urses have social and pro-fessional responsibilities toadvocate and care for theneediest of persons. Mutualunderstanding between

patients and nurses frequently is basedon personal experience, however.Unless a nurse genuinely has experi-enced poverty, it may be difficult forhim or her to truly understand thestruggles that impoverished patientsface. A nurse’s socioeconomic statusmay facilitate or inhibit him or her fromempathizing with the needs of impov-erished patients. Increased awareness ofthis issue and a better understanding ofresources available to patients in needcan help nurses provide the best possi-ble care for these patients.

FACTS ABOUT POVERTYThe financial demands of providing

housing, utilities, child care, food, trans-portation, and health care often exceedthe incomes of the working poor. Pov-erty is extremely complex, with multi-faceted causes and consequences. In herbook Cultural Diversity in Health andIllness,1 Spector diagramed a cycle ofpoverty linking common factors facedby impoverished populations (eg, insuf-ficient salaries, subsistence economy,poor nutrition, lack of potable water,densely populated housing) to a highincidence of illness. Disease processesare exacerbated by high health carecosts and lack of preventive care. Thesefactors continue to result in poor eco-nomic production and an ongoing cycleof poverty. As poverty worsens, there isa resultant increase in malnutrition,infectious diseases, homelessness, infantmortality, mental illness, family vio-lence, and crime.2

A significant issue for impoverishedpatients is their limited ability to receivehealth care services. As a result, when

impoverished patients do enter thehealth care system, their pathology maybe more advanced and often theirexpected outcomes are unfavorable.

A person’s health can be affected byhis or her income. An increased incomeallows a person greater access to healthcare and enables him or her to live inbetter and safer neighborhoods. Theseneighborhoods commonly are locatedaway from industrial pollution orknown hazardous waste sites. In addi-tion, adequate nutrition, exercise, andstress-reduction techniques oftenrequire discretionary income.1

Single mothers and their children areone of the largest demographic groupsliving in poverty.2 Many unwed moth-ers lack the education necessary to earnan adequate income. A majority of thesewomen have to work full time outsideof the home, as mandated by the legis-lation titled the Personal Responsibilityand Work Opportunity ReconciliationAct of 1996.3 A minimum-wage salarydoes not enable a person to escapepoverty. In addition, many singlewomen also leave relationships becauseof physical or emotional abuse. Stevensreported that an estimated 60% of appli-cants to Aid to Families with DependentChildren are women who have left situ-ations of domestic violence.2

Stevens suggests that our cultureoften blames individuals for their po-verty.2 This ideology may hinder com-munity or social transformation effortsthat are directed toward radical changeor even a critique of unjust societal sys-tems, including the health care system.

NURSING IMPLICATIONSMost perioperative nurses recognize

that some of their patients are impover-ished. In the perioperative setting, how-ever, a patient’s socioeconomic statusmay be masked because of the focus on

NOVEMBER 2006, VOL 84, NO 5 • AORN JOURNAL • 837© AORN, Inc, 2006

Patients in poverty

S P E C I A L N E E D S P O P U L A T I O N S

Michelle Byrne,RN

N This is thedebut of theSpecial NeedsPopulationscolumn. Thesearticles willdescribeissues, com-plications,interventions,specificneeds, regula-tory require-ments, andnew informa-tion regardingcare of vulnerablepatientgroups, in-cluding olderadultpatients,pediatricpatients,patients withdisabilitiesor specific illnesses, andpatientsaffected byparticularsocial condi-tions or cul-tural issues.

838 • AORN JOURNAL

NOVEMBER 2006, VOL 84, NO 5 Special Needs Populations

TABLE 1Perioperative Implications: Poverty

Preoperative care• Assess a patient for undiagnosed or untreated chronic illnesses. • Ask sensitive questions to determine if a patient has enough

money or food to meet his or her needs. • Question the patient’s use of community resources and have

referral materials available. • Involve a social worker as soon as possible. • Assess a patient’s need for a nutritional consultation. • Be aware that

• a patient may lack resources for child care on the day ofsurgery and end up bringing children along and

• a patient’s current illness may precipitate a loss of income orjob status, which will worsen his or her economic status.

Intraoperative care• Review preoperative assessment and note the patient’s nutri-

tional status. • Review laboratory test results to assist in the diagnosis of

comorbidities.• Be aware that

• a patient may be at an increased risk for wound infection,pressure ulcers, or delayed healing because of currenthealth status;

• a patient may opt for local anesthesia solely because offinancial limitations, not necessarily because of personalpreference; and

• anxiety, depression, or mental illness may be exacerbatedwith the stress of a surgical intervention.

Postoperative careDischarge teaching should include ascertaining if the patient hasaccess to the following resources:• pharmacy services,• wound and postoperative care products,• transportation,• nutritional needs,• support systems, and• a telephone.If not, a nurse may be able to work with social services or otheragencies to provide the patient with these resources.

TABLE 2Web Sites With Information on Poverty*

Institute for Research on Poverty http://www.irp.wisc.edu

National Coalition for the http://www.nationalhomeless.orgHomeless

US Census Bureau http://www.census.gov

US Council of Catholic Bishops http://www.usccb.org

Worldbank http://www.worldbank.org

* Access verified 7 Sept 2006.

the surgical procedure andthe patient’s physiologicresponse to the surgical inter-vention. If a philosophy ofholistic health is truly actual-ized, many nurses will needto broaden their perspectiveand knowledge of thisincreasingly prevalent socialproblem. Table 1 contains alist of issues related to impov-erished patients in the periop-erative setting. Table 2 con-tains a list of web sites thatprovide information on globaland national issues related topoverty. Nurses are encour-aged to review local demo-graphics and other availableresources to understand thebreadth of poverty-relatedissues as well as the supportsystems that are available intheir area.

NURSE ADVOCACYIn an editorial for Nursing

Ethics,4 Fasting encouragednurses to fight for the rightsof people who have no accessto health care or the resourcesnecessary for full humandevelopment. She questionswhether nurses have theknowledge and skills that arenecessary to affect societalinjustices through communityinvolvement and legislativeinitiatives.

Many colleges and univer-sities currently require stu-dents to participate in serv-ice-learning programs. Whena student participates in oneof these programs, he or shecontributes personal time to acommunity agency. By help-ing to record patients’ histo-ries and physical assessments

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Special Needs Populations NOVEMBER 2006, VOL 84, NO 5

at a homeless or women’sshelter, for example, nursingstudents have the opportunityto reexamine their precon-ceived ideas and break downtheir misperception of differ-ences between themselvesand the impoverished popula-tion. Reutter et al5 andDeLashmutt and Rankin6

have documented additionalstrategies to expose nursingstudents to impoverishedpatients. Students were ableto negotiate with social serv-ice agencies, landlords, healthcare providers, utility compa-nies, and charities on behalfof their clients.

AORN CHAPTER INVOLVEMENTMany AORN chapter

members participate in com-munity projects, especiallyduring the holidays. Theneeds of the community,however, are ongoing. Indi-vidual chapters are encour-aged to seek out new oppor-tunities to make a differencein their local communities. Acall to community action mayneed to begin by increasingchapter members’ awarenessof this issue. Many web sitesoffer learning materials suchas videotapes and quizzes,some of which may be pur-chased for a nominal fee.These resources could beused during a chapter meet-ing in combination with aspeaker from a local agencyor university who could

address issues related topoverty. These resources alsocould be used by employerswho then could sponsor com-munity service projects.

A CALL TO ACTIONIn 2005, an estimated 37

million people were living inpoverty nationally.7 Mostnurses can only imagine howdifficult it would be to meetthe economic demands of ris-ing costs in health care, trans-portation, and housing thatare placed on a person livingon a minimum-wage salary.The poor are disadvantagedbecause of their limitedaccess to health care as wellas their lack of the necessaryresources to live a healthylife. How can perioperativenurses make a difference?Increased awareness of thissocial issue is the first step,and awareness is a founda-tional precursor to action. ❖

MICHELLE BYRNERN, PHD, CNOR

ASSOCIATE PROFESSOR OF NURSING

NORTH GEORGIA COLLEGE

DAHLONEGA, GA

NOTES1. R E Spector, Cultural Diversityin Health & Illness (Upper Sad-dle River, NJ: Pearson/PrenticeHall, 2004).2. P E Stevens, “A nursing critiqueof US welfare system reform,” Ad-vances in Nursing Science 23 (De-cember 2000) 1-11.3. “Fact sheet: Administration forchildren and families: The PersonalResponsibility and Work Oppor-tunity Reconciliation Act of 1996,”US Department of Health and Hu-man Services, http://www.acf.dhhs.gov/programs/ofa/prwora96.htm(accessed 7 Sept 2006).4. U Fasting, “Poverty limits hu-man freedom and a person’s dig-nity,” Nursing Ethics 8 (January2001) 3-4.5. L I Reutter et al, “Nursing stu-dents’ beliefs about poverty andhealth,” Journal of Advanced Nurs-ing 48 (November 2004) 299-309.6. M B DeLashmutt, E A Rankin,“A different kind of clinical expe-rience: Poverty up close and per-sonal,” Nurse Educator 30 (July/August 2005) 143-149.7. “Income climbs, poverty stabi-lizes, uninsured rate increases,”US Census Bureau Newsroom,http://www.census.gov/Press-Release/www/releases/archives/income_wealth/007419.html (accessed 7 Sept 2006).

RESOURCESAday, L A. At Risk in America:

The Health and Health Care Needs ofVulnerable Populations in the UnitedStates (San Francisco: Jossey-BassPublishers, 2001).

“Poverty USA—Catholic cam-paign for human development—A hand up, not a hand out,” Uni-ted States Conference of CatholicBishops, http://www.usccb.org/cchd/poverty/povertyusa/involved.shtml(accessed 7 Sept 2006).

Iceland, J. Poverty in America: AHandbook (Berkeley, Calif: Univer-sity of California Press, 2003).

The poor are disadvantaged by

their limited accessto health care as

well as their lack ofthe necessary

resources to live ahealthy life.