Changing students’ perceptions of the homeless: A community service learning experience
Introduction
Homelessness continues to be a problem in the United States and abroad. The National Alliance to End Homelessness (2017) reported in January 2016 approximately 550,000 people sleeping either on the streets, in their cars, in an emergency shelter, or a transitional housing program in the US. In the United Kingdom the average life expectancy for a homeless person is 42 years with one third experiencing untreated health conditions (Goodier et al., 2015). Access to healthcare continues to be a problem in the US, UK and across the world.
At a local level the Point in Time Homeless Census (University of Arkansas, Community and Family Institute, 2017) reported that in an area with the total population of 425,000, the homeless population grew from an estimated 2462 in 2015 to 2951 in 2016. The lack of a consistent place-to-call home leads to many health concerns. Jackson (2011) identified skin and foot problems among the homeless population as a health risk related to living outdoors in wet conditions with little opportunity to maintain cleanliness. Mental health issues, substance abuse problems, and chronic illnesses are compounding factors for the health issues faced by homelessness (Koh and O'Connell, 2016). Health programs for the homeless should be tailored to the unique characteristics of this vulnerable population (Evans and Conroy, 2012).
Negative attitudes and disrespect found in healthcare or shelter settings has been identified by the homeless as a barrier to healthcare (Pennington et al., 2010). Boylston and O'Rourke (2013) found evidence that healthcare professionals' attitudes toward the poor contributes to the health disparities and lack of access to care by these vulnerable populations. Nursing education should create learning experiences with the homeless and other vulnerable populations to change the attitudes and disrespect found in healthcare settings that further promote healthcare disparities.
Clinical practicum experiences which allow for student interaction with patients are an important part of the nursing education curriculum (Zrinyi and Balogh, 2004). Nursing schools expose students to a variety of settings to learn to apply the skills and knowledge necessary to provide care to patients. While gaining these abilities in acute care hospital settings is an integral part of a nursing education, community settings are serving an equally important role in preparing the nurses of the future (Schoon et al., 2012). Interacting with vulnerable populations through community clinical practicum experiences enable students to gain insights and knowledge to guide future practice for maintaining the health of the communities they will serve.
Nursing education should consider these experiences for students to interact and work with vulnerable populations in order to gain an understanding and sensitivity to the unique challenges these populations face related to health and healthcare (Loewenson and Hunt, 2011). Examining the effectiveness of these experiences for impacting students’ attitudes and beliefs of the homeless population can provide support for implementing this experience in a nursing curriculum. The experience can meet program outcomes and the learning needs for students to transition from care of individuals to the care of communities and vulnerable populations within those communities (Randolph et al., 2016).
One specific group considered to be a vulnerable population is the homeless. Students often enter a clinical experience with a vulnerable population with preconceived ideas about that population (Hunt, 2007) and the homeless population is no exception. Many students may not have any experiences with the homeless population and may have preconceived beliefs and possibly fears that could interfere with quality nursing care. Students may view the homeless population as a group with stereotypical views instead of many unique individuals facing various, and many times multiple, challenges (Kooken et al., 2014). Providing community clinical practicum experiences is a valuable part of changing future nurses’ perceptions of the homeless population and improving access to healthcare for people who are experiencing homelessness.
Service learning provides students an opportunity to engage with the community and develop an awareness of the health disparities that exist within that community (Thomas and Smith, 2017). Service learning engages students through participation in an organized activity that meets recognized community needs and through reflection on the activity for deeper understanding of theoretical content, a broader appreciation for the impact nursing can make and a sense of responsibility to the community. Benefits to service learning include opportunities to develop assessment, communication, critical thinking, and collaboration skills while gaining an awareness of the diversity of the community (Gaberson et al., 2015, p. 159–162). By exposing students to the homeless using a service learning model, they are more likely to understand the health related challenges of this vulnerable population and provide quality care in their practice after graduation (Lashley, 2008).
The reflection component of service learning allows the students a time of self-discovery of preconceived beliefs and values as they prepare to enter the nursing profession. Gaining an awareness of ones beliefs and values is a part of becoming culturally competent which can translate to professional practice (Loewenson and Hunt, 2011). The benefit of a service learning experience with the homeless allows students an opportunity to establish a sensitivity and awareness of the needs of the homeless population (Lashley, 2007).
The relationship between service learning or clinical practicum experiences with the homeless population and the attitudes of nursing students toward this population is well represented in the literature. Several studies measured nursing students' perceptions and attitudes about the poor and homeless, and found that the students participating in a clinical experience with this population reported an increase in empathy and a change in attitude (Boylston and O'Rourke, 2013, Stanley, 2013, Schoon et al., 2012, Kooken et al., 2014, Bowker et al., 2013, Loewenson and Hunt, 2011, Hunt, 2007, Pennington et al., 2010, Lashley, 2007). Kooken et al. (2014) found students demonstrated a positive change in attitude toward mentally ill, homeless patients as a result of being involved in a clinical experience in a shelter for homeless men. A clinical experience in a homeless camp allowed the nursing students to develop empathy, become advocates for the homeless and seek change in their local community (Bowker et al., 2013). Hunt (2007) describes nursing students as developing a sense of empathy, understanding advocacy and therapeutic communication at a level they did not prior to their experience with the homeless population. Loewenson and Hunt (2011) found a significant positive change in senior nursing students' attitudes concerning the homeless population after participation in a 3 month clinical experience. Pennington et al. (2010) found that students changed their perspective concerning homeless patients following a clinical practicum experience with the vulnerable population.
The ability to change students’ attitudes and behaviors about vulnerable populations by creating effective service learning or clinical practicum experiences is well supported. While most of the published information on this topic discusses experiences in urban settings, the authors of this study decided to implement a clinical practicum experience in a southern university town with a population of approximately 75,000 people. The purpose of this project was to decrease the negative attitudes and disrespect exhibited by those in healthcare (nurses) that was found in the literature as barriers to healthcare. The goal of this project was to examine attitudes and perceptions of nursing students toward the homeless population before and after participation in a service learning clinical practicum experience. The findings provide confirmatory evidence to add to the existing body of knowledge on the subject, strategies for implementation, and insights for nurse educators when developing a community service learning clinical practicum experience.
Section snippets
Sample and design
This project was a case study that measured attitudes using a qualitative open-ended questionnaire distributed to one clinical practicum group in a pre-test/post-test design. The group was comprised of eight students (7 females; 1 male) from one program of nursing offering a baccalaureate degree from a major University in the south. These eight students were enrolled in a Community Nursing clinical practicum course offered in the final semester of the program of study. The project received
Results and discussion
The goal of this project was to examine attitudes and perceptions of nursing students toward the homeless population before and after participation in a service learning clinical practicum experience. The overall purpose was to decrease and minimize the potential for negative attitudes and disrespect exhibited toward the homeless by those in healthcare (nurses) through changes in attitudes and beliefs. The open-ended student responses on the questionnaires were analyzed using a constant
Summary
This project describes a mutually beneficial service learning clinical practicum experience for the nursing students and the homeless in one community-based non-profit organization in the US. Through the development of a partnership between a community organization and a nursing program, a service learning clinical practicum experience was created with the homeless population. This unique service learning clinical practicum experience allowed students the opportunity to interact and provide
Conclusions
Nurse educators across the world are challenged to engage students in clinical experiences with vulnerable populations to change the attitudes and perceptions that are barriers to healthcare. Elimination of barriers can lead to improvement in the overall health of communities served. Creating service learning experiences which support opportunities where students can become advocates for patients in all walks of life is the responsibility of nursing education (Fahrenwald et al., 2007, Stanley,
Conflict of interest
Janet Gardner and Jan Emory report no conflict of interest in the development of this project. Conflict of Interest: None include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.
Funding
This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval details
The project received approval from the University Research Review Board. Students provided voluntary consent to participate in the study.
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