5.1.3.1 Evidence from narrative

5.1.2.1.1 Definition 

Narrative: A spoken (recorded) or written account of connected events ¹⁶

Narrative generally refers to the recounting of real events in healthcare or the telling of a story. ¹ From a systematic review perspective, this type of data is likely to be related to accounts of experience from the perspective of patients, health professionals or other stakeholders in enterprises related to the phenomenon of interest of the review.  The narrator puts forward an account of a series of events or actions that may involve one or more people; and the account may be a ‘real’ or fictional story. Paley and Eva ¹⁷ distinguish between the term’s narrative and story, arguing that a ‘story’:

“…Is an interweaving of plot and character, whose organization is designed to elicit a certain emotional response from the reader, while ‘narrative’ refers to the sequence of events and the (claimed) causal connections between them. We suggest that it is important not to confuse the emotional persuasiveness of the ‘story’ with the objective accuracy of the ‘narrative’.” ^{17 (page 1)}

They argue that narrative is best defined as a reported sequence of events rather than a broad term for non-medical discourse. For them, narrative is the recounting of one or more real or fictitious events that relates this sequence of events and makes causal claims about them. These claims may be true or false, and they can certainly be tested. The authors propose that narrative is different to a story - a story is also a recounting of a sequence of events, but a story also organizes its various constituents in such a way as to elicit a particular effect, and this can sometimes detract attention from, or even be mistaken for, the implicit claims about causation. ¹⁷

Important sources of narrative data in evidence-based healthcare include (but are not limited to): patient stories or classic illness narratives; clinicians’ stories; narratives about clinician-patient encounters; recollections captured through written (eg. diaries) or other media; and grand stories or metanarratives.¹⁸ They argue that both evidence of cause and effect and other relationships generated through primary research on groups and populations (focusing on generalities) and the evidence generated through the description of the ‘specific, unique and singular’ (focusing on particularities) are important in evidence-based healthcare. This is referred to as the “…tensions between the known and the unknown (or at least the knowable and the unknowable), the universal and the particular, and the body and the self.” ^{19(page 296)}  Greenhalgh ¹⁸ concurs with this, asserting “…appreciating the narrative nature of illness experience and the intuitive and subjective aspects of clinical method does not require us to reject the principles of evidence-based medicine.” ^{18(page 325)}

Narrative has always played an important role in our understandings of health and illness and in the health professions. Narratives and stories about patients, the experience of caring for them, and their recovery from illness have always been shared both in the community and across the health professions. Narratives have been, and continue to be, a source of knowledge or evidence, alongside the gold standard of randomized controlled trials. They provide meaning, context and perspective and can act as a bridge between the evidence of large-scale randomized-controlled studies and the art of applying this knowledge to a single patient.

The insights of Paley and Eva ¹⁷ are useful in examining narrative as evidence and in considering its appraisal. Of importance is the distinction they draw between ‘story’ as “an interweaving of plot and character, whose organization is designed to elicit a certain emotional response from the reader” and ‘narrative’ as an account of a “sequence of events and the (claimed) causal connections between them.”^{17 (page 1)} They stress the importance of not confusing “…the emotional persuasiveness of the ‘story’ with the objective accuracy of the ‘narrative’” and they “…recommend what might be called ‘narrative vigilance’”^{17 (page 1)} when considering narrative as evidence. Central to ‘narrative vigilance’ is the concept of narrativity.  Narrativity is something that a text has degrees of. It is constituted by a series of elements whose presence is associated with ‘high’ narrativity, and whose absence is associated with ‘low’ narrativity.  They present a ‘narrativity ladder’ (see Figure 1 below), which ranges from a simple recounting of one or two events to a more complex account:

Figure 1: Narrativity Ladder/ Degrees of narrativity ^{17 (page 87)}

Paley and Eva ¹⁷ argue that a story sits at the ‘high’ narrativity end of a continuum and that an account that incorporates features 4–8 on the narrativity ladder should be regarded as a story. While all stories are narratives, not all narratives are stories.

Sources of this type of data may be found in the grey literature and located from printed publications or on the websites of patient groups, professional associations or industry/provider groups. It may also include spoken accounts (video or audio with transcripts), or blogs. Narratives are increasingly a common data source, but are collected outside the frame of formal research.