Abstract
This paper proposes the need for further qualitative research to gain valuable insight into individuals’ experiences of health and illness and the suitability of narrative inquiry as a methodology to investigate these experiences. It is essential to increase qualitative knowledge of individuals’ experiences of illness in order to improve and personalise their care. Narrative inquiry aims to understand knowledge gained from the individual’s narrative of their experiences. Narrative inquiry explores experiences through the dimensions of temporality, sociality and spatiality. The aspect between these dimensions provides an exploratory structure for narratives surrounding health and illness: temporality – when did the illness begin, how will it influence the future; sociality – cultural and personal influences on views of illness; spatiality – surroundings, such as hospitals, and their influence on the health–illness perspective. Narrative inquiry not only provides a deep understanding of the investigated phenomena, it is also provides a rich vibrant narrative presentation of findings for the reader and user of research.
Introduction
People often tell stories of their illness and these narratives can be very informative and revealing. In 1992 Broyard wrote ‘storytelling seems to be a natural reaction to illness. People bleed stories…’,1(p.21) and in 1995 Frank reminded us ‘whether ill people want to tell stories or not, illness calls for stories’.2(p.55) Illness narratives can be studied to reveal further knowledge of what is important in the care of ill individuals. There is a need to recognise the unique individual person and not to undervalue their knowledge by objectifying and generalising their experience; this is especially true for the chronically ill person. Including the person’s illness
Positivistic research and biomedical models often dominate research in illness understanding, regularly overlooking the individual’s perspective. 4 Quantitative research can define, and support, clinical solutions such as medical outcomes and efficacy, although quantitative research seldom provides insight into an individual experience. 5 Positivist research, although very useful, has its limitations especially when exploring a person’s individual experiences. People’s experiences matter, but often traditional positivistic research investigates outcomes, ignoring the individual and not capturing the influence of the ordeal itself.
Background
The interpretive paradigm includes many methodologies, of which narrative inquiry is one. This paper will explore Clandinin and Connelly’s framework for narrative inquiry.6,7 Clandinin and Connelly have used narrative inquiry in educational research since the early 1990s.6,7 With an increased interest in narratives, a continued development and clarification of this methodology has followed.6–9 Narrative inquiry explores the experience of an individual and how social, cultural and environmental factors impact and shape the individual’s experiences. It explores knowledge gained from experiences. It is commonly used in sociology and educational research.8,10 The use of narrative inquiry as a methodology in nursing research is increasing and has been used in nursing research on topics such as supporting practice development in mental health,11–13 exploring relations in nursing14,15 and therapeutic relationships.16,17 The use of narrative inquiry research into nurses’ and family members’ experiences of a ‘fairy garden’ in a hospital setting revealed how through narratives social, cultural and environmental surroundings shape an individual’s experience.18,19 There is, however, limited research into patients’ experiences of illness; something narrative inquiry is well suited to explore.
Narrative inquiry is a qualitative methodology that takes into account the relationship between participant and researcher. It is a compassionate methodology. The inclusion of social, cultural and environmental influences on illness understandings makes narrative inquiry very suitable for research in health as it incorporates all dimensions that impact the individual’s health experience.20,21 These experiences are captured in the living and telling of narratives, and can be studied by listening, observing, reading and interpreting text. Narrative inquiry is a way to understand experience and a way to study experience.6–9
Aim
This paper proposes the need for further qualitative research to gain valuable insight into patients’ experiences of health and illness and the suitability of narrative inquiry as a methodology to investigate these experiences. It is essential to increase qualitative knowledge of patients’ experiences of illness in order to improve and personalise their care.
Narrative inquiry
Narratives, or stories, are part of our lives, supporting our understanding of experiences as our narratives are interrelated in time, environment and culture; reflecting our understanding of an event.6–9 Narrative inquiry’s relational perspective within the research process, gives participants time to build a relationship with the researcher and share their narrative. This has the potential to provide a relationship that could offer the participants the security needed to be truly open in their narrative, and by that give a deeper understanding of their illness experience.
Polkinghorne, 5 Riessman, 22 together with Clandinin and Connelly6,7 are amongst research scholars promoting narratives as a research methodology. Polkinghorne refers to the tensions between available academic research and his work as a clinician, and highlights the need for research that would support his clinical work, and considers narrative knowing as an important path to knowledge in the human sciences. 5 Riessman describes narratives as composed for an intended audience in a particular culture; hence they can be interpreted and investigated to find social undertones and explanations for events. 22 Connelly and Clandinin explore the participant’s experience of the event under investigation to gain experiential knowledge.6,7 In contrast to many interpretative methodologies narrative inquiry does not ‘dissect’ the narrative into smaller units to find themes and trends but instead analyses the narrative as a ‘whole’ seen from temporal, social and spatial perspectives. 9
Ontology
The ontological perspective of narrative inquiry emphasises the holistic and relational nature of one’s being, attending to the relation between the researcher and the participants during the research phase. The narrative experience is a continuous link between past, present and implied future within the social, cultural and environmental contexts. 9 In carrying out narrative inquiry, researchers are co-constructing their own lived experience as researchers in their social world which they will share with the participants and also in their findings.7,9 It is important to keep the narratives intact and not to dissect the person behind the narrative. 9
Relational framework of temporality, sociality and spatiality
Clandinin and Connelly’s framework of narrative inquiry highlights the dimension of temporality (time), sociality (people, social influences) and spatiality (space, environment) as central in the narrative exploration and presentation of research.6,7 The narrative is framed, and always in relation, within these three dimensions and the influence between them impacts on the narrative, hence the researcher attends to the relations and interweaving influences between these dimensions in the narrative as they conduct their research.7–9
Temporality: Past, present and future
It is human to make sense of experiences by telling stories and people live a continuous narrative. The narratives told are often experiences from the past, but as these narratives are communicated, the experience will be remembered and changes will be made to accommodate for similar experiences. This temporal aspect will also allow for the social change that happens over time. When people look back at narratives they experienced some years ago, the social changes becomes apparent and what seemed socially accepted then might no longer be so. Past experiences will have an influence on how a patient experiences their present situation and previous encounters in healthcare influence how they perceive their future.7–9
Sociality: The personal, social and cultural
Narratives are central to our identity and self; our experiences are understood through narratives – not necessarily verbalised. We think and dream narratively. Narratives always have a social tone, depending on who the audience is the narrative will change. While telling and listening to narratives, people narratively construct, and repeatedly re-construct, their identity and who they socially are connected to evolves. When a person is able to elaborate on their own experience and provide their personal narrative, this allows them to highlight what is important to them and thus provides vital information for further care. A person’s narrative will be influenced by the audience, be it a researcher, a family member or a stranger, they will undoubtedly influence how the narrative is told and what the person is willing to include in their narrative.7–9
Spatiality: Place and environment
The environment – spatiality – will also influence how an event is experienced by the person involved. Understandings from institutions, such as schools and hospitals, will also impact on the participant’s experience. Cultures build their social backgrounds by how people understand and identify their environment. This will be reflected in their narratives, and environments are often described in great detail. Later, when the experience is narrated, the environment in which the narrative is told will also influence how it is presented.7–9
The visibility of the interconnectedness of the three dimensions is obvious; where (spatiality), when (temporality) who and why (sociality) becomes vital parts of the persons narrative. As the researcher views the relationships between all these components, a deeper understanding of the event will become clear and commonalities between different persons’ experiences becomes visible and this can inform and highlight storylines that might have been previously concealed.7–9
Emplotment
Emplotment is the amalgamation of multiple interviews/conversations into one narrative that encompasses the events discussed, presented in a sequence that creates a narrative plot. 23 A narrative without a plot would be a string of words with no beginning or ending.23,24 A plot highlights events and moves the narrative forward. The promotion, and collection, of people’s narratives about their health could contribute to improved care and thereby person satisfaction. The emplotment of these, often short, narratives will create informative narratives of people’s realities, improving person–nurse communication. Emplotment offers a way of transforming fragmented, scattered and sometimes contradictive communication into understandable narratives. 23 In addition, the therapeutic properties of storytelling should not be underestimated. Often a narrative is told more than once and each time the ‘reality’ of the narrative becomes clearer, both for the narrator and the listener. The retelling of the narrative could support the person in this endeavour and support healing.23,24
Relational research
Narrative inquiry investigates a person’s experience of an event and what the person finds to be most important. Narrative inquiry creates a narrative using the participants’ experience moulded together through the three dimensions of narrative inquiry with the researcher to construct an emplotted narrative where participants’ narratives create a vibrant and deep exploration of their experiences of illness. 9 The construction of a storyline is one feature of narrative inquiry that creates an informal presentation of findings. In order to create such a narrative the relationship between researcher and research participant becomes vital for an authentic outcome. Narrative inquiry using Connelly and Clandinin’s framework recognises the importance of this relationship and does not see the researcher as a silent observer.7–9 Josselson emphasises the importance of this holistic view and considers collaboration with the participant as central in the final presentation of the research narrative. 25 In health research, where individuals are often in a dependent and vulnerable situation, the opportunity to create an equal relationship between researcher and participant could improve the openness of their narrative.
Ethical consideration
The relational aspect of narrative inquiry creates a deeper connection between the researcher and participant. This trust and rapport created together with the participant will build a research relationship where personal memories and experiences can be described in great emotional detail and their can be importance explained. 25 As the relationship evolves, further and deeper narratives will be encountered and the researcher needs to pay particular attention to the ethical aspects of working with the collected data. The inclusion of the participant’s views during the data exploration contributes to the ethical soundness of narrative inquiry. The narratives presented should reflect the degree of openness and self-disclosure the participant felt was appropriate during their participation in the research. 25
Discussion
As Polkinghorne points out, there is a need to create a better understanding of the person’s experience, not by studying numbers and statistics. 5 People are individuals and should be allowed to express their narratives, and researchers need to be able to listen to them and incorporate this new knowledge as clinicians. To be able to verbalise the illness experience often allows a person to gain a better understanding of their situation and improve their quality of life.2,26
Although three dimensions – temporality, spatiality and sociality – form a narrative, and can be considered separately, they are always in a relationship to each other. In some narratives the sociality might have the strongest influence, and at other times possibly the spatiality will be the dominant influence of the narrative and it is these relational influences that give depth to this methodology. Their narrative might not be an entirely authentic recounting of the event, but it is the reality the person experienced. 9
Narrative inquiry can assist the researcher and participants to form a relationship of trust that can better assist other health professionals to cater for the needs of individuals. Some noticeable factors set narrative inquiry approach apart from other methodologies;8,9 the absence of a research question is one such factor of difference. Instead, narrative inquiry researchers see research as a puzzle where both researcher and participant add pieces to the ‘whole’ to create a clearer picture of the sought after experience. 9 There is a notion that experiences will change and that there is no absolute truth to be found. The understanding of experiences as narratives and findings from these narratives will support and strengthen future knowledge and education as well as informing practice. 9
Another noticeable difference is how the data are presented. The finished product is in itself a narrative belonging to both the participant and the researcher as it contains the narrative from the participant framed by interpretation from the researcher. This amalgamated narrative contains the temporal dimension (experiences from the past and visions for the future), sociality (how the narrative is presented in the cultural and social environment), and spatiality (the narrative includes a description of surroundings, sometimes both where the narrative was experienced and where the narrative is told).8,9
A further consideration in the use of this methodology is the acceptance of the relationship a researcher and participant will form during the data collection. This relationship will continue during the writing phase where the participant will have an input to the finished product.9,25 These factors create a finished narrative that is different from other methodologies in healthcare research. The result is a longer, more detailed finished presentation with fewer participants. Narrative inquiry has its roots in the humanities and social research where it is accepted and understood. In healthcare the norm tends still to be quantitative research for development of best evidence-based practice with an embedded absolute truth, often eliminating the individual experience and what matters to the person.
Conclusion
Narrative inquiry provides a framework well suited for health research and the relational structure of narrative inquiry can provide a deeper and broader exploration of a person’s experience. Living with a chronic illness or surviving an acute illness can be a life-changing experience and these narratives of illness are descriptions of an individual’s experience of their situation, reflected by surroundings, such as hospitals, previous illness and life experience. Hence a person’s narratives provide a deep detailed view of their illness experience and inform how we can best provide future care. There is a need for more qualitative research to improve and integrate tailored and holistic care for the ill individual. The relational properties of narrative inquiry provide both researcher and participant with a foundation to engage and develop connections, and through this to establish a deeper and broader understanding of the phenomena under investigation.
The ontological nature of narrative inquiry reflects the creation of a narrative and the results; throughout the research both researchers and participants are influenced and changed in one way or another. The presentation of findings as emplotted narratives creates an insight into the personal experiences under investigation. With few participants and longer involvement in the research process, these narratives reflect the three dimensions of temporality, sociality and spatiality, exposing how time, culture and environment influence both participants’ and researchers’ experiences. The presentation of the completed research in a narrative form could make findings available to a broader audience.
Narrative inquiry not only provides a deep understanding of the investigated phenomena, it is also provides a rich vibrant narrative presentation of findings for the reader and user of research.