Nurse Education Today 35 (2015) 1–3
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Big Ideas Medical memoir: A tool to teach empathy to nursing students Although nursing students attain factual knowledge and learn skills in their education, allowing time to teach students about empathy can be lost in the constraints of the curriculum. The students' focus is often limited to memorizing facts for the next exam in order to achieve high grades. Acquiring hands-on skills and passing tests are essential to a nursing education, but achieving these goals does not necessarily create a well-rounded nurse. In their 2010 seminal work, Benner, Sutphen, Leonard, & Day (2010) emphasize caring practice and the development of empathy in nurses. Using a medical memoir in the classroom is a strategy for achieving this goal, bringing together theoretical and clinical learning as well as broadening students' perspectives. Searching for unique ways to engage students, the obstetrical nursing faculty at a large university in the north-eastern United States came upon the medical memoir Small Wonder, the Story of a Child Born too Soon (Small Wonder), by LaScala (2009). Soon, the nursing students were reading and discussing the book during the specialty semester. This book describes the premature birth of a baby and her first year of life, as well as the impact the crisis of having a low-birthweight infant imposes on family dynamics. Reading this memoir and completing related assignments affords students a view through the eyes of the writer, who also happens to be a nurse and the mother of the baby at the center of the memoir. Using the combination of her nursing background and personal experiences, LaScala, who is the author of Small Wonder and also the second author of this article, took a medical situation as well as an emotional situation and combined them to tell lay readers the story of her child's first year of life. This translates well to the nursing student audience who often has little experience in the challenging aspects of life experienced by their patients. Fahrenwwald, Bassett, Tschetter, Carson, White, & Winteroer (2005) described nursing students as using personal or vicarious experiences to generate an emotional connection with patients. Because traditional undergraduate students are usually between eighteen and twenty-two years of age, their life experiences are, by definition, limited. In addition, students usually see patients during the course of a short hospital stay. In contrast, the memoir allows students to follow a family for one year. Reading and writing about a year in the life of the premature baby and her mother as patients and as members of a family promotes students' empathy. Theoretical Concepts Empathy and caring have always been considered core nursing values. In The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) the American Association of Colleges of Nursing (AACN) states, “Caring is a concept central to professional nursing practice. Caring as related to this essential encompasses the nurse's empathy for, connection to, and being with the patient, as well as the ability to translate these affective characteristics into compassionate, sensitive,
http://dx.doi.org/10.1016/j.nedt.2014.10.001 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
and patient-centered care.” As the body defining baccalaureate nursing education, AACN makes clear to all faculty and students that empathy is a key component of caring and important to a nursing education. Sawatzky, Enns, Ashcroft, Davis, & Harder (2009) describe caring theory as being as important to the education of new nurses as it is to nursing practice. Caring focuses on the therapeutic relationship (Watson, 1999) with the burden on the nurse to be open to the patient's experience. According to Olshansky (2007), caring is integral to nursing, but it is not necessarily innate to nurses. These statements point out the importance of developing caring and empathy during pre-licensure nursing education. In her now classic article on patterns of knowing, Carper (1978) defines empathy, under the heading of esthetic patterns of knowing, as “…the capacity for participating in or vicariously experiencing another's feelings,” (Carper, 1978, p, 18.). She goes on to say that as the nurse becomes more skilled at empathy her nursing care becomes more effective and satisfying (Carper, 1978). Reading a medical memoir can begin this process in the novice nurse by providing a way to see nursing care through the eyes of a patient by being immersed in the patient's firsthand experience.
Literature Review Nurse researchers have examined the development of empathy in nursing students in a variety of ways. Brunero, Lamont, & Coates (2010) published a review of empathy education in nursing. “The studies reviewed demonstrated that it is possible to increase nurses' empathic ability” (p.71). Christianson (2009) studied Norwegian nursing students' development of “authentic concern for patients,” finding that it “…is connected to and involved in the patient's situation. This implies the ability to be touched and take in the other individual's experience and condition,” (p.431). From this perspective, each student brings his or her unique, limited life experience to the capacity for empathy. Few traditional undergraduate students have parented. Rather, their most accessible reference in the nuclear family is to the child; this phenomenon was seen frequently in students' essays and assignments about Small Wonder. Although this perspective can be helpful in some clinical situations, it does not support empathy for adult patients and misses the pregnant or parenting patient entirely. Add to the situation the findings of studies on today's college-age students which have found them to have a tendency toward characteristics that include entitlement (Levine, 2006) and narcissism (Twinge & Campbell, 2009) and the need for education fostering empathy becomes crucial. In summary, it is clear that the nursing student would benefit from experiencing the point of view of the patient. How to achieve affective learning within already tight curriculum constraints has been explored through research. Studies have found autobiographical writing (DasGupta & Charon, 2004), reading popular literature (Moyle, Barnard, & Turner, 1995; Engsrtrom & Hunter, 2007), acting the part of the patient in simulation (Pamosky & Diaz, 2009), art, music, and film (Jensen & Curtis, 2008) all too be effectively in teaching empathy to
2
Big Ideas
Table 1 Sample Study Guide questions. 1. What qualities or nuances of behavior might a nurse bring to the first hospital admission? 2. Write a different kind of nurse–patient–EMT scenario on the ambulance ride. 3. Describe the Baystate admitting nurse's presentation and affect; describe the mother's feelings during her admission. 4. How does it make you feel to think about being graded by your patients? 5. What do you think of this mother's grading system? Was she fair? 6. What do people talk about when they tell about their hospitalizations? 7. What adjectives do you want patients to use about you? 8. What words would you not like to hear about yourself? 9. With knowledge and experience, a nurse may determine that a patient “shouldn't” have as much pain as s/he is describing. Discuss pain-control issues. How does a nurse manage patients with different pain thresholds? 10. What might the nurse be thinking as she prepared to hand the baby boy to his teen mother who was talking on the phone? 11. How could the nurse have made more of her interaction with the mother? 12. Rewrite or role-play the teen mother scene with the goal of trying to get the mother to interact with her baby; a second goal would be to have the nurse assess the mother's level of knowledge about how to feed and relate to her baby. 13. Describe the nursing tasks the nurse named Gayle was performing as she talked with the mother. 14. What made Gayle so good at her job? 15. What would have happened if Gayle had simply taken the information the mother had given her – “I have a headache because I’ve been crying” – and treated her from an emotional/psychological standpoint instead of looking at the problem from a physiological perspective as well? 16. Talk about the art/science of nursing as it relates to this situation. 17. What makes coming out of the isolette and being held by her parents a stressful procedure for the baby? 18. Why was it important for the parents to hold their baby? 19. Were the risks of taking the baby out of her protected atmosphere worth the benefits of holding her? Is there any way to quantify your response? 20. What were the strengths in this family? 21. What were the disadvantages they faced in this medical crisis? 22. Think of a situation in your life or one you have observed where a person or a family have been well-supported through a crisis. What did that support look like? 23. What will you take from this story and apply to your future practice?
nursing students. The use of a medical memoir, specifically, broadens this list of atypical approaches to teaching and learning about empathy.
interest to specialties beyond obstetrics include: family dynamics through crisis; psychosocial development of the toddler, or the toddler as sibling; post-operative nursing care; symptoms, causes and treatment of preterm labor; breastfeeding complications; situational and postpartum depression, and causes; pediatric renal pathology; and the role of parents in pediatric illness. Memoir as Part of an Assignment Through several semesters of using the memoir in the undergraduate curriculum, the authors developed two options for using the book as a part of written assignments. A Study Guide (see Table 1) was developed to highlight themes in the book. It breaks the story into components, asking questions that delve into the complexity of a premature birth. The Study Guide is arranged in the order of scenes and situations as they appear in the book, with pagination to help students find pertinent sections. The Study Guide can be used in a variety of ways. One can divide the class into sections, with individual groups answering assigned Study Guide questions; then presenting answers back to the class. Alternatively, the professor can divide Study Guide questions randomly among the students who answer their questions as a written assignment. The questions might be answered differently by students when they are in their pediatrics, maternity or psychiatric nursing clinical rotations. They should bring different – and hopefully broader – frames of reference to their answers as their clinical experience expands. This guide could be used as a template for a similar guide using a different memoir. A second written assignment format evolved because of student feedback regarding the book. Some students had difficulty seeing how the memoir related to their courses, since they primarily saw low-risk patients and the story describes a high-risk situation. To address these concerns, an essay assignment was developed. Students choose a health issue affecting the family from their clinical experience and compare it with the same issue in the memoir's family. The class brainstorms the connecting themes (see Table 2). By comparing two families' experiences, students deepen their understanding of the breadth of the birth experience, including high verses low-risk situations. This assignment requires that students integrate the clinical and didactic branches of their education. Students choose themes of personal interest. The list
Using the Memoir in Class In Small Wonder the author experiences a profound sense of loss: loss of her normal pregnancy, loss of the fully-formed baby she'd been looking forward to delivering, inability to hold the baby, frustration and great sadness at not being able to nurse the baby, the separation from the newborn and need to parent an 18-month old child at home, as well as trying to maintain a marriage under such duress. These are some of the milestones that became the mother's story. Interwoven in the challenges this mother meets are the stories of her doctors and nurses and the caring practice they did or did not bring to this baby, mother and family. Through these vignettes the students see examples of a variety of styles of caring practice and judge the kinds of caregivers they would like to either emulate or avoid. What makes the book especially pertinent for a nursing classroom is the nurse–author voice. Not only is LaScala telling a multifaceted story, but she tells it from the viewpoint of someone who has worked in a hospital and in the healthcare world, as a patient herself, and as the mother of a baby who remains a patient over the first year of her life. LaScala knows the hospital system and its players. She has been a part of the system from the same point of view as the student readers. By reading the book, they begin to see both the familiar and the unfamiliar. By doing so, students stretch their world view bringing a broader frame of reference to their nursing work. This memoir could be used across specialties as a point of reference to a real life family health crisis as it affects pediatric and psychiatric nursing care. Some examples of issues explored in Small Wonder of
Table 2 Themes for case comparison essay. Assumptions, value judgments by medical staff Breastfeeding Cesarean vs. vaginal birth Couple disparities, dealing with grief and loss Couple disparities, dealing with parenting Depression, PTSD in parents of newborns Economic status of families Educational level of families Effect on/role of sibling Effect on/role of father Family in crisis Grading healthcare providers Guilt in mothering/parenting Health insurance issues High vs. low-risk delivery Maternal–infant bonding Maternal–infant physical contact Maternal loyalty and guilt — attend to which child? Maternal separation from newborn Medical parents as family Mother role, self-concept in transition Mother–patient role vs. nurse role Normal vs. traumatic birth Nurse portrayals, role of the nurse Parenting the sibling at home Role of the father Separation from newborn Support systems, social and extended family
Big Ideas Table 3 Student responses to assignment comparing a family from a clinical experience to the family in the memoir. “Small Wonder was great. The reading was enjoyable and down-to-earth. Meeting {the author} was helpful because we got to see how the baby did and ask questions.” “Keep the Small Wonder presentation. Seeing her {the author} in person made the book come alive for me.” “Usually I dread the readings for class. But this one was fun. I read it straight through.” “I worked in a NICU last summer. I can see how this book described the experience of so many patients.”
3
and related novels are abundant and written on a wide array of topics (see Table 4). Faculty in any nursing area could consider expanding their courses to include medical memoirs as a means of engaging students, promoting caring practices, and integrating course content. Although in this project no instrument was used to measure empathy before and after the reading and writing assignments, using such a measurement device would be helpful in determining quantitative change. Research on integrating affective education into existing curricula and assessment of efficacy of educational tools designed to teach caring and empathy will benefit students, faculty and ultimately, patients. References
Table 4 Sample medical memoir list. Dorris, Michael. (1989). The broken cord. New York, New York: HarperCollins Publishers. (Story of an adopted child with fetal alcohol syndrome) Gabriel, S. (2009). Eating pomegranates: A memoir of mothers, daughters, and the BRCA gene. New York, New York: Scribner. (Story of a woman with BRCA gene and associated cancers) LaScala, S. (2009). Small wonder: The story of a child born too soon. Gill, MA : Barton Cove Press. (Story of the birth and first year of a premature infant and her doctor and nurse parents.) Lovelace, D. (2008). Scattershot: My bipolar family, a memoir. New York, New York: Dutton. (Story of a man growing up in a family with bipolar illness.) Van Gelder, K. (2010). The Buddha and the borderline: My recovery from borderline personality disorder through dialectical behavior therapy, Buddhism, and on-line dating. Boston: New Harbinger Publications.
of issues lengthened with each class that used the book as students discovered the depth and complexity of issues present in real-life experience. Again, the assignment could be altered to work for a different medical memoir to make it work in a variety of settings. Students have provided feedback about using the book throughout the course and in the course evaluation at the end of the semester. Their comments about using the memoir as an augmentation to classroom and clinical experiences has been overwhelmingly positive (see Table 3). Through their comments and evaluation of their written work, several aspects of the memoir have emerged as significant to student learning. These include identification with Sarah (the infant), identification with Susan (the mother and nurse), or with other nurses in the book; analysis of themselves as viewed through the eyes of a patient; seeing a broader view of the patient's experience rather than a snapshot in time; recognizing lifelong healthcare/psychological/ family-relationship issues related to childhood illness; and assessing the influence of caregivers on the patient and families' experiences. Discussion The use of a medical memoir in the undergraduate nursing classroom has proven to be enriching on many levels. By widening the nursing student's view of the patient experience, the authors provide traditional undergraduate students an opportunity to expand and deepen their knowledge, and their capacity for empathy. Medical memoirs
American Association of Colleges of Nursing, 2008. The Essentials of Baccalaureate Education for Professional Nursing Practice. Author, Washington, DC. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical Transformation. Jossey-Bass, San Francisco, p. 186. Brunero, S., Lamont, S., Coates, M., 2010. A review of empathy education in nursing. Nurs. Inq. 1 (7), 64–73. Carper, B., 1978. Fundamental patterns of knowing in nursing. Adv. Nurs. Sci. 1 (1), 13–23. Christianson, B., 2009. Cultivating authentic concern: exploring how Norwegian students learn this key skill. J. Nurs. Educ. 48 (8), 429–434. DasGupta, S., Charon, R., 2004. Personal illness narratives: using reflective writing to teach empathy. Acad. Med. 79 (4), 351–356. Engsrtrom, J., Hunter, R., 2007. Teaching Reproductive Options Through the Use of Fiction: The Cider House Rules Project. JOGNN, (September/October, 464 -470). Fahrenwwald, N., Bassett, S., Tschetter, L., Carson, P., White, L., Winteroer, V., 2005. Teaching core nursing values. J. Prof. Nurs. 21 (1), 46–51. Jensen, A., Curtis, M., 2008. A descriptive qualitative study of student learning in a psychosocial nursing class infused with art, literature, music, and film. Int. J. Nurs. Educ. Scholarsh. 5 (1), 1–9. LaScala, S., 2009. Small Wonder: The Story of a Child Born Too Soon. Barton Cove Press, Gill, MA. Levine, M., 2006. The Price of Privilege: How Parental Pressure and Material Advantage are Creating a Generation of Disconnected and Unhappy Kids. HarperCollins, New York, NY. Moyle, W., Barnard, A., Turner, C., 1995. The humanities and nursing: using popular literature as a means of understanding human experience. J. Adv. Nurs. 21, 960–964. Olshansky, E., 2007. What do we mean by compassion and caring in nursing and why does it matter anyway? J. Prof. Nurs. 23, 247–248. Pamosky, D., Diaz, D., 2009. Teaching caring and empathy through simulation. Int. J. Hum. Caring 13 (3), 44–46. Sawatzky, J., Enns, C., Ashcroft, T., Davis, P., Harder, B.N., 2009. Teaching excellence in nursing education: a caring framework. J. Prof. Nurs. 25, 260–266. Twinge, J.M., Campbell, W.K., 2009. The Narcissism Epidemic: Living in the Age of Entitlement. Free Press, New York. Watson, J., 1999. Postmodern Nursing And Beyond. Churchill Livingstone, Edinburgh.
Maud Low College of Nursing, University of Massachusetts, Amherst, USA Corresponding author at: Clinical Assistant Professor, College of Nursing, University of Massachusetts, Amherst, U.S.A. Susan LaScala Deerfield Academy, Deerfield, MA, USA
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Big Ideas Medical memoir: A tool to teach empathy to nursing students Although nursing students attain factual knowledge and learn skills in their education, allowing time to teach students about empathy can be lost in the constraints of the curriculum. The students' focus is often limited to memorizing facts for the next exam in order to achieve high grades. Acquiring hands-on skills and passing tests are essential to a nursing education, but achieving these goals does not necessarily create a well-rounded nurse. In their 2010 seminal work, Benner, Sutphen, Leonard, & Day (2010) emphasize caring practice and the development of empathy in nurses. Using a medical memoir in the classroom is a strategy for achieving this goal, bringing together theoretical and clinical learning as well as broadening students' perspectives. Searching for unique ways to engage students, the obstetrical nursing faculty at a large university in the north-eastern United States came upon the medical memoir Small Wonder, the Story of a Child Born too Soon (Small Wonder), by LaScala (2009). Soon, the nursing students were reading and discussing the book during the specialty semester. This book describes the premature birth of a baby and her first year of life, as well as the impact the crisis of having a low-birthweight infant imposes on family dynamics. Reading this memoir and completing related assignments affords students a view through the eyes of the writer, who also happens to be a nurse and the mother of the baby at the center of the memoir. Using the combination of her nursing background and personal experiences, LaScala, who is the author of Small Wonder and also the second author of this article, took a medical situation as well as an emotional situation and combined them to tell lay readers the story of her child's first year of life. This translates well to the nursing student audience who often has little experience in the challenging aspects of life experienced by their patients. Fahrenwwald, Bassett, Tschetter, Carson, White, & Winteroer (2005) described nursing students as using personal or vicarious experiences to generate an emotional connection with patients. Because traditional undergraduate students are usually between eighteen and twenty-two years of age, their life experiences are, by definition, limited. In addition, students usually see patients during the course of a short hospital stay. In contrast, the memoir allows students to follow a family for one year. Reading and writing about a year in the life of the premature baby and her mother as patients and as members of a family promotes students' empathy. Theoretical Concepts Empathy and caring have always been considered core nursing values. In The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) the American Association of Colleges of Nursing (AACN) states, “Caring is a concept central to professional nursing practice. Caring as related to this essential encompasses the nurse's empathy for, connection to, and being with the patient, as well as the ability to translate these affective characteristics into compassionate, sensitive,
http://dx.doi.org/10.1016/j.nedt.2014.10.001 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
and patient-centered care.” As the body defining baccalaureate nursing education, AACN makes clear to all faculty and students that empathy is a key component of caring and important to a nursing education. Sawatzky, Enns, Ashcroft, Davis, & Harder (2009) describe caring theory as being as important to the education of new nurses as it is to nursing practice. Caring focuses on the therapeutic relationship (Watson, 1999) with the burden on the nurse to be open to the patient's experience. According to Olshansky (2007), caring is integral to nursing, but it is not necessarily innate to nurses. These statements point out the importance of developing caring and empathy during pre-licensure nursing education. In her now classic article on patterns of knowing, Carper (1978) defines empathy, under the heading of esthetic patterns of knowing, as “…the capacity for participating in or vicariously experiencing another's feelings,” (Carper, 1978, p, 18.). She goes on to say that as the nurse becomes more skilled at empathy her nursing care becomes more effective and satisfying (Carper, 1978). Reading a medical memoir can begin this process in the novice nurse by providing a way to see nursing care through the eyes of a patient by being immersed in the patient's firsthand experience.
Literature Review Nurse researchers have examined the development of empathy in nursing students in a variety of ways. Brunero, Lamont, & Coates (2010) published a review of empathy education in nursing. “The studies reviewed demonstrated that it is possible to increase nurses' empathic ability” (p.71). Christianson (2009) studied Norwegian nursing students' development of “authentic concern for patients,” finding that it “…is connected to and involved in the patient's situation. This implies the ability to be touched and take in the other individual's experience and condition,” (p.431). From this perspective, each student brings his or her unique, limited life experience to the capacity for empathy. Few traditional undergraduate students have parented. Rather, their most accessible reference in the nuclear family is to the child; this phenomenon was seen frequently in students' essays and assignments about Small Wonder. Although this perspective can be helpful in some clinical situations, it does not support empathy for adult patients and misses the pregnant or parenting patient entirely. Add to the situation the findings of studies on today's college-age students which have found them to have a tendency toward characteristics that include entitlement (Levine, 2006) and narcissism (Twinge & Campbell, 2009) and the need for education fostering empathy becomes crucial. In summary, it is clear that the nursing student would benefit from experiencing the point of view of the patient. How to achieve affective learning within already tight curriculum constraints has been explored through research. Studies have found autobiographical writing (DasGupta & Charon, 2004), reading popular literature (Moyle, Barnard, & Turner, 1995; Engsrtrom & Hunter, 2007), acting the part of the patient in simulation (Pamosky & Diaz, 2009), art, music, and film (Jensen & Curtis, 2008) all too be effectively in teaching empathy to
2
Big Ideas
Table 1 Sample Study Guide questions. 1. What qualities or nuances of behavior might a nurse bring to the first hospital admission? 2. Write a different kind of nurse–patient–EMT scenario on the ambulance ride. 3. Describe the Baystate admitting nurse's presentation and affect; describe the mother's feelings during her admission. 4. How does it make you feel to think about being graded by your patients? 5. What do you think of this mother's grading system? Was she fair? 6. What do people talk about when they tell about their hospitalizations? 7. What adjectives do you want patients to use about you? 8. What words would you not like to hear about yourself? 9. With knowledge and experience, a nurse may determine that a patient “shouldn't” have as much pain as s/he is describing. Discuss pain-control issues. How does a nurse manage patients with different pain thresholds? 10. What might the nurse be thinking as she prepared to hand the baby boy to his teen mother who was talking on the phone? 11. How could the nurse have made more of her interaction with the mother? 12. Rewrite or role-play the teen mother scene with the goal of trying to get the mother to interact with her baby; a second goal would be to have the nurse assess the mother's level of knowledge about how to feed and relate to her baby. 13. Describe the nursing tasks the nurse named Gayle was performing as she talked with the mother. 14. What made Gayle so good at her job? 15. What would have happened if Gayle had simply taken the information the mother had given her – “I have a headache because I’ve been crying” – and treated her from an emotional/psychological standpoint instead of looking at the problem from a physiological perspective as well? 16. Talk about the art/science of nursing as it relates to this situation. 17. What makes coming out of the isolette and being held by her parents a stressful procedure for the baby? 18. Why was it important for the parents to hold their baby? 19. Were the risks of taking the baby out of her protected atmosphere worth the benefits of holding her? Is there any way to quantify your response? 20. What were the strengths in this family? 21. What were the disadvantages they faced in this medical crisis? 22. Think of a situation in your life or one you have observed where a person or a family have been well-supported through a crisis. What did that support look like? 23. What will you take from this story and apply to your future practice?
nursing students. The use of a medical memoir, specifically, broadens this list of atypical approaches to teaching and learning about empathy.
interest to specialties beyond obstetrics include: family dynamics through crisis; psychosocial development of the toddler, or the toddler as sibling; post-operative nursing care; symptoms, causes and treatment of preterm labor; breastfeeding complications; situational and postpartum depression, and causes; pediatric renal pathology; and the role of parents in pediatric illness. Memoir as Part of an Assignment Through several semesters of using the memoir in the undergraduate curriculum, the authors developed two options for using the book as a part of written assignments. A Study Guide (see Table 1) was developed to highlight themes in the book. It breaks the story into components, asking questions that delve into the complexity of a premature birth. The Study Guide is arranged in the order of scenes and situations as they appear in the book, with pagination to help students find pertinent sections. The Study Guide can be used in a variety of ways. One can divide the class into sections, with individual groups answering assigned Study Guide questions; then presenting answers back to the class. Alternatively, the professor can divide Study Guide questions randomly among the students who answer their questions as a written assignment. The questions might be answered differently by students when they are in their pediatrics, maternity or psychiatric nursing clinical rotations. They should bring different – and hopefully broader – frames of reference to their answers as their clinical experience expands. This guide could be used as a template for a similar guide using a different memoir. A second written assignment format evolved because of student feedback regarding the book. Some students had difficulty seeing how the memoir related to their courses, since they primarily saw low-risk patients and the story describes a high-risk situation. To address these concerns, an essay assignment was developed. Students choose a health issue affecting the family from their clinical experience and compare it with the same issue in the memoir's family. The class brainstorms the connecting themes (see Table 2). By comparing two families' experiences, students deepen their understanding of the breadth of the birth experience, including high verses low-risk situations. This assignment requires that students integrate the clinical and didactic branches of their education. Students choose themes of personal interest. The list
Using the Memoir in Class In Small Wonder the author experiences a profound sense of loss: loss of her normal pregnancy, loss of the fully-formed baby she'd been looking forward to delivering, inability to hold the baby, frustration and great sadness at not being able to nurse the baby, the separation from the newborn and need to parent an 18-month old child at home, as well as trying to maintain a marriage under such duress. These are some of the milestones that became the mother's story. Interwoven in the challenges this mother meets are the stories of her doctors and nurses and the caring practice they did or did not bring to this baby, mother and family. Through these vignettes the students see examples of a variety of styles of caring practice and judge the kinds of caregivers they would like to either emulate or avoid. What makes the book especially pertinent for a nursing classroom is the nurse–author voice. Not only is LaScala telling a multifaceted story, but she tells it from the viewpoint of someone who has worked in a hospital and in the healthcare world, as a patient herself, and as the mother of a baby who remains a patient over the first year of her life. LaScala knows the hospital system and its players. She has been a part of the system from the same point of view as the student readers. By reading the book, they begin to see both the familiar and the unfamiliar. By doing so, students stretch their world view bringing a broader frame of reference to their nursing work. This memoir could be used across specialties as a point of reference to a real life family health crisis as it affects pediatric and psychiatric nursing care. Some examples of issues explored in Small Wonder of
Table 2 Themes for case comparison essay. Assumptions, value judgments by medical staff Breastfeeding Cesarean vs. vaginal birth Couple disparities, dealing with grief and loss Couple disparities, dealing with parenting Depression, PTSD in parents of newborns Economic status of families Educational level of families Effect on/role of sibling Effect on/role of father Family in crisis Grading healthcare providers Guilt in mothering/parenting Health insurance issues High vs. low-risk delivery Maternal–infant bonding Maternal–infant physical contact Maternal loyalty and guilt — attend to which child? Maternal separation from newborn Medical parents as family Mother role, self-concept in transition Mother–patient role vs. nurse role Normal vs. traumatic birth Nurse portrayals, role of the nurse Parenting the sibling at home Role of the father Separation from newborn Support systems, social and extended family
Big Ideas Table 3 Student responses to assignment comparing a family from a clinical experience to the family in the memoir. “Small Wonder was great. The reading was enjoyable and down-to-earth. Meeting {the author} was helpful because we got to see how the baby did and ask questions.” “Keep the Small Wonder presentation. Seeing her {the author} in person made the book come alive for me.” “Usually I dread the readings for class. But this one was fun. I read it straight through.” “I worked in a NICU last summer. I can see how this book described the experience of so many patients.”
3
and related novels are abundant and written on a wide array of topics (see Table 4). Faculty in any nursing area could consider expanding their courses to include medical memoirs as a means of engaging students, promoting caring practices, and integrating course content. Although in this project no instrument was used to measure empathy before and after the reading and writing assignments, using such a measurement device would be helpful in determining quantitative change. Research on integrating affective education into existing curricula and assessment of efficacy of educational tools designed to teach caring and empathy will benefit students, faculty and ultimately, patients. References
Table 4 Sample medical memoir list. Dorris, Michael. (1989). The broken cord. New York, New York: HarperCollins Publishers. (Story of an adopted child with fetal alcohol syndrome) Gabriel, S. (2009). Eating pomegranates: A memoir of mothers, daughters, and the BRCA gene. New York, New York: Scribner. (Story of a woman with BRCA gene and associated cancers) LaScala, S. (2009). Small wonder: The story of a child born too soon. Gill, MA : Barton Cove Press. (Story of the birth and first year of a premature infant and her doctor and nurse parents.) Lovelace, D. (2008). Scattershot: My bipolar family, a memoir. New York, New York: Dutton. (Story of a man growing up in a family with bipolar illness.) Van Gelder, K. (2010). The Buddha and the borderline: My recovery from borderline personality disorder through dialectical behavior therapy, Buddhism, and on-line dating. Boston: New Harbinger Publications.
of issues lengthened with each class that used the book as students discovered the depth and complexity of issues present in real-life experience. Again, the assignment could be altered to work for a different medical memoir to make it work in a variety of settings. Students have provided feedback about using the book throughout the course and in the course evaluation at the end of the semester. Their comments about using the memoir as an augmentation to classroom and clinical experiences has been overwhelmingly positive (see Table 3). Through their comments and evaluation of their written work, several aspects of the memoir have emerged as significant to student learning. These include identification with Sarah (the infant), identification with Susan (the mother and nurse), or with other nurses in the book; analysis of themselves as viewed through the eyes of a patient; seeing a broader view of the patient's experience rather than a snapshot in time; recognizing lifelong healthcare/psychological/ family-relationship issues related to childhood illness; and assessing the influence of caregivers on the patient and families' experiences. Discussion The use of a medical memoir in the undergraduate nursing classroom has proven to be enriching on many levels. By widening the nursing student's view of the patient experience, the authors provide traditional undergraduate students an opportunity to expand and deepen their knowledge, and their capacity for empathy. Medical memoirs
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Maud Low College of Nursing, University of Massachusetts, Amherst, USA Corresponding author at: Clinical Assistant Professor, College of Nursing, University of Massachusetts, Amherst, U.S.A. Susan LaScala Deerfield Academy, Deerfield, MA, USA
