It has been well established that storytelling is part of what makes us human and the way that cultures throughout history have taught, learned, and built community (Lawrence & Paige, 2016). There is an increasing literature base supporting the use of storytelling in nursing education, especially when it is built around specific nursing practice models (Timbrell, 2017).
Nurse educators use storytelling as an aesthetic strategy to help students to understand their relationship to themselves and others, exploring, imagining, rehearsing, and reflecting on the reality of their nursing practice (Haigh & Hardy, 2011; Schwartz, 2012). Storytelling in nursing pedagogy is generally thought to be effective (Price et al., 2015; Timbrell, 2017; Wheeler et al., 2016). Stories, both spontaneous and planned, are often conveyed verbally. Nursing faculty adapt their stories to meet both expressed and perceived needs of their students. A limitation to the live performance of storytelling is its lack of reproducibility. Use of recorded story (e.g., video) removes the issue of reproducibility. Limitations of live performance restrict its availability for use in a class situation, especially if the class is held in an asynchronous online environment. In addition, as writers are often advised, “Show, don't tell” in order to more effectively engage the reader. Video is thought be more effective than spoken narrative because of its ability to stimulate visual learning (Schwartz, 2012). This makes use of recorded performance not only attractive for reasons of feasibility but also for consistency and reproducibility. In other words, by using recorded video, we can improve the effectiveness and reliability of our teaching methods.
Digital stories, which are multimedia videos that may include photos, animation, sound, music, text, and narration, have been shown to be effective in nursing education (Price et al., 2015; Waugh & Donaldson, 2016). The mechanism by which this effectiveness occurs is thought to include the students relating to the information, seeing themselves applying it, being involved, and experiencing it as realistic (Davidson, 2004; Timbrell, 2017). Outcomes of exposure to digital storytelling have been described as including four experiences—learning, emotional engagement, reflective experience, and transformation—all appropriate to nursing learning objectives (Christiansen, 2011).
In the context of accelerated, second-degree nursing programs, faculty are challenged to provide an extremely organized curriculum that includes respect for the adult learner, early immersion, engagement via life–work experience, and implementation of appropriate pedagogical adaptations of broader curricular concerns (Christoffersen, 2017). Nursing faculty involved in this project used the technique of storytelling to teach nursing ethics to accelerated, second-degree students. Our original ideas were simple. We thought that an engaging video story would affect the students' knowledge, beliefs, and attitudes related to creating caring and healing spaces for seriously ill people. We were about the mechanism by which these study outcomes were achieved following exposure to storytelling. When we discovered the concept of narrative transportation (NT), we wondered if the extent of any changes would vary with the amount of nt reported by the students when watching the video. It turns out that our work was more innovative than we expected.
During the literature search, we discovered work relevant to this question, but it did not come from the discipline of nursing. Full text searches of CINAHL® for narrative transportation and nursing, or nursing education, did not yield any nursing research using NT. In other disciplines related to health care, greater NT was associated with behavior changes associated with skin cancer (Dillard et al., 2018), and intentions to participate in cancer research (Neil et al., 2019); “negative expectancies with alcohol drinking” in young adults (Banerjee & Greene, 2013); stronger anti-cocaine expectancies (Banerjee & Greene, 2012); lower perceived barriers to HPV vaccination (Krakow et al., 2017); mitigation of the intensity of mental distress (Shipman & McGrath, 2016); increased intentions to perform skin self-examination (Jensen et al., 2017); safer sex communication (Donné et al., 2017); higher intake of vegetable dishes in preschool children (Nicklas et al., 2017); and fear arousal, perceived persuasiveness, and behavioral intentions to make lifestyle changes with narrative health messages about colon cancer (Chen et al., 2015). In a published review of literature related to narrative as an intervention in the field of colorectal cancer screening, the underlying mechanisms of narrative remained unclear, but certain types of narrative (defined as personal stories conveyed on video, or in text) were effective in increasing self-efficacy, affective forecasting, and engagement, and others were effective in increasing or decreasing fear (Woudstra & Suurmond, 2019).
The concept of NT, also called narrative transport, describes a phenomenon in which the listener empathizes with story characters, the story activates the listener's imagination, and the listener experiences suspended reality while listening to the story (van Laer et al., 2014). The phenomenon of NT is well known in fields that attempt to alter consumer behavior. Originally used in the advertising industry, it is being applied to health and risk messaging with the understanding that stories that are more transporting will be more effective in creating attitude or behavior change (Green & Fitzgerald, 2017). NT occurs when listeners imagine that they are in the story themselves; maximizing transportation is an important consideration in the development of advertising campaigns (Green, 2004; Green & Brock, 2000). Results of NT include affective and cognitive phenomena and belief changes that affect attitudes, intentions, and behaviors (van Laer et al., 2014). For example, using the NT scale that inspired our work (Green & Brock, 2000), NT has been associated with increased intention to engage in cancer screening, self-care, information seeking, and personal risk assessment (Neil et al., 2019). It appears that NT affects phenomena that are desirable within the context of nursing education.
We used the strategy of storytelling by showing, Wit (Nichols, 2001), a made-for-cable movie adaptation by Emma Thompson and Mike Nichols of the Pulitzer Prizewinning play by Margaret Edson. The movie, about a patient's experience of treatment for stage 4 ovarian cancer, met learning objectives for our class, was well produced, and has been successfully used in medical education (Spike & Sain, 2009).
There were two study questions: (a) Does watching a professionally produced video affect students' knowledge, beliefs, and attitudes related to creating caring and healing spaces for seriously ill people, and (b) does the extent of that change (if any) vary with the amount of NT reported?
The sample consisted of 88 students in an introductory nursing class within a second-degree, accelerated program at a large public university in New England. International review board (IRB) approval was granted by the home university of the program. Students had no lecture, discussion, or assigned reading on nursing ethics or holistic nursing values before the class in which data were collected. An investigator-designed 15-item, 5-point Likert scale pretest–posttest instrument was administered to assess students' knowledge, beliefs, and attitudes related to the educational objectives of the class (Table 1). The investigators developed the instrument based on concepts they deemed important in creating caring and healing spaces for seriously ill people, such as understanding the needs of patients, nurse presence, the delivery of “bad” news, therapeutic communication, understanding of procedures and policies surrounding end-of-life issues, use of the arts, and ethical considerations. These were also concepts that were addressed in the movie Wit. Questions were developed to have both positively and negatively worded items. The Cronbach's alpha for the instrument was .73, suggesting that the instrument had internal consistency and was reliable. Face validity was established through review by the five doctorally prepared faculty teaching in the program. On the pretest, students were asked if they had viewed the movie Wit, or had read or seen the play; no student had.
Pretest and Posttest
Following the video, the posttest of knowledge, beliefs, and attitudes and the investigator-adapted Story Experience Questionnaire, assessing NT, were administered. The Story Experience Questionnaire was an adaptation of a commonly used instrument developed in the field of consumer marketing (Green & Brock, 2000). Although the original questionnaire was based on reading a narrative, investigators determined that it was appropriate to measure NT experienced while watching a video. The investigators' adaptation changed the language to “being mentally involved in,” or “listening to the story.” It included 12 Likert-type items with 5-point scales. The Story Experience Questionnaire's Cronbach's alpha was .86, suggesting that the instrument had internal consistency and was reliable.
Post-study debriefing included instructor-led online discussion. These discussions were part of the nursing curriculum but outside of the scope of the IRB-approved protocol and were not recorded or analyzed.
There were statistically significant improvements between the pretest and the posttest total scores in all items, except questions related to informed consent for treatment. These items experienced a ceiling effect, in which initial scores were at the top of the scale and there was no room for improvement. The total score was the sum total of all individual item scores with selected item scores reverse coded as needed. For example, a high score (strong agreement) for item 1 (“I understand the needs of the patient with cancer”) indicated knowledge of content specified in objectives, whereas a low score (strong disagreement) for item 13, (“sometimes there is nothing more a nurse can offer to help a patient”) indicated knowledge of content specified in objectives. For purposes of analysis, the scores for items 9, 10, 11, 13, and 15 were reverse-coded. The possible range of scores for the pretest and posttest was 15 to 105. The actual range of scores for the pretest was 67 to 100 and 72 to 104 for the posttest. The total score change was the difference in total score between the pretest and the posttest and this was statistically significant (M = 7.06, SD = 5.80, t = 11.090, df = 82, p = .000).
The measure of NT was the sum total of all items in the Story Experience Questionnaire with selected item scores reverse coded as needed. For example, a high score (strong agreement) for item 1 (“While I was listening to the story, I could easily picture the events in it taking place”) indicated experience of narrative transportation, whereas a low score for item 9 (“I found my mind wandering while listening to the story”) indicated experience of NT. For purposes of analysis, the scores for item 9 were reverse-coded. NT scores, reflecting the experience of NT, ranged from 35 to 81, with a mean of 64.89, of a maximum possible score of 84, a median of 65.00 and standard deviation of 10.29.
The correlation between NT and total score change was r = .303, p = .005. Correlations between NT and item scores reached statistical significance for items 3 (nurse presence, r = .272, p = .011) and 14 (the use of the arts in nursing education, also r = .272, p = .011).
A stepwise linear regression analysis with a dependent variable of post-test score and independent variables of NT and pretest score revealed two significant models. In the first model, NT explained 39.3% of the variance in the posttest score (F = 52.357, r = .627, r2 = .393, p < .001). In the second model, NT plus pre-test score explained 56.3% of the variance in posttest score (F = 51.503, r = .750. r2 = .563, p < .001. The F change between the two models was significant at p < .001.
A stepwise linear regression analysis with a dependent variable of change in total score between pre and posttest and independent variables of NT and pretest score revealed two significant models. In the first model, NT explained 16.1% of the variance in total score change (F = 15.498, R = .401, R2 = .161, p < .001). In the second model, NT plus pretest score explained 29.1% of the variance in total score change (F = 16.404, R = .539, R2 = .291, p < .001).
Using a hierarchical linear regression technique, we found that adding NT strengthened models explaining both posttest scores and score change (R2 = .563 [p < .001] and .449 [p < .001], respectively, with both F changes p < .001. In the first model predicting posttest scores, pretest alone explained 37.2% of the variance in posttest scores (F = 47.902, R = .610, R2 = .364, p < .001). In the second model pretest plus NT explained 55.2% of the variance in post-test scores (F = 51.503, R = .750, R2 = .563, p < .001). The p value for the change between models was p < .001.
In the first model predicting total score change, pretest alone was not a significant predictor (F = 3.149, R = .193, R2 = .037, p = .080). In the second model, pretest plus NT explained 29.1% of the variance in total score change (F = 16.404, R = .539, R2 = .273, p < .001.) The significance of the change between models was p < .001.
From these models, we can conclude that NT is an important predictor of both the final score and the amount of change in scores experienced by nursing students watching a video narrative.
Because there was no control group, we cannot establish causation. We can show only associations between extent of NT and outcomes. Use of the movie Wit was associated with increases in scores in beliefs and attitudes related to the care of seriously ill individuals. There was a statistically significant, moderate, positive correlation between students' scores for NT and the amount of change in test scores. This suggests that increasing experience of NT is positively associated with increasing test scores. Change in items concerned with nurse presence and the role of the arts in nursing education had an independent significant positive correlation with NT scores. Students who experienced more NT made more progress in these items, compared with students who experienced less NT. If class learning objectives include values such as nurse presence, patient engagement, and use of the arts, then teaching methods that induce NT are desirable. The regression analysis suggests that NT is one of the means by which learning occurs, and that by providing the opportunity for students to experience empathy and engagement in the context of a credible story, the educator can enhance learning. The NT experience might be part of the mechanism by which learning occurs.
It is of utmost importance in nursing programs to affect students' knowledge, beliefs, and attitudes related to creating, caring, and healing spaces for seriously ill people. The authors of this study found that NT is significantly associated with learning. This research supports the idea that the more that students experience NT, the more they learn. Further research is suggested to answer questions regarding methods to enhance the effectiveness of storytelling, including techniques for enhancing NT. Research designs making it possible to show a statistically significant moderation effect for NT would be of interest.
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Pretest and Posttest
|To what extent do you agree with each of these statements? Select the number that most closely matches your opinion.|
|1.||I understand the needs of the patient with cancer.|
|2.||The nurse should be present when the physician delivers bad news.|
|3.||The nurse should be present when the physician speaks with the patient about treatment.|
|4.||The patient has the ultimate authority for determining DNR (Do Not Resuscitate) status.|
|5.||There is no good way to deliver bad news.|
|6.||It is important for the patient to fully understand the personal risks and benefits of proposed treatment.|
|7.||Treatment decisions should be influenced by ethical decisions.|
|8.||How a procedure is carried out can be more important than the procedure itself.|
|9.||When a patient is unconscious (heavily medicated, comatose, etc.) health care providers can talk freely in their presence.|
|10.||It is not helpful to talk to patients who are unresponsive.|
|11.||The most important thing in treating cancer is to take the full dose of chemotherapy.|
|12.||It is important for patients to read and understand the consent for before signing it.|
|13.||Sometimes there is nothing more a nurse can offer to help a patient.|
|14.||Poetry and art should be included in nursing education.|
|15.||When appropriate, the provider should override the patient's resuscitation (DNR) wishes.|