Month: May 2015

Health Care Bucket Lists

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Bucket list: a list of things you want to accomplish before you die. Derived from the saying, “kick the bucket,” a euphemism for dying–although no one seems to agree on the derivation of “kick the bucket.”

I recently ran across my own bucket list that I wrote when I was twelve years old. I wrote it as part of a seventh grade creative writing assignment. My mother kept all of my childhood writing and presented the packet to me before she died–something for which I am eternally grateful. My short stories about toothbrushes coming to life give me glimpses of my younger self that cannot be accessed through any other medium. Here is my bucket list at age twelve:

  1. Own a pair of sandhill cranes
  2. Have a zoo where all the animals can run free
  3. Have a greenhouse as big as a football field
  4. Learn to ride a unicycle
  5. Go to Australia
  6. Keep an otter
  7. Build my own house over-looking a lake
  8. Write a children’s book

I believe that I wanted to be a writer, a naturalist, or a veterinarian–most definitely not a nurse. My favorite books were (not surprisingly by my bucket list), Aldo Leopold’s A Sand County Almanac and Gavin Maxwell’s Ring of Bright Water.

What would my bucket list, my hopes for the future of health care be like? Since I am no longer young and idealistic, my health care bucket list comes out sounding way too jaded and cynical. So I turned to question to my younger and hopefully still idealistic senior nursing students. “What are your hopes for health care?” was my specific in-class reflective writing question to them a week or so ago. I asked them to write out a list of their top ten hopes.

Out of the 140 or so students, the vast majority listed some version of “universal access to quality and affordable health care.” Another frequently listed item was “provision of culturally humble health care,” as well as “eliminate racism in healthcare.” Many included ‘an emphasis on community-based primary health care,” and “more funding for public health.” Improved patient safety efforts, especially through good interprofessional health care team communication and safe nurse-to-patient ratios in hospitals, was a top-listed item. Closely related to that was “improve working conditions to reduce nurse burnout.” Improved access to better mental health services (including the astutely stated question “why are mental health units so ugly?”) and reducing stigma for mental illness and substance use issues, were also frequently mentioned. “Improving end-of-life and beginning-of-life care” as a way to improve quality of life as well as better use of our health care dollars was another top choice.

Here are some additional student ‘hopes for health care’ that make my heart sing and that give me more than a bucketful of hope for the future of health care:

  • To see the person, not the illness.
  • To create a nursing image that represents our smarts and not just our compassion (and nurses aren’t asked, “why didn’t you become a doctor?”)
  • To have more nursing involvement in policy change. Use my knowledge of the challenges faced by my patients to inform policy advocacy.
  • To ensure that ‘the least among us’ receives the best care possible, and “that I am courageous and prepared enough to advocate for the least among us.”
  • That we realize our patients have backstories that need to be recognized in order to provide the best care for them.
  • Full scope-of-practice for nurses uniformly across the country.
  • I hope I still have hopes for the health care system.

The Color of Hospitals

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Detail from “The Truth and Nothing But the Truth” mixed media installation, 1989, Gayle Bard. Main lobby of the University of Washington Medical Center.

What is the color of hospitals? For most people it’s that peculiar, putrid-green of hospitals we now associate with the movie One Flew Over the Cuckoo’s Nest and other nightmarish, disorienting places of illness, distress, disease, and death. The fact that Martha Stewart has revived the shade, renaming it ‘Sea Glass Green,’ and making it oh-so-hip-retro mixed with ‘Jadeite’ green, doesn’t make it much better.

I did a bit of historical research into ‘hospital green’ for an essay I am writing called ‘Medical Maze,’ about the disorientation caused by our modern health care system for patients, families, staff, and students. Over my years working and teaching and researching within health care, I had heard rumors now and then that the hospital green had something to do with blood. Turns out, these rumors were correct.

Much of our modern health care system–especially the growth and technological advances within health care–come from wars. Hospital green, originally called ‘spinach green,’  was invented during WWI by the American surgeon Harry Sherman. At the time, most all surfaces of hospitals and clinics were painted white, the color associated with purity and cleanliness. Dr. Sherman, who was busy doing numerous surgeries in St. Luke’s San Francisco hospital, found the contrast of blood against the white sheets and walls and staff uniforms to be too glaring. He couldn’t discern the fine detail of the anatomy of patients necessary for successful surgeries. So, using color theory, he experimented with different colors and in 1914 he came up with the ‘spinach green’ as a complement to blood red. He convinced the hospital to help him create a totally green operating room–walls, sheets, and the surgeon’s uniforms. I imagine though, that the St. Luke’s nurses kept their white hats and uniforms. The ‘spinach’ hospital green quickly spread to other hospitals across North America.

At around the same time, the East Coast-based hospital architect, William Ludlow, also advocated the use of ‘calming green’ within hospitals, as well as other ‘colors of nature’ including “…the glorious golden yellow of sunshine.” (Note, this is not the sickly jaundiced yellow of the hospital and health sciences complex I currently work in.) Reading some of what Ludlow wrote about hospitals, I’ve discovered a strong liking for the man. In an article he wrote in 1918 in The Modern Hospital, he states, “the word ‘hospital’ brings to mind a huge caravanary of austere aspect without and glaring white sterility within, a pile without cheer and without welcome.” He goes on to point out that hospitals at the time were built around the mass casualty wartime hospital model, and thus were not designed with individual health and well-being in mind. The title of his article (and speech before the Twentieth Annual American Hospital Association meeting) was: “In Time of War Prepare for Peace–War Time Psychology Forced Us to Think of Men In Terms of Groups, But it is Individual Soul That Counts In Every Sphere–Including Hospitals.”

 

Crip Time Lessons

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“On Listening to Wagner” collagraph by Ruth Singley Ensign, 1983

True confession: I had no idea what ‘crip time’ meant until I heard the term used in the recent International Health Humanities Conference plenary session response by David Serlin, Associate Professor of Communication and Science Studies at University of California, San Diego. I wasn’t sure I heard him correctly, and wrote down ‘crypt time or crib time or crip time”‘ in my notes.

From the context within which he used the term, I figured out that it was crip time, as in ‘crippled time,’ a term used within disability studies. Serlin used crip time almost interchangeably with the more familiar (and to me, overused) term ‘slow time.’ The Australian disability rights advocate Anne McDonald wrote this beautiful passage to describe crip time:

I live life in  slow motion. The world I live in is one where my thoughts are as quick as anyone’s, my movements are weak and erratic, and my talk is slower than a snail in quicksand. I have cerebral palsy, I can’t walk or talk, I use an alphabet board, and I communicate at the rate of 450 words an hour compared to your 150 words in a minute – twenty times as slow. A slow world would be my heaven. I am forced to live in your world, a fast hard one. If slow rays flew from me I would be able to live in this world. I need to speed up, or you need to slow down. ~from the Anne McDonald Centre website.

Serlin also spoke of the ‘non-modal subject’ and challenged the linearity that is built into academia. That last point I can relate to, what with our straight railroad ‘tenure tracks,’ our straight and largely isolated/isolating silos of academic disciplines, and our straight and bewilderingly complex academic buildings and medical centers. And I can wax ranting-ly lyrical on the proliferation of the straight-laced Microsoft PowerPoint slide decks used in teaching and in presenting academic research. Serlin did begin his talk by stating that “PowerPoint corrupts absolutely,” although he then used PowerPoint slides…

The non-modal subject, as in the outliers, the freaks, the ‘not normals,’ the ‘not averages’–where do they fit within all of this and what lessons can they teach those of us who ‘pass’ as normals? Because, we should remember, that we are all either disabled or ‘not yet’ disabled in one form or another.

~note: “On Listening to Wagner,” the collograph by my artist mother, Ruth Singley Ensign, is a representation of some of her synesthesia (‘colored hearing’), a perceptual condition of mixed sensations. A handicap or a gift?

Watching the Corn Grow: Health Care in America’s Rural Heartland

IMG_4416Rural health care is an important and oftentimes overlooked topic in discussions of health policy. It is also a sorely neglected topic within the education of health professions students. Since all the major academic medical centers in the U.S. are by necessity located in larger urban areas, the course content and clinical rotations for health science students focus on the urban or suburban health care contexts. Also, as a colleague of mine pointed out recently, any health researcher/academic wanting to focus on rural health would be committing career suicide. That reminded me of what an academic advisor told me early in my career–that focusing on the health of people experiencing homelessness was a dead-end career move. News alert: no one in positions of power and privilege (including NIH grant reviewers) really care about health issues of marginalized people. Perhaps my advisor was right, but I’m glad I didn’t listen to her.

Ignore your roots at your own peril! I grew up in rural Virginia, in a house on a dirt road that was connected to a dirt ‘rural route’ road with no name. In a house with no curtains on the windows since the nearest neighbor lived several miles away. In a house surrounded by woods and corn fields. I got my occasional health care from a country doctor in his country clinic with its 1940s-era medical equipment. Not unlike many young people who grow up in more isolated rural areas, I could not wait for the day I could ‘legally’ move to a city and never look back at what I saw as the stiflingly -limited scope of rural living. Backwards and bucolic. ‘Watching the corn grow,’ as my city friends used to tease me. Rural areas anywhere in the world are, to me, both of these because they are typically socially and politically conservative, as well as being in lovely and peaceful settings.

Imagine my surprise yesterday when I accompanied an interprofessional health sciences rural health course student field trip to the rural hinterlands of Eastern Washington. I try to challenge myself to go outside my comfort zone on occasion, and yesterday was one of those times. In the twenty or so years I have lived and worked in Seattle, I have only ventured east of the Cascades (within my state) once before, and that was just barely over ‘the Pass’ in Ellensburg for a public health Medical Spanish intensive course. Yesterday we visited several community health clinics, a public health clinic, and a community ‘critical access’ hospital in the tiny crossroads towns of Mattawa (supposedly an Indian word for “where is it?” population: 4,437 ) and Othello (population: 7,364). These were both dusty, semi-arid, almost desert places where I expected tumbleweeds to blow through town along with Wild-West shootouts.

‘Downtown’ Mattawah, Washington

 

But here, in the middle of this dusty, no-stoplight, tiny town of Mattawa, was this gorgeous state-of-the-art, wrap-around, one-stop shopping, culturally-relevant clinic, Wahluke Family Clinic, part of the Columbia Basin Health Association. The Association’s motto is “Keeping healthy those who feed the world.” The outside/front entrance of the Wahluke Family Clinic:

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And the front desk/lobby/check-in area of the clinic: IMG_4387 (1)

 

A tour of the clinic, which has an amazing array of primary health care services including family medicine (physicians, physician assistants, nurse practitioners, RNs), dental/orthodontics, vision care, behavioral health (mental health and chemical dependency services), diabetic footcare/shoes, pharmacy services (including delivery and a drive-through pharmacy), all under one gorgeous roof, with clean, lovely-decorated facilities throughout, a rooftop, sunny staff lunch/break-room and outdoor patio, a fully-equipped indoor gym for all staff members, and original artwork throughout. It all felt unreal, like, really? is this how primary healthcare can be? and wait! this is part of our safety-net health care system, since they are a community health clinic with federal funding, and serving primarily a Spanish-speaking migrant farm worker and lower-income rural population. Plus, it is out in the middle of nowhere.

Besides the dizzying array of health care services, what most impressed me about this clinic (and its linked clinics in nearby Othello), was the attention to the aesthetics of the patient areas, with use of original artwork, seemingly by Hispanic/Latino artists–such as the one in the first photo included in this post.

In stark contrast, were these patient care hallways (mental health services at the Adams County/Othello Public Health Department–why does public health have to be so perpetually, well, frumpy and unappealing?): IMG_4422

and this (is it really even artwork?) hanging on the walls of the small community hospital in Othello (with 90% of its patients being Latina women giving birth):IMG_4426

 

 

 

 

Although I realize I do not know enough about the health care in these small towns/rural areas, I wonder if the quality/cultural appropriateness of a clinic or hospital’s artwork is a good indicator of the facility’s overall healthcare quality. Perhaps in addition to Dr. Paul Farmer’s two indicators of healthcare quality–gardens and bathrooms–could be added artwork/general aesthetics.

I’m not planning to move back to a rural area anytime soon, but after yesterday’s field trip with health science students, I have a greater appreciation of what well-run community-based primary care services in rural areas can look like.

I am a Nurse, Just a Nurse

11164759_1057759667571978_8700043668876075012_nFor many years, whenever anyone said to me, “Oh! You’re a nurse,” I would correct them and say, “No, I’m a nurse practitioner.” Why? As if identifying myself as a nurse was somehow beneath me? As if being a nurse practitioner meant I wasn’t really a nurse, or I was more than a nurse because I could diagnose and treat medical problems, something nurses can’t do? As if I was too intelligent to be ‘just’ a nurse?

I was not born to be a nurse; I was not called to be a nurse. I didn’t need multiple-choice tests and multiple sessions of career counseling at pivotal junctures in my life to tell me these facts. What with the Myers-Briggs Type Indicator, the Strong Interest Inventory, the Eureka Skills Inventory, and the Holland Personality test results, my career counselor proclaimed, “You don’t have the personality, the interests or skills test results to match nursing.” It seems I was meant to be a writer. Oops. Too late. When she told me this I had already been a nurse/nurse practitioner for over thirty years. Of course, it was my job as a nurse practitioner and nurse educator (and most definitely not as as an unpaid writer) that allowed me to take these expensive tests in the first place.

But oh the places nursing has taken me! If I had it all to do over again, if I didn’t have to worry about being a single mom earlier in my career trying to earn a decent income, if I could choose any of the health professions to ‘become,’ I would choose to be a nurse. I would choose to be the ambivalent, skeptical, social-justice minded, community/public health-focused nurse that I am. Last summer I reflected on where community health nursing has taken me, and I made this short digital storytelling video: “My Story of Community Health Nursing.”  Even though this was my first video, and I see that it is clunky in places, I revisit/re-watch it on occasion to remind myself of who I am, and of why I love to do the work I do–including teaching nursing students and encouraging them to consider becoming a community/public health nurse.

The photo included in this post is a ‘retouched’ photo of a University of Washington School of Nursing promotional placard reading “I am a #huskynurse.” It’s not that I’m opposed to proclaiming myself an over-sized, plump nurse. But I am opposed to being a (branded) nurse. I am an–unqualified– nurse. I am a nurse. I am a community/public health nurse.

Happy National Nurses Week and Happy 195th birthday to Florence Nightingale!

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“Just a Nurse” is used with a nod to the work of Suzanne Gordon, a journalist who writes about/is a longtime advocate for nursing.

The Ugly Underbelly of the Health Humanities

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“Release Your Plans” oil on canvas by Denver-based artist Daniel Spricks.

Ugly, as in ‘unpleasantly suggestive, causing disquiet, likely to involve violence of some sort, repulsive.’ Underbelly, as in ‘beneath the surface, hidden, vulnerable, corrupt, sordid.’ Health humanities, as in the relatively new transdisciplinary field linking the arts and humanities with health and healthcare. Health humanities is both the term and the international movement intended to widen the more traditional field of medical humanities with its focus on physician practice and physician education. (See The International Health Humanities Network for more information.)

I have just returned to my life in Seattle after four days in Denver spent pondering the ugly underbelly of the health humanities. I was a participant-observer at the 4th Annual International Health Humanities conference, Health Humanities: The Next Decade, held at the University of Colorado School of Medicine Center for Bioethics and Humanities. The stated purpose of the conference was to “…bring together scholars, educators, clinicians, health advocates, students, patients and caregivers in an effort to identify the core issues and guiding values as well as define the expanding scope of the health humanities.”

Out of 100 or so conference participants, I believe I was one of only three nurses. Professor David Flood from the College of Nursing and Health Professions at Drexel University served as a conference committee member, but there were no nurses (unless they were deeply closeted nurses) who presented at the conference. The third nurse was Jamie Shirley, PhD, a terrific nurse ethicist and lecturer at the University of Washington Bothell campus. At the risk of adding to the tiresome ‘whiny nurse syndrome/trope in academese,’ I can’t help asking, “Where were the nurses?” As this was hands-down the best, most thought-provoking conference I’ve ever been to–and was, correctly I think, proclaimed as a historic conference with far-reaching consequences–why weren’t there more nurses at ‘this table?’

What I most loved about the conference was that the planners, speakers, and participants all openly acknowledged and explored the ugly underbelly of the health humanities. Not just who/what groups of people are included and excluded within the theory and practice (and international conference) of the health humanities, but other and perhaps more uncomfortable questions, such as:

By attempting to train medical, nursing, and other healthcare professions students in ‘narrative competence,’ are we turning this into yet another skill to include on a checklist? (The ‘tyranny of competencies’ as it has been called.) And, as Katie Watson, JD of Northwestern University Feinberg School of Medicine pointed out in a session on narrative advocacy, is a focus on narrative competence ignoring the fact that perhaps this is intrusive, itself a form of violation–of violence? Do we as teachers of the health humanities understand what it costs our students (as well as ourselves) to be opened up/made more vulnerable to the emotional pain of patients, of families, of communities, and of the world? Do we do enough to help our students ‘learn how to carry’ (or perhaps how to carry and then let go of) traumatic patient/community stories? Where does the ‘enterprise of narrative medicine’ fit within the health humanities? What are the professional consequences of doing radical art, radical writing, radical practice, and I’d add, radical teaching? By attempting to widen medical humanities to health humanities, are we adding to the cult of healthism?

And an ‘ugly underbelly’ question that I asked in a session yesterday (when I stepped outside of my observer role): why is religion/spirituality seemingly a taboo topic within the health humanities? Throughout the conference people tip-toed around religion and spirituality. Don’t people see that the privileging of secular humanism, the marginalizing–or worse, belittling–the role of religion and spirituality within our world, within healthcare practices, within health policy, within our own lives, is a grave danger? I’m not referring to a grave danger to our ‘souls,’ whatever that may mean, but rather to our lives together in communities, to the common good, to the civil discourse necessary for democracy.