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Street nurses seek out forgotten Australians

A dedicated and inspiring group of nurses walk the streets of Melbourne providing care to an overlooked segment of society, writes Flynn Murphy

For a time, Kim Williams would meet a woman in the public toilets of Melbourneā€™s CBD in order to change the wound dressings on her damaged legs.

ā€œShe just wouldnā€™t go to a clinic so I didnā€™t have a choice ā€“ I just had to disinfect everything and make it as hygienic as possible,ā€ Williams says.

Williams is a nurse with the Royal District Nursing Serviceā€™s Homeless Persons Program (HPP), and her patient was one of more than 100,000 homeless people in Australia.

The homeless often arenā€™t connected with health workers or case managers. Their first contact with the health care system might be when deteriorating health forces them into a hospital emergency department, either by their own initiative or via ambulance or police.

Community nurses who specialise in bringing primary care to the homeless are often the only reason their clients do not entirely miss out on healthcare.

These multi-skilled, experienced and highly independent nurses walk the streets and can meet their clients anywhere from soup kitchens and temporary accommodation to parks and alleyways. They provide primary healthcare, nursing care, counselling and first aid. To provide follow-up checks, they keep records of a group of people who all too often go unrecorded. It is challenging work which helps those in desperate need and eases the strain on emergency departments.

This year, these nurses finally got some recognition when the HPP was named a finalist in the 10th Annual Melbourne Awards.

Nursing Review spoke with Theresa Swanborough, who has managed the program for the past 25 years. In that time the employee base has grown from four to 38 nurses, all co-located in a range of agencies in inner, middle and outer Melbourne. Swanborough says the ongoing gentrification of the inner city has pushed many homeless people out of the areas they traditionally inhabited to the outer reaches of the city, and the HPP has expanded its scope to match.

Swanborough says a holistic approach is the key to caring for the homeless. ā€œOur nurses are all very solid clinicians, but weā€™re not just episodic, not just focused on a clinical response,ā€ she says. ā€œIdeally we work with others or, if thatā€™s not possible, we provide a holistic response ourselves. Weā€™ll provide healthcare, but weā€™ll also sort out income and find housing.ā€

The HPP has two key mandates, Swanborough says. The first is to provide primary healthcare to the homeless. The second is to improve the access of homeless people to medical care through advocacy, collaboration with other agencies and network-building. It is a way of ensuring those who might again slip through the cracks have access to ongoing care in the medium and long term.

The nursing service is a tight ship. It has 1146 registered clients and in the past financial year has allocated more than 10,000 hours to registered clients and almost 1500 to unregistered clients.

The program recorded 16,118 contacts with registered and unregistered clients in the same period.

Many involved nurses going, for instance, to parks where the homeless tend to congregate.

General outreach nurse Ann Hatchett, who has been with the nursing service for 15 years, describes such a beat in detail. Hatchett works in the inner-Melbourne suburb of Fitzroy. Every Tuesday, she goes to a park in a ritual that has been in place for more than seven years.

ā€œWe provide breakfast and thereā€™s someone from the legal service and the justice centre, and people from drug and alcohol [outreach programs], a podiatrist, physiotherapist, people from the Victorian Aboriginal Health Service ā€“ a range of services,ā€ Hatchett says. ā€œQuite often I link with people there that are hard to catch, or people come to seek me out because they know itā€™s the one place Iā€™m going to be every week.

ā€œThereā€™s a bit of a transient population and then there are people who have been around the traps for a long time. Thereā€™s a guy Iā€™ve been seeing for a while who has a nasty cough and I finally convinced him to let me take him for a chest X-ray. It took a little while but we at least got that and now heā€™s booked in for another appointment.ā€

Swanborough says her nurses must be self-motivated because they require a high level of independence and autonomy to do their jobs effectively.

ā€œOn any given day the nurses get to decide and prioritise who needs what. The downside is that there are so many people with so many needs it can be a bit of a challenge but in the end, if you decide you need to spend eight to 10 hours working with one person on one issue, you can do just that.ā€

Hatchett says the work is independent but relies on the cooperation of multi-disciplinary services.

Establishing trust is one of the hardest things about the job. ā€œA lot of [clients] are very resistant because they feel like they are not going to be taken seriously,ā€ she says. ā€œThey feel like because they drink or take drugs, people wonā€™t care about their other issues.

ā€œI find that you get the most answers by asking no questions. We do a comprehensive assessment of course, but if I stood there with a computer or a notepad and started scribbling things down, Iā€™d get nowhere. But I might [see] someone whoā€™s wearing a Richmond hat, and Iā€™ll sort of start talking about Jack Riewoldtā€™s goal kicking or something like that.

ā€œIf you strike up a conversation about absolutely nothing, and youā€™re doing that with one person, the others actually observe you. They observe how you talk to them and, of course, that you help them. Quite a lot of our referrals are from other clients ā€“ people saying, ā€˜The nurse helped me; maybe she can help you.ā€™ And then they start introducing themselves to you, even if they donā€™t want anything, and you become a kind of fixture. Thatā€™s what community nursingā€™s all about.ā€

Hatchett says one of the biggest challenges of providing healthcare to homeless people is non-compliance with medication, treatment regimes and check-ups. But these hurdles can be overcome by working with clients and really listening to their needs.

ā€œI had a guy a few years ago who was in his early 30s, disconnected from his family, and a very heavy drug and alcohol user. He kept being taken to hospital because he kept overdosing. He was referred to me because he was also linked with a mental health service and wasnā€™t taking his medication. I worked with him for some time and worked out he didnā€™t take his medication because it made him feel unwell. He didnā€™t tell the [psychiatrist] because he thought they wouldnā€™t care.

ā€œWe changed the medication, got him linked with a drug and alcohol [program], found him housing, got him re-linked with his family ā€“ which was hard, since heā€™d stolen from them. But weā€™d say things like, ā€˜Well, heā€™s moving into a new house, why donā€™t you get him a rice cooker,ā€™ instead of money, which they were still worried about.

ā€œThat was a few years ago and now heā€™s linked in with his community, heā€™s got a cat and a goldfish, heā€™s even getting a bit of pay from a place heā€™s started volunteering at.

ā€œNow he gets up in the morning and feels he has a reason to get up. At first our clients might just go to an appointment because a nurse said it was what they need to do, but then they realise itā€™s actually helping them, making them feel better. This was about how he thought about himself.

ā€œIf they know we believe in them, they trust us and they start to believe in themselves. That makes a big difference.ā€

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