Patricia Benner, R.N., Ph.D. FAAN
During the past 30 years, more ethicists have paid attention to the role of narratives in presenting exemplary practice. More attention in learning and understanding moral life and ethical comportment is being paid to exemplary people and events that reveal and demonstrate excellent ethical comportment. Narratives can reveal the actor’s agency in the situation, and also create aspirations to live up to the excellent lives and events (Benner, 1984; Benner, Kyriakidis, Stannard, 2010; Zagzebski, 2015). In her 2015 Gifford Lectures, Dr. Zagzebski explores moral theory in relation to exemplars, and in relation to education. She points out that exemplars usually presented in some narrative form helps us understand the good life, but also makes us want to emulate the exemplar. Narratives are typically organized by the concerns related to the event and by notions of good, and breakdowns in practice performance. Narratives can capture relational ethics, contextual aspects of clinical situations, and also thinking-in-action as the event unfolds. It is hard to imagine how we could teach any practice discipline without using narratives that present excellent practice and/or excellent practitioners to fill in how the science, knowledge, and notions of good practice can be embodied and lived out by the practitioners.
In our scientific and technological age, narratives tend to get marginalized. We like algorithms, “standards”, decontextualized “objective” truths. But no practice can continue to be self-improving, or a living practice without working out how the science and technology are to be used to help and not harm. Business speaks in terms of the bottom line. The shorter the text messages, the better. It is getting harder for us to slow down and listen, pay attention, and learn directly from practice experience (Crawford, 2015). In our hurried, fast-paced work, we want the “gist” or Cliff Notes version of the story. We do not worry about covering over subtle relational aspects of the story. We want the story mediated by theory, or a classification of the story’s genre. In this post-modern information age, we prefer to go behind the story and explain it rather than to enter it in order to understand what happens, what matters, what are the concerns, and risks? We typically want to “stand over against” the story and explain it rather than understand it. But in the relational, caring work, that we do in nursing, medicine, social work, and teaching, it is the experiential learning that comes from that immersion real lives and real events that are essential to a self-improving and good practice. I want to draw to our attention to what can be learned, “caught” and taught by narratives. To fully embrace this it is essential for you to take narratives seriously in their own terms and not dismiss them as “soft” or unable to teach us about good practice in their own right.
Narratives can Capture Clinical Reasoning Across Time in Unfolding Cases
Clinical reasoning is a form of practical reasoning; in fact, clinical reasoning is a perfect analogue for practical reasoning. Significance, the “in-order-to”, the “for-the-sake” of particular concerns are described and exemplified in actual clinical situations. Narratives unfold as an event changes across time, and these changes described by nurses in narratives help both the narrators and students, better understand patients’ responses to therapies across time, and notice and understand different trends and trajectories of patient’s illness as described across time by narrative.
First person experience in caring for patients, or in the patient’s family stories about an illness, captures clinical reasoning across time through changes in the patient and or changes in the clinician’s understanding. Clinical understanding requires context and sequence of events over time to be understood. (Benner, 2001; Benner, Hooper-Kyriakidis, Stannard, 2010).
Narratives can Reveal the Narrator’s Perceptual Grasp of the Whole Situation and Guide How Thinking Unfolds in the Situation
In the book, “Logic of Practice”, Bourdieu (1980;1990) points out that human experts start their engaged practical reasoning by recognizing the nature of the whole clinical situation. This gives the clinician a way to start, considering only the most salient aspects of a whole clinical situation, i.e., the most significant, relevant aspects in a particular clinical situation at the time. By recognizing the nature of a whole clinical situation, and coming to the situation with a deep background understanding, the clinician does not get lost in multiple variables that are not relevant in the situation. In philosophy, the problem of proliferating variables that come up when building a situation element by element was called “the limits of formalism” in the earlier stages of artificial intelligence. Reading and writing and reflecting narratives help students better recognize the nature of whole situations. Human experts have to stay open and curious, because we can come to the situation and misunderstand it, get the wrong “take” or grasp of the situation. The human expert requires openness and curiosity. For example, the expert nurse must consider the question, “If the is volume depleted, why is his blood pressure not responding to the bolus of fluids?” The expert must be flexible and open to disconfirming, or counter evidence, to his or her grasp of the situation.
Clinical Narratives Organize Concerns in the Narrated Event
Narratives are organized by concerns of the clinician involved in the clinical situation. Students learn a sense of salience, in the particular clinical situation as it unfolds in the story. A sense of salience is based on background experiential learning, about what is more or less important in different clinical situations. A sense of salience is more often “caught” rather than “taught” explicitly outside particular clinical situations. A sense of salience cannot be isolated from context because something is only significant relative to the particular important concerns in the situation. This is why opportunities for situated thinking and coaching are necessary for any practice discipline. Narratives include the intents, meanings and notions of good in the telling of the eventful story itself. For example, a nurse might say: “I was concerned that he had misunderstood the nature of his disease and the purpose of the surgery.”
Human experts handle context, and the meaning of the ordering of changing events. These are called the “Frame Problem” and the “Changing Relevance Problem” in early AI attempts to build situations element by element. (Dreyfus, 1992; Rubin,J. in Benner et.al, 2009)
Human Expertise comes from being Immersed in Real Situations and Learning from Them: Practice is a way of Knowing, in its own Right.
The clinician always knows more than they can say (Polanyi, 1958). Narratives disclose practical and ethical reasoning in accounts of real events as experienced by the story teller.(Dreyfus,1992; Geertz, 1987) When a student describes a clinical situation narratively, they can learn to articulate skills, notions of good, manifestations of particular clinical conditions and so on, even before they completely understand them, and even when they don’t have clear explanations for events. In retelling a clinical experience in an ‘experience-near’ students will notice new aspects of the situation as a result of the telling. Narratives can raise questions and consciousness so that discovery, understanding and even explanation can proceed. Skilled know-how, knowing-how and knowing-when, is a form of practical knowledge rich with contextual knowledge that goes beyond “knowing about” and “knowing that.” Much unarticulated knowledge is embedded in the practice of a clinician describing a clinical situation.
Emotions, and Emotional Engagement with the Patient and the Patient’s Situation Create a Primary Perceptual Access to Situations and to Rationality
Skills of patient involvement can be revealed in narratives. One of the measures of a nurse’s involvement with the patient/family is how much the reader or listener learns about the patient’s personhood and concerns in the nurse’s narrative of a particular clinical situation. If the storyteller discloses little about the patient as a person, most likely the nurse has not been engaged by the patient’s story or life-world concerns or threats to identity created by the illness. He or she has not been sufficiently open and curious or immersed in the clinical situation. Students can gain clinical and relational imagination by hearing how a nurse related to and connected to patients/families in particular clinical situations. Rational problem solving is inextricably linked to emotional openness, and attunement of the problem solver (See Damasio, 1994). Separating the cognitive and affective domains is never really possible within the person or learner, because one’s access to any situation is through emotional valences—openness or defensiveness, closed mindedness and so on.
Learning from Narratives Can Create Emotional Learning, along with Clinical and Moral Imagination.
Narratives enable students to learn by narrated examples of particular nurse patient relationships. Narratives of actual clinical situations can be singular universals for the clinician and the listener. For example, a clinical story of staying connected, curious and responsive about a patient’s fears around dying can help the clinician respond in situations that have the same “universal concern” but quite different facts, or even context. A socially-embedded practice, particularly one that depends on connection, trust, communication and relationality to engage meaningfully with patients and families, requires the kind of relational qualities and meanings that are encountered by being in the situation, or by having someone else vividly describe the situation. A practice is always storied.
We enlarge relational, ethical, clinical imagination through discovering actual concrete possibilities in practice as revealed by narratives about specific patient situations. Narratives open up mood, connection, and one’s relational stance within the particular clinical situation. Students learn vicariously, the skills of patient and problem engagement from narratives, where things went well, or broke down.
Narratives can uncover Real Events and Understanding of Unfolding History (both immediate and long-term history)
Vivid narratives come from an immersive experience where new insights are gained. The embodied skillful knowledge of the clinician experiences the clinical situation from a deep background understanding, and being attentive and involved in the clinical situation. Good practice requires a skillful clinical agent who cares about what happens in the clinical situation. The story teller himself or herself, usually learns from telling a clinical story, noticing new aspects of the situation through remembering and describing the unfolding events. The practitioner and/or listener can gain new possibilities in practice. For example: “Oh, the nurse didn’t insist on the patient doing P.T. first thing in the morning because of the patient’s arthritis pain.” Through particular clinical stories, students can develop a more nuanced, moral and clinical imagination what is likely to be effective or ineffective.
Narratives Can Reveal Perception and the Narrator’s Perspectives
The story teller’s perceptual grasp and access to the clinical situation are revealed in the narrative through details such as where the story begins, what is included, what might be left out, what the storyteller notices, or fails to notice. How the clinician’s understanding changes as the story unfolds with the event narrated. Knowing how, knowing when, situated use of knowledge can be revealed in narratives. One can move theoretical knowledge and concepts into actual use within clinical situations and gain a deeper understanding of the concepts. It is this kind of practical situated thinking that is at the forefront of educational research, due to the discovery that students may understand complex statistical concepts, or math problems in practical situation, when they cannot recognize or think explicitly about the statistical or mathematical theories behind their practice (Chaiklin and Lave, 1993; Lave, 1988). Narratives from actual practice can help students learn how to be engaged and think like a nurse. Skills of problem engagement and patient engagement can be exemplified and better understood in narrative accounts of real patient relationships and illness/care situations.
Narratives can Reveal Biases and Blind Spots, and Raise the Listener’s or Reader’s Consciousness
Narratives can enlarge one’s ability to understand different cultures, families and social situations. In this way, especially when thoughtfully reflected upon, narratives can raise one’s consciousness. Consciousness-raising, where learners encounter their own biases and blind spots in actual situations, can expand learners’ understandings, capacities to relate, and can enable the learner to be more open and fair-minded when confronted with different life-worlds, values and social practices.
Narratives are a form of indirect discourse, to use Kierkegaard’s language (Kierkegaard, 2004). Narratives give an inside, engaged account of actual practice, and real life-world concerns. All human beings are finite with their own cultural, experiential and time-bound understandings. Narratives can help students gain a better vision of what skillful engagement looks like with the problem at hand, or with interpersonal concerns of the patient and family because narratives can help us dwell in a different life-world through example, illustrations, relationships, and concerns.
References and Bibliography
Benner, P.( 2001) From Novice to Expert. Upper Saddleback, NJ: Prentice-Hall
Benner, P., Hooper-Kyriakides, P., Stannard, D. (2010, 2nd Ed.) Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach. New York: NY. Springer
Benner, P. (1994c). The role of articulation in understanding practice and experience as sources of knowledge in clinical nursing. In J. Tully (Ed.), Philosophy in an age of pluralism: The philosophy of Charles Taylor in question (pp. 136-155). New York: Cambridge University.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010) Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass and Carnegie Foundation for the Advancement of Teaching.
Bourdieu, P., (1980;1990) The Logic of Practice. Stanford, CA: Stanford Univ. Press.
Chaiklin, S., Lave, J. (1993) Understanding Practice. Cambridge, UK: Cambridge University Press.
Charron, R. (2001). Narrative medicine, a model for empathy, reflection, profession and trust. Journal of American Medical Association, 286(15), 1897-1902.
Crawford, M.B. (2015) The world beyond your head: On becoming an Individual in an age of distraction. New York, NY: Farrar, Straus and Giroux.
Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt.
Damasio, A. R. (1994). Descartes error: Emotion, reason and the human brain. New York: Putnam.