Reflexivity and Relational Spaces: Experiences of Conducting a Narrative Inquiry Study With Emerging Adult Women Living With Chronic Pain

Abstract

Clandinin and Connelly’s narrative inquiry methodology was used to understand the lived and told stories of two emerging adult women (aged 18–29) living with chronic pain. The aim of this paper is to share the experiences of the first author—a graduate student and novice researcher—of creating relational spaces with emerging adult women living with chronic pain, and the experience of co-creating knowledge through the methodological lens of narrative inquiry. There are 12 qualitative touchstones that narrative inquirers attend to when using narrative inquiry, and we present the experiences of a novice narrative inquirer in relation to selected touchstones. Narrative inquiry can greatly contribute to nursing knowledge, and implications for nursing practice and research are discussed.

Keywords

chronic pain emerging adult women identity methodology narrative inquiry nursing qualitative young adult women Canada

Chronic pain is the third-largest health problem worldwide, and women are disproportionately affected (Ballweg et al., 2010; Finley et al., 2018; Malin & Littlejohn, 2012). Unfortunately, researchers often alter or fragment the stories of those experiencing pain, illness, or disability, thereby silencing their voices and experiences (Holloway & Freshwater, 2007). Qualitative research is valuable in understanding lived experience, yet the storied landscape of chronic pain remains primarily quantitative in nature. Since the experience of chronic pain is highly individual, narrative inquiry is an ideal methodology for exploring and understanding the lived experience of individuals with chronic pain. Additionally, the researcher’s personal and practical justifications for the research often drive their motivation for the inquiry, making the experience of conducting Clandinin and Connelly (2000)'s form of narrative inquiry unique since the inquiry is shaped by past, present, and future experiences of both the researcher and participants. Narrative inquiry requires that the researcher metaphorically places themselves alongside the participants, practicing deep reflexivity while living and being in the relational inquiry space (Clandinin & Caine, 2013). While this profound self-reflection may be difficult for some researchers, the researcher’s personal and practical justifications for the research often drive their motivation for the inquiry (Clandinin & Caine, 2013).

An important aspect of analyzing and interpreting individual health and illness experiences, such as chronic pain, is understanding how social landscapes shape them (Bloomberg & Volpe, 2018). Although narrative inquiry has the potential to capture the complex and personal nature of health and illness experiences, few researchers have used Clandinin and Connelly's (2000) specific form of narrative inquiry to study chronic pain (MacDonald, 2006; Siemens, 1999). Narrative inquiry, much like nursing practice, is not a straightforward process; there is no exact linear process, and the abstract methodology can be challenging for some researchers to grasp (Lindsay & Schwind, 2016). While the use of narratives in research is not new, the application of Clandinin and Connelly's (2000) specific form of narrative inquiry within nursing research is a relatively recent development (Wang & Geale, 2015). Given the highly relational aspect of nursing practice and the importance of understanding patients’ lived experiences, nursing researchers can greatly benefit from using Clandinin and Connelly's (2000) form of narrative inquiry as a methodology for conducting qualitative research.

A narrative inquiry study was conducted with emerging adult women living with chronic pain (Finlay, 2022). The aim of this paper is to share the researcher’s experiences in forming relational spaces with the participants and co-creating knowledge through the methodological lens of narrative inquiry (Clandinin & Connelly, 2000). First, we describe the methodological approach and methods used in the narrative inquiry study. Then, using our study for context, we offer insights into the first author’s experience of conducting a narrative inquiry as a novice researcher. We explore the reasons for selecting narrative inquiry as a methodology, challenges and opportunities present at some of the touchstones of narrative inquiry, and the ongoing reflexivity required by the researcher throughout the research process. We pay close attention to the methodological commitments of narrative inquiry and offer an understanding of some of the key tenets, or touchstones, of narrative inquiry.

Methods

Narrative inquiry serves both as a research methodology and a means of understanding experience (Clandinin & Caine, 2013). It centers on the idea that experience is a social phenomenon, evolving through the telling and re-telling of stories. Thinking narratively often challenges the dominant narrative of a phenomenon, which is a widely accepted story that influences how people perceive and interpret a specific experience (Clandinin, 2007; Clandinin & Connelly, 2000). In the context of health and illness experiences, the dominant narrative impacts how individuals understand and respond to such experiences. The researcher-participant relationship is pivotal in narrative inquiry and is cultivated through the telling and sharing of stories (Bloomberg & Volpe, 2018).

Methodological Approach: Narrative Inquiry

While other qualitative approaches such as phenomenology and grounded theory analyze themes that emerge from data, narrative inquiry explores the storied experiences of individuals. Both narrative inquiry and qualitative case studies involve in-depth exploration of complex phenomena; however, narrative inquiry focuses on understanding experience as told through story in the context of time, place, and sociality. This allows for a deeper understanding of how personal, social, and cultural narratives intersect and shape individual experiences. The focus is not on finding a definitive answer, rather, the research puzzle evolves throughout the inquiry as new data is generated and analyzed (Clandinin & Caine, 2013). Our research puzzle pertained to how the experience of living with chronic pain influences the identity of emerging adult women.

Setting, Recruitment, and Sample

Through purposive sampling, participants who can share their experiences of the phenomenon under study are invited to participate in narrative inquiry. In our study, the first author worked with several clinics who provide care to women living with chronic pain. Typically, in narrative inquiry, a small number of participants is recommended to allow for multiple, in-depth conversations (Clandinin, 2007; Kim, 2016). Inclusion criteria were determined in relation to our research puzzle and phenomenon under study, and is as follows: aged 18 to 29, female sex and identifying as a woman, self-report living with persistent non-malignant pain for greater than 3 months duration at the time of recruitment, speaks English, has sought health care related to the pain, and able to provide informed consent for study participation. Two participants who met the inclusion criteria were included in the study after an informed consent process was completed. The study received ethics approval from the University of Calgary Conjoint Health Ethics Board (REB21-0540).

Data Generation

In narrative inquiry, data collection is referred to as data generation to recognize the active co-creation of narratives that involves both the researcher and participant (Clandinin, 2016). The main method of data generation in our narrative inquiry was in-depth conversations with each participant. Each conversation lasted 1 to 2 hr and was conducted virtually due to the COVID-19 pandemic; each participant met with the first author for four conversations as part of data generation. Field texts included conversation transcripts, the first author’s field journal, participant artwork, pain journals, essays, poetry, and researcher-created annals¹ used as study artifacts² (Clandinin, 2016).

Data Analysis and Research Texts

To understand how participants’ identities have evolved over time in the context of place, social interaction, and social landscapes, Clandinin and Connelly’s (2000) conceptual framework of the three-dimensional narrative inquiry space is used for data analysis. The three-dimensional narrative inquiry space comprises three commonplaces central to the inquiry: time/continuity (the dimension of past, present, and future), sociality/interaction (the personal and social dimension), and place (the dimension of place/situation) (Clandinin & Connelly, 2000; Clandinin et al., 2007; Connelly & Clandinin, 2006; Green, 2013).

Field texts were analyzed using this three-dimensional space and shaped into interim research texts, followed by final research texts (Clandinin & Connelly, 2000). This process is not linear, as transitioning field texts to research texts through analysis in narrative inquiry is an evolving, reflective process where the researcher searches for meaning and understanding of field texts in relation to the research puzzle (Clandinin, 2016; dela Cruz, 2014). In our narrative inquiry, research texts became the retelling and discussion of participant experiences living with chronic pain, and the master’s thesis became the final research text (Clandinin & Connelly, 2000). Interim research texts were shaped by analyzing transcripts according to methods described by Clandinin (2016). Stories took shape in written form over a period of time, marked with the first author immersing into field texts, and were formed and retold from conversation transcripts and other field texts, using field journal notes to assist in interpretation of narrative meanings (Clandinin & Caine, 2013; Nasheeda et al., 2019).

After retelling each participant’s narrative account, the first author engaged in a process of reading and rereading transcripts and narrative accounts within the three-dimensional narrative inquiry space to identify narrative threads³ that resonated across participant narrative accounts (Clandinin, 2007; McLeod & Lynch, 2000). Narrative threads, also known as resonant threads, are central narratives or patterns that reverberate across individual narrative accounts and form the beginning of final research texts for dissemination (Clandinin et al., 2019).

Trustworthiness

To ensure trustworthiness of research findings, conversations were had with participants throughout the research process to negotiate meaning and establish accuracy. Interim research texts were used to engage participants in follow-up conversations, solidify interpretation of their narratives, and led to generating more field texts as needed to ensure authenticity (Clandinin, 2016). Follow up communication with participants occurred until narrative accounts were finalized with each participant. This allowed final texts to accurately reflect participants’ stories and meanings interpreted from their narratives. In addition, to enhance trustworthiness, feedback and guidance was obtained through participation in a relational response community, a critical aspect of narrative inquiry to share and discuss final research texts with other narrative inquirers (Clandinin & Caine, 2013).

Through engaging in discussions with their supervisor, supervisory committee, and colleagues in a narrative inquiry reading group, the first author received responsive feedback and further examined how their experiences and those of participants have been shaped in relation to the research puzzle. Another important component of the first author’s development as a narrative inquirer was a graduate course on narrative inquiry, where they discussed field texts, their narrative beginnings, and other reflective writing to better understand the complexities of their narrative beginnings and our research puzzle. These relational response communities were intentionally created and encouraged theoretical and methodological development of the narrative inquiry.

Relational Responsibilities and Spaces in Narrative Inquiry

In this section, we now turn to the uniqueness of narrative inquiry with respect to the steadfast responsibilities of the narrative inquirer in creating and sustaining relational spaces within the narrative inquiry. We focus on the experiences of the first author as they cocreated, negotiated, and attended to these relational spaces. The first author’s experience in conducting this study is explored in relation to some of the touchstones of narrative inquiry (Clandinin & Caine, 2013)—markers that demonstrate the methodological commitments in narrative inquiry. First, we explore the motivations behind the first author’s decision to take up narrative inquiry as a research approach. Second, we discuss challenges and opportunities present at two of the 12 touchstones of narrative inquiry. Finally, we offer insight into the first author’s ongoing reflexivity while conducting the narrative inquiry and writing a masters’ thesis.

Selecting Narrative Inquiry

The first author intentionally selected Clandinin and Connelly’s (2000) form of narrative inquiry over other qualitative methodologies for their master’s research study. Access to narrative inquiry experts at affiliated and nearby institutions was an influencing factor in deciding to use narrative inquiry, however, played a minor role in the context of several other reasons.

First, narrative inquiry as a research methodology allows for a collaborative, relational approach; it does not begin with an established research question accompanied by an expected answer. The power of story was further evident to the first author when reviewing other narrative inquiries that explore disability experiences. The first author wanted to look at identity and human experience yet needed to do so in a way that emerging adult women, who have learned to silence their stories, would be able to open up and guide the first author in the direction to understand what has shaped their experience and identity in living with chronic pain. Recognizing that experiences told through story can help to understand how individuals make sense of their illness, and that narrative inquiry would allow participants so share their emotional and physical experiences with pain over time without dissection, the first author felt narrative inquiry would be well-suited to understand the complex and stigmatized experience of living with chronic pain. Since experience is understood as a social phenomenon in narrative inquiry and chronic pain is contextual, narrative inquiry was further chosen due to its emphasis on understanding how social landscapes enable or constrain the individual. For the first author, understanding how meaning is made from experience and what factors influence identity became key aspects of the methodology that supported data generation and analysis.

Second, the first author’s lived experience with chronic pain as an emerging adult woman meant they were well-positioned for this narrative inquiry and this personal experience likely assisted in establishing rapport with the participants. The practice of bracketing by researchers—remaining objective during the research process by suspending their personal biases, values, beliefs, and experiences—is not practiced in narrative inquiry. Instead, the narrative inquirer becomes part of the narrative inquiry study as an active participant, alongside the research participant, for without understanding who we are as the narrative inquirer, we are not “awake to the way we attend to the experiences of research participants” (Clandinin & Connelly, 2000, p. 36).

While the first author had personal ties to the research topic, it was not until writing their research proposal that it became clear that narrative inquiry was the ideal research methodology for a topic where bracketing is not realistic or compatible with the methodology, for the researcher’s narrative beginnings provide a foundation for the relational space that the inquiry takes place in. The emphasis on self-reflection in narrative inquiry appealed strongly to the first author and offered unique insights into the participants’ experiences alongside the first author’s.

Third, narrative inquiry is a choice qualitative methodology when little known about a topic. Clandinin and Connelly’s (2000) form of narrative inquiry views experiences through storytelling as knowledge, and allows for one to start with a broad inquiry to focus on the experiences that are important to the participant. In this way, the first author was able to evolve and shape the inquiry throughout the research process as they co-created data with the participants. The first author chose a research topic that had personal meaning; rather than eliminating themself from the research, narrative inquiry values the researcher’s reflections and experiences, encouraging intense reflexivity to help understand the participant’s experiences and co-create data. This also allows for the touchstone in narrative inquiry of mutual vulnerability, allowing for authenticity alongside the participant to encourage genuine sharing of stories and experience.

Touchstones of Narrative Inquiry: Challenges and Opportunities

There are 12 qualitative touchstones of narrative inquiry that serve as markers for the methodological commitments of a researcher engaged in narrative inquiry. These touchstones represent the philosophical foundations and methodological commitments of narrative inquiry and the narrative inquirer. Furthermore, commitment to the touchstones of narrative inquiry supports the ethical and rigorous conduct of narrative inquiry (Clandinin & Caine, 2013). In this section we focus on two selected touchstones of narrative inquiry, relational responsibilities and narrative beginnings, as experienced by the first author in working alongside women living with chronic pain.

Relational Responsibilities

One of the central tenets of narrative inquiry is the relational spaces and accompanying responsibilities that are located within the research space. Relational responsibilities in narrative inquiry refer to the ethical considerations and steps taken to establish and maintain ethical researcher-participant relationships (Clandinin & Caine, 2013). It is important to understand narrative inquiry spaces as spaces of belonging for both researchers and participants; spaces that are continually marked by ethics and attitudes of openness, mutual vulnerability, reciprocity, and care (Clandinin & Caine, 2013).

One challenge to creating the narrative inquiry space for this study was the COVID-19 pandemic. Due to public health recommendations at the time of data generation, the entirety of the inquiry space was created virtually via Zoom. Rather than meeting in a room on-campus (where the participants would metaphorically enter the researcher’s world) or visiting participants in their respective homes (where the researcher would be entering the participant’s space), a virtual inquiry space was created together. This virtual Zoom space allowed for the researcher and participant to see into each other’s world through glimpses into each other’s homes. The balance of power somehow felt more equal this way, despite not being able to physically come alongside participants “in the midst” (Clandinin & Caine, 2013, p. 169) of their lives. Still, we wonder how the first author might have come to know the participants differently if they had not been restricted to Zoom.

Entering the narrative inquiry space with the participant came with a sense of vulnerability for the first author in different ways. For example, even with many years of nursing practice in sexual health, the first author felt a sense of humility entering the narrative inquiry space with each participant. Despite years of professional nursing experience, the first author discovered with each participant the evolving landscape of chronic pain, the experiences shared through stories for each participant, awakening to shared moments of vulnerabilities with research participants. In addition, the first author experienced tensions within the narrative inquiry space as they lived relationally alongside with each research participant. For example, prior to embarking on the narrative inquiry journey, the first author reflected on their socialization as a nursing student and in professional nursing practice as it relates to setting boundaries with patients and people in practice. Nurses are often socialized to uphold strong professional boundaries between their personal and professional lives. For the first author, this created tensions within the narrative inquiry space, initially struggling to embrace the relational way of being with each participant, and eventually the experience of shared vulnerability within the narrative inquiry space:

For so long, I had been conditioned not to speak of my disability. It lived in a separate consciousness—omnipresent, but only known to me, never public. However, last fall, when I chose narrative inquiry as my research methodology, I gradually accepted that I needed to share this part of my lived experience [. . .] Today I met with [participant name] via Zoom for the first time. I was nervous [. . .] How much do I share about me? Do I share my own diagnoses at all? [. . .] I thought a lot about mutual vulnerability again. How much of myself do I share? I try to remember that I am a researcher here, here to learn of her experiences. Yet so often, I relate entirely to her experiences. (Finlay, 2022)

Narrative Beginnings

In the journey of conducting narrative inquiry work, the first author attended to their own narrative beginnings, reflecting on their experiences as a registered nurse and as a woman living with chronic pain. The experience of attending to narrative beginnings often brings the narrative inquirer into a state of vulnerability, making public their personal justifications and reasons for undertaking a narrative inquiry study about a particular phenomenon. Initially, it was difficult for the first author to disclose their lived experience with chronic pain until they understood the importance of their own stories in the research, valuing their experience as an integral component of the narrative inquiry (Clandinin & Caine, 2013).

Reflecting on one’s narrative beginnings is an important first step in embarking on a narrative inquiry study alongside people with lived experiences; placing oneself alongside research participants led to deep reflection and self-exploration, and in positioning oneself within a shared relational research space. The journey of discovering one’s narrative beginnings can be challenging and difficult for several reasons. For the first author, there was deep contemplation of how much of their own narrative beginnings they were willing to share with participants.

The tensions of being in a shared relational research space were accompanied with deep reflection and the practice of wakefulness (Clandinin et al., 2018). Wakefulness (Greene, 1977) refers to being wide-awake, attentive, and curious to the layers of complex experiences made visible in narrative inquiry. Being wakeful opened opportunities to shared vulnerability, fostering a deeper commitment to the narrative inquiry by both the researcher and participant. In discovering one’s narrative beginning at the outset of narrative inquiry work, often the narrative inquirer experiences a sense of vulnerability, being wakeful to the personal significance of the phenomenon studied through narrative inquiry. Sometimes, one’s narrative beginnings are connected to the narrative inquirer’s very personal connections to the phenomenon understudy. In addition, such vulnerabilities are linked to the potential of making one’s personal connections to the narrative inquiry visible to others, including the participant.

I, too, have learned to hide my personal stories not just in my work and school life, but also my family life, with many friends, and most strangers. The biggest secret recently was my illness—I have lived with widespread, chronic, and debilitating pain since age 15, which has gradually worsened and resulted in no longer being able to do many of the activities I love. Only in the last few years have I received some answers around the cause of my pain, and this year I received a clinical diagnosis of Ehlers-Danlos syndrome. Why is this relevant? The part of me that lives, and has lived, with constant pain, is part of my narrative beginnings, and part of what brings me to my Master of Nursing research. (Finlay, 2022)

Ongoing Reflexivity During Transition to Final Texts: “World Traveling” as Researcher and Patient

Maintaining reflexivity in narrative inquiry and examining one’s own positionality is also an important relational responsibility of the narrative inquirer. For the first author, composing a thesis as the final research text of this inquiry led to both challenges and profound reflexivity, much of which has influenced who they are as a narrative inquirer, registered nurse, and future doctoral student. Challenging their own narratives around professional boundaries and academic research complemented over 100 pages of reflective field journal notes and autobiographical writing composed since beginning data generation.

Throughout writing their thesis, in pivoting their nursing practice as a sexual health nurse to a qualitative chronic pain researcher, the concepts of mutual vulnerability, “world traveling,” wakefulness, and merging identities became frequent ruminations as the first author returned again and again to the ontological commitment of narrative inquiry and its commonplaces of time, sociality, and place. The first author was reflecting on readings for a narrative inquiry discussion group 1 day when they began to notice strong emotions:

I was contemplating again my reasons for doing this work—my personal, practical, and professional justifications. I felt the responsibility in retelling [participant names]’s stories. I felt passionate about doing this work, but also immense pressure.

The thoughts I had reminded me to return to the question of who I am in in this inquiry, to practice wakefulness. How was I positioning myself as the researcher, someone with lived experience of chronic pain, and a registered nurse? A strong personal and social justification was to improve the experiences of others with chronic pain navigating the world, by making visible the experiences of [participant names]. There were narratives that could further the dominant narrative about women with pain as malingering; I wondered, “should I exclude those narratives?” (Finlay, 2022, p. 132–133)

By wanting to increase awareness of the challenges that emerging adult women with chronic pain face, it would have been easy to exaggerate the participants’ negative experiences accessing health care while making less visible their positive experiences. One of the first author’s reflective journal entries read:

I think about how I will write about our time together in my thesis. I do not want to silence [participant]’s stories of emotional pain: of self-harm, trauma, a teenhood marred by psychiatric admissions. These stories are part of her personal journey, and her physical pain is intricately linked backward and forward to her mental wellness journeys. (Finlay, 2022)

Recalling Lugones’ (1987) metaphor of world traveling, the first author kept close the narrative inquiry touchstone of “coming alongside in the midst” (Clandinin & Caine, 2013, p. 34) and situated themself in being attentive to their own worlds, the worlds of each participant, and the worlds that were co-composed by themselves and the participants (Clandinin & Caine, 2013; Dewart et al., 2020). The process of identity formation, reflection, and completion of the final texts were a deeply reflective process at times that was both taxing and transformative:

Yes, disability is a spectrum, and pain is invisible, but the world is not designed for us. We adapt to the world instead, and there are costs. I have learned this from [participants] and I see the world a little bit differently now. I see it from the perspective of someone with a disability doing their best to navigate an environment that is not designed for them. I see it from the perspective of someone that lives in a world that does not see them. The knowledge [participants] shared will stay with me long past the time we remain in contact, and I wonder in what small ways I have shaped their lives, too. I hope that they feel seen. (Finlay, 2022, p. 138)

In sharing their own stories of living with chronic pain throughout the research process, the first author experienced a sense of unburdening and freedom in allowing their previously hidden chronic pain to become visible. In becoming a narrative inquirer, they have also learned to listen to the silences in conversation: silences that suggest silenced voices and stories untold. This inquiry has helped the first author to be more attentive to the needs of others, while validating some of their own experiences that are similar to the participants’.

Discussion: Narrative Inquiry and Contributions to Nursing Knowledge

It has been argued that nursing science would greatly benefit from using narrative inquiry as a methodology in research (Green, 2013; Lindsay & Schwind, 2016; Wang & Geale, 2015). Several nurse researchers have conducted Clandinin and Connelly’s (2000) form of narrative inquiry to generate knowledge pertaining to people’s experiences of identity (Caine, 2007; dela Cruz, 2014; Dewart et al., 2021; Estefan et al., 2019; Smith et al., 2018). As the affective emotional aspect of chronic pain is highly personal (Barnes et al., 2018; Smith & Sparkes, 2009), narrative inquiry is a valuable methodology to understand the complex experience of living with chronic pain. By understanding how participants make sense of their experiences through stories, how chronic pain has shaped, and continues to shape, the identity of emerging adult women can be understood.

Narrative inquiry also aids in understanding topics were little is known, and, to re-examine dominant narratives about a phenomenon. Furthermore, inquiring narratively into a stigmatized phenomenon may reduce dominant narratives that contribute to marginalization, by challenging what is assumed to be true about the population under study. There is a power in story, and narratives can help illuminate the complex and dynamic nuances of a health experience without decontextualization (Wang & Geale, 2015).

Finally, the methodology of narrative inquiry is symbiotic with researchers who posit personal or practical experience on a topic. As Clandinin and Connelly (2000) iterate, without understanding what brings each of us to research puzzles, we run the risk of entering into relationships without a sense of what stories we are living and telling in the research space. There is a reciprocal shaping of both the researcher and the research when conducting narrative inquiry, and this allows for rich data to be generated when the researcher has personal or practical experience with the research topic, allowing for deep reflexivity and a strong rapport with the participants. What arises is an ontological commitment to the methodological touchstones of narrative inquiry and a new understanding of experience. Narrative representation of research findings, including narrative inquiry, is increasingly being seen as a means for knowledge translation in nursing and health sciences (Clandinin & Caine, 2013). As a novice narrative inquirer, the first author also observed a shift in their nursing practice from inquiring narratively into the lives of others:

My practice as a registered nurse has also been shaped by this inquiry. I have begun to challenge some of the boundaries created by institutional narratives that exist between the patient and healthcare provider, finding ways to inquire meaningfully alongside patients in my professional role. [. . .] I realized that this narrative inquiry has shifted the way I attend to relational ethics outside of my graduate work, helping me to “understand more deeply the ways that moving slowly allow the possibility of living and listening” (Clandinin et al., 2018, p. 94). Subsequently, my desire to continue challenging the dominant social, cultural, and institutional narratives in each world I inhabit has only been fueled further. (Finlay, 2022)

Many pain leaders in North America leaders describe personal experience with pain as a significant motivator for influencing change, and literature suggests that personal stories of pain should be embraced in the training of future pain leaders (Carr et al., 2016). Examining one’s own personal, practical, and social justifications of a narrative inquiry is a prerequisite to beginning the inquiry, and these justifications are revisited throughout the inquiry process (Clandinin & Connelly, 2000). Hence, narrative inquiry is a beneficial methodology to explore phenomena that cannot be separated from the personal, practical, or social experiences and knowledge of the researcher themselves.

Implications for Nursing Practice and Research

There are several implications for nursing that arose from this narrative inquiry. Here, we focus on relational considerations and implications for nursing research. Findings from our narrative inquiry indicate emerging adult women may not feel comfortable bringing up their pain concerns with health care providers due to stigma, previous experiences of dismissal, and power dynamics in the patient-provider relationship. Dismissal and disbelief about chronic pain from friends, family, and health care providers are stigmatizing and can lead to shame, self-blame, and demoralization (Bernhofer et al., 2017; Carter, 2002; Werner & Malterud, 2003). In our experience, participant experiences of invalidation of pain from family and health care providers shaped how the participants story themselves, viewing their own pain experiences as less valid and silencing their pain experiences to avoid being dismissed by others.

The importance of validation, communication, and empathy when caring for emerging adult women with chronic pain highlights the need for authentic relational practice in nursing. When adequate communication and education were absent from the participants’ experiences of pain in places of health care, negative perspectives of the health system were perpetuated and inferior care outcomes resulted, shaping future interactions of dismissal and disappointment with health care providers. The participants from our narrative inquiry revealed how they felt validated in reading the narrative accounts that we co-created, and how they felt seen. This reinforces the importance of understanding the individual through their experiences across time, place, and relationships not only in the narrative inquiry space but in spaces of health care to improve the therapeutic relationship and ultimately lead to more holistic, effective care for emerging adult women living with chronic pain.

Findings from this study also indicate family relationships have a significant impact on individual pain beliefs during adolescence and emerging adulthood; in this study, those family relationships were primarily mother-daughter relationships. Hence, nurses can improve patient care by fostering the family’s understanding of their child’s pain. Family nursing theories emphasize the importance of collaborative family relationships in illness management (Kaakinen et al., 2018; Kokorelias et al., 2019; Leahey & Wright, 2016; Lyons & Lee, 2018). Effective family functioning enhances patient and family quality of life, and nurses can assist to improve holistic care outcomes within the context of familial relationships (Lyons & Lee, 2018).

Considering little qualitative research exists on the specific impact of chronic pain in emerging adults, the research considerations that arose from our narrative inquiry are vast. Given the invalidation of pain in emerging adults and a lack of tailored services toward this demographic, nursing interventions tailored to emerging adults—and women—should be offered. In addition, availability of interdisciplinary services outside of work and school, age specific support groups, and discussions around topics of importance to this age group (e.g., identity, self-management, body image, side effects of medications, pain and sleep, navigating relationships and sexuality) should be considered when developing care pathways.

Since much of the literature on chronic pain focuses on middle-aged to older individuals, more research on chronic pain is needed on emerging adults and emerging adult women, who have unique pain experiences (Brown et al., 2021). Canadian research lacks emphasis on a holistic understanding of the pain experience (Canadian Pain Task Force, 2019) and emerging adult women with chronic pain are a particularly understudied population (Hirsch, 2018). Additionally, individuals with chronic pain may be more vulnerable to challenges faced during emerging adulthood (Twiddy et al., 2017).

Longitudinal studies could address existing gaps in knowledge on etiology, incidence, treatment effects, and outcomes of chronic pain in emerging adults (Brown et al., 2021), as well as studies that examine how tailored interventions can improve quality of life when designed in the context of age and gender. Given that the last Canadian study that provides chronic pain prevalence estimates for emerging adult women was published in 2011 (Schopflocher et al., 2011), current population studies are necessary to evaluate the present burden of chronic pain in emerging adults. In general, a greater focus on the understanding of unique pain experiences during emerging adulthood is warranted to improve treatment options and long-term outcomes for this demographic (Brown et al., 2021).

Nurses are ethically responsible for compassionate care by striving to understand and care for the health care needs of patients (Canadian Nurses Association, 2017). Moreover, nurses are reflective in practice, continually creating knowledge. This knowledge is situated relationally and can have significant social impacts when directed toward policy development, research, and education. Contributing to “making visible the silence, disruptions, and complexities inherent in people’s experiences” (Clandinin & Caine, 2013, p. 175), narrative inquiry can offer a way to enhance quality of care as well as quality of experience for educators, students, and patients (Lindsay & Schwind, 2016).

Conclusions

Narrative inquiry often begins with the researcher’s personal, practical, and social justifications for a particular phenomenon. These shape the evolving research puzzle, and ours pertained to how chronic pain shapes the identity of emerging adult women. With the two participants that engaged in our inquiry, field texts were generated that included conversation transcripts, the first author’s field journal, participant artwork, participant pain journals, essays, poetry, and researcher-created annals. Field texts were analyzed using Clandinin and Connelly’s (2000) framework of the three-dimensional space, and then transitioned into interim research texts. Through analysis, narratives were shaped into narrative accounts, across which narrative threads resonated. Still in collaboration with participants, interim research texts were shaped into final research texts, including the first author’s Master of Nursing thesis (Finlay, 2022).

In this paper, we describe the first author’s experiences creating relational spaces in the study while adhering to the methodological commitments of narrative inquiry. These experiences were discussed in relation to selected qualitative touchstones—markers that demonstrate the methodological commitments in narrative inquiry (Clandinin & Caine, 2013). Important ethical considerations for the participant-researcher relationship arose, and the first author practiced reflexivity, mutual vulnerability, and wakefulness to attend to the relational responsibilities of the inquiry. Coming alongside the midst of ongoing lives, challenges and benefits arose from creating an entirely virtual relational space. Throughout the inquiry, the first author reflected on their own experiences to remain present and attentive to unfolding stories, co-create meaning, and to maintain a researcher-participant relationship grounded in the ethics of care. While the first author’s lived experience with chronic pain likely made negotiating entry to the field easier, it required paying close attention to relational ethics. As one approach to understand how their own experiences influenced the research, the first author engaged with their response communities and returned to their personal, practical, and social justifications for the inquiry.

The invisibility of pain means that it is often absent from conversations and not recognized as an issue within health care interactions (Hirsch, 2018). Conversely, in narrative inquiry, the researcher commits to remaining attentive, present, and responsive in the researcher-participant relationship (Clandinin & Caine, 2013). Our use of narrative inquiry as a study methodology elicited rich data and a greater understanding of the health care experiences of emerging adult women living with chronic pain, revealing the criticality of validation, empathy, and adequate communication in places of health care.

Narrative inquiry is a worthwhile tool for understanding the complex and personal nature of chronic pain, and it can be used to re-examine dominant narratives and understand understudied populations. Additionally, the use of narrative inquiry in research is beneficial for researchers who have personal or practical experience with the topic. Stories, including our own, have utility in nursing and are a fundamental aspect of the human experience. When studied with Clandinin and Connelly’s (2000) form of narrative inquiry, stories can offer profound insight into complex individual, sociocultural, and institutional narratives that shape the experiences of health and illness.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jenise Finlay

Notes

Author Biographies

Jenise Finlay, MN, BScN, RN is a research assistant at the University of Calgary, Faculty of Nursing, in Calgary, Alberta, Canada.

Añiela dela Cruz PhD, MSc, RN is an associate professor at the University of Calgary, Faculty of Nursing, in Calgary, Alberta, Canada.

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