Trauma-informed care, harm reduction, and population-level advocacy. These are three topics essential to my work as a family nurse practitioner. I wish I had known about them thirty-five years ago when I began my first job after graduation from the Medical College of Virginia (Virginia Commonwealth University). I gained these essential skills through my work with people marginalized by poverty and homelessness. I now include all three topics in my health policy and health equity courses for DNP students at the University of Washington School of Nursing in Seattle.
That's what struck me the most when I recently re-read my article in The Nurse Practitioner Journal from July 1989 (under my then married name, Josephine Ensign Bowdler), “Health Problems of the Homeless in America." I wrote this article based on my work as a nurse practitioner at what became one of our nation's first Health Care for the Homeless (HCH) primary care clinics in my then hometown of Richmond, Virginia (Crossover Clinic, subcontracted with The Daily Planet, which then took over the HCH clinic). I cringed when I read my own words in which, in essence, I blamed people for their substance use disorders. I was heartened to see that I at least acknowledged the fact that the stress and trauma from the state of homelessness exacerbates mental health and addiction issues. In conclusion I stated, “Primary care providers need to examine their feelings about poverty and homelessness, and avoid the extremes of blaming the victim or attempting to rescue the victim. (…) It is important to remember that homeless persons are often using considerable energy to satisfy their basic physiologic and safety needs. Attention to proper health care can come only after these survival needs are addressed." (p. 51)
What I didn't write about in the article because it had not yet happened, was the fact that I was about to lose my job, home, and family, and spiral into and out of homelessness as a young adult. Like anyone who experiences homelessness, this was due to a myriad of factors, including a history of unaddressed childhood trauma. The majority of people who experience homelessness, especially teens and young adults, have a history of significant trauma. Decades later I would write about this time in my medical memoir, Catching Homelessness: A Nurse's Story of Falling Through the Safety Net (2016) and further (in terms of trauma-informed care and gender-based violence) in Soul Stories: Voices from the Margins (University of California Medical Humanities Press, 2018). The experience of homelessness changed how I view not only homelessness, but also our health and social care systems. And the drive to examine my own and our nation's feelings about and approaches to poverty and homelessness led to a 6-year-long research project culminating in my newest book, Skid Road: On the Frontier of Health and Homelessness in an American City (Johns Hopkins University Press, 2021). The research for this book took me from hands-on healthcare work precepting our students in downtown Seattle homeless shelters to dusty archives in Seattle, as well as in London and Edinburgh (for research on the Scottish and English Poor Laws that underlie our country's Poor Laws).
The topic of advocacy in nursing education—including nurse practitioner education—if taught at all, typically focuses solely on individual patient advocacy. It often takes the stance that patient advocacy is a characteristic and virtue exclusively of nurses and not any other healthcare professionals on the healthcare team. This is untrue and unhelpful to the provision of quality patient care. Oftentimes, as in my own nursing education so many decades ago, the overly deified and uncritically examined historical figure and example of Florence Nightingale is invoked. Policy-level and political advocacy, especially for populations marginalized by race, ethnicity, sexual identity, socio-economic level, disability, national origin, or living situation are too rarely taught or modeled. However, I see that changing, mainly because our students advocate for these important changes. They give me hope, not only for the future of the profession of nursing and of the role of nurse practitioners, but also for the future of our healthcare system.
Josephine Ensign, DrPH, MPH, ARNP is a professor in the Department of Child, Family, and Population Health Nursing at the University of Washington, Seattle, Wash.