By Julie Ivey
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.
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).
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).
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.
Standards of Care
American 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).
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).
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.
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).
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).
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 issue and join with
others who actively promote familybased 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).
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).
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
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.
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.
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.
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).
Policies Continued
 Policies implemented to
assist those in need are:
 Medicare
 Medicaid
 ObamaCare/Affordable
Care Act
 Affordable Housing
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).
Resources Continued
 Living in poverty is living without





 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.
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).
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 by Dupéré, 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.
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.
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).
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
Health Care Environment for Those
in Poverty
 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.
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).
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.
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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