Writing Sample: Music Therapy for Nurses: Thinking Critically About Healthcare

Troy Croom

English 832

Prof. Whiteside

15 December 2014

Music Therapy for Nurses:

Thinking Critically About Healthcare

Before entering graduate studies at SFSU for English Composition, I was in a pre-nursing program where all classes were taught by lecture and lab where, unlike my graduate work, no opportunity was created for discussion or critical thinking. Beyond the memorization of scientific data, the only analytical exercises were applications of anatomical facts to lab questions, but never the chance to question the ideologies that underpin the healthcare industry. My research suggests that pre-nursing courses share this same lecture tradition with many nursing schools. Not surprisingly, there has been an outcry in recent years for more critical thinking for nursing school pedagogy. (2008; Ozkahraman, 2011; Shin, 2008; Walker, 2003). In the spirit of this scholarship, the goal of this paper is to offer a proposal to apply notions of literacy as a social act to help students develop critical thinking skills in the nursing room classroom.

Literacy Review

The literacy foundation for this proposal stems from the importance of insisting on the understanding multiple literacies, rather than the conventional, narrow view of literacy. Where the term literacy has for too long described learners simplistically and ineffectually as literate or illiterate, capable or incapable, the term literacies takes the broad view that all people are capable of multiple literacies, developing and utilizing literacies for various kinds of communication and success, for example, math literacy, computer literacy or health literacy (Barton & Hamilton, 2000; Kern, 2004; Walter, 1999; Weinstein-Shr, 1989, Santos, 2014; Nutbeam, 2000). Literacy has been described using a variety of metaphors -- literacy as skill, literacy as task, literacy as practice and, finally, literacy as critical reflection, also referred to as critical thinking or as social action (Barton & Hamilton, 2000, p. 13 , Hernandez-Zamora, 2010, p.9, Walter). For the purposes of this paper, I shall use the term literacy as social action.

Promoting health literacy as a social act is a vital movement empowering students with a greater understanding of health practices and health services ( Nutbeam, 2000; Santos, 2014) Although this paper discusses music therapy as a heath literacy, I’m tailoring the term to fit my proposal in an unconventional way. Where heath literacy generally addresses the education of the marginalized directly, helping them improve health habits or to locate and access health services (Nutbeam, 2000; Santos, 2014), my application of literacy empowers the marginalized -- that is, the elderly in long-term care facilities -- indirectly by empowering tomorrow’s nurses with a therapy not normally at their disposal, namely music therapy.

My proposal is informed by key voices in the literacy field who have helped re-imagine literacy as a social act, as opposed to viewing literacy as a social practice. As Barton and Hamilton and others use the term, literacy as social practice limits its scope to reporting the way literacy operates to improve life on the interpersonal and intergroup level (Barton and Hamilton, 2000; Weinstein-Shr, 1989). However, as Walter (1999)points out, this perspective tends to simply record literacy events, rather than asking difficult questions about assumptions behind the status quo and prescribing options for action. (p.35) 

In this way, literacy as a social practice tends to enforce the dominant ideology, repeating what some call marginalization of individuals and groups, without offering a remedy. (Freire, 2001; Hernandez-Zamora, 2010; Walter, 1999) Interpreting literacy, not merely as a social practice, but as a social act, creates a much more active social dynamic. The former sees literacy as a personal problem, not a social issue, thus requiring no resistance to the status quo. Where the former lays the burden of illiteracy on individuals’ problems, the latter perspective sees literacy issues as systemic and calls on leaders in the field to address the political implications of education, and the need for promoting literacy as critical reflection. (Freire, 2001; Wallerstein, 1983; Walter, 1999) On the personal level, this approach has the potential to help students discover their voice, their true identity, since literacy is a “fundamental practice for self-authoring one’s place in the world” (Hernandez-Zamora, 2010, p. 9) or in Freire’s words, in learning to read, students learn to “read the world” (as cited in Kern, 2014, p. 36). Indeed, Freire (2001) goes so far as to say that literacy is meaningless unless it leads to “the right of self-expression and world-expression.” ( p. 340) 

Beyond the personal level, critical thinking can lead to the betterment of society overall, as it challenges people to re-think social priorities, thus reshaping the “collective consciousness” with revolutionary implications. (Walter, 1999, p. 44) In this sense, literacy has the power to affect the masses, whether they’re conscious of these literacy events or not (Barton & Hamilton, 2000, p. 13).

Why Music Theory?

My interest in applying music therapy to the nursing school classroom started after seeing the documentary “Alive Inside” on using personal music systems for Alzheimer’s and dementia patients in long-term rest homes. In the film, patients presented iPods with music chosen to match patients’ preferences come to life in a miraculous way. People largely limited to drug therapy, previously withdrawn and non-communicative for years, unable to remember specific memories of their lives -- thus essentially devoid of a sense of identity -- now recall vivid details of their lives with fluid speech and often ecstatic recovery of their personal identities. Thus, where drug therapy has apparently failed, music therapy holds tremendous promise. Moreover, the benefits, and the importance of, administering music therapy in this personal way are based on solid, peer-reviewed research. (Gerdner, 1992; Remington, R., Abdallah, L., Devereaux Melillo, and Flanagan, J., 2008).

Dan Cohen, MSW, a former social worker, has made it his mission to promote this program of personalized music therapy, which he named Music and Memory.org. In addition, Cohen has developed a series of webinar workshops to train rest home personnel across the country in the application of this therapy. As successful as the program has been already, Cohen has met with major resistance from rest homes, though the reason is unclear. One doctor in the film who is sympathetic to Cohen’s mission explains that, while there would be no problem in prescribing $1,000 in medications for a patient, the powers that be are very reluctant to help out with $40 for a personal iPod due to existing regulations, possibly the power of the pharmaceutical industry. (“Alive Inside,” 2014) The mystery behind this is a central part of the workshop.

If Cohen’s Music and Memory program has met with obstacles, nonetheless, it seems ideally suited for the purposes of my proposal, that is, challenging the nursing school classroom with a fresh perspective on treatment of dementia while championing literacy as a social act. In fact, perhaps because this program has met with resistance, this further legitimizes my proposal since this controversial approach, as represented by the film “Alive Inside,” seems the ideal conversation piece for igniting critical thinking in a nursing school classroom.

It should be noted, incidentally, that this application of critical thinking quite likely differs from the one typical nursing school pedagogy calls for. Where that literature urges teachers to move toward student-centered pedagogy to help students think analytically, I’ve seen no encouragement toward questioning the health industry. However, in my proposal, I hope to inspire students to find their own voices, to ask the difficult questions about the industry in an environment that welcomes inquiry and reflection.

THE PROPOSED WORKSHOP

The Guest Speaker

I’m calling this presentation a “workshop” because I visualize an outside instructor trained in this specific curriculum going from nursing school to nursing school as a guest speaker to present the proposed lesson plan. This guest instructor would need very specific qualifications. In addition to being an affable and professional communicator, he/she would ideally have training in gerontology nursing; experience in long-term nursing facilities; experience in treatment of dementia patients; an understanding of the ideologies and regulations that govern local long-term facilities.

The Lesson Plan

Goals: after completing this workshop, students will be able to:

Discuss the challenges facing dementia patients in long-term care.

Discuss the challenges facing nurses who treat dementia patients.

Discuss the power of the pharmaceutical industry on long-term facilities.

Evaluate critical thinking benefits for the nursing school curriculum.

The lesson plan overview:

1. Introduction: Brief Presentation -- teacher and program (5 minutes)

teacher’s background:

the background, purpose and agenda of the workshop:

“Alive Inside”

Music and Memory.org

the purpose and benefit of a critical thinking workshop

2. Getting Acquainted:

Individual quick write -- guided questions (10 minutes)

Why did you become a nurse?

What do you anticipate will be the most enjoyable parts of your job as a nurse?

What do you think will be the most challenging parts of the job?

Small group work (2--3 people) -- discuss quick writes (10 minutes)

3. Whole Group discussion of Students’ Schema --

finding out what they already know (15 minutes)

What training do you have in treating dementia patients?

What experience, if any, do you have in treating dementia patients?

From what you’ve learned, what are the symptomatic issues of dementia patients?

From what you’ve learned, what are the benefits of pharmaceutical treatment for dementia patients?

What do you know about the benefits of music therapy, especially personalized music therapy?

What is your experience with critical thinking exercises in nursing school?

4. Presentation of Film Clips from “Alive Inside” (25 minutes)

5. Whole Group Discussion -- initial reactions to film (5 minutes)

6. Small Group Discussion-- guided questions (20 minutes)

How do you think it feels to be a nurse for dementia patients?

From the film, how successful do you think drug therapy is?

From the film, how successful do you think music therapy is?

Why do you think Dan Cohen has had so much resistance in promoting personal music therapy with iPods?

What would it take to help you make a balanced decision on the benefits of music therapy vs. drug therapy for these patients?

7. Quick Meta-Write (10 minutes)

Your thoughts on workshop content:

How much do you value the information in “Alive Inside”?

How much do you question the long-term care system?

How much do you question the pharmaceutical industry?

Evaluate critical thinking exercises for the nursing school curriculum (1-3 lines each)

How useful was this workshop today?

How important do you think it is to be able to question the industry you’re about to enter into?

Why is it important for students to be able to express their opinions?

Reconvene -- individuals volunteer personal reports from the Meta-Write

(10 minutes)

Application of Theory

My proposal echoes scholarship in a significant ways. First, as a critical thinking lesson, the way it makes students question their world, and in the way they have to take a stand, these are steps toward developing voice and identity (Friere, 2001; Hernandez-Zamora, 2010; Wallerstein, 1983; and Walter, 1999 ). Second, from a very pragmatic point of view, informing nursing students about music therapy empowers them (Friere, 2001; Hernandez-Zamora, 20120) with a useful option, should conventional therapy fail, while introducing them to the options of alternative medicine in general.

As to specific classroom techniques, the workshop begins by getting acquainted with the students in order to build on their shared schema (Kern, 2014) by asking students to grapple with their experiences and their feelings, which they use to synthesize final conclusions after making meaning from a text (p,94). In this way, I borrow from concepts of “redesigning meaning” from existing Available Designs. (Kern, 2014, p. 55) I use film as a text, which functions as a code to trigger emotional response from students to help them express their feelings in problem posing exercises. (Wallerstein, 1983, p. 20). Arguably the film’s strongest tools, it might be argued, are the stories it presents; stories are effective in the literacy classroom, Kern (2014) posits, because they are “the overt expression of schematic knowledge.” (p. 99) In fact, my lesson plan harkens back to Kern’s “three Rs” -- responding, revising and reflecting (p. 307) After seeing clips from “Alive Inside,” students evaluate their initial interpretations in small group discussion; after hearing others’ viewpoints, students consider possibly revising their opinions in a dialectic. In the final Quick Meta-Write, students reflect upon the ways the documentary and the critical thinking exercise have affected their thinking.

Potential Challenges

Naturally, not every nursing school will be interested in sponsoring a critical thinking workshop. Some schools may see my lesson as someone trying to push his own ideology. Even if my program is embraced, the presenter has to be careful to focus on critical thinking, rather than “transmitting a world view.” (Auerbach, 2001, p. 271) Likewise, even if the presenter is very careful, there’s the chance that some students may interpret the lesson as a political class, rather than a critical thinking class. Granted, there is sometimes a fine line between the two. As Auerbach says, “. . . the dilemma is . . . how to acknowledge and embrace the . . . political nature of participatory pedagogy without imposing a political analysis. This is the dilemma I struggle with in all my teaching.” (p. 271) Of course, another challenge is that my nursing students, unlike Wallerstein’s students, may have had little or no specific life experience with the code I present. To some extent, the success of my program hinges on more general schema that students can connect to through the stories in the film.

Conclusion

Encouraging nursing students to question the overarching assumptions of the healthcare community can help them develop critical thinking skills, which can make them more adept and independent in thinking for themselves, an essential skill for nurses since, so often in healthcare settings, patients’ problems don’t always go “by the book.” Opening students’ minds to the benefits of alternative therapies can equip them with new techniques when the traditional means fail, and help develop their confidence in other solutions. In a sense, though, this only takes literacy as far as literacy as a skill.

The greater potential of literacy as a social act, I feel, is to give students the permission to ask questions in ways that they perhaps never could in typical nursing school classrooms. Granted this permission, students are empowered, I hope, to consider how the health care industry provides care and how it limits care; how nursing schools provide a learning opportunity and how they may sometimes hinder learning. If this empowers students, it is because they’re challenged to think outside of conventional confines, yet within a safe and supportive environment, redefining their sense of identity with the power to question power.

Perhaps the most interesting conclusion that I have found regarding literacy as a social action is it fluidity of application. Where, historically, the application of this theory (Friere, 2001; Hernadez-Zamora, 2010; and Walter, 1999) has been to aid the marginalized, especially those trapped by poverty or prejudice, I find it fascinating that the same theory of equally empowers educated, middle-class nursing students, stymied by American educational and health systems and, thus, oppressed in a sense as well. In both applications, literacy offers students the key to open doors once presumed to be pad-locked shut.

References

Auerbach, E. (2001) “Yes, but . . .”: Problematizing participatory ESL pedagogy. Campbell, P & Barnaby, B. (Eds.) Participatory practices in adult education.

New York: Lawrence Erlbaum. 267-305.

Barton, D. & Hamilton, M. (2000). Literacy practices. In Barton, D. and Hamilton, M. & Ivanic, R. (Eds.) Situated literacies: Reading and writing in context, 7-15. London: Routledge.

Freire, P. (2001). The adult literacy process as action for freedom. In Beck, S. & Nabors-Olah, L. (Eds.) Perspectives on language and literacy: Beyond the here and now. (335-351) Cambridge, MA: Harvard Educational Review.

Hernandez-Zamora, Gregorio. (2010). Decolonizing literacy: Mexican lives in the era of global capitalism. New York: Tonawada.

Gerdner, L.A. (2012). Individualized music for dementia: evolution and application of evidence-based protocol. World Journal of Psychiatry. 2 (2), 26-32.

Kern, Richard (2014). Literacy and language leaning. Oxford, England: Oxford University Press.

Nutbeam, D. (2000) Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Oxford University Press. 15 (3), 259-267.

Ozkahraman, S. & Yildirim, B. (2011). An overview of critical thinking in nursing and education. American International Journal of Contemporary Research. 1 (2), 190-196.

Cole, B. & MacDougald, A. (producers), Rossato-Bennet, M. (director). (2014) Alive inside. United States: Bond/360.

Remington, R, Abdallah, L., Devereaux Melillo, K. and Flanagan, J. (2006) Managing problem behaviors associated with dementia. Rehabilitation Nursing, 31 (5). (Sept- Oct). 186-192.

Santos, M. (2014) ESL participation as a mechanism for advancing health literacy in immigrant communities. Journal of Health Communication: International Perspectives, 19 (6). 89-105.

Shin, K. (1998) Critical thinking ability and clinical decision-making skills among senior nursing students in associate and baccalaureate programmes in Korea. Journal of Advanced Nursing, 27. 414-418.

Walker, S. (2003) Active learning strategies to promote critical thinking. Journal of Athletic Training, 38 (3). 263-267.

Wallerstein, N. (1983). Language and culture in conflict: Problem-posing in the ESL classroom. Reading, MA: Addison Wesley Publishing.

Walter, Pierre (1999). Defining literacy and its consequences in the developing world. International journal of lifelong education. 18 (1) (Jan-Feb 1999), 31-48.

Weinstein-Shr, G. (1989). From the mountaintops to the city streets: an ethnographic investigation of literacy and social practice among the Hmong of Philadelphia. 272- 292. Pennsylvania: University of Pennsylvania Press.