Understanding narratives in health care
Understanding narratives in health care

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Understanding narratives in health care

1 What is a narrative?

Price (2011) explains that narrative derives from the Latin ‘narrare’ (recounting) and ‘gnarus’ (skilfully). He notes that individuals create narratives for themselves – stories that help them give meaning to their experiences. These may help shape what they strive for and commit to.

In some instances, narratives may become habitually used: they represent personal constructs, set explanations, and attitudes that are believed to define experience and help predict what is likely to happen next in social encounters. Discovering, and sometimes challenging, personal constructs may contribute towards what constitutes improvement (Mallick and Watts, 2007). The ambiguity of living means that individuals engage in a great deal of sense-making – this is especially true when someone becomes ill, requires support, treatment or rehabilitation. In these circumstances people search for explanations to understand experience itself and (possibly) to share this with others (see for example, Sawyer, 2011). Therefore narratives are very important.

A successful narrative is notionally one that is consciously considered and which shows an understanding of what is entailed in making sense of what is happening. The explanation of events feels personally credible, sustainable and usable. It can be shared with others: ‘This is what happened to me and this is how I have coped’. In practice, however, narratives are not often this simple (Caughlin et al., 2011). Narratives evolve incrementally making it difficult for the individual to take stock of what they think and they may have significant doubts about how others might receive the narrative. Listeners may welcome the explanation, or perhaps judge the individual’s response as weak, naïve, deluded or prevaricating.

Stories shared have an emotional value. Baruch (1981), for instance, reported how parents account of their children’s recovery and health care support changed over time. Where their child’s progress was not as anticipated, parents might develop ‘atrocity stories’. These help explain the gap found between their expectations and achievements. Recounting atrocity stories might involve asking others to agree that shortfalls in outcomes are largely someone else’s fault.

Individuals may be more or less capable of expressing their narrative. The fears (and other emotions) that can attend illness may make it especially difficult for the patient – or relative – to summarise their understanding of what is happening and what seems a good thing to do. Here, a narrative is sometimes that which underlies the verbal accounts shared by individuals. It is as if the narrative has fragmented and only some pieces of it have floated to the surface of our attention.

Schultz and Flasher (2011) remind us that individuals are daily challenged to make sense of existence and to piece together what they, and others, are doing. Every interaction represents a complex set of activities, including:

  • Striving to make sense of my situation, who I am and what I want to achieve or contribute
  • An interrogation of what others are doing, offering or saying – this may change my understanding of myself and the situation
  • An examination of what we are doing together, what this interaction represents (e.g. problem solving, diagnosis, goal setting, refining or augmenting a skill)

This sort of interaction can be represented diagrammatically (Figure 1).

Described image
Figure 1: Accounts, narratives and practice meanings

Activity 1

Study Figure 1 above and provide answers to the following questions:

  1. What, within this figure, might help to explain why some interactions between practitioner and client and between fellow professionals, may be less successful?
  2. What, within the figure, might help you to deliberate on why the definition of improvement, or the purpose of a project linked to that, could be difficult to agree?
  3. Is there anything associated with the figure that suggests why some changes may take longer than others?

Note down your answers before looking at our feedback below.


Question 1

The first thing to reflect on is that personal narratives may be more or less explicitly expressed in those personal accounts shared as part of the interaction. The accounts may also be more or less witting. (A definition of ‘witting’ being: ‘Many of the accounts, that you and others share, may be described as witting. That is, words are chosen to produce a desired effect, to portray you in a favourable light or to achieve particular objectives.’)

It is quite possible that during an interaction both parties are not completely sure what they want from the encounter and hope to discover something valuable as they proceed. If individuals approach interactions with a different purpose, or if they discover a purpose that makes them feel less comfortable, then the interaction may seem less successful.

Hickman et al (2009) discuss how such misconceptions can undermine communication with older patients. An incomplete grasp of narratives in play often makes it harder to agree what constitutes an improvement, expert practice or sustainable change. As individuals engage in interactions they may be dealing with very complex ideas and feelings relating to their personal narrative. For example, during dialogue:

  • The clinical scientist is worried about compromising rigorous test and sample standards (narrative – what it means for me to be a scientist). The manager is more concerned with cost efficient processes (what it means for me to manage other people).
  • The healthcare student is alarmed at their feelings towards abortion. This is confronted as they complete placements in areas of related care (a narrative about what they value and believe ethical). The tutor may be concerned to understand what seems like an ‘attitude problem’ on the part of the student (possibly correcting a learning strategy).
  • The physiotherapist who examines what it really means to stay updated during the last year of her full time career (what is enough update here, what responsibilities do I have given that I am soon to retire). Her manager meanwhile faces an audit of the updates completed by staff (sustaining effectiveness and efficiency).
  • The relatives wrestle with their mixed feelings about a dying patient whom they are now asked to care for at home. This is difficult because palliative care staff seem to have such high standards. They might witness our mixed feelings about a patient whom we are responsible for, but don’t necessarily love. The palliative care practitioner, meanwhile, wants to liaise successfully with the family and cannot understand their reluctance to discuss some aspects of the patient’s support.

In some instances (such as those above), there may be few, or no, shared accounts – no agreed dialogues about what is underway.

Question 2

All of the points made in response to question 1 could contribute to collaboration difficulties, but there may be others. In some instances, especially those related to service or system improvements, there may be multiple stakeholders interacting on the project, each attending, more or less clearly, to their personal narratives. Each may begin with a different notion of what the shared accounts are or should be and what the dialogue is about. Different members of the team may be more or less aware of the agendas that underpin the requirement to act in some way now. Perhaps an organisation has shared some agenda concerns, but not others? Perhaps the change has been portrayed as one sort of change, but stakeholders believe that it is another?

To illustrate this, imagine a healthcare organisation that is required to significantly change their service provision. This could be a hospital or a GP practice. One of the most common prompts, or agendas, to change is alterations to funding arrangements: those concerning who purchases services, what they pay for these same services and how the service provider is meant to compete for custom. Each of the stakeholders asked to contribute has a general awareness of the changing circumstances of healthcare and economic climate prevailing. But most stakeholders will have an incomplete understanding of all the change agenda. There may be particular concerns associated with income streams, what can or should be afforded, the profile of staff, their skills, expertise and stage reached in their career.

Those asked to steer the change may emphasize some aspects of the work over others. It might be ‘branded’ in particular ways and this in turn might either convince stakeholders or leave them feeling cautious. As the change gets underway and interactions develop, the stakeholders cannot dismiss the personal narrative concerns that haunt them. Indeed, some may become more acutely aware of their personal narratives than before (‘my job is on the line here’, ‘our profession is getting sidelined’, ‘what motivates me is not what the organisation is striving for now’). Factors such as these indicate why collaboration may be more difficult. They suggest why change can be so complex and stressful, or sometimes, exciting.

Question 3

Where there are multiple personal narratives in play and a large number of stakeholders are asked to interact, some with more power than others, and the agenda concerns influencing the interaction may be more or less well understood, –change can take longer and a great deal more effort. Significant time might have to be spent agreeing the terms of what you are trying to do. Concerns will have to be acknowledged and explored. In some instances, caveats agreed on what will or will not be done. Figure 1 identifies a number of different areas in which delays might arise, as individuals overcome their emotional discomforts, dialogues are agreed and all try to understand the nature and the need for change.

Having understood what narratives are – how they might interact with contexts, agendas and be represented by accounts, questions nevertheless remain. How do you spot narratives? How do you identify factors which potentially shape what others expect of you (i.e. your expertise?) How do you recognise narratives that might be directing what you do?


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