Poverty has a rippling effect on many aspects of health and well-being, including hunger, malnutrition, inadequate housing, social discrimination, and exclusion, as well as a lack of access to basic resources (Chetty et al., 2016). Poverty can be defined as the experience of living within the constraints of limited economic resources and encompasses a wide range of income thresholds depending on geography (Jamison et al., 2018). As a result, poverty is a worldwide phenomenon that persists in every resource setting and has become increasingly prevalent in the United States (Jamison et al., 2018). In 2017, an estimated 40 million people in the United States were living in poverty, including 17.5% of children (younger than age 18 years) (Fontenot, Semega, & Kollar, 2018). The association between socioeconomic position and health disparities is well-documented throughout the literature. High proportions of community-level income inequality are associated with premature mortality (Chetty et al., 2016) and increased unmet health care needs (Tumin, Menegay, Shrider, Nau, & Tumin, 2018). Furthermore, socioeconomic status influences self-rated health across generations (Link et al., 2017), and health disparities associated with poverty impact health more than the lack of health insurance (Marmot, 2015).
Nurses and other health care professions seek to close the gap in health disparities experienced by those in poverty by providing equitable, culturally competent care and through advocating for just policies nationwide (Mahony & Jones, 2013). Nurses also must obtain the knowledge, skills, and attitudes necessary to work with diverse populations, including individuals experiencing poverty. Ideally, the acquisition of a culturally competent skill set occurs through experiences within nursing education curriculum. A comprehensive understanding of social determinants of health is crucial to developing nursing students' knowledge and attitudes toward diverse populations, and should include an emphasis on the structural antecedents of poverty (Magnan, 2017). Many scholars emphasize the need for health care professionals to understand that poverty has predominantly structural causes, as opposed to viewing poverty as a stigma-tized, personal deficiency (Chetty et al., 2016; Woolf, 2017).
Empathy toward vulnerable populations is a known component of culturally competent care of health care professionals (Olson & Hanchett, 1997). Empathy involves cognitive understanding rather than emotional expression and incorporates a knowledge-based awareness of another person's perspective. Health care professionals demonstrate empathy through communicating their understanding of a patient's experience and perceptions (Lipp et al., 2016). Increased empathy in health care providers can significantly improve health outcomes among vulnerable populations, including symptom management and medication adherence, through increased communication and shared decision making (Mercer et al., 2016). An emphasis on empathy in nursing behavior can improve patient-nurse communication and reduce patient distress (Olson & Hanchett, 1997), and is a valuable construct to teach and evaluate during baccalaureate nursing education (Petrucci, La Cerra, Aloisio, Montanari, & Lancia, 2016).
Baccalaureate public health nursing courses often incorporate hands-on experiences or simulations involving individuals living in poverty. Poverty simulations, service-learning, and volunteer experiences have become popular pedagogic strategies in undergraduate nursing courses and often have demonstrated an ability to improve students' perceptions toward poverty (Turk & Colbert, 2018). Positive attitudes toward the structural causes of poverty were noted among junior-level students in one study (Noone, Sideras, Gubrud-Howe, Voss, & Mathews, 2012) and resulted in greater empathy for the experiences of those in poverty following a simulation centered on poverty in another study (Johnson, Guillet, Murphy, Horton, & Todd, 2015).
Not all poverty-related experiences in nursing education have a measurable impact on student knowledge or attitudes. Prior history of poverty or working with individuals in poverty may affect nursing students' attitudes and the curriculum's ability to create a change in negative perceptions toward vulnerable populations (Turk & Colbert, 2018). Health care professionals may understand the relationship between poverty and poor health outcomes, but they may not have examined their personal beliefs, unconscious biases, and judgments of those living in poverty prior to entering clinical practice (Hellman, Cass, Cathey, Smith, & Hurley, 2018). The state of the existing evidence presents an opportunity for further research to better understand the impact of students' personal background on learning with public health nursing courses.
In an effort to enhance the impact of public health nursing courses within the undergraduate curriculum, a cross-sectional, descriptive study of two distinct cohorts of a baccalaureate senior-level nursing program at one large urban university was conducted. The aim of this study was to determine the relationship between empathy, attitudes toward poverty, and demographics on entry into a public health nursing course. It was hypothesized that measures of empathy and attitudes toward poverty would differ significantly according to demographic factors and program cohort.
Sample and Setting
The convenience sample included 140 traditional and 135 full-time accelerated baccalaureate nursing students enrolled in a required public health nursing course at a large university in the northeastern United States. Students were provided a link posted to their online course management system describing the aims of the study; of an aggregate of 275 students in both cohorts, a total of 104 students (38%) agreed to participate. This study received approval from the university's institutional review board.
A demographic survey, the Jefferson Scale of Empathy, and the Attitude Toward Poverty-Short Form (ATP-SF) were used for this study. The demographic survey collected information regarding students' age, gender, ethnicity, religion, political beliefs, and exposure to poverty through family life or volunteer experience. The Jefferson Scale of Empathy (Hojat et al., 2018) is a self-report scale consisting of 20 items that are ranked using a Likert-type format with responses ranging from 1 (strongly disagree) to 7 (strongly agree). The possible range of scores is 20 to 140, with higher scores indicating greater levels of empathy. Criterion-related validity and convergent validity has been established among medical students, physicians, and nurses (Hojat et al., 2018). The ATP-SF was developed to assess student perceptions of poverty and has well documented psycho-metric properties with construct validity supported by factor analysis, convergent validity, and known-groups validity (Yun & Weaver, 2010).
The primary investigators were nursing faculty separate from the public health nursing course faculty members. The public health nursing course faculty members provided a link to the surveys and study description with the online course management system. On the first day of class, students were informed of the study's purpose and the location of the survey description and link. There was no penalty or consequence for students' grade if they did not complete the survey. As this was an anonymous voluntary survey of students, individual informed consent was not required by the institutional review board of the university.
Data were analyzed using SPSS® version 25. Descriptive statistics were obtained for all measures, with means and standard deviations for continuous variables, and frequencies or percentages for categorical variables. Student demographic characteristics were analyzed first for all participants and then subsequently by cohort (traditional or accelerated). Differences in demographic characteristics by cohort were assessed using chi-square tests. Finally, independent t tests were used to assess for differences in attitudes toward poverty and empathy scores according to separate demographics and cohort.
Of the 104 senior-level nursing students who participated in the study, 82 students (78.8%) comprised the traditional cohort and 22 students (21.2%) comprised the accelerated cohort. The majority of students were female (n = 92, 88.5%), and ranged in age from 21 to 29 years (n = 90, 86.5%), with only 2.5% of respondents older than age 40 years. Political affiliations were defined on a continuum, with students able to report their political affiliation as neither, slightly, moderately, or extremely liberal or conservative. More than a third of students reported having slightly or moderately liberal views, whereas 38.5% (n = 40) reported neither liberal nor conservative political views. A minority of students reported extremely liberal (n = 3, 2.9%) or extremely conservative (n = 1, 1%) political affiliations. Demographic characteristics of the participants are summarized in Table 1.
Students differed in racial background significantly by cohort, with a greater percentage of students in the accelerated cohort representing nonwhite racial backgrounds (n = 11, 50%) compared with students in the traditional program (n = 18, 22%; p < .05). In their personal experiences of poverty, almost one third of traditional cohort students (n = 27, 32.9%) reported living below the poverty line at some point in their lives, which was significantly different than the percentage of accelerated cohort students (n = 4, 18%; p <.05). Finally, students in the accelerated cohort had significantly more prior volunteer experience (n = 18, 81.8%) with individuals in poverty than students in the traditional cohort (n = 44, 53.7%; p < .01).
Empathy and Attitudes Toward Poverty
Of the 104 students who completed the demographic survey, 79 (76%) students completed the Jefferson Scale of Empathy and the ATP-SF. Empathy scores ranged from 71 to 115, with a mean score of 87 (SD = 28.3), and ATP-SF scores ranged overall from 63 to 105, with a mean score of 72.7 (SD = 19.3). Subsequent analysis included independent t tests using demographic variables. Students with higher empathy scores were more likely to report a lack of prior volunteer experience with individuals experiencing poverty (t = −1.9, p < .05). There were no other significant differences in total empathy or total attitudes toward poverty based on past personal experience with poverty, age, gender, race, religion, political affiliation, or program cohort.
Often in nursing education, educators emphasize a need for exposure to diverse groups of people to increase awareness and competence, and to decrease stigma and bias (Gallagher & Polanin, 2015). However, prior exposure to individuals living in poverty through volunteer experience was associated with less empathy in the nursing students surveyed in this study. The findings highlight a need for students to engage in experiences that involve more than time spent with diverse groups of people but instead that also allow for substantive interaction and relationship building. Previous pedagogical research related to culturally competent nursing practice puts forth reflective journaling, peer reflective practice, and fostering curiosity as crucial parts of learning to work with diverse populations (Papadopoulos, Shea, Taylor, Pezzella, & Foley, 2016). Methods that involve identifying and building on prior experience, as well as creating a shared learning environment with those with different life experience are necessary (Garneau, 2016).
Within a community or public health nursing course, it is important for nurse educators to appreciate the background of their student body. In this study, although the students in the traditional cohort had more personal experiences of poverty, the accelerated students reported more volunteer experience with individuals experiencing poverty. Accelerated students come to nursing education after previous completion of a baccalaureate degree in another field. Volunteer experience often is required in many universities in multiple disciplines; however, the purpose and structure of the experiences can vary (Bryant-Moore et al., 2018). Service opportunities should aid students in increasing their awareness of another person's lived experience and provide an impact for the community served.
Nearly a third of the traditional cohort reported personal experience with poverty, but it is important to note that none of the demographic factors were significantly associated with differences in the mean scores of attitudes toward poverty or empathy. Previous work has noted mixed results related to demographics associated with attitudes toward poverty (Wittenauer, Ludwick, Baughman, & Fishbein, 2015) and empathy (Yang et al., 2018), and it is likely that these measures are influenced by not just one factor, but rather by a complex set of experiences. Acknowledging the prior or current life experience of students is still crucial, and critical reflective practice can foster cultural competence development (Garneau, 2016). There is limited evidence that individuals who have overcome adversity may have less compassion toward those who are actively experiencing adversity (Ruttan, McDonnell, & Nordgren, 2015). As educators, it is necessary not to make assumptions about students' backgrounds, but instead to engage students in identifying and addressing their knowledge, attitudes, and potential biases regarding diverse populations.
There are several limitations to this study. A convenience sample was used, and students who agreed to participate may not represent the student cohort as a whole. There were less students in the accelerated cohort than in the traditional cohort, resulting in differences that may not have been detected. Finally, responses to the instruments were self-reported and are not diagnostic of any emotional or cognitive condition.
Nurses have the opportunity to address the adverse health effects of poverty through culturally competent care, including communication and shared decision making. Nursing education can improve cultural competence through addressing past experience with populations experiencing poverty. Public health nursing courses need to provide students not only with exposure to individuals experiencing poverty, but also with opportunities for reflection to examine personal beliefs, unconscious biases, and judgments of those living in poverty (Hellman et al., 2018). This study was an initial step in understanding how empathy and attitudes toward poverty differ in nursing students based on prior experience and demographics, and provides a foundation for future curriculum development and education inquiry.
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|Characteristic||Traditional Cohort, n (%) (n = 82)||Accelerated Cohort, n (%) (n = 22)|
| 21 to 29||70 (85.4)||20 (91)|
| 30 to 39||10 (12.2)||1 (4.5)|
| 40 to 49||2 (2.4)||1 (4.5)|
| Female||71 (86.7)||21 (95.4)|
| Male||9 (11)||1 (4.5)|
| Asian||7 (8.5)||6 (27.2)|
| African American||7 (8.5)||4 (18.1)|
| Hispanic||4 (4.9)||1 (4.5)|
| White||64 (78)||11 (50)|
|Volunteer experience with individuals living in poverty|
| Yes||44 (53.7)||18 (81.8)|
| No||38 (46.3)||4 (18.1)|
|Personal experience with poverty|
| Yes||27 (33)||4 (18.1)|
| No||46 (56)||15 (68.1)|
| Christianity||59 (72)||14 (63.6)|
| Judaism||6 (7.3)||1 (4.5)|
| Islam||1 (1.2)||0 (0)|
| Buddhism||3 (3.7)||1 (4.5)|
| Other||0 (0)||2 (9)|
| No affiliation||10 (12.2)||3 (13.6)|
| Extremely liberal||3 (3.7)||0 (0)|
| Moderately liberal||17 (20.7)||9 (40.9)|
| Slightly liberal||11 (13.4)||2 (9)|
| Neither liberal nor conservative||32 (39)||2 (9)|
| Slightly conservative||8 (9.8)||0 (0)|
| Moderately conservative||9 (11)||0 (0)|
| Extremely conservative||1 (1.2)||0 (0)|