The Travelator of Racism

indexA few blog posts ago I wrote about the use of metaphor in health policy, focusing on the Cliff of Health analogy developed by Dr. Camara Jones. (See “Falling off the Funding Cliff of Good Health”). Dr. Jones is a family physician and epidemiologist who until recently was Research Director on Social Determinants of Health and Equity at the CDC in Atlanta. She resigned from that position in December to become President Elect of the American Public Health Association. She also IMG_3541teaches at the Morehouse School of Medicine. This photograph, which I took on Friday this week, shows Dr. Jones on the right with my colleague and epidemiologist Dr. Wendy Barrington.

Dr. Camara Jones was in Seattle to consult with the University of Washington School of Medicine on diversity issues. She gave a riveting (and standing room only) Grand Rounds talk “Achieving Health Equity: Naming, Measuring, and Addressing Racism and Other Systems of Structured Inequity.” And on Friday she talked with School of Nursing students, faculty, and staff about these same issues. In person she is warm, engaging, funny, and a gifted storyteller. As she says, she uses stories–allegories (which are really extended metaphors with a ‘lesson’)–to distill and clarify complex public health concepts and ‘difficult to discuss’ topics like racism. I highly recommend watching her recent (July 10, 2014) TEDxEmory videotaped talk “Allegories on Race and Racism,” in which she tells four stories: 1) Japanese Lanterns: Colored Perceptions, 2) Dual Reality: A Restaurant Sign, 3) Levels of Racism: A Gardner’s Tale, and 4) Life on a Conveyor Belt: Moving to Action. Conveyor belt, or moving walkway, is also called ‘travelator’ by those clever Brits.

The conveyor belt allegory is one of her most recent, and as far as I can tell she has not yet included it in any of her published articles. Dr. Jones said she has extended the ‘conveyor belt of racism’ analogy from the work of Beverly Daniel Tatum, author of Why are all the Black Kids Sitting Together in the Cafeteria? And Other Conversations About Race, Beverly Tatum (1997). Tatum writes about what it means to be antiracist:

“I sometimes visualize the ongoing cycle of racism as a moving walkway at the airport. Active racist behavior is equivalent to walking fast on the conveyor belt. The person engaged in active racist behavior has identified with the ideology of White supremacy and is moving with it. Passive racist behavior is equivalent to standing still on the walkway. No overt effort is being made, but the conveyor belt moves the bystanders along to the same destination as those who are actively walking. Some of the bystanders may feel the motion of the conveyor belt, see the active racists ahead of them, and choose to turn around, unwilling to go to the same destination as the White supremacists. But unless they are walking actively in the opposite direction at a speed faster than the conveyor belt- unless they are actively antiracist- they will find themselves carried along with the others” (pp 11-12).

It is highly telling that many of the online quotes of this passage from Tatum’s book conveniently delete both sentences that include ‘White supremacist,’ as if  it is ‘that which cannot be spoken.’ Camara Jones extends the conveyor belt/travelator of racism allegory by pointing out there are three stages of anti-racist action: 1) name it–look for and point out the racism inherent in the conveyor belt; 2) ask ‘how is racism operating here?’–not only walk backwards on the conveyor belt, but seek out the mechanisms and the history behind the building of the conveyor belt; and 3) organize and strategize to act with others who are trying to dismantle the mechanism behind the conveyor belt–to stop it. In her Grand Rounds speech, Dr. Jones pointed out that we have to talk about and understand history, we have to ask ‘how did this problem get to be this way?’ “Often knowing and uncovering the history behind how we got this problem can give us ideas of how to address it.”

I continually struggle to find ways to include meaningful course content and discussions about racism and health in the community health nursing and health politics and policy courses I teach, as well as in my narrative medicine/health humanities courses. Using the allegories on racism developed by Dr. Camara Jones has been among the most effective teaching tools.

If you haven’t done this already, try taking the Implicit Association test on race, available online through Harvard University. Make sure you are well-rested and feeling both left-right hand coordinated and willing to have your world rocked before taking this test!


Complicating Forgiveness

IMG_2754Forgiveness sounds so warm and fuzzy and facile. And religious: Forgive us our debts (or trespasses) as we forgive our debtors (or trespassers)…. Like a joyous sunflower turning its laughing seedy face toward the warmth and the light.

But wait. That sunflower looks decidedly sinister. Could there be a dark, prickly underbelly to forgiveness? Is forgiveness always a good thing?

These are questions I’ve been asking myself as well as ‘asking’ various experts through an extensive search of the academic literature related to forgiveness (mainly within the fields of philosophy, psychology, and counseling). These questions have led to more questions: Can you forgive someone or something like an institution–a hospital system for instance–for wrongdoing in the absence of an admission of guilt and a sincere apology? What constitutes a sincere apology? What constitutes sincere forgiveness versus a too-quick-to-give (or forced into) ‘cheap grace’ forgiveness? Do you have to forget to forgive? What is self-forgiveness and why is it important? What are the power dynamics, including gender dynamics, embedded in forgiveness? Who has the ‘right’ to forgive? Are there some instances of wrongdoing (like the atrocities of the Holocaust and of various genocides around the world, or like severe child abuse) that are of such great magnitude that they are unforgivable? Can there be reconciliation without forgiveness?

Forgiveness and its close relations of shame, guilt, righteous indignation, anger, revenge, restitution, reconciliation, and restorative justice are highly relevant to health care, to public/community health, and to all health care providers. There are the all too frequent medical errors leading to patient injuries and deaths. There are the ‘second victim’ casualties to health care providers involved in medical errors. There are the just and unjust cultures of hospitals, medical systems, and health regulatory boards. There are the U.S. Public Health Services’ infamous Tuskegee Syphilis Study and its lingering effects. There are worsening environmental justice issues, racism, gender-based violence, police brutality, and global health inequities.

Within health care provider education in the U.S. we now include course content and interprofessional mock trainings on ‘error disclosure.’ We try to identify and intervene with incompetent or ‘bad apple’ students. We have student counseling services for students struggling with emotional issues. We have (or rather we should have) faculty development trainings on how to provide clear, constructive student performance feedback in a supportive, non-shaming way. But we don’t really have a place for open discussion of forgiveness, shame, vulnerability, and uncertainty. We’re all about measuring and having students attain ‘competencies.’

The closest I ever come to teaching about forgiveness, vulnerability, and shame is when I touch on the concept and practice of cultural humility in my community health course (the best description of cultural humility is the short video Cultural Humility: People, Principles and Practice by Vivian Chavez). As social worker, therapist, and researcher Brene Brown points out, we can’t have constructive conversations about race, class, power, and privilege without addressing shame. If you haven’t already seen it, I encourage you to watch her 20 minute TED talk “Listening to Shame.” It reminds me of how much I love the profession of social work.

Out of the thirty or so scholarly books and articles I have read on the topic of forgiveness, here are the ones I found most helpful, provocative, and powerful:

  • The Sunflower: On the Possibilities and Limits of Forgiveness, by Simon Wiesenthal (Shocken Books, 1976, 1997). The first part of this book is Wiesenthal telling the story of his experience as a Jewish prisoner in a Nazi concentration work camp in Poland. He was picked at random by a Nazi nurse to visit a young, dying SS officer who wanted to ‘confess his sins’ to a Jewish person and ask for forgiveness. Wiesenthal sat for hours by the patient’s beside listening to him–at one point he brushed a fly away from the patient’s bandaged head–but he stayed silent and did not forgive him. The episode bothers him and he asks people what they would have done in the same or similar situation. The remainder of the book is comprised of responses from various theologians (Jewish, Christian, Buddhist, and Muslim) and philosophers. This is a book that will haunt you long after you’ve finished reading it.
  • Before Forgiving: Cautionary Views on Forgiveness in Psychotherapy, edited by Sharon Lamb and Jeffrie G. Murphy (Oxford University Press, 2002)–and especially Sharon Lamb’s chapter “The Good, the Bad, and the Ugly: Psychoanalytic and Cultural Perspectives on Forgiveness.” She writes about power dynamics and gender politics vis-a-vis forgiveness. “Gender conformity then is ‘met’ when a woman forgives her wrongdoer and lets go of resentment, even at the cost of self-respect.” (or safety as she add in the case of abuse and intimate-partner violence).
  • “Shame, guilt, and the medical learner: ignored connections and why we should care,” by William Bynum and Jeffrey Goodies, Medical Education, 2014, 48:1045-1054.)
  • For an amazingly rich sci-fi take on the topic of forgiveness, there is Ursula Le Guin’s book Four Ways to Forgiveness, the first part of which is titled “Betrayals.”
  • In the realm of fiction, Naseem Rakha’s novel The Crying Tree (Broadway, 2009) is carefully researched and beautifully written. It’s a fictionalized account of the complicated grief process of the mother of a murdered teenage son who forgives and befriends her son’s murderer while he awaits his execution on death row. This novel is based on Rakha’s work as a journalist covering the death penalty in Oregon.

Of God and Toilets

Public_VIP_latrine_(photo_taken_in_2011)_(5529288428)As I finish grading student papers for an undergraduate  community health course, I am reminded of the two most influential courses in all of my undergraduate and graduate education: 1) Comparative World Religions taught by Clyde Holbrook, Oberlin College in 1980; and, 2) Water and Sanitation taught by Clive Shiff at Johns Hopkins School of Public Health in 1992 (in which we applied a problem-based learning/case study approach to a Zimbabwe village water and sanitation project in a team-based approach with health care providers from mostly resource-poor countries). These two courses on seemingly disparate topics were the most personally transformative for me in terms of expanding my worldview and enhancing my critical thinking skills. Those, in turn, are two of the most important educational outcomes or standards that I aim to teach to in my work educating future nurses and other health care professionals.

As a society, as a world, what do we most want and need in health care providers? Yes, of course, we want and need intelligent, highly competent providers who are up-to-date on all of the latest scientific, evidence-based practice guidelines. But robots can do that. What we really want and need are flesh-and-blood, compassionate, grounded, and questioning humans who understand at a visceral level what it means to face existential questions of life and death; what it means to face complex personal and community-level ethical issues; and what it means to wrestle with the visceral, practical questions such as how to best to take care of basic bodily functions (like pooping and peeing) and how a community can obtain safe, clean drinking water (and the complex political, cultural, social, and historical issues related to that access).

In order to have more health care providers capable of such things, in order to ‘humanize health care,’ we need to have better support of the humanities within basic primary education, undergraduate education, graduate education, and continuing education…. Ah yes, and we need to have more health care (especially nursing) educators who have meaningful exposure to, education in, and orientation towards the humanities. By humanities I mean “the study of how people process and document the human experience” (source: Stanford Humanities), which typically includes the academic disciplines of: philosophy, literature, religion, art, music, history, and language/linguistics. Humanities and a ‘liberal arts’ education are foundational to our country and to democracy; they are also currently being undermined by a focus on ‘practical’ jobs-based education in STEM (non-humanities) subjects: Science, Technology, Engineering, and Math. As an important counterpoint to that trend, I encourage you to view the brief (7 minute) video “The Heart of the Matter” by the American Academy of Arts and Sciences (to accompany their 2013 report of the same name).

Remember to ask the important questions: who are we? where did we come from? why are we here? where are we possibly going? and where is a safe place to poop?

Narrative Medicine Collection

product_thumbnail.phpHere are a few of my current favorite narrative medicine/medical humanities things:

  • Heart Murmurs: What Patients Teach Their Doctors (UC Medical Humanities Press, 2014). This new collection of personal narratives by physicians, edited by my colleague Sharon Dobie, MD, a family medicine doctor who teaches and practices relationship centered care. In these essays Dr. Dobie and thirty-five other physicians explore lessons they’ve learned from patients.
  • Those whacky and wonderful Brits have a much better health care system than we do, and they have this wonderful new (creative) collection (is it a book? is it a collage?) on medical humanities. Published by the Wellcome Collection, Where Does It Hurt? The New World of the Medical Humanities is both entertaining and thought-provoking. (While you’re at it, spend some time browsing their website for fun quizzes, interactive educational games, videos, and more). Here’s what they say abut the book:
    “What does it mean to be well? Or ill? And who, apart from you, really knows which is which? Contemporary definitions of medicine and clinical practice occupy just one small corner of a vast field of beliefs, superstitions, cultures and practices across which human beings have always roamed in the search to keep themselves, and others, feeling well.The label ‘medical humanities’ is the best effort we’ve made so far to define the fence that encloses that very large field; recognising that it’s a space in which artists, poets, historians, film-makers, comedians and cartoonists – in fact every one of us – has as much right to explore as any humanities-schooled or clinically trained professional. This book is a walk through that field, a celebration of its rich diversity, a dip into some of the conversations that are going on within it, an attempt to get it in perspective – and an invitation to you to join the conversation yourself.”
  • The always friendly folks in the middle of cornfields in Iowa (University of Iowa) put on a terrific annual narrative medicine conference: The Examined Life Conference. They just announced that a keynote speaker for their upcoming conference (April 16-18, 2015) is poet Jimmy Santiago Baca. His memoir A Place To Stand (Grove Press, 2002) was made into a documentary released last month.

Ice Bucket Challenge for Ebola

imagesThe U.S.-based ALS (Lou Gehrig’s Disease) Association has struck gold with it’s social media fundraising campaign, the ice bucket challenge. Even my neighbor across Lake Washington, the gazillionaire and global health guru Bill Gates has doused himself with ice water and presumably has donated money towards ALS research. As of today, the ALS Foundation has raised 88.5 million dollars, and according to news reports, they are trying to figure out what to do with all the money.

ALS is a terrible disease with a terrible burden on not only the ALS patient, but also on his or her family due to the years of increasing and intensive home care usually associated with the disease. I had a childhood friend who developed ALS, and my elderly father spent many hours doing direct care so that the patient’s wife could get some rest. I suppose ALS has been lumped in with ‘orphan diseases,’ diseases and disorders that are relatively rare, unknown, unsexy, and unprofitable for the large multinational drug industry. So it is a good thing the ALS Foundation now has more funding for research. By contrast, cancer and Alzheimer’s Disease are both big, scary, well-known diseases that get most of our research funding. That’s because they are both highly profitable diseases for drug companies and for the health care system.

But why not do an ice bucket challenge to raise money and awareness for devastating diseases like Ebola?

An ice bucket challenge to raise funds for Ebola research, education, and health care, would likely fail because Ebola, like the disease burden from most other infectious diseases, is largely isolated to the poorest and most remote villages of Africa. “It’s over there where the poor, illiterate, ignorant Africans live, so who cares?” (I’m quoting an imaginary Archie Bunker, but it is a very real and highly prevalent belief in our country). It seems that there have only been two confirmed cases of Ebola in the U.S. so far. They were both white American, Christian missionaries working in Africa who were flown back to the U.S. on private jets and given state-of-the-art (expensive) inpatient health care–including experimental medications– at the CDC-associated hospital in Atlanta. Of course, they both recovered and have now returned to their homes.

Meanwhile, nurses and doctors and burial workers in Liberia, Sierra Leone, Guinea, and Nigeria struggle to take care of an increasing number of Ebola patients. The NYT this week published an article and accompanying video highlighting the work of amazing nurses in Sierra Leone–nurses like Josephine Finda Sellu–who are taking care of Ebola patients because: “You have no options. You have to go and save others (…) You are seeing your colleagues dying, and you still go and work.” (“Those who serve Ebola victims soldier on” by Adam Nossiter and Ben Solomon, 8-23-14).

For some important (and largely overlooked) perspective, consider the findings of this recent study on the global health disparity in disease burden and in disease research. In their April 2014 PLOS (open-access, peer-reviewed scientific journal) article “Attention to Local Health Burden and the Global Disparity of Health Research,” researchers Evan, Shim, and Loanidis found that “the production of health research in the world correlates with the market for treatment and not the burden of disease.” Measuring disability-adjusted life years (DALYS–a now standard health measure for the number of years lost due to ill health, disability, or premature death), they report a global disease burden from infectious/parasitic diseases (such as HIV, TB, diarrheal diseases, malaria–and Ebloa) of 269 million years worth of DALYs. This is in stark contrast to the global disease burden of all malignant neoplasms (cancers) of 69 million years of DALYs. Then they show that the overwhelming majority of the world’s medical research dollars goes to cancer and to neurological diseases (mainly Alzheimer’s Disease, but ALS also falls into this category). They conclude that “the inequality of research limits current quality of care in less developed countries.”

Please remember that and also the heroic work of nurses like Josephine Finda Sellu, whenever you hear anyone mutter any sentiment close to “It’s over there where the poor, illiterate, ignorant Africans live, so who cares?”

I propose an ice bucket challenge for Ebola. Instead of wasting clean water and ice (luxury items, of course, in villages like those in Sierra Leone), consider donating money to support the work of organizations like Doctors Without Borders or Partners in Health. Practice what physician Paul Farmer calls pragmatic solidarity. Pass it on…

Narrative Medicine “Closer” Close Reading In Practice

1384151134Over the past several weeks, in the narrative medicine (NM)  summer course I am teaching, we have been using the ‘closer’ NM close reading approach that I proposed in my last blog post: focusing on the elements of emotion, silence, surprise, and metaphor/imagery. I’ve also asked the students for written feedback on what it is like to use this closer reading technique, as well as how they envision incorporating what they learn from it into their practice as health care providers.

The course is offered through the innovative School of Interdisciplinary Arts and Sciences at the University of Washington, Bothell Campus. The majority of the forty students in my course are nurses, most with Associate Degree preparation, who are now in their BSN completion program (finishing the equivalent of a four-year undergraduate degree program). It is a very diverse class in terms of age, gender, country of origin, ethnicity, race, years of work experience within health care, etc. Earlier in the quarter they all read/learned/practiced Charon’s close reading drill for narrative medicine: frame (includes gaps/silences), form (includes metaphor/imagery), time, plot, desire.

For in-class practice of the closer NM close reading approach, I used various poems from Between the Heartbeats: Poetry and Prose By Nurses, edited by Courtney Davis and Judy Schaefer (U of Iowa Press, 1995). “Burnt-out Offerings” by Sandra Smith with the stanza “We have become/those old crusty nurses/we used to pity and avoid.”–and Courtney Davis’ haunting “The Nurse’s Pockets” both resonated strongly with the students. I also used Kelly Siever’s more nuanced “Breath” and “Between the Heartbeats.”

Students commented that emotion and surprise in the poems were the easiest and most immediate for them to identify, and that metaphor and silence “…need more digging to discover and are more challenging.” Many of the students said that silence was something they had not considered before, that they found it intriguing but difficult. Overall, students felt this NM ‘closer’ reading approach was less technical, “less reserved and detached,” and that it “comes more easily and is something I can see myself using in practice.” One student wrote: “I can see this being used with patient interactions. Taking time to asses one’s reaction to a patient statement or story can prompt further questions, clarify biases, and create deeper understanding.”

I’m still refining how I teach this closer NM close reading approach, and especially how to guide students in how to listen for the silences, for whose voices and perspectives are heard and whose aren’t, and why.


A Narrative Medicine “Closer” Close Reading Drill

DSC00673In the narrative medicine course I teach at the University of Washington I have been using Rita Charon’s narrative medicine close reading drill (as described in her chapter “Close Reading” from her book Narrative Medicine: Honoring the Stories of Illness, Oxford University Press, 2006). I was taught this  narrative medicine close reading drill in the workshops I have taken with Dr. Charon at Columbia University.

As she writes in the opening of her chapter on close reading, “Narrative medicine makes the case that narrative training in reading and writing contributes to clinical effectiveness. By developing narrative competence, we have argued, health care professionals can become more attentive to patients, more attuned to patients’ experiences, more reflective in their own practice, and more accurate in interpreting the stories patients tell of illness” (pg 107).

I was first introduced to narrative medicine in the fall of 2010 when I took the Narrative Medicine ‘101’ workshop at Columbia University. I wrote two reflective (and in retrospect, rather cheeky yet truthful) blog posts about my experience: “The Cult of Narrative Medicine” and “Postpartum Narrative Medicine.”  I stumbled into narrative medicine through my mid-life existential crisis of questioning the meaning of all my striving in terms of clinical practice and teaching nursing–and by practicing the mid-life crisis ‘cure’ by doing the Jungian thing of returning to my adolescent passion of reading (and writing). Then, using the crystal ball of Google searches, I discovered Rita Charon and narrative medicine.

That is the backstory. What I want to highlight in this blog post is my continual nagging–no niggling–suspicion that something is just not right with Rita Charon’s narrative medicine close reading drill. It has taken me years to be able to articulate what bothers me about her drill. I find that it is too cold, cerebral, intellectual; to practice it somehow further objectifies the ‘patient’ and holds them at arm’s length in order to dissect and measure. I have come to that conclusion by applying it to my own clinical practice as well as to my teaching of health professional students.

While trying to practice a ‘close reading’ of an actual patient and his or her story, I kept returning to the lesson of the Test Your Awareness video: “It’s easy to miss something you’re not looking for.” I became so wrapped up in noticing the minute details of what the patient was saying, that I missed the gestalt of the person telling the story. I also missed the fact that I was in a (professional) relationship with this person, that I was an active participant in the clinical encounter, and that I was being affected emotionally by this encounter: their story was ‘reading me.’  And in using this narrative medicine close reading drill with health professions students, I have found that they get all hung up with their anxieties over ‘doing this drill thing correctly’ as though I’m testing them on pathophysiology. (This applies to medical students who one would think have had a more liberal arts education, as well as to more ‘technical college’ nurses who have not likely had university-level courses). None of this can be viewed as ‘humanizing’ the practice of medicine.

What I find most compelling in narrative medicine or medical humanities more broadly, is the application of reflective (and reflexive, self-reflective, but not the ‘bathetic trip to nowhere of importance,’ sentimental, navel gazing variety) practice for health care professionals. My colleague, family medicine physician, teacher,  and writer Sharon Dobie has written about this in terms of the importance of self-awareness and mindful practice in relationship-centered health care (“Reflection on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education” Academic Medicine vol 82, issue 4, 2007, pp422-427).

I’m still in the process of refining my approach to ‘teaching narrative medicine,’ but here is my alternative to Rita Charon’s narrative close reading drill. My closer (to home) close reading drill:

  • Emotion: What do you feel while reading this (or while listening to this patient illness narrative)? What is the overall mood or emotional effect of the piece? And why do you think it evokes this particular response for you?
  • Surprise: What stands out to you the most? What is unexpected?  This is like Roland Barthes’ term ‘punctum’ in Camera Lucida, or as Arthur Frank puts it “what distracts you but is not the focus of the narrative.” (from a narrative analysis workshop I took with him at a qualitative research conference in Banff, Canada years ago).
  • Silence. What is unsaid in this? Whose voices or perspectives are included and whose are left out?
  • Metaphor (and it’s close cousin simile). The use of imagery and the poetics of the piece.

That’s it. The most important components of a narrative medicine ‘close reading.’ The next time I teach a narrative medicine course, I plan to use these as a close reading guide.


The Changing Landscape of Health Care Jobs in the United States

IMG_2285Attention all new nursing grads and other health care job-seekers: Today in the NYT there is a fascinating interactive feature “How the Recession Reshaped the Economy, in 255 Charts” by Alicia Parlapiano and Jeremy Ashkenas. It helps illustrate where the health care jobs are in our country, what the average salaries are within different sectors of the health care system, and what the trends are in terms of growth (or decline) of the different sectors.

Using data from the U.S. Bureau of Labor Statistics, the authors illustrate in easy-to-read charts how the number of jobs have changed for a particular industry over the past decade. These data are only available for private industries, so for health care, public health jobs are (unfortunately) not included. The only middle-wage private industries that did not lose jobs during the recession were those within health care.

One of the charts is titled The Medical Economy and here is what stands out to me:

  • Health care industries that were relatively unaffected by the recession and that have shown steady growth include home health care services, outpatient care centers (both general outpatient care and ones specific to mental health), and physician’s offices.
  • Health screening programs (including blood and organ banks) have recovered and grown.
  • Psychiatric and substance abuse hospitals have recovered and grown.
  • General medical-surgical hospitals remained relatively unaffected by the recession but appear to be mostly flat in terms of growth.
  • Specialty hospitals (excluding psychiatric and substance abuse) have recovered and grown, but they have shown a substantial decline in jobs since March 2012 (with a small blip back up over the past few months). I would imagine these changes for specialty care hospitals are correlated with the roll-out of ACA, especially changes to Medicare reimbursement for hospital care.

Take home lesson for people in the job-search mode within health care: Follow the money and look for jobs in the economically healthier parts of the U.S. health care system. Don’t rely on hospitals as the only places for job-searching.

Take home lesson for those of us in the role of nursing (or other health care professions) education: These ‘hard’ economic data provide even more good reasons to recruit and prepare students for work in primary care, community-based, non-acute care settings.

New Zealand Postcards: Self-care and the Sea

DSC01150…i nga wa o muri. The surge of the sea. Whether you think of time as something you move through, so that your past is necessarily behind you, or whether you conceive of time as an encompassing continuum (so that your past stands before you, while wrapping you round, and your future is never-present but ready, waiting behind—i nga wa o muri), there is always the pulse of the sea. In us and round us, the sea. We have that constancy. ~ Keri Hulme

This quote is from Hulme’s lovely book HomePlaces (Hodder and Stoughton, Auckland, 1989). I found the book yesterday as a ‘rare’ book in a bookstore in the town of Hokitika on the West Coast, South Island, New Zealand. For my community health course this quarter we’re reading Hulme’s The Bone People (one of my favorite books since it was published in 1984 and a good choice for teaching community health in New Zealand). After purchasing the copy of HomePlaces, I tramped up the beach several miles back to the hostel where we’re staying. A rouge wave from the wild Tasman almost took me—and the book—out to sea. Perspective. Being next to (and inadvertently in) the very cold sea, as well as being temporarily unhooked from the chatter of the internet, has reminded me of the importance of mindfulness training and of self-care in our personal and professional lives.

Professional burnout is never a pleasant thing to have (or to be around). I have crashed and burned in clinical settings at least twice in my life, so I know what it feels like and what personal and collateral damage it can do. And I’m beginning to feel a bit crispy in terms of my academic role this quarter. Something about living with my undergraduate students 24/7 for three months in ten different youth hostels all over both islands of New Zealand was just not a good idea. My passion for teaching is in serious need of refueling (along with the minivan I’m driving them around in).

Compassion fatigue, moral distress, and professional burnout—the gooey mess that health care professionals—and especially nurses—are prone to. What’s the antidote—besides getting whacked by a rouge wave from the Tasman and washed out to sea?

Self-care. Not the self-indulgent variety of going off to expensive spas and eating dark chocolate, but real self-care. What Rachel Naomi Remen, MD calls heart care: “ways of keeping your heart alive in health care.” David Bornstein wrote a nice NYT article “Medicine’s Search for Meaning” about Dr. Remen’s work (Sept 18, 2013). It focuses on physician burnout and mentions that half of all medical students burn out by the end of their training. Nurses burn out at even higher rates, especially in their first few years of practice.

I’ve read (and used in some of my courses) Remen’s book Kitchen Table Wisdom.  But after reading the NYT article, I decided to see what all the fuss was about. I signed up for Dr. Remen’s telephone conference/training call in mid-November. I’m often cynical about self-care, but I also know that cynicism is a marker for burn out. Plus, mid-November in Seattle is a dark and gloomy time, so a little brush-up on self-care sounded like a good idea.

Remen points out that the heart is devalued within health care. She states, “science (the head) is a tool of healing but is not the source of healing—that is the heart.” The heart is an organ of vision—that helps us discern the meaning of the work we do. She outlines a way of establishing a practice that supports the ability to ‘find meaning on purpose’ in one’s work (as opposed to having to be whacked over the head by it).

In response to several questions from some of the conference caller participants, Dr. Remen admitted that we’re all having to work within a broken health care system, but, “that doesn’t prevent us from taking time for self care; staying alive within the system isn’t about changing anything outside of yourself.” And she used this analogy: “If I can’t have a wonderful long drink of fruit juice, I won’t take another sip of water.” She deflected more questions along the same line by saying, “I don’t have an answer for changing the system.”  What I thought—and wanted to say—was that self-care keeps us alive (and healthy) and perhaps gives us more energy to work for systems change. And, of course, that is what Dr. Remen has been doing all these years through her work and writing.

She recommends a series of ‘heart practices.’ The following are the two that I like the most. 

  1. Connect to yourself by the mindfulness practice of attention to one’s breathing. “Paying attention at the very end of an out breath as a moment of absolute rest and peace.” Practicing this can build the capacity to come to rest.  
  2. At the end of the day, ask yourself “What surprised me today?” and “What touched my heart today?”

Sometimes in my more cynical moments this all sounds so woo-woo and kum-ba-yahish, but I am convinced that it works. And I will try to pass it on to my students.

Radical Hat-Burning Nurses Unite!

IMG_1082Radical nurses are back, or perhaps they never left and are just becoming more visible, more organized. The photo here is of my nurse’s cap-wearing trained seal mascot given to me by a friend in nursing school–who promptly dropped out of school because she was too radical for them.

There is the Radical Nurse on Facebook (aka Rebekah Dubrosky, RN) who says of herself, “Radical nurse goes to graduate school with hopes of starting a nursing revolution!” Her profile photo is of the formidable radical nurse and mother of public health nursing, Lillian Wald. Ms. Dubrosky is a doctoral student in the College of Nursing at the University of Wisconsin/Milwaukee. She just published a very good article “Iris Young’s Five Faces of Oppression Applied to Nursing” (Nursing Forum vol 48(3):205-210, July/Sept 2013).

There is the newly-formed Rebellious Nursing! group, which had its first national conference this past fall in Philadelphia. They state: “We believe that Nursing is an inherently political profession and that all nurses are rebellious.” I’m not sure I agree with their tag line, but I do love their logo of a white nurse’s cap going up in flames. An extension of the bra-burning second wave feminists and the corset-burning first-wave feminists. The third-wave feminists seem to have nothing left to burn so they’re putting the push-up bras and corsets back on. (Just kidding. Don’t burn me all you wonderful third-wave feminists–including my former nursing student who introduced me to Rebellious Nursing!).

Going back to the second-wave feminists, there was Casandra: Radical Feminist Nurses Network from the 1980’s. Some of their old newsletters are on Peggy Chinn’s blog, NurseManifest. Peggy Chinn, RN, PhD, is Professor Emerita, University of Connecticut, but she will never truly retire.

There were also Radical Nurse Groups (RNGs) active in the 1980’s within the UK. A nurse blogger who goes by the pseudonym Grumbling Appendix (gotta love British humor) and who works in an NHS hospital (hence the need for a pseudonym), is now archiving material for the RNG’s. In the recent post in the New Left forum, Grumbling Appendix makes the observation that some things have not changed much. I love the Radical Nurses Archive: So….Just How Radical Are You? It includes a funny-sad multiple-choice test from 1982 (when I graduated from wretched nursing school wearing a wretched nurse’s cap), although I need a Brit to help interpret the final scoring scheme.

For an amazing blast from the past that is also sobering in terms of how little things have changed, take a look at the 20 minute film The Politics of Caring from 1977 (produced, directed, and edited by Joan Finck and Timothy Sawyer in collaboration with Karen Wolf, RN.) It is posted on Peggy Chinn’s NurseManifest blog. The only difference between then and now that I see is that the nurses then were still wearing white nurse’s caps (non-flaming) and white dress uniforms (and oh my! those disgusting thick white opaque pantyhose that kept the oh my! pubic hairs from dropping off onto the operating room floor!) There’s something about ‘radical’ and the use of exclamation points….

In the film they begin by saying that while nurses are the largest component of the healthcare workforce they have the least say in health policy. Familiar? They discuss the disconnect between what is taught in nursing school about providing quality of care, and the reality of what is possible within the practice environment. (I hear this from my students all the time). They also question whether nursing can even be called a profession when the majority of nurses don’t have control over their work environments. And they discuss the tensions within nursing with the then newly-emerging role of advance practice nurses/nurse practitioners, pointing out (somewhat rightly so) that these ‘new nurses’ were mainly working within the medical model of care.

As a community health nurse I was fascinated to hear the nurses in the film talk about “the mecca of community nursing” as a place where nurses could practice ‘real nursing’ focusing on health prevention and promotion within the nursing model of care. Community health is what attracted me to nursing in the first place and it continues to be what I love most about my work. But we need hospital nurses and there are nurses who love working in hospitals and don’t want to have to ‘trade up’ to community health, or to become a nurse practitioner or a nursing professor in order to have greater control over their working conditions. Besides unions and Radical Nursing! groups, what is there for them?