Occupational Therapy In Health Care, 29(1):54–62, 2015 C 2015 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.958888
ORIGINAL ARTICLE
Digital Storytelling: An Innovative Tool for Practice, Education, and Research Occup Ther Health Downloaded from informahealthcare.com by University of Otago on 01/05/15 For personal use only.
Shalini Lal1 , Catherine Donnelly2 , & Jennifer Shin3 1
School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada, 2 School of Rehabilitation Therapy, Queen’s University, 3 The Four Villages Community Health Centre
ABSTRACT. Digital storytelling is a method of using storytelling, group work, and modern technology to facilitate the creation of 2–3 minute multi-media video clips to convey personal or community stories. Digital storytelling is being used within the health care field; however, there has been limited documentation of its application within occupational therapy. This paper introduces digital storytelling and proposes how it can be applied in occupational therapy clinical practice, education, and research. The ethical and methodological challenges in relation to using the method are also discussed. KEYWORDS. Arts-based methods, community-based, knowledge translation, narrative, participatory, qualitative methods
It has long been recognized that storytelling is a powerful vehicle for reflection, recovery, and therapeutic action. For example, Mattingly (1991) described how storytelling helps facilitate understanding of patients’ illness experiences and the clinical reasoning process. Greenhalgh & Hurwitz (1999) highlighted how stories provide opportunities for gaining a holistic understanding of the issues that clients face, providing a foundation for engaging in client-centered practice. Moreover, the act of storytelling has been characterized as a critical process that humans use to make sense of biographical disruptions related to illness and other events in their lives (Bury, 2001; Frank, 1995; McAdams, 2001; Riessman, 2008). Modern technology has taken the act of storytelling to new heights, resulting in a range of opportunities and tools for creating, learning, teaching, and sharing knowledge in engaging ways and through innovative formats. Digital storytelling is one such tool. Digital storytelling is an innovative participatory method that combines storytelling, group work, and technology to facilitate the creation Address correspondence to: Shalini Lal, PhD, School of Rehabilitation, Faculty of Medicine, University of ´ (Quebec) ´ Montreal, C.P. 6128, succursale Centre-ville, Montreal Canada H3C 3J7 (E-mail: shalinilal88@ gmail.com) (Received 18 February 2013; accepted 24 August 2014)
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of 2 to 3 minute multi-media video clips expressing a personal or community story. Digital storytelling is relatively novel in its application within the health care field, though the literature on this method has emerged more prominently in recent years. A search of the peer-reviewed occupational therapy literature did not reveal any studies using the digital storytelling method, suggesting that it has been untapped for its potential use. Since digital storytelling has multiple potentialities for application in the field of occupational therapy, educators, researchers, and clinicians could benefit from being informed about this approach. This paper provides an introduction to the digital storytelling method and explores how it can be applied to occupational therapy drawing from literature as well as the authors’ experiences.
THE PROCESS OF DIGITAL STORYTELLING Digital storytelling was developed in the late 1990’s and promoted through the Center for Digital Storytelling in Berkeley, California. The Center partners with communities and organizations to support the sharing of first person accounts (personal narratives) as a platform for community action through the facilitation of digital storytelling workshops. The Center operates under the direction of key founder, Joe Lambert, who has a background in arts activism and theatre production. The Center’s website (Stories: At a Glance, n.d.) provides many examples of digital stories that have been created through its workshops over the years though many variations of this method have been documented in the literature (e.g., Cumming et al., 2010; Jernigan et al., 2012). Digital stories are typically created through group-based workshops, which are considered to be a critical aspect of the method. Workshops are designated for the public or customized for a specific organization or group (e.g., health care providers or patient population). A standard workshop usually takes place over the course of days and involves eight to twelve participants. The first day is used for introductions, an overview of digital storytelling, sharing of personal stories, script review and development, and a tutorial in Photoshop. The second day is teaching of the technical skills necessary to put the story into digital form, and the third day is used for finishing the digital story and showing the stories made in the group (Lambert, 2013). One element of the workshop that is considered to be a valuable component of the digital storytelling process is the sharing of stories within a story circle (Lambert, 2013). Story circles are used progressively throughout the three days as a way for participants to get to know each other, listen to each other’s stories, and, give and receive feedback on stories and scripts. Using the story circle, the facilitator has the responsibility for ensuring that trust is established such that each person and his/her story is held with the highest level of nurturance and respect. Although digital storytelling is not described as a therapeutic process, the experience has nonetheless been expressed by participants as being, “transcendent,” “cathartic,” and “transformative” (pgs. 32, 145, 168) and as an empowering way of reclaiming and sharing one’s personal experiences.
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THE OUTCOME A digital story is a two-three minute multi-media video clip that includes narrative, visual (digital video, photographs, artwork), and performance (music, voice) mediums for the purpose of expressing an individual or community story. There are many kinds of stories that can be told through the digital story format. Examples of topics that have been expressed in digital stories include: hope (Wexler et al., 2013); place, community, equity, education, housing, social justice (Jernigan et al., 2012); help-seeking (Cumming et al., 2010); health (Gray et al., 2010); identity, experience of health and human services, important people in an individual’s life (Stories: At a Glance, n.d.); violence, poverty, and isolation (Digital Stories, n.d.). Digital stories are powerful vehicles through which to create and share knowledge. The impactful experiences that are sometimes evoked by viewing digital stories of others can possibly be attributed to the integration of different art forms into one product. Combining multimedia adds layers of depth and increases the potential for an emotional and sensorial experience for the audience. By adhering to the limited duration of the story, the storyteller is required to get to the heart of the matter rather efficiently and in this way the format is effective in capturing life’s defining moments or turning points (Lambert, 2013). The condensed format is conducive to sharing the story with others and allows for them to be easily uploaded to the internet (Meadows, 2003) opening up numerous possibilities for file sharing, repeat viewings, and audience distribution. It is important to remember that although multi-media (e.g. photos, music) are important contributors to the impact of the digital story, they serve mainly as tools for the storyteller. The power of the digital story remains in the content of the story and how it is expressed, with less preoccupation with the actual visuals, lighting, background, and sound effects (Lambert, 2013). APPLICATION FOR OCCUPATIONAL THERAPY Community Practice There are studies to demonstrate the therapeutic use of digital storytelling. Wexler et al. (2013) used digital storytelling within the context of a positive youth development framework with young people living in Northern Alaska. Over a 3 year period, 39 digital storytelling workshops were conducted with 432 youth from elementary, middle, and high schools across 12 rural Alaskan villages. The youth produced 566 digital stories highlighting positive aspects of their lives within the context of a suicide prevention initiative. Twenty-seven youth from the total sample were interviewed to obtain a more in-depth understanding of their digital storytelling experiences. The participants expressed that participating in the digital storytelling process provided them with a sense of achievement and personal mastery, enabled them to reflect on positive aspects of their lives, and an opportunity to strengthen their relationship with important people through sharing of the videos. Cumming et al. (2010) investigated the impact of watching a digital story on help seeking in a sample of 539 women recruited on-line. Watching the digital story increased women’s sense of empowerment and likelihood of seeking help for a health issue they felt embarrassed to discuss, providing preliminary evidence that digital
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stories can promote help-seeking behaviors. Digital stories have also been used for providing health-related information and support. For example, Fix et al. (2012) used digital stories as a central component of an educational intervention on hypertension control in African-Americans. They also incorporated evidence-based information within the digital stories that were produced. Certain features of digital storytelling make it particularly relevant for use with specific populations. Gray et al. (2010) discussed the value of storytelling and creative expression for Native populations and the potential of using these activities for health promotion. They also illustrated how digital storytelling has been adopted by Native communities including a center that was launched in 2009 in Seattle, Washington, that specifically focuses on digital storytelling for and by native communities. Given that 98% of youth in North America between the ages of 18–29 now use the internet (Pew Research Center, 2013), information and communication technologies have potential for being leveraged to deliver health-related information, support, and interventions to young people. As such, the technological aspects involved in digital storytelling may also make it attractive to young people. This is supported by Wexler et al. (2013) who highlighted that young people may have difficulties in articulating complex experiences and have a general affinity for selfexpression using technology. Using these examples, digital storytelling could be applied in occupational therapy practice as a therapeutic tool to promote self-expression, personal reflection, patient education, and for connecting clients to other individuals who have experienced similar health conditions. It might be used across the continuum of care as well as in different areas of practice. For example, it could facilitate learning and sharing of experiences related to meaningful activities; community participation; illness and recovery; the built and social environment; rehabilitation services, and overcoming disability. An example of using this process was undertaken within an innovative program launched through a partnership between a Community Health Centre, local community artists, and a practicing community-based occupational therapist. Community Health Centres (CHC’s) are a model of interprofessional primary health care that integrate primary care with other health promotion and community development services. They focus on primary care, illness prevention, health promotion, community capacity building and service integration (Ontario Community Health Centres, 2013). The partnered initiative (titled Journeys to Health) encouraged participants to explore the theme of health as it related to their lives and personal circumstances through various arts-based mediums including the creation of digital stories. Digital stories were created by youth, health workers, and women living in shelters (Digital Stories, n.d.). For example, youth shared their stories about housing and social housing, and women shared stories about their experiences of living in a shelter. As some participants were unable to physically attend the workshops as they faced significant and multiple morbidity health conditions, staff visited participants in their homes to gather photos and record participant stories related to their experiences at home, in the community, and of the health services they received. Participants expressed that the act of storytelling was experienced as therapeutic, and the stories were shared with members of the broader community to
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foster a deeper understanding of health and social justice. The final stage of the project involved the collation of the multiple arts-based projects, including digital stories, photographs, and other arts-based media, in an exhibit presented to the community.
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Education The use of digital storytelling has been documented within health care education and continuing education (Cueva et al., 2012; Cueva et al., 2013; Dupain & Maguire, 2007; Hardy, 2007; Sandars et al., 2008; Sandars & Murray, 2011; Stacey & Hardy, 2011). As Hardy (2007) emphasizes, reflection is a critical skill for health care professionals; digital storytelling supports the principles of actively engaging students in reflecting upon knowledge they have gained as well as on their experiences, rather than passively receiving information from the world. The Patient Voices Programme (Patient Voices, n.d.) provides an illustrative example of how digital storytelling facilitates reflection, learning, and support within the context of health care education. In one of the program’s projects, eight recently graduated nurses participated in a digital storytelling workshop to create stories based on their early career experiences of working within the health care system (Stacey & Hardy, 2011). Themes highlighted by the nurses’ stories included: conflicts in interacting with more experienced nurses; therapeutic relationships; and coping with distressing events in practice. Through a focus group evaluation, participants expressed that they valued the opportunity to reflect on their experiences and to create a resource, which would help other new nurses in their transition to the work environment (Stacey & Hardy, 2011). Dupain and Maguire (2007) adapted the digital storytelling approach to create a digital storybook assignment to teach students about health concepts. They found that as students participated in the collection and sorting of digital artifacts to create their stories, they experienced a deeper and active engagement in the learning process and the assignment contributed to their understanding of health-related concepts. Digital stories can be used to support reflective practice in students (Sandars et al., 2008; Sandars & Murray, 2011) and prepare students for their transition to clinical practice (Stacey & Hardy, 2011). Within the context of continuing education, Cueva et al., (2013) studied the impact of using digital storytelling as a key component of a cancer education course based on the perspectives of 67 community health workers in Alaska. Respondents expressed that digital storytelling was supportive to their learning and they perceived it as a culturally respectful way of providing health messages. At a 3-year follow-up, 23 of the respondents noted that they had also changed their own behaviors as a result of the digital storytelling experience. These examples provide support for developing the use of digital storytelling in occupational therapy education. For educators, digital storytelling could be a tool to engage occupational therapy students and support reflective practice. Using a modified form of a digital story, students at the University of British Columbia created a 3-minute video to describe what is occupational therapy. The video was well received by the community and won a national competition hosted by the Canadian Association of Occupational Therapists.
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Potential for Research Digital storytelling has been used as a research method in community-based and/or ethnographic research as a stand-alone tool or complementary to other methods (Gray et al., 2010; Gubrium, 2009). In occupational therapy research, digital storytelling could potentially be used to understand how individuals experience disability and recovery. Subsequently, these digital stories could also be used as platforms for discussion during interviews and focus groups. Researchers might also consider inviting participants in the analysis process as is done in the photovoice method (Lal et al., 2012). In addition, the digital stories could be used to disseminate findings in an accessible and engaging way. Stories created by clients about their experiences in rehabilitation or within the health care system might also be used for improving quality of care. As a new data gathering technique, digital storytelling could offer opportunities for researchers to simultaneously create and represent knowledge that is authentic to the understanding of people’s experiences, perspectives, and behaviors. It would allow participants to reflect on themes or research questions, tell stories in response to these questions, reflect upon the meaning of these stories/events, and participate in the representation of these findings through the creation of tangible products, which participants also get to keep. This is unusual in the conventional practices of social inquiry (e.g. interviewing, questionnaires) where participant opportunities to actively engage in the analytical and representational process of the data are less common. The group aspect of digital storytelling and the nature of relationships characteristic to the process (i.e. among participants and between facilitators and participants) is indicative of a participatory-centered approach to conducting research and program evaluation. The outcomes of the digital storytelling process (i.e. digital stories) are tangible products that might be used to raise awareness and promote social change. CHALLENGES TO USE IN OCCUPATIONAL THERAPY Although digital storytelling has potential for effective use in occupational therapy, several issues pertaining to ethics, adaptations to population context, methodology, and process and outcomes, warrant further consideration as this method begins to be applied in occupational therapy. Gubrium et al. (2014) recently explored the ethical challenges pertaining to the use of digital storytelling identifying six issues in particular: confusion around the goals of a digital storytelling project (e.g. addressing research, practice, advocacy), recruitment of marginalized or vulnerable populations (e.g. protection versus exclusion, emphasis on product or aesthetics instead of process, risk of harm through exposing a story, confidentiality versus ownership/acknowledgement of story, and understanding consequences related to the release of materials. To address these issues, Gubrium et al. proposed several solutions. First, the practitioner should ensure that all stakeholders are in agreement with the specific goals of the project prior to implementation. The participants need to be informed about the risks and benefits of participation and having psychosocial supports in place in case the need arises for those sharing experiences associated with trauma. Practitioners should encourage all participants to obtain consent from any individual that is featured in their digital story. The practitioners should ensure the storyteller’s well-being and autonomy remain central
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to the process of developing a digital story, as opposed to a facilitator’s agenda of shaping the product. Although credit should be ensured for the storytellers, the option of using a chosen pseudonym needs to be offered. Finally, there should always be a thorough discussion of the ethics and videography during digital storytelling workshops, including negotiation of how stories will be used. Thus, this method of intervention requires diligent attention to ethical considerations to minimize risk and maximize benefits for participant. Moreover, further research on this topic is warranted before it is widely applied in occupational therapy and rehabilitation practice. Work from related areas can be used to help navigate the ethical issues associated with using digital storytelling. For example, Wang & Redwood-Jones (2001) discussed the ethics involved in the use of photovoice (a method that uses photography and group process) as an action research tool and Lal et al. (2012) described the ethical and methodological considerations in using photovoice with marginalized and/or disabled populations which may also be applicable here. In terms of methods, the types of adaptations needed for applying digital storytelling to specific vulnerable populations (e.g. with physical disabilities, children, youth, and elderly) need to be further explored. For example, it may be difficult for some participants to physically attend workshops. The technology used in a workshop may need to be adapted to different levels of ability. Another consideration is that the process and technological nature of the craft requires some level of skill from the facilitator. Moreover, the traditional process of 3 days may need to be lengthened and adapted depending on participants’ needs, increasing the resource costs financially and in terms of human resources for facilitating and applying the tool. As digital storytelling is increasingly applied in health-related settings, it will be important to consider incorporating an evaluation component to such initiatives. Evaluation could focus on examining the barriers and facilitators of implementing digital storytelling in practice, education, research, and knowledge translation. It would also be worthwhile to evaluate the outcomes of using this tool, for example in relation to community change and health-related outcomes on participants. In addition, it would be important to examine the feasibility and utility of digital storytelling for use with various populations (e.g. youth). CONCLUSION Digital storytelling is an innovative tool that combines group process with modern technology to create and share personal stories. It shows promise for application within the field of occupational therapy—as a useful tool for therapists, educators, and researchers. In clinical practice, it can be used to promote self-expression, patient education, and peer support through sharing stories. It can be applied in different settings such as in the community, rehabilitation centers, and hospitals. As an educational tool, digital storytelling can facilitate a deeper engagement of students in the learning process on concepts pertinent to occupational therapy. In research, digital storytelling can be leveraged as a participatory method to understand themes pertaining to occupation, therapy, disability, rehabilitation, health services, and recovery. Moreover, digital stories can facilitate the dissemination of research findings in accessible and engaging ways, conveying key messages to promote the quality of care.
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The use of expressive media, narrative approaches, and group process are key components of digital storytelling that may already be familiar to occupational therapists. Nonetheless, there may be a learning curve for therapists not familiar with the various technological tools used in digital storytelling, however, it is important to note that many of the tools used in digital storytelling are now popular culture media (e.g. digital cameras) and are increasingly becoming user-friendly (e.g. video software applications). Occupational therapists are well positioned to contribute knowledge on the use and the impact of digital stories, particularly with populations experiencing physical and psychosocial disabilities. As the profession moves forward in applying digital storytelling within clinical practice, research, and education, it will be important to document and investigate its use, such as the ethical and methodological challenges of using digital storytelling with marginalized, disabled, and/or vulnerable populations. In conclusion, digital storytelling is a tool with wide-ranging potential for occupational therapy warranting further consideration within the field. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
ABOUT THE AUTHOR Shalini Lal, BScOT, MSc, PhD, Assistant Professor, School of Rehabilitation, Faculty of Medicine, University of Montreal. Catherine Donnelly, BScOT, MSc, PhD, Associate Professor, School of Rehabilitation Therapy, Queen’s University. Jennifer Shin, MEd, OT Reg (Ont), Occupational Therapist, The Four Villages Community Health Centre
REFERENCES Bury M. (2001). Illness narratives: Fact or fiction? Sociology of Health and Illness, 23, 263–285. doi: 10.1111/1467-9566.00252 Cueva M, Hicks T, Kuhnley R, & Cueva K. (2012). A wellness course for community health workers in Alaska: “Wellness lives in the heart of the community.” International Journal of Circumpolar Health, 71. doi: 10.3402/ijch.v71i0.19125 Cueva M, Kuhnley R, Revels LJ, Cueva K, Dignan M, & Lanier AP. (2013). Bridging storytelling traditions with digital technology. International Journal of Circumpolar Health, 72. doi: 10.3402/ijch.v72i0.20717 Cumming G, Currie H, Moncur R, & Lee A. (2010). Web-based survey on the effect of digital storytelling on empowering women to seek help for urogenital atrophy. Menopause International, 16(2), 51–55. Digital Stories (n.d.). Retrieved from journeys to health website, http://digitaljourneys. wordpress.com/digital-stories/ Dupain M, & Maguire LL. (2007). Health digital storytelling projects. American Journal of Health Education, 38, 41–43. Fix, G. M., Houston, T. K., Barker, A. M., Wexler, L., Cook, N., Volkman, J. E., & Bokhour, B. G. (2012). A novel process for integrating patient stories into patient education interventions: Incorporating lessons from theater arts. Patient Education and Counseling, 88, 455–459. Frank, A. W. (1995). The wounded storyteller: Body, illness, and ethics. Chicago, IL: University of Chicago Press.
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Gray, N., De Boehm, C., Farnsworth, A., & Wolf, D. (2010). Integration of creative expression into community based participatory research and health promotion with native Americans. Family and Community Health, 33(3), 186–192. doi: 10.1097/FCH.0b013e3181e4bbc6 Greenhalgh T, & Hurwitz B. (1999). Narrative based medicine: Why study narrative?. BMJ: British Medical Journal, 318(7175), 48–50. Gubrium, A. (2009). Digital storytelling: An emergent method for health promotion research and practice. Health Promotion Practice, 10(2), 186–191. Gubrium AC, Hill AL, & Flicker S. (2014). A situated practice of ethics for participatory visual and digital methods in public health research and practice: A focus on digital storytelling. American Journal of Public Health, 104(9), 1606–1614. Hardy, P. (2007). An investigation into the application of the Patient Voices digital stories in healthcare education: quality of learning, policy impact and practice-based value. Belfast: University of Ulster. Retrieved from: http://www.pilgrimprojects.co.uk/papers/phardymsc.pdf Jernigan V, Salvatore A, Styne D, & Winkleby M. (2012). Addressing food insecurity in a Native American reservation using community-based participatory research. Health Education Research, 27, 645–655. Kleinman A. (1988). The illness narratives: Suffering, healing, and the human condition. New York, NY: Basic Books. Lal S, Jarus T, & Suto MJ. (2012). A scoping review of the photovoice method: Implications for occupational therapy research. Canadian Journal of Occupational Therapy, 79(3), 181–190. doi:10.2182/cjot.2012.79.3.8 Lambert J. (2013). Digital storytelling: Capturing lives, creating community. Routledge: New York, NY. Mattingly, C. (1991). The narrative nature of clinical reasoning. The American Journal of Occupational Therapy, 45, 998–1005. McAdams, D. P. (2001). The psychology of life stories. Review of General Psychology,5, 100–122. doi: 10.1037//I089-2680.5.2.100 Meadows, D. (2003). Digital storytelling: Research-based practice in new media. Visual Communication, 2, 189–193. doi:10.1177/1470357203002002004 Ontario Community Health Centres. (2013). The CHC model of care. Retrieved December 15, 2013 from http://www.ontariochc.org/index.php?ci id=2341&la id=1 Patient Voices. (n.d.). Retrieved from Patient Voices website, http://www.patientvoices. org.uk/index.htm Pew Research Center (2013). Internet and American life project spring tracking survey, April 17-May 19, 2013. Retrieved December 15, 2013 from: http://pewinternet.org/Trend-Data(Adults)/Whos-Online.aspx Riessman CK. (2008). Narrative methods for the human sciences. Thousand Oaks, CA: Sage. Sandars J, & Murray C. (2011). Digital storytelling to facilitate reflective learning in medical students. Medical Education, 45, 649–649. doi:10.1111/j.1365-2923.2011.03991.x Sandars J, Murray C, & Pellow A. (2008). Twelve tips for using digital storytelling to promote reflective learning by medical students. Medical Teacher, 30, 774–777. doi:10.1080/01421590801987370 Stacey G, & Hardy P. (2011). Challenging the shock of reality through digital storytelling. Nurse Education in Practice, 11(2), 159–164. doi:10.1016/j.nepr.2010.08.003 Stories: At a Glance (n.d.). Retrieved from Center for Digital Storytelling website, http://storycenter.org/stories/ Toussaint DW, Villagrana M, Mora-Torres H, de Leon M, & Haughey MH. (2011). Personal stories: Voices of Latino youth health advocates in a diabetes prevention initiative. Progress in Community Health Partnerships: Research, Education, and Action, 5(3), 313–316. Wang CC, & Redwood-Jones YA. (2001). Photovoice ethics: Perspectives from flint photovoice. Health Educ Behav, 28(5), 560–572. doi:10.1177/109019810102800504 Wexler L, Gubrium A, Griffin M, & DiFulvio G. (2013). Promoting positive youth development and highlighting reasons for living in northwest Alaska through digital storytelling. Health Promotion Practice, 14(4), 617–623. Wyatt TH, & Hauenstein E. (2008). Enhancing children’s health through digital story. Computers, Informatics, Nursing: CIN, 26(3), 142–8. doi:10.1097/01.NCN.0000304779.49941.44
ORIGINAL ARTICLE
Digital Storytelling: An Innovative Tool for Practice, Education, and Research Occup Ther Health Downloaded from informahealthcare.com by University of Otago on 01/05/15 For personal use only.
Shalini Lal1 , Catherine Donnelly2 , & Jennifer Shin3 1
School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada, 2 School of Rehabilitation Therapy, Queen’s University, 3 The Four Villages Community Health Centre
ABSTRACT. Digital storytelling is a method of using storytelling, group work, and modern technology to facilitate the creation of 2–3 minute multi-media video clips to convey personal or community stories. Digital storytelling is being used within the health care field; however, there has been limited documentation of its application within occupational therapy. This paper introduces digital storytelling and proposes how it can be applied in occupational therapy clinical practice, education, and research. The ethical and methodological challenges in relation to using the method are also discussed. KEYWORDS. Arts-based methods, community-based, knowledge translation, narrative, participatory, qualitative methods
It has long been recognized that storytelling is a powerful vehicle for reflection, recovery, and therapeutic action. For example, Mattingly (1991) described how storytelling helps facilitate understanding of patients’ illness experiences and the clinical reasoning process. Greenhalgh & Hurwitz (1999) highlighted how stories provide opportunities for gaining a holistic understanding of the issues that clients face, providing a foundation for engaging in client-centered practice. Moreover, the act of storytelling has been characterized as a critical process that humans use to make sense of biographical disruptions related to illness and other events in their lives (Bury, 2001; Frank, 1995; McAdams, 2001; Riessman, 2008). Modern technology has taken the act of storytelling to new heights, resulting in a range of opportunities and tools for creating, learning, teaching, and sharing knowledge in engaging ways and through innovative formats. Digital storytelling is one such tool. Digital storytelling is an innovative participatory method that combines storytelling, group work, and technology to facilitate the creation Address correspondence to: Shalini Lal, PhD, School of Rehabilitation, Faculty of Medicine, University of ´ (Quebec) ´ Montreal, C.P. 6128, succursale Centre-ville, Montreal Canada H3C 3J7 (E-mail: shalinilal88@ gmail.com) (Received 18 February 2013; accepted 24 August 2014)
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of 2 to 3 minute multi-media video clips expressing a personal or community story. Digital storytelling is relatively novel in its application within the health care field, though the literature on this method has emerged more prominently in recent years. A search of the peer-reviewed occupational therapy literature did not reveal any studies using the digital storytelling method, suggesting that it has been untapped for its potential use. Since digital storytelling has multiple potentialities for application in the field of occupational therapy, educators, researchers, and clinicians could benefit from being informed about this approach. This paper provides an introduction to the digital storytelling method and explores how it can be applied to occupational therapy drawing from literature as well as the authors’ experiences.
THE PROCESS OF DIGITAL STORYTELLING Digital storytelling was developed in the late 1990’s and promoted through the Center for Digital Storytelling in Berkeley, California. The Center partners with communities and organizations to support the sharing of first person accounts (personal narratives) as a platform for community action through the facilitation of digital storytelling workshops. The Center operates under the direction of key founder, Joe Lambert, who has a background in arts activism and theatre production. The Center’s website (Stories: At a Glance, n.d.) provides many examples of digital stories that have been created through its workshops over the years though many variations of this method have been documented in the literature (e.g., Cumming et al., 2010; Jernigan et al., 2012). Digital stories are typically created through group-based workshops, which are considered to be a critical aspect of the method. Workshops are designated for the public or customized for a specific organization or group (e.g., health care providers or patient population). A standard workshop usually takes place over the course of days and involves eight to twelve participants. The first day is used for introductions, an overview of digital storytelling, sharing of personal stories, script review and development, and a tutorial in Photoshop. The second day is teaching of the technical skills necessary to put the story into digital form, and the third day is used for finishing the digital story and showing the stories made in the group (Lambert, 2013). One element of the workshop that is considered to be a valuable component of the digital storytelling process is the sharing of stories within a story circle (Lambert, 2013). Story circles are used progressively throughout the three days as a way for participants to get to know each other, listen to each other’s stories, and, give and receive feedback on stories and scripts. Using the story circle, the facilitator has the responsibility for ensuring that trust is established such that each person and his/her story is held with the highest level of nurturance and respect. Although digital storytelling is not described as a therapeutic process, the experience has nonetheless been expressed by participants as being, “transcendent,” “cathartic,” and “transformative” (pgs. 32, 145, 168) and as an empowering way of reclaiming and sharing one’s personal experiences.
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THE OUTCOME A digital story is a two-three minute multi-media video clip that includes narrative, visual (digital video, photographs, artwork), and performance (music, voice) mediums for the purpose of expressing an individual or community story. There are many kinds of stories that can be told through the digital story format. Examples of topics that have been expressed in digital stories include: hope (Wexler et al., 2013); place, community, equity, education, housing, social justice (Jernigan et al., 2012); help-seeking (Cumming et al., 2010); health (Gray et al., 2010); identity, experience of health and human services, important people in an individual’s life (Stories: At a Glance, n.d.); violence, poverty, and isolation (Digital Stories, n.d.). Digital stories are powerful vehicles through which to create and share knowledge. The impactful experiences that are sometimes evoked by viewing digital stories of others can possibly be attributed to the integration of different art forms into one product. Combining multimedia adds layers of depth and increases the potential for an emotional and sensorial experience for the audience. By adhering to the limited duration of the story, the storyteller is required to get to the heart of the matter rather efficiently and in this way the format is effective in capturing life’s defining moments or turning points (Lambert, 2013). The condensed format is conducive to sharing the story with others and allows for them to be easily uploaded to the internet (Meadows, 2003) opening up numerous possibilities for file sharing, repeat viewings, and audience distribution. It is important to remember that although multi-media (e.g. photos, music) are important contributors to the impact of the digital story, they serve mainly as tools for the storyteller. The power of the digital story remains in the content of the story and how it is expressed, with less preoccupation with the actual visuals, lighting, background, and sound effects (Lambert, 2013). APPLICATION FOR OCCUPATIONAL THERAPY Community Practice There are studies to demonstrate the therapeutic use of digital storytelling. Wexler et al. (2013) used digital storytelling within the context of a positive youth development framework with young people living in Northern Alaska. Over a 3 year period, 39 digital storytelling workshops were conducted with 432 youth from elementary, middle, and high schools across 12 rural Alaskan villages. The youth produced 566 digital stories highlighting positive aspects of their lives within the context of a suicide prevention initiative. Twenty-seven youth from the total sample were interviewed to obtain a more in-depth understanding of their digital storytelling experiences. The participants expressed that participating in the digital storytelling process provided them with a sense of achievement and personal mastery, enabled them to reflect on positive aspects of their lives, and an opportunity to strengthen their relationship with important people through sharing of the videos. Cumming et al. (2010) investigated the impact of watching a digital story on help seeking in a sample of 539 women recruited on-line. Watching the digital story increased women’s sense of empowerment and likelihood of seeking help for a health issue they felt embarrassed to discuss, providing preliminary evidence that digital
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stories can promote help-seeking behaviors. Digital stories have also been used for providing health-related information and support. For example, Fix et al. (2012) used digital stories as a central component of an educational intervention on hypertension control in African-Americans. They also incorporated evidence-based information within the digital stories that were produced. Certain features of digital storytelling make it particularly relevant for use with specific populations. Gray et al. (2010) discussed the value of storytelling and creative expression for Native populations and the potential of using these activities for health promotion. They also illustrated how digital storytelling has been adopted by Native communities including a center that was launched in 2009 in Seattle, Washington, that specifically focuses on digital storytelling for and by native communities. Given that 98% of youth in North America between the ages of 18–29 now use the internet (Pew Research Center, 2013), information and communication technologies have potential for being leveraged to deliver health-related information, support, and interventions to young people. As such, the technological aspects involved in digital storytelling may also make it attractive to young people. This is supported by Wexler et al. (2013) who highlighted that young people may have difficulties in articulating complex experiences and have a general affinity for selfexpression using technology. Using these examples, digital storytelling could be applied in occupational therapy practice as a therapeutic tool to promote self-expression, personal reflection, patient education, and for connecting clients to other individuals who have experienced similar health conditions. It might be used across the continuum of care as well as in different areas of practice. For example, it could facilitate learning and sharing of experiences related to meaningful activities; community participation; illness and recovery; the built and social environment; rehabilitation services, and overcoming disability. An example of using this process was undertaken within an innovative program launched through a partnership between a Community Health Centre, local community artists, and a practicing community-based occupational therapist. Community Health Centres (CHC’s) are a model of interprofessional primary health care that integrate primary care with other health promotion and community development services. They focus on primary care, illness prevention, health promotion, community capacity building and service integration (Ontario Community Health Centres, 2013). The partnered initiative (titled Journeys to Health) encouraged participants to explore the theme of health as it related to their lives and personal circumstances through various arts-based mediums including the creation of digital stories. Digital stories were created by youth, health workers, and women living in shelters (Digital Stories, n.d.). For example, youth shared their stories about housing and social housing, and women shared stories about their experiences of living in a shelter. As some participants were unable to physically attend the workshops as they faced significant and multiple morbidity health conditions, staff visited participants in their homes to gather photos and record participant stories related to their experiences at home, in the community, and of the health services they received. Participants expressed that the act of storytelling was experienced as therapeutic, and the stories were shared with members of the broader community to
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foster a deeper understanding of health and social justice. The final stage of the project involved the collation of the multiple arts-based projects, including digital stories, photographs, and other arts-based media, in an exhibit presented to the community.
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Education The use of digital storytelling has been documented within health care education and continuing education (Cueva et al., 2012; Cueva et al., 2013; Dupain & Maguire, 2007; Hardy, 2007; Sandars et al., 2008; Sandars & Murray, 2011; Stacey & Hardy, 2011). As Hardy (2007) emphasizes, reflection is a critical skill for health care professionals; digital storytelling supports the principles of actively engaging students in reflecting upon knowledge they have gained as well as on their experiences, rather than passively receiving information from the world. The Patient Voices Programme (Patient Voices, n.d.) provides an illustrative example of how digital storytelling facilitates reflection, learning, and support within the context of health care education. In one of the program’s projects, eight recently graduated nurses participated in a digital storytelling workshop to create stories based on their early career experiences of working within the health care system (Stacey & Hardy, 2011). Themes highlighted by the nurses’ stories included: conflicts in interacting with more experienced nurses; therapeutic relationships; and coping with distressing events in practice. Through a focus group evaluation, participants expressed that they valued the opportunity to reflect on their experiences and to create a resource, which would help other new nurses in their transition to the work environment (Stacey & Hardy, 2011). Dupain and Maguire (2007) adapted the digital storytelling approach to create a digital storybook assignment to teach students about health concepts. They found that as students participated in the collection and sorting of digital artifacts to create their stories, they experienced a deeper and active engagement in the learning process and the assignment contributed to their understanding of health-related concepts. Digital stories can be used to support reflective practice in students (Sandars et al., 2008; Sandars & Murray, 2011) and prepare students for their transition to clinical practice (Stacey & Hardy, 2011). Within the context of continuing education, Cueva et al., (2013) studied the impact of using digital storytelling as a key component of a cancer education course based on the perspectives of 67 community health workers in Alaska. Respondents expressed that digital storytelling was supportive to their learning and they perceived it as a culturally respectful way of providing health messages. At a 3-year follow-up, 23 of the respondents noted that they had also changed their own behaviors as a result of the digital storytelling experience. These examples provide support for developing the use of digital storytelling in occupational therapy education. For educators, digital storytelling could be a tool to engage occupational therapy students and support reflective practice. Using a modified form of a digital story, students at the University of British Columbia created a 3-minute video to describe what is occupational therapy. The video was well received by the community and won a national competition hosted by the Canadian Association of Occupational Therapists.
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Potential for Research Digital storytelling has been used as a research method in community-based and/or ethnographic research as a stand-alone tool or complementary to other methods (Gray et al., 2010; Gubrium, 2009). In occupational therapy research, digital storytelling could potentially be used to understand how individuals experience disability and recovery. Subsequently, these digital stories could also be used as platforms for discussion during interviews and focus groups. Researchers might also consider inviting participants in the analysis process as is done in the photovoice method (Lal et al., 2012). In addition, the digital stories could be used to disseminate findings in an accessible and engaging way. Stories created by clients about their experiences in rehabilitation or within the health care system might also be used for improving quality of care. As a new data gathering technique, digital storytelling could offer opportunities for researchers to simultaneously create and represent knowledge that is authentic to the understanding of people’s experiences, perspectives, and behaviors. It would allow participants to reflect on themes or research questions, tell stories in response to these questions, reflect upon the meaning of these stories/events, and participate in the representation of these findings through the creation of tangible products, which participants also get to keep. This is unusual in the conventional practices of social inquiry (e.g. interviewing, questionnaires) where participant opportunities to actively engage in the analytical and representational process of the data are less common. The group aspect of digital storytelling and the nature of relationships characteristic to the process (i.e. among participants and between facilitators and participants) is indicative of a participatory-centered approach to conducting research and program evaluation. The outcomes of the digital storytelling process (i.e. digital stories) are tangible products that might be used to raise awareness and promote social change. CHALLENGES TO USE IN OCCUPATIONAL THERAPY Although digital storytelling has potential for effective use in occupational therapy, several issues pertaining to ethics, adaptations to population context, methodology, and process and outcomes, warrant further consideration as this method begins to be applied in occupational therapy. Gubrium et al. (2014) recently explored the ethical challenges pertaining to the use of digital storytelling identifying six issues in particular: confusion around the goals of a digital storytelling project (e.g. addressing research, practice, advocacy), recruitment of marginalized or vulnerable populations (e.g. protection versus exclusion, emphasis on product or aesthetics instead of process, risk of harm through exposing a story, confidentiality versus ownership/acknowledgement of story, and understanding consequences related to the release of materials. To address these issues, Gubrium et al. proposed several solutions. First, the practitioner should ensure that all stakeholders are in agreement with the specific goals of the project prior to implementation. The participants need to be informed about the risks and benefits of participation and having psychosocial supports in place in case the need arises for those sharing experiences associated with trauma. Practitioners should encourage all participants to obtain consent from any individual that is featured in their digital story. The practitioners should ensure the storyteller’s well-being and autonomy remain central
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to the process of developing a digital story, as opposed to a facilitator’s agenda of shaping the product. Although credit should be ensured for the storytellers, the option of using a chosen pseudonym needs to be offered. Finally, there should always be a thorough discussion of the ethics and videography during digital storytelling workshops, including negotiation of how stories will be used. Thus, this method of intervention requires diligent attention to ethical considerations to minimize risk and maximize benefits for participant. Moreover, further research on this topic is warranted before it is widely applied in occupational therapy and rehabilitation practice. Work from related areas can be used to help navigate the ethical issues associated with using digital storytelling. For example, Wang & Redwood-Jones (2001) discussed the ethics involved in the use of photovoice (a method that uses photography and group process) as an action research tool and Lal et al. (2012) described the ethical and methodological considerations in using photovoice with marginalized and/or disabled populations which may also be applicable here. In terms of methods, the types of adaptations needed for applying digital storytelling to specific vulnerable populations (e.g. with physical disabilities, children, youth, and elderly) need to be further explored. For example, it may be difficult for some participants to physically attend workshops. The technology used in a workshop may need to be adapted to different levels of ability. Another consideration is that the process and technological nature of the craft requires some level of skill from the facilitator. Moreover, the traditional process of 3 days may need to be lengthened and adapted depending on participants’ needs, increasing the resource costs financially and in terms of human resources for facilitating and applying the tool. As digital storytelling is increasingly applied in health-related settings, it will be important to consider incorporating an evaluation component to such initiatives. Evaluation could focus on examining the barriers and facilitators of implementing digital storytelling in practice, education, research, and knowledge translation. It would also be worthwhile to evaluate the outcomes of using this tool, for example in relation to community change and health-related outcomes on participants. In addition, it would be important to examine the feasibility and utility of digital storytelling for use with various populations (e.g. youth). CONCLUSION Digital storytelling is an innovative tool that combines group process with modern technology to create and share personal stories. It shows promise for application within the field of occupational therapy—as a useful tool for therapists, educators, and researchers. In clinical practice, it can be used to promote self-expression, patient education, and peer support through sharing stories. It can be applied in different settings such as in the community, rehabilitation centers, and hospitals. As an educational tool, digital storytelling can facilitate a deeper engagement of students in the learning process on concepts pertinent to occupational therapy. In research, digital storytelling can be leveraged as a participatory method to understand themes pertaining to occupation, therapy, disability, rehabilitation, health services, and recovery. Moreover, digital stories can facilitate the dissemination of research findings in accessible and engaging ways, conveying key messages to promote the quality of care.
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The use of expressive media, narrative approaches, and group process are key components of digital storytelling that may already be familiar to occupational therapists. Nonetheless, there may be a learning curve for therapists not familiar with the various technological tools used in digital storytelling, however, it is important to note that many of the tools used in digital storytelling are now popular culture media (e.g. digital cameras) and are increasingly becoming user-friendly (e.g. video software applications). Occupational therapists are well positioned to contribute knowledge on the use and the impact of digital stories, particularly with populations experiencing physical and psychosocial disabilities. As the profession moves forward in applying digital storytelling within clinical practice, research, and education, it will be important to document and investigate its use, such as the ethical and methodological challenges of using digital storytelling with marginalized, disabled, and/or vulnerable populations. In conclusion, digital storytelling is a tool with wide-ranging potential for occupational therapy warranting further consideration within the field. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
ABOUT THE AUTHOR Shalini Lal, BScOT, MSc, PhD, Assistant Professor, School of Rehabilitation, Faculty of Medicine, University of Montreal. Catherine Donnelly, BScOT, MSc, PhD, Associate Professor, School of Rehabilitation Therapy, Queen’s University. Jennifer Shin, MEd, OT Reg (Ont), Occupational Therapist, The Four Villages Community Health Centre
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