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Thursday, April 22, 2010

Voice and agency


Janna, my Dalmatian, is a talker. She has always grumbled, moaned, sighed, barked, yodeled, and done this weird, uncanny half-whine, half chant when she is very excited about something amazing like finding my sock on the laundry room floor. Her sister, Maggie, is much quieter and very much the slightly-sneaky observer who notices everything. Most of the time, all that talking gets Janna what she is after—the lion’s share of attention. From her, much more than all that nursing literature out there, I’ve learned the deep connection between voice and agency. We are able to act as our own agents when our voice is heard; when we are marginalized, our voice is dismissed, or ignored, or simply drowned out by louder voices, and our ability to act as our own agent is negatively impacted. Our ‘vote’ is not counted. That toddler, sitting on his mom’s lap for an immunization, was clearly registering his vote. Thankfully, for his greater health, we shifted that vote with our distraction technique of bubble-blowing, otherwise his voice would have given rise to the agency of running out of the room!


As nurses we take this connection between voice and agency, between vulnerability and marginalization very seriously. On a daily, an hourly, basis we care for people who are made vulnerable by situation and have a voice, and people who are made vulnerable by society and have little-to-no voice. We see their disparate outcomes in recovery. For nurses, social justice is an integral component of practice: health and wellness outcomes are connected to voice and agency, vulnerability and marginalization.

Traditionally, nurses have always stood shoulder-to-shoulder with their patients, identifying with an equal plane of social power, acting as translators of ‘orders’ and advocates seeking to catch the ear of the white-coated medical elites. I cannot count the times that I have sat beside patients helping them think through and jot down questions they will take on their next doctor’s visit, seeking to give voice to their personal concerns and to have agency into their care. We act to empower these patients by coaching them to use their voice to gain ground in that short eight minutes they have the ear of their physician.

The dynamics of nursing have changed with time. We are now all-too-often fiscally restrained by time and outcomes not of our choosing; we are also moving up the ladder professionally and are beginning to sense the power distance growing between patients and ourselves. Along with the health care system, we are becoming ‘bigger’ and patients are becoming smaller. It is difficult to have your voice heard in the vast system that is the business of healthcare.

We cannot lose this innate call within nursing to identify voice, agency, vulnerability, marginalization in our care. To do so, would change the core of nursing. The pressure of practice today, however, is to move toward programs of interventions and guidelines of practice based on outcomes. There is everything right in this move, except that the decision to keep or axe a program or produce a guideline of practice is only as good as the evidence supporting it. Much of the evidence of which we are basing these fiscally-imposed decisions is from data that has failed to adequately capture the impact of nursing care interventions on patient outcomes.

For example, nurses’ care is often reduced to ‘tick sheet’ documentation that speeds up our world and is much easier to digitally record, however fails to record most of the actual care encounters that make up our shift. Narrative charting does not translate well to a digital world. The narrative portion of the chart (Nursing Notes) is helpful for communication between providers during an episode, but is disregarded after discharge. There is a huge component of nursing that has increasingly become invisible to decision makers, policy writers, and program evaluators. Two things happen with invisible voices: marginalization and lack of agency. We also forget who we are—a loss of identity because the new generation of nurses lose the connection of the ‘way things were.’

Doom and gloom for our profession? Of course not. We do need to acknowledge that change is the only constant in healthcare :-) … and we will continue to change with the needs of patients and populations. That is nursing and that is good. However, I do believe that to keep our strong core of advocacy and this commitment to social justice that informs our direct care and practice, we do need to strongly advocate for nursing sensitive indicators to be included in EHR systems so that we can document our care in a more complete, meaningfully manner. We need to raise our voices about what our direct and indirect care has contributed to outcomes of individual and groups of patients, of our communities and patient populations, or we will lose our ability to do what we do best. We need to learn to clearly articulate our needs as a profession and as individual professionals in our unique contexts of care, because if we cannot give voice to our needs this directly impact our ability to act, to be, nurses. Our agency is on the line.

God speaks as a still small voice. He also gets our attention by speaking in diverse ways (not necessarily louder). He speaks so that we can become bold in the knowledge of his great love for us and our neighbors. There is no exclusivity about such love. There is no circle of immunity to marginalization. We are called as nurses and as people of God to hear and to care. Let us support one another in continuing—and increasing—our ability to do so.


Wednesday, April 21, 2010

Hearing that voice


Hearing voices … this phrase conjures so many thought-directions. Nurses are all-to-familiar with patients who are tortured by the voices in their heads—as are Chaplains, for other reasons! Devout believers from diverse religions, sects, and cults yearn to hear and discern the voice of God … the Universe … or, Gaia herself. Everyday people driving to work, eating in diners, scrubbing their showers, tending their kids, long to discover the voice within—that proclaimed wise voice who knows who we truly are, why we are here, and what we are meant to do. For isn’t that the meaning of the current pop-wisdom rolling from cable to TV screen to living room: “Follow your heart … listen to the wise intuition residing deep in your … body … mind … heart … soul … spirit (depending on the originator)?” 

The voice is everything in our culture. No, I’m not talking about American Idol and the entire pantheon of spin-off talent shows across the networks. I’m talking about our culture’s unified fixation with THE voice—ours! Or so our individualism would say … Although we are driven to have our voice heard, we tend to hear that individualistic voice of ours simply echo back to us the voice of the majority—or the loudest, most media-drenched segment of the ‘majority,’ anyway! It seems we have ambivalence about voice: we want to have our voice heard and yet, like middle-schoolers, we want to fit in. We find it almost impossible to stand out against that media wave we identify with as the majority voice. Perhaps our fascination with trend-setters and cultural icons is a sign of this ambivalence of longing to be heard yet wanting to be one of the crowd. Perhaps our intoxication with celebrity status is a symptom of our yearning to have our very own voice ‘stand out.’

That said, our culture prides itself on its individualism: we see ourselves as pioneers, trailblazers, and our nations as having been forged on the backs of single-minded leaders who subdued the wild frontier. We, the colonizers of the West, have difficulty understanding any culture that does not cultivate individual voice over communal identity. To our Western minds, having a ‘voice’ means having a vote; raising your voice is an ability to protest, to have your needs made known, and presumably, met. To be ‘voiceless’ means to not have a say in the matter; the voiceless are marginalized, made invisible and helpless in our world.

We continue to have our challenges with raising our voice and listening to voices and most of our problems probably come from frantically trying to do both at the same time. Judge Judy is forever citing the old saw that says something like this, “We have two ears and one mouth for a reason—listen two times for every one time you open your mouth.” I am amazed at the graciousness of God that he did not give us ten ears and one mouth … Interestingly, the voice of God in Scripture varies from ‘still and small,’ to the roaring of a lion and a tornado, to the braying of a donkey, and the blowing of horns. Apparently, we don’t hear ‘so good’—and God finds it necessary to get our attention by mixing it up! I immediately conjure up the image of ourselves as the so-easily-distracted toddler who is wailing, ‘NO!’ one minute and staring mutely at a cascade of bubbles the next … As nurses, we are lightning-fast quick draws in pulling out those bubble wands during immunization encounters! 

My dissertation research project is called, ‘Lift up Your Voice.’ There are voices within our society that we have difficulty hearing within healthcare and as a society. This may be due to loss of capacity or functionality from the speaking, or voice side of things, or inattention and marginalization from the hearing end of the conversation. Individuals that live in residential care face huge challenges in being heard in our frantic, technology-driven society and our over-stretched, assembly-line healthcare system that cannot afford to pause to listen for indistinct voices. I am noting the many ways individual nurses and other direct care givers seek to incorporate the individual voice of residents in daily care; and I am seeking to hear the voices of these residents to shed light on what we are doing right and how we can better hear their voices.

Over the next few entries, I will be exploring the concept of voice and reflecting on themes that are emerging as I begin to listen. My hope is that I will learn to use my two ears and only one mouth in my own daily all-encompassing practice of care.