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Claiming the Narrative Wave With Story Theory

Liehr, Patricia PhD, RN; Smith, Mary Jane PhD, RN, FAAN

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doi: 10.1097/ANS.0000000000000303
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Abstract

SURFERS CATCH the wave at a very precise moment to allow for the most energized ride to the shore. Yogis,1 an experienced longboard surfer and a philosopher who ties surfing to everyday living, talks about chasing the rhythm of ocean “bursts”: “Senses move from fuzzy to high-definition. Brain and lungs and heart begin to tingle. And with each silly surge, I am lighter...” (p. xiii). Some of us catch the wave in a much gentler manner than surfers, while we are at least waist-deep in salt water. As the wave rhythm peaks before breaking, it lifts us off our feet for one exhilarating moment. We diligently watch for the next opportunity and we do it over and over again, sometimes drifting easily toward the shore as the zenith of each wave subsides.

Over the last few decades, there has been a narrative wave that has advanced and subsided but subtly moved toward endorsement by prestigious creditors, such as the Institute of Medicine,2,3 through a focus on patient-centeredness, and the National Endowment for the Humanities,4 through recognition of the powerful healing nature of coming to know through literary processes. There is hardly a week that is devoid of the power of story to affect health, such as reaching those with dementia,5 affecting life change for veterans,6 or shaping the identity of adolescents across diverse cultural origins.7

Actually, nursing may have been one of the first health care disciplines to catch a tip of the narrative wave when Nightingale discussed the importance of listening and the need for nurses to beware of inundating those in our care with too many distracting words.8 She was giving attention to the prudent use of words during nursing practice. Despite this early recognition of the power of words, story took a back seat as an indicator of well-being, often relegated to a category named “anecdotal,” while numerical descriptors rose to superiority as valid empirical data. According to Reed, empirical data extend to include observation of “biological indicators, self-reports, investigator perceptions, informant projections, motor behavior, and personal stories.”9(p74)

Peplau10 emphasized the importance of attention to listening, prompting query about

Statement of Significance

What is known or assumed to be true about this topic:

Nurses have long known the importance of narrative for nursing practice. In practice, we routinely pursue stories to inform our actions. In qualitative research, stories are data. Despite our recognition of the importance of stories for the discipline, we have had limited discipline-specific structural guidance regarding approaches for embracing narrative as critical evidence.

What this article adds:

This article provides a structure, story theory, which can be used to guide story-sharing in practice and story-gathering in research. It offers a way for nurses to recognize and use stories from practice and research as valuable guiding evidence. In doing so, it also offers a way for nurses to claim the narrative wave as a dimension of disciplinary knowledge development.

the patient's perspective and the details that infuse the perspective with meaning. Berman and colleagues11 addressed the importance of marrying words with numbers to broaden one's sense of what is being observed when creating a direction for change ... so, 2 decades ago, the narrative wave was rising for the discipline of nursing and these days, we are more likely to be catching the narrative wave. In reality, words, narrative, and stories have had a pivotal place in nursing practice over the decades. Novice to expert nurses know that hearing what patients have to say is critical to the delivery of quality care. However, nurses have been slow to claim the narrative wave as a disciplinary force that can bring energy to every encounter with those in our care or enable high-definition clarity about human experiences when systematically applied in nursing research. The purpose of this article is to describe story theory within the context of claiming the narrative wave to advance knowledge for the discipline of nursing.

CLAIMING THE NARRATIVE WAVE WITH STORY THEORY

Story theory

Story theory, first introduced in 1999, is grounded in early research and practice experiences of the authors.12 We found that when inquiring about a topic that deeply resonated with another, such as being pregnant in high school or moving beyond a heart attack to get on with everyday living, there was an outflowing of thoughts and feelings about times and circumstances that were both revealing and meaningful to the person. It came to us that when telling one's story with someone who is intentionally listening, there were moments of insight for the person that enabled acceptance of one's life circumstance if only for the moment. We were also aware that this moment had the power to set the stage for future direction. We originally called this acceptance of the moment, attentively embracing story, the original theory name.12 With critique from colleagues, we eventually changed the name to story theory.13

Story theory holds assumptions from the unitary transformative philosophical perspective as described by Margaret Newman and colleagues.14 The interrelated assumptions of story theory are that persons (a) change in a transformative mutual process with their world; (b) live an expanded present where the past is expressed in the moment while future intentions are taking shape in the here and now; (c) experience meaning as a resonating awareness that comes with reflection on what is, was, and can be.13 These assumptions come together as a foundation for the narrative happening that occurs when a person engages with the nurse who is guided by the theory. In this narrative happening, persons connect with self-in-relation to their world through intentional dialogue with the nurse who cares to listen. In “ah-hah” waves where insight surfaces to make meaning of life circumstance, ease is possible for the person engaged with the nurse.

The 3 concepts of story theory are intentional dialogue, connecting with self-in-relation, and creating ease.13Figure 1 depicts the relationship of the concepts with each other along with concept-related processes that bring the theory to life in practice and research. The first concept, intentional dialogue, is the central nurse-person process for gathering a story of a health challenge that complicates everyday living. The challenge is sometimes simple and sometimes complex but regardless of its intricacy, it always complicates the life of the person who is engaging with the nurse to tell the story. Essential to intentional dialogue is the nurse's true presence, nonjudgmental focusing/refocusing on what is, was, and can be, all in the context of what matters most about the health challenge. As the story unfolds, the nurse queries emergence by centering on understanding the story from the other's perspective. Nothing can be assumed about another's story. Only the person who has lived the experience knows the story particulars, choosing to tell only so much at a time. In this way, the story is never finished; there is always more.

Figure 1
Figure 1:
Story theory model. Reprinted with permission from Liehr P and Smith.13

The second concept is connecting with self-in-relation,13 an active engagement in the process of acknowledging self as related to others in a developing story plot that is uncovered through intentional dialogue. This includes awareness of significant people and times, bodily expressions (eg, symptoms; physiologic indicators; feelings), and a sense of both history and future in the present moment.

The third concept of story theory is creating ease.13 Ease comes as story moments come together and there is an “ah-ha” lift of understanding that allows freeing oneself from previously self-imposed limits. Freeing oneself is a manner of moving to resolve a health challenge.

Table 1 defines theory assumptions about change, expanded present, and meaning. It also describes story theory concepts of intentional dialogue, connecting with self-in-relation, and creating ease, articulating connections to the integral processes essential for theory use in practice and research.

Table 1
Table 1:
Assumptions and Concepts of Story Theory

Engaging to hear another's story

The principles of theory-guided story engagement are consistent regardless of whether the nurse is practicing or doing research. Engaging to hear another's story requires (1) true presence, (2) reflective focus on connecting (time with time, self with self, and self with others), and (3) sensitivity to a wave of energy that indicates ease. We have found that an effective way to catch the holistic rhythm of a health challenge story is to use a story path.13 Story path begins with a dialogue on where the person is at the present time with a health challenge by asking the question, “What matters most to you right now about your life situation?” Next, the query extends to the past with a discussion of happenings in the past related to the present circumstance that matters most. The last phase of the story path approach is to move to the future by asking about hopes and dreams as related to the present circumstance. A story path can be depicted on a horizontal line (see Figure 2). Bearing witness to another's story by way of cocreating a story path can enable vision with glimpses into the complex context of one's circumstance and provide a sense of previously unrealized understanding or ease.

Figure 2
Figure 2:
Rose's story path.

Engaging to hear another's story in research, story-gathering, is distinguished from story-sharing, the narrative happening that occurs in nursing practice. Distinguishing qualities of gathering and sharing become apparent as each is described.

Implicit in story-sharing is the recognition of a health challenge, which can be any life circumstance that is complicating living in the moment. When using story theory to guide practice, the nurse's intention is to promote ease by coming to understand what matters most, supporting the story-sharer's weaving of a coherent “whole” in the process of dialogue. Even when someone is managing a life-changing diagnosis such as breast cancer or HIV, what matters most may be a circumstance such as physical appearance or work responsibilities. Story theory requires that the nurse stay with the concern that matters most, knowing that it is one relevant thread of a complex health challenge that has brought the story-sharer to the health care provider. When engaging in story-sharing, the nurse does not name the focus of dialogue even in the presence of a known life circumstance or diagnosis.

When using story theory for research, the nurse's intention is to address a research question through systematic story-gathering. Unlike practice where the story-sharer names what matters most, the nurse researcher approaches the participant knowing a phenomenon of interest that is central to a research question. For instance, the researcher may be interested in understanding the health challenge of obesity or losing a loved one or beginning life as a married woman. Dialogue begins by exploring the present experience of the health challenge being studied, before moving to the past and then the future. Table 2 presents the story of Rose, collected as part of a research study on the health challenge of being overweight. In this instance, Rose's story is an exemplar to demonstrate the nature of the information that can be gleaned when using a story path. It is one record in a data set exploring the health challenge of being overweight.

Table 2
Table 2:
Rose's Story

Using story theory to guide research

When using the story theory to guide research, the recorded story-gathering is transcribed and read carefully to make a judgment about the description as related to a research question. Story inquiry method, a systematic qualitative approach, provides guidance for analysis. The 5 processes of story inquiry method are as follows: (1) gather stories about a health challenge that complicates everyday living; (2) decipher dimensions of the health challenge; (3) describe the high points, low points, and turning points of the story plot, (4) describe movement toward resolving; and (5) synthesize the findings to address the research question.13 The research question directs the analysis and may include one or all of the concept-related processes: complicating health challenge, developing story plot, and/or movement toward resolving. In the example of Rose's story, the research question was: “What is the story plot (high points, low points, and turning points) related to the health challenge of being overweight?”

High points are defined as times when things are going well, low points as times when things are not going well, and turning points as deciding moments or shifts in perspective that alter life direction.13Table 3 represents story plot components of being overweight for Rose.

Table 3
Table 3:
Rose's Story Plot With High Points, Low Points, and Turning Points

The high points, low points, and turning points in Rose's story plot begin to paint a picture of significant dimensions of the health challenge of being overweight. This exemplar on use of story inquiry method analysis with one individual would be repeated with the remaining participants in the study. A synthesis would then be created by lifting the level of abstraction in the grouping of high points, low points, and turning points across all participants to create the findings regarding the story plot of being overweight. A synthesis of high points, low points, and turning points is a pattern of the story plot for the health challenge of being overweight. When analyzed in this way, the nurse researcher would be using a deductive content analysis process, sometimes called directed content analysis,15 to distinguish high points, low points, and turning points. However, analysis of story data can occur by applying phenomenological as well as content analysis approaches, inclusive of deductive and inductive processes. Regardless of method, an accumulation of studies conceptualized using story theory to investigate a health challenge will generate nursing knowledge for application in nursing practice.

Table 4 highlights research that has integrated story theory to guide study methods.

Table 4
Table 4:
Story Theory–Guided Research

Seventeen research studies were identified through 2 approaches: a CINAHL search using the search term “story theory” and identification of research studies in a recent chapter addressing story theory.13 All 17 cited story theory in their reference lists. The studies, which were published between 2006 and 2018, include 8 published in the past 5 years. In addition to study method (eg, story inquiry, content analysis, phenomenological), Table 4 notes the studies that used a story path for data gathering and those that explicitly addressed the health challenge and story theory concepts, connecting with self-in-relation and creating ease, in the research question. Eighty-two percent of the studies used a story path for data gathering; 41% specifically addressed the health challenge with story theory concept-related processes in the research question. These studies often used story inquiry method, inclusive of inductive/deductive content analysis. Some of the health challenges addressed in these studies were lifestyle change,19 coming home from war,24 living with diabetes,25,32 and Native American adolescent stress.22 When the research question did not explicitly cite processes relevant to theory concepts (health challenge; story plot; moving to resolve health challenge), the health challenge being investigated was implicit in the question. Examples of health challenges implicit in research questions include headache for adolescents,31 informal caregiving,17,21 and integrating exercise breaks into the workday.26

When the method was identified as “phenomenological” and the question asked about the structure of meaning of the lived experience, then connecting with self-in-relation could be found in the themes that depicted the meaning of the lived experience. Some examples of connecting with self-in-relation from the studies in Table 4 include self-knowledge and seeking relationships with others for adolescents who are overweight,18 recognizing self as vulnerable for women with migraine headaches,23 mothering,29 and a changed view of self for female veterans coming back from war.28

Moving to resolve a health challenge enables ease; 47% of the studies noted in Table 4 addressed the idea of “moving to resolve” the health challenge even when it was not specifically noted in the research question. For instance, the earliest study in Table 416 used 24-hour ambulatory blood pressure as an indicator of ease responsive to story-centered care. In another example, a study of headache in adolescents31 reported that adolescents used self-management of medication, sleep, and self-transcendence to resolve their challenge. Sometimes, resolving is a future-oriented reality. Beginning to think about how things could change in the future uncovered these descriptions: reaching out to create meaning and comfort,20 choosing a positive outlook,19 making the most of pain-free time,23 accepting support,27 and developing inner strength.30 Ease is a lived experience of health, and studies that describe movement to resolve a health challenge contribute to the body of knowledge on this critical experience of health.

Using story theory to guide practice

Story theory provides appropriate guidance for practice whenever the nurse is working with a person who is confronting a health challenge. Health challenges are life challenges that can range from time-limited worries to planned life-change events to life-altering diagnoses. Health challenges are circumstances that create uneasiness for someone in the nurse's care. Engaging another in story-sharing may occur for only one short time, or it may occur over multiple visits, as would be expected with nurse coaching encounters.33 Regardless of the length or frequency of the encounter, the story-sharer guides the direction of dialogue when identifying what matters most.

There are multiple approaches that can be used for story-sharing in practice, and each is tied to what matters most while connecting with self-in-relation through story plot. For instance, a family tree can be cocreated with the story-sharer to shed light on sources of support and connection. One powerful approach for use during story-sharing can be review of relevant self-monitoring data, such as 24-hour blood pressure monitoring for a person diagnosed with early hypertension16 who wants to avoid taking antihypertensive medication. The most frequently used engagement approach for both practice and research is the story path. Figure 1 represents a story path configured using Rose's story as a practice exemplar. The large dark circle represents Rose's identification of what matters most. The descriptors around the horizontal line represent high points and low points. The small gray circles on the line indicate turning points.

Attending to what matters most, Rose is embarrassed about her size, she has no time to exercise, and she has difficulty following her diet. This pressing concern is juxtaposed with her belief that she is on the path to weight loss by following a stricter diet and exercising. The juxtaposition creates a nexus for the nurse's dialogue with Rose during nursing practice. There would be more discussion about the space between what matters most and reaching her goal of 170 lb. There may be inclusion of electronic monitoring of activity and daily calorie intake that could be the substance of ongoing discussion. The nurse would want to know more about Rose's connection with her parents and how her engagement with them may or may not support her goal of weight loss. The story path becomes a document of focus for ongoing practice sessions.

Nurses rely on story-sharing during practice to optimize care and promote ease. However, there is little published work linking theory to practice stories in the peer-reviewed nursing literature.34 Story theory is one structure ideal for uncovering the theory-practice link by providing direction for story-sharing/health-coaching activity. Nurses are well prepared to claim the narrative wave in nursing practice and story theory can facilitate claiming.

THE NARRATIVE MOVEMENT

The definition of story theory proposed by the authors indicates that “story is a narrative happening of connecting with self-in-relation through intention dialogue to create ease.”13(p244) This definition locates story within the larger context of the narrative movement that has received mounting attention in recent years. This theory context calls attention to the norm of correspondence proposed by Kaplan35 as the foundational philosophical conception of truth when considering the importance of a theory. Correspondence poses the question: “How does the theory fit the existing evidence? For story theory, does it fit as a narrative happening?”

Charon36 popularized the phrase narrative medicine. She believes narrative medicine engages health care providers in a “fellowship of mortality,”4 where the common ground of humanness sets the stage for meaningful conversation and where the “N of one”'4 shines as a way for the provider to understand patient uniqueness. She identifies 3 dimensions of narrative medicine: attention, representation, and affiliation.37 Attention, recently described as radical listening, is giving self over to the story of the patient.4 Representation, the recording of another's story, extends beyond traditional chart recording to include the provider-patient encounter. Finally, affiliation is referred to as the “goal of care”4 that shifts interactions from problem solving to witnessing.

Fitzpatrick and colleagues38–40 offer narrative nursing as a reflective practice of storytelling about personal experiences with patients and families. Storytelling comes as one thoughtfully considers meaningful situations with patients and families and then shares these experiences with other nurses and student nurses.

The descriptions of narrative medicine and nursing resonate with story theory. Each has a strong emphasis on connecting to hear the unique story of another. The distinguishing quality occurs with story theory's structured guidance for research in both story-gathering and story analysis. This sort of guidance is an untouched quality in either narrative medicine or nursing, which both primarily focus on education and practice. Still, the ideas from narrative medicine and nursing contribute to the complex pattern of connection characterized as correspondence, which Kaplan notes as reliant on “the bedrock of common sense.”35(p313) Charon and Fitzpatrick are not the only scholars who have caught the narrative wave in the last few decades. Other scholars have addressed the wave through life story work, digital stories, and talking circles. Each is briefly addressed to emphasize the nature of the wave and correspondence with story theory.

Life story work is a biographical approach designed to center on the story of past, present, and future thoughts and experiences in order to help people integrate the past into the present with the future to enhance well-being.41,42 Davies and Hodges41 based their work on attachment theory with children who experienced being separated from family and suffer significant trauma. The authors use an attachment line to track the child's experiences of home care, foster care, adoption, and other significant and traumatic life changes. They indicate that this line can facilitate connecting past, present, and future in a way that the child can then begin to find resolution and healing. The attachment line promoted by these scholars corresponds with the story path, guided by story theory. Interestingly, both the attachment line and the story path are theory-guided albeit from distinct but related disciplinary perspectives, psychology and nursing.

Digital stories are short audiovisual narratives that synthesize components such as personally spoken story words, images, and music to create a powerful multimedia product that documents life experience.43 The field of digital storytelling has been gaining momentum during the past decade, boosted by endeavors such as StoryCenter.org44 and StoryCorps.net.45 The systematic approach provided by StoryCenter has spawned research that was couched as an “innovative community-based participatory method” in 200943 and a “critical narrative intervention” in 2019.46 Implicit in StoryCenter's structured approach is human connection through story-sharing.

Talking circles emerged from Native American tradition as a way to respectfully come together to share significant stories in an environment of “complete acceptance by participants.”47 In addition to accomplishing the purpose of enlivening human connection, the talking circle also serves as a ritual for healing.47 It invites speaking from the heart, engaged listening, and honoring what is said as sacred and protected. It is a symbol of belonging, where an atmosphere of safety is created supporting participants to express thoughts, feelings, and opinions without judgment.33

Struthers,48 a Native-American scholar, introduced talking circles as an intervention to address the epidemic of diabetes occurring in the US American Indian population. Participants reported that the opportunity to share their stories conveyed a sense of trust and connection. More recently, Lowe and colleagues47 have demonstrated the effectiveness of talking circles as interventions to address substance use and obesity among Native American youth.

Life story work, digital stories, and talking circles add depth to the dimensions of the advancing narrative wave, contributing to understanding the place of story in health care practice and research. They honor story as critical evidence documenting unique humanness. Going back to the questions of correspondence: How does the theory fit the existing evidence? For story theory, does it fit as a narrative happening? We believe that it does. The time has come for nurses to claim the narrative wave, and story theory provides an avenue for our claim.

Nurses have long known the importance of story and have recognized the potential of attentive listening to promote ease. Story theory provides a nursing discipline-specific structure that facilitates story-gathering during research and story-sharing during practice. To attend to unique health challenges for those in our care, nurses must embrace the idea that listening to another's story about what matters most is as essential as any other vital sign. Story theory can help nurses raise recognition of stories from practice and research as valuable guiding evidence, thereby claiming the narrative wave as an integral facet of disciplinary knowledge development.

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Keywords:

story-based nursing practice; story-based nursing research; story path; story theory

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