Why use stories?
Using stories to give context and enhance students understanding of medicine was a purpose highlighted by both stakeholders and supports evidence from previous studies (21, 22). Students believed that when stories were used within lectures, they felt more involved in the teaching enabling them to pay more attention. Educators also noticed that students are more engaged when they employ this technique echoing research findings (12, 23).
Storytelling allows educators to share with students some realities of medicine. Most research agrees with this purpose however, Greenhalgh in 2001 explained stories provide a poor account of medical conditions and traditional medical teaching and textbooks are superior (24, 25). These differences could be explained by stories representing how things happen in real life in comparison to textbooks. Perhaps now over twenty years on, students and educators prefer a variety and balance of both to properly prepare students for their careers. Could both pedagogic forms serve a purpose, and it is not one or the other but instead understanding when each method is most effective within teaching? Knowing this might help inform educators of when to deliberately employ these teaching methods.
Previous research reveals storytelling, as a tool helps students empathise (11, 26). Many student respondents concurred; however, no educators identified this benefit. Despite this understanding, are educators aware of storytelling’s potential importance for successful medical student development?
Stories positively impacted students in this study. They reported learning about empathy, discovering the realities of medicine, being offered a context for learning, and feeling more engaged. The considerable alignment between the purposeful use of stories emerging from our student data with the evidence identified through our literature review could give confidence to educators using this method and encourage them to deliberately utilise it more.
What types of stories should be used?
Nearly every stakeholder thought of stories as re-telling past experiences to promote learning. Attenborough and Abbott (27) defined storytelling similarly. Students and faculty both suggested that case-based stories are told the most in medical teaching and are successful at promoting and enabling discussion between educators and students. This interaction can help educators explore for instance ethical issues and person-centred care (22). Other publications concur that case-based stories are highly valued, extensively used and can have a positive impact on student's clinical knowledge, and professional values (23, 28).
Students believed that shocking stories deepened their understanding of concepts and helped with information recall. Likewise, Clark (23) argued using shock or surprise within stories helped expand students clinical knowledge. We might infer that for students to find stories beneficial for learning they should involve some sort of emotive impact such as surprise, interest, or laughter.
Using humour also emerged from the data, as students felt it promoted more rapport and engagement with educators who utilised this teaching method. Its effectiveness in medical teaching has been previously recognised as it can create relaxed learning environments and makes teaching and learning enjoyable for both parties, when used appropriately (29, 30). The potential danger of mocking patients or doctors within a funny story was acknowledged by an educator and a similar problem has been highlighted by Piemonte (31) who explains it can damage students’ professional values.
Several authors have written on the role of humour in health care for instance in palliative care (32, 33) and more explicitly in higher education (34, 35). Jones (4) helpfully adapted Dean and Gregory (32) cautions and guidelines on the use of humour which is presented in Fig. 1.
Figure 1 Adapted from cautions and guidelines on the use of humour (32, 36)
Caution 1 Never introduce yourself in a humorous manner unless your reputation has proceeded you.
Caution 2 Never use humour to conceal a lack of preparation or inadequate knowledge of the subject matter.
-
Make fun of yourself not others
-
laugh with people and not at them
-
Select material that relates to your topic or listeners
-
Believe in your material
-
Deliver your material well
-
Learn techniques for good delivery
-
Avoid ethnic/ sexist etc put-downs
-
Give listeners permission to laugh
-
Use savers if the joke or story doesn’t work
-
Timing and intuition are important for choosing when and when not to utilise humour
Our study suggests some imbalance where surprising and humorous stories are the most valued by students, yet educators use case-based accounts the most. Our findings suggest that the deliberate type of story chosen, informed by an understanding of and reflection on the different benefits of each might be strategically valuable for all stakeholders.
Value of Stories
Both stakeholders highly valued and enjoyed storytelling. Students from this study and others highlight the popularity of this teaching method (21, 23). Students benefit from this enjoyment as they may be more likely to engage with teaching (37). The findings suggested that educators needed more clarity on students’ attitudes towards stories being used within teaching. Perhaps this transparent account of the seeming value and purpose of stories might encourage more educators to deliberately use this method and help students to integrate ideas from stories and anecdotes into reflective activities.
Students believed stories also progressed learning by prompting recall, understanding context, advice for future career choices and engaging interest which literature suggests can deepen approaches to learning. (4, 21). These less direct purposes of storytelling were less evident in the data from faculty perhaps because they are delivering stories as opposed to experiencing them.
Storytelling is known to impact professional identity development (27). Although students didn’t specifically acknowledge this, two groups of interviewees explained that hearing stories about good and bad clinical practice will help shape their future careers. Only one educator, acknowledged storytelling helping by involving students in the community of practice, developing a sense of belonging and encouraging them to progress, qualify and develop a sense of identity as a doctor. Belongingness in higher education can be defined as feeling accepted, appreciated and safe in the respected learning environment (38). This sense of belonging is highly valued for its positive impact on learner development, academic achievement and student wellbeing (39, 40). Through sharing medical stories can educators enhance belongingness amongst students and help them develop professional values?
In an earlier study, Jones (4) conceptualised the concept of a story as a learning platform. Figure 2 shows stories as learning platforms whereby sharing a story with learners served to convey concepts, ideas, and information. Analysis of data gathered using questionnaires and focus groups, populated by diverse educators she identified five potentials. Firstly, to encourage reflection on the shared experience, to engage learner interest, to create a positive learning environment, generation of eureka moments – verisimilitude and finally the opportunity to generate discussion and debate on a topic.
We hope that disseminating these findings to educators could create a greater awareness of the value of stories and encourage educators to make more deliberate efforts to use them to their full potential.
Safe & Effective storytelling
Both stakeholders expressed their fears that using stories could compromise patient confidentiality. This could be avoided through training or education ensuring patients or subjects aren’t easily identifiable (perhaps by altering some non-essential details) when bringing life experience or stories into teaching (31). For example, a faculty development workshop, reflecting on participants’ own experiences of storytelling could be created to help develop guidelines for safe and effective storytelling.
The delivery of stories was important to more students than educators. Students believed that for stories to be engaging and worthwhile they had to be told enthusiastically. Clark (23) also acknowledges the power educators have when choosing what stories to tell and how they are delivered.
It seemed for educators having the confidence and the experience to deliver stories influenced their use of this pedagogic tool. Students believed that having clinical experiences to draw on is essential for using stories within medical teaching. Interestingly, this reinforces that many participants thought of stories as real-life experiences and specifically only believed clinical stories are used or could be used within teaching. Stories have been used previously to deliver the less clinical aspects of medical teaching such as basic science but many participants overlooked this (21). Widening the perception of stakeholders’ definitions of storytelling might be valuable for faculty development as not every story within medical teaching needs to be clinical or patient orientated. Consider perhaps whether using metaphors as stories, and hence learning platforms, might help educators convey basic science medical teaching and complex ideas and attitudes?
The literature surrounding storytelling in higher education generally suggests stories need to be relevant to teaching to benefit the learner (7). Similarly, this opinion emerged from students in this study. Does this mean stories should be constrained to those only with immediate relevance? Table 1 articulates the similarities between effective pedagogic intervention and storytelling which suggests this opinion may be unnecessarily constraining. Circulating this to stakeholders involved in teaching might be valuable to articulate the wider benefits of storytelling to enhance their deliberate use.
Addressing these conceptualisations as components of faculty development to promote safe and effective storytelling could guide educators on how to optimise choice and delivery of stories deliberately aligned to the desired learning processes or outcomes.
Reflection
Storytelling has been linked multiple times to successfully promoting reflection in learners, however, the term reflection didn’t explicitly appear in our data (22, 43, 44). Many of the themes already explored implicitly involve reflection and the interview itself involved participants reflecting on past experiences. Experiencing or delivering an emotive story can be thought of as a reflective process especially if it includes a “learning-point” that students can bring into future learning and practice (45). Perhaps neither stakeholder group acknowledging it illuminates how storytelling might facilitate an unconscious type of reflection. Moreover, storytelling could be part of the “hidden curriculum” within undergraduate medicine by promoting reflection, professional identity and the other purposes already described. Perhaps this too could be a focus for faculty development designed to articulate these benefits and enhance understandings of the implicit potentials of storytelling such as promoting reflective practice.
This discussion allowed the development of a possible theory for the successful utilisation of stories within medical teaching. This theory incorporates the study themes and is summarised in Figure 3.
Strengths & Limitations
The strengths of this study include triangulation between the stakeholders and the primary researcher’s (CR) insider perspective which has helped interpret and understand responses. She was assisted by LJ an experienced supervisor, who has undertaken previous research into storytelling for pedagogic purposes. We coded together during data analysis to enhance the trustworthiness of the inductive interpretation and mean-making. Whilst this study does not claim to be generalisable we hope its findings resonate sufficiently to increase discourses relating to the deliberate use of storytelling across other medical faculties.
The study also had some limitations. It had a relatively small size of sixteen, however theoretical saturation was still assumed to be achieved. Selection bias may have been introduced through disclosing the title and focus of the study during recruitment and attracting a sample who favour storytelling within teaching. Unfortunately, the research does not represent the entire medical school as no fifth-year students participated. However, it might be assumed that respondents’ views on storytelling by year five are unlikely to change, as there weren’t many differences in responses between the different year groups sampled.