Narrative medicine and humanities for health professions education: an experimental study

ABSTRACT

Background

Narrative medicine can serve as a tool to empathize with human beings’ predicament and suffering. The research intended to examine whether the use of narrative medicine to form an empathetic connection could bring any positive impacts on health professions students.

Methods

A two-group quasi-experimental design was adopted to examine whether the intervention of narrative medicine to form an empathetic connection could demonstrate differences between the experimental group (35 students) and the control group (32 students) with regard to professional identity, self-reflection, emotional catharsis, and reflective writing competency. These 67 participants were health professions students in a medical university (mean age = 20.02; SD = 0.23), with varied majors in health disciplines. The 16-week intervention was the use of narrative medicine to form an empathetic connection with those suffering, via the three stages of narrative medicine: attention → representation → affiliation. The quantitative instruments included a professional identity scale (PIS-HSP), a reflective thinking scale (RTS-HSP), and an emotional catharsis scale (ECS-IN), as well as an analytic reflective writing scoring rubric (ARWSR-HSP). To triangulate the quantitative results, the study also used the student interviews. The SPSS software was used to analyze the data.

Results

The quantitative results demonstrated that the narrative medicine-based intervention could bring positive effects on the health professions students. After going through the intervention, the students in the experimental group had stronger professional identity, a higher reflective thinking level, more emotional catharsis, and greater improvement in reflective writing competency than those not receiving the intervention, though some subscales not reaching statistical significance.

Conclusion

This research results proved that the use of narrative medicine to form an empathetic connection could bring positive impacts on health professions students regarding professional identity, self-reflection, emotional catharsis, and self-reflective writing competency.

KEYWORDS:

• Narrative medicine
• empathetic connection
• emotional catharsis
• professional identity
• self-reflection

1. Introduction

Because health professionals have been trained to focus on their patients’ history of disease in order to keep patients alive longer than expected [1], while confronting with life-and death situations, they would pay more attention to the evidence-based medicine, not caring too much about patients’ human experiences concerning pain, suffering, desperation, or even dying [1,2]. Moreover, with compassion fatigue and empathy burnout due to long working hours and constant experience of death and grief [3], they may gradually lose the willingness to listen to patients’ illness stories and unable to empathize with patients by imagining their fear and suffering [4]. Therefore, when confronting critical life-and-death situations, health professionals may be unprepared or unable to deal with ethical/moral dilemmas and conflicts, as their focus may prioritize personal, professional, and organizational values [5]. The negligence of patients’ illness experiences may lead to a deterioration in communication among patients, doctors, nurses, therapists, and healthcare professionals [6].

However, the deterioration in communication can be filled up with the use of narrative medicine. Charon [7] defined ‘narrative medicine’ as a skill to develop the ability to ‘recognize, absorb, interpret, and be moved’ by illness stories, which can be used to train health professionals to witness the suffering of patients. Research has shown that sharpening literary narrative skills can bring positive impacts upon health professionals and patients. Also, they can facilitate self-reflection [8–10], empathetic connections [8], and professional identification [11,12]. As Charon [7] asserted that with the use of illness narrative threads, health professions students and health professionals can give meaning to metaphoric expressions, facilitate the development of moral imagination given contradictory points of view, and most importantly, work together with patients to provide quality care [4,7,8]. In addition, through ongoing narrative construction, students can gradually develop a strong connection and identification with the health profession and thus develop their collective professional identity [13].

Narrative medicine focuses on the ethical and humanistic side of medicine. In contrast to evidence-based medicine, which focuses on disease and scientific content, narrative medicine focuses on the communication among patients, patient families, and health professionals [14]. Hence, narrative medicine also plays a significant role in health provider-patient communication in developing a healing relationship, which can be regarded as an interpersonal interaction between patients and providers, including cognitive and affective components, such as caring, empathy, understanding, and how message is transmitted [15,16]. The illness narrative skills of ‘attention, representation, and affiliation’ can help health professionals increase their sensibility and empathy when faced with dilemmas and frustrating clinical or healthcare situations in order to carry on their professional work [17]. Moreover, while using narrative medicine as a tool to realize their professional limits and predicaments, healthcare professionals can reflect upon ethical/moral dilemmas happening in healthcare settings, and hence give meaning to their own lives while constructing their professional identity [18,19].

For health professions students, while contemplating over patients’ illness or controversial issues in literary narratives, they can raise skepticism over these issues to make sense of a dilemmatic situation in a clinical or healthcare setting, hence developing self-reflection capacity to explore controversial issues, intellectually and affectively [20]. Moreover, with illness narrative writing and storytelling as self-reflection, they can realize their professional limits and have a chance to pour out their negative emotions, for instance, fear or anger, and thus reach an emotional release and catharsis [7,21,22]. Illness stories can also be used to arouse students’ ethical/moral imagination. The ethical/moral issues raised in stories, novels, dramas, poetry lead the would-be health professionals to read the narratives involved in ethical/moral dilemmas and begin to pay attention to human suffering [23]. In addition, through the mimetic actions in novels, memoirs, or illness narratives, they may arouse their ethical/moral imagination to receive, interpret, and ethically/morally reason human’s pain, predicament, or suffering, which would help them better understand and deal with ethical/moral dilemmas when they are going to make decisions later on in real clinical and healthcare settings [4].

2. Methods

Though narrative medicine has been studied, there is no research using narrative medicine via literature and visual art to form an empathetic connection with those suffering. In order to let health professions students have an opportunity to review narrative medicine and mimetically go through life experiences of patients, patient families, physicians, nurses, and other health professionals, the study intended to use narrative medicine as a mechanism for an empathetic connection with those suffering in literature and visual art to examine whether the narrative medicine-based intervention would positively impact health professions students with regard to professional identity, self-reflection, emotional catharsis, and self-reflective writing competency. Therefore, this study put forward the following research hypotheses, shown as Table 1.

Table 1. A list of proposed research hypotheses.

Null Hypothesis	Dependent variables	Dependent subscale variables
1. There is no difference in the awareness of professional identity between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.	Professional identity	Professional commitment and devotion Emotional identification and belongingness Professional goals and values Self-fulfillment and retention tendency
2. There is no difference in reflective thinking between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.	Self-reflection	Reflective skepticism Self-examination Empathetic reflection Critical open-mindedness
3. There is no difference in emotional catharsis between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.	Emotional catharsis	Emotional identification as self-healing Emotional release for compensation Emotional adjustment for intellectual growth
4. There is no difference in reflective writing competency between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.	Reflective writing competency	Focus and context structure Ideas and elaboration Voices and points of view Critical thinking and representation Depth of reflection on personal growth Language and conventions

2.1. Quasi-experimental design

The research adopted a two-group quasi-experimental design to examine the impact of narrative medicine-based intervention on health professions education in terms of professional identity, self-reflection, emotional catharsis, and reflective writing competence. Quasi-experiments are often conducted to examine the effectiveness of an educational intervention in settings in which random assignment is difficult or impossible because the field settings or the groupings may already exist prior to the experiment [24,25]. A coin flip was used to allocate the two groups in an elective course to the experimental group (IN – EC—Literature and Visual Art; 35 students) and the control group (_nonIN – EC—Literature and Visual Art; 32 students). The intervention lasted for 16 weeks and included a 2-hour in-class session and a 2-hour-minimum self-directed study each week. Before and after the intervention, both group students were required to take the pretests and posttests on professional identity, self-reflection, emotional catharsis, and reflective writing competency. The two groups were taught by the same instructor and were provided with the same teaching material, including literature and visual arts. The only difference was that the experimental group was instructed using narrative medicine to form an empathetic connection.

After the intervention, both groups were compared with respect to the pretest and posttest results of a professional identity scale, a reflective thinking scale, an emotional catharsis scale, and an analytic reflective writing scoring rubric. The pretest and posttest results were used for data analysis to examine their learning performances and the feasibility of the intervention. Following the questionnaire collection, semi-structured personal interviews were conducted to realize the participants’ inner feelings and reflections about the narrative medicine-based intervention. Twelve students receiving the intervention volunteered to participate in the interview. All the interview content was recorded and transcribed for more detailed analysis.

2.2. Participants

In this research, a two-group quasi-experimental design was used. These 67 participants were health professions students in a medical university (mean age = 20.02; SD = 0.23), with varied majors in health disciplines, such as medicine, nursing, dentistry, psychology, nutrition science, physical therapy, occupational therapy, public health, medical informatics, occupational safety and health, etc. Among the 67 students, 40 students (59.70%) were female, and 27 students were male (40.30%). These students had received service-learning education and training upon enrollment. They might go to nursing homes, hospitals, or any medical or healthcare institutions; hence they had some experience of interacting with patients, patient families, and health professionals in clinical and healthcare settings. The research got approval of the Institutional Review Board’s (IRB) of Chung Shang Medical University Hospital (No. CS16157, dated 9 January 2017) in accordance with the relevant ethical research guidelines [26]. Before the data collection, a researcher let students know the research purpose; their identities were kept strictly confidential, and the data were analyzed anonymously. However, the participants in the elective course did not know whether they were in the control group or experimental group in order to prevent bias in research results, such as Hawthorne effect, John Henry effect, etc. As mentioned, the only difference was that the experimental group students were instructed using narrative medicine to form an empathetic connection with those suffering in literature and visual art. Therefore, they were required to go through the three stages of narrative medicine-based mechanism: attention → representation → affiliation. As for the control group, the students did not go through the three stages of narrative medicine to form an empathetic connection but were situated in a traditional lecture class, with some group discussions and question-and-answer exercises.

2.3. Intervention: Illness narrative as an empathetic connection to literature and visual arts study

As previously mentioned, the difference between the two groups was the use (or lack thereof) of narrative medicine to form an empathetic connection. To facilitate an empathetic connection to literature and visual arts, the following six narrative skills, proposed by Engel, Zarconi, Pethel, et al. [27] for narrative medicine, were applied while experimental group students were reading or writing narrative medicine:

• practice of ethical/moral imagination

• practice of empathic attendance and attentive listening

• close reading and interpretation of ethical/moral dilemmas in texts

• reflective writing and narration of illness stories

• ethical/moral reasoning with illness stories

• engagement in narrative ethics/morality.

In addition, to empathize with people’ predicament and suffering, the experimental group students were also asked to familiarize themselves with the three stages of narrative medicine, attention → representation → affiliation, in order to give meaning to metaphoric expressions and construct ethical or moral imagination from contradictory points of view and thereby reflect upon the medical care process and grasp significance in the narrative medicine. Among the narrative skills, attention referred to being mindfully present in clinical encounters; representation referred to becoming involved in clinical encounters in order to find significance, and affiliation referred to building an emotional connection with patients, patient families, and other healthcare professionals. Because these participants were students from various health disciplines, when introducing scheduled medical ethics/humanities topics, the instructor focused on the ethical and humanistic side of healthcare literature and visual art in critical life-and-death situations to help students build an ethical/moral imagination to manage ethical/moral dilemmas and conflicts so as to prepare these health disciplines students confront ethical, moral, or social issues that might arise in the clinical and healthcare settings [28]. After that, the experimental group read and wrote stories about illness in order to consider the patients’ and healthcare professionals’ viewpoints, as well as patient families’, hence forming an empathetic connection with them.

As for the control group students, though using the same material as the students in the experimental group, the instructor did not teach them how to use the three stages of narrative medicine (attention → representation → affiliation) to construct ethical or moral imagination from contradictory points of view. Instead, the instructor adopted a more conventional approach; the control group students were given traditional lectures, not have the chance to access the three stages of narrative medicine (attention → representation → affiliation) to construct ethical or moral imagination. They were given the lectures most of the time and mostly focusing on the explanation of medical ethics and humanities in the teaching material, with no practice of empathic attendance and attentive listening to illness stories.

To facilitate peer interaction and discussion about the ethical/moral dilemmas and conflicts hidden in literature and visual arts, after reading medical ethics-/humanities-related issues in the literature and visual arts study, the experimental and control groups were requested to regularly login the Moodle Learning website to post, in approximately 380–500 words, a summary, their feelings, a reflection, or responses or resolutions regarding the dilemmas and issues raised. Since the discussion itself was not in person, the forum provided a comfortable environment where students might scrutinize and learn with each other [29]. Moreover, due to the nature of an asynchronous online discussion, the students were not expected to provide feedback instantaneously, which allowed them more time to reflect and offer comments about the issues. The course content and teaching material are shown in Supplementary 1.

2.4. Instrumentation

The study intended to examine whether the narrative medicine-based intervention would positively impact health professions students with regard to professional identity, self-reflection, emotional catharsis, and self-reflective writing competency. Therefore, to reach the objectives, the following scales and rubric were used for measurement.

2.4.1. Professional Identity Scale for Healthcare Students and Providers (PIS-HSP)

A collective healthcare professional identity is a key factor to let healthcare professions students and professionals have same goals and values to facilitate interdisciplinary collaboration for quality care [30,31]. Hence, in order to assess the participants’ level of collective professional identity among the interprofessional healthcare community, Liao and Wang’s [11] study of the PIS-HSP scale was used to measure the participants’ professional identity level, with 9 denoting ‘completely agree’ and 1 denoting ‘completely disagree.’ The short-form PIS-HSP scale, with overall Cronbach’s α 0.89, included 18 items and four factors: ‘professional commitment and devotion’ (6 items; factor loadings: 0.644–0.886; Cronbach’s α: 0.91), ‘emotional identification & belongingness’ (4 items; factor loadings: 0.854–0.888; Cronbach’s α: 0.93), ‘professional goals & values’ (4 items; factor loadings: 0.573–0.943; Cronbach’s α: 0.88), and ‘self-fulfillment & retention tendency’ (4 items; factor loadings: 0.563–0.822; Cronbach’s α: 0.78).

The 18-item PIS-HSP scale also showed acceptable convergent validities; also, the discriminant validities were proven with the square root of every AVE value higher than the r between factors [11]. The short-form PIS-HSP scale has a maximum score of 162 and a minimum score of 18. The higher the score, the higher the level of participants’ professional identity [11]. Based on the present sample, the Cronbach’s α for the whole scale and the four factors were 0.97, 0.96, 0.96, 0.92, and 0.91, respectively.

2.4.2. Reflective Thinking Scale for Healthcare Students and Providers (RTS-HSP)

Reflective thinking involves deliberate consideration and integration of prior experience and knowledge to facilitate positive interactions between doctors, healthcare professionals, patients, and patient families [32]. To assess the level of reflective thinking, the 9-point Likert scale of RTS-HSP [32] based on the responses of 579 subjects was used, with 9 meaning ‘always’ and 1 meaning ‘never.’ The RTS-HSP, with overall Cronbach’s α 0.87, included four factors and 22 items: reflective skepticism (6 items; factor loadings: 0.66–0.80; Cronbach’s α: 0.84), self-examination (6 items; factor loadings: 0. 65–0.85; Cronbach’s α: 0.84), empathetic reflection (5 items; factor loadings: 0.65–0.77; Cronbach’s α: 0.80), and critical open-mindedness (5 items; factor loadings: 0.60–0.87; Cronbach’s α: 0.77) [32]. The PIS-HSP scale has a maximum score of 198 and a minimum score of 22. The higher the score, the higher the student’s reflective thinking level. Based on the present sample, the Cronbach’s α for the whole scale and the four factors were 0.94, 0.84, 0.91, 0.89, and 0.91, respectively.

2.4.3. Scale Measuring Emotional Catharsis through Illness Narratives (ECS-IN)

Emotional catharsis is the process of strongly expressing repressed or immediate negative emotions, such as pity, fear, stress, and anxiety, in order to release hostility or trauma in the mind, and thus generate a certain positive emotion or change in one’s life [33,34]. In this study, a short form emotional catharsis (ECS-IN) scale [35] was used to measure the emotional catharsis level of students, with 9 indicating ‘strongly agree’ and 1 indicating ‘strongly disagree.’ Students receiving higher scores on the ECS-IN were interpreted as having stronger emotional catharsis. The 18-item ECS-IN, with overall Cronbach’s α 0.946, included three factors: ‘emotional identification as self-healing’ (7 items; factor loadings: 0.747–0.886; Cronbach’s α: 0.930), ‘emotional release for compensation’ (7 items; factor loadings: 0.724–0.814; Cronbach’s α: 0.907), and ‘emotional adjustment for intellectual growth’ (4 items; factor loadings: 0.688–0.899; Cronbach’s α: 0.888). The phrase ‘emotional identification as self-healing’ scale refers to emotional identification with the person in illness narratives to achieve emotional release and self-recovery. The phrase ‘emotional release for compensation’ refers to dealing with inner anxiety, fear, or negative emotions to unleash negative feelings and thus find relief via illness narratives. The “emotional adjustment for intellectual growth’ refers to the use of illness narratives to deal with ambivalences in clinical or healthcare settings so as to regulate emotions and thus reach intellectual growth [35,36].

The 18-item ECS-IN scale also showed acceptable convergent validities, and the discriminant validities were proven [35]. The ECS-IN scale has a maximum score of 162 and a minimum score of 18. The higher the score, the stronger the emotional catharsis a participant had [35]. Based on the present sample, the Cronbach’s α for the whole scale and the three factors were 0.97, 0.95, 0.94, and 0.95, respectively.

2.4.4. Analytic Reflective Writing Scoring Rubric for Healthcare Students and Providers (ARWSR-HSP)

An analytic reflective writing scoring rubric (ARWSR-HSP) developed by the researchers [37] was used to assess students’ reflective writing competency toward medical conflicts and ambivalent feelings in terms of their ‘focus and contextualization,’ ‘ideas and elaboration,’ ‘voices and points of view,’ ‘critical thinking and representation,’ ‘depth of reflection regarding personal growth,’ and ‘language and style.’ Given that the dimensions of ‘critical thinking and representation’ and ‘depth of reflection regarding personal growth’ were salient characteristics, they were doubly weighted. Therefore, the range of possible scores for ARWSR-HSP was 0 to 40. Those who scored between 40 and 35 were considered to have excellent reflective writing; those who scored between 34 and 28, strong reflective writing; those who scored between 27 and 21, good reflective writing; those who scored between 20 and 14, acceptable reflective writing; those who scored between 13 and 7, weak reflective writing; and those who scored between 6 and 0, unacceptable reflective writing. The interrater reliabilities using Spearman’s correlation coefficients were between 0.757 and 0.946; the interrater reliabilities using weighed kappas were between 0.706 and 0.884. The intrarater constancy estimates were between 0.825 and 0.930. Two well-trained blind graders assess students’ reflective competency before and after the intervention to prevent bias in outcome assessment [38].

2.5. Data analysis

The research adopted the Statistical Package for Social Sciences (SPSS; version 14.0) to examine the quantitative data, including one-way MANOVA (Multivariate Analysis of Variance) and one-way MANCOVA (Multivariate Analysis of Covariance). MANOVA and MANCOVA are good for simultaneous measurements of two or more dependent variables in an experimental study with two or more experimental and control groups and hence can protect against Type I errors, compared to running a multiple ANOVA procedure [39,40].

Prior to the parametric tests, the study first used Skewness and Kurtosis to examine the assumption of normal distribution. According to Hair [41], to assess whether the skewness and Kurtosis values are in normal distribution, the cut-off values ± 2.58 (at 0.01 significance level) and ± 1.96 (at 0.05 significance level) are most commonly used values. Byrne [42], after reviewing the kurtosis values, confirmed that kurtosis equal to or greater than 7 indicates a deviation from the normality. Kline [43] thinks that the absolute value of skewness ‘|ˆγ₁ |>3.0 are described as “severely” skewed’|‘|ˆγ₁ |>3.0 are described as “severely” skewed’|‘|ˆγ₁ |>3.0 are described as “severely” skewed’ (p. 76), and that ‘|ˆγ₁ |>3.0 are described as “severely” skewed’the absolute value of kurtosis ‘|ˆγ₁ |>3.0 are described as “severely” skewed’|“the absolute value of kurtosis ‘|ˆγ₂ |>10.0 suggests a problem’|“the absolute value of kurtosis ‘|ˆγ₂ |>10.0 suggests a problem’ (p. 77). Furthermore, to test the multivariate normal distribution, the Mahalanobis distances and the critical points of the Chi-squared distribution were examined. The number of degrees of freedom for the Chi-squared distribution is equal to the number of variables; thus, for three variables, it has three degrees of freedom. At the 0.05 significance level, the corresponding critical point of Chi-square distribution based on three degrees of freedom is 7.815; the corresponding critical point with four degrees of freedom is 9.488; the corresponding critical point with five degrees of freedom is 11.070 [44,45]. If the maximal Mahalanobis distance is less than the corresponding critical points of the Chi-squared distribution, the sample data are in a multivariate normal distribution [44,45]. Then, the study used MANOVA to compare multivariate sample means. In order to control the potential initial group differences, the study further used pretest results as covariates and used one-way MANCOVA to adjust the means in order to reduce any systematic bias [40]. The confidence level was 95% (p < 0.05). In addition, Pillai’s Trace was used to test the homogeneity of variance (the covariance matrices) and to robust Type I error [46], with the p-value >0.05 indicating the homogeneity of the covariance matrices [46–48]. The Pearson correlation (|r|) for the variables was also used to test the multicollinearity, with the |r| < 0.9 indicating no evidence of multicollinearity [40].

3. Results

Before any further parametric analysis, the researchers used Skewness and Kurtosis to examine the outliers and multivariate normality. After preliminary analysis, the researchers found no extreme Skewness values and Kurtosis values. The Skewness values were within the range of ± 2, mostly within ± 1; the Kurtosis values were within the range of ± 7. Furthermore, the maximal Mahalanobis distances are less than the corresponding critical points of the Chi-squared distribution: 7.815 for three variables, 9.488 for four variables, and 11.070 for five variables; hence it can be known that the sample data are in a multivariate normal distribution. Also, with no outliers, the data were normally distributed and hence could be used for further parametric analysis and for null hypothesis testing.

3.1. Quantitative results of hypothesis testing

3.1.1. Null Hypothesis 1

There is no difference in the awareness of professional identity between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.

To test Null Hypothesis 1, For the pretest of PIS-HSP using MANOVA, the Pillai’s Trace is 1.308 (p = 0.277 > 0.05), indicating the equal variance and homogeneity of the covariance matrices. The pretest results also did not indicate any significant differences between the means of the experimental group (means = 82.51, 38.86, 36.23, and 32.80) and those of the control group (means = 88.69, 39.88, 37.59, and 30.72) for ‘professional commitment and devotion’ (F(1, 65) = 0.984; p = 0.325 > 0.05), ‘emotional identification and belongingness’ (F(1, 65) = 0.063; p = 0.803 > 0.05), ‘professional goals and values’ (F(1, 65) = 0.465; p = .0.498 > 0.05), and ‘self-fulfillment and retention tendency’ (F(1, 65) = 1.020; p = 0.316 > 0.05). To put it another way, these two groups were homogeneous in the awareness of professional identity.

After the 16-week intervention, with the application of the pretest results as covariates, a one-way MANCOVA was applied to determine whether professional identity pretest scores would make a difference in the posttest scores. For the posttest of PIS-HSP using MANCOVA, the Pearson correlation (|r|) values for the factors were between 0.263 and 0.836 (|r| < 0.9), indicating no evidence of multicollinearity. In addition, the MANCOVA results (see Table 2) indicated a significant relationship between the pretest scores and posttest scores in ‘professional commitment and devotion’ (Wilks’ Λ: 0.307; F(4, 58) = 32.703; p < 0.000), ‘emotional identification and belongingness’ (Wilks’ Λ: 0.768; F(4, 58) = 4.382; p < 0.01), ‘professional goals and values’ (Wilks’ Λ: 0.123; F(4, 56) = 103.424; p < 0.000), and ‘self-fulfillment and retention tendency’ (Wilks’ Λ: 0.092; F(4, 56) = 143.678; p < 0.000).

Table 2. MANCOVA results for the PIS-HSP posttest.

	Covariance
Posttest	Professional commitment and devotion (pretest)	Emotional identification and belongingness (pretest)	Professional goals and values (pretest)	Self-fulfillment and retention tendency (pretest)
	Wilks’ Λ F(4, 58) (p-value)
	0.307 32.703 (<0.000**)	0.768 4.382 (0.004**)	0.123 103.424 (<0.000**)	0.092 143.678 (<0.000**)
	Tests of Between-Subjects Effects F(1,61) (p-value)
Professional commitment and devotion	64.752 (<0.000**)	0.055 (0.816)	0.925 (0.340)	0.636 (0.428)
Emotional identification and belongingness	22.171 (<0.000**)	4.644 (0.035*)	1.764 (0.189)	1.060 (0.317)
Professional goals and values	0.078 (0.781)	0.401 (0.529)	334.467 (<0.000**)	1.172 (0.283)
Self-fulfillment and retention tendency	0.612 (0.437)	0.171 (0.680)	0.328 (0.569)	422.130 (<0.000**)

Note: Experimental group: N=35; Control group: N=32.

Wilks’ Λ: Wilks’ lambda

F(4, 58): F(hypothesis degrees of freedom, error degrees of freedom)

*p< 0.05; **p< 0.01

Because there were significant relationships between the pretest scores and posttest scores (as in Table 2), in order to reduce any systematic bias, the researchers had to further use one-way MANCOVA to adjust the means [40]. After adjustment, the MANCOVA results (as in Table 3) showed that the adjusted posttest means of the experimental group (means = 49.61, 43.54, and 36.99, respectively) were significantly higher than those of the control group (means = 44.93, 38.82, and 33.30, respectively) in ‘emotional identification and belongingness’ (p < 0.05), ‘professional goals and values’ (p < 0.000), and ‘self-fulfillment and retention tendency’ (p < 0.000). Hence, with the p-value less than 0.05, the null hypothesis was rejected in these three subscales. Nonetheless, in ‘professional commitment and devotion,’ although the adjusted posttest mean of the experimental group was higher (mean = 98.30) than that of the control group (mean = 92.64), there was no significant difference (p=0.099 > 0.05) between the two groups. With the p-value larger than 0.05, the null hypothesis failed to be rejected in the subscale.

Table 3. The adjusted posttest means for the PIS-HSP in MANCOVA.

Posttest	Group	Adjusted Mean	(SD)	p-value
Professional commitment and devotion	ExperimentalControl Control	98.30 92.64	(2.28) (2.39)	.099
Emotional identification and belongingness	ExperimentalControl Control	49.61 44.93	(1.29) (1.35)	<.017*
Professional goals and values	ExperimentalControl Control	43.54 38.82	(0.50) (0.52)	<.000**
Self-fulfillment and retention tendency	ExperimentalControl Control	36.99 33.30	(0.49) (0.52)	<.000**

Note: Experimental group: N=35; Control group: N=32.

SD: Standard deviation

*p< 0.05; **p< 0.01

3.1.2. Null Hypothesis 2

There is no difference in reflective thinking between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.

To test Null Hypothesis 2, for the pretest of RTS-HSP using MANOVA, the Pillai’s Trace is 0.246 (p = 0.911 > 0.05), indicating the equal variance and homogeneity of the covariance matrices. There were also no significant differences in the pre-test results between the experimental group (means = 34.83, 40.11, 32.86, and 32.40, respectively) and the control group (means = 36.19, 40.41, 32.47, and 32.44, respectively) on reflective skepticism (F(1, 65) = 0.439; p = 0.510 > 0.05), self-examination (F(1, 65)=.021; p = 0.887 > 0.05), empathetic reflection (F(1, 65)=.059; p = 0.809 > 0.05), and critical open-mindedness (F(1, 65) = 0.001; p = 0.981 > 0.05). That is, these two groups were homogeneous in reflective thinking.

After the intervention, with the pretest results as covariates, the researchers adopted a one-way MANCOVA to determine whether professional identity pretest scores would make a difference to the posttest scores. For the posttest of RTS-HSP using MANCOVA, the Pearson correlation (|r|) values for the factors were between 0.396 and 0.685 (|r| < 0.9), indicating no evidence of multicollinearity. The MANCOVA results (see Table 4) indicated a significant relationship between the pretest scores and posttest scores in ‘reflective skepticism’ (Wilks’ Λ: 0.343; F(4, 58) = 27.795; p < 0.000), ‘self-examination’ (Wilks’ Λ: 0.371; F(4, 58) = 24.561; p < 0.000), ‘empathetic reflection’ (Wilks’ Λ: 0.557; F(4, 58) = 11.539; p < 0.000), and ‘critical open-mindedness’ (Wilks’ Λ: 0.525; F(4, 58) = 13.112; p < 0.000).

Table 4. MANCOVA results for the RTS-HSP posttest.

	Covariance
Posttest	Reflective skepticism (pretest)	Self-examination (pretest)	Empathetic reflection (pretest)	Critical open- mindedness (pretest)
	Wilks’ Λ F(4, 58) (p-value)
	0.343 27.795 (<0.000**)	0.371 24.561 (<0.000**)	0.557 11.539 (<0.000**)	0.525 13.112 (<0.000**)
	Tests of Between-Subjects Effects F(1,61) (p-value)
Reflective skepticism	32.777 (<0.000**)	0.012 (0.913)	0.001 (0.975)	10.072 (0.002**)
Self-examination	1.231 (0.271)	50.162 (<0.000**)	0.113 (0.738)	1.511 (0.224)
Empathetic reflection	0.176 (0.677)	0.144 (0.705)	21.087 (<0.000**)	3.105 (0.083)
Critical open-mindedness	0.207 (0.650)	0.036 (0.851)	4.502 (0.038*)	53.750 (<0.000**)

Experimental group: N = 35; Control group: N = 32

Wilks’ Λ: Wilks’ lambda

F(4, 58): F(hypothesis degrees of freedom, error degrees of freedom)

*p< 0.01; **p< 0.01

Because of the significant relationships between the pretest scores and posttest scores (as in Table 4), to reduce any systematic bias, the researchers further used one-way MANCOVA to adjust the means [40]. After adjustment, the MANCOVA results (as in Table 5) showed that the adjusted posttest means of the experimental group (means = 44.58, 48.22, 40.05, and 38.33, respectively) were significantly higher than those of the control group (means = 41.30, 44.79, 37.44, and 34.89, respectively) in ‘reflective skepticism,’ ‘self-examination,’ ‘empathetic reflection,’ and ‘critical open-mindedness.’ Hence, the null hypothesis was rejected when the p-value was below 0.05.

Table 5. The adjusted posttest means for the RTS-HSP in MANCOVA.

Posttest	Group	Adjusted Mean	(SD)	p-value
Reflective skepticism	ExperimentalControl Control	44.58 41.30	(.78) (.82)	.005**
Self-examination	ExperimentalControl Control	48.22 44.79	(.75) (.79)	.003**
Empathetic reflection	ExperimentalControl Control	40.05 37.44	(.71) (.75)	.014*
Critical open-mindedness	ExperimentalControl Control	38.33 34.89	(.82) (.86)	.005**

Note: Experimental group: N=35; Control group: N=32.

SD: Standard deviation

*p< 0.05; **p< 0.01

3.1.3. Null Hypothesis 3

There is no difference in emotional catharsis between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.

For the pretest of ECS-IN using MANOVA, the Pillai’s Trace is 0.491 (p = 0.690 > 0.05), indicating the equal variance and homogeneity of the covariance matrices. There were also no significant differences in the pre-test results between the means of the experimental group (means = 74.66, 56.69, and 48.66, respectively) and those of the control group (means = 76.97, 59.47, and 52.03, respectively) in ‘emotional identification as self-healing’ (F(1, 65) = 0.169; p = 0.682 > 0.05), ‘emotional release for compensation’ (F(1, 65) = 0.509; p = 0.478 > 0.05), and ‘emotional adjustment for intellectual growth’ (F(1,65) = 1.327; p = 0.254 > 0.05). That is, these two groups were homogeneous in emotional catharsis.

After the intervention, with the pretest results as covariates, a one-way MANCOVA was used to determine whether professional identity pretest scores would make a difference to the posttest scores. For the posttest of ECS-IN using MANCOVA, the Pearson correlation (|r|) values for the factors were between 0.682 and 0.828 (|r| < 0.9), indicating no evidence of multicollinearity. The one-way MANCOVA results (see Table 6) also indicated a significant relationship between the pretest scores and posttest scores in ‘emotional identification as self-healing’ (Wilks’ Λ: 0.326; F(3, 60) = 41.276; p < 0.000), ‘emotional release for compensation’ (Wilks’ Λ: 0.314; F(3, 60) = 43.605; p < 0.000), and ‘emotional adjustment for intellectual growth’ (Wilks’ Λ: 0.323; F(3, 60) = 41.869; p < 0.000).

Table 6. MANCOVA results for the ECS-IN posttest.

	Covariance
Posttest	Emotional identification as self-healing (pretest)	Emotional release for compensation (pretest)	Emotional adjustment for intellectual growth (pretest)
	Wilks’ Λ F(3, 60) (p-value)
	0.326 41.276 (<0.000**)	0.314 43.605 (<0.000**)	0.323 41.869 (<0.000**)
	Tests of Between-Subjects Effects F(1,62) (p-value)
Emotional identification as self-healing	6.699 (0.012*)	0.078 (0.780)	2.682 (0.107)
Emotional release for compensation	60.031 (<0.000**)	0.790 (0.377)	5.079 (0.028*)
Emotional adjustment for intellectual growth	3.994 (0. 050)	81.172 (<0.000**)	10.934 (0.002**)

Note: Experimental group: N=35; Control group: N=32.

Wilks’ Λ: Wilks’ lambda

F(3, 60): F(hypothesis degrees of freedom, error degrees of freedom)

*p< 0.05; **p< 0.01

Due to the significant relationships between the pretest scores and posttest scores (as in Table 6), to reduce any systematic bias, the researchers further used one-way MANCOVA to adjust the means [40]. After adjustment, the MANCOVA results (as in Table 7) showed that the adjusted posttest means of the experimental group (means = 66.97 and 60.85, respectively) were significantly higher than those of the control group (means = 63.38 and 57.08, respectively) in ‘emotional release for compensation’ and ‘emotional adjustment for intellectual growth.’ Hence, with the p-value less than 0.05, the null hypothesis was rejected in these two subscales. However, in ‘emotional identification as self-healing,’ although the adjusted posttest mean of the experimental group was higher (mean = 85.70) than that of the control group (mean = 82.14), there was no significant difference (p = 0.107 > 0.05; see Table 7) between the two groups. When the p-value larger than 0.05, the hypothesis was not rejected in the subscale.

Table 7. The adjusted posttest means for the ECS-IN in MANCOVA.

Posttest	Group	Adjusted Mean	(SD)	p-value
Emotional identification as self-healing	ExperimentalControl Control	85.70 82.14	(1.49) (1.60)	.107
Emotional release for compensation	ExperimentalControl Control	66.97 63.38	(1.10) (1.15)	.028*
Emotional adjustment for intellectual growth	ExperimentalControl Control	60.85 57.08	(0.78) (0.82)	.002**

Note: Experimental group: N=35; Control group: N=32.

SD: Standard deviation

*p< 0.05; **p< 0.01

3.1.4. Null Hypothesis 4

There is no difference in reflective writing competency between the health professions students using narrative medicine to form an empathetic connection and those not using narrative medicine.

For the pretest of reflective writing competency using MANOVA, the Pillai’s Trace is 0.751 (p = 0.611 > 0.05), indicating the equal variance and homogeneity of the covariance matrices. There were also no significant differences in the pre-test results between the experimental group (means = 2.74, 2.17, 2.60, 2.31, 2.43, and 3.46, respectively) and the control group (means = 2.47, 2.16, 2.72, 2.13, 2.63, and 3.38, respectively) in ‘focus and context structure’ (F(1, 65) = 2.500; p = 0.119 > 0.05), ‘ideas and elaboration’ (F(1, 65) = 0.006; p = 0.941 > 0.05), ‘voices and points of view’ (F(1, 65) = 327; p = 0.569 > 0.05), ‘critical thinking and representation’ (F(1, 65) = 0.949; p = 0.334 > 0.05), ‘depth of reflection on personal growth’ (F(1, 65) = 0.910; p = 0.344 > 0.05), and ‘language and conventions’ (F(1, 65) = 0.104; p = 0.748 > 0.05). That is, these two groups were homogeneous in reflective writing competency.

After the intervention, with the use of the pretest results as covariates, a one-way MANCOVA was applied to determine whether reflective writing competency pretest scores would make a difference to the posttest scores. For the posttest of reflective writing competency using MANCOVA, the Pearson correlation (|r|) values for the factors were between 0.106 and 0.527 (|r| < 0.9), indicating no evidence of multicollinearity. The one-way MANCOVA results (see Table 8) also indicated no significant relationship between the pretest scores and posttest scores in ‘focus and context structure’ (Wilks’ Λ: 0.894; F(6, 54) = 1.064; p = 0.395 > 0.05), ‘ideas and elaboration’ (Wilks’ Λ: 0.930; F(6, 54) = 0.674; p = 0.671 > 0.05), ‘voices and points of view’ (Wilks’ Λ: 0.911; F(6, 54) = 0.877; p = 0.518 > 0.05), ‘critical thinking and representation’ (Wilks’ Λ: 0.887; F(6, 54) = 1.141; p = 0.351 > 0.05), ‘depth of reflection on personal growth’ (Wilks’ Λ: 0.855; F(6, 54) = 1.531; p = 0.186 > 0.05), and ‘language and conventions’ (Wilks’ Λ: 0.824; F(6, 54) = 1.922; p = 0.094 > 0.05). However, in the tests of between-subjects effects, the one-way MANCOVA results indicated a significant interaction between the pretest in ‘critical thinking and representation’ and the posttest in ‘ideas and elaboration’ (F(1, 59) = 4.558; p = 0.037 < 0.05), between the pretest in ‘critical thinking and representation’ and the posttest in ‘depth of reflection on personal growth’ (F(1, 59) = 4.537; p = 0.037 < 0.05), and between the pretest in ‘language and conventions’ and the posttest in ‘language and conventions’ (F(1, 59) = 8.438; p = 0.005 < 0.001).

Table 8. MANCOVA results for the ANMWSR posttest.

	Covariance
Posttest	Focus and context structure (pretest)	Ideas and elaboration (pretest)	Voices and points of view (pretest)	Critical thinking and representation (pretest)	Depth of reflection on personal growth (pretest)	Language and conventions (pretest)
	Wilks’ Λ F(6, 54) (p-value)
	0.894 1.064 (0.395)	0.930 0.674 (0.671)	0.911 0.877 (0.518)	0.887 1.141 (0.351)	0.855 1.531 (0.186)	0.824 1.922 (0.094)
	Tests of Between-Subjects Effects F(1,59) (p-value)
Focus and context structure	1.553 (0.218)	0.005 (0.946)	0.856 (0.359)	0.980 (0.326)	0.833 (0.365)	0.474 (0.494)
Ideas and elaboration	2.428 (0.125)	0.001 (0.976)	1.783 (0.187)	4.558 (0.037*)	0.383 (0.538)	2.726 (0.104)
Voices and points of view	0.011 (0.916)	2.288 (0.136)	0.567 (0.455)	2.779 (0.101)	3.652 (0.061)	0.019 (0.891)
Critical thinking and representation	0.019 (0.890)	0.425 (0.517)	0.974 (0.328)	0.770 (0.384)	0.121 (0.729)	1.268 (0.265)
Depth of reflection on personal growth	0.094 (0.760)	0.016 (0.901)	0.197 (0.659)	4.537 (0.037*)	0.208 (0.650)	0.159 (0.691)
Language and conventions	0.010 (0.922)	0.684 (0.412)	0.197 (0.658)	0.065 (0.800)	2.136 (0.149)	8.438 (0.005**)

Note: Experimental group: N=35; Control group: N=32.

Wilks’ Λ: Wilks’ lambda

F(6, 54): F(hypothesis degrees of freedom, error degrees of freedom)

*p< 0.05; **p< 0.01

Due to the significant relationship between the pretest scores and posttest scores (as shown in Table 8), in order to reduce any systematic bias, the researchers further used one-way MANCOVA to adjust the means [40]. After adjustment, the MANCOVA results (as in Table 9) showed that the adjusted posttest means of the experimental group (means = 4.20, 3.90, 4.00, 4.16, and 4.09, respectively) were higher than those of the control group (means = 3.63, 3.14,, 3.63, 3.04, and 3.06, respectively) in ‘focus and context structure,’ ‘ideas and elaboration,’ ‘voices and points of view,’ ‘critical thinking and representation,’ and ‘depth of reflection on personal growth.’ Hence, with the p-value less than 0.05, the hypothesis was rejected in these five subscales. However, in ‘language and conventions,’ although the adjusted posttest mean of the experimental group was higher (mean = 3.77) than that of the control group (mean = 3.54), there was no significant difference (p = 0.181 > 0.05; see Table 9) between these two groups. With the p-value larger than 0.05, the hypothesis was not rejected in the subscale.

Table 9. The adjusted posttest means for the ANMWSR in MANCOVA.

Posttest	Group	Mean	(SD)	p-value
Focus and context structure	ExperimentalControl Control	4.20 3.63	(0.11) (0.11)	.001**
Ideas and elaboration	ExperimentalControl Control	3.90 3.14	(0.15) (0.16)	.001**
Voices and points of view	ExperimentalControl Control	4.00 3.63	(0.10) (0.10)	.012*
Critical thinking and representation	ExperimentalControl Control	4.16 3.04	(0.15) (0.16)	<.000**
Depth of reflection on personal growth	ExperimentalControl Control	4.09 3.06	(0.17) (0.18)	<.000**
Language and conventions	ExperimentalControl Control	3.77 3.54	(0.11) (0.12)	.181

Note: Experimental group: N=35; Control group: N=32

SD: Standard deviatio

*p< 0.05; **p< 0.0

This study aimed to examine whether the intervention of narrative medicine to form an empathetic connection could result in positive effects on health professions students with regard to professional identity, self-reflection, emotional catharsis, and reflective writing competency. The findings suggest that before the intervention, both groups were homogeneous in professional identity, self-reflection, emotional catharsis, and reflective writing competency; however, after the intervention, students using narrative medicine to form an empathetic connection had stronger professional identity, a higher reflective thinking level, more emotional catharsis, and greater improvement in reflective writing competency than students not using narrative medicine. To provide a clear illustration of the results, the following table (Table 10) provides a summary to highlight the differences between the two groups.

Table 10. A summary to highlight the differences between the two groups.

Scale & factors	Professional Identity (PIS-HSP)
Group comparison	Professional commitment and devotion			Emotional identification and belongingness			Professional goals and values			Self-fulfillment and retention tendency
Comparison using MANCOVA	_			*			**			**
Scale & factors	Reflective Thinking (RTS-HSP)
Group comparison	Reflective skepticism		Self-examination			Empathetic reflection			Critical open- mindedness
Comparison using MANCOVA	**		**			*			**
Scale & factors	Emotional Catharsis (PIS-HSP)
Group comparison	Emotional identification as self-healing				Emotional release for compensation			Emotional adjustment for intellectual growth
Comparison using MANCOVA	_				*			**
Scale & factors	Reflective Writing Competency (ANMWSR)
Group comparison	Focus and context structure	Ideas and elaboration			Voices and points of view		Critical thinking and representation	Depth of reflection on personal growth			Language and conventions
Comparison using MANCOVA	**	**			*		**	**			_

Note: *p< 0.05; **p< 0.01.

3.2. Results of the interviews

The results of the student interviews revealed that the students using narrative medicine to from an empathetic connection had stronger professional identity, a higher reflective thinking level, more emotional catharsis, and greater improvement in reflective writing competency than students not using narrative medicine. They enjoyed the class, saying that:

• Through the three stages of attention-representation-affiliation, I can have a chance to identify with those health professionals and those suffering in literature and visual art scenarios and hence somehow have an emotional identification and belonging to the health profession (F3; F15; F18; M3; M9; M12; F Female student; M Male student).

• I am glad for going to be a member of the health profession and have a great interest in the profession (F8; F11; F12; F 15; M2; M8; M10).

• I am willing to devote to my health professional knowledge so as to provide quality care for patients (F3; F8; F11; F 12; F18; M2; M3; M8).

• Moreover, some participants expressed that while having an emotional connection with those suffering, they could reach a state of emotional catharsis, saying that:

• While having an emotional connection with those suffering, I can release my negative emotions, such as sadness, grief, anger, etc. and somehow reach a mental or emotional balance in my life (F8; F11; F12; F18; M3; M9; M10; M12).

• Paying attention to the plots about the death of the dearest, I reach an affiliative connection with them and hence have a chance to vent the grievances I do not want to face (F3; F11; F12; M3; M8).

• By posting reflections on ethical/moral dilemmas and conflicts, I can safely voice my fears or those strong emotions that I feel embarrassed and afraid to express (F3; F11; F12; F15; F18; M2; M3; M8; M10).

• Through reading and writing these illness narratives, I am free to express my inner feelings so as to vent my emotions (F8; F11; F15; M3; M9; M12).

• By releasing emotions through illness narratives, I come to understand that life, death, illness, and aging are part of the human experience and attempt to cope with them (F3; F12; F15; M3; M10; M12).

In addition, some students also revealed that through reading these plots regarding ethical/moral dilemmas and conflicts, they learned how to see things from different perspectives, being more reflective and introspective, saying that:

• I check the credibility of the source of information before deciding how to handle dilemmas and conflicts in the simulated clinical or healthcare scenarios or situations (F3; F8; F11; F18; M3; M9; M10).

• I try to understand an experience from others’ points of view (F8; F11; F15; F18; M2; M3; M9).

• I try to consider other people’s feelings from different angles (F3; F11; F12; F18; M2; M8; M10).

• I try to figure out, question, and test all supporting arguments and refuting arguments about the ethical/moral dilemmas and conflicts (F8; F12; F15; F18; M2; M3; M8; M10).

• While reflecting on the dilemmas, I try to think and explore both positive and negative thoughts (F3; F11; F5; F18; M2; M8; M9; M12).

Based on the above quantitative results and qualitative interview excerpts to triangulate the quantitative results, it is shown that the narrative medicine-based intervention could bring positive effects on the health professions students. After going through the intervention, the students in the experimental group had stronger professional identity, a higher reflective thinking level, more emotional catharsis, and greater improvement in reflective writing competency than those not receiving the intervention, though some subscales not reaching statistical significance.

4. Discussion

The quantitative results revealed that, in professional identity, there were significant differences in ‘emotional identification and belongingness,’ ‘professional goals and values,’ and ‘self-fulfillment and retention tendency.’ The results revealed that those receiving narrative medicine to form an empathetic connection had the opportunity to observe and reflect over narrative medicine in simulated clinical/healthcare scenarios or situations. Moreover, while interacting with peers or instructors and sharing their opinions or reflections upon the clinical and healthcare issues, having an empathetic connection with others, they could begin to see things not only from certain medical or healthcare group but also from the perspective of an interprofessional community of health professionals. Hence, while taking a step toward realizing their interprofessional goals, values, and identities, in order to facilitate interprofessional collaboration [11,49], they would have a stronger collective professional identity for the health profession, with a set of values, goals, attitudes, and skills shared with others within the health profession community. The results are consistent with Monrouxe’s [50] study, suggesting that, narrative medicine can help students have a chance to reflect their professional identities and hence form the ability to develop a sound professional identity for practical purposes. The results also correspond with Miller et al’s study, revealing that the art and humanities training via narrative medicine interventions can help health professions students facilitate their professional identity development [12]. Because the participants had received some service-learning education and training and had some experience to interact with patients, patient families, and professionals, while narrating clinical or healthcare experiences in their service-learning practice or in the literature and visual art scenarios, they can use narrative medicine as a tool to negotiate with and make sense of events around them, such as patient suffering, illness experiences, and professional goals, which would all lead to an impact upon their development of a strong professional identity [50]. In addition, the results also correspond with Beck’s, Cooren’s, and Feldman’s studies [51–53], revealing that personal narratives, as well as collective narratives, can help people understand themselves, deal with high emotions, and act reflectively to help develop their own innate and genuine identity.

However, there was no significant difference in ‘professional commitment and devotion.’ It could be possible that, because ‘commitment’ refers to one’s emotional connection to an organization and one’s feeling of bearing an obligation to the organization [54], these students, despite having acquired medical and health care knowledge at school, along with service-learning education and training in the school, have not yet had much chance to assimilate their knowledge and skills with professional training; hence, they have not yet had a chance to connect or commit to an organization.

Regarding self-reflection, the students receiving narrative medicine to form an empathetic connection had significantly higher scores in ‘reflective skepticism,’ ‘self-examination,’ ‘empathetic reflection,’ and ‘critical open-mindedness.’ The study corresponds with Dasgupta and Charon’s study on narrative medicine [8], demonstrating that empathy can bring in a positive impact on self-reflection. The findings also correspond with Karkabi et al.’s, Miller’s et al.’s, and Savitha et al.’s [12,55,56] research in that narrative medicine can facilitate self-reflection in health professions education because these illness narratives as narrative medicine can function as reflective narratives to examine ethical/moral challenges, conflicts, or dilemmas in clinical or healthcare scenarios. Moreover, as Liu et al., Jasper, and Savitha et al. [12,56–58] suggest, while serving as reflective narratives, narrative medicine can help the narrators to put themselves in someone else’s shoes, and while appreciating diverse perspectives, they can be more open-minded and have insight into those suffering. In addition, while being more empathetically and critically reflective about those suffering, they would shield themselves from unexamined judgments; instead, with sensitivity and sharp observation, illness narrators, through reflection, can resolve personal conflicts, dilemmas, ambivalences, or even discrepancies to facilitate empathetic interactions with patients, thereby developing a more positive relationship between patients and health professionals.

Regarding emotional catharsis, there were significant differences in ‘emotional release for compensation’ and ‘emotional adjustment for intellectual growth,’ but not in ‘emotional identification as self-healing.’ The results correspond with Ullrich and Lutgendorf’s [59] and Tsey’s [60] research, which mentioned that narrative journaling and writing, with the use of reflectivity, can lead to an emotional catharsis, as one pours out negative feelings of powerlessness and hence facilitates well-being. Namely, health professions students can use narratives as a channel to manage their ethical/moral conflicts and ambivalent or negative feelings. Moreover, while scrutinizing these conflicts, ambivalences, or negative feelings happening in clinical scenarios, they can construct them into a meaningful storyline, which further validates and confirms their professional identity. Moreover, while reflecting on the narrative medicine, professionals can review mistakes or crucial problems in these clinical cases; they can also reflect on these mistakes or problems and formulate strategies in advance to address these mistakes or problems. As Benigh, Duke et al., and Karkahi et al. [55,61,62] suggest, while critically reflecting upon these clinical or healthcare cases or incidents to bring cognitive and affective meaning to the illness narratives, participants may gain insight into the conflicts, ambivalences, and dilemmas in these critical cases and incidents and make sense of them. Therefore, through these illness narratives as narrative medicine, they can free themselves, change their attitudes, find balance, and further reach intellectual growth and improvement [63,64].

However, although DeSalvo’s [65] study shows that narrative medicine can become ‘healing narratives’ to heal those narrating from trauma, the experimental results showed that experimental group students did not have significantly higher scores in ‘emotional identification as self-healing.’ Nevertheless, their scores were higher than their counterparts’. The reason why experimental group students did not reach a significant difference in ‘emotional identification as self-healing’ could be because the subjects participating in the study were still students, with little clinical or prior healthcare experience in professional practice [66], not to mention access to acute patients or terminally ill patients. With no or few illness narratives as narrative medicine to reflect upon, they did not have the opportunity to connect their feelings to patients’ suffering or ailments in clinical cases or incidents to bring about insights and reflections. Therefore, it became difficult for them to emotionally identify with those suffering and reach self-healing.

As for reflective writing competency, the students receiving narrative medicine to form an empathetic connection received significantly higher scores in ‘focus and context structure,’ ‘ideas and elaboration,’ ‘voices and points of view,’ ‘critical thinking and representation,’ and ‘depth of reflection on personal growth,’ but not in ‘language and conventions.’ As mentioned previously, while using narrative medicine as a means of reflective narratives, students can empathize with others, appreciate different perspectives, and become more open and gain a deeper understanding of those who suffer emotionally and physically [12,56–58]. The results revealed that those using narrative medicine demonstrated an insightful understanding of the reflective theme. They could perceive and analyze a specific event or experience in depth, while taking diverse perspectives into consideration. The results correspond with Kea et al.’s [67] research, mentioning that while being engaged in reflective writing, students could achieve self-analysis and reflective thinking. Moreover, through using reflective writing regarding narrative medicine, students can gain access to a diverse perspective, leading them to develop critical thinking abilities, with supporting arguments and counterarguments being thoroughly considered. The results also consistent with Karkahi et al.’s and DasGupta and Charon’s studies [8,55], stating that the practice of narrative medicine can increase the depth of reflection and the achievement of personal growth because the practice requires that participants reflect upon daily clinical experiences from their perspectives as healthcare professionals or from the perspectives of others, such as patients, patient families, or even those passing away. While sharing narrative medicine with each other, participants are able to hear different voices and consider multiple perspectives; by critically analyzing these perspectives, they can experience personal growth.

However, though those receiving narrative medicine to form an empathetic connection had a higher score in the competence of ‘language and conventions,’ these two groups did not differ significantly in the competence, which involves the ability to use language conventions appropriately for written communication, such as spelling, grammar, punctuation, word choice, and sentence structure. The reason for not reaching a statistical significance could be possible that the competence of ‘language and conventions’ is an essential competence in the development of written comprehension [68]. Both the experimental and control groups, as medical university students, had already required basic language rules and grammatical structure [69,70]; therefore, they had at least basic competency, such as choosing appropriate words or correct grammatical structures, to facilitate their reflective writing.

Overall, the research findings suggest that the use of narrative medicine is worth recommending to form an empathetic connection. By using narrative skills and the three stages of narrative medicine (attention → representation → affiliation) to form an empathetic connection, students can have more opportunities to mimetically experience the life of patients and those suffering, as well as health professionals. Moreover, they can also develop a better understanding of the difficult situations, conflicts, and dilemmas that people suffer from. Therefore, they can construct their professional identities, enhance their self-reflection, and reach an emotional catharsis.

5. Conclusion

This study demonstrated that the use of narrative medicine to form an empathetic connection could lead to positive learning outcomes for health professions students regarding professional identity, self-reflection, emotional catharsis, and self-reflective writing competency. This research results proved that the use of narrative medicine to form an empathetic connection could bring positive impacts on health professions students because it let these students have opportunities to mimetically experience the lives of patients, patient families, and healthcare professionals, hence gaining a better understanding of the difficult situations, conflicts, and dilemmas that they may suffer from. With the practice of narrative medicine, students could successfully release their emotional stress, find meaning in their lives, and build their professional identity.

However, there may be some limitations in the study. First, the study adopted a quasi-experimental design because random assignment of participants was impossible. Second, the study was in a single-blind study; only the participants were blinded, not knowing whether they were in the experimental group or control group. Even though the experimenters had two well-trained blind research assistants code and assess students’ pretest and posttest results, the experimenters knew which study group the participants were in. In addition, although the intervention plays a big role in the lack of listening and empathy in health professions students or professionals, for those experiencing empathy burnout or compassion fatigue, they may lose the patience or willingness in attentive listening and empathy. Additionally, these participants were health professions students majoring in health or medicine adjacent fields, not graduate-level healthcare students or current healthcare workers. Therefore, any researcher wanting to use the results of the study should carefully examine the study context and the similarity of the participants. Future research may examine the feasibility of using narrative medicine to reduce health providers’ empathy burnout or compassion fatigue and preserve their empathy toward their patients.

Availability of data and materials

Due to IRB regulations, the datasets generated in the research cannot be shared publicly for the privacy of the participants. Upon reasonable request, it may be available from the corresponding author.

Institutional review board statement

This study and the experimental protocols were approved by the IRB of Chung Shang Medical University Hospital (No. CS16157, dated 9 January 2017).

Acknowledgments

The authors express appreciation for those participating and supporting the research.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2023.2235749

Additional information

Funding

The research was funded by the Ministry of Science and Technology, R.O.C.