The aim of this article is to describe methods incorporating creative uses of classic literature about death and dying in a writing course for nurses. The students were registered nurses who had returned to school to obtain their baccalaureate degree. In one of the first courses, "Writing in Nursing," the content is nursing-oriented yet the goals are similar to those of the broader university, which include scholarship, creativity, and acquiring technical writing skills. The class was composed of 37 students; a third were new graduates from an associate degree program with no professional nursing experience, a third were professional registered nurses with 5 to 9 years experience, and the remainder had considerable acute care nursing experience. Very few had experience in community health nursing.
An essential "provocative" theme is required to fit with the companion courses of home nursing and community health. The theme of death and dying was chosen for its rich literature base, and its pertinent application to home care, hospice nursing, and alternative nursing interventions with chronic illness populations. The concept of death fits well with other areas of study such as nursing of families and the concepts of hope and helplessness.
The following paragraphs demonstrate ways that students made connections between literature and their clinical experiences, how they came to explore their inner and spoken voice in regards to death and their practice, and how a technical and scholarly writing program empowered these nurses by enriching their lives as well as those for whom they cared. The method behind much of this writing came from the Amherst Writers and Artists Institute begun by Patricia Schneider (1993), whose work has demonstrated remarkable personal growth and empowerment of low-income women and their families through writing. The learning activities in this course were selected writing activities including free-writing, responses to classic and contemporary literature on dying, and free-drawing. Prior to the conclusion of the semester, selected students gave written permission for excerpts of their work to be published anonymously.
SELECTED WRITING ACTIVITIES
A goal of this course was to merge technical writing with creative work. Writing activities varied from 10-minute free-writings to longer, reflective responses to classic pieces. Student papers varied from creating poems about the loneliness of hospital life, to argument papers concerning active euthanasia, as well as critiques of novels focusing on death. Blending scholarly writing with the profoundly moving and controversial topics surrounding death provided opportunities for nursing students to discuss research, express their feelings, argue their opinions, and empathize with the human condition of death.
Group learning activities were an outgrowth of brief weekly free- writing activities, as described by Elbow (1973). Free writing is a process of unlearning and relearning to write, by putting thoughts on paper continuously and uninterrupted for 10 minutes. The goal of a free-Write is to produce a continuous stream of thought on paper. By putting aside correcting, interruptions, and hesitations, a voice emerges on paper. This voice will ultimately become incorporated frito the writing work. The breadth of topics for free writing allowed the groups to connect with themselves and then with the larger group on personal and professional topics. Popular topics were how students got their names, how they learn, describing something they once had that was now gone, thoughts while riding in a hospital elevator, and their personal description of knowing and becoming.
Short writing exercises were "invitations" to write, not commands, allowing students to choose topics important to them. Small groups focused on listing themes with intergroup and intragroup discussion. For example, we discussed the feelings staff and patients experience in hospitals-fear, shame, and loneliness. Students visited hospitals, sat in waiting rooms, and rode in elevators, then free wrote about their observations and feelings. One student wrote about her experience as she was being wheeled to surgery
"....Quiet humming machinery, floor bells dinging, doors opening loudly, shutting coldly, boldly. . My tone pensive, my brows furrowed, my lips dry my thoughts racing, my senses acutely aware of my surroundings."
Another student wrote a poem about her impressions while riding the hospital elevator with strangers.
At my feet
At my watch
For these are strangers.
The meaningless stares
The clearing of throats
The occasional smiles
As we wait
In this quiet chamber?
Much discussion emerged around these characterizations, and concepts such as empathy, interaction, and reaching out to others were addressed as important caring characteristics. For the first time, many students could apply abstract concepta to concrete situations.
A poem about uncomfortable feelings riding in an elevator to work, was entitled Silence.
As I stand
I look away
I look up.
Anywhere but at your face.
Don't talk to me
I won't talk to you.
Stay out of my space
And I won't enter yours.
Here comes my floor
I can finally get off
My silent ride on the elevator.
These nurses were allowed to write about and then discuss taboo subjects such as not liking parts of their job or work environment. For some, honest, selfreflection made facing one's feelings a bit easier.
Responses to the Classic Literature
Students were asked to begin reading a classic piece of literature on death. The three book choices were, The Death of Ivan Ilyich by Leo Tolstoy (the death of a dying Russian aristocrat written at the turn-ofthe-century), On Death and Dying by Elizabeth Kubler-Ross (interviews of clergy and psychiatrists with dying patients, written in the mid 1960s), and The Power Within by Wendy Williams (short stories about women dying of cancer, written in 1990). The goals were to acquaint students with scenarios about dying individuals, in particular social contexts, at a particular point in history, and to compare the similarities and differences in what they read with their actual home nursing practicum.
Comparisons were done in small group discussions as well as in individual writing. One student compared health care today with that of Ivan Ilyich's era. ". . . Death is inevitable for all mankind whether it be at the end of the 19th century or the end of the 20th century. [Tolstoy] portrays an individual yearning for honest assistance in search of love, harmony, and delight within creation as he experiences the passages through the unfamiliar event called death."
This student goes on to challenge nursing to, "stretch beyond oneself and focus on the concepts of hope and honest assistance in helping others." The character Gerasim became a metaphor for nursing. ". . . Gerasim's relationship with Ivan Ilyich came close to Ivan's desperate wishes. He assisted Ivan to 'see the light,' to capture the essence of the stage of death called acceptance." Discussions emerged about nursing's role and feelings of worth and accomplishment from nursing work.
Following discussion of the classic works, and based on their perceptions, students were asked to create images of death. Random images were selected and shared with the class on an overhead projector. This activity was borrowed from work done by Bertman (1991), who has developed a curriculum around the notion of providing perspectives on terminal illness to support health care workers involved with the dying and their families. Composite pages were then made of all images, and students were asked to study them and respond to (1) the usefulness in portraying an image of death with art, (2) sharing in others' images, and (3) what meaning drawing a death image had for them.
While students had no problem seeing that death was conceptualized individually, recurrent positive and negative themes were noted. Primarily death was viewed in a positive light, as an extension of life. One student wrote, "My image represented a closure of one state of being and a beginning of a new state. The majority of images to me showed death as a peaceful transition from Tiere' to there'. Very few were negative. I think it was good to see others' versions of what death meant to them at their present stage in their lives."
Sharing in other students' images one student responded, "I am able to visualize how others view death; to extrapolate how nurses may deal with death on the job; spirituality versus nothingness." And another student concluded, "My colleagues are all nurses. I believe as a group we have all witnessed death and dying more than any other group. It is good to share a closeness of thoughts about death to support each other."
Although death was viewed primarily in a positive light, students also saw death had another side. A student wrote, "I saw darkness or black representing the pain, and loss as an initial response to death." Another student described her image as it went up on the screen. It showed a large sad face, not unlike the famous lithograph by Edvard Munch, The Scream." She said, "I work in a nursing home and so many people have died recently. It's horrible, they are in such pain and agony. . . . It's just horrible." The negative aspects almost always referred to the pain and suffering in the late stages of dying, and for the pain of those left behind. Group work allowed for a sharing of feelings about death resulting in validation for some and illumination for others.
Death and dying is a thread in nursing education that is usually only touched on briefly during discussions on ethics, in post clinical conferences, or as an elective course. More than two-thirds of this writing group had never had a course on death and dying, and yet these are the "front fine" caregivers who rarely stop to grieve their own losses when their patients die. Many of them felt grief was reserved for the family or loved ones. A natural outcome from focusing on this theme was that students learned how to explore the research about nursing interventions around death and dying, the importance of interviewing, getting to know the family and the dying individual as a unit, and self-reflection.
Self-exploration and finding one's voice was facilitated through this course. One student wrote, "Tm in [this] program to expand my knowledge base by sharing my views with others. It helped me grow." Another student wrote, "To define an abstract concept [like death] is difficult in words, but pictures express the concept in a universal language." Finally a student wrote, "It helps me to feel more connected with [others]." Such learning experiences were enhanced by free writing, small group discussions, and free drawing. Among all of the teaching tools used in this course, the classic literature assignment was essential in demonstrating to students that death is a powerful life event that needs to be shared to promote learning and healing.
The author wishes to acknowledge the contributions of the following students: RoseAnn Engbers, Phyllis DuComb, Gina Belluci-DiLizia, Elaine M. Georges, Kevin Conroy, Holle R Garvey, Sue Castenera, Linda Gaudette, Deb Renholm, Sue Krasner, Deb Dearden, and Kim Sweet.
- Bertman, S. L. (1991). Facing death. New York: Hemisphere Publishing Corporation.
- Elbow, P. (1973). Writing without teachers. London: Oxford University Press.
- Kubler-Ross, E. (1969). On death and dying. New York: Macmillan Publishing Company.
- Schneider, P. (1993). The writer as an artist: A new approach to writing alone and with others. Los Angeles, CA: Lowell House.
- Tolstoy, L. (1981). The death of Ivan Ityich. New York: Bantam Books.
- Williame, W. (1990). The power within. New York: Harper & Row.