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A day in the life of ... a lead nurse for the homeless

Our house is a very mad house with four children under the age of eight, a dog, a working mum and a minister as dad. It usually comes to life at 7.30am as I get up and organise the children. At about 8.45am my husband drops me off at the GP practice where I work.

I have only recently started working at the practice; before I was working as a locum practice nurse and had a contract with the surgery that provides the homeless care. I work 15 hours a week, providing five sessions of general nursing care and chronic disease management. It is a varied job, and I have recently started a master's course in nurse practitioning, which should enable me to provide a better service of care as I am the only practice-based nurse. Working by myself also forces me to meet regularly with other primary care nurses in my locality, as I have to ensure my practice is up-to-date.


This is a busy practice in a largely residential area. We have nearly 2,800 clients registered. The client list covers all social classes and ages. Many live in a nearby large housing estate where low income is prevalent and there are many social problems. I have a good working relationship with Lisa, our health visitor, and Kelly, the nursery nurse. As a small practice we are able to communicate effectively and form a unified approach to care. An example is our attitude to those who "dna" (did not attend) for baby immunisation. We have managed to improve the uptake on immunisations and are now achieving national targets. Thankfully, this team was already in place when I started here.

When I arrive I head for reception and pick up any messages. The beauty of a small practice is that there are few messages so they can be dealt with quickly. As I am the only practice nurse, paperwork is a large part of my role. Our busiest time of the year is March through to June due to our audit work.

My session runs from 9.00am to 11.50am. The morning passes quickly. Today I see 12 patients and do everything from new-patient checks to providing travel advice. I do have set clinics for diabetes, asthma, coronary heart disease and baby immunisations. The rest of my appointments are for general nursing care. This means that my day can be extremely varied.

At 11.50am I have 10 minutes to catch up on paperwork.
I run overtime as I need to order some minor surgery supplies for later in the week and Japanese encephalitis vaccine for a client going backpacking around Asia.

A quick cup of tea and I run to catch the bus. I am now off to the direct-access hostel for the homeless. Bournemouth ranks in the top 10 for homeless figures. The hostel was opened in September 2002. It is a purpose-built building with accommodation for 40 residents. Before this new building there was a day and a night shelter in an old church near the town centre, run by a charity. The accommodation was very basic but it met an important need in the local community.

When plans for the new building were developed, the service was put out for tender and Bournemouth Churches Housing Association took it over. The existing medical services were completely moved over. These services are provided for by the surgery I worked in previously as a practice nurse. They have kept me on contract to continue this work, and I have done so since 2000. The medical service is put forward as a tender to the PCT on a regular basis. They provide the salaries for both the doctor and myself, and the GP employs me directly. The main problem with this system is the lack of funding for equipment such as a telephone line. Various people use the room, so who should fund it? A lot of the equipment we have we received from charitable organisations.

A GP attends the hostel twice a week, and I run a drop-in clinic three times a week. We share the suite with a community psychiatric nurse, who I try to speak to once a week. We both attend local council action groups on a regular basis.I head to reception when I enter the building and am handed a walkie-talkie and a list of clients who want to see me today. Safety is an important consideration in the hostel. The medical rooms are on the second floor away from the main day centre. There is a panic button, and staff are always on hand to help.

Today five clients have asked to see me, but they may not all be here. People who are homeless are not known for their good timekeeping! I suppose when you do not have a timetable to your day timekeeping is not so important. Today I wash and dress one man's feet. He has cellulitis and is a chronic alcoholic and I do not think he has been taking his antibiotics. He promises he will see me on Wednesday. I also see a man who wants to be referred to a primary treatment centre. I have not seen him before so I take down his details. During his consultation he is registered as a temporary patient with the doctor at the hostel. I arrange for him to make an appointment to see the doctor tomorrow.

Forms need to be updated on a regular basis, and we can see up to 30 new clients in a week. It is a very mobile population as clients sometimes find help at the local YMCA or move back home. There are a few regulars who I have gotten to know quite well. They often greet me in the street!

Today only two people from my appointment list have turned up. I manage to review the client notes and tidy the room. As I leave I get a message that someone else needs to see me. A member of staff brings up a young lady who thinks she may be pregnant. She is relieved to find she is not pregnant, and we chat about contraception. She was on the contraception injection in the past.

After an interesting morning I sign out of the hostel and say my goodbyes to the staff. Every day is different at the hostel. Sometimes people just want to talk and use the excuse of a minor ailment to see me. I see a wide range of clients with anything from minor ailments to seeking help for detox. Obviously there are a large number of clients who take illicit drugs or are dependent on alcohol. These individuals do not always start on the streets with dependency problems. Some have lost everything for various reasons and turn to drugs or alcohol to help them cope. The satisfying part of my job is seeing people trying to change their lives, but it is exasperating trying to help when there is such a shortage of funds for treatment. Often other addicts become their "family", and they will be in constant association with them unless they are rehoused. Some clients who I have got to know well have died of an overdose or other drug-related complications.

As a nurse rather than a doctor there are opportunities to develop a good rapport with clients. Some have found it difficult to register with doctors or have had a previous bad experience. A lot of what I do comes under the title of health promotion. This work does not end at the hostel - I often chat to people on the streets. Last year I was able to identify a patient with tuberculosis and get them treated, just by speaking to them on the street. I try to treat clients in a holistic way. A lot of what I do now comes under the remit of a nurse practitioner, and I would like to see the service develop to a nurse-led service because of the benefits to the client group.

I do feel limited in the care I provide, but know that the course I have recently started will make a difference. One benefit is that I am improving my health assessment and diagnosis skills. The title of nurse practitioner has also given me extra credence with other health professionals.

Today I get home at 2 o'clock and have an hour before I have to collect the children from school.

I find both jobs very satisfying. I am working in an advancing field of nursing and have a vision for future practice development. I have a good working relationship with the doctor in the surgery where I am based, and I have been able to start new clinics. The homeless work has huge scope for improvement. I would like to see a more integrated team of health professionals offering a wider range of services, such as dentistry and chiropody. The work needs a higher profile within the PCT and local council. That will develop as long as those who work in it have a vision for improvement.