Advance For Nurses

Nursing the Homeless Holistically

   By Sylvia Coleman


It's about 40 degrees and there's a woman sitting outside on N Street with enough layers of clothing to fight an Antarctic blast. She holds her small frame as if the multiple layers will escape her clearly unyielding clutch. Perched in her path is a dented shopping cart she guards with an unflinching eye. Its contents are bulging between the openings of its small, squared, metal frame. She moves around the block several times today, disappearing and reappearing with a slow pounce on the pavement—always with her cart in tow. 

To most, she appears lost. To Wellness Center Director Dixcy Bosley-Smith, MSN, RN, FNP, she is one of the many homeless women who has found what some consider Washington, DC's best kept secret—the Wellness Center at N Street Village Inc.—a haven that provides a plethora of holistic therapies designed to rejuvenate the mind and body, where women can rebuild their nomadic lives.

And with the program, women seem to release a piece of their "shopping cart baggage" everyday. Many have gone from living on the streets to residing in N Street's temporary shelter, group homes and on-site apartments.


Meek Beginnings

The Wellness Center, one of 10 integral components of N Street Village, offers massages, aerobics, meditation, creative writing, programs on women's issues, facials, herbal tea time, vitamins, healing touch, nutrition/healthy cooking, spirituality, psychotherapy, art therapy, t'ai chi, self-defense, HIV prevention, stress reduction, psychodrama, an eye clinic, yoga, cancer prevention education, wellness seminars, pet therapy, weight maintenance, acupuncture and dental services.

Most Wellness programs are taught by volunteers—primarily professional therapists and some by students specializing in the complementary therapies. Nursing students, both bachelor's and master's candidates, play a key role in the program's success.

Prior to coming to N Street, Wellness Center founder Bosley-Smith, a community health nurse for 16 years, worked at a Washington, DC, shelter for homeless men. Along the way, she became interested in women's health, specifically, the effects of complementary medicine/alternative therapy for poor women. A nurse friend directed her to N Street Village, where its efforts were already geared toward homeless women in three target areas: domestic violence, drug abuse and mental illness.

"They wanted to really look at those issues specifically and ... stop putting a Band-Aide on it," said Bosley-Smith of the recovery programs that target these areas.

She approached N Street officials with the idea of the Wellness Center in hopes that it would enhance the work of N Street's treatment programs.

"I wanted to start something that would be wellness focused and holistic, and would encourage the women to take responsibility for their own health," said Bosley-Smith. "It would be something where women who would otherwise not have the opportunity given their financial conditions, could experience these healing modalities."


The programs, including the Wellness Center, which opened in 1997, are now housed in a new $16 million complex called N Street Village Inc., a national model for homeless populations, according to Bosley-Smith.

Nurses Come on Board

Maintaining holistic care among the N Street community meant not only bringing in various professions, but quite naturally, Bosley-Smith's nursing peers. As a family nurse practitioner, Bosley-Smith does occasional assessment and treatment, but her primary function is to nurture the women through health programs that teach self-care, self-healing—both mentally and physically—and facilitate referrals to volunteer practitioners who come to the center. "We're really trying to look at some of the underlying causes of why they're here to begin with," said Bosley-Smith.

For medical care, clients receive referrals to free and reduced medical clinics throughout the city. Some of the homeless clients use government assistance to pay for that care.

Cynthia Rosenwald, RN, and Cassandra Wilson, MSN, RN, CSP, are the other two on-staff nurses at the Wellness Center. Rosenwald specializes in HIV/AIDS education, coordinates women's health groups and does individual counseling. As assistant director, Wilson uses a combination of holistic approaches in conjunction with her 25 years of experience as a nurse. Not only does she hold group sessions on self-esteem and conflict resolution, she uses her training as a musician to conduct music therapy sessions.

"You are really feeling like you make a difference by just helping people raise their self-esteem," says Wilson of what she describes as the most rewarding aspect of her nursing career.

And because she, Rosenwald and Bosley-Smith are nurses, they have the needed expertise to administer or recommend care beyond the Wellness Center or beyond the care administered at N Street's on-site medical clinic.


Nursing Students

Nursing students come on Tuesdays and Wednesdays and teach such health education groups as hypertension, diabetes, flu/cold prevention, menopause and foot care. They also provide one-on-one counseling with the women and even assist with the on-site dental care. In addition to these responsibilities in the Wellness Center, the nursing students may help out in N Street's day program in the Bethany Women's Center or stay in the overnight shelter.

"I think that's a profound experience for a nursing student, because when you see someone in a clinical setting, you have no idea what their home life is about," says Bosley-Smith. She hopes that understanding a homeless person's background and their plight will help the students administer more compassionate care for their future patients.

"I tell them all the time, that it is by chance that we are not them and they are not us," says Bosley-Smith.

Toniesha Morton, BSN, RN, and nursing student Jennifer Muller, who did their clinicals at N Street, agree.

Morton, who worked at N Street during the fall of 1999, currently works at Prince George's Hospital Center's intermediate critical care unit and says her experience in the Wellness Center was invaluable. Although she had worked with the homeless previously, she says nothing compared to her experience at the Wellness Center, which allowed her to connect with the homeless on a more intimate level.

"The Wellness Center is what makes N Street different from any other place I've been," says Morton of the shelters she has seen. "It helps with the continuum of health care." She says she was shocked to learn that the women she interacted with had backgrounds that were no different from hers and some of her peers.

"Some people had been very successful in their careers ... They're people with a past," explains Morton. For instance, she was stunned to encounter homeless women with both bachelor's and master's degrees.

Morton became close with a homeless resident who had a rare disorder. Eventually, she was able to help the woman find resources to manage the disease, but as with many of the homeless women the nurses encounter, Morton had to establish trust.

"We weren't there for a long time," said Morton of the semester-long clinicals. "It takes time to build a rapport so that they can trust you and tell you things about themselves." To gain their trust, Morton and Muller had to be consistent. Their continual presence helped win some of the women over. Some of the women felt comfortable enough to discuss their problems and share their journals with the nursing students.

Also, many of the homeless women felt comfortable letting a nurse or nursing student check their vital signs or change a dressing and often sought out additional medical care upon their recommendations.

Through her experience at the Wellness Center, Morton was exposed to different resources around DC that are available to the homeless and poor; information she uses in her current position, she says, where she encounters many homeless.

Muller says her experience was enriched because of Sister Mary Hartnett, MS, RN, CS, her nursing instructor at Catholic University of America, who brings students to N Street for their clinical rotation. Because Hartnett had been there for several semesters, Muller says the homeless were more apt to trust the nursing students she brought to the Wellness Center.

"The [homeless] women are amazed by the Wellness Center. It makes them interested in taking care of themselves ... I wish all nursing students could have that experience at N Street. It helps you with dealing with people," says Muller.


Tackling the Major Issues

A number of women at N Street have mental illness. The Wellness Center has tailored therapies to meet their needs including individual and group therapy. It has used psychodrama, pottery classes and writing groups as a creative means of dealing with mental illness.

Assessment of eating disorders is another key component of the Center. Bosley-Smith says some women have gained weight as a result of their previous lifestyle, where they had to settle for whatever they could find to eat. Others gained weight from taking psychotropic or antidepressant medications or from overeating to suppress the effects of mental illness.

She also said that many of the women have been sexually traumatized. "Often, there are eating disorders associated with that," explains Bosley-Smith.


Massage, acupuncture, reiki, sexual trauma group therapy and individual psychotherapy have been very effective in restoring a survivor of sexual trauma.


Making A Transition

Indeed, every homeless woman at N Street has a personal battle to wage. Take for instance, Janice, a recovering crack addict.

The 44-year-old has only been at N Street since Jan. 6 and says she has already reaped substantial benefits from its Wellness Center. Although she's in a treatment program, N Street's Harriet Tubman Residential Recovery program, she says biweekly acupuncture helps tremendously with symptoms of withdrawal.

This form of acupuncture, auricular therapy, is particularly recommended for addiction treatment. Five needles are placed along the earlobe, which target different organs of the body. Tapping into these points is believed to release toxins from the body.

Janice, who has one adult child, says she became homeless after losing both her job and apartment while paying out of pocket for her mother's nursing home care. After detoxing at the local general hospital, the Navy veteran eventually linked up with female staff at the Veterans Hospital who recommended she go to N Street Village.

Soon, she was properly diagnosed with bipolar disorder and began treatment with Depakote™ (divalproex sodium, Abbott). She's feeling much better now and spends each day taking advantage of several wellness programs, like massage, group therapy and art therapy. She also receives dental and eye care from the Wellness Center.

"The biggest thing here is that it is a safe environment," says Janice. "The nurses are very helpful ... You can go to them with anything and they'll give you their best suggestions. Without the Wellness Center, [N Street] would just be another treatment program without any time to work on you," says Janice.

As Janice improves, she hopes to take advantage of programs outside of the Wellness Center, like career planning.

Perhaps, one N Street resident sums it up best: "We're the healthiest homeless women ever. I feel sorry for the 'haves' because we're the 'have-nots' and we're doing pretty good!"




That mainstream market of holistic therapies and herbals Wellness Center Director Dixcy Bosley-Smith, MSN, RN, FNP, envisioned for homeless women is now used by at least 46 percent of the nation.1 Here are a few tips to develop a wellness mecca in your own area.

Bosley-Smith first created a vision for the Wellness Center, including who would be involved and how. She then compiled a survey of holistic therapies asking pre-selected DC residents which ones they could teach.

Of course, the next step is to secure a location. In the case of Bosley-Smith, it worked best to partner with an organization already established. Other venues may include local community centers and nonprofit family centers, where there is a need for free and reduced cost health care.


Key to her success was sending a request for volunteers to local schools and national agencies that specialized in alternative practices, like the Traditional Acupuncture Institute and the American Art Therapy Association Inc. (AATA).


Enthusiastic Responses

Soon, the responses started rolling in and Bosley-Smith could see that she had sold them on the prospect of gaining needed training in their fields, helping an underserved population and possibly obtaining internship credit from their schools.

"It was an opportunity to learn that health care is not a privilege, but a right and if we really believe this is health care, we should offer it to everybody," says Bosley-Smith of holistic treatments that she believes society has deemed as elitist medicine.

Bosley-Smith's desire to combine complementary therapies with the nurse practictioner training she received in school stemmed from interacting with patients in severe pain, like chronic back pain and headaches.

"All we had to really offer the poor were prescriptions," said Bosley-Smith. "We couldn't say, 'Let's see if a series of massage therapies or physical therapy or see how a round of acupuncture could treat your migraine headaches.'"

While some may view these treatments as "elitist therapies," more and more HMOs are offering them at reduced rates for the insured. And people like Bosley-Smith are extending that care to those less fortunate.

To make that happen, Bosley-Smith had to do some grant writing. She found many grants just by asking different health care professionals like her massage therapist, if there were any available in the profession. As a result, she applied for grants from such organizations as the American Massage Therapy Association, the Mary Fisher Foundation for AIDS services and the Wheat Ridge Foundation, which funds innovative health programs.

Equipment and products came from donations she formally requested from company's like Oakworks, which donated the massage therapy products. Bosley-Smith obtained medications from various pharmaceuticals that were also willing to give.

Although the legwork involved in the development of a wellness center is challenging, the nurses at N Street's Wellness Center say the pay off—the resident's well-being—is worth it.

—Sylvia Coleman




1. Eisenberg, D., et al. (1998, November). Trends in alternative medicine use in the United States, 1990-1997. JAMA, 280(18), 1569-1575.