Telling clinician and patient stories increases empathy in nurses

By Louise Kinross 

A six-week narrative group for inpatient nurses at Holland Bloorview promoted greater empathy for patients and families, for each other, and for the nurses themselves, according to a study published in The Journal of Pediatric Nursing last month.

I was a facilitator on this project, which was led by Keith Adamson, then collaborative practice leader at Holland Bloorview. The other facilitators were Andrea Charise (photo centre left), who directs an undergraduate health humanities program at the University of Toronto, and Shelley Wall, a medical illustrator and assistant professor in Biomedical Communications at U of T. Sonia Sengsavang (photo right), a PhD candidate in developmental psychology, was research assistant and Michelle Balkaran (left), a nurse and now an interim operations manager here, was part of the research team.

I will write pieces on each of three areas where the group was shown to improve empathy. The first was empathy for patients and families.

Each 90-minute 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, ‘Write about a time that you received care’ or ‘In a three-panel comic, tell the story of a patient through their parents’ eyes.’ Participants then shared and discussed their work.

In the study, empathy is described as “The capacity to imagine the situation of each patient and their family—understanding their feelings and perspective, and responding in ways that make patients feel heard and cared for…” 

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

Prior to the group, nurses expressed a desire to understand the family’s perspective, but often in the jargon of patient and family-centred care, the study found. For example, they “partner” with the family, and “Think of yourself being in their shoes,” but don’t give specific examples.

After the intervention, participants described a new understanding that every family has a unique backstory—the complex, often painful experiences that occur before and during the current care episode. This backstory guides concrete ways to express empathy, through kindness, listening, being aware, flexible and patient, trying not to judge, and giving the family the benefit of the doubt.

“These stories helped me think, Okay, this is a young girl,” one nurse said. “She misses her mom. Let’s just take five minutes.” Another said: “trying not to be so quick to judge things and to listen better.” And another: “On Tuesday when I was doing a port needle with a patient who has cancer…I [thought], ‘oh my goodness they are sick for a long time and it seems, like never-ending’…that insight that I got from the comic…it’s like ‘Yea, this must be really hard in their life.’”

Along with this new recognition of the complexity and fragility of families comes the understanding that nurses’ words and actions have tremendous power to help or harm.

Prior to narrative training, participants described a tension in balancing “direct nursing”—their medical tasks, procedures and documentation—with providing emotional support. Given time pressures and the expectation to maintain professional detachment, they prioritized technical tasks over emotional support, describing the latter as “outside my nursing hat.”

After the narrative group, the nurses elevate compassion, listening, being flexible and providing a safe space to families, as being on par with direct nursing tasks. For example, “Yes, we do the technical stuff but we feel like we’re so much more the emotion, the support, as well,” one said. And: “Really taking that time to sit down, as we were experiencing in the six-week [intervention], right? Give them a safe space.”

Nurses also reported being more likely to share personal information if they felt it would help them connect with families on a human level. “Sometimes telling [patients/families] something about your own life may put them at ease or help them relate better to the situation they’re in.”

The researchers coined the phrase moral empathic distress (MED) to describe a new, emerging concept in rehab nursing. “MED can be considered an internal state associated with nurses’ feelings of profound helplessness, which emerges when nursing interventions are unlikely to alleviate a pediatric patient’s physical pain or chronic condition,” they wrote. This was heightened in rehab because clinicians develop relationships with children and families over months to years. Pre-intervention, nurses described this dilemma: “It’s more like picking up your own child, right?” said one participant. “So when we see suffering it’s more disturbing.”

After narrative training, participants were more likely to recognize that when there is no medical solution, their emotional presence with patients and families was invaluable. “Maybe there’s nothing more we can do, but… what I’ve learned is just to be present for the family and be their support,” said one. “And to hold their hand and to tell them, ‘Cry and be mad, because that is normal—you’re going to grieve.’”

Through storytelling, participants learned that their peers all experience work-related emotions like regret, grief and helplessness. Knowing that they were not alone in these emotions helped them cope. “One of the other [nurses]…was reading her piece and taking about how her patient was in pain and she was trying to help and it’s not helping,” one participant said. “And in the intervention she’s crying. You know, seeing how it’s not just me who gets really emotional and thinks about it—it’s other staff too.”

We'll explore how the narrative group increased empathy for participants' work peers and themselves in future posts.

This project was funded by a Catalyst Grant from the Bloorview Research Institute.

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U of T docs say ridicule, yelling, rude emails a part of their world

By Louise Kinross

A new study in Academic Medicine looks at uncivil behaviour among doctors—from eye rolling and open ridicule to yelling, throwing objects, sending unkind e-mails and posting disparaging social media comments. University of Toronto researchers interviewed 49 doctors who are faculty in U of T’s department of medicine and work at six teaching hospitals to describe rude behaviour they see or experience, and look at organizational ways to prevent or stem it. The study references a systematic review that showed almost 60 per cent of medical trainees reported experiencing harassment or discrimination, and another study in which 30 per cent of physicians said they saw rude, dismissive or aggressive behaviour by doctors on a weekly basis. BLOOM interviewed co-investigator Dr. Reena Pattani, who works in internal medicine at St. Michael's Hospital.

BLOOM: Why were you interested in this topic?

Reena Pattani: I have immense job satisfaction and a lot of meaningful work relationships, but I think there are always ways to improve the culture of a workplace. This project emerged from a collaboration with senior author Sharon Straus, where we looked at data from a 2015 survey that showed that while faculty in our department have many positive, collegial relationships, many had observed, heard about, or been affected by uncivil or unprofessional behaviour.

We wanted to look at how the organization can play a role in responding to incivility, rather than resorting to solutions that focus only on the individuals perpetrating it. We looked at workplace factors that breed stress and burnout, and create heightened emotions that can lead to a toxic environment.

BLOOM: Is kindness a simple definition for civility?

Reena Pattani: It is. We talked about an obvious moral definition of civility in terms of the Golden Rule: Treat others as you wish to be treated. There are also practical reasons that we need civility in a workplace that has the complexity of medicine. We have people coming together to take care of patients suffering from acute or life-threatening conditions, and incivility may have an impact on patient outcomes.

BLOOM: How did you define rudeness in your study?

Reena Pattani: We didn’t want to be prescriptive. We asked our participants what they had witnessed in terms of form and content. There were three big categories in terms of form. Furtive behaviours included eye rolling or muttering derogatory comments or exclusion. There were face-to-face incidents like ridicule, a personal attack, interrupting, yelling or throwing an object. The third type was online: not responding to e-mails, or responding in a passive-aggressive way, or posting a disparaging comment on a social media platform.

BLOOM: What was the rudeness about?

Reena Pattani: There were disagreements about next best steps in a case, or treatment recommendations, collaboration on a publication, negotiations around promotions or remuneration, and workload distribution. There were instances of discrimination based on seniority or sub-specialty or the way scholarly time was being used in an academic centre.

BLOOM: It was interesting that the paper refers to these behaviours as ‘low intensity,’ even though it includes bullying, which probably isn’t perceived as low intensity by the person experiencing it.

Reena Pattani: I appreciate that feedback. By calling it low intensity we’re not trying to minimize its seriousness or impact. It’s more that these events were perceived as being ‘sub-threshold’ to report. People experienced something unsettling, but there wasn’t a clear pathway to bring it to someone’s attention.

BLOOM: Did anyone identify targeted discrimination based on race or other types of diversity?

Reena Pattani: We didn’t specifically inquire about that and participants didn’t volunteer that information in their answers. Absolutely that warrants further exploration. The tough thing about studying that is that you need to develop a study that ensures people aren’t identified.

BLOOM: You interviewed each doctor for up to an hour each. Were you surprised by anything you heard?

Reena Pattani: Yes, absolutely, though I wasn’t involved personally in the interviews. There were a lot of surprises with regards to the types of experiences people had and the egregious nature of their experiences. Also, one of the challenges was respecting their privacy and the confidentiality that is required to undertake a study like this.

BLOOM: I found it interesting that while most interviews were done by phone, a couple of participants asked to do them in person.

Reena Pattani: Yes, we had an ethics amendment to create safer processes for participants to share their views. Some people felt more comfortable doing the interview in person. We wanted to be really thoughtful about how we respected individuals who participated, and we gave them the opportunity to review their comments. Twenty-five people reviewed their comments, five edited them and one person chose to remove comments.

BLOOM: It shows how cautious and afraid people are. When respondents talked about the negative impact of rudeness on patient care, did they give examples?

Reena Pattani: The conflicts were around consultations and treatment recommendations. The downstream of that is that people might be less likely to reach out to a terse colleague in the future, so you could see poorer collaboration.

BLOOM: I was so interested in your work because I reported on an Israeli study where they showed in NICU simulations that rude words from a parent or medical colleague impaired individual and team performance.

Reena Pattani: That was a very impressive study. Those things are harder to study in a natural environment, but a lot of this evidence needs to come together to understand the impact of this lack of professionalism and devise strategies to counter it.

BLOOM: Doctors in your study identified their non-employee status in hospitals as a contributor to rudeness. Does that mean because no one is there to police behaviour, they take advantage?

Reena Pattani: No, I don’t think they’re taking advantage. This was something specific to the Canadian context. In our academic system in Toronto, physicians are considered self-employed. They're appointed to a hospital or university, but they operate on a fee-for-service basis paid for by the Ministry of Health.

Most physicians in Toronto's academic hospitals don't receive funding from the university or hospital. So it may be hard to know where the jurisdiction is to respond to poor behaviour, whether it’s at the hospital or university level. There’s also a sense that there are only extreme levers to respond to unprofessional behaviour, such as revoking hospital privileges or a university appointment. Our participants felt that there wasn't an obvious way to report these things.

BLOOM: Doctors also identified silos between the hospital and university and within department divisions as contributing to a more impersonal and hostile environment.

Reena Pattani: They don’t directly make things more hostile, but when the environment is more impersonal, it lowers the threshold to exhibit curt behaviours. You have relative anonymity. If you’re rude to someone, it won’t have a direct impact on you, because it’s not a relationship that you’re cultivating on a daily basis, over time.

BLOOM: Respondents felt that leaders may have encouraged a competitive environment. Are these medical leaders, and does this start in medical school?

Reena Pattani: There are many incredible leaders operating in the hospital and the university. But occasionally, a leader may be promoted for other skills, like excellent long-term vision or strategy, but their skills or ability to recognize and act on incivility isn’t as high.

One of the reasons we wanted to study incivility in an academic centre is the idea of the hidden curriculum in medicine—that there are things that are learned that relate to norms that aren’t found in textbooks, but from apprenticeship and observation and role-modelling. If uncivil behaviours don’t go addressed, it sends a message that this is a social norm that is acceptable.

BLOOM: Doctors in your study referred to a culture of silence.

Reena Pattani: I think there’s discomfort around reporting. Or there may be a history where something is reported, but the unprofessionalism goes unaddressed, because leaders aren’t equipped with the right training or resources to address it.

BLOOM: So people are less likely to report in future.

Reena Pattani: There may also be a fear of reprisal or retribution.

BLOOM: I was surprised that the doctors didn’t identify the emotional side of working with patients who are suffering or dying as a contributor to rudeness. You do mention at the end, under root causes, emotional burnout.

Reena Pattani: The honest truth is it may reflect the fact that we didn’t specifically ask about that piece. In the conclusion, we talk about root causes, and not necessarily attributing uncivil behaviour to a personality issue, but considering issues like burnout or mental health. In our introduction, we also highlight the existential nature of the work, which involves taking care of patients who are sick, and how it can take a toll on healthcare providers.

BLOOM: We did a narrative group with our inpatient nurses, and they came into the group thinking they were the only ones experiencing emotions like helplessness, grief or regret, and that they had to hide them. Through storytelling, we were able to show that everyone experiences these emotions. That reduced stress, because they didn’t feel like they had to walk around pretending they were invulnerable, and they were more likely to reach out to co-workers proactively to come up with creative solutions to difficult clinical and family situations. I wonder, if you change only organization structures, but you don’t help doctors better cope with suffering, whether rudeness would continue to be an outlet?

Reena Pattani: There is a growing recognition of the emotional toll of this work, and there's a movement in narrative medicine that's currently being embraced by many physicians. A lot of hospitals and universities are doing local interventions. At St. Michael's Hospital, we hold Reflections on Medicine rounds where some of my colleagues facilitate discussions on topics like making mistakes and end-of-life care. We also have members of the university's department of medicine leadership team who have experience with narrative medicine, and are leading efforts to integrate it into our training programs.

BLOOM: What were the main ways doctors suggested for reducing rudeness in your study?

Reena Pattani: They were grouped under three headings: prevention, reporting, and addressing incivility. Under prevention, they asked for clear definitions of incivility that included examples. A suggestion was to share examples, while maintaining anonymity, from within our local department, to serve as an education and deterrent tool. Doctors want more transparency around how resources are allocated, not just in terms of remuneration, but also including research and admin support, as this will minimize competitiveness.

In terms of reporting, they suggested anonymous online reporting, having designated individuals within departments who could serve as an ombudsman or advocate, or an external party to ensure complete independence.

They also asked for role clarification to determine whether the hospital or university is the jurisdiction to deal with incivility. There were calls for very clear processes, timelines, and consequences, with an emphasis on fairness and rehabilitation for both the victim and perpetrator.

From a workplace culture perspective, there were suggestions to use citizenship and professionalism as factors in decision-making about who gets awards and who’s promoted, so that there’s a clear expectation that professionalism is an essential skill.

BLOOM: What is the main message you hope hospitals take away from the study?

Reena Pattani: I think health-care organizations are increasingly appreciating the role they can play in shaping culture and in setting the tone for professionalism. Our participants were able to offer a frontline perspective on some of the organizational factors that contribute to incivility, and also ways organizations can be more proactive in preventing and addressing it. A lot of solutions need to be tested, but the ones that came out in our study are fairly low cost and easy to implement.

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A nurse's stories reveal the heart of medicine

By Louise Kinross

I just finished The Language of Kindness: A Nurse's Stories of Life, Death and Hope and I can't get the images of author Christie Watson's British patients out of my head.

There is Betty, a frail old woman lying on a hospital stretcher with chest pains, following the recent death of her husband. After getting her a sandwich and a cup of tea, Christie holds her "paper-thin hand," closes her eyes and listens to her talk about her youth, till Christie is watching "a young woman in a dress made of parachute silk dancing with her new husband..."

There is the 14-year-old boy with cystic fibrosis that Christie readies for a new set of lungs. She wets his lips with a sponge in sterile water, and takes his Game Boy, swearing "to guard it with my life." When the porter comes to take him to the operating room, he turns to ask if she'll be with him. "The whole time," she tells him. "I'll be there."

There is Jasmine, the 12-year-old girl on a ventilator and dying, after a house fire. Her brother is nearby, also on a ventilator. Their mother has died. When an aunt arrives, the doctor explains the severity of Jasmine's injury and that they need to "let nature take its course."

The aunt doesn't understand. "Let nature take its course?" she asks Christie, confused.

"She is dying," Christie says.

"Jasmine's aunt is too shocked to hear a narrative," she explains to the reader. "She needs blunt, quick information to break through the shock."

Then, before bringing the aunt in to see her niece, Christie and another nurse tenderly wash the girl's hair, to remove the overpowering smell of smoke. "Smelling the lingering smoke will surely make it worse for Jasmine's aunt," she writes. "Sometimes, not making it worse, is all we can do."

There are nurses who work a night-shift, then travel two hours to the funeral of Samuel, a premature baby they've cared for. They've been up for 21 hours, Christie notes.

One of the nurses, Christie writes, has been at Samuel's bedside round the clock for months, singing to him, holding his hand and stroking his hair. Christie recalls watching her pull a container of bubbles from her pocket, then blow them gently above Samuel, popping them one by one, as he kicked his legs.

Christie writes largely in the present tense. In her poetic and philosophical book—which weaves in history, science, architecture and social commentary—she brings the hospital alive with vivid descriptions of the sights, sounds, and smells of each unit, and the complex characters who are her patients, their families and her co-workers. "Nursing is a career that demands chunks of your soul on a daily basis," she writes.

This book shows clearly why nurses, who spend the most time with patients, are in a unique position to provide not just physical and medical care, but emotional support, in a flexible, non-judgmental way that honours a patient's story and helps them feel heard and understood.

I listened to this as an audio book that Christie reads, and it was captivating.

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