Exploring the Relational Intervention of Storytelling: A Qualitative Study of the Patient Stories Project in a Single ICU.

OBJECTIVES: Our study objective was to explore nurses' experiences of how the Patient Stories Project, an intervention consisting of garnering and sharing ICU survivor stories with the ICU team, influenced their perceptions of the value of their work and their nurse-patient relationships.
DESIGN: This was a qualitative descriptive case study that used thematic analysis.
SETTING: This study was conducted in a single, 34-bed adult ICU in a Canadian tertiary care teaching hospital, serving a mixed medical and surgical patient population and employing over 200 nurses.
SUBJECTS: Semistructured focus groups with 12 ICU nurses were conducted between June 2019 and July 2019. INTERVENTION: The Patient Stories Project is a systematic process for collecting and sharing former patients' stories. On a regular basis, former ICU patients return to the ICU to say, "thank you," share their experiences, and tell their stories to staff.
MEASUREMENTS AND MAIN RESULTS: Storytelling through the Patient Stories Project gives meaning to nurses' work and provides avenues for nurses to think about their work more positively. Key themes were as follows: 1) perspective taking, 2) emphasizing the value in caring, 3) providing positive closure, 4) engendering team belonging, and 5) building a sense of hope.
CONCLUSIONS: This study addresses the Critical Care Societies Collaboratives "call to action" to create a healthy work environment. Nurse focus group participants articulated how an initiative such as the Patient Stories Project may augment the relational aspects of work that are important to nurses, as well as their patients and families. Our study results have implications for the importance of using storytelling as a relational strategy to protect against depersonalization and cynicism, elements of burnout.

Critical care areas such as ICUs are dynamic. Critical care teams are continually learning and mastering advancements in medical care while developing relationships with patients and families. Within the ICU team, nurses are regularly exposed to stressful events, such as death and trauma and care provision that is often perceived as futile or uncertain (1). Nurse-patient interactions are further impaired by patients’ inability to communicate due to artificial airways, mechanical ventilation, sedation, delirium, and neurologic deficits (2). While caring for critically ill patients, nurses often adopt task-oriented approaches to meet the demands of these medically complex patients and to cope with high stress situations (3). A predominant focus on nursing tasks, such as technical procedures, can negatively impact the nurse-patient relationship (4).

Relational practice characterizes nurse-patient relationships founded on relational concepts, such as trust, empathy, and respect (4). Nurses goals are to listen, advocate, and ensure that care wishes of patients and their families are represented during each visit from the doctor, specialist, or other member of the healthcare team (e.g. pharmacist, physiotherapist). Given their one-to-one assignment each shift with the same patient, ICU nurses have opportunities to forge particularly meaningful nurse-patient relationships. Relational practice, however, can be threatened by the task-like, technical world of ICUs. The presence of nurse burnout often signifies unsupportive work environments and the devaluing of nurses’ workplace contributions (5)

Burnout is characterized by emotional exhaustion, cynicism, and depersonalization due to chronic exposure to workplace stressors and lack of emotional resources and supports (5). A recent review of 91 empirical studies on nurse burnout found significant associations between burnout and intent to leave, sickness absence, decreased job performance, and decreased perceived general health (6). Nurse burnout can occur as a result of moral distress and is identified in the literature as negatively impacting interprofessional teamwork and contributing to nurse attrition (6, 7). Further, moral distress is linked to poor collaboration with physicians, thereby jeopardizing the quality of decision making in the ICU environment (7, 8).

Burnout is considered to be the opposite of workplace engagement on an employee well-being continuum (5). Organizations that recognize and value relational aspects of nursing practice foreground its significance and make visible the value of nurses’ work, resulting in nurses’ self-reports of increased job satisfaction, organizational commitment, workplace engagement, and decreased turnover intentions (9). In 2016, the Critical Care Societies Collaboratives (CCSC), published a noteworthy document in four major journals, calling attention to burnout among critical care health professionals. The CCSC was a “call to action” to protect the health and wellness of care providers in critical care (10). To raise ICU nurses’ awareness of nurse-patient relationships and the value of nurses’ work, the Patient Stories Project (PSP) was initiated by nursing staff in the ICU of a Canadian tertiary care centre in 2017. The ultimate goal of the PSP is to reduce risk of burnout among ICU nurses.

The therapeutic power of storytelling in the context of illness and trauma has long been recognized (11). Through storytelling, patients and families create narratives that incorporate their illness/trauma experience into a new “life history” of what they have gone through and who they have become. Through patient storytelling, healthcare providers have opportunities to appreciate their influence on a patient’s construction of their new life history (11). One storytelling approach, Public Narrative, was developed by Marshall Ganz as a means of creating a motivational collective experience and enhancing social bonds among individuals (12, 13). The Public Narrative approach is particularly useful when considering the ways in which stories constructed by patients (i.e., patient stories) might imprint on nurses, for example by bringing into focus their relational connections to their patients. Ganz’s public narrative includes three foundational elements: a story of self, a story of us, and a story of now (13). As a patient tells their story, a “story of self,” nurses see themselves from the patient’s perspective, and a “story of us” begins to form among those who cared for that patient. The story of us represents a collective identity of nurses’ importance to that patient and their family. A story of us can be inspirational and empowering, creating a new and hopeful “story of now” for those nurses (13). Overall, patient stories have the potential to raise nurses’ awareness of the unique and valued nature of their work and remind them that they make a significant difference to patients and families (12, 13). The underlying theoretical proposition of this study is that nurse burnout and related sequelae, such as moral distress, can be mitigated through patient stories.

The aim of this qualitative study was to explore nurses’ experiences of how the PSP, as storytelling intervention, influenced their perceptions of the value of their work and their nurse-patient relationships.

MATERIALS AND METHODS

Setting

This research was conducted in a province of Canada. The setting of the study was a 34-bed adult ICU in a tertiary care inner city teaching hospital, serving a mixed medical and surgical patient population. The ICU nursing staff consists of over 200 employees.

Design

In this study, a qualitative descriptive case study design was chosen, which allowed for a rich description of nurses’ perceptions of the PSP (14). Qualitative descriptive design is commonly used by nurse researchers to describe study participants’ experiences with a phenomenon of interest (14). Case studies provide an in-depth analysis of a “case,” which can be a person, an event, or in this case, one group of ICU nurses. Data may be from a variety of sources: For this study, we conducted nurse focus groups (FGs) (15). Thematic analysis was used to systematically identify and explore qualitative themes brought forth by study participants. With this kind of analysis, there are typically two to three levels of codes, beginning with descriptions of actual words and phrases that are characterized by themes at an interpretive level of coding (16).

Research Ethics

The study was approved by the institutional ethics review board of the hospital (V19-00949) and the university (H19-00949). All subjects provided written and informed consent.

Participants

A convenience sample of ICU registered nurses (RNs) was recruited via workplace e-mail announcements and study posters in nurse lounges. Snowball sampling was used to obtain additional recruits. Inclusion criteria included RNs with at least 1 year of ICU experience and familiarity with the PSP. Patients, families, and their PSP stories were not a part of this study. Our case study focus was on nurses’ perceptions of the PSP and its potential influence on their patient-nurse relationships and their valuing of nurses’ work contributions.

The PSP

At the study site, former patients and their families often voluntarily return to the ICU before or after being discharged from an inpatient unit or rehabilitation facility. During these visits they say, “thank you” and recall what was important to them during their ICU stay. The ICU nurses started to recognize how patients’ visits and their stories were making a positive difference to them. Given the potential influence of patients’ stories, the PSP project was created to garner and share these stories with the nurses and other members of the ICU team. When patients/families return to the ICU, nursing staffs give them an organizational consent form with a description of the project and a request to answer and complete a set of questions about their ICU experiences (Table ). Returned stories (by mail, e-mail or in-person) are displayed for staff on a dedicated PSP bulletin board. Many families include photos, drawings, and news clippings of significance to them. We currently do not track the return rate of patient stories, but at any one time, there are usually four stories on display, and the stories are typically rotated every 5 months on the PSP bulletin board.

Data Collection

The patient stories that were displayed for the PSP were not included as data for this study. Rather, the data were collected through three 1-hour long FGs with nurses working in the ICU, which were conducted between June and July 2019. An interview guide (Table ) with semistructured questions was used to elicit in-depth responses from nurse FG participants, with the three primary questions posed being:

1) What did you think about the PSP when it was introduced in the ICU?

2) Tell me about the feelings and experiences you have had by hearing the patients’ stories.

3) How has the PSP influenced your work in the ICU?

The three audio-recorded FGs were professionally transcribed verbatim and deidentified.

Data Analysis

The research team followed an analytic process described by Clarke and Braun (16). The transcribed data were uploaded and managed in NVIVO (version 12; QRS International [CAN], British Columbia, Canada). At a descriptive coding level, two of the authors independently, inductively coded one transcript for key words and phrases. A coding framework of descriptive labels and exemplar quotes was collaboratively developed by the two researchers and shared with other members of the team. This process was repeated for the other two transcripts, to ensure coding rigor through regular reflection, review, and discussion of coding labels and exemplar quotes from the three transcripts. At a second, interpretive level of coding, this process of independent coding and then collaborative review of thematic labels were carried out to ensure agreement with respect to the assignment of themes most reflective of patterns and meanings in the exemplar quotes.

RESULTS

The 12 study participants ranged in age from 32 to 47 years, all identified as women and were all full-time employees with 5–20 years of ICU experience. Ethnicities were self-identified by participants and included nine Caucasians, one Black, one Zoroastrian, one South Asian. Through our analysis of their accounts, we inductively identified five themes that captured nurses’ experiences of how the PSP influenced their perceptions of the value of their work and their nurse-patient relationships. The five key themes were as follows: facilitating perspective-taking, emphasizing the value in caring, providing positive closure, engendering team belonging, and building a sense of hope. The following sections provide descriptions of each theme with substantiating quotes. The quotes are identified by FG (e.g., FG1).

Facilitating Perspective Taking

The act of storytelling by a patient triggered nurse perspective-taking. Perspective-taking in this study refers to nurses’ capacity to imagine the experience of critical illness from the patient’s perspective. By listening to patients’ stories, the study participants began to see the patients as individuals with family, friends, colleagues, and a life outside and beyond the ICU. Through perspective-taking, the study nurses shifted their perspective of patients as statistics and bed assignments to people who had survived a critical illness. The patient’s story served as a catalyst for nurses to reflect on their own preconceptions about the patient and expected outcomes. Several participants commented on their assumptions that life-saving efforts would end with a negative outcome, yet patient stories provided opportunities for these nurses to consider the inherent uncertainty of predicting medical outcomes and patient priorities. For example, one nurse explained:

This person’s going to, you know, be in a persistent vegetative state or whatever. Like, what’s the point? We’re not helping them. So when you see someone who initially had that type of prognosis go home and have, you know, a good quality of life, I think it kind of brings the focus around and helps with that sort of burnt (sic) out, jaded tone that happens when you’re really, really overworked. FG2

The nurses commentaries indicated their increased willingness to question their assumptions and to consider other outcomes after critical illness:

We have our biases of, like, “I would never want to live if I was this way”. But then you ask them, and they might not be perfect or the way they were pre-ICU, but they find a new version of what is good for them. FG1

Some study participants described a more permanent change in their perspectives and approach to practice, particularly in situations where futility might be a concern.

It definitely changed my biases to how quickly I’m judgmental in saying, “What are we doing here? Like, we’re just torturing the patient.” But hearing him say that [he was grateful to be alive] has changed me. In certain circumstances, I’m like, you know what? We don’t know. We’re not god, we don’t know the result, we can’t control everything, so maybe they will make it and be happy with the decision their family or loved ones made for them. FG1

Through perspective-taking, study participants recognized the positive longer term effects of their nursing care on patients and families. Participants linked their new perspectives to the easing of burnout and moral distress.

And you know, people actually do get better, it’s nice to be able to actually show new practitioners that are coming in that, like, hey, so we acknowledge that moral distress, moral residue, like, bad things are going to happen in the ICU. It is what it is. Mortality rates are high. That’s the nature of the work you’re going to do. However, there is also an opportunity to really change people’s lives for the better. They can survive, and you—we do good things, despite how it feels sometimes. FG1

Of note is that participants described their preference for thinking of patients as more than a statistic. Perspective-taking helped them shift from survival rates and performance indicators to patient stories.

I don’t connect with statistics, I connect with stories, I connect with people. As I get older in my life and my nursing career, I’m looking for more stories and connection, like human connection. I identify more with—I find the Patient Stories Project more meaningful than statistics. FG3

Emphasizing the Value in Caring

Nurse perspective-taking through the patient’s story was, perhaps, the impetus for nurses to recognize the value of caring or the relational aspects of nursing practice. The study participants described how they learned through the patient stories that the relational aspects of care meant more to patients and families than technical proficiency.

I do find that that’s the one thing that always shines bright for me through the stories, is that it’s the work and it’s the compassion and the empathy of the people involved that saves people, not the medicines and not the technology. FG1

With some of the stories, like, they remember the smallest things, like, “So-and-so rubbed my feet,” or whatever, and it makes you…You know what? Like, “They washed my hair.” They didn’t remember who did the best CPR. FG2

Emphasizing the value of caring was linked to easing of burnout as the nurse participants acknowledged how relational practice and the value of caring is what matters the most.

It’s very, very easy to distance ourselves when we’re caring for patients. They don’t—they’re not acting like their normal selves; they’re not dressed like their normal selves. And that does damage to ourselves as caregivers. You know, it’s sort of…compassion fatigue, burnout and all the other ills that come along with critical care practice. And so, I think that talking about patients in the context of their life following the ICU matters. FG1

You invest so much. You go to your job and you’re going to spend more than 12 hours knowing every detail of this person’s body and advocating for them and going up to battle for them. I think the one thing that Patient Stories shows quite clearly is that it’s not technology that saves people’s lives. FG1

Providing Positive Closure

Study participants shared how they “lost sight” (FG1) of patients among their task-oriented shifts. Once patients are discharged from the ICU, nurses’ memories of them fade. The patient’s care space is cleaned and readied, and a flurry of activity ensues as a new patient arrives who is requiring critical life-saving measures. “We’re so focused on tasks and getting everything done (FG1).” The patient stories provided the opportunity for nurses to learn about the person they cared for and to have positive closure.

It was validating. So, it was nice to have that closed loop feedback with that patient even, like, a month after that happened. I feel like this, the Patient Stories really, we can learn as nurses, we can learn from our patients a lot. FG1

And then when you have a Patient Story or someone who comes in the unit, and word spreads like fire, and then you’re sitting in that staffroom, and the morale completely changes and everybody’s more lighthearted and you’re talking about the positive things, and you kind of sometimes just fog out all the crap that you’re dealing with during your shift and just focus on that [positive]. And I find it, like, it carries through the hospital. FG1

Nurses’ statements indicated that positive closure with patients’ outcomes may be associated with reduced moral distress, a risk factor for burnout.

It’s like a very visual reminder, for me anyway, that we do good work here, regardless of how we feel sometimes when we go home, or you know, the moral distress that we feel, the compassion fatigue that we feel, we do good work, and people do get better after that. FG3

Team Belonging

This theme captures study participants’ descriptions of how PSP made the nurses feel part of a team. The study participants described how patient stories gave rise to a sense of teamwork and team belonging in their ICU environment.

Like, she did so well. I mean, it took a lot of work from a lot of people. So I get overwhelmed by it because I’m so proud of the work that we do here as a team, and I don’t think we acknowledge it or give ourselves credit for that, and I think that the patient—like, the—they let us know. FG3

FG discussions revealed how team belonging fostered feelings of engagement, pride, and a shared experience among colleagues.

I think the Patient Stories Project and—is an opportunity for that, for team building through shared experience—and that’s the storytelling thing, no doubt, is that you know, like, that’s how you build group identity, is like, “okay, well, we’re the group that does this”. It’s like this shared experience, and being able to reflect on shared experience, which is how you bring—you know, build team cohesiveness. FG3

One thing I really appreciated was it [the PSP] gave me pride back and made me really proud of the unit, and my colleagues, specifically nursing. FG 1

In the ICU environment, nurses’ contributions to the team can be overshadowed by the medical care and technology. The PSP created an opportunity to increase the visibility of nursing and validated how nurses contribute as team members, as evidenced in the following quote:

Patient Stories is something that can be incorporated into the daily work life, I feel like that’ll help retention, right, because it’ll encourage that debrief, it’ll encourage that conversation, it’ll encourage the acknowledgement of the team, not just the one physician. FG1

Building a Sense of Hope

Building a sense of hope depicts nurses’ capacity to convey hope to others, in addition to themselves. The study participants gave examples of how they witness stressful situations, death, frequent delivery of invasive painful interventions, and futile care situations. They acknowledged how they often use detachment, distancing, and task-based care to cope. Building a sense of hope represents a state of mind that nurses said allows them to stay relationally connected to their patients and shift their perspective from the impossible to the possible.

And I think it gives us an opportunity to acknowledge that side of our work, about the hope that we want to maintain. FG 3

Mindset is so much of it, and I think that that’s the biggest change in how I felt about it, is when people would come in and be super optimistic about their family, I’d be like, “Oh, like, you need to be realistic,” whereas now I’m like, “No, you need to—you don’t give up.” FG2

DISCUSSION

In this study, we found that in hectic ICU work environments, storytelling has the potential to give meaning to nurses’ work and provide avenues for nurses to think about their work differently, positively, and relationally. Customary interventions to address burnout focus on work environment factors, such as workload management and adequate staffing (17). Our study used a relational approach of patient storytelling to strengthen nurse-patient relationships and hopefully counteract burnout among nurses and the ICU team overall. The identified themes shape the “story of self”, the “story of us”, and the hopeful “story of now.”

Although the themes were inductively created in the context of this study, they complement Ganz’s three phases of storytelling (2011). The story begins with the patient’s “story of self”. The PSP encourages patients and families to tell their story in their own words (13). In this study, the perspective-taking theme represents how the nurses saw themselves and their care through the experiences of patients and their families. Perspective-taking is necessary to close an “us-them” gap that results in distancing and devaluing. Through perspective-taking, individuals become more aware of their judgments, stereotypes, and behaviors that distance them from others (18). Cynicism, a type of burnout, is exhibited as relational detachment from patients and others. Nurses recruited for this study described how they were cynical, detached, and focused on technical aspects of their work. By imagining themselves from the patient’s vantage point, the nurses began to recognize the value-laden importance of their work.

The “story of us” is represented by the themes, emphasizing the value in caring and providing positive closure. According to Ganz (2011), the “story of us” represents a collective identity around shared values. In this study, nurses identified how patients’ stories raised their awareness and valuing of the relational, humanizing aspects of their work (vs the technical), and their capacity to gain positive closure after caring for patients and families during stressful and morally challenging circumstances.

What emerged is the “story of now” and its two themes, team belonging and building a sense of hope. These themes represent nurses’ pride in their team and their desire to share their hope and inspiration with other patients and families. Teamwork has been identified in the literature as a contributing factor for job satisfaction and retention among ICU nurses, positively impacting nurse health and well-being and the sustainability of the team (8, 19). Team work has also been associated with workplace engagement, which has the capacity to build empowering work environments (20). In this study, a sense of team belonging was associated with nurse descriptions of teambuilding, engagement, pride in work, and the importance of inclusivity (versus medical dominance). Leveraging the potential benefits of teamwork in the ICU has the capacity to reduce levels of burnout among nurses and build and sustain a healthy work environment (21).

The sense of hope theme is another attribute of the “story of now.” Hope is a state of mind that protects nurses against burnout and fuels work satisfaction by reducing a nurse’s vulnerability to emotional exhaustion (22). Hope can nurture resiliency by introducing an alternative way of thinking during stressful situations (22). Overall, building a sense of hope can positively influence nurses’ perceptions of the value of their work—for themselves and for their patients and families.

In this study, we found that patient stories foreground a set of values that matter to nurses. By reading these stories and reflecting upon them individually and collectively, nurses have the capacity to improve the quality of working relationships with those who are sharing similar experiences and acting together on behalf of a common calling. This relational approach may be a protective buffer against burnout (9, 13). Furthermore, the PSP may be a strategy to support patients and families during their post ICU recovery. Posttraumatic stress disorder is a common consequence for patients who have spent time in critical care settings (23). The PSP offers the unique ability for patients to share their narrative after critical illness. A body of literature suggests that the process of constructing and telling stories may be a therapeutic means for patients to psychologically recover after intensive care (24). Further investigation of patients’ and their families’ perspectives on storytelling is needed.

This study focused on nurse burnout and nurses’ perspectives of the PSP. Based on the two FG questions related to “other” feedback and PSP expansion to areas outside the ICU, participants supported inclusion of other ICU team members (e.g., allied health, physicians and specialists), and they supported the introduction of the PSP project to other departments (e.g., medicine-surgery, emergency services). Further research is needed, therefore, to broaden the scope and scale of the PSP approach to burnout prevention.

LIMITATIONS

Limitations of this study include a single case study in one ICU with a small sample of nurses. The all-female sample had a diverse range in ages and years of experience. Individual interviews versus FGs may have captured the influence of different demographic factors on nurses’ perspectives of the PSP. Given the voluntary nature of the study, participants may have been more positive about the PSP than those nurses who chose not to participate in the research. The lead author was known to many of the participants having worked as a nurse at the setting; however, the co-authors had no connections to the nurse participants, offering an impartial view and a counterbalance to the analysis of the data.

CONCLUSIONS

This study addresses the CCSC “call to action” to create a healthy work environment for ICU healthcare providers at risk of burnout (10) in order to support high-quality patient and family care. Nurse FG participants articulated how an initiative such as the PSP may augment the relational aspects of work that are important to nurses, as well as, their patients and families. Our study results have implications for the importance of using storytelling as a relational strategy to protect against depersonalization and cynicism, elements of burnout that nurses in our study described as outcomes from working in highly complex, and ethically challenging ICU settings.

ACKNOWLEDGEMENTS

We would like to thank the critical care nurses who offered us their time and participated in the interviews.

Table 1.

PSP Questions for Patients and Families

Questions
Q1 What brought you to the ICU?
Q2 What is life for you like today?
Q3 What would you or your loved ones want to say to the ICU?
Q4 What do you or your loved ones want the ICU to know about you?
Q5 Do you have a favorite quote or words to live by?

Table 2.

Focus Group Interview Guide

Questions
Q1 What did you think about the PSP when it was introduced in the ICU?
Q2 Tell me about the feelings and experiences you have had by hearing patients’ stories.
Q3 How has the PSP influenced your work in the ICU?
Q4 Would the PSP be useful to nurses in other practice areas? Why or why not?
Q5 Anything you would like to share about the PSP that has not been said?

PSP = Patient Stories Project.