Assessing nurse practitioner and medical student experience and self-efficacy caring for patients and families living in poverty

Asefeh Faraz Covelli; Sivan Ben-Maimon; Olanrewaju Falusi; Ashley Darcy-Mahoney

doi:10.4103/EHP.EHP_24_19

ORIGINAL RESEARCH

Year : 2020 | Volume : 3 | Issue : 1 | Page : 27-32

Assessing nurse practitioner and medical student experience and self-efficacy caring for patients and families living in poverty

Asefeh Faraz Covelli¹, Sivan Ben-Maimon², Olanrewaju Falusi³, Ashley Darcy-Mahoney⁴
¹ School of Nursing, The George Washington University, Washington, D.C, USA
² School of Medicine and Health Sciences, The George Washington University, Washington, D.C, USA
³ School of Medicine and Health Sciences, The George Washington University; Children's National Hospital, Washington, D.C, USA
⁴ School of Nursing; School of Medicine and Health Sciences, The George Washington University, Washington, D.C, USA

Date of Submission	03-Sep-2019
Date of Acceptance	26-Nov-2019
Date of Web Publication	13-Mar-2020

Correspondence Address:
Dr. Asefeh Faraz Covelli
1919 Pennsylvania Avenue, Suite 500, Washington, DC, 20006, (206) 724-7795
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EHP.EHP_24_19

Abstract

Purpose: There is a lack of data on the effectiveness of medical and nurse practitioner (NP) programs in preparing students to address the social determinants of health (SDH). The purpose of this study was to assess and compare medical and NP students' experience and self-efficacy caring for patients and families living in poverty. Methods: This descriptive, cross-sectional study was conducted via online survey administered to a sample of 4^th-year medical and 2^nd-year primary care NP students. Ninety-eight (72 NP and 26 medical) students completed the survey, 34.8% and 15.8% of the classes respectively participated. The survey was administered via E-mails sent by NP program directors and medical school course directors, with several reminder E-mails. Results: A small percentage of medical and NP students rated their educational programs as excellent in preparing them for primary care practice and addressing SDH, however NP students felt more comfortable providing care to low-income patients than did medical students. Lack of time and knowledge of resources was the most significant barrier cited by both medical and NP students. Discussion: Curricular redesign and intraprofessional education are areas of research to understand how to better prepare medical and NP program graduates to care for patients living in poverty.

Keywords: Health professions education, medical students, nurse practitioner students, poverty, social determinants of health

How to cite this article:
Covelli AF, Ben-Maimon S, Falusi O, Darcy-Mahoney A. Assessing nurse practitioner and medical student experience and self-efficacy caring for patients and families living in poverty. Educ Health Prof 2020;3:27-32

How to cite this URL:
Covelli AF, Ben-Maimon S, Falusi O, Darcy-Mahoney A. Assessing nurse practitioner and medical student experience and self-efficacy caring for patients and families living in poverty. Educ Health Prof [serial online] 2020 [cited 2022 Aug 14];3:27-32. Available from: https://www.ehpjournal.com/text.asp?2020/3/1/27/280539

Introduction

While there has been increasing awareness of the impact of social and behavioral factors on health, there is a lack of data on the effectiveness of medical and nurse practitioner (NP) training programs in preparing students for addressing the social determinants of health (SDH) at the point of care. Medical and NP education includes training the future health-care workforce to meet the needs of the communities they serve; a vital component of that is understanding the unique cultural and social issues that affect various populations. This has the potential to improve patient outcomes and improve health in the United States (US). Developing curricula to better educate and train medical and NP students requires timely data on the curriculum's current strengths and weaknesses in these areas. Understanding students' exposure to families with financial difficulties and how confident they are in their ability to begin conversations around food insecurity, employment status, need for childcare, transportation, and stress management would be valuable. The purpose of this study was to assess and compare NP and medical students' knowledge regarding issues that affect patients living in poverty and their feelings of preparedness for addressing them.

Background

Childhood poverty has been a proven predictor and risk factor for adverse health outcomes in adulthood. SDH, such as poverty, account for 20% of overall health outcomes.^[1] While health-care spending has increased and a number of health-care outcomes have worsened in the US, and as other industrialized nations have outperformed the US, on many health indicators, there has been an increased emphasis on social and economic inequities as causes for poor patient outcomes and overall population health.^[2] Solutions to these health problems cannot solely depend on medical care, but rather must incorporate initiatives to encourage the health-care workforce to address SDH. These SDH include, but are not limited to, all forms of discrimination, socioeconomic status, and disparities in access to basic health resources such as healthy food, housing, and transportation. Acknowledging the importance of SDH will help “health-care providers better understand patients, effectively communicate about health-related conditions and behavior, and improve health outcomes.”^[1] As a major contributor to the well-being and health of patients, addressing SDH is critical for effective patient care and should therefore be incorporated into the curriculum for burgeoning health professions students. Upon graduating, students should feel prepared to address SDH in their clinical encounters. Exposure to this construct during their education would better prepare students, and therefore the workforce, to discuss and address patient concerns, ultimately providing patients with comprehensive medical care that improves health outcomes.

There have been recent calls for integration of SDH into health professions' curricula. In 2010, the Liaison Committee on Medical Education, which is responsible for setting the accreditation standards for medical schools, made changes to educational standards to include both public health and preventive medicine. Their logic for this change was that a pathway to addressing health inequities and SDH is through the education of future health-care workers.^[3] With these changes, they hope that an “educated, activated, and diverse workforce will emerge, well-suited to tackle the persistent health disparities in the US.”^[1] Similarly, nursing education has made recommendations to integrate SDH into the curricula.^{[4],[5],[6],[7],[8]} In 2019, the National League for Nursing (NLN), an accrediting body in nursing education, released a statement calling for integration of SDH into nursing education curricula. Recognizing that health is inextricably linked to the social, economic, environmental, political, and cultural forces that shape the world around us, they stated, “the NLN believes that the SDH should be integrated throughout graduate and undergraduate nursing courses and not isolated in community-based courses. The need is to be intentional about integration.”^[8] This statement goes on to discuss the assessment of SDH, along with physical, cultural, and functional assessment of patients, families, and communities, as an essential competency for graduates. In medical education, the Social Mission movement and Beyond Flexner Alliance have called for broader recognition of the importance of SDH and a better understanding of the substantial health disparities within the US. As a result, new and emerging ideas are circulating and important experiments in curricular redesign are taking place at many medical schools.^[9] It has been suggested that rather than merely introducing SDH content into didactic content, experiential exposure in the clinical setting is crucial in health profession student understanding of factors that affect health inequities.^{[7],[10],[11]} It is the role of health education systems to equip their students with the skills and confidence to address the underlying social and environmental factors contributing to patients' medical conditions.

Following the changes in accreditation standards and curriculum redesign recommendations in medical and nursing education, it is imperative to assess whether these standards are being met. The lack of data on the effectiveness of health education programs to prepare students to address SDH in the clinical setting makes this assessment challenging. It is critical to analyze the strengths and weaknesses of these programs in order to implement effective changes to the curriculum with the intention of addressing educational gaps.

Methods

Design

A cross-sectional descriptive design was used to describe the experiences of final-year NP students in primary care specialties and 4^th-year medical students to understand their perspectives and experiences caring for patients in poverty. Survey data were collected and managed using REDCap^® electronic data capture tools hosted at Children's National Health System.

Participants

After receiving Institutional Review Board approval, a sample of 2^nd-year primary care NP and 4^th-year medical students from one urban university located in Washington, D.C., were recruited to participate in the study. To meet inclusion criteria, participants must have: (1) been a 2^nd-year primary care NP student or 4^th-year medical student, (2) been at least 18 years of age, and (3) used English as their primary language. NP students in their 1^st year or in acute care specialties and medical students not in their 4^th year were excluded from the study because the student perspective during their primary care clinical rotation was the focus of this study.

Instrumentation

A researcher-developed survey instrument based on a previous survey used in pediatric residency graduates was revised for the current NP and medical students.^[12] Two similar but slightly different (discipline specific) versions of the survey were created to be specific to NP and medical students' experiences, respectively, to collect data on their primary care experience providing care to patients in poverty. Questions included in the survey included perception of program preparation for providing primary care, engaging in advocacy and addressing SDH, and comfort and barriers in providing care for low-income patients.

Procedure

In fall 2018, NP program directors and medical school course directors were asked to send an E-mail to their 2^nd-year primary care NP and 4^th-year medical students, respectively, with information about the survey and a link to the secure REDCap^® survey website. Follow-up reminders were sent to participants 7, 14, and 21 days after the initial recruitment E-mail to increase the response rate. After reading the informed consent front page, the study candidate checked a box agreeing to participate and then began the survey. The survey consisted of 28 questions and took approximately 10 min for most participants to complete. All those who completed the survey were offered a chance to win one of the five $50 gift cards by providing their E-mail address on a secure page that was kept separate from their responses.

Data were downloaded and analyzed using SPSS software version 26.0.^[13] Descriptive statistics were conducted for percentages, means, and standard deviations (SDs) of demographic characteristics. t-tests and Chi-square tests were used to compare the two groups on their educational experiences and barriers in providing care for low-income patients.

Results

Ninety-eight (72 NP and 26 medical) students out of a total of 372 (207 NP and 165 medical) students completed the survey. Of the NP students, 91.7% (n = 66) were women with an average age of 36 years (SD = 8.4), all of whom had previously worked as a registered nurse (RN). The majority of the NP student sample (69.4%) had 5 or more years of prior experience as an RN. Of the medical students, 73.1% (n = 19) were women with an average age of 29 years (SD = 2.5). Nearly 85% (n = 22) of these medical school students did not begin medical school directly after completing their undergraduate degree, with the majority (72.7%) of these students gaining work experience during their time between undergraduate school and medical school and over half (54.5%) of them obtaining clinical experience during this period. [Table 1] and [Table 2] summarize the demographic characteristics of the NP and medical student sample, respectively.

Table 1: Demographic statistics of nurse practitioner students

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Table 2: Demographic statistics of medical students

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Only 15.3% (n = 11) of the NP students and 11.5% (n = 3) of the medical students rated their program as excellent in preparing them for primary care practice, and only 16.7% (n = 12) of NP students and 7.7% (n = 2) of medical students rated their program as excellent in preparing them to address SDH. However, 63.9% (n = 46) of NP students reported feeling very comfortable providing medical care to low-income patients, whereas only 34.6% (n = 9) of medical students reported feeling this way. [Table 3] summarizes NP and medical student educational experiences.

Table 3: Nurse practitioner and medical student educational experiences

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Approximately half of the medical and NP students rated lack of time as a very significant barrier to providing care for low-income patients in addition to a lack of knowledge of resources being a very significant barrier to 69.2% (n = 18) of the medical students and nearly 41.7% (n = 30) of the NP students. Notably, only 23.6% of the NP students (n = 17) and 30.8% of the medical students (n = 8) cited a lack of training as a significant barrier to providing care for low-income patients. Finally, 19.2% (n = 5) of the medical students and 20.8% (n = 15) of the NP students reported a lack of lived experience in poverty as a very significant barrier to providing care for low-income patients. [Table 4] compares NP and medical student barriers to providing care for low-income patients.

Table 4: Barriers to providing care for low-income patients

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When the two groups were compared, there were no significant differences between NP and medical students in their program ratings, comfort level in caring for low-income patients, or the barriers they cited in providing this care. However, medical students were more likely than NP students to cite a lack of knowledge of resources as a significant barrier to providing care to low-income patients (P = 0.019).

Discussion

This study provides important information about NP and medical student experiences and comfort caring for patients living in poverty. It is concerning that few students felt that their program was excellent at preparing them for primary care practice or to address SDH. In the current health-care climate, prevention and health equity are paramount and should be the cornerstone of any health professions education curriculum. Health professions education programs should reassess their curricula to incorporate deeper engagement with these topics in order to adequately prepare their graduates.

Interestingly, NP students were far more comfortable than medical students in providing care to low-income patients, which may be a result of their extensive prior RN experience or secondary to personal circumstances. This is supported by previous studies which suggest that NPs with extensive prior clinical experience are well equipped for working with underserved populations.^{[14],[15],[16]} This difference may also be influenced by curricular differences between NP and medical school programs. However, the specific differences between the two curricula were not explored in this study. In addition, a lack of lived experience in poverty was less of a barrier in NP students than medical students, suggesting that prior life experience may have an impact in providing care to patients in poverty.

Finally, lack of time and resources in primary care settings are barriers faced by both medical and NP students, suggesting that improving care to low-income and underserved populations needs to start with specific and deliberate clinical transformation. This could include increasing the length of visits, providing easy-to-access information on-site that can be shared with patients, and providing a patient navigator to assist patients with psychosocial needs. Health professions training in such an environment would significantly improve medical and nursing providers' ability to provide patient-centered, equitable care.

Service learning, which has been suggested in the literature as an effective approach to teach SDH, may also be an answer. This approach combines direct community-based engagement with specific preparation, learning objectives, and reflection.^[17] Service learning differs from traditional clinical experiences in that it involves an academic–practice collaboration in offering an intentional community-based clinical experience that addresses SDH.^[7] The reflective exercises following a clinical experience in the community where SDH are discussed are key to connecting objectives to the service experience.^[18] Importantly, students who participate in a service learning experience are more likely to participate in similar activities following graduation.^[17] This would directly enhance the health professions workforce in addressing SDH, achieving the goal of improving the integration of SDH in medical and nursing education.

As with any research, this study has some limitations. This study only sampled 4^th-year medical and NP students from one university, limiting its generalizability. The sample size for the medical students was half of the NP students, and NP and medical school program curricular differences were not investigated, making comparisons challenging. Self-selection of participants may have introduced sampling bias as those with particularly positive or negative experiences may have chosen to participate. It is difficult to generalize the findings secondary to a lack of information about the population from which the sample was drawn in terms of demographics. Although the survey instrument was previously used in a sample of recent medical graduates, it was not previously validated in a sample of NP and medical students. Finally, the survey included only quantitative questions, and may not have accounted for nuances regarding the student experience or what components of their educational program had the most impact on their preparation to care for patients living in poverty.

Conclusions

This study demonstrated that medical and NP students do not feel well prepared for primary care practice and to address SDH. NP students are more comfortable than medical students in providing care to low-income patients, possibly because of their previous work experience as nurses. Curricular redesign and intraprofessional education opportunities are areas of research to understand how to better equip graduates with the ability to care for patients living in poverty. Further research is needed to understand whether the difference between NP and medical students' comfort in caring for underserved patients stems from a difference in curriculum or prior experience in health care. Understanding NP and medical student preparation for addressing SDH is important given the continued demand for primary care services and lack of access to health care in many areas in the US.

Financial support and sponsorship

This project was supported by the Josiah Macy Jr. Foundation as part of the Macy Faculty Scholars program and the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) Award number K02HP308150201. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

Conflicts of interest

There are no conflicts of interest.

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