Experiential, service-based learning is particularly salient in the training of nursing and public health students for whom real-world, hands-on experiences, combined with reflection and discussion with faculty and fellow students, aids in preparation for upcoming roles with diverse populations (Cashman & Seifer, 2008; Institute of Medicine, 2003; Jarrell et al., 2014; Loewenson, & Hunt, 2011; Schmidt, George, & Bussy-Jones, 2016). For individuals experiencing homelessness, comprehensive health needs exist. The prevalence of diabetes, obesity, mental health concerns, addictions, respiratory and infectious diseases, and dental decay is higher among homeless and housing-insecure populations relative to the general population (Kantayya, Hawkins, & Koon, 2014; National Health Care for the Homeless Council, 2011). When compounded by barriers in obtaining preventive care, including limited insurance coverage, challenges in applying for medical assistance, inadequate transportation, reduced health literacy, and difficulty attaining appointments with providers, the health disparities facing homeless populations are profound (Kantayya et al., 2014).
Working with vulnerable populations and experience in addressing social determinants of health is considered an important component of nursing and public health education (American Association of Colleges of Nursing, 2008; Healthy People, n.d.; The Public Health Foundation, 2014; Quad Council of Public Health Nursing Organizations, 2011). First-hand experience with homeless individuals can illuminate for students in health professions programs the profound effect of social determinants on health and the challenge of acquiring adequate and culturally sensitive health care, and can elicit an appreciation for the role health care providers can have on the overall health care experience. Negative attitudes held by the health care workforce toward vulnerable populations can represent another barrier to use health-related services among the homeless. Structured service–learning may help to enhance student sensitivity and overcome the barrier of inexperience with housing-insecure populations perceived by some health professionals (Jarrell et al., 2014; Loewenson & Hunt, 2011; McNeil, Guirguis-Younger, Dilley, Turnbull, & Hwang, 2013).
These training-related barriers to effectively serve housing-insecure populations may be modifiable through experiential learning. Schmidt et al., (2016) found that medical students required to visit neighborhoods of patients developed increased appreciation for resource differences between low- and high-income neighborhoods, increased awareness of social determinants of health, and enhanced cultural competency when caring for vulnerable patients. Clayton and Dilley (2009) reported that service-learning at a soup kitchen with vulnerable populations challenged the perceptions of homelessness in nursing students. Specifically, nursing students were surprised by the prevalence of homelessness in their community, the number of women, infants, and children who were homeless, and the lack of community services to assist with identified needs Clayton & Dilley, (2009). Within public health education, service-based exposure to housing-insecure populations is associated with reductions in stereotypes (Hart, Gomez, & Raman, 2016).
Unfortunately, social service agencies and health care networks frequently lack resources to fully meet the demand from homeless and housing-insecure populations, particularly in rural areas (Adler, Pritchett, Kauth, & Mott, 2015). Effective completion of the U.S. Department of Housing and Urban Development's (HUD) Point-in-Time (PIT) count (2014), which serves to assist agencies with receiving annual funding and identify needed services, represents a challenge, as well as a critical opportunity to demonstrate the local area's need for services and funding (HUD, 2014). Participation in the PIT count can serve to bring a human face to discussion of the social determinants of health and may foster development of culturally appropriate care and service delivery among students in the health professions.
All undergraduate students enrolled in sections of Prepracticum in Public Health and senior nursing students in community health participated in experiences designed to provide first-hand exposure to people facing homelessness and housing insecurity. Each class received an in-depth overview of social and health disparities facing this population, local services available, and the role HUD's PIT count (2014) plays in funding services (HUD, 2014). The PIT count is a federally mandated count of unsheltered homeless conducted on a single date in January (HUD, 2014). Count completion requires canvassing locations across the county including known and suspected homeless camps, parking lots, food banks, shelters, and community meals; interviewing potentially housing-insecure individuals; and recording observations at each venue (HUD, 2014).
Following the in-depth class overview of the PIT count delivered by a local social service agency, students were invited to join community partners in completing the PIT count as part of clinical field-based requirements. Volunteers received additional training on PIT count procedures and safety measures, and they met leaders from social service agencies who served as count group leaders. For the January count, groups of students traveled throughout the county collecting data. This county-wide canvassing, completed mostly on foot, was challenged by below freezing temperatures and searching more than 1 foot of snowfall. The adverse conditions contributed to the authenticity of the task by bringing homeless living conditions into sharp focus.
Following completion of the PIT count, a second classroom presentation at midsemester provided students with preliminary PIT count findings including the prevalence of homelessness. During this class, students participated in moderated discussions of their experiences with local experts as is recommended as a summary service learning experience (Astin, Vogelgesang, Ikeda, & Yee, 2005). Beyond the count, additional learning experiences included the option for volunteering at the homeless day center. Student contributions included facilitating client in-take, talking with clients and learning about their experiences to increase center–client trust, and helping link clients to services. In addition, students were exposed to the day center's medical clinic through provider shadowing. Nursing students unable to participate in the count due to schedule conflicts prepared and delivered health education posters at community meal sites serving homeless and food-insecure populations.
Students completed a pre–postassessment of their perceptions of and willingness to work with homeless populations using the validated Health Professionals Attitude Toward Homeless Inventory (HPATHI; Buck et al., 2005). All original HPATHI questions were used with minor edits to reflect a nursing and public health role, rather than a physician-specific role. Students also completed a checklist indicating which homeless-related experiential learning opportunities were completed. Finally, qualitative data elements were collected from all students. Specifically, nursing students posted a reflective journal summary of their experience, including implications for their future nursing roles, and reviewed a salient article. Public health students engaged in qualitative focus group discussions to reflect on their experiences and implications for future work; comprehensive notes on discussion content were taken. Constant comparative analysis was used to guide theming of all students' qualitative reflections. Although the purpose of all data collection was to summarize changes in student perceptions to inform our curricular development, findings may hold relevance for similar programs nationally.
Collaboration was established between community partners and our university's public health and nursing programs to support completion of the HUD (2014) mandated PIT count and to promote student engagement with populations experiencing homelessness. Twenty-eight students contributed more than 69 combined hours in completing the PIT count. Student participation increased the number of county-wide count participants during previous years and enabled a larger proportion of the county to be canvassed, thereby improving the degree to which the surveillance data collected reflected the true level of need within the community. Students also contributed time in the homeless day center and surrounding social service agencies before and after the count in service to this housing-insecure population. For example, 17.9% of students met with clients at the day center and packed bags of supplies for distribution to homeless community members, and 44% of nursing students also provided nutrition education at food pantries and interacted with clients there.
Impact on Students
PIT count service-learning enabled interaction with community members across various settings and activities. Following precount training, the most common count-related experiences included searching for homeless individuals at agencies (i.e., Salvation Army; 64.3%), asking questions of those experiencing homelessness (60.7%), and searching for homeless individuals in parking lots (i.e., at Walmart) (50%). Exploring known or suspected homeless camps in the woods (14.3%) was the least common experience reported.
Field-based experiences, trainings, and discussions together comprised the learning experience and a variety of changes in student perception were associated with this experience. In HPATHI responses, the proportion of students agreeing or strongly agreeing with the statement “my knowledge regarding the problem of homelessness is adequate” increased from 23.1% precount to 51.9% (p = .004) postcount. In contrast, more students agreed or strongly agreed that “homeless people are dangerous, aggressive, and physically threatening” after the count (42.3%) compared with precount (21.1%, p = .037). Further, at postassessment, most students (82.7%) agreed or strongly agreed that “homeless people come from all walks of life,” whereas 75% strongly agreed or agreed “I feel it is important to provide care and services to all socioeconomic groups,” and 84.6% agreed or strongly agreed “I feel comfortable being part of a team when providing care/services to the homeless.” Although each of these proportions represented a statistical decrease during baseline, the proportion endorsing each statement remains high and reflects support for those experiencing homelessness.
Through the stories shared by PIT count interviewees, social determinants of health were illuminated for students, and students had occasion to serve as a public health resource linking housing-insecure populations to community-based resources. These resources include health care, shelter, housing, food pantries, and community meal options. Qualitative theming of debriefing sessions among nursing students reflected initial discomfort and hesitancy with approaching individuals to interview, fearing they may insult someone. Other themes included surprise at the positive attitudes and friendly demeanor of those approached. Students also noted the concern many housing-insecure individuals had for others in need of services. Further, students were deeply moved by housing-insecure individuals thanking them for the work they were performing during the count. Among public health students, additional common themes included students' surprise that homeless populations included children, families, and the elderly. Students also expressed being taken back by how dirty, wet, and cold they became during their searches, which contributed to a central, universal theme of enhanced empathy through PIT count participation. In addition, many students discussed their underestimation of the community's level of need at the outset and agreed overwhelmingly that their knowledge regarding the problem of homelessness increased dramatically through the service-learning experience. Overall, students felt the experiences were positive.
Students from undergraduate nursing and public health programs engaged in service-learning to complete the PIT count of the homeless in multiple settings. All were immersed in classroom-based learning surrounding housing insecurity, and many participated in field-based immersion activities. Changes in HPATHI responses and qualitative findings reflect a range of effects on student affect—specifically, a more nuanced appreciation for complexities and challenges facing housing-insecure populations. Although some quantitative findings reflected a more positive assessment of housing-insecure populations, others were more negative. However, declines in support for homeless populations were not entirely unexpected due to the unexpectedly high level of baseline support reported; similar mixed evaluation results have been found previously (Boylston & O'Rourke, 2013; Buck & King, 2009; Woodhead, Sperry, Bower, & Fitzpatrick, 2009). This educational intervention's outcomes indicate that students gained a more positive assessment of and appreciation for the range of individuals experiencing homelessness, as was found in other service-learning projects (Buch & Harden, 2011; Clayton & Dilley, 2009; Hart et al., 2016; Loewenson & Hunt, 2011), and suggest that PIT count participation can be a meaningful experience.
Also noteworthy is the range of alternate experiences students engaged in outside of the PIT count itself. Creation of health education materials for this population is a different hands-on experience than count participation; however, it represented a successful response to students' scheduling conflicts, but still facilitated development of cultural competency. As academic programs look to increase service-learning, while also demonstrating their value, participation in the PIT count is potentially valuable mechanism for field-based work. Further, as the count is required nationally, opportunities for multiple academic programs to join forces to assess student learning and also support community completion of national mandates warrant further investigation. Our experience found integrating students with those experiencing homelessness can change student affect, knowledge, and interests, and also benefit social service agencies in reaching their goals. This educational innovation leaves open the door for future research designed to elucidate the content, setting, length, and intensity of interactions needed to facilitate maximum change among students. Further, initiatives to include the PIT count as experiential learning within a curriculum should consider both quantitative and quantitative pre–postassessments to understand how the experiences influence students' affect, cultural competence, and work within interprofessional teams when caring for housing-insecure individuals or populations.
- Adler, G., Pritchett, L.R., Kauth, M.R. & Mott, J. (2015). Staff perceptions of homeless veterans' needs and available services at community-based outpatient clinics. Journal of Rural Mental Health, 39, 46–53. doi:10.1037/rmh0000024 [CrossRef]
- American Association of the Colleges of Nursing. (2008). Tool kit of resources for cultural competent education for baccalaureate nurses. Retrieved from http://www.aacnnursing.org/Portals/42/AcademicNursing/CurriculumGuidelines/Cultural-Competency-Bacc-Tool-Kit.pdf?ver=2017-05-18-143552-023
- Astin, A.W., Vogelgesang, L.J., Ikeda, E.K. & Yee, J.A. (2005). How service learning affects students. Retrieved from https://heri.ucla.edu/PDFs/HSLAS/HSLAS.PDF
- Boylston, M.T. & O'Rourke, R. (2013). Second-degree bachelor of science in nursing students' preconceived attitudes toward the homeless and poor: A pilot study. Journal of Professional Nursing, 29, 309–317. doi:10.1016/j.profnurs.2012.05.009 [CrossRef]
- Buch, K. & Harden, S. (2011). The impact of a service-learning project on student awareness of homelessness, civic attitudes, and stereotypes toward the homeless. Journal of Higher Education Outreach and Engagement, 15(3), 45–61.
- Buck, D.S. & King, B.T. (2009). Medical students' self-efficacy and attitudes toward homeless patients. Virtual Mentor, 11, 32–37. doi:10.1001/virtualmentor.2009.11.1.medu1-0901 [CrossRef]
- Buck, D.S., Monteiro, F.M., Kneuper, S., Rochon, D., Clark, D.L., Melillo, A. & Volk, R.J. (2005). Design and validation of the health professionals' attitudes toward the homeless inventory (HPATHI). BMC Medical Education, 5, 2. https://doi.org/10.1186/1472-6920-5-2 doi:10.1186/1472-6920-5-2 [CrossRef]
- Cashman, S.B. & Seifer, S.D. (2008). Service learning: An integral part of undergraduate public health. American Journal of Preventive Medicine, 35, 273–278. doi:10.1016/j.amepre.2008.06.012 [CrossRef]
- Clayton, L.H. & Dilley, K.B. (2009). Service learning: Population focused nursing for the homeless at a soup kitchen. Nurse Educator, 14, 137–139. doi:10.1097/NNE.0b013e3181a026fc [CrossRef]
- Hart, T., Gomez, F. & Raman, P. (2016). Service learning and perceptions of homelessness. Academic Exchange Quarterly, 20(2), 54–59.
- Healthy People. (n.d.). Social determinants of health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
- Institute of Medicine. (2003). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies Press.
- Jarrell, K., Ozymy, J., Gallagher, J., Hagler, D., Corral, C. & Hagler, A. (2014). Constructing the foundations for compassionate care: How service-learning affects nursing students' attitudes towards the poor. Nurse Education in Practice, 14, 299–303. doi:10.1016/j.nepr.2013.11.004 [CrossRef]
- Kantayya, V.S., Hawkins, A.O. & Koon, A.D. (2014). Homelessness and physical health in the United States. In Cockerham, W.C., Dingwall, R. & Quah, S. (Eds.), The Wiley Blackwell encyclopedia of health, illness, behavior, and society (March2014 ed.). Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118410868.wbehibs281 doi:10.1002/9781118410868.wbehibs281 [CrossRef]
- Loewenson, K.M. & Hunt, R.J. (2011). Transforming attitudes of nursing students: Evaluating a service-learning experience. Journal of Nursing Education, 50, 345–349. doi:10.3928/01484834-20110415-03 [CrossRef]
- McNeil, R., Guirguis-Younger, M., Dilley, L.B., Turnbull, J. & Hwang, S.W. (2013). Learning to account for the social determinants of health affecting homeless persons. Medical Education, 47, 485–494. doi:10.1111/medu.12132 [CrossRef]
- National Health Care for the Homeless Council. (2011). Homelessness & health: What's the connection. Retrieved from https://www.nhchc.org/wp-content/uploads/2011/09/Hln_health_factsheet_Jan10.pdf
- The Public Health Foundation. (2014). Core competencies for public health professionals. Retrieved from http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf
- Quad Council of Public Health Nursing Organizations. (2011). Quad council competencies for public health nurses. Retrieved from http://www.achne.org/files/Quad%20Council/QuadCouncilCompetenciesforPublicHealthNurses.pdf.
- Schmidt, S., George, M. & Bussy-Jones, J. (2016). Welcome to the neighborhoods: Service learning to understand of social determinants of health and promote local advocacy. Diversity and Equality in Health and Care, 13, 389–390. doi:10.21767/2049-5471.100081 [CrossRef]
- U.S. Department of Housing and Urban Development. (2014). Point-in-time count methodology guide. Retrieved from https://www.hudexchange.info/resources/documents/PIT-Count-Methodology-Guide.pdf
- Woodhead, E.L., Sperry, J.A., Bower, E.H. & Fitzpatrick, K.M. (2009). Attitude change following homeless clinic experience. Family Medicine, 41, 83–84.