Thursday, August 23, 2018

Storytelling bonds nurses in ways that improve care

By Louise Kinross

A six week narrative group for inpatient nurses at Holland Bloorview increased nurses' empathy for each other by unmasking their common vulnerability, according to a study published in The Journal of Pediatric Nursing last month.

BLOOM reported earlier on how the narrative training increased empathy for patients and families.

This piece looks at how the six, 90-minute sessions of writing, drawing and talking about their emotional reactions to work elicited greater compassion for each other, broke stereotypes and deepened work bonds and collaboration.

Each session began with reading of a patient story, poem or comic that addressed common themes in children's rehab such as 'Seeing from different points of view; 'Obstacles to empathy,' and 'Making room for hope.'

Facilitators led a discussion of the reading, then gave participants a related writing or drawing prompt. For example, 'In a three-panel comic, tell the story of a patient through their parents' eyes.' Participants then discussed and shared their work.

In the study,  empathy is defined as "The capacity to imagine the situation of each patient and their familyunderstanding their feelings and perspective, and responding in ways that make patients feel heard and cared for."

Participants worked with children hospitalized at Holland Bloorview following painful bone surgeries or life-changing trauma, such as traumatic brain injury, or with complex medical problems. Each nurse did an in-depth interview before and after the group.

Prior to the intervention, participants often described the nursing community negatively. For example, "When I first started I didn't really feel that supported," said one participant. "And it's a nursing culture thing that nurses eat their young." Novice and experienced nurses tended to hold stereotypes about each other. For example, "I thought of them as kind of such a hard exterior." Participants did refer to a few trusted relationships: "I have my go-to, good colleague on the floor that I can vent to."

Sharing stories, whether written or drawn, allowed nurses to see themselves in each other in a personal, unifying way: "That was me," said one. And broke stereotypes: "I was how much they had to share and how much emotion they really have."

After the narrative group, nurses were more likely to view the nursing community in a positive, cohesive way. "Listening to what some of the other nurses were saying made me a little more empathetic to my fellow staff. Sometimes we can be hard on one another." And "This is more than just about what we're doing for families and patients. This is about the nursing staff being empathetic and caring towards one another as well, so we can come to work and do our work effectively and be in a comfortable environment." Participants reported a new recognition that to provide the best care, team members need to be "observant" and "in tune" with peers.

The study also found a change in the nurses' willingness to express vulnerability—to share work-related emotions like regret, grief and helplessness. Pre-intervention responses reflected resistance to appearing vulnerable. "I was concerned, and maybe still a little bit, sharing with the rest of the group..." said one. "You're not sure who's going to be [in the intervention] and how—what they'll say." They feared they were alone in these emotions and would be judged. Expressing vulnerability was described as a last resort, and in ways that suggested the nurse was victimized, such as leaving the room to cry alone.

Storytelling revealed the nurses' common humanity, and a new acceptance of all feelings as being "okay" and "normal" emerged. As one participant said: "The narrative intervention reinforced that you're not alone; people have those same feelings even after 30 years' experience... We cried together, we laughed together, and I didn't feel bad about it and it was okay." Many comments spoke to how sharing stories in a safe space deepened relationships among the nurses and gave them a renewed sense of respect and concern for each other.

This translated into a change in nursing practice. Before the narrative group, participants described peer collaboration as task-oriented. For example, they would help one another with a patient's toileting, medication or lifting. After the intervention, they described seeking each other out to reflect on difficult clinical situations. "Some of the poetry that we read or even the comics... really made you look at the experiences of both patients and nurses. And then to be able to talk about them after, like 'What did you think about this?'"

Participants reported being more likely to turn to each other to brainstorm, role-play and debrief in difficult clinical situations. "Before [the intervention] I would always ask what to do, [but] now I'm trying to collaborate more with my team by bringing up, 'This is what I found. This is what I think solutions can be' and talking it out. In my general practice... I have more confidence in my team and I feel less intimidated to speak to my team members."

Nurses said the intervention helped them to view challenging nursing situations more flexibly and creatively, and to be less judgmental of families, each other and themselves.

This study was funded by a Catalyst Grant from the Bloorview Research Institute. The lead investigator was Keith Adamson, then collaborative practice director at Holland Bloorview. Also on the team was Sonia Sengsavang, a PhD candidate in developmental psychology from Laurier University and Michelle Balkaran, a nurse who is now an interim operations manager at Holland Bloorview. The three facilitators were Andrea Charise and Shelley Wall, both professors at the University of Toronto, and BLOOM editor Louise Kinross, who is also the parent of a son who has been an inpatient at Holland Bloorview.