Homeless Peoples' Description of Civil and Uncivil Healthcare Interactions

Purpose: The purpose of this on-going study is to explore homeless people’s perceptions of their interactions with nurses and gain an understanding of the impact of civility and incivility on their health outcomes.

Civility is a crucial element in therapeutic communication and healthy patient relationships; conversely, incivility can negatively influence healthcare environments and patient care (American Association of Colleges of Nursing, 2008; The Joint Commission, 2008). The Joint Commission (2008) has recommended implementation of strategies to manage incivility in health care. Civility, which involves mutual respect, fairness, caring, and relationship building, is foundational to nursing practice (AACN, 2008; Jenkins, Kerber, & Woith, 2013); therefore, it is prudent for nurse leaders to devise strategies for identifying, intervening and preventing episodes of incivility among nurses. Vulnerable populations, especially homeless people, may be particularly at risk for experiencing uncivil behavior from nurses (Irestig, Burstrom, Wessel, & Lynoe, 2010).

Homelessness is a significant problem around the world (Daiski, 2007; Irestig et al., 2010). In the United States it is estimated that 650,000 people experience homelessness on any given day (U. S. Department of Housing and Urban Development, 2010) and as many as three million Americans have been classified as homeless (Haley & Woodward, 2007). For the purposes of this study, we used Nickasch and Marnocha’s (2009) definition of homelessness: homeless people are those who do not currently have a consistent, adequate residence in which to spend the night. This includes those who reside temporarily in homeless shelters and those who spend the night in places that do not provide adequate shelter, or are not intended for human habitation, such as parks or abandoned buildings.

Homeless people experience a much lower quality of health than people in the general population (Daiski, 2007; Lebrun-Harris et al., 2013; Nickasch & Marnocha, 2009; Seiler & Moss, 2012). They have a greater likelihood of suffering from untreated health problems complicated by anxiety, mental illness, and substance abuse (Irestig, 2010; Lebrun-Harris et al., 2013; Seiler & Moss, 2012); their health is apt to be further compromised by inadequate nutrition, lack of privacy, threat of violence, and the physical toll of living outdoors (Daiski, 2007; Lebrun-Harris et al., 2013; Seiler & Moss, 2012).

The homeless do not receive adequate healthcare (Lebrun-Harris et al., 2013; Nickasch & Marnocha, 2009); they often spend a majority of their time and energy on obtaining the basic necessities of life, such as food and shelter (Nickasch & Marnocha, 2009). They seek healthcare only after these basic survival needs have been met (Cocozza Martins, 2008; Nickasch & Marnocha, 2009; Seiler & Moss, 2012). When they do seek healthcare, they experience difficulty accessing appropriate care, and are more likely to visit emergency departments than are people with homes (Lebrun-Harris et al., 2013; Seiler & Moss, 2012). Researchers have suggested that negative or indifferent attitudes toward the homeless population may affect the ability to improve their plight (Bolyston & O’Rourke, 2013; Hocking & Lawrence, 2000). Furthermore, these negative attitudes could impact the ability of nurses to provide compassionate care to this vulnerable population (Chung-Park, Hatton, Robinson, & Kleffel, 2006), leading to poor health outcomes.

Leininger’s (1991) Culture Care Diversity and Universality theory and Sunrise Model guide this study. Leininger’s (1991) theory encourages us to view the person holistically within the context of their culture. This model was chosen because our perceptions of others are framed by our own cultural backgrounds, and in order for us to provide best care, we need to understand the needs of others through their perspectives and experiences.

Methods: In this qualitative study in progress, we are recruiting a purposive sample of 15 homeless adults, drawn from homeless people who visit a drop-in ministry for the poor and homeless. Interviews will continue until data saturation is reached. A sample size of fifteen will give us maximum variation; the community from which the sample is drawn has little variability in healthcare delivery systems. Given this narrow variability, we anticipate more homogeneity in the healthcare experiences of homeless people. Moreover, our goal is not to generalize findings, but to obtain a rich description of participants’ experiences. We are currently conducting face-to-face, open-ended, audiotaped interviews to elicit descriptions of their experiences while seeking and receiving healthcare. Inclusion criteria are aged18 or older, homeless as defined by Nickasch and Marnocha (2009), English speakers, and cognitively intact. Interviews take place in the drop-in ministry. At the completion of interview sessions, tapes are transcribed verbatim, and transcriptions and field notes are analyzed for emerging themes. Qualitative data are analyzed through concept analysis identification of themes.

Results: At this writing, we have interviewed eight of our targeted fifteen participants. They range in age from 18 to 53 years and have been homeless from four months to 27 years. Several themes are emerging as we conduct interviews. Participants described their interactions with nurses as generally civil, however all participants at this writing have also experienced uncivil behavior from nurses; they described these interactions as being very upsetting. Participants have reported nurses rolling their eyes at them, complaining about them to co-workers, telling them to get a job, and chastising them for not doing anything with their lives. They said they wait longer to receive care than people who can pay for services. They suspected that some nurses judged them for being homeless and did not see them as individuals. Most participants said they sought care primarily in emergency departments, but some also frequented free clinics and private practices. Most participants selected healthcare facilities based on how well they had been treated in the past. They described good care as being treated with kindness and respect. They wanted nurses to show interest in them and provide individualized care.

Conclusions: We will use our findings to develop an education intervention to improve undergraduate nursing students’ knowledge of homelessness from the perspective of those who live it. We hope to enhance student nurses’ understanding of the importance of civility in their interactions with homeless people.