Caring for vulnerable and marginalized populations has been, and continues to be, central to the practice of nursing, as well as Christian service. Helping those who are homeless is strategically related to the Code of Ethics for Nurses with Interpretive Statements (American Nurses Association, 2015). Provision 9 states: “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (p. 31). This provision addresses collaboration on social, political, and economic levels where nurses help lead efforts to develop and implement public health legislation, policies, and programs, “that promote and restore health, prevent illness, and alleviate suffering” (p. 32). In addition to this broader level of influence, nurses can be individually involved in caring for those who are vulnerable, such as the homeless. However, due to the scope and complexities of the problems associated with homelessness, nurses may feel overwhelmed and ill-equipped to make a significant difference in the lives of homeless individuals.
Numerous strategies for ending homelessness are described in the literature and largely include resource-intensive, publicly supported housing and comprehensive physical and mental health programs (Mares & Rosenheck, 2011 ; McGraw & Herrell, 2010 ; Pauley et al., 2016 ; Tsai, Mares, & Rosenheck, 2012 ; Weinstein et al., 2013). However, only a small body of literature examines the role of spirituality in recovery from homelessness (Belcher, 2003 ; Snodgrass, 2013 ; Timmons, 2011). Unfortunately, the transforming power of God often is the missing element in services for the homeless. Consequently, those who are homeless are provided with limited options to experience hope, healing, and transformation in their lives.
This article will describe one homeless shelter's successful, Christ-centered, comprehensive approach to helping individuals and families recover from homelessness. The integral role of the nurse as a member of the multidisciplinary team is described.
THE PROBLEM OF HOMELESSNESS
“The poor will always be with you.” These are the words Jesus spoke to his followers 2,000 years ago (Mark 14:7). Homelessness is on the rise in the United States and has emerged as one of the most significant social issues and population health concerns in recent decades (Hauff & Secor-Turner, 2014 ; Hodge, Moser, & Shafer, 2012). Although estimates vary, general agreement exists that the number of homeless people has significantly increased since the 1970s (Hodge et al.; Wachholz, 2005). According to the Department of Housing and Urban Development (HUD, 2016), during January 2016 (a winter month), at least 549,258 people were homeless on any given night. The majority (68%) of these individuals were staying in homeless shelters, whereas approximately 32% were living unsheltered. Additionally, the National Law Center on Homelessness and Poverty (2016) reports that approximately 3.5 million Americans experience homelessness each year, and over 7 million are at imminent risk for homelessness. Economic instability contributes to risk for, and the experience of, homelessness.
Factors linked to chronic homelessness include mental illness and addiction to drugs and/or alcohol. Veterans and ethnic minorities are disproportionately represented among the homeless. Domestic abuse is another cause of homelessness among women. Primary factors that have contributed to the recent rise in homelessness include shortages of affordable housing and a simultaneous increase in poverty (Finfgeld-Connett, 2010; HUD, 2017; Mares & Rosenheck, 2011). In addition to increasing numbers, the composition of the homeless population is changing. Families with children are among the fastest growing sector of the homeless population, with the majority of these families being headed by single mothers (Finfgeld-Connett; Hodge et al., 2012 ; National Coalition for the Homeless, 2012).
In the United States homeless individuals experience a mortality rate three to four times that of the general population. The majority of chronically homeless individuals have multiple comorbidities, including mental illness, chronic medical conditions, and co-occurring substance abuse disorders. Cardiovascular diseases, diabetes, sexually transmitted diseases (STDs), dental problems, and other treatable and preventable chronic conditions contribute heavily to excessive morbidity and mortality in the homeless population (Weinstein et al., 2013 ; Zur & Jones, 2014).
The multifaceted healthcare needs of the homeless population are magnified by extreme social, cultural, and financial barriers, making it difficult for homeless individuals to acquire essential treatment for their health problems (Zur & Jones, 2014). Barriers to care include: (a) affordability, accessibility, or acceptability of services, (b) lack of transportation and child care, (c) no insurance, (d) complexity of healthcare system. Additionally, the pressure to focus on immediate needs, such as obtaining food, shelter, or employment, precludes many from addressing higher-level needs. Faulty decision-making skills, self-destructive behaviors, as well as critical and disrespectful attitudes of healthcare providers have also been cited as reasons for not seeking care (HUD, 2016; Pennington, Coast, & Kroh, 2010; Zur & Jones). Consequently, homeless individuals characteristically experience exacerbations of their often numerous and serious health problems at higher rates than the general population (Zur & Jones).
HOMELESS NO MORE
Dallas LIFE, a Christian, nonprofit, 500-bed rescue mission and homeless shelter in downtown Dallas, Texas, has been serving the homeless for over 60 years. Aside from meals, medical care, and a place for needy men, women, and children to stay, Dallas LIFE offers a comprehensive, 10-month recovery program. The program includes addiction recovery, life skills and job readiness classes, professional counseling, and intensive spiritual development classes. The program also assists residents to acquire full-time employment, further their education, reconnect with family, and find affordable housing. For those with special needs, Dallas LIFE offers programs and services to meet the needs of the disabled, elderly, veterans, and children.
The Homeless No More program is the creation of Reverend Bob Sweeney, who has been executive director of the shelter since 2005. Sweeney explains (personal communication, August 30, 2016) that Homeless No More is the product of 25 years of his combined experience as the executive director of one of the nation's largest homeless shelters, a pastor, and a chaplain in a maximum-security prison. Experience taught him that to see true change in an individual's life, the focus must be on long-term, transformational change, not solely on alleviating the short-term consequences of homelessness. He envisioned a continuum of care through which all aspects of a person's life are addressed, including spiritual, mental, psychosocial, emotional, relational, and physical needs. His vision led to the birth of the Dallas LIFE model comprehensive recovery program for the homeless.
Individuals typically seek shelter at Dallas LIFE following a catastrophic life event. A broken or abusive relationship, the loss of a job, the loss of a loved one, a long-term illness, or a sudden diagnosis is often the final straw that plunges a person into homelessness. Though no one is immune from such crises, individuals coming to Dallas LIFE usually lack the physical or mental stability, education, faith, family, or finances to cope effectively with their situations. Many tend to abuse drugs and/or alcohol.
On that premise, Dallas LIFE is committed to offering a continuum of care, providing residents positive, long-term, trusting relationships, as well as tools to make positive decisions, develop coping mechanisms, and weather life's storms (See sidebar, Judy: A New Beginning—at 65!). Classes in parenting, finance, computer skills, anger management, the psychology of addiction, resume writing, and men's/women's issues enable individuals to clearly evaluate past mistakes and struggles, current options, and future potential. Men's and women's program directors develop individualized plans for each new resident. Individual counseling is offered, and accountability is maintained, with the philosophy that only through accountability can a life be rebuilt and the former street life replaced.
Point of entry into this continuum of care is fairly simple. One must choose to join. All new arrivals at the shelter are provided with five free nights of food and lodging, during which detailed information about the program is provided. On the fifth day, individuals have the option to join the program or pay $10.00 daily for food and lodging at the shelter. Approximately 65% choose to join the program (Dallas LIFE, 2014a). Many times, those who are initially reluctant to join, do so after developing trusting relationships with staff, as well as receiving encouragement from residents experiencing the life-changing benefits of the program.
Dallas LIFE (2014b) records indicate that 9 out of 10 of residents who have completed the Homeless No More program have successfully recovered from homelessness and have become vibrant and productive members of society. The program's success has garnered local, state, and national attention, and has captured the interest of the nation's lawmakers. State and U.S. Representatives have visited the shelter, and Reverend Sweeney has twice been invited to Washington, DC, to speak before the 2015 and 2016 Congressional Homelessness Caucuses.
FOUR PHASES OF INTERVENTION
The 10-month Homeless No More recovery program is divided into four phases. Phase One is a 30-day period in which residents are required to remain on the Dallas LIFE grounds. This is a time for residents to usher in a new life and leave the old behind them. During this time, many residents are detoxing, getting drugs out of their systems. Therefore, it is imperative to avoid old associates, hangouts, and habits. The focus is on building new relationships, while recovering from past hurts. Once strong in their recovery, there is time to rebuild healthy relationships.
Residents are learning responsibility during those first 30 days by working hard to establish new habits. Whether assisting in the kitchen or caring for their temporary home, every person at Dallas LIFE has a cleaning job. Even the most menial tasks add inextricably to character development.
In Phase Two, a 60-day period, residents receive privileges resulting from their hard work, including passes to leave, phone calls, and visits. Staff members believe if residents endure the first 30 days, they are committed to life change. However, with privileges also comes greater responsibility. Adults attend classes at the shelter from 9:00 a.m. to 3:00 p.m. Children are bused to local schools; preschoolers are cared for at a nearby day care while parents are in class. Classes such as the psychology of addiction, Alcoholics Anonymous, anger management, parenting, budgeting, computer skills, résumé preparation, and job readiness classes begin in Phase Two. Education is viewed as essential to successfully overcoming homelessness. According to Reverend Sweeney (personal communication, August 30, 2016), most residents come to Dallas LIFE with a 9th or 10th grade education, and with this in mind, help is offered to broaden education and enhance life skills.
Residents attend weekly computer classes to learn basic skills, enhance language and writing skills, and prepare to reenter the workplace. General Education Development classes are offered, a job search is initiated, and residents sign up for available low-income housing in anticipation of the time they will be ready to be on their own.
In Phase Three, a 90-day period, residents find part-time employment. Dallas LIFE frequently offers paid positions to residents with compatible skill sets—laundry, custodian/janitorial, food service, and security. Though the ability to bring in income is pivotal to future success, residents are discouraged from working more than 20 hours weekly during Phase Three, as additional hours could interfere with classes and acquisition of new life skills.
Residents also begin attending a church of their choice. Prior to this time, residents attend church services and Bible studies at the shelter. In Phase Three, residents receive passes for overnight family visits. Becoming part of a church community, developing outside support systems, and healing old familial wounds are vital to recovery and long-term success.
Finally, in Phase Three, residents are assigned a mentor. Mentors are carefully screened and selected and must be godly, mature believers, committed to meeting one-on-one for a minimum of 90 minutes every other week.
In Phase Four, the last 4 months of the program, residents still attend a few classes but are devoting more time to pursuing full-time employment. Residents who have reached Phase Four usually are given priority for available, affordable housing in the city. Dallas LIFE holds two yearly graduation ceremonies, complete with caps, gowns, and music. Staff members, volunteers, mentors, and family are encouraged to attend and celebrate the beginning of new life.
Dallas LIFE offers 30 days of free food and lodging to each new graduate. Afterward, graduates are offered an additional 30 days of pay-to-stay. Graduates usually need about four paychecks to launch and live independently. They have worked very hard, and Dallas LIFE is committed to facilitating their success.
Staff members regularly receive visits, phone calls, letters, postcards, and emails from graduates, thanking Dallas LIFE and describing the amazing work God has done in their lives. It is a joy and privilege to see lives restored and witness the miraculous change that occurs when an individual is set free from the burden of self, by the grace of a loving God.
MULTIDISCIPLINARY TEAM, COLLABORATIVE PARTNERSHIPS
The comprehensive nature of the program, and Dallas LIFE's commitment to caring for the whole person, dictates a multidisciplinary approach and collaborative partnerships with other service providers and community stakeholders. Dedicated staff members and volunteers include professionals representing medicine, nursing, social services, law, education, business, early childhood development, psychology, counseling, technology, resource development, and finance. Other partners include cosmetologists/barbers, exercise and fitness experts, and retirees from the Social Security Administration, who assist residents with applications for assistance. Members of a local running club have adopted Dallas LIFE and run weekly with residents. Church groups and other organizations host parties, after-school activities, field trips, and summer camps for children. Student organizations have redecorated at the shelter.
The formation of collaborative partnerships is crucial to the fulfillment of Dallas LIFE's mission. Partnerships include: (a) a community mental health agency that provides psychiatric services for residents suffering from mental illness; (b) a partnership with a local community college that allows graduates from Dallas LIFE to obtain an associate's degree or vocational training free of charge; (c) a local faith-based day-care center that offers free child care for preschoolers at Dallas LIFE, while parents are attending classes or working; (d) academic partnerships that afford social work, counseling, medical, and nursing students with rich clinical learning experiences. Additionally, faculty members and students provide needed care to residents and services to the shelter.
IMPLICATIONS FOR NURSING
My experiences (Robin) at Dallas LIFE have taught me that whether they work, volunteer, or advocate, all nurses are equipped for an integral role in helping homeless and at-risk individuals (see Sidebar: Nursing at Dallas LIFE). The following five points are practical interventions nurses can implement:
- Treat each person as a unique individual and worthy of respect. Many times, homeless individuals fear patronizing or judgmental attitudes of healthcare providers. The expression of authentic concern and compassion can bring healing to a badly battered self-esteem and open the door for a trusting relationship.
- Serve as a resource and referral person. Be knowledgeable of sources of assistance for homeless individuals and those living in poverty. Many times upon hospital discharge, it is a nurse who refers a homeless patient to Dallas LIFE and initiates a social work consult to arrange transportation to the shelter.
- Be an advocate. By taking time to genuinely listen, nurses can identify individual needs and overcome barriers to getting needs met. Advocacy also can take the form of meeting the needs of organizations serving homeless and at-risk populations. Encourage groups, such as nursing organizations and faith communities, to become involved and conduct drives to collect clothes, toys, socks, toiletries, and so on. Baylor University nursing students regularly conduct Gallon of Love campaigns, in which they collect gallon plastic bags of needed toiletries and personal hygiene products for residents at Dallas LIFE.
- Use your nursing knowledge, abilities, and skills to meet a vital need. Never underestimate creative ways you can support, inform, and teach. A nurse colleague, who works as a diabetic educator at an outpatient clinic, was inspired by my service; however, her schedule left little time to volunteer. She now teaches a 1-hour nutrition class for residents with diabetes, twice monthly.
- Nurse educators. Academic partnerships with organizations serving homeless and at-risk populations afford students opportunities for first-hand experience responding to individual and societal needs, and to grow compassion for vulnerable and marginalized populations. I began teaching at Baylor University Louise Herrington School of Nursing in 2013, and currently take my community health nursing clinical groups to Dallas LIFE weekly each semester. Students provide care to residents, including assessment, screenings, referral, health education, and health fairs. Additionally, students can engage in advocacy and interact in a collaborative manner with members of a multidisciplinary team. These experiences help cultivate an attitude of lifelong service among students, and several Baylor graduates now volunteer as RNs in the clinic. The experiences at Dallas LIFE integrate faith with learning and model the servant leadership of Jesus to students.
Serving at Dallas LIFE is a privilege. The rewards of a program that teaches Christ-centered accountability, personal responsibility, and commitment to faith and family are invaluable. It is the authors' hope that this article will educate, inspire, and encourage nurses to make a life-changing difference in the lives of the homeless. Look for homeless services and ministries in your community and explore what their needs are. Caring for those who are overlooked or looked down upon by society embodies the very heart of nursing and of our loving God.
Judy: A New Beginning—At 65!
“Most shelters don't know what to do with someone like me.”
By “someone like me,” Judy is referring to the fact that she was 65 years old when she arrived at Dallas LIFE. In the world of homeless recovery, senior adults are something of an anomaly.
Judy's world had unraveled in a moment, when a random drug test at work resulted in felony charges for carrying her own daily prescription medications in one prescription bottle. A prolonged legal battle continued, left Judy without a job—and with the realization that she had become addicted to prescription drugs.
She went to live with relatives in East Texas, “but I didn't want to be around all their meds,” Judy reflects. An Internet search revealed that Dallas LIFE was a place that took seniors, and she soon made her way there. The kindness of the staff and residents made a strong first impression, and within a short time she joined the New Life recovery program. She also completely stopped taking medications because for the first time in a very long time, Judy sensed that God was with her and would give her the strength to change. She graduated from the program in February 2014 and now lives happily in her own apartment. “Dallas LIFE helped me find God, taught me patience, and gave me hope,” Judy says confidently. She believes in the power of a new beginning—and that it can still happen at 65 (Dallas LIFE, 2014c)!
Nursing at Dallas LIFE
I (Robin) was introduced to Dallas LIFE in 2006. After relocating to Plano, Texas, I attended a church close to home and joined a home Bible study. That is where my Dallas LIFE story began. After learning that I taught nursing, a member of the home group began to tell me about her volunteer service in a dental clinic at a homeless shelter in downtown Dallas. She told me they needed nurses for the weekly health clinic.
I had no experience with homeless ministry beyond passing out water bottles, sandwiches, and blankets to homeless persons. I had never set foot in a homeless shelter, nor was I enthusiastic at the idea. My guilty conscience, however, as well as my new friend's prompting, compelled me to volunteer.
My enthusiasm waned further when I arrived at the shelter, located in a tough neighborhood of downtown Dallas. As I pulled into the driveway, I was greeted by a large, timeworn, three-story building that resembled an old factory. The shelter was surrounded by an intimidating fence. I was waved in by the resident worker at the gate and found a parking place near the entrance, but was reluctant to enter.
My hesitancy dissipated the moment I stepped inside. The shelter was spotless; the walls were freshly painted in bright, cheerful colors. The environment was warm and inviting, and I was greeted by smiling faces. I was escorted to a small clinic located in the middle of the shelter. Although the clinic was humble and sparsely equipped, volunteers were providing care in a professional, proficient, and caring manner. We opened the evening with prayer and set to work. Men, women, and children lined up, waiting to be seen. We encountered myriad acute and chronic conditions, ranging from diaper rash to diabetes. By the end of the night, I knew I had found my calling.
Today, we have a new and modern clinic, thanks to a generous donation from an anonymous benefactor. I am the volunteer clinic coordinator, overseeing 50 volunteers; I coordinate operations of the dental, vision, and medical clinics. I draft policies and procedures, recruit volunteers, coordinate with other medical service providers, and make referrals as needed. I also function as a nurse consultant to Dallas LIFE staff members on shelter-related health concerns.
Many Dallas LIFE residents arrive with serious, complicated health issues that have gone untreated or have not been effectively addressed. High prevalence of chronic conditions among residents include diabetes, hypertension, cardiovascular disease, liver and kidney disease, mental illness, hepatitis C, and arthritis. Residents also present with acute conditions, including skin disorders, seasonal allergies, gastrointestinal problems, and respiratory infections. We often help manage residents' treatment regimens in between appointments at county hospital clinics or with primary care providers.
As with any enclosed population, communicable diseases can spread rapidly throughout the shelter. Preventing the transmission of disease is essential to safeguarding the health of residents, staff members, and volunteers. Dallas LIFE staff members appreciate effective health promotion and risk-reduction interventions. Clinic volunteers conduct health education classes, distribute handouts, and display posters throughout the shelter on various health-related topics. We provide free flu vaccinations to residents, through a partnership I formed with a major pharmacy chain.
Dental caries, missing teeth, and gum disease are common among residents, and some are systemically ill due to serious dental issues. Our dental clinic provides basic services, such as teeth cleaning, fillings, extractions, and dentures. Restoring dental health is rehabilitative and elevates self-esteem, improves nutritional status and overall health, and allows residents to present a professional image during job interviews. Through our vision clinic, residents obtain nonprescription and prescription glasses. Many residents have suffered with poor vision for years, and the restoration of sight has moved some to tears.
Our residents can be a challenging population, and some do not possess appropriate social skills. Some residents have personality disorders and mental illness, as well as substance abuse issues and addictive personalities, with active drug-seeking behaviors. Though most residents are appreciative of help, a few can be rude and demanding. We acknowledge a destructive behavior pattern or a negative character trait in an individual but are careful to distinguish the behavior from the individual. Our adage is: But for the grace of God, go I. Without a doubt, love and compassion are the greatest resources offered to residents.
- National Homeless Coalition—http://nationalhomeless.org
- U.S. Department of HUD—https://portal.hud.gov/hudportal/HUD
- Dallas LIFE—http://dallaslife.org
- National Law Center on Homelessness & Poverty—https://www.nlchp.org