Poverty Simulation: Implications on Nursing Curriculum

APHA session 4167 Tuesday 11/3/2015

• Dr. Lori Pierangeli, PhD, RN, FCNAssociate Professor, Department of Nursing, lpierangeli@esu.edu

• Dr. John Kraybill-Greggo PhD, LSW, ACSWAssociate Professor, Department of Sociology, Social Work and Criminal Justice: Chairperson and Graduate Program Director, jkgreggo@esu.edu

• Dr. Chin Hu PhDAssociate Professor, Department of Sociology, Social Work and Criminal Justice, chu@esu.edu

Disclosures

• We have no off-label or experimental uses of a commercial product or service discussed in this presentation

• We acknowledge no financial, professional or personal conflict of interest.

Learner Objectives

Describe the impact of a poverty simulation on undergraduate nursing students’ attitudes toward those in poverty; evolving professional identity & professional practice; development of empathy and sensitivity for

vulnerable populations. List additional strategies and experiential techniques in

nursing education to enhance the competence of nursing students in working with those in poverty.

Background

•Nurses and other public health professionals are continuing to provide services to tens of Millions of Americans living in poverty, experiencing low food security and lacking health insurance.

•It is essential for helping professionals to gain some qualitative understanding of the day-to-day experiences of the poor in the U.S. in a manner that increases their awareness rather than to have professional practice guided by anecdotal observations or misconceptions fostered by prevailing political and societal attitudes or beliefs.

Background

•Several nursing education groups have stressed the importance of preparing nursing students to work with a variety of patient populations including vulnerable populations – American Association of Colleges of Nursing,

(AACN), 2008; – NLN, 2005), – Quad Council of Public Health Nursing

Organizations

The Poverty Simulation• Widely used throughout the United States • Designed to help participants begin to understand what it might be like

to live in a typical low-income family, surviving month to month. • Participants assume the roles of up to 26 different families facing

poverty during the course of four 15 minute weeks . – newly unemployed, – recently deserted by the “breadwinner” of the family, – homeless and others are recipients of government assistance

programs such as Temporary Assistance to Needy Families (TANF). – senior citizens on retirement or disability, grandparents raising

grandchildren, and single person households. • Family tasks during simulation:

– provide for basic necessities and shelter • (Missouri’s Community Action Poverty Simulation, 2011).

Literature (see handouts)

• A growing number of studies investigating the attitudes of nursing students toward poverty and the poor are highlighted in the literature and dissertations.

• Many studies have used the Atherton scale, “Attitudes Toward the Poor”

• All studies reported that poverty simulation is an effective tool– for impacting student perceptions about living in poverty, and – has moved students toward more positive attitudes of those in

poverty, and the structure and stigma surrounding poverty.

LiteratureThe Missouri Community Action Poverty Simulation

• Yang, K., Woomer, G., Agbemenu, K., & Williams, L. (2014). • The poverty simulation led to a

• greater empathy for possible experiences of the poor, • greater understanding of barriers to health care

• medication costs, transportation & financial issues, & low priority to self care;

• changed their practice • sought out & provided community referrals; initiated inter-professional

collaborations.

• Sword, W., Reutter, L., Meagher-Stewart, D., and Rideout, E. (2004).

• The greater the personal contact with poverty the better the attitude toward the poor, and enhanced understanding of the issue.

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Literature

• Patterson, & Hulton, (2012). – Pre-sim readings were assigned– scores on the stigma factor of poverty demonstrated statistically

significant changes• Live better than I do; Welfare makes people lazy. (disagree)

– poverty simulations are an effective teaching strategy for experiencing reality of poverty, realizing need for more resources & services, & changing attitudes toward poverty.

• DeLashmutt, & Rankin, (2005). – Attitudes moved toward more positive attitudes on post-test on the

factors of personal deficiency and stigma with the only significant change in stigma attitudes. Specifically

• they would pay higher taxes to support programs for the poor and • society has a responsibility to support the poor.

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Literature• Menzel, Clark & Darby-Carlberg, (2009).

– Evaluated the effect of the poverty simulation on senior UG BS level nursing students’ attitudes and judgments related to the poor.

– Atherton scale, Short form.– Post simulation: Students reported

• amazement at the barriers they faced (as participants) meeting their simulated families’ basic needs due to unavailable resources.

• the exercise shifted their attitudes on the causes of poverty and the many difficulties the poor face in maintaining food and shelter, even when they have employment.

– Conclusion: A poverty simulation is an effective means to • “widen student perspectives on the complex ecology of poverty, and • changes attitudes about those it ensnares, an overlooked and often

demonized subculture” – (Menzel, Personal Communication, August 18, 2011).

Methodology• Dual-design approach utilizing pretest/posttest and follow-

up focus groups. • IRB granted; Anonymous & voluntary research surveys but

not for the poverty simulation itself• Participants completed the short form of the Attitudes

toward Poverty (ATP) Scale immediately pre- and post poverty simulation, and 3 months post simulation prior to the focus groups.

• Focus groups:– random selection for follow-up focus groups– three months post sim – two focus groups, one each of seniors and juniors.

Scale

• A 21-item multidimensional short form of the Attitudes Toward Poverty (ATP) scale (Yun and Weaver,

2010). – widely used;– statements that reflect attitudes expressed by some in

U.S. society toward poverty and the poor;– identifies three factors (or subscales): personal

deficiency, stigma and structural perspective; – five point Likert, 1=strongly agree to 5=strongly

disagree.”

Research Questions Reported in this Presentation

1. *What are the attitudes of baccalaureate nursing students toward poverty and the poor? (Attitude scale)

2. *What experiences do students identify as having the greatest influence on their attitudes toward poverty? (Demographic profile)

3. *What is the effect of a poverty simulation on nursing attitudes toward people in poverty? (Attitude scale)

4. *What influence does participating in the poverty simulation have on nursing students’ evolving professional identity and professional practice? (Focus groups)

Focus Groups

• The focus group questions centered on the influence participating in the poverty simulation had on nursing students’ – attitudes, – evolving professional identity, and – professional practice.

• Two focus groups– juniors– seniors

Focus Group Questions1. In what ways, if at all, did participating in the poverty simulation influence your view of poverty and poor people in the US? If not, how did participating reinforce your views?

2. What, if anything, did you do with any new awareness about the poor?

3. What influences, if any, did participating in the poverty simulation have on your sense of identity as an evolving nursing professional?

4. What influences, if any, did participating in the poverty simulation have on your beginning practice as an evolving nursing professional?

5. What else, if anything, stands out for you as you think about the experience of participating in the poverty simulation?

Additional Questions (Randall, 2008)

• Which location for clinical experience has had the greatest influence on your attitude toward poverty? (Check one)

__ Small Hospital __ Large Hospital __ Community __Not applicable• I have contact with the poor.

__More than once a week __Once a week __Less than once a week __Less than once a month

• Which experience(s) have influenced your attitude toward poverty? (Please check all that apply).__nursing theory courses _clinical nursing courses __academic courses other than nursing (such as sociology or electives) __volunteer work, including mission trips. __service learning organized through your college or university _employment

• Which experience has had the greatest influence on your attitude toward poverty?__nursing theory courses _clinical nursing courses _employment __academic courses other than nursing (such as sociology or electives) __volunteer work, including mission trips __service learning organized through your college or university

• What other experiences have influenced what you think about poverty?

Participants• Junior and Senior nursing students

– including RN to BSN students; – both male and female; – all 18 years of age or older. – N = 51 with no missing data, male/female

• Initially included a control group, – freshman and sophomore nursing students,

• However, the group was not similar to the experimental group therefore not included in this presentation.

Findings

Quantitative and Qualitative

AnalysisWilcoxon paired signed-rank test

• Wilcoxon paired signed-rank test – to determine the impact of Poverty Simulation on nursing students. – Non-parametric version of a paired sample t-test, – an appropriate test for ordinal level variables and where there is no

assumption of normality in the difference between pre- and post scores.

• Perceptions of poverty, 5-point Likert scale variables– Ranges: “1=strongly agree”, “2=agree”, “3=neutral”, “4=disagree”,

“5=strongly disagree.” • Lower value (1 and 2) indicates more critical view of the poor

and • higher number (4 and 5) indicates more understanding view of

the poor.

ParticipantsDEMOGRAPHIC CHARACTERISTICS

Sample characteristics N %Class standing: Junior 30 58.8

Senior 21 41.2Gender: Male 10 19.6

Female 41 80.4Financial situation: Secure 44 86.3

Insecure 7 13.7Residence: Urban 2 3.9

Suburban 33 64.7Rural 16 31.4

Analysis: Demonstrates significant difference between pre- and post- scores among 10 items -1

Three areas indicate student perception changed for “more understanding”(less critical) of the poor:

• Welfare makes people lazy è Become more understanding that poor are poor not because they are lazy. p<.01

• People are poor due to circumstances beyond their control è Become more understanding that there are factors beyond individual control (“circumstances”) that explain why poor become poor. p<.05

• If I were poor I would accept welfare benefits è Become more understanding that welfare benefits are deemed acceptable. p<.01

Analysis: More Critical -2

Seven areas that indicate where student’s perception became “more critical” of the poor:

• Poor people are dishonest è Learned the manner in which the poor utilize resources (must “cheat” to work around the system for example.) (Unsure if this is a moral judgment) p<.01

Analysis: More Critical -3

• Poor people are different from the rest of society. p< .01

• Poor people act differently. p<.01

• I believe poor people have a different set of values from other people. p<.05

Analysis: More Critical -4

· Children raised on welfare will never amount to anything. è Become critical to and concerned with the ways children are affected in a poor family environment. p<.01  

• Students in general disagree with the statement; their perceptions have changed from stronger disagreement to “less” disagreement or more neutral;

• In other words, nursing students felt that children’s

futures might be negatively affected given the environment they were raised in.

Analysis: More Critical -5

· Poor people think they deserve to be supported è Become critical to the lack of personal responsibility of the poor? (Simulation emphasis is on how to reach out to resources). p<.01

· Society has the responsibility to help poor people è Become critical to the lack of personal responsibility of the poor. p<.05

Analysis -6 • Items associated with personal traits (poor people are

dirty or have lower intelligence) are not significant. – Meaning that students did not develop stereotypes

of the poor through this exercise.• After the simulation exercise students came to

understand that people who receive welfare are not lazy and their poverty is often times a result of their circumstances.

Discussion

• Possible reasons for only a few transformations in the attitudes of the students as reported in the findings may be – many stereotypes of the poor are engraved in us

through a lifetime of exposure (environment, culture, family values system we were raised in), & hard to change

– a one hour poverty simulation (plus debriefing) and some related class content may not be enough to impact many attitudes significantly.

* What experiences do students identify as having had the greatest influence on their attitudes toward

poverty? Curriculum and Other- Pre-sim

Frequency Valid % Cumulative %

Nursing Theory 4 7.8 7.8

Clinical Course 10 19.6 27.5

Gen Ed course 6 11.8 39.2

Volunteer Work 17 33.3 72.5

Service Learning 1 2.0 74.5

Employment 8 15.7 90.2

Multiple Responses 5 9.8 ---

Total 51 100.0 100.0

Participant Experiences with Poverty

Parameter Frequency Valid %Had friends assisted (WIC, school lunch, food stamps, subsidized housing)

31/51 Yes = 60.8

Had family assisted (see above)

14/51 Yes = 27.5

They themselves lived in poverty

9/51 (if combined with family then 23/51

Yes = 17.6 If combined with family then 45.1%

Know someone on Medical Assistance

23/51 45.1

Worked with individuals in poverty

17/51 33.3

Received or knows someone utilizing CHIP

15/51 29.4

Lived in economically deprived neighborhood

7/51 13.7

Focus Group Responses

Impact on view of poverty and the poor, What they did with any new awareness,

Impact on evolving professional identity as a nurse, Impact on beginning nursing professional practice.

Themes Emerging Across the Two Focus Groups

Question #1

In what ways, if at all, did participating in the poverty simulation influence your view of poverty and poor people in the US? If not, how did participating reinforce your views?– Response themes were:

• eye opening; • challenged stereotypes; • growing empathy and awareness of frustration and other

emotions; • aware that there is help available, but it is hard to access.

Question # 2 “What, if anything, did you do with any new

awareness about the poor?”

• Response themes were: – Important to understand each person’s individual experience;– need to be prepared (to respond and intervene effectively as

a nursing professional to the impact poverty has on health status).

Question #3“What influences, if any, did participating in the poverty simulation have on your sense of identity as an evolving nursing professional?”• Response themes were:

– Importance of being non-judgmental as a professional nurse,

– importance of being a patient advocate,– importance of collaborating with other professionals to

assist patients in accessing resources.

Question #4“What influences, if any, did participating in the poverty simulation have on your beginning practice as an evolving nursing professional?” •Response Themes were:

– to identify and challenge one’s assumptions and biases; – to assess the needs of the poor and uninsured patients not only to

provide cost efficient care but to connect them with other resources to address needs;

– To influence health and social policy. – allowed us to understand community health (other systems of care)– it sensitized us to the possible concerns of our patients…”where do

they grocery shop…do they shop for food…”

Question #5

• “What else, if anything, stands out for you as you think about the experience of participating in the poverty simulation?”

• Response themes were: – very valuable experience, – importance of resources to address the needs of the

poor, – eye opening perspective-giving. – realized that I “can’t generalize…need to individualize”

each persons experience with poverty

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Individual Student Feedback

• From an RN-BSN student: – “Thanks for your effort getting all of us to this

simulation. I grew up one of twelve kids in real poverty where crab apples knocked off a tree, sustained us on many days. I have my thoughts on "the system". I think this simulation was excellent for young nursing students to play out and I bet it had a lasting impact”.

Limitations

• Size of the sample• Director (of the simulation) bias• Missing data

– Some students failed to record assigned survey number for post test

• Unable to match some post-tests therefore not used

Curriculum Implications

• Implement the poverty simulation (and survey) early in the nursing curriculum in order to – get to know the attitudes of the students – have time to address attitudinal changes due to the simulation (- or +)

before clinical experiences begin in order to increase awareness of the difficulties the poor face on a daily basis and possibly cultivate culturally competent care when working with this vulnerable population

• Address negative attitudes throughout the curriculum– Post conferences and focus groups– Maternal child health course with single mothers– Discuss structural impacts on poverty– Discuss any exposure to HCP with negative attitudes toward the poor

Curriculum Implications• Based on student ranks of greatest influence of attitudes toward poverty

(volunteer work, employment, clinical courses), develop, recommend, or assign service learning/clinical opportunities with the vulnerable. – crisis center clinical experiences,– interdisciplinary activities with the poor

• Consider requiring/suggesting elective courses related to poverty

• Develop and thread clinical experiences throughout the curriculum to expose students to vulnerable populations, and over more time, to reinforce the realities of lives lived in poverty.

• Consider developing additional role packets for the simulation that may be missing from the kit but that represent concerns specific to your local community with regard to the poor. – agencies - services - resources– IE HCP who does not accept Medical Assistance, a slum landlord, etc.

Curriculum Implications

• Practice competencies can be further addressed before or after a poverty simulation through – community assessments, – community agency reports, – policy assessment or evaluation assignments,– advocacy assignments, – family care plans, – community teaching projects and – service-learning opportunities

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Curriculum Implications based on Student General Feedback (in brief)

Consider developing the simulation with interdisciplinary students (health sciences, sociology, business, education majors, etc.).

“Recommend doing this for other students…[it] puts poverty in perspective”

Any student in “professional programs” would benefit from this.”

Future suggestions—“coordinate that it’s not the day before a major exam”

Feedback with facilitated debriefing—”one student who argued… negative attitudes continued”…”wish we had more time to discuss and debate her”

“More time needed/desired” for final debriefing

Curriculum Implications

• Based on the findings, the poverty simulation process and experience can provide to students and the curriculum the ability to address some of the core competencies of professional nursing organizations (Quad Council, AACN, and NLN) in areas of:– Communication, – Dimensions of Practice Skills, – Cultural Diversity & – Leadership and Systems Thinking Skills

• See handout

Quad Council

• Communicates– with cultural sensitivity” (p.5)– effectively with individuals, families, groups, & as a member of

inter-professional teams” (p.5). • Dimensions of Practice Skills

– Utilize an ecological perspective– Partners effectively with key stakeholders and groups in care

delivery– Identifies opportunities for advocacy for interventions, – Utilizes community assets & resources to promote health &

deliver care– Describes the role of government, & private & non-profit

sectors in the delivery of community health services

Quad Domain

• Leadership & Systems Thinking Skills– Uses individual, team and organizational learning opportunities for development as a

PHN – Adapts PHN care delivery in consideration of changes in the PH systems, & larger

social, political and public health environments

• Cultural Diversity– Utilizes social determinants of health to work effectively with diverse individuals

families and groups. – Adapts public health nursing care …based on cultural needs and differences.– Explains factors contributing to cultural diversity– Demonstrates culturally appropriate PHN practice with individuals, families, peers, &

community members. • (Verbalized in focus group comments).

•

AACN and NLN - See Handout• AACN (2008) Need to educate nurses who are

– sensitive to a diverse population which includes race, ethnicity, culture… socioeconomic status & health disparities;

– advocate for social justice & commitment to health of vulnerable populations & elimination of health disparities;

– understand complex relationships of determinants of health • Baccalaureate programs prepare grads to

– reflect on values and beliefs r/t professional practice, &– recognize impact of attitudes, values & expectations on care.

• NLN: Nurse educator prepares grads – for practice that reflects current trends & community & societal

needs

Conclusions• Study results affirmed that the poverty simulation :

– positively impacts some attitudes toward the poor;– can have lasting effects on students attitudes (Focus group 3 months later)– makes a positive difference in a nursing students’ evolving professional identity and

professional practice.

• This activity can serve to identify negative attitudes that can be addressed sooner in the curriculum through other clinical experiences and assignments. – Perhaps students experience clinical environments that model negative

attitudes toward the poor?

• The poverty sim (Experiential techniques) can effectively be employed to further advance progress toward achieving some of the competencies outlined by the AACN, the NLN, and the Quad Council of Public Health Nursing Organizations.

• Student comments support the use of the simulation

Questions ?

Thank you! You have been a great audience!

Reference and competency handouts available by contacting Dr. Pierangeli