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Storytelling Elevates Nursing Practice at Massachusetts General Hospital

 |  By Jennifer Thew RN  
   March 24, 2015

First-person accounts of clinical experiences help MGH nurses reflect on and apply new knowledge to their clinical practice. The hospital even includes written clinical narratives in employees' annual performance evaluations.

Nursing is often called an art and a science. But what, specifically, makes nursing an art? If you ask a few nurses they'd likely say that the art lies in the use of soft skills like interpersonal communication, empathy, and active listening, while the application of clinical knowledge makes it a science.

When I was in nursing school two decades ago, I learned it was important to find a balance between those two sides of the caregiving coin. Nursing has evolved since then, and today there's a much greater emphasis on evidence-based practice, tracking clinical outcomes, and synthesizing data into patient care. Throw in the increased use of technology and it can seem like the science of nursing has trumped its art.

But at Massachusetts General Hospital in Boston it's a different story—literally. Clinicians there have been practicing the art of storytelling since 1996. That's when Jeanette Ives Erickson, DNP, RN, FAAN, senior vice president for patient care services and chief nurse at MGH, spearheaded the use of clinical narratives as a way to help clinicians in nursing, occupational therapy, physical therapy, respiratory therapy, social work, and speech-language pathology articulate their contributions to their patients, their colleagues, and the organization.

Twenty years later, storytelling through clinical narratives has become an essential part of the culture at MGH. In a new book, Fostering Clinical Success: Using Clinical Narratives for Interprofessional Team Partnerships from Massachusetts General Hospital, Ives Erickson, along with co-authors Marianne Ditomassi, DNP, RN, MBA; Susan Sabia, BA; and Mary Ellin Smith, RN, MS, share how MGH's narrative culture has helped elevate the science of nursing through reflective practice.

Ditomassi, executive director of patient care and Magnet recognition at MGH, and Smith, professional development manager at MGH in the Institute for Patient Care, explained to me how they use clinical narratives to enhance nurses' clinical skills and further their professional development.

Details bring clinical situations to life

 "A clinical narrative is a first-person story from a clinician regarding a patient situation that has meaning to them," says Ditomassi. Recognizing the right story to tell is easy, as a rule. "It's usually the [one] that stays with you no matter what."

Struggles and triumphs alike can present opportunities for deep learning about the clinical process.

"We ask [clinicians] to tell us about what was happening, what they were thinking, and what stood out to them," she says. "When you engage them in what happened by asking questions, the story moves to become something larger and much more involved."

Small details bring the big picture into focus and help the manager and clinician understand the nuances of the situation.

Small details bring the big picture into focus and help the manager and clinician understand the nuances of the situation.

"Our practice is much more than the facts," says Smith. "It's contextual."

Once the story has been told verbally, the clinician writes it down. This helps him or her reflect on what occurred, why and how it happened, what they could have done differently, and what was done well.

Setting a course for staff development

The clinical narrative isn't just a chance for sharing and understanding an experience. At MGH, written clinical narratives are included in employees' annual performance evaluations.

"The clinical narrative serves as a platform to discuss the clinician's practice and professional development goals moving forward," says Ditomassi. "The director and CNS [clinical nurse specialist] can hone in and understand challenges in a new way."

This helps identify specific areas of practice where clinicians can grow their skills. "In the past when you had an appraisal, those areas for continuing development may not have been as clear," says Ditomassi.

The stories help managers tailor a professional development plan to meet the unique needs of staff members. "There can be individual coaching, education, or time spent with a clinical expert," says Ditomassi.

If there was any skepticism from clinicians about sharing their stories during a performance evaluation, that uneasiness has long since resolved.

"Staff realize this is the most powerful conversation they will have this year, because it's about their practice," says Smith.

Changing nursing practice

MGH's experience illustrates the many ways nursing science can benefit from the art of storytelling. The authors say the use of clinical narratives helped create a reflective practice environment that has contributed to improvements in patient safety, nursing care, interprofessional communication, and patient and staff satisfaction.

"It's had a critical impact in making our work visible," says Smith. "Through dialogue with the writer you get to appreciate the clinician's critical thinking and expertise in practice."

"It brings a depth to practice that sometimes others, nurses included, overlook," says Ditomassi.

Ditomassi says after hearing or reading a colleague's clinical narrative, nurses begin to critically assess their own practice.

"They might ask questions like: 'Why is she good with that patient? How is she able to do that? What's in her toolbox?' " she says.

When they find themselves in a similar situation, nurses can recall what they learned from their colleagues' clinical narratives and apply that knowledge to their own situations.

"It gives me a landmark in country that is new to me and helps me find my way," says Ditomassi.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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