Narrative vigilance: the analysis of stories in health care

Abstract

The idea of narrative has been widely discussed in the recent health care literature, including nursing, and has been portrayed as a resource for both clinical work and research studies. However, the use of the term 'narrative' is inconsistent, and various assumptions are made about the nature (and functions) of narrative: narrative as a naive account of events; narrative as the source of 'subjective truth'; narrative as intrinsically fictional; and narrative as a mode of explanation. All these assumptions have left their mark on the nursing literature, and all of them (in our view) are misconceived. Here, we argue that a failure to distinguish between 'narrative' and 'story' is partly responsible for these misconceptions, and we offer an analysis that shows why the distinction between them is essential. In doing so, we borrow the concept of 'narrativity' from literary criticism. Narrativity is something that a text has degrees of, and our proposal is that the elements of narrativity can be 'sorted' roughly into a continuum, at the 'high narrativity' end of which we find 'story'. On our account, 'story' is an interweaving of plot and character, whose organization is designed to elicit a certain emotional response from the reader, while 'narrative' refers to the sequence of events and the (claimed) causal connections between them. We suggest that it is important not to confuse the emotional persuasiveness of the 'story' with the objective accuracy of the 'narrative', and to this end we recommend what might be called 'narrative vigilance'. There is nothing intrinsically authentic, or sacrosanct, or emancipatory, or paradigmatic about narrative itself, even though the recent health care literature has had a marked tendency to romanticize it.

Estudio de la calidad de la asistencia al moribundo en un hospital

“…Como narraciones testigo que con su verdad y pasión experienciales empujan al examen de prácticas médicas y preceptos éticos aceptados 17 . Las narraciones autobiográficas de los pacientes o las de sus seres queridos son importantes porque tienen un valor considerable como testimonio: Algunas de ellas ofrecen comentarios desde el punto de vista del paciente o de sus familiares sobre cuestiones éticas como la autonomía y el respeto por las personas, la veracidad y el consentimiento informado, la beneficencia y a veces incluso sobre la no-maleficencia 18 . En su forma ideal, la ética narrativa reconoce la primacía de la narración del paciente (o de su ser querido) 19 pero anima a que se escuchen diferentes voces y que surjan múltiples narraciones de aquellos cuyas vidas están implicadas en la resolución de un caso 20 : Paciente, familia, médico, enfermero, amigo, trabajador social, etc., pueden compartir sus narraciones en un coro dialógico 21 que puede ofrecer la mejor posibilidad de respetar a todas las personas implicadas.…”

Narratives in specialist palliative medicine

“…Understanding and developing our narrative skills with the aim of improving our comprehension of patients’ and our own experiences requires what Paley and Eva describe as “narrative vigilance” 22. They point out four misconceptions about narrative (p93–4).…”

“…First, recent nursing and medical literature have tended to romanticise the subjective stories of professionals and patients. These authors comment on the persuasive subjective details of patients’ stories that can be honest, moving, insightful and revealing but also mistaken, disingenuous, evasive and beside the point (Nelson, p xvi;11 Paley and Eva, p9322). The narrative form does not necessarily add credibility, and there is no methodological need for us to “believe” narrative accounts.…”

Understanding the Person through Narrative

“…Narrative truth refers to the phenomenon of having the core plot and meaning of a story subjectively consistent for the person telling it, while the actual historical events may differ; narrative approaches to the nature of subjective experience allow for multiple realities [38, 39]. Paley and Eva caution against romanticizing personal narratives, stating that there is no inherent authenticity about them, suggesting that caregivers be vigilant about how to use narratives as part of a history [40]. What is clear is that narratives cannot definitively reveal historical facts, but rather the meanings, life patterns, and emotional impact events have for clients.…”