Teaching Student Nurses About the Lived Experience of Homeless People Through a Photovoice Intervention

Friday, 20 July 2018

Cindy H. Kerber, PhD, PMHCNS, BC1
Sheryl Henry Jenkins, PhD, ACNP-BC, RN2
Wendy M. Woith, PhD, RN, FAAN2
Kim Schafer Astroth, PhD, RN2
(1)Mennonite College of Nursing, Mennonite College of Nursing at Illinois State University, Normal, IL, USA
(2)Mennonite College of Nursing, Illinois State University, Normal, IL, USA


After a seven year decline in the number of homeless people in the United States, the United States Department of Housing and Urban Development (HUD; 2017) reported an increase of almost 1%, to 553,000. Homeless people have more health problems (Bernstein, Meurer, Plumb, & Jackson, 2015) and they have reported receiving inadequate health care, including incivility, disrespect, and rushed care from nurses (Woith, Kerber, Astroth, & Jenkins, 2016). When homeless people are treated uncivilly, they may be reluctant to seek care in the future (Woith et al., 2016; Dawson & Jackson, 2013). Therefore, the behavior of nurses toward the homeless is critically important to meeting their healthcare needs. Nurse educators are instrumental in conveying the need for respectful advocacy for the homeless to their students. In order to be effective advocates, students must understand homelessness and the hurdles homeless people face each day (Boylston & O’Rourke, 2013; Woith et al., 2016).

All humans experience implicit bias, or the attributing of stereotypical features to groups of people; this trait is implicit in that it occurs without our conscious awareness (Blaine, 2013). Healthcare professionals, including nurses, are not exempt from implicit bias and their preconceptions are manifest when they interact with patients (Hall et al., 2015). Implicit bias negatively impacts patient care and causes patients to be less likely to seek help (Blair et al., 2013; Hall et al., 2015). The literature primarily addresses implicit bias toward ethnic and racial minorities (Blair et al., 2013; Hall et al., 2015), but health care providers also exhibit bias toward the poor and homeless (Boylston & O’Rourke, 2013; The Joint Commission, 2016; Woith et al., 2016). We found few studies that addressed healthcare from the homeless person’s point of view (Rae & Rees, 2015; Woith et al., 2016).

Nurse educators must provide specific education, focused on homelessness to give students an opportunity to understand and empathize with the homeless (Seiler & Moss, 2012). Few such teaching strategies have been developed and empirically tested (Kooken, Baylor, & Schwend, 2014; Rasmor, Kooienga, Brown, & Probst, 2014). Photovoice has been used as an education strategy for nursing students (Garner, 2014), but we found no studies in which this technique was used to teach students about homelessness. Photovoice is a form of community-based, participatory research in which members of the community of interest are provided with cameras and asked to take pictures that illustrate their lived experiences (Wang & Burris, 1997). Photovoice typically involves participants who are marginalized or stigmatized (Garner, 2014), and therefore is particularly useful for exploring the lived experience of homeless persons.

The purpose of this study is to develop and test a photovoice intervention to teach nursing students what it is like to be homeless, thereby enhancing empathy and broadening attitudes toward this vulnerable population. The research question is: What are the differences in students’ attitudes toward poverty before and after participating in a photovoice intervention on homelessness.


This mixed methods study will be conducted in the mid-western United States. We will test the intervention by measuring students’ attitudes toward poverty in general, and through focus groups in which researchers will further explore students’ attitudes toward the homeless and elicit their feedback concerning the effectiveness of the intervention.

Phase 1: Intervention Development. A convenience sample of 10 homeless adults will be recruited from a homeless shelter. Participants will be provided with disposable cameras and given 48 hours to take pictures that depict their experiences as homeless individuals. The researchers will then meet with participants, collect the cameras, and process the film. After the film is processed, the participants will meet with the researchers to select their top two photos and tell their story about those pictures. Narratives will be audio recorded and subsequently transcribed. Posters will be developed from the pictures and associated narratives.

Phase 2: Procedure. A convenience sample of 90 beginning nursing students will be recruited from their first semester Health Assessment course. Participants will be randomly assigned to either the control or intervention groups. Both groups will provide demographic data and complete a pre-test, Attitudes toward Poverty Scale (Atherton et al., 1993), early in the semester. Late in the semester, the intervention group will meet for a one hour poster-discussion session in which they view the posters and narratives and discuss homelessness with a homeless person. At the next scheduled class meeting, all students will take the post-test. The intervention will be offered at a later date for those students in the control group. Students in the intervention group will be invited to participate in one of up to three, one-hour focus groups of 5-6 participants each. Focus groups will be audio-recorded for later transcription.

Data Analysis. For the quantitative portion of the study, differences in pre and post test scores will be analyzed using t-tests. Reliability of the scale in this study will be tested using Cronbach’s alpha. Significance will be set at p < 0.05. For the qualitative portion of the study, focus group data will be analyzed through content analysis of themes.


Study in progress.

Conclusion: The findings of this study may assist nurse educators in developing similar photovoice interventions to enhance students’ understanding of homelessness. Photovoice may also be used to teach students about how their patients experience a variety of cultural conditions or physical and mental disorders.