The America That Is Not For Me: Part 25

Nursing Foundation was the class, one of my favorite nursing courses.

We read Theresa Brown’s The Shift: One Nurse, Twelve Hours, Four Patients' Lives, an extremely important book I think showed up too late in my nursing education, for Nursing Foundation. I have come to see this book as one of those major works aspiring healthcare professionals, especially nurses, should read with absolute seriousness if they are to gain a deeper understanding of the political nature of the U.S. healthcare industry and the demanding complexion of the nursing profession. In reviewing this work for my international readership, I wrote Kwarteng (2017):

In a nutshell, the book eloquently celebrates nurses and their enormous impact on the healthcare system in terms of the delivery of quality care and generally, of improving health outcomes for patients, as well as man's responsibility toward his fellow man—a critical celebration of our humanity for short…

No doubt this is a must-read book that should be on required reading lists for medical/health science and social work programs, in spite of my reservations about and rambling critique of it, even while I also submit that current nursing curriculum development should include formal instructional and didactic directions on nurse-doctor teamwork and collaboration which nursing and medical students are supposed to learn.

However, the foregoing parenthetic remark is only natural from the point of view of the contextual calculations of a tendentious reviewer like me who, very much like Ms. Brown, also wants to appreciate this complex and mercurial world, human life, and human dignity using the same critical lens as hers to reshape his grand vision of human caring, as well as to ease human suffering in both the short- and long-term. I believe these were what Jean Watson and Florence Nightingale fundamentally stood for.

Though the book doesn’t address the important question of how much physical, emotional and mental capital one might need to pull through the rigors and challenges of nursing education, it fired my imagination the same way Chinua Achebe’s Things Fall Apart, Ngugi wa Thiong’o’s Weep Not, Child, Ama Ata Aidoo’s Anowa and The Dilemma of a Ghost, Emily Brontë’s Wuthering Heights, and Thomas Hughes’ Tom Brown’s School Days did to me in high school. The Shift enthralled me so much so that on August 13, 2017, just after I had finished reading it, with an unbroken flow of effortful attention, I communicated my impressions about it to Dr. Fara Bowler:

Dear Prof. Bowler,
Good morning. Please how do you do?
Well, I bought a copy of Theresa Brown's book The Shift: One Nurse, Twelve Hours, Four Patients’ Lives and enjoyed reading it so much so that I even decided to review it for some seven international websites.

It is surprising that I used to follow her writings in the The New York Times but, unfortunately, never came across this book. Of course I have not been reading the Times as I used to when I lived in New York, before relocating to Colorado in 2012. Thanks for bringing this impressive and wonderful book to my attention (Please note: I will be one of your students next this fall).

And, here, I want to share this review with you (here is the link to the review article)…

Dr. Bowler replied the following day:
Wow. Extremely impressive, Francis. Wonderful work.

Do you write professionally?
You experienced everything that I was hoping for you from the book. Thank you for embracing it.

See you in a few weeks!
Thanks, Fara
I responded the same day:
Good afternoon Prof. Bowler,
Thanks so much for your response.
I read this wonderful book and realized that all my professors, teaching assistants, and the department as a whole are doing a great job teaching their students. As a matter of fact I suddenly became so proud of you all and the department.

And yes, I do write professionally…
Importantly, the trenchant and non-moralizing language of The Shift reveals a strong correlation between class-based didactic abstraction and the tricky praxis of occupational professionalism. I experienced the weighty complexity of this important question of correlation firsthand―a subtle variable in nursing education―as our instructors walked us through Nursing Foundation.

Further, the instructors of Nursing Foundation brought a rich tradition of clinical and didactic backgrounds, a long tenure of empirical tutelage―which students leeched off to sustain the intellectual élan of their collegiate existence, expert knowledge based on the operational dynamics of the patient- and family-centered clinical method, mastery of professorial presence and authority and pedagogy, and academic leadership to bear on producing quality and confident nurses.

The nursing faculty at Anschutz Medical Campus, University of Colorado, encouraged students to avail themselves of this high caliber suite of qualities tout de suite following their admission and subsequent socialization with professors and clinical instructors, to enrich their educational and clinical experiences as they lumbered through the thorny vines of their nursing education.

An additional factor pointing to the vast richness of faculty individuation brought out the best in students.

It was ultimately a student’s primary responsibility to harness the embedded resources of his or her emotional capital in response to the physical exaction of nursing education and to see to it that these immanent resources fitted in with the standard profile of faculty individuation for the student’s benefit and character development―intellectual, occupational and professional maturation.

Drs. Fara Bowler and Gail Armstrong taught this exciting class, Nursing Foundation.

In addition to teaching this didactic course, the Director of the Clinical Education Center & Simulation, Dr. Bowler, a Certified Healthcare Simulation Educator, was also actively involved in the experiential or clinical education of nursing students. However, it was her expertise in caring science, namely of wedding clinical instruction to the didactic method that made her stand out as a competent knowledge disseminator, a respected educator, and a formidable thinker.

Given that she was easy to talk to, that she was very respectful of students and their views, Dr. Bowler opened her office to students who were keen on sharing their stories and experiences. I’ve personally benefitted from the largesse of her esteemed extroversion, intelligence, and professorial warmth.

Dr. Bowler, one of my favorite professors, directed the Clinical Education Center (CEC) and Simulation Center.

Both centers offered clinical instructors and students alike ample opportunity to interact, to collaborate, and to review clinical scenarios and case studies as part of care strategies for patients of different age groups, races and ethnicities, language and cultural groups, religious and political persuasions, and nationalities in various clinical simulation contexts.

Students got to explore the challenges and benefits of participatory management, group dynamics―team and collaborative learning, logistical readiness and medication inventory management, active learning, intercultural communication, clinical skills/competency assessment, cross-cultural awareness, clinical professionalism, patient advocacy, clinical debriefing and performance evaluation, and safety issues―healthcare protocols and mock surveys.

Using these manifold tools to address questions of clinical assessment and patient care during mock emergencies in the Simulation Center didn’t always come easy or naturally to me due to the nature of my retiring disposition and relative uneasiness in and around crowded spaces. I could never consciously develop a facility for establishing a rapport with mannequin simulators, for I couldn’t bring myself to conceptualize any pragmatic relationship between human beings and mannequin simulators.

Mannequin simulators are soulless, inhuman―nonhuman.

And human beings aren’t nonhuman!
Besides, culture defines humans while humans still remain the unquestioned, seminal authors and creators of culture, unlike mannequin simulators!

Granted that communication is an essential component of culture, one has no choice but to grapple with the question of whether it is even possible for accultural human beings to communicate with non-cultural, lifeless mannequin simulators.

Thus insofar as the troika of intercultural communication, transnational communication and cross-cultural awareness is concerned, and effectively applying this theoretical troika to the praxis correlate of improving patient-centered outcomes went, Molefi Kete Asante’s and his colleagues’ The Global Intercultural Communication Reader provides the kind of analytic depth, methodological insight, and scholarly breadth that I couldn’t get from the nursing program although my professors, clinical and non-clinical, equipped us with the basic tools that we could use to effectuate improved patient care.

I did, however, avail myself of ideas from the research of Asante and his colleagues to make up for glaring shortcomings in didactic and clinical instruction. This may sufficiently explain how I managed to push myself beyond the limits of my formal nursing education―but more particularly of my clinical simulation experiences, for I wanted to attain a well-rounded education and a deeper understanding and grasp of clinical organization beyond the specialized narrowness of my nursing education.

It turned out that, contrary to my expectations, the ontological anatomy of healthcare simulation would send me to another strange multiverse where the anonymous voices of clinical instructors mediated the interactions between humans and the artificial world of mannequin simulators in incomprehensible ways.

The fact that these mannequins were grossly incapable of emotional expression, of organic physiologic individuation, of thinking, and of biomechatronic awareness of human touch, non-verbal and verbal communication, and emotions drove me to question research studies that consistently affirm the practical utility of simulation as a viable means through which the clinical education of nursing students supposedly gained on a sense of empirical attestation was, for me, an idea I found difficult to swallow.

For one thing, I couldn’t bring myself to appreciate or understand how those anonymous voices that became incarnate in clinical instructors before and after clinical sessions and during debriefing sessions were factored into the discursive contexts of these research studies. In other words a clinical instructor who was deemed theoretically sick, bedridden, and almost dying gained health and physical strength, and then became an integral participant in the debriefing process in the wink of an eye makes for magic rather than science, potentially calling into question the foundational methodological rigor upon which these research studies were constructed.

Thus, the mechanical suddenness of this transition and transformation from vocal or verbal anonymity to the physical and emotional presence of flesh and blood and vocality doesn’t sufficiently account for the supposed correlation one should expect between praxis and theory, especially when this is critically viewed within the broader context of clinical dramatizations of case studies.

And for another, how nursing students suddenly transitioned into professional nurses in the narrowest constraints of time while administering care under the weight of mock emergencies and even in less stressful clinical situations in the Simulation Center, disturbed the hypothetical equilibrium that one should expect to exist among the praxis of direct care strategies and didactic mobilization of the tricky instruments of human psychology and clinical instantiation of case studies.

Indeed, mock emergency and true emergency are drastically different in their degrees of chaotic perturbation, expectations and situational fuzziness and therefore, as might be expected, students’ likely psychological and hormonal responses to patients needing urgent care in a charged simulated learning environment, mock or true, will also naturally conform to a drastically different approach to organizational finesse and tactical prudence in relation to how students effectively deploy practice guidelines and practice standards in the heat of the moment.

My contention is that it’s practically impossible to assess let alone measure the impact of emotional exhaustion, vicarious and historical trauma, social and family support, psychological distress, secondary trauma, or compassion fatigue on nursing students―whether the particular clinical or learning environment they find themselves in is the CEC or the Simulation Center, or both, because students’ background or prior knowledge of their hypothetical patients―mannequin simulators in this case―and cases they might be working on several days before, including on the very day they execute their scheduled clinical assignments, removes any latent capacity to cause them psycho-emotional distress. Students in this case have elbowroom to negotiate themselves out of any perceived entanglement of psycho-emotional distress before presenting themselves in a simulated learning environment to carry out their scheduled clinical assignments.

The fact that the human element is absolutely missing at the juncture of the cadaveric details between mannequin simulators and human interactions adds to my layered concerns, and yet the faceless voices of clinical instructors who remained far removed from the spatial anatomy of the reality of clinical intimacy in the simulated learning environments we found ourselves in as nursing students, further complicated the highly touted simulation paradigm as the most efficient tool in the package for the clinical education of nurses, a contention I acknowledged elsewhere.

What’s more, the kind of mannequin simulators my colleagues and I worked with hardly represented all the major body types we see across the variegated spectrum of human anatomy―or of body habitus. How can I, for instance, effectively transfer the experiential knowledge on an endomorphic body type to mesomorphic and ectomorphic body types, and vice versa, in both simulated learning environments and real-life situations, say, in a hospital or clinic where accurate clinical knowledge of body types makes all the difference in patient satisfaction, dietary habits, safety, education and quality? How do I effectively handle the case of a sick mannequin patient that is also theoretically physically aggressive and gratuitously violent? How do I use a reflex hammer on a mannequin patient as part of a neurological and physical examination?

Using the same mannequin simulators of the same body type and skin complexion, white for the most part, for different diagnostic case studies across the color spectrum of white, black, Asian and everything in between simply didn’t make scientific sense. The fact that most of the mannequin simulators spoke flawless English ignored the changing demographics of the US. Why all the mannequin simulators we worked with remained bedridden in the same rooms all the while didn’t reflect the facts of clinical practice in the real world. Using the same mannequin simulator to represent youth, middle age, and old age in different clinical scenarios didn’t help matters either.

And yet simulated patients, that is, trained actors and actresses, could have been hired in place of mannequin simulators.

Though cost is a major factor that could not be ignored in considering whether to hire or recruit simulated patients for the job, one would not downplay the ontological and biologic closeness of simulated patients to patients in the real world.

In spite of the fact that simulated patients couldn’t still match real patients in absolute exactness, they were far better than mannequin simulators in terms of their close anatomic and physiologic approximation to human patients. I could also understand that mannequin simulators were reliable in one sense and one sense only, that they were always available for use at any time school was in session unlike simulated patients whose reliability wasn’t always a given.

But I guess the internal structures of case studies intended for clinical dramatization in the Simulation Center and the CEC should be radically redesigned to accommodate these considerations for purposes of conceptual clarity and existential attestation of material facts linking theory to praxis, in such a way that the student does not incur additional problems from procedural digestion of case studies by merely trying to instantiate or objectify complex abstractions.

Finally, performing clinical procedures such as capillary refill, pain and cardiopulmonary assessments, physical examination, subjective and objective questioning of a mannequin patient evidently don’t carry the same intimate feel of humanity when the faceless voices of instructors are transplanted into the vapid spaces of artificial existence.

These clinical considerations constituted themselves into a suit of nagging questions that had been sitting heavy on my stomach for some time now, a series of questions which the clinical lectures of Prof. Kathy Foss, a Clinical Development Coordinate at the Anschutz Medical Campus, attempted to answer.

Even so, clinical corollaries in the form of probing questions lingered in my mind so long as these nagging questions remained insufficiently accounted for within the context of my particular experiences, both in simulated and off-site clinical environments, and in point of fact, I couldn’t deny the fact that I owed my love for the clinical component of my nursing education to the methodological expertise and leadership presence of Profs. Foss and Bowler, as well as their clear understanding of the vast possibilities which pedagogical affordances presented students in clinical practice and education.

Prof. Foss told me about her visit to Africa and when she’d asked me where exactly I think she should visit next in Africa, my quick response was Ghana. “I will consider your proposal when I make up my mind to visit Africa on my next trip,” I remember her telling me against the backdrop of an infectious smile.

This explains how affable she is.
And again, I can recall another interesting conversation she’d with three different groups from my cohort program including mine, Group N, about anorexia and how Karen Carpenter died from it. This conversation took place at the Simulation Center. “Who in this class wants to tell me who Karen Carpenter was?” she asked with remarkable vocal clarity. The class was silent, almost dead. “She was a singer,” she continued, “and she had a number one hit. Does anyone remember this song?”

The dead silence remained unperturbed.
“The Carpenters,” I replied.
“Correct,” she said.
“And the number one hit song is ‘Top of the World,” I added.

I later communicated with her about The Carpenters and the kinds of music genres I usually enjoyed listening to, to which she responded with the following email on December 20, 2017:

Hello Francis,
Karen Carpenter did have a very soulful voice and as if every tone was articulated. I need to be careful not to go too far back in time, as most of the nursing students I try to teach, don’t have the same reference points, or experience. In turn, I always need to ask the question, “who is….?” This is always amusing to me because the response is typically starts with the question, “What rock do you live under?”

is interesting to me that music is now categorized; people are slotted into marketing categories by the music they tune into. Most days now, I prefer to listen to Al Green, Marvin Gaye, Bill Withers, Smokey Robinson, The Isley Brothers, The Staple Singers, Stevie Wonder, The Temptations and then toss in smooth jazz, Valdimir Horowitz and Garrick Ohlsson. I am also moved by hymns (probably has to do with my childhood). Nothing that would be played at the gym.

Kathy
Prof. Foss, an intelligent and industrious and dedicated educator, was another favorite professor of mine. She was one of the major reasons I decided to write a book about my American and nursing experiences. As a matter of fact she sent me the following email on June 2, 2018 after I’d communicated to her, Dr. Teresa Connolly, and Dr. Tammy Spencer about the complex and difficult nature of my American experiences:

Hello Francis,
I hope that you are well and persevering through all the challenges of the nursing program!

I've been thinking....which is never profound or meaningful, but are thoughts nonetheless.

Have you written a book? Would you be interested in exploring writing a book about "nursing school"? There are survival guides to nursing school written (and digital videos) already. To me they seem to be missing the element of finding out about yourself as a person and resiliency. My thought would be to write about nursing education processes from two perspectives, one as the student, the other as the instructor. Maybe this starts as an article. I have no idea of how to start, except to create outline topics.

You are a gifted writer, which I believe is based on the unique ability to see "things" beyond the obvious.

I understand competing time demands, need to prioritize and accepting if feedback if you think writing about the topic is not worthwhile.

Kathy Foss