Sep 30, 2019
Foster care—a social determinant of health
Take away messages:
- The overrepresentation of Indigenous children in the foster care system in Canada signifies a systemic inequity.
- Shifting child welfare policy from crisis-based to preventative and supportive interventions may create opportunity to minimize child apprehensions.
- Nurses can contribute to improving the child welfare system by engaging in culturally sensitive interactions with patients/families and advocating for culturally sensitive policy informed by Indigenous values.
All BScN nursing students are required to participate in a community clinical practicum in their fourth year. In my practicum, I had the opportunity to engage with elementary school students, most of whom were Indigenous. I am extremely grateful to have been welcomed into their community for this part of my educational journey. I witnessed the absolute resiliency and strength of the children in the face of seemingly overwhelming odds, as well as the kinship among their community. My experiences in this clinical were especially powerful because I had the opportunity to establish long-lasting relationships with several children who were in the child welfare system. I also had the chance to participate in the Blanket Exercise (KAIROS Canada, 2019), which opened my eyes to the intricacies of systemic racism in Saskatchewan and the gross overrepresentation of Indigenous youth in the Canadian child welfare system (Sinclair, 2016). I realized that these children, so emotionally impressionable, returned home from school every night to relative strangers. In this article, I examine the effect of contact with the foster care system on health status through the lens of Carper’s Ways of Knowing framework (1978).
Empirics and socio-economics
The overrepresentation of Indigenous children in the Canadian child welfare system is well documented. Aboriginal children make up only 7% of the child population in Canada but constitute 85% of the children in foster care in Saskatchewan (Sinclair, 2016). These statistics highlight some poorly designed policies that contribute to the seizure of First Nations children. For example, the federal government distributes approximately 22% less funding for on-reserve child welfare services than the provincial government provides for the same services, off-reserve (Tait, Henry, & Walker, 2013).
Another skewed policy is that child welfare services apprehend children based on just two categories: “abuse” and “neglect.” In Saskatchewan, most of the children in foster care are taken based on the latter (Tait et al., 2013). In many such cases, social factors that are beyond the parents’ control have contributed to “physical neglect, failure to supervise, and parental substance abuse” (Tait et al., 2013, p. 44). For example, parents who attended residential school may have experienced intergenerational trauma that could be a factor in their developing a substance use disorder, and this should be considered before children are apprehended. Substance use disorders are a recognized mental illness according to the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013), and people suffering from them need to be supported through treatment rather than punished. If parents were struggling with another mental illness, such as depression or anxiety, we wouldn’t consider taking their children from them, but the stigma surrounding substance use disorders perpetuates this inequality (Lloyd, 2018).
Currently, the child welfare system is funded and driven by crisis-based and tertiary interventions (Tait et al., 2013). This downstream approach serves only to create more problems. In contrast, an upstream approach—including colonial reconciliation, addressing poverty, and mental health strategies—could prevent children from needing to be removed from their families in the first place.
The statistics cited above reflect the relevance of the socio-economic way of knowing, which includes income and social status, both of which may determine whether your child will be allowed to remain in your home or will be taken away. This reflects a systemic inequity that requires change by a conscious shift in practice and policy.
There is also a substantial amount of empirical evidence that suggests emotional, mental, and physical trauma typically accompany foster care, and that “foster care alumni are at risk for poor school performance and low educational attainment” (Mersky & Janczewski, 2013, p. 368). The same study also suggests that children transitioning out of foster care display greater psychological and behavioural deficits than maltreated children who are never placed in care. Further, a US study found that between 50–80% of children in foster care meet criteria for a mental health disorder, and 23% meet criteria for more than one (Hambrick, Oppenheim-Weller, N’zi, & Taussig, 2016). In addition to abuse and neglect, transitions in primary caregivers were adverse experiences that disrupted attachment relationships (Hambrick et al., 2016). These studies suggest that the interventions routinely implemented by Canadian child welfare services may be contributing to the problem rather than remedying it. Another study found that 22–35% of teen mothers in foster care between the ages of 17 and 19 “definitely” or “probably wanted” to become pregnant, and that “infants functioned to fill emotional voids in their mothers’ lives” (Aparicio, Pecukonis, & O’Neale, 2015, p. 45). This study also suggests that foster care only perpetuates the cycle of early motherhood, poverty, and lower educational attainment, and continues to have a negative impact on the other social determinants of health.
Cultural identity plays an integral role in child development and remains important into adulthood (Harris, Jackson, O’Brien, & Pecora, 2009). Children who are taken from their birth families and placed in a culturally different foster family are at risk of losing or struggling with their own cultural identity (Harris et al., 2009). In most areas of Canada, including Saskatchewan, most foster families are Euro-Canadian; this situation carries a significant risk that Indigenous children may associate their identity with the “failures” of their Indigenous parents in contrast to their Euro-Canadian foster parents (Tait et al., 2013, p. 44). These studies demonstrate that confusion over cultural identity carries the risk of related emotional, mental, and social turmoil.
Ethics and aesthetics
The Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses (2017) clearly describes the duty to provide culturally safe and competent care. According to the CNA Code, “When providing care, nurses do not discriminate on the basis of a person’s race, ethnicity, culture, political and spiritual beliefs, social or marital status, gender, sexual orientation, age, health status, place of origin, lifestyle, mental or physical ability or socio-economic status or any other attribute” (p. 17). Manitoba’s Child and Family Services Act (1985) dictates that consideration must be given to a child’s “cultural, linguistic, racial, and religious heritage” (Sinclair, 2016), and British Columbia has similar standards. Saskatchewan, however, has no specific recommendations for Indigenous children (Sinclair, 2016), despite the province’s significant Indigenous population. This lack of culturally sensitive policy is a barrier for nurses to provide culturally safe and ethical nursing care. Nonetheless, one of the University of Saskatchewan’s College of Nursing standards—on which nursing students are evaluated throughout every clinical experience—includes advancing the role of the RN and encouraging research and policy-making. When policies affect our patients in a negative way, it is our duty to speak out and act to change them.
Another ethical responsibility described in the CNA Code (2017) involves self-reflection. All professionals have a duty to closely examine their own ethical and cultural norms and how their values and beliefs influence their perspective and practice. If practitioners reflect on the origins of their ideas of family and parenting, this will prompt understanding, and mitigate judgment and bias, when they come across parenting styles that do not match their own. Self-reflection is the foundation on which to cultivate culturally safe practice and policy.
Navigating culturally sensitive care and policy development requires the aesthetic way of knowing (Carper, 1978). The aesthetics of nursing include nuances that are difficult to quantify. Knowing how to respectfully ask for help, learn and practice culturally safe care, and approach sensitive topics—such as child welfare—fall under the aesthetic way of knowing. Nursing aesthetics involve personalizing care to every patient, and continually reflecting and learning (Carper, 1978). Aesthetics are dynamic and cannot be learned through a textbook; they are learned only by engaging in meaningful experience with patients.
While there is much research documenting the effects of foster care on children, I could find little on the effect of this phenomenon on the parents. I volunteer at a Student Wellness Initiative Toward Community Health (SWITCH) after-hours clinic located in a core neighbourhood. During my time there, I have noticed a pervasive pattern: the emotional and indirect physical effects on a parent of having an estranged child are devastating. I observe that parents who have lost their children to the Crown, even temporarily, experience a steep decline in mental health and sometimes develop or intensify an addiction. Because of the nature of our meeting (at a clinic), I realize that I am more likely to see people struggling with a substance use disorder. This is a trend I feel deserves consideration when discussing foster care. Even involvement with the child welfare system that does not result in loss of custody can follow parents all their lives, similar to a criminal record. In considering contact with the foster care system as a social determinant of health, we must also consider that it applies not only to children but also to parents.
My experiences in clinical practice have caused me to develop a moral dissonance. Yes, Indigenous children are overrepresented in the Canadian foster care system, and that must change. Certainly, spending time in foster care affects a person’s health status in childhood and adulthood. I find myself wondering, no matter the race of the family in question, what is the best-practice intervention for children who live in an abusive or neglectful home? How can we ensure the child’s safety while providing support to the biological family, so that the child can return to the parents’ care as quickly as possible, without damaging the health status of both the family and the child?
I believe the answer lies in culturally safe policy and practice, as well as changes in funding allocation to allow for prevention of unsafe situations, rather than crisis management. This principle is true whether in social work, nursing, medicine, or other sectors. Highlighting Indigenous values, and increasing the number of Indigenous policy-makers and consulting allies, would be huge first steps in creating a safer, more equitable child welfare system in Canada. Every intervention and support system should be tried before an apprehension occurs, including and especially considering Indigenous views of parenting. For example, allowing dual parenting between parents and grandparents, even before formal kinship fostering is mandated, could prevent an apprehension. In turn, advocating for equity within the social determinants of health can help mitigate the intrusiveness of the foster care system. Equity means increasing affordable housing, secure and affordable food sources, access to primary health care, and more.
Nurses can work toward equity by utilizing their full scope of practice and role on the interprofessional team by advocating for their patients. Addressing changes to child welfare policy and supports for children and parents in the foster care system requires nurses to be active advocates. Nurses must continue to consult their patients and the community for direction, guidance, and help with patient- and community-centred advocacy and capacity building.
All healthcare and social work professionals must also make a conscious effort to engage in self-reflection regarding personal and societal parenting practices. Through reflection, professionals can identify biases toward Indigenous family structures and parenting styles within their own practice, as well as within policy.
Continuing education is another nursing responsibility that must be supported by post-secondary institutions and employers. We are obliged, as nurses and as citizens, to take advantage of experiential learning at every turn, as well as seek out theoretical knowledge.
It is my hope that the philosophy I have outlined will contribute to guiding nurses according to best-practice empirical and ethical standards for patients and communities.
The authors wish to recognize Gary Beaudin-Manager of Community and Resource Development for Greater Saskatoon Catholic Schools. His insights into navigating foster care alongside children in the school system were invaluable contributions to this article.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Aparicio, E., Pecukonis, E. V., & O’Neale, S. (2015). “The love that I was missing”: Exploring the lived experience of motherhood among teen mothers in foster care. Children and Youth Services Review, 51(April), 44-54.
Canadian Nurses Association. (2017). Code of ethics for registered nurses [PDF, 880.4 KB].
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.
Child and Family Services Act, CCSM c. C80 (1985).
Hambrick, E. P., Oppenheim-Weller, S., N’Zi, A. M., & Taussig, H. N. (2016). Mental health interventions for children in foster care: A systematic review. Children and Youth Services Review, 70, 65-77.
Harris, M. S., Jackson, L. J., O’Brien, K., & Pecora, P. J. (2009). Disproportionality in education and employment outcomes of adult foster care alumni. Children and Youth Services Review, 31(11), 1150-1159.
KAIROS Canada (2019). The blanket exercise.
Lloyd, M. (2018). Health determinants, maternal addiction, and foster care: Current knowledge and directions for future research. Journal of Social Work Practice in the Addictions, 18(4), 339-363.
Mersky, J. P., & Janczewski, C. (2013). Adult well-being of foster care alumni: Comparisons to other child welfare recipients and a non-child welfare sample in a high-risk, urban setting. Children and Youth Services Review, 35(3), 367-376.
Sinclair, R. (2016). The Indigenous child removal system in Canada: An examination of legal decision-making and racial bias. First Peoples Child & Family Review, 11(2), 8-18.
Tait, C., Henry, R., & Walker, R. (2013). Child welfare: A social determinant of health for Canadian First Nations and Métis children. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 11(1), 39-53.
White, J. (1995). Patterns of knowing: Review, critique, and update. ANS Advances in Nursing Science, 17(4), 73–86.