Abstract
Holistic nursing practice requires an understanding of the constraints of poverty as one of the social determinants of health. Future nurses need to be change agents for social justice. A descriptive, qualitative study was conducted to explore students’ experience of the Missouri Association for Community Action Poverty Simulation© (CAPS) and its impact on empathy and social justice awareness among a purposive sample of 56 sophomore baccalaureate nursing students at a public university in the Northeastern United States. Inductive thematic analysis was applied to data collected from a postparticipation reflection paper. Five themes emerged: (a) emotions, (b) personal history of poverty, (c) empathy, (d) rising advocacy, and (e) lessons learned. The results support that the CAPS simulation provides an experiential opportunity which impacts empathy and foundational attitudes to be a change agent for social justice. Recommendations include structured education about social determinants of health prior to the CAPS simulation, continued education throughout nursing curricula, and experiential opportunities to apply social justice skills before graduation.
Implications for Practice and Research
To address health-care disparities and promote social justice, educators need to prepare nursing students to care for diverse and vulnerable patient populations. Interpersonal empathy is a prerequisite for social empathy, and is the antecedent to social justice. In the Community Action Poverty Simulation, participants role-play a typical month of living below the poverty line, navigating their community to meet basic needs with a minimal income and facing challenges related to employment, childcare, food security, and chronic illness. Participants reported a deep appreciation of the varied personal, societal, and structural barriers faced by individuals and/or their families, as well as their realizations of the tenuous nature of day-to-day survival.
Poverty is a prevalent problem for many individuals and families and one of the most significant social determinants of health (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). The U.S. federal government defines poverty based on a family's size and income (U.S. Census Bureau, 2020). The threshold for poverty, also known as the poverty line, in 2021 was $12,880 for an individual or $26,500 for a family of four (U.S. Department of Agriculture, 2021). Despite the provisions set forth in the American Nurses Association's Code of Ethics with Interpretive Statements (2015) regarding treating patients equally, bias and stereotypes held by health-care professionals perpetuate health inequities (FitzGerald & Hurst, 2017). Nurses play a pivotal role in identifying and addressing health disparities. Therefore, it is essential that nurse educators foster a holistic perspective of the social determinants of health and an empathic understanding of the constraints of poverty so that students can be change agents for social justice.
Background
Poverty impacts 37.2 million people in the United States (11.4% of the total population; U.S. Census Bureau, 2020). The COVID-19 pandemic increased the vulnerability of those living at the poverty line (Patel et al., 2020). People living in poverty have more limited access to quality health care, higher incidence of mental illnesses and chronic diseases, higher mortality, and shorter lifespans (ODPHP, n.d.). Nurses require a holistic understanding of the impact of poverty on other social determinants to address health-care disparities and promote health equity across the population.
Bias
Although several forces drive health-care disparities in the United States, implicit bias results in the negative evaluation of a person based on race, ethnicity, culture, sexual orientation, gender identity, disability, and/or economic status (Institute of Medicine, 2003). Bias and stereotypes perpetuate differential treatment and can lead to higher morbidity and mortality (FitzGerald & Hurst, 2017). A study by Wittenauer et al. (2015) found that nurses with less clinical practice experience had more stigmatizing beliefs about poverty. Nursing students who come from different backgrounds than their patients may not understand the challenges presented by social determinants of health that can contribute to bias and impede quality patient-centered care. Curricular exposure and experiential learning activities such as the Community Action Poverty Simulation (CAPS) developed by the Missouri Community Action Network (2022) provide opportunities for nursing students to reflect and learn about their own biases and may encourage awareness and advocacy.
Social Justice
Social justice is a core value of nursing (American Association of Colleges of Nursing [AACN], 2021). Nurses have an ethical duty to create equity in social and health outcomes for vulnerable and disadvantaged communities. An understanding of social determinants of health and analysis of community issues are required in order to be change agents for improved outcomes (Elliott & Sandberg, 2021).
Empathic understanding is integral to equitable, patient-centered care and is required for nurses to advocate for social justice (Hellman et al., 2018). Interpersonal empathy is a prerequisite for social empathy (Segal, 2018) and is the antecedent to social justice (Cartabuke et al., 2019). Social empathy is a macro perspective for applying empathy to social groups such as those who live in poverty, and requires a holistic perspective on structural disparities (Segal, 2018).
To address health-care disparities and promote social justice, educators need to adequately prepare nursing students to care for diverse and vulnerable patient populations (Elliott & Sandberg, 2021). Fostering empathy and integration of social justice into the curriculum can enhance the knowledge, skills, and attitudes needed to be change agents. Elliott and Sandberg (2021) state, “teaching social justice involves helping students develop an empathic understanding of vulnerable populations, the ability to critically analyze social determinants of health, and knowledge of how to advocate collaboratively to become agents for change” (p. 545). Yet a study by Habibzadeh et al. (2021) found the concept of social justice in the nursing curriculum to have insufficient educational content, limited competency of educators, and inadequate educational strategies. Educators must challenge students’ perceptions and attitudes toward poverty in order to serve as change agents and advocate for equity (Abu, 2020).
Community Action Poverty Simulation
The Missouri Community Action Network (2022) developed the Community Action Poverty Simulation (CAPS) which allows participants to role-play a typical month of living below the poverty line. The objectives of the CAPS simulation are to promote poverty awareness, increase understanding, inspire local change, and transform perspectives (Missouri Community Action Network, 2022). Simulation participants must navigate their community to meet basic needs with a minimal income and are faced with challenges related to employment, childcare, food security, and chronic illness. Luck of the Draw cards designate unexpected occurrences, such as car repairs or medical expenses. At the end of the simulation, participants, community volunteers, and a facilitator debrief to make connections between the simulated experience and the CAPS objectives.
Theoretical Framework
Experiential learning theory suggests that knowledge is acquired through experience (Kolb, 1984). Learners are changed through a cyclical four-phase process: (a) concrete experience, (b) reflective observation, (c) abstract conceptualization, and (d) active experimentation (Kolb, 1984). Learning is a holistic process created by a transformative experience (Kolb, 1984). Kolb's theory aligns with simulation-based education as it provides a concrete active learning experience where participants experience the challenges of poverty. Reflective observation allows participants to think about their experiences and confront prior perceptions and attitudes. During the debriefing phase of the simulation, participants reflect on the experience. Reflective journals can further promote learning from experiential activities and help develop a greater understanding of these experiences. This reflective process allows students to enter the stage of abstract conceptualization in which they make meaning of the experience. Participants form new knowledge and reframe thinking based on the simulation. Lastly, active experimentation is where the learner applies new knowledge; in nursing, this occurs in the traditional clinical setting and in simulation-based education.
Methodology
Aim
The aim of this study was to explore the student experience of the CAPS simulation and its impact on empathy and social justice awareness in baccalaureate nursing students.
Sample and Setting
A purposive sample was recruited from sophomore baccalaureate nursing students enrolled in a Nutrition course at a public university in the Northeastern United States.
Students in their first semester of the nursing program were enrolled in the following courses: Introduction to Nursing Theories, Health Assessment, and Nutrition. The concepts of poverty, social justice, and healthcare disparities were scaffolded into these courses. Each course contained an assignment that discussed these issues as they relate to the course content. In Introduction to Nursing Theories, students studied the theory of social justice, social determinants of health, as well as the influences of past and present nursing theorists. In Health Assessment, students analyzed barriers to care experienced by people living in poverty and the potential impact that lack of care may have on health. In Nutrition, students were taught about social determinants of health and participated in an oral presentation discussing food insecurity and community resources.
The CAPS simulation was conducted during the second half of the semester and followed the directions outlined by the Missouri Community Action Network. The debriefing session was conducted by two nursing faculty members and lasted about 90 min.
Recruitment of participants was via an email sent to all sophomore nursing students enrolled in the Nutrition course. It included a brief explanation of the study, requirements, and a description of the potential risks and benefits of participating in the study. During a class session in the Nutrition course, a co-investigator invited students to participate in the study, answered questions, and obtained students’ informed consent. A total of 65 students were invited to participate in this study; 56 students elected to participate, a participation rate of 86%.
Research Design
A descriptive, qualitative research design was chosen to capture the experiences of nursing students participating in the CAPS simulation and gain a deeper understanding of students’ perceptions of the simulation's impact on empathy and social justice awareness. According to Sandelowski (2010), this design utilizes a naturalistic perspective to discover straightforward descriptions of an experience. A qualitative descriptive approach does not go into a deep exploration of interpretation, but keeps the researcher close to the data (Sandelowski, 2000). It allows the researcher to discover perspectives and understandings of a phenomenon, compared to a phenomenological approach, which explores lived experiences (Bradshaw et al., 2017).
Data Collection
Students were required to write a reflection paper within one week after the simulation. This timeframe allowed students to process and further reflect on their experiences. The assignment was graded as pass/fail. Data was collected from the 56 participants’ reflections.
Data Analysis
The data were analyzed using reflective thematic analysis with an inductive approach (Braun & Clarke, 2006, 2022). Inductive thematic analysis is a dynamic process aimed at summarizing the data. Students’ reflection papers were the source of data in this study and were de-identified to protect the participants’ anonymity. The reflection paper instructions asked participants to consider their CAPS simulation experience and insights gained in answering the following questions:
What feelings did you experience during the month of poverty? How did other people respond to your needs? How did you feel about the response? Has the simulation changed or not changed your perspective? Explain. What does poverty have to do with health inequities? Do you anticipate that this simulation will influence your nursing practice? How?
Participants described their experiences and perspectives of the CAPS simulation and its impact on empathy and social justice awareness in the reflective papers. The papers were read and reread by the research team to become familiar with the data and obtain an overall sense of the students’ experience of participating in the CAPS simulation. Significant statements were identified, and codes were generated. The codes were continuously discussed, and codes were constructed into themes using an iterative inductive process. The themes were further analyzed and condensed to capture the experience of the students until the research team reached a consensus. Although the focus was on the description of the experience, Sandelowski (2010), stated that some degree of interpretive analysis is inevitable with a qualitative description approach. However, it does not go beyond the phenomenon being studied and stays “data near.” The reflections were reread to determine that no new important data emerged. The research team concluded that the information was redundant and no further coding was possible (Polit & Beck, 2022); therefore, data saturation was achieved. An exhaustive description of the results was written to fully articulate the participants’ perceptions.
Trustworthiness
Lincoln and Guba's (1985) guidelines were applied using Bradshaw et al.'s (2017) means to support and ensure rigor in qualitative descriptive research. The researchers ensured the principles of confirmability, credibility, dependability, and transferability. Prior to data analysis the research team examined their own belief systems and experiences relating to poverty. Uncovering one's own bias was done so that the researchers could be open to the phenomenon under investigation. Reflexivity is a necessary component of the research process to ensure trustworthiness (Bradshaw et al., 2017). The researchers utilized member checking to validate themes and identified exemplary quotes from participants. To enhance credibility, the results of the research were then shared with participants for validation. Participants validated findings and no changes were suggested. Prior to data collection, the researchers outlined the study procedures and processes to be followed and maintained an audit trail. Purposeful sampling and thick descriptions were provided so that transferability was met. The authentic narratives represent both the experiences and intentions of the participants and represent the dominant themes in the study (Younas et al., 2023).
Ethical Considerations
The study was approved by the university's Institutional Review Board (IRB No. 21087). The students were informed that all data would be deidentified and remain anonymous to the principal investigator (the professor teaching the Nutrition course). The coresearcher emphasized that participation in the study was voluntary and would not affect the students’ academic grades nor their standing in the nursing program. They were also informed that there were no significant risks or benefits associated with participation in the study itself and that they may withdraw from the study at any time without penalty. All the students were required to participate in the simulation and complete the reflection as part of the course, whether they participated in the study or not. Poverty simulations can be stressful, particularly for participants who have grown up in poverty. Students were made aware of campus resources if participation in the CAPS simulation triggered stress.
Results
Thorough data analysis led to the identification of five distinct themes: “emotions,” “personal history of poverty,” “empathy,” “rising advocacy,” and “lessons learned.” Significant statements characterizing each theme are discussed below.
Emotions
Many participants reported similar emotions regarding their participation in the poverty simulation. Although there are many definitions of emotion (Madsgaard et al., 2022), the American Psychological Association (2023) defines emotion as “a complex reaction pattern, involving experiential, behavioral, and physiological elements, by which an individual attempts to deal with a personally significant matter or event” (para. 1). Many of the participants described stress, anxiety, helplessness, hopelessness, and sadness related to their experience during the simulation. Participant 8 shared “During the month of poverty, I experienced so many feelings at once.” Another participant discussed some of the emotions felt during the simulation: I felt ashamed, panicked, afraid, stressed, and desperate. These are all internally directed feelings. I think that anger is the next stage of those feelings, and that's what the first set of feelings looks like when they are expressed outwardly. (Participant 15)
Another participant shared, The response I received from those around me made me feel invisible and unimportant. I learned during the simulation that it is almost impossible to get any kind of sympathy from those around you because their situations were usually just as bad or even worse. (Participant 26)
Personal History of Poverty
Several participants disclosed that they had either overcome poverty in childhood or were currently experiencing poverty at the time of the simulation. Though I have my own personal experiences with poverty, I received a new perspective. Initially, I assumed that because I have endured the daily struggle in regards to poverty it would be less stressful for me to handle. Nonetheless, once the simulation started the instinct of survival and stress immediately kicked in. (Participant 11)
I personally have not only experienced poverty in my childhood with a single mom household, but it is something that I am experiencing today as well. Originally when I heard that we were going to complete the poverty simulation it gave me anxiety. I am currently experiencing what would be known as generational poverty and struggle with trying to afford to get an education and provide an adequate lifestyle for my two sons. Part of me felt slightly embarrassed to be actually living the reality of poverty in which our simulation was meant to depict. However, upon completing the simulation and hearing my peer response of empathy to the simulation … I felt more at ease with having participated. (Participant 11)
Empathy
Participants discussed how the simulation experience gave them the ability to ‘walk in the shoes' of someone living in poverty. Many participants reflected that they developed a greater sense of empathy for those who live in poverty. One participant stated: This experience will make me a more understanding and empathetic nurse. To truly have empathy you need to be able to put yourself in the shoes of the other person; if you cannot draw from some relatable experience, you cannot even attempt to understand how a person is feeling and where these emotions and actions are stemming from. (Participant 32)
Today has taught me to feel empathy for these patients and helps to understand the struggles that (they) have to endure. I was able to be in their shoes and experience some of the things they have to endure every day. (Participant 27)
Rising Advocacy
Participants focused on various aspects of social justice and social determinants of health, revealing a deep appreciation of the varied personal, societal, and structural barriers faced by individuals and/or their families as well as their realizations of the tenuous nature of day-to-day survival. Several participants expressed an understanding of how it is nearly impossible for any individual or family to thrive. Awareness of the reactivity of and the limitations of social support programs was consistently expressed by participants. One participant stated: What I observed was that our system of public support is reactive and not proactive. You must demonstrate destitution in order to receive assistance. But why do we so often have to wait until we’ve hit rock bottom before we qualify for assistance? This forces those living at the poverty level to maintain this life of high stress and chaos without ever moving out of their socioeconomic status. Living at the poverty line means that we are one large bill, one missed day of work, one issue with health away from devastation. (Participant 25)
Lessons Learned
Several participants stated that participating in this simulation changed their perspective on poverty and would influence their nursing practice. Every person has a background, story, and battle you know nothing about, and they come into your life as a nurse most often looking for that comfort, care and support. This experience has truly humbled me, and I am honored to take this knowledge with me into my career as a future nurse. (Participant 37)
As a future nurse I now feel a sense of responsibility in making sure that the care I provide for others goes beyond a ‘physical injury.’ It is my duty to see the person as a ‘whole’ when trying to correctly assess their health because there will be factors outside of the scope of practice that ultimately plays a significant part in their wellness. (Participant 2)
Discussion
This study aimed to evaluate the impact of the CAPS simulation on empathy and social justice awareness in baccalaureate nursing students. The participants’ reflections revealed that students perceived the simulation as a valuable learning experience. Overall, the participants embraced the simulation as an opportunity to experience the life of someone living in poverty. Our findings showed that the CAPS simulation fostered empathy and the foundational attitudes to be change agents for social justice. There were many lessons learned by participants that can be applied to their future practice. These findings have several implications for nurse educators.
Kolb's theory (1984) provides insight into how to apply the CAPS simulation to facilitate educational outcomes. Prior to the concrete experience of the simulation, both preceding knowledge and life experiences helped shape participants’ attitudes. The curriculum in the three sophomore nursing classes intentionally wove topics of poverty, social determinants of health, health-care disparities, and social justice theories into the courses. Although the structured educational intervention was not formally part of the study, it is believed this educational content scaffolded a higher level of learning with the implementation of the CAPS simulation. Boylston and O’Rourke (2013) suggested that attitudes improve with clinical and didactic exposure to people living in poverty.
Personal History of Poverty
A personal history of poverty, growing up in and/or currently living in poverty, influenced participants’ perceptions of the learning outcomes and helped reframe those experiences for their future practice. Daley and Campbell (2018) provided a framework for learning in nursing education, where participants arrived at a simulation with unique views that were shaped by past experiences. Those who reported overcoming poverty gained a deeper understanding of and appreciation for their experiences. Additionally, participants currently living in poverty reflected on the gained perspective on the support systems available to them.
This study took place at a public university that has a high population of first-generation college students. Although demographic data was not collected, several students shared a personal history of living in poverty. Similar to Loomis and De Natale (2017), participants in the CAPS simulation shared their personal history of living in poverty during the debrief. DeBrew et al. (2020), in a poverty simulation involving RN-to-BSN students, found that negative stereotypes brought up by students in the debrief can cause undue pain to students who grew up in or were living in poverty. DeBrew et al. recommended that the facilitators must remind students that the stories of the families are real, and to be respectful of their colleagues. Students’ reflective comments in this study did not bring up negative stereotypes of their peers. On the contrary, participants reflected on their peers’ empathy expressed in the debriefing and how that renewed their trust in the nursing profession.
Emotions Experienced
The simulated month in poverty provided the concrete experience described by Kolb's theory (1984). Students expressed both positive and negative emotions in response to taking on the role of someone living in poverty. Negative emotions included stress, anxiety, helplessness, hopelessness, and frustration. Positive emotions included gratitude and pride. The emotions that the participants reported were enhanced by their interactions with various community agencies, in accord with other studies involving CAPS simulation, specifically stress (Nickols & Nielsen, 2011) and frustration (Lowey, 2021). The attitudes and biases displayed by the members of the community agencies provided a more holistic insight into both individual and systemic factors that contribute to health disparities. The emotions evoked by the simulation-based experience were powerful and may have contributed to the learning outcomes. Madsgaard et al. (2022) stated that “emotions are a part of a cementing and driving force of learning” (p. 2).
Empathy
The results of this study were consistent with previous literature showing that the CAPS simulation fostered empathy (Kruse & El-Khoury, 2022; Loomis & De Natale, 2017; Turk & Colbert, 2018). Nurses are motivated to provide empathic care, which is the ability to understand a person's situation, emotionally respond to the insight, and then act in a compassionate manner (Morse et al., 1992). Empathy can be further expanded to go beyond the individual and have a greater understanding of marginalized groups. Segal (2018) described empathy as a “broad overarching concept” that encompasses both interpersonal and social empathy (p. 3). Social empathy goes beyond the individual level to a macro perspective aimed at marginalized groups, and requires an understanding of the social, economic, and political circumstances. Participants reported greater awareness and a holistic perspective of the inequities created by poverty. The researchers found that the experience of the simulation helped foster both interpersonal and social empathy.
Rising Advocacy
A deeper sense of interpersonal and social empathy along with an expanded awareness of social justice was expressed by participants. Social empathy was displayed in reports of attitudes toward civic engagement for social action. Participants recognized their role in advocating for improving the macro systems that impact the health and wellness of people living in poverty. A positive change in attitudes toward those living in poverty set the foundation to be rising advocates for social change. However, an empathic understanding is not enough to be a change agent for social justice issues (Elliott & Sandberg, 2021). It cannot be expected that one simulation will create expert advocates for social justice. Continuous exposure to concepts of social determinants of health and marginalized populations will help to sustain attitudes toward social justice.
Lessons Learned
The last stage of Kolb's theory (1984), active experimentation, will occur in clinical practice. Although some participants had worked in clinical settings, most would not begin their clinical encounters until the following semester. Clinical settings are where students can apply the learned knowledge and allow for the full application of Kolb's theory. Participants reflected on how this experience will influence their future professional practice. There were numerous lessons learned from the experience of living in poverty. Participants expressed greater knowledge and understanding of the issues around the social determinants of health and their role in breaking down barriers for marginalized populations.
Structured education on the social determinants of health, as well as experiential and clinical opportunities working with marginalized populations, must begin early in the curriculum through repeated exposure and opportunities. Using sophomore-level students in this study may have contributed to the reports of improved empathy levels. As students progress through a nursing program, some researchers have found that empathy levels decline (Ferri et al., 2017; Kesbakhi & Rohani, 2020; Ward et al., 2012). Turk and Colbert (2018) concluded that experiences such as poverty simulation should be done early in the nursing curriculum. The goal is for students to have more diverse experiences by exposing them to economically disadvantaged populations throughout the nursing program. Early development of knowledge, skills, and attitudes toward poverty may foster social empathy and help lay the foundation to be change agents.
Limitations
The purposive study sample consisted of sophomore nursing students in a baccalaureate nursing program at a public university in the Northeastern United States, therefore limiting its generalizability to all nursing students. It's important to consider that the nine students who chose not to participate may have had the most personal experience of poverty themselves or may have been the least open to having their perspectives changed, thus potentially reducing the richness of the data. Another limitation was the potential for social desirability. The concept of empathy is also taught throughout the curriculum and is considered in many of the nonclinical assignments throughout the program. The faculty's focus on empathy and social justice may have primed participants for an evolution of their empathetic thought processes, with the CAPS simulation being the catalyst that allowed the depth of self-reflection postsimulation. Because the reflections were an assignment linked to a course, this may have influenced the authenticity of student perceptions.
Implications for Nursing Education
This study indicates that the incorporation of the CAPS simulation early in the nursing curriculum is a practical way to encourage empathy, increase awareness of the issues and barriers of social determinants of health, and inspire students to become change agents for social justice. Additionally, incorporating educational strategies that discuss the social determinants of health into the curriculum is strongly encouraged to maximize the potential benefits of the poverty simulation. The CAPS simulation served as a strategy and vehicle for participants to reflect on their personal beliefs and biases and develop an empathic understanding of poverty. Planned activities need to be included throughout the curriculum for active participation in empathic understanding and social justice. This experience ultimately empowered participants to serve as change agents for social justice. Future research should explore students’ personal experiences of poverty and their impact on empathy and attitudes toward social justice as well as whether educational interventions prior to the CAPS simulation enhance educational outcomes and are transferable to future behaviors.
Footnotes
Acknowledgments
The research team expresses gratitude to the Central Connecticut State University Innovation Grant for funding the CAPS kit and training.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Central Connecticut State University (Innovation Grant).
Author Biographies