Chapter 1: Creating a Narrative Culture

INTRODUCTION

Consider for a moment the following highly impactful and insightful statements:

• “I knew something was wrong.”

• “I stayed silent. I knew that she needed time to finish telling me her story rather than the story my questions or comments would lead her toward.”

• “I felt a sense of urgency in everything I was doing.”

Have you ever been talking with clinicians and heard similar comments and wondered how they knew something was wrong or when and how to intervene? What they saw that others did not? Such questions come not only from curiosity but also from recognizing that you do not know the answer to those questions. And, if you cannot quantify the answer, then how can you possibly evaluate it, teach it, and share it?

It was this frustration that led people in healthcare disciplines—including but not limited to nurses, therapists, and social workers—to seek the answers to these questions using clinical narratives to understand and articulate practice. These stories of clinical practice can be written and shared, and they allow individual clinicians to articulate, reflect, and understand their work. In addition, narratives make visible the clinical excellence and expertise of the clinician and provide an opportunity for shared learning.

EXPLORING NARRATIVES IN THE LITERATURE

A clinical narrative is a first person “story” written by a clinician that describes a specific clinical event or situation. Narratives allow clinicians to reflect on who the patient is and how that knowledge informs how clinicians care for patients, make decisions, and collaborate with the members of the healthcare team. Patricia Benner, PhD, RN, FAAN, has written extensively on the use of narratives to articulate skill acquisition in nursing practice (Benner, 1984; Benner, Tanner, & Chesla, 1996) and the clinical wisdom embedded in practice (Benner, Hooper-Kyriakidis, & Stannard, 2011). In her work on educating nurses (Benner, Sutphen, Leonard, & Day, 2010), she used narratives to articulate best practices in teaching and in the student experience of integrating the theory taught in educational programs and the reality of the clinical settings. To understand the informal power of nurses, Paynton (2008) used narratives to identify ways nurses were able to manage systems to advocate for patients. Cathcart and Greenspan (2012, 2013) used narratives to describe skill acquisition in nurse manager practice.

Narratives have given insight into the moral comportment of nurses (Benner, Sutphen, Leonard-Kahn, & Day, 2008) as they care for increasingly complex patients in highly technological environments in the rapidly changing healthcare environment. Narratives are used in multiple disciplines, such as social work (Riessman & Quinney, 2005) and education (Schultz & Ravitch, 2013). In 2009, administrators at the Columbia University College of Physicians and Surgeons ...