The PRISM model: a new framework for interpreting health narratives

Introduction

Donald Polkinghorne’s seminal text, Narrative Knowing and the Human Sciences (1988), positions narrative as the inquiry of the “reality of human experience, both that present in and that hidden from awareness”. This series of articles has demonstrated that storytelling has many purposes, not least because stories privilege the lived experience of the storyteller, have the power to elicit a response from the listener, and act as a vehicle for analysis and interpretation, “deepening and enlarging the human existence”, as Polkinghorne (1988) suggests. Launer (2018) argued that by centring professional work around the principles of attentive listening, careful inquiry and offering opportunities for easier and creative narration, practitioners can build stronger interactions with those they work with.

As practitioners, we are immersed in stories. While it is important to respect the utility and value of empirical research and theoretical evidence to inform teaching and learning, narratives are complementary in serving several functions. They:

• Position those in receipt of care as central characters along a path of health and illness;
• Respect the storyteller as a partner in learning;
• Contextualise personal experiences;
• Create a space for reflexivity and transformative learning;
• Have the potential to develop the listener’s empathy of the reality of the lived experience.

We hope that the stories told in this series have captured your interest as practitioners and, as Sandelowski (1991) stated, uncovered the art of nursing. Stories reveal the voice of the human experience and on occasions may have resonance with our own experience as professionals, allowing us to develop a more empathic relationship. They shape our perspectives, challenge our beliefs and value systems, and have the potential to reaffirm narratives as a source of evidence for health and social care practice.

However, questions need to be posed on to the future landscape of narrative inquiry as an evidence base for practice. This is alongside it being a platform for personal and professional development.

Where do we go from here?

• Educational programme philosophies should value and respect the voice of those who have lived experience, so that there is transparency as to the expectations and commitment required for learners and educators alike. Box 1 features an example from our university;
• Educators should move away from coproduction as rhetoric. This can be achieved through a commitment to privilege and embed the voice of those with lived experience, and to recognise narratives as an evidence base for practice. This can be realised through the development of collaborative and respectful partnerships;
• Opportunities are needed in curricula, which provide learners with support in the analysis, interpretation and sense making of narratives, while also recognising that this can be professionally and personally challenging;
• Reflective and clinical supervision models should be embedded in curricula. While working on this series, we recognised the need for a structured framework to support learners to interpret stories. We, therefore, developed the PRISM model (Box 2) to guide them through the analytical and interpretative process;

Further research is required on the impact, reach and sustainability of the learning that has emerged from narrative inquiry, from both the storyteller’s and the listener’s perspective.

The PRISM model

Narrative inquiry invites the listener to consider the lived experience through a different lens, analogous to the way in which a prism sheds light in different directions onto a visual landscape. There are no right and wrongs in interpreting a story as we will all view the prism from different starting positions, whether that be as a practitioner, a person with their own lived experience or a learner. When white light enters a prism, a spectrum of colours of the rainbow is emitted. Likewise, when we encounter a story, from whichever lens we are looking through, narrative threads or themes will emerge which collectively form the spectrum.

For each of the stages of the PRISM model, guiding questions can help the interpretative process.

P - Person

Inherently people are storytellers, whose narratives are a valuable source of evidence about their lived experience.

Guiding questions
Who is the person? What is their story about? What is their background? Is there a context to their story that indicates why they are telling it now? Who might be the intended listener? What is their motivation to share their story?

R - Relationship

Narratives describe and reveal a person’s relationship with their lifeworld, their illness and associated journey, the health and social care services, their significant others, and their self and identity. This may also involve their ‘relationship’ with drugs, prescribed or otherwise, with food, with their perceptions and understanding of the diagnosis, and with their treatment options.

Guiding questions
What relationships are described with significant others, organisations, practitioners, treatment plans, and the person’s illness? What is the nature of these relationships? How have these relationships influenced their lived experience? How have these relationships affected their understanding of the illness trajectory? How do these relationships impact the person and significant others?

I – Interpretation

Narratives are interpreted by the narrator and listener.

Guiding questions
What narrative lens did you as the listener approach the story from? What are the key messages, themes and narrative threads of the story? Is there a narrative tone that accompanies the story? Is language literal, figurative or metaphorical? What is your reaction to the story?

S – Sense making

As the reader, making sense of the narrative from your perspective is an important element of narrative inquiry.

Guiding questions
What sense do you make of the narrative and its relevance for your professional and personal learning and development? Are there hidden or covert messages to be revealed? Why do you think the story was told at this time and in this particular way? What did the storyteller focus on? Has the story contributed to your personal narrative as a practitioner? Did the responses challenge you in any way? What are the salient narrative threads which comprise your sense making? What responses did the story evoke in you from a personal and professional perspective?

M – Motivation

To listen and hear the profound messages emerging from narrative inquiry and consider motivation to act.

Guiding questions
What messages arise from your interpretation and sense making? Where does your motivation lie: is it personal, professional and/or pedagogical? How will you work with the story? How will using this interpretative process inform your professional practice?

Working through these guiding questions allows us to reflect on the content and context of narratives in a structured way that is supportive of learning.

Series summary

This series has reminded us of the influence and power of narrative inquiry in nurse education and practice, reflective of Murray’s (1999) influential quote:

“Narrative is constructed within a personal and social context. While disease exists in physical terms we interpret and transform through narrative. Narrative gives disease a personal history.”

The concept of narrative inquiry has been introduced and student reflections on stories that they heard as part of a module entitled ‘Learning from the Lived Experience’ contextualised the complexities of the human experience through the illness journey. The series has presented a critical debate of the language of narrative and the use of metaphors as a way of both telling stories and understanding them. Stories were also told from the practitioner’s perspective, as a tool for personal and professional reflection and development.

Through the art of storytelling, the meaning of illness is revealed, the interpretation of which deserves to position itself as a respected and valuable contribution to the evidence base that informs health and social care. Person-centred care will continue to be mere rhetoric unless there is a genuine commitment by practitioners and educators alike to privilege the lived experience and engage in a meaningful way with those who are personally affected by illness. The alternative risks homogenising medical diagnoses to one description and threatens “to expunge its primary subject – the living, experiencing patient” (Leder, 1990).

Conclusion

This article has looked to the future of narrative inquiry in nurse education and proposed a new model, the PRISM model, which can be adopted to guide interpretative approaches to analyse stories. Whoever the storyteller is, stories can reveal the threads and themes, which comprise an individual’s lived experience and have the power to influence practitioners and the way they work.

Embedding narrative inquiry in an educational philosophy and curricula confirms a commitment to privilege the art of storytelling as a forum for sense making and makes the human experience of illness more accessible.

As a final thought:

“Remember today and always why you came into this crazy, challenging, heart-wrenching, and wonderful profession of nursing. Remember your stories, and the sustaining wonders of our work. No matter what the future holds, you will be prepared by keeping a story in your heart.” (Tanner, 2002)