Influences on Health Care Delivery
The health care delivery system is rapidly changing as the popu-lation and its health care needs and expectations change. The shifting demographics of the population, the increase in chronic illnesses and disability, the greater emphasis on economics, and technological advances have resulted in changing emphases in health care delivery and in nursing.
Changes in the population in general are affecting the need for and the delivery of health care. The 2000 U.S. census data indi-cated that there were 281,421,906 people in the country (Pluviose-Fenton, 2001). This population expansion is attributed in part to improved public health services and improved nutrition.
Not only is the population increasing, but the composition of the population is also changing. The decline in birth rate and the increase in life span attributed to improved health care have re-sulted in fewer school-age children and more senior citizens, most of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of minority groups to the inner cities and a migration of middle-class people to sub-urban areas. The number of homeless people, including entire families, has increased significantly. The population has become more culturally diverse as increasing numbers of people from dif-ferent national backgrounds enter the country. Because of such population changes, the need for health care for specific age groups, for women, and for a diverse group of people within spe-cific geographic locations is altering the effectiveness of tradi-tional means of providing health care and is necessitating far-reaching changes in the overall health care delivery system.
The elderly population in the United States has increased signif-icantly and will continue to grow in future years. In 1999, the na-tion’s 34.5 million adults older than 65 years of age constituted 12.7% of the population, with a ratio of 141 older women to 100 older men. The number of people in the United States older than 65 years of age is expected to reach 20% of the population by the year 2030. In addition, persons age 85 years and older con-stitute one of the fastest-growing segments of the population. Ac-cording to the U.S. Bureau of the Census (2000), the number of people age 65 to 74 years was 8 times larger in 1999 than in 1900, and the number of people age 75 to 84 years was 16 times larger— but the number of people age 85 years and older was 34 times larger in 1999 than in 1900.
Many elderly people suffer from multiple chronic conditions that are exacerbated by acute episodes. Elderly women, whose conditions are frequently underdiagnosed and undertreated, are of particular concern. There are approximately three women for every two men in the older population, and elderly women are expected to continue to outnumber elderly men. The health care needs of older adults are complex and demand significant invest-ments, both professional and financial, by the health care industry.
An appreciation for the diverse characteristics and needs of indi-viduals from varied ethnic and cultural backgrounds is important in health care and nursing. Some projections indicate that by 2030 racial and ethnic minority groups will comprise 40% of the population of the United States (Gooden, Porter, Gonzalez, & Mims, 2000). With increased immigration, both legal and illegal, this figure could easily increase to more than 50% by the year 2030 or even earlier. As the cultural composition of the popula-tion changes, it becomes increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups bring to the health care setting different health care beliefs, values, and practices, as well as different risk factors for some disease conditions and unique reactions to treatment. These factors significantly affect the way an individual re-sponds to health care problems or illness, to those who provide the care, and to the care itself. Unless these factors are understood and respected by health care providers, the care delivered may be inef-fective and health care outcomes may be negatively affected.
Culture is defined as learned patterns of behavior, beliefs, and values that can be attributed to a particular group of people. In-cluded among the many characteristics that distinguish cultural groups are the manner of dress, language spoken, values, rules or norms of behavior, gender-specific practices, economics, politics, law and social control, artifacts, technology, dietary practices, and health beliefs and practices.
Health promotion, illness prevention, causes of sickness, treat-ment, coping, caring, dying, and death are part of the health-related component of every culture. Every person has a unique belief and value system that has been shaped at least in part by his or her cultural environment. This belief and value system is very important and guides the individual’s thinking, decisions, and ac-tions. It provides direction for interpreting and responding to ill-ness and to health care.
To promote an effective nurse–patient relationship and positive outcomes of care, nursing care must be culturally competent, ap-propriate, and sensitive to cultural differences. All attempts should be made to help the individual retain his or her unique cultural characteristics. Providing special foods that have significance and arranging for special religious observances may enable the patient to maintain a feeling of wholeness at a time when he or she may feel isolated from family and community.
Knowing the cultural and social significance that particular situations have for each patient helps the nurse avoid imposing a personal value system when the patient has a different point of view. In most cases, cooperation with the plan of care is greatest when communication among the nurse, the patient, and the pa-tient’s family is directed toward understanding the situation or the problem and respecting each other’s goals.
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