The Future of Nursing

Lillian Wald’s public health nurse uniform

The future of nursing should begin with people and community/population health. And to do that we need to disrupt our tired, outdated approach to nurse education. Not by tweaking here and there. Not by investing tons of money in yet more high tech simulation labs and “dummies.” Not by asking ourselves and our students, “What would Florence do?” (as in the Florence Nightingale, important as she is). Rather, we should begin by asking, “What would Dorothea do?” (as in Dorothea Dix, US and international mental health reformer) and “What would Lillian do? (as in Lillian Wald, the “mother of public health nursing” and founder of the Henry Street Settlement House in New York City).

“Begin with people, not body parts,” is what one of our nursing students told us recently when she heard that we are disrupting our pre-licensure nursing program at the University of Washington. Starting this coming academic year (begins in September), we will begin with people—with community, public health nursing instead of the longstanding “traditional” acute care medical-surgical nursing. I am excited to be teaching this “new” community/public health nursing course. It will begin at the true beginning with the social determinants of health equity. Not just with the social determinants of health (SDH)—those factors that affect our health from where we live, work and play. The social determinants of health equity extends past the SDH to acknowledge and address the inequities inherent in our society that affect health, including structural racism, and all the other “isms” of longstanding discrimination against women, persons of color, LGBTQ people, disabled folks, and the aged. Dr. Camara Jones and her “Cliff of Good Health” is the best illustration of this.

The Future of Medicine 2030 Seattle Town Hall was held at the University of Washington this morning. This builds on and extends the work of the Institute of Medicine’s Future of Nursing report back in 2010. The theme of today’s town hall meeting was “High Tech, High Touch.” I was dismayed (okay, I was irritated) that the lead speaker at today’s event was a physician, Molly Coye, who is an executive-in residence with AVIA, a network of US health systems “solving problems with digital technologies.” It is the “The Future of Nursing” after all and not “The Future of Our Insanely Expensive and Ineffective US Healthcare System.” And it should be led by nurses!

The one truly inspirational speaker at today’s event was a nurse—Dean Kenya Beard from Nassau Community College in New York. She spoke of some of the drawbacks of health technology and how they can amplify health inequities and how most of the proprietary algorithms for high tech “solutions” lack transparency. She called out the pressing need for nurse educators to “rise above any level of discomfort” and address structural racism and interventions that work. As to structural racism in our country she stated, “humans created it and only humans can destroy it.” She ended her talk with, “We need daring ingenuity.”

My question/comment which I posted online during the town hall was this:

“Why aren’t we using the much more useful term “social determinants of health equity” versus the rather status quo term “social determinants of health”? Why aren’t we killing forever the outdated and unhelpful message to our nursing students that they “have to have at least two years of inpatient med-surg” work before they go on (yes, go on) to community, public/population health nursing? Why aren’t we stopping the practice of educating nursing students to be “agents of social control” and instead to be “agents of social change?” Also, thanks for the refreshingly honest and necessary presentation and perspective from Kenya—Brava!

Homelessness Started Two Years Ago

Richmond, Virginia 1986. Covering up Homelessness

An important news update brought to you by President Trump: Homelessness started two years ago in our country and it is the fault of liberal states, of liberal people in sanctuary cities such as Los Angeles, San Fransisco, and New York. And Seattle. Oh yes, and our president claims that it is the fault of homeless people themselves. “They like living that way.”

“We’ve never had this in our lives,” he said in a FOX news interview with Tucker Carlson last week. When asked by Carlson what we should do about it Trump responded, “Take the (homeless) people and do something.” Presumably by that, he means clear homeless people away, dispose of them out of sight. Perhaps in detention centers along the US-Mexican border. Or behind rows of doors from torn-down affordable urban housing as in the photograph above from my hometown of Richmond, Virginia. I took that photograph in 1986 on my way to my work as a nurse with homeless people.

Trump pointed to his clearing out of homeless people in Washington, DC when he moved into the White House. He claims he told people that he had leaders of the world coming to see him, the President of the United States, and “they can’t be looking at that” referring to visible poverty and homelessness in our nation’s capital.

That this revisionist history, these lies, would be laughably absurd in a different context, a different time—perhaps sometime in our hopefully brighter future—is one thing. But that wistful and wishful thinking only highlights the current dangers in this rhetoric. People believe what Trump and Carlson say. People act on what Trump and Carlson say. “Take the (homeless) people and do something” leads to vigilantism and physical attacks (and killings) against people who are or who “look homeless.”

University Vaticans

Suzzallo Library, University of Washington, Seattle

What do contemporary American universities have in common with the Roman Catholic Church? Massive collusions and coverups of systematic sexual assaults and abuse of girls and boys, women and men. We have seen the accumulating evidence, what with high profile cases such as the one of former USA Gymnastics and Michigan State University sports physician Larry Nassar who sexually assaulted at least 300 girls and young women. As Sophie Gilbert states in her recent article in The Atlantic, Nassar “did benefit from a culture that closed ranks around him and defended him long after he’d been exposed”—including by officials at Michigan State University. (Sophie Gilbert, “A New Film Reveals How Larry Nassar Benefited From a Culture of Silence,” The Atlantic, May 2, 2019)

But it is not only high profile cases that should outrage us and call for systematic reforms. There is a steady, almost weekly, string of news stories about sexual assaults on our college campuses and the egregious university culture of silence—silence and silencing (and further abuse) of survivors. Such silencing is not, as is often cited as an excuse, to protect the safety and reputations of the survivors and the perpetrators of abuse. Such silencing is first and foremost to protect the reputations of the universities in order to keep those private and corporate donations pouring in. More people need to understand this. More journalists need to call it out.

A recent and close to home sexual assault (and university silencing) was exposed this week by Seattle Times reporter Asia Fields. In her June 12th article, “UW finds star athlete’s sexual assault allegation credible, but athletic executive quietly moved on,” Fields tells of the 2017 sexual assault of Cassandra Strickland, a female University of Washington undergraduate student and volleyball player by UW senior associate athletic director Roy Shick and the university’s handling of the assault investigation. When Shick discovered the university investigation, he resigned and subsequently was hired by Grand Canyon University as vice president of advancement (he has now been fired). The UW internal investigation of the assault found “sufficient evidence to support the finding that Mr. Shick’s behavior amounted to sexual harassment.” But those findings were shared only with “those with the need to know,” which included UW president Ana Marie Cauce, the athletic director, and people in the university’s legal department.

The University of Washington legal department and investigators entered into a quiet settlement with Cassandra Strickland, giving her $20,000 for mental health treatment, but with the stipulation that she “sign a release allowing the university access to her counseling records to check on her participation and progress in treatment.” They also had her sign a waiver of any future claims against the university.

Seattle attorney Rebecca Roe, who has represented clients who were sexual assault survivors at the University of Washington, is quoted as saying, “I find that totally and completely offensive. The Catholic Church used to try to do that.”

The Seattle Times broke this story, resorting to using our Washington State public records laws to obtain the redacted University of Washington internal documents relating to this case. But also, Cassandra Strickland, the strong survivor, was willing to go on record with these powerful words: “My story is not unique. There are hundreds, if not thousands of other girls at other universities, whose stories are being buried to protect the reputation of the schools they attend. It’s a problem, it’s been a problem for far too long and we need to change that.”

Being a University of Washington professor, I am devastated and enraged by what happened to her. I also know it has happened—and likely will continue to happen—to many more of our students. For decades, I worked beside a faculty member widely known to sexually harass and intimidate our female students. Nothing was done except require him to keep his office door open when meeting with female students. I tried to discreetly steer young female students away from working with him—but otherwise, I felt powerless. And I was complicit in a university system that allowed the abuse to continue. No more.


Know Your Rights: Sexual Harassment and Sexual Assault Under Title IX” by the American Association of University Women.

End Rape on Campus

And, from the Seattle Times article: “If you have experienced sexual assault and need support, you can call the 24-hour National Sexual Assault Telephone Hotline at 800-656-HOPE (800-656-4673). There is also an online chat option.

Survivors in King County can call the King County Sexual Assault Resource Center’s 24-hour Resource Line at 888-99-VOICE (888-998-6423) or visit”

Honor the Stories

Once upon a time, as a child living on land in Virginia where the Powhatan had lived, I dressed as an Indian princess—Pocahontas most likely—and tried to learn to paddle a canoe, silently, “like an Indian.”

Once upon a time, as a young teenager, I was dressed in white flowing robes and a feathered Indian headband, paddled out into the middle of the James River at Jamestown at night (amidst a raging thunderstorm), and brought back to the bonfired beach as the Spirit of Chanco to the amazement of the group of Episcopal Church campers gathered there. Even more bizarrely, I was then blindfolded, placed in the back of a white-painted hearse, and roughly driven around Surrey County as some sort of initiation into the inner circle of place. Writing that now, I see the echoes of the KKK—although, of course, I was the ‘wrong’ gender for that. Ironically, the ‘real’ Chanco was male.

Once upon a time, quite recently in fact, as I was writing a book chapter about Chief Seattle’s daughter, Kikisoblu, also known as Princess Angeline, she began to appear to me in dreams. Her voice whispered—okay, sometimes yelled—over my shoulder as I tried to honor her story. Her story, at least as I have heard it, is layered with the stories of so many other Native American girls and women who have lived with—and in too many cases, died by—gender-based violence. Honor their stories.

My own heritage is white European- American and not Native American. I recognize the danger inherent in cultural appropriation and the long tradition of “stealing stories.” I also recognize the responsibility of using my privilege as a white academic writer to amplify stories and voices.

Abigail Echo-Hawk, Chief Research Officer for the Seattle Indian Health Board, states: “I always think about the data as story, and each person who contributed to that data as storytellers. What is our responsibility to the story and our responsibility to the storyteller? Those are all indigenous concepts, that we always care for our storytellers, and we always have a responsibility to our stories.”

Echo-Hawk goes on to talk about what she decided to do with the results of a CDC-funded 2010 study on the experience of sexual violence by Seattle-area Native American and Native Alaskan women. She states, “The Seattle Indian Health Board had decided to not publish this information because of how drastic the data was showing the rates of sexual violence against Native women. There were fears that it could stigmatize Native women, and that would cause more harm than good. But those women had shared their story, and we had a responsibility to them, and to the story, and I take that very seriously.”

(Sources: “Abigail Echo-Hawk on the art and science of ‘decolonizing data” by Manola Secaira, Crosscut, May 31, 2019 and “Nearly every Native American woman in Seattle survey said she was raped or coerced into sex” by Vianna Davila, The Seattle Times, August 23, 2018).

Swamp Lessons

What does a swamp possibly have to do with health, homelessness, and community health nursing?

Quite a lot as it turns out. I have spent the past year exploring possible answers to this question, as well as many other “swamp questions” and “swamp lessons.” It has been—and continues to be— a weekly deep-dive radical self-care sort of exercise. At the end of each week, I walk to the closest swamp or swamp-like spot of nature, wherever I am in the world, and I sit, observe, and write reflective entries into my swamp journal.

While I have traveled outside of Seattle fairly frequently and lived part of the past year in the UK, when I am at home I always walk to Yesler Swamp on Union Bay in Lake Washington. The photographs included in this post are from my Yesler Swamp walks over the past few weeks.

My weekly practice of swamp walks has been an important source of grounding for me (yes, pun intended since swamps are, at best, ‘quaking ground’) as I have navigated the interesting murky waters of being a leader of the community-campus Doorway Project. The politics involved with this community health project have been considerable. Subtext. Subterfuge. Unnecessary dramas. Wanting to shout “Bullshit!” in so many meetings I have lost count. Take it all back to the swamp and sit with it and see my way through.

Also, my weekly swamp walks and reflections have helped me wade through the new-to-me experience of dealing with the emotional weightiness of developing empathy with ‘historical figures’ such as “insane paupers,” homeless people I have come to know (at least at some level) through my research and writing of my current book project, Skid Road. Who knew (not me) that homeless people long dead could be just as real and deserving of compassion and empathy as those still living?

Unmasking Academia

Full Professor Mask

An academic life has many bizarre and Kafkaesque moments. As an ‘outsider academic’ I try to find humor within these moments as that helps me not take either the academic bubble—or myself—too seriously. This time of year we are asked to provide “updated CVs with accomplishments for the past academic year highlighted in yellow.” CVs, those courses or chronicles of our (academic) lives, are supposed to grow by the (academic) year and can become upwards of 50 or more pages by the time one becomes a full professor. I read advice from some supposedly successful academic that she did not accept any request to do anything unless it would add to her CV. Absurd, yes. An exercise in hubris, yes. Exhausting and in the end—meaningless. Yes.

My alternative CV for this past academic year: I survived. I loved my Fulbright fellowship time in Edinburgh. I read many nonacademic books. My favorite book that I read this past academic year was To the River by Olivia Laing. It has to do with the River Ouse. It has nothing to do with nursing.

The giant binder of promotion materials that went into my relatively recent promotion to full professor was returned to me. It served as a doorstop in my office for awhile. Then, after stubbing my toes on it one time too many, I tore up all the paper into tiny strips and turned the mushy mess into this paper mache mask. It is one of my proudest achievements.

After sleeping on this post, I woke up to re-read one of my favorite books from my adulthood: Carolyn G. Heilbrun’s Writing a Woman’s Life. This is a book I read when it first came out in paperback in 1988 while still living in my hometown of Richmond, Virginia. It is a book I managed to carry with me even when I spiraled into homelessness—and it is a book that remains on my bookshelf. This passage from the end of Heilbrun’s book has a much different meaning for me now and relates to the content of this post:

“I once titled an Amanda Cross detective novel Death in a Tenured Position, and it occurs to me now that as we age many of us who are privileged— not only academics in tenured positions, of course, but more broadly those with some assured place and pattern in their lives, with some financial security—are in danger of choosing to stay right where we are, to undertake each day’s routine, and to listen to our arteries hardening. I do not believe that death should be allowed to find us seated comfortably in our tenured positions. Virginia Woolf described this condition in Mrs. Dalloway: ‘Time flaps on the mast. There we stop; there we stand. Rigid, the skeleton of habit alone upholds the human frame. Where there is nothing’ (55). Instead, we should make use of our security, our seniority, to take risks, to make noise, to be courageous, to be unpopular.” (p. 131)