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Patient stories project : a solution-based approach to decrease burnout in critical care Gurney, Lara Nicole 2019

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	 PATIENT	STORIES	PROJECT:	A	SOLUTION-BASED	APPROACH	TO	DECREASE	BURNOUT	IN	CRITICAL	CARE		by	LARA	NICOLE	GURNEY			A	THESIS	SUBMITTED	IN	PARTIAL	FULFILLMENT	OF	THE	REQUIREMENTS	FOR	THE	DEGREE	OF			Master	of	Science	in	Nursing	in	The	Faculty	of	Graduate	and	Postdoctoral	Studies				THE	UNIVERSITY	OF	BRITISH	COLUMBIA	(Vancouver)			 December	2019	©	Lara	Nicole	Gurney,	2019	 ii  The	following	individuals	certify	that	they	have	read,	and	recommend	to	the	Faculty	of	Graduate	and	Postdoctoral	Studies	for	acceptance,	a	thesis	entitled:		 Patient	Stories	Project:	a	solution-based	approach	to	decrease	burnout	in	critical	care			submitted	by	 Lara	Nicole	Gurney	 	 in	partial	fulfillment	of	the	requirements	for	the	degree	of	 Master	of	Science	In	 Nursing		Examining	Committee:	Dr.	Maura	MacPhee	Supervisor		Dr.	Paddy	Rodney		Supervisory	Committee	Member		Dr.	Fuchsia	Howard	Supervisory	Committee	Member	Dr.	Leanne	Currie	Additional	Examiner			        iii  Abstract		Problem:	Burnout	is	particularly	prevalent	among	nursing	staff	in	intensive	care	units	(ICUs),	and	it	is	associated	with	job	dissatisfaction,	staff	shortages,	and	high	turnover	rates	(Moss,	Good,	Gozal,	Kleinpell,	&	Sessler,	2016).	Burnout	is	also	related	to	negative	outcomes	associated	with	the	quality	and	safety	of	patient	care,	such	as	medical	errors,	decreased	patient	satisfaction,	and	higher	rates	of	health	care-associated	infections	(Moss	et	al.,	2016).	Nurse	burnout	is	a	significant	problem	in	high	intensity	environments,	such	as	ICUs.	Background:	One	potential	buffer	against	nurse	burnout	is	nurses’	awareness	of	the	value	of	what	they	do.	The	Patient	Stories	Project	(PSP)	was	initiated	to	share	patients’	stories	of	their	ICU	experience	with	those	nurses	who	cared	for	them.	Through	stories,	nurses	have	another	lens	to	appreciate	the	value	of	their	work	and	the	importance	of	nurse-patient	relationships.		Purpose:	The	purpose	of	this	study	was	to	explore	nurses’	perspectives	of	the	PSP.		Is	there	evidence	that	the	PSP	influences	nurses’	perceptions	of	the	value	of	nurse-patient	relationships?	Design	and	methods:	This	was	a	qualitative	descriptive	design.	Semi-structured	face-to-face	interviews	with	12	critical	care	nurses	were	conducted	between	June	2019-July	2019.	Thematic	analysis	was	used	to	code	data	from	the	focus	groups.		Results:	The	findings	from	this	study	demonstrate	that	story	telling	has	the	potential	to	give	meaning	to	nurses’	work.	The	PSP	provides	avenues	for	nurses	to	think	about	their	work	differently	and	positively.	Five	themes	emerged:	(a)	perspective	taking	(b)	recognizing	the	value	in	humanizing	care	(c)	cultivating	positive	closure	for	the	nurses	(d)	creating	a	sense	of	belonging	through	teamwork	(e)	creating	a	sense	of	hope.		Conclusion:	The	PSP	(patient	storytelling)	may	be	a	relational	strategy	to	protect	against	burnout	among	nurses.	Storytelling	may	also	have	the	capacity	to	go	beyond	the	ICU	environment	to	buffer	against	stress	among	healthcare	providers,	their	patients,	and	families	in	other	settings.					 iv  Lay	summary		This	study	was	motivated	by	personal	experiences	with	nurse	burnout	in	one	ICU	environment	in	lower	mainland	Vancouver.	As	an	ICU	practitioner	and	educator,	it	has	been	challenging	to	see	nurses’	investments	in	nurse-patient	relationships	go	unrewarded.	We	are	often	recognized	by	the	organization	and	colleagues	for	our	technical	proficiency.	In	reality,	what	matters	to	nurses	is	what	they	do	for	patients	and	their	families—relational	aspects	of	nurses’	work	that	far	exceed	tasks.			I	did	this	study	because	I	am	advocating	for	my	nursing	profession,	to	increase	the	visibility	and	value	of	what	we	do	as	nurses.	My	hope	is	that	raising	awareness	of	all	nurses	do,	nurses	will	value	their	professional	roles	and	be	less	susceptible	to	burnout.																				 v  Preface	This	dissertation	is	original,	unpublished,	independent	work	by	the	author,	L.	Gurney.			L.	Gurney	made	substantial	contributions	to	the	conception	and	design	of	the	study,	ethics	approvals,	acquisition	of	data,	analysis,	and	interpretation	of	data.	The	supervisor,	M.	MacPhee,	assisted	with	development	of	the	coding	framework	and	did	consistency	checks	on	10%	of	the	data.	The	committee,	M.	MacPhee,	F.	Howard	and	P.	Rodney,	assisted	with	manuscript	revisions.	All	authors	read	and	approved	the	final	manuscript.	 Ethics	approval	was	obtained	from	the	University	of	British	Columbia	(UBC)	research	ethics	board	(H19-00949)	and	Vancouver	Coastal	Health	(VCH)	certificate	of	operational	approval	(V19-00949).		 	                        vi  Table	of	contents	Abstract	 ……………………………………………………………………………………………………………	 iii	Lay	summary	 ……………………………………………………………………………………………………	 iv	Preface	 ………………………………………………………………………………………………………………	 v	Table	of	contents	 ……………………………………………………………………………………………….	 vi	List	of	tables	 ……………………………………………………………………………………………………	 viii	Acknowledgements	 …………………………………………………………………………………………...	 ix	Dedication	 ……………………………………………………………………………………………………….	 x		 	 	CHAPTER	ONE:	Main	Paper	 ………………………………………………………………………………	 1		 	 		 Introduction	 …………………………………………………………………………………	 1		 Background	 …………………………………………………………………………………...	 2		 Relational	practice	 ………………………………………………………………………...	 2		 Story	telling	 …………………………………………………………………………………...	 3		 Proposition	 …………………………………………………………………………………..	 3		 	 	 	CHAPTER	TWO:	The	Study	 …………………………………………………………………………………	 4		 	 		 Aims	 …………………………………………………………………………………………….	 4		 The	patient	stories	project	(PSP)	 …….……………………………………………..	 4		 Design	 …………………………………………………………………………………………...	 5		 Sample/	participants	 ……………………………………………………………………	 5		 Data	collection	 ………………………………………………………………………………	 5		 Ethical	considerations	 ……………………………………………………………………	 6		 Data	analysis	 …………………………………………………………………………………	 6		 Rigour	 …………………………………………………………………………………………...	 6		 	 	 	CHAPTER	THREE:	Findings	 ………………………………………………………………………………	 7		 	 	 		 Perspective	taking	 ………………………………………………………………………...	 7		 Recognizing	the	value	in	humanizing	care	 ……………………………………….	 8		 Cultivating	positive	closure	for	the	nurses	 ……………………………………….	 10		 Creating	a	sense	of	belonging	through	teamwork	 …………………………….	 11		 Creating	a	sense	of	hope	 ………………………………………………………………..	 12		 	 	 	CHAPTER	FOUR:	Discussion	 ………………………………………………………………………………	 13		 	 	 		 Limitations	 …………………………………………………………………………………...	 14		 	 	 	CHAPTER	FIVE:	Conclusion	 ………………………………………………………………………………	 15	 vii  	 	 	 		 Epilogue	 ……………………………………………………………………………………….	 15		 Conflicts	of	interest	 ………………………………………………………………………...	 15		 	 	 	References	 ………………………………………………………………………………………………………..	 16		                       viii  List	of	tables	Table	1	 PSP	questions	for	patients	and	families	………………………………………………………5	Table	2	 Focus	group	interview	guide………………………………………………………………………6	Table	3	 Themes	………………………………………………………………………………………………..…...7																						 ix  Acknowledgements	I	offer	my	enduring	gratitude	to	the	faculty	at	the	University	of	British	Columbia	and	my	work	colleagues,	who	have	inspired	me	to	continue	my	work	in	pursuit	of	creating	healthy	work	environments	and	increasing	the	visibility	of	nursing.	I	owe	particular	thanks	to	Dr.	M.	MacPhee,	whose	passion	in	leadership	has	taught	me	to	strive	for	change.				                    x  Dedication	To	nurses,	what	you	do	is	seen,	what	you	do	is	valued,	you	matter.		              1  CHAPTER	ONE		MAIN	PAPER		Introduction	The	intensive	care	environment	is	dynamic;	critical	care	nurses	are	continually	learning	and	mastering	advancements	in	medical	care	while	developing	relationships	with	patients	and	family.	Within	the	critical	care	team,	nurses	are	regularly	exposed	to	stressful	events,	such	as	death	and	trauma,	while	bearing	the	pressure	of	significant	responsibility	for	the	care	of	their	patients	and	patients'	families.	This	stress	and	pressure	are	then	compounded	by	the	high	incidence	of	ethical	challenges	encountered	within	critical	care,	including	provision	of	care	that	is	perceived	to	be	futile	or	uncertain	(Karanikola	&	Mpouzika,	2018).	Nurse-patient	interactions	are	impaired	by	patients’	inability	to	speak	due	to	artificial	airways	and	supportive	breathing	machines	(mechanical	ventilation).	Nurse-patient	interactions	may	be	further	impaired	during	critical	illness	by	sedation,	fatigue,	delirium,	or	neurological	disease	(Happ	et	al.,	2012).	While	caring	for	critically	ill	patients,	nurses	often	use	task-oriented	approaches	to	nursing	care	as	a	coping	mechanism	for	high	stress	situations	(McLean,	Coombs,	&	Gobbi,	2016).	A	predominant	focus	on	nursing	tasks	negatively	impacts	the	nurse-patient	relationship	(Doane	&	Varcoe,	2007).		The	complexity	of	nursing	in	an	intensive	care	unit	(ICU)	requires	optimal	nurse-patient	relationships	and	a	work	environment	that	fosters	relational	practice.	Multiple	workplace	stressors,	including	impediments	to	nurse-patient	relationships,	increase	risk	of	nursing	burnout.	Over	time,	burnout	manifests	as	emotional	and	cognitive	distancing	from	work	and	in	some	instances,	exit	from	the	job	and	from	nursing	(Haddad	&	Toney-Butler,	2018;	Maslach	&	Leiter,	2017).			Burnout	is	particularly	prevalent	among	nursing	staff	in	ICUs,	and	it	is	associated	with	job	dissatisfaction,	staff	shortages,	and	high	turnover	rates	(Moss	et	al.,	2016).	Burnout	is	also	associated	with	negative	outcomes	associated	with	the	quality	and	safety	of	patient	care,	such	as	medical	errors,	decreased	patient	satisfaction,	and	higher	rates	of	health	care-associated	infections	(Moss	et	al.,	2016).		To	raise	ICU	nurses’	awareness	of	nurse-patient	relationships	and	the	value	of	nurses’	work,	the	Patient	Stories	Project	(PSP)	was	initiated	by	nursing	staff	three	years	ago.	The	ultimate	goal	of	the	PSP	is	to	reduce	risk	of	burnout	among	nurses.		On	a	regular	basis,	former	ICU	patients	return	to	the	ICU	to	say,	‘thank	you,’	share	their	experiences,	and	tell	their	stories	to	staff.	The	PSP	has	created	a	systematic	process	for	collecting	and	sharing	former	patients’	stories.	When	former	patients	voluntarily	return	to	the	ICU,	nursing	staff	give	them	an	organizational	consent	form	with	a	description	of	the	project	and	a	request	to	answer	and	complete	a	set	of	questions	about	their	ICU	experiences.	Their	returned	 2  answers	are	displayed	for	staff	on	a	dedicated	PSP	bulletin	board.	The	PSP	has	grown	in	popularity,	particularly	among	the	ICU	nurses.	The	purpose	of	this	qualitative	descriptive	study	is	to	determine	the	relevance	of	the	PSP	to	nurses.		Background		The	growing	critical	care	nursing	shortage	is	associated	with	burnout	and	subsequent	high	turnover	rates	that	negatively	impact	ICU	healthcare	teams	and	patient	care	delivery	(Poncet	et	al.,	2007).	Work	environments	with	excessive	turnover	rates	foster	decreased	productivity,	poor	unit	morale,	and	increased	absenteeism	(Moss	et	al.,	2016).	Work	environments	that	do	not	recognize	the	human	side	of	work	propagate	nurses’	vulnerability	to	burnout	(Maslach	&	Leiter,	2016).		Burnout	manifests	in	nurses	with	feelings	of	overwhelming	exhaustion,	cynicism	with	detachment	from	the	job,	depersonalization	of	patients,	and	devaluing	of	the	work	and	the	nurse-patient	relationship	(Maslach	&	Leiter,	2017).	Critical	care	units	have	higher	turnover	rates	compared	to	other	nursing	units	(Demery	Varin	et	al.,	2018).	Approximately	25-33%	of	critical	care	nurses	manifest	symptoms	consistent	with	burnout,	and	up	to	86%	of	critical	care	nurses	experience	one	of	the	three	typical	symptoms	(Moss	et	al.,	2016).	From	a	relational	practice	perspective,	the	presence	of	burnout	signals	disruption	of	the	nurse-patient	relationship.		Relational	practice		Relational	practice	is	not	new	to	nursing.	It	is	at	the	core	of	nursing	values	(Doane	&	Varcoe,	2007)	and	it	is	a	fundamental	component	of	the	nurse-patient	relationship	(Feo	&	Kitson,	2016).	Relational	practice	is	thoughtful	care,	where	the	nurse	considers	the	uniqueness	of	the	patient,	the	environment,	and	contextual	factors	each	time	care	is	provided	(Doane	&	Varcoe,	2007).		Relational	practice	is	associated	with	enhanced	nurse-patient	relationships	that	positively	impact	patients’	healing	and	recovery	(Feo	&	Kitson,	2016).			Khan	et	al	(2018)	reviewed	the	literature	for	factors	influencing	nurses’	intentions	to	leave	adult	ICUs.	High	levels	of	nursing	stress	were	associated	with	insufficient	time	to	provide	care	for	patients	and	their	families	in	critical	care	settings,	indicating	an	association	between	relational	practice	and	nurse	retention	in	ICUs	(Khan,	Jackson,	Stayt,	&	Walthall,	2019).	The	culture	of	ICUs	poses	additional	threats	to	the	nurse-patient	relationship.	In	high	acuity,	high	technology	settings,	such	as	ICUs,	diagnosis	and	cure	often	overshadow	relational	care	(Feo	&	Kitson,	2016).	Organizations	that	recognize	and	value	relational	aspects	of	nursing	practice	foreground	its	significance	and	make	visible	the	value	of	nurses’	work,	resulting	in	nurses’	self-reports	of	increased	job	satisfaction,	organizational	commitment	and	workplace	engagement,	and	decreased	turnover	intentions	(Keyko,	2014).		 3  Story	telling		Patient	stories	highlight	nurses’	relational	connections	to	their	patients	from	the	patient	perspective.	“Public	narrative,”	created	by	Marshall	Ganz,	is	a	story-telling	approach	that	taps	individuals’	values	and	intrinsic	motivations	and	enhances	social	bonds	(Hilton	&	Anderson,	2018;	Odugbemi,	Lee,	&	Ganz,	2014).	Ganz’s	public	narrative	includes	three	foundational	elements:	a	story	of	self,	a	story	of	us,	and	a	story	of	now	(Odugbemi	et	al.,	2014).	As	a	patient	tells	their	story,	a	“story	of	self,”	nurses	see	themselves	from	the	patient’s	perspective,	and	a	“story	of	us”	begins	to	form	among	those	nurses	who	cared	for	that	patient.	The	story	of	us	represents	a	collective	identity	of	nurses’	importance	to	that	patient	and	their	family.	A	story	of	us	can	be	inspirational	and	empowering,	creating	a	new	and	hopeful	“story	of	now”	for	those	nurses	(Odugbemi	et	al.,	2014).	Patient	stories	have	the	potential	to	raise	nurses’	awareness	of	the	unique	and	valued	nature	of	their	work,	and	remind	them	that	they	make	a	significant	difference	to	patients	and	families	(Hilton	&	Anderson,	2018;	Odugbemi	et	al.,	2014)	Proposition		The	underlying	theoretical	proposition	of	this	study	is	that	burnout	in	critical	care	nurses	can	be	addressed	through	patient	stories.	Patient	stories	give	relevance	and	value	to	nurse’s	work,	decreasing	burnout	and	creating	a	powerful	“story	of	us.”									 4  CHAPTER	2	THE	STUDY	Aims	The	aim	of	this	qualitative	study	was	to	explore	the	use	of	storytelling	through	the	PSP	to	influence	nurses’	perceptions	of	the	value	of	their	work.		Nurses	familiar	with	the	PSP	were	interviewed	for	this	study.	Patients,	families,	and	their	PSP	stories	were	not	a	part	of	this	study.			The	patient	stories	project	(PSP)	Patients	and	families	occasionally	return	to	the	ICU	to	visit	staff	before	returning	home	or	after	being	discharged	from	an	inpatient	or	rehabilitation	facility.		During	their	visits,	they	typically	share	their	recollections	of	being	in	the	ICU,	and	they	express	their	appreciation	to	the	healthcare	team,	particularly	the	nurses	who	cared	for	them	over	extended	periods	of	time.	Given	the	power	of	patients’	visits	and	interactions	with	staff,	a	systematic	process	was	created	for	garnering	and	for	sharing	patients’	stories	with	the	ICU	team.	Storytelling,	which	is	fundamentally	relational,	was	utilized	as	the	approach	to	share	patients’	stories	within	the	ICU.			To	collect	patient	stories,	a	letter	was	developed	with	support	from	the	healthcare	organization’s	public	relations	officer,	the	ICU	clinical	nurse	specialist,	and	the	social	worker.	The	PSP	letter	asks	patients	and	families	to	answer	five	questions	about	themselves	and	their	return	to	life	outside	the	hospital.	Table	1	contains	the	five	PSP	questions.		The	ICU	staff	often	lose	contact	with	patients	and	families	after	transfer	from	the	ICU.	The	PSP	consent	form	and	questions	are	only	given	to	those	patients	and	families	who	return	to	the	ICU	voluntarily.	When	patients	and/or	families	return,	staff	explain	the	PSP	to	them.	Patients	and	families	are	asked	to	take	the	organizational	consent	form	home,	to	consider	the	questions,	and	to	complete	and	return	their	‘stories’	at	their	convenience	by	mail,	email,	or	in	person.	The	project	was	initiated	in	2016	and	approximately	one	story	is	returned	every	six	months.		The	five	questions	patients	and	families	completed	and	returned	to	the	ICU	are	listed	in	table	1.					 5  TABLE	1	PSP	questions	for	patients	and	families		Q1					What	brought	you	to	the	Intensive	Care	Unit	(ICU)?		Q2					What	is	life	for	you	like	today?		Q3					What	would	you	or	your	loved	ones	want	to	say	to	the	ICU?		Q4					What	do	you	or	your	loved	ones	want	the	ICU	to	know	about	you?		Q5					Do	you	have	a	favorite	quote	or	words	to	live	by?			When	a	story	has	been	returned	to	the	ICU,	the	story	and	any	accompanying	pictures	and	messages	are	displayed	on	a	PSP	bulletin	board	where	all	team	members	have	access	to	these	stories.		Four	stories	are	displayed	at	a	time,	and	stories	are	routinely	rotated	on	the	board.	All	stories	are	eventually	stored	in	a	binder	in	the	team	lounge.		Design	The	study	used	a	qualitative	descriptive	design	to	explore	the	use	of	storytelling	to	understand	nurses’	perceptions	of	the	value	of	their	work	in	ICU.	This	qualitative	research	method	aims	to	illuminate	the	particulars	of	human	experience	by	identifying	patterns	of	meaning	that	emerge	from	the	data	(Lioness,	Kavanaugh,	&	Knafl,	2003).	Thematic	analysis	was	used	to	systematically	identify	and	explored	themes	brought	forth	by	critical	care	nurses	in	focus	group	interviews	(Clarke	&	Braun,	2017).	Sample/participants	The	setting	of	the	study	was	a	34-bed	closed	adult	ICU	in	a	tertiary	care	teaching	hospital,	serving	a	mixed	medical	and	surgical	patient	population	and	employing	over	200	nurses.	The	study	utilized	a	convenience	sample	of	critical	care	nurses.	After	obtaining	institutional	ethics	approval,	this	study	was	advertised	via	poster	in	the	ICU	nurses’	lounge	and	study	emails	to	nurses’	work	email	accounts.	Snowballing	was	used	to	obtain	additional	recruits	(Polit	&	Beck,	2017).		To	be	included	in	this	study	critical	care	nurses	had	to	have	had	a	minimum	of	one	year	of	experience	in	the	ICU	and	had	participated	in	the	PSP.		Twelve	critical	care	nurses	were	recruited.		Data	collection	Data	was	collected	through	three	one-hour	long	focus	group	interviews	conducted	over	a	two-month	period	between	June	and	July	2019.	Data	collection	methods	included	semi- 6  structured	interview	questions	(Table	2).		Interviews	were	audiotaped	and	professionally	transcribed	verbatim.	Nurses,	health	care	staff,	patients,	and	families	were	de-identified.	TABLE	2	Focus	group	interview	guide		Q1					What	did	you	think	about	the	Patient	Stories	Project	(PSP)	when	it	was	introduced														in	the	Intensive	Care	Unit	(ICU)?		Q2					Tell	me	about	the	feelings	and	experiences	you’ve	had	by	hearing	patients’	stories.			Q3					How	has	the	PSP	influenced	your	work	in	the	ICU?			Q4					Would	the	PSP	be	useful	to	nurses	in	other	practice	areas?	Why	or	why	not?		Q5					Anything	you	would	like	to	share	about	the	PSP	that	has	not	been	said?				Ethical	considerations	 	The	study	was	approved	by	the	institutional	ethics	review	board	of	the	hospital	(V19-00949)	and	the	university	(H19-00949).	Data	was	stored	in	an	encrypted,	password-protected	university	workspace.		Data	analysis	Data	was	managed	with	NVivo	12.		The	transcripts	were	inductively	coded	for	key	words	and	phrases,	and	a	coding	framework	of	thematic	ideas	was	created.	The	coding	framework	was	used	to	organize	and	re-organize	the	themes	and	their	exemplar	quotes	(Polit	&	Beck,	2017).		Rigour	Trustworthiness	was	established	by	utilizing	Lincoln	and	Guba’s	(1985)	conceptual	framework.	NVivo	12	was	used	to	establish	clear,	logical	links	between	the	data,	codes,	and	themes.	Credibility	and	authenticity	were	achieved	by	linking	quotes	from	study	participants	to	themes,	which	were	derived	by	interpretations	of	the	data	and	constantly	moving	back	and	forth	between	the	entire	data	set	and	specific	exemplars	(Clarke	&	Braun,	2017).	Reliability	was	achieved	with	consistency	checks	on	all	the	transcripts	by	a	second	independent	coder.		Reflexive	journal	notes	were	used	throughout	coding	and	analysis	to	account	for	biases	and	highlight	important	patterns	emerging	in	the	data	(Polit	&	Beck,	2017).			 7  CHAPTER	3	FINDINGS	The	study	participants	ranged	in	age	from	32	to	47	years.	They	were	all	registered	nurses	(RNs),	females,	and	full-time	employees.		The	five	key	themes	for	questions	1-3	are	in	table	3.	These	questions	were	the	primary	questions	used	for	all	the	focus	group	participants.	The	other	two	questions	pertained	to	recommendations	for	using	the	PSP	in	other	areas	besides	the	ICU	and	additional	comments.		TABLE	3	Themes		Perspective	taking	Recognizing	the	value	of	humanizing	care		Cultivating	positive	closure	for	the	nurses		Creating	a	sense	of	belonging	through	teamwork		Creating	a	sense	of	hope		Perspective-taking	Storytelling	begins	with	perspective-taking.	When	a	patient	shares	their	personal	“story	of	self,”	nurses	have	opportunities	to	see	themselves	from	the	patient’s	perspective.		Through	storytelling,	nurses	see	patients	as	people	with	family,	friends,	colleagues,	and	a	life	outside	what	happened	to	them	in	the	ICU.	The	patient	is	no	longer	a	statistic	or	number.	Perspective-taking	is	foundational	to	relational	practice.	In	this	study,	perspective-taking	was	represented	by	nurses’	self-reflections	about	their	biases,	decisions,	and	behaviors.	The	nurses	recounted	several	occasions	where	they	could	not	believe	that	a	patient	had	survived	a	critical	illness.	The	patient’s	story	helped	them	self-reflect	on	preconceptions	they	had	about	the	patient	and	anticipated	outcomes.		One	nurse	shared	their	self-reflections:	This	person’s	going	to,	you	know,	be	in	a	persistent	vegetative	state	or	whatever.	Like,	what’s	the	point?	We’re	not	helping	them.	So	when	you	see	someone	who	initially	had	that	type	of	prognosis	go	home	and	have,	you	know,	a	good	quality	of	life,	I	think	it	kind	of	brings	the	focus	around	and	helps	with	that	sort	of	burnt	(sic)	out,	jaded	tone	that	happens	when	you’re	really,	really	overworked.	FG	2		We	have	our	biases	of,	like,	I	would	never	want	to	live	if	I	was	this	way.	But	then	you	ask	them,	and	they	might	not	be	perfect	or	the	way	they	were	pre-ICU,	but	they	find	a	new	version	of	what	is	good	for	them.	FG	1		 8  Personal	stories	in	the	patient’s	words	were	of	high	value	to	the	nurses.	Critical	care	teams	are	provided	with	numbers	and	statistics	of	how	the	unit	is	performing.	Teams	base	their	performance	on	measurable	indicators	such	as	readmission	rates,	deaths,	and	infection	rates.	These	measurements	do	not	reflect	relational	aspects	of	the	thoughtful	care	and	time	that	nurses	devote	to	patient	care.		When	nurse-patient	relationships	are	not	seen	as	an	important	indicator	to	overall	unit	performance,	nurses	are	at	risk	of	burning	out.	Patient	stories	foster	relational	connectedness	and	are	a	relational	indicator	of	the	value	of	nurses’	work.		 I	don’t	connect	with	statistics,	I	connect	with	stories,	I	connect	with	people.	I	think.	As	I	get	older	in	my	life	and	my	nursing	career,	I’m	looking	for	more	stories	and	connection,	like	human	connection.	I	identify	more	with	–	I	find	the	Patient	Stories	Project	more	meaningful	than	statistics.	FG	3		There’s	nothing	like	seeing	somebody	come	back	that	you	advocated	with	withdrawal	[of	care]	on.	FG	1		It	definitely	changed	my	biases	to	how	quickly	I’m	judgmental	in	saying,	‘What	are	we	doing	here?	Like,	we’re	just	torturing	the	patient.’	But	hearing	him	say	that	has	changed	me.	In	certain	circumstances,	I’m	like,	you	know	what?	We	don’t	know.	We’re	not	god,	we	don’t	know	the	result,	we	can’t	control	everything,	so	maybe	they	will	make	it	and	be	happy	with	the	decision	their	family	or	loved	ones	made	for	them.	FG	1	Our	stats	are	kind	of	different	from	what	we	feel,	yet	if	you	look	at	the	stories,	they’re	all	young,	and	they’re	all	survivors.	Our	mean	age	is	40,	our	mortality	is	the	lowest	in	the	nation,	and	yet	what	we	do	is—what	we	think	is	they’re	all	old	and	they’re	all	dead.	FG	1		The	nurses	described	how	seeing	outcomes	through	the	patient/family	lens	made	them	less	skeptical	and	more	trusting	of	the	family’s	decisions.				And	I	think	that’s	made	my	job	to	nurse	in	a	critical	care	area	like	this	easier	because	now	I	know	I’m	not	making	these	decisions;	the	physicians	aren’t	making	these	decisions.	We’re	making	these	decisions	with	the	family,	and	the	family	is	95	percent	of	the	time	the	best	person	to	make	that	decision	in	a	safe	environment.	FG	1			Recognizing	the	value	in	humanizing	care		Perspective-taking,	through	the	patient’s	story	of	self,	humanizes	nursing	care	and	facilitates	nurses’	capacity	to	recognize	the	value	of	relational	practice.		In	this	study,	the	story	of	“us”	evolved	as	nurses	highlighted	their	capacity	to	develop	therapeutic	 9  professional	relationships	with	their	patients	and	families.	They	emphasized	how	the	relational	aspects	of	care	meant	more	to	patients	and	families	than	technical	proficiency.			One	nurse	said:	I	do	find	that	that’s	the	one	thing	that	always	shine	bright	for	me	through	the	stories,	is	that	it’s	the	work	and	it’s	the	compassion	and	the	empathy	of	the	people	involved	that	saves	people,	not	the	medicines	and	not	the	technology.	FG	1		Other	focus	group	participants	shared:	With	some	of	the	stories,	like,	they	remember	the	smallest	things,	like,	‘So-and-so	rubbed	my	feet,’	or	whatever,	and	it	makes	you.	You	know	what?	Like,	that—or,	‘They	washed	my	hair,’	they	didn’t	remember	who	did	the	best	CPR.	FG	2		It’s	very,	very	easy	to	distance	ourselves	when	we’re	caring	for	patients.	They	don’t—they’re	not	acting	like	their	normal	selves;	they’re	not	dressed	like	their	normal	selves.	And	that	does	damage	to	ourselves	as	caregivers.	You	know,	it’s	sort	of…	compassion	fatigue,	burnout	and	all	the	other	ills	that	come	along	with	critical	care	practice.	And	so,	I	think	that	talking	about	patients	in	the	context	of	their	life	following	the	ICU	matters.	FG	1		The	“story	of	us”	represents	the	close	connections	that	nurses	forge	with	their	patients	and	families	in	the	ICU.	Nurses	listen	and	advocate	for	them	throughout	the	entire	ICU	admission.	With	each	visit	from	the	doctor,	specialist,	or	member	of	the	health	care	team	(i.e.	pharmacist,	physiotherapist)	they	ensure	the	care	wishes	of	the	patients	and	their	families	are	represented.		Critical	care	nurses	develop	these	relationships	as	a	result	of	being	assigned	to	a	patient	with	in	a	1:1	ratio	on	each	of	their	shifts,	thereby	being	present	at	one	bedside	for	12	hours.		You	invest	so	much.	You	go	to	your	job	and	you’re	going	to	spend	more	than	12	hours	knowing	every	detail	of	this	person’s	body	and	advocating	for	them	and	going	up	to	battle	for	them.	FG	1		In	complex	high	stress	work	environments,	the	nurse-patient	relationship	is	repeatedly	compromised	by	operational	and	structural	demands	of	the	unit	and	hospital.	Consequently,	task-oriented	activities	overshadow	the	development	of	the	nurse-patient	relationship	and	the	“story	of	us”.		As	technology	advances,	more	critical	thinking	and	knowledge	are	required	to	manage	advanced	equipment	for	specialized	populations.	Nurses	and	teams	shift	their	focus	to	elaborate	lifesaving	equipment.		Through	the	patients’	stories,	nurses	acknowledged	how	relational	care	is	what	matters	the	most.		 10  I	think	the	one	thing	that	Patient	Stories	shows	quite	clearly	is	that	it’s	not	technology	that	saves	people’s	lives.	FG	1		And	you	know,	people	actually	do	get	better,	it’s	nice	to	be	able	to	actually	show	new	practitioners	that	are	coming	in	that,	like,	hey,	so	we	acknowledge	that	moral	distress,	moral	residue,	like,	bad	things	are	going	to	happen	in	the	ICU.	It	is	what	it	is.	Mortality	rates	are	high.	That’s	the	nature	of	the	work	you’re	going	to.	However,	there	is	also	an	opportunity	to	really	change	people’s	lives	for	the	better.	They	can	survive,	and	you—we	do	good	things,	despite	how	it	feels	sometimes.	FG	1		Because	the	PSP	submissions	included	pictures,	the	focus	group	participants	described	how	they	were	influenced	by	photographs	of	PSP	patients	attending	university	classes,	graduating	from	high	school,	or	participating	in	sporting	activities	or	travel.	These	displays	provided	the	visual	evidence	of	patients	going	on	with	their	lives	post-ICU.				 [We	see]	lives	of	normalcy	and	“doing	things	that	make	them	happy.	FG	1	Cultivating	positive	closure	for	the	nurses	Positive	closure	is	a	third	theme	related	to	the	story	of	us.		Patients’	stories	provide	positive	closure	for	nurses’	work	and	shift	nurses’	mindsets	from	the	grief	and	uncertainty	to	value	and	purpose.	This	shift	represents	relational	connectedness	and	further	development	of	the	story	of	us.		After	patients	are	discharged	from	the	ICU,	they	fade	from	the	ICU	team	memory.	The	patient’s	care	space	is	cleaned	and	readied,	and	a	flurry	of	activity	ensues	as	a	new	patient	arrives	requiring	lifesaving	measures.	“We’re	so	focused	on	tasks	and	getting	everything	done	(FG1)”.	This	quick	turnaround	allows	no	time	for	nurses	to	pause	and	reflect.	Lack	of	processing	time	can	result	in	feelings	of	emptiness	from	not	knowing	if	the	patient	survived	the	rest	of	their	hospital	journey.	Focus	group	participants	shared	how	they	“lost	sight”	(FG1)	amongst	their	task-oriented	shifts.	It	was	validating.		So,	it	was	nice	to	have	that	closed	loop	feedback	with	that	patient	even,	like,	a	month	after	that	happened.	I	feel	like	this,	the	Patient	Stories	really,	we	can	learn	as	nurses,	we	can	learn	from	our	patients	a	lot.	FG	1			And	then	when	you	have	a	Patient	Story	or	someone	who	comes	in	the	unit,	and	words	spreads	like	fire,	and	then	you’re	sitting	in	that	staffroom,	and	the	morale	completely	changes	and	everybody’s	more	lighthearted	and	you’re	talking	about	the	positive	things,	and	you	kind	of	sometimes	just	fog	out	all	the	crap	that	you’re	dealing	with	during	your	shift	and	just	focus	on	that.	And	I	find	it,	like,	it	carries	through	the	hospital.	FG	1		 11  So,	everybody’s	invested,	and	they	themselves	were	like,	you	know,	we	don’t	think	he’s	going	to	make	it.	But	he	did	so	well,	so	well,	and	I	think	it	makes	it	worthwhile	for	everybody,	so	every	team	member,	I	think,	gets	positively	influenced	by	these.	FG	1			It’s	like	a	very	visual	reminder,	for	me	anyway,	that	we	do	good	work	here,	regardless	of	how	we	feel	sometimes	when	we	go	home,	or	you	know,	the	moral	distress	that	we	feel,	the	compassion	fatigue	that	we	feel,	we	do	good	work,	and	people	do	get	better	after	that.	FG	3		I	would	say	the	more	frequently	that	we	see	it,	you	know,	it	takes	time	to	change	behavior	or	way	of	thinking,	and	so—and	it	has	to	be—it	has	to	be	a	culture	in	the	ICU	too	where	we’re	helping	each	other	to	be	a	little	bit	more	positive,	I	think,	by—you	know,	that’s	why	I	think	it’s	important	we	see	the	Patient	Stories.	We	sort	of	share,	like—it’s	like	often	in	the	break	room,	someone	will	say,	‘Hey,	did	you	see	such-and-such	came	through?’	you	know,	‘and	they’re	doing	really	great,’	and	so	that	idea	to	help	as	a	group	be	more	positive.	FG	3		And	just	the	fact	that	you	have	to	stop	in	your	day	to	read	it,	so	that	is,	like,	you’re	taking	time,	you’ve	slowed	down,	and	now	you’re	just	reflecting	on	this	patient’s	experience	and	maybe	your	experience	with	them	is,	like,	a	good	break	in	the	day.	FG	1		Creating	a	sense	of	belonging	through	teamwork		The	“story	of	now”	is	the	new	story	that	nurses	construct	about	themselves	and	their	work.	This	theme	captures	nurses’	descriptions	of	how	PSP	made	them	feel	part	of	a	team:	sharing	in	similar	experiences	and	working	together	on	behalf	of	patients.		It’s	just	like,	wow,	we	are	awesome.	And	it	gave	me	that	sense	of,	like,	belonging.				FG	1		Like,	she	did	so	well.	I	mean,	it	took	a	lot	of	work	from	a	lot	of	people.	So	I	get	overwhelmed	by	it	because	I’m	so	proud	of	the	work	that	we	do	here	as	a	team,	and	I	don’t	think	we	acknowledge	it	or	give	ourselves	credit	for	that,	and	I	think	that	the	patient—like,	the—they	let	us	know.	FG	3		I	think	the	Patient	Stories	Project	and—is	an	opportunity	for	that,	for	team	building	through	shared	experience—and	that’s	the	storytelling	thing,	no	doubt,	is	that	you	know,	like,	that’s	how	you	build	group	identity,	is	like,	okay,	well,	we’re	the	group	that	does	this.	It’s	like	this	shared	experience,	and	being	able	to	reflect	on	shared	experience,	which	is	how	you	bring—you	know,	build	team	cohesiveness.	FG	3		 12  One	thing	I	really	appreciated	was	it	[the	PSP]	gave	me	pride	back	and	made	me	really	proud	of	the	unit,	and	my	colleagues,	specifically	nursing.	FG	1	What	the	patient	stories	did	was	it	just	gave	me	a	sense	of	pride,	of	being	from	this	unit	and	working	with	the	nurses	that	I	work	with,	because	almost	every	patient	talked	about	the	nursing.	FG	1		In	the	ICU	environment	nurses’	contributions	to	the	team	can	be	overshadowed	by	the	physicians,	specialists,	and	technology.	The	participants	expressed	dismay	or	a	feeling	of	being	left	out	when	their	work	was	devalued	or	unrecognized.		The	PSP	made	nursing	work	visible,	and	validated	they	were	contributing	members	of	the	team.	Nurses	expressed:	Patient	Stories	is	something	that	can	be	incorporated	into	the	daily	work	life,	I	feel	like	that’ll	help	retention,	right,	because	it’ll	encourage	that	debrief,	it’ll	encourage	that	conversation,	it’ll	encourage	the	acknowledgement	of	the	team,	not	just	the	one	physician.	FG	1			Creating	a	sense	of	hope		“Story	of	now”	includes	nurses’	capacity	to	convey	hope	to	others,	in	addition	to	themselves.	Creating	a	sense	of	hope	represents	a	state	of	mind	that	allows	nurses	to	stay	relationally	connected	to	their	patients	and	shift	their	perspective	from	the	impossible	to	the	possible.	It	is	this	hope	that	creates	a	new	story	for	nurses:	Nurses	can	draw	on	these	hopeful	stories	that	raise	awareness	of	the	unique	and	valued	nature	of	their	work.			All	the	nurses	gave	examples	of	how	they	witness	stressful	situations,	death,	and	frequent	delivery	of	invasive	interventions	in	futile	care	situations.	The	nurses	acknowledged	how	they	often	use	detachment,	distancing,	and	task-based	care	to	cope.		They	described	how	the	impact	of	the	PSP	stories	on	them	has	shifted	their	mindsets	and	inspired	them	to	give	hope	to	current	patients	and	families	in	their	care.		I	am	so	much	more,	like,	I’ll	tell	parents,	like,	‘Don’t	give	up	hope.’	FG	2		Mindset	is	so	much	of	it,	and	I	think	that	that’s	the	biggest	change	in	how	I	felt	about	it,	is	when	people	would	come	in	and	be	super	optimistic	about	their	family,	I’d	be	like,	‘Oh,	like,	you	need	to	be	realistic,’	whereas	now	I’m	like,	‘No,	you	need	to—you	don’t	give	up.’	FG	2		And	I	think	it	gives	us	an	opportunity	to	acknowledge	that	side	of	our	work,	about	the	hope	that	we	want	to	maintain.	FG	3			 13  CHAPTER	4	DISCUSSION		In	hectic	work	environments,	storytelling	has	the	potential	to	give	meaning	to	nurses’	work	and	provide	avenues	for	nurses	to	think	about	their	work	differently	and	positively.	Customary	interventions	to	address	burnout	focus	on	work	environment	factors,	such	as	workload	management	and	adequate	staffing	(O’Brien-Pallas,	Murphy,	Shamian,	Li,	&	Hayes,	2010).		This	study	used	a	relational	approach,	patient	storytelling,	to	strengthen	nurse-patient	relationships	and	hopefully	counteract	burnout	among	nurses	and	the	ICU	team.	The	identified	themes	shape	the	“story	of	self”,	the	“story	of	us”,	and	the	hopeful	“story	of	now.”		We	do	not	know	if	the	PSP	will	decrease	burnout	in	complex	ICU	environments.	We	have	qualitative	evidence	from	this	study,	however,	that	the	relational	aspects	of	nurses’	work	matter	to	patients,	and	their	stories	give	value	to	the	work	nurses	do.		Patient	stories	may	be	a	buffer	against	burnout.		Although	the	themes	were	inductively	created	in	this	study,	they	complement	Ganz’s	three	phases	of	storytelling	(2011).	The	story	begins	with	the	patient’s	“story	of	self”.		The	PSP	encourages	patients	and	families	to	tell	their	story	in	their	own	words	so	that	nurses	are	not	left	wondering	if	their	work	has	value	(Odugbemi	et	al.,	2014).	In	this	study,	the	perspective-taking	theme	represents	how	the	nurses	saw	themselves	and	their	care	through	the	experiences	of	patients	and	their	families.		Perspective-taking	is	necessary	to	close	an	‘us-them’	gap	that	results	in	distancing	and	de-valuing.	Through	perspective-taking,	individuals	become	more	aware	of	their	judgements,	stereotypes,	and	behaviours	that	distance	them	from	others	(Galinsky,	Ku,	&	Wang,	2005).		Cynicism,	a	type	of	burnout,	is	exhibited	as	patient	detachment.		Nurses	in	this	study	described	how	they	were	cynical,	detached,	and	focused	on	technical	aspects	of	their	work.	By	imagining	themselves	from	the	patient’s	vantage	point,	nurses	began	to	recognize	the	value-laden	importance	of	their	work.		The	“story	of	us”	is	forged	through	the	two	themes	of	humanizing	care	and	positive	closure.	According	to	Ganz	(2011),	the	“story	of	us”	represents	a	shift	in	people’s	identity	of	who	they	are	and	what	they	value	about	themselves.	The	“story	of	us”	contains	those	values	that	connect	individuals	to	others	with	similar	values.	In	this	study,	the	‘values’	that	shifted	nurses’	perspectives	about	their	work	were	the	capacity	to	acknowledge	the	importance	of	the	relational,	humanizing	aspects	of	their	work	(versus	the	technical),	and	their	capacity	to	gain	positive	closure	after	caring	and	advocating	under	stressful	and	morally	challenging	circumstances	for	patients	and	their	families.			 14  What	emerged	is	the	“story	of	now”.	Nurses	described	their	pride	in	their	team	and	their	desire	to	share	their	hope	and	inspiration	with	other	patients	and	families.	“A	story	of	now	communicates	the	urgent	challenge	to	those	values	that	demand	action	now”	(Odugbemi	et	al.,	2014,	p.282).	Teamwork	has	been	identified	in	the	literature	as	a	contributing	factor	for	job	satisfaction	and	retention	among	critical	care	nurses,	positively	impacting	nurse	health	and	well-being	(Demery	Varin	et	al.,	2018).	Leveraging	the	potential	benefits	of	teamwork	in	the	ICU	has	the	capacity	to	reduce	levels	of	burnout	among	nurses	and	build	a	healthy	work	environment	(Khan	et	al.,	2019).			Creating	a	sense	of	hope	can	also	positively	influence	nurses’	perceptions	of	the	value	of	their	care.	Hope	is	a	state	of	mind	that	protects	nurses	against	burnout	and	fuels	work	satisfaction	by	reducing	the	nurse’s	vulnerability	to	emotional	exhaustion	(Rushton,	Batcheller,	Schroeder,	&	Donohue,	2015)	.	Hope	can	nurture	resiliency	by	allowing	the	nurse	to	adopt	an	alternative	way	of	thinking	during	task	based	stressful	situations	which	negatively	impact	the	nurse-patient	relationship	(Rushton	et	al.,	2015).		Patient	stories	foreground	a	set	of	values	that	matter	to	nurses	and	the	work	they	do.		By	reading	these	stories	and	reflecting	upon	them	individually	and	collectively,	the	PSP	has	the	capacity	to	improve	the	quality	of	working	relationships	from	those	who	are	sharing	in	similar	experiences	and	acting	together	on	behalf	of	a	shared	calling,	ultimately	decreasing	the	threat	of	burnout	(Keyko,	2014;	Odugbemi	et	al.,	2014).	The	PSP	has	grown	in	popularity	within	its	home	institution.	Nurses	in	other	departments,	such	as	the	emergency	department	and	medical-surgical	units,	have	initiated	their	own	versions	of	the	PSP.	Executive	leadership	is	promoting	this	intervention	as	a	strategy	to	promote	psychological	health	and	well-being	in	the	workplace.	In	addition,	there	is	potential	for	the	PSP	to	become	a	strategy	to	support	patients	and	families	during	their	recovery	journey	after	critical	illness	and	trauma.		Post-traumatic	stress	disorder	is	a	common	consequence	for	patients	who	have	spent	time	in	critical	care	settings	(Egerod,	Christensen,	Schwartz-Nielsen,	&	Ågård,	2011).	The	PSP	offers	the	unique	ability	for	patients	to	share	their	narrative	after	critical	illness.	A	body	of	literature	suggests	that	the	process	of	constructing	and	telling	stories	may	be	a	means	to	help	patients	recover	psychologically	after	intensive	care	(Williams,	2009).		Limitations	A	limitation	is	the	small	sample	size	of	this	study,	although	there	was	high	agreement	across	focus	groups	with	respect	to	themes.	This	research	should	be	extended	to	interdisciplinary	ICU	teams,	patients,	and	their	families	to	gain	other	perspectives	on	the	PSP.		 15  CONCLUSION	This	study	is	one	answer	in	the	“call	to	action”	to	create	a	healthy	work	environment	for	potentially	all	members	of	ICU	teams	at	risk	of	burnout	(Moss	et	al.,	2016).	Focus	group	participants	demonstrated	how	the	PSP	can	augment	the	relational	aspects	of	work	that	are	important	to	nurses	and	to	their	patients	and	families.	Storytelling	may	be	a	relational	strategy	to	protect	against	cynicism,	depersonalization,	and	turnover	among	nurses	who	work	in	highly	complex	and	ethically	challenging	ICU	settings.	Storytelling	may	also	have	the	capacity	to	go	beyond	the	ICU	environment	to	buffer	against	stress	and	trauma	among	healthcare	providers,	their	patients,	and	families	in	other	settings.		Epilogue		Conversations	and	operational	planning	have	ensued	with	the	associate	vice	president	of	medicine,	quality	and	safety,	professional	practice	and	communications	directors	to	further	share	and	implement	the	PSP	within	the	organization	and	produce	an	online	version	for	staff	and	public.	Conflicts	of	interest	No	conflicts	of	interest	have	been	declared	by	the	author(s).													 16  References	Clarke,	V.,	&	Braun,	V.	(2017).	Thematic	analysis.	Journal	of	Positive	Psychology,	12(3),	297–298.	https://doi.org/10.1080/17439760.2016.1262613	Demery	Varin,	M.,	Graham,	I.	D.,	Squires,	J.	E.,	Dilig-Ruiz,	A.,	MacDonald,	I.,	&	Vandyk,	A.	(2018).	Job	satisfaction	among	critical	care	nurses:	A	systematic	review.	International	Journal	of	Nursing	Studies,	88(July	2017),	123–134.	https://doi.org/10.1016/j.ijnurstu.2018.08.014	Doane,	G.	H.,	&	Varcoe,	C.	(2007).	Relational	practice	and	nursing	obligations.	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