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Issues in Nursing: Improving Outcomes for Homeless in Acute Care

Abigail OBrien
Ferris State University











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Abstract
This purpose of this paper is to answer the PICOT question, Does education and sensitivity
training for nurses improve homeless patient outcomes in the acute care setting? Research
regarding the perceptions of nursing care towards this population is extensive and education
towards providing care is in current literature, but there is a limited amount of research on
whether or not the homeless patient population felt that their outcomes improved after
implementation of sensitivity training. Majority of nursing research and education discusses care
for the homeless patient in the community health setting. Despite the prevalence of community
nursing research regarding homelessness as one facet it is evident in practice that this population
is seeking treatment in Emergency rooms and hospitals due to lack of a primary care provider
and no chronic health management. Often homeless are referred to as having their own culture
and are negatively viewed in the media. Nurses in hospitals are becoming increasingly
desensitized to the needs of the homeless population because of misconceptions that all patients
suffer from mental illness and substance abuse. Despite the disparities this population faces
nurses may become despondent to the need to provide empathetic support. After reviewing
nursing systems on a local and national level it is evident there is a culture aimed toward
providing patient centered care. Nursing theory is applied to the problem as well as an approach
to solving interpersonal problems with leadership tactics and assessing personal biases.






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Issues in Nursing: Improving Outcomes for Homeless in Acute Care
Homelessness is a pervasive problem in the United States. According to ------ there are---
living ---- ( ). The definition of homeless is lacking a stable night time residence, (
HHA ). There are many variables that account for the high incidence of homeless people.
These variables are: mental illness, drug and alcohol dependence, ostracism based on sexual
orientation, domestic violence and poverty. To understand why people are homeless a brief
history of the community mental health act and our current state of economy is necessary.
Mental institutions are recorded in America starting in the early 1700s with vast
accounts of inhumane treatment and occupants living in squalor. Until the beginning of the
nineteenth century, after the industrial revolution poorhouses were known for taking in the
downtrodden and unfortunate of society; these establishments were funded by the state taxes.
Dorthea Dix, a Civil War Army nurse takes much credit for advocating for the humane treatment
and implementation of mental health asylums to be separate from the poorhouses. Psychiatric
care and care of indigent, disabled and other unwanted members of society were housed in the
asylums that flourished across the country. These asylums were a sanctuary and self-sufficient
community unto themselves. It was not until the mid-twentieth century that new medications
were said to treat some of the major complications associated with the ailments of tenants in the
asylums that the idea of transitioning the patients behind the sanctuary walls would be appealed.
When President John F. Kennedy took office in the 1960s he implemented the Community
Mental Health Act that lead to the construction of our mental health system today. ( ).
Patients in the asylums were released into the community for the first time in their lives and now
there is no state institutionalization for this patient population. This population has to follow up
with Community Mental Health and adhere to medication regimens; otherwise, often harmful
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behaviors may interfere with activities of daily living. Twenty five percent of the current
homeless population is considered mentally ill ( ).
There is still another seventy five percent of the homeless population that society tends to
forget about living without mental illness, and also without stable housing. Even though
Medicaid , Medicare, public assistance, workmans compensation, unemployment and disability
payments as well as other government funds are available as supplement they are often not
enough to support the cost of living for people that end up accruing debts and cannot live
affordably, leaving them homeless.
Community health appears to be a deemed provider of care for this population as it serves
community members at low cost, sliding scale, or free ( grant money provided) and accessible
services at the community health department. Nurses and educators often travel from site to site
throughout counties to aide in giving vaccination and providing screening programs. Although
beneficial to the homeless population it is still a necessity to seek medical and nursing care
outside of the preventative and health promotion realm that community health provides.
Homeless patients present to Emergency rooms with varying degrees of complaints.
Environmental exposures, overdoses, exacerbations of chronic health conditions and evidence of
physical violence contribute to admissions to hospitals. The chronically homeless are acclimated
to living day to day and many are substance dependent in conjunction with mental illness. This is
a subset of patients that have their own culture. Nurses may refer to these patients with chronic
conditions being seen in the acute care setting as frequent flyers. Often, the sight of these
patients with mental illness and substance dependence brings out the worst in some of the best
bedside nurses.
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There is a lack of sensitivity within the nursing culture when faced with the homeless
population. Perhaps the lack of sensitivity is based on the fear that patients choose to be living
the way they are, primarily because they are not seen as tax payers like the rest of us.
Perceptions of what homelessness entails are mis-conceptualized by the general public and as
nurses there is an opportunity to reach out to this vulnerable population. Reasons for
homelessness are varying, and just as each patient is an individual their individual story should
be taken into consideration before passing judgment on the circumstances that have amassed into
the situation they are presently in. The goal of the nurse should be to promote independence and
provide referrals to help homeless patients achieve optimal level of functioning in society.
Providing care based on the current nursing research, the present culture and environment of
systems within nursing; that promote high quality care as well as nursing and interdisciplinary
theories will provide analysis, synthesis and implications for nursing practice.
Theory Base
Implications for the bedside nurse as stated by Virginia Henderson in her Care theory is
that nurses care for a patient until independence can be resumed ( ). Henderson stated there
are fourteen components of nursing needs that are applicable to the care of physiological,
spiritual, moral and psychological care that preserves the independence of a patient. These
fourteen components are:
breathe normally, eat and drink adequately, eliminate body wastes,
move and maintain desirable postures, sleep and rest, select suitable clothes-dress and
undress, maintain body temperature within normal range by adjusting clothing and
modifying environment, keep the body clean and well groomed and protect the
integument, avoid dangers in the environment and avoid injuring others, communicate
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with others in expressing emotions, needs, fears, or opinions, worship according to ones
faith, work in such a way that there is a sense of accomplishment, play or participate in
various forms of recreation, learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities ( ).
The premise of this nursing theory explores the nurse assisting a patient with basic needs,
these needs are requirements to maintain normal functioning. Henderson emphasized empathy
towards patients to assist with meeting the fourteen basic needs. This theory states that the
individual, environment, health and nursing care have a unique dependence on each other. The
health component that is most relevant to the care of homeless in the acute care setting is the
final component claiming that patients should be able to use available health facilities. Obviously
homeless patients can and do use health facilities, but it is the hindrance to their optimal health
when uneducated nurses without sensitivity training deliver inadequate care to provide the
components towards the population. Homeless individuals often do not get adequate nutrition,
rest and do not have proper clothing to accommodate the climate they live in. Delivering these
components of care are ways to improve the independence of patients and help rehabilitate back
to baseline functioning. When physiological functioning is restored the nurse has the
responsibility to promote optimal health and refer patients to resources that will help alleviate
disparities they ensue on a daily basis. The bedside nurse should work in conjunction with social
work and implement ways to find stable sources of shelter, nutrition and clothing as well as an
outpatient support network and counseling.
An interdisciplinary theory that coincides with the Care theory Henderson proposed is
Abraham Maslows Hierarchy of needs. Maslow was a Humanistic psychologist that proposed
there are five levels of basic needs that humans strive to achieve. The levels are on a hierarchical
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pyramid and without fulfilling the first level of needs an individual cannot successively climb
the pyramid up to the next level. The levels are: physiological needs, safety, belongingness,
esteem and self-actualization. The first level that needs to be met is the need for air, water, food,
and sleep, without these basic needs being met individuals suffer with maintaining functionality.
Homeless patients have difficulty meeting the very basic needs that motivate the desire to strive
for anything but survival. The second level is safety. Safety is the feeling of stability with
consistency of income, freedom of fear from violence and being able to act in accordance with
personal beliefs without retribution. The third level on the pyramid is belongingness; this
coincides with fear of retribution and being able to communicate with peers in a cohesive way.
Belongingness includes feelings of intimacy, making and maintaining friendships and being part
of a family. The fourth level is esteem, this level includes the feeling worthy and having the
capability to utilize intrinsic motivation to find self-worth and strive to make achievements and
set goals in life. The last level is self-actualization, this level is not often attained by individuals
that suffer with remorse or regret in their life. Self-actualization is the ability to achieve the
highest potential in the trajectory of a persons life (Maslow).
Homeless people often struggle to survive, unable to have consistent access to food and
shelter disallowing the expansion past the first level of the hierarchy. Without initiating the first
steps of the pyramid individuals cannot move up the pyramid to achieve optimal functioning.
The goal of the nurse is to provide for basic physiological needs first and promote safety while
caring for homeless patients in the acute care setting while educating and promoting stability to
transition into the next steps. Goal setting by patients in conjunction with the nurse are essential
to providing care that promotes moving up the hierarchy. An assessment of the healthcare
environment is necessary to determine if facilitating these goals of care are a possibility.
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Assessment of Environment























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