A narrative medicine‐based training program increases the humanistic care quality of new nurses in cancer hospital

With the change of medical model, the cancer nurses should not only pay attention to patients' physical pain, but also patients' psychological distress, which requires cancer nurses to have a high quality of humanistic care. This study aims to explore the humanistic care quality of new nurses in cancer hospital and effects of the narrative medicine‐based training program on the new nurses of cancer hospital. A total of 101 new nurses in a cancer hospital received the narrative medicine‐based training in 2020. Before and after the training, they were investigated with humanistic care quality questionnaire and empathy ability questionnaire. The course included narrative therapy overview, narrative medicine overview, narrative nursing, psychological nursing cases of cancer patients, and so on. After training, the total score of the humanistic care and quality empathy ability increased significantly, and the comparison was statistically significant. The total score of empathy after the training (98.44 ± 2.23) was higher than the score before the training (86.35 ± 7.53) (p < .05). The total score of humanistic care quality after the training (184.45 ± 14.34) was higher than the score before the training (161.45 ± 15.45) (p < .01). The scores of all dimensions were statistically significant. The narrative medicine‐based training program could increase the empathy ability of the new cancer nurses and improve the humanistic care quality. This program is suitable for clinical promotion and application. The study findings could have implications for medical institute to increase the humanistic care quality of new nurses.

What are the key findings?
• The narrative medicine-based training programme can improve the empathy of new nurses.
• The narrative medicine-based training programme can improve the quality of humanistic care of new nurses.
How should the findings be used to influence policy/practice/research/education?
• Nurses should provide humanistic care for cancer patients.
• Nurses should be trained through narrative medicine-based training programme to increase their empathy ability, especially for new nurses.
• The results of this study can provide a reference for developing education programme by medical university or hospital.

| INTRODUCTION
The incidence of cancer is getting higher and higher. 1  have not yet a systematic curriculum to improve the quality of nurses' humanistic care, which resulting in the nurses' low quality of humanistic care and affecting the implementation of clinical humanistic care, especially in new nurses. New nurses are nurses who are still in the standardized training of nurses within 3 years of their entry. 2 Narrative medicine refers to the practice of narrative medicine, that is, by absorbing, explaining and responding to patients' stories and dilemmas, clinicians provide them with respect, empathy and vitality of medical care. We previously constructed the narrative medicinebased training program. In this study, we explored the effects of this program on the new nurses of caner hospital.

| BACKGROUND
In the 20th century, medical educator William Orem pointed out that the drawbacks of medical practice lie in the separation of science and humanism, the alienation of technological development from humanism. 3 Medical practice needs the unity of scientific spirit and humanistic spirit. The integration of science and humanities is the inevitable requirement of the unity of truth, goodness, beauty, and perfection of medicine. 4 With the change of medical model, nursing model has gradually changed from "disease-centered" to "people-centered, patient-centered" humanistic care model. Nursing as a life discipline, humanistic care has become its ultimate pursuit. 5 Nowadays, cancer has become the first major disease affecting human health. Cancer patients experience great physical and mental pain from diagnosis to treatment to rehabilitation. Therefore, as a professional cancer nurse, they need to have the quality of humanistic care. The essence of nursing humanistic care requires nurses not only to have rich knowledge of care and high ability of care, but also to have a keen sense of care and deepen the concept of care. These four aspects constitute the core elements of nurses' humanistic care quality. 6 However, due to the different abilities and ways of teaching, the quality of humanistic care of nurses is relatively weak, especially in new nurses. 7 The cultivation of nurses' humanistic care ability is a long-term process, and the process of clinical practice reflects patients' humanistic needs more directly. Nursing humanistic care course is an effective way to cultivate students' humanistic care quality. 8 However, the cultivation of humanistic care in a single course is limited. It is necessary to incorporate nursing staff's caring behavior into the scope of nursing management on the basis of a certain theory and penetrate into all aspects of clinical nursing, so that clinical nurses can establish a good feeling of humanistic care and become conscious, and acts that translate into work. 9 At the same time, because the quality of humanistic care is the category of moral quality, with the characteristics of complexity, implicitness, experience and practice, it is the development process of individual knowledge, emotion, intention and internalization. These characteristics determine the complexity of humanistic care education. 10,11 Simple theoretical preaching is difficult to work.
Nurses need to experience care, arouse inner love, sympathy and other emotions, as well as sensitivity and empathy to other people's care needs. 12 In 2001, American scholars put forward the concept of narrative medicine, that is, medicine practiced by narrative ability, and clinicians provide medical care full of respect, empathy, and vitality by absorbing, explaining and responding to patients' stories and situations. 13 Its core is empathy and reflection. Modern medicine needs the return of humanity, whether it is a front-line medical staff or a doctor. The managers of the treatment institutions have reached a consensus. Narrative medicine: a banner of humanity returning to medicine. It has attracted much attention in Europe and America, but narrative medicine in China is a new thing. There are not many literatures of narrative were reported. The application of narrative medicine abroad can be divided into two parts. One is to promote narration among doctors and medical students, that is to improve their narrative ability by medical education. Another application direction of narrative medicine is in medical dispute mediation. In Japan, there is a training material, named the theory and practice of dispute management, which is based on the theory of narrative medicine. The introduction of narrative medicine in China is mostly as the form of reflection on medical humanities. The application of narrative medicine is rare, and there is less discussion on the application of it in the field of nursing.
Based on the core theory of narrative medicine and oncology clinical nursing practice, our previous research had developed a narrative medicine-based training program. In this study, we explored the effect of the program of the narrative medicine-based training program, to give reference for medical institute to increase the humanistic care quality of nurses.

| Aims
To explore the humanistic care quality of new nurses in cancer hospital and effects of the narrative medicine-based training program on the new nurses of cancer hospital.

| Hypotheses
We evaluated two hypotheses:

| Design
A self-control study was used to explore the effect of the narrative medicine-based training program on the humanistic care quality and the empathy ability of new nurses.

| Participants
We recruited new nurses at a cancer hospital in September 2020.
Inclusion criteria: (1) registered nurse; (2) have completed the prejob training and have worked for 6 months to 3 years; (3) informed consent to participate in this study. Exclusion criteria: (1) new nurses who could not participate in the whole course or dropped out of the course for any reason (e.g., health, family, etc.). were excluded.

| Intervention
Our narrative medicine-based training program had three 2-h lectures, each lecture 1 week apart, and monthly a narrative nursing case report after three lectures for 6 months. Before training, the humanistic care quality and empathy ability of these nurses were assessed. After 6 months of training, the quality of humanistic care and empathy of the population were reassessed. The curriculum of this study is theoretical teaching, through lectures, group discussions, questions and answers, and PowerPoint presentations, to enable new nurses to master systematic knowledge of narrative medicine, narrative therapy, and narrative nursing. The educational program based on narrative medicine was implemented in three 90-min sessions. The content of the first session is about narrative medicine, narrative nursing overview and watching short films for case introduction; The content of the second session is the core technology of narrative nursing. Through the form of Balint group, we discuss a case, use narrative technology as the method, and use sitcom method to simulate real events. Through this training form, we can better know how to do empathic thinking. The third session was for new nurses to find cases around them for narrative nursing case analysis and practical implementation, and PPT presentation in class.

| Data collection
Data were collected on the quality of humanistic care and empathy of the population before (baseline), and after the training. The higher the score (total points calculated after conversion of inverse questions), the higher the empathy ability, which can be expressed as follows: PT, perspective-taking (PT); FS, Fantasy (FS); EC, empathic concern (EC); Personal distress (PD). The value of Cronbach's α for the questionnaire is .875.

| Ethical considerations
The original study was approved by the Institutional Human Subjects Protection Committee (No. 2019-009) and all study-site administrative departments. Those who agreed to participate signed written consent.

| Validity and reliability
First, a protocol was developed for the intervention as well as protocols and instructions for each instrument. The content validity of the intervention protocol was assured with three experts with specialties in narrative medicine, narrative therapy and narrative nursing. Second, the training was delivered by experts in narrative medicine. The quality of the training was also ensured by monthly case report. The data were input by two researchers to ensure accuracy.

| Response rate
Of 101 new nurses who met the inclusion criteria, all agreed to participate. After the training program, all participates completed the reassessment, with a response rate of 100%.

| Narrative medicine-based training program increase the empathy ability of the new cancer nurses
The total score of empathy was 86.35 ± 7.53 and 98.44 ± 2.23 (p < .05) before and after the training respectively ( Empathy is a special skill in interpersonal communication. It is an emotional response to others' emotional experience, or an emotional experience from others' standpoint to their inner state. 16 With the gradual deepening of the recognition of humanistic care in the field of health, empathy has also become a research hotspot in the domestic medical field. Nursing empathy is the ability of nurses to identify and understand patients' situations and emotions, the entry point of nurse-patient relationship, and one of the essential qualities of nurses. 17 Improving nursing empathy is conducive to better perceiving patients' needs, improving the ability to predict patients' behavior, enhancing nursing ability, improving nursing quality, reducing nursing errors and improving nursing efficiency. 18  5.2 | Narrative medicine-based training program increase the humanistic care quality of the new cancer nurses Table 2 shows that the narrative medicine-based training program improved the quality of humanistic care of new nurses.
For many years, the medical community has been advocating medical staff for patients, we should achieve "the parents" heart of doctors', but the effect is still to be improved. It is not that there is a problem with that, but the operability of this requirement needs to be improved easily to formalized. Narrative medicine promotes nursing leadership by return of human nature, which provides a starting point.

ACKNOWLEDGMENT
The authors would like to thank all new nurses participated in this study.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

ETHICS STATEMENT
The original study was approved by the Institutional Human Subjects Protection Committee (No. 2019-009) and all study-site administrative departments. Those who agreed to participate signed written consent.