Nurse Education in Practice (2007) 7, 181–186

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Storytelling: A clinical applicationfor undergraduate nursing students

Misty Schwartz, Amy Abbott *

Creighton University School of Nursing, 2500 California Plaza, Omaha, NE 68178, United States

Accepted 25 June 2006

Summary Faculty from Creighton University School of Nursing participating in agrant set out to design and implement a model for teaching health care manage-ment in community-based settings. The goal of the grant was to cross-educate acutecare faculty on how to provide holistic care to patients transitioning between acutecare and the community with a focus on underserved and vulnerable populations andto incorporate this into acute care clinical experiences with students. One of therecurring topics during grant discussions was the importance of getting to knowthe patient’s story and how it impacts the nurse–patient relationship. Key themesrelated to storytelling that emerged during grant meetings were listening, partner-ship, reciprocity, and solidarity. Grant participants identified various methods inwhich stories could be obtained and shared with others for educational purposes.Various storytelling techniques were implemented in the classroom and clinical set-tings as a means for teaching and learning. Examples of specific techniques imple-mented included case studies, journals, stories from practice, life reviews, andreminiscence therapy. The aim of the storytelling projects was to get students togather information from multiple sources and to put it into a cohesive story in orderto provide comprehensive, holistic, and individualized care.

�c 2006 Elsevier Ltd. All rights reserved.

KEYWORDSStorytelling;Teaching–learningtechniques;Community nursing

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‘‘I may forget your name and the specifics of whatyou said but I will not forget your story and how itmade me feel.’’ – Excerpt from Fuld grant partic-ipant’s journal

471-5953/$ - see front matter �c 2006 Elsevier Ltd. All rights reseoi:10.1016/j.nepr.2006.06.005

* Corresponding author. Tel.: +1 402 280 2000/2038; fax: +102 280 2045.E-mail addresses: damewood@creighton.edu, aabbott@

reighton.edu.

Helene Fuld Trust grant

Creighton University School of Nursing (CUSON) re-ceived a Helene Fuld Trust grant. Five facultymembers were selected to design and implementa model for teaching health care management incommunity-based settings. Each was assigned acommunity health nursing faculty mentor. Thegoals of the grant were to: (a) cross-educateacute care faculty on how to provide holistic care

rved.

182 M. Schwartz, A. Abbott

to patients transitioning between acute care andthe community with a focus on meeting the needsof underserved and vulnerable populations and (b)incorporate what the faculty learned into theiracute care clinical experiences with students.During the two year grant period, the facultymet as a group to review community health con-cepts. Seminars were conducted to enhanceknowledge and appreciation of these conceptsand to discuss issues and challenges facing acutecare nurses when preparing patients for returnto the community.

During the clinical component of the grant, fac-ulty spent time with various community healthnurses (CHN) observing and participating in theirroles. Additionally, each acute care faculty andcommunity health faculty mentor met at scheduledtimes to discuss grant experiences. All grantparticipants then came together to sharecontent from clinical experiences and individualdiscussions.

One of the recurring topics during discussionswas the importance of getting to know the pa-tient’s story and how stories impact the nurse–patient relationship. During clinical experiences,faculty observed CHNs using storytelling as a meansof introducing the patient, gathering data, teach-ing, and planning patient care.

Nurses sometimes refer to patients by a diseaseprocess, such as the open heart in room four or thewomen with the gangrenous foot. However, theseCHNs moved beyond the illness or disease and gotto know the patients’ stories. During clinical experi-ences at the local homeless shelter, a connectionbe-tween the CHN andmany residents was observed. Bythe CHN’s continued presence and showing an inter-est in them, the residents eventually opened up andtold their stories. Over time, they trusted and con-fided in the CHN, ultimately allowing more compre-hensive and individualized care because the CHNknew who they were and who they had become.The faculty identified how getting to know each res-ident’s story was pivotal for this vulnerable popula-tion. A resident verbalized that he felt he wasreceiving care that was different from care he hadreceived in other segments of the health care sys-tem. The CHN looked beyond their homelessnessand respected them and their need for personalizedcare.

Many of the CHN’s expressed that learning thepatient’s story emerged from their experiencesand the role. This specialty requires that nursesrecognize the person behind the patient, identifythe relationship that exists between them, andunderstand the expectations implicit in thisrelationship.

What is storytelling?

‘‘I need to realize that each patient has a story thatfar exceeds the health history taken in the hospi-tal.’’ – Senior student

Storytelling is a way of teaching and learningthat originated even before the development ofwritten language (Yoder-Wise and Kowalski,2003). There are as many different definitions ofstories as there are stories themselves. Webster’sdictionary (1998) broadly defines a story as a‘‘narration or recital of that which has occurred,a description of past events, a history, a state-ment, a record’’. One of the most often cited def-initions is the one given by Labov (1967) where astory is a personal account by which some previ-ous personal experience is transmitted by meansof a verbal description in an attempt to recreateevents that are assumed to have occurred. Sorrelland Redmond (2002) state that a story is an indi-vidual’s account of an event that creates a mem-orable picture in the mind of the listener. A Fuldgrant participant verbalized that the story is‘‘getting to the core of the human being which al-lows provision of the most comprehensive carepossible’’.

Storytelling benefits patients, nurses and stu-dents. The patient is able to express who theyare, relieve tensions, and resolve conflicts. Italso provides the chance to reflect and remi-nisce, which can be therapeutic in helping pa-tients cope with current conditions andillnesses. As a result, patients may develop anincreased sense of accomplishment and self-awareness.

The nurse benefits from storytelling by derivinginformation from the story that may not havebeen collected from a basic health history andphysical assessment. Stories have much to offeras a way of understanding. Other useful purposesinclude aiding in designing plans of care andenhancing patient–nurse communication. It canalso be a method for staff education and develop-ment by validating the rich experiences of nursesand the value of connections with colleagues(Banks-Wallace, 1999; Lindesmith and McWeeny,1994).

Storytelling is gaining ground as a tool for bothclinical practice and research because of the bene-fits to the students (Banks-Wallace, 1999). It can beused in the clinical and classroom settings as ameans to help students better understand andappreciate an individual’s lived experience andfacilitate positive outcomes (Koenig and Zorn,2002; Sorrell and Redmond, 2002). Storytelling is

Storytelling: A clinical application for undergraduate n

a way of teaching that stimulates thought andreflection and enhances the attainment of knowl-edge (Werle, 2004). It also helps to enhance self-esteem, develop critical thinking, teaches ethicsand cultural sensitivity, improves communicationtechniques, and role models strength and hope(Davidhizar and Lonser, 2003).

During grant discussions, faculty realized theconcept of storytelling was vital to teach stu-dents, as it is an effective way of transmittingknowledge and promoting problem solving. Notonly do students need to learn the basic nursingessentials and technical skills but they need tolearn the interpersonal skill of how to convey awillingness to listen even when they are busy.Students need to let patients know they are avail-able and allow time for storytelling dialogues tooccur. The hope is that patients will take theseopportunities to open up, therefore, providingstudents insight into their lives (Banks-Wallace,1999). Students use critical and analytical think-ing skills to extract the principals and messagesfrom stories; through this process faculty wereable to help them become better problemsolvers.

Ethical considerations

According to Creighton University’s InstitutionalReviewBoard (IRB), research is defines as a ‘‘system-atic investigation that includes research develop-ment, testing, and evaluation, and is intended todevelop or contribute to generalizable knowledge’’.This educational project was reviewed by the IRB atthis institution and it was determined that it did notmeet the criteria for a full or exempt review.Rather,the purpose of this project was to improve educa-tional processes in the school of nursing and it didnot need IRB approval.

When using storytelling as a tool for teaching, itis important to maintain confidentiality and ano-nymity of all of the individuals willing to share theirstories. When faculty use this method they do notuse names or any personal patient information thatmay identify them as the ‘storyteller.’ Permissionwas obtained from all grant participants andstudents to use excerpts from discussions or jour-nals for the purpose of educating others aboutstorytelling.

Grant themes

Key themes related to storytelling emerged duringthe grant process. The four themes were listening,partnership, reciprocity, and solidarity.

Listening

‘‘It sometimes is better to listen to our patient

instead of asking all the questions or doing all thetests and procedures on them. They will tell youexactly what you need to know in order to treatthem properly if you are just willing to listen.’’ –Senior nursing student

The first theme, listening, was identified as oneof the most important responsibilities of a nurseand the foundation for all other themes. Using sto-ries, as a means for learning requires that studentsand nurses be open to hearing both the spoken andhidden concerns expressed within the context ofthe story. Listening to the whole story instead ofjust its parts is essential in understanding themeaning to the storyteller (Evans and Severtsen,2001; Labov, 1967).

The CHNs also had the philosophy that listeningwas a vital nursing responsibility. Each plannedtime during their visits to make a point of lettingthe patient know that not only did they have thetime to listen, but that they were truly interestedin the story the patient had to tell. These dialoguesallowed trust to develop and the willingness towork together was gained.

Passing on of cultural and familial traditions wasone of the primary purposes of storytelling identifiedin the literature (Banks-Wallace, 1999; Sorrell,2000). Listening to the patient’s story helped thestudents deliver quality care by understanding theindividual’s traditions and what the illness meantto them and their family. Storytelling gave the stu-dents insight into how culture impacts decisionmak-ing and responsiveness to caregivers and taughtabout the patient’s value and belief systems.

The patient’s concerns were not always spokenbut often were embedded within the context ofthe story. Therefore, if students can truly masterthe skill of listening, they may identify subtle ethi-cal concerns and/or educational needs of the pa-tient and their family. By recognizing these needs,students will be able intervene appropriately to pro-vide the necessary consults or referrals which ulti-mately improves care.

ursing students 183

Partnership

Partnership was the second grant theme identified.By learning a patient’s story, CHNs designed andimplemented therapeutic interventions, whichwere congruent with and meaningful to the pa-tient’s needs. This collaboration allowed both theCHN and the patient to participate in planning care

184 M. Schwartz, A. Abbott

and identifying common goals. Each party bringssomething different to this relationship. The patientbrings expertize about their life and investment intheir own health and the nurse contributes clinicalexpertize and health care knowledge to this part-nership (Banks-Wallace, 1999).

Stories help students recognize the humandimension of patients and their families. They alsoassist students in gaining an appreciation of themultidimensionality of care and the complexity ofpreparing patients for their return to the commu-nity. By working toward this common goal, a trust-ing partnership was formed (Koenig and Zorn, 2002)and students were able to implement quality carethat was realistic, individualized and holistic.

As mentioned, the patient’s story does not al-ways have to be spoken. The following exampledemonstrates how a partnership can enhance theoverall care of a patient. This is a portion of a let-ter from a daughter to the nursing staff lettingthem know her father’s story as he had difficultytelling it himself due to a stroke:

‘‘Please note the following and share with yourstaff so care for Mr. F. is as personal and individu-alized as possible.

(1) He worked as a farmer all his life, had his stokein his late 70’s and has spent the last threeyears in a nursing home. My mother died whenhe was in his mid-60’s. He always had a verystrong work ethic and a passion for the farmlife. He lived in a rural community where hisrelationship to extended family members wasstrong, they all lived close by – as were hisrelationships forged over seven decades withmany neighbors and friends. Like many retiredfarmers, he sold seed corn as a part-time jobto provided him with income and socialization.

(2) As for his daily routine: he listens to a regionalfarm radio station twice daily and he listens tothe local town radio. (The daughter providedthe nursing staff the station numbers and thetimes of the programs.)

(3) He likes to drink hot cocoa while reading thelocal town paper, the paper of the state capitalcity, and farm magazines. This is his eveningroutine after supper. Please set this readingup for him.’’

Reciprocity

Storytelling promoted a common bond, whichyielded mutual exchanges and benefits to both thepatient and the CHN. The respect developed be-

tween them enhanced the partnership. This connec-tion was labeled reciprocity (McCormack, 2003). Asstories were shared, information was both taughtand learned (Koenig and Zorn, 2002). According toOlthuis et al. (2006), reciprocity is based on the con-cept of reversibility. It is an act that involves givingand receiving from all parties engaged in the caringrelationship. When patients begin to see the nurseas a human being with vulnerabilities, reciprocitybecomes even more significant and there is a realsense of being connected.

Through reciprocity, the students and the pa-tients were involved in planning, managing, andevaluating care, thereby creating a sense of mutu-ality or the recognition that others’ values areequally important. This ultimately enhanced theoverall delivery of care, improved outcomes, andstrengthened the likelihood of the patient takingownership in the health care plan.

A senior student shared an example of reciproc-ity during a clinical post-conference. The youngman she was caring for had died after being shot.His mother had spent every moment at his bedsideand she and the student had gotten to know one an-other’s stories quite well. After the young man’sdeath, the student and mother were saying goodbyeto one another and the encounter ended with thestudent giving the mother a hug. The mother ex-pressed how grateful she was for that gesture andstated that she would light a candle for the studentin church. The clinical instructor took the opportu-nity to make the point that by the student knowingthe mother and son’s stories, the student was ableto know that it was ok to give this mother a hugand that since the mother knew the student’s story,she knew she would appreciate the fact the motherwas ‘lighting a candle for her.’ Another point theinstructor emphasized was how this example dem-onstrated that the need for reciprocity is universal.

Solidarity

‘‘After losing my mom to cancer, taking care of a

patient with breast cancer was scary to me but inthe end I think getting to know her story was a ben-efit to all because I was able to relate to her youngchildren. I loved taking care of her and her familyyet I’m not sure if this experience was for her ben-efit or mine.’’ – Junior nursing student

The final theme, solidarity, emerged because theCHNs advanced the relationships by knowing eachpatient’s story. By listening to patients’ stories,partnerships developed and matured into recipro-cal relationships. This created feelings of unitybased on a common interest – the best care for

Storytelling: A clinical application for undergraduate nursing students 185

the patient. Solidarity comes from the Latin deriva-tive solidare, which means to ‘‘join togetherfirmly’’ (as cited in Kelly, 1998). Rorty (1989) andKelly (1998) have addressed solidarity in the litera-ture by stating there is a universal need to exchangebeliefs and desires with others with some inherentrisks involved, yet bonded by mutual feelings of re-spect and dignity for each other. This connection isnot just an empathetic gesture, but a commitmenton behalf of both participants to obtain some sort ofpositive transformation of both people.

Although students have patients’ best interest inmind, it can be difficult for them to achieve this typeof relationship. In order for this connection to occur,there is a breadth, depth and rapport that needs totake place. This is challenging in a student–patientrelationship because the length of time spent witheach patient is often limited to a few hours or a cou-ple of days. Regardless of the length of the encoun-ter, as educators it is important to teach students tostrive for the ultimate goal of solidarity.

Storytelling techniques

The literature is flooded with uses of storytelling.Although nurses have always listened to patients’stories, storytelling has only recently been recog-nized as a valid technique of teaching and learning.During the grant experience, participants identifiedthe significance of listening and telling stories foreducational purposes. Some of the learning out-comes they wanted the students to accomplishwere: (a) develop an understanding of the methodsused to obtain the patient’s story; (b) develop thecapacity to comprehend the wholeness of the pa-tient (body, mind and spirit); (c) gain insight aboutthe relationship between the health care recordand the patient’s story from the patient’s perspec-tive; (d) understand the influence of the opinion ofothers on the development of an understanding ofthe patient; (e) appreciate the power of listening;(f) appreciate the power of withholding judgment;and (g) increase security in caring for patients.

Grant participants realized that storytelling pro-vided an avenue for students to perform specificassessments, interventions and evaluations. Byusing storytelling, students were able to assess clin-ical health needs and gather pertinent informationin order to make better decisions about the healthcare plan. But it went beyond just data collection;it was an attempt to make sense of it. Storytellinginteractions with patients and families provided ameans for individuals to convey their hopes,fears, dreams, priorities and preferences for care(Banks-Wallace, 1999; Yoder-Wise and Kowalski,2003). It also gave students an opportunity to gain

an awareness of their own roles, values, visions,and goals. Students were taught to use techniquessuch as open-ended or unstructured interviews, lifereviews and reminiscence therapy to gather more indepth information about the patient’s story.

Because information in stories is more oftenremembered and cherished (Yoder-Wise and Kowal-ski, 2003), faculty involved with this grant, reportedthat they often used stories from their own experi-ences to enhance learning. Examples used includedpublished case studies, small group work using sce-narios, vignettes, and reflective analysis. Facultywove stories from practice into the didactic portionof courses as well as into clinical conferences tomodel both good and poor nursing interventionsand to illustrate various concepts. Students oftenmade positive remarks on evaluations of facultywho used these techniques, stating that the storyhelped them learn and retain content.

Stories provided a common language to describethe human experience that seems to cross all cul-tures, races, genders and enhanced multidisciplin-ary learning in the clinical setting. When thestudent shared patients’ stories with members ofthe health care team, improved outcomes resultedthat may not have occurred without the teamknowing this information. For example, a patientwas about to undergo permanent pacemaker inser-tion. During the course of his hospitalization, hehad shared with the student about his job as awelder and his excitement for discharge so hecould get back to ‘‘doing what he loved’’. Thisraised concerns with the student as she knew thiswould not be possible if he had the pacemaker in-serted. The student shared this information withthe physician who then discussed the options withthe patient. As a result of this collaboration, thepatient opted not to have the surgery and wentback to his welding job.

Journaling was another means faculty used todisseminate patients’ stories. Grant participantshad students write a journal about the patient’sstory based solely on information gathered fromthe health care record. The students and facultywere astonished at the difference between eachof the journal entries. There were many instanceswhere students had read something in the chartabout the patient’s history and based the entirejournal entry on that information. Then, afterinteracting with the patient, discovered what theythought was true was inaccurate.

The journal assignments helped students dis-cover the importance of learning the patient’sstory and not relying solely on the medical record.A student wrote about the frustration she assumedher patient might experience in dealing with a glass

186 M. Schwartz, A. Abbott

eye, loss of vision and being in an unfamiliar set-ting. While caring for the patient, the student as-sessed pupillary response and realized that bothpupils were reacting to light. These findings madethe student recognize that the patient did not havea glass eye as documented throughout the medicalrecord nor was the patient frustrated in any way.The patient had the glass eye for many years wasextremely well adjusted to the vision issues andthe student and patient spent many hours overthe next two days establishing what the studentcalled in the journal, ‘‘a very beneficial profes-sional bond’’. The student’s second journal entrynoted the discrepancy between the documentationin the chart and the patient’s reality. The studentaffirmed that this was an example of how one per-son’s documentation can affect others by notknowing the patient’s story.

Another example occurred on a TransitionalCare Unit (TCU) where students were assigned toa patient with paraplegia who had been hospital-ized repeatedly for wound care. The patient hadbeen distant and despondent with staff during hismany stays. A student cared for the patient forthree weeks during the rotation. When the clinicalrotation ended, the instructor had the studentwrite what was learned about the patient’s story.This journal was then shared with the incominggroup of students and this process of writing andsharing continued during each of the rotationsthroughout the semester. The instructor noticedphysical as well as mental improvements in this pa-tient. Many of the TCU nurses expressed that theyfelt the way in which the students cared for this pa-tient had made a huge difference in his overall de-meanor and in taking responsibility for his owncare. The staff member said that since the studentswere there, the patient had taken an interest inlearning more than ever before and had only beenhospitalized once since the semester ended.

Summary

Every person has a story to tell and stories havepower. The themes, listening, partnership, reci-procity, and solidarity, emerged from the grant be-cause the participants saw how important eachtheme was in obtaining patients’ stories. Facultywere able to teach students about course contentand help them remember necessary details of pa-tient care whereas students were able to impact

the care provided. The ultimate goal of storytellingwas to teach students to gather information fromthe patient, medical record, family members, andother members of the health care team and toput it all together into a cohesive story. This goalwas achieved in both the classroom and clinicalsettings. As one of the grant participants stated,‘‘Storytelling is sharing. Someone teaches; some-one learns; someone is vulnerable and exposing;someone is compassionate and validating.’’

Acknowledgements

A special thank you to Dr. Beth Furlong, Mary SueWydeven and Dr. Joan Norris for your input, guid-ance, and mentoring.

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