The purpose of this project was to improve Masters Entry Program in Nursing pre-licensure student empathy and understanding for their patients who may be living in poverty.
Poverty is a powerful social determinant of physical and mental health (Manseau, 2015). Manseau (2015) reported that childhood poverty is related to higher rates of depression and anxiety and lower academic achievement. Work in the area of social determinants of health highlights that zipcode is more predictive of health and wellness than genetic code highlighting the importance of health care professionals taking a broader perspective about the provision of healthcare. Healthcare providers who have not directly experienced the daily struggles of the poor often do not understand the full impact that poverty has on health. The education of future health professionals provides the opportunity to bring that broader perspective into the classroom and expose students to the challenges of living in poverty through simulation.
The literature regarding the efficacy of poverty simulation as an instructional strategy is largely consistent and reflects a positive shift in student attitudes about the stigma of poverty. When measured, students demonstrated an increase in knowledge about the experience of poverty (e.g. Aspden, Sheridan & Harrison, 2016; Clarke, Sedlacek, & Watson, 2016; Menzel, Willson, & Doolen, 2014; Richey Smith, Ryder, & Bilodeau, 2016; Strasser, Smith, Pendrick Denny, Jackson & Buckmaster, 2013; Vliem, 2015; Yang, Woomer, Agbemenu, & Williams, 2014). A poverty simulation learning experience was piloted with two cohorts of MEPN students, 32 in their first year of the program, 24 in the second year. Student knowledge post-simulation was evaluated using a combination of pre- and post-tests including open text responses, and written self-reflections.
Methods:
The Community Action Poverty Simulation (CAPS) in 2002 was adapted by the Missouri Association for Community Action. The CAPS tool was selected because of accessibility and the volume of literature supporting the tool (e.g. Clarke et al., 2016; Kidd & Hartman, 2015; Kihm & Knapp, 2015; Selvia, 2014; Todd. De Guzman, & Zhang, 2016; Yang et al., 2014).
Faculty created open-ended questions to correlate with the post-poverty simulation Active Learning Scale which assesses student feelings about the poverty simulation in relationship to their thinking about working with people living in poverty (Vandsburger, Duncan-Daston, Akerson & Dillon, 2010). Fifty-three of the 54 participating students responded to the Active Learning Scale and the corresponding open-ended questions. In addition, 15 of the 32 first year students completed free-form written reflections. nVivo 11 was used to facilitate data analysis. All researchers reviewed the qualitative data. Two researchers independently completed initial coding, coding was then compared, similar themes were collapsed, and final themes were decided upon.
Results:
Three primary themes reflected students’ learning outcomes: (a) Scarcity of resources, (b) the lived experience of poverty, and (c) application of the lessons learned to nursing.
Scarcity of resources: The concept of “not enough” emerged, whether it was money, services, transportation, time or other resources. Multiple students identified inadequate public transportation and inadequate housing as areas that needed to be addressed and how difficult it was to “plan a day around a bus schedule”. Students were also reflective about how unhelpful it was to be given a handout with resources especially when some of those resources may not be available or restrictions may make accessing the resources near impossible. Multiple students identified that basic needs (food, shelter, transportation) may come before seeking healthcare, meaning that health was not and sometimes could not be prioritized.
The lived experience of poverty: Generally, students reported that when simulating the lives of those in poverty they felt stressed, anxious, and frustrated as they struggled with trying to complete their tasks. Some students found the experience challenging and reflected about what it would be like to have to live in poverty for a lifetime, and not just in a simulation lasting a few hours. Students also noted that what may externally seem like poor choices, are really circumstances which force individuals decide between to sub-optimal options:
It opened up my eyes in the fact that sometimes "bad" choices are often made under pressing circumstances and should not be judged, for there were no "good" options for people to choose from.
The majority of students responded that they had a better empathetic understanding of the degree to which people living in poverty experience stress, frustration and limited, often undesirable, options.
Application of the lessons learned to nursing: Students reported how their simulation experience related to their thinking about nursing practice. Several strategies were described including: teaching people how to efficiently navigate the complex healthcare system, improved patient care understanding the difficult context of healthcare within impoverished circumstances and improved advocacy and policy change.
Conclusion:
It appeared that learning occurred in a deep and meaningful way for most students, moving from their heads and academic minds to their ability to clinically reason, critically think, to feel the experience in their guts and develop compassion and solution oriented goals.