Understanding poverty through virtual simulation: implications for student clinical practice

Introduction

People and families who have low-income and are living in poverty utilize a significant part of the nation’s healthcare system. According to the United States Census Bureau, 11.4 % of families in the United States live below the poverty line [1]. Within nursing education, clinical rotations for undergraduate nursing students commonly emphasize hospital-based and acute care approaches to nursing, leaving less room in the syllabus for community-based care education, especially related to individuals experiencing poverty. Nursing education curricula has not traditionally integrated social determinants of health including job security and other conditions in the environment that influence where people are born, live, work, and age [2]. With recent recommendations from the American Association of Colleges of Nursing (AACN) [3] to introduce competency-based nursing education, additional emphasis is placed on the need to actively engage students in learning activities and assessments. Further, the impact of COVID-19 on nursing education also revealed gaps in nursing curriculum delivery methods, demonstrating a clear need to provide alternative modes of delivery to supplement face-to-face teaching environments. Evidence demonstrating the effects of virtual poverty simulation usage in nursing education is currently limited based on a literature review. To date, use of a face-to-face poverty simulation among nursing students has been demonstrated to be an effective poverty teaching intervention, through increasing student nurses’ empathy and compassion, promoting understanding of the association between poverty and health, and stimulating social justice [4]. Subsequently, the purpose of this paper is to demonstrate the use of a virtual poverty simulation using the online game to improve nursing student understanding of community-based care for patients and families who have low-income and are living in poverty.

Sample

The sample included senior-level nursing students from a Midwest baccalaureate nursing program (United States). All nursing students enrolled in the spring 2021 cohort during a community clinical rotation were included, with a total sample of 89. No inclusion or exclusion criteria were included because students were preselected in the admission process to the nursing program, prior to the development of this quality improvement study. Demographic data collected from students included their age, gender, ethnicity, and if the student had previously lived in poverty. Demographic data was listed as a question on the anonymous survey completed during the study. No data was retrieved from private student files. The majority of the study participants identified as Caucasian, while a smaller percentage identified as non-Caucasian. 93 % of the study participants were female and 7 % were male. The mean age of study participants was 22 years of age. Variables included previous misconceptions, bias, or personal life experiences related to poverty and impoverished populations.

Methods

Results

The post-simulation reflective journaling and the SET-M were used to determine the results of this quality improvement project. Both data sets were compiled using online surveys. The reflective journals and the SET-M online surveys were analyzed using thematic analyses to determine if student learning occurred.

The SET-M data concluded that 98 % of students agree or strongly agree that completion of prework increased confidence and learning of patients and families with low-income. 94 % of students agree or strongly agree that participating in the simulation empowered them to make clinical decisions and increased confidence in prioritizing care and interventions for patients and families who have low-income while communicating and reporting information with the interdisciplinary team. Additionally, 98 % of students agree or strongly agree that engaging in the simulation debriefing contributed to their learning, was valuable in improving clinical judgement, and provided the opportunity for self-reflection. Lastly, 94 % of students agree or strongly agree that the simulation overall increased feelings of the desire to foster patient safety.

Reflective journal analysis revealed four common themes. Social empathy, improved understanding of patients and families who have low-income, increased awareness of inadequate decision-making skills of patients and families who have low-income, and the cyclic nature of poverty were the four themes that emerged from journal analysis. Other less common themes that emerged were compassion and social justice.

Discussion

Social empathy and the cyclic nature of poverty were recognized by students in journal entries. Acknowledgement of the understanding that lack of general financial and social means contributes to the cyclic and generational nature of poverty was noted by many participants. Another observation made by students was the inability of families who have low-income to develop financial plans due to limited finances and knowledge or access to resources which further contributes to poverty. Students demonstrated understanding of the contributing factors related to families living in poverty, after participating in the virtual poverty simulation, Additionally, students manifested a nonjudgmental and empathetic attitude towards patients and families who have low-income and who live in poverty. The sense of increased awareness of the difficult yet necessary decisions patients and families who have low-income must make, was remarkably noted after the students experienced this simulation.

The reflective journal themes are evidence that numerous students were unaware of the many facets of poverty. Recognizing the barriers and challenges related to poverty stimulates a sense of social empathy and desire to assist patients and families in navigating their personal situation. Students appeared to be potentially influenced by the virtual poverty simulation because it allowed them to role play the difficult choices patients and families who have low-income and live in poverty. Placing themselves in the place of these patients and families allowed students to reevaluate preconceived notions of this specific population. Students were also unfamiliar with the numerous challenges and barriers families had to overcome to reach those services. Finally, students reflected upon the realization that poverty is a cycle and they learned the pivotal role nursing can play in assisting patients experiencing poverty.

Implications for an international audience

Implementation of the virtual poverty simulation using the online game, Spent, provided an opportunity to demonstrate a virtual simulation during a time period time when face-to-face learning was impossible (i.e., COVID-19 pandemic restrictions). In addition, the virtual poverty simulation was shared with other online baccalaureate programs within the College of Nursing for adoption into their curriculum. This virtual poverty simulation also provides an opportunity to expand to other schools within the university setting such as education, social work, elementary and secondary education, and police science. The virtual element of this simulation provides flexibility and space for multiple participants that previously had been a barrier to in-person poverty based simulations or poverty based clinical options.

Conclusions

Utilization of the virtual poverty simulation improved learning outcomes for students based on the results of this quality improvement project. Students reported an improved understanding of barriers related to health for patients and families who have low-income and live in poverty. Further, use of this virtual poverty simulation will offer nursing instructors a standardized simulation template that can be recreated in the future, and used in both traditional and nontraditional educational settings.