Poverty is considered to be one of the most influential social determinants of health (Boozary & Shojania, 2018; Office of Disease Prevention and Health Promotion, 2019; World Health Organization, 2019). Nurses must learn the impact of poverty on the lives and health of individuals they care for in order to deliver equitable and effective care. When nurses possess a negative attitude toward people living in poverty, this can negatively influence patient care (Jarrell et al., 2014).
Simulation in clinical education provides a structured learning environment that represents or amplifies actual or potential clinical situations and prepares students for clinical experiences in a safe environment (Gaba, 2004; Gillan, van der Riet, & Jeong, 2014). Simulation in poverty-related learning can provide a degree of realism, which may facilitate affective learning objectives and improve knowledge-based learning goals. Realism of simulated experiences is described in three aspects of fidelity: conceptual, physical, and emotional. Conceptual fidelity reflects accuracy in the clinical aspects of the scenario or experience. Physical fidelity reflects the degree to which the simulation duplicates the appearance of reality. Emotional fidelity is the extent a simulation can psychologically make the student feel as if it is real (Choi et al., 2017).
Simulated poverty teaching interventions have been demonstrated to be an effective means to teach students about the experience of living in poverty (Lampiris, White, Sams, White, & Weintraub, 2017; Noone, Sideras, Gubrud-Howe, Voss, & Mathews, 2012; Yang, Woomer, Agbemenu, & Williams, 2014) and can result in more empathy and compassion for those who are poor (Nickols & Nielsen, 2011). Participation in a simulated poverty teaching intervention can help promote an understanding of the relationship between poverty and health. However, simulated poverty teaching interventions, which offer a safe way for participants to experience poverty while providing an opportunity for increased appreciation and sensitivity for social justice, are varied (Reid & Evanson, 2016). The degree of conceptual, physical, and emotional realism must be considered when selecting a simulated poverty teaching intervention because simulation-based teaching interventions can be resource heavy and require additional money, space, and time on the part of university faculty, staff, and students.
The purpose of this study was to evaluate baseline undergraduate nursing student attitudes toward people living in poverty, to evaluate the effectiveness of simulated poverty teaching interventions within an undergraduate nursing curriculum, and to compare two simulated poverty teaching interventions.
A total of 320 freshmen and sophomore nursing students participated in one of two different simulated poverty teaching interventions designed to sensitize participants to the realities of life for people living in poverty. Students in this course did not have any prior exposure to poverty content in the curriculum other than minimal statements contained in their textbook. Students in their first nursing course, taken as a freshman or a sophomore, were assigned to a simulated poverty teaching intervention as a course requirement. Assignment to either simulated poverty teaching intervention was determined by semester. Students participating in the Fall 2014 or Spring 2015 semesters experienced a Community Action Poverty Simulation (CAPS). Students participating in the Fall 2015, Spring 2016, Fall 2016, or Spring 2017 semester experienced an Oxfam America Hunger Banquet®. Prior to collecting data, students were informed they could opt out of data collection if desired. In lieu of a formal consent form, consent was obtained using an oral script.
First Intervention: CAPS
We conducted CAPS, a simulated poverty teaching intervention experience designed to sensitize students to the plight of individuals living in poverty (Missouri Association for Community Action, 2012) with our nursing students. The CAPS was assessed by the nursing faculty to be high in conceptual fidelity and has been used by other educators to sensitize students to the day-to-day challenges faced by low-income individuals (Noone et al., 2012; Patterson & Hulton, 2012; Yang et al., 2014). The CAPS was trademarked in 2002 and revised most recently in 2012. The CAPS has been used for experiential learning in other disciplines (Steck, Engler, Ligon, Druen, & Cosgrove, 2011) and provides participants with an interactive learning experience through role-playing the struggles people living in poverty face on a daily basis.
Over 3 hours, the CAPS simulated a typical 4-week period that might be experienced by families and individuals living in poverty in the United States. Students were assigned roles as members of low-income families (e.g., single parents, senior citizens, and unemployed people) and received a packet with simulated tasks that needed to be completed during the simulated month. Each week in the month was condensed into a 15-minute segment. During the CAPS, students were tasked with navigating a network of community agencies that provide health and social services, financial support, and transportation passes to eligible individuals (e.g., social services, school, bank, grocery store). Various tasks included finding jobs, getting children enrolled in daycare or school, and paying bills. The CAPS was conducted in a large room with tables for community agencies positioned on the perimeter of the room. Debriefing groups consisted of one faculty member, two to three volunteers, and several families. A guide was provided with debriefing questions to discuss including “What happened to their families during the “month?” “How did you feel during the poverty simulation?” “What knowledge can be carried forward into your future profession as a registered nurse?” and “Did any views about those living in poverty change?” The discussions were lively and inclusive, with some individuals expressing their real-life struggles of coping with similar issues brought up during the simulation. Students also became familiar with several types of services available in the community and the acronyms (e.g., EBT, or electronic benefits transfer; TANF, or temporary assistance to needy families) used for government programs.
Conceptual fidelity for the CAPS experience was enhanced by debriefing prior to and after the simulation. Physical fidelity was enhanced with the use of transportation passes, cash money, and several confusing forms to complete. Emotional fidelity was promoted with the use of both community and faculty volunteers serving as the community agency service providers, such as teacher, banker, police officer, social worker, and nurse, and handing out “Luck of the Draw” cards.
Second Intervention: Hunger Banquet
We also conducted Oxfam America Hunger Banquets (Oxfam America, 2015), a simulated poverty teaching intervention experience designed to sensitize students to the plight of individuals living in poverty by simulating the unequal distribution of food and resources across global populations. The Oxfam organization lists its mission as creating solutions to poverty, hunger, and social justice. Oxfam America, a nonprofit organization based in Boston, Massachusetts, provides supplies and support for organizations that conduct Hunger Banquets, including a free tool kit titled “How to Host an Oxfam America Hunger Banquet” ( https://www.oxfamamerica.org/take-action/events/oxfam-hunger-banquet/). The tool kit provides explicit instructions on how to organize, promote, and conduct a hunger banquet in the United States, which colleges, universities, and churches often host (Harris, Harris, & Fondren, 2015; Navarro, 2009). Prior to the Hunger Banquet experience, students were informed they would be provided a meal and were instructed not to bring outside food. Upon arrival, they were randomly assigned to their designated socioeconomic status by drawing a ticket from a container. Based on their randomly selected ticket, a matching wristband was provided which was used to determine their eating location, type, and quantity of food served. During the prebrief, participants sat for a 10-minute presentation on worldwide poverty, hunger, and famine. Statistics about hunger were provided by the World Health Organization and Oxfam America. Students were then moved to their assigned meal areas. High-income participants, approximately 15% of the total, were served before others and ate a gourmet meal served by well-dressed volunteers. Middle-income participants, approximately 25% of the total, had a limited amount of table space and had to wait in line for someone to serve them a simple meal of rice and beans. Middle-income participants drank clean water from a plastic cooler. Low-income participants, approximately 60% of the total, sat closely together on the floor serving themselves plain rice with “dirty” (coffee-tainted) water. The Hunger Banquet was conducted in a large room with one table and 10 chairs for participants randomly selected to the high-income group, and just chairs for participants randomly selected to the middle-income group, and floor seating for participants randomized to the low-income group. The Hunger Banquets were conducted over a 2-hour period.
Debriefing occurred in small groups with a mixture of students from all three income levels. Questions in debriefing included, “What personal choices can we make to impact this unequal distribution, or bring about a fairer distribution of resources?” and “How did it feel to be in (a particular income group) watching and knowing what was going on around you?”
Conceptual fidelity for the Oxfam Hunger Banquet experience was enhanced by debriefing before and after the simulation. Physical fidelity was enhanced with real food and a structured eating environment. Emotional fidelity was promoted using an interactive script and compelling pictures used in the screen presentation and played throughout the simulation. These pictures helped bring poverty statistics to life.
The Undergraduate Perceptions of Poverty Tracking Survey (UPPTS) (Blair, Brown, Schoepflin, & Taylor, 2014) and a demographic survey were administered to students pre- and postintervention. The UPPTS (Blair et al., 2014) is a 39-item survey using a 5-point Likert scale used to measure student attitudes toward people living in poverty. It was designed to provide educators with information about the influence of their educational efforts in the area of poverty on their students. The UPPTS provides information regarding undergraduate student's perceptions of those living in poverty in three areas: general attitudes toward those living in poverty, empathy for those living in poverty, and commitment to addressing poverty via direct action or support for programs and services that aid the poor. Further, Blair et al. (2014) postulated that general attitudes toward the poor exist in the form of a continuum with underlying beliefs about the causes of poverty (i.e., flawed character versus limited opportunity) lying at the extremes.
For this study, a lower total score on the UPPTS indicates a negative view of those living in poverty. A lower score also indicates a lower level of empathy for those living in poverty, and it is more likely the respondent views those living in poverty as having some type of flawed character. A higher total score indicates a positive, more empathetic view of those living in poverty and an increased likelihood of viewing the underlying cause of poverty as a lack of resources and opportunity (Blair et al., 2014). This survey has been used previously to evaluate efficacy of simulated poverty teaching interventions (Smith, Ryder, Blais, & Schneck, 2017).
After approval in July 2014 from Pace University's Institutional Review Board, the CAPS was conducted in the Fall 2014 semester to assess feasibility, pilot instruments, gather baseline data, and train volunteers. In the Spring 2015 semester, a CAPS was again conducted. Hunger Banquets were conducted in the subsequent four semesters: Fall 2015, Spring 2016, Fall 2016, and Spring 2017. Paired t tests were used to compare pre- and postintervention UPPTS total scores with each cohort of students. They were independent samples. The UPPTS was administered 1 to 2 weeks before each simulated poverty teaching intervention and 1 to 2 weeks afterward. However, student responses were paired and results from the fall 2014 semester were excluded from aggregate data due to difficulties in data collection. The sample size of each simulated poverty teaching intervention by semester was: CAPS-Fall 2014 (N = 37); Spring 2015 (N = 57); Hunger Banquet-Fall 2015 (N = 28); Spring 2016 (N = 93); Fall 2016 (N = 12); Spring 2017 (N = 93). The total sample size for the two CAPS was 94 (N = 94) and the four Hunger Banquets was 226 (N = 226). Total participants for both simulated poverty teaching interventions was 320.
The 39 questions on the UPPTS were scored using the six subcategory factors: welfare attitudes (12 questions), poor different (eight questions), do more (six questions), equal opportunity (six questions), fundamental rights (three questions), and lack of resources (four questions). An overall score using all 39 questions was calculated by adding the six factor scores. The total scores range from 39 to 195. Reliability scores for the pretest and posttest (as well as combined) were completed for each of the six scales. Pretest scores were between 0.76 to 0.82; posttest scores were between 0.82 to 0.87; and total scores were between 0.81 to 0.83. The reliability scores are similar to initial reliability scores for the UPPTS, with a range of 0.71 to 0.84. When using 0.7 as a cutoff for acceptable reliability scores, all reliability scores are within this range, with most above 0.8.
The CAPS had 57 participants in the Spring 2015 semester, with corresponding means and standard deviations for pre-and posttests. Listwise deletion was used for subscores with missing values. A paired t test was conducted on the overall score and found that the posttest amounted to an average increase of 10.8 points, with a standard deviation of 13.04 (95% CI [7.31, 14.30]). This was statistically significant, with t(55) = 6.20. The biggest contributors to the increase was in the welfare attitudes subcategory (M = 3.89, SD = 5.85, t(55) = 4.98) and the do more subcategory (M = 2.18, SD = 3.50, t(56) = 4.69). The equal opportunity subcategory (M = 1.77, SD = 3.49, t(55) = 3.83) and lack of resources subcategory (M = 1.32, SD = 2.91 t(55) = 3.41) also showed a statistically significant increase. The fundamental rights factor showed no difference. This could be attributed to the students' pretest having an average of 14.12 with three questions, meaning they had a very positive view toward fundamental rights prior to the intervention.
The Hunger Banquet was conducted over four semesters with pre- and posttest averages provided below for each semester. The overall score increased by an average of M = 2.95 points, with a standard deviation 13 and t(212) = 3.30 (95% CI [1.19, 4.70]). Regression analysis found statistically significant contributors to this increase was due to an increase in the welfare attitudes (M = 1.89, SD = 5,82, t(216) = 4.79) and an increase in students wanting to do more (M = .89, SD = 3.91 t(220) = 3.37). When comparing the two simulated poverty teaching interventions, the overall posttest score improved by a greater amount with the CAPS (M = 10.80, SD = 13.04, 95% CI [7.31, 14.30]) compared with the Hunger Banquet (M = 2.95, SD = 13.01, 95% CI [1.19, 4.71]). Here, t(267) = 4.02. A regression was run on the overall posttest score with the overall prescore and whether or not they attended the CAPS or the Hunger Banquet. Control for the pretest score was achieved by entering it into the regression model as a covariate. Thus, in predicting posttest scores based on pretest scores, we could predict that someone with the same pretest score would score 8 points higher on the posttest score with the CAPS compared with the Hunger Banquet. Statistical significance was found, t(266) = 4.27 (p < .001) and showed that controlling for the overall pretest score, the poverty simulation showed an 8-point increase in the overall score (M = 8.15, SD = 1.91, 95% CI [4.40, 11.91]). The CAPS was limited to the Fall 2014 and Spring 2015 semesters because coordination and training of the large number of volunteers (N = 24) required was resource intensive and not sustainable over time.
A variety of simulated poverty teaching interventions necessitating varying resources to implement are available. Nurse educators must identify the most effective teaching methods to provide knowledge and promote the attitudes that reflect the standard of the professional nurse, including empathy. Our study confirmed that the CAPS is more effective in creating a more positive view toward people living in poverty by improving attitudes, compared with the Hunger Banquet. The CAPS experience provided students an opportunity to gain a greater understanding of poverty-related barriers to health care, such as transportation issues and medication costs, and exposed them to some potential community resources.
The university allowed for adequate space and resources to accomplish the execution of the CAPS and hunger banquets. Resources included financial support for the initial purchase of the CAPS toolkit and the cost of food for the Hunger Banquets. Data collection occurred during class time, which significantly enhanced response rate.
A convenience sample of nursing students from freshman and sophomore classes were used. The majority of nursing students were Caucasian, Christian, and female, and they described themselves as middle class. The poverty simulation instructions call for individuals in poverty to work the community resource tables to enhance realism, whereas in this simulation, volunteers included faculty, staff, and community members. Facilitators varied in debriefing experience, experiential learning theory, and knowledge of poverty-related resources.
University and college programs should consider incorporating a poverty simulation experience such as the CAPS into the curriculum prior to students entering the clinical setting. Ongoing experiences could include other evidence-based simulated poverty teaching interventions to improve student knowledge of resources available to patients who may benefit.
Longitudinal studies using the UPPTS should be done at intervals after the initial poverty simulation experience to evaluate retention of any change in attitudes. This information would be helpful in guiding the recommended frequency of such experiences. Additional studies may also demonstrate unique differences in nursing student cohorts based on age, gender, income, or other factors. This research only evaluated two possible simulated poverty teaching interventions to sensitize nursing students to the daily struggles of those living in poverty, but other simulated poverty teaching interventions should be studied for determination of value and cost effectiveness. This study indicates that the use of both the CAPS and the Hunger Banquet improves attitudes toward those living in poverty; however, additional studies are needed to evaluate whether the improvement in attitudes is associated with changes in behavior, particularly when related to direct patient care.
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