It struck me this week that curiosity—the time and space necessary for nurturing curiosity—has little to no place in our institutions. Not in the university or in our classrooms or in the hallowed halls of government or in our health care system. Instead of open-minded curiosity that can lead to innovative solutions to big problems like homelessness, we rely on snap judgements and decisions based on our close-minded, biased, preconceived notions.
Curiosity did not kill the cat. Curiosity is necessary for growth and survival and resilience in the face of adversity. Curiosity is necessary for empathy, for perspective-taking and imagination and creativity. Babies and small children are naturally curious, but as they grow up, formal education largely forces them to suppress curiosity. Students, and especially university students, are typically afraid to ask questions for the fear of appearing incompetent and stupid. We grade students based on their answers and not on the quality of their questions. University professors, including nurse educators, do not model a healthy valuing and practicing of curiosity. We are forced to specialize in a “focused area of study,” to become (or at least to pretend to be) experts with answers and not wise educators with yet more questions.
Tenelle Porter, Phd, a behavioral psychology scholar at the University of California, Davis describes intellectual humility as the ability to acknowledge (to ourselves and to others) that what we know is quite limited. She points out that university professors are not known for having high levels of intellectual humility, yet fostering intellectual humility (closely linked with higher levels of curiosity) in students leads to greater learning and later career success. In addition, intellectual humility is associated with a greater openness to hearing and considering different viewpoints—something that is sorely lacking in our society and in our classrooms.
All of our current ‘wicked problems’ such as racism, homelessness, environmental issues, human gene editing, violence against women, mass murders, and terrorism, cannot be addressed constructively by science or technology. As the late Donald Schon wrote:
“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the use of research-based theory and technique. In the swampy lowlands, problems are messy and confusing and incapable of technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern.” (Schon, D.A. “Knowing-in-action: The new scholarship requires a new epistemology,” 1995, Change, November/December, 27-34.)
In order to muck through the swampy wicked problem areas, we need–more than ever–the humanities. Before we continue down the path of denigrating the humanities (Rubio wanting more welders/less philosophers) and decimating university programs in the humanities, we need to ask ourselves if this is who we want to be–both individually and collectively. Where would we be without grounding in history, language, literature, comparative religion, philosophy, ethics, archeology, the theory/philosophy of law, and the criticism/theory of art? The excellent short (7 minute/ June 2013) video “The Heart of the Matter” by the American Academy of Arts and Sciences explores this question. “No humanities? No Soul,” George Lucas states.
Adams was, of course, ‘preaching to the choir’ in that most of the audience consisted of academic-types from the different disciplines traditionally considered the humanities. I didn’t recognize anyone else from the health sciences, and none of the audience members asking questions identified themselves as being from science or technology fields. This was disappointing, although not surprising. After all, even physically the UW’s Intellectual House is surrounded by buildings that house the humanities and is a far trek from health sciences or any of the science and technology buildings. But as Adams emphasized towards the end of his talk, there’s a great need to increase the intersection of the humanities with science/technology/medicine (health sciences more broadly). The humanities bring the important tools of reflection. Reflection on what it means to be human. Reflection of what it means to be a citizen.
Entering our fourth and final week of this university study abroad in New Zealand program, “Empowering Healthy Communities,” I continue to reflect on how to incorporate service-learning in an international setting, and how to incorporate it in an ethical and meaningful manner. By service-learning with a community health focus I use Serena Seifer’s definition:
“Service-learning is a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens.”(Seifer SD. 1998. Service-learning: Community-campus partnerships for health professions education. Academic Medicine, 73(3):273-277.)
Within a community health and health professions context, service-learning focuses on student engagement in non-clinically focused service work. Thus, our typical community health nursing clinical rotations are not technically considered service-learning, although the lines can get blurred at times.
In a health systems course I teach for senior nursing students, I have included a service-learning option. Students in my course have concurrently volunteered as emergency youth shelter overnight workers, assisted in food banks, and served as buddies for hospice patients. Through this work they can step out of their ‘learning technical skills’ nursing student roles and begin to make systems-level connections and practice critical thinking skills. It has worked well because I’ve partnered with our wonderful University of Washington Carlson Leadership and Public Service Center. They do all the legwork in establishing and nurturing community partnerships, defining student service-learning placements, and monitoring student progress.
Including service-learning in study abroad university-level programs can make for high impact educational experiences. Studies indicate that inclusion of service-learning in study abroad programs significantly increases students’ sense of connectedness with a wider world community. It also helps students confront their own biases and prejudices, and increases their comfort in working within diverse communities. But those benefits come from well-designed study abroad programs that include pre-departure workshops/readings, embedded critical reflective writing by students with faculty feedback, and debriefing sessions after service-learning activities.
Done poorly, international service-learning can be exploitative and can deepen cultural arrogance and economic disparities. As Sara Grusky points out in her article “International Service-Learning: A Critical Guide from an Impassioned advocate,” most international service-learning study abroad programs from the U.S. are done in poor countries, and can become nothing more than ‘poverty tourism.’ (From the American Behavioral Scientist. 2000. 43: 858-867.)
New Zealand is not a poor country and it continues to rank much higher than the U.S. on many health and wellbeing scales. Yet it suffers from rising socio-economic and health inequities. During our study abroad program we have visited a variety of communities–some have been in higher socio-economic brackets, but most have been within impoverished, multi-ethnic and Maori communities. Before doing any community-based service-learning projects, we’ve first learned about the local and national context, including cultural, political, and socio-economic factors impacting the community. Students learn this through carefully chosen readings, and from talks by community leaders.
My co-leader for this program, Jim Diers, is a social worker and an international consultant on community-led, asset-based development. He has a decade or so experience working with various communities throughout New Zealand. So between his contacts and those of the New Zealand based community-development group, Inspiring Communities, we developed this study abroad program. Jim believes in more upstream thinking, policy-changing work versus direct service. It’s an important point, but I think there is room for both in life and in educating university students for their role as civically-engaged change agents. Students have stated that they are now more interested in knowing about and getting involved with their own ‘home’ communities, and of doing service-learning in the Seattle area.
Here are photographs and brief descriptions of various service-learning activities the students have been involved with during the program. Some of the activities were planned ahead of time and others ‘just happened’ spontaneously. All of them were driven by the community members. They have expanded my notion of what ‘counts’ as international service-learning.
This past week in the Narrative Medicine course I am teaching, I introduced students to the approach to close reading (she refers to it as a drill) as taught by Dr. Rita Charon and her colleagues at Columbia University’s Program in Narrative Medicine. I then had students apply this to do their own close reading of JD Salinger’s short story “To Esme, With Love and Squalor.”
As a way of introducing them to close reading I had them read Rita Charon’s chapter “Close Reading” in her book Narrative Medicine: Honoring the Stories of Illness (Oxford University Press, 2006). This is a weighty chapter in a weighty book and I have discovered that many of my students were simply overwhelmed by it. So here is my streamlined version of ‘doing’ a close reading drill as applied to narrative medicine. I present the elements of close reading in the order I like to do them myself because it is more the way I read and analyze what I read.
1.Desire (Dr. Charon’s term). What appetite or emotion is satisfied by reading this? What bodily sensations do you have while reading this? What intellectual or emotional desires arise? Put more simply: what is the overall feeling you have when reading this? (A related and interesting question would be: And what does this reveal about you as the reader?)
2.Frame. What’s included and what’s left out of this narrative? Where did this first appear—what was the intended audience of the work? For instance, Salinger’s short story first appeared in the New Yorker in 1950. What can we surmise about his intended audience?
3.Temporal scaffolding. How is time handled in the narrative?
4.Form. Structure, genre, narrator, use of metaphor, allusion (especially what other works are referred to either explicitly or implicitly?), and diction
5.Plot. What happened.
Dr. Charon makes the case that learning the skills of close reading as applied to narratives, whether written or in plays, movies, etc, can help health care providers learn to be more attuned to the illness narratives of their patients. Careful reading, careful listening, it makes sense at some level and I am teaching that to my students. Salinger’s short story that I had them read and analyze through close reading is a complex but engaging piece of writing. It has enough content about the health effects of war—PTSD especially—that nurses and others in the health professions find it interesting. Salinger’s use of frame, time, diction, and metaphor are exquisite. So this short story makes for a good—but sufficiently challenging—narrative on which to practice close reading. I found that most students did well with this assignment and really dug in. Since class this past week fell on July 4th, this was an individual take-home assignment, so I have not yet had the opportunity to discuss it with them in class.
I always have these nagging questions in the back of my mind: Does close reading detract from the pleasure of reading? And by extension, does ‘close reading’ a patient’s illness narrative detract from the pleasure of the patient-provider interaction? Do we start thinking about patients less as people and more as stories to be analyzed, stories to be recorded in our heads and then later used as material for our own written stories? Does that start to distance us from our patients? Is it like walking up a familiar flight of stairs—pleasantly distracted—then thinking about walking up the stairs and by paying attention to it, tripping? If writers consciously try to pay attention to the craft of writing, does the art of their writing suffer?
I’ve been re-reading one of my favorite books, David Ulin’s The Lost Art of Reading: Why Books Matter in a Distracted Time (Sasquatch Books, 2010). He raises these questions as well—for writers and readers in general. He states, “(…) I recognize this as one of the fallacies of teaching literature in the classroom, the need to seek a reckoning with everything, to imagine a framework, a rubric, in which each little piece makes sense. (…) leaving us with scansion, annotation, all that sound and fury, a buzz of explication that obscures the elusive heartbeat of a book.”
If I used this class assignment again I would add the personal reflection writing prompt: Write about a time when you were so overwhelmed by emotions that you had difficulty communicating—or write about a time when you were caring for a patient experiencing this.
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.
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 (firstname.lastname@example.org or under ‘contact form’ at www.Leegutkind.com).
I’m continuing on my line of thought from my last post “On Reflection,” and have been considering how reflective practice and its counterpart of empathy can be taught in nursing school. How can we do a better job of helping students grow in emotional and moral maturity? How can we as health care providers and teachers do a better job of growing in our emotional and moral maturity?
Maura Spiegel who teaches in the Columbia University Narrative Medicine program gave a talk “Reconceptionalizing Empathy” last fall at the Narrative Medicine workshop I attended. She maintains that empathy cannot be taught, it can only be cultivated, and that a common mistake for health care providers in thinking about empathy is the idea that “I can know you—or that empathy can be a conduit into a patient’s inner life.” The psychoanalyst Donnel Stern maintains that empathy is an interpretation like any other observation, and that empathy is often implicit knowing or “pre-reflective unconscious, an unthought known:” a dimension of experience which is in some sense known, but not yet available to reflective thought or verbalization.”
Metaphor, poetry and art speak directly to our implicit knowing—they are, in Maura’s words, “mediated sources of understanding.” In health care, this is where narrative medicine and the medical humanities step in. Attentively watching movies, reading novels or poetry—or writing and reading our own stories—can tap into the sources of empathy. Language can become an ally again, and the experience of empathy can be made available for reflection. Making more room in nursing curricula for narrative medicine/nursing would be one way to help cultivate empathy in students—and perhaps even in faculty members.
Being able to access empathy and then to reflect on the experience are important skills for nurses. Certain patients or health care situations will affect us more than others. It is easier to have empathy for patients we assess as being “like us” in whatever aspects. Patients, groups or populations viewed as “the other,” are more difficult to have empathy for.
I recently read a collection of essays called The Other by Ryszard Kapuscinski (Verso, 2008). Over his long career as a journalist, he traveled throughout the developing world, reporting on major wars and revolutions. Kapuscinski was influenced in his thought by the philosopher Levinas, who is known for the phrase, “the self is only possible through the recognition of the Other.” Kapuscinski extends that thought by writing, “…the Other is a looking glass in which I see myself, and in which I am observed—it is a mirror that unmasks and exposes me, something we would prefer to avoid.”
Whenever we talk about “The Other” or “Othering” in nursing education, it is almost always in the context of working with patients and groups from “other cultures” or who have stigmatizing conditions such as schizophrenia. We don’t do a very good job at helping students to use their own inevitable discomfort in looking in that mirror to see what is reflected back, to see what is exposed. Sometimes these sorts of issues get handled by students in reflective journals in their clinical rotations, and sometimes it gets discussed in small group seminars—but those times are very few and almost seem to happen by accident. They aren’t explicitly cultivated. One of the problems that I see is that nursing faculty aren’t very comfortable in looking in the mirror themselves, so they aren’t able to model that for students. Encounter Groups for nursing faculty sound like a horror movie in the making, and continuing education conferences on how to cultivate empathy are close behind in the shudder index. One promising change may be that the next generation of nurse educators will be—well—younger, and perhaps more widely educated, more well-traveled, and further along on the emotional and moral maturity scale. That’s my hope.
A familiar phrase, and one that I think about often as I teach. It is appropriately humbling, an antidote to hubris. The phrase originates from George Bernard Shaw’s play “Man and Superman: A Comedy and a Philosophy,” from the main character’s “Maxims for Revolutionists.” The phrase is included in a section on education and reads, “He who can, does. He who cannot, teaches.” It is accompanied by: “A fool’s brain digests philosophy into folly, science into superstition, and art into pedantry. Hence, a university education.” In his lengthy introduction to the play, Shaw writes, “(…) what we call education and culture is for the most part nothing but the substitution of reading for experience, of literature for life (…).” Shaw had a very unhappy childhood educational experience in Dublin, Ireland, was largely self-taught while living in London, and became a life-long ardent believer in socialist reforms.
In a practice discipline such as nursing, the tension between education and practice—between teaching and doing—is ever present. Further complicating this tension is the emphasis on nursing research in university-based nursing schools. Nursing is considered a minor (or wanna be) profession. As Patricia Benner and her co-authors state in their book Educating Nurses: A Call for Radical Transformation(Jossey-Bass, 2009), for the past thirty years nursing faculty and administrators have focused most of their attention on developing nursing research. Benner attributes this to the pressure to increase the prestige of nursing within academic settings. I am still unclear just what “nursing research” does to increase the prestige of nursing—or even what it means. Is nursing research any research having to do with nursing practice or workforce issues? Is it any research having to do with anything as long as it is led by a nurse? I gave up teaching nursing research because I felt like a hypocrite since I didn’t understand or value it. In my experience, research methods classes taught in schools of nursing are not very rigorous, especially when compared with research methods courses in schools of public health or psychology.
Now nursing practice I do understand and value. I am an accidental nursing educator, and an occasional health services researcher. My first and real love is clinical work as a nurse practitioner. To apply Shaw’s maxim: I can and I do, but I also can’t and I teach. While my students value this clinical relevance, it isn’t valued within my school of nursing. This isn’t unique, as I hear a similar lament from my nurse educator colleagues at other top-rated schools of nursing. It also isn’t unique to nursing, as my academic physician friends tell me the same thing happens in schools of medicine.
Both the Educating Nurses and the IOM Future of Nursing Report emphasize the need for lessening the existing disconnect between classroom theory and clinical practice in nursing education. They point out that many nurse educators have not practiced nursing in many years and, therefore, have a hard time including appropriate classroom experiential learning. Much of nursing theory courses are taught with an overreliance on endless PPTs, busy work, and an emphasis on rote memorization. Nurse educators teach the way they were taught. It is not teaching; it is torture.
One of the most influential books on my own teaching of nursing is Donald Shon’s Educating the Reflective Practitioner (Jossey-Bass, 1987). It doesn’t mention nursing at all, but is nonetheless applicable to nursing education. In the book he talks about professional practice as more of an art that a science, and emphasizes the teaching of reflection-in-action, a sort of higher-level critical thinking.
Here is his opening paragraph from the book:
“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest might be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and nonrigorous inquiry?”
Contrast this with an unfortunate statement in Educating Nurses: “Critical thinking alone cannot develop students’ perceptual acuity of clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking.” The authors have obviously misunderstood the definition of “critical” as applied to critical thinking, where “critical” is understood to be the “exercising of careful judgment or observation.” It is having an inquisitive spirit, questioning underlying assumptions—including one’s own assumptions—of being able to think about thinking. Critical thinking is the opposite of Shaw’s fool’s brain and is necessary for effective swamp work, the terrain of most nursing practice.
Dr. Comstock (1915-2007) was one of my favorite professors out of many (too many) years of higher education. To those of you unfamiliar with him, George Comstock was a professor of epidemiology at the Johns Hopkins University of Hygiene and Public Health (now the less hygienic Johns Hopkins Bloomberg School of Public Health). Dr. Comstock was an expert in TB control and treatment. He taught advanced epidemiology at Hopkins for over 50 years, and he never really retired. His wife said that in his final weeks of life he was reviewing journal articles. He was a kind man, humble even, lived and breathed epi and could explain complex epi concepts in clear and humorous ways. He used no lecture notes that I ever saw. He was 88 years old when he became emeritus professor (sort of retired), but he kept teaching epidemiology of TB until he died.
He was an outlier. Dr. Comstock was someone who should and could teach well past the ‘normal’ retirement age. I do not plan to be an outlier in academia. The topic of “Professors who won’t retire” is the elephant in the room in academia (including in nursing) and is the title of a good “Room for Debate” series in the New York Times. The authors discuss the financial and intellectual difficulties placed on universities (and fields of study) by professors deferring retirement. A professor of history contends that history can benefit from having an older academic ‘workforce,’ whereas other fields of study, such as the sciences can be weakened by a lack of ‘new blood and fresh ideas.’ I wonder where nursing is in this sort of debate? “The Future of Nursing” report (mentioned last post) discusses the lack of pedagogical progress of most nursing instruction (meaning we don’t really know or care how effective we are at how we teach nursing–and we teach the way we were taught in nursing school). So, if we haven’t made much progress in teaching nursing since Florence Nightingale‘s day, I suppose it doesn’t matter that we are an aging lot?
“The Future of Nursing: Leading Change, Advancing Health,” is a weighty tome published/released by the Institute of Medicine and the Robert Wood Johnson Foundation on October 5, 2010, and is written about by Pauline Chen, MD in her NYT article “Nurses’ Role in the Future of Health Care” (Nov 18, 2010). Dr. Chen’s article has been one of the most e-mailed NYT articles since it appeared last week, and at last count it had a total of 91 reader’s comments. It got people’s attention. I find it interesting that in her article, Dr. Chen links to the IOM report ($51 and you can read it), but doesn’t mention that the exact same report is available for free on the RWJ website (also has its own Facebook page). There is a 600 plus page version and a 4 page “Brief Summary” version, both free.
In the 600 page version, Chapter 4 is devoted to nursing education, and among other things, they address “the aging cadre of nursing researchers and educators.” We are dropping like mosquitoes around one of those electrified zapping machines. And there’s no one to replace us. The IOM/RWJ report states there are 5,000-5,500 unfilled nurse educator positions around the US. In my own school of nursing, within three years something close to 70% of our faculty will be 65 or older (disclosure: I’m not even close to being one of those…). Of course, that doesn’t mean they will retire, but that’s another story. That statistic is public information already, as is the fact that many other faculty in major schools of nursing across the country are ‘getting out’ of nursing education–burnt out, put out, or lured out by better opportunities in health care industry of one sort or another. Many of those are people I consider to be the best, brightest, most creative nursing educators we had. The IOM/RWJ report has many excellent recommendations about improving nursing education, but I wonder how they will get done with what’s left of our nursing professor workforce.