The need for methodological development within qualitative clinical caring research

Abstract

The next issue of Scandinavian Journal of Caring Sciences will contain a supplement which main theme is on development of research methodologies. The arguments and discussion in this editorial are not related to the papers in this issue of the journal and thus stands on its own. In this editorial, we will discuss qualitative methodology in special. We recognize the necessity of using quantitative methods in nursing and caring sciences. There is important research using quantitative methodologies as for example within quality of life and so on. However, in this paper, we want to highlight questions regarding qualitative research methodologies. Polit & Beck (1) explain naturalistic methods and qualitative research in this way: Naturalistic methods of inquiry deal with the issue of human complexity by exploring it directly. Researchers in naturalistic traditions emphasize the inherent depth of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, naturalistic investigations emphasize understanding the human experience as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative and subjective (p. 17). An aim of naturalistic and qualitative inquiry is to grasp the holistic, dynamic and individualistic aspect of human phenomena experienced in health care, nursing and caring sciences. Some characteristics of a qualitative design are that it is flexible and that there is always a need to adjust the design according to what happens during the data collection period. Glaser (2) calls this ‘theoretical sampling’ in grounded theory where one adjust whom to have as informants or new settings in accordance with what has already been found empirically from the earlier informants. Another characteristic is that qualitative design often uses multiple data sampling methods, data sampling triangulation, for example both interviews that are transcribed to text and observation with field notes as text. These transcripts of text are analysed by qualitative methods, such as hermeneutic interpretation, qualitative content analyses and constant comparative analysis until one reach a grounded theory, phenomenological analysis or discourse analysis to mention some. A main aim of the qualitative design whether one uses one or another method of analysis is to be holistic and to understand a phenomenon and grasp the whole as well as it is possible for humans to grasp holistically and describe this through text such as narratives themes or categories. Nordic College of Caring Science (NCCS), which is the owner of Scandinavian Journal of Caring Sciences, arranged in April 2010 its annual conference. Professor Slettebø (3) wrote an editorial December 2009 presenting this year’s conference. The theme for the conference 2010 was ‘Methodological innovations from a human science perspective’. One main discussion was how to improve methodologies to grasp the unique in caring situations. Nursing and caring phenomena focus on the unique individual, and the research should develop knowledge regarding these unique phenomena. But how can the researcher make valid and transfer knowledge from one case to other relevant cases? Some of the key-note speaker’s points will shortly be referred to as an example on how NCCS by the conference has highlighted methodological issues in caring sciences. Professor and Nurse Marit Kirkevold, in her key-note speech, argued for more case-oriented research where the unique in the nursing context could be transparent and open for research. Nursing and caring is not about the general but about the unique and the relational meeting between carer and the cared-for. Our methodologies should fit these unique phenomena and describe and prescribe how to act in the meetings to create a caring environment for the cared-for. Another key-note speaker, professor and philosopher Anders Lindseth, argued that this may be done through a method focusing on reflection. The caring sciences need to reflect upon our genuine scientific discipline and what the disciplines’ genuine area of praxis and research are. By hermeneutic and phenomenological reflection upon unique situations in caring practice, we may find appropriate ways to explore caring science as discipline. Professor and Nurse Ingegerd Bergbom as the first key-note speaker discussed the necessity of exploring methods that give answer to the problem phenomena in caring sciences. She argued that the context is a part of understanding when or how caring may be helpful or not for the cared-for. And an important issue is that our problem at hand must be decisive for what method we should use. To explore caring phenomena, central elements such as narratives, texts and pictures/videos may be used to find the real essence of the unique phenomena in nursing and caring sciences. Here, the phenomenological, the case studies and the hermeneutical methodologies will be helpful. We will further in this editorial especially discuss hermeneutical methodology and link it to the humanistic and naturalistic research in caring sciences. This editorial is written from the overall perspective viewing health and caring sciences as humanistic sciences. With this position in mind, we want to shed light on and discuss some methodological issues that might be developed further in the future. The research methodology that is applied should be consistent with both the perspective and fundamentals of the respective discipline, and the methods used should be decided by the phenomena under study. Among several methodologies, we take the stance that hermeneutic approaches is one important way to develop knowledge in sciences where human phenomena are the issues. As we know, Gadamer (4) states that hermeneutics is not techniques to gain understanding but to clarify the conditions for understanding. It is therefore relevant to ask the question whether our data sampling procedures and techniques in qualitative studies are consistent with this ideal. Are interview and observation procedures too sterile to really acquire renewed understanding? Do we ‘conduct’ interviews or observations in a way that allows renewed understanding for both parties to happen, to use Gadamer’s words, let fusion of horizons to become a reality? Is it apt to think that the meaning of the genuine conversation should help to come closer to what hermeneutics is about and thus better understand the phenomena under study? Gadamer (4) says that the more genuine a conversation is, the less its conduct lies within the will of either partner. Rather, we fall into conversation, or even we become involved. In what way is it plausible to attain genuine conversations in research? Even though Gadamer gives some recommendations for how to be involved in a genuine conversation, we can ask questions how it is possible in an interview situation to live up to the ideal of being with another in the dialogue where one shall allow oneself to be conducted by the subject matter to which the partners in the dialogue are oriented, as he says. In spite of the experienced challenges, these authors are of the opinion that a genuine conversation in a hermeneutic sense is both possible and necessary in research to understand caring phenomena in a way that goes beyond the surface. We argue in this way because research emerging from the genuine conversation approach reveals itself through its writing. As we understand Gadamer (4), one cannot ‘learn’ to conduct a genuine conversation, even though we think that it is possible and important to reach the level of this conversation. We therefore argue that the genuine conversation in research is an important issue that needs to be more elaborated and developed in years to come. To be involved in a genuine conversation in research, it is crucial that the researcher is hermeneutical attuned. We also are of the opinion that if appropriation of the subject matter (in this case genuine conversation) is to be fulfilled, Bildung is a precondition. When one establishes the Gadamerian notion of Bildung as a basis, this entails that the Bildung ‘result’ related to genuine conversation emerges through an inner formative and cultivational process that has nothing to do with a technical construction. Gadamer claims that Bildung can help us to understand human science. We argue that this also is true for the subject matter at hand here. This is in line with his notion of theoria, which must first and foremost be regarded as a type of contemplation (5). Devotion is authentic participation, being totally involved in and carried away by what one sees (4). It might be that this kind of devotion is the meaningful and necessary precondition that allows us to become in the genuine conversation. Binding and Tapp (6) elaborate Gadamer’s genuine conversation and point out that the aim of such a conversation is not to grasp the intention behind what the other is saying, rather the concern is entirely with the subject matter. Gadamer’s hermeneutical approach is sometimes called ‘ontological’, not simply that it is probing the fundamental nature of being (although it takes on this Heideggarian quality too), but in that it is trying to describe what there really is in the ‘universal’ hermeneutical categories of being: language, text and meaning. If we could get into position to see this aright, then we would not have developed some further explanatory power, which will shed light on as yet unread texts or in Gadamer’s key terms, we would not have a method for understanding, but rather we would have truth. Adopt a method and you foreclose the requisite openness to the particular horizon of the work, rendering it most likely that you will miss its truth, or at least suggesting that if you do encounter truth in it, then this will be more by luck than by judgment. Alternatively, being in dialogue with the text, in its specificity and with respect to its own agenda, you will have a chance of being open to its truth or of encountering its truth. The experience of truth to which Gadamer appeals is found to depend less on epistemology, or the theory of knowledge in the strict sense, than on a ‘grounding’. If the understanding is a matter of event, we do not really know how, nor from where, it comes. It is produced, it rocks and nourishes us. Gadamer draws on the crucial term ‘experience’, and this concept is understood in the way meant by Aeschylus (pathei mathos: we learn through suffering): experience that strikes us and becomes part of us, more deeply than any syllogism or analytic argument. Hermeneutics means that we let what seems to be far away and alienated speak again. Thus, a new light falls on the text of the ‘play’ through this other language and how we reed it. The researcher gets a picture of the clinical reality as it is experienced or comprehended by patients inductively. However, induction can never originate any new idea whatever, for it simply confirms what was already tentatively contributed to knowledge. At the very most, it corrects the value of a ratio or slightly modifies a hypothesis. The movement between the reflective readings of the text in the light of the research question is an important step of the scientific building. Qualitative induction may also result in a refutation of a theory. Interpretation becomes necessary when understanding breaks down and the world appears strange or alien to us, or when suffering becomes unbearable. Even if it is a masterly re-creation, it must lack some of the overtones that vibrate in the original text (voice of the patient). Deduction plays an important role in setting forth creative and successful hypothesis that allow the researcher to begin generating promising new ideas. Thus, the researcher gets to the next stage or mode of reasoning – deduction and theory-filled empirics. Epistemological choices are directed by an explicit ontology, which forms the sounding board for the outlines of the theoretical perspective. The research process proceeds in accordance with the hermeneutical circle, where understanding increases step by step in the form of still pictures. This interpreted empiricism is a basis for abduction; it stands to reason that induction and deduction serve as a springboard for the abductive leap (7). Abductive inference is the generative principle of how scientific knowledge is expanded. According to Peirce (8), abduction is originary in respect to being the only kind of argument that starts a new idea. The abductive suggestion comes to us like a flash. It is an act of insight although of extremely fallible insight. Peirce continued the long tradition that started with Plato and Aristoteles and that emphasized that logic is not confined to setting up patterns for valid deductive inference. Logic is not a matter of formal exercise only, but rather deals with knowledge in a broad sense and knowledge in turn is a guide to life. Both the hypothetico-deductive and the inductive methodologies are inadequate because they both neglect the abductive process, which moves from data to theories and new explanations, hypothesis and conceptual patterns. Discovery means that something new is brought (or abduced) to the theory. Background theories and suppositions guide the search for new ideas, but at the same time, data and ‘surprising phenomena’ instigate that search. Abduction is not just about one move from a surprising fact to an interpretation but rather the deliberate way researchers ‘press on’ for new interpretations on the basis of the theoretical perspective and data requiring understanding. Guessing instinct means that one finds a solution or ‘sees’ that it is right even before any clear evidence for it is recognized. This kind of expertise develops bit by bit when nurse researchers dwell within their research area long enough, reading and rereading and making different interpretations of the text (9). In abductive methodology, theory-ladenness and observation-ladenness are not alternatives, but both are operative in dynamical research processes. In an abductive research model, new ideas emerge by taking various clues and restrictions into account and by searching and combining existing ideas in novel ways. Peirce may be seen as providing a foundation for the contemporary claim that scientists do not know fully what they are going to create until they create it. For him, spontaneity was the essence of creativity. Abduction portrays the potential and the possibilities and is closely connected to the ontological question. Abduction is a way of discovering caring phenomena and meaningful underlying patterns and to integrate surface and deep structures. Thus, abduction becomes essential in the phase of theory generation in caring science. Within clinical research, there is a striving towards developing a research design that is in unison with the basic idea of knowledge development anchored in a hermeneutical research tradition. There is a need in qualitative research to test new designs, which consider the patient’s vulnerability and develop knowledge, as well as integrate research findings in practice. According to Lindholm et al., (10, 11, 12) a caring science theory will be translated to give a concrete significance for caring practice. The hermeneutical design with an element of application includes change and revision of understanding, a revision that can create progress in nursing care (11). Hermeneutical understanding is a unit of understanding, interpretation and application. Application is the fundamental element in hermeneutical understanding which means an inner fusion of interpretation and understanding (4). Clinical application research (12) has been inspired by classic action research. In contrast to action research with focus on solving practical problems, being intervening and creating social changes, clinical application research follows a hermeneutic tradition, which includes preunderstanding, understanding, interpretation, and application and professional preunderstanding with focus on knowledge development. The epistemological foundation of application research can be traced to hermeneutics, in contrast to classic action research that is based on critical theory (10, p. 50). A basic idea within clinical application research is that the research should contribute to a revision of clinical practice as new realization, which, through the participation of co-researchers, can change understanding for and care of patients in practice (10, p. 49; 12). Clinical application research, as well as action research, has a participatory research approach, which stimulates others apart from the researcher to actively participate in the research process. A participatory research approach includes both taking action and developing and integrating the knowledge on which the actions are based. In participatory research, researchers and participants deal with problem identification and research design by discussing the issues, reflecting and making decisions about the research area. The researchers control and bear the responsibility for knowledge development, implementation of research and the scientific approach (10, p. 53; 12). Participatory research means that researchers and participants do research together, where the aim of the collaboration is to create knowledge about and for practice. Within action research, it is the researcher who is active and contributes to improvements and solutions of the problem under study, in contrast to application research, where the co-researchers become active participants in the knowledge development through an element of application and thus contribute to changes in practice. The action in action research can be compared to development work, while application research contributes to theory generation. By using clinical application research, there is an alternative to classic action research, where the researcher faces the caring reality. Through the element of application, the co-researchers could create a dialogue between active nurses and academic researchers with the purpose of integrating theory and practice. Through its hermeneutic approach, application research demands that co-researchers and researchers become aware of their professional preunderstanding (10, 12). The participation of the co-researchers means that they take part in research meetings and ‘in the hermeneutic room’ and are responsible for data collection (10, p. 53; 12). The research becomes both inductive and deductive when the co-researchers open up contextual issues from practice and the scientific researchers deductively present contextual issues based on theory and previous research. Understanding will be the central element in the hermeneutical approach because it involves a movement of reflection. Co-researchers and researchers cannot beforehand separate between the productive prejudices that make understanding possible from what in itself leads to misunderstanding, which is why the research group, ‘the hermeneutic room’ consisting of researchers and co-researchers, was created. The reflective spirit of the ‘research room’ plays an important role in showing how understanding leads to new understanding and not only to explain and solve problems within one field, as in classic action research. By participating, the co-researchers expand their caring science, ethical and methodological knowledge, which participants in action research do not normally do. Classic action research strives to be problem-solving, while application research strives for the co-researchers to be trained simultaneously with participating in scientific research to affect current habits and revise as well as develop practice. Action research can be seen as development work, while the participants of application research, through research meetings, are trained in a scientific approach while actively participating in scientific research. Much too often, the research focuses directly on problems and why questions and the intent of the research is mapping, which might easily divert us away from the ‘thing’ in itself, scientifically speaking (12).