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 Melbourne’s CBD in order to change the wound dressings on her damaged legs.

“She just wouldn’t go to a clinic so I didn’t have a choice – I just had to disinfect everything and make it as hygienic as possible,” Williams says.

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

The homeless often aren’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. “Our nurses are all very solid clinicians, but we’re not just episodic, not just focused on a clinical response,” she says. “Ideally we work with others or, if that’s not possible, we provide a holistic response ourselves. We’ll provide healthcare, but we’ll also sort out income and find housing.”

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.

“We provide breakfast and there’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 – a range of services,” Hatchett says. “Quite often I link with people there that are hard to catch, or people come to seek me out because they know it’s the one place I’m going to be every week.

“There’s a bit of a transient population and then there are people who have been around the traps for a long time. There’s a guy I’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 he’s booked in for another appointment.”

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

“On 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.”

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. “A lot of [clients] are very resistant because they feel like they are not going to be taken seriously,” she says. “They feel like because they drink or take drugs, people won’t care about their other issues.

“I 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, I’d get nowhere. But I might [see] someone who’s wearing a Richmond hat, and I’ll sort of start talking about Jack Riewoldt’s goal kicking or something like that.

“If you strike up a conversation about absolutely nothing, and you’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 – people saying, ‘The nurse helped me; maybe she can help you.’ And then they start introducing themselves to you, even if they don’t want anything, and you become a kind of fixture. That’s what community nursing’s all about.”

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.

“I 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 wasn’t taking his medication. I worked with him for some time and worked out he didn’t take his medication because it made him feel unwell. He didn’t tell the [psychiatrist] because he thought they wouldn’t care.

“We changed the medication, got him linked with a drug and alcohol [program], found him housing, got him re-linked with his family – which was hard, since he’d stolen from them. But we’d say things like, ‘Well, he’s moving into a new house, why don’t you get him a rice cooker,’ instead of money, which they were still worried about.

“That was a few years ago and now he’s linked in with his community, he’s got a cat and a goldfish, he’s even getting a bit of pay from a place he’s started volunteering at.

“Now 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 it’s actually helping them, making them feel better. This was about how he thought about himself.

“If they know we believe in them, they trust us and they start to believe in themselves. That makes a big difference.”

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