RESEARCH

Healthcare experiences of the homeless

Bonnie Nickasch, RN, MSN, FNP, APNP (Family Nurse Practitioner)1 & Suzanne K. Marnocha, PhD, RN, CCRN
(Associate Professor and Director of Traditional Undergraduate Program)2
1 Thedacare, Appleton, Wisconsin
2 University of Wisconsin, Oshkosh, Wisconsin

Keywords
Homelessness; healthcare experiences;
grounded theory; vulnerable populations.
Correspondence
Bonnie Nickasch, RN, MSN, FNP, APNP,
122 E. College Avenue, Appleton, WI 54912.
Tel: 206-222-2049; Fax: 206-222-2049;
E-mail: bonnie.nickasch@thedacare.org
Received: August 2007;
accepted: February 2008
doi:10.1111/j.1745-7599.2008.00371.x
Abstract
Purpose: To explore the healthcare experiences of homeless individuals and
inform providers of the barriers created by the situation of homelessness.
Data sources: This was a qualitative research study using a grounded theory
approach. The sample included homeless individuals older than 18 years living
in northeastern Wisconsin.
Conclusions: This research provided rich insight into the healthcare experi-
ences of the homeless. Five key conclusions were made: (a) the great majority of
homeless people have an external locus of control; (b) most homeless individ-
uals lack the necessary resources to meet their physical needs of shelter, air,
water, and food; (c) most homeless individuals lack the financial resources to
seek adequate health care; (d) access to resources is limited because of poor
transportation, telephones, and mail; and (e) all those interviewed felt that
healthcare providers lack compassion for the homeless.
Implications for practice: Healthcare providers can use the concepts discov-
ered in this study to help improve their skills and comfort level when working
with homeless individuals. A decrease in acute illnesses and an increase in the
effective management of chronic disease resulting in fewer long-term compli-
cations and medical costs because of these unnecessary complications could be
seen. Healthcare professionals may also volunteer to become more involved
with the care of the homeless if they are confident in their skills. Improving the
health of the homeless in the community will result in improvements in the
overall health of the community.

Homelessness is a social problem that has been on the rise
since the early 1980s (Gelberg et al., 2002). There is little
agreement among researchers on what is classified as
homelessness; however, researchers do agree that home-
lessness is increasing, and with homelessness comes many
healthcare challenges and beliefs. Therefore, a focus on the
homeless as a population should not be overlooked by
health professionals.
Homeless individuals expend tremendous energy on
survival strategies such as obtaining food, shelter, and
a place to rest (Capponi, 1997; McCormack & Gooding,
1993). Only after these basic human needs have been
satisfied are they able to focus on their other health issues
(Flynn, 1997). This struggle is also supported by Maslow’s
(1970) hierarchy of needs, which postulates that human
beings are motivated by unsatisfied needs and that certain
lower needs must be satisfied before higher needs can be
satisfied. According to his theory, one must first satisfy the
necessities of air, water, food, and sex prior to satisfying
other needs. Yet, despite these enormous obstacles, many
homeless are classified as resilient (Rew, Taylor-Seehafer,
Thomas, & Yockey, 2001).
Several studies have focused on the negative health
consequences of homelessness (Pfeil & Howe, 2004;
Rew, Taylor-Seehafer, & Fitzgerald, 2001; Rotheram-
Borus, Mahler, Koopman, & Langabeer, 1996; Yoder,
Hoyt, & Whibeck, 1998). However, adapting clinical prac-
tice to the health needs and living situations of the home-
less has remained challenging for clinicians. Strehlow,
Kline, Zerger, Zlotnick, and Proffitt (2005) surveyed

Journal of the American Academy of Nurse Practitioners 21 (2009) 39–46 ª 2009 The Author(s) 39
Journal compilation ª 2009 American Academy of Nurse Practitioners
Healthcare experiences of the homeless B. Nickasch & S.K. Marnocha

diverse clinicians caring for the homeless and found that Problem statement
adapted clinical practice guidelines can be implemented
The current qualitative theory study was designed to
for the care of homeless individuals. This article clearly
expand on what is known about the experiences of home-
identifies the unique needs of this aggregate group and
less individuals who seek health care. An understanding
the clinical utility of evidence-based practice guidelines
of the healthcare experiences within this group may
adapted for care of the homeless patient. However, few
expose unknown beliefs and practices and as a result lead
studies have addressed the positive health practices of this
to changes in the working relationship between health-
vulnerable population. Little is known about homeless
care providers and homeless individuals. As a result, the
individuals’ experiences with the healthcare system, posi-
homeless individuals may have more positive experiences
tive or negative.
in healthcare settings and presumably more accurate diag-
nosis and improved treatment and outcomes.
Theoretical framework
This study used Glaser and Strauss’ (1967) grounded
Methodology
theory approach to qualitative research. Emerging from
the field of sociology, this inductive approach to research
Research design
allows investigators to compare units of interview tran-
scripts in order to identify and organize the common The purpose of this study was to gain a better under-
themes that exist within them. The grounded theory standing of the homeless individual’s healthcare experi-
approach is an iterative process of induction, deduction, ences. A grounded theory design was used because so little
and verification. is known about the topic. According to Speziale and
Carpenter (2003), the main purpose of selecting a groun-
Review of literature ded theory approach is to allow the researcher more
flexibility and freedom to explore a phenomenon in depth.
The literature reviewed revolved around the ongoing
In this type of research, the researcher begins by asking
acute and chronic medical problems of the homeless pop-
very broad questions but continually refines the questions
ulation, their delay in seeking care, and demographic
throughout his study. The goal of having broad, open-
characteristics. There were also studies of the contributing
ended questions is to allow study participants to define
factors to homelessness such as domestic violence, pov-
what is important to them, whereas other approaches
erty, and death of a spouse. Some studies have focused on
could begin with assumptions, hypothesized as important,
homelessness; however, their focus has been on the expe-
by the researcher. As topics emerge, the researcher refines
rience of homelessness and the meaning of health and
the questions and continues gathering data until the point
resiliency of some homeless individuals. There have even
of saturation is reached. According to Polit and Beck
been a few studies addressing the healthcare provider’s
(2004), ‘‘the point of saturation is the point in the study
experience with providing care to the homeless. After
where a sense of closure is attained because new data yield
extensive literature review, only one study was identified
redundant information’’ (p. 731).
that addressed the personal evaluation of a homeless indi-
Data were collected through individual interviews that
vidual’s healthcare experiences (Martins, 2003).
were audio recorded and transcribed verbatim. Field notes
Homelessness in the United States is considered to be a
were taken, and participant observations were recorded
leading social problem. A homeless individual needs a wide
throughout the study.
variety of social strategies just to survive. These individuals
find themselves in a range of difficult situations, such as
Population, sample, and setting
having inadequate shelter, lacking food, or lacking health
care. These situations correlate with an increase in mental The target population for this study was homeless indi-
and physical problems within the homeless population. viduals; the accessible population was homeless individuals
According to Power, French, Connelly, George, et al. in northeastern Wisconsin. Homelessness is a term upon
(1999), the health status of the homeless person is whose definition many cannot agree. For the purposes of
extremely poor when compared to the general population. this study, the definition of homeless individual is a person
Many believe homeless individuals avoid seeking care at who lacks a fixed, regular, and adequate nighttime resi-
all costs. However, in a recent study in Boston, it was dence and has a primary nighttime residency that is (a)
shown that 100% of recently deceased homeless individ- a supervised publicly or privately operated shelter, (b) an
uals (n = 13) had experienced multiple recent contacts institution that provides a temporary residence for
with the medical, psychiatric, and substance abuse systems individuals intended to be institutionalized, or (c) a pub-
(O’Connell, Mattison, Judge, Allen, & Koh, 2005). lic or private place not designed for regular sleeping

40
B. Nickasch & S.K. Marnocha
accommodation for human beings (U.S. Department of
Housing and Urban Development, 1987).
In this study, the researcher used a convenience sample
of homeless individuals by contacting a key informant
from the local community clinic who introduced the
researcher to two potential research participants. These
individuals were identified based on their long-standing
relationship with the community clinic and their length of
homelessness. One of these individuals agreed to be inter-
viewed. From this point on, snowball or network sampling
was used to gather the rest of the sample. In other words,
study participants were gained through referrals from
earlier informants. Data saturation was obtained after
interviewing nine homeless individuals.
Criteria for inclusion included (a) 18 years of age or
older, (b) ability to understand and speak English, and (c)
willingness to volunteer for an interview and have the
interview audio-taped. Criteria for exclusion included
homeless children younger than 18 years.
The demographic characteristics used to describe the
sample included age, educational attainment, length of
time homeless, and work history. Previous research had
shown that these characteristics have contributed signifi-
cantly to the understanding of the homeless in Canada
(McCormack & Gooding, 1993). Therefore, it was hypoth-
esized that these demographics would also contribute to
the understanding of homelessness anywhere throughout
the United States.
Demographic characteristics were gathered by self-
report using a pencil-and-paper form. Interviews were
conducted in a quiet location at the local emergency
shelter or local community clinic. The exact location
was determined based on the homeless individual’s pref-
erence related to transportation and comfort level. Both
locations were quiet, confidential, and nonintimidating.
Procedures for data collection
Protection of human participants
Approval from the University of Wisconsin Oshkosh
institutional review board (IRB) for the protection of
human participants was obtained prior to data collection.
An informed consent was obtained from each participant
agreeing to be interviewed. Eight of the participants also
agreed to be audio-taped. All audiotapes are stored in
a locked boxed according to IRB protocols.
Procedures for collecting data
Individualized open-ended questions via a one-to-one
interview were used for data collection. The following four
questions were asked:
Healthcare experiences of the homeless
1. What are some of your healthcare experiences as
a homeless individual?
2. Do you have any suggestions for healthcare professio-
nals related to providing care to the homeless individual?
3. What is your definition of health?
4. Do you believe in an internal or external locus of
control? (The researcher used the analogy of who is driving
your bus—are you in charge of what happens to you or is
someone else in charge of what happens in your life?)
Participants were also asked to complete a demographic
questionnaire related to age, educational attainment,
length of time homeless, and work history. Eight of the
interviews were tape-recorded after gaining written
informed consent from the informants, and the other
interview was transcribed during the interview per
request of the interviewee not to be audio-taped. Inform-
ants were asked four open-ended questions and filled out
a short demographic questionnaire. The interview times
ranged from 20 to 60 min per informant. After completion
of the interview, participants were thanked and given
a $3 food coupon.
Prior to data collection, the researcher engaged in a for-
mal process of ‘‘bracketing’’ to explore and record initial
personal preconceptions, values, and beliefs about the
homeless population. These opinions were formed from
life experiences as well as from the researcher’s current
work as an emergency room nurse and from recent expe-
riences as a nurse practitioner student at the local com-
munity clinic and local emergency shelter.
Following procedures established by Glaser and Strauss
(1967), the process of data collection, coding, and analysis
occurred simultaneously. The researcher continually re-
viewed the data obtained and revised the research ques-
tions to better capture data from the participants. The data
from the first interview were analyzed, and additional
probing questions were added to future interviews.
The questions were continually analyzed and adjusted
to better gain knowledge related to the homeless health-
care experience.
Reliability and validity
A member check was performed to ensure creditability.
Two of the participants met with the researcher after the
study was completed to discuss the common themes that
were identified by the researcher. They were asked to
assess whether they felt that the themes adequately
described their perceptions of their healthcare experien-
ces as a homeless individual. Both participants agreed
that it was an excellent portrayal of their perceptions.
According to Lincoln and Guba (1985), member checks
are the most important technique in establishing credi-
bility of qualitative data.
41
Healthcare experiences of the homeless
Data analysis
As the data were collected (i.e., interviews, participant
observation, field notes), they were coded. The interviews
were transcribed verbatim, data were coded, concepts
were defined, and emerging themes identified. After de-
termining the major overarching themes and concepts, an
extensive literature review was executed to expound/
expand the developing theory. Last, the data were com-
pared with data from past studies to determine if the
emerging themes were congruent. The steps of reduction,
selective sampling of the literature, and selective sampling
of the data were followed to help guarantee that the
sample was adequate and the data gathered were sufficient
(i.e., that data saturation had been reached).
Limitations
The possible limitations identified in this study related to
the adequacy of the sample and included:
1. The sample may be biased because of the convenience
sample technique. The use of snowball sampling may have
resulted in a sample of individuals from the same social
group with similar views. Many times people associate with
those who have similar views and avoid those with differing
views. If this is the case, the results are less generalizable.
2. The methodological challenge of defining the concept of
homelessness might have resulted in inclusion of individuals
who were not representative of the homeless population.
3. The interview format made it difficult for the partic-
ipants to tell their whole story. The brief encounters may
not be truly representative of their entire life experiences.
4. The sample is not generalizable to children younger
than 18 years because they were not included in the
sample.
Results
Demographic data
Fifteen individuals who were purportedly homeless were
identified through snowball sampling. One of the identified
participants did not meet the eligibility criteria for the study
because he did not lack a fixed, regular, and adequate
nighttime residence most days of the month. Four other
potential participants met the criteria but chose not to
participate in the study for various reasons, including fear
of their ideas being published, personal feeling that the
research would not benefit them, it would be a ‘‘waste of
time,’’ and transportation concerns. Nine of the individuals
agreed to participate and completed the interview process.
The average length of homelessness was 7 weeks, and the
range was 4 days to 6 months. Three of the participants had
been homeless prior to this current homeless experience.
42
B. Nickasch & S.K. Marnocha
The ages of the homeless individuals ranged from 18 to
66 years with a mean age of 40.5 years. Four of the
participants were male and five were female. One partici-
pant was African American, one was Native American, and
seven were Caucasian. Four of the participants did not
complete high school. The number of years of education
ranged from 2 years of elementary education through 1.5
years of postsecondary education.
All nine participants in the study had seen a healthcare
provider within the past 3 years, and five of them had seen
a healthcare provider in the past month. Eight of the
participants identified at least one medical condition from
which they were suffering. The medical conditions were
amblyopia, degenerative joint disease, diabetes, hyperten-
sion, hypothyroidism, or migraines. Eight of the partici-
pants suffered from at least one type of mental illness,
including bipolar disease, depression, obsessive-compulsive
disorder, or schizophrenia. Three were recovering alco-
holics and two were recovering drug addicts.
Interview findings
Analysis of the participants’ views of their healthcare
experiences identified a large range of themes. An over-
arching theme of the participants’ descriptions of their life
experiences, specifically in regard to health care, was their
identification of an external locus of control. Within this
theme were four underlying subthemes, including lack of
attainment of physical needs, lack of affordability, lack of
available resources, and lack of compassion of healthcare
providers. Each of these subthemes contained additional
subsets. Figure 1 shows a depiction of this model. The
participants identified an external locus of control as the
main cause of their circumstances. External locus of con-
trol is exhibited in individuals who believe the events of
their lives are controlled by external circumstances, such
as fate or luck. This theory of locus of control is based on
Rotter’s (1954) social learning theory.
For example, one participant said, ‘‘I am totally a victim of
my circumstances . right now I lack complete free will .
life is dictating to me.’’ Another participant stated, ‘‘The
circumstances of my life is why I am where I am.’’ Whereas
a middle-aged homeless man said, ‘‘I don’t have any fucking
control over what happens . life is not fair. You and all your
tooty-fruity friends go home every night to your nice warm
homes and don’t give a damn about us. People should be
more generous.’’ And a young high school dropout in
trouble with the police stated, ‘‘I don’t have any control
over who my parents are, where I lived growing up,’’
implying he is not in control of what happens to him.
Although each participant described his or her individ-
ual experiences in a different manner, they each demon-
strated what is known as the concept of external locus of
B. Nickasch & S.K. Marnocha
External
Locus of Control
Lack of
Attainment of Lack of
Physical Needs Affordability
Inadequate Excessive
Shelter
Inadequate
Insufficient Food
Inadequate
Hygiene
Facilities
Figure 1 Themes and subthemes from interviews.
control. They feel someone or something else is controlling
their life, and they lack many of the resources necessary to
lead a healthy life.
Theme 1: Lack of attainment of physical needs
For many homeless people, unmet physical needs can
lead to a downward spiraling of their health. This is
supported by Maslow’s (1970) theory of the hierarchy
of needs, which postulates that human beings are moti-
vated by unsatisfied needs and that certain lower needs
need to be satisfied before higher needs can be fulfilled.
According to his theory, one must first satisfy the details of
shelter and food prior to satisfying other needs.
Homeless individuals lack shelter, clothing, and healthy
food. When asked why a homeless man decided to live on
the street without shelter rather than stay at the local
homeless shelter, he stated, ‘‘I tried that, I can’t take it, all
the people, it makes my mind go crazy.’’ Another reason
many homeless reported they were on the streets and not
in a shelter was because they were in trouble with the law
or had a felony on their record, therefore disqualifying
them from homeless shelter services. In this study, 33%
(n = 3) of the participants were unable to seek shelter
services because of a history of felony or current con-
flicts with the law. They could receive food with no
Healthcare experiences of the homeless
Lack of Lack of
Available Compassion of
Resources Health care
Providers
Overcrowded
Community Stereotyping
co-pays
Clinics
Inadequate
Health Presumptions
Transportation
Insurance
Lack of
Telephone
Access
questions asked but could not sleep at the shelter for
the night.
One homeless man with poorly controlled diabetes
stated, ‘‘It’s difficult you know. You can’t get three hot
meals in this damn city, just a cold breakfast and a hot
lunch. I try to eat right, I am diabetic, but I eat what I can
get.’’ Another gentleman said, ‘‘I am not getting good sleep,
I am not eating probably as I should and my health in
general living on the streets is stressed.’’
These unmet physical needs place a great burden on an
individual’s health. If one does not sleep well, his or her
immune system is not as effective. One hundred percent
(n = 9) of the homeless individuals interviewed went to
the local Salvation Army and homeless shelter for a cold
breakfast and a warm meal over the lunch hour each day.
However, they struggled with the fact that often they were
not eating as well as recommended considering their
chronic health concerns.
One man with diabetes expressed the frustrations of not
being able to find three warm meals each day and
described how he would hoard extra food from the lunch
program to save for dinner each evening. He emphasized
the fear of developing hypoglycemia some nights because
he was unable to eat appropriately. He was able to obtain
free medications and diabetic testing supplies but seldom
43
Healthcare experiences of the homeless
took the recommended amounts of insulin for fear of
hypoglycemia related to lack of access to meals.
Theme 2: Lack of affordability
The participants felt that the term ‘‘free clinic’’ was used
too loosely. A homeless woman stated, ‘‘There is no such
thing as a free clinic,’’ and a homeless man said, ‘‘Plus, it
isn’t free like they say it is. Where am I going to find the
$9.00 just to see the doctor . ?’’ ‘‘I feel like a beggar . it
hurts your self esteem . it puts you in a depressive state.’’
Eight of the participants alluded that it is difficult to get
insurance; ‘‘to get health insurance here in (city) you have
to be disabled, blind, crippled or crazy . ’’ and even with
insurance, the cost of the office visits, medications, and
treatments, it is more than most can afford. None of the
nine study participants had health insurance.
A young lady with a seizure disorder stated, ‘‘Yes, um I
have about $80,000 in medical bills . it could be closer to
the $100,000 mark . it is absolutely terrible because
everything is based on money . I have always been
a second class citizen when it comes to medical attention.’’
She goes on to say that she wanted to attend the community
smoking cessation program, but she was not able to because
she did not have the ‘‘$9.00 it costs to walk into the door.’’
Another woman portrays a picture of society through
her eyes by this statement, ‘‘Okay it just is hard to look out
at everyone when everyone you see look like they got. You
know what I am saying? Here in (city) . they hide all their
homeless, they put them in the corner somewhere. Now
when you walk down, when you go down (city), Wiscon-
sin you wouldn’t believe there are homeless here. (City)
hides their stuff. They kick them over in the corner and
cover it up. I’ve learned that since I been here. I didn’t
know (city) had homeless people. I did not. . You don’t
see no bums on the street here.’’
One hundred percent of the participants in the study
also alluded to the difficulties they encountered trying to
obtain health insurance and also the financial burden that
paying for the insurance placed on them. Jezewski’s
(1995) study on homeless found that lack of health insur-
ance was a major barrier to health care.
Theme 3: Lack of available resources
Another homeless adult with schizophrenia expressed
his need for assistance with the paperwork: ‘‘But I can’t fill
out that paperwork with my mind racing like it does . if
they would have taken the time to help me fill out the
paperwork that would have helped a lot . Just the way I
was feeling, my mind racing, . ’’ This statement expresses
frustration with the system and has been shown in mul-
tiple studies on homelessness. Jezewski’s (1995) study
44
B. Nickasch & S.K. Marnocha
about the core of facilitating health care for homeless
persons describes the problematic paperwork maze that
homeless people must struggle through to obtain adequate
care. He identified the struggle to complete all necessary
paperwork as a major obstacle to care.
All participants in the current study verbalized that they
were aware of the local community clinic, but 67% (n = 6)
felt that the services were not available when they needed
them. They perceived the community clinic as better than
nothing but expressed frustration with the lack of timeli-
ness. For instance, when asked why they did not use the
community clinic, one participant stated, ‘‘I think they are
too busy and I am not sure they’d have time for me. I know
a lot of people wait days to get in and that it is really
crowded.’’ Another said, ‘‘If they are gonna provide assis-
tance to the homeless or the low income, make sure that
they provide it in a timely and professional manner versus
making people wait to go through a lot of red tape to get
what they need.’’
Several participants elaborated on this theme by
describing the difficulties they have encountered trying
to set up services or appointments. The homeless indi-
vidual lacks a permanent address or a telephone number,
which makes scheduling of doctor’s appointments and
utilization of community resources more difficult. One
participant emotionally vented about her frustrations
related to applying for county services, giving a detailed
explanation of the application process, phone tag, and
difficulties receiving the appropriate paperwork because
she had to use someone else’s mailbox for a return
address. What frustrated her most is she ‘‘didn’t have
the damn stamp’’ to mail it back when she finally received
all the appropriate paperwork.
Eight of the participants expressed concerns related to
a lack of affordable transportation. For instance, one
homeless woman stated, ‘‘There were some times that
they wanted me to get a blood test, and I didn’t get it until
later cause I couldn’t get there . ’’ She went on to describe
her struggle with being disabled and the lack of bus services
in the county in which she lived. She stated that she did not
have enough money for cab services and the county lacks
resources to provide taxi vouchers, leaving her without
many options. She was compassionate about the fact that
‘‘transportation is a big issue,’’ and being disabled with
a medical diagnosis of seizure disorder makes getting
a driver’s license impossible.
Theme 4: Lack of compassion
Many homeless expressed feelings of disappointment
with how they were treated. They felt that they were
judged by their appearance. As one homeless man stated,
‘‘It is hard to stay clean when you live on the street. If you
B. Nickasch & S.K. Marnocha
notice, you can’t really tell I am homeless by the way I am
groomed, but my clothes are filthy. I shave everyday, and
clean up at restrooms and stuff, but it is hard to wash
laundry cuz even when I scrape up enough money to do
laundry at the Laundromat I can’t wash the clothes I am
wearing you know. It is difficult you know, living on the
streets, I am a person too, have some fucking compassion,
I am not a piece of shit.’’
‘‘Well, it seems like I was just another part of their job.
I didn’t feel like a . person, I just felt like I was part of their
job and they shoved me through. Get me in and out as fast
as they can. A kind of process.’’ ‘‘I may be homeless . but I
am still a person. Regardless, I need some respect. I am not
just a number, or something, or an obstacle that someone
needs to overcome.’’ ‘‘And I don’t understand how people
of a profession to save lives work for money. I don’t see
that. Yes you have to live, and the money you get you can
live real good off of, but there are people that don’t have
that money to pay to you and you took an oath to take care
of these people. How can you turn them down and let
them go out there and die?’’ She goes on to describe some
of the lack of compassion she has seen in the healthcare
industry.
Another homeless person’s advice for the healthcare
provider providing services to the homeless was, ‘‘Be
compassionate. Don’t think I am a lazy no good son of
a bitch just because I am homeless. Don’t think I have no
feelings just because I don’t cry when I tell you about my
abusive relationships. Ask me lots of questions, because I
am more likely to tell the whole story if you give me more
than one chance to answer the tough question. I am an
abused woman I need help, from compassionate and
caring health care providers.’’ ‘‘Don’t judge me strictly
on my past. Give me a chance to talk.’’ ‘‘Don’t cut me
off. I made a few bad choices recently but that doesn’t
mean I am a bad person.’’
Discussion of results
The goal of nursing research is the discovery of a theory
from data generation and analysis to explain a particular
phenomenon. Glaser and Strauss’ (1967) grounded theory
approach to qualitative research is an excellent approach
to use when interested in the social experience. It allows
the researcher to uncover the inner meaning of a particular
life event.
The current research study is supportive of this theory.
This is evident in the participants’ candid description of the
challenges they meet as homeless people. Each participant
described his or her life as being controlled by external
surroundings. They described a lifestyle with unfulfilled
physical needs, unaffordable and unavailable health care,
and perceptions of uncompassionate care.
Healthcare experiences of the homeless
Analyzing the transcripts and scrutinizing the major
statements led to an overarching theme and four subsets.
Through the use of constant comparison and level I, level
II, and level III coding (Glaser & Strauss, 1967), it is likely
fair to say that a commonly held theory of fatalism in the
poor and homeless was validated with this research.
Healthcare providers will be able to use this insight to
examine their own feelings and improve the care they give
to homeless people. It is essential to improve relationships
with homeless clients and the management of chronic
disease in these difficult circumstances.
Conclusions
The following conclusions are based on the results of this
study: The great majority of homeless people have an
external locus of control. Therefore, most homeless indi-
viduals feel they are not in control of what happens to
them; whatever happens is outside of their control.
Healthcare providers need to be aware of this when assess-
ing and managing the health of a homeless individual.
Healthcare providers may need to readjust their interven-
tions to better serve this population.
Most homeless individuals lack the necessary resources
needed to meet their physical needs. Healthcare providers
must make sure the most basic physical needs of shelter,
air, water, and food are met before trying to address con-
cerns related to health. Assisting the patient to find shelter
may be the most important step that can be taken by a
healthcare provider. It is essential to get back to the basics.
Most homeless individuals lack the financial resources
to seek health care. If they are lucky enough to see a health-
care provider, they may not have enough money to follow
through on discharge advice. Healthcare providers must be
diligent in asking the questions related to how patients will
afford a medication or treatment device. If patients are
unable to afford the medication, the prescription will be of
no use to them. Healthcare providers need to assess the
situation and seek alternatives for obtaining necessary
resources for patients. Another similar conclusion relates
to the availability of resources. Increasing the numbers of
community clinics will not be effective if the people in
need cannot access their services. The availability of tele-
phones and transportation services is integral to the uti-
lization of services. Just having the services is not good
enough; healthcare providers must be aggressive in their
outreach efforts to get the services to those in need.
Last, 100% (n = 9) of the participants felt that healthcare
providers lack compassion. Healthcare providers must
remember that all individuals deserve basic health care.
It is a human right to feel respected and have someone
listen to one’s needs and an important part of each indi-
vidual’s well-being. It is essential to keep one’s biases in
45
Healthcare experiences of the homeless
check when caring for diverse populations and to provide
compassionate care to all those in need. Healthcare pro-
viders must focus on helping the homeless overcome their
problems by demonstrating unconditional positive regard.
Accepting individuals for who they are with openness and
genuineness (Rogers, 1951) is a core nursing value.
Implications
The role of the healthcare provider is one of collabora-
tion with individuals regardless of their social, economic,
or personal beliefs. Working with homeless individuals is
a unique situation about which many healthcare providers
feel uneasy. Providers may lack the education and support
necessary to fully understand this diverse population and
their unique needs. A decrease in acute illnesses and an
increase in the effective management of chronic disease
resulting in fewer long-term complications and medical
costs because of these unnecessary complications could be
seen. Healthcare professionals may also volunteer to
become more involved with the care of the homeless if
they were confident in their skills. Improving the health of
the homeless in the community will result in improve-
ments in the overall health of the community.
Nursing research
Future research must focus on the homeless individual’s
needs related to health care. The diversity of the homeless
population and the needs of the homeless are unlike any
needs found in other groups of individuals. Both qualita-
tive and quantitative research is needed to focus on how to
initiate better services and provide better care while
empowering those who are homeless to have a greater
sense of control over their lives.
Specific studies with select homeless populations would
be beneficial; for example, little is known about the health-
care needs of homeless individuals with diabetes. It may
also be beneficial to repeat this study of the healthcare
experiences of the homeless with a larger, more diverse
sample in other geographic areas, particularly urban and
rural populations.
Summary
The opportunity to interview nine homeless individuals
has provided insight into the views of the homeless in
regard to health care. The identification of an external
46
B. Nickasch & S.K. Marnocha
locus of control and the lack of attainment of physical
needs, lack of affordability of care, lack of available resour-
ces, and the lack of compassion on the part of healthcare
providers were very evident throughout all interviews.
These insights can help improve the care provided to
homeless populations.
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