Shocking News: Nurses Can (and do) Read and Write

Who would have thought the world would come to this? A world in which there are so many nurses who are not only reading real books, but also writing real books, or essays, or poems, or short stories—so many nurses with the audacity (and ability) to obtain writing credentials, MFAs, writing certificates, and bona fide publications in non-nursing literary magazines and anthologies for God’s sake! Shocking indeed.

That was one of the main takeaway messages I got this week from listening to a podcast interview with Lee Gutkind on RN.FM radio. Lee Gutkind is the founder and editor of the literary magazine Creative Nonfiction; he is also the editor of the recently published anthology I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse, edited by Lee Gutkind (In Fact Books, 2013).

In the radio interview, Gutkind states that the anthology was something he had wanted to do for a long time. Whenever he pitched the book idea to publishers they rejected it, saying it was a bad idea because nurses don’t write and nurses don’t read. So with the support of the Jewish Healthcare Foundation he published it himself under the new imprint of the Creative Nonfiction Foundation. Gutkind admits that he was surprised by the volume of submissions to the anthology, that the submissions “were so much better than we expected,” and “how many had writing degrees, writing experiences, as well as being nurses—it was encouraging to us.”

The book was first released in early April, quickly sold out, and is now into its third printing. (Amazon says it is out of stock/due in 1-3 months but they should have it in stock much sooner than that. Elliott Bay Book Company has the book in stock and can ship it to you. They hosted our reading of the book this week/is what photo is of). Jane Gross, in her May 20th NYT book review ‘Semi-invisible’ Sources of Strength, wrote of the anthology:

It is beautifully wrought, but more significantly a reminder that these “semi-invisible” people, as Lee Gutkind calls them in this new book, are now the “indispensable and anchoring element of our health care system.”

I would argue that nurses always have been the ‘indispensable and anchoring element in our health care system’ and that most laypersons have long recognized this fact. Perhaps what is different now is that people higher up in the rigid health care system hierarchy are being forced to recognize this. The forces contributing to this shift are fascinating and complex, but have to include the growing proportion of BSN prepared nurses in our country’s workforce. Both Jane Gross and Canadian nurse author Tilda Shalof (whose essay Ms. Gross quotes from) are dating themselves by focusing on the outdated rift between diploma/Associate’s degree (ADN) and four-year university-educated nurses in tertiary care settings. Ladies: in the U.S. that battle is over. As the authors of the Institute of Medicine’s 2010 The Future of Nursing: Leading Change, Advancing Health report states:

The formal education associated with obtaining the BSN is desirable for a variety of reasons, including ensuring that the next generation of nurses will master more than basic knowledge of patient care, providing a stronger foundation for the expansion of nursing science, and imparting the tools nurses need to be effective change agents and to adapt to evolving models of care. (p. 4-9)

Currently, 50% of the U.S. nursing workforce are BSN prepared; the Future of Nursing report has set the goal to increase that to 80% by 2020. What a BSN education includes that an ADN education does not, are grounding in liberal arts (including literature and writing), leadership development, and public health/health policy competencies (more complex systems-level thinking)—all essential ingredients for more nurses to be readers, writers, and change agents in our health care system.

Something that I found disturbing in the radio interview and discussion was how much the two nurse radio hosts stayed stuck in the tiresome tropes of “nurses as an oppressed profession,” (and specifically that they are oppressed by physicians) and that nurses “empower patients.” “Empowering” someone else is a slippery slope ethically and even practically, and nurses are not the only members of the healthcare team to advocate for patients. As to nurses being oppressed—oppression is understood to mean the unjust or cruel exercise of power. Yes, there are still ‘unjust cultures’ within hospitals that negatively impact nurses (as in the case of Kim Hiatt here in Seattle), but to extrapolate that to the statement that all nurses are oppressed is not only incorrect, it is unhelpful. Unhelpful to the image of nursing and unhelpful to the improvement of our health care system.

One of the radio hosts recommended that Gutkind offer a nurse writer conference—as a way to bring nurse writers together, to foster a community of nurse writers. Gutkind replied by encouraging listeners to e-mail him if they are interested in such a conference (information@creativenonfiction.org or under ‘contact form’ at www.Leegutkind.com).

On Reflection

In August people check out. While sitting in various meetings this past week, I noticed that even the people who show up in August are mentally checked-out. This was an even more pronounced pattern when I lived on the east coast—for us lefties, every month is a laid-back sort of month. Luckily for me my (noisy) neighbors have checked-out for the week, all packed away on a camping trip. I can hear my bamboo growing. I can hear myself think.

I’m metacogitating: thinking about thinking. If it is anything like thinking about walking up stairs while walking up stairs (and tripping as a result), this could be dangerous. That leads me to reflection and what it means to be a reflective practitioner (of any sort), and why reflective practitioners are important to have in health care.

Two things led me to this topic this week. First, I am on an interprofessional health sciences service-learning group where we discussed ways to encourage meaningful student reflection. Donald Schon’s The Reflective Practitioner was invoked, along with reflective journaling, Rita Charon’s parallel chart, and various narrative medicine sorts of activities. Second, I had a psych nurse ask me why we don’t have nursing students do IPRs anymore. I had to reach back into the scary dark recesses of my brain to even know what he was talking about. Interpersonal Process Recordings—a long and tedious process of reconstructing a nurse-patient interaction, complete with dialogue and non-verbal cues—and then written self-reflection on what went well/didn’t, why, and what could be done better next time. I remember writing IPRs for my psych BSN course. Typically, five minutes of conversation resulted in at least seven pages of writing and reflection and hours of work. Not surprisingly, IPRs originated in psychology and social work counseling programs and were then adopted by nursing. IPRs are intended to be used within counseling supervision—trainees meeting with seasoned clinicians to develop self-assessment and communication skills. IPRs in nursing education have been more in line with creative writing—confabulation—made up dialogue—and aren’t typically discussed with, but are merely written up and handed to the instructor. I don’t remember confabulating my IPRs, but I didn’t discuss them with my instructor—thankfully, as my psych clinical instructor wasn’t exactly a model of good communication (or of good mental health for that matter). I am intrigued by research findings I ran across indicating that the more nursing education students have, the worse their communication/interpersonal skills become. (Harrison, et al. “Assessing Nurses’ Communication” Western Journal of Nursing, 1989). I’m not sure if this study has been replicated on a larger scale and using longitudinal data, but it would explain so much in my life….

Proponents of reflective thinking go way past Schon, to Dewey and Lewin, and back to Socrates. Reflection is a key component of critical thinking—critical thinking being outcome-oriented analysis and an ability to examine a situation from multiple perspectives. Critical thinking and reflective thinking are essential skills for nurses. Health care workers have to make numerous complex decisions affecting patient care. Generally these decisions have to be made quickly, with incomplete and imperfect information. Thinking on your feet or reflection-in-action is a necessary clinical skill—and not lapsing into short cuts or inattention, because that’s where medical errors often occur. Reflective practice contributes to self-assessment and life-long learning—essential for continuing competence of health care workers.

But how do you really teach critical thinking and reflective thinking? By looking through many nursing school syllabi and reading the course objectives, you’d think that critical thinking skills were well covered. However, when you look at what is actually done in those classes and how students are evaluated, it is almost exclusively targeted at ‘lower-order thinking’ in Bloom’s revised taxonomy of thinking: remembering. In clinical nursing courses, the learning goes higher from understanding to applying—and sometimes eking into analyzing. This leaves the ‘higher order’ levels of thinking of evaluating and creating untouched. These are the levels of learning where reflection really kicks in. In my experience teaching nursing at the BSN level, there simply is not enough time or space for teaching to higher order thinking. Basic skills (“Bedpans 101”) of med-surg types of things—the remembering and the applying take precedence. Then there is the issue of raw material to work with, the leading a horse to water sort of conundrum. You can’t encourage the development of higher order thinking in nursing students if they don’t want to drink from that trough.

Truth-tellers and nursing leadership

“Tell all the truth but tell it slant–” (Emily Dickenson) I have been re-reading Dickenson’s poem as well as Foucalt’s “Fearless Speech” series of lectures while thinking about the state of truth-telling in nursing leadership. Truth-telling to me connotes honesty, integrity and courage, which are all essential ingredients of good leadership. Truth-telling in the classical sense involves self-reflection and truth-telling to oneself. There is an art to good truth-telling. I believe that the current nursing leadership in our country has a lot to learn in all of these areas of truth-telling.

First though, just who are nurse leaders? My working definition of “nurse leader” is anyone who is a nurse of some sort who has the power and position, or the power of position to be able to effect change on systems–whether the system is a hospital unit, an entire hospital, some other health-related agency public or private, a public health program, a unit of or an entire school of nursing. Perhaps they are the nurses chosen (by other nurse leaders) to be part of the RWJ Nurse Executive Nurse Fellows Program, or chosen (by other nurse leader/fellows) to be a Fellow of the American Academy of Nursing (FAAN). Do you notice a pattern here at all? The inner circle, the “old girls’ network of nurse leaders chooses who to let into the inner circle. This, of course, is human nature, and nursing is no different in many ways from say, medicine. Except that it is significantly different from medicine in terms of power and prestige–not essential ingredients to truth-telling, but they help in being heard and not being killed in the process.

The Dean of my school of nursing, Marla Salmon, ScD, RN, FAAN recently said that the focus in nurse leadership should not be about increasing the status of nursing as a goal, but rather to have nursing be partners in leading improvements in health care: It’s not just about nursing getting in the door, but it’s what happens when they’re at the table. I like this, but I like thinking about this table not as a sandbox with people (and nurses especially) “playing nice” and not throwing sand in Jimmy’s face–but rather thinking of the table as the Ancient Greek marketplace where truth-telling, open debate and reflection were encouraged.

We do not practice or encourage truth-telling in our profession of nursing. As nurse educators we actively discourage our students from voicing different viewpoints from our own, or from the accepted Cannon of Sacred Nursing. I recently read a document on revising the BSN essentials (e.g.: the most important things we want BSN-prepared RNs to be ‘taught’) and it stated that we should not teach/practice critical thinking “because it is too critical.” And in the practice of nursing it is obvious that nurse leaders shoot the messenger when line staff RNs “speak the truth” about patient safety issues.How is any of this going to change if the existing nurse leaders don’t start modeling more truth-telling in all of it’s ancient connotations?

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