This chapter outlines the development of a Framework of Narrative Practice to be utilised in the assessment, planning, implementation and evaluation of care in long-term care settings for older people. Although, the framework is new and aims to guide staff who wish to develop care through a narrative approach, it does incorporate aspects of the Person-centred Nursing Framework of McCormack and McCance (2006, 2010). Its primary purpose is to implement a narrative-based approach to help nurses operationalise person-centred care.

Increasing regulation internationally and the need to provide services that are driven by a quality agenda has prompted the need for services that are based on best practice evidence, continuously improve quality and are service user driven (Department of Health and Children 2003). In Ireland both the National Standards for Residential Care Settings (Health Information Quality Authority 2007) and the Nursing and Midwifery Regulator’s (An Bord Altranais 2009) Professional Guidance for Nurses Working with Older People have been established to promote high quality care. The 2006 version of the Person-centred Nursing Framework (McCormack & McCance 2006) was previously used as the underpinning philosophy for a national collaborative practice development programme in the Republic of Ireland (the National Person-centred Care Practice Development Programme: McCormack et al. 2010). However, during the implementation of this programme, it became evident that the life experiences of residents in residential care were not taken into account when planning or developing their care. The impetus for the study described in this chapter stems from both my personal involvement in the National Person-centred Care Practice Development Programme as an internal facilitator, and my background as a practice development facilitator in a residential setting for older people. The lack of understanding among staff regarding the importance of life history and the absence of a suitable framework for nurses to utilise in obtaining this information when planning care, provided a further impetus.

The study described here is based on my doctoral research, which was conducted in the Republic of Ireland in a residential care setting for older people. This was an 18-month collaborative action research practice development programme with Clinical Nurse Managers (CNM) (), registered nurses (), support workers () and residents () in two units within this setting.

The study is underpinned by theories of emancipatory practice development (Manley & McCormack 2004), person-centred practice (McCormack & McCance 2006, 2010) and narrative inquiry (Heidegger 1962; Polkinghorne 1988; Ricoeur 1991). Both practice development (PD) and person-centred care (PCC) have been linked in the literature for a number of years, with many writers outlining their interdependent relationships and often hypothesising that one cannot be implemented without the other (Manley et al. 2008; Dewar & MacKay 2010; McCormack & McCance 2010). Indeed, their symbiotic relationship has been well defined in a number of studies that have used these methodologies as theoretical underpinnings or frameworks on which to pin the research approach (Lamont et al. 2009; McCormack et al. 2010; Brown & McCormack 2011). McCormack (2004) in an editorial for the Journal of Nursing Research goes so far as to declare the central focus of PD as ‘the development of increased effectiveness in person-centred practice’.

So how does a narrative approach to care fit with these two approaches, and is there room for it within these reciprocal concepts? It can be argued that narrative not only connects to sociology, literature and history (Richardson 2000), but also the tenets of narrative connect it to practice and by extension to person-centred care. Narrative has been described as ‘the primary schema through which human experience is made meaningful’ (Polkinghorne 1988, p. 125) and is a way of maintaining and creating order out of experience. It also links the individual to his or her context. Therefore how people become who they are is because of the way they have engaged with the contexts they have been part of (McCance et al. 2011). These contexts are constantly changing, and this affects the way persons learn. Central to the Person-centred Nursing Framework is ‘knowing self’ and by extension knowing others. It involves knowing the values of the patient but also being clear about one’s own values and beliefs. Narrative approaches promote a culture of caring because they value the voice of not only the storyteller but also that of the listener/re-teller (Bochner 2001). Knowledge, that is, narrative knowledge, can promote a more caring relationship where the narrative can influence the way care is carried out or planned. Narrative deals with meanings, contexts and perspectives, and this is similar to the Person-centred Nursing Framework that enables understanding. It privileges a person-centred approach by making the person and their story central to the event.

The aim of the study was to develop and evaluate a methodological framework for a narrative-based approach to practice development and person-centred care in residential aged care settings.

The objectives were:

1. 1. How does narrative help to achieve a depth of understanding of the life-world of older adults in residential care?
   
2. 2. To what extent does the implementation of a narrative approach to care enable nurses to operationalise person-centred care?
   
3. 3. How do nurses make sense of narrative experiences in the assessment, planning, delivery and evaluation of care?

The study was conducted over two phases. Phase 1 was concerned with the development of a methodological framework that was based in part on the Person-centred Nursing Framework of McCormack and McCance (2010), and Phase 2 was concerned with implementing and evaluating that framework in practice, taking an action research approach.