Socially determined factors, such as living in an unstable economic environment, play a significant role in predicting health outcomes of population groups (Centers for Disease Control and Prevention, 2018). In fact, socioeconomic conditions are among the most powerful predictors of chronic disease in the United States (Shaw, Theis, Self-Brown, Roblin, & Barker, 2016). Socially determined health factors are not routinely addressed by nurses during the provision of care. However, nurses are currently being called to become more active in roles to develop and support policies—health care and other—that address social determinants. Activities that extend beyond bedside care are necessary to support the goal of a national culture of wellness (Robert Wood Johnson Foundation, 2015) and are also intended to address the needs of the most vulnerable patient groups. However, nurses report that they lack confidence, skills, and knowledge related to advocacy on the policy level (Staebler et al., 2017). Teaching strategies that enhance knowledge and empower students to engage in advocacy are necessary to improve the policy role of the nurse.
The specific aim of this project was to examine the impact of using the game of Monopoly to create a simulated environment of economic disparity in an introductory-level population health nursing course. Monopoly has been used in similar ways in sociology (Coghlan & Huggins, 2004; Waren, 2011; Wright-Maley, 2013). Adapting the game in a similar manner for the nursing classroom was intended to challenge student perspectives about socially constructed systems, poverty, and the connection of these factors to resulting disease patterns and disparities.
The Creation of Simulated Social Environments
Simulating environments supports the development of the ability to assess and adjust to a situation taking into account external forces and dynamics (Kelly, Berragan, Husebø, & Orr, 2016). Simulation experiences that address social environment are necessary for students, who may not be exposed during typical clinical rotations, to adequately assess and plan for contextual factors that affect health outcomes (Mauro et al., 2018). Creating simulated social experiences is not intended to enhance a specific clinical skill, but to prepare the student for the complexity of the health care environment and stress the importance of acknowledging the patient's background as essential to provision of adequate care. In fact, the National League for Nursing (2015) recommends that students be engaged in contextual factors, specifically in simulation, because this shifts the focus from skill acquisition to creating meaning.
Creating an environment where students are able to experience the vulnerability associated with economic forces and social structures firsthand is an opportunity to challenge the “pull yourself up by your bootstraps” mentality that can be so common among those not exposed to structural inequality. Student learning outcomes supported by this simulation include: discuss social determinants of health and health disparities for vulnerable populations; discuss the professional identity of the nurse as an advocate for stigmatized, vulnerable, and underserved groups; and discuss the ethical implications of health care disparities for vulnerable groups.
Addressing Vulnerability and Empathy Through Active Learning
Problems accessing high-quality affordable care, securing safe, reasonably priced housing, and acquiring well-paying jobs that support stability are only the tip of the iceberg for socioeconomically disadvantaged, vulnerable groups. Intentionally placing students in an experiential situation has the potential to shift the student's point of view, decrease judgment, and enhance empathic concern for these populations. The student is able to recognize that economic situations influence all decisions made by the patient, including decisions about health. This creates an ethical dilemma for nurses whose goal is to provide equal care to all.
Empathic perspective-taking and using imagination to ask the question “What would I want if I were this person?” are prerequisites to provision of effective patient-centered, ethical, and compassionate care (Hojat, 2016). Compassion has been shown to improve with clinical exposure to different populations, cultures, and situations (Loomis & De Natale, 2017). Therefore, exposing students to simulated scenarios may have the potential to enhance empathy.
The recognition that acute care treatment is only a temporary solution to the broader problem of health disparities compels nurses to consider their own roles in improving health disparities at a policy level. Awareness of these concepts needs to begin in undergraduate education, ideally in the first semester of nursing courses.
Innovative Use of Monopoly in the Nursing Classroom
Cross-sectional descriptive methods were used to guide this innovation with prelicensure nursing students (n = 52 , n = 49 ). All students enrolled in the course were required to participate in the simulation. Permission was gained to use oral debriefing responses and written reflections as a component of data analysis. Data were collected from each group at one point in time. Student reflective comments were compared between years; however, similar results were obtained and therefore the word data was combined into one thematic report. The program reflects the typical demographic of traditional baccalaureate nursing students. The average age was 23 years, the majority of the students were female (n = 80 of 101), and the majority of the students were White (n = 53) followed by Hispanic/Latino (n = 27). Institutional review board approval was obtained for the study conducted in conjunction with this innovation.
The board game Monopoly was used to simulate a social environment of disparity. A large classroom was prepared with eight square tables equipped with a set of modified rules (Table 1). Eight students were randomly assigned to a table and position number and were given a tag to reflect their social position (e.g., banker, white numbered tag, red numbered tag). Each number was associated with specific property ownership, a starting monetary amount, and a specific time to enter gameplay. Position one was associated with the greatest financial benefit and best property selections and was the first to enter gameplay. Position eight was associated with the least financial benefit and no property and was last to enter gameplay. The game ended when the majority of players were out of money, or when 2 hours had passed. Most of the players in positions three to eight were no longer in the game after 2 hours. The remaining players had monopolized the property and had the greatest amount of financial gain.
Modified Monopoly Rules
Structured oral debriefing was used to guide the reflective process. One hour was allowed for debriefing due to the complex nature of the simulation and the multiple concepts that could potentially be explored. Oral debriefing was guided by three questions: “Describe how you are feeling,” “Describe what happened,” and “How did this experience challenge your thinking?” Oral debriefing took place in the large group. Students were also asked to complete a written reflection of the simulation. Written debriefing responses were collected 2 days following the simulation to allow time for reflection. Data from the oral debriefing process and written reflections were collected and analyzed for content using Miles, Huberman, and Saldana's (2014) tiered method of content analysis. The oral and written responses included themes of awareness, emotional response, empathy, and advocacy.
Awareness: Injustice, Marginalization, and Inequitable Opportunity
Awareness of injustice and marginalization was reflected through statements such as “I felt immediately inferior to the other players. I thought I should have more money. It wasn't fair,” and “My personal biases became apparent. I thought anybody could make their situations better. But you play the cards you are dealt.” Other students related the experience directly back to vulnerability, stating, “The social gradient came to life before my eyes,” and “It is very unfair to know that if you start with a small amount, it is impossible to get more.” Statements such as “Going to jail actually became a preference rather than going around the board again,” and “I definitely see how people are marginalized and how this would impact stress and eventually health,” exposed an understanding and awareness of the experience of marginalized groups. One student reflected on her own personal experience, stating, “I thought I had it bad growing up because I couldn't have all of the name brand clothes. I can't believe how shallow that was. I felt marginalized. What a joke!” Awareness of inequitable opportunity was revealed in student statements such as “It is a different way to live. They live paycheck to paycheck…like passing go,” and “The majority were struggling in the game, it needed to be more equitable.” Statements such as “In my position, I didn't have the same chances as everybody else to be successful because I had less and got started late,” “The gap in money between the groups was so big,” and “This game is so much like life. It is so unfair” also exhibited an enhanced awareness of inequity.
Emotional Response: Disappointment, Frustration, and Anger
Emotional responses to patient experiences can be one way to harness affective domain development in students. Disappointment, frustration, and anger were echoed in student statements such as, “I was surviving but never thriving, it was frustrating,” and “I was so disappointed to be number seven. It really made me angry to see how easy it was for the other players.” Other students were surprised at their own frustration and anger, stating, “I have been poor my whole life, this should be nothing new, then I lost almost everything I had. I had the least of everybody. I was jealous of the other players and angry… it just seemed to come so easy to everybody else,” and “I actually became so frustrated and player one was so greedy, I wanted to strangle her.”
Empathy was revealed in student statements such as “We expect people to be able to make good health decisions. But if they don't have money or resources, it isn't that simple. I realize this now after this class,” “The money situation was so stressful, I almost lost my ability to communicate. It made me really think about what it means to have very little,” and “I certainly wouldn't be thinking about buying fresh fruit and vegetables if I couldn't pay rent.” Students also displayed empathy in statements that reflected how they would change practice as a result of this experience, “This made me realize that you really need to get to know your patients and understand their situation so you can be a better nurse and make sure everybody is treated equally,” “You need to keep an open mind as a nurse and recognize that how people live is not always by their own design,” and “I have to show empathy. I even tried during the game, but I said, ‘Don't whine about your position, just play it.’ I realized that if this was a patient, that would be a horrible way to treat them. I have to truly try to see it from the patient's point of view.”
Advocacy: Working for Equality
Being an advocate and working for equality were shown in statements such as “You can even start off okay, but it doesn't take much to slip into a vulnerable group financially. A couple of bad rolls of the dice and you might be out. This doesn't seem right. There should be protections for that,” and “People who don't have to care about them often just ignore the lower class. I think this is how they end up like they do a lot of times. Everybody seems so busy caring about themselves. It seems like nurses have an opportunity to change this.” Students also expressed the lack of confidence that correlates with what is currently written about baccalaureate-prepared nurses and advocacy. “This opened my eyes, but I will need more confidence to speak to senators and representatives about these issues in health care.”
Ultimately, student perspectives shifted. Statements that reflected student empowerment to address some of the broader issues that impact health included, “We should work to protect people from vulnerability. In our country, we are always focusing on things that don't really matter. We need to get real and start addressing the real problems,” “Sometimes people just don't have control over their situations. This really helped me see that advocacy is necessary and since nurses have experience with people who are sick because of the social set up, we are the right people to do the job,” and “This game made me realize the difference I need to make as a nurse and a human being in general. All people should have the same opportunities. Especially the same opportunities to be healthy.”
Simulating Environments for Health
Simulating environmental issues that impact health may be a particularly powerful method of enhancing empathy and inspiring advocacy. The Monopoly experience stresses the importance of considering contextual factors in making health care decisions. In order to understand context, nurses need to be able to see the situation from the patient's perspective and be able to imaginatively stand in the patient's shoes. Perspective-taking, one of the foundational components of empathy, is altered through experience (Hojat, 2016). This experience clearly enhanced empathy. Empathy is typically explored within the confines of the nurse–patient relationship but has rarely been explored as a general response to vulnerable groups. To date, no data exist on how this type of exposure cultivates nursing student empathy. This knowledge is essential, as empathy is the foundation for provision of compassionate care.
This simulated environment also provided the foundation for advocacy work in baccalaureate-prepared nursing students. Although not all nurses will become policy advocates, they all must be aware of the impact of policy on social contexts and how these affect health outcomes. An exploration of the underlying social, economic, and inequitable nature of health disparities and the political forces that play a role influence the nursing student's intent to advocate for vulnerable groups. The shift in student perspectives related to socially determined health factors does not necessarily guarantee social advocacy. However, the reflective responses from students indicated an enhanced understanding of the need for nurses to act as policy advocates on the vulnerable patient's behalf.
Conclusions and Recommendations
Student responses indicated that this innovation had an effect on awareness and ability to empathize with people from socioeconomically disadvantaged groups. The ability of nursing students to find and develop their voices in health policy and political advocacy was also affected. This simulation was low cost and easy to set up, which made it feasible for implementation by one faculty member. Most introductory courses in nursing are large, and this active learning technique can be used with a large group of students at one time.
More research is necessary on the role that simulations, specifically context-based simulations, influence nursing student development. Well-designed quantitative studies that advance knowledge on this topic would be useful. An in-depth understanding of student attitudes toward poverty and empathy and how these might shift following a strategy such as this would be advantageous.