But is It Hermeneutic Enough ?: Reading for Methodological Salience in a Scoping Review of Hermeneutics and Implementation Science

Abstract

Hermeneutic methods have been widely used in health research. Through conducting a scoping review of hermeneutic studies related to implementation in healthcare, we identified various approaches and common strengths across studies. The review was part of a larger study exploring how hermeneutics could contribute fresh perspectives to implementation science. We looked at a large number of studies that reported some use of hermeneutics with a focus on what they had to say about processes of implementation in health care environments. While meeting our primary goal of identifying what was salient to implementation, we came up against the question of what made for a strong hermeneutic study. Through an extensive process of evaluation and discussion, several common elements emerged across studies that used hermeneutics: participatory conversations, reflective spaces, attention to alterity, and close-up granular detail. In this article, we outline the review process, then focus on six articles that met our criteria for relevance to implementation and hermeneutic strength. We discuss how some or all the common elements appeared in the articles, despite wide variations in topic and in how hermeneutics was applied. We argue that strength in hermeneutic research stems from a dialectic between applied principles and outcomes.

Hermeneutics has become a commonly used term in qualitative research literature from nursing and other practice disciplines. It indicates a cluster of interpretive methods that can trace their principles and priorities back to the work of hermeneutic philosophers such as Gadamer and Ricoeur. In the course of a scoping review about implementation science and hermeneutics, we looked at a large number of studies that reported some use of hermeneutics with a focus on what they might have to say about processes of implementation in health care environments. While meeting our primary goal of identifying what was salient to implementation, we came up against the question of what made a good hermeneutic study. We have discussed the implementation focus elsewhere – in the present paper, we consider our criteria for good hermeneutic work in qualitative research. We discuss the papers we selected in the latter stages of the scoping review to highlight what it was we found made them effectively “hermeneutic.”

Hermeneutics in Research

Before getting to a detailed discussion of sources from the scoping review in terms of their hermeneutic effect, we need to outline the context and philosophical antecedents of hermeneutic research that formed the background to our review. Hermeneutics is now well established as a source for methodological guidance in qualitative health research, particularly in nursing. It is an approach to research that is firmly rooted in the philosophical tradition of hermeneutics. There are core common principles in hermeneutic philosophy, as well as some divergent points of emphasis among different authors. We outline here the common themes and some of the differences to suggest how its uptake in research reflects the philosophical sources, which in turn helps explain subsequent adaptive variations introduced by researchers.

Hermeneutics is a branch of 20th century Continental philosophy that developed out of phenomenology and Heidegger’s ontological concern with being-in-the-world as an interpretive struggle for meaning. This is why hermeneutics is sometimes paired with phenomenology in research literature. As one of our selected sources stated, “Heideggerian hermeneutics is a phenomenological research approach introduced into nursing by Benner” (Darbyshire, 1994, p. 860), referencingPatricia Benner, 1984 landmark phenomenological study of how nursing expertise develops through practice. Other researchers have argued for a greater distinction between phenomenology, which lays emphasis on close description of the structures of phenomena, and hermeneutics which emphasises interpretation that is necessarily a product of language and historical context.

The two most significant figures in the development of hermeneutic philosophy in its modern form were Hans-Georg Gadamer and Paul Ricoeur. Respectively, German and French thinkers, they published their first works about hermeneutics, independently of each other, in 1960. Whereas Gadamer continued to refine his ideas about hermeneutics for the rest of his life (he died in 2002 at the age of 102), Ricoeur focused on a variety of topics throughout his career, giving varying degrees of prominence to hermeneutics (Grondin, 2014). They had some fundamental points of agreement as well as some differences. We review those briefly as far as they are relevant to health research and our scoping review. Both thinkers saw interpretation as fundamental to human understanding and argued that interpretation is always contextual and influenced by culture and history in ways that are often beyond individual awareness. They placed great emphasis on language as the medium for understanding and on dialogue, with others, texts, or symbols as a vital way of gaining new perspectives from outside of our existing viewpoints (Grondin, 2014).

For the purposes of hermeneutic research, the most noticeable difference is that Ricoeur (2007) showed some influence of French structuralism in his account of textual interpretation. He devoted more attention to how interpretation is carried out in contrast to Gadamer’s emphasis on interpretation as a part of how human beings make sense of the world. Researchers who cite Ricoeur will sometimes say they make an initial “naïve” reading of data before analysing it more closely based on his account of apprehending the structure, or overt meaning of a text before reading it with a more critically interpretive intent (Ricoeur, 2007).

These variations, however, are in the end less important than the impetus behind the application of hermeneutics to research in health care. Caputo (2018), a philosopher, has written about his engagement with scholars and practitioners from nursing and other practice disciplines who have taken up hermeneutics. He captured the hinge-point between philosophy and health research, writing “Hermeneutic judgement inhabits the distance between the universal and the individual, negotiating the difference. The nursing station is strategically positioned at that point in between the calculable and the incalculable” (Caputo, 2018, p. 229). Hermeneutics is one way of meeting the need of health researchers to find rigorous ways of investigating actual practice in which scientific knowledge and institutional rules interact constantly and messily with the contingencies of unique human lives and experiences.

Nevertheless, there is a difficulty in applying principles from hermeneutic philosophy to research because of the distance between the two. Nowhere does Gadamer or Ricoeur give directions on how to conduct hermeneutic research into health-related areas of relational experience. During our scoping review, we looked primarily for relevance to the subject matter of implementation, then for expression of core hermeneutical principles more than theoretical exposition. When we stood back and reflected on the papers that we finally included in the scoping review, we realised that there was a surface diversity in hermeneutic approaches. This gave us the opportunity to consider more closely what it was about these five papers that made them “hermeneutic.”

Our research team for the scoping review included five nurse academics who have worked with hermeneutic research and could draw on a wide range of reference including the foundational figures of Heidegger, Gadamer, and Ricoeur and more recent contributors to hermeneutic philosophy such as Davey (2006), Grondin (1994), Caputo (1987, 1993, 2018), and Kearney (2001, 2002). Our guiding imperative was that there are topics of interest to researchers in practice disciplines that need to be understood not only in terms of personal experiences (as in much qualitative research) but more deeply, and more complicatedly, in terms of temporal, cultural, and institutional contexts (Moules et al., 2015). Among our final five studies, the space between philosophy and health research was traversed in different ways with varying degrees of explanatory methodological detail.

Scoping Review

In the course of the scoping review, we began with 2415 sources that we reduced to 282 for full text review, from which we identified 27 as potentially useful, and finally to five articles that we felt fully met our criteria (yet which we still continued to debate). In the earlier stages of screening, first of abstracts, then 282 full text articles, we worked in pairs using an online platform, DistillerSR, to compare notes and resolve any conflicts between reviewers. We discarded most articles early on because they did not meet one or more of our basic criteria of relevance: they needed to be about health or health care, implementation, and to make use of hermeneutics. The review process will be described in much greater detail in a forthcoming paper. For the purposes of the current article the relevant point of judgement is where we decided that articles met criteria of being about health care and implementation, but they were not hermeneutic enough. One of the most frequent reasons for making this judgement was seeing a pattern of reporting data organized into themes with little theoretical or analytic work to make connections between data and any wider context. Such studies may afford some descriptive information about a given topic but typically fail to engender any new insights or understanding (Paley, 2017; Thorne, 2016). We already identified this as a weakness in some studies in the second stage of review from 282 to 27 articles where other criteria of relevance were also in play. At the next stage, we looked more closely at the strength of how hermeneutic principles appeared in studies. For example, we evaluated uses of dialogue to open up understanding and attention given to diverse viewpoints. We looked at consideration of contextual factors in implementation processes and how attitudes and beliefs could shift over time. In the following sections, we discuss our reasons for putting aside 22 articles in the penultimate stage of review, to delineate our criteria about being sufficiently hermeneutic. We then focus on the strengths we saw in our final selection of five articles, and on the variations from our starting assumptions around what hermeneutic research looks like.

Looking for Effective Hermeneutics

By the point we had narrowed our selection down to 27 articles, we had already decided that each did have some relevance to implementation in healthcare and that they made use of hermeneutics in their study design. We also noted that these studies often incorporated hermeneutics into implementation in some way, for example, through creating forms of reflective space in which discussions of care could happen. To evaluate the final 27 we met as a team (face to face, in the last days before COVID lockdowns came into force) and discussed each article. At this stage, our decisions became less clear-cut than in earlier rounds, since there would be a range of opinions, and the final decision to include or exclude was based on a consensus reading of the paper as a whole. A decision to exclude reflected a variety of interwoven concerns about the value of the findings to our study goals and the strength and congruency of the method. If there was an overriding deciding element, it was the sense of potential effectiveness in the world, not necessarily in the form of concrete proposals for change, but of tussling with a problem cogently in the contingencies of real-world practice.

Where we decided that papers were not sufficiently hermeneutic, that usually meant that analysis and findings defaulted too much towards the qualitative research lowest common denominator of organization into themes. Researchers conscientiously derived their themes from examination of interview data, but themes were more organization of material than a means of advancing analysis. In many cases, there was also an emphasis on phenomenological description over interpretive analysis, in some cases associated with a reading of Ricoeur in his more structuralist approach to textual analysis (Charalambous, 2010). Presentation and analysis of results did not necessarily correlate with the philosophical preamble in the paper. There could be a disjunction between philosophical rhetoric and analytic delivery.

For example, the authors of one study of experiences of family carers (Anker-Hansen et al., 2019) stated their “inquiry was framed by Gadamer’s philosophical perspective on hermeneutics” (p. 4) and gave a brief outline of Gadamer’s ideas. However, in their findings section, they organized interview data into themes, sub-themes, and finally “meaningful units” (p. 4) which simply served as ways of labelling similar points expressed across the interviews. At times, themes bordered on he commonplace, such as the observation that “emotional work is a common experience in the care partner role” (p. 6). None of this is to say that the study, and the data as reported, did not have value in bringing forward details of the experiences of family carers, in relation to the homecare policy environment in Norway where the study took place. However, there was a disjunction between the interpretive work demanded of researchers, implied by the use of hermeneutics, and the flatness of the findings.

In another example, in a study of parents’ experiences with their children receiving radiotherapy (Gardling et al., 2017) the theoretical framework at some points added unneeded complication. The authors followed “a hermeneutic-phenomenological approach inspired by van Manen” (p. 141) and used his four-part framework of “lived space, lived time, lived body, and lived human relations” (p. 145) to guide their analysis. However, the framework did not necessarily add any depth of insight to the findings or discussion. One conclusion, for example, was that parents “felt in their bodies” their children’s anxiety, which “prompted them to act in a way a parent should, which relates to lived body” (p. 145). It is a vivid observation, but hardly unexpected that parent-child empathy is deeply felt and that parents care for their children (leaving aside the normative “should” and its implications). Simply adding that it is an embodied experience fails to provide any detail of what it means to people, or of practical implications for healthcare providers.

Amongst the 22 papers rejected at the final review stage, we did find elements that were also present in the final five. Two studies for example used a participatory research design, where hermeneutics was used in data analysis (Dellenborg et al., 2012; Lindwall et al., 2018) but we found the analysis lacked depth or sufficient critical distance from the raw data. Several studies identified the need for some form of reflective space in which practitioners could make sense of problems arising in practice, as did two of the final five included in the scoping review (Darbyshire, 1994; Larsson & Blomqvist, 2015). Carlsson et al. (2014) for example described a project in Sweden of introducing Reflective Teams into clinical settings to facilitate discussion around practice. In our judgment, however, the hermeneutic analysis lacked depth, and relied too much on description such as observations about the difficulty of scheduling group meetings for busy clinical teams.

Through reading the 27 articles closely and discussing them extensively as a group, we developed the sense of a continuum of hermeneutic strength, which could not readily be judged against a checklist of hermeneutic principles. We found ourselves using a lexicon of words like “superficial,” “flat” or “mundane” where we set aside articles as not delivering strong hermeneutic analysis of the topic. Our judgements about the papers treated them as a whole, so that we were not looking for hermeneutic orthodoxy, but for an imaginative application of hermeneutic principles to a topic of clinical value and salience to implementation. This is how we differentiated among the 22 articles we rejected and the five we retained.

Hermeneutics in the Five Retained Articles

The five articles selected for final inclusion in the scoping review were diverse in subject matter and approach. In this section, we give a short outline of each study and discuss what it was we saw as “hermeneutic” in the context of our scoping review. We address the sources that authors cited for their hermeneutic methodologies and salient principles that we found in the papers.

Darbyshire (1994) designed, implemented, and evaluated an undergraduate nursing course in Scotland using arts and humanities to cultivate deeper understandings of human experience, develop analytic abilities, and create a community of learning. He emphasized dialogue in constructing a course that gave plenty of room for students to discuss materials from the arts and humanities in relation to aspects of nursing and health. Evaluation followed the same underlying principles, using focus groups to gather students’ thoughts about the course and to draw on the community of learning that had developed.

Darbyshire’s article from 1994 is considerably older than the others, which go back no earlier than 2014. He made far more use of Heidegger than Gadamer, referring to “Heideggerian hermeneutics [as] a phenomenological research approach introduced into nursing by Benner” (1994, p. 860). The strength of Darbyshire’s (1994) article from the standpoint of our review was the congruence between activity and hermeneutic principle. The objective of using materials from the arts and humanities is itself congruent with hermeneutic philosophy. Darbyshire used Heidegger’s hermeneutic-phenomenology to advocate for arts and literature as conduits into “the nature of the lived experience of illness, health, disability, dying or other human experience” (Darbyshire, 1994, p. 858). Interpretation was then incorporated into the assessment of the course, giving students wide scope to search for examples of arts and literature and giving grades for interpretive thinking and openness to others’ ideas. Likewise, the evaluation of the course was carried out using focus groups in order to provide a space of reflective dialogue in which students could share their views and shape them in conversation with peers and group facilitators.

Greenhalgh et al. (2017) carried out a hermeneutic systematic review of how telehealth has been taken up for patients with heart failure. Their review was wide-ranging, encompassing basic medical science about heart failure and treatments, and qualitative studies of the experience of living with heart failure. Their approach enabled them to discuss their findings in relation to each other, to note discrepancies between objectively desirable outcomes and actual patient experience, and to make concrete recommendations for greater use of qualitative and participative research methodologies.

Their “hermeneutic systematic review” (Greenhalgh et al., 2017, p. 1) of telehealth in management of heart failure used a method designed by Boell and Cecez-Kecmanovic (2014), who cite Gadamer as well as Ricoeur, Heidegger, Schleiermacher, Kearney, and Wittgenstein in their paper laying out a hermeneutic approach to literature review. Boell and Cecez-Kecmanovic’s approach to literature review consists of two interacting cycles of searching and accessing literature, and analysis and interpretation. New cycles of searching can be instigated by the development of new arguments as reviewers critically read and assess the literature. The review process thereby embraces the interpretive efforts of the researcher in assessing literature for its quality and relevance, seeing it as an intellectual endeavour that requires recursive reading, critical engagement, writing, and more reading.

By using the hermeneutic review approach, Greenhalgh et al. (2017) arrived at a wide-ranging review from which they made clear arguments for seeing tensions between contrasting groups of literature in an application of the hermeneutic principle of working with difference through dialogue. Literature about heart failure as a clinical condition, and treatment recommendations based upon it, often ignored the realities of living with heart failure and the resulting obstacles patients experienced in following treatment plans. They identified the resulting contrast between “‘cold’ biomedical practice…focused on data exchange and…outcome measures” (p. 12) and “a ‘warm,’ relationship-based, adaptive practice that engages with the patient’s unique predicament” (p. 12). The review method allowed them to bring two streams of literature into dialogue with each other, in order to highlight differing horizons of attention and to critique one body of literature in terms of the other.

Larsson and Blomqvist (2015) studied pain assessment among a group of six staff on a musculoskeletal rehabilitation unit in Sweden. They ran a series of eight focus group sessions over five months and reported on changes in how participants talked about patients, their perceptions of pain, and intra-team attitudes over the course of the group’s life. Their headline method was participatory research, using hermeneutics in data analysis.

Although Larsson and Blomqvist (2015) did not discuss it in any detail, they have their main source for hermeneutic analysis as Nystrom et al.’s (2003) “lifeworld theory approach” (p. 761). They described it as an approach that emphasizes concrete description of experiences and attitudes found in real-world settings. In spite of mentioning Gadamer’s recognition that we always bring assumptions into how we make sense of the world, they argued such assumptions should be “withheld” (p. 762) which sounds similar to the practice of bracketing associated with phenomenological research. It was difficult for us to discern, from the paper itself, how philosophical sources were being mediated to arrive at research process decisions.

They described how they organized data into “key topics” (p. 468) of how participants talked about patients, their own roles, and team relationships. Then, “meaning units were identified in the text, and a tentative interpretation was made” (p. 468). Both the phrase “meaning units” and the passive voice in this sentence hint at the phenomenological emphasis in their analysis. There is an absence of an active interpreter who might look beyond the data itself to develop interpretive accounts in relation to relevant theory or literature that bring new insight to the topic of research.

In the case of this study, it was not the direct claim to hermeneutics that we found useful so much as an implicit evocation of hermeneutics in the participatory design. The thematic analysis of the data is just that, organization into three subjects that occurred repeatedly in interviews. However, what separates this paper from many other thematic studies is its temporal dimension. The data were not derived from single interviews about the topic of the study, but from a series of seven focus groups. Participants therefore had opportunities to test out ideas with each other in group sessions, as well as reflect on what had been said between groups. The findings show a clear process of changing understandings in each of the themes over the course of seven sessions. The hermeneutic principle of shifting understanding through dialogic exchange was enacted in the conduct of the project itself.

Thirsk et al. (2014) conducted a hermeneutic study of how registered nurses in Canada addressed psychosocial issues for patients with chronic renal disease and their families. Based on interview data, they identified that nurses tended to over-emphasize individual responsibility for health behaviours and pay less attention to complex contextual factors that affected patient attitudes and choices. In their discussion, they introduced attribution theory from psychology to make sense of this phenomenon and to propose using more contextualized, social models of health in nursing education and research to influence practice.

Thirsk et al. (2014) described their research as “hermeneutic inquiry as guided by Gadamer’s philosophy of understanding” (p. 2117). They made use of several secondary hermeneutic sources from research literature (Koch, 1996; Moules, 2002; Moules et al., 2004) in addition to Gadamer’s (2004) original work, especially in the sub-section about methodological rigour. This section brings hermeneutic principles into the frame of research, for example, in the assumption of the richness of individual cases (Jardine, 1992) and relation of parts of the data to the topic as a whole (Moules, 2002). They noted that they turned to previous literature in response to emergent interpretations as they analysed data (Jardine, 2006).

Based on close reading of how nurses talked about patients’ health behaviours, the researchers noted nurses’ often over-emphasized personal choice without taking into account other factors of socioeconomic status, education, or system needs. Using attribution theory to analyse their data, they were able to build a coherent argument that false attribution of others’ motives can affect how nurses work with patients, and consequent health outcomes. Attribution theory thus introduced a new horizon of understanding serving to articulate new understanding of their topic and in such a way that a renal nurse reading the article could identify specific ways to be mindful of their communication and to avoid misattribution of motives to patients and families.

Xiao et al. (2018) explored cross-cultural diversity in older adult care homes in Australia and how it affected communication between staff and residents, in varying configurations of cultural difference among and between the two groups. They interviewed residents and family members and ran focus groups with staff members. They framed their data analysis using Giddens’ (1984) structuration theory to draw out interactions between individual experiences, roles, and institutional factors to arrive at implications for individual and managerial level practices.

Xiao et al.’s (2018) work was more complicated in the way hermeneutics finds its way into their study. They used the term “double hermeneutic” (p. 3) taken from Giddens (1984), who drew on Gadamerian hermeneutics as one among many sources in creating a theory that is sociological in focus. Although he makes use of the central idea of fusion of horizons, he gives it a turn towards social and institutional structures that shape meaning for human agents, in contrast to the original focus in Gadamer on encounters between individuals or with texts (Kilminster, 1991). Nonetheless, Xiao et al. did pay close attention to individual interactions within an institutional setting.

One feature of Xiao et al.’s (2018) study of cross-cultural communication in care homes that marked it out as hermeneutic was that participants were drawn from residents, family members, and staff members. They gathered data from both sides of the institutionally constructed dialogue passing between providers and recipients of care (including family members). Hermeneutic research often includes only one group or another, on either side of a structured dialogic situation. In health care research, this is generally a clinical staff group such as nurses and a patient or client group defined by a feature such as diagnosis or care setting.

Another strength of Xiao et al.’s (2018) study was that they identified the polyvalence of cross-cultural communication in the care homes without making rigid a priori assumptions based on group identities. They recognized – in a phenomenological, descriptive way – that cultural diversity was a feature of both care provider and resident groups, creating many different possible combinations of cultural backgrounds, first languages, or degrees of fluency in a shared language, generally English.

How Hermeneutic Principles Bring Strength to Research

Members of the research team with the greatest previous involvement in hermeneutic research were the most surprised by the differences in approach among the final five papers. There was little hermeneutic uniformity in method, but instead a pluralist, flexible use of hermeneutic principles. Reading back into our review process and discussion we identified some threads that recurred in some or all of the five papers. In each case, we found there was a clear element of application, where hermeneutic principles were brought to life in the conduct of the research.

Participatory Conversations

Darbyshire (1994) and Larsson and Blomqvist (2015) both had elements of participation in their projects. They did not simply interview participants post hoc about a topic of interest, but ran a project over time in which students (Darbyshire) or healthcare providers (Larsson and Blomqvist) took part, and then were also interviewed as research participants. Data came from the processes of the projects as well as later reflection. There is an affinity between participatory research and hermeneutics where dialogue, which lies at the heart of hermeneutics, is part of a project. This was the case in both of these studies.

Darbyshire’s course was designed around opportunities for discussion among students of problems they encountered in learning nursing, using affordances of artworks and literature to articulate nuanced aspects of human relationships. Larsson and Blomqvist used a form of group clinical supervision to focus on one issue in care, that of pain assessment. Through talking with other practitioners in a safe environment, away from the immediate exigencies of providing care, dialogic process led to a widening of perspective and greater empathetic appreciation of the situation of patients and other team members. Hermeneutics is also consistent with the movement towards patient-oriented research (Canadian Institutes of Health Research, 2021) that includes services users’ voices in research processes.

Gadamer’s concept of “fusion of horizons” (2004) is based on the idea that different participants in a dialogue each bring their own perspective, or horizon. It is through open exchange of positions, that there can be a meeting of horizons, not necessarily leading to agreement or sameness, but to a shift in thinking through a widening of the available horizon. Inclusion of service-user perspectives is an example of this, and one that has obvious relevance to implementation science. One of the strengths of the Greenhalgh et al. (2017) review was the juxtaposition of scientific evidence about heart failure management with qualitative studies about what it feels like to have heart failure. Although in the form of a literature review, not a participatory study, the authors nonetheless demonstrate a fusion of horizons in discussing their findings.

In two studies (Darbyshire, 1994; Larsson & Blomqvist, 2015), there was a blending of the phenomenon being studied and the method, a kind of doubled application. The principle that dialogue opens up possibilities of new understanding was applied in the student classes and group supervision respectively, and then further applied by using interviews to evoke reflections from participants about their experiences. By contrast, Greenhalgh et al. (2017) applied the dialogic principle to texts so that differing kinds of data about the same phenomenon could be read against each other to evoke new insights of relevance to practitioners.

Reflective Spaces

A second feature was the need for reflective space in which understanding can happen. In some instances, the creation of space was part of the topic being studied, as with Larsson and Blomqvist’s (2015) discussion groups, which met seven times over five months. In Thirsk et al.’s (2014) study, the reflective space was part of the research process. Part of the researchers’ data analysis was to introduce a body of theory that shed light on the interview data. Through discussing their data in relation to attribution theory they were able to move beyond reporting on the experiences of health care providers and set those experiences against a wider, critical horizon. As a result of moving into a reflective, discursive space of analysis they could articulate well-argued recommendations for improving practice by paying greater attention to what patients have to say and withholding judgement.

Reflective space is one of those nice terms that meet with general approval and yet the studies also point to the challenge of making space inside actual institutions and routines. One of the implications for application in these studies is the need for a commitment to literally scheduling and reserving temporal and physical spaces for people to gather and reflect. Caputo (2018) noted the significance of institutions for applied hermeneutic work, since “…interpretation is not a free-floating immaterial spirit. It is stubbornly stuck in the glue of institutional life…” (p. 220). It is beyond the scope of this paper (thankfully) to find solutions to the real-world challenges of making space but highlighting this as a theme does draw attention to how good hermeneutic studies have paid attention to the limits and affordances of institutional life.

Paying Attention to Alterity

Attention to alterity is a persistent thread in hermeneutic philosophy, implicit in any dialogic encounter, and made more explicit by writers after Gadamer such as Caputo (1993) and Kearney (2002). Gadamer implies respect for the other in the primacy he gives to conversation, in which listening is at least important as speaking, and with an effort to remaining open to hearing what the other person has to say. More recently, Kearney (2002) argued for the role of discernment in making out what the other presents and what kind of response is demanded. Xiao et al.’s (2018) study exemplifies the concern for alterity by addressing the issue of cross-cultural communication in nursing homes in Australia. Both resident and staff groups and multicultural and multilingual, so that the problem is not about training staff but of facilitating good communication amidst a multitude of possible cross-cultural combinations. Thirsk et al. (2014) identified a failure of good discernment where nurses’ assumptions about patients got in the way of accurately hearing their needs.

Paying attention to alterity is crucial in applying hermeneutics to research if findings are to go further than communicating accounts of experience, even though that alone can be valuable in allowing ignored or muted voices to be heard. For Xiao et al. (2018), alterity was already present in the object of study and readily apparent. Through attention to an instance of difference within an institutional set of structures, they were able to put forward solutions, at different levels of influence, to the problem of speaking – literally – across barriers of language and culture. Thirsk et al. (2014) noted a problem of alterity that showed up in their data, and for them application was more a matter of articulating the problem and then proposing solutions. Greenhalgh et al. (2017) made use of alterity when they found a fissure in the literature which allowed the authors to better understand two perspectives, each in the light of the other.

Close-Up Views

Another feature of strong hermeneutic research lies in confirmation of its roots in phenomenology. Our final five studies all contained an element of fine-grained description, of close attention to the phenomenon in question, almost as if slowing it down and zooming in for close-up images. Studies that rely solely on interview data tend to miss this component, where impressions of participants are simply reported without the researchers contributing a coherent frame of reference for the data. The intention in this style of research is stated as representing the phenomenon, but it cannot always do that effectively when it is actually reporting what people said about the phenomenon when removed from the actual events being examined.

Phenomenological close attention ought to be applied in good hermeneutic research because of its “commitment to studying the lifeworld and, in particular, situated human action” (Moules et al., 2015, p. 63). New understanding that is worthwhile has to be based upon a detailed view of the phenomenon of study, in actuality as well as in relevant literature, such that findings are persuasively connected to what is already known.

Conclusion: What Is Hermeneutic Enough?

By closely reading hermeneutic health research literature for relevance to implementation, we developed criteria of quality that did not fit with any particular approach to hermeneutics in research. On reflection, this is not surprising. Gadamer or Ricoeur never considered the application of their ideas to health care research, even though Gadamer (1996) did engage with medical audiences around questions of health and illness. We did find, however, congruence between hermeneutic principles and those papers we found the most helpful in our scoping review. One characteristic is the active use of dialogue, looking at texts, statements, beliefs, points of view, in relation to others such that it creates a need for new understanding or insight to take shape to be able to articulate a fresh horizon of understanding. The combination of two kinds of research findings by Greenhalgh et al. (2017) in the form of a literature review is a good example of this principle at work, with only second level use of actual interview dialogues from studies included in the review. Alertness to context is another vital hermeneutic principle, that understanding is always based upon existing assumptions that in turn lead back into acquired traditions and ways of seeing (health care providers in contrast to health care users for example or differing professional perspectives according to acculturation in a specific discipline). Context as an influence on how we understand can also be seen in the way structures and institutions embody traditions and assumptions, which in turn set limits and affordances for those inside them (Ricoeur, 1995).

Our scoping review was about hermeneutics and implementation. Inevitably, as the metaphor of horizon would lead one to expect, our choice of papers was determined by the theme of implementation in relation to hermeneutics. We cannot assume that these five papers, or even the 2771 papers in the first round of review, are representative of the whole field of hermeneutic research. We have emphasised application in the discussion of strengths in ways that might not always be so important for research that is less concerned with concrete implementation. Nevertheless, by trying to answer the question of what makes for strong hermeneutic research, the lens of implementation enabled us to focus on recurrent hermeneutic principles that contributed to what we judged to be stimulating and useful pieces of research.

In the end, what we decided was effective hermeneutic research was the result of dialectic between applied principles and outcomes. There was not an obvious methodologic orthodoxy at work, but even where papers were light on theoretical exposition, we could see the application of hermeneutic principles at work on a concrete topic. Where the process also produced persuasive insights that could inform practice, beyond reporting of unsurprising observations, we saw the purpose and value of hermeneutic research come to life.

Epilogue

As we moved into the data analysis phase of the study in Spring 2021, we recognized we needed to update our literature review which had been completed originally in February 2020. Following the same search terms and databases, we identified 356 new articles for review. In the final stage, of full group discussion, we selected one article out of five that met our criteria of relevance to implementation in healthcare and hermeneutic strength.

We chose to represent the updated search as an epilogue to the main paper, which had been fully drafted by the time we had finished the second review process. Our “horizon” of understanding of what made for an effective hermeneutic study had been shaped already by going through the first review process, including lengthy discussions among the whole team. It is consistent with the hermeneutic idea of iterative, dialectical development of understanding to show the temporal progression of our search in the context of this paper.

The one article we added (Hughes et al., 2020) shared two authors with one of our original five (Greenhalgh and Shaw were co-authors also of Greenhalgh et al., 2017), which followed the same mode of hermeneutic literature review (Boell & Cecez-Kecmanovic, 2014). The subject matter of the later article was more conceptual, attempting to make usable sense out of disparate understandings of integrated care. The authors’ hermeneutic approach allowed them to articulate differences in how the concept of integrated care was used in the literature with the goal of helping researchers or policy makers to make more precise, well defined use of the concept. Hermeneutically, the review showed a plurality of possibilities, influenced by practice context and project goals, without striving to impose any one formula. By contrast with the earlier paper, it lacked the human, experiential dimension of the authors’ distinction between “warm” and “cold” ways of studying people with heart failure (Greenhalgh et al., 2017). However, this was a function of the subject matter and methodologically the authors again used hermeneutics to generate more complex and thus more realistic accounts of phenomena in healthcare lifeworlds.