Paradigm for research

It is important, when carrying out research studies, that the researcher clarifies both the epistemological and ontological framework to enable readers to judge the relevance of the methodological approach (Mantzoukas 2004). In this way, I wanted to identify the study‟s underpinning tenets from which judgment about its quality could be made.

There is a range of assumptions embedded in different paradigmatic frameworks that needto be articulated. What follows in this section is a description of these ontological and epistemological assumptions to help the reader understand the paradigmatic position in which this study is based.

There is increasing recognition that there are different ways of developing knowledge. The epistemology of positivism, where methods to generate knowledge are objective and independent of the world they are researching, may not fully help us understand the complexities of health care practice, since much of practice cannot be explained in a way that is linear and based on cause and effect (Susman & Evered 1978). Chapter 2 has already identified the complex and multifaceted nature of the concept of compassion and caring and the need to understand this in the context of its application.

An alternative approach is the interpretative model. Central to the interpretive paradigm of knowledge generation is an individual‟s interpretation of the world and their

interaction with others so as to establish social norms (Mason 2002). The search is for meaning and understanding, and whilst the researcher takes account of the participants‟ perspective, this is still judged against the researcher‟s frame of reference (Carr & Kemmis 1986). Critics of this approach argue that it fails to examine the origins, causes and results of people adopting certain interpretations of their actions and thus falls short of addressing the theory practice gap (Carr & Kemmis 1986; Swanson & Chenitz 1982).

Much of the debate about the value of different worldviews in guiding inquiry focuses on the way science is interpreted. Gergen (1978) argues that science should not be about finding social laws that aim for prediction and control, but that science should strive for a generative capacity and by this he means:

Capacity to challenge the guiding assumptions of a culture, to raise fundamental questions regarding contemporary social life, to foster re-consideration of that which is „taken for granted‟ and thereby furnish new alternatives for social action (Gergen 1978, p.1346).

The epistemological stance taken in this study is that knowledge is not pre-existing or fixed or stable. Rather, knowledge is produced through practices, interactions and experiences. Thus a methodological approach that allows examination of the concept of

compassion in the context of its application with a range of social actors, namely patients, families and staff was considered essential.

A more pluralistic view of knowledge generation is embraced by contemporary

philosophers and scientists where a wider range of philosophies can underpin knowledge generation (Carper 1978; Gibbons et al. 1994).

Social constructionism is a world view that underpins participatory approaches such as action research and appreciative inquiry (Gergen 1999; Gergen & Gergen 2003). Within this paradigm much of our understanding of the world is said to be a reflection of our perceptions of the world of which there are multiple interpretations. This worldview advocates that one view is not superior to another. Individual thought is influenced by social processes which produces knowledge. Knowing is viewed as taking place through interaction within a social system, and is therefore created in the context of its

application. This world view acknowledges that to describe, measure or change how one views reality requires the interaction of various factors, such as language and cultural expression. Rather than trying to focus on truth in the sense of objective thoughts, the focus is on looking at ways in which people socially construct their world.

Hosking (2002), however, offers a critique of social constructionism. She argues firstly that, in social constructionism, the scientist positions himself outside the inquiry, thus maintaining the subject – object distinction and secondly, that this worldview is

concerned with a socially constructed product rather than the processes used to achieve this. Hosking also believes there is an overemphasis on the importance of conceptual (spoken) language rather than other forms of language, and what she refers to as co- ordinations, which could be nonverbal communication, and actions. All of these contribute to the social construction of reality. Given this critique Hosking argues for a version of social constructionism, which she refers to as relational constructionism.

In relational constructionism, assumptions about what exists are underpinned by concepts such as co-action and relational practice, which involve people entering into dialogue to

make sense of what is happening (Jonsdottir, Litchfield & Pharris 2004), and embrace the notion of multiple realities. By this they mean that we can present different selves

depending on the relationships and the contexts that surround a situation. This worldview redefines the relationship between the researcher and the participants from one that privileges the knower/researcher to a more equal relationship where multiple realities are seen as different but equal. The researcher is viewed as one expert amongst many and is part of the process rather than apart from it (Hammersley 1992; Murphy & Dingwald 2001). This suggested to me that I needed to constantly work together with participants, be open and curious about what was happening and be reflexive so that I was continually examining my role in the context of the research in order to suspend assumptions and be part of the process.

This emphasis on language and dialogue may seem to limit the voices of those who are unable to communicate in this way. Thus a broad interpretation of dialogue is necessary, for example, using visual methods to enable this dialogue. Visual methods used in my study are discussed later in this chapter.

Hosking (2002) explicitly argues against trying to reach consensus and sees relational constructionism as being about including and enabling multiple realities. This is realised in both appreciative inquiry and action research via the aim of empowering people through the construction of their own knowledge in a process of action and reflection. I would argue however, in a study that aims to bring about change and development, that some agreed action in the form of consensus is necessary from a purely pragmatic standpoint. This position was adopted in this study.

This paradigm argues that constructions we make about the world are influenced by cultural and historical knowledge and that these influences are important sources of understanding and interpretation. It argues however that we have a choice in the way we use this knowledge. This preconceived knowledge is not fixed and stable. So constructing knowledge, although filtered by history, policy and culture, happens in the here and now and can change dependent on the situation. Thus, what is constructed is local knowledge.

Development of local knowledge/theory is celebrated in both appreciative inquiry and action research. It could be argued that constructing local knowledge with the participants during the research process is empowering and more likely to lead to sustainable change. This was highlighted in Chapter 2 as a key antecedent to achieving this goal.

Inquiry and intervention are left joined in the relational constructionist paradigm. This recognises the fact that relational processes in themselves construct reality. Inquiry is intervention. Processes of understanding and change can happen simultaneously. The focus therefore is less on developing action per se, but rather on careful questioning and listening and this in itself becomes an intervention. Questions that help people to explore possible ways of being in a relationship are important. Thus if the questions asked are designed to open up possibilities, (such as in AI the unconditional positive question is asked) this will influence the way in which people relate and respond to the inquiry. The inquiry and thus intervention may initially be carried out by the researcher. However, through role modelling and collaboration the participants themselves may become the inquirers. Since one of the purposes of the research was to support others to initiate and sustain change, a process of inquiry which in itself aims to be empowering was

appropriate to my study.

In summary, key themes in relational constructionism include:

 seeing the inquirer as part of (rather than apart from) the inquiry;  recognising multiple local-contextual knowledge/practices;

 recognising the influence of knowledge from history, politics and culture and that how we use these depends on the situation and this can change;

 including the inquirers‟ own knowledge/practice as just one of many communities of practice; and

 seeing inquiry as intervention (where intervention is agreed by the participants) (Hosking 2002).

This emphasis on relationships within this paradigm fits well with the theoretical underpinnings of relationship-centred practice in both care-giving and practice development described in Chapter 2, where this involves acknowledging

interdependence, communicating openly with patients, staff and families and creating supportive environments where all of those involved are encouraged to flourish and grow. In addition, recognising who we are as practitioners is crucial to delivery of effective care and “Without such self knowledge a practitioner‟s own emotional response to patients‟ needs may act as a barrier to effective care” (Tresolini & Pew-Fetzer Task Force 1994, p. 38).

The relational constructionist paradigm can be seen to frame or incorporate many

different forms of inquiry, including co-operative inquiry (Reason 2004), action research (Meyer 2000), appreciative inquiry (Cooperrider & Srivastva 1987), and approaches to community social psychology (Hosking 1999; McNamee 2002).

It was appreciative inquiry (AI) that was the chosen approach for this study. The

following sections give an overview of AI, identifyelements of action research that were incorporated into the AI approach and highlight how the principles of relational

constructivism are relevant.