Axon: Creative Explorations

Keywords: Portraiture — qualitative methodology — creative-based — nursing — resilience

 

Introduction

The nursing workforce in Australia is a workforce under pressure. Within in-patient settings, rapidly increasing turnover of more acutely ill or co-morbid patients, and staff retention issues, place staff under increased pressure to maintain safe and quality healthcare provision. In nurse education settings the increasing imperative to recruit more students into the profession, combined with financial cutbacks to tertiary education, also lead to staff retention issues; and this creates a similar tension. Yet many Registered Nurses (RNs) do remain in their chosen work setting, displaying tenacity and resilience despite these issues. Resilience, which engenders wellbeing, is especially important in these contemporary healthcare settings, where nurses are under duress (Tusaie & Dyer 2004).

Resilience is commonly known as the ability to ‘bounce back’, to adapt or adjust positively over time to trying circumstances, to ‘weather the storm’ (Masten 1994). This study was guided by Ungar’s definition, which suggests that resilience is better understood as follows:

In the context of exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being and their capacity individually and collectively to negotiate for these resources to be provided in culturally meaningful ways. (Ungar 2008: 225; emphasis in original)

Few researchers seek to debrief nurses by hearing their personal narratives of aspects of nursing work. Providing nursing stories from the nurse’s own words is a powerful way of filling this gap. Storytelling can assist in making visible the personal, professional and contextual components of resilience within a nurse’s work and, through the use of story — a language common to us all — share with others the wisdom learned by these nurses.

The knowledge and practice of nursing is influenced by the need to understand experiences, whether it be their own nursing experiences or those of their patients, clients, residents or participants, in order to articulate the essence of that experience and its meaning: to tell the story. Formerly, medical and nursing language and research were framed only within the positivist paradigm, with quantitative approaches to health and healthcare considered the only source of evidence. More recently, research approaches that use dialogue and discourse have allowed a greater understanding of narrative and storytelling in the practice of medicine and nursing, and this provides a vibrant new perspective (Robertson & Clegg 2017; Shields, 2016).

A creative arts approach can add to health research, enhancing the wellbeing of research participants and the communities from which they come, by creatively engaging with key insights from ‘expert’ participants who offer their unique perspectives of human health and of nursing. The arts-based writing of those insights or stories is the transformative medium that allows the sharing of the collective sense of a phenomenon under study that ‘animates the ordinary’ (Stewart 2011: 452), connecting readers through the creative language of storytelling while still maintaining academic rigour. Nearly everyone loves a good story, as such narratives are usually pleasurable and evoke a sense of shared knowledge. Portraiture is an innovative and creative qualitative approach that was developed to construct a collection of verbal portraits through ‘painting’, via an interpretive and creative written ‘canvas’. Within the portraits are the nurses’ stories of resilience, presented with reference to their nursing work and experiences, as they reflect upon and give insights into resilience in nursing.

 

Creative-led resilience research: Portraiture

The aim of the research was to try to understand what the nurses’ perceptions are of resilience, and their thoughts, beliefs and understanding of its effect on themselves and their practice. Portraiture was chosen to illuminate nursing resilience as it can yield important insights and understanding about resilience in a creative way, through the use of a written canvas rather than a painted one: that is, through words rather than brushstrokes (Cope, Jones & Hendricks 2015). Developed by Sarah Lawrence-Lightfoot, Portraiture is a combination of several qualitative approaches: an amalgamation of ethnographic methods, life history and narrative inquiry (Lawrence-Lightfoot & Davis 1997).

Traditional methods of data collection such as interviews and observation were used to produce and translate knowledge about nursing resilience into valid, compelling written portraits. The researcher began this study by listening to each participant nurse’s story and, through the unfolding of those stories, learned the common threads of what being resilient meant to the nurses. During the course of the interviews, each nurse stated they felt grateful for the opportunity to talk about their nursing — a work choice so personal and critical in their life. The participants in this research wanted their stories told, and they wanted to be listened to. Further, the portraits allowed the nurses to have a voice, whether for emancipation or to explore or reflect on their specific circumstance of nursing in times of healthcare disarray (Cope 2012).

These nurses were ‘key informants’ from within nursing, and the researcher was privy to insider norms and mores within nursing (Geertz 1973). As early as 1997, Reed-Danahay notes that ‘The voice of the insider is assumed to be more ‘true’ than that of the outsider’ (1997: 4). The truthfulness in the participants’ voices provides a new readability, ‘an aesthetic whole’ (Lawrence-Lightfoot & Davis 1997: 28) within the person-centred portraits. The portraits constructed are creative and interpretive, yet remain scholarly, crafted and cohesive narratives that capture the unique experiences in storied form, and using nursing voices that connect with readers on an individual level. The nurses’ experiences, their words, their voices, and their truths, reveal resilience through their own stories. The words of the participants and the interpreter (the researcher or Portraitist) meet and meld, blending in colour and texture, and chiaroscuro or shading, throughout the portraits.

Although only nine participants were framed into portraits for this study, it was a size that permits ‘the deep case-orientated analysis that is the hallmark of all qualitative enquiry, and that results in … a new and richly textured understanding of experience’ (Sandelowski 1995: 183). Each portrait is a unique creative interpretation of each participant’s story. Therefore, replicating a study such as this would be difficult.

 

Listening for a story

The process of undertaking Portraiture is an intensive one, as ‘listening for a story’ often is (Cope 2012). The distinction from traditional research approaches, where researchers strive to maintain objectivity and seek to eliminate bias, is evident because in this mode the portraitist aims to: ‘embrace and share in the passion of the portraits, and is more palpable than in any other methodological form for their visibility which is central to, highly valued and acknowledged in the narratives’ (Cope 2012: 169). This approach provides nursing research with portraits of real nurses and their experiences of contemporary nursing: stories that are diverse, yet resonant with the themes of resilience, presented through a palette of science and art.

The interpretive process sought to uncover each individual’s experience of their context of nursing, and to develop an understanding, or make sense, of their stories of resilience. ‘Meaningfulness’ is bestowed on expression by interpretation, which seeks to ‘identify patterns, extract themes, and begin to distinguish beliefs and behaviours’ (Wolcott 1994: 107). The portraitist attempts to provide a detailed examination and description of the experiences and events of resilience, and is concerned with the meanings attributed to those experiences by the nurses; that is, the explanation of their ‘lifeworld’. The researcher takes a primary role in searching for meaning within the participant’s personal world, to ‘see their mind’s eye’ (Gadamer 1979).

Every day, nurses encounter experiences that test them, and their ability both to resist and to maintain equilibrium through resilient behaviours was evident in their accounts of their experiences. In reflecting on contemporary nursing settings, Portraiture as methodology does not focus on negatives but rather bases its approach on successes, and thus it acts as a counter-narrative. The narrating of the nurses’ experiences do not merely recount the pressures of the current health care system but, with creative intent, fashion and interpret portraits that demonstrate the nurses as survivors and victors, actively engaged in their own resilience (Cope 2012).

Nine nurses from three distinct contemporary Australian nursing settings were observed and interviewed concerning resilience within their work, once ethical approval had been gained from the University and each healthcare site (Project 08-43). The occupational and everyday life/work events of contemporary nursing were fashioned onto the canvas of the portrait, revealing a composite image of individuals’ beliefs regarding the organisation in which they work, in the current place and time (Lawrence-Lightfoot & Davis 1997). The portraits reflect workload, nurse management, education, residential aged care, and the general sense of what nursing is today.

The settings included residential aged care and acute tertiary hospitals, and involved middle managers and nurse academics. Their distinctive accounts of nursing resilience, embedded with observations around their resilience in context, express feelings and thoughts about their experiences and deliver messages in narrative form that are otherwise not easily articulated.

 

‘Painting’ the portraits

Lawrence-Lightfoot and Davis write that Portraitists have the advantage of documenting:

initial movements and first impressions, and noting what is familiar and what is surprising. The Portraitist gathers, scrutinises, and organises the data and tries to make sense of what she has witnessed (1997: 187).

Memos, field notes and recordings may be used in addition to the portraits, as they contain descriptions of the physical landscape, details of place, descriptions of everyday occurrences, and aim to capture what is superficially apparent but adds to the ‘painted layers’ of each setting, the ‘chiaroscuro’ of person and place (Denzin & Lincoln 2008). Lawrence-Lightfoot and Davis describe the method of Portraiture as: listening for a view of the whole (interviewing); taking some perspective (reflecting); illuminating the voice (interpreting); developing relationships, and seeking artistic refrains and emergent themes (data analysis); and composing the narrative or shaping the story to present the aesthetic whole (the portrait).

This is achieved through the intimate sharing of real stories, allowing the participants’ voice to emerge through a blend of observation and interview, an amalgam of ethnography and case study (Cope, Jones & Hendricks 2015). The Portraitist needs to be fully immersed in the story of each participant and to write and conclude that experience before moving on to the next (Lawrence-Lightfoot 1983). This is because the writing of a portrait and the analysis of the data occur concurrently and continuously, and is aided by writing down and thinking about all of the new questions that reflection on each interview generated. Constantly reflecting every day on what was found interesting, appealing, similar or dissimilar, and building upon the reflections as themes and insights emerge, enables the coherent construction of a finely crafted portrait.

Erlandson, Harris, Skipper and Allen (1993) assert that Portraiture is welded to the creation of literature, vivid with ‘thick description’ (Geertz 1973). The portraits are truthful presentations of what one is seeing, and they rest on the development of rapport between participant and listener and/or researcher so that the narrative environment is able to foster interaction and verisimilitude. In this project, the nine nurses all had a story to tell and the Portraitist listened intently and actively; we were partners in the research process, espousing a holistic perspective, revealing the participants in their time and context, and embracing sensitivity (Lawrence-Lightfoot 1983). The portraits also make known attitudes and feelings, providing the text with ‘expressive content’ (Lawrence-Lightfoot & Davis 1997: 28). This in turn offers the vivid description that leads to the emergence of artistic refrains or emergent or universal themes against the background of time. The data become portraits, fashioned with the nurse’s voice, while the researcher becomes the portraitist, ‘becoming through the telling’ (Jackson & Mazzei 2008: 309), writing and re-writing, reframing the ‘brushstrokes’ to ‘paint’ the words while immersed in the nurse’s story.

 

Portraits and findings

The data analysis involved a line-by-line review of transcripts that were transcribed verbatim, plus field notes and memos, collapsed into categories and codes redolent of resilient behaviours as guided by Seligman’s (1991) positive psychology framework. Patterns within the nurses’ responses were grouped together where shared experiences were identified. Thematic analysis of the interview transcripts assisted in enriching the illumination of place, time and the nurses under study, organised, presented and ‘voiced’ as portraits of the nine participants.

Eight themes evidenced that the nurses were developing and maintaining personal resilience that had direct effect on why they chose to remain working within the health care environment, in times of duress. The eight themes were: managing self; staying positive; valuing support; ‘paying it forward’; passion for the profession; taking on challenges; experiencing adversity and growing through it; and, leadership. The participants (represented here by pseudonyms) are:¹

Mary-Anne: someone who is always looking on the bright side. She points to a resident walking by, clutching a bottle of antiseptic hand gel to her bosom.

She’s a magpie she is. If she likes something – tomorrow she’s got it! Watch out, she likes your jeans – don’t leave them in the toilet! One day, you know, she collected all the washing from the laundry which was mainly knickers and then she flung them all out of her window. They landed on a bush — it looked like a knicker tree! Unfortunately her room was diagonal to the Manager’s office and it was truly not a good look just outside her window!

Maggie is probably short for magical because I sat down with her, for my first interview, and it was such a thrill to begin! It was the beginning of my research journey and it was a great dialogue. Maggie was giving me insights into her life story, tales of her resilience, and demonstrating her humour throughout. I instinctively knew that the write up of her portrait was going to be magical.

April who, when I asked if she had considered involvement in the research, nodded her head enthusiastically and reached immediately for the forms to fill in. While contemplating the pseudonym of her choice she said ‘This is the hardest part — I need a fancy Hollywood name … mmm what name should I have?’ I commented that this was her chance to choose the name that she had always wanted and fantasised about, or perhaps use other names her mother had considered calling her. ‘Ah’, she said, ‘That’s it! My mother always wanted to call me April.’ So April she is.

Grace sees her work as giving her the opportunity to unearth her heart, and in the process extend her soul and her spiritual existence, through her nursing and midwifery teaching philosophy.

Lucky, who is biding her time. Although she is committed to the here and now of nursing and midwifery, she has big plans for her future.

Ginger arrives, and is happy to sign the consent forms prior to interview. She too can’t decide on a name.

I suggest the first thing that comes into my mind:

‘You can call yourself anything — like Jezebel or whatever.’

‘What!’ she says. ‘Do I look like a Jezebel?’ We both laugh. ‘Well I won’t call myself by my internet name, that’s a boy’s name, so that wouldn’t be appropriate. I’ll be Ginger’.

Vivien is a skilled professional taking stock of her nursing career and her life, which are both experiencing huge change and upheaval.

Jean asks me ‘Do you remember all these songs?’ The radio is playing sixties jukebox music in the background.

I was a rock ’n roller. We saved our money and went to the Rolling Stones concert — wowee! Let’s have a cup of coffee but keep dancing. It’s Friday morning and it’s springtime.

Jade had just had another had ‘god-awful’ day with all the stress that goes with management and transfer of patients to and from acute care facilities. She apologised and said she just didn’t think the interview was going to happen as scheduled — although she did offer two fifteen minute gaps to speak with me between medication administration and another meeting. We decided by mutual agreement that a full-on immersive interview session would be better, and set up an appointment for the next day.

I returned the next day and she announced, ‘You know, I will be giving up my lunchbreak for you.’

I countered with a twinkle in my eye,‘Yes but I have chocolate!’

A big smile covered her face as I said, ‘But I am not sure whether to give it to you before or after the interview.’

She said I had better make it after.

These nine nurses often turned their negative nursing conditions and workplace experiences into positive learning and coping proficiencies, making meaning from their challenging issues, and endowing themselves with resilience through the soft power of voicing their story (Seligman 1991). For example, where Mary-Anne discusses being careful about voicing her decisions and her next moves concerning issues that worry her in her residential aged care environment, she demonstrates personal self-control in her ‘wait and see’ approach. She remarks:

My tension ... with ... issues and ... with the paperwork and the paper work has mounted up and I still don’t feel convinced that it is all going to work out yet. I’ve just got to wait and see.

April too evidences the managing of self where she comments on managing complaints:

I try not to take it; I used to take it very personally. [She laughs ruefully.] Now I try and sort of diffuse it, and look at it not as a personal thing. It’s a team thing really. It makes you a bit more aware, makes you a bit more … you double-guess before you say anything … you know, all that sort of thing.

All the nurses stay positive in light of their workload, reflecting on lessons learned from work and life experiences. Jade muses:

Nurses are very good at reflecting. I think it’s the vast majority of nurses who think like that, and I think that. I know I feel like that or you wouldn’t stick at it. When girls go home or I go home you’ll think ‘what a shit of a shift’; but you think ‘we’ll sort that out tomorrow’. They [the staff] are resilient; it would be just being able to, or a big part of it is being able to, reflect on the challenges of the previous shift. That’s my idea of resilience: taking it on the chin — and the ability to go back for more and feeling that, accepting that you didn’t do something very well, but you will do better next time.

The support of others, either family, friends or work colleagues, was often provided in words of encouragement, by sharing a coffee or a laugh, and talking over a problem; and this was valued by the nurses. Lucky attests:

The team I was working with was the only thing that actually kept you sane because they had lots of experience with different areas and lots of knowledge and forethought.

Ginger echoes this: I surround myself with people I like because they bolster me, of course.

This shared support is also ‘paid forward’ where the nurses regard assisting others that they work with either via mentoring clinically, academically or managerially as aiding their own happiness at work and their own resilience. Vivien explains:

I stay in nursing because I want to make a difference; and it’s cheesy, but I can see lots of things to improve outcomes for patients. I like to think I can lead by example, that I’ve been doing it a long time and that there is no substitute for expertise.

April reiterates:

I’d like to be remembered as doing my very best for the people that I have been made responsible for; I hope I’ve improved their life or maintained their life or contributed to their life and their relatives and friends, and I’d also like to be remembered as a good team member as well.

Not only do the nurses have a desire to help others; they also have a passion for the profession of nursing, which was a driver for them being interested in the study. Maggie, for example, had survived a crisis in confidence as a fledgling nurse. She demonstrates resilience by adapting successfully after stressful work events and affirms:

I didn’t experience doubt or loss of confidence with my nursing skills as such, but certainly as a person I did. I suppose it was because I was in a managerial position, not really a nursing one ... but I went back to nursing ... and the job ... was just wonderful: my passion.

The participants’ passionate commentary is summed up by Jade who notes:

38 years. 38 years is a long time … with nursing, and I’ve seen lots of different things ... I never wanted to do anything else ... we are all here because we love it!

Even though nursing work is challenging, the nurses within the study rose en masse to that challenge. Vivien says:

It is a hard slog; I’ve never worked so hard. ... I do feel overwhelmed every day. Overwhelmed by the management load and the added responsibility for patients and staff ... that’s the way I am … I just knuckle down and I do the work. I work my arse off and get it done. That’s hard work, it is.

Jean says: They only see what’s not done, not what has been done. But that’s the lovely challenge of it!

Jade comments that she thrives on challenge:

I was actually asked to manage one ward, then I asked could I do ortho [orthopaedic] ward as well? And I said, I don’t know how to do one, so give me two and I’ll see how I go. So maybe I am an adrenaline junkie; I do like a challenge; I know that ... I could be called; I do like a challenge!

This hardiness of resilience is never as evident as when Grace tells of challenges encountered while working in a rural and remote setting; she says:

I wasn’t sure if I was going to return to child health … do I want to work for them again? … But I did go back to child health and in fact … it made me dig my little heels in.

Leading by example is forcefully declared by Vivien:

I said to the boss, ‘I will not compromise the patients’; I am very worried about opening the floodgates. I wasn’t comfortable. If it was affecting patients, I would go; I would have to make a stand, make a protest if the care is not optimum for the patient.

 

Discussion

The identification of the themes and aspects in the nurses’ stories informed the research on how the nurses demonstrated resilience in their nursing work. The nurses ‘told’ the researcher their story, and she then creatively interpreted and developed their portraits. The residential aged care nurses were coping with the frail elderly who are living longer, and with chronic conditions requiring optimum care. The nurse academics were dealing with constant change in their digital teaching world, with media-savvy students; and the nurses in acute care management positions were dealing on a daily basis with high turnover of staff and patients.

The analysis of each nurse’s story led to the formation of the eight themes: managing self, staying positive, valuing support, ‘paying it forward’, passion for the profession, the taking on of challenge, experiencing adversity and growing through it and leadership, where each of the themes are the point of their stories. Allowing the nurses to tell their story was the priority: their narratives underpinned, embedded and demonstrated the resilience that is inherent in their stories. The portraits encompass the themes, link the nurses’ stories, and collectively represent nurses as highly resilient with a capacity to deal with dynamic and changing healthcare issues, able to laugh, lead and leave a legacy for those they work with. The nurses have the willingness to take on challenges, and although they may have experienced personal or professional adversity, they have the fortitude to cope and consider the longer-term consequences to all involved, wishing to leave a legacy of their experience behind them. The nurses’ emotional maturity is prominent, evidencing their ability to be and make use of support where it is needed.

There is general consensus that nursing workplaces are inherently stressful, yet the portraits developed directly from the nurses’ stories demonstrate that stress and disarray, rather than encouraging these nurses to leave the profession, motivates them to stay working within it. The nurses may be putting ‘a good spin’ on things, and masking the reality of contemporary healthcare settings; but they told their stories their way, and their portraits creatively showcase their ability to thrive despite difficult, adverse and strenuous personal working conditions.

 

Conclusion

Through the gathering of observational and interview data from each nurse and each setting, portraits were creatively developed that hold at their core the voice of the resilient nurse, and enable new insights for nursing and resilience research. Portraiture methodology can make available, for a wider readership, vibrant portraits of resilient nurses and nursing through everyday language rather than jargon. The nurses are the experts of their own reality, and the portraits enabled an authentic connect between past and present experiences of resilience to emerge and be shared, through the positive view of success that Portraiture recommends.

The portraits developed are not intended to be definitive depictions of nursing but are presented to offer an experience of a new qualitative methodology that is innovative in its perspective, where success is celebrated, and creative description is valued. The portraits are indicative of the personal resilience that may remain invisible to onlookers unless they are voiced through a portrait. The portraits add to the research of nursing and resilience in new way.

 

Notes

1. All nurses are identified only by pseudonyms; and all quotations are taken verbatim from the transcripts of the interviews.