Homeless people in the U.S. are often underinsured or uninsured and have many unmet healthcare needs.1-2
Many of their health problems are related in large part to their living situation. Street life exposes people to the extremes of hot and cold environments and compounds their health risks. Homeless people have high rates of trauma, poor nutrition, chronic disease as well as various skin and foot disorders.1
Miriam’s Kitchen was founded in 1983 in response to an urgent need for services for the homeless in Washington, D.C. through a collaboration of The George Washington University Hillel Student Association, Western Presbyterian Church and United Church.
The mission of the “soup kitchen” is to provide individualized services that address the causes and consequences of homelessness in an atmosphere of dignity and respect, both directly and through facilitating connections in the area.
Recognizing the scope of the healthcare needs of those who are homeless and the increasing homeless population in the District of Columbia, the School of Nursing (SON) at The Catholic University of America (CUA) chose to set up a combined faculty service and student learning project by implementing an onsite foot clinic at Miriam’s Kitchen.
This article describes the implementation and first two years of conducting the foot clinics, including the lessons learned, the challenges faced, and the continued sustainability and improvement of the clinic.
Identifying the Need
Three elements coalesced to bring about this service learning project.
First, in the fall of 2010, the clientele at Miriam’s Kitchen expressed a need for a foot clinic, leading to the leadership team at the Miriam’s Kitchen reaching out to a member of the faculty at the CUA School of Nursing (SON) to see if they would be willing to help fill this need. A physician’s assistant program at another local university had previously held a foot clinic at the soup kitchen.
Second, CUA was approaching its 125th anniversary, and had chosen to mark the celebration by inviting students, faculty, staff and alumni to provide community service. The commitment was to complete 125, 000 hours of community service.
Third, the Olivian Society, the CUA SON graduate nursing organization (GNO), was searching for a sustainable community service project. The leadership of the GNO, as well as the administrative team of the SON, welcomed the notion of providing a foot clinic.
Miriam’s Kitchen leadership, SON administrators and representatives from the GNO subsequently met to establish a process for moving forward.
Laying the Groundwork
During the first year many efforts where needed to lay the groundwork for the foot clinic.
An organizational committee introduced the project to the wider SON community through a Sock Drive for the homeless in 2010. Several SON organizations, including the Student Nursing Association and Sigma Theta Tau, Kappa Chapter also participated in the event. The Sock Drive awakened the SON to the needs of the homeless within the Greater Washington community and introduced them to the mission of Miriam’s Kitchen.
The dean of the SON recommended that an in-service be provided about foot care for those students and faculty interested in the clinic. A board certified podiatrist offered a lecture on the basics of foot care in a homeless population. The lecture was videotaped and made available on the SON website, along with the PowerPoint presentation. Students and faculty can review the lecture and PowerPoint prior to participating in the foot clinic. Later, in the spring of 2011, the SON and Miriam’s Kitchen established a Memorandum of Understanding.
In July 2011, a trial foot clinic was conducted with one graduate student and one faculty member. The team provided care for eight clients and was able to assess the benefits and challenges of providing a clinical service in a non-clinical setting. The team also confirmed the immense need for foot care at the soup kitchen, with many of the clients expressing their gratitude for the service.
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IN THEIR SHOES: (From left) Dara Winfield, MPH, RN, Melissa Hladek, FNP-BC, MS, Janice L Hinkle, PhD, RN, CNRN, and Kate Baasch, MA, ATR, senior art therapist and case manager, Miriam’s Kitchen, Washington, D.C., sport necklaces made for them by guests of the soup kitchen when honored collectively as “Volunteer of the Year.” Not pictured is Timothy Godfrey, SJ, DNP, RN, PHCNS-BC, another member of a group of former FNP students and faculty from The Catholic University of America recognized for their service to homeless individuals in the onsite foot clinic they helped establish. photo courtesy Janice Hinkle |
The First Two Years
In the first academic year of operation approximately 55 volunteers served 156 patients ranging from 21 to 78 years of age. Initially all were male but in the second semester of operation three to four females began attending regularly. The majority of the clients were African-American in ethnicity.
At the end of the first year, the foot clinic team was presented with a ‘Volunteer of the Year Award’ by the kitchen. Individuals who frequented the kitchen, most of them homeless, made some fabulous necklaces for the team to mark the occasion.
The award improved our visibility and seemed to increase interest from volunteers as in the second academic year of operation approximately 85 volunteers were engaged. The number of patients served increased as well, to 220. Approximately 75% were male and 25% were female, and still ranged in age from 21 to 78 years.
The foot issues during the first two years included tinea pedis, onychomycosis of the toe nails, and general lack of foot care leading to fissures, corns and calluses. Several cases were quite severe requiring referral for more extensive treatment.
Volunteers provided verbal referral for patients in need of further care to the two resources available to this population. The first is a mobile healthcare van that visits Miriam’s Kitchen one day a week, and the second is a local homeless shelter for the medically fragile which provides daily outpatient medical services.
Learning from Experience
After the second clinic experience, it became clear that greater organization was necessary due to the large number of individuals who requested foot care, the limited space to provide care, and the fluctuating number of volunteer students and faculty available to help.
A minimum of five volunteers are needed for the clinic to run smoothly, including one person for patient intake, one to manage the foot bath, two to provide foot care, and one to provide back-up as needed.
One of the faculty members developed an intake form which helped track the number of patients and the services they received. A core leadership team began having regular meetings, arriving on-site early, and assigning faculty and student volunteers to specific roles prior to the start of each clinic.
Figure 1 displays the usual flow of clients through the foot clinic. The coordination of efforts in the clinic diminished confusion for the clients seeking care and enhanced the service experience for the volunteers since each had a specific role to play.
Enlisting others to help with the provisioning of items needed for the clinic became vital for the sustainability of the program. Coordinating outreach efforts to targeted groups for specific donations succeeded in finding sponsors who, for example, provided a year’s worth of anti-fungal ointment to the clinic. Outreach to the student population and faculty at the school of nursing was successful in replenishing the supply of new socks which clients receive when they come to the clinic.
Opportunity for Collaborative Learning
A significant benefit that emerged from the foot clinic was the opportunity to strengthen a collaborative working relationship between the SON students and faculty with the kitchen staff.
Developing partnerships and collaborating with community members has become central to community health nursing education, and SONs are devising creative opportunities to enhance these partnerships for nursing students.3,4,5 The cooperation and expertise of the center’s staff was crucial for targeting patients most in need of care, and for modeling appropriate interventions when some become agitated or disruptive.
Along with providing community service, the clinic has provided a unique opportunity for nurses to collaborate across programs and specialties. A range of nursing students from undergraduate to the post-doctoral fellow level teamed up with faculty members to provide care at the kitchen.
A variety of nurses representing various disciplines are represented as well. Nurses with expertise in family practice, neurology, mental health, and public health each contribute to the quality of care being offered to the homeless; but more importantly, they are modeling for the students (and for themselves) the importance of nurses collaborating with one another.
Challenges & Solutions
There are numerous challenges to starting and sustaining a program to provide foot care services for a homeless population at a non-clinical site such as Miriam’s Kitchen. These challenges include volunteers, supplies, facility set-up, clientele and leadership sustainability.
First, the foot clinic is run by volunteers. Regardless of what degree students are pursuing, nursing students are busy individuals and recruiting them has been a challenge. An informal student survey suggested schedule conflicts and lack of free time were primary reasons for not volunteering.
A second challenge is funds and supplies for the continuation of the service. Basic supplies include: mycotic toenail scissors, buckets, chlorox, soaking basins, soap, paper towels, gloves, Lysol spray, operating room booties, cotton-tipped swabs, and small plastic sandwich bags. The initial clinics also demonstrated the need for further supplies such as: clotrimazole cream, moisturizer cream, nail files, bunion pads, bacitracin, cotton gauze, shoe insoles, and socks.
To meet these needs, the team solicited funds and donations. Successful efforts included: annual funds for foot clinic supplies set aside by the GNO, a one day announcement on the main university web site, and a one year supply of anti-fungal cream donated by a specific group. The sock drive netted 120 pairs of socks in 2011, and the sock drive in 2012 was even more successful and netted approximately 450 pairs of socks.
A further challenge is conducting a foot clinic in a non-clinical setting. Storage for supplies at the Kitchen is difficult to secure. The physical lay-out of the site provides its own challenges in that the water source for the foot bath is at the opposite end of the facility from the rooms designated for the foot care clinic. Finally, the clients soak their feet in one office and walk to another office for foot care. After various experiments to protect newly soaked feet, the clients don operating room booties to walk to the care space safely.
A significant portion of the clients have mental health issues. This does not routinely pose a problem. The mentally ill client, however, may be reluctant to provide health history information that can help with assessing their needs and referring appropriately. Due to these mental health issues, most of the clients are not very receptive to referrals to health care sources available to the homeless.
Lastly, there is the challenge of leadership sustainability. The MSN program is a two year program; every two years, the baton must be passed to a new student leader to coordinate the service learning project. Faculty must also continue to value this project and volunteer their time to the effort.
Serving the Vulnerable
Three elements coalesced to bring about this service learning project. The first was the identified need at a local soup kitchen, second was the university’s commitment to service, and third was the school of nursing’s graduate student association’s dedication to one service project.
During the first year of operation, faculty and students learned that coordination of efforts is critical for the provision of care and for the sustainability of the conducting a foot clinic at a local soup kitchen. In the second year of operation interest in the clinic and organization became even stronger.
By meeting the challenges of bringing together the expertise of community members, students at different levels of their educational experience and the expertise of nurses from various specialties, the foot clinic provided a needed service to the community as well as offering an educational opportunity for everyone involved.
Students and faculty learned much in conducting the foot clinic at Miriam’s Kitchen for two continuous academic years. The opportunity highlights the challenges and rewards of working with a homeless population as well as the role community partnerships can play in meeting the healthcare needs of a vulnerable population.
References for this article can be accessed here.
Janice L Hinkle is a self-employed nurse author and editor, president-elect of the American Association of Neuroscience Nurses, and was co-director of the foot clinic at Miriam’s Kitchen while employed at The Catholic University of America (CUA), both in Washington, D.C. Melissa Hladek is a family nurse practitioner (FNP) at Unity Health Care, Washington, D.C., former director of the FNP program and former clinical assistant professor at CUA; she was co-director of the foot clinic with Hinkle. Dara Winfield is an FNP in the Department of Virology at Metropolitan Hospital in New York City. Timothy Godfrey teaches Community Health Nursing and Ethics and Social Policy at the University of San Francisco. Winfield was enrolled in the FNP program and Godfrey was a post-doctorate fellow, both at the CUA SON, when they volunteered at the foot clinic.
