Narrative Nursing: Better Care Through Reflection

      "Play is the work of children.”

This is a small piece of the advice Jeanne Churchill, DNP, CPNP-PC, assistant professor at Columbia Nursing, gives students on the first day of their clinical rotation in pediatrics. Echoing guidance offered by a growing number of clinical instructors in many fields of medicine, she assigns them homework designed to help them reflect on the care they provide to patients and families. The assignment: write an essay about a patient they treat, a clinical situation, or a moment of self-reflection.

Some of our most profound experiences, such as witnessing a birth, suffering with a loved one or comforting someone who is dying can’t be expressed through scientific writing, Churchill says.  Narrative writing allows students to process their experience, explore their understanding of what they are doing, why they are doing it, and the impact it has on themselves and others.

“The Entry to Practice Program is fast paced, and students can become so focused on memorizing facts and knowing the science of nursing that they don’t pause to reflect on the more human aspects of nursing that involve touching patients and listening to them and considering each patient in the context of their individual circumstances,” says Churchill. “By asking them to write a narrative essay about a patient or family member, what I am really asking them to do is to dig deep and reflect on their interactions. These interactions, in addition to the specific indicated medical treatment, can profoundly impact how well the children do.”

The notion of narrative nursing dates back to Florence Nightingale, whose detailed writings about poor conditions in military hospitals during the Crimean War prompted an overhaul of the British army’s health care system. To Churchill, Nightingale’s legacy in narrative nursing can be distilled to a single sentence Nightingale once wrote: “Observation tells us the fact, reflection the meaning of the fact.”

And reflection permeates the essays Churchill’s students produce.

One student, who has had little contact with children before the first day of her pediatrics rotation, reflects on what play means in the course of treating a six-year-old boy with end stage renal disease. Daniel, the name she gives the boy in her essay, has been hospitalized more than 20 times, often for urinary tract infections.  He needs a kidney transplant. And he thinks about his situation in terms of his urine: Pale yellow is good and deep amber is bad; a faint odor is good and a concentrated ammonia-like stench is bad.

Offering his nurse a toy dinosaur, he invites her to play, she recalls:

I am sucked into his world. Daniel grabs the disposable bedside stethoscope and we transition to playing “doctor and patient.” He listens to my heart, and asks me questions: “How old are you? How are things at home? Who is the boss in your house?” Then he looks imploringly: “Do you take all of your medications?” I say yes, and he prods: “Are you lying to me?” And I can’t help but think that this has come from somewhere.

To build trust, even with the youngest patients, you have to show them trust. As his nurse learns from playing that day, trust comes faster when you listen to what they’re really saying and try to speak their language. At the end of her time with Daniel that day, she reflects:

 I think play is the work of children because it’s through play that they make meaning of their lives. It is hard work for them to create and represent that meaning, just as it is hard work for us to accept that six-year-olds need kidney transplants. Illness is a lot to make sense of, but I think I caught a glimpse of Daniel’s attempts when he said, in his best dinosaur-deep voice: “Your pee smells good.”

For another student, and another patient, the notion of play looks markedly different. She is treating a five-year-old Saudi Arabian girl with microvillus inclusion disease, a rare genetic disorder that blocks digestion and leads to a life of constant vomiting and explosive diarrhea. The girl speaks limited English, and has been hospitalized for weeks without any family at her bedside because her parents can’t leave her siblings to join her. The hospital assigned a nanny to watch over the girl. And the girl calls this nanny “mama.”

With this young patient, communication with her nurse begins with a ball. This nurse found a ball on the floor and started playing catch with another caregiver in the room.

The girl’s eyes vacillated, hypnotized by the movement off the ball. And then she wanted in. So we threw the ball in a triangle. Instant. Friendship. The ball flew back. And forth. Back. And forth. And she cried with glee. She wasn’t able to go outside and play, but she would enjoy herself. Because this is her reality. She should be learning English in school, but instead, she is learning it in this hospital room. She will learn the word “digestion” before she learns the word “playground.” Because this is her reality.

This girl should be NPO, her nurse knows, which stands for “nil per os” in Latin, or “nothing by mouth.” But this little girl loves drinking from a cup. An exception is made: 

She loves the soothing cool of water sliding down her throat. And even though she is well aware that she will vomit right after, she still drinks. Because despite the consequences, we all know what it is like to do things for instantaneous pleasure. And this is her reality.

In cases like this, Churchill says it’s the job of nurses to go beyond basic patient care to provide the love and support that would ideally be given by a parent. This little girl, who remains in the hospital awaiting evaluation for a small bowel transplant, has no idea what life looks like outside the hospital walls. She has never seen it. 

“As nurses, we are part of her reality, and we try hard to make it a good one,” Churchill says. When students go into the room knowing they will need to create a narrative later, they focus on nuances that might be easy to overlook in a quick check of the chart and a standard patient assessment. With the intensity of focus comes a deeper understanding of patients as individuals, not just clinical problems in need of solutions.

“In pediatrics, the tiny details are very important because young children can’t tell you what’s wrong or how to make it better,” Churchill says. “And sometimes, you can’t make it better, you can just be present and listen to the child’s story until you see even a small way to offer the love and support they would get if they were healthy and at home.”