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Introduction

Hawaii has the third highest rate of homelessness among other cities of the USA. Almost half of those who live in shelters or streets are lifelong residents of Hawaii, and constitute more than forty percent of older people, who are vulnerable to chronic diseases and other health related issues.

More than fifty percent of the families consist of more than one adult, who works part time or full time, yet do not earn enough money for a permanent shelter. There is a general recognition that the deficit of sufficient health care facilities and affordable housing is the key reason for their deteriorating condition.

While the Federal Government juggles the stakeholders’ interest, social service organizations scramble to satisfy the short and long term requirements of individual homelessness. Most admit that merely providing affordable housing would not resolve all current problems, until a better health improvement structure is established for the vulnerable homeless population of Hawaii.

Increased life expectancy results in increasing ratio of older persons living in Hawaii. For promoting health among older people, the Federal Government, since 2008 has been conducting a community program for older persons. The majority of health workers involved in such programs is nurses who conduct regularly health post integration service for the older people.

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From the general observation, the key duties of nurses are more focused on medication action when they carry out blood measurement, attending complaints of the older people and giving them health education individually and also providing medication facilities.

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Unfortunately, concerning a large number of older people population in Hawaii region, even though the nurses conduct health related programs regularly, sufficient data is not available regarding characteristics of the older population, which includes the most common health complaint or chronic illness suffered by older people in this region. The data itself is significant in assisting the older people performing self care. The fact remains that the older population has a high prevalence of self-care deficiencies besides chronic illness (Yuan, 2011).

Based on Dorothea Orem’s self-care theory, self-care is the practicing of activities that persons initiate and perform on their behalf for maintenance of well-being and health. The humans have the capability and willingness to perform self-care. Whenever there is a requirement of continuous self-care, which requires the implementation of scientific knowledge and use of specific techniques, then there is a need of nursing for providing the care or for designing it. Hence, the information regarding older people including their common symptoms and characteristics is critical to design suitable self-care treatment for them. Considering the significant baseline data on characteristics of the older population in Hawaii as well as how the older people do self-care, this study will highlight the experiences of older people on self-care in terms of attitude, knowledge and practice in regard to vulnerable population of Hawaii (Orem, 1995).

1. Using Orem’s Model Description of the Vulnerable Population

Orem General Theory of Nursing

From a perspective of healthcare, vulnerability peculiar to an individual is susceptibility to disease from a physical, mental, or sociological viewpoint. Melnyk (2010) states the theory on the concept of public health that the whole population is vulnerable, which directs to vulnerability by virtue of status: i.e., some groups face the risk at any given point comparative to other groups or individuals. The older population and people with chronic mental illnesses come under this definition of vulnerable population and possibly two conceptual models of nursing can help them. Since those people with a mental illness have increased risks of being incapable to manage, identify ways to maintain health, Orem’s theory is helpful to this vulnerable population. The older persons have greater exposure to maintain a healthy living because of self-care deficits that occur in the aging process. Orem’s self-care deficit theory assists the patients to overcome any deficiency to the maximum of the individual’s capacity.

The self-care theory links patient analysis with nursing diagnosis, discharge planning, expected patient outcomes, external agency reports, and clinical research.

There exist three sub theories within Orem’s model. The theory of self-care deficit explains how a person can take advantage from nursing since they are subject to self-derived or health related limitations. The second sub theory of self-care says that care is a learned behavior, which purposely regulates functioning, development, and human, structural integrity. The third theory of nursing systems explains how nurses can use their capabilities to design, prescribe, and offer nursing care (Orem, 1995).

Application to Vulnerable Population

For providing nursing care, Orem classifies operations which are professional-technical, including prescriptive, diagnostic, and treatment or regulatory and case management. The application of Orem’s theory in nursing practices is significant as a framework in a diversification of settings, including ambulatory clinics, acute care units, nursing homes, community health programs, hospices, and rehabilitation centers. This theory is applicable to patients with diseases or conditions that include alcoholics, adolescents with chronic disease, the chronically ill, rheumatoid arthritis, head and neck surgery, and cardiac conditions. The theory is also applicable to selected age groups that include the aged, mothers with newborns, and children (Salit, 1998).

Example

Anya is 28 years old, married, and six months pregnant. She is suffering from anemia, is underweight and undergoing the care of a healthcare center. Entire data compiled from the patient’s records, and a home visit shows that her self-care requirements are not satisfactory including food, rest, and healthy activity. She needs guidance in food diet but can bear on her own. Her priority diagnoses are low activity level, inadequate food consumption, and fatigue due to lack of rest.

Diagnostic and Prescriptive Operations

All three priority diagnoses listed are related to the prevention of health deterioration. In this patient’s case, the self-care deficit theory of nursing suggests a supportive nursing system, which creates personalized care for her. 

The individualization of nursing system is accomplished through covering primary conditioning factors and meeting self-care requisites on the therapeutic self-care demands. The outcome is health promotion, health status maintenance, and avoidance of further deterioration in health by strengthening of the self-care agency. Unless there is a provision to provide expected outcomes, the nursing system design can change.

Regulatory Operations

The self-care theory of nursing is extremely beneficial with this client. This theory shifts the focus away from disease to the strengths and weaknesses of the self-care agency.  It is apparent that the patient does seek to prevent the conditions threatening her health; still she needs assistance in this area. The significant self-care deficiency relates to the area of nutrition. Under the guidance of this theory, the nurse performed analysis of the self-care agency in the context of the basic conditioning factors (McLaughlin, 2002).

2. Significance of problems related to its vulnerability, local and national statistics

Vulnerability causes sickness in people, reduces their lifespan, and relates to the inadequacy in housing, income, food, education, and social inclusion. The circumstances, which increase vulnerability, are social exclusion; chronic malnourishment; chronic illness, disability; homelessness; mental illness, and drug abuse; living with HIV/AIDS; foster children and veterans suffering from acute, shocking stress disorder.

McLaughlin (2002) explains, in modern society, various categories of patients suffer lower quality of health care with regard to accessibility of care, satisfaction with care and sufficient receipt of care, nonelderly women with disabilities; ethnic minority and mentally disabled.

In this paper the significance of health care refers to vulnerable population in Hawaii, the financial effect on the homelessness, the funding used to help in health and illness trends and assessment of risk to the prevailing health care system if such homelessness rate continues to rise despite the implementation of Patient Protection and Care Act 2010.

In July 1987, the Federal Government enforced the McKinney Homeless Assistance Act, since the needs of health care measures were not satisfactory. The aim of McKinney Act was to provide emergency food and shelter, physical and mental health care besides education and job training.

The homeless population faces financial stress just the same as a low income group, and there is always an increased stress because of inability to afford health care. Although there are health care centers that provide medications freely, according to nurses, older persons are negligent about their self care and totally depend on nursing care that makes the task of nurses more difficult. 

The mental health services for homeless sets asides funds for states to provide services for the elderly homeless people with mental illnesses. The elderly veterans can avail services through the Veterans Administration for support services with regard to their health care.  

Homelessness is expensive. It costs HUD's Emergency Shelter Grants program approximately $8,067 for an emergency shelter bed, which is more than the annual cost of a federal housing.

While looking at medical treatment, hospitalization, emergency shelter services, and incarceration expenses, it becomes clear that homeless people are expensive for taxpayers as well as cities. The homelessness accesses the most expensive health care services when they come to the hospital (Martell, 2010).

A study of hospital admissions in Hawaii reveals that 1,800 adults are responsible for 575 hospitalizations and $4.5 million in admission cost. The expenditure for treating homeless individuals was approximately $3.5 million or $2,500 per person. National Alliance to End Homelessness explains that homelessness cause serious health care problems such as addiction, psychological disorders, HIV/AIDS, alcoholism; inability to treat these medical problems can accelerate danger to society along with increasing the cost.

The homeless vulnerable population does not have means of transportation; they depend upon shelter homes, and soup kitchens to fulfill their survival needs. They are more concerned of immediate need for shelter, clothing, food then seeking health care, and they avoid health care intervention until the minor problems become an urgent medical emergency. The lack of information about where to get treated is again a barrier to their health. As a result, homeless people are likely to die three to four times earlier than the general population (Kushel, 2002).

3. Evaluation of adequacy of current strategies to break the cycle of vulnerability, including ethical implications of current strategies

Self-Care Model and Older Persons

According to McLaughlin (2002), Orem’s self-care theory offers a purposeful strategically framework on which it is possible to build a powerful gerontological nursing practice that can break the vulnerability cycle in Hawaii. Older persons are more vulnerable to risks and illness, possess similar universal life requirements as other human beings, and these are fundamental needs for the maximum and integrated functioning of the total individual. The factors of illness, disability, and age can restrict the ability to fulfill any of such demands, which in turn, subsequently leads to the need for assistance in the form of nursing services. It becomes a responsibility of a nurse to reduce or minimize restrictions imposed by mental, physical, and socioeconomic limitations.

An individual equipped with a wealth of social skills possesses the capability to lead a normal, active life, which includes social interaction and friendships. The people who know the hazards of cigarette smoking are more capable to protect themselves from health problems related with this habit. On the other hand, an older person living alone may not be able to provide sufficient diet for themselves and depend on others for meal preparation. Further, an older diabetic person cannot self-inject the insulin and is incapable to meet the therapeutic demand for insulin administration.

Vulnerability may result if an individual has no desire or decides against action. If a person has no interests in eating healthy meals because of loneliness and social isolation, a dietary deficiency can occur. A hypertensive person’s lack of desire and the decision to neglect meat products and potato chips in the diet may be because of the belief that it is not that much worth, which may result in a real health threat. The person who is not aware of the significance of physical activity may not recognize the need of a healthy diet, which is necessary to arise from bed during sickness, and thus may develop complications (McLaughlin, 2002).

It is not easy to change deeply formed attitudes, beliefs and values. Although the nurse must respect the right of persons to form decisions affecting their lives, if restrictions limit their ability in their self-care demands, the nurse can break the cycle of vulnerability by explaining the advantage of an action by providing information and motivating. Under some circumstances, with mentally incompetent or emotionally sick person, decisions and desires can supersede by professional judgments.

Self care ability is similar to a necessary condition for the recognition of self care activities and evolves continuously in the course of time. Some older people being more vulnerable become dependent of health care when their self-care capability reduces, and if the person is successful in meeting life activities then there is no requirement for nursing treatment, except to strengthen the ability for self-care. The incapability to fulfill demands leads to a need for nursing treatment independently. Nursing actions direct toward strengthening of self-care capacities, minimizing or eliminating self-care restrictions, and providing direct health services, or helping a person when it is not possible to fulfill the demands independently (Melnyk, 1983).

There must be a consideration while assessing the effect of the illness on the person’s self care, and identifying suitable nursing treatment ensuring that the demands imposed by illness are adequate. Self-care is significant to well being, and nursing treatment must focus on vulnerable older people to enhance their wellness.

4. Proposed community and public health nursing interventions in roles of manager, advocate, teacher, caregiver and researcher

The nurse assists the patients to distinguish and use resistance resources to promote, maintain health, enhance the sense of coherence and prevent disease. The role of caregiver demands the nurse to offer hands on direct care. In this role, the nurse gives psychological and physical assistance and comfort, thereby developing the person’s physical and interpersonal general resistance resources. For executing the role of caregiver the nurse practices affective, psychomotor, and cognitive skills for maintaining and enhancing the patient’s sense of coherence. In the roles of consultant, coordinator and collaborator nurses work with other health care professionals, to assure optimum delivery of patient care. For example, effective coordination of health services provides an efficient delivery of care that, in turn, gives conservation of physical and emotional resistance resources for the client.

Consultation and collaboration with health care providers result in patients securing general resistance resources essentially to improve health. For implementing the roles of coordinator, consultant, and collaborator the nurse fully understands the role of other professionals and health care system, being skillful in establishing interpersonal relationship, and respecting the contributions of the patient and other health care providers (McLaughlin, 2002).

In the role of a teacher, the nurse shares their knowledge, information, experience and facilitates learning related to illness and health. This information is beneficial for healthy people who can use such information to improve or maintain the healthy state. Moreover, persons can use such knowledge to understand current therapies and thus they can think of rational decisions about future therapy. The teaching role directly relates to cognitive and evaluative general resistance resources. In order to apply the role of a teacher, the nurse recognizes that teaching learning principles is possible for skilled professionals by sharing experience and knowledge with others both in writing and verbally.

In a role of the advocate, the nurse works to encourage the patient to incur control and a direction in search of ways and means for making public health services system more sensitive to requirements of the patient. As the advocate for patients, the nurse works to improve access to services. The nurse supports the rights to make a choice concerning the character and degree of their health services, recognizing that separate cultural beliefs and practice of public health services influence on patients’ choice. The role of the advocate thus demands knowledge of various cultures and ethics in order to enhance the patients socio cultural General Resistance Resources (Orem, 1995).

Conclusion

Functional competency and capability of self care is significant for leading an independent life for older people living independently as well as in hospitals. Knowledge and information of self care among older people is crucial among them so that they can identify risks and plan their care accordingly. As for the nurses’ role, the information regarding self care of older people is highly critical while determining the nursing requirements of older people and also nursing educational program for them.

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