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Social Science & Medicine 70 (2010) 754–762
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Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Patients’ narrative accounts of open-heart surgery and recovery: Authorial
voice of technology
Jennifer Lapum a, *, Jan E. Angus b, Elizabeth Peter b, Judy Watt-Watson b
a
b
Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canada
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
a r t i c l e i n f o
a b s t r a c t
Article history:
Available online 29 December 2009
In this narrative inquiry, we examined patients’ experiential accounts of technology in open-heart
surgery and recovery. A convenience sample of sixteen individuals was recruited from a preoperative
clinic at a regional centre for cardiac services in Canada. Each participated in two interviews following
transfer from cardiovascular intensive care and 4–6 weeks post discharge from the hospital. Participants
also documented their experiences in journals during the first 3–4 weeks following discharge. The focal
point of the study’s theoretical foundations was narrative emplotment, which directs attention to the
active processes of plot construction and shaping forces of stories. In our narrative analysis, we used
narrative mapping to document the temporal flow of events. We found that technology acted as the
authorial voice, or controlling influence, over how participants’ narratives were shaped and unfolded.
Key were the ways in which technology as the authorial voice was linked with participants becoming
background characters and surrendering agency. Problematic and important to health care professionals
is ensuring that authorial voice shifts back to patients so that they become active in shaping their own
course of recovery. This study underscores the benefits of using literary techniques such as narrative
analysis in health science research. Examining the narrative structures and forces that shape patients’
stories sheds light on how health care professionals and their technologically-driven practices of care
strongly affect the stories’ content and how they unfold. By focusing on how stories unfolded, we
revealed ways in which cardiac surgery practices and patients’ course of recovery could be enhanced.
Ó 2009 Elsevier Ltd. All rights reserved.
Keywords:
Canada
Narrative inquiry
Authorial voice
Patients’ experiences
Technology
Cardiac surgery
Coronary artery bypass graft
Aortic and mitral valve replacement and
repair
Introduction
Stories are recounted by individual speakers, but storytelling is
shaped in intricate ways. The complex and social act of creating
a tellable tale reveals as much about the author as it does about an
experience. Narratives of illness and recovery are shaped by institutional and social forces that influence the ways that individuals
recount stories (Frank, 1995; Kierans, 2005; Mattingly, 1994). In
open-heart surgery and recovery, not much is known about
patients’ experiences of technology and the shaping forces of their
stories. Since technology is omnipresent in health care, it is
important to consider the ways that it appears in patients’ narrative
accounts.
Despite abundant research examining outcomes of mortality,
morbidity, and economics, patients’ experiences of technology have
been largely neglected (Gagnon et al., 2009; Lehoux, 2008). This is
a significant omission in cardiac surgery considering that patients
* Corresponding author. Tel.: þ1 416 979 5000.
E-mail address: [email protected] (J. Lapum).
0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2009.11.021
come into close contact with technology in its many guises. For
these reasons, we conducted a narrative inquiry to explore patients’
experiential accounts of technology in open-heart surgery and
recovery and considered the intricate ways that narratives were
shaped. Further understanding patients’ experiences of technology
and how their stories are shaped will be useful to enhance practices
of care and courses of recovery.
It has been argued that technology and associated routines of
care may focus attention away from patients, resulting in dehumanization and distress (Barnard & Sandelowski, 2001; Kleinman,
1988). Patients are often unaccustomed to technology, which
creates potential for stress, fear, and ambivalence. Practitioners,
however, are well versed in technology in which technologicallydriven routines of care and the presence and use of object technology follow as a matter of course. For them, the extraordinariness
of technology becomes ordinary and familiar in ways that may
deter practitioners from recognizing that patients are undergoing
an unfamiliar, traumatic, and life-altering event.
Issues of identity and agency are salient when considering
patients’ experiences of technology. Since agency is a human
J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
capacity and process to act and make choices (Hardin, 2001), it has
the tendency to shift along a continuum during illness. When
individuals do not or are unable to fully enact agency during the
course of illness, the way they define and understand themselves
shifts. Numerous studies have noted shifts in identity associated
with cardiac surgery (e.g., Dingley, Bush, & Roux, 2001; Hawthorne,
1993; King & Jensen, 1994; Leegaard & Fagermoen, 2008; Lindsay,
Smith, Hanlon, & Wheatley, 2000; Plach & Stevens, 2001). Reflected
in this literature are patients’ descriptions of depersonalization and
lack of control (e.g., Doering, McGuidre, & Rourke, 2002; Hunt,
1999; Radley, 1996; Schou & Egerod, 2008). Increasingly blurred
boundaries between human and machine have led to shifting
identities that are ambiguous and indefinite (Haraway, 2000). In
cardiac surgery these boundaries are invasively challenged on
multiple levels from temporary insertion of monitoring and therapeutics devices to surgical insertion of heart grafts and valves.
Nancy (2002), a French philosopher who himself had cardiac
surgery, described this shifting identity. He referred to the surgical
intervention as an intruder that entered his body and described
confusion concerning his heart as a foreign object (Nancy, 2002).
Radley (1996) echoed similar sentiments, suggesting that bypass
surgery becomes part of patients’ ‘‘identity, their heritage – a mark
on their biography’’ (p. 135).
Although technology has not been an explicit focus in cardiovascular research, some insights have been offered. When examining patients’ experiences, researchers have often focused on
object technology such as machines, tubes, and wires (e.g., Gardner,
Elliot, Gill, Griffin, & Crawford, 2005; Grap, Blecha, & Munro, 2002;
Shih, Chu, Yu, Hu, & Huang, 1997). Important in this work are
paradoxical descriptions of technology as distressing and unfamiliar, but also providing a sense of security. Also, critical to
exploring patients’ experiences of technology (but receiving less
empirical attention) are the socially-embedded components (Benner, 2003; Lehoux, 2008). There is a body of cardiovascular research
that has offered analytic insight into these social components,
although technology was not a focus of their work (Doering et al.,
2002; Dunckley, Ellard, Quinn, & Barlow, 2007; Gardner et al., 2005;
Hunt, 1999; Micik & Borbasi, 2002; Tolmie, Lindsay, & Belcher,
2006). It has been found that in technologically-intense environments, ‘‘the flaw is not turning to the device per se; it is the turning
away from the person’’ (Almerud, Alapack, Fridlund, & Ekebergh,
2008, p. 60). Since technology has significant impacts on patterns of
practice, it cannot be reduced to the mere usage and presence of
objects in health care. Cognitive and behavioral responses from
practitioners result from technological readings from devices such
as monitors and ventilators. Often, these responses are organized
according to standardized care maps, clinical protocols, and algorithms. In order to fully understand patients’ experiences in this
current study, it was necessary to consider the complexity of
dimensions intricately woven with object technology, including the
various people involved and the logics and practices of care (Barnard, 2002; Sandelowski, 2000).
Although closely related, it is critical to note that technology was
the focus of this study and not medicine. Technology and the
socially-embedded components are one dimension of medicine
that sometimes take precedence over humanistic and psycho-social
practices during certain critical and acute illnesses. However,
medicine is governed by varying discourses and encompasses an
array of values, logics, and practices that shift with context, discipline and patient cases (Hirschauer, 1998; Mol & Berg, 1998).
In order to enhance cardiovascular practices of care and address
gaps in the literature, it is important to understand how patients
make meaning of technology and how it is featured in their experiential accounts. In this paper, we examine study findings related
to how technology acted as a dominant discourse and shaped
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participants’ narratives. We highlight the problematic and also
beneficial ways that technology affected patients’ experiences of
open-heart surgery and recovery.
Methods
A narrative methodology was employed, which maintained an
orientation to stories (Clandinin & Connelly, 2000). Telling stories is
a familiar way for individuals to talk about their experiences by
using existing social patterns that are learned early in life. Although
approaches to narrative inquiry vary, in this study we began by
thinking with stories (Frank, 1995). This approach entailed engaging
cognitively in the story, but also morally, emotionally and
aesthetically (Richardson, 1994). Engaging on these various levels
assists researchers to be drawn deep into stories and respond
authentically with participants. This approach is critical because
storytelling is a dialogical process between the teller and listener.
Two central tenets that underpinned our method were temporality and contextuality. They were important because people are
temporal beings (Conle, 1999) in that their stories are shaped over
time. Also, stories are always told from a particular vantage point
(Conle, 1999; Frank, 2000). Attention to temporality and contextuality facilitated our understanding of why particular stories
were being told and why in that way. People tell different types of
stories for different reasons depending on the context. Individuals’
experiences of surgery are embedded in their biographical course,
which may involve temporal and contextual shifts in identity.
A sense of morality often emerges through storytelling about how
one should live or conduct one’s social life (Frank, 2002).
Researchers can help participants reflect on meaning by drawing
attention to and exploring certain facets of stories.
Underpinning this study was an understanding that experience
is linguistic (Allen & Cloyes, 2005; Scott, 1992). As Allen and Cloyes
(2005) stated, ‘‘Experiential accounts are narratives, if we are clear
that we are studying how they talk, then we can treat these
accounts more rigorously by asking more questions, not just about
what they said, but why they said it that way (p. 103).’’ Therefore,
research findings were not just a summary of what participants
said, but a linguistic and contextual examination of how and why
stories unfolded as they did. This ontological assumption also lent
itself to a narrative epistemology. This epistemology is a way of
knowing that occurs through stories (Clandinin & Rosiek, 2007) and
by thinking with stories (Frank, 1995). Although storytelling is
relative to context, the ways in which participants’ stories unfolded
were juxtaposed against each other and generalized in terms of
these processes.
The focal point of the study’s theoretical foundations was
narrative emplotment, which originates in literary theory and
involves attention to plot lines (Frye, 1957; Mattingly, 1994).
Narrative emplotment is an active and temporal process of constructing a plot; storytellers depict how characters, events, interactions, and outcomes are related (Holloway & Freshwater, 2007;
Kierans, 2005; Mattingly, 2007). It facilitates analysing the point of
a story and how meaning is constructed in acts of storytelling
(Kierans, 2005). Because of the temporal nature of storytelling,
emplotment is shifting and fragile (Mattingly, 1994). Narratives
may be re-emplotted as stories are re-told and storytellers reposition themselves as circumstances change. Therefore, it was critical to be sensitive to the temporality of narrative emplotment.
Participants and setting
Approval was obtained from the University of Toronto Research
Ethics Board and the hospital where recruitment occurred.
A convenience sample was purposefully selected to include men and
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J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
women undergoing first time coronary artery bypass graft (CABG)
and/or valve repair or replacement surgery. Recruitment occurred in
a preoperative clinic at a regional centre for cardiac services. Individuals were approached by the registered nurse in the clinic. Those
individuals interested in information about the study were referred
to the first author and informed consent was obtained.
Sixteen individuals were recruited, including 8 men and 8
women with ages ranging from 59 to 85. Because narrative inquiries amass a large quantity of rich data, it is recommended that
sample sizes be kept small in order to contribute to an in-depth
understanding (Holloway & Freshwater, 2007). Furthermore, the
sample selected was homogenous in that participants were
undergoing surgery at the same hospital in which the presence and
use of object technology and practitioners’ routines of care were
comparable and surgeries involved similar pathways of recovery.
Surgical procedures included CABG (n ¼ 6), mitral or aortic valve
repair/replacement (n ¼ 6) and combined CABG and valve repair/
replacement (n ¼ 4).
Data collection
Data collection began in November 2006 and was completed in
June 2007. Methods included two narrative-based interviews with
each participant and participant journals. Interview One was
completed 2–4 days following transfer from cardiovascular intensive care, while individuals were still in hospital. These interviews
were purposefully short because of the acute phase of recovery
(mean length ¼ 20 min). Following this interview, participants
were given journals to document their experiences for the first 3–4
weeks following discharge. Oral and written instructions were
included with a short list of open-ended questions to provide
direction but enough flexibility to write openly. Interview Two
occurred in participants’ homes at 4–6 weeks following discharge
(mean length ¼ one hour 10 minutes). Semi-structured interview
guides were employed to address certain areas. Interviews
commenced with broad open-ended questions to encourage
participants to begin their stories at moments that were most
important to them. As well, questions were based on participants’
emerging stories. Examples of questions included: Tell me about
waking up from surgery? What was going on around you? What
did you see? Tell me about the technology? How did it make you
feel? Tell me about your recovery?
constructed by asking specific questions of the text such as, What is
happening? Who is involved? What are they doing? Why are they
telling this story in this way? How is technology part of the plot
line? These maps were helpful in comparing stories and identifying
ways that technology was emplotted. Attending to these maps
facilitated our analytic focus on the dominant ideologies that
emerged and narrative types that framed stories (Frank, 1995, 1998;
Fraser, 2004).
Results
We found that technology was incorporated as the dominant
discourse that structured participants’ narratives. Participants
internalized components of this discourse and its prevailing
meanings of values, identity and behaviour; hence, technology
emerged as the authorial voice and shaped their stories. Authorial
voice is the controlling influence of how a story unfolds. It often
reflects the dominant discourse (Duffy, 2007). Although we found
nuances in the narrative flow of stories, two common and significant transitions occurred in authorial voice. First, we discuss ways
that technology acted as a pervasive discourse that was swiftly
incorporated into stories and became the authorial voice. Of
importance were the ways that technology was positioned at
centre stage; this was linked with participants becoming background characters and surrendering agency. Second, we discuss
ways that authorial voice became re-anchored in participants’
personal and biographical perspectives, albeit with a technological
consciousness. Problematic and important to practitioners is
ensuring that authorial voice shifts back to patients so that they
become active in shaping their course of recovery. The interview
quotations that follow are accompanied by details about each
participant’s age, relationship status and operative procedure.
Authorial voice of technology
Data analysis
Issues of authorship surfaced as particularly relevant. Although
participants were the narrators, technology acted as the authorial
voice shaping and structuring their stories. A prominent finding
was the notably similar ways that stories unfolded, particularly
during the preoperative and early postoperative period. Technology, and all that flowed from it, provided the raw materials and
channeled participants’ narratives into particular trajectories.
These discursive elements of technology simultaneously provided
participants with a resource and a limitation.
Narrative analysis, which provided the overarching analytic
framework, began by thinking with stories (Frank, 1995). It was an
approach that began during the interviews and continued into the
iterative readings of transcripts and journals. This approach
required that researchers become aesthetically engaged, personally
dwell within stories, and avoid the immediate inclination to
analyse (Bochner, 2001; Frank, 2000). Hence, the analytic phase
commenced by just listening (Frank, 1998) and hearing and feeling
what was happening. Although analysis involved attention to
content, a focus was also placed on narrative form, how stories
were put together, and what structures storytellers drew upon
(Lieblich, Tuval-Mashiach, & Zilber, 1998). We attended to facets of
temporality, contextuality, plot, scene and characters in order to
understand processes and activities involved in narrative
emplotment.
Narrative mapping was used as an analytic tool to highlight
emplotment patterns and stories’ components (Lapum, 2009).
Visual maps of stories were constructed on an 8 1/2 11 inch piece
of paper for each of the participants’ interviews; these involved
documenting narrative flow and sequence of events. Maps were
Technological ‘‘fix’’
Technology promptly emerged as the authorial voice when
participants described the supposed decision to have surgery. This
decision was constructed as the only viable option to fix the
problem. Bob (age 71, married, CABG 4) bluntly wrote in his
journal about his response to the doctor’s recommendation to have
surgery: ‘‘My wife and I talked it over and concurred. Was there
really a choice?!’’ Edwin (age 81, married, mitral valve repair)
echoed similar sentiments, indicating that death was a consideration: ‘‘They said if I don’t have it, I only have a year to live.’’
Plot lines were framed according to a technologically-driven
ending of cure. Over half of participants specifically referred to
being ‘‘fixed.’’ This plot line functioned as a coping resource that
pulled them through the difficult times, but also as a limitation in
which realities of the recovery process were neglected preoperatively. Linda’s (age 84, widowed, mitral valve replacement and
CABG 1) path of recovery diverted from the script she was
previously prepared to follow, and she had to reconcile herself to
this non-linear actuality. Despite current physical discomforts, the
expected culmination of cure gave her comfort:
J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
You have to focus on the end result . It was more difficult than I
thought it would be. There are a lot of things that you have to do
that you don’t really count on. Wearing a pacemaker, oxygen in
your nose . I just looked at the end results and I thought ‘‘that
would be good.’’ They would fix my heart. Despite worries about
the risk of death, participants incorporated prospects of a technological fix. Kristi (age 58, common law, aortic valve replacement and aortic graft) envisioned a positive outcome based on
her surgeon’s confidence: ‘‘He made me feel comfortable with
the surgery so I wasn’t worried that I might die. There’s always
that possibility . you have to go in with a positive outlook.’’ It
was apparent that participants generally felt comfortable and
relieved to let the authorial voice of technology prevail in hopes
of what it could offer them. The mere probability of being fixed
averted dwelling on possibilities of death. This technological fix
appeared as a set of logics and risk calculations (offered by
practitioners) and interpreted by participants. The anticipated
fix acted as a resource that provided possibilities of a probable,
positive outcome:
I asked the surgeon what the mortality rate was and he said,
‘‘Oh, 5–10%’’ and I thought that’s all right. Then I asked the
anesthetist and he said ‘‘You’re all right, your lungs are clean, so
you won’t have any problem.’’ . and someone said, ‘‘these heart
doctors here, they’ve never lost a patient,’’ so I wasn’t too
worried when I heard that . Now, I don’t know whether that’s
true or not, but I took it as gospel anyway. (Edwin)
Shift of authorial voice to technology was reflected as an externalization of agency. In participants’ stories, technology became an
increasingly dominant player. Participants characterized themselves as becoming more passive with an inevitable surrendering of
agency. Two participants repeated the same phrase: ‘‘whatever
happens, happens’’ (Greta [age 65, married, CABG 2 and aortic
valve replacement] and Joseph [age 72, married, mitral valve
repair]). Participants indicated that you had to give up control
because of their unfamiliarity and lack of expertise with the technology. Fear was enfolded in these stories, but as Greta stated ‘‘You
just have to let it go and hope for the best . you have to trust the
doctors because you’re under.’’ Margaret (age 72, married, aortic
valve replacement) described changing her mindset and doing what
practitioners told her. She recalled just ‘‘turning my head off . I
closed my eyes and figured let them do what they’re going to do.’’
‘‘Plugged in’’
Technology as the authorial voice manifested as a technological
discourse in which standardized processes resulted in stories that
held marked similarities. In conjunction with the technological fix
that set the scene for participants’ narratives, the experience of
being ‘‘plugged in’’ structured the temporal flow of events. Participants described the physical act of being ‘‘hooked up’’ (Wayne, age
64, married, CABG 1) or ‘‘plugged in’’ (Jack, age 56, married, aortic
valve replacement) as their bodies were attached to technological
objects. They provided a similar catalogue of events that led to their
losing consciousness (e.g., putting on a gown, receiving sedation,
receiving an intravenous puncture). Although a sense of security
emerged with the frequency with which these procedures were
completed, tensions were inherent in the standardization associated with technology. A marker in Bob’s story was concern that
standardization masked his individuality and potentially meant
inattention to unique features of his body:
People said it’s routine, but it’s not routine. This is the only time
I’ll do it, ‘‘please God.’’ It’s routine for Dr. L, in that he does this on
a monthly basis. . [but] every time Dr. L incises a patient, it’s
a different patient, [he]doesn’t know what’s going to happen
when he makes that incision. Everything can turn upside down.
757
I’m serious, this happens, so the danger is becoming routine.
Nevertheless, participants emphasized the critical importance
of technology. Bob continued to write in his journal that
‘‘technology was replacing and supporting the vital functions of
my body . if they weren’t working, you would be dead.’’
Linked with the shift of authorial voice to technology was an
emerging sense of passivity as control was surrendered. Highlighted in the next excerpt is the abundant use of third person and
lack of first person pronouns, which is reflective of the shift of
authorial voice to technology. In this context, it is salient to reiterate
that technology encompasses the various objects that are
embedded in patients’ bodies, but also the practitioners who activate and survey these tubes and monitors. Joseph characterized
himself as passive and practitioners as taking an active role:
What they did as soon as you enter the hospital, they take all the
information, they give you a robe and put you in bed, they want
to prepare you . she gave me a pill, she said, ‘‘Put under your
tongue.’’ . and she said, ‘‘Okay we’re going to take you to the
operating room.’’ ‘‘Thank god,’’ I said, ‘‘We’re finally going.’’
Interestingly at the end of this excerpt, he used a plural first
person pronoun: ‘‘We’re finally going.’’ This linguistic usage
suggests a surrendering of agency and coalescence with technology including the practitioners that oversee the embedded
objects and the preoperative routines.
Technology as the authorial voice was reflected in participants’
descriptions of the ways in which their bodies would not be able to
function normally and machines would do what their bodies did
naturally. Participants were careful to explain that agency was
transferred to practitioners: ‘‘I think about the physical act of what
they did, the cuttings, shutting the heart off, re-routing the blood
supply. It’s a big deal, that I wouldn’t be responsible for doing it
myself . It’s still the people that drive it [technology]’’ (Jack).
During the postoperative period, Graham (age 59, married,
CABG 3 and aortic valve replacement) experienced issues of
tachycardia. This bodily disruption reinforced the lack of control he
was able to exert over his body:
The valve decided that it was going to take on a life of its own.
My heart was in the 180 rate. It was very disturbing . it was like
somebody was inside with a hammer trying to get out . I don’t
want to spring a leak or cause this valve to come unglued.
Furthermore, he positioned practitioners as the active players
because of their expertise. He stated ‘‘they’re watching me on
the machine . it was normal for them to see that. It scared the
shit out of me.’’ Although there was a sense of relief and confidence that practitioners knew what they were doing, there was
also fear about just how vulnerable one would be:
You think you’re a guinea pig. They’re going to experiment on
you. They’re going to stop your heart [crying]. . it is a little
apprehensive, you’re going to be stuck on the gurney and about
half dozen people will be doing a very tricky operation. You
hope the knife doesn’t slip. (Edwin). Edwin’s worries represented the ultimate vulnerability that occurs when one enters
the technologically-induced sleep of heart surgery.
Re-anchoring of authorial voice
Later in participants’ narratives, authorial voice began to more
clearly originate from their personal and biographical perspectives.
Hence, emplotment of narratives reflected more heterogeneity as
participants positioned themselves based on their own personal
context. As the surgical event receded, participants began to
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J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
position themselves at centre stage and increasingly characterized
themselves as active players. Technology receded into the background of the plot line just as a character in a play would move
backstage. However, technology persisted in narratives as a technological consciousness.
Resuming authorship with a technological consciousness
Through a sequence of postoperative events, authorial voice
became re-anchored in the particularities of self. Participants began
to plot their own course of recovery within the realm of possibilities
offered by technologically-driven protocols. Through varying timeframes, they began to re-establish agency and aspects of their
previous identity through embodied activities (e.g., walking). Abbey
(age 80, married, CABG 3) portrayed herself as a ‘‘strong’’ older
woman and quickly re-established agency. Although she described
having ‘‘just to go with the flow,’’ she described resistance to
medications that she was given in the hospital: ‘‘I said ‘don’t give
them to me, I won’t take them’ . I’m not taking a pill I don’t need.’’
Participants perceived the removal of various technological
devices and being able to engage in self-care as significant markers
of progress. They narrated these events in ways that indicated
technology no longer physically claimed their bodies. This shift
signified that participants were resuming authorship of their
stories. Ashur (age 61, married, aortic valve replacement) described
these events as a ‘‘release,’’ wherein his biographical course shifted:
‘‘It was a release, mentally and physically. . When they start to
take them [pacer wires and urinary catheter] out, it gives me the
real joy that it is done. That it’s going towards recovery.’’ Margaret
referred to the removal of tubes and wires as becoming more
recognizable: ‘‘[I was] getting back to being myself.’’ These events
prompted Bob to recognize that he was regaining bodily control
and re-establishing agency, although a technologized voice
remained. Strikingly apparent in the following excerpt is a linguistic
pattern that reflects the persistent dominance of technological
relations in his narrative. He shifts back and forth from third to
second person pronouns with the sparse use of first person
pronouns. Particularly interesting was his use of ‘‘we’’ towards the
end of the excerpt, indicating that technology was still a part of him
and incorporated into his recovery. The usage of ‘‘we’’ suggests that
his recovery involves technological intricacies including objects,
practitioners who maintain and remove them, and his own
embodied activities to function:
Whatever they [object technology] were doing, your body is
now able to take over that function. . When they took out all, it
meant that you had gone from being totally dependent on these
tubes to the fact that now your body was taking over these
functions, that I could breathe on my own. . which meant we
had moved onto phase one of recovery .. You feel like you’re
getting close to being normal. Each one, is a step in the right
direction, that you don’t need this thing, you’re going to survive
on your own. His narrative pointed to strong biographical
associations in which reconstituting identity involved an
embodied capacity to perform basic functions.
Being discharged home accelerated the shift of authorial voice to
participants. Many participants began to re-characterize self as
being an active player in recovery. Kristi wrote in her journal: ‘‘I am
taking a journey that I have not traveled before, how I come out of
this, is all up to me.’’ According to Joseph, discharge was akin to
being released from the technologically-structured routines of the
hospital. Social connections and comforts in the home prompted
a psychological sense of healing:
You are in your own kingdom. You’re not cooped up in one room
and waiting for the nurse to come in, give you a pill, check your
blood pressure. You can do what you want. You don’t feel like
you’re sick because you’re in your own home. I felt a lot better,
psychologically. I am at home.
For others, going home was a difficult transition in which the
resumption of authorial voice was more gradual. Some participants
expressed ambivalence in ways that reflected a technological
consciousness as they attempted figure out how to perform selfcare. Underpinning Raz’s (age 63, married, CABG 4) narrative was
the belief that responsibility was transferred to him. However, he
indicated that he could not fully understand the logics and hence
could not fully initiate the expected practices:
They shouldn’t be telling me this, the patient, because I can’t
take on all that. I can’t remember anything. They should be
telling that to somebody, what I use the term ‘‘sober.’’ . The day
they discharge me, it was a rush to get rid of me. They should
have more ample time to explain. You on so much drugs, you
really can’t remember. Raz emphasized that family should
always be included during the provision of discharge information. Wayne described the discharge process as superficial
because the rapid dispensing of information left little time to
absorb or discuss the material: ‘‘I felt that they went over things
in a rushed manner . the impression I got was, ‘get out!’’’ He
continued to indicate a need for hospitals to ‘‘update the release
procedures so that there’s a little more, you’re not just thrown to
the wolves when you’re released, there’s somebody who is
going to keep track of you.’’ The metaphorical expression
‘‘thrown to the wolves’’ represents how individuals often feel
when they are abruptly discharged from hospitals where they
had felt protected. At home, technology became a background
character and participants described feeling at risk for harm.
Self-sufficiency
As the surgical event receded and participants regained authorial voice, a theme of self-sufficiency was established. Participants
began to position themselves as active players in the plot line.
Velinka (age 66, married, CABG 1) insisted that she had her own
role to play and recognized that dimensions related to technology
were not fully responsible for her recovery: ‘‘I’m alive. Now, it’s my
turn.’’ As Joseph described attempting to return to his activities, he
included passages implying how he resisted identifying with the
dependency involved in being cared for by others. Underpinning
this resistance was masculine identity as he attempted to become
self-sufficient and re-establish independence:
They said I should not force myself, warning health will come with
time. As much as I tried, the person, look, I’ve always been active,
and, well, they said, ‘‘Don’t too often climb the stairs.’’ I’m going up
the stairs and there’s my wife or there’s my son or my sister,
whoever was behind me, being scared that I’m going to faint and
fall down. I said, ‘‘I’m okay. Would you go and do what you have to
do.’’ He continued to describe a resistance against the expected
pathways: Doctor L says, ‘‘By Easter you should be okay.’’ I got
news for you doctor, I’m okay now . They say ‘‘don’t lift’’ .
Physically, I feel I can. But they say ‘‘don’t rush it’’ but I’m rushing
it. I can do it. They say one step or two steps, I just keep on walking.
Joseph acknowledged the advice of providers and understood his
family’s need to protect him, but also that he must find a way
through all of these influences by trusting how his body feels.
As a technologized authorial voice became re-anchored in the
particularities of self, participants struggled with vulnerability and
anxiety. In Kristi’s narrative, what became evident was that
returning to the familiar space of home facilitated the entrance of
an authorial voice that was ambivalent:
J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
It was a two-edged sword. I didn’t want to go back to the
[hospital] room, even though that’s where my comfort zone was,
because everybody was taking care of all my needs. I think it’s
the comfort of everybody monitoring you. You’re coming home
and going ‘‘there’s nobody going to be monitoring, what if
something happens?’’ However, Kristi progressively regained
confidence in her home by acknowledging her own selfsufficiency.
Unfamiliar sensations prompted participants to re-align relationships with the body. It appeared that just knowing whether
these sensations were normal would have alleviated participants’
concerns. Authorial voice in Margaret’s story flowed from her
efforts to interpret her bodily sensations and determine what was
normal:
I wish I could have talked to somebody with what I’m feeling in
here. I’m hoping this is healed. I’m assuming it is. One of the
reasons I assume it is, at one point I felt a sneeze coming on . It
was excruciating. Now I have sneezed and I cough and it’s okay. .
All I want to know is, is what I’m feeling part of the normal getting
over this process? Because it doesn’t say anything about that in
the book [discharge booklet]
Technology entered into the instructive materials presented at
discharge about what activities they should and should not engage.
Participants’ efforts to understand and comply with this advice
influenced their activities at home. However, these passages suggested that guidelines were not tailored and expected timelines
were not clear, making it difficult to incorporate into the specificities of their daily lives. According to Wayne,
No one is standing there saying, ‘‘Now you can lift.’’ I sort of
assumed that if I can drive, then I’ve reached the point where I’m
not likely to split open. . If there was some schedule that
looked after you when you got out, you’d have a better idea of
when you could go back to work, when you could start to lift the
garbage can, get back to normal. You’re kind of left with these
things, don’t lift anything heavy, for how long? Other participants described difficulty interpreting the discharge materials:
It [discharge booklet] covers a lot of stuff. It mentions about your
breathing ten times every hour. I know I didn’t do that and I
wasn’t sure how long I was to keep doing that . Am I to do that
when I walk? .. I don’t know whether I’m supposed to be doing
a fast walk or slow walk or does it matter? (Dianne, age 76,
divorced, CABG 4)
Self-surveillance was one way that participants personally
interpreted and incorporated technological knowledge into their
own context of recovery. This strategy reflected how they were
regaining authorial voice, but with a newly organized consciousness. From exposure to surveillance practices in the hospital, Kristi
learned to reassure herself by self-monitoring:
Sometimes my heart would race. If I don’t hear it, I’m going,
‘‘Okay, I’m still breathing, obviously my heart is still going.’’
That’s scary. .. I do check my pulse and I know when I listen to
my heart if I’m just sitting back, in a quiet room, my heart will go
back to a regular pace. I just stay there until I feel reassured that
it’s not skipping. Although participants resumed authorial voice,
technology still ebbed and flowed into their stories.
Discussion and conclusions
We noticed striking shifts in authorial voice by examining
participants’ stories through a literary lens and considering
discursive influences of narrative emplotment. To elaborate on the
759
temporal shifts of authorial voice, we discuss the ways that technology was emplotted as the authorial voice that shaped and
structured participants’ narratives. Then we discuss the shift of
authorial voice in becoming re-anchored in the personal and biographical perspectives of participants. Since technology as an
authorial voice can act as both a resource and a limitation, it is
critical to understand how practitioners can mediate these shifts in
voice at appropriate times.
Eclipsing the unique voices of patients
Authorial voice became located in and contingent on technology, and participants’ full authorship was eclipsed, particularly
during the preoperative and early postoperative periods. This
finding speaks to the ontological foundations in which stories were
co-constituted temporally and contextually. Although participants
were the narrators or tellers of their own stories, a polyphony of
voices acted as influences. Particularly notable was how the technological discourse acted as a powerful force that shaped stories.
Practitioners were key players that were enfolded into the
technological discourse and became part of this authorial voice.
Similar to Fox’s (1992) ethnography of surgery, in our study
surgeons activated the dominant social voice in participants’ stories
that provided authority and hope based on the logics and risk
calculations that were offered. Hence, story plot lines were channeled according to a technological fix. Because of nurses’ close
proximity to patients, they were also key players and maintained
a plot line that was driven by a technological end of cure. As
described by participants in this study, and reflective of the literature, nurses’ practice is technologically focused and highly
routinized (Philpin, 2007; Sandelowski, 2000; Scott, Estabrooks,
Allen, & Pollock, 2008). As with other work (Karlsson, Johansson, &
Lidell, 2005), reliance on practitioners and their surveillance practices provided patients with security and optimism. Emplotment of
technology in participants’ narratives was often mediated by
nurses’ actions and interactions. Although technological vigilance
was important, participants noted the critical importance of
humanistic care. Authorial voice of technology became problematic
when practitioners neglected listening and responding to patients
in personalized ways.
Shifting of authorial voice to technology appears to have
involved externalization of agency. As suggested by Kierans and
Maynooth (2001), when people are diagnosed with a disease, their
sense of agency is suppressed and moved outside of them. Participants in our study entered into an unfamiliar domain where they
had no other choice but to relinquish agency to technology in hopes
of what it could offer them (i.e., the scripted telos: cure). Reflected
in other research (King & Jensen, 1994; Radley, 1996; Trumbull,
1993) as well as our study, the close coalescence with machines and
bodily dependence shifted agency. During the course of surgery and
recovery, participants’ stories reflected that they were not
responsible for the functioning of their bodies and were unable
enact agency. This shift resulted in the simultaneous presence of
both fear, because they had no control, but also relief, because
control over the surgical outcome was now in the hands of a team
of expert practitioners. Although other work has found that
patients can experience a strong sense of agency in terms of
adhering to proper positioning during diagnostic testing so that the
body can be effectively visualized (Blaxter, 2009), in heart surgery
the patient is medically-induced into a state of unconsciousness. As
Radley (1996) found in his work, patients undergoing heart surgery
described a period of non-being on the surgical table where they
relinquished complete control to practitioners. Similar to Rier’s
(2000) study on his own ICU experience, patients undergoing
critical or acute illness cannot always be active players. At times,
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J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
they need to relinquish agency in order to maintain a sense of
security, comfort and optimism (Rier, 2000). In our study, participants’ stories involved a temporal suspension of agency that only
returned through embodied activities and progress in recovery.
The eclipsing of participants’ unique voices was a discursive act
in which technology quickly appeared at centre stage. The technological discourse constituted a script resulting in a universal
sequence of events that led up to surgery and provided expected
pathways that resulted in a markedly similar unfolding of narratives. This is not to say that strict templates existed, but that
narrative emplotment was socially orchestrated (Mattingly, 2007).
People often have a sense of the stories that they will tell because of
the scripts that are available to them (Frank, 2006). Typical scripts
of cardiac surgery involved an expected trajectory in which the
culmination was a technological fix. Shift of authorial voice to
technology was prompted by the logics and risk calculations
practitioners offered. In our study, as in other research (e.g., Micik &
Borbasi, 2002), stories reflected how pathways were used to
identify whether recovery was following a normal trajectory. These
scripts acted as a resource for participants providing an optimistic
and hopeful trajectory and helping them move beyond periods of
distress and physical discomfort.
On the other hand, technology as the authorial voice also acted
as a limitation. Practitioners and their discursively-driven logics and
practices inadvertently provided the raw materials and narrative
structures for participants’ stories (Kohn, 2000; Mattingly, 1994). In
our study, practitioners appeared to activate and maintain a script
that followed this linear plot line. Technological elements give
shape to dominant discourses that can constrain patients to tell
a story that follows a particular pattern of progress (Kierans, 2005).
This scripted pattern not only inspires the common restitution
narrative that Frank (1998) described, but also reveals ways that
storytelling is shaped by discourse. Found in our study and also
noted by Kierans (2005), narrative emplotment framed by a story
ending with cure can be problematic. This finding is particularly
relevant since our study, among others, have reported that recovery
from cardiac surgery is non-linear and more complex than patients
expect (Dunckley et al., 2007; Gardner et al., 2005; Micik & Borbasi,
2002; Tolmie et al., 2006). To veer off this emplotment pattern was
unfamiliar, and participants did not necessarily have other plots to
draw from, which enhanced uncertainty and anxiety. Complexities
of storytelling can be at odds with how linear narratives are
purported to unfold by technological hegemony in health care.
When patients’ experiences were non-linear or did not culminate in
the scripted conclusion of restored health, narrative tension ensued,
embroiled with dissonance and ambiguity.
Although the patient as author occasionally emerged through
personal and emotional tellings, the technological discourse
dominated narrative structure. Prompted by a technological
discourse, participants in our study oscillated between first and
third person storytelling, creating a narrator that van Peer (1986)
would describe as diffuse. Narrations became impersonal,
progressively shifting to an abundant use of third person and
a diminishing of first person pronouns, which reflected the shift of
authorial voice to technology. Usage of third person pronouns
creates an absence of the narrator in the discursive situation (van
Peer, 1986). Linked with this shift were ways that patients positioned themselves as passive, non-agential, background characters
in their stories. At the same time, technology became an increasingly dominant player through the processes and routines of care
that practitioners enacted. The characterization of technology as
a dominant player acted as both a resource and a limitation
providing access to the visceral surfaces below the skin, but also
risking a neglect of patients’ voices. At times, knowledge produced
by technology takes precedence over the voice of patients and their
own intimate insight of bodily symptoms (Blaxter, 2009; Scarry,
1985). It is not technology itself that is alienating, but the technological practices of care that structure the patient encounter and
can limit dialogical approaches to communication (Blaxter, 2009;
Doering et al., 2002; Hawthorne, 1990).
‘‘Sing[ing] ourselves in’’
Participants began to resume authorial voice as the surgical
procedure receded and the course of recovery progressed. Not only
did technology become more of a background character, but the
shifting of authorial voice back to participants reflected less scripted narratives. Stories included more personal and unique elements
that were rooted in the particularities of self. Recounting of stories
became strongly influenced by one’s own personal voice that
included contextualized experiences based on biographical and
social positioning (Mishler, 1984). Since technology was no longer
the authorial voice, more variations in stories emerged based on
participants’ own positioning. Nevertheless, this resumption of
authorial voice incorporated a technological consciousness. Similar
to Radley’s (1996) notion that medicine becomes part of patients’
identity, participants in our study not only defined themselves in
technologized ways, but engaged the social voice of technology in
actions of self-surveillance.
To further understand this shift in authorial voice, we refer to
a metaphor that pertains to voice in writing as being both personal
and social (Elbow, 2007). Social elements of voice (in this case the
discourse of technology) shaped participants’ stories, but the
personal voice began to flower. Participants began to ‘‘sing themselves in,’’ and their own particularities became an influential force
in the unfolding narrative:
We all have a chest cavity unique in size and shape so that each
of us naturally resonates to one pitch alone . In this metaphorical world, then, even if we figure out the system, we are
stuck. If we want to be heard we are limited to our single note. If
we want to sing other notes, we will not be heard. And yet, if we
are brave and persistent enough to sing our note at lengthdto
develop our capacity for resonancedgradually we will be able to
‘‘sing ourselves in’’: to get resonance first into one or two more
frequencies and then more. Finally, we will be able to sing
whatever note we want to sing . we only manage this flowering if we are willing to start off singing our own single tiresome pitch for a long time and in that way gradually teach the
stiff cells of our bodies to vibrate and be flexible (Elbow, 1998,
pp. 281–282).
Because the technologized pathways of recovery provided
a sense of security and reassurance, participants were careful to
adhere as best as they could. However, participants became more
competent as active players and began to sing themselves into their
recovery over varying periods of time through embodied activities,
successes at returning to normal capacities and speaking up about
their individual perspectives (e.g., control over bodily functions,
walking, resisting medications).
Resuming authorial voice involved participants’ singing themselves into their course of recovery. Stories reflected a liminal
ebbing and flowing of authorial voice between participants and
technology. Participants had to be ‘‘brave and persistent’’ (Elbow,
1998, p. 282) and work hard in order to re-establish self-sufficient
capacities to function and resume agency. Other research has found
that patients focused on returning to normal activities of daily
living, but these often involved a reconfiguration within the realm
of what was possible (Keller, 1991; King & Jensen, 1994; Theobald &
McMurray, 2004). Resuming a technologized authorial voice
manifested itself in participants personally interpreting and
J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762
incorporating pathways of recovery into the specificity of their
daily lives. Technology acted as a resource providing participants
with knowledge about expected pathways of recovery. However, at
times technology acted as a limitation because participants
described ambiguity about how to incorporate pathways of
recovery into their home life. As reported in other research (Lukkarinen, 1999), some participants promptly enacted agency and
took an active role in recovery. As in our research, some described
feeling stranded and unsure, whereas others were quicker to sing
themselves in and let technology remain a backstage character.
Critical to patients’ successful recovery were practitioners’
prompts and encouragement to follow pathways and engage in
self-care. Through these prompted actions, participants began to
engage in their recovery and characterize themselves as becoming
active players and practitioners as shifting to supporting roles. Of
great significance is how practitioners can act as supporting characters in helping with transitions of authorial voice from technology back to patients. Because the dominant discourse of
technology resulted in influential structures that shifted identity to
a sense of passivity and externalization of agency, patients need to
be supported in regaining some level of self-sufficiency before they
are discharged. This is a critical transition so that individuals
actively engage in their recoveries and characterize themselves at
centre stage. Such a process would provide opportunities and
instances of success for patients to begin singing themselves in and
resuming authorial voice before they are discharged from the
structured and safe environments of hospitals. Where authorial
voice remained with technology at the juncture of discharge in the
current study, participants’ stories reflected a strong sense of
vulnerability and a lack of self-sufficiency. As Radley (1988) has also
noted, it is important to examine patients’ experiences of recovery
from heart surgery within a longitudinal framework. Although
authorial voice shifted back to participants, the question remains:
does a technological consciousness remain indeterminately?
Drawing from a literary lens sheds light on the ways that
shifting of authorial voice to technology reflected an eclipse of the
patient as author and ways that practitioners can ensure that
patients sing themselves back into their recovery and their life. This
unique approach to narrative inquiry highlighted the importance of
attending to stories in health care research that has implications for
altering practices to enhance patient outcomes.
Acknowledgements
This paper is related to the first author’s doctoral research that
was completed at the Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto. She acknowledges and is thankful for the
fellowships and awards received during this time that allowed her
to focus upon and complete her doctoral education: Heart & Stroke
of Canada Nursing Research Fellowship; Strategic Training Program
for Cardiovascular Nurse Scientists stipend, a partnership between
the Canadian Institutes of Health Research: Institute of Circulatory
and Respiratory Health and the Heart and Stroke Foundation;
University of Toronto Fellowships; and Canadian Nurses Foundation award. As well, her PhD supervisor and committee were
essential to the completion and rigorous conduct of this study.
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