Catalyzing Empathy Using a Poverty Simulation With Baccalaureate Nursing Students

Poverty, one of the most influential social determinants of health, is a phenomenon experienced in low, middle and high-income countries (WHO, 2017). In the United States, poverty among women and children is rapidly rising, with almost 15 million children living below the poverty line nationwide (Walker & Druss, 2017). Poverty is associated with poor health, especially complex and multi-morbid conditions. As these children grow, they in turn are living at higher risk of premature death and disability (Gitterman et al, 2016). Addressing persons living with poverty long-term health issues, necessitates addressing social determinants of health. Among these are some of the structural causes of poverty: financial insecurity, food insecurity and housing insecurity. Understanding poverty is essential to the development of relationships between healthcare professionals and patients living with poverty. Fundamental to the science and art of healing, the nature of interpersonal interactions between caregiver and patient not only defines the quality of the patient’s experience as a recipient of care, it helps determine patient outcomes (Hojat et al., 2011). Empathic interactions almost always lead to positive patient outcomes, including increased patient satisfaction and adherence. Building that human connectedness is as essential to one’s health and empathy is foundational to that connection (Del Canale et al., 2012). Empathic communication is likely to improve patient outcomes for populations who are profoundly in need of safe, quality care.

Students are exposed to patients from varying socioeconomic backgrounds including the homeless, those living in poverty and those who require public assistance when immersed in the clinical experience. However, student attitudes and behaviors when interacting with these vulnerable populations are not formally evaluated. Poverty simulation has become increasingly popular in nursing education, yet the impact of such training on nursing students is not well documented in the literature. In an effort to foster empathy and understanding of persons who are impoverished, our study used a poverty simulation as a strategy to assess empathy and attitudes towards the structural causes of poverty.

Poverty is a phenomena often studied on the micro (individual) or macro (societal) level. For students, it is an abstract concept to grasp, especially if it occurs as a result of structural factors. The theoretical framework we used in this study was the Social Ecological Model (SEM) which addresses the behavioral and environmental contexts of health promotion interventions. In this model, environmental factors are considered from the intrapersonal, interpersonal, institutional, community and public policy levels. Use of a SEM engages interventions targeted towards multiple levels with the goal of obtaining sustainable positive effects from an intervention (Strasser, Smith, Denney, Jackson, & Bickmaster, 2013).

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We used a descriptive comparative design to measure healthcare professional student's self-report of empathy and attitudes towards poverty before and after participation in a poverty simulation. The poverty simulation is a three-hour experience which simulates one month in the life of a family with a limited income. An entire city was created in a 3000 sq. ft. space using tables, chairs and signs to delineate community services and businesses, such as a community health clinic, a homeless shelter, and a bank. These services and agencies are staffed by volunteers from the community and nursing college faculty. The student participants assume the roles of up to 26 families, attempting to navigate employment, childcare, food and shelter for one month. The program begins with a brief explanation of poverty and ends with a debriefing by faculty.

In addition to a brief demographic survey, student participants were asked to respond to two instruments before the poverty simulation and a few months after the simulation. One instrument measured empathy in healthcare professionals. A higher score means that the student has more of a tendency toward empathic engagement in patient care. It is a reliable instrument with internal consistency of 0.78 (Fields, et al., 2011). The second instrument was the Attitude toward Poverty Scale (APS) which measured student understanding of structural and individual causes of poverty (Yun & Weaver, 2010). Structural causes include inequities in society and health policy. Individual causes include personal choices. We used the APS short form which is considered a reliable instrument with internal consistency of .87. This scale has three factors: personal deficiency, stigma, and structural perspective. A higher score indicates that the student believes that poverty is a result of structural deficiencies in our society, versus personal or individual deficiencies (Yun & Weaver, 2010).

The students entering the simulation who completed the surveys (N=81) scored moderately high on both the empathy scale (M=85.9) and attitudes towards poverty scale (M=72.4 scores on both instruments did not differ significantly after the poverty simulation (N=28, p=.51). Students who were in the traditional BSN program did differ significantly from the other two types of students in the FACT and the Community and Trauma program. Students in the traditional BSN program had more personal experiences of poverty and had volunteered with those experiencing poverty more frequently, with close to a third of traditional students having lived below the poverty line at some point in their lives. Also, students in the traditional program were currently caring for significantly more dependents in their household than any other program.

What is known in the literature is that empathy, a crucial element in the nurse’s repertoire, improves outcomes in the population it serves. Nurses are poised to influence structural causes of poverty, including access to healthcare services and referral to community resources. A poverty simulation provides an opportunity for student reflexivity, an understanding of the barriers faced by those experiencing poverty as they navigate through healthcare systems. Experiencing poverty through simulation allows the learner to examine personal beliefs, unconscious biases, and judgements of those living in poverty. Learning associated with poverty simulation may not be long-lasting, which may indicate a need for a multi-faceted approach that better engages the socio-cultural aspects of poverty. It is important for the next generation of health care providers to understand the linkage between structural causes of poverty, and health outcomes. Moreover, a better understanding of the challenges of poverty has the potential to mobilize health care clinicians and providers to influence policy change to better protect one of society’s most vulnerable populations (Strasser, Smith, Denney, Jackson, & Bickmaster, 2013).