Changing the Face of Nursing:
Teaching Writing to First-Year Nursing Students

This essay will describe a signature course I developed as a result of my dissertation research. Currently we are offering only this course, but our hope is to expand this discipline-specific composition instruction to include both junior level undergraduate and graduate courses.

RATIONALE

In her 2001 text, The Nursing Profession, Norma L. Chaska asserts that nursing education must adapt to the current changes occurring in higher education. These changes pivot around the concept that the paradigm under which we are now operating calls for a focus on "achievement of desired outcomes" rather than on process. Furthermore, Chaska states, "Nursing, like all health care, needs a knowledge worker for the information-age. A knowledge worker nurse is one whose practice is grounded in skills associated with (a) critical thinking and clinical judgment; (b) teamwork and communication; (c) new technologies; and (d) leadership, management, and delegation" (144, emphasis mine). Moreover, in August 2001, the Texas Higher Education Coordinating Board developed a plan for "closing the gaps in higher education." Goal Two of this plan includes closing the gaps in success by increasing the number of successful graduates in several areas including nursing and allied health. "Successful graduates" should include those students who not only master the skills required for competent nursing, but also the discourse required to represent and advance the profession.

This discourse includes writing, a strand of communication woven together with listening, talking, reading, and thinking. Writing is a process that develops as we hear what others have to say, talk through our own ideas with other writers, and read what others have written. Writing and reading instruction leads to superior critical thinking skills. Research for my dissertation, "Collaboration or Subordination? The Role of Rhetoric in the Conception of Primary Healthcare Providers," shows that what is being written both about and by nurses is confining the nursing community a subordinate position. For example, Dr. Mary Mundinger's article published in The New England Journal of Medicine in 1994 raised the ire of primary care physicians nationwide because she failed to consider her audience.

Similarly, a study published in the January 5, 2000, edition of JAMA by Dr. Mundinger and others was ineffective in convincing the medical community of the validity of the nurse practitioner movement due to the authors' failure to anticipate the intended audience's objections. Had these authors been trained in rhetorical principles such as purpose and audience, and had they received instruction in the artistic appeals, these innovative pieces might have been more successful in advancing the nurse practitioner movement in particular, and the nursing profession in general.

Because rhetoric is the integrating core for the study of human communication, education in rhetorical principles allows the student to study and utilize the nuances of discourse that affect the informative, persuasive, exploratory, and expressive use of language, whatever the subject matter. Here we discuss the practice of contextualizing health care writing through a course I designed to reach these goals as well as to satisfy the specific state goal of closing the gaps of success in nursing education.

METHODOLOGY

The methodology for this two-semester first-year writing course includes a five-step approach:

The nurse as observer (two-part project)
The nurse as narrator
The nurse as ethnographer
The nurse in society
The nurse in debate

Each of these core components of the course focuses on critical thinking, teamwork and management skills, and new technologies as well as oral and written communication. While these skills are essential to all projects in the course, we will highlight the critical skill being evaluated by the project in each individual project.

THE NURSE AS OBSERVER, PART I: For this assignment, students create a descriptive paragraph of a place. One of these descriptions is positive; the other is negative. The purpose of this exercise is to help students understand how words create subjectivity. One primary objective of first-year writing is to help students see the difference between telling about a subject and showing readers—through words and images—the subject. Here students are practicing the essential skill of thinking critically about their words as well as beginning to develop analytical skills, and their final projects are evaluated for their understanding of how language can create worlds. These skills will transfer to the upper level writing course in that they will take with them a newly-found understanding of the power of language, and they will use these skills on the job as they understand that their own angle of vision can affect patient treatment.

THE NURSE AS OBSERVER, PART II: This assignment asks the students to, together with a partner, observe a person. However, the students are cautioned not to speak to one another during the observation. They are given a discrete set of criteria to record regarding their subject. Students are then asked to separately construct a profile of this person. After creation of individual profiles, the students are asked to compare and contrast their respective profiles with their partner's profiles. The purpose of this assignment is to help the students begin to understand that they can construct simple objective observations. Although their profiles are not identical, the students usually successfully create similar profiles when they focus on using nonjudgmental language, and when they utilize the "showing vs. telling" skills they have been practicing for Part I. They are then asked to reflect on the entire project, parts I and II, and to begin to synthesize this newly-found knowledge of subjective versus objective, and how words can create an angle of vision. These skills are essential for upper-level nursing courses not only as the students become more mature researchers, but also as they begin their clinical rotations. They will use these observational skills as practicing nurses and nurse practitioners in assessment, treatment plan development, and charting.

THE NURSE AS NARRATOR: Students begin to learn the art of interview and narration with this assignment. They are given a set of questions to help create a systemic appraisal of an individual's beliefs, values, and practices in order to begin to understand how to provide culturally competent health care. Although this cultural assessment is a junior level nursing assessment course assignment, I have put a twist on the assignment. Students create a cultural assessment of themselves prior to interviewing their partner in order to gain practice in writing narrative information. After the interview is complete, each student writes up the assessment of themselves and the assessment of their partner. The students then exchange papers. Each student thus has two assessments of themselves: one written by the partner, and one written by the student. The idea here is to help students begin to understand how words can create people as well as places; indeed, some students find that the people created by their partners are not recognizable. We are all aware of the possibilities for miscommunication that exist in ordinary conversations. This assignment helps the students recognize that the dangers of miscommunication may be even greater when information is written, and the opportunities for clarification present in face-to-face communication are absent. This is especially important for health care professionals working in a field where miscommunications may in fact be matters of life and death .

THE NURSE AS ETHNOGRAPHER: For this assignment, students are asked to explore a particular cultural subgroup of their own choosing and to create an ethnography of that group. Ethnography is a form of research focusing in the sociology of meaning through close field observation of sociocultural phenomena. Ethnography is important to the anthropological community because it creates written documentation that this culture does, in fact, exist. Ethnography is important to the composition student as it objectifies the principle that language is shaped by the purposes of its users. Students establish what knowledge differentiates this group from others. Moreover, students are given further opportunity to practice the task of close observation and inference based on data gathered.

Students are asked to determine, particularly, what language group members must have in order to be an "insider." The purpose of this assignment is to help students synthesize the knowledge they've gained in the previous assignments: objectivity, accuracy of reporting, awareness of judgmental language, and the connection between listening, looking, and writing. Furthermore, students begin to practice the process of thought in inquiry: hypothesis—data collection—inference—testing. This process will help them with synthesis of research in upper level courses and will assist them in becoming aware and sensitive to cultural differences on the job.

THE NURSE IN SOCIETY: This assignment asks a group of students to view a film that has a nurse as one of the central characters. Some examples of films we have analyzed include Nurse Betty, One Flew Over the Cuckoo's Nest, In Love and War, and Serving in Silence. The purpose of this assignment is to help students begin to think about the ways in which popular culture perpetuates or explodes the stereotype of the nurse. Additionally, students begin to understand the popular conception of the nurse. In addition, I also ask the students to research the theme related to nursing history inherent in their chosen film. For example, the group who watches One Flew Over the Cuckoo's Nest will research the history of psychiatric nursing. Those who analyze In Love and War explore Florence Nightingale's influence on nursing. Thus, the students gain some basic research tools. They are then asked to give an oral presentation on their project. Initially, I had planned to have them create a web site that would facilitate adding to the body of knowledge regarding nursing history. However, the first time the course was taught, we simply ran out of time and were not able to incorporate that project into the semester. The web portion of this project, however, is important for learning new technologies and understanding visual rhetoric and how the medium and message are interdependent, and I will continue having students work toward this culmination of critical thinking and writing processes and skills.

THE NURSE IN DEBATE: This part of the plan incorporates the entire second semester of first-year composition. We begin the semester with heuristic assignments designed to help the students decide on a topic they will explore the entire semester. They are only limited in that the topic must be a current issue in the healthcare profession. Many of the students chose to explore the nursing shortage—a pertinent issue, indeed. We spend approximately the first month of class exploring various issues so that the students can create arguments that will be valid and debatable. The students then move into the research phase of the semester. I ask them to write a short, informative article on their chosen topic. However, what they must do in this assignment is to expand the body of knowledge regarding the opposition's side of their debate. I have found that having the students take the opposing side and helping them gather research against their own point of view helps them begin to understand how the issue might be debatable (especially since first-year students often come into class seeing things from a very narrow perspective). In addition, this essay gives them a chance to "try on" new ideas as well as to generate the information they will need to effectively counter opposing views.

The students progress to an analysis of the cause and/or consequence of their issue. This assignment helps them gather background information about their issue. Their final project is a solution proposal. To create this, the students must first generate a classical argument using the information they've gathered from the first two assignments. They must then argue for a realistic, feasible solution to the problem. This solution proposal is presented to the class in a seminar that we hold at the end of the semester. Students are asked to imagine themselves in the professional situation and to conduct themselves accordingly.

RESULTS

The results of this work were astonishing last year, in the pilot project of this program. I was fortunate enough to have one of the senior nursing faculty, Dr. Patricia Hamilton, attend the solution proposal seminar for my class, and she was amazed at the depth of thought these students had generated. In fact, she wrote: "The quality of the rhetoric was outstanding and the recommendations for addressing the shortage were of an extremely high caliber. As a matter of fact, they were on a par with those of an expert panel here in the Dallas/Ft. Worth area convened to suggest remedies for the shortage." So, it would seem that this program has incredible potential not only to help students be better students but also to help create better professionals.

And the students apparently feel the same way. In an end-of-semester reflection, one student writes: I learned so much from this class that I will use in my future. Before this semester, nursing just sounded like a good option for me. I knew the basics of what nurses do, their salary, and I really wanted to go into the medical field, too. After researching this semester in English class, I had mixed feelings about my major, like if nursing is what I really wanted to do with my future. The more I researched, the more I wanted to become a nurse and try to bring on change to all of the issues I explored. I am definitely looking forward to practicing nursing so I can apply what I've studied. I am so lucky that I was given the opportunity to explore a topic that will be so beneficial in the future.

And another writes:

We are situated uniquely to begin to transform these beginning students into Chaska's "knowledge worker" nurses. Not only are they learning and practicing critical thinking skills. They are also rehearsing working in teams, communicating with one another, learning new technologies, and exploring the worlds of leadership and management. We are helping prepare our students for engaging in critical inquiry as they begin to observe the physical world and translate those observations into written inferences. Our hope is that these students will continue to hone the skills they learn in our classrooms as first-year writers and then again at the junior level. We believe that, if students take these rhetorical skills into the workplace, they will change the face of the nursing profession. They will bring new knowledge into the medical field. And, they will represent themselves as knowledgeable, credible, and valid members of the healthcare community.