MIEET

Using a PATHOGRAPHY 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).

ABSTRACT describes a

This

article

collaboration

between nursing and English

An evolving concept, cultural competence in nursing can be broadly defined as "an ongoing process with a goal of achieving ability to work effectively with culturally diverse groups and communities with a detailed awareness, specific knowledge, refined

faculty to pilot and study the use of a pathography to develop nursing students' cultural competence. The setting is a nursing program in an urban community college serving

skills, and personal and professional respect for cultural attributes, both differences and similarities" (2, p. 96). Since nursing curricula are 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 cultural characteristics," which may further perpetuate stereotyping (4, p. 19S)? This article describes a joint project between nursing and English faculty in an urban community college serving students who speak more than 100 languages or dialects natively and more than half of whom are foreign born. Faculty from the two disciplines collaborated in piloting and studying the use of a pathography to develop nursing students' culturally competent selves. This collaboration reveals that components of the English curriculum, such as close reading and critical writing, can be integrated into nursing classes to enhance the teaching of cultural competence. Interpreting a pathography cultivates students' compassion for the patient and family. A series of exercises challenges students to critically read complex transcultnral interactions and apply relevant nursing concepts to analyzing these situations in health care delivery.

many foreign-born students. Interpreting a pathography was found to develop students' compassion for the patient and family. Exercises and assignments were used to challenge students to critically read complex transcultural interactions and apply relevant nursing concepts to analysis of these situations in health care delivery. The essay assignment presented challenges to students because of their writing skills.

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Pathography in the Nursing Classroom Nurse educators and their colleagues in medicine have long employed fictional and autobiographical literature to teach the human aspects of clinical practice (5). As a pedagogical strategy, storytelling is found to be useful for developing students' selfesteem, value systems, critical thinking, reflective skills, and, above all, cultural eompetencc (6-13),

Students could IDENTIFY WITH THE NARRATIVE not only professionally but also personally. Some students, who had IMMIGRANT BACKGROUNDS, recalled that when they first came to the United States, they had been treated the SAME WAY THE MOTHER in the story was treated:

An important narrative genre for nursing education is pathogra"That's how I felt when I was phy or illness narrative (7, 1418). Hawkins defines this genre, mistreated. That's how people with an composed of "autobiographies dismissed. " and biographies about illness," as "a reconstruction of experience = = = ^ ^ = ^ ^^^="=^^=""^^ that promotes healing" (19, p, 222). She sees the recent popmom to take the baby away. Ten minutes later, the doctor ularity of English-language illness narratives as a reaction to came and said there was nothing special about the baby. the dehumanizing medical system, which focuses mainly on This is no emergency, he explained. Your mom told me the the disease, ignoring the patient (19-20). The pathography nurses nearby were shaking their heads, though they resurrects the overlooked person by "situating the illness didn't say anything audible" (22, p. 398). experience within the author's life and the meaning of that The mother could not win due attention from the medical life" (19, p. 224). The genre also reflects the ways culture staff until the twin's regular pediatrician, affiliated with and society shape perceptions of the body, categorization of another hospital, intervened and transferred her there. The bodily symptoms, and interpretations of complaints (21). baby died in the second hospital. More Than a Case The pathography used in this pilot, titled "More Than a Case," was written by co-author TMT about a case that he managed when he was a social worker in New York working for a child welfare agency (22). The protagonist is a Chinese woman, a single mother raising several children, including newborn twins. She spoke limited English and was on welfare. One of the twins was born with disabilities and was referred to the agency where TMT was employed. The other twin. Baby Ann, was born healthy, but she suddenly fell sick and died of a rare viral infection. TMT's story recounts the events leading to the May 27 crisis and the mother's ordeals as Baby Ann's condition deteriorates, with more seizures, more rashes, and rising fever. TMT, the narrator, tells the other twin, who survives, how her mother watched helplessly as she continued to be dis5 2 Nursing Education Perspectives

missed by health care providers. Sensing her baby was in danger, the mother relinquished her usual docility to assert her concerns to the doctor: "May 27. IV was applied again. Baby Ann's body was red, and she was shivering. Your mom called the doctor. No one came. A nurse said the doctor was busy. Your mom was irate, saying your sister was in the ICV. The nurse said the doctor was busy writing reports. Your mom took the baby with IV and everything attached to the docoffice. The baby is in a sericondition, cried your mom. Who told you to come? the docjj,^ yeed back. He ordered your

Class Activities and Assignments The nurse faculty, DS and ITC, piloted the pathography in Perspectives of Nursing (an introductory nursing course) and the Science and Art of Nursing II - Management and Leadership (the capstone practical nursing course), respectively. Before the pilot, they had used combinations of role play, lecture, and a group research paper to teach cultural competence. Eor this pilot, DS and ITC collaborated with their eolleague TMT to develop activities around "More Than a Case" to substitute for their old lessons. The new activities had three stages. Eirst, students were assigned to read "More Than a Case" and prepare for study questions. (See Sidebar 1.) While individual questions varied in focus, their overall purpose was to develop cultural competence by challenging students to read the

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pathography closely and apply nursing concepts to an analysis of transcultural issues delineated in the text. The second stage was class discussion. Students in small groups discussed the study questions. Then the nurse faculty, joined by TMT as a guest, led a whole-class discussion. The third stage was a writing assignment that asked students to select one of the study questions and develop a short patient/family assessment essay and a long critical essay. Student Learning To assess the effectiveness of the pathography in developing students' cultural competence as an ongoing process, the authors observed and analyzed not only students' oral and written responses to the assignments, but also their behaviors. What follows are the authors' observations.
COULD THIS POSSIBLY HAPPEN IN THE HOSPITAL? The

and angry tben. However, sbe learned from "More Than a Case" that she must treat all patents in the same professional manner, including the ones who insult her with racial slurs. DS and ITC found that the story continued to live with the students even after the lesson was over. Informal faceto-face and email discussions of the pathography continued among students and between faculty and students. ITC learned that following the illness narrative lesson, some students began to adopt culturally sensitive language wben interacting with one another in the classroom and beyond. ITC also observed that while the writing assignment did not require library researcb, some students were so interested in tbe topic of cultural diversity that they researched it on their own and incorporated some researched materials in their critical essays. W Y DID IT HAPPEN IN THE W Y IT DID? "More Than a H A Case" challenged students to go beyond tbe misleadingly simplistic "laundry lists of cultural characteristics" to delve into how the illness experience intersects race, gender, class, culture, language, education, and family background. DS observed tbat nursing students, sometimes influenced by simplistic representations of doctors and patients in the media, do not fully understand the implications of diversity for the complicated process of eare delivery. Some of DS and ITC's students, for instance, initially suggested "easy" prescriptions for the mother's plight: "She should have sought a second opinion"; "if I were the mother, I would have asked for the results of the tests"; "the mother shouldn't have returned to the same hospital again and again when they couldn't even give a diagnosis." Through class discussion and the writing assignment, students were able to develop a deeper understanding of the mistreatment of the mother. Based on the details of the pathography, they examined reasons for the mother's behavior and the service provider's negligence. Students did not simply attribute the hospital's general negligence to tbe

pathography was a powerful text that touched the students and motivated them to think about diversity, health care disparities, and their roles as nurses. The nurse faculty found that the use of the pathography was more effective in engaging students in these issues than their former pedagogy. Students felt compassion toward the family. Tbey were livid that the dying baby and the frustrated mother were failed by the entire system: "The doctors were doing nothing, the nurses were doing nothing, the social worker was doing nothing." Some students simply did not believe tbat such systemic negligence could have happened in health care. DS's students could identify with the narrative not only professionally but also personally. Some of her students, who had immigrant backgrounds, recalled tbat when they first eame to the United States, they had been treated the same way the mother in the story was treated: "That's how I felt when I was mistreated. That's how people with an accent and no money are dismissed." For some of ITC's students, tbe story reminded tbem of their being professionals of color. Jenny said tbat she could never forget being called a "nigger" by a patient. Sbe was very upset

Sidebar I. Sample Study Questions for "More Than a Case" I. Who tells Baby Ann's story? To whom is the story told? What insights, biases, and limits does the narrator have? 2. How do you, as a nurse, assess the mother?

Your assessment should address the following: a) her cultural, language, economic, and family background, b) the development of her self-esteem during Baby Ann's hospitalization, and c) her strengths and weaknesses in advocating for and taking care of Baby Ann.

3. If you were the nurse on duty on May 27, would you do anything different to better address the needs of the mother and Baby Ann, to better intervene between the family and the doctors? What would be your difficulties?

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mother's overall submissiveness as a recent Asian immigrant. Instead, they saw this cultural factor in connection with the mother's lack of support as a single mother taking care of two newborns, her class as a Medicaid-paying client, and her language barrier. They also observed how the mother defied the stereotype of Asian respect for the authorities and confronted the doctor when she saw that her daughter was in danger.

unprofessional behaviors, they could also suggest appropriate consometimes influenced by SIMPLISTIC duct and actions based on the nursing concepts they had learned. REPRESENTATIONS of doctors and Many students noted that if they were on the floor on May 27, they patients in the media, would have immediately requested translation service to better comdo not fully understand municate witb the mother. As June noted, "Language barriers pose the implications of diversity challenging communication issues at every level of the health care for the complicated process delivery system, creating a critical need for appropriate linguistic serof care delivery. vices." In addition, students would In examining the health care have reviewed and provided accuproviders' behaviors, DS and rate documentation in the patient's chart for continuity of ITC's students were able to evaluate the clinical situation by care. June noted that there were many lapses in the services considering relevant details of the story, synthesize and provided to Baby Ann. As a nurse, she is obligated to ensure apply the nursing concepts they had learned, and make judgthe dehvery of appropriate and timely treatment, take notes of ments about the doctors and nurses involved. Students' disany lapses, alert the health care team, and take proper steps. cussion of the May 27 episode is a case in point. Since the Doing this professionally is important because, as another stuchild was "running a high fever," Fei Fan observed, it was dent. Von, argued, "my first priority is to my patient, which "unacceptable" for the doctor to tell the mother that there was "nothing special" about this baby and there was "no means both Baby Ann and her mother." emergency." For Fei Fan, the doctor put more efforts in Reflections The use of the pathography proved effective in "controlling the so-called 'hysterical mother' than finding developing students' culturally competent selves. There were out what was wrong with the baby." Other students noted difficulties that needed to be addressed, bowever. The greatthat this doctor got his priorities wrong; he focused more est difficulty came from students' critical writing skills. In attention on the report he was writing than on tbe mother's the authors' college, nursing students have only taken one or legitimate concerns. two composition courses. The essay assignment proved chalJune observed that the nurse was as incompetent as the lenging for some students, particularly, but not exclusively, doctor. When the mother requested a meeting with the docthose students whose native language was not English. ITC tor, June noted that the nurse simply said the doctor was observed that although the class discussion helped students busy. She should have informed the physician of the meeting brainstorm ideas for their essays, it was necessary to stage request, and if the physician did not fulfill this request, "the the writing assignment more, using Writing in the Disciplines proper chain of command should have been informed." The (WID) strategies to provide early feedback to students' outnurse's failure to advocate for tbe patient and the family was lines and drafts (23). ITC also found tbat it was sometimes "inexcusable behavior." difficult for nurse faculty to assess student essays whose Not only could the students critique the medical providers'

Nursing students,

Sidebar 2. Writing in the Disciplines Writing in the Disciplines at LaGuardia Community College is a yearlong program providing faculty participants with support to design and pilot a writing-intensive version of a course that they choose. During the year, faculty members take part in small-group and largegroup meetings that help them integrate writing as a key component into their course. Participants are individually assisted by a writing fellow. For more information, visit the program's website at v/ww.lagcc.cuny.edu/wid.

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readability was compromised by language and structural errors and/or second-language interferences. Nurse educators may benefit from faculty development programs such as WID. (See Sidebar 2.) Despite the challenges, DS and ITC concluded that the use of the pathography was more effective than their old lessons in developing nursing students' culturally competent selves as an ongoing process. The story itself became a site of inquiry where students felt passionate about the characters and their interactions, analyzed the transcultural issues, synthesized and apphed the nursing concepts they had learned, and practiced their critical reading and writing skills. It was a site where the three faculty members were not lecturers about cultural characteristics, but facilitators of discussions about hfe experiences of transcultural interactions. It was by getting inside a story

that learning across cultures and disciplines took place, not only 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 City University of New York, Long Island City. lona Thomas-Connor, MA, RN, CNE, is an associate professor and coordinator of nursing programs, LaGuardia Community College. Ting Man Tsao, PhD, is an associate professor in. the English Department, LaGuardia Community College. Dr. Tsao acknowledges his mother, Siu Tamd Tsao, a nurse and a lifetime caregiver. For more information, contact Dr. Tsao at ttsao@lagcc.cuny.edu.
Key W o r d s Pathography - Cultural Competence - Narrative Pedagogy -

Close Reading- Critical Writing Skills - Nursing Education

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