The student as a narrator

The dead child

The class has just completed its second period of clinical practice with acutely, critically and/or chronically ill patients. Presently the class is assembled for two days to reflect on this clinical practice. On the first day they wrote a narrative on a situation of their choice related to their clinical practice, and these narratices are the basis for reflection on the second day. Rita initially refuses to share her story with us but finally gives in to our prodding and reads the following story with a quivering voice.

''The telephone rings like it often does at the intensive care unit. I do not know what the call is about or how it will affect me. It was the emergency ward reception. The message was: ''A three-year-old boy with respiratory failure is soon arriving. Can you get down here with the defibrillator?'' The ward was quiet, so I went along to help carry the equipment. I then decided to stay to participate in the admission of the three-year-old. I had a few minutes to think and prepare myself for what was about to happen. This was very early in my clinical practice period, and I had almost no experience in this field: ''stupid and ignorant.'' I focused more and more intensely on the tension surrounding the impending events and what I could learn from this. Activity increased around me, and the preparations were punctually carried out. I ended up outside the active team and therefore had the opportunity to observe what had to be arranged and prepared for receiving the patient. This included preparing the medication, testing the defibrillator, intravenous equipment, cardiac board, bag-valve-mask resuscitator and other equipment. It was all extremely fascinating, and everyone worked at great speed. A young life had to be saved! The ambulance blared, door thrown open, the paramedic with a lifeless young child in his arms. A pair of dark brown eyes staring into space - he is not blinking playfully as a vital, active three-year old should. There is nothing resembling a sign of life from the little human on the oversized bench.

The team is working up a full sweat, giving everything they have. It is fantastic to see people carry out such meaningful and important work. They are fighting for his life. They have to win this battle!

The team activates me - they need my help. I participate actively in the efforts to save life. I do not know the boy, but how beautiful he is! Thoughts flash: ''You shouldn't be lying here so lifeless and cold: you should be jumping around, being joyous about life's countless surprises and miracles, investigating how everything works, where you are and who you are.'' I have a calling, something to keep my hands busy. I feel cool and calm, knowing that I am in command of the situation. Aren't I?

The minutes fly by, and the struggle goes on. The boy's mother arrives. She holds his hand, comforting and soothing her precious gift of life. About 20 minutes

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have passed, and he has not been breathing since 19:00, and it is now 20:40.

The decision is made. The boy is disconnected from all the wires and tubes, the machines are switched off, the intravenous drip is discontinued. All is lost! The atmosphere in the room changes. Everything is quiet except for the mother's comforting and wailing voice. She rocks the boy in her arms as if she believes that he is just sleeping.

I take a final look at him as I leave with the physicians. He is not resting in peace; how painful it is to see this, so unjust.

In the corridor, the physicians gather for a quick discussion on the cause of the respiratory failure. The boy had been ill earlier in the week with vomiting, diarrhoea, fever, lethargy and other signs. He had improved and acted like a normal three-year-old. Today: sudden respiratory failure. Perhaps aspiration pneumonia says one physician, and maybe bacterial infection says another. But they do not know, and an autopsy is necessary. The general practitioner who was on the front line is praised for rapid action and skilled work. The physician is overwhelmed and reacts strongly. The physician cries.

I am standing in the outer circle and no one notices me. I begin to react too. Feelings rise up, and slowly but surely, I began to realize what I just experienced. I had not even thought about it. I had probably not taken into serious consideration the probable end result when I decided to stay in the emergency ward room. We had all the technology of modern medicine at our disposal to save this young life, but fate had another will today. The powerful impressions overwhelm me. I turn suddenly and head for the intensive care unit.

The lump in my throat is throbbing, and the tears are about to gush. But as I am taking determined strides up the stairs, I decide that crying now is not appropriate. I have to be, or at least learn to become, ''professional.'' I fight hard with myself, with internal collisions in all directions. The nurse looks intensely at me and asks how it went. Before I respond, another message comes: one of ''my'' patients died while I was down in the emergency ward. I respond with a choked voice. Then the tears take over, forcing themselves upon me against my will. Everything is painful and horrible. A comforting arm hugs me and we sit down alone in the kitchen and talk while I try to figure out what is happening with me. A process has been initiated within me. My brain and emotions are working overtime. A young child has been brutally and senselessly taken. A family is left with overpowering grief about a child they loved and cherished so highly. We never know what life will bring!''

The classroom iscompletely quiet. Most students are swallowing and wiping away their tears. I also have to compose myself before I can speak aloud. This class, which has not really been very cohesive, is now focused on supporting the narrator. We have an honest and excellent discussion about the impact of the impressions we get from clinical practice and what we can do to reflect on these. As a teacher, I feel the humility of my role in relation to the students and their role in the educational situation.

I write, therefore I am

Jo Bech-Karlsen (1) is a journalist who wrote a book called ''I write, therefore I am.'' The title plays on the famous cogito, ergo sum (I think, therefore I am) of the Renaissance philosopher René Descartes. Descartes' point was that thinking proves human existence; one can doubt anything except the fact that one thinks. Doubt in itself is also a kind of thought, and this proves that the doubter is a thinking being. Bech-Karlsen believes that writing is a method of clarifying one's own thoughts. Writing is one way of promoting thinking. Bech-Karlsen says that people become ''authoritative subjects'' when they write. When I write, I am proving that I exist. Furthermore: I am finding out who I am.

If Bech-Karlsen is right, can this be used in relation to nursing students in an educational situation? Can students benefit from writing narratives about their daily experiences in clinical practice? Can students discover who they are as nurses by writing stories from their clinical practice? Is this a way to become conscious about one's role as a student?

I teach second-year nursing students, and about three years ago the faculty agreed to emphasize the narrative method in instruction. We present the students with storytelling as a method, the characteristics of a narrative story and what differentiates the form of comprehension generated by storytelling from other forms of comprehension. During the two clinical practice periods of the second year, the students are required to write narratives based on their practice. We have used these narratives as the basis for reflection in

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the class. During this same period I have urged the students to give me their narratives. If they were willing to, they gave written informed consent to the use of their stories for instructional purposes and in any publications written. After more than two years I had gathered 18 stories. I decided to go back to these students with questions related to their stories. How did you benefit by writing this story? Have you shared it with other people? What feedback, if any, did you get from these people? Do you consider it important to share the story with other people? What thoughts do you have about nursing after writing this story?

Of the 18 students who were given these questions, 10 responded. I used these responses from the students to determine whether they support Bech-Karlsen's hypothesis that I write, therefore I am. I will introduce this by discussing storytelling, reflection and writing as a phenomenon.

Telling a story

Stories in the broadest sense are the narratives people have been telling one another for millennia. Narratives are stories from lived experience. Bech-Karlsen says that stories have always been our most important source of knowledge and that humans have used stories to orient themselves in the world. Many nurses, including Marit Kirkevold (2), Kari Martinsen (3) and Patricia Benner (4), have written about storytelling and its characteristics. All three believe that storytelling is well suited to promoting the acquisition of practical knowledge from experience. Kirkevold emphasizes that narrative comprehension is the human tendency to create order and meaning from the various events of life by incorporating them into a larger, coherent life-history. Narrative comprehension is considered to complement logical and scientific comprehension, which attempts to organize and explain events by searching for universally true conditions and contexts. Martinsen focuses on the fact that storytelling uses tuned language: everyday language that is colourful, personal and rich in detail. This linguistic façade makes the situation come alive for the audience and integrates them into the plot. The perceptual appeal allows one to reach other people. The immediacy and the chords in the language move us, whereas scientific language does not touch us in the same way. Scientific language does not target the emotions but pretends to be neutral, objective and without regard for feelings. Using emotionally rich language in storytelling allows the storyteller to develop a skill that Martinsen calls perceptual comprehension. This includes perceptual presence, being able to interpret other people's intentions and feelings and comprehending their physical and verbal expressions. One is cast into the situation and empathizes with other people and their situation in a perceptually immediate manner. Martinsen believes that both perceptual comprehension and conceptual comprehension are required in what she calls judgement: assessing a practical situation correctly. Kirkevold argues that one feature of storytelling is that it compiles isolated experience-based knowledge and skills and thereby provides a form of insight that can counteract one-sided cultivation of the logical and scientific way of thinking.

Reflection and writing

Bengt Molander (5), a philosopher, believes that reflection means taking a step back to think about oneself, which is what one does when one wants to obtain a new perspective on a situation. He says that people cannot be completely absorbed in action, which contrasts with Donald Schön (6), who emphasizes that reflection occurs during action. What Schön calls reflection during action, Molander would call awareness during action. Molander thus believes that reflection occurs after action, and each person needs to figure out who I am that is acting in relation to my fellow actors. He says that the reflection process provides an opportunity for discovering or being confronted with what one has done or who one is. The process also allows the opportunity for both questions and answers. Molander indicates that a reflection process requires calm and careful deliberation and thereby time. He says that the person reflecting often requires help to make the results visible. People thus need help to become aware of various factors. He asserts that this process of making change visible requires verbalization.

Torlaug Løkensgard Hoel (7), an early childhood teacher, has focused on reflection in relation to writing. She believes that there are two models for writing. The first she calls ''think first, write later.'' This model requires careful thought about what one wants to write before the words take on a material form. When the thoughts are clarified, they can be written. According to this model, writing is the conversion of thoughts to a material form in words. The other model is ''integrated writing and thinking.'' This model poses writing

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as an instrument of thought processes: how one teases out and organizes one's thoughts. Language and thought thus become inseparable, and writing becomes a process and requires reflection. Bech-Karlsen says that writing is investigating. Writing is not merely relating what you have figured out but just as much to figure out what you have figured out. One may often not know what one thinks until one writes it. Bech-Karlsen compares writing to entering a gate and working one's way into the landscape within, and the password is a thought or a picture.

What did the students emphasize in relation to reflection after they wrote their stories?

A story to grow on

At the end of her story, Rita considers how to figure out what is happening to her. ''A process has started within me,'' she says. She has just experienced a dramatic situation, and I believe that she is signalling that she already has begun a process of creating order and meaning from these events. After she wrote the story, she said:

''Writing the story has primarily allowed me to conclude the events I experienced. The story was the last part of working out this process. I felt as if I grew or matured as a result of writing the story. I transferred what happened to a narrative on paper and then later I could view the event from a distance. This was a positive process, and I could relate to the experience in a more immediate manner. I also confirmed that I can manage to verbalize my feelings, thoughts and experiences.''

Rita makes several points. One is that writing helped her to conclude the events. I believe that she is saying that writing the story released her from many of the feelings associated with the experience; she placed them in their proper perspective. The fact that she had written the story allowed her to view the situation from the outside, which Molander calls reflection. Writing the story allowed Rita to push her feelings aside and allow reason to emerge. She could then view the situation more objectively. This is in accordance with Bech-Karlsen (1, page 12), who says:

''Reason and emotion complement and reinforce one another, just as reflection complements the storytelling and makes it richer and more complete. Storytelling and reflection are siblings and not strangers who never meet. I tell a story and reflect, and therefore I am.''

Rita describes a process that led to her being able to view the situation from an external vantage point. This process can also be considered achieving a perspective on a dramatic situation, which is necessary to allow reflection and learning. Reflection has clearly strengthened Rita. She says that she ''grew with or matured in the process of writing the story.'' She worked through her experience in this way and says that this led to growth and maturation. She also indicates that it provided self-affirmation because she was able to verbalize her feelings and thoughts.

Bech-Karlsen also emphasizes that writing is both processing and reflection. Writing about an event that has affected one in some way means writing the experience into one's memory. Rita would probably have remembered the event for a while, even though she had not written about it. But writing about it helped her to work through it and imprint it vividly in her memory, which allows her to retrieve it from memory in similar situations later. Being able to draw on a repertoire of previous situations and experiences is an important part of obtaining knowledge through experience. Molander compares this with recognizing people's faces: recognizing the face of a situation. The familiar situation will become a pattern or prototype for interpreting the new situation.

Creating inner order

Most of the students emphasize the significance of reflection. One says:

''Writing about a very recent, direct experience forces one to reflect. During a period of clinical practice, one receives many impressions that need digesting and much that needs to be learned, and many demands are placed on the student. The result is that we have no time for substantial reflection.''

This student makes an important point. She considers reflection to be important but also says that accomplishing this adequately is difficult; one reason is all the demands placed on her as a student. Molander asserts that reflection requires time, calmness and deliberation. Reflection thus requires space. Do we provide this space for students in the educational process? Can we organize this better than we do at present? This student underscores that many impressions need to be digested and much needs to be learned. According to what Hoel says about the model of integrating writing and thinking, writing would greatly help a student who has ''many impressions needing digesting'' during a period of clinical practice. The writing process provokes reflection. Bech-Karlsen says that writing

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is investigation. Author Eli Wiesel once said that he writes just as much to understand as to be understood. Writing can thus be used to clarify one's own thoughts, and Rita's statements are evidence for this. She even mentions writing as being part of a process.

Promoting curiosity

Reflection is linked to the actual process of writing, but having a narrative in written form also provides opportunities for additional reflection. As one student said: ''This allows me to retrieve my experience again and again and to relive the situation.'' Other students describe the specific benefits they have received from the reflection associated with writing. They indicate that they have become more aware of certain aspects of nursing, such as communication with the patient. One student writes about a situation in which the task was to inform a patient before a surgical procedure. The patient seems to be calm before the procedure and says that he has no questions. After the operation he is very anxious and scared, and in addition to experiencing pain he is afraid he will die. The student says:

''In writing this story, I acquired more knowledge on the topic of preoperative information. This has thereby improved my ability to give patients better information and to impart a greater degree of security.''

Writing a story has clearly increased the student's curiosity; she wanted to know more about this topic. Satisfying her curiosity has improved her prerequisites for providing good care for patients at this stage. Writing a story based on a specific situation can help in entering into a dialogue with the situation. Molander asserts that people can use this dialogue to bring forth the knowledge and insight they already have, and this is also a way to reveal where knowledge is lacking.

Promoting self-understanding

Another focus is that writing a story leads to self-understanding. One student relates a situation in which she is receiving a patient who was admitted with alcohol intoxication. She begins by mentioning that she has positive and appropriate attitudes towards her fellow human beings. She believes that everyone has equal value and an equal right to receive considerate care and treatment. Nevertheless, her attitudes were sorely tested in a meeting with this patient:

''The patient was indescribably filthy. The smell of urine, faeces, old dirt and sweat blended with the smell of old alcohol and made it nearly impossible for us to breathe. Our task was to take off his clothes, wash him and lay him in a bed. It was a disgusting job, even though I do not consider myself to be Ms. Sensitive. The situation did not improve when the man began to emerge from his stupor when we started to move him back and forth. Then our work was rewarded with swearing and cursing, and all the while he whacked us where he could. I must honestly say that my empathy with this man had vanished, at least at that time. He was simply too revolting.''

The student reflected on writing this story: ''Writing this story made me reflect about my own attitudes; this was a fairly unsettling process but I understand myself better.'' The process of writing gave the student more insight into who she is; she knows herself and her limits even better. She has experienced with her own body what Molander says in relation to the reflection process: that a person in this process can be confronted with what he or she has done and who she or he is. The student says that this process was unsettling. She paid a price, but she got something in return. I believe that writing the narrative becomes especially important in such contexts. When we experience situations that challenge our attitudes or values, it can be easy to repress thoughts about the situation because it hurts to examine oneself. But as the student says: writing the story forced her to reflect about her own attitudes.

Opening the door

Bech-Karlsen says that the strength of a story is that it opens the door to sympathetic insight. We are fully involved in narratives and allow ourselves to be touched. The students supported this hypothesis. It became clear that stories involve the people who are privileged to share them. All the students underscore that getting feedback from others was positive. The content of the feedback varied, however. One student said that sharing her story opened the eyes of many of her fellow students about the problem she discussed. Another student said that her story caused others to share their experiences, which confirms that a story can open doors. A third student says that she shared her story with other students, and this resulted in a discussion of the situation based on an ethical dilemma in clinical practice. They discussed what could be ethical and unethical in the given situation. Sharing the story with others thus lays the basis for further reflection. It would also be positive for

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a student's self-esteem to be able to say that he or she initiated the reflection process by writing the story. All these factors are various facets of reflection. Writing a story allows the student to achieve a more distant perspective on the situation and see it from another vantage point. The following factors are associated with learning.

Feelings are key in learning

Several students said that sharing their story with others was a good experience. One said that this helped her to ''bring my frustration and uncertainty to the surface and to release the pressure from the inside.'' Another stated: ''I shut off all the external factors and allowed myself to be overwhelmed and to recognize that I was erupting - I just let it flow out of me. This was the solution to eliminating some inner pain that really was not mine!'' Both these statements indicate the importance of bringing forth feelings and placing these in a context. Nils Magnar Grenstad (8), an early childhood teacher, asserts that feelings represent strong forces in the personality. Another early childhood teacher, Otto Lauritz Fuglestad (9), points out that the starting-point for integrating cognition and emotion in an educational situation is a new perspective on emotion as a basic driving force for human behaviour.

Based on what Grenstad and Fuglestad said, it is important that the student take advantage of feelings as a positive resource in learning. Feelings should not dominate but should be balanced with and integrated in the other processes of learning. Getting students to open up to using feelings as a positive resource in the learning process requires them being aware of these feelings. David Kveback (10), a family therapist, says that unconscious feelings (ones that have not been verbalized) will control a person's inner atmosphere, which again influences people's attitudes towards everything they encounter, be it people or tasks. Grenstad says that repressed feelings wear down the human organism physically and also promote mental problems.

In ''Learning is Discovering'' (8), Grenstad emphasizes that feelings influence people's focus of attention, as feelings demand attention. This limits people's ability to focus attention on other matters. Feelings linked with factors not related to the current educational situation will retard learning. Grenstad also maintains that, when feelings are not recognized or are repressed, people's ability to remain in touch with their feelings will gradually be weakened.

Repressing feelings requires energy, and this will drain energy and attention in an educational or clinical encounter. This will also result in the student not being able to be what Martinsen calls perceptually present in a situation. She says that feelings are required to be able to participate instead of remaining detached. Further, these feelings contain comprehension and are distinguished from various emotional states that are obsessive or focused inward. Martinsen's comprehension cannot be achieved except through the feelings required to enter this state. She further asserts that feelings are not merely a condition for recognition but also contain recognition.

The strength of storytelling in this context is that it covers both the affective and cognitive aspects. Using language that can be described as everyday and in tune makes one embrace feelings. Hoel emphasizes that the process of writing can help people to become conscious of their unconscious.

What do I know?

One student says: ...''I felt somewhat courageous as I dared to focus on my own faults and shortcomings on this topic. Sharing my story was a step on the road to becoming more open to myself and to others.'' This student underscores two important factors in relation to learning. She dared to focus on her own shortcomings in this topic. Molander emphasizes recognizing one's limits in knowledge. He says that achieving knowledge and comprehension and extending them requires knowing the limits of one's own knowledge. Insight into one's own limits and inadequate knowledge requires attention and reflection. Molander calls this the dual structure of knowledge: recognizing ones knowledge as it is as well as through the limits of this knowledge. The fact that this student became more open towards herself and others is in accordance with Bech-Karlsen's experience. He says that reflecting on his own narratives has made him more open to other people's stories. This openness will increase the student's comprehension and knowledge.

Conceptual and perceptualcomprehension

Students' thoughts after writing their story are based on the situation they describe. These thoughts, or what they have learned about nursing, therefore vary. Rita emphasizes the following in this context:

''The concepts of caring, empathy, sympathy, humanity and personal development have acquired a

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richer content for me. I believe that this experience has made me stronger in situations when the patient is in crisis or reacting to loss. I feel that I know a little more about what it is like to be a professional nurse in a very emotional work situation. I can also see clearly that nursing is a profession in which one gives much of oneself on a personal level. And that one learns well through many years of job experience how people really are: normal and abnormal reactions and patterns of reactions. I can also understand the importance of developing the ability to read people's body language.''

What Rita says here is relevant to Martinsen's two types of comprehension: perceptual and conceptual comprehension, which are both necessary in what she calls judgement. Rita had a conceptual comprehension of the concepts of caring, empathy, sympathy, humanity and personal development before the relevant situation arose.

Rita was open and present in the situation. What she perceived in the situation from the mother, nurses, physicians and herself was that the concepts have ''acquired a richer content'' for her. Through her experience and reflection, she has obtained knowledge, which has changed in nature from being general to being personal. She now owns this knowledge.

Focusing attention

The student who described receiving an alcohol-intoxicated patient says:

''Going to school does not make anyone a nurse. Memorizing which hormones are produced in the pituitary gland, being able to describe the acid-base balance of the body or being able to rattle off countless procedures does not make anyone a nurse. This is merely the foundation that is required to start the actual training in which one acquires practical knowledge. This is obtained through experience, through interest in other people and through knowing oneself.''

This student indicates the importance of practical knowledge and important prerequisites for acquiring this knowledge. This is in accordance with Molander's comprehension of practical knowledge. He calls this ''knowledge in action'' and emphasizes ''in'' because he considers knowledge to be primarily linked to various human activities. A key aspect of his theory is that knowledge is a form of attention. This attention is learned within an activity or a problem area, and people must teach themselves to observe, listen and absorb both familiar and unfamiliar input. He says that the prerequisites for this attention are pride, commitment and interest. I believe that the various statements by the students show that telling a story can create pride, commitment and interest.

Achieving recognition

Some students emphasize as positive the fact that they have received support from the other students after they shared their story. One says that she was told ''that she was a strong person if she could handle this type of situation and that she would become a good nurse.'' She received confirmation or recognition from the other students and this is positive for her. Rita obtained recognition because she was brave enough to share such a strong and emotional personal experience with the class. As a teacher, I saw that this was positive for the class milieu and the learning achieved in the class. The class had not been unified, and some students had felt insecure and alienated from the others. Rita sharing her story with the others opened up the other students. They recognized their feelings and focused on supporting Rita, who says: ''I obtained considerable sympathy for the reliving reaction I experienced while reading my narrative aloud in class. My fellow students had empathized with the story and had to wipe tears away afterwards.'' The other students also brought forth their own experience in a different way than I believe they would have if they had not shared Rita's experience.

The two voyages

The students have demonstrated that writing leads to reflection. Writing organizes the process of reflection among individuals or in groups. In some cases, writing forces the student to reflect, and the student considers this to be inherently positive. The students have further demonstrated that they have learned a great deal by writing a story. Writing has helped to bring forth their own thoughts and to know themselves better. They show that they know themselves better as a person and as an empathetic being as well as who they are as nurses. Based on what these students assert, I conclude that Bech-Karlsen's ''I write, therefore I am'' also applies to students. Writing has caused the students to become authoritative subjects who can see more clearly who they are.

Based on what these students have indicated, writing stories based on clinical practice presents a substantial potential for learning. In connection

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with my thesis (12), I conducted a study of how nursing students experience practical learning. One of the students in the study took on the task of reflection in relation to writing. This student kept a diary and felt that she benefited tremendously from this. She says: ''We should be encouraged more to keep a diary. In any case, I think that it is good for me.'' As a teacher, I can see the significance of encouraging students to write, but I do not believe that this is sufficient. Some students will comply with this suggestion but others will not. I therefore believe that teachers must do more if we want students to take advantage of storytelling in the process of reflection. We can choose to require that students write narratives based on clinical practice. Another option with which I have had positive experience is allocating time in the students' class schedule so that they can write a story. I do this, for example, after the students have ended their periods of clinical practice in the second year of nursing education. The students then form groups of four and read each other's stories aloud. This allows everyone to get feedback on their story in the form of recognition or support and can be the basis for reflection within the group. Each group chooses one story to be presented to the class as a whole, and this is used to promote reflection for the whole class.

Hoel compares writing to being on a ''voyage of discovery.'' Writing is thus a sea to be sailed twice. The first is a voyage to discover and explore an uncharted landscape; the second trip is as a tour leader to accompany your intended audience. I believe that many students need help in undertaking both these voyages, and this requires examining how the educational process can be organized to promote this.

For references see the Danish version "Den studerende og fortællingen".