Journal of Nursing Education

Major Article 

Influence of a Poverty Simulation on Nursing Student Attitudes Toward Poverty

Joanne Noone, PhD, RN, CNE; Stephanie Sideras, PhD, RN; Paula Gubrud-Howe, EdD, RN, FAAN; Heather Voss, MSN, RN; Launa Rae Mathews, MS, RN, COHN-S

Abstract

This study aimed to determine a poverty simulation’s influence on nursing students’ attitudes toward poverty. Five cohorts of baccalaureate nursing students participated in the study; two cohorts (experimental group, n = 103) participated in the simulation and three did not (control group, n = 75). The Attitudes Towards Poverty Short Form was administered before the simulation and 6 weeks later; higher scores indicated more positive attitudes toward poverty. Experimental group pretest scores were higher. Higher pretest global scores were negatively correlated with religious affiliation (Spearman’s rho = −0.294, p = 0.000) and positively correlated with prior poverty exposure (Spearman’s rho = 0.284, p = 0.000) and liberal political views (Spearman’s rho = 0.444, p = 0.000). Controlling for pretest differences, posttest mean scores for the experimental group (78.73) were significantly higher (p = 0.007). The poverty simulation is an engaging learning experience providing an opportunity for students to gain sensitivity in working with this population.

Dr. Noone is Associate Professor, Dr. Sideras is Assistant Professor, and Ms. Voss is Clinical Assistant Professor, Oregon Health and Science University School of Nursing, Ashland; Dr. Gubrud-Howe is Associate Professor, and Ms. Mathews is Clinical Assistant Professor, Oregon Health and Science University School of Nursing, Portland, Oregon.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Joanne Noone, PhD, RN, CNE, Associate Professor, Oregon Health and Science University School of Nursing, 1250 Siskiyou Boulevard, Ashland, OR 97520; e-mail: noonej@ohsu.edu.

Received: September 18, 2011
Accepted: May 30, 2012
Posted Online: September 14, 2012

Abstract

This study aimed to determine a poverty simulation’s influence on nursing students’ attitudes toward poverty. Five cohorts of baccalaureate nursing students participated in the study; two cohorts (experimental group, n = 103) participated in the simulation and three did not (control group, n = 75). The Attitudes Towards Poverty Short Form was administered before the simulation and 6 weeks later; higher scores indicated more positive attitudes toward poverty. Experimental group pretest scores were higher. Higher pretest global scores were negatively correlated with religious affiliation (Spearman’s rho = −0.294, p = 0.000) and positively correlated with prior poverty exposure (Spearman’s rho = 0.284, p = 0.000) and liberal political views (Spearman’s rho = 0.444, p = 0.000). Controlling for pretest differences, posttest mean scores for the experimental group (78.73) were significantly higher (p = 0.007). The poverty simulation is an engaging learning experience providing an opportunity for students to gain sensitivity in working with this population.

Dr. Noone is Associate Professor, Dr. Sideras is Assistant Professor, and Ms. Voss is Clinical Assistant Professor, Oregon Health and Science University School of Nursing, Ashland; Dr. Gubrud-Howe is Associate Professor, and Ms. Mathews is Clinical Assistant Professor, Oregon Health and Science University School of Nursing, Portland, Oregon.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Joanne Noone, PhD, RN, CNE, Associate Professor, Oregon Health and Science University School of Nursing, 1250 Siskiyou Boulevard, Ashland, OR 97520; e-mail: noonej@ohsu.edu.

Received: September 18, 2011
Accepted: May 30, 2012
Posted Online: September 14, 2012

Poverty affects 46.2 million people in the United States (DeNavas-Walt, Proctor, & Smith, 2011). The 2009 and 2010 U.S. Census data show that poverty rates have increased in the United States from 13.3% in 2008 to 15.1% in 2010 (Bishaw & Macartney, 2010; DeNavas-Walt et al., 2011). Between 2008 and 2010, the poverty rate for children younger than 18 years increased from 19% to 22% and for people between the ages of 18 to 64 years from 11.7% to 13.6% (DeNavas-Walt et al., 2011; U.S. Census Bureau, 2010). Poverty has been shown to be a major social determinant of health. According to Beckles and Truman (2011):

The socioeconomic circumstances of persons and the places where they live and work strongly influence their health. In the United States, as elsewhere, the risk for mortality, morbidity, unhealthy behaviors, reduced access to health care, and poor quality of care increases with decreasing socioeconomic circumstances. (p.13)

Understanding barriers to health and health care among people living with poverty is integral to equitable, patient-centered health care.

The Institute of Medicine (IOM; 2003) identified patient-centered care as one of five core proficiency areas. In the Future of Nursing report (IOM, 2010), the IOM committee called for nursing education reform to align learning that prepares graduates to meet the needs of the patients for whom they care. To deliver patient-centered care to those living with poverty, nurses must have an understanding of poverty and, more importantly, the influence of poverty on health-related decisions. Both the American Association of Colleges of Nursing (2008) and the National League for Nursing (2010) include social justice in discussions of core competencies for undergraduate nurses, including reflection of personal biases and attitudes that may interfere with person-centered care. The AACN Essentials of Baccalaureate Education for Professional Nursing Practice (2008) also affirms that preparation of the undergraduate nurse should include an advocacy role to reduce health disparities for vulnerable populations. Negative attitudes toward the poor may interfere with the provision of patient-centered care, equal treatment of all patients, and advocacy for social justice. It is important to understand how learning activities in a prelicensure nursing curriculum contribute to students’ understanding of issues related to poverty. The purpose of this quasi-experimental study was to determine the influence of a poverty simulation on undergraduate nursing students’ attitudes toward poverty and their understanding of the link between poverty and health.

Literature Review

Attitudes toward the poor can generally be grouped into a structural perspective versus an attitude that being poor is a result of individual failure or personal deficiency (Sun, 2001). In a structural perspective, beliefs about why people are poor are related to the structural barriers imposed by society rather than due to individual traits or failures (Sun, 2001; Wear & Kuczewski, 2008). In contrast, beliefs that poverty is related to individual factors, such as laziness or other personal character deficits, may contribute to stereotyping of patients and lack of individual care. Reutter, Sword, Meagher-Stewart, and Rideout (2004) conducted a cross-sectional survey of 740 baccalaureate nursing students in Canada to ascertain their beliefs about poverty and health. The researchers examined beliefs regarding four possible mechanisms linking poverty and health: that (a) the link is a myth, with the relationship being one of bias in measurement, (b) the link is a result of drift, with poor health occurring first and then resulting in a drift into poverty, (c) the link is a result of a personal deficiency, with those in poverty being more likely to make unwise health choices, and (d) the link is structural, meaning that the living conditions associated with poverty contribute to poor health. The study by Reutter et al. (2004) found that greater curricular exposure to poverty issues and a positive attitude toward those in poverty predicted a structural explanation for poverty. Recommendations included more emphasis on the issues of poverty within the nursing curriculum, particularly on experiential learning activities “that will lead to more positive perceptions of those living in poverty” (Reutter et al., 2004, p. 307).

The goal of learning activities related to poverty in health education is to promote a movement toward the structural perspective (considered a more positive attitude toward the poor) and away from negative stereotyping. Clinical learning activities described in the nursing literature promote such an understanding. These learning activities usually involve clinical placements or service-learning activities with people in poverty (DeLashmutt, 2007; Hunt, 2007).

Given the growing concern of limited clinical placements for nursing students, opportunities to implement learning activities using simulation were explored. In 2008, Menzel, Clark, and Darby-Carlberg (2010) implemented a poverty simulation, similar to the one described in this study, in a baccalaureate curriculum and studied its influence on 48 nursing students’ attitudes toward poverty. A 43-item Attitudes Toward Poverty questionnaire was administered before and after the simulation. Improvement in attitudes toward the poor was demonstrated, with significant improvement in 14 items. However, in that one-group study, it is unknown whether these attitude scores were related to the poverty simulation, participation in the course, or both.

The purpose of the current quasi-experimental study was to determine the influence of a poverty simulation on undergraduate nursing students’ attitudes toward poverty and their understanding of the link between poverty and health. The research questions for this study were:

  • What are student characteristics associated with attitudes toward the poor?
  • How does participation in a poverty simulation influence students’ attitudes toward the poor?
  • How does participation in a poverty simulation influence students’ understanding of the link between poverty and health?

The Simulation

A 3-hour poverty simulation was developed by the Missouri Association for Community Action (n.d.) to educate and sensitize participants to the realities of living with poverty. The simulation requires a large classroom or gymnasium that can accommodate 40 to 80 participants. Participants are assigned to one of 26 families at or near the poverty level; families can range from an elderly person living alone to a multigenerational family, including children, of five to six people. The goal during the simulation is for the family to live for 1 month and obtain food and shelter and pay the bills (one 15-minute period during the simulation constitutes 1 week). Participants interact with community agencies, including school and work, that surround the perimeter of the room, where participants simulate going to work and school, buying food, paying bills, and obtaining resources. Fifteen to 20 volunteers are needed to role-play staff at the community agencies. Debriefing occurs at the end of the simulation.

Faculty developed the following objectives for the simulation: participation in this simulation will provide the opportunity to immerse in the lived experience of poverty as an individual and as part of a family to (a) develop an expanded understanding of the effects of poverty on health and (b) develop a deeper understanding of the structural barriers faced by people living in poverty. Implementation of this poverty simulation requires scheduling and training volunteers to help staff each of the community agencies, in addition to setting up the physical space. Due to the labor-intensive nature of this simulation, faculty had an interest in determining whether this learning experience achieved the desired objectives.

Method

Setting and Participants

This study occurred in a public university at a school of nursing with five campuses spread across the state. All undergraduate nursing students are enrolled in a common curriculum taught by different faculty on the specific campus. Five cohorts of undergraduate nursing students (N = 178) at each of the campuses in the junior-level Populations Based Care course were the participants of this study. Institutional review board approval for this study was received prior to data collection. Two of the cohorts experienced the Poverty Simulation learning activity in addition to the standard curriculum of the course (experimental group, n = 103), and three cohorts received only the standard curriculum (control group, n = 75). Students were asked to complete a 21-item Attitudes Towards Poverty Short Form (ATP-SF) questionnaire at the beginning and end of the term. Demographic information was obtained, as well as students’ beliefs about the link between poverty and health. The simulation took place for the experimental group at the beginning of the term after the pretests were administered and 6 to 7 weeks prior to the posttest assessment.

Two hundred nine students were enrolled in the course over the five campuses; 84 students did not experience the poverty simulation and 125 did. One hundred seventy-eight matched pretests and posttests were returned, for a response rate of 85%. Seventy-five matched responses were returned from the control group from a possible 84, for a return rate of 89% for the control group, and 103 of a possible 125 for the experimental group, for a response rate of 82%.

Instrument

To evaluate research question 1, standard demographic information was collected. In addition, financial stability and exposure to poverty were also assessed. Financial stability was self-reported on a scale from 1 (very secure) to 6 (very insecure). For poverty exposure, students were asked if they ever received social assistance, lived in an economically deprived neighborhood, or had friends or family who were economically deprived. Possible scores were 0 to 3 based on the number of exposures to poverty they reported. Demographic factors that have been associated with attitudes toward poverty in prior research studies include political identification and exposure to poverty (Cozzarelli, Wilkinson, & Tagler, 2001; Wilson, 1996; Yun & Weaver, 2010).

To evaluate research question 2, the ATP-SF was administered to students. The original Attitudes Towards Poverty (ATP) scale is a 37-item scale with a Cronbach’s alpha of 0.93 (Atherton & Gemmel, 1993). A factor analysis did not reveal any subscales. Yun and Weaver (2010) demonstrated good psychometric properties of a 21-item ATP-SF of the scale, with a Cronbach’s alpha of 0.87. The ATP-SF questionnaire is a 5-point Likert scale, with each item scored on a scale from 1 to 5 (six items reverse scored), with higher numbers indicating more positive attitudes toward poverty. A potential global score ranging from 21 to 105 can be obtained by summing the item scores.

To evaluate research question 3, differences in the groups about their beliefs and the link between poverty and health were examined. Students were asked on the pretest and posttest to choose one of four statements that they considered to be the best explanation of the link between poverty and health:

  • People drift into poverty because of poor health.
  • Poor people are unhealthy because of living conditions (a structural perspective).
  • Poor people are unhealthy because their behavior makes them unhealthy.
  • There is no link between poverty and health.

These items were piloted and refined by Reutter et al. (2004).

Results

Research Question 1

Data were analyzed using SPSS software package, version 19. To answer research question 1, descriptive statistics of frequencies and percentages were used to analyze demographic information (Table 1). Students did not significantly differ between groups on gender, age, ethnicity, race, financial stability, or poverty exposure.

Demographic Characteristics of the Cohort Sample

Table 1: Demographic Characteristics of the Cohort Sample

Students differed between the experimental and control groups on the basis of religion, political attitudes, and mean pretest attitude scores. Significant differences (likelihood ratio = 14.85, p = 0.011) were noted between the groups in religion, with the experimental group having a larger percentage of students with no religious affiliation (59.2%) compared with the control group (34.67%). A significant difference (likelihood ratio = 14.28, p = 0.001) was also noted in politics between the groups, with 67% of the experimental group being liberal compared with 40% of the control group. These differences were attributed to the different geographic locations (urban versus rural) of the campuses.

Mean pretest scores were significantly (p = 0.000) higher for the experimental (mean global = 78.75; SD = 9.73) than the control group (mean = 69.84; SD = 9.45). To understand the relationship between pretest global score differences and demographics, correlations were performed among the pretest and several demographic factors. To calculate the correlation for religious demographics, participants were grouped to according to whether they had a religious affiliation. Data were recoded for religion and political views as follows: 0 = no religious affiliation; 1 = religious affiliation; 0 = conservative; 1 = liberal. A higher pretest global score was negatively correlated with religious affiliation (Spearman’s rho = −0.294, p = 0.000), and positively correlated with prior poverty exposure (Spearman’s rho = 0.284, p = 0.000) and liberal political views (Spearman’s rho = 0.444, p = 0.000).

Research Question 2

To answer research question 2, an analysis of covariance was performed on posttest global scores given the differences between the groups on pretest measures. Controlling for pretest group differences, corrected posttest mean global scores for the experimental group (78.73; standard error = 0.79) were 3.5 points higher than for the control group (75.27; standard error = 0.94), which was significant at p = 0.007. Variables that were different between groups on pretest measures and theoretical variables from the literature were selected as covariates. Pretest scores and poverty exposure were the only two significant contributors to the model that were controlled for as covariates (Table 2).

Analysis of Covariance Results for Posttest Scores

Table 2: Analysis of Covariance Results for Posttest Scores

Because the experimental group had higher ATP-SF scores on the pretest, a subset of both groups was examined to understand the attitudes of participants who had a low-to-moderate ATP-SF score on the pretest. We were particularly interested in this group because they had more negative views of the poor on the pretest. We looked at a sample of 102 students from both the experimental and control groups who scored low to moderate on the pretest and selected a sample of students scoring below a 78. This cutoff score was selected to maximize sample size, while eliminating those with the highest pretest scores. For a global score of 78 of a possible 105 points, the average item score would be between 3 and 4 on a 5-point Likert scale. No significant differences were noted on pretest scores between groups. The experimental subset had a pretest mean of 69.5 (SD = 6.5) and the control subset has a pretest mean of 66.7 (SD = 7.4), which was nonsignificant at F = 3.65, p = 0.06. Significant growth was seen on the global score from pretest to posttest scores for this subset in the experimental group compared with the control group (Figure 1). Posttest means for the experimental group rose 5.5 points to a mean of 75 (SD = 9.1), whereas the posttest means for the control group rose 1.5 points to 68.2 (SD = 10.3). This difference was significant (F = 6.135, p = 0.015).

Global score changes for subset of low to moderate scorers on pretest.

Figure 1. Global score changes for subset of low to moderate scorers on pretest.

Research Question 3

To answer research question 3, the difference between groups regarding students’ beliefs about the link between poverty and health was examined. The structural perspective choice—that the living conditions associated with poverty contribute to poor health—was the desired response regarding the link between poverty and health, in contrast to less accurate choices of a drift into poor health, a person’s behavior as the cause, or no actual link. Figure 2 outlines the findings on this item. Most of the students in both groups had the desired structural perspective viewpoint on the pretest (60% of the control group and 57.3% of the experimental group). Data were recoded to 1 = structural viewpoint and 0 = all other responses, given that some choices had a small number of responses. No significant differences were noted on the pretest and posttest in the control group (chi-square = 3.7; p = 0.054), with 60% of students continuing to choose this link. However, on pretest–posttest changes, more students in the experimental group showed an improved understanding that the structural conditions associated with poverty contribute to poor health. A significant increase in the experimental group scores occurred, from 57.3% to 70.9% of those who chose the structural link between poverty and health. This posttest change was significant in the experimental group (chi-square = 5.17, p = 0.023).

Differences in explanations between poverty and health. * Data were recoded to 1 = structural viewpoint and 0 = all other responses, given that some choices had a small number of responses. Note. Experi = experimental group; pre = pretest; post = posttest.

Figure 2. Differences in explanations between poverty and health. * Data were recoded to 1 = structural viewpoint and 0 = all other responses, given that some choices had a small number of responses. Note. Experi = experimental group; pre = pretest; post = posttest.

Discussion

The findings from this quasi-experimental study reaffirmed findings from previous nursing education studies related to the benefits of learning activities aimed at improving students’ attitudes toward the patients for whom they will care. Reutter et al. (2004) found that greater curricular exposure to poverty issues was linked to a more structural viewpoint regarding the link between poverty and health, and this finding was supported in our study. Students who experienced the poverty simulation had a greater endorsement of the structural viewpoint on the link between poverty and health than did students who did not experience the poverty simulation. This quasi-experimental study also affirmed the findings of Menzel et al. (2010) in their single group study of the positive effects of a poverty simulation on nursing students’ attitudes toward the poor. Controlling for pretest group differences, students who experienced the poverty simulation reported significantly more positive attitudes toward the poor than those who did not, especially for those who had a more negative attitude at baseline.

Findings from this study also demonstrated that students’ attitudes toward the poor are influenced by their beliefs and experiences. Higher pretest scores were negatively correlated with religious affiliation and positively correlated with prior poverty exposure and liberal political views. The association between positive attitudes toward the poor and liberal political views has been reported elsewhere (Cozzarelli et al., 2001; Yun & Weaver, 2010), as has the association with prior poverty exposure (Sword, Reutter, Meagher-Stewart, & Rideout, 2004). The finding of an association between negative attitudes toward the poor and religious affiliation may be linked to conservative beliefs among the religious, but further exploration is warranted.

Limitations

There were certain limitations to this study—it was a cohort study and random assignment was not performed. Other factors that were not evaluated in this study may have contributed to students’ attitudes and beliefs. In addition, although the course outcomes and syllabi are identical for the courses delivered on various campuses, the curriculum content and emphasis on certain content may have varied among the five cohorts. Each campus had different faculty, which may also have influenced the findings. Although the poverty simulation demonstrated attitudinal change in the experimental group at 6 weeks, it is unknown whether these changes will be retained and for how long.

Conclusions

The implementation of health care reform will have a profound effect on the near future of health care environments as uninsured Americans receive access to health care. Consequently, nurse graduates will care for increasingly diverse populations, including patients who struggle because of socioeconomic status.

The poverty simulation met the objectives for the participants, and study results affirmed the value of implementing this learning activity that requires a significant resource allocation. The experimental group gained an expanded understanding of the influence of poverty on health and a deeper understanding of the structural barriers faced by people living in poverty. In addition, it had an even greater influence on student understanding in those with more negative attitudes toward the poor at baseline. The poverty simulation is a unique, engaging learning experience that was proven to have a positive effect on nursing students’ attitudes toward poverty and is worth the investment. Providing an opportunity within a nursing curriculum for students to gain an accurate view of poverty and its influence on health care decisions supports the goals of the Institute of Medicine for patient-centered health care. Further exploration of how simulated learning activities can help students confront biases and personal beliefs that may prevent them from delivering person-centered care to vulnerable populations is recommended.

References

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  • Reutter, L.I., Sword, W., Meagher-Stewart, D. & Rideout, E. (2004). Nursing students’ beliefs about poverty and health. Journal of Advanced Nursing, 48, 299–309. doi:10.1111/j.1365-2648.2004.03199.x [CrossRef]
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  • Sword, W., Reutter, L., Meagher-Stewart, D. & Rideout, E. (2004). Baccalaureate nursing students’ attitudes toward poverty: Implications for nursing curricula. Journal of Nursing Education, 43, 13–19.
  • U.S. Census Bureau. (2010). Income poverty and health insurance coverage in the United States: 2009. Retrieved from http://www.census.gov/prod/2010pubs/p60-238.pdf
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Demographic Characteristics of the Cohort Sample

Demographic Experimental Group (n = 103) Control Group (n = 75) Test p
Gender Chi-square = 2.51 0.616
  Male 18 (17.5%) 11 (14.7%)
  Female 85 (82.5%) 64 (85.3%)
Ethnicity Likelihood ratio = 2.46 0.292
  Hispanic 4 (3.9%) 5 (6.7%)
  Non-Hispanic 99 (96.1%) 69 (92%)
  No Answer 0 1 (1.3%)
Race Likelihood ratio = 4.48 0.344
  American Indian/Alaskan Native 4 (3.9%) 3 (4%)
  Asian 6 (5.8%) 2 (2.7%)
  Black/African American 0 (0%) 1 (1.3%)
  White 93 (90.3%) 68 (90.7%)
  Native Hawaiian/Pacific Islander 0 (0%) 1 (1.3%)
Age (y) Likelihood ratio = 6.79 0.079
  20–29 60 (58.3%) 56 (74.7%)
  30–39 30 (29.1%) 16 (21.3%)
  40–49 9 (8.7%) 2 (2.7%)
  ⩾ 50 4 (3.9%) 1 (1.3%)
Financial stability (1 = very secure to 6 = very insecure) F = 3.953 0.051
  Mean 3.16 3.49
  Standard deviation 1.09 1.19
Poverty exposure (range, 0 to 3) F = 0.462 0.497
  Mean 1.59 1.49
  Standard deviation 0.901 1.03
Religion Likelihood ratio = 14.85 0.011
  No religious affiliation 61(59.2%) 26 (34.7%)
  Christian 28 (27.2%) 37 (49.3%)
  Catholic 8 (7.8%) 10 (13.3%)
  Jewish 1 (0.97%) 0 (0%)
  Buddhist 1 (0.97%) 1 (1.3%)
  Other 4 (3.9%) 1 (1.3%)
Political beliefs Likelihood ratio = 14.28 0.001
  Conservative 28 (27.2%) 38 (50.7%)
  Liberal 69 (67%) 30 (40%)
  No answer 6 (5.8%) 7 (9.3%)
Pretest mean 78.75 69.84 F = 37.278 0.000
  Standard deviation 9.73 9.45
Posttest mean 81.73 71.21
  Standard deviation 10.62 11.49

Analysis of Covariance Results for Posttest Scores

Statistic Experimental Group (n = 103) Control Group (n = 75) F p
Adjusted posttest score meansa 78.73 75.27 7.467 0.007
Standard error 0.79 0.94

10.3928/01484834-20120914-01

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