Tag: Health

Expanding What ‘Counts’ as International Service-Learning

P1000535 (1)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.

IMG_5285 (1)
Spontaneous musical jam session with young people at the Te Oro music, dance, and art center in Glen Innes in East Auckland. We had spent the day on the Ruapotaka marae (Maori land and meeting house) and were planning to help with stream restoration but it rained too hard–stream flooded, so we did this instead.
Version 2
Girls from the Baking Club at the Waitangirua Community Services center challenged our male students to a fitness test. This is their pre-contest strategy huddle. Our guys lost and so they had to do a line dance/song. Everyone was laughing so much our faces hurt afterwards. But this was all initiated by the girls of the community. This is part of the Wesley Community Action program in the greater Wellington area.
P1000689
This photo is of a very spontaneous and unexpected service-learning project our students engaged in. We visited a community-primary school center in Epuni, north of Wellington. They have a huge school garden and this arts and crafts center where they bring together community elders with the children to share stories and teach craft skills. Our students were asked to help knit squares for blankets for the children. The students who knew how to knit taught our non-knitter students, who in turn taught other students. Amazing.
IMG_5590
Donning our borrowed gum boots and getting down and dirty weeding, turning compost, and double-digging vegetable beds at the community Fruit and Vegetable Co-op headquarters in the heart of Cannons Creek, Porirua, Note the recycled glass paneled greenhouse (minus the roof)–they are from cast off phone booths.

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.

 

 

 

 

 

Version 2

Version 2
Helping bag fruit and vegetables at the Salvation Army in Cannons Creek, Porrirua, north of Wellington. This is part of a fruit and vegetable co-op in one of the more impoverished areas of New Zealand. But as the residents told us that day–the government calls them impoverished… The New Zealand public health unit helps fund this innovative ‘non-charity’ project.

The Exquisite Corpse Hits the Hospital

IMG_4164
“Imprint of the Intangible” Mixed media, 2000, Heather Hawley. University of Washington Medical Center.

The exquisite corpse is a French surrealist parlor game named after one of their first nonsensical collaborative sentences, “The exquisite corpse will drink new wine.”  There are written and arts-based (including drawing, collage, sculpture, theater, and dance) versions of the exquisite corpse. They all emphasize elements of unpredictability, collaboration, and tapping into unseen/subconscious sources of creativity. And just plain fun.

This summer I adapted the written version of the exquisite corpse for use in the hospital-based narrative medicine/health humanities course I am teaching. I first had students divide themselves into groups of 4-5 people, each person with a clean piece of paper. Then, I asked them to write one sentence across the top of the paper and base the sentence on one concrete observation about their classroom. I gave them 30 seconds to write the sentence and then asked them to pass their papers to their right. They had another 30 seconds to write a second sentence in response to the first. Before passing the paper again, they were asked to fold down the paper in order to hide the first sentence. We repeated this exercise a total of five times. At the end, they could unfold their papers, read, and share with the class what the group had come up with based on their initial sentence. Much laughter ensued. Then, I had each student write a short reflection on what the experience was like for them.

I learned this classroom version of the exquisite corpse at the 2015 Chuckanut Writers Conference from two writers/creative writing teachers, Brenda Miller and Lee Gulyas, who both teach at Western Washington University in Bellingham. Miller and Gulyas have a recent collaborative essay, “Come Closer,” published in Sweet: A Literary Confection (vol. 7, issue 3, 2015) and an intriguing interview by Carmella Guiol with them about this essay and their collaborative process (July 16, 2015). In their workshop, we were all writers of various sorts, and the prose/poetry pieces our groups came up with were quite funny, creative, and profound.

As were the pieces that my students produced, although they mostly were much more matter-of-fact and not as fanciful as I expected them to be. These were nurses after all–nurses tasked daily with life and death decisions. Flights of fancy and parlor games are typically frowned upon among health care providers. But, since teaching is in itself a creative endeavor, I try to take calculated risks in the classroom and try new things. For this one I’d give myself a B+ for effort.

Feedback from the students (from their written reflections) ranged from, “this felt like a drinking game” (note: no alcohol was consumed in the auditorium as far as I know), through “I don’t understand why we did this exercise,” to perhaps more insightful, critical thinking responses including these:

“Even though we are talking about the same topic we said or have different points of view about our classroom. How we described it is different person-to-person. This is common in workplaces, like when we have to write up patient care plans, we hardly agree on them.”

“I enjoyed the spontaneity of doing this exercise. So much of our class work and assignments has been related to following directions exactly and making sure we are doing everything right.”

“I’m thinking this would be a good tool if I was leading a patient support group or leading a class. Patients with chronic illness get told all the time about what it the right thing to do and this could be used to let them tell their stories a different way.”

In thinking over how this went–my first attempt at doing the exquisite corpse exercise with a group of hospital-based nurses–I’ve realized I probably need to fine tune it for this setting and for these ‘parlor game’ players. Next time I would keep everything the same with the exception of the initial sentence writing prompt. Instead of having them write about their classroom, I’d ask them to write a sentence about a recent frustration at work–and that it can be a minor and seemingly frivolous frustration (in oder to keep it from getting too deeply emotional for this collaborative writing exercise). My aim would be to have it more directly pertinent to their work as nurses, while maintaining the fun, spontaneity, and collaborative nature of the exercise. As physician-educator and innovator in the health humanities Alan Bleakley says, “health humanities creates a serious play space.”

Boots On, For My Father

IMG_1232 - Version 3On Father’s Day, here is a piece I wrote about my father’s last years of life, and his quest to die at home, with his boots on, which he did last fall, despite a whole Southern Gothic region-full of subtext and intrigue. If you haven’t yet read Atul Gawande’s powerful and important book, Being Mortal: Medicine and What Matters in the End (Metropolitan Books, 2014), I highly recommend it. The following essay, “Home Death,” I wrote appeared in the Johns Hopkins Public Health Magazine (Spring 2013).

“Natural death, almost by definition, means something slow, smelly and painful. Even at that, it makes a difference if you can achieve it in your own home and not in a public institution.” ~ George Orwell

In his essay “How the Poor Die,” Eric Arthur Blair (pen name George Orwell) describes his month-long stay in a French public hospital in the winter of 1929. He was treated for pneumonia in a crowded open-ward public hospital, where he observed many indigent patients dying under the indifferent care of “slatternly nurses” and doctors and medical students “… with a seeming lack of any perception that the patients were human beings.” He fled the hospital before being discharged, but the hospital was a probable source of the tuberculosis that would later cause his death, at age 46, in a London public hospital.

Like the majority of people in the U.S., my father would rather not die in a hospital—public or private. Studies consistently indicate that more than 80% of patients wish to avoid hospitalization and intensive care treatment during the terminal phase of an illness. In most cases, hospital deaths are considered to be less than ‘good deaths’ because they are not where patients want to die, combined with the high-cost of hospital end-of-life care.

My father would rather die at home with his boots and gardening gloves on, surrounded by family and trusted caregivers. At eighty-nine years old and suffering from the ravages of advanced congestive heart failure, my father is one of the burgeoning number of the ‘very old’ frail elderly facing end-of-life decisions. And I am one of the even larger number of baby boomers approaching retirement while simultaneously helping care for an elderly family member. My father lives in Virginia; I live across the country in Seattle. Nevertheless, my father appointed me his health care proxy. I naively thought that being a nurse practitioner with an advanced degree in public health would help stack the odds in favor of my father having the home death he desires.

I know what it is like when end-of-life care works well. Four years ago I helped my mother have a relatively peaceful home death in hospice. She was eighty-five years old and died of breast and lung cancer. End-of-life predictions are, of course, much more accurate for patients with cancer than they are for patients with congestive heart failure. I had to intervene with her oncologist to stop the chemotherapy that was clearly doing more harm than good. But I expected that. Oncologists are programmed for aggressive treatment and have a difficult time, as the writer Atul Gawande says, letting go. My mother died six weeks after stopping chemotherapy, and two days after learning that her vote helped turn Virginia for Obama. Hers was a good death.

Although I was able to take time off from my job to help my mother in her final illness, my father was her primary home caregiver. Now, with my father living alone, he is hiring caregivers so he can qualify for home hospice. In the past six weeks he has moved through four different health care settings: acute care teaching hospital, nursing home for physical rehabilitation, back to his private home with visiting nursing, and now with home hospice. Besides Medicare, my father has good supplemental private health insurance, and he has sufficient savings to cover out-of-pocket expenses.

Despite my father’s resources, helping him navigate his final days has been a Kafkaesque nightmare tinged with perverse humor. Having worked within the U.S. health care system as a primary care provider for thirty years, I was prepared for the lack of care coordination across health care settings. I was even prepared for his myriad health care providers misplacing his Advance Medical Directives. I keep a scanned copy with me at all times to e-mail or fax it to whichever health care site he’s currently in. But I wasn’t prepared for April Fools’ Day this year.

For transparency and context I should add that I teach health policy to nursing students at a major academic medical center in Seattle. On April Fools’ Day, a Sunday this year, I was in Seattle preparing notes for my upcoming class presentation on patient-centered care. One of my father’s neighbors in Virginia called to tell me my father had skipped church to go to the emergency department of the nearby teaching hospital. He had been complaining of shortness of breath and not feeling well. It takes something serious for my father to miss church.

When I called the hospital to find out his status, the emergency department clerk told me I needed to tell her my father’s “secret HIPAA patient password” before she could even tell me whether he was in the hospital. She added that they strictly enforce this password because the hospital has so many patients involved in gang shootings and domestic violence. She didn’t change her mind when I pointed out that my father was an eighty-eight year old widower and retired Presbyterian minister who had signed his Advance Medical Directive forms appointing me his health care prox in their hospital administrative offices less than a year ago. She said they had no record of it and they had to treat all patients the same, so my only option was to come to the hospital in person. I did make a notation for my health policy class that this interaction was a good example of the need for improved patient-centered care, as well as for more appropriate use of patient privacy rules.

By the time I got through the hospital gatekeepers to be able to talk to my father, a cardiac surgeon had been called down to the emergency department and had convinced him to sign consent forms for a high-risk, high cost, low-to-no-benefit, quasi-experimental transapical arotic valve replacement. Less than six months post-surgery, my father was back in the same teaching hospital for rapidly accelerating heart failure, and I was flying in from Seattle to advocate transferring him to home hospice.

In its current form, our healthcare system conspires against the possibility of older people having a natural, good death at home. While there are pockets of improvement in terms of fewer hospital deaths for the very old, there are accompanying shifts towards more patients seeing ten or more medical specialists in their last six months of life, greater use of intensive care units, and more patients dying in nursing homes. As with my father’s experience, much of the blame falls on teaching hospitals: tenacious places known for medically aggressive treatment. I get the argument that this aggressiveness is what drives medical innovation and makes U.S. high-tech medical care among the best in the world. But when it comes to the care of the very old, that argument does not hold up—unless the elderly are donating their bodies to medical science before they are dead.

According to many studies (reflected in the Dartmouth Atlas of Health Care data) the number of teaching hospital beds in a region is associated with a higher percentage of hospital deaths without a concomitant improvement in overall population health. If the primary mission of teaching hospitals is to educate our future health care professionals, what is it we are teaching them about death and end-of-life care? Perhaps it would benefit everyone if we who work in academic medical centers remember that our students will soon be taking care of us in our own final days.

Josephine Ensign, MPH ’92, DrPH ‘96, is a nurse and writer who teaches health policy at the University of Washington in Seattle.

Apolitical Intellectuals Teaching Health Policy?

IMG_4099
Collection of health politics and policy teaching materials on my desk at work.

Is it desirable, indeed, is it even possible to teach health policy without also teaching politics? What would it mean to be an apolitical intellectual teaching health policy to future health care professional students?

As a lyrical definition of ‘apolitical intellectual,’ here are the first stanzas of  a poem by the Guatemalan poet and revolutionary Otto Renee Castillo, translated by Francisco X Alarcón. The full text of poem is available here and a powerful ‘spoken word’ version using a slightly different translation is available here .

APOLITICAL INTELLECTUALS
One day
the apolitical
intellectuals
of my country
will be interrogated
by the humblest
of our people.

They will be asked
what they did
when their country was slowly
dying out,
like a sweet campfire,
small and abandoned.

Basically, as I would interpret it, apolitical intellectuals have a lot of book knowledge and an escapist ‘life of the mind’ sort of attitude, but no practical, down-to-earth working knowledge of power and privilege. I do not aspire to be an apolitical intellectual teaching health policy to future health care professionals.

But I do aspire to be balanced and fair in my approach to teaching health policy. That is one of my prime duties as a teacher. Since I lean towards the Progressive side of politics, especially as politics relates to health and social justice issues, I bring that lens to the teaching of health policy. Many of my health policy current events articles come from the NYT or the (non-partisan but still left-leaning) Kaiser Family Foundation, and many of my videos (as in the photo above) are produced by PBS. I have tried, with limited success, to bring in more Conservative-leaning course readings, videos, and guest speakers. I find that it is difficult to find credible, intelligent, research/data-backed Conservative sources.

If I were teaching health policy at a university in close proximity to Washington, DC, I would probably have better luck finding good Conservative-leaning guest speakers. For instance, the DC-based Heritage Foundation has much different politics from my own, but they are credible, intelligent, and thought-provoking. They currently have an interesting section on their website: “Stop Obamacare Now.”

Since I am about to go on a year-long sabbatical in order to focus on my Skid Road and Soul Stories research and writing projects, I get to put away my health policy teaching materials. Both projects are public scholarship focusing on health policy for homeless and marginalized populations. As such, they are taking me even further away from being an apolitical intellectual. I consider that a good thing, but I do wonder how it will affect my teaching of health policy once I return to the university.

On Strike

IMG_4119
Red Square and Suzzallo Library, University of Washington. Photo credit: Josephine Ensign/2015.

What would happen if you didn’t show up to work, if you walked out of work, if you went on strike? Would anyone notice? Would anyone suffer? Besides earning a (hopefully ‘living wage’) paycheck and (hopefully) decent benefits including heath insurance, how essential is the work we do? And just how expendable are we?

These questions have been on my mind over the past several weeks as a labor dispute rumbles along at the University of Washington in Seattle where I teach. Our faculty members are not unionized, but our teaching assistants are part of the labor union UAW Local 4121. They just voted (90% in favor) to strike if their union representatives can’t negotiate a new work contract with the university by April 30th. Among the union’s terms is one calling on the university to adhere to the City of Seattle’s new minimum wage ordinance that went into effect at the beginning of this month. They are also asking for better health insurance benefits. Their most recent (and first ever) strike was for fifteen days at the end of the academic year in June 2001. Fortunately, I was not teaching at the time, but I understand that the strike created a problem for final exams and grades. (See Columns: University of Washington Alumni Magazine article “Briefing: First Ever TA Strike Hits UW Campus.”)

By now we are all aware of the escalating cost of a college education. An increasing body of research indicates that the largest contributors to this tuition increase are the expansion of the number of university administrators and their inflated (six and seven digit) salaries. The increase in tuition certainly is not going to increased salaries/benefits for most faculty members or to graduate student employees (nor to improved teaching facilities/see paragraph below). An April 5, 2015 NYT op-ed article by Paul F. Campos, “The Real Reason College Tuition Costs So Much,” is refreshingly direct and clear on these issues.

There are approximately 4,500 teaching and research assistant graduate students who work for the University of Washington. My son is one of them, as is my current and best ever teaching assistant. She helps me keep track of and grade all the weekly writing assignments for the close to 150 senior nursing students in a writing-intensive health policy course. She also helps me do battle with the antiquated A-V classroom equipment. Just last week she helped me avoid being electrocuted by a malevolent, malfunctioning microphone that they had jury-rigged to a large boombox on the podium (because the A-V equipment had completely died). I am (still) here to attest to the fact that teaching assistants are indispensable.

And while union membership has been declining in the U.S. over the past several decades, it has been increasing for healthcare workers, and especially for nurses employed by hospitals. That hospitals, including the supposedly not-for-profit hospitals, are big businesses that run like factories, is a well-established fact. Healthcare reform efforts have placed increasing financial pressures on hospital administrators who typically turn these into ‘lean work’ initiatives for the hospital employees below them. ‘Lean work’ probably has some fancy management-speak definition, but it really means that those lower in the food-chain (such as nurses) run their butts off trying to do more work with far less resources.

As Alana Semuels writes in The Atlantic (“The Little Union that Could” November 3, 2014), the small but growing union National Nurses United (NNU) has been especially effective at battling the Goliaths of healthcare power and at winning many of these battles. NNU has pioneered the use of one-day strikes to pressure hospital administrators to provide nurses with the resources they need, such as safe nurse-to-patient ratios and adequate Ebola safety equipment. When Arnold Schwarzenegger was Governor of California and tried to block a state law that would provide safe nurse staffing levels, the nurses of NNU helped to block the Terminator’s block: California remains the only state to mandate safe nurse (RN)-to-patient ratios in hospitals. Yes! Power to the people/nurses!

Here’s some interesting food for thought: When physicians strike, patient mortality goes down; when nurses strike, patient mortality goes up. A physician colleague of mine always tells my students this when he gives a guest lecture in my health policy course. It always grabs students’ attention and it’s not just a random, sensationalized statement. It is backed by a growing number of studies from the U.S. and from other countries (see below). In healthcare, the work of nurses matters. In higher education, the work of graduate student teaching assistants matters.

****** References:

“Evidence of the Effects of Nurses’ Strikes”  by Jonathan Gruber and Samuel A. Kleiner, National Bureau of Economic Research, March 2010.

“Doctors’ Strikes and Mortality: A Review” by Solveig Cunningham, Kristina Mitechell, KM Venkat Narayan, Salim Yusuf. Social Science and Medicine. 2008. 67:1784-1788.

Seattle Times article “Grad students employed by UW vote to strike if contract talks fail” by Katherine Long, April 22, 2015.)

“UW regents flee as student activists speak up” by Katherine Long, April 8, 2015, Seattle Times.

The Art of Healing

IMG_3996
“Imago” Collograph/Print, 1970, Ruth Singley Ensign

Art heals, or at least it can, given the ‘right’ art and the right circumstances.

Art is therapeutic. Art therapy, as defined by the American Art Therapy Association is: “…a mental health profession in which clients, facilitated by the art therapist, uses art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, improve reality orientation, reduce anxiety, and increase self-esteem.”

An increasing number of U.S. hospitals have arts programs, which include art therapy, musical performances, and installations of visual art. The nonprofit Center for Health Design has an excellent free resource Guide to Evidence-based Art. I, of course, particularly love this statement in the Guide:  “Perhaps the most prominent pre-cursor to the art initiative in hospitals today is Florence Nightingale’s Notes for Nursing ([1860], 1969) describing the patients’ need for beauty and making the argument that the effect of beauty is not only on the mind, but on the body as well.”

The healing power of art has even made it into the stalwart and conservative Wall Street Journal (see Laura Landro’s article from August 8, 2014 here). Research studies indicate that exposure to art related to nature or representational art with a positive, uplifting message helps calm anxious patients, speeds healing, and reduces the need for pain medication. I assume by ‘nature’ they mean the calm, peaceful side to nature and not the chaotic, destructive, lion eating the lamb side of nature–which is, after all,  just as natural.

Lately, I’ve been visiting Seattle-area hospitals to take in their public art and to write Ekphrasitic poetry with my poet-psychotherapist friend and narrative medicine colleague, Suzanne Edison. Suzanne is the mother of a child with a rare autoimmune disease and she teaches writing workshops with patients, families, and healthcare professionals. Here is one of my favorite pieces of art that Suzanne and I stumbled upon, located at Harborview Medical Center in the Radiology Department waiting room.

IMG_3614
“Journey: Hands” Mixed Media, 1997, Peggy Vanbianchi

The two times in my life when I was hospitalized–when I was thirty, for abdominal surgery for a benign tumor and then when I was forty and was partially paralyzed from lateral myelitis/inflammation of the spine–I remember that there was absolutely no artwork on the walls of my rooms. The rooms were stark and sterile and dark and did nothing to contribute to my healing.

In contrast, I do vividly remember the artwork that surrounded my bed and couch when I convalesced at home after my second hospitalization. These three prints of my mother’s (Ruth Singley Ensign) are the ones that kept me company and that became part of my liminal dream-wake life in the days and weeks it took me to return to full functioning. Only the middle one, “Mountain Quiet,” could be considered a suitable ‘healing piece of art’ according to the Guide to Evidence-based Art. The other two, and especially “Ladder to a Room Apart” (my favorite piece of my mother’s prolific body of artwork) probably would be deemed too abstract and disturbing to be included in any institutionalized healing arts program. Perhaps hospitals could start a ‘lending art’ sort of program for patients and patients’ families to be able to choose their own healing art to display on their walls.

IMG_3951
“My Moon Neither Rises Nor Sets” Etching/Print, 1979, Ruth Singley Ensign
IMG_3968
“Mountain Quiet” Collograph/Print, 1989, Ruth Singley Ensign
IMG_3986
“Ladder to a Room Apart II” Collograph/Print, 1984, Ruth Singley Ensign
IMG_4013
Ruth Singley Ensign, artist (1927-2008). Photo credit: Josephine Ensign, 1977.
IMG_4003
Ruth Singley (Ensign). Artist. Photo credit: Jack Murray, 1942.

 

Hospital Healing Gardens

Sheltering Arms Hospital labyrinth and park. Richmond, Virginia. Photo credit: Josephine Ensign/2014

Our hospitals are bustling, intimidating, drama-filled, miraculous, expensive, technology-driven, antiseptic, and confusing places. Anything that can make them more ‘grounded’ and healing should be a welcome thing.

The first photo here is of the walking meditation outdoor labyrinth and wheelchair accessible park/paracourse that was associated with the (now closed) Sheltering Arms Hospital in Richmond, Virginia. This is where I would go for stress-reduction and perspective-seeking when I worked as a rehab nurse at the hospital (1980s), and then much later when my father was in home hospice nearby.

Paul Farmer, physician, anthropologist, global health activist, and founder of the Harvard-based Partners in Health, says that he has two main markers of quality of health care in a hospital that he visits anywhere in the world. His are not the usual quality of health care indicators those of us who work in health care and health services research think of. For hospitals, these include such things as: 1) timely and effective health care for conditions such as heart attack, 2) lower complications (and deaths) from surgeries, 3) lower hospital-acquired infections, and 4) patient report of good communication with doctors and nurses (see the very useful and consumer-friendly online tool based on national Medicare data, Hospital Compare). No, for Dr. Paul Farmer a hospital’s restrooms and gardens are what reveal its overall quality of care.

The fascinating topic of restrooms I will leave for another time, but hospital gardens are something I want to focus on here.

Modern hospitals trace their roots to the cloistered buildings of religious monastic orders that took in those too poor or disabled to be taken care of in their own homes by family members. These early hospitals were often built around a courtyard with a medicinal/herb garden, fruit trees, and a kitchen garden.

Garden of the Hospital in Arles 1, by Vincent Van Gogh. Public Domain license Wikimedia Commons.

The hospital healing garden shown here was an inner courtyard garden of the psychiatric hospital in southern France where Vincent Van Gogh was a patient. The view is from his hospital room. He also painted his famous series of blue irises from the hospital’s gardens. In letters he wrote to his family, he relayed how these gardens were an important part of his tenuous hold on mental and physical health.

Florence Nightingale knew the importance of nature in hospital reform and redesign. She emphasized the role of fresh air, sunlight, flowers, and of patients being able to see out of the window instead of looking at a wall. “She wrote, ‘I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers’ she noted, adding ‘people say the effect is only on the mind. It is no such thing. The effect is on the body too'”(quote from the Wellcome Trust blog post ‘Why every hospital should have a garden,‘ 11-8-13). I wonder what Nightingale would say about our ‘modern’ hospitals banning the delivery of fresh flowers or plants to patients for fear of allergies or mold or whatever it is they fear.

Yesterday I went in search of the healing garden at the University of Washington Medical Center (UWMC) where I work (and where I have been a patient–for a bit more on that see my Medical Maze photo description in Pulse: Voices From the Heart of Medicine 1-23-15 ). I remembered it as an almost shockingly calming and contemplative space near the coffee shop adjacent to the main surgery wing. The UWMC healing garden was a rooftop garden designed by local UW landscape architect Daniel Winterbottom who specializes in healing/restorative gardens. I sought the healing garden in vain, as it was torn down several years ago to make room for yet another wing to this already massive hospital and medical center (at over 6 million square feet of mostly concrete, the UWMC/Health Sciences complex is the world’s largest single university building). The very helpful UWMC information desk staff directed me to this spot (see photo below) as the ‘backup’ healing garden. It appears to be a series of mud puddles with a no smoking sign and smokers happily puffing away. Clearly, there’s much work to be done.

IMG_3681
UWMC mud puddle ‘healing garden.’ Photo credit: Josephine Ensign/2015

Resources:

The Therapeutic Landscape Network has a searchable index ‘Gardens in Healthcare and Related Facilities.’

An excellent (and expensive! see if your local library has/can get a copy) book on the topic is Therapeutic Landscapes: An Evidence-based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, by Clare Cooper Marcus and Naomi Sachs (Wiley: 2013). It includes an extensive collection of case studies of different types of healing and therapeutic gardens associated with hospitals, rehabilitative facilities, nursing homes, and hospices.

Harborview Art Walk and Ekphrasis

P1000172 - Version 2
Harborview Medical Center, Seattle Photo: Josephine Ensign/2015

What do art and poetry and Seattle’s largest public hospital have to do with each other? My colleague, poet Suzanne Edison, and I set out together this week on a mission to find possible answers to that question. We spent a half day doing our own art walk through the lovely and eclectic collection of public art at Harborview Medical Center in downtown Seattle. Then we sat in one of the hospital’s street-side cafes facing the Medic One emergency bays, sipped coffee amidst the occasional swirl of red lights and sirens, and wrote Ekphastic poetry in response to pieces of art that particularly moved us.

Our wonderful King County-based arts and culture organization, 4Culture, has a useful webpage with links showing photographs and describing some of the major pieces of art at Harborview. As they state:

“The Public Art Collection at Harborview has been growing since 1977 and is based on the belief that the arts can counterbalance the emotional, psychological, technological and institutional intensities of the medical center by reducing stress and conveying a sense of individual dignity and worth upon all who enter its doors.”

In choosing the artwork for display in public spaces–busy hallways, specialty clinics, and the numerous waiting room areas–careful consideration is given to things like inclusion of a diversity of artists, artistic styles, and themes. Peggy Weiss, who directs the art program at Harborview, explained to me that they have to try and balance having art pieces be interesting and healing across the wide range of patient populations they serve. (See my previous blog post “A Photo Ode to Harborview” from 1-31-15 for another ‘take’ on Harborview and for photos of its outdoors View Park artwork).

I took photographs of pieces of art and of particular spaces inside and outside the main Harborview (old) hospital, being careful to exclude any people in order to respect patient (and staff and patient family member’s) privacy. Here are some photos of art that I found most engaging and moving:

P1000164
Artist: Dempsey Bob “The Wolf Helper” 1999 cast bronze and horsehair location: atrium in main hospital. Photo: Josephine Ensign/2015.
IMG_3642
Artist: Sultan Mohamed “Royal Family,” 1997 oil on canvas The placard explains that he was inspired by the saying by Ethiopian elders, “Religious beliefs are an individual right but the country belongs to everyone.” Location: in hallway outside entrance to cafeteria Main hospital.
IMG_3616
Artist: Peggy Vanbianchi “Journey: Hands” Mixed Media Location: waiting room of Radiology/outpatient, second floor of main hospital
IMG_3619
Artist: Peggy Vanbianchi “Journey: Journal” mixed media Location: waiting room of Radiology outpatient department second floor of Main hospital.

This piece, ‘Journal,’ with its collection of enigmatic words, such as ‘refuge,’ ‘passage,’ ‘quest,’ ‘search,’ and ‘restore,’ lent itself to our first writing prompt: Take a word from the journal and write from it. I chose ‘refuge’ and wrote a free form poem that took me in surprising directions. The other writing prompts that we came up with were: 1) Write as if two pieces of art are in conversation, 2) Take one piece of art and write from its perspective, and 3) Have a figure in a piece of art be in conversation with the artist.

My main poem that came out of our art walk/Ekphrastic poetry writing day is titled “Harborview Refuge,” and has somehow manifested itself back into its own piece of art of the same name. Using my black and white photographs on various photo transfers (packing tape and acrylic gel medium), along with bits of my poem written on strips of bandage tape, here is my work-in-progress:

IMG_3661 - Version 2

As you can see from these three photographs included in my mixed-media art piece, I am taken by the Art Deco architecture and details of Harborview’s main hospital, which opened in 1931. The almost Gothic gargoyle-looking figure on the right adorns the top of the pillars at the main entrance to the ‘old hospital,’ next to the emergency department.

Harborview Medical center has a tradition of ‘poetry happens.’ Seattle-based writer Wendy Call was a Harborview writer-in-residence in 2010/2011. She worked on a project Harborview Haiku and American Sentences. As part of her project, Wendy shared her poetry with patients and staff and also encouraged them to write their own haiku/American Sentences.

And for anyone who wants to read some recent examples of ekphrastic poetry (and perhaps be inspired to write/submit your own poem in response to a photograph), take a look at Rattle‘s Ekphrasis Challenge.

The Crazy-Making Quantified Self

number-70828_640“Know your numbers” proclaims the American Heart Association, health care providers, employer ‘wellness’ programs, and multiple well-meaning but annoying relatives. We are continually admonished to monitor our weight, blood pressure, hours of sleep, caloric intake, and blood sugar/cholesterol levels–even the numbers of steps we take every day. It is becoming easier to self-monitor many of these numbers, what with the Fitbits, Jawbones, Fuelbands, Nudges, and the soon-to-be released and oh so aptly named iWatch. There is even a pregnancy monitoring app, Wildflower (really? who picked this name?), which keeps track of pregnancy weight gain and other pregnancy milestones. We have entered the age of the Quantified Self, the Quantified Self being a term, a movement, and a blog of the same name developed Wired Magazine San Fransisco-based journalist Gary Wolf. But is the Quantified Self craze making us healthier and more self-aware or just making us crazier and more self-absorbed?

As medical sociologist Deborah Lupton writes in her forthcoming book chapter/article You Are Your Data: Self-Tracking Practices and Concepts of Data  (see resources below), quantified self-tracking discourses:

include the notions that quantified data are powerful entities; (…) data (and particularly quantified or quantifiable data) are an avenue to self-knowledge; (…) quantifiable data are more neutral, reliable, intellectual and objective than qualitative data, which are intuitive, emotional and subjective; self-tracked data can provide greater insights than the information that a person receives from their senses, revealing previously hidden patterns or correlations; self-tracked data can be motivational phenomena, inspiring action, by entering into a feedback loop; (…) and data about individuals are emblematic of their true selves.

Besides the very real and potential misuses and abuses of self-tracking health data, including bias and discrimination by the U.S. Big Brothers of employers and health insurance companies, the use of these health data devices can become addictive and can trigger distorted body image and eating disorders. They also feed into our propensity to fall into the traps of ableism and healthism: judging and blaming people (and ourselves) when they (or we) aren’t thin enough, fit enough, happy enough, ‘able’ enough, healthy enough, fill-in-the-blank enough. We start to aim for the highest attainable and measurable ideal of bodily health instead of viewing health as something that allows us to do the things that give life meaning–things like family, community, spirituality, and fulfilling work.

I love health promotion and public health, but those of us working in this field can be a boring and sanctimonious lot. I stopped attending American Public Health Association (APHA) national meetings because I always felt I was joining a cult or attending a mass religious revival. Flocks of people wearing sensible shoes. I imagine many if not most of the APHA members are early adopters of all these get fit and health monitoring gadgets.

People like Deborah Lupton have conducted research and written wise critiques of the Quantified Self movement. I haven’t seen much discussion of the inherent classism of the movement, besides people pointing out the barriers of cost of all these gadgets. But beyond the purchase price cost of the gadgets, access to the internet for tracking and analyzing and comparing data, there’s also the fact that poor people don’t have the luxuries of eating good, healthful food, or the time to exercise. And then there’s the ‘bigger picture’ fact that all these self-monitoring health activities have much less impact on our health and longevity than we believe. Even access to high quality health care doesn’t matter as much as we think it does. One of the biggest factors in our health status–especially here in the pull-yourself-up-by-the-bootstraps U.S.–is where we are on the socio-economic ladder. The other little known fact is that the decidedly subjective self-rated overall health status of people remains the single best predictor of future morbidity and mortality. So, instead of wedding yourself to a Fitband, consider asking yourself on occasion, “In general, I would say my health is: Excellent, Good, Fair, or Poor?”

______________________

See the 3-5-15 post “Changing Representations of Self-Tracking” by Deborah Lupton on her blog This Sociological Life.

The quote included above is from Lupton’s chapter in the forthcoming book Lifelogging: Theoretical Approaches and Case Studies About Self-tracking (tentative title), edited by Stefan Selke to be published by Springer Press.

For a rather alarming report on the uses/misuses/abuses of self-tracking health data, read the Forbes article Wearable Tech is Plugging Into Health by Parmy Olson (6-19-14).

For an excellent and now almost ‘classic’ academic but accessible book related to this topic, I highly recommend Deborah Lupton’s The Imperative of Health: Public Health and the Regulated Body, Sage, 1995. I pulled my copy off of my bookshelf (along with her excellent Medicine as Culture book), and discovered this most interesting and ironic bookmark. It is a YMCA promo brochure cover photograph of me holding my toddler son. This was the year I taught Jonathan to swim. This is the year I coped with a messy divorce by swimming 2,000 miles. I logged them on the YMCA competition bulletin board  (yes, I won) and I wore a Nike waterproof heart rate monitor….IMG_3598

Ten Neglected Classics of Nursing Literature

IMG_2631Recently, The American Scholar had an article by their editors entitled “Ten Neglected Classics” (1-13-15).  As they state, “…the following books are works we think ought to be read by more people, works that we keep coming back to but aren’t talked about as much as we would like.” This article got me thinking about what books I would include on my list of ‘ten neglected classics of nursing literature.’

I quickly ruled out any and all of the Cherry Ames series. I did not grow up wanting to be a nurse and I never read any of the Cherry Ames nurse series until……okay…true confession: I have never been able to read any of the Cherry Ames books. But I do own one (the photo here is of the cover of the book I own, a 1948 edition of Cherry Ames Cruise Nurse, by Helen Wells). The concluding sentence of the book is the oh so enticing cliffhanger: “And somehow  she knew that although the cruise had come to a happy ending, her friendship with young Dr. Monroe had only just begun.” Someone should write a modern-day feminist kick-ass version of Cherry Ames , or perhaps a lesbian soft-porn version….. But I digress.

Any list of classics, including my list of Top Ten Neglected Classics of Nursing Literature, is highly subjective. Here are my inclusion criteria: 1) about nursing or have a strong lead character–or a strong and memorable character– who is a nurse; 2) books or at least novella-length works; 3) books/works I have read and have in my personal library to refer back to frequently; 4) are still in print/easily accessible; 5) be well-written enough and of wide enough appeal (as in not in a nursing ghetto) to be called literature; 6) not be by or about Florence Nightingale. Oh. I broke that last rule. The term ‘classics’ is also highly subjective, and I include books that have already stood the test of time, as well as more recent books that I believe will stand the test of time.

Here they are:

1) One Flew Over the Cuckoo’s Nest by Ken Kesey. Includes the legendary character of Nurse Ratched. I’ve written about her in a previous blog post ‘Nurse Ratched’s Backstory’ (7-16-13). I love Nurse Ratched.

2) God’s Hotel by Victoria Sweet. Even though this book is mainly about physicians and hospitals, it also includes strong and memorable nursing figures, such as the hospital matron who knitted blankets for her patients.

3) Call the Midwife: A Memoir of Birth, Joy, and Hard Times by Jennifer Worth. There are three book in this series but the first is by far the best.

4) The Beautiful Unbroken: One Nurse’s Life by Mary Jane Nealon.

5) Critical Care: A New Nurse Faces Death, Life, and Everything in Between by Theresa Brown.

6) I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse, edited by Lee Gutkind. Note: even though I have an essay included in this anthology, I do not receive any payment from sales of the book.

7) On Being Ill by Virginia Woolf along with Notes From Sick Rooms by (Virginia’s mother who was also a nurse) Julia Stephen.

8) Eminent Victorians (chapter on Florence Nightingale is hilarious and enlightening about this complex person) by Lytton Strachey.

9) Between the Heartbeats: Poetry and Prose by Nurses, edited by Cortney Davis and Judy Schaefer.

10) _______________________ I racked my brain and tore up my bookshelves in search of a tenth book worthy of being included in my list, but I have yet to find one. Please add your recommendations/nominations.