Patient stories can offer students opportunities to gain insight into how care affects their patients’ experiences, and to reflect and learn from this
Patient stories have a range of benefits in nurse education. This article describes how stories from the Patient Opinion website are used by the University of Edinburgh to help student nurses gain insight into patient experiences. It gives an analysis of two excerpts, and discusses how good communication leads to positive patient experiences and the negative impact of poor communication.
Citation: Tevendale F, Armstrong D (2015) Using patient storytelling in nurse education. Nursing Times; 111: 6, 15-17.
Author: Fiona Tevendale is third-year student nurse at the University of Edinburgh; Dorothy Armstrong is visiting fellow at the University of Edinburgh and professional adviser to the Scottish Public Services Ombudsman.
- This article has been double-blind peer reviewed
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Stories from patients and their families can offer valuable feedback to health professionals and organisations about their users’ experiences of healthcare services. The University of Edinburgh gives undergraduate nurses a subscription to Patient Opinion, the UK’s main independent patient feedback website (Box 1), which provides them with access to a repository of patient stories. This article examines the benefits of using these stories in teaching and learning in nurse education.
Box 1. Patient Opinion
Patient Opinion aims to promote connection, collaboration and change in healthcare by:
- Enabling patients to share their experiences of healthcare services
- Notifying healthcare providers of feedback relevant to them
- Enabling healthcare providers to demonstrate publicly that they listen to and engage with feedback, and to show when they make changes
- Giving health professionals access to real-time feedback
The power of storytelling
Stories offer a range of benefits in nurse education. They enable students to develop a deeper understanding of certain issues and experiences, encourage problem solving and help to close the gap between human experiences and the theories used to explain them.
Using stories in teaching is empowering because they enable learners to reframe experiences and shift their perspective to focus on details or take an overall view. Stories, including those on Patient Opinion, can challenge us and encourage new learning and discovery (Owen, 2004).
Traditionally, storytelling has been used for centuries to pass on wisdom; this suggests stories would be valuable in nurse education. Real-life stories have a unique quality where emotion, tone and imagery illustrate the storyteller’s perspective; a meaningful story enables practitioners to identify what is most important to service users. Qualitative research in nursing extracts stories in a semi-structured way and is making an increasing contribution to the design and development of health services (Newell and Burnard, 2011).
The value of sharing stories
The value of learning from stories has been acknowledged in the Scottish Government’s (2014) strategy, Setting the Direction for Nursing and Midwifery Education in Scotland. The strategy was developed to help nurses collaborate in developing academic and clinical knowledge, and encourages the use of service users’ views.
Reading positive stories can be encouraging and inspirational for students, and serve as a counterpoint to recent negative portrayals of nursing in the media. However, negative stories are equally useful as they challenge us to look from another perspective and critically assess what could be done to improve or prevent a poor experience. Reflecting on and analysing patient stories before they go on their first placement can give students an insight on what is genuinely important to patients.
The facility to share stories online is an innovation in how feedback is gathered and applied to practice; improving communication and clinical governance was a key area highlighted by Francis (2013). Having stories available online is an ideal method for identifying areas requiring attention as well as for giving praise. The use of storytelling is not all about identifying what is wrong - it is also about sharing what people believe works well.
Patient Opinion in the classroom
The University of Edinburgh funds subscriptions to Patient Opinion for student nurses on two undergraduate modules - professionalism, and evidence and research. Students receive emails with links to new stories posted on the website that are relevant to the modules. The website is simple to use and enables students to search key concepts and access stories.
Patient Opinion is introduced to students in their first year, and continues to be included throughout their degree programme. Stories from the website are used for online discussion boards and during tutorials, when students analyse and discuss experiences and feed back to each other.
Interactive lectures and tutorials on listening to service users are held; in one session students picked a post card with an illustration that represented how they felt about a patient story read during the lecture. The exercise encouraged us to appreciate the service user perspective and understand why patients might feel distressed or impressed about their experiences. The stories allow us to:
- Identify important professional attributes;
- Develop critical analysis and appreciative enquiry skills;
- Find out at the earliest opportunity what matters to the people we care for.
I (Fiona Tevendale) recently finished a surgical placement on a neurosurgery ward. Before I started, I read some Patient Opinion stories about experiences in the neurosurgical specialty. I found two short excerpts (outlined in Boxes 2 and 3) striking; they encouraged me to reflect, compare and relate to this placement. I adapted Gibbs’ (1988) model for reflection because it has a logical analysis and evaluation process, and includes a conclusion and action plan enabling me to show what I have taken from the stories to incorporate into future practice.
Box 2. Case study 1
“Incredible care at James Cook Hospital […] They looked after my son like he was a relative and he started to come on [in] leaps and bounds. The nurses were so lovely and, although my son was still really poorly, they managed to make him smile… nothing was too much trouble… the consultant was very understanding and helpful.”
Reading this story, I was struck by how the mother described the relationship between her son and the nurses, and its effect on his progress. The emotion expressed in the simile “like he was a relative” has imagery along with connotations of the resilient bonds within a caring family and a sense of belonging and compassion. Considering relationships in greater depth, communication skills and compassion are at the centre of the therapeutic bonds made between nurses, patients, relatives and the wider healthcare team (Collins, 2009). To make a connection with the patient requires compassion, verbal and non-verbal communication skills, enthusiasm and motivation, light humour, kindness and approachability. The mother in the excerpt gives the impression that the multidisciplinary team would go the extra mile to ensure her son’s needs were met. Her tone suggests she felt reassured that the staff were committed to helping her son, ready to listen and able to give him the time he needed to recover.
The story relates well to my neurosurgery placement because I met some patients who were seriously ill and their families. I cared for them, listened to their worries, answered their questions and liaised with their care team; I felt they trusted me. Through my experiences on the ward and from the story, I recognise the importance of supporting and involving the family in the decision-making team process from their perspective and a nursing perspective. The transparency and honesty of professionals is necessary to create a trusting relationship, in which the patient and family feel they are respected and listened to (Collins, 2009). My communication skills are developing as I progress. I hope to have the confidence to overcome barriers to good communication, and apply theory and experience to build effective therapeutic relationships.
Box 3. Case study 2
“The good and bad of inpatient neuro. During the first 24 hours I met 11 health professionals (nurses and doctors): a total of three of them actually introduced themselves to me - the rest told me neither name nor job title… this left me feeling isolated and angry… Where some staff fall down is in the ability to communicate effectively with each other and with their patients.”
The tone of the patient writing this story really grabbed my attention. From the first line, I could tell the person writing this felt disappointed and frustrated with their experience, and I wanted to find out why. Reflecting on it unravels a story of poor communication, a lack of continuity and a lack of basic professionalism. Viewed from the patient’s perspective, the situation is unique. I feel I can empathise with the frustration and confusion the patient felt when admitted to hospital, and why they also felt frightened and abandoned.
It is basic good manners to formally introduce yourself when meeting someone new. Neglecting to inform patients who you are and what you are doing for them gives the impression you are rushing, and automatically makes you seem less accessible or approachable; this will have a negative impact on any therapeutic relationship formed. Not knowing who they can rely on and with whom they can share concerns can make patients feel isolated. Again, communication is at the heart of the quality of care; patients will always appreciate people who seem available and approachable, trustworthy and honest. It is important that the team communicates well - it was obvious to the patient in the story when the team was dysfunctional. The patient appeared not to feel reassured or at ease, which is particularly distressing to people who are feeling ill and likely to be frightened.
The story enabled me to identify ways in which the situation could have been better. For example, better continuity of care would have shown commitment and compassion, as would a named nurse to share concerns with and who was able to check on the patient regularly. If this had not been possible, explaining why the patient was seeing so many different health professionals, and offering reassurance and time to ask questions would have improved the patient’s experience. Body language is important to show active listening, as described by Egan’s SOLER mnemonic (Square, Open, Lean, Eye contact, Relaxed); non-verbal communication skills such as this can make patients feel involved, understood and respected (Morrissey and Callahan, 2011).
The first patient story highlights the positive outcome associated with good communication skills in practitioners, effective team working and the benefits of building therapeutic relationships. In contrast, the second story focuses on the distress caused by poor communication, poor team working and a lack of compassionate care.
I can learn from these stories, and hope to strengthen the skills required to ensure my communication, compassion and team-working skills are effective. We learn a lot from observed behaviours, and this in turn influences our approaches (Burnard and Gill, 2008). A good role model - for example, in a story about a nurse, nursing assistant or other exceptional team member - can help me adopt attributes such as motivation, active listening, leadership.
Transferring the concepts to my own practice, I have adopted a quick and simple routine at the start of a shift:
- Go to the patients in my care, say hello and introduce myself;
- Write their team’s names on the whiteboard by their bed;
- Ensure they have their buzzer to hand in case they need anything.
Meeting all patients in my care at the beginning means they recognise me, and will know that they can can rely on me and find out about their own individual care. In return, I feel that I get to know individual patients better and understand what is important to them. As I gain experience and involvement in care planning, I hope I will be able to offer increasing insight and help to patients.
The stories from Patient Opinion have threads of emotional fibre that entwine naturally with the teaching and learning of undergraduate student nurses. The four domains on which our learning is based are from the pre-registration standards of values:
- Communication and interpersonal skills;
- Nursing practice and decision making;
- Leadership and teamwork (Nursing and Midwifery Council, 2010).
The short excerpts in Box 2 contained aspects of each domain; I found the main aspects influencing the service user experience are:
- Communication skills;
- Effective team working;
- Building therapeutic relationships;
- Being caring, kind and compassionate.
The 6Cs (care, compassion, communication, commitment, courage, competence) (NHS Commissioning Board and Department of Health, 2012) can be demonstrated vividly in the form of stories, and truly allow us to understand how important they are in the nursing context. The quality of therapeutic relationships built on communication skills will determine whether a patient has a positive or negative experience. Sharing stories where mistakes or improvements are made allows students and professionals to learn and reflect, which will minimise the likelihood of a poor experience from recurring.
Reading stories where the elements of care are all excellent is inspiring and reassuring for student nurses, especially given the problems in healthcare publicised by the media and the horrifying issues identified by Francis (2013). Newly qualified nurses can use stories to discuss, analyse, reflect and assimilate changes into practice to give the best person-centred care and meet the modern demands on the healthcare system. As a student nurse and a service user, I believe the increasing ease of communicating with health services will give the public more confidence to share their experiences, and that this sharing will promote honesty, equality and trust.
- Storytelling has been used for centuries to pass on wisdom
- Patient stories can help students improve their understanding and problem-solving abilities
- Stories enable practitioners to identify what is most important to patients
- Online sharing of stories is innovative in the way feedback is gathered and applied to practice
- Quality of therapeutic relationship quality determines whether patients have a positive or a negative experience
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Collins S (2009) Good communication helps to build a therapeutic relationship. Nursing Times; 105: 24, 11.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.
Gibbs G (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Centre for Staff and Learning Development, Oxford Brookes University.
Morrissey J, Callahan P (2011) Communication Skills for Mental Health Nurses. Maidenhead: Open University Press.
Newell R, Burnard P (2011) Research for Evidence-Based Practice in Healthcare. Oxford: Wiley-Blackwell.
NHS Commissioning Board, Department of Health (2012) Compassion in Practice: Nursing, Midwifery and Care Staff - Our Vision and Strategy.
Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education.
Owen N (2004) More Magic of Metaphor: Stories for Leaders, Influences, Motivators and Spiral Dynamic Wizards. Carmarthen: Crown Publishing.
Scottish Government (2014) Setting the Direction for Nursing and Midwifery Education in Scotland: The Strategic Aims from the Chief Nursing Officer’s Education Review. Edinburgh: Scottish Government.