“It’s time to read like you give a damn!” is the tagline admonishment to the University of Washington Health Sciences Common Book series, of which my book, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, was this last academic year’s Common Book. I have added “write like you give a damn!” to remind me of why I write, why I read, and why I do the work that I do. It is the moral imperative of working towards a socially just world. As George Orwell stated so eloquently in his essay “Why I Write,” there are four great reasons to write:
Political purpose—”and political purpose in the widest possible sense. Desire to push the world in a certain direction, to alter other people’s idea of the kind of society that they should strive for.”
“How are you going to tell your story, so that people who don’t know anything about your story get something from it. And you are not in charge of what they get. Sure, you are vulnerable, but you are still a storyteller.”
Sherman Alexie was speaking about his new memoir You Don’t Have to Say You Love Me (New York: Little, Brown and Company, 2017), which is mainly the story of his complicated grief for his mother, Lillian Alexie, who died several years ago. And about the health effects of intergenerational trauma that he has experienced. In his memoir, Alexie writes about his childhood growing up in poverty on the Spokane Indian Reservation in Washington State—about his serious health issues and childhood sexual abuse—about his mother’s rape and discovering that she is the product of a rape. I am dismayed at the insensitive (and as I read it, racist and misogynistic—questioning, for instance, the veracity of his mother’s rape) June 13, 2017 NYT review by Dwight Garner “Sherman Alexie’s Complicated Grief for his Mother.”
Alexie, in a recently published open letter, writes eloquently about the re-traumatizing and triggering effects on him that having his memoir out in the world has had. He states that he needs to “take a big step back and do most of my grieving in private.” While his memoir remains in the public domain, he has canceled the rest of his promotional tour events for the rest of the year in order to take care of his mental health—to tend to the ghosts of his mother and ancestors.
I applaud his letter and his honesty. I also understand what he means when he writes of ghosts and hauntings. Part of my motivation for writing Catching Homelessness was to deal with the presence of ghosts in my childhood and my life, which were and are marked by intergenerational trauma. One of the most frequent questions I have been asked by readers of my book is something along the lines of, “But tell me, did you really see the ghosts you write about?” As if a memoir, a book of non-fiction, cannot include something as unverifiable—as poetic— as a ghost? As if an educated, scientifically-grounded person cannot believe in, much less write about believing in, ghosts? I imagine that the person asking me this question has had a fairly easy life. I’d like to think that they realize—at least at some level—their privilege in that regard and are genuinely attempting to reach for some level of empathy and understanding for what it is like to be haunted. That is what “reading like you give a damn!” is all about: at the very least it is stepping outside your own comfort zone, finding the capacity for empathy leading to action.
And here I share the thought-provoking outreach packet for Catching Homelessness, put together by my social-justice-in-action colleagues at the University of Washington. 2016-2017 Outreach Packet copy
Leave things better than you found them was a lesson I was taught as a nineteen-year old college student during my study-abroad experience. That, along with celestial and non-celestial navigation, how to sail a 125′ Topsail Schooner, how to survive a Force 9 gale off the coasts of Labrador and Newfoundland, how to identify a multitude of sea creatures—including a 70′ Balaenoptera musculus (blue whale), how to take depth soundings of a Newfoundland fjord while perched in the bow of a tiny dinghy, and how to write and type a scientific report while rolling around on the high seas. Oh yes, and the poetics of sea shanties. All skills and knowledge and experiences that have served me well in life, reinforcing for me that value of experiential, immersion study-abroad programs.
But it is the seemingly trivial lesson of leaving things better than you found them that comes back to me most often, including this past week during the vicissitudes of the latest round of “let’s mess up our U.S. healthcare system even more.”
During my S.E.A Semester study-abroad program, Captain Carl Chase, our taciturn and highly capable and salty leader, sat us all down the first day of our voyage and explained that, in addition to our academic and sailing and galley work for the next six weeks, we were expected to find one thing we could do to do leave the ship in better shape than we had found it. He left it up to us to figure out what to do and then he would provide the materials and guidance necessary to complete our project. My project became the carving of a wooden knob for the battered galley teapot which had lost its knob. I liked to complain about the difficulty prying the top off the teapot and then realized I could—and should—stop complaining and do something to fix the problem.
Whenever I find myself complaining about things, like the ugly weed-filled concrete planters in the main courtyard at work, or the direction our country is going, or the direction the profession of nursing is going, or any of the myriad of issues I care about, I remember Captain Chase and the teapot knob and try to find some achievable improvement I can make.
And I know I am not alone in this effort. For instance, the Canadian nurse writer Tilda Shalof was recently highlighted in the Toronto Star article and accompanying video interview, “Medical Waste Becomes Massive Medical Art Mural.” As she prepares to retire from her decades working as an ICU nurse, Shalof turned the acres of brightly-colored plastic covers to various medical supplies into a beautiful art mural to adorn the hospital’s walls.
(Note: parts of this Yale School of Nursing 2017 commencement speech were adapted from the chapter “Soul Story” included in my forthcoming book Soul Stories: Voices from the Margins.)
Good afternoon. Thank you Dean Kurth, and all the faculty, staff, students, and the friends and family members of today’s graduates, for this opportunity to speak to you about a topic I am passionate about: nursing. But not traditional nursing—not the Lady with the Lamp during the Crimean War—and not the white uniform-clad nurse angel of Hallmark moments. About that nurse angel, to paraphrase Virginia Woolf and her similarly stifling angel of the house: whenever you feel the shadow of her wings or the radiance of her halo, take up the inkpot or whatever modern equivalent is nearby and fling it at her. Because nurses are flesh and blood people. Nurses are not supernatural beings. We, as nurses, are human beings. Today, I want to talk to you about the real life transforming and transformational nursing of which you are all a part. I want to talk to you about radical nursing. And about the radical self-care it takes to be a radical nurse.
Radical. Not necessarily in the political use of the word. Instead, I mean radical, in the OED definition “of or relating to a root or roots—fundamental to or inherent in the natural processes of life, vital.” It is derived from the Latin radicalis, which referred to “the moisture or humour once thought to be present in all living organisms as a necessary condition of their vitality.”
What feeds and waters your soul? What draws you to the work that you do?
The question of what draws us to the work that we do as nurses is an essential one. It is a radical one. It is a question which demands from us the act of digging deep through the layers of our being, down into the root system. It demands from us the time and space necessary to examine and then continue to re-examine our answers as we move through life. It demands the use of the arts and humanities in order to explore fully. The tools necessary to do this digging are not included in your nursing science toolkit. They are included in your arts in nursing and creative writing awards program led by Dr. Linda Honan. They are included through the meditation, yoga, and other self-care opportunities you have had here at the Yale School of Nursing. They are included in the creative pursuits you brought with you into nursing and that hopefully you have continued to nurture.
Because if we don’t attend to the work of that question—of what draws us to the work that we do— it often becomes an Achilles’ heel, tripping us up, making us lame. If we are not careful, the root of our passion for our work can become the biggest source of professional burnout.
I know this from personal experience. I have burned out—flamed out—rather spectacularly at least once in my career as a nurse. I now know my own particular set of warning signals for when I am beginning to get crispy, and I have worked out an action plan consisting of a short list of self-care that for me includes creative writing, and “real” books (not textbooks), and libraries, and more time in nature and with my family and friends.
I’ll tell you a condensed version of my cautionary tale about my first and worst experience with burnout. I wasn’t able to really think about this episode of my life until more recently as I began to write about it—creatively and reflectively.
A few years ago, I was in New York for a week to attend the narrative medicine workshop at Columbia University. I was there to learn ways to incorporate the stories of health, healing, and the human condition into my work. After the workshop was over, I spent a Sunday walking the length of Manhattan in flip-flops, which was a very silly thing to do since I ended up with a badly infected blister on the bottom of one foot.
But as I walked through Manhattan, I pondered questions that had been flashing through my head like an existential version of the NASDAQ sign in Times Square. Why am I attracted to the suffering of others? Why have I spent the past thirty years working as a nurse with homeless and marginalized people? Would I be happier—and able to afford a better pair of shoes—if I was drawn to work as a shoe buyer for Saks Fifth Avenue? The latter question occurred to me as I hobbled past the wrought-iron festooned display windows of Saks’ flagship store.
In one of our last narrative medicine workshop sessions we were asked to, “write about the last real thing that happened to you.” My last real thing had occurred the week before, during my work in Seattle. I teach health policy to nursing students at the University of Washington. Together with colleagues in the Schools of Medicine and Dentistry I help train and precept groups of medical, nursing, and dental students in the provision of basic foot and dental care for homeless people. The week before my New York trip, we had done one of these Teeth and Toes clinics at Seattle’s largest homeless shelter.
The shelter is in the downtown core of Seattle, at the bottom of the original Skid Road, which earned its name from the frontier town’s cedar logs, public inebriates, and Gold Rush prostitutes that all rolled downhill together into the mudflats and salt waters of Puget Sound. Entering the building, I was hit by the smell of a horse stable, something hay-sweet mixed with urine. The smell took me back to my work at the Cimmerian warehouse of the Richmond Street Center in Virginia, where I began my work with homeless people in the 1980s, and where I rolled down my own version of Skid Road and was homeless for six months.
Later that evening, as I inspected various scars or open wounds on the homeless clients’ feet, my mantra to them became, “What happened here?” Some people had simple replies, such as, “I was in a bad car accident a year ago.” Others were more complex. One patient was a woman dressed in a stained orange t-shirt, her short red hair flying away from florid, puffy cheeks. She stared at the ceiling while mumbling to herself, as if in prayer, her hands held in front of her neck, fluttering. I had the impression she was trying to catch hold of her exposed and scattered soul. Her only reply, while still looking at the ceiling and twitching her hands even faster, was, “I get nervous with too many questions.”
What happened here? is a question I asked myself about my own spiral into homelessness. At age twenty-five I was a respectable Southern preacher’s wife and a newly graduated nurse practitioner, running a health care for the homeless clinic in downtown Richmond. In a photograph of me from this time I’m kneeling on the floor of the clinic, my long straight hair falling in my face, and I’m washing the feet of a bearded Vietnam veteran homeless patient. I mostly worked alone in the clinic, tending to the health needs of thirty or more homeless patients each day for more than three years. I have no photo of myself towards the end of those years when I became a severely depressed divorcee without a job, living in my car and in abandoned sheds. There is no coherent story of this time, no map recording my journey, no facile answers to the question of what happened, only a mosaic of metaphors: rolling down Skid Road, falling into the rabbit hole, exposing my scattered soul, eating myself with rage—and flaming out. In retrospect, I see that my descent was partially caused by an extreme case of professional burn out, something nurses are especially prone to.
The term “professional burnout” comes from Graham Greene’s novel A Burnt-out Case, set in a Colonial British Congo leprosy clinic staffed by an atheist physician and Catholic nuns as nurses. The physician explains that a burnt-out case is a leprosy patient whose disease has burned itself out: the patient no longer has active leprosy but has the scars such that he or she is unable to re-enter normal life. In a conversation with the Father Superior of the village, the physician tells him of the issue of a leprophil: a person who is attracted to the suffering of lepers—who loves suffering and poverty and illness—a form of schadenfreude. He states that leprophil nurses “…would rather wash the feet with their hair like the woman in the gospel than clean them with something more antiseptic.” He likens leprophils to people who love and embrace poverty. The leprophil “makes for a bad nurse and ends by joining the patients.” The physician tells the priest that a patient can detect when someone loves their disease, their poverty, their suffering, instead of loving them as a person.
Why are people drawn to work with the lepers, outcasts, and homeless of the world? Is it, as the priest states in Greene’s novel, dangerous to ask what lies behind the desire to be of use, for we “might find some terrible things”? This virtuous work or calling or vocation or zeal, whether religious or secular, can feed the Hungry Ghost ego. It can become one’s identity; it can become addictive and destructive. I know this because I became my work and through it I became homeless.
The lesson here is: please do not become your work. That goes for all of us, whether we are graduates or teachers or administrators. In order for all of us to work together to help make our world a better, healthier place for everyone—which itself is a radical idea—it requires radical nurses who practice radical self-care.
Nursing is the largest healthcare profession worldwide, yet continues to have the least direct influence on health policy. Within nursing we have people working in four categories: 1) direct service providers; 2) advocates who help make systems work better for people; 3) organizers who bring people together to change or create new systems; and my personal favorite, 4) rebels—people who speak truth to power and who agitate for radical change. The key is to recognize your own strengths, where you are most comfortable working at any given time in your career—but to also see the value in the range of roles played by different people. Because an effective social change movement and an effective, compassionate, and equitable healthcare system, require people—require nurses—working together in all of these roles.
The Yale School of Nursing may be small, but its graduates have an outsized positive impact on the healthcare system, here in the US as well as globally—and even in terms of planetary health. Graduates: you don’t have big nursing shoes to fill, you have your own shoes, your own important career paths to blaze.
MY HOMETOWN OF RICHMOND, Virginia is a city anchored to its past by bronze and marble Confederate shrines of memory, by an undying devotion to the cult of the Lost Cause. I was born and raised in the furrowed, relic-strewn Civil War battlefields on the city’s tattered eastern edge. A captive of its public schools, I was taught official Virginia history from textbooks approved by the First Families of Virginia. But I came to understand the shadowed history of my state by caring for its homeless outcasts.
These lessons began while I was in nursing school. The modern hospital of MCV curled around the former White House of the Confederacy like a lover. My clinical rotations were nearby in the crumbling brick former colored-only hospital, which then housed indigent and homeless patients as well as prisoners. Most of these patients were black, so I called it the almost-colored-only hospital. The prisoners, shackled to their beds and accompanied by brown-clad armed guards, were from the State Penitentiary located across town. One of my patients was a death-row inmate. When I spoon-fed him his medications, I was simultaneously afraid for my own safety and ashamed of being an accomplice to murder. I knew I was nursing him back to health only to return him so he could be killed by the state. I wanted to talk to him, ask about his family, about his life in and outside of prison, but the stone-faced armed guard loomed over me. I knew from experience not to discuss my ambivalent feelings with my nursing instructor. She considered these to be inappropriate topics. I wanted to finish nursing school as fast as I could, so I kept silent. (From the chapter “Relics” in Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, pp. 57-58).
These words—my own words— have come back to me this week as I followed the news of contested sites of memory, of whitewashed Civil War memorials literally being fought over once again in places like New Orleans and Charlottesville, Virginia—and perhaps soon in my hometown of Richmond, Virginia. In Charlottesville, white nationalists waved lit torches and chanted “You will not replace us” in front of a statue of General Robert E. Lee in a city park. (source: Associated Press, Washington Post, “Torch-wielding group protests Confederate statue removal” May 14, 2017). New Orleans has begun the removal of four Confederate monuments in the city, starting with the Battle of Liberty Place monument commemorating the Crescent City While League’s violent fight against desegregation of the city’s police force—in 1876 during Reconstruction. (source: Christopher Mele, New York Times, “New Orleans Begins Removing Confederate Monument, Under Police Guard” April 24, 2017).
Richmond, as the former Capital of the Confederacy, likely has the largest collection of statues to Confederate “war heroes” of any city. I took my driver’s test on the then still cobblestoned streets of Monument Avenue, a five-mile long stretch of tree-lined divided grand boulevard punctuated by traffic circles around five towering statues of civil war heroes. A sixth and very controversial statue was added in 1996 at the far western end of the avenue—of native Richmonder Arthur Ashe (1943-1993). Besides being an international tennis star, Ashe was also a civil rights and HIV/AIDS activist, and a champion of urban health equity work. His memorial statue on Monument Avenue portrays him standing, holding books in one hand (he was also an excellent student and UCLA college graduate) and a tennis racket in the other hand. In the statue, he faces west, away from the Confederate statues. When Ashe was growing up in segregated Richmond, he was barred from playing tennis in the city’s whites only parks—and, ironically, he also would have been barred from even walking down Monument Avenue, a whites only residential area.
Since Monument Avenue in Richmond is a designated national park and indeed, is the only national park to consist of city street, it is unlikely that any of the Confederate statues will be removed anytime soon. But perhaps it is time to rename the street Memorial Avenue. This idea comes from University of Richmond professor of philosophy Gary Shapiro in his NYT opinion page essay “The Meaning of Our Confederate ‘Monuments'” (May 15th, 2017). Shapiro points out that records of city planners of the Confederate “war hero” statues on what would become Monument Avenue, “show that they meant to legitimize and dignify the white supremacist regime that had taken hold in Virginia.” He quotes philosopher of art Arthur Danto who states, “We erect monuments so that we shall always remember, and build memorials so that we shall never forget.”
Instructive and remarkably prescient here are words of Henry James, in his travelogue book The American Scene, in the chapter “Richmond” about his visit to Richmond in the late winter of 1905. A late snowstorm prevented him from traveling very far from the center of Richmond, but he describes his walk to the then newly developing Monument Avenue and the statue of Robert E. Lee (erected in 1890). James reflects on his visit to Richmond and writes:
“History, the history of everything, would be written ad usum Delphini—the Dauphin being in this case the budding Southern mind. This meant a general and a permanent quarantine; meant the eternal bowdlerization of books and journals; meant in fine all literature and all art on an expurgatory index. It meant, still further, an active and ardent propaganda; the reorganization of the school, the college, the university in the interest in the new criticism.” p. 374 Henry James, The American Scene (London: Chapman and Hall, Ltd).
My own then budding Southern mind, educated in the Virginia public schools of Battlefield Park (named for the Civil War Battle of Cold Harbor) Elementary School, Stonewall-Jackson Junior High School, Lee-Davis High School—and then VCU/MCV nursing school—was negatively affected by that still-lingering, ardent, white supremacist propaganda. Through my father I am related to Varina Davis, First Lady of the Confederacy. That legacy, and the work that I have done and continue to do to actively resist racism, is something I do not want to forget.
The American Nurses Association has declared this National Nurses Week (May 6-12, 2017) theme as “Nursing: The Balance of Mind, Body, and Spirit” to accompany their designation of 2017 as “The Year of the Healthy Nurse.” To help nurses celebrate the week, a host of businesses are offering “freebies” to nurses, including 1,000 calorie cinnamon rolls. I have nothing against high-calorie baked goods, but to celebrate nurses I recommend books and inkpots. Books, as in real books by real nurses (my current favorites listed below). And inkpots? I explain that in the following excerpt from my upcoming commencement address to graduates of the Yale School of Nursing:
“Thank you for this opportunity to speak to you about a topic I am passionate about: nursing. But not traditional nursing—not the Lady with the Lamp during the Crimean War—and not the white uniform-clad nursing angel of Hallmark moments. About that nurse angel, to paraphrase Virginia Woolf and her similarly stifling angel of the house: whenever you feel the shadow of her wings or the radiance of her halo, take up the inkpot or whatever modern equivalent is nearby and fling it at her. Because nurses are flesh and blood people. Nurses are not supernatural beings. We, as nurses, are human beings. Today, I want to talk to you about the real life transforming and transformational nursing of which you are all a part. I want to talk to you about radical nursing. And about the radical self-care it takes to be a radical nurse.”
I have always bristled at the mention of nurses as angels and included this pet peeve of mine in a previous blog post from January 10, 2016: “Sick Nurses.” So I was delighted to run across a poem, “Killing the Nurse in the House,” by nurse and poet Cortney Davis. I had the pleasure of reviewing her forthcoming collection of poems, Taking Care of Time(Michigan State University Press), which won their Wheelbarrow Books Poetry Prize. This is the endorsement I wrote: “Searing and unsentimental, the poems of Cortney Davis serve as haunting and truth-telling companions. Whenever I am in need of inspiration or of reconnecting with compassion and with all it means to be human, I return to Davis’s ’stories tamed on the page.’ Although, as in her poem ‘The Snake Charmer,’ Davis knows her poems connect us with the wild, untamable places of our lives.” Taking Care of Time avoids the overly religious (to me) themes that have appeared in some of Davis’ recent writing. It will have a permanent place in my home library once it is published.
My current favorite “Real Books by Real Nurses” (and yes, I do include my own and yes, I do realize that this is not a very diverse group of authors and welcome suggestions of books I may not know about):
The opening keynote speaker was Scott Montgomery, a geoscientist and lecturer in the UW Jackson School of International Studies and author of numerous books, including The Chicago Guide to Communicating Science(University of Chicago, 2003). For his talk, titled “A Story in 25 Images,” he practiced what he preaches by using PPT for showing a series of images to accompany a story (with a traditional narrative arc) of his journey as a communicator of science. Most of his images were abstract geology sorts of themes, but the ones that included human images portrayed only white men in suits. Yes, I was wearing my critical feminist academic bonnet, and yes, there were many women and persons of color in the audience. One young female attendee pointed out in the Q&A session that women within the academy face significant barriers, not just to entering science fields, but also to have non-traditional, public-facing and public-engaging scholarly work—barriers faced by men as well but to a lesser degree. And this is not only a gendered, but also a “minoritized” (her term and one that I like) issue.
The middle part of the day’s workshop consisted of panel discussions and break-out sessions focused on various issues of working with the media in all its varied forms—from TV and newspapers to podcasts, blogging, and other types of social media. I moderated a lunchtime round table discussion on academic freedom and public scholarship, two overlapping topics close to my heart. I didn’t share this in the session, but I have had to fight to defend my academic freedom in terms of this blog over its now seven year history. And public scholarship, such as what I do in my work on health and homelessness? It would seem that it is not deemed “nursing science,” whatever that term even means. But hopefully that is a cohort effect that will change for the better.
I was part of the final panel, “Navigating the Path from Research to Public Policy,” along with Dr. Simone Alin from UW Oceanography and NOAA; Washington State Senator Rueven Carlyle;Sally Clark, former Seattle City Councilmember and current Director, Regional and Community Relations, External Affairs at UW; and Tim Thomas, with the Urban@UW Homeless Initiative. The moderator’s question to the three of us panelists who are researchers was, “Can you tell us a little about how you’ve been involved in informing policy-making through your research.” Indeed, I can and I did, including a mention of my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, which is research-informed and is written as a policy narrative—policy narrative being defined as ” a new genre of writing that explores health policy through the expression of personal experiences” by the editors of the Narrative Matters section of the health policy academic journal Health Affairs. Narrative Matters needs better inclusion from nurse writers, but that is another story for another day.
“I did a lot of foot care at the clinic… Of course, it had its Biblical roots, but there was something about foot washing that most people found comforting and even pampering…I knew that having your feet cared for could somehow make you feel better all over…Almost all the homeless patients I saw had foot problems. They had to walk around town to get to different agencies, meal sites, and day-labor pools. They walked in the rain and the snow and the heat, usually in ill-fitting, secondhand shoes with dirty, holey socks, and carrying heavy backpacks.”~ from my bookCatching Homelessness: A Nurses Story of Falling Through the Safety Net, pp 86-87.
In this excerpt, I was referring to homeless patients I cared for when I worked as a nurse practitioner at the CrossOver Clinic in my hometown of Richmond, Virginia in the mid to late 1980s—over thirty years ago. But I could be (and indeed, am now) writing about currently homeless people and foot care here in my adopted hometown of Seattle, Washington.
There is this brief part of a haibun (prose mixed with haiku) reflection I wrote after helping with a foot clinic at ROOTS Young Adult Shelter in the University District near where I work: “Tonight in the homeless shelter a 19-year-old man from Georgia says, ‘My momma always told me not to go barefoot and I didn’t listen. That’s why my feets so bad. And I have to walk everywhere on them now.’ He reaches down and gently rubs his brown gnarled feet soaking in a white plastic basin. His feet are darkly scarred and calloused: the feet of an old man.
And there is this description of a foot care clinic I helped with at Mary’s Place, a downtown Seattle women and children’s homeless drop-in center: “The most delightful—and tender—foot clinic patient we had that morning was the petite three-year-old daughter of a young North African immigrant mother. The child pushed around a pink plastic toy shopping cart from the shelter’s playroom, and she wore a dress, bright striped tights, black Mary Janes, and a huge pink feather boa around her neck. She came and sat on a metal folding chair while one of the students washed her mother’s feet. The little girl wanted her own feet to be given the same attention, so her mother removed her shoes and tights. Baby toes! So cute!… I wanted to scoop her up and protect her from the traumas, the abuses of the world. But, of course, I knew I couldn’t do that. It made me sad to watch her toes curl up in delight as she splashed her feet in the basin of soapy water.”