Working with People Experiencing Homelessness in Europe

ABSTRACT In Europe, the widespread transition from the Traditional Staircase (TS) model to the Housing First (HF) model is transforming the way social service providers work with people experiencing homelessness. This study examined social service providers’ perspectives in both models regarding factors that facilitate or hinder their work. Data were collected through 17 photovoice projects involving 81 social service providers from eight European countries. The results show factors affecting social service providers’ work at three levels: systemic, organizational, and individual. Professionals in TS and HF identified similar topics; however, TS providers discussed more obstacles to work. Implications for practice are discussed.


Introduction
Homelessness can be defined as the lack of access to minimally adequate housing (Busch-Geertsema, 2016). It entails a marginalization process that extends beyond a loss of housing to negatively impairing people's physical, psychological, and social well-being (Beijer, Wolf, & Fazel, 2012;Fazel, Geddes, & Kushel, 2014;Fazel, Khosla, Doll, & Geddes, 2008). These problems affect not only the lives of people experiencing homelessness but also the social service providers who work with them, that is, staff members who engage in direct service with service consumers or "clients." Social service providers may experience an increased risk of burnout and stress caused by helping people with multiple problems (Fisk, Rakfeldt, Heffernan, & Rowe, 1999;Lemieux-Cumberlege & Taylor, 2019). Indeed, frontline workers in homeless shelter reported higher rates of traumatic stress (one-third of the participants in the study of Schiff & Lane, 2019) than frontline staff providing other emergency services (e.g. police, firefighters, see review of Berger et al., 2012). Moreover, the daily interaction with clients experiencing trauma in helping relationships over extended periods of time may increase the probabilities of their exposure to trauma perpetrated by others (Schiff & Lane, 2019).
Furthermore, the literature shows that people experiencing homelessness face multiple barriers accessing and using homeless services (Canavan et al., 2012). Like in other fields (e.g., individuals abusing substances, see Pinto, Chen, & Park, 2019), these barriers affect and, in turn, are affected by the way in which clients interact with social service providers (e.g., mutual distrust; see Kryda & Compton, 2009), with the organizations (e.g., distant location, rigid rules; Wusinich, Bond, Nathanson, & Padgett, 2019), and with the social systems/community (e.g., stigmatization; Belcher & DeForge, 2012). According to the relational conceptual framework (Pinto et al., 2019), the homeless services system encompasses relationships between clients and their social service providers and service organizations, and refers to a broader socioeconomic system in which services are located.
Because social service providers' well-being and their working conditions can strongly influence client outcomes (Manning & Greenwood, 2018), it is crucial to include social service providers' perspectives in homeless research (Doherty, Bond, Jessel, Tennille, & Stanhope, 2020;Gaboardi et al., 2019;Henwood, Shinn, Tsemberis, & Padgett, 2013). Although burnout has been studied among social service providers (e.g., Lemieux-Cumberlege & Taylor, 2019), little research has been conducted on factors affecting social service providers' work that may increase the risk of work-related stress and then affect the relationship with clients. Literature covering adult homelessness typically focuses on the analysis of clients' outcomes (health, integration, well-being) and especially on interventions to improve their housing status (Aubry, Nelson, & Tsemberis, 2015a;Fitzpatrick-Lewis et al., 2011). Fewer studies focus on social service providers' perspectives (Gaboardi et al., 2019), their wellbeing, and the factors affecting their work (Mullen & Leginski, 2010;Olivet, McGraw, Grandin, & Bassuk, 2010). Moreover, as confirmed by another study (Lemieux-Cumberlege & Taylor, 2019), the complexity of the relationship between staff well-being, client needs, and the socio-political context is best probed using qualitative methodologies. To the best of our knowledge, few studies take social service providers' prospective as the starting point to explore specific factors that could affect their work with people experiencing homelessness (Wirth, Mette, Prill, Harth, & Nienhaus, 2019), and no study has used a qualitative method at the cross-national level regarding the same topic.
This study explored the factors that facilitate or hinder the work of social service providers in homeless services using the photovoice method. The inherent difficulty of the work is further complicated by a policy shift in service delivery, with most of Europe transitioning from the Traditional Staircase (TS) model to the Housing First (HF) model. Thus, the two main aims of the present study are (1) to explore social service providers' perspectives regarding factors that facilitate or hinder their work in European homeless services and (2) to determine whether there are differences in the factors identified for HF and TS services. In this study we focus on the client-centered relational model as opposed to a bureaucratic analysis because the relational demands were the most consequential area of note from social service providers in the change from TS to HF as we see below.

Homeless services: a comparison between Housing First and Traditional Staircase services
In Europe, homeless services are classified based on the degree to which they are housing-focused, that is, using ordinary housing or making someone "housing ready" through support and treatment, and the kind of support they provide to the person (Pleace, Baptista, Benjaminsen, & Busch-Geertsema, 2018). The homeless services include emergency and temporary accommodation; non-housing support services (e.g., day centers, outreach, food distribution, and medical services); and housing-focused support services, with centers providing and sustaining housing (e.g., HF services).
Focusing on organizations that provide housing for people experiencing homelessness, it is critical to emphasize the difference between emergency and temporary accommodations services (TS) and housing-focused support services (HF). In general, emergency and temporary accommodation are provided within the same building, offering basic emergency shelter with a bed, food, and access to low support. In these services, providers help clients to access external services or find housing. These are examples of support-focused, low-intensity services (e.g., shared emergency accommodations/shelters). HF services are centered on attaining and sustaining an independent home for people experiencing homelessness. In these services, staffs offer high support and housing and play a key role in reducing long-term and chronic homelessness associated with high and complex support needs (Tsemberis, 2010).
Recently, several organizations have transitioned away from the TS to HF model. Originally, HF was implemented in New York in 1992 by the organization Pathways to Housing (PtH) to invert the logic behind traditional homelessness policies (Tsemberis & Eisenberg, 2000). The PtH considered living in a home as an inalienable human right and based the service philosophy on the principle of choice being given to the client. Then, the practice of PtH has spread and become an "evidence-based practice" (Stanhope & Dunn, 2011;Tsemberis, 2011) thanks to the results achieved, the scientific validation of these results, and the latter's political appropriation (Lancione, Stefanizzi, & Gaboardi, 2018).
This ongoing trend, which started in the United States (Tsemberis, 1999) and then spread to Canada (Worton et al., 2018), Australia (Johnson, Parkinson, & Parsell, 2012), and Europe (Busch-Geertsema, 2014), represents a "policy shift" in the homelessness field. HF is an example of "urban policy mobility" (Lancione et al., 2018), changing both the policy of homeless services and the philosophy of intervention, that is, a radical change in the modus operandi of an organization (goals, times, activities). The TS model posits that a person must follow multiple steps before reaching independent housing (from the street to a shelter, from the shelter to a group apartment, among others) and meet some criteria to be "housing ready," whereas the HF model posits that a person should access an individual, scattered-site, and permanent home as the first step on a path to autonomy and recovery based on a person-centered approach (Padgett, Henwood, & Tsemberis, 2016;Tsemberis, 2010).
This change also implies a shift in professional practice and social service providers' demands. Based on the differences between the two models described above, we hypothesized three main differences between HF and TS. First, in HF, the relationship between the social service provider and client is characterized by a focus on person-centered care (Doherty et al., 2020). Moreover, in HF, each intervention is planned based on users' characteristics and choices, with consumer-driven services; thus, the staff accepts consumers' ability to be self-directed, even when difficult (Henwood et al., 2013). Instead, in TS, the interventions are characterized by standard guidelines, and social service providers attempt to have clients conforming to system-centered goals. In TS, clients face various barriers to accessing services (Wusinich et al., 2019), which make them feel unwelcome and affect their relationship with social service providers, frequently characterized by distrust (Wen, Hudak, & Hwang, 2007). This implies a less regulatory role of social service providers in HF that may help them create a positive relationship with clients and have lower stress levels than professionals in TS.
The second hypothesis regards the organizations' system. In HF, social service providers work in a flexible and multidisciplinary team, while TS staff work in services (e.g., a shelter) with rules and scheduled hours with a low professionals-to-clients ratio. Moreover, in HF, clear principles and a welldefined working model guide the professional practice . Having professional guidelines, a stronger value-mission alignment, and HF positive outcomes documented in the scientific literature can help professionals experience lower stress levels and greater job satisfaction (Lenzi et al., 2021).
The third hypothesis concerns the relationship between professionals and the social systems and the wider community. HF implies a process of co-production and co-creation of the services that occur not only with individual service clients but also with the community (Brandsen & Honingh, 2018). Indeed, in HF, the houses are scattered around the city and rented from the private market. This also implies working with landlords and the neighborhood, presumably encountering difficulties due to the stigmatization of people experiencing homelessness by citizens (Aubry et al., 2015b;Belcher & DeForge, 2012). This could lead to a more stressful experience for social service providers in HF.
Overall, this policy shift implies a process of change that is difficult to analyze using standardized tools. For this reason, we used a qualitative methodology to capture, with a visual component, the differences between HF and TS in the organizations working with people experiencing homelessness.

Factors affecting social service providers' work in homeless services
Homeless services work with a population having multifaceted needs (e.g., frequent physical, psychological, and social problems). The daily experience of working with clients in precarious circumstances may engender fatigue and powerlessness in social service providers, especially when they have high goals and expectations for clients, with a consequent increase in the risk of burnout (Fisk et al., 1999;Lemieux-Cumberlege & Taylor, 2019;Mullen & Leginski, 2010). In literature, there is agreement that the challenges faced by social service providers are also related to organizational factors, especially deriving from an individual-organizational mismatch (Kulkarni et al., 2013;Wirth et al., 2019) and that stress symptoms are not only due to individual characteristics but are often linked to the work environment (Maslach, 2017). For example, low-wage work environments can lead to turnover, and a stressful work environment can decrease the quality of care (Olivet et al., 2010). The bureaucratic system, high workload, clients' suffering, and little experience of success emerged as common challenges experienced by staff who work with refugees and people experiencing homelessness. The staffs have expressed the need for training, external counseling, and supervision to deal with the difficulties inherent in this job (Wirth et al., 2019).
Past literature has investigated the perspective of social service providers regarding service goals (Gaboardi et al., 2019) and how professional values guide their work (Henwood et al., 2013). Sometimes, social service providers may encounter difficulties in applying their professional values owing to organizational limitations (e.g., lack of resources, workload, communication issues; Gaboardi et al., 2019).
Research has suggested factors that could support working with people experiencing homelessness. For example, a study analyzing homeless services suggests that performance is enhanced when teams have well-defined goals, regular feedback on performance, administrative support, guidelines for coordinating teamwork, and supportive leadership (Olivet et al., 2010). The authors suggest the importance of practices in three areas: creating multidisciplinary teams, supervising and supporting staff, and training (Olivet et al., 2010). Moreover, it is important to project future needs, define competencies and skills, and develop leadership and management training (Mullen & Leginski, 2010). In studies about social service providers with refugees and individuals experiencing homelessness, the opportunity to derive meaning from work and find support within the team were identified as common facilitators (Wirth et al., 2019). Moreover, the availability of training and psycho-social supervision to social service providers was positively associated with work engagement and negatively associated with burnout (Lenzi et al., 2021).
However, in the homelessness field, specific factors affecting social service providers' work were investigated only by a few studies, especially from a cross-national perspective. Therefore, factors influencing social service providers' work should be analyzed to prevent the risk of burnout.

Photovoice as participatory action research to explore working context
The present study utilized the photovoice methodology to explore how social service providers experience their working environment. Photovoice is a participatory action research method that allows participants to capture their living context and express their ideas and emotions visually by shooting photographs (Wang & Burris, 1997). This method integrates photography and critical discussion to examine topics from the perspective of the resident experts (Wang, 2003), namely the staff working in homeless services. People can identify, represent, and then improve the contexts in which they are inserted using the photographic language (Wang & Burris, 1997), becoming active participants in the processes of analysis.
According to Wang (2003), the photos facilitate the emergence of reflections in the participants and the identification of common problems through group discussion. Photographs have the potential to reveal deeper and hidden emotions or ideas on complex issues that this target may have difficulty expressing in face-to-face interviews. Photographs are expedients to promote critical discussions in a group setting where people can reflect on creating social change. The photographic language is equal, imminent, and universal, representing an efficient way to communicate with organizational leaders, policymakers, and the community and to compare social service providers' perspectives from a different setting (e.g., different services and countries). As Rahman, Ghesquiere, Spector, Goldberg, and Gonzalez (2020) stated, human service organizations can benefit from photovoice by offering professionals an opportunity to reflect on their working environment without additional paperwork or pressure and fear of retaliation by leaders or supervisors (Ang, Uthaman, Ayre, Lim, & Lopez, 2019).
This method is useful for three main reasons: (1) there are no standardized tools for analyzing homeless services. Workload is one of the challenges of social service providers (Wirth et al., 2019), so we used a methodology that would help them find a moment of shared reflection and promotion of creativity, which are rare in their work experience. (2) The work with people experiencing homelessness is often invisible and not always valued by the community. For this reason, we used an empowering methodology that gives social service providers value and the chance to be research protagonists. (3) Photovoice allows us to communicate with the community and politicians and disseminate research findings using a simple and immediate language (i.e., photography). In addition, photovoice has the potential to promote social change in the context in which it takes place alongside the wider community. This is especially important when it comes to homeless services, for which advocacy is crucial (Mosley, 2012); thus, we chose a methodology that could empower participants and promote social change (Wang, 2003).
Given the potential of this methodology in analyzing work contexts (Rahman et al., 2020), by creating social change and comparing different settings through a universal language, we used photovoice to explore homeless services by comparing providers' staff of TS and HF social services.

Procedure
This study is part of a larger European project called HOME_EU: "Homelessness as Unfairness." It was a three-year-long (2016-2019), multi-method project funded by the Program "Horizon 2020." It aimed to provide a comprehensive understanding of homelessness in Europe through the analysis of multiple points of view, such as that of citizens, policymakers, people experiencing homelessness, and social service providers (Ornelas & Vargas-Moniz, 2021). This research focused on the Social Service Provider's Study, aimed at analyzing the experience of social service providers working with people experiencing homelessness. The first stage consisted of a qualitative analysis of photovoice projects in eight countries to explore which factors affect social service providers' work in homeless services. In the second stage, a new quantitative measure for the organizational analysis of homeless services was created based on the main findings of the photovoice projects (Gaboardi, Disperati, Lenzi, Vieno, & Santinello, 2020). The European Ethics Committee and the Ethics Committee of each University/ Research partner of the HOME_EU Consortium approved the research.
Data were collected during May-June 2017 using the photovoice method in eight European countries involved in the HOME_EU project (France, Ireland, Italy, The Netherlands, Poland, Portugal, Spain, and Sweden). The HOME_EU partners in each country used convenience sampling to assemble organizations with at least four workers, both in HF and TS services. Because photovoice requires a high level of participant involvement, time, and trust with the facilitator, we asked HOME_EU partners to involve organizations they had already worked with for other research. In addition, although sampling was based on availability, we gave specific criteria for the selection of organizations and social service providers: a) involve in the research at least one program of each type (TS and HF); b) when possible, sampled organizations in the same cities; c) at least four staff members from each program; d) only staff members who was employed in the services for at least six months so that they had enough work experience to report on the study and who worked together as a team; e) participants engaged in direct service with users, not merely administration.
All meetings were scheduled during times reported by participants to be convenient. Participants completed consent forms adapted based on the laws in their countries and took part in the study voluntarily without financial compensation. Emphasis was placed on the voluntary nature of participation and the fact that it would not influence employment in any way.
The photovoice project was divided into four sessions, which took place weekly or every two weeks, each lasting about two hours. Local researchers, who were independent from the services, conducted the sessions in each country, following the steps below.

Session 1: introduction and review of the project and training
Facilitators met with the participants to discuss the photovoice process, underlying issues around power and ethics. Participants were informed of the importance of reflecting on their working context and using photography to share their work experiences.

Session 2: photographic training and assignment
Facilitators trained participants in the use of cameras (composition, lighting, contrast, and other techniques) that could help them to represent their experiences, strengths, and struggles through photography. Participants were instructed to take pictures responding to the following questions: What are the factors that help your work? What are the main obstacles?
Session 3: sharing/discussing photos Each participant selected three to five representative photos. A discussion about them was guided through a photovoice technique called "SHOWeD" (Wang, 2003). Each letter of this acronym corresponds to a question, and a series of questions prompt the participants to critically analyze the content of their photographs: What do you See here? What is really Happening? How does this relate to Our lives? Why does this problem or strength Exist? What can we Do about it? Then, the participants contextualized the photographs by telling stories about what the photographs meant to them. Finally, they summarized with the researchers the discussions of the photographs in main themes. The facilitator asked which themes were priority and shared by the majority, trying not to influence the choice. The group collectively decided on the themes they considered most relevant to their work and wished to communicate to the community. Overall, participants generated photos, titles, and captions. During the discussions, they were asked to select and share their photographs and encouraged to think about themes related to the pictures. After the meeting concluded, facilitators read aloud the themes to ensure a group consensus was reached and gave the participants the opportunity to modify the listed themes. The discussion went on until the topics were saturated and the participants had nothing else to add to the themes already discussed. At this stage, the researcher tried to be neutral, facilitating discussion but not influencing the choice of themes. Each group discussion lasted about 2 hours. Some projects split the discussion into two meetings to have more time to discuss the photographs.

Session 4: report
The themes chosen by the participants were collected in a draft report written by the researchers before the last meeting. Key themes discussed in the meetings were shared with participants, and social service providers selected photographs that best represented each theme. During the final meeting, the draft report was reviewed with the group, further refined, and discussed until a consensus among participants was reached. Participants had one week to make additional changes to the report. Only in one country, the sharing of results took place online because participants could not attend more than three in-person meetings.
Finally, printed copies of the participant-approved reports were shared with leaders of the organizations involved to promote awareness of the organizations' limitations and strengths. Some projects have developed operational proposals for the organization's leader aimed at improving the working environment within the service. Leaders were able to use the suggestions in the reports to improve the services (e.g., in Italy, an organization enhanced internal communications strategies and offered training and psychosocial supervision).

Participants
A total of 17 photovoice projects (HF = 8; TS = 9) were conducted, and they involved 81 social service providers (HF = 39; TS = 42). Most participants identified as female (n. 49, 60.5%; HF = 20, TS = 29), and the mean age was 39.4 (24-68 years; HF = 39.5; TS = 39.3). In each country, one HF and one TS photovoice project was conducted (except for Italy, where two HF and one TS photovoice projects were conducted, and Poland, where two TS photovoice took place as there were no HF programs in the country at that time).

Data analysis
Data were analyzed following three steps: Step 1: photovoice research methodology Participants identified the main themes, following the pattern of Powers, Freedman, and Pitner (2012), as explained in the procedure (see Sessions 3-4).
Step 2: cross-national analysis As there were no previous studies that used photovoice method at the cross-national level, to the best of our knowledge, we decided to proceed as follows: facilitators translated the reports and picture captions into English using standardized translation/back-translation procedures (Beaton, Bombardier, Guillemin, & Ferraz, 2000). According to an ecological perspective (Bronfenbrenner, 1977) and the relational conceptual framework (Pinto et al., 2019), we classified factors affecting social service providers' work into three levels: systemic, organizational, and individual, in order to highlight the challenges in the relationships between social services providers and: service' clients, their organizations, and the broader socioeconomic system.
The cross-national analysis was conducted by three Italian independent researchers (one doctoral student, one research assistant, and a full professor) and shared with all Consortium partners, discussing the discrepancies until reaching an agreement (Padgett, 2012). In total, 195 photos (HF = 97, TS = 98) were included.
Step 3: comparative analysis between HF and TS The occurrence of themes within the HF and TS services was tabulated. In addition, we analyzed the content of the photos and captions to see if the same theme was discussed differently between the two models. Specifically, we checked whether the factor identified by participants (in TS or HF) was an obstacle or a facilitator to their work. The results showed in this paper refer to the secondary analysis (Steps 2 and 3). To manage the themes, we used Microsoft Excel (2011).
To analyze participants' perspectives about their working contexts from a constructionist epistemological position, we used an inductive and participatory approach. Researchers' backgrounds may have influenced the data analysis. Indeed, photovoice project facilitators had diverse backgrounds (medicine, social work, community psychology), but all the researchers involved in this study had experience in homelessness research. Overall, the themes were discussed and identified by participants, while the results of the cross-national analysis were shared with the partners and presented at the 3rd International Housing First Conference (Santinello, Gaboardi, Disperati, Lenzi, & Vieno, 2018). All research participants were invited and had the opportunity to share and discuss the crossnational results.

Themes
Following an ecological perspective (Bronfenbrenner, 1977) and the relational conceptual framework (Pinto et al., 2019), we classified the themes discussed in the photovoice projects into three levels: systemic (relationship between social service providers and the broader community), organizational (social service providers' relationships with their organizations), and individual (relationships with the clients' or social service providers' life). Table 1 summarizes the themes and sub-themes identified by the participants. After the description of the themes discussed, the main differences between HF and TS will be presented.

Systemic level
Regarding systemic factors, participants talked about the importance of institutional arrangements, especially the need to have economic resources to implement the services. However, having financial resources is not enough, and social service providers also report their need to feel that their work is influencing policy, as a participant noted: "the symbol of the organization is known. It is through this that we can intervene and try to change the political system and direct our attention to the situations we are facing" (Portugal, TS) and as shown in Figure 1. Feeling that one's work affects policy can contribute to a more rewarding experience for workers, who perceive the value of what they are doing.
Social service providers also underlined the importance of connecting their service with the community (i.e., citizens and other services). They suggested that involving citizens in services could help integrate the clients into the community, overcoming citizens' prejudice against people experiencing homelessness or their lack of understanding of homeless services, as shown in Figure 2. A participant declared: "speaking with neighbors to learn about the situation of the homeless people and to change their perspective on them" (Spain, TS).
Further, social service providers believed that collaboration with other services in the community (local associations, psychiatric services, social, health, and employment agencies) was a key to helping people experiencing homelessness. Collaboration with other services is useful as it lightens the workload of professionals: thanks to networking, sharing challenges and coordinating strategies with other services, professionals' work can result more efficient and less tiring, thus decreasing the likelihood of burnout. However, this collaboration is not always well managed or well-defined, and it can be an obstacle to social service providers' work (e.g., because of bureaucratic procedures or lack of explicit and shared working protocols).

Organizational level
At the organizational level, the physical environment of the services was identified as a factor influencing social service providers' work. In particular, three elements were underlined by social service providers: the geographic location of the services (e.g., "the location of the service is an obstacle Socio-psychological supervision helps to deal with the feelings emerging in the provider-client relationship Modalities to work with clients: -Obstacles to relationship The work is facilitated by the creation of a good provider-client relationship based on: doing something together, involving them in a process to improve their well-being, or using a working model to support them -Strategies -Importance of relationship Individual Clients' characteristics Clients' chronic problems (e.g. substance abuse, mental illness and combination of problems) could obstacle the provider-client relationship and the process of clients' recovery Provider-client relationship Providers tendency to empathize with the clients, which makes it difficult to balance their engagement with the clients because it is too far from the city center and difficult to reach," Portugal, TS); the quality of the services' buildings (e.g., "working in a beautiful place is beautiful," Italy, HF); having adequate and functional tools and equipment (e.g., "within the organization, there are too many obstacles due to technical problems, such as Wi-Fi that does not work," The Netherlands, TS). Working in an inadequate physical environment, without appropriate and functioning tools, can increase the risk of stress in workers because they are forced to devote more time to bureaucracy and reduce the time devoted to nurturing the relationships with clients. Relationships among the staff were frequently mentioned as organizational factors influencing social service providers' work. Moreover, social service providers considered the relationships among colleagues a positive factor that favors their work and well-being. In general, the relationships between supportive colleagues are characterized by mutual support, communication, and team spirit, as shown in Figures 3 and 4, and as a participant expressed: "a safe and trusted team [. . .] we can share everything with each other, we are always there for each other" (The Netherlands, HF). Staff emphasized the importance of having a shared vision and mission, especially a vision of hope. Professional training and psychosocial supervision, identified as facilitators, can foster relationships between colleagues. Having moments to share work-related emotions and struggles fosters professionals' well-being and protect them from the risk of developing burnout symptoms.  Strong leadership (e.g., by a service coordinator) also emerged as a key issue (but in only one HF staff in one country): "I am working alone at my territory but am permanently connected to my coordinator, [. . .] I think I have a trusting relationship with my coordinator" (Spain, HF). Role definitions were also identified as an important factor by staff. Professional roles must be clearly defined, but flexibility and autonomy can promote social service providers' freedom and choice (e.g., working hours, scheduling, breaks). Clarity of roles helps in understanding the limit of one's responsibilities and duties, thus leading to a more efficient distribution of tasks and decreasing the overall workload. According to participants, clarity is not only important for professional roles but also the program rules. Regulations also emerged as obstacles when perceived as lacking clarity or when rigid bureaucratic rules made it difficult to help all the people in need (e.g., being unable to accommodate people without identity documents).
The theme of contradictions was discussed in some services. Some examples include: "the team actually has really good outcomes, but there are things that when we're missing them, they cause an awful lot of stress" (Ireland, HF); or "probably the system does not work as it should to promote autonomous persons, and it promotes dependence to the system" (Spain, TS). Contradictory rules and lack of clarity can lead to perceptions that workloads are excessive. The necessity to do more work than expected because of administrative demands is a constraint that reduces the time dedicated to the  relationship with clients, for example, "administration and registration are at the expense of time we could spend with clients" (The Netherland, TS) or as shown in Figure 5. Working in a context of frequent emergencies, with no structured working hours and in multiple settings could encroach on their ability to organize their own free time, as confirmed by a participant: "emergency situations at work condition the choices in my private life" (Italy, TS). So, this can affect worker's well-being by increasing the risk of burnout.
The factor most frequently discussed was the relationship with clients. This is not surprising because this factor is central to the mission of services being researched. The staff discussed three aspects of relationships with clients. The first aspect had to do with obstacles in working with the clients, in particular the difficulty in creating provider-client relationships, as shown in Figure 6., or as a participant declared: "long waiting times before a client can move to a new home!" (The Netherlands, TS). The lack of trust-building between practitioner and client does not help in creating a collaborative relationship and then it not allow to achieve service's goals. The other two aspects were facilitators: strategies for supporting clients (doing something with them, involving them in a process to improve their well-being, or using the new HF model to support them), and the importance of a relationship between social service providers and clients to promote change in clients' lives. Creating a positive relationship with clients encourages collaboration and involvement in the recovery process. This  favors not only the well-being of the user but also of the professional: being able to achieve the users' goals through a relationship of trust increases job satisfaction and decreases the risk of relational deterioration (one of the factors of burnout), i.e. a psychological withdrawal from work and clients, usually resulting from a dysfunctional attempt to deal with emotional exhaustion (Maslach, Schaufeli, & Leiter, 2001).

Individual level
Individual factors also affected work in homeless services. The first factor was the difficulty in working with people who had complex and multidimensional needs. Clients' chronic problems (e.g., substance abuse, mental illness, or a combination of problems that hinders the process of recovery) could generate feelings of frustration and powerlessness in social service providers, as a participant explained: "you can get people out of the streets, but it's hard to take street life out of the people" (The Netherland, HF). This can increase fatigue and emotional exhaustion due to the frustration deriving from not being able to achieve service goals with users. Moreover, these factors could affect their willingness to work and their attitudes toward the possibility of change, as shown in Figure 7. The second factor was participants' tendency to empathize with clients, and hence the difficulty in  balancing their engagement with clients, as shown in Figure 8 and as confirmed by a participant: "finding a balance between what the professional does for a client and what the client can do" (The Netherland, TS). Social service providers oscillate between compassion and detachment, reporting that finding a balance is the best way to foster relationships and one's well-being. Empathizing too much with clients risks an unbalanced social service provider-client relationship. Simultaneously, too much detachment can hinder the creation of a relationship of trust, which is the basis of helping relationships. Emotional balance and involvement in the relationship can help improve the well-being of professionals, by decreasing the risk of stress due to the difficulty of managing emotions with clients.

Differences between housing first and traditional staircase services
In analyzing the differences, we noted distinct barriers and facilitators to social service providers' work at three different levels, as shown in Table 2. Overall, TS social service providers identified more barriers than HF staff, but there were both commonalities and differences between the two models. At the systemic level, in both HF and TS, social service providers have identified citizen opinion as a barrier. HF social service providers also discussed the institutional arrangement as a barrier, especially for the difficulty to find homes for clients. The relationship with other services instead seems to be a barrier for TS social service providers, while it is a facilitator for HF staff. While participants in HF identify collaboration as an opportunity, in TS, social service providers experience collaboration as a work overload. This is probably because in HF professionals collaborate with a well-organized and connected network of services and have more time to dedicate to the users (since the professional-client ratio is low). In TS, professionals have to find resources outside of their service (health services, home search) and this may increase stress due to constant interaction with the bureaucratic system and the single services that are not part of a systematic network.
At the organizational level, the differences between the two models are more obvious. While work overload was discussed equally in HF and TS, staff in TS identified more barriers to their work. Indeed, most of the barriers in TS are connected to organizational aspects: location, lack of tools and space, and forced sharing of space for clients. Conversely, in HF, some organizational aspects facilitate the work of social service providers: the building's quality, having a flexible role and sharing responsibilities with colleagues, and training. In addition, working with clients in their house allows them to work with a future perspective in an environment that respects the client's freedom; this allows professionals to work with clients on different goals, based on desires and inclinations rather than basic needs (e.g., eating and sleeping, see Gaboardi et al., 2019).
The only common aspect of the two models is represented by support between colleagues. For all participants, the supportive relationship between colleagues was a factor that facilitated work and alleviated burdens of the job (including emotional burden). Regardless of the type of service, professionals look to their peer group as the primary source of emotional and professional support, which is critical in influencing their well-being.
At the individual level, there does not seem to be any striking difference. Both HF and TS identify user characteristics as barriers. Furthermore, clients with multiple problems make the work difficult since it is hard to guide them along a path of change and find the right balance between program goals and clients' resources.

Discussion and implications
The research aimed to explore factors that influence the work of social service providers with people experiencing homelessness and to analyze differences among the factors identified for HF and TS services.
At the systemic level, prior literature has identified the relationship with other services in the community as an important factor in working with people experiencing homelessness (Rapp et al., 2010). What is more novel is the importance of relationships with citizens and politicians. As hypothesized, HF staff face the challenge of finding homes for clients. Having to deal with public institutions and the private market can be stressful. Moreover, in this service sector, it seems important to create collaborative governance among organizations or programs with specific competences and resources for facilitating the creation and adaptation of collaborative projects or networks (Ansell & Gash, 2018). Because people experiencing homelessness have multiple problems (health, mental, social), they cannot be addressed by one service alone. Collaboration between programs is necessary and implies Building's quality:

Working in a beautiful place is beautiful
Location and impersonality of the service: The location of the center is an obstacle because it is far from the city center and difficult to reach. a broad view of goals that you might not otherwise achieve on your own. Collaborative governance needs the definition of a collaborative structure (with rules and practices) and collaborative processes (based on trust, commitment, and a shared understanding of the problem; Bryson, Crosby, & Stone, 2015). Contrary to our hypotheses, the relationship with citizens' opinions was a barrier for both models. It seems that citizens' opinions regarding homelessness can influence the work of social service providers. This result in TS is not surprising considering the spread of the "not in my backyard" politics (NIMBY) as an increasingly popular response to homelessness, i.e. local citizens mobilizing in opposition to the presence of people experiencing homelessness and shelters (Dear, 1992;Henig, 1994;Lyon-Callo, 2001). For this reason, it is important to explore citizens' opinions on this issue (e.g., Petit et al., 2018) and implement community awareness projects to help services connect with the community and get citizens to overcome prejudices, as suggested by participants. In line with this need, in Italy, Poland, and France, participants and researchers organized exhibitions in strategic places of the city to present the photovoice results to the community and local politicians. Citizens, social workers in other community services, local media, and local politicians visited the exhibitions. Selected photos from all the European projects were presented for the first time in Padua, Italy, in an exhibition hosted at the Municipality Center in June 2018  as part of the 3rd International Housing First Conference.
Regarding the organizational level, some differences between HF and TS were identified. TS providers were more likely to discuss obstacles. While in TS, providers mostly discussed concrete aspects of facilities, such as location, the impersonality of service, and collective living, HF providers identified more facilitators, such as training, role flexibility, and quality of facilities. As hypothesized, social service providers perceived the advantage of working in a flexible and multidisciplinary team. In shelters, space and time to create a relationship with clients is compromised owing to a high number of clients and the lack of a safe space, such as the house in HF, where one can dedicate time exclusively to one person. This theme is summarized by the following photo caption: "House, a new step, a new challenge, a new opportunity" (The Netherlands, HF). As hypothesized, social service providers perceive the home as an environment that fosters relationships with clients, in line with the personcentered approach (Doherty et al., 2020).
Instead, the relationships among colleagues and the support among the team were frequently discussed as facilitators in both the models. A previous study identified support among team members as one of the most important features in services for people experiencing homelessness (Wirth et al., 2019). This is consistent with literature stressing the importance of strategies (e.g., team building) for strengthening cooperation, communication, and cohesion in the team (Salas, Shuffler, Thayer, Bedwell, & Lazzara, 2015;Weller, Boyd, & Cumin, 2014). Participants emphasized how discussion meetings among the staff could be useful to share the vision, increase support among colleagues, and clarify the rules of the services.
Although social service providers were encouraged to talk about their organizations, they also discussed clients' characteristics and the social service provider-client relationship. In line with another study (Wirth et al., 2019), some important factors are directly related to clients' needs or the relationship with them. The phenomenon called "putting clients first" was apparent (Kosny & Eakin, 2008), so that the clients' needs come before the needs of the social service providers themselves. It seems that the providers need specific and clear strategies to facilitate the relationships with clients (e.g., doing something together, creating space and time to meet face-to-face). As underlined by the literature, good team performance is associated with well-defined goals, regular feedback on performance, and guidelines for coordinating teamwork (Olivet et al., 2010). Only in HF providers discussed the importance of having a clear working model (that is, the HF model) but did not mention specific procedures that guide helping relationships with clients. As suggested by the literature, it would be useful to have psycho-social supervision that would guide social service providers through the difficult process of helping clients with their problems (Choy-Brown, Stanhope, Tiderington, & Padgett, 2016;Lenzi et al., 2021). Moreover, at the individual level, the need of balancing relationships with clients and the difficulty in working with people having multiple needs were identified as obstacles by social service providers both in HF and TS. As in another study, maintaining professional boundaries counted both as a job demand and a coping strategy to prevent staff's mental illness (Wirth et al., 2019). Indeed, we have identified these factors as individual elements, but they may also be attributed to a lack of training and psychological support from the organization. For staff members, having the opportunity to talk about the emotional impact of their work to a qualified supervisor could help in managing their well-being (Choy-Brown et al., 2016;Wirth et al., 2019). Simultaneously, having theoretical frameworks on how a helping relationship works could help providers understand how to create a good relationship. Many ways of analyzing and interpreting relationships have been proposed, especially when discussing helping relationships. Frequently used frameworks include the "therapeutic alliance" (Bordin, 1981) or the "developmental relationship" based on four characteristics: power, emotional attachment, progressive complexity, and reciprocity (Li & Julian, 2012). Working alliance is a consistent predictor of positive treatment outcomes across different clinical interventions in the adult psychotherapy literature (Margison et al., 2000). Future research could investigate which factors constitute a supportive relationship between social service providers and clients in homeless services.
Regardless of the working model, the relationship is the key element in working with people experiencing homelessness, as proposed by the relational conceptual framework (Pinto et al., 2019). As an implication for professional practice, we suggest that social service providers should consolidate skills to improve relationships with clients, among the staff, and with other community services (e.g., psychiatric services, local associations). The results show how social service providers face challenges that are independent of organizations, regardless of the model, such as the public opinion of citizens and clients' characteristics. However, several barriers depend on the type of organization. Indeed, the biggest differences between HF and TS are at the organizational level. Furthermore, HF seems to be a model that facilitates the work of social service providers and, therefore, their well-being. Training, flexible roles, sharing of responsibilities, and working in independent houses are elements of the program that make the work of professionals easier, especially when compared to TS. Not only that, in HF professionals emphasize the importance of having a context that allows building a relationship with the client, where they can set individualized goals with the person. Getting out of the shelter or group settings (TS) helps both the beneficiaries and the professionals because they can focus on the future, working together with the person in a space of privacy where a trusting relationship can be built and this may increase professional well-being and job satisfaction. Since one of the main challenges for professionals is to create a positive and balanced relationship with users, leaders should invest in working models such as HF that facilitate relationships between social service providers and clients.
Overall, as showed in another study (Collins-Camargo, Chuang, McBeath, & Mak, 2019), nonprofit human service organizations, such as homeless services, operate within a complex, competitive, and under resourced environment. As we have seen from the results, the challenges of professionals relate not only to the organizations in which they work, but also to the broader system in which they are embedded and to collaboration with policy and other services. Collins-Camargo et al. (2019) suggested eight strategies to manage the external pressures: advocacy; investment in data and technology; use of data and evaluation; practice and program change; collaboration with peer agencies; collaboration with public agencies; adjust staffing; and training and professional development. These strategies may represent effective managerial practices to pursue service mission despite the external pressures.

Limitations
Regarding the method, photovoice provided an opportunity to examine the organizational contexts of homeless services, as confirmed by a recent study (Rahman et al., 2020). This research in the European context has identified factors affecting social service providers' work in homeless services comparing HF and TS. In addition to the substantive findings, the cross-national study illustrates a novel method for conducting qualitative research across eight nations with eight different languages (Gaboardi et al., 2022). This new procedure was made possible by the continual interactions among the project's Consortium members, and it was based on a common detailed protocol about planning (aims, recruitment, setting, role of the moderators and assistant, ethics), process (detailed explanation of each step of the photovoice project), and participatory analysis.
Nevertheless, the research had some limitations. The researchers were different for each country, so they may have been influenced by the style of conducting groups and translating key findings into English for cross-national analysis. The translation could have affected the meaning; furthermore, we used only the pictures selected by each team (not all the photos they took). The reports varied in length, which may have reflected differences in understanding of what should be included among the key themes or comfort with English translation. To reduce translation problems, all partners used standardized translation/back-translation procedures (Beaton et al., 2000). Overall, the research protocol for analysis used several strategies to reduce potential bias and enhance the trustworthiness of the interpretation, including having two independent coders in each country, prolonged engagement with participants, and group discussions between the researchers involved in the research (Padgett, 2012).

Conclusion
The present study contributes to the limited research on social service providers' perspectives regarding homeless services. Social service providers identified a range of factors affecting their work at systemic, organizational, and individual levels, underling facilitators and barriers characterizing HF and TS. The results suggest the importance of creating organizational contexts, such as HF, facilitating positive relationships among colleagues, between social service providers and clients, and with the larger community. Indeed, the most discussed factors included challenges in the relationships with the broader community (such as citizen prejudice and difficulty in influencing policy), the importance of peer relationships among colleagues, and the difficulty in balancing the relationship with clients. Although these are common challenges to the two types of service, in HF professionals seem to have the best conditions to be able to build an effective relationship with clients: not working in a group setting (e.g. shelter), having privacy to talk to the person, having a clear working model that guides professional action, having a forward-looking vision, and working with an individualized approach focused on resources (and not only on basic needs). These factors not only help the user, as demonstrated in the literature (Tsemberis, 2010), but also the professionals because they can work in a context where it is possible to create an effective professional relationship among colleagues and also with the clients that helps them feel useful and therefore reduces the risk of burnout. Although this research has highlighted the challenges and benefits of HF compared to TS, future studies could also investigate the perspective of other stakeholders. For example, other studies could analyze the perspectives of neighbors of people in HF apartments or politicians and leaders of organizations to understand what challenges the model poses not only for professionals, but also for the broader community. Triangulating the data (social service providers-communityusers) could give us a more complete picture to better understand the remaining problems left that are not completely resolved by HF. In conclusion, we suggest that paying attention to the working conditions of social service providers allows workers to do their job to the best of their capacities, with the potential to improve their well-being, the quality of the service, and therefore clients' outcomes.

Disclosure statement
No potential conflict of interest was reported by the authors.