The writing of narratives and the development of collaborative practices for teamwork

This paper aims to analyze the potential of the narrative as a supplementary strategy for the development of teamwork through collaborative practice. It is a qualitative study, analyzing semi-structured interviews applied to 18 students of the Federal University of São Paulo, Campus Baixada Santista, pertaining to the Physical Education, Physiotherapy, Nutrition, Psychology, Social Work and Occupational Therapy programs. Results reveal that writing narratives sensitizes for care in multi-professional health teams, through agreements and respect for professional and personal characteristics of each one.

Inter-professional education; Health education; Narrative; Collaborative practices; Teamwork

Palavras-chave

O objetivo deste artigo é analisar o potencial da narrativa como mais uma estratégia para o desenvolvimento do trabalho em equipe, por meio da prática colaborativa. Consiste em estudo qualitativo, com análise de entrevistas semiestruturadas, aplicadas a 18 estudantes da Universidade Federal de São Paulo, Campus Baixada Santista, de Educação Física, Fisioterapia, Nutrição, Psicologia, Serviço Social e Terapia Ocupacional^(e). Resultados revelam que a escrita de narrativas sensibiliza para o cuidado em equipe multiprofissional de saúde, por meio de acordos e do respeito às particularidades profissionais e pessoais de cada um.

Educação interprofissional; Educação em saúde; Narrativa; Práticas colaborativas; Trabalho em equipe

El objetivo de este artículo es analizar la narrativa como una estrategia más para el desarrollo del trabajo en equipo a través de la práctica colaborativa. El presente texto consiste en un estudio cualitativo con análisis de entrevistas aplicadas a 18 estudiantes de la Universidad Federal de São Paulo, Campus Baixada Santista, de los cursos de Educación Física, Fisioterapia, Nutrición, Psicología, Trabajo Social y Terapia Ocupacional. Los resultados revelan que la escritura de narrativas sensibiliza a los estudiantes para el cuidado en equipo multidisciplinario de salud, por medio de acuerdos y del respeto de las características profesionales y personales de cada uno.

Educación Interprofesional; Educación en salud; Narrativa

Introduction

The present article has the purpose of developing a reflection on the important role of narratives in professional training and in health care, based in an educational strategy that is being implemented in the Baixada Santista Campus of the Federal University of Sao Paulo (Unifesp-BS), for the interprofessional education of social workers, physical education, physiotherapists, dietitians, psychologists and occupational therapists.

From a broad perspective, narrative is the name given to a “set of linguistic and psychological structures, historically and culturally transmitted, framed by the individual level of mastery and by the combination of socio-communicative techniques as well as the linguistic skills” ¹ (p.526).

In this way, narratives are part of human experience, as humans spend a large part of their lives telling stories. Through narratives it becomes feasible to understand the more complex texts and contexts of their experience. This idea guided the varied research lines about how memory is organized, life stories, the intentions and ideals of the self, corresponding to the “personal identities” of the narratives. The quest for attributing meaning can be considered as the human life central aspect¹ and is through language that humans give significance and re-signify their lives.

Narratives have a central role in the interactions between the individuals and their conscience, letting them to perceive, to experience and make judgments of their actions, the course of their lives, allowing for a process of structuring and re-structuring their conscience².

The origin of the concept of narrative is dated by Hydén³ in the research on medical and illness beginning in the 80’s, citing the fact that those studies were usually related to the concepts of identity and self.

From the 90’s on, Rita Charon and other scholars began to systemize the issues related to patients’ narratives. In 2006 Charon coined the term Narrative Medicine to give name to a methodology that proposes a patient-centered medical activity, including attentive and empathic listening. In this methodology, the medical practice must demonstrate acknowledgment and assimilation skills and the capacity of interpreting stories of illness as therapeutic tools, complementing Evidence-based Medicine^4,5.

These issues show how narratives contribute to patients’ treatment, interpreting their illness experiences, their way to cope with disease and the transformations that those processes bring to their daily life and their significant others^4,5.

The studies also show that narratives help to develop empathy in health practitioners, to enhance patients’ trust and to create compassion for pain and suffering for those who receive care. This type of discourse may also foster practitioners’ reflection on their own practices, aimed to improve diagnosis and approaches⁵.

The National Curricula Guidelines (NCG)⁶ for training future health professionals in undergraduate courses, issued between 2001 and 2004, shape the profile of a graduate/practitioner that undergoes a training geared towards being “generalist, humanist, critical and reflexive”, taking into account not only biological and technical dimensions, but also psychosocial aspects of persons “in their own historical moment”. These guidelines add to the specific technical contents, those from the Human and Social sciences, to complete the development of these professionals.

If we acknowledge that there are certain issues in health care that are not matter of objectivity, there is a need of invest in a training that is geared towards the linkage between the practitioner and the patient, developing empathy, trust and improving the patient adhesion to treatment.

Narratives are still more relevant in professional education, as a practice that fosters sensitive listening, observation, rapport, problematization, autonomy, the practice of questioning, the dovetailing of theory and practice and the knowledge of the practicum settings⁷.

An advantage of working through narrative skills in the health professional training has to do with the chance of developing a practitioner that is more alert to the patients and their experiences. Furthermore, the practitioners become more reflexives regarding their own actions and more accurate when interpreting the life stories of their patients⁵.

Several Brazilian higher education institutions are developing changes in the traditional discipline-centered and profession-specific model of training, as in the case of the Baixada Campus of the Federal University of Sao Paulo (Unifesp-BS), trying to promote a breakthrough in the predominant professional profiles.

This Campus uses a pedagogic proposal focused in interprofessional and interdisciplinary learning in health, to graduate a professional that is committed to teamwork⁸.

Interprofessional Education (IPE) is characterized for teamwork, that following Peduzzi⁹, “is a modality of collective work shaped by the reciprocal relationship between technical interventions and agent interactions”. This strategy trains the professionals for collaborative practice, recognized by the World Health Organization in 2010 through the position paper Framework for Action on Interprofessional Education and Collaborative Practice. This document has the aim to put together strategies and concepts to thrust IPE and collaborative practice, acknowledging the fragmentation and the difficulties of world health systems to respond to unattended health need¹⁰.

IPE in health professional courses gained visibility in the National Curricular Guidelines for graduate courses in Medicine, issued in 2014, that remarks the importance of a kind of care where the inter-professional work in teams is prevalent¹¹.

In the Political-Pedagogic Project of the Baixada Santista Campus⁸ the curriculum organization follows four main lines (axis): 1. Work in Health; 2. The Human Being in the biological dimension; 3. The Human Being and the social insertion; and 4. Approaching a specific practice area in health.

This structure allows the students to learn about their own specific area while at the same time they may get acquainted with the training areas of the other students, to take into consideration different dimensions of illness other than their biological aspects⁸.

Teaching-learning activities are structured in modules by semester and teachers of different areas give lectures to mixed groups.

In the axis Work in Health (WH), both students and teachers are exposed to experiences conducive to questioning the closed theories that are impervious to real life situations, and are requested to exercise their clinical reasoning and to deal with clinical/ethical/political dimensions that impact working in health¹².

In one of these activities, students are guided to develop clinical narratives in pairs of two different professions, using as a source the listening of a life story of population residing in regions of higher social “vulnerability” in the city of Santos, Sao Paulo state. The relevance of working with narratives is seen in the opportunity of putting together students, health services and the context of daily life and health situation of the users of those services.

This paper has the objective to analyze the power of the narrative as an strategy for developing teamwork and consequently, collaborative practice¹³.

Methods

This article is a by-product of the Master’s degree research “Interprofessional Education and the process to produce narratives: building learning pathways”¹⁴. That study had as a general purpose to describe and analyze the trajectory of the 2^nd.year students in the following courses: Physical Education, Physiotherapy, Nutrition, Psychology, Social Work, and Occupational Therapy in the Unifesp-BS, to create life stories narratives in interprofessional pairs, with populations resident of higher social vulnerability areas in Santos, Sao Paulo state: Centro, Morro and Northeast areas.

The Master’s degree research was of qualitative, exploratory and descriptive nature and its project received clearance from the Ethics Research Council of the Unifesp in April 5^th.,2013 through resolution 238.348.

Two instruments for data collection were used: a multiple choice questionnaire, applied to 146 students enrolled in the Module under study, and semi-structured interviews to 18 of them, recorded, written and analyzed through Content Analysis, in the modality of Thematic Analysis¹⁵.

The questionnaire had 9 closed questions, exploring aspects on the behavior of students related to their habits of writing and reading, with the purpose of classify them in a descriptive way.

In order to obtain in depth information on the process conducing to the narratives, interviews happened during the semester in three stages: the first, at the beginning of the module, with the objective of assessing data on previous knowledge about narratives in health and about the obstacles that students were expecting in order to write this kind of text. The second, after supervision in the classroom with teachers had as its objective to gather information about the writing process and the impediments/facilitators that were found in practice. The third, after the ending of a narrative was intended to get information on the contributions of working through narratives in the students’ life.

The thematic analysis was performed following 3 major themes: 1 “Impediments and facilitators when producing a narrative”; 2. “Narrative production in the interprofessional context”; 3. “Impacts of the experience in producing narratives in the students”.

In this article the focus will be on the results and discussions of the category 2.

Due to ethic reasons, students were identified only by their courses: FIS (Physiotherapy), NUT (Nutrition), EF (Physical Education) and PSI (Psychology), and also by the research stage: F1 (phase 1), F2 (phase 2) and F3 (phase 3).

Results and discussion

Results of all three stages of the interviews were convergent due to the fact that many of the elements supposed to be obstacles or facilitators for the joint writing of narratives, found in F1 are later confirmed in F2 and F3. This article is directed to the questions related to teamwork and collaborative practices.

A remarkable fact from the interviews was to perceive how the narrative had the potential to promote teamwork, as that activity in pairs of students of different courses, facilitates the development of essential skills for this type of work, e.g. listening, negotiation, dialogue, decision-making, considering the boundaries of each profession and respect for differences.

At the beginning, the main focus was to research the facilitators/obstacles found to write narratives from the perspective of textual construction, as those of the choice of narrative focus, text organization, among others.

Later, and as interviews happened, other elements surfaced, specifically the pitfalls and advantages of writing and working in interprofessional pairs, due to agreement attitudes.

It was noticed that there was a need of making agreements between the students of each pair, which in turned remarked the importance of dialog and articulation, looking for problem and conflict-solving, using consensus and common attitudes. The interview analysis shows how these competencies crosscut the three phases of the research, as highlighted by the students.

Trying to fill the gap existent in the classification of the competencies needed for collaborative practice, Barr¹³ proposes three types: Common (common competencies for all professions); Complementary (specific for each professional area and that may articulate complementarily with the others); and Collaborative (those that are used to collaborate with professionals in the same area of activity, with professionals of a different areas, with non-professionals, within the same organization, among different organizations, with patients, carers, volunteers and community groups.

Regarding the common competencies, writing narratives help to be aware that several characteristics of practitioners, such as to know how to listen, to be tolerant, to be open to other practitioners’ opinions, to be ready to concede, that are essential for the student to find in her/his colleague a partner in the task of knowledge building. Being aware of this new dimension prepares the students to cope even with the competitive instinct and the personal and professional differences:

[…] you need to be like this… to be open… you know? To the opinion of both of us, right? […] to be open to… opinions and…try to find common ground…right? sometimes you have an idea and the other has a different one… but if you are patient to stop…listen…it is possible to find a mid term that is ok for both […] (NUTF3).

In their words, the students show how they have overcome differences in the pair of colleagues, as long as they exercise mutual respect:

[…] I see that my pair and me had a bit of a difference in that point… like… when writing… he wrote in a very formal way and I was more informal…and such…so then… when we needed to write the narrative… we pieced together the informations… and the wording was more his… but trying to speak a little bit like me […] (NUTF3).

[…] I think that the proximity with another person… with an individual was what moved me more… because is a different reality… the reality of the citizen… even her age… because she is pretty old… her values are different from mine […] in the beginning … was quite weird to live close to these differences […] Me and my partner had also differences […] and at that point I realized how important because in the future as a professional… we will need to understand those differences and acknowledge all the social… cultural and political aspects to be able to integrate with the biological aspects of the patient… right? of the individual that we are going to work with […] (EFF3).

To work with a friend is in fact easier for the task ahead, but even when this circumstance is not present, the students participating in the interviews learned how to cope with the hardship of interaction. Therefore, writing narratives in pairs also foster respect to differences, as the students learn to take into consideration the colleague’s opinion to contribute towards a common interest, the citizen’s.

In Batista’s words¹⁶:

IPE is geared towards an education for inter-professionalism in which teamwork, debating about professional roles, commitment in solving problems and trade-offs in decision-making are the main hallmarks. For this end, to value the history of different professional areas, to consider the other as a legitimate partner in building knowledge, respect for differences towards the quest, the dialogue, the challenge, the commitment and the responsibility, are the essential components.

Collaborative competences are evident in the reports of the students since the first stage of interviews (F1), even before the fieldwork:

[…] It is going to be a challenge, I think […] when it’s time to talk… and define what we are going to write, there is a whole discussion to have […] I may want something but my partner may want another and both visions may complete each other, thus… I will need to understand what she is trying to tell me and she needs to do the same with me […] when… it’s individual choice … there you decide what you want to write and just write it… no one is going to say “look… that’s not right”… and when you work in a pair or even in a group…it’s different because there you have… several minds thinking together and several ideas… and there you need to elaborate and pick […] (NUTF1)

In the second round of interviews, during the writing process, dialog was identified as one of the main aspects to overcome the challenge of joint work, to reach consensus among students:

[…] after the field visits, we gathered together and talked […] in the field diary, we put a whole bunch of things, that helped a lot when writing the narrative, because I had one point, she had another but when we talked, we understand each other and what was the important thing to write down […] (NUTF2).

This statement, from an Occupational Therapy student in the third phase of interviews is an example of the acknowledgement of professional activity boundaries, from the start of the course, and the chance it opens to joint learning, as a facilitator of knowledge interchange and of knowledge aggregation; confronting that complementary competencies:

[…] I think that when I graduate I will not work alone… that’s why I need this conection with the other courses… other people […] many times the pairs are composed with guys that are not from our daily routine… I don’t talk that much with other people… but in the classroom she is my pair… so we begin to learn respect for the other’s space… to get to know about what she does… because oftentimes we think ‘ Well… Nutrition… is just making menus and that’s it! And it’s not like that, you know? […] (TOF3).

According to Batista¹⁶, the need for integrating professional work in health care, through new ways of interaction in teamwork, allowing for knowledge interchange and experiences that respect diversity, will conduce to cooperation for transformatives practices in health care, to foster partnerships in building joint projects and to open ways to stable dialogue.

Is in the same sense that Aguilar-da-Silva et. al.¹⁷ stress that “the competency of each professional isolated, is not enough to cope with the complexity of responding to health needs, therefore it is required flexibility in the competency boundaries to be able to give comprehensive care”(p.175).

When students realize that remaining inside their professional training area, they will not be able to perform without help from outside, they open up for working in teams and for comprehensive action.

The students, acknowledging and respecting their pair’s activity, also strengthen their own perception of being part of a team. In this situation each practitioner makes decisions using her own professional skills towards a common goal^9,18.

The idea of a juxtaposed group may enhance the perception of disease care through a biologic model and a fragmented patient. Teamwork model, on the other hand, benefits from concepts of comprehensive care of the human being and facing the true population needs, using a bio-psycho-social model^9,18.

Narrative is in this sense, a way for the student to learn in the context of comprehensive care, as each one needs to be alert and immersed in the listening of the life stories of the citizens, as every detail may reveal a tip for adjusting treatment.

Another issue that emerged from interviews was the one related to the narrative in an interprofessional context as facilitating the writing.

As a general matter, the findings showed that students acknowledge the positive aspects of working in interprofessional pairs, even before the beginning of the Module activities, in the first phase of the interviews. This statement of a Nutrition student shows how the fact of the collaboration of a colleague will help organizing ideas “[…] when you are with somebody else … it’s easier… to put together the ideas […] two people thinking together makes[…] easier when… writing a better text… you know, more coherent…when you put together two opinions […]” (NUTF1).

Writing in pairs is therefore a facilitator element, as the students have the chance to share the “linkage” of their words, writing is perceived as easier. Their reports show that the encounter with a colleague from other area, and needing to establish a rapport to achieve a good life story of one or several characters makes easier to learn about the training area of the co-writer.

[…] how we write…is not that different… therefore I think it was helpful… each of us begins to awake something in the other… and that makes the understanding, see? Because of that good relationship…is not what each of us do, no!...is what we do together…[…] it’s cool this thing of… being from different areas, because I found how several things in OT were super… cool…and I told her ‘oh my god, how awesome that thing that you guys do!!...(FISF1).

[…] I think it’s easier to be in a pair […] related to the fact of being of other course […] I think it may add up in the narrative because of …other knowledge… other lectures […] many Physiotherapy things I don’t even fathom, right? and she brings that information from her area… it’s easier than if I needed to check by myself […] (PSIF1).

Writing in pairs is also cited in different reports as a very peaceful work. It is well known from the elementary and high school experience, that writing in pairs may end up being a task of just one of the components. Instead, in these narratives, even though mostly written halfway for one of the students and then completed by the other, based in the field notes of each one, there was always an agreement and consensus between the two of them.

“She wrote it too verbatim… so it was a discourse cut in pieces…short statements…words like…you know…a very homely vocabulary… and talking about that… I showed her examples…told her ‘look…for instance…its is a more articulated discourse…for someone else to read…this looks more as an informal chat…don’t you think it’s better to adapt those parts… and she ‘right…you’re right…doesn’t make any sense’ then it’s awesome to accept criticism and redo it and was cool…looks as a unified text…written by one person… because she suggested to write it in first person… and I bought into it and then… when I suggested her to modify it… she was cool with it … so we had a great partnership… we worked together well […] we adapted the slang… grammatical errors…Portuguese mistakes…ok?”. (PSIF3).

This speech shows the importance of individual writing of the field notes and of the final report, as a way of co-responsibility from both in the narrative writing.

In the final stage of the study a Physiotherapy student reported not having problems in the narrative writing in pairs, because of familiarity with the colleague:

[...] it was so easy… I had a great affinity with the person… that helped a lot…we didn’t even fight once…we were great partners…we completed each other…was a cool job to do […] (FISF3).

Following Capozzolo et al.¹² there is a need to be alert to question how “differences and proximity between convivial collective and professional teams” have not been examined in the training and it bears the risk of “transforming professional teamwork in a viable resource only when there is the ideal condition of being a team of friends”.

Narrative production may in the end, acknowledge that writing in pairs will strengthen aspects of interprofessional teamwork. In order to this end, opening room for discussion about the process involving the narrative elaboration, stressing the feelings, will highlight its importance for managing personal conflicts.

Final considerations

Writing narratives in pairs in interprofessional education appears to be a creative, critical, reflexive and innovating experience for teaching Health Sciences, as a part of the second year curriculum of undergraduate courses in Unifesp-BS. This active teaching methodology may be used as an additional facilitating tool to develop basic competencies for collaborative practice.

The students’ statements showed that common, complementary and collaborative competencies crosscut the different stages of joint writing.

The methodological choice of analyzing the trajectory of the students when writing the narratives, in three phases, brought advantages to the research, as it revealed the depth and width of the joint writing work process

It is important to remark that the methodological choice shifted the direction of the study, making possible to acquire knowledge about issues that were beyond the initial objective of the Master’s research, meaning to investigate the textual obstacles and facilitators involving writing narratives before the beginning of activities (F1); during the process in the practicum (F2); and in the end of activities (F3). Those issues also involved the challenges of the interprofessional pairs for the students as the activity happens in a context of interdisciplinary and interprofessional training, and is cross-cut by interactions among students, teachers, practitioners, users, community and health services.

The study showed itself a considerably valid input for health professional training and practice, analyzing in a critical way the results of an innovating experience where future professionals develop basic skills for teamwork, such as to be open to listen, to negotiate, to dialogue, to make decisions, to understand their own professional boundaries and to pay mutual respect to differences.

Another point to be remarked is that the study deals with an activity that brings in itself experiences such as illness to the center of the care process, focusing in the individual and in the psycho-social aspects of such illness, thus contributing for a more humane care practices.

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Publication Dates

• Publication in this collection
  13 May 2016
• Date of issue
  Oct-Dec 2016

History

• Received
  11 Sept 2015
• Accepted
  23 Jan 2016