Public Health Nursing Vol. 22 No. 4, pp. 354—359 0737-1209/05 # Blackwell Publishing, Inc.

SPECIAL FEATURES: PRACTICE CONCEPTS

The Child Welfare System: Through the Eyes of Public Health Nurses
Janet U. Schneiderman
ABSTRACT Objective: This qualitative descriptive study investigates how public health nurses working within the child welfare system view the organization and the organizationÕs effect on their case management practice. Design: Semistructured interviews were conducted utilizing the Bolman—Deal Organizational Model. This model identifies four frames of an organization: symbolic, human resources, political, and structural. Sample: A purposive sample of nine nurses and one social worker was selected to participate in comprehensive interviews. Results: Data analysis identified two main themes. The first theme was the presence of organizational structural barriers to providing case management. The second theme was the lack of political influence by the nurses to change the structure of the organization; hence, their skills could be more completely utilized. Conclusions: Public health nurses who work in child welfare will need to systematically analyze their role within the organization and understand how to work in Òhost settings.Ó Nursing educators need to prepare public health nurses to work in non-health care settings by teaching organizational analysis. Key words: child protective services, organization, public health nursing.

The purpose of this exploratory qualitative descriptive study was to investigate how public health nurses working in the child welfare system in a large metropolitan county in California view the organization. The study utilized the Bolman—Deal Organizational ModelÕs (1997) four frames for organizational analysis: symbolic, political, human resource, and structural. Public health nurses have joined social workers in providing care for children in foster care, and how nurses fit within the organizational culture and structure will affect their ability to provide health case management to these children.

Janet U. Schneiderman, R.N., Ph.D., Assistant Professor, University of Southern California School of Social Work, Los Angeles, California. Correspondence to: Janet U. Schneiderman, University of Southern California School of Social Work, 669 West 34th St, SWC 226, Los Angeles, CA 90089-0411. E-mail: juschnei@usc.edu

Foster care is the out of home placement in temporary residential care provided to a minor child as a result of neglect or dependency hearing (Hacsi, 1995). The child welfare system is the governmental agency that assumes responsibility for the protection of childrenÕs welfare and including the responsibility for children in foster care. There is consistent and overwhelming evidence to support the idea that children in foster care have higher than expected rates of chronic illness (Barton, 1999; Stein, Evans, Mazumdar & Rae-Grant, 1996). These health issues of foster children include physical illness, mental illness, and developmental disabilities (Schneiderman, 2003). The child welfare system is responsible for the education, health, and welfare of over 580,000 children in the United States, with California having 91,000 of foster children, approximately 16% of the population (Leslie et al., 2003; Rivera, 2004). In 1994, the American Academy of Pediatrics published national standards for health care services for foster children. But these standards were not being met, and there was a Òcall to armsÓ for systematic

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changes that included hiring public health nurses for health case management (Delchert, 2001; Institute for Research on Women and Families, 1998). Smart (1999) studied how public health nurses functioned prior to this new infusion of money and the addition of public health nurses in child welfare. Smart noted that the small number of nurses had limited effectiveness and could only complete health records on high risk and very young foster children. Geppert, Marrufo, and Rapoport (2004) found that Medicaid utilization by foster children increased slightly (between 1 and 3%) for counties that had a higher percentage of public health nurses per foster child after the first year of implementation of the foster care nursing program in California. Part of the responsibility of the new public health nurses is completing the health and education passport, a multidisciplinary record that will follow the foster child from placement to placement (American Academy of Pediatrics, 1994; Takayama, Wolfe, & Coulter, 1998). Lewandowski and GlenMaye (2002) studied interdisciplinary teamwork in child welfare settings. Although no nurses were subjects in their study, they found that the four top barriers to effective team processes were the inadequacy of communication, resources, professional respect, and role clarity. The Bolman and Deal Model (1997) provides a framework that is nonprescriptive, flexible, and has been used to describe health care, social service, and business organizations. The model includes four frames to study organizations. The symbolic frame looks at the commitment to the work, the culture of the organization, and perceptions of leadership. The political frame looks at power (who has it, who uses, and who wants it) and at conflict. The human resources frame includes the organizationÕs ability to meet the workersÕ needs, informal communication, and worker satisfaction. The fourth frame, the structural frame, includes the organizationÕs goals, roles, hierarchy, formal communication, and coordination of services.

child welfare system. The nurses actually worked for two different organizations, but all the nurses were public health nurses, had similar job descriptions, and were housed in the child welfare offices throughout the county. Interviews were conducted with both key informants and general informants. The total number of subjects interviewed was nine, including two key informants, six general informants, and one social worker. The two key informants were the administrative nurse supervisors from the two organizations which employed the nurses. The six general informants included three nurses each chosen by the nurse supervisors from each organization. Nurse participants were required to have at least 1-year experience in their jobs and were chosen by their supervisors for their expertise and to sample a broad geographic area of the county. The social worker was selected by one of the foster care nurses as a social worker who Òused the nurses well.Ó Institutional approval was received from all participating organizations, and all subjects signed an informed consent.

Methods
Sample The participants of the study were chosen from a purposive population with critical case sampling. The population for the study was the foster care nurses (n ¼ 100) and social workers working in the

Data collection This study used descriptive qualitative research methods, in which in-depth interviews of child welfare nurses and a social worker provided the primary data. A semistructured interview was conducted with each consenting participant. The interview-guide questions were derived from the theoretical framework of Bolman—Deal Organizational Model. Interview questions were divided into four categories, the framework of the model. The symbolic frame category included questions about the core values of the organization, leadership, rituals, and meetings. The next category, the political frame, included questions about recognized people of power, coalitions, influence, and physical location. Questions about feelings about work, motivation, relationships to coworkers, training, and ability to have ideas heard were part of the third category, human resources. The final category of structure included questions about organizational goals, workload allocation, hierarchy of authority, decisionmaking, and conflict. The interview guide provided a structure for the data collection, although the researcher followed up with questions to clarify and expand the subjectsÕ thoughts and ideas to capitalize on situation.

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Analysis The interviews lasted from 1 to 2 hr in length and were conducted in the Child Welfare Offices. The interviews were audio taped. Interviews were typed verbatim immediately following the interview. The transcripts were then compared to the recordings to assure accuracy. The researcher employed member checking and telephoned the subjects when she had a question. Reliability was assured by the use of triangulation with data from interviews and observations. The researcher recorded observations about the subjects and the environment during the interviews. These observations were compared to the interview data. The analysis of the interview data followed a template analysis style, using the Bolman—Deal categories for beginning the analysis. Then, the meaning units and themes were compared across interviews and finally the findings were synthesized and validated by checking with the participants. The findings were recontextualized to apply the findings to other settings.

changes prior to the start of the study. Therefore, the subjects did not identify the present leadership as visionary. The nurses did find their meetings with other nurses, departmental and statewide, valuable. Nurses had some issues with the meetings with social workers.
I go to unit meetings because thatÕs the level that youÕre functioning. Direct face to face with the social workers. I mean literally just last week, a worker that IÕve been dealing with for two years finally got the point of the Health Education Passport and the questions stopped.

Results
All interview data are from nurses except when followed by the notation Child Social Worker (CSW), when the interview is from the social worker.

Political frame The political climate is tense, because the organization is under the microscope of the county board of supervisors and the media. The nurses noted that anxiety pervades the system: ÒThe system, with the social workers, can be a vindictive system. If something happens, the social worker can be penalized.Ó The social workers hold the power within the organization. Power within the system came from longevity, and unfortunately, the nursing supervisors for both the units had just resigned. Because the nurses are in the minority, they felt they had little power and wanted to gain influence and access by providing valued services to the social worker. They felt they could work within the system to make changes.
No, I donÕt think the nurses have a lot of power. They need to be represented more. (CSW) All you have to have are one, two or three really significant medical cases and the social workers realize what an asset you have been in problem solving and then they are your best allies.

Symbolic frame The nurses readily accepted the core values of the child welfare system but included health as part of safety. They compared the child welfare values to that of physicians and their dictum to Òdo no harm.Ó They saw the terrible harm being done to the children and wanted to make sure that their health did not suffer. The nurses felt that they needed to be an advocate both for the child and for the system itself.
In this job there is not a single child in the system because of what that child has done themselves. ItÕs the environment that they came out of, so this is a population that needs advocacy like nobody else. So itÕs actually a pleasure for me to know that when I step up to the bat, IÕm giving voice to a child who needs to have a voice.

Human resources frame Nurses enjoyed their work and felt rewarded from the importance of what they were doing but were frustrated by the large number of cases. The nurses felt helping children was their calling. Unfortunately, nurses also saw that they were not always being used appropriately by the organization.
I keep getting dumped on. I know the ideal nurse ratio and what they want us to do is really follow these kids so each nurse should probably have no more than two [social work] supervisors.

The child welfare system had undergone frequent leadership changes over the past 5 years. Even the nursing leadership in both the organizations had

The nurses worked well with each other and were trying to form better relationships with social workers.

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The work relationships with social workers were hampered by the sense of mistrust within the department, but the nurses saw some improvement: ÒThe social workers are coming more to the nurses and theyÕre relying on our expertise and then asking us to go to the hospital with them.Ó The nurses also noted that the large system and hierarchical nature of the organization made change very difficult. The nurses used their own supervisors to try to promote their message about the importance of the health of children.

why we are here.Ó Nurses understood that the quality of their work depended on the social workersÕ acceptance, use, and reliance on nurses for health case management. Nurses realized that social workers had a difficult job and a huge responsibility. Nurses wanted to be a part of the team, but the structure was not in place to assure this would happen.
I depend on my social worker to be my eyes. When my social worker comes back to me and says, Òyou know it just looks funny, something isnÕt right.Ó 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 theyÕve been dead on, dead on. The CSW and the nurse have to be a team, however, not all CSWs function the same. . . . CSWs are not mandated (and) not required (and) we donÕt have to give the medical file to the nurse. (CSW)

Structural frame The nurses accepted the organizational goal of safety and wanted to meet this goal by connecting children to the correct medical services promptly. This goal was often hard to achieve because of the difficulties within the health delivery system, in terms of finding appropriate and available providers and getting information about health visits. The nursing staff had autonomy in terms of distribution of nurses between offices and in terms of structuring their work routine over the day. Work evaluation was done by counting cases using logs, and the nurses wanted better methods to truly evaluate whether their work made a difference in the health of the children. Specific guidelines and procedures were well defined in the nursesÕ job duties. The nurses took comfort in the clarity of what was expected of them, both from the point of view of the structure of their work and to avoid potential conflicts with social workers.
They tell you use your professional judgment and in this system your professional judgment can get you in trouble. The nurse walks a thin line in (Child Welfare system) . . . If the child dies or something happens to a child, you are scrutinized and the papers, the newspaper reporters are merciless. They condemn you with twisted facts and it was nightmare. We were originally going to do independent home visits, but I just felt so scared for those nurses out there by themselves, it took a while to see that it is meant for joint home visit since you have a social worker with you.

This lack of structure for referrals coupled with the nursesÕ feeling that they were unable to affect policies and procedures frustrated the nurses. The nurses tried to fit into the hierarchical structure of the organization and solve problems at the lowest level possible. The nurses wanted to avoid conflict.
I find myself acquiescing most of the time or going around it quietly. 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, and nurturing and I donÕt even think that they would confront anybody. (CSW)

Discussion
Two themes were derived from the data. The first theme is the structural barrier to client access. The lack of access to the target population resulted from unclear referral structure, thus limiting the nursesÕ ability to provide adequate health case management and causing job frustration. 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 organization. Bolman and Deal (1997) noted that for different situations, a particular perspective might be more helpful than another. In the nursesÕ cases, their perspectives primarily focused on their

Although the nurses understood their role, the social workers were not sure about what nurses could or could not do. This lack of clarity frustrated the nurses: ÒIt [my job description] is fairly well defined but others I work with, social workers, havenÕt a clue

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participation, effort, and skill to be effective in the organization. But in the case of needing the organizationÕs 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 second theme was the lack of political influence. Child welfare nurses did not possess political power because of their lack of longevity, limited numbers, and the hierarchical nature of the child welfare system. 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. Bolman and Deal (1997) also 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. Therefore, structural change in the organizations will be more difficult without the political power to affect change. The study has limitations. The study only investigated nursesÕ perception of the child welfare organization. Only one social worker was interviewed in terms of her perception of the nursesÕ role within the organization. The size of the sample was small, nonrandomized, and may limit generalizability of the study. Limitations of the descriptive qualitative format were inherent in this study. The investigation used one metropolitan county in California 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 conduct the study prohibited this approach. Nurses are increasing moving into non-health care community settings such as child welfare. In health care settings, nurses have significant power by virtue of their numbers. The nurses can learn from social work practice about how best to work in Òhost settings,Ó i.e., working in a smaller department with specialized services (nursing) which is part of a larger organization (child welfare) (Barker, 2003). Nurses need to demonstrate their value to the organization and clearly articulate their contributions to be an accepted minority in the workplace. They need to establish realistic expectations about

their role within the organization and be comfortable in taking and using power to promote their client accomplishments, establish professional turf, and maintain their autonomy and authority (Bronstein, 2003; Dane & Simon, 1991). The dearth of community clinical settings has forced faculty to look at nonhealth care placements, such as child care centers, senior centers, and community social service agencies (Schneiderman, Jordan-Marsh, & Bates-Jensen, 1998). Community health nursing educators can use the findings as an impetus to teach organizational theory and utilize organizational analysis to prepare students to be successful in host settings. Future research is suggested in several areas including foster care nursesÕ effect on the health of foster children and integration and communication between services for foster children. 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 childrenÕs long-term health outcomes. Research into how social workers and nurses adopt teamwork and partnership skills and how those skills shape intervention choices will make health case management of foster children more successful. Large-scale multidisciplinary research needs to be done to see how connections between child welfare, the health care system, and the schools impact the health of foster children.

Acknowledgments
This article is based on the authorÕs doctoral dissertation from the Rossier School of Education, University of Southern California, Los Angeles, CA.

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