Application in the World of Understanding: Researchers’ Experiences of Participation in Reflective Dialogues

Abstract

The aim of this study was to describe researchers’ experiences of participation in reflective dialogues through a hermeneutic application research approach. The aim was also to describe their perspectives on application, that is, the inner appropriation and application of theory into practice and vice versa. Twenty-one clinical coresearchers and four scientific researchers participated in reflective dialogues in a project on ethical sustainable caring cultures, in which an application research approach was used. The study included questionnaires, a focus group interview, and conversations. The findings show that participation in the reflective dialogues required that the participants are present, open for dialogue, share a common interest in the thematics of the dialogue, and are given space to express themselves. The participants described their experiences of the dual meaning underlying application. Application research strengthened the relationship between research and clinical practice and it contributed to the development of theory.

Introduction

A fundamental question in health care research is how to develop research designs that facilitate the implementation of research in clinical practice, that is, the practical application of theory. Through methodological approaches such as action research (Coghlan & Casey, 2001), participatory action research (Leykum, Pugh, Lanham, Harmon, & McDaniel, 2009), co-operative inquiry (Hummelvoll & Severinsson, 2005), collaborative inquiry (Heron & Reason, 2006), action science (Reason, 1988), and action learning (Pedler, 1991), researchers can incorporate the perspectives of clinically active health care staff while finding new ways of unifying theory and practice. Ranheim and Arman (2014) maintain that a clinical application research design strengthens the relationship between research and clinical practice. Such a research design has been used in different studies during the last decade (Arman, Ranheim, Rehnsfeldt, & Wode, 2008; Karlsson, Nyström, & Bergbom, 2011; Lindholm, 2003; Lindwall, Råholm, Lohne, Tolo Heggestad, & Nåden, 2018; Lindwall, von Post, & Eriksson, 2010). According to Ranheim and Arman (2014), clinical application research has more didactic than scientific benefits for health care staff. Titchen (2014) maintains that its design resembles practice development. However, we argue that even if the primary goal of clinical application research is to emphasize caring science theory in clinical practice, it also contributes to the development of theory.

Koskinen and Nyström (2017), who have further developed clinical application research toward a hermeneutic approach within caring science, emphasize that the starting point for the methodology becomes clearer if one calls it hermeneutic application research. According to Gadamer (1989), understanding includes application. Understanding through application is thus the common denominator between theory and practice (Gadamer, 1989). In application research, the dual meanings underlying application are revealed: inner appropriation and action (Koskinen & Nyström, 2017; Lindwall et al., 2010). In hermeneutic application research, emphasis is placed on human dialogue through which theory and praxis can become one. The approach can also be termed as participatory hermeneutics (cf., Davey, 2015).

Despite that various participatory-oriented research approaches have been used for the purpose of unifying theory and practice, there have been few investigations of how researchers experience similar research designs. According to Bergold and Thomas (2012), in participatory-oriented research, nonprofessional research partners may at first view participation in a project with anxiety, distrust, and detachment and view themselves as outsiders. However, this changes during the course of participation, resulting in feelings of personal empowerment, self-confidence, and belonging. Raelin and Coghlan (2006) also found that the possibility to reflect on a research theme together with others contributed to deeper reflection, which in turn generates understanding that goes beyond the present context and challenges the individual’s premises and entire frame of reference. Through reflecting on research together with others, an individual’s capacity for action develops (Kemmis & McTaggart, 2005). According to Raelin and Coghlan (2006), such a deeper level of reflection may be necessary to integrate theory and practice. Although there are some studies that investigate the role that researchers have in participatory-oriented research (Greenwood & Lewin, 1988; Hummelvoll & Severinsson, 2005), we have nonetheless not found any studies that describe researchers’ personal experiences of participation.

The aim of this study was to describe researchers’ experiences of participation in reflective dialogues through a hermeneutic application research approach. The aim was also to describe researchers’ perspectives on understanding through application, that is, the inner appropriation and application of theory into praxis and vice versa.

Background

A research project titled “Ethical Sustainable Caring Cultures” was carried out at a central hospital in Finland (Nyholm, Salmela, Koskinen, & Nyström, 2018). The main aim of the project was to gain further understanding of the ethical values central to the realization of sustainability in care. The project followed a hermeneutic application research approach and included scientifically educated researchers who collaborated with clinically active professional nurses, so-named coresearchers (Koskinen & Nyström, 2017; Lindholm, 2003). The collaboration, which allowed us to investigate the concept of application, took the form of reflective dialogues.

The term reflective dialogue is used here in accordance with Gadamer (1989), who describes such dialogue as a movement between questions and answers, a movement that has no beginning and no end, and as an act of interpretation toward understanding. Through dialogue, an individual’s understanding is set in motion. One’s personal preunderstanding or what one knows about the topic will be explicitly visible, yet, at the same time, every participant looks at the topic from a fresh perspective or horizon and try to understand it differently (Moules, Field, McCaffrey, & Laing, 2014). It is by bringing forth that which is unfamiliar that the dialogue is kept alive. The dialogue strives to be a fusion of horizons or common understanding even if the participants know that there is no final interpretation and another understanding is always possible (Gadamer, 1989). Reflection is emphasized in dialogue, because it is central to the process of understanding (Ekebergh, 2009). When we encounter something new, we also reflect on our past experience, and this creates new understanding. According to Gadamer (1989), through reflection, we are lifted from the limitations and barriers created by our own reality. The dialogues included in this study can be considered reflective, in that they incorporate reflection and the consideration of ethical values.

The term application is also used here in accordance with Gadamer (1989). Gadamer maintains that there is an element of application in understanding that leads to a change in how one perceives the world. The essence of application research can be described as researchers striving to gain understanding through inner appropriation, which allows for new possibilities for actions or practice (Koskinen & Nyström, 2017). In our study, the dual meaning underlying the moment of application is clarified, that is, how researchers appropriate and apply the new understanding reached through reflective dialogues. Of the researchers in this study, the clinical coresearchers understood the theory and applied the new understanding in clinical practice, whereas the scientific researchers understood the clinical practice and reapplied this understanding to theory.

Method

Participants and Data Collection

Clinical coresearchers from eight hospital units were invited to participate in reflective dialogues on ethical values. Twenty-one clinical coresearchers from psychiatric, medical, surgical, laboratory, and x-ray contexts participated alongside four scientific researchers in the reflective dialogues, for a total of 25 participants. Three dialogue groups were formed and the scientific researchers with theoretical knowledge led the groups. The groups met 6 times each for 2 hours per time over the course of 6 months. The research approach selected for the study ensured that caring science theoretical knowledge or theory and a common view of reality or ontology formed the basis for discussions. Prior to each dialogue, the participants were given a written presentation, based on theoretical knowledge, of the actual ethical value being discussed, allowing participants opportunities for personal reflection. During the dialogues, the researchers reflected together on how different ethical values can be understood in clinical practice and how theoretical knowledge about these values can be expressed.

The clinical coresearchers were sent a questionnaire via e-mail 2 weeks after participating in the dialogues. The questionnaire consisted of four closed-ended and four open-ended questions about the organization of and their participation in the reflective dialogues, how the dialogues had contributed to new or different understanding of the ethical values discussed, and whether the new understanding had changed their manner or actions in clinical practice. Half of those asked answered the questionnaire. Five months after our initial analysis of the questionnaire was completed, six clinical coresearchers were invited to participate in a focus group interview, comprised of two clinical coresearchers from each setting. During this interview, focus was placed on the participants’ understanding, application, understanding of theory and practice. The four scientific researchers met 1 week after the dialogues were completed and discussed the dialogues during a conversation, which was recorded. The scientific researchers met again 5 months after the dialogues for another conversation, about the themes discussed during the focus group interview, which was also recorded. Both the questionnaire and the questions asked during the focus group interview and subsequent discussions were drawn up by the researcher responsible for the project.

Analysis of Data Material

The material from the questionnaire, the focus group interview, and the two recorded conversations were analyzed using qualitative content analysis inspired by Graneheim and Lundman (2004). We read through all of the data material a number of times while searching for domains, that is to say those parts of the material that related to a respective research question. From these domains, we sought meaning units that were relevant to the purpose of the study. The meaning units were condensed and categorized. The categories that emerged are presented in the findings in the form of three main categories with associated subcategories.

Ethical Considerations

In this study, we have followed the guidelines for good scientific praxis as described by the Finnish Advisory Board on Research Integrity (2018). Consent for this study was obtained from the participating care organization’s upper management. The participants were given a cover letter containing information about the study, and the purpose of reflective dialogues was explained. Participants were also guaranteed confidentiality. Participation in the study was voluntary and written informed consent was sought prior to participation. In an application research study, it is difficult for researchers to provide comprehensive information about the research process ahead of time (Löfman, Pelkonen, & Pietilä, 2004), because the participants in such projects influence the research process. Consequently, an ethical approach should always be employed; application research is comparable with a social process, where mutual and respectful interresearcher relationships are important (Winter & Munn-Giddings, 2001).

Findings

Researchers’ Experiences of Participation in Reflective Dialogues

In our results, we see that the researchers experienced that participation in the reflective dialogues required that participants are present, open for dialogue, share a common interest in the thematics of the dialogue, and are given space to express themselves.

Participants are present and open for dialogue

The clinical coresearchers expressed worry that they did not possess sufficient knowledge to participate in the dialogues, that the dialogues would not have any added value and that their participation would amount to a waste of time. These participants often came to the dialogues directly from clinical work. They emphasized the importance of being able to leave their care setting and work duties behind prior to participating in a dialogue. It was therefore important that the reflective dialogues were characterized by a measured pace and calm. The clinical coresearchers experienced the scientific researchers closing the door to the room when the dialogues took place as a tangible indicator that now was the time for dialogue. This signaled that, from the moment the door closed, each and every individual was allowed the opportunity to listen to himself or herself and others.

You must be allowed to unwind and mentally calm down.

When she closed the door to the outside, it felt like being enclosed in the world of dialogue.

The scientific researchers underscored that it was challenging for them to emerge from their academic world, an environment they experienced as being safe and familiar. They were aware of the complexity of scientific theories and that the clinical coresearchers experienced scientific language as being difficult to understand. The scientific researchers were worried that they would not be able to explain the scientific theories and that they would be considered outsiders. They also worried about whether the dialogues would merely revolve around the inadequacies of care, because the fundamental idea behind hermeneutic application research is to reveal the caring and the good. They also stressed the importance of creating a certain initial atmosphere for the dialogues, which they considered to be a condition for reflection and thinking.

You translate the scientific language into a language that everyone can understand. It is not easy to not have access to one’s entire language.

It requires a certain atmosphere for the participants to be able to deeply reflect.

The clinical coresearchers, conversely, described how well the scientific researchers managed to create a special atmosphere as “conductors” of the process and leaders. The clinical coresearchers experienced that the atmosphere for dialogue was created when the scientific researcher started the dialogue by repeating the common understanding that the participants had come to during the previous dialogue. This was experienced as a way to “reenter” the dialogue.

Participants share a common interest in the thematics of the dialogue

According to the clinical coresearchers, it was important that those participating in the dialogue were genuinely interested in the thematics of the dialogue and that there was a common interest toward which attention was focused. The dialogue gave rise to questions and reflections that were both interesting and confusing. The clinical coresearchers could clearly see a connection between the thematics and their clinical work.

The dialogues were very rewarding. At times they were interesting, a little confusing but sometimes we got stuck in small scientific details.

What we were talking about could be directly associated to our own work.

The scientific researchers expressed the importance of conducting a dialogue on questions that are important for both caring science and clinical practice. They were surprised that the clinical coresearchers were so engaged in the discussions. The scientific researchers admitted that they had been worried that neither the establishment of a common interest in the thematics of the dialogue nor a meeting between theory and practice would be possible. They had also been worried about being able to articulate the participants’ common understanding.

It was of course our task to articulate the common new understanding. Personally I thought that it was a huge challenge and a difficult task to articulate the association between theory and practice.

Participants are given space to express themselves

The clinical coresearchers expressed that they participated in the dialogues to learn something new and that they actively participated. According to the clinical coresearchers, it was important that the scientific researchers emphasized that everything revealed during the dialogues was neither repeated nor passed on. The clinical coresearchers experienced the atmosphere as being “permissive,” that everyone in the group was given the space to express themselves and that a sense of trust existed among the group. During the dialogue, they were afforded the time and opportunity to express their thoughts, which gave them a sense of freedom. Still, one of the clinical coresearchers stated that she sometimes consciously stopped herself from expressing her thoughts out of a fear of expressing thoughts that could be perceived as being too philosophical, theoretical, or abstract.

There were no appraisals in the group and no one was disparaged.

It felt liberating that there finally was time to discuss ethical questions in depth.

The scientific researchers also experienced that scientific theory was given space and taken seriously. With the help of caring science theory, the dialogues were elevated to a higher level of abstraction. The clinical coresearchers in turn described in a lively manner various clinical images of the concepts in clinical practice, which resulted in the scientific concepts gaining a richer meaning.

The scientific concepts worked as tools and I could help the participants verbalize their experiences.

The concept responsibility was given a more nuanced content when I heard their stories.

Researchers’ Experiences of Application

The participants described their experiences of the dual meaning underlying application. They maintained that an inner appropriation can occur when one is “in wonder” while simultaneously respecting that which is different. They also experienced that they apply the new understanding by changing their way of being, as well as by contributing to clinical practice and the development of theory.

To be in wonder

Participation in the dialogues entailed that the participants listened to others and made new insights, which resulted in the clinical coresearchers beginning to question the assumptions that they had previously taken for granted. This was also true for the scientific researchers, for example, in regard to the theory and their own motivations for working as researchers.

I reflect on why I chose the nursing profession, what good care actually entails and how my way of being and acting influences patients and colleagues.

The scientific researchers expressed that when they extended an invitation to the clinical coresearchers, there existed an unspoken promise: that they should be responsible for keeping the reflective dialogue focused and ongoing. This unspoken promise was easy to keep, but maintaining a state of wonder was challenging. As leaders of the dialogue, the scientific researchers experienced that the clinical coresearchers found it difficult to rest in wonder long enough to understand in a new way.

Wonder was not kept alive long enough until answers were stated.

Respecting that which is different

The coresearchers’ descriptions of what had happened in regard to their understanding during the dialogues did not merely pertain to the themes discussed. They gained insight into the importance of communicating with and respecting others. They realized how important it is to hear others’ opinions and how important it is that individuals think differently, because this opens new ways of thinking and new understanding.

The scientific researchers stressed that respect for the other’s otherness was the ethical foundation for the dialogues. Confidence in the validity of caring science theory grew among both the scientific researchers and clinical coresearchers during the course of the dialogues.

I realized that we sometimes have different ways of expressing the same thing, and that you can understand things from a different point of view when you listen to others.

For me it was significant to realize that theory really is viable in practice.

Changing one’s way of being

Regarding whether the dialogues resulted in a changed approach to clinical work, the clinical coresearchers expressed that it was more an issue of a greater ethical awareness that was actualized through the dialogues. Both the clinical coresearchers and scientific researchers described that they changed their way of being and meeting others through an increased awareness and more reflection. They even experienced that they had developed greater understanding for their work colleagues’ ways of being, felt encouraged to discuss ethics with their colleagues, and that the sense of fellowship at their work units had been strengthened. Some clinical coresearchers experienced that the dialogues were health promotive.

I think more about how I behave and meet patients and colleagues and all what that means in our work fellowship.

The dialogues improved own wellbeing, they confirmed when you doubted and gave the strength to continue. They gave comfort and hope.

The scientific researchers in turn described that they had developed as researchers because they were able to lead the dialogues and had become more competent in communicating and conveying scientific theory in a way that could be understood by others. They also expressed that they understood Gadamer’s expression of theory as praxis in a new way.

Contributing to clinical practice and science

The clinical coresearchers experienced that the dialogues did not create an entirely new understanding of the ethical values that the discussions pertained to, because they had previously possessed knowledge of ethics. The new knowledge pertained to making those ethical values being discussed visible in their daily work and that it is possible to realize theory in practice.

The dialogues have put words to events in everyday life.

I understand the theory in practice. But what did practice give to the theory?

For the clinical coresearchers, it was important to participate in and contribute to the development of theory, that is, to see one’s contribution to science. The scientific researchers expressed in turn the importance of that a scientific theory makes a difference and that they wished to contribute to the development of practice. They maintained that the dialogues contributed to basic research by highlighting what an ethical sustainable caring culture entails. The scientific researchers also maintained that the dialogues contributed to the development of clinical caring science, for example, through nuanced clinical images of the ethical values.

I learned more not only about what-questions but also how.

We did not have basic knowledge of what ethical sustainable caring cultures entail which is needed if one at the end of the research process is to be able to contribute new knowledge to caring and caring science.

Discussion

Our findings show that researchers experience participation in reflective dialogues as being conditional on a measured pace and calm and the participants being interested, present and given the space to express themselves. Sharing a common interest in the thematics of dialogues is, in accordance with Moules et al. (2014), a kind of personal address. The participants here described that differing opinions were allowed and that the dialogues were characterized by a genuine interaction and presence in the here and now, which is in line with Koskinen and Nyström’s (2017) description of the hermeneutical room where an ethical spirit exists. Still, one can ask whether carefulness and respect can be a barrier to genuine openness in a dialogue. Similar to what was seen in a study by Bergold and Thomas (2012), the clinical coresearchers here at first experienced their participation as being imbued with anxiety and feelings of outsidership. Both the clinical coresearchers and scientific researchers experienced their participation in the dialogues as challenging, though more interesting than frightening. Yet, in the end, both the scientific researchers and the clinical coresearchers felt empowered (Raelin & Coghlan, 2006). While the need to understand ethics from a deeper perspective was obvious to all participating in this study, even if one is able to articulate and express one’s thoughts, it is still not easy to relinquish one’s preunderstanding (Gadamer, 1989), enter a state of wonder, and exist in an open search for new understanding. Still, while the coresearchers found it confusing to exist in a constant, open search for new understanding, this was perhaps not always confusing enough to make them change and open up new horizons in their life and practice.

In a hermeneutic application research approach, understanding as application and a transformational power (cf., Davey, 2015) is a central moment. The participants here described their experiences of the dual meaning underlying application. An inner appropriation could occur first when one was in wonder and simultaneously respected that which is different. As Hansen (2000, 2008) notes, inner appropriation is a sort of dance between dwelling and wonder in a dialogue that facilitates the existential moment or understanding. Here, the participants experienced that they applied new understanding through a greater ethical awareness, by changing their way of being as well as by contributing to clinical practice and the development of theory. The reflective dialogues increased the clinical coresearchers’ ethical sensitivity and influenced their patient encounters, work fellowship, and occupational health. Application occurred when scientific caring science concepts and a shared language for caring were highlighted and articulated. Similar findings were seen in a study by Ranheim and Arman (2014), who found that when caring science theory and practical clinical knowledge are combined, a process occurs in the understanding of caring. It is in the interaction between theory and practice that caring consciousness increases. The clinical coresearchers described their changed attitudes in care work, which in turn contributed to more awareness and intellectual insights. Ranheim and Arman (2014) furthermore found that clinical coresearchers gained clinical caregiving knowledge and increased awareness of their profession. The scientific researchers here experienced that they better understood Gadamer’s (1989) thesis that there exists in all understanding an inextricable link between theory and praxis after the dialogues. Using Gadamer’s (1989) terminology, this study shows that application research should be compared with an educational journey that is intended for all researchers who participate in this type of research—not just for clinical practitioners.

Some researchers maintain that hermeneutic application research has a more didactic than scientific goal (Ranheim & Arman, 2014) and that it bears similarities to practice development (Titchen, 2014). We find that the role of theory building in the literature of this methodology is understated, and our experience suggests that the development of theory does occur in application research. We maintain that reflective dialogues with a hermeneutic application research approach contribute not only to practice when theories are applied but also to basic knowledge in caring science and clinical caring science. The theoretical contribution from hermeneutic application research pertains to the understanding of a scientific concept or the concept’s contextual characteristics. Thus, hermeneutic application research that fails to contribute new scientific knowledge does not reach the target the research approach deems requisite.

What is the strength of reflective dialogues with a hermeneutic application research approach in terms of caring ethics research? Can reflective dialogues contribute to understanding in the same manner as ethical reflections or deliberative dialogues? Söderhamn, Kjöstvedt, and Slettebø (2015) describe ethical reflections as “reflections on ethical issues and possible alternatives of actions” (p. 1945) that require the ability to engage in critical thinking. Söderhamn, Kjöstvedt, and Slettebø highlight ethical reflection as a method whereby care staff gain knowledge and the ability to solve ethical situations. Deliberative dialogue in turn pertains to knowledge translation and the development of consensus to find the best course of action (Boyko, Lavis, Abelson, Dobbins, & Carter, 2012). However, the goal of reflective dialogues with a hermeneutic application research approach is to understand—to understand one’s own and others’ perceptions and come to the point that unites and creates a common understanding where theory and praxis become one. Reflection in application research is directed at and limited to “the thing itself” (cf., Gadamer, 1989) and its purpose is neither to solve problems nor find new actions, even if new understanding gained through individual, inner appropriation allows for new possibilities for action. Through reflective dialogues, focus is moved from a critical approach to a unifying approach and from the individual to the common (cf., Koskinen & Nyström, 2017), which contributes to an increased ethical sensitivity in relation to one another and others—including both patients and work fellowship. In reflective dialogues, the main emphasis is placed on that which brings together and leads to unified understanding, where theory and praxis become one. The goal of reflective dialogue is to reach the fusion of different horizons, which is more important than solving ethical conflicts. We maintain that the articulation of the fusion of horizons or the common understanding greatly contributes to each and every individual increasing his or her understanding. The experience of sharing understanding with others is something that resonates and gives an individual the strength to go out in clinical practice and implement that which one has understood. At the same time, it is exactly this articulation of shared and common understanding that challenges a scientific researcher’s theoretical and hermeneutical competence.

There are many challenges involved in applying a hermeneutic application research approach. Prior to the start of reflective dialogues, clinical coresearchers’ must commit themselves to participating in each dialogue and scientific researchers’ must strive to improve their theoretical and research skills, as these are essential prerequisites. The scientific researchers’ participation in the dialogues can be characterized as a movement of “both . . . and,” a movement from leader to participant and back, as a translator of theory to practice and of practice to theory, as a guardian of an ethical atmosphere and simultaneously the elicitor of new knowledge. One challenge for the scientific researchers here was keeping the sense of wonder alive (cf., Hansen, 2008). This entailed the scientific researchers allowing a dialogue’s reflective questions to remain “open” or unanswered, despite the clinical coresearchers expecting an answer in regard to the realization of theory in their practical care work. Not only did the actual act of reflection require plenty of time, but it was also challenging to find the time to “rest” in theory or practical caring situations to gain new understanding. It was demanding for the scientific researchers to continuously demonstrate the equal value of practical and theoretical knowledge while concurrently contributing to the theoretical knowledge as a participant and clarifying theory by translating the clinical coresearchers’ accounts from clinical practice as dialogue leader. It would be beneficial if two scientific researchers could share this responsibility, especially given the complexity inherent in such a research design.

Conclusion

This study demonstrates that participants in reflective dialogues with a hermeneutic application research approach are subject to certain conditions. The participants must share a common interest in the thematics of the dialogues, be present and dare enter the world of understanding, allow themselves to be in wonder and respect that which is different. In the hermeneutical room in the world of understanding, an ethical spirit prevails that allows the participants the space in which to express themselves. This study shows that it is the moment of application in understanding that changes the participants’ manner of being, even if the dialogues are relatively few in number.

The findings from this study lead us to maintain that reflective dialogues with a hermeneutic application research approach strengthen the relationship between theory and clinical practice. This thereby contributes not only to practice by facilitating the use of theory but also to basic knowledge in caring science and clinical caring science, thus making possible both the use of research and the development of theory.