Poverty Simulation: Educating students and providers in healthcare disciplines to reduce bias

Presenter(s)

Farron Kilburn, Megan England

Abstract or Description

Abstract Title: Poverty Simulation: Educating students and providers in healthcare disciplines to reduce bias 

Background & Problem: Poverty is a determinant of health that is associated with higher rates of chronic illness and poor health outcomes (Braveman, Arkin, Orleans, Proctor, & Plough, 2017). For individuals from more privileged backgrounds, health equity can be an abstract concept. Many have a limited understanding of the practical implications poverty has on health outcomes. This disconnect can perpetuate existing health inequities, limit perspectives, and negatively affect attitudes (Elias et al., 2016).   

Purpose: It is critical for healthcare providers, especially nurse practitioners, to understand and reduce negative attitudes about the impoverished and underserved to improve patient care and health outcomes. The purpose of this study is to reduce stigma surrounding poverty and to increase cultural competency of nurse practitioners and those working in human service professions.  

Discussion of issue or concepts/variables of interest: A Nursing School in the Southeast implemented the Community Action Poverty Simulation (CAPS) from the Missouri Community Action Network as a tool to help graduate nursing students, undergraduate students in health and human service disciplines, and community providers understand the reality of poverty and how it impacts individuals’ health care choices. As a COVID-19 adaptation to the in-person poverty simulation, researchers administered an online tool in Spring 2020 and Summer 2021 called SPENT, a virtual game developed by Urban Ministries of Durham with similar objectives as CAPS (Urban Ministries of Durham, 2012).  

Project Scope - Population, Sample, & Setting: Through 2019-2020 there have been three face-to-face poverty simulations with a total 186 participants. Face-to-face CAPS took place on-campus at a mid-sized urban institution of higher education. Graduate family nurse practitioner (FNP) students participated as part of their coursework, and undergraduate and graduate students from education, nutrition, physical therapy, and public health programs also participated. Up to 10% of participants were community members. Over Spring 2020 and Summer 2021 there were 67 Spent Game participants (with the Diamond Debrief methodology applied). Participants were FNP students and undergraduate students from multiple disciplines. Two additional face-to-face poverty simulations took place in November 2021. Data is being analyzed from the November simulations and is forthcoming. Additional SPENT game data (n=41) from Fall 2021 is being analyzed.

Methodology: The Attitude Toward Poverty Scale (ATPS) was utilized to assess three factors affecting attitudes toward poverty pre- and post-simulation for the in-person CAPS. The ATPS utilizes a Likert-scale to evaluate stigma, structural perspectives, and personal deficiencies regarding poverty (Yun & Weaver, 2010).  In the online SPENT Game intervention, we applied the Diamond Debriefing tool used in health care simulations to provide a thorough prebrief and debrief framework for groups of 20 students (maximum) at a time before and directly following the SPENT Game activity (Jaye, Thomas, & Reedy, 2015). The same ATPS pre- and post-surveys were administered before and after the SPENT Game. Each simulation data set was analyzed separately and as an aggregate whole using paired t-tests and SPSS. Results were consistent across each in-person simulation. SPENT Game participant data was collected and analyzed separately to compare outcomes.

Findings and Conclusions: Paired samples t-test have shown a statistically significant change in attitudes towards people living in poverty across all three factors for the in-person CAPS poverty simulation (1) stigma (p<.001), (2) structural perspectives (p<.001), and (3) personal deficiency (p<.05). The significance of the scores remained consistent across graduate nursing students, undergraduate students in helping professions, and community members. The virtual Spent Game data results differed slightly. Pre-test scores for both in-person and virtual Spent Game participants were comparable. The virtual SPENT Game data showed a statistically significant change in overall attitudes toward people living in poverty (p<.001); however, when analyzing  the data across all three factors, only one, stigma, showed a significant pre- and post-test change (p<.001) while the structural perspectives and personal deficiency factors did not reveal significant shifts in attitude change as a result of the intervention. Outcomes for graduate nursing student Spent Game participants differed from other student participants when analyzed separately; graduate nursing student data revealed significant changes in overall attitudes toward poverty (p<.001), stigma (p<.001) and personal deficiency (p<.05).  

Implications: The CAPS has been integrated into the nurse practitioner curriculum and subsequent simulations have been scheduled to take place each semester on the University campus. Other courses from various human service departments on campus have responded to the significant results in shifts around attitudes toward poverty by  also integrating the face-to-face poverty simulation into their curriculum. Preliminary virtual SPENT Game outcomes utilizing the diamond debrief framework indicate positive, significant results, though not as significant as a face-to-face intervention. Integration of a CAPS simulation and the virtual Spent Game tool using the diamond debrief framework into NP Program curriculum are two data-supported, replicable strategies for shifting student attitudes toward poverty and preparing future NPs and those in service professions  to provide more culturally competent care.  

References: 

Braveman, P., Arkin, E., Orleans, T., Proctor, D., & Plough, A. (2017). What is health equity? Retrieved from https:// www.rwjf.org/en/library/research/2017/05/what-is-healthequity-.html 

Elias, T., Williams, K. R., Hershey, T. B., Documet, P. I., Barinas-Mitchell, E., & Gary-Webb, T. (2016). The Health Equity Certificate program: A targeted approach to reducing health disparities and increasing the competence of health professional students. Pedagogy in Health Promotion, 3, 187-194. doi:10.1177/2373379916665637 

Jaye, P., Thomas, L., Reedy, G. (2015). The diamond: A structure for simulation debrief. Clinical Teaching, 12(3), 171-175.  

Urban Ministries of Durham. (2012). SPENT. Retrieved from http://playspent.org/ 

Yun, S. H., & Weaver, R. D. (2010). Development and Validation of a Short Form of the Attitude Toward Poverty Scale. Advances in Social Work, 11, 174-187. 

Learning Objectives: 

·      Explain how to facilitate an interprofessional face-to-face and virtual poverty simulations and promote them in your community.  

·      Describe learning benefits and outcomes for face-to-face poverty simulation participants.  

·      Describe learning benefits and outcomes for online virtual Spent Game using the Diamond Debrief framework. 

·      Identify how a poverty simulation can shift attitudes toward poverty.