Path Ography

8/3/2019 Path Ography

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MIEETUsing a P A T H O G R A P H Y to

DIANN SLADE, lONA THOMAS-CONNOR, AND TING MAN TSAO

ULTURAL COMPETENCE IS KEY TO THE DELIVERY OF SAFE AND EFFECTIVE

PATIENT CARE IN THIS INCREASINGLY GLOBALIZED WORLD (1-3).

An evolving concept, cultural competence in nursing can bebroadly defined as "an ongoing process with a goal of achievingability to work effectively with culturally diverse groups and com-munities with a detailed awareness, specific knowledge, refinedskills, and personal and professional respect for cultural attributes,both differences and similarities" (2, p. 96). Since nursing curriculaare already overcrowded (4), how can faculty effectively integrate this"ongoing process" of developing cultural competence in their courses?How can they avoid using "laundry lists or recipes of cul tura l charac-terist ics ," which may furth er pe rpe tua te stereotypin g (4, p. 19S)? Thisarticle describes a joint project between nursing and English faculty in an urbancommunity college serving students who speak more than 100 languages ordialects natively and more than half of whom are foreign born. Faculty from thetwo disciplines collab orated in piloting and studying the use of a pathog-raphy to develop nursing students' culturally competent selves. This col-laboration reveals that components of the English curriculum, such asclose reading and critical writing, can be integrated into nursing classesto enhance the teaching of cultural competence. Interpret ing a pathog-raphy cultivates students' compassion for the patient and family. Aseries of exercises challenges students to critically read complex tran-scultnral interact ions and apply relevant nursing concepts to analyzingthese situations in health care delivery.

ABS TRAC T This articledescribes a collaborationbetween nursing and Englishfaculty to pilot and study theuse of a pathography to devel-op nursing students' culturalcompetence. The setting is anursing program in an urbancommunity col lege servingmany foreign-born students.Interpreting a pathography wasfound to develop students 'compassion for the patient andfamily. Exercises and assign-ments were used to challengestudents to critically read com-plex transcultural interactionsand apply relevant nursing con-cepts to analysis of these situ-ations in health care delivery.The essay assignment pres entedchallenges to students becauseof their writing skills.

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Pathography in the Nursing Class-room Nurse educators and theircolleagues in medicine have longemployed fictional and autobio-graphical literature to teach thehuman aspects of clinical prac-tice (5). As a pedagogical strategy,storytelling is found to be usefulfor developing students' self-esteem, value systems, criticalthinking, reflective skills, and,above all, cultural eompetencc(6-13),

An important narrative genrefor nursing education is pathogra-phy or illness narrative (7, 14-18). Hawkins defines this genre,composed of "autobiographiesand biographies about illness," as"a reconstruction of experience = = = ^ ^ = ^that promotes healing" (19, p, 222). She sees the recent pop-ularity of English-language illness narrative s as a reaction tothe dehumanizing medical system, which focuses mainly onthe disease, ignoring the patient (19-20). The pathographyresurrects the overlooked person by "situating the illnessexperience within the author's life and the meaning of thatlife" (19, p. 224). The genre also reflects the ways cultureand society shape perceptions of the body, categorization ofbodily symptoms, and interpretations of complaints (21).More Than a Case The pathograp hy used in this pilot, titled"More Than a Case," was written by co-author TMT about acase that he managed when he was a social worker in NewYork working for a child welfare agency (22). The protago-nist is a Chinese woman, a single mother raising several chil-dren, including newborn twins. She spoke limited Englishand was on welfare. One of the twins was born w ith d isabili-ties and was referred to the agency where TMT wasemployed. The other twin. Baby Ann, was born healthy, butshe suddenly fell sick and died of a rare viral infection.

TMT's story recounts the events leading to the May 27 cri-sis and the mother's ordeals as Baby Ann's condition deteri-orates, with more seizures, more rashes, and rising fever.TMT, the narrator, tells the other twin, who survives, howher mother watched helplessly as she continued to be dis-

Students could IDENTIFYWITH THE NARRATIVE not only

professionally but also personally.Some students,who had IMMIGRANT BACKGROUNDS,

recalled that when they f irst cameto the United States,

they had been treated the SAME WAYTHE MOTHER in the story was treated:

"That's how I felt when I wasmistreated. Tha t's how people with andismissed. "

missed by health care providerSensing her baby was in dangethe mother relinquished he r usudocility to assert her concerns the doctor:

"May 27. IV was applieagain. Baby Ann's body was reand she was shivering. Youmom called the doctor. No oncame. Anurse said the doctwas busy. Your mom was irasaying your sister was in thICV. The nurse said the doctowas busy writing reports. Yomom took the baby with IV aneverything attached to the dooffice. The b aby is in a se

condition, cried your moWho told you to come? the do

^^^="=^^=""^^ jj,^ yeed back. He ordered yomom to take the baby away. Ten minutes later, the doctcame and said there was nothing special about the babThis is no emergency, he explained. Your mom told m e tnurses nearby were shaking their heads, though thdidn't say anything audible" (22, p. 398).

The mother could not win due attention from the medicstaff until the twin's regular pediatrician, affiliated wianother hospital, intervened and transferred her there. Tbaby died in the second hospital.Class Activities and Assignments The nu rse faculty, DS anITC, piloted the pathography in Perspectives of Nursin(an introductory nursing course) and the Science and Aof Nursing II -Management and Leadership (the capstopractical nursing course), respectively. Before the pilothey had used combinations of role play, lecture, andgroup research paper to teach cultural competence. Ethis pilot, DS and ITC collaborated with their eolleagTMT to develop activities around "More Than a Case" substitute for their old lessons.

The new activities had three stages. Eirst, students weassigned toread "More Than aCase" and prepare fstudy questions. (See Sidebar 1.) While individual quetions varied in focus, their overall purpose was to develcultural competence by challenging students to read t


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pathography closely and apply nursing concepts to ananalysis of transcultural issues delineated in the text. Thesecond stage was class discussion. Students in small groupsdiscussed the study questions. Then the nurse faculty,joined by TMT as a guest, led a whole-class discussion. Thethird stage was a writing assignment that asked students toselect one of the study questions and develop a shortpatient/family assessment essay and a long critical essay.Student Learning To assess the effectiveness of the pathogra-phy in developing students' cultural competence as an ongo-ing process, the authors observed and analyzed not only stu-dents' oral and written responses to the assignments, but alsotheir behav iors. What follows are the auth ors' observations.

COULD THIS POSSIBLY HAPPEN IN THE HOSPITAL? Thepathography was a powerful text that touched the studentsand motivated them to think about diversity, health caredisparities, and their roles as nurses. The nurse facultyfound that the use of the patho graphy was more effective inengaging students in these issues than their former peda-gogy. Students felt compassion toward the family. Tbeywere livid that the dying baby and the frustrated motherwere failed by the entire system: "The doctors were doingnothing, the nurses were doing nothing, the social workerwas doing nothing." Some students simply did not believetbat such systemic negligence could have happened inhealth care.

DS's students could identify with thenarrative notonlyprofessionally but also personally. Some of her students,who had immigrant backgrounds, recalled tbat when theyfirst eame to the United States, they had been treated thesame way the mother in the story was treated: "That's howI felt when I was mistreated. That's how people with anaccent and no money are dismissed." For some of ITC'sstudents, tbe story reminded tbem of their being profes-sionals of color. Jenny said tbat she could never forgetbeing called a "nigger" by a patient. Sbe was very upset

and angry tben. However, sbe learned from "More ThanCase" that she must treat all patents in the same professional manner, including the ones who insult her witracial slurs.

DS and ITC found that the story continued to live witthe students even after the lesson was over. Informal faceto-face and email discussions of the pathography continuedamong students and between faculty and students. ITClearned that following the illness narrative lesson, somstudents began to adopt culturally sensitive language wbeninteracting with one another in the classroom and beyondITC also observed that while the writing assignment did norequire library researcb, some students were so interestedin tbe topic of cultural diversity that they researched it otheir own and incorporated some researched materials intheir critical essays.

WHY DID IT HAPPEN IN THE WAY IT DID? "More ThanCase" challenged students to go beyond tbe misleadinglysimplistic "laundry lists of cultural characteristics" to delvinto how the illness experience intersects race, gender, classculture, language, education, and family background. DSobserved tbat nursing students, sometimes influenced bysimplistic representations of doctors and patients in themedia, do not fully understand the implications of diversityfor the complicated process of eare delivery. Some of DS anITC's students, for instance, initially suggested "easy" prescriptions for the mother's plight: "She should have sougha second opinion"; "if I were the mother, I would have askedfor the results of the tests"; "the mother shouldn't havereturned to the same hospital again and again when theycouldn't even give a diagnosis."

Through class discussion and the writing assignment, stu-dents were able to develop a deeper understanding of themistreatment of the mother. Based on the details of thepathography, they examined reasons for the mother's behav-ior and the service provider's negligence. Students did nosimply attribute the hospital's general negligence to tbe

Sidebar I. Sample Study Questionsfor "More Than a Case"I. Who tells Baby Ann's story? To whom is

Your assessment should address the fol low- 3. If you were the nurse on duty on May 27,ing: a) her cultural, language, economic, andfamily background, b) the development of her

would you do anything different to betteraddress the needs of the mother and Baby

the sto ry told? W ha t insig hts, biases, and lim- self-esteem during Baby Ann's hospital ization, Ann , to better intervene between the familyits does the narrator have?2. How doyou , as a n urse, assess the mother?

and c) her strengths and weaknesses in advo-cating for and taking care of Baby Ann .

and the doctors? What would be your diffi-culties?

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mother's overall submissivenessas a recent Asian immigrant.Instead, they saw this culturalfactor in connection with themother's lack of support as a sin-gle mother taking care of twonewborns, herclass as a Medic-aid-paying client, and her lan-guage barrier. They alsoobserved how the mother defiedthe stereotype of Asian respectfor the authorities and confrontedthe doctor when she saw that herdaughter was in danger.

In examining thehealth careproviders ' behaviors, DS andITC's students were able to evaluate the clinical situation byconsidering relevant details of the story, synthesize andapply the nursing concepts they had learned, and make judg-ments about the doctors and nurses involved. Students' dis-cussion of the May 27 episode is a case in point. Since thechild was "running a high fever," Fei Fan observed, itwas"unacceptable" for the doctor to tell the mother that therewas "nothing special" about this baby and there was "noemergency." For Fei Fan, the doctor put more efforts in"controlling the so-called 'hysterical mother' than findingout what was wrong with the baby." Other students notedthat this doctor got his priorities wrong; he focused moreattention on the report he was writing than on tbe mother'slegitimate concerns.

June observed that the nurse was as incompetent as thedoctor. When the mother requested ameeting with the doc-tor, June noted that the nurse simply said the doctor wasbusy. She should have informed the physician of the meetingrequest, and if the physician did not fulfill this request, "theprope r chain of command should have been informed." T henurse's failure to advocate for tbe patient and the family was"inexcusable behavior."

Not only could the students critique the medical pro vid ers '

Nursing students,sometimes influenced by SIMPLISTIC

REPRESENTATIONS ofdoctors andpatients inthe media,

do not fully understandthe implications of diversityfor the complicated process

of care delivery.

unprofessional behaviors, thecould also suggest appropriate coduct and actions based on the nuring concepts they had learneMany students noted that if thewere on the floor on May 27, thewould have immediately requestetranslation service tobetter communicate witb the mother. As Junnoted, "Language barriers pochallenging communication issuat every level of the health cadelivery system, creating a criticneed for appropriate linguistic sevices." In addition, students wouhave reviewed and provided acc

rate documentation in thepatient's chart for continuity ocare. June noted that there were many lapses in the servicprovided to Baby Ann. As anurse, she is obligated to ensuthe dehvery of approp riate and timely treatmen t, take notesany lapses, alert the health care team, and take proper stepDoing this professionally is imp ortant because, as another stdent. Von, argued, "my first priority is to my patient, whimeans both Baby Ann and her mother."Reflections The use of the pathography proved effectivedeveloping students' culturally competent selves. There wedifficulties that needed to be addressed, bowever. The greest difficulty came from students' critical writing skills.the authors' college, nursing students have only taken one two composition courses. The essay assignment proved chlenging for some students, particularly, but not exclusivethose students whose native language was not English. ITobserved that although the class discussion helped studenbrainstorm ideas for their essays, it was necessary tostathe writing assignment mo re, using Writing in the D isciplin(WID) strategies to provide early feedback to students' olines and drafts (23). ITC also found tbat itwas sometimdifficult for nurse faculty to assess student essays who

Sidebar 2. W rit in g in the Disciplines Writing in the Disciplines atLaGuardia Comm unity College is a yearlong program providing faculty participanwith support to design and pilot a writing-intensive version of a course that they choose. During the year, faculty members take pa rt in small-group and larggroup meetings that help them integrate wr iting as a key comp onent into th eir course. Participants are individually assisted by a writing fellow. For more infomation, visit the program's website at v/ww.lagcc.cuny.edu/wid.

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readability was compromised by language and structuralerrors and/or second-language interferences. Nurse educatorsmay benefit from faculty development programs such as WID.(See Sidebar 2.)

Despite the challenges, DS and ITC concluded that the useof the pathography was more effective than their old lessons indeveloping nursing students ' culturally competent selves as anongoing process. The story itself became a site of inquiry wherestudents felt passionate about the characters and their interac-t ions, analyzed the transcultural issues, synthesized andapphed the nursing concepts they had learned, and practicedtheir critical reading and writing skills. It was a site where thethree faculty members were not lecturers about cultural char-acteristics, but facilitators of discussions about hfe experiencesof transcultural interactions. It was by getting inside a story

that learning across cultures and disciplines took place, noonly among students but also among teachers. L - ^

About the Authors Diann Slade, MSN, RN, is an assistant professor of nursing, LaGuardia Community College of the CitUniversity of New York, Long Island City. lona Thomas-ConnorMA, RN, CNE, is an associate professor and coordinator onursing programs, LaGuardia Community College. Ting MaTsao, PhD, is an associate professor in. the English DepartmenLaGuardia Community College. Dr. Tsao acknowledges himother, Siu Tamd Tsao, a nurse and a lifetime caregiver. Fomore information, contact Dr. Tsao at [email protected].

Key Words Pathography - Cultural Competence - Narrative Pedagogy Close Reading- Critical Wri ting Skills - Nursing Education

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Path Ography