Working with homeless families comes with its fair share of challenges, but what is it like on a day-to-day basis?
Many health visiting teams across the UK currently have a ‘vulnerable families’ or ‘specialist team’ set up on a needs-led basis, with the aim of reducing the health deficit in complex families. One of the earliest homeless health visiting teams was set up by Shirley Goodwin in the early 1980s, in London. At about the same time, four nurses in Toronto were setting up a street health drop-in centre. Homelessness was not and is not confined to the UK.
The term ‘homelessness’ conjures up all sorts of images, and tends to invoke a negative stereotype. Personally, I grew up in Wolverhampton fascinated by the local tramp, Jozef Stawinoga, who lived in a tent for 30 years. He wasn’t homeless; he was ‘roofless’ by choice.
The earliest documented homeless shelters were introduced in the 1930s, offering support to ‘vagrants’. As the increasing number of rough sleepers in London increased in the 1960s, the Shelter and St Mungo’s charities became established, and still support people today. The first legislation to protect homeless people was passed in parliament in 1977 and specified criteria for priority need, which included those who were pregnant or had dependent children. The provision of temporary accommodation was absolutely invaluable as it created visibility for the problem. Many homeless families remain invisible, however, due to transiency, and probably have the highest levels of vulnerability as services fail to keep up with them.
The health visitor role
The specialist health visitor role for homeless families generally incorporates a wider geographical area and smaller caseload than generic health visitors. This supports delivery of an enhanced service to address the health inequalities through comprehensive assessment, planning and implementation of an effective service. There is evidence that homelessness during pregnancy is associated with an increase in infant mortality and morbidity.1 This is compounded by the fact that families tend to crisis-manage health problems, often presenting inappropriately to emergency departments or walk-in centres. Depression and stress can impact on the parent/child relationship and adults have reduced capacity to provide consistent and perceptive nurturing. Establishing a trusting relationship is thus pivotal to delivering an efficacious specialist health visiting service.
Visits are carried out to families within the accommodation and a package of care negotiated, underpinned by the Healthy Child programme.2 It is fundamental that health messages are delivered in a sensitive and timely way to be most effective, and encompass maternal mental health, nutrition and safety, parent-child attachment and early identification of growth problems, ill-health or developmental disorders.
Children in temporary accommodation often lose out on school and nursery education and infants can experience a significant decline in general development function.3 Helping caregivers to provide sensitive, responsive and protective parenting in a stimulating environment is therefore vital to lessen the impact of early childhood adversity. Referral pathways must be clear and there has to be an effective interface between services to champion the best possible care. The challenge for specialist health visitors is the client turnover in the caseload. Liaison is a big part of the role and is reliant on an effective working relationship with housing staff working with the families.
Being a specialist health visitor working with homeless families is the most complex and challenging role I have ever had, and the most rewarding. The most fulfilling element of my role is the last visit to the family when they have moved into a property as it celebrates the end of a journey I’ve travelled with them.
What I do
As a young child I had no great aspiration to be a nurse but that changed at the age of nine. I was involved in a road collision, which killed my father and left me with a much-too-young awareness of the fragility of life. At 17 years of age I worked as a volunteer at a local long-stay children’s hospital. The children were mostly disabled, and the style of nursing very different from now. I also volunteered at local playgroup for disadvantaged children and spent the summer between my A levels helping out on a play scheme. I started my nurse training 30 years ago, still unsure of my chosen career path.
My initial job, once qualified, was working as a staff nurse on the coronary care unit, which ignited my interest in illness prevention. I completed a self-funded part-time health education course over 12 months and was also employed as a part-time practice nurse setting up health promotion sessions. This led me into midwifery and after two years I secured a community post, working in rural south Staffordshire. Discharging families to the health visitor at 10 days postnatal left me feeling unfulfilled, as I did not have the opportunity to see the baby and family grow and thrive.
As a student health visitor I was curious about the specialist role and spent a day with the specialist health visitor for homeless families. She had a trusting relationship with the families and was passionate about finding the most innovative ways to meet their needs. She was responsible for setting up the service in Wolverhampton in 1991 to meet the needs of the increasing numbers of homeless families. Two decades on, she interviewed me, keen to find someone as ambitious in the role as she had been.
And here I am. I love my job and feel privileged to be with families at their most fragile, and overwhelmed by their determination to overcome life’s obstacles and create a better future for their children. On a day-to-day basis I visit families and support them using a holistic approach. I often see families long enough to develop a strong relationship as there may be in temporary accommodation for up to six months. During this time I visit them regularly in the refuge or hostel to ensure there are no unmet family health needs. My final visit to a family is in the new home once they have secured accommodation, prior to handing over to the generic health visiting team. The most essential part of my tool kit is my invisible ‘can opener’ – my effective listening and communication skills that enable me to gain a deep insight into the issues that individuals are really confronting
Being creative has been essential to enable me to find the many potential resources available to the families. Organisations and charities have been extremely generous in their donations of white goods, mattresses and brand-new toys. Most recently, I have acquired 40 brand-new baby play mats to support a project I am launching to address the increased incidence of developmental delay in babies.
Being a specialist health visitor is very enriching, and one of my most recent significant achievements has been to receive the title of Queen’s nurse. This will support me to continue to champion the role and improve patient care. In my spare time I enjoy anything that involves relaxation, reading, spa days, baking or family meals out. I am trustee for a local charity that provides activities for disabled children and am a member of a parents steering group, which influences local services and facilities for disabled children.
My 30-year career in nursing has been a massive learning experience, spending privileged time with humans during their most elated and most vulnerable moments. I wouldn’t have chosen a different path.
1. Stein JA, Lu M, Gelberg L. Severity Of Homeless And Adverse Birth Outcomes. Health Psychology 2000;19:524-34
2. The Healthy Child Programme: Pregnancy And The First 5 Years Of Life. Department of Health, 2009
3. Sleed M, James J, Barandon T et al. A Psychotherapeutic Baby Clinic In A Hostel For Homeless And Homeless Families: Practice And Education’. Psychology and Psychotherapy: Theory Research and Practice 2011;86:1-126