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Social Science & Medicine 70 (2010) 754–762

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Social Science & Medicine

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Patients’ narrative accounts of open-heart surgery and recovery: Authorialvoice of technology

Jennifer Lapum a,*, Jan E. Angus b, Elizabeth Peter b, Judy Watt-Watson b

a Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canadab Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada

a r t i c l e i n f o

Article history:Available online 29 December 2009

Keywords:CanadaNarrative inquiryAuthorial voicePatients’ experiencesTechnologyCardiac surgeryCoronary artery bypass graftAortic and mitral valve replacement andrepair

* Corresponding author. Tel.: þ1 416 979 5000.E-mail address: jlapum@ryerson.ca (J. Lapum).

0277-9536/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.socscimed.2009.11.021

a b s t r a c t

In this narrative inquiry, we examined patients’ experiential accounts of technology in open-heartsurgery and recovery. A convenience sample of sixteen individuals was recruited from a preoperativeclinic at a regional centre for cardiac services in Canada. Each participated in two interviews followingtransfer from cardiovascular intensive care and 4–6 weeks post discharge from the hospital. Participantsalso documented their experiences in journals during the first 3–4 weeks following discharge. The focalpoint of the study’s theoretical foundations was narrative emplotment, which directs attention to theactive processes of plot construction and shaping forces of stories. In our narrative analysis, we usednarrative mapping to document the temporal flow of events. We found that technology acted as theauthorial 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 becomingbackground characters and surrendering agency. Problematic and important to health care professionalsis ensuring that authorial voice shifts back to patients so that they become active in shaping their owncourse of recovery. This study underscores the benefits of using literary techniques such as narrativeanalysis 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 carestrongly affect the stories’ content and how they unfold. By focusing on how stories unfolded, werevealed ways in which cardiac surgery practices and patients’ course of recovery could be enhanced.

� 2009 Elsevier Ltd. All rights reserved.

Introduction

Stories are recounted by individual speakers, but storytelling isshaped in intricate ways. The complex and social act of creatinga tellable tale reveals as much about the author as it does about anexperience. Narratives of illness and recovery are shaped by insti-tutional and social forces that influence the ways that individualsrecount stories (Frank, 1995; Kierans, 2005; Mattingly, 1994). Inopen-heart surgery and recovery, not much is known aboutpatients’ experiences of technology and the shaping forces of theirstories. Since technology is omnipresent in health care, it isimportant to consider the ways that it appears in patients’ narrativeaccounts.

Despite abundant research examining outcomes of mortality,morbidity, and economics, patients’ experiences of technology havebeen largely neglected (Gagnon et al., 2009; Lehoux, 2008). This isa significant omission in cardiac surgery considering that patients

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come into close contact with technology in its many guises. Forthese reasons, we conducted a narrative inquiry to explore patients’experiential accounts of technology in open-heart surgery andrecovery and considered the intricate ways that narratives wereshaped. Further understanding patients’ experiences of technologyand how their stories are shaped will be useful to enhance practicesof care and courses of recovery.

It has been argued that technology and associated routines ofcare may focus attention away from patients, resulting in dehu-manization and distress (Barnard & Sandelowski, 2001; Kleinman,1988). Patients are often unaccustomed to technology, whichcreates potential for stress, fear, and ambivalence. Practitioners,however, are well versed in technology in which technologically-driven routines of care and the presence and use of object tech-nology follow as a matter of course. For them, the extraordinarinessof technology becomes ordinary and familiar in ways that maydeter practitioners from recognizing that patients are undergoingan unfamiliar, traumatic, and life-altering event.

Issues of identity and agency are salient when consideringpatients’ experiences of technology. Since agency is a human

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capacity and process to act and make choices (Hardin, 2001), it hasthe tendency to shift along a continuum during illness. Whenindividuals do not or are unable to fully enact agency during thecourse of illness, the way they define and understand themselvesshifts. Numerous studies have noted shifts in identity associatedwith cardiac surgery (e.g., Dingley, Bush, & Roux, 2001; Hawthorne,1993; King & Jensen, 1994; Leegaard & Fagermoen, 2008; Lindsay,Smith, Hanlon, & Wheatley, 2000; Plach & Stevens, 2001). Reflectedin this literature are patients’ descriptions of depersonalization andlack of control (e.g., Doering, McGuidre, & Rourke, 2002; Hunt,1999; Radley, 1996; Schou & Egerod, 2008). Increasingly blurredboundaries between human and machine have led to shiftingidentities that are ambiguous and indefinite (Haraway, 2000). Incardiac surgery these boundaries are invasively challenged onmultiple levels from temporary insertion of monitoring and ther-apeutics devices to surgical insertion of heart grafts and valves.Nancy (2002), a French philosopher who himself had cardiacsurgery, described this shifting identity. He referred to the surgicalintervention as an intruder that entered his body and describedconfusion concerning his heart as a foreign object (Nancy, 2002).Radley (1996) echoed similar sentiments, suggesting that bypasssurgery becomes part of patients’ ‘‘identity, their heritage – a markon their biography’’ (p. 135).

Although technology has not been an explicit focus in cardio-vascular research, some insights have been offered. When exam-ining patients’ experiences, researchers have often focused onobject 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 areparadoxical descriptions of technology as distressing and unfa-miliar, but also providing a sense of security. Also, critical toexploring patients’ experiences of technology (but receiving lessempirical attention) are the socially-embedded components (Ben-ner, 2003; Lehoux, 2008). There is a body of cardiovascular researchthat 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 environ-ments, ‘‘the flaw is not turning to the device per se; it is the turningaway from the person’’ (Almerud, Alapack, Fridlund, & Ekebergh,2008, p. 60). Since technology has significant impacts on patterns ofpractice, it cannot be reduced to the mere usage and presence ofobjects in health care. Cognitive and behavioral responses frompractitioners result from technological readings from devices suchas monitors and ventilators. Often, these responses are organizedaccording to standardized care maps, clinical protocols, and algo-rithms. In order to fully understand patients’ experiences in thiscurrent study, it was necessary to consider the complexity ofdimensions intricately woven with object technology, including thevarious people involved and the logics and practices of care (Bar-nard, 2002; Sandelowski, 2000).

Although closely related, it is critical to note that technology wasthe focus of this study and not medicine. Technology and thesocially-embedded components are one dimension of medicinethat sometimes take precedence over humanistic and psycho-socialpractices during certain critical and acute illnesses. However,medicine is governed by varying discourses and encompasses anarray of values, logics, and practices that shift with context, disci-pline and patient cases (Hirschauer, 1998; Mol & Berg, 1998).

In order to enhance cardiovascular practices of care and addressgaps in the literature, it is important to understand how patientsmake meaning of technology and how it is featured in their expe-riential accounts. In this paper, we examine study findings relatedto how technology acted as a dominant discourse and shaped

participants’ narratives. We highlight the problematic and alsobeneficial ways that technology affected patients’ experiences ofopen-heart surgery and recovery.

Methods

A narrative methodology was employed, which maintained anorientation to stories (Clandinin & Connelly, 2000). Telling stories isa familiar way for individuals to talk about their experiences byusing existing social patterns that are learned early in life. Althoughapproaches to narrative inquiry vary, in this study we began bythinking with stories (Frank, 1995). This approach entailed engagingcognitively in the story, but also morally, emotionally andaesthetically (Richardson, 1994). Engaging on these various levelsassists researchers to be drawn deep into stories and respondauthentically with participants. This approach is critical becausestorytelling is a dialogical process between the teller and listener.

Two central tenets that underpinned our method were tempo-rality and contextuality. They were important because people aretemporal beings (Conle, 1999) in that their stories are shaped overtime. Also, stories are always told from a particular vantage point(Conle, 1999; Frank, 2000). Attention to temporality and con-textuality facilitated our understanding of why particular storieswere being told and why in that way. People tell different types ofstories 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 howone should live or conduct one’s social life (Frank, 2002).Researchers can help participants reflect on meaning by drawingattention to and exploring certain facets of stories.

Underpinning this study was an understanding that experienceis linguistic (Allen & Cloyes, 2005; Scott, 1992). As Allen and Cloyes(2005) stated, ‘‘Experiential accounts are narratives, if we are clearthat we are studying how they talk, then we can treat theseaccounts more rigorously by asking more questions, not just aboutwhat they said, but why they said it that way (p. 103).’’ Therefore,research findings were not just a summary of what participantssaid, but a linguistic and contextual examination of how and whystories unfolded as they did. This ontological assumption also lentitself to a narrative epistemology. This epistemology is a way ofknowing that occurs through stories (Clandinin & Rosiek, 2007) andby thinking with stories (Frank, 1995). Although storytelling isrelative to context, the ways in which participants’ stories unfoldedwere juxtaposed against each other and generalized in terms ofthese processes.

The focal point of the study’s theoretical foundations wasnarrative emplotment, which originates in literary theory andinvolves attention to plot lines (Frye, 1957; Mattingly, 1994).Narrative emplotment is an active and temporal process of con-structing a plot; storytellers depict how characters, events, inter-actions, and outcomes are related (Holloway & Freshwater, 2007;Kierans, 2005; Mattingly, 2007). It facilitates analysing the point ofa 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). Narrativesmay be re-emplotted as stories are re-told and storytellers repo-sition themselves as circumstances change. Therefore, it was crit-ical to be sensitive to the temporality of narrative emplotment.

Participants and setting

Approval was obtained from the University of Toronto ResearchEthics Board and the hospital where recruitment occurred.A convenience sample was purposefully selected to include men and

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women undergoing first time coronary artery bypass graft (CABG)and/or valve repair or replacement surgery. Recruitment occurred ina preoperative clinic at a regional centre for cardiac services. Indi-viduals were approached by the registered nurse in the clinic. Thoseindividuals interested in information about the study were referredto the first author and informed consent was obtained.

Sixteen individuals were recruited, including 8 men and 8women with ages ranging from 59 to 85. Because narrative inqui-ries amass a large quantity of rich data, it is recommended thatsample sizes be kept small in order to contribute to an in-depthunderstanding (Holloway & Freshwater, 2007). Furthermore, thesample selected was homogenous in that participants wereundergoing surgery at the same hospital in which the presence anduse of object technology and practitioners’ routines of care werecomparable and surgeries involved similar pathways of recovery.Surgical procedures included CABG (n ¼ 6), mitral or aortic valverepair/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 inJune 2007. Methods included two narrative-based interviews witheach participant and participant journals. Interview One wascompleted 2–4 days following transfer from cardiovascular inten-sive care, while individuals were still in hospital. These interviewswere purposefully short because of the acute phase of recovery(mean length ¼ 20 min). Following this interview, participantswere given journals to document their experiences for the first 3–4weeks following discharge. Oral and written instructions wereincluded with a short list of open-ended questions to providedirection but enough flexibility to write openly. Interview Twooccurred in participants’ homes at 4–6 weeks following discharge(mean length ¼ one hour 10 minutes). Semi-structured interviewguides were employed to address certain areas. Interviewscommenced with broad open-ended questions to encourageparticipants to begin their stories at moments that were mostimportant to them. As well, questions were based on participants’emerging stories. Examples of questions included: Tell me aboutwaking up from surgery? What was going on around you? Whatdid you see? Tell me about the technology? How did it make youfeel? Tell me about your recovery?

Data analysis

Narrative analysis, which provided the overarching analyticframework, began by thinking with stories (Frank, 1995). It was anapproach that began during the interviews and continued into theiterative readings of transcripts and journals. This approachrequired that researchers become aesthetically engaged, personallydwell within stories, and avoid the immediate inclination toanalyse (Bochner, 2001; Frank, 2000). Hence, the analytic phasecommenced by just listening (Frank, 1998) and hearing and feelingwhat was happening. Although analysis involved attention tocontent, a focus was also placed on narrative form, how storieswere put together, and what structures storytellers drew upon(Lieblich, Tuval-Mashiach, & Zilber, 1998). We attended to facets oftemporality, contextuality, plot, scene and characters in order tounderstand processes and activities involved in narrativeemplotment.

Narrative mapping was used as an analytic tool to highlightemplotment patterns and stories’ components (Lapum, 2009).Visual maps of stories were constructed on an 8 1/2� 11 inch pieceof paper for each of the participants’ interviews; these involveddocumenting narrative flow and sequence of events. Maps were

constructed by asking specific questions of the text such as, What ishappening? Who is involved? What are they doing? Why are theytelling this story in this way? How is technology part of the plotline? These maps were helpful in comparing stories and identifyingways that technology was emplotted. Attending to these mapsfacilitated our analytic focus on the dominant ideologies thatemerged and narrative types that framed stories (Frank, 1995, 1998;Fraser, 2004).

Results

We found that technology was incorporated as the dominantdiscourse that structured participants’ narratives. Participantsinternalized components of this discourse and its prevailingmeanings of values, identity and behaviour; hence, technologyemerged as the authorial voice and shaped their stories. Authorialvoice is the controlling influence of how a story unfolds. It oftenreflects the dominant discourse (Duffy, 2007). Although we foundnuances in the narrative flow of stories, two common and signifi-cant transitions occurred in authorial voice. First, we discuss waysthat technology acted as a pervasive discourse that was swiftlyincorporated into stories and became the authorial voice. Ofimportance were the ways that technology was positioned atcentre stage; this was linked with participants becoming back-ground characters and surrendering agency. Second, we discussways that authorial voice became re-anchored in participants’personal and biographical perspectives, albeit with a technologicalconsciousness. Problematic and important to practitioners isensuring that authorial voice shifts back to patients so that theybecome active in shaping their course of recovery. The interviewquotations that follow are accompanied by details about eachparticipant’s age, relationship status and operative procedure.

Authorial voice of technology

Issues of authorship surfaced as particularly relevant. Althoughparticipants were the narrators, technology acted as the authorialvoice shaping and structuring their stories. A prominent findingwas the notably similar ways that stories unfolded, particularlyduring the preoperative and early postoperative period. Tech-nology, and all that flowed from it, provided the raw materials andchanneled participants’ narratives into particular trajectories.These discursive elements of technology simultaneously providedparticipants with a resource and a limitation.

Technological ‘‘fix’’Technology promptly emerged as the authorial voice when

participants described the supposed decision to have surgery. Thisdecision was constructed as the only viable option to fix theproblem. Bob (age 71, married, CABG � 4) bluntly wrote in hisjournal about his response to the doctor’s recommendation to havesurgery: ‘‘My wife and I talked it over and concurred. Was therereally a choice?!’’ Edwin (age 81, married, mitral valve repair)echoed similar sentiments, indicating that death was a consider-ation: ‘‘They said if I don’t have it, I only have a year to live.’’

Plot lines were framed according to a technologically-drivenending of cure. Over half of participants specifically referred tobeing ‘‘fixed.’’ This plot line functioned as a coping resource thatpulled them through the difficult times, but also as a limitation inwhich realities of the recovery process were neglected preopera-tively. Linda’s (age 84, widowed, mitral valve replacement andCABG � 1) path of recovery diverted from the script she waspreviously prepared to follow, and she had to reconcile herself tothis non-linear actuality. Despite current physical discomforts, theexpected culmination of cure gave her comfort:

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You have to focus on the end result . It was more difficult than Ithought it would be. There are a lot of things that you have to dothat you don’t really count on. Wearing a pacemaker, oxygen inyour nose . I just looked at the end results and I thought ‘‘thatwould be good.’’ They would fix my heart. Despite worries aboutthe risk of death, participants incorporated prospects of a tech-nological fix. Kristi (age 58, common law, aortic valve replace-ment and aortic graft) envisioned a positive outcome based onher surgeon’s confidence: ‘‘He made me feel comfortable withthe surgery so I wasn’t worried that I might die. There’s alwaysthat possibility . you have to go in with a positive outlook.’’ Itwas apparent that participants generally felt comfortable andrelieved to let the authorial voice of technology prevail in hopesof what it could offer them. The mere probability of being fixedaverted dwelling on possibilities of death. This technological fixappeared as a set of logics and risk calculations (offered bypractitioners) and interpreted by participants. The anticipatedfix 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 theanesthetist and he said ‘‘You’re all right, your lungs are clean, soyou won’t have any problem.’’ . and someone said, ‘‘these heartdoctors here, they’ve never lost a patient,’’ so I wasn’t tooworried when I heard that . Now, I don’t know whether that’strue or not, but I took it as gospel anyway. (Edwin)

Shift of authorial voice to technology was reflected as an exter-nalization of agency. In participants’ stories, technology became anincreasingly dominant player. Participants characterized them-selves as becoming more passive with an inevitable surrendering ofagency. Two participants repeated the same phrase: ‘‘whateverhappens, happens’’ (Greta [age 65, married, CABG � 2 and aorticvalve replacement] and Joseph [age 72, married, mitral valverepair]). Participants indicated that you had to give up controlbecause of their unfamiliarity and lack of expertise with the tech-nology. Fear was enfolded in these stories, but as Greta stated ‘‘Youjust have to let it go and hope for the best . you have to trust thedoctors because you’re under.’’ Margaret (age 72, married, aorticvalve replacement) described changing her mindset and doing whatpractitioners told her. She recalled just ‘‘turning my head off . Iclosed 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 thatheld marked similarities. In conjunction with the technological fixthat set the scene for participants’ narratives, the experience ofbeing ‘‘plugged in’’ structured the temporal flow of events. Partic-ipants described the physical act of being ‘‘hooked up’’ (Wayne, age64, married, CABG� 1) or ‘‘plugged in’’ (Jack, age 56, married, aorticvalve replacement) as their bodies were attached to technologicalobjects. They provided a similar catalogue of events that led to theirlosing consciousness (e.g., putting on a gown, receiving sedation,receiving an intravenous puncture). Although a sense of securityemerged with the frequency with which these procedures werecompleted, tensions were inherent in the standardization associ-ated with technology. A marker in Bob’s story was concern thatstandardization masked his individuality and potentially meantinattention to unique features of his body:

People said it’s routine, but it’s not routine. This is the only timeI’ll do it, ‘‘please God.’’ It’s routine for Dr. L, in that he does this ona monthly basis. . [but] every time Dr. L incises a patient, it’sa different patient, [he]doesn’t know what’s going to happenwhen he makes that incision. Everything can turn upside down.

I’m serious, this happens, so the danger is becoming routine.Nevertheless, participants emphasized the critical importanceof technology. Bob continued to write in his journal that‘‘technology was replacing and supporting the vital functions ofmy body . if they weren’t working, you would be dead.’’

Linked with the shift of authorial voice to technology was anemerging sense of passivity as control was surrendered. High-lighted in the next excerpt is the abundant use of third person andlack of first person pronouns, which is reflective of the shift ofauthorial voice to technology. In this context, it is salient to reiteratethat technology encompasses the various objects that areembedded in patients’ bodies, but also the practitioners who acti-vate and survey these tubes and monitors. Joseph characterizedhimself as passive and practitioners as taking an active role:

What they did as soon as you enter the hospital, they take all theinformation, they give you a robe and put you in bed, they wantto prepare you . she gave me a pill, she said, ‘‘Put under yourtongue.’’ . and she said, ‘‘Okay we’re going to take you to theoperating room.’’ ‘‘Thank god,’’ I said, ‘‘We’re finally going.’’Interestingly at the end of this excerpt, he used a plural firstperson pronoun: ‘‘We’re finally going.’’ This linguistic usagesuggests a surrendering of agency and coalescence with tech-nology including the practitioners that oversee the embeddedobjects 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 tofunction normally and machines would do what their bodies didnaturally. Participants were careful to explain that agency wastransferred to practitioners: ‘‘I think about the physical act of whatthey did, the cuttings, shutting the heart off, re-routing the bloodsupply. It’s a big deal, that I wouldn’t be responsible for doing itmyself . 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 oftachycardia. This bodily disruption reinforced the lack of control hewas 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 likesomebody was inside with a hammer trying to get out . I don’twant to spring a leak or cause this valve to come unglued.Furthermore, he positioned practitioners as the active playersbecause of their expertise. He stated ‘‘they’re watching me onthe machine . it was normal for them to see that. It scared theshit out of me.’’ Although there was a sense of relief and confi-dence that practitioners knew what they were doing, there wasalso fear about just how vulnerable one would be:

You think you’re a guinea pig. They’re going to experiment onyou. They’re going to stop your heart [crying]. . it is a littleapprehensive, you’re going to be stuck on the gurney and abouthalf dozen people will be doing a very tricky operation. Youhope the knife doesn’t slip. (Edwin). Edwin’s worries repre-sented the ultimate vulnerability that occurs when one entersthe technologically-induced sleep of heart surgery.

Re-anchoring of authorial voice

Later in participants’ narratives, authorial voice began to moreclearly originate from their personal and biographical perspectives.Hence, emplotment of narratives reflected more heterogeneity asparticipants positioned themselves based on their own personalcontext. As the surgical event receded, participants began to

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position themselves at centre stage and increasingly characterizedthemselves as active players. Technology receded into the back-ground of the plot line just as a character in a play would movebackstage. However, technology persisted in narratives as a tech-nological consciousness.

Resuming authorship with a technological consciousnessThrough a sequence of postoperative events, authorial voice

became re-anchored in the particularities of self. Participants beganto plot their own course of recovery within the realm of possibilitiesoffered by technologically-driven protocols. Through varying time-frames, they began to re-establish agency and aspects of theirprevious identity through embodied activities (e.g., walking). Abbey(age 80, married, CABG � 3) portrayed herself as a ‘‘strong’’ olderwoman and quickly re-established agency. Although she describedhaving ‘‘just to go with the flow,’’ she described resistance tomedications that she was given in the hospital: ‘‘I said ‘don’t givethem to me, I won’t take them’ . I’m not taking a pill I don’t need.’’

Participants perceived the removal of various technologicaldevices and being able to engage in self-care as significant markersof progress. They narrated these events in ways that indicatedtechnology no longer physically claimed their bodies. This shiftsignified that participants were resuming authorship of theirstories. Ashur (age 61, married, aortic valve replacement) describedthese events as a ‘‘release,’’ wherein his biographical course shifted:‘‘It was a release, mentally and physically. . When they start totake them [pacer wires and urinary catheter] out, it gives me thereal joy that it is done. That it’s going towards recovery.’’ Margaretreferred to the removal of tubes and wires as becoming morerecognizable: ‘‘[I was] getting back to being myself.’’ These eventsprompted Bob to recognize that he was regaining bodily controland re-establishing agency, although a technologized voiceremained. Strikingly apparent in the following excerpt is a linguisticpattern that reflects the persistent dominance of technologicalrelations in his narrative. He shifts back and forth from third tosecond person pronouns with the sparse use of first personpronouns. Particularly interesting was his use of ‘‘we’’ towards theend of the excerpt, indicating that technology was still a part of himand incorporated into his recovery. The usage of ‘‘we’’ suggests thathis recovery involves technological intricacies including objects,practitioners who maintain and remove them, and his ownembodied activities to function:

Whatever they [object technology] were doing, your body isnow able to take over that function. . When they took out all, itmeant that you had gone from being totally dependent on thesetubes to the fact that now your body was taking over thesefunctions, that I could breathe on my own. . which meant wehad moved onto phase one of recovery .. You feel like you’regetting close to being normal. Each one, is a step in the rightdirection, that you don’t need this thing, you’re going to surviveon your own. His narrative pointed to strong biographicalassociations in which reconstituting identity involved anembodied capacity to perform basic functions.

Being discharged home accelerated the shift of authorial voice toparticipants. Many participants began to re-characterize self asbeing an active player in recovery. Kristi wrote in her journal: ‘‘I amtaking a journey that I have not traveled before, how I come out ofthis, is all up to me.’’ According to Joseph, discharge was akin tobeing released from the technologically-structured routines of thehospital. Social connections and comforts in the home prompteda psychological sense of healing:

You are in your own kingdom. You’re not cooped up in one roomand 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 likeyou’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 theresumption of authorial voice was more gradual. Some participantsexpressed ambivalence in ways that reflected a technologicalconsciousness as they attempted figure out how to perform self-care. Underpinning Raz’s (age 63, married, CABG� 4) narrative wasthe belief that responsibility was transferred to him. However, heindicated that he could not fully understand the logics and hencecould not fully initiate the expected practices:

They shouldn’t be telling me this, the patient, because I can’ttake on all that. I can’t remember anything. They should betelling that to somebody, what I use the term ‘‘sober.’’ . The daythey discharge me, it was a rush to get rid of me. They shouldhave more ample time to explain. You on so much drugs, youreally can’t remember. Raz emphasized that family shouldalways be included during the provision of discharge informa-tion. Wayne described the discharge process as superficialbecause the rapid dispensing of information left little time toabsorb or discuss the material: ‘‘I felt that they went over thingsin a rushed manner . the impression I got was, ‘get out!’’’ Hecontinued to indicate a need for hospitals to ‘‘update the releaseprocedures so that there’s a little more, you’re not just thrown tothe wolves when you’re released, there’s somebody who isgoing to keep track of you.’’ The metaphorical expression‘‘thrown to the wolves’’ represents how individuals often feelwhen they are abruptly discharged from hospitals where theyhad felt protected. At home, technology became a backgroundcharacter and participants described feeling at risk for harm.

Self-sufficiencyAs the surgical event receded and participants regained autho-

rial voice, a theme of self-sufficiency was established. Participantsbegan to position themselves as active players in the plot line.Velinka (age 66, married, CABG � 1) insisted that she had her ownrole to play and recognized that dimensions related to technologywere not fully responsible for her recovery: ‘‘I’m alive. Now, it’s myturn.’’ As Joseph described attempting to return to his activities, heincluded passages implying how he resisted identifying with thedependency involved in being cared for by others. Underpinningthis resistance was masculine identity as he attempted to becomeself-sufficient and re-establish independence:

They said I should not force myself, warning health will come withtime. 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 upthe 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 andfall down. I said, ‘‘I’m okay. Would you go and do what you have todo.’’ He continued to describe a resistance against the expectedpathways: Doctor L says, ‘‘By Easter you should be okay.’’ I gotnews 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 rushingit. I can do it. They say one step or two steps, I just keep onwalking.Joseph acknowledged the advice of providers and understood hisfamily’s need to protect him, but also that he must find a waythrough all of these influences by trusting how his body feels.

As a technologized authorial voice became re-anchored in theparticularities of self, participants struggled with vulnerability andanxiety. In Kristi’s narrative, what became evident was thatreturning to the familiar space of home facilitated the entrance ofan authorial voice that was ambivalent:

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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’sthe comfort of everybody monitoring you. You’re coming homeand going ‘‘there’s nobody going to be monitoring, what ifsomething happens?’’ However, Kristi progressively regainedconfidence in her home by acknowledging her own self-sufficiency.

Unfamiliar sensations prompted participants to re-align rela-tionships with the body. It appeared that just knowing whetherthese sensations were normal would have alleviated participants’concerns. Authorial voice in Margaret’s story flowed from herefforts to interpret her bodily sensations and determine what wasnormal:

I wish I could have talked to somebody with what I’m feeling inhere. I’m hoping this is healed. I’m assuming it is. One of thereasons I assume it is, at one point I felt a sneeze coming on . Itwas 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 gettingover this process? Because it doesn’t say anything about that inthe book [discharge booklet]

Technology entered into the instructive materials presented atdischarge about what activities they should and should not engage.Participants’ efforts to understand and comply with this adviceinfluenced their activities at home. However, these passages sug-gested that guidelines were not tailored and expected timelineswere not clear, making it difficult to incorporate into the specific-ities of their daily lives. According to Wayne,

No one is standing there saying, ‘‘Now you can lift.’’ I sort ofassumed that if I can drive, then I’ve reached the point where I’mnot likely to split open. . If there was some schedule thatlooked after you when you got out, you’d have a better idea ofwhen you could go back to work, when you could start to lift thegarbage can, get back to normal. You’re kind of left with thesethings, don’t lift anything heavy, for how long? Other partici-pants described difficulty interpreting the discharge materials:It [discharge booklet] covers a lot of stuff. It mentions about yourbreathing ten times every hour. I know I didn’t do that and Iwasn’t sure how long I was to keep doing that . Am I to do thatwhen I walk? .. I don’t know whether I’m supposed to be doinga fast walk or slow walk or does it matter? (Dianne, age 76,divorced, CABG � 4)

Self-surveillance was one way that participants personallyinterpreted and incorporated technological knowledge into theirown context of recovery. This strategy reflected how they wereregaining authorial voice, but with a newly organized conscious-ness. From exposure to surveillance practices in the hospital, Kristilearned 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 tomy heart if I’m just sitting back, in a quiet room, my heart will goback to a regular pace. I just stay there until I feel reassured thatit’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 examiningparticipants’ stories through a literary lens and consideringdiscursive influences of narrative emplotment. To elaborate on the

temporal shifts of authorial voice, we discuss the ways that tech-nology was emplotted as the authorial voice that shaped andstructured participants’ narratives. Then we discuss the shift ofauthorial voice in becoming re-anchored in the personal and bio-graphical perspectives of participants. Since technology as anauthorial voice can act as both a resource and a limitation, it iscritical to understand how practitioners can mediate these shifts invoice at appropriate times.

Eclipsing the unique voices of patients

Authorial voice became located in and contingent on tech-nology, and participants’ full authorship was eclipsed, particularlyduring the preoperative and early postoperative periods. Thisfinding speaks to the ontological foundations in which stories wereco-constituted temporally and contextually. Although participantswere the narrators or tellers of their own stories, a polyphony ofvoices acted as influences. Particularly notable was how the tech-nological discourse acted as a powerful force that shaped stories.

Practitioners were key players that were enfolded into thetechnological discourse and became part of this authorial voice.Similar to Fox’s (1992) ethnography of surgery, in our studysurgeons activated the dominant social voice in participants’ storiesthat provided authority and hope based on the logics and riskcalculations that were offered. Hence, story plot lines were chan-neled according to a technological fix. Because of nurses’ closeproximity to patients, they were also key players and maintaineda plot line that was driven by a technological end of cure. Asdescribed by participants in this study, and reflective of the liter-ature, nurses’ practice is technologically focused and highlyroutinized (Philpin, 2007; Sandelowski, 2000; Scott, Estabrooks,Allen, & Pollock, 2008). As with other work (Karlsson, Johansson, &Lidell, 2005), reliance on practitioners and their surveillance prac-tices provided patients with security and optimism. Emplotment oftechnology in participants’ narratives was often mediated bynurses’ actions and interactions. Although technological vigilancewas important, participants noted the critical importance ofhumanistic care. Authorial voice of technology became problematicwhen practitioners neglected listening and responding to patientsin personalized ways.

Shifting of authorial voice to technology appears to haveinvolved externalization of agency. As suggested by Kierans andMaynooth (2001), when people are diagnosed with a disease, theirsense of agency is suppressed and moved outside of them. Partic-ipants in our study entered into an unfamiliar domain where theyhad no other choice but to relinquish agency to technology in hopesof what it could offer them (i.e., the scripted telos: cure). Reflectedin other research (King & Jensen, 1994; Radley, 1996; Trumbull,1993) as well as our study, the close coalescence with machines andbodily dependence shifted agency. During the course of surgery andrecovery, participants’ stories reflected that they were notresponsible for the functioning of their bodies and were unableenact agency. This shift resulted in the simultaneous presence ofboth fear, because they had no control, but also relief, becausecontrol over the surgical outcome was now in the hands of a teamof expert practitioners. Although other work has found thatpatients can experience a strong sense of agency in terms ofadhering to proper positioning during diagnostic testing so that thebody can be effectively visualized (Blaxter, 2009), in heart surgerythe patient is medically-induced into a state of unconsciousness. AsRadley (1996) found in his work, patients undergoing heart surgerydescribed a period of non-being on the surgical table where theyrelinquished complete control to practitioners. Similar to Rier’s(2000) study on his own ICU experience, patients undergoingcritical or acute illness cannot always be active players. At times,

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they need to relinquish agency in order to maintain a sense ofsecurity, comfort and optimism (Rier, 2000). In our study, partici-pants’ stories involved a temporal suspension of agency that onlyreturned through embodied activities and progress in recovery.

The eclipsing of participants’ unique voices was a discursive actin which technology quickly appeared at centre stage. The tech-nological discourse constituted a script resulting in a universalsequence of events that led up to surgery and provided expectedpathways that resulted in a markedly similar unfolding of narra-tives. This is not to say that strict templates existed, but thatnarrative emplotment was socially orchestrated (Mattingly, 2007).People often have a sense of the stories that they will tell because ofthe scripts that are available to them (Frank, 2006). Typical scriptsof cardiac surgery involved an expected trajectory in which theculmination was a technological fix. Shift of authorial voice totechnology was prompted by the logics and risk calculationspractitioners offered. In our study, as in other research (e.g., Micik &Borbasi, 2002), stories reflected how pathways were used toidentify whether recovery was following a normal trajectory. Thesescripts acted as a resource for participants providing an optimisticand hopeful trajectory and helping them move beyond periods ofdistress and physical discomfort.

On the other hand, technology as the authorial voice also actedas a limitation. Practitioners and their discursively-driven logics andpractices inadvertently provided the raw materials and narrativestructures for participants’ stories (Kohn, 2000; Mattingly, 1994). Inour study, practitioners appeared to activate and maintain a scriptthat followed this linear plot line. Technological elements giveshape to dominant discourses that can constrain patients to tella story that follows a particular pattern of progress (Kierans, 2005).This scripted pattern not only inspires the common restitutionnarrative that Frank (1998) described, but also reveals ways thatstorytelling is shaped by discourse. Found in our study and alsonoted by Kierans (2005), narrative emplotment framed by a storyending with cure can be problematic. This finding is particularlyrelevant since our study, among others, have reported that recoveryfrom cardiac surgery is non-linear and more complex than patientsexpect (Dunckley et al., 2007; Gardner et al., 2005; Micik & Borbasi,2002; Tolmie et al., 2006). To veer off this emplotment pattern wasunfamiliar, and participants did not necessarily have other plots todraw from, which enhanced uncertainty and anxiety. Complexitiesof storytelling can be at odds with how linear narratives arepurported to unfold by technological hegemony in health care.When patients’ experiences were non-linear or did not culminate inthe scripted conclusion of restored health, narrative tension ensued,embroiled with dissonance and ambiguity.

Although the patient as author occasionally emerged throughpersonal and emotional tellings, the technological discoursedominated narrative structure. Prompted by a technologicaldiscourse, participants in our study oscillated between first andthird 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 anda diminishing of first person pronouns, which reflected the shift ofauthorial voice to technology. Usage of third person pronounscreates an absence of the narrator in the discursive situation (vanPeer, 1986). Linked with this shift were ways that patients posi-tioned themselves as passive, non-agential, background charactersin their stories. At the same time, technology became an increas-ingly dominant player through the processes and routines of carethat practitioners enacted. The characterization of technology asa dominant player acted as both a resource and a limitationproviding access to the visceral surfaces below the skin, but alsorisking a neglect of patients’ voices. At times, knowledge producedby 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 techno-logical practices of care that structure the patient encounter andcan 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 surgicalprocedure receded and the course of recovery progressed. Not onlydid technology become more of a background character, but theshifting of authorial voice back to participants reflected less scrip-ted narratives. Stories included more personal and unique elementsthat were rooted in the particularities of self. Recounting of storiesbecame strongly influenced by one’s own personal voice thatincluded contextualized experiences based on biographical andsocial positioning (Mishler, 1984). Since technology was no longerthe authorial voice, more variations in stories emerged based onparticipants’ own positioning. Nevertheless, this resumption ofauthorial voice incorporated a technological consciousness. Similarto Radley’s (1996) notion that medicine becomes part of patients’identity, participants in our study not only defined themselves intechnologized ways, but engaged the social voice of technology inactions of self-surveillance.

To further understand this shift in authorial voice, we refer toa metaphor that pertains to voice in writing as being both personaland social (Elbow, 2007). Social elements of voice (in this case thediscourse of technology) shaped participants’ stories, but thepersonal voice began to flower. Participants began to ‘‘sing them-selves in,’’ and their own particularities became an influential forcein the unfolding narrative:

We all have a chest cavity unique in size and shape so that eachof us naturally resonates to one pitch alone . In this meta-phorical world, then, even if we figure out the system, we arestuck. If we want to be heard we are limited to our single note. Ifwe want to sing other notes, we will not be heard. And yet, if weare brave and persistent enough to sing our note at lengthdtodevelop our capacity for resonancedgradually we will be able to‘‘sing ourselves in’’: to get resonance first into one or two morefrequencies and then more. Finally, we will be able to singwhatever note we want to sing . we only manage this flow-ering if we are willing to start off singing our own single tire-some pitch for a long time and in that way gradually teach thestiff cells of our bodies to vibrate and be flexible (Elbow, 1998,pp. 281–282).

Because the technologized pathways of recovery provideda sense of security and reassurance, participants were careful toadhere as best as they could. However, participants became morecompetent as active players and began to sing themselves into theirrecovery over varying periods of time through embodied activities,successes at returning to normal capacities and speaking up abouttheir individual perspectives (e.g., control over bodily functions,walking, resisting medications).

Resuming authorial voice involved participants’ singing them-selves into their course of recovery. Stories reflected a liminalebbing and flowing of authorial voice between participants andtechnology. Participants had to be ‘‘brave and persistent’’ (Elbow,1998, p. 282) and work hard in order to re-establish self-sufficientcapacities to function and resume agency. Other research has foundthat patients focused on returning to normal activities of dailyliving, but these often involved a reconfiguration within the realmof what was possible (Keller, 1991; King & Jensen, 1994; Theobald &McMurray, 2004). Resuming a technologized authorial voicemanifested itself in participants personally interpreting and

J. Lapum et al. / Social Science & Medicine 70 (2010) 754–762 761

incorporating pathways of recovery into the specificity of theirdaily lives. Technology acted as a resource providing participantswith knowledge about expected pathways of recovery. However, attimes technology acted as a limitation because participantsdescribed ambiguity about how to incorporate pathways ofrecovery into their home life. As reported in other research (Luk-karinen, 1999), some participants promptly enacted agency andtook an active role in recovery. As in our research, some describedfeeling stranded and unsure, whereas others were quicker to singthemselves in and let technology remain a backstage character.

Critical to patients’ successful recovery were practitioners’prompts and encouragement to follow pathways and engage inself-care. Through these prompted actions, participants began toengage in their recovery and characterize themselves as becomingactive players and practitioners as shifting to supporting roles. Ofgreat significance is how practitioners can act as supporting char-acters in helping with transitions of authorial voice from tech-nology back to patients. Because the dominant discourse oftechnology resulted in influential structures that shifted identity toa sense of passivity and externalization of agency, patients need tobe supported in regaining some level of self-sufficiency before theyare discharged. This is a critical transition so that individualsactively engage in their recoveries and characterize themselves atcentre stage. Such a process would provide opportunities andinstances of success for patients to begin singing themselves in andresuming authorial voice before they are discharged from thestructured and safe environments of hospitals. Where authorialvoice remained with technology at the juncture of discharge in thecurrent study, participants’ stories reflected a strong sense ofvulnerability and a lack of self-sufficiency. As Radley (1988) has alsonoted, it is important to examine patients’ experiences of recoveryfrom heart surgery within a longitudinal framework. Althoughauthorial voice shifted back to participants, the question remains:does a technological consciousness remain indeterminately?

Drawing from a literary lens sheds light on the ways thatshifting of authorial voice to technology reflected an eclipse of thepatient as author and ways that practitioners can ensure thatpatients sing themselves back into their recovery and their life. Thisunique approach to narrative inquiry highlighted the importance ofattending to stories in health care research that has implications foraltering practices to enhance patient outcomes.

Acknowledgements

This paper is related to the first author’s doctoral research thatwas completed at the Lawrence S. Bloomberg Faculty of Nursing,University of Toronto. She acknowledges and is thankful for thefellowships and awards received during this time that allowed herto focus upon and complete her doctoral education: Heart & Strokeof Canada Nursing Research Fellowship; Strategic Training Programfor Cardiovascular Nurse Scientists stipend, a partnership betweenthe Canadian Institutes of Health Research: Institute of Circulatoryand Respiratory Health and the Heart and Stroke Foundation;University of Toronto Fellowships; and Canadian Nurses Founda-tion award. As well, her PhD supervisor and committee wereessential to the completion and rigorous conduct of this study.

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