Joumal of Advanced Nursing, 1996,24,174-184

Implementation of a hermeneutic inquiry innursing: philosophy, rigour and representationTina Koch RGN B A (Sociology) Commumty Health Certificate PhDProfessor of Nursing, RDNS Chair of Domiciliary Nursing, Royal Distnct Nursing Serviceand School of Nursing, Flinders University of South Australia, GPOBox 2100, Adelaide5001, Australia e-mail nugak @ gamgee cc flinders edu au

Accepted for pubhcation 6 September 1995

KOCH T (1996) Journal of Advanced Nursing 24,174-184Implementation of a hermenentic inqiiiry in nnrsing. philosophy, rigonr andrepresentationTbe tbesis of tbis paper is tbat researcbers working in mterpretive traditionsneed to address tbree central issues pbilosopby, rigour and representationTbis paper discusses tbe process of an bermeneutic inquiry as a researcbmetbodology used m seeking to understand tbe experiences of older patientsadmitted to an acute bospital Tbe metbodology includes tbe pbilosopbicalframework and assumptions imderpinning tbe researcb Pbilosopbicalbermeneutics guides tbe inquiry as a reflection of tbe researcb process Tbreeissues concerning legitimation of tbe bermeneutic researcb process arise tbepbilosopbical underpinnings of tbe metbodology, representation, or tbeparticipation of tbe researcber m making data, and ngour, or tbe way m wbicbtrustwortbiness of bermeneutic researcb can be established I recommend tbatGadamer's primacy of application to tbe understanding of texts can also beapphed to understanding of bealth environments I conclude that Gadamer'spost-modem sensibility regarding text and the framework of Guba & Lincoln'sfourth generation evaluation are compatible v«tbin a bermeneutic inquiry

TMTROniirTTniSI * study is accomplished This is important vis h viscongruence with the philosophical approach and the

In this paper the term 'methodology' includes the philo- estahlishment of ngoursophical framework and assumpbons underpinning the This paper focuses on philosophical hermeneubcs,research In fact, I take the position shared by Cadamer guided hy ideas from the Heideggenan-Gadamenan(1976) and Van Manen (1990) who suggest there is no tradibon (see Appendix) However, it is prudent to ohservemethod, there is only tradibon, l e that hermeneubcs is an exceedingly complex field where

each theorebcal posibon cames with it major contradic-a hody of knowledge and insights, a history of lives of thinkers bons in terms of methodolc^ical lmplicabons I rec-

and authors, which constitutes hoth a source and a methodologi- ommend that each inquiry determine its own cntena forcal ground for present human science research practices ngour (trustworthiness) and I argue for expansion of the

(Van Manen 1990) concept of ngour m qualitabve researchThree issues concemmg legitimabon ofthe hermeneubc

Moreover, as a certam mode of mquiry is lmpbed m the research process are addressed the philosophical under-term 'method', methodology is the theory hehmd the pinning of the methodology, the parbcipabon of the'method' This methodology descnbes the process hy researcher m making the data, and the way m which thewhich insights about the world and the human condibon trastworthmess of this hermeneubc research study may heare generated, mterpreted and commimicated In terms of estahlishedresearch pracbce it means recording the way in which

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Implementation of a hermeneutic inquiry

The study

The study itself is not the focus of this paper, rather theissues surrounding a hermeneubc mquiry will heexplored However, a short descnpbon of the study, con-cemmg the expenences of older pabents admitted to anacute hospital, is relevant here

This study is viewed as the lmbal stage of a fourth gener-ation evaluabon (Guba & Lincoln 1989) The first threegenerabons of evaluabon have been categorized as'measurement-onented', 'objecbve-onented' and 'judge-ment-onented' whereas fourth generation evaluabon is'negobabon-onented' The appeal of fourth generabonevaluabon is the centrality ofthe nghts of all 'stakeholders'to place their claims, concerns and issues on the negobat-ing tahle and parbcipate in the development ofthe service

The evaluator acts as a facilitator of the evaluation pro-cess 'Stakeholders' refers to all people m the settmg whoare affected hy the evaluation, including pabents, nurses,managers, evaluators, medical, domesbc and other staffIts intention is outcome-onented and moves heyondmeasurement to negobatmg quality of care In this study,the negobabon starts with pabents The assumpbonunderlymg this study is that not all parbcipants involvedin an evaluabon are heard The focus is upon listening tothe voices of older pabents

An important feature, adopted from Guha & Lincoln(1989), IS the nobon of 'constmcbon' In the present studypabents are asked what matters to them ahout their care,and their stones are termed 'construcbons' The researchquesbon is What are the expenences of older patientsadmitted to the acute care sector' To answer this, I askpabents to tell me what it is like heing m hospitalConstrucbons are used to represent meanmgful descnp-tions that patients form to make sense of the sibiabons inwhich they find themselves

The study takes place in two wards designated for careof the elderly The setbng is in a 1000-hed NHS hospitalm the United Kingdom There are two quasi-Nighbngalewards each capahle of receiving 22 acutely ill olderpabents One ward accommodates women, the other menThe two research wards were huilt m the 19th century asa Poor Law insbtution Many of the pabents could recallthe time when the wards funcboned as a workhouse

Contextual data are vital to this study and depict theways in which pabents are connected with the worldPnmary data are viewed as contextualized life events(Benner & Wmhel 1989) In the present study, one suchevent is the pabent's admission to hospital A field joumal,conversabons and mterviews with pabents and relatedliterature provide sources for contextual data

In addibon to contextual data, 14 pabents are inter-viewed, each on several occasions and their concernsrefiect the 'roubne genatnc style of care' (Baker 1978),depersonalizabon, care depnvabon and genatnc segre-

gabon The stones reflect human feeiu^s and lived expen-ence The telling, hearing and unravelhng of stones isinvolved

The purpose of this study is to provide a constructedreality of pabents' expenences that 'is as mfonned andsophisbcated as it can be at a parbcular point in bme'(Guha & Lincoln 1989 p 44) This paper discusses the pro-cess of a hermeneutic mquiry as a research methodolc^m seeking to understand the situabon of older pabentsm hospital

LOCATING AN INTERPRETIVE TRADITION

Qualitative research involves an mterprebve, naturalisbcapproach to its parbcipants (Denzin & Lincoln 1994) Butwhile qualitative resesirch is a term covenng a vanety ofresearch methodologies ongmating m the tradibons ofphilosophy, anthropology, psychology, history and soci-ology, there eire few similanbes hetween the methodo-logies Qualitabve methodologies differ m terms ofphilosophical underpinnings, theoretical, ontological andepistemological orientations, shared understandings andpurpose (Guha & Lincoln 1989) This has meant that nurseresearchers have come to consider the philosophical hasesof their selected research tradibon, and have had to cometo terms with the mterprebve pracbces withm thattradition

If the nurse researcher is considenng using the lnqmrytradibon of phenomenology, the expectabon would he thatits ongins would be traced from Brentano, Husserl,Heidegger, Weber and Schutz (see Appendix) It wouldalso he important to show the way in which nurseresearchers have used their philosophical constructs toinform their lnqmry process It is suggested that excursionsinto the philosophical literature provide the soundness(rigour) of a methodology However, these amorphousphilosophical areas are a potential minefield and guid-ance from an expenenced scholar familiar with themIS required Wrestlmg with ohscure German texts isnot the objecbve, hut rather guided reading of some ofthe metaphysical arguments which have the potentialto increase imderstandmg of the processes of mterprebveresearch

In considenng the philosophical hase of this her-meneubc inquiry, I helieve it important to make a disbnc-bon between phenomenological approaches I suggest thatthere are disbncbons between Husserlian (transcendental)and Heideggenan phenomenological (existenbal/her-meneutic) tradibons

Phenomenology can refer to the method of inquirydeveloped hy Husserl (1859—1938) who mtroduced theconcept of life-world (lebenswelt), or lived expenenceHusserl's phenomenology was the culminabon of theCartesian tradibon, and came to mean the study of phen-omena as they appear through the consciousness

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Phenomenological research followii^ Husserl seeks thenature of the meamng of human lived expenence Theresearch quesbon is usually 'What is it like ' This ques-bon IS answered hy means of phenomenological reducbon'brackebng' m search ofthe essence ofthe expenence Thehallmark of a genumely phenomenological inquiry is thatits task IS 'a matter of descnbmg' Central to this tradibonIS that the descnpbon 'lives' In reading the descnpbon,the reader has a sense of hemg moved by the story from theparticipant's life Thus representation relies upon usmgthe actual words of the person who has the expenence,and the pracbce of bracketing out the researcher's worldand preconceptions The critical issue of representation isprecisely whether hrackebng is possihle and plausihie

Husserl's student, Heidegger, reacted against Cartes-lanism and extended Husserl's philosophy hy examiningits ontological status Heideggenan phenomenology issomebmes descnbed as existenbal phenomenology, or,following Gadamer (1976), philosophical hermeneuticsHeidegger (1962) declares nothmg can he encounteredwithout reference to the parson's background understand-ing, and every encounter entails an interpretabon hasedon the person's hackground, in its 'historicality' As inHusserlian phenomenological research, the quesbon'What IS it like ' can he asked, and data are generatedfrom similar sources, e g interviews and narrabvesHowever, m suhsequent analysis, data generated by theparbcipant is fused with the expenence of the researcherand placed m context The interpretation becomes amerger of data sources, or a constmcbon Heidegger cnb-cises hoth the ohjecbve and subjective positions ofCartesianism An interpreter inevitably hnngs certainhackground expectabons and frames of meaning to hear mthe act of understanding These cannot he bracketed

Philosophical hermeneutics

The onginal source of this tradibon lies in the interpret-abon of scnptural passages, and it encompasses the theoryand pracbce of mterpretabon This pracbce of mterpret-abon was extended hy 19th century German philosophersto cover the whole of human existence 'world as text'

Gadamer is the crucial figure in philosophical hermen-eubcs and, as a student of Heidegger, his philosophyextends Heidegger's existenbal ontological explorabon ofunderstanding hy providing an emphasis on languageGadamer's inquiry m Truth and Method (1989) exploresthe possihility of interpretabon, he does not provide amethod for interpretation He suggests that philosophicalhermeneutics is 'a refiecbon about what is gomg on inusing "methods"' (Gadamer, interviewed hy Boyne 1988,p 33) Key philosophical constructs are the hermeneubccircle, dialogue and the fusion of honzons as metaphorsfor understandmg m mterprebve work Gadamer'sprovocabve formulabon of prejudice will he illustrated

The hermeneutic circleThe hermeneubc circle is a metaphor taken fromHeidegger to descnbe the expenence of moving dialecb-cally hetween the part and the whole However, Gadamerplaces a stronger emphasis on language Gadamer claimslanguage and history supply the shared sphere m the her-meneubc circle Gadamer's ontological perspecbve sug-gests that understanding is a mode of bemg, so that whenhe talks ahout understandmg he is talking about existenceUnderstandmg, like conversabon, is always a reciprocalrelabonship (Hekman 1983) The aim of this expenence isnot to imderstand hetter, but differently

Philosophical hermeneubcs affirms the posibon of theresearcher in the hermeneubc circle 'The hermeneuticcircle cannot be avoided, rather it is a matter of gettinginto It properly' (Bleicher 1980 p 103)

DialogueGadamer equates the metaphor of dialogue with the logicof quesbon and answer The real power of hermeneubcalconsciousness 'is our ability to see what is quesbonable'(Gadamer 1976 p 13) Following Socrates, he recogmzedthree different tjrpes of quesbons rhetoncal, pedagogicaland genuine Genuine questions define true dialogue andthese lead in several possible directions and to severalpossible answers (Gadamer 1976 p xxi) This is not anarhitrary procedure hecause a quesbon is always relatedto the answer that is expected in the text Understandingoccurs when we surrender to the movement of quesbonand answer For a text to become an object of interpretabonit must ask a quesbon of the mterpreter It takes us to adiscovery of something new, something not recognizedhefore (Thompson 1990)

The idea of Gadamer's hermeneutic circle includes keep-ing the dialogue open through quesbon and answerInterviews and conversations are non-directive so thatpabents are ahle to tell their stones in which ever waythey wish This approach is in contrast to the interviewersdirectmg the course of the mterview or asking set ques-bons Thus the approach is open, allowing the parbcipantto take you with them m their narrabon I used quesboningthat maintained a focus on expenence, such as 'Cem yontell me about hemg m this ward' What is it like here' Howwould you descnhe your expenence here' What happenedtoday'' The goal ofthe interview was to ohtam the pabent'sdescnpbon of the expenence The probes used weredetermined by the course of the conversabon

The aim was for the fiow of conversabon to he controlledhy the pabent The major aim was to locate the pnvatevoices of pabents within the context of the acute hospital

Fusion of honzonsThe nobon of fusion of honzons is another metaphor forunderstanding Interpretabon always occurs through thefusion of honzons Gadamer defines honzon as the range

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of vision that mcludes everythmg that can be seen irom aparbcular vantage pomt But Gadamer (1976 p 10) assertsthat honzons are temporal, a person does not have a closedhonzon, it is always m mobon

The histoncal movement of human life consists of the fact that itIS never utterly hound to any one standpoint, and hence can neverhave a truly closed honzon

Fusion IS the coming together of different vantage pomtsThe process leadmg to fusion of honzons is more like aposture, or a way of conductmg yourself, a willingness toopen yourself to the standpomt of another so that you canlet their standpomt speak to you, and let it influence youThe task of understanding is to show how a fusion hasoccurred (Gadamer 1976) This task is achieved m researchwnting, by showing the way m which the researcher par-bcipates in makmg data, depicting the expression (forexample pabents' voices) m the social context (the wards)in which it occurred, and then showing how the horizonsofthe mterpreter and interpreted are fused (Hekman 1983)The social context would include the histoncal and cul-tural honzons of the participants in the event The honzonof the mterpreter includes the historical and specificideological perspecbves

In order to expenence the fusion of honzons, it is neces-sary to 'tolerate the amhiguity of relaxing (not eliminabng)one's own pre-conceptions' (Thompson 1990 p 246)Gadamer (1976 p 152) states that

the hermeneutic attitude supposes only that we self-consciously designate our opinions and prejudices and qualifythem as such, and m doing so stnp them of their extremecharacter

PrejudiceA related concept of Gadamer's is that of 'prejudice'Gadamer (1976) uses the term 'tradibon' to refer toHeidegger's nobons of background, co-consbtubon andpreconcepbons He claims that the operabon of tradibonm advance of our reflecbon means we always have preju-dices It IS not unlike the analogy of Merleau-Ponty (1962),who explains that it is not necessary to see the light, hutonly what it lllummates However, without the light,nothmg would be seen So it is, also, m the operation oftradibon m advance of reflecbon That is, the honzonincorporates the hackground meanmgs and frame ofreference

Pre-understandmgs are hnguisbcsilly conveyed Preju-dice IS a forestructure or a condibon of knowledge m thatit determines what we may find mtelhgihle m any givensituabon Such forestmctures reflect social referencegroups, they are a product of gender, culture, race, and classIn this sense, the vantage pomt then encompasses 'what wefind as mtelligible given our specific cultured jjerspecbvesand our place in history' (Thompson 1990 p 245)

Gadamer presents a posibve concept of prejudice andargues for its need of hermeneubcal 'rehahihtabon'(Gadamer 1976 p 9) He states that prejudice is not some-thmg negabve or something we should try to eliminate,but that instead we only have access to the world throughour prejudices It is not so much our judgements as ourprejudices that consbtute our 'hemg' In other words,prejudices are not necessanly erroneous nor necessarilydistortions of truth Instead the histoncity of our existenceentails that prejudices ' consbtute the initial direct-edness of our whole ahility to expenence Prejudices arebiases of our openness to the world' (Gadamer 1976 p 9)

Prejudices are merely the condibons by which weencounter the world as we expenence something We takeprejudices (value posibons) with us mto the researchprocess and these assist us to imderstand

CENTRAL ISSUES FOR THIS HERMENEUTICINQUIRY

In the discussion of research camed out accordmg toaltemabve paradigms, the descnpbons of legibmabon (theissue of ngour) and representation (the issue of whosevoice IS hemg heard, e g the researcher's, the participant'sor hoth) are central concerns Denzm & Lincoln (1994)descnhe the first as the cnsis of legitimacy (traditionalcritena for evaluabon and mterprebng qualitative researchhave hecome prohlemabc) and the second as the cnsis ofrepresentabon (where the researcher's authonty remamsunder assault) If hoth legitimabon and representabon arecrises m qualitabve research, then resolution of thesecnses should he the current preoccupabon of most 'quali-tabve' researchers Indeed, these are central issues for thishermeneubc mqmry The importance of Gadamer's contn-hubon for this study is the attenbon to detail m theresearch process, especially concermng issues of represen-tabon and legitimabon

Representation: participation in making data

Whereas Husserlian phenomenology draws solely on theexpenence of the 'other' under the auspices of a smglepoint of view, m this study neither the pabent nor theresearcher can assume a pnvileged posibon in mterpret-abon I suggest tbat the applicabon of bracketing and thehermeneubc circle are mutually exclusive The method-ological lmplicabons of this for nursmg research are pai-bcularly perbnent m the analysis of data Thus analysesusmg the frameworks of Colaizzi (1978), Giorgi (1985) andParse et al (1985) follow the Husserlian tradibon andare hased on decontextualising and recontextuabsmgTranscnpts are disaggregated mto a senes of fragments,which are then regrouped mto overarching analybcthemes A difficulty anses m escapmg the mibal categoneswhich lend themselves to recapitulatmg posibvist

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assumpbons The researchers remam aloof, the panoramaof their views and mterests are hracketed This is the way'essenbal' knowledge is generated

Analyses which follow Heidegger or Gadamer view dataas text (I should pomt out that my use of the term 'text'encompmsses a hroad range of events and situabons)Researchers hnng their mterests to the data, wherebymeaning and sigmficance may he read mto it This is partof the ongoing process of ohservation, interviewing, read-ing and wnting This approach pays more attenbon to thestructure ofthe texts This means suspension ofthe analyt-ical mode through readings and rereading of all sources ofdata It IS recognized that data are themselves textual prod-ucts, and that they report emd mcorporate rhetoncalaccomplishments on the part ofthe participants (includingthe researcher) This approach concerns itself with a narra-bve which can reflect a story, an event and the effect ofthe narrative on the reader The parbcipant is self-interprebng, the story is couched m a narrative format andIS hiographical in its point of view This approach impliesthat understandings are made rather than found

The Heideggenan-Gadamenan position is thatinterpreters parbcipate in making data precisely becausethe hermeneubc circle cannot he avoided (Grondin 1994p 111) Co-constitubon demands that pnmary data beregarded as contextualised life events, with the person'sand the researcher's perspecbves specified This refers toGadamer's notion of 'the fusion of horizons' It is importantto know how researchers constme the shape of their realityand the way m which they give a credihle account of itThis reflexive tum has rsused unanticipated dilemmasahout representation and legibmabon (standpomt/pos-lbon or voice) It requires analysis of the lnbmate relabon-ship hetween the research process and the findings itproduces The reflexive character of this study renders itnot only 'non-objecbve' but incomplete and bound to thecontext and perspecbves of the researcher

Getting into the hermeneubc circle 'properly' relies onmamtaimng a reflexive joumal Thus the daily journal isessential m recording the way in which my honzon isworking I support the nobon that credibility is enhancedwhen researchers descnbe and interpret their expenenceas researchers

Stones are told hy self-mterprebng pabents, who havehrought to them their pre-understandings At the sametime, I hnng my pre-understandmgs and prejudices to theresearch process No attemp't is made to disguise these Myown mode of thought is something that cannot be elimm-ated or hracketed, I parbcipate in making data

Rigour: trustworthiness ofthe study

In the last two decades the issue of ngour (lmbally referredto as rehahility and validity) in qualitabve research haspersisted as an hegemonic legacy of empmcal-analybcal

research, and continues to challenge new researchers asthey shift from a convenbonal empincal-analybcal para-digm to altemabve paradigms There is a large amountrecent literature concerning ngour in qualitabve research(Brink 1987, Guba & Lmcohi 1989, Hmd et al 1990, Hoffat1991, Hardmg 1992, Leinmger 1992, Webb 1992, Beck1993,1994, Bhavanmi 1993, Breitmayer et al 1993, Lather1993, Porter 1993, Sandelowski 1993, Denzm & Lincoln1994, Hogston 1995) It is evident that the language andconcepts are changmg which, I helieve signals a reconcep-tuahsmg of the nobon of ngour

While there is a lack of consensus regarding the idea ofngour, legitimacy of knowledge clcums are dependentupon demonstrating that the research study is trustworthyand believahle These recent readings suggest that there isan expanded concept of ngour m 'qualitative' research ItIS my opinion that an inquirer needs to engage in thisliterature and select or develop the most appropriate cn-tena for their parbcular study The responsibility lies withthe writer to show the way m which a study attempts toaddress the issue of ngour It is for the reader to decide ifthe study is believable The issue regarding the mostappropnate cnteria is one that must he resolved by theindividual nurse researcher

Central to the discussion of rigour in qualitabve researchIS the awEireness of many paradigms and the way m whichvarious philosophical positions inform the research pro-cess Rigour and legitimacy are tied to the way m whicha research paradigm's ontology and epistemology informthe interpretive framework hrought to the quesbon

In the lmplementabon of this hermeneubc research pro-cess I wnte about the way m which my insights into theworld and the human condition are generated, interpretedand communicated In terms of research pracbce it meansrecordmg the way in which a study is accomplished Thishermeneubc inquiry is inevitably influenced hy my values(Gadamer's nobon of prejudice) This affects the answersI give to the research quesbon hecause the cntena whichdetermine helievahility are dependent on my parbcularperspecbve

'Understanding is enbrely mediated hy the proceduresthat precede it and accompany it' (Rahinow & Sullivan1987 p 14) Clearly descnhmg procedures, e g theorebcalnotes, methodological decisions, plans for analysis andmterprebve frameworks, is an essenbal part of thisresearch process For the purpose of this inquiry, trust-worthiness may be established if the reader is able to auditthe events, influences and acbons of the researcher So mthis paper it is argued that a trail ofthe decisions, theoreb-cal, philosopical and methodological, has the potenbal toclanfy the research process and estahlish trustworthinessof the study These decisions are recorded m a joumal andmade availahle to the reader in the detailed wntmg of thestudy The study's cleum to legibmacy is the appeal to anaudit process

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In addibon, I select and apply Guba & Lmcoln's (1985)term 'transferability', which is dependent upon the degreeof similanty hetween two contexts This means that theongmal context must he descnhed adequately so that ajudgement of transferability can he made by readers Inother words, there should be sufficient contextual mfor-mabon to make similar readings possible by others (Guha& Lincoln 1989)

The exact conditions of data generation are tjrpicallyunder-reported or frequently reported m a standardizedmanner, ohsciinng a complete picture of what occurredThe context must he descnhed adequately so that a judge-ment of transferahility can be made by readersIncorporabng joumal data provides a rich context In myfield joumal I noted my response to the hospital and wardsetting In addition, information was gathered to help myunderstanding of the setting and I observed events suchas the physical environment, orgsmizabonal structure,daily ward routines, nurse staffing and medical rounds

Another methodological responsibility is to demonstratethe fusion of honzons, that is to say, the horizons of theliterature, my preconceptions and data 'Getting into thehermeneutic circle properly' means using my own experi-ence as data and hemg aware of my hackground, and when-ever possihle, showing how these interact with pabents'stories Joumal data provide a context for pabents' stonesIn addition, presenting multiple data sources, namelyjoumal entries, conversabons with patients and their rel-atives, interviews and data from ohservation, serves toproduce the best construction ofthe pabents' expenences,and contributes to the trustworthiness of the researchprocess

Existential presence

Existenbal presence is vital for the present study The her-meneutic experience is charactenzed hy the openness ofthe exchange (Gadamer 1976) This methodology is dis-tmguished from others pnmanly hecause the interviewstyle IS open Openness is crucial This means hemg awareof hody language emd concentrating on the process ofattenbve listemng

As menboned earlier I do not ask specific quesbons, theexchange is entirely open I am conscious of the way Iconduct myself dunng conversations and interviews m theact of listening I am willmg to open myself to pabents'stones, to let their stories speak to me, emd let them influ-ence me I attempt to demonstrate a presence hy listeningThis openness of mterview style requires pracbce

I converse with ahout 50 patients, and notes from theseconversations are recorded in the field journal Also, 14pabents provide addibonal core mterview data Only tape-recorded conversabons with pabents are categorized asinterviews It is necessary to meet with each pabent manybmes With one pabent, Ada Jones (a ficbonal name) the

conversabons and mterviews contmue for 6 monthsPabent control of bmiog is cmcial, not only of the timingof the interview, hut also of the frequency of mtarviews

Pabents' stones and exemplars merge with contextualdata, and literature is progressively incorporated tomediate understandmg and delivered m a construcbon Idiscuss my expenence in making data m a decision trailin joumal data where I have made my concerns and pos-ition clear (Koch 1994) The point is that my hackgroundand these joumal data ulbmately influence the einalysis ofthe interviews That is to say, I hnng my prejudices/valuesto the analysis of interview data I accept that a value-onented approach is unavoidahle and contams a pre-understandmg which originates m the researcher's histori-cal context I take the position that these values, ratherthan getting in the way, make the research meaningful toIts readers

I attempt to make my concerns and position clear regard-ing ethical issues, impoverished physical environment,lnflexihle organization of nursmg care and my graphicexperiences in the wards It is heyond the scope of thispaper to give more than a preliminary scan of the nch datagenerated In the section to follow I will present some ofthe voices of older pabents Normal procedures werefollowed for ethics committee approval, and fictionalnames are used

Voices of older patients

Pabents' concerns revolve around issues such as food,safety, comfort, hygiene and the feeling that their care iscompromised hy the use of untrained staff Patients tendto interpret their situabon hy making excuses for caredeprivation on the grounds that nurses eire largelyuntrained and that there are not enough staff I elect tocluster these care neglect exemplars under the umhrella of'care depnvabon'

Fall out of bedFalls are prevalent in the male ward, hut these are nottreated as exceptional events either hy the nursing staff orthe patients Nurses are usually told ahout incidents atthe hemd-over report, hut documentabon does not alwaysaccompany the report Falls are somebmes hidden fromofficial records, and therefore not included m thehospital's incident statisbcs

lnformabon ahout falls sometimes emerged m the courseof my discussions with pabents Whereas a nurse wouldhe likely to see em incident like a pabent's fall as a possihleprofessional transgression, a pabent is not coming to theinterpretabon from the same hackground Because of myovm personal expenences, and my father's death m hospi-tal following a fall the previous year, it was mevitable thatfalls hecame very important m my mterpretabon of thedata Clearly my value posibon is evident m selectmg this

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excerpt That these mcidents have the potenbal for senousconsequences appears not to be appreciated by staff norby patients Stones are divulged as if they were unremark-able everyday events Ronald Allen had this to say ahoutfallmg out of bed

Someone fell out of hed this mommg over there He has a handageon his head The scah on my head from the fall last week appearsto he healing They actually saw me fall I think The doctor leftme on the edge of the hed after listening to my chest, and I justslid off, hut it wasn't too had hecause the clothes came oB withme and hroke the fall

In the same interview, as I recorded m my joumal

Ronald asked me if I knew that he had fallen out of hed today Isaid, 'No, It was not mentioned at report at 12md (This is thefifth patient fall out of hed this week)

Ronald made known this detail about falling in a verymatter of fact, almost casual, manner

Mommg routine'Routine genatnc style' charactenzed the orgamzabon ofwork on these wards Patients feel powerless and withoutcontrol m the face of the ngid bmetahle, being sat m achair for hours, having nothing to do, and being depnvedof information about their treatment Genatnc routme isdescnhed by Hilda East m the following way

They haven't got the staff to do the johs they have got to do Imean in the morning, I am more likely as not to he awake andwaitmg for a commode Because I have water prohlems I amawake waiting for it Now they get me out of hed and say, 'Do youwant to sit in your chair''' And I say yes, and I get a commodeAnd ahout that much water in a howl (indicates ahout an mch)And my face cloth is dropped m it, and my soap is dropped mIt, my talc is put on the side, and my towel is put on the side,and my dirty night dress from the day hefore is pulled off, andthere a clean one is set there Then they say 'Right Hilda, youwash yourself Well how can you with one arm'' Oh yes I've hadwashes Sometimes, when they have got time they will come andwash me I've had two full haths And I can wash all down oneside, wash under one ann and under my hreast But I can't washthis other side

7 don't ask unless it is important'These pabents find themselves colluding with inadequatenursmg care Lilian Lewis had this to say

They haven't got time to change my hed everyday here They areworked to death here Only it's at certain times they are husy Atmeal time, dinner time That's my only complamt really Youcan't get anjrthing done I mean something that is important Idon't ask unless it is important

The congested routme appears to stretch nurses to theumaximum capabilibes, emd pabents feel that they cannot

complam To them it is obvious that nurses are run offtheir feet, and it is their role to dimmish not mcrease theburden

7 wasn 't prepared'Lack of mformabon is intimately bed to lack of controlJoseph Ide provided some droll msights and tedks ahouthemg vulnerahle when the power appears to he mvisihle

Yes I do feel vulnerahle I don't know if that is the word I wantlack of mdependence, of movement, lack of information Forinstance this mommg I was just sittmg here, just having my hreak-fast I was all set up for a wash, shave and everything when theman from X-ray said 'You are going for a hrain scan' I said, 'Wait,hy tomorrow I won't have a hrain left' I was to have a hrain scanand no one had hothered to tell me m advance I hadn't even hada shave or an}rthmg I don't suppose that would show m the X-rayshut I wasn't prepared They should have given me wammgWhoever ordered the hrain scan should have told the ward or mewhat to expect Somehody should have told me hut this is it,you see, you are on your own The authonty in charge hecomeslnvisihle

The expressions used by pabents to descnbe their situ-abons carry connotabons of hemg trapped m a prisonOlive Kay, extends this to feelmgs of despair

It IS like hell It is The noise' I can't adjust to it, it is always thereI try I can't compete with the noise That noise is awful I can'tsleep hecause that noise is there all the time I can't get away Ican't cope I can't I can't compete I can't talk It is unhearahle tome My speech has gone I feel myself that I'll never he the sameagain When I walk my head falls on my chest I have no controlover it I want to die

The helplessness expenenced hy Olive is extreme,because she had httle control over her hody or her situ-abon Many of these accounts are evocabve, and conveyconcerns rarely expressed m nursing literatures

DepersonalizationExemplars of care depnvabon and roubne geriatric stylehave uncovered the fact that individual concerns are oftenIgnored, and feelmgs of hemg treated as an object are aconsequence of the 'genatnc routine' Personal caremvolvmg bodily funcbons such as washing, hathing andassisbng with toiletmg are recogmzed to he very pnvate,and pabents who require assistance with mbmate tasksare very vulnerahle It is easy to understand how pabentsfelt depersonalized, when nursmg ceire was given m thecontext of the roubne genatnc style

Being talked down toConcerns reflecbng depersonedizabon refer not only tobemg treated like an ohject, hut are also associated with

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'old' and bemg treated as a less than responsibleadult Jane Codd shares the followmg story

Some people would say it doesn't matter, hut it hothers me youknow I hate to he talked down to like a child Like the othermght, I was coming hack from the tahle This old lady (pointmgto the hed next to her) was calling out to me I thmk she wantedsomething I only moved from the end of the hed towards her, Isaid to her 'Do you want something''' There was a nurse on theopposite side looking after that sick lady And she turned aroimdand shouted 'You' I turned around and said, 'Are you speakmgto me'' She said 'Yes, get hack m that chair' So I said 'Excuseme', I said, 'this lady called me' (I didn't get a chance to find outwhat she wanted Sometimes it is just a tissue or something small)'This lady had just called me' She said 'Oh sit down, never mind'That kind of thing, I mean I was doing nothing at all, I was amazed'Get in that chair', she shouted 'It's none of your husmess', shesaid And she wasn't even a nurse or a sister, just an auxiliaryYou see, we are all treated the same Things like that upset you

Bemg treated m the same way as others (in the sensethat others were mentally incapacitated) had the effect ofdiscrediting her sense of idenbty and esteem

7 don't think of myself as an old lady'On the whole, however, patients are trouhled hy theirsegregabon based on age Elsie Freelmg was vexed hy the'G' for 'genatnc' on case note files

I am old, I am 82, funny enough, hut I don't think of myself as anold lady I mean I found out what the G was in front ofthe numher,I really got a hit vexed, hecause I didn't really think of myself asgenatnc Well I think I am young and I am 82 I don't thmk thatI am old at all hecause I make things for old people I wasknitting here the other day One of the nurses and a lady walkedpast and said what are you knittmg'' Bed socks I said for the oldladies at B And they hurst out laughmg Did you hear shedoesn't think she is an old lady'

Elsie Freelmg does not think of herself as an old ladyshe rejects the stereotype Among pabents, use ofthe word'old' does not refer to calendar age hut rather to a state ofdecline and infirmity What she is rejecbng is more likelyto be the negabve image of mcapacity and 'senility' Oftenpabents used the term 'genatnc' to refer to a confused oldperson Elsie could be forgiven for rejecting the lahel 'old',as this did not fit her own expienence

Multiple data sources

Thus understandmg is pursued hy the fusion of honzons(or data sources) and refers to the merging of construcbonsoffered hy pabents, hy my mterpretabon of situabonsexplicated m joumal excerpts, hy my personed and pro-fessional background and by selected literature Thecommon expenences conveyed by exemplars are denvedfrom mulbple data sources, and I contmue to move m

direcbons which are fruitful m developing further under-standing throii^h reading a wide range of hteratures As Iread, I mcorporate these literatures to fuse with myown understandii^ The dialogue conbnues hecause aconstrucbon is never complete, there are always otherconstrucbons that will compete with mme

THE EMERGING CONSTRUCTION

In this secbon, readers are expected to engage m a dialoguewith the newly developed construcbon, as it is open toseveral readings Existenbal phenomenology cannot beused to prove or show that one readmg is more effecbvethan another (Van Manen 1990 p 8) In fact, it is lmperabvethat dialogue continues, and that new constmcbons eireshaped

I will give here the constmcbon developed m 1992 Thisconstrucbon is as mformed and sophisbcated as it couldhe at that parbcular pomt m time The construcbon actsas a summary of the situabon as I saw it m 1992

Given that the literature corresponds with the pabents'stones denved from my research, it is discouraging to findthat the culture of inhumane care has heen perpetuatedand that prohlems ldenbfied many years ago are sbll evi-dent m the research wards I refer m parbcular to the cul-ture of the 'roubne genatnc style', the lnacbon of nursesand the inadequate or mappropnate responses hy auxiliar-ies, hy which patients were douhly disadvantaged Byexposmg such concerns I am not merely dwelling on theplight of older patients and on the inadequacy of the healthservice, hut making a profound cnticism of nursmg'sacquiescence in allowing situabons of care depnvation toremain unchallenged and unchanged

One perplexing prohlem is the merba of lnsbtubons,their slowness to change As the literature suggests this isnot due to lack of recommendabons Rather, there arehroad recommendabons refemng to educabon of all heedthcare workers, to orgamzabonal change, to adequate mate-nal and human resources and to nurse control of long-staywards Recommendabons also call for re-examinabon ofroutmes m genatnc wards and of methods of dehvenngnursmg care, quesboning of the use of untrained personneland the delivering of care hased on medical pnonbes Iwould support these recommendabons I turned to litera-ture on agemg and ageism to try to understand why sohttle has changed in the years between these studies

I examined the cultural percepbons of agemg, mcludingmisconceptions held by nurses ahout ageing In the effortto understand the condibons of discnmmabon and mar-gmahzabon of older people, the roots of e^eism weretraced to common cultural percepbons I identified twofeatures of stereotypes which continue to mfiuence thehealth care of older people the hiomedical status of olderpeople, emd age segregabon Central to stereotyping ofolder people is a deeply rooted a^eist perspecbve which

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permeate the thinkmg of health workers, pabents and thewider community

Pabents comply with their situabon of powerlessnessyet refuse the 'old' status for themselves Bemg 'old' istransmitted very negabvely hy pabents and nurses, whichmeans that nurses devedue pabents and, at the same bme,devalue themselves as carers for older patients and, assuch, are devalued hy the organization in which theywork

The hiomedical construction of old age produces a viewof the human heing as a machine with hody parts that arehreakmg down mto decline and decay Such a mechamsbcview permits the hody to he viewed as medical propertyThis perspective remforces the low esteem in which olderpeople are held, reduces them to ohjects in heds, and dis-courages understanding of older pabents as human heingswho want to he m control of their own lives

Age segregation can he used hy msbtutions for pro-cessmg people Patients ohject to such processing and donot want age segregation Older people are treated as ahomogeneous group, and are systemabcally disadvantagedand discnmmated against There are numerous pro-fessional nursmg transgressions which are specific towards run on the pnnciples of 'roubne geriatric' care Theresearch wards are resource-depnved, hoth in material andhumem terms The way resources are distnhuted dependson the heliefs and pnonbes of the decision makers Thiscan only he challenged by empowenng nurses and patientsthrough democrabc processes Change will not occur unbluntenahle working condibons are addressed and resourcesare reedlocated

One of the arguments for segregabon of older patients isthat they require specialist skills However, nurses m theresearch setbng are disadvantaged m terms of these skills,as the pabents' ceu'e depnvabon experiences painfullyimply I quesbon the need for segregabon, and argue thatthe pabents required nursing skills that are needed hypabents of all ages Pabents want to he acknowledged asindividuals

My intention was to open a dialogue with pabents tocontribute to the development of their participabon mfourth generation eveduabon I gave feedhack to nursingstaff on the research wards, readmg to them exempleirsfrom patients Staff provided stones of care depnvabonthat complemented mine I was surprised and homfiedthat staff were so aware of the daily professional trans-gressions (care depnvabon and depersonedizabon) in thereseeirch wards

CONCLUSION

It IS heyond the scope of this paper to give more than emincomplete glance at the mulbple mterprebve layers ofthis research process emd pracbce If the constmcbonidentified is similar to that found in much of the literature

on elderly [mople in hospital, what then does thisapproach tell us that past research does not' I bebeve thatIts power lies m hearmg older pabents' voices where otherapproaches (observabon, structured interviews, pabentopinion surveys) have not, and the fusion with the vividjoumal accounts given hy the researcher as data Indeedthe focus of this paper is on methodological issues, e g itsuggests the way in which ngour may he estahlishedthrough journal data and details the merging researcher-researched roles (Koch 1994) Joumal entnes incorporatedmto the text can reveal the way in which the researcherpeirbcipates in making the data

I suggest that Gadamer's primacy of applicabon to theunderstanding of texts cem also he applied to understand-ing health environments In the current study I use layersof interpretabon from a vemety of sources to make a con-stmcbon of a health, social and political situation At thesame time I accept that the ememcipation I envisage is nomore ahsolute than any other ideal I acknowledge that Iam hnngmg to the mterprebve framework a 'prejudice'ahout what consbtutes social good and that all I can do isto acknowledge this view openly I conclude thatGadamer's post-modem sensibility regarding the text, andthe framework of Guba & Lincoln's fourth generabonevaluation are compatible withm a hermeneutic inquiry

References

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Benner P & Wmhel J (1989) The Primacy o/Canng Stress andCoping m Health and Illness Addison Wesley Menlo Park,California

Beck C T (1993) Qualitative research the evaluation of its credi-hility, fittingness and auditahility Western Joumal of NursingResearch 15(2), 263-266

Beck C T (1994) Rehahility and validity issues in phenomenologi-cal research Western Journal of Nursing Research 16(4),254-267

Bhavanmi K -K (1993) Tracing the contours of feminist researchand feminist ohjectivity Women's Studies International Forum16 (2), 95-104

Breitmayer B J , Ayres L & Knafl K (1993) Triangulation m quali-tative research evEtluation of completeness and confirmationpurposes IMAGE Joumal of Nursing Research 25(3), 237-243

Bnnk P (1987) On rehahility and validity m qualitative researchWestern Joumal of Nursing Research 2, 157-159

Bleicher J (1980) Contemporary Hermeneutics Hermeneutics asa Method, Philosophy and Cntique Routledge and KeganPaul, London

Boyne R (1988) Interview with Hans-George Gadamer Theory,Culture and Society 5(1), 25-34

Colaizzi P (1978) Psychological research as the phenomenologistviews it In Existential-Phenomenological Alternatives forPsychology (Valle R & King M eds), Oxford Umversity Press,London, pp 48—71

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Denzm N & Lmcoln Y (1994) hitroduction entering the field mqualitative research In Handbook of Qualitative Research(Denzm N & Lmcohi Y eds). Sage, London, pp 1-17

Dreyfus H & Drejrfus S (1987) From Socrates to expert systemsthe lnmts of calculative rationahty In Interpretive SocialScience A Second Look (Rahmow P & Sullivan W ed).University of Califonua Press, Berkeley, California,pp 327-350

Dreyfus H (1987) Husserl, Heidegger and modem existenhalismIn The Great Philosophers An Introduction to WestemPhilosophy Magee B (ed) BBC, London pp 252-274

Gadamer H (1976) Philosophical Hermeneutics (Linge D ed),Umversity of California Press, London

Gadamer H (1989) Tmth and Method 2nd rev edn Revised andtranslated hy Wemsheimer J & Marshall D ContinuumPuhlishing, New York

Gadamer H (1987) The prohlem of historical consciousness InInterpretive Social Science A Second Look (Rahinow P &Sullivan W eds), Umversity of California Press, Berkeley,California, pp 82-140

Grondin J (1994) Introduction to Philosophical HermeneuticsTranslated hy Wemsheimer J Yale University Press, NewHaven, Connecticut

Giorgi A (1985) Phenomenology and Psychological ResearchDuquesne University Press, Pittshurgh

Guha E & Lincoln Y (1989) Fourth Generation Evaluation Sage,Newhury Park California

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Heidegger M (1962) Being and Time Translated hy Macquane J &Rohinson E Basil Blackwell, Oxford

Hekman S (1983) From epistemology fo ontology Gadamer'sHermeneutics and Wittgensteiman social science HumanStudies 6(3), 205-224

Hind P S , Scandrett-Hihden S & McAulay L S (1990) Furtherassessment of a method to estimate rehahility and validity ofqualitative research findings Joumal of Advanced Nursing15, 430-435

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APPENDIX

Franz Brentano (1838-1916)

German-Austrian philosopher who made an important contn-hution to empirical psychological philosophy particularly themental concept of 'lntentionality' or directness to ohjects Thisdescnption of lntentionahty is the view that consciousness isalways conscious of something

Marbn Heidegger (1889-1976)

German philosopher and student of Husserl Being and Time(1927) constitutes his magnum opus in which he explores thequestion of hemg He is the most original and influential philos-opher in the continental tradition Phenomenology, existentialismand deconstruction are his mtellectual traits as are many social-critical or neo-marxist strands of thought

Edmund Husserl (1859-1938)

German philosopher who is recognized as the founder of themovement known as phenomenology The main mfiuence onHusserl's thought was the intentional psychology of Brentanounder whom he studied in Vienna from 1884 to 1886 The influ-ence of Husserl's thought has increased in the shift from phenom-enology to existentialism Husserl's goal was to create apresuppositionless philosophy

Hans-Georg Gadamer (1900-)

German philosopher whose main contnhution is the developmentof the idea that hermeneutics is the most fundamental aspect ofall disciplines Hermeneutics is the theory and practice ofinterpretation (e g cnticism of hihlical texts) hut this concept hasheen extended to cover the whole of human existence andhas heen made a hasis for a projected science of the human asdistinct from the natural world Hermeneutics is now conceptual-ised as an approach to analysis of texts that stresses that prior

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understandmgs and prejudice shape the mterpretive processGadamer suggests that that while some mterpretabons are hetterthan others, none can ever he final

Alfred Schutz (1899-1959)

Austnan sociologist who emigrated to the United States in 1939Schutz developed phenomenological sociology In order to graspthe work of Schutz it is necessary to appreciate that of Max Weherand Edmund Husserl, hefore understandmg the synthesis of soci-ology and phenomenology The mam thesis of his work is theanalysis and descnption of everyday life (the life world) and itsassociated states of consciousness In the process of the studyjudgements ahout the social structure are 'hracketed off'

Mead George (1883-1931)

Amencan social psychologist who is associated with the Chicagoschool, and was influential in the development of s5Tnholic inter-actionism The intellectual roots of the concept of self, as devel-

oped hy Mead argue, that reflexivity is crucial to the self as asocial phenomenon Mead hased his role theory upon this aspectof human hehaviour In Mead's philosophy a person's sense ofself emerges through social interaction, and the relationshiphetween the self and society is an ongoing communication ofsymholic commumcation The grounded theory method devel-oped hy Glaser & Strauss (1967) takes a S3miholic mteractiomstpersf>ective

Max Weber (1864-1920)

German sociologist whose main contnhutions to modem socialscience are m the areas of rationalization, the protestant ethicthesis, analysis of power politics in relation to German societyand in the philosophy of social sciences particularly his analysisof the methodological and philosophical prohlems of sociologyWeher started hy definmg sociology as a science which attemptsto understand social action mterpretatively and to explain it caus-ally in Its course and effects Weher's famous concept of verstehenIS closely connected with his theory of suhjectively meanmgfulconduct

184 @ 1996 BlackweU Science Ltd, Joumal of Advanced Nursing, 24, 174-184