It was my job to feed the chickens before went to school It was one of those chores that most farm kids did in those days. When they heard me coming, they'd start cackling. They were always under your feet. They'd peck your shoes and ankles and as far up your legs as they could get. I hated those darn chickens. Now I can't even bend my fingers, I sure couldn't feed them today. I won't feed them again. I wouldn't even mind the pecking.
Bill's story reflects who he was yesterday and who he is today. Stories are the language that older adults use to talk about their lives. Such stories, or narratives, as Bill's, explicate personal experiences, which suggests significance. Historically, storytelling has been an important mode of revealing an individual's experience. Yet, only recently have nurses come to value the importance of narrative (Sandelowski, 1994).
The purpose of this article is to articulate the power of stories to advance the well being of older adults and the implications for gerontological nurses of a commitment to support older adults as storytellers. Stories within an aging context are emerging in the professional literature. Running's (1996) study elicited personal interpretations of aging. She used eight adults older than 85 years to critique the biographical book by Scott-Maxwell (2000), The Measure of My Days. Thematic analysis described an aggregate reaction to it. ScottMaxwell's discussion of being a burden was the single idea that all eight agreed upon. All described being a burden to their loved ones as their number one worry.
Moloney (1995) employed stories from older women as a way to ascertain and understand the meanings of being strong. The assumption underlying her study was a belief that all women possess the potential for inner strength. Mayers (1995) explored storyteiling as a method to increase interaction with residents among long-term care staff. However, her discussion was superficial. Clark and Standard (1997) used stories as a therapeutic technique to assist family caregivers to re-story (think about the original narrative from a new or different perspective) negative aspects of their caregiving experiences.
The introduction of stories into gerontological nursing is reflective of the increasing interest in stories and narrative inquiry by nurse scholars. Diverse phenomena have been explored within the qualitative landscape of narrative inquiry or storytelling, including the following:
* Caring action (Astrom, Norberg, & Janssen, 1993; Baker & Diekelmann, 1994).
* Bereavement (Carter, 1989).
* Suffering (Charmaz, 1999).
* Ethic of care (Parker, 1990).
* Ethical reasoning (Benner, 1991; Uden, Norberg, Lindseth, & Marhaug, 1992).
* Reflective practice (Durgahee, 1997).
* Knowledge development (Boykin & Schoenhofer, 1991).
* Healing with HIV clients (Nye, 1997).
* Living with disease processes (Haggstrom, Axelsson Sc Norberg, 1994).
* Nursing education (Heinrich, 1993).
* Health promotion (BanksWallace, 1998.
Using stories as a data collection tool has value because researchers gain an understanding of an experience from a different perspective than that gained from quantitative studies. Koch (1998) articulated the value of story as a legitimate research product when she wrote:
careful, reflective, systematic study of phenomena or experience taken to advance human understanding can count as research (p. 1189).
Boykin and Schoenhofer (1991) proposed that stories were a method of organizing and communicating knowledge, and an important link to nursing practice. Stories are one way of knowing about individuals, and of having a framework to understand current health care experiences.
THE POWER OF STORIES FOR OLDER ADULTS
A story is a synthesis of feelings, knowledge, and inner perceptions, captured in an episode in time. Stories are the threads that weave together the life of an older adult. Each older adult begins to collect stories early in childhood. They are the raw material from which the sense of self emerges. Each older adult is involved in several different stories at the same rime - the story of self, family, life in the community, and perhaps Ufe in the long-term care institution. The sharing of personal stories is a means by which individuals establish and maintain intimacy with one another, and through which selected aspects of identity are shared.
There is a power in stories. They reveal the causes and consequences of actions taken. They address personal perceptions and values, and examine and judge their worth. As Freda said:
Tm %; it's so hard in here [nursing home]. My son is dying of cancer and he didn't need me to worry about I didn't want him to worry about me. I made the decision to come here, but it isn't like home. They give me my meals here, and help with my bath. They have bridge games once a week upstairs. One of the nurses gives me my pills.
Such a narrative captures the significance of what it is to be old. As the story unfolds, the primary concern for Freda may not be the necessity of nursing care for her self, but rather her need to deal with the anticipated death of her son. The analogy is made of a story within a story - an outer and an inner one. The outer story is the initial words used by Freda to describe an experience and to establish a relationship with the listener. This outer story is the host for the inner one - one that reveals her feelings regarding her anticipated loss. Often it is easier for clients to tell an outer story than to articulate their feelings.
While not documented within the literature, this story within a story may offer depth of insight for the nurse into the older client. This possibility is evident in Beatrice's narrative. As she said:
My daughter and son-in-law thought that I could not keep up my house. They said that I couldn't stay living in a big old house. My daughter was really concerned over me. I did have trouble mowing the lawn; I just couldn't work my garden any more. I had a fall one day, and well they [family] thought that 1 would be better off here [nursing home]. I really had to think about it, but I came around. It took a while but I like it here. I miss my things; we had to get rid of a lot.
As the narrative unfolds, the outer story for Beatrice is the requirement to obtain easier living arrangements. The inner story is her need to deal with the changes that relocation brings. Reflected in this inner story, is her personal loss of home and most of her belongings. The significance in this context is the value placed by Beatrice on home and family. As Beatrice's location in the world changed, she searched for meaningfulness in the experience. The loss of her home was rewarded by the lessened anxiety of her daughter. There was a perceived reward for relocating. It provided stability to Beatrice through her maintained relationship with her family. Storytelling helped to provide meaning to the move. More than just a sad memory of past events, the activity of recounting led to an enhanced sense of understanding and meaning. This is the power of stories and their telling.
Recounting stories communicates the memories, hopes, frustrations, and perhaps the pain of an older adult's experiences. As Kate said:
My husband is in a room in the next wing [of the nursing home]. He has Alzheimer's and I just couldn't look after him any more. My arthritis is too bad. So we both came here. Before he got sick, we did everything together; lots of trips, family outings. Now they look after both of us. We eat our meals together. We have separate bedrooms. He is in a different wing of the building. He doesn't know where he is. I couldn't have him in the same room as me. I can't take his behavior like I use to be able to do; it takes too much coping.
Each older adult, such as Kate, has a subjective understanding of one's own story and the inherent meaning in it. A story carries this meaning, and conveys it to another in the telling. There is power in this process because it carries knowledge about the teller to the nurse. In so doing, the older adult is able to influence the course of nursing actions, because the nurse implements care with greater knowledge of the client.
Thus, storytelling is a means of collecting the data required in the planning and implementation of nursing care, through listening to the personal voice. One collection mechanism which could employ stories is health histories (Keddy, 1988). In a narrative sense, health histories are made, not taken (Donnelly, 1989). They are created as individuals tell their stories to nurses who incorporate them into the care plans and other formulations (e.g., heath histories, nurses* notes). If a nurse listens to several stories of an older resident, patterns of meaning, feelings, or experiences can be identified. The outcome is the construction of a life portrait - a series of photographs of an older adult's life. Storytelling is a strategy to conduct reminiscence and life review interventions. Reminiscing is the process or practice of thinking about or telling about past experiences. Life review is one aspect of reminiscing, and involves the review of remote memories, the expression of related feelings, the recognition of conflicts, and the relinquishment of self-inhibiting viewpoints (Ebersole & Hess, 1998).
To return to Kate's story, through the knowledge gained from it, nursing staff can provide her with the psychosocial care she needs, with an emphasis on how to cope with the decline in her husband's health. This may mean supplying information about the cause of the changes in her husband, or perhaps providing time for them to be together, yet also giving her time and space to withdraw from him when she requires it. Another power to stories is evident in Kate's narrative. Narrating a story about a problem situation reduces it to manageable components. It alters the manner in which the older adult views the experience, and offers possible ways of dealing with it.
An older adult often accepts the negative stereotypes of aging because of previous stories told about growing old. This is true in the following story as told by Chris, who has been caring for her husband for many years:
I remember my mum caring for her mum. Her mum always wore black, she use to sit in the rocker and rock. Every year they had to get my aunt in to care for gran when my mum went on holiday for a week. Now I am caring for my husband. I suspect that my daughter will one day care for me. But I don't want her to. That's why I have told her I will go into a nursing home. She has her own life to live.
Chris expects to grow old, yet she also anticipates entering a long-term care facility, where others will care for her. This is her recognition of aging, and what she believes society requires of her. From Chris's story, another power of stories is evident - the normalization they give to life. In the telling, stories are a personal tactic to establish or maintain as normal an existence as possible.
The process of telling a story may be profoundly enlightening. Some older adults have said, "I learned something about myself today," or "I never thought about it that way before." The story and its telling serve to help an older adult identify personal myths. For example, if an individual believes the myth that aging changes are negative and then hears a story to the contrary, that person may learn that aging does have rewards. Such identification helps in the process of changing the myth.
Another power of stories lies in their ability to transform older adults into valued teachers. Burnside (1975) wrote, "they... teach not from books but from long experience in living" (p. 1 800). To be valued, one must first be recognized, and hearing an older adult's story is a way of valuing that person. Nursing staff convey the value of older adults by inviting them to share their stories. Through responses from nurses, older adults' comments are honored explicitly. Baker and Diekelmann (1994) said the following:
It is the storied nature of our existence that sets up the possibility for one of us to dwell within the lived experience of another (p. 67).
Recognizing that each older adult is an ongoing and unfinished story, and that their experience with nurses or nursing home staff represents a small, although significant, part of their journey is to affirm the worth of that individual.
LISTENING TO STORIES
Nurses who learn to listen to their own stories are better able to understand those of older adults. Hearing one's own story, reflecting on its meanings and inherent feelings, and considering connections between present, past, and future events provides insights into the skills that one needs to be a practitioner. Such listening is more difficult than one might initially think. Assumptions and biases must be ignored. To do so, nurses need to create a climate that supports listening to and telling stories with each other and with older adults.
Effective listening is the foundation of a story narrative. Regardless of how astute the nurse is with questioning and probing, older adults will reveal little if caregivers do not show they care. The storyteller must feel connected to the nurse before sharing a story. This is particularly true for older residents who are physically or otherwise challenged. For the older adult to invest energy into the telling of a story, the nurse must also invest significant effort in the listening.
Nurses should listen and ask questions to clarify. However, they should not pass judgment or offer advice. Being heard unconditionally, even for a few moments, validates the worth of an older adult. A climate supportive of storytelling develops. Listening to a story and being attentive to the words and metaphors used by the older adult in describing symptoms presented within the story is important. Symptoms included in a story may provide insight into the experience described within the story.
Through listening, the strengths of an older adult may be affirmed. It helps to validate positive attributes about an older adult that are revealed in a story. Affirmation provides older adults with reminders of personal traits and coping strategies that might provide strength at another time.
One strategy to create the type of climate needed for storytelling is to reflect on one's relationships with older adults - how one helps them develop or watches them be destroyed (i.e., develop dysfunctionally). Another strategy is to recognize older adults' comfort preferences (e.g., seating arrangements, personal space needs). Comfortable seating arrangements allow greater freedom of expression and ease in telling stories.
Older adults can be encouraged to tell their stories in numerous ways. Communication skills are among the tools used. Nurses may encourage communication by wondering aloud and sharing questions to help older adults express and explore their concerns and feelings. Questions such as, "Perhaps you wonder how all this might influence your living here?" or "what is it like living here?" might be asked. Nurses may express an interest in an older adult's life by saying, "I'd like to understand more about..." or "I wonder how you felt when your son...?" Broad openings encourage storytelling, such as, "If you were writing the story of your life, what would be the title?"
There are other practical tips to facilitate storytelling. For example, nurses may ask older adults to do the following:
* Show a photograph from childhood.
* Share a story about oneself and a favorite pet.
* Tell about the first flight on an airplane.
* Describe what was it like when a first child was born.
* Recount a story about waiting at home during the war.
* Tell a story about the first trip taken.
* Recant a honeymoon story.
These suggestions can be implemented in a group context. Older adults may benefit by sharing in the stories of others. Learning from peers helps facilitate understanding of how to deal with numerous agerelated events, many of which are stressful. However, sharing in such a context does have implications for practice. The level of trust and confidence in the group participants may limit the depth of feelings shared by an older resident. Hearing the sad stories of others may trigger feelings of sadness or depression.
While some older adults discuss the feelings accompanying their stories, others must be directed to do so. The simplest method is to ask the older adults how they feel about the story. Nurses may need to encourage older adults to tell several stories, and listen for recurring emotions, to more fully understand the older adult's feelings. One way to do this is to encourage storytelling chronologically, beginning with early childhood. A continuous life story with its dominant feelings will emerge, rather than a series of unconnected narratives.
Nurses should reinforce to older adults that their stories are important. This is illustrated in the following exchange:
Nurse: Losing a husband is quite a loss. It has been quite a recent loss for you.
Marjorie: We came home from the funeral together for the family gathering, but the children couldn't stay. They have lives of their own. I spent the next few days in the house alone. My friend next door phoned every day, but I did not want to go out. I did not want to have to come home to an empty house.
Then my son wanted me to go house hunting. He got hold of a real estate agent and die three of us went out. When! got home, the real estate agent dropped me off, my son couldn't stay. He had to go back to work. I couldn't walk into the house.
Nurse: You were unsure how you were going to manage without him.
Marjorie: I sat on die doorstep and cried. My next door neighbor came out to water his garden, and saw me sitting there. He asked if anything was wrong, and I said "no." He went inside, and a few moments later, his wife came out She came and sat with me. She hugged me, and went into the house with me. I did not have to go in alone.
Marjorie: Yes, she is a friend, a good one. I wasn't alone.
There is both an inner and outer story in Marjorie's narrative. The outer one is the description of the support of her neighbors. The inner one is her fear of being alone. Her husband's death had changed her life.
Storytelling may be an emotional event for an older adult. Nurses need to recognize this possibility. The nature of storytelling implies a willingness to be open with feelings. One becomes vulnerable, at risk of emotional distress. Destructive stories are sometimes difficult to transform into something positive in the mind of an older adult. Some stories are selfdefeating and alienating. These stories need to be re-told so alternatives to self-criticism can be generated. Such alternatives include self -awareness and identification of strengths or emerging empowerment. It is appropriate for nurses to explore whether these stories are best shared between themselves or within a group format.
Because storytelling is a subjective experience characterized by mutual participation, the older adult will benefit from a shared communication and a feeling of caring from the nurse. Partly by the way that the story is told, partly by the resolution of the story, and partly by the interventions of the nurse, the older adult's needs are acknowledged and met. As Patricia said:
It is not the dying that I am fighting but the losing of my two granddaughters. I am going to miss them so much - their high school graduations, their weddings, even their children. I do not know how I can give them up. I don't want to lose them. I do not want them to forget me.
Patricia was dying of ovarian cancer. She had accepted the reality of her death, but an underlying need existed to hold on to her grandchildren and to mourn for her losses. The nurse recognized this need and encouraged Patricia through storytelling to talk about the two girls who she described as the "light of my life." She also suggested that Patricia keep a journal for each her grandchildren. Patricia's journals told the stories of grandmother and grandchildren, of times spent together, and of her future hopes for them. It gave Patricia a tie to them that she believed would help them, remember her.
Nurses have listened to stories for many years, however they have not documented their effectiveness or outcomes because the power of stories was not acknowledged. More research in this area would be valuable. Nurses are now beginning to ask questions such as:
* What are the experiences for which storytelling is an appropriate intervention?
* Do stories affect nurses' attitudes toward older adults?
* Does the opportunity to tell one's story influence self esteem?
Comparisons of before-and-after interaction patterns might be one qualitative study to answer some of these questions.
Stories have a power to advance the well-being of older adults. Stories help nurses to understand the experiences of older adults. This understanding changes the way gerontological nurses practice. Nursing care becomes more reflective of the individuality and life experiences of older adults. Those who work with older adults should take advantage of the opportunity to listen to their stories and perceive their power.
The names of clients quoted in this story have been changed, and their stones used with permission.
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