An Extended Statement on Narrative Accounts That Illustrate Nursing Practice

Copyright, 1991

Background Understanding of Clinical Narratives

This approach is based upon two major premises. First, that there are two kinds of knowledge involved in human expertise: practical knowledge, "knowing how," and formal knowledge, "knowing that." While these two forms of knowledge are related, the relationship isn't unidirectional or linear. "Knowing how" may precede "knowing that." Indeed, much of "knowing how" may be so contextual and situational that it does not lend itself to being grasped in formal theoretical terms. Also, new theoretical understanding may set up new possibilities of asking new questions or looking for new alternatives.

The practical world is always more complex than can ever be captured by a formal theoretical model. This does not mean that the practical world is completely random, capricious or chaotic. Even chaos and random events can quickly become patterned due to human responses to those events. Because the practical, everyday world is made up of habits, skills, practices, common meanings, cultures and customs, there are always patterns. Human expertise is characterized by the ability to read situations, to recognize and understand patterns. Unlike formal expert systems, human experts can read fuzzy resemblances and patterns that may even have subtle differences.

Second, when the person becomes competent in the practical world of whatever enterprise or profession, the situation is seen as full of risks and opportunities as patterns. The world becomes more differentiated. When the person becomes proficient, a current situation is read in terms of past whole situations. Experience, as it is used in this perspective, always means a turning around of preconceptions or an adding of nuances to a former understanding of a situation; it never means the mere passing of time. Instead of understanding and performance being idealized as cool, rational, distant, and unemotional, performance is linked to emotional investment in good outcomes and in avoiding bad outcomes. Once performers become competent, they realize that they must choose a plan or perspective, and choosing one plan or perspective precludes others; risk and opportunity are involved and the performer is invested in the outcome. Good outcomes are deeply satisfying and poor outcomes cause disappointment.

Narrative Knowledge

How does one capture "practical knowledge," everyday understanding or "know how?"

It is best captured in narrative or "story" form that includes all the feelings of risk, opportunity, concerns meaning, chronology, changing relevance, complete with puzzles. This way "know how" can be charted even though "knowing that" or theoretical knowledge may be incomplete or even nonexistent. When you write an clinical narrative, you are encouraged to give first person accounts of the critical incident (clinical narrative) that include your concerns, hunches, dialogue, changing understanding over time, puzzles. You are encouraged to give the story complete with fears, risks, opportunities, and satisfactions in order to uncover the practical knowledge and the reading of the situation.

I. How to select an clinical narrative:

Actually, the clinical narrative selects you in a way. A particular situation stands out in your mind because it is laden with significance. It expresses important knowledge or meanings or expresses your notion of excellent practice or a breakdown in practice. So the best clinical narratives will select themselves because they are the situations that you think of over and over again. They stand out for you. Typically you do not remember the outstanding situations through generalizations or labels, but directly as a memorable instance, a valued time, or with a sense of pride and pleasure over outcomes or even a point of major difficulty from which you learned a great deal.

Phrases that may jog your memory:

• a situation that stands out as the quintessence of good nursing practice.
  
• a clinical situation that taught you something new, opened up new ways of helping, new lines of inquiry, or made you notice something new.
  
• a memorable patient or encounter that taught you something new.
  
• a situation where you clearly made a difference.
  
• a challenging situation due to breakdown, conflict or error.
  It is usually easier to think of particular situations rather than categories or types of situations. You can trust that a situation stands out because it was meaningful in a variety of ways and on a number of different levels.

II. Writing the Clinical Narrative.

The clinical narrative should be presented as a narrative account.
You may use the typical abbreviated telling of the nursing practice situation, but after that it should be a story with a first person reporting style. Actually, you may want to "tell" your story first into a tape recorder and then transcribe the tape and edit it, tightening it and filling in any needed details.

Oral reporting of the clinical narrative may be helpful because the oral tradition is less linear than writing and it is more natural to include thoughts, feelings, and concerns in the oral tradition. Length is a consideration. But it is best to tell the complete so try first and then edit it down to the essential narrative account, preferably to four or five double-spaced, typewritten pages, though you should not be too concerned about the question of length.

You may want to have a colleague read your clinical narrative to see if there are questions or missing information you may have overlooked. A colleague, who also may have cared for the patient, may help you capture the description you want. It is not essential to have outside readers, but as with any writing, an outsider can help you fill in familiar information you may have taken for granted.

There are a few things you should note when editing your clinical narrative. Avoid summary statements or general phrases that do not communicate what actually occurred.

For example, avoid phrases such as: "I analyzed the possible dangers to the patient and took action to minimize them," or "I gave emotional support," or "The patient felt better." Instead, tell the reader how you recognized the possible dangers, how you minimized them, how you gave emotional support and, where possible, the actual outcomes. Include dialogue, when possible, to give the reader a first-hand account of the situation as it unfolds. Include your concerns or what you were anticipating when you took a particular action because that gives a window to your judgment. You should change the patient's identifying information, such as name, age, family configuration, or any other identifying information if you feel you need to protect confidentiality.

It would be helpful if the situation you choose as a clinical narrative could be shared publicly with others in the hospital. You should indicate whether or not you give permission for any shared use of the narrative at the end of your clinical narrative.