An evaluation of storytelling in NHS organisations has revealed it has great potential to improve services and patient experience, and can develop staff caring capabilties
Capturing the stories of patients, carers and staff can help drive service improvement. An evaluation among NHS organisations in NHS Midlands and East found that organisations are committed to using storytelling but how it is used varies widely. Where organisations took a systematic approach to storytelling, positive outcomes were more readily evident. This article gives examples of how individual trusts have used storytelling.
Citation: McIntyre L et al (2015) An evaluation of storytelling in the NHS. Nursing Times; 111: 6, 18-21.
Authors: Lyn McIntyre is deputy nurse director - patient experience; Rachel White and Siobhan Lendzionowski are both leadership support managers - patient experience; all at NHS England (Midlands and East); Eleanor Sherwen is patient experience manager at NHS England (Essex area team).
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
The use of storytelling by nurses is becoming an important tool for understanding how patients perceive the healthcare they have received. Patient stories build on survey information by allowing patients to give qualitative insights needed to improve the delivery of quality and flow of care.
Following the introduction of the Health and Social Care Act 2012 and architectural changes to the NHS, the newly formed NHS England, Midlands and East Patient Experience Network felt it was important to understand the impact of patient stories (NHS Midlands and East, 2012). The strategic health authority NHS Midlands and East (now defunct) wanted to create a revolution in patient and customer experience, with the use of patient stories at board level being central to this region-wide ambition.
In 2012, an online survey was carried out across the region to capture information from 100 organisations on the use of patient stories, supported by case-study interviews across 11 trusts. This highlighted that, although the use of patient stories across NHS Midlands and East’s area was relatively recent, it was widespread among trusts. There was, however, limited evidence of its use by commissioners. The survey concluded that “hearing” the patient voice enables a greater understanding of the issues affecting patients and brings reported experiences to life. It was unclear whether progress was continuing.
After this survey, we conducted a study to look at the use of patient stories and their impact on NHS organisations in the Midlands and East region (as defined by NHS England). This comprised three strands of work; the main focus was understanding patient story programmes in action.
Using the Department of Health’s (2012) Compassion in Practice strategy to underpin the delivery action plan, the regional network highlighted that using patient stories to understand patient experiences is still a priority for the NHS. We therefore decided that conducting a formative evaluation would help gain a baseline from which developments could be targeted.
The study aimed to:
- Understand patient stories in action;
- Ensure rigour in the findings by using research-based methodology;
- Appreciate the organisational complexities in which storytelling was happening;
- Build strategic relationships and working partnerships while NHS England was in its first year as a commissioning body;
- Capitalise on any desire to progress the use of storytelling while the study was being done;
- Identify the progress of storytelling in the region since the 2012 survey had been carried out so the findings of this new study could be mapped against the results of the 2012 survey;
- Enable NHS England to learn from the study approach and method.
Realist evaluation was the preferred approach to understand the:
- Complex causal relationships between the mechanisms used to support a patient story programme;
- Context in which the mechanisms were operating;
- Resulting outcomes.
Realist evaluation does not ask whether a programme works but seeks to understand what works across the region for whom and in what circumstances (Pawson and Tilley, 2004; 1997).
It was important to recognise and value the work done in the 2012 survey. This formed a basis for this study and helped to develop the initial theories to be tested.
NHS organisations (healthcare providers and commissioners) were invited to participate through identified patient experience leads from each regional area team. Data was gathered via an evaluation form that had previously been developed and tested. Additional supporting evidence was also submitted.
Through the responses, natural groupings of the different NHS organisations emerged, along with insight specific to each group. The findings were peer reviewed to give the analysis process rigour.
During the study a potential patient story programme framework emerged. This, with other resources identified during the literature review, gave a basis for a potential improvement framework. The realist evaluation findings were used to find out more about regional progress.
The initial stage of any realist evaluation is concerned with working through theories derived from previous understanding. For this study, the initial theory to be tested emerged from conversations, feedback from the pilot work, patient revolution literature, academic literature and personal knowledge.
A draft or hypothesised patient story programme was developed from this initial theory (White, 2013). To arrive at a final programme specification or framework, the data from the returned evaluation forms and supporting evidence were examined for relationships or outcome patterns following an iterative learning process (Pawson and Tilley, 2004; 1997).
Responses were received from 17 clinical commissioning groups (CCGs), 10 acute trusts or acute foundation trusts, four hospital community trusts, two mental health trusts, two ambulance trusts and two NHS England area teams. The study findings are outlined in Box 1.
Box 1. Summary of study findings
- Storytelling is a vital way of listening to the patient voice and remains a strong area of work throughout the region
- Both providers and commissioners are using patient stories, but how they use them and the tools they adopt to capture, share and learn from them differs greatly throughout the region
- There is a notable commitment from commissioners and providers to continue having regular conversations around patient stories and to progress storytelling in the region, which is currently focused on sharing existing tools and templates
- Technology is helping to advance the collection and use of patient stories. This is an area of fast-growing development for both providers and commissioners, not just in terms of how stories are collected but also how they are then shared
- Where system thinking had been applied and patient stories clearly linked into organisational learning and reporting processes, outcomes were more readily observed. This was evidenced in the case studies (Boxes 2 and 3). This interconnectivity could suggest that greater learning and change for individuals, as well as for the organisation, are then achieved
- A broader view of what constitutes a “patient story” exists within the region. Stories from carers and the workforce are currently being used. Storytelling can be used to assess values as part of the recruitment process, and can contribute to board objective setting, performance monitoring, team and individual development, training, education, revalidation and personal development reviews. Additionally, it was suggested that storytelling should not be restricted to health but has a valuable role to play in the wider health and social care context
CCGs have developed quickly in a short space of time. Some have systematic processes and structures in place to use patient stories, clearly linked to local and national commissioning priorities that show outcomes; some, however, do not use stories.
In some commissioning organisations, stories are used on an ad-hoc basis to set context at meetings or raise awareness. It is clear that not all are using patient stories or placing value on them to inform commissioning work. Commissioning organisations that are using patient stories for internal or personal learning tend to use them in unstructured and informal ways, so it is difficult to evaluate the impact of their use.
NHS healthcare providers
We found providers use patient stories far more consistently than commissioners and a greater sense of value is placed on the learning they can provide. However, there is notable variation across the region in how they are used in practice.
Interestingly, staff stories were found to have an emerging important role in these organisations. The case studies in Boxes 2 and 3 highlight how trusts in the Midlands and East regions are using patient stories to improve patient and carer experiences.
Box 2. Birmingham and Solihull Mental Health Trust Meriden Family Programme
Birmingham and Solihull Mental Health Foundation Trust has been using patient stories within its Meriden Family Programme service. The service’s multidisciplinary team delivers training and works with staff on involving carers and patients in behavioural family therapy. The service has successfully used patients’ and carers’ stories on inpatient wards as part of its Staying Well recovery planning sessions. The storytelling has identified that carers are often the first people to spot the early warning signs of when a patient is beginning to relapse. This information has given nurses a new insight into the importance of carers’ involvement in care planning and their role in reducing relapses and readmission. Telling patients’ and carers’ stories has also improved discharge planning as it identified issues that were delaying discharge.
Source: Danks (2014)
Box 3. South Worcestershire Clinical Commissioning Group
South Worcestershire Clinical Commissioning Group, in partnership with the Worcestershire NHS health economy and the Stroke Association, has been listening to the stories of people who have had a stroke to identify how care could be improved. Staff and patient volunteers carried out patient story interviews on stroke inpatient wards via community NHS services and at the local Stroke Association support group. Information from the stories gave nurses the confidence to make changes to improve the care they were providing. The stories showed that the information pack on the ward did not meet patients’ discharge needs; in particular, there was insufficient emotional support after having a stroke and patients did not know how to access the support that was available. This resulted in a new information pack being developed that clearly identifies the psychological support and services available in the region.
The ultimate outcome of this study was the emergence of a potential storytelling programme framework (Table 1, attached). This, along with other resources identified through the literature review, will be published in a final report later this year. These resources, which provide the basis for a potential improvement framework, may be useful for all learning organisations in the region that want to develop the use of stories.
Week of action
To effectively communicate the study findings and help organisations share their storytelling learning with others, a regional week of action took place in September 2014. This created further interest in storytelling and to date has resulted in a series of personal pledges being made, and resources and storytelling templates being shared between organisations.
Patients, members of the public and health professionals were encouraged to join the conversation and share their experiences of patient stories. The hashtag #PtStories was included in tweets before and throughout the week. Fig 1 shows the most-used phrases by users of the hashtag about patient stories and the week of action.
A focus of the week was a national Twitter chat, which raised many questions about developing the regional work in conjunction with other organisations to develop a national programme or campaign. Work is ongoing in the region to develop a resource hub with an online toolkit. Organisations are being encouraged to share their case studies, templates and resources to support others and develop storytelling in the region.
Implications for practice
Our work has highlighted that formal structures need to be in place to help the storytelling process, particularly within meetings, to create outcome-focused thinking and action planning. This enables the learning from the story to translate down to ward and individual practitioner level, thereby creating a visible evidence trail of organisational learning that is open to external scrutiny.
Strategic and operational leadership will embed the storytelling programme into the heart of the organisation and ensures all the processes are well supported and connected internally. Formalised support for the listener and the storyteller is vital; however, this emerged as one of the least-evident components of a storytelling programme across all organisations.
Evidencing the impact of the stories - and the outcome felt by the storyteller in particular - will drive satisfaction, thereby leading to greater programme support from storytellers and organisational learning. Across all organisations, there was little observable evidence of systematic learning and programme development.
No “one-size” toolkit will fit all organisations, which is why it is important that there is a local drive progressing storytelling nationally, regionally and within individual organisations.
A widened interpretation and use of the term “patient story” is needed - as such, storytelling programmes should consider the local value of using staff and carer stories alongside patient stories.
The commitment and use of patient stories remains strong within the NHS England Midlands and East region and, within the new NHS architecture, many organisations are still exploring the value of patient stories and how to use them effectively.
This study provides further evidence that ongoing storytelling conversations are needed in a way that ignites and inspires action. However, understanding the local context - what works for whom and under what circumstances - and sharing that knowledge, is pivotal to achieving storytelling success for all.
Storytelling can be used in various ways, including to develop leadership skills. Denning (2005) highlighted its importance for developing leaders, stating it offers a route to the heart; this is where you must go if you are to motivate people, not only to take action but also to do so with energy and enthusiasm. He states that, in transformational change, leadership involves inspiring people to act in unfamiliar and often unwelcome ways - and that PowerPoint slides or presenting cascades of numbers or data will not achieve this goal.
Effective storytelling has the potential to translate the goal into a compelling picture that will improve the services we deliver for patients and their families as well as for staff.
- Storytelling has a valuable role to play across health and social care
- Understanding organisational purpose, culture and storytelling context is critical to achieving the best outcomes from it
- Within the new NHS structure, many organisations are still exploring how to use patient stories effectively
- A storytelling programme framework and resources are available to guide organisations
- Frontline health and social care staff can develop their compassion and caring capabilities through storytelling
- The full reports are available online on the NHS England website.
Danks J (2014) Working with families within an in-patient setting. Meriden Newsletter; 4: 1, 2-3.
Denning S (2005) The Leader’s Guide to Storytelling. San Francisco, CA: Jossey-Bass.
Department of Health (2012) Compassion in Practice.
NHS England, Midlands and East (2014) What’s the Story? Storytelling Within the NHS (Midlands and East). Part One: Realist Evaluation Study Findings.
NHS Midlands and East (2012) Creating a Revolution in Patient and Customer Service Experience. Using Patient Stories.
Pawson R, Tilley N (2004) Realist Evaluation.
Pawson R, Tilley N (1997) Realistic Evaluation. London: Sage.
White R (2013) Patient Stories: a Realistic Evaluation within the NHS across the Midlands and East Region. Dissertation proposal, Faculty of Health and Wellbeing, Sheffield Hallam University (unpublished).