Developing and Implementing a Narration of Care Framework to Teach Nurses When and How to Narrate Care.

Background: It is generally well-known that narration of care is critically important to high-quality nursing care. Narration of care is loosely defined as a nurse's ability to describe to patients and families the clinical purpose behind nursing practice, what is hoped to be achieved, and the "why" (or clinical rationale) behind nursing activities. Despite the importance of narration of care, there is little practical guidance given to nurses about how to narrate care-what makes for effective or ineffective narration of care. Objective: Our aim was to develop a framework for teaching nurses and patient care assistants (PCAs) on how to effectively narrate care. In this article, we provide a practical framework for teaching nurses and PCAs how to narrate care. We describe the process of developing the framework as part of quality improvement efforts and implementing a course for eight hospitals based on the framework. Methods: Consistent with a Plan-Do-Study Act (PDSA) quality improvement approach, we developed the framework by first conducting a data and literature review, then convening a taskforce, discussing with patients on our existing committees, and finally formulating a framework. We then drafted supplementary cases and course material and implemented a course to teach nurses and PCAs how to narrate care. Results: The narration of care framework (NOC) that we developed and implemented consisted of the following five principles, which can be called RECAP as an acronym: 1. The "R" in RECAP stands for removing uncertainty. 2. The "E" in RECAP stands for explaining the environment. 3. The "C" in RECAP stands for being calm and sincere. 4. The "A" in RECAP stands for assume nothing. 5. The "P" in RECAP stands for personal connection. As for the course developed based on the RECAP principles, there was a total of 276 course offerings conducted by 30 facilitators, and 7341 nurses and PCAs completed the course. The evaluations reflected that 99% of learners believed their learning was improved by the course. Discussion: There are several multifaceted benefits to NOC: nurses' and PCAs' capability to narrate care well shows empathy and compassion to patients; it strengthens patient understanding and education that can lead to improved patient outcomes; and it helps allay patients' uncertainties and anxieties. In essence, narrating care in an effective manner cultivates a strong nurse-patient therapeutic relationship. Yet, in the absence of any practical guidance, nurses and PCAs are left to develop narration skills on their own, learning by trial and error, and, in doing so, perhaps failing to meet patients' needs and failing to fully derive the many benefits that the NOC is designed to achieve. Our hope is that, if hospital systems adopt our work, nurses and PCAs can comfortably and confidently enter the profession knowing the purpose or narrating care, its many benefits, and how to practically conduct sufficient narration, and what would constitute insufficient narration. Hospitals, in turn, can specify and clearly articulate their expectations for nurses and PCAs narrating with patients-what would make for a strong, compassionate process and what would be inadequate. For more experienced nurses, they can use the RECAP framework to reflect on their own practices and perhaps strengthen or refreshen existing skills. Conclusions: NOC is acknowledged, somewhat implicitly, as being critical to nursing and PCA practice, yet practical instruction and specified principles are lacking. We aimed to fill this gap by developing, implementing, and teaching a practical framework, armed with many tools nurses can use.