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Perspective: Lessons Learned on Teaching Narrative

Perspective: Lessons Learned on Teaching Narrative

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Perspective: Lessons Learned on Teaching Narrative

By Bruce H. Greenfield, PT, MA (Bioethics), PhD

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For the past several years, we have been teaching physical therapist students at Emory University to write narratives with the goal of fostering reflection and reflexivity during their clinical experiences. Our initial foray into narrative writing began in 2007 as an ad hoc writing assignment. Students were instructed to describe a clinical experience during their short term, 2-week clinical placement after each of the clinical science courses in acute care, musculoskeletal and neurologic rehabilitation. The impetus of these writing assignments was for students to vent about frustrating experiences with their clinical instructors, other health professionals, their patients/clients and families. They were given a set of guiding questions to develop their narrative, including:

What was the central issue you encountered?
What confused you about the issue/case?
What feelings did you experience during this issue?
How did you and/or others address the issue?
What did you learn about yourself from this issue/case/encounter?
What would you do differently if you encountered this situation again?

Beyond these guiding questions and a word limit of 500 to 700 words, the students were not formally trained for writing reflective narratives. Specifically, we did not provide students background information of the theory and principles related to reflection, reflexivity and their links to professional and contextual knowledge. Given the lack of background material and training, we were not surprised to find that many of the narratives lacked the depth and quality of reflection and reflexivity that would have otherwise made them meaningful learning experiences. For example, when we analyzed a sample of 30 narratives written by students based on levels of reflection defined by Hatton and Smith,1 43 % of the student narratives never reached beyond the level of descriptive writing. That is to say, many of the students simply described their experiences without linking the experiences to their thoughts and feelings or linking theory to practice.

In so far as we wanted students to develop narrative reasoning and use narrative for clinical learning, our challenge was to develop an effective narrative program for students to use across all their clinical experiences. The questions we asked were: what is it we needed to do, how did we need to do it, and what lessons did we learn?

First, we realized that writing narratives to promote student reflection and reflexivity was a skill that needed to be learned and built upon incrementally throughout their professional training. Delany and Molloy2 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 two 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. Based on their template, our first step in refining the process of narrative writing was to introduce students to the principles and theory of narrative as a pedagogical tool to facilitate learning in the clinic early in the curriculum. Currently, our students are introduced to the narrative approach to ethical decision-making during their 1st 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. In this approach, they learn to identify relevant questions to complete the story.

Secondly, we used a narrative model to facilitate deeper levels of reflection. At Emory University students are encouraged to write narratives guided by prompt questions from the Gibb’s model during their initial 2-week clinical experiences and during their 1st 10-week clinical internships.3 Students are asked to follow the 6 circular phases of the Gibb’s model – the first two 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; as well as 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. The Gibb’s 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.

Third, we have integrated narrative unbundling activates during the students’ short-term and long- term clinical internships. According to Shulman,4 narratives are second order experiences –the interpretation of the first order experience – of 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. But narratives 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, so that a structure is provided within which students and clinicians can work together to develop a shared meaning of an experience. 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.

Fourth, narrative can be used as a learning tool as well as an outcome measure. In their use of reflective narratives, Delaney and Watkins5 report the positive results from physical therapy students’ perspectives and feedback were that it provided them with increased confidence in their clinical learning; it validated their personal role and perspectives in clinical learning; it was enjoyable and it provided a safe forum for sharing and bonding with other students. The negative aspects were that it was separate to the focus and emphasis of the other components of their clinical learning, and the discussions were sometimes slow and repetitive.

In conclusion, through a process of trial and error, faculty at Emory slowly refined and developed the pedagogical tools of narrative writing currently integrated throughout the curriculum. Students are writing narratives to reflect on both their short-term and long-term clinical experiences. In addition, our orthopedic and neurologic physical therapist residents are also writing narratives. These narratives are being used as a learning tool to help residents develop critical thinking, as well as an outcome measure. Already formative data is emerging from this work – the residents demonstrate progressive skill in writing narrative along with a changing focus of the narrative that moves from the traditional case-based description to uncovering and grappling with the deeper contextual, value laden issues in managing patient care.

Finally, the Emory physical therapy faculty has begun their own narrative writing program to help faculty reflect on their teaching experiences with students. These narratives will contribute to reflective teaching practice, and promote teaching skills to support context related teaching and learning.

References

1. Hatton N, Smith D. Reflection in teacher education: towards definitions and implementation. Teaching & Teaching Educ. 1995; 11: 33-49.

2. Delany C, Molloy, E. Critical reflection in clinical education: beyond the ‘swampy lowlands’’. In: Delany C, Molloy E, eds. Clinical Education in the Health Professions. Sydney, Australia: Elsevier; 2009: 3-24.

3. Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford, UK: Further Education Unit, Oxford Brookes University; 1988.

4. Shulman LS. The Wisdom of Practice: Essays on Teaching, Learning and Learning to Teach. San Francisco, CA: Jossey-Bass; 2004.

5. Delaney C, Watkins D. A study of critical reflection in health professional education: ‘learning where others are coming from. Adv Health Sc Educ. 2009; 14: 411-429.

About the Author(s)


Bruce H. Greenfield, PT, MA (Bioethics), PhD

Bruce Greenfield, PT, MA (Bioethics), PhD is an Associate Professor in the Division of Physical Therapy and the School of Medicine and Senior Fellow in the Center for Ethics at Emory University. Dr. Greenfield is a well-known physical therapy educator and qualitative researcher. He serves on the APTA Ethics and Judicial Committee, and on the editorial boards of the Journal of Physical Therapy Education, the Journal of Orthopedic and Sports Physical Therapy and the Journal of Humanities in Rehabilitation. He wrote this poem, Imprisoned, as an experience of what it may be like to a heretofore healthy individual during and immediately after a spinal cord injury. The poem mixes memory with present reality as the narrator links immediate sensory experiences of hearing, sight, touch and smell to past experiences. In some ways, the poem reflects how memory is used to construct present meaning and understanding. The aim of the poem was to imagine the horror and the slow realization that one with a life changing injury awakens to. It is what Susan Sontag refers to in moving from the Kingdom of the Well, to the Kingdom of the Sick, with illness as the night side of life.

 

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