What It's like to be Poor: Teaching RN-to-BSN Students about Poverty

Why a Poverty Simulation?

The poverty simulation we have used for many years with our prelicensure students has been found to be a beneficial way to introduce core concepts taught in a community health nursing course. However, the simulation had not been used with RN-to-BSN students taking a similar community health course. To better align the two courses, the nursing school faculty decided to include the poverty simulation for the RN-to-BSN students as well. Aligning the prelicensure and RN-to-BSN courses is important, as both groups of students are earning the same degree and, therefore, must meet the standards set forth by the American Association of Colleges of Nursing's (AACN's) Essentials for Baccalaureate Education for Professional Nursing Practice (AACN, 2008). Further, in a study of 117 RNs using the Attitudes Toward Poverty Short Form, Wittenauer and colleagues found negative attitudes toward people in poverty; however, nurses with a BSN degree or higher, as compared to nurses with an Associate's Degree or Diploma, tended to view poverty from a structural standpoint rather than as a personal flaw (Wittenauer, Ludwick, Baughman, & Fishbein, 2015). Poverty simulations have been found to improve future healthcare workers ‘attitudes toward people in poverty (Clarke, Sedlacek, & Watson, 2016; Noone, Sideras, Gubrud-Howe, Voss, & Matthews, 2012). Would a one-day poverty simulation have the same impact on RNs, who are already enculturated into the nursing profession?

The Poverty Simulation

The Community Action Poverty Simulation (CAPS), developed by the Missouri Community Action Network (Missouri Community Action Network, n.d.), is an interactive experience that sensitizes participants to the realities of poverty. Participants role-play the lives of low-income families, from single parents trying to care for their children to senior citizens trying to live on Social Security income alone. The goal of the experience is for each individual to survive for a month, facing daily stressors and challenges that a person in poverty is likely to encounter—for example, figuring out problems with transportation to and from work or school, how to put food on the table with little income, and how to manage a chronic illness.

The students receive a role to play that represents a person with a particular story and family. The people represented in the simulation were developed based on actual stories encountered by individuals and families throughout the United States who live in poverty.

The simulation takes 2 to 4 hours, including time for debriefing. The scenario is that students, who have been placed into families, will spend one month living in poverty. Each 15-minute segment is equivalent to 1 week. During the week, students work with their simulated families to navigate daily life, which may include going to work, paying bills, and seeking help from community agencies. Some of the struggles that students encounter include managing transportation requirements in order to move between agencies, as well as forgetting their photo identification cards which results in not accomplishing their business with the agencies. They may forget to secure their assets, which may result in theft, or even forget to attend to their children (represented by dolls), which are often left unattended and hungry.

Resources in the form of representatives of community agencies are available to assist the families and are included in the simulation. Faculty and community volunteers usually serve in these roles. It is a challenge for the participants to realize what they need to do, and which agencies can help them. Throughout the simulation, a director helps manage the flow and time, and answers student questions if needed. The director also leads the students in the debriefing, helping them make connections between the simulation experience and course concepts.

The Importance of Debriefing

A great deal of learning occurs during the debriefing phase of the simulation experience. Proper debriefing creates an environment that fosters understanding; either reinforces or alters the knowledge, skills, and attitudes of the participants; and further develops the professional role. The students are brought together to reflect on the poverty experience, share their thoughts with one another, and gain further knowledge about individuals experiencing poverty.

As practitioners, the RN-to-BSN students bring professional experience to debriefing which is very different from that of the traditional prelicensure students, who may be working in health care and in contact with patients and families, but not in the role of a professional nurse. They can reflect on interactions with patients they have cared for who experience poverty. They often admit their dependence on the social worker to interject and make opportunities and resources available to the patient, so they can focus on other nursing tasks. After participating in the poverty simulation, the students often share in debriefing how the experience gives them empathy for the patient rather than sympathy. This newfound empathy awakens the advocate in the nurse. The new knowledge gained during debriefing can reshape the professional role of the nurse, as each student will have future encounters with patients experiencing poverty.

A surprising finding during debriefing has occurred when students share that they grew up in poverty. This seems to happen more often with the RN-to-BSN students than with the prelicensure students. For students who grew up in poverty, this simulation can be painful, especially when negative stereotypes of people in poverty are brought forward by other students. The debriefer must take care to remind students that these situations are real, and are not to be made fun of or belittled.

Student Feedback

After completing the simulation, students completed a brief survey through our learning management

The goal of the experience is for each individual to survive for a month, facing daily stressors and challenges that a person in poverty is likely to encounter (for example, transportation to and from work or school, putting food on the table with little income, and managing a chronic illness).

For students who grew up in poverty, this simulation can be painful, especially when negative stereotypes of people in poverty are brought forward by other students; the debriefer must take care to remind students that these situations are real, and are not to be made fun of or belittled.

Future Plans

Consistently positive feedback from students has created a desire to continue some type of poverty simulation for RN-to-BSN students in their community health nursing course. However, continuing evaluations and revisions are necessary to ensure that this experience remains worthwhile. While the structure (student roles, vendor roles, and overall room setup of the CAPS simulation) cannot be changed, adaptations have to be made in the delivery, often driven by the number of students in the course. For small classes, the number of families and vendors is reduced, which gives the faculty the ability to choose the family scenarios. The simulation is designed to be adapted to meet the needs of the group.

Assessing the students ‘attitudes before the simulation as well as after the simulation would be a helpful addition, perhaps utilizing the Attitudes Toward Poverty Short Form, as described by Wittenauer et al. (2015), especially since some researchers have found that a one-time poverty simulation may change attitudes at the time, but those attitude changes do not last (Browne & Roll, 2016; Nickols & Nielsen, 2011). Hellman and colleagues ‘solution to this was to divide the simulation into two parts presented over 2 weeks and to include reflective journaling throughout the 2 weeks (Hellman, Cass, Cathey, Smith, & Hurley, 2018). An adaptation we have made is to supplement the face-to-face simulation with other online activities and reflections that simulate poverty. However, because the RN-to-BSN students are already working, they have opportunities to apply this new knowledge immediately to their nursing practice, rather than waiting, as prelicensure graduates do. The simulation debriefing allows them to share stories from practice that relate to the simulation experience.

Because health care is not specifically addressed in this simulation, students may need help in reflecting on the impact of poverty on health (Patterson & Hulton, 2012). Because of this, students complete a concurrent assignment on health-care financing, specifically Medicare, Medicaid, and private insurance, to learn more about the cost of health care.

Finally, plans are being made to create simulations that can be used to teach students about poverty regardless of the number enrolled in the course or where the cohort is geographically located. Because the poverty simulation we have been using is designed for large groups, we have created an additional simulation that can be used with fewer students. It involves making a home visit to a homeless person in a shelter. And because the current trend is for RN-to-BSN programs to be online, we are exploring ways to create video simulations for our students, particularly those located far away geographically. Some online programs using virtual simulation have yielded positive outcomes (Breen & Jones, 2015).

Overall, the use of the poverty simulation with RN-to-BSN students appeared to be beneficial to students ‘learning important course concepts in their community health nursing course. While some students reported that their attitudes toward people in poverty did change in the short term, more evidence is needed to determine how to sustain these changes over time. However, the goal of addressing the AACN Essentials was met through this simulation experience, and we plan to continue to use poverty simulations with RN-to-BSN students.