Art in debrief: a small-scale three-step narrative inquiry into the use of art to facilitate emotional debriefing for undergraduate nurses

Abstract

Background

The context of the research was in a setting where undergraduate nursing students spend 50% of their programme in clinical practice and 50% in a higher education institute. Research participants were undertaking the adult branch of nursing education.

Aims

• To explore emotional debriefing in relation to nursing practice.

• To highlight the emotional concerns of the research participants regarding clinical placement.

• To gain an insight into the use of art/creativity in emotional debriefing.

Methods

Narrative inquiry was used to gain an insight into, and a deeper understanding of, how undergraduate nurses feel about their clinical placement experiences. The research was carried out in three stages: the art intervention, a diary account of the art intervention, and a follow-up face-to-face discussion between each participant and the researcher.

Results

The findings suggest the intervention helped the participants to articulate and process their emotions. All participants acknowledged the importance of the three-step approach, with follow-up to the art intervention.

Conclusions

This research project has highlighted the potential value of a creative approach to emotional debriefing. A wider inclusion of the arts could be explored. Facilitation of emotional debriefing may help build resilience in undergraduate nurses. There is growing recognition for the need to foster resilience in undergraduate nursing student programmes.

Introduction

A classroom encounter with a group of third-year student nurses led to the recognition of a need among undergraduate students to be able to talk about their experiences from clinical placement. I have had a variety of personal nursing and teaching experiences that have led to an acknowledgement of the value of art and creativity in processing thoughts and articulating emotions. Freshwater and Stickley (2004) acknowledge the significance of self-awareness and emotional management in nurse development, with regard to critical reflection and deeper learning; this led me to consider how art may be used to facilitate nurse development by exploring student experiences. A review of the literature revealed that debriefing in nursing is generally confined to simulation for students (Dreifuerst, 2009; Reese et al., 2010), or after important events in critical care or specialist environments (Healy and Tyrrell, 2013; Maloney, 2012). Thus, I identified a gap in the debriefing process for student nurses and began to consider how I might be able to explore the use of art/creativity as an aid to emotional debriefing.

The intention for my research was to carry out a three-step approach: to invite participants to select or create a piece of art that relates to an emotion experienced on clinical placement, to write a narrative account in relation to the same, and participate in a one-to-one follow-up discussion with the researcher. My intention was to find out whether this gave the participants an opportunity for emotional debriefing. Information about the proposed research was given to third-year students, and participants were recruited into the study after expressing an interest and subsequently volunteering to take part. Third-year students were specifically targeted as they were the group who had originally expressed concerns about a lack of facilitation for emotional debriefing. Although six students initially came forward, only three felt they would have the time required to commit to the three stages of the research. However, I felt this low number would not detract from a small-scale study intent on capturing individual experiences. For the purpose of this research, art is considered in relation to the expression of feelings rather than for aesthetic purposes.

I first searched for literature with varied combinations of the terms ‘debrief’ and ‘nursing’ or ‘student nurse’ as I wanted to get a broad idea about how debriefing is currently being addressed. I also wanted to get a greater understanding of what debriefing may mean to different people so I could relate this to my own understanding of the term. Much has been written about debriefing in critical care, palliative care and surgery. There was also a significant number of resources relating to simulation and debriefing. Debriefing is generally considered to be the facilitation of analysis of events that have occurred, in order to gain greater insight into what has happened and why, taking into account human factors of the experience (Ahmed et al., 2012; Wood, 2009; Zigmont et al., 2011). Reflection in nursing is already a well-established and valued practice, and is now a requirement for revalidation (Nursing & Midwifery Council (NMC), 2017). Offering a three-stage approach, with the opportunity to discuss the experience, would go beyond private reflection and potentially facilitate emotional debriefing around issues that were important to the individual rather than in relation to a specific clinical event.

I followed my initial searches into debriefing with a review of the literature into the use of the arts in either nursing or medical education. This included search terms such as ‘art’, ‘art therapy’, ‘creativity’ and ‘humanities’ along with ‘health care’, ‘medicine’, ‘nursing’ and ‘debriefing’. My intention was to find out how creativity has been used in healthcare education and whether it has been used as an aid to debriefing. The benefits of using the arts in medical education are well documented and have been encouraged for well over a decade (Fish and Coles, 2005; General Medical Council, 2003). However, a literature review by Ousager and Johannessen (2010) highlights a lack of evidence supporting the sustaining benefits of incorporating humanities into medical education. Other studies have attributed the use of art and creativity in nurse education to improvements in problem solving, communication and critical thinking (Casey, 2009; Chan, 2012; Kalischuk and Thorpe, 2002). Robinson (2007a) describes an increased level of emotional cognisance among some student nurses where art was implemented into the pre-registration nursing programme.

Methodology

Andrews et al. (2008) describe narrative inquiry as an attempt to derive meaning from stories rather than just gathering information. On researching the meaning of narrative, I wanted to consider its appropriateness as both method and methodology for my research project. I wanted to find out about emotional experiences, using creativity as part of the debriefing process. I began to consider creativity beyond the artistic intervention part of my research project as well as extending into the written narrative of the participants and the subsequent discussion and analysis of the same. Holloway and Freshwater (2007) acknowledge the potential benefits of narrative research for both participants, and researcher; the process of telling their story may be therapeutic for the participants and listening to the stories may elicit both personal and professional growth in the researcher. Narrative inquiry was considered an appropriate choice to facilitate a small-scale study with an intention to explore the experiences of each individual. The incompleteness of narrative is perfectly described in the following statement by Johns (2006: 37), who states that ‘Narrative is never completely formed. It is always evolving through dialogue’. This helped me to review what I was hoping to achieve through data analysis and led me to acknowledge the value of producing a piece of research that captures moments: I wanted to capture lived experiences within the transiency of the student nurses’ role. I also wanted to consider the usefulness of allowing the telling of these experiences, through visual, written and spoken narrative, as a potential debriefing method, but also as an evolving story as part of the student journey.

Olsson (2007) recognises the roles of both personal and social identity in education research in acknowledging the link between personal qualities and values, social aspirations and the need to belong. This is pertinent to my research project from the perspective of considering the emotions of student nurses in relation to the clinical environment: clinical placement for student nurses can be viewed as a form of society into which they must fit in order to survive the process of becoming qualified nurses. Johns (2006) stresses that failing to address the emotional development of student nurses fails to facilitate the development of emotionally intelligent and critical-thinking practitioners. This is supported by many who have highlighted an imbalance in nursing education due to failure to incorporate humanities into nursing education; emotional intelligence and empathy are both valued as essential skills for well-rounded, holistic healthcare practitioners (Chan, 2014; Johnson and Jackson, 2005; Wilkstrom, 2001). Ewing and Hayden-Miles (2011) recognise the value of narrative and art in drawing out the lived experiences of individuals within the context of their environment. Lazenby (2013) considers it is the lived experience of individuals that is paramount to both nursing research and practice.

Art as narrative

The first element involved producing or selecting an image that relates to an emotion or feeling associated with a recent clinical placement experience. I felt that this offered the opportunity for beginning the student narrative as it would enable the students to select or produce an image that would begin the process of telling their story. This is supported by Robinson (2007a), who has explored the use of art to facilitate the expression of emotions and determines that art may offer an alternative method of telling a story for individuals who might find it difficult to begin to articulate their feelings. A study by Huet (2012), which explores the use of art therapy in healthcare, also acknowledges the benefits in using art to unlock emotions and facilitate dialogue. Participants in the studies by both Huet (2012) and Robinson (2007a) described their involvement with art as a platform for emotions to be acknowledged and processed.

Frei et al. (2010) acknowledge the value of visual arts in nursing education and recognise the potential of the visual arts in supporting the construction of narrative. This concurs with my own view that art can be used to unlock emotions that allow a story to begin. However, Jack (2012) warns of a reluctance among some students to undertake art-based projects as they fear their work will be judged on artistic merit. I felt that this was overcome by providing clear instructions to the research participants regarding the option to select an image already in existence if they preferred not to create their own work. Either selecting or producing an image gave the same opportunity for the unfolding of their story. This is supported by Pavill (2011), who considers any involvement with the arts to be a form of communication.

Written narrative

The second element of my research involved the participants writing a short narrative account of the arts intervention. Goodson (2013) describes the telling of a story as a way of individuals presenting themselves to the world. However, he cautions that the narrative must be considered within the context of its existence in order to interpret meaning; this led me to consider the importance of relating the students’ narrative accounts to their role as students in a clinical environment, and their transience within the clinical team.

Enabling the students to develop their story by writing a diary-like account of how and why they chose, or produced, a particular image in relation to their emotions facilitated the evolving narrative. This is summed up perfectly by Frank (1995: 22), who states that ‘The truth of stories is not only what was experienced but equally what becomes experience in the telling and its reception’. This helped me to realise the value of narrative inquiry in allowing the relationship between the participants and researcher to develop the story further. This is supported by Andrews et al. (2008), who recognise the role of the narrative inquirer in facilitating the unfolding of the story and finding links between stories as they unfold. This value is worthless in relation to reliability or generalisability, but is simply of value in learning about individual experiences. This concurs with views expressed by Goodson (2013) and Polkinghorne (1988), both of whom extol the value of knowing within the context of the experience for the sake of understanding the lives of people. Butler-Kisber (2010) argues in favour of credibility over validity in narrative research.

Narrative by discourse

The third method of data collection was by means of an informal and unstructured interview with each research participant. Johns (2006) describes narrative as ever changing through interchange; this led me to acknowledge that any attempt to discuss the story with the storyteller influences and moves the story on. I was aware that my role as interviewer would influence any discussion that would take place, and I sought to minimise this by applying as little structure as possible to the process. Butler-Kisber (2010) discusses the significance of participant voices being predominant in the research process to add authenticity and ethical value, and I felt that an unstructured interview would help to keep the participant voice as the driving force in any discussion.

According to Clandinin and Connelly (2000), another way of increasing trustworthiness is to offer research participants the opportunity to review and amend how the researcher has interpreted conversations. Encouraging the students to review my summary of their discussions and add any changes, or further comments, gave me the opportunity to be open and reflexive about the process of interpreting the data. This helped to create a balance between the voice of the researcher and that of the research participants, as recommended by Clandinin and Rosiek (2007). However, the voice of the researcher is also integral to the process of narrative inquiry: Goodson (2013) acknowledges the importance of hearing the voice of the researcher in order to establish emerging concepts from the stories, and the experiences of people within the context of the inquiry.

Results

Hunter (2009) advises the use of a framework that enables the researcher to present and interpret the material in a coherent manner. I created a framework that incorporated data analysis under the terms visual, thematic and contextual. Dividing the analysis into these three headings would enable me to make greatest use of the information collated in order to portray coherence in both analysis and interpretation of the data.

Visual analysis

Riessman (2008) describes the process of visual analysis whereby images are often interpreted in conjunction with written and spoken narrative; the images can be used to tell a story themselves or the story can come from discussing or explaining the selection of an image. The first element of my research project, the selection or production of the image, was considered the first part of their story. Other authors have recognised the relevance of art in storytelling, and in uncovering emotions (Frei et al., 2010; Robinson, 2007b; Thresher et al., 2013).

The first participant selected an image of a woman squashed into a cardboard box. The box is quite small and the woman appears to be desperate to break free of this confinement; yet the box is open and somehow she remains within its confines. This immediately gave me a sense that the student may have chosen this image to portray some level of frustration with her situation, but also a feeling of helplessness; the box was open, yet the woman seemed to remain there. I was aware that my interpretation of the situation is not a key element of the research process, but I acknowledge that it is impossible to see the image and not give any consideration to why the student may have chosen it. This connection is acknowledged by Thresher et al. (2013), who suggest that although interpretation is subjective to the individual, the observer automatically becomes connected by attempting to relate to the image.

The student’s written narrative contained powerful negative emotions, namely ‘anger, frustration, annoyance and confusion’. The student felt that there were many factors in the clinical setting that were out of her control but adversely affected her learning opportunities. The box in the chosen image represents the student’s extreme frustration and anger with having to contain her emotions. She felt that she could not express her concerns to the very nurses who would be responsible for signing her competency documents, and wrote ‘I didn’t want to bring this up as I didn’t want to get them off side’. A sense of helplessness was emerging from the student’s narrative, and this may have come from her perceived lack of control or power within the clinical setting. A study by Clarke et al. (2012) highlights a prevailing fear among undergraduate nurses about getting a poor evaluation from clinical practice placements; this often leads to a reluctance to speak out and a willingness to put up with poor or inconsiderate treatment. This sense of helplessness was an important factor to consider with regard to student wellbeing and psychological health.

The second participant chose an image of a young kitten, alone and looking anxious. On reading the accompanying narrative I found the student was anxious about the vulnerability of a service user who was attempting to give up alcohol; she expressed her fear about his ability to cope, the level of support available and a history of previous failed attempts. On analysing the image in context with the written account, like the previous image it had a link to negative emotions and a perception of helplessness. The student wrote the following: ‘When we were leaving I was anxious that the patient would go back to drinking if the right support were not implemented.’ During a follow-up discussion with the student she was able to review both the chosen image and the accompanying narrative account. She reported that ‘it took me right back there’ and confirmed a sense of helplessness on leaving the patient. Moscaritolo (2009) recognises high anxiety levels among student nurses in relation to coping with the needs of service users and expressing concerns to the team. Although this story is remarkably different from the previous one, it has similarities in relation to the expression of negative emotions and a portrayal of limited influence or control over the situation, which adds to the state of anxiety.

The third participant created an image to represent his feelings. The image (Figure 1) was overwhelmingly dark but with some very bright glimmers of light beaming through. The accompanying narrative contained many mixed emotions, including frustration, uncertainty and confusion, but also a sense of feeling valued and supported on clinical placement. Mixed emotions regarding clinical placements are recognised by Gray and Smith (2000), who partially attribute this to the quality of support available through mentorship in clinical practice. The student went on to describe the clinical experience as ‘Having moments of haziness and feeling like I am in a storm, but with breakthrough moments of calm and being able to see the long path’. In a follow-up conversation the student confirmed that producing the art helped him to process thoughts and emotions from the clinical placement. The student also felt that both the art and, corresponding narrative were more effective than reflective writing in helping him to explore his feelings. Brown et al. (2008) recognise the benefits of using written narrative alongside art in order to facilitate a greater understanding and exploration of the emotions that emerge. There is much support for the use of art in enhancing emotional development and providing therapeutic benefits such as improved coping mechanisms and emotional intelligence (Chan, 2012; Orkibi, 2012; Winner, 2005).

Figure 1.

Image attributed to anonymous research participant.

Thematic analysis

Searching for themes that emerge from narrative data has been included by many researchers within their framework for analysis (Feldman et al., 2004; Hunter, 2009; Riessman, 2008). What was most striking when reviewing the data collected was the perceived helplessness and lack of control among the students about being in the clinical environment (Table 1). Some of this could be attributed to the limitations imposed upon them by their student status and their transient membership within the multidisciplinary team. This can lead to students feeling undervalued and has been recognised as an ongoing problem (Emanuel and Pryce-Miller, 2013; Last and Fulbrook, 2003). The perceived helplessness could be related to an unwillingness to ‘rock the boat’ for fear of failing the placement. This fear is well documented in several studies on the experiences of undergraduate nurses (Clarke et al., 2012; Gray and Smith, 2000; Mabrouk Abd El Rahmen, 2014). However, as discussed by Mabrouk Abd El Rahmen (2014), there is also a responsibility for faculty to take care of student welfare while on placement. The participants in my research project did not feel that the current link-lecturer role adequately facilitates student debriefing with regard to emotional issues encountered on clinical placement. All three participants felt that the debriefing process may best be addressed as a follow-up after placement as it was often impractical and uncomfortable to discuss events while still on placement.

Table 1.

Emerging themes and sub-theme.

Emerging themes	Numbers	Sub-themes	Numbers
Power imbalance influenced by student status and need to fit in	n = 3	Fear of achieving sign-off if concerns were raised	n = 2
Link-lecturer role not meeting emotional needs	n = 3	Preference to debrief when placement has finished	n = 3
Busyness of mentors, limiting learning opportunities and opportunity to discuss anxieties	n = 2	Frustration about progress on clinical placement	n = 2
Greater value attached to time spent in clinical practice	n = 3	Perceived theory–practice imbalance; difficulties in relating academic work to clinical practice	n = 2
Perceived lack of control over situations encountered in clinical practice	n = 3	Anxieties over service users and care provision	n = 2

Contextual analysis

Kawachi et al. (1999) describe contextual analysis as the analysis of media or text in relation to both the actual text itself and the context of its setting. Although clinical placements are perceived as stressful by many students (Timmins and Kaliszer, 2002), they are also valued by students as the most significant part of the training programme (Myrick et al., 2006). Frustration from a student perspective frequently comes from a perceived theory–practice imbalance as many students fail to recognise the value of the proportion of time spent on the academic aspects of the programme (Last and Fulbrook, 2003). This sentiment was echoed by two of the participants in this research project; both mentioned their frustrations with coursework and often struggled to understand its relevance. Similar findings are reported in recent nurse education literature (Crigger and Godfrey, 2011; Taylor et al., 2010).

There was also a perception among two of the students that the busyness of mentors sometimes limited the students' learning opportunities and did not allow time for them to discuss their anxieties. A literature review by Emanuel and Pryce-Miller (2013) recognises a common perception among undergraduate nurses that mentors are too busy to support their learning, which can lead to increased student anxiety. Rowe and Sherlock (2005) acknowledge the high-stress clinical environment and the effects of burnout as factors that negatively affect the behaviour of older nurses towards newer members of the team, often resulting in verbal abuse and aggression. Fear of failing placement is recognised as a reason why student nurses may become anxious and worried if they speak out (Emanuel and Pryce-Miller, 2013).

Although there is link-lecturer support available for students while on clinical placement, there is often reluctance among students to disclose the difficulties they may be encountering (Fisher et al., 2012). A study by MacIntosh (2015) suggests that this may be because there is little understanding among students as to what the responsibilities of the link lecturer are, and that there is a lack of standardisation to the application of the role. This was congruent with the opinions of all three research participants, who felt that the level of link-lecturer support available varied greatly from one placement to another. This led to reluctance to rely on this support and hesitancy to discuss difficult or emotional concerns.

Discussion

The images and the associated narrative accounts created by the participants were discussed at length with each participant during a follow-up conversation. During these discussions there was consensus among participants that the image facilitated the beginning of a process that allowed them to focus on their own feelings in relation to clinical placement. The image prompted the commencement of a debriefing process because it fostered a starting point for considering emotions that may initially be difficult to articulate. This is endorsed by Ewing and Hayden-Miles (2011), who recognise the positive role of art in facilitating the expression of feelings evoked by imagery. The value of art is well recognised as a tool for problem solving and the development of critical thinking skills (Huet, 2012; Johnson and Jackson, 2005). Marnocha and Marnocha (2007) extol the merits of art and humanities in emotional development as part of nursing education, and this appears to be corroborated by the participants undertaking this small research project: all three participants reported the combined elements of the project as enabling them to focus on and articulate emotional experiences. All three participants acknowledged the positive benefits of following on from the image with the written narrative and discussion in facilitating the processing of their emotions.

The significance of themes emerging from the stories of individual research participants is in establishing a link between the experiences and a commonality in meaning (Goodson, 2013). Identifying themes enables the researcher to interpret the meaning in relation to the wider context, taking into account the external influences such as policy and social aspects of nurse education. Cohen et al. (2013) warn of the limitations of interpretive approaches to qualitative research analysis with the use of small-scale social exploration. I feel that this can be somewhat counterbalanced by considering the wider context of healthcare environments alongside the narrower context of the students’ stories.

McKie (2012) recognises the significance of context and argues for the inclusion of the arts and humanities in nurse education in order to produce well-rounded, balanced practitioners who understand not only theory and technology but also the emotional needs of service users, colleagues and themselves. This is supported by the data emerging from my research: the students appear to experience emotions in relation to the suffering of service users and there is a desire, perhaps even a need, to express these emotions. One of the students felt that the image enabled her ‘to focus on the core issue rather than just whinging about things’. She also felt that writing the narrative helped her to explore her feelings about her relationship with the service user and other members of the professional team. The context of the student experience was also highlighted during a discussion with the third student, who felt that there is no adequate provision for students to debrief following emotional events, such as death, experienced in clinical practice. There was a perception that everyone was too busy and the focus was on achieving learning outcomes. When asked to elaborate on this point, the student expressed a view that everyone else just got on with things, which led to reluctance on his part to express emotional vulnerability. The lack of provision for emotional support in nursing education is highlighted in many studies where a case for inclusion of humanities and the arts is explored (Ewing and Hayden-Miles, 2011; Jack, 2012; McKie, 2012).

The context of environment is central to the discussion of emotional issues experienced by students. Nursing students are socialised into the culture of nursing by their mentors. During discussion with all three research participants there was a perceived pressure for students to immediately fit in and comply with the system in order to successfully complete their placement. The pressure to achieve clinical competencies can lead to both the student and the mentor ignoring the emotional impact of learning to be a nurse. Ignoring the emotional impact of nursing can lead to early burn out and can inhibit nurses in displaying empathy towards service users (Rowe and Sherlock, 2005; Timmins and Kaliszer, 2002; Wikstrom, 2001). McKie (2012) acknowledges a growing recognition for a wider curriculum that attends to the human element of nursing. However, there is acknowledgement that nursing curricula are still largely influenced by a demand for scientific and technical knowledge (Rolfe, 2010).

I felt that a limitation during my research project was the available time: incorporating three stages of data collection was very time-consuming, and this influenced the number of participants I could realistically recruit and process through the project. However, I felt that the subjective nature of the inquiry was not compromised by having a small number of participants as I was able to collect rich subjective material and allow time for each student to review a summary of our discussion and add any further comments. I have not argued a case for validity or reliability during this research project as my aim was not to measure but to understand human experience within the confines of my inquiry. According to Butler-Kisber (2010), applying transparency to the process throughout the project allows a claim for credibility and trustworthiness. I consider that this approach adds value to my research outside of the realms of validity and reliability. Findings from this small-scale research inquiry are specific to this project, unlikely to be replicated, and therefore not generalisable to the adult nursing student population. However, I would argue that the findings are of interest to anyone involved in nurse education as they present an authentic insight into the lives of three individual student nurses within the context of the inquiry and thus within the context of nurse education and the healthcare setting.

Conclusion

The main aim of the study was to explore the use of art as a potential tool to facilitate emotional debriefing. Narrative inquiry was the research method chosen to gain an insight into, and a deeper understanding of, how student nurses feel about their clinical placement experiences. The findings suggest that the intervention helped the participants to articulate and process their emotions, with all three participants acknowledging the importance of follow-up to the art intervention. Implications for practice are to highlight the need for emotional debriefing and to consider the role of art and humanities in facilitating this. This research project has highlighted the potential value of a creative approach to emotional debriefing. A wider inclusion of the arts, for example art, drama, music and poetry, could also be explored. However, it is acknowledged that work of this nature, due to the time needed, may be difficult to incorporate into the curriculum and to replicate on a larger scale. Nonetheless, the emotional needs of nursing students should not be ignored if the aim is to produce resilient practitioners. There is growing recognition of the need to foster resilience in undergraduate nursing programmes (Grant and Kinman, 2013; Thomas and Revell, 2016).

Key points for policy, practice and/or research

• The research concurs with what I have noted in classroom encounters with student nurses during anecdotal discussion: emotional debriefing after clinical placement is not being adequately addressed.

• The use of art has been explored as an aid to debriefing and has been shown to be of benefit in allowing the process of emotional debriefing to begin.

• There has been recognition among all three participants that the three stages of the research allowed their story to unfold and develop. All participants felt that the follow-up to the art intervention was critical to the debriefing process.

• Incorporating greater use of art and creativity into the nursing curriculum may help to promote resilience.

Biography

Carol Kinsella Frost is a Senior Lecturer in adult nursing at the University of Hertfordshire. Prior to moving to the higher education setting, she gained extensive teaching and nursing experience within the Royal Brompton and Harefield and the Hillingdon Hospital NHS Foundation Trusts from 2002. Carol is passionate about the positive benefits of using art and creativity to enhance both teaching and learning. She has developed an interest in exploring the use of art in emotional debriefing and this was pursued in her MEd research project. Carol presented her research on this topic at the Royal College of Nursing Education Conference in 2017.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethics

Ethical approval was gained in accordance with the University of Hertfordshire's School of Education approved ethical checklist and British Educational Research Association (BERA) guidelines (BERA, 2011). All participants were given an information sheet and attended an information session prior to agreeing to take part. Confidentiality and any potential limitations were discussed. Written consent of participants was gained. Follow-up information regarding available support for emotional issues of concern was also provided.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.