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Narrative Initiative Program Helps Staff Become More Resilient to Stress

Erin Bendas, DO admits she was skeptical about the Write-Read-Reflect Narrative Initiative, a program to help health care professionals learn how to better communicate with their patients. But weeks later she was not only impressed by their improved communication skills, but also their resilience to stress. And, since the program occurred just before the COVID-19 pandemic, the timing couldn’t have been better.

St. Luke’s University Health Network and the Narrative Initiative have won a silver award in the John A. Hartford Foundation Tipping Point Challenge, a national competition to accelerate the spread of skills, ideas and solutions to improve health care for the seriously ill. St. Luke’s submission, Serial Interdisciplinary Write-Read-Reflect Narrative Experiences to Meaningfully Strengthen Reflective Listening Skills, was selected from among more than 100 entries from health systems, hospitals, clinics and insurers throughout the country.

Dr. Bendas, program director of St. Luke’s Hospice and Palliative Medicine Fellowship, said the Read-Write-Reflect narrative process evolved to become a tool that enabled physicians and other health care professionals to decompress, build resilience to everyday stresses and grow stronger as a team. Palliative care is a specialized medical care that focuses on providing patients relief from pain and other symptoms of serious illness. Dr. Bendas, who is also St. Luke’s section chief of palliative medicine and supportive care, led the program with Lorraine Dickey, MD, MBA, founder and CEO of The Narrative Initiative LLC. Michael Pipestone, MD, a St. Luke’s palliative care physician, and Nicole Defenbaugh, PhD, rounded out the project team. The award is sponsored by the Foundation and the Center to Advance Palliative Care (CAPC).

The first group to complete the program at St. Luke’s consisted of pastoral care residents (chaplains) and Hospice & Palliative Care Medicine fellows (physicians), all of whom were participating in training programs for their relative disciplines. The following year, psychiatry residents joined a new batch of pastoral care residents and palliative care fellows and Dr. Bendas, Dr. Dickey and Dr. Defenbaugh conducted a study around the experience. This year, family medicine residents were added.

Each session of the narrative method begins with the group facilitator giving the participants a verbal prompt, such as a single word or short phrase, and then asking them to take three minutes to write about a fulfilling or challenging experience related to the prompt. For example, the term might be to write about an “experience you had that was challenging” or “an experience that was uplifting.” Then, each participant reads what they have written aloud.

“Then, we ask, how did it feel to write that story? How did it feel to read that story and hear your own words?” Dr. Dickey explained. “Next, we ask the audience how did it feel listening to that story and what did you hear in that story that makes you want that person on your team? The participants respond by saying things like compassion, self-awareness, honesty, directness, and by doing so define the group’s core values.”

When the program was first described to Dr. Bendas, she was unsure. At the time, she was trying to find innovative ways to train fellows to become well-rounded professionals. While she knew how to design her program to teach skills like patient care and medical knowledge, she was looking for a way to teach more esoteric skills, like professionalism and interpersonal skills. After a conversation with Dr. Defenbaugh and Dr. Pipestone, proponents of the program, she decided to try Write-Read-Reflect and participated in an exercise where the prompt was, “your name.”

“It turns out I had some pretty strong opinions about my maiden name, Smith, and how it was so generic,” she said. “I never wanted to be a generic person, and that’s what I wrote about. It shocked me. I had no idea I had those feelings tucked away. After that experience, I said, OK, let’s just try it. It was a leap of faith.”

Dr. Dickey added, “You have to get over that hump that the program is too touchy-feely. But once you realize the internal value of it, you’re surprised by the validation you receive from sharing your experiences with people who get it.”

The prompts of St. Luke’s program are based on the Accreditation Council for Graduate Medication Education (ACGME) milestones. They are:

• Stressors and Supports
• Compassion Satisfaction and Compassion Fatigue
• Interdisciplinary Team Dynamics
• Diversity, Bias and Judgment
• Working with the Imminently Dying
• Ethics and Moral Distress
• Religion and Spirituality

These words are all related to what doctors encounter when caring for patients.

The program has helped the participants gain resilience as a way to mitigate burnout, Dr. Bendas said. Being a medical resident or a fellow is already incredibly challenging but even more so during a pandemic, which began shortly after the program started.

“In the very beginning of the pandemic, we were terrified,” Dr. Bendas said. “COVID was new and we didn’t know what was happening. We were caring for a lot of dying people and their families, and it was very hard. This vehicle came upon us at the perfect time.”

Dr. Dickey added that it’s crucial to care for the people who care for the patients. Health professionals are leaving in large numbers. “In medicine, we think about outcome, outcome, outcome,” Dr. Dickey said. “But when you stop and think about what you have control over, it’s very little. We think we have control over death and dying, but we don’t.” The Narrative Initiative process enables health care professionals support one another through the sharing of their stories and perspectives.

At the beginning and end of each year, residents and fellows take a survey that measures burnout, compassion and fatigue. The tool provides qualitative and quantitative results, and Dr. Bendas was surprised to see amazing improvements. In another measurement tool, participants reported that the Write-Read-Reflect method improved their professionalism, well-being, resilience and ability to listen without judgment. Furthermore, they conveyed that they could immediately use the reflective listening techniques with patients and colleagues, and even in their personal lives.

By sharing their stories, the participants learn they share common values, Dr. Dickey said. After a few sessions, the group bonds in a way that otherwise can take years to develop. “Later, when something difficult happens or there’s a crisis, they know they can trust the person next to them.”

In addition, learning that colleagues understand their feelings, and have had similar experiences, helps the participants to decompress, Dr. Dickey said. Write-Read-Reflect provides an opportunity to unload burdens and resentments they have carried for years, or even decades – like removing heavy rocks they’ve been carrying in their backpacks.