Creating empathetic nurses

Poverty simulation puts nursing students into low-income patients’ shoes

By California State University, Bakersfield

October 15^th, 2024

At California State University, Bakersfield, nursing students are taught more than the clinical essentials of caregiving. The program also emphasizes empathy, but putting themselves in their patients’ shoes can be difficult without knowing the fuller picture of their lives.

With Kern County consistently at the bottom of health and prosperity rankings, future nurses can expect to encounter patients who live in poverty and might struggle with their health as a result. To give them a better idea of the challenges these patients deal with daily, the Nursing Department held a poverty simulation last month.

“The goal for us is for people to have better understanding and more empathy and to recognize the challenges people with low income have to face,” said Dr. Heidi He, associate professor of nursing. “The reality is we’re in health care, and poverty affects every aspect of social determinants of health.”

For the simulation, around 60 students and faculty members were assigned roles in family units, such as a single parent, a pregnant teen, a young child or a senior citizen. They were given a packet with a description of the family and its individual members, sources of income, family possessions and bills, identification documents and various other items that they would need to survive the month, such as transportation passes and some cash.

The student housing multipurpose room on campus was transformed into a miniature community, with everything from banks and grocery stores to homeless centers and jails. Every 15 minutes was a week, with participants given specific tasks to try to make ends meet.

To pay their mortgage and bills, they would need to work to earn money. To go to work or drop off kids at school, they would need a transportation pass. Those with preschool-aged kids would have to find childcare. With unexpected expenses and obstacles to resources, it was easy for participants to fall behind in one aspect or another, with several family units facing eviction by the end of the simulated month.

“You feel like you’re getting ahead and you get slapped with a bill, or you feel like you’re getting ahead and your child gets sick and you can’t go to work for a week,” nursing student Jillian Pitre explained in a debriefing following the simulation. “It was just barrier after barrier.”

Resources from organizations such as a community action agency, social services department and an interfaith center could provide help, but finding the time or means to get there could be a challenge in itself.

“We all agreed that we felt overwhelmed,” said student Mackenzie Christner, summing up her discussion group’s sentiments. “It kind of threw us off knowing how many resources we had. We had to make ends meet just by doing what we needed to do every day. Going to work, getting food … It kind of stressed us out trying to make ends meet.”

Participants review instructions and packet material.

Inside the packets were transportation passes, some cash and information about the families' belongings, which they might choose to pawn for extra money.

Participants could visit a payday advance business to get quick cash.

Participants could also pawn belongings for additional money. Some participants purchased a gun and robbed other families and businesses.

Every simulated week, students would line up for the bank and supermarket, many with children accompanying them.

With basic survival being so complicated, it was no wonder that most participants didn’t prioritize a visit to the doctor over other necessary errands, or their medication over food for their families.

“Healthy choices were not a priority because Maslow’s hierarchy: if your basic needs are not met, then nothing else matters,” Pitre said. “(My character) was also 16 and pregnant and trying to get through school and that was really hard ... Healthy lifestyle choices were not even on my mind.”

When patients don’t follow medical advice, nurses must take into consideration the obstacles that might be in their way, Dr. He said.

“As health care providers, before we label a patient ‘noncompliant,’ let’s look at why,” she told the students. “If they don’t have the chance to purchase food, whatever healthy lifestyle choices that we recommend, of course they’re not going to be implemented.”

For many students, the simulation was not entirely unfamiliar. Several mentioned that it rang true to their own experiences growing up, with a few noting that it made them more appreciative of what their parents did to provide for their families.

“It sounds like it surprised some people (that people go through this),” said nursing student Carl Allen. “I hope this helps whoever’s thinking that realize that this is real life for a lot of people. I grew up like this, so now I’m just realizing even more how much my dad really had to do for us.”

The poverty simulation is a kit created by the Missouri Community Action Network, purchased by the CSUB Nursing Department with funds from two grants: a U.S. Department of Health and Human Resources (HHS) Health Resources and Services Administration (HRSA) Advanced Nursing Education Workforce (ANEW) Program award and Nurse Education, Practice, Quality and Retention (NEPQR) Simulation Education Training (SET) Program award.

The simulation was first held in February, led by representatives from the Missouri Community Action Network. Dr. He plans to hold a poverty simulation every semester, with one already in the works for spring.

“Health outcomes are so poor in the community, and I think we have the obligation, as a school and a department, to do what we can to improve them,” Dr. He said. “We have to look at the root cause. We can’t just ask people to buy something healthy while they’re in a food desert. You can’t make people go exercise when they’re in an environment that’s not safe to be outside. We really should understand the social determinants of health, and poverty is one of those things that affects every aspect.”

Future nurses aren’t the only ones who can benefit from this practice in empathy, so Dr. He hopes students in public health, social services, education and other relevant majors consider joining an upcoming poverty simulation. Future teachers especially might come away from the simulation understanding why attending school or finishing homework isn’t always the top priority for their students.

“When we look at why our educational attainment is so low, you have to look at the whole picture,” Dr. He said. “Having that empathy and understanding is important.”