This is a story about the collection and subsequent analysis of 18 months’ worth of observational and interview data using the
‘indirect approach’ in phenomenology. The story highlights the great benefits of such an involved research focus for environments where many of the working challenges are not explicit. It also explores the difficulties of such a close integration. The challenges of allowing phenomenological principles to drive the management of a large and complex data set are also explored.
The study formed the basis of my PhD thesis (Hobson, 2003) and aimed to explore individual nurses’ engagement with perceived moral problems as they occurred on an acute cancer unit. The backdrop to the study was an inadequate empirical base in ethical decision-making. Existing evidence demonstrated a lack of focus on clinical practice, with a subsequent lack of insight into the encounter between the nurse and a moral question. I felt that this indicated a participative research approach where nurses’ intuitive ethical judgements were the focus of the study. It was apparent from the literature that such judgements were difficult for nurses to put into words and were likely to be hidden within day-to-day clinical practice.
I therefore needed an approach that would preserve the ‘voices’ of individual participants by a process of rich description both of their perceived and embodied values. I found the philosophical approach of Heideg-ger especially useful in this regard. Studying the involved practical viewpoint of people in situations in order to examine meaning and significance was exactly what I wanted to do. I chose an existential phenomenological approach for this reason.
Data collection was undertaken over a period of 18 months, based on one acute cancer treatment ward at a London teaching hospital between 1999 and 2001.
During this time, observation participation was em-ployed to gain access to the everyday experience of nurses on the ward. Informal interviews later explored nurses’ perception of ethical issues occurring on the ward.
Access to the ‘everyday’
As Angie describes in Figure 14.1, the indirect approach in phenomenology examines the pre-cogni-tive background of participants in order to illuminate aspects of their life and social worlds. I participated in the work of the ward to gain familiarity with the everyday experiences of nurses, and also to develop trusting relationships. My own training as a registered nurse gave me initial understanding of the language and types of activities undertaken. I also enjoyed easier access to the nurses’ shared background practi-ces and involved coping with the world (Table 14.1).
These aspects of integration into the ward facilitated access to nurses’ expressed and enacted values, and particularly to the ways in which they attached ethical significance to certain aspects of patient care.
I was interested both in accessing nurses’ con-sciousness of their ethical values and their embodied
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Table 14.2 Differences in research methods DIRECT APPROACH
Phenomenological Sociology
INDIRECT APPROACH
Existential Phenomenology OBSERVING ( Detached, uninvolved observer
( Observation not key method because cannot reliably access participant’s subjective meaning contexts
( Sometimes used to provide:
– common, shared experience for discussion in in-depth interview
– opportunity, through focused conversations during observation, to get inside participants’
heads
( Naturally occurring/focused conversations audio-taped for stimulated recall in interview
( Connected, involved observer
( Essential method because of required ‘being with’ participants/sharing ontological meanings and background practices and immersion in participants’ life world
( Field notes capture unreflective activity of others and self, i.e. body skills and ways of being-in-the-world (physically, energetically , emotionally, intuitively, imaginatively, soulfully)
QUESTIONING ( Researcher asks open questions to encourage reflection upon everyday experience and common-sense theorizing
( Seeks participants’ understanding of their conscious ways of construing social contexts, situations and logic by which they conduct their activities
( Prises open the taken-for-granted (doubting) ( Asks how they judge own situations,
decision-making and action-taking
( Takes open approach to ensure participants dependent on own ways of construing actions/social context
( Asks participants specific, rather than general questions to give closer access to practice and taken-for-granted knowledge (general questions get general answers about theory or what they typically do)
( Questioning during interviews and spontaneous conversations helps participants to tell stories in everyday language rather than reflection-on-action or theorizing
( Questions not aimed at encouraging reflection upon experience, rather at helping participant to focus on stories that matter, have value (thus accessing what is significant for participant)
( Inviting participants to express and question meaning of meanings in everyday practice through paintings, clay-modelling, movement,
( Purpose is to re-present participants’ own understandings, subjective meaning context or
‘first-order’ constructs with researcher’s objective meaning context or ‘second-order’
constructs to create a typification or abstract
‘ideal-type’
( Typification describes and interprets way participants made sense of a situation and which were either common to all participants or to all instances within one case
( Seeks to understand participants’ constructs by leaping from objective to subjective meaning context – achieved through bracketing/
suspending prejudices and prior theoretical understandings
( Researcher uses own knowledge, senses, emotions, intuitions, imagination to understand nuances, subtleties and meanings embedded in texts
( Interprets meaning of meanings within texts ( Brings own interpretations, prejudices,
‘horizons’ to dialogue, dialectically, with text within hermeneutic circle
( Hermeneutic circle – reiterative process of looking at parts in relation to whole and whole in relation to parts
( Interpretation is synthesis or ‘fusion of horizons’, i.e. ‘horizons’/prejudices of participants and researcher
( Artistic expression, e.g. metaphor, imagery, poetry for synthesis of data and dissemination Source: Titchen, 2000.
values. Nurses’ expressed values were known cogni-tively and I accessed them by questioning (see Table 14.2 – questioning). Their enacted values were accessed by observing through ‘being with’ in a shared, social situated way of being (Table 14.1). In practice this meant hearing nurses’ everyday language with patients, their stories told to colleagues and what they empha-sized at key times of information exchange in order to understand what was ethically significant for them.
Gaining their trust
An initial hurdle to becoming accepted on the ward was the difficulty in negotiating access to the real world of nurses and the care they provided. I came to the ward with the explicit aim of becoming a participant and entering a dialogue with the nurses on the ward about their practice. I was not prepared for the difficulty in negotiating a kind of ‘being with’
research relationship with the nurses.
Nurses had readily signed consent forms following information-giving meetings and an initial four month period of my attendance at ward handovers and meetings. However, when I was on the ward, nurses avoided my presence. Although very friendly and courteous, I was aware of being politely excluded from nurses’ conversations and the delivery of care. I decided to do familiar jobs on the ward that did not require specialist knowledge, such as making beds, delivering meals, running to the pharmacy and de-livering commodes or bedpans. After a few days of this, the ward bedpan washer broke. I spent the whole shift ferrying a series of bedpans to the next ward’s washer. During this time, I had more questions about the research from nurses than I had had in the entire period of attempted integration. In order to achieve
‘shared, social and situated ways of being with’
participants (Table 14.1) I needed to be willing to do the things the nurses had to do, and to experience for myself the background practices and social context of the nurses. Only then did they see me as having any right to ask questions, because only then did I share in the situation in which they were operating.
Nurses then began to be more searching in their questions about what I was trying to achieve. I began to have a welcome place in informal coffee room discussions and a place in care planning meetings for patients. Nurses would actively seek me out if they thought I should be attending a particular event. Very often, it was interesting just to see what they thought was important for me to hear. As a result, I was able
to access what was significant for them (Table 14.2 – listening and questioning). Individual nurses began to discuss with me their reactions to medical decisions with which they disagreed. They also began to share more private feelings about patients and their relatives.
In this way, access to the everyday world of nurses facilitated further access to their ‘ethical stories’, revealing what they felt to be morally significant.
I took extensive field notes during this period of working alongside the nurses. These involved an account of events, records of conversations and impressions of how nurses had responded to particu-lar events. These were collated in a qualitative analysis software package, called Nud.Ist (Non-numerical un-structured data: Indexing, searching and theorizing). I chose this because it allowed the coding and storage of data, line by line, around central analytical concepts called nodes. In practice this meant that I could first group data around individual nurses and from this develop further shared categories to build the analysis.
Interviews took place with the same 18 nurses I had been working alongside, who already felt familiar with me and able to discuss their feelings freely. I returned to working with them after the interview so that contextual data would provide a commentary on what had been shared. The interviews provided an opportunity for nurses to talk further and explore areas of concern in their field of practice.
During the interviews, questions and responses were developed and shaped by dialogue between us.
I don’t mean that I was sharing my experiences but that by listening to the answers to questions, it was possible to see their interpretation of the question and to let this shade the meaning constructed. Questions became part of a circular process in this way. In other words, both through observing and questioning, the participants and I entered a hermeneutic circle and were interpreting meanings through a synthesis or
‘fusion of horizons’ (Table 14.2 – interpreting), a process that I continued throughout data interpreta-tion. Recording details such as pauses and emphasis in the subsequent transcription enabled this process and the developing meaning to become clearer. After the interview I would return to working alongside the nurses. In this way a broader understanding could be gained (see Table 14.2 interpreting: first bullet point).
Dealing with the data
Observational and interview data were interlinked in order to achieve a contextual account of individual 1 4 P H E N O M E N O L O G Y
nurses’ ways of being. This enabled the analysis to draw on an integrated understanding of nurses’
experiences, where different types of data were interlinked rather than used to critically review the other. The interview transcripts and field notes were used to create a text for each nurse, whereby key experiences connected with ethical concerns were identified. The fact that I had shared in the events in question provided insight into the nuanced meanings attributed by nurses in such situations. The synthesis of nurses’ texts led to the identification of shared experiences between nurses.
The length of time spent in coming alongside individual nurses and the level of access it allowed meant that the study was able to examine the many barriers to ethical decision-making. Perceived ethical issues were avoided, both by individual nurses and by the medical team as a whole. Nurses often did not feel able to ask questions about the care in which they were involved, and their coping strategy of emotional distancing appeared to contribute to a lack of moral engagement with patients. This finding was a product of having been involved with participants’ life world (Table 14.1).
The lack of a credible ethical language in practice and the effects of hierarchical decision-making also hindered open discussion of ethical issues. These discoveries were first made at the individual level, and then as the study progressed it was impossible not to notice that they were shared across the nurses, and and to broader issues in the treatment of dying patients.
At the same time, the pattern of my involvement in the ward began to affect my ability to remain a researcher as well as a participant. There were costs associated with being an involved, connected re-searcher (Table 14.2).
Costs of emotional involvement
I had realized that ethical issues were not discussed and that decisions about them did not appear to get made. However, I was not asking critical questions about this because, having shared so much with the nurses, I identified with them very strongly. I was therefore not following crucial lines of enquiry.
Instead, there was some temptation to abandon all pretence at research in order to be totally involved and just help out. Writing and reviewing journal entries and field notes during this time proved to be a crucial means by which I realized what was
happening. I saw that I was becoming too immersed in the surroundings to be able to function effectively as a researcher.
I had heard and read about the benefits of clinical supervision and as a result sought to find an appro-priate mentor. Fortunately there was a senior re-searcher within my university who had significant clinical experience in oncology and was not involved with either the research or the site. This meant that she could remain impartial while understanding the nature of patient care on the unit. She listened to my accounts of events on the ward and reflected with me on my responses to them. This strategy proved to be very effective in regaining a participant stance as opposed to one of unquestioning involvement. It enabled me to plan the focus of data collection more clearly.
Doing existential phenomenological research re-quires emotionally mature, reflexive researchers who can maintain a critical stance while living the daily experience of those they are alongside. Good emo-tional and intellectual support is crucial. A good research supervisor will provide this to some extent, but further emotional support is of great value in keeping the researcher on the road.
However, the benefits of an involved research stance, with a focus on the individual’s construction of what is significant, were to lay bare what many nurses felt to be ‘under the carpet’. Events taking place in the everyday were articulated for the first time, offering the potential for healthcare staff to openly confront ethical issues.
Resting place
My research methodology was tailor-made for the questions at hand. I was interested both in accessing nurses’ consciousness of their values and their em-bodied values. However, I decided to locate the study firmly in existential phenomenology because of the need for an involved, connected observer stance in order to access practical ethical concerns. I also wanted to interpret data arising from expressed values, as described in Figure 14.1 as ‘searching between the lines’. As Angie points out, methodologi-cal distinctions can be reconciled given a transparent epistemological and ontological position.
The method I used had great benefits for eliciting unarticulated concerns hidden in the everyday. It also had pitfalls for reflexivity during periods of intense exposure to participants’ social worlds.
Annotated bibliography
Benner, P. (ed.) (1994) Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness.
London: Sage.
Provides theoretical and practical support for all stages of Heideggerian hermeneutic inquiry, e.g. how to dialogue with texts through the development of paradigm cases, exemplars and thematic analyses.
Crotty, M. (1996) Phenomenology and Nursing Research. Melbourne: Churchill Livingstone.
This book has provoked an interesting, critical debate about phenomenological research in nursing.
Dey, I. (1993) Qualitative Data Analysis. London and New York: Routledge.
I (DH) used this book to help me use qualitative data analysis software without prejudicing the phenomenological approach.
Edwards, C. and Titchen, A. (2003) ‘Research into patients’ perspectives: relevance and usefulness of phenomenological sociology’, Journal of Advanced Nursing, 44(5): 450–60.
Demonstrates the close fit between investigation of the patient’s perspective and Schutz’s phenomenological sociology. Pinpoints similarities and differences between phenomenological sociology and symbolic interaction-ism.
Gadamer, H.-G. (1981) Reason in the Age of Science. London: MIT Press.
Gadamer’s development of Heidegger’s phenomenology has been key in enabling researchers to develop hermeneutic data analysis and interpretation approaches, more related to artistic appreciation and interpretation than scientific method.
McNiff, S. (1998) Art-Based Research. London: Jessica Kingsley.
Immersing self in the hermeneutic circle requires us to create open spaces, let go of clutter, suspend conventions of common logic and engage in processes more akin to artistic appreciation and expression. This book could provide a trigger for researchers to find their own ways.
Magee, B. (ed.) (1987) The Great Philosophers: An Introduction to Western Philosophy. London: BBC Books.
Hubert Dreyfus, in critical conversation with Brian Magee (pp. 254–77), lucidly explains the key ideas of, and differences between, Husserl’s and Heidegger’s phenomenologies.
Riessman, C.K. (1993) Narrative Analysis. Qualitative Research Methods Series 30. Thousand Oaks, CA, London and New Delhi: Sage.
An excellent insight into the hermeneutic analysis of interview transcripts.
Schutz, A. (1970) On Phenomenology and Social Relations. ed. H.R. Wagner. London: University of Chicago Press.
Sets out a system of sociological thought and procedure in accessible language with concepts that can be used by researchers to develop systematic data gathering and analysis strategies.
Titchen, A. and McIntyre, D. (1993) ‘A phenomenological approach to qualitative data analysis in nursing research’, in A. Titchen (ed.), Changing Nursing Practice through Action Research, Report No. 6, Oxford:
National Institute for Nursing, pp. 29–48.
Describes a data analysis approach built on Schutz’s concepts of first- and second-order constructs and bracketing. Compares this approach with structured and grounded theory approaches.
Van Maanen, M. (1990) Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. New York: State University of New York.
A must read for researchers exploring contemporary understandings of phenomenology.
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Further references
Giorgi, A. (ed.) (1985) Phenomenology and Psychological Research. Pittsburgh, PA: Duquesne University Press.
Heidegger, M. (1962) Being and Time. New York: Harper & Row (1st edn, 1927).
Hobson, D. (2003) Moral Silence? Nurses’ Experiences of Ethical Decision-Making at the End of Life. PhD Dissertation, City University, London.
Husserl, E. (1964) The Idea of Phenomenology. trans. W. Aston and G. Nakhikan. The Hague: Nijhoff.
McCormack, B. (2001) Negotiating Partnerships with Older People: A Person-centred Approach. Aldershot:
Ashgate.
Titchen, A. (2000) Professional Craft Knowledge in Patient-Centred Nursing and the Facilitation of Its Development, University of Oxford DPhil Dissertation. Kidlington, Oxon.: Ashdale Press.