Conducting Phenomenological Research in Medical Education

Abstract

Phenomenology originated as a philosophy that qualitative methodologists later translated and adapted into empirical research practices. Also referred to as applied phenomenology, this qualitative methodology aims to describe and understand a phenomenon as perceived by those who have experienced it. It conveys and shares lived experiences, making it a valuable method for medical education research. Although its popularity is rising within medical education, limited literature provides insights into how phenomenology can be applied in this field. This paper aims to prepare novice researchers by offering a guide for developing a phenomenological study. We begin by describing the similarities and differences between the two key types of phenomenology, transcendental (descriptive) and hermeneutic (interpretive) phenomenology. This is followed by the core tenets of the methodology that researchers should know, including the concepts of phenomena and essences. We conclude with practical steps for conducting phenomenological research, starting at the beginning of the research process with learning about prominent scholars in the field to data analysis at the end. Understanding the key principles of this methodology can ensure its accurate use and representation in medical education. Additionally, by providing an introductory guide to phenomenology, we hope to make this methodology more accessible to novice health professionals and scholars in medical education.

Introduction

Many qualitative methodologies have been developed for sharing people’s experiences, but phenomenology is the most well-known for capturing lived experiences. Phenomenology aims to describe and understand a phenomenon as perceived by those who have experienced it (Teherani et al., 2015). It focuses on describing what participants experienced and how they perceived that phenomenon (Neubauer et al., 2019; Teherani et al., 2015). Although capturing lived experiences is phenomenology’s most notable aspect, other methodologies, including narrative inquiry and autoethnography, also strive to describe lived experiences, albeit differently from phenomenology (Ajjawi et al., 2024). Narrative inquiry provides an account of an individual’s experiences as articulated by the individual, but, unlike phenomenology, does not focus on gaining information about pre-reflective moments (Ajjawi et al., 2024; Islam & Sayeed Akhter, 2022). Pre-reflective moments refer to “the lived meaning of [a] lived experience” that has not been introspectively reflected on, but instead, has been recovered by “reflect[ing] on the originary sensibility or primordiality of what the experience was like” (van Manen, 2017b, p. 812). Capturing pre-reflective moments ensures that details of the phenomenon are recorded. Conversely, autoethnography captures the lived experiences of the researcher, which may include pre-reflective moments but significantly differs from phenomenology in terms of the types of participants studied and the analytical processes employed (Ajjawi et al., 2024). We offer an overview of essential components to consider when conducting a phenomenological study, intending to make it more accessible to novice health professionals and scholars.

Phenomenology is frequently used in education and social sciences research. Within health professions education research, phenomenology has been utilized in nursing research for decades (Zahavi & Martiny, 2019). Within medical education, some may consider it difficult to utilize phenomenology as a result of the paradox that exists between phenomenology investigating pre-reflective structures and medical learning involving the acquisition and transformation of an experience. However, many phenomenological studies have solved this through the incorporation of critical reflection, where medical students write reflection-in and reflection-on-action (Schön, 1987). Reflection-in-action focuses on students reflecting in the moment on why they responded the way they did, while reflection-on-action requires students to reflect after the experience on their response (Schön, 1987). Critical reflection has proven to be effective, as portrayed in a study conducted by Dharamsi et al. (2010), which had students write reflections on their experiences on an international services learning trip. They found that critical reflection greatly assisted with students’ learning experiences (Dharamsi et al., 2010). While there has been less adoption of this approach in medical education, phenomenology can reveal both successful areas and those requiring improvement and development. For example, a study conducted by Tavakol et al. (2012) explored medical students’ experiences of empathy. Their study revealed that students consider empathy essential for their career, with many reporting it as a valuable component of medical education that is best taught through role modeling (Tavakol et al., 2012).

Although phenomenology is gaining popularity in medical education research, some scholars have pointed out its misrepresentation in certain studies, implying confusion about essential aspects of phenomenology (Ajjawi et al., 2024). Additionally, there is limited literature regarding how phenomenology can be applied in medical education research, rendering it less accessible and challenging for novice researchers considering its use (Rietmeijer & Veen, 2022). Based on the findings of these reports and the dearth of literature on the use of phenomenology in medical education, we aim to provide an introductory guide on how phenomenology can be successfully utilized and applied in medical education research.

Types of Phenomenology

Transcendental and Hermeneutic Phenomenology

Understanding how the fundamental philosophers and their schools of thought provide the foundation for different types of phenomenology is crucial. This will allow the researcher to choose the methodology for their study that will align with the researcher’s objectives and their position.

Classical phenomenologists such as Husserl spoke of a pure description of a lived experience that individuals experience daily. In his founding and development of transcendental phenomenology, Edmund Husserl began by moving away from positivist thinking, as he disagreed with the positivist notion that subjective experiences were not as valuable as objective experiences (Neubauer et al., 2019). Husserl claimed that an individual’s perception of phenomena could be studied scientifically and that our understanding of science depends on our “inner evidence,” or knowledge held in our consciousness, where a phenomenon needs to be studied (Husserl, 1970). Husserl believed the lived experience of a phenomenon had characteristics or universal features that may help researchers develop generalizable descriptions (Neubauer et al., 2019). These descriptions signify the accurate nature of a phenomenon being investigated. To achieve these generalized descriptive accounts, researchers attend to transcendental subjectivity by blocking their assumptions and biases to gain the true accounts of their study participants’ experiences (Staiti, 2012). Epistemologically, according to Husserl’s notion of phenomenology, every experienced phenomenon can be studied, which urges us to study lived experiences and examine them beyond sensory perception, for example, from hearing and touch to experiences of thought, feeling, imagination, or sentiment (Reiners, 2012).

Martin Heidegger’s hermeneutic approach emphasizes that “the meaning of phenomenological description as a method lies in interpretation” (Heidegger, 1962, p. 61). It is a “process that refers to the way people interpret and make sense of experiences, usually by naming them according to their pre-existing values and ways of seeing the world” (Willis, 2001, pp. 7–8). Hermeneutics describes the art of interpretation within context, including social and linguistic contexts, by focusing on an individual’s background. Hermeneutic phenomenology is well suited for insider researchers as they embrace shared lived experiences to help inform their research (Shaw & Anderson, 2018). Ontologically, Heidegger valued human experiences and humans as active participants who are knowledgeable about themselves. Heideggerian phenomenology focuses on humans and their relation to the world, asking questions such as, how do participants make sense of their world? (Reiners, 2012). This is different from Husserl’s approaches, which focus purely on the participants’ descriptive accounts. Interpretation requires creative imagination, which is possible if the individual has experienced a particular lived experience themselves (Reiners, 2012).

Core Tenets of Phenomenology

Phenomena

The ‘phenomena’ that a phenomenologist is interested in are defined as anything and all “that are appearing, showing, manifesting, making evident or ‘evidencing’” (Moran & Mooney, 2002, p. 5; Vagle, 2018). Originally, phenomenologists were interested in investigating everyday experiences, as evidenced by Heidegger’s study on “What is it like to be bored?” (Heidegger, 1995, as cited in van Manen, 2017b, p. 815). Philosophers like Husserl recommend a suspension of our natural attitude to learn and understand a phenomenon more clearly. The natural attitude of everyday life assumes that an objective reality exists independently from the perceiving subject, and we experience it without questioning our relationship to it (Husserl, 1931). Suspending our natural attitudes or our beliefs regarding the relationship between the subject and object can help reveal attributes of phenomena that were not known to us previously. As a result, phenomenology is considered to be “the study of what it is that appears in consciousness” (van Manen, 2017a, p. 775). Husserl believed that phenomena could be studied from one’s consciousness, with consciousness being composed of information from the person and their world (Laverty, 2003). Heidegger added that an individual’s consciousness is a result of their “historically lived experience,” including the culture that they were born into (Laverty, 2003).

Along with these differences in phenomena, another aspect of phenomenology that defines the methodology is the notion of lived experiences. A key distinction between experiences and lived experiences is the focus on capturing pre-reflective descriptions of the experience from participants (Teherani et al., 2015). Researchers should aim to gather as much information about the in-the-moment experience as possible by encouraging participants to tell a story about their experience and provide rich details to produce a mental image (van Manen, 2017b). Along with more information and vividness, van Manen (1997) believes descriptions of lived experiences should have experiential concreteness, which can be achieved using four existentials: spatiality (lived space), corporeality (lived body), temporality (time) and relationality (how an individual experiences themself and others).

Essences

The concept of essences is a cornerstone of phenomenology, as scholar Merleau-Ponty and Bannan (1956) states “phenomenology is the study of essences” (p. 59). According to Husserl (1931), essence denotes “that which is common or universal, the condition or quality without which a thing would not be what it is” (as cited in Moustakas, 1994, p. 100). Essence is the shared characteristics or structures that constitute a phenomenon, and, as Polkinghorne (1989) notes, are essential to experiencing the phenomenon. In other words, the essence of a phenomenon is essential to its experience; without it, the phenomenon itself changes. For instance, if a participant reports experiencing racial slurs in a study on gender discrimination, the actual phenomenon being described is likely racial discrimination. An important aspect of essences is that they are dynamic and evolving, as they continue to emerge and unfold over time, and are continuously generated for a phenomenon as time goes on (Moustakas, 1994). The essences identified in a particular study are situated within the specific context in which they were collected, including the researcher’s perspective and biases (Moustakas, 1994). Rather than contradicting one another, the findings of one researcher can complement and build on the other. As new events and versions of a phenomenon arise, novel essences and meanings can emerge, offering an in-depth understanding of the phenomenon being investigated (Dahlberg, 2006).

Research Process for Conducting Phenomenology

Prominent Scholars

Understanding the contributions of some prominent phenomenological scholars can assist researchers with selecting the best method for their study. These figures have facilitated the advancement of phenomenology by developing various phenomenological models that can be applied to different areas of research.

Clark Moustakas was a psychologist who developed a phenomenological model based on the philosophical ideas of Husserl and the work of other phenomenologists. Their book, Phenomenological Research Methods, describes the key concepts that shape transcendental phenomenology and provides guidelines for researchers to utilize when conducting phenomenological research (Moustakas, 1994). Moustakas’ methodology is extremely structured in comparison to other phenomenological methodologies, such as the one developed by Max van Manen and Michael van Manen, which are more reflexive (Roulston, 2018). Moustakas’ phenomenological model has been used in numerous fields, including psychology, healthcare and gender studies (Moustakas, 1994). A study conducted by Liao et al. (2021) used this methodology to investigate the experiences of medical students who took a narrative medicine course, as they needed a methodology that would produce a description of the experience. This methodology may be easier for novice researchers looking to use transcendental phenomenology for their study.

Max van Manen is a philosopher recognized for their work in advancing hermeneutic phenomenology rooted in Heidegger’s philosophy. Researching Lived Experience was their first book written depicting their model of hermeneutic phenomenology (Roulston, 2018). van Manen’s methodology can be applied to areas of nursing, medicine, education and more (van Manen, 2017b). Moreover, Michael van Manen has further delineated hermeneutic phenomenology, and has used the methodology in medicine, such as their study that looked at the ethical decisions that parents faced when their newborn was in neonatal intensive care (van Manen, 2014).

Karin Dahlberg and Helena Dahlberg are qualitative researchers who utilized the philosophy teachings of Husserl, Heidegger, Merleau-Ponty and Gadamer to develop reflective lifeworld research (RLR) (Dahlberg et al., 2008). Lifeworld research aims to “discover, analyze, clarify, understand and describe meaning” (Dahlberg et al., 2008, p. 96). Their book, Reflective Lifeworld Research, emphasizes the importance of remaining open when utilizing this methodology rather than following strict steps (Dahlberg et al., 2008). A study conducted by Lindberg et al. (2018) used reflective lifeworld research to examine the experiences of nursing students who attended reflective seminars that taught about caring science.

Amedeo Giorgi is a psychologist who is known for building a descriptive phenomenological method rooted in Husserl’s and Merleau-Ponty’s philosophy. Giorgi aimed to develop a methodology that could help with learning about the whole person within psychology instead of studying individual human functions (Giorgi, 2012). They modified Husserl’s original methods by analyzing experiences through a psychological lens, such as the step of free imaginative variation, which assists with finding psychological insights from these descriptions (Giorgi, 2012). Hvidt et al. (2022) conducted a study using Giorgi’s phenomenology of learning methodology to investigate how medical students learn empathy.

Research Team

Working as a multidisciplinary team can ensure higher quality data, as a result of multiple researchers weighing in on decisions that impact different aspects of the study. For instance, having several scholars discuss the results of the study and its interpretations can enhance the accuracy of the findings (Barry et al., 1999). Furthermore, forming a team of individuals from different fields can enhance the research study, whether it is through the combination of diverse perspectives and insights or through the various resources that individuals have access to (Barry et al., 1999). Overall, conducting a research study as a team may ensure a more organized research process (Milford et al., 2017). To establish a strong research team for a qualitative research project, there should be experts who have experience and familiarity with the specific methodology being used. Furthermore, qualitative research teams should include researchers with expertise in interviewing, as the quality of data collected is highly dependent on participants’ responses and the subsequent probes from an interviewer (Sofaer, 2002). In addition to this, research teams conducting a study using hermeneutic phenomenology should also include a researcher who shares the lived experience being investigated, since this approach requires researchers to co-construct their data with participants, by drawing from their background and lived experiences (Laverty, 2003).

Research Question

Developing a research question is crucial to selecting a methodology (the framework that researchers use as a guide (Bryman, 2008)) and methods (the tools researchers use in collecting data (Bryman, 2008)), as the type and content of a research question determines the methodology (Englander, 2012). In the case of phenomenology, research questions are formulated to find “the meaning of a phenomenon” (Englander, 2012, p. 17), or to understand a phenomenon (van Manen, 2017a). Research questions in phenomenology are typically written in the format of “What is it like to…?” or “What is this experience like?” (van Manen, 2017a, p. 776) to highlight the lived experience or phenomenon that the research study will be investigating. Moreover, phenomenological research questions often include the study population or the individuals whose lived experiences will be explored (Frechette et al., 2020), along with contexts such as time and place. For example, what is it like leading junior medical residents as an attending physician in Canada? What is it like to experience discrimination as a medical student in a healthcare setting? In addition, understanding the philosophical backgrounds of descriptive and interpretive phenomenology can also play a role in developing a strong research question (Englander, 2012). Research questions written for transcendental phenomenology tend to focus more on participants’ descriptions of their lived experiences, as opposed to hermeneutic phenomenology, which focuses on participants’ interpretation of their lived experiences (Willis, 2001).

Beware of Ethical Issues

Four core ethical principles can be followed to guide the development of a research study: beneficence, non-maleficence, autonomy and justice (Beauchamp & Childress, 2012; Varkey, 2021). Beneficence refers to the researcher’s responsibility to work in favour of the participants’ best interests by providing support and ensuring their welfare throughout the study (Varkey, 2021). Non-maleficence refers to the researcher’s responsibility to not cause harm to participants (Varkey, 2021). These two principles hold researchers accountable for the well-being of their participants by forcing them to weigh the benefits against the potential negative impact of their research on participants. In phenomenological research, these principles are often considered for phenomenological interviews, as recounting lived experiences can cause distress to participants (Walker, 2007). Researchers should have a plan prepared for assessing participants’ reactions, such as distress or discomfort, and should also consider the actions they will take if a participant reacts negatively (Grossoehme, 2014; Usher & Holmes, 1997). Autonomy refers to the belief that all individuals should have the right to make their own decisions (Varkey, 2021). Providing informed consent is one instance where this applies, where researchers are obligated to inform participants about the study, including any benefits and risks associated with it (Walker, 2007). Justice refers to ensuring that all participants are treated fairly and equitably (Varkey, 2021). This may mean treating people differently due to their different needs. Additionally, this principle also applies to the power dynamic that exists between the researcher and participant (Canadian Institutes of Health Research et al., 2022).

Research Participants

The focus of phenomenology is not on generalizing findings but rather on describing a phenomenon as experienced by the sample chosen (Polkinghorne, 1989). Additionally, phenomenology does not claim that the experiences found will match the population’s experience with the phenomenon but rather the experiences are seen as findings that are specific to those studied and their context, which may apply to others (Polkinghorne, 1989).

Recruitment in phenomenological research calls for purposeful sampling, where individuals are selected for their rich experiences of a phenomenon (Frechette et al., 2020). While some topics, such as the development of empathy, may be studied with any group of participants, other topics, such as studying the lived experiences of those with cerebral palsy, will only apply to certain individuals. As a result, it is up to the researcher to find individuals with unique, diverse lived experiences of the phenomenon being investigated to gather as many essential components of the phenomenon as possible (Polkinghorne, 1989). Researchers should define what their sample will look like in advance, by considering what they know about the phenomenon (Englander, 2012) and the lived experiences necessary for understanding it (Grossoehme, 2014). The purpose of phenomenological research is to describe a phenomenon as accurately as possible, not generalize (Englander, 2012). Consequently, a researcher may consider sample sizes of 5-25 individuals depending on their study objectives (Grossoehme, 2014). In addition, some scholars such as Giorgi have argued that a researcher may need more participants to achieve a wider range of descriptions and interpretations of a phenomenon (Giorgi, 2008).

Data Collection Method(s)

Choosing the right data collection method for a study is just as imperative to the quality of a study as the collected data. When using phenomenology, researchers should aim to select methods that will best help the phenomenon appear without external forces such as interpretation or memory (Rietmeijer & Veen, 2022). Many methods can be used to collect data for phenomenological studies, with the goal of capturing as many different lived experiences of a phenomenon as possible (van Manen, 2014). One way of collecting an experience can be through asking participants to write their experiences, known as a lived-experience description (van Manen, 2014). Researchers can ask participants to describe a specific example and to describe the feelings and moods associated with it. Another method for collecting data is close observation, where the researcher immerses themself and participates in the participant’s lifeworld (van Manen, 2014). This method is great for participants who may not be able to write or talk about their experiences, such as children. Field notes are another form of data that can be collected through observation, where researchers record details of the experience being observed, along with the researcher’s thoughts and feelings during it (Rashid et al., 2019).

Out of all the possible data collection methods, conducting phenomenological interviews is by far the most popular method for both types of phenomenology. Phenomenological interviews differ slightly from traditional qualitative interviews, as the former focuses on obtaining as rich and detailed a description of lived experience as possible from participants (Giorgi, 2009). Additionally, these interviews are often semi-structured, where researchers prepare a few questions ahead of time, but otherwise ask spontaneous, follow-up questions to participants’ answers (Grossoehme, 2014). It is best practice to start a phenomenological interview by asking participants to describe an experience they had where they encountered the phenomenon, and then ask spontaneous questions following a participant’s answers to learn more about the phenomenon (Englander, 2012). Ideally, researchers should try to use non-directive prompts where possible to avoid influencing participants (Rietmeijer & Veen, 2022). In addition to listening to what the participants say about their experience, there should also be a focus on silences and non-verbal cues that may provide more information regarding a participant’s experience (van Manen, 1997).

Data Analysis

Horizontalization and Crystallization

Horizontalization is a key step in phenomenological reduction, which is the first stage of the data analysis process. Phenomenological reduction aims to produce a textural description of the phenomenon by describing the “what” of it - the characteristics and qualities that embody the phenomenon (Moustakas, 1994). The first step to this process is horizontalization, where researchers read through each interview/focus group transcript, field note, or lived-experience description and select “horizons,” or statements that represent a distinctive characteristic of the phenomenon’s meaning. For example, in a study conducted on empathy, the researchers selected statements from transcripts that represented student experiences of empathy (Tavakol et al., 2012).

Crystallization refers to a process that “combines multiple forms of analysis and multiple genres of representation into a coherent text or a series of related texts, building a rich and openly partial account of a phenomenon” (Ellingson, 2009, p. 4). Laura Ellingson developed a framework for researchers to use when applying crystallization to their qualitative projects. Crystallization can take place in two forms: integrated and dendritic. Dendritic crystallization is an ongoing process that aims to find meaning through multiple forms of text without combining them into a single text so that you can explore the phenomenon from different angles. For example, a researcher who is investigating the experiences of medical residents of visible minority status may choose to collect multiple forms of data, such as phenomenological interviews, field notes and artifacts that are emotionally significant to participants. Through dendritic crystallization, the researcher would publish an academic paper on the findings from the interviews, then another paper on field notes and lastly, publish artifacts collected separately. In contrast, integrated crystallization requires different forms of data to be combined into a single text, such as a book or article (Ellingson, 2009). In this scenario, a researcher may decide to combine all the different forms of collected data about medical resident experiences into a single dissertation.

Interpretative Phenomenological Analysis (IPA)

Interpretative phenomenological analysis (IPA) is a widely used and debated approach developed by Jonathan Smith. IPA is based on two prominent theories, symbolic interactionism, which focuses on “the meanings individuals ascribe to events,” and phenomenology (Smith, 1996, p. 263). IPA aims to “explore the participant’s view of the world” and gain understanding of an individual’s personal experience of a phenomenon (Smith, 1996, p. 264). Using this methodology in medical education can assist in illuminating the subjective perceptions of individuals who have the same experiences, such as a study conducted by Patel et al. (2015) that looked at the perceptions of medical students who failed a medical school assessment.

Although IPA incorporates the philosophical teachings of Husserl, many scholars debate whether IPA should be considered as a phenomenological approach. van Manen has specifically identified multiple aspects of IPA that differ from traditional phenomenology, such as how IPA focuses on describing an individual’s experience instead of focusing on describing the phenomenon (van Manen, 2017a, 2018). As a result, van Manen argues that IPA provides a more psychological analysis instead of a phenomenological one (van Manen, 2018). Other scholars mention issues such as problems with generalizing findings and disagreement over whether phenomenology should have systematic steps (Pringle et al., 2011; van Manen, 2018).

Bracketing

Husserl attempted to shape phenomenology into a more scientifically rigorous methodology through notions such as transcendental subjectivity. Transcendental subjectivity involves an ongoing evaluation of the researcher’s impact on the study, enabling them to mitigate any biases that arise (Reiners, 2012). This notion of Epoché or bracketing (Husserl, 1931) biases require researchers to keep an audit trail of their biases and predisposed assumptions, ensuring that they do not weave into their data. This allows for a more open and objective data analysis, focusing only on the participants’ descriptive accounts (Chan et al., 2013).

Bracketing biases and assumptions can also enable conditions for a greater understanding of a phenomenon. Reflexivity is one way of engaging in bracketing, where a researcher records their thoughts and reactions as the study progresses and explores their influence on the study and vice versa (Clancy, 2013; Holloway & Biley, 2011). Through reflexivity, researchers are able to understand their biases more, enabling them to provide a nuanced and well-grounded explanation of study participants’ experiences (Clancy, 2013). To facilitate this, medical education scholars should ideally include a positionality statement and a section detailing their interests and background.

Conclusion

Using phenomenology as a research methodology within medical education research requires careful thought and consideration. Applying a methodology that focuses on pre-reflective experiences to a field that concentrates on acquiring knowledge from experiences can be difficult if not navigated correctly. Additionally, to conduct a true phenomenological study and gain the essence of an experience, medical education researchers must immerse themselves in their project, which may be considered time-consuming for some. Phenomenology aims to describe phenomena as experienced by a group of people as best as possible, which can help with illuminating areas that require change and improvement. Within medical education, this ensures that patient care and experiences continue to improve, whether it is through learning about patient experiences or the experiences of health professionals.