Abstract
Most of us agree that healthcare, including nursing should be based on the best possible evidence, whether it concerns the establishment of policy for large populations or care for individual patients. But how can we define the nature and quality of evidence? In the last decades, based on a positivistic, biomedical view, evidence has mainly been defined by criteria that focus on decontextualized, standardized knowledge and randomized control trials are seen as the highest standard for scientific rigor. Qualitative health researchers who desire the status of ‘evidence-based’ have to position themselves in this approach, which is complicated because they have to modify their language-based research in line with an approach that deals with numbers. Further, whatever they do, qualitative research still qualifies as the lowest level of evidence. Another option, as we also can see, is to declare that one does not pay attention to evidence.
My approach to this is first to establish two statements: 1) All research that is considered scientific must relate to the claim of evidence; 2) Qualitative research cannot build upon a foundation designed for a radically different kind of research.
The first statement is easy, because if evidence is not at all involved, it is not about science but something else, e.g. fiction, journalism. The second statement needs more exploration.
Quantitative approaches are population oriented: homogeneous groups of patients from the same clinical conditions are in focus. Whereas in real life, many issues and problems are heterogeneous. Quantitative approaches are mainly disease oriented, rather than person or health oriented. In short, quantitative research is built upon positivist assumptions such as dualism, atomism, and reductionism, which represent values that are not compatible with the intentions of qualitative nursing research. In such research, the aim is mainly to adopt a more complex and meaning-oriented perspective that includes existential and social contexts. There is an interest in health, wellbeing and people’s capacity to run their life projects, despite illness. Qualitative research embraces complex existential matters and lived experience.
A solution to the seemingly insoluble problem is to choose an altogether different path. Qualitative research is too imperative to be wasted in non-scientific or positivist frameworks. Instead of forcing non-measurable phenomena into quantitative matrices my solution is to make a new beginning in theory of science, to identify the world of qualitative phenomena, and from there to build a new approach that satisfies the desire for evidence. Such a new beginning can be found with the help of phenomenology, including hermeneutic philosophy, which challenges the positivist approach and provides a non-dualistic, non-reductionist and holistic view on humans and existence. High-quality, in-depth phenomenological inquiry has the potential to illuminate the fundamental meaning structure of phenomena, thereby providing insight into the ontological nature of existential reality.
To answer questions of evidence we now need to see how phenomenology understands science in terms of objectivity, validity and generalizability.
Objectivity concerns the relation between the researcher and the phenomenon in question. First of all, objectivity should not be mistaken for objectivism, which means to investigate something in the world from a detached position outside of that world, simply, because that is a completely false position. Everyone, including every researcher, is already in the world, involved there with others, in a world of values, relationships and all kinds of meanings. In phenomenology the necessary position is described as lifeworld ‘which furnishes the ground for all cognitive performance and all scientific determination’ as Husserl describes it.1(p.41) It follows that objectivity does not preclude our involvement; indeed, we can never free ourselves from this involvement. As long as we live, we act from within a lifeworld, characterized by intentionality. 2 Phenomenology thus acknowledges and starts from connection instead of detachment. Objectivity therefore means to be aware of this ontological fact.
Research should not result in findings that show what the researcher wishes, (already) sees, or believes. What science demands from researchers is a shift from the ‘natural attitude’ that characterizes the matter-of-course everyday world to a phenomenological/scientific attitude of (self) reflection. In phenomenological research, this shift of attitude has been explicated as the capacity of the researcher to ‘bridle’ the streaming process of understanding so that it does not happen too hastily or preemptively, thus confining the impact of the ever-present pre-understanding. 3 Researchers’ immediate involvement requires that they should adopt an open phenomenological attitude that ‘slackens the intentional threads which attach us to the world and thus brings them to our notice’.4(p.xv) For researchers, this means to know how this attitude of alert, self-aware, and reflective openness can be practiced throughout the research. The challenge is to find a way to continuously remain open to the phenomenon and new understandings as well to one’s own interpretation.
Validity means a fundamental cornerstone of science, built upon the recognition that there is no traditionless, history-free, or in other ways context-free research. Again, detached objectivity is a delusion. It follows that detached validity is also a delusion. Human science research is meaning-oriented and, as a consequence, validity is associated with meaning. In research built on phenomenological theory and aiming at evidence, we must see the difference between content and meaning. We do not refer to what people say (as in content analysis, opinion research or journalism) but what meanings there are in their description of a phenomenon, their lived experience of something in their world, or that which is meaningful in their lives.
The notions of objectivity and validity place demands on openness. Openness in qualitative research is often connected to the analysis, which of course is a focal point of objectivity and validity. However, the notion of openness also challenges the choice of data collection method. It must be emphasized that there is no one qualitative method that is more objective or valid than any other per se, that there is not one method that guarantees evidence. All questions of method must be related to the phenomenon and the research questions. If we nevertheless have the ideal of openness in mind there are a few methodological aspects that could be considered.
Questionnaires as well as written stories, where the research participant is invited to compose a text about an event or describe a phenomenon, are often judged as objective sources of data. A reason that is presented is that the participant is relatively independent; the researcher is not involved in the ongoing process of writing. This may be of interest in some studies. At the same time openness is limited here. If we are interested only in opinions, shallow views, what people like or dislike, again, this may be a good way to investigate. But these methods do not allow for following-up questions such as, What do you mean by ‘the nurses were “good”/“bad”’? Tell me more about that! How was that for you? How did that make you feel? Please give me an example of such a situation. We should not suspect that people lie in such situations, but we know that people do not always say what they think or feel, that there are things that may not occur as something interesting or worth telling about, and they also say things that are ‘correct’ at that moment in time. If objectivity and validity are required, we must seriously reflect upon whether questionnaires and written stories contribute with meaning.
Interviewing serves openness better. Then all kinds of following-up questions and urges can come into play, in favour of the phenomenon that can be further illuminated.
Another example of method is observation, which from the perspective of evidence is imperative when there are speaking or language impediments, or if the participant’s cognitive level is low. Seeing people acting in significant situations can then be the proper method of investigation. However, a weakness with observation is that it is only the researcher who is ‘wording’ the experiences. For objectivity and validity reasons I therefore recommend all observations to be combined with some sort of dialogue with the participant. If that is not at all possible parents, spouses or other close ones can be of help. From such point of view other combinations also serve the purpose of evidence. Interviews can be launched from written stories or be followed up in observations. Questionnaires and written stories can be combined with interviews.
Generalization
The impact of qualitative research findings, e.g. in phenomenological research, is often played down, based on the argument that the study sample is too small to allow for confidence in the generalizability of findings, or due to a sampling procedure with no randomization. However, all research results should be of a kind that can be generalized, i.e. they should be meaningful to more people than just those involved in the study. All research, including phenomenological inquiry, wants to reach knowledge that goes beyond concrete individuals.
All kinds of research have generalization challenges. For example, in statistical research, all findings are related to populations and systems, and both researchers and practitioners must complete the process with interpretive work to be able to relate the conclusions to a distinct individual, be it a patient, a client, or a student, within her/his unique context.
For qualitative research, e.g. based on the notions of objectivity and validity above, a challenge is to avoid the presentation of fragmented results such as ‘themes’ or ‘categories’ without clarifying what they are parts of (which demonstrates another example of a positivistic remnant), in favour of findings in the form of a general structure of meaning. Such structure, which enables evidence to be, encompasses both essential meanings of a phenomenon and the individual experiences. The essential meanings illuminate the very character of the phenomenon without which it would not be that specific phenomenon. The description of individual experiences completes the view of the phenomenon, illuminating the phenomenon’s variations and somewhat unique experiences.
Important to note is that from a phenomenological point of view, there is no dualism between particularity and generality; they are of each other. Instead of allowing for polarization of that which belongs together, we should embrace the complexity of understanding, which in fact is founded in the complexity of existence, the intricate web of life, where meaning recognizes the in-between; in-between objectivity and subjectivity, in-between generality and uniqueness, in-between essences and individual experiences.
However, also important to emphasize is that essential meanings as well as individual experiences are contextual. It follows that phenomenological truths should not be understood as final or as law-like givens. Instead, an objective, valid and generalizable result should be considered an ongoing conversation which is never finished, depending on questions, intentions and context. Gadamer’s term anwendung, 5 which in English is translated as application or ‘usability’, displays the idea that generalization is a question of how research findings can come into play, how they can be used and practiced, based on coherent and logical reasoning of the limitations for applicability.
In summary
The prevailing scientific conception of evidence in health research is derived from positivism, and the ideal is quantitative knowledge. Objectivity, validity, and generalizability are usually associated with detached, value-free, decontextualized, standardized knowledge that pertains to general populations, rather than the existentials of each individual person that all health research sooner or later should relate to. In this view, phenomenological findings are considered to be of some importance, but not sufficiently scientific to provide an evidential basis for policy or practice.
Phenomenological theory of science has the potential to provide insight into the ontological and epistemological nature of reality, and in a way that better meets the evaluation requirements for robust research. As a consequence, phenomenology can become an exemplar for how qualitative research in general can make convincing arguments and thus be better appreciated.