Solohub, N. & Melrose, S. (2008). Challenge and opportunity in an inner-city practicum. The Canadian Nurse, 104(8), 6-8.
Traditionally, most nursing students complete their mental health practicums on in-patient psychiatric units. However, licensed practical nurses pursuing a post-licensure university education can be expected to already have experience in institutional settings. What they are not as likely to have had are opportunities to join multidisciplinary teams providing community mental health care, particularly to inner-city clients. In this article we describe a unique practicum one student was involved in as part of a psychiatric/mental health nursing course for online students in the Post-LPN BN program at the Centre for Nursing and Health studies at Athabasca University.
Although few community agencies have been able to accommodate our requests to place nursing students, Boyle Street Community services agreed to accept and preceptor Nicholas Solohub, a post-LPN student, for an eight-week, full-time practicum. In his journal entries, Nicholas offered his initial impressions of the agency, his growing understanding of stigma and the development of genuine regard for the inner-city clients and agency staff. Some of those entries are shared here.
Boyle Street, established in 1971, is a multi-service agency serving over 8,000 people each year. Its programs, designed to meet the individual and community needs of people in the inner city, include an adult outreach service, housing support, youth and adult drop-ins, and group homes for children and youth.
The agency also collaborates with Streetworks to deliver harm reduction services to injection drug users.
In one of his first journal entries after he started working at the agency, Nicholas wrote:
I entered this practicum both as a student and a practising LPN with four years of experience on an acute orthopaedic surgical unit. I had cared for the mentally ill, the homeless and clients with addiction problems. But the interactions were entirely within an institutional environment providing acute postoperative care; there was no time to understand a client’s lifestyle or background.
An unfortunate result of this approach was that I would see these individuals discharging themselves against medical advice, being only partially compliant or leaving the unit unannounced. These actions were usually met with further stigmatization and discrimination by health-care professionals, from all disciplines, who made few attempts to understand the individuals’ issues and explore new aspects of providing care.
During discussions with instructors and agency preceptors, Nicholas explored the sense of powerlessness that he was beginning to observe among the inner-city client population. He had moved away from the familiarity of nursing in a hospital and was now interacting with clients on their own terms. He spoke about “switching roles” and began to view the experience of hospital care through the eyes of those who are homeless. His observations led him to reflect on the power and control that nurses and other health-care professionals have over this population.
Once, Nicholas accompanied a man who was very reluctant to seek care to an emergency department. During their hours together, while they waited for a psychiatric admission, the client shared his feelings — hurt, resentment, anger — and Nicholas felt the man’s lack of trust in the system. The client left the hospital before he could receive help. In an effort to understand this experience, we began to explore the literature pertaining to stigma.
Nicholas’s experience of walking with an inner-city client into a hospital was quite different from how he had been coming to work every day on a hospital unit. The stigmatization that homeless, mentally ill and addicted clients can face in health- care settings was now apparent to him. Given that nurses need to know more about homeless clients in order to meet their unique health-care needs, Nicholas wanted to know why educational opportunities like this one weren’t available to more nursing students. Students need such opportunities to help them gain insight; otherwise the potential for inner-city clients to continue to be stigmatized is great.
Nicholas’s respect for clients grew as he took part in daily intakes, rode in the Streetworks van and spent a night at a downtown shelter:
As a student nurse, I was out of my institutional (hospital) element, in unfamiliar surroundings, and the homeless/mentally ill/addicted individuals were in an environment that was home to them. Perceptions of having power and control over these individuals dissipated as I began to engage them.
I feel that switching environments was one of the greatest contributors to my personal and professional development — and a key factor in helping me become more aware. I was afforded the chance to get to know, understand and respect just how unique these individuals are and how difficult their everyday life is.
I appreciate the dynamic approach of the nursing role and how nursing care can be delivered at the community level. With the help and guidance of the nursing manager and staff nurses, through interacting directly with the community and by applying a non-judgmental and non-stigmatizing approach, my view has slowly evolved (and continues to evolve); these individuals are unique, dynamic, resilient and highly resourceful. I value their rights and dignity.
Nicholas’s time in this setting was clearly a transformative educational experience. and he was proud of his contributions to the agency. For example, he determined that a need existed among clients to have a better understanding of caring for their casts. As an experienced orthopaedic nurse, he developed a practical and easy-to-understand teaching handout geared to the specific needs of homeless clients.
Nicholas saw the profound difference that an accepting attitude from health-care professionals can make. The following entry shows how this attitude led to a completely different outcome than the earlier incident in the emergency department:
A community elder was taken to a nearby emergency department because of a seriously infected knee. This individual was severely intoxicated, had been wearing the same clothes for several days, was unkempt and had soiled himself repeatedly. as we interacted with the triage nurse, she remained professional, courteous and composed. This approach served to promote the elder’s compliancy to wait the multiple hours it took to be seen and treated by a physician. as we left him in his wheelchair awaiting assessment, he assured us he would stay until a physician could see him. As a result, he was admitted and given wound debridement and IV antibiotics to treat his infection over the next two weeks. a simple acknowledgment of this individual’s dignity was a huge factor in getting treatment and being far more well than when he was brought in to hospital.
What Nicholas gained from his practicum was deep and meaningful. No doubt the clients he met benefited as well. Given that nurses can be expected to meet homeless, mentally ill and addicted clients in many aspects of their practice, it is critical that we provide opportunities for students to communicate with clients from inner-city agencies. Educators should promote ongoing collaboration between universities and inner-city agencies to ensure these opportunities are available.
The authors thank Maureen McQueen, undergraduate programs coordinator, and Kari Krell, academic coordinator, Centre for Nursing and Health studies, Athabasca University; and Marliss Taylor, manager, Amber Krasowski and Andrea Griffiths, Boyle Street.