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Phenomenology, Hermeneutics and Inquiry Based Researchwithin the Human Sciences

Richard Hovey, Ph.D.

Research Director: Consumers Advancing Patient SafetyAdjunct: University of Calgary

© 2009 R. Hovey

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Today

n Introductionn Participatory Research n Interpretive phenomenology an overviewn An overview of phenomenology and

hermeneutics in human science researchn Other researchn Conversation

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Partners in our Care: Patient Safety from a Patient Perspective

Awaiting / Journal of Quality and Safety in Health Care …

Participatory Research TeamHovey, Morck, Nettleton, Robin, Findlay, Bullis,

and Massfeller

Patients & Family Members (PFSC) Alberta Health Systems Representatives (CHR)

Interpretive Researchers

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Interpretive inquiry

Interpretive inquiry involves theselection of participants thatcan appropriately inform aperspective on a particular topicand Invite new understanding ofit

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Patient’s voice?n Lyons: “Should patients have a role in patient

safety?” n Entwistles: “Differing perspectives on patient

involvement in patient safety” articles.

Problem?

n Talked about patients but not with them. n What was the patient's point of view?

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Patient and Family Safety Council invited to write interpretive memo responses in reaction

to the articles

n 4 PFSC members wrote interpretive memos perspectives as patients and family.

n The research team grounded within the interpretive phenomenological tradition

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Participatory Process

n The process of analysis in this study involved the individual interpretive scholars thorough reading of the textual interpretive memos and subsequent writing of their own analytical interpretations.

n Back to the whole

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Research Team

n The final analysis of the narrative data returned to the 11 PFSC members

n Ensuring that the patient’s voice accuratelyreflected perceptions about the patient's role inpatient safety

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The Tension

Patient and family centred care and involvingpatients in promoting safety are intended tocomplement the services of health care providers,not to replace them. Health care is a humanisticfield. In my opinion, it should be viewed in terms of quality, including the successful relationshipbetween the (health care) provider and the patient.The importance of safety in that relationship is agiven. (Member, PFSC, 2008)

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Pros …

n self-interest and motivation for a good outcome

n the patient is available and proximally close to the situation so that “if a symptom changes, the patient will be the first link in the chain to experience and have the opportunity to communicate this change”

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predictable reliability

Lyons:

“we cannot assume a patient or family member tohave skills or personalities to positively contribute tothe care process.”

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Cons …

Breakdown:

n Concern about patient diversity, age, culture, personality, language, intelligence, and human factors could potentially negate any reliable implementation of patient involvement was argued by Lyons.

n Defaulting to a generalization about ALL patients

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Patient as evidence

With regard to the cons that she (Lyons) stated, Ipersonally find it undermining and condescending,“Although it could be seen as an enormous asset ifpatients were clinically skilled and confidentenough to define, clarify and update their own carepathways”. This implies that the patient voice isnot only not valued but any skill that they maypossess is dismissed as incompetent. (Member, PFSC, 2008)

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Information Retention and the Distressed Patient

n Lyons offered evidence to demonstrate that patients do not retain information provided to them by the health care practitioner.

“I think that educating and encouraging patients tobe more involved in their care can help andimprove patient safety. If the focus on patientsafety doesn’t begin with, and include the patient,a valuable piece of the health care process is lost.”(Member, PFSC, 2008).

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Who needs to know that …

Adults do not learn well when

n Distressed

n Subjected to new and confusing jargon / professional language / appropriate level

n Content and context of adult learning theories and principles are not practiced or even known

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Tension / Assumptions

one perspective about patient safety formedical audiences … medical journals / CE / Conferences

n Dismissing the Patent voice as a valid source of evidence …

n Medical studentsn Communication n Medical Partners

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Other ResearchPatient safety:n CAPS – 100 +interviewsn Developing health

professional educationalapproaches thattranscend pedagogicalmodels

n Interpreting the patient as partners in their and other’s care

n Prostate cancer education

n Chronic illnessn Reflective education for

health care professionals n Communication n Adult learning for

patients n Transformational

experiences for children

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Interpretative Studies

Leder (1990) stated, “I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutical self understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject-the living, breathing, experiencing patient” (p. 9).

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Hermeneutic Interpretation

[to explain about what happened to mymother is]… “like putting your hand in apocket full of razorblades. It’s very painfuland people don’t necessarily see the littlesmall cuts. But I feel it’s very important that Ispeak out about my experience.”(Sherry, CAPS Interview 2008)

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Pocketsn Metaphorical pockets the deep

and private places in our minds, where we think, meditate, remember, feel, and suffer. Razorblades

n Small cuts nobody can seen Scar tissuen Blood letting n we live not to suffer / avoid

events, encounters and relationships / pain

secrets / conceal

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To live authentically means to wake up, to be shaken / disrupted / thrown from

our day-to-day living

n emotional cost of bringing these to the forefront of our existence. if I reach too deeply into this pocket:

n Will I survive these wounds?n Will I be able to recover from these wounds? n Who can I tell? n Am I losing my sense of self?n How do I get back?

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life without razorblades in pockets

10 years …n Vulnerabilityn Searching for answersn No one took

responsibility for mother’s death

n Medical error

recovery of selfn Disclosure n Perspective

Transformation n Consumers Advancing

Patient Safety n Trust n Vulnerability

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Vulnerability n Often perceived as a frailty, a fatal flaw or

weakness

n Latin vulnerabilis: meaning to wound or open

n To Levinas (1996) this opening of self, being susceptible to physical or emotional injury in being vulnerable, is the inescapable call revealed in the face of the other.

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Vulnerability

n This sense of vulnerability does not point to frailty, dependence or loss of social autonomy

n Rather, it is connected to recognition of the suffering of another. In this way we are signifying an openness and nearness available for the other

n This form of vulnerability is requisite to relational ethics

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Responsibility for the “Other”

n According to Levinas (1996) it is the pivotal loci of responsibility for another human being.

n A call to ethics in relationship begins with this interruption of self by self (Levinas, 1996).

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“Well, it’s morelike she was falling and nobody tried to catch her.”

“Well, first they lost their sister, they lost their mother, andthey didn’t really understand the anger. They didn’tunderstand the things that they picked up about the doctorthat we had so highly regarded all of a sudden was now thebad guy. And my three-year-old looked at me one dayabout four months or so after my daughter died and hesaid, “Mommy, did the doctors hurt Annie?” You think aboutwhat was going on in his mind and I said, “Well, it’s morelike she was falling and nobody tried to catch her.” So Ithink we’ll have many issues to work through in the years tocome as a result of the event.” (Sabina, CAPS, 2008)

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Phenomenology

Phenomenology isconcerned with a thing,or topic, which occursin the world and has todo with a person andtheir experience of thatthing or topic.

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Interpretive phenomenology as a method (research literature)

n Used to uncover the understanding of phenomena experienced by individuals through the analysis of their descriptions.

The Three Schools of Phenomenology

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The first school is eidetic / Husserl

Descriptive phenomenologyn obtain a fundamental knowledge of

phenomena.n objective in nature / interpretation

not openly discussedn reduction of the phenomenon

objectivity consistent with the positivist paradigm

n bracketing out other influences as the means to finding the essence of a phenomenon was to understand it.

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Heidegger, Husserl’s Student …

Created a shift in emphasisfrom Husserlianphenomenology which isconcerned with descriptionAnd the nature of knowledgeas an epistemologicalknowing of some-thing

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Human-being as Being

…toward understandingthe nature of existenceas ontological

Being-in-the-worldLife-world Day-to-day

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The second school of phenomenology Heidegger …

Interpretation as a means to understand text / actions / art / experience / traditions / history …

n Heidegger’s incorporation of hermeneutics

n clarify the conditions of understanding for the purposes of ontology

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From the Cartesian back to Interpretation

“Bracketing” out one’sprejudgement is replaced

Presuppositions are not toBe eliminated orSuspended because theyhelp with theinterpretations.

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Heideggerian phenomenology

n understanding the topic is not complete until it is interpreted through the conceptualization of the hermeneutic circle.

n The phenomenology Heidegger presents is different from Husserl’s transcendental phenomenology because of interpretation.

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Moving to understanding in context

Hermeneutic inquirygrounded by HeideggerIs referred to asn hermeneuticsn interpretativen phenomenology n orn Existential phenomenology

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Philosophical Hermeneutics

is used when referringspecifically to the work ofGadamer’s branch ofhermeneutics

Hermeneutic-phenomenology

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The Third School is guided by the Dutch School

This phenomenologyis a combination ofdescriptive and InterpretativePhenomenology MakingPhenomenology available tomany!

How to do phenomenology

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Max van Manen University of Alberta

Van Manen (1997), of the Dutch School, states, “Phenomenology describes how one orients to lived experience, hermeneutics describes how one interprets the ‘text’ of life. Furthermore, hermeneutic phenomenology is different from phenomenology as it comprehends the project of phenomenology intellectually and understands it ‘from the inside” (p.8).

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Hermes’ (the trickster) / The Raven

n communications from the gods to humans was never clear, straight forward or explicit

n messages meant to be interpreted

n interpretation finds the meaning hidden within the text – deeper

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Raven spirits are usually seen as jokesters and pranksters

Raven in America, particularly theNorthwest coast region, is bothdemiurge (a very strong,driving, and influential force orpersonality) and trickster, both heroand villain, and often at once andThe same time. Raven is the greatest shape shifterof them all, being able to changeinto anyone and anything to getwhat he wants.

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art of understanding

Gadamer (1996), “If we put ourselves in someone else’s shoes, for example, then we will understand him [we then] become aware of the otherness, the indissoluble individuality of the other person--by putting ourselves in his position” (p. 304-305).

(bracketed added by Hovey, 2008)

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the task of hermeneutics

Ricoeur (1984) …to reconstruct the set of operations by which a work lifts itself above the opaque depths of living, acting, and suffering, to be given by an author to readers who receive it and thereby change their acting” (p. 53).

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The tension

Hermeneutics as a methodology …

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End

Thank You!

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References n Lyons M. Should patients have a role in patient safety? A safety

engineering view. Qual Saf Health Care 2007;16:140-2.n Entwistle AV. Differing perspectives on patient involvement in patient

safety.n Qual Saf Health Care 2007;16:82-3.n Alberta Health Services: Calgary Health Region website,

http://www.calgaryhealthregion.ca/qshi/patientsafety/pt_family_safety_council/ (accessed 21 Dec 2008).

n Consumers Advancing Patient Safety: envisions a partnership between consumers and providers to create global health care systems that are safe compassionate and just. http://www.patientsafety.org/(accessed Jan 2008)

n Gadamer HG. The enigma of health: The art of healing in a scientific agen (Gaiger & Walker, Trans.). Stanford, CA: Stanford University Press,

1996.n Ricoeur P. Hermeneutics and the human sciences: Essays on language,

action and interpretation. New York: Cambridge University Press, 1998. n van Manen M. Researching the lived experience: Human science for

action sensitive pedagogy. London, Ontario: Althouse Press, 2003.

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References n Hovey R, Paul J. Healing, the patient narrative-story and the medical

practitioner: A relationship to enhance care for the chronically ill patient. Int J Qual Methods 2007;6(4):53-65.

n McWilliam CL. Continuing education at the cutting edge: Promoting transformative knowledge translation. J Contin Educ Health Prof2007;27(2):72-9.

n Willans J, Seary K. ‘I’m not stupid after all’: Changing perceptions of selfn as a tool for transformation. Australian J Adult Learning 2007; 47(3): 432-

452.n Taylor WE. Transformative learning theory. New Directions Adult Contin

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n Svenaeus F. The hermeneutics of medicine the phenomenology of health: Steps toward a philosophy of medical practice. Kluwer Academic Publishers 2000.

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