Caring for Hospitalized Children in Foster Care: Provider Training, Preparedness, and Practice Free

Inpatient pediatric providers (pediatric hospitalists and advanced practice providers [APPs], bedside nurses, social workers [SWs], and case managers) with prior experience caring for CYFC in the hospital setting were identified from 6 hospitals in the mid-Atlantic region. The hospitals varied in size and type, including 3 freestanding children’s hospitals, 2 children’s hospitals within an academic medical center, and 1 community hospital (Table 1). A pediatric hospitalist was identified as initial point of contact for recruitment within each hospital and then participants were subsequently recruited using snowball and purposive sampling.¹⁴  Snowball sampling allows participants that enroll in the study to refer individuals that also meet eligibility criteria to the researchers for potential inclusion. Purposive sampling was used to ensure a mix of provider types (ie, medical doctor [MD], nurse, SW) from each site. Sixty-nine individuals were identified as potential participants by the hospitalist point of contact or by subsequent participants. An invitation to participate in the study was emailed to potential participants by our study team; a total of 38 agreed to participate, 26 passively or actively declined to participate, and 5 did not meet eligibility criteria. Recruitment was stopped once thematic saturation was achieved. The Johns Hopkins School of Medicine Institutional Review Board approved the study and informed consent was obtained. No trainees participated in this study.

Participants completed an audiotaped, semistructured, 1-on-1 interview. Interviews focused on inpatient provider experience caring for CYFC in the hospital. Questions were determined a priori based on review of foster care literature and through consultation with professionals with foster care expertise. Interview questions ( Appendix) were developed to capture participant role, training, and preparedness in caring for CYFC, knowledge of child welfare systems and processes, challenges and facilitators of inpatient care for CYFC, and strategies to improve inpatient care. To ensure face validity and understandability, questions were pilot tested with 3 providers (nurse, physician, SW) and modified based on feedback.

Interviews were conducted by 1 author (B.D.W.), a MSPH student with qualitative interview training, between June and December 2019. She had no prior relationship with any of the study participants nor prior experience caring for CYFC. Interviews were conducted in-person or via telephone and lasted 25 to 70 minutes (average 38 minutes). Interview recordings were transcribed using a professional transcription service. Participants were given the opportunity to review and edit their transcripts before analysis; participant checking did not occur after analysis.

Qualitative content analysis was applied to interview transcripts using Dedoose Version 9.0.17.¹⁵  The study team developed an initial coding scheme based on codes that emerged through preliminary analysis of a subset of transcripts. Responses were coded within the following interview domains: provider training and preparedness, practice challenges related to caring for CYFC, and strategies to improve care. Two study team members (R.M.S. and R.R.S.) independently reviewed and coded a sample of 5 transcripts, which were compared to identify and resolve disagreement and update the codebook before 1 team member (R.M.S.) coded the remaining transcripts. A subset of transcripts was subsequently double coded by another team member with expertise in qualitative research methodology (R.R.S. and P.K.D.) to ensure consistency in coding. Next, codes were grouped into themes, which were reviewed and agreed upon by all authors. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study.¹⁶ 

Although interview questions regarding training, preparedness, and frequency of interaction with CYFC were asked in open-ended format ( Appendix), some responses lend themselves to categorical grouping (ie, very prepared, somewhat prepared, not prepared) and are reported using simple statistics, frequency (percent). In reporting results, “participants” refers to all provider types, whereas it explicitly states when referring to specific provider types (ie, SWs, non-SW participants). The term “clinicians” is used to denote MDs and APPs. Of note, data from this study relevant to discharge practices and delays in discharge were analyzed and published separately.¹⁷ 

A total of 38 interviews were conducted with 14 pediatric hospitalists, 1 APP, 11 bedside nurses, 10 SWs, and 2 case managers. There were between 4 and 8 participants (median 6) from each of the 6 hospital sites (Table 1). The majority of participants reported frequent (at least monthly) interactions with CYFC in the hospital (Table 2). However, many of the bedside nurses, SWs, and case managers had daily or weekly interactions (Table 2). Participants identified multiple reasons why CYFC are admitted to the hospital. The most common reasons identified were general pediatric illnesses (eg, asthma, acute illnesses), failure to thrive, medical neglect, nonaccidental trauma, and social holds (ie, child is medically cleared but social concerns delay discharge).

Themes that emerged within each of the 3 domains (training and preparedness, practice challenges, strategies to improve ability to care for CYFC) are described with illustrative quotations in Tables 3, 4, and 5, respectively. Participant quotations have been edited for anonymity and clarity.

Despite frequent interactions with patients in foster care, the majority of clinicians, nurses, and case managers reported receiving little or no training about the foster care system or caring for this population in a hospital setting (Table 3). Participants stated that most of their knowledge was from experiential learning on-the-job and nearly all (97%) desired more training (Table 2). Of the participants interviewed, SWs were the only group that reported formal training about the child welfare system.

Many of the clinicians and bedside nurses expressed limited understanding of foster care placements and the legal processes related to foster care (Table 3), including confusion about the different types of foster care placements (ie, group homes, medical foster care) and legal authority for consent.

Participants were also asked to comment on their preparedness for assessing and addressing the unique needs of CYFC in the inpatient setting (Table 2). Many of the clinicians and bedside nurses felt comfortable providing medical care but not addressing the social or legal aspects of caring for this population. They described a reliance on hospital SWs to help navigate the processes related to the foster care system (Table 3).

SWs routinely reported feeling very prepared to address the needs of and care for CYFC (Table 2). Some also felt overextended as they spent significant amounts of time answering questions and teaching physicians and nurses about foster care systems and processes (Table 3).

Participants acknowledged that there are multiple, unique aspects and associated challenges of caring for hospitalized CYFC. Despite limited training, participants identified multiple ways in which they had to modify their practice or “do things differently” while caring for this population (Table 4).

Correctly identifying that a child is in foster care is an essential step in caring for CYFC. Unlike a specific medical condition that is listed on the problem list, participants explained how it was not always evident that a child was in foster care when looking at their chart. Frequently, participants relied on the caregiver at bedside to provide this information. Clinicians and nurses also asked SWs or reviewed SW notes to clarify foster care status, whereas SWs often contacted a child welfare worker with questions.

Most of the time this process went smoothly, but there were certain situations where challenges arose. Non-SW participants acknowledged how sometimes identifying a child’s foster care status fell outside their scope of questioning, which could lead to misidentification of CYFC. Specifically, they reported forgetting to ask about social history or assuming the caregiver at the bedside was the biological parent. Additionally, there were times when caregivers did not self-disclose that they were a foster parent.

Participants expressed that determining who could consent for medical care and then obtaining consent was challenging and could lead to delays in care for CYFC or errors in the consent process (ie, getting consent from the wrong person). Many clinicians and nurses reported that they lacked training and knowledge about the consent process for this population and depended almost exclusively on SWs. In contrast, SWs had knowledge about consent processes and felt comfortable determining who could consent. Participants described challenges obtaining consent because of difficulty contacting the legally authorized individuals, namely the biological parents or child welfare.

Many participants reported documenting that the child is in foster care somewhere in the medical record but not in a consistent location. It was most commonly documented in a note in the assessment or plan, history of present illness, or social history. Very few reported adding foster care status to the problem list. SWs report consistently documenting the child’s foster care status in their social work note or in social history.

Participants explained that providing high quality care for hospitalized CYFC requires increased communication with caregivers (ie, foster parents, biological parents) and many individuals across different systems of care, including health care, child welfare, and legal (ie, court system). They also shared scenarios where there was a lack of information sharing or miscommunications, leading to additional stress for all individuals involved and sometimes causing disruptions in care (eg, delays in discharge planning).

Participants described how CYFC have unique social situations and there are often complex interpersonal relationships between biological parents, relatives, foster parents, and the child. Additionally, many of these children experienced significant physical or psychological trauma. Participants illustrated how these complexities superimposed on the stresses of having a child in the hospital created highly emotional situations. The majority of non-SW participants lacked prior training in trauma-informed care. Yet, they had to navigate complicated dynamics among biological and foster families as well as the trauma history of their patients. They described these situations as stressful, challenging, and upsetting.

Participants identified strategies that could be implemented to enhance their ability to care for hospitalized CYFC. These strategies included: increasing SW capacity, expanding provider training, standardizing electronic medical record (EMR) documentation and order sets, and improving communication and information sharing among team members (Table 5).

In this multisite study, inpatient pediatric providers described their experience caring for CYFC in the hospital setting. The majority of inpatient pediatric clinicians and bedside nurses in our study had minimal training about the foster care system and the needs of CYFC, despite interacting with this population frequently. Participants identified unique challenges caring for CYFC, including identifying when a child is in foster care, navigating the consent processes, documenting information consistently, engaging in multisystem team communication, and managing complex psychosocial situations.

Although medical providers (ie, clinicians, nurses) lacked training, they expressed feeling prepared to care for CYFC as long as they had access to hospital SWs. Unfortunately, SWs in our study reported feeling overextended; the shortage of SWs is not a novel concern and has been an ongoing issue for all patients requiring social services support.¹⁸  Although study data were collected prepandemic, SW staffing shortages and burnout have only worsened during the pandemic.^19,20  Working within the current SW constraints, medical providers may, out of necessity, have to take on some foster care-related issues. Therefore, it is important to consider ways to enhance their confidence and comfort to care for CYFC, such as through increased training and use of clinical decision support systems (CDSS).

Nearly all participants expressed a desire for more training and identified specific topic areas of interest, including foster care system and placements, legal processes of foster care, community resources for CYFC, and trauma-informed care. Although hospitals have increased medical provider training to recognize child maltreatment, very few programs have been established to teach pediatric providers and trainees about foster care.^21,22  An understanding of the foster care system and associated legal processes may enhance medical providers’ ability to communicate through common language with child welfare team members, document information appropriately, and provide comprehensive, yet efficient, care that is tailored to the needs of CYFC.

Trauma-informed care is a framework in which to engage with individuals who have experienced trauma by acknowledging the impact of trauma and emphasizing safety, trustworthiness, collaboration, and empowerment in all interactions.²³  The necessity for a trauma-informed approach for CYFC has been documented repeatedly.^6,24, Given the prevalence of trauma among CYFC, pediatric providers should provide trauma-informed care to help prevent retraumatization and begin the healing process.^25,26  However, the majority of non-SW participants in our study reported inadequate or no training about trauma-informed care. Previous studies have shown that a trauma-informed care curriculum improved medical providers’ comfort in using this approach.^27,28  The Society of Hospital Medicine developed a curriculum for pediatric hospital medicine core competencies; section 3 includes clinical specialties with a section on child abuse but there is currently no section for providing trauma-informed care.²⁹  Adding trauma-informed care as a core competency for pediatric hospitalist fellowship training as well as a necessary component of medical training and continuing medical education requirements could help providers promote resilience and prevent retraumatization of patients and their families.^25,30  The American Academy of Pediatrics Council on Foster Care, Adoption, and Kinship Care already has an array of resources and published guidelines about trauma-informed care and providing medical care for CYFC that could guide curriculum development.^1,31,32  Individuals from local child welfare agencies could partner with hospitals to provide education about laws, processes, and information specific to their jurisdiction.

CYFC are a defined population with unique but predictable needs, yet our study participants experienced challenges and practice inconsistencies in addressing these needs. Utilizing CDSS, such as alerts, triggers, order sets, clinical pathways, and templates for documentation within the EMR, can play an important role with standardizing approaches to care.³³  CDSS applied to inpatient care of pediatric conditions, such as asthma and sickle cell anemia, are shown to improve patient safety, increase adherence to clinical guidelines, reduce costs, and decrease length of hospitalization.^34–36  The use of CDSS during admission and throughout the hospitalization could help to guide providers in delivering consistent and high-quality care to CYFC. For example, our data showed that providers lack a standardized approach to document foster care status and important contact and legal information within the EMR; inconsistent documentation can lead to inappropriate information sharing and errors in obtaining consent (ie, from the wrong person). Creating a standardized protocol to add “Foster Care status” as a “flag” in the chart could then trigger order sets with specific note templates, common orders, and links to clinical guidelines or best practices for caring for CYFC. Documentation templates could prompt providers to ask relevant foster care questions (eg, When did the child enter foster care and any recent changes in placement? Are the biological parents involved? Who has medical decision-making authority?) and encourage consistent documentation of key contact information (eg, child welfare worker phone number and back up number) to support more timely communication. Incorporating best practice alerts and links into the EMR could help remind providers about uploading legal documents, documenting or updating information about who can consent, and principles of trauma-informed care.

There are limitations to this study. Participants were recruited exclusively from hospitals in the mid-Atlantic region; their responses and experiences may differ from providers who live in other parts of the country, limiting generalizability. Additionally, interview questions may have elicited response bias when providers were asked if they desired additional training. There were limited perspectives from APPs given that only 1 was included in this study. Moreover, individuals who declined to participate may have had differing views from those who agreed to participate. Despite the limitations, this study provides important insights about inpatient pediatric providers’ experiences caring for CYFC and highlights the need to further explore and address the perceived challenges.

There are unique medical, social, and legal aspects of caring for CYFC in an inpatient setting, which can pose challenges to providers with limited training about CYFC and trauma-informed care. This study provides insight on the inpatient pediatric provider experience of caring for CYFC and the specific challenges they face, which include identifying a child’s foster care status, documentation, consent, communication, and navigating complex social situations and trauma. Guided by participants’ suggestions, there are achievable educational and health information technology interventions that could enhance pediatric providers’ ability to care for this population.

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1. Could you tell me about your professional background?

2. How often do you interact with children in foster care in the hospital setting?

   • (a) In any given month, how many of your patients are children in foster care or are planned to be discharged to foster care?

3. If a child in foster care is admitted to your hospital, what is your role in caring for that child?

4. What are the reasons these children are admitted to the hospital?

5. Approximately what percentage of these children are entering foster care for the first time directly from your hospital?

6. Why are these children already in or entering foster care?

7. What is your understanding of the types of foster care placements that are available?

   • (a) What about your understanding of group homes?

8. How are you made aware, if at all, that a patient is in foster care?

   • (a) What are the barriers to identifying patients in foster care, if any?

9. Do you document in the electronic medical record that the child is in foster care?

   • (a) Do you add that the child is in foster care to the patient’s problem list?

10. What do you do differently, if anything, as you care for a child in foster care in the hospital as compared with a child not in foster care?

11. Considering discharge planning– what do you do differently, if anything, when discharging a child to foster care from the hospital, as compared with discharging a child not in foster care?

12. What do you think are the unique medical needs of patients in foster care?

13. What do you think are the unique social needs of patients in foster care?

14. How prepared do you feel to assess and address the unique medical and social needs of your patients in foster care?

15. What training have you received regarding:

    • (a) General information about foster care or child welfare?

    • (b) Caring for children in foster care in the hospital?

16. Do you think you would benefit from any additional training or education regarding children in foster care?

17. When caring for a child in foster care, what interaction do you have (if any) with individuals from child welfare or social services?

    • (a) How would you describe the overall communication between you and these individuals from child welfare or social services?

18. When caring for a child in foster care, what interaction do you have with caregivers (ie, biological parents, foster parents, relatives)?

    • (a) How would you describe the overall communication between you and these caregivers?

19. Are there any other types of individuals you interact with when caring for children in foster care?

    • (a) How would you describe the overall communication between you and these other individuals?

20. What has been your experience with the collaboration between medical providers and child welfare providers in monitoring the health of these children?

21. Can you give an example of a time when you were caring for a patient in foster care in the hospital and you think:

    • (a) Things did not go well?

    • (b) Things went particularly well?

22. What are some of the challenges in your hospital when caring for children in foster care?

    • (a) What could help you address those challenges?

23. Any unique challenges or delays in discharge for children in foster care compared with children not in foster care?

    • (a) What could help you address those challenges?

24. What, if any, are additional challenges to caring for and/or discharging children who are in foster care and have serious behavioral health problems?

25. What, if any, are additional challenges to caring for and/or discharging children who are in foster care and are medically complex? For example, children who have multiple chronic medical problems, use medical technology or equipment, see multiple subspecialists, etc.

26. In general, what is your understanding of who has the legal authority to make medical decisions for children in foster care?

27. When caring for a child in foster care, how do you determine who can provide informed consent, such as for a procedure or surgery?

28. Is information about who can consent documented in the electronic medical record?

29. What challenges are there with obtaining consent for children in foster care, if any?

30. Do you have any experiences related to DNR orders for children in foster care?

31. What things, for example, people or systems, make caring for your patients in foster care easier?

32. What changes might improve care for children in foster care in your hospital system?

33. Is there anything else you would like to tell me or you think we should know about caring for children in foster care in the inpatient setting?

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