Examining Courage Through Personal Story

The Narrative Initiative, LLC, (or TNI) uses unique facilitated validated narrative techniques and interactive narrative sessions to invite professionals to come together and examine cultural challenges in their workplace environments. I founded TNI in 2017 based on 10+ years of research-based, peer-reviewed, unique, facilitated narrative techniques designed to help healthcare professionals and community members examine communication challenges inherent in critical relationships, including the critical relationships found between patient and provider.

TNI was invited to participate in the General Assembly Member Presentation break-out session at the American Academy for Physician Leadership (AAPL) Annual Spring Summit. The topic, Narrative Courage, was designed specifically to complement the overall theme of the AAPL meeting: The Courage to Lead.

This is a report on a quest by TNI to answer two questions:

1) Are TNI’s unique facilitated and validated narrative techniques using personal story effective for senior physician leaders?

Since 2006, TNI’s research has demonstrated our narrative techniques are effective with frontline healthcare professionals from all backgrounds. However, getting an audience of senior physician leaders from different backgrounds together is difficult. AAPL’s annual meeting provides a unique opportunity to understand how senior physician leaders view the value of this specific type of a narrative experience.

2) Can an introductory narrative session as short as 20 minutes with a small audience be effective?

TNI generally uses platforms that range from 60 to 90 minutes where participants share their stories with professional facilitators and each other. While on occasion introductions to our narrative techniques have been as short as 30 minutes, we’ve never attempted to provide participants an introduction and narrative experience in 20 minutes.

On May 4, the AAPL General Assembly Member Presentation session consisted of 17 different small-group presentations that were designed to last 20 minutes. Participants started at the session of their choice. At the end of 20 minutes, participants had five minutes to move to another small group of their choice. Therefore, participants could experience three small-group presentations during this 75-minute session.

The TNI session was titled Narrative Courage for Physician Leaders: Examining Courage Through Personal Story. Given the limited time, a brief five-minute introduction was provided and then participants got right to the narrative experience. This involved a short writing and then reading exercise. Participants had the opportunity to complete a validated survey about their narrative experience. They also could voluntarily sign a consent form and leave their short narrative with a TNI staff member for research and educational purposes. This article is based on the results of this survey and is accented with selected narratives from the participants.

This report details the following results: 1) participant demographics; 2) participant impressions of their narrative experience benefitting their personal and professional resiliency, their ability to listen closely without judgment, and their ability to immediately use new learned skills in their personal and professional lives, as measured by Likert scores; 3) participant open comments on the value of this narrative experience; and 4) inclusion of select participant narratives.

Key TNI Narrative Survey Results

This interactive facilitated narrative experience on the topic of narrative courage was exceptionally well-received among participating senior physician leaders. In fact, while the total number of participants was small (n = 7) these results are similar to those we have witnessed with healthcare professionals (nurses, physicians, etc.) since 2006.

Question 1: Are TNI’s unique facilitated and validated narrative techniques using personal story effective for senior physician leaders?

Answer: YES

Question 2: Can an introductory narrative session as short as 20 minutes with a small audience be effective?

Answer: YES

Demographics

Participants represented the physician leadership fields of chief medical officer, vice-chair of operations, medical director, and consultant.

All participants reported working over 15 years in medicine with 86 percent working in medicine more than 20 years.

Likert score questions

The results of the Likert questions on our validated narrative surveys demonstrate the following:

1. All participants “definitely agree” or “strongly agree” their narrative experience benefits their personal and professional sense of resiliency.

2. All participants “definitely agree” or “strongly agree” their narrative experience enhanced their ability to listen without expectations.

3. All participants “definitely agree” or “strongly agree” they left with the ability to immediately use new communication skills they practiced in their professional and personal lives.

Of particular note, no one noted this was a difficult experience. At TNI we fully recognize that our form of facilitated narrative exchange may not be everyone’s cup of tea, though the vast majority report this is a positive and beneficial experience. It is interesting to note the entire group of senior physician leaders felt this to be a positive and beneficial experience.

Open-ended questions

Participant responses to the open-ended questions about the value of their narrative experience centered on the value of stories, reflection/heightened awareness, leadership (specifically “Humanistic Leadership”), and listening.

With regard to how their narrative experience could be improved, all participant comments addressed wanting more exposure to our narrative work.

Participant final reflections on their narrative experience were very positive:

• 67 percent (4 of 6) of comments expressed this was a positive experience or expressed appreciation.

• 16 percent (1 of 6) of comments recommended that AAPL extend this session to 1 hour in the future.

Detailed TNI Participant Survey Results

Participants wrote on the following narrative prompt developed specifically for this session:

Take 3 minutes to write about an experience you had with a patient, a family member, or a colleague or an experience that you witnessed with a patient, a family member, or a colleague where you felt that courage was needed to do or say something yet you found it difficult or challenging to act or speak with courage or alternatively, you found that acting or speaking with courage was uplifting and inspiring.

Part I: Overall survey response and demographics

A total of 10 conference attendees participated in this narrative session: Session 1 = 3, Session 2 = 4, Session 3 = 3. A total of 7 completed narrative surveys were collected for an overall 70% completion rate.

For reporting purposes, physician leadership positions were divided into four major categories: chief medical officer (CMO), vice-chair of operations (vice chair), hospital/medical director (med director), and physician consultant (consultant).

Field of Work: Medicine

All participants reported working in the field of medicine. Physician leadership positions reported (see Figure 1):

CMO n = 3

Med Director n = 2

Vice Chair n = 1

Consultant n = 1

Figure 1. Participant leadership positions 100% from medicine

Years in Field of Work

All participants reported more than 15 years in medicine. Note: 87 percent of participants reported more than 20 years of experience.

1 year n = 0

1-2 years n = 0

3-4 years n = 0

5-10 years n = 0

11-15 years n = 0

16-20 years n = 1

> 20 years n = 6

Figure 2 shows participant years of experience in medicine based on their reported position of physician leadership.

Figure 2. Participant years of work in medicine

Part II: Participant responses to statements evaluated with Likert scoring

Participants were asked to respond to three statements:

Question 1: Today’s narrative experience will benefit my personal and/or professional sense of well-being and resilience.

Question 2: Today’s narrative experience will benefit my ability to listen closely without expectations.

Question 3: I will be able to apply what I practiced or witnessed today to my personal and/or professional life.

Please give your honest opinion for each statement. Circle 1 of 5 possible answers that BEST DESCRIBES your opinion of your experience with today’s narrative session.

Likert Scoring

5 = definitely agree

4 = probably agree

3 = not sure

2 = probably disagree

1 = definitely disagree

Summary: All participants (Figure 3)

Figure 3. All participant answers to Likert questions

Individual survey Likert questions

Question 1: Today’s narrative experience will benefit my personal and/or professional sense of well-being and resilience. (Figure 4)

Figure 4. Narrative session benefits my personal/professional sense of resilience

Question 2: Today’s narrative experience will benefit my ability to listen closely without expectations. (Figure 5)

Figure 5. Narrative session benefits my ability to listen without expectations

Question 3: I will be able to apply what I practiced or witnessed today to my personal and/or professional life. (Figure 6)

Figure 6. Ability to immediately apply what I practiced or witnessed today in my personal or professional life

Part III: Participant open-ended comments

Participants were asked to comment on three open-ended questions. Results are shown by frequency of major category of comment. Individual comments as written are then detailed by category.

Question 1: What are your impressions about the value of this narrative experience as it relates to your personal and/or professional life? (Figure 7)

Figure 7. Participant comments on the value of narrative experience

Reflection and heightened awareness

1. Made me realize how difficult it is to write my story

2. Improves perspective

The power of stories

1. Sharing stories allows physicians to connect to the human side of very technical work

2. Storytelling is a crucial human experience

Value to leadership

1. Humanistic leadership

The value of listening

1. To listen longer

Question 2: How can we improve this narrative experience to better benefit you? (Figure 8)

Figure 8. Participant comments on how to improve this narrative experience

Key finding: All participant comments show desire for more time with this experience.

More time

1. More time

2. Keep on it

3. I wish I had used this more as a med staff chief

4. More time

5. Need more of it

Question 3: Do you have any other comments about today’s narrative experience? (Figure 9)

Figure 9. Participant final comments

Positive

1. Enjoyed.

2. Well done!

3. Fantastic!

Appreciation

Grateful to practice and share stories

Application

Needs to increase to 1 hour for AAPL

Other

Where are your stories chronicled?

Selected Participant Narratives

Note: Selected participants’ narratives are included in this report. All participants had the option of keeping their personal stories or leaving them with TNI for educational use, research, and possible publication. Those who opted to leave their narrative with us signed a consent form releasing TNI to use their story in a de-identified format.

Prompt: Narrative Courage

Take 3 minutes to write about an experience you had with a patient, a family member or a colleague — or an experience that you witnessed with a patient, a family member, or a colleague — where you felt that courage was needed to do or say something yet you found it difficult or challenging to act or speak with courage … or alternatively…you found that acting or speaking with courage was uplifting and inspiring.

Results

Total participants n = 10

Stories written n = 10

Stories read verbatim n = 10

Stories left with TNI n = 4

Stories kept by participant n = 6

Participant Narratives

Author: Medical Director

30th Female with > 50 ED visits

Chronic abd pain

→ anxiety induced

→ mislabeled

→ Ext[ensive] ED/GI workups

→ “labeled”

→ concern was she would be mistreated or suffer a medical error/harm from team member bias while rounding stopped into her ED tx room; & asked “what is it like for you on a good day?”

→ told me her story

→ suggested coping mechanisms

→ no longer ED visits.

Made her “1 of [my] success stories”

Author: CMO

During residency.

Patient came to me for different somatic symptoms, aches & pains & had been to many different physicians before this visit with similar complaints. Her body language somehow made me suspicious that she may be a victim of intimate partner violence. I was uncomfortable to ask her this as I did not know at the time how to open the conversation feeling she would consider it an affront or too personal to ask.

Author: Vice Chair

Witnessed event.

Partner assigned a case. Pt with significant metastatic pulm dz bound for a hospice setting. The procedure was anesthesia for a G-tube. A frank discussion with the pt & my partner was about the possibility of a prolonged intubation & the resulting loss of hospice setting. Despite pressure from primary team & IR MD, the pt & partner declined the procedure & the pt went to hospice.

Author: CMO

As CMO we had [a] poorly trained & selected OB-GYN. I acted with courage to discuss shortcomings with physician and partner. ID issues. Extended FP PE. Look for solutions. None in our system.

Sat with physician — ID values & goals. ID what we would/could say & offered support.

Eventually — not able to support. Created an exit strategy with dignity and helped physician move on. Honest with potential employers as to physician’s situation.