Simulating Poverty for Better Nurses and Better Healthcare
By: Minnie Wood, MS, APRN, ANP-BC
Lecturer and Clinical Instructor
A nursing student taps her foot impatiently while waiting in a long line to cash her laminated-paper paycheck. She is joined by her fictional family. Her teenage son is, in fact, a medical student and her boyfriend is a current dental student. He is relaying the story of the errands he did while she was at work. He tried and failed to keep their power on without enough money to pay the utility company this week. While talking, she bounces their baby-doll child as they develop a plan for what to do next. This is just one scene among hundreds that play out during the UNLV poverty simulation, an experiential exercise that exposes students to the realities of day-to-day life for low-income families.
For more than ten years, the UNLV School of Nursing has been providing poverty simulations for Level 2 students while they study population/community health nursing. More recently, this training has expanded into an interprofessional educational experience with the Schools of Medicine, Dental Medicine, and Physical Therapy. With trained facilitators and a kit from the Missouri Community Action Coalition, this unique experience allows students to role-play as individuals and families living in poverty. The goals of the simulation are to increase students’ empathy for people living in poverty and to develop a deeper understanding of the systemic and structural issues that complicate and contribute to it. These goals are in keeping with the Institute of Medicine’s Future of Nursing 2030 initiative and the consensus recommendations to increase the capacity of health professions’ students to recognize and address the social determinants of health.
What are the social determinants of health? The World Health Organization describes the social determinants of health as “the conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinates of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.”
These include factors like socioeconomic status, housing, transportation, education, employment, access to health care, and many more. The social determinants play a sizable role in health outcomes independently and influence individual health behaviors like smoking, nutrition, and physical activity as well.
The social determinants of health—and the public policies that shape them—can be challenging for students to grasp, especially when their educational experiences generally focus on one-to-one patient encounters in a clinical environment. With a state poverty rate that is higher than the national rate, it is urgent that students have curricular experiences that align with this reality. The poverty simulation gives students in the health professions the opportunity to have a hands-on experience that brings the lived experiences of low-income families to the foreground.
Approximately 80 students can participate in one poverty simulation experience. Participants are randomly assigned to a family for one simulated month. The family must work or look for a job, go to school, access childcare, pay bills, encounter health issues, engage with community resources, and even encounter surprises like an unexpected expense. Faculty, staff, and community partners act as employees of businesses and service organizations found in most communities. Among others, the poverty simulation features an employer, a supermarket, a bank, a homeless shelter, a daycare, a school, a social services agency, a realty agency, a utility company, a pawn shop, a health clinic, a police officer, and a quick cash business. Over the course of the four, fifteen-minute simulated weeks, students begin to feel a sense of urgency and their pace quickens. They can often be found running across the gym to line-up for services or opportunities. There is often an increase in illegal activities as the simulation develops.
After the simulation ends, interprofessional groups of students gather with a faculty for a debrief. Faculty provide prompts and questions for students to share their experiences, perspectives, and insights. Many common themes emerge including a feeling of stress and never having enough time with family; engaging in unsafe or illegal activities to get by; simply not having enough money; ignoring health or medical concerns; the importance of transportation and extended hours of operation; the stress of being a child in a poor family; not knowing what resources are available or how to access them, and being subjected to rules and procedures in order to obtain services. One nursing student summed it up nicely: “I never really thought about why someone wouldn’t prioritize their health. But I was just so busy the whole month trying to care for my family, it was the last thing on my list.”
The next poverty simulation for nursing students is June 1st. Alumni, partner organizations, and all members of the community are invited to volunteer. Please contact Minnie Wood at firstname.lastname@example.org for more information.