Arts and Health: Creative Writing as a Reflective Method in Healthcare

Introduction

In this essay I shall explore how creative writing can aid practitioners in the formation of therapeutic nursing relationships. I will first discuss some of the benefits and barriers to the establishment of the therapeutic relationship in nursing. I then turn to the potential of the use of the arts within health care, to establish reflective and self-aware practitioners. Following this, working towards closure of the essay, I turn to the value of reflective practice, including the benefits of creative writing to aid my awareness of self, particularly within the nursing role. In this context, I focus on my creative attempt, a fairy tale entitled The Girl and the Well, which can be found as an appendix to this essay, below the reference list.

Therapeutic relationships in nursing: benefits and barriers

All nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory communication. They must take account of individual differences, capabilities and needs. (NMC 2010) To develop and inform our knowledge of patient health needs, nurses must build up a strong rapport with those in their care. They must establish a ‘therapeutic relationship’ (NMC 2010) in which patients feel able to express their needs, beliefs, social/cultural contexts and any pre-existing health knowledge. Good communication is essential in the negotiation of the therapeutic nurse and patient relationship. It has the potential to not only affect the actual care delivered but also how the patient perceives it. As Jootun and McGhee (2011, 41) state: ‘Poor communication can compromise care, which can lead to undue anxiety and frustration on the part of the patient’.

However, effective communication is a complex skill and can, particularly within nursing practice, prove problematic. Communication, as Balzer Riley states, ‘involves the reciprocal process in which messages are sent and received between two or more people’ (cited in Bach and Grant 2011, 11). These messages and delivered both consciously and subconsciously via body language, verbal discourse, eye contact, etc.

The communication process can become further distorted by the interpretation of these messages, which will inevitably be translated through individual schemas (Niven 1995). Schemas referred to an internal storage system informed by facts, experiences, beliefs and views, which we compare and contrast all new and incoming information to (Niven 1995). Processing this information allows us to make sense of our surroundings, to shape our social perception. However, the sense derived is not necessarily a universally accepted perception, as Niven and Robinson explain: ‘each individual’s different observations has been influenced by his or her background. The scene is constant, but the observations are different’ (1994, 40).

This highlights the fluidity of perceptions and their potential to become unconsciously prejudiced. In turn, this can lead to the individual selectively recalling information that can lead to the formation of what Oliver (1993) refers to as negativity bias. Individual prejudices and/or biases can form barriers to communication and therefore the successful formation of a therapeutic nursing relationship. Acknowledging that these barriers may be unconsciously constructed, how then do we as nurses overcome them and create ‘the right conditions for the development of mutual trust’? (Niven and Robinon 1994, 45).

The arts in health care

The nursing theorist Peplau (1952) proposed that is through the exploration of one’s ‘self’ that nurses may start to over come the barriers to therapeutic patient relationships. Peplau (1952, 12) argued that ‘Self insight operates as an essential tool and as a check in all nurse-patient relationships that are meant to be therapeutic’. This is a belief that remains popular in the twenty-first century and is supported by Freshwater (2002, 6): ‘Knowing and recognising self through self-awareness and self-consciousness … can be seen to be fundamental to the development of caring alliance which is to be therapeutic’. Wagner (2002, 121), further argues that the notion of self-awareness is fundamental to our understanding of what caring is:

Implicitly threaded throughout definitions of caring is the need to develop a sense of self, a sense of knowing ones beliefs and values, intention to help, moral commitment to be present, ability to respond competently to another’s need, and willingness to entre therapeutic relationships that encourage human connectedness.

So, how then does the nurse become more self-aware? Wagner (2002, 128) suggests ‘art therapy’ as a possible means, explaining that through the creative process one can unearth the ‘expressions of the unconscious psyche’. The use of artistic methods of expression in health is also promoted by Staricoff (2004, 24), who declared that the ‘relationship between the arts, particularly literature and medicine, stimulates insights into shared human experiences and individual difference, and increases the language and thoughts of the practitioner’.

Staricoff argues for the importance of literary works, which contemplate issues of illness and death, as a valuable resource for practitioners to aid reflection on clinical practice. Wagner (2002) extends on this argument in his assertion that, while the benefits of studying established artists’ work are clear, healthcare practitioners should personally participate in the creative process in order to develop greater awareness of self and personal knowing. However, the creative process and the encouraged confrontation of personal experience is not always an appealing or easy task particularly to those who have been encouraged to focus on the science of nursing and not its art.

The value of reflection

Reflection on and in practice is a process, which has long been encouraged in nursing and nursing education (NMC 2010). As a students nurse I have been encouraged to reflect on my experiences of nursing practice with placement mentors. Indeed, it is an NMC competency, which they have assessed my ability to engage in.

However, not until a recent meeting with my mentor did I fully appreciate the importance of self-refection and the impact it might have on my practice. During this meeting my mentor asked me to reflect on any personal barriers I might have which would prevent me from delivering care. My initial inclination was to reply in the negative; after all I came to nursing with the simple desire to care. However, I wanted to give her enquiry the reflection and attention it deserved and so I took my time to consider my personal values and beliefs.

This led to a consideration of how I have come to hold my personal values and beliefs, my experiences of life so far. In doing so, a somewhat contentious personal memory was re-surfaced, one that I was not aware still had to power to bother me. As with most unwanted/painful memories my initial response was to push it aware, ignore it and hope it goes away. However, through it surfacing I realised this memory/experiences was most likely the sort of potential issue my mentor wanted me to be aware of.

This was clearly an issue, that should I be reminded of it during practice, consciously or subconsciously, could effect my delivery of care. My unwanted memory was from my childhood experiences of living with a parent suffering from alcoholism. Alcohol addiction remains a predominant issue it the UK with ‘1.2 million alcohol-related hospital admissions in England in the year 2011/12, a 135% increase since 2002/03 (Alcohol Concern, 2014) It is inevitable that in my role as a student nurse (and a future registered nurse) I will be delivering care to patients effected by alcohol abuse. This is an issue I needed to reflect on more deeply on to ensure it did not ever bias my care.

I decided to use creative writing as a therapeutic technique to explore this issue. To gain a better understanding of my self in the hope that an increased self-awareness would deconstruct any barriers I may construct to in the attempted formation of therapeutic relationships with my patients. Creative narratives offer the writer permission to explore their own story (Grant et al. 2011) and thus use the art of storytelling therapeutically. Slater (2005,4) similarly argues that creative writing is therapeutic as ‘your own fears and short-comings will find expression in the process… the stories you generate will at once reveal to you your mind while offering up chances to change it.

However, while the reflective output from my creative endeavors promised to be beneficial to my future nursing practice, I found myself daunted by this personal and emotional task and sought some creative distance from it. I found my distance in the simplistic and symbolic style of the fairy tale. In the security of the traditional fairy tale third person narrative I reflected on my experiences of my mothers descent into alcohol addiction when I was a child. This narrative choice was not only elected to maintain fidelity to my genre’s structure but also for the theoretical therapeutic distance it provides. By writing in the third person, in a fantasy world of undefined time and place, using symbols and metaphors to represent emotionally painful issues and events, one can externalize one’s feelings and thoughts without having to explicitly confront them directly. I found this technique worked as a sort of mediator between my realistic memories and the feelings that arise from them. It is the symbolic nature of fairy tales, which have made them a useful and respected therapeutic device in the emotional treatment of children and adults (Brun et al. 1993).

In reflecting on my piece The Girl and the Well, I became aware of its somewhat typical representation of Freud’s theory of separation anxiety. This was expressed well by Bettelheim (1976, 145), who stated: ‘no greater threat in life than that we will be deserted, left all alone. Psychoanalysis has named this – man’s greatest fear – separation anxiety; and the younger we are, the more excruciating is our anxiety when we feel deserted’.

In acknowledging this Freudian interpretation I was able to accept and reflect and on potential feelings of anger at the neglect of myself as a child. In representing my mother I incorporated the formulaic fairy tale element of ‘splitting’ (Warner 1995, 212), a conscious writing strategy that divides the mother figure into two different characters, the ‘good’ mother and the ‘bad’ mother. The severing of the mother figure into these morally polarized beings allows me as the writer to ‘preserve an internal all-good mother when the real mother in not all-good … [and] permits anger at the bad mother’ (Warner 1995, 212). This strategy allowed me to really reflect on my more complex and conflicting feelings about my mother, a process that I found surprisingly cathartic.

Although I found creative writing for self-reflection an overall positive experience, it was a long process. I didn’t just write the entirety of my story in one sitting and feel suddenly healed and enlightened. It took time. It was a reflective period in which I felt completed to read and not just write. I remembered, sought out and re-read Sharon Olds (1987) poem ‘After 37 Years My Mother Apologizes for My Childhood’, which I feel aided my reflection and helped construct the image of my mother in the my tale. At this stage I feel ready to let my fairy tale go, it has served its purpose and provided ‘testimony’ (Grant 2011, 2) to my lived experiences.

Conclusion

I feel that my attempt at utilizing creative writing to explore my self, and therefore become a more self-aware caregiver, was successful. A nurse’s beliefs can be, as Ersser (2002, 56) argues, be ‘communicated to the patient with or without intention’, which highlights just how important it is for nurses to be self-aware in practice. Although I would never knowingly behave in a prejudiced way towards my patients, I feel this deeper reflection has made me more aware of a pre-existing potential issue, which I have had the proactive opportunity to work on. It has also made me more appreciative of the personal narratives patients have and that are always being constructed. As, Slater (2005, 11) argues, ‘Everyone, absolutely everyone had a tale to tell. And everyone, absolutely everyone will have to revise it, only to revise it again’. I believe the learning process has allowed me the freedom to really develop myself independently as a reflective writer and nursing practitioner, a progression I’m not sure I would have been able to succeed to in a more formally structured module.

Charlotte Pendlington, BSc (Hons) Nursing (Mental Health) student

References

Alcohol Concern. 2014. Campaign: Statistics on Alcohol [website] http://www.alcoholconcern.org.uk/campaign/statistics-on-alcohol [ accessed 20 May 2014]

Bach, S. and A. Grant. 2011. Communication & Interpersonal Skills for Nurses. 2nd ed. Exeter: Learning Matters.

Bettelheim, B. 1976. The Uses of Enchantment: The Meaning and Importance of Fairy Tales. London: Thames and Hudson.

Brun, B., E. W. Pedersen and M. Runberg. 1993. Symbols of the Soul: Therapy and Guidance Through Fairy Tales. London: Jessica Kingsley Publishers Ltd.

Ersser, S.J. 2002. The presentation of the nurse: a neglected dimension of the therapeutic nurse-patient interaction? In: Nursing as Therapy. 2nd ed. edited by McMahon, R and A. Pearson. Cheltenham: Nelson Thornes Ltd.

Freshwater, D. 2002. The Therapeutic Use of Self in Nursing. [Online] London: Sage Publications. Available from: http://www.uk.sagepub.com/upm-data/9470_011394Ch1.pdf [Accessed 15 May 2014].

Grant, A., F. Bailey and H. Walker. 2011. Our encounters with madness. Ross-on-Wye: PCSS Books.

Grant, A. 2011. Introduction: Learning for narrative accounts of the experience of mental health challenges. In: Our encounters with madness, edited by Grant, A., F. Bailey and H. Walker. Ross-on-Wye: PCSS Books.

Jootun, D. and G. McGhee. 2011. Effective communication with people who have dementia. Nursing Standard. 25(25): 40-46.

Niven, N. 1995. Health Psychology: An Introduction for Nurses and Other Health Care Professionals. 2nd ed. Edinburgh: Churchill Livingstone: 25-42.

Niven. N and J. Robinson. 1994. The Psychology of Nursing Care. Leicester: BPS Books: 39-64.

Nursing and Midwifery Council. 2010. The code: Standards of conduct, performance and ethics for nurses and midwives. [Online] London: Nursing and Midwifery Council. Available from: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF [Accessed 20 May 2014].

Olds, S. 1987. The Gold Cell. New York: Knopf.

Oliver, R. W. 1993. Psychology & Health Care. London: Billlière Tindall: 159-176.

Peplau, H. E. 1952. Interpersonal Relations in Nursing. New York: Putnam.

Slater, L. 2005. Blue Beyond Blue: Extraordinary Tales for Ordinary Dilemmas. London: W. W. Norton & Company Ltd.

Staricoff, R.L. 2004. Arts in Health: a review of the medical literature. London: Arts Council England.

Wagner, A.L. 2002. Nursing Students Development in Caring Self Through Creative Reflective Practice. In: Therapeutic Nursing: Improving Nursing Care Through Self-Awareness and Reflection, edited by D. Freshwater. London: SAGE Publications Ltd.

Warner, M. 1995. From the Beast to the Blonde: On Fairy Tales and Their Tellers. London: Vintage.

The Girl and the Well

Once upon a time, there was a little girl who lived in the heart of a dark forest. Her name was Little Rose and once upon a time she had been happy. Little Rose had grown up in the comfort of a cosy cottage with her young and beautiful mother whom she loved dearly. Although she considered herself content, Little Rose’s mother was a curious woman with a longing to travel and know all there was to know about the world. One day, tiresome of their modest cottage, Little Rose’s mother announced that she was to journey alone into the forest in search of new and exciting delights to return home with. “Oh Mother,” sobbed Little Rose “please do not go! Or, if you must, take me with you. I won’t be any trouble.” Unaltered by her child’s pleas Little Rose’s mother kissed her daughter on the cheek, made her promise not to leave the cottage, and set out upon her expedition alone.

All alone Little Rose sat by the cottage window and awaited her mother’s return. Years past and yet Little Rose kept her little nose pressed against the pane of glass, willing her mother to walk through the clearing to their cottage; to return home. One day, to her great joy, Little Rose did see her mother emerge from out of the trees and towards their little cottage. “Oh Mother, you have returned to me! You are home. How I have missed you,” shrieked Little Rose as she ran to embrace her mother. However, as she got closer she froze and gasped. The woman in front of her, although with a likeness to her mother, was old and haggard. “You are not my Mother! My Mother is beautiful with a sweet face and fare skin. Your skin is sallow, your mouth is mean, your eyes are red. Oh where is my Mother? What have you done to her?” cried Little Rose. Irritated by the child’s wails, the changed mother pushed her daughter aside with a rough dirty hand, entered the cottage and closed the door behind her.

Left outside, on the other side of the door, Little Rose fell to the ground and sobbed. After a time, when she felt herself more steady, she picked herself up and crept to the window. Carefully peering through, she looked in horror at the sight which presented itself before her. There on the bed was her mother, she was not asleep but awake, breathing smoke, drinking a blood red potion and cackling a strange broken laugh. Her head was swaying an unnatural sway as she began to cough, sending forth hideous flecks of red and yellow slime from clenched cracked black teeth. “This monster is not Mother,” whispered Little Rose as she backed away from the door of her once happy home. “I shall find Mother and together we shall rid our home of this false creature,” vowed Little Rose.

All alone Little Rose set out for the first time into the woods in search of the loving mother she remembered. The woods were dark and unwelcoming and as Little Rose tried to make her way through the masses of unruly branches her hair and clothes were seized and shredded by sharp thorns. As night approached, and the little light that shone through the trees died, the woods became alive with the sound of wild and angry animals shrieking, hissing and growling their warning to those unfortunate enough to cross their path. Hungry and cold, Little Rose persisted on her desperate journey, wandering in circles and calling out for her lost loving mother. “Oh Mother, shall we ever find each other?” As she sobbed these words a worn old owl flew down and perched upon a branch close to where Little Rose lay. “Do not cry Rose, I can tell you where your mother is,” softy hooted the owl. “Where? Please tell me at once! I beg you!” implored Little Rose. Suddenly with a wide sweep of his wings the owl took flight and glided off in and out of the trees, “follow me,” he hooted as he disappeared into a mass of vines and leaves.

Pushing her way through the dense brier Little Rose came to a dry barren patch of earth upon which stood a rickety stone well. The owl perched itself upon the edge of the well hooting “here you are Rose, just as you asked.” Bewildered and overwhelmed with disappointment Rose began to yell “how could you? How could you be so cruel? My mother is not here! Oh, I am all alone and I will never see her again.” As her cries became whimpers the owl flew down and placed itself next to Little Rose sighing softly “you are not alone Rose, and you are not a little girl anymore, see how you have grown.” Rose looked down at her self and gasped, it was true she was no longer a child, indeed she was now a grown woman.

“Once upon a time,” continued the owl “a young woman entered these woods thirsty for adventure and exotic treasures, dissatisfied with the riches her life already held, she let her blind and selfish greed guide her on her journey and it led her to this very well. This is the ‘well of temptation’ and only those willing to forsake their souls to it may drink from it.” Rose slowly stepped toward the well and begrudgingly peered into its depths, “the blood red potion,” she exclaimed “oh mother, was I not enough for you?” The owl stared hard at Rose, “what do you wish to do now my dear? Perhaps you too would like to partake from the well? Or perhaps your heart yearns to return home?”, questioned the owl. Rose glanced again at the well, the thick red liquid was rich and velvety, its aroma strong and enticing. “I am so thirsty” murmured Rose, “maybe I should have just a little … I have no home now … even if I do wish to return there.”

She lowered the old pail into the well and once it was full carefully drew it back towards herself, she lifted it towards her lips and was about to take her first sip when she froze in horror. There staring back at her, reflected in the alluring liquid, was the haggard sallow face which had possessed her mother. “No” she cried, “No, this is not what I want! I want to go home! I want to go home!” As she declared her last words Rose threw the pail back into the well and ran as fast as she could out of the barren land and through the woods. She passed vines and brambles shouting to them “I want to go home!” and as she did they parted, clearing her way. She ran into the darkest part of the woods and shouted at the hidden sky “I want to go home!” and suddenly the trees swayed their branches aside letting the newly risen sun shine through. “I want to go home!” she yelled once again and as she did she ran out of the trees into a clearing leading to a lovely little cottage. Rose stopped in front of the cottage. Suddenly the cottage door flew open and out ran a beautiful little girl calling “Mother! Oh Mother you have returned! You have come back to your Little Rose!” Rose took the little girl in her arms, kissed her on the cheek and softly whispered “yes my little one, Mother is here, Mother is home.” Hand in hand they walked together back into the cottage where they lived together happily ever after.