The act of creating stories is integral to life itself. It is through our stories that we live, create communities, understand cultures, follow dreams, and find meaning. It is through stories that we name, share, and make sense of illness experiences (Frank, 1995, 2010). “Story telling allows us to create knowledge by transforming experiences” (Carroll, 2010, p. 235), thereby articulating, sharing, and shaping meaning within and between ourselves and our communities. Narrative has emerged as an often used concept within nursing literature and beyond (Brown, Kirkpatrick, Mangum, & Avery, 2008; Gadow, 1999; Sakalys, 2003). The call to narrative perspectives, narrative inquiry, and narrative research is broad and beckoning (Holloway & Freshwater, 2007), resting on a social constructionist philosophical approach whereby the world is viewed as discursively constructed (i.e., personally, socially, and culturally) through narratives (Gergen, 2009; Madigan, 2011). As Charon (2006) suggested, stories unite us, expose what is important, and allow affiliations to be visible. These developments in narrative knowledge are underscored by calls for person-centered care (Berwick, 2009; Miles & Kezzich, 2012; Morgan & Yoder, 2012), shared or collaborative decision-making models that explicitly value patient and family experience, and quality of life.
How, then, do educators teach about the importance of narrative in the caring for people who are ill? This article delineates a learning approach that was undertaken with students to explore the role of narrative in nursing practice.
The primary purpose of this learning session was to explore the role of story telling and narrative knowledge when engaging with people living with illness. A second purpose was to contrast empirical clinical data with narrative data, as well as to explore how understanding patient's stories relate to nursing practice, person-centered care, and collaborative decision making.
This learning activity was designed using small-group processes of four to six undergraduate students who were assigned one of the following scenarios in a 90-minute classroom setting. Ideally, each scenario would be completed by two groups of students (i.e., a total of six groups). The groups are then asked to work with the same scenario in both Phase I and Phase II of the learning activity. The three scenarios are deliberately created to be relatively simple and include a combination of personal and social aspects of illness to set the stage for understanding the social and personal construction of illness and of stories.
Scenario A. A 32-year-old Aboriginal woman was brought by ambulance to the emergency department of the local hospital. She had been discovered wandering in a shopping center parking lot. She was confused and quickly became unconscious. After admission to the emergency department, she was diagnosed as hypoglycemic (i.e., insulin induced). From her medical history, it was known that she has type I diabetes and that she was diagnosed at age 14. From the hospital records, it is evident that this was her third insulin reaction in the past 2 months. She was treated in the emergency department and, after she was stable, was admitted to a medical floor for observation.
Scenario B. A 56-year-old man of African heritage was working out in his garden 1 week ago and began to experience chest pain. He was rushed to the local emergency department where he was diagnosed as having a myocardial infarction. He had no previous history of chest pain. After undergoing angioplasty, he spent 2 days in the cardiac care unit of the hospital and was then transferred to a general cardiac floor. He is expected to be discharged.
Scenario C. An 84-year-old man of European heritage was brought by ambulance to the emergency department. He reportedly had fallen while outside shoveling snow. A neighbor came to his assistance and called the ambulance. After an examination, the man was found to have a fracture of his left hip. Cognitively, he was somewhat confused. He was admitted to the hospital and, from his medical history, it was also known that he has long-standing hypertension.
Imagine that you are the nurse assigned to this patient. It is your first time caring for this person and as part of your first meeting you are required to complete a nursing assessment, including psychosocial aspects, using a familiar assessment tool or strategy. Select a recorder, then together as a group, describe what components you would include in an assessment based on the scenario provided in the next 20 minutes. After the group has completed this portion of the activity, put your notes about the assessment aside and proceed to the second half of the activity.
Imagine that you are a group of writers, and story-tellers. It is your privilege to write this person's life story, from their perspective (briefly). You may begin any way you wish, if you would like you may even become artists and draw pictures that describe this person's life or poets and write a poem describing who this person is in their life. Use your imagination—you are being asked to be creative. One again, have someone record your discussions (20 minutes). At the end of this time as a group, you are expected to create a story in the person's own words (approximately 1 page) to be shared with the class (again, this could be a drawing or a poem).
The following questions may be used to guide your discussions. You are not expected to answer all of these questions, but rather to use the questions to spark discussion. Two types of questions exist, the first set relates to the person's life story and the second set relates to their experience of health, illness, and healing. General life story questions to consider include: Who is this person in his or her everyday life? What is important to the person in his or her life? Who is important to him or her? What is one of his or her favorite memories? What is one struggle that he/she has had in life and how has he or she coped with it? How does the person typically go about his or her day?
Health, illness, and healing questions to consider include: What brought this person to being ill at this specific time? What is his or her greatest concern about the illness? How has the illness changed life for him or her? In what ways does the person feel healthy? Who is it that the person most wants to talk with about the illness? How does the person believe he or she is responding to the experience of being ill? What are his or her greatest concerns about their illness? How is healing possible for the person at this time?
After students have completed both phases of the learning activity, they are asked report their responses. As a whole class, scenario A, scenario B, and scenario C are reviewed sequentially, reporting on the assessment component (phase I). The purpose is to explore the similarities and consistencies in the assessment components both within a scenario (i.e., all groups using scenario A) and across scenarios. The second aspect of the debriefing involves the sequential reading or sharing of stories created by each group in phase II of the learning activity (i.e., scenarios A, B, then C). Students are asked to simply listen to each of the stories. A facilitated discussion ensues, contrasting the forms of knowledge gleaned through the assessment process and the diversity of stories developed within phase II of the learning activity. Students are asked to reflectively write on (a) the differences between narrative knowing (i.e., storytelling) and empirical knowing (i.e., nursing assessment) by describing how each may impact collaborative decision making and patient-centered care, and (b) their own experience within the learning activity by contrasting phase I and phase II.
Reflecting on Student Participation
Students approached phase I of the learning activity with a serious and focused intent using their well-founded nursing knowledge. Regardless of the theory or framework that students may have chosen to use in completing the assessment, students were focused on describing empirical details, specifically those that have relevance to the trajectory of the disease process or treatment. Relevant laboratory data, physical assessment parameters, and psychosocial factors that affect the disease process were carefully detailed with precision and a discerning stance. These data were perceived as being critical to high-quality practice, and considerable effort was put into obtaining a complete profile of the patient. Groups working on the same scenario demonstrated a high consistency in the data (e.g., categories and parameters of assessments). The importance of standardization of assessments and of data parameters was evident. When looking across scenarios, it was also evident that although some variations in components of assessments are specific to a certain disease process, many of the categories of assessment remained consistent, with normative values being an important basis of decision making.
During phase II, students were challenged to take on a creative role. They sometimes began the story-making process with reticence and concern that they were being asked to “make up a person's story,” uncomfortable with the creative process and the assumption that they could know the person's life story. However, their energy typically shifted quickly. Students became animated and expressive as they begin to creatively develop the life story. Emotive aspects were often evident, with students expressing feeling of sadness, joy, fear, and sometimes anger as they work through different aspects of the person's life and illness narrative. In phase I where disagreement between students incited logical debate founded in nursing knowledge, differences of opinion in phase II were focused on importance of the story ascribed to the person in the scenario. This process was often broadening and the interaction between students in the group led to the incorporation of new ideas and different perspectives and the challenging of stereotypes as students passionately advocated for the meaning of illness to the person.
In reporting on phase II, the spontaneity, uniqueness, depth, and meaning of experience in the words of the person living with illness dominated. This was mirrored by the passion that students expressed in coming to understand and appreciate who the person is in their own life. Immediately apparent in the “listening to the stories” was diversity, difference between patients within one scenario, and differences between people across scenarios. These differences extended to the context of people's lives, their social environment, life circumstances, family experiences, and, ultimately, to the construction of the meaning of illness. Of specific importance was the development of an understanding that narratives are both socially inscribed and personally constituted (i.e., they reflect sociocultural truths, as well as personal perspectives). The questions provided as a guide in the framework of the learning activity were less evident as the life story expands and encompassed the depth of people's experience. The variations in stories also elicited wide-ranging responses with students describing more or less affinity toward a specific story, as well as uncovering assumptions or judgments about a specific person or story.
Points to Ponder
This activity raises deep philosophical questions about the nature of nursing knowledge and the construction of relationships between nurses and people living with illness. The outcomes of learning activity have been profound in students' awareness of their nursing practice.
Ways of Knowing
Much evidence exists for the importance of empirical knowledge (i.e., assessment) to high-quality nursing practice (Melnyk & Fineout-Overholt, 2011). Early in their educational programs, students learn the basic components of an assessment and the parameters by which that assessment data are analyzed. Similarly, interventions and outcomes are based on evidence and are ideally measurable to ensure the integrity and effectiveness of nursing care. However, in this learning activity, students have the opportunity to juxtapose empirical and narrative data, recognize the contribution of empircal data, and begin to understand the role of narrative knowledge. The stories that the students produce are often rife with tensions evident in people's stories (e.g., inconsistencies, paradoxes, or irresolvable challenges), metaphors (e.g., social construction of illness), and familial and social parameters of health and illness (e.g., personal, as well as collective). Through discussion, students highlight and appreciate the importance of contextualized ways of knowing that bring forth not only the uniqueness of the person, but also the complexity, situatedness, and construction of the illness. The goal, then, is not necessarily to denounce one form of knowledge, nor to assimilate narrative knowledge into a standardized assessment. Rather, the goal is to explore both the complementarity and the divergence of these two ways of knowing and to examine how these two forms of knowledge have a significant impact on what is seen by the nurse and by the patient and to highlight the power of narrative in developing patient- and family-focused care.
Importance of Narrative Knowing to Nursing Practice
Stories of health and illness are foundational to the genesis of the relationship between the nurse and the person living with the illness. Nurses must recognize the knowledge and, thus, the power that is present within patients' stories. The sharing of stories not only has the potential to ameliorate illness suffering and to promote healing (Frank, 1991; Sakalys, 2003), but also offers a means—perhaps the only means—by which patients and nurses can authentically partner. Therefore, narrative or personal knowing (Chinn & Kramer, 2010) strikes at the heart of the quest for patient-centered approaches to care and collaborative decision making. Nursing knowledge is matched by the patient and his or her family, knowledge of their own lives, and experiences of illness. In this way, engaging with patients and their families becomes a partnership between two or more people and also between two forms of knowing, each with its own important contribution. As nurses, we will never know the whole story of the person living with illness; however, in recognizing that these two forms of knowledge are essential to the effective provision of care, we shift toward a relational practice where the inter-sectionality of knowing becomes paramount. Inter-sectionality is critical for nurses in advocacy work where, for example, nurses bring their knowledge of disease trajectory and the social determinant factors underlying disease and patients bring their experience of illness situated in their economic realities and concomitant life stressors. The notion of working together and collaborating, challenges the veracity of longstanding constructions of patient behavior, such as compliance or adherence, and opens opportunities to both contextualize and shape nursing practice.
This learning activity provides an opportunity to explore different forms of knowledge and their influence on nursing practice. Narratives of people living with illnesses are elicited to provoke discussion about ways of knowing and the impact of ways of knowing on relational practice.
- Berwick, D.M. (2009). What ‘patient-centered’should mean: Confessions of an extremist. Health Affairs, 28, w555–w565. doi:10.1377/hlthaff.28.4.w555 [CrossRef]
- Brown, S.T., Kirkpatrick, M.K., Mangum, D. & Avery, J. (2008). A review of narrative pedagogy strategies to transform traditional nursing education. Journal of Nursing Education, 47, 283–286. doi:10.3928/01484834-20080601-01 [CrossRef]
- Carroll, V.S. (2010). “Once upon a time…” —Narrative in nursing. Journal of Neuroscience Nursing, 42, 235–236. doi:10.1097/JNN.0b013e3181ee513e [CrossRef]
- Charon, R. (2006). Narrative medicine: Honoring the stories of illness. New York, NY: Oxford University Press.
- Chinn, P.L. & Kramer, M.K. (2011). Integrated knowledge development in nursing. St. Louis, MO: Mosby.
- Frank, A.W. (1991). At the will of the body: Reflections on illness. New York, NY: Houghton Mifflin Harcourt.
- Frank, A.W. (1995). The wounded storyteller: Body, illness, and ethics. Chicago, IL: University of Chicago Press. doi:10.7208/chicago/9780226260037.001.0001 [CrossRef]
- Frank, A.W. (2010). Letting stories breathe: A socio-narratology. Chicago, IL: University of Chicago Press. doi:10.7208/chicago/9780226260143.001.0001 [CrossRef]
- Gadow, S. (1999). Relational narrative: The postmodern turn in nursing ethics. Research and Theory for Nursing Practice, 13, 57–70.
- Gergen, K. (2009). Relational being: Beyond self and community. New York, NY: Oxford University Press.
- Holloway, I. & Freshwater, D. (2007). Narrative research in nursing. Oxford, UK: Blackwell.
- Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association.
- Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.
- Miles, A. & Mezzich, J.E. (2012). Person-centered healthcare: Addressing chronic illness and promoting future health. International Journal of Person Centered Medicine, 2, 149–152.
- Morgan, S. & Yoder, L.H. (2012). A concept analysis of person-centered care. Journal of Holistic Nursing, 30, 6–15. doi:10.1177/0898010111412189 [CrossRef]
- Sakalys, J.A. (2003). Restoring the patient's voice the therapeutics of illness narratives. Journal of Holistic Nursing, 21, 228–241. doi:10.1177/0898010103256204 [CrossRef]