Abstract
This perspective article provides a justification for and an overview of the use of narrative as a pedagogical tool for educators to help physical therapist students, residents, and clinicians develop skills of reflection and reflexivity in clinical practice. The use of narratives is a pedagogical approach that provides a reflective and interpretive framework for analyzing and making sense of texts, stories, and other experiences within learning environments. This article describes reflection as a well-established method to support critical analysis of clinical experiences; to assist in uncovering different perspectives of patients, families, and health care professionals involved in patient care; and to broaden the epistemological basis (ie, sources of knowledge) for clinical practice. The article begins by examining how phronetic (ie, practical and contextual) knowledge and ethical knowledge are used in physical therapy to contribute to evidence-based practice. Narrative is explored as a source of phronetic and ethical knowledge that is complementary but irreducible to traditional objective and empirical knowledge—the type of clinical knowledge that forms the basis of scientific training. The central premise is that writing narratives is a cognitive skill that should be learned and practiced to develop critical reflection for expert practice. The article weaves theory with practical application and strategies to foster narrative in education and practice. The final section of the article describes the authors' experiences with examples of integrating the tools of narrative into an educational program, into physical therapist residency programs, and into a clinical practice.
Over the past several decades, the physical therapy profession has strongly emphasized rigorous application of scientific method where positivist notions of objectivity, reliability, and validity are highly valued methods of knowledge and practice.1–3 One consequence of developing research-informed boundaries of clinical knowledge is increasing clarity about what is missing from this knowledge base,4 such as research and education that focuses on psychosocial (environmental and personal) factors influencing patient care and experience.5–11
Strategies to integrate psychosocial and patient-centered approaches to physical therapist practice and education include the use of high-fidelity simulation, standardized patients, and expansion and early integration of clinical practice experiences.12 Although patient simulations capture more realistic patient-provider interactions, the traditional clinical case framework underpinning this approach is often based on a technical, rational, and deductive approach to evaluation and population-based evidence in support of interventions and standardized outcome measures.13 Expanding clinical placement opportunities exposes students to a range of patients and contexts, but this alone may not guarantee students' development of broad-based competence, just as being in a health care environment does not guarantee learning. In the dynamic and sometimes uncertain clinical practice environment, students often find it difficult to make sense of their encounters and interactions with patients.4,6
Accordingly, there is a need to provide pedagogical tools to purposefully advance a student's learning and insights into the qualitative aspects of his or her practice. The use of narrative is one pedagogical approach that provides an interpretive framework for analyzing and making sense of texts, stories, and other experiences within learning environments. Narrative works to construct a story of an experience to promote a deeper and more coherent understanding of clinical experiences.13–18 Narrative enables students and clinicians to reflect on a case from multiple perspectives, including their own. A narrative begins by identifying a setting—the location and time in which the story takes place—within which the narrator introduces characters. It proceeds with one or more episodes, in which characters act in particular ways toward particular ends, and concludes with some indication of how the episodes coalesce into one story. Highlighting context, characters, and plots allows a narrative to carry meaning, to potentially counter a reliance on objective measures of practice, and to build a bridge or create dialectic that connects the objective and subjective in clinical practice experience to help therapists iteratively move between these 2 essential aspects of human experience.
The use of narrative is strongly grounded in the 2 core concepts of reflection and reflexivity. As both a descriptive and interpretive process, reflection has been defined in several different ways (Tab. 1).19–30 As a framework for interpreting practice, learners use reflection to concretely describe an experience and examine the issues of concern to clarify meaning. Clarification and probing of meaning are done by the learner individually, with a mentor, or in a community of other learners. Reflection is particularly useful to critically probe students' and clinicians' metacognitive skills (ie, thinking about their thinking) to explore the thinking process behind a clinical decision. In this way, the aim of reflection is designed to be transformative—aiming for new levels of understanding, meaning, and insights about clinical care.
Key Characteristics of Reflection
Reflexivity is linked to reflective practice. However, reflexivity focuses on awareness of how students' and clinicians' values and beliefs interact with others and influence their perspectives and behaviors.29–31 Reflexivity, therefore, helps students and clinicians recognize any personal and professional biases that influence their decision making in a clinical encounter.
In this article, we highlight how the use of narrative as a pedagogical tool may enhance physical therapists' capacities to expand their thinking, clinical reasoning, and understanding of practice. We suggest that narrative is a pedagogical tool that can work to facilitate therapists' ability to move from a positivist paradigm to a more reflective and context-based understanding of their own professional practice and their patients' unique circumstances and contexts. We also argue that including the use of narratives in practice and education has the potential to transform approaches to the development and application of professional knowledge.4 The specific purposes of this article are: (1) to examine conceptions of professional knowledge and its application in physical therapist reasoning and practice, (2) to discuss the use of narrative as a pedagogical tool for broadening these fundamental tenets and processes of clinical reasoning, and (3) to highlight some educational and clinical examples of using narrative to engage student learning and to improve clinical practice.
Knowledge Claims and Knowledge Use in Physical Therapist Practice
Three types of knowledge that are important to physical therapy are epistemic, phronetic, and ethical knowledge.12 The use of evidence in practice presupposes the importance of a specific type of knowledge: technical and rational knowledge, or what Aristotle32 considered epistemic knowledge—that is, scientific knowledge that provides a universal and theoretical understanding of something about the world. It is defined as:
[T]he conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice…in more thoughtful identification and compassionate use of individual patients' predicaments.33(p71)
According to Flyvbjerg, “Episteme is scientific, universal, invariable and context-independent knowledge.”34(p57) Based on contemporary standards, most would consider epistemic knowledge as technical and rational knowledge (the type of knowledge that undergirds traditional, positivistic scientific inquiry), a deductive (top-down) approach to knowledge acquisition. A physical therapist uses epistemic knowledge when using a clinical prediction rule to categorize a patient problem for treatment or applies a theory or principle to practice (for example, applying an extension exercise based on the McKenzie protocol to a theoretical patient with a contained, protruded disk at L5–S1). The use of epistemic knowledge in and of itself is noncontextual. Epistemic knowledge represents what the evidence says that we should do in the presence of a hypothetical patient with a particular pattern of impairments and medical diagnoses.
The second type of knowledge is phronetic knowledge (ie, knowledge in action, procedural knowledge, praxis knowledge, tacit knowledge).12,32 Phronetic knowledge integrates evidence-based practice knowledge, requiring judgment and experience. Clinicians using phronetic knowledge or reasoning consider the context of care and the practical issues that affect care. Included in this type of knowledge is an understanding of the psychosocial issues that influence care, including cultural, socioeconomic, psychological, and familial issues that affect decision making. Expert clinicians apply this type of knowledge so that they can understand how, why, and when it is best to use a particular intervention for a patient in a particular situation. Studies have demonstrated how expert clinicians integrate different types of knowledge and clinical reasoning, including deductive, inductive, and narrative reasoning.35–38 Phronetic knowledge results from the ability to reflect-in-action. According to Schön,6 a practitioner who reflects-in-action is able to make immediate adjustments and modifications as required during treatment. Because reflection and action occur simultaneously, it may not be apparent to the expert clinician or the student watching the experts thinking in action, unless, as in the example below, an experience is reflected on and written about later.
In the following narrative, an expert clinician tells the story of her initial rehabilitation encounter with a patient with a spinal cord injury as she tries to set priorities for her treatment approach. The narrative's author is a board-certified neurologic clinical specialist in physical therapy and practices at a large urban teaching hospital. She wrote this narrative as part of her portfolio for recognition as an advanced clinician in the hospital's Clinical Recognition Program.39 The excerpt reflects the use of phronetic knowledge. She wrote:
Joe is alone, resting…. As we are talking and beginning to evaluate his movement and sensation, it is apparent that he is having more difficult breathing, and his cough is congested and ineffective. I decided it is more important to address his pulmonary system and begin to assess his ventilation. Speaking with Joe's nurse and the medical fellow in the ICU [intensive care unit], we discuss his tenuous respiratory status and the need to clear his secretions with blind endotracheal suction…. I anticipate that this may be required for a few days.
Ethical knowledge, the third type of knowledge, entails the consideration of the professional's as well as the patient's values. Clinicians who apply ethical knowledge to practice understand the relational aspect of clinical practice that is judgmental and value-laden and apply ethical reasoning to help make clinical decisions for the best interests of the patients and their stakeholders. According to Purtilo and Doherty,40 clinicians who use ethical knowledge and reasoning act as moral agents to help their patients make decisions regarding the right thing to do at the right time in a particular case. Clinicians who integrate their ethical knowledge within clinical practice are able to recognize, analyze, and clarify ethical issues embedded in clinical care and are able to make decisions that are in the best interest of all major stakeholders. Clinicians who exhibit ethical knowledge are patient-centered, focusing on the well-being of the whole person and making certain that the patient's values, concerns, and preferences have moral weight in the clinical decision-making process.40 They also exhibit mindful practice—the ability to be aware of ones' own mental and emotional processes, listen attentively, recognize bias and judgment, and act with principles and compassion. To be mindful is to be empathetic—to understand the patient's own suffering and to be able to distinguish the patient's experience from his or her own.41
The expert physical therapist quoted above continued her story about caring for the young man who had experienced a spinal cord injury to his thoracic spine that left him unable to move his legs. She wrote, “Five days after our first encounter, Joe asks me a question that I have been anticipating: ‘Will I be able to walk?’ Telling him, ‘Your spinal cord is severely damaged, and it is unlikely you will walk, but given the best treatment, we cannot say never…. We need to start from where we are right now….’” She reflects about questions of this nature:
I have treated many patients with spinal cord injuries over my years as a physical therapist. Earlier in my career, I could perform the skills necessary to gather information, construct a plan for treatment, provide good care, and assess discharge needs, but I am sure that I did not consider so carefully the psychosocial impact of such [a] life-altering injury. [My] greater skill learned was listening, because without listening, I would not know what patients and their families were ready to hear. There will be patients and families who are just too overwhelmed by injury…those who take much longer to grieve for the loss of one's future before they can embrace a new future…. I know I need to be prepared and be flexible and adjust my approach to meet patients' and families' needs.
Use of Narrative as a Teaching and Reasoning Tool
Narrative has received considerable attention as a powerful tool for reflecting on practice in a range of health professions, including nursing,13,16 medicine,42–51 occupational therapy,52 psychology,14,18 and physical therapy.53,54 Because narratives encourage students to broadly interpret their clinical experiences as they tell a story, a narrative about clinical practice works to integrate technical and rational knowledge with phronetic and ethical knowledge in clinical care.4 Narrative tools assist therapists in clinical reasoning and in interpreting their practice by “getting the inside out”14(p36) to better understand the lived experience and sense-making of their patients' and their own experiences.55
In the 1980s, the noted educational psychologist Jerome Bruner was one of the first to advocate for narrative ways of knowing.14 Bruner observed that, unlike analytical thinking, narrative thinking brings different insights and meanings to the intense social interactions that often constitute patient care. He argued that narrative without analysis is naive and analysis without narrative is meaningless because the essence of narrative knowing is to frame and link human interactions into a plot or a story line. The story line provides a temporal structure to understand human experiences by linking individual events to a larger whole. Creating stories either through writing or talking about experiences requires reflection-on-action, a process Schön6 described as instrumental in acquiring the practical knowledge central to professional practice.
For Bruner,14 narrative thinking was particularly powerful for understanding the human condition because when constructing a story or hearing a story, we are able to uncover and explore the situated action of the actor or agent, intention or a goal, events, and the cultural surround of that action. At the same time that we construct the story, we should probe for what Bruner referred to as the “inner landscape”—what those involved know, think, or feel or do not know, think, or feel.
Rita Charon26 is best known as a pioneer in teaching medical students and residents in the narrative skills of recognizing, absorbing, interpreting, and understanding the value of the stories of illness. For Charon, the roots of reflection are seeded in the narrative dialogue between the patient and the health care professional, and its meaning is constructed and conveyed through language. In her teaching, she uses a system of parallel charting to write first-person stories about her experiences with selected patients. Charon suggests there is much more to a person's illness story than can be captured on a traditional medical chart. What is particularly problematic for health professionals trained in a largely biomedical model of medicine is to understand a patient's personal illness script related to their disease or injury. Charon describes how narrative medicine provides the clinician an opportunity to listen carefully to and reflect upon a patient's experiences with illness, representing that experience in a story or narrative, and ultimately providing the clinician insights that foster a strong commitment in caring for that patient. These ideas are particularly relevant for physical therapist practice, where therapists form close bonds with their patients and depend on their patients' cooperation and active engagement in their rehabilitation. In the section that follows, we provide guidelines for integrating reflective narratives into physical therapy curriculum.
Learning for Practice: Educational Examples
Jensen4 astutely observed that physical therapists are drawn to their profession because they like to get things done; they like to motivate and help people. However, they generally do not want to engage in deep philosophical conversations and epistemological discussions. An initial goal of introducing narrative, therefore, is to demonstrate how narrative can be meaningful and relevant to physical therapy practitioners. The following section describes the authors' experiences with integrating the tools of narrative into an educational program, into physical therapist residency programs, and into a clinical practice.
Integration of Narrative in Physical Therapist Education and Clinical Practice
Based on our experiences with students and clinicians, writing narratives is a skill that needs to be taught, learned, and practiced in the same way that problem solving and other forms of clinical reasoning require practice and explicit instruction. Delany and Molloy30 describe both horizontal and vertical integration (within and across curriculum) of reflective writing in their physical therapy curriculum in an Australian context. Students are introduced to underlying theory and principles of reflection and methods for writing narratives. During the first 2 years of their physical therapy curriculum, students are given critical reflection writing assignments to identify learning incidents from practical classes, personal lectures, or case-based learning groups and to reflect on the influence of those learning experiences and on their own personal knowledge and assumptions about practice knowledge claims (Tab. 2). During their clinical experiences, students are given narrative prompts to write reflexively, increasing their awareness of how their own values and beliefs interconnect with other perspectives and with the social and environmental contexts (Tab. 3).29,30
Narrative Prompts for Reflective Writing
Narrative Prompts to Facilitate Reflexive Writing
At Emory University in the United States, narrative experiences are similarly developed and integrated throughout the curriculum. Students are introduced to the narrative approach to ethical decision making during their first semester, with an emphasis on the idea that ethical issues are embedded in the experiences of everyday life and are represented in the story of the characters, events, and ordering of events. Students practice analyzing cases to identify “narrative gaps” in the story, including the perspectives of other stakeholders. There is a particular focus on learning what questions need to be asked and answered to provide additional information and insight. During their second semester, students practice narrative writing about their classroom experiences and are prompted with guiding questions for critical reflection and narrative writing (Tab. 4). Narrative prompts work to provide students with targeted questions for not only finding the right answers but also identifying and exploring the uncertainty or ambiguity of a situation.55
Integrated Narrative Experiences Across Curriculum
In both of these examples of teaching, narrative models are used to facilitate deeper levels of reflection.56–59 For example, Gibbs' model56 provides students with the framework to move from describing their experience (using a first-person account) to describing their thoughts and feelings as the experience unfolds. At Emory University, students are encouraged to write narratives guided by prompt questions from Gibbs' model during their initial 2-week clinical experiences and during their first 10-week clinical internships (Tab. 4). Students are asked to follow the 6 circular phases of Gibbs' model. The first 2 phases encourage them to describe their experience using first-person accounts. Students are asked to place themselves into the action and avoid using abstraction to describe what occurred, using concrete examples instead. These phases are followed by evaluative phases (where they judge the value and meaning of the experience and discuss their thoughts and feeling in response to the experience). The final phases involve analysis of what went right or wrong and finally how they would address a similar situation in the future. Gibbs' model appears to guide students to move between a description of an experience and an explanatory framework that explains its meaning, providing the student increased insight into practice. During their 10-week clinical internships, the students progress to writing 2 reflective narratives—the first after 3 weeks of the clinical experience and the second at the end.
Process of Unbundling
Narrative theory suggests that the meaning of a story or narrative is always co-constructed and exists in the coming together of storyteller and listener (author and reader). Rather than being confident that they know the author's intended meaning, readers bring their own meaning-making ability to bear in understanding what the narrative means to them. According to Shulman,55 narratives are second-order experiences—the interpretation of the first-order experience (the actual case or event). In the written narrative, the first co-construction of meaning occurs between the clinician who experienced the situation and, through the benefit of time and language, the same clinician who reflects on that experience and writes the story. Narratives also invite third-order experiences—additional layers of interpretation and meaning making. Through their sharing, narratives afford the opportunity to engage in collaborative, rather than individualistic, reflection. A structure is provided within which students and clinicians can work together to develop a shared meaning of an experience. The eFigure illustrates the progression and interconnection of how shared meaning is created from a writer's original engagement in an experience through personal to group reflection.
In our teaching, we emphasize the primacy of group discussion, deliberation, and debate in the examination of the narrative. The process is dialogic; different members of the group explore different perspectives on the nature of the problem, the available elective actions, or the import of the consequences. Narratives almost always reveal more than the author was aware of or intended to reveal in the telling of the story.60,61 The interaction with a group helps the writer unbundle additional meaning and understanding. Because of this, however, it is critical that the discussion occurs in a safe environment for all involved. An attitude of genuine curiosity about the experience, wanting to understand rather than trying to judge the rightness or wrongness of the author's actions or decisions, helps to create this safe space.39
At Emory University, we have integrated narrative unbundling activities during the students' short-term and long-term clinical internships (semesters 3, 4, and 5) (Tab. 4). During these initial unbundling activities, students meet in smaller groups and read their narratives to each other. A faculty member guides students to ask probing questions and discussions of each narrative for themes and meaning based on the prompts listed in Table 5.
Prompts Used to Facilitate Group Discussions About a Narrative
For the students' long-term clinical affiliation, a course was created on the Emory Blackboard educational site. After writing their narratives, students used Blackboard (Blackboard Inc, Washington, DC) to participate in an online group discussion. Groups consisted of 6 or 7 students (from a cohort of 70 students). The purpose of small groups was to facilitate follow-up discussion and ultimately develop a shared meaning of each group member's experience. Each group member uploaded his or her narrative, and the other members provided in-depth responses (1 to 3 paragraphs offering their reflections on the narrative). Group members, including the narrative's author, were asked to pose questions and make comments on others' posts in order to further probe meaning and sharpen understanding of the narrative.
Integrating Narratives Into Residency Program
Based on our experiences of integrating narrative tools to enhance physical therapist students' clinical learning, we have instituted a program of narrative writing for our physical therapy residents at Creighton University and Emory University. The residents were trained in the theory and skills of narrative writing and reflection and were asked to write narratives during their 1-year residency in orthopedics and neurology (Tab. 4). Each student wrote narratives across 3 time placements. As is the case with physical therapist students, our goals of narrative training for residents are to help them develop tools of reflection and reflexivity for expert practice.
Experiences of Massachusetts General Hospital (MGH)
At MGH, narratives are part of a hospital-based interprofessional development program.39 As they move through each defined level, clinicians write a first-person description of a clinical experience or situation that was meaningful to them. That narrative is read by one or more department leaders, who meet with the clinician to further discuss and “unbundle” the experience. This process facilitates the therapist's deeper reflection on the meaning of the clinical experience and applications it may have for their practice. For example, questions may be directed to specific words the clinician chose to describe the situation: “You write that the patient interview felt like a ‘battle.’ Tell me more about that.” Or questions may probe thoughts and feeling underlying the written statement: “You describe that you were seeing this patient immediately after they had been given an unexpected prognosis. How did this change your thinking about the session?” The content of these discussions differs from the department's traditional case presentation.
Over time, the use of narrative as a vehicle for reflection and learning from experience has expanded to other role groups. For example, clinical instructors share and discuss narratives of student/patient/clinical instructor interactions related to teaching strategies and student learning challenges. This group unbundling is facilitated by the center coordinators of clinical education, who bring expertise in both narrative interpretation and clinical education. Table 6 provides a summary of narrative experiences across education, residency, and clinical care.
Summary of Experiences Using Narrative Across Professional Education, Residency Program, and Clinical Development Program
Lessons Learned
In summary, we have integrated narratives throughout our curricula, residency programs, and clinical practices. Based on our experiences, we have learned several lessons to effectively help our physical therapist students, residents, and clinicians learn to write and interpret reflective narratives about their clinical experiences.
Not all narratives are created equal; reflective writing is a skill that needs to be taught, learned, and practiced. Writing good narratives requires time and opportunities to develop this skill.
Stories need to be shared; faculty, clinical instructors, and clinical mentors need to create narrative friends and a safe environment for sharing stories. Narrative theory suggests that the meaning of a story is always co-constructed between the storyteller and listener (author and reader).
Reflective narratives can be both a learning process and outcome measures. Narrative provides a powerful tool for educators and clinicians to gain more insight into the thinking of their learners. Recent studies have focused on evaluating narratives for themes and categories and levels of reflection across clinical experiences.13,22,30,53
Conclusion
There is increasing recognition of the need for greater balance between the humanistic and the technical aspects of physical therapist practice. This increased recognition has contributed to an interest in education methods to promote and help students and clinicians to incorporate the qualitative and quantitative aspects of their practice. In this article, we suggest that narrative methodology is an appropriate pedagogical tool to assist students in exploring their own development and experiences and, most importantly, those of their patients.
In this article, we have highlighted how narrative provides a powerful framework for educators to assist students to engage in reflective and reflexive practice. Narratives and the questions that prompt narrative reflection provide a vehicle for uncovering the broader aspects of a patient's context. They work to support clinical reasoning, which incorporates psychosocial and sociocultural elements of patient care. Importantly, narratives assist in redefining dominant conceptions of what counts as physical therapist practice and expand clinical thinking and practice to include not only the use of epistemic technical knowledge but also the use of phronetic and ethics-based knowledge. We believe such an expansion in knowledge use and reflection is vital for the physical therapy profession to respond to the contextual complexities of clinical practice.
In this article, we have described our strategies with specific examples of integrating narrative experiences throughout different levels of professional education and development. Through our own reflection of the successes and shortcomings of these experiences, we continue to experiment with and modify our approach. We encounter skeptical students and clinicians who need to be convinced that the story is an important construct in the delivery of high-quality, patient-centered care and who need to be reassured that their reflective writing is not assessed according to the stance or viewpoints they take but rather according to their degree of engagement in the process of critical reflection. Our experiences have taught us the importance of incrementally and consistently integrating narrative throughout curriculum and clinical practice. Our challenge is to find ways to see our knowledge generation and construction in its broadest sense with evidence from multiple sources.
Footnotes
All authors provided concept/idea/project design and writing. Dr Greenfield provided project management.
- Received March 6, 2014.
- Accepted November 26, 2014.
- © 2015 American Physical Therapy Association
References
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