Standing in this wonderful old seat of learning, I am reminded of one of its’ famous graduates – Sean Armstrong – at whose funeral we gathered in Belfast in June 1973. On the night he died, a friend with whom he and his new wife spent some time in Scotland, had a vision of a huge tree falling and new shoots springing to life from it – this was read from a letter by Sean’s wife at the grave-side. I met him once as a group of us – including nurses – sat on the floor, listening to him speak with enthusiasm on the value of, and need for, voluntary service (we all worked with Voluntary Service International at the time) – his enthusiasm for life and his great hope for the future.
This conference is about nursing, and public health. I am now, more than ever before, totally convinced that seeing nursing in a purely clinical role diminishes our capacity to see the complete human being, including our own individuality and complexity. The OUTSIDER in all of us can be dismissed and consequently, our ability to understand the OUTSIDER in the other.
‘There are dozens of Dublins and we all think we know our own. But sometimes we can be jolted into a realisation that we don’t know our city at all. All around us there can move backwards and forwards people whose lives have a different heartbeat, whose hopes and dreams and expectations are wildly far from our own.’ This is true of all cities.
Maeve Binchy said in her foreword to ‘Not just a Bed for the Night’ co-authored by Alice Leahy and Anne Dempsey, published by Marino Books in 1995.
In 1974, I carried out research based on a questionnaire and clinics held in night shelters with a group of doctors working in a voluntary capacity. Based on this work, and the generosity of the late Ann Rush, TRUST – a private charitable trust – was set up in 1975. The organisations’ aims are:
“to serve homeless people in need by promoting human services which would meet their immediate and long-term needs and by these means to encourage their development and give their lives a dignity which is their birthright.” …from the Deeds of TRUST
The philosophy of TRUST is based on two central principles:
• The recognition of every individual’s right to be treated as an autonomous and unique human being.
• The need to restore the dignity of individuals whom society has labelled deviant and undesirable.
Daily we meet up to 40 men and women who are living rough, in Dublin and beyond. Our services include the provision of shower / bathing facilities, a change of clothes – as part of an holistic health service, information on their rights and entitlements, meeting people on the level they are at, to address their more complex needs. The people we meet are perceived by wider society as being different and difficult. They suffer from the effects of isolation, neglect and health problems, exacerbated by lifestyle. Accessing mainstream services – particularly basic accommodation is a major problem. We meet increasing numbers of people ‘re-settled’ in totally unsuitable accommodation, and then out homeless again.
” … The question of a better service for vagrants would lie, in my opinion, rather in the field of prevention than cure and there is comparatively little that the hospital can do beyond attempting to treat the cause (where it can be ascertained) and the result of vagrancy…”
J.O’Dea, Medical Administrator, St. James’s Hospital, Dublin, in 1974, Medical Care for the Vagrant – this could be today, you will agree!
We meet people daily, whose bodies are:
• Ravaged by disease and violence
• Pressure sores from sleeping out in all weathers, sometimes sleeping in urine soaked clothes for weeks
• Infected and untreated minor skin conditions and major skin problems e.g. leg ulcers
• Lice infected heads
• Scabies
• Bodies suffering from malnutrition
• All the medical conditions common to the general public but exacerbated by their living conditions
• Minds and souls dispirited by feelings of despair and inadequacy
• Human beings taken over by addiction to society’s drugs, including alcohol and gambling
• Human beings pushed from service to service – just like figures on a broken or incomplete chess board
• People who are unable to read or write, and as a result become stressed because of letters arriving, for example, a man called for jury service whose doctor was unaware of his difficulties and wouldn’t write him a letter.
• Some unable to get relief for minds at breaking point only solution at times a brown envelope of medication
• Some trying to create some sense of normality after years locked away in institutions and others just relocated from one institution to another in the name of progress
• Many who have attempted suicide and some who sadly succeed
• Families distraught at what has become of their loved ones
• Caring individuals at breaking point
The Nature of Homelessness
‘The word homelessness sounds self-explanatory, but in relation to people who either sleep rough or use hostels and night shelters, homelessness is merely a symptom of a more deep-seated set of problems. For this reason, the solution is more complex and difficult that the provision of housing. …People who are homeless have often rejected the conventional values of society or have been themselves rejected. It is not surprising that many have been in prison or mental hospitals or both. In a society, which is intolerant, imprisonment or admission to a mental hospital is the usual response. …Once set on a downward path (often as a result of things over which they had no control) such people may readily enter a spiral which ensures that they become more and more distanced from their fellow citizens and have less and less in common with those who have loving families, houses and regular income. …It is not surprising that there are no simple solutions to their problems. The provision of a flat does not solve their difficulty. What is needed perhaps is a slow and often difficult process, which has as it’s main objective the restoration of a sense of personal worth. That is why the philosophy of TRUST centres, not on the important medical, nursing and social service, which it provides, but upon the restoration of human dignity to those whom the rest of the world appears to despise.’
Professor James McCormick, former head of the Dept. of Community Health, TCD, Trustee and Former Chairman of TRUST, in TRUST booklet.
June
June presented at TRUST over three years ago – in her 40’s but appearing to be in her 70’s – she called 3 or 4 times, didn’t speak, looked emaciated. Her body language spoke volumes – she looked like a caged animal with her eyes darting from person to person.
After coaxing and understanding from Geraldine, she eventually removed her hat – her hair was green and matted. From walking around the city day and night, her feet were dirty and bleeding – she had an allowance book with £2,000 Irish unclaimed.
Over a period of time, we discovered she had lived in a women’s hostel for some time but was eventually barred. Geraldine dropped into a local church at 07.30am regularly, only to find her sitting in a back row pew, shivering.
A community Welfare Officer succeeded in getting her B&B accommodation and we asked local Gardai to keep an unobtrusive eye. She started to collect her money and called to TRUST on and off. She was seen as ‘successfully coping’. The B&B shut down, and she disappeared. Assurances were given that Eastern Regional Health Authority staff had got her another B&B but no one could tell us where.
She re-appeared 2 months ago – after almost two years – in exactly the same situation. We start all over again. It is important that we do not allow ourselves to think that because she has ‘failed’ in society’s eyes, we must ignore or pressurise her – that she came back is what is important.
Our centre is situated in the heart of the liberties – one of the ancient, historical areas of Dublin – well documented by Swift – in fact we are in the shadow of St. Patrick’s Cathedral where he was Dean. Today, if Dean Swift walked our streets, what would be his response, we often wonder?
The Iveagh Trust was set up by the Guinness family over a hundred years ago, and we rent – for a nominal sum – part of the basement of the Iveagh hostel. The thickness of our walls and wooden flooring are reminiscent of great craftsmanship, vision and altruism.
‘I was most impressed by your service. The bright coloured walls and wooden floors were warm and welcoming, and mirrored the bright cheerful staff who welcomed me… I was particularly impressed by the pictures on the wall, which captured the sensitive nature of the people who use your service and speaks of a place where everyone is accepted just as they are. Those pictures tell me that every life is a work of art. I felt I was in a solid, comfortable place and ordinary enough to feel at home’
Dr Kieran McKeown, Social and Economic Research Consultant, after a visit to TRUST
Staff:
• A Board of Trustees support the staff
• 3 full-time, 1 part-time, one full-time volunteer and a number of other volunteers work in TRUST
• Staff are represented at Board meetings and are fully involved in all decision making
• The team is Nurse-led – all staff have a specific responsibility and all are multi-skilled. The ability to work together with flexibility is key to efficient running of the centre. Male & female staff members are present at all times.
• All medical procedures are carried out only by nurses
• In-house training is ongoing. A weekly breakfast meeting ensures sufficient time to discuss issues of importance
• Health and safety guidelines are all strictly adhered to
• A procedure book is regularly updated
• All staff are involved in advocacy, which is a key component of our work
• All staff are encouraged to keep up to date on current affairs and justice issues
• Confidentiality is respected. Prying into one’s personal history is not allowed.
• Daily record is kept of the numbers seen and the work carried out.
• Monthly report is presented to Trustees
• All students on placement are required to adhere to plans drawn up and complete assessment form.
• In the last 12 months – one student PHN and 13 student gardai have completed two-week successful work placements with TRUST.
• Emphasis is placed on valuing staff and their well-being and contentment is never lost sight of (who cares for the carer?)
Daily we are reminded of those gone before us and in the development of services, it is vital that recognition be given to past colleagues who had great gifts but limited resources, and few opportunities to speak out.
Education:
Soft words like ‘client’ or ‘customer’ can distance us from people needing help. They also lull us into a false sense of security that people who are homeless are being cared for to the best of society’s ability.
These words also give the impression that the person who is homeless has the same rights as a consumer. This is not the case. They infer that someone who is homeless has the same power as a customer or client of, say, a bank or a department store.
The language of consumerism used in assessing funding (like ‘performance indicators’) pressurises services to work only with people likely to be successful – further alienating the homeless person most in need – and service providers can be equally lulled into a sense of achievement. As a society, we need to be more aware of how we use language, to understand its power and to take into account its effect on people who are vulnerable. All TRUST data produced emphasises the above.
• Pocket size information booklet
• Web site – www.trust-ireland.ie – click on all buttons for full information
• Video – A Fragile City – made by award winning film makers, Esperanza Productions – and shown on National TV
• Students on placement
• TRUST training day – ‘the Homeless Experience’
• National Essay Competition – Transition Year 2000 / 2001
• National Art Competition – 2nd level schools – 2002 / 2003
• We make submissions where relevant to Government Departments.
• Interviews on Radio, TV & in Print Media
All the above are carried out to create a greater understanding of exclusion and the need for advocacy based on same.
If we work with compassion and sensitivity, it must follow that we become advocates. An advocate, in my dictionary, has several meanings, but in our case, speaking out on behalf of another is the one of choice – to be an advocate can lead to isolation…
Writing before the coming on stream of the 4 year degree programme, Judith Chavasse, former Director of the Department of Nursing, UCD said in: ‘Not Just a Bed for the Night’
‘Nurses are the only professional group trained exclusively within the health service. Most student nurses enter straight from school into a hierarchical training system. To survive, they rapidly learn to conform. Hospital research in the 1980’s found that student nurses’ experiences encouraged adaptation seldom reflected on and usually internalised by the end of training.
Most nurses are women. It has been argued that, out of mistaken loyalty, women often support structures and practices, which are oppressive to others. Alternatively, the internalisation may have been refined to the extent that nurses have ceased to see injustice and have identified with the oppressive system. Anyone who demonstrates against this may provoke a storm of protest, as happened when research showed that some patients are treated differently if they are unpopular with nurses.
Rebels, whether patients or staff, have a hard time in hospitals. Many nurses who maintain a rebellious streak leave the hospital system and exercise their caring role to great effect in a different environment.’
We, as nurses, have few opportunities to reflect on caring, compassion etc. Why should this be the case?
Current trends from abroad show the value of emotional intelligence over technical expertise – this point we have always stressed. But do we as nurses place enough value on sensitivity, compassion and empathy? I think not! At times, emotional intelligence is undervalued and, I would argue, not understood, yet if we are to work with the most isolated human beings without emotional intelligence, we will all be the poorer.
Emotional Intelligence is valuable in areas of management / partnerships / research, but difficult to quantify and define. We need to value nursing – we need to value ourselves, and ultimately need to ensure that the most isolated of human beings have equal status at the planning / discussion table – this may be uncomfortable but is essential and life enhancing.
Emphasis focusing on public health – primarily that of the community – does ignore the individual, and in the area of homelessness – all could easily be seen just as rootless and roofless statistics. Nurses with no knowledge of the broader societal issues – add to this marginalisation – and no one benefits. Nurses should not allow themselves to be isolated from the broader debate, or much worse, become part of the problem.
Vulnerability is most obvious when ill, when one hands over one’s body and mind to the care of others – we as nurses who should be in touch with human feelings (including our own) and not just technicians, or statistic gatherers. Over a hundred years ago, Andrew Lang said: “He uses statistics as a drunken man uses lampposts – for support rather than illumination.” We should not be silenced or intimidated in our attempts to speak out on behalf of those in our care. We may ourselves – one day – need someone to speak for us.
‘I met quite a few homeless people and yet in that busy setting was unable to treat them as people – only treat their condition, which more often than not, is a result of their lifestyle. This is the uniqueness of TRUST in that it is not a treatment centre for a condition but a people centre. …People are treated in a holistic sense in that body and mind are cared for totally…’
Quote from a recently qualified nurse who left nursing frustrated to pursue a different profession who spent time on placement in TRUST, Summer 2002.
Thomas
A very withdrawn 70-year-old man living in a hostel for years was known to us, as we daily walked past – he never looked healthy. Hostel staff asked us to see him – he had a number of years ago self-referred to a casualty department, giving a different DOB and home address (this is not unusual, as homeless people or those with a hostel address feel rightly or wrongly that a better service will follow). This leads to problems re follow up. He had no medical card and saw no need for same.
After much persuasion, he was escorted to a local GP who saw him and referred him to a local hospital for C/3 urea breath test (helicobatric pylori), which showed positive.
Hospital prescriptions must be transferred to medical card prescription to get medicine. Tablets were divided into morning and evening use and hostel staff agreed to administer same. He completed the course of medication and felt much better.
His medical card was eventually processed – a hospital appointment for follow-up was made for November. We in TRUST will have to ensure the appointment is kept.
“Vagrant patients tend to leave hospital before their treatment has been completed. Sometimes they return in an inebriated condition and the whole process has to be recommenced. His reply perhaps best summed up that clash of concern and frustration. It continued: ” from the administrative point of view, it is very difficult to contact relatives in case of serious illness or death because those patients frequently have great reluctance to give information about their next of kin”
Comment from Dr. O’Dea, St. James’s Administrator, in Medical Care for the Vagrant in Ireland, 1974 – A Simon Ireland Report By Alice Leahy R.G.N., R.M.
A quarter of a century later, nothing has changed, however, we would not use the term vagrant.
Peter
In his 50’s, appears to enjoy the role he has defined for himself caring for others who are homeless, writing poetry, which he sells, and his social contacts. Self-neglect and depression are also a part of his life. He has slept rough for years, spent time in prison and has had numerous flats.
Money made from selling his poetry on the streets and a small pension make it difficult for him to meet bureaucratic requirements to get a medical card. This ensures he has no medical cover apart from good will of GP’s. He is susceptible to infection due to living conditions, poor diet, combined with huge alcohol intake and, at times, tranquillisers.
He recently got extensive grease burns – from a chip pan that he heats over a gas stove – to his hand, which was badly infected. He complained of numbness around fingers, and severe pain in his hand.
– The wound was exuding pus and very excoriated.
– He was very distressed and had a general feeling of malaise
He was feeling extremely cold, tired and very lethargic. There was ‘tracking’ on his left arm and a lot of pain and discomfort.
Treatment
The obvious nursing procedures were carried out to :
– reduce inflammation
– ease pain
– prevent further infection
– promote healing
Initial treatment was in an effort to prevent further infection and this was countered with a broad-spectrum antibiotic. He had little knowledge in relation to his condition and as a result was unable to effectively take his medication. The staff at TRUST kept his medication on the premises and gave him two tablets in the morning and tablets in separate envelopes with written instructions for same throughout the remainder of the day. He was commenced on ‘orovite’, which contains vitamins B+C to promote skin healing.
Daily dressings, completion of antibiotic course, and vitamins worked successfully.
His general well-being improved. He continues to bring us flowers weekly – we allow him to give as well as receive – a sign of our real friendship, which has contributed to above.
John
When John was in his late 70’s, he decided to move to a hostel when living alone became difficult for him – he liked his independence. He felt his security was threatened and he was aware that nieces and nephews cared for him. Moving involved changing his address and all that that entails: changing his doctor, his post office where he received his Old Age Pension, and many other practicalities – including deciding what he could take with him.
He settled in, having the choice if he wanted to mix with other residents, or not. Technically, the hostel became his home – meals were cooked, laundry done and the only responsibility was to pay his weekly rent, which was subsidised by the Eastern Regional Health Authority.
After a number of years, his health deteriorated, his mobility became a problem, looking after his personal hygiene, walking to the local shops – even visiting his G.P., walking to the nearest toilet created problems, which led to soiled clothes and bed wetting.
We arranged chiropody, organised eye test and glasses. Weekly assisted baths ensured he maintained his appearance, skin was checked regularly especially for pressure sores. TRUST supplied changes of clothing when required. Income was insufficient to provide a change of clothes etc., it may have been necessary for him to attend a clothing centre to get same – he was a proud man, and would have preferred going to a shop, but this would have also proved difficult for him.
When his medical card ran out, he mislaid the notification, which requested a birth certificate for proof of age, even though he had had a card for years! To get same, involved calling to the Birth Registrations Office some miles away from the hostel, with no direct bus service.
All forms left in local welfare office were mislaid twice – his rapidly deteriorating health meant he could not walk up the hill to the office even though only 5 minutes away. A TRUST volunteer informed the office staff, who said they would phone him when the card was ready – he had no phone. Three visits, and numerous phone calls later, he got a medical card number. His GP had arranged a geriatric appointment at our request – hostel staff were using a wheel chair to take him to his GP.
Numerous appointments in Day Hospital followed – numerous tests were ordered. The procedure in OPD is not always patient friendly – a consultant says ‘ see you on 02/12’ – the patient is rarely told that it is necessary to go to appointment desk. On all his hospital and GP visits, TRUST staff or hostel staff escorted him. It was patently obvious the man was losing weight, was in severe pain, and needed care delivered by trained staff in a proper setting with at least some basic comforts.
Following a letter to the hospital consultant from TRUST, he was admitted to hospital, where staff visited him. There, he refused to let hospital staff bathe him. One afternoon, 3 weeks later, he was transferred to the Hospice – no one was informed – and he died within the week.
Involvement of TRUST staff at least meant that John was in comfortable surroundings. At times this perhaps is all we can do, but even that required enormous involvement, which could never be adequately described in current nursing literature / research.
‘May we quite simply state that attempting to communicate with various groups and individuals is on the whole a most frustrating task. We often wonder if it is indeed humanly possible to get across the message of true co-operation.’
‘If we are to push for fundamental change in the whole area of homelessness, then a certain amount of constructive research is necessary. We feel strongly however that it must be pursued with the greatest caution. It is clear to us that the ‘research industry’ uses that section of our society, which is the most vulnerable and the least able to battle for it’s rights as its source of material. We must never forget that we are working with human beings, who for the most part have been battered by our society and who for so long have been pushed about as just another number in a cold inhuman bureaucracy’
That last quote was from Leahy & Magee – Report on Broad Medical Services For Single Homeless People in the City of Dublin – March 7th 1976 – 26 years later, in the new millennium – and nothing has changed.
