Journal of Aging Studies 34 (2015) 177–182
Contents lists available at ScienceDirect
Journal of Aging Studies journal homepage: www.elsevier.com/locate/jaging
Emerging themes in using narrative in geriatric care: Implications for patient-centered practice and interprofessional teamwork Phillip G. Clark ⁎ Program in Gerontology and Rhode Island Geriatric Education Center, University of Rhode Island, Quinn Hall 100, 55 Lower College Road, Kingston, RI 02881, USA
a r t i c l e
i n f o
Article history: Received 2 September 2014 Accepted 24 February 2015 Available online 12 March 2015 Keywords: Narrative Patient-centered practice Interprofessional teamwork
a b s t r a c t Narrative approaches are increasingly used with older adults by different health professionals in a variety of care settings to provide unique and powerful insights into the patient's lifeworld and the meaning of their illness. Understanding these approaches requires insight into the narratives of both the patient and the provider. Different health professions have differing attitudes toward aging and are socialized into distinct ways of framing the problems of older adults. In a patient assessment, they may co-construct different stories that create the basis for interprofessional collaboration, posing challenges for communication among members of the team. This paper develops a conceptual framework for characterizing the use of narrative as the development of sets of “voices” reflecting a dynamic interaction between the provider and the patient, including the use of master narratives, stories and counterstories, and plots and subplots. The literature on the use of narrative with older adults in the professions of medicine, nursing, and social work is reviewed comparatively to develop a typology of these professional differences and the basis for them. Implications and recommendations for the development of new models of patient-centered care and interprofessional practice with older adults are developed. © 2015 Elsevier Inc. All rights reserved.
The central, activating, and organizing event in clinical care occurs when the sick person gives an account of himself or herself, and someone trained to help receives that account.—Rita Charon (2012, p. 343)
We don't see things as they are; we see things as we are.—Anaïs Nin (Baldwin, 2000, p. xii) Health and social care professionals working with older adults use stories every day when they take a patient history, perform an assessment, or develop a care plan. Ideally, such narratives should keep the focus of care on the patient or client, and they can become powerful methods of communicating and
⁎ Tel.: +1 401 874 2689; fax: +1 401 874 9322. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.jaging.2015.02.013 0890-4065/© 2015 Elsevier Inc. All rights reserved.
collaborating with other care providers. Thus, narrative methods, patient-centered practice, and interprofessional teamwork are all interrelated and have the common goal of improving the care and quality of life of older adults. However, each profession has its own distinctive method of gathering unique patient information, selectively choosing the most important elements of the patient's story, and packaging and presenting it in a way that reflects that profession's own approach to understanding the patient's world. Different professions literally see the world differently, which is a reflection of how they are educated and socialized and the embodiment of particular values and assumptions about what is important to focus on in providing care. Thus, each professional will co-create, with the patient, a different narrative; when the providers come together as an interprofessional team, it is essential that these different stories be recognized as such and effectively integrated into an overall assessment and care plan that incorporates many clinical voices.
178
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Particularly in the care of older adults, differing health and social care professionals may approach the patient with a different set of “master narratives,” generalized or archetypal formats for thinking about a patient, his or her problems, and the set of solutions to be considered. These master plots may reflect unquestioned assumptions about what it means to be old, what older adults are like, and what factors should be emphasized in providing their care. Unfortunately, such frameworks often reflect stereotypes and ageist beliefs that limit care options and prevent seeing the patient as he or she really is. Thus, an older adult may be trapped in a professional narrative of decline and deterioration, and a counterstory emphasizing continued personal growth and development may be required to free him or her from its constraints and limits. To explore these issues, this paper will develop a framework for understanding the basis for how different health and social care professions approach the older patient and their story, incorporating elements of professional identity that are a reflection of differing values and assumptions. It is important that each profession's narrative be understood as it relates to the way in which that provider interacts with the patient. The co-construction of the patient narrative is thus a function of the active and selective processes used by the professional in its development. Following the presentation of this framework, the literature on the professions of medicine, nursing, and social work will be reviewed on the basis of research on their attitudes toward older adults and their use of narrative methods. These professions were chosen on the basis of their often being considered as the core disciplines in providing care to older adults. The “story of aging” that they bring to a clinical encounter with older persons will influence the way in which they relate to the patient, assess and evaluate his or her needs, and contribute to the development of the care plan. In other words, the lens through which they see the process and experience of aging will color their understanding of the patient and his or her lifeworld. Finally, implications of this analysis for how different professionals collaborate on interprofessional teams will be explored, particularly with respect to the communication about what are the patient's problems and how they can be solved. Different professional voices are essential in addressing the complex health issues that many adults face as they grow older and have to manage a variety of chronic diseases with multifaceted implications for the quality of their lives.
An understanding of a professional's self-narrative is the first step toward gaining insights into the process of co-constructing the patient's story. “Professional narratives are highly specialized forms of narrative that draw on the expertise and expert knowledge that professionals bring to their work” (Loftus & Greenhalgh, 2010, p. 86). Different professionals acquire differing values related to the patient and patient care through the process of education and socialization into their profession (Clark, 1997), which color their understanding and interpretation of such patient care factors as quality of life (Clark, 1995). Differing professions may define the patient's problems differently, thereby setting up a particular range of solutions to be considered and creating different narrative genres in the process (Lingard et al., 2007). As already discussed, an essential component in coconstructing the patient narrative is relationship, which is jointly constructed in a dynamic and ongoing process by both the provider and the patient over time, including elements of the past, present, and future (Walker, 2007, as cited in Holstein et al., 2011). This essential dialogue between provider and patient—in which certain types of information are selectively gathered, packaged, and presented by the professional in a highly stylized manner—is ideally based on an integrative and joint interpretive process, drawing on the unique perspectives and lifeworlds of both participants. In this process, it is important that the emerging narrative reflects balanced input from both parties; if one or the other version of the story becomes dominant, there is a risk that elements important to the other co-author will be distorted. For example, the formatting of the “proper” medical narrative may rely on the technical-scientific world of the physician taking precedence over the lived experience of the patient (Waitzkin et al., 1994). In addition, patient narratives may become “abbreviated or distorted in clinical applications as practitioners have sought to fit rich and varied narratives into the format of the ‘admissions form' or ‘clinical history'” (Gaydos, 2005, p. 255). This is also the case when the traditional method of assessment focuses on a patient's deficits or deficiencies, rather than on his or her strengths and resources (Graybeal, 2001). The co-construction of the patient's story must rely on placing the patient at the center of his or her own story and care, the essence of the patient-centered approach discussed earlier.
Different professions' approaches to dialogue with older adults Co-creating the patient narrative Biographical approaches are increasingly tied in the clinical literature to understanding the older patient as a person and to developing patient-centered care (Clark, 2001). As Clarke et al. (2003) suggest, “Person-centred care necessitates that practitioners learn more about the older person as an individual, together with a better understanding of the patient's personal meanings, experiences, and attitudes” (p. 698). This means looking beyond the “mask” of age, illness, and disability to see the person's true self and life. In addition, it connotes the development of a genuine relationship with the patient that reveals underlying values in terms of the choices facing him or her and the constraints on those choices that may exist (McCormack, 2004).
Different professions bring differing “lenses” to their interaction with the patient, in terms of how they “see” him or her. These perspectives are a reflection of different patterns of professional socialization, as well as differing attitudes toward aging and working with older adults. These powerful influences can create very biased master narratives of older patients and severely limit the ability of professionals to practice truly patient-centered care. The literature on medicine, nursing, and social work will be reviewed in order to understand both the similarities and the differences among these professions and their impacts on caring for older adults. As indicated earlier, these three professions were chosen on the basis of their often being considered the core disciplines on the health care teams that address the complex needs of older adults.
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Medicine As Estes and Binney (1989) originally argued and Kaufman et al. (2004) have more recently reiterated, the dominant narrative of aging in medicine is one of inevitable disease, decline, and decay. Growing old is viewed through the lens of pathology and considered to be a problem requiring medical treatment. This master narrative both reflects and reinforces the prevailing social discourse on aging, in which the individual aging body is turned through culturally legitimated norms into a “body object” for biomedical intervention (Yamasaki, 2009). The recent emergence of the anti-aging field within medicine and its emphasis on keeping old age at bay by extending healthy life only serves to reinforce the perception that aging is a disease to be treated medically, not a normal stage of life to be embraced with all its potentials and pitfalls (Terrill & Gullifer, 2010). Thus, it is not surprising that, despite calls for greater training in geriatrics among medical students, negative attitudes toward older adults persist, due to student exposure to sick and frail older adults with multiple comorbidities and cognitive impairment that only serve to reinforce negative stereotypes (Westmoreland et al., 2009). Older adults are often seen as “frustrating” and “boring” in a clinical culture that emphasizes treatment to restore patients to their previous level of functioning. For example, some medical students have expressed the feeling that the care of older adults is primarily nursing or social work, and that they did not go to medical school to do this type of routine, basic, maintenance kind of care that does not have significant impacts on improving patient outcomes (Higashi et al., 2012). The general effect of such attitudes is to create “moral prejudgments” about certain classes of “frustrating” patients that make it more difficult to see the patient as a unique individual. Although medical students may have a combination of both positive and negative reactions to older patients, this ambivalence is often trumped by a master narrative that sees them as needy, complex, and dependent (Higashi et al., 2012). The overall impact in the actual clinical care of older adults by physicians is to marginalize psychosocial contextual factors in favor of the more biomedical ones (Waitzkin et al., 1994). Thus, in the physician's co-construction of the patient's story, psychosocial factors are systematically ignored or downplayed, despite their importance to the quality of life and care of the patient. This is because “the technical world of medicine uses a speech genre…that does not lend itself well to a full exploration of contextual issues” (Waitzkin et al., 1994, p. 340). Thus, the voice of medicine, with its emphasis on the technical details of disease and its treatment, does not speak to the complexities of the lifeworld of the patient, with his or her everyday social relationships and activities (Nordam et al., 2003). Nursing Given its traditional emphasis on holistic, patient-centered care, it is not surprising that as a profession nursing emphasizes the use of narrative methods in clinical practice with older adults (e.g., Buckley et al., 2013; Clarke, 2000; Hirst & Raffin, 2001; Mitty, 2010). However, studies also document negative attitudes toward older adults on the part of nursing students (Cozort, 2008), as well as the detrimental effects of ageism as a
179
barrier to the development of effective therapeutic relationships between nurses and older patients (Eymard & Douglas, 2012). The literature on the importance of narrative in nursing practice provides further insights into the varied nature of stories told by older patients. Insofar as older adults lead storied lives, illness or hospitalization may represent an “interruption of reflection” in a longer storyline (Hsu & McCormack, 2011). We might extend this characterization to suggest that such occurrences represent sub-stories in a larger story. They afford an opportunity for the nurse to engage in a dialogue with the patient that enables them together to co-construct the meaning of the present situation as a component of reflective practice. This theme of interpreting the meaning of interruptions or transitions in care is echoed in research on the movement of older adults into residential care, in which “key plots” of uncertainty, identity, and power/control can be used to describe their experiences (Lee et al., 2013). Thus, an illness, transition, and rehabilitation narrative can be described as a dynamic “work in progress,” in which change is understood as part of the larger reappraisal of circumstances and evolving values and priorities (Price, 2011). The concept of a “compromise narrative” is also described in the nursing literature, one that captures the dual responsibility of the provider, on the one hand, to show concern for the patient, while, on the other, to follow practice guidelines for meeting clinical needs and reducing risk (Price, 2011). The notion of balance in narrative is again introduced by the need in person-centered care to consider both strengths and weaknesses, and deficits and assets, in a patient narrative, especially in such cases as those involving older adults with dementia (McKeown et al., 2010). It is easy for older adults to be “trapped” in a narrative of loss that requires counterstories for their release. “Counterstories are the stories which people tell and live that offer resistance to dominant cultural narratives” (Phoenix & Smith, 2011, p. 630). This may especially be the case when dealing with aging in women (Feldman, 1999; Terrill & Gullifer, 2010), the very old (Koch et al., 2010), and instructional settings (Shenk et al., 2008). Older adults may need to resist the power of society and other people who present them with a script of aging that they reject. “Narratives are always linked to the question of power. We ‘story’ our lives, but we should always investigate where our ‘storyline’ comes from, and ask: Who gave me this ‘script’?” (Ådlandsvik, 2012, p. 24). Social work Historically, social work has emphasized the empowerment of the patient or client and the importance of values at the center of its profession (Clark, 1997). Through the 1990s, social work as a profession did not mount a timely response to the recognized and growing need to educate more students in working with older adults, due to (1) lack of adequately trained faculty, (2) low student interest, and (3) ageist attitudes (Snyder et al., 2008). Similarly, the development of the scientific basis for the role of social work with older adults has been under-addressed (Raveis et al., 2010), resulting in a negative impact on clinical social work practice with this population. In contrast to the more biomedical model associated with medicine, social work emphasizes the psychosocial aspects of the client's lifeworld. In particular, and in marked contrast with
180
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
the medical model of aging, social work has developed a strengths-based approach that recognizes a client's accomplishments and resources rather than emphasizes their deficits (Graybeal, 2001). In particular with older adults, this philosophy states that individuals know their own life, including its lessons and experiences, the best (Perkins & Tice, 1995). They are the experts in their own narrative, although it is sometimes the job of the social worker to make them aware of this fact by empowering them to have a greater voice in their own care. Importantly, social workers recognize the ownership of one's story by showing respect to their older adult clients (Sung & Dunkle, 2009). In addition, social workers are trained to “rule in” those factors in co-constructing the patient's narrative that might be left out by other, more biomedically oriented professions (Qualls & Czirr, 1988). For example, social workers may introduce into the discussion of an assessment and the development of a care plan such psychosocial aspects of a patient's life as work, income, and family issues that are left out by physicians' traditional focus on disease management. Thus, social work plays a critical role in ensuring that the patient's story encompasses the entire context of his or her life, not just those aspects that are more narrowly disease-specific.
from others (Loftus & Greenhalgh, 2010). Importantly, the presence or absence of team members who have critical information to share about the patient's story can shape the team's options for action and ultimately affect the outcome of care for the patient (McClelland & Sands, 1993; Opie, 1997). Also, and importantly in the context of the earlier discussion about negative attitudes toward older adults on the part of medical students, it is interesting to note that geriatric educational interventions incorporating an interprofessional team model have had positive impacts on the attitudes of physicians-in-training toward older adults and those with chronic illness. In addition, utilizing an interprofessional model of education broadens the understanding of the psychosocial context of aging for medical students and improves their ability to see the patient more holistically (Maurer et al., 2006; Yuen et al., 2006). Clearly, highlighting the need for multiple professions and many voices in geriatric care can have a positive effect on raising the awareness of physicians of the need for recognizing the whole older adult as the center of care and of the critical importance of interprofessional teamwork in providing that care.
Interprofessional teamwork with older adults
If narrative methods, patient-centered practice, and interprofessional teamwork have one thing in common, it is the accurate and complete co-construction of the patient's story of his or her own life as it is related to health and social care. A key element in this process is the use of reflection by the different care providers. For example, in co-constructing the patient's narrative through dialogue with him or her over time, professionals must become aware of how their own education and socialization affect their perspectives on the patient and his or her limitations. Similarly, in the team discourse in which the different patient assessments are analyzed and an integrated care plan developed, members must become cognizant of the meaning of the information they present and how it relates to that provided by other professionals. They must recognize the worldviews they embody and those of the others on the team. “Metacognition” is the term used to describe this thinking about one's own thinking and that of others (Clark, 2009). Reflection is also related to gaining insight into how professionals' own attitudes toward aging may shape the ways in which they approach older patients in the clinical context. In particular, stereotypes and ageism may interfere with a provider's ability to co-construct an accurate and complete patient story. Larger cultural and social contexts, as well as health professions' educational programs and experiences, may have provided a negative and biased view of aging. The master narrative provided by these factors and forces may be misleading or wrong, resulting in assessments and care plans being developed that are incomplete or ineffective at addressing the real issues facing an older adult. In this instance, convincing counterstories are needed to challenge the dominant narrative being forced upon an older patient. Narrative approaches with older adults can be powerful methods of maintaining the focus in health care on the patient. After all, it is his or her initial account of need that starts the clinical encounter, and it is the requirement to remain centered on that story that should motivate health and social care providers in developing a plan to address it. Although each
The literature on the use of narrative by different health professions working with older adults also serves to reinforce the importance of collaborative practice and interprofessional teamwork. If the narratives of different professions each have a unique, yet incomplete, perspective on the patient's story, then it is essential that these providers come together to share their information to construct a complete picture of the older adult and his or her life in its entirety. For example, from the nursing perspective, Hsu and McCormack (2011) discuss how the reinterpretation, reconfiguration, and reintegration of different provider narratives by a team are necessary to construct an accurate picture of the patient in such settings as rehabilitation, where the individual and their life context must be holistically taken into account to achieve patient-centered practice. Similarly, from the standpoint of medicine, Waitzkin et al. (1994) argue that it is essential in geriatric care to take into account the contextual, psychosocial aspects of a patient's life—and not just the biomedical—when developing a comprehensive care plan to address the complete picture of the patient's health-related situation. For many older adults with complex chronic diseases and multiple comorbidities, it is important to consider all aspects of their life story—which is virtually unachievable when relying only on physicians to provide adequate care. The metaphor used in the narrative literature on interprofessional teamwork invokes the concept of multiple “voices” being necessary in the construction of the complete patient narrative (Clark, 2014). The “multivocality” of teamwork (Poirier, 2002) requires the incorporation of many perspectives on the patient's situation, as well as the development of dialogue and discourse on how to integrate them. Different professions must tell the patient's story, framed in the narrative genre structures of their own disciplines, to pass on critical information to the team. There are “interpretive gaps” in the narratives of different professions that can only be filled by the contributions
Discussion and implications
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
professional interacting with that patient will have a different lens or perspective on how to interpret or make meaning of that narrative, it is ultimately his or her responsibility to be sure that it is accurate and leads to the effective treatment needed for quality care. For complex older patients with multiple, chronic health conditions, this goal ultimately can best be achieved by interprofessional teamwork. Combining the literature on narrative in the health professions of medicine, nursing, and social work reveals the essential importance of insuring effective communication among all the members of a health care team. It is at this level that the individual narratives of all the different care providers must come together in a single, unified story of the patient and his or her needs (Clark, 2014). In a fundamental way, through their individual assessment stories, members of the team collaboratively co-create a care plan for the older patient that unifies their individual perspectives and ways of seeing the patient into a single voice. A narrative approach to geriatric care highlights the growing need for health and social care professionals to work together effectively to provide high quality health care to the growing numbers of older adults.
Acknowledgments An earlier version of this paper was presented in a symposium on “Telling the Story of Narrative Gerontology: Enhancing, Extending, and Expanding Insights into Aging and Caring” at the 42nd Annual Scientific and Educational Meeting of the Canadian Association on Gerontology, Halifax, Nova Scotia, Canada, October 17–19, 2013.
References Ådlandsvik, R. (2012). Narratives and old age. In I.F. Goodson, A.M. Loveless, & D. Stephens (Eds.), Explorations in narrative research (pp. 21–32). Rotterdam, The Netherlands: Sense Publishers. Baldwin, D.C. (2000). Foreword. In T.J.K. Drinka, & P.G. Clark (Eds.), Health care teamwork: Interdisciplinary practice and teaching. Westport, CT: Auburn House/Greenwood. Buckley, C., McCormack, B., & Ryan, A. (2013). Valuing narrative in the care of older people: A framework of narrative practice for older adult residential care settings. Journal of Clinical Nursing, 23, 2565–2577. http://dx.doi.org/ 10.1111/jocn.12472. Charon, R. (2012). At the membranes of care: Stories in narrative medicine. Academic Medicine, 87, 342–347. http://dx.doi.org/10.1097/ACM.0b013e3 182446fbb. Clark, P.G. (1995). Quality of life, values, and teamwork in geriatric care: Do we communicate what we mean? The Gerontologist, 35, 402–411. http://dx. doi.org/10.1093/geront/35.3.402. Clark, P.G. (1997). Values in health care professional socialization: Implications for geriatric education in interdisciplinary teamwork. The Gerontologist, 37, 441–451. http://dx.doi.org/10.1093/geront/37.4.441. Clark, P.G. (2001). Narrative gerontology in clinical practice: Current applications and future prospects. In G. Kenyon, P. Clark, & B. de Vries (Eds.), Narrative gerontology: Theory, research, and practice (pp. 193–214). New York: Springer. Clark, P.G. (2009). Reflecting on reflection in interprofessional education: Implications for theory and practice. Journal of Interprofessional Care, 23, 213–223. http://dx.doi.org/10.1080/13561820902877195. Clark, P.G. (2014). Narrative in interprofessional education and practice: Implications for professional identity, provider-patient communication, and teamwork. Journal of Interprofessional Care, 28, 34–39. http://dx.doi. org/10.3109/13561820.2013.853652. Clarke, A. (2000). Using biography to enhance the nursing care of older people. British Journal of Nursing, 9, 429–433. http://dx.doi.org/10.12968/bjon. 2000.9.7.6323. Clarke, A., Hanson, E.J., & Ross, H. (2003). Seeing the person behind the patient: Enhancing the care of older people using a biographical approach. Journal of
181
Clinical Nursing, 12, 697–706. http://dx.doi.org/10.1046/j.1365-2702.2003. 00784.x. Cozort, R.W. (2008). Student nurses' attitudes regarding older adults: Strategies for fostering improvement through academia. Teaching and Learning in Nursing, 3, 21–25. http://dx.doi.org/10.1016/j.teln.2007.07.013. Estes, C.L., & Binney, E.A. (1989). The biomedicalization of aging: Dangers and dilemmas. The Gerontologist, 29, 587–597. http://dx.doi.org/10.1093/ geront/29.5.587. Eymard, A.S., & Douglas, D.H. (2012). Ageism among health care providers and interventions to improve their attitudes toward older adults: An integrative review. Journal of Gerontological Nursing, 38, 26–35. http://dx.doi.org/10. 3928/00989134-20120307-09. Feldman, S. (1999). Please don't call me “dear”: Older women's narratives of health care. Nursing Inquiry, 6, 269–276. http://dx.doi.org/10.1046/j.14401800.1999.00041.x. Gaydos, H.L. (2005). Understanding personal narratives: An approach to practice. Journal of Advanced Nursing, 49, 254–259. http://dx.doi.org/10. 1111/j.1365-2648.2004.03284.x. Graybeal, C. (2001). Strengths-based social work assessment: Transforming the dominant paradigm. Families in Society: The Journal of Contemporary Human Services, 82, 233–242. http://dx.doi.org/10.1606/1044-3894.236. Higashi, R.T., Tillack, A.A., Steinman, M., Harper, M., & Johnson, C.B. (2012). Elder care as “frustrating” and “boring”: Understanding the persistence of negative attitudes toward older patients among physicians-in-training. Journal of Aging Studies, 26, 476–483. http://dx.doi.org/10.1016/j.jaging. 2012.06.007. Hirst, S.P., & Raffin, S. (2001). I hated those darn chickens: The power in stories for older adults and nurses. Journal of Gerontological Nursing, 27, 24–29 (doi: http://hdl.handle.net/10755/166939). Holstein, M.B., Parks, J.A., & Waymack, M.H. (2011). Ethics, aging, and society: The critical turn. New York: Springer. Hsu, M.Y., & McCormack, B. (2011). Using narrative inquiry with older people to inform practice and service developments. Journal of Clinical Nursing, 21, 841–849. http://dx.doi.org/10.1111/j.1365-2702.2011.03851.x. Kaufman, S.R., Shim, J.K., & Russ, A.J. (2004). Revisiting the biomedicalization of aging: Clinical trends and ethical challenges. The Gerontologist, 44, 731–738. http://dx.doi.org/10.1093/geront/44.6.731. Koch, T., Turner, R., Smith, P., & Hutnik, N. (2010). Storytelling reveals the active, positive lives of centenarians. Nursing Older People, 22(8), 31–36. Lee, V.S.P., Simpson, J., & Froggatt, K. (2013). A narrative exploration of older people's transitions into residential care. Aging and Mental Health, 17, 48–56. http://dx.doi.org/10.1080/13607863.2012.715139. Lingard, L., Schryer, C.F., Spafford, M.M., & Campbell, S.L. (2007). Negotiating the politics of identity in an interdisciplinary research team. Qualitative Research, 7, 501–519. http://dx.doi.org/10.1177/1468794107082305. Loftus, S., & Greenhalgh, T. (2010). Towards a narrative mode of practice. In J. Higgs, D. Fish, I. Goulter, S. Loftus, J. -A. Reid, & F. Trede (Eds.), Education for future practice (pp. 85–95). Rotterdam, The Netherlands: Sense Publishers. Maurer, M.S., Costley, A.W., Miller, P.A., McCabe, S., Dubin, S., Cheng, H., et al. (2006). The Columbia Cooperative Aging Program: An interdisciplinary and interdepartmental approach to geriatric education for medical interns. Journal of the American Geriatrics Society, 54, 520–526. http://dx.doi.org/10. 1111/j.1532-5415.2005.00616.x. McClelland, M., & Sands, R.G. (1993). The missing voice in interdisciplinary communication. Qualitative Health Research, 3, 74–90. http://dx.doi.org/10. 1177/104973239300300105. McCormack, B. (2004). Person-centredness in gerontological nursing: An overview of the literature. Journal of Clinical Nursing, 13(Suppl. S1), 31–38. http://dx.doi.org/10.1111/j.1365-2702.2004.00924.x. McKeown, J., Clarke, A., Ingleton, C., Ryan, T., & Repper, J. (2010). The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing, 5, 148–158. http://dx.doi.org/ 10.1111/j.1748-3743.2010.00219.x. Mitty, E. (2010). Storytelling. Geriatric Nursing, 31, 58–62. http://dx.doi.org/10. 1016/j.gerinurse.2009.11.005. Nordam, A., Sørlie, V., & Förde, R. (2003). Integrity in the care of elderly people, as narrated by female physicians. Nursing Ethics, 10, 388–403. http://dx.doi. org/10.1191/0969733003ne589oa. Opie, A. (1997). Thinking teams thinking clients: Issues of discourse and representation in the work of health care teams. Sociology of Health & Illness, 19, 259–280. http://dx.doi.org/10.1111/j.1467-9566.1997.tb00019.x. Perkins, K., & Tice, C. (1995). A strengths perspective in practice: Older people and mental health challenges. Journal of Gerontological Social Work, 23, 83–97. http://dx.doi.org/10.1300/J083V23N03_06. Phoenix, C., & Smith, B. (2011). Telling a (good?) counterstory of aging: Natural bodybuilding meets the narrative of decline. Journals of Gerontology (Series B), 66, 628–639. http://dx.doi.org/10.1093/geronb/gbr077. Poirier, S. (2002). Voice in the medical narrative. In R. Charon, & M. Montello (Eds.), Stories matter: The role of narrative in medical ethics (pp. 48–58). New York: Routledge.
182
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Price, B. (2011). Making better use of older people's narratives. Nursing Older People, 23(6), 31–37. Qualls, S.H., & Czirr, R. (1988). Geriatric health teams: Classifying models of professional and team functioning. The Gerontologist, 28, 372–376. http://dx.doi.org/10.1093/geront/28.3.372. Raveis, V.H., Gardner, D.S., Berkman, B., & Harootyan, L. (2010). Linking the NIH strategic plan to the research agenda for social workers in health and aging. Journal of Gerontological Social Work, 53, 77–93. http://dx.doi.org/10.1080/ 01634370903361953. Shenk, D., Davis, B., & Murray, L. (2008). In their own words: Using narratives to teach gerontology. Gerontology & Geriatrics Education, 29, 239–247. http://dx.doi.org/10.1080/02701960802359474. Snyder, C.S., Wesley, S.C., Lin, M.B., & May, J.D. (2008). Bridging the gap: Gerontology and social work education. Gerontology & Geriatrics Education, 28(4), 1–21. http://dx.doi.org/10.1080/02701960801962864. Sung, K. -T., & Dunkle, R.E. (2009). How social workers demonstrate respect for elderly clients. Journal of Gerontological Social Work, 52, 250–260. http://dx. doi.org/10.1080/01634370802609247. Terrill, L., & Gullifer, J. (2010). Growing older: A qualitative inquiry into the textured narratives of older, rural women. Journal of Health Psychology, 15, 707–715. http://dx.doi.org/10.1177/1359105310368180.
Waitzkin, H., Britt, T., & Williams, C. (1994). Narratives of aging and social problems in medical encounters with older persons. Journal of Health and Social Behavior, 35, 322–348 (doi: http://0-www.jstor.org.helin.uri.edu/ stable/2137213). Walker, M. (2007). Moral understandings (2nd ed.). New York: Oxford University Press. Westmoreland, G.R., Counsell, S.R., Sennour, Y., Schubert, C.C., Frank, K.I., Wu, J., et al. (2009). Improving medical student attitudes toward older patients through a “Council of Elders” and reflective writing experience. Journal of the American Geriatrics Society, 57, 315–320. http://dx.doi.org/10.1111/j. 1532-5415.2008.02102.x. Yamasaki, J. (2009). Though much is taken, much abides: The storied world of aging in a fictionalized retirement home. Health Communication, 24, 588–596. http://dx.doi.org/10.1080/10410230903242192. Yuen, J.K., Breckman, R., Adelman, R.D., Capello, C.F., LoFaso, V., & Reid, M.C. (2006). Reflections of medical students on visiting chronically ill older patients in the home. Journal of the American Geriatrics Society, 54, 1778–1783. http://dx.doi.org/10.1111/j.1532- 415.2006.00918.x.
Contents lists available at ScienceDirect
Journal of Aging Studies journal homepage: www.elsevier.com/locate/jaging
Emerging themes in using narrative in geriatric care: Implications for patient-centered practice and interprofessional teamwork Phillip G. Clark ⁎ Program in Gerontology and Rhode Island Geriatric Education Center, University of Rhode Island, Quinn Hall 100, 55 Lower College Road, Kingston, RI 02881, USA
a r t i c l e
i n f o
Article history: Received 2 September 2014 Accepted 24 February 2015 Available online 12 March 2015 Keywords: Narrative Patient-centered practice Interprofessional teamwork
a b s t r a c t Narrative approaches are increasingly used with older adults by different health professionals in a variety of care settings to provide unique and powerful insights into the patient's lifeworld and the meaning of their illness. Understanding these approaches requires insight into the narratives of both the patient and the provider. Different health professions have differing attitudes toward aging and are socialized into distinct ways of framing the problems of older adults. In a patient assessment, they may co-construct different stories that create the basis for interprofessional collaboration, posing challenges for communication among members of the team. This paper develops a conceptual framework for characterizing the use of narrative as the development of sets of “voices” reflecting a dynamic interaction between the provider and the patient, including the use of master narratives, stories and counterstories, and plots and subplots. The literature on the use of narrative with older adults in the professions of medicine, nursing, and social work is reviewed comparatively to develop a typology of these professional differences and the basis for them. Implications and recommendations for the development of new models of patient-centered care and interprofessional practice with older adults are developed. © 2015 Elsevier Inc. All rights reserved.
The central, activating, and organizing event in clinical care occurs when the sick person gives an account of himself or herself, and someone trained to help receives that account.—Rita Charon (2012, p. 343)
We don't see things as they are; we see things as we are.—Anaïs Nin (Baldwin, 2000, p. xii) Health and social care professionals working with older adults use stories every day when they take a patient history, perform an assessment, or develop a care plan. Ideally, such narratives should keep the focus of care on the patient or client, and they can become powerful methods of communicating and
⁎ Tel.: +1 401 874 2689; fax: +1 401 874 9322. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.jaging.2015.02.013 0890-4065/© 2015 Elsevier Inc. All rights reserved.
collaborating with other care providers. Thus, narrative methods, patient-centered practice, and interprofessional teamwork are all interrelated and have the common goal of improving the care and quality of life of older adults. However, each profession has its own distinctive method of gathering unique patient information, selectively choosing the most important elements of the patient's story, and packaging and presenting it in a way that reflects that profession's own approach to understanding the patient's world. Different professions literally see the world differently, which is a reflection of how they are educated and socialized and the embodiment of particular values and assumptions about what is important to focus on in providing care. Thus, each professional will co-create, with the patient, a different narrative; when the providers come together as an interprofessional team, it is essential that these different stories be recognized as such and effectively integrated into an overall assessment and care plan that incorporates many clinical voices.
178
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Particularly in the care of older adults, differing health and social care professionals may approach the patient with a different set of “master narratives,” generalized or archetypal formats for thinking about a patient, his or her problems, and the set of solutions to be considered. These master plots may reflect unquestioned assumptions about what it means to be old, what older adults are like, and what factors should be emphasized in providing their care. Unfortunately, such frameworks often reflect stereotypes and ageist beliefs that limit care options and prevent seeing the patient as he or she really is. Thus, an older adult may be trapped in a professional narrative of decline and deterioration, and a counterstory emphasizing continued personal growth and development may be required to free him or her from its constraints and limits. To explore these issues, this paper will develop a framework for understanding the basis for how different health and social care professions approach the older patient and their story, incorporating elements of professional identity that are a reflection of differing values and assumptions. It is important that each profession's narrative be understood as it relates to the way in which that provider interacts with the patient. The co-construction of the patient narrative is thus a function of the active and selective processes used by the professional in its development. Following the presentation of this framework, the literature on the professions of medicine, nursing, and social work will be reviewed on the basis of research on their attitudes toward older adults and their use of narrative methods. These professions were chosen on the basis of their often being considered as the core disciplines in providing care to older adults. The “story of aging” that they bring to a clinical encounter with older persons will influence the way in which they relate to the patient, assess and evaluate his or her needs, and contribute to the development of the care plan. In other words, the lens through which they see the process and experience of aging will color their understanding of the patient and his or her lifeworld. Finally, implications of this analysis for how different professionals collaborate on interprofessional teams will be explored, particularly with respect to the communication about what are the patient's problems and how they can be solved. Different professional voices are essential in addressing the complex health issues that many adults face as they grow older and have to manage a variety of chronic diseases with multifaceted implications for the quality of their lives.
An understanding of a professional's self-narrative is the first step toward gaining insights into the process of co-constructing the patient's story. “Professional narratives are highly specialized forms of narrative that draw on the expertise and expert knowledge that professionals bring to their work” (Loftus & Greenhalgh, 2010, p. 86). Different professionals acquire differing values related to the patient and patient care through the process of education and socialization into their profession (Clark, 1997), which color their understanding and interpretation of such patient care factors as quality of life (Clark, 1995). Differing professions may define the patient's problems differently, thereby setting up a particular range of solutions to be considered and creating different narrative genres in the process (Lingard et al., 2007). As already discussed, an essential component in coconstructing the patient narrative is relationship, which is jointly constructed in a dynamic and ongoing process by both the provider and the patient over time, including elements of the past, present, and future (Walker, 2007, as cited in Holstein et al., 2011). This essential dialogue between provider and patient—in which certain types of information are selectively gathered, packaged, and presented by the professional in a highly stylized manner—is ideally based on an integrative and joint interpretive process, drawing on the unique perspectives and lifeworlds of both participants. In this process, it is important that the emerging narrative reflects balanced input from both parties; if one or the other version of the story becomes dominant, there is a risk that elements important to the other co-author will be distorted. For example, the formatting of the “proper” medical narrative may rely on the technical-scientific world of the physician taking precedence over the lived experience of the patient (Waitzkin et al., 1994). In addition, patient narratives may become “abbreviated or distorted in clinical applications as practitioners have sought to fit rich and varied narratives into the format of the ‘admissions form' or ‘clinical history'” (Gaydos, 2005, p. 255). This is also the case when the traditional method of assessment focuses on a patient's deficits or deficiencies, rather than on his or her strengths and resources (Graybeal, 2001). The co-construction of the patient's story must rely on placing the patient at the center of his or her own story and care, the essence of the patient-centered approach discussed earlier.
Different professions' approaches to dialogue with older adults Co-creating the patient narrative Biographical approaches are increasingly tied in the clinical literature to understanding the older patient as a person and to developing patient-centered care (Clark, 2001). As Clarke et al. (2003) suggest, “Person-centred care necessitates that practitioners learn more about the older person as an individual, together with a better understanding of the patient's personal meanings, experiences, and attitudes” (p. 698). This means looking beyond the “mask” of age, illness, and disability to see the person's true self and life. In addition, it connotes the development of a genuine relationship with the patient that reveals underlying values in terms of the choices facing him or her and the constraints on those choices that may exist (McCormack, 2004).
Different professions bring differing “lenses” to their interaction with the patient, in terms of how they “see” him or her. These perspectives are a reflection of different patterns of professional socialization, as well as differing attitudes toward aging and working with older adults. These powerful influences can create very biased master narratives of older patients and severely limit the ability of professionals to practice truly patient-centered care. The literature on medicine, nursing, and social work will be reviewed in order to understand both the similarities and the differences among these professions and their impacts on caring for older adults. As indicated earlier, these three professions were chosen on the basis of their often being considered the core disciplines on the health care teams that address the complex needs of older adults.
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Medicine As Estes and Binney (1989) originally argued and Kaufman et al. (2004) have more recently reiterated, the dominant narrative of aging in medicine is one of inevitable disease, decline, and decay. Growing old is viewed through the lens of pathology and considered to be a problem requiring medical treatment. This master narrative both reflects and reinforces the prevailing social discourse on aging, in which the individual aging body is turned through culturally legitimated norms into a “body object” for biomedical intervention (Yamasaki, 2009). The recent emergence of the anti-aging field within medicine and its emphasis on keeping old age at bay by extending healthy life only serves to reinforce the perception that aging is a disease to be treated medically, not a normal stage of life to be embraced with all its potentials and pitfalls (Terrill & Gullifer, 2010). Thus, it is not surprising that, despite calls for greater training in geriatrics among medical students, negative attitudes toward older adults persist, due to student exposure to sick and frail older adults with multiple comorbidities and cognitive impairment that only serve to reinforce negative stereotypes (Westmoreland et al., 2009). Older adults are often seen as “frustrating” and “boring” in a clinical culture that emphasizes treatment to restore patients to their previous level of functioning. For example, some medical students have expressed the feeling that the care of older adults is primarily nursing or social work, and that they did not go to medical school to do this type of routine, basic, maintenance kind of care that does not have significant impacts on improving patient outcomes (Higashi et al., 2012). The general effect of such attitudes is to create “moral prejudgments” about certain classes of “frustrating” patients that make it more difficult to see the patient as a unique individual. Although medical students may have a combination of both positive and negative reactions to older patients, this ambivalence is often trumped by a master narrative that sees them as needy, complex, and dependent (Higashi et al., 2012). The overall impact in the actual clinical care of older adults by physicians is to marginalize psychosocial contextual factors in favor of the more biomedical ones (Waitzkin et al., 1994). Thus, in the physician's co-construction of the patient's story, psychosocial factors are systematically ignored or downplayed, despite their importance to the quality of life and care of the patient. This is because “the technical world of medicine uses a speech genre…that does not lend itself well to a full exploration of contextual issues” (Waitzkin et al., 1994, p. 340). Thus, the voice of medicine, with its emphasis on the technical details of disease and its treatment, does not speak to the complexities of the lifeworld of the patient, with his or her everyday social relationships and activities (Nordam et al., 2003). Nursing Given its traditional emphasis on holistic, patient-centered care, it is not surprising that as a profession nursing emphasizes the use of narrative methods in clinical practice with older adults (e.g., Buckley et al., 2013; Clarke, 2000; Hirst & Raffin, 2001; Mitty, 2010). However, studies also document negative attitudes toward older adults on the part of nursing students (Cozort, 2008), as well as the detrimental effects of ageism as a
179
barrier to the development of effective therapeutic relationships between nurses and older patients (Eymard & Douglas, 2012). The literature on the importance of narrative in nursing practice provides further insights into the varied nature of stories told by older patients. Insofar as older adults lead storied lives, illness or hospitalization may represent an “interruption of reflection” in a longer storyline (Hsu & McCormack, 2011). We might extend this characterization to suggest that such occurrences represent sub-stories in a larger story. They afford an opportunity for the nurse to engage in a dialogue with the patient that enables them together to co-construct the meaning of the present situation as a component of reflective practice. This theme of interpreting the meaning of interruptions or transitions in care is echoed in research on the movement of older adults into residential care, in which “key plots” of uncertainty, identity, and power/control can be used to describe their experiences (Lee et al., 2013). Thus, an illness, transition, and rehabilitation narrative can be described as a dynamic “work in progress,” in which change is understood as part of the larger reappraisal of circumstances and evolving values and priorities (Price, 2011). The concept of a “compromise narrative” is also described in the nursing literature, one that captures the dual responsibility of the provider, on the one hand, to show concern for the patient, while, on the other, to follow practice guidelines for meeting clinical needs and reducing risk (Price, 2011). The notion of balance in narrative is again introduced by the need in person-centered care to consider both strengths and weaknesses, and deficits and assets, in a patient narrative, especially in such cases as those involving older adults with dementia (McKeown et al., 2010). It is easy for older adults to be “trapped” in a narrative of loss that requires counterstories for their release. “Counterstories are the stories which people tell and live that offer resistance to dominant cultural narratives” (Phoenix & Smith, 2011, p. 630). This may especially be the case when dealing with aging in women (Feldman, 1999; Terrill & Gullifer, 2010), the very old (Koch et al., 2010), and instructional settings (Shenk et al., 2008). Older adults may need to resist the power of society and other people who present them with a script of aging that they reject. “Narratives are always linked to the question of power. We ‘story’ our lives, but we should always investigate where our ‘storyline’ comes from, and ask: Who gave me this ‘script’?” (Ådlandsvik, 2012, p. 24). Social work Historically, social work has emphasized the empowerment of the patient or client and the importance of values at the center of its profession (Clark, 1997). Through the 1990s, social work as a profession did not mount a timely response to the recognized and growing need to educate more students in working with older adults, due to (1) lack of adequately trained faculty, (2) low student interest, and (3) ageist attitudes (Snyder et al., 2008). Similarly, the development of the scientific basis for the role of social work with older adults has been under-addressed (Raveis et al., 2010), resulting in a negative impact on clinical social work practice with this population. In contrast to the more biomedical model associated with medicine, social work emphasizes the psychosocial aspects of the client's lifeworld. In particular, and in marked contrast with
180
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
the medical model of aging, social work has developed a strengths-based approach that recognizes a client's accomplishments and resources rather than emphasizes their deficits (Graybeal, 2001). In particular with older adults, this philosophy states that individuals know their own life, including its lessons and experiences, the best (Perkins & Tice, 1995). They are the experts in their own narrative, although it is sometimes the job of the social worker to make them aware of this fact by empowering them to have a greater voice in their own care. Importantly, social workers recognize the ownership of one's story by showing respect to their older adult clients (Sung & Dunkle, 2009). In addition, social workers are trained to “rule in” those factors in co-constructing the patient's narrative that might be left out by other, more biomedically oriented professions (Qualls & Czirr, 1988). For example, social workers may introduce into the discussion of an assessment and the development of a care plan such psychosocial aspects of a patient's life as work, income, and family issues that are left out by physicians' traditional focus on disease management. Thus, social work plays a critical role in ensuring that the patient's story encompasses the entire context of his or her life, not just those aspects that are more narrowly disease-specific.
from others (Loftus & Greenhalgh, 2010). Importantly, the presence or absence of team members who have critical information to share about the patient's story can shape the team's options for action and ultimately affect the outcome of care for the patient (McClelland & Sands, 1993; Opie, 1997). Also, and importantly in the context of the earlier discussion about negative attitudes toward older adults on the part of medical students, it is interesting to note that geriatric educational interventions incorporating an interprofessional team model have had positive impacts on the attitudes of physicians-in-training toward older adults and those with chronic illness. In addition, utilizing an interprofessional model of education broadens the understanding of the psychosocial context of aging for medical students and improves their ability to see the patient more holistically (Maurer et al., 2006; Yuen et al., 2006). Clearly, highlighting the need for multiple professions and many voices in geriatric care can have a positive effect on raising the awareness of physicians of the need for recognizing the whole older adult as the center of care and of the critical importance of interprofessional teamwork in providing that care.
Interprofessional teamwork with older adults
If narrative methods, patient-centered practice, and interprofessional teamwork have one thing in common, it is the accurate and complete co-construction of the patient's story of his or her own life as it is related to health and social care. A key element in this process is the use of reflection by the different care providers. For example, in co-constructing the patient's narrative through dialogue with him or her over time, professionals must become aware of how their own education and socialization affect their perspectives on the patient and his or her limitations. Similarly, in the team discourse in which the different patient assessments are analyzed and an integrated care plan developed, members must become cognizant of the meaning of the information they present and how it relates to that provided by other professionals. They must recognize the worldviews they embody and those of the others on the team. “Metacognition” is the term used to describe this thinking about one's own thinking and that of others (Clark, 2009). Reflection is also related to gaining insight into how professionals' own attitudes toward aging may shape the ways in which they approach older patients in the clinical context. In particular, stereotypes and ageism may interfere with a provider's ability to co-construct an accurate and complete patient story. Larger cultural and social contexts, as well as health professions' educational programs and experiences, may have provided a negative and biased view of aging. The master narrative provided by these factors and forces may be misleading or wrong, resulting in assessments and care plans being developed that are incomplete or ineffective at addressing the real issues facing an older adult. In this instance, convincing counterstories are needed to challenge the dominant narrative being forced upon an older patient. Narrative approaches with older adults can be powerful methods of maintaining the focus in health care on the patient. After all, it is his or her initial account of need that starts the clinical encounter, and it is the requirement to remain centered on that story that should motivate health and social care providers in developing a plan to address it. Although each
The literature on the use of narrative by different health professions working with older adults also serves to reinforce the importance of collaborative practice and interprofessional teamwork. If the narratives of different professions each have a unique, yet incomplete, perspective on the patient's story, then it is essential that these providers come together to share their information to construct a complete picture of the older adult and his or her life in its entirety. For example, from the nursing perspective, Hsu and McCormack (2011) discuss how the reinterpretation, reconfiguration, and reintegration of different provider narratives by a team are necessary to construct an accurate picture of the patient in such settings as rehabilitation, where the individual and their life context must be holistically taken into account to achieve patient-centered practice. Similarly, from the standpoint of medicine, Waitzkin et al. (1994) argue that it is essential in geriatric care to take into account the contextual, psychosocial aspects of a patient's life—and not just the biomedical—when developing a comprehensive care plan to address the complete picture of the patient's health-related situation. For many older adults with complex chronic diseases and multiple comorbidities, it is important to consider all aspects of their life story—which is virtually unachievable when relying only on physicians to provide adequate care. The metaphor used in the narrative literature on interprofessional teamwork invokes the concept of multiple “voices” being necessary in the construction of the complete patient narrative (Clark, 2014). The “multivocality” of teamwork (Poirier, 2002) requires the incorporation of many perspectives on the patient's situation, as well as the development of dialogue and discourse on how to integrate them. Different professions must tell the patient's story, framed in the narrative genre structures of their own disciplines, to pass on critical information to the team. There are “interpretive gaps” in the narratives of different professions that can only be filled by the contributions
Discussion and implications
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
professional interacting with that patient will have a different lens or perspective on how to interpret or make meaning of that narrative, it is ultimately his or her responsibility to be sure that it is accurate and leads to the effective treatment needed for quality care. For complex older patients with multiple, chronic health conditions, this goal ultimately can best be achieved by interprofessional teamwork. Combining the literature on narrative in the health professions of medicine, nursing, and social work reveals the essential importance of insuring effective communication among all the members of a health care team. It is at this level that the individual narratives of all the different care providers must come together in a single, unified story of the patient and his or her needs (Clark, 2014). In a fundamental way, through their individual assessment stories, members of the team collaboratively co-create a care plan for the older patient that unifies their individual perspectives and ways of seeing the patient into a single voice. A narrative approach to geriatric care highlights the growing need for health and social care professionals to work together effectively to provide high quality health care to the growing numbers of older adults.
Acknowledgments An earlier version of this paper was presented in a symposium on “Telling the Story of Narrative Gerontology: Enhancing, Extending, and Expanding Insights into Aging and Caring” at the 42nd Annual Scientific and Educational Meeting of the Canadian Association on Gerontology, Halifax, Nova Scotia, Canada, October 17–19, 2013.
References Ådlandsvik, R. (2012). Narratives and old age. In I.F. Goodson, A.M. Loveless, & D. Stephens (Eds.), Explorations in narrative research (pp. 21–32). Rotterdam, The Netherlands: Sense Publishers. Baldwin, D.C. (2000). Foreword. In T.J.K. Drinka, & P.G. Clark (Eds.), Health care teamwork: Interdisciplinary practice and teaching. Westport, CT: Auburn House/Greenwood. Buckley, C., McCormack, B., & Ryan, A. (2013). Valuing narrative in the care of older people: A framework of narrative practice for older adult residential care settings. Journal of Clinical Nursing, 23, 2565–2577. http://dx.doi.org/ 10.1111/jocn.12472. Charon, R. (2012). At the membranes of care: Stories in narrative medicine. Academic Medicine, 87, 342–347. http://dx.doi.org/10.1097/ACM.0b013e3 182446fbb. Clark, P.G. (1995). Quality of life, values, and teamwork in geriatric care: Do we communicate what we mean? The Gerontologist, 35, 402–411. http://dx. doi.org/10.1093/geront/35.3.402. Clark, P.G. (1997). Values in health care professional socialization: Implications for geriatric education in interdisciplinary teamwork. The Gerontologist, 37, 441–451. http://dx.doi.org/10.1093/geront/37.4.441. Clark, P.G. (2001). Narrative gerontology in clinical practice: Current applications and future prospects. In G. Kenyon, P. Clark, & B. de Vries (Eds.), Narrative gerontology: Theory, research, and practice (pp. 193–214). New York: Springer. Clark, P.G. (2009). Reflecting on reflection in interprofessional education: Implications for theory and practice. Journal of Interprofessional Care, 23, 213–223. http://dx.doi.org/10.1080/13561820902877195. Clark, P.G. (2014). Narrative in interprofessional education and practice: Implications for professional identity, provider-patient communication, and teamwork. Journal of Interprofessional Care, 28, 34–39. http://dx.doi. org/10.3109/13561820.2013.853652. Clarke, A. (2000). Using biography to enhance the nursing care of older people. British Journal of Nursing, 9, 429–433. http://dx.doi.org/10.12968/bjon. 2000.9.7.6323. Clarke, A., Hanson, E.J., & Ross, H. (2003). Seeing the person behind the patient: Enhancing the care of older people using a biographical approach. Journal of
181
Clinical Nursing, 12, 697–706. http://dx.doi.org/10.1046/j.1365-2702.2003. 00784.x. Cozort, R.W. (2008). Student nurses' attitudes regarding older adults: Strategies for fostering improvement through academia. Teaching and Learning in Nursing, 3, 21–25. http://dx.doi.org/10.1016/j.teln.2007.07.013. Estes, C.L., & Binney, E.A. (1989). The biomedicalization of aging: Dangers and dilemmas. The Gerontologist, 29, 587–597. http://dx.doi.org/10.1093/ geront/29.5.587. Eymard, A.S., & Douglas, D.H. (2012). Ageism among health care providers and interventions to improve their attitudes toward older adults: An integrative review. Journal of Gerontological Nursing, 38, 26–35. http://dx.doi.org/10. 3928/00989134-20120307-09. Feldman, S. (1999). Please don't call me “dear”: Older women's narratives of health care. Nursing Inquiry, 6, 269–276. http://dx.doi.org/10.1046/j.14401800.1999.00041.x. Gaydos, H.L. (2005). Understanding personal narratives: An approach to practice. Journal of Advanced Nursing, 49, 254–259. http://dx.doi.org/10. 1111/j.1365-2648.2004.03284.x. Graybeal, C. (2001). Strengths-based social work assessment: Transforming the dominant paradigm. Families in Society: The Journal of Contemporary Human Services, 82, 233–242. http://dx.doi.org/10.1606/1044-3894.236. Higashi, R.T., Tillack, A.A., Steinman, M., Harper, M., & Johnson, C.B. (2012). Elder care as “frustrating” and “boring”: Understanding the persistence of negative attitudes toward older patients among physicians-in-training. Journal of Aging Studies, 26, 476–483. http://dx.doi.org/10.1016/j.jaging. 2012.06.007. Hirst, S.P., & Raffin, S. (2001). I hated those darn chickens: The power in stories for older adults and nurses. Journal of Gerontological Nursing, 27, 24–29 (doi: http://hdl.handle.net/10755/166939). Holstein, M.B., Parks, J.A., & Waymack, M.H. (2011). Ethics, aging, and society: The critical turn. New York: Springer. Hsu, M.Y., & McCormack, B. (2011). Using narrative inquiry with older people to inform practice and service developments. Journal of Clinical Nursing, 21, 841–849. http://dx.doi.org/10.1111/j.1365-2702.2011.03851.x. Kaufman, S.R., Shim, J.K., & Russ, A.J. (2004). Revisiting the biomedicalization of aging: Clinical trends and ethical challenges. The Gerontologist, 44, 731–738. http://dx.doi.org/10.1093/geront/44.6.731. Koch, T., Turner, R., Smith, P., & Hutnik, N. (2010). Storytelling reveals the active, positive lives of centenarians. Nursing Older People, 22(8), 31–36. Lee, V.S.P., Simpson, J., & Froggatt, K. (2013). A narrative exploration of older people's transitions into residential care. Aging and Mental Health, 17, 48–56. http://dx.doi.org/10.1080/13607863.2012.715139. Lingard, L., Schryer, C.F., Spafford, M.M., & Campbell, S.L. (2007). Negotiating the politics of identity in an interdisciplinary research team. Qualitative Research, 7, 501–519. http://dx.doi.org/10.1177/1468794107082305. Loftus, S., & Greenhalgh, T. (2010). Towards a narrative mode of practice. In J. Higgs, D. Fish, I. Goulter, S. Loftus, J. -A. Reid, & F. Trede (Eds.), Education for future practice (pp. 85–95). Rotterdam, The Netherlands: Sense Publishers. Maurer, M.S., Costley, A.W., Miller, P.A., McCabe, S., Dubin, S., Cheng, H., et al. (2006). The Columbia Cooperative Aging Program: An interdisciplinary and interdepartmental approach to geriatric education for medical interns. Journal of the American Geriatrics Society, 54, 520–526. http://dx.doi.org/10. 1111/j.1532-5415.2005.00616.x. McClelland, M., & Sands, R.G. (1993). The missing voice in interdisciplinary communication. Qualitative Health Research, 3, 74–90. http://dx.doi.org/10. 1177/104973239300300105. McCormack, B. (2004). Person-centredness in gerontological nursing: An overview of the literature. Journal of Clinical Nursing, 13(Suppl. S1), 31–38. http://dx.doi.org/10.1111/j.1365-2702.2004.00924.x. McKeown, J., Clarke, A., Ingleton, C., Ryan, T., & Repper, J. (2010). The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing, 5, 148–158. http://dx.doi.org/ 10.1111/j.1748-3743.2010.00219.x. Mitty, E. (2010). Storytelling. Geriatric Nursing, 31, 58–62. http://dx.doi.org/10. 1016/j.gerinurse.2009.11.005. Nordam, A., Sørlie, V., & Förde, R. (2003). Integrity in the care of elderly people, as narrated by female physicians. Nursing Ethics, 10, 388–403. http://dx.doi. org/10.1191/0969733003ne589oa. Opie, A. (1997). Thinking teams thinking clients: Issues of discourse and representation in the work of health care teams. Sociology of Health & Illness, 19, 259–280. http://dx.doi.org/10.1111/j.1467-9566.1997.tb00019.x. Perkins, K., & Tice, C. (1995). A strengths perspective in practice: Older people and mental health challenges. Journal of Gerontological Social Work, 23, 83–97. http://dx.doi.org/10.1300/J083V23N03_06. Phoenix, C., & Smith, B. (2011). Telling a (good?) counterstory of aging: Natural bodybuilding meets the narrative of decline. Journals of Gerontology (Series B), 66, 628–639. http://dx.doi.org/10.1093/geronb/gbr077. Poirier, S. (2002). Voice in the medical narrative. In R. Charon, & M. Montello (Eds.), Stories matter: The role of narrative in medical ethics (pp. 48–58). New York: Routledge.
182
P.G. Clark / Journal of Aging Studies 34 (2015) 177–182
Price, B. (2011). Making better use of older people's narratives. Nursing Older People, 23(6), 31–37. Qualls, S.H., & Czirr, R. (1988). Geriatric health teams: Classifying models of professional and team functioning. The Gerontologist, 28, 372–376. http://dx.doi.org/10.1093/geront/28.3.372. Raveis, V.H., Gardner, D.S., Berkman, B., & Harootyan, L. (2010). Linking the NIH strategic plan to the research agenda for social workers in health and aging. Journal of Gerontological Social Work, 53, 77–93. http://dx.doi.org/10.1080/ 01634370903361953. Shenk, D., Davis, B., & Murray, L. (2008). In their own words: Using narratives to teach gerontology. Gerontology & Geriatrics Education, 29, 239–247. http://dx.doi.org/10.1080/02701960802359474. Snyder, C.S., Wesley, S.C., Lin, M.B., & May, J.D. (2008). Bridging the gap: Gerontology and social work education. Gerontology & Geriatrics Education, 28(4), 1–21. http://dx.doi.org/10.1080/02701960801962864. Sung, K. -T., & Dunkle, R.E. (2009). How social workers demonstrate respect for elderly clients. Journal of Gerontological Social Work, 52, 250–260. http://dx. doi.org/10.1080/01634370802609247. Terrill, L., & Gullifer, J. (2010). Growing older: A qualitative inquiry into the textured narratives of older, rural women. Journal of Health Psychology, 15, 707–715. http://dx.doi.org/10.1177/1359105310368180.
Waitzkin, H., Britt, T., & Williams, C. (1994). Narratives of aging and social problems in medical encounters with older persons. Journal of Health and Social Behavior, 35, 322–348 (doi: http://0-www.jstor.org.helin.uri.edu/ stable/2137213). Walker, M. (2007). Moral understandings (2nd ed.). New York: Oxford University Press. Westmoreland, G.R., Counsell, S.R., Sennour, Y., Schubert, C.C., Frank, K.I., Wu, J., et al. (2009). Improving medical student attitudes toward older patients through a “Council of Elders” and reflective writing experience. Journal of the American Geriatrics Society, 57, 315–320. http://dx.doi.org/10.1111/j. 1532-5415.2008.02102.x. Yamasaki, J. (2009). Though much is taken, much abides: The storied world of aging in a fictionalized retirement home. Health Communication, 24, 588–596. http://dx.doi.org/10.1080/10410230903242192. Yuen, J.K., Breckman, R., Adelman, R.D., Capello, C.F., LoFaso, V., & Reid, M.C. (2006). Reflections of medical students on visiting chronically ill older patients in the home. Journal of the American Geriatrics Society, 54, 1778–1783. http://dx.doi.org/10.1111/j.1532- 415.2006.00918.x.
