The nature of narrative and story
Stories are reflections on people’s experience and the meaning that this experience has for them. Narrative research is a useful way of gaining access to feelings, thoughts and experience in order to analyse them. For many decades, health research had focused on the decisionmaking and thoughts of professionals and their measurement of the treatment outcomes, while the feelings and ideas of the patient, the ‘insider’, tended to be neglected. This changed with the advent of qualitative health research. The perspectives of patients are uncovered through their stories.
Many researchers apply the terms ‘narrative’ and ‘story-telling’ interchangeably, although others make a distinction. Frank (1995) uses the concepts of story and narrative differently: He cites the term ‘story’ when discussing the tales people tell, and narrative when referring to ‘general structures’ that encompass a number of particular stories. Paley and Eva (2005) claim that story integrates plot and character – both need to be present – while narrative comprises both sequence of events and causal links between them. However, the line between story and narrative is blurred, and we shall occasionally use these terms interchangeably. Even Frank admits that a distinction between the two is difficult, and Riessman (2008) too sees these terms as ambiguous.
Researchers refer to life stories, biographies or narratives; Labov (1972), one of the first sociologists to carry out research through narratives, sees the term narrative as more specific – as events in the past that are being retold. First person narratives provide much material for research. It must be remembered, however, that their content emerges from memory, and that people’s memories are selective (Skultans, 1998). Nevertheless, the remembered events, as well as the experiences people choose from their vast store of memory, focus on the significant aspects of their social reality.
Narrating helps people to make sense of their experience. It unveils the intentions and motives of human beings to the researcher. Individuals remember an experience, tell the story sequentially as they perceived it happening and seek explanations for events and actions while interpreting and reflecting on them. However, narrators prioritise; some events and experiences carry more importance than others; according to the specific social context or the people to whom they speak, they emphasise different aspects of the story. They might neglect or fail to mention some issues or events, or they might exaggerate others, depending on their perspective or the audience to whom they speak.
Carter (2004) illustrates the value of children’s narratives of pain and how they can influence clinical practice by allowing professionals to hear children’s voices and have empathy for them.
An Australian study of the mental health of men in rural areas used narrative inquiry (Gorman et al ., 2007). These men’s stories of resilience and survival showed how they coped with problems.
McIlfrick et al. (2007) used narrative analysis to explore patients’ experiences of chemotherapy in a day hospital. These patients viewed their experiences as both negative and positive, the former relating to the dehumanising aspects of treatment and the latter to social relationships with other patients and the maintenance of a sense of normality. The researchers used an in-depth analysis of patients’ narratives.
Narratives are not only used in research but also in psychotherapy and in clinical and developmental psychology, mostly in the form of life stories. In sociology and anthropology too, narrative is seen as useful for examining culture, society or social and cultural groups. They are popular in medicine or nursing to gain the patient perspective. Charon (2006), a doctor, discusses the ‘practice of narrative medicine’ to which we can add ‘the practice of narrative nursing’, meaning that health professionals witness the lived experiences of illness, and they become more aware of the suffering and pain of their clients.
Lieblich et al. (1998) maintain that it is natural for people to tell stories. Researchers can use this talent to elicit stories from their participants. Participants affirm their identities through narratives. Ricoeur (1984, 1991) also affirms the ability of human beings to integrate actions and thoughts into a coherent narrative and create a link between past, present and future. Narrators create and affirm their identities through telling their tale. While sociologists such as Arthur Frank, Julius Roth and others have written portrayals of their illness and told their own story, lay people tell of the process and progress of their condition. Riley and Hawe (2005) stress the processual, dynamic and culture-bound nature of narratives; thus time and context are essential elements which researchers need to take into account.
Narrative research
Narrative research is a broad term and can incorporate other approaches – a narrative study may be an ethnography, take a phenomenological approach or use discourse analysis, but it can also stand as an approach on its own. It refers to ‘any study that uses or analyses narrative material’ (Lieblich et al., 1998: 2). In this chapter it is used as an approach which is separate from other qualitative forms of inquiry.
A few narrative researchers believe, as Elliott (2005) does, that narrative inquiry can be quantitative as well as qualitative; however, to have lengthy stories from participants needs a more flexible approach and open questions and for these quantitative methods are inappropriate.
Narratives in health research
Although the use of narratives for research and other purposes has gone on in an informal way for a while, it is relatively recent in health research (Frid et al., 2000). Narratives develop and increase professional knowledge, and through the acquisition of this knowledge they can improve care. Stories enable professionals to understand their clients and gain access to their experience and the meaning they give to this experience. For clinical and professional practice it means ‘the focus of narrative will enable nursing [and other health professions] knowledge to be grounded in concrete situations’ (Frid et al., 2000: 3). It is not easy for health researchers to abandon their own assumptions and focus on the stories of ill people. Frank (2000) gives examples of this. He also refers to the difficulty professionals have to listen to the voice of patients, to hear what is relevant to those who suffer, because professionals have more skills to respond to patients as ‘medical subjects’ rather than ‘ill persons’ (our italics).
Narrative accounts in healthcare can be obtained from a number of different groups:
- Patients or clients
- Caregivers and relatives
- Colleagues and other professionals
Narratives from the point of view of the patient can be seen in several ways.
Patients, for instance, might tell their experience of an illness or a chronic medical condition or of care and treatment by professionals. Ill people tell stories to show what it means to be sick. New mothers tell stories about the meaning of childbirth. Old people tell stories about the meaning of old age in the context of this society. Narratives can also be a reaction to care and medical treatment, or as a counterperspective to that of health professionals. Through narratives and narrative interpretations, patients and clients may also attempt to justify their own actions and behaviour. As long as patients tell their stories, they might feel that they have some control. In addition, they use these narratives to achieve an attempt at normality: they compare their ill selves to their normal social, physical and psychological condition. Holloway and Freshwater (2007) summarise some of the reasons for storytelling which many authors have discussed, for instance Kellas and Manusov (2003), Riessman (2008) and others.
Through storytelling people have the possibility to
- give meaning to experiences, in particular suffering;
- interpret and verbalise important events and share them with others;
- present a holistic view of experience and perspective;
- try to find adjustment when conditions are unalterable;
- confirm group membership in a shared culture;
- attribute blame or responsibility to themselves or others;
- take control over their own lives.
Many authors have shown that telling stories also has healing functions (for instance Pennebaker, 2000 or Brody, 2003), though narrative inquiry has a different purpose, and healing or alleviating suffering and pain are unintended consequences – though of course welcome.
McCance et al. (2001) use narrative methodology to explore caring in nursing practice. They use it as a means to ‘tap into the patient experience’. It is not easy to gain access to people’s feelings and thoughts but eliciting a narrative may help in this process. Telling stories about specific experiences rather than giving general accounts or thinking in general terms is ‘real’ for patients; they often tell the story sequentially along temporal dimensions. Greenhalgh and Hurwitz (1998: 45) claim that narratives used in healthcare research can
- set a patient-centred agenda;
- challenge received wisdom;
- generate new hypotheses.
Through their stories, patients help health professionals to focus on their perceptions and experiences rather than applying a professional framework immediately. If professionals truly listen to patients, they might also hear the unexpected and will be able to change their own assumptions if necessary.
Relatives are narrators of their care-giving experience as it happened and seek explanations for their own behaviour, for the patients’ reactions and for professional care and treatment. Through this, they are able to justify their own thoughts and actions to professionals and researchers. Caregivers of patients with Alzheimer’s disease, for instance, tell the sequence of events and discuss the behaviour of their relatives and their own reaction towards them. Essentially, caregivers attempt to share what caring means to them.
Researchers and health professionals use patient narrative to locate the sufferer at the centre of his or her illness. They see the narrative as a useful path to the understanding of sick people and the illness experience, as interpreted by patients in a specific cultural framework. Professionals – be they individual professionals in interaction with particular patients or professional groups who define specific conditions or illnesses within a biomedical framework – give different versions from patients. Both versions are valid and together might give the full picture. Sakalys (2000), in particular, addresses the question of culture in a discussion of narratives and claims that the social and cultural interpretation defines the illness experience and the sick role for the individual. Narratives also demonstrate the conflicts and dilemmas between individual meanings and healthcare ideologies.
In professional education and practice, narrators might tell the story of interaction in specific situations and of learning or teaching experiences. The researcher’s aim is the understanding of the essence of that experience in the context of the participants’ lives. Josselson (1995) claims that empathy and narrative show the way to people’s reality; understanding of this can be achieved through qualitative research. Kleinman (1988) also urges ‘empathic listening’. Health professionals need both empathy for and stories from their clients. Nurse and midwife teachers, in particular, often use narratives to teach students reflection and clinical decisionmaking as well as empathy.
The following research shows the value of narratives. An exploration of how people with motor neurone disease talk about living and coping with their condition demonstrates how survival is the essential element in the findings. Brown and Addington-Hall (2008) carried out longitudinal narrative interviews over 18 months with 13 individuals. Although the participants’ narratives were unique, they also contained common elements. Brown and Addington-Hall point out that storylines are ‘organising threads’ that help professionals to understand and help these individuals and their families.
Types of narrative
Jovchelovitch and Bauer (2000) list the two dimensions of narrative and storytelling: the chronological dimension where narratives are told in sequential form with a beginning, a middle and an end, and the non-chronological, which is a plot constructed as a coherent whole from a number of events – small tales which combine into a big story. According to Paley and Eva (2005), certain conditions need to be fulfilled in the configuration of a plot:
It depends on the storyteller what he or she wishes to communicate to others or what to leave out of the story. People organise their experience through narratives and make sense of them, not least by relating them to time. Indeed, Bruner (2004: 692) states that the only way to account for ‘lived time’ is in the form of narrative. Narratives allow access to a person’s perceived reality in many different ways. Richardson (1990) describes many of these types of stories:
Often, narratives contain a number of overlapping stories. We shall illustrate these by examples (real, but not necessarily literal, comments):
The everyday story
In the everyday story, people tell how they did everyday things and carry out their normal tasks: ‘ … And then I went out into the garden and did some work, and then I came inside and sat down.’ Most patients import these everyday stories into the history of their condition, care and treatment.
When researching people’s experience in hospital, one of our students found that their narratives always tended to start at a time before they arrived. ‘We were watching television, I had just made a cup of tea when it happened … and then my wife called the ambulance, I could hardly walk, and then they went through the night with all lights blazing and a lot of noise.’
Autobiographical stories
In an autobiographical story people link the past to the present and future: ‘I used to go dancing, but now I can’t dance any more, I shall probably never dance again because of my pain.’ Through autobiographical stories people also justify and explain their actions: ‘Because I had such an awful pain in my back I could not have regular work.’ In autobiographies in which individuals tell their illness history, they demonstrate that they see their own stories as unique and quite separate from those of others. The storyteller can link together various disparate events through narrative (Polkinghorne, 1995): ‘ . . . And then I went into the garden, and I did some work, and then my back went . . . and that’s why I am unemployed now.’
Example of autobiographical tale
Sparkes (1996) draws on his own experiences to illustrate the power of narrative. He connects his own story of ‘the fragile body-self’ with the experiences of others and their ‘biographical disruptions’. Speaking of ‘identity loss’, chronic illness and feelings about masculinity, he links his discussion to the cultural and social context.
Biographical stories
Biographical stories, however, link individuals with each other. Reading and listening to biographical stories enables them to share and compare their experiences. The stories guide beyond the subjective to intersubjective understanding and empathy by living in a shared world. By writing accounts of others’ stories, researchers help readers understand the feelings and vulnerability of others. An element of the autobiographical or biographical tale is the victory story in which individuals demonstrate how they overcame adversity by describing their feelings and actions (Sandelowski, 1996).
Cultural stories
Through the cultural story participants tell, they make visible and demonstrate meanings in a particular cultural context, for instance the meaning of death or the understanding of disease: ‘I had epilepsy. In our society people don’t understand that, and I was labelled as not quite normal.’ Or ‘My back pain is invisible, nobody believes that it exists, if I had a broken leg I would not be labelled lazy or work shy.’ Or ‘Everybody wants you to have the baby in hospital, in an earlier time, you could have it at home. Luckily times are changing again.’
Collective stories
In research the collective story is significant. By retelling a number of stories, for instance of patients, professionals or students, researchers reflect the thoughts and paths of a group or collective of people with similar experiences and give a portrayal of a condition or patterns of experience. For instance, a person suffering from pain might mention that others are much worse off, or that new mothers tell stories that are embedded in the culture of motherhood. Collectivity creates a Gestalt or whole picture of the condition or experience. For nurses and midwives this means that they might recognise the needs of the group members and improve their care.
Illness narratives
Kleinman’s (1988) The Illness Narratives is probably the best known example of narrative in the health and illness arena though not in research.
Patients use narratives to seek meaning and make sense of their suffering, and they want to share this with ‘significant’ others. The researcher on the other hand, re-tells stories in order to give voice about participants’ feelings and thoughts. It is questionable, however, that the account is always the authentic voice of the participants because researchers translate and interpret the narrators’ tales. Paley and Eva (2005) query the concept of truth as it is sometimes applied to narrative. They believe that ‘truth’ in the factual sense is irrelevant and that meaning and interpretation are important, not whether the story is factually ‘real’. Sandelowski (1996: 122) also criticises the naïve notions of stories as either true or false. Nevertheless, researchers make an attempt to represent the ideas of the participants. Although the narration may be true in its meaning, it is not always based on fact or objective reality but is a social construction and perception of what has happened to the narrator. At a time when people have little power to act – for instance when they have experienced an illness, breaking up of a relationship or another trauma in their lives – they attempt to explain this in a different language from that of those in power. To paraphrase Bruner (1991: 11): the patient tells the tale in ‘life talk’ (that is, in ordinary language) while the professional listens to it and translates it into professional language.
People often tell stories about their illness, particularly when the condition threatens their lives such as in an acute illness or when it restricts their daily activities and intrudes on normal life. Through illness and suffering, individuals often have an impaired sense of self, and on this they reflect. As it is of such importance to them, they attempt to tell their story to their significant others such as family and friends, employers and work colleagues. They tell it also to the health professionals, doctors and nurses. For each of these groups, ill people adopt different ways of telling.
Illness narratives differ from other stories in that they have an altered temporality while in ordinary tales the present connects effortlessly to the past and future. The future of those telling about their illness is sometimes uncertain and occasionally non-existent.
Frank (1995) proposes three different forms that narratives can take:
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