In 2013, more than 45 million Americans (14.5%) lived in poverty (U.S. Census Bureau, 2013). Disparities in poverty are seen across demographic groups. In 2010, poverty rates were higher among Blacks (27.4%) and Hispanics (26.6%) than non-Hispanic whites (9.9%), families headed by single women (31.6%) than single men (15.8%) or married couples (6.2%), and foreign-born residents (26.7%) than U.S.-born residents (14.4%). With a population of more than 26 million residents (U.S. Census Bureau, 2014), Texas is the second most populous state in the country and faces great health and social disparities. For example, Texas has the ninth highest poverty rate at 16.3% (U.S. Census Bureau, 2007) and the highest rate of people without health insurance at 22.1% (Smith & Medalia, 2014).
Poverty is consistently linked to poorer health outcomes across the life span (Kaplan, 2009), interacting with other social determinants of health (e.g., educational opportunities, jobs that provide livable wages and benefits, housing quality, neighborhood safety, and access to healthy and affordable food). These social determinants have a greater impact on health than access to health care (Chokshi, 2010; Link & Phelan, 1995); however, most of the collective efforts to reduce health disparities have focused on increasing access to health care. It is therefore essential for nurses, as the largest group of health care providers, to be familiar with the challenges of living in poverty, how such challenges influence the effectiveness of their interventions with individual patients, and what they can do to better and more compassionately care for the underserved.
Public health nurses work intimately with issues related to poverty and health, often providing referrals and complex case management for low-income clients enrolled in multiple social welfare programs (e.g., Medicaid, Temporary Assistance to Needy Families, food stamps, and Section 8 housing). A commitment to social justice is widely recognized as a competency for entry-level public health nursing practice (Garcia, Schaffer, & Schoon, 2014). As such, concepts related to poverty, social justice, and health equity are logically integrated into undergraduate public health nursing courses. Despite the nursing profession’s historical commitment to social justice, critics argue there are gaps in educating nursing students about social justice and the social and structural determinants of health (Chinn, 2014; Mohammed, Cooke, Ezeonwu, & Stevens, 2014; Wilson-Thomas, 1995). Downstream approaches, such as individual-focused behavior change, predominate nursing education at the expense of encouraging students to understand and intervene on upstream, structural causes of health inequities (Mohammed et al., 2014).
Simulation exercises are commonly used in nursing education to reinforce concepts learned in didactic and clinical settings—traditionally in acute care (American Association of Colleges of Nursing, 2008). Poverty simulation and service-learning exercises also are used by nurse educators to help students understand social justice and the social and structural determinants of health (e.g., Jarrell et al., 2014; Patterson & Hulton, 2011). This article describes one such exercise, In Their Shoes, that was developed by a team of undergraduate public health nursing faculty at a large public university in the southwestern United States.
Description of In Their Shoes Activity
Concerned that traditional lecture-style teaching methods alone were not helping students understand the social determinants of health, social justice, and challenges faced by underserved populations in accessing health and social services, didactic and practicum faculty worked together to develop a poverty simulation exercise. Whereas many poverty simulation exercises take place within a classroom setting, In Their Shoes placed students directly in the community to literally walk a mile in the shoes of a client seeking services. Based on scenarios each faculty member had encountered in their public health nursing practice experience, several scenarios of clients needing health and social services were developed. Scenarios included:
- A woman in her 50s who is new to town, is living out of her car, is unemployed and uninsured, has several chronic conditions, and recently ran out of medication.
- A low-income family of six who has no access to healthy, affordable food and is concerned about obesity among their four young children.
- A mother of two who is trying to escape domestic violence and has no car, no money, and no essential documents to secure employment or assistance (e.g., birth certificates).
- A homeless adolescent mother who was beaten and kicked out of the house by her drug-abusing parent after discovering she was pregnant.
- A young veteran who recently got out of the military and is suffering from posttraumatic stress disorder.
- A woman in her 70s who is legally blind, lives in a rural area with limited public transportation, and needs transportation for a medical appointment.
- A single undocumented mother who has a child with a disability and needs to find a clinic for immunizations and a school to accommodate the child’s special needs.
Faculty worked together to coordinate the activity during two didactic classes and one practicum day in the 10-week course. Students were introduced first to concepts of health and social disparities, social mobility, and social justice during an interactive 3-hour didactic class that combined lecture with videos and active learning strategies. Students were presented concepts and evidence related to income inequalities within the United States and its relation to health disparities across nations (e.g., Index of Health and Social Problems; Wilkinson & Pickett, 2009), critical social theory and critical race theory, and the factors most likely to result in social mobility (i.e., structural factors versus the rare but widely celebrated instance of “pulling oneself up by the bootstraps”). In addition, readings for the week included a chapter from a book following the plight of children and families living in a low-income, underserved community (Kozol, 1995); this chapter was integrated throughout the lecture as a small group discussion that allowed students to apply concepts discussed in the lecture. Students also were asked to complete an online poverty simulation prior to going to their practicum the following day (Urban Ministries of Durham, 2011).
The next day in practicum, students were assigned a case scenario and sent out into the community in small groups of three to five students on a “scavenger hunt” to acquire resources for the person or family in their scenario. For example, students who were assigned the adolescent mother scenario often decided to visit legal services to learn more about the emancipation process. Students were required to use public transportation to get to agencies that could help the client in their case scenario. The faculty believed this was important, as many clients must rely on public transportation, which is a time-consuming process. The faculty emphasized to the students the importance of personal safety and awareness. Students collected application forms and flyers from the agencies they visited and recorded field notes about their experience.
The following week, students returned to the didactic course to reflect on their experience. In their practicum groups, the students began to summarize the case scenario they had and reflected on their experience (e.g., challenges encountered, lessons learned, and how the experience would impact their nursing practice when caring for underserved clients). Next, new groups of four to five students were created in a “jigsaw” fashion, with each member of the group representing a different case scenario. Students shared their reflections from their case scenario, and the group wrote down five insights or experiences that were common across case scenarios.
In Their Shoes has been conducted for three semesters, and the activity has received positive feedback from students each semester. After the activity, during clinical conference and also in lecture, students were able to verbalize how meaningful the learning activity was, their understanding of the community environment, the daily challenges faced by underserved clients in the community, and how nurses—regardless of their practice setting—can apply public health core concepts and functions when referring clients to community resources. Common reflections expressed by students across semesters included being surprised by the number of community resources available for underserved individuals and families, feeling frustrated by various challenges they encountered in accessing resources, and expressing how the experience served to make them more aware and compassionate advocates for their underserved clients.
Surprised by the Number of Community Resources
Many students expressed surprise at the amount of community resources available to help those in need. In particular, students commented on the helpfulness and friendliness of staff at the various agencies they visited. Feedback from groups included:
- The staff were very passionate about assisting not only immigrants they are housing but anyone in need.
- It was awesome to see how tight-knit the community was. If people were in need, the community really came together, we saw.
Challenges Faced in Accessing Resources
Despite many comments on the amount of community resources available and positive interactions with staff at agencies, many students expressed frustration in accessing resources. Common frustrations included receiving inaccurate information on agency Web sites, being referred from agency to agency without ever accessing services, long waiting lists, and the amount of red tape one must cut through to access resources. Feedback from groups included:
- There are so many resources available to people in need but there is so much paperwork/red tape that lengthens the process.
- Multiple scenarios experienced waiting lists to receive resources, so we also had to explore short-term solutions.
- “You can look online” is not the same as providing helpful information. Web sites are difficult to navigate and not everyone has Internet in the first place.
- We make assumptions that there are benefits available but if these patients do not have a valid identification, documents, etc., then they can’t obtain these benefits.
- Some of the offices and clinics were only open one day a week and by appointment only.
- It isn’t easy to get resources. There seems to be a lot of curves, rather than a straight road that gets you to your destination.
Students commented on how time consuming and overwhelming it was to try and access community resources. Challenges of using public transportation were particularly emphasized:
- If you had to transfer buses, the expenses added up. I would rather save the money to feed my family or for other essential needs.
- It was a very confusing experience even for somebody with a college education.
- Time is EVERYTHING! It takes a lot of time to navigate, to explain your case, to get the “family”’ all in one place so you can travel around the city, etc. Maybe this is where people get discouraged in the process of finding resources?
- By the end of this activity, I was so frustrated because I felt like I accomplished nothing and in reality I didn’t if this was my actual situation. This individual would have lost their income for the day and would have struggled to feed their family. I was able to have an insight of what this population feels on an everyday basis. It helped me gain a new perspective and respect for the underserved population.
Students also reflected on how possible they thought it would be for the clients in their scenario to “pull themselves up by the bootstraps” and get out of poverty. Sample comments included:
- Extremely difficult. By the time a person needs/applies to WIC [Women, Infants, and Children]/Section 8, they are already in a destitute situation. The time it takes for the programs to be processed so the individual can benefit, too much time will pass and likely their situation will worsen.
- Ensuring that one receives these benefits and maintains them requires upkeep and time; after that how much time is left to manicure one’s skill set and “build” a resume?
- It will be hard for social mobility because they are so concerned with making it day-to-day they don’t have the opportunity to move up by going to school or their children’s future like saving for college.
- I always knew it was difficult but I never understood it until now.
Impact on Nursing Practice
Regardless of what practice settings students decide to pursue after graduating, they will encounter clients from a variety of underserved backgrounds. Students were asked to reflect on how the In Their Shoes experience would impact their nursing practice. The most common student responses were that they would be more empathetic and compassionate to the plight of the underserved, and better advocates for clients in need of services. Comments included:
- It gave us insight into their types of situations, and now we will be better equipped to provide empathetic care. We now understand that these resources (WIC, section 8) are long processes and not immediately available.
- Now we have a better understanding of how difficult it can be to get these resources. It is not just laziness. It is a challenge for many patients to miss work and spend a day on the bus.
- In the future, I will always think about my In Their Shoes activity and what it was like to try to obtain services when I was sick with no insurance and no transportation. I will remember how people in the clinic treated me and the level of respect I was given. I will always remember that the clients I am treating may have spent all day traveling to get to the facility, they may be on a limited budget, and they may be very unsure of the health care system in general. I will make sure to make their experience at the hospital, doctor’s office, clinic, etc. very positive, and provide the best care possible.
Faculty Reflections and Future Directions
The collaboration between didactic and practicum faculty for the In Their Shoes exercise was recognized by the authors’ school of nursing with an Innovations in Teaching Award. In future semesters, the exercise will continue to be refined, implemented, and evaluated. Future directions include a quantitative evaluation of the exercise, using pre- and posttest questionnaires to evaluate changes in students’ knowledge (e.g., process of accessing community resources, influence of poverty on health), awareness (e.g., nurse’s role in addressing social and structural determinants of health), and opinions (e.g., compassion toward the underserved) as a result of participating in the In Their Shoes exercise. In addition, three semesters’ worth of information is now available about community resources (e.g., brochures, application forms) submitted by students as part of their grade for the assignment. Plans for the future include organizing these materials into a “resource book” that can be used by nursing students throughout their program. Such a resource book could be kept in the learning center and checked out, or copies could be made and distributed to students for use throughout their various practicum rotations.
Although faculty expected students to face challenges using public transportation to access resources, the level of frustration experienced by students was unexpected; despite carefully putting together a plan of action prior to the activity, the students did not have enough time to access all of the resources needed by the clients in their scenarios. This was viewed as a positive unanticipated learning outcome for students, as they experienced firsthand what many clients relying on public assistance experience everyday as they work to make a better life for themselves and their families. Certain unintended experiences, however, might not be as desirable and require care and attention to mitigate. For example, it is likely that some students in each semester had experienced poverty and had firsthand knowledge about accessing social services (Drevdahl, 2013). Faculty must be sensitive to these students’ experiences and balance their right to respect and privacy with an obligation to educate students who have no personal experience with poverty or accessing social services. This will help create a more compassionate nursing workforce that empathizes with the underserved, is competent in working with the existing systems of health and social services, and is inspired to work toward social justice and reducing health and social disparities.
Other programs around the country are encouraged to develop and evaluate similar activities to expose their students to the challenging realities of living in poverty. Such activities have great potential to get students to think practically about what they need to do as nurses to best serve vulnerable and underserved populations. Faculty should reflect on their own public health nursing practice experience to develop scenarios that reflect the local culture and resources available to assist such populations. In developing these scenarios, they should anticipate challenges and frustrations students might experience. Likewise, faculty may incorporate theory (e.g., critical social theory) and facts about poverty, health, and upward mobility to encourage critical thinking and reflection among students. Above all, it is crucial to create a safe space for students to reflect on their attitudes toward vulnerable and underserved populations, which may influence their nursing practice perspective.
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