An Rx for poverty insensitivity

When nursing student Cameron McGuire participated in a learning experience that attempted to replicate real-life poverty, he was surprised that in his assigned role he had to pawn a TV to keep from getting evicted.

Student Kellie Wilmes said she fleetingly thought about stealing for the first time when she faced a series of simulated catastrophes and classmate Paneeta Aviles felt helpless watching her sim parents struggle to make ends meet and not get needed medical help.

McGuire, Wilmes and Aviles are juniors in Oregon Health & Science University School of Nursing at the Ashland campus, and they spent a day in April in a carefully designed exercise to better understand how poverty interferes with a patient's ability to get medical treatment. They and others in their class have since applied what they learned at hospitals and clinics.

"I work in an emergency room," says Aviles, 38, of Gold Hill, "and I have seen this situation. For some people, this isn't a sim; it's real."

Now, she says she talks to families with more compassion about the obstacles that might prevent them from showing up on time for an appointment or getting prescriptions.

OHSU professor Heather Voss, who organizes the poverty sim, says it's critical that nurses, who spend more time with patients than doctors, understand the factors that get in the way of the recommended course of treatment.

Studies reported by the World Health Organization and in respected journals show that poverty leads to ill-health and ill-health keeps poor people poor. Voss cites other research that links poverty's stress to hypertension, heart disease, depression, suicide, addictions and other unhealthy conditions.

This is the seventh time Voss has organized the poverty sim, which requires about 100 hours of preparation and dozens of volunteers to play the part of a banker, pawnbroker, boss, cop or a grocery clerk who sells food and hands out warning slips to sim parents who don't adequately feed their children.

The nursing school relies on sims to give students close-to-realistic experiences. A floor of Britt Hall on the Southern Oregon University Campus looks like a hospital with mannequins representing different stages of life. There are sim newborns, pregnant women and dying patients.

In the poverty sim held on the SOU campus, students are assigned roles to play in a typical low-income family. They are given a limited number of cards that represented objects they could pawn for money and transportation passes required for them to "arrive" at work, a bank or social service agency.

Throughout the experience, they are also thrown unforeseen challenges: a sickness, accident, loss of a job. They are under time and money constraints and have to make hard decisions.

Wilmes, 31 of Gold Hill, played a single, working mom whose unsupervised sim child was taken away by human services. "I felt guilty that I wasn't home," she says, adding that the experience taught her that although resources may be available, they may be difficult to access.

The poverty sim was a pilot program on the Ashland and Portland OHSU campuses in Spring 2011. After comparing attitudes among students who participated to those who didn't, OHSU administrators decided to hold the sim on all five campuses. Voss has also produced the sim for Rogue Community College students and La Clinica's staff.

The simulation takes place in a large room arranged with tables and chairs into "neighborhoods." Volunteers representing public health, day care and other agency officials sit at tables and offer or deny services.

Three chairs simulate a family's home. If something goes wrong, the family may return to find their chairs are upside down, indicating that they have been evicted.

Voss explains that each of the 50 to 75 students is given a scenario of a family profile and a role. Regardless of their age or gender, they may be assigned to be a single mom, elderly man, teenager or young child. Some begin in a homeless shelter. Others are struggling to pay the rent and utilities with meager paychecks and little benefits.

The goal is to house and feed the family over a month (15 minutes represents one week). They also have to deal with unplanned emergencies.

"Students are not given any preparation for the simulation," says Voss. "People who are living in poverty don't know what's going to happen."

To receive services from the agencies, they must hand over a transportation pass that represents the time or expense it took to walk, buy gas or take a bus. "We know that transportation is one of the greatest barriers to accessing services," says Voss. "Students not accustomed to this get frustrated that they can't be served."

She says some students have personal experience with poverty, while others are completely unaware of what life is like without money. "The things they take for granted can hamper their progress in the sim. They tell us, 'I would just call to pay my bill,' and we have to tell them that they don't have a cellphone or their land line was shut off," says Voss.

Afterward, they talk among their sim family about the stress of trying to accomplish the planned tasks and how hard it was to recover from a setback. Then they join a larger group of students to discuss how the experience could change their practice as a nurse.

McGuire, 22 of Ashland, played the role of a 50-year-old man. He says that "small things became big things. I had to decide if I should spend my time depositing a paycheck to pay a bill and buy food, or go to work. I lost a week's pay so I could eat."

By the second or third simulated week, he says he felt frustrated and enormous stress. "We should have taken our blood pressure before, during and after the sim," he says, speaking like a nurse.

Recalling how sim families had to worry about child care or losing a job to get to the clinic and then not having money to pay for medication, he says: "I will think longer before I call someone 'noncompliant' again."

Voss says she can talk about poverty's impact on health, but simulating it allows students to be more aware of a patient's real circumstances.

She continues: "We hope to change attitudes about poverty. Not everyone can pull themselves up, not everyone is in poverty because of something they did or didn't do. The car breaks down and they can't get to work, they lose their job, then their house. We have to look at the structure that our society provides or doesn't provide that doesn't allow for people to rise out of their low-income situation."

Reach reporter Janet Eastman at 541-488-3950 or

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