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Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…
September 8, 2011

Storytelling is a hallmark at the Institute for Safe Medication Practices—a practice we embed in practically every aspect of our work. While we use and promote a vast array of sophisticated medication safety improvement tools, measures, and technologies, our most fundamental strategy to create change is a simple one—to create compelling stories about medication errors and impactful change strategies to draw attention to problems and encourage people to act. Anyone involved in patient safety knows that improvement strategies are most effective within a culture that ensures any changes are well understood, embraced, and sustained.1 And there is no better way to inspire and sustain cultural change than through the simple craft of telling factual stories that move listeners into action.1

 The Power of the Story
Storytelling is a familiar form of communication, one that resonates with us. Factual stories educate us, touch us, and inspire us to take action. They are an efficient vehicle for getting people to understand, remember, and accept new information.2 One thing is certain; lessons without stories rarely lead to learning and change.3 It is the contextual details and the exposed humanity in stories that serve as the catalyst for change. No matter how powerful patient safety research data is, there is often nothing more powerful than a story to garner the motivation necessary to learn and change. Here’s why…

 Stories attract attention. Stories expose dilemmas in a way that greatly enhances our attentiveness to the problem. They grab and hold our interest in ways that research data and quantitative numbers alone cannot.

 Stories promote critical thinking. Since primitive times, stories have been the primary media used to communicate information, learn about life, transmit cultural norms, make sense of experiences, and express emotions.4 Seeing or hearing stories unfold makes analysis not just an intellectual experience but a much deeper personal experience. Stories incite important questions, often challenge pre-existing assumptions, and open us up to new ways of thinking about an issue.5

 Stories are memorable. People are more likely to remember information shared through a story than information presented through data or detail points.6 Stories lead to contemplation and reflection on how they apply to one’s own life. They are memorable because they often resonate with one’s own experiences. 

 Stories create empathy. Studies reveal that sharing a factual story can nurture healing by empowering victims to give voice to their experiences, leading to a better appraisal of the situation and enhanced understanding and empathy for story participants.4 Story readers/listeners experience vicariously the emotions of the storyteller—pain, fear, or joy, for example. The story becomes a shared narrative that increases the sense of community among the entire organization.   

 Stories inspire and incite change. Studies demonstrate the positive persuasive effects of stories, particularly when compared to abstract presentations of data. In one study, a story about a young woman who used tanning beds and later developed skin cancer was more persuasive in decreasing intentions to tan among college students than a statistical message that provided numerical evidence about cancer risk with tanning bed use.4,7 Another study by the Kaiser Family Foundation showed the impact of short storylines that unfold in the entertainment world.4,8 For example, one in seven viewers of the television show ER consulted with a physician about a medical condition they had seen on the show. The study is a testament to the story’s ability to inspire, motivate, and make a difference in people’s lives.    

Challenges with storytelling
Legal and public disclosure concerns. The primary barrier to storytelling in healthcare is the secrecy that has long accompanied risk and errors to keep them hidden from accusatory eyes. Today, many healthcare providers have shown an interest in sharing stories within their organizations about actual hazards and errors for the purpose of improving safety. Yet, important stories remain untold in many organizations—particularly if a patient has been harmed—due to legal concerns and the risk of unwanted public disclosures. Most organizations are hesitant to tell their stories outside the confines of their internal peer review/quality improvement processes. Staff feedback about risk and errors is narrowly focused on involved units and individuals. This cloak of secrecy makes it virtually impossible for the entire organization to learn from its mistakes.          

As a stop-gap effort, some organizations have been sharing just the “lessons learned” from events, which amounts to a list of required system and behavioral changes without the backstory that could provide the rich details needed to motivate staff to make and sustain the changes. Even if efforts are initially successful in instituting the changes, it is not enough if the culture cannot sustain the change.  

Recommendations
In today’s litigious society, it is unrealistic to expect organizations to simply share unbridled stories of risk and error outside or within the organization. However, given the immense value of storytelling in helping to keep our patients safe, we have provided what we believe are reasonable recommendations, many of which come from healthcare organizations that use storytelling as a safety tool.

Setting the stage. Establish a safe and trusting environment in which the organization’s stories can be reported, crafted, and shared without fear of external exposure, undue internal embarrassment, or unjust discipline of involved staff. See our 2006 September 7 and September 21 newsletters (www.ismp.org/Newsletters/acutecare/archives.asp) for recommendations regarding the adoption of a Just Culture that encourages reporting of risk and errors along with frank discussions—including storytelling—about their causes.   

Crafting the stories. Stories should be crafted with just enough detail to: 1) describe the key risks or events leading up to an adverse event, 2) describe the key causes of the risk or error, 3) link the causes and adverse outcomes (potential or actual) to the desired system or behavioral changes, 4) describe the lessons learned, and 5) make the story memorable. If measurement data exist to support the story’s conclusions, provide links or references to the data for those who want more information. Some stories, if used for feedback, may initially exclude the lessons learned or recommended changes to encourage discussion and analysis of the risk or error.

When crafting the story, to the extent possible, de-identify the patient, the individual who reported the risk or error, and staff involved in the risk or error so it cannot be traced back to specific individuals or patients. While stories should be truthful, unnecessary details should be omitted, and minor changes to the story (e.g., patient’s exact age/weight or gender) can be made to facilitate de-identification if the key causes of the risk or error and the lessons learned are not jeopardized or misrepresented. If necessary, build fictional stories loosely based on actual reported risks, errors, or events that are common enough to be salient and relevant to most clinical staff; however, always disclose the fact that the stories are fictional. Storytelling can possess a negative connotation, such as the “spinning” of yarn (story) for the purpose of manipulation, not learning. Thus, fictional stories and their purpose should be fully disclosed.

Include stories from internal and external sources (e.g., ISMP newsletters) about risk, close calls (good catches), errors, and adverse events. Using internal sources for stories helps staff see risks lurking in their everyday activities and sends a message that the organization and everyone who works there are committed to safety. Using external sources for stories prompts the evaluation of similar risks within the organization that may otherwise be hidden, lying dormant for years before they cause an adverse outcome. Using stories from external sources may be a great starting point for organizational storytelling, as these stories are often less threatening to staff and eliminate any legal risks.

In addition to stories about risks and errors, create stories about the organization’s achievements in safety and acts of caring.3 These uplifting stories can be rewarding to staff, reinforce specific safety strategies, and motivate staff to continue participating in safety improvements.

Sharing the stories. Establish a simple yet formal process for sharing internal and external stories that focus on risk, errors, adverse events, and improvements. Describe how storytelling will be used within your quality improvement/peer review processes, the level of confidentiality required among storytellers and story listeners/readers, and how to clearly communicate these expectations through confidentiality policies   and/or signed confidentiality agreements. Determine and describe the venues at which stories can—department and committee meetings, orientation programs, educational programs—and cannot—discussions in the cafeteria, hallways, in direct patient care areas, via telephone—be shared. Organizations may want to consider sharing stories through appointed safety mentors who first attend a safety meeting where stories are formally shared, and then take those stories to frontline staff at more personalized staff meetings.9 If a particular medication safety story is difficult to tell within an organization, consider reporting it to ISMP in its capacity as a Patient Safety Organization, which we will then de-identify and share with a wide healthcare audience while protecting anonymity.  

Determine whether organizational stories can be shared verbally or in writing, or both. If stories are shared in writing during meetings, hospitals may want to print the stories on colored paper and collect the written materials at the end of the meeting for proper disposal. Consider creating ad-hoc or planned reenactments of the stories.1,3 There is anecdotal evidence to suggest that the ‘told’ story has more impact than a ‘read’ story because of the dynamic that is created between the storyteller and listener.3 The printed text does not convey the speech rhythms, tone, pitch, eye contact, actions, gestures, grins, frowns, and other human expressions of the storyteller.10 As a storyteller speaks, the listeners reconstruct the story taking cues from the storyteller not apparent in a written story. Verbal stories also invite group discussion, as do stories that are open to inquiry before conclusions are drawn about its meaning. Interrupting the story before the lessons learned to allow such dialogue can be a powerful learning experience and result in innovative ideas for safety strategies. 

Organizational leaders that are visible in the retelling of stories, either as the teller or listener, can send a powerful message to staff about their commitment to patient safety.1 Good catch recognition by leaders during unit huddles or department meetings can be used as one facet of visible leadership storytelling. Planned focus group sessions facilitated by leaders offer another venue for leadership storytelling. 

Conclusion
As you reflect on the ways you might collect and share both external and internal organizational stories, keep in mind that it is through the telling of these stories that we will fully break the code of silence surrounding medical errors and make substantial headway on our journey to safer healthcare. As profoundly articulated by Donald Berwick when he was leading the Institute for Healthcare Improvement, “We need more firesides, not spreadsheets.”3 We urge you to find ways to utilize this largely untapped resource for meaningful dialogue and improvement.

Let the stories unfold…

References:

1) Institute for Healthcare Improvement. Embrace the power of storytelling. Accessed on June 30, 2011 at: www.ihi.org

2) Pitzer A. Statistics vs. storytelling: the grudge match? Nieman Storyboard. November 9, 2010.

3) Stone R. Storytelling: a powerful, unexpected ally in the fight to improve patient safety. Storytelling, Self, Society. 2006;2(2):68-86.

4) Gray JB. The power of storytelling: using narrative in the healthcare context. J Commun Healthcare. 2009;2(3):258-274.

5) Tyler JA. Storytelling and organizations: introduction to the special issue. Storytelling, Self, Society. 2006;2(2):1-4.

6) Kearns S. Storytelling in healthcare enhances experience for patients and providers. HealthLeaders Media. June 15, 2009.

7) Greene K, Brinn LS. Messages influencing college women’s tanning bed use: statistical versus narrative evidence format. J Health Commun. 2003; 8(5):443-61.

8) Brodie M, Foehr U, Rideout V, Baer N, et al. Communicating health information through the entertainment media. Health Affairs. 2001;20(1):192-199.

9) Campbell M, Carrico C, Moore CK, Palmer TL. Christiana Care Health System: safety mentoring program. In: Advances in Patient Safety: New Directions and Alternative Approaches. Eds: Henriksen K, Battles JV, Keyes MA, et al. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

10) Woodhouse J. Storytelling and narratives: sitting comfortably with learning. In: Strategies for Healthcare Education. Ed: Woodhouse J. Oxon, United Kingdom:Radcliffe Publishing Ltd; 2007:61-70.

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