Narrative Reflection in Critical Care

Storytelling is not a word most of us associate with critical care. Yet storytelling is an integral part of the human experience, and structured storytelling is frequently evoked in the intensive care unit, from the notes we write to the verbal handoffs at shift change and conversations in the break room. Storytelling is a powerful form of communication that has been shown to decrease posttraumatic distress, improve immune function, and address health equity gaps.²  Narrative writing is a formal application of storytelling. Dr Rita Charon, often considered the founder of narrative medicine, describes the potential for clinicians to

Narrative has been studied as a therapeutic intervention in the intensive care unit, especially in the form of diaries—written by patients⁴  (including at the end of life⁵ ), written for patients and families by clinicians,⁶  and written by family members.^7–9  These diaries have been shown to improve posttraumatic stress disorder, anxiety, and depression in the months following discharge.¹⁰  Narrative has also been used to help clinicians understand patients’ experience of critical illness.¹¹  Beyond patient care, narrative reflection may have untapped potential as a tool for self-reflection for nurses¹²  and physicians.¹³ 

The “hidden curriculum” in health care—that which we learn through the culture of our work environment—instructs us to respond to the witness of trauma or the experience of being a secondary victim through repression and gallows humor.^14,15  These are often natural responses to unexpected events and may seem to maintain our ability to continue to function in the moment. Traumatic experiences occur during a shift, and countless other patients and tasks await. Our natural responses and the cultural reinforcement they are paired with are not effective long-term means of dealing with the trauma we encounter often on a daily basis.¹⁶  These short-term coping strategies do not yield desirable long-term results. Some organizations—and clinicians—have instituted a pause in the wake of an event such as a death.¹⁷  Jonathan Bartles, the nurse who instituted the pause, received the Pioneering Spirit Award from the American Association of Critical-Care Nurses in 2018.¹⁸  Such moments have the potential to draw on the power of “words without words.”¹⁹  Narrative exercises have the potential to carry these moments further and deeper.

What makes narrative different from unstructured storytelling or storytelling with a direct clinical purpose such as report at shift change? The intentional focus on reflection is one important aspect. Three mechanisms of action are proposed for the story-teller/writer: emotional disclosure, cognitive processing, and social connection.² 

Many clinicians may be apprehensive of narrative writing as what is written may itself be triggering—emotional disclosure may “open the floodgates.” This is a reasonable and expected concern. We have trained ourselves to close and lock that door, and to open it flies in the face of that conditioning. We suggest that such a strategy, though perhaps effective in the moment, is harmful in the long run and worsens satisfaction with the work, potentially contributing to burnout in the form of cynicism and emotional exhaustion. Simply put, repression is at best a short-term strategy that may lead to significant long-term consequences.¹⁶ 

Narrative writing can also be deployed as a cognitive behavioral intervention²⁰ ; such an approach yielded significant improvements in depressive symptoms and perceived stress for clinicians even at the height of the COVID-19 pandemic.²¹  Interestingly, these findings were not replicated during the following several years of the pandemic; the difference was possibly due to low uptake of the narrative workshop. Participants who engaged in narrative writing benefited, but engagement decreased over time.²²  Although narrative may have a powerful impact on addressing the experience of trauma, depressive symptoms, and stress, it cannot substitute for systems-level interventions to address the root causes of burnout, such as high acuity and volume of workload, frustrations with processes and technologies such as the electronic medical record, and a lack of psychological safety, among others.^23,24 

Narrative has also been studied as a tool to improve understanding and communication, suggesting that developing narrative competency could help “promote a better sense of self as well as meaningful relationships with colleagues and even the public.”^25(p190) Resident physicians in a pediatric intensive care unit have noted narrative exercises as meaningful, supporting both active reflection and sharing.²⁶  Narrative has been studied in the context of improving interprofessional education and collaboration as well. Gowda and colleagues²⁷  provided training sessions in narrative to improve interprofessional collaboration. In their report, they noted, “One staff member said that the sessions allowed ‘the whole care team’ to ‘just talk to each other like human beings.’”^27(p56) The authors consider the potential for creative works to create a “democratizing space” where interprofessional colleagues can connect more easily.²⁷  Narrative workshops break down the silos among professions and across hierarchies, allowing improved communication and peer support.

Narrative interventions are challenging to implement and may not always produce the expected improvement in the experience of care delivery.²⁸  Without confidentiality, the design of such studies may be hampered as the output of narrative reflections may cast the institution, leadership, or colleagues in a negative light. As with other similar efforts, there are countless ways to deploy such an intervention—ranging from the training of facilitators to selection of participants, incentives for and against participation, and secular trends in the local practice of critical care. Despite these concerns, these interventions hold promise for improving clinicians’ well-being and patients’ outcomes alike.

Regardless of the potential, these tools have had limited uptake. Common barriers for clinician participation in narrative reflection include time, workload, fear of legal retaliation, and fear of emotional labor. These barriers can be overcome through training, protected time, and addressing the stigma and apprehension around engaging with our exposure to trauma and burnout.^4,29  Further research into these programs can help us understand what is most effective and practical for clinicians and patients. With that knowledge, we hope to see more of these programs implemented across intensive care units. Reflective practices run contrary to the established intentional repression that we hone over years of practice in intensive care. However, those who engage in such practices may find much more in themselves than trauma. Perhaps repressing the traumatic experience buries more than the pain; after all, in moments of crisis, our humanity is what makes us vulnerable. Many have lamented about the loss of the human in health care. Narrative experiences are, perhaps, one means of bringing humanity back to the bedside.