Nursing Narratives

*This story originally appeared int he Spring 2015 issue of Columbia Nursing Magazine. 

The first year of nursing school is intense, nonstop, and leaves little time for reflection. Because of this, students tend to focus more on the scientific knowledge than the emotional, social, and psychological aspects of nursing. Assistant Professor Jeanne Churchill, DNP, who directs the ETP program’s five-week pediatrics rotation, wanted to change that. She had personally discovered that writing about nursing’s non-medical elements gave her the critical distance to explore her feelings about her own clinical experiences. Her students also needed this distance, to step back and remember why they went into the profession: to take care of human beings, not just diseases.

Churchill began assigning narratives to help students reflect on the quality of their interactions with patients. “I wanted them to explore the personal impact of their experiences, and how their feelings and reactions could help them become better nurses.”

One such student was Brian Lohotsky. The first-year ETP student wrote about Lauren, an eighteen-year-old patient who had been admitted for acute asthma exacerbation. Lohotsky was on the third day of his pediatrics rotation at NewYork-Presbyterian Hospital when he was assigned to care for Lauren. Medical personnel had stabilized her, and during the course of her recovery, she began to open up to him. She was a single mother with a sick child at home, had a boyfriend and dreamed of attending medical school. She also had a history of intubation for acute asthma exacerbation, and dreaded the procedure, fearing it might further separate her from her daughter. Lohotsky’s assignment to write about this episode focused on Lauren’s fear:

She grieved that she couldn’t breathe, that the albuterol wasn’t working, that she wanted to shower, that she wanted to go home, that she missed her daughter. And again that she missed her daughter. And again.

By writing Lauren’s story, Lohotsky recognized that, “She wasn’t just a kid having an asthma attack. She had in the back of her mind her kid, her schooling, her boyfriend.”

Describing the scene for Churchill’s class gave him clarity about the kind of nurse he hopes to be. “She just needed a little bit of reassurance, which would have helped her just as much as the medications,” he says. “If you’re preoccupied with administering meds and looking at numbers, and not looking a patient in the eye and using your own social radar, you’re going to miss the individual reaction that your patient is having.”

He adds, “When I’m a nurse and actually practicing in a situation like Lauren’s, I would probably ask the supervising health care provider if there might not be another option besides medication.”

Building Self-Confidence

Writing about their clinical experiences helps students notice the small things that make a difference, says Churchill, which can play an important role in the healing process. These small things can be as simple as spending time with a sick adolescent, as Lohotsky did; or, as another student wrote, holding the hand of a developmentally disabled boy, Izzy, who had been admitted to the pediatric intensive care unit for respiratory failure, and one month later, still depended on ac-pap machine to breathe:

I just held his hand; told him that he was doing a great job, and made sure that he knew that in that moment I was there for him. Then it happened. That moment in time when I was able to physically see his body relax, just a little bit. His breathing became just a bit less laborious, and more regular. His pulse dropped only by a few digits. However, for him, that tiny step made all the difference in the world.

Treating the Entire Family

To expand students’ appreciation of the significance of their role during a birth, Laura Zeidenstein, DNP, director of Columbia’s Nurse Midwifery program, also assigns reflective writing. She says the essays and poems she has students write boost their confidence in their own usefulness, as did one assignment to write a poem about their hands during birth. “Their hands are a big part of what students do,” she says. “Writing about their hands helps them learn to trust in themselves as clinicians.”

Writing about her hands helped Tiana Miller- Breland ’12 ’14, understand that even as a nurse midwifery student, she brought needed skills to a woman’s labor and birth. “I realized that while I’m waiting, even in my stillness, I’m assessing and thinking with my hands,” says Miller-Breland, who wrote:

We, hands, are here to watch, to wait, to anticipate. To protect, support, prevent. To guide, to reach, to rest. To stretch. To flex, to elevate, to grasp. To grip, to Hold, to clamp. To cut, to dry, to catch. To welcome, to present.

To help students understand how to care for the whole family, Zeidenstein has them write from the perspectives of the expectant parents, as well as the soon to- be birthed baby. Birgit Dugan ’10 ’12, described one father’s anxiety during his wife’s labor:

I’m biting my nails, pacing the floor, on the verge of tears. I hate that you’re crying out in pain and I can’t take it away. I feel helpless.

Then, Dugan imagined a baby’s impatience to enter the world:

I feel a drop as suddenly

My bouncy world begins to leak

And now my head is well applied

I feel the need for “out!” inside.

Making Connections

To cope with the stress of caring for very sick or terminal patients, nurses recognize that they must guard against interjecting emotional distance between themselves and their patients. Yet, it’s because narrative nursing creates the space for clinicians to reflect on their and their patients’ experiences that Lindsey Wright finds it so personally and professionally rewarding. A first year ETP student, simultaneously working toward her masters in Narrative Medicine program at Columbia, Wright established a bi-monthly narrative nursing group for her fellow students. Group members read and reflect on literature, and share personal writing about their clinical experiences. “Narrative nursing helps me empathize and genuinely listen to my patient,” Wright says. In this way, narratives are making her more nurturing and open, compassionate, and better able to connect with her patients. “It makes me a gentler, kinder, more insightful nurse.”

Facing Fears

Writing about their limits as caregivers often helps students understand and accept that they, like their patients, are human and vulnerable. When a student realized that she was unable to physically comfort, a six–year-old boy with epidermolysis bullosa (EB), a genetic disease that causes the skin to blister and slough off after the slightest contact, she wrote:

Without the power of touch, I felt useless and incapable.

“The very thing she has been taught to do she cannot do – and that is to provide comfort through touch,” Churchill notes. Yet, writing about her anguish deepened the student’s compassion for her patient:

I thought about how I would feel if no one could touch me, if my friends could not put an arm around my shoulder when I was upset or rub my back when I was crying.

Sometimes caring for patients, particularly those who have suffered interpersonal violence, triggers students’ own painful memories. Zeidenstein says that reflective writing can help students cope with these memories. Students who have not suffered from interpersonal\ violence can still evaluate it in their patients’ lives by writing about it imaginatively. “My role as a teacher is to say, ‘you can imagine what this is like. You might not want to, but you won’t fall apart from imagining it.”

She has students write about a time when they felt powerless, or isolated, or about how it feels to envision the destruction of a favorite place. “It’s okay to feel angry, frustrated, or re triggered,” she says. “Students don’t have to avoid these feelings to be good clinicians. They just have to recognize them and use them constructively.” Recognizing and accepting their own responses helps make students more receptive to patients, more empathic, and more accessible. “If you’re more comfortable, your patients will perceive that,” Zeidenstein says. “They’ll feel safe. They’ll feel that ‘we’re in this together.’”