Thoughts on the therapeutic use of narrative in the promotion of coping in cancer care

Feasibility of a Digital Storytelling Intervention for Hematopoietic Cell Transplant Patients

Patients undergoing hematopoietic cell transplantation (HCT) are at risk for psychological and social impairment given the rigors and multiple sequelae of treatment. The purpose of this pilot study was to test the feasibility of a digital storytelling (DS) intervention for HCT patients, and to examine limited efficacy of the intervention relative to control arm on psychological distress and perceived social support. Adult HCT patients (n = 40, M age = 59.2 years) were enrolled immediately post-HCT and randomly assigned to either DS intervention or information control (IC). DS participants viewed four 3-min personal, emotionally rich digital stories, and IC condition participants viewed four videos containing information about post-HCT care. Feasibility regarding recruitment, enrollment efforts, and change scores from pre- to post-intervention (Δs) on depression, anxiety, and perceived social support were tracked. Fifty-four (51.4%) of 105 eligible patients consented. Forty (74%) patients completed the intervention. All but one completed the post-intervention assessments demonstrating that HCT patients can be recruited and retained for this intervention. On average, perceived social support increased for the DS group (Δ = 0.06) but decreased for the IC group (Δ = - 0.05). Anxiety and depression improved over time in both conditions. Viewing digital stories with content evoking emotional contexts similar to one's own health challenges may improve perceptions of social support among HCT patients. How DS can improve perceived social support for both short-term and longer-term sustained effects in a longitudinal study is an area ripe for additional investigation.

Why We Swab: A library of stories in stem cell donation

BACKGROUND

Stories are powerful in their ability to disseminate information in a meaningful way. We hypothesized that a stem cell donation story library optimized for social media could support the education and recruitment of committed unrelated hematopoietic stem cell donors from needed demographic groups.

STUDY DESIGN AND METHODS

We developed Why We Swab, a library of stories on stem cell donation (facebook.com/WhyWeSwab; instagram.com/WhyWeSwab; twitter.com/WhyWeSwab), and evaluated its impact across social and traditional media as well as on eligible potential donors' knowledge and attitudes towards donation.

RESULTS

As of December 2021, the library included 28 story arcs featuring 45 storytellers from diverse ancestral backgrounds, including 8 donor-recipient stories. Overall, the stories reached >92,000 people across social media. Notably, stories were republished by 18 print/ broadcast media outlets in Canada and by major medical organizations. A series of stories shown to 33 eligible potential donors improved mean total scores on a donation knowledge test (64% to 85%, p < 0.001), reduced mean ambivalence scale scores (3.85 to 2.70, p < 0.001), and improved participants' willingness to register as donors (45% to 73%, p < 0.005). Data are also shown demonstrating that stakeholders valued the library and that its deployment was associated with improved donor recruitment outcomes in Canada.

CONCLUSION

Why We Swab is accessible and relevant to a wide audience, including stem cell donor registries and recruitment organizations seeking to improve their recruitment efforts as well as to blood and organ & tissue donation organizations who can adapt the Why We Swab model to their audiences.

The Human Need for Equilibrium: Qualitative Study on the Ingenuity, Technical Competency, and Changing Strategies of People With Dementia Seeking Health Information

Background

Prior research on health information behaviors of people with dementia has primarily focused on examining the types of information exchanged by people with dementia using various web-based platforms. A previous study investigated the information behaviors of people with dementia within a month of their diagnosis. There is an empirical gap in the literature regarding the evolution of health information needs and behaviors of people with dementia as their condition progresses.

Objective

Our work primarily investigated the information behaviors of people with dementia who have been living with the condition for several (4 to 26) years. We also aimed to identify their motivations for changing their information behaviors over time. Our primary research questions were as follows: how do people with dementia get informed about their condition, and why do people with dementia seek information about their condition?

Methods

We adopted an action research approach by including 2 people with dementia as members of our research team. Collaboratively, we conducted 16 remote 1-hour contextual inquiry sessions with people living with mild to moderate dementia. During the study sessions, the first 40 minutes included semistructured interviews with participants concerning their information behaviors, followed by a 20-minute demonstration of their information-seeking strategies. Data from these interviews were analyzed using a constructivist grounded theory approach.

Results

Participants described their information needs in terms of managing the disrupted physiological, emotional, and social aspects of their lives following a diagnosis of dementia. They used various information behaviors, including active search, ongoing search, monitoring, proxy search, information avoidance, and selective exposure. These information behaviors were not stagnant; however, they were adapted to accommodate the changing circumstances of their dementia and their lives as they worked to re-establish equilibrium to continue to engage in life while living with a degenerative neurological condition.

Conclusions

Our research revealed the motivations, changing abilities, and chosen strategies of people with dementia in their search for information as their condition evolves. This knowledge can be used to develop and improve person-centered information and support services for people with dementia so that they can more easily re-establish equilibrium and continue to engage in life.

Leveraging Stories to Promote Health and Prevent Cancer

Many challenges are associated with communicating health messages to promote healthy behaviors and prevent cancer including limited health literacy levels, varied life experiences, and different learning styles. In this issue of Cancer Prevention Research, Chen and colleagues codeveloped personal, audiovisual digital stories using community-engaged, Digital Storytelling. Their goal was to improve the attitudes of and vaccination intention for human papillomavirus among Vietnamese American mothers of unvaccinated children ages 11-14. This spotlight discusses the implications of their results and further the broader use of stories as tools to promote health and prevent cancer-particularly in underserved minority and immigrant populations. See related article, p. 465.

The Experiences of Recovered COVID-19 Patients in Baqiyatallah Hospital: A Qualitative Study

The emerging COVID-19 disease affects not only the physical health but also the emotional and psychological health of patients. This study aimed to explain the experiences of 22 recovered COVID-19 patients in Baqiyatallah hospital, Tehran, Iran. Data were collected through in-depth semi-structured interviews. All interviews were recorded and transcribed and then analyzed using the conventional content analysis method. This resulted in emergence of 3 themes "emotional-sensational paradox", "spiritual growth", and "experienced mental-psychological effects", with 11 main categories and 33 subcategories. The results of the study can be used to develop instructions and guidelines for the families of patients as well as healthcare teams to provide effective measures and interventions to minimize the suffering of patients and the damage to mental health.

Emotional disclosure in palliative care: A scoping review of intervention characteristics and implementation factors

BACKGROUND

Emotional disclosure is the therapeutic expression of emotion. It holds potential as a means of providing psychological support. However, evidence of its efficacy in palliative settings is mixed. This may be due to variation in intervention characteristics.

AIM

To derive a greater understanding of the characteristics of potentially effective emotional disclosure-based interventions in palliative care by:(1) Developing a taxonomy of emotional disclosure-based interventions tested in people with advanced disease and(2) Mapping and linking objectives, outcomes, underlying mechanisms, and implementation factors.

DESIGN

A scoping review drawing on Intervention Component Analysis to combine evidence from studies' methods, results, and discussion sections.

DATA SOURCES

Six databases were searched to May 2020 including CINAHL, PsycINFO, and MEDLINE. Studies of emotional disclosure in adults with advanced disease were included. Study quality was appraised using an established tool.

RESULTS

Seven thousand seven hundred ninety-two unique records were screened, of which 25 primary studies were included. Intervention characteristics were grouped into classes within three domains: topic of disclosure, format, and dose. Evidence was not available to determine which, if any, of the characteristics is most effective. Thematic synthesis of evidence from methods and discussion sections identified factors to consider in tailoring an emotional disclosure-based intervention to this setting, including: population characteristics (e.g. time since diagnosis), providing a safe environment, and flexibility in format.

CONCLUSIONS

This review approach facilitated a clearer understanding of factors that may be key in developing emotional disclosure-based interventions for palliative populations. Intervention Component Analysis has potential for application elsewhere to help develop evidence-based interventions.

Re-grounding the concept of liminality by foregrounding spatial aspects in experiences of cancer care

Liminality captures the passing stages in transitioning from one sociocultural status to another. As its spatial dimension remains under-examined, we analyse this in experiences of people affected by cancer. We review liminality in cancer-related literature and juxtapose this with empirical material. Analysing interview data (with eight patients) and participant-made photos highlights why places may be experienced differently throughout a period of illness and how places of diagnosis and care 'stretch' across locations. We conclude that exploring liminality's spatial dimension has implications for people 'living beyond' cancer, advances sociological understandings of (cancer) illness, and may inform healthcare facility design.

The experience of patients with cancer on narrative practice: A systematic review and meta-synthesis

BACKGROUND

In recent years, narrative practice has been applied in clinical settings to address the relational and psychological concerns that occur in tandem with physical illness. It is an emerging strategy to treat patients as individuals with their own stories, rather than purely based on symptoms.

OBJECTIVE

To synthesize the experience of patients with cancer using narrative practice.

METHODS

Following a systematic search strategy, a literature search was conducted to identify qualitative studies on the experience of patients with cancer using narrative practice. Nine databases were searched up to April 2018, which included six English databases and three Chinese databases. A meta-synthesis was conducted to synthesize the findings of the included studies.

MAIN RESULTS

Seven studies out of 2894 studies were included in this review. Patients with cancer had different preferences on narrative practices. In terms of the impacts of narrative practice on patients with cancer, six themes were identified, which included '(a) reducing the gap between patients and clinicians; (b) healing effect; (c) social connection; (d) facilitating self-reflection, self-recognition and self-realization; (e) risk of negative impacts; and (f) Patients' preference on different approaches of narrative practice'.

CONCLUSIONS

Patients with cancer experienced positive effects regarding narrative practice. Although some patients may experience negative effects, narrative practice is a humanized way to provide care for patients with cancer in the clinical settings.

Patients' illness narratives-From being healthy to living with incurable cancer: Encounters with doctors through the disease trajectory

BACKGROUND

Narrative medicine emphasizes how stories can increase the understanding of patients' experiences and give important insights into how patients interpret and strive to make meaning in the situation they find themselves in.

AIM

The aim of this study was to gain insight into the illness narratives of cancer patients, from the day they suspected that something was wrong until living with incurable cancer.

METHODS AND RESULTS

Six men and seven women, aged 47 to 79 years, diagnosed with metastatic cancer and undergoing chemotherapy with life-prolonging intent in an oncology outpatient clinic, were asked to tell their illness stories as freely as possible, without guiding questions. Stories were tape recorded, transcribed, and analyzed by a thematic narrative analysis. Encounters with doctors through the disease trajectory were highlighted by all narrators. Several informants described poor communication and consequences in the form of "doctors delay" and substandard psychosocial care. Continuity in follow-up and the physician's ability or inability to break bad news and adapt information to the patient's wishes and preferences were particularly emphasized.

CONCLUSION

A key finding was the importance of the doctor's role throughout the whole trajectory. A good doctor-patient relationship was characterized by continuity of care in follow-up, and trust acquired over time, based on the physician's thorough medical knowledge combined with sensitive communication and empathy.

Connecting one's own illness story to the illness experiences of others on a website-An evaluation study using the think aloud method

OBJECTIVE

It is well described how telling one's illness story can help to cope with illness, but little is known about the processes of reception of other people's stories. This study aimed to analyse patients' reception processes of other patients' experiences while using a website (www.krankheitserfahrungen.de - DIPEx Germany).

METHODS

A text analysis of think aloud transcripts was conducted, using data from a usability study of the website krankheitserfahrungen.de. Twenty patients with the same conditions as presented on the website (chronic pain, diabetes type 2, inflammatory bowel disease, epilepsy) were assigned to the study, asked to use the website and concurrently to think aloud. The sessions were audio recorded, transcribed and analysed using grounded theory methodology.

RESULTS

Study participants started to talk about their own illness experiences while using the website. They constantly compared their experiences with those they read about. Participants' verbalised experiences were categorised according to three underlying themes: significant emotions, unresolved problems, and inevitability and acceptance.

CONCLUSION

Reception of a variety of illness experiences presented online led patients to consider their own challenges in coping with their illness.

PRACTICE IMPLICATIONS

Providing other patients' experiences in information and education materials helps patients to deal with their own illness.

Foregrounding the built environment in the experience of cancer care: A qualitative study of autobiographical cancer narratives

BACKGROUND

For cancer patients, exposure to cancer care facilities entails confrontation in multiple ways. The value ascribed to these places grows over time and can be expected to affect the experience of care.

OBJECTIVE

The purpose of this study was to foreground the role of the built environment in this experience.

METHODS

This qualitative study is based on seven autobiographical narratives written by cancer patients being treated in Belgium or in neighbouring countries.

RESULTS

The thematic analysis of these accounts raises awareness of architecture's role in the experience of cancer patients. Their radius of action is typified by the contrasting adventurous undertakings and shrinking lifeworlds. The built environment furthermore provides leads to metaphors for patients to reformulate their experiences of illness and care.

CONCLUSIONS

Deterritorialised landscapes of cancer care include multiple, geographically dispersed places of care, rather than a single prominent care facility. Simultaneously, exposure to buildings where formal cancer care takes place is intense and meaningful. Metaphors are linked to the built environment and can be seen, through their use in the narratives, to support coping. Further research could look into the potential of metaphors to enhance understanding between stakeholders collaborating around design for cancer care.

A digital self-management intervention for adults with type 2 diabetes: Combining theory, data and participatory design to develop HeLP-Diabetes

BACKGROUND

Digital health interventions have potential to contribute to better health outcomes, better healthcare and lower costs. However, evidence for their effectiveness is variable. The development and content of digital health interventions are often not described in enough detail to enable others to replicate the research or improve on previous interventions. This has led to a call for transparent reporting of intervention content and development.

PURPOSE

To describe the development process and content of a digital self-management intervention for people with type 2 diabetes (HeLP-Diabetes) that has been found to achieve its target clinical outcome, the reduction of HbA1c, a measure of glycaemic control.

METHOD

We synthesised theory, data from existing research evidence and international guidelines, and new qualitative data from target users to identify the determinants of self-management and the content to be included in HeLP-Diabetes. Using an ongoing iterative participatory design approach the content of the intervention was written, produced, reviewed and changed.

CONCLUSION

It is possible to develop and transparently report self-management programmes for long-term conditions, which reflect current best evidence, theoretical underpinning and user involvement. We intend that reporting the development process and content will inform future digital intervention development.

Using a six-step co-design model to develop and test a peer-led web-based resource (PLWR) to support informal carers of cancer patients

OBJECTIVE

To co-design and test the acceptability of a peer-led web-based resource (PLWR) for cancer carers to provide practical and emotional advice on common issues.

METHODS

A six-step co-design model informed PLWR development. Content was developed through three cancer carer workshops and monthly meetings with an expert advisory team (n = 12). User-testing was conducted via web-based survey and telephone interview. Descriptive statistics and thematic analysis were utilised. Google analytics explored site visits, commonly used components, and time spent using the PLWR.

RESULTS

The PLWR was developed to deliver cancer carer information tailored to each stage of the illness trajectory regardless of cancer type, in the form of videoed personal experiences. From November to May 2018, there were 2789 unique visits to the PLWR with 743 returners. The majority of time was spent on the full unclipped peer stories (414 views), and diagnosis-specific information (159 views), with less time spent on bereavement, cancer treatment, or self-care (120 views each). Fifty-five individuals completed the resource evaluation, with 10 participating in telephone interviews. Fifty-four carers rated the resource as excellent, useful, and easy to use. The web-based videos were regarded as convenient as and less burdensome than written information. The resource provided relevant information, potentially reducing isolation and uncertainty.

CONCLUSION

The content and design of the PLWR appear acceptable to cancer carers. The co-design model is an effective way to develop appropriate information for service users and could be utilised as a framework for development of other interventions in a variety of disease groups.

Considerations and recommendations for conducting qualitative research interviews with palliative and end-of-life care patients in the home setting: a consensus paper

OBJECTIVES

To present and discuss the views of researchers at an academic palliative care research centre on research encounters with terminally ill patients in the home setting and to generate a list of recommendations for qualitative researchers working in palliative and end-of-life care.

METHODS

Eight researchers took part in a consensus meeting to discuss their experiences of undertaking qualitative interviews. The researchers were of varying backgrounds and all reported having experience in interviewing terminally ill patients, and all but one had experience of interviewing patients in their home environment.

RESULTS

The main areas discussed by researchers included: whether participation in end-of-life research unintentionally becomes a therapeutic experience or an ethical concern; power relationships between terminally ill patients and researchers; researcher reflexivity and reciprocity; researchers' training needs. Qualitative methods can complement the home environment; however, it can raise ethical and practical challenges, which can be more acute in the case of research undertaken with palliative and patients at the end-of-life.

CONCLUSIONS

The ethical and practical challenges researchers face in this context has the potential to place both participant and researcher at risk for their physical and psychological well-being. We present a set of recommendations for researchers to consider prior to embarking on qualitative research in this context and advocate researchers in this field carefully consider the issues presented on a study-by-study basis.

[Shifting of Centricity: Qualitative Meta Synthetic Approach on Caring Experience of Family Members of Patients with Dementia]

PURPOSE

This study aimed to synthesize the caring experiences of Korean family members of patients with dementia through a qualitative meta-synthesis method.

METHODS

By searching through nine Korean and English databases, we compared 37 qualitative studies on caring experiences of family members of patients with dementia. The selected studies were synthesized through meta-synthesis, proposed by Sandelowski and Barroso (2007).

RESULTS

The meta-synthesis elicited four themes: tough life due to care for patients, changes in relationships, adaptation to caregiver's roles, and new perspectives of life through personal growth. Caregivers were shocked when a sudden diagnosis of dementia was made prior to any preparation on their part. They were tied to their patients all the time and their mind and body got exhausted. Their relationship with patients began to change and they looked at them differently. They experienced conflicts with the other non-caring family members and were alienated from them. They were also socially isolated. However, by building their own care strategies and utilizing social resources, they gradually adapted to their caregiver roles. Finally, they experienced personal growth and acquired a new perspective toward life by accepting their roles and finding meaning in their lives. Shifting the caregiver's centricity from themselves to the patient was the process of becoming human beings who actively constructed their realities while giving meaning to their painful lives and interacting with the environment.

CONCLUSION

The results of the study can be useful for nurses in understanding the experiences of caregivers of the patients with dementia and in providing them with practical interventions.

Living Fully in the shadow of Mortal Time: Psychosocial Assets in Advanced Cancer

Objective: This study aimed to characterize the strategies and psychosocial conditions that influence how resilient people live in the face of advanced cancer. Methods: Grounded theory interviews and a survey of 10 resilient people with advanced cancer were collected and analyzed. Findings: Personal assets — including positive relationships, purpose in life, faith, and mastery — contributed to living fully in mortal time. Strategies included embracing paradox, reframing time, deepening connections, and aligning actions with priorities. Open-ended interviews yielded rich illness and life stories; many participants requested a copy of the transcript. Conclusion: Resilient people use a range of strategies to thrive in the face of advanced cancer.

Narratives of meaningful endurance - how migrant women escape the vicious cycle between health problems and unemployment

Migrant women in Europe have a higher incidence of health problems and have disproportionately high unemployment rates. We examine how Dutch and Turkish, Moroccan and Surinamese first and second generation migrant women escape the vicious cycle between health problems and unemployment by using the theory of the Sense of Coherence (SOC). We study how SOC works and whether SOC is also applicable outside the domain of health. Our findings from life story interviews (N = 54) show that women can escape this vicious cycle through the meaningful reconstruction of adversity. Women can put a halt on the on-going negative chain reaction through focusing on the meaning and purpose of adversity. We name such life stories narratives of meaningful endurance, which are characterized by structure, authorship and meaningful reconstruction, in opposition to its counterpart, narratives of non-directional distress. The three respective components of SOC - comprehensibility, manageability and meaningfulness - enable the attainment of a narrative of meaningful endurance and individuals with a stronger SOC are more likely to tell narratives of meaningful endurance. Theoretical and policy implications of our findings are discussed.

Hope Tree: An Interactive Art Installation to Facilitate the Expression of Hope in a Hospice Setting

Background:

Individuals confronting a terminal illness can experience intense psychological distress. Previous research has shown that hope can enhance one’s ability to acknowledge, accept, and fight a terminal illness. Patients can continue to have hope or be hopeful, even in the face of a terminal illness. Can participation in a creative writing practice improve the expression of hope in a hospice setting?

Methods:

In this program evaluation, each expressed hope placed on the “Hope Tree” was independently coded by all research team members utilizing inductive content analysis. Overall themes were derived using a constant comparative approach and arranged into overarching themes based on consensus.

Results:

Eight major themes emerged from the data: “Peace,” “Dreams,” “Total well-being,” “Acknowledgment of loss,” “Relationships,” “Hospice care,” “Spirituality,” and “Dichotomies.”

Conclusion:

The Hope Tree is a creative art project that can be used within a hospice environment to promote hope among family members and the health-care professionals who care for patients.

Pilot randomised controlled trial of focused narrative intervention for moderate to severe depression in palliative care patients: DISCERN trial

BACKGROUND

Depression is poorly detected and sub-optimally managed in palliative care patients, and few trials of psychosocial interventions have been carried out in this group of patients.

AIMS

A pilot trial to determine the effect of a focused narrative intervention on depression in palliative care patients when used in addition to usual care.

DESIGN

Patients scoring 10 or higher on Patient Health Questionnaire-9 randomised to focused narrative intervention in addition to usual care or usual care only and followed up at 2, 4 and 6 weeks. A reduction of five points on Patient Health Questionnaire-9 was regarded as clinically significant response to treatment.

SETTING/PARTICIPANTS

Palliative care patients aged over 18 recruited from hospice day care services - exclusion criteria included an estimated prognosis of 6 weeks or less, cognitive impairment and unable to understand written or spoken English.

RESULTS

Out of 57 participating patients (71% female), with mean age 65.1 years (range 36-88 years), 33 patients were randomised to the intervention and 24 to usual care only. Mean Patient Health Questionnaire-9 score at baseline was 16.4. Patients receiving intervention had greater reduction in Patient Health Questionnaire-9 score at 6-week follow-up ( p = 0.04). Median survival was 157 days for intervention and 102 days for control group patients ( p = 0.07).

CONCLUSION

This pilot trial suggests a focused narrative intervention in palliative care patients with moderate to severe depression can reduce depression scores more than usual care alone. Patients receiving intervention appeared to have longer survival. These results support the need for a fully powered trial.

Suffering in Advanced Cancer: A Randomized Control Trial of a Narrative Intervention

BACKGROUND

Advanced cancer can erode patients' wellbeing. Narrative interventions have improved patients' wellbeing, but might not be feasible for widespread implementation.

OBJECTIVES

(1) Test the effects of miLivingStory, a telephone-based life review and illness narrative intervention with online resources and social networking, on community-dwelling advanced cancer patients' wellbeing. (2) Explore intervention use and satisfaction.

PATIENTS AND SETTING

Stage III or IV cancer patients having completed initial therapy were randomized to miLivingStory or to an active control group, miOwnResources. Data and Analysis: Primary outcomes measured at baseline, two and four months included subscales for the FACIT-Sp peace and meaning and the POMS-SF depressed, anxious, and angry mood, scored on 0-4-point Likert scales. Linear mixed modeling, controlling for baseline primary outcome scores, tested for group comparisons of repeated outcome measures. Pairwise comparisons tested for within- and between-group differences. Intervention use and satisfaction data were collected automatically and by survey.

RESULTS

Eighty-six primarily white, female patients with high baseline wellbeing completed the study. There were no between-group differences at baseline or at two months. At four months, miLivingStory had a direct and positive effect for peace (2.86 vs. 2.57, p = 0.029), a trend effect for lower depressed mood (0.55 vs. 0.77, p = 0.097), and appeared to protect against the control group's declining wellbeing between two and four months. miLivingStory use was low and assessed as helpful to quite helpful.

CONCLUSIONS

Telephone-based narrative interventions hold promise in improving advanced cancer patients' wellbeing. Further testing of delivery and implementation strategies is warranted.

Living with life-prolonging chemotherapy-control and meaning-making in the tension between life and death

Chemotherapy, radiotherapy, hormone therapy and immune therapy have made many cancers chronic, potential curable diseases rather than inevitably fatal, but the treatments are often both mentally and physically stressful even if the side effects varies. The right use of palliative chemotherapy is a complex issue and there are many aspects to take into consideration. The aim of the study was to gain insight into the illness narratives of cancer patients, from the day they suspected that something was wrong up to the present day where they are living with incurable cancer, undergoing life-prolonging chemotherapy. Thirteen narrators were included. They were all cancer patients on chemotherapy with the intention of prolonging life (informed by their oncologist) in an outpatient's clinic in Norway. Narrative analyse of their illness stories was applied. The main findings showed that the narrators considered their lives worth living in spite of the treatment. They seemed to take control and build a new life on "what was left after the storm," and described how they found meaning living in the tension between life and death.

Feasibility and acceptability of active book clubs in cancer survivors - an explorative investigation

BACKGROUND

While the increasing number of people surviving cancer is promising, the long-term health effects warrant broad, innovative interventions. We investigated the feasibility and acceptability of a 24-week intervention called 'Active Book Club' comprising audio book listening, pedometer walking and supervised book club meetings.

MATERIAL AND METHODS

An exploratory and descriptive design was applied. Qualitative data included baseline and post-intervention focus group interviews as well as post-intervention individual interviews. The study also included data on retention, attendance, and adherence. Seventeen self-referred cancer survivors with various oncological and sociodemographic backgrounds were included.

RESULTS

Eight (47%) participants completed the entire intervention. Their median attendance at the book club meetings was eight [interquartile range (IQR) 6-9] of nine possible, and they reached the walking step goal in a median of 11 (IQR 7-12) of the first 12 weeks, and seven (IQR 1-10) of the last 12 weeks. The qualitative analysis revealed five themes including: Motivation and expectations (i.e. reasons for enrollment), Attentive listening (i.e. experiences of the audio book format), Affected by the story (i.e. experiences of the content of the books), Group involvement (i.e. experiences of the book club meetings) and Walking regularly (i.e. experiences of the walking program). Overall, findings revealed that while audio books may bring new meaning to physical activity and serve as a relief from own concerns, certain stories may affect some individuals negatively. The substantial dropout rate, however, suggested that modification is necessary and that patient involvement in choice of literature may be critical to enhance acceptability.

CONCLUSION

The 'Active Book Club' represents a novel psychosocial intervention potentially supporting physical activity adoption and mental health in cancer survivors. However, several issues related to feasibility and acceptability including choice of literature genre, format and supervision of book club meetings need to be considered before larger scale clinical trials are initiated.

Stories That Heal: Understanding the Effects of Creating Digital Stories With Pediatric and Adolescent/Young Adult Oncology Patients

The purpose of this philosophical hermeneutic study was to determine if, and understand how, digital stories might be effective therapeutic tools to use with children and adolescents/young adults (AYA) with cancer, thus helping mitigate suffering. Sixteen participants made digital stories with the help of a research assistant trained in digital storytelling and were interviewed following the completion of their stories. Findings from this research revealed that digital stories were a way to have others understand their experiences of cancer, allowed for further healing from their sometimes traumatic experiences, had unexpected therapeutic effects, and were a way to reconcile past experiences with current life. Digital stories, we conclude, show great promise with the pediatric and AYA oncology community and we believe are a way in which the psychosocial effects of cancer treatment may be addressed. Recommendations for incorporating digital stories into clinical practice and follow-up programs are offered.

Examining the role of patients’ experiences as a resource for choice and decision-making in health care: a creative, interdisciplinary mixed-method study in digital health

Background

Traditional health information has been based on facts and figures and not on patient experience (PEx). Websites featuring people’s accounts of their experiences of health and illness are popular as a source of information, support and much else. However, there are concerns that experiential information on the internet might have adverse effects on health.

Aims

To find out whether, when and how the NHS should incorporate PEx into online health information and elucidate the mechanisms through which PEx might influence health, develop a tool to measure the effects of online PEx, explore how PEx is used, and investigate the feasibility and acceptability of a randomised controlled trial of online PEx.

Methods

Mixed methods, including a conceptual literature review, qualitative secondary data analysis, the development of a new questionnaire, online ethnography, observational and experimental studies in an internet café environment, and finally feasibility trials to compare new websites based on PEx with those based on facts and figures.

Results

The review concluded that online PEx could affect health outcomes through seven domains (information, support, affecting relationships, providing ideas on how to use health services, influencing behaviour change, learning to tell the story and visualising illness). We developed the e-Health Impact Questionnaire, which demonstrates good psychometric properties and is suitable for use across different health groups and various styles of online information. Online ethnographic studies found three types of PEx on multiple sclerosis (MS) platforms: accounts of ‘living with MS’, self-expression and creativity, and experiences of health care and treatment. Observational and laboratory-based methods included studies of how people find and use PEx to inform health choices. We developed a three-stage model (gating, the engagement loop and outcomes) which guided the development of six prototype multimedia websites featuring either experiential information (intervention) or factual information (comparator) for three exemplar health issues. We evaluated the feasibility and acceptability of a trial of the prototype PEx websites, comparing self-report and process measures with a comparator. In the three conditions we randomised 87 (smoking cessation), 148 (asthma), and 42 (caring for someone with MS) participants. At final (2-week) follow-up, retention rates were 75%, 82% and 86%, for smoking cessation, asthma and MS carers, respectively. Usage of the allocated websites was low. The median number of logins to the websites over the 2-week period was two, two and four; the median number of page views was 10, 15 and 27.5, respectively, with a median total duration on site of 9 minutes, 17 minutes and 31.5 minutes respectively. There were no reported adverse events or harms. The qualitative interviews with 30 trial participants found that the trial methods were acceptable and not burdensome and that preferences for combinations of different types of information were both idiosyncratic and dependent on timing and need.

Limitations

This programme used a pragmatic, mixed-methods approach, in which we adapted some standard approaches (e.g. realist review). The conceptual review provided a framework for the whole programme but did not draw on a single overarching theoretically informed approach. Instead, we used relevant theory and methods from the work package leads, who represented a range of disciplines.

Conclusions

Online PEx is not seen as an alternative to facts, or to care from a health professional, but is used in addition to other sources of information, support and expression. This programme of work indicates how the sharing of online PEx may benefit people, and how this can be measured. A randomised controlled trial is feasible but an allocated ‘exposure’ to a ‘dose of information’ is far from from how online experiences are shared in everyday life. Future work evaluating online health interventions which incorporate personal experiences should aim to reflect ‘natural’ use of the internet and might include online ethnography and offline interviews. Studies might explore how and why people use online sources of experience-based health information, and the effects on subsequent behaviour and health and social outcomes in different conditions. Future intervention research evaluating online health interventions should examine and explain issues of engagement and use, and seek to identify how to increase engagement.

Trial registration

Current Controlled Trials ISRCTN29549695.

Funding

This project was funded by the Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 17. See the NIHR Journals Library website for further project information.

Meaning Construction in Palliative Care: The Use of Narrative, Ritual, and the Expressive Arts

Individuals and families make sense of the world and their experiences through a process of meaning construction. Narrative is an important means of constructing meaning. The diagnosis of life-threatening or life-altering illness often forces revision in the life narrative and the reconstruction of meaning. This article discusses the process of meaning construction and highlights the use of narrative, the expressive arts, and ritual to create meaning and connection. All members of the palliative care team play an important role in helping patients and families tell the stories of their illness and their lives and find meaning and purpose at the end of life. The use of rituals is discussed along with verbal and art-based methods for eliciting patient and family narratives. The relationships among patient, family, and practitioner are seen as powerfully therapeutic and potentially transformative for all involved.

The Absent Breast: Speaking of the Mastectomied Body

Worldwide, approximately 1 in 11 women have breast cancer at some time in their lifetime. The majority are successfully treated with surgery, then radiotherapy and/or chemo-therapy. Survival brings its own problems, however, including an underlying ontological problem: What is the part of the body left after a mastectomy? Women talking about their experiences of mastectomy are faced with complex referential tasks with regard to their bodies at different stages of the past and present, within different discourses (medical, sexual, maternal), and from different perspectives (the individual and the generic, their own perspective and that of their medical professionals). Drawing on anthropological research conducted among Australian women, we illustrate how women resolve difficulties of reference to the site of the mastectomy, and examine the shifts in perspective that are marked by different lexical choices.

The Power of Digital Storytelling as a Culturally Relevant Health Promotion Tool

Digital storytelling is an emergent method in health promotion. It addresses health inequities by combining technology with the voices of members of vulnerable, often underrepresented populations. The overall goal of this pilot project was to explore if digital storytelling could be a culturally relevant health promotion tool for Hispanics/Latinos to share their experiences with cancer, or other diseases. Promotores participated in a train-the-trainer workshop. Community members worked with trained promotores to create digital stories through community workshops. We conducted one-on-one interviews with digital story creators to elicit perspectives and assess their experience. One overarching theme among storytellers was the power of storytelling. Supporting subthemes that emerged in the interviews were (1) connection and communication, (2) lack of opportunities and barriers to telling stories, and (3) potential for disease prevention awareness and education. This study found digital storytelling to be culturally relevant for Hispanics/Latinos of Mexican origin. For these storytellers it was a uniquely valuable tool for sharing personal stories of overcoming or managing health issues. Participants found the digital story experience to be positive and beneficial. It provided a healing outlet to reflect on a difficult experience and find support within one's own community.

An interpretative phenomenological analysis exploring the lived experience of individuals dying from terminal cancer in Ireland

Objective:

The experience of living with dying has attracted limited research. We utilized interpretive phenomenological analysis to explore the lived experience of individuals with terminal cancer receiving palliative care in Ireland.

Method:

Participants were purposely selected from public interviews that had been conducted between 2006 and 2011. The study included the accounts of eight participants (N = 8; six females and two males) with a diagnosis of terminal cancer. Participant ages ranged from 36 to 68 years.

Results:

Three master themes emerged from the analysis: the personal impact of diagnosis, the struggle in adjusting to change, and dying in context. The results revealed that participants were still living while simultaneously dying. Interestingly, participants did not ascribe new meaning to their lives. The terminal illness was understood within the framework of the life that had existed before diagnosis. They strove to maintain their normal routines and continued to undertake meaningful activities. Management of unfinished business and creation of a legacy were salient tasks. Social withdrawal was not present; rather, participants engaged in emotional labor to sustain valued roles. However, we found that within the public domain there is a paucity of education and discourse supporting individuals at the end of life. The hospice was noted as an important external resource. Each participant experienced a unique dying process that reflected their context.

Significance of Results:

Healthcare professionals need to recognize the subjectivity of the dying process. Dying individuals require support and options to maintain their personhood.

Family stories of end-of-life cancer care when unable to fulfill a loved one's wish to die at home

OBJECTIVE

Control over place of death is deemed important, not only in providing a "good death," but also in offering person-centered palliative care. Despite the wish to die at home being endorsed by many, few achieve it. The present study aimed to explore the reasons why this wish is not fulfilled by examining the stories of ten individuals who lost a loved one to cancer.

METHOD

We adopted a narrative approach, with stories synthesized to create one metastory depicting plot similarities and differences.

RESULTS

Stories were divided into four chapters: (1) the cancer diagnosis, (2) the terminal stage and advancement of death, (3) death itself, and (4) reflections on the whole experience. Additionally, several reasons for cessation of home care were uncovered, including the need to consider children's welfare, exhaustion, and admission of the loved one by professionals due to a medical emergency. Some participants described adverse effects as a result of being unable to continue to support their loved one's wish to remain at home.

SIGNIFICANCE OF RESULTS

Reflections upon the accounts are provided with a discussion around potential clinical implications.

Chronic cancer: counseling the individual

Advances in medicine significantly improved outcomes for many cancer patients, effectively moving it from an acute disease to a more chronic one. Living with a chronic cancer often prompts an existential search for meaning, as multiple losses impact the individual on a personal and familial level. At the same time, these patients must learn to adapt to the functional and relational changes necessitated by their disease. Two theoretical perspectives, meaning-making and family systems, are useful in understanding the experience of patients with chronic cancer and offering psychosocial interventions aimed at improving overall adjustment.

Living with a pituitary tumour: a narrative analysis

This study aimed to synthesise the illness narratives of individuals living with a pituitary tumour. Eight adults with a pituitary tumour were recruited from an endocrinology service in the north-west of England. A narrative methodology was adopted which investigated elements of the individual narratives such as metaphor and structure but which also aimed to produce a joint account of experience in this particular illness context by extracting themes across the stories; these are presented as part of a chronological narrative. However, the resulting group story was also analysed in terms of different types of narrative plots. The group narrative started from the recognition of symptoms and then diagnosis though treatment to post-treatment and future plans. In terms of narrative plots, one notable element of the joint narrative was the flow between the culturally dominant restitution narrative, where participants focused on treatment and recovery and the chaos narrative when recovery did not seem possible. The findings contain many elements consistent with previous research; however, the use of a celebrity figure to communicate about the illness experience and a perception that objects or individuals should not be taken at face value emerged as more novel findings.

The impact of patient narratives on self-efficacy and self-care in Australians with type 2 diabetes: stage 1 results of a randomized trial

A randomized-controlled trial (RCT) was conducted from September 2009 to June 2011. National Diabetes Services Scheme registrants diagnosed with type 2 diabetes and aged 30-70 years were invited to participate in a 3-week intervention programme with follow-up at 4 weeks and 6 months. Data were collected using self-report questionnaires in the participant's homes. The intervention group received diabetes factsheets and a DVD comprising patient stories (narratives) of type 2 diabetes management. The control group (CG) received factsheets only. The RCT evaluated the impact of patient narratives on the study outcomes, self-efficacy and self-care, using the Aust/English Diabetes Management Self-efficacy Scale and the Summary Diabetes Self-care Activities measure. Participants were randomly assigned to the intervention or CG using block randomization. The study was not blinded. Six hundred and seventy people enrolled into the study with 335 allocated to each group. At 4 weeks, data were available for 598 participants. t-tests were used to analyse the results. The mean difference between the groups for self-efficacy was 7.2 units (P < 0.001, 95% Confidence Interval (CI) 3.8, 10.7) favouring the intervention group. Change in self-care behaviours during the previous 7 days was also significantly greater for the intervention group: general diet (0.31 days, 95% CI 0.13, 0.48), specific diet (0.26 days, 95% CI 0.05, 0.46), exercise (0.51 days, 95% CI 0.23, 0.80), blood glucose (0.52 days, 95% CI 0.19, 0.85) and foot care (0.38 days, 95% CI 0.06, 0.71). Narrative communication shows promise as a valuable component of type 2 diabetes self-management programmes.

REGISTRATION

ACTRN 12609000210279.

A pilot randomised controlled trial to reduce suffering and emotional distress in patients with advanced cancer

INTRODUCTION

A pilot trial was carried out to determine if a focussed narrative interview could alleviate the components of suffering and anxiety and depression in advanced cancer patients.

INTERVENTION

Patients recruited were invited to participate in a focussed narrative interview and reflect on their perspectives on their sense of "meaning", regarding suffering and their psychological, physical, social and spiritual well being - the emphasis was on allowing the patient to tell their story. Patients were encouraged to share what resources they themselves had utilised in addition to what professional care they may have received, to maintain a sense of well being.

METHOD

Patients with advanced metastatic disease were recruited from hospices in the North West of England - the only exclusion criteria were not being able to understand written and spoken English and a non cancer diagnosis. At recruitment patients were asked to complete a numerical scale for suffering; the Brief Edinburgh Depression Scale, Edmonton Symptom Assessment Scale (ESAS), FACIT Spiritual well being questionnaire, Demographic information was collected and patients were randomised to either the intervention arm of the trial or the usual care arm of the study. Patients in both groups were invited to complete each measure at 2, 4 and 8 weeks.

RESULTS

One hundred people were recruited into the study - 49 were randomised to intervention group and 51 to control group. The median age of patients was 66 years age range (31-89 years) and 68% of patients were female. At baseline the ECOG performance of 75% of patients recruited was 1 or 2. The median survival of all patients in the study was 169.5 days (range 10 days to still alive at end of study). There was no significant difference at any timepoint in scores on suffering measure between intervention group and control group. At each time point the intervention demonstrated mean improvement in scores for depression and anxiety on ESAS - the greatest changes for both depression and anxiety were seen at 4 weeks.

CONCLUSION

This pilot randomised controlled trial of a focussed narrative intervention demonstrated an improvement in mean changes in scores for depression and anxiety at 2, 4, and 8 weeks. We suggest this intervention may have beneficial effects on depression and anxiety, but a larger powered trial is required to determine the full effects.

Health and illness in a connected world: how might sharing experiences on the internet affect people's health?

Context

The use of the Internet for peer-to-peer connection has been one of its most dramatic and transformational features. Yet this is a new field with no agreement on a theoretical and methodological basis. The scientific base underpinning this activity needs strengthening, especially given the explosion of web resources that feature experiences posted by patients themselves. This review informs a National Institute for Health Research (NIHR) (UK) research program on the impact of online patients’ accounts of their experiences with health and health care, which includes the development and validation of a new e-health impact questionnaire.

Methods

We drew on realist review methods to conduct a conceptual review of literature in the social and health sciences. We developed a matrix to summarize the results, which we then distilled from a wide and diverse reading of the literature. We continued reading until we reached data saturation and then further refined the results after testing them with expert colleagues and a public user panel.

Findings

We identified seven domains through which online patients’ experiences could affect health. Each has the potential for positive and negative impacts. Five of the identified domains (finding information, feeling supported, maintaining relationships with others, affecting behavior, and experiencing health services) are relatively well rehearsed, while two (learning to tell the story and visualizing disease) are less acknowledged but important features of online resources.

Conclusions

The value of first-person accounts, the appeal and memorability of stories, and the need to make contact with peers all strongly suggest that reading and hearing others’ accounts of their own experiences of health and illnesss will remain a key feature of e-health. The act of participating in the creation of health information (e.g., through blogging and contributing to social networking on health topics) also influences patients’ experiences and has implications for our understanding of their role in their own health care management and information.

Living through gynaecological cancer: three typologies

AIMS AND OBJECTIVES

The aim of this qualitative study is to highlight how women experienced living through gynaecological cancer.

BACKGROUND

The increasing number of long-term survivors after cancer has created a greater need for knowledge about how patients live through the illness.

DESIGN

A qualitative design, with a phenomenological-hermeneutical perspective, provided the framework for the study.

METHOD

Thirty-two unstructured in-depth interviews with 16 women were conducted. Each woman was interviewed twice: one year apart, and five and six years after treatment, respectively. Stepwise meaning condensation was used to analyse the data.

RESULTS

Based on the women's first-hand stories about their experiences with cancer, we identified three typologies, describing different ways in which the women negotiated encountering and living through cancer. These typologies are the emotion- and relationship-oriented women, the activity-oriented women and the self-controlled women.

CONCLUSIONS

There are substantial differences regarding how women process the experience of cancer. The findings add valuable knowledge about the impact cancer can have on women's lives and can be of help for nurses who support patients during treatment and follow-up.

RELEVANCE TO CLINICAL PRACTICE

Understanding different ways women can experience living through cancer is fundamental for the development and improvement of cancer care. Allowing time for the women to talk with nurses about their cancer experiences could be essential during treatment and follow-up. Nurses can support the women by listening to their stories, accepting their emotions and informing them in detail. The findings in this study imply that strengthening nurses' listening and conversational competence can be of importance for supporting patients after cancer. By building on the women's own stories, it might be possible to create a follow-up process that is individually tailored for each cancer patient.

Men at risk: considering masculinity during hospital-based social work intervention

The needs of hospitalized male patients are often unrecognized and unmet. Men occupy greater than half of all inpatient hospital beds and incur a broad array of illnesses and injuries at higher rates than women--yet often receive health care that pays surprisingly little attention to the concept of patient masculinity, or to masculinity's influence on the male patient's perspectives, behaviors, goals, interests, needs, and challenges. Little emphasis is placed on considering hospitalized male patients as men , understanding their need for patient-centered care within this context, and intervening in ways that regularly allow strengths to be adequately recognized and utilized. In this article, we explore how hospital social workers can reconsider masculinity as a vibrant and formative component of male patients' lives and actively view its characteristics as comprising more than just potential challenges to medical treatment--but also as untapped sources of resilience and strength.

Comparing narrative and informational videos to increase mammography in low-income African American women

OBJECTIVE

Compare effects of narrative and informational videos on use of mammography, cancer-related beliefs, recall of core content and a range of reactions to the videos.

METHOD

African American women (n=489) ages 40 and older were recruited from low-income neighborhoods in St. Louis, MO and randomly assigned to watch a narrative video comprised of stories from African American breast cancer survivors (Living Proof) or a content-equivalent informational video using a more expository and didactic approach (Facts for Life). Effects were measured immediately post-exposure and at 3- and 6-month follow-up.

RESULTS

The narrative video was better liked, enhanced recall, reduced counterarguing, increased breast cancer discussions with family members and was perceived as more novel. Women who watched the narrative video also reported fewer barriers to mammography, more confidence that mammograms work, and were more likely to perceive cancer as an important problem affecting African Americans. Use of mammography at 6-month follow-up did not differ for the narrative vs. informational groups overall (49% vs. 40%, p=.20), but did among women with less than a high school education (65% vs. 32%, p<.01), and trended in the same direction for those who had no close friends or family with breast cancer (49% vs. 31%, p=.06) and those who were less trusting of traditional cancer information sources (48% vs. 30%, p=.06).

CONCLUSIONS

Narrative forms of communication may increase the effectiveness of interventions to reduce cancer health disparities.

PRACTICE IMPLICATIONS

Narratives appear to have particular value in certain population sub-groups; identifying these groups and matching them to specific communication approaches may increase effectiveness.

The family care coordinator: paving the way to seamless care

The care of a child/adolescent with cancer or a blood disorder is complex and often long term, involving many interdisciplinary team members across services and geographical boundaries. This experience can be overwhelming for patients and their families, highlighting the need for a family care coordinator (FCC) to help them navigate their care path. The purpose of this article is to illustrate the concept of family care coordination as experienced by the IWK Health Center in Nova Scotia, Canada, with the intent of sharing a valuable model of care with other pediatric hematology/oncology services. Key components of the role are ongoing assessment, education, partnerships, communication, support, and advocacy. Essential resources and pathways are required to implement the role and optimize patient/family outcomes, facilitating consistent and accessible care, enhancing quality and safety, building trust, and gleaning efficiencies. Inherent FCC challenges are identified as time constraints, replacement issues, maintaining professional boundaries, and emotional burnout. A FCC can enable seamless, individualized care for children/adolescents and their families with pediatric oncological and hematological disorders, optimizing the outcomes for all involved.

Art therapy with cancer patients during chemotherapy sessions: An analysis of the patients' perception of helpfulness

Objective:

Art therapy has been shown to be helpful to cancer patients at different stages in the course of their illness, especially during isolation for bone marrow transplantation, during radiotherapy treatment, and after treatment. The aim of this study is twofold: (1) to assess whether patients during chemotherapy sessions perceive art therapy as helpful and (2) to outline in which way art therapy is perceived as helpful.

Method:

157 cancer patients attending an Oncology Day Hospital (Siena, Italy) met the art therapist during their chemotherapy sessions. The art therapist used the same art therapy technique with each patient during the first encounter (“free collage”); afterward the relationship would evolve in different ways according to the patients' needs. A psychologist interviewed a randomized group of 54 patients after the chemotherapy treatment using a semistructured questionnaire.

Results:

Out of the 54 patients, 3 found art therapy “not helpful” (“childish,” “just a chat,” “not interesting”). The other 51 patients described their art therapy experience as “helpful.” From patients' statements, three main groups emerged: (1) art therapy was perceived as generally helpful (e.g., “relaxing,” “creative”; 37.3%), (2) art therapy was perceived as helpful because of the dyadic relationship (e.g., “talking about oneself and feeling listened to”; 33.3%), and (3) art therapy was perceived as helpful because of the triadic relationship, patient–image–art therapist (e.g., “expressing emotions and searching for meanings”; 29.4%).

Significance of results:

These data have clinical implications, as they show that art therapy may be useful to support patients during the stressful time of chemotherapy treatment. Different patients use it to fulfil their own different needs, whether it is a need to relax (improved mood) or to talk (self-narrative) or to visually express and elaborate emotions (discovering new meanings). Some illustrations of patients using the art therapy process to fulfill these three different needs are provided.

Locating relationship and communication issues among stressors associated with breast cancer

This article clarifies how the social contexts in which breast cancer survivors live can contribute to the stress they experience because of the disease. Guided by Solomon and Knobloch's (2004) relational turbulence model and Petronio's (2002) communication privacy management theory, this study explores personal relationship and communication boundary issues within stressors that are associated with the diagnosis, treatment, and early survivorship of breast cancer. A qualitative analysis of discourse posted on breast cancer discussion boards and weblogs using the constant comparative method and open-coding techniques revealed 12 sources of stress. Using axial coding methods and probing these topics for underlying relationship and communication issues yielded 5 themes. The discussion highlights the implications of the findings for the theories that guided this investigation and for breast cancer survivorship more generally.

How people with motor neurone disease talk about living with their illness: a narrative study

AIM

This paper is a report of a study which explores patients' experiences and how they talk about living and coping with motor neurone disease.

BACKGROUND

Living with motor neurone disease is challenging, frightening and disabling. It leads to progressive physical decline, normally with a prognosis of 3-5 years. Patients have to deal with many problems, including loss of mobility and the inability to communicate. There is little evidence about how people manage these problems or live with this illness.

METHOD

Narrative case studies were used, the unit of analysis being a patient living in their own home or a care home. Thirteen adults were recruited through purposeful sampling. Longitudinal narrative interviews were conducted at three-monthly intervals over an 18-month period in 2005-06. Interviews were analysed focusing on the form and content of the patients' narratives.

FINDINGS

Four types of narrative, or storyline were identified. The sustaining storyline is about living life as well as possible through keeping active and engaged in life. In contrast, the enduring storyline concerns living in an insurmountable situation leaving the person feeling disempowered, unable to fight for life or against death. Survival is the essence of the preserving storyline, while the fracturing storyline concerns loss and fear of what is to come.

CONCLUSION

Storylines help make sense of complex narratives by encouraging closer attention and active listening to the stories and serve as organizing threads to help patients, families and healthcare professionals better understand living with motor neurone disease.