Over dinner recently, my husband asked me if I was still writing blog posts. I replied, “No, not really.” When he asked me why not, I recounted how I had started writing this Medical Margins blog back in 2010 as I was processing my elderly father’s final illness and the insanity of the US healthcare system, especially related to end-of-life care. In my blog, I then moved on to trying to rekindle a passion for the rather problematic (to me) profession of nursing. Then, I became interested in the health humanities and the somewhat insular academic world of narrative medicine. And, always, homelessness. Fast-forward to today, and my writing time and energies go towards writing books on homelessness and health.
I am a part-time, nine-month employee and professor. I live for my summers off now when I have uninterrupted time to write and be a grandmother. This past summer, I made good writing progress on my next book, tentatively titled Way Home, about the contemporary landscape of homelessness in Seattle and King County. Refining and tightening my storytelling approach to writing (with terrific assistance from an editor), I edit out passages I might love but which do not pass the “So what?” test. I keep these darlings in a Word file titled “Extra.”
COVID caught up with me this summer, along with a bad bout of COVID rebound, and yet I pushed myself to continue writing. Some of these fever-induced passages ended up in the “Extra” file. Here is one I like, although it most likely will not make it into the final book manuscript. The photograph, however, likely will.
Consider the shopping cart. Constructed of wire and plastic and supported by four wheels, the cart’s purpose is to carry store merchandise before and after purchase. The shopping cart, developed during the Great Depression by an American man for use in grocery stores by housewives, becoming super-sized and non-gendered, an exquisite symbol of capitalism. The shopping cart, appropriated by people experiencing homelessness, serving as container and conveyance for their remaining belongings, a somber symbol of the fallout from late capitalism.
Long before Washington became a state, the first official caregivers of people with mental health problems were immigrant nurses from Montreal. Often overlooked and forgotten, the Catholic Sisters of Charity of Providence opened “St. John’s Lunatic Asylum” near Fort Vancouver in 1861. Caring for the mentally ill was part of their charitable and religious mission.
Today, nurses remain the largest providers of behavioral health treatment. Giving compassionate, quality care to people struggling with mental illness and substance use disorders, mental health nurses assume that families, friends, and others can no longer provide. Yet, they are consistently underpaid.
In 1862, when the Washington Territorial Legislature awarded the Sisters a three-year contract to provide inpatient care for the mentally ill, it contracted to pay $8 per person per week. The Sisters took in private-pay patients because the government funding was so low.
Despite the low payment, the Sisters offered high-quality care. A notable component of the treatment was careful observation, helping prevent suicide or other harmful behaviors. Consistent with prevailing treatment recommendations that a good environment would restore the mind, the Sisters offered housing in a beautiful, healthy locale.
Visiting St. John’s in 1863, Territorial Governor William Pickering was satisfied with the Sisters’ care; however, the Territory failed to make payments. The following year, the Territory made partial payments, offering devalued paper greenbacks worth only 50 to 80% of face value instead of the coin currency that Mother Joseph, the Superior, desired. The Sisters’ bill remained unpaid by the Territorial Legislature until 1872.
Despite the lack of payment, the Sisters worked under the contract until 1866, when the Territory awarded the contract to lower bidders, a father and son partnership in Monticello. They transferred patients to the hastily built asylum lacking any nurses or physicians. Conditions at the Monticello asylum raised cries of alarm. An inspection revealed a “shameful negligence of duty” toward a female patient who had become pregnant. Patients lived in filth and standing water.
In 1869, the acclaimed nurse and advocate for the mentally ill, Dorothea L. Dix, visited our region. Dix spearheaded the opening of state-supported mental hospitals across the U.S. and Europe, using advocacy and her detailed first-hand documentation of asylum conditions. Learning of conditions at Monticello, she urged the Governor to remove the patients from Monticello. Worried that bad publicity could detract from the status of the new territory, the Legislature determined to open a permanent public institution with a resident physician. Later known as Western State Hospital, the new institution opened in 1871. Due to a lack of adequate state support, safe staffing, infrastructure maintenance, and quality of patient care, Western State lost federal certification and funding support in 2018.
Our historical experiences highlight essential questions about who will pay for the necessary treatment that our mentally ill brothers and sisters require. Privately funded initiatives, religious organizations, and charities can provide aid, but their goodwill and funding resources are limited. In 2019, Washington legislators approved legislation to improve our mental health system.
With the combination of the protracted COVID-19 pandemic, a worsening mental health crisis, especially for our young people, and half of the nurse workforce nationally burned out and considering quitting, we need to pay and support our nurses and our future nurses. From workplace violence prevention, safe nurse staffing laws, to pay parity for psychiatric nurse practitioners (SB 5222), we should learn from the past to ensure a better present and future.
Amidst the raging debates about what to do about homelessness in Seattle and King County, the voices of people who work—and live—at the intersection of health and homelessness are drowned out. That needs to change if we hope to make any real progress towards solving homelessness and suffering in our city and neighborhood. With the aim of increasing a diversity of voices and perspectives on homelessness, I’m happy to share our Reader’s Theater script, “Listening to Seattle’s Skid Road: Testimony from the Edge.”
Join us for a (free, virtual) Reader’s Theater and hear the voices of unhoused individuals, caregivers, and more, as we consider the toll that homelessness takes on our community—as well as amplifying local examples of innovative solutions.
Thursday, November 18, 6:30-8 pm (PST), University of Washington Libraries.
“Listening to Seattle’s Skid Road: Testimony from the Edge” was written by Josephine Ensign, DrPH, professor UW School of Nursing; and Lorraine McConaghy, Ph.D., public historian; with assistance from Lisa Oberg, librarian, UW Special Collections. The script is based on interviews conducted by Josephine Ensign with people working—and living—at the intersection of health and homelessness in Seattle, as well as Josephine Ensign’s recent book, Skid Road: On the Frontier of Health and Homelessness in an American City (Johns Hopkins University Press). Funding support for the Reader’s Theater script came from a 4Culture Heritage Award.
Everyone, it seems, is burned out these days. Frontline nurses, doctors, public health workers, and other healthcare providers who are weathering yet another vicious turn in the COVID-19 pandemic. Frontline service providers, short-staffed and short supplied. Parents struggling to parent well amidst the crazy-making politicized strife over a safe return of their children to in-person teaching at schools. Homeless and near homeless people trying to survive and maintain hope as eviction moratoriums end. Climate refugees and Afghan refugees. The list goes on.
How to manage the massive burnout we’re almost all feeling?
Having survived some rather spectacular professional and personal life burnouts in my life, and feeling it again as I face yet another academic year full of ‘pivots and uncertainties’ (words I now despise), with the responsibility to teach future nurses about our besieged public health and broken healthcare systems, burnout prevention is high on my list of priorities.
Cutting through the growing piles of research studies on burnout and its second cousins of moral distress , secondary trauma, vicarious trauma, and compassion fatigue, I am drawn back to two main resources that I find most helpful. The first resource is the book by Seattle-area social worker Laura van Dernoot Lipsky with Connie Burk, Trauma Stewardship: An Everyday Guide for Caring for Self While Caring for Others. I re-read sections of this book when I am beginning to feel ‘crispy,’ on the verge of burning out. I especially appreciate her inclusion of systematic oppression, trauma-informed care, clear explanation of trauma mastery, all combined with liberal use of appropriate humor. For a good introduction to her and her work, take a look at this TEDx talk from 2015 at the Washington Correction Center for Women, “Beyond the Cliff.”
The second resource I use and recommend to my students is the work of Rachel Naomi Remen, MD and her Heart Journal practice. She encourages asking yourself at the end of the day, “What surprised me today? What moved me or touched my heart today? What inspired me today?” Although I am an early morning journal writer, I try to incorporate at least some of these questions into my reflective writing, especially when I know I’m at risk of burning out.
As part of my Skid Road project on health and homelessness, I had the privilege of conducting a series of oral history interviews with thirty-six people working—and sometimes having lived—at the intersection of health and homelessness in Seattle. One of the questions I asked the interviewees was, “What advice do you have for people in terms of burnout prevention?” I loved the wide variety of responses to this question. Krystal Koop, MSW, replied, “And that’s another thing with burnout. You are going to get burned out every once in a while, and that’s okay. Don’t beat yourself up about it. It’s okay.”
But my favorite response to this question was from Benjamin Danielson, MD. He said, “Burnout is an interesting thing. I think about life balance the way I think about bicycle balance. If you are sitting still on a bicycle and you try to balance, you fall over. So keeping everything exactly balanced in a moment is pretty unlikely. But a bicycle in movement over time – the balance is very much there. It’s important to not examine just one moment and know whether everything is perfectly balanced, but it is important to keep track of the things that are important to you, and the people that you love and love you, and stay connected to those things.”
Welcome to the strange new world! When I first conceived of and began research for what became my newest book, Skid Road: On the Frontier of Health and Homelessness in an American City, I knew I was in for a lot of hard work and more than a few surprises. What I didn’t know was that it would take over five years to complete the research and more than two years to write and see though to publication. And that I would have it published during a prolonged pandemic. But, needs must, an archaic yet useful (mostly British) way of acknowledging an unfortunate reality and continuing on. Thank you to Johns Hopkins University Press for publishing this book. They are leaders in public health and the history of medicine, and that, combined with the fact that I am a JHU Bloomberg School of Public Health alum, make them one of my dream publishers.
Helping to launch this book into the world will be a much different experience than for my previous two books, back when I was able to travel and do in-person book events. I am okay with that, especially after realizing the benefits of virtual book talks and events as both a participant and as a speaker. Access to a much wider audience, including people with mobility or health issues. Much better for the environment. Suited to the introvert that I am. I look forward to virtual book events and will provide updates and links to events (all free, of course) under my Events page on this website.
In the sea of bad journalism on homelessness, a few shiny good ones wash up on the shore. This (linked below) is one of the best, most thorough, and balanced articles on homelessness I have read. The inclusion of the history and place-based stories of Venice adds to its power. And the compassionate photographs by Glenna Gordon are stunning. Here in Seattle where we have one of our country’s highest rates of homelessness (along with NYC and San Fransisco), we have similar ongoing messy public debates about solutions. The business-sponsored “Compassion Seattle,” which is misleading and misguided seems headed for a vote in November.
Here are my latest two brief (5-minute) educational videos that are part of my Skid Road project and linked with my forthcoming book, Skid Road: On the Frontier of Health and Homelessness in an American City. “Ark of Refuge” is about the Housing First model of care, how Seattle has been a leader in the implementation of this model, and about the historical (and colorful) figure of Dr. Alexander de Soto and the Wayside Mission Hospital. “Shacktown” is about Seattle’s longstanding lack of safe, affordable housing and how homelessness here is tied to our city’s historical land use, municipal zoning laws, and exclusionary and racist housing policies. Please share them widely and consider using them in your own teaching and/or advocacy work.
As our country edges towards post-pandemic individual and community life, we see clear evidence of deepening economic and racial inequities. Any walk or drive through our urban areas, from Washington, DC to Los Angeles, reveals a steep rise in visible poverty and homelessness, especially for persons of color. With this rise comes an increased push to criminalize people for being homeless. From my nearly forty years as a nurse and researcher working with homeless populations, and my lived experience of homelessness as a young adult, I know that criminalizing poverty and homelessness does not work. It only worsens the problem.
Here in Seattle, which already had one of our nation’s highest rates of homelessness and income disparities before the pandemic, tents and other temporary living structures made of cast-off materials line the hillsides along I-5, appear on sidewalks, and in green spaces such as ravines and city parks. Cars, RVs, and trucks with screened off windows and windshields—the temporary homes of vehicle residents— dot the landscape. A house next door to my own home in a mixed-income neighborhood near the university where I work, has changed from being an informal refuge for homeless squatters to a ‘flipped’ single-family home currently on the market for $1.2 million.
Early in the Covid-19 pandemic, when we were asked to shelter at home and congregate living spaces such as emergency shelters were known to flame the spread of the virus, public health officials locally and nationally moved to limit shelter capacity and placed moratoriums on both evictions from housing and homeless encampment clearances. Motels were turned into Covid isolation and recovery units for unhoused people. Despite the motels and pauses on evictions, visible homelessness increased exponentially.
Eviction moratoriums, an effort to prevent a wave of new homelessness in the economic fallout from the pandemic, although being challenged, appear to have more staying power than the hold on encampment clearances. In February of this year, the city of Mercer Island, one of the highest income ZIP Codes in the Seattle-King County area, enacted legislation to ban camping in public parks. (1) The Auburn City Council recently passed more punitive anti-homelessness legislation, allowing the charging of criminal trespassing for people camping overnight on any city property. (2) People now face a $1,000 fine and/or 90 days in jail if they fail to follow through with individualized plans aimed at either moving them into housing or at least out of the jurisdiction. Council members who voted in favor of this criminal penalty characterize the new law as “compassionate accountability.” In Seattle, a group composed of mainly business people is calling their effort to resume encampment clearances “Compassionate Seattle.” (3) They aim to secure enough signatures to bring to vote a change in the Seattle City Charter requiring the city to provide more permanent, supportive housing and simultaneously to clear parks and other public spaces of homeless encampments by criminalizing them.
Criminalizing homelessness has a long history in our country despite the fact that it has never worked. As the National Law Center on Homelessness and Poverty documents, criminalization worsens homelessness and racial inequities by weighing down already impoverished people with hefty fines, jail sentences, and criminal records. (4, 5) Criminalization diverts money away from supportive housing, and basic health—including mental health and substance use disorder treatment—that are more cost-effective at preventing and addressing homelessness. Communities that criminalize homelessness have higher rates of violence against people living or even appearing to be homeless. (6)
If criminalizing homelessness does not work, why do we keep returning to it? Part of the reason has to do with the fact that it was foundational to our country. Our various state-level poor laws, including vagrancy laws, are based on the Elizabethan Poor Laws adopted by the original thirteen British colonies. British social historian David Hitchcock points out that “Christian charity and proper punishment were delicately connected in English culture,” a connection reflected in the English Poor Laws. (7) English paupers were sent to the colonies as punishment, in what Hitchcock terms “welfare colonialism.” (8)
Benjamin Franklin, the vocal proponent of the “pull yourself up by your bootstraps” American metaphor of personal transformation through hard work, openly despised poor people and advocated for sending them to the western frontier, which at that time was Western Pennsylvania. (9) Franklin viewed this practice as a survival-of-the-fittest sort of endeavor that would simultaneously rid the East Coast cities of urban blight and disease, force the assimilation of immigrants, and improve the character and hardiness of Americans.
This westering, frontier mentality has reverberations today in Seattle, from the increase in Tiny House Villages looking eerily like the shacktown Hoovervilles of the Great Depression, to the burgeoning vehicle residents similar to the Dust Bowl’s Rubber Tramps who lined city parks, as well as the RV residents depicted in “Nomadland.” Recently, a team of human rights lawyers invoked the frontier-era Homestead Act of 1862 in King County Superior Court. (10) They were representing a homeless construction worker who lived in his truck against the city of Seattle for impounding his truck and charging him $557 in impound fees. (The city of Seattle appealed the ruling to the Washington Supreme Court, which heard arguments on March 16, with a ruling expected within a few months.)
Punishing people for being down and out and homeless is not the answer. Increased and sustained funding for safe, affordable, supportive housing, well-connected with primary health care that is inclusive of mental health and substance use treatment, is what works to address homelessness. Policies and programs led by people with the lived experience of homelessness make them more innovative and effective.
7. David Hitchcock, “’Punishment Is All the Charity That the Law Affordith Them’: Penal Transportation, Vagrancy, and the Charitable Impulse in the British Atlantic, c. 1600-1750,” New Global Studies 12, no. 2 (2018): 195-215 (quote, 200), https//doi.org/10.1515/ngs-2018-0029.
9. Nancy Isenberg, White Trash: The 400-year Untold History of Class in America, (New York: Viking, 2016)
In my almost 40 years of nursing, I have heard about, read about, and taught about nurse bullying, but I had never experienced it directly—until yesterday while working as a Covid vaccinator in a hospital setting.
The American Nurses Association (ANA) defines nurse bullying as “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.” As I write that, I wonder why they include “unwanted” in the definition. Who in their right mind would want to be bullied? And even if that were the case, it would not make bullying okay. The ANA includes bullying in its statement on workplace violence. They point out that nurse bullying threatens patient safety, diminishes quality of care, and contributes to nurse burnout/staff turnover. Nurses who are bullied suffer a host of physical and emotional repercussions, including higher rates of depression and suicide.
“Nurses eating their young” is an oft-repeated phrase when referring to nurse bullying. I imagine that Florence Nightingale was quite the nurse bully. It seems to be ingrained in our profession and treated almost like a necessary rite of passage. Nurse bullying can begin in nursing school, with students being subjected to humiliation and intimidation by professors, clinical instructors, and school administrators. In some studies (see references below), over half of graduating nursing students report having witnessed (bystander) or been the recipient of nurse-on-nurse bullying in clinical rotations. The vast majority of nurse bullying happens in hospital settings, perhaps perpetuated by the high stress, high stakes clinical outcomes, heavy workloads, and low job autonomy of nursing within the rigidly hierarchical hospital setting.
I know that many frontline hospital nurses across our country and in other countries hard hit by the pandemic are burned out and angry after over a year of treating patients with COVID-19 and seeing so many of them die. Many nurses are tired of being portrayed as “angels on earth.” And, of course, the pandemic is far from over despite the rollout of safe and effective vaccines. Perhaps the vaccine clinic nurse manager yesterday is one of those burned out, pissed off nurses. It doesn’t excuse the bullying behavior she threw my way (I’ll spare you the details but it went way past incivility) and to a patient who, post-vaccination, asked to use the restroom (located next to the clinic) and she told him curtly that he had to wait the full 15 minutes of post-vaccine observation. Seriously, a patient is a person who has the right to use the restroom. I’d had enough and escorted the patient to the bathroom, waited outside to make sure he was okay, and then excused myself from the presence of that nurse bully. And reported her behavior in the hopes that she will be removed from that specific role and offered professional coaching of some sort. But I’m not going back to that setting, at least not as a clinician. I’ll find a better place to volunteer as a nurse vaccinator.
I’m attempting to turn this distressing experience into a teachable moment, for myself, and for students I teach. I now know from direct experience that nurse bullying is real.
Cole Edmonson and Caroline Zelonka, “Our Own Worst Enemies: The Nurse Bullying Epidemic,” NURS ADMIN Q. 2019, vol 43(3):274-279.
Note: I received this message in response to this post:
“As I’m sure you know, workplace violence is a critical issue affecting not only nurses, but patients and their quality of care. That’s why ANA launched #EndNurseAbuse – a nationwide initiative to eliminate physical and verbal abuse, sexual harassment, and bullying in the workplace. #EndNurseAbuse galvanizes nurses, health care stakeholders, and consumers across the nation to reduce violence and harassment against nurses. Visit the #EndNurseAbuse resource center to see the video that brings to life actual accounts from real nurses who have experienced various forms of violence and abuse on the job. While you’re there, please take a minute to sign the #ENA pledge and share!
Always a nurse, or so the saying goes. Events of the past year, and especially of the last week, have taught me the truth of that saying, at least on a personal level.
I am and have been over the course of my 39-year career (counting from when I first started nursing school), a public health nurse (TB and hypertension control nurse with the health department in Richmond, Virginia), an inpatient stroke/neuro ward nurse, a rehabilitation nurse, an HIV/AIDS nurse at an LGBTQ community clinic, a Health Care for the Homeless nurse and family nurse practitioner. I have been (still am) a nurse researcher, a nursing professor, and a writer who happens to be a nurse. Always a somewhat skeptical/critically-thinking nurse (still am), questioning our healthcare system, our profession of nursing, and our socio-political system as a country.
Ever since the COVID-19 pandemic became a reality over a year ago, like many people throughout the world, I have reassessed my professional roles. What’s essential and what’s not? Essential: teaching population health and health policy as well as possible to our future nurses; becoming even more politically engaged to speak up on important issues like racism in health care, gender-based violence, and hate crimes against LGBTQ people/people living homeless/Asian-Americans; growing my network of politically engaged, progressive nurses across the country; spreading evidence-based public health information about the pandemic/pushing back against the cacophony of mis-information and outright lies; thinking and acting like a public health nurse, which I have realized is the kind of nurse I have always been. Not essential: university internal politics; worry about being productive with the usual expectations of grant-writing and peer-reviewed journal writing. My pandemic mantra has and continues to be: accomplish less, experience more.
This past week, the day after my two-week post second Pfizer COVID-19 vaccine dose, I began volunteer work as a COVID-19 vaccinator at a local public hospital. I asked for and received an excellent nurse practitioner mentor to shadow at first to get up to speed on the proper vaccination protocol, then sat down at my assigned station and began talking with patients and giving them the vaccinations. Yesterday, the vaccination clinic nurse supervisor introduced herself (both of us behind masks, of course) as one of my public/population health students years ago. She said she is an acute care nurse who has been working on the frontlines of the pandemic “since day one.” I thanked her for her work as a hospital nurse and as a nurse supervisor for the vaccine clinic, and gently reminded her that she is doing vital public/population health nursing.
I told my husband and family members (all, except my two-year-old granddaughter vaccinated now), that working as a volunteer public health nurse at the COVID-19 vaccination clinic feels like the most important and personally satisfying work I have done in my entire nursing career. Spread the word: These vaccines save lives and livelihoods. They give us hope.
(Please note: the photograph here was ‘staged’ and contains no patient or provider information.)