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Storytelling as a Teaching Technique

torytelling has been used for centuries as a powerful vehicle for communication, recreation, entertainment, education, and to pass on cultural identity.1,2 It is a vital and unique ingredient of the human experience.3 Regardless of medium (legend, myth, folk tale, fairy tale, poem, novel, film, or play) stories are enjoyed by everyone.3 While stories, whether fiction or poetry, were historically narrated; todays modes of communication include printing, radio, TV, cinema, and Internet. Stories have appeal because they capture interest and attention, enable recall of details by association, and bring facts to life by putting them in personal scenarios. Storytelling is increasing in stature in the United States. The National Storytelling Network promotes the establishment of local chapters, voice coaching for storytellers, grants, a youth storytelling Olympics, and a Web site with services for storytellers. A national festival, acclaimed as 1 in 100 events in North America, has sparked a renaissance in storytelling. Internationally, Tellebration is a worldwide storytelling event.4 Stories have provided a way to maintain a cultural heritage. In his enchanting book The Way to Rainy Mountain, Momaday tells legends and stories of the Kiowa people, a Native American nation.5 The Kiowa migrated from the northwest to the territory now occupied by the states of Kansas, Arkansas, and Oklahoma. Today, the culture is preserved by traditional dances, fine arts, crafts, and stories. Adults tell stories as a way to interpret history to children. Family history is often passed on through stories, diaries, or books about the family. It must be appreciated that often storytellers tend to tell events in a way that supports their position and positive self-image. Shameful events such as the Holocaust, slavery, or Hiroshima may be told from the unique perspective of the person telling the story.6 However, stories are some-

Ruth Davidhizar, DNS, CS, RN, FAAN Giny Lonser, BA, RN

For centuries storytelling has been used a powerful communication vehicle. It is also useful in nursing education to enhance self-esteem, develop critical thinking, model behaviors, and to teach cultural sensitivity and communication skills. The authors discuss the use of storytelling in the nursing literature and in a nursing course.

times unbiased. In the Bible the Israelites chose to tell their shameful stories as well as the heroic stories so that their children would understand that what God did was right. Thus, it is important for listeners to be able to discern stories that might have bias and to appreciate why certain details may be added or omitted at the storytellers discretion.

Storytelling in Healthcare
Storytelling is an important strategy in the provision of healthcare. Because the healthcare environment is increasingly dominated by technology and the collection of impersonal information against a background of market forces and competition, storytelling has personal appeal.1 In an environment that alienates nurses from each other and their patients, storytelling offers a humane approach that responds to emotional need. Stories provide meaning to patient teaching and can provide meaningful anecdotal accounts of what to do and to avoid. Use of stories can stimulate learning when teaching children about preventive healthcare strategies.7

been found to assist in development of assessment skills. Evans and Severtsen report use of stories as a way to assist nursing students to listen and to collect data for cultural assessment.8 Baccalaureate nursing students caring for clients in long-term care facilities were assisted to learn to listen in a nonjudgmental, contextual way to the beliefs and values of the storyteller. Darbyshire notes that nursing educators can assist students to understand lived experiences and to gain appreciation for influences of lived experiences on health by soliciting and listening to stories.9 Stories can assist in gaining insight into the clients lived experience with illness within the context of their culture.10 As a new nurse educator, the second author soon became aware that often positive comments on course evaluations about class instruction related to storytelling as a teaching technique. Students related success in learning to stories told in class. Students attributed success in testing to being able to associate facts with a story. Years later, when alumni of
Authors affiliations: Dean (Dr Davidhizar), Administrative Assistant to Dean (Ms Lonser), Division of Nursing, Bethel College, Mishawaka, Ind Corresponding author: Ruth Davidhizar, DNS, CS, RN, Dean of Nursing, Bethel College, 1001 W McKinley Ave, Mishawaka, IN 46545 (davidhr@bethelcollege.edu).

Storytelling in Nursing Education

Storytelling is a valuable strategy in nursing education to develop skills in clinical settings. Storytelling has also

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early classes address the faculty what is remembered is the stories. You were the best instructor because of the stories. Class was so interesting. I never had trouble with your tests because I remembered the facts from the stories. You told about what happened when you looked a paranoid patient in the eye too steadily and I never fogot it. The simplicity and immediacy of the storytelling tradition offers a powerful tool that contextualizes and humanizes nursing knowledge as well as facilitating a deeper understanding of self and others within ethical and cultural contexts.1 In nursing education it is generally agreed the lecture-demonstration format traditionally used needs to change.11 Faculty are adopting more interactive techniques that involve small group work, assessment of vignettes, case studies, and patient situations. Storytelling as a nonlecture strategy can capture student attention and promote critical thinking. Little data are available in the literature to indicate how students actually perceive use of storytelling by nurse educators. Methods of using storytelling in the classroom, the benefits of storytelling, and information from sophomore nursing students on their perceptions of storytelling as a classroom technique are provided. It is important to determine whether nursing students actually perceive storytelling as beneficial. It is also important to determine if their perception varies over time in an educational program that purports to use storytelling as a teaching strategy.

this knowledge. The faculty turned to the first-year student and said, Please tell us what you did? The student replied confidently, I put a newspaper on the floor in the corner of the room, put the specimen cup on it, and asked Mr. Jones to squat on the cup. I left the room to give him privacy just like weve been taught. Later, the faculty said to the senior, You can share this example in our post conference today on delegation of responsibility. We can use this story with your classmates to illustrate some important concepts (J. Bounty, personal communication, June 24, 2002). The faculty was discussing negotiation as a technique to gain cooperation. She described a personal anecdote to the nursing students of preparing a student to give a Fleets enema to a coronary patient on bed rest by asking what she would do. The student responded that she had done several enemas, knew the patient should lie on his left side, and stated she did not need any assistance. A short time later the faculty stopped by the patients room, found the patients bed empty, and heard voices from within the bathroom. She knocked on the door, called the student out, and asked what was happening. The student smiled, Everything is fine. He didnt want an enema in bed, so we negotiated and he is lying on a bath blanket in the bathroom on his left side (J. Bounty, personal communication, June 24, 2002). Storytelling methods utilized by nursing faculty can be categorized into three types: 1) use of stories that role model good and bad nursing interventions and illustrate concepts; 2) use of scenarios, case studies, and vignettes for analysis; and 3) use of reflective analysis.

promotes empathy and understanding; it allows the student to vicariously benefit from the experiences of an expert and thus avoid repeating painful experiences and can emulate successful ones.12

Analyzing Scenarios and Critiquing Vignettes

Van Eerden reports on use of critical thinking vignettes as a method of assess student outcomes.13 In her study students role-play a nurse-client interaction using a case study prompt. Student performance outcomes in skills, demonstration, communication, teaching, problem solving, critical thinking, identification of resources, and resource to environmental cues are all evaluated in the role-play interaction. Evaluation criteria for the vignettes include: acts responsibility, communicates easily, values self positively, learns effectively, thinks critically and creatively, works cooperatively, and works productively. As well as a way to measure student performance outcomes, scenario and critique can be used in the classroom to stimulate the development of selected skills in a group situation in which students learn from each other. Nursing faculty at Bethel College have used critique of role-play vignettes in the classroom to assist in the development of cultural competencies and ability to critique cultural interventions. Critiques of clinical vignettes are used in the classroom and in a clinical problem-solving course to assist students in preparation for NCLEX-RN.

Methods of Using Storytelling in the Classroom

The senior nursing student was busy and asked the first-year student on her team if she knew how to collect stool specimens. Oh, yes, her younger colleague asserted. The senior handed her the specimen cup. When the student returned and presented the specimen cup to the senior student, the faculty member who observed this interaction asked the senior if she had given instructions on how to collect stool specimens. She reassured the faculty that the first-year student had

Reflective Analysis
Reliving clinical experiences through storytelling is a meaningful way for students to learn in postconferences or in the classroom. Reflection on a situation is a method of learning and teaching professional maturity through the critical analysis of an experience.14 The examples listed are powerful ones of how to appropriately and inappropriately use delegation and negotiation in clinical settings. Whether the example is shared by the faculty or by students, reflective analysis can result in attainment of learning objectives.

Stories That Role Model Good and Bad Nursing Interventions and Illustrate Concepts
Nursing faculty who can report personal experiences through stories can role model effective nursing interventions and assist students to learn through noneffective personal anecdotes. Telling personal experiences

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Evans and Severtsen describe a series of classroom sessions designed to teach students to learn to listen to stories.8 In a series of two 2-hour class sessions, faculty first contract stereotypical stories with true stories and assist students to see how stereotypes can create bias. Faculty then use narrative pedagogy, teaching and learning through stories, to create a safe place for students to focus on live experiences. After students and faculty share stories, guidelines for nonjudgmental listening and respect are practiced as stories are evaluated for meaning and skills are gained in cultural knowledge and how others view health. Evans and Severtsen8 describe use of a childrens book about two Indian youths, Crow and Weasel, to assist in learning about values and beliefs and discovering personal cultural bias.

cessfully, students are often encouraged. Students comment, The fact that you did something wrong encourages me, or If you can make that kind of mistake and be the wonderful nurse you are, I know there is hope for me.

To Develop Critical Thinking

Storytelling has been used to assess a students ability to think critically. This may be done in a variety of ways. Studies may report case studies and actions taken as a way to provide reflection on personal actions. A novice can report actions taken and be assisted by an expert who asked probing and reflective questions to enhance the his/her ability to understand the dynamics of the interaction.15

To Teach Ethics
Personification is especially appropriate when teaching ethics. Living discussion on ethical principles is stimulated by strategies such as role-plays and vignettes. Discussion is also enhanced if students can relate their own experience, values, and morals to the scenario being evaluated. Ethical dilemmas have always existed in nursing practice. However, with todays advanced technology, more complicated and advanced ethical topics are part of daily nursing care and include organ transplantation, euthanasia, abortion, use of fetal tissue for research, do-not-resuscitate orders, and the fear and concern in caring for clients with AIDS.16 Use of stories and other situational techniques promote opportunity for students to be involved and to draw their own personal opinions.

Benefits of Storytelling in the Classroom

Enhance Self-esteem
As a child growing up in Alaska, I interacted with Eskimos who traditionally used blinking as an indication of agreement. Today, sometimes a faculty member or other individual I am talking to will say, Are you listening to me? and I realize I have not been nodding, the typical way of showing hearing and understanding in the midwest, but blinking. We often do behaviors that we have learned in our culture of origin automatically (R. Davidhizar, personal communication, July 1, 2002). When I was first in Vietnam, I would explain to patients about their medication and they would nod and smile. I thought this meant they understood what I was saying. I was surprised when the patient came back a week later and had never even opened the medication container. I soon realized the nodding and smiling was because I was the smart American nurse, and had nothing to do with understanding or agreeing to be compliant (R. Stauffer, personal communication, 1990). When a respected faculty member tells a personal anecdote about an interaction with a patient in which a nursing intervention was used unsuc-

To Teach Cultural Sensitivity

Space is a concept that varies between persons of different cultures. A church in northern Indiana sponsored a Vietnamese family who immigrated to the United States and needed assistance getting settled. The five-member family was given a large ranch-style house, formerly used as a parsonage. The church members felt this space should meet their needs. However, very shortly they learned the family had invited many friends and relatives

to live with them. The parishioners were concerned that the family had become too crowded. When the transcultural nurse at the church assisted the congregation to understand the different needs for space that may be found in different cultures, the church members began to appreciate that the family was uncomfortable in the large ranch-style house because of the empty spaces and to respect the familys need for closeness. Later, they assisted the family members to design and build their own home. The house was compact and smaller and it met the familys needs for not having large open spaces (R. Davidhizar, personal communication, July 1, 2002). When one of the Vietnamese family members was hospitalized, she was visited by the church pastor. When the pastor entered the room, Mrs. Wong burst out crying. He was not aware that in Vietnam clergy visitation is usually associated with last rites, and she feared this visit meant that instead of the minor illness about which she had been told, she actually was gravely ill. A few minutes later the flower committee from the Sunday school class arrived with a bouquet. When they entered the room, Mrs. Wong again burst out crying. The church members were unaware that in Vietnam flowers are usually reserved for funerals. Flowers were another indication to Mrs. Wong that she was fatally ill (R. Davidhizar, personal communication, July 1, 2002). Because many nursing students are white caucasian women with little exposure to other cultures, understanding of appropriate approaches to persons culture requires techniques. These techniques can be developed by knowledge of diverse cultures, knowing how to be culturally sensitive, and being aware of personal cultural characteristics and stereotypes.8,17 Stories of cultural insensitivity can help to illustrate the need for cultural assessment and responsiveness. A faculty telling stories such as those included here will be affirmed by student comments such as, I really learned from that. I will always remember this story and be more sensitive to patient needs. Nwoga reports a study of 11 African American mothers use of sto-

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ries with their daughters as a way to discourage their daughters from making some of the same mistakes they reportedly made, such as becoming pregnant during their teenage years.18 Use of ethnocentric models such as this can be a valuable strategy for community health nursing practice and provide examples of how to deliver culturally competent care.

To Provide Role Modeling

Use of storytelling has been utilized by Alcoholics Anonymous for many years as a method of sharing experiences that provide strength and hope.12 The same concept applies to nursing education. A faculty member can share experiences that provide the novice with strength and hope of personal ability to be a nurse. When experts role model successful strategies, novices can vicariously benefit. In From Novice to Expert, Benner provides a theoretical framework for storytelling in terms of role modeling.19

Storytelling Survey Storytelling makes class more interesting to me. I remember things better in a vivid context. Stories make recall of important facts easier for students. Storytelling is especially important for nursing faculty. Stories keep class from becoming boring. Stories help students appreciate a faculty members clinical expertise. Stories help students appreciate a faculty members knowledge. Stories help students remember the concept. Stories make complex concepts easier to understand. Students can learn nurses dont have to be perfect. Stories can help students remember answers for tests. Stories inspire students to be better nurses. If faculty tell stories, students feel more satisfaction. Stories give me positive feelings about my teacher. Stories inspire confidence that I can face similar situations. Stories increase my sensitivity for people and their feelings. Stories increase cultural sensitivity. Stories involving conquering adversity give me hope that I can conquer it, too. Students sometimes dont remember anything the faculty taught except for the stories. Professional students dont need stories to learn concepts. Some faculty waste time with stories. Faculty telling about their own lives is inappropriate in the classroom setting.

To Teach Communication
Storytelling has been used to improve language and communication abilities in individuals with learning disabilities.21 Role-play and interactive practice prompted by vignettes can be used in the classroom to teach students communication skills, which can be used in clinical settings.

How Do Nursing Students Perceive Storytelling?

Storytelling is used throughout our curriculum; students are exposed to a variety of strategies related to storytelling such as role-play, discussion of nurse-patient scenarios, case studies, and stories about relating to client situations including clients who are culturally diverse or have spiritual needs. These strategies were used in Introduction to Community Concepts, a course for sophomore baccalaureate nursing students. To evaluate the impact of this teaching approach, we asked students to respond to a series of statements (see sidebar) using a Likert scale of 1 (not at all) to 5 (always). Students most strongly agreed that storytelling made class more interesting, helped them remember by putting

content in a vivid context, and made recall of important facts easier. Students most strongly disagreed with the statements that faculty telling about their own lives was inappropriate, faculty wasted time with stories, and that professional students dont need stories to learn concepts. While our students response to storytelling cannot be generalized, it does affirm that storytelling was viewed as an effective and helpful teaching strategy. Students also commented on the course evaluation that the stories were one of the special aspects of this class. As a result of this storytelling project, additional questions were developed to further explore perceptions of storytelling throughout the nursing program.

current students must be prepared to enter. Nursing researchers and educators are exploring use of storytelling as a technique to enhance health promotion. Nursing education and nursing educators should be alert to this growing body of research, which can be applied to personal teaching strategies. References
1. Bowles N. Storytelling: a search for meaning within nursing practice. Nurs Ed Today. 1995;15(5):365-369. 2. Koch T. Storytelling: is it really research? J Advan Nurs. 1998;28(6);11821190. 3. Park K. Oliver Twist: an exploration of interactive storytelling and object use in communication. Br J Spec Ed. 2001;28(1):18-25. 4. National Storytelling Network. Welcome to storynet. Available at: http://www. storynet.org. Accessed July 1, 2002. 5. Momaday S. The way to Rainy Mountain. Tucson: University of Arizona Press; 1996. 6. Bailey W. Tell the Story: Worship and Wisdom for Living. Winnipeg: Mennonite Publishing House; 2002. 7. McKennis A. How I do it-a trip to the seashore with Mr. Sun Bunny: teaching sun and ear safety to children ages 3 to 7 through play and storytelling. Head & Neck Nurs. 1999;17(1):18,26. 8. Evans B, Severtsen B. Storytelling as cul-

Summary
Storytelling is a creative teaching strategy that enables nursing faculty to expand beyond traditional classroom techniques to a technique that equips nursing students to respond to care needs of the 21st. century. Storytelling offers the potential to facilitate learning, capture interest and attention, and promote the critical thinking necessary for the complex healthcare world that

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tural assessment. Nursing and Health Care Perspectives. 2001;22(4):180-184. 9. Darbyshire P. Lessons from literature: caring, interpretation , and dialogue. J Nurs Ed. 1995;34:211-216. 10. Smith M, Liehr P. Attentively embracing story: a middle range theory with practice and research implications. Scholarly Inquiry for Nursing Practice. 1999;13:187-210. 11. Jeffries P, Rew S, Cramer J. Studentcentered versus traditional methods of teaching basic nursing skills in a learning laboratory. Nurs Ed Perspectives. 2002;23(1):14-19.

12. Lunt A. My side. J Psychosoc Nurs, 2000;38(11); 44-45. 13. Van Eerden K. Using critical thinking vignettes to evaluate student learning. Nursing and Health Care Perspectives, 2001;22(5):231-235. 14. Durgahee T. Reflective practice: nursing ethics through storytelling. Nurs Ethics: An Intl J Health Care. 1997;4(2):135-146. 15. McKay E, Ryan S. Clinical reasoning through storytelling: examining a students case story on a fieldwork placement. Br J Occup Ther, l995;58(6):234238.

16. Irvin S. Creative teaching strategies. J Cont Ed Nurs. 1996:27(3):108-114. 17. Giger J, Davidhizar R. Transcultural Nursing: Assessment and Intervention. St. Louis, Mo: Mosby Year Book; 1999. 18. Nwoga I. African American mothers use stories for family sexuality education. MCN. 2000;25(1):31-36. 19. Benner P. Novice to Expert. Mento Park, Calif: Addison-Wesley; 1984. 20. Klecan-Aker J. A treatment program for improving storytelling ability: a case study. Child Language Teaching Therapy. 1993;9(2):105-115.

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