This article explores the use of digital stories as an innovative method for engaging nurses in continuing education and professional development to advance nursing practice. In recent decades, digital stories have been used in traditional nursing education contexts to enhance collaborative learning and reflection (Christiansen, 2011; Price, Strodtman, Brough, Lonn, & Luo, 2015). Early evidence now suggests that digital stories may have the potential to transform health care systems by cultivating understanding and compassion (De Vecchi, Kenny, Dickson-Swift, & Kidd, 2017; Hardy & Sumner, 2018; Laing, Moules, Estefan, & Lang, 2017; Moreau, Eady, Sikora, & Horsley, 2018). However, limited research explores the use of narratives in health care systems to influence practice, particularly nursing care of families. Although the need for changes in family nursing practice has been identified (Duhamel, 2017), there is an absence of evidence focused on educational strategies using digital stories to support the translation of family nursing knowledge to practice.
A prior pilot project (Eggenberger & Sanders, 2016) examining an educational intervention with nurses focused on family nursing practice provided the foundation for the current work. This initial project's education component included an element of storytelling, with a family story about the struggles of a critical illness serving as a launching place for a nurse education class. Building on the pilot project's strategy became important given that study participants reported the value of listening to this story and advancing their knowledge. Conclusions from the pilot study informed how research is needed to examine the feasibility and impact of using digital stories as an educational strategy in an academic–practice partnership and reducing the technical burdens of creating digital stories in nonclassroom settings.
The current work focused on using digital stories prompted during video-recorded dialogues as support materials for an educational workshop. This work took place during a flat hierarchy (i.e., no levels of management among partners) partnership between nursing faculty at a medium-sized university located in the Midwest United States and clinical nurses at a large, urban teaching hospital. The partnership's goal was for nurse faculty and clinical nurses to collaborate in designing an educational strategy for implementing family nursing interventions. Digital stories were used to assist with increasing nurses' understandings and transferring family nursing knowledge to practice. During the planning phase, the partnership evaluated feasibility and logistic concerns to determine the process for creating digital stories in the hospital setting. Other researchers (De Vecchi et al., 2017; Gubrium, Hill, & Flicker, 2014; Stenhouse, Tait, Hardy, & Sumner, 2013) have reported challenges with creating digital stories outside of traditional classroom settings. Specific barriers this partnership needed to navigate were scheduling challenges, time and support needed to create digital stories, and access to computers, software, and other hardware. The following questions guided the current projects' process for addressing these issues in an acute care setting academic–practice partnership:
- How can the established digital storytelling framework be adapted to reduce logistic concerns and technical demand?
- How can the established framework be adapted without diluting a digital story's value to empower empathy and compassion?
Approaches to Creating Digital Stories
Defining digital stories and the frameworks used for creating them seems especially important as research using digital stories continues to expand. Digital stories can be widely defined as stories created using digital tools. Using digital technology this way has been described by de Jager, Fogarty, Tewson, Lenette, and Boydell (2017) as “digital storytelling in a generic sense, meaning the use of any digital media to tell a story” (p. 2554). This article expands their description by using generic digital storytelling (GDS) as a clarifying term. GDS differs from the digital storytelling (DST) framework pioneered by Joseph Lambert and continued at StoryCenter (formerly called the Center for Digital Storytelling). DST is workshop driven and typically conducted over 3 days (Lambert, 2010). Participants engage in a seven-step process that includes “Owning Your Insights” (step 1); “Owning Your Emotions” (step 2); “Finding The Moment” (step 3); “Seeing Your Story” (step 4); “Hearing Your Story” (step 5); “Assembling Your Story” (step 6); and “Sharing Your Story” (step 7) (Lambert, 2010). By the end, storytellers create a short video assembled from pictures, voiceover audio recording, music, and text into cohesive personal narratives. In sum, DST storytellers not only learn more about the storytelling craft but also the technical skills of creating digital narratives.
Drawing the distinction between GDS and DST from the outset seems helpful as research continues to explore the use of digital stories in various contexts. Systematic literature reviews investigating digital storytelling in health care professions (Moreau et al., 2018) and in research (de Jager et al., 2017) have indicated a possible need for this. Moreau et al. (2018) were explicit in writing “an important question raised by our findings is: what constitutes or counts as digital storytelling” (p. 213). Effort to draw distinction between DST and GDS was also evident in the study by de Jager et al. (2017), who used “broad operationalism of Lambert and colleagues' (Lambert, 2009) DST method” to determine whether to include specific articles reporting on digital storytelling in their systematic review (p. 2554). Those researchers were interested in investigating articles published on DST as established by Lambert. One other important aspect of their operationalized defining was the inclusion of the following elements that are hallmark of DST as practiced by StoryCenter: “a.) an audio-visual narrative; b.) including still images; c.) and voice-over narration; d.) of 2 to 5 minutes' duration; e.) created by participants” (de Jager et al., 2017, p. 2554). These criteria are helpful in discerning between GDS and DST, especially criterion “e.” Participants' use of digital technology to create their own digital stories is imperative to the DST. In contrast, GDS permits researchers to cocreate digital stories with, or create digital stories for, participants. In the current work, a GDS process was used during an academic–practice partnership. The goal was to explore how to create digital stories in a hospital setting while reducing technical burdens and time commitment.
The Current Project
The flat hierarchy Academic–Practice Partnership (“Partnership”) was established to collaborate and develop education materials focused on advancing nursing practice with families. This Partnership was composed of two teams: the Academic Team (“Academic”) and the Translational Practice Team (“Translational”). Academics (n = 3) included two nursing faculty with expertise in family nursing research and family nursing competencies and one faculty with communication and digital storytelling background. Nurses from each unit (n = 15) became the Translational members. The Partnership used the following four-phase approach in codesigning an educational workshop focused on family nursing practice in the health care setting: planning and storytelling (phase 1); story assembly and theme analysis (phase 2); sharing stories and educational workshop (phase 3); and sustainable approaches to create digital stories for future education workshops (phase 4).
This project took place at a level-1 adult trauma center in a large, urban teaching hospital. The hospital's patient population reflects the urban setting and includes low-income, uninsured, and vulnerable populations. The specific setting was an 18-bed intensive care unit with 70 nurses and a 49-bed acute care unit (with 15 intermediate and 34 telemetry beds) with 90 nurses. This project received approval for human subjects research by clinical and academic review boards. Academic team members were CITI Program-certified in Basic Biomedical Research, Basic Social & Behavior Research, and Responsible Conduct of Research.
A four-step GDS approach was used to create first-person digital stories told by 15 nurses on the Translation team. The steps included: video recording semistructured dialogues about meaningful experiences nurses had with family in their practice at the hospital (step 1), editing out conversational turns by Academics from the videos so that only nurse stories remained (step 2), reviewing and analyzing all nurse stories for themes and thematic connections (step 3), and selecting specific nurse stories to share for exploring themes during the educational workshop (step 4). Academic and Translational team members worked together during steps 3 and 4.
Phase 1: Planning and Storytelling. It became clear to the Partnership that a GDS approach to creating digital stories could reduce implementation barriers associated with using DST. Managing 160 different work schedules, technology familiarity levels, and access to necessary hardware and software onsite was determined infeasible. Instead, the partnership deployed the four-step process previously described.
Video-recorded dialogues between Academic and Translational partners took place at the level-1 hospital over a 2-day period. All dialogues began with Translational partners being prompted by Academic partners to tell their stories. Follow-up questions were asked as the dialogue progressed to prompt reflection on what those stories meant to the nurses and their nursing practice. Academic partners began dialogues with Translational partners by using the open-ended statement, “Please tell me a story about a meaningful experience with a family in your practice in this setting.” The significance of empathetic feelings when listening to partnership members was prioritized. Furthermore, the Academic Team members' communication with Translational nurses displayed an attitude of listening without judgement of actions and emotions. Due to the partnership's established flat hierarchy and prior relationship building, Translational nurses could trust that the Academic Team would not attempt to shape how they told their stories or owned their insights as dialogues developed organically.
Phase 2: Creating and Analyzing Stories. Academic and Translational teams collaborated to create digital stories from the video-recorded dialogues before reviewing and analyzing video data. The teams mutually agreed that conversational turns recorded during the dialogues would be edited out, so only the nurse's story remained. Edits were made by a member of the Academic team who is a trained video editor with digital storytelling and documentary background. The original meanings of each nurse's personal narrative were confirmed as intact by Academic and Translational members.
While analyzing stories, coding analysis with pattern identification was used to identify themes related to family nursing practice (Denzin & Lincoln, 2018; Streubert & Carpenter, 2011). The teams shared findings from watching the stories, identified story themes, explored educational foci, and set the direction for the educational workshop. Nurses' stories highlighted elements of family experiences with coping and the influence of nurses' actions on families during acute illness. It was determined that these stories could provide opportunities for other nurses to reflect and increase understandings to influence their thinking and actions. Phase 2 concluded with Academic and Translation Teams selecting specific, thematically grouped stories to be used during the educational workshop.
Phase 3: Sharing Stories and Educational Workshop. The Academic–Translational team delivered the educational workshop to a total of 160 nurses in small groups (n = 10 to 12) over a 3-month period. Nurse stories were used to portray themes identified as areas of concern for nurses and families. The themes represented distinct areas for potential intervention related to uncertainty, presence, trust, caring, celebration, and hope. Prior to delivery, the Academic partners had input from Translational partners on the themes found within their stories. During each educational workshop, Translational partners worked with their group participants to discuss implementation of evidence-based family nursing interventions appropriate for their nursing practice and their unit. After workshops, all educational program participants completed Likert-scale evaluations and provided narrative responses describing their reactions to participating. In addition, Academic and Translational partners debriefed about workshop value from educator and clinical perspectives.
Phase 4: Sustainable Approaches. This multiyear partnership is currently in Phase 4, which focuses on implementing strategies and, in partnership with nursing faculty, designing a sustainable program of informing staff nurses about family nursing interventions.
A total of 160 nurses were invited to and participated in 6-hour, small group (n = 10 to 12) educational workshops held over a 3-month period. Findings show that using a GDS approach instead of DST resulted in a less technologically and time-intensive process. Survey and narrative responses to the workshop indicated that the digital stories seemed to empower empathy and compassion.
First, all educational program workshop participants completed evaluations that reported value in the workshop. In addition to the high numerical rating on Likert scales by all participants, narrative responses also provided significant findings. For example, the stories and storytelling were the most commonly identified response to an open-ended question asking participants' perceptions about the most valuable component of the educational workshop. Quotes such as “Hearing the other nurses' stories and thoughts were [sic] the most valuable” and “Being able to hear a story from my unit made me know that I am not alone and helped me think about what we could do together to make a change in our unit” were a prevalent and consistent finding.
The worth of using digital stories as a strategy was further supported with statements such as, “Hearing from our own nurses made the workshop realistic and relatable” and “The stories made me think about our nurses and better understand our families.” The potential for these stories to influence practice also became evident in narrative data. Exemplary quotes included, “I never thought of how the family feels during this type of illness,” “I will never think of the family the same after this workshop,” and “I feel more able to talk with families about those difficult situations now.”
Second, the academic members also reported the value of using digital stories from an educator's perspective during debrief sessions. This team often debriefed to reflect on how stories had prompted powerful dialogue among participants during the workshop. Using the stories of nursing staff to share current evidence related to family nursing interventions supported the authenticity of the academic faculty. Despite delivering the workshop multiple times, faculty continued to be encouraged that workshop participants developed unique plans to implement evidence based on the stories. The academic–practice partners were consistently impressed with the extensive and formidable list of proposed practice changes related to family nursing. Even though faculty were experts who had experience teaching the workshop content, they noted “The nurse-family stories offered new ways to help participants embrace the challenges of family nursing practice in the acute care setting” and “The nurse and family experiences in the stories made the gap in practice and evidence more visible to participants.” In addition, the translational members of the team frequently commented on participants' engagement in the stories.
The Academic–Practice Partnership found merit in using GDS as a strategy to assist with transferring family nursing knowledge to practice. If the Partnership's goal was to design a training to cultivate compassion and understanding, it seemed antithetical to create a training that was insensitive to the already taxing work of nurses caring for critically ill patients. The frank realization was that nurses in this setting did not need to learn any new technology software or hardware. However, what they could benefit from was experiencing a peer-nurse retell and reflect on the concrete details of meaningful, lived experiences with a family undergoing acute illness. Academic–Practice partners consistently reported in planning sessions that reflection on peer nurse stories about working with families had potential to influence beliefs and attitudes related to current practice.
This partnership work can be added to the body of research evidence that suggests digital stories may have potential to transform health care systems by cultivating compassion and understanding. Nurses who participated in the educational workshops found value in hearing and seeing the stories of peer nurses. The workshops seemed to promote empathy for family and the challenges associated with nurses providing care for families experiencing acute illness. Some of the key benefits of including the digital stories were that nurses could also empathize with each other's common stories and identify shared language. Many reported to each other and members of the Academic team that specific details and reflection prompted them to reflect more on their own nursing practice. Participants found the use of digital stories meaningful to their reflection on the ways they plan to interact with a family experiencing acute illness.
Work throughout the partnership also confirmed that teams can experience logistic difficulties when creating digital stories to support training workshops conducted outside of classroom settings. It was not feasible to train 160 nurses in the DST process as practiced by Story-Center. It also was not feasible to train the 15-member Translational Team in DST. Nurses who engaged in the educational workshops experienced the benefits of stories told by Translational team members, but those storytellers did not have to complete the technical work of recording or assembling those stories. The partnership demonstrated that it is feasible to use GDS and create value for those who learn from those stories.
An area for further investigation is to explore whether it is meaningful to continue making strong discernments between DST as practiced by StoryCenter and GDS. This work finds it to be necessary. Future researchers may find the distinction helpful when designing and describing their approach to creating digital stories. It is important that researchers not inadvertently stretch DST to something it is not as they adapt to meet needs within their research contexts. It likewise seems valuable to have an operationalized term, such as GDS, for digital stories created using processes different than DST verbatim. As evidenced by the work of Moreau et al. (2018) and de Jager et al. (2017), there does appear to be a need for a clarity of terms. It is the position of the current authors that using GDS as a term acknowledges the various ways digital stories can be made while safeguarding SC's valuable DST process. This study not only discovered it is possible to create digital stories using GDS but also that the stories created retained the capacity to empower increased empathy and compassion in health care. Feedback from educational workshop participants indicated value of learning from the digital stories created. This study affirms that innovative strategies, such as using digital stories, have potential to advance continuing education and staff development opportunities.
Partnerships formed with academic and clinical teams may support positive educational outcomes that cannot be achieved without the two working together. As noted by other researchers (Duhamel, 2010; Svavarsdottir, Tryggvadottir, & Sigurdardottir, 2012; Svavarsdottir et al., 2015), academic–practice partnerships may be a key implementation variable in setting educational goals, directions, and outcomes. Given that caring for families requires an understanding of the family illness experience (Denham, Eggenberger, Young, & Krumwiede, 2016; McDaniel, Doherty, & Hepworth, 2014), digital stories may be useful to help practicing nurses to develop understandings and knowledge needed to care for these families. Educators and leaders in health care systems can use GDS to increase feasibility for implementation in the acute care setting. Additional research is needed to evaluate the efficacy of the digital stories in educational programs. Further evaluation of the long-term impact of storytelling methodology on family nursing practice is important to advance educational opportunities for nurses in health care settings.
To our knowledge, this is the first study that examines the process of academic and practice partners focusing on family nursing knowledge through digital stories. Cofacilitation of educational workshops with expert educators and practitioners working together to create the stories, analyze the meanings of the stories, and develop educational directions using those stories shows potential as an implementation strategy in health care systems (Hardy & Sumner, 2018). By encouraging reflection and developing empathy for families and nurse peers, digital stories of nurse–family experiences supports the transfer of family nursing practice knowledge and has potential to transform education processes in acute care settings.
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