Poetry: a reflective practice tool for nurses and midwives

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Pract. Dev. Health Care 6(4) 203–212, 2007Copyright © 2007 John Wiley & Sons, Ltd DOI: 10.1002/pdh

Innovation in practice

Poetry: a refl ective practice tool for nurses and midwives

Maralyn Foureur—Professor of Midwifery, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, PO Box 123, Broadway Sydney, NSW 2007, Australia

Rachel Bush—Poet in Residence 2004, Wellington Hospital, Capital Coast District Health Board, Wellington, New Zealand

Jan Duke—Professor and Head of School, Graduate School of Nursing Midwifery and Health, Faculty of Humanities and Social Sciences, Victoria University of Wellington, New Zealand

Cate Walton—Research Nurse, Clinical Effectiveness Unit, Graduate School of Nursing Midwifery and Health, Faculty of Humanities and Social Sciences, Victoria University of Wellington, New Zealand

ABSTRACT

This article describes the practice of a ‘poet-in-residence’ in a tertiary hospital in New Zealand, a country with a unique bicultural foundation. During her residency, the poet worked with hospital staff to gain insight into how nurses and midwives contribute to health outcomes. As well as creating 12 poems which make the work of nurses and midwives more visible, the poet provided poetry readings in two clinical areas and conducted a refl ective practice exercise using the co-creation of poetry, with a group of newly graduated nurses. This residency demonstrated the importance of connecting the world of science and technol-ogy with the world of lived experience and how poetry can help nurses and midwives to express the complexity of human care practice. Copyright © 2007 John Wiley & Sons, Ltd.

Key words: nursing/midwifery education, poetry, refl ective practice

Practice Development in Health CarePract. Dev. Health Care 6(4) 203–212, 2007Published online 5 November 2007 in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pdh.237

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Introduction

In 2003, the New Zealand Poetry Society began a pilot scheme ‘Poetry in Places’, aimed at promoting and creating poetry in places, particularly work places. In December 2003, the then Director of Nursing and Midwifery at Capital Coast District Health Board (CCDHB) approached ‘Creative New Zealand’ to sponsor a poet-in-residence project at Wellington Hospital. The proposal was that a poet-in-residence be appointed to work at the hospital for a period of three months. A poet-in-residence project also fi ts well within New Zealand’s bicultural foundation, as it addresses not only the cultural heri-tage of the indigenous peoples of New Zealand, the Maori, but also complements the oral traditions of other imported cultures. It was proposed that the poet would work in the hospital setting for an equivalent of two days a week for 12 weeks, with additional support provided by the Graduate School of Nursing and Midwifery at Victoria Uni-versity. During this time, she would experience the hospital environment, its nursing and midwifery services and the ‘language’ used within this environment, develop new poetry relating to those services and the ‘language’ specifi c to those services, and provide in-house poetry readings for staff and clients.

Poetry within the New Zealand context

Story telling, song, prayer and poetry have an important place in the traditions of many cultures. Aotearoa, New Zealand, is a country with a multicultural population that is founded upon a bicultural heritage: the culture of the original settlers, who are recog-nized as the indigenous peoples of New Zealand, the Maori, and the culture of the majority population, known as New Zealand Europeans or Pakeha. New Zealand’s founding document, the Treaty of Waitangi, guarantees to the Maori the right to retain control of their land, whenua; traditions and ways of life, tikanga; and language, te reo. Within the New Zealand health setting, therefore, it is important to respect, under-stand and encourage the Maori world view of health, which differs from the European scientifi c traditions, in that it places a far greater emphasis upon the role of the spirit, the land and the ancestors in health and healing.

When a Maori member of the whanau (family) is in childbirth-labour, unwell or nearing death, members of the community gather to perform karakia (prayer) and waiata (song) to support the infant towards birth, the spirit of the loved one towards health, and the soul of the departing one on the next stage of their journey. The use of poetry in health therefore sits well within the paradigm of this cultural group, and encouraging its use within the health care setting may help and support non-Maori to understand the glimpse they are seeing of the Maori world view (Colquhoun, 2006; New Zealand Ministry of Health, 2002; Papps, 2005).

The poet-in-residence project

Rachel Bush was appointed poet-in-residence at Wellington Hospital. Rachel made three visits to Wellington between September and December 2004, during which time

Poetry: a refl ective practice tool 205


she observed staff working and spent time in the neonatal intensive care unit, the an-tenatal ward, the intensive care unit and in the rehabilitation ward. During her visits to the hospital, Rachel spoke mostly to nurses, midwives and their patients. She also spent time at the Fuel Bar, a small coffee bar in the main hospital corridor, where she encountered a variety of other hospital staff. Rachel stressed that she needed to spend time getting to know people so that they would be comfortable to speak openly with her about their work, but she did note that the staff were not allocated time to talk to her and that: ‘talking to me was one more thing to do in the very busy day of a nurse or midwife’.

During her tenure as poet-in-residence, as well as gathering experiences for writing poetry, on two occasions Rachel read poetry to staff and patients in the assess-ment, treatment and rehabilitation unit. This gave rise to discussions, during which stories of early lives were shared and topics such as radio talk-back shows, being in hospital and feelings about poetry were discussed. One staff member also revealed that she herself was a poet, sharing poetry she had written about the staff and their work. Staff members were very touched that she had used this medium to celebrate their lives and work.

As well as reading poetry, Rachel also initiated a project which she called ‘Open Windows’. Rachel approached other New Zealand poets, who ‘gifted’ (the poets and their publishers gave permission for their poems to be used in this way) 14 of their poems for use during this project and within the hospital setting. For 14 days, one poem daily was sent out, using e-mail, to senior nurses, midwives and other hospital personnel. The poems were sent to a total of 334 staff e-mail addresses. Each poem was accompanied by an introduction from Rachel, and recipients were encouraged to print these out and put them on walls, in their units, staff rooms, wards, waiting rooms, and to give a copy to any nurse or patient who might enjoy them (but only within the hospital setting).

Rachel also ran a workshop for recently graduated nurses employed in the New Graduate Programme at the hospital. Firstly, she spoke briefl y about her work as poet-in-residence and then she read three poems, talking about how writing poetry can be used as a way of refl ection, enabling the author to focus on and clarify a problem, worry or unresolved issue. Using a technique previously developed by the poet Kenneth Koch (1977), and discussed by Dickson (1999), Rachel then encouraged the nurses to write their own poems. The nurses were divided into groups. Each member of a group was given a strip of paper and asked to write two lines, completing the fi rst line, which began, ‘I used to . . .’, and then the second line, ‘But now I . . .’. The nurses were encouraged to complete each of these two lines as truthfully as they could, using their experience of nursing for the topic, and thinking about how things had changed since they graduated, and in what way. They were encouraged to think about what they believed about nursing, and the things they did as nurses. What did they enjoy; what did they worry about or dread? What were they feeling about the role and the job of being a nurse?

The lines they wrote were then joined together to make a whole poem, keeping each pair of lines together; and then each group invented a title for their poems. The completed poems were read and discussed as a way of refl ecting on practice. The poems

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produced were made into a booklet for each nurse to keep, and have recently been published within the hospital environment. One of the class poems is reproduced here.

Sands through the hour glass

I used to see wounds and bandagesbut now I see Lives, Fears, Hopes and Resilience

I used to be scared of nursing and would crybut now I feel confi dent in my practice and can smile

I used to think it is easier to nurse people to deaththan it is to nurse them to lifebut now I am learning to do both

I used to get a queasy tummy with all the yucky smellsbut now I’ve learnt to block my nose and smile when I clean their toes

I used to be mechanical, fret about recordings and forget about the patientbut now it’s about Bob, or Joe, their baby Jane, who’s teething at the momentOh! – and how much have you drunk today?

I used to think nurses had endless patience, a smile inherent in their naturebut now I know – after six days on, no meal break, two too many patientsfour bells and a puddle of haematuria awaiting mesometimes we are just good at faking it

I used to believe knowledge was one of the most important attributes in a nursebut now I have realised a smile is all it takesfor a patient to remember me by

Graduate Nurse ProgrammeClass PoemsOur fi rst year of clinical practice15/12/2004Group poem written by seven of the class members

The fi nal stage of the poet in residence programme involves the publication of the 12 poems that Rachel wrote from her experience of being the poet-in-residence in a new book, published in December 2006 (Bush, 2006). The book is called ‘All Patients Report Here’. Of her poems, Rachel said:

‘. . . some of these poems relate to the work of nurses and midwives. However,

as my poems tend to be discoveries rather than statements about a previously

decided point of view, other aspects of hospital life, including my own reactions

to the experience of being a ‘poet-in-residence’, have found their way into these

poems’.



One of Rachel’s poems is reproduced here, with permission.

Some days it’s hard

Mr Shaw died this morning.I showed in his visitorsand he was dead butI felt his pulse.I said I am sorry,I think Mr Shawmay have passed awayand I said I think we need the doctorand the doctor came butthere was no drug to prescribeand no more doses to calculate,Mr Shaw had gone. Then the doctor left us.But the visitors stayed, his cousin from Melbourneand his daughter who lives in Mount Albert.They looked at me and none of us could speak.

Rachel BushPoet in ResidenceWellington Hospital2004

Outcomes arising from the poet-in-residence project

Over the three-month period that Rachel worked as poet-in-residence, we were able to observe several benefi ts arising from this project. These benefi ts are: the highlighting of the work of nurses and midwives, the use of poetry as a tool for new graduate nurses to refl ect on their practice experiences, and, fi nally, the opening up of channels of communication and the sharing of experience.

The poems that Rachel wrote during her time as poet-in-residence highlight the work of nurses or midwives, as well as showing a range of patient experiences en-countered during her residency. Additionally, the poems produced during the new graduate workshop have been published in a booklet, which has recently been distrib-uted throughout the hospital environment. As a result of the positive feedback about the poetry-writing exercise, the New Graduate Clinical Educator now includes time to write refl ective poetry as an integral part of the new graduate programme. Several po-ems written by Rachel during her time as poet-in-residence were used by the neonatal unit in their annual report, to highlight the work of the unit and staff. One of these poems is reproduced here, with permission.

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Little man

His ribbed pale beaniebig as a duck’s egghas fallen behind his head,lies in the incubator bya small stuffed kangaroo.His duvet is patchwork and eachpatch has sewn on it, a blue giraffe.He is growing bigger than a kitten.Through a porthole his motherfeather-strokes one shoulder.He makes so little soundbut sounds of words reachhim. His mother speaks, and a nursewho calls him Little Man becausehe is.

Rachel BushPoet in ResidenceWellington Hospital2004

The reading and sharing of poetry in the assessment, treatment and rehabilita-tion unit opened up lines of communication and brought people closer together. People began to share life experiences, ideas and feelings. In addition, one staff member was able to reveal her own use of poetry to celebrate the lives and work of her nursing col-leagues and to manage the experiences that were generated during her work within the health care environment.

The literature

The poet-in-residence project appeared to have many benefi ts for those people who fi nd themselves within the hospital environment, either as a patient, or as a member of the team of people working to enhance and promote the health outcomes of those patients. We were interested to fi nd out whether this experience was unusual or whether there were examples within the literature that supported our experiences.

One of the fi ndings from our literature search was that there is a large body of literature in which patients, the consumers of the health system, write poetry to explore their experiences of being a patient, of being ill; to explore their own mortality and to demonstrate their experiences of the people who care for them (Abse, 1998; Campbell, 2002; Clelland, 2004; Willms, 1999).

As well as discovering poetry written by consumers of health care, in the course of our search of the literature we also found many examples of poetry written by nurses



and other health care providers (Abse, 1998; Clelland, 2004; Fraser, 1996; Furman, 2006). While the American Journal of Nursing is one publication that features a forum for nursing stories and poetry, Dellasega (2003) found that there is actually very little poetry and prose written by nurses and midwives that is published outside of profes-sional publications. One exception to this is in the book Intensive Care: More Poetry and Prose by Nurses, edited by Davis and Schaefer (2003), in which work from 64 authors from around the world is published. This book features many poems and stories that provide vivid examples of the work of nurses. In this book, the central theme demon-strates not only the work of nurses, but also the emotional confl icts that nurses can experience through the sharing of such feelings as grief and loss, and anger.

Poetry not only demonstrates the work of the profession, but it also provides a medium for nurses to explore the complexities of their profession, to manage the frus-trations and stressors that they encounter in their day-to-day working lives and to communicate this to each other, and to people outside of the profession (Bonebakker, 2003; Colquhoun, 2006; Hunter, 2002; Kidd and Tusaie, 2004; Marchand and Kushner, 2004, Meites et al., 2003; Olsen, 2002; Peterson, 2002; Phillip et al., 1994; Raingruber, 2004; Rudolf and Storr, 2003; Sargent, 1979; Schneiderman, 2002; Wagner, 2000; Willms, 1999).

Using poetry, nurses can explore, articulate and refl ect on their experiences and observations while working within health care settings (Hunter, 2002; Kidd and Tusaie, 2004). Nurses are often faced with situations of moral ambiguity, as well as situ-ations where they are faced with the reality that they will, when providing nursing care, exacerbate a patient’s pain and suffering. Additionally, there are many times when all of the care and hard work that a nurse provides will not improve the outcome for the patient and/or for their loved ones. Reading and/or writing poetry can provide an outlet for the nurse to refl ect on, relieve or reduce the tensions generated during these occur-rences (Bolton, 1999; Wagner, 2000).

As a creative medium, poetry can explore the point of view of the patient, the health care professional or the observer, allowing for description and exploration of experiences and opening the reader or writer to the reality of another’s experiences, reactions and beliefs (Abse, 1998; Campbell, 2002; Clelland, 2004; Davis, 2001; Fraser, 1996; Kidd and Tusaie, 2004; Phillipp and Robertson, 1996; Pini and Horton, 1995; Rudolf and Storr, 2003; Willms, 1999).

A further fi nding from our literature search is highlighted by Trautman (1971), who found that poetry written by nurses (and midwives) about their work has been in-creasing in volume and quality, which mirrors the professional development of these disciplines. As nursing has developed from a profession that focused on the tasks of patient care, to an understanding of the myriad factors within the patient’s life and the health care environment that have an impact on the patient’s health and health out-comes, nurses have increasingly used the forum that poetry provides to express and explore the complexities of the modern nursing environment.

While many people see the area of health care as being one where scientifi c inquiry is a necessity, medicine, nursing and midwifery are healing arts (Abse, 1998).

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The increasing technological advances within these professions can create an environ-ment where the human experience can be overwhelmed by the demands of the tech-nology required to provide health care. Using poetry to describe and illuminate the human experience within this high-tech environment can ensure that a balance is maintained between the demands of health technology and the experiences of those who either use this technology or experience its use on themselves and their bodies (Abse 1998; Ahlzen, 2002; Evans and Greaves, 2002; Rudolf and Storr, 2003; Sakalys, 2002).

Finally, we found a description of a nurse-initiated project conducted at the Royal Aberdeen Infi rmary in Edinburgh that aimed to provide visitors and patients with access to poetry. As with the ‘Open Windows’ project, poems were supplied with the intention of providing a respite from the hospital environment. For busy hos-pital staff, who had little time out from their work, the aim was to have poems available that could be read during short breaks in their working day (Macduff and West, 2002).

Summary of the poet-in-residence project

The poet-in-residence project at Wellington hospital ran for a period of three months in late 2004. Poetry was provided via e-mail to nursing leaders and other staff groups, with the intent that this poetry be shared within the hospital environment. The gen-erosity of the poets who gifted their poetry for this project must be acknowledged. It is not known how these poems were received or what contribution their receipt made to the hospital environment; however, as has been shown by McDuff and West (2002), the provision of poetry for the use of staff and patients within the hospital environment is not unique to this project.

Poetry readings held by the poet facilitated discussions between the poet, the patients and the staff of the unit. Staff and patients had the opportunity to learn more about each other, during discussions about their early lives and about current events as portrayed by radio talk-back shows. During these discussions, one staff member, who herself wrote poetry, was able to discuss this and to share her poetry with her colleagues, leaving them overwhelmed by her acknowledgment of their lives and work. This high-lighted, for this group, the benefi ts of using poetry for refl ection of experiences encoun-tered within the hospital work environment and how poetry can refl ect the reality of the work that nurses do, and the impact of this work on their lives.

The most signifi cant outcome from the poet-in-residence project was that the positive feedback from the group workshop in poetry writing for new graduate nurses has resulted in the permanent inclusion of a poetry-writing exercise within the annual New Graduate Programme conducted at Wellington Hospital.

The successful completion of the poet-in-residence project has highlighted the benefi ts to nurses and midwives of using poetry to manage the complexities of their work experiences and their work environment, and demonstrated the importance of the arts to nursing and midwifery. The provision of poetry workshops for health care



professionals may help them to manage work place stress and also enhance communica-tion between workers and between professions.

There has been a proposal to make the poetry produced during the poet-in-residence project available to patients and staff in the form of postcards that would be available in central locations. This is awaiting publication of the poems in book form, so that issues of copyright can be appropriately addressed.

Acknowledgements

This work was sponsored by three organizations: Creative New Zealand; Graduate School of Nursing, Midwifery and Health, Faculty of Humanities and Social Sciences, Victoria University of Wellington; and the Capital Coast District Health Board

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Address correspondence to Professor Maralyn Foureur, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, PO Box 123, Broadway Sydney, NSW 2007, Australia. Tel: +61 +2 9514 4834; Fax: +61 +2 9514 4835. E-mail: [email protected]

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Poetry: a reflective practice tool for nurses and midwives