Nurse Education in Practice 14 (2014) 680e685
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Relate better and judge less: Poverty simulation promoting culturally competent care in community health nursing Kyeongra Yang a, *, Gail Ratliff Woomer b, 1, Kafuli Agbemenu c, 2, Lynne Williams d a
Lienhard School of Nursing, College of Health Professions, Pace University, 861 Bedford Road, L306, Pleasantville, NY 10570, USA UMPC/Jefferson Regional Home Health, 1020 Lebanon Rd, W. Mifflin, PA 15122, USA c Department of Health and Community Systems, School of Nursing, University of Pittsburgh, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA d Southwest PA Area Health Education Center, 5614 Elgin St, Pittsburgh, PA 15206, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 September 2014
The study aim was to evaluate the effectiveness of a poverty simulation in increasing understanding of and attitudes toward poverty and resulting in changes in clinical practice among nursing seniors. A poverty simulation was conducted using a diverse group of nursing professors and staff from local community agencies assuming the role of community resource providers. Students were assigned roles as members of low-income families and were required to complete tasks during a simulated month. A debriefing was held after the simulation to explore students' experiences in a simulated poverty environment. Students' understanding of and attitude toward poverty pre- and post-simulation were examined. Changes in the students' clinical experiences following the simulation were summarized into identified categories and themes. The poverty simulation led to a greater empathy for the possible experiences of low income individuals and families, understanding of barriers to health care, change in attitudes towards poverty and to those living in poverty, and changes in the students' nursing practice. Use of poverty simulation is an effective means to teach nursing students about the experience of living in poverty. The simulation experience changed nursing students' clinical practice, with students providing community referrals and initiating inter-professional collaborations.
Keywords: Poverty simulation Community health nursing Cultural competency
© 2014 Elsevier Ltd. All rights reserved.
Introduction Nursing is a field built upon the value of compassion with deep empathy for the patients at its core. Empathy is based upon the ability to understand other's joys and sorrows and often derives from personal experience; it is one of the attributes that develop a sense of cultural competency. Simulation prepares nursing students for clinical experiences in a safe environment without fear of injuring real patients (Gillan et al., 2014). It has been used in settings ranging from acute or critical care nursing to end of life care, and helps in preparing healthcare providers for future interprofessional collaboration
* Corresponding author. Tel.: þ1 914 773 3242; fax: þ1 914 773 3357. E-mail addresses: [email protected] (K. Yang), [email protected] (G.R. Woomer), [email protected] (K. Agbemenu), [email protected] (L. Williams). 1 Tel.: þ1 412 653 8142. 2 Tel.: þ1 412 624 7838; fax: þ1 412 383 7293. http://dx.doi.org/10.1016/j.nepr.2014.09.001 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
(Gillan et al., 2014; Kowitlawakul et al., 2014; Murdoch et al., 2014). Simulation can take place in different forms, including case studies, role play, high-fidelity human patient simulation, or virtual simulation in an online environment. Depending on the form used, instruction can rely heavily on computer-driven models or be based on individual or group interaction (Dunnington, 2014; Foronda et al., 2014). In an age when increasing numbers of U.S. families live below the poverty level, nursing students must develop an understanding of the barriers and frustrations experienced by persons with vastly limited resources. According to the 2011 report on the health status of the nation (National Center for Health Statistics, 2012), the number of U.S. families living below the poverty level has continuously increased for all races (11.1% in 1973 to 14.3% in 2009) with a higher number in minority groups (e.g., 25.8% in Black or African Americans and 25.3% in Hispanic or Latino populations in 2009). This report also showed that 20.1% of children under age 18 were affected by poverty in 2009, compared with 14.2% in 1973. In addition, as a social determinant of health, poverty is significantly
K. Yang et al. / Nurse Education in Practice 14 (2014) 680e685
related to obesity among women (Ogden et al., 2010), sedentary lifestyles (Centers for Disease Control and Prevention, 2012), emergency room visits among young adults (Kirzinger et al., 2012), and an increase in cardiovascular risk factors (Seligman et al., 2010). While there are numerous learning modalities for the nursing student, simulation is recognized as a valid tool in preparing the undergraduate student. Simulation increases students' confidence in their clinical skills (Harder, 2010) and enhances student selfefficacy in providing family centered care (Cardoza and Hood, 2012). Simulation is becoming an essential part of health care education because it can provide opportunities for student clinical preparation and enhancing learning in a safe environment. Simulation can also offer the opportunity to learn about aspects of culture, such as poverty, that effect health outside of traditional clinical environments. Simulation activities can supplement clinical learning and also boost students' self-confidence prior to the actual experience (Simones, 2008). Existing evidence shows that a poverty simulation can help students in nursing better understand poverty (Noone et al., 2012; Patterson and Hulton, 2012) as well as students in other health science programs, such as social work (Vandsburger et al., 2010). Since exposure to poverty increases understanding of structural factors explaining poverty and health (Reutter et al., 2004), it is beneficial to implement a poverty simulation in educational settings with students who may not have had much exposure to poverty in their personal life. Currently poverty simulation is used by nursing programs to facilitate nursing students' understanding of the challenges faced by individuals and families living in poverty. However, there is little information on how this simulation has influenced clinical practice. Although the simulation described may be similar to other simulated studies reported in the literature, this study is pertinent at this time to expand the literature on how students learn about the problems faced by families and individuals living below the poverty level. The purpose of this study was to evaluate effectiveness of a poverty simulation in increasing understanding of and attitudes toward poverty and changes in clinical practice among baccalaureate nursing seniors. Methods Simulation We conducted a poverty simulation experience in the seniorlevel community health nursing course (three times for three different cohorts) using the Community Action Poverty Simulation, originally developed for the Missouri community (Missouri Association for Community Action, n.d.). The purposes of the simulation were to sensitize students to the day-to-day challenges faced by low-income families and to prepare students for their clinical practicum in the community where they interact, teach, and provide healthcare to individuals whose income is below the poverty level. In order ensure a more realistic experience we recruited a culturally diverse group of faculty, staff, and clinical preceptors from community agencies to assume various roles in the simulation as community resource providers. All had experience working with low-income individuals and families from different cultural groups and were sensitive to their needs and feelings. The students were assigned roles as members of fifteen low-income families (e.g., single parents, senior citizen, unemployed adults) and received a packet with simulated tasks to be completed during a simulated month (condensed into 15-min segments, each representing one week) while navigating a maze of community agencies that provide health and social services, financial support, and transportation to eligible individuals (e.g., social services,
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school, bank, grocery, pawn shop). Examples of their tasks included: finding employment, feeding the family, paying rent, ensuring children enrolled in daycare or school and paying utility bills. The simulation was conducted in a large conference room with tables for community agencies surrounding the assigned student groups. To provide a more relevant experience to our students, we invited local community agencies to be part of the simulation (e.g., Urban League of Greater Pittsburgh, Midwife Center for Birth & Women's Health, Mercy Parish Nurse and Health Ministry Program). Attempts were made to match community volunteers to their particular roles. For example, an employee of the energy assistance fund participated in the simulation as the “utilities” company employee. A week prior to the simulation, the students received background reading materials, such as the federal poverty level, national and local statistics of poverty, and its associated health outcomes. On the day of the simulation, students were again introduced to major concepts involved in the simulation and completed the pre-simulation survey. Consideration of student safety in regards to potential emotional reactions to the simulation was made. During the introduction to the simulation, the nursing students were informed that while this activity was a simulation, it did in fact mirror some of the realities that individuals in the group might have experienced themselves or known family or friends who experienced the situations. In that manner, the students were encouraged to be respectful of each other, to realize that this was not a “game” but a learning experience, and that they should consider the simulation as a stepping point for learning and understanding. During the simulation, faculty members were available to identify any student who was emotionally affected by the poverty simulation experience and to debrief with them afterward if necessary. At the conclusion of the two-hour simulation, students completed the post-simulation survey and participated in a debriefing session during which they had the opportunity to discuss their reactions to the simulated experience of living in poverty. The debriefing session was conducted by course faculty and some community agency personnel. The larger group of nursing students was divided into smaller groups in order to encourage discussion. During debriefing, small group leaders asked questions from a guide provided in the simulation packet. Examples of the questions included “What happened to families during the month in poverty?” “How did they improve their situation during the month?” “Discuss feelings experienced during month in poverty” “How did other people respond to your needs” and “Share insights or conclusions you have come to about the life experience of low-income families.” In addition, nursing professors, staff, and community leaders who took part in the simulation also sat in on the groups and contributed their insight and personal experiences during the students’ debriefing. Evaluation methods After the simulation, the following questionnaires were used to evaluate the simulation experience. A semi-structured Poverty Simulation Reaction questionnaire was used to evaluate understanding of poverty. This questionnaire consists of five Likert-Type items (1 ¼ no understanding, 2 ¼ little understanding, 3 ¼ moderate understanding, 4 ¼ quite a bit of understanding, and 5 ¼ almost complete understanding) and three open-ended questions. The five Likert-Type items evaluated understanding of the financial pressures, difficult choices faced by individuals with few resources, challenges in improving situation, emotional stresses, and impact of the social service system among individuals living in poverty (Greder and Warning, 2005). The three open-ended
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K. Yang et al. / Nurse Education in Practice 14 (2014) 680e685
Results
questions asked about feelings and changed attitude during the simulation and insights about the life experience of low-income families. Finally, on a scale of 1e10 (10 is high), an overall rating of the simulation experience was requested. A 21-item of Attitude Toward Poverty Scale (Yun and Weaver, 2010) was used to examine students' attitude toward poverty. This scale uses five Likert-type categories (strongly agree, agree, neutral, disagree, and strongly disagree). The scale was originally developed by Atherton and his colleagues (1993) as a 37-item questionnaire. Later, Yun and Weaver (2010) developed a shorter form (21 items with three factors). The scale has established reliability and validity with undergraduate students. Higher scores indicate a more positive attitude toward poverty. A total global score (ranges from 21 to 105) and three subscale scores (7-item personal deficiency, 8-item stigma, and 6-item structural perspective) were calculated. Examples of personal deficiency items included being different from the rest of society, being dishonest, having a different set of values, and acting differently. The stigma subscale focuses on questions about fraud, living better, feelings of entitlement, being lazy, and welfare recipients consuming a major part of the federal budget. The structural perspective subscale includes one's willingness to support social programs and society's responsibility to help the poor. The experience ended with students completing a question on their plans to volunteer with services for the poor in the future. At six weeks after the simulation, a follow-up survey offered students an additional opportunity to share their experience as to how the simulation influenced their clinical experience during the term. Students' participation in the evaluations was completely voluntary. The completion of the questionnaires was entirely anonymous, to ensure students' responses were not identifiable in any way. Institutional Review Board approval was obtained. This project was part of an evaluation of educational strategies, curricula, or classroom management methods, so it was considered an exempt research.
The most frequently reported feelings about poverty were frustration, stress, worthlessness, anxiety, and helplessness. After the simulation (Cohort 3; n ¼ 62), students significantly changed their attitude toward poverty in a positive direction in general (mean ± SD: 72.6 ± 9.3 vs. 75.9 ± 8.8; p ¼ .001). Personal deficiency (mean ± SD: 27.8 ± 4.2 vs. 28.2 ± 3.4; p ¼ .364) and structural perspective (mean ± SD: 20.3 ± 2.7 vs. 20.9 ± 2.8; p ¼ .061) were not significantly changed, but feelings about stigma (mean ± SD: 24.9 ± 5.2 vs. 27.0 ± 4.8; p < .001) were significantly improved after the simulation.
Statistical analysis
Implication of simulation experience in the clinical practicum
Paired t-tests were conducted to compare understanding of poverty and attitude toward poverty between pre- and postsimulation. The level of significance was set at a ¼ .05. Open ended answers about feelings, attitudes, and insights about poverty as well as their clinical experience influenced by the simulation were summarized by identified categories and themes using content analysis.
Before the simulation, 66.1% of students (n ¼ 41) reported having plans to volunteer with services for the poor in the future, and after the simulation, the number of students increased to 48 (77.4%). Students shared how the poverty simulation experience influenced their clinical practicum in the hospital or community. Findings were summarized into four main themes: general understanding of people with a low socioeconomic status (SES),
Three cohorts of nursing senior students (N ¼ 233) participated in the simulation over three academic terms (i.e., Fall 2010, Spring 2012, and Spring 2013) and 199 students (85.4%) completed the questionnaires. Table 1 shows the project information. Students' overall rating of the simulation was above average (8.25 on a 1e10 scale with 10 being the highest overall rating). Understanding of poverty Survey findings revealed (Fig. 1) that student Cohorts 1 and 2 (n ¼ 137) significantly increased their understanding of the financial pressures (mean ± SD: 2.89 ± 0.84 vs. 4.15 ± 0.58), difficult choices faced by individuals with few resources (mean ± SD: 2.76 ± 0.91 vs. 4.15 ± 0.68), challenges in improving situation (mean ± SD: 2.75 ± 0.88 vs. 4.10 ± 0.66), emotional stresses (mean ± SD: 2.89 ± 0.99 vs. 4.24 ± 0.70), and impact of social service system (mean ± SD: 2.59 ± 0.83 vs. 3.99 ± 0.77; all ps < 0.001). Out of 62 students (Cohort 3), 71% (n ¼ 44) reported that the simulation helped them to better understand the lives of people living in poverty. Feeling and attitude toward poverty
Table 1 Summary of the project. Cohort
Academic term
Participation in the simulation n
Completion Of the evaluation n (%)
Evaluation Tools
Concepts Understanding, attitude, feelings, insights, overall satisfaction Understanding, attitude, feelings, insights, overall satisfaction Attitude and influence on nursing practice
I
Fall 2010
83
70 (84.3)
Semi-structured Poverty Simulation Reaction questionnaire
II
Spring 2012
75
67 (89.3)
Semi-structured Poverty Simulation Reaction questionnaire
III
Spring 2013
75
62 (82.7)
Attitude toward Poverty Scale and Follow-up survey regarding influence on clinical practice
233
199 (85.4)
Total Number
K. Yang et al. / Nurse Education in Practice 14 (2014) 680e685
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Fig. 1. Understanding of Poverty (Cohorts 1 and 2: n ¼ 137).
understanding barriers to health care, change in attitudes and feelings toward poverty, and change in nursing practice. General understanding of people with a low SES Students reported the simulation was an eye-opening experience that increased their understanding of patients in their clinical settings who have incomes under the poverty level. “The poverty simulation was a great way to experience handson the struggle of even day to day tasks when faced with limited financial resources. Certain aspects that I hadn't considered such as transportation costs were made more real to me. Now when [at my clinical site] my patients don't show up for an appointment or have trouble getting there, I can understand much better.” “It helped make me a little more empathetic and open-minded towards the plight of people who live in poverty. It's easy to dismiss their needs and difficulties but I think awareness in the situations of others is the first step towards solving their problems.” “The poverty simulation influenced my clinical practicum because many of the people that I interacted with were below the poverty line. I was much more sympathetic to their plight, knowing that many of the circumstances that cause poverty are out of their control, and once you get below the poverty line, it is really hard to get above it!!” Understanding barriers to health care Students indicated they could more fully understand their clients' poverty-related health care concerns such as medication cost, transportation, difficulty in prioritizing self-care. Students also felt better prepared to interact with people with financial problems.
and why they weren't taking better care of themselves. After the simulation, it is easier to understand that when someone is financially struggling, priorities often shift towards basic survival and away from things such as health maintenance and healthier eating habits and practices.”
Change in feelings and attitudes Students reported that the simulation experience helped them become more empathetic and sympathetic to families living in poverty, to understand poverty better, and not to make judgments based on SES. “The simulation helped me to relate to and be more sensitive to these clients [in poverty].” “I was much more sympathetic towards these patients after the simulation” “Made me more accepting of people [and] not to judge others based on socioeconomic status [in order to] provide equal care” “It helped me be more compassionate [at my clinical site].” Change in nursing practice After the experience, the nursing students provided examples about how the poverty simulation influenced their clinical practice. They reported that they more frequently investigated possible resources, made referrals, and sought inter-professional collaborative practice to help underserved clients. “It made me more sympathetic to people when they talked about not being able to afford medications or certain treatments, so I went and talked to social work to see what they could do for them.” “I realized the importance of being familiar with local resources so that I would be able to quickly refer people.”
“It made me more aware of my patients' financial state and concerns with follow-up care and compliance. I had a patient who couldn't afford her BP medication and therefore it was uncontrolled and she ended up with a type B abdominal aortic aneurysm.”
“My experience in the poverty simulation … widened my understanding of the components involved in poverty. I frequently had to refer patients to social services to get assistance with transportation and payment.”
“The poverty simulation opened my eyes to the daily struggles of the impoverished in our area. Before the simulation, it was difficult to understand how patients could come into the hospital in such poor health conditions. I couldn't understand how
“Made me more aware of the resources available for those who are struggling to make ends meet; which then allowed me to provide information for the patients I came in contact with during community clinical.”
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Fig. 2. Pathway to culturally competent nursing practice.
Discussion Our study confirmed that poverty simulation could aid the development of culturally competent care in nursing students. As illustrated in Fig. 2, this study demonstrated that increased understanding of poverty and positive change in attitude toward poverty resulted in culturally competent nursing practice. As found with previous studies (Noone et al., 2012; Patterson and Hulton, 2012), students, after the simulation, had an increased understanding of financial pressure, difficult choices, challenges, emotional stresses, and social services system. Student attitude to poverty stigma also significantly changed. By better understanding the difficulties faced by people living in poverty, students reported interacting with their clients less judgmentally and more sympathetically. The simulation made them more inclined to find a solution for a client by investigating available local resources, making referrals, and seeking inter-professional collaborations in their clinical practicum. Based on these positive changes in clinical practice, the authors recommend that the poverty simulation activity takes place earlier in nursing curriculadideally at the nursing freshman or sophomore level, before clinical practicums begin. This will provide opportunities to increase awareness and cultivate culturally-sensitive practice throughout their undergraduate education. In addition, this study also illustrated that a poverty simulation would be an optimum teaching method to educate a group of students without previous poverty exposure or personal experience. The poverty simulation was an opportunity to augment student learning by exposing senior level traditional nursing students to barriers to health care and available community resources for the poor. The simulation fostered a greater understanding of health care barriers related to medication cost, transportation issues, and the low priority given to self-care among the poor due to competing life situations. In addition, our simulation activities provided unique interaction with local agencies in our own community. The students learned about existing local community agencies to which they can refer clients as needed for more assistance. In our review of the use of simulation in nursing education, we found articles reporting on studies done all over the world. However, we did not specifically find any on poverty simulation outside the USA. This type of simulation would be a great tool for international colleagues
when their health care system and community resources are appropriately reflected. The simulation was replicated each term using the Community Action Poverty Simulation and organized by the same faculty members (GRW, KY). We reported on three cohorts of our community health nursing class (Fall 2010, Spring 2012, and Spring 2013). We did not perform the simulation in 2011 because the community resources were not available that year. Each cohort may have had slightly different experiences as a result of interactions with fellow students (e.g., possible difference in “family” dynamics) and the community resource volunteers (e.g., available resources and their providers assigned to the simulation each term). In addition, role playing during the simulation is admittedly not likely to result in an exact replication of method or the experience of poverty; however, students participating in the simulation will achieve increased empathy regarding the range of possible experiences. Student safety in regards to potential emotional situations was ensured by explaining to students that while this is a simulation, it can evoke emotional reactions due to personal circumstances or experiences of poverty. However, there were no visible indications of emotional distress among the students during our simulation or debriefing. In order to ensure confidentiality and avoid any possible influence on the course grade, students' responses were not identifiable in any way; therefore, no demographic information on individual participants (i.e., the students) was matched with the evaluation of the simulation. However, a large sample size and high response rate made it possible to make conclusions about the simulation experiences and its educational effects on changing understanding, attitude, and clinical practice among nursing seniors. Conclusions Responding to the challenge of teaching complex health and social issues to nursing students, this simulation was found to help students examine their own knowledge, personal beliefs and values as they relate to poverty. The simulation provided students with a better understanding of the impact of poverty on health and offered opportunities to learn about various existing community resources
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for the low-income, underserved populations in our region. As a result of this simulation experience, students were inclined to provide information on available resources, collaborate with, and make referrals to community agencies or social services. The results of the study reveal positive impact of poverty simulation on undergraduate nursing practice to ensure culturally competent, needspecific care. Conflict of interest statement There is nothing to disclose. References Atherton, C.R., Gemmel, R.J., Haagenstad, S., Holt, D.J., Jensen, L.A., O'Hara, D.F., Rehner, T.A., 1993. Measuring attitudes toward poverty: a new scale. Soc. Work Res. Abstr. 29 (4), 28e30. http://dx.doi.org/10.1093/swra/29.4.28. Cardoza, M.P., Hood, P.A., 2012. Comparative study of baccalaureate nursing student self-efficacy before and after simulation. Comput. Inform. Nurs. Cin. 30 (3), 142e147. http://dx.doi.org/10.1097/NCN.0b013e3182388936. Centers for Disease Control and Prevention, 2012. Facts about Physical Activity. Retrieved April 4, 2013, from. http://www.cdc.gov/physicalactivity/data/facts. html. Dunnington, R.M., 2014. The nature of reality represented in high fidelity human patient simulation: philosophical perspectives and implications for nursing education. Nurs. Philos. 15 (1), 14e22. http://dx.doi.org/10.1111/nup.12034. Foronda, C., Gattamorta, K., Snowden, K., Bauman, E.B., 2014. Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: a pilot study. Nurse Educ. Today 34 (6), e53ee57. http://dx.doi.org/10.1016/ j.nedt.2013.10.007. Gillan, P.C., Jeong, S., van der Riet, P.J., 2014. End of life care simulation: a review of the literature. Nurse Educ. Today 34 (5), 766e774. http://dx.doi.org/10.1016/ j.nedt.2013.10.005. Greder, K., Warning, J., 2005. Involving marginalized families in shaping polices: roles for cooperative extension. In: Berke, D.L., Wisensale, S.K. (Eds.), The Craft of Teaching About Families. The Haworth Press, Inc., New York, pp. 79e97. Harder, B.N., 2010. Use of simulation in teaching and learning in health sciences: a systematic review. J. Nurs. Educ. 49 (1), 23e28. http://dx.doi.org/10.3928/ 01484834-20090828-08.
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Kirzinger, W.K., Cohen, R.A., Gindi, R.M., 2012. Health Care Access and Utilization Among Young Adults Aged 19-25: Early Release of Estimates from the National Health Interview Survey, January-september 2011. National Center for Health Statitics. Retrieved April 4, 2013, from. http://www.cdc.gov/nchs/data/nhis/ earlyrelease/Young_Adults_Health_Access_052012.pdf. Kowitlawakul, Y., Ignacio, J., Lahiri, M., Khoo, S.M., Zhou, W., Soon, D., 2014. Exploring new healthcare professionals' roles through interprofessional education. J. Interprofessional Care 28 (3), 267e269. http://dx.doi.org/10.3109/ 13561820.2013.872089. Missouri Association for Community Action. n.d. Community Action Poverty Simulation. Retrieved April 3, 2013, from. http://www.communityaction.org/ Poverty%20Simulation.aspx. Murdoch, N.L., Bottorff, J.L., McCullough, D., 2014. Simulation education approaches to enhance collaborative healthcare: a best practices review. Int. J. Nurs. Educ. Scholarsh. 10 (1), 307e321. http://dx.doi.org/10.1515/ijnes-2013-0027. National Center for Health Statistics, 2012. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. U.S. Government Printing Office, Washington, DC. Noone, J., Sideras, S., Gubrud-Howe, P., Voss, H., Mathews, L.R., 2012. Influence of a poverty simulation on nursing student attitudes toward poverty. J. Nurs. Educ. 51 (11), 617e622. http://dx.doi.org/10.3928/01484834-20120914-01. Ogden, C.L., Lamb, M.M., Carroll, M.D., Flegal, K.M., 2010. Obesity and Socioeconomic Status in Adults: United State, 2005e2008. National Center for Health Statistics, Hyattsville, MD. Patterson, N., Hulton, L.J., 2012. Enhancing nursing students' understanding of poverty through simulation. Public Health Nurs. 29 (2), 143e151. http:// dx.doi.org/10.1111/j.1525-1446.2011.00999.x. Reutter, L.I., Sword, W., Meagher-Stewart, D., Rideout, E., 2004. Nursing students' beliefs about poverty and health. J. Adv. Nurs. 48 (3), 299e309. http:// dx.doi.org/10.1111/j.1365-2648.2004.03199.x. Seligman, H.K., Laraia, B.A., Kushel, M.B., 2010. Food insecurity is associated with chronic disease among low-income NHANES participants. J. Nutr. 140 (2), 304e310. http://dx.doi.org/10.3945/jn.109.112573. Simones, J., 2008. Creating a home care simulation laboratory. J. Nurs. Educ. 47 (3), 131e133. Vandsburger, E., Duncan-Daston, R., Akerson, E., Dillon, T., 2010. The effects of poverty simulation, an experiential learning modality, on students' understanding of life in poverty. J. Teach. Soc. Work 30 (3), 300e316. http:// dx.doi.org/10.1080/08841233.2010.497129. Yun, S.H., Weaver, R.D., 2010. Development and validation of a short form of the attitude toward poverty scale. Adv. Soc. Work 11 (2), 174e187.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Relate better and judge less: Poverty simulation promoting culturally competent care in community health nursing Kyeongra Yang a, *, Gail Ratliff Woomer b, 1, Kafuli Agbemenu c, 2, Lynne Williams d a
Lienhard School of Nursing, College of Health Professions, Pace University, 861 Bedford Road, L306, Pleasantville, NY 10570, USA UMPC/Jefferson Regional Home Health, 1020 Lebanon Rd, W. Mifflin, PA 15122, USA c Department of Health and Community Systems, School of Nursing, University of Pittsburgh, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA d Southwest PA Area Health Education Center, 5614 Elgin St, Pittsburgh, PA 15206, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 September 2014
The study aim was to evaluate the effectiveness of a poverty simulation in increasing understanding of and attitudes toward poverty and resulting in changes in clinical practice among nursing seniors. A poverty simulation was conducted using a diverse group of nursing professors and staff from local community agencies assuming the role of community resource providers. Students were assigned roles as members of low-income families and were required to complete tasks during a simulated month. A debriefing was held after the simulation to explore students' experiences in a simulated poverty environment. Students' understanding of and attitude toward poverty pre- and post-simulation were examined. Changes in the students' clinical experiences following the simulation were summarized into identified categories and themes. The poverty simulation led to a greater empathy for the possible experiences of low income individuals and families, understanding of barriers to health care, change in attitudes towards poverty and to those living in poverty, and changes in the students' nursing practice. Use of poverty simulation is an effective means to teach nursing students about the experience of living in poverty. The simulation experience changed nursing students' clinical practice, with students providing community referrals and initiating inter-professional collaborations.
Keywords: Poverty simulation Community health nursing Cultural competency
© 2014 Elsevier Ltd. All rights reserved.
Introduction Nursing is a field built upon the value of compassion with deep empathy for the patients at its core. Empathy is based upon the ability to understand other's joys and sorrows and often derives from personal experience; it is one of the attributes that develop a sense of cultural competency. Simulation prepares nursing students for clinical experiences in a safe environment without fear of injuring real patients (Gillan et al., 2014). It has been used in settings ranging from acute or critical care nursing to end of life care, and helps in preparing healthcare providers for future interprofessional collaboration
* Corresponding author. Tel.: þ1 914 773 3242; fax: þ1 914 773 3357. E-mail addresses: [email protected] (K. Yang), [email protected] (G.R. Woomer), [email protected] (K. Agbemenu), [email protected] (L. Williams). 1 Tel.: þ1 412 653 8142. 2 Tel.: þ1 412 624 7838; fax: þ1 412 383 7293. http://dx.doi.org/10.1016/j.nepr.2014.09.001 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
(Gillan et al., 2014; Kowitlawakul et al., 2014; Murdoch et al., 2014). Simulation can take place in different forms, including case studies, role play, high-fidelity human patient simulation, or virtual simulation in an online environment. Depending on the form used, instruction can rely heavily on computer-driven models or be based on individual or group interaction (Dunnington, 2014; Foronda et al., 2014). In an age when increasing numbers of U.S. families live below the poverty level, nursing students must develop an understanding of the barriers and frustrations experienced by persons with vastly limited resources. According to the 2011 report on the health status of the nation (National Center for Health Statistics, 2012), the number of U.S. families living below the poverty level has continuously increased for all races (11.1% in 1973 to 14.3% in 2009) with a higher number in minority groups (e.g., 25.8% in Black or African Americans and 25.3% in Hispanic or Latino populations in 2009). This report also showed that 20.1% of children under age 18 were affected by poverty in 2009, compared with 14.2% in 1973. In addition, as a social determinant of health, poverty is significantly
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related to obesity among women (Ogden et al., 2010), sedentary lifestyles (Centers for Disease Control and Prevention, 2012), emergency room visits among young adults (Kirzinger et al., 2012), and an increase in cardiovascular risk factors (Seligman et al., 2010). While there are numerous learning modalities for the nursing student, simulation is recognized as a valid tool in preparing the undergraduate student. Simulation increases students' confidence in their clinical skills (Harder, 2010) and enhances student selfefficacy in providing family centered care (Cardoza and Hood, 2012). Simulation is becoming an essential part of health care education because it can provide opportunities for student clinical preparation and enhancing learning in a safe environment. Simulation can also offer the opportunity to learn about aspects of culture, such as poverty, that effect health outside of traditional clinical environments. Simulation activities can supplement clinical learning and also boost students' self-confidence prior to the actual experience (Simones, 2008). Existing evidence shows that a poverty simulation can help students in nursing better understand poverty (Noone et al., 2012; Patterson and Hulton, 2012) as well as students in other health science programs, such as social work (Vandsburger et al., 2010). Since exposure to poverty increases understanding of structural factors explaining poverty and health (Reutter et al., 2004), it is beneficial to implement a poverty simulation in educational settings with students who may not have had much exposure to poverty in their personal life. Currently poverty simulation is used by nursing programs to facilitate nursing students' understanding of the challenges faced by individuals and families living in poverty. However, there is little information on how this simulation has influenced clinical practice. Although the simulation described may be similar to other simulated studies reported in the literature, this study is pertinent at this time to expand the literature on how students learn about the problems faced by families and individuals living below the poverty level. The purpose of this study was to evaluate effectiveness of a poverty simulation in increasing understanding of and attitudes toward poverty and changes in clinical practice among baccalaureate nursing seniors. Methods Simulation We conducted a poverty simulation experience in the seniorlevel community health nursing course (three times for three different cohorts) using the Community Action Poverty Simulation, originally developed for the Missouri community (Missouri Association for Community Action, n.d.). The purposes of the simulation were to sensitize students to the day-to-day challenges faced by low-income families and to prepare students for their clinical practicum in the community where they interact, teach, and provide healthcare to individuals whose income is below the poverty level. In order ensure a more realistic experience we recruited a culturally diverse group of faculty, staff, and clinical preceptors from community agencies to assume various roles in the simulation as community resource providers. All had experience working with low-income individuals and families from different cultural groups and were sensitive to their needs and feelings. The students were assigned roles as members of fifteen low-income families (e.g., single parents, senior citizen, unemployed adults) and received a packet with simulated tasks to be completed during a simulated month (condensed into 15-min segments, each representing one week) while navigating a maze of community agencies that provide health and social services, financial support, and transportation to eligible individuals (e.g., social services,
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school, bank, grocery, pawn shop). Examples of their tasks included: finding employment, feeding the family, paying rent, ensuring children enrolled in daycare or school and paying utility bills. The simulation was conducted in a large conference room with tables for community agencies surrounding the assigned student groups. To provide a more relevant experience to our students, we invited local community agencies to be part of the simulation (e.g., Urban League of Greater Pittsburgh, Midwife Center for Birth & Women's Health, Mercy Parish Nurse and Health Ministry Program). Attempts were made to match community volunteers to their particular roles. For example, an employee of the energy assistance fund participated in the simulation as the “utilities” company employee. A week prior to the simulation, the students received background reading materials, such as the federal poverty level, national and local statistics of poverty, and its associated health outcomes. On the day of the simulation, students were again introduced to major concepts involved in the simulation and completed the pre-simulation survey. Consideration of student safety in regards to potential emotional reactions to the simulation was made. During the introduction to the simulation, the nursing students were informed that while this activity was a simulation, it did in fact mirror some of the realities that individuals in the group might have experienced themselves or known family or friends who experienced the situations. In that manner, the students were encouraged to be respectful of each other, to realize that this was not a “game” but a learning experience, and that they should consider the simulation as a stepping point for learning and understanding. During the simulation, faculty members were available to identify any student who was emotionally affected by the poverty simulation experience and to debrief with them afterward if necessary. At the conclusion of the two-hour simulation, students completed the post-simulation survey and participated in a debriefing session during which they had the opportunity to discuss their reactions to the simulated experience of living in poverty. The debriefing session was conducted by course faculty and some community agency personnel. The larger group of nursing students was divided into smaller groups in order to encourage discussion. During debriefing, small group leaders asked questions from a guide provided in the simulation packet. Examples of the questions included “What happened to families during the month in poverty?” “How did they improve their situation during the month?” “Discuss feelings experienced during month in poverty” “How did other people respond to your needs” and “Share insights or conclusions you have come to about the life experience of low-income families.” In addition, nursing professors, staff, and community leaders who took part in the simulation also sat in on the groups and contributed their insight and personal experiences during the students’ debriefing. Evaluation methods After the simulation, the following questionnaires were used to evaluate the simulation experience. A semi-structured Poverty Simulation Reaction questionnaire was used to evaluate understanding of poverty. This questionnaire consists of five Likert-Type items (1 ¼ no understanding, 2 ¼ little understanding, 3 ¼ moderate understanding, 4 ¼ quite a bit of understanding, and 5 ¼ almost complete understanding) and three open-ended questions. The five Likert-Type items evaluated understanding of the financial pressures, difficult choices faced by individuals with few resources, challenges in improving situation, emotional stresses, and impact of the social service system among individuals living in poverty (Greder and Warning, 2005). The three open-ended
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Results
questions asked about feelings and changed attitude during the simulation and insights about the life experience of low-income families. Finally, on a scale of 1e10 (10 is high), an overall rating of the simulation experience was requested. A 21-item of Attitude Toward Poverty Scale (Yun and Weaver, 2010) was used to examine students' attitude toward poverty. This scale uses five Likert-type categories (strongly agree, agree, neutral, disagree, and strongly disagree). The scale was originally developed by Atherton and his colleagues (1993) as a 37-item questionnaire. Later, Yun and Weaver (2010) developed a shorter form (21 items with three factors). The scale has established reliability and validity with undergraduate students. Higher scores indicate a more positive attitude toward poverty. A total global score (ranges from 21 to 105) and three subscale scores (7-item personal deficiency, 8-item stigma, and 6-item structural perspective) were calculated. Examples of personal deficiency items included being different from the rest of society, being dishonest, having a different set of values, and acting differently. The stigma subscale focuses on questions about fraud, living better, feelings of entitlement, being lazy, and welfare recipients consuming a major part of the federal budget. The structural perspective subscale includes one's willingness to support social programs and society's responsibility to help the poor. The experience ended with students completing a question on their plans to volunteer with services for the poor in the future. At six weeks after the simulation, a follow-up survey offered students an additional opportunity to share their experience as to how the simulation influenced their clinical experience during the term. Students' participation in the evaluations was completely voluntary. The completion of the questionnaires was entirely anonymous, to ensure students' responses were not identifiable in any way. Institutional Review Board approval was obtained. This project was part of an evaluation of educational strategies, curricula, or classroom management methods, so it was considered an exempt research.
The most frequently reported feelings about poverty were frustration, stress, worthlessness, anxiety, and helplessness. After the simulation (Cohort 3; n ¼ 62), students significantly changed their attitude toward poverty in a positive direction in general (mean ± SD: 72.6 ± 9.3 vs. 75.9 ± 8.8; p ¼ .001). Personal deficiency (mean ± SD: 27.8 ± 4.2 vs. 28.2 ± 3.4; p ¼ .364) and structural perspective (mean ± SD: 20.3 ± 2.7 vs. 20.9 ± 2.8; p ¼ .061) were not significantly changed, but feelings about stigma (mean ± SD: 24.9 ± 5.2 vs. 27.0 ± 4.8; p < .001) were significantly improved after the simulation.
Statistical analysis
Implication of simulation experience in the clinical practicum
Paired t-tests were conducted to compare understanding of poverty and attitude toward poverty between pre- and postsimulation. The level of significance was set at a ¼ .05. Open ended answers about feelings, attitudes, and insights about poverty as well as their clinical experience influenced by the simulation were summarized by identified categories and themes using content analysis.
Before the simulation, 66.1% of students (n ¼ 41) reported having plans to volunteer with services for the poor in the future, and after the simulation, the number of students increased to 48 (77.4%). Students shared how the poverty simulation experience influenced their clinical practicum in the hospital or community. Findings were summarized into four main themes: general understanding of people with a low socioeconomic status (SES),
Three cohorts of nursing senior students (N ¼ 233) participated in the simulation over three academic terms (i.e., Fall 2010, Spring 2012, and Spring 2013) and 199 students (85.4%) completed the questionnaires. Table 1 shows the project information. Students' overall rating of the simulation was above average (8.25 on a 1e10 scale with 10 being the highest overall rating). Understanding of poverty Survey findings revealed (Fig. 1) that student Cohorts 1 and 2 (n ¼ 137) significantly increased their understanding of the financial pressures (mean ± SD: 2.89 ± 0.84 vs. 4.15 ± 0.58), difficult choices faced by individuals with few resources (mean ± SD: 2.76 ± 0.91 vs. 4.15 ± 0.68), challenges in improving situation (mean ± SD: 2.75 ± 0.88 vs. 4.10 ± 0.66), emotional stresses (mean ± SD: 2.89 ± 0.99 vs. 4.24 ± 0.70), and impact of social service system (mean ± SD: 2.59 ± 0.83 vs. 3.99 ± 0.77; all ps < 0.001). Out of 62 students (Cohort 3), 71% (n ¼ 44) reported that the simulation helped them to better understand the lives of people living in poverty. Feeling and attitude toward poverty
Table 1 Summary of the project. Cohort
Academic term
Participation in the simulation n
Completion Of the evaluation n (%)
Evaluation Tools
Concepts Understanding, attitude, feelings, insights, overall satisfaction Understanding, attitude, feelings, insights, overall satisfaction Attitude and influence on nursing practice
I
Fall 2010
83
70 (84.3)
Semi-structured Poverty Simulation Reaction questionnaire
II
Spring 2012
75
67 (89.3)
Semi-structured Poverty Simulation Reaction questionnaire
III
Spring 2013
75
62 (82.7)
Attitude toward Poverty Scale and Follow-up survey regarding influence on clinical practice
233
199 (85.4)
Total Number
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Fig. 1. Understanding of Poverty (Cohorts 1 and 2: n ¼ 137).
understanding barriers to health care, change in attitudes and feelings toward poverty, and change in nursing practice. General understanding of people with a low SES Students reported the simulation was an eye-opening experience that increased their understanding of patients in their clinical settings who have incomes under the poverty level. “The poverty simulation was a great way to experience handson the struggle of even day to day tasks when faced with limited financial resources. Certain aspects that I hadn't considered such as transportation costs were made more real to me. Now when [at my clinical site] my patients don't show up for an appointment or have trouble getting there, I can understand much better.” “It helped make me a little more empathetic and open-minded towards the plight of people who live in poverty. It's easy to dismiss their needs and difficulties but I think awareness in the situations of others is the first step towards solving their problems.” “The poverty simulation influenced my clinical practicum because many of the people that I interacted with were below the poverty line. I was much more sympathetic to their plight, knowing that many of the circumstances that cause poverty are out of their control, and once you get below the poverty line, it is really hard to get above it!!” Understanding barriers to health care Students indicated they could more fully understand their clients' poverty-related health care concerns such as medication cost, transportation, difficulty in prioritizing self-care. Students also felt better prepared to interact with people with financial problems.
and why they weren't taking better care of themselves. After the simulation, it is easier to understand that when someone is financially struggling, priorities often shift towards basic survival and away from things such as health maintenance and healthier eating habits and practices.”
Change in feelings and attitudes Students reported that the simulation experience helped them become more empathetic and sympathetic to families living in poverty, to understand poverty better, and not to make judgments based on SES. “The simulation helped me to relate to and be more sensitive to these clients [in poverty].” “I was much more sympathetic towards these patients after the simulation” “Made me more accepting of people [and] not to judge others based on socioeconomic status [in order to] provide equal care” “It helped me be more compassionate [at my clinical site].” Change in nursing practice After the experience, the nursing students provided examples about how the poverty simulation influenced their clinical practice. They reported that they more frequently investigated possible resources, made referrals, and sought inter-professional collaborative practice to help underserved clients. “It made me more sympathetic to people when they talked about not being able to afford medications or certain treatments, so I went and talked to social work to see what they could do for them.” “I realized the importance of being familiar with local resources so that I would be able to quickly refer people.”
“It made me more aware of my patients' financial state and concerns with follow-up care and compliance. I had a patient who couldn't afford her BP medication and therefore it was uncontrolled and she ended up with a type B abdominal aortic aneurysm.”
“My experience in the poverty simulation … widened my understanding of the components involved in poverty. I frequently had to refer patients to social services to get assistance with transportation and payment.”
“The poverty simulation opened my eyes to the daily struggles of the impoverished in our area. Before the simulation, it was difficult to understand how patients could come into the hospital in such poor health conditions. I couldn't understand how
“Made me more aware of the resources available for those who are struggling to make ends meet; which then allowed me to provide information for the patients I came in contact with during community clinical.”
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Fig. 2. Pathway to culturally competent nursing practice.
Discussion Our study confirmed that poverty simulation could aid the development of culturally competent care in nursing students. As illustrated in Fig. 2, this study demonstrated that increased understanding of poverty and positive change in attitude toward poverty resulted in culturally competent nursing practice. As found with previous studies (Noone et al., 2012; Patterson and Hulton, 2012), students, after the simulation, had an increased understanding of financial pressure, difficult choices, challenges, emotional stresses, and social services system. Student attitude to poverty stigma also significantly changed. By better understanding the difficulties faced by people living in poverty, students reported interacting with their clients less judgmentally and more sympathetically. The simulation made them more inclined to find a solution for a client by investigating available local resources, making referrals, and seeking inter-professional collaborations in their clinical practicum. Based on these positive changes in clinical practice, the authors recommend that the poverty simulation activity takes place earlier in nursing curriculadideally at the nursing freshman or sophomore level, before clinical practicums begin. This will provide opportunities to increase awareness and cultivate culturally-sensitive practice throughout their undergraduate education. In addition, this study also illustrated that a poverty simulation would be an optimum teaching method to educate a group of students without previous poverty exposure or personal experience. The poverty simulation was an opportunity to augment student learning by exposing senior level traditional nursing students to barriers to health care and available community resources for the poor. The simulation fostered a greater understanding of health care barriers related to medication cost, transportation issues, and the low priority given to self-care among the poor due to competing life situations. In addition, our simulation activities provided unique interaction with local agencies in our own community. The students learned about existing local community agencies to which they can refer clients as needed for more assistance. In our review of the use of simulation in nursing education, we found articles reporting on studies done all over the world. However, we did not specifically find any on poverty simulation outside the USA. This type of simulation would be a great tool for international colleagues
when their health care system and community resources are appropriately reflected. The simulation was replicated each term using the Community Action Poverty Simulation and organized by the same faculty members (GRW, KY). We reported on three cohorts of our community health nursing class (Fall 2010, Spring 2012, and Spring 2013). We did not perform the simulation in 2011 because the community resources were not available that year. Each cohort may have had slightly different experiences as a result of interactions with fellow students (e.g., possible difference in “family” dynamics) and the community resource volunteers (e.g., available resources and their providers assigned to the simulation each term). In addition, role playing during the simulation is admittedly not likely to result in an exact replication of method or the experience of poverty; however, students participating in the simulation will achieve increased empathy regarding the range of possible experiences. Student safety in regards to potential emotional situations was ensured by explaining to students that while this is a simulation, it can evoke emotional reactions due to personal circumstances or experiences of poverty. However, there were no visible indications of emotional distress among the students during our simulation or debriefing. In order to ensure confidentiality and avoid any possible influence on the course grade, students' responses were not identifiable in any way; therefore, no demographic information on individual participants (i.e., the students) was matched with the evaluation of the simulation. However, a large sample size and high response rate made it possible to make conclusions about the simulation experiences and its educational effects on changing understanding, attitude, and clinical practice among nursing seniors. Conclusions Responding to the challenge of teaching complex health and social issues to nursing students, this simulation was found to help students examine their own knowledge, personal beliefs and values as they relate to poverty. The simulation provided students with a better understanding of the impact of poverty on health and offered opportunities to learn about various existing community resources
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for the low-income, underserved populations in our region. As a result of this simulation experience, students were inclined to provide information on available resources, collaborate with, and make referrals to community agencies or social services. The results of the study reveal positive impact of poverty simulation on undergraduate nursing practice to ensure culturally competent, needspecific care. Conflict of interest statement There is nothing to disclose. References Atherton, C.R., Gemmel, R.J., Haagenstad, S., Holt, D.J., Jensen, L.A., O'Hara, D.F., Rehner, T.A., 1993. Measuring attitudes toward poverty: a new scale. Soc. Work Res. Abstr. 29 (4), 28e30. http://dx.doi.org/10.1093/swra/29.4.28. Cardoza, M.P., Hood, P.A., 2012. Comparative study of baccalaureate nursing student self-efficacy before and after simulation. Comput. Inform. Nurs. Cin. 30 (3), 142e147. http://dx.doi.org/10.1097/NCN.0b013e3182388936. Centers for Disease Control and Prevention, 2012. Facts about Physical Activity. Retrieved April 4, 2013, from. http://www.cdc.gov/physicalactivity/data/facts. html. Dunnington, R.M., 2014. The nature of reality represented in high fidelity human patient simulation: philosophical perspectives and implications for nursing education. Nurs. Philos. 15 (1), 14e22. http://dx.doi.org/10.1111/nup.12034. Foronda, C., Gattamorta, K., Snowden, K., Bauman, E.B., 2014. Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: a pilot study. Nurse Educ. Today 34 (6), e53ee57. http://dx.doi.org/10.1016/ j.nedt.2013.10.007. Gillan, P.C., Jeong, S., van der Riet, P.J., 2014. End of life care simulation: a review of the literature. Nurse Educ. Today 34 (5), 766e774. http://dx.doi.org/10.1016/ j.nedt.2013.10.005. Greder, K., Warning, J., 2005. Involving marginalized families in shaping polices: roles for cooperative extension. In: Berke, D.L., Wisensale, S.K. (Eds.), The Craft of Teaching About Families. The Haworth Press, Inc., New York, pp. 79e97. Harder, B.N., 2010. Use of simulation in teaching and learning in health sciences: a systematic review. J. Nurs. Educ. 49 (1), 23e28. http://dx.doi.org/10.3928/ 01484834-20090828-08.
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