Exploring Occupational Inheritance while Standing Together on the Precipice of Dementia.
"...my mom is a nurse. My sister's a nurse. And my Mom wanted me to be a nurse right out of high school and I didn't wanna do it. And so I was working, you know, jobs that weren't really going anywhere. And then I decided, hey, I need to do something with my life...so I chose nursing... but I. ..I feel like it's a good decision. I think I'm good at it and I like doing it...it's in my blood, I think." (1)
His story was typical of the stories I heard from many of my nursing students, though he was certainly not a typical nursing student. (2) Cheryl Beck found that students--males and females--name mothers, fathers, sisters, and grandparents, aunts, and uncles as dynamic influences in their decision-making about nursing as a career choice. (3) This is consistent with "in my blood" narratives I had heard from my students. I was curious about how many nursing students were raised by nurse parents, how their parents shape their values and attitudes, and how those values and attitudes lead to altruistic, rather than practical, reasons for choosing the profession. I wondered what values their children believed they bring from their nurse parents to the nursing profession, a profession they claim is in their blood. My mother is a nurse. I have also said that nursing is in my blood and I instantly connected with my student's use of the phrase.
In 2013, the editors of Nursing Education Perspectives wrote, "The development of professional identity is a continuous process that begins with admission to the nursing program..." (4) I believe that development of professional identity might begin long before admission to the nursing program, particularly so for students raised by nurses. If so, I share the privilege of shaping their professional identities with their nurse parents. That is, I believe their nurse parents contribute to student internalization of the core values identified for all nurses by the National League for Nursing: caring, diversity, ethics, excellence, holism, integrity, and patient-centeredness. (5) H. L. Goodall, Jr. suggested that we inherit the stories, experiences, and identities of our fathers, mothers, grandmothers, and grandfathers as a narrative inheritance, or the storied lives that they leave us to make sense of our own lives. (6) Based on Goodall's premise that the stories of those who came before us in our families provide "a framework for understanding our identity through theirs," (7) I embarked upon an oral history and autoethnographic inquiry to explore my mother's contributions to my professional identity and inform my practice as a nurse educator. I believe that stories, experiences, and identities are primary vehicles for transmitting values from nurse parents to their children, and, as such, are not just a narrative inheritance, but also, specifically, an "occupational inheritance." Occupational inheritance is the greater-than-chance tendency for individuals to choose occupations that are very similar to those of their parent and researchers have associated this tendency with value transmission. (8) With this essay, I contribute to this issue on family methodologies a description of the inquiry I conducted with my mother to explore my occupational inheritance. In so doing, I had to confront the methodological and personal challenges of capturing her nursing practice history as she stands on the precipice of her descent into dementia.
A Narrative, Autoethnographic Journey
Autoethnography is a research methodology in which an author uses their own experience to describe--and sometimes critique--cultural beliefs, experiences, and practices. Autoethnographers engage in laborious and nuanced self-reflection, often referred to as reflexivity, to identify and interrogate intersections between themselves and society. Arthur Bochner and Carol Ellis write that autoethnographers show "people in the process of figuring out what to do, how to live, and the meaning of their struggles." (9) I use autoethnography to explore the development of my professional identity as a nurse and nurse educator, as well as the contributions my mother made to the development of my identity. At first, I struggled with the idea of using autoethnography, resistant to writing about myself, and not understanding how my mother's oral stories, written narratives, and scrapbooks might serve my journey into the methodology.
As the oral history interviews with my mother unfolded, I began to settle comfortably into the methodology and soon discovered that my mother's narratives were rich tools for me to think with on my autoethnographic journey. I began reflecting on my workdays and making notes about how I engaged as a nurse educator with my students and fellow nurse educators. I asked myself, "How do my values and attitudes drive the way I engage in my work? How do I display my values and attitudes to my students and other nurse educators? How might my values interfere or facilitate my work with students and other nurses engaged with my students? How do my behaviors reflect my mother's values and attitudes?" Conducting family research with my mother has helped me to discern the basis for my own values and attitudes and to relinquish outdated views that no longer serve my profession. By engaging in an autoethnographic process, I hope to figure out how better to help my students develop their professional identities, to live better as a role model for my students and other nurse educators, and to determine the meaning of my struggles to do so.
Nursing Values Inherited: It's in My Blood!
I began my autoethnographic journey about development of my professional identity by writing and reflecting upon my own beginnings in the profession. I was the oldest of four children and my mother sometimes allowed me the special opportunity to sit on the end of her bed while she prepared for the night shift at the hospital. I remember watching my mother iron and put on her crisp, white uniform, bobby pin her nurse's cap to her once-weekly coiffed hair, carefully don white stockings so to avoid runs, and polish her heeled, white leather shoes. While she dressed, my mother would talk to me about what she did while at work and what she enjoyed about her work. To this day, I can visualize my mother inspecting herself in her mirror, adjusting her uniform and cap, and pinning on her nametag and the special pin she received when she graduated from her nursing program. Her uniform and pins were symbols of the profession to which she was so proud to belong--a pride that was evident to me, even as a young child.
My father and mother were first-generation college graduates and they held respected roles within their communities--my father a minister, my mother a nurse. My mother had developed herself professionally so that she was well qualified to assume the role of Director of Nurses at the small hospital in the community to which my father moved us when I was a teenager. My mother became a small-town champion who contributed to the well-being of her community in critical ways. She developed programs to serve our migrant and uninsured populations, implemented training programs for the hospital staff, and facilitated acquisition of new equipment for the hospital, and, thus, expanded the variety of treatments the hospital offered. Influenced by second wave feminism, I was convinced that I was destined for a more traditionally male occupation--certainly not nursing. Even though I was under the impression that the local physicians, hospital administrator, hospital board members, and the community-at-large appreciated the expertise my mother brought to the hospital, I viewed nurses as the weakest agents in the nurse/physician power dynamic--as helpmates following orders. I was annoyed by conversations during which adults asked me if I was going to be a nurse like my mother and resisted the idea of pursuing nursing as an occupation. I believe that people, who inquired about my career aspirations, saw me as capable of achieving the same level of professional success that my mother had achieved--capable of becoming a champion in my own right. I had yet to realize that people asked me about becoming a nurse because they saw me as capable of becoming a nurse like the nurse my mother was, rather than simply because my mother was a nurse.
I am not sure how I came to abhor the idea of nursing as a profession. Perhaps I was vulnerable to the impression left by the image of nursing projected in popular television shows, such as Dr. Kildare, common in the 1950s and 1960s, as "kind, sweet, and marriage-oriented" and rarely depicted as doing "skilled work." (10) Or, perhaps, I picked up on my mother's pattern of communicating deferentially with physicians in their offices or at the hospital, or because the medical and nursing professions are so gendered historically, a power hierarchy results in which nurses appear unwilling to question doctors' orders." Perhaps, I recognized the symbolic representations of my mother's uniform--a site of conflict between group identity and individual expression, a metaphor for class divisions within the healthcare professions, and mandated by those in power. (12) Maybe, my feelings came from reading in one of her nursing school textbooks that, "Many nurses would be surprised to know that to the public they are generally considered as beautiful. Listen to the exclamations where a group of nurses are in public review. A group of teachers or librarians do not cause such a reaction...and so they decide that nurses as a class are beautiful." (13) On the other hand, perhaps it was reading The Nightingale Pledge that I found tucked inside my mother's nursing school textbook. It goes like this:
I solemnly pledge myself before God and in the presence of this assembly to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care. (14) Do you see it, too?
Good jobs for teenagers were hard to come by in our small community, so when I was sixteen, I accepted my mother's offer to work part-time as a hospital ward clerk. On weekends, I answered the telephone, stocked medical supplies, and kept the nurses' stations clean and organized. I put patient charts together and transcribed physicians' orders, while developing my medical vocabulary and learning about diseases and disorders and diagnostic studies. My job exposed me to situations most high school juniors and seniors have no occasion to experience--women birthing babies, mothers and their children in the Saturday Migrant Clinic, people with serious mental health disorders and alcohol and drug dependencies, people with bloody, traumatic injuries, people suffering from chronic illnesses, people dying, and people grieving.
My mother outfitted me with white uniform pants and tunics that she sewed for me herself--tunics that fit my petite-skinny frame smartly, with two large pockets to hold the all important red, green, and black pens and ever-sharp pencils necessary to code patient records with information relevant to the day, evening, and night shifts. She taught me to be systematic in my work, to follow a sheet of written physician's orders, top to bottom, check and double-check, dating and initialing every line. She taught me that my tasks--no matter how small and unimportant they might seem--were critical to supporting the work of the healthcare team and that safety depended upon implementing procedures systematically. She taught me that hard work and adherence to organizational policies leads to excellence, while I thought I was biding time in a high school job, building my bank account to help pay for college, in pursuit of a more male-dominated profession.
After completing a business degree and working as a manager in the retail business for a year, I realized that finding a chair in which an elderly man could sit while waiting for his purchases to come down the big-store conveyor belt was more satisfying to me than my department having the highest sales for the quarter. Upon reflection, I acknowledged that I had been leaning back toward healthcare even before I graduated from college, opting to take psychology and sociology courses as electives, taking a first aid class, and even, in choosing my major--personnel management--a major I viewed as caring about human beings. All but one of my summer jobs had been at a hospital, where I worked with my mother, and I missed working in healthcare.
I soon began nursing school, moved in with my mother, and took a part-time job at the large, metropolitan hospital where she began working after she and my father divorced. We both enjoyed our late afternoons and evenings together, after she arose from her daytime sleep and I returned from nursing school. I benefited from the opportunity she offered to debrief my clinical experiences, talk about what I was learning in class, and ask questions about policies and procedures. We discussed the challenges inherent to the nursing profession, joyous and sad experiences with patients, and the things that made me anxious. I realize now, that these sensemaking sessions were not unlike the narrative pedagogy described by Nancy Diekelmann and Pamela Ironside as a pedagogy for nursing that is derived from merging interpretive pedagogies (critical, feminist, postmodern, and phenomenological) and conventional pedagogies (15)--my nursing school dominated by conventional pedagogies, my mother contributing more opportunities for interpretation. When nursing instructors lacked time for narratives in the content-saturated curriculum of my program, my mother offered a narrative, and personal, pedagogy, bringing facts to life, demonstrating caring and other values. (16) My mother's narratives also allowed me to benefit vicariously from her experiences--those of an expert nurse--and avoid repeating her painful experiences. (17) I looked forward to these sensemaking sessions with my mother and my professional identity began to take shape--her values and attitudes having long ago seeded my own values and attitudes. I believe that my mother also benefited from these sessions, as she revisited her early nursing memories and reinterpreted them within the context of current practice.
"It's in my blood," my student claimed. Is it really? Lawrence Hill, who writes that others often suggested that writing was in his blood, about the successful writing careers of his father and older brother, asserts:
...it is smug and self-satisfying to declare oneself special because of family blood. One is no more special because of the blood in the family than one is special by dint of the accident of one's country of birth. Does being a Canadian, or being a member of the Hill family, make me more special--more deserving of privilege, more entitled to comfort, more valuable as a human being, than any person in any country? Of course not. (18)
With Hill's words in mind, I remind myself that my mother offered me, not blood, but something else that contributed to my professional identity as a nurse--values and attitudes, and work experience in healthcare settings. When compared to my fellow nursing students, I had no more right, was no more special, and no more deserving of becoming a nurse than they. However, when I entered my nursing program and the profession, I was wearing a cloak of nursing capital, my occupational inheritance, much like I might have worn my mother's nursing cape around my shoulders, development of my professional identity already well on the way.
Parental Influence on Nursing as Occupational Choice
Children who know their parents' professions well are more likely to develop corresponding work values and, thus, to select their parents' profession. (20) Nurse researchers have explored the influence of significant others on occupational choice and discovered that having a relative who is also a nurse does not necessarily result in encouragement, and relatives may either warn against being a nurse or actively encourage it. (21) Katrina McLaughlin, Orla Muldoon, and Marianne Moutray found that family members already in the healthcare professions help to provide a more realistic picture of being a nurse and are important sources of informational and instrumental support. (22) One of their participants, a 21-year-old woman, shared, "My mum was a nurse...she always warned me it was stressful and not very well paid. But she felt the rewards it brings on a personal level made up for its pay and stress." (23) This statement I could have made about my own mother.
Consistent with the findings of scholars who study occupational inheritance, in general, and occupational choice, regarding nursing, my mother contributed to the development of my work-related values and attitudes and helped me to understand the negative and positive aspects of the profession. My mother's stories about nursing served functions similar to the functions of broader storytelling practices that occur in families, constructing codes about the nursing profession, providing morals and lessons for moral behaviors, and constructing nursing identities that connect our nursing generations. (24) Findings by McLaughlin, Muldoon, and Moutray seem to indicate that other nurse parents also offer their occupational inheritance via narratives about the stressors and rewards. (25) Like my mother, they model values and attitudes about the profession. Nurse educators, such as myself, must acknowledge the occupational inheritance our students bring and encourage our students to reflect upon their inheritances, while facilitating development of their professional identities.
Oral History and Nursing
According to Mark Kruman and Madeleine Leininger, advocating for oral history methodology in nursing, a knowledge of history allows nurses to understand how the past impinges on the present. Without a past, the authors claim, there is no meaning to the present, nor are we able to develop a sense of ourselves as individuals. Studying history enables nurses to place contemporary nursing practices in broader comparative context and to consider how nurses conducted their work in other times. (26) Traditional nursing histories describe working conditions and the evolution of the profession from before the era when Florence Nightingale practiced in the mid-1800s, to the present, and biographies of nurse leaders are readily available. However, accounts by ordinary grassroots nurses are also significant and warrant documentation for posterity. Although I believe my mother was an exemplary nurse, I also believe that she was an ordinary grassroots nurse who did significant work at the bedside. Without my mother and other nurses like her, patients would not live. I began the oral history project with my mother, understanding that her nursing skills are obsolete and that her knowledge of contemporary healthcare is lacking, but that, at her core, her nursing values are intact.
Challenges of Conducting an Oral History Project with an Aging Mother
A mid-octogenarian, my mother has lived independently for almost forty years with good health. The year we began our oral history project, she was still using her computer to access genealogy websites and exchange email messages with family members far and near--her children, as well as distant cousins. She was beginning to rely upon me to handle complex tasks such as arranging to replace her storm-damaged roof. The year that we began our oral history project was the last year that she prepared and filed her income taxes herself. She was beginning to isolate herself from the world more and more and her world was becoming smaller and smaller. Her routines, which she relied upon for a sense of security, and her resistances, the things about which she felt anxious, my three siblings and I attributed to her eccentric and introverted personality.
My mother has a keen interest in capturing her historical roots and passing them on to her children and she devoted much of her time to this interest. Prior to beginning our project, she distributed copies of her genealogical research amongst her children, captured all her family artifacts in scrapbooks sorted according to individuals in the family, and organized photographs, letters, certificates, etc., related to her nursing career into seven separate scrapbooks--one for each place where she was educated and/or employed. She viewed her work on her nursing career scrapbooks as an extension of her work to capture our family history. She took great delight in sharing her scrapbooks whenever her children or grandchildren slowed down enough to give her attention. I admit that my attention, at least for looking at old pictures and reading genealogical records, was hard for my mother to capture. When I suggested collecting an oral history about her nursing career, my mother viewed our project as an extension of the work she had completed already. She was hesitant only because she did not understand what I intended to do with the information she provided. Though we read the IRB-approved consent form together, I was not sure she understood the purpose of the project and I experienced an ethical blip in my consciousness. She seemed to grasp that by collecting her stories through oral history interviews, I would be able to develop a better understanding of her professional identity. However, she seemed to find it difficult to grasp how understanding her stories would help me to make sense of my identity and how she contributed to shaping my identity. She saw no point to donating transcripts of our interviews nor to archiving her artifacts with the library at her alma mater. I left the consent form with her to digest for a few days. She was proud of her nursing career and, I believe, felt that her ordinary, grassroots nursing career had mattered, and so she consented. I proceeded, trusting that, with reflexivity, I would know the right thing to do with her data. At the time, I knew that, if nothing else came of the project, I would be slowing down long enough for her to enjoy reminiscing about her past, and that she would be relieved that she was a step closer to her own goal of passing on her personal and family history.
I quickly discovered the methodological and personal challenges of capturing my mother's stories through oral history interviews, her memory waning and narrativity beleaguered, requiring me to draw from deep within for compassion, patience, and gentle persistence. I feel foolish when I think about my IRB proposal for our project and the process I outlined about the way it would go. Nothing went as I described in the proposal, the comfort of our mother-daughter relationship enabling my mother to overtake the driver's seat and drive the project down the route she chose. IRB proposal be damned! She was going to do it her way. It was her story to tell and she knew, as the owner of her data, that it was she, not me, who was in control of the interviews.
During our first interview, she lost her train of thought and was unable to get back on track. "Well, evidently, I enjoyed trying to help people, and uh, uh, there's, there's one story, that, uh, 1... I wanted to tell you about, uh...um...um..." I waited, careful not to put words in her mouth, "...uh...I don't know (chuckle)", she gave up, and, after a long pause and no apparent emotional distress, began searching through her scrapbooks until she found something that sparked another story. At one point, my mother thought of something she wanted to show me and began searching her home for the item. I waited patiently, wondering if I should turn off my recorder. The longer she searched, the more uncomfortable I became. I reflected on some of her behaviors from the recent past and realized that I might have been missing cues that she was experiencing mild cognitive impairment. The sick feeling in my stomach grew. I knew that, whether she had Alzheimer's disease, vascular dementia, or one of the other types of dementia, the illness would take my mother from us. I understood the incredible psychological, financial, and eventually, physical burden that caring for a family member with dementia puts on families--and in our case, would put on me, her eldest daughter, living nearest to her. My future with my mother flashed before my eyes, and life, as I knew it--my career, my degree, my personal time, everything--seemed threatened. Like Daniel Bakan, writing about his mother who had Alzheimer's disease, I began to grieve my mother before her death, (27) and experienced an acute urgency to finish our project before she was no longer able to narrate her life.
By our second interview, a few weeks later, my mother's motivation to complete the project was evident. For example, when I began the interview with a question about the previous interview, she interrupted, "Before, before you do that, you might, you might want to take a look at that" and handed a manuscript to me that she had keyed on her computer. Her eyes steady on me as I skimmed the document, "You can read that out loud if you wanna," she said. I knew there was no "you wanna" about it. She would persist, and I would need to follow her direction. The document contained a summary of her work experiences, a resume of sorts--clearly containing the experiences that mattered most to her. She had compiled this document by reviewing the artifacts in her scrapbooks--every artifact dated and captioned as carefully as she documented her nursing care in her patients' charts. I took this as a sign that she was fully on board with the project. We referred to that list repeatedly to validate places and dates of her stories as we talked. Getting the facts "right" was important to my mother and, when we were unclear about places and dates, she would say, "Let me double-check that."
She also made a careful list of the stories about her experiences that she wanted to share during future interviews, and then during our interviews, she systematically checked the topics off her list. One of my mother's stories related to a picture of a nurse in the scrapbook dedicated to her first nursing job, the job she held prior to beginning nursing school. The nurse sat, day after day, with a patient whose room was at the top of the stairs leading to the basement. In the case of the small hospital where she worked, she told me, the hospital segregated "the Blacks" in the basement. Until my mother told me this story, it had not occurred to me that she began her nursing career in times of segregation. She told me that the nurse had been observing her, over several days, and caught her as she came up the stairs to compliment her about the care she provided to the African American patients--care the nurse believed was worthy of note. Capturing this story about caring for her African American patients, and other stories stimulated by the artifacts in her scrapbooks, was important work--important for her, in the telling, and important for me to hear, clarify, and document for our family. Reflecting on one notation my mother made in the margin of her nursing school textbook, I believe that, rather than evidence of a savior mentality, my mother's acts of care for her patients were reciprocal, and in serving others, she found "certain joy from making people happy."
It occurs to me, with the help of critical friends, that a parallel emerges between my mother mentoring me into the nursing profession and providing a scaffold for my current self as the researcher conducting this oral history project and autoethnography. She readily provided the data in her scrapbook, already somewhat "coded" and organized by location, wrote new sensemaking documents about her past after we began our project, and tried to correct my spelling and grammar when she reviewed the transcripts of the interviews. These behaviors indicate to me that she intended to help me complete the oral history project and to help me do it well. Further, I believe that it was her intent to exercise some control over how I portrayed her nursing career in her oral history. By helping me discover her data and selecting the stories she told, she helped me to construct the story she wanted told on her behalf. In essence, though I had been inheriting my mother's occupation all along, nuanced from my perspective, her contribution to the oral history project was a narrative inheritance that she "packaged" for my use, from her perspective.
It was interesting to me the events that she did not remember, but that impressed me enough to remember them clearly, though some of these memories occurred well over forty years earlier. For example, one of my memories from high school, she could not recall, and when I related this event to her, I could see in her eyes that she was not the least bit surprised to hear the story about herself. This memory, though, elicits strong feelings for me to this day. Early one icy cold morning, after a snowstorm that raged all night, I stood on our front porch and watched my mother fishtail her car back and forth across the road on her way to the hospital, two miles away. She was determined to get to her patients and relieve the night shift nurses so they could find an empty bed and sleep--putting her own safety at risk. I know that I remember the event because I was afraid for her life. I have never doubted that my mother loved her children and that mothering us was, and still is, an important aspect of her identity. After revisiting this memory with my mother and discussing her perspective regarding her actions, I realize that this event, perhaps more than any other, demonstrated her commitment to her profession and the importance of her profession to her identity. I understand that this memory is one part of my occupational inheritance that compels me to be equally committed to my students and the nursing program in which I teach, sometimes risking my own welfare.
According to Ronald Pelias, our stories are acts of privileging what we deem worthy of telling and as our tales unfold, we decide who the central characters are and how to render them. (28) My mother's stories were certainly acts of privileging what she deemed worthy of telling. As are my own. Perhaps, more likely, according to her, she privileged the stories and the details in her stories, that she recalled, and that she recalled them because they were important enough for her to remember--her ability to recall, a function of importance of her stories to her identity. I asked her, "Mama, how do you remember some events, but not others? Do you have an explanation for that?" Her explanation, "that just must not have been important enough for me to remember" and "it was just how I was supposed to do things, so I guess it wasn't a big enough deal to remember". I am glad that I remember these stories--and others--they contribute to my understanding of how she helped to shape my professional identity, by role modeling caring, diversity, ethics, excellence, holism, integrity, and patient-centeredness.
I began the project expecting the experience to be laden with narratives. My mother was still able to locate and root herself in her history and stories, but the narratives did not flow as freely as I expected them to flow. During our fourth interview, having finished our review of her scrapbooks, I picked up her nursing school yearbook and began flipping through the pages. One photograph in her yearbook caught my eye. The photograph contained images of four women, two of them dressed as scarecrows and two of them wearing overalls and their faces painted black. The caption read, "Welcoming new students at a party." I was a shocked that the yearbook editors featured this image and caption predominately on the "social" page of her nursing school yearbook. She looked the picture over but could not remember anything about it and could not recall that she attended the welcome party. However, talking about this photograph segued into a conversation about the mission trips she participated in during summers between college years, during the 1950s. I learned that, upon her urging, the director of the Southern Baptist missions, in St. Louis, allowed her to organize and conduct their first vacation bible school for "Blacks." Though she did much of her mission work while she was working on her baccalaureate degree in English, that mission work, she told me, was the stimulus that directed her toward becoming a nurse. She told me that it was then that she realized that the American healthcare system fails to serve all Americans adequately, and she decided that she wanted to become a nurse missionary--not just a missionary--and serve others.
Until we began our conversation about her dream to become a missionary, I had not given much thought to what prevented my mother from achieving her dream. I asked her directly, "What prevented you and Dad from becoming missionaries?" and discovered a secret she had kept from me my whole life. My mother met my father during her final year of college and they married two years later, during the summer before the last year of her nursing program. My mother became pregnant with me shortly after they married. The two of them returned to their schools and traveled across the state to see each other occasionally. After graduating, my father accepted a role as minister at a small church near the town where he grew up and my mother began her first job as a Registered Nurse. My father began seminary, the last step required to qualify with the Southern Baptist Conference as a missionary couple. The seminary was two hours away from where they lived so, during the week, my father stayed in an apartment that he shared with friends. By then, I had been born, and my mother relied upon a baby sitter to care for me at night when he was gone. My mother cared for me during the day, sleeping only when I napped. She shared that she resented that my father was gone and spent his evenings, during the week, playing cards with his friends while she was working full-time and trying to care for a newborn, and getting so little sleep. I had always thought that my parents were unable to become missionaries because my father dropped out of seminary due to financial reasons and that my father felt pressure to return home to help care for his child. During our last interview, my mother shared with me, for the first time ever, her perception about the reason that she and my father did not become missionaries. I was born with a rare birth defect, for which there is no cure. The defect put me at high risk for infection and my mother was concerned about taking me into a country that might be unable to support my medical needs. It surprised me that I had never realized that the reason they did not become missionaries had something to do with me. I was sad when I heard that my mother's dreams, like those of many mothers, were lost as she grieved her imperfect child. I am not the least bit surprised that she tried to protect me from this secret for so long. Finally, I believe, late in life and on the edge of dementia, she was able to let this secret go, confident that my self-esteem was no longer at stake. I wonder if I ever would have learned her secret about my life, had we not conducted this family research.
Toward the end of our work together, after we finished sifting through all of her scrapbooks and yearbooks, I was feeling a bit disappointed that her artifacts had stimulated fewer stories than I expected and that she offered so little grist for the interpretive mill. I was feeling particularly disappointed about the way that she seemed to think about things such as lack of diversity in the nursing profession and I was having difficulty reconciling some of my mother's explanations with my own values. I picked up her textbook, Professional Adjustments by Lena Dixon Dietz, (29) hoping that she might offer meaningful interpretations about the notations in her book. She was able to offer only short explanations for why she might have made some of the notations. I was almost ready to give up and end our project, feeling like I had yet to work out the meaning of my occupational inheritance, when her copy of The Nightingale Pledge fell out of her book. I read the pledge, line by line, and asked, "What does this mean to you?" fully expecting the pledge to have very different meaning for her than it has for me. When I read, "With loyalty will I endeavor to aid the physician in his work," she talked about the importance of aiding the physician as the "eyes and ears" on the ground - the person closest to the patient. Then...with a sparkle in her eye...she gave me a "yes, but!" and told me that, to her, the next line, "And devote myself to the welfare of those committed to my care" (30) was the most important line of all. She then shared several stories about advocating for her patients, such as the time she delivered a baby in the emergency department, after a physician refused to see the patient and dismissed her to go on to another hospital. She expressed, with certainty, that her primary responsibility was to the patient, not the patient's physician. Now, that was the nurse I understood my mother was and the nurse I believe myself to be. That was the essence, the meaning, of my occupational inheritance.
Dementia and Autobiographical Memory
When I began to suspect that my mother was experiencing mild cognitive impairment, I turned to the medical and psychology literature to expand my understanding about the different types of dementia, diagnostic studies, and treatments. The term "dementia" encapsulates a collection of symptoms resulting from a progressive deterioration of cognitive function that cannot be accounted for by normal aging, and that have an impact on day-to-day activities. (31) Dementia, of multiple types, is manifested by (1) memory impairment, and (2) one or more of the following cognitive disturbances: (a) aphasia, or loss of ability to understand or express speech; (b) apraxia, or inability to perform particular purposive actions; (c) agnosia, or inability to interpret sensations, and, hence, to recognize things; and (d) disturbance in executive functioning. (32) When we began our oral history project, my mother was experiencing some memory concerns and her executive functioning, especially regarding episodically performed tasks, was lacking. Recently, she displays agnosia and some minor aphasia.
A concept in the literature, which was new to me, was the concept of autobiographical memory, or the ability to remember the personal past. (33) I soon realized how loss of autobiographical memory, a multifaceted cognitive, social, and motivational system, (34) would affect many areas of my mother's life and is central to her subjective sense of identity, facilitating a sense of personal continuity, and familiarity with the past. (35) Deficits in autobiographical memory are especially pronounced in individuals with dementia. Authors have associated autobiographical memory impairment in Alzheimer's disease with a weakened sense of self, as well as identity impairments. (36) Michael Bury suggests that, like other chronic illnesses, impairment of autobiographical memory in dementia, creates an identity crisis--an autobiographical disruption--for the person with dementia as well as their caregivers. (37) My new understanding about autobiographical memory and dementia deepened my sense of urgency for completing our oral history project and heightened my sense of the importance of conducting family research.
Digging deeply into the dementia literature, I learned that many research studies offer specific interventions with supporting rationale. As dementia progresses, voluntary (or strategic or controlled) retrieval becomes difficult, if not impossible. Difficulty accessing the specific, episodic details of an event is attributable to the loss of executive functioning/control processes evident in general aging and dementia. Therefore, people who are aging or who have dementia may benefit from detailed cues from their past, enhancing the possibility for spontaneous retrieval of episodic details. (38) Moreover, situational cues within the current environment might lead to involuntary (spontaneous) retrieval of a specific memory, circumventing the strategic (voluntary) retrieval process that is heavily reliant on executive functioning. (39) Regarding the relation between items in homes and cuing responses, visual details seem to be important, as well as how often the person encounters the item, and the role the item has in day-to-day life. (40) Capturing my mother's oral history was, possibly, the perfect intervention for helping her to retain her sense of self and identity! Since finishing the oral history project, my mother and I have implemented several projects that will serve as cues for voluntary retrieval of memories about her nursing career. For example, we put together a shadowbox that contains all her nursing pins, name tags, a picture of her in her nursing cap, a copy of The Nightingale Pledge, and we display the box predominately on her living room wall, along with certificates representing her accomplishments. We have printed and placed the transcripts from my mother's oral history as well as the documents she produced to aid our work, into a notebook that we keep with her scrapbooks. Together, we took another copy of the transcripts, and annotated the transcripts with notes directing us to related artifacts in her scrapbooks. I hope that these reminders will help her to retain her autobiographical memory. Even after her memory is gone, I believe we can review our work in a way that helps her to feel pride in who she was.
None of the work my mother and I have completed together would have been possible had she not collected and carefully preserved her artifacts in her scrapbooks, long before we began our project. It is unclear to me, and my mother cannot recall exactly, when she began putting these particular scrapbooks together, though we are both quite sure that she did so after she retired. When I asked, "Tell me about doing the work on your scrapbooks?" she seemed perplexed about why I would ask such a question. Probing further elicited responses such as, "Well, I liked my work" and "I think I was a good nurse, and I know the doctors thought I was a good nurse, too." My mother made her list of stories to share, and we checked them off, one by one, her intent to assure that we captured all the stories she thought best represented her career. She handed those stories over to me and was counting on me to capture them the way she told them, to give the impression she intended to portray, and to secure them for our family beyond her death. Though not my intent at the start of this oral history project, I have become familiar with the works of several authors who write about the experiences of caring for a family member living with dementia. They have provided me with a preview of things to come. Though my mother was still relatively capable of sharing her life narrative when we began our project together, she was standing on the precipice of dementia and memory loss, her stories, sentences, and constructions soon to be lost. I am fortunate that we were able to capture my mother's narratives before she stepped off the edge of the precipice of dementia.
Enacting Ethics in Research with an Intimate, Vulnerable Other
While conducting this oral history project my identities as daughter, nurse, and researcher seem to collide...the researcher hoping to advance understanding about how nurse parents shape the professional identities of their children becoming nurses...the nurse, obligated to advocate for an aging woman exhibiting signs of mild cognitive impairment...and the daughter, anxious to share her admiration for her mother while also feeling protective. I also have an ethical responsibility to my readers--to declare the circumstances of this oral history project--that my mother's mild cognitive impairment brings into question the degree to which she is capable of telling her stories. Mark Freeman, who wrote about telling his mother's story, pointed me toward yet another ethic--the ethic of preserving my mother's story and doing it justice, despite her early dementia. (41) My mother's shifting capacity for recall when I interviewed her for our oral history project complicated my effort to satisfy my ethical obligation to preserve her nursing knowledge and experience, as an extension of her scrapbooks. I hope that in striving to do justice to her life, I have preserved the narrative, occupational inheritance she offers to my family.
Marilys Guillemin and Lyn Gillam delineate two dimensions of ethics, procedural and situational. (42) Of course, prior to embarking upon this oral history project with my mother, I tended to procedural ethics, acquiring institutional review board approval, ensuring adequately informed consent, confidentiality, rights to privacy, avoiding deception, and protecting my participant from harm. I submitted this IRB application during doctoral coursework, teaching full-time, planning a wedding with my daughter, occasionally traveling three hours one-way to provide respite for my sister who was caring for my ill father and stepmother, and I had no concerns about my mother's vulnerability. I was too busy to see it.
After beginning the project and realizing the changes in my mother, I began to struggle with the dimension of situational ethics, or "ethics in practice." (43) How well did she understand my intentions for the research study and what might happen with the data that she provided? How much does she understand today, four years later? I finally came to believe that there is no certain answer here. However, I believe wholeheartedly that my mother understood the consent form that she signed, when she signed it, and that, as we conducted the oral history project, she willingly, and eagerly, shared her materials and corrected facts as we worked. I am certain that she understood that she would be offering her stories publicly, and understood the implications well enough to request that I not share names of people and organizations, and that I not share her name or image. In my estimation, the possibility that anyone will ever identify themselves as a character in any of my mother's stories that I share as examples in my writing, or even recognize who she is, are very, very remote and the good her stories can do far offset those possibilities.
Carolyn Ellis (2007) added a third dimension of ethics to those of Guillemin and Gillam (2004), relational ethics. (44) Drawing from Ellis, who also wrote about her living mother, an intimate other, I act from my heart as well as my mind to enact relational ethics, acknowledging the bond with my mother and taking responsibility for my actions and their consequences. I aim to present my mother in a kind and considerate, but authentic manner, while doing no harm. I have wracked my brain trying to imagine the harm that could come to my mother by exposing her vulnerability in an academic journal. I believe that the risks of publication do not approach the risks she otherwise encounters daily in her community. Does my mother understand what I write about her cognitive impairment? Like Ellis's mother, my mother read an early draft of this document. (45) She views my depiction of her as typical of a woman with an aging brain. She is beginning to admit to being forgetful and having trouble finding words, and that her mind is "just going crazy." She declines to use the labels I use to describe her disease as if doing so will keep her disease, and her independence-threatening children at bay. If there is something about which my mother experiences anxiety, she seems to work at retaining that concern on the surface of her memory, where she is more likely to retrieve it. She will bring that concern to me repeatedly until we have addressed the source of her anxiety. This work is not one of those concerns. My mother views this work as a way for her to extend her contribution to the nursing profession. Mild cognitive impairment is a nursing concern. My mother is a nurse and if sharing her story will help others, she wants to help. These outcomes outweigh any concerns she might have--the rewards worth any costs. To this aim, my mother entrusted her stories to me.
G. Thomas Couser wrote about the ethics of representing vulnerable subjects, and claims, "the closer the relationship between writer and the subject, the greater the vulnerability or dependency of the subject, the higher the ethical stakes, and the more urgent the need for ethical scrutiny". (46) With Couser's concern in mind, let me offer for scrutiny, a little slice of my mother's life. Lately, my mother seems to spend most of her time in the moment, thinking about what I refer to, as her "day-to-day." On a daily basis, she focuses on taking her medications, watching for the mail carrier to arrive, playing Sudoku on her computer, feeding the birds and squirrels, reading Aunt Annie's Mystery Club books, using her remote control to find her favorite television programs, doing needlework, and listening to country western music. Every few days, she works at paying her bills, setting up the few medications and supplements she will take over the next week, and makes a grocery list for our shopping trip. She has trouble learning new things and trouble unlearning old things, particularly when she must do those things episodically, only every few days, or more, like starting her new dishwasher. She fights valiantly to retain her independence, relying upon her intelligence, creativity, and comfort with the same systematic note-taking processes she used as a nurse to safely care for her patients.
Were you to interview my mother today, you would be impressed by her bright, piercing blue eyes, almost impish, challenging look, still rich, tenor voice, sharp sense of humor, and strong hand grip. Her energy will expand and glow once she becomes comfortable with you and the interview process, and you convince her that you are truly interested in her story. The cognitive impairments you are likely to notice are difficulty finding her words, recalling facts, and that she may ask you to repeat yourself often. She will repeat herself often. She will tell you once, twice, maybe even three times, that she is healthy because she is always moving to music. I expect that my mother may one day have difficulty remembering the names of her caregivers, of her loved ones, and, even remembering her own name. Not only is her name at risk with passing time, but also, her identity.
It occurs to me that, for the most part, my mother's stories are immaterial to those uninformed or unfamiliar with my mother. However, it is these very stories, and other stories I have inherited, that provide me with a framework for understanding my identity through hers. (47) Autoethnography is a useful tool for making sense of my occupational inheritance--for which my mother is the foundational touchstone. While interviewing her, I realized that I needed to conduct the autoethnographic work of exploring beliefs, experience, and practices of our nursing profession. Our collaborative memory work helped me to tease out and create new connections between our nursing generations. Thinking about my narrative inheritance from my mother as an occupational inheritance was my "way in" to doing work on family methodology and the nuances that come with doing research on/with family members. My mother's professional identity, made evident by capturing her stories through oral history interviews, was an important avenue for exploring my professional identity, and, in a broader sense, her contribution to the identities of all my family members. By writing this essay, and related work to follow, I am fulfilling my mother's wishes to share her career with a broader audience than the family for which she originally intended her narratives. With my age and maturity comes a revised perception about how my mother enacted her profession. No longer is she the nurse who could do no wrong, nor is she the nurse who was the doctor's helpmate, but a nurse who understood that her primary role was to advocate for her patients. Unlike Freeman's mother, (48) my mother was able to help me tell her story about her life as a nurse and to help me to do justice to her story. Unexpectedly, our project to tell her story became more than the story about her nursing life but also a story about a mother and daughter, standing together on the precipice of dementia. I grieve the memories she was unable to recall, as if loss of those memories threatens the very foundation that affirms my professional identity, along with hers--a part of my narrative, occupational inheritance already gone.
Oklahoma State University Oklahoma City, OK
(1) Participant response to question asked during interview for ongoing research project about students who fail and return to repeat a nursing course.
(2) According to the National League for Nursing, in 2016, only 15% of students enrolled in U.S. pre-licensure nursing programs were male. This data reflects an increase of almost 10% over the previous decade. "Percentage of Students Enrolled in Nursing Program by Sex and Program Type, 2016." NLN Data View[TM], accessed November 29, 2017, http: //www.nln.org/docs/default-source/newsroom/nursing-educationstatistics/percentage-of-students-enrolled-in-nursing-program-by-sex-and-program-type-2016-(pdf).pdf?sfvrsn=0.
(3) Cheryl Beck, "The Experience of Choosing Nursing as a Career," Journal of Nursing Education 39, no. 7 (2000): 320-22.
(4) June Larson, Marilyn Brady, Lynn Engelmann, Bro. Ignatius Perkins, and Cathleen Schultz, "The Formation of Professional Identity in Nursing," Nursing Education Perspectives 34, no. 2 (2013): 138.
(5) National League for Nursing (NLN), Outcomes and Competencies for Graduates of Practical/Vocational, Diploma, Associate Degree, Baccalaureate, Master's, Practice Doctorate, and Research Doctorates in Nursing. New York: Author, 2010.
(6) Goodall, Harold, A Need to Know: The Clandestine History of a CIA Family (New York: Routledge, 2006), 497.
(7) Ibid, 23.
(8) Howard Aldrich and Phillip Kim, "A Life Course Perspective on Occupational Inheritance: Self-Employed Parents and Their Children," in The Sociology of Entrepreneurship, eds. Martin Ruef and Michael Lounsbury, (Bingley: Emerald Group Publishing, Ltd., 2007), 33-82.
(9) Arthur Bochner and Carolyn Ellis, "Communication as Autoethnography," in Communication as...: Perspectives on Theory, ed. Gregory Shepherd, Jeffrey St. John, and Ted Striphas (Thousand Oaks, CA: Sage, 2006), 11.
(10) Philip Kalisch, Beatrice Kalisch, and Margaret Scobey, Images of Nurses on Television (New York: Springer Publishing Co., 1983).
(11) Jackie Jane Churchman and Carole Doherty, "Nurses' Views on Challenging Doctors' Practice in an Acute Hospital," Nursing Standard 24, no. 40 (2010): 42-47. https: //doi.org/10.7748/ns2010.06.24.40.42.c7830.
(12) Christina Bates, "Looking Closely: Material and Visual Approaches to the Nurse's Uniform," Nursing History Review 18 (2010): 167-88.
(13) Lena Dixon Dietz, Professional Adjustments (Philadelphia, PA: F.A. Davis Company, 1951), 57.
(14) "The Nightingale Pledge," Farrand Training School for Nurses in Harper Hospital (Detroit, MI), 1893.
(15) Nancy Diekelmann and Pamela Ironside, "Developing a Science of Nursing Education: Innovation with Research," Journal of Nursing Education 41, no. 9 (2002): 379-80.
(16) Mary Kirkpatrick and Sylvia Brown, "Narrative Pedagogy: Teaching Geriatric Content with Stories and the 'Make a Difference' Project (MADP)." Nursing Education Perspectives 25, no. 4 (2004): 183-87.
(17) Alan Lunt, "Storytelling: How Non-Consumer Professionals Can Promote Recovery," Journal of Psychosocial Nursing and Mental Health Services 38, no. 11 (2000): 42-45.
(18) Lawrence Hill, Blood: The Stuff of Life, Toronto, ON: House of Anansi Press, Inc. (2014), 147.
(20) Martin Gubler, Torsten Biemann, and Silvio Herzog, "An Apple Doesn't Fall Far from the Tree--Or Does It? Occupational Inheritance and Teachers' Career Patterns," Journal of Vocational Behavior 100 (June, 2017): 1-14. https: //doi.org /10.1016/j.jvb.2017.02.002.
(21) Judith Cohen, Mary Val Palumbo, Betty Rambur, and Joan Mongeon, "Middle School Students' Perceptions of an Ideal Career and a Career in Nursing," Journal of Professional Nursing 20, no. 3 (2004): 202-10. https://doi.Org/10.1016/j.profnurs.2004.04.001.
(22) Katrina McLaughlin, Orla Muldoon, and Marianne Moutray, "Gender, Gender Roles and Completion of Nursing Education: A Longitudinal Study," Nurse Education Today 30, no. 4 (2010): 303-7. https://doi.Org/10.1016/j.nedt.2009.08.005.
(23) Ibid, 409.
(24) Melissa Aleman, Melissa Wood, and Katherine W. Helfrich, "Inheriting the Narratives of Dementia: A Collaborative Tale of a Daughter and Mother," Journal of Family Communication 10, no. 1 (2010): 7-23. https: //doi.org/10.1080/15267430903385784.
(25) McLaughlin, Muldoon, and Moutray, "Gender, Gender Roles and Completion of Nursing Education," 303-7.
(26) Mark Kruman and Madeleine Leininger, "Historical Method: Implications for Nursing Research," in Qualitative Research Methods in Nursing, ed. Madeleine Leininger (Philadelphia, PA: Saunders, 1985).
(27) Daniel Bakan, "The Fountain Pen," Creative Approaches to Research 9, no. 1 (2016): 4-18.
(28) Ronald Pelias, "H. L. Goodall's A Need to Know and the Stories We Tell Ourselves," Qualitative Inquiry 14, no. 7 (2006): 1309-13. https://doi.org/10.1177/1077800408322680.
(29) Dixon Dietz, Professional Adjustments.
(30) "The Nightingale Pledge."
(31) Clive. Ballard and Carol Bannister, "Criteria for the Diagnosis of Dementia," in Dementia, ed. David Ames, Alistair Burns, John O'Brien (Boca Raton, FL: Taylor & Francis Group, 2010).
(32) Tobias Haeusermann, "The Dementias--A Review and a Call for a Disaggregated Approach," Journal of Aging Studies 42 (August, 2017): 22-31. https://doi.Org/10.1016/j.jaging.2017.06.004.
(33) Susan Bluck, Nicole Alea, Tilmann Habermas, and David C. Rubin, "ATALE of Three Functions: The Self-Reported Uses of Autobiographical Memory," Social Cognition 23, no. 1 (2005): 91-117, https: //doi.org/10.1521/soco.18.104.22.168198.
(34) David Pillemer, "Directive Functions of Autobiographical Memory: The Guiding Power of the Specific Episode," Memory 11, no. 2 (2003): 193-202. https://doi.org/10.1080/741938208.
(35) Stanley Klein, "The Self: As a Construct in Psychology and Neuropsychological Evidence for Its Multiplicity," Wiley Interdisciplinary Reviews: Cognitive Science 1, no. 2 (2010): 172-83. https: //doi.org/10.1002/wcs.25.
(36) Sally Prebble, Donna Addis, and Lynette J. Tippett, "Autobiographical Memory and Sense of Self," Psychological Bulletin 139, no. 4 (2013):815-40. https://doi.org/10.1037/a0030146.
(37) Michael Bury, "Chronic Illness as Biographical Disruption," Sociology of Health & Illness 4, no. 2 (1982): 167-82. https://doi.org/10.1111/1467-9566.ep11339939.
(38) Amanda Miles, Lise Fischer-Mogensen, Nadia Nielsen, Stine Hermansen, and Dorthe Berntsen, "Turning Back the Hands of Time: Autobiographical Memories in Dementia Cued by a Museum Setting," Consciousness and Cognition 22, no. 3, (2013): 1074-81. https: //doi.org/10.1016/j.concog.2013.07.008.
(39) Marie Kirk and Dorthe Berntsen, "A Short Cut to the Past: Cueing via Concrete Objects Improves Autobiographical Memory Retrieval in Alzheimer's Disease Patients," Neuropsychologia, 110 (2018): 113-122. https://doi.Org/10.1016/j.neuropsychologia.2017.06.034.
(40) Annemarie Zijlema, Elise van den Hoven, and Berry Eggen, "A Qualitative Exploration of Memory Cuing by Personal Items in the Home," Memory Studies (June, 2017): 1-21. https: //doi.org/10.1177/1750698017709872.
(41) Mark Freeman, "From Absence to Presence," in On (Writing) Families, eds. Jonathan Wyatt and Tony Adams. (Boston, MA: Sense Publishers, 2014).
(42) Marilys Guilleman and Lynn Gillam, "Ethics, Reflexivity, and 'Ethically Important Moments' in Research," Qualitative Inquiry 10, no. 2(2004): 261-80. https: //doi.org /10.1177/1077800403262360.
(44) Carolyn Ellis, "Telling Secrets, Revealing Lives: Relational Ethics in Research With Intimate Others," Qualitative Inquiry 13, no. 1 (2007): 3-29. https: //doi.org/10.1177/1077800406294947.
(46) Thomas G. Couser, Vulnerable Subjects: Ethics and Life Writing. Ithaca, NY: Cornell University Press (2004), xii.
(47) Goodall, A Need to Know.
(48) Mark Freeman, "From Absence to Presence," in On (Writing) Families, ed. Jonathan Wyatt and Tony Adams. (Boston, MA: Sense Publishers, 2014).
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