L1 - Understanding Narratives in Health Care Printable

Understanding narratives in health care
K829_1

About this free course
This free course is an adapted extract from the Open University course K829
Transforming professional practice:
http://www3.open.ac.uk/study/postgraduate/course/k829.htm.
This version of the content may include video, images and interactive content that
may not be optimised for your device.
You can experience this free course as it was originally designed on OpenLearn, the
home of free learning from The Open University - www.open.edu/openlearn/health-
sports-psychology/health/understanding-narratives-health-care/content-section-0.
There you’ll also be able to track your progress via your activity record, which you
can use to demonstrate your learning.
Copyright © 2016 The Open University
Intellectual property
Unless otherwise stated, this resource is released under the terms of the Creative
Commons Licence v4.0 http://creativecommons.org/licenses/by-nc-
sa/4.0/deed.en_GB. Within that The Open University interprets this licence in the
following way: www.open.edu/openlearn/about-openlearn/frequently-asked-
questions-on-openlearn. Copyright and rights falling outside the terms of the Creative
Commons Licence are retained or controlled by The Open University. Please read the
full text before using any of the content.
We believe the primary barrier to accessing high-quality educational experiences is

cost, which is why we aim to publish as much free content as possible under an open
licence. If it proves difficult to release content under our preferred Creative Commons
licence (e.g. because we can’t afford or gain the clearances or find suitable
alternatives), we will still release the materials for free under a personal end-user
licence.
This is because the learning experience will always be the same high quality offering
and that should always be seen as positive – even if at times the licensing is different
to Creative Commons.
When using the content you must attribute us (The Open University) (the OU) and
any identified author in accordance with the terms of the Creative Commons Licence.
Page 2 of 29 12th February 2016
http://www.open.edu/openlearn/health-sports-psychology/health/understanding-narratives-health-
care/content-section-0
The Acknowledgements section is used to list, amongst other things, third party
(Proprietary), licensed content which is not subject to Creative Commons
licensing. Proprietary content must be used (retained) intact and in context to the
content at all times.
The Acknowledgements section is also used to bring to your attention any other
Special Restrictions which may apply to the content. For example there may be times
when the Creative Commons Non-Commercial Sharealike licence does not apply to
any of the content even if owned by us (The Open University). In these instances,
unless stated otherwise, the content may be used for personal and non-commercial
use.
We have also identified as Proprietary other material included in the content which is
not subject to Creative Commons Licence. These are OU logos, trading names and
may extend to certain photographic and video images and sound recordings and any
other material as may be brought to your attention.
Unauthorised use of any of the content may constitute a breach of the terms and
conditions and/or intellectual property laws.
We reserve the right to alter, amend or bring to an end any terms and conditions
provided here without notice.
All rights falling outside the terms of the Creative Commons licence are retained or
controlled by The Open University.
Head of Intellectual Property, The Open University
978-1-4730-1319-3 (.kdl)
978-1-4730-0551-8 (.epub)

Contents
 Introduction
 Learning outcomes
 1 What is a narrative?
 2 Identifying others’ narratives
 3 Identifying your narratives
 4 Examining narratives
 5 Comparing narratives
 Conclusion
 Keep on learning
 References
 Further reading
 Acknowledgements

Introduction
In this free course it is argued that one important means of improving practice skills,
service provision to clients and healthcare systems, is a better understanding of the
narratives used by individuals to describe things such as need, quality, improvement
and change. As Taylor (2003) observes, practitioners are engaged in the creation and
sharing of healthcare narratives. Exploring these, as well as empirical evidence, is
important if healthcare is to be improved.
It is suggested that much of what triggers improvements, and may sustain efforts,
rests upon the ways individuals interpret what is happening and what they are doing.
Understand this, and improvement may be managed more strategically.
This OpenLearn course is an adapted extract from the Open University course : K829
Transforming professional practice.

Learning outcomes
After studying this course, you should be able to:
 define what is meant by a narrative and how that may differ from an
account of healthcare experience
 begin exploration of narratives – those that are relevant in local
practice, those of patients/clients and of healthcare practitioners.

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).
Figure 1: Accounts, narratives and practice meanings
View description - 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.
View discussion - Activity 1
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?

2 Identifying others’ narratives

Others’ personal narratives may be partially available to you through the accounts
they share – those that betray their interests, fears, uncertainties, delights, motivation
and state of comfort. However, individual conversations, in which they share ideas
and feelings, might not be enough to formulate a clear understanding of their
narratives.
It may require examination of many such conversations before observations about

possible narratives in play can reasonably be suggested. Reflective practice requires
that you interrogate, and invite others to interrogate, your tentative ideas about what
concerns and issues relevant individuals may have. Descending into the swampy
lowlands of reflective practice, Schon (1983) emphasizes that the individual still
needs to scrutinize what they encounter. It is necessary to make notes on what you
hear and to refer to these frequently. By doing so, competing interpretations of what
has been heard can be aired.
In both counselling and research interviewing, enquirers are frequently required to

check their understanding of what the individual has said. Such pauses, ‘to let me just
check what you are telling me’ are more readily managed in formal interviews.
During the flow of healthcare interaction few such chances to evaluate a personal
understanding of what has been said arise. The understanding check has to be lightly
handled and offered periodically as a summary of what you think has been agreed.
The onus is on the reflective practitioner to listen harder and to relate that heard today
to what has previously been understood in the days before. Insights into narratives
grow incrementally and at first are rarely certain (Schultz and Flasher, 2011).
Attending to accounts from the same people over time is necessary too because the
narrative that underpins what they say, may itself still be forming and could be
dynamic. This is especially true where individuals find themselves in new situations –
for example as patients, carers, project colleagues, leaders or as those responsible for
new services. The individual incrementally explores what they feel, what they want to
do, how they wish to seem and what they hope to contribute. Additional revelations
(relating to a health diagnosis or perhaps to a treatment plan on a project concerning a
revised time table) could all challenge the narrative. This may lead the individual to
develop different perspectives and attend to different personal priorities.
Activity 2
Conduct an exercise that helps you practise this interpretation of what someone else
says and under conditions that allow you to go back and think again about what you
heard. Practising this, before you return to interpreting real time accounts shared at
work, is a worthwhile activity as it helps you attend to what might be important.
Step 1: Select a patients’ stories website from the internet. These can be found by
searching ‘patient stories’ on your browser. Some websites present their stories in
written form (e.g. www.healthtalkonline.org/) Many others sites provide more
interesting short video clips for you to view (e.g. www.patientstories.org.uk or
www.nhs.uk/Planners/Yourhealth/Pages/Realstories.aspx. Both forms of account are
valuable as, within your practice, you might be examining written (e.g. letters of
complaint or commendation, patient diaries) or oral accounts (your face-to-face
encounters with patients, or accounts heard over the telephone). However, for this
exercise, the shared video accounts may be the best.
Step 2: From the catalogue of stories on offer, select one that relates well to either
your area of practice, or something which simply intrigues you. Note down what you
believe is the narrative that the individual is sharing. Remember, this may relate to
different things, e.g. ‘how I am feeling’, ‘what I have been doing’, ‘what I expect of
you or other practitioners’. Make a brief comment on the emotional state of the
individual and whether that seems to affect how the individual talks about their
experiences and what they focus on. Shared accounts are likely to be reflections on
past experiences. Do you think that the passage of time, in some way, affects the
account and helps to arrange narratives in ways that can more readily be reported?
Step 3: Run the video clip several times to help you attend closely to what is being
said. In this step we suggest that you write nothing down and listen attentively to what
is said and how it is expressed.
Step 4: Now make a careful note of the reference for this video clip, its title, website
source (the URL) and then write a single paragraph regarding what you thought the
narrative was. What is important in this account and what do you sense concerns the
individual?
Next, write a second short paragraph regarding what was interesting or difficult as
you tried to interpret the account. Did you find yourself cautioning yourself about
what could reasonably be interpreted? Were other things ‘much more obvious’? If so,
provide details as to why.
Step 5: Repeat the review process with a further one or two video or written accounts
so as to ascertain whether different voices, different people (and their circumstances)
make it easier or harder to examine what is being conveyed. Make two paragraph
records for each and note what you discover. Whose account was harder for you to
hear? For example, if someone from another culture shares an account, was that
harder for you to understand? Were there reference points in their account that you
didn’t completely comprehend?
Step 6: Invite a colleague to review one of the video clips. Did they think the
individual was expressing the same narrative as you?

3 Identifying your narratives

You might imagine that everyone fully understands our own narratives: what we are
currently dealing with psychologically, at a personal level, what we believe and value,
what our attitudes are towards different things. But in reality, no such perfect insights
exist. We are unable to account completely for all of our personal narratives (Shapiro
et al., 1983). It is difficult to fully know our narratives for a variety of reasons:
 Some issues and insights might seem too painful.

 Your narratives don’t remain constant – they respond to circumstances
that you find yourselves operating within. Sawyer (2011) ably
demonstrates the ways in which narratives can become increasingly
revealing.
 Your narratives may be intimately related to another person’s (for
example as a spouse or partner) and therefore be difficult to
disentangle.
 Some narratives may be more formal – those that you adopt associated
with your professional life. Ambiguities can remain however, for
instance where religious, cultural and personal values compete with
professional values and requirements.
The fact that personal narratives can be so difficult to explore has given rise to much
work by psychotherapists, other counsellors and life coaches. In this course however,
you are not asked to embark on an amateur form of psychotherapy. Rather, you are
encouraged to become more introspective about the narratives that you believe you
are dealing with today. To consider what part these may play with regard to the
improvement and interactions you are interested in. For example:
 You are exploring a chosen skill, and have discovered that your
conception of excellence is strongly associated with the volume and
variety of the things you know. But it seems more difficult to
examine how, and when, you use that knowledge. You therefore
examine why your notion of expertise centres so much on knowledge
and less on skill.
 You are playing a leading role in a service improvement project
designed to help your hospital laboratory team act in a more
consultative way with those healthcare professionals who request
various tests. As things progress you start to note some discomforts
when liaising with medical consultants. You wonder what it is about
that working relationship – and your part in it – that might impede the
project’s progress.
 As part of the work to improve annual staff appraisals, you have
convened a series of speak easy sessions so that staff can share with
you their perceptions of these events and what purpose they have.
You are vaguely aware that you share some misgivings about these.
You wonder what you must do to run these meetings and advance the
project fairly, whilst attending to your employer’s, as well as staff’s,
needs.
Activity 3
Note down any techniques that you think you might use to help identify and
understand narratives that you are using – those that might materially affect your
chosen project. Once you have noted down your ideas, look at our feedback below.
View discussion - Activity 3

4 Examining narratives
You have now practised the interpretation of others’ accounts and searching for
narratives that might be expressed there. Did you find that difficult? Did colleagues
interpret things differently? Whilst at first the examination of accounts and the
identification of narratives will perhaps seem problematic, it is likely that you will
become better at this. Talking about yours and others’ narratives helps you to
articulate ideas in a more inquisitive way. To examine where narratives are more or
less clear and constant and where they collide as beliefs and expectations differ.
The process of narrative identification and analysis is progressive and demanding, so

it is important to discuss your discoveries and compare your worries. The amassing of
accounts, the ways in which you and others describe things will become interesting in
itself. It can seem a revelation that so many agendas or needs were in play. That
which previously seemed frustrating in practice may now seem more tolerable. Your
comprehension of the complexity of healthcare, and of change will have grown.
Perhaps the narratives help clarify what is critical within your chosen skill and what
remains underdeveloped. Perhaps these narratives indicate what appears to advance or
inhibit the service improvement project. Perhaps they help you to clarify the work
underway within your system improvement? Figuratively it might look rather like
this:
Figure 2: Gathering accounts, identifying and then examining narratives
View description - Figure 2: Gathering accounts, identifying and then examining

narratives
There is no formula for the correct number of accounts (what people said) to collect
nor the right number of narratives (what people meant) to identify. Instead, the
numbers are a function of how hard you concentrate on your field work, how adept
you become at reflection and what seems justifiable in terms of narratives that you
can discuss clearly. Too many and you may struggle to make sense of what you are
discovering.
In practice, some of these accounts may be variants of the same thing. The accounts
may come from different people and yet still contribute to your stock of narratives.

Whilst everyone is individual, it is nonetheless true that people have things in
common. For example, if you are attending to patient concerns, there may be a
collective need amongst patients to secure enough information to feel in control of
recovery/rehabilitation when they go home. This is a collective narrative (regaining
control).
A similar approach should be adopted towards narratives which underpin verbal

accounts. If you have too many recorded, then it may be difficult to discuss them
later. Some narratives may be too vague for you to confidently analyse. Others might
coalesce into one after further analysis. Some draft narratives simply don’t ‘make the
cut’. They are not clear and coherent enough to feature in the later stages of your
work. Of course, if there seems a deficit of narratives, then you should discuss your
accounts further. Are there narratives here that you agree could be carefully
speculated about, which could be discussed?
You might decide that you have arrived at three or four narratives that seem clear,
significant and worthy of examination. In what ways are they significant for the
project you have in hand?
Table 1 indicates some ways in which narratives affect the project you are
conducting:
Table 1 Some possible relationships between narratives and improvement
Narrative Significance
The narrative clarifies your chosen Attending to narratives, your own and
improvement, it indicates what is others’, will often help to clarify your
required, what is working or problematic, project: what is involved in enhancing a
what represents a way forward. skill or implementing a service or
system improvement. Listening harder,
and more, to different people can
deepen your understanding of the
project work in hand.
The narrative confuses the improvement This may dismay you but it does help to
– it indicates why progress is difficult, show how a project has started without
what has not yet been understood or all the right insights. It might suggest
agreed. that work will need to continue for
longer.
The narrative counters your Understanding what opposes the
improvement, it contests what was improvement, what limits or prevents it
considered important to do. is important. You have to decide how to
proceed. Should you adjust your goals
to accommodate the new insight or try
to counter what you or others are most
concerned about?
The narrative adds dimensions to the This can be exciting, as you think about

improvement, it indicates more that needs the potential discoveries yet to be made.
to be understood or, possibly, done. A note of caution however: your project
needs to be written up in assessments
along the way so you do have to reach
periodic and interim conclusions!
The narrative refocuses the improvement, Daunting as this seems, the insights
it indicates a different, higher, priority or gained here might save your
better value direction for work. improvement – rescuing what might
otherwise not develop very far.
The narrative resources the This is an exhilarating discovery, but be
improvement, it indicates why something careful to be clear and certain about
is valuable or valid and further fuels your what you have found. It is vital that you
endeavour and commitment. verify your discoveries, discussing your
reflections with others before making
your final proposals for change.
The narrative shifts your mode of This is rarely the case. If it happens,
thinking Perhaps you have thought about however, it is critical to discuss your
this project in the wrong way. ideas with others. The focus of project
work will shift significantly and you
need to determine what it is possible to
discover and report in the remaining
time.
View description - Table 1 Some possible relationships between narratives and

improvement

5 Comparing narratives
Figure 2 portrays enquiries in rather a linear way (helpful for explanation but not
necessarily completely representative of all work in the field). Before you reach
conclusions it is wise to compare narratives. A collection of narratives may impact on
a project, bringing about unexpected outcomes. You might discover that some
narratives seem to accelerate a service improvement helping you to refine a skill, to
devise something better with clients or a system that works to best effect in your
organisation. Other narratives may have an inhibiting effect, acting as a brake upon
your improvement. The net effect is an improvement that seems to be advancing in
some regards but stalling in others.
Take stock of the net balance of influences that advance and detract from the
improvement that you strive for. Decide which barriers to the improvement need to be
addressed, or whether you will build on those parts of the change that are already
proceeding well. You might, in extremis, shift the focus of the project and accept that
modified goals will be agreed. During that consultation period, you will benefit from
what you have discovered whilst interrogating narratives, and from the evidence
review you engaged in.
Comparing narratives will help you to choose your next action. It will enrich your
understanding of advancement in practice. It will help you to test what you see as
most desirable, what seems achievable within a given span of time and what you
thought ‘most people agreed about’. If it leaves you more cautious, measured and
ruminative about the process of improvement, then you will have discovered
something very important. Improvements that are sustainable are often hard won.
That which seemed straightforward at the outset, might be more taxing in the doing.
This is project experience: a disciplined form of evaluative thought that will stand you
in good stead when you lead, or contribute, to future projects.
The next questions are:
1. In the light of these insights into narratives, do I wish to change

something?
2. In the light of these insights must we change something in order to
succeed?
3. Do these insights suggest that we might usefully modify our goals in
some way?
4. Do the insights gained highlight the importance of communication and
attending more closely to what others perceive?
5. Will we, in some way, try to counter the narratives that slow this
progress?
6. Will we instead accept these and work further on those narratives that
seem to sustain or accelerate the improvement?

Conclusion
You have now completed this short exploration of narratives, those that patients or
relatives might use and that you might employ yourself. Narratives are important
since they tell the story of what is, and has been, happening to ourselves. Therefore
understanding these can be invaluable when planning healthcare and understanding
how others react to the care or treatment that we arrange. Misunderstood narratives
(those that have not been adequately attended to) can be the cause of complaint,
confusion, or even greater risk in healthcare. By attending to narratives more closely,
you will be better equipped to work successfully with clients and colleagues – those
with a vested interest in healthcare improvement.

Keep on learning
Study another free course

There are more than 800 courses on OpenLearn for you to choose from on a range
of subjects.
Find out more about all our free courses.
Take your studies further

Find out more about studying with The Open University by visiting our online
prospectus.
If you are new to university study, you may be interested in our Access Courses or
Certificates.
What’s new from OpenLearn?

Sign up to our newsletter or view a sample.
For reference, full URLs to pages listed above:
OpenLearn – www.open.edu/openlearn/free-courses
Visiting our online prospectus – www.open.ac.uk/courses
Access Courses – www.open.ac.uk/courses/do-it/access
Certificates – www.open.ac.uk/courses/certificates-he
Newsletter – www.open.edu/openlearn/about-openlearn/subscribe-the-openlearn-
newsletter

References
Baruch, G. (1981) ‘Moral tales: parents’ stories of encounters with the health
professions’, Sociology of Health and Illness, vol. 3, no. 3, pp. 275–96.
Caughlin, J., Mikucki-Enyart, S., Middleton, A., Stone, A. and Brown, L. (2011)
‘Being open without talking about it: a rhetorical/normative approach to
understanding topic avoidance in families after a lung cancer diagnosis’,
Communication Monographs, vol. 78, no. 4, pp. 409–36.
Hickman, J., Caine, K., Pak, A., Rogers, W. and Fisk, A. (2009) ‘What factors lead to
healthcare miscommunications with older patients’, Journal of Communication in
Healthcare, vol. 2, no. 2, pp. 103–18.
Mallick, J. and Watts, M. (2007) ‘Personal construct theory and constructivist drug
education’, Drug and Alcohol Review, vol. 26, pp. 595–603.
Price, B. (2011) ‘Making better use of older people’s narratives’, Nursing Older
People, vol. 23, no. 6, pp. 31–37.
Sawyer, A. (2011) ‘Let’s talk: a narrative of mental illness, recovery, and the
psychotherapist’s personal treatment’, Journal of Clinical Psychology: In session, vol.
67, no. 8, pp. 776–88.
Schon, D. (1983) The Reflective Practitioner: How Professionals Think in Action,

New York, Basic Books.
Shapiro, D., Heil, J. and Hager, F. (1983) ‘Validation of the Johari window test as a
measure of self disclosure’, Journal of Social Psychology, vol. 120, pp. 289–90.
Schultz, D. and Flasher, L. (2011) ‘Charles Taylor, Phronesis and medicine: ethics
and interpretation in illness narrative’, Journal of Medicine and Philosophy, vol. 36,
no. 4, pp. 394-409.
Taylor, C. (2003) ‘Narrating practice: reflective accounts and the textual construction
of reality’, Journal of Advanced Nursing, vol. 42, no. 3, pp. 244–51.

Further reading
Sawyer, A. (2011) ‘Let’s talk: a narrative of mental illness, recovery, and the
psychotherapist’s personal treatment’, Journal of Clinical Psychology: In session, vol.
67, no. 8, pp. 776–88. Sawyer is exceptional in that she rehearses both patient and
practitioner narratives, having been a patient suffering from a mental illness and later
a healthcare professional.
Speed, E. (2007) ‘Discourses of consumption or consumed by discourses? A

consideration of what ‘consumer’ means to the service user’, Journal of Mental
Health, vol. 16, no. 3, pp. 307–18. Some narratives become powerful, widely
deployed and sometimes hotly contested, they become ‘discourses’. This is a good
illustration of discourses related to healthcare consumerism.

Acknowledgements
Price, B. (2011) ‘Making better use of older people’s narratives’, Nursing Older
People, vol. 23, no. 6, pp. 31–37.
This free course was written by Bob Price.
Course image: North Charleston in Flickr made available under Creative Commons
Attribution-ShareAlike 2.0 Licence.
Except for third party materials and otherwise stated (see terms and conditions), this
content is made available under a Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 Licence.
The material acknowledged below is Proprietary and used under licence (not subject
to Creative Commons Licence). Grateful acknowledgement is made to the following
sources for permission to reproduce material in this course:
Every effort has been made to contact copyright owners. If any have been
inadvertently overlooked, the publishers will be pleased to make the necessary
arrangements at the first opportunity.
Don't miss out:
If reading this text has inspired you to learn more, you may be interested in joining
the millions of people who discover our free learning resources and qualifications by
visiting The Open University - www.open.edu/openlearn/free-courses

Activity 1
Discussion
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.
Back

Activity 3
Discussion
Some of the things that you might do include:
 Write notes about your speculations as and when they occur. Make a
note of the date of your recordings. Those who conduct research
using approaches such as phenomenology, grounded theory, case
study research and ethnography frequently report the value of such
notes and the insights available within them. The information
obtained provokes questions about how they think and what they
assume. The same may be true for you when you reflect on recent
healthcare interactions. As your enquiries progress, an audit trail may
emerge that helps you describe exactly what narratives are active for
you and how these play a part in the service, skill, or system
improvement.
 Find a trusted companion to talk about your insights with. Talking
about your ‘take on things’, the narratives that you deal with and
which can either enhance or detract from the project, can help you to
articulate your discoveries.
 Read material on professional philosophy and values which
characterizes your work and profession. This may help you to
crystallize what interests, motivates or concerns you. For example, if
you are motivated by more holistic healthcare, what then does holism
really mean for you and how is it expressed?.
 Think back to how your personal philosophy was formed. What
influences helped to shape how you think, what you value, what
challenges or worries you. Culture, family, education and formative
life experiences may be important here.
Back

Figure 1: Accounts, narratives and practice

meanings
Description
The figure consists of a central box, labelled ‘practice interaction’ and four other
boxes, two on either side that capture that which influences such practice interactions.
The two boxes on the left of the central box represent the very personal influences on
practice interaction. These include the text:
Box 1: Personal narratives
 who I am
 what I do
 what I am worth
 what I need or deserve
 what I offer or contribute
 what happens to me (End of text.)
Box 2: Personal accounts
 as client
 as colleague
 as practitioner (perceived and role related) (End of text.)
The narratives (Box 1) underpin the personal accounts (Box 2), that which individuals
actually verbalise, and which may be closely associated with their role, that of
practitioner, patient, colleague or similar.
The two boxes on the right hand side of the central box relate to the public influences
on practice. The far right box (Box 4) is headed Contextual drivers and pressures
and summarises the contextual drivers and pressures that affect what is done. This box
contains the text:
 political
 economic
 ideological
 organisational
 consumerist (End of text.)
All practice interaction is affected by these. In the near right box (Box 3), and
influenced by such drivers, are the shared accounts, the discourses that then result,
those that describe ‘what we are doing’. Box 3 Shared accounts (discourses)
contains the text:
 what we are doing (End of text.)
Back

Figure 2: Gathering accounts, identifying

and then examining narratives
Description
This figure consists of a flow chart of text boxes, with three at the far left, influencing
a central box that then influences the box at the right.
The three boxes at the left of the figure describe the influences that shape the analysis
of that heard as accounts, the examination of underpinning narratives. In the top left
hand box this is ‘accounts shared by clients’, in the middle left box this is ‘accounts
shared by colleagues’ and in the bottom left hand box this is, ‘my own accounts’.
Each of these contribute to the middle box that is labelled ‘a collection of narratives’,
some of which are shared and some of which are private. The accumulation of
narratives, now better understood through scrutiny, then permit (in the right hand box)
the connection of narratives to project interests and the identification of important
discourses there. The enquirer makes connections through accounts to underpinning
narratives and on to discourses, those that need to be attended to as part of the project.
Back

Table 1 Some possible relationships between

narratives and improvement
Description
Table 1 Some possible relationships between narratives and improvement is a
two-column, seven-row table. The two columns are headed ‘Narrative’ and
‘Significance’. Each row describes a possible discovery associated with the analysis
of narratives (left column) and its possible significance for the improvement under
consideration (right column).
Left column, row 1: The narrative clarifies your chosen improvement, it indicates
what is required, what is working or problematic, what represents a way forward.
Right column, row 1: Attending to narratives, your own and others’, will often help to
clarify your project: what is involved in enhancing a skill or implementing a service
or system improvement. It may also help you to identify one or more discourses that
determine project success. Listening harder, and more, to different people can deepen
your understanding of the project work in hand.
Left column, row 2: The narrative confuses the improvement, it indicates why
progress is difficult, what has not yet been understood or agreed. Right column, row
2: This may dismay you, but it does help to show how a project has started without all
the right insights. It might suggest that work will need to continue for longer, perhaps
beyond the scope of this module and the TMAs and EMA that you write in
association with it (in those you will therefore be reporting interim insights and
proposals).
Left column, row 3: The narrative contradicts your improvement, it contests what
was considered important to do. Right column, row 3: Understanding what opposes
the improvement, what limits or stymies it, is important. You have to decide how to
proceed. Should you adjust your goals to accommodate the new insight or try to
counter what you or others are most concerned about?
Left column, row 4: The narrative adds dimensions to the improvement, it indicates
more that needs to be understood or, possibly, done. Right column, row 4: This can be
exciting, as you think about the potential discoveries yet to be made. A note of
caution however: your project needs to be written up in assessments along the way so
you do have to reach periodic and interim conclusions!
Left column, row 5: The narrative refocuses the improvement, it indicates a different,
higher, priority or better value direction for work. Right column, row 5: Daunting as
this seems, the insights gained here might save your improvement – rescuing what
might otherwise not develop very far.

Left column, row 6: The narrative resources the improvement, it indicates why
something is valuable or valid and further fuels your endeavour and commitment.
Right column, row 6: This is an exhilarating discovery, but be careful to be clear and
certain about what you have found. It is vital that you verify your discoveries,
discussing your reflections with others. You will later need to combine these insights
with those gained from reading in Block 2 before making final proposals for change.
Left column, row 7: The narrative shifts your paradigm of thinking, perhaps you
have thought about the project in the wrong way. Right column, row 7: This is rarely
the case. If it happens, however, it is critical to discuss your ideas with your tutor. The
focus of your project work will shift significantly and you need to determine what it is
possible to discover and report in the remaining time.
Back


L1 - Understanding Narratives in Health Care Printable

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

L1 - Understanding Narratives in Health Care Printable

Uploaded by

Copyright:

Available Formats

Understanding narratives in health care

Understanding narratives in health care

Copyright © 2016 The Open University

We believe the primary barrier to accessing high-quality educational experiences is

Head of Intellectual Property, The Open University

Page 3 of 29 12th February 2016

Page 4 of 29 12th February 2016

Page 5 of 29 12th February 2016

Page 6 of 29 12th February 2016

A successful narrative is notionally one that is consciously considered and which

Page 7 of 29 12th February 2016

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

Figure 1: Accounts, narratives and practice meanings

View description - Figure 1: Accounts, narratives and practice meanings

Note down your answers before looking at our feedback below.

View discussion - Activity 1

Page 8 of 29 12th February 2016

2 Identifying others’ narratives

It may require examination of many such conversations before observations about

In both counselling and research interviewing, enquirers are frequently required to

Page 10 of 29 12th February 2016

3 Identifying your narratives

 Some issues and insights might seem too painful.

View discussion - Activity 3

Page 12 of 29 12th February 2016

The process of narrative identification and analysis is progressive and demanding, so

Figure 2: Gathering accounts, identifying and then examining narratives

View description - Figure 2: Gathering accounts, identifying and then examining

Page 13 of 29 12th February 2016

A similar approach should be adopted towards narratives which underpin verbal

Table 1 Some possible relationships between narratives and improvement

Page 14 of 29 12th February 2016

View description - Table 1 Some possible relationships between narratives and

Page 15 of 29 12th February 2016

The next questions are:

1. In the light of these insights into narratives, do I wish to change

Page 16 of 29 12th February 2016

Page 17 of 29 12th February 2016

Study another free course

Find out more about all our free courses.

Take your studies further

What’s new from OpenLearn?

For reference, full URLs to pages listed above:

Visiting our online prospectus – www.open.ac.uk/courses

Access Courses – www.open.ac.uk/courses/do-it/access

Page 18 of 29 12th February 2016

Schon, D. (1983) The Reflective Practitioner: How Professionals Think in Action,

Page 19 of 29 12th February 2016

Speed, E. (2007) ‘Discourses of consumption or consumed by discourses? A

Page 20 of 29 12th February 2016

This free course was written by Bob Price.

Don't miss out:

Page 21 of 29 12th February 2016

Hickman et al (2009) discuss how such misconceptions can undermine

 The clinical scientist is worried about compromising rigorous test and

Page 22 of 29 12th February 2016

All of the points made in response to question 1 could contribute to collaboration

To illustrate this, imagine a healthcare organisation that is required to significantly

Page 24 of 29 12th February 2016

Page 25 of 29 12th February 2016

Figure 1: Accounts, narratives and practice

Page 26 of 29 12th February 2016

Figure 2: Gathering accounts, identifying