By Mike Rose
The head of the hospital bed is elevated so that the mannequin is sitting upright, mouth open, an I.V. pole to the left, a table and tray to the right, a chair at the foot of the bed for visitors, a bulletin board in the mannequin’s line of sight. This is the simulation room where student nurses administer medications to the patient, take vital signs, hook up an I.V., and answer questions posed by the instructor, Ms. Green, who sits behind a curtain watching the student on a video monitor.
Right now it’s Molly’s turn. Ms. Green is explaining that the patient, a Mrs. Bowman, is scheduled for a thyroidectomy. Molly, who is in the second semester of a four-semester program, listens, her hands across her belly. Then she nods, smiles, knocks on the wall, and walks out from behind the curtain into the hospital room. “Good morning, Mrs. Bowman, I’m Molly, your nurse for today. Nice to meet you. How are you feeling?”
“Well,” the instructor says, channeling Mrs. Bowman, “I’ve never had surgery before, and I’m kinda worried.”
“I understand. I do,” Molly says, moving to the side of the bed. “Do you have any questions for me?”
Mrs. Bowman: What should I expect after the surgery?
Molly: Well, you’ll be fatigued, and it will be hard to swallow. So we’ll keep you upright. We’ll monitor you.
Mrs. Bowman: What will the nurses be looking for?
Molly: We’ll be looking for infection. We want to be sure you’re draining nicely.
Mrs. Bowman says that her doctor told her some things, but she forgot, and begins to ask Molly about the features of the disease, and Molly knows a fair amount about them, though draws a blank on several symptoms. The patient, still concerned, returns to possible complications beyond infection, and Molly mentions swelling but admits she can’t think of the others, but, er, will get back to her. Then it’s time to debrief.
Molly walks back to the video monitor, shaking her fists in the air. “I studied everything but that!” Ms. Green tells her she did well – it is her first time, after all – that she has a nice way with patients, and that she needs to read up on the disease itself. Then they settle in to look at the video of Molly and Mrs. Bowman.
Across the campus, Mr. Franco, an instructor in the Diesel Technology Program, is walking out from behind his podium. “So you’re at the middle of the bus’s chassis,” he says, “and you’re getting a weak reading on your meter.” He pauses for emphasis. “But, you know, the problem could be twenty feet away, up in the bulkhead. How would you find out?”
Mr. Franco is taking his students through a long series of troubleshooting procedures. The thirty men packed into the room range in ages from early 20s to mid-40s; some are in the program after kicking around in short-term, dead-end jobs while others had decent work that went south when the economy tanked. Their classroom sits atop a giant automotive shop and is cold and spare, except for Mr. Franco’s elaborate computer equipment – which he uses to animate diesel technology.
The students all have laptops – their own or on loan from the program – which they use in concert with Mr. Franco’s lectures and also to take exams from the lectures and from the textbook, the hefty fifth edition of Heavy Duty Truck Systems, full of dense print on chassis electrical circuits, hydraulics, drive shaft assemblies, transmissions, and a whole lot more. Some students have three or four highlighters of different colors on the table by their books. They also use the laptops for engine diagnostics once they tromp down a flight of bare metal stairs to the shop below where truck cabs, hoods open, and large engines up on stands await them. Mr. Franco illustrates his lectures in the shop, and the students have to troubleshoot problems with the various engines that he has disabled, writing up a diagnosis and list of parts needed for repair, then actually doing the repair to see if an engine runs. As one of the students said to me, there’s no bullshitting that test.
I spent close to two years visiting the occupational programs at this community college – nursing, welding, construction trades, diesel and automotive, fashion – each one providing an entrée into a whole world of traditions, and complex practices, and standards of excellence. Some people came into these worlds with knowledge of them – they were employed in a doctor’s office or grew up working on cars – and, in some cases, have a deep emotional connection to the occupation. One nursing student put in her binder a cutout of a nurse she had made in kindergarten. Some students enroll after high school, but most have had other jobs, or were unemployed, or had been out of the labor market raising children. Some occupations draw heavily from programs like these: 60% of new nurses, for example, come from them. In all cases, this new profession holds the promise of a better job and, with luck, a career with some stability.
The programs are demanding – the textbook for Medical-Surgical Nursing, a two-semester course, is 2,500 pages long – and some have pretty high attrition rates. Many students have families and other big-time responsibilities; there are always a few guys in the diesel program nodding off because they are coming to class right after working the graveyard shift. Without financial aid, or unemployment insurance, or a few small scholarships a fair number of students would not be able to attend at all.
Those who succeed develop powerful skills and bodies of knowledge. There are all the facts about physiology or diesel combustion and a range of techniques and tricks of the trade, but there are also ways of thinking, habits of mind, at least within the occupation. I am struck, for example, by the careful attention paid to mastering very small, but fundamental, skills, and developing a watchful, methodical approach to them. One of the student nurses close to getting her R.N. put it so well: “It’s the simple stuff that makes the difference.” Hooking up an I.V. bag is a good example, the many simple (though cumulative) steps: how to hold the bag, how to hold the insert tube, sterilizing the ports, getting air out of the tubes, clamping, labeling the tubes, double checking the contents of the bags, and so on. When the nurses first try it, they are maladroit or forget steps, and they practice and practice, “trying to put it all together in my head,” as one expressed it. Then it comes together. They can do it over a sink, then on a mannequin, then eventually under supervision on the hospital floor. They understand the principles behind it. And they will get to the place where they incorporate this skill into broader regimens of treatment that involve application of knowledge, diagnosis, judgment.
I’m also impressed with the problem-solving and troubleshooting that is integral to these occupations. The diesel program is built around it; after all, the mechanic’s job kicks in when a vehicle malfunctions. “You’re like a doctor,” one of the students tells me. “You use all your senses, and you also ask the driver, what’d you hear? Smell? And you put that together.”
This skill at problem-solving is ultimately made possible by a quality I watched develop in all the trades I observed: the understanding of the body or a vehicle as more than the sum of its parts, as a system. A symptom in one part of the body can be signaling a problem somewhere else. “We don’t want a big repository of facts,” the Director of the nursing program told me. “We want students to think!” “The textbook gives you the mechanisms,” a diesel student explains, “their function and their purpose. But Mr. Franco, he gets us to see that when x fails, then y fails. Man, that’s a whole different story.”
There is a lot being written these days about so-called “soft” job skills: responsibility and punctuality, the ability to communicate and cooperate, workmanship, persistence. They are typically distinguished from “cognitive” skills, meaning everything from literacy and numeracy to the skills of the trade. Although I’m not sure that “cognitive” and “soft” skills are two distinct categories, students do come into occupational programs with habits, past successes or failures, and personality characteristics that will affect their performance. But these qualities can also develop in and through the programs if the work grabs a student’s attention and imagination. Whether as children or adults, we don’t develop these qualities in a vacuum but through human interaction and meaningful activity. (A sure-fire way to fail to instill “soft skills” would be to talk about them in the abstract or to lecture to students about them.) When our mind is engaged, when we can see ourselves learning how to do things, when we develop knowledge – then we also begin to care about the quality of what we do.
Ultimately, we’re talking about identity, about our sense of who we are. When occupational programs are well-conceived, those students who succeed in them are socialized into the values of the trade: workmanship, ethical practice, standards of excellence. These values might well get compromised in particular people’s lives or in the marketplace, but students appropriate them and express them in judging their own work and the work of others. What also happens is that students incorporate what they learn into their lives and begin to move through the world in a different way. A student nurse told me about being at a park and a man nearby passed out. She automatically ran over to help the guy while someone called 911. She knew what to do and what questions to ask. “Oh my gosh,” she thought later, “I really am a nurse.”