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SECOND-DEGREE BACHELOR OF

SCIENCE IN NURSING STUDENTS'PRECONCEIVED ATTITUDES TOWARD

THE HOMELESS AND POOR:A PILOT STUDY

MARY T. BOYLSTON, RN, MSN, EDD, AHN-BC⁎ AND ROSEMARIE O'ROURKE, RN, MSN†

sor ofcal Nutor, Easress cooad, St223/12

of ProElsevie

The current economic climate of the United States has contributed to the crisis in health caredelivery services. As a result, an increasing number of individuals present as poor and vulnerable.Currently, poverty rates in the United States are climbing, with literature clearly reflecting anassociation between poverty and ill health. With a number of economic barriers to health care,it has been suggested that health care providers' attitudes and subtle prejudices have alsocontributed to access. These preconceived negative attitudes can shame and embarrassvulnerable, homeless, immigrant, and poor individuals from attempting to access care. Thisresearch attempted to identify preconceived attitudes that second-degree baccalaureate nursingstudents possess prior to clinical exposure to poor and homeless populations throughqualitative and quantitative investigative methods. Senior-level community health studentspreparing to deliver health care at a suburban homeless day shelter were asked to describe theirexperiences and opinions relative to homeless and poor persons before and after their actualcontact with this population. Collected data suggest that there are subtle stereotyping andnegative attitudes regarding the plight of overtly impoverished individuals before rendering care.After an 8-hour clinical experience with the aforementioned population, attitudes toward thevulnerable slightly improved, suggesting that clinical and didactic exposure to the plight of poorpopulations may assist to sensitize student nurses to exude compassion through a holistictherapeutic nurse–client relationship. (Index words: Impoverished; Homeless health care;Preconceived Student attitudes toward homeless; Health care barriers; Barriers to health careaccess; Nursing care for the homeless and poor; Nursing education) J Prof Nurs 29:309–317,2013. © 2013 Elsevier Inc. All rights reserved.

H ISTORICALLY, ACCESS TO health care has beenaffected by politics, the economy, and the evolving

culture of the United States. Economic issues facing thenation include an increase in poverty, homelessness, andhigher prices for heating oil, groceries, and gasoline (TheHenry J. Kaiser Family Foundation, 2008). Consequently,companies and businesses attempt to survive financially

Nursing, Eastern University, St. Davids, PA.rsing Resource Laboratory Assistant and Adjuncttern University, St. Davids, PA.rrespondence to Dr. Boylston: Eastern University, 1300. Davids, PA 19087. E-mail: mboylsto@eastern.edu/$ - see front matter

fessional Nursing, Vol 29, No. 5 (September/October), 2013:r Inc. All rights reserved.

by firing or laying off employees, which has added to thecomplexity of the crisis facing the nation and its residents.With the changes in the economy, which can alter anindividual and family's socioeconomic status, citizens maywitness an exacerbation in poverty levels past the reported8.1 million of the nation's families documented in 2008with a concomitant rise of uninsured children (U.S.Census Bureau, 2011). As individuals, groups, andfamilies grapple with the financial issues, the ripple effectof the economic downturn has affected many poor personsbecause access to health care has been compromised.Despite political attempts at health care reform, as many as50.7 million individuals remain uninsured in 2009,impacting personal and familial health (U.S. Census

pp 309–317 309http://dx.doi.org/10.1016/j.profnurs.2012.05.009

310 BOYLSTON AND O'ROURKE

Bureau, 2011). A recent Harvard study reported that anestimated 45,000 die each year because of lack of healthinsurance. In other words, one person dies every 12minutes (Wilper, Woolhandler, Lasser, McCormick, Bor,& Himmelstein, 2009).

Without resources, individuals and families have fewerchoices regarding health care and often rely upon freeclinics for assistance. Despite the availability of freehealth care in a number of communities, it has beenfurther reported that the poor and marginalized have haddisappointing experiences with the medical industrybecause of negative attitudes such as perceived stereo-typing, prejudice, and biases displayed by health careprofessionals causing further health disparities (Harrison& Falco, 2005; Zrinyi & Balogh, 2004). Accessing freecare can be a humbling and humiliating experience forany person. Facing cold stares, long lines, and apathetichealth care providers can exacerbate the situation to thepoint where people avoid health care altogether until acrisis erupts. The negative provider attitudes can therebyinfluence individuals' desires to try to access health careor continue with follow-up studies or tests. Individualsdo not want to be ignored, embarrassed, or marginalized.With the refusal to seek health care services for healthpromotion and acute illnesses, the result is an increase inchronic illnesses that could have been prevented withroutine health care visits (Parkinson, 2009).

Based on the effects of the economy and its impact onpoor persons, health care disparities, and disappointinginteractions associated with health care providers, thisresearch sought to examine one of the potential problemsthat can exist for indigent persons needing to access care,most notably, the attitudes of health care workers. Thispilot study attempted to identify what preconceivedattitudes are present in second-degree student baccalau-reate nurses before actual contact with overtly poorpersons. The results may serve as an initial step ingathering much needed data on a growing aggregate inthe United States and direct educators to developprograms that dispel myths that negatively influencestudent and future nurses' behaviors and attitudes.

Literature ReviewThe literature abounds with information about disparitiesleading to chronic illness and death in vulnerablepopulations (Centers for Disease Control & Prevention[CDC], 2008). There is also evidence of solutions withincommunities that allay such disparities (Benkert, Peters,Tate, & Dinardo, 2008). However, there is little researchto investigate if health care workers possess preconceivedattitudes toward the poor and the homeless. “In part,efforts to alleviate poverty in women and men willdepend on an understanding of the attitudes thatAmericans hold toward the poor” (Cozzarelli, Tagler, &Wilkinson, 2002, para 3). Therefore, it is the purpose ofthis pilot study to determine if senior second-degreebachelor of science in nursing (BSN) students possesspreconceived attitudes toward the poor and the homelessand whether personal exposure to the populations in a

clinically supervised setting can identify and perhapsalter the aforesaid attitudes.

Poverty and HomelessnessAccording to the U.S. Department of Housing and UrbanDevelopment (2007), homelessness is defined as the stateof being without a fixed or adequate nighttime residence,which includes those temporarily housed in shelters orwelfare hotels. Reasons for homelessness include, but arenot limited to, poverty, mental illness, and addictions. Inaddition, a poor person may demonstrate a need thatcannot be satisfied by personal resources and result inmedical, financial, or social crisis. The need may includehousing, finances, health care, employment, or anynumber of issues that cause dependency on society forassistance. Specific poverty guidelines are availablethrough the U.S. Census Bureau; however, based uponrecent statistics, the official poverty rate has climbed from14.3% in 2009 to 15.1% in 2010. Presumably withescalating numbers of poor persons living in the UnitedStates, increasing incidents of ill health will be experi-enced by the poor who will struggle to overcome anumber of barriers to access and health disparities.

Health DisparitiesHealth disparities that are evident by differences in healthoutcomes can be related to social standing, demo-graphics, environment, and geographic location. Accord-ing to the CDC (2008): “Health disparities arepreventable differences in the burden of disease, injuryand violence, or opportunities to achieve optimal healthexperienced by socially disadvantaged racial, ethnic, andother populations groups and communities. Thesedisparities are unjust, unfair and directly related to thehistorical and current unequal distribution of social,political, economic, and environmental factors” (para 2).Similarly, the National Partnership for Action to EndHealth Disparities (NPA), an organization created by theU.S. Department of Health and Human Services (2010),defines health disparities pertaining to the gaps evidentbetween the care of minorities and nonminorities.Consequently, intrinsic and extrinsic factors contributingto health disparities include, but are not limited to,poverty, environmental threats, physical access to healthcare, individual and behavioral factors, rural versus urbanlocations, gender, neighborhood features, and education-al inequalities (Anderson, 2010; CDC, 2011).

In essence, the current data on minority health reflectthe results of a health care system that denies access tocare through poor planning, provider ignorance, pro-vider attitudes, and inadvertent tolerance of discrimina-tory practices. Part of the issue can be related to healthcare provider education. Further, the health care beliefsof different cultures may be poorly understood byfrontline nurses causing fear and misunderstanding(Maze-Martino, 2005).

Yet, the more accurate determinant of the nation'shealth assesses outcomes as a result of care. Improvedhealth outcomes such as decreasing mortality rates of

311BSN STUDENTS' PRECONCEIVED ATTITUDES

minorities can occur in a climate that assures fair, equal,and ethical health care treatment (Weisfeld & Perlman,2005) by elimination of barriers.

BarriersThe NPA (U.S. Department of Health and HumanServices, 2010) articulated a list of barriers to includeeconomic, geographic, linguistic, cultural, and healthcare financing. In 2009, KFF (2010) reported that themost significant health care barriers among the non- andunderinsured included no usual source of primary care,postponing or not seeking needed care due to cost, andinability to afford medication. Conversely, the Institute ofMedicine (IOM; 2002) suggested that health caredisparities can be due to the subtle differences in theways that health care providers care for the poor andmarginalized. In other words, issues of affordability,access, location, language barriers, and providers' dis-criminatory practices such as attitudinal displays seem toresonate throughout the literature (Flores, 2006; Hwang,2001; Johnson, 2001; Robert Wood Johnson, 2009; VanRyn & Pu, 2003).

Poverty is a situation or way of life that impacts theperson and family in a holistic manner. The mind, body,emotions, environment, and spirit are affected in waysthat can only be reported by individuals who have hadpersonal experience. With the lack of an adequate incomeor advocate, the person and family are at the mercy of asystem that is fraught with barriers preventing them fromaccessing health care. The barriers limit the individual'saccess to preventive services, diagnosis, treatment, andfollow-up care. For example, the lack of health insurance(Hwang, 2001) caused by extreme poverty can beconsidered a major risk factor leading to homelessness,premature death, delays in seeking care, noncompliancewith therapy, and cognitive impairment. Consequently,Hatton, Kleffel, Bennett, and Nancy Gaffrey (2001)suggest that homeless people have a more difficult timeaccessing health care than families who are poor. Further,the stigma of homelessness itself can be considered abarrier to health care access.

Once patients have had access to health care, theattempt to maintain a healthy lifestyle is further met withbarriers. The poor and homeless may not be able to followdietary suggestions or restrictions because of inadequatefunds. In addition, they may not be able to affordprescription or over-the-counter medications becausethey do not have health insurance. Without discretionaryfunds, individuals and families cannot pay for insulin,medications, or medical supplies (Hwang, 2001).

Johnson (2001) further asserts that because oflanguage or educational barriers, many do not under-stand documents or written instructions. Cultural andlanguage barriers are evident through the misinterpreta-tion and/or miscommunication between health careprovider and patient (IOM, 2002; Flores, 2006). Povertyand political inaction contribute to access issues, yet oncea person is able to access health care, the attitudes of

workers may pose as a preventable barrier that dismissesthe impoverished as unworthy of treatment.

AttitudesIn 2002, groundbreaking information was released by theIOM after studying potential causes of health disparities(IOM, 2002). Data gleaned from the review of 100national studies suggest that bias, prejudice, and stereo-typing were some factors that contribute to healthdisparities. Through the secondary analysis of existingdata, it was determined that disparities exist more as aresult of inaction by health care providers rather thanrefusal of service or noncompliance by minorities.

Prejudice and discrimination can be construed asenvironmental factors that make a physiological impacton their targets. The aforementioned bigotry and bias canaffect the quality of rendered care. Further, a psycholog-ical barrier formed by mistrust between the patient andthe health care provider may emerge and impact theoutcome. As a result, the indigent have fewer options andare more likely to postpone screenings leading topreventable illnesses (Ackerson & Gretebeck, 2007;The Henry J. Kaiser Family Foundation, 2010). Parkinson(2009) concurs and suggests that negative attitudesdisplayed by nursing professionals toward the indigentmay ultimately affect their willingness and desire to seekhealth care for either preventive or acute and chronicillnesses. Also to be considered with these results is thathealth care workers may not be aware of their subtleprejudices or nonverbal behaviors such as facial expres-sions, which may cause them to stereotype patients(IOM, 2002; U.S. Department of Health and HumanServices, 2010). Studies profiled by the IOM give reasonfor a need to investigate attitudes of health care workerstoward indigent populations. Despite an awareness of thebarriers to health care access, Van Ryn and Pu (2003)assert that health care providers may intentionally orunintentionally communicate lower expectations fordisadvantaged patients, which may further contribute tothe disparities and ultimately affect the outcomes oftreatment. The IOM (2002) suggests the need forresearch on how a patient's race or ethnicity influenceshealth care providers' decision making and quality ofcare. According to the IOM, “…there is considerableevidence that even well-intentioned whites who are notovertly biases and who do not believe that they areprejudiced typically demonstrate unconscious implicitnegative racial attitudes and stereotypes” (p. 4). Cozzarelliet al. (2002) studied 206 middle-class college students'attitudes toward the poor, stereotypes, and attributionsfor poverty and whether their thoughts and feelingstoward poor women were different than poor men. Datadisclosed that the studied population had negativeattitudes toward the poor, especially the men.

Similarly, impoverished participants in various stud-ies experienced some degree of negative attitudes inconjunction with difficulty in accessing care orcommunicating care needs (Johnson, 2001; Wetta-Hall, Ablah, Dismuke, Fredrickson, & Berry, 2005).

312 BOYLSTON AND O'ROURKE

This further underscores the need to investigate theattitudes health care workers may possess, as they maylogically interfere with care, thus becoming anotherbarrier to service.

Published in a Hungarian study, Zrinyi and Balogh(2004) questioned whether student nurses would fail toprovide care to a homeless client. Alarmingly, somestudent nurses admitted to withholding care fromhomeless individuals. The findings suggested that therespondents with lower education tended to be lesstolerant of immigrant populations. Consequently, datahighlight the ongoing need for diversity education thatleads to improved and innovative care solutions.

Two separate studies using pretest assessment ofattitudes toward indigent populations in conjunctionwith a practical experience and post experience testingof attitudes demonstrated improved attitudes towardindigent persons following clinical opportunity for theircare (Buchanan, Rohr, Stevak, & Sat, 2007; Rose, Miller,Lyons, & Cornman-Levy, 2003). Smedley, Stith, andNelson (2003) suggest that faculty develop cross-cultural curriculum to educate students using casestudies. Further, the addition of a clinical practicumthat is supervised by faculty and rigorously evaluatedcan prepare the students to ultimately care for apopulation that has been ignored and deserving ofquality health care. Therefore, socialization of the nurseduring the educational process and the examination ofvalues and attitudes that impact professional practicemay be integral in preparing the graduate to identifyand perhaps alter preconceived negative attitudestoward the poor.

Nursing EducationNurse educators develop curriculum and implementclinical experiences that “prepares the graduate nurse tomeet the demands of the current health care arena”(Clark, 2004, p. 347). With the changes in health careand society, the curriculum is dynamic, fluid, and revisedto accommodate shifts in health care, reimbursement,population changes, and needs of system itself. With thatsaid, professional socialization of the student is anessential component of this formative process. Studentsdo not enter college, an associate degree, or hospital-based nursing program as “blank slates.” They arrive withpreconceived thoughts and ideas about health care,people, and nursing that are either accurate or need tobe challenged. Therefore, the socialization process can beinstrumental in helping to develop professional values(Rognstad, Nortvedt, & Aasland, 2004). Educatorsprepare the students to meet the rigors of the programand socialize the student to become a graduate nurse withcritical thinking skills and professional values prepared toenter into practice. Therefore, faculty, curriculum,classrooms discussions, and clinical experiences areessential tools in guiding students' value-based approachto health care while incorporating investigative tools tomeasure the effectiveness.

NeedNearly 50.7 million people or 16.7% of the U.S.population were without health insurance in 2009(U.S. Census Bureau, 2011). With the growing numberof uninsured and poor people, the ability to accessprimary health care services or necessary prevention andfollow-up care has been limited. This entity in tandemwith homelessness can further lead to health caredisparities, which can be defined as differences in thequality of care received related to ability to pay, race,culture, age, gender, place in society, or sexualorientation (Harrison & Falco, 2005). The harsh realityis that the poor have more evidence of chronic diseaseand a higher mortality rate than those who have theadvantage of consistent access to the range of healthservices (CDC, 2008). The literature reflects evidence ofhealth care disparities that could be interpreted asdiscrimination (Harrison & Falco, 2005; Williams,2007) and can affect the quality of patient care especiallyamong minority patients. However, once the underlyingprejudice or attitudes have been identified, they may bealtered with mentoring and education. For this reason,identifying underlying biases and preconceived attitudestoward the poor and homeless among student baccalau-reate nurses may prevent further discrimination andeliminate a preventable barrier to care.

Problem StatementProfessional nurses provide health care in multiplesettings as they interface with members of the generalpopulation in a number of ways from physical care tohealth promotion activities. Furthermore, overtly poorpopulations face numerous barriers to health care, whichinclude, but are not limited to, negative attitudesdisplayed by health care providers. It stands to reasonthat with escalating numbers of poor persons, nurses willbe involved with rendering care or making decisions thatimpact access to care. By identifying students' precon-ceived attitudes toward the aforementioned population,faculty can create curricula and immersion experiencesexposing students to the truth and issues that plague thehomeless and poor, thereby potentially eliminating apreventable barrier to health care.

Research QuestionBased on data supporting negative attitudes displayed byhealth care professionals posing a preventable barrier tohealth care access, the researchers pose the question:What are the preconceived attitudes of second-degreesenior baccalaureate nursing students toward the poor?What is the impact of an 8-hour immersion clinicalexperience on those attitudes?

LimitationsThis pilot study may be limited by analysis of a smallconvenience sample of student baccalaureate nursesfrom a small liberal arts and sciences ChristianUniversity completing a community health clinical in asuburban day room for the homeless and poor. A study

313BSN STUDENTS' PRECONCEIVED ATTITUDES

that compares a more heterogeneous population ofstudent nurses in city, rural, and suburban settings maybe more generalizable.

Methods and ProceduresA mixed-method research design has been implementedfor the collection of data pertinent to this study. As such,there has been simultaneous collection of qualitative andquantitative data resulting in methodological triangula-tion. The co-investigators recognized that study partic-ipants may hold a variety of opinions related to poorpopulations relative to their own life experience up untilthis point in time. It is with this understanding that theco-investigators conducted taped interviews bracketingpersonal beliefs about the poor and homeless to elicithonest responses from participants. The research com-menced with institutional review board approval. Otherpreliminary details included author's permission to usethe Survey on Social Issues (Guzewicz & Takooshian,1992) and individual participant written consent withpermission to disengage from the research at any time.

The research proper began with participants' comple-tion of a pretest survey (prior to clinical exposure), apersonal interview (immediately prior to clinical expo-sure), clinical experience in a homeless day shelter, post

Table 1. Survey on Social Issues

For each item below, please circle one:A (Agree strongly), a (Agree), n (No or mixed opinions), d (DisagOf course there are no right or wrong answers, only personal opinanonymous.** THANK YOU!

About poor people:1. a A N D d Though I know that their condition is not alway2. a A N D d I can't understand why some people make such

could improve their condition if they tried.3. a A N D d Although we don't like to face it, most people o4. a A N D d I am in favor of a government guaranteed minim

income per year.5. a A N D d Kindness, generosity, and love are characteristicAbout homeless people6. a A N D d Society is responsible for people being homeless7. a A N D d Many homeless have themselves to blame.8. a A N D d Society should not have to support or house ho9. a A N D d Society is turning away and letting down the hom10. a A N D d A nation should be ashamed of its homeless proAbout people in general11. a A N D d Human nature being what it is, there will always12. a A N D d People cannot be trusted.13. a A N D d A few leaders could make this country better th14. a A N D d Most people who don't get ahead just don't hav15. a A N D d An insult to one's honor should not be forgotte16. a A N D d If one works hard enough, he is likely to make a17. a A N D d Anyone who is able and willing to work hard ha18. a A N D d A distaste for hard work usually reflects a weak19. a A N D d The one who can approach an unpleasant task w20. a A N D d People who fail at a job usually have not tried haPlease describe yourself:21. Age: ____ 22. Sex: ____ 23. Occupation: ________________ 225. Highest education: ___ Less than high sch. ___H. S. diploma. __26. (Optional) Please write any comments you have on these issues

clinical survey (upon completion of 1-day experiencewith indigent and homeless), and post care conference. Afocus group discussion was conducted at the end of thefollowing semester (6 months after completion of shelterexperience) to present the emerging themes gleaned frompersonal interviews.

ParticipantsA convenience sample was recruited for the pilot study.Fall semester, senior, second-degree BSN studentsmatriculated in a Christian University were gatheredbefore the beginning of the required community healthclass and associated clinical practicum. After explanationof the research, survey, interview, and focus group, 100%of the class (N = 14) agreed to participate.

SurveyThe investigators incorporated the 20-item Survey onSocial Issues, which assesses public attitudes towardhomeless (PATH) as depicted in Table 1. Each item isanswered as agree strongly, agree, no or mixed opinions,disagree, or disagree strongly. The intention of PATH isto measure six personality factors that include “attitudetoward homeless, attitudes toward the poor, achievingtendency, just world, authoritarianism, and the need for

ree), or D (Disagree strongly).ions. Save any comments for the end of the survey, This survey is

s their own fault, I find poor people unpleasant to be around.a fuss over the disadvantaged state of the poor. Most of them

n welfare are lazy.um annual income - so nobody would receive less than a certain

s found more among the poor than among the rich.

.

meless people.eless.blem.

be war and conflict.

an all the laws and talk.e willpower.n.good life for himself.s a good chance of succeeding.ness of character.ith enthusiasm is the one who gets ahead.rd enough.

4. Race: ____________Some college. ____College grad. ____Grad. School. (More space on back).

Table 3. Paired Samples Test

t dfSignificance(two-tailed)

Pair 1 TotalPreTotalPost

−0.188 13 .853

314 BOYLSTON AND O'ROURKE

approval” (Guzewicz & Takooshian, 1992, p. 70). Thefirst 10 items of the PATH “about poor people” and“about homeless people” were analyzed by the researchinvestigators. The internal reliability has been reported asα = .74, whereas construct validity had demonstrated aconsistent pattern. The survey was completed beforeclinical exposure in the day room and immediately afterthe 8-hour clinical intervention.

InterviewAfter the pretest was completed and placed in anenvelope, each participant individually met with a co-investigator and asked the following questions:

a. Have you had personal experience with homelessness?b. Are the homeless and/or poor responsible for his or

her plight?c. Is the public responsible to help the poor?d. Why are so many people homeless and/or poor?

Although the questions were not open ended, partic-ipants were encouraged to add personal commentsduring the interview to explain their answers.

Focus GroupSix months after the completion of the pre- and post-PATH surveys, clinical practicum, and compilation ofinterview data, the participants met for 45 minutes in auniversity classroom as a focus group to affirm theemerging themes and data extrapolated from the study'smethodology. Notes, taken verbatim, were transcribedwhile the focus group was videotaped. The clinicalinstructor and co-investigator conducted the focus group.

PATH ResultsAs depicted in Table 2, a paired-samples t test wasconducted to evaluate the impact of the intervention onparticipants' scores on the first 10 items of PATH. Resultsindicated that there was no statistically significantdifferences between the means before and after theintervention (Time 1: M = 16.9, SD = 3.6; Time 2: M =17.2 SD = 3.8), t(13) = −0.19, P = .85. Table 3 representspaired sample t test. As displayed in tabular format, therewas no significant difference between means of thegroups; however, there was a slight increase between thepre- and posttest mean.

InterviewsInterviews conducted after the pretest PATH survey werecompleted and generated the following data.

Table 2. Paired Samples Statistics

M n SD SEM

Pair 1 Total pretest 16.9286 14 3.56186 .95195Total posttest 17.2143 14 3.82660 1.02270

Have You Had Personal Experience WithHomelessness?

Most (71.5%) of the participants did not have anypersonal experience with homelessness, whereas 28.5%responded that they had some personal experience.

Are the Homeless and/or Poor Responsible for Hisor Her Plight?

When asked if the homeless and/or poor are responsiblefor his or her own plight, 78.5% of the participantsanswered “yes.” During an interview, one studentsuggested, “Some people take advantage of free servicesand do not pursue steady work.”

Is the Public Responsible to Help the Poor?All of the participants (100%) suggested that the public isresponsible to help the homeless and poor. A theme thatemerged from interview analysis is society can be judgedaccording to how it treats its homeless population.Further, society, such as government/religious groups, isresponsible and has a duty to care for the homeless.

Why are So Many People Homeless and/or Poor?When asked why so many people are homeless and/orpoor, participants' answers varied from controlledsubstance abuse, mental and physical illness, unemploy-ment, divorce, or lack of family support. In addition, lackof education, unemployment, and sparse communityresources may increase numbers of homeless. Alsomentioned during interviews were additional reasonssuch as the effects of “bad friends, irresponsible spending,and unhealthy lifestyles” and discrimination against poorpeople can lead to homelessness.

Focus GroupBased on the emerging themes generated by the focusgroup, students commented that the clinical exposurewith the poor in the homeless day room was a “positiveexperience” for them. The students verbalized that theywere “shocked by a shelter” in the suburbs. They had noidea what to expect and could not tell the differencebetween the people who were homeless and the staffbecause the homeless in the day shelter looked “normal.”Students further commented that many individuals andfamilies are “one paycheck away” from being homeless.

Another theme that emerged was the students did notfully understand the actual role of the nurse in such asetting. They did not know how to approach the clientsand were unsure about their role, especially withimmigrants and feel language was a considerable barrier.Yet, many concurred that nursing care in shelters such asthe day room is necessary work.

315BSN STUDENTS' PRECONCEIVED ATTITUDES

DiscussionThere was a very slight and not statistically significantdecrease in negative attitudes based on PATH resultsindicating that an 8-hour clinical experience may not beenough time to make a difference in preconceivednegative attitudes toward the homeless and poor. Thelack of statistical significance can be attributed to thesmall sample size; however, the qualitative datademonstrate the beginnings of changed attitudesamong participants.

The preclinical interview data suggested students wereconfused by the shelter's location in an affluent region aswell as the homeless presenting as normal people, asevident by the statement: “I did not know who wasworking there and who was homeless.” In addition, therole of the nurse and interacting with individuals whocould not speak English were also considered sources ofstress for the students, as evidenced by, “….there aremany language barriers…” and “I am not sure how tocare for undocumented aliens.”

Based on the triangulation of collected data, whichincluded focus group analysis, the 1-day clinicalexposure with an overtly poor population resulted infewer focus group negative statements about attitudes,fear, poverty, and homelessness as well as a buddingempathy as evidenced by the statements, “It was a goodidea to include the experience in community education”and “It was an eye opening experience….It's a perspec-tive we need to see….” Empathy emerged as a dominanttheme as another student shared with the focus group:“Someone was brought in after spending a cold nightsleeping under a tractor trailer. I complain when I have towalk the dog in the cold.” Participants further suggestedpoverty seems to be multifaceted and complex, therebyaccessing health care can prove to be challenging. Basedon focus group data, students articulated an understand-ing and compassion.

Focus group statements such as, “There is anawareness of the vulnerability…you take it on…thiscould be me….” and “They had a tenuous hold on theirdignity….” suggested the impact of face-to-face contactwith people in need was valuable to the educationalprocess. Furthermore, with an 8-hour clinical experienceas a study intervention, students verbally expressed agreater understanding to the plight of the indigent. Onestudent said: “I had no idea what to expect. I wassurprised that everyone looks the same….the homelesslooked the same as the volunteers. …you have an imagein your mind of what a homeless person looks like…usually they are sleeping on a grate in the city….”Similarly, a participant remarked: “I was nervous.”Another student concurred and commented: “I wasshocked that an affluent community had a shelter andclinic. I did not think that they had homeless people.”

As the focus group data were analyzed, studentsverified that the internal and external factors areassociated with homelessness. Internal factors includethe use of drugs and alcohol and mental illness. In

contrast, external factors listed by the students includedunemployment, inadequate community resources, dis-crimination, language barriers, and undocumented citi-zenship status. Further, participants' perspectives seemedaltered with comments such as, “Society had a duty tocare.”The focus group data demonstrated an evolvingcompassion toward the homeless and immigrant patientcare but also suggested the need in the shift ofresponsibility toward personal wellness.

RecommendationsBased on the results of the mixed-methods pilot studythat focused on identifying preconceived attitudes ofsenior baccalaureate student nurses toward the poorand homeless in a suburban homeless day room,faculty mentoring and personal interaction with theovertly impoverished in a clinical or shelter setting cancreate an opportunity for students to understand theimpact of poverty on health and wellness and thereforepotentially alter existing preconceived attitudes.According to Peplau's Theory of Interpersonal Re-lations, therapeutic nursing care begins with establish-ing a rapport with the patient and family and buildinga trusting nurse–patient relationship (George, 2010).The personal interactions give the formerly anonymousa face and name, thereby shifting perceptions of thereality of homelessness and poverty.

Furthermore, it behooves student nurses to haveclinical exposure and theoretical instruction regardingpoverty and homelessness (Buchanan et al., 2007; Roseet al., 2003). It may be in the best interest of studentsand poor persons to educationally plan experiences thatallow the student to develop realistic, positive, andcompassionate attitudes that lead to the initial steptoward asking and receiving health care. This mayultimately assist in eliminating additional health careaccess barriers. Data from PATH showed a slight shift innegative attitudes toward positive, although the findingswere not significant; however, with an increase in thenumber of opportunities to care for the poor, attitudesmay significantly be altered as evidenced by thestudents' ability to place names and personalities tothe formerly anonymous.

Once the 8-hour clinical experience was over, studentsarticulated more reasons for homelessness and poverty.Yet, the aforesaid list offered by participants forhomelessness and poverty was not complete. Therefore,analysis of issues that plague poor populations in healthcare can be integral constructs within prelicensurenursing programs. In addition, the building of classcontent with case studies and clinical exposure focusingon the unique needs of the poor begin the process ofconstructing a foundation of knowledge that maychallenge preexisting attitudes toward any populationin preparation for professional practice.

On the basis of concerns articulated by students duringthe focus group, participants were unsure what their rolewas with poor immigrant populations and therefore

316 BOYLSTON AND O'ROURKE

suggest that additional education in cross-culturalnursing care is warranted. Adding conversational Spanishas an elective, seminar, or workshop would be helpful ineliminating some of the aforementioned language barriers(Flores, 2006) and promoting understanding whilefacilitating communication.

Lastly, the results of the research demonstrated a needto alter the investigative method of the next study toinclude PATH pretest and interview with open-endedquestions during program orientation rather than waitingfor the community health clinical. The posttest would bedistributed at the end of the 2-year program to graduatingseniors along with gathering for a final focus group on thesubject. The population recruited for the sample shouldbe larger with a more heterogeneous population ofstudents. The goal of the impending research will be toascertain whether the BSN program itself, rather than one8-hour clinical experience, can initially identify andconsequently impact students' preconceived attitudestoward the poor and homeless.

ConclusionSociety has a duty to care for all populations based uponthe American Nurses Association (2001) and valuesembraced by the nursing profession. This research with alimited study population continues the process ofunderstanding how preconceived student attitudes to-ward the poor and homeless can begin and ultimatelytransfer into a dysfunctional nontherapeutic nurse–patient relationship upon graduation. Students entereducation with preconceived attitudes regarding anumber of issues. However, with lecture, case studies,and clinical exposure focusing on marginalized andvulnerable populations, faculty have the opportunity toattempt to alter existing attitudes. The actual socializa-tion process takes years of formation, yet nursing facultywith curriculum deliberately focused on poverty andhealth-related issues have a unique opportunity to impactthe development of positive, nonjudgmental professionalattitudes. Through mentoring and education, graduatescan make a difference in the way the poor and homelessare treated in the realm of health care through carefulself-reflection. As some attitudinal health care barriers arefractured within the small studied population, graduatenurses can focus on changing a system through politicalactivism, volunteerism, and communication. By caringfor society's vulnerable citizens, nurses can lead the wayto change and health care reform. Nursing students innumbers alone have the capacity to make a societalimpact and advocate for human rights and justice.

On the basis of the results of this investigation, theresearchers suggest the continued building of scientificknowledge supporting compassionate nursing care for allpopulations. Nurse educators are called to offer acomprehensive, multidisciplinary curriculum that spansall ages, races, ethnicities, and socioeconomic standing incommunities as a holistic approach to nursing care beginswith a positive attitude toward the treatment and care ofall individuals.

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