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Nursing Center Without Walls Provides Health Care to Vulnerable Populations
By SUSAN SIMS-GIDDENS, EdD, RN
Dr. Sims-Giddens is an associate professor and teaches in the undergraduate and graduate nursing programs at Missouri State University. She is actively involved in community agencies that serve vulnerable populations. Her research interests include community engagement of nursing students through service learning; nursing students’ attitudes and beliefs about poverty; vulnerable population access to healthcare, and the impact of music therapy in outpatient drop-in centers for the homeless.
“Can you help us? We just had an infant die last week– sudden infant death syndrome we were told”. The story unfolded as the director of a homeless shelter described the situation of a single, much too young mother discharged from the hospital without skills to care for her infant. Representatives from several community agencies gathered after the director called several friends asking for any assistance to prevent such an event from happening again. One agency representative contacted the Department of Nursing at Missouri State University asking if we could provide any assistance to the shelter. The director was “lost for ideas about how to help the families at the homeless shelter to cope with this tragic loss and how to prevent another death”. Four agency representatives and a nursing faculty member met at the shelter and began brainstorming about how to assist the men, women, and children who were residents of the shelter. From this initial conversation, a partnership evolved between the homeless shelter and the Department of Nursing at Missouri State University.
Two of the nursing faculty began talking about including the homeless shelter as a clinical site for nursing students. How the shelter would benefit from basic healthcare and our students would have the opportunity to learn about the culture of poverty, as well as provide our community with a valuable service. We did not have an actual building to use, not even extra closet space to hold materials we could take with us and our students. Our nursing center without walls was created out of necessity and the equipment was added to our offices.
As conversations continued and the plan to include the homeless shelter as a clinical site for our nursing students progressed, we began to explore how best to make the most of this exciting opportunity. Two clinical courses were already designated as service-learning courses and what better way to expand student learning experiences? We initially introduced students to the culture of poverty and vulnerable populations through discussion and creation of a budget based on poverty level income. In the context of our nursing program, we define vulnerability as those individuals at risk for poor physical, psychological, or social health. We believe anyone can be vulnerable at any point in time. After students developed a budget and identified “extra” items needed such as healthcare or health insurance premiums that were not included, they understood the lack of access to healthcare for this population. Additionally, we discussed where the vulnerable population sought healthcare and the cost of an emergency room visit. Students began to visualize how they could assist this population by providing healthcare education and referrals to low-cost or no-cost healthcare alternatives.
As we incorporated the homeless shelter into our list of community clinical sites, it became clear that there was a need for a larger project to meet healthcare needs. The concept of a wellness center without walls would make us more flexible in providing health education. Our students identified areas of interest and working in groups they developed the mission, philosophy, goals, and objectives of our nursing center and named our organization Coalition of Health Communities (CHC). In addition, the students defined the nursing role as one of assessment, education, and referral for the residents with whom they work. As the word of our work spread from one agency to another and community residents talked about “their nurses from the university”, we began to include more shelters. Meeting with students over lunch on clinical days, we decided to include those shelters without a nursing presence to demonstrate the impact of nursing on healthcare. The CHS has expanded to 10 agencies without a nursing presence to assess, educate, and refer homeless and vulnerable populations. These agencies use the Nursing Center without walls for their residents’ nursing needs.
The nursing workforce meeting the healthcare needs consisted of 2 full-time nursing faculty who teach nursing theory in the classroom. The students are oriented to the community concept across the curriculum and one part-time clinical instructor works with approximately 30 students at agencies where our students provide care during the fall and spring semester.
Undergraduate seniors and graduate students, working through the CHC, developed healthcare educational materials and programs based on common health problems identified, as well as empowerment tools that allow the residents to be in charge of their healthcare decisions. Common health problems seen in this population include diabetes, high blood pressure, obesity, stress, and addiction to smoking. Items such as a small multiple-fold card for immunizations and blood pressure readings were designed by students, allowing residents to track and be in charge of their health record. The homeless population does not have storage facilities and all personal items must be carried and small health cards may be carried in shirt pockets or wallets with easy access.
Vulnerable individuals prefer to be taught individually as opposed to group education sessions as each person believes their particular situation and need is different from others. Educational deficits are easily assessed with a vulnerable population; however, time must be spent with these individuals to establish a trusting relationship before implementing a teaching plan. Our experience working with this population has given us insight to the importance of teachable moments at the time residents show a readiness to learn. In one teaching session a resident stated “Ok, I know I need to quit smoking but right now my stress level is so high about not having a home and until I figure out a place to live, I can’t tackle giving up my cigarettes”.
Many of our students are unfamiliar with the vulnerable residents in our community. Students who worked with the CHC the previous semester or year mentor the new students. Students teach residents about the medications they are taking. The clinical supervisor oversees student activities, discusses resources, and assists students to collaborate with community partners. Student placement in this project is dependent upon student interest in working with the vulnerable population. The culture of poverty is significantly different than what the students are comfortable with, therefore, it takes students approximately four weeks to orient to the agency and environment, as well as establish working relationships with both the residents and staff. For example, some students were frightened. However, after they began talking to residents and hearing stories about companies closing, loss of well-paying jobs or making bad life decisions they began to understand poverty can happen to anyone at any time.
One student worked with an African-American resident with known high blood pressure and who had not taken his medications for two months. He repeatedly stated he would seek treatment at the free medical clinic, however, failed to do so. As the student described her interaction, “he is very quick to get frustrated” because he feels “it’s not happening fast enough”. “We also discussed increased risk of other diseases due to being an African American male. This led to a discussion of what a sustained arterial pressure can cause such as coronary heart disease or stroke and how damaging these conditions can be to a quality of life. I kept the discussion very future oriented in order for him to visualize how his future can be with uncontrolled blood pressure. This discussion helped, but at times made the resident more frustrated by having to deal with ‘one more thing’.” The student “too felt frustrated at times during the discussion with the resident regarding hypertension. However, I felt I really got through to him due to the fact that he, already being in tune with his health, recognized the fact that he can’t leave his hypertension untreated. It made me happy that he said he would establish with the clinic on Monday. Now I’ll have to see if he did! My experience this week made me reflect on all of the times, when my father was sick, how frustrated I would get when I thought he didn’t get the right care, fast care; when I thought about all of the what ifs…I realized I had been in the same place this man is at, frustrated with the past and the future. The past is what is, but the future can be better with hope, positive thinking and caring for yourself. My quote this week is from Abraham Lincoln: ‘A house divided against itself cannot stand.’ I like to think of the body as the house…if an individual refuses to seek care to allow his/her body systems to work together, in union, it will, at one point fall apart.”
Consistency of presence is necessary to maintain the trust relationships with the resident to meet their health care needs. Many of our residents have not had positive experiences with the health care system in the past and they, too, enter a trusting relationship cautiously with our students. However, once the relationship is established, many residents proudly introduce our students as “their nurse” or come to the free medical clinic because “my nurse told me to come”.
The service-learning model of instruction expects students to make the connection between nursing education, direct application of knowledge, and working collaboratively in agency partnerships to serve the population in the community. Students who participate in nursing service-learning courses may transfer knowledge and experience to a variety of work settings over the course of their career. Students use reflective thinking, drawing upon their past experience and present action to evaluate the effectiveness of their intervention with populations and how to improve future interactions.
Another student chose to incorporate Betty Neuman’s system model that views health as a continuum of wellness to illness, one that is constantly changing. In the student’s description of her experience “this theory was successful when I encountered a young lady who came to us with facial cellulitis. Using the model, I looked at all the variables that affect her health. Looking at her physical external environment, this was a girl sleeping in a crack house on the floor and probably without any blankets. This environment on its own is conducive to all types of infections. Internally, and socially, she was also dealing with a lot of stressors particularly in regards to her relationship with certain people in her life. She has developed a psychological defense system of denial among other things that make it difficult to get through to her. The social community that this girl is in is also a great detriment to her health as she is heavily influenced by friends to do such things as IV drug use. I had to talk to her and educate her on all these issues. Her cellulitis was also complicated by a facial abscess which is scheduled to be drained early next week. With this drainage comes a wound on her face that would need to be packed and kept clean. I reminded her to come to the agency everyday if possible so this site can be kept clean and watched for any further signs of infection. She was also talked to about what she would need to do to get off the streets and the crack house which pose as a threat to her health and the cleanliness of her future wound. How she would need to get back on the waiting list for low-income housing to get off the streets, and an opportunity to get her GED and hopefully make a better life and living situation for herself. I also discussed with her about the people she hangs around with. She had expressed some need to quit IV drug use but was unwilling to go to rehab. She had to know that as long as she stays with the people she is with now, recovery is going to be an uphill battle that she probably will not succeed at.
The student reflected “this week I reminded myself that just because I have all the information that a person may need to make their lives a little bit better, it does not mean that they are going to take it. Yes, it is a little frustrating but in any situation an individual can only do so much for another.”
It is difficult to measure success with the homeless population because they are transient. Many come to appointments intermittently for a variety of reasons. Many lack transportation or do not view an appointment for a blood pressure or blood glucose check as a priority. But when we do see our residents they call us by name and know we are there to help them feel better. We feel better too, knowing we are giving back to our community and the residents who live here.
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