Every person has the right to access health services that meet their needs. This includes people affected by homelessness. Accessing healthcare is a major issue for homeless people and these people suffer some of the poorest health in our society. It is the intention of this assignment to analyse nursing strategies in relation to improving healthcare for single homeless adults. It will include a critical analysis of the main theoretical and clinical principles relevant to critical care. The assignment will conclude with recommendations for clinical practice and educational development of nursing practitioners in relation to the nurse's role in helping to improve the healthcare of single homeless people.
The definition of homelessness is very broad but homelessness is covered by a number of homeless situations. According to Shelter Scotland (2012) homelessness means that you do not necessarily need to be sleeping of the streets. Some people stay on the sofas of friends or relatives, others choose to squat. Some live in unsuitable accommodation which may be overcrowded or live in hostels (Shelter Scotland 2012). The Royal College of Nursing (2012) states that the majority of homeless people are single people with no partners or close families. They live in insecure or temporary accommodation or perhaps sleep on the streets and these people can face huge inequalities when trying to access healthcare facilities and services (RCN 2012). To achieve the goal of ending homelessness, it is vital to improve the health of people who are homeless especially single people. This is crucial to reducing health discrimination, unfairness and differences.
The Scottish Government (2012) recently published the "Operation of the Homeless Persons Legislation in Scotland" which revealed that in 2011-2012 there were 35,515 homeless assessments and 91% of these were accepted as homeless and in priority need. This is a huge increase since 2001-2002 when it was recorded as 73% being accepted as homeless. 42% of these applications were from single men and 22% from single women. The statistics also revealed that 28% of people become homeless due to disputes within the household but only 5% became homeless due to discharge from hospital (The Scottish Government 2012). According to Crisis (2009) it is the policy of most local authorities that they have no statutory obligation to house people who are considered low priority - this makes the single homeless group mostly helpless to insufficient or no housing at all.
A national health audit carried out by Homeless Link (2010) found that 8 out of 10 homeless people have one or more physical health need and 7 out of 10 homeless people have at least one mental health need. The audit also reported that 1 in 3 homeless persons regularly eat less than 2 meals per day. 1 in 5 homeless persons stated that they found it difficult to manage their health needs and required support (Homeless Link 2010). A report by Crisis (2011) revealed that the average death of a homeless man is just 47 years old and a homeless woman is 43 years old, compared to the average age of 77 years old for the general population. The report also revealed that homeless people are 9 times more likely to commit suicide than the general population and just over a third of all deaths are caused by drug and alcohol abuse (Crisis 2011). Being homeless influences considerably the physical and mental health and well-being of people.
A comprehensive literature review was conducted using the following online databases: MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Intute and Wiley Interscience Journals. The key words used to search were: homelessness, nursing strategies, healthcare, single adults, homeless and health needs. The search was limited to primary research studies published in the English language during 7 years prior to July 2012. When the key words of homelessness/single adults was used 24,830 articles were found but they were not accurate or relative to the main areas to be examined. A narrower search was undertaken which included nursing strategies/healthcare and this located 1,362 articles although many of these referred to resources which were irrelevant. Some of the key articles from the search are included in this assessment and references for further reading are included in the reference list.
Healthcare is a major issue for homeless people and nurses must be aware of the complicated array of health problems facing homeless people along with the numerous obstacles that they may experience when trying to obtain any healthcare. In accordance with The Nursing and Midwifery Council (2008) Code of Conduct, the nurse must work with others to protect and promote the health and well-being of those in their care and act as an advocate in order to assist them to access the relevant health and social care they may need along with information and support (NMC 2008).
Health promotion was a frequent topic in the literature that was studied on improving the healthcare of single homeless people. The nursing literature which was looked at, also defended the opinion that health promotion is an essential part of the nurse's role (Piper 2009). The nurse's role in health promotion and health education involves taking into account all of the processes involved from assessing, planning, implementing and evaluating, as these are all essential elements of a health promotion programme (Barrett 2012). According to National Institute for Clinical Excellence (2010), health promotion is an activity that intends to prevent disease or promote health. The method of health promotion concentrates on health and not the illness. It also helps to recognise that sometimes the health of homeless people can be influenced by factors outside that person's control.
One of the key aspects of health promotion is attitude and to suggest ways to change attitude and its associated behaviour is of the main objectives in health promotion (Bartholomew et al. 2011). It is vital to adopt the most important approach to health promotion and Piper (2009) suggests five approaches to health promotion: medical, behavioural change, educational, empowerment and social change. According to Casey (2007) health promotion combines a way of working with patients and clients to promote health. To provide structure for health promotion, several health promotion models have been developed. One of the better known and most popular one is Tannahill's model of health promotion (1995) which describes health promotion as three interlinked circles that include health education, health prevention and health protection. As the circles overlap they form the seven components of health, and number five on the list - positive health education - is aimed at changing behaviour. Changing behaviour could be done by either educating single homeless people in positive health or by showing the consequences of poor health. Health education is described as an activity aimed at informing people about the prevention of disease (Neeraja 2011).
Dahlgren and Whitehead (1991) established the Determinants of Health model which explained how health is shaped by a variety of factors either positively or negatively. Economic, social and environmental conditions can determine the health of people and populations and also included in this model are the essential changes in the circumstances of daily life. Such factors can decide whether or not a person is in the right position, either physically, socially or personally to meet their requirements, succeed and be able to cope with changes in their situations (WHO 2012).
The health belief model is a good model for dealing with problem behaviours that single homeless people have and that induce health concerns, for example, high consumption of alcohol or drug abuse. This health belief model is one of the first theories of health behaviour. It was created originally by Rosenstock (1966) who wanted to try and explain why hardly any people were taking part in programs to prevent and detect disease. According to Taylor and Kermode (2006) the health belief model suggests that the vulnerable person's health associated behaviour is determined by the person's awareness of four critical areas. These critical areas being, 1. the seriousness of a possible illness, 2. how vulnerable the person is to that illness, 3. the advantages of taking a precautionary action and 4. the barriers to taking that action. Rawlett (2011) suggests that the health belief model suggests a better way to understand and foresee how patients will act in connection to their health and how they will abide with their healthcare treatments. With issues concentrating on patient compliance and preventative healthcare treatments the health belief model is often applied in nursing.
Nurses must be able to recognise that wherever they work they will always be a health promoting nurse and they have a contribution to make to reduce the health inequalities that are experienced by vulnerable groups such as single homeless people. Nurses must have excellent communication skills and interpersonal skills such as honesty, empathy, openness and so on if they are to be a good health promoter. It is important that they involve this group of people with decisions and actions that may affect them. Therefore it is important to develop a good nurse-patient relationship with these single homeless people, many of which have very complex health needs. The nurse-patient relationship is essential to the delivery of care. By use of verbal and non-verbal communication skills, nurses can offer three core conditions in person-centred care. These being, empathy, genuineness and unconditional positive regard.
The first condition and skill is empathy and this is the beginning of a helping relationship. It is the ability to enter into and understand the world of the single homeless person and being able to communicate this understanding to them (Egan 2002). Rogers (1994) defined the second condition of genuineness as a personal quality or relationship characterised by open and honest communication where by professionals do not hide behind their roles. The third condition, that the nurse must be able to offer is unconditional positive regard, often referred to as acceptance. This involves the nurse taking a non-judgemental attitude towards her patient and being able to accept and respect them for who and what they are (Freshwater 2010). This is not just a show of acceptance but it is an attitude that is then demonstrated through behaviour.
The homeless person as a patient should be able to feel as if they can freely express their emotions without fear of being rejected by the nurse. Hough (2007), says the patients need to feel valued unconditionally even when what they bring to the nurse may not be positive - in fact it may be frightening or upsetting. This may be particularly true of patients who are homeless and their social circumstances are greatly reduced. They may feel embarrassed or ashamed and could also be anxious as to what the nurse will think of them. The nurse must therefore own the necessary skills to put aside any personal prejudices and provide a safe and accepting environment for this patient group. Hough (2007) is careful to point out that whilst this does not necessarily mean that the nurse must like or approve of everything these patients say or do, it is important for the nurse to be able to separate their own views from that of the homeless patient.
Hough (2007) suggests that the whole philosophy behind unconditional positive regard is to allow this patient group to feel accepted, therefore they are more likely to accept themselves and be confident in their own abilities. Nurses must put aside any pre-judgements and opinions, accept the homeless patient at face-value and to try to treat the issue that they are currently presented with. Nurses cannot let any judgements affect the relationship with the patient because it might affect the care and treatment they receive. The nurse-patient relationship does not exist without these core conditions or at least it will not have a positive outcome.
It is important to build up a good working relationship with any patient, including single homeless people. Trust, respect and good communication skills are all essential. Effective nursing requires us to be assertive, responsible and to help our patients achieve the best possible health status (Balzer Riley 2008). Effective communication is more than delivering high quality patient-centred care, it also allows patients, especially single homeless patients to feel involved in their care, which can make a significant difference to their outlook on their treatment (Collins 2009). The nurse must provide holistic care for all patients, not just single homeless people and the goal is to listen to the whole person and provide them with empathetic understanding. Another key point is that the nurse must be non judgemental no matter what the patient's circumstances are. They must be keen to develop a therapeutic relationship as they learn to accept people for who they are as each of us have had different experiences throughout life and these experiences make us who we are.
Wilkins (2010) is keen to point out that there is not much difference between the nurse's attempt to communicate unconditional positive regard and empathic understanding and the homeless person's awareness of them. What the nurse communicates is not always understood and perhaps with respect to simplifying the understanding of unconditional positive regard, it may be necessary to have patience, consistency and genuineness of acceptance (Wilkins 2010). Nurses must develop their communication skills so that they may become more skilled in their interpersonal contact with patients including vulnerable patients.
Nurses work with a diverse variety of people from a wide range of social circumstances, including single homeless people, with difference beliefs and values around health. This could be related to sexual health, alcohol consumption, smoking and so on. Freshwater (2010) suggests that many single homeless people continue with their dangerous health behaviours despite having information about the adverse and potentially damaging aspects of their actions. This makes it difficult for the nurse to engage in any health promotion activities whilst continuing to value and respect the patient and in fact it may be that the patients' and nurses' beliefs may cause conflict on the whole (Freshwater 2010). The nurse-patient relationship is a professionally close and private one and in order for it to be effective it needs to reflect trust, caring, hope and autonomy. It is in the therapeutic relationship, that true person-centred care is the product of genuine engagement and with this patient group, there fears are being uncovered according to Ruddick (2010). A therapeutic relationship cannot be maintained with the expression of unconditional positive regard. Before the homeless patient can understand themselves they must be able to accept themselves.
The result of poor health may be caused by the relationship between health and homelessness in relation to health inequalities. Most of the literature studied identified the same problems, one of which was that poor living conditions explained the ill-health suffered by single homeless people (William and Law 2011). Respiratory problems in this group of people was often caused by the cold and damp conditions that they endured, along with infections caused by poor washing facilities (Dobson 2011). Conditions such as circulatory problems, inflammatory conditions, sexually transmitted infections, poor nutrition and physical trauma are all being reported at nurse-led clinics according to Atherton et al. (2004). Nurses and healthcare professionals may feel that they are unready and not fully prepared to care for vulnerable homeless people. This defenceless and powerless group of people may already be quite ill and have problems accessing the care they need, for these reasons the care that the homeless persons receives may not be of the highest standard (Seiler and Moss 2012).
Further evidence suggests that there is an increase of mental health problems with single homeless people and an increase of intentional self harm (Martin 2008). This in turn highlights the issue of whether homelessness aggravates the symptoms of mental illness.
Evident causes for homelessness are high alcohol consumption and using drugs by injection (Whitbeck 2012). Uncertainty, lack of control, feelings of hopelessness and despair often weaken the homeless and they lose their ability to meet their self-care needs (Cross et al. 2012). Routines are impossible for those that are homeless such as taking medications on time, such as insulin, which needs to be stored properly. Syringes are often stolen where there is no safe place to keep them and the living environment is dangerous. Specialist nurses who have had additional training to deal with mental health issues can assist in addressing the multiple health needs of this specific group and make sure that they have the required access to primary care (Vandiver 2009).
William and Law (2011) identified that nurses are more likely to come across single homeless people in a variety of settings, including accident and emergency departments, outpatient clinics and also community settings such as nurse-led clinics or even in the streets. In order to identify the complicated needs of the single homeless person, it is important that the nurse has good knowledge and a variety of skills thus allowing them to provide holistic care by trying to evaluate their biological, psycho-social and sexual health (William and Law 2011). The issue of healthcare for homeless people was the core of a special project by Queen's Nursing Institute (QNI 2012), a registered charity dedicated to improving the nursing care of people in their own homes. They developed a project called "Opening Doors", which was involved with improving the care of people who are homeless. The project calls upon the expertise of nurses and healthcare professionals to improve the health of homeless people in particular single homeless people. This project was especially useful for accident and emergency care staff who work with homeless people as the accident and emergency department is normally the first port of call for these people.
Davis (2012) maintains that single homeless people can raise particular problems for accident and emergency staff, for example, the majority of this group are not registered with general practitioners. Therefore accident and emergency staff become their main primary care source. When homeless patients present at the accident and emergency department with conditions which may be due to the effects of drug or alcohol abuse, this can be very challenging for the staff. The patients may become abusive towards staff and the police may need to be involved. When questioned about their drug or alcohol use, many homeless patients become defensive and think that they are being judged. They do not understand the importance of complying with their course of treatment and often become non-compliant. This in turn then causes them to be unable or unwilling to access community healthcare services (Davis 2012).
Accident and emergency staff must work closely with all the relevant agencies to ensure that these homeless people receive the support they want on discharge. This can be extremely difficult as many single homeless people discharge themselves before any sort of support can be put in place. The Department of Health (2003) produced a good practice guide which identified that all admission and discharge policies should be in place at all acute hospitals. Therefore all single homeless people are known on admission and all relevant services such as primary care services, homelessness services and so on are informed of their expected discharge (DH 2003). Three years later, the Department of Health (2006) produced another guide which reiterated to hospitals, primary care trusts, voluntary organisations and local authorities that there should be procedures which state that no person should be discharged from hospital into inappropriate accommodation or onto the streets (DH 2006).
Community health partnerships, or CHP's for short, bring together the public, voluntary organisations, local authorities and health services. Together, they co-ordinate and plan the delivery of health and social care services locally. Community health partnerships provide a wide range of community based health services delivered in homes, health centres, clinics and so on. These include district nursing, mental health, podiatry, physiotherapy, addiction and learning disability services. Staff delivering these services will work closely with other local health professionals, including general practitioners, dentists, pharmacists and opticians to plan and develop services across the CHP area (Fife Rights Forum 2010).
In certain areas up and down the country, more and more health centres and GP practices are providing nursing teams who can offer out reach services to the homeless population. The teams can run open-access, nurse-led clinics in day centres or homeless hostels for single homeless adults. One particular homeless nursing team that was explored was Three Boroughs Primary Health Care Team (NHS 2012). This team was made up of senior community nurses who worked along side the practice general practitioners, a local dentist and chiropodist who all provided services to the single homeless. Clients are encouraged to register with a doctor at the practice and once registered then the client is expected to visit their doctor with any ongoing health problems. This homeless team also offer case management services which focuses mainly on clients who make inappropriate use of the accident and emergency department (NHS 2012). However, it must be stipulated that single homeless people may be hesitant to inquire about healthcare because of the fear of being frowned upon, disapproved or judged (Kemp et al. 2006).
End of life care is also an important issue for single homeless people due to their lack of settled home and also poor social contacts available to support them. Homeless charity St. Mungo's (2010) and researchers from Marie Curie Palliative Care Research Unit (2011) have joined together to produce guidelines for identifying homeless people who are in need of end of life care. The majority of people who received care and support from St. Mungo's in 2009-2010 died from liver failure. The review found that homeless people were often in denial about the amount of alcohol they drunk and was it was doing to their health. They were also unwilling to work with health care services and other support workers or take the blame for their drinking. Hostel residents were also hesitant about being admitted to hospital because there would be controls placed on their behaviours (Nursing Times 2011). It is hoped that these guidelines and reviews will put into practice a plan of being able to work with various palliative care organisations and others to raise awareness of the need for end of life care for this disregarded group of people. NHS Guidance (2011) has helped to promote knowledge and understanding of the end of life needs of homeless people but it has been recognised that further training and study is required. Nurses and specialist staff can work with support workers and hostel staff to ensure that single homeless people can access the appropriate end of life care should they wish to do so.
The final section of this assignment will look at the holistic approach to caring for the single homeless person. A holistic approach to caring is vital. For any nurse to be successful, it is important that they are able to work holistically. They must also be flexible, be culturally aware, and have non-discriminatory attitudes (Burton and Ormrod 2011). Rather than the diagnosed disease being taken into account, holistic care is an approach to patient care in which social factors along with physiological and psychological factors of the patient's condition are all considered. Health professionals should be treating the single homeless person as a whole and encouraging them to better manage their conditions. However, it is important that nurses, dealing and connecting with single homeless people, reflect on the manner in which their nursing role can have an influence on, which will help them to address all their needs (Davis 2011).
Nurses must remember to take into consideration the 'social world' of their patients and to recognise their social situations. Issues within the social and protective environment can impact on health and development (Bromley and Cunningham-Burley 2010). The nurses role is to recognise the relationship between social issues and health and to be aware of cultural differences.
This assignment has highlighted some of the current research on nursing strategies in relation to improving healthcare for single homeless adults. It has also examined key areas including the main theoretical and clinical principles relevant to critical care. There were significant gaps in the literature, particularly when researching training and education development of nursing practitioners in relation to the nurse's role in helping to improve the healthcare of single homeless people. This then identified key areas for future development.
The following are a few recommendations for future clinical practice and educational development of nurses who are caring for single homeless people. As holistic and person-centred care is vital to meet the medical and psychological needs of this vulnerable group, healthcare professionals should develop a better understanding of their social situations. Trust, respect and good communication skills are all essential. Effective nursing requires us to be assertive, responsible and to help our patients achieve their goal. Some staff fail to understand a patients' social situation. Nurses should have a positive attitude towards homeless people and their behaviours. Nurses need to develop their skills in ethical issues, cultural sensitivity and health promotion. This will enable them to recognise health-promoting opportunities, develop and organise health promotion so that is becomes essential to practice. As nurses must have knowledge and awareness about the health needs of single homeless people, they therefore have key leadership roles to play in organising the healthcare for this particular group of people. Appropriate training and information should be available to nurses which is relevant to health and the homeless, for example, mental health training, training on drugs and alcohol abuse and so on.
Further recommendations should include improved access to ordinary health services for people sleeping rough, in hostels or other temporary accommodation. Single homeless people should be supported to register with a general practitioner and individual general practitioners could choose to run a local enhanced service (LES) to meet the needs of this disadvantaged group. Voluntary agencies such as St. John's ambulance service could provide a nurse-led service via mobile clinics on the street - giving out advice, assessments, referrals, first aid and so on. By providing these additional services, this may help to keep single homeless people out of hospital longer. It is important that there should be national recognition that single homeless people require a more adapted, combined and successful health service which can reduce any differences in the quality of care.
Therefore, in conclusion, this assignment has looked at the impact of health on the single homeless person. There has been adequate research and studies done on healthcare for the homeless and the difficulties that they face when trying to access healthcare, however, there is inadequate research on the role of the nurse working with homeless people in the United Kingdom. It is important for nurses to participate to help reduce health inequalities that are experienced by single homeless people. Nurses must be good health promoters and contribute to developing their education and skills which in turn will give them positive attitudes when caring for single homeless people. This assignment has also looked at how being homeless has influenced considerably the physical and mental health, and well-being of people. It has analysed how difficult it is for single homeless people to access healthcare and what can be done to improve this, for example, ease of access to nurse-led clinics, mobile clinics, substance misuse services and so on. This in turn should then help to reduce the inappropriate use of accident and emergency departments.
Single homeless people must be acknowledged and accepted for who they are and not for what they may have done. The key is for the nurse to listen to the whole person and provide them with empathetic understanding. Another key point that has been looked in detail is acceptance and that the nurse must be non judgemental no matter what the person's circumstances are. Reflecting back over this assignment it is obvious that the nurses role is to recognise the relationship between social issues and health. To achieve the objective of ending homelessness it is vital to improve the health of people who are homeless - especially single homeless people.