Understanding Vulnerability: A Nursing and Healthcare Approach

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The exclusion criteria of the articles were studies that did not meet the inclusion criteria mentioned above.

CHAPTER EIGHT

Payments to hospitals, physicians, and other health care providers also should be designed to encourage coverage of cost-effective models of care delivery that have been shown to attain better outcomes including satisfaction and functional outcomes. In this context, nursing should pay attention to its professional practice, fighting for better work conditions and fostering self-care. Action Call to a Failing Industry , Czeresnia D, Freitas CM, organizadores. By adjusting payments for health status, health plans will be rewarded for developing quality programs that attract high-cost individuals with chronic conditions, whereas these incentives are lacking when paying plans average rates. In some cases, different quality measures may need to be used to assess the care provided to vulnerable populations. Payments to health plans and providers should promote quality health care and improved health and functional status for all patients, including vulnerable populations.

Thus, we have selected 24 articles for analysis. The five-year-period for the inclusion of the studies in the integrative review was to assess the most updated concepts regarding vulnerability and nursing. To organize and tabulate data, the researchers prepared a data collection instrument with: Articles according to country of origin were distributed the following way: The studies selected were classified according to the following types of publication, according to the journals' definition: As for the years of publication of the articles between and , the data collected presented the following distribution, presented in Picture 1.

The articles have been classified according to type of study and the theoretical reference adopted, and were thus characterized: The selected studies were characterized according to the population studied, displaying a broad picture of the populations that are considered vulnerable, some examples are: An overview of the work of nursing professionals during the process of human living can be demonstrated through the characterization of the clinical specialties approached by the selected studies, as specified: Last, the studies were characterized regarding the thematic focus used, showing some perspectives and operationalizations of the concept of vulnerability for nursing care, some examples are: The descriptors Vulnerability, Health Vulnerability, Vulnerable Populations, associated with Nursing present studies that highlight the vulnerability potential of some specific populations, allowing to know and understand the differences, how each person, individually and in group, experience and face the health-disease process 5.

The unfavorable social, economic, political and cultural conditions of the individuals contribute to their loss of autonomy and the establishment of an asymmetric relationship with the health team and the institution, favoring the establishment of a relation of power between them and thus the restriction of citizenship of these individuals, families or social group Currently, the concept of risk reaches almost all dimensions of life.

Risk is related with the idea of the adverse, subject to uncertainty 8 ; and it is seen as a potential threat that may lead to a reaction, that is adverse to the health of people exposed to it, or yet, to the possibility of harm in several dimensions such as: The assumption is that to avoid risk, one must recognize, accept and, whenever possible, avoid it.

Because of that, several behaviors may not be considered in certain risk situations. Thus, risks are considered as socially built processes and are articulated by individual behaviors and by the collective perception of risk Epidemiological risk is defined as the likelihood to occur a certain health-related event, estimated based on what happened in the recent past. Also, it can be understood as an individual factor, referring to some personal characteristics such as family history, habits, lifestyle, among others. In this context, changes in personal risk behaviors become the focus of the intervention Thus, the individual risk was used by Epidemiology in the beginning of the 80's, when the fast spread of AIDS worldwide was associated with some sexual practices and with the use of drugs.

With the development of studies about the disease and the first study searching for a treatment, the concept of "risk group" started to be criticized because of its objectivist and analytical-discriminative feature There are some conditions of life that are not controlled by people, such as poor diet or education, inadequate distribution of wealth, unfavorable working conditions, poor sanitary conditions, and most of the times, one cannot choose these In addition to this set of conditions, there are also violence aspects, unemployment, social inequalities and gender and power relations, absence of government and public policies in several social spaces, leading to situations of lack of protection, social abandonment, directly reflecting on the health-disease process.

Therefore, based on the setting displayed, the term vulnerability started to be used in public health, going beyond its biological dimension and incorporating other elements to assess some diseases. The term vulnerability characterizes a person or population group that becomes more or less vulnerable due to a set of political, economic, cultural and psychological processes, and the biomedical processes such as genetics, risk factors connected with family history, race etc.

The concept of social vulnerability encounters the reality currently faced by the AIDS epidemic, since there is a greater occurrence of this disease in the marginalized sector of the society The individual component includes the quality of information that individuals present on the problem, the ability to understand and incorporate these pieces of information to their daily lives, as well as the interest and the possibilities to put them into practices for protection and prevention.

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The social component refers to obtaining information that depend not only on individuals but also on the access to the media, to education, resources, the possibility to influence on political decisions and overcoming cultural barriers. The programmatic component includes resources that individuals need so that they are not exposed to risk situations, the public policies for disease prevention and control, the timely application of resources and availability of inputs necessary for protection, the level of commitment of the institutions, and the programs in the different care levels 12, Thus, the assessment of vulnerability components can be used as a reference to interpret any worsening.

Understanding the underlying sources of vulnerability is critical, not only because of the need to influence the development of targeted quality improvement efforts, but also because addressing the problems vulnerable groups encounter requires coordinated efforts throughout the health system. In particular, populations vulnerable to health care quality problems need to be accounted for in the design of effective systems for health care delivery, the choice of appropriate health care quality measures, and the adaptation of payment mechanisms.

With their focus on patients' acute and urgent problems, traditional models of health care delivery often lack the systematic assessments, preventive interventions, education, coordination and integration of care, and psychosocial support that vulnerable patients, particularly those with chronic conditions, also need Wagner, Innovative models of health care delivery have emerged that attempt to better incorporate these elements of care, but continued research and development of more effective and efficient approaches for meeting the health care needs of patients with chronic conditions, disabilities and other sources of vulnerability remain important.

While continued innovation in this area is important, it also must be accompanied by evaluation to determine effectiveness. To date, there is a lack of evidence supporting improved functional status or other clinical outcomes resulting from many health care delivery approaches for individuals with chronic illness or disability. Some elements of health care delivery that are particularly relevant to patients with chronic conditions include the use of multidisciplinary teams, continuity of care, patient and family empowerment, case management, and outreach or home-based care.

A review of more than 50 published studies assessing whether innovative health care programs emphasizing these elements improved outcomes for individuals with chronic illness or disability 1 found that improved clinical and functional outcomes were not consistently demonstrated. The review did find evidence that in general these approaches improved patient satisfaction with their care, but other improved outcomes were limited to specific models of health care within particular populations of patients.

Specific areas where evidence demonstrated that innovative health programs improved outcomes are summarized below:. The lack of consistent evidence for improved clinical outcomes highlights the need for significant investment in research and innovation of health care delivery models addressing the needs of individuals with chronic conditions and other vulnerable populations.

Understanding Vulnerability: A Nursing and Healthcare Approach

Evidence of enhanced patient satisfaction from models of health care delivery that emphasize continuity of care, multidisciplinary approaches, patient empowerment, and outreach to community settings should guide the development of innovative approaches to care that also aim to improve functional status and clinical outcomes. As evidence is developed to demonstrate effective models of care, health care providers should commit to practicing evidence-based care. Appropriate approaches to caring for individuals with chronic conditions, however, should recognize the unique needs of individual patients.

For example, while innovative approaches to caring for individuals with mental illness e. Several health plans have designed innovative programs intended to provide better care for individuals with chronic conditions, and further demonstration and evaluation of such programs should be encouraged. Examples of these unique programs include:.

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Other populations beyond individuals with chronic conditions also face vulnerabilities that should be addressed in designing health care delivery systems. Delivery systems need to assure access to the specific types of care that are needed by subgroups of the population, including women's health care, geriatric care, and pediatric care.

The availability of culturally-sensitive health care professionals and systems is particularly important for patients with communication barriers as well as for racial and ethnic minorities as further discussed in Chapter Telemedicine technologies, public programs that provide incentives for health care professionals to practice in underserved rural areas, and the availability of prehospital emergency services are delivery system characteristics that have the potential to improve health care delivery for patients whose location poses a barrier to accessing quality care.

In addition, certain types of providers, including academic health centers and community health centers, have played an especially important role in delivering comprehensive, high quality care to vulnerable populations who otherwise could be underserved. Changes in the health care system that affect those organizations' ability to continue in this role have the potential to increase the problems of access to appropriate care that vulnerable groups disproportionately face.

Finally, establishing national aims for improvement, while not targeted specifically to vulnerable populations, is intended to stimulate efforts to improve the quality of health care delivery see Chapter 3. The setting of aims, while national in focus, should be sufficiently robust to reflect the needs of specific vulnerable populations and localities.

This can be achieved through establishing specific objectives within the broader aims that reflect the unique needs of vulnerable populations, and ensuring that the tracking of national aims can support efforts to identify particular areas of concern to local areas and vulnerable populations. Vulnerable populations require special attention in the design of health care quality measurement strategies for three distinct reasons.

First, a focus on the quality of care experienced by vulnerable populations could provide new insight into health system problems or identification of problems that otherwise could go undetected. Second, some vulnerable groups are more likely to fall through the cracks.

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Understanding Vulnerability: a Nursing and Healthcare Approach focuses on vulnerability experienced every day by patients and clients in healthcare, and. The notion of vulnerability is critical to person-centred andhigh-quality nursing and healthcare practice, and underpins allnursing education. Understanding.

The same factors that contribute to their vulnerability can also affect their ability to safeguard their own needs and interests adequately. Third, for a variety of technical and other reasons, health care quality problems experienced by vulnerable populations are not well captured by measurement efforts designed for the general population. For the most part, these efforts do not utilize data collected over time or across multiple different settings for health care delivery.

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Finally, because individuals with chronic illness and disability consume a disproportionate share of health care resources relative to their share of the population, measuring the quality of their experiences with the health care system will lead to a focus on high-cost areas.

Health care quality measurement for vulnerable populations either could be undertaken separately or be included in general strategies for evaluating quality. The combination of general and targeted strategies is most likely to identify efficiently and effectively the highest priority quality problems for vulnerable populations. In some cases, it may be less expensive to oversample one group in the population to explore whether the subgroup is experiencing more or different quality problems. In other cases, the use of specially tailored measures may be more effective.

Including vulnerable populations in general strategies for quality measurement is likely to be more sustainable over the long run and sends the important signal that evaluating quality for vulnerable populations is equally, if not more, important. This strategy allows comparisons between vulnerable and general populations when the same measures are used. Such approaches may be more efficient if special sampling procedures can augment a generally applied measure so that evaluating problems for vulnerable populations can be done simultaneously. There are a few reasons, however, why targeted approaches might be necessary.

For persons vulnerable due to economic circumstances, the key to including them in monitoring systems is the availability of variables to identify such persons and methods for bringing data on their patterns of utilization into integrated data systems e.

Chapter 21 Vulnerability and Vulnerable Populations An Overview

For persons vulnerable due to health status, the key to inclusion in monitoring is the expansion of appropriate criteria for evaluating their care and the development of methods that can support analyses of quality problems using small samples. For persons who are vulnerable due to communication challenges, the key to inclusion will be the development of measurement tools that can be used with such populations.

Different Quality Measures Needed. In some cases, different quality measures may need to be used to assess the care provided to vulnerable populations. Certain health care problems experienced by vulnerable populations differ from those encountered by others in the health care system either by their nature or in the frequency with which such problems are encountered , and will require a different set of measures to evaluate the quality of care they receive.

For example, evaluating the quality of care delivered to persons with certain rare conditions may require developing clinical measures specific to the particular condition e. In other cases, existing measures might be adapted or refined to better accommodate vulnerable populations. Medicare and Medicaid, as public programs that insure a disproportionate share of many vulnerable populations e. In efforts to develop new health care quality measures, the deficits in quality that pose the greatest risk to vulnerable populations and the types of measures most likely to identify such deficits should be taken into account.

Focusing new measure development on technical process quality has a number of advantages. First, scientifically sound measures of technical process quality are the most sensitive dimensions for providing an early warning of potential threats to health outcomes. A good measure of technical quality is one that is linked to health outcomes-- meaning that adhering to the indicator process more often will increase the likelihood of producing better health outcomes. Process monitoring provides an early warning signal.

When problems with processes are identified, interventions can be launched to improve processes before many individuals experience poor outcomes. Second, process evaluation allows quality improvement efforts to examine structural and access features that may be contributing to poor quality.

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Third, technical process is the area that is most difficult for individuals to evaluate for themselves. About this product Description Description. Clinically she worked as a District Nurse and specialist practitioner for older people. Clinically she worked as a District Nurse. Publication Data Place of Publication.

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