Introduction
This research study paper has been clearly written and the authors are explicit in their methodology. The issue is that the homeless are denied proper health care access. The study has investigated the issue in San Diego, California and come up with some positive findings which others could use for the homeless in their community. A qualitative research using the grounded theory design has been expertly done and reported on.
Problem
This study focused on the problem of health care for the 15000 homeless people in San Diego, California. The poor who had homes were ensured of nursing care and provided the access to healthcare. However the homeless who had greater needs for nursing care were practically denied the best care. Their needs were not yet assessed. Issues of their access to health care facilities were not investigated. Whether they had any care-fragmentation and whether they had any difficulty in getting the medicines were other issues that needed study. Nursing care facilities were intended for the homeless population and this study would provide the baseline data.
Study Purpose
It intended to investigate the perceptions of the homeless to the kind of health care needs, whether they had sufficient access to health care facilities like the primary care centre and emergency hospitals and whether they were satisfied with the services accorded to them. It also gave the homeless a chance to come out with suggestions of what they required in the name of nursing care. The analysis of the data availed of in the study would provide a better picture of the needs of the homeless. The perceptions of the homeless as to when they need emergency services must be determined. The possible problems that affect their perceptions would be their state of mind, their priorities in relationship to food and shelter and their experiences with the health care system.
Research question
This has not been provided but it can be assumed to be something like the following:
What are the perceptions of the homeless with regard to their access to health care and utilizations of services, with reference to
- whether they had sufficient access to health care facilities like the primary care centre and emergency hospitals
- whether they were satisfied with the services accorded to them
- what their experiences with the health care system are
- when they needed emergency services.
- whether they had issues of care-fragmentation
- whether they had difficulty in getting medicines
- whether they had follow-up care
- whether lack of health insurance has affected their access to health care.
The question is broad in perspective and sufficient to get plenty of matter for qualitative analysis.
Study Design
The grounded theory design was used for this qualitative study. In this design a theory was to be generated based on the perceptions of the participants and would be evolved at the end of the study from the data collected. Another advantage is that a systematic analysis is possible. The design seems appropriate here as pre-conceived notions about the response of the participants from the semi-structured interviews are not possible and a theory cannot be used at the start of the study. Also the semi-structured interviews were intended to add more questions based on the earlier answers of the participants. These therefore would be different for most of the participants. The suggestions from earlier answers may require these extra questions to elicit the maximum and best answers.
Subjects and setting
The participants had to be homeless and residents of San Diego for a minimum period of 1 week as these were the main criteria and the aim of the study was to investigate the health care services of the homeless. They had to know English as they needed to comprehend the questions in the semi-structured interviews and had to be able to answer themselves. They needed to be having enough memory to recall their experiences. Those above 18 years only were selected so that the ethical issue of a guardian answering for the participant does not arise: all answers had to be given without anybody’s help for the interview to be authentic. Gender, race and ethnicity were not considered as the homeless were from various races and ethnicities and there were males and females. This is also considered appropriate.
49 participants were interviewed and this number may be sufficient for conclusions to be drawn from data analysis. In the grounded theory design, the sample size should provide enough in-depth data (Auberbach and Silverstein, 2003). They should be revealing sufficient “patterns, concepts, categories, properties, and dimensions” of the perceptions on health care issues of the homeless (Strauss & Corbin, 1998). Theoretical saturation must be the technique used for deciding the sample size. In that case, we can be sure that no new information is possible from more participants. If this method was followed in the study and the data showed a repetition of answers towards the last interviews, this saturation may have been obtained. Theoretical sampling may be done to ensure that those who answer well and give more perceptions are included in the grounded theory study. This ensures quality data.
Sometimes participants withhold personal answers and those pertaining to ethics. This may harm the study in that the sample size would then have to be increased to get more answers (Morse, 2000). However this issue is not seen here.
The setting was in the open in a daytime service centre for the homeless in a local spot for the easy approach of the participants. This setting was good in that this was a place frequented by the homeless for care. No other person came here and the issue of ridicule or feeling small did not arise. A fenced patio was used. The interviews were conducted in absolute privacy and each person was interviewed separately. The setting was therefore right.
Data Collection Methods
Data collection was done through the semi-structured interviews. Only one person was allowed to be interviewed at one time. The interview was completed in the presence of the interviewer. There was no chance of anybody helping the participant to write his answers. Digital recording was done for maximum reliability and for later use. Following the interview, a debriefing process was conducted and the report verified.
The approach was ethically correct. Anyone who had the chance of emotional distress or psychological needs during the interview was referred to the family nurse practitioner for an intervention. A written consent was obtained from the participant. Credibility was obtained after the interview by verifying the report. An incentive of $20 was given to each participant. The study got its approval from the Institutional Review Board (IRB) at Point Loma Nazarene University.
More than 50 people were present at the interview. The observation that the interview was terminated after 49 interviews suggests that data saturation could have been achieved. When the answers were persistently similar, the decision to stop was probably taken.
Data Analysis
The data was analyzed using the Strauss-Corbin method.Then it was transcribed and coded in a series of steps. By the standards of coding in the grounded theory design, open coding is done to conceptualize the incidents in the data. Core variables are distinguished. Then selective coding is done based on the core variable. Finally theory coding integrates the theory that has evolved. These steps have not been mentioned but we can presume that is the technique used here. The use of the recorded sessions has been a good feature of this study. The data analysis is appropriate for the data collected and consistent with the grounded theory design.
The descriptive data gave the demographics of the participants. The contextual data gave details enquired for the healthcare questions. Three facilities were opted for health care access. Surprisingly transportation was not a barrier and homelessness was not a stigma by the participants. The two care categories identified were “existing in the moment” and “losing ground over time”. The critical moments were loneliness, isolation and crisis. There were two options for the participant. The first choice improved their chances of access and the other worsened it. Illness causes the patient to neglect access to care. Isolation would cause a person to seek connection. A crisis would cause the person to cry out for help. Spiraling up occurred when a positive option was used. Visibility to society and health services occurred with the positive attitude. With the negative option, the opposite occurred.
Strengths of the study
Study findings were obtained from oral and written reports; they were therefore better studied as the oral reports could be time and again be heard for further discussion whenever necessary. Any other community could use these findings for their homeless population. Care providers could change their attitudes to the healthcare for the homeless in any community, based on these findings. Health care services could intervene in moments of crisis and use the spiraling-up options.
Limitations of the study
The voices of homeless children were not being investigated. Participants were giving perceptions of experiences rather than having actual health care access. Sheltered individuals were not included.
Implications for nursing
The study findings are valid in that they have given us an idea of how the homeless perceive the access to health care and how these services must be accessed to them. That holistic nursing is called for when the homeless need care is obvious in this study. One is able to understand that the homeless patient seeks the emergency department according to his perception of an illness, not exactly because it is an emergency; he is calling for help due to despair. Reassurances to allay their fears, balm for their despair, therapy for their mental illness and shutting the eyes to their lack of knowledge of rules of the ED are some of the steps of holistic nursing that are necessary for bringing them over to our side.
References
Auberbach, C. F, & Silverstein, L. B., 2003, Qualitative data: An introduction to coding and analysis. New York: New York University Press.
Morse, J., 2000, Determining sample size. Qualitative Health Research, 10, 1, 3-5.
Strauss, A., & Corbin, J., 1998, Basics of qualitative research. Thousands Oaks, CA: Sage Publications.