Public Health Nurs. 2017;34:585–591. wileyonlinelibrary.com/journal/phn | 585© 2017 Wiley Periodicals, Inc.
S P E C I A L F E A T U R E S : C L I N I C A L C O N C E P T S
Enhancing a public health nursing shelter program
Margo Minnich DNP, RN | Nancy Shirley PhD, RN
Creighton University College of Nursing, Omaha, NE, USA
Correspondence Margo Minnich, DNP, RN, Creighton University College of Nursing, Omaha, NE, USA. Email: firstname.lastname@example.org
Abstract The Shelter Nurse Program offers important nursing care and resources that help meet the health needs of the homeless population and improve the health of homeless individuals and families. However, formalized program goals and objectives, along with an evaluation plan that demonstrates population outcomes, had never been devel- oped even as the program has evolved over time. Thus, the agency sought our assis- tance as public health nursing consultants to enhance the overall program to improve the health of the homeless population. To accomplish this, we worked with the agency and the shelter nurses throughout each step of the process to assess the needs of the program, develop appropriate goals and objectives, and develop an effective outcome evaluation plan for the existing Shelter Nurse Program. Lessons learned included the value and applicability of the selected program development model, the importance of agency ownership and active participation by front- line workers, and the value of edu- cating the workers and introducing resources throughout the process.
K E Y W O R D S
homeless persons, program evaluation, public health nursing practice
1 | ENHANCING A PUBLIC HEALTH NURSING HOMELESS SHELTER PROGRAM
A public health nursing service in a Midwestern metropolitan commu- nity contracts with area homeless shelters to provide care to homeless individuals and families. This Shelter Nurse Program began in 1987, when public health nurses who were serving families began noticing increasing numbers of referrals for women and children living in area shelters. When the program began, it served only women and children, but has since expanded to serve all homeless individuals and families living in the community. The public health nurses serving the shelters strive to ensure homeless individuals have access to needed health- care, social services, and other community resources. The nurses ad- dress acute and chronic health issues, assess health needs, perform first aid and injury care, provide health education, and make referrals to healthcare providers and other community agencies.
The Shelter Nurse Program offers important nursing care to meet the health needs of homeless individuals and families. The public health nursing service, along with community members, acknowl- edge the good work being done by shelter nurses and recognize that the nurses positively impact the health of the individuals they see.
However, formalized program goals and objectives, along with an eval- uation plan that demonstrates population outcomes, had never been developed.
All nursing care, including public health nursing care, should be evaluated for effectiveness (Tymkow, 2014). Understanding this, the public health nursing service became interested in developing a comprehensive evaluation plan for the Shelter Nurse Program. Because an evaluation of this kind is not easily done, particularly with the homeless population, the agency sought assistance from the authors, public health nursing consultants at a local university. The public health nursing consultants included two doctorally prepared College of Nursing faculty members specializing in public health nurs- ing. Initially, the agency undertook this project simply to gather data about the effectiveness of the program. The agency planned to use the evaluation to improve the quality of the program and the health status of the population, and to seek sustainable funding sources to support the work of the Shelter Nurse Program. To accomplish this, we worked with the agency and the shelter nurses to assess the needs of the program, develop appropriate goals and objectives, and develop an effective outcome evaluation plan for the existing Shelter Nurse Program.
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2 | ORGANIZING FRAMEWORK
Grimes and Weller (2012) introduced the Elements of the Program Development and Evaluation Process Model to guide public health program development. The model recommends a continuous cycle of program development and evaluation that can begin anywhere in the process, but includes analysis of the problem, specification of goals and objectives, development of a program plan, and implementation and evaluation with specific actions for each phase (see Figure 1). We selected the Grimes and Weller model for this project because many elements of the Shelter Nurse Program were already in place and this model allowed us to analyze the program as it existed, building on the elements that were effective while enhancing those that needed development, without establishing a completely new program. We used this model to guide the process for this project, serving as the methodology, with each phase of the process building on the previ- ous phase.
3 | ANALYZE THE PROBLEM
Following the phases of the Program Development and Evaluation Process Model, we began by analyzing the problem (Grimes & Weller, 2012). Our first step was reviewing the current literature for home- lessness and health issues. This information helped us to understand the problems faced by homeless individuals, helped determine the ex- tent of these problems within the population, and identified the fac- tors that directly and indirectly contribute to these problems and the subsequent nursing interventions that may be needed.
A complex and multifactorial connection exists between home- lessness and poor health (National Health Care for the Homeless Council, 2011). Acute and chronic health problems and associ- ated circumstances related to those health problems, such as job
loss and depletion of personal savings, can lead to homelessness (Burke, Johnson, Bourgault, Borgia, & O’Toole, 2013; Daiski, 2007). Homelessness, in turn, can lead to new health problems and exacerba- tion of existing health problems. Living on the street and in crowded shelters places homeless people at high risk for certain health prob- lems, including infectious diseases (Feske, Teeter, Musser, & Graviss, 2013; Notaro, Khan, Kim, Nasaruddin, & Desai, 2013) and harmful weather exposures (Frencher et al., 2010). People who do not have stable housing often lack the resources to properly manage chronic diseases. For example, hypertension, diabetes, and asthma require rigorous self- care management, including medication, diet, and envi- ronmental controls, all of which are difficult without a stable home (Bonugli, Lesser, & Escandon, 2013; Daiski, 2007). Healing and recu- peration from minor health issues like cuts or common colds may be complicated or delayed due to difficulties with proper hygiene and rest (Bonugli et al., 2013; Frencher et al., 2010). The health of this popula- tion is often complicated by co- occurring physical, mental, substance abuse, and social problems (Bonugli et al., 2013; Daiski, 2007; Levitt, Culhane, DeGenova, O’Quinn, & Bainbridge, 2009).
The literature addressing healthcare and homelessness is vast and addresses a wide variety of topics including the physical and mental health needs of individuals and various interventions provided in clin- ics or other settings (Hwang & Burns, 2014). However, there is lim- ited literature available on public health nursing and the population of homeless individuals.
One systemic review by Speirs, Johnson, and Jirojwong (2013) identified six true research studies that evaluated outcomes of public health nursing care for a homeless population. Public health nurses were generally able to improve the knowledge and health behaviors of the homeless population (Speirs et al., 2013). Other studies demon- strated positive findings as well. Public health nurses working with nursing students on a social marketing project improved flu vaccina- tion rates among shelter clients (Metcalfe & Sexton, 2014). Homeless
F IGURE 1 Grimes model for program development and evaluation [Color figure can be viewed at wileyonlinelibrary.com]
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clients demonstrated improved knowledge about specific communi- cable disease and overall well- being after participating in health pro- motion activities conducted by public health nurses (Nyamathi et al., 2013). Most significantly, homeless individuals reported improved vitality and mental health status with decreased substance use after receiving basic public health nursing services, similar to those pro- vided by the Shelter Nurse Program (Savage, Lindsell, Gillespie, Lee, & Corbin, 2008). These positive findings and the limited number of public health nursing intervention studies with the homeless popula- tion make this as an area for further study and suggest the need for a strong evaluation plan for the Shelter Nurse Program.
We continued our analysis of the problem by collecting data about the Shelter Nurse Program directly from the nurses working in the pro- gram. We received preliminary information from the program direc- tor, worked alongside each of the nurses, and observed their work at the shelters and with clients. We interviewed the nurses using open- ended questions about their priority goals in working with the pop- ulation, typical interventions, and process for documentation. After completing this data collection, we met with the nurses and director as a group to clarify and confirm our findings.
Our findings indicated that the shelter nurses, like most public health nurses, have a wide range of responsibilities. They provide indi- vidualized nursing care for the shelter residents. They provide health promotion services such as health education and vaccine support for the shelter population. Additionally, the nurses act as health liaisons between clients, shelter staff, community agencies, and healthcare providers. In this role, they provide education and guidance to shelter and other community agency staff.
The shelter nurses maintain a high level of autonomy. Each of the shelter nurses keeps a schedule of shelters and programs where she provides services and organizes her practice based on professional as- sessment, judgment, and national standards of practice. The nurses work in different kinds of programs, including many emergency home- less shelters and transitional housing shelters, as well as drug and alcohol treatment programs, shelters for battered women, an emer- gency drop- in center for youth, and a case management program for chronically homeless persons who are at high risk for health complica- tions wherever they are housed. The various programs and the clients served by them have different needs and required services and the nurses adjust their care to meet these needs. As a result, the nurses have adapted different goals and systems of documentation depend- ing on the uniqueness of the facilities and clients being served. This has made overall evaluation of program outcomes difficult.
Before we began, evaluation of the Shelter Nurse Program had largely consisted of documenting assessments and interventions on individuals and compiling numbers and demographic information of client contacts each day on a standardized flow sheet. However, given the transient nature of the homeless population, follow- up was often not possible, so the tracking only counted the numbers of new and established clients and the services provided. It did not evaluate outcomes for the population and provided no evaluation of the effec- tiveness of the program. The agency further conducted client satisfac- tion surveys annually. These questionnaires were administered to the
clients served by the shelter nurses for a scheduled period each year. The survey asked the clients to rank the nurses on several areas in- cluding: “The nurse treated me respectfully” and “The nurse instructed me on how to meet my health needs.” The survey further asked for comments. These assessments focused on client satisfaction, provided only a limited evaluation of the Shelter Nurse Program, and did not provide any information on the impact the nurses have on the health of the homeless population. This review of literature and analysis of the current program helped us move to the next phase to develop goals and objectives.
4 | SPECIFY GOALS AND OBJECTIVES
During our interviews with the shelter nurses, we discovered that the nurses each had several goals in their work. We met with the nurses as a group to discuss themes from our observations and interviews and identified key program goals. The nurses identified priority goals for their work including: establishing a regular source of care, assessing clients and prioritizing issues for individuals, managing medication and other treatment, referring to appropriate healthcare and social ser- vices, establishing relationships with clients, and establishing relation- ships with the agencies. To develop a strong, sustainable evaluation plan, we decided, together with the nurses, to start with only a few prioritized goals and objectives.
At this point, we reviewed the Healthy People 2020 program and website (United States Department of Health and Human Services, 2014) with the nurses and discussed relevant goals and objectives for their work in the Shelter Nurse Program, focusing on the goals and objectives that best captured what they had identified during our interviews. During this time, we were driving the work. However, after that meeting, the nurses spent time considering all we had discussed and reviewing Healthy People 2020 on their own. They identified objectives that best described the impact that they hoped to have on the improvement of health in the homeless pop- ulation and came together at their next regular monthly meeting, without us as consultants, to finalize their priorities. The program director reported their decisions back to us. This was the first time we saw evidence that the shelter nurses were taking ownership of this program improvement project.
Once the nurses identified the direction they wanted to take, we formalized the program goals and objectives and submitted them to the nurses for approval. We worked collaboratively with the shelter nurses, discussing back and forth until we had goals and objectives that the nurses agreed were appropriate and would meet the needs of the program.
• Goal 1: Improve access to comprehensive, quality healthcare services. ○ Objective: Increase the percentage of persons who report
having a source of ongoing healthcare. • Goal 2: Improve health-related quality of life and well-being for all
individuals in the program.
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○ Objective: Increase the percentage of adults who report good or better general health
• Goal 3: Improve self-efficacy in disease and health self-care man- agement for all individuals. ○ Objective: Increase the percentage of adults who report feeling
able to take care of their health. • Goal 4: Improve follow-up for referrals.
○ Objective: Increase the percentage of individuals who follow up on referrals.
The selected goals and objectives were consistent with the agency vision to improve the lives and health of people in the community. Additionally, these goals and objectives met the needs of the program and could be used to plan the program and develop an appropriate eval- uation strategy.
5 | PLAN THE PROGRAM
Following the Grimes Model, the planning phase would build on the goals and objectives identified in the previous phase (Grimes & Weller, 2012). The shelter nurses implemented evidence- based interventions every day that addressed the goals and objectives developed for this program and had many anecdotal stories of individuals they had helped. In fact, the goals and objectives developed out of the work the shelter nurses were already doing. However, the standardized flow sheet only documented certain interventions, and the agency wanted to track the interventions used by the nurses more comprehensively.
Thus, this phase focused on developing a system to standardize the documentation of the nursing care and client outcomes so that the information could be used in program evaluation.
To help with this, we introduced the Minnesota Department of Health Division of Community Health Services, Public Health Nursing Section (2001), previously known as the Public Health Intervention Model and often referred to as “The Wheel” (Keller, Strohschein, Lia- Hoagberg, & Schaffer, 2004) to define the public health nursing inter- ventions for the Shelter Nurse program. This model, utilizing a wheel image, defines the scope of public health practice by the type of in- tervention and the level of focus as individual, community, or systems, rather than the location where services are provided (see Figure 2). The Intervention Wheel is population- , practice- , and evidence- based, making it ideal for identifying and describing the interventions for the Shelter Nurse Program (Keller, Strohschein, Lia- Hoagberg, et al., 2004). This model focuses on the population, while looking at individ- ual interventions, reflecting the practice model for the Shelter Nurse Program. Since the model arose from analysis of the actual work car- ried out by practicing public health nurses, it is immediately useful for public health nurses working in shelters. Furthermore, it has been used in a wide variety of research with public health nurses and other public health professionals, making it highly applicable to the Shelter Nurse Program (Keller, Strohschein, Schaffer, & Lia- Hoagberg, 2004).
The Intervention Wheel provides public health nurses a consistent way to explain how their practice contributes to the improvement of health in the population (Keller, Strohschein, Lia- Hoagberg, et al., 2004). Various agencies have used the Intervention Wheel to develop
F IGURE 2 Public health interventions wheel [Color figure can be viewed at wileyonlinelibrary.com]
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position descriptions, educate staff, plan programming, manage daily work of programs, and develop effective documentation (Keller, Strohschein, Schaffer, et al., 2004). This model would allow nurses to use the 17 interventions and levels of focus presented in the model to document their interventions as part of an overall evaluation plan.
In addition to documenting interventions, we wanted to track progress toward the established objectives. We decided to develop the evaluation plan based on something that was familiar to the shel- ter nurses, because this would help foster buy- in from the nurses and long- term sustainability. We considered two possibilities: we could ei- ther implement an evaluation plan based on the flow sheet the shelter nurses completed daily to document their work, or we could imple- ment an evaluation plan annually during the client satisfaction survey. After discussing this with the nurses and reflecting on program needs, we decided that we wanted true program evaluation that would be on- going throughout the year. So, with input from the shelter nurses, we developed an evaluation tool that built on the flow sheet the nurses used to count their patient contacts. We extended the flow sheet with columns to document interventions and measures for each of the ob- jectives. At each client contact, the nurses would document the inter- ventions that were used. Additionally, they would document progress toward objectives. We discussed many options for documenting this. The nurses felt that it was best to answer some questions with a sim- ply yes/no response. For example, the nurses asked each client at each contact if they had access to a regular source of care and entered yes or no on the flow sheet. For other measures, the nurses decided to use a 10- point scale to best reflect changes in client response from visit to visit. For example, the nurses asked the clients to rank on a 10- point scale how healthy they felt and recorded that number. We reviewed the flow sheet with the nurses and the nurses developed a spread- sheet they could complete during each visit.
6 | IMPLEMENT AND EVALUATE
Finally, we worked through the last phase of the Grimes Model: im- plementation and evaluation (Grimes & Weller, 2012). The shelter nurses piloted the tool in their day- to- day work for two weeks. We learned several important lessons. First, this system for ongoing evalu- ation was cumbersome and time- consuming for nurses to conduct at each visit. Many of the client contacts were quick and the evalua- tion added several questions, making visits take significantly longer than expected. The clients expressed confusion as to why they were being asked so many similar questions at each visit. Additionally, many
of the clients struggled using a 10- point scale to report how good they felt or how well they felt they could meet their health needs. We again considered the possibilities for the program evaluation. We could reduce the number of questions asked or shorten the scale from 10- points to 5- points. However, because of the response from clients and their experiences during the pilot, the nurses felt they could not sustain this kind of evaluation throughout the year. They wanted a more comprehensive evaluation addressing each of the objectives and they felt the survey questions fit better with the client satisfaction survey, so they decided to conduct the evaluation during a 2- week pe- riod annually. This was another point at which that we saw the shelter nurses taking ownership of this project. It became clear that we were acting as consultants on their project and they were ready to finish this on their own.
After the pilot study, the agency set aside the evaluation plan until they conducted the annual client satisfaction survey. The format for the survey remained the same as used previously with some minor, yet significant, changes. The new survey gathered information about the length of time clients had accessed care with the Shelter Nurse Program, an important variable to consider for program outcomes. Furthermore, the nurses changed questions and the wording of ques- tions to be consistent with the evaluation plan. For example, the question, “The nurse instructed me on how to meet my health needs” changed to “After meeting with the nurse, I am better able to take care of my health needs.” The shift reflects a focus on outcome evalu- ation measuring the established goals and objectives for the program. This evaluation was done entirely by the Shelter Nurse Program staff, demonstrating total ownership of the program development and eval- uation project. The agency felt that this evaluation plan addressed the established goals and objects and best met the needs of the agency and their clients. The Shelter Nurse Program will continue to use the evaluation tool to promote quality improvement and secure sources of funding for the program.
7 | LESSONS LEARNED
We learned many lessons throughout this project. First, this project reinforced the applicability of the Grimes Model for use in program development and evaluation for existing programs. Program develop- ment and evaluation should happen in a cyclical, nonlinear fashion. This is especially true for existing programs. For this project, using this approach allowed us to work with the shelter nurses to build on areas that were well- developed while changing those that needed
F IGURE 3 Locus of control and decision- making [Color figure can be viewed at wileyonlinelibrary.com]
Agency Public Health Nurses
Start of the Project Comple�on of Project
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improvement. Establishing goals and objectives was vital for solid evaluation, which had not been done before this project. Furthermore, this model promotes a continuous assessment and improvement pro- cess, encouraging program growth and development over time. Each year, the Shelter Nurse Program staff can evaluate their program needs and conduct appropriate evaluations.
Second, we learned the importance of agency ownership of this process. Early in the process, we worked to foster trust with the di- rector and nurses by meeting with them face- to- face and focusing on their perceived needs, rather than our own. At our first meeting, we brought lunch to share with the staff, promoting a relaxed, collabora- tive environment. We worked in partnership with the front- line work- ers throughout the process and deferred to their expertise. The shelter nurses developed trust for the process and were active participants throughout the project. Most importantly, we began the handoff pro- cess at the start of the project. Once we communicated the framework for the process, the nurses gained confidence and took ownership of the work. We shifted the locus of control over the project from us as the public health nursing consultants to the shelter nurses through- out the project, allowing the Shelter Nurse Program staff to inde- pendently finish the final phase of the project (see Figure 3).
Finally, we learned the importance of introducing resources throughout the process. While all the shelter nurses are public health nurses, many have been out of formal education for some time. They were not familiar with some of the resources introduced during this project, like Healthy People 2020 and the Wheel, or they were not familiar with the use of these resources in a practical way. Introducing the resources at appropriate points in the process allowed the nurses to develop their own understanding of program development and evaluation. While this was not an expectation of this project, it became important for the nurses’ growth, as well as successful completion of the project. Furthermore, this helped the nurses feel included in the process and prepared them for future development and evaluation of this program.
This project utilized the Elements of the Program Development and Evaluation Process Model introduced by Grimes and Weller (2012) to enhance an existing public health nursing program and de- velop a comprehensive evaluation plan. The Shelter Nurse Program staff sought assistance from public health nursing consultants on this project. As the consultants, we worked closely with the shelter nurses throughout each phase of the process. Following the process established in the model and working collaboratively with the shel- ter nurses, we analyzed the problem, specified goals and objectives, planned the program, and implemented and evaluated the program. We learned many lessons throughout this process, including the value of using the Program Development and Evaluation Process Model it- self, the importance of agency ownership and active participation by front- line workers, and the importance of educating the workers and introducing resources throughout the process.
Margo Minnich http://orcid.org/0000-0002-2397-0945
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How to cite this article: Minnich M, Shirley N. Enhancing a public health nursing shelter program. Public Health Nurs. 2017;34:585–591. https://doi.org/10.1111/phn.12353