On the Other Side of the Rails
Homelessness: What’s the Emergency?
I think of emergency nursing as a particular brand of nursing care that occurs before and during medical diagnosis. The definition of an emergency is not the least bit subjective to those of us with specialized training in a specific triage acuity scale; however, it is very much open to interpretation on the part of the patient. Years of nursing work in West Baltimore, first in emergency departments and now in the community, have left me open to other interpretations as well—what is an emergency? And therefore, what is emergency nursing?
Like many instructors at schools of nursing, my colleagues and I were scrambling to find COVID-19 compliant clinical experiences in community health for undergraduate students for the fall of 2020. Prior, my students and I had been doing street outreach that focused on naloxone distribution and training through a neighborhood-based outreach center. However, in the absence of on-site services at the center, such as meals, clothing closet, showers, and laundry, we were very concerned with our homeless neighbors’ ability to meet basic needs, in addition to staying safe from the virus, not getting assaulted, and not overdosing. Out of this struggle, street outreach with essential service delivery was born!
Since the fall of 2020, students and I have delivered food, gallon jugs of water, clothing, hygiene and COVID-19 supplies, and sometimes even tents to homeless neighbors sleeping rough in West Baltimore. We also provide wound care (typically to those injecting drugs, but also to those with open abrasions and lacerations from assault), triage services, naloxone training, and risk-reduction education. A peer recovery advocate is typically with us to usher interested neighbors into recovery. As we stand conversing, food is devoured, and water is used for spot cleaning and brushing teeth. While we dress wounds, we hear stories:
I was jumped last night, he hit me with a brick…
Men sometimes followed me back to the abandoned house where I stayed so I sleep on the sidewalk now…
My buddy found a dead body back there a few weeks back…
I haven’t seen my baby in 6 months, but my social worker says she’s getting adopted…
I don’t go to the emergency room unless I have to ‘cause they hate on us there…
I got hookworm now. They say it’s from not having a place to go to the bathroom…
My students are in their last semester, so I feel as though they are ready to get into the semantics of this. I ask them to consider these homeless neighbors as their patients. They don’t have enough healthful food to eat, or enough water to wash. They don’t get enough sleep because the street is noisy, they are afraid of their belongings getting stolen, and it’s too hot or too cold or too wet. They are afraid for their physical safety. The bottom of Maslow’s pyramid is crumbling beneath them. If that’s not a medical emergency, it must be some sort of nursing emergency. How are we not doing emergency nursing dragging this wagon full of supplies around West Baltimore? My students agree this is the core of nursing by Nightingale standards and this must be some sort of emergency nursing.
Students often use the word “eye-opening” during post-conference, referring to the conditions that their homeless neighbors must endure with little relief. They express that their street outreach experience will definitely enhance their care for patients experiencing homelessness in the future. One student experienced a moral dilemma, asking “How can we just leave them like that?” I shared that in my ED practice, I felt a much bigger moral dilemma in discharging a person experiencing homelessness back to the street where they couldn’t possibly adhere to discharge instructions. As a community nurse I feel a sense of relief working through my neighbors’ problems slowly, week after week, even if I can’t find them sometimes.
My point is this: I want to see homelessness recognized as a nursing emergency. I want nurses of all specialties to recognize this, but especially emergency nurses, who are so often the touch point for people experiencing homelessness. When they are discharged back to the street after a visit, they are discharged back into an emergency. Homelessness can’t simply fall into the purview of community-based nursing. We all need to recognize the emergency, understand the contributing factors, and take emergency action.
I have 3 suggestions on how to improve care for those experiencing homelessness. First, emergency nurses need to screen patients for homelessness and other social determinants of health1. We can’t intervene if we don’t know what’s going on. Second, if your emergency department cares for homeless neighbors regularly, consider hiring a case manager with a Housing First approach2 and a peer recovery advocate3, and designating a space within your emergency department for these disciplines to work with your patients. Third, get to know your local community health workers, including your local health department. Find out if anyone is doing street outreach in the neighborhood around your emergency department, and if so, how might you liaise effectively? I recognize that many emergency departments are under-resourced and lack physical space, but these approaches might jive nicely with the community benefits programs required for many hospitals to maintain their non-profit status. The Housing First strategy (rather than treatment first) reduces ED recidivism substance use, and honors personhood2.
Finally, thank you emergency nurses for all you do to care for this marginalized group! Know that your kindnesses are appreciated beyond what their words can express. I know because they told me.
- Moen M, Storr C, German D, Friedmann E, Johantgen M. A review of tools to screen for social determinants of health in the United States: a practice brief.Popul Health Manag. 2020;23(6):422-429. doi:10.1089/pop.2019.0158
- Adame AL, Perry C, Pierce E. Community and Housing First: a qualitative analysis of USA residents' perspectives.Health Soc Care Community. 2020;28(4):1292-1300. doi:10.1111/hsc.12962
- Waye KM, Goyer J, Dettor D, et al. Implementing peer recovery services for overdose prevention in Rhode Island: An examination of two outreach-based approaches.Addict Behav. 2019;89:85-91. doi:10.1016/j.addbeh.2018.09.027
Megan Doede is an assistant professor of nursing at University of Maryland School of Nursing and a community nurse in West Baltimore. Her areas of expertise include hospital work environments, nursing workforce issues, and the care of low-income, urban populations and people experiencing homelessness. Prior to her graduate work, she worked as an emergency nurse for 13 years and was the recipient of the 2013 Maryland Emergency Nurses Association State Council Scholarship Award. She lives in Baltimore City with her husband and two sons.
How to contribute
We encourage submissions from any reader who has been touched by the healthcare system. Some contributors may be involved directly in patient care and might want to share the impact a patient, family, or colleague had on them. Others may want to write about life “on the other side of the rails” …those moments when the caregiver becomes the patient…or maybe sees healthcare from the vantage point of a family member. Inquiries can be sent to [email protected]