To address challenges in Canada’s health care system, change is required. Systems thinking, including an awareness of interconnectivity, system boundaries, and the influence of perspectives, can help us to be prepared for change; yet it must also inform effective action. Taking action, or intervening in a system, requires a focus on letting go of ineffective attitudes, processes, hierarchies, policies, and paradigms. Stories and storytelling are ubiquitous in human experience and influence how we understand our systems and intervene. Stories can also help us see what we must let go of and, at the same time, connect the system more effectively to itself. Specifically, a focus on the diverse stories of actors across the health care system has the potential to bring about systems change by helping us better understand the health care system and how we can intervene effectively. To highlight the value of stories and storytelling, one of the authors shares her own story of being diagnosed with non-Hodgkin lymphoma. Reflecting on this story and the process of storytelling more generally, we highlight how the collaborative process of sharing and hearing stories could facilitate systems change in health care.
KEY WORDS: storytelling, systems thinking, systems change, health care, organizational change
Although Canada’s health care system is considered a source of national pride, we are hearing increasingly that it is breaking and is rife with complex challenges.1,2 Canada is losing ground; according to the Commonwealth Fund International Health Policy Survey, the Canadian health care system’s performance ranks 9 out of 11 industrialized countries.3 Prominent health economist and former CEO of the Canadian Medical Association, Bill Tholl, said, “Canada’s decentralized set of health care systems continue to struggle to address the formidable challenges of growing health disparities among and between our indigenous peoples, the global threat of cybersecurity, an unprecedented scourge in terms of the opioid crisis, and the growing needs of an aging population” (personal communication, 20 Oct. 2017).
Although Tholl went on to say that a great deal of good work is being done, given that health care is a complex, adaptive social system,* there is likely no one quick fix. Rather, more holistic approaches exploring interconnectivities and interdependencies among resources, stakeholders, and technology in response to increasing demands for high-quality, accessible, and timely health care are required.4
Reflecting on the words of Lewis Thomas,5 a medical essayist:
When you are confronted by any complex social system… with things about it that you are dissatisfied with and anxious to fix, you cannot just step in and set about fixing with much hope of helping. This is one of the sore discouragements of our time.... If you want to fix something you are first obliged to understand... the whole system.
Thus, in the context of health care, how can we understand the system to support its transformation, and what role can each of us play as agents of change? In this article, in an effort to begin answering these questions, we explore the potential power of stories and storytelling to catalyze systemic change. We also highlight the importance of multiple stories to adopt a systems lens and propel action to help the health care system adapt to and meet the challenges we face today and into the future. Top
Systems thinking and systems change
To assist in understanding and making changes to complex, adaptive, social systems like health care, systems thinking is often considered critical. Although there is no one unifying definition to encapsulate systems and systems thinking, systems are generally thought to comprise a number of facets: elements, the parts that make up or constitute the whole; links between the parts, the processes and interrelations that hold the parts together; boundaries, the limits that determine what is inside or outside of the system; and the perspectives each of us holds.6
Furthermore, Meadows7 brought our attention to the outcomes of a system, stating that “a system is a set of elements or parts that is coherently organized and interconnected in a pattern or structure that produces a characteristic set of behaviors, often classified as its ‘function’ or ‘purpose’” (p. 188). However, as Meadows’ work suggests, how one views or defines the system will also shape the interactions and outcomes. In our health care system, something more is required beyond how we view the situation, and the reasoning behind any actions we take, to bring about positive change.
Systems thinking offers ways to view a situation through a more holistic lens. It is an orientation that supports us to understand more deeply the linkages, relationships, interactions, interdependencies, and behaviours among the elements of which the system is comprised. According to Senge,8 systems thinking is a “conceptual framework, a body of knowledge and tools…, to make the full patterns clearer and to help us see how to change them effectively” (p. 7). Building from Meadows’ articulation of systems, Stroh9 refers to systems thinking as the ability to understand interconnections in a system “in such a way as to achieve a desired purpose” (p. 16).
However, a systems thinking orientation also requires us to be aware of how our own perspectives and interpretations may differ from those of others in different contexts and the actions, results, and consequences that arise from our framing and sense making.6 In essence, to approach complex challenges like health care with a systems orientation requires that we work together to understand the multiple ways we comprehend and make sense of the system to develop a more holistic understanding of what works, for whom, and under what circumstances.
There is sometimes a tendency to describe the health care system as something outside of us, a set of structures, processes, and rules that govern how we work. However, according to the systems-thinking literature, we are not separate from the systems of which we are part. As Senge8 said, “Systems thinking shows us that there is no outside; that you and the cause of your problems are part of a single system” (p. 67). How then, can we look at the health care system from different perspectives including those of physicians, nurses, health care staff, educators, patients, communities, and families to develop a more holistic understanding of what works, for whom, and under what circumstances to support systems change?
Finally, it is important to note that although systems thinking encourages us to view situations and contexts differently, changing the system also requires us to act. This could mean letting go of or “releasing” something to create space for something to grow10,11 or “doing” or “being” something new or different to connect the system more effectively to itself. How can we do this, and how can we also recognize what to let go of to bring about positive change in health care? We argue that stories and storytelling could play an integral role to support meaningful systemic change. In this article, we explore the role of stories and storytelling in our health care system; however, first we share a story to ground this discussion in storytelling and possible action. Top
A window into the health care system: Cheryl’s story
At the age of 33, I was working on my doctorate and traveling back and forth to Uganda. I was relatively healthy, albeit exhausted, and, given everything that was happening in my life, that seemed relatively normal. And so, when I went for my annual physical and inquired about a lump in my groin, the possibility that it was simply an ingrown hair seemed probable; however, it did not seem to go away.
A year later, the lump remained. This time, I was sent for some tests. I specifically recall having an ultrasound and, after the technician examined my groin, she asked if there were any other areas that felt abnormal. When I asked if something was wrong, she responded that she could not divulge such information; however, I sensed from her interaction something was amiss.
Several weeks later, I saw a surgeon, and as he palpated the areas, he questioned why I was there; from his perspective I was young and healthy and it was likely nothing. I left his office in tears. Six weeks later I had a biopsy. Two days later the surgeon called, I was diagnosed with non-Hodgkin lymphoma. I had cancer.
A month later, I met my oncologist, still unaware of the type of cancer I had, the staging, or what my prognosis was. I was scared, alone, and confused. Fortunately, when my oncologist walked into the room, he greeted me and said, “Tell me about you, not about your symptoms, but about who you are.”
In that instant, I felt like my perspective mattered. That day, and over the next couple of years, we discussed and explored treatment options together. It felt safe to ask questions and to express my concerns. Rather than feeling like a passive participant, I felt I was an active agent in my own health care.
Reflecting on my experience, I wondered how my story could contribute to better understanding of the health care system. I also wondered how my story differed from others (e.g., other people living with cancer, my oncologist, my nurses) and was curious about the role stories could play in facilitating change.
The power of storytelling
Wheatley12 argued that “If a system is in trouble, it can be restored to health by connecting it to more of itself. To make a system stronger we need to create stronger relationships…. The system is capable of solving its own problems” (p. 145). Stories can connect us to the human faces and voices of those in the health care system, including those we are here to serve. In the context of Cheryl’s story, this could mean engaging in conversations between patients and health care providers to better understand the “other” more fully.
Not only do stories and storytelling have the clear potential to connect our health care system to itself, but they might also help us uncover elements of our systems that we might well let go of. For example, Zimmerman and colleagues13 talked about how bureaucratic processes and attitudes, and even artificial hierarchies, can stand in the way of effective collaboration. In Cheryl’s story, artificial and ineffective hierarchy emerged at various points. This story inspired us to wonder whether the process of how a diagnosis is communicated could be revisited or adapted to help allay patients’ fears.
Stories and storytelling also have the potential to help us understand the health care system from multiple perspectives and enhance our understanding of the system, its interactions, and outcomes. According to King,14 stories shape our reality. In essence, stories are active and influential agents of systemic change. Yet, in a system that is considered to be heavily influenced and informed by bureaucracy, hierarchy, and expertise, there is the potential for stories to be limiting if we choose to privilege one story over another. As Adichie15 noted, “There is danger in a single story. The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.” Top
In Cheryl’s story, differing perspectives and unspoken stories limited meaningful understanding. To create systems change in health care requires us to privilege and understand multiple and diverse narratives from the perspectives of physicians, nurses, health care staff, educators, administrators, technicians, patients, and many others. Creating space to understand this interwoven complex web of narratives can support us to see and understand the system through different lenses or points of view, understand its complexity beyond our own scope, and highlight new possibilities for change. In the context of Cheryl’s story, this could be gathering stories from her physician, the oncologist, the surgeon, and others to build a broader understanding of system complexities.
Finally, stories and storytelling have the power to bring us together and refine our shared vision and commitment to change. Through the process of storytelling, both narrator and audience become intimately involved in the same story,16 and storytelling becomes a collaborative process of “retrospective meaning making.”17
According to Bolman and Deal,18 storytelling can also be an important tool for enhancing and perpetuating culture, identity, and tradition. Stories give flesh to shared values and sacred beliefs. Everyday life in organizations brings many heartwarming moments and dramatic encounters. Turned into stories, these events fill an organization’s treasure chest with lore and legend. Told and retold, they draw people together and connect them with the significance of their work (p. 407).18
Perhaps most important in relation to systems change, Senge8 suggested that storytelling can highlight a “teleological explanation” enrolling narrator and audience in a clear and higher purpose, “an understanding of what we are trying to become” (p. 354). Through stories we can redefine our shared values and our commitment to system change. In the words of the late Richard Wagamese, storytelling can support us to co-create “the best possible story we can while we’re here; you, me, us together.”19
In essence, storytelling has the potential to reconnect us to our higher purpose and redefine our shared commitments. In the context of Cheryl’s story, this could mean involving patients like Cheryl in decisions regarding health care to ensure that patients, physicians, and other health care actors are committed to the same purpose and outcomes.
Reflections and conclusion
Stories and storytelling are ubiquitous in human experience.20 Stories have perpetuated knowledge and culture since the dawn of time and have potential to serve as effective interventions toward positive change in health care. Stories and storytelling can shed light on the complexity of the system and highlight possibilities to bring about systems change by connecting the system more effectively to itself and/or identifying what in the system we can let go of.
Holding space for multiple stories and narratives from a diversity of actors in the health care system also offers an opportunity to further understand the complexity of the system and take relevant and effective actions toward change. Finally, storytelling can bring us together to reimagine our collective purpose. Now we are faced with the challenge of how — how can we create space to share stories with one another and change the health care system, story by story? Top
References
1. Martin D. Better now: six big ideas to improve health care for all Canadians. Toronto: Allen Lane; 2017.
2. Simpson C, Walker D, Sinclair D, Wilson R. How healthy is the Canadian health-care system? National Post 2017;25 Sept. Available: https://tinyurl.com/y7l8yqea
3. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. New York: Commonwealth Fund; 2017. Available: https://tinyurl.com/y7olbe55
4. Qudrat-Ullah H. Better decision making in complex, dynamic tasks. New York: Springer; 2014.
5. Thomas L. On meddling. In The medusa and the snail: more notes of a biology watcher. New York: Bantam; 1980.
6. Williams B, Hummelbrunner R. Systems concepts in action: a practitioner’s toolkit. Stanford, Calif.: Stanford University Press; 2009.
7. Meadows D. Thinking in systems: a primer. White River Junction, Vt.: Chelsea Green; 2008.
8. Senge P. The fifth discipline: the art and science of the learning organization. New York: Currency Doubleday; 1990.
9.Stroh DP. Why good intentions are not enough. In Systems thinking for social change. A practical guide to solving complex problems, avoiding unintended consequences, and achieving lasting results. White River Junction, Vt.: Chelsea Green; 2015:12-8. Available: https://tinyurl.com/y9m8ddj3
10.Gunderson L, Holling C. Panarchy: understanding transformations in human and natural systems. Washington, DC: Island Press; 2001.
11.Hurst DK, Zimmerman BJ. From life cycle to ecocycle: a new perspective on the growth, maturity, destruction, and renewal of complex systems. J Manage Inquiry 1994;3(4):339-54.
12.Wheatley M. Leadership and the new science: discovering order in a chaotic world. San Francisco: Berrett-Koehler; 1999.
13.Zimmerman B, Reason P, Rykert L, Gitterman L, Christian J, Gardam M. Front-line ownership: generating a cure mindset for patient safety. Healthc Pap 2013;13(1):6-22.
14.King T. The truth about stories: a native narrative. Toronto: House of Anansi; 2003.
15.Adichie CN. The danger of a single story (video). New York: TEDGlobal; 2009: at 13:05. Available: https://tinyurl.com/mh9v5hl
16.Riessman C. Narrative methods for the human sciences. Thousand Oaks, Calif.: Sage; 2008.
17.Chase S. Narrative inquiry: multiple lenses, approaches, voices. In Denzin N, Lincoln Y (editors). The Sage handbook of qualitative research (3rd ed.). Thousand Oaks, Calif.: Sage; 2005: 651-6.
18.Bolman L, Deal T. Reframing organization: artistry, choice, and leadership. San Francisco: Jossey-Bass; 2003.
19.Polling J. We are story. The Times 2017;16 March. Available: http://www.mindentimes.ca/we-are-story
20.Baldwin C. Storycatcher: making sense of our lives through the power and practice of story. Novato, Calif.: New World Library; 2005.
Authors
Cheryl Heykoop, DSocSci, is an assistant professor at the School of Leadership Studies, Royal Roads University, Victoria, British Columbia, where her research and teaching focus on “nature-based leadership,” participatory action research, story-telling, and resilience.
Guy Nasmyth, PhD, is an associate faculty member with the School of Leadership Studies, Royal Roads University. With a focus on leadership development and research into collaborative leadership, he has a longstanding interest in systems thinking and collaboration. Top
Correspondence to:
Cheryl.1heykoop@RoyalRoads.ca or
Guy.Nasmyth@RoyalRoads.ca
This article has been peer reviewed.