The narrative approach is a learning method used to enhance the meaning and experiential aspect of medical education, and is widely used when recalling, imagining and retelling past experiences [1,2]. Learning through narratives includes changes in knowledge and attitudes. Rita Charon at Colombia University introduced “narrative medicine” (NM) in 2000 as a clinical framework that improves “scholarship, education, and clinical practice,” as well as fostering “empathy, reflection, professionalism, and trustworthiness” [3]. NM is a patient-centered approach focusing on the development of narrative skills and self-awareness that incorporates “attending, representing, and affiliating” in clinical encounters. “Attention” revolves around a patient’s visit and the interaction of the clinician with the patient, “representation” refers to a physician’s understanding of a patient’s illness as articulated in written form, and “affiliation” refers to deep reflections that are analyzed and shared with colleagues in the form of narratives. The use of narrative skills in clinical practice is essential in order to diagnose and treat diseases. Narrative skills include “reading, writing, and attending” in illness stories that are components of reflective training. Reflective training improves trainees’ understanding of patients’ culture, increases their commitment to colleagues, and enhances the effectiveness of the healthcare team [4]. In addition, narratives can be used for teaching professionalism, empathy, multicultural education, and other aspects of medical education [5]. Therefore, NM has been introduced as a valuable tool in medical education and constitutes an approach to “professional development” in medicine [6].

NM is being taught more frequently at many universities around the world, with different educational aims and within the framework of various programs. By the same token, its educational effectiveness has been examined in previous studies [6]. Although some educational guides have been provided for reflective training, providing an educational framework with guidelines for how to implement an NM course would be useful, especially for universities with no experience with NM that intend to implement NM as an innovative teaching method.

This study was conducted to develop a checklist to validate the framework of an NM program based on Gagne’s instructional design model in Iran through consensus of a multidisciplinary expert panel. The specific goals were as follows: first, the framework for an NM program was developed; second, a checklist to validate the framework of NM was suggested; and third, the checklist was tested by an expert panel for consensus.

This research was part of a project with the ethics code IR.MUI.REC.1396.3.472 at Isfahan University of Medical Sciences in Iran. Informed consent was obtained from the panel members.

This was a modified Delphi expert panel study that included 2 phases: (1) developing the framework, and (2) forming an expert panel to achieve consensus regarding the framework. This study took a year (September 2018 to September 2019) to review the literature and to design, implement, and finalize the framework.

Seven experts were recruited by purposive sampling to participate in the expert panel. Their specialties were medical education, curriculum development, instructional design, internal medicine, psychiatry, and narrative analysis. All of the participating specialists were from Iran, and all participants were familiar with NM. Due to the interdisciplinary nature of NM, experts were selected who had multidisciplinary and interdisciplinary specialties (Supplement 1).

The median of the ratings was calculated using IBM SPSS ver. 23.0 (IBM Corp., Armonk, NY, USA).

The educational framework incorporating NM was designed based on the 3 components of Gagne’s theory. This framework includes learning outcomes, learning circumstances, and training activities. A summary of this program concerning teaching professionalism is provided in Supplements 3 and 4. The recommended program based on the 9 training activities in Gagne’s theory encompassed learning stages, training activities, instructions, media, and teaching methods (Supplement 4).

The experts agreed on 16 indicators after the third round. In the first round, 14 indicators were sent to experts via email. In the second round, there were differences in the ratings of the indicators in the first round. After the group discussion, the experts suggested changing 2 indicators, making minor modifications, and adding 2 new indicators. In the third round, 16 indicators were rated by experts and the framework was confirmed with minor changes in writing (Table 4). Of note, indicators 1 and 3 did not exist in the first round; they were recommended in the second round by the experts and were added to the checklist for the third round (final checklist in Table 2). In the second round, the experts only gave comments to improve the framework, and after revision, they confirmed it in the third round. Finally, 16 valid indicators for the framework were approved and 100% agreement was obtained among the experts (median values in the range of 7–9, with no disagreement).

We conducted this study to develop a framework to teach and evaluate an NM program based on Gagne’s theory and to develop a validation tool by obtaining consensus in the expert panel. We adapted the 9 training activities in Gagne’s theory for the 3-stage NM model. The experts reached full agreement after 3 rounds and approved the framework. This framework encompasses learning results based on interior and exterior learning circumstances and 9-step learning activities in NM. This framework can provide a scaffold for initial learning at universities in Iran that intend to present an NM program, and can serve as a practical guide for faculty members who are planning to implement an NM course for the first time. Since NM is an innovative teaching method in medical education, and subject matter specialists are also limited, this structured program will be helpful for medical instructors. The 16 checklist indicators to validate the framework of an NM program constitute a meaningful innovation in this field. This tool was also agreed upon by a panel, so that it can be used to evaluate an NM program.

Various universities have provided some rubrics or reflective training guides to improve reflection [4,11,12]. Charon and colleagues provided a reflective writing guide to teach reflection through creative writing and close reading that included “reading, writing, and attending to the stories of illness.” Creative writing emanates from theories of aesthetics and emphasizes understanding, description, and acceptance [4]. Accordingly, some studies used 3 stages (reading, reflection, and group discussion), while others applied 2 stages (reading or reflection and group discussion) for teaching NM [6]. We also developed and applied a 3-stage model for the NM framework.

Applying reflection in medicine is effective for improving communication skills, professionalism, critical thinking, clinical knowledge, practical understanding, clinical reasoning, and the reduction of medical and diagnostic errors [11]. Therefore, reflective training is an important part of medical education. Accordingly, students’ reflective capacity should be evaluated, given the value of reflection for life-long and clinical decision-making [13]. The REFLECT rubric is a practice guide developed by Wald et al. [11] for reflective writing training. Due to the clear explanation of reflection levels and writing components in the REFLECT rubric, we recommend using this tool in reflective training and applying it both for teaching and evaluating reflective capacity.

Furthermore, it is essential for educators to provide effective feedback in order for students to develop their level of reflection. For this purpose, a comprehensive and practical tool called BEGAN was designed by Reis and colleagues at Brown University as a practical guide for teachers to foster reflective capacity in reflective writing [14]. We recommend using a feedback guide such as the Pendleton Rules to provide feedback [15]. It is worth noting that NM has 2 important components: teaching guided reflection and providing constructive feedback to learners. These components are essential to improve reflective capacity.

Because NM was first implemented in Iran at Isfahan University of Medical Sciences, we were limited in the selection of experts in the field in terms of their institutional background. However, the expert panel also included 3 specialists (medical education, internal medicine, and psychiatry) who had spent a part of their professional career or academic education at universities outside of Iran (including the United States, Sweden, and Germany) and were familiar with the subject of NM. To minimize this limitation, we included multidisciplinary experts who examined the different dimensions of the framework.

In clinical education, NM can be used as a teaching method and as a basis for teaching reflection and improving core competencies in medicine. This study provided an explicit and clear framework for describing the process of teaching NM, adapted with an instructional design model as a structured program. Additionally, reflective training in the NM model is highly compatible with the training activities presented in Gagne’s theory. The importance of this framework lies in its applicability and ease of use by medical teachers for educational goals. Furthermore, adapting Gagne’s theory to apply to the NM model is a positive aspect of this study because of its impact on enhancing the quality and effectiveness of teaching and promoting life-long learning. This framework can serve as a guide for educational departments at medical universities to implement NM programs. The checklist presented in this study can be used widely to evaluate the framework of NM courses.