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Promoting a Collaborative Approach in Treating the Complex Issues of a Homeless Veteran

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Homelessness evokes many feelings from the non-homeless ranging from pity to disgust to empathy. The notion of preference to homelessness is foreign to most who have an inclination to “fix” the situation, without fully understanding the implications of both the underlying causes or the solutions. While the physiological aspects of health may be very obvious, it is often the psychosocial aspects of one’s life that predicts outcomes. Social determinants of health in part include factors such as education, environment, resources, and economic stability. Many of the issues around homelessness and health care encompass a complicated trajectory for outcomes.

This teaching strategy helps students better understand the evaluation of the risks and benefits of homelessness and collaboratively optimize a client’s expectations. Through the utilization of a motivational interview approach, reflection on feelings of homelessness and assessment of underlying mental health co-morbidities, the student explores how to maintain a client’s independence and develop a plan of care for a homeless Vietnam War Veteran. Communication techniques are greatly emphasized.

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Promoting a Collaborative Approach in Treating the Complex Issues of a Homeless Veteran

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Learning Objectives
Students will:
- Explore myths related to homelessness
- Explore their own feelings regarding homelessness
- Assess identified expectations of both the client and health care team in the context of client functioning
- Reflect on their own feelings about their own right to independence
- Utilize a motivational interviewing approach to collaboratively plan care based on the client’s needs
- Assess and understand co-morbid mental health concerns
Learner Pre-Work
Listen to the monologue of Butch Sampson or download the printed copy. Ask students to consider the questions below as a way to more fully understand Butch’s life experience.
- What social determinants of health are influencing Butch’s situation?
- What are Butch’s expectations of seeking help for his foot?
- What is the health care team’s expectation of caring for Butch?
- Is Butch’s housing situation compromising his health situation? If so how?
- Can you foresee Butch’s independence being compromised?
- What do you see as the priorities in caring for Butch?
- How do you feel about Butch’s resistance to “do-gooders”?
- How is Butch’s vague paranoia contributing to any health concerns?
- Does Butch fit the criteria for schizophrenia or any other psychiatric diagnosis?
- How is Butch’s need for independence highlighted in the monologue?
Suggested Learning Activities
1. The exploration of the provider’s views on a patient’s situation often has an effect on how information is communicated. For example, if the provider has negative feelings about an aspect of the patient's life, it could be a barrier to teaching and ultimately outcomes. This exercise allows the student to explore their own feelings about patients like Butch. It can either be done with an audience response system (download the PowerPoint for the audience response system) or with KAHOOT IT, a free system allowing students to respond using their cell phones. Both of these allow for anonymous responses by the students, and help to launch rich discussions in the classroom. The PowerPoint document includes speaker notes. The questions in this activity are as follows:
- Most people who are homeless have put themselves in that situation
  1. I totally agree
  2. I agree with most cases
  3. Sometimes this is the case
  4. I totally disagree
- Being homeless may be a better alternative to living in a home with rules
  1. I can't imagine that anybody feels this way
  2. This may be true depending on the rules
  3. In rare cases this might be the case
  4. I believe this is the case with many people
- People who are homeless are lazy and need to get a job
  1. This would solve their problem
  2. There are many factors that contribute to homelessness
  3. People who work can still be homeless
  4. Most people who are homeless are unable to get a job
- There is a higher percentage of homelessness among:
1. Veterans
2. Mentally Ill People
3. Middle Aged People
4. Substance abusers
- I will never be homeless
1. I can't imagine a situation where this would happen to me
2. Never say never. This could happen if a series of events goes wrong
3. I know how to access resources to prevent this
4. I have been homeless
- My independence is:
1. Not that big of a deal for me
2. Fairly important to my well- being
3. A significant part of who I am
4. Not something that I can control
2. As you listen to Butch’s monologue how would you use a motivational interview approach to collaborate with him to optimize his health? Watch the Motivational Interviewing: Linking Behaviors video(or another video that more specifically describes the stages of motivational interviewing such as 3 Motivational interviewing Core Skills in Action) to better understand the technique where a conversation is centered on a collaborative approach to changing behaviors rather than telling the patient what they need to do.

Download the PowerPoint slides related to using a therapeutic motivational interview approach in talking with Butch. The slides can be used as part of a class discussion or can be assigned in groups for the students to process. It is also an appropriate tool to use in an online setting.
Suggested Reading

Muhrer, J. (2012). Making evidence-based health care relevant for patients. The Journal for Nurse Practitioners, 8(1), 51-55. doi:10.1016/j.nurpra.2011.07.026

Östlund, A., Wadensten, B., Kristofferzon, M., & Häggström, E. (2015). Motivational interviewing: Experiences of primary care nurses trained in the method. Nurse Education in Practice, 15(2), 111-118. doi:10.1016/j.nepr.2014.11.005

Wynn, S. D., Sherrod, R. A., & Oliver, J. S. (2011). Caring for veterans in rural areas: Psychiatric nurses must seek out local resources. Journal of Psychosocial Nursing & Mental Health Services, 49(7), 10-11. doi:10.3928/02793695-20110609-03
Author Information

Laureen Tavolaro-Ryley, MSN, RN
Community College of Philadelphia
Philadelphia, PA