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JHNXXX10.1177/0898010115587582Journal of Holistic NursingNurses’ Narrative Journey / Edwards
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jhn
research-article2015
Practice
The Personal Narrative of a Nurse A Journey Through Practice Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN Buckinghamshire New University, Uxbridge
Journal of Holistic Nursing American Holistic Nurses Association Volume XX Number X XXXX 201X 1–8 © The Author(s) 2015 10.1177/0898010115587582 http://jhn.sagepub.com
This article examines my phases of holistic learning concerning how I became a nurse, using story presented in a personal narrative style. I have incorporated my own stories to elaborate my journey. First, my early life in the East End of London and how this influenced my becoming a nurse. Second, I give an account of my journey through practice, where I examine how I developed my own learning from professional practice, drawing on some personal illustrations presented as stories. I have set out to explore how my stories of practice have influenced my progress, and I present a personal account of such learning in general from the lens of a nurse educator. Keywords: adults; students; holistic theories and practices; narratives; nursing practice and personal growth
Introduction Human beings have always told themselves and others stories, which explain what is happening, what they are doing, and why it is valuable. Health care relies on such stories that patients share, which enable nurses to understand the holistic needs of patients, and the stories that nurses tell helps them make sense of caregiving. In this article I concentrate on my stories that I have used and that have affected my practice and helped me learn and improve. In this way my practice has helped me gain insight, understand care and compassion, express emotions, and have a better understanding of and find meaning in clinical experience. When these experiences are ordered into stories and shared, new meanings and understanding can give birth to new ideas not thought of when examining practice alone. The purpose of sharing this is to help readers get enthused about what is possible as a student and with the help of others such as mentors. It is argued that by understanding our own stories, the habitual explanations of what is done and why, we are better able to understand, change, and deliver holistic practice. But this article starts from a slightly different place, a personal one, and the
sometimes uncertain process of making sense of messy experience is aided through the exploration of my narrative drawn from my own practitioner perspective facilitated by story.
Writing a Personal Narrative Gaydos (2005) and more recently Thieman and Darby (2009) identify that personal narrative is a form of autobiographical storytelling that gives shape to experience, with “narrative” being regarded here as a substantial big picture and “story” as a smaller part of it, as suggested by Fairbairn and Carson (2002). Personal narratives are important in nursing, as determining a person’s self-story is often a way of fixing a starting point for his or her struggle toward personal growth; for me this included using stories of my clinical practice experience. Author’s Note: Please address correspondence to Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN, Senior Lecturer, Department of Pre-registration Nursing, Faculty of Society and Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, Middlesex UB8 1NA, UK; e-mail: [email protected].
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I use my own personal narrative in the way identified by Gaydos (2005), who argued that narratives can restore feelings otherwise lost and provide direct contact with lives we formerly led or now lead. They can help clarify the important ways in which we are individuals in our own right with unique identities. This view resonated with me, as my childhood in the East End of London had become lost, and only when I joined higher education did my early background somehow seem significant. For example, Story 1: My Story 1 Significant to me and the use of stories, is that every Sunday all of my extended family would meet, sing, or just tell stories. One particular story details how my passionate nature can be linked to the fact that my grandfather was a Welsh farmer who was stationed in France during the First World War. While in France he met my grandmother, a French noblewoman of high birth. When she married my grandfather, her family, so the story goes, disowned her. Married, they both traveled back to England and found a rundown old house in the East End of London. I like to think I have a doctorate because my mother always believed in educating my sister and myself, encouraging us to stay on at school and sharing in our hopes and plans for our continuing education. My creativity and ingenuity are drawn from when I was a child, living on the 12th floor of a block of high-rise flats, where without assistance I could not reach the button to ride the lift back up, so I would carry a carefully designed stick in my back pocket. Innovation and creativity have been carried over into my professional life through my research and writing. My willingness to be open and to share my experiences with others is spontaneous, instinctive, and natural and originates in my experiences as a child in the East End where a strong sense of kinship based on trust existed with virtually every neighbor and local resident.
By engaging with and delving into my early life in the East End, I started to appreciate its role in shaping the person I have now become, and how it helped me develop a sense of self-understanding. Insight into myself allowed me to focus not on myself but on delivering compassionate care to others.
In Bruner’s (2002) book Making Stories, he refers to the “creation of self,” in which he implies that self is in some way external to, and separate from, the stories we make. He suggests that narrative only gives the briefest look at ourselves. Yet, in part, the purpose of personal narrative must be to reveal ourselves to ourselves. Indeed, self-awareness may not always focus on our personal concerns but can also involve a commitment to others. Thieman and Darby (2009) give a personal narrative that reveals a form of self-awareness that expresses their commitments and responsibilities as a nurse. This way of looking at self-awareness is one I find most useful as a nurse. By engaging with my personal narrative, I was able to delve into my early life, and through this process, I started to appreciate its role in shaping the person I had now become. For as nurses we are only capable of demonstrating empathy when we understand what we want to and are able to give, and this involves using self as part of becoming a nurse. Matsumoto (2009) demonstrates how unsettling narratives of life can be, and Bruner (2002) suggests this can apply to all of us. However, the purpose of writing my personal narrative using a collection of my own stories was to make sense of my own life lived in clinical practice, and though this was sometimes disturbing, I persevered. The personal narrative that emerged has brought my nursing life to the surface and given me an appreciation of the value of my own stories of clinical practice. Moving my stories of practice from being implicit or tacit to being explicit I critique, analyze, learn, and understand my practice better and as a nurse lecturer draw meaning from them.
The Beginning One Christmas, when I was 12 or 13, I was taken by my parents to the accident and emergency department of a very large London hospital, suffering from a headache and sensitivity to light. I was admitted with query bacterial meningitis, but as it turned out, I only had viral meningitis or bacterial encephalitis, which are not as serious as the former. I cannot remember which diagnosis was eventually given, but it was the lesser diagnosis, and as my mum and dad could not say either, it did not really matter that much to them anyway, as long as I was all right.
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While in hospital over the Christmas period, I enjoyed watching the festivities on the ward and realized that I wanted to become a nurse (My Story 2). My Story 2 Making the decision to be a nurse was only the beginning of things. When I made the decision that I wanted to help others, I had no idea of the great dive I would make into a strong current that was to carry me to places I had never dreamed of when I first made it. I never gave up on wanting to do nursing as my career. I had made my decision. I knew I would get to do it and I managed to just get into my nurse training with the minimum of five O levels.
I started as a student nurse in 1977, qualified in 1981, and worked as a staff nurse and sister until 1991. Yet I did not appreciate the significance and value of these years of clinical experience; they were tacit, unstated, and silent. I took it all for granted, not thinking very much about it, reflecting on it, or analyzing it; however, story helped me make my practice more explicit. As a lecturer I began to look back to my practice years and view them as stories worthy of being made explicit rather than remaining tacit. I remembered my life as a nurse on the wards, encountering practice as a realm of different experiences involving images, noises, sensations, smells, feelings, grief, happiness, caring, and loving. The experiences presented emerged as a language expressing my everyday practice life as a nurse, and I began to view them as stories worthy of bringing from being just tacit, in what I refer to as the prenarrative phase, to a phase of remembering (see later).
The Life Cycle of a Nurse People writing their personal narratives begin in many different places as described by Nelson et al. (2012). Gaydos (2005) highlights that narratives usually start with memories that are emotionally intense and important to self-definition. I start when I was a student nurse, and draw on my own stories of clinical practice. I reflect on my career as a nurse, and I look more closely at my own stories and how they had enhanced my own practice development. My lived experience has been narrated into story form, “organized” in order to make sense of my
clinical experiences, which up until this point were tacit or taken for granted. It is through the organization of experiences into story that helped me make explicit my clinical practice, which can then be analyzed and explored. Put another way, it is the perspectives we take on experience and the use we make of it that matter; story can be one way to facilitate this use. Stories have a message and communicate an idea, and possess a meaning for the teller and the reader. Uncovering the message is often the purpose of the story (Bruner, 2002), a view supported in a study by Kothari et al. (2012), although the message may be so well concealed that even the teller is not aware of it. Stories have an implicit message, or messages, but we can be blind to them. As I returned to my stories, I began to identify the particular aspects that stood out. I include my own stages that helped me develop insights into my practice, which have been labeled as the prenarrative stage and the stages of remembering, writing, and sharing. Each of these stages is explored and is crystallized in terms of my individual experiences.
The Prenarrative (the Representation of Experience) One starting point for the discussion on my use of story is the notion of embodied learning (Draper, 2014) incorporating, as Boud (2010) calls it, a “taken-for-granted phase”—a “presupposition,” that is, what exists prior to interpretation or cognitive or social construction. Mason (2002) recognizes that practice is embodied but refers to it as not noticing, in that it can exist apart from any meanings the individual gives to it. Watson and Rebair (2014) state that noticing is integral to nursing practice and thus “not noticing” can have serious effects. Van Manen (1990) also points to the prenarrative, which for him is the world as the nurse immediately experiences it rather than how she/he conceptualizes, categorizes, or understands it. Regarding my own narrative, I began to look back, from my current position as a nurse educator, at my learning through engaging with my stories and became aware of a period before remembering, a period when I walked through the wards day and night, encountering practice as my prelinguistic realm of experience. This was a time when I did not express what I was experiencing or
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indeed learning about, but I was at one with the world of clinical practice. I was conscious only of patients that I cared for and interacted with, and I took it all for granted, not thinking about it, reflecting on it, or analyzing it. I refer to this as my prenarrative stage. Thinking as a nurse educator and looking back to my own development as a nurse, I can identify a time when I did not notice my experiences of practice and was ignorant of their value and potential. However, I would not say that it passed me by. This world of immediate everyday experience, the world that I inhabited as a nurse, was always there as an inalienable presence, and it is this that I use as the starting point for my journey.
Remembering Stories About Practice For a story to be remembered, it has to have some sort of impact and (practice) value (Dewey, 1938/1997), perhaps involving emotion or feelings. Bruner (2002) argues that a story begins with some breach in the expected state of things, usually something going awry, otherwise there is no story to tell. The story has to be of a certain quality, and individuals can filter stories that are worth remembering and those that are not. Mason (2002) stresses the importance of filtering, as our attention is highly selective. Individuals undoubtedly need to sift through their stories to find the ones that are worth telling, as there is often too much to notice in any practical situation and we could not cope with all the possible interpretations. Remembering a story can make explicit the shift from the taken-for-granted prenarrative to the recognition of the experiences embedded in practice. Another way of putting this is that remembering can bring to the fore what is tacit or implicit in practice, and make it explicit or conscious. Stories have a role in the meaning-making processes needed to give sense to practical experience. The notion of remembering is represented by Mason (2002) and is termed noticing. Watson and Rebair (2014) point out that noticing is about how nurses can perceive what is happening around them, and should be something nurses do all of the time. As professional nurses, we are sensitized to notice certain things, particularly the patients we care for (My Story 3).
My Story 3 I arrived one morning as a student nurse, and following an assessment of my patients found that Fred needed to be washed and changed first, as he had been incontinent in the bed. I went to ask my colleague for assistance. She replied that her patient Angus needed to go to the toilet first, for which he required two people and he needed to go now. It was difficult at the time to decide who went first, I had to concede with my qualified colleague that Angus should go to the toilet first and we took him together.
This story, when examined through the lens of a nurse lecturer, features my development of reflection-in-action, first identified by Schon (1983) as the moment-to-moment decision-making skill that can contribute to professional practice. I had to consider both sides: On one hand, Fred, if left in a wet and soiled bed, could develop pressure ulcers. On the other, if Angus was left to wait for the toilet he might be incontinent and left in a wet and foulsmelling bed and at risk of developing pressure ulcers while waiting for us to finish washing Fred. The reflection-in-action takes place in my mind, my “on the spot” reflection, and enables me see to the tension, listen to other’s views, admit when I was wrong, and make the right decision. Berterö (2010) takes the view that exploring reflection-in-action through story can make it not only visible but also understandable, and the risk of taking practice for granted is reduced. The journey continued as I began to attend to, and make overt, certain features in my stream of consciousness that were my clinical practice experiences.
Writing the Stories Down In this phase I began to make sense of my stories, and according to Attard (2011) and Bartlett (2015), this is aided by writing the story down. Writing down stories can be very useful but is not enough, and Masson (2005) contends that if writing down the story is the extent to which (narrative) accounts go, the potential for influencing and informing the future is limited. As a nurse on the ward, stories helped me value my clinical practice experiences, and I began to uncover the potential for using stories as a way to
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organize and explore, to help me to understand and make sense of my own practice experiences (My Story 4). My Story 4 As a staff nurse a patient was admitted to the medical ward from Accident and Emergency following a stroke. It was very severe and he had lost all feeling down one side and lost his speech, except for the words “knife, fork, and spoon.” Over the next couple of days it was evident that every time you spoke to him, he could not express any other words except by stating clearly and precisely “knife, fork, and spoon.” I would say “Hello!” he would reply “Knife, fork and spoon!” Followed by “How are you feeling today,” his answer each time was “Knife, fork, and spoon.” It was frustrating for all the team and even more so for his loving wife of 60 years. He could not walk or communicate, and his condition deteriorated. The movement in his arm and leg never returned and he sadly died 5 days following admission. His wife was not upset or distraught, nor was she in floods of tears or inconsolable; she was desolate, lost, and looked abandoned by the sudden loss of her husband. She informed me just before she left the ward, what losing her husband felt like: “It is like a physical amputation; like I have just had my right arm cut off, and I would give it willingly if it would bring him back to me.”
I can see as a nurse educator that each story builds on another, and this story helped me not just be empathetic but also understand compassion toward patients and become sensitized to what it might be like for someone to suffer the loss of their lifelong partner. This story revealed more to me about compassion and caring than could have been achieved through theory alone. The story helped me see my practice and learn that I could not stand with his wife at the bedside without being deeply moved. I could not be an impartial authority without showing tenderness and reverence in the presence of death. In this practice experience, I can see I was intimately involved, something not possible when engaging with theory. I was uncertain as to whether it was acceptable to express my feelings and emotions, but building on my skills of reflection-in-action I managed my emotional attachment in a way that promoted both caring and compassion as well as resonating with my own identity as a nurse. I see
that part of my practice is emotional and that this helped me understand the context in which my nursing took place and learn more about myself. I thought about sharing these written personal experiences with others as my journey continued.
Sharing Stories Another element included in my journey through practice is the sharing of stories. One of the first stories I organized, wrote down, and shared was concerned with a patient I cared for while working in Australia (My Story 5). The stories I shared about my clinical practice are real (My Story 6). They enabled me to think about and reflect on what may have been happening, and promoted my understanding and learning (My Stories 5 and 6). My Story 5 One particular situation, while working as a nurse in Australia, was the case of a young Aboriginal man who had severe liver failure associated with alcoholism. He was admitted to intensive care with bleeding due to lack of clotting factors. It was rumored when he arrived on the unit “the bone had been pointed at him.” This, in the Aboriginal culture, meant that his spirit/soul had left his body and he was already “a dead man.” No one would visit him or enquire about his condition. To all Aborigines he was dead. I understood this as I had come across it before, and it was generally my experience the patient died. This was not what was so significant about the experience. I was caring for the patient, his condition was deteriorating; he was bleeding from his stomach, mouth, and rectum. Blood products and vitamin K had been administered to try and stem the bleeding. He continued to bleed and I was upset, as I had cared for him a number of days now, and no one had visited him in that time. The consultant doctor arrived with an assortment of junior doctors; he and his followers gathered around the bed, took one look at the patient and said “Well that’s it then!” I was furious and told him that if he could not be respectful to leave the bed area. My Story 6 A patient I cared for, back in England, had just returned from cardiac surgery and while recovering from the anesthetic he became very violent towards
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6 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX the nurses caring for him, swearing and using very strong language. He was thrashing out at nurses kicking, hitting, and swearing. This was affecting his blood pressure and heart rate, which could put too much pressure on his newly grafted cardiac/coronary arteries, so it was decided to ventilate and sedate him for longer. The next 2 days weaning from the ventilator was attempted but he again became violent toward nurses/staff and even his relatives; this worsened on suctioning down his breathing tube. His relatives were distraught as he was generally a very well-mannered man, kind, and caring’ they could not understand his behavior. It was decided that this behavior could be the result of his major operation and that he had undergone a personality change, which has been documented in the literature following surgery of this nature. On the third day it was decided to wake him up, as his physical condition no longer warranted further invasive ventilation and treatments. His drugs were reversed and in a matter of hours he was extubated. When he woke he explained to us that he thought the Irish Republic Army was torturing him: He had been in the army and had served in Northern Ireland during the worst of the trouble there.
Through my sharing of stories with students in the classroom and in my doctorate work in an open way, I could express my emotions freely to others. Edwards (2014) suggests that stories can have a huge emotional significance—essential for the development of holistic nursing. For, story can join all the separate parts involved in caring for individuals and the dimensions of nursing (including emotions), and connect each together as a whole. In addition, through sharing others can offer their opinions and see the various tensions and different choices that were available. Through the sharing process a deeper understanding of my stories began to develop. Through critique and analysis of them with students and supervisors I was able to locate additional insights that I had not observed when scrutinizing them alone. For example, Story 5 helped me view doctors from a different perspective. I had previously concluded that generally doctors had the authority in health care and nurses do as the doctors’ request, but caring for this patient changed this for me. I felt I was now telling them what to do with authority and
confidence and showing care and compassion for the patient. Nothing is what is seems in Story 6, and to fully understand confusion, disorientation, and aggressive behavior a broad range of knowledge and expertise is required before judgment about a patient’s mental state can be made. Prevention of violent incidents is the foremost principle, but this may not always be possible if physiological causes from which this patient could be suffering are the reason for the violence—for example, pain, hyperglycemia, neurological impairment, and side effects of medicines. My written stories when shared helped me remember other stories. Sharing stories also encourages others to remember their own stories. Stories are, in my view, the common language of nurses, as they use a shared language, common to all and require no additional knowledge of complex medical terminology. I needed to be able to express myself to others, to get my voice heard (My Story 7), to speak in my own words, the language of practice. My Story 7 When I was a staff nurse in charge of a general medical ward I had in the course of the afternoon noticed a patient’s condition was deteriorating. I called the doctor, as I was concerned. I felt the patient needed to be reassessed. I got the doctor on the phone and he promptly asked me “What is the patient’s blood pressure?” I went to look at the patient’s chart, got the results, and returned to the phone to inform the doctor. Once completed I was asked another question and each time I went back and forth to the charts or patients notes to find out the answer to each question in turn. My inability to tell the full story to the doctor about the patient’s worsening condition failed to get the doctor’s same level of concern, consequently the doctor did not come.
The experiences presented as story made me feel inadequate as I could not communicate to a doctor about a deteriorating patient, and as such this story did not contribute to my sense of fulfillment as a nurse. However, I learned that by turning around the feelings derived from the story I was cementing more sharply applied learning. What emerged was an awareness of gaps in, and a need to update and
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add to, my knowledge, as I struggled to articulate in medical language my feelings of unease. I was showing concern about a patient, but I could not tell this to others: I had to use another language the language of medicine. Story can be a language expressing everyday practice life as a nurse in a way that medical language alone cannot. Calman (2000) and Edwards (2014) suggest that nurses need to learn how to tell their stories better. Consequently, later on in my journey I learned to tell better stories, I told them to doctors over the phone. The use of story allowed me my own style of expression, assisted my communication, and gave me a voice: The subsequent times, I used story, the doctor always came.
Conclusion In this article I detail how I came to value my early life as significant in my development as a nurse, educator, and researcher. I show how in this way my clinical practice experiences presented as story helped me unscramble, assess, and explore my practice in an attempt to develop a better understanding of it from the lens of a nurse educator. I found it useful to divide my practice narrative into four stages—prenarrative, remembering, writing stories down, and sharing stories. By using such a strategy, my practice became structured and more differentiated rather than remaining undifferentiated and unstructured. In this article I begin to acknowledge and identify the tacit implicit nature of my clinical practice experience and to develop the use of story as a strategy for making it explicit. Once explicit, stories can be analyzed, and critiqued to identify learning and professional development. From the perspective of a nurse educator, for me, it was reflection-in-action, empathy, care and compassion, emotions, insight into self, gaps in knowledge, and how to tell a better more informed story. When the stories are shared, new insights can emerge building on them and developing additional insights, new ideas, meanings, and understanding not thought of when scrutinizing them alone. From my lens as a nurse educator, a different view of the power of doctors emerged and nothing is as it seems. The identification and mutual exchange of reallife experiences told in a story can facilitate learning, professional development, understanding, and
meaning finding and self-exploration and make a case for using story as an aid to learning. It highlights how stories can connect to practice and give access to the real world of nursing. The role of the educator can be more concerned with facilitating the exploration of practice rather than just disseminating knowledge. After this journey through practice using story, interesting and important issues remain to be explored, so in different ways the story continues.
References Attard, K. (2011). The role of narrative writing in improving professional practice. Educational Action Research, 20, 161-175. Bartlett, K. (2015). Wonderful stories about nursing are a fitting legacy. Nursing Standard, 25(42), 31. Berterö, C. (2010). Reflection in and on nursing practices: How nurses reflect and develop knowledge and skills during their nursing practice. International Journal of Caring Sciences, 3(3), 85-90. Boud, D. (2010). Relocating reflection in the context of practice. In H. Bradbury, N. Frost, S. Kilminster, & M. Zukas (Eds.), Beyond reflective practice: New approaches to professional lifelong learning (pp. 25-36). London, England: Routledge. Bruner, J. (2002). Making stories: Law, literature, life. Cambridge, MA: Harvard University Press. Calman, K. C. (2000). A study of storytelling humour and learning in medicine. London, England: The Stationary Office. Dewey, J. (1997). Experience and education. New York, NY: Touchstone. (Original work published 1938). Draper, J. (2014). Embodied practice: Rediscovering the “heart” of nursing. Journal of Advanced Nursing, 70, 2235-2244. Edwards, S. L. (2014). Using personal narrative to deepen emotional awareness of practice. Nursing Standard, 28(50), 46-51. Fairbairn, G. J., & Carson, A. M. (2002). Writing about nursing research: A storytelling approach. Nurse Researcher, 10, 7-14. Gaydos, H. L. (2005). Understanding personal narratives: An approach to practice. Journal of Advanced Nursing, 49, 254-259. Kothari, A., Rudman, D., Dobbins, M., Rouse, M., Sibbald, S., & Edwards, N. (2012). The use of tacit and explicit knowledge in public health: A qualitative study. Implementation Science, 7(20). Retrieved from http:// www.implementationscience.com/content/7/1/20 Mason, J. (2002). Researching your own practice: The discipline of noticing. London, England: RoutledgeFalmer.
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8 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX Masson, V. (2005). Voices of experience: nurses’ personal stories illuminate and enrich clinical practice. American Journal of Nursing, 105(12), 78-79. Matsumoto, Y. (2009). Dealing with life changes: Humour in painful self- disclosures by elderly Japanese women. Ageing & Society, 29, 929-952. Nelson, G., Andel, A., Curwood, S., Hasford, J., Love, N., Pancer, S., & Loomis, C. (2012). Exploring outcomes through narrative: The long term impact of better beginning, better futures on the turning point stores of youth at ages 18-19. American Journal of Community Psychology, 49, 294-306. Schon, D. A. (2002). The reflective practitioner: How professionals think in action. London, England: Ashgate Arena.
Thieman, L., & Darby, J. (2009). “Let me tell you about being a nurse.” Nursing, 39(48), 46-47. Van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. New York: State University of New York Press. Watson, F., & Rebair, A. (2014). The art of noticing: Essential to nursing practice. British Journal of Nursing, 23, 514-517. Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN, is currently a senior lecturer at Buckinghamshire New University. She teaches on the degree in undergraduate nursing. She completed her Doctorate in Education (EdD) using narrative inquiry in March 2013.
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JHNXXX10.1177/0898010115587582Journal of Holistic NursingNurses’ Narrative Journey / Edwards
1
jhn
research-article2015
Practice
The Personal Narrative of a Nurse A Journey Through Practice Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN Buckinghamshire New University, Uxbridge
Journal of Holistic Nursing American Holistic Nurses Association Volume XX Number X XXXX 201X 1–8 © The Author(s) 2015 10.1177/0898010115587582 http://jhn.sagepub.com
This article examines my phases of holistic learning concerning how I became a nurse, using story presented in a personal narrative style. I have incorporated my own stories to elaborate my journey. First, my early life in the East End of London and how this influenced my becoming a nurse. Second, I give an account of my journey through practice, where I examine how I developed my own learning from professional practice, drawing on some personal illustrations presented as stories. I have set out to explore how my stories of practice have influenced my progress, and I present a personal account of such learning in general from the lens of a nurse educator. Keywords: adults; students; holistic theories and practices; narratives; nursing practice and personal growth
Introduction Human beings have always told themselves and others stories, which explain what is happening, what they are doing, and why it is valuable. Health care relies on such stories that patients share, which enable nurses to understand the holistic needs of patients, and the stories that nurses tell helps them make sense of caregiving. In this article I concentrate on my stories that I have used and that have affected my practice and helped me learn and improve. In this way my practice has helped me gain insight, understand care and compassion, express emotions, and have a better understanding of and find meaning in clinical experience. When these experiences are ordered into stories and shared, new meanings and understanding can give birth to new ideas not thought of when examining practice alone. The purpose of sharing this is to help readers get enthused about what is possible as a student and with the help of others such as mentors. It is argued that by understanding our own stories, the habitual explanations of what is done and why, we are better able to understand, change, and deliver holistic practice. But this article starts from a slightly different place, a personal one, and the
sometimes uncertain process of making sense of messy experience is aided through the exploration of my narrative drawn from my own practitioner perspective facilitated by story.
Writing a Personal Narrative Gaydos (2005) and more recently Thieman and Darby (2009) identify that personal narrative is a form of autobiographical storytelling that gives shape to experience, with “narrative” being regarded here as a substantial big picture and “story” as a smaller part of it, as suggested by Fairbairn and Carson (2002). Personal narratives are important in nursing, as determining a person’s self-story is often a way of fixing a starting point for his or her struggle toward personal growth; for me this included using stories of my clinical practice experience. Author’s Note: Please address correspondence to Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN, Senior Lecturer, Department of Pre-registration Nursing, Faculty of Society and Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, Middlesex UB8 1NA, UK; e-mail: [email protected].
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I use my own personal narrative in the way identified by Gaydos (2005), who argued that narratives can restore feelings otherwise lost and provide direct contact with lives we formerly led or now lead. They can help clarify the important ways in which we are individuals in our own right with unique identities. This view resonated with me, as my childhood in the East End of London had become lost, and only when I joined higher education did my early background somehow seem significant. For example, Story 1: My Story 1 Significant to me and the use of stories, is that every Sunday all of my extended family would meet, sing, or just tell stories. One particular story details how my passionate nature can be linked to the fact that my grandfather was a Welsh farmer who was stationed in France during the First World War. While in France he met my grandmother, a French noblewoman of high birth. When she married my grandfather, her family, so the story goes, disowned her. Married, they both traveled back to England and found a rundown old house in the East End of London. I like to think I have a doctorate because my mother always believed in educating my sister and myself, encouraging us to stay on at school and sharing in our hopes and plans for our continuing education. My creativity and ingenuity are drawn from when I was a child, living on the 12th floor of a block of high-rise flats, where without assistance I could not reach the button to ride the lift back up, so I would carry a carefully designed stick in my back pocket. Innovation and creativity have been carried over into my professional life through my research and writing. My willingness to be open and to share my experiences with others is spontaneous, instinctive, and natural and originates in my experiences as a child in the East End where a strong sense of kinship based on trust existed with virtually every neighbor and local resident.
By engaging with and delving into my early life in the East End, I started to appreciate its role in shaping the person I have now become, and how it helped me develop a sense of self-understanding. Insight into myself allowed me to focus not on myself but on delivering compassionate care to others.
In Bruner’s (2002) book Making Stories, he refers to the “creation of self,” in which he implies that self is in some way external to, and separate from, the stories we make. He suggests that narrative only gives the briefest look at ourselves. Yet, in part, the purpose of personal narrative must be to reveal ourselves to ourselves. Indeed, self-awareness may not always focus on our personal concerns but can also involve a commitment to others. Thieman and Darby (2009) give a personal narrative that reveals a form of self-awareness that expresses their commitments and responsibilities as a nurse. This way of looking at self-awareness is one I find most useful as a nurse. By engaging with my personal narrative, I was able to delve into my early life, and through this process, I started to appreciate its role in shaping the person I had now become. For as nurses we are only capable of demonstrating empathy when we understand what we want to and are able to give, and this involves using self as part of becoming a nurse. Matsumoto (2009) demonstrates how unsettling narratives of life can be, and Bruner (2002) suggests this can apply to all of us. However, the purpose of writing my personal narrative using a collection of my own stories was to make sense of my own life lived in clinical practice, and though this was sometimes disturbing, I persevered. The personal narrative that emerged has brought my nursing life to the surface and given me an appreciation of the value of my own stories of clinical practice. Moving my stories of practice from being implicit or tacit to being explicit I critique, analyze, learn, and understand my practice better and as a nurse lecturer draw meaning from them.
The Beginning One Christmas, when I was 12 or 13, I was taken by my parents to the accident and emergency department of a very large London hospital, suffering from a headache and sensitivity to light. I was admitted with query bacterial meningitis, but as it turned out, I only had viral meningitis or bacterial encephalitis, which are not as serious as the former. I cannot remember which diagnosis was eventually given, but it was the lesser diagnosis, and as my mum and dad could not say either, it did not really matter that much to them anyway, as long as I was all right.
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While in hospital over the Christmas period, I enjoyed watching the festivities on the ward and realized that I wanted to become a nurse (My Story 2). My Story 2 Making the decision to be a nurse was only the beginning of things. When I made the decision that I wanted to help others, I had no idea of the great dive I would make into a strong current that was to carry me to places I had never dreamed of when I first made it. I never gave up on wanting to do nursing as my career. I had made my decision. I knew I would get to do it and I managed to just get into my nurse training with the minimum of five O levels.
I started as a student nurse in 1977, qualified in 1981, and worked as a staff nurse and sister until 1991. Yet I did not appreciate the significance and value of these years of clinical experience; they were tacit, unstated, and silent. I took it all for granted, not thinking very much about it, reflecting on it, or analyzing it; however, story helped me make my practice more explicit. As a lecturer I began to look back to my practice years and view them as stories worthy of being made explicit rather than remaining tacit. I remembered my life as a nurse on the wards, encountering practice as a realm of different experiences involving images, noises, sensations, smells, feelings, grief, happiness, caring, and loving. The experiences presented emerged as a language expressing my everyday practice life as a nurse, and I began to view them as stories worthy of bringing from being just tacit, in what I refer to as the prenarrative phase, to a phase of remembering (see later).
The Life Cycle of a Nurse People writing their personal narratives begin in many different places as described by Nelson et al. (2012). Gaydos (2005) highlights that narratives usually start with memories that are emotionally intense and important to self-definition. I start when I was a student nurse, and draw on my own stories of clinical practice. I reflect on my career as a nurse, and I look more closely at my own stories and how they had enhanced my own practice development. My lived experience has been narrated into story form, “organized” in order to make sense of my
clinical experiences, which up until this point were tacit or taken for granted. It is through the organization of experiences into story that helped me make explicit my clinical practice, which can then be analyzed and explored. Put another way, it is the perspectives we take on experience and the use we make of it that matter; story can be one way to facilitate this use. Stories have a message and communicate an idea, and possess a meaning for the teller and the reader. Uncovering the message is often the purpose of the story (Bruner, 2002), a view supported in a study by Kothari et al. (2012), although the message may be so well concealed that even the teller is not aware of it. Stories have an implicit message, or messages, but we can be blind to them. As I returned to my stories, I began to identify the particular aspects that stood out. I include my own stages that helped me develop insights into my practice, which have been labeled as the prenarrative stage and the stages of remembering, writing, and sharing. Each of these stages is explored and is crystallized in terms of my individual experiences.
The Prenarrative (the Representation of Experience) One starting point for the discussion on my use of story is the notion of embodied learning (Draper, 2014) incorporating, as Boud (2010) calls it, a “taken-for-granted phase”—a “presupposition,” that is, what exists prior to interpretation or cognitive or social construction. Mason (2002) recognizes that practice is embodied but refers to it as not noticing, in that it can exist apart from any meanings the individual gives to it. Watson and Rebair (2014) state that noticing is integral to nursing practice and thus “not noticing” can have serious effects. Van Manen (1990) also points to the prenarrative, which for him is the world as the nurse immediately experiences it rather than how she/he conceptualizes, categorizes, or understands it. Regarding my own narrative, I began to look back, from my current position as a nurse educator, at my learning through engaging with my stories and became aware of a period before remembering, a period when I walked through the wards day and night, encountering practice as my prelinguistic realm of experience. This was a time when I did not express what I was experiencing or
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indeed learning about, but I was at one with the world of clinical practice. I was conscious only of patients that I cared for and interacted with, and I took it all for granted, not thinking about it, reflecting on it, or analyzing it. I refer to this as my prenarrative stage. Thinking as a nurse educator and looking back to my own development as a nurse, I can identify a time when I did not notice my experiences of practice and was ignorant of their value and potential. However, I would not say that it passed me by. This world of immediate everyday experience, the world that I inhabited as a nurse, was always there as an inalienable presence, and it is this that I use as the starting point for my journey.
Remembering Stories About Practice For a story to be remembered, it has to have some sort of impact and (practice) value (Dewey, 1938/1997), perhaps involving emotion or feelings. Bruner (2002) argues that a story begins with some breach in the expected state of things, usually something going awry, otherwise there is no story to tell. The story has to be of a certain quality, and individuals can filter stories that are worth remembering and those that are not. Mason (2002) stresses the importance of filtering, as our attention is highly selective. Individuals undoubtedly need to sift through their stories to find the ones that are worth telling, as there is often too much to notice in any practical situation and we could not cope with all the possible interpretations. Remembering a story can make explicit the shift from the taken-for-granted prenarrative to the recognition of the experiences embedded in practice. Another way of putting this is that remembering can bring to the fore what is tacit or implicit in practice, and make it explicit or conscious. Stories have a role in the meaning-making processes needed to give sense to practical experience. The notion of remembering is represented by Mason (2002) and is termed noticing. Watson and Rebair (2014) point out that noticing is about how nurses can perceive what is happening around them, and should be something nurses do all of the time. As professional nurses, we are sensitized to notice certain things, particularly the patients we care for (My Story 3).
My Story 3 I arrived one morning as a student nurse, and following an assessment of my patients found that Fred needed to be washed and changed first, as he had been incontinent in the bed. I went to ask my colleague for assistance. She replied that her patient Angus needed to go to the toilet first, for which he required two people and he needed to go now. It was difficult at the time to decide who went first, I had to concede with my qualified colleague that Angus should go to the toilet first and we took him together.
This story, when examined through the lens of a nurse lecturer, features my development of reflection-in-action, first identified by Schon (1983) as the moment-to-moment decision-making skill that can contribute to professional practice. I had to consider both sides: On one hand, Fred, if left in a wet and soiled bed, could develop pressure ulcers. On the other, if Angus was left to wait for the toilet he might be incontinent and left in a wet and foulsmelling bed and at risk of developing pressure ulcers while waiting for us to finish washing Fred. The reflection-in-action takes place in my mind, my “on the spot” reflection, and enables me see to the tension, listen to other’s views, admit when I was wrong, and make the right decision. Berterö (2010) takes the view that exploring reflection-in-action through story can make it not only visible but also understandable, and the risk of taking practice for granted is reduced. The journey continued as I began to attend to, and make overt, certain features in my stream of consciousness that were my clinical practice experiences.
Writing the Stories Down In this phase I began to make sense of my stories, and according to Attard (2011) and Bartlett (2015), this is aided by writing the story down. Writing down stories can be very useful but is not enough, and Masson (2005) contends that if writing down the story is the extent to which (narrative) accounts go, the potential for influencing and informing the future is limited. As a nurse on the ward, stories helped me value my clinical practice experiences, and I began to uncover the potential for using stories as a way to
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organize and explore, to help me to understand and make sense of my own practice experiences (My Story 4). My Story 4 As a staff nurse a patient was admitted to the medical ward from Accident and Emergency following a stroke. It was very severe and he had lost all feeling down one side and lost his speech, except for the words “knife, fork, and spoon.” Over the next couple of days it was evident that every time you spoke to him, he could not express any other words except by stating clearly and precisely “knife, fork, and spoon.” I would say “Hello!” he would reply “Knife, fork and spoon!” Followed by “How are you feeling today,” his answer each time was “Knife, fork, and spoon.” It was frustrating for all the team and even more so for his loving wife of 60 years. He could not walk or communicate, and his condition deteriorated. The movement in his arm and leg never returned and he sadly died 5 days following admission. His wife was not upset or distraught, nor was she in floods of tears or inconsolable; she was desolate, lost, and looked abandoned by the sudden loss of her husband. She informed me just before she left the ward, what losing her husband felt like: “It is like a physical amputation; like I have just had my right arm cut off, and I would give it willingly if it would bring him back to me.”
I can see as a nurse educator that each story builds on another, and this story helped me not just be empathetic but also understand compassion toward patients and become sensitized to what it might be like for someone to suffer the loss of their lifelong partner. This story revealed more to me about compassion and caring than could have been achieved through theory alone. The story helped me see my practice and learn that I could not stand with his wife at the bedside without being deeply moved. I could not be an impartial authority without showing tenderness and reverence in the presence of death. In this practice experience, I can see I was intimately involved, something not possible when engaging with theory. I was uncertain as to whether it was acceptable to express my feelings and emotions, but building on my skills of reflection-in-action I managed my emotional attachment in a way that promoted both caring and compassion as well as resonating with my own identity as a nurse. I see
that part of my practice is emotional and that this helped me understand the context in which my nursing took place and learn more about myself. I thought about sharing these written personal experiences with others as my journey continued.
Sharing Stories Another element included in my journey through practice is the sharing of stories. One of the first stories I organized, wrote down, and shared was concerned with a patient I cared for while working in Australia (My Story 5). The stories I shared about my clinical practice are real (My Story 6). They enabled me to think about and reflect on what may have been happening, and promoted my understanding and learning (My Stories 5 and 6). My Story 5 One particular situation, while working as a nurse in Australia, was the case of a young Aboriginal man who had severe liver failure associated with alcoholism. He was admitted to intensive care with bleeding due to lack of clotting factors. It was rumored when he arrived on the unit “the bone had been pointed at him.” This, in the Aboriginal culture, meant that his spirit/soul had left his body and he was already “a dead man.” No one would visit him or enquire about his condition. To all Aborigines he was dead. I understood this as I had come across it before, and it was generally my experience the patient died. This was not what was so significant about the experience. I was caring for the patient, his condition was deteriorating; he was bleeding from his stomach, mouth, and rectum. Blood products and vitamin K had been administered to try and stem the bleeding. He continued to bleed and I was upset, as I had cared for him a number of days now, and no one had visited him in that time. The consultant doctor arrived with an assortment of junior doctors; he and his followers gathered around the bed, took one look at the patient and said “Well that’s it then!” I was furious and told him that if he could not be respectful to leave the bed area. My Story 6 A patient I cared for, back in England, had just returned from cardiac surgery and while recovering from the anesthetic he became very violent towards
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6 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX the nurses caring for him, swearing and using very strong language. He was thrashing out at nurses kicking, hitting, and swearing. This was affecting his blood pressure and heart rate, which could put too much pressure on his newly grafted cardiac/coronary arteries, so it was decided to ventilate and sedate him for longer. The next 2 days weaning from the ventilator was attempted but he again became violent toward nurses/staff and even his relatives; this worsened on suctioning down his breathing tube. His relatives were distraught as he was generally a very well-mannered man, kind, and caring’ they could not understand his behavior. It was decided that this behavior could be the result of his major operation and that he had undergone a personality change, which has been documented in the literature following surgery of this nature. On the third day it was decided to wake him up, as his physical condition no longer warranted further invasive ventilation and treatments. His drugs were reversed and in a matter of hours he was extubated. When he woke he explained to us that he thought the Irish Republic Army was torturing him: He had been in the army and had served in Northern Ireland during the worst of the trouble there.
Through my sharing of stories with students in the classroom and in my doctorate work in an open way, I could express my emotions freely to others. Edwards (2014) suggests that stories can have a huge emotional significance—essential for the development of holistic nursing. For, story can join all the separate parts involved in caring for individuals and the dimensions of nursing (including emotions), and connect each together as a whole. In addition, through sharing others can offer their opinions and see the various tensions and different choices that were available. Through the sharing process a deeper understanding of my stories began to develop. Through critique and analysis of them with students and supervisors I was able to locate additional insights that I had not observed when scrutinizing them alone. For example, Story 5 helped me view doctors from a different perspective. I had previously concluded that generally doctors had the authority in health care and nurses do as the doctors’ request, but caring for this patient changed this for me. I felt I was now telling them what to do with authority and
confidence and showing care and compassion for the patient. Nothing is what is seems in Story 6, and to fully understand confusion, disorientation, and aggressive behavior a broad range of knowledge and expertise is required before judgment about a patient’s mental state can be made. Prevention of violent incidents is the foremost principle, but this may not always be possible if physiological causes from which this patient could be suffering are the reason for the violence—for example, pain, hyperglycemia, neurological impairment, and side effects of medicines. My written stories when shared helped me remember other stories. Sharing stories also encourages others to remember their own stories. Stories are, in my view, the common language of nurses, as they use a shared language, common to all and require no additional knowledge of complex medical terminology. I needed to be able to express myself to others, to get my voice heard (My Story 7), to speak in my own words, the language of practice. My Story 7 When I was a staff nurse in charge of a general medical ward I had in the course of the afternoon noticed a patient’s condition was deteriorating. I called the doctor, as I was concerned. I felt the patient needed to be reassessed. I got the doctor on the phone and he promptly asked me “What is the patient’s blood pressure?” I went to look at the patient’s chart, got the results, and returned to the phone to inform the doctor. Once completed I was asked another question and each time I went back and forth to the charts or patients notes to find out the answer to each question in turn. My inability to tell the full story to the doctor about the patient’s worsening condition failed to get the doctor’s same level of concern, consequently the doctor did not come.
The experiences presented as story made me feel inadequate as I could not communicate to a doctor about a deteriorating patient, and as such this story did not contribute to my sense of fulfillment as a nurse. However, I learned that by turning around the feelings derived from the story I was cementing more sharply applied learning. What emerged was an awareness of gaps in, and a need to update and
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add to, my knowledge, as I struggled to articulate in medical language my feelings of unease. I was showing concern about a patient, but I could not tell this to others: I had to use another language the language of medicine. Story can be a language expressing everyday practice life as a nurse in a way that medical language alone cannot. Calman (2000) and Edwards (2014) suggest that nurses need to learn how to tell their stories better. Consequently, later on in my journey I learned to tell better stories, I told them to doctors over the phone. The use of story allowed me my own style of expression, assisted my communication, and gave me a voice: The subsequent times, I used story, the doctor always came.
Conclusion In this article I detail how I came to value my early life as significant in my development as a nurse, educator, and researcher. I show how in this way my clinical practice experiences presented as story helped me unscramble, assess, and explore my practice in an attempt to develop a better understanding of it from the lens of a nurse educator. I found it useful to divide my practice narrative into four stages—prenarrative, remembering, writing stories down, and sharing stories. By using such a strategy, my practice became structured and more differentiated rather than remaining undifferentiated and unstructured. In this article I begin to acknowledge and identify the tacit implicit nature of my clinical practice experience and to develop the use of story as a strategy for making it explicit. Once explicit, stories can be analyzed, and critiqued to identify learning and professional development. From the perspective of a nurse educator, for me, it was reflection-in-action, empathy, care and compassion, emotions, insight into self, gaps in knowledge, and how to tell a better more informed story. When the stories are shared, new insights can emerge building on them and developing additional insights, new ideas, meanings, and understanding not thought of when scrutinizing them alone. From my lens as a nurse educator, a different view of the power of doctors emerged and nothing is as it seems. The identification and mutual exchange of reallife experiences told in a story can facilitate learning, professional development, understanding, and
meaning finding and self-exploration and make a case for using story as an aid to learning. It highlights how stories can connect to practice and give access to the real world of nursing. The role of the educator can be more concerned with facilitating the exploration of practice rather than just disseminating knowledge. After this journey through practice using story, interesting and important issues remain to be explored, so in different ways the story continues.
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8 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX Masson, V. (2005). Voices of experience: nurses’ personal stories illuminate and enrich clinical practice. American Journal of Nursing, 105(12), 78-79. Matsumoto, Y. (2009). Dealing with life changes: Humour in painful self- disclosures by elderly Japanese women. Ageing & Society, 29, 929-952. Nelson, G., Andel, A., Curwood, S., Hasford, J., Love, N., Pancer, S., & Loomis, C. (2012). Exploring outcomes through narrative: The long term impact of better beginning, better futures on the turning point stores of youth at ages 18-19. American Journal of Community Psychology, 49, 294-306. Schon, D. A. (2002). The reflective practitioner: How professionals think in action. London, England: Ashgate Arena.
Thieman, L., & Darby, J. (2009). “Let me tell you about being a nurse.” Nursing, 39(48), 46-47. Van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. New York: State University of New York Press. Watson, F., & Rebair, A. (2014). The art of noticing: Essential to nursing practice. British Journal of Nursing, 23, 514-517. Sharon L. Edwards, EdD, MSc, PGCEA, DipN (Lon), RGN, is currently a senior lecturer at Buckinghamshire New University. She teaches on the degree in undergraduate nursing. She completed her Doctorate in Education (EdD) using narrative inquiry in March 2013.
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