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Stories at work: reflective writing for practitioners
LITERATURE AND MEDICINE
I
Literature and medicine
I
Stories at work: reflective writing for practitioners
Gillie Bolton
Every triumph, disaster, or joy of our lives is a story waiting to be written. We create this dynamic literature about ourselves and patients, patients create it about us, and colleagues give us principal or walk-on parts in their own dramas. Stories and poems in The Lancet, the Journal of the American Medical Association, and the British MedicalJournal‘ bear witness to this. These are well-thumbed pages; even doctors who claim never to peruse these journals know these stories. Why? Because such stories are data-banks of experience, knowledge, and skill: they are embedded in practice. Reading or hearing stories makes skilled experience and knowledge available not only to colleagues, trainees, and students, but also to the writers themselves. Reflective writers can study their own decision-making processes, relationships with colleagues, and responses to patients; analyse their hesitations, and gaps in skill and knowledge; and face difficult and painful episodes. The opinions, judgments, and viewpoints of colleagues are valuably obtained (and there is also an enhanced awareness and understanding of ethical issues) when such accounts are written and discussed in a confidential forum. Professional stress can also be relieved by this writing and discussion process. Positive findings have resulted from research into a “framework that has allowed doctors to reflect on and evaluate their emotional responses to everyday practice through writing an ‘emotional diary”’.2 This is the substance of reflective practice, a term which has been around for many years, but which has gained a great deal more usefulness by being harnessed to the explorative and expressive power of creative writing, and the supportive and educative force of effective facilitated small-group work. Together, these elements have become Rejlective Writing for Practitioners courses from the Studies at Work project,’,‘ which has been developed in the UK.
Postgraduate medical and nursing education in t h e UK These reflective writing courses have been delivered over the past 10 years in various settings in the UK. They include: a multidisciplinary Master in Medical accredited postgraduate medical education courses for general practitioners nurse inservice training and training for supervision; and inservice training for full practice teams, such as primary
Lancet 1999; 354: 243-45 Institute of General Practice and Primary Care, Sheffield University, Community Sciences Centre, Herries Road, Northern General Hospital, Sheffield S5 7AU, UK (G Bolton MA) (e-rnail: g.boltonOsheffield.ac.uk)
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THE LANCET Vol354 *July 17, 1999
care, child-health care (psychiatrists, paediatricians, &c), and care of the elderly. An online postgraduate course for GPs is being successfully piloted; each member compiles a portfolio of reflective writings, reflections upon the writings, responses from other group members, evidence of discussion with colleagues (eg, team members), and research they have done (eg, internet or literature searches). All communication is electronic in a closed e-mail group; each member writes accounts that are read and commented upon by the other members, who also make research suggestions. This mode of communication inevitably has distinct advantages and disadvantages; it is particularly appropriate for busy, reasonably articulate clinicians, but requires careful facilitation. A group member reflected how it “enables you to meet colleagues you would probably never meet otherwise”.
Writing and reading The process of working in these courses is simple: participants are asked to write freely, with no planning or forethought, on a fairly open theme such as “a person who has been important to me”. An effective piece of writing, which communicates back to the writer as well as to his or her audience, takes no longer than the time to put the words on the paper. The immediacy of the process fosters the creation of writing that is fresh, invigorating, and fascinating. The fictionalised or autobiographical story is the most common form of writing, but poetry and drama are also created. Participants have plenty of time to read their writing and reflect silently before deciding how much to read to the group (occasionally the writing is too personal for any to be shared). Groups are always closed and small, ideally no larger than eight, to foster confidence, confidentiality, and trust. Careful facilitation ensures that the discussions focus on the content of the writings, not on the writers: these are not personal therapeutic groups. Sometimes advice about redrafting is given to help the writer face vital issues addressed. For example, a clumsy and involved passage usually indicates a confused or poorly grasped incident in the writer’s mind; although the group helping to clarify the issues has the additional benefit of improving the quality of the writing, these are not creative writing groups. Groups vary in the extent to which they focus on personal issues and on the technical aspects of the writing. The importance for some participants of addressing personal issues reflects their confidence in the group, and their awareness of the extent to which personal issues affect the professional.
243
LITERATURE AND MEDICINE
Death Drawing by Alice Rowland.
The background of this process is a mixture of the teaching of creative writing (the writing process itselo, therapeutic principles (eg, unconditional positive regard for the writers and their writing), and the theory and practice of small-group-work facilitation. An effective group is not just merely a bunch of people who happen to be in a room together: the process needs to be fostered. For example, the group needs to feel safe enough without being undynamically cosy; it needs unobstrusively to be kept to the task in hand; personally intrusive inquiry must be deflected; and care has to be taken that each member has an appropriate share of time, and that the group is brought to a proper close so that members are not left part-way through a process. These groups usually meet for 3 hours monthly or weekly for a set period of between three and 12 sessions, though one group has run for more than 5 years. The group always writes together (including the facilitator) for the first session, to introduce the principles and methods; thereafter participants bring their writings, and the group spends all the time discussing them. Day and weekend courses have successfully been run; this intensive contact allows for dynamic development of the writings and discussions.
heard can never be unheard. Something written can be destroyed even without being reread by the writer. Writing is a staged process involving reading, redrafting, editing, and sharing only when the writer is ready. These stages enable writers to reflect and consider their work before they involve another reader; so the writer can afford to say more to the silent page. This whole creative process can be rewarding, increasing selfconfidence and self-esteem.8 These attributes of writing ensure than when pieces of explorative, reflective writing are used as the basis of a group discussion, the depth and significance of the work the group undertakes can be enhanced.’a4 A discussion with one significant reader, such as a co-mentor, tutor, supervisor, or friend can offer clarity and startling insight.
What’s it all about? The writings and discussions can be about any aspect of professional life or of personal life that is affected by (and affects) the professional. Death is a common thread. However often practitioners face it, care for it, facilitate it, fend it off, the subject of death is still too often a problem. Death is always associated with guilt, grief, pain, fear, anger, disbelief, denial, hopelessness, and only occasionally acceptance. The practitioner’s own mortality, and that of their loved ones, always stares them in the face, as does their (generally unwarranted and irrational) sense of guilt. After the group has heard each piece of writing, topics for discussion are: suggestions as to how they might have acted differently; a discussion of how the patients, relatives, or other clinicians might have felt, or the ethics of a particular incident; and descriptions of similar events from other participants’ experience. The group members draw out whatever issues are of value and interest to them and the writer. This process takes considerable energy; it is demanding because there can be no wearing of
Writing rather than telling stories Writing is different from talking or thinking: it can have a far deeper reflective and educative function. Writing enables the writer to express and clarify experiences, thoughts, and ideas that are problematic, troublesome, hard to grasp, or hard to share with another. Writing also enables writers to discover and explore issues, memories, feelings, and thoughts they hadn’t acknowledged. Why does writing have this power? Writing stays on the page unchanged, so it can be worked on the next day or year, and then extended. Unlike thinking and talking, written thoughts and ideas can be organised and clarified at this later stage. In speaking to others, we severely-and usually unconsciously-edit what we say (except for those emotional occasions when words are blurted out and afterwards regretted), because something spoken and
244
THE LANCET * Val 354 * July 17,1999
LITERATURE AND MEDICINE
defensive professional masks. Yet the writers receive in proportion to their willingness to put in (panel).
The role of narrative and poetry in medicine Reflective writing is part of a deep and valuable tradition of stories in m e d i ~ i n e .Brendan ~ Sweeney points out the place of narrative in medicine: “If the illness produces a significant disability, the doctor becomes temporarily a co-author [to the patient’s lifenarrative]”, or even becomes a central character, and sometimes “helps the patient write the last chapter of the narrative”.” Trish Greenhalgh and Brian Hurwitz have recently edited an exploration and celebration of narrative in medicine.” Controlled research has proved that expressive, explorative, and reflective writing relieves stress and fosters understanding.” Dannie Abse, physician-poet, reporting his experience of writing with students in the USA, said: “Poems on the page lie there and do not lie; their own progenitor can scrutinise them as if they were spiritual X-rays . . . Poems . . . profoundly alter the man or woman who wrote them”.” Writing or telling narratives of experience is extremely important in the training of doctors. It enables clinicians to examine their practice critically from a wide perspective, and to increase their understanding and empathy by exploring a range of experience, knowledge, and emotions other than their own. We are our stories; writing and rewriting them keeps us alert, alive, and flexible. Writing and sharing stories and poems keeps us questioning: questioning medical practice, our patients, ourselves.
T H E LANCET * Vol354 *July 17,1999
Reading the stories and poetry of many studies and practitioners over the last 12 years has been a tremendous privilege; I would like to thank the writers, especially Mark Purvis. Nick Fox, Nigel Mathers, Amanda Howe, Kate Billingham, David Hannay, Janet Hargreaves, Sonya Yares, Pat Lane, and Stephen Rowland have been instrumental in the development of my principles and practice; Faith McLellan, Trish Greenhalgh, Maggie Eisner, Adam Forman, and David Flews have offered invaluable editorial help; Marilyn Lidster and Jan Morrison have given constant support.
References Jones Elwyn G. So many precious stories: a reflective narrative of patient based medicine in general practice, Christmas 1996. BMJ 1997; 315: 1659-63. Howard J. The emotional diary-a framework for reflective practice. Educ Gen Pract 1997; 8: 288-91. Bolton G. Stories at Work Fictional-critical writing as a means of professional development. Br Educ Res J 1994; 20: 55-68. Fox N. Postmodernism, sociology and health. Buckingham: Open University Press, 1993. Heller T. A G P writes: In: Serious fun: the arts in primary health care. Yorkshire & Humberside Arts Publication, 1997. Purdy R. Writing refreshes my practice. Med Monitor March 6 , 1996. Brimacombe M. The emotional release of writing. GP Dec 13, 1996. Bolton G. The therapeutic potential of creative writing: writing myself. London: Jessica Kingsley Publishers, 1998. Brody H . Stories of sickness. New Haven: Yale University Press, 1987. 10 Sweeney B. The place of the humanities in the education of a doctor: the James Mackenzie lecture. BrJ Gen Pract 1998; 48: 998-1102. 11 Greenhalgh T, Hurwitz B. Narrative based medicine: dialogue and discourse in clinical practice. London: BMJ publications, 1998. Putting stress into words: health, linguistic and 12 Pennebaker JW. therapeutic implictions. Behaw Res Ther 1995; 31: 539-48. 13 Abse D. More than a green placebo. Lancet 1998; 351: 362-64.
245
I
Literature and medicine
I
Stories at work: reflective writing for practitioners
Gillie Bolton
Every triumph, disaster, or joy of our lives is a story waiting to be written. We create this dynamic literature about ourselves and patients, patients create it about us, and colleagues give us principal or walk-on parts in their own dramas. Stories and poems in The Lancet, the Journal of the American Medical Association, and the British MedicalJournal‘ bear witness to this. These are well-thumbed pages; even doctors who claim never to peruse these journals know these stories. Why? Because such stories are data-banks of experience, knowledge, and skill: they are embedded in practice. Reading or hearing stories makes skilled experience and knowledge available not only to colleagues, trainees, and students, but also to the writers themselves. Reflective writers can study their own decision-making processes, relationships with colleagues, and responses to patients; analyse their hesitations, and gaps in skill and knowledge; and face difficult and painful episodes. The opinions, judgments, and viewpoints of colleagues are valuably obtained (and there is also an enhanced awareness and understanding of ethical issues) when such accounts are written and discussed in a confidential forum. Professional stress can also be relieved by this writing and discussion process. Positive findings have resulted from research into a “framework that has allowed doctors to reflect on and evaluate their emotional responses to everyday practice through writing an ‘emotional diary”’.2 This is the substance of reflective practice, a term which has been around for many years, but which has gained a great deal more usefulness by being harnessed to the explorative and expressive power of creative writing, and the supportive and educative force of effective facilitated small-group work. Together, these elements have become Rejlective Writing for Practitioners courses from the Studies at Work project,’,‘ which has been developed in the UK.
Postgraduate medical and nursing education in t h e UK These reflective writing courses have been delivered over the past 10 years in various settings in the UK. They include: a multidisciplinary Master in Medical accredited postgraduate medical education courses for general practitioners nurse inservice training and training for supervision; and inservice training for full practice teams, such as primary
Lancet 1999; 354: 243-45 Institute of General Practice and Primary Care, Sheffield University, Community Sciences Centre, Herries Road, Northern General Hospital, Sheffield S5 7AU, UK (G Bolton MA) (e-rnail: g.boltonOsheffield.ac.uk)
-
THE LANCET Vol354 *July 17, 1999
care, child-health care (psychiatrists, paediatricians, &c), and care of the elderly. An online postgraduate course for GPs is being successfully piloted; each member compiles a portfolio of reflective writings, reflections upon the writings, responses from other group members, evidence of discussion with colleagues (eg, team members), and research they have done (eg, internet or literature searches). All communication is electronic in a closed e-mail group; each member writes accounts that are read and commented upon by the other members, who also make research suggestions. This mode of communication inevitably has distinct advantages and disadvantages; it is particularly appropriate for busy, reasonably articulate clinicians, but requires careful facilitation. A group member reflected how it “enables you to meet colleagues you would probably never meet otherwise”.
Writing and reading The process of working in these courses is simple: participants are asked to write freely, with no planning or forethought, on a fairly open theme such as “a person who has been important to me”. An effective piece of writing, which communicates back to the writer as well as to his or her audience, takes no longer than the time to put the words on the paper. The immediacy of the process fosters the creation of writing that is fresh, invigorating, and fascinating. The fictionalised or autobiographical story is the most common form of writing, but poetry and drama are also created. Participants have plenty of time to read their writing and reflect silently before deciding how much to read to the group (occasionally the writing is too personal for any to be shared). Groups are always closed and small, ideally no larger than eight, to foster confidence, confidentiality, and trust. Careful facilitation ensures that the discussions focus on the content of the writings, not on the writers: these are not personal therapeutic groups. Sometimes advice about redrafting is given to help the writer face vital issues addressed. For example, a clumsy and involved passage usually indicates a confused or poorly grasped incident in the writer’s mind; although the group helping to clarify the issues has the additional benefit of improving the quality of the writing, these are not creative writing groups. Groups vary in the extent to which they focus on personal issues and on the technical aspects of the writing. The importance for some participants of addressing personal issues reflects their confidence in the group, and their awareness of the extent to which personal issues affect the professional.
243
LITERATURE AND MEDICINE
Death Drawing by Alice Rowland.
The background of this process is a mixture of the teaching of creative writing (the writing process itselo, therapeutic principles (eg, unconditional positive regard for the writers and their writing), and the theory and practice of small-group-work facilitation. An effective group is not just merely a bunch of people who happen to be in a room together: the process needs to be fostered. For example, the group needs to feel safe enough without being undynamically cosy; it needs unobstrusively to be kept to the task in hand; personally intrusive inquiry must be deflected; and care has to be taken that each member has an appropriate share of time, and that the group is brought to a proper close so that members are not left part-way through a process. These groups usually meet for 3 hours monthly or weekly for a set period of between three and 12 sessions, though one group has run for more than 5 years. The group always writes together (including the facilitator) for the first session, to introduce the principles and methods; thereafter participants bring their writings, and the group spends all the time discussing them. Day and weekend courses have successfully been run; this intensive contact allows for dynamic development of the writings and discussions.
heard can never be unheard. Something written can be destroyed even without being reread by the writer. Writing is a staged process involving reading, redrafting, editing, and sharing only when the writer is ready. These stages enable writers to reflect and consider their work before they involve another reader; so the writer can afford to say more to the silent page. This whole creative process can be rewarding, increasing selfconfidence and self-esteem.8 These attributes of writing ensure than when pieces of explorative, reflective writing are used as the basis of a group discussion, the depth and significance of the work the group undertakes can be enhanced.’a4 A discussion with one significant reader, such as a co-mentor, tutor, supervisor, or friend can offer clarity and startling insight.
What’s it all about? The writings and discussions can be about any aspect of professional life or of personal life that is affected by (and affects) the professional. Death is a common thread. However often practitioners face it, care for it, facilitate it, fend it off, the subject of death is still too often a problem. Death is always associated with guilt, grief, pain, fear, anger, disbelief, denial, hopelessness, and only occasionally acceptance. The practitioner’s own mortality, and that of their loved ones, always stares them in the face, as does their (generally unwarranted and irrational) sense of guilt. After the group has heard each piece of writing, topics for discussion are: suggestions as to how they might have acted differently; a discussion of how the patients, relatives, or other clinicians might have felt, or the ethics of a particular incident; and descriptions of similar events from other participants’ experience. The group members draw out whatever issues are of value and interest to them and the writer. This process takes considerable energy; it is demanding because there can be no wearing of
Writing rather than telling stories Writing is different from talking or thinking: it can have a far deeper reflective and educative function. Writing enables the writer to express and clarify experiences, thoughts, and ideas that are problematic, troublesome, hard to grasp, or hard to share with another. Writing also enables writers to discover and explore issues, memories, feelings, and thoughts they hadn’t acknowledged. Why does writing have this power? Writing stays on the page unchanged, so it can be worked on the next day or year, and then extended. Unlike thinking and talking, written thoughts and ideas can be organised and clarified at this later stage. In speaking to others, we severely-and usually unconsciously-edit what we say (except for those emotional occasions when words are blurted out and afterwards regretted), because something spoken and
244
THE LANCET * Val 354 * July 17,1999
LITERATURE AND MEDICINE
defensive professional masks. Yet the writers receive in proportion to their willingness to put in (panel).
The role of narrative and poetry in medicine Reflective writing is part of a deep and valuable tradition of stories in m e d i ~ i n e .Brendan ~ Sweeney points out the place of narrative in medicine: “If the illness produces a significant disability, the doctor becomes temporarily a co-author [to the patient’s lifenarrative]”, or even becomes a central character, and sometimes “helps the patient write the last chapter of the narrative”.” Trish Greenhalgh and Brian Hurwitz have recently edited an exploration and celebration of narrative in medicine.” Controlled research has proved that expressive, explorative, and reflective writing relieves stress and fosters understanding.” Dannie Abse, physician-poet, reporting his experience of writing with students in the USA, said: “Poems on the page lie there and do not lie; their own progenitor can scrutinise them as if they were spiritual X-rays . . . Poems . . . profoundly alter the man or woman who wrote them”.” Writing or telling narratives of experience is extremely important in the training of doctors. It enables clinicians to examine their practice critically from a wide perspective, and to increase their understanding and empathy by exploring a range of experience, knowledge, and emotions other than their own. We are our stories; writing and rewriting them keeps us alert, alive, and flexible. Writing and sharing stories and poems keeps us questioning: questioning medical practice, our patients, ourselves.
T H E LANCET * Vol354 *July 17,1999
Reading the stories and poetry of many studies and practitioners over the last 12 years has been a tremendous privilege; I would like to thank the writers, especially Mark Purvis. Nick Fox, Nigel Mathers, Amanda Howe, Kate Billingham, David Hannay, Janet Hargreaves, Sonya Yares, Pat Lane, and Stephen Rowland have been instrumental in the development of my principles and practice; Faith McLellan, Trish Greenhalgh, Maggie Eisner, Adam Forman, and David Flews have offered invaluable editorial help; Marilyn Lidster and Jan Morrison have given constant support.
References Jones Elwyn G. So many precious stories: a reflective narrative of patient based medicine in general practice, Christmas 1996. BMJ 1997; 315: 1659-63. Howard J. The emotional diary-a framework for reflective practice. Educ Gen Pract 1997; 8: 288-91. Bolton G. Stories at Work Fictional-critical writing as a means of professional development. Br Educ Res J 1994; 20: 55-68. Fox N. Postmodernism, sociology and health. Buckingham: Open University Press, 1993. Heller T. A G P writes: In: Serious fun: the arts in primary health care. Yorkshire & Humberside Arts Publication, 1997. Purdy R. Writing refreshes my practice. Med Monitor March 6 , 1996. Brimacombe M. The emotional release of writing. GP Dec 13, 1996. Bolton G. The therapeutic potential of creative writing: writing myself. London: Jessica Kingsley Publishers, 1998. Brody H . Stories of sickness. New Haven: Yale University Press, 1987. 10 Sweeney B. The place of the humanities in the education of a doctor: the James Mackenzie lecture. BrJ Gen Pract 1998; 48: 998-1102. 11 Greenhalgh T, Hurwitz B. Narrative based medicine: dialogue and discourse in clinical practice. London: BMJ publications, 1998. Putting stress into words: health, linguistic and 12 Pennebaker JW. therapeutic implictions. Behaw Res Ther 1995; 31: 539-48. 13 Abse D. More than a green placebo. Lancet 1998; 351: 362-64.
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