Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 Project HOPE: Hearing Other People’s Experiences Sitka Arianna Beech, Laurel Carlsen, Rae Cunningham, Stephanie Francisco, Joy Huffman, Maria Lee, Susan Nguyen, and Ashley Sapp University of Alaska, Anchorage Alaska’s homeless are concentrated in Anchorage with roughly 1,200 people living in emergency shelters, transitional housing, or makeshift camps outdoors (Anchorage Coalition to End Homelessness 2015). While definitions vary by agency, homelessness as referenced in this paper describes the experience of a person “who has no fixed nighttime residence or who has a nighttime residence that is designed to provide temporary shelter or is a public or private place not intended to provide sleeping accommodations for human beings” (Maurer and Smith 2013, 534). With the election of Mayor Ethan Berkowitz in 2015, there is a renewed policy and effort in Anchorage to house the city’s homeless, turning the public spotlight on a population that often goes unseen (Andrews 2015). Social workers, shelter staff, law enforcement, and healthcare providers (HCPs) are among Anchorage’s professionals that frequently work directly with the local homeless population. HCPs are uniquely positioned to interact with the homeless when they are the most vulnerable. However, providers are likely to feel underprepared from their training and education to handle the complex health and social needs of the homeless (McNeil, Guirguis-Younger, Dilley, Turnbull, and Hwang 2013). We conducted a review of the literature to assess the reported needs of homeless individuals, including their experiences with HCPs. We also reviewed qualitative research examining the attitudes of providers, nurses, and nursing students toward the homeless client. Articles that explored educational interventions on students’ attitudes toward the homeless were examined to develop our intervention and recommendations. Few studies examine the priority needs and quality of life issues among the homeless population from their perspective. A study conducted with 140 homeless individuals in four Canadian cities concluded that the priorities of the homeless extend beyond housing to include: healthcare access, living conditions, finances, employment, relationships, and recreation (Palepu, Hubley, Russell, Gadermann, and Chinni 2012). These themes were further distilled to four general concepts: autonomy, stability, respect, and equality of rights (Palepu et al. 2012). When it comes to health-related needs, homeless individuals often have different priorities than those determined by the HCP. A common finding in a phenomenological study conducted in the United Kingdom was that homeless individuals felt that their needs were not prioritized and went under-addressed or dismissed altogether (Rae and Rees 2015). Some individuals felt that they received substandard care and unrealistic advice from HCPs who disregarded their living situation (Rae and Rees 2015). Several studies found that patient perceptions of discrimination from nursing staff and other providers are a significant predictor of whether patients will seek healthcare services in the future. One study found that a single bad experience with a HCP can result in a homeless individual not seeking clinic services, even if he or she has serious health problems (Oudshoorn, Ward-Griffin, Forchuk, Berman, and Poland 2013). Experiences in which homeless individuals felt unwelcome in healthcare encounters were consistent with feelings of being dehumanized, not listened to, or disempowered (Wen, Hudak, and Hwang 2007). Homeless women interviewed in another study reported that negative experiences were associated with HCPs’ use of primarily dehumanizing, authoritative, and disrespectful communication styles (Biederman and Nichols 2014). The results of a random-controlled trial found that those who reported discrimination in Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 2 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 healthcare settings were 32 times more likely to correlate discrimination due to mental illness (Skosireva, O’Campo, Zerger, Chambers, Gapka, and Steriopoulos 2014). In a mixed methods study of ethnic and racially diverse persons experiencing mental illness and homelessness, 61.5% perceived discrimination being due to homelessness or poverty, 50.6% due to race, ethnicity or skin color, and 43.7% due to mental health problems or alcohol/drug use (Zerger, Bacon, Corneau, Skosireva, McKenzie, Gapka, and Stergiopoulos 2014). The homeless patient’s perception of discrimination is consistent with HCPs’ attitudes toward the homeless. A systematic literature review identified the existence of negative attitudes among nurses towards homeless people, which included regarding the homeless as dehumanized objects (Parkinson 2009). Other studies suggest that similar attitudes exist among nurses toward patients with a history of illicit drug use (Chu and Galang 2013). Additional research is needed to examine HCPs’ attitudes toward the homeless who also experience substance abuse and or mental illness. Proposals as to why negative attitudes exist largely center on the fact that HCPs are lacking in clinical exposure and specific training to address the social determinants of health affecting the homeless population (McNeil et al. 2013). Therefore, interventions to change the stigma of homelessness among HCPs are largely directed at nursing and medical students in their undergraduate education (Dugani 2011). In a cross-sectional study of medical students and emergency room physicians, researchers found that students had a higher level of empathy and interest in caring for the poor when compared to ER physicians who were in mentoring roles (Fine, Zhang, and Hwang 2013). The researchers suggest that clinical experiences that incorporate health screening and promotion before ER experiences may better prepare students as well as foster their empathy for the homeless population (Fine, Zhang, and Hwang 2013). In a randomized control study, the group who received an educational program about homelessness were less likely to believe that homelessness is due to personal characteristics, were more likely to believe that homelessness is a solvable problem, and had a less negative attitude toward the homeless when compared to the control group (Wisehart, Whatley, and Briihl 2013). Four additional studies each showed a positive change in attitude among nursing students towards homeless individuals following an experience in which they worked directly with the homeless population (Parkinson 2009). The research consistently supports the development of clinical placements that expose students to the complex needs experienced by homeless people in a non-emergency setting. Such placements hold the promise of contributing to students’ personal growth, increasing their sense of social responsibility, and ultimately breaking barriers to healthcare access for the homeless population. Additional evidenced-based research is needed to determine which educational model works best. Assessment The first step in this phenomenological research was to organize semi-structured interviews with the homeless population. We designed a survey that included ten questions (Appendix A). Of the ten, four questions were for demographic purposes to determine the age group, gender, ethnicity, and veteran status of participants interviewed. The additional six questions were open-ended prompts focused on past experiences in healthcare settings and current challenges facing the homeless population in Alaska. Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 3 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 Although the assessment was not organized to focus on any particular demographic, only those that were age 18 and older were permitted to be included. Of the 74 participants interviewed, 21 (28%) were women and 53 (72%) were men. Three participants (5%) were between 18 and 25 years old, ten (14%) were between 26 and 35 years old, 16 (21%) were 36 to 45, 36 (48%) were 46 to 59, and nine (12%) were over 60 years of age. Ten (13%) of the participants were veterans compared to 63 (86%) non-veterans. One person (1%) was unsure whether he would be considered a veteran. The vast majority of persons surveyed identified themselves as Alaska Native individuals; this group made up 61% (45 total) of the individuals interviewed. Thirteen (17%) identified as White, seven (9%) identified as Black, three (4%) described themselves to be of Hispanic ethnicity, two (3%) individuals identified as Asian, two (3%) as Native American, and two (3%) did not identify with any of the above ethnicities. Interviews were conducted over a five-day period at three Anchorage locations, including Central Lutheran Church, Brother Francis Shelter, and Project Homeless Connect. During each interview, participants had the option of receiving foot care from one student while another student recorded responses to the survey questions. Foot care consisted of cleansing and assessing both feet followed by appropriate treatments, which included filing and trimming toenails, exfoliation, moisturizing, and occasional application of mentholated ointment for treatment of fungal infections. This was all done under the supervision of our professor, Dr. Michele Burdette-Taylor, PhD, MSN, RN-BC, CWCN, CFCN. Using the two-person team approach in assessment allowed for a safer setting, and may have resulted in better understanding of the client’s responses. This method of data collection demonstrated caring and interest in each individual, which promoted communication. An additional benefit was that in some instances the foot care took longer than the interview, which allowed for conversations to develop at a comfortable, relaxed pace. The casual, unhurried design may have especially aided communication with the Alaska Native segment of the population, who can be less comfortable talking at length in clinical and formal settings. Diagnosis Nursing students at University of Alaska Anchorage (UAA) have minimal community- based clinicals that provide a focused exposure to the homeless population. Little is known about nursing students’ attitudes towards the homeless as well as homeless individuals’ experiences with healthcare providers. Based on our assessment findings and review of the literature, a diagnosis of readiness for enhanced knowledge related to insufficient clinical experience with the homeless population was applied. Planning Our diagnosis of readiness for enhanced knowledge prompted us to plan a teaching intervention. We discussed ways to translate the experiences with the homeless population and present them to future nurses. It was our hope that by sharing quotes, pictures, and stories from these individuals that a sense of empathy and awareness of the unique needs of the homeless population would increase among our audiences. The structure for our interventions was guided by the responses we obtained from the qualitative portion of the surveys. These responses were sorted into themes, which were supported by quotes and anecdotes from the interviews. This sorting process resulted in the Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 4 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 identification of five themes: barriers, perceptions, relationships, trauma, and desire for independence. Barriers is a theme that represents perceived hindrances in issues like obtaining health care, employment, and sobriety. These barriers perpetuate a feeling of hopelessness and frustration expressed by the homeless population surveyed. The theme of perception relates to the stereotypes and negative labels that the homeless population feels are placed on them, which can marginalize their identity and sense of personhood. Relationships is a theme that reflects the burden of lost relationships, the need for privacy as well as social connections, and different types of interpersonal conflict experienced. Trauma encompasses the experiences of abuse, violence, and physical and emotional injuries, which often marked the beginning of an individual’s homelessness. This theme not only represents horrific experiences, but remarkable examples of resilience. Lastly, desire for independence was a theme expressed in the desire to start over, to be self-sufficient, and to recover. Despite difficult life circumstances and apparent obstacles, some participants verbalized future goals and plans. Our goal was to represent the homeless population as individuals, putting a spotlight on their own experiences and stories. We felt that by teaching nursing faculty and students particularly, our findings have the potential to influence these current and future providers and ultimately the healthcare system in positive ways. Intervention Our project consisted of two primary interventions to raise awareness of the homeless population in Anchorage and share the qualitative findings from the interviews conducted. The first intervention targeted nursing students specifically, consisting of a 25-minute presentation to approximately 40 undergraduate students enrolled in their third semester of community/public health nursing. We created a PowerPoint presentation that gave the students an introduction and background of our population based on the literature, which led to a discussion on the effect of health care providers’ attitudes with the homeless population. Using the nursing process, a summary of our assessment, diagnosis, plan, and implementation regarding Project HOPE was explained to the students. After presenting our future recommendations, a robust question and answer period followed, allowing us opportunity to clarify and describe experiences. Several informational documents were given to the students including a brochure summarizing the data collected, a pamphlet containing quotes and stories gleaned from our qualitative surveys, and a list of volunteer opportunities the students could pursue on their own to become involved and serve the homeless population in Anchorage. At the end of the presentation, the students were requested to complete a comment card (Appendix B). The second intervention was an all-day event called “Project HOPE: Hearing Other People’s Experiences” held in the lobby of the Health Sciences Building at UAA. Our project name holds significant meaning and came about as we interviewed one participant who explained that HOPE: Hearing Other People’s Experiences is a popular concept in the 12-step recovery program Alcoholics Anonymous. It is the idea that sharing one’s personal experience of hardship and recovery will instill hope in others to recover. At the Project HOPE event, we displayed the real-life stories, photographs, and quotations from the homeless individuals we had surveyed. A table of community resources was offered to all who visited our event along with the same brochure and pamphlet presented to the nursing class previously. As individuals walked through this central gathering area of the Health Science Building, they could view the pictures and stories displayed at their leisure. This gave our group opportunities to discuss our project and Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 5 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 answer the many comments and questions that were generated. We invited all to complete the comment cards available and a majority of participants did so. Evaluation The method of evaluation consisted of comment cards that were collected during the two interventions. The comment cards consisted of five Likert scale statements, two close-ended questions regarding participation in community services for those experiencing homelessness, and one open-ended question inviting general feedback (Appendix B). The first three Likert scale statements, which were adapted from the Health Professional’s Attitude Towards the Homeless Inventory (HPATHI) survey, composed a basic assessment of the respondent’s attitude toward the homeless individual. HPATHI is an “instrument that measures providers’ attitudes toward the homeless and could offer meaningful information for the design and implementation of educational activities that foster more compassionate homeless health care” (Buck, Montero, Kneuper, Rochon, Clark, Melillo, and Volk 2005). Ideally the assessment of nursing students’ attitudes toward the homeless would have included a pretest to determine the level of awareness and empathy before the interventions. This was not feasible due to time constraints and also the ethics of conducting an assessment on a convenience sample of nursing students. A significant limitation of the project was that awareness and empathy for the homeless population could not be accurately measured and therefore evaluated as a result of the interventions. There was a total of 173 comment card evaluations obtained from both interventions. Almost two-thirds (65%) of the respondents were students in nursing and health-related fields. The majority of comments (79%) indicated that they strongly agreed that homeless people have a right to basic health care. In response to the statement: Homeless and non-homeless people cannot really understand each other, the majority of comments were either undecided (37%) or disagreed (28%). The majority (66%) did not agree with the statement: Homeless people choose to be homeless. Based on the benchmarks established by the HPATHI survey, this basic assessment suggests positive attitudes among the respondents toward the homeless (Buck et al. 2005). Administration of the full-length HPATHI to nursing students before and after clinical experiences with the homeless would yield more meaningful results. The immediate impact of the interventions may have stimulated interest in serving the local homeless population. Of the nursing students surveyed, 36% indicated that they have not participated in community service with the homeless, but the majority (73%) expressed interest in a clinical rotation in which they serve the homeless. This interest was also indicated by one of the comment cards that stated, “It would be great if you guys would push to have clinical experiences added into the school of nursing curriculum.” Another response from a nursing student commented that they “[w]ould love to see some of the affiliated organizations take students for Community Health offered in the junior year of the nursing curriculum.” Other comment cards noted that they [nursing students] were glad we had worked with homeless individuals, as they felt this was a population that needed aid and advocacy. Recommendations A discussion of HCPs’ attitudes towards the homeless population would be incomplete without presenting our recommendations directed to the nursing faculty and undergraduate nursing students. Expanding service learning and clinical opportunities in the community should Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 6 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 be paramount for nursing educators, as classroom knowledge is insufficient (Jarrell, Ozymy, Gallagher, Hagler, Corral, and Hagler 2014). This would help meet educational objectives such as increasing students’ cultural competency, skill in assessing vulnerable populations, and an increased awareness of services and policies (Jarrell et al. 2014). This is particularly valuable to future nurses in light of Anchorage’s diverse makeup. Students who have ample opportunities to provide health screening and promotion activities for vulnerable populations are less likely to feel overwhelmed during future clinical encounters, especially in the emergency room (Fine, Zhang, Hwang 2013). There are untapped community clinical opportunities in Anchorage, including but not limited to the Brother Francis Shelter, the Domiciliary (a residential treatment facility for homeless veterans), Clare House, and Anchorage Neighborhood Health Clinics. As a side note, while our project concentrated on homeless adults in general, other subpopulations such as women, teens, and children may well benefit from future assessments and interventions. Most undergraduate clinical experiences are faculty directed, but examples from the literature can guide future nursing students seeking community clinical experience. In 2007, students at the University of Toronto independently formed partnerships with community health providers and opened a clinic for Toronto’s underserved (Dugani 2011). Increased empathy and social accountability through direct experiences with underserved populations can empower students and spark innovative ideas that link education with community needs (Dugani 2011). These direct experiences also enable students in identifying and managing unconscious bias, a barrier to the therapeutic relationship (Teal, Gill, Green, and Crandall 2012). In addition, there is a need for nursing school administrators to monitor and promote positive role modeling by preceptors. When caring for the homeless and underserved client, clinical supervisors’ attitudes can influence students’ beliefs and behaviors positively or negatively as discussed previously (Fine, Zhang, and Hwang 2013). Conclusion Project HOPE laid the groundwork on which other students in health-related fields might build. This group of senior-level baccalaureate nursing students collected valuable data that has the potential to inform future interventions with the homeless population and health care providers who serve them. The sustainability of the project will require the continuation of the partnerships established with community leaders and service organizations, as well as future opportunities to share our findings through print and oral presentations. Our professor, Dr. Michele Burdette-Taylor, is passionate about community health nursing and working with the homeless population. Her guidance will be an asset to future nursing students at UAA. ~ I'd like to thank Professor Shelly Taylor for guiding us through this bold project and my co- authors for their hard work and patience. To the un-housed men and women in Anchorage, thank you for sharing your stories. I carry your insights with me in my nursing practice. – Laurel Carlsen Project HOPE succeeded under the watchful mentoring of our professor: Dr. Michele Burdette- Taylor PhD, MSN, RN-BC, CWCN, CFCN. Special thanks also to Central Lutheran Church, Brother Francis Shelter, and Project Homeless Connect for providing the venues for our Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 7 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 interviews and community service. Finally, thanks to all the individuals who were willing to talk and tell their stories to us – you are the heart of it all. – Joy Huffman This project was made possible by the guidance and heart of our Professor Dr. Michele Burdette- Taylor PhD, MSN, RN-BC, CWCN, CFCN, and through the help of Brother Francis Shelter, Central Lutheran Church, and Project Homeless Connect. A special thanks to my group who put in countless hours and taught me through their strengths. And finally thank you to all the participants in Project Hope. You have forever touched my heart and I am truly grateful for this experience. – Ashley Sapp References Anchorage Coalition to End Homelessness. 2015. “Point in Time Count – Anchorage.” http://www.anchoragehomeless.org. Andrews, L. 2015. “Anchorage Mayor Aims to House 300 Homeless People in 3 Years.” Alaska Dispatch News. http://www.adn.com/article/20151117/anchorage-mayor-aims-house- 300-homeless-people-3-years. Biederman, D. J., and T. Nichols. 2014. “Homeless Women’s Experiences of Service Provider Encounters.” Journal of Community Health Nursing 31: 34-48. Buck, D., F. Monterio, S. Kneuper, D. Rochon, D. Clark, A. Melillo, and R. Volk. 2005. “Design and Validation of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI).” BMC Medical Education 5 (2). Chu, C., and A. Galang. 2013. “Hospital Nurses’ Attitudes Toward Patients with a History of Illicit Drug Use.” Canadian Nurse 109 (6): 29-34. Dugani, S. 2011. “Development of IMAGINE: A Three-Pillar Student Initiative to Promote Social Accountability and Interprofessional Education.” Journal of Interprofessional Care 25 (6): 454-456. Fine, A. G., T. Zhang, and S. W. Hwang. 2013. “Attitudes Towards Homeless People Among Emergency Department Teachers and Learners: A Cross-Sectional Study of Medical Students and Emergency Physicians.” BMC Medical Education 13 (112). Jarrell, K., J. Ozymy, J. Gallagher, D. Hagler, C. Corral, and A. Hagler. 2014. “Constructing the Foundations for Compassionate Care: How Service-Learning Affects Nursing Students' Attitudes Towards the Poor.” Nurse Education in Practice 14 (3): 299-303. Maurer, F. A., and C. M. Smith. 2013. Community/Public Health Nursing Practice: Health for Families and Populations. 5th ed. St. Louis, MO: Elsevier. http://www.anchoragehomeless.org/ http://www.adn.com/article/20151117/anchorage-mayor-aims-house-300-homeless-people-3-years http://www.adn.com/article/20151117/anchorage-mayor-aims-house-300-homeless-people-3-years Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 8 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 McNeil, R., M. Guirguis-Younger, L.B. Dilley, J. Turnbull, and S. W. Hwang. 2013. “Learning to Account for the Social Determinants of Health Affecting Homeless Persons.” Medical Education 47 (5). Oudshoorn, A., C. Ward-Griffin, C. Forchuk, H. Berman, and B. Poland. 2013. “Client-Provider Relationships in a Community Health Clinic for People Who are Experiencing Homelessness.” Nursing Inquiry 20 (4). Palepu, A., A. M. Hubley, L. B. Russell, A. M. Gadermann, and M. Chinni. 2012. “Quality of Life Themes in Canadian Adults and Street Youth who are Homeless or Hard-to-House: A Multi-Site Focus Group Study.” Health and Quality of Life Outcomes 10 (93). Parkinson, R. 2009. “Nurses’ Attitudes Towards People who are Homeless: A Literature Review.” Diversity in Health and Care (6): 1-14. Rae, B. E., and S. Rees. 2015. “The Perceptions of Homeless People Regarding their Healthcare Needs and Experiences of Receiving Healthcare.” Journal of Advanced Nursing 71(9): 2096-2107. Skosireva, A., P. O’Campo, S. Zerger, C. Chambers, S. Gapka, and V. Stergiopoulos. 2014. “Different Faces of Discrimination: Perceived Discrimination Among Homeless Adults with Mental Illness in Healthcare Settings.” BMC Health Services Research 14 (376). Teal, C. R., A. C. Gill, A. R. Green, and S. Crandall. 2012. “Helping Medical Learners Recognize and Manage Unconscious Bias Toward Certain Patient Groups.” Medical Education 46 (1): 80-8. Wen, C. K., P. L. Hudak, and S. W. Hwang. 2007. “Homeless People’s Perceptions of Welcomeness and Unwelcomeness in Healthcare Encounters.” Journal of General Internal Medicine 22 (7): 1011-1017. Wisehart, C. G., M. A. Whatley, and D. S. Briihl. 2013. “The Effectiveness of the Faces of Homelessness Educational Program on Student Attitudes Toward the Homeless.” North American Journal of Psychology 15 (3): 483-494. Zerger, S., S. Bacon, S. Corneau, A. Skosireva, K. McKenzie, K, S. Gapka, and V. Stergiopoulos. 2014. “Differential Experiences of Discrimination Among Ethnoracially Diverse Persons Experiencing Mental Illness and Homelessness.” BMC Psychiatry 14 (353). Beech, Carlsen, Cunningham, Francisco, Huffman, Lee, Nguyen, and Sapp 9 Undergraduate Journal of Service Learning and Community-Based Research, Volume 6, Fall 2017 Appendix A: Survey Survey by UAA Nursing students January 2016: Project HOPE: Hearing Other People’s Experiences Objective: The purpose of this survey is to bring awareness to nurses who might better serve those experiencing homelessness. Signature line for consent: ______________________________________________ Survey taken by: __________ 1. Age range: 1-17 18-25 26-35 36-45 46-59 over 60 2. Gender: M or F 3. Ethnicity: NA White Native Alaskan Black Hispanic Asian Pacific Islander Other 4. Are you a Veteran? Y or N 5. Tell me about your living situation. Do you see yourself as homeless? If so, how long have you been homeless? 6. Do you have access to health care services? Y or N If yes, where? 7. Tell me about a story or experience you had with a nurse or doctor. 8. What services would you like to see offered for yourself or people experiencing homelessness? 9. What are your main needs / challenges? 10. What would you like nurses & doctors, or people in general, to know or understand about being homeless? Appendix B: Comment Card Project HOPE Program of study: __________________________ Strongly disagree – 1 – 2 – 3 – 4 – 5 – Strongly agree 1. Homeless people have a right to basic healthcare. 1 2 3 4 5 2. Homeless and non-homeless people cannot really understand each other. 1 2 3 4 5 3. Homeless people choose to be homeless. 1 2 3 4 5 4. I am comfortable providing care to a homeless person. 1 2 3 4 5 5. I am interested in a clinical rotation working with the homeless. 1 2 3 4 5 6. I have participated in community service events with those who experience homelessness. Circle: Yes/No If yes, how? Circle any: Soup kitchen/ Shelter visits/ Church affiliation/ Project Homeless Connect/ Other We would appreciate any feedback about project HOPE: