Collegian (2014) 21, 21—32

Available online at www.sciencedirect.com

j ourna l h omepage: www.elsev ier .com/ l ocate /co l l

The foster carer’s experience: An integrative review

Stacy L. Blythe, RN BN (Hons) PhD (Candidate)a,∗, Lesley Wilkes, RN, PhDb,1,Elizabeth J. Halcomb, RN, PhDc,2

a University of Western Sydney, School of Nursing and Midwifery, Family & Community Health, Research Group, Locked Bag 1797,Penrith South DC, NSW 2751, Australiab University of Western Sydney/Nepean Blue Mountains Local Health District Locked Bag 1797, Penrith, NSW 2751, Australiac University of Western Sydney, Family & Community Health Research Group, School of Nursing and Midwifery, Locked Bag 1797Penrith, NSW 2751, Australia

Received 10 May 2012; received in revised form 10 December 2012; accepted 10 December 2012

KEYWORDSFoster care;Children;Nursing;Family health;Child well-being

SummaryBackground: Foster carers have a significant responsibility in caring for children who are unableto live with their birth families and represent a key determinant in child outcomes. Difficul-ties in recruiting and retaining quality foster carers have resulted in an increase in researchinvestigating foster carers and their experiences in recent years.Aim: To synthesise current literature investigating foster carers and their experiences to enablea better understanding of their unique care-giving context.Method: The electronic databases CINAHL, Health Source, MEDLINE, Pscyh-articles, PsycINFOand sociINDEX were searched using the key terms; ‘foster carer’, ‘foster parent’, ‘foster mother’and ‘foster father’. Articles were included if they reported primary data about foster carersexperiences in the English language. Papers published prior to 2000 were excluded in orderto provide a contemporary perspective of the foster carer experience. Data was extracted,tabulated and thematically analysed.Findings: The findings from this review revealed the provision of foster care to have bothpositive and negative effects on foster carers personal well-being. These effects are largelyreliant of foster carers perception of their role as either parental or professional, the nature oftheir relationships with child welfare personnel, and their ability to manage children’s difficultbehaviours.

Conclusion: It is important for nurses to understand caregiving as it occurs in a variety of contexts. Nurses need to have an awareness and understanding of the value and role foster carers have in the lives of vulnefoster carers to identify and exp© 2012 Australian College of Nu

∗ Corresponding author. Tel.: +61 02 4570 1930; fax: +61 02 4570 1420.E-mail addresses: s.blythe@uws.edu.au (S.L. Blythe), l.wilkes@uws.e

1 Tel.: +61 2 4734 3181; fax: +61 2 4734 3182.2 Tel.: +61 2 4620 3344; fax: +61 2 4620 3199.

1322-7696/$ — see front matter © 2012 Australian College of Nursing Ltd. Published by Elsevier

http://dx.doi.org/10.1016/j.colegn.2012.12.001

rable children. In so doing, nurses are well positioned to assistress their needs in relation to their important caregiving role.

rsing Ltd. Published by Elsevier Ltd.

du.au (L. Wilkes), l.halcomb@uws.edu.au (E.J. Halcomb).

Ltd.

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nternationally, the health and well-being of children3 liv-ng in foster care is a matter of concern (Council ofustralian Governments, 2009; Woods, 2008). In Australia, aational Framework for child welfare provides opportunitiesor collaboration between government and non-governmentrganisations within health, justice, education and welfareectors to protect and promote the health and well-beingf Australia’s children (Council of Australian Governments,009). As health professionals, nurses play a vital role withinhis framework and are variously responsible, within theiriverse roles, for monitoring, maintaining and managing theealth and well-being of children in foster care.

It is well recognised fact that the children living in fos-er care experience an increased incidence of physical,ental and developmental health issues compared to the

eneral population (Carbone, Sawyer, Searle, & Robinson,007; Nathanson & Tzioumi, 2007). Accordingly, children inoster care likely have more frequent interactions than otherhildren with the health care system, and subsequently,urses. In order to provide optimal care, it is imperativehat nurses recognise and understand the context in whichhese children live and develop (Jackson & Borbasi, 2000).

Foster carers have a significant responsibility in caringor children who are unable to live with their birth families,any of whom experience significant behavioural, emo-

ional and developmental problems (Orme & Buehler, 2001).n this caring capacity, foster carers represent a key deter-inant in child outcomes (Cashmore, Paxman, & Townsend,

007; Cole, 2005; Leathers, 2006). Difficulties in recruit-ng and retaining quality foster carers, internationally andithin Australia, have resulted in an increase in research

nvestigating foster carers and their experiences in recentears (Ciarrochi, Randle, Miller, & Dolnicar, 2011; Colton,oberts, & Williams, 2008; Smyth & McHugh, 2006). It isow timely to synthesise these studies to evaluate whats currently known about foster carers and their experi-nces of providing foster care. Such a review can serveo increase nurses’ awareness and understanding of thismportant care-giving context, identify amenable factorsontributing to foster carer attrition, and highlight areas forurther research.

urpose

his paper seeks to synthesise the peer reviewed litera-ure describing the experiences of foster carers publishedetween January 2000 and March 2012.

ethod

s a summary of extant literature, integrative reviews havehe potential to contribute to evidence based practice and

re therefore subject to methodological standards regardinglarity, rigour and replication. Using the integrative lit-rature review method outlined by Whittemore and Knafl

3 ‘‘A child is defined as a person 0—17 years’’ (Australian Institutef Health and Welfare, 2011).

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S.L. Blythe et al.

2005), a comprehensive search of the literature was con-ucted for papers published between January 2000 to March012 using: CINAHL, Health Source, MEDLINE, Pscyh-articles,sycINFO and sociINDEX. Key search terms included fosterarer, foster parent, foster mother and foster father. Articlesere included if they reported primary data about fosterarers experiences in the English language. Papers publishedrior to 2000 were excluded in order to provide a contem-orary perspective of the foster carer experience.

The initial search yielded 1214 articles (Fig. 1). Follow-ng the removal of duplicates, opinion pieces, discussionapers, reviews and case studies; articles were assessedased on the relevance of the title and/or abstract. Arti-les using multiple data sources were excluded if thendings relevant to foster carers were not separately pre-ented. Articles focussing on the psychological construct ofttachment between foster carers and children and arti-les measuring the effectiveness of foster carer trainingrograms were excluded as these largely focus on childutcomes. This resulted in 77 articles which were indepen-ently considered for possible inclusion by three reviewers.rticles were excluded at this stage it they investigated spe-ific sub-groups of carers or children or did not report fosterarers experiences. A detailed list of excluded articles cane obtained, upon request, from the corresponding author.tudies which met the inclusion criteria were assessed forethodological rigour as described by Whittemore and Knafl

2005). As Whittemore and Knafl (2005) recommend, givenhe small number of relevant studies, none were excludedased on methodological standards.

Data analysis was an iterative process. Using a standard-sed form designed to enable the accurate and consistentxtraction of data from individual studies, the first authorompiled relevant study elements to facilitate analysis. Dataas further reduced and entered into a table. Given the pre-ominately qualitative nature of included studies, thematicnalysis was used to identify commonalities between studyndings.

esults

n total, 18 articles met the inclusion criteria (Table 1). Stud-es were conducted in several countries, namely; the Unitedingdom/Ireland (n = 6; 33.3%), the United States of American = 4; 22.2%), Canada (n = 4; 22.2%), Australia (n = 3; 16.6%)nd New Zealand (n = 1; 5.5%). The majority of studies wereualitative (56%; n = 10), while 4 (22%) used quantitativeethods and 4 (22%) employed mixed methods. Given theiversity of methodologies, the findings of this review areresented in a descriptive summary (Whittemore & Knafl,005). Three major themes emerged from analysis of thencluded papers: (1) the foster carer, (2) the foster carernd the system, and (3) the foster carer’s well-being. Eachf these consisted of two sub-themes which are discussedelow (Table 2).

he foster carer

or several decades, the literature has described the fos-er carer’s role as both ambiguous and arduous (Coltont al., 2008). The ambiguity largely arises from the unique

The foster

carer’s experience

23

Table 1 Included studies.

Article Country Study aim Sample Data collection The foster carer The foster carer and the system The foster carer’s well-being

Parentvs. pro-fessional

Personal char-acteristics

Relationships Resourcesand support

Positiveeffects

Negativeeffects

Broadyet al.(2010)

Australia To investigatetheexperiences offoster parentsto provide toexplore theimplications ofinadequatetrainingprocedures andthe need forongoingsupport

12 fosterparents;11female, 1 male

Focus group (7participants); 5individualinterviews

X X X X X

Brown andCalder(2000)

Canada To describe theneeds of fosterparents.

30 fosterfamilies; 27females, 22males

Telephoneinterviews andconceptmapping

X X X

Brown andCampbell(2007)

Canada To determinehow fosterparents definesuccessfulfoster care.

61 fosterparents; 51female, 10male

Telephoneinterviews andconceptmapping

X X X

Buehleret al.(2003)

USA To investigatefamilial andparentalfactors thatpromote orinhibitsuccessfulfostering.

22 fosterparents; 14female, 8 male

Semi-structuredinterviews

X X X

24

S.L. Blythe

et al.

Table 1 (Continued)

Article Country Study aim Sample Data collection The foster carer The foster carer and the system The foster carer’s well-being

Parentvs. pro-fessional

Personal char-acteristics

Relationships Resourcesand support

Positiveeffects

Negativeeffects

Farmeret al.(2005)

UK To examine theextent of strainon the fostercarers ofadolescents, itsinfluence onparentingpractices andthe overallimpact onplacementoutcomes.

68 fosterfamilies; 47couples, 19single females,2 single males

GHQ, SDQ,interviews

X X X

Hendrix andFord(2003)

USA To explore theimpact ofhardiness onfosters carers

82 fosterfamilies

Survey, FHI X

Hudson andLevasseur(2002)

Canada To identifysupportsneeded tomaintain thecaring role offoster parents.

66 fosterparents; 58female, 8 male

Postalquestionnaire

X X X

Kirton(2001)

England The impact ofpayment uponfoster carers

20 femalefoster carers

Interviews X X

MacGregoret al.(2006)

Canada To examinemotivation,support, andretention offoster parents.

54 fosterparents; 49female, 5 male

Focus groups X X X X

The foster

carer’s experience

25

Table 1 (Continued)

Article Country Study aim Sample Data collection The foster carer The foster carer and the system The foster carer’s well-being

Parentvs. pro-fessional

Personal char-acteristics

Relationships Resourcesand support

Positiveeffects

Negativeeffects

Morgan andBaron(2011)

UK To explore therelationshipbetween fosterchildrens’behaviouraldifficulties andthe stress,anxiety anddepressionexperienced bytheir carers.

58 fostercarers; 40female, 16male

Survey (SDQ,PSI-SF, HADS,DBSES)

X

Murrayet al.(2011)

New Zealand To explorefoster carers’perceived needfor support andtraining.

17 fostercarers; 14female, 3 male

PSI, CBEI, semi-structuredinterviews

X X X X

Orme et al.(2006)

USA To measure theimpact ofsupport onfoster carers

304 fostermothers, 111foster fathers

Survey(CHAP-SR,CFAI-A)

X

Pickin et al.(2011)

UK To investigatethe everydayexperiences offoster carers

5 foster carers;4 female, 1male

Photographsand interviews(Phenomenol-ogy)

X X X X X

Riggs,Augoustinos,et al.(2009)

Australia To explore howfoster parentsplay out theirrole as carers.

80 participants;49 female, 31male

Interviews,focus groups

X X X X

RosenwaldandBronstein(2008)

USA To understandthecharacteristicsof fosterchildren thatfoster parentsboth preferredand notpreferred.

13 fosterparents

Focus groups X X X X X

26

S.L. Blythe

et al.

Table 1 (Continued)

Article Country Study aim Sample Data collection The foster carer The foster carer and the system The foster carer’s well-being

Parentvs. pro-fessional

Personal char-acteristics

Relationships Resourcesand support

Positiveeffects

Negativeeffects

Samraiet al.(2011)

UK to explorefoster carers’experiencesandexpectations inrelation toplacementoutcome,current supportand whatsupportsystems maycontribute topositiveplacementoutcome.

8 foster carers;7 female, 1male

Semi-structuredinterviews(GroundedTheory)

X X X X X

ThomsonandMcArthur(2009)

Australia To developunderstandingabout fostercarersexperiencesusing thetheory theoryof familyboundaryambiguity andambiguous loss.

90 surveys, 12interviews

Surveys,interviews

X X

Wilson et al.(2000)

UK To investigatecarersreactions tothe stressfulevents

932 fostercarers

Surveys, GHQ X X

The foster carer’s experience 27

Potentially relevant articles identified by

electron ic literature search (n=121 4)

Articles examined by pa nel o f three reviewers (n=77 )

Articles excluded due to methodological inclusion crit eria (n=1137)

Articles excluded after detailed examination (n= 59)

Articles included in thi s review (n=18 )

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characteristic of foster care spanning both the public andprivate domains (Kirton, 2001). The responsibility for dailycare-giving, nurturing and behaviour management is diffi-cult as foster children often have complex social, emotional,behavioural, educational and physical needs (Teicher et al.,2003). Discussions aimed at resolving the ambiguity andminimising the complexity associated with providing fostercare have largely focussed on the development of profes-sionally recognised skills and identity (Kirton, 2007; Wilson& Evetts, 2006). Several included studies highlight thatdespite considerable debate, these two features signifi-cantly impact on the foster carer’s experience and mayeven influence their personal well-being (Broady, Stoyles,McMullan, Caputi, & Crittenden, 2010; Hudson & Levasseur,2002; Kirton, 2001; Pickin, Brunsden, & Hill, 2011; Riggs,Augoustinos, & Delfabbro, 2009; Rosenwald & Bronstein,2008; Samrai, Beinart, & Harper, 2011; Thomson & McArthur,2009).

Parent vs. professionalIncluded studies reveal that collectively, foster carers strug-gle to define their role. The majority of foster carers eitheridentify themselves as parents to the children in foster care

(Broady et al., 2010; Hudson & Levasseur, 2002; Kirton, 2001;Pickin et al., 2011; Riggs, Delfabbro, & Augoustinos, 2009),as professional service providers working together with thechild welfare system (Hudson & Levasseur, 2002; Kirton,

Table 2 Themes.

Theme Sub-theme

The foster carer Parent vs. professionalPersonal characteristics

The foster carerand the system

RelationshipsResources and support

The foster carer’swell-being

Positive effectsNegative effects

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001; Rosenwald & Bronstein, 2008; Samrai et al., 2011) ors a hybrid of the two (Kirton, 2001; Thomson & McArthur,009). Examination of these studies provides insight intoactors influencing foster carers perception of their role.

Kirton’s (2001) interviews with 20 female foster car-rs revealed that their perceptions of their role can varyetween individual placements, with some categorised as‘work and others as parenting’’ (p. 207). Pickin et al. (2011)ound that individual foster carers struggle within them-elves to reconcile their ‘‘transitory parental role’’ (p. 67).enerally, a parental role is conceptualised as permanent.owever, foster care is often required or provided on a tem-orary basis. The length of time a child resides, or is likelyo reside, within the foster home impacts on how fosterarers characterise their role (Broady et al., 2010; Kirton,001; Riggs, Delfabbro, et al., 2009). Broady et al. (2010)oncluded that the attachment between foster carers andhildren in care is strengthened with the passage of time.s attachment developed and deepened, they determinedhat foster carers were more likely to adopt a parental iden-ity (Broady et al., 2010). Similarly, Kirton (2001) identifiedhat foster carers differentiate their role according to theype of foster care being provided. They describes short-erm foster care akin to a job, whereas long-term fosterare enabled carers to identify as parents (Kirton, 2001).he literature demonstrated that this parental role was aundamental part of the foster carer’s individual identitynd had negative implications for carers’ self-esteem andmotional well-being when not duly acknowledged (Broadyt al., 2010; Riggs, Delfabbro, et al., 2009).

ersonal characteristicsersonal characteristics associated with being an effectiveoster carer were identified within several included studiesBroady et al., 2010; Brown & Calder, 2000; Buehler, Cox,

Cuddeback, 2003; Farmer, Lipscombe, & Moyers, 2005;

endrix & Ford, 2003; MacGregor, Rodger, Cummings, &eschied, 2006; Orme, Cherry, & Rhodes, 2006; Pickin et al.,011). Love, understanding and patience were described asttributes which facilitate positive child outcomes (Brown &

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alder, 2000; Buehler et al., 2003; MacGregor et al., 2006).any foster carers describe the importance of being altru-

stically motivated and child focussed (Broady et al., 2010;rown & Calder, 2000; Buehler et al., 2003; MacGregor et al.,006; Pickin et al., 2011). A deep, heartfelt concern for chil-ren was variously articulated as the incentive to provideoster care. Such motivation was described as intrinsicallyewarding and viewed as a sustaining factor during times oftress and frustration (Buehler et al., 2003).

Foster carers’ demonstrated capacity to identify theirwn personal limitations enabled them to seek solace andespite when needed. Several studies highlight the impor-ance of foster carers developing and maintaining individualersonal support networks independent from child wel-are systems (Brown & Calder, 2000; Buehler et al., 2003;armer et al., 2005; Murray, Tarren-Sweeney, & France,011; Orme et al., 2006; Pickin et al., 2011; Samrai et al.,011). The ability to develop such networks is describeds essential as a strategy for mitigating foster carer strainFarmer et al., 2005; Samrai et al., 2011). Orme et al.2006) found that the composition of these networks influ-nced the length of time women provided foster care.pecifically, women who received support from only theirwn extended biological family were found to foster 26%ewer years compared to women whose networks comprisednrelated professionals or a religious group (Orme et al.,006).

The diversity of personal characteristics reportedlyequired by foster carers is somewhat contradictory. Car-rs are described as needing to be both: flexible andtructured; easy-going and posses stress coping skills; calmnd assertive; able to work with and tolerate the sys-em (Brown & Calder, 2000; Buehler et al., 2003). Thisange of personal characteristics may be reflective of theariety of study participants, their individual experiencesr the respective types of foster care provided. Alterna-ively, this dichotomy may reflect foster carers individualapacity to posses and exercise disparate personal charac-eristics.

Hendrix and Ford (2003) used the family hardiness indexFHI) to measure the impact of the characteristic on car-ng. This study demonstrated that foster families who plano continue fostering demonstrate higher levels of hardinessompared to both families who do not provide foster carend foster families who do not intend to continue foster-ng.

he foster carer and the system

espite the variation in the policies, procedures and goalsf child welfare systems between various countries and inach locality (Bromfield & Higgins, 2005; Maluccio, Canali,

Vecchiato, 2006), foster carers identify that working withnd navigating child welfare systems is more stressful thanaring for foster children (Buehler et al., 2003; Farmert al., 2005; Rosenwald & Bronstein, 2008). Foster carers’

xperiences of the child welfare system are generally arti-ulated in terms of their relationships with system personnelnd their ability to access the required resources and sup-ort.

KRst

S.L. Blythe et al.

elationshipseveral studies revealed foster carers relationships withhild welfare personnel had a significant impact on the car-rs (Broady et al., 2010; Brown & Calder, 2000; Brown &ampbell, 2007; Farmer et al., 2005; Hudson & Levasseur,002; MacGregor et al., 2006; Murray et al., 2011; Pickint al., 2011; Riggs, Delfabbro, et al., 2009; Rosenwald &ronstein, 2008; Samrai et al., 2011). In their study of32 foster carers, Wilson, Sinclair, and Gibbs (2000) foundhat nearly 20% (n = 182) had experienced significant dis-greements with child welfare personnel. Yet having a goodelationship with child welfare personnel is essential toffective foster care and optimising child outcomes (Brown

Calder, 2000; Brown & Campbell, 2007; Murray et al.,011; Samrai et al., 2011). Good relationships are charac-erised as having effective communication which enablesnformation sharing, conveys mutual respect and encouragesoster carer input into decision making (MacGregor et al.,006; Rosenwald & Bronstein, 2008). When good relation-hips are experienced, foster carers feel valued, involvednd encouraged to continue providing foster care (Broadyt al., 2010; MacGregor et al., 2006; Samrai et al., 2011).onversely, poor relationships with child welfare person-el impede optimal fostering (Buehler et al., 2003) andontribute to both placement breakdown and foster carerttrition (Wilson et al., 2000). Relationships are deemedroblematic when communication is poor (Samrai et al.,011). Child welfare personnel are perceived to be unre-ponsive to and dismissive of foster carers when their callsre not returned, information is not relayed and foster car-rs are not involved in decision making (Hudson & Levasseur,002; MacGregor et al., 2006; Murray et al., 2011). Fosterarers within this relational milieu reportedly feel frus-rated, undervalued and disrespected (Hudson & Levasseur,002; MacGregor et al., 2006; Murray et al., 2011; Pickint al., 2011; Riggs, Delfabbro, et al., 2009; Rosenwald &ronstein, 2008; Samrai et al., 2011).

Factors impacting poor relationships with child welfareersonnel are elucidated within several studies (Broadyt al., 2010; Buehler et al., 2003; MacGregor et al., 2006;urray et al., 2011; Rosenwald & Bronstein, 2008; Samrait al., 2011). High levels of child welfare personnel turnovers seen to contribute to poor communication, as well as fos-er carers confidence in both the system and themselvesBroady et al., 2010; Buehler et al., 2003; MacGregor et al.,006; Murray et al., 2011). Farmer et al. (2005) reported

significant correlation between changing the allocatedhild welfare worker and foster carer strain. The inexperi-nced personnel (Buehler et al., 2003) and heavy caseloadsRosenwald & Bronstein, 2008) resulting from high staffurnover as well as the complexities of individual person-lities (Samrai et al., 2011) are also ascribing factors.

esources and supportoster carers reportedly seek both emotional and practi-al support from the child welfare system (Brown & Calder,000; Brown & Campbell, 2007; Hudson & Levasseur, 2002;

irton, 2001; MacGregor et al., 2006; Murray et al., 2011;osenwald & Bronstein, 2008; Samrai et al., 2011). Suchupports are deemed essential for effective foster care,he maintenance of foster carers health and well-being and

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carer retention (Brown & Campbell, 2007; MacGregor et al.,2006). Emotional support is largely reliant on foster car-ers’ relationship with child welfare personnel (Hudson &Levasseur, 2002; Murray et al., 2011). As has been described,when this relationship is viewed positively foster carersfeel emotionally supported (Hudson & Levasseur, 2002;MacGregor et al., 2006).

Brown and Calder (2000) characterised child welfarepersonnel as the gate keepers to practical supports andresources. Thus, it would seem positive relationships withchild welfare personnel convey emotional support andenable access to practical support. The practical supportsfoster carers expect from the child welfare system primar-ily include: finance, respite and training. Monetary paymentas a form of support was reported in five included studies(Brown & Calder, 2000; Hudson & Levasseur, 2002; Kirton,2001; MacGregor et al., 2006; Samrai et al., 2011). Fos-ter carers’ experiences of this form of support differedboth across and within studies, with some satisfied and oth-ers desiring more (Hudson & Levasseur, 2002; Kirton, 2001;MacGregor et al., 2006). These perceptual differences likelyreflect the differing economies and financial supports withinindividual countries. Four included studies identified respiteservices as a necessary, but difficult to obtain, form of prac-tical support (Hudson & Levasseur, 2002; MacGregor et al.,2006; Murray et al., 2011; Samrai et al., 2011). For some fos-ter carers respite services provide a reprieve from the dailydemands of providing foster care and enable them to havetime with their own biological families, particularly theirbiological children (Hudson & Levasseur, 2002; MacGregoret al., 2006). One barrier identified to respite was fostercarers concern for the foster children’s well-being (Hudson& Levasseur, 2002; Murray et al., 2011). These foster car-ers worried that respite may create a sense of instability orcause the children to feel abandoned or rejected (Hudson& Levasseur, 2002; Murray et al., 2011) Reliance upon pay-ments as income was also found to prevent foster carers useof respite services as payments often ceased for the durationof respite (Kirton, 2001).

Although not a focus of this review, practical support inthe form of training was discussed in four studies (Hudson& Levasseur, 2002; MacGregor et al., 2006; Murray et al.,2011; Samrai et al., 2011). Training to deal with children’scomplex behavioural issues was a clear priority (Hudson& Levasseur, 2002; MacGregor et al., 2006; Murray et al.,2011). MacGregor et al. (2006) suggest this training shouldbe individualised according to respective children’s needs.Foster carers have also identified their need to develop self-care strategies (Murray et al., 2011). In addition to actualskill acquisition and development, training is valued as itaffords opportunities for emotional support between fos-ter carers (Hudson & Levasseur, 2002; MacGregor et al.,2006).

The foster carer’s well-being

The provision of foster care can be seen to have both posi-

tive and negative effects on the personal well-being of fostercarers. In turn, the wellbeing of foster carers has concomi-tant effects on foster placement stability, child outcomesand foster carer retention (Wilson et al., 2000).

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29

ositive effectsenerally, the experience of providing foster care isescribed as intrinsically rewarding (Buehler et al., 2003;acGregor et al., 2006; Rosenwald & Bronstein, 2008). Per-

onal satisfaction is gained by providing children with a safe,table nurturing home environment which enables childreno grow and mature (Buehler et al., 2003). In so doing, fosterarers contribute to a greater good and feel personally use-ul (Buehler et al., 2003; MacGregor et al., 2006; Rosenwald

Bronstein, 2008). The reciprocal loving relationships whichevelop between foster carers and children are reward-ng for the carer (Broady et al., 2010; Pickin et al., 2011).oreover, for some, providing foster care meets their ownersonal desires to parent and have a family when unableo do so by other means (Riggs, Delfabbro, et al., 2009).everal studies indicate the provision of foster care to have

positive effect on the entire family, enabling the devel-pment of respect and acceptance of differing cultures andalue systems (Brown & Campbell, 2007; MacGregor et al.,006; Samrai et al., 2011).

egative effectsoster carers manage an increased incidence and severityf behavioural difficulties with children in care compared tohe general population (Broady et al., 2010; Farmer et al.,005; Morgan & Baron, 2011; Murray et al., 2011). This haseen found to negatively impact on carers individual well-eing (Broady et al., 2010; Buehler et al., 2003; Farmert al., 2005; Morgan & Baron, 2011; Murray et al., 2011;osenwald & Bronstein, 2008; Wilson et al., 2000), as wells create tension within the foster family (Broady et al.,010; Wilson et al., 2000).

Management of difficult behaviours is described astressful, tiring, time-consuming and unrelenting (Pickint al., 2011; Rosenwald & Bronstein, 2008; Wilson et al.,000). Morgan and Baron (2011) identified a signifi-ant positive correlation between children’s behaviouralifficulties and foster carers (n = 58) levels of stressr = −0.69, p < 0.01), anxiety (r = 0.49, p < 0.01) and depres-ion (rs = 0.25, p < 0.05). Parental efficacy (Morgan & Baron,011) and supportive personal networks (Farmer et al.,005) have both been found to partially mediate theseegative effects on foster carer well-being. Conversely,urray et al. (2011) reported foster carers well-being equiv-lent to parents at large, despite children’s increasedehavioural difficulties. The small sample size (n = 17), how-ver, means that this conclusion must be interpreted withaution (Murray et al., 2011).

Foster carers experience fear and grief due to the poten-ial transitory nature of foster care (Broady et al., 2010;uehler et al., 2003; Pickin et al., 2011; Riggs, Delfabbro,t al., 2009; Thomson & McArthur, 2009). Foster carersear becoming too attached to the children, and oncettached, fear losing the children (Broady et al., 2010;iggs, Delfabbro, et al., 2009). The later appears heightenedhen foster carers perceive themselves fulfilling a parental,

ather than professional, role (Broady et al., 2010; Riggs,elfabbro, et al., 2009). Coupled with foster carers fear of

osing a child is their articulated sense of powerlessness inelation to the child welfare system (Broady et al., 2010;ickin et al., 2011; Thomson & McArthur, 2009; Wilson et al.,000).

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When a child is removed from a foster family, carerseportedly experience bereavement (Pickin et al., 2011;amrai et al., 2011; Thomson & McArthur, 2009). This griefas been reported regardless of the reasons for the child’semoval and whether or not the decision is supported byhe foster carer (Pickin et al., 2011; Samrai et al., 2011;homson & McArthur, 2009). Feelings of grief are exacer-ated when not recognised or validated by others (Riggs,elfabbro, et al., 2009; Thomson & McArthur, 2009).

iscussion

xtant foster care research literature generally focuses onhe children in care (Ciarrochi et al., 2011). Such researchften considers the foster carer as a resource and a deter-ining factor on the overall outcomes for the children in

are (Cashmore et al., 2007; Cole, 2005; Leathers, 2006).espite their demonstrated influence on the children inare, comparatively little research has focussed on theoster carers themselves. This review highlights persistentssues, provides new insights and enables a fuller aware-ess of the experiences and effects of providing fosterare.

This review provides evidence that despite consider-ble discussion, the role of the foster carer remains poorlyefined. The need for role clarification is paramount, givent is seen to have a profound impact on foster carers’ well-eing (Broady et al., 2010) and the potential for concomitantffects on the children in care (Riggs, Augoustinos, et al.,009; Schofield & Beek, 2005). Regardless how individualoster carers characterise their role (parentally or profes-ionally) the dyadic nature of caring relationships meansheir experiences will directly impact the children in theirare in a similar fashion (Chou, 2000; Early, Gregoire, &cDonald, 2002).

Caring for children with complex physical, mental andevelopmental health difficulties is arduous (Duchovic,erkensmeyer, & Wu, 2009; Early et al., 2002), and requireskills and support beyond that of traditional parentingEllermann, 2007; Hollin & Larkin, 2011). Foster carers needoth personal and professional support to provide optimalare given the well documented complexity and magnitudef foster children’s health difficulties (Schneiderman, 2004;ebster & Temple-Smith, 2010). Support in the form of

roup training programs serves to equip foster carers withkills and knowledge of various childhood related difficultiesRork & McNeil, 2011; Turner, Macdonald, & Dennis, 2007).his review affirms the use of such programs given theirotential to increase parental efficacy and provide network-ng opportunities for foster carers, subsequently improvingoster carer well-being.

It is evident from the findings that foster carers experi-nce heightened levels of anxiety, depression and stress inelation to their care giving role. These experiences varyccording to how they characterise their role and relateo the child welfare system and its personnel. In light ofhe challenges recruiting and retaining foster carers, the

necdotal and empirical evidence suggesting the provisionf foster care has negative implications for care providersell-being is concerning. The factors addressed within this

eview need to be considered in the context of existing child

cW2p

S.L. Blythe et al.

elfare policy, particularly given the concomitant effects ofoster carer well-being on the children in care.

mplications for nurses

aregiving occurs in a variety of contexts and is known toave positive and negative implications for both the carerovider and recipient (Van Manen, 2002). It is importantor nurses to understand that within these contexts, care-ivers value the services provided to the care recipient,ut also desire to have their own needs recognised andddressed (Wynaden et al., 2006). By acknowledging fosterarers caregiving experiences, nurses increase their aware-ess and understanding of the value and role foster carersave in the lives of children. In so doing, nurses will be wellositioned to assist foster carers to identify and expressheir needs in relation to their important caregiving roleMcMurray, 2004).

While the National Framework emphasises the health andell-being of children, it should not be to the detriment of

hose caring for them (Council of Australian Governments,009). Strategies to support foster carers as individuals,s well as care providers, are warranted and may serveo reduce attrition. To date, providing appropriate supporto foster carers has proven challenging and may require aew approach to both policy and practice. In their capac-ty as health care professionals, nurses are well positionedo advocate for both social and health reform. As newrameworks are developed, there is a clear need for nurseducation regarding their specific roles and responsibilitiesn regards to child welfare issues. This knowledge may assisturses to effectively collaborate with and support fosterarers in their caregiving role.

imitationshe findings of this review should be considered within the

imitations of the review process and the studies reviewed.ample sizes of included studies vary markedly, ranging from

(Pickin et al., 2011) to 932 (Wilson et al., 2000) par-icipants. There is a preponderance of female participantsepresented in these studies compared to male foster car-rs. Although no specific gender based issues were identifiedn this review, the gender imbalance may contribute to aemale biased perspective. Further, several studies eithereport on aggregate samples or neglect to differentiateetween foster carers involved in the provision of variousypes of care (e.g. long-term, short-term, respite and/orrisis foster care). Since there is evidence of perceptualifferences between individuals providing different typesf foster care (Blythe, Jackson, Halcomb, & Wilkes, 2012;udson & Levasseur, 2002; Riggs, Delfabbro, et al., 2009),uch mixed samples potentially fail to provide the completeicture. The majority of studies relied on cross-sectionalamples and included individuals with varying lengths ofxperience providing foster care. This is a point of con-ern, as such sampling may result in ambiguous findings ashe needs, perspectives and experiences of providing foster

are have been shown to evolve with time (Blythe, Halcomb,ilkes, & Jackson, 2012; Hudson & Levasseur, 2002; Lauver,

008; Marcellus, 2008). That is, the limited experiences anderspectives of a novice foster carer are likely to differ to

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those of a seasoned foster carer. Future research shouldacknowledge that foster carers are not a homogenous pop-ulation and these differences should be taken into accountparticularly when considering application of results (Rork &McNeil, 2011).

Conclusion

This paper reviewed 18 studies investigating the experiencesand effects of providing foster care. In spite of the intrinsicrewards of foster care this review has identified experi-ences which negatively impact on the well-being of fostercaregivers. These adverse effects include: role ambiguity,poor relationships with child welfare personnel, a perceivedlack of personal and practical support and difficulty manag-ing challenging behaviours of children. Increased parentalefficacy and reliance upon personal support networks wereidentified as mitigating factors.

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