Caring for People in Poverty

1. Caring for People in Poverty By Julie Ivey

2. Learning Objectives From this seminar students will be able to: • Describe poverty and the three different types of poverty. • Recognize the role of the public health nurse. • Explain the assumptions and barriers involved in poverty • Understand and think about their own biases toward poverty. • Understand and list some reasons people in poverty may not seek medical care. • Realize that culture and minorities play a part in those in poverty.

3. Poverty and Who is Affected • Poverty “impacts health, well being, and quality of life for generations” (Sheer, 2007, p. 1) • Extreme Poverty: Cannot meet basic needs for survival • 1.4 billion people • Moderate Poverty: Basic needs are barely met • 1.6 billion people “In the United States, an estimated 37 million Americans (12%) live below the official poverty line”. (Kotler, Lee, 2009, p. 2).

4. Relative Poverty • Relative Poverty: “(in which household income is less than a proportion of average national income)” (WHO, 2013, p. 1). • “All types of poverty adversely affect health” (WHO, 2013, p. 1). • Poverty is found in every country, not just the underdeveloped countries. • 1 billion people are estimated to be living in relative poverty and 4 billion can be considered poor (Kotler, Lee, 2009).

5. Root Cause Analysis • Issue: Caring for those in poverty and the insensitive interactions with these patients with the nurse. • Likely Causes: Not understanding one’s biases, lack of cultural awareness, or lack of poverty awareness. • Solutions: educating nurses about poverty, helping nurses determine their biases, educating nurses on the resources available for those in poverty. This will assist nurses to provide meaningful quality care.

6. Standards of CareAmerican Nurses Association • Collaboration: • “The nurse caring for the acutely and critically ill patient uses skilled communication to collaborate with the team of patient, family, and healthcare providers in providing patient care in a safe, healing, humane, and caring environment”(Bell, 2008, p. 16). • Implementation: • “The nurse caring for the acutely and critically ill patient implements the plan, coordinates care delivery, and employs strategies to promote health and a safe environment”(Bell, 2008, p. 12). • Resources Utilization: • “The nurse caring for the acutely and critically ill patient considers factors related to safety, effectiveness, cost, and impact in planning and delivering nursing services” (Bell, 2008, p. 15).

7. Leininger’s Culture Care Framework • The main focus of cultural care frameworks is to assist nurses to avoid ethnocentric assessments, so that they can provide care that is responsive to the recipient’s cultural perspective (Care as Cultural Phenomenon, 2007). • “Leininger refers culture to the specific pattern of behavior which distinguishes any society from others” (Care as Cultural Phenomenon, 2007, p. 2). • “the lifeways of an individual or a group with reference to values, beliefs, norms, patterns, and practices” (Care as Cultural Phenomenon, 2007, p. 2).  • Nurses must understand their own cultural values, beliefs and practices in order to prevent cultural biases, imposition of practices, major cultural conflicts, and unethical care (Care as Cultural Phenomenon, 2007). 

8. Culture Care Continued • According to Srivastava, (2008) There are three elements to the culture care framework: Cultural sensitivity, cultural Knowledge, and cultural resources. • For cultural competence to be put into practice, nurses must go beyond understanding culture (Srivastava, 2008). • This model will guide nurses on what to do in different situations to be more culturally competent. • Nurses need to be culturally competent. • People in poverty are more likely to be of a minority and another culture.

9. What Compromises Physical and Emotional Health in Those in Poverty? • “Studies indicate that the material and social deprivation, exclusion, and stress experienced by those living in poverty can compromise physical and emotional health” (Cohen, McKay, 2010, p. 64). • Food or housing security, access to social services, freedom from racism, fear, and stigmatization impact health (Cohen, McKay, 2010).

10. Poverty, Illness, and Disease • Increased risk for disease and illness • People in poverty are sick more and have more chronic disease (Brinkley-Rubinstein, 2009). • Little to no money means no medical attention for some • “Chronic diseases can cause individuals and families to fall into poverty and create a downward spiral of worsening poverty and disease” (WHO, 2013, p. 13). 

11. How is Poverty Related to Nursing? • Nurses Care for all types of patients, as well as patients in poverty. • Nurses need to recognize poverty as a major health issueand join with others who actively promote family-based care and become advocates for the healthcare of vulnerable populations (Sheer, 2007). • Public health nurse’s “primary responsibility includes health promotion and prevention of illness of individuals, families, communities, and populations—with particular attention to the needs of vulnerable populations” ( Cohen, McKay, 2010, p. 66).

12. Role of The Public Health Nurse • “Working primarily at the individual/family level • Focusing on mandatory programs, particularly maternal and newborn care • providing education and support to poor women related to healthy behaviors, healthy child development, and coping skills • Involved in case advocacy related to housing issues, and facilitating access to social services and other community resources • Minimally involved in community development or advocacy related to policy/ social change • Not involved in a formal process of monitoring the prevalence or impact of CFP” (Cohen, McKay, 2010, Table 2).

13. Reaching Out for Care • “Research has shown that when poor people seek out services, they do not always obtain the help they need. Furthermore, qualitative studies have revealed that poor people often suffer negative experiences with health and social services. They may feel misunderstood, looked down upon, judged, stigmatized, and discounted” (Dupéré, O’Neill, DeKonick, 2012, p. 782). • Nurses can make the difference in the perceptions of those in poverty by understanding their own biases to provide culturally competent care. • A qualitative study of men in poverty in Canada found that there were many reasons they did not seek medical care even when it was needed. • pride, trouble recognizing warning signs, distrust in the health system

14. Below Average Affect Theory • Some people believe that they are somewhat below average in ability in some situations. • People with low self-esteem or who are in a depressed state may perceive their life this way (Kruger, 1999). • This effect also happens for particular abilities and situations. They feel inadequate compared to others. • Believing that you are worse than average, you can excuse yourself from ever trying. Poverty is a very important topic and it affects all disciplines, not only nursing.

15. Maslow’s Hierarchy of Needs Theory • Physiological Basic needs: food, liquid, sleep, oxygen, sex, freedom of movement, and a moderate temperature. • When any of these are lacking, people feel hunger, thirst, fatigue, shortness of breath, sexual frustration, confinement, or the discomfort of being too hot or cold. • Those in Poverty think of little else than their basic needs because they are not met.

16. Nightingale’s Theory of Nursing • Environment: “poor or difficult environments led to poor health and disease” (Selanders, 2010, p. 84). • External and internal components • This theory fits people in poverty because they often are living in poor conditions, and have limited supply of nutritious foods and clean water. People in poverty are at an increased risk for disease and poor health according to Nightingale’s theory.

17. Policies in Poverty •  ”poverty can be alleviated or even eradicated with the right policies” (McKenzie, 2010, p. 1).  • The key is implementing programs that have been shown to work (McKenzie, 2010). • Studies have been done in 38 countries to implement programs against poverty. One specifically was in Kenya. • “Researchers found that school absenteeism was linked to intestinal worms. When de-worming pills were administered to children, researchers found that absenteeism was reduced by 25%” (McKenzie, 2010, p. 1).

18. Policies Continued • Policies implemented to assist those in need are: • Medicare • Medicaid • ObamaCare/Affordable Care Act • Affordable Housing

19. Resources For Those in Poverty • A study by Peterson and Litaker (2010), reported a relationship between contextual economic conditions and access to health care. They also found that greater regional poverty was associated with a higher likelihood of reporting an unmet need for health care among residents of both rural and urban areas. • “This study provides evidence that regional poverty has a consistent deleterious association with access to health care in both rural and urban settings, controlling for individual and contextual differences between these settings” (Peterson, Litaker, 2010, p. 380).  

20. Resources Continued • The resources available in my area for those in poverty are shelters, the food pantry, free or low cost medications, health department, and heat and electrical bill assistance. • Living in poverty is living without resources. The resources are: • FINANCIAL • EMOTIONAL • MENTAL • SPIRITUAL • PHYSICAL • SUPPORT SYSTEMS • RELATIONSHIPS/ROLE MODELS • KNOWLEDGE OF HIDDEN RULES: Knowing the unspoken cues and habits of a group (Panyne, 2005, p. 7).

21. Quality and Safety Those in poverty may not have clean drinking water, sanitary places to live, healthy food to eat, clean clothes to wear, and access to health care. • In areas of poverty, there is increased violence causing safety issues. • Poverty causes a decreased quality of life and life expectancy. • Poverty also increases the risk of illness and chronic diseases (Brinkley-Rubinstein, 2009). • A study byDupéré, O’Neill, and De Koninck (2012) found that Men in poverty in Canada did not use health care services due to distrust in the health care system among other things.

22. What Can Nurses Do About Quality of Care for Those in Poverty? Nurses can promote a healthy environment by asking open ended questions, sitting with the patient, listening, and showing that they care. Nurses can also: • Promote positive interactions between the nurse and patient. • Educate nursing staff to be sensitive to different cultures, minorities, and those in poverty. • Continue to provide care that is patient-centered.

23. Assumptions About Poverty • Assumption 1. “most people are poor because they choose not to work” (Linkon, 2010, p. 1). • Laziness • Assumption 2. “if people are poor, it’s entirely their own fault” (Linkon, 2010, p. 1). • They choose to be uneducated and not work • Assumption 3. “government’s role should be to push people to work hard, not support those in need” (Linkon, 2010, p.1). People tend to treat those in poverty with disdain, suspicion, and are demeaning and dehumanizing (Linkon, 2010).

24. Barriers to Poverty • Low Education/Job Skills • Low-wage Employment/Unemployment •  Single Motherhood • Lack of Health or Dental Care • Unreliable Transportation • Lack of Affordable Housing • Childhood Poverty  • Lack of Access to Affordable, Quality Child Care • Outliving Resources • Lack of Access to Treatment for Addiction and Mental Illness • Criminal Record • Racial /Cultural Factors • Inadequate Assets/Asset Traps

25. Health Care Environment for Those inPoverty • People in poverty often do not seek care until they are in a critical condition. • They also may not realize warning signs until it is too late. • Nurses may have biases against those in poverty. They may treat them differently. • Patients in poverty may have language barriers or educational barriers that need to be addressed appropriately. • Coming to the hospital can be intimidating and even frightening to those in poverty. • These patients may not know what resources are available to them.

26. Implications and Inferences • Nurses caring for patients in poverty must build a trusting relationship with the patient. • Provide a safe caring environment • Communicate effectively in terms the patient will understand: ANA Standard 11. Communication • Educate the patient in a way the patient will understand. • Educate the patient on how to care for themselves. • Provide resources available to them in their area. • Provide resources available to the patient in poverty within their area. • Standard 15. Resource Utilization: The registered nurse utilizes appropriate resources to plan and provide nursing services that are safe, effective and financially responsible (Bell, 2008). • Get involved, be an advocate • “Strategies for nurses to join the fight against poverty include becoming politically active in lobbying for equity in healthcare and supporting health policy benefiting the poor” (Sheer, 2007, p. 1). • Within their community, nurses can “join with others who actively promote family-based care and become advocates for the healthcare of vulnerable populations” (Sheer, 2007, p. 1).

27. Outcomes • By building a trusting relationship with patients, they are more likely to listen to the health care professional and go back when care is needed. • When a nurse educates a patient in poverty in a way the patient can understand, they are more likely to take charge of their health and not ignore warning signs. • A patient that was given information on resources is more likely to use the resources available. • Nurses who are aware of their own biases are able to provide better care for those in poverty.

28. Interventions/Strategies to Improve Quality and Safety • To improve quality of care, nurses must engage the patient in his or her own care. • Teach, answer questions, and provide information so patients can make informed decisions • “Patient-centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs” (QSEN, 2012, p. 3). • Use of health risk assessments on patients in poverty who have chronic conditions help improve quality and safety. • Health risk assessments provide patients and nurses with customized tools that help change behavior and improve care. • This tool encourages preventative care and self management. • “Quality Improvement (QI): Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems” (QSEN, 2012, p. 3). • Patients need to feel safe when going go the hospital or other health care settings. • Build a trusting relationship with patients in a safe environment

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