‘Saying it without saying it’: using poetry as a way to talk about important issues in nursing practice

Abstract

The aim of this study was to explore the ways in which student nurses use self-authored poems to think about important aspects of nursing practice. Being a nurse can be rewarding in that it affords opportunities to care for and communicate with others. However, it can also yield challenges, and nurses are often faced with practice filled with uncertainty, grief and loss. Our findings suggest that students can use poetry writing to meaningfully explore nursing practice, engage with critical thinking and consider the feelings of others. Of particular note were the ways in which students use metaphor to explore emotional and relational aspects of practice and the technique of self-distancing when describing difficult and angering events. The work has implications for nurse education and practice. Proactively encouraging students to adopt particular ways of expressive writing might be beneficial for student health and wellbeing. Such an approach has the potential to improve quality care provision and support the emotional health of student nurses, which might lead to a reduction in compassion fatigue, stress and attrition.

Keywords

interpretation metaphor phenomenology poetry self-distance student nurse

Introduction

Nurse education has previously been criticised for focusing on the empirical side of nursing at the loss of the more personal and emotional aspects, which can lead to a task-orientated approach to care delivery in the practice setting (Williams, 2013) and the depersonalisation of care. This is something which has been discussed at some length in the media over recent years, most notably during the investigation into the failings of the United Kingdom Mid Staffordshire NHS Foundation Trust from January 2005 until March 2009. The Francis Report (2013) made 290 recommendations, making particular reference to the culture and practice of nursing. Observations were made about how the organisational focus was on corporate goals above safe and effective care provision. From a student’s perspective, undergraduate nurse education can be challenging and emotionally stressful, and a focus on task completion can lead students to consider leaving their programme (Banks et al., 2012; Jack and Wibberley, 2013). Therefore, finding ways to enhance the aesthetic and personal ways of knowing in nursing is required, and seems particularly relevant whilst nurses are undertaking their pre-registration education and considering the type of nurse they would like to become. What is needed, therefore, is a medium that allows student nurses to explore the personal aspects of their nursing practice in a safe and secure environment; one in which they will not be judged, but that will allow them to express themselves in an honest and cathartic manner.

Engagement with the arts offers multiple benefits when thinking about nursing practice, and has been used in nurse education in different ways; for example, painting as a way of developing emotional self-awareness (McAndrew and Warne, 2010), the creation of masks to assess therapeutic communication competencies (Emmanuel et al., 2010) and the consideration of published stories to explore the meaning of ageing (Jack, 2013). Poetry is another art form that has been used effectively across many disciplines as a means of supporting student learning, for example in sports science (Threlfall, 2013), teacher education (Speare and Henshall, 2014), social work (Furman et al., 2008) and medical education (McBain et al., 2015). The act of writing poems affords advantages over reading and discussing published poems in that it enables a deeper exploration of personal feelings (Jack and Tetley, 2016). As educators, it supports our exploration of the students’ lifeworld and helps us to connect with them in meaningful ways. Writing poems affords a freedom of expression not found in traditional reflective writing, and is an empowering and student-centred approach (Coleman and Willis, 2015). Reflective writing using traditional reflective templates might also be viewed as a way of restricting, rather than enabling, experiential learning (Coward, 2011), with students attempting to fit their feelings into boxes rather than expressing themselves freely. Therefore, we suggest that poetry writing could present a solution in terms of providing a safe framework for the exploration of nursing practice at a personal level.

There are many examples of how student-authored poetry has been shown to be beneficial in nurse education; for example, in providing an effective way to express ideas and reflect on clinical practice among student nurses (Biley and Champney-Smith, 2003). Poetry has also been shown to be helpful in supporting an exploration of compassionate practice (Jack and Tetley, 2016), encouraging the development of empathy (Davis, 1997), and as a means of support during difficult times (Osmond et al., 2012). It is well known that poetry writing exhorts a beneficial effect on student nurses; however, what is less well known is how the creation of poetry might have implications for aesthetic learning, and how it might positively affect the ability of student nurses to cope with personal aspects of practice.

This study aims to explore the ways in which student nurses craft poems to record and reflect on important aspects of nursing practice. Using student-authored poems as data, we explore how these poems were used as a proxy to articulate and discuss personal nursing practice.

Methodology

The aim of this research was to consider the ways in which student-authored poems supported the exploration of personal nursing practice. Through our experiences of facilitating poetry writing with students, we had discovered that some students choose to remain ‘hidden’ behind their poems in one or more ways: by speaking indirectly through their work, leaving the reader to decide for themselves what the poem is about; using the voice of, or writing as if they were the service user; or through the use of metaphor. We were keen to explore these thoughts and experiences, and utilised interpretive phenomenology to support our understanding. Interpretive phenomenology has been described as an effective research approach when attempting to understand others’ experiences (Cohen, 2000), and we considered this approach particularly helpful when reaching understandings about poems as it supports an exploration of the meanings often hidden behind the words. Such an approach can lead to a different understanding of the phenomenon being studied (Annells, 1996), which is important when attempting to uncover the lifeworld of our student nurses. Furthermore, given the subjective nature of analysing the poetry of others, having the ability to make meaning of these words ourselves seemed an effective way to consider and analyse the data. As Dahlberg (2006) suggests, interpretive phenomenology is not a fixed method, but more of an approach to research, which seems fitting when analysing the unique and individual nature of students’ poems. Just as using traditional reflective frameworks can restrict students, using a fixed method might restrict rather than encourage a creative analysis of their work.

A crucial part of our interpretation is grounded in our own experiences, as we use these to reach different understandings of the data, in this case, the student-authored poems. As researchers, we differ in terms of our professional backgrounds and the exposure we have had to health care practices. The first researcher (KJ) has been a nurse for 28 years and has a special interest in the use of poetry as way to support exploration of nursing practice (see e.g. Jack and Tetley, 2016). Conversely, the second researcher (SI) is an expert in the relationship between science and poetry (see e.g. Illingworth, 2016), and has an understanding of the use of poetry for developing student engagement in higher education.

We are similar in that we have a love of poetry and a desire to encourage students to engage with this way of writing, as a means of learning, development and enjoyment. However, we also bring different experiences to our interpretation, and believe this enriches the process to provide a wider interpretation of the ideas within the poems. Discussing our experiences adds to the credibility of the interpretation, and is in line with the qualitative validity framework suggested by Cho and Trent (2006). However, there remains a need to engage in a process of distanciation, whereby we distance ourselves from our pre-understanding (Wiklund et al., 2002). By doing this we are more receptive to new perspectives found in the poems.

As part of a first-year undergraduate module, student nurses at Manchester Metropolitan University are asked to write a poem about a meaningful nursing issue, relating to, for example, communication, caring, or the act of ‘being a nurse’. The poem is then shared in a small-group activity where students are asked to discuss their poem and the meaning and significance of it. The students are then requested to upload their work onto the online resource ‘Caring Words’ (www.caringwords.mmu.ac.uk), a website designed to engage students in a poetry community where they can share their work and read the poems written by their peers. This site (which has been live for 5 years) was designed to reduce the feelings of isolation often expressed by student nurses when experiencing difficult aspects of practice; for example, the feelings of distress following a death. The content of the website is driven by our students. Whatever they feel is important drives their poetry writing and, in turn, decides the direction of the community. To encourage thinking, as educators, we suggest topics and this is especially helpful for those students who might not know where to ‘start’.

We independently performed a review of the poems on the Caring Words website, which at that time was host to over 300 poems from 10 nursing cohorts, with a view to analysing those poems which students had used as a proxy to discuss important nursing issues. We individually chose poems that we thought made most clear the use of poetry as an exploratory and reflective tool in relation to personal nursing practice. There was some overlap in our choices and we discussed the poems until mutual consensus was reached about the final six to be included in the interpretive stage. We then discussed the poems chosen until interpretation was agreed in line with the hermeneutic circle articulated by Heidegger (1926/1962). Lines of each poem were discussed in the context of the whole piece, and vice versa. According to Heidegger (1926/1962), this cycle of whole–parts–new–whole leads to a different understanding of the observed phenomenon, meaning understanding is only truly reached when we view the parts against the backdrop of the whole. This process supports our rationale to present the poems as whole pieces rather than thematically. Many poems include lines of powerful imagery which, if used as data in isolation, might convey meanings not imagined by the writers or those reading unless read within the context of the whole poem. Reading lines in isolation can lead us to misunderstand, as we are exposed to the headline-grabbing lines without getting a feel for the whole piece of work. In addition, we suggest that including whole poems adds to the credibility of the research, as readers are left to decide the meanings of the poems for themselves. Furthermore, we agree with Shapiro (2004: 176), who describes the breaking up of poems into themes as ‘aesthetic murder’. We consider each poem not only as data, but as a piece of art, and in this sense they need to remain complete.

It is important to note that the epistemology that was adapted for this study is one of constructivism, not constructionism; that is, we are concerned with the learning and exploration taking place through poetry writing rather than the quality of the finished poem. This is because we were keen to support students’ development in innovative and helpful ways without them feeling under pressure to complete a perfect work of art. Our students are not necessarily creative writers or poets and they should not feel under pressure to develop these skills whilst on their nursing programme. Our role is not to judge poems but to accept all contributions as being valuable. Ethical approval for this study was gained from the University Ethics Committee, and students gave permission for us to use their poems as data for this study, during submission of their work to the Caring Words website.

Results

The chosen poems explored a range of intra- and interpersonal experiences, with most of them describing the difficult nature of communication and the implications of when the important dialogue between patient and nurse breaks down. Some of the chosen poems were written from the perspective of the student nurse and others were written using the patient’s voice. Presented in the following is our interpretation of each poem, which is based on the whole–parts–new–whole approach outlined in the Methodology section.

The first poem utilised metaphor to tell the reader (the patient) that the nurse can identify with them and act as an advocate, helping them do the things that they are unable to do unaided. This is suggested by the metaphors of ‘all ears’ and ‘I will be your voice’. Writing in this way enables the student to explore advocacy, a concept that might be easier to communicate through expressive writing in this way. This poem is written by one person, although it speaks on behalf of two unified voices. However, the reality of nursing practice is often somewhat different from the ideal described in this poem. Having the time to listen to patients at all times of day might be unrealistic, and perhaps this is explained by the fact that the poem has been written by a student in their first year of the programme, with little experience of practice. The lines of the poem, when considered against the backdrop of the English National Health Service, reveal an incongruence between the ideal and the reality, and this might only be discovered by the student as they progress through their nursing programme.

Trust

I want to be kind,

Offer you peace of mind,

You can tell me your fears,

I promise I am all ears,

I will be your voice,

Ensuring you have a choice,

I will listen to what you have to say,

No matter the time of day,

Please know I am always here for you,

And you can trust me too.

In contrast to ‘Trust’, the following poem uses metaphor as a way of alienating the nurse from the patient, and might be more representative of the daily lives of some student nurses during placement experiences. In this poem, the student seems to be working alone and unsupervised even though students are meant to be supernumerary during placement hours. The poem explains a single incident between two people, although the background context is one of short staffing, lack of mentors and students getting through their placements rather than experiencing meaningful learning. There is a sense of anger and desperation on both sides of the relationship, and the title ‘The Nameless Bed’ hints at depersonalising practice. Both nurse and patient are writers in this poem and metaphor is used to demonstrate the disparate relationship that has arisen between them, with the phrases ‘I’ll be a wreck’ and the depersonalising description ‘bed four’.

The Nameless Bed

‘Nurse, Nurse’

Moaned a voice from a nameless bed

‘Nurse, Nurse’

Leave me alone I think in my head

‘Nurse, Nurse’

Can’t that patient see I’m working alone?

‘Nurse, Nurse’

Oh, I must go to answer that phone

‘Nurse, Nurse’

‘Yes, I’ll be there in a sec’

‘Nurse, Nurse’

By the end of this day I’ll be a wreck

‘Nurse, Nurse’

‘Yes bed four, what is it?’

‘Oh Nurse, I just want to say your caring has been shhh… …’

In the next poem, the nurse used a variety of idioms to convey the importance of communication. An idiom is a commonly used expression whose meaning does not usually relate to the literal meaning of its words. In this poem, phrases such as ‘say what’s on your mind’, ‘lending an ear’ and ‘put yourself in their shoes’ helps the nurse to identify with the patient. In addition to the literal advice that is given – ‘Communication must always be kind’, ‘It must be perfect and patient’ – these idioms support the poem as an ‘aide memoire’ to nurture effective relational practice.

Being there for a Patient

Communication takes place in many hospitals

It must be perfect and patient

Communication must always be kind

You have to say what’s on your mind

Lending an ear is always important

To listen not just hear

Communication is hard sometimes you see

But it is always key

Sometimes patients need a good chat

To try and get their worries off their back

Being there for a patient whenever they need you

And sometimes trying to put yourself in their shoes

The following two poems are presented in contrast to ‘Being there for a Patient’ in that they demonstrate the alienation which can be felt when communication breaks down. The first, ‘Around my Bed’, describes the alienation felt when communication is ineffective. The potent phrase ‘like I’m cattle’ describes the depersonalisation felt as the medical team discusses the patient’s case. This then leads on to the use of a powerful metaphor to describe the patient’s feelings, with their dignity being described as ‘in tatters’. The second, ‘Pete’, was written from a distance and involves a conversation between ‘Pete’ and ‘Nurse Kerry’, with the narrator describing the outcome of each conversational exchange. This poem is an effective example of how expressive writing can be used as a proxy to discuss an important issue, as whilst the writer does not at any point overtly discuss ‘communication’, they manage to articulate an ineffective exchange between patient and nurse very effectively. Bolster and Manias (2010) describe discrepancies between the perceived and real behaviour of nurses when providing person-centred care, with nurses overestimating the effectiveness of their approach. Further, for student nurses, task completion might take priority over effective communication for reasons such as lack of confidence and an inadequate knowledge base (Tuohy, 2003). However, if student nurses are exposed to negative role-modelling practices, such as those described in these poems, they too might emulate these styles. Instead, students value exposure to positive role models who are integral to their professional development (Donaldson and Carter, 2005).