The Real World
Nursing school programs allow students to gain hands-on experience treating indigent patients — and explore the world of community-based care

By Linda Childers
June 5, 2003

The woman lived in a makeshift shelter, part of a homeless encampment far from the city's skyscrapers and coffee bars.

Each week, two nursing students from the Washington State University College of Nursing in Spokane visit the encampment to check on the residents' health. One woman in particular continued to provide the students cause for concern. She was severely depressed, and they suspected she was diabetic, but their attempts to have her evaluated at the university's medical clinic were always met with resistance.

Then, one day several months ago, the students experienced a breakthrough with their patient. Maybe it was something one of the students said, or maybe it was the compassion they had shown the woman during the past year. Whatever triggered her change was cause for celebration-the woman agreed to accompany them to the university's People's Clinic for further evaluation and treatment.

Today, for the first time in many years, the woman receives consistent medical care for her mental and physical conditions.

Washington State is one of many nursing schools across the country giving students real-world experience in caring for indigent patients. Beyond the classroom doors, the students visit worlds that are a far cry from the middle-class neighborhoods most call home. From homeless shelters to roadside encampments to single-room occupancy hotels, these students serve as health care providers to an often-overlooked patient population.

"Working with homeless patients provides our student nurses with a powerful learning experience," said Carol Allen, Ph.D., MSN, RN, an instructor in the Intercollegiate College of Nursing at WSU's College of Nursing. "And in many cases, we are the only health care providers for this population."

For the past 15 years, WSU community health students have worked in pairs providing care to some of Spokane's poorest residents. They work two days a week, two to six hours a day, caring for low-income and homeless patients with chronic health problems, mental illness and drug addictions.

Nursing students provide services such as blood pressure screenings, dietary counseling for good nutrition, smoking cessation counseling and disease management counseling for diabetes and hypertension.

"The first day one of our nursing students visits the homeless, they return with a 'deer in the headlights' look about them," Allen said. "But over time, they discover these people are strong and resilient, they have names and they are no longer invisible people you avoid looking at on the street."

The WSU program isn't mandatory for nursing students, but it is one of the most popular course options.

"We have more requests from students who want to be involved in this program than we can fill," Allen said. "It's a learning experience far different than anything our students experience in the classroom."

At the University of California, San Francisco, prelicensure nursing students in the master's entry program of nursing and advanced practice nurses complete part of their residency requirements at the Glide Health Clinic.

The clinic, founded in 1997, is a joint partnership between the UCSF School of Nursing's Department of Community Health Systems, Glide Memorial United Methodist Church and Catholic Healthcare West-West Bay Region.

"Glide has always provided a variety of services to vulnerable individuals, including persons who are homeless," said Joanne Saxe, MS, ANP, RN, director of the adult nurse practitioner program and clinical professor at the Department of Community Health Systems. "For example, Glide has provided the needy with food, recovery and child care programs, so a health clinic was a natural extension of their offerings."

The Glide Health Clinic is open four half days a week and is staffed by UCSF nurse practitioner faculty members, nursing students and Glide clinicians and staff members. The students complete anywhere from 30 to 400 clinical hours during any given academic year at the clinic, which serves about 2,000 clients.

In addition to offering a full range of primary care and psychiatric services, the clinic offers complementary care services including acupuncture, chiropractic care, massage therapy, guided imagery, energy healing and Reiki.

"Many of our clients haven't had access to health care in many years, so their initial visit can be a daunting experience," Saxe said. "Many of our patients discover that starting out with complementary care services is a comfortable first step for engaging in care."

At the University of Iowa, health promotion and disease prevention are lessons taught to the homeless as part of the nursing students' clinical health rotation.

"Our college town, Iowa City, has a growing homeless population that many students never knew existed," said Susan Lehmann, MSN, RN, clinical instructor at the College of Nursing. "Our students are accustomed to caring for clients in hospital settings that are clean and controlled. This program shows them that many persons live with limited resources and in difficult circumstances once they leave the protection of the hospital."

Although caring for the homeless can be a life-changing experience for many nursing students, it might not be feasible for all universities to implement such a program.

"Universities need to have a faculty member who sees the potential impact that nursing students can have with this population," Lehmann said. "The school needs to be willing to develop relationships with key advocates in the community and to be creative in finding a location to offer the services."

Funding also can be a challenge for student nursing programs. The University of Iowa began its nursing outreach program two years ago when it received the Helene Fuld Grant, which provides funding for community health studies.

Each semester, students volunteer as nurse case managers at Shelter House, a homeless facility.

"All of our services are provided free of charge and often prevent minor health problems from escalating into emergency room visits," Lehmann said.

Working in a program for indigent patients can also alter the career paths of many nursing students.

Students learn how important it is to build trust with their homeless patients and get hands-on experience practicing their communication and critical thinking skills as they work with patients who often have tremendous needs, chronic problems and may have trouble articulating their needs.

"Some students realize that working with low-income populations is their passion," Lehmann said. "Others, while appreciating the training, find they are more cut out to work in a traditional hospital setting."