Using Evidenced-Based Simulations to Enhance Care of Vulnerable Populations

Negative attitudes and discriminatory behaviors of nurses and other health-care professionals towards individuals with health disparities are prevalent and are associated with serious adverse consequences to the health, quality of care, and quality of life. Simulations can provide valuable learning opportunities to develop students’ awareness, knowledge and skills in working with vulnerable populations. Learning opportunities that facilitate an understanding of the lived experience of clients has the potential to change attitudes (Byrne, Platania-Phung, Happell, Harris, & Bradshaw, 2015). Additionally, authentic learning experiences can facilitate students’ understanding of the trajectory of client experience and their associated response to client situations, thus improving clinical practice (Kelly, Berragan, Husebø, & Orr, 2016). Increasingly, experiential learning experiences through simulation are being recommended to teach students about the structural inequities and lived experiences of vulnerable populations, including the poor (Reid & Evanson, 2016), the mentally ill, (Byrne, Platania-Phung, Happell, Harris, & Bradshaw, 2015) and victims of domestic violence (Adelman, Rosenberg, & Hobart, 2015). The purpose of this presentation is to discuss the results of two multi-site research studies that focused on simulations with vulnerable populations: a poverty simulation and mental health simulation of care of a client with schizophrenia. Poverty is one of the social determinants of health. In order to deliver patient-centered care, it is important for nurses to have an understanding of the impact of poverty on health-related decisions (Reid & Evanson, 2016). Clients with mental illness experience health disparities in part due to the negative attitudes by health care providers and associated stigma associated with the disease. Simulation has great potential to provide learning opportunities to enhance student understanding of stigma, social justice, and health disparities (Mawji & Lind, 2013).

The purpose of this presentation is to describe lessons learned from two multi-site studies of simulation based learning activities. Both studies were completed in undergraduate nursing programs and focused on improving understanding of and attitudes toward individuals experiencing stigma and health disparities. Study 1 compared changes in attitudes and understanding of students who completed a three-hour poverty simulation with a control group of students who did not complete the simulation. Five cohorts of 178 junior baccalaureate nursing students (each from a different nursing program) enrolled in a populations course participated in the study; two of the cohorts participated in the poverty simulation and three did not. A 21-item The Attitudes Towards Poverty Short Form (ATP-S) questionnaire was administered at the beginning of the course and at the end. The ATP-S A has a global score of a range of 21- 105 obtained by summing the item scores; higher scores indicate more positive attitudes towards poverty. Three subscales have been identified: Personal deficiency, stigma, and structural perspective. Assessment of students’ beliefs about the link between poverty and health were also collected. Controlling for pretest group differences, posttest means for the experimental group (78.73) were 3.5 points higher than for the control group (75.72), which was significant at .007. Changes in posttest scores was attributed for the experimental group to growth in structural perspective subscales. There was a significant association between the simulation and participants’ beliefs about the link between poverty and health due to living conditions (a structural perspective) rather than behavior, drifting into poverty, or no link (chi square = 14.1, p=.003).

Study 2, also a multi-site study, explored the impact of a simulation on attitudes and behaviors towards individuals with schizophrenia. . The purpose of this study was to determine if students who participated in the simulated learning activity would demonstrate a) greater knowledge about mental health problems; b) reduced negative attitudes towards individuals with schizophrenia; c) greater empathy; and d) greater behavioral intent to interact with clients with mental illness as compared to those who experience traditional mental health didactic and clinical learning experiences. This multi-site study used a quasi-experimental comparison of treatment and control groups of 145 students enrolled in a chronic illness course in their second year of undergraduate nursing education. The control group were exposed to traditional didactic classroom and practicum experiences. The treatment group additionally experienced a simulation which included individual simulated auditory hallucinations followed by a standardized patient interaction of a client with schizophrenia. Variables measured included empathy, attitudes about schizophrenia, fear and behavior intentions. An analysis of covariance model was used to test for differences between groups; the moderating effect of experience with people with mental illness was also examined. The intervention group showed significantly lower negative emotional perceptions, with greater difference for participants with less experience at baseline. Changes in empathy were not significant. The moderating effect of level of experience was evident for student report of decreased fear and increased intent to interact.

Ongoing translation of educational practices aimed at preparing nurses to improve outcomes for vulnerable populations remains critical in our current healthcare environment. Nurses in all practice areas are likely to interact with individuals with mental illness or those living in poverty. Facilitating learning opportunities through evidence-based simulations to improve nursing attitudes and behaviors towards people experiencing stigma can enhance the quality of care and quality of life of those populations.