Providing Education for Diabetics in Homeless Shelters
Lynn M. Scott
State University of New York Institute of Technology
Public Health Nursing 474
November 01, 2012
Diabetes is a non-discriminatory disease, and the physical and emotional stressors of being homeless increase the incidence of type 2 diabetes in this population. Due to the increasing number of shelter residents and subsequent free-clinic patients, as well as an increase in the number of these patients newly diagnosed with this illness, health care providers in this setting have the challenge of providing education related to the treatment and management of this illness.
The homeless population is more prone to chronic illness. According to Arnaud, et al., (2012),
“Many health disorders are more frequent among homeless people who use public welfare services than in the general population”and “the prevalence [of diabetes] is likely to be higher among homeless people, as it is in populations with low socio-economic status” (p. 601). Published studies have found a high prevalence of diabetes in the homeless in comparison to that of the general population, with a higher incidence of major complications, despite a younger-aged population, shorter period since diagnosis, and moderate blood sugar control. The homeless face a myriad of challenges when it comes to managing diabetes, and the responsibility of glucose control and diabetic education falls to the staff in the free clinics that serve these individuals. The National Health Care for the Homeless (2007) sufficiently summed up the challenges of diabetic medical management of the homeless when they stated “Clinicians who provide care to homeless people living with diabetes face complex challenges to adapt their practices to address the rigors of diabetes treatment while accommodating for the realities of their patients’ lives” (p. iii). The education of patients with diabetes is an essential step in wellness promotion and primary prevention of diabetic complications such as podiatric wounds and retinopathy.
The rationale in the development of a diabetic education project geared at the homeless population is based upon the amount of time that providers spend in educating newly-diagnosed and poorly-controlled type 2 diabetics. An easy-to-read handout entitled “I Have Diabetes. Now What?” (attached as Appendix A, English, and Appendix B, Spanish) was designed for the provision of up-to-date, streamlined education among providers and a reference resource for the patients. The reason that this particular population was chosen to provide this type of wellness promotion is due to the high rate of type 2 diabetes in this population, the physical and emotional stress placed upon these diabetics, and the challenges faced by their providers in providing management and education about the disease.
An appropriate community nursing diagnosis for homeless patients diagnosed with type 2 diabetes is as follows:
Knowledge deficit related to disease process, diet, possible complications, and medical management related to the lack of information about type 2 diabetes.
Demographics, epidemiology, and morbidity/mortality
According to Jones, et al., (2009) “mortality rates of the homeless in North America are at least 3-5 times greater than that seen in the general populations of Canada and the United States. Cardiovascular diseases, of which Type 2 diabetes is included, are a major cause of mortality in homeless adults between 45 and 64 years old and are three times more common in the homeless aged 25 to 44 years when compared to an age-matched general population” (p. 70). Though there was no increase in the prevalence of diabetes in the above-referenced studied population, 43% of homeless patients diagnosed with diabetes demonstrated poor glucose control (HgbA1C > 8.4%).
Individuals with type 2 diabetes more than doubled worldwide over the past 30 years. As a result, it has become an epidemic of great proportions for all countries. This disease has been observed to have increased among all age groups but even more so in the younger population. The causes of type 2 diabetes are both genetic and environmental. It is clear that the more stressors in an individual’s life, the more challenges that are presented in treatment, management, and education of the homeless diabetic patient.
The National Law Center on Homelessness and Poverty found 3.5 million people living in the U.S. are likely to experience homelessness in a given year and reports the life expectancy for a homeless individual is 45-49 years. The primary cause of death among the homeless is complications related to chronic illness, such as diabetes.
Identification of Challenges of Health Management and Education of Diabetic Homeless Patients
All patients with diabetes have health maintenance and educational challenges due to the complexities of the disease. However, the homeless patient frequently has mental health and/or addiction comorbidities which have the potential to cause cognitive and memory impairments that make education and subsequent health maintenance very difficult. The homeless have little or no financial resources, including health insurance. As a result, referrals to specialty providers such as endocrinologists, podiatrists, and ophthalmologists, as well as obtaining necessary prescription medications and diabetic supplies for adequate glycemic control, are near to impossible. The homeless face nutritional challenges due to the fact that their food and fluid intake is irregular and, when they are provided meals, their choices for low-carbohydrate, no-concentrated sweets, are limited; shelter foods are high in carbohydrate concentration. Due to a high rate of transience, proper follow up, education, and continuity of care are either interrupted or unattainable.
Identification of Teaching and Learning Goals
The goals of diabetic teaching and learning for homeless patients at the free clinic are:
Verbalization of understanding the causes of type 2 diabetes
Identification of the risk factors for type 2 diabetes
Identification of the symptoms of type 2 diabetes
Return demonstration of performing glucose monitoring
Recording of glucose monitoring results
Reporting high and low results to healthcare provider
Verbalization of understanding of signs, symptoms, and treatment of hyperglycemia
Verbalization of understanding of use of oral diabetes medication
Return demonstration of drawing up, injecting, and storing insulin
Verbalization of importance for regular follow up and keeping appointments with health care provider, and
Verbalization of understanding the potential complications of poorly controlled type 2 diabetes.
Specific behavioral objectives for the diabetic homeless population
Cognitively the patient will be able to:
Recall information provided in teaching sessions as evidenced by correct answers to the educator’s questions.
Explain (in their own words) the importance of the adhering to the prescribed medication regimen.
Record fingersticks as evidenced by accurate completion of the glucose monitoring log.
Identify foods and environmental influences that may have adversely affected blood sugar levels.
Predict the effects of poor glucose control on his body (i.e., poor wound healing); and
Explain the importance of keeping all follow up appointments with their healthcare provider(s)/clinic staff.
With regard to the psychomotor domain goal, the patient will be able to correctly perform a
fingerstick, demonstrating the levels of progression from observer to mastery of this particular skill.
For affective learning domain objectives, the patient will:
Be receptive to the education provided and return-demonstrate glucose monitoring skills and/or insulin administration.
Remain committed to learning about self-care related to type 2 diabetes as evidenced by keeping all follow-up appointments in the clinic.
Integrate modification of diet and stress levels as evidenced by good glycemic control, and
Demonstrate good health maintenance behaviors for a period of three months as evidenced by no infections or diabetic complications for that period of time.
Outline of Project
The goal of the project was to create a teaching aid for the staff and patients at the free clinic to assist in diabetes education. The need for the project was identified through the amount of time this author observed that staff spent teaching clinic patients about diabetes. The project had to be streamlined so that all clinic staff could provide the same patient education, and a hand-out format was created so that the patients could take something with them for future reference.
The bulk of the handout’s information was obtained from the American Diabetic Association. This reference was chosen due to its up-to-date and easy-to-understand information. The handout was tailored for the educational and cultural needs (see Spanish handout, Appendix B) of the patients and equipment at the Capital City Rescue Mission, and was divided into three categories: (1) Understanding Diabetes, (2) Management of Diabetes, including monitoring, medication (oral and insulin), nutrition, exercise, stress reduction and management, and follow up.
The project was reviewed by both the managing nurse practitioner and the charge nurse of the clinic. Minor adjustments were suggested by both and incorporated by this author. The handout was then ready to be used by staff for patient education. Assessment of both the staff and patients’ responses to the handout, as well as follow up, will remain ongoing. Staff will be using the handout as an adjunct to physical demonstration of the skills for diabetic management.
Diabetes is a physical, emotional, medical, and financial challenge to those diagnosed with the disease and presents complex issues for homeless patients and the healthcare providers who help them attempt to manage their glucose levels and prevent further complications from this disease. The biggest challenge for both the patients and their medical providers is how to manage diabetes when the patients, with little or no resources or support, are faced with the additional daily stress of physical and emotional survival. The following three articles support this hypothesis as well as suggesting ways in which free medical clinics/shelter staff can provide optimal care.
Health Care for the Homeless Clinicians’ Network (2007) discusses the diagnosis and evaluation of the homeless patient with diabetes, which includes diagnostic tests to identify diabetes and assessment of the patients’ resources, living situation, support system, and educational barriers, as well as the plan and management of the disease, which includes monitoring, medication, follow-up and identification of realistic expectations for patient follow through. This article provides excellent ideas to tailor the care for the homeless diabetic, including the following: “Clinicians should teach shelter staff the signs and symptoms of hypoglycemia. This is critical since hypoglycemia may be mistaken for intoxication. If the patient is conscious and able to swallow, the shelter staff can give oral glucose, e.g., an orange drink. If the patient is unresponsive or unable to swallow, the shelter staff should immediately call 911 for help” and “work with shelter staff to provide before bedtime diabetic appropriate snacks for patients” (p. 7). These suggestions are attainable, require relatively few resources, and may assist in optimal glucose management and prevention of complications in the homeless diabetic living in a shelter. This literary resource was all inclusive in the best ways to adapt patient care to meet the challenges of the homeless population.
Arnaud, et al. (2009) performed a study on 9 homeless shelters in Paris, France which confirmed the challenge to more effectively manage diabetes in this population and the need to develop a plan of care that would realistically optimize the management and glycemic control of homeless diabetics in order to prevent complications, especially those related to podiatry. The outcome of the study revealed the following recommendations:
“Not ‘demonize’ insulin: new injection materials and insulin are compatible with irregular meals and with a lower risk of hypoglycaemia;
Teach homeless people to recognize the symptoms of hypoglycaemia and always bring sugar with them; avoid the use of sulphonyluria and prefer the use of metformin to other OHA;
Systematically perform a capillary glucose test to a person in great precarity, who is admitted to the emergency unit and act accordingly; and
Systematically examine the feet to detect lesions, grade the podiatric risk, and provide adequate and early preventive podiatric care. However, this follow-up is extremely difficult and requires establishing adequate health care networking” (pp. 602- 603).
The previous suggestions are easily instituted within the practice of a shelter’s free medical clinic. With proper management and education, shelter residents with diabetes will be able to keep their insulin vials/pens in designated refrigerators, as well as obtain follow-up education and regular foot inspection to prevent podiatric complications. As homeless patients spend a good deal of time walking and do not always have the financial ability to obtain protective, supportive footwear, there is an increased risk for infection or loss of digit or limb related to poor diabetes control. Adequate glucose control and reinforcement of diabetic teaching will assist in prevention of diabetic complications. A limit of this study is related to the geographical location in which the study was performed.
Some researchers believe that the key to reduce disease in the homeless population is to eradicate homelessness and poverty. Jones, et al. (2009), confirm the challenges: “The homeless represent a population struggling under the collective burdens of residential and nutritional instability, poor social networks, educational/skills training deficiencies, personal safety issues and significant levels of substance abuse, mental illness and physical disease” (p. 73). They discussed the risks of cardiovascular disease, including diabetes, among the homeless and attributed the increase in rates of illness related to a delay in seeking treatment which results in a sicker patient by the time they present for evaluation and disease management. Prevention and treatment will decrease the rate of morbidity and mortality. Suggestions for attaining these goals included: “ameliorating and preventing homelessness [and poverty], increasing shelter access and food quality, increasing personal safety, improving health care access and prevention and management of chronic disease, mental illness and substance abuse” (p. 73). It is the responsibility of the shelters’ medical providers to educate their clinic/shelter staff and patients in order to be able to provide optimum diabetic care to the homeless population (i.e., dietary staff in relation to better nutritional options for diabetic residents). An identified limit of this literary source is that, while promoting the eradication of homelessness and educating shelter staff, suggestions for achieving this goal are not made other than to link health care providers and governmental housing agencies.
In summarizing the review of the three (3) previous literature sources, all identify the increased rate and risk of complications from diabetes in the homeless population and provide goal-oriented and attainable suggestions for improving the management, treatment, and education of the patient by their healthcare providers.
In evaluation of the assessment of the homeless diabetic patient, an overwhelming need for patient education was identified. The staff of free me
dical/shelter clinics across the United States is burdened by this challenge due to the constraints on time, lack of educational resources, patient illiteracy, mental illness, substance abuse, and lack of motivation to learn. The need for an educational resource that could streamline and simplify patient education, while having a handout that patients could refer to independently, was the motivation in the creation of this project.
This project was welcomed by the staff of the Capital City Rescue Mission (CCRM) in Albany, New York. They appreciated the additional effort and time put into making the project culturally sensitive to their Spanish-speaking patients. This project has been implemented by the staff of the CCRM in the absence of this author due to the completion of the clinical assignment prior to the project’s introduction to staff and patients. However, the feedback has been positive, and the staff has verbalized that the patient goals and behavioral objectives are not only attainable but easily reinforced by all staff at the clinic. It has been this author’s experience that most of the homeless patients with type 2 diabetes want to learn about their disease process and management; it is why they seek out medical attention at the clinic in the first place. It can only help to have a visual focus for both the patient and the staff to decrease the amount of time spent successfully reinforcing educational highlights. In the absence of other diabetic educational material at the CCRM other than staff experience, this project could only be successful in improving homeless patients’ understanding of the treatment and management of type 2 diabetes.
American Diabetes Association. (1995-2012). Diabetes basics. Retrieved from
National Health Care for the Homeless Council, Inc. . (1999). Diabetes care: old challenges, new
strategies. Healing Hands: A Publication of the HCH Clinicians’ Network, 3(6), 1-4.
I have Diabetes. Now what? Understanding Diabetes
Diabetes is a disease that causes high blood sugar due to decreased insulin in the body.
Type 1 Diabetes: seen in children and young adults; the body does not produce insulin, a hormone that turns food into energy.
Type 2 Diabetes: more common in adults; the body either does not make enough insulin or the body’s cells ignore insulin.
The education in this packet will focus on Type 2 Diabetes.
Management of Diabetes
Ways in which to monitor and treat Type 2 Diabetes:
Monitoring sugar levels with fingersticks Learn how to use your glucose monitor as there are many different types. Be sure your strip codes match the monitor.
Wash your hands before doing your fingerstick.
Use a lancet to get a drop of blood from the end of your finger near your nail. Use a different finger each time.
Insert the strip into the monitor.
Put the drop of blood on the testing strip.
Insert the strip into the monitor when instructed.
Write down the results in your glucose log and treat as directed; report high numbers (hyperglycemia) and low numbers (hypoglycemia) as directed to your health care provider.
Symptoms of hyperglycemia: High fingerstick result, increased thirst, and increased urination. Treatment as recommended by health care provider. Might also exercise and cut down on the amount of food you are eating.
Symptoms of hypoglycemia: Shaky, lightheaded, sweaty, hungry, headache, moody, clumsy, confused, tingly around mouth. Immediate treatment is a ½ cup of juice or soda (not diet) or 4 teaspoons of sugar.
Medication Pills: Can only be used with Type 2 Diabetes. Works best if taken regularly as prescribed and used together with blood glucose monitoring, meal planning, and exercise.
Insulin: Prescribed if diet, exercise and pills not controlling blood sugar levels.
Types of Insulin:
Rapid-acting: works in 5 minutes, peaks in 1 hour, and lasts for 2-4 hours
Regular or short-acting: works within 30 minutes, peaks in 2-3 hours
Intermediate-acting: works in 2-4 hours, peaks in 4-12 hours, and lasts for 12-18 hours
Long-acting: works in 6-10 hours and lasts for 20-24 hours.
It is important to know the difference between your insulins if you use more than one kind. Nutrition Choose fish and lean meats (chicken, turkey, pork). Remove the skin from chicken and turkey.
Choose lots of vegetables and fruits, avoiding corn, peas and potatoes.
Choose whole grain foods like wheat bread/pasta.
Choose non-fat dairy items such as skim milk.
Choose water and diet soda instead of soda, juice and sweet ice tea.
Avoid sweet, high-calorie snacks and desserts such as cookies, cakes, chips, and ice-cream.
Choose high fiber foods such as whole grains, nuts, and vegetables.
Watch food portions.
Find an exercise activity that you enjoy such as walking, running, or lifting weights. Start slow, make an exercise schedule, and stick to it.
Reduce and Manage Stress Diabetics have an increased risk for anxiety and depression; talk to someone if you are feeling stressed, nervous, or sad.
The hormones caused by stress might increase your blood glucose levels.
Stress can lead to poor health management and, as a result, poor glucose control.
Ways in which to reduce stress:
Make positive life changes by removing yourself from the causes of stress.
Increase your coping skills by positive inner talk and positive thinking.
Practice relaxation techniques through slow breathing.
Deal immediately and directly with diabetes complications and health issues.
Skin and Foot Care Skin care: people with diabetes are prone to changes in their skin, itching, and infections. Diabetics are sometimes slow to heal. If you have any unusual skin changes, a painful or persistent wound, suspect an infection, or think you might be having an allergic reaction to your medications, seek medical help immediately.
Foot care: diabetics are more prone to foot problems. To perform good foot care, you must:
Check your feet daily for cuts, sores, or ingrown toenails.
Keep your feet clean and dry.
Always wear shoes and socks.
Protect your feet from extreme heat and cold.
Keep the blood moving to your feet; avoid crossing your legs, wiggle your toes frequently, and exercise.
Seek medical attention for any injuries to your toes or feet.
Follow Up Follow-up with your healthcare provider is important so that your diabetes can be well managed.
Your healthcare provider will check your fingerstick record and glucose levels, adjust your medications as needed, provide you with education about diabetes, and check your feet.
You should notify your healthcare provider with any questions, concerns, and changes in your health.
Complications of Untreated/Uncontrolled Diabetes
Uncontrolled/untreated diabetes places you at great risk for the following:
Eye complications, including blindness.
Dental complications, including tooth decay and loss.
Foot complications, including amputation of your toes or feet.
Skin complications, including bacterial and fungal infections.
Heart disease, including blocked arteries and heart attack.
High blood pressure.
Diabetes is a complicated disease that can be well managed if you commit to taking care of yourself and working together with your healthcare provider.
American Diabetes Association (1995 – 2012). Diabetes basics. Retrieved on
10/31/12 from www.diabetes.org/diabetes-basics/?loc=Global.NavDB.
Tengo Diabetes. ¿Y ahora qué?
1. Entender la Diabetes
La diabetes es una enfermedad que causa azúcar en la sangre debido a la disminución de la insulina en el cuerpo.
una. Diabetes tipo 1: se observa en niños y adultos jóvenes, el cuerpo no produce insulina, una hormona que
convierte los alimentos en energía.
b. Diabetes tipo 2: es más común en los adultos, el cuerpo no produce suficiente insulina o las células del cuerpo ignoran la insulina.
La educación en este paquete se centrará en la diabetes tipo 2. 2. Manejo de la Diabetes
Las formas en que para controlar y tratar la diabetes tipo 2:
una. Seguimiento de los niveles de azúcar con punciones Aprenda a usar su monitor de glucosa, ya que hay muchos tipos diferentes. Asegúrese de que sus códigos de tira coincida con el monitor.
Lávese las manos antes de hacer tu dedo.
Use una lanceta para obtener una gota de sangre de la punta de su dedo cerca de la uña. Use un
dedo diferente cada vez.
IV. Inserte la tira en el monitor.
V. Coloque la gota de sangre en la tira de prueba.
VI. Inserte la tira en el monitor cuando se le indique.
VII. Anote los resultados en el nivel de glucosa registrar y tratar como se indica; reportar números altos (hiperglucemia) y los números bajos (hipoglucemia), según las indicaciones de su médico.
Los síntomas de la hiperglucemia: High resultado punción en el dedo, aumento de sed, aumento de la micción y. El tratamiento recomendado por el médico. Podría también hacer ejercicio y reducir la cantidad de alimentos que usted come.
Los síntomas de la hipoglucemia: Cámara movida, mareos, sudoración, dolor de cabeza hambre, de mal humor, torpe, confuso, con hormigueo alrededor de la boca. El tratamiento inmediato es una taza ½ cucharaditas de jugo o refresco (no dietético) o 4 de azúcar.
I. Píldoras: Sólo se puede utilizar con diabetes tipo 2. Funciona mejor si se toma con regularidad
prescrita y utilizada como junto con el control de la glucemia, plan de alimentación y ejercicio.
II. Insulina: Prescrito si no de dieta, ejercicio y pastillas para controlar los niveles de azúcar en la sangre.
A. Tipos de insulina:
• Acción rápida: funciona en 5 minutos, picos de 1 hora, y tiene una duración de 2-4 horas
• Regular o de acción corta: funciona en 30 minutos, en los picos de 2-3 horas
• De acción intermedia: obras en 2-4 horas, picos de 4-12 horas, y tiene una duración de 12-18
• Larga duración: funciona en 6-10 horas y tiene una duración de 20-24 horas.
Es importante conocer la diferencia entre las insulinas si se utiliza más de un tipo.
I. Elija pescado y carnes magras (pollo, pavo, cerdo). Quite la piel del pollo y el pavo.
II. Elige un montón de verduras y frutas, maíz, guisantes y evitar las papas.
III. Elija alimentos de granos integrales como el pan de trigo / pasta.
IV. Elija no grasos artículos lácteos como la leche descremada.
V. Escoja agua y soda de dieta en lugar de refrescos, jugos y té helado dulce.*
VII. Elija alimentos ricos en fibra como cereales integrales, frutos secos y verduras.
VIII. Mira las porciones de alimentos.
Encuentra una actividad de ejercicio que usted disfrute, como caminar, correr o levantar pesas. Comience despacio, hacer un programa de ejercicio, y se adhieren a ella.
e. Reducir y Controlar el Estrés
I. Los diabéticos tienen un mayor riesgo de ansiedad y depresión, hablar con alguien si se siente
estresado, nervioso o triste.
II. Las hormonas causadas por el estrés pueden aumentar sus niveles de glucosa en sangre.
III. El estrés puede conducir a la gestión de la mala salud y, en consecuencia, el control deficiente de la
IV. Las formas en que para reducir el estrés:
• Hacer cambios positivos en su vida por dejar de recibir en las causas de estrés.
• Aumentar sus habilidades de afrontamiento por charla positiva interna y el pensamiento
• Practique técnicas de relajación mediante la respiración lenta.
• Encarar de manera inmediata y directa con complicaciones de la diabetes y los problemas de
• Haga ejercicio con regularidad.
f. Piel y Cuidado de los Pies
I. cuidado de piel: las personas con diabetes son propensas a los cambios en la piel, picazón e
infecciones. Los diabéticos son a veces tardan en sanar. Si usted tiene cualquier cambio inusual en la
piel, una herida dolorosa o persistente sospecha una infección, o cree que puede estar teniendo una
reacción alérgica a los medicamentos, busque ayuda médica de inmediato.
II. Cuidado de los pies: los diabéticos son más propensos a problemas en los pies. Para realizar un buen
cuidado de los pies, usted debe:
• Revise sus pies todos los días para detectar cortes, llagas o uñas encarnadas.
• Mantenga sus pies limpios y secos.
• Use siempre zapatos y los calcetines.
• Proteja sus pies del calor y frío extremos.
• Mantenga la sangre en movimiento a sus pies, evitar cruzar las piernas, mover los dedos de los
pies con frecuencia, y el ejercicio.
• Busque atención médica de las lesiones en los dedos o en los pies.
I. El seguimiento con su profesional de la salud es importante para que su diabetes puede ser bien
II. Su profesional médico le examinará los punción capilar niveles récord y la glucosa, ajustar sus
medicamentos según sea necesario, le proporcionará educación sobre la diabetes, y revise los pies.
III. Usted debe notificar a su proveedor de atención médica si tiene preguntas, preocupaciones, y los
cambios en su salud.
3. Las complicaciones de la no tratada / no controlado Diabetes
No controlada / sin tratamiento para la diabetes que pone en gran riesgo de lo siguiente:
una. Complicaciones oculares, incluyendo la ceguera.
b. La pérdida de audición.
c. Complicaciones dentales, incluyendo caries y pérdida.
d. Las complicaciones del pie, incluyendo la amputación de los dedos del pie o los pies.
e. Complicaciones en la piel, como infecciones bacterianas y fúngicas.
f. Las enfermedades del corazón, incluyendo bloqueo de arterias y ataques cardíacos.
g. La presión arterial alta.
h. La enfermedad renal.
La diabetes es una enfermedad compleja que puede ser bien administrado si usted se compromete a cuidar de sí mismo y trabajar en conjunto con su proveedor de atención médica.
Asociación Americana de Diabetes (1995 - 2012). Fundamentos Diabetes. Consultado el
10/31/12 desde www.diabetes.org/diabetes-basics/?loc=Global.NavDB.
Lynn M. Scott, RN, IBCLC
20 Powers Road
Averill Park, New York 12018
Scottydawg2000@aol.com November 25, 2012
Capital City Rescue Mission
259 South Pearl Street
Albany, New York 12202
Attention: Sarah Schoof, NP, and Linda Brown, RN
Dear Sarah and Linda:
I wanted to express my sincere appreciation for the opportunity that you both afforded me in allowing me to complete my Public Health Nursing II clinical at the Capital City Rescue Mission’s clinic. Not only was I able to observe a myriad of public health nursing issues, but I had the opportunity to work alongside some of the most dedicated and compassionate medical staff with whom I have ever had the pleasure of meeting. It was an honor and a privilege to provide care for each patient I met in the clinic, and I left each day feeling as though I had received more blessings than I had been able to provide. Even though I have been a nurse for 21 years, I learned a great deal about the challenges of and opportunities for public health nursing care and education.
I do not view the completion of my clinical as the end of my relationship with the Mission; I view it as the beginning of my position as a volunteer in the clinic and look forward to many more opportunities to work beside you and provide care to those in need.
Again, thank you for this wonderful opportunity. May our Lord bless you and provide for all your needs as you serve Him.