Nursing Students Attitudes’ Toward the Homeless

Friday, 28 July 2017

Patricia MacWilliams Bowe, DNP, MS
Andrew B. Phillips, PhD
MGH Institute of Health Professions School of Nursing, Boston, MA, USA


A person who is homeless is someone without fixed housing. The individual may move from couch to couch, motel to temporary shelter, a car to a tent, with no place to call home, minimal belongings, and no sense of permanency. This writer’s career has long been one of working with homeless populations. During a twenty year period at Boston Health Care for the Homeless Program (BHCHP) many nursing students from a number of schools in the Boston area had a clinical rotation at this site. Clinical placements began with a tour of the shelter and a discussion around preconceived notions and perceptions about homelessness. Many students acknowledged that they expected to see the stereotypical alcoholic older man, and were surprised to see a younger population. For the majority of students who were initially unsure of the shelter environment and unfamiliar with the context and difficulties faced by homeless people, it was always a positive experience to watch them grow, expand their view of the population, and truly see them for who they are: humans who have a right to health care. A few students actually asked to be placed back at the clinic for a second semester as they truly appreciated the population, including the unique quirks and the inherent humanness involved despite the hardships the patients experienced. Those students who embraced the experience wholeheartedly expressed appreciation for the opportunity of the experience, how it changed their view of the population as a whole, and how they had a better understand the challenges faced by the patients. As a result, they strongly predicted that their practice as a registered nurse or nurse practitioner would be improved accordingly.

Challenges in caring for the homeless include that, as a group, they lack financial resources, difficulty adhering to a healthy diet, hygiene issues, and lack of storage for personal items. When diagnosed with serious health conditions such as cardiac disease, cancer, and psychoactive substance abuse disorders, members of the homeless population are at a higher risk of mortality compared with the general population as abstracted from the Massachusetts Department of Public Health death occurrence files for 2003-2008 and analyzed by Baggett, Hwang, O’Connell, Porneala, Stringfellow et. al (2013). The three major causes of death for the homeless in this analysis were drug overdose, cancer, and heart disease. Younger homeless adults (25-44 year old) had a 9 times greater risk of dying than the general population of Massachusetts, and midlife homeless adults (45-64 year old) died at a rate 4.5 times higher than the general population of Massachusetts.

As a population the homeless are highly vulnerable. More than one million homeless patients in the United States are treated yearly. Chances are high that nurses will interact with a homeless patient at some point in their career. Homeless patients are admitted at a higher rate and have longer lengths of hospital stays than the rest of the population. They often suffer from serious health conditions and many have psychoactive substance abuse disorders leaving them at higher risk of mortality compared with the general population. Homelessness does not discriminate as people of every age, race, color, gender, religion and education are affected. However, clinical rotations with the homeless are not part of the standard nursing curriculum. Providing a clinical experience in a homeless setting may provide a more accepting attitude of working with this growing population.


The specific aims of this project were:

    1. To examine nursing students’ attitudes towards the homeless
    1. To determine whether previous exposure to the homeless influences the attitudes of nursing students towards the homeless.

Two methods were adopted to address these specific aims – a literature review and a survey of nursing students using a validated tool measuring attitudes towards the homeless.


The literature review identified thirty-seven potential resources of which eight were identified as relevant to the specific aims of this study. Six studies presented survey data results. Five of the six reported both pre and post survey results after the respondents had direct contact with the homeless in a clinical setting. A common theme noted throughout the literature was the more exposure to the homeless population and its adverse effects on health, the more positive the attitude of the student regarding the patients’ health care needs with the recognition that homelessness was perceived to be a result of societal causes and not personal failings. While experiences reported in the literature varied from one day to two weeks, a brief one day interaction, resulted in positive feedback (Boylston and O’Rourke, 2013) which supports the emphasis on exposure and curriculum in achieving more positive attitudes towards the homeless.

Using a validated instrument - Attitudes Towards Homelessness Inventory (ATHI, Kingree and Daves, 1997), an email was sent to 125 second degree direct entry pre licensure Masters- level nursing students soliciting voluntary anonymous participation in completing the survey. Over a period of 30 days 13 respondents participated in the 11 item survey.

The ATHI is divided into 4 sub categories, 1) personal causation, 2) societal causation, 3) affiliation and, 4) solutions (Table 2). Total overall scores ranged from 39-46 with a mean of 42.8, out of a possible 11-66 indicating an overall positive attitude as the higher the number the more positive the attitude. Responders indicated that perception of homelessness was based more on societal causes (mean 2.51) than personal causes (mean 4.12) with a positive relation towards solutions of homelessness with a mean of 5.38. Eleven of the twelve respondents had previous experience with the homeless which correlated to a positive attitude about this population (mean 3.38) and a positive perspective towards solutions for homelessness (mean 5.38). These responses indicated disagreement with such statements as “little can be done.”, “rehab is too expensive”, “cannot adopt a normal lifestyle.”

Table 2 – Survey results by Attitudes Towards Homelessness Inventory Sub-Category. Individual scores for each survey statement can range from 1-6. PC = personal causation, SC = societal causation, AFF = affiliation and, SOL = solutions.

Survey Statement


Mean Score

Homeless people had parents who took little interest in them as children.



Most circumstances of homelessness in adults can be traced to their emotional experiences in childhood.



Most homeless persons are substance abusers.



Recent government cutbacks in housing assistance for the poor may have made the homeless problem in this country worse.



The low minimum wage in this country virtually guarantees a large homeless population.



Recent government cutbacks in welfare have contributed substantially to the homeless problem in this country.



I feel uneasy when I meet homeless people.



I would feel comfortable eating a meal with a homeless person.



Rehabilitation programs for homeless people are too expensive to operate.



There is little that can be done for people in homeless shelters except to see they are comfortable and well fed.



A homeless person cannot really be expected to adopt a normal lifestyle.



Attitude toward homeless index (11-66)



It is evident that little research exist that support the theory that exposure to the homeless population improves attitudes of students toward homeless patients beyond the qualitative results noted in some of the studies. Further research would be beneficial to help guide curriculum development. Undergraduate nursing students are exposed to many facets of health care. Understanding a vulnerable population such as the homeless and acknowledging the effects of negative attitudes towards the delivery of care would provide insight to both educators and students. As a result, the vulnerable population, specifically the homeless, would be better served.

Continued research to build the evidence to support the hypothesis that experience with the homeless population correlates with a positive attitude on a broader scale would help drive nursing program curricula to incorporate a homeless experience. Compassionate care and a positive attitude should be fostered as part of the nursing education.

While this survey was conducted with a specific focus on the homeless population, the overarching philosophy could be translated to other vulnerable populations worldwide.