At the end of a community health nursing home visit, a young senior baccalaureate student said, "I will never forget providing condoms and teaching a teenage couple how to use them today!" Another student commented that she had made a difference by securing baby food through the WIC program and then demonstrating how to prepare and feed cereal to a four-month-old hungry baby. The students were excited and eager to share their nursing experiences in a family homeless shelter with their peers.
Using a Homeless Shelter for Student Learning
Community health nursing students at Murray State University have had clinical experiences at local health centers, home health agencies, schools, and industries for many years. It was felt that in addition to these traditional learning experiences, students could benefit from visiting families in shelters (Anderson & Martaus, 1987). The task was to locate such a clinical site in this rural farming area of Kentucky. Large shelters for the homeless are common in big cities, but it was questionable whether homeless people and shelters existed in this rural community (Aprile, 1989; Tackett, 1991).
Gathering the Facts
A quick assessment revealed that there were indeed homeless people in their own home town. An estimated 300 families were without housing at any given time. Homelessness was not solely a street phenomenon; there were people living in extremely overcrowded, inadequate housing conditions. A small, family transitional shelter was operated by a local volunteer agency (McClure & Dickman, 1988).
Apartments were rented by the agency in a pubUc-assisted housing complex. Each apartment had a living room, kitchen, laundry room, and five bedrooms and accommodated up to 20 people. Residents were responsible for their own food preparation and laundry. The agency provided basic food items, soap, detergent, cleaning supplies, bed linens, and towels. Agency staff worked with residents to secure jobs and permanent homes. Group meetings, educational sessions, and parenting classes were available at the shelter. Residents were multicultural and of all ages. They stayed at the shelter from one to several weeks and most had no income or health care provider.
After discussions with the agency and local health center staff it was decided that community health nursing students would test the shelter as a clinical site for one semester.
Planning for Learning Experiences
Through literature review and further assessment, it was determined that most clients experience a crisis due to their homeless situation. They have low selfesteem and experience feelings of powerlessness. Most health care provided is at the secondary and tertiary prevention level (Kenyon & Blau, 1991; Saucier, 1991).
Learning objectives for this group of students included:
* Collect data from appropriate sources.
* Identify present and potential health needs of clients.
* Work with clients to set realistic goals.
* Formulate written nursing care plans.
* Use community resources and/or other health care team members in planning care.
* Provide counseling and teaching to clients.
* Provide for continuing of care by making appropriate referrals.
* Consider social and cultural factors in implementing care.
* Assist clients to use their own strengths in independently meeting their needs.
* Make a written evaluation of nursing care that is based on identified needs stated on the care plan.
Since there was no appropriate assessment form, the instructor developed one and it was tested. There was a need to keep the form brief because families were in states of crises and only short-term needs could be addressed; homeless people often resent constant questioning and probing from community agency staff; and students would have limited contact with some of these families. The final form, Short-Term Adult Homeless Nursing Assessment, served to gather information for nursing intervention. (This form may be obtained by contacting the author.)
Each student took a nursing bag containing health assessment equipment on shelter visits. A plastic laundry basket was used to transport additional supplies such as scales, Denver Developmental Screening Kit, small and extra large blood pressure cuffs, dipstick urine testing material, glucometer, reference books, and forms. A file of educational handout material was compiled, i.e., prenatal, parenting, personal hygiene, disease processes (Meyers, 1989; O'Connell & Groth, 1991).
Several record-keeping methods were considered. It was decided that if shelter residents had records at the health center, they would be used by students to document visits. If there were no records, students used existing health center master record, care plan, and nurses' notes forms for documentation. Care plans were reviewed and revised each day. All these records were placed in permanent health center files at the end of the semester.
Students became very involved in securing items for shelter residents. They asked other students, faculty, friends, and local churches for donations of clothing, personal hygiene supplies, cosmetics to help improve self-esteem, books and magazines, games, toys, emergency supplies of diapers and infant formula. A small fundraising project, ?ß?? yourself and help the homeless" donation jar, was started in the nursing department. Several companies were contacted and a Umited amount of nonprescription drugs and suppUes was made available. The local health center physician served as consultant and provided medical directions as needed.
Colorful signs were designed and posted to remind shelter residents of the date and time for student nurse visits. Arrangements were made to call the shelter resident manager early each lab day for a current list of residents so that students could plan for special situations.
A large basket of apples placed on the kitchen table by students helped to communicate caring feelings to shelter residents on each visit. Students selected specific famiUes and found a private room or corner for assessment and teaching. The famüies were interested, receptive, and shared many needs. There was the young mother with a history of spouse abuse who was seven months pregnant; a teen-aged couple with a four-month-old son and no way of providing for him; a single mother with four preschool children and expecting another child; a middle-aged couple with hypertension and back pain; and a 30-year-old woman who had abused drugs.
Many health needs similar to those found in homeless literature were identified by the students: lack of self-esteem, posttraumatic stress disorder, substance abuse, anxiety, depression, psychosomatic complaints, child and spouse abuse, anemia, malnutrition, upper respiratory infections, dental problems, various chronic diseases, immunizations, developmental delays, lack of parenting skills, and need for family planning assistance (Bowdler, 1989; Homes, 1990; Lindsey, 1989; Pearson, 1988; Rafferty, 1989a, 1989b; Wright & Weber, 1987).
At the end of each lab day, students shared experiences and did problemssolving to help find ways of meeting family needs. Reports from students included:
* A teen-aged mother with an infant son didn't understand how to take oral contraceptives correctly; at least one pül was missing from three different packages. Her husband felt that he could not use condoms because they were all too small. The student nurse did appropriate teaching on the spot and referred them back to the family planning clinic.
* A dentist was located who would accept Medicaid payment and appointments were made for a family's three children who had never seen a dentist.
* A young pregnant woman was taught about early signs of labor, breast feeding, and newborn care.
* Teaching about personal hygiene and diet was done on one visit when it was discovered that several residents had diarrhea. An over-the-counter drug was provided.
* A referral was made to an alcoholism treatment center.
* Appointments were made for several children at the health center immunization clinic.
* A 50-year-old man was taught about hypertension control and exercises for back pain.
* Stress management techniques were taught on several occasions.
* The Denver Developmental Screening test was completed on children. Developmental delays were identified and they were counseled and referred to the appropriate source for help.
* A young woman with a history of spouse abuse and depression was referred to the spouse abuse center.
* A social worker was consulted when child abuse was suspected in a family.
* Students discussed routine health maintenance issues such as growth and development, nutrition, sleeping problems, safesex habits.
Aggregate level needs were identified within the shelter, such as the need to "child proof the shelter and make it more safe; emergency poison control, ambulance, fire, poUce, and hospital phone numbers were posted; basic four food group visuals were place in the kitchen; a hand-washing reminder was left in bathrooms; a community resources booklet was left at the shelter.
On the last shelter visit for the semester, the students and instructor gave a HaUoween pizza party. Money from the fundraising projects was used to buy pizza, party decorations and treats, and a jack-olantern. Each child's face was painted for the occasion.
Learning and Helping: A Two- Way Street.
Students met their learning objectives. As the semester's work at the shelter was evaluated, it became clear that it had truly been a "two-way street." Shelter famiUes and students had benefited. Often children would greet students at the door by throwing their arms around their legs for a big hug! The student nurses became sensitive to group needs, felt that housing and health should be a human right, and began to understand the importance of nursing and political advocacy. They learned to approach these families with caring and respect, and provided support as they coped with problems in their lives. Neither students or families will ever forget these experiences.
- Anderson, J.A., & Martaus, T-M. (1987). Combining community health and psychosocial nursing. A clinical experience with the homeless for generic baccalaureate students. Journal of Nursing Education, 26, 189-193.
- Aprile, D. (1989, December 10). Homeless women. The Courier Journal [Louisville, KY], pp. H1.H17.
- Bowdler, J.E. (1989). Health problems of the homeless in America. Nurse Practitioner, 14(7), 44-51.
- Homes, M.E. (1990). American homeless. Santa Barbara, CA: Contemporary World Issue.
- Kenyon, T.L., & Blau, J. (1991). What you can do to help the homeless. New York: Simon & Schuster.
- Lindsey, A.M. (1989, March/April). Health care for the homeless. Nursing Outlook. 37, 7881.
- McClure, D., & Dickman, J. (1988). Homelessness in Kentucky 1986 House Concurrent Resolution 147. Frankfort, KY: Kentucky Legislative Research Commission.
- Meyers, D. (1989). Client teaching guide for home health care. Rockville, MD: Aspen.
- O'Connell, J., & Groth, J. (1991). The manual of communicable diseases in shelters. Boston, MA: Ine Fund for the Homeless & The Boston Foundation.
- Pearson, L. J. (1988, April). Providing health care to the homeless, another important role for NFs. Nurse Practitioner, 13(4), 39-48.
- Rafferty, M. (1989a). Standing up for America's homeless. American Journal of Nursing, 89, 1614-1617.
- Rafferty, M. (1989b). How nurses are helping the homeless. American Journal of Nursing, 89, 1618-1619.
- Saucier, K.A. (1991). Perspectives in family and community health. St. Louis: Mosby- Yearbook.
- Tackett, M. (1991, March 17). Homeless are also a problem for rural U.S. Chicago Tribune, Section 1, pp. 1, 22.
- Wright, J.D., & Weber, E. (1987). Homelessness and health. Washington, D.C.: McGraw-Hill Healthcare Information Center.