Woman and Man role play as a mother and father in a poverty simulation

Cultural Humility: Gaining First-Person Experience and Empathy for the Health and Life Impact of Living in Poverty

Patricia Benner, R.N., Ph.D., FAAN
Copyright January, 2016

We choose the term “cultural humility” rather than the more ambitious, and misleading term, “cultural competency” in the title, because even within one’s own dominant culture, much can be learned and many blind spots exist between local cultures, between social classes, and between disparate social contexts. Cultural competency can be elusive and never guaranteed given the limits of any one person’s exposure to cultural differences.Woman speaking after a poverty simulation

Living in poverty, has its own cultural structures and constrained possibilities. Living in poverty creates a cultural chasm with mainstream America, due to the hardships and exclusions imposed by poverty, especially in the context of a wealthy society. Consciousness-raising about blind spots and negative biases can help students literally see new issues and new concerns in the poverty simulation (and in any cross-cultural simulation). Many nursing students come from a middle-class background and have little knowledge of the health care access and poor health outcomes for those living in poverty.

Encouraging students to remain curious, stay open and responsive as they actively listen and pay attention, can enlarge the student’s understanding of the barriers created by poverty. Experiencing the demands and constraints of poverty can help students stretch their clinical imagination about how to work more effectively with people with limited financial means. The students need to compare and contrast the experience of listening with a “judging eye” and “clinical eye” versus a curious, respectful, attentive and open eye (Martinsen, 2006, p.97). (See also, EducatingNurses.com Article November, 2015, “Being Present, Meeting the Patient as a Person, Preserving Personhood, Taking up the Ethical Call of Nursing”). Bias is not the only problem, nurses need to know the available social services, any assistance available to obtain prescribed medications, and how to help patients gain assistance to transportation for appointments, resources for child care and so on.

In our highly individualistic U.S. society that values independence, achievement and public displays of success and wealth, being poor is highly stigmatizing for the person in poverty. It is a cultural predilection in an individualistic society, to “blame the victim,” citing individual faults for being poor. Part of this blaming the victim of poverty, is a coping self-defense and protection on the side of caregivers. Imagining the poor person as totally “other,” i.e. different from oneself, can seem to further separate the risk of being poor for the caregiver who does not want to become poor or assume social, political or economic responsibility for the poor. Blaming the victim can also be seen in situations where the patient is blamed for their illness, so that the health care provider feels separate and less vulnerable to falling ill themselves. Here the philosopher Emanuel Levinas (1988), who called attention to the ethical and moral claims the human face makes on everyone, can remind us as nurses, that the goal is to see the “other” as other, that is, not the same, or a replica of the self, but equally importantly, to never see the person as “wholly other.”

On the EducatingNurses.com Facebook page, we have posted a think piece on the impact of Emanual Levinas work on ethics by Aaron James Wendland, cited below. I think Levinas speaks to the very heart of nurses as compassionate strangers. All human beings share common vulnerabilities, risks, situated possibilities as a result of a shared or common humanity, e.g., embodiment, finitude, and many shared environmental and social risks beyond one’s control. As noted in a New York Times article by Aaron James Wendland:

Concretely, the irreducible humanity of other human beings is found in the face. Faces confront us directly and immediately and they refuse typologies. Levinas indicates the irreducibility of others by speaking of God’s presence in the face, but his account of the face also illustrates another aspect of human beings: vulnerability. The face is naked, exposed, and open to attack. It is hungry and thirsty. And it seeks protection and nourishment. Levinas invokes the stranger, the widow and the orphan as examples of deprivation. We could also add asylum seekers and embattled exiles as acute cases of suffering. However, Levinas’s general account of vulnerability shows us how hospitality in the face of another’s need constitutes individual human beings and bespeaks a humanity that precedes and is more fundamental than the establishment of all national boundaries [or “exclusion” of others as fellow human beings with common needs and vulnerabilities and possibilities].
Levinas has taught us that our responsibility for others is the foundation of all human communities, and that the very possibility of living in a meaningful human world is based on our ability to give what we can to others. And since welcoming and sharing are the foundation upon which all communities are formed, no amount of inhospitable nationalism can be consistently defended when confronted with the suffering of other human beings. “In the relationship between same and other, my welcoming of the other is,” as Levinas puts it, “the ultimate fact.” It is the hospitality of humanity, or a peace prior to all hostility. And in this primary peace, in this basic welcoming of refugees, Levinas reminds us that “things figure not as what one builds but as what one gives.”

In her interview, Heather Voss, Faculty of Record for the Poverty Simulation, tells a story of meeting and caring for a professional woman who is now impoverished by a catastrophic and bankrupting illness. We are reminded that no one in the U.S. is ever immune from health care bankruptcy. We cannot isolate the one in poverty as “wholly other” because we are all vulnerable to poverty, for many often-unforeseen reasons.

As noted above despite our cultural differences, human beings share common vulnerabilities, risks, and situated possibilities as a result of our common humanity, e.g., embodiment, finitude, and many environmental and social risks beyond one’s control.

The Community Action Poverty Simulation (CAPS) implemented by the Oregon Health Care Consortium for Nursing Education captures a large 90-person simulation of the role poverty plays in health and capacity for gaining health care access in the U.S.A. health care system. Community Action Poverty Simulation (CAPS) developed this simulation. CAPS promotes a greater understanding of poverty and greater empathy for those living in poverty. During the simulation, participants role-play the lives of low-income families from single parents trying to care for their children to senior citizens trying to maintain their self sufficiency on Social Security.

Poverty Simulations: Experience Living in Poverty

The Community Action Poverty Simulation (CAPS) Packet can be purchased through the community action website

The packet provides all the materials needed to recreate this simulation. This experience can stimulate community service providers’ participation with students, and increase their understanding of the role of poverty in health care disparities.

childframe_012416Some of the learning opportunities provided by this highly effective simulation help students enlarge their clinical imagination for concrete interventions in caring for those short on funds and also for Public Health Advocacy. The simulation can be enriched by the research literature on the Social Determinants of Health, and Policy. Learning the skills for personal and professional advocacy for improving the health of those living in poverty is a powerful and meaningful way to help students learn empathy for the life experience of those who are poor. The simulation experience is designed to help students empathize realistically with the poor, to stretch their clinical imagination about how to best serve as a knowledgeable and compassionate nurse. A concrete, on-the- ground understanding of the challenges of living in poverty along with the nursing care accommodations needed to make health care more accessible and affordable, can begin with this simulation.

The EducatingNurses.com video series on the Poverty Simulation is a multi-part program designed to help teachers replicate this large scale simulation.

  1. Part One captures how the simulation is planned, introduced and set-up.
  2. Part Two provides examples of the actual simulation with student nurse participants playing family member roles, e.g., as an elderly person, child, or parent. Community service member-participants take on various roles found in any community, including the local market, the “criminal element”,  the jail, the public school, transportation services, social services, the hospital, and so on.
  3. Part Three provides the students’ reflections on their experience of “being poor” and seeking needed community services. A major learning goal of this simulation is to teach students the impact of poverty on health care access and health and health outcomes. The students experientially learn what it is like to cope with poverty within a family develping empathy for those in poverty. Students in the debriefing state that they now understand how important it is to learn the available social services. In a larger group setting, the students also re-examine their experience through the lens of the nurse.
  4. Part Four is an in-depth interview with Heather Voss on the experience and behind-the-scenes information about implementing this simulation. We agree with Dr. Voss that all schools of nursing should design a similar learning experience for their nursing students.

Developing Understanding and Empathy

In their debriefing, the students experience overwhelming stress from standing in long lines for services, of not being able to gain access to transportation and the lack of time for interpersonal relationships in their “families”. Notably, they are not pointing to the “other,” i.e.,that “person living in poverty,” but their own, shortened and attenuated experience of being poor and experiencing the social context of poverty.

Cultural Humility, Curiosity, Attentiveness and Responsiveness

Nurses are in a strong front line position to advocate for attending to the social determinants of health, and addressing the social inequities that create health care disparities. But this cannot happen unless students are guided to transform their personal front-line experiences of the health outcomes of living in poverty, and other social and educational inequities. Negative views of the poor will not create the clinical imagination and compassion that are needed in working with the poor. This simulation should be accompanied by a strong and persuasive reading of the current evidence on health care inequities. Essential in all nursing curricula is a deeper understanding of the social determinants of health as they are intertwined with systemic, economic and political issues.

For example, Linden Farrer, Claudia Marinetti, Yoline Kuipers Cavaco, and Caroline Costongs (2015), Cohen and Marshall (2016), address the issue of advocacy in a highly individualistic culture and urge moving beyond a decontextualized and individualistic advocacy for improving public health (PH):

…multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviors, consistent with the emergence of neoliberal governance. If the PH sector is to fulfill its advocacy role in catalyzing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices. (Cohen and Marshall, 2016; p.1)

Through the Poverty Simulation, students can take their experiential learning about being poor, to the social, political and economic levels of analysis. In other words, take the empathic and newly gained concrete understandings of structural constraints to the policy level without leaving behind their newly gained, rich experiential learning. The goal is not to generalize and objectify the experience of poverty, but to use their experiential learning at the public level, without forgetting the personal and social experience of living in poverty.

Cohen BE1, Marshall SG. Does public health advocacy seek to redress health inequities? A scoping review. Health Soc Care Community. 2016 Jan 7. doi: 10.1111/hsc.12320. [Epub ahead of print]

Levinas, Emmanuel, (1988) Otherwise than Being, or Beyond Essence. (Alphonso Lingis, Transl.)Pittsburgh, PA.: Duquesne University

Linden Farrer, Claudia Marinetti, Yoline Kuipers Cavaco, and Caroline Costongs. (2015) “Advocacy for Health Equity: A Synthesis Review” The Milbank Qt. A Multidisciplinary Jo. of Population Health and Health policy. Milbank Q. 2015 Jun; 93(2): 392–437. Published online 2015 Jun 4. doi: 10.1111/1468-0009.12112 PMCID: PMC4462882

Wendland, Aaron J. “What do we Owe Each Other ?” The Opinion Pages, Opinionator, The Stone, New York Times January 18, 2016 3:45 am http://opinionator.blogs.nytimes.com/2016/01/18/what-do-we-owe-each-other/?smprod=nytcore-iphone&smid=nytcore-iphone-share

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Fitzpatrick, Kevin Michael, Editor of Book of Readings ( 2013) Poverty and Health [2 volumes] A Crisis among America’s most vulnerable. Santa Barbara: ABC-CLIO, LLC Publ.

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