Researching Health Care as a Meaningful Practice: Toward a Nondualistic View on Evidence for Qualitative Research

The Notion of Objectivity

Objectivity concerns the relation between the researcher(s) and the phenomenon in question. But how do we understand “objectivity”? Husserl (1936/1970, 1939/1973, 1913/1998) argues that the whole idea of objectivity is completely misunderstood by contemporary science. Within the positivistic paradigm, objectivity is associated with detachment: The world is external and the researcher attitude should be independent and value-free. Besides showing how impossible this project is, Husserl (1936/1970) calls this the positivistic reduction, meaning that science is reduced to mere “fact-minded science.” This leads to what he calls “the crisis in science,” because we do not live in such a world. Science, he argues, has thereby “lost its meaning for life” (Husserl, 1936/1970, p. 5).

Husserl (1939/1973) emphasizes the lifeworld as the foundation of all understanding. The lifeworld, he says, is “the world in which we are always already living and which furnishes the ground for all cognitive performance and all scientific determination” (Husserl, 1939/1973, p. 41). Furthermore, in slightly different ways, Husserl (1936/1970, 1939/1973, 1913/1998), Merleau-Ponty (1961/1964a, 1961/1964b, 1946/1964c, 1948/1968, 1945/1995, 1948/2004), and Gadamer (1960/1995) assert that the seamlessness of existence demands from science a thorough insight into the phenomenology of perception, and that, as it is an experience of or about some object, the central structure of an experience is its intentionality, its being directed toward something. 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.

It follows that phenomenological researchers acknowledge that research starts from connection instead of detachment. All researchers have some relationship and a certain understanding of the phenomenon in focus, known from experience or through established knowledge. Researchers thus attempt to understand the world or a phenomenon as something that they are already part of. All researchers should begin with this awareness. Then, as a matter of course, to be objective in a phenomenological sense, 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 or 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 preunderstanding (Dahlberg, Dahlberg, & Nyström, 2008). In other words, researchers’ immediate involvement requires that they should adopt an open, wondering phenomenological attitude that “slackens the intentional threads which attach us to the world and thus brings them to our notice” (Merleau-Ponty, 1945/1995, p. xv).

Dahlberg et al. (2008) and Finlay (2011) describe this phenomenological open attitude as one that is led by the phenomenon and an ongoing curiosity about it, “not making definite what is indefinite still” (Dahlberg et al., 2008). It is a “dance between striving for reductive focus and reflexive self-awareness” (Finlay, 2008, p. 8), a process of retaining wonder and openness to the world while reflexively restraining preunderstandings. Such thorough reflectivity helps to problematize the natural attitude, to slacken the firm intentional threads that tie us to the world, but it should be absolutely clear that we can never cut them off, or overcome our own subjectivity (Spence, 2016). In life—and thus in (all forms of) science—there is no dichotomy between subjectivity and objectivity. There is only a dynamic in-between. In the words of Gadamer (1960/1995), this open attitude includes a kind of sensitivity which

. . . involves neither “neutrality” with respect to content nor the extinction of one’s self, but the foreground and appropriation of one’s own fore-meanings and prejudices. The important thing is to be aware of one’s own bias, so that the text can present itself in all its otherness and thus asserts its own truth against one’s own fore-meanings. (pp. 268–269)

For researchers, this means that one needs to know how this attitude of alert, self-aware, and reflective openness can be practiced, and how we can see the phenomenon under study, while being aware of our perceptive lenses all through the research (Spence, 2016). A common mistake is to see the phenomenological attitude as something to be engaged in only at the beginning of the research. However, inquiry is a continuous beginning (cf. Merleau-Ponty, 1961/1964a), that is, from the first identification of research focus to the presentation of findings. It is thus not merely about “bridling” the preunderstanding that leads us to the study, but about “bridling” our understanding as a whole, all through the researching activity. The challenge for the researcher is to find a way to continuously remain open to new understandings as well to one’s own interpretation.

To reach objectivity in a phenomenological sense, every researcher should therefore focus on discovering that she or he was wrong, that she or he did not know at all. In Gadamer’s (1960/1995) words, “the otherness” of the phenomenon requires exploration of the difference from what one already knows. Besides the ongoing use of a reflective journal we, like Spence (2016) among others, have experienced that it is indispensable to engage in ongoing dialogue with other researchers as this helps to reduce blind spots and challenges us to see the phenomenon and one’s evolving understandings “with new eyes.”

The Notion of Validity

Certainly, health research has to be valid as patients, clients, health professionals, and students—among others—largely rely on the fact that scientific knowledge (that guides professionals) is legitimate, not only in general terms but also more specifically with regard to their own well-being and/or professional practice. This places a huge responsibility on researchers when it comes to validity and reliability (Dahlberg, 2014). Actually, validity is a fundamental cornerstone of science.

In research, validity is commonly described as the degree to which a scientific study measures what it intends to measure: Does it actually measure the concept it is supposed to measure? And if repeated, is the measuring (instrument) consistent and reliable? Does it give the same measurement under the same circumstances? Clearly, this view comes from a positivistic paradigm, assuming that the world is stable and that one can take a detached, external, and independent position toward that stability. We assume, however, that human existence cannot be meaningfully understood from such a detached position. In the words of Polkinghorne (1986),

The traditional notions of validity and reliability in research design imply a system of concepts that is stable, context-free, and clearly delineated from one another, yet human existence points toward a conceptual system that changes, is context-dependent and is organized around prototypical instances. (p. 129)

In line with Polkinghorne, we believe there is no traditionless, history-free, or in other ways context-free research in any form of science (Dahlberg et al., 2008, p. 339); detached objectivity is a delusion. It follows that knowledge should not be dissociated from life and experience. This brings us to the following questions: How can we understand validity in a way that is consistent with phenomenology? How can we rethink validity in a way that supersedes this dualism in scientific traditions? What determines sound validity from a phenomenological perspective?

Polkinghorne (1988) states that validity refers to “well-grounded and supportable” findings and conclusions. However, he adds, human science is not a system limited by closed reasoning and formal logic. While having the capacity to resist challenge or attack, conclusions always remain open-ended (Polkinghorne, 1986, 1988, 2007) Importantly, this should not be seen as a flaw in research or its evidential character; instead, it should be seen as a principal characteristic of human nature and thus of (human science) research.

From a phenomenological perspective, research should be meaning-oriented. As Merleau-Ponty (1945/1995) states in his famous preface, “Because we are in the world, we are condemned to meaning” (p. xix). In phenomenological research, validity is thus associated with meaning, and researchers need to know the difference between content and meaning, for example, in a narrative. Researchers also need to find out how it is epistemologically and methodologically possible to understand the deeper meanings of the lifeworld. As researchers, we do not refer to “what” people say (content analysis or opinion research); rather, we attempt to refer to how they interpret what is meaningful in their lives.

An example may help: Several participants in a study into the wish to die of older people free of mental or terminal illness, cogently talked about ideating on a self-chosen death. They said they preferred to die quickly to spare themselves decline and suffering. In the participants’ words, “I want to die at the right moment.” At first sight, it seemed they were ideating on a so-called balance-suicide or rational suicide: After cognitively weighing the pros and cons, they came to the conclusion that they were better off dead. However, when the participant and the researcher talked about lived experience (and not about their opinions or intentions), their situation seemed to be far more ambivalent. They also told stories about postponing death, and lingering hope that life might still have something to offer. Indeed, by listening very carefully and by talking about events in everyday life, these older people turned out to be “caught” between ideating on a self-chosen death and actually performing one. The liminality of this in-between period has been characterized as an existential, appealing dilemma after a putatively coherent decision was made (van Wijngaarden, Leget, & Goossensen, 2016a).

The above example illustrates the phenomenological focus on the questions being researched: the importance of relating to the participants in ways that support their return to their ordinary life experiences (van Manen, 2017a, 2017b) and their reflections on them. The main emphasis in research is not on the informants and what they express, but on the meaning structure of the phenomenon (Dahlberg et al., 2008; van Manen, 2017a). Such a nuanced focus makes huge difference in all forms of qualitative research. Wanting to illuminate meaning is, however, not that easy. Meaning is always contextual, as Merleau-Ponty (cf. 1948/1968; 1945/1995) strongly argues in several texts. Consequently, researchers should address contextuality when presenting their conclusions. We will address the issue of contextuality in the next section.

The Notion of Generalization

All kinds of research have generalization challenges. For example, in statistic research, all findings are related to populations and systems. As a consequence, both researchers and practitioners must complete the process with interpretive work for them to relate the conclusions to a distinct individual, be it a patient, a client, or a student, within her or his unique context (Thorne & Sawatzky, 2014). It follows that every researcher should think through the notion of generalizability. In this regard, there is no radical difference between the concepts of generalization in qualitative or quantitative research. The interpretation and assessment of generalizability is based on underlying ontological, epistemological, and methodological assumptions (Dahlberg, 2014; Dahlberg et al., 2008).

However, the impact of qualitative research findings—and in particular of 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. Indeed, it has been argued that generalization and theory development do not belong to phenomenological research at all. We disagree, and we encourage phenomenological researchers not to accept that such research results only relate to those few who participate in the studies. Research results should be of a kind that can be generalized, that is, they should be meaningful to more people than just those involved in the study. Phenomenological inquiry wants to reach knowledge that goes beyond concrete individuals (Dahlberg et al., 2008; Halling, 2010; Svenaeus, 2000; van Manen, 2014, 2017a). All qualitative researchers can make convincing arguments about the generalizability and the transferability of their findings.

Instead of presenting fragmented results such as “themes” or “categories” without clarifying what they are parts of (which demonstrates another example of a positivistic remnant), a phenomenological study aims to present “an essence,” “a general structure of meaning” or another way of presenting both structure and texture of the phenomenon under research (Dahlberg, 2006; Dahlberg et al., 2008). This essence refers to a common thread through the variety of participants’ experiences. It illuminates the very character of the phenomenon “without which it would not be that specific phenomenon” (Dahlberg, 2006). The aim to provide such an essential meaning structure—and thus no separate categories—is really a core-strength of phenomenological inquiry in comparison with other qualitative studies. Furthermore, a description of an essential meaning structure obviously implies a certain generalizability of the findings, otherwise it would not be essential.

While there are also distinct differences between phenomenology and grounded theory (Creswell & Creswell, 2007; Starks & Brown Trinidad, 2007), we suggest that a well-developed “core category” in grounded theory might also be in line with such an essential phenomenological description. A core category in grounded theory is also a fundamental, empirically well-grounded, patterned description that can best explain the problem that the people under research are dealing with. Moreover, in phenomenology as well as in grounded theory, researchers should never force the experiential data to generate such outcomes. Rather, mindful openness should let outcomes emerge from data.

To make things more complicated, while phenomenological research strives to describe the essential meaning of the phenomenon under research, it is also clear that meaning should always be viewed as contextual and infinite. This idea of contextuality might seem to compromise the generalizability claim. However, a full description of the meaning structure of the phenomenon contains both essential, general meanings (i.e., structure) and meaning nuances (i.e., texture), such as quotes from interviews, which reveal the variations (Todres, 2007). A full description of an essence should always be accompanied by an analysis of particularities, nuances, and unique contextual variations in the meaning of the phenomenon. It is this full structure of both generality and particularity that should say something new and enhance our understanding of the specific phenomenon under research.

Merleau-Ponty (cf. 1961/1964b, 1948/1968, 1945/1995) has demonstrated how every generality is already present in particular meaning, and every particular meaning is present in the generality. Particularity and generality, uniqueness and sameness, is a natural paradox within being and of the lifeworld. There is thus no dualism between particularity and generality; they are of each other. Instead of allowing for polarization of that which belong 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 (Dahlberg, in press). In phenomenological research and, we argue, in all qualitative research, it is thus necessary to move between particularity and generality, between the most concrete and lived personal expressions and the more general meanings (Dahlberg, 2006).

It follows that phenomenological truths should not be understood as “final and law-like absolutes” and “conclusive distinctions between the true and the false” (Halling, 2010; Todres, Galvin, & Dahlberg, 2007; van Manen, 2014). Instead, phenomenologically understood truth should be considered “possibilities around which unique variations and actualities can occur”; an “on-going conversation which is never finished and depends on questions and context” (Todres et al., 2007, p. 58).

Given these considerations, it follows that phenomenological inquiry does not aim at logically valid deductive conclusions it seeks to provide plausible and inceptive insights into the primal meaning structures of lived experiences. Subsequently, phenomenological truths and thus phenomenological evidence are ambiguous and never complete (van Manen, 2014). In this context, generalization is thus not understood as universal, factual, and/or quantitative generalization, but as an “existential generalization” (van Manen, 2014).

Furthermore, the term transferability can help to better understand the idea of generalization in qualitative research. It means that results, for example, descriptions of general structures of meaning, interpretations of meanings, or theories are applicable within different settings. This understanding of generalization is advocated by Gadamer (1960/1995) in his use of the term anwendung, which in English is usually translated as “application” even if usability would be a better translation. According to this idea, 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.