Creating a narrative culture

By Jeanette Ives Erickson, Marianne Ditomassi, Susan Sabia, Mary Ellin Smith | 04/01/2015
 
This chapter from Fostering Clinical Success: Using Clinical Narratives for Interprofessional Team Partnerships From Massachusetts General Hospital lays the groundwork for systematic use of clinical narratives to improve patient care and increase patient, family, and staff satisfaction while reducing costs. The authors share their model for a narrative culture that has become a key component of Massachusetts General Hospital’s evidence-based practice implementation.
 

 
Fostering Clinical Success book coverConsider for a moment the following highly impactful and insightful statements:
  • “I knew something was wrong.”
  • “I stayed silent. I knew that she needed time to finish telling me her story rather than the story my questions or comments would lead her toward.”
  • “I felt a sense of urgency in everything I was doing.”

Have you ever been talking with clinicians and heard similar comments and wondered how they knew something was wrong or when and how to intervene? What they saw that others did not? Such questions come not only from curiosity but also from recognizing that you do not know the answer to those questions. And, if you cannot quantify the answer, then how can you possibly evaluate it, teach it, and share it?

It was this frustration that led people in healthcare disciplines—including but not limited to nurses, therapists, and social workers—to seek the answers to these questions using clinical narratives to understand and articulate practice. These stories of clinical practice can be written and shared, and they allow individual clinicians to articulate, reflect, and understand their work. In addition, narratives make visible the clinical excellence and expertise of the clinician and provide an opportunity for shared learning.

Exploring narratives in the literature
A clinical narrative is a first person “story” written by a clinician that describes a specific clinical event or situation. Narratives allow clinicians to reflect on who the patient is and how that knowledge informs how clinicians care for patients, make decisions, and collaborate with the members of the healthcare team. Patricia Benner, PhD, RN, FAAN, has written extensively on the use of narratives to articulate skill acquisition in nursing practice (Benner, 1984; Benner, Tanner, & Chesla, 1996) and the clinical wisdom embedded in practice (Benner, Hooper-Kyriakidis, & Stannard, 2011). In her work on educating nurses (Benner, Sutphen, Leonard, & Day, 2010), she used narratives to articulate best practices in teaching and in the student experience of integrating the theory taught in educational programs and the reality of the clinical settings. To understand the informal power of nurses, Paynton (2008) used narratives to identify ways nurses were able to manage systems to advocate for patients. Cathcart and Greenspan (2012, 2013) used narratives to describe skill acquisition in nurse manager practice.
 
Narratives have given insight into the moral comportment of nurses (Benner, Sutphen, Leonard-Kahn, & Day, 2008) as they care for increasingly complex patients in highly technological environments in the rapidly changing healthcare environment. Narratives are used in multiple disciplines, such as social work (Riessman & Quinney, 2005) and education (Schultz & Ravitch, 2013). In 2009, administrators at the Columbia University College of Physicians and Surgeons inaugurated a program in narrative medicine.
 
Creating a narrative culture
Massachusetts General Hospital (MGH) is a large, tertiary-care, academic medical center deeply rooted in the case study methodology of study and research. Despite the available supporting literature, there were clinicians and leaders who challenged the attention and focus on the narrative as a way to develop reflective practice and professional development. Narratives, many felt, were “too soft” and lacked the rigor found in the case study approach in which data and facts were the focus as the writer walked his or her colleagues through the process of analysis. The MGH senior vice president for patient care and chief nurse who was appointed in 1996 began to educate and influence clinicians’ and leadership’s understanding of the power of the narrative to articulate and describe the unique role of the clinical disciplines at MGH.

At the time, the department of Nursing and Patient Care Services (NPCS) was fairly new and comprised six disciplines:

  • Nursing
  • Occupational Therapy
  • Physical Therapy
  • Respiratory Therapy
  • Social Work
  • Speech–Language Pathology

The clinicians in these six disciplines primarily worked in silos, with only a broad understanding of what the other disciplines did. The creation of NPCS brought with it some anxiety for the therapists in the therapy departments, as they were joining a service in which they were greatly outnumbered by nursing professionals. They wondered how they could maintain their unique identity and practice.

Through open forums, the senior vice president and chief nurse heard those concerns and began a process in which professionals in each discipline articulated their domain of practice. This process allowed the people in each discipline to reflect on their work and then to share their unique contributions to the care of the patient, the organization, and the team. She then took this work a step further and asked NPCS clinicians to make their domains of practice come alive by telling a narrative that reflected their work as a member of the discipline. She recognized that some clinicians who felt comfortable writing progress notes describing their plan and care of patients and the patients’ response to that care might have felt vulnerable in writing a document that described the clinical situation and their thinking and decision-making in the delivery of care to those patients.


NARRATIVES BUILD SKILLED CLINICIANS

Clinicians in MGH’s department of Nursing and Patient Care Services have long valued their collaboration with Patricia Benner (1984), whose hallmark book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, used narratives to articulate and describe the nurses’ changing clinical world as they transitioned from novice to expert. Benner’s work built on the Dreyfus Model of Skill Acquisition (1986). Together, the Dreyfus brothers’ and Benner’s research described that skilled know-how comes not just from knowing what to do—the performance of a task, knowing the policy, or attending a class—but how and when to do it, which occurs in the active engagement with the world. For the healthcare disciplines, this refers to their clinical practice.


The senior vice president and chief nurse challenged her executive team and nursing directors to create forums and opportunities for clinicians to share their stories. Staff meetings at many units and departments at MGH now include a clinician telling a story about a patient or situation that had meaning for the clinician. Leaders have received coaching on how to use these stories to build reflective practice in their staff. For leaders, this means closely listening to the story and asking unbundling questions that would allow the clinician to move deeper into his or her understanding of the event and, from that, to create opportunity for new learning.

The senior vice president and chief nurse continued her work in creating a narrative culture by setting the expectation that clinicians in NPCS would submit a clinical narrative with their self-evaluation as part of the annual performance review. When staff members challenged this decision, the senior vice president and chief nurse engaged with them on what their experience had been with the existing performance appraisal: Did they believe that the performance appraisal adequately reflected their work and professional development over the past year? The answer was generally no. She then asked staff to reflect on what the performance appraisal experience would be like if they could talk about a situation in the past year that had meaning for them—a situation in which they were at their best or an experience they learned from. Would that story, in addition to the rest of the components of the performance appraisal, demonstrate more about their practice and their ongoing professional needs than the review process already in place? With her leadership, and the leadership of NPCS, the narrative became and continues to be an integral part of every clinician’s performance appraisal.

The narratives continued to be woven into the culture of NPCS with their prominent display in the department’s bimonthly newsletter, Caring Headlines. In the newsletter, a narrative written by a clinician in NPCS is featured, accompanied by a reflective commentary from the senior vice president and chief nurse. Authors of the narratives often receive emails from colleagues, known and unknown, telling them how impressed they were by the practice described in the narrative and asking more questions about it.

MGH NPCS is fortunate to have a robust award and recognition program thanks to its patients and families and benefactors. Every year, clinicians across MGH are nominated for these awards and submit a portfolio, which includes a clinical narrative. Award selection committee members describe that the narrative enables them to see the criteria for the award come to life and informs their decision-making process as they select a recipient.

As narratives became solidly embedded in the culture of MGH, clinicians—who initially might have responded that they did “nothing special” in the care of a patient—told their stories and recognized subtle nuances that they had not identified previously. Through the questioning and curiosity of a colleague or leader, they further explored their interaction with the patient/family, their clinical reasoning, and their work with their peers and members of the healthcare team. For many nurses, therapists, and social workers, narratives allowed them an insight into their actions and thinking that had been missing and made it possible for them to engage in their work more deeply and with greater attention and intention.

The narrative has taught clinicians and leaders at MGH another way of knowing: knowing through the engagement of the clinician in the care of the patient. The narrative allows the reader to enter into the clinician’s world—what clinicians are seeing and thinking, and how they are making decisions. The narrative takes the theoretical knowledge of the case study and enriches it with the clinician’s experiential knowledge. Through the blend of both sources of knowledge, the story of the patient and the care of that patient and family come into greater focus. This form of knowledge was critical in the development of the MGH NPCS Clinical Recognition Program, in which narratives have enabled us to articulate the themes and criteria of practice for the six disciplines (Nursing, Occupational Therapy, Physical Therapy, Respiratory Therapy, Social Work, and Speech–Language Pathology).

Using clinical narratives to develop an interdisciplinary clinical recognition program
In 2002, the department of Nursing and Patient Care Services (NPCS) at MGH launched a Clinical Recognition Program (CRP) designed to recognize and celebrate the clinical practice of all direct-care providers. The CRP, the first-of-its-kind interdisciplinary program, needed to meet the professional development needs of clinicians across the healthcare disciplines.
 
The senior vice president and chief nurse believed that a program to recognize and celebrate the knowledge and skill of direct-care providers was essential to professional development. Not only had clinical staff expressed an interest in such a program, but the senior vice president and chief nurse also felt that an interdisciplinary recognition program would help unite the disciplines and underscore the department’s commitment to clinical excellence. In June 1997, she appointed a professional development committee, comprised of representatives from the six NPCS disciplines, to lead the first phase of the program development effort and to develop the framework for a CRP.
 
Guiding principles
As a first step, members of the committee articulated a set of principles to guide their work. These principles served several purposes:
  • Underscored the importance of the direct provider’s role
  • Highlighted how experience, collaboration, formal education, and self-reflection promote learning
  • Emphasized the importance of recognizing each clinician’s contribution to patient care
  • Acknowledged the uniqueness of each discipline and the need for interdisciplinary representation in program development

The principles grounded the group’s thinking and ultimately exerted a strong influence on the CRP’s framework.

A conceptual framework
The committee members then needed to identify a conceptual framework to understand and explicate the practice of the clinicians in NPCS, and their search brought them to the work of Dreyfus and Dreyfus (1986) and Benner (1984). The Dreyfus Model of Skill Acquisition provided a framework for understanding and describing the development of expertise in practice. Benner and her colleagues have worked extensively with the model in clinical settings using the interpretative phenomenology approach of the clinical narrative. Using this approach, the clinical narrative gives the reader insight into the context of the event, including the actions the clinician took and the meaning those actions had.
 
The committee members put a call out to clinicians across NPCS for their narratives, and it was through reading, discussing, and analyzing those narratives that the committee members were able to identify the themes and criteria for the initial CRP model:
  • Clinician–patient relationship: The interpersonal engagement or relational connection between the clinician and the patient and/or family.
  • Clinical knowledge and decision-making: The understanding attained through formal and experiential learning.
  • Teamwork and collaboration: The development of effective relationships with unit-based colleagues and other members of the healthcare team promotes the best possible outcome for the patient and family.
  • Movement: Through observation, palpitation, and touch, the therapist uses knowledge and skill to assess the patients’ functional ability.

In the introductions to the subsequent chapters, we define these themes that form the framework for the CRP.

Levels of practice
Returning to the work of the Dreyfus brothers and Benner, the committee members identified four levels of practice that they believed applied to all six disciplines: 
  • Entry: At this level clinicians are learning to apply newly acquired knowledge and skills to a multitude of patient care situations. Entry-level clinicians initially draw on learned facts and rules to organize care and guide practice. As they gain experience, they are increasingly able to recognize the uniqueness of each patient situation and modify care to meet each patient’s needs. The Entry-level clinician understands the role of other disciplines and consults with peers in designing a plan of care.
  • Clinician: At this level clinicians have acquired broad experience in caring for patients and have often developed a sound understanding about the care of a particular patient population. They routinely draw on learned facts and experience as well as an understanding of possible outcomes when designing a plan of care. They have learned to recognize patterns in clinical practice and use this knowledge as they make clinical decisions. They act as resources to colleagues and are strong advocates for patients.
  • Advanced clinician: At this level clinicians have typically acquired in-depth knowledge about the care of a particular patient population and an appreciation for the many factors that influence care. In caring for each patient, they constantly consider not just the possibilities—or what could happen—but the probabilities—or what is most likely to happen given the clinical and organizational factors at hand. They routinely consult with and serve as a resource to others and influence practice on their unit/department.
  • Clinical scholar: At this level clinicians demonstrate exquisite foresight in planning patient care, are recognized as experts in planning patient care, are recognized as experts in their area of specialization, and are adept at negotiating conflict and collaborating with others. Clinicians at this level are reflective by nature and readily integrate knowledge gained by reflection into their practice. They are able to respond intuitively to patients’ needs and engage in clinically sound risk-taking. They are skilled at creative problem-solving, and they routinely lead efforts to strengthen the many organizational systems that support patient care.

By reviewing the narratives, the committee then specified criteria for the levels related to each theme. The criteria specified were “generic” in nature because the criteria applied to clinicians in all six disciplines. These generic criteria were then reviewed by members of each discipline, who enhanced them to better reflect a particular discipline’s practice and to distinguish among practice levels. With this refinement completed, the work of the professional development committee ended, and the focus moved to implementation.

The implementation process
As part of the implementation process, the Structure and Process Subcommittee identified the process and portfolio requirements for the four levels and the makeup and role of the review and appeals board process. The Education Subcommittee developed the plan to educate clinicians and leadership, and the Marketing Subcommittee addressed the issues of marketing and communication of the program.
 
The Implementation Committee used various approaches to inform and educate NPCS leaders and staff about the CRP. Early outreach efforts targeted clinical leaders. Gaining their support was considered crucial because those individuals would need to recognize staff at the Entry and Clinician levels as well as coach and endorse clinicians at the Advanced Clinician and Clinical Scholar levels. The senior vice president and chief nurse held a retreat with more than 100 clinical and administrative leaders, which was followed by additional group sessions and individual consultations. Educational sessions were held for the Review Board and Appeals Board to ensure there was a consistent understanding of the levels and criteria of the CRP.
 
In April 2002, the CRP was officially launched, and the Implementation Committee was replaced by a Steering Committee that was charged with overseeing CRP operations, monitoring the new program’s effectiveness, and continuing its ongoing development. In the years since, the program has changed in response to feedback from clinicians and leadership. Nothing that occurred was unexpected given the culture change of implementing a program as large as the CRP, but at each challenge the NPCS leadership and clinicians chose to focus on improving and redesigning the program rather than reinventing it.
 
We have learned from our work in implementing a narrative culture that ensuring attention to the CRP must be ongoing. Today, the CRP plays an important role in the professional development of NPCS clinicians, and work is underway to expand the program to other disciplines, including Chaplaincy. What has been most significant has been the program’s effect on the way clinicians and directors discuss clinical practice. The CRP has not only promoted a narrative culture and created more opportunities for examining practice but has also given directors and staff a language to discuss practice and clinical excellence—a language that is shared within and across all disciplines in NPCS.
 
In their own words
The rest of this book includes the narratives of clinicians at MGH, but we believe these stories are much like stories that you might hear where you work. The authors of these narratives, who are probably similar to the clinicians you work with, will tell you what they did was nothing special—it was what anyone would do. We, like you, know that this is not true, but it is true that we often take for granted the exquisite compassionate care they deliver. We know the clinicians will deliver that care, and so we often stand back and watch rather than actively engage with the clinicians to understand what they are thinking as they care for this patient in that situation at that moment. It is in this questioning that the clinicians reflect and make their practice visible to themselves, their colleagues, and the organization.
 
Following each narrative is a brief commentary, which we provide to highlight key elements and skill in the narrative. The questions that follow—which we hope are similar to the questions you might have had while reading the narrative—are designed to be used to promote reflection and learning by the reader.

We know that one cannot write all one knows. We know the challenge in describing the exact moment when the patient is ready to learn, the feel of the ambu bag as one tries to oxygenate a patient in respiratory distress, or the feeling one gets when one knows “something is wrong.” The only way we can understand the practice is by being curious and interested enough to ask questions and then be patient enough to listen to the answers.

Summary
The goal of this chapter is to show how one hospital’s initial decision to incorporate narratives into its culture has continued to inform and strengthen its professional practice environment almost two decades later. The simplicity of the intervention, telling a story that has meaning in your practice, has allowed disciplines to focus on a shared goal—the desire for excellent patient care—and allowed leaders to understand and influence the practice environment in a new way.
 
Using the narrative as a foundation, MGH NPCS has created a recognition model that provides a pathway for professional development and the articulation of clinical expertise.
 
None of this work was easy, nor is the work complete, but it does continue. As MGH NPCS continues to create innovative models of care, we look beyond the metrics to the lived experience of what these changes mean. We listen to the narratives of patients and clinicians to identify themes and patterns, watching for signs of success or stress and making adjustments along the way. RNL
 
Jeanette Ives Erickson, DNP, RN, NEA-BC, FAAN, is senior vice president for Patient Care and chief nurse at Massachusetts General Hospital (MGH). Marianne Ditomassi, DNP, RN, MBA, is executive director of Patient Care and Magnet Recognition at MGH. Susan Sabia, BA, is executive editor of Caring Headlines, the newsletter for MGH Nursing and Patient Care Services. Mary Ellin Smith, MS, RN, is professional development manager in the Institute for Patient Care at MGH.
 
References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
 
Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-in-action approach (2nd ed.). Philadelphia, PA: W.B. Saunders.
 
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Boss.
 
Benner, P., Sutphen, M., Leonard-Kahn, V., & Day, L. (2008). Formation and everyday ethical comportment. American Journal of Critical Care, 17(5), 473–476.
 
Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in nursing practice caring. Clinical Judgment and Ethics. New York City, NY: Springer Publishing.
 
Cathcart, E., & Greenspan, M. (2012). A new window on nurse manager development: Teaching for the practice. The Journal of Nursing Administration, 42(12), 557–561.
 
Cathcart, E., & Greenspan, M. (2013). The role of practical wisdom in nurse manager practice: Why experience matters. The Journal of Nursing Administration, 21(10), 964–970.
 
Dreyfus, H. L., & Dreyfus, S. E., with Athanasiou, T. (1986). Mind over machine. New York, NY: Free Press.
 
Paynton, S. (2009). The informal power of nurses for promoting patient care. OJIN: The Online Journal of Issues in Nursing, 14(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/
No1Jan09/ArticlePreviousTopic/InformalPowerofNurses.html
 
Riessman, C. K., & Quinney, L. (2005). Narrative in social work, a critical review. Qualitative Social Work, 4(4), 391–412.
 
Schultz, K., & Ravitch, S. M. (2013). Narratives of learning to teach: Taking on professional identities. Journal of Teacher Education, 64(1), 35–46.
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