (Almquist, Cambaliza, Johnson & Ward,
2001).
The difficulties meeting the health care needs of foster care children and the
proposed solutions call for a new way at looking at health and health care. Viewing
health issues from a Social Ecological Model accounts for both the causes of illness
and proposes new ways to promote holistic health, prevent illness, and treat patients.
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This model takes into account age, gender, race, ethnicity and socioeconomic
differences that affect how individuals function and grow, and therefore directly and
indirectly influence heath risks and resources (Institute of Medicine, 2000). The
Public Health Interventions (PHI) Model described by the Minnesota Department of
Health (2000) operationalizes the Social Ecology Model for community health
nurses, including the new foster care nurses and school nurses. The social, political
and economic environments of the Social Ecological Health Model are the same as
the broad determinants of health in the PHI Model. The model emphasizes the focus
on population-level interventions, identification of the at-risk groups, assessment of
health status to determine health needs and identifies 17 family, community, and
system-wide nursing interventions
The Social Ecological Model and the Minnesota Public Health Interventions
are incorporated in the job descriptions of the new cadre of public health nurses
(foster care nurses) employed by DCFS (Department of Social Services, 1999b).
These nurses join school nurses in providing care for California’s foster care
population. The foster care nurses and school nurses need to collaborate with each
other and will have to work closely with the social worker in the child welfare
system. The organizational climate of the setting in which nurses work will influence
their ability to affect change and function fully in their roles. The Bolman and Deal
(1997) framework for organizations will provide a lens to look at how nurses
function within the child welfare system and the schools. The structural, human
resource, political and symbolic frameworks will allow the researcher to explore the
nurses’ experience working within the child welfare system and the schools. An
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analysis of the frameworks can identify the prominent framework of the
organization and whether the frameworks of the organization enhance or detract
from the ability of the nurse to function fully in his/her role.
Review o f the Problem
The application of the Social Ecological Model of Health by foster care
nurses and school nurses has the potential of dramatically affecting the health and
health care of school-age foster care children. This health model holds promise for
directing interventions more upstream and improving the health promotion of this
population of children. The effectiveness of community health nurses working with
school-age foster care children and their families will depend on the nurses’ ability to
provide appropriate interventions (as specified in the Minnesota PHI Model) within
the context of the child welfare system and the school system. The organizational
context of practice will provide a backdrop for adoption of a health promotion
philosophy. Nursing educators will need to prepare nurses to work in organizational
settings such as schools and child welfare where the nursing workforce is not
dominate.
Purpose o f the Study
The purpose of the study is to investigate whether nurses adopt the theoretical
framework of Social Ecological Model of Health and whether their practice is
theory-based. The study looked at this potential for theory-based practice in two
organizational contexts, the Child Welfare System and the School. The study
investigated whether the organizational context buffers or enhances the ability of the
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nurse to carry out his/her role and whether the organization affects
communication, case finding and choices of actual interventions.
Research Questions:
1. What do nurses want/intend their role to be in providing health
promotion/education for foster care children and their families and how are
these role perceptions similar or different between the school setting and the
child welfare setting?
2. What strategies and interventions do nurses actually use in their role of
providing health promotion/education for foster care children and their
families?
3. What similarities or differences of the organizational structure of schools and
the child welfare system affect nurses’ role in the health of foster care
children and their families?
4. How does the organizational context of the school and the child welfare
system affect the nurses’ choices of services, clients and communication?
Methodology and Data Sources
In-depth interviews of foster care nurses, school nurses and a social worker
provided the primary data for this qualitative study. The interviews explored the
nurses beliefs about what they want or intend to practice to care for the population of
school-age foster care children and their perceptions of the organization in which
they work. The goal of the Study is to learn about the phenomena from the
perspective of those working in the field. The phenomena being researched are the
congruence between what the nurses believe about health care for the foster care
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population (in terms of adoption of the philosophy of the Social Ecological
Model) and their actual practice (in terms of the Minnesota Public Health
Interventions). This congruence was analyzed in terms of organizational context, the
Child Welfare System and the School organization. This study is applied qualitative
research that is trying to generate potential solutions to a human and societal problem
(Patton, 1990).
The multi-method (triangulation) qualitative approach was used to conduct
this research. This study utilized interviews, observations, and a survey in order to
triangulate the results. A Social Worker was interviewed to triangulate the
perceptions of the nurses in terms of organizational structure and the cooperation
between the two professions. The researcher designed the interview guides to answer
research questions one, three and four. The interview guides were based on the
theoretical foundations of the study, the Social Ecological Model of Health,
Minnesota Public Health Interventions, and the Bolman-Deal Organizational model.
Separate interview tools were designed for each of the population groups: foster care
nurses, school nurses and social workers. A survey of the frequency that nurses
practice the 17 Minnesota PHI and four-hour observations were completed to answer
question number two regarding the nurses’ actual practice.
A purposive population with critical case sampling was used for this study.
The population for the study is the foster care nurses working in Child Welfare
System (CHDP and DCFS) and school nurses working in the Pasadena School
District. Interviews were conducted with both key informants and general
informants. The three key informants were the administrative nurse supervisors in
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CHDP and DCFS (Child Welfare) and an administrative nurse supervisor in the
School. The general informants were 3 nurses chosen by the nurse supervisors from
both CHDP and DCFS. The 3 school nurses were chosen from the five Pasadena
Elementary schools with the highest numbers of foster children. The Pasadena
DCFS nurse suggested a social worker who she felt utilized the foster care nurses
well.
All interviews were typed to allow analysis. The researcher did the analysis
by hand without using a computer program. The analysis of the interview data
followed the guidelines for phenomenological research. Each interview was broken
into segments and the researcher looks for meaning units and themes in the
segments. Then the meaning units and themes are compared across interviews and
finally the findings are synthesized and validated by checking with the participants.
The structural descriptions took into account regularities of thought, judgments and
recollection that underlie the experience of the phenomenon of nurses working in
foster care and give meaning to it (Gall, Borg & Gall, 1996). Analysis of the
observations included coding by the researcher using the definitions of the 17
Minnesota interventions, summarizing the intervention survey, and comparing the
observations to the survey. Two independent coders agreed with the researcher 77%
and 84 %.
Selected Findings
Research Question One: Nurses' Intentions in Providing Care and
Similarities/Differences between School and Child Welfare Setting
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The central goal for all nurses was providing holistic, preventive health
care to foster children. The purpose of the care depended on the organization’s
vision. School nurses wanted to ensure school attendance and thereby a chance for
the child to learn and child welfare nurses wanted to ensure the safety of the child by
meeting their health needs. Both groups of nurses identified the restraints of time
and access to the population. Child welfare nurses added the difficulties working
within the health care delivery system and within their limited job description as
further restraints.
School nurses and child welfare nurses felt that providing multidimensional
health care with an emphasis on mental health would meet the goal. School nurses
expressed that they could meet this goal within their job responsibilities. The child
welfare nurses felt they needed to be part of a multidisciplinary team to meet the
goals. The timing of the interventions was ongoing for school nurses but early
(even before the child entered the “system”) for child welfare nurses. Interventions
differed for the two groups of nurses. School nurses felt that case management
should be provided by the child welfare system and the school nurses’ role was to
make occasional referrals and provide standard (the same as other students) health
education and care. The child welfare nurses identified the need for a broader role of
complete health case management with documentation of the health picture in the
Passport, and provision of comprehensive health education to the entire family. The
poor quality of the foster parents made the interventions more difficult for both
groups of nurses.
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181
Finally, the school nurses and child welfare viewed the causes of poor
health for foster children differently. The school nurses viewed the problems of the
child welfare system as the cause of poor health. Child welfare nurses
acknowledged the role being in the “system” plays, but also identified socio-cultural
issues associated with poverty and the health issues resulting from lack prenatal care
to drug exposure during birth as important factors in these children’s poor health.
Research Question Two: Interventions used by nurses in their roles
The greatest differences between the type of interventions practiced by
school nurses and child welfare nurses are related to the independent or dependent
nature of the intervention. The three interventions reported most frequently and
observed most frequently with school nurses were screening, health teaching, and
surveillance. These interventions can be and were observed to be practiced
independent of other practitioners such as teachers, parents, or even the school
nursing aides. The interventions reported and most frequently observed with child
welfare nurses were consultation, referral and follow-up, surveillance and case
management. All but surveillance need other members of the team to be effective.
These interventions were observed in conjunction with CSWs, physicians, and foster
parents.
Both groups of nurses overestimated the frequency that they practice
advocacy, consultation, and counseling. Advocacy requires acting on someone’s
behalf with a focus on developing that person to become their own advocate.
Consultation is interactive problem solving with a client so the client can select the
best solution. Counseling is having an interpersonal relationship that increases the
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client’s capacity for self-care and coping. All these interventions require
interaction with a client that increases the client’s ability to make healthy choices,
advocate for themselves or perform self-care. These interventions require the nurse
to let go of the process and let the client do for himself. The process is in educating,
exploring solutions, and allowing freedom for the client to use the information to
make choices. Most of the observations reflected the nurse intervening on behalf of
the client and not involving the client in the process or choices.
Question number three: Similarities and Differences in Organizational Structure
Symbolic Frame. Both school nurses and child welfare nurses accepted and
agreed with the core values of the organizations in which they work. They would
like the core value to include more emphasis on health of children. The school
nurses recognized the influence that the community played in setting the
organization’s goals. Both groups of nurses were committed to their own role in
helping reach the goals of their organizations. The nurses in both organizations were
more aligned to their fellow nurses than their non-nursing coworkers, teachers and
social workers. They derived satisfaction from the ritual meetings with their nursing
colleagues. The school nurses viewed the head of the school organization as
visionary and a strong leader. The child welfare nurses were not convinced that the
head of the child welfare organization was strong, partly due to the frequent changes
in the leadership position.
Political Frame. School nurses were not involved in the political nature of
the school organization. Even though they wanted some changes to occur, they did
not want to become involved in making those changes. Child welfare nurses, on the
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183
other hand, were committed to affecting change but the political climate of their
organization did not allow them to be change agents. The child welfare nurses were
acutely aware of the punitive nature of their organization. Both groups of nurses felt
that their power was limited. All nurses used their supervisors to voice their
concerns while child welfare nurses also used their personal relationships with social
workers to affect change. The child welfare nurses recognized that the power was
held by social workers. Child welfare nurses took as active a part in the political side
of their organization as they could, within the boundaries of the recognized hierarchy
and recent changes in the nursing leadership. School nurses basically preferred
keeping to themselves and doing their job.
Human Resource Frame. Both school nurses and child welfare nurses liked
what they did, got personal rewards from their work, and were motivated by their
love of children. Both groups of nurses felt supported by their supervisors and
enriched by the educational opportunities provided by their organizations. The
school nurses’ insular nature allowed them to feel appreciated and valued by the
other school nurses. The child welfare nurses wanted to become part of the larger
organization because they highly valued teamwork. The child welfare nurses felt
less valued because their ideas were not heard loudly in such an unwieldy, large
organization. Both groups of nurses wanted to do more in their jobs so they could
feel more satisfied in their work,
Structural Frame. Child welfare nurses and school nurses wanted and
required a structured environment, but the structure of their organizations made it
difficult to do their job. The structure of the organizations supported the
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organizations’ primary goals but not the complementary goal of health. Nurses
in both organizations took comfort in the clear job descriptions and responsibilities
as well as the autonomy that allowed them to organize their work independently. The
greatest difference between the nurse groups was in the need for interdependence
with other disciplines. School nurses had ambivalence about their dependence on
teachers and wanted to primarily work independently. Child welfare nurses were
clear in their desire to be part of the team with social workers but the organization’s
structure was ambivalent. There was no mandate for the legal case manager, the
social worker, to include nurses as part of their routine work with the foster families.
The child welfare nurses worked within the system to make themselves noticed,
valuable, and used. Both groups of nurses wanted to avoid conflict and utilized their
knowledge of their responsibilities to settle disagreements.
Question Number Four: Organizational Influence on Nurses ’ Choice in Clients,
Services and Communication
Communication between child welfare nurses and school nurses was
successful when it occurred. Child welfare nurses or social workers occasionally
took the lead and sought school nurses. This type of communication is supported by
the fact that nurses were aligned personally and professionally with other nurses as
seen the symbolic frame. Since the child welfare nurses valued teamwork, they
identified ways in which communication could be improved between their
organization and the schools.
Communication within the Child Welfare Organization was less effective
internally because of the lack of clarity regarding the use, updating, and distribution
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185
of the Health and Education Passport. Child welfare nurses wanted improved
communication with CSWs and employed their strong human resource frame to
encourage more teamwork. School nurses were insular and did not routinely seek
communication outside their nursing group.
Choices of clients were limited due the structural limitation of the two
organizations. The CSWs acted as gatekeepers and did not systematically refer
appropriate cases to the nurses. The child welfare nurses employed other means to
find cases although direct referrals from the case manager would make the flow of
work more efficient. The structure of the school organization did not allow nurses to
single out foster children since their care was supposed to be the same as any other
student. The actual care given to foster children depended on the nurses’
interpretation of their job descriptions. Although both child welfare and school
nurses wanted to do more for children than they presently could, school nurses felt
that given the time their job description allowed them to do what they wanted to do.
Child welfare nurses wanted to do more than their job description allowed.
Conclusions
Nurses who work with children in foster care need more organizational
support to provide the most comprehensive case management for this population.
The foster care nurses were not able to be utilized to their fullest capacity within the
Child Welfare Organization because they were not fully integrated into the
organizational structure. The school nurses were not able to provide the extra
support foster children need because the organization did not allow the foster child to
be singled out for the attention that the child needed. Although both groups of
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186
nurses recognized that they had time restraints, the lack of organizational
structure significantly added to the nurses’ inability to provide adequate care.
The Bolman Deal Organizational Model provided a useful lens for viewing
the School and the Child Welfare System. The nurses’ perceptions of the frames of
the organization in which they worked identified specific issues that were vital to
their integration in the organization and their ability to fully function in their roles.
These issues included the lack of access to the foster children either due to gate-
keeping on the part of DCFS social workers or organizational vision of equal care for
all by the school district. The nurses’ strength in the human resource and symbolic
frames could not overcome the contrary and inconsistent structural frames in their
organizations. The nurses’ lack of political power from apathy (for school nurses) or
from minority status (for child welfare nurses) made their ability to address these
issues to meet their own and their patients’ needs very difficult. The nursing
leadership was not strong enough to overcome the individual nurses’ lack of power.
Adoption of the Social Ecological Model of Health was vital to wanting to
provide comprehensive upstream health care to children in foster care.
Acknowledging the importance of the child’s historical social, psychological,
physical and familial influences led to the child welfare nurses’ desire to provide
interventions that would meet total health needs. School nurses did not fully
recognize these influences and therefore were content to provide the standard health
screening, health education and emergency assistance to the foster children. Both
groups of nurses recognized the foster child’s significant need for mental health care
although neither could meet that need consistently or fully.
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187
The type of interventions the nurses practiced was determined by their
practice (independent vs. dependent) and by the lack of partnerships with their
clients. School nurses’ emphasis on independent practice resulted in a more limited
use of community or system-focused interventions. Child welfare nurses’ desire for
a team approach coupled with the CSWs’ resistance to teamwork within their
organization resulted in the nurses’ overestimation of the frequency of interventions.
Both groups of nurses noted that they wanted to advocate, counsel and consult with
clients but wanted to do things for the client rather than involve the client in a
partnership.
The type of organization shaped the nurses’ choices and practice. Nurses in
schools have a long history and tradition in that setting yet the Study illustrated that
the nurses chose to practice in isolation rather than integrated into the work setting.
Nurses in health care settings have traditionally work in multidisciplinary teams but
in a setting in which the nurses dominate. Nurses in child welfare desired a team
approach but could not break in to the “host setting” of the social worker. Dr.
Madeleine Stoner, a professor in the School of Social Work at the University of
Southern California, defines a host setting as an organization in which a worker is a
guest. (Personal Communication, May 18, 2003) Both school and child welfare
nurses are working in organizations with “host settings,” and neither group has
successfully accommodated to that type of practice setting. The school nurses chose
working in a silo situation and the child welfare nurses were frustrated in their
attempts to become part of the DCFS team.
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Implications
Practice
Nurses are increasingly moving into community settings. The traditional role
of the nurse in the acute care hospital has long been structured to utilize the
capabilities and abilities of the RN. It is vital that community organizations develop
the structure that supports nurses’ work to avoid the frustration of the nurses
expressed in the Study. Non-health care community providers are not as versed in
the multiple roles that RNs play in the workforce. Baccalaureate (BSN) RNs have a
myriad of skills and knowledge that can make health and health care better for
individuals, families and populations. Since many managers of community agencies
that are beginning to employ nurses may not be aware with the talents and
capabilities of PHNs, these managers need to consult with leaders in community
nursing to familiarize them with how this new workforce can be used.
Organizational managers must do more than provide clear job descriptions
for nurses in the work environment. Managers need the structure in place that
assures that nurses will be a part of the workflow and that all their capabilities will
be employed. Managers also need to be aware of the possibility that other workers
are also not familiar with the BSN RNs’ capabilities and must educate all workers on
how the new nurses can and should be part of the workforce team. This integration
needs organizational approval, clear structural guidelines, and buy-in from the other
professionals.
This is especially true for managers in the Los Angeles County DCFS. The
organizational structure is not in place to assure that the foster care PHNs are
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189
working to their fullest capacity. CSWs are not clear about the role of nurses and
they do not consistently or adequately utilize the PHNs for health management of
their cases. The health management includes the Health and Education Passport.
The organizational managers of DCFS need to restructure the workflow within the
district offices to include specific, clear and consistent guidelines about which cases
need referrals to PHNs and how the Health and Education Passport is to be used and
by whom. CSW managers need to enforce these guidelines. The culture of the
DCFS central and local offices need to support the interdisciplinary work of PHNs
and CSWs, and make sure that there is no mistrust between the two disciplines.
Unnecessary fear of organizational reprisals has no place in the culture of a healthy
organization.
The organizational managers in the Pasadena School District also need to
restructure the interface of school nurses and foster children. The dictum of treating
all students the same is not in the best interests of the foster child. The school nurses
are aware of the increased health needs of these children, especially their mental
health care needs. Identifying foster children for increased services will allow school
nurses give the services that this population requires. Managers need to enlist the
political support of the community to make students’ health issues a priority. Also
working more closely with DCFS will assure that health records (specifically the
immunization record) follow the child and the foster child will not miss school days
when he or she moves from foster home to foster home.
Employing nurses to assure health safety for foster child is not enough.
Policy makers must be cognizant of how the nurses will work with CSWs and others
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190
in the Child Welfare Organization. The job descriptions of the foster care nurses
were developed in Sacramento but they did not address how the nurses were going to
work within the existing structure in the various Child Welfare Departments. Those
job descriptions should be reevaluated to see if the restrictions in practice are
realistic and in the best interests of the foster children. The nurses’ integration in the
workings of DCFS is poor and prohibits the PHNs from actually performing their
tasks. It is unfortunate that the nurses are spending significant time attempting to
access foster children’s records rather than reviewing those records.
Policymakers must also continually assess the integration of different
organizations and systems serving the foster care population. Nurses can be a bridge
between schools, the health care system, and the child welfare system. The Study
illustrated how nurses tend to listen and talk among themselves to work on health
concerns of their clients. Policymakers can capitalize on this connection by
encouraging the nurses who already work in these organizations to connect with each
other. This encouragement should include developing mechanisms for
communication and rewarding integration between systems. Specifically, school
nurses need to be made aware of the nurses in DCFS so they can dialog about their
students and use each other to meet the foster child’s health needs.
Baccalaureate nursing schools provide the community health education for
PHNs in California. Community health educators need to incorporate the Social
Ecological Model of Health in their curriculums to assure that students are aware of
the role that the environment plays in health outcomes. The Minnesota PHI model
operationalizes the Social Ecological Health Model for PHNs’ practice. PHNs use
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191
the Minnesota PHI model more fully to provide comprehensive health care when
they have adopted the Social Ecological Model of Health. The Minnesota PHI
model is an integral part of the Los Angeles County Public Health Nursing Practice
Model (Smith & Bazini-Barakat, 2003). This practice model has recently been
adopted for all public health departments in the State of California. Therefore, since
all new RNs working as PHNs in the Public Health Departments in California need
to understand and adopt this new practice model, it is even more imperative that the
students’ education include a greater emphasis on the broad determinants of health as
defined in the Social Ecological Model.
Nursing faculty need to teach the importance of interdisciplinary teamwork to
their students. Nurses who work with other disciplines are able to influence the
health of communities and systems more effectively. Nursing students in their
public health clinical rotation have difficulty witnessing and participating in
multidisciplinary teamwork with the mentoring PHNs. Practicing PEINs either do
not consistently practice teamwork or they do not engage their assigned nursing
students in this part of their practice. Nursing faculty must encourage the clinical
liaisons at the public health sites to include students in situations that call for
teamwork. If the PHNs are not practicing teamwork, the nursing faculty either need
to design clinical experiences in the sites or use case studies to encourage optimum
multidisciplinary practice.
Baccalaureate nursing students are taught about leadership, management and
as part of their undergraduate curriculum. Understanding about the power
relationships within organizations is important to being a leader or even an effective
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192
follower. Nursing students need more case studies and more experience in
developing their political expertise to work in the diverse environments that PHNs
are working in now and will be in the future. The Study illustrated the importance of
political activism to achieve change and to assure that nurses have the structure in
place to practice effectively.
The Study also illustrates that nursing students need to be knowledgeable
about how organizations function and grow. Nursing faculty need to teach how to
read and create effective organizations since many of their students will be working
outside the acute care setting. Much of what nursing students are being taught refers
specifically to hospitals and outpatient settings, yet nurses are working in far more
diverse organizational settings. In these settings, nurses will not be in the majority
and need to be experienced and knowledgeable in how to work in “host settings.”
University-based programs that educate RNs in other disciplines need to be
aware that integrating nurses in the non-traditional roles is difficult for organizations
and the nurses, themselves. Hospital-based nurses are accustomed to a structured,
task-oriented environment in which their services are understood by all of the
members of the healthcare team. The Study illustrated how the nurse subjects valued
their clear understanding of their job descriptions and human resources within the
organization. As nurses begin being educated in Masters in Business
Administration, graduate Education schools, and Social Work Schools, the students
and the faculty need to avoid ambiguity about how their students’ nursing skills and
knowledge can be integrated into their new education and skills.
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193
The University of Southern California School of Social Work is
designing a program to recruit BSN nurses. The program will meld the nursing skills
with Master of Social Work skills to produce a “new professional.” The faculty
designers of this program need to be cognizant of nurses’ desire for structure in
designing clinical rotations for this nurse-social worker. The faculty must work with
the clinical facilities to make sure that the community organization wants, accepts
and will utilize this new professional. Although it is not exactly clear why CSWs in
DCFS were reticent in accepting nurses into their social work organization, it is clear
that this lack of acceptance affected the nurses’ ability to do their job effectively.
The faculty need to work make sure that this does not happen as the nurse-social
work students begin to assume new roles in community settings.
Finally foster parents need to ask for copies of the Health and Education
Passports for their foster children. These passports should be shared with their
health care providers. Foster parents need to be made aware of the foster care nurse
assigned to their foster child so they can consult with the nurse regularly about health
issues and utilize their expertise in health emergency situations.
Research
Future research is suggested in several areas: a) foster care nurses’ effect on
the health of foster children, b) integration and communication between services for
foster children, c) nurses’ ability to use organizational knowledge and political
power to restructure their practice and d) relationship between teamwork, client
involvement and effective interventions.
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The Child Welfare system has invested heavily in recruiting PHNs for
health care management of foster children. There is an assumption that nurses will
be better at diagnosing, intervening and obtaining necessary health care for children
in foster care than the mandated case manager, the CSW. PHNs need access and
influence over the health care recommendations to actually affect any change in
health outcomes. Also, the Health and Education Passport needs to reflect the
nurses’ interventions and the up-to-date health care needs and services delivered to
the foster children. The Passport will be significant tool in evaluating the nurses’
impact on health. Longitudinal studies should focus on whether the foster care
nurses are actually able to meet the health care needs of this fragile population and
whether that care affects the children’s long term health outcomes.
The Study tells of the difficulty in connecting the health care system to the
school system to the child welfare system and to the courts. The nurses in the
schools and in DCFS can be conduits for that connection. Their stories about the
difficulties retrieving historical information about foster children’s life
circumstances, health care records, and school records makes the nurses in the
systems frustrated and the situation seem almost hopeless. Sometimes specific
nurses are able to overcome the barriers and reach out to get the information they
need or give information that will be helpful to the child. The child abuse reporting
laws offer a glimpse on how those seamless connections can be made. Nurses’
timely court interviews with birth parents after detainment hearings are sometimes
successful in capturing health histories that may be lost to the child after he enters
the foster care system. It is important to study how connections can be improved,
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195
how organizations can support those connections, and the results of connecting
the various services.
With the movement of nurses into organizations not usually associated with
nursing practice, the nurses’ assumptions, expectations, and practice guidelines are
being challenged. Nurses have been historically the majority players in health care
organizations. Even though physicians in acute care settings overtly seem to have
the power, often it is the nurses who run hospital organizations. Nurses gained this
power not from being political savvy, but from their numbers and their importance in
making the system function. Working in new non-health care focused organizations
such as Child Welfare, nurses will need more than a strong symbolic and human
resource commitment to make their practice an integral part of the organization. If
nurses want to make their practice successful in organizations, they will need a
strong basis for understanding organizational theory and a structure that supports
their ability to care for clients and the backing of the other workers within the
organizations. It will be useful to study how nurses can acquire organizational
knowledge and use political power to make the structure of non-health care related
organizations accommodate nursing practice.
The practice of nurses in community settings will be affected by the
requirement to provide care as a team in partnership with clients. Nurses in child
welfare valued teamwork, whereas nurses in the school setting wanted to be
independent practitioners. The types of interventions each nurse group performed
differed as a result of the nature of their practice. Nurses in new practice arenas will
not have the ability to choose to be independent of others and will need to learn the
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skills and attitudes that lead to teamwork. Effective interventions require
building the clients’ capability for self care. Research into how nurses adopt
teamwork and partnership skills and how those skills shape intervention choices will
make nurses more valuable to community organizations such as schools and child
welfare.
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197
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Asset Metadata

Creator Schneiderman, Janet U. (author)

Core Title Exploration of the role of nurses in caring for children in foster care

School Rossier School of Education

Degree Doctor of Education

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, health,health sciences, nursing,OAI-PMH Harvest,sociology, public and social welfare

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Marsh, David D. (committee chair), Stoner, Madeleine (committee member), Stromquist, Nelly (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-651122

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Legacy Identifier 3116783.pdf

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Document Type Dissertation

Rights Schneiderman, Janet U.

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