Nurse-led primary health care for homeless men: a multimethods descriptive study

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

The perspectives of homeless people using the services of a mobile health clinic in relation to their health needs: a qualitative study on community-based outreach nursing

Background

Significant social and health issues are associated with homelessness. Negative experiences with the healthcare system are also frequent and cause people experiencing homelessness to avoid health services.

Aims

The purpose of this study was to (1) explore participants' health needs concerning outreach nursing services and (2) describe the perceptions and preferences of people who access this form of community-based intervention.

Methods

We conducted a critical ethnography with semi-structured interviews of 12 people experiencing homelessness who receive the services of a nurse-led mobile clinic, and 60 hours of observation during the provision of these services.

Results

Our results describe the perspectives of people experiencing homelessness in three main categories: (1) worrisome health and social needs, (2) non-use of healthcare and (3) what connects us to health services.

Conclusions

Timely access to healthcare is an important issue for people experiencing homelessness. Nurse-led clinics meet needs that go far beyond health issues.

A systematic scoping review of primary health care service outreach for homeless populations

BACKGROUND

Homeless populations (HPs) have difficulties obtaining necessary medical care, and primary health care service outreach (PHSO) might be useful to bridge this gap.

OBJECTIVE

Using the Centre for Evidence-Based Management Critically Appraised Topics framework, to provide systematic evidence of the usefulness of PHSO interventions for HPs.

METHODS

A systematic search was conducted in 4 electronic databases: PubMed, Web of Science, CINAHL, and Cochrane (publication dates between January 1980 and November 2020). In total, 2,872 articles were identified. Primary research about PHSO for HPs in high-income countries were included. Data were extracted from eligible studies, summarized, and collated into a narrative account.

RESULTS

Twenty-four studies that described and evaluated PHSO interventions for adults experiencing homelessness were selected in the final synthesis. Most studies had a nonrandomized design. PHSO was found to successfully address some barriers to health care access for HPs through flexible appointments in convenient locations, fostering an understanding relationship between doctor and patients, and provision of additional basic necessities and referrals. Outreach was provided for a range of health care concerns, and several solutions to engage more HPs in primary care, improve continuity of care and to decrease the running costs were identified. Outreach also helped to implement preventative measures and reduced emergency service admissions.

CONCLUSION

Our review adds to the evidence that PHSO likely improves health care access for HPs. Further studies over longer time periods, involving collaborations with experts with lived experience of homelessness, and utilizing randomized study designs are needed to test outreach efficacy.

Perceptions of mobile and acute healthcare services among people experiencing homelessness

OBJECTIVES

This paper presents findings from our collaborative research on the perceptions and preferences of people experiencing homelessness regarding outreach nursing services.

METHOD

We conducted qualitative research using a critical ethnography approach.

SAMPLE

A total of 15 participants were interviewed individually (n = 12 people experiencing homelessness) and in focus groups (n = 3 care providers). We also conducted direct observation.

RESULTS

This paper focuses on one of the core categories that emerged from the data analysis "Perception of Health Care." This category emerged from the following three subcategories, which we will present in this paper: (1) Conflicting Relationships with Institutional Health Services; (2) Perception of Outreach Services; (3) Recommendations from Mobile Clinic Users.

CONCLUSION

There are a range of perceptions of health services among people experiencing homelessness. Some are satisfied with the care received in the public health system, while many have experienced dehumanizing practices. Overall, outreach services are a promising strategy to reach people who are not served by the traditional modes of care delivery. Based on our findings, we suggest several key practices to personalize and adapt healthcare services and foster inclusive environments to better serve people experiencing homelessness.

Scoping review: Scope of practice of nurse-led services and access to care for people experiencing homelessness

AIMS

To investigate the scope of practice of nurse-led services for people experiencing homelessness, and the influence on access to healthcare.

DESIGN

A scoping review.

DATA SOURCES

On 20 November 2020, the following databases were searched: CINAHL, Embase, MEDLINE, PubMed and Scopus.

REVIEW METHODS

Included studies focused on people experiencing homelessness aged 18 years and over, nurse-led services in any setting and described the nursing scope of practice. Studies were peer-reviewed primary research, published in English from the year 2000. Three authors performed quality appraisals using the mixed methods assessment tool. Results were synthesized and discussed narratively and reported according to the PRISMA-ScR 2020 Statement.

RESULTS

Nineteen studies were included from the United States (n = 9), Australia (n = 4), United Kingdom (n = 4) and Canada (n = 2). The total participant sample size was n = 6303. Studies focused on registered nurses (n = 10), nurse practitioners (n = 5) or both (n = 4), in outpatient or community settings. The nursing scope of practice was broad and covered a range of skills, knowledge and attributes. Key skills identified include assessment and procedural skills, client support and health education. Key attributes were a trauma-informed approach and building trust through communication. Important knowledge included understanding the impact of homelessness, knowledge of available services and the capacity to undertake holistic assessments. Findings suggest that nurse-led care facilitated access to healthcare through building trust and supporting clients to access services.

CONCLUSION

Optimized nursing scope of practice can facilitate access to healthcare for people experiencing homelessness. Key factors in enabling this include autonomy in nursing practice, organizational support and education.

IMPACT

The broad range of skills, knowledge and attributes reported provide a foundation from which to design an educational framework to optimize the nursing scope of practice, thereby increasing access to healthcare for people experiencing homelessness.

The Health Needs of Regionally Based Individuals Who Experience Homelessness: Perspectives of Service Providers

The bidirectional relationship between homelessness and poor health and the barriers that individuals who experience homelessness face when trying to access healthcare are well documented. There is, however, little Australian research exploring the situation of individuals who experience homelessness in regional contexts and, moreover, from the perspective of service providers. A qualitative descriptive methodology underpinned this study, with in-depth semi-structured interviews being conducted with 11 service providers to identify barriers to care faced by people who experience homelessness and barriers that service providers themselves experience in supporting this population. The key barriers identified were client-level barriers: living day-by-day, financial, health literacy, mental health conditions, behaviour, safety and stigma; provider-level barriers: few bulk-billing doctors, fragmented services, limited resources, negative past experiences with healthcare; and system level barriers: transportation, over-stretched healthcare services. The combined impact of these barriers has significantly contributed to the desperate situation of people experiencing homelessness in Launceston. This situation is likely replicated in other regional populations in Australia. Given that individuals experiencing homelessness have higher rates of every measure in health inequality, steps need to be taken to reduce barriers, and a standardised approach to health care urgently needs to be implemented by governments at the state and national level to improve the health of regionally based individuals experiencing homelessness.

Rethinking Primary Care Delivery Models: Can Integrated Primary Care Teams Improve Care Experience?

Background:

Integrated Primary Care Teams (IPCTs) have four key characteristics (intensive interdisciplinary practice; advanced nursing practice with an expanded role; group practice; increased proximity and availability) aimed at strengthening primary care in Quebec, Canada. The purpose of this paper is to examine the care experience over time of patients who have an IPCT as their primary source of care.

Methods:

We used a quasi-experimental longitudinal design based on a pre-and-post administered survey at a 2-year interval without a control group. We measured patient-reported accessibility, continuity, comprehensiveness, responsiveness and outcomes of care.

Results:

Results showed that patients who were newly registered with an IPCT had a significant increase in reported care experience, whereas patients who have been registered with an IPCT for 2 years prior to the first round of data collection had already high reported care experience that was maintained over time. Moreover, linear regression models showed statistically significant different increases in the dimensions of care experience by site and patients’ characteristics.

Conclusions:

Our results suggest that the IPCT model is tailored to the needs of its target populations, resulting in improved Patient Reported Experience Measures. These results imply that broader implementation of innovative and flexible community-based care models should be considered by policymakers.

Health and access to healthcare in homeless people: Protocol for a mixed-methods study

BACKGROUND

Homelessness is a more complex problem than the simple lack of a place to live. Homeless people (HP) often suffer from poor health and premature death due to their limited access healthcare, and are also deprived of basic human and social rights. The study protocol described here aims to evaluate the complex relationship between homelessness and health, and identify the barriers and facilitators that impact access to healthcare by HP.

METHODS

This is a mixed-methods study that uses an explanatory sequential design. The first phase will consist of a cross-sectional study of 300 HP. Specific health questionnaires will be used to obtain information on health status, challenges during the COVID-19 pandemic, self-reported use of healthcare, diagnoses and pharmacologic treatments, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and human basic needs and social support (SSQ-6). The second phase will be a qualitative study of HP using the "life story" technique with purposive sampling. We will determine the effects of different personal, family, and structural factors on the life and health status of participants. The interviews will be structured and defined using Nussbaum's capability approach.

DISCUSSION

It is well-known that HP experience poor health and premature death, but more information is needed about the influence of the different specific social determinants of these outcomes and about the barriers and facilitators that affect the access of HP to healthcare. The results of this mixed methods study will help to develop global health strategies that improve the health and access to healthcare in HP.

Development and Initial Evaluation of a Nurse-Led Healthcare Clinic for Homeless and At-Risk Populations in Tasmania, Australia: A Collaborative Initiative

People who are homeless experience significantly poorer health than the general population and often face multifaceted challenges engaging with public healthcare services. Mission Health Nurse-led Clinic (MHNC) was established in 2019 to meet the healthcare needs of this marginalised population in Launceston, Tasmania. This study examines barriers to healthcare access amongst individuals who experience homelessness, client and staff perceptions of the MHNC services and explored opportunities for service expansion. Descriptive statistics were drawn from administrative data, and all interviews were thematically analysed. A total of 426 presentations were reported for 174 individuals experiencing homelessness over 26 months. The median client age was 42 years and 60.9% were male; A total of 38.5% were homeless or lived in a supported accommodation. The predominant reasons for clinic visits included prescription requests (25.3%) and immunisations (20.1%). A total of 10 clients and 5 City Mission staff were interviewed with three themes emerging from the findings: personal vulnerability, disconnectedness and acceptability of the MHNC. The MHNC services were reported to be highly appreciated by all clients. Mental health and allied health, extra operating hours and maintaining the flexibility of walk-in appointments were suggested as expansion areas for the service and were highlighted as ways to increase engagement for improved health outcomes. Continued partnerships with interprofessional primary healthcare providers would contribute to addressing unmet healthcare needs in this vulnerable population.

Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain

Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.

A Critical Ethnography of Outreach Nursing for People Experiencing Homelessness

People experiencing homelessness have a high prevalence of substance abuse and mental and physical problems. Although they have very complex health needs, they face many barriers that reduce their access to health care and social services. Several research studies have shown the need to implement adapted nursing interventions to address these crucial access issues. In this article, we present the results of a critical ethnography of outreach nurses who work with homeless people (n = 12). Robert Castel's theoretical model, which focuses on the process of social disaffiliation, provided the conceptual underpinnings for this research. Our qualitative data analysis revealed four categories, namely 1) the professional role and identity of nurses; 2) the social function of outreach nursing; 3) clinical realities and 4) disaffiliation and stigmatization. Our findings highlight the need to raise awareness among health care providers about the ethical, clinical and organizational issues of homelessness, particularly the mechanisms of exclusion and stigmatization in health care settings that affect people experiencing homelessness.

Developing an Embedded Nursing Service within a Homeless Shelter: Client's Perspectives

This phenomenological case study of a newly developed nursing service, embedded within a homeless shelter in the South East of England, uses semi-structured to elicit experiences and perceptions of clients within the service. Participants (n = 6) were interviewed using a semi-structured approach and identified three broad themes: impact of previous healthcare experiences, benefits of embedding healthcare within the shelter, and future service development. The study illuminates the diversity and complexity of healthcare needs of homeless people, as well as offers a unique insight into the service user’s perception of the service.

Quotidiano de equipes de consultório na rua: tecendo redes para a promoção da saúde

Resumo Objetivo compreender as potências e limites para a promoção da saúde de pessoas em situação de rua no quotidiano da equipe de Consultório na Rua. Método estudo de casos múltiplos holístico-qualitativo, fundamentado na Sociologia Compreensiva do Quotidiano, realizado com dois informantes-chave e 20 profissionais de equipe de Consultório na Rua de duas capitais do Sul do Brasil. Utilizou-se a Análise de Conteúdo Temática. Resultados as potências para a promoção da saúde de pessoas em situação de rua advêm da articulação da rede intrasetorial e intersetorial pela equipe de Consultório na Rua, além do vínculo e da redução de danos. Os limites enfrentados para desenvolver ações de promoção da saúde se deparam na especificidade e características desse público na terceirização da assistência social, na gestão, na política. Conclusões e implicações para a prática a promoção da saúde ainda é um desafio para a equipe a ser superado perante as demandas de agravos, o tratamento do adoecimento e a lógica biomédica. As estratégias intrasetoriais e intersetoriais podem ser estabelecidas para alcançar ações em rede e efetivamente promover saúde, contemplando direitos fundamentais à vida de pessoas em situação de rua, mesmo em um quotidiano com condições desfavoráveis de viver e conviver.

Critical ethnography of outreach nurses- perceptions of the clinical issues associated with social disaffiliation and stigma

AIMS

The aim of this study was to gain a better understanding of how nurses experience their practice with homeless people. More specifically, we wanted to consider the role as it is practised and certain clinical characteristics associated with social disaffiliation and stigma.

BACKGROUND

Previous research has shown the need to implement adapted nursing interventions to address the problems homeless people encounter in obtaining health services. According to the literature, such interventions have positive health outcomes for homeless people, who exhibit complex health needs.

DESIGN

We chose critical ethnography as our research method.

METHOD

Semi-structured interviews were conducted with 12 nurses who work with people experiencing homelessness in Eastern Canada. They were selected using the convenience sampling method. Recruitment was conducted between June-October 2019.

FINDINGS

Four categories emerged from the qualitative analysis of the data: (1) the professional role and identity of nurses; (2) the social function of outreach nursing; (3) clinical realities; and (4) disaffiliation and stigmatization. In this article, we will present the findings associated with the fourth category.

CONCLUSION

Nursing practice with this population is conducted in non-traditional settings such as shelters, community groups, camps, and the street. Nurses must be able to gain acceptance in these environments in order to forge trusting relationships with disaffiliated and stigmatized patients. Our analysis of the data also indicates that nurses who care for homeless people may be subject to stigma by association or "courtesy stigma."

IMPACT

The results of this critical ethnography are useful in that they highlight the clinical interventions and health policies best suited to a highly marginalized clientele that is poorly served by traditional health services.

Evidence for an integrated healthcare and psychosocial multidisciplinary model to address rough sleeping

People who sleep rough/experience unsheltered homelessness face barriers accessing mainstream healthcare and psychosocial services. The barriers to service access exacerbate poor health, which in turn create additional challenges for rough sleepers to access health and psychosocial services, including stable housing. The study presents descriptive statistics to identify housing outcomes of people working with a Multidisciplinary Model that comprises integrated healthcare and psychosocial support, and qualitative data with clients and service providers to investigate how the Model is experienced and delivered in practice. Fieldwork was conducted between December 2016 and March 2018 with the Multidisciplinary Team operating in Cairns, in the far north of Australia. Qualitative data are drawn from in-depth interviews with 26 rough sleepers and 33 health and psychosocial service providers from the Multidisciplinary Team and the wider service system. Descriptive statistics show that 67% of clients who were sleeping rough were supported to immediately access stable housing, and at the end of the program, all clients remained housed. The qualitative findings illustrated how integrated healthcare and psychosocial outreach enabled people sleeping rough to overcome barriers they experienced accessing mainstream healthcare and other services. With the benefit of healthcare, people felt sufficiently well to engage with the psychosocial service providers to have their housing and other psychosocial needs addressed. This article demonstrates how individual responsibility for and control over healthcare is not only a matter of the individual, but also a matter requiring systems change and the active provision of resources to cater for the constraints and opportunities present in people's immediate environments.

Care avoidance among homeless people and access to care: an interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people

BACKGROUND

Because of their poor health and social vulnerability, homeless people require specific care. However, due to care avoidance, homeless people are often not involved in care. This study aims to get insights into reasons for and kinds of care avoidance among homeless people and to provide suggestions to reach this target group.

METHODS

Semi-structured individual interviews were conducted among street pastors (n = 9), spiritual caregivers (n = 9), homeless outreach workers (n = 7) and formerly homeless people (n = 3). Participants were recruited by purposive sampling in the four major cities in the Netherlands (Amsterdam, Utrecht, Rotterdam, The Hague). The verbatim transcripts were analysed using thematic analysis.

RESULTS

The term care avoidance was perceived as stigmatizing. Care avoidance is found to be related to characteristics of the homeless person (e.g. having complex problems, other priorities) as well as of the system (e.g. complex system, conditions and requirements of organizations). The person-related characteristics suggestions to involve homeless persons include tailoring care and building relationships, which might even be prioritised over starting care interventions. Setting limits on behaviour without rejecting the person, and an attitude reflecting humanity, dignity and equality were also important factors in making care more accessible and lasting. As regards system-related characteristics, the suggestions include clear information and communication to homeless people who avoid care as being crucial in order to make care more accessible. Other suggestions include quiet and less busy shelters, a non-threatening attitude and treatment by professionals, self-reflection by professionals and finally a change of policy and legislation regarding available time.

CONCLUSIONS

Reasons for care avoidance can be found in the interplay between both the individual and the system; measures to reduce care avoidance should be taken at both levels. These measures are centred on lowering the barriers to care inter alia by incorporating building trust and understanding into the care provided.