Impact of Homelessness on Access to Primary Care

Homeless lifestyle: The impact
for adult patients in Primary Care

ABSTRACT

Purpose: To understand the homeless
lifestyle, how this impacts on the care received in Primary Care services and
how these services could improve to benefit the homeless.

Which Citation Styles Can You Handle?

We get a lot of “Can you do MLA or APA?”—and yes, we can! Our writers ace every style—APA, MLA, Turabian, you name it. Tell us your preference, and we’ll format it flawlessly.

Method: A critical review of
literature using a systematic search across databases Medline and CINAHL, as
well as searching UWE library for the appropriate articles.

Findings: The homeless lifestyle and the
needs of those meant that certain areas were identified, these being mental
health support, support with substance abuse, self-neglect and poor nutrition.
Homeless people felt that there was difficulty in accessing healthcare services
and that they were judged by healthcare professionals.

Conclusions: For there to be
improvement in the health and wellbeing of the homeless it is essential that
there is access to health services and support for mental health and addiction.
A suggestion to improve the care is to create an awareness package for
healthcare professionals to understand the needs of the homeless and improve
engagement, reducing lack of support and judgement felt by the homeless.

Summary:

What is known on this subject?

Are Writing Services Legal?

Totally! They’re a legit resource for sample papers to guide your work. Use them to learn structure, boost skills, and ace your grades—ethical and within the rules.

Statistics acknowledge
the increasing numbers of homeless in the UK, this impacts the needs of those
who are homeless as there is a lack of support from healthcare services. The
little support and difficulty to register with GP surgeries creates a negative
effect on the health seeking behaviours of the homeless.

What does this review add?

This review looks at
the homeless lifestyle and the most common areas of healthcare needs for those
who are homeless. This helps suggest a plan to improve healthcare services in
order to provide for the needs of the homeless.

What’s the Price for a Paper?

Starts at $10/page for undergrad, up to $21 for pro-level. Deadlines (3 hours to 14 days) and add-ons like VIP support adjust the cost. Discounts kick in at $500+—save more with big orders!

Key Words: homeless, healthcare, needs,
services, service improvement

1. INTRODUCTION

Homelessness
is still an ongoing issue in the UK. Statistics show an estimated 3569 people
sleep rough on a night in England, which is an increase of 30% from the year
before and tragically double the number since 2010 (DCLG, 2016). Although these
figures are likely to be higher as there are many homeless that stay in
hostels, at friends or families or other accommodation, this is known as hidden
homeless and these people are not included in the numbers (Homeless Link,
2016).

Crisis (2016) recognise the increase of homelessness due to cuts in housing benefit, funding for homelessness services and the lack of housing. It is highly likely these changes will cause a further increase in homelessness. This will impact on nursing practice as those who are homeless are more likely to suffer with ill health and face long term health problems, Homeless Link (2010) found that 41 per cent of homeless reported a long term physical health problem compare to only 28 per cent of the general population, therefore as nurses we will be treating these patients in community and hospital services.

The
average age of death for those who are homeless is only 47 compared to the most
common age of death in the UK for men being 85 and women 89 (Thomas, 2012; Office
for National Statistics, 2016). The large gap in ages of death can be down to
poor health and wellbeing for the homeless with up to 80% of homeless having
mental health problems (Homeless Link, 2014). The challenge for adult nurses is
to help recognise the urgent need for supporting this vulnerable group of adult
patients, both physically and psychologically and identify the skills required
to support holistic care. The statistics highlight that healthcare has to
improve, to meet the needs of the homeless, improve mortality rates and quality
of life.

Is My Privacy Protected?

100%! We encrypt everything—your details stay secret. Papers are custom, original, and yours alone, so no one will ever know you used us.

This study will explore the homeless lifestyle and how it impacts on nurses and other healthcare professionals care for the homeless in Primary Care. The literature will help highlight the issues of being homeless, giving more insight on how nurses, healthcare and systems can improve to support the needs of the homeless, as well as suggesting a service improvement plan to develop the care delivered by healthcare teams which will ensure those who are homeless receive good quality, holistic care they are entitled to. This will improve the health and wellbeing and patient experience in the long term. Jackson and Irwin (2011) state how nurses should treat everyone with dignity and humanity, to understand the needs of the patient and show care and compassion to respect each individual equally as dignity, equality and diversity are the fundamental rights for all individuals.

2. METHODS

This
chapter will explore the process in which evidence is found to carry out a
critical analysis. The ability to think critically is an important factor
within the nursing profession, to be able to deliver safe and high quality
healthcare there is a need for critical thinking as well as experience and
decision making in practice (Benner et
al, 2008). This has become a an important factor in nursing as the Nursing
and Midwifery Council (2015) state to always practice in line with best
available evidence. 

2.1 Search Strategy

Firstly
a wide search of literature was performed using the University of the West of
England (UWE) online library to identify key themes around the homeless
lifestyle and the support offered. Finding key themes is important for
searching databases as it helps start the process of finding the key words that
refer to the topic, as databases gather information from the use of keywords
(Aveyard, 2013). The databases CINAHL and MEDLINE were chosen to select papers
for this review, CINAHL was used as it is a good source for qualitative studies
in the nursing profession and MEDLINE being a great source for research in the
medical field, especially for UK papers around homelessness as well as all
research being peer reviewed makes it a worthy database (Wright et al, 2015; U.S National Library of
Medicine, 2016).

The
diagram in Appendix 1 shows the process of the search for appropriate articles.
Using an asterisk helped to widen the sensitivity of the search, also known as
truncated words. This will search for the key word and other words that begin
with the searched word which will locate more articles as spelling may be
different in countries such as the US to UK (Harvard, 2007). To further enhance
the search, the Boolean phrases AND plus OR were used to include more papers
with each of the key terms searched for (Gerrish and Lacey, 2010).

Is AI Involved in Writing?

Nope—all human, all the time. Our writers are pros with real degrees, crafting unique papers with expertise AI can’t replicate, checked for originality.

Inclusion
and exclusion criteria was used to establish the scope and validity of the
reviews searched for (Meline, 2006). The articles used for this review were
included due to relevance of adults living a homeless lifestyle, many articles
were excluded due to their relevance with palliative care, dentistry and
homeless youth under the age of sixteen, these could not be used as the topic
is focusing on homeless in the community and accessing GP practices which has
relevance to adult nursing, not specifically the end of life or dentistry. From
the relevant research that had been found, a technique called snowballing was
used to improve understanding of the topic and key themes as well as
identifying major writers that have been referenced within the chosen articles
and carried out further studies (Davis et
al, 2011).

2.2 Limitations

A
limitation of the research was the lack of studies based in the UK, this meant
American and Canadian articles had to be used which were transferable to the
healthcare system in the UK. Leung (2015) explains how qualitative research can
focus on a certain population or local area therefore generalisability may be
limited, on the other hand Larrabee (2009) states that gathering evidence from
other locations as well as the UK gives more consistency to the findings as
there has been a broader search of literature to be able to gather conclusions.

Many
articles were excluded due to the relation to dentistry and palliative care,
even though these are areas of nursing these are specific topics that are not
going to be covered in this review. If these were included the topic area would
be too broad and there may be excessive information sources which would cause
difficulty in choosing what needs to be included in the review (Dawidowicz,
2010). Therefore these articles were excluded to keep the review focused on
healthcare services in the community.

Another
limitation is the articles that had been located but were outside the ten year parameter.
Tappen (2011) suggests that going back fifteen to twenty years when researching
is useful to find the original work which is of importance. However due to the
ever changing protocols and guidelines within nursing and the increasing
dilemma of homelessness it is important to keep within ten years to make sure
the literature is up to date when relating to the topic (Stevens, 2013).

Why Are You the Best for Research?

Our writers are degree-holding pros who tackle any topic with skill. We ensure quality with top tools and offer revisions—perfect papers, even under pressure.

2.3 Critiquing Tool

The
Holland and Rees framework (2010) will be used to critically review the
selected articles as there are two different checklists for qualitative and
quantitative studies and has a simple layout to follow and understand. The
critical appraisal skills programme (CASP, 2013) will be used alongside the
Holland and Rees framework to make sure all areas have been identified as the
tool consists of checklists to ensure studies have been appraised correctly
(National Collaborating Centre for Methods and Tools, 2011). The main areas
highlighted from the review were, mental health, substance abuse and neglect,
hunger, poor healthcare support and difficulty accessing health care services,
these will be elaborated on within Chapter 3.

3. CRITICAL REVIEW

This
chapter will focus on the main themes that have arisen from the four articles
chosen to support this review. The literature includes a cohort study which
looks at the mental health problems of the homeless and the relationship with
health service (Hodgson, Shelton and Bree, 2014), a qualitative papers that
explore the issues of homelessness and the perceptions of the homeless
regarding their health and healthcare experiences (Rae and Rees, 2015), a
quantitative paper examining substance use among homeless and the prevalence
between this and access to healthcare and addiction treatment (Palepu et al, 2013). The last paper is a
quantitative study focusing on substance abuse severity among homeless and
non-homeless adults (Huntley, 2015). These papers will be compared and
discussed below, Appendix 2 will include an overview of the selected papers.

3.1 Impact of Mental Health and Difficulty Accessing GP Services

The
study by Hodgeson, Shelton and Bree (2014) has recognised a problem in
homelessness and mental health, it was found that a high percentage (87.8%) of
young people in the sample who were homeless had psychiatric disorders, those
most common being post-traumatic stress disorder (PTSD) and anxiety with addiction
to alcohol and substances making this a worthwhile topic to research. Due to
the study being carried out in one area of Wales and majority of the sample
being white British, the results may lack generalisability, although results
from studies carried out in Western countries identified a high prevalence
between homeless and mental health illnesses therefore Hodgson, Shelton and
Bree’s (2014) findings can be transferrable to other ethnic groups (Fazel et al, 2008). Using random sampling in
additional areas in the UK would remove any bias as it would represent a larger
target population for cultural groups and as such become more generalisable
(Aaronson, 2011).

Shelton
et al, (2009) acknowledges how mental
illness can increase the risk of homelessness as well as hindering the process
of moving on from being homeless and managing the tasks involved. Being
homeless can increase the chances of developing a mental health illness as well
as making a current one worse, finding a place to live can make an enormous
difference to one’s mental health (Mind, 2014). The study found that nearly a
third (31.1%) of the participants had accessed mental health services within
the previous six months which was a limited number considering there were 87
per cent with a mental illness. Furthermore these statistics could lack
validity due to the participants who were living in temporary accommodation
being supported to join a General Practitioner practice which may have
increased the chances of the participants reaching out and using the service,
as GP’s would refer those to relevant services, these numbers may not reflect
the rest of the homeless UK population suggesting mental health service use
could be lower.

Who Writes My Assignments?

Experts with degrees—many rocking Master’s or higher—who’ve crushed our rigorous tests in their fields and academic writing. They’re student-savvy pros, ready to nail your essay with precision, blending teamwork with you to match your vision perfectly. Whether it’s a tricky topic or a tight deadline, they’ve got the skills to make it shine.

The
limited numbers of homeless using mental health services could be related to
the difficulty in accessing services, a quantitative paper by Rae and Rees
(2015), (see Appendix 2), looks at the experiences of homeless regarding
healthcare. Many felt they were low priority, had prejudice against them and
were not listened to by nurses, in other literature healthcare experiences are
positive where clinicians have listened, did not judged and showed an interest
and concern for the patient, therefore this compassion and respect should be
carried out for every patient as well as the homeless, attending GP surgeries
to ensure there is equality for all patients with different backgrounds (Raven et al, 2011). Not only does the paper
recognise the discrimination that is being faced but there is a major issue
with the homeless registering with a GP surgery, a study by Williams and
Stickley (2010) had found that a homeless person is 40% less likely to be
registered with a General Practitioner in the UK compared to a domiciled
person, many of the participants had been refused registration as they had no
fixed abode therefore proof of address could not be presented. The Health and
Social Care Act (2012) brought in statutory duties in the NHS (National Health
Service) to have regard to the need and reduce inequalities, although Woolcott
(2008) acknowledges that there is a lack of improvement in access to primary
care. The CQC (Care Quality Commission) (2016) expect all practices to register
those who are homeless with no fixed abode, the homeless are able to use a
temporary address or the practice address can be used to register them,
therefore it is unclear as to why homeless patients are having difficulty to
register. This may be a limitation in the study as the inconsistency of
services has not been examined and without interviews with healthcare
professionals to ask why there is a hesitation to register the homeless as
patients the issue cannot be resolved, although education on this process would
benefit healthcare workers to ensure all practices understand that the homeless
can be registered.

Research
by St Mungo’s (2016) showed worrying evidence in the lack of mental health
services for homeless due to budget cuts, leading to longer waiting lists
limited levels of intervention meaning people are sleeping rough for longer,
with homelessness itself causing a deterioration in mental health and those
with complex needs having limited or no support, this prevents the homeless
from succeeding to find jobs and better their circumstances (Reeve et al, 2006).

With
budget cuts to services leading to limited support, more pressure will be put
on the use of GP services. Homeless link (2014) had acknowledged that many
homeless were refused access to a GP due to missing previous appointments,
attending an appointment can be challenging due to the transient characters of
the homeless, with this in mind more community services or walk in centres
should be available for the homeless to attend at any time to give support with
mental health, substance abuse and any further issues (Crisis, 2005). On the
other hand Rae and Rees (2015) had discovered from interviews with the homeless
that flexibility from the GP was appreciated and meant there was improved patient
engagement and increased support from day services, as a result these GP
practices who understand the homeless lifestyle and needs will receive positive
outcomes but many of the participants who felt they did not receive good care
from their GP practice would rather visit A&E (Accident and Emergency)
department, this correlates with the study by Hodgson, Shelton and Bree (2014)
where a quarter of the participants had attended an emergency department.
Furthermore, Homeless Link (2014) state that a homeless person visits A&E
four times more than the general public, which suggests that homeless are using
emergency departments as their preferred choice of healthcare. If the homeless
were made to feel welcome in their local primary care settings then this may
reduce the numbers of homeless using A&E and decrease the unnecessary use
at a time when there is tremendous pressure to see patients.

Participants
in the Rae and Rees (2015) study had mentioned that they had been released from
hospital or prison without any place to stay or any information given to them
on where they could find shelter, St Mungo’s (2012) had found that more than 70
per cent of homeless people were being discharged from hospital back to the
streets leading to an increase in damage towards their health. Following this
research the Department of Health (2015) had announced a ten million fund to
improve the discharge process for homeless people when leaving hospital,
Homeless Link (2015) were commissioned to evaluate the project which had very
positive outcomes, this included 69 per cent of homeless having appropriate
accommodation after discharge, 72 per cent not having to be readmitted 28 days
post discharge and 84 per cent of voluntary sectors reported a good working
relationship with the NHS and most importantly patients stated there were
higher standards of care as there was non-judgemental treatment and more
support in hospital and post discharge. This hard work could be undone without
further long term investments, although these statistics demonstrate that when
communication is improved between services and staff are educated on the
support for homeless post discharge, this will ultimately prevent re admission
of the homeless which will save the NHS money and improved discharge policy
will have a major impact on the lives of the homeless, improving their chances
of better health.

Will My Paper Be Unique?

Guaranteed—100%! We write every piece from scratch—no AI, no copying—just fresh, well-researched work with proper citations, crafted by real experts. You can grab a plagiarism report to see it’s 95%+ original, giving you total peace of mind it’s one-of-a-kind and ready to impress.

Although
services have improved in certain areas, there are still difficulties to
overcome. Healthcare professionals have a difficult task in helping homeless
patients to improve or manage their mental health condition. Many of those who
are homeless may feel it is too late therefore have no interest in getting help,
within the findings of Hodgson, Shelton and Bree (2014) out of the 121
participants, 10 had refused to take part for the second time due to lack of
interest. For those who want help, the advice given to manage the symptoms
would usually include listening to music, having reassuring thoughts, getting
enough sleep, physical exercise and eating a healthy diet (Mind, 2015), however
this advice is not beneficial for those who are homeless. Research has
identified how lack of sleep contributes to obesity, poor diet as well as
increasing mental illness, drug abuse and higher rates of violence meaning
healthcare professionals are limited in the support they can offer if
accommodation is not available (Olsen, 2014). Many homeless may not seek
assistance as they have little motivation and low self-worth or feel
embarrassed because of their mental health illness, due to feeling stigma and
discrimination as a result of being homeless, having a mental health condition
would add more pressure making it harder for homeless to ask for help and deny
having any mental health issues (O’Reilly et
al, 2009).

Furthermore,
improving services by increasing staff awareness, providing homeless with more
care and dignity will give those who are homeless a more positive experience,
as past events have caused personal trauma which could impact on communication,
but having awareness to help improve those skills and communicate positively
may reduce the chances of homeless patients not attending the services provided
to aid recovery (Mental Health Network NHS Confederation, 2012).

To
summarise, it is essential that those who are homeless have access to GP
practices and mental health services as there is a link between high percentages
of homeless suffering with mental health conditions, especially anxiety and
PTSD (Rae and Rees, 2015; Hodgson, Shelton and Bree, 2014). Although there are
currently budget cuts to mental health services, nurses and healthcare
professionals have a responsibility to provide support and refer to services
that can help to manage the illness and provide stability to lead a life off
the streets.

3.2 Substance Abuse, Self-Neglect and Poor Nutrition

In
a quantitative paper by Palepu et al (2013),
it was found that problematic drug use was associated with physical and mental
health needs that were not being met, with many of those who are homeless
having chronic health conditions as well as ever having a diagnosis for a
mental health problem were also linked with the health care needs that were not
treated. This compares with another quantitative study used for this review,
Huntley (2015) established that mental health status and being homeless were
significant predictors of substance abuse severity in adults, this was also a
factor for adults who were above the homeless status. There may have been
social desirability bias used in the paper by Palepu et al (2013) as three poor cities in Canada were used, therefore
these would be classed as vulnerable areas where people may face increased ill
health and homelessness compared to additional areas within Canada, therefore
the prevalence of drug and alcohol addiction would be higher in these areas.
However the findings of unmet physical and mental health needs and lack of services
or support for the homeless correlates with the findings from Huntley (2015) as
there were participants without support for mental health disorders facing
addiction issues, therefore this ensured the validity of the findings from
Palepu et al (2013). Although the
study by Huntley (2015) had limitations due to the use of convenience
non-random sampling, having a potential for bias due to the lack of
consideration for the whole population, meaning there is low external validity
(Emerson, 2015). However the sample consisted of all ethnic groups, variety of
socioeconomic status and mixed genders, this ensures generalisability of the
findings and with a census from Office of National Statistics (2011)
identifying England and Wales as becoming more ethnically diverse, this
confirms the need for research to include all ethnic groups.

Can You Use Any Citation Format?

Yep—APA, Chicago, Harvard, MLA, Turabian, you name it! Our writers customize every detail to fit your assignment’s needs, ensuring it meets academic standards down to the last footnote or bibliography entry. They’re pros at making your paper look sharp and compliant, no matter the style guide.

Due
to drug and alcohol abuse being associated with significant mortality and
morbidity it is a concern that those with a high comorbidity burden are not receiving
help, it is highlighted that those scoring low physical and mental health
scores with two or more chronic comorbidities were connected to having unmet
health care needs (Baggett et al, 2010).
On the other hand, it was found among the homeless, having a chronic medical
condition had an increased the chance of having a doctor as their usual care
source, although this likelihood decreased with each year the participant had
spent homeless (Palepu et al, 2013; Khandor
et al, 2011), this outcome related to
a study from Eyrich-Garg et al (2008)
as the results found that those with a limited or smaller amount of social
support were associated with a longer length of time being homeless. This
evidence suggests there are mental and physical needs that are not being
treated, therefore drugs and alcohol are being used as an alternative where
there is lack of support and services to help those who are homeless (Palepu et al, 2013; Huntley, 2015).

Within
the study by Palepu et al (2013), having
a primary care provider had a positive association with accessing treatment for
addiction, reinforcing the importance of engagement in care for patients. As
discussed previously this compares with the experiences of patients in the UK
study by Rae and Rees (2015) as they had expressed that when there was
flexibility from the GP it had helped keep the patient engagement as healthcare
professionals had been accommodating, making the homeless feel staff are
willing to help, therefore patients would turn up to appointments and get
referred to further services to ensure drug and alcohol addiction was being
treated. Access to addiction services needs to be improved as substance use can
be a major barrier for a homeless person to progress towards residential
stability or to engage in mental and physical health care (Patterson et al, 2012). Huntley (2015) highlighted
mental health status being a critical factor of substance abuse severity even
for those who are past the homeless status, Karim (2006) suggested how housing
first models for rehabilitation have improved mental health as a result of
housing being provided, but further evidence has found that when homelessness
is dealt with, after a period of four years there are high levels of mental
illness continuing in former homeless people, although it is not known what
mental health support was used in this period of time (Martijin and Sharpe,
2006). Therefore, if there is limited support from mental health services the
mental illness will worsen and homelessness will be prolonged  it is essential that addiction and mental
health are both treated and have continued support once off the streets to end
the cycle of mental health issues and substance abuse. The continuation of
support is important as it was recognised that those who were homeless had an
increased association with accessing addiction treatment, this may be due to
support workers or councillors who attend shelters help to direct them to
services for addiction compared to those who are in vulnerable housing who
receive limited support and may continue or relapse into substance abuse
(Huntley, 2015; Palepu et al, 2013).

All
the studies discuss the difficulties in accessing healthcare, the unmet,
physical and mental health needs and those living with chronic health conditions
(Rae and Rees, 2015; Hodgson, Shelton and Bree, 2014; Huntley, ; Palepu et al, 2013). These is indication of the
difficulty in accessing healthy food, evidence suggests that an inadequate food
and nutrition intake contributes to ill-health, chronic health conditions and
premature death (Feantasa, 2017). The participants in the study by Rae and Rees
(2015) stated that the lack of resources such as money, shelter and food
influenced their health, with limited money more junk food is eaten because it
is cheaper therefore there is a lack of choice to eat healthier options,
furthermore charities that provide food may not have a large variety of choice
to cater for any cultural diet requirements for those who are homeless and the
services may have limited meal hours, infrequent opening times and the distance
to travel may create a barrier for an individual to obtain a meal from the
charity (Tarasuk et al, 2009). Having
nearby access to charities or money to buy nutritious food would suggest an
improvement in an individual’s health, although those who are homeless can
choose in how they spend their money, therefore it cannot be assumed that money
would be spent on food as items such as drugs and alcohol may be a higher priority.

In
summary, there are similarities in findings with mental health being a
contributing factor for substance addiction. Eighty per cent of respondents in
findings from Homeless Link (2010) reported some form of mental health issue,
Crisis (2017) recognises that 39 per cent of homeless people surveyed reported
they were taking drugs or recovering from a drug problem and those taking drugs
are seven times more likely to be homeless compared to the general population
(Kemp et al, 2006). There is a need
for comprehensive health care services that include mental health support and
addiction treatment within primary care and the community to prevent and help
those with addiction to drugs and alcohol.

Can I Change My Order Details?

For sure—you’re not locked in! Chat with your writer anytime through our handy system to update instructions, tweak the focus, or toss in new specifics, and they’ll adjust on the fly, even if they’re mid-draft. It’s all about keeping your paper exactly how you want it, hassle-free.

4. PLAN TO IMPLEMENT SERVICE IMPROVEMENT

This
chapter will focus on the key finding from Chapter 3, identifying how adult
nurses and healthcare services can improve their care and support for the
homeless. The service improvement plan will be identified, discussing ways in
which the plan can be implemented as well as an evaluation. Lastly, there will
be a reflection of personal learning from completing this project.

4.1 Key Findings from Chapter 3

Chapter
3 had identified the lack of care and support homeless people face from
healthcare professionals. Considering the complexity of needs for those who are
homeless and lack of awareness adult nurses and other healthcare professionals receive
around the healthcare needs, there is no doubt the care and support for the
homeless is not being implemented. Although not every issue can be discussed
from the findings, it is evident that adult nurses and other healthcare
professionals can make a change and increase positive engagement with homeless
patients, maintaining dignity, reducing the judgement and stigmatisation that
those who are homeless feel they receive from healthcare workers and improve
communication. This will ensure each individual’s healthcare needs are being
met and the homeless will have positive outcomes from healthcare services.

The
NMC (2015) acknowledges how nurses should always treat people with kindness,
respect, compassion and assumptions are to be avoided, to recognise diversity
and individual choice. Although the participants from Rae and Rees (2015) had
commented on the prejudice against them and how it was hard to talk to nurses
on times as they did not listen, when one is not treated as an individual and
communication is poor this blocks engagement between the patient and nurse. If
nurses could treat the homeless with respect, there would be more willingness
from the patient to communicate with healthcare professionals, discussing their
healthcare needs and the services available to aid the treatment process. If
nurses could receive more education on the homeless lifestyle this would
provide an increased awareness of the different health problems of the people
who are homeless, which would lead to an expansion of knowledge to give an in
depth assessment of the needs of homeless patients on first contact (Chung-Park
et al, 2006). This increase of
knowledge and awareness will give healthcare professionals insight into the
available services and resources for homeless people, therefore collaborating
with other health and social care professionals is essential for the care of
the patient, the NMC (2015) states, a timely and appropriate referral should be
made to another practitioner when it is in the best interest of the individual
needing any action, care or treatment (Wen et
al, 2007).

Having
an increased awareness for adult nurses to provide positive engagement with the
homeless consolidates the values of nursing, especially the 6Cs; care,
compassion, competence, communication, courage and commitment (NHS England,
2016). When each of these values are carried out patients feel supported and
cared for, homeless people will feel that healthcare professionals want to help
them and treat them as equals to provide holistic care. Good communication
improves patient quality of care and is essential for building a therapeutic
relationship between patient and nurse, improvements in communication will help
homeless people to not feel judged or treated unequally, therefore
relationships can be built between patient and healthcare professional to allow
the mental and physical health of homeless patients to be managed appropriately
(Kourkouta and Papathanasiou, 2014).

How Do I Order a Paper?

It’s a breeze—submit your order online with a few clicks, then track progress with drafts as your writer brings it to life. Once it’s ready, download it from your account, review it, and release payment only when you’re totally satisfied—easy, affordable help whenever you need it. Plus, you can reach out to support 24/7 if you’ve got questions along the way!

4.2 Service Improvement Plan

For
changes to be made within the NHS and primary care setting, a plan needs to be
put in place to ensure all homeless patients will receive effective healthcare.
There are many nursing assessment tools for older people, diabetes and many
other specialities, although for people who are homeless there are lack of
tools and resources for healthcare professionals to follow (National Institute
for Health and Care Excellence, 2017). In 2014 the Queens Nursing Institute
(QNI) had recognised a need for developing a health assessment tool for
community nurses who work with homeless people after a survey had identified
that there was no regular system in place for screening homeless patients. It
was found that around 70 different methods were being used to assess homeless
patients with many nurses using no assessments, homeless suffer with substance
abuse, severe mental health conditions and many seeking asylum therefore
complex knowledge and skills are needed as well as flexibility and a
compassionate attitude. Therefore it is essential for healthcare professionals
to have access to an assessment tool, care plan or awareness package to support
homeless patients (Osborne, 2014).

To
implement service improvement an awareness package would need to be created to
educate healthcare professionals. The package should include protocols and
assessments to follow when in contact with a homeless patient, the package
should answer the following questions:

• Is
  the patient identified as homeless?
• Are
  staff aware of the importance of identifying homeless people and are there set
  questions to ask to ascertain a person’s housing status?
• Are
  staff aware of the housing options for patients and who needs to be informed?
• Have
  relevant support agencies been contacted?
• Is
  the patient linked with any support services? If not appropriate action must be
  taken to refer to relevant services such as substance misuse, mental health or
  supported housing projects etc.

The
use of this package will give healthcare professionals the confidence to
communicate appropriate information when providing a service to homeless
patients. Training could be provided on the issues homeless patients face and
how these can be managed, when healthcare professionals are giving insight into
the homeless lifestyle, prejudice and stigmatisation may be reduced (Homeless
Link; St Mungo’s, 2012).

The
package could be made available online for all healthcare professionals to
access, communication is essential to inform all members of staff about the
online awareness package. Multi-disciplinary team meetings, or staff briefings
would provide the chance to disseminate the use of the new awareness package,
it is important that all healthcare professionals are informed about the
importance of the package to ensure it is put to use when working with homeless
patients to benefit the care they receive. It is inevitable that there will be
barriers faced when making changes, nurses will need to analyse the gap between
current practice and the recommended changes, this will help identify any
potential barriers that will be faced (NICE, 2007). The main barriers for the use
of the awareness package are the healthcare providers’ attitude towards change
and their beliefs of the homeless. The need for the awareness package is to
increase the way adult nurses communicate and engage with homeless patient to
provide more support, as nurses work as part of a team colleagues may
positively influence others to change their practice and managers can use their
position to reward nurses who demonstrate positive and compassionate attitudes
towards homeless, this can be done through appraisals which will reinforce
positive behaviour and overcome the barriers faced (Parkinson, 2009).

How Quick Can You Write?

Need it fast? We can whip up a top-quality paper in 24 hours—fully researched and polished, no corners cut. Just pick your deadline when you order, and we’ll hustle to make it happen, even for those nail-biting, last-minute turnarounds you didn’t see coming.

4.3 Evaluation of Service Improvement

To
evaluate the difference the awareness package has made to the experiences
patients face in primary care services, a study similar to Rae and Rees (2015)
could be used. The use of interviews with patients who access care in areas
where the awareness package has been implemented will identify if there are
positive outcomes. The findings can be compared with the results from the Rae
and Rees (2015) study to evaluate if changes on homeless patients perceptions
on the way they are treated by healthcare professionals has improved. Using
qualitative research methods such as interviews give a more detailed insight
into sensitive areas where people may not want to talk about issues in large
groups but feel comfortable in a one to one interview (Gill et al, 2008). This method would be
appropriate to gather the perceptions of homeless and could be used to gain
further perceptions from staff members on the effectiveness of the awareness
package. It may be difficult to keep contact with the participants due to many
homeless having no fixed abode and using temporary accommodation such as
hostels that may only be able to provide shelter for a small period of time, therefore
homeless participants will have to find alternative accommodation which could
mean moving location (Shelter, 2014). Although, if relationships are improved
between homeless and health professionals more contact and effort from the
homeless will be made to stay in the area to have access to the local primacy
care services.

Furthermore,
it was discussed in chapter 3 that those who are homeless visit Accident and
Emergency four times more than the general population, this is due to the
negative experiences homeless have faced in primary care, therefore they will
only attend healthcare services when there is an emergency (Rae and Rees, 2015;
Homeless Link, 2014; Hodgson, Shelton and Bree, 2014). Therefore if homeless
patients are receiving improved care due to the awareness package then A&E
admissions of the homeless will decrease as the homeless will be accessing
primary care services to manage their healthcare. This will have a positive
impact on the cost of treatment for the homeless, St Mungo’s (2013) investigated
the cost of healthcare for the homeless. Due to homeless not accessing
healthcare services this will lead to a deterioration in health and an
admission to A&E with a longer length stay and multiple readmissions to
treat the chronic illnesses, as a result this will have a major implications
financially on the NHS. If the cost of treatment can be reduced and save the
NHS money then there will be increased positivity to use the awareness package
and make improvements in care and improve the health and wellbeing of the
homeless.

4.4 Personal Learning

The
homeless lifestyle is not an area focused on within the adult nursing degree,
during a placement at a GP surgery there were many patients who were homeless
and I had found myself interested in this area, wanting to have more
information surrounding the care and services available for the homeless. It
was surprising the different healthcare conditions homeless people face both
physically and mentally and the lack of support and judgement they faced from
healthcare professionals. This meant there was change needed in the way
homeless people are treated.

The
research had indicated that when healthcare professionals were flexible,
friendly and listened to the patient, there was an increased positivity towards
engagement and wanting to improve their health by attending various addiction
or mental health services. Having an awareness of the homeless lifestyle and
understanding their needs can help to build a therapeutic relationship,
therefore homeless patients would feel comfortable as they are not facing
judgement or discrimination. This change in care by healthcare professionals is
a positive step for homeless patients to receive better quality care and an
improved quality of life.

REFERENCES

Aaronson, L.
(2011) Sampling. Encyclopedia of nursing research [online]. New York:
Springer Publishing Company. [Accessed 06 February 2017].

Can You Handle Tough Topics?

Absolutely—bring it on! Our writers, many with advanced degrees like Master’s or PhDs, thrive on challenges and dive deep into any subject, from obscure history to cutting-edge science. They’ll craft a standout paper with thorough research and clear writing, tailored to wow your professor.

Aveyard, H. and
Sharp, P. (2013) A Beginner’s Guide To
Evidence-Based Practice In Health And Social Care. Second Edition.
Maidenhead: McGraw Hill Open University Press.

Baggett, T.P.,
O’Connell, J.J., Singer, R.E. and Rigotti, N.A. (2010) The unmet health care
needs of homeless adults: a national study. American
Journal of Public Health [online]. 100, pp. 1326-1333. [Accessed 16 March
2017].

Benner, P.,
Hughes, R.G. and Sutphen, M. (2008) Patient
Safety and Quality: An Evidence-Based Handbook for Nurses [online]. USA:
Agency for Healthcare Research and Quality. [Accessed 24 January 2017].

Care Quality
Commision (2016) Nigel’s surgery 29:
Looking after homeless patients in General Practice. Available at: http://www.cqc.org.uk/content/nigels-surgery-29-looking-after-homeless-patients-general-practice [Accessed 11 March 2017].

Chung-Park, M.,
Hatton, D., Robinson, L. and Kleffel, D. (2006) RN-to-MSN students’ attitudes
toward women experiencing homelessness: a focus group study. Journal of Nursing Education [online].
45, pp. 317–322. [Accessed 11 April 2017].

How Do You Match Professor Expectations?

We follow your rubric to a T—structure, evidence, tone. Editors refine it, ensuring it’s polished and ready to impress your prof.

Crisis (2005) Access to mainstream public services for
homeless people. Available at: http://www.crisis.org.uk/data/files/document_library/research/service_access_lit_review.pdf London: Centre for Economic and Social
Inclusion.

Crisis (2016) About Homelessness. Available from: http://www.crisis.org.uk/data/files/publications/Homelessness%20briefing%202016%20EXTERNAL.pdf [Accessed 10 January 2017].

Davis, N.,
Clark, A., O’Brien, M., Plaice, C., Sumpton, K. and Waugh, S. (2011) Learning Skills for Nursing Students. Exeter:
Learning Matters Ltd.

Dawidowicz, P.
(2010) Literature Reviews Made Easy: A
Quick Guide to Success. USA: Age Publishing.

How Do You Edit My Work?

Send us your draft and goals—our editors enhance clarity, fix errors, and keep your style. You’ll get a pro-level paper fast.

Department for
Communities and Local Government (2016) Rough
sleeping in England: autumn 2015 [online]. London: Department for
Communities and Local Government. Available from: https://www.gov.uk/government/statistics/rough-sleeping-in-england-autumn-2015 [Accessed 10 January 2017].

Department of
Health (2015) New fund to improve the
health of homeless people [online]. Available at: https://www.gov.uk/government/news/new-fund-to-improve-the-health-of-homeless-people [Accessed 14 March 2017].

Didenko., E.
and Pankratz., N (2007)“Substance Use: Pathways to homelessness? Or a way of
adapting to street life? Visions: BC’s
Mental Health and Addictions Journal [online]. 4(1), pp. 9-10. [Accessed 16
March 2017].

Emerson, R.W.
(2015) Convenience Sampling, Random Sampling, and Snowball Sampling: How Does
Sampling Affect the Validity of Research? Journal
of Visual Impairment & Blindness [online]. 109 (2), p. 164. [Accessed
21 April 2017].

Eyrich-Garg,
K.M., Cacciola, J.S., Carise, D., Lynch, K.G. and McLellan, A.T. (2008)
Individual charecteristics of the literaly homeless, marginally housed, and
impoverished in a US substance abuse treatment-seeking sample. Social Psychiatry and Psychiatric
Epidemiology [online]. 43, pp. 831-842. [Accessed 16 March 2017].

Can You Brainstorm Topics?

Yep! We’ll suggest ideas tailored to your field—engaging and manageable. Pick one, and we’ll build it into a killer paper.

Fazel, S.,
Kholsa, V., Doll, H. and Geddes, J. (2008) The prevalence of mental disorders
among the homeless in western countries: systematic review and meta regression
analysis. PLoS Medicine [online].
5(12), pp. 1670-1681. [Accessed 06 February 2017].

Feantasa (2017)
Policy Paper on Food, Nutrition and
Homelessness. Available at: file:///C:/Users/PrasantP/Downloads/statementonfoodnutritionhomelessness_final.pdf%20(2).pdf [Accessed 31 March 2017].

Gerrish, K. and
Lacey, A. (2010) The Research Process in
Nursing. Sixth Edition. Oxford: Blackwell Publishing.

Gill, P.,
Stewart, K., Treasure, E. and Chadwick, B. (2008) Methods of data collection in
qualitative research: interviews and focus groups. British Dental Journal [online]. 204, pp. 291-295. [Accessed 19
April 2017].

Harvard, L.
(2007) How to conduct an effective and valid literature search. Nursing Times [online]. 103(45), pp.
32-33. [Accessed 28 January 2017].

Hodgeson, K.J,
Shelton, K.H and Bree, M.B.M (2014) Mental health problems in young people with
experiences of homelessness and the relationship with health service use: a
follow up study. Evidence Based Mental
Health [online]. 17(3), pp. 76-80. [Accessed 06 February 2017].

Homeless Link
(2010) Homelessness and Health Research [online].
Available at: http://www.homeless.org.uk/facts/our-research/homelessness-and-health-research [Accessed 02 April 2017].

Do You Offer Fast Edits?

Yes! Need a quick fix? Our editors can polish your paper in hours—perfect for tight deadlines and top grades.

Homeless Link
(2014) The unhealthy state of
homelessness [online]. London: Homeless Link. Available from: http://www.homeless.org.uk/sites/default/files/site-attachments/The%20unhealthy%20state%20of%20homelessness%20FINAL.pdf [Accessed 10 January 2017].

Homeless Link
(2015) Investment needed to continue
homeless hospital discharge improvement [online]. Available at: http://www.homeless.org.uk/connect/news/2015/feb/09/investment-needed-to-continue-homeless-hospital-discharge-improvement [Accessed 14 March 2017].

Homeless Link
(2016) Hidden homelessness. Available
from: http://www.homeless.org.uk/facts/homelessness-in-numbers/hidden-homelessness [Accessed 10 January 2017].

Homeless Link
and St Mungo’s (2012) Improving Hospital
Admission and Discharge For People Who Are Homeless. Available at: http://www.homeless.org.uk/sites/default/files/site-attachments/HOSPITAL_ADMISSION_AND_DISCHARGE._REPORTdoc.pdf [Accessed 11 April 2017].

Huntley, S.
(2015) A Comparison of Substance Abuse Severity among Homeless and Non-Homeless
Adults. Journal of Human Behaviour in the
Social Environment [online]. 25 (4), pp. 312-321. [Accessed 10 January
2017].

Jackson, A. and
Irwin, W. (2011) Dignity, humanity and equality: Principle of Nursing Practice.
Nursing Standard [online]. 25(28),
pp. 35-37. [Accessed 21 April 2017].

Can You Start With an Outline?

Sure! We’ll sketch an outline for your approval first, ensuring the paper’s direction is spot-on before we write.

Karim, K.,
Tischler, V. and Gregory, P. (2006) Homeless children and parents: short term
mental health outcome. International
Journal of Social Psychiatry [online]. 52, pp. 447-458. [Accessed 06
February 2017].

Kemp, A.,
Neale, J. and Robertson, M. (2006) Homelessness amongst problem drug users:
prevalence, risk factors and trigger events. Health and Social Care in the Community [online]. 14 (4), pp.
319-328. [Accessed 08 February 2017].

Khandor, E.,
Mason, K., Chambers, C., Rossiter, K. and Cowan, L. (2011) Access to primary
health care among homeless adults in Toronto, Canada: results from the Street
Health survey. Open Med [online]. 5,
pp. 94-103. [Accessed 16 March 2017].

Kourkouta, L.
and Papathanasiou, I.V. (2014) Communication is Nursing Practice. Journal of the Academy of Medical Sciences
of Bosnia and Herzegovina [online]. 26 (1), pp. 65-67. [Accessed 11 April
2017].

Larrabee, J.
(2009) Nurse to Nurse Evidence Based-
Practice. New York: McGraw- Hill Medical.

Leung, L.
(2015) Validity, reliability and generalizability in qualitative research. Journal of Family Medicine and Primary Care [online].
4(3), pp. 324-327. [Accessed 28 January 2017].

Martijin, C.
and Sharpe, L. (2006) Pathways to youth homelessness. Social Science and Medicine [online]. 62, pp. 1-12. [Accessed 06
February 2017].

Meline, T.
(2006) Selecting studies for systematic review: Inclusion and exclusion
criteria. Contemporary Issues in
Communication Science and Disorders [online]. 33, pp. 21-27. [Accessed 28
January 2017].

Can You Add Charts or Stats?

Definitely! Our writers can include data analysis or visuals—charts, graphs—making your paper sharp and evidence-rich.

Mental Health
Network NHS Confederation (2012) Mental
health and homelessness: Planning and delivering mental health services for
homeless people. Available at: http://www.housinglin.org.uk/_library/Resources/Housing/Policy_documents/mental_health_homelessness.pdf [Accessed 08 February 2017].

Mind (2014) Housing and mental health. Available
from: http://www.mind.org.uk/information-support/guides-to-support-and-services/housing/common-problems/#.WJiWX1OLTIU [Accessed 06 February 2017].

Mind (2015) Anxiety and panic attacks. Available
from: http://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/self-care-for-anxiety/#diet [Accessed 08 February 2017].

National
Coalition for the Homeless (2009) Substance
Abuse and Homelessness. Available at: http://www.nationalhomeless.org/factsheets/addiction.pdf [Accessed 16 March 2017].

National
Collaborating Centre for Methods and Tools (2011) Critical appraisal tools to make sense of evidence [online].
Available at: http://www.nccmt.ca/resources/search/87 [Accessed 30 January 2017].

NHS England
(2016) The 6Cs. Available at: https://www.england.nhs.uk/leadingchange/about/the-6cs/ [Accessed 11 April 2017].

NICE (2007) How to change practice [online]. London:
National Institute for Health and Clinical Excellence.

NICE (2017) Nursing assessment tools. Available at: https://www.evidence.nhs.uk/search?q=nursing+assessment+tools [Accessed 11 April 2017].

Nursing and
Midwifery Council (2015) The code:
Professional standards of practice and behaviour for nurses and midwives. London:
NMC.

Office For
National Statistics (2011) Ethnicity and
national identity in England and Wales 2011. Available at:  www.ons.gov.uk/ons/rel/census/2011-census/key-statistics-for-local-authorities-in-england-and-wales/rpt-ethnicity.html [Accessed 21 April 2017].

What About Multi-Part Projects?

We’ve got it—each section delivered on time, cohesive and high-quality. We’ll manage the whole journey for you.

Office for
National Statistics (2016) National life
tables, UK: 2013-2015 [online]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/20132015 [Accessed 10 January 2017].

Olsen, H.B
(2014) Homelessness and the impossibility of a good night’s sleep. The Atlantic. Available at: https://www.theatlantic.com/health/archive/2014/08/homelessness-and-the-impossibility-of-a-good-nights-sleep/375671/ [Accessed 08 February 2017].

O’Reily M,.
Taylor, H.C. and Vostanis, P. (2009) “Nuts, schiz, psycho”: An exploration of
young homeless people’s perceptions and dilemmas of defining mental health. Social Science and Medicine [online]. 68
(9), pp. 1737-1744. [Accessed 08 February 2017].

Osborne, K.
(2014) Community nurses to get tool for assessing homeless patients. Nursing Standard [online]. 28 (52).
[Accessed 11 April 2017].

Palepu, A.,
Gadermann, A., Hubley, A.M., Farrell, S., Gogosis, E., Aubry, T. and Hwang,
S.W. (2013) Substance Use and Access to Health Care and Addiction Treatment
among Homeless and Vulnerably Housed Persons in Three Canadian Cities. PLOS One [online]. 8 (10), pp. 1-9.
[Accessed 10 January 2017].

Do You Adapt to International Rules?

Yes! UK, US, or Aussie standards—we’ll tailor your paper to fit your school’s norms perfectly.

Parkinson, R.
(2009) Nurses’ attitudes towards people who are homeless: a literature review. Diversity and Equality in Healthcare [online].
6, pp. 1-14. [Accessed 11 April 2017].

Patterson, M.,
Somers, J. and Moniruzzaman, A. (2012) Prolonged and persistent homelessness:
Multivariable analyses in a cohort experiencing current homelessness and mental
illness in Vancouver, British Colombia. Mental
Health and Substance Use [online]. 5, pp. 85-101. [Accessed 29 March 2017].

Raven, M.C.,
Doran, K.M., Kostrowski, S., Gillespie, C.C and Elbel, B.D. (2011) An
intervention to improve care and reduce costs for high-risk patients with
frequent hospital admissions: a pilot study. Health Services Research [online]. 11, p. 270. [Accessed 09 March
2017].

Reeve, K.,
Casey, R., Goudie, R. (2006), Homeless
Women: Still being failed yet striving to survive. Crisis, London.

Shelter (2014) Staying in a hostel. Available at: https://england.shelter.org.uk/get_advice/homelessness/emergency_accommodation_if_homeless/living_in_a_hostel [Accessed 19 April 2017].

What does a complex assignment mean?

If your assignment needs a writer with some niche know-how, we call it complex. For these, we tap into our pool of narrow-field specialists, who charge a bit more than our standard writers. That means we might add up to 20% to your original order price. Subjects like finance, architecture, engineering, IT, chemistry, physics, and a few others fall into this bucket—you’ll see a little note about it under the discipline field when you’re filling out the form. If you pick “Other” as your discipline, our support team will take a look too. If they think it’s tricky, that same 20% bump might apply. We’ll keep you in the loop either way!

Shelton, K.H.,
Taylor, P.J., Bonner, A. and Bree, M.B.M (2009) Risk factors for homelessness:
evidence from a population-based study. Psychiatric
Services [online]. 60(4), pp 465-472. [Accessed 06 February 2017].

St Mungo’s
(2012) Hospitals discharging homeless
people onto the street [online]. Available at: http://www.mungos.org/press_office/1283_hospitals-discharging-homeless-people-onto-the-street [Accessed 14 March 2017].

St Mungo’s
(2013) Health and Homelessness:
Understanding the costs and role of primary care services for homeless people [online].
Available at: http://www.mungos.org/documents/4153/4153.pdf [Accessed 19 April 2017].

St Mungo’s
(2016) Stop the scandal: Can people
living in homelessness accommodation access mental health services [online].
Available at: https://www.england.nhs.uk/wp-content/uploads/2016/07/stop-the-scandal.pdf [Accessed 06 February 2017].

Who is my writer? How can I communicate with him/her?

Our writers come from all corners of the globe, and we’re picky about who we bring on board. They’ve passed tough tests in English and their subject areas, and we’ve checked their IDs to confirm they’ve got a master’s or PhD. Plus, we run training sessions on formatting and academic writing to keep their skills sharp. You’ll get to chat with your writer through a handy messenger on your personal order page. We’ll shoot you an email when new messages pop up, but it’s a good idea to swing by your page now and then so you don’t miss anything important from them.

Stevens, K.
(2013) The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas.
The Online Journal of Issues in Nursing [online].
18(2). [Accessed 30 January 2017].

Tappen, R.M.
(2011) Advanced Nursing Research: from
theory to practice. Sudbury: Jones and Bartlett Learning.

Tarasuk, V.,
Dachner, N. and Loopstra, R. (2014) Food banks, welfare and food insecurity in
Canada. British Food Journal [online].
116 (9). [Accessed 31 March 2017].

Thomas, B.
(2012) Homeless kills: An analysis of the
mortality of homeless people in early twenty-first century England [online].
London: Crisis. Available from: http://www.crisis.org.uk/data/files/publications/Homelessness%20kills%20-%20Executive%20Summary.pdf [Accessed 10 January 2017].

U.S National
Library of Medicine (2016) Fact Sheet
Medline. Available from: https://www.nlm.nih.gov/pubs/factsheets/medline.html [Accessed 27 January 2017].

Wen, C.K.,
Hudak, P.L. and Hwang, S.W. (2007) Homeless people’s perceptions of welcomeness
and unwelcomeness in healthcare encounters. Journal
of General Internal Medicine [online]. 22, pp.1011–17. [Accessed 11 April
2017].

Williams, S.
and Stickley, T. (2010) Stories from the streets: people’s experiences of
homelessness. Journal of Psychiatric and
Mental Health Nursing [online]. 18, pp. 432-439. [Accessed 09 March 2017].

Woolcott, M.
(2008) Access to primary care services for homeless mentally ill people. Nursing Standard [online]. 22(35), pp.
40-44. [Accessed 09 March 2017].

Wright, K.,
Golder, S. and Lewis-Light, K. (2015) What value is the CINAHL database when
searching for systematic reviews of qualitative studies?
BioMed Central [online].
4(104), pp. 1-8. [Accessed 27 January 2017].

APPENDIX 1

APPENDIX 2