People who are homeless rely heavily on acute health care facilities to meet basic health care needs. Medical-surgical nurses play a fundamental role in the health care and health outcomes of patients who are homeless. According to the Institute of Medicine, health care providers’ bias and stereotyping contribute to health disparities among marginalized and vulnerable populations. Because attitudes are linked to clinical decision making and behaviors, revealing how nurses’ attitudes towards patients who are homeless develop and transform is paramount to improving health disparities of the homeless population. The purpose of this study was to explore nurses’ clinical experiences with patients who are homeless in order to discover how attitudes toward care of the homeless develop and transform. Interpretive phenomenology was used to describe and interpret the experiences of 11 medical-surgical nurses who cared for patients who were homeless and reported their attitudes toward this marginalized population had transformed. Nurses’ clinical experiences ranged from 3 to 40 years. Audiotaped semi-structured interviews were conducted. Data analysis was ongoing throughout data collection as delineated by Diekelmann and Allen (1989) and expanded by Minick (1992). Five themes were revealed through interpretation of the rich data. The themes were ‘Discovering homelessness,’ ‘Finding common ground,’ ‘Piecing it together,’ ‘A daily struggle,’ and ‘Relationships based on distrust.’ Nurses’ attitudes were in constant development and transformation. Nurses’ life and clinical experiences created opportunities for attitude transformations. Experiences associated with attitude transformation were identified. Nurses’ experiences revealed how nurses enter practice with an established attitude toward this marginalized population. As nurses came to realize that homelessness was no longer an abstract, intangible concept rather homelessness existed and was present in their day-to-day nursing practices their attitudes began to transform. Nurses sought common experiences with patients who were homeless to create a sense of connectedness in nurse-patient relationships. Nurses described a daily struggle of maintaining positive, non-judgmental attitudes. Nurses shared how early experiences of negative encounters with patients who were homeless created feelings of distrust thus altering nurse-patient relationships with future patients who were homeless. This study contributes to nursing knowledge by revealing how medical-surgical nurses’ attitudes develop and transform and how experiences are associated with attitude change. Recommendations for nursing practice, education, research are identified.

Background: Implementation of evidence-based knowledge in healthcare is challenging with success rates less than optimal at times. This is particularly true in the area of pressure ulcer prevention. Attention to use of the affective domain in educational interventions to implement best practices may be part of the solution. Purpose: The ultimate purpose of this study was to compare the use of two different educational interventions on medical-surgical nurses' behavioral intent to use evidence-based practice in preventing pressure ulcers. Theoretical Framework: The theoretical framework for this study was the theory of planned behavior. Methods: This study proceeded in three phases and collected both qualitative and quantitative data for instrument development and instrument testing. The resultant instrument was used to collect data for hypothesis testing in a cluster randomized experiment. Results: The theory of planned behavior was not fully supported in this study. Attitudes toward pressure ulcers were predictive of behavioral intent. Nurses who experienced the affective domain educational intervention showed significant improvements over the control group on attitude and perceived behavioral control. Behavioral intent and subjective norm were not impacted. Conclusions: A reliable and valid theory of planned behavior derived instrument was created. The theory of planned behavior was partially supported. An affective domain intervention has the potential to favorably impact nurses in valuing pressure ulcer prevention, despite any barriers.

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