Epistemic Justice,Navigating a Moving Horizon

Abstract

As a participatory action researcher, I guided a team at a children’s hospital to develop learning during the bedside ward round. Yet, no sooner than at the end of the research I realised that I was not so much the emancipating guide I thought I was. Instead, I re-enacted the hierarchical pattern. In this autoethnography I aim to explore my capacity to respond to the ethical and activist call for epistemic justice. The co-authors and I jointly analysed the emerging patterns through the lens of complexity theory and theories of desire. I recognised that as a participant in a complex system I couldn’t control that all stakeholders were acknowledged as knowers by bringing them together. I participated in the pattern of the ward by sometimes moving along with existing hierarchical interaction patterns and at other times breaking them. My own desires for authority and belonging attuned me to similar desires in others. In hindsight I saw that desires drove participants to seek greater voice, that it was difficult to discern one’s own voice, and that the dominant voice changed per situation. Epistemic justice was not static but evolved throughout the study leading me repeatedly to revise my assumptions, I was navigating a moving horizon. I acted as a postilion d’amour, messaging experiences and assumptions participants did not dare sharing directly. In doing so, I fostered utilising everyone’s knowledge and experience, and I addressed conflicting views while maintaining connection to all. My autoethnographic story can sensitise action researchers to perceive their own participation in systemic patterns, the dynamics of hierarchy and belonging, and how they can in-fluence - though never fully control - the development of epistemic justice in research.

Prologue: The Last Meeting of the Research Team

It is a sunny morning when the last meeting of the research team at the children’s ward in a Dutch middle-sized hospital is about to begin. We hear a loud twittering sound. Through the large windows of the light white room, we can see a murmuration of starlings. They seem to be dancing happily in the sun before landing in a tree nearby.

I am still fiddling with cables and computers when my attention is captured by a conversation between nurses Esther and Carla. Esther: “Veronique the supervising resident was explaining to the resident what she could do better next time extensively, but she said nothing to me! Am I not important enough? Is it not interesting to teach me something?” At first it strikes me as uncomfortable, as if I, or we, failed to produce the planned progress improving the daily medical bedside visit. Yet almost at the same time I feel sort of proud that Esther by now expects that the doctors also pay attention to the teaching of nurses.

Ten minutes after the supposed start of the meeting the nurses, the patient’s representative Hedwig, ward manager Bea and project leader paediatrician Suzanne are all present. But both Arie, the supervising paediatrician, and Jolande, the resident ward physician are still absent. When Suzanne is speaking to Arie on the telephone, she answers him politely. But when she returns to her seat it shows that she is not amused. Bea asks: “Is he not in the house? “Yes, he is, he is on the outpatient clinic and so is Jolande”. Bea’s face, signals: okay, so he is not giving priority to the meeting.

My first reaction is one of despair. I prepared the meeting carefully, because for me this is the most important meeting of the research. We would finally discuss how they had learned to improve the medical visit as a team in the past year. That is the central research question about which I will have to publish. Until then, the team being occupied by realising the improvements, was not yet ready for answering that question. And just now the physicians are absent!

I conceal my disappointment and propose to start the meeting anyway and that if they will not show up, I will speak with them one to one. I present the findings of my last participant observation and interviewing round. Right from the start Esther and Carla are reacting to the findings and a lively interaction evolves. At some point they are discussing with Suzanne whether the nurses should present a 12-hour or a 24-hour summary of the patient’s condition during the medical visit. When the discussion comes to a close, I remark “Here it is happening, this is valuable. You are exchanging your expectations, experiences and perceptions and the end of the dialogue is that you have a shared sense of value of presenting 24 hours. It is these conversations that spurred the change in the ward over the last few months.”

At the end of the meeting, we are all very content that we had such a good meeting. We repeat that it is such a pity that Arie and Jolande, were absent.

When leaving the room with Hedwig she says “Well, it was not so bad after all, that Arie wasn’t here. Now there was much more interaction with and input from the nurses.” I agree with her. In earlier meetings the nurses only probed now and then single questions or suggestions, which seemed to fall like seeds on unfertile ground. Usually, Arie seemed too impatient for longer dialogues, and dominated the conversation.

Usually after the research meetings, the nurses took up the seeds and started to water them by initiating dialogues with peers, the ward physician, and in the end with supervisors Arie and Gert. Suzanne sometimes worked the ground by having a conversation with Arie one to one and by arranging a small, short meeting. I myself had one to one conversations with Suzanne, as well as with the nurses, and tried to support them in starting dialogues and in taking the lead, which they did. However, in hindsight I see that at the same time I re-established the status quo and power asymmetries at the ward. In the meetings I caught myself often glancing at Arie for agreement. As such I re-enacted the pattern and culture of sub dominance and felt incapable of mending that.

Afterwards, when I speak to Jolande, she explains why these long meetings, taking 1,5 hours, are difficult for the physicians. They are only with three, and the work of a whole day must be done anyway. Thus, usually halfway the meetings she starts to get distracted knowing the things she will have to do after the meeting. The day of the last research team meeting there were several acute patients that came to the ward via the emergency room. I think to myself “ah, so it was not just reluctance to participate”. When listening to her view on the learning in the project, I am caught by surprise about the beautiful insights she shares. She reveals that she strategically judges the success rate of an improvement plan and that she worked together outside the meetings with the nurses to prepare improvements at the ward. She says: “I think it is very important that you do it together and make the plan together. Thus, the process is just as important as the content.” She chuckles as she says: “Some of the changes are things I have already experienced very positively in other hospitals: the use of the whiteboard, a structure to fall back on, the struggle of who do you let speak first, involving parents beforehand but leaving the medical nursing part to the nurse. So those things, I think, are widely shared. So, it's actually the process of joint collaboration which is the learning here. This research created a nice team feeling to work on it.”

Why did I never hear these opinions and experiences in the meetings? She was always a good listener and usually agreed with Arie. I realise that I did not succeed at all in giving everybody a voice in the meetings.

When I speak to Arie by video call, the first thing he explains, is that it did not feel as his research. From his perspective it was thrown at him with little choice to refuse. In his opinion there were many time-consuming meetings while other projects of himself were lingering because of lack of time and attention. Having had a meeting only a few weeks before, he was annoyed about having a meeting again. He did not read his mail close enough to realise that the other meeting was a “catch up meeting” whereas this was the last research team meeting. Notwithstanding his annoyance, he probably would have come if there had not been so many acute patients. During our conversation his initial irritation softens. He is slowing down his speech, he becomes interested in the discoveries of the research and shows vulnerability by asking for feedback on his behaviours in the ward round. Also, he formulates: “In hindsight, I really like being involved in this, it's insightful”. “Basically, the nurses are far more important and influential to improve the ward round than we physicians are. They are there all days, we often no more than one or two days a week”. I’m caught by surprise, because during the research he seemed to feel the ward round as the responsibility of the ward supervisors and he usually was quite strong headed about the preferred solutions.

Musing somewhat after closing the call my interpretation of the events and my role in it changes again. I realise that the research team, including myself, did not only negotiate what was relevant in the ward-rounds, but also the relevance of the research and the relevance of each participant. I also realise that I was not so much the director of the process, but unconsciously I followed the pattern of the professionals. I did not change the hierarchy in the meetings. We all changed our perceptions and assumptions and addressed underlying conflicts and hierarchy by picking up the seeds sown in the meetings and by seeking dialogue in bilateral and smaller meetings. It did partially resolve the conflicts but more important, it created emphatic understanding for the other perspective and influenced positions and territories. In the end all seemed to be content with the results and their own contribution in it.

The Plan-Do-Study-Act cycles of the Participatory Action Research (PAR) were no more than the moving landmarks providing a sense of direction in the lingering route of a murmuration of starlings. And while progressing to the landmarks, the murmuration produced many beautiful forms that were not anticipated nor intended. We don’t know if starlings experience this as an effortless happy dance or as a competition for being in the lead. Bird twittering sounds joyful to us while usually bird songs are meant to defend or obtain territory.

Introduction

The prologue narrates my doubts about my capability as a participatory action researcher to give all stakeholders a voice in the participatory action research (PAR) study. I have already written several pieces wherein I reflect on my role as a PAR researcher, but I felt I needed a more in-depth analysis to deepen my understanding of how I might foster epistemic justice. In the paper addressing the central research question of the PAR study - how to learn and improve in the workplace? - a reflexivity section was included to disclose the authors’ theoretical predispositions and positionalities (van Harten et al., 2025). Elsewhere, the author team reflected on the action researcher’s role in catalysing transformation within the complex system of the ward (van Harten, Niessen, et al., 2025). Yet, I contend that my reflections on the doubts surrounding my efforts to nurture epistemic justice warrant an autoethnographic account, one that may resonate with fellow action researchers and attune them to their own (im)possibilities in advancing this core PAR principle.

PAR is underpinned by the ethical imperative that research must honour the interests of the individuals whose work or lives are under investigation and that their experiential knowledge shall be valued (Abma, 2020; Abma et al., 2019; Banks & Manners, 2012; Groot et al., 2019; Reason & Bradbury, 2001, p. 1). Consequently, the action researcher ensures that every participant has a voice and prevents marginalisation of participants who are already less heard.

I thought I had secured epistemic justice by gathering a PAR team with all stakeholders (see Table 1) in which they could voice their wishes and concerns.

Table 1.

Members of the PAR Team, and Other Persons Figuring in the Selected Scenes

PAR team
Nurses	Esther and Carla
Ward physician (resident)	Jolande
Paediatrician and project leader	Suzanne
Supervising paediatrician	Arie (gert being his back up)
Nursing ward manager	Bea
Parents’ representative	Hedwig,
A junior quality and safety advisor.	(Not figuring in the selected scenes)
PAR researcher	Annet.
Others participating in the ward rounds figuring in the scenes
The supervising resident in the last term of her education	Veronique
Senior supervising paediatrician	Gert

Epistemic injustice is a concept coined by Miranda Fricker (2007). She defines it as “A distinctively epistemic genus of injustice, in which someone is wronged specifically in their capacity as a knower”. She distinguishes between two forms: testimonial injustice, in which a knower is not acknowledged because of prejudices - such as the prejudice that medical propositional knowledge holds greater value than nursing or experiential knowledge - and hermeneutical injustice: in which one’s (tacit) knowledge is not acknowledged because language and concepts are not adequate to convey it. For instance, participants may lack the vocabulary to express their intuitive understandings or feelings in a meeting. To prevent this type of epistemic injustice some researchers have explored alternative modes of expression, including artistic representations, body language, or metaphors (Schuurman et al., 2025).

The concept of epistemic justice intersects with the notions of voice, emancipation and influence. Voice denotes the capacity to articulate one’s views and, importantly, to be heard, be recognized, and influence decision-making (Lawy, 2017). It becomes emancipatory when marginalised participants attain a position in which their voices are both heard and valued.

In this autoethnographic account I draw on two types of autoethnographic (AE) data: self-observation via recordings, and self-reflection (Chang et al., 2012, p. 74). Both types of data focus on the present, whereas AE often uses also archival data from the past or interviews to collect views on one’s own life, now and in the past, from different sources.

There are several first person action studies that reflect on the role of the action researcher and more specifically on ethics, power dynamics and culturally imbued perceptions (Barlas et al., 2005; Groot et al., 2019, 2020; Heen, 2005; Kara, 2017; Kroeger, 2023; Ramsey, 2005). Groot and colleagues argue that epistemic justice is not the sole responsibility of the action researcher, but a mutual responsibility (Groot et al., 2019). Another study describes the dynamic inquiry relationships between co-researchers in a PAR seeking to balance intimacy and confrontation (Abma, 2000). However, to my knowledge there remains a paucity of studies that illustrate the dynamic process of epistemic injustice in which testimonial and hermeneutic epistemic injustice are enacted alternately by different participants and evolve over time, making epistemic justice a moving horizon for the action researcher.

Furthermore, by thinking with theory on desire (Barlas et al., 2005; Groot et al., 2019, 2020; Heen, 2005; Kara, 2017; Kroeger, 2023; Ramsey, 2005) and complexity theory (Davis & Sumara, 2005b) I provide a new angle on this ongoing methodological discussion on epistemic justice.

My aim is to explore my capacity as a PAR researcher to respond to the ethical and activist call for epistemic justice within a change process at a Dutch hospital ward.

By choosing autoetnography as a writing strategy and using metaphors I can convey the multi layered and intertwined insights about the movements of the action researcher and the movements of the participants at the hospital ward. In the word movements I refer to the internal movements (drives, emotions) as well as the external movements (behaviours) related to epistemic justice.

Method

“What we understand autoethnography to be, dictates how we undertake it” (Stahlke Wall, 2016).

In this article I want to share stories of how I initially attributed emancipatory successes and failures to myself as the responsible action researcher, and how this perspective broadened in the course of events. It was not about successes and failures, not about responsibility, and it was not all because of me. The stories show the interaction patterns, the interpretations participants assign to it, the changes in the interpretations, and my role in it as a participatory action researcher.

There is methodological debate on what autoethnography should be (Denzin, 2006; Muncey, 2010, pp. 5-8). Some advocate the relevance of a strongly evocative story about the self and do not want to diminish the strength of the story by following the traditional scheme a scientific paper, where analysis and contribution to theory are imperative (Adams & Herrmann, 2023; Bochner & Ellis, 2016, p. 80; Davis & Sumara, 2005b; Pelias, 2018). Others emphasise that the purpose of narrative is to reveal a cultural sociological phenomenon, which should be addressed scientifically by showing rigorous method, theory, and analysis in which the self is connected to a particular ethnographic context rather than the focus of it (Anderson, 2006; Atkinson, 2006). In this paper I present an evocative story, but I do not leave it entirely to the reader to infer its meaning.

There is also a fine line between research reflexivity and autoetnography. Stahlke Wall (2016) for example states: “[..] the reflexive analysis of research experiences should not be labelled as autoethnographic. Even though they serve an important purpose, they are essentially methodological articles rather than explorations of substantive social issues.” This paper is primarily a reflection on my guiding role as action researcher and how I fulfilled the call for epistemic justice. Yet, as the reflection unfolded, it became clear that I was part of the system, the particular ethnographical context, and as such my reflections on hierarchy and inclusion revealed just as much about myself as about the others. Thus, the methodological reflection rendered a story that is not only relevant for other action researchers but also for patients, health professionals and hospital managers involved in quality and safety improvement. An autoethnography is the best form to convey this double-layered or intertwined methodological and ethnographic message.

Finally, there is a subtle difference between autoetnography and first-person action research. First-person action research involves “widening our awareness to include possible incongruities among our intent, our strategy, our actual performance, and our effects” (Torbert, 2001). Although in first person action research it is also relevant to show and not only tell to support one’s analytic claims, in autoetnography the story comes first and in principle should be able to convey it’s message by itself. As mentioned above, opinions differ on the extent to which additional analysis is required. Furthermore, in every action research whether it is first, second or third person, the action is central. It aims to bring about change in, for and with the actors. It is about reflection in action. This paper is situated in a PAR study but is not about the PAR study. It is the result of a retrospective reflection, to understand and inform future actions, instead of reflection in action to steer the course of actions at hand.

Autoethnography, as a research and writing strategy, is particularly well-suited to illuminate and make palpable a broader social phenomenon through a personal engaging story, often from a viewpoint that is usually concealed or silenced (Ellis & Bochner, 2000; Handbook of Autoethnography, 2013; Kara, 2017). By connecting the personal reflective account to a broader social phenomenon, and by critical reflection with more authors, one averts the risk of self-indulgence (Ellis & Bochner, 2000). Autoethnography requires a different evaluative framework (Adams & Herrmann, 2023; Nowell et al., 2017) and a different form of analysis. In autoethnography, the evocative or narrative aspect is crucial. A narrative supports a holistic understanding of simultaneous different layers and invites to hear what is silenced.

For this reason, this article began with a narrative prologue and will also include situational sketches in the analysis. Yet we also share our critical analysis and theoretical perspective because these directed our choices for what to narrate and what to leave out. Furthermore, the analysis may evoke the experience of re-interpretation of the story in the reader (Joe et al., 2012, p. 21) and therefore a reinterpretation of their own stories and experiences. A similar effect was noticed by Boal (Boal et al., 1990) when he invited audience members with ideas for change for the play on stage to demonstrate their ideas. He noticed that they not only imagined the change but started to practice it in daily life.

The empirical materials that informed the narrative were collected during (recorded) meetings with the research team (Table 1), in bilateral conversations, and during the three observation and semi structured interview rounds that were performed at the start of the PAR and after action cycle one and two. Table 2 gives an impression of the volume of the data.

Table 2.

Number of Observations and Interviews

Observation days	29
Observed visits	110
Interviewed parents/questionnaires	82
Interviews by telephone	33
Research team meetings	10

For the one-year study I made reflective fieldnotes. I selected the scenes for their learning potential. The first selection of scenes was made on their potential to illuminate how I felt about and acted in my efforts to establish a voice for all participants and acknowledging all sort of knowledge. A pivotal event was the realisation that I had been reinforcing hierarchical patterns. When discussing that event with the co-authors one of them remarked “Epistemic justice is not a responsibility, in the sense of accountability, it is about response-ability” (Haraway, 2008, p. 70) being able to respond, to be present, to take care. This shifted my perception, made me read additional theory, and influenced the analysis. The second selection was made to illuminate when participants felt they had (not) a voice and (no) influence and, how this related to observable behaviours and events, it shows the difference between feeling heard and being heard. The second selection was influenced by the discussion with my co-authors in which one of the authors remarked “as participant in a complex system you can’t direct the course of events, you can be present in them.” This again shifted my attention to how epistemic justice evolved in the interactions in the system instead of in the interactions with me or because of my actions.

For the analysis the authors used the method of “thinking with theory” (Jackson & Mazzei, 2013) to reflect on the patterns within the team and within the researcher. By “plugging in” theories, this method explores which new insights or narratives emerge. This method does more justice to complexity and generates new insights. The risk of analysing stories by deconstructing them into codes and categorizing these in themes, is that one reproduces well-rehearsed notions from earlier research and that all interesting contradictions and frictions in the data are removed.

The first theory that is plugged in is complexity theory (Davis & Sumara, 2005a, 2005b; Decuyper et al., 2010). The hospital or care unit is complex and unpredictable, and so is the research itself. Complex systems adapt and learn and transform as a whole. From this perspective, one focuses on recurrent patterns, that are slightly different each time and yet recognisable as similar. Davis and Sumara (2005b) see ‘occasioning’ as a critical skill for the researcher in complex systems: “[..] attending to and selecting from among those possibilities that present themselves to her or his awareness. In this sense conducting action research is about minding -being mindful in, being conscious of, being the consciousness of- the collective”.

The second theory or perspective that is plugged in is the social psychological and philosophical perspective on motives and desires. In this perspective humans are seen first of all as social beings, where the desire for belonging and hierarchical order are deeply embedded (Baumeister & Leary, 1995; Gere & MacDonald, 2010). Our primal desires to belong to a group and to cherish a hierarchy provide us with affection and security (Waal, 1989). Deleuze et al. (2009; Jackson & Mazzei, 2022, pp. 112-131; Verhaeghe, 2011) focus on desires as the motor for the affective connections that make it possible to navigate through the social world. They clarify how the desire for power and belonging function in daily situations, how the desires of individuals come together in the “desiring machine” and what is being produced by this machine (Jackson & Mazzei, 2022).

Consent for Publication

This article is not read in advance by the co-researchers in the action research, but they are just informed about the article. Together we did a study focused on a research question we chose together. All participants provided consent for participation in that study and for publicising about it. The publication about the PAR was co-authored by a co-researcher. However, this article is primarily about myself and my interpretation of situations. No doubt each of the co-researchers will have different recollections of how, when, and why things happened. A single event can produce many stories. Within autoethnography it is a discussion about how to deal ethically with the fact that an auto-ethnography also reveals information about other persons. Several authors argue that it is accepted to refrain from asking for consent or doing a member check depending on the situation. There are no clearly defined rules for that choice (Bochner & Ellis, 2016; Ellis, 2007; Tamas, 2011). In this case we chose not to do so because the participants felt already overburdened with work. A leading topic in the PAR study was the time they had to spend on the PAR study and especially the meetings in addition to their clinical work. They had not consented to spending additional time after the research. We anonymised names and the hospital’s identity is withheld. Additionally, the stories we share are respectful, there are no victims nor perpetrators, just good intentions.

Results and Discussion

The Action Researcher Partaking in the Search for Influence

Just as a small cauliflower rose represents the pattern of the whole cauliflower, the prologue tells my story, the story of the entire research team, and the story of the entire ward-round team, including parents. It is a story about the emotional and relational dynamics that unfolded in our interactions, our strive to improve our place within the group, our desire to be heard and acknowledged, and the importance of these dynamics in realising epistemic justice.

Like myself, the other participants often felt unrecognised, relegated to a secondary position, or overruled. This becomes apparent right at the beginning of our meeting, in Esther’s anecdote about the feedback she didn’t receive, in Suzanne’s annoyance, and in my own sense of failure due to the absence of the doctors. It also echoes in conversations with Arie, who felt obliged to participate in the research, and Jolande, who remained silent in meetings and preferred to express her opinion at other moments to avoid causing offence. Conversely, individual participants took pride in their achievements. I was proud that Esther expects feedback from a doctor, the nurses were proud that they gained more say in the ward-round, and Suzanne was proud that “her” poster was a success. In these emotions of disappointment and pride, recognition, and misrecognition, being influential and powerless, the what and the who are intertwined. When participants didn’t show up at the meetings, I interpreted the message as that they deemed “my” research and me unimportant.

Embedded in my feelings of disappointment and pride, was that I took credit for the results achieved.

I ascribed myself an unrealistic amount of influence. The other participants also lacked a clear understanding of their own influence or position. This lack of clarity is evident in the prologue and in numerous other situations within this research. Below, I outline some examples in which participants felt they had no influence when they actually did. Realising the difference between felt influence and observable influence, I asked myself “Can I speak of epistemic justice (acknowledgement as a knower), when participants do not feel acknowledged?” In hindsight I saw the development of everyone’s influence and acknowledgement and came to see epistemic justice not as a static thing but as something that evolves during the study. Yet, in the last meeting, still every individual had its own perception of contribution, influence, acknowledgement. That is the messy material I, as an action researcher, had to work with.

In a small meeting with doctors and nurses, I shared my observation that during the ward-round, only the method of medication administration was mentioned and not the medication itself. I argued that this could lead to misunderstandings and pose a risk. Gert, the paediatrician, promptly responded, “In practice, that never leads to problems, right (looking at colleague Arie)?” Arie said, “Indeed, I don’t know of any cases.” After a brief silence, the current resident emphasised, “But in light of the recently renewed emphasis on medication safety, it is crucial to specify the correct medication accurately.” The paediatricians, looking at each other with a slightly embarrassed smile: “Well, we can’t disagree with that, of course.” They committed to self-training in this area and leading by example. I felt put in my place. Between the lines I heard: “You, as a layperson, don’t know what a medical risk is,” or “We’ll decide what’s important ourselves.” I withdrew to the position assigned to me. In hindsight, I realize that my contribution was necessary for the development of a new policy. In this instance, the “subordinate” resident acted upon my suggestion, which was acknowledged by the paediatricians. They may have done so as they esteemed the resident for the skilled physician she was proving to be, but also because she was not an outsider. In other words, I caused a ripple, and it resonated through the resident, so it did not dissipate. In this example, despite being in a subordinate position, I was able to exert influence on the matter.

Parents often mentioned that the doctor during the ward-round determined what treatment was going to be given to their child, and many of them wanted that too, after all “they know best what is needed to make my child better.” They positioned the doctor at the top of the hierarchy. At the same time, they experienced influence when their concerns and questions were heard. Some even to the extent that they described the decision-making process as shared decision-making, while I as an observer, and the care givers, often did not see shared decision-making. What the parents couldn’t see was what happened in the team meetings. Of all the improvement possibilities I had identified, the parents’ suggestions impressed the professionals the most. At the parents’ instigation, they chose to prepare parents better, to specify concrete times, and to use the whiteboard to write down questions and discharge goals. When it turned out that parents appreciated the new sequence in the ward-round, where parents speak after the nurse, it created support among the doctors who were initially not enthusiastic about the change. Much of this influence fell out of their sight. They had already gone home when these changes took hold in practice.

The nurses felt that their expertise and the importance of their nursing expertise were not acknowledged by the doctors. They felt validated in this by numerous non-verbal examples: only being allowed to speak after the parents during the ward-round, having to wait during the ward-round until the doctors finished their teaching, not being asked for their assessments, doctors arriving late or leaving early from a joint meeting, and a lack of willingness to join their coffee breaks as they used to, among others. They also felt vulnerable towards their fellow nurses. If they stood out too much, they believed it would not be appreciated by their colleagues, and they would not only become unpopular but also lose their support for the new working methods.

The nurses felt disrespected and powerless and yet the biggest changes initiated were due to the initiative of the nurses in the research team. They brought in that the nurse should have a say first. To accommodate them, the doctors were committed to a faster discharge procedure and the Tractus methodology ¹ . All these things combined made Esther able to say in the final meeting, “Now our nursing expertise is called upon much more”.

Resident Jolande had put in one sentence in a meeting of the research team that she had good experience with the Tractus method of information transfer in the visit in another hospital. At the meeting itself, that comment fell dead, no more than a small ripple. But afterwards, the nurses had come back to it in a bilateral with her. They had been triggered by the signal that doctors were appreciative of the working methods of some of the nurses. They felt challenged and wanted to harvest that appreciation themselves. Together with Jolande, they had pre-cooked a proposal to introduce Tractus in the visit. Now they still had to convince the senior supervising paediatrician. I had taken the initiative to convene a small meeting between the doctors and nurses with the agenda of “what do you expect from each other?”. Then, in the course of the conversation, the nurses brought in “We can better meet your expectations if we start working according to Tractus”. When the senior paediatrician was convinced that that proposal had a lot of support from all the nurses, he agreed to the proposal, although he himself was convinced of a different method. I thought that as a facilitator/action researcher, I had steered the conversation in the right direction, and this was the outcome. After the conversation with Jolande, I saw that there were two initiatives that reinforced each other. Two ripples that became one wave together.

Senior supervising paediatrician Gert strongly opposed the idea of nurses speaking before parents during the ward-round. This went against his belief that the parents should come first and, therefore, speak first. He also felt that it was up to both supervising paediatricians to decide on it. After all, the medical visit was their responsibility. However, the change was already set in motion, and he was too late to reverse it. Nonetheless, supervisors Arie and Gert, had significant influence. Everyone in the research team felt that no final decisions could be made without the senior supervising physician Gert also having his say on it, even though he was not on the research team. The paediatricians influenced the course of events by their supervision of the residents. They paid attention to the discharge criteria, the questions on the whiteboard and invited the nurses. This way the residents immediately understand that this was considered important by them. During the course of the study, fellow paediatrician Suzanne had several bilaterals with them to keep them hooked, she too was careful not to bruise her colleagues too much, as she still wanted to work pleasantly with them for several more years.

In the experiences of the others, I see my own experiences reflected and vice versa. I am part of the pattern woven collectively. Although not in the moment of action, I was the mindful consciousness of the collective (Davis & Sumara, 2005b). This makes my story not a biographical story but an auto ethnographical story.

Healthy complex systems are in constant disequilibrium, in which agents use frictions and conflicts as opportunities for negotiation and exploration, rather than as events to avoid (Davis & Sumara, 2001). In these systems influence often takes unexpected and subtle turns, like in a murmuration where all starlings can influence the direction by responding to seven neighbouring starlings, but no one is control. Any small discussion, gesture and conversation can set a disequilibrium in motion, often visible in hindsight only (van Harten, Niessen, et al., 2025). Understanding a ward unit as a complex system implies letting go pre-existing beliefs about the linear effect one can achieve in favour of epistemic justice. An example of how a small conversation set a disequilibrium in motion, occurred in the PAR team meeting wherein I shared my observation of the nurses leaning against the wall during the medical visit, speaking no more that 15% of the time. My verbal sketch created an image that physicians and nurses alike recognised instantly. It encapsulated the nurses’ unspoken sentiments – those they had hitherto been reluctant to articulate. By articulating the unsayable through the image of the nurses leaning against the wall, I interrupted the hermeneutical epistemic injustice. The image fostered empathetic understanding among the physicians and galvanised the nurses into action, thereby initiating a process of disequilibrium which appeared to advance more epistemic justice.

The Agents in the Pattern: The Desiring Machine

The complexity metaphor describes the pattern but does not expose the drives that generate the pattern, and it doesn’t reveal how the pattern is perceived and experienced by the participants. What drove me and what drove others and where did it lead to? How did it render someone a voice?

Lacan (Jackson & Mazzei, 2022; Verhaeghe, 2011) mainly views desire as the need to meet the expectations of others. The primary question is not “What do I want?” but rather “What do others want from me? What do they see in me? What am I for the other?” Verhaeghe (2011) places this desire to meet expectations in the context of our primal needs as social mammals. For us as humans, it is necessary to belong to a group. And for the group, it is necessary that someone in the group is authoritative. Authority is not necessarily patriarchal but can change according to circumstances and the expertise needed at present. Thus, belonging, intimacy, affection, and hierarchy or authority are fundamental and dominant drives in his view. These drives are often unconscious, and we may not have a clear understanding of them. Naturally, these drives also create friction. There is friction between belonging and standing out, in the competition for position, and in meeting conflicting expectations of different inclusions. There is also friction when the status quo is disrupted by unexpected events from outside. We can recognise in the narratives that heedfully addressing the frictions spurred testimonial epistemic justice, in which assumptions were changed, and the knowledge or experience of others were afforded greater recognition. During the study the nurses moved in the medical visit from the wall to the bedside of the patient, gained more conversation time, took more often the initiative to add remarks or questions, and were more often asked for their opinion by the physicians.

In the view of Deleuze en Guattari (Jackson & Mazzei, 2022, p. 112) it is not so relevant to examine what desire means or where it comes from, but rather if it works, how it works, and for whom it works. Thus, their way of thinking is helpful in reflecting on the pattern of movements.

I wanted to be recognized as someone who can observe and interpret, and who knows how to conduct (scientific) action research. Especially the latter was challenging at the beginning because my approach to research through PAR was initially not seen as scientific in their eyes. This generated a certain tension within me. Thinking with Lacan, I wanted to meet expectations to gain recognition and authority. Thinking with Verhaeghe (2011), I wanted to be liked. This is a very basic, instinctive, social need but is also connected to the necessity of gaining cooperation, creating a harmonious work atmosphere, and temporarily being included in the group, which is crucial for action research. Desires for authority and belonging can compromise the pursuit of epistemic justice. Being eager to receive support and appreciation from Rene, I paid more attention to his opinion in the meeting that to the other opinions. At the same time, it was also necessary not to lose him for the study.

Every time my expertise and insights were recognized, or when my proposals were accepted and resulted in change, I simultaneously felt that I gained authority. This professional appreciation went hand in hand with personal appreciation and a sense of belonging. As the research progressed, the nurses became friendlier and more helpful, and some who were initially quite reserved invited me to have lunch together later. They felt seen and acknowledged by me, which generated recognition of me as a researcher and perhaps also appreciation and sympathy as a person. Intimacy and authority easily became connected.

The desire for recognition and appreciation as a knower from another discipline (desire for authority as a good nurse, a good physician or a good researcher) was a significant motivator to address friction and enable a movement with the entire department. The desire to belong within their own professional group prevented the forerunners in the flock from flying alone. There were an alternation and balance between seeking friction and maintaining contact. Thinking with Deleuze and Guattari (Deleuze et al., 2009), action research functioned as a “desiring machine”: a process in which different desires, forces, intensities, and flows are connected to one another and set to work, much like in a hub where different plugs are connected, creating the potential for transformation and movement. In this case a movement towards more epistemic justice and, inherently, in transformation of their work processes.

Seeing the movements and transformations, it becomes clear that the pattern is formed by desires for belonging, meeting expectations, status, recognition, appreciation in varying inclusions, sympathy, empathy, and friction, interactions in sight and out of sight of those involved, and events that trigger other events. Influence was often granted to individuals or groups from an empathetic understanding of the other’s experience and/or from the desire for appreciation or sympathy. The phrase “granting influence on others” captures the paradoxical nature of this. After all, who is in the lead: the “granter” or the one who is granted the lead? In the context of this swampy pattern, the concept in-fluence is in this case more appropriate than leadership, power, or epistemic justice. The word in-fluence captures the notion of initiatives, new experiences, and new relationships constantly flowing into the whole, transforming the whole.

As was noted by van Harten (van Harten, Niessen, et al., 2025) the sense of influence was reinforced when, at the end of the project, much improvement could be harvested in the eyes of those involved. At the same time, the improvements could be harvested because the sense of growing influence, motivated them for the changes: a self-reinforcing loop fostering epistemic justice.

Fostering Epistemic Justice as a Postilion d’amour

In participatory action research, the action researcher fulfils many roles (Ortiz Aragón & Brydon-Miller, 2018). When it comes to the role of the emancipator, my story makes clear that this is not so much about “accountability” but much more about being responsive and “responding to” situations where one voice is heard more than another, or where one kind of knowledge is valued more than another (experiential knowledge, nursing knowledge, medical knowledge).

The PAR team reflected the complexity of the workplace, including all its relationships and conflicts. Having everyone at the table did not automatically imply that everyone made themselves heard. My inability to ensure everyone’s voice in the meetings was due to existing relationships and the limitations of my perception and interpretation in the moment. Furthermore, I tended to see the PAR meetings as conclusive occasions instead of as starting occasions. In hindsight I could see that after the meetings, co-researchers started to talk one to one on topics, they had not reacted to in the meeting itself. Often one needed to think over things before knowing what to think of it or how to act on it. The meetings served as opportunities to prepare the ground and drop seeds, while the subsequent one-to-one conversations provided the space to nurture these seeds and observe which ones started to grow.

I also stayed in touch one to one with what was happening outside the scheduled research moments. So it could be that in the research team meetings not everyone was heard equally, but there were many other moments that were sometimes more appropriate. Sometimes with me as action researcher, but often without me, out of my sight. Epistemic justice was created by all participants in the research team and evolved over time.

In my story, it becomes clear how important it was to hear and see each other, to recognize and appreciate, and to be empathetic. This generated the willingness to follow each other alternately and to do each other favours. Yet participants did not easily share their experiences directly. As an action researcher, I supported this by feeding back the experiences I had heard in interviews and observed during observations. I did this at the ward, by sharing information received from parents (with their consent) with the professionals, or by sharing information between and about professionals (van Harten, Niessen, et al., 2025), but also in the PAR team.

I felt like a “postilion d’amour.” In the old days, the postilion d’amour was the messenger on horseback (Figure 1) who delivered the messages of lovers who did not dare to speak to each other directly. Sometimes sensitive messages were in code language.

Figure 1.

A Postilion Heralding His Arrival

The discussion at the ward handled about the order in the medical visit and about Tractus, but it was code language for the underlying discussion about: Who is more important? Is my nursing knowledge acknowledged? Is the relevance of our medical education acknowledged? Do they really see my child? How do I gain respect as a nurse from the physicians?

Through me, the experiences and perspectives of those involved could come together, and they could empathise with each other’s perspectives and learn about each other’s expectations. By donning the hat (Ortiz Aragón & Brydon-Miller, 2018) of the postilion d’amour, I could connect viewpoints and contribute to fulfilling the desires for belonging and authority. As such, I was one of the influences that flowed into the desiring machine and generated epistemic justice.

By reflecting on the patterns and underlying desires and by writing the autoethnography I sensitised my perception and enriched my intuition, which will enable me a next time to consciously seize the occasion in the moment (Davis & Sumara, 2005b; Varela, 1999) balancing contrasting ideals of emancipation and epistemic justice, staying connected and constructive friction.

Conclusion

As an action researcher, I unconsciously and intuitively sometimes re-enacted the hierarchical pattern in the research team meetings. Like the other co-researchers, I initiated interactions and the sharing of experiences within and outside the research meetings. I did so as a group member, researcher, facilitator but most of all as a postilion d’amour. In doing so, I facilitated changes in perspective and contributed to meeting the desires for belonging and authority that ruled the interaction patterns in the ward and the research team. This way I in-fluenced into the desiring machine that led to new responses to existing frictions and to new perceptions of the distribution of influence. By doing so I balanced the call for emancipation and epistemic justice in PAR, the value of constructive friction and disequilibrium and the need to stay in touch with all participants, and I accepted that, as a consequence, epistemic justice sometimes recedes and at other times comes to the forefront, making it a moving horizon to navigate.

By reading my auto-ethnographic story and the subsequent analysis, participatory action researchers can sensitize themselves to perceive recurrent patterns, the underlying desires of hierarchy and inclusion, and their own possibilities to in-fluence epistemic justice and emancipation, for example by fulfilling the role of the postilion d’amour.

Limitations

Inherent in an autoethnography is that the experiences and reflections are situated in a very personal situation. Only when the story resonates in stories of the reader, it will generate meaning. Therefore, I took the space for storytelling. As stated in the method section, I also wanted to share my reflections on the events. Yet the inherent danger of that is that the reader loses its engagement with the story.