Narrative Methodology to Examine Medical Students’ Experiences of Adverse Events

This article serves as a guide for medical education scholars seeking to implement narrative methodology, using an example to demonstrate the process. Narrative methodology is a qualitative approach to producing knowledge based on the idea that people are natural storytellers and that stories are a tool for understanding experiences of self in the context of community, culture, and history.^1,2 Stories are points of connection; through stories, humans contribute to communities, create meaning, and engage in relationships.^3,4

Narrative methodology is a valuable research tool in medical education because it permits educators to develop a deeper understanding of difficult topics² and allows learners to understand and connect with their patients.¹ Narrative’s emphasis on story centers on setting and actors, allowing researchers to explore complex, socially situated learning experiences from the perspectives of key individuals⁵ (eg, clinicians, residents, medical students, educators, and leaders). While a narrative methodology offers the researcher practicality and flexibility, it is not subject to the constraints of some other qualitative approaches that seek to create theory, need a specific location, or require long-term engagement in a specific cultural context. Further, because narrative is story-based,¹ this methodology aligns with tenets of family medicine, including care that is comprehensive, community-based, and longitudinal. The focus of narrative methodology on the human experience and relationships³ allows for connections between patients telling their stories and the practitioner, supporting the development of empathy and trust in the therapeutic relationship.¹

In the following sections, we describe important areas for future health professions researchers to consider when thinking about using narrative methodology.

Narrative methodology uses a constructivist worldview.⁵ That is, truths are multiple and socially situated; people construct their reality through social interactions, and environments are also shaped by human behaviors.⁵ This approach to truth is different from positivist or postpositivist worldviews that position truth as discoverable and objective. This difference is important because the stories we tell ourselves often change over time and within different contexts. Thus, by being grounded in constructivism, narrative methodology allows for a deeper understanding of how students make meaning of critical learning experiences (eg, professional identity, social connections).^6,7,8,9

With a core emphasis on storytelling, setting, and the social construction of lived experiences, narrative methodology lends itself to examining phenomena that change over time (eg, disease progression) and social dynamics between groups of actors (eg, relationships between children, caregivers, and clinicians).⁶ Examples of potential topics for narrative analysis are shown in Table 1. A narrative approach has been useful in medical education to explore topics such as interprofessional education, learner’s professional identity formation, and shame.^10,11,12 Narrative stories have been proposed as a powerful tool for physicians to learn about patients’ illnesses and to increase connections, particularly when diagnostic uncertainty exists.¹ Storytelling is also an opportunity to identify a community that supports the telling of difficult narratives¹³ and allows for a deeper understanding of the processes that affect how experiences are constructed from internal and external perspectives.^5,6

Narrative data collection focuses on participants’ stories about specific events or phenomena within the context of their life histories.⁵ Thus, interviews and oral histories are common forms of data collection.³ Interviews tend to be narrower in scope and can occur as a single interview or staggered over a series of several meetings. Oral histories are more open-ended, tend to be told in first-person, and focus on a broader range of experiences.^3,5 As digital and multimedia storytelling expand, the types of data included within narrative methodology also have grown to include photos, videos, and physical items that are meaningful parts of people’s stories.⁶

Narrative methodology is flexible. When engaging in data analysis, different approaches can be applied (eg, holistic, situated, linguistic, agentive, and sequential) to highlight aspects of the data that are important to the context of medical education.⁷ The holistic lens focuses on connections within and between stories to build an overall theme, provide comparisons across stories, and combine stories to create meaning.⁷ Often researchers will start the analytic process by writing short vignettes (ie, summaries of the interviews) for each participant.^3,5,6 In the section that follows, we provide an example of holistic data analysis.

Quality within narrative methodology is assessed through indicators, including the depth of the analysis, credibility, and dependability.¹⁴ The depth and richness of participants’ stories is important because that allows for a complete understanding of the story content, how the story is told, the sequence of events, the relationships, the recurring patterns and themes, and the social and cultural environment for the narrative.³ Credibility assesses how well findings represent participants’ views.¹⁴ Credibility acknowledges that the truth may not be entirely objective but rather resulting from interactions where multiple voices and perspectives engage in collaborative discourse to construct knowledge and understanding.¹⁴ For instance, credible findings in a project on diabetes management would have variations in the stories told by different people (eg, parent, child, siblings, external care providers). Dependability is a measurement of reliability and is achieved via documentation of methodological decisions captured in memos and an audit trail. Examples of memos are provided in Table 2.

While powerful in revealing nuances of personal stories, narrative methodology can present challenges. For example, the potential for misinterpretation, leading to false narratives, is a serious concern. Researchers must remain sharply aware of alternative stories and inherent limitations arising from the coconstruction of narratives.³ For instance, a patient’s first-person account of their experience and illness may differ substantially from electronic medical records. The subjectivity of interpretation, influenced by the researcher’s own cultural context and positionality, further complicates analysis.¹ Researchers must carefully examine their own feelings and assumptions that can impact their perspectives and the coconstruction of the narrative.¹⁵ Maintaining objectivity and openness to diverse viewpoints while avoiding assumptions is crucial, yet difficult.³ Another consideration is the time necessary to conduct interviews and analyze the qualitative data.^5,6 Investigators should factor time considerations into research planning. With its potentially intricate interprofessional relationships and diverse populations, family medicine offers researchers an opportunity to use narrative to evaluate “wicked problems” demanding nuanced understanding.^2,6 We hope that a focused guide on effectively applying narrative methodology within family medicine can help scholars navigate these challenges and ensure rigorous, meaningful research.

To elucidate how narrative methodology can be applied, we present an example study exploring medical students’ accounts of clinically significant adverse events (CSAEs). CSAEs are stressful events—events where students feel psychological or physical symptoms in response to the event. Examples include experiences with patient safety events or patient death.^16,17,18 Without proper awareness of possible adverse secondary effects of CSAEs and support for students, these events place students at risk for secondary traumatic stress, feelings of guilt, anxiety, responsibility, failure, loss of confidence, loss of satisfaction, and alterations of career trajectories.^19,20,21,22 Although substantive literature exists about CSAEs for clinicians,^16,17,18,19 medical students’ experiences remain relatively understudied, and students may be uniquely at risk during rotations due to their developing knowledge and experience, role identification within the team, and less experience coping with stress.^20,21 We used narrative methodology to understand how medical students experienced and navigated CSAEs during rotations, as part of a study approved by an institutional review board.

Multiple important research questions could be asked about CSAEs. We were interested in how students construct meaning after a CSAE, as opposed to describing the frequency of CSAEs or exploring differences between students who experienced CSAEs and those who did not. Our focus on understanding meaning within a natural environment situated this study within qualitative research.²³ From that point, we considered how the study would look if conducted from various qualitative methodological approaches, including ethnography, case study, phenomenology, grounded theory, narrative, and a generic inductive approach.^24,25,26 We decided to eliminate ethnography because of time constraints and because understanding the cultural aspects of CSAEs was not the primary goal.²⁴ We eliminated a case study approach because the research did not have a place and space in which to bind the study.²⁵ We opted not to use phenomenology because we were more interested in participants’ stories than in exploring the essence of CSAEs; and we decided not to use grounded theory because our goal was not to generate a theoretical understanding.^26,27 Thus, we decided to use a narrative approach because we wanted to center the participants’ voices and learn more about the interplay between their unique settings and social interactions as they related to CSAEs.^26,27

When considering the various narrative lenses in medical education,⁷ we selected a holistic lens because that allowed us to highlight complexities of the individual story, draw connections within the story, and make comparisons across stories to synthesize meanings.^5,7,27 A holistic approach allowed the team to develop a complex understanding of how students experienced CSAEs and how that may shape professional identity formation.⁷ In the following sections, we describe study methods and explain how the study was conducted.

To ensure participation of students with a breadth of clinical experiences, only students who completed at least 6 months of clinical rotations were eligible. Students were recruited from medical schools in the United States by emails sent to department chairs in obstetrics and gynecology through the Council of Chairs of Gynecology and Obstetrics listserv, personal contacts who worked with students, and recruitment posts on social media sites such as Facebook. Purposive and snowball sampling was used to ensure diverse participation, with the goal to include students from a variety of institutions (public and private) and rotation locations (public, private, and safety-net hospitals) for maximum variation.

An interview guide was developed based on previously reported experiences of clinicians following CSAEs^{16,17,18,19,20,21} and one author’s experiences as a peer supporter for clinicians and as a clinician who has experienced CSAEs on a personal level. The interview guide included open-ended questions to describe experiences related to clinically significant adverse events, thoughts, and emotions. Additional probes were used to explore emotional reactions and the support provided or desired following experiences. Students were asked what they found most and least helpful and what advice they would give to other students. The goal of these questions was to develop the participant’s narrative about their experiences. Specifically, questions aimed to identify how students experienced support and whether it was perceived as sufficient or lacking, with the goal of understanding how individuals made meaning of their experiences with CSAEs. A copy of the interview guide is provided as Supplementary file 1. Interviews were conducted between December 2024 and February 2025, lasted between 30 and 60 minutes, and were recorded using Google Meet. Transcripts were de-identified prior to analysis. Interviews were conducted until thematic saturation was reached, when interviews contained no new themes or information compared to prior interviews.

For the duration of this study, the author team met regularly to discuss findings. We continually reflected on our positionality and involvement as clinicians and educators and the role that positionality played in our interpretation of findings. Because narrative analysis involves cocreation of narrative stories between the participant and interviewer, the contributions of the interviewer are considered through reflexivity. Our author team consisted of a maternal-fetal medicine physician with CSAE experiences and experience supporting clinicians after a CSAE and educators with marginalized identities who conduct research with marginalized populations. These positionalities shaped the lens through which the authors made sense of student narratives, while also allowing for a sensitive and empathetic approach to interviewing. One of the benefits of qualitative analysis, including narrative analysis, is that it honors individual experiences and recognizes the influence of our own stories in the shared construction of the narrative.

We applied a holistic lens to interviews to synthesize connections within individual stories and to generate overall themes compared across all stories.⁷ Interviews were transcribed and coded using inductive coding techniques (ie, developing codes and themes from the data), and codes were grouped according to main themes. Following the completion of approximately every third interview, interviews were coded and reviewed by the team. Minor modifications were made to the interview guide to ensure understanding and depth of responses. Reflective memos (ie, written records of researchers interpretations and thoughts related to the interviews)⁶ summarized main themes and reflected on the interviewer’s personal relationships with narratives. The holistic lens was used to develop a complex understanding of the individual stories and identify common threads across stories.⁷

While narrative methodology provides an important emphasis on developing meaning from personal experiences, caution must be exercised to avoid using the data to create false narratives; and researchers must be cognizant of the existence of alternative stories and other limitations from the coconstructor of the story.³

The first memo was a summary of the interview and key themes, and the second memo was a personal reflection of the interviewer’s identification with the story. Examples of excerpts from memos are shown in Table 2. Group discussions (among researchers) were conducted approximately every 3 to 4 weeks until consensus was reached. After all interviews were coded, memos were completed and comparisons across stories were made⁷ to emphasize the unique aspects of the student experience and apply the holistic lens to identify common themes across individual stories. Coding examples are shown in Table 3. We used inductive coding to develop themes from interviews and to ensure that the themes were derived from the data.

Writing reflective memos provided space for interviewers to reflect on thoughts and interpretations of narrative data and to document common themes across multiple narratives. Using memos was an important step for crafting the overall story. We chose summary and personal reflections to better understand individual stories and apply the holistic lens⁷ to the data to identify cohesive threads across individual stories.

The first step includes an initial assessment of whether narrative analysis is helpful in answering your research question. Narrative analysis affords rich insight into individual stories and how individuals make meaning of and interpret experiences.^3,5 Researchers can gain insight into social constructs of the narrative and the value of interpretation in the context of the surrounding social, cultural, and political environment.^5,6,22 We chose narrative analysis to focus on the student narrative of CSAEs and how student interactions with social and cultural environment shaped their experiences and coconstruction of knowledge. Investigators considering narrative analysis should consider their research questions and determine whether narrative analysis will best answer the question and provide rich insights from an individual perspective. Researchers considering the use of narrative analysis for medical education should further consider proposed narrative lenses,⁷ which may further their research question and the application of narrative analysis. In our example, we chose a holistic lens to understand the student experience across narratives and the impact of CSAEs on professional identity formation.

Second, the investigator should be open to other perspectives and interpretations. Although narrative analysis affords a rich and individualized perspective, one of its limitations is the possibility that a different understanding and perspective of the narrative story exists.^3,5 Critically important is that narrative researchers allow time to fully reflect on the story and carefully consider alternative perspectives and meanings.^5,6 Alternative narratives should be fully considered and discussed in the research report. In this example, we considered multiple perspectives and alternatives through rigorous group discussions and analyses with the investigators.

Third, investigators must account for the extra time necessary to conduct narrative analysis and reflect on the data and their meaning. While narrative analysis is rewarding and can highlight the unique perspectives of individuals in a social context,^3,5 this methodology takes considerable time to read, analyze, and reassess narrative stories of participants.^5,6 Thus researchers should plan additional time to collect, analyze, and interpret data to ensure that adequate understanding and diverse perspectives are considered and that commonalities and differences are thoroughly explored across narrative stories.

Fourth, investigators must include personal perspectives and reflexivity. Researchers coconstruct the participants’ stories,^3,5 and a critical step is for researchers to thoughtfully examine their own perspectives and biases with a formal reflexivity statement and remain open to alternative views and interpretations to ensure they are not unnecessarily limiting understanding.^3,5,6 Researcher reflexivity statements should be included in the research report. Furthermore, diverse perspectives on the research team provide a balanced assessment of the interpretation of stories. We included detailed memos with reflections on the investigators’ personal relationships with the study, and investigators included reflexivity statements with reflections on how individual positionalities affected the lens through which they viewed the data.

Finally, investigators should consider how to effectively use the results of the narrative analysis to evoke positive change. Because of the rich and deep understanding of the individual perspective, considering ways to use this narrative to effect change is important. Examples include opportunities to address challenging or “wicked problems” in medical education² and to use social constructs and integration to advocate for improvements and changes to benefit society.^5,12,13 In our example, we explored student experiences after CSAEs and aim to use findings to generate actionable recommendations to improve student outcomes and support.

A well-planned and thoughtful approach to the incorporation of narrative analysis into the researcher’s toolbox has the potential to benefit participants and society by tackling difficult questions, improving relationships and social connections by centering the stories of individual participants.

Narrative analysis relates to medical education because it teaches learners and clinicians the importance of exploring stories and learning from the individual’s experiences. This approach is important for developing understanding and rapport with patients¹ and is also important for understanding the human experience as educators and addressing significant problems in health care and medical education.^2,4 Although family medicine physicians may be less familiar with qualitative and narrative techniques, the foundational skills are part of medical education and include listening and interpreting patients’ stories and building a partnership with patients to improve their health. These skills and abilities can be applied to the realm of narrative analysis as part of qualitative research to tackle challenging problems and explore the multidimensional and personal aspects of individual stories.¹³ Using narrative analysis allows us to learn from common threads across individual stories about student experiences and provides us with opportunities to improve medical education and support learners as they navigate CSAEs.

The contents of this paper are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of War (DoW) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US Government. The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences (USUHS), the United States Department of War (DoW), or the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.