Analysis of influencing factors of narrative medicine competence in the clinical nursing population in Hunan province, China: a cross-sectional study

Abstract

Objective

To explore the current status of clinical nurses’ narrative medicine (NM) ability and its related influencing factors, so as to provide a theoretical basis for nursing managers to develop targeted nurse training programmes.

Design

A cross-sectional study.

Setting

A total of 1792 clinical nurses from eight medical institutions in Hunan province were selected as participants using convenience sampling.

Main outcome measures

Online questionnaires were employed to collect general data, NM competence scores, empathy ability scores and personality trait scores from the participants.

Participants

A total of 1820 questionnaires were collected, with 28 deemed invalid due to contradictory responses. The final dataset included 1792 valid questionnaires, resulting in a valid recovery rate of 98.5%.

Results

The total NM competence score averaged at 153.37±18.34. Marital status, having children, hospital grade, empathy ability score and challenges faced in carrying out NM were identified as influential factors through multiple linear regression (p<0.01). These factors collectively explained 71.9% of the total variation in the NM competence of clinical nurses.

Conclusion

Clinical nurses in this study demonstrate an intermediate level of NM competence. Marital status, having children, hospital grade, empathy ability score and challenges in carrying out NM emerge as the primary factors affecting NM competence among nurses. The findings suggest that nursing managers should implement targeted measures to improve the NM competence of clinical nurses, thereby fostering their professional growth.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A convenient sampling method quickly and efficiently collected data of a large number of clinical nurses to ensure sufficient sample size.

• This study covered a number of medical institutions in Hunan province through online questionnaires, which increased the breadth of the study, and the response rate was relatively high.

• The selection of the survey scale underwent a strict reliability and validity test, which ensured the accuracy of the measurement results.

• This study was designed as a cross-sectional study, so we cannot determine cause-and-effect relationships between variables.

• The study population in this study is geographically specific, which may limit the general applicability of the findings.

Introduction

Narrative medicine (NM), originating in the USA and introduced by Rita Charon in 2001, represents a paradigm shift in medical practice by integrating narrative competencies. Gaining prominence through the Master of Narrative Medicine programme at Columbia University, NM is defined as the ‘medicine practiced through narrative competence’. It harnesses individuals’ narrative abilities, seamlessly blending professionalism and universality in medicine and establishing a conduit between the realms of science and the humanities. NM has evolved into a model for medical humanism and effective healthcare practices worldwide.^{1 2} NM, centred on communication, writing and reflection, serves as a powerful tool to empathise with patients, build trust between doctors and patients, improve patient compliance and elevate the overall healthcare experience. It proves effective in collecting and interpreting patient medical records, facilitating shared decision-making between healthcare providers and patients and providing valuable insights for treatment plan development. Additionally, NM opens a window for patients to comprehend the field of medicine and the roles of healthcare professionals, fostering mutual understanding and mitigating doctor–patient conflicts.

NM introduced to China in 2011, it responds to the escalating demand for medical services, which has led to strained doctor–patient relationships, frequent medical disputes and elevated stress levels and burnout among medical staff.3,6 NM, proven to enhance physician-patient connections, facilitates a deeper understanding of patient’s physical and psychological conditions, tailors treatment plans to individual needs and promotes patient adherence to treatment regimens.^{1 7 8} Furthermore, NM has demonstrated efficacy in reducing burnout among medical professionals.⁹ It is important to note that the effectiveness of NM depends on the narrative competence of a single performer. Narrative competence involves the ability to recognise, absorb, interpret and be moved by the stories of illness, and forms the bedrock of NM. This competence empowers doctors to better understand patients’ illness narratives, fostering heightened empathic abilities and professional spirit, ultimately improving healthcare quality and nurturing stronger doctor–patient relationships.¹⁰

Given that nurses serve as the primary implementers of NM, a thorough assessment of the current status and influencing factors of NM competence among nurses is essential.¹¹ The role of strong empathy ability in enhancing the psychological resilience of nurses and their capacity to navigate emotional responses are particularly pivotal for the development of NM competence.¹² At present, the cultivation of NM ability in the field of nursing is receiving more and more attention, which cannot only improve the quality of nursing but also effectively reduce the job burnout of nursing staff.^{13 14} Studies have confirmed that nurses with good NM ability are able to understand and respond more deeply to patients’ needs, which is of great significance for improving patients’ treatment experience and compliance.^{15 16} Additionally, personality traits, influenced by environmental factors, play a significant role in shaping behaviour. Individuals characterised by outgoing, emotionally stable dispositions and harmonious interpersonal relationships tend to exhibit higher work enthusiasm, foster a conductive work atmosphere and experience lower levels of burnout.¹⁷ Hou Jia-kun et al¹⁸ highlighted the impact of the organisational climate on the NM skills of nurses. While existing studies have predominantly explored the NM competence of nurses in various specialties,^{19 20} there are limited studies to explore the relevant influencing factors. The need for evidence-based verification of the influences of multiple variables on NM competence remains apparent.^{21 22} In addition, the general characteristics of NM ability of clinical nurses in China are still lacking. Therefore, this study aims to explore the current status of clinical nurses’ NM ability and its related influencing factors, so as to provide a theoretical basis for nursing managers to develop targeted nurse training programmes.

Methods

Design

This study adopted a cross-sectional research design, distributing nurse questionnaires online. Clinical nurses from eight medical institutions in Hunan province were selected through convenience sampling in August 2022. Participants received comprehensive information about the study’s purposes and testing methods, providing written informed consent.

Inclusion criteria and exclusion criteria

Inclusion criteria were as follows: (1) possession of a nurse practice certificate; (2) a minimum of 1-year work experience; and (3) provision of informed consent and voluntary participation.

Exclusions comprised nurses not actively working during the survey period, such as those on maternity or sick leave. To ensure unique questionnaire responses, the system allowed only one submission per IP address.

Instrumentation

1. General information: The questionnaire encompassed participants’ gender, age, working years, professional title, education level, parental status, marital status, hospital grade and whether they had undergone narrative care training.

2. Narrative Competence Scale (NCS): The level of competence in NM was assessed using the NCS developed by Wanzhen et al²³ Comprising 27 items distributed across three dimensions—attentional listening (9 items), reflective reproduction (6 items) and comprehension response (12 items)—each item is rated on a seven-point Likert scale, ranging from 1 (very inconsistent) to 7 (very consistent). Items 4 and 11 are reverse-scored, resulting in a total score range from 27 to 189. A higher total score indicates a superior level of NM competence. The Cronbach’s α coefficient of the whole scale was 0.959.

3. Jefferson Scale of Empathy-Health Professionals (JSE-HP): Developed by Hojat et al, the JSE-HP measured empathy levels among medical students and healthcare professionals.²⁴ Consisting of 20 entries categorised into three dimensions— perspective selection, transpersonal thinking and emotional care—each item is rated on a seven-point Likert scale, ranging from 1 (least agree) to 7 (most agree). The total score ranges from 20 to 140, with a higher score indicating a heightened level of empathy. The total Cronbach’s α of the scale was 0.857, and the Cronbach’s α of the three dimensions was 0.610~0.884, which had high reliability.

4. Eysenck Personality Questionnaire-Revised, Short Scale for Chinese (EPQ-RSC): The EPQ-RSC, the widely adopted personality questionnaire in China, includes four dimensions: introversion-extroversion (E), psychoticism (P), neuroticism (N) and covertness (L). E, N and P constitute three independent dimensions of personality, while L is a hypothetical personality trait representing a stable personality function in itself. With each dimension comprising 12 items, totalling 48 items, participants responded with either a ‘yes’ or ‘no’ for each item. A ‘yes’ corresponds to a score of 1, while a ‘no’ indicates a score of 0. A higher score suggests a more pronounced expression of the personality trait. In this study, the Cronbach’s α coefficient of the tested population was 0.776.

Patient and public involvement statement

None.

Data analysis

The statistical analysis was conducted using SPSS 25.0 software. The normality of the continuous data distribution is evaluated using Kolmogorov-Smirnov test. The count data were expressed as the number of cases and percentages, while measurement data conforming to normal distribution were expressed as mean±SD. For non-normally distributed measurement data, the presentation included M (P25, P75). Independent samples were subjected to t-test, one-way analysis of variance, Spearman’s correlation analysis and multiple linear regression analysis to analyse factors influencing NM competence. Statistically significant differences were indicated by p<0.05.

Results

General information

A total of 1986 questionnaires were sent out and 1820 were valid, with a response rate of 91.6%. In the 1820 questionnaires collected, 28 were invalid due to contradictory responses. The final dataset included 1792 valid questionnaires, resulting in a valid recovery rate of 98.5%. Among the 1792 clinical nurses included in this study, 1013 (56.5%) worked in tertiary hospitals, while 779 (43.5%) worked in secondary hospitals. The gender distribution comprised 1735 females (96.8%) and 57 males (3.2%). In terms of age, 209 (11.7%) were<25 years old, 1074 (59.9%) were 25–35 years old, 412 (23.0%) were 36–45 years old and 97 (5.4%) were >45 years old. The range of working experience varied from 1 to 39 years, with an average of 11.53±7.16 years. Among the participants, 294 (16.4%) had 1–5 years of working experience, 242 (13.5%) had 6–10 years and 168 (9.3%) had 11–39 years. Regarding educational attainment, 345 (19.3%) had college experience, 1400 (78.1%) held bachelor’s degrees and 47 (2.6%) had obtained master’s degrees. Marital status indicated that 262 nurses were unmarried (14.6%), 1526 were married (85.2%) and four were divorced (0.2%). Of the total, 1005 had children (56.1%). In terms of working titles, 887 were junior nurses (49.5%), 737 were intermediate nurses (41.1%) and 168 were senior nurses (9.3%). A total of 567 nurses had participated in narrative care training (31.6%). When asked about the difficulty of implementing NM in the clinic, 838 (46.8%) reported high difficulty, 889 (49.6%) reported average difficulty and 65 (3.6%) reported low difficulty.

NM competence, empathy ability and personality trait scores of clinical nurses

The overall score for clinical nurses’ NM competence was 153.37±18.34. Breakdown scores included attentive listening at 48.34±6.94, understanding and responding at 69.56±9.61 and reflective representation at 35.47±4.61. Empathic ability received an overall score of 89.03±13.33, comprising perspective taking at 44.83±7.70, emotional care at 28.66±6.04 and empathic thinking at 15.54±2.26. Additionally, clinical nurses scored 7.20±2.99 on introversion–extroversion, 2.11±1.59 on psychoticism, 5.43±3.71 on neuroticism and 7.23±2.54 on deception (table 1).

Table 1. Scores of narrative medicine competence, empathy ability and personality traits among clinical nurses.

Measure	Number of items	Score range	Actual score (mean±SD)
Total narrative medicine ability	27	27–189	153.37±18.34
Attentive listening	9	9–63	48.34±6.94
Understanding response	12	12–84	69.56±9.61
Reflective reproduction	6	6–42	35.47±4.61
Total empathy ability	20	20–140	89.03±13.33
Perspective taking	10	10–70	44.83±7.70
Emotional care	7	7–49	28.66±6.04
Empathic thinking	3	3–21	15.54±2.26
Introversion–extroversion	12	0–12	7.20±2.99
Psychoticism	12	0–12	2.11±1.59
Neuroticism	12	0–12	5.43±3.71
Lying	12	0–12	7.23±2.54

Comparison of NM competence scores among nurses with different characteristics

One-way analysis of variance (t-test or F-test) was conducted, using the total NM competence scale as the dependent variable and general information (eg, age, gender, marriage, education, position and having children) as independent variables. No statistically significant differences (p>0.05) were found in the total scores of NM competence based on gender, age, department, years of work, education or title. In contrast, statistically significant differences (p<0.05) were observed for marital status, presence of children, hospital grade, job status and perceived difficulty in implementing NM (table 2).

Table 2. Differential analysis of factors influencing narrative medicine skills in clinical nurses.

Variable	N	Attentive listening	Understanding response	Reflective reproduction	Total score of narrative skills scale	t/F test	P value
Marital status						1909.41	0.000
Unmarried	262	37.76±8.93	52.53±9.15	28.13±5.53	118.42±12.76
Married	1526	50.21±4.33	72.6±5.39	36.79±2.71	159.60±9.90
Divorced	4	29.75±15.95	22.25±7.04	13.50±7.59	65.50±5.19
Parenthood
Yes	1005	52.22±3.42	74.65±4.65	37.63±2.55	164.50±8.11	39.862	0.000
No	787	43.39±7.13	63.06±10.37	32.71±5.15	139.16±17.94
Hospital						−3.038	0.038
Secondary	779	48.03±7.50	69.01±9.72	35.18±4.67	152.22±18.67
Tertiary	1013	48.74±6.10	70.27±9.42	35.85±4.50	154.87±17.81
Position						4.028	0.018
None	1578	48.25±7.12	69.33±9.84	35.36±4.72	152.94±18.79
Nurse manager and above	202	49.05±5.41	71.20±7.65	36.32±3.63	156.57±14.44
Training received
Yes	567	49.10±7.39	71.94±9.17	36.54±4.28	157.58±17.26	5.523	0.044
No	798	48.14±6.92	68.89±9.40	35.15±4.53	152.18±18.21
Difficulty of narrative medicine implementation
High difficulty	838	47.40±7.13	71.94±9.17	34.67±4.97	162.05±20.21
Moderate difficulty	889	49.12±6.41	68.89±9.40	36.07±4.04	156.00±16.28	32.46	0.000
Low difficulty	65	49.88±9.35	67.64±9.96	37.66±5.09	149.91±19.55

Correlations between NM competence, empathy and personality scores of clinical nurses

Pearson correlation analysis revealed a positive correlation between the total NM competence score among clinical nurses and the total Jefferson empathy score, as well as each dimension of the empathy score (r=0.229, p<0.001). Conversely, no correlation was found between the total NM competence score and the four personality trait dimensions (table 3).

Table 3. Correlation between clinical nurse’s narrative medicine ability and empathy ability.

Items	Attentive listening	Understanding response	Reflective reproduction	Total score of narrative nursing ability
Total score of empathy ability	0.249**	0.173**	0.177**	0.229**
Perspective selection	0.238**	0.191**	0.196**	0.239**
Emotional care	0.139**	0.084*	0.092*	0.059*
Perspective taking	0.289**	0.344**	0.355**	0.379**
Extraversion	0.937	0.528	0.924	0.746
Psychoticism	0.946	0.530	0.432	0.615
Neuroticism	0.029*	0.363	0.940	0.187
Lie	0.128	0.442	0.935	0.318

Note: *P*p<0.05, **P**p<0.001.

Multiple linear regression analysis of factors influencing NM competence scores of clinical nurses

Multiple linear regression analysis was conducted with the total NM competence score as the dependent variable and nine variables exhibiting statistically significant effects in univariate and correlation analyses (marriage, having children, hospital grade, position, NM familiarity, NM development, challenges in carrying out NM and total empathic competence score) as independent variables. The analysis showed that marriage, having no children, hospital grade, empathic ability and challenges in carrying out NM were the primary factors influencing NM competence among nurses (p<0.05). These factors collectively explained 71.9% of the total variance (table 4).

Table 4. Multiple linear regression analysis of factors influencing narrative medicine competence among clinical nurses.

Variable	B	SE	β	t	P value
Constant	122.078	2.949	–	41.395	0.000
Marital status	27.861	0.727	0.543	38.331	0.000
Presence of children	−15.406	0.538	−0.417	−28.615	0.000
Hospital grade	1.122	0.480	0.030	2.335	0.020
Empathy total score	0.043	0.018	0.031	2.339	0.019
Difficulty in implementing narrative nursing	−1.745	0.435	−0.054	−4.015	0.000

Note: R2=0.720, Adjusted R2=0.719, F=762.599, Pp<0.001.

Discussion

NM competence scores of clinical nurses in Hunan province above average

The total NM competence score of clinical nurses from eight medical institutions in Hunan province in this study was 153.37±18.34. The result aligns with the findings reported by Wanzhen et al for nurses in 14 general hospitals in Jiangsu province (153.97±15.15),²³ reflecting a score rate of 81.14%, indicative of an above-average level. Among the dimensions of NM competence, attentive listening exhibited the lowest total score (48.34±6.94), corresponding to a score rate of 76.73%. Effective listening is critical for nurses to comprehend patient narratives, fostering improved nurse-patient relationships and enhancing nursing care.²⁵ Potential contributing factors to this observation include:

1. Nursing human resource shortage: Many nurses perceive limited communication time patients due to human resource constraints, hindering their ability to actively engage in patient narratives.²⁶

2. Listening skills: Despite nurses’ willingness to attentively listen, constraints in listening ability, lack of sensitivity, confidence in patient narrative and information acquisition gaps may impede their ability to effectively extract key information from patients.²⁷

To address these challenges, nursing managers can enhance nurse-patient communication and enhance nursing service quality by optimising communication time through strategic scheduling and human resource allocation. Implementing methods, such as group discussions and real-world case study, can improve nurses’ listening skills and promote harmonious relationships with patients. Moreover, nursing staff can leverage technology, such as WeChat, to engage with patients post-discharge, participate in online diagnosis and treatment and proactively improve their NM competence.

Factors influencing the NM competence of clinical nurses

Marital status and children

In this study, both marital status and having children emerge as influential factors affecting the NM competence of clinical nurses. The NM competence score of married nurses was significantly higher than that of unmarried and divorced nurses (p<0.05), consistent with the survey-based findings of Yu Cuixiang et al.²⁸ Unmarried or divorced nurses might exhibit a more self-centred approach, lacking family constraints and potentially showing diminished empathy and consideration for others in daily life. In contrast, married nurses, benefiting from robust family and social support, may demonstrate heightened consideration for others, engaging in post-work discussions and consequently exhibiting improved NM competence.²⁹ Furthermore, the NM competence score of nurses with children surpassed that of nurses without children (p<0.05), consistent with the findings of ZhengQimi et al.³⁰ Influenced by traditional Chinese concepts, women with children often bear greater family responsibilities and serve as primary caregivers. Consequently, nurses with children may bring more empathy to their clinical work, offering enhanced care and comfort to patients compared with their childless counterparts.

Hospital grade

Hospital grade emerged as a notable factor influencing NM competence among clinical nurses (B=1.122, p<0.001). Nursing staff in level III hospitals had a higher NM competence score than their counterparts in level II hospitals (p<0.05), consistent with the results reported by Zhou Heng et al.³¹ This could be attributed to several factors:

1. Top-down implementation: Some tertiary hospitals have implemented narrative nursing practices from top–down management, ensuring that clinical nurses are well-versed in the fundamentals of narrative nursing.

2. Staffing challenges in secondary hospitals: Secondary hospitals, often grappling with insufficient nursing staff, may result in busier nurses who allocate less attention to the psychological aspects of patient care.³¹

3. Emphasis on technology over communication skills: Management priorities in secondary hospitals may lean towards improving medical and nursing technology, potentially at the expense of cultivating communication skills and related abilities among nurses.³²

As societal expectations for healthcare rise, patients increasingly prioritise their health. In situations where patients’ demands are not promptly met, dissatisfaction may manifest as verbal attacks against nursing staff. Therefore, nursing managers in secondary hospitals should intensify training initiatives for nurses in narrative nursing skills. Encouraging the use of amiable language, fostering diverse perspectives, active listening and understanding patients’ needs can significantly contribute to creating an environment where patients feel heard, understood and respected.

Empathy

Empathy emerged as a significant factor influencing NM competence among clinical nurses in this study (B=0.044, p<0.001). Empathy plays a pivotal role in fostering mutual trust and understanding between individuals, establishing the formation of robust relationships.³³ The empathic competence score among clinical nurses in this study (89.03±13.33) exceeded that reported by Wang Pei et al.³⁴ for nurses in six general hospitals in Jiangsu province (62.10±7.47). However, the score rate was 63.59%, slightly lower than the findings of Wang Pei et al. Exploring the dimensions of the empathy scale, the emotional care dimension exhibited the lowest score (score rate=58.49%). This can be explained as follows:

1. Educational focus on professionalism: Domestic nursing education mainly focuses on imparting professional knowledge and practical skills, often neglecting the cultivation of emotional skills among nurses.

2. Experience and burnout impact: As nurses accumulate working experience, the occupation becomes less novel, potentially leading to a decline in curiosity and even burnout. This may result in a reduced sensitivity to the emotional changes of patients and their families.

Correlation analysis indicated a positive correlation between the total NM competence score of clinical nurses and the total empathic competence score, along with scores for each dimension of the empathy scale (p<0.05). Essentially, clinical nurses with higher empathic competence exhibited elevated NM competence. Prior studies have suggested that narrative nursing education can improve empathic competence among clinical nurses.35,37 However, due to the absence of systematic and comprehensive research on narrative nursing education in China, the training content remains in an exploratory stage. In clinical settings, narrative nursing faces challenges, marked by a deficiency in narrative nursing skills, time and location constraints, a lack of effective incentive mechanisms and patients’ preferences to communicate with doctors.³⁸ Given that improving narrative competence is a time-consuming process, nursing managers can advance narrative nursing skills through systematic training and lectures, fostering a continual improvement in the empathic competence of nurses.

Difficulty in conducting NM

The difficulty in conducting NM emerged as an influential factor in the NM competence of clinical nurses (B = −1.634, p<0.001). A lack of narrative skills among nurses stands as one of the impediments to the clinical development of NM.³⁹ While nurses acknowledge the importance of patients expressing their inner emotions, they often hear patient stories without subsequent analysis and reflection. Many healthcare workers, despite their willingness, lack the appropriate sensitivity, skills and confidence to actively engage with patients’ narratives. Training nurses to enhance their listening, reading, questioning, writing and reflection skills is crucial to improving existing training methods and facilitating the development of NM skills. However, time- and location-related constraints pose challenges to the development of NM competency. Nurses commonly perceive busy clinical workloads and a lack of time as hindrances to patient-nurse communication, affecting the development of patient-nurse relationships. Wu Jinfeng et al⁴⁰ found that direct and indirect nursing time accounts for 43.18%–51.87% and 48.13%–56.82% of total nursing time in Chinese hospitals, respectively. This excludes time spent communicating with patients and their families, highlighting the negligible time allocated for talking to patients and listening to their narratives. Changing this time allocation and promoting NM among nurses necessitate managerial actions such as increasing nurse staffing, implementing flexible scheduling, ensuring a reasonable distribution of nursing tasks, using new technologies for efficiency improvement and converting unused spaces into patient confession rooms.⁴¹

The previous studies on clinical nurses have highlighted age, education and professional title as factors affecting NM competence^{11 30}. This study does not find statistically significant effects for these factors. This divergence may be related to the small proportion of male and highly educated nurses in the study population. Additional studies encompassing multiple provinces and diverse nurse populations are warranted, and further empirical research is essential to advance the understanding and improvement of NM competence among clinical nurses.

There are several limitations that should be acknowledged in this study. First, the samples in this study were all from medical institutions in Hunan province, which may increase selection bias and may limit the application of this study’s findings in other regions. Second, the reliance on self-reported measures for data collection may introduce bias or inaccuracies in responses. Third, the cross-sectional design impedes the establishment of causality or determinisation of the temporal relationship between variables. Longitudinal studies would provide greater insights into the factors influencing NM competence over time. Lastly, there may be unmeasured variables or confounding factors that could influence the NM competence of clinical nurses, not considered in this study. These potential factors should be research in future for a more comprehensive understanding of NM competence among nurses.

Conclusion

The NM competence scores of clinical nurses in Hunan province surpass the average level. Clinical nursing managers should take targeted measures to improve the NM competence of Chinese clinical nurses with reference to the main factors affecting the NM ability of nurses, including marital status, having children, hospital grade, empathic ability and difficulty in carrying out narrative care.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.