Narrative relations : resources for meaning-making and person-centred practices in geriatric care

Abstract

Narrative approaches in healthcare have attracted a lot of academic attention, suggesting a strong potential in narrativity to help shift healthcare towards more compassionate and person-centred practices. Yet, there is still a need to better understand how narrativity might be understood, made relevant, and realized by healthcare staff in their everyday practices. Drawing on ethnographic fieldwork, healthcare professionals’ practice-based experiences shared in focus groups discussions, and narrative theory, this thesis puts everyday healthcare practices at the centre of inquiry, with the overall aim to develop a deepened understanding of narrativity as a potential resource for person-centredness and meaning-making in inpatient geriatric care practice. This compilation thesis includes four academic papers, each contributing to illuminating different aspects of narrativity in everyday practices. The initial studies shaped the design of the latter, thus building cumulative knowledge pertaining to the overall aim. Drawing on ethnographic fieldwork, Paper I explores how narrative meaning-making takes place and unfolds on a geriatric ward and discusses that in relation to contextual conditions and person-centred care. The findings render a multifaceted portrayal of the relational and intersubjective character of narrative meaning-making in healthcare practices and show how mundane events and activities of everyday life on a ward were often undervalued in terms of offering opportunities for exploring and co-creating possible understanding of patient situations between them and staff. Papers II & III are based on a constructivist grounded theory methodology. Vignettes developed from the previous ethnographic fieldwork were used to prompt focus group discussions with healthcare professionals. Paper II explores healthcare professionals' experiences and reflections about the use of narration in their everyday work. The findings reflect narration as an ongoing practice of mutual narrative interchange between multiple narrators, including patients, significant others, and staff, and thus introduce the notion of engaging in narrative relations. Moreover, the findings suggest potential consequences for clinical practice of people’s engagement in narrative relations. Paper III expands understanding about the notion of narrative relations by exploring how and where narrative relations are adopted and enacted in everyday practice on a geriatric ward. A main finding was the existence of a twofold practice whereby some activities and actions were generally approved as authorized tasks or routines, i.e. acknowledged practice, while other activities were not assigned this status, and thus took place as underground practices. Together with the concepts of clinical frontstage and backstage, the analysis constructed four distinct arenas for engaging in narrative relations. The findings discuss the transboundary function of narrative relations to interconnect these arenas and contribute to continuity in everyday practices. Finally, Paper IV explores conditions for engaging in narrative relations on a geriatric ward by delving into how healthcare staff interpret conditions for their practices. The findings from a hermeneutic analysis contribute to a deepening understanding of how everyday healthcare practices unfold not only governed by predefined organizational conditions, but that these conditions are continuously interpreted by people, which affect how practices are enacted. Whilst some interpretations were aligned with attitudes and activities enhancing narrative relations, others simultaneously thwarted narrative relations by enacting task-orientation, division, and a focus on measurable biomedical or functional improvements and outcomes.

In summary, this thesis suggests a broadened understanding of narrativity that expands the focus beyond eliciting verbal narratives and coherent stories when aiming for fostering person-centredness, to entail a relational approach of continuously tapping into the ongoing narrative meaning-making that people – both staff and patients – engage in. This approach builds on the notion that multiple narratives continuously communicate through narrative relations. When consciously and ethically cultivated, staff practices of engaging in narrative relations may contribute to uphold foundational relational qualities in healthcare.