Professional Quality of Life of Foster and Kinship Carers in Australia,United Kingdom,and the United States: A Scoping Review

Search Technique

We used the Population, Concept, and Context framework (Peters et al., 2021) to formulate the inclusion criteria. When our pilot search for “carer” AND “out-of-home care” AND “quality of life” synonyms returned relatively few items, and only from the United Kingdom. We expanded the inclusion criterion to include stress, well-being, satisfaction, negative affect, positive affect, and health-related quality of life as ProQOL subscale-related concepts as shown in Table 1.

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Table 1.

Framing the Scope and Question for the Review.

Population (P)	Concept (C)	Context (C)
Out-of-home carers, including foster carers, kinship carers, and foster parents	Professional quality of life, quality of life, compassion satisfaction, burnout, compassion fatigue, secondary traumatic stress, stress, well-being, satisfaction, positive affect, and negative affect	Original research conducted in Australia, United Kingdom, and United States, reported in English in peer reviewed journals

Eight electronic databases were searched: Scopus, ProQuest, CINAHL, PsycINFO, Web of Science, PubMed, SAGE Journals, and JSTOR (Supplemental Material 1: Search strategy for each database) by the second author. A total of 3,944 references were identified for screening. Following the removal of duplicates and nonempirical journal articles, 2,702 studies were exported to Covidence (https://app.covidence.org), a tool for online inclusion/exclusion screening, for further screening. A two-step process involving screening of title and abstracts first and then full-text review was performed independently by the first and second authors, In each step, disagreement was discussed until a consensus was achieved. A total of 70 studies were included in final analysis. Figure 1 shows the study selection flowchart of this review.

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Figure 1.

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram of studies included.

Studies Included

Articles for inclusion (n = 70) consisted of 18 Australian studies of determinants of ProQOL or its related concepts (n = 15) and measurement of ProQOL or its related concepts associated with interventions (n = 3), 11 studies from the United Kingdom (determinants n = 5; interventions n = 6) and 41 from the United States (determinants n = 25; interventions n = 16). Studies were divided by country and type (determinants or interventions).

Data Synthesis

A spreadsheet was created to chart the data that answers the research questions. Information on authorship, aim of research, methods of research, and key findings were recorded and synthesized in summary format. The process was carried out by the second author and discussed with other authors. Disagreement was discussed until a consensus was achieved. Code and theme development was guided by ecosocial model to emphasize relationships between human condition and the settings in which individual and collective action takes place (Wendt, 2021). The ecosocial model appreciated the complex interplay between multifaceted conditions affecting ProQOL or its related concepts and interventions associated with the caring role. It consists of three nested layers: the individual which focuses on personal action frameworks like carer’s interpersonal relationships, roles, and activities; the relational which addresses interconnections and links between ProQOL or its related concepts and individuals’ immediate settings including funding agencies, service providers, and foster care agencies and serves as a platform for stakeholders to work together; and the sociopolitical which centers on political decision-making and assists in identifying connections between ProQOL or its related concepts and interventions and policy, structures, and bureaucracy such as foster care system (Wendt, 2021). The model provided a comprehensive framework to organize different factors associated with ProQOL and its related concepts as well as the interventions to improve them in a systematic way, enabling observation of the system influences across determinant- and intervention-related study foci across the three countries. In this review, we categorized studies as individual focused if they addressed the factors or interventions centered on the carers’ personal or social life and circumstances. Studies were categorized as relational focused if they examined the factors or interventions related to funding agencies, service providers, and foster care agencies and addressed the interactions between carers, child welfare organizations, and other groups working together to ensure the welfare and development of the children and young people. Studies were regarded as sociopolitical focused if they focused on the factors and interventions related to foster care systems or policies.

Carer ProQOL, Aspects, and/or Related Concepts

Studies across the three countries differed in terms of their focus on individual, relational, or sociopolitical aspects associated with ProQOL and/or related outcomes for carers (Figure 2). More than 85% of studies from the United Kingdom (n = 10) and 70% from the United States (n = 29) had their interest in individual factors associated with carer ProQOL or its related concepts, compared to Australian research that focused more heavily on relational or sociopolitical factors.

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Figure 2.

Percentages of studies at the individual, relational, and sociopolitical levels.

Studies Focused on Individual Factors

Several studies focused on individual factors and reported the impact of carer’s interpersonal relationships, roles, and activities on their career well-being. Australian studies in particular highlighted the difficulty carers face in fulfilling their responsibilities and meeting high expectations. For instance, Breman et al. (2018) found that the role demands associated with children’s challenging behaviors were the primary cause of stress and burnout among carers. Some studies have indicated a link between children’s emotional and behavioral issues and the difficulties and stress carers face in meeting their needs (Fergeus et al., 2019a, 2019b; Harnett et al., 2014; McKeough et al., 2017). Others reported that carers often find themselves caught in conflicts among fostered children or between fostered children and their own other close family members, requiring carers to intervene which adds to their pressures (Harnett et al., 2014; Kiraly et al., 2020; McKeough et al., 2017). Stress is amplified when carers lack adequate time for themselves (Fergeus et al., 2019a).

Studies in the United Kingdom have likewise demonstrated a correlation between behavioral problems in children and poor psychological well-being of carers (Anthony et al., 2019; Holt & Birchall, 2022; Morgan & Baron, 2011). In relation to ProQOL-related concepts, two studies found that caring for traumatized children frequently leads to secondary traumatic stress for the carers (Bridger et al., 2019; Hannah & Woolgar, 2018). Sloan Donachy (2017) reported that caring for traumatized children can lead to conflicting emotions, being constantly on edge, and a loss of positive self. It was also revealed that burnout, compassion satisfaction, and primary trauma had direct effect and self-care had indirect effect on carers’ secondary traumatic stress (Bridger et al., 2019), and that psychological inflexibility and thought suppression were positively associated with both carers’ secondary traumatic stress and burnout, which were negatively associated with carers’ intent to continue fostering (Hannah & Woolgar, 2018). Anthony et al.’s (2019) longitudinal study indicated that carers’ sense of competence was negatively associated with initial anxiety and depression and positively associated with a steeper decline of depression over 4 years post-placement. Other factors that may contribute to poor ProQOL include a lack of support from family and friends and conflict with children’s birth families (Bridger et al., 2019; Holt & Birchall, 2022). Consistent with Australian studies, the high demands placed on UK carers to manage children with complex problems also adds to their stress (Holt & Birchall, 2022; Sloan Donachy, 2017).

Many US studies focused on internalizing and externalizing behaviors of children as the major source of stress for carers (Barrett et al., 2021; Bundy-Fazioli et al., 2013; Cooley et al., 2015; Fawley-King et al., 2020; Goemans et al., 2017; Leathers et al., 2019; Lin, 2018; Nadeem et al., 2017; White et al., 2021). Two studies linked high family dysfunction and low family competence to carer strain (Gleeson et al., 2016; Julien-Chinn et al., 2017). In addition, relationship have been found between judgmental attitudes of families and friends and high carer stress ( E.R.Barnett et al., 2017; K. C. Barnett et al., 2021). On the other hand, support from family and friends was found to be associated with low stress levels in multiple studies (Fawley-King et al., 2020; Gleeson et al., 2016; Leathers et al., 2019; Lin, 2018; Sharda, 2022; Sharda et al., 2019; Woods, 2021). Several studies reported that factors such as ethnicity, age, marital status, financial status, and mental health status predict carer contentment (Denby et al., 2014; Leathers et al., 2019; Miller & Grise-Owens, 2021; Richardson & Futris, 2019). Lack of resilience was also identified as a predictor of high stress in three studies (Bundy-Fazioli et al., 2013; Cooley et al., 2015; Xu et al., 2022).

Two studies from the United States showed associations between carer stress and maladaptive parenting behaviors such as poor monitoring, inconsistent discipline, and low attachment or engagement with children (Lopez et al., 2022; Shklarski, 2019). The stress levels experienced by carers was shown in other studies to be influenced by the age of the children in care and the placement phase, with younger children and initial placement being predictors of higher stress level (Nadeem et al., 2017; White et al., 2021), as were children’s trauma and their conflicts with adult children in the household (Bundy-Fazioli et al., 2013). It was also reported that couple parenting stress in foster families was related to the perceptions of both parent and their partners regarding their marriage and the co-parenting relationship (Richardson & Futris, 2019). In addition, research revealed a variety of factors associated with caring stress including advanced age, poor overall health, and limited social life among grandparent carers (Sprang et al., 2015; Woods, 2021).

Studies Focused on the Relational Level

Regarding the factors at relational level, many studies examined relations between carers and entities having control over their care work, with most informed by research in Australia. Two Australian studies showed that poor communication by child welfare workers was associated with carer stress and feelings of incompetence (Kiraly et al., 2015; Octoman & McLean, 2014). The actual interference by child welfare workers, involving critique of parenting, was also reported to contribute to feelings of incompetence among carers (Blythe et al., 2013). Furthermore, the authoritative and reductionist attitudes of workers were argued by Fergeus et al. (2019b) to create conflicts for carers when directives were perceived not in the child’s best interests. Three studies expanded on the notion of poor communication in contexts where cultural sensitivity was imperative, observing that a lack of sensitivity by child protection workers created additional tensions for carers (Kiraly et al., 2015; McPherson et al., 2022; Randle et al., 2018). Likewise, the UK study by Bridger et al. (2019) showed a perceived a lack of practical and therapeutic support from their professional environment in addition to that received from family and friends.

Studies from the United States have found that poor communication between child protection workers and carers led to frustration for carers, as it inhibited children’s access to necessary services ( E.R.Barnett et al., 2017; K. C. Barnett et al., 2021; Schneiderman et al., 2012). Research also showed that unrealistic expectations, demands, and lack of respect communicated by court authorities, child welfare agencies, and other professionals toward carers contributed to their stress ( E.R.Barnett et al., 2017). These relational factors were linked to poor carer–child pairing in the Australian study by Randle et al. (2018), resulting in higher rates of placement breakdowns and stress for both children and carers.

Studies Centered at the Sociopolitical Level

The governance of social provision processes, including the foster and kinship care system, is managed at the sociopolitical level. While the foster system prioritizes the welfare of children over economic benefits, in practice, there is a struggle between authorities. Australia, the United Kingdom, and the United States have different approaches, with Australian research reporting more on the stressors at the sociopolitical level. There was an absence of UK studies addressing the factors associated with carer’ ProQOL at sociopolitical level.

Blythe et al. (2013) argued that caring for children was challenging and stressful when dealing with complex sociopolitical issues. They advised that child protection systems were bounded in policy red-tape informing practice that is not appreciative of the complexity involved in caring (Blythe et al., 2013). This finding was consistent with the range of Australian studies that demonstrated policy informing child protection practice characterized by abundant home visits, heavy scrutiny of carers, promises of supports not given, and insufficient financial resources resulting in inadequate care (Blythe et al., 2013; Harnett et al., 2014; Kiraly et al., 2020; McPherson et al., 2022; Randle et al., 2018). Two studies reported carer feelings of being dictated to, thereby diminishing their rights to make decisions related to the children in their care (Fergeus et al., 2019a; Octoman & McLean, 2014). Carers in these studies were denied access to historical information about the children, which could have better enabled their approach to child-centered care (Fergeus et al., 2019a; Octoman & McLean, 2014). Denied access to historical information was linked to difficulties, frustration, and burnout in trying to navigate services and supports with the children (Fernandes et al., 2021; Kiraly et al., 2015; McPherson et al., 2022). Australian research generally showed that carers wanted greater autonomy to do things that are in the best interests of foster children, along with more support, such as the support to promote mental health children in their care, the support from the government, and accessing respite (Fergeus et al., 2019b; Fernandes et al., 2021; Octoman & McLean, 2014; Randle et al., 2018; Zuchowski et al., 2019).

Several Australian studies (Harding et al., 2020; McKeough et al., 2017; Randle et al., 2018) also showed that informal carers, specifically grandparent carers, have a crucial role to play in supporting children’s lives, but they face heavy burden that can negatively impact their health and received little support. Blythe et al. (2012) noted that sociopolitical factors can lead to carers being treated like second-class parents. The UK study by Bridger et al. (2019) showed that the provision of a range of appropriate resources and supports could uplift carers’ political status and individual well-being, nonetheless these interact across level impacting the sense of well-being at the relational. level. A few US studies focused on sociopolitical factors associated with carer stress emphasized poor governance and inadequate access to primary and specialty services for children and young people in care ( E.R.Barnett et al., 2017; Schneiderman et al., 2012; White et al., 2021; Woods, 2021), resulting in an unstable support system for carers (Barrett et al., 2021). Although training was provided, a lack of post-training resources left carers feeling unsupported (Barrett et al., 2021). Carers reported a lack of systemic supports and resources as a source of stress (Cooley et al., 2015), including barriers in obtaining health insurance and transportation for the children (Schneiderman et al., 2012; Woods, 2021; Xu et al., 2022).

Interventions Reporting Outcomes on ProQOL or Related Concepts

Improvement to ProQOL or its related concepts associated with carer interventions was described in 27 studies across the three countries. We explored and reported herewith the impact and significance of interventions reported in relation to ProQOL or its related concepts among foster and kinship carers. Meta-analysis of the effectiveness of these interventions in terms of reducing secondary stress, burnout, and compassion satisfaction falls outside of the scope of our review. We note, however, that there are gaps between the caring stress-related problems experienced by carers and the interventions available to them.

Our search located three studies from Australia. One, known as the CP, is a therapeutic foster care program that reportedly has positive impact on the outcomes of children in care who have experienced trauma. Specific to the carers, Frederico et al. (2014) evaluated the CP, proposing that it was therapeutic for reason of offering carers a voice. Key outcomes were that the carers believed they were well-trained, had personal knowledge of the children, and felt personally valued. In a later mixed methods analysis, Frederico et al. (2017) demonstrated associations between therapeutic foster care training and carer retention, fewer foster child placement breakdowns, and unexpected exits. They reported that carers who participated in the program liked the assistance, training, continuous education, and flexible financial access. The third Australian intervention study, the Circle of Security-Parent Program, was evaluated by Krishnamoorthy et al. (2020). While program outcomes showed little impact on parent–child relationships, positive impact on overall carers stress was substantial.

Among the six UK studies reporting interventions, there were four intervention types: attachment-centered parenting (Begum et al., 2020), IY Parenting Program (Hutchings & Bywater, 2013), Reflective Fostering Program (Midgley et al., 2019, 2021; Ranzato et al., 2021), and KEEP—Keeping foster and kinship carers trained and supported program (Roberts et al., 2016). All were designed to reduce the negative effect of children’s challenging behaviors on the psychological well-being of carers. The attachment-centered parenting program showed increased carer confidence to manage children’s needs and implement therapeutic parenting as outcomes (Begum et al., 2020). Program outcomes of IY was significant reduction in child problem behaviors in association with lower levels of depression among the carers (Hutchings & Bywater, 2013). Three evaluations of the Reflective Fostering Program, involving only carers, indicated improved levels of stress associated with applying training with children in their care who had emotional and behavioral problems (Midgley et al., 2019, 2021; Ranzato et al., 2021). Roberts et al. (2016) examined the outcomes of KEEP programs, which demonstrated significantly lower carer stress upon program completion.

Program interventions with carers in the United States also showed improvements post-intervention (i.e., Chakawa et al., 2020; Mersky et al., 2015). The Family Minds program that aimed to improve reflective functioning of carers indicated decreased stress levels at program completion (Adkins et al., 2018, 2021). Feldman (2017) evaluated the Family Group Decision Making program, showing reduced parenting stress and improvements in social support, family needs, and child well-being. Furlong et al. (2021), who evaluated IY, reported improvements to children’s social, emotional, and behavioral difficulties, parenting competency, and carer stress. Price et al. (2014), likewise, found positive correlation between children’s problem behaviors and carer stress associated with engagement in the KEEP training program.

Many interventions focused on training carers to manage children’s adverse behaviors, involving pre- and post-program measures via RCT or quasi-experimental methods, only one study sought understanding of longer-term outcomes. This was an RCT of the Parent Management Training Oregon involving 9-months of intensive intervention in the United States with carers and children (Maaskant et al., 2017). Measures upon program completion reported that child-related parenting stress and parent-related stress had declined (Maaskant et al., 2017), but these intervention effects had worn off by 4-month follow-up (Maaskant et al., 2016). Several other studies reported mixed results, including Monahan et al. (2013) study of grandparent and kinship carers showing high levels of satisfaction with program interventions, but the impact of the intervention on reducing caregiving stress and burden was inconclusive.

A few interventions directly with carers focused on self-management of psychological well-being. Richardson, Pettit et al. (2021), for example, examined the effect of mindfulness training in relation to parenting stress and adult relationship stress and found that mindfulness contributed to foster couple caregivers’ relationship quality and individual well-being. Richardson, Mallette et al. (2021), however, reported gender differences in a co-parenting intervention. It was indicated that while both men and women experienced perceptions of positive change in support from their co-parent, there were higher levels of moderated positive change in parenting stress among men but not women.

According to Strozier (2012), attending carer peer groups led to significant increases in social support for carers. Interestingly, out of 16 US intervention studies reviewed, the majority focused on individual-level interventions, with only one by E.R.Barnett et al. (2019) examining the impact of trauma-informed mental health services on the relationships between carers and children. The findings of this study suggest that such services can play an important role in moderating these relationships.