What is a poverty simulation? For starters, it's not a game. But it is a unique, hands-on way our nursing (and other health) students are learning how to be more empathetic and see what it's like for people on or below the poverty line to receive proper care. Hear from the simulation organizers themselves on what these students are learning that has a tremendous impact on their community outlook and their professional and personal education.
Recorded August 16th, 2022. For more information on UNLV Nursing's community initiatives, visit https://www.unlv.edu/nursing/community
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Joe Gaccione 0:03
Hello and welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, Communications Director for the School of Nursing. Each semester, UNLV Nursing participates in an interactive event called the Poverty Simulation. Second semester students in their community nursing course act out various scenarios under scripted identities that show them what it's like to live on, near, or below the poverty line for a full month. Students have to live these lives in four 15 minute increments. Each of those increments represents a week. So, in 15 minutes, a student has to worry about groceries, hospital bills, looking for work, transportation, and childcare. Despite the acting and scripted components, the Poverty Simulation is not a game. It's an outside-the-box educational tool to build empathy within healthcare students and to show how community systems can always be improved. Joining me today from UNLV Nursing are Minnie Wood, and Jill Racicot. Minnie is not only a lecturer and clinical instructor, but she's also the Director of Clinical and Community Partnerships within the school. She's helped lead the Poverty Simulation for years along with Jill, who is the nursing school’s Projects Coordinator. Together, they're preparing for the Fall Poverty Simulation. Minnie, Jill, thank you both for joining us.
Minnie Wood 1:15
Thanks for having us.
Jill Racicot 1:16
Joe Gaccione 1:17
To start with, can you each describe what your role normally entails for the Poverty Simulation?
Minnie Wood 1:21
Sure, I'll start. I'm the coordinator for all of the clinical experiences for the community nursing course and the Poverty Simulation is one of those clinical experiences, giving students you know, this hands-on, immersive experience. So, what I do is prepare the students for that, for the experience with some, making sure they have some content around that, they're prepared for the event, and I make sure that we have enough volunteers among our faculty, especially volunteers from our community partners, people who, you know, work with community agencies that we work with really like to come and participate in the Poverty Simulation. And so, I make sure we have enough people, usually we need about 24 people to make each Poverty Simulation run and it takes a little bit of doing.
Jill Racicot 2:09
So, I'm on the backside in more of the operations. And so, I'm making sure that we have a space secured, equipment needed, because we do need a larger gymnasium, like space to run the poverty sim, to set up our mini community, I make sure that we have tables and chairs, and then also coordinate with Minnie since it is an interdisciplinary activity, that we've got dates that work for both all the programs and all the students.
Joe Gaccione 2:31
And Jill, you've been with UNLV nursing for about 15 years now so you've seen how the Poverty Simulation was introduced to UNLV. How did that happen?
Jill Racicot 2:38
Sure. It came from one of our community instructors, I'd say 10, 12 years ago, Dr. Menzel and Dr. Michelle Clark, who were looking for interactive simulation, like experiences for community nursing students. There's just not a lot out there. And so, they came across this teaching tool. It's from the Missouri Action Coalition group, they put it out and we were fortunate enough that the Dean at the time supported sending a faculty member to get trained as the facilitator, the purchasing of the kit, and then we brought it back. And it's, really, we've got, we've maximized the return on that investment over the years, using that kit time and time again. And then I was fortunate enough, when both Dr. Menzel and Dr. Michelle Clark left, I was then sent to be trained as a facilitator to run it. And so, here we are today and I can't tell you how many Poverty Sims I have coordinated over the years.
Joe Gaccione 3:25
And for a visual for people out there. So, we mentioned the gymnasium before, the gym is lined up with groups of chairs for all the students, nursing, medical, and dental for spring and fall semesters. And then there are tables, almost like, in like a rectangle format, and each table represents a different community agency and that could be a hospital, could be a grocery store, could be a school, and the students have to go to each table depending on what their script says. Now, the students aren't aware of who they're going to play beforehand, but how do you prepare them for this kind of event?
Minnie Wood 3:57
Well, you're right, they don't know anything really about what's going to happen. And we don't really do much preparation for the simulation itself. What we do is preparation, you know, for the content they're about to, so we sort of immerse them. It's part of a unit that they're learning about poverty and vulnerability and how that relates to health care. So, they have, you know, a few things that happen. They have, you know, lectures and classroom activities that are related to poverty and vulnerability, they have a movie that they watch, a documentary that we show every semester, it's part of the Unnatural Causes series, it's called, “In Sickness and In Wealth,” and it's about how income and health are tied together. And then, you know, we do offer up, I want to make, it's important to make it clear that some of our students are living in poverty now, you know, we have students that may be low income, that are living in poverty, that may even be homeless or have experienced homelessness in the past. So, one bit of preparation that we do sometimes is to offer to students the possibility that they might not want to participate In the Poverty Simulation, especially if they think it might be triggering, and so, those students have the opportunity to participate as one of the agencies, usually where our volunteers are, instead of, instead of as a member of a family.
Joe Gaccione 5:14
And we mentioned that before, that it's not a game. I mean, I've sat in on some simulations, and you see the kids, the students running around, they're trying to get their tasks accomplished and the stakes there are low, not compared to what it's like in the real world, but it's a reminder that people are living this daily.
Minnie Wood 5:32
Yeah, and I would say that I think the feedback that we receive from students, especially when we debrief at the end of the simulation, and then throughout the semester, is that their experience is not one of it being a game. It can be quite stressful to participate in, or at least they feel the pressure of time and of all the different tasks that a family has to complete, you know, to pay the rent, to pay the utilities, to make sure that children in the family are cared for, to make sure they have transportation to and from work, that they've taken care of their healthcare needs, that they're, if they've been evicted, that they have a place to go. So, these things, it really is crafted in such a way that those pressures are felt in real time and I think it does come through.
Jill Racicot 6:16
I would agree, it's a very powerful activity and there's an immediate connection for the students. We hear, you know, just like any other simulation, or learning activity, we have the opportunity to debrief with the students at the end. And so, we break them into five or six, seven, small groups. We have a facilitator, usually one of our clinical instructors who will lead that debrief, and you really hear, you know, those students' feedback, and they are seeing and feeling it. And now, you know, can make it a little more relatable to their clients that they're going to be working with, that not everybody, when they get discharged from the hospital, you give them all those instructions, and they go out and just do it, right? It's being aware of what they're going home to and what challenges they may have.
Joe Gaccione 6:53
And I want to clarify before when I said the stakes are low. For that simulation, though, there are no actual like, real life consequences. Every week, every increment that they have to do, these 15 minutes, it gets more intense, then you start noticing towards the end, evictions start happening, people can get sent to jail, there's juvenile hall for any student that's portraying a child, the students are so wrapped up in what they have to do that they might forget they've dropped off a child at child care, or they might leave a child at home because they have to make those decisions. And that decision-making kind of leads into my next question, as far as what are the most important skills and takeaways you want the students to have after completing this?
Minnie Wood 7:31
Yeah, so I think the skills and takeaways are on a couple of different levels. And the most basic level is, kind of what we've already started to describe, is we want them to have an experience that will begin to increase their empathy for patients or clients that they might work with who are living in poverty, right? So, starting to understand some of the systemic influences and causes so that they're going to be better providers of healthcare in general, so that they're going to have a better understanding of some of the barriers and obstacles that exist for patients who live in poverty. You know, how hard is it for them to get to the clinic? How challenging is it for them to actually get the medicine that's been prescribed? Or to actually make the changes, that in their lives that are being suggested by their health care providers? That's one level. There's another greater level too, which is about looking at what we call the social determinants of health, right? We know that the, like, our zip code is more important than our genetic code, when it comes to how long we're going to live, what, what kind of chronic diseases we're going to have and how those outcomes are going to be. That shouldn't be the case. That means that we have a lot of disparities and inequity in our health across income lines. So, we want students really to begin to see the way systems impact each other, how systems relate with each other and create barriers and obstacles for patients, and how different policies have the potential to impact our, you know, our communities’ lives in different ways. So, we're really trying to get them to start thinking big like, “Oh, it turns out that this is an issue with transportation. Well, what if the transportation system were different? What if access to care were different?” That part is a little bit harder. That is not something I think that immediately comes out from the Poverty Simulation, but Poverty Simulation is one tool that's used as a part of a curriculum, you know, an overall curriculum that addresses vulnerability as well.
Jill Racicot 9:38
I'd have to agree, it's the building of empathy and compassion. And then, the bigger picture of healthcare is just not a silo. You know, it's impacted by a multitude, many things.
Joe Gaccione 9:49
And one of the things that I've noticed in other simulations, is you'll throw in a random life event because as we all know, life will do that on its own. I saw situations where a tenant might be told they're evicted when, in fact, they did pay rent, but the landlord just conveniently lost the receipt and there's no proof and then you have to get the sheriff involved. So, it's like throwing those moments in to really show that as much as you can plan, there are still going to be moments that you have to be ready for, you have to be ready for surprises, which sounds like a paradox.
Minnie Wood 10:18
That's one of the reasons that I really love having representatives from real community agencies come and participate in the simulation, because during debrief, they can talk to the students too, about how real those scenarios are. And that's the reason why those things are built into the Poverty Simulation because it does happen, people get evicted for not having a cash receipt, you know, people get taken advantage of, or we have some of the highest payday loan rates in the country in Nevada, and, you know, students are trying to get, you know, loans and doing all sorts of things to survive. So, it is really, there's unexpected things that happen, things that they might not have thought of, but they're really, you know, they're quite realistic. And one of the other things, you know, Jill hands out, one of her roles as the facilitator is to hand out these, you know, cards with the unexpected life events. And another one that happens is that students get informed that they haven't been eating enough, they haven't bought enough groceries, so they get a nutrition alert. And we talk about that later in the debrief. They'll say, “Oh, I think we did pretty, we did pretty well, you know, we have a little, you know, money left,” or something. And we’ll say, “Well, did you get one of those nutritional alerts?” “Oh, yeah.” So, it turns out, your family didn't get fed. In real life, that would be your very first priority, right? And the rest of these things would sort of fall by the wayside until everyone had eaten. So, you know, we can't replicate things perfectly, but we certainly can start a lot of conversation around it.
Joe Gaccione 11:43
And you see the sacrifices that they have to make, we've mentioned before, they might leave a child at daycare or at home, because they have to get somewhere else, you know, that there might be a job opportunity. We've seen students steal from other students because they get desperate. It starts out like everyone's more or less on the same playing field, even though they're playing different characters, they have to start from somewhere. But then by that last week, you see where they have to go to. And if you don't, I mean, if you don't have enough money, you don't have a bus pass, you can't go, you can't go to school, can't go to work.
Minnie Wood 12:11
Yeah, the, we close in the simulation, school is closed during the third week for spring break. And so, school-aged children, there needs to be childcare for school-aged children. So, students will report making what they don't think are great decisions about how to care for their, you know, care for their kids during that week, like, maybe leave them with a not particularly trusted neighbor, or with a teenager that lives down the street. Now, our intention is not to create judgment around those kinds of situations, but rather for them to think about, “What does it mean to have accessible, affordable or even universal childcare and a community? What does it take? How do policies like that get created? What policies do we have in place? How are community and social and public policies related to health,” right? Sometimes, students come into a nursing program thinking, “Oh, well, this is healthcare and this isn't.” But in community nursing and population health, we think about how all those social, social determinants, all these other things influence health as well.
Joe Gaccione 13:12
We talked before about nursing students during the fall and spring semesters are joined by dental and medical students from UNLV as well. What's that inner professionalism like among the students? Do you notice a difference when it's just the nursing students by themselves?
Jill Racicot 13:26
My initial is no, I don't think so. When I go around, and I listen to the debriefs at the end, when there's all three disciplines there, I don't hear a lot of crosstalk, but I hear a lot of the individual disciplines talking about their like, being mindful of the clients they're going to be working with, like I've heard the dental student talking about when they're going to open up private practice, potentially being mindful of having evening hours, having maybe a weekend, a month or something to be more accessible to their clients. So, I feel like they kind of stay in their lane but I think as long as you're hearing it, maybe somebody's picking up on it.
Minnie Wood 13:59
Yeah, I think it's just, you know, and they don't get a lot of exposure to each other. So, it's just a great opportunity to, to just be with the other, you know, some of the other health professions, they have to be part of each other's family while they're there. And there's definitely some universal takeaways for all of them that especially, one of the biggest ones, I think, is that, seemingly, across the professions, they realize that in these simulated families, healthcare, it just can't be a priority. There's so many other things going on for these families, surviving throughout the month that they realize that their own healthcare is pushed to the bottom of the list. And it's kind of a joke when you're putting on the simulation that if you need to give somebody a role, who can only sort of be half-there or can't participate the whole time, we put them in the health clinic. And the reason we put them in the health clinic is basically nobody visits the health clinic during the simulation because they're too busy doing other things and just sort of taking care of their lives.
Jill Racicot 14:54
Well, it's very ironic, you know, that we're using health care students because that's the beauty of this Poverty Simulation is, is that it is, you know, universal to all disciplines. So, it can be social workers, it can be school, you know, school districts, it can be nonprofits, it can be, you know, a very diverse, diverse group. It's not, it was not developed for healthcare in mind, but we use it in our healthcare sciences. And that yeah, again, the irony that we have three prominent healthcare providers, and they all, every family unit, they don't fill their prescriptions and then like I said, food nutrition is the other one that I find very interesting.
Joe Gaccione 15:29
Telling someone to be more empathetic is easier said than done. When you're trying to teach empathy to a nursing student, how do you know like, are there other signs when you know that they've hit it? Like, they know, they recognize how important it is, versus, “Okay, so I'll just be nicer to future patients?”
Minnie Wood 15:43
Right. Well, that's a great question. And, you know, I'm not an expert on, in this sort of building of empathy, but I think in, in a clinical group, in a group with eight students, that's how we do our community clinical experiences. This is one big, big, you know, group all together. But then throughout the semester, we work with a group of eight out in a community setting. So again, Poverty Simulation is one experience among many throughout the semester, it's one element. So, I think empathy building is a process, I think it's going to depend on your sort of positionality, your own perspective as well, right? There may be some students where this is not only a no-brainer, it's their already experience. Of course, they have empathy for people who are living in poverty, they've had that experience themselves, that's an experience in their family. Maybe if you're a student who's grown up in a more privileged area, or form of more privileged background, having this experience is the start of a little bit of an eye-opening exposure to how your patients, you know, some of your patients might be living in the future. But it's one experience, they're going to be out in the community doing other experiences with their group throughout the semester, we have clinical faculty that will work with them and they'll always be debriefing and discussing and talking about these things throughout. So, empathy itself is not a measure, but we have clinical outcomes and clinical objectives in our courses that have to do with being able to provide adequate care and quality care for vulnerable patients and that is something that is more measurable. And if you have a lot of biases, or if you're lacking in empathy, it's harder to provide good care. And I think that becomes quite noticeable. So, that's the sort of best I can answer that question. I don't know, if you have anything to?
Jill Racicot 17:28
No, I think that's the part is, is empathy can't be taught in one lesson or one activity. And so, I, again, that's why we come back to using the Poverty Simulation and how valuable a tool it is. And especially we, we found that it fits really nice, they're nice in the, towards the beginning of their community clinical experience, because it does give those students you know, as you've said, a safe place to, you know, experience these challenges, these barriers and be, you know, able to really relate to what a family that's struggling, and what it means then to have a major health care episode or impact. Empathy is a tough one. I know we're talking about research right now with potentially building compassion and this is a learning experience that could help build compassion, but that's, that's coming,
Minnie Wood 18:14
There's sometimes conflict in a healthcare environment between, I guess, the kind of care that you would like to be able to provide and the kind of care that's available and, or, you know, and the services that are available. And that's absolutely the case, we, you know, most of our students work in, you know, in profit-driven healthcare systems. It can create incredible ethical conflicts. So, you know, we do talk about what kinds of changes can be made and what, you know, so policy is made, not just at the federal and the state level, but it's made on a nursing floor as well. It's made in a hospital. It's made in a community agency. And so, how do we center our patients, especially our vulnerable patients, to try to make the improvements that we can, even if we have systems that are working in ways that can be quite harmful to our health? So, it's a lot to balance. It's a lot to balance.
Joe Gaccione 19:04
Minnie, Jill, thank you very much for coming in the booth and talking with us today. That's all I have for you.
Minnie Wood 19:09
Jill Racicot 19:10
Joe Gaccione 19:11
This year's Poverty Simulation in the fall will be October 1. Thank you for listening, everyone. Stay tuned for more episodes. Have a great day.
Transcribed by https://otter.ai