Nurse Log: A Winter Solstice Gift of Quietude

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A decorated nurse log (stump) on Orcas Island, Washington. Photo credit: Josephine Ensign/2015

Recently, I spent a week ‘off the grid’ on a solo writing retreat at one of my favorite places on earth: Orcas Island in Washington State’s San Juan Islands. In my experience, going off grid, off e-mail, off social media, off any news is both deeply restorative and refreshingly loopy. Restorative, of course, because the electronic umbilical cord connection with the world creates a constant anxious buzz that is typically only apparent when it is absent. Refreshingly loopy because the cessation of that baseline buzz creates space for our brains to make sudden strange connections and leaps into uncharted territory.

One of these loopy leaps for me happened through the nurse log. Anyone who has ever lived in or traveled through the soggy, glacial-scoured forests of the Pacific Northwest, is familiar with the term ‘nurse log’–an example of which I include in this post. Nurse log, as in a decaying part of an older tree (log, or stump, as in this photo) that provides the ideal environment of moisture and nutrients and even shelter from competition, for a new tree to start its life. An example of resilience, adaptation, and thriving in the face of adversity. An example of the circle of life.

A metaphor for where I am in my nursing and teaching career: on sabbatical, gone fishing, taking a break, lying fallow and untilled, at least from my usual clinical and teaching responsibilities. More time to study important things, like the state of homelessness, the role of narrative in health and healing, the history of charity health care–and the lifecycle of evergreen trees. More time for travel–not to faraway lands–but to places right here at home. More time to cultivate and appreciate quiet.

It strikes me that we don’t allow enough space and time for quiet. We now recognize the importance of quiet in hospitals to allow patients to heal from illness, trauma, and surgery–although actually providing this for patients is spotty at best. I was reminded by Health Care for the Homeless, Seattle/King County Public Health nurse Heather Barr recently that emergency and transition shelters for people experiencing homelessness are often chaotic and cacophonous places. She advocates the addition of quiet rooms and quiet hours when she works with shelter staff around implementing trauma-informed care. People who are struggling with PTSD are often triggered by noise. I’ve often observed the role of a healing quiet space in public libraries for homeless and marginalized people who otherwise don’t have such sanctuaries. As health care providers, as caregivers, as teachers we should remember the gift of stillness and of quiet.

I am a Nurse, Just a Nurse

11164759_1057759667571978_8700043668876075012_nFor many years, whenever anyone said to me, “Oh! You’re a nurse,” I would correct them and say, “No, I’m a nurse practitioner.” Why? As if identifying myself as a nurse was somehow beneath me? As if being a nurse practitioner meant I wasn’t really a nurse, or I was more than a nurse because I could diagnose and treat medical problems, something nurses can’t do? As if I was too intelligent to be ‘just’ a nurse?

I was not born to be a nurse; I was not called to be a nurse. I didn’t need multiple-choice tests and multiple sessions of career counseling at pivotal junctures in my life to tell me these facts. What with the Myers-Briggs Type Indicator, the Strong Interest Inventory, the Eureka Skills Inventory, and the Holland Personality test results, my career counselor proclaimed, “You don’t have the personality, the interests or skills test results to match nursing.” It seems I was meant to be a writer. Oops. Too late. When she told me this I had already been a nurse/nurse practitioner for over thirty years. Of course, it was my job as a nurse practitioner and nurse educator (and most definitely not as as an unpaid writer) that allowed me to take these expensive tests in the first place.

But oh the places nursing has taken me! If I had it all to do over again, if I didn’t have to worry about being a single mom earlier in my career trying to earn a decent income, if I could choose any of the health professions to ‘become,’ I would choose to be a nurse. I would choose to be the ambivalent, skeptical, social-justice minded, community/public health-focused nurse that I am. Last summer I reflected on where community health nursing has taken me, and I made this short digital storytelling video: “My Story of Community Health Nursing.”  Even though this was my first video, and I see that it is clunky in places, I revisit/re-watch it on occasion to remind myself of who I am, and of why I love to do the work I do–including teaching nursing students and encouraging them to consider becoming a community/public health nurse.

The photo included in this post is a ‘retouched’ photo of a University of Washington School of Nursing promotional placard reading “I am a #huskynurse.” It’s not that I’m opposed to proclaiming myself an over-sized, plump nurse. But I am opposed to being a (branded) nurse. I am an–unqualified– nurse. I am a nurse. I am a community/public health nurse.

Happy National Nurses Week and Happy 195th birthday to Florence Nightingale!

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“Just a Nurse” is used with a nod to the work of Suzanne Gordon, a journalist who writes about/is a longtime advocate for nursing.

Dear Nursing Grads: Even More Reasons to Go Directly Into Community/Public Health Nursing

urbanleagueWay back in the not-so-groovy 1980s when I graduated from nursing school, all of my nursing instructors told me I would have to work in a hospital setting for several years before being able to work in community/public health, which is what drew me to nursing to begin with. Thankfully, I did not listen to them and went straight into my first nursing job as Hypertension Nurse Coordinator for the Richmond Health Department. This is a photo of me wearing my requisite navy blue public health nursing duds and shaking hands with then Virginia Governor Chuck Robb. I was in his office that day with the Richmond Urban League staff with whom I worked on community-based hypertension control projects in churches. I loved my first job as a public health nurse and I have continued to love all my subsequent community/public health nursing jobs since then. I would have made a miserable hospital nurse and most likely would have left nursing altogether if forced to work in a hospital. To be clear, I have nothing against hospital nurses (and indeed they have saved my life in the past!), but the community is where my passion lies.

Why are nursing instructors still telling nursing students that they have to work in a hospital setting upon graduation? Is it because this is what they were told and they don’t question it? Where in the world do they get this silly and completely outdated notion that hospital nursing experience is the only experience that makes for a ‘real nurse?’ Why would a nurse with hospital experience make for a better community/public health nurse? And why are we still educating nurses almost exclusively in acute care/tertiary care hospital settings?

In a 1961 New England Journal of Medicine article “The Ecology of Medical Care,” Kerr White wrote about how serious questions could be raised about medical and nursing students’ clinical experiences in academic medical center hospitals–giving them a limited and biased view of the health care needs of a community. “Medical, nursing, and other students of the health professions cannot fail to receive unrealistic impressions of medicine’s task in contemporary Western society” (as quoted in Thomas Bodenheimer and Kevin Grumbach’s Understanding Health Policy: A Clinical Approach, McGraw-Hill, 2012). Surely in ‘modern’ nursing education we could easily find more community-based clinical rotation sites in areas like pediatrics, OB/GYN, psych, and chronic disease and transition care. The 2010 Institute of Medicine’s Future of Nursing report admonished us to do that; four years later I see no concrete improvements in this area.

I’ve written about this topic before and refer you to the still relevant blog post from 2012, Dear Grads: Please Go Directly Into Community/Public Health Nursing. Along with the advice and links to resources I gave in this previous post, I add the following:

  • We need to make it easier (and preferable) for pre-nursing students to gain volunteer experience in outpatient and community settings and not simply send them to the closest hospital to be modern-day Candy Stripers. Here in Seattle some rewarding (based on student feedback) community-based health care volunteer opportunities are with the 45th Street Homeless Youth Clinic, Bailey-Boushay House (HIV AIDS and hospice care), and Needle Exchange programs.
  • Nursing students can add to their community/public health toolkit (and hence, boost their employment opportunities) by seeking out extra trainings in community/public health-related topics. For instance, the Institute for Healthcare Improvement’s Open School Professional online course “Introduction to Population Health” is an excellent resource (and is free when your school is a member). Another great (local) resource I use in my teaching is the free online certificate trainings offered through the University of Washington’s Northwest Center for Public Health Practice.
  • In addition, I highly recommend that nursing students (and all nurses) attend an Undoing Institutional Racism workshop by the People’s Institute Northwest. The People’s Institute for Survival and Beyond is a national program with headquarters in New Orleans. If you don’t live in the Seattle area check out their website for links to upcoming trainings in your area. Our school uses their Undoing Racism workshop as a required diversity course since it is so powerful and professionally done.
  • Learn another language if you don’t already know one! Take a medical Spanish course. Participate in a travel immersion course or experience, especially if it focuses on some aspect of community health or social well-being.
  • Go straight into community/public health nursing if that is where your heart is!

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?

Weekend Writing Retreat for Nurses/NYC

Here is a terrific writing retreat geared for nurses. I took a writing workshop this past April with Joy Jacobson and Jim Stubenrauch (at U of Iowa’s Examined Life conference) and can attest to the fact that they are wonderfully supportive teachers.

From the Center for Health, Media & Policy at Hunter College (CHMP) HealthCetera blog:
Weekend Writing Retreat for Nurses
by Jim Stubenrauch
If you’re a nurse who writes or one who wants to write, please join us for Telling Stories, Discovering Voice: A Writing Weekend for Nurses, to be held July 19-21, 2013 in New York City. This is a chance for all nurses and nursing students to strengthen and expand their capacity to write in a variety of modes and genres, including personal essays, poetry, and fiction, as well as blog posts and articles on clinical and health policy topics. We’ll write together in a safe and supportive environment, share our writing aloud, offer encouragement and constructive feedback, and discuss the role of narrative in medicine and nursing. We’ll also examine the potential for using social media as a public-health tool.

The conference will be led by CHMP poet-in-residence Joy Jacobson and senior fellow Jim Stubenrauch. This special event is co-sponsored by the Center for Health, Media & Policy at Hunter College (CHMP) and the Hunter-Bellevue School of Nursing, and is offered as part of the CHMP’s program in Narrative Writing for Health Care Professionals. Participants will receive 17 continuing education units.

We’re very excited that Karen Roush, clinical managing editor of the American Journal of Nursing and the founder of The Scholar’s Voice, will be the keynote speaker. Karen has extensive experience as a writer, teacher, and nurse and has published books, scholarly articles, personal essays, and poetry.

The price for the conference (including continental breakfast and lunch each day) is $675 + $20 registration fee until July 1; $725 + $20 fee after July 1. Groups of six or more from one institution receive a discount price of $575/person. Students receive a 20% discount. Register for the event online at https://ceweb.hunter.cuny.edu/cers/CourseBrowse.aspx. (In the “Search Courses” window at the upper left, enter course code SEMTSDV.) Or call 212 650-3850.

Want to know more? Check out these two blog posts about last summer’s workshop: in the first, attendee Patricia Wagner Dodson, BSN, RN, MA, CCRN wrote that “in this workshop community of real nurses and real writers, a consensus seemed to emerge: the stories need to be told. The workshop was the beginning of the telling.” In the second, I shared some of my own impressions of the weekend, with excerpts from pieces written during and after the workshop by two other participants, Karen Hardin, MS, RN and Amy Dixon, BSN, RN.

Becoming a Nurse: The Events

becominganurseThis week Jane Gross in the NYT wrote a nice review of the new book I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse, edited by Lee Gutkind (In Fact Books, 2013). The title of the book review is  ‘Semi-invisible’ Sources of Strength, referring to the fact that nurses are often the un-sung, un-heard, un-seen cast members in the grand drama that is modern medicine. Semi-invisible sources of strength: I suppose then that nurses are to health care what the backbone is to the human body? Lumpy and bumpy, semi-visible through the skin, at times painful? OK, I’ll stop with the analogy.

In the days following the NYT book review, True Stories of Becoming a Nurse quickly became one of their top sellers. In the past day it has been in the top 20 on Amazon. Fascinating to see the book filed under “healing,” “spirituality,” and “personal transformation,” as if it belongs in Whole Foods next to the crystals and incense and socks made of recycled bamboo. Thanks Jane Gross for writing the review and thanks NYT for including it. That Ms. Gross focused her review on the old old and seriously tiresome rift between diploma-trained and university-educated nurses in tertiary care settings is unfortunate—but understandable given that she was writing the review as a testament to her diploma-trained RN mother. I get it; I’ll move on to more important topics.

Our University of Washington (with support from 4Culture)-sponsored Becoming a Nurse book launch on April 18th at Suzzallo Library in Seattle was a great success. We had a total of five nurse author panelists who read from their anthology essays. Many, many thanks to the four panelists (Kim Condon, Eddie Leuken, Lori Mulvihill, and Karla Theilen) who paid their own way out here to attend the event. I only had to ride my bike two miles in the rain to get to the event—several of the other panelists flew in from across the country). Many, many thanks as well to the mighty team of UW Health Science librarians (Tania Bardyn, Lisa Oberg, Joanne Rich, and Janet Schnall) for organizing, hosting, and recording the event. The video recording of the readings is here . Note that the audio quality is much better than the video but you can see our general shapes as we read!. You can’t see the wonderful audience but they packed the room—standing room only. Thanks all you supportive audience members!

In case you missed the UW Suzzallo Library Becoming a Nurse event, we will have another Becoming a Nurse reading next month (Tuesday June 11th, 7pm) at Elliott Bay Book Company in Seattle. I will be reading along with Eddie Leuken and Karla Theilen). All three of us will read excerpts from our anthology essays, as well as new work.

This Friday (May 24th) at 6:30pm I’ll be reading at the Northwest Folk Life Festival in Seattle as part of the 2013 Jack Straw Writers Program. (6:30-7:30pm SIFF Cinema/Narrative Stage). Kathleen Flenniken, poet laureate of Washington State will be the host/KUOW sponsors the event. I’ll be reading from new work from my collection of poetry and prose I’m working on called Soul Stories: the stories feet can tell about the journey of homelessness. In the essay I’ll read I ask myself (and partially answer) the questions: why am I drawn to the suffering of others? Why have I spent the past thirty years working as a nurse with homeless and marginalized people? Wouldn’t I be happier if I was drawn to work as a shoe buyer for Saks Fifth Avenue? Questions I am sure many nurses and others in helping professions ask themselves.

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The following is the press release for the book.

I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse
Edited by Lee Gutkind
Featuring new work by Theresa Brown, Tilda Shalof, and others.

 

As editor Lee Gutkind points out in the introduction to I Wasn’t Strong Like This When I Started Out, “there are over 2.7 million working RNs in the United States (not to mention our many LPNs and LVNs), compared to about 690,000 physicians and surgeons. There are more nurses in the United States than engineers … or accountants and auditors … And, yet, many of us take the work these men and women do for granted.”

 

This collection of true narratives captures the dynamism and diversity of nurses, who provide the vital first line of patient care. Here, nurses remember their first “sticks,” first births, and first deaths, and reflect on what gets them through long demanding shifts, and keeps them in the profession. The stories reveal many voices from nurses at different stages of their careers: One nurse-in-training longs to be trusted with more “important” procedures, while another questions her ability to care for nursing home residents. An efficient young emergency room nurse finds his life and career irrevocably changed by a car accident. A nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS, and a home care case manager is the sole attendee at a funeral for one of her patients. What connects these stories is the passion and strength of the writers, who struggle against burnout and bureaucracy to serve their patients with skill, empathy, and strength.
Pub. Date: March 2013, ISBN: 978-0-393-07156-6, 5 ½ x 8 ¼, Trade Paper, 278 pages,
$15.95, Distributed by Publishers Group West

 

Lee Gutkind has explored the world of medicine, technology and science through writing for more than 25 years. He is the author of 15 books, including Many Sleepless Nights: The World of Organ Transplantation, and the editor of five anthologies about health and medicine, including At the End of Life: True Stories About How We Die.

In Fact Books is a new imprint founded and edited by Lee Gutkind, editor and founder of Creative Nonfiction. In Fact Books titles help create an understanding of our world through thoughtful, engaging narratives on a wide variety of topics and real-life experiences. All titles are distributed by Publishers Group West. For more information, please visit http://www.infactbooks.com.
For interview requests and other media related questions, please contact:
Hattie Fletcher at fletcher@creativenonfiction.org or (412) 688-0304.

 

Bedside Nursing

British nurse in nurses' station.
British nurse in nurses’ station. (Photo credit: Wikipedia)

Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.

Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.

Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.

Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.

Then there is the fact that hospital-based jobs for nurses are rapidly disappearing as hospital administrators reduce their nursing staff, and as more hospitals merge or close altogether. Some experts claim that one-third of all hospitals in the US will close by 2020 (see David Houle and Jonathan Fleece’s post on KevinMD. 3-15-12)

Bedside nursing is probably a term that needs to be, well, put to sleep.