Inherent to quality practice of any nursing specialty such as forensic nursing is the content provided in the generalist baccalaureate curriculum. That content underpins the accumulation of specialized knowledge and practice. From this basis, a generalist nurse can approach a nursing specialty from a holistic, caring framework embedded in a social justice perspective. Because of a positive correlation historically occurring between poverty and violence, nurse educators must approach social justice in the context that every nursing student will most likely encounter patients from vulnerable populations such as those living in poverty and with health disparities. When examining rates of stranger and intimate partner violence, Lauristen, Rezey, and Heimer (2014) found a positive correlation between poverty and violence and noted that rates of violence, particularly against women, increased significantly (Faber & Miller-Cribbs, 2014). In addition, Loya (2014) asserts that those facing economic instability face an increased risk for sexual violence. To further compound dynamics of poverty, victims in abusive relationships often miss days at work or are unable to work because of a controlling partner. Some victims may participate in high-risk behaviors such as drugs or alcohol (Farber & Miller-Cribbs, 2014). In addition, nurse educators must impress upon students that those living in poverty may resort to high-risk behaviors as means of survival. Those practicing high-risk behaviors and trapped in impoverished situations pose a higher probability of being eventually cared for by a forensic nurse in the contexts of intimate partner violence, sexual violence, intentional injury, and neglect. Presenting such populations to students effectively, nurse educators must present information in the context of social justice.

Social justice is an idea many professions and especially those related to health care identify as necessary to incorporate into practice. It is suggested by Windsor, Shorkey, and Battler (2015) that "social justice requires a society where resources are equitably distributed and the full potential of all of its members is supported" (pp. 60-61). Drevdahl (2013), however, argues that social justice has not been adequately defined but proposes an understanding of "justice as having to do with fairness, especially with respect to how people are treated, how decisions are made, and how resources are distributed, all of which apply to health and health care" (p. 49). Nevertheless, one is cautioned to examine the meaning further by Edmonson, McCarthy, Trent-Adams, McCain, and Marshall (2017) stating that "social justice is more than treating people fairly; it involves rejection of the status quo for the greater good" (para. 17). Although the definition may be debatable, many agree that social justice is a worthy pursuit requiring the involvement of many healthcare areas. Dilworth-Anderson, Pierre, and Hilliard (2012) discuss how the application of social justice for healthcare is not exclusive to one area of healthcare but rather all areas. They further add that, "in the context of health disparities, social justice refers to the minimization of social and economic conditions that adversely affect the health of individuals and communities" (Dilworth-Anderson et al., 2012, pp. 26-27). Finally, the American Nurses Association emphasizes the importance of social justice in their ethics and human rights statement asserting that "ethics, human rights, and nursing converge as a formidable instrument for social justice and human rights must be diligently protected and promoted" (Butts & Rich, 2016, Appendix B, p. 483).

There is limited research examining the incorporation of social justice into undergraduate nursing education, yet social justice is central to leadership within the nursing profession (Groh, Stallwood, & Daniels, 2011). The American Association of Colleges of Nursing sets forth the Essentials for Baccalaureate Education as the guide for building the framework and curricular elements for baccalaureate nursing education in the 21st century. The teaching of social justice is identified as one of the essentials of baccalaureate nursing education (Groh et al., 2011). Among the assumptions put forth by the Essentials document is that student nurses will be educated in a way that promotes practice from a holistic, caring framework as they provide direct and indirect care for diverse populations. Weaving social justice into baccalaureate nursing education in contexts of vulnerable populations and health disparities is vital to our society and our patients.

An integral part of understanding and promoting social justice as nurses is the development of social empathy. As defined by Segal (2011), "social empathy is the ability to more deeply understand people by perceiving or experiencing their life situations and as a result gain insight into structural inequalities and disparities" (p. 266). Segal and Wagaman (2017) found that social empathy developed student' understanding of social justice. Nurse educators strive to find methods by which to assist the students' development of social empathy. Simulations are proving to be gateways to an increased understanding of patient experiences.

Since the 1940s, nursing education has promoted increased use of simulations as excellent teaching tools because students become stakeholders in the process of learning (Sanford, 2010). Using contextually based simulations to explore conditions that create opportunities and inequalities, students learn in three ways: through exposure, by which students learn of the differences and inequalities that structure people's lives; through explanation, which promotes the students to gain insight of how and why lives are structured because of differences and inequalities; and through experience, by which students imagine themselves in the lives of people whom they consider to be different from themselves (Adelman, Rosenberg, & Hobart, 2016). Poverty simulations provide contextually based learning environments by which students can gain knowledge in these three ways. Nickols and Nielsen (2011) concluded after their experience with poverty simulation that simulation was an adjunct to the classroom and "develops a more nuanced understanding of what it means to be poor[horizontal ellipsis] [where] surely, this[horizontal ellipsis]understanding is a precursor, if not a companion, of social empathy" (p. 40). Therefore, nurse educators might consider the use of poverty simulations to build social empathy and assist students in understanding social justice.

The purpose of a poverty simulation is to encourage students to reflect on the misconceptions, biases, and judgments regarding people who live in poverty and experience some of the pressures that they face within a safe environment. Segal (2011) asserts that the best way to change inequalities and disparities is to create experiences in which people can gain "deep contextual knowledge and have experiences that create empathetic insights into the lives of people who are oppressed" (p. 267). Without developing social empathy, people may be prone to believing stereotypes and be intolerant of others who are different. In contrast, Segal proposes that developing social empathy leads to positive behaviors and interactions such as cooperation, altruism, helping others, deepened understanding of others' needs, belief in social responsibility, and consideration of needed social changes. Segal further asserts that "individual empathy alone is insufficient to lead us to solutions for large-scale domestic or global problems. Therefore, if the understanding of large-scale social problems like poverty is limited to individual perception, it can be flawed or inaccurate" (p. 270).

Design/Methods

To identify changes in attitudes and understanding of living in poverty in senior baccalaureate students, a team of nursing researchers conducted an exploratory qualitative study using content analysis to investigate the possible increase in empathy and social justice beliefs among undergraduate nursing students. The researchers situated the study in a state university baccalaureate nursing program's community health course for senior level nursing students. Study participants numbered 113 and were between the ages of 22 and 47 years, were predominantly female (male = 14, female = 99), largely White (White = 110, Black = 2, Pacific Islander = 1), and lived in primarily a rural area before entering the university (rural = 79, urban = 34). As one of the final courses of their education, the "healthcare of communities" course is perfectly situated to immerse students into practices promoting an appreciation of living in poverty and a greater understanding of social justice. In addition, most of these graduates will practice within a state having poverty rates above the national average with one of every six residents living in poverty (18.4%; Times Free Press, 2014). It is imperative for them to gain in-depth understanding as it will significantly influence their nursing practice. As a generalist curriculum is a requirement of nurses who may specialize in forensic nursing, it is essential that educational methods fostering the development of increased empathy and practice of social justice behaviors be incorporated.

The poverty simulation kit was developed by the Missouri Association for Community Action. After university institutional review board approval, individual reflection journals from three different intervals of the two-part poverty simulation activity provided data for analysis. The poverty simulation occurred on 2 different days with at least 1 week in between sessions to promote student reflection on the experience. Before the first simulation experience, students were asked the following questions to examine their understanding of and initial feelings toward those who live in poverty. The reflection journal questions used were as follows: "Describe what you think 'living in poverty' means," "What would that experience be like?", "Why do you think people live in poverty?", "Why do you think the unemployed/underemployed can't find a job?", "Under what circumstances should the government help people?", "How do you feel when you see people living on the street?", and "Do you think that people who are living in poverty are to blame for their situation?" After completing the first poverty simulation session and before entering into the second session, students were asked to describe their feelings about participating in the simulation a second time using the following question: "As you think about entering the poverty simulation for the second time, please describe your feelings." After completion of the second simulation session, students answered questions about their experience, were encouraged to explore how their feelings may have changed because of the two simulation sessions, and were prompted to share how they would use this experience to guide their future nursing practice. The questions used were as follows: "How will your experience in the poverty simulation affect your future nursing practice?"; "If you were given the opportunity to describe the effects of living in poverty on your decision making to your colleagues, what would you say?"; and "How have your feelings about poverty and living in poverty changed as a result of participating in the poverty simulation?" Inductive content analysis of the students' reflection journals by the research team occurred at the conclusion of all simulation sessions. Central themes and student exemplars are presented in the following section.

Findings

Reading, analyzing, and inductive interpretive process produced three constitutive patterns and eight supporting themes. The constitutive patterns were "exploring self and previous beliefs," "enhanced understanding," and "recognizing need for action." Data revealed that students performed a process of self-reflection about previously held opinions of the impoverished population.

Exploring Self and Previous Beliefs

Students' responses lead to the constitutive pattern of "exploring self and previous beliefs." Supporting themes of this pattern included "feeling unsafe," "blaming the poor," and "doing anything to survive." The concept that the impoverished and homeless live in unsafe environments led many students to report feelings of danger and need for caution when exposed to this population.

I am cautious when I see homeless people. I question their intent.

It is easy to feel fearful due to the stigma surrounding homeless people. Homeless people can often be dangerous.

Sometimes these people also frighten me because I am scared they may try and steal from me.

Sometimes I am even fearful of those living on the street because there are situations where they can be quite aggressive.

Data included information about who students felt were to blame for this population's situation and when government assistance was appropriate. Many felt that poor decision-making (ie, criminal activity, drug and alcohol abuse, poor financial planning) and lack of initiative or drive were largely to blame. Students also voiced that government assistance should be withheld from those of this population who participate in illegal activities, with drug screening being a qualifying caveat. This resulted in the supporting theme "blaming the poor."

I do not believe that people who abuse the system should be helped anymore; examples include drug abuse, selling food stamps and fraud.

I do not support government assistance for people with long arrest records and those who cannot pass drug tests.

You can also have those people who are just too lazy to get jobs or buy drugs and partake in illegal activities which prevents them from getting jobs, and I feel these types of people are to blame for their poverty.

I believe that some of the people living on the streets are "to blame" because of the choices that they made[horizontal ellipsis]whether it be drugs or gang association.

Presimulation responses targeted participants' preconceptions regarding the impoverished population. Before participating in the simulation, students reported a negative feeling toward the impoverished and high rates of criminal activity among this population. Between the first and second simulation sessions, students expressed a better understanding as to why this vulnerable population is often associated with criminal activity and an unsafe environment. Illegal activity began to be viewed as a means of getting by and a way of survival, leading to the theme "doing anything to survive." They reported finding themselves considering or engaging in illegal acts during the simulation as a means of survival.

With these situations, many times, people are forced to participate in illegal activity (drug dealing, prostitution, etc.) simply to make ends meet and provide that bare minimum for their families.

There came a point in time during the simulation where all of our resources had been exhausted and my mind immediately thought about doing illegal activities just to provide for my family.

You almost stop caring about the consequences of the situation. You don't care if you have to steal money to feed your child, because if you do not feed your family they could possibly die.

These people are often so desperate that they will turn to illegal activities to make money and this is often out of necessity, not because they have poor moral character.

It was stressful and overwhelming. This leads to poor decision making because you eventually get to a point where you simply have to do whatever you can to survive. Whether it may be something unethical or illegal.

Enhanced Understanding

Supporting the constitutive pattern of "enhanced understanding," themes of "living stressfully" and "affecting one's health" emerged from the data. Students reflected on the emotions that would surround living an impoverished life. Feelings of fear, high stress, hopelessness, and frustration repeatedly appeared in the students' reflection entries as well as a general change in perspective regarding members of this population. Reflecting on the experiences and emotions that someone in poverty might feel resulted in expressions of empathy, compassion, and sadness by the students. For some, the simulation increased previously held feelings; for others, such feelings emerged from exposure to an unknown or unnoticed way of life. Students particularly referenced the population's ability to access health care.

The experience (poverty) would be scary, stressful, and a daily struggle.

It can truly happen to anyone. You do not have to be lazy or a drug addict to be living in poverty.

It has changed my way of thinking because previously, I figured that people who lived in poverty put themselves in that situation.

It's no wonder this population is so vulnerable to disease and health concerns. Aside from not being able to afford and often receive health care because of logistical concerns, the amount of stress these people deal with is enough for anyone to have a mental breakdown, every day.

Ultimately poverty causes individuals to make decisions that might make a negative impact on health and wellness but if they don't make those choices them or their children might not eat or have a place to live.

My health came last to my child's and other family members. I imagine this is the same in true impoverished family situations.

After the completed simulation sessions, researchers prompted students to explore how the constraints of poverty impacted their decision-making and how the experience might influence their future nursing practice. Many reported that the overwhelming stress of poverty ultimately led to poor decision-making during the simulation. They also reported gaining a greater understanding of why this population resorts to criminal activity and acknowledged the misconceptions surrounding noncompliance versus inability to comply within this population.

Recognizing Need for Action

In addition, a recognition of a desire to change current nursing care for persons experiencing impoverishment was evident. Composing the constitutive pattern of "recognizing the need for action" are the supporting themes of "listening actively and compassionately," "calling for advocacy," and "promoting equity." The constitutive pattern of "recognizing the need for action" is most evident in the prevalence of students voicing a desire for action to problem-solve for impoverished patients. This was expressed in terms of being engaged listeners, being active observers, and being involved participants with their patients. To recognize when intervention is needed, "listening actively and compassionately" should be a nurse's first response as manifested in the following exemplars.

It makes you want to work with them more and really connect with them so you know they aren't going home worried about what is going to happen next.

I think this will also help me to work with my patient struggling with this issue to be able to handle life decisions and issues if I understand their stress.

I feel this simulation will help me remember during times of stress and/or when patients are asking for multiple items you never know what they are going through at home and to show compassion for them because you never know one's situation.

I think seeing it from a family's perspective helps me better understand how to be compassionate and look differently at situations and hopefully when I do get the opportunity to care for a homeless or the very low income population, that I can be better of assistance and help to make changes to their lives.

The supporting theme of "calling for advocacy" was evident throughout students' reflections. Advocacy was linked to an increased desire for action after a better understanding of impoverished people, an expressed goal of decreasing the struggle or stress of those in poverty, an emphasis on self-awareness for better treatment of these patients, and realization that nurses have active roles in advocacy in all facets of patient care. After experiencing restraints inherent in poverty, students emphasized the need to avoid complacency in providing care.

As a nurse, my goal is to be an advocate for these patients who may not understand the medical system process or what they are able to receive and I hope to be their voice.

I never judged someone based on their financial status before simulations[horizontal ellipsis]. This simulation has opened my eyes that I need to go above and beyond to advocate for my patient more that I already do.

I will also remember to keep this simulation in mind when advocating for patients by avoiding unnecessary charges and making sure they can afford the medications that are prescribed.

We must refer them to the right people in order for them to obtain needed resources in order for survival. It's our job to be patient advocates and assure our patients can maintain health status outside of the hospital.

Finally, self-awareness of prejudice and need for equal treatment were observed in the theme of "calling for advocacy." A prompter question in a reflection journal guided students to consider how they would approach teaching their colleagues about poverty. This question encouraged students to connect the current poverty simulation to their future nursing environment.

I would tell my colleagues poverty isn't what you think it is[horizontal ellipsis]. Next time you have a patient who is living in poverty or homeless, consider his/her story and be an advocate not a gossip in the nurse's station.

I would say [to future nursing colleagues] to have patience and treat all patients the same. Even though it may be easy to judge, we never know what someone has been through.

We, as nurses, must remain non-judgmental and treat the patient the best we possibly can, no matter what our views or opinions may be.

I would advise them to not be so quick to bash a patient about not having insurance or attending a cardiac rehab session. Sometimes patients have to pick between going to cardiac rehab and eating.

Forgive them if they are not the "best" patient, because they are just worried about how they will be able to make it.

The final supporting theme of the constitutive pattern "recognizing need for action" is the supporting theme of "promoting equity." Health inequity presented in terms of poor perception and stereotypes by health providers. Responsibilities highlighted by students included educating and connecting patients with health resources, reflecting on patients' situations before judging, increasing self-awareness of prejudice, and probing beyond the surface to assess needs. Education was a large component to responses about the nursing role. There was evidence of understanding that education needs to be appropriate and meaningful as well as having an emphasis on long-term health and access.

For a nurse, it is crucial for us to educate these patients that there are support groups, education on finances, benefits, and other great tools and resources that could really benefit them and save them a lot of stress and worry.

Sometimes people's needs get overlooked due to different circumstances but as nurses, and as a nurse who has experienced a poverty simulation, it is very important that we do everything within our power to help them receive the aid they need.

Since I know that some people are struggling, but don't want to ask for help, I will make an effort to talk to my patients and find out about their home life situation.

Discussion

The intent of a poverty simulation in nursing education is to prepare students for best practice after graduation. Often, in simulations, learning may be mechanical, focusing on tasks; however, on occasion, learning may be profound. Nevertheless, even when learning begins at the mechanical level, understanding may evolve into the profundity the nursing profession is attempting to cultivate through practice. As shown in this study, after completion of the first simulation session, a change in perspectives among students became evident. Students verbalized that poverty is a complex situation and the causative reasons for such are multifaceted. In addition, students expressed that overcoming poverty is a difficult task and living this way is most often not by choice. Although understanding perceptions and stereotypes can decrease equity, students came to better understand that lack of resources (i.e., money and time) decreased equity as well. Students' changing perspectives especially focused on how the impoverished population accesses and uses health care. Student beliefs evolved to increased sympathy and compassion, which challenged their previously held beliefs. Furthermore, such newly discovered understanding fostered a cry for advocacy on behalf of their patients. In addition, the overarching idea presented that, through better and informed care, there can and should be a decrease in the struggle and stress of poverty. Use of the poverty simulation in this study supported findings in nursing and other disciplines (Nickols & Nielsen, 2011; Patterson & Hulton, 2011). Vandsburger, Duncan-Daston, Akerson, and Dillon (2010) reported that "[horizontal ellipsis]it is encouraging to presume that if students are exposed to the experience of being poor and they incorporate such experiences, they are more prepared to engage in working with the poor upon graduation" (p. 312).

Implications for Clinical Forensic Nursing Practice

Simulations to teach technical skills, procedures, and other nuances of forensic nursing practice are common. However, methods to impart beliefs and ethics that contribute to ethical forensic nursing practice are rare (Doane, Pauly, Brown, & McPherson, 2004). Social justice and social empathy as emphasized in the studied poverty simulation provide much needed prominence on the ethical development of new nurses. New nurses compose the recruitment base for the future of forensic nursing practice. As such, encouraging heightened levels of compassion and empathy for vulnerable populations whom they will serve will only improve the quality of care provided. Further proven methods that increase compassion and empathy toward vulnerable populations might also lead students to choose forensic nursing over other nursing specialties. Such increases in social empathy and promotion of social justice will inevitably affect their future practice and inform their development as forensic nurses.

Conclusion

Participating in a poverty experience can be utilized for those becoming nurses to promote awareness, provide a greater understanding of this population, and motivate change. Such is also true for those specializing in forensic nursing. Understanding poverty will allow the nurse to recognize and respond to the root of health problems and to advocate for social justice strategies and policies that promote population health (DeChesney & Anderson, 2016). As advocacy is a learned behavior that must start with understanding and recognizing the vulnerability of clients, use of a poverty simulation to expose students to the circumstances of the impoverished is a valid educational tool promoting social justice.

References