I was at the point of leaving oncology. And there was one story in particular about an AIDS patient, and the doctor feeling like he had nothing to offer. Sometimes we [nurses] feel like we don’t have anything to offer ... And [now] I don’t feel so all alone and I needed that. I feel like it [the story] probably kept me in oncology. And I’ve been able to share [it] when I see others go through the burn-out symptoms.
In 2004, we (a program officer with a state humanities council and a practicing RN) teamed up to pilot a Literature & Medicine: Humanities at the Heart of Healthcare® program at a community hospital in North Carolina. We expected the program would have a wide appeal, and it did. Unit secretaries, certified nursing assistants, physicians, nurses, librarians, administrative staff and pharmacists were all represented in the pilot. We were also fairly sure that the program would offer a structure for these health care professionals to reflect on their work and perhaps find some common ground across disciplines as well as race, class and gender. But, what we didn’t fully anticipate was that that would be only part of the equation. Comments we heard right after each discussion session, and later, while working on the hospital floor, and even later, during post-program evaluations, revealed that almost all of the participants had been moved in unexpected ways; some even said they were profoundly changed by it.
“When I see one of the other Lit & Med people in the hall now, there’s a real connection between us that others have noticed ... [the program] helped me understand that other medical people go home and feel the same pain, or same disappointment, or discouragement and sadness for patients [that I do].”
Why, we wondered, might this be the case? We have participated in various kinds of reading and discussion groups before, but we have never seen the kinds of transformations suggested by the quote above. Is there something in the nature of health care practice that gives literature a surprising power? And, if so, is there anywhere this is needed more than in health care today? Certainly these are not new questions; almost everyone we have spoken with who has been involved in Literature & Medicine for any length of time has wandered along these lines of inquiry. But having witnessed it first-hand, we wanted to try not only to make some sense of our experience, but to also place it in a larger context of meaning by focusing on one particular group of health care professionals. Given that one of us is a nurse, it makes sense to focus on that profession. This short article is our attempt to open a discussion about the program’s particular value for hospital nurses, for we believe that Literature & Medicine offers a unique renewal experience, one that is particularly relevant to nurses.
In nursing schools all around the country, emerging professionals are taught that their approach to medicine should be holistic; that they ought to “think big,” in ways that take into account the emotional and spiritual needs of their patients as well as their physical condition. The profession is built upon the premise that intuition and empathy are as important to patient care as technical skills. And it is precisely this potential, to simultaneously practice art and science, which attracts many to the profession today. Indeed, as a society, we are invested in this image of nurses. We want them to be compassionate, smart and skilled in what they do. We want nurses to see us as more than a set of medical problems. We want them to connect with us as human beings.
But what nurses experience when actually working in hospitals (and other settings, for that matter) challenges, and more often fails to nurture, this connection of heart and mind. There is a serious gap between the theories and methods of practice that nurses learn in school and the realities of the hospital clinical setting. The reasons for this are far too complex to explore in any depth here, but our experience suggests that there are at least three important factors worth mention.
First, many hospitals are facing severe financial constraints. As one hospital nurse recently told us, it’s pretty clear that hospitals “have to have their eye on the bottom line. They are geared toward getting the patients in and getting them out.” Given this, continuing education for nurses is more likely to invest in improving technical skills for treating the patient’s body, than to address the role nurses may have in the patient’s emotional and/or spiritual health. The latter is seen as something extra, nice if you can get it, but not necessary to positively affect patient outcomes.
The second reason lies in the sheer pace of hospital nursing practice. It is not unusual for nurses to be on their feet for twelve, thirteen, even fourteen hours at a time. Their days are spent treating patients, dealing with concerned family members, and negotiating within power relationships with physicians. It is physically grueling, mentally demanding, and sometimes heartbreaking work that leaves no time and place to stop, to reflect on practice, to feel and process the pain of this work.
Third, the culture of hospital nursing includes an expectation that nurses will preserve an emotional distance from patients. If a nurse gets “too close” to a patient and/or family, he or she risks informal admonishment (or worse, pity) from fellow nurses and may experience a sense of shame. It takes an internal toll to quash those feelings, and at the same time, makes it difficult to cultivate human compassion for a patient’s sufferings and fears.
All three factors — lack of continuing professional development in holistic nursing, the fast pace of hospital nursing, and the implicit code among nurses that feelings should not be shown — collide in the nurse’s everyday experience on the hospital floor and make it difficult for the “traditional” model of nursing to thrive. As the opening quote suggests, and our observation of hospitals supports, many nurses become isolated and burnout in these conditions. Our experience with the Literature & Medicine program suggests that it provides a way to bridge the gap between what nurses strive for professionally and the realities of their professional lives.
In the winter of 2004, the North Carolina Humanities Council organized a pilot of the Literature & Medicine program in a local community hospital. Once a month for six months, nurses came together with other medical professionals and workers to discuss their viewpoints, experiences and reactions to the stories. And they came prepared to talk about how those narratives connected to their experiences, memories and states of mind. One nurse later told us: “I was just interested in talking to other people in the medical field, to see if they had some of the feelings I have.” From the very first session, people shared with remarkable candor in ways that said this was a time and place where it is appropriate to talk about what you dared not otherwise.
By the end of the pilot, it was clear that strong bonds had formed among participants, bonds that are still visible almost a year later. As one nurse recently told us, “When I see one of the other Lit & Med people in the hall now, there’s a real connection between us that others have noticed ... [the program] helped me understand that other medical people go home and feel the same pain, or same disappointment, or discouragement and sadness for patients [that I do].”
After the pilot concluded, Dr. Susan Letvak, a nurse specializing in narrative research at the University of North Carolina, Greensboro, conducted a focus group evaluation of the program. She asked participants how it influenced their practice. “Their comments,” she wrote, “spoke to how beneficial the program was for not only their patient care, but also for their interpersonal relationships at work.” For instance, a nurse reported that Anne Fadiman’s book, The Spirit Catches You and You Fall Down, (about the fundamental lack of understanding and communication between a Hmong family and the western medical system in a struggle to help an epileptic child) influenced how she works with non-English speaking patients. “We have a lot of Spanish people and a lot of Vietnamese people around us every day and it [the story] makes me wonder now ... [do they understand me]? I have changed how I approach them and their understanding of their care.” That same story helped another nurse consider “some of the biases” she had. “I think it helped me get some of those behind me a little bit. And I think I’m a better nurse now ... I have my patience back and tolerance and a little better understanding of some people that I probably would have judged differently before.”
As Dr. Letvak told us, “The impact the program made on the individual’s practice was most impressive.” There was a lot of enthusiasm for the program when it began. After the first program, participants “couldn’t wait for the next one.” And, as time went on, “... it got better. I mean I looked forward to it. You know, I was really pushing myself to make sure that I got my reading done because ... I wanted to see everybody again. I enjoyed it. I really did.” When asked if she would participate in the program again, a nurse quickly replied “in a skinny minute.” We pressed her-why? “Why would I do it again? It was a place, a safe place to share experiences and emotions that you don’t have time for on the floor. And just because you don’t have time for them, doesn’t mean you don’t experience them on some level. The stories helped me bring forward past experiences that I had left behind and not dealt with or had time to reflect on.” Quite simply and yet remarkably, the Literature & Medicine discussions were the only place this could happen and that, she said, “makes it invaluable.” Another participant summed it up beautifully; Literature & Medicine was, she said, “a mind experience.”
Frankly, our pilot illustrated that we know but a little about the potential impact programs like Literature & Medicine have for hospital nurses. Obviously it would take more investment on our part to figure out and demonstrate if, how, and to what degree such a program could benefit nurses in NC over a long haul. But, without question, hospital nursing is in crises, and anecdotal evidence suggests that Literature & Medicine plays a substantially positive role in nursing practice; indeed one that can re-energize and even transform nurses. Given a choice, said one nurse, “If I’m ever in the hospital, I want a nurse who’s gone through the [Literature & Medicine] program.” Clearly she believes the program makes for better nurses, and who could be a better judge?
What would you like future feature articles to explore? Send us your ideas! Email Lizz Sinclair.
Literature & Medicine has received major support from the National Endowment for the Humanities.