A Ricoeur-Inspired Approach to Interpret Participant Observations and Interviews

Abstract

In-depth knowledge of what it means to patients to receive health care services is crucial to the development of adequate protocols for nursing. Qualitative research allows us to gain important insight into what is experienced by and meaningful to patients. The French philosopher Paul Ricoeur’s thoughts have inspired qualitative researchers to conduct various forms of analysis and interpretation that increase our knowledge of ways of being-in-the-world. This article describes and discusses how a specific approach to derive in-depth knowledge of patients’ lived experiences can be taken. A combination of participant observations and interviews was used to generate data. Field notes and transcribed interviews were gathered as one collective text and analyzed and interpreted with inspiration from Ricoeur’s thoughts on narratives and interpretation. This approach is argued to be a significant way of developing in-depth knowledge of patients’ lived experiences. Such knowledge is important within nursing science.

Introduction

A consequence of the recognition that qualitative and quantitative research methods should complement each other in the effort to improve health care is a readiness to listen to the patient. Over the past decades, the use of qualitative methods has grown within nursing and other health care research. It is increasingly acknowledged that the patient’s experiences and voice are valuable. Qualitative research, in which an explorative design—including interviews and participant observation—is adopted, seeks to allow the patient to disclose what is of particular meaning to her or him. This has become a significant factor in nursing research, as part of the recognition of the patient as an expert in the field of being a patient.

In qualitative research, the aim of which is to explore patients’ lived experiences, to generate valid knowledge it is essential that a critical approach is taken throughout the entire process. The French Philosopher Paul Ricoeur’s phenomenological-hermeneutic philosophy represents a fruitful inspiration for designing methods of interpretation to gain insight into how patients experience being-in-the-world. Increasingly, more researchers are inspired by his theory of narrative and interpretation (Ricoeur, 1976, 1984) in their interpretation of data (Charalambous, Papadopoulos, & Beadsmoore, 2008; Ek, Sahlberg-Blom, Andershed, & Ternestedt, 2011; Missel & Birkelund, 2011).

In the late 1990s, the Danish nursing researcher Birthe D. Pedersen took the first steps toward developing a method of interpretation inspired by Ricoeur’s philosophy (Pedersen, 1999). In her work, she investigated nurses’ experiences through language and cognition by conducting interviews with nurses and observations in hospital departments. In the interpretation of the interviews, Pedersen created a three-level analytical model that allowed for an interpretation of how nursing praxis is expressed through narration (Pedersen, 1999). In the following years, other Scandinavian researchers—among them the Swedish researcher Anders Lindseth—argued for interview interpretation using this three-level Ricoeur-inspired approach to investigate patients’ experiences. Subsequently, six Scandinavian researchers (Dreyer & Pedersen, 2009; Lindseth & Norberg, 2004; Wiklund & Lindholm, 2002) published papers about methods they had developed that were inspired by Ricoeur’s philosophy. However, those papers focused solely on the interpretation of interviews with patients. Moreover, it is commonly used in ethnographic research to conduct both interviews and participant observations as complementary methods to provide in-depth knowledge of phenomena under investigation (Hammersley & Atkinson, 2007; Hounsgaard, 2004; Spradley, 1980; Wadel, 2014). The current article intends to fill a gap in the literature and clinical research by presenting how a Ricoeur-inspired approach can be used to interpret a gathered set of data covering both interviews and participant observation conducted in the same study of what it means to patients to receive particular health care services.

The aim of this article is to describe and discuss a way to derive in-depth knowledge of patients’ lived experiences when participant observation and interviews are used as complementary methods and analyzed as a coherent set of data material with inspiration from Paul Ricoeur’s philosophy.

An Introduction to a Specific Ricoeur-Inspired Phenomenological-Hermeneutic Approach

For years, it has been our privilege to explore patients’ experiences in scientific studies. We have achieved access to their views and feelings by conducting Ricoeur-inspired phenomenological-hermeneutic analysis and interpretation of gathered sets of data, consisting of both field notes and interview transcriptions which together covers what is investigated (Agerskov, Ludvigsen, Bistrup, & Pedersen, 2015; Andersen, Thomsen, Bruun, Bødtger, & Hounsgaard, 2017; Simonÿ, Dreyer, Pedersen, & Birkelund, 2015; Simonÿ, Pedersen, Dreyer, & Birkelund, 2015; Specht, Kjaersgaard-Andersen, & Pedersen, 2015). This specific approach draws on particular premises from Ricoeur’s philosophy (Ricoeur, 1976, 1984). In this article, we will elaborate these premises and show how they are crucial to the overall analysis and interpretation in studies that take this approach.

First, we will present key theoretical points from Ricoeur’s philosophy that form the basis of the approach.

Second, we will argue how, in study application and interpretation of data, participant observation and interviews can be used as complementary methods to investigate patients’ lived experiences with reference to Ricoeur’s philosophy of language.

Third, we describe how one complete text—consisting of gathered field notes and transcribed interviews—can be analyzed and critically interpreted, inspired by Ricoeur’s theory of narrative and interpretation. This is illustrated by new examples of analysis and interpretation of data from a study that investigated what it means to patients afflicted by a minor heart attack to participate in a hospital rehabilitation program. The study design and former analysis are described by Simonÿ et al. in previous publications (Simonÿ, 2015; Simonÿ, Dreyer, et al., 2015; Simonÿ, Pedersen, et al., 2015).

Finally, a discussion of the approach is presented.

Ricoeur’s Thoughts on Language and Reflections

It can be argued that Ricoeur is a bridge builder between phenomenology and hermeneutics. In his work, he focused on textual interpretation as the primary aim of hermeneutics and developed a theory of interpretation in which he took into account language, reflection, understanding, and the self (Ricoeur, 1976, 1984). He combined phenomenology with a critical hermeneutic philosophy, making it possible to come to a realization from a text and reach a new understanding through critical interpretation (Ricoeur, 1976).

According to Ricoeur, the phenomenological assumptions are that language is not merely a system, but that it articulates lived experiences. Therefore, new recognition of being-in-the-world can be achieved. Furthermore, Ricoeur emphasizes that language is crucial to our existence and experience of the world. He states that a person becomes aware of his or her participation in the world by talking about it (Ricoeur, 1976). In addition, language is central, in the sense that it is neither sign nor concept, but an expression of impressions which include experiences of how we are affected and thereby moved in a situation. This subjectivity is central to and characteristic of Ricoeur’s thinking. Thus, the lived experience and recognition of being in the world are expressed through language. One is characterized by one’s physical existence, by being able to sense, move, think, tell, and be affected by a situation. Ricoeur (1976) puts it as follows:

Because we are in a world, because we are affected by situations, and because we orient ourselves comprehensively in those situations, we have something to say, we have experience to bring to language. (p. 20)

In line with this statement, we take both the experiences of the patients (what is said) and of the researcher (what is observed) into account. We let the language of both sources speak to us about the lived experiences of the context and the lived life of the patients. By persistently following the thinking of Ricoeur (1973), the language and thus the informants’ narratives and the researcher’s observations are valuable, because experiences gained from the narratives and observations depend on whether or not they are told. Ricoeur emphasizes that a person gains experience only when working through lived incidents, using the forces of the narrative language, that is, when the person makes a stop, takes a step back, and through reflection draws lessons from the experiences that he or she has gone through (Pedersen, 2005; Ricoeur, 1973). As researchers, we accept both the reflections of the researcher and the reflections of the participants as valuable data. We see them as not just a copy of reality, but as expressions of an interpreted world (Pedersen, 2005; Ricoeur, 1984). When conducting participant observation and interviews, we are able to capture what is observed and said and to transform it into a text. According to Ricoeur, text fixation (writing) is the full manifestation of discourse (Ricoeur, 1976, 1984). Ricoeur states that when the discourse undergoes fixation as a text, it achieves independence in relation to the author and the original situation, which results in a beneficial distance from the situation. Discourse is the language as an event in a dialectical way—between event and meaning—and is a way of revealing “what the text is speaking about.” Ricoeur states that language is built up as a hierarchy of acts; when something is said, it is expressed by way of a power of request. This generates certain responses that lead to one being affected and moved in the situation. Thus, the way words and actions are expressed forms the basis of initial analysis and interpretation of the phenomena under investigation. When conducting observations, the researcher is able to observe this movement in the specific moment and document it as a field note (cf. Emerson, Fretz, & Shaw, 1995; Hammersley & Atkinson, 2007).

Participant Observation and Interviews as Complementary Methods in Data Generation

With reference to Ricoeur and the above-mentioned forces of language, a world can be opened up to the researcher in a manner that can be characterized as a hermeneutic spiral (Ricoeur, 1976, 1984). When the researcher’s reflections during the data generation are considered an act of interpretation, new important insight can be gained in this part of the study. In phenomenological-hermeneutic studies, in which the aim is to gather new knowledge of what is meaningful to patients, conducting interviews is often used. In this section, it will be elaborated and argued that phenomena can be more comprehensively investigated if not only interviews but also participant observation are performed in the same study, because by complementing each other they facilitate a thorough unfolding of lived experience.

Participant observation performed with inspiration from Hammersley and Atkinson, and Spradley (cf. Hammersley & Atkinson, 2007; Spradley, 1979, 1980) allows for an insight into the context in which the patients participate. It allows researchers to investigate how participants express themselves over time, both in bodily terms and by means of statements, how they interact with each other and with health professionals, how they experience their life situation, what is meaningful to them, and how they respond to certain health services. The researcher is a participant in some situations, both as a part of what is happening—often as an active listener and observer—and as the performer in informal conversations (Hammersley & Atkinson, 2007; Spradley, 1979). It is particularly favorable if the participant observations are conducted repeatedly over a longer period and include a variety of roles between full participation and full observation. Thereby, a broad perspective can be captured on how the participants develop their perceptions during the course of a study (Hounsgaard, 2004). Taking this kind of position will ensure that there is room for an open investigation. It opens up the researcher’s attention and sensitivity to what is important to the participants and therefore makes clear what it is that is relevant to explore further (Agerskov et al., 2015; Andersen et al., 2017; Hounsgaard, 2004; Simonÿ, Dreyer, et al., 2015; Simonÿ, Pedersen, et al., 2015; Specht et al., 2015). By focusing on what is observed and expressed by the participants and how it is revealed, rich data can be generated (Emerson et al., 1995; Hammersley & Atkinson, 2007).

Insight into what is significant to the patients—that is, the lived experience—can be supplemented by conducting interviews. Narrative interviews can give further in-depth insight into what is meaningful to the participants through their stories (Fog, 2004; Kvale, 1996). By transcribing the interviews and reading them, the researcher can not only capture the way of being-in-the-world that is disclosed by the participants but can also identify whether anything should be explored deeper, either in interviews or in observations.

As a whole, such data generation can be characterized as a dynamic process between what is expressed orally and what is expressed by behavior, interaction, body language, atmosphere, and quotations from the observed situations. Combining these resources for data collection provides richer sets of data, where the verbal quotes are substantiated by behavior and vice versa. Furthermore, this combination of interaction and verbal communication provides a basis to establish a close relationship between the researcher and the participants, allowing for access to more in-depth data. In this sense, an initial impression opens the researcher’s mind up to the lived experience and allows further investigation and interpretation—in a movement between understanding and explanation, through the language (cf. Ricoeur, 1976). As an example, from a study of cardiac rehabilitation (Simonÿ, 2015), the researcher found that there was a remarkably positive and encouraging tone between the patients in the rehabilitation sessions. She noted that the patients were very open and respectful to one another and that there were smiles, laughter, and a tendency to engage deeply in healthy competition. Because in the interviews the patients also expressed that it was “uplifting” and “encouraging” to them to participate in the group-based exercises, it became relevant to explore this phenomenon deeper during the subsequent observations and interviews.

In the following, a specific, three-level method is elaborated for Ricoeur-inspired analysis and critical interpretation, based on one collective text consisting of field notes and transcribed interviews. The method is illustrated with reference to an example of a new analysis and interpretation of data from the above-mentioned study on patients’ lived experiences of participating in cardiac rehabilitation when afflicted by a minor heart attack and is shown in Table 1.

Table 1.

An Example of a Structural Analysis Regarding the Finding: As a Heart Patient in Rehabilitation, You Become a Member of an Edifying Fellowship.

Units of Meaning: “What Is Said/What Is Observed”	Units of Significance: “What Is Being Talked About/ What the Observation Is About”	Theme
P9: “One or two days after returning home from the hospital, I received an invitation by mail. It said that I had been enrolled on Heart Team Two and that they had planned an eight-week programme. And of course I signed up. And there are more sides to it. First, there is the professional one, i.e. regarding the exercises. And then of course there is also the social aspect. And there is no doubt that this also plays a part. It does not really require much before you obtain a kind of teammate feeling, seeing that we are all in the same boat. It has been quite a pleasant experience.” (Int.) The physiotherapist explains that we are going to play ball. We are going to work together and are given points each time our team gets hold of and grabs a ball that we have thrown to her or him. We play for about ten minutes. We work hard and are enthusiastic about the game. We use sports terms and similar exclamations, depending on whether it goes well or not so well for our team. We correct each other and laugh when the ball ends in the dustbin by mistake. Our pulse rate goes up and the mood gets better as the game progresses. We compete against each other, playing skittles for two minutes. The physiotherapist praises us. He says that our team plays at a high level. It brings the mood up even further. (FN) P4: “Indeed. It has definitely been the best situation when being together with the others on the heart team. I like these people. It was really nice being together.”(Int.) P11: “When you have been together on more occasions, you end up feeling that you belong.” (Interview) Then we form a relay team where, as a team, we are going to collect a deck of cards. We are to run up to four hula hoop rings and find playing cards. If you have run up to one of the rings and there are no cards you can use, you have to run back to your team and send the next runner along. The cards have to be collected in the right order in each of the four colours. We rack our brains to remember which cards are where and then guide each other in relation to our recollection of where the cards are. It is fun. We laugh and cheer each other on. It is as if the world around us is completely forgotten. We are so absorbed in the game. (FN) P8: “What I think is that, if you had been sent home without having had the chance to be together with the others, then you wouldn’t have known about their reaction. It gives you a little more than just going there to do your exercises. What you also see is what the others are capable of. And your next thought is: if they can manage it, you could possibly also manage it yourself.” (Int.)	Participating in the in-hospital rehabilitation is like entering a shared sanctuary for the patients. When the training becomes intense, a shared involvement arises, which means that the world outside the training hall becomes distant for a while. In the training hall, there is a growing atmosphere of harmony, liberated energy, and joy. A positive, shared energy means that the training is easily executed and effective. When the patients and physiotherapists interact in this positive atmosphere, it works as an encouragement. Realizing that fellow patients manage the strenuous training quite well enables the patients to dare put pressure on themselves. A competitive spirit arises, making the patients want to and trust in their capability to fight to win. The patient has a genuine feeling of being a member of a special kind of team, which they name “The Heart Team.” They treasure the time they spend in this team with the fellow patients with whom they feel connected because of and with their hearts. When being together, they feel comfortable and find a natural way to deal with not only the training but also their common life situation.	Becoming a member of an edifying fellowship

Note. An example of a structural analysis made of field notes (FN) and interviews (Int.), from the study of what it meant to patients afflicted by a minor heart attack to participate in cardiac rehabilitation. The arrows indicate that the process of structuring units of meaning and units of significance and identifying themes can be characterized as dialectical because the analysis moves forward and backward among these three levels.

Data Analysis and Critical Interpretation and Discussion of One Coherent Text With Field Notes and Transcribed Interviews

Using a Ricoeur-inspired approach to the process of analysis and interpretation, new insight can be achieved into the meaning of the lived experience (Ricoeur, 1976). As regards the approach presented in this article, it is noteworthy that the entire set of data material includes not only the patients’ verbal expressions but also observations of the context that they are part of with bodily expressions and interactions. This allows a picture to be created, with a diversity of nuances detailing how the lived life is experienced. Accordingly, the approach provides the opportunity to reach a novel understanding of what it is like to be a patient, when receiving particular health care services.

The process of analysis and critical interpretation takes place in dialectical movements between three levels, consisting of naïve reading, structural analysis, and critical interpretation and discussion (Pedersen, 1999, 2005). This process encompasses movements between explanation and comprehension, wherein lies an inherent validation of initial preconceptions and presumptions (Dreyer & Pedersen, 2009). Below, we describe how the approach facilitates the references from the text into the world (Dreyer & Pedersen, 2009).

In using interview texts and field notes for data analysis, living conversation and observations become fixed in text and replace the previous dialogical relationship between the participant of the study and the researcher. This creates a distance from the narrator, whereby the text becomes detached from the authors—the researcher and the participants—and takes on its own life. According to Ricoeur, instead of the author’s voice, the text now contains a “narrative voice” which becomes the narrator in the text (Dreyer & Pedersen, 2009; Ricoeur, 1976). A narrative implicitly contains an interpretation of the narrator’s experienced reality. Ricoeur discusses the duality of reality presented in a narrative—the real world versus the experienced world. The narrative constitutes a description of the real incident (in our case, based on both interview and observation) which provides insight into both an observed world and a personally experienced world (Pedersen, 2005).

In the following, the approach is demonstrated as a process, which starts with naïve reading, followed by structural analysis and completed with critical interpretation and discussion. It should, however, be noted that the process includes a dialectical movement between the three levels, as illustrated in Figure 1, and therefore is not that structured in reality.

Figure 1.

Illustration of the process of analysis and critical interpretation.

Note. Analysis and critical interpretation take place in dialectical movements between three levels, consisting of a naïve reading, structural analysis, and critical interpretation and discussion.

Naïve Reading

The intention of the naïve reading is to achieve an initial understanding and to recognize the meaning of the text as a whole. The approach to the text is open-minded and the immediate impressions—what moves the researcher—are noted. The process of identifying and transforming key elements from the text involves an element of guesswork (Pedersen, 2005). The naïve reading in the present example from the study of what it means to participate in cardiac rehabilitation led to the impression that the atmosphere during the training had a positive impact on the patients. Both the patients’ quotations and the descriptions from the field observations in the example in Table 1 reflect this. The noteworthy aspect is that this positive impact is expressed very thoroughly when the text covers not only the observed tone, interactions, and expressions from the concrete context but also the narratives from the patients. This allows for performing an in-depth interpretation of what is experienced by the patients in the rehabilitation that is rich. Thus, the naïve reading of field notes and interview transcripts represents one first initial level of an analysis of lived experiences that is addressed by several different angels. Ricoeur describes it as “a naïve grasping of the meaning of the texts as a whole” (Ricoeur, 1976, p. 74). He emphasizes that the subsequent interpretation includes a movement between explanation and understanding that leads to a sophisticated mode of understanding—an understanding in which the interpreter, supported by explanatory procedures and through distanciation, achieves a new insight into what a text reveals. Ricoeur describes this as an appropriation (Ricoeur, 1976).

Structural Analysis

The function of the structural analysis is to open up the whole text and to make further interpretations possible. First, the text is split up into “units of meaning,” representing “what is said and/or observed.” Next, units of significance are identified as descriptions of “what the text speaks about.” Thus, the analysis is conducted as a dialectical process, moving from “what is said and/or observed” to “what the text speaks about,” leading to the emergence of patterns, subthemes, and main themes. This process is carried out as an ongoing internal validation of themes in relation to the naïve reading, units of meaning, and units of significance (Ricoeur, 1976). Hereby, an appropriation of the data set is fulfilled. The interpreter has achieved insight into the meaning of the lived experiences.

The advantage of analyzing data from participant observations and interviews as one text is the privilege of having units of meaning that contain not only what is seen but also what is expressed by body language or tone and what is said. Through the structural analysis, it becomes possible to make an interpretation across the text and identify units of significance. As shown in the present example (Table 1), one unit of significance is found to be “Participating in the in-hospital rehabilitation is like entering a shared sanctuary for the patients.” This unit of significance is further disclosed in Table 1 and titled under the theme “Becoming a member of an edifying fellowship.” Hereby, the use of explanation and comprehension in the interpretation includes a validation of the text as a whole. What is identified in the parts of the data is held up against what is captured by the whole set of data. Both what is observed by the researcher in different situations and what various patients state are taken into account. This thereby enhances the credibility of the data by ensuring that what is found is part of the coherent whole.

The process of deriving units of significance and themes constitutes the foundation for describing the findings of the study. It is therefore an important advantage to have both observations and patients’ narrations because it leads to comprehensively descriptive phenomenological findings. Such well-covered interpretation of the patients’ lived experience, gives a sound basis for further critical interpretation and discussion.

Critical Interpretation and Discussion

In the critical interpretation and discussion, the intention is to reach a further comprehensive and sophisticated understanding of the text. Based on the structural analysis, supported by explanatory procedures, the parts are put back into a new narrative communication that illustrates the appropriation of the text (Ricoeur, 1976). In this way, the focus is on what the text is about. To move the findings from the individual to the universal level, the structural analysis will be discussed in a dialogue that includes reference to other relevant theories and studies (Pedersen, 2005). Thus, in the critical interpretation and discussion, it becomes possible to gain a new understanding of what the lived experiences of the patients are. In our example, the process enabled a new way to reflect on how the patients experienced becoming part of an edifying fellowship, as described in Table 2. Because the patients’ lived experiences of participating in cardiac rehabilitation are interpreted across this broad data set, a new, comprehensive understanding can be achieved that is very thorough and close to what actually happens in the experienced real life.

Table 2.

Critical Interpretation and Discussion.

This interpretation finds that the patients afflicted by a minor heart attack value being together in “The Heart Team” during cardiac rehabilitation. This is in line with several other studies of cardiac rehabilitation showing that patients benefit from being with peer patients (Isaksen & Gjengedal, 2006; Jones, Greenfield, & Jolly, 2009; Pryor, Page, Patsamanis, & Jolly, 2014). The novel finding in the present study is that a certain shared positive atmosphere edifies the patients during the training. They feel like they are offered a shared sanctuary that involves harmony, liberated energy, and joy. By being together in this sanctuary, they experience increased well-being and find a natural way to deal with not only the training but also life itself. According to the Danish Philosopher Søren Kierkegaard, the belief in the possibility of the good life is to have hope. Kierkegaard (2013) claims that a person’s hope can edify another (p. 253). In this sense, the edifying fellowship in “The Heart Team” provides the participants with hope—the hope that a good life is realistic for them. This is important for nurses and other health care professionals to take into account in the care for patients afflicted by a minor heart attack.

Note. An example of critical interpretation and discussion that follows the structural analysis is presented in Table 1.

Thus, in-depth knowledge can be derived when a sophisticated understanding is critically interpreted and discussed with theory and other research. As shown in Table 2, the critical interpretation and discussion reveals that the edifying fellowship includes a hope-giving aspect that is experienced as an appreciated existential support to the patients. This knowledge clarifies that important personal benefits can be achieved from participating in cardiac rehabilitation. It highlights that being afflicted by a minor heart attack can be experienced as an existential effort, which should be addressed in the care of the patients. It furthermore reflects that the fellowship among cardiac patients might have unused potentials that could be brought into consideration when developing clinical practice. In this light, the findings can bring fruitful perspectives on nursing research and clinical practice.

Discussion

This article demonstrates how in-depth knowledge of patients’ lived experiences can be gained when participant observation and interviews complement each other and are analyzed using a Ricoeur-inspired approach. Drawing from the premises of Ricoeur’s philosophy, it is highlighted that experiences of being-in-the-world as a heart patient during cardiac rehabilitation are both expressed and interpreted by the language used (Ricoeur, 1976, 1984). The perspective, which includes not only patients’ narratives but also how they interact and express themselves over time and researcher participation during observation sessions, provides a nuanced set of data material ready for analysis on three levels. This results in significant in-depth findings that comprehensively cover aspects of heart patients’ lived experiences during cardiac rehabilitation.

It has been argued in this article that combining participant observation and interviews enhances opportunities to collect rich data. The approach allows for the formation of first impressions during the data generation and the opportunity to let such initial impressions be further examined to explore in depth what is happening during cardiac rehabilitation and experienced by the patients. Using Ricoeur’s term, the researcher is initially affected and moved, and this forms the basis of in-depth analysis and interpretation. Other studies investigating different areas within nursing science have demonstrated this strength during data generation (Agerskov et al., 2015; Andersen et al., 2017; Simonÿ, Dreyer, et al., 2015; Simonÿ, Pedersen, et al., 2015; Specht et al., 2015). What should be noted is that, here, the language represents the medium of the investigation. A new world is revealed to the researcher through the language because interpretation is taking place during data generation. In this sense, the researcher moves between an understanding of the language and an explanation by the language; by means of that, the data are used to explain what is understood. As Ricoeur points out, the aim of ordinary language is communication and the aim of scientific language is argumentation. He argues that both languages are necessary to capture the meaning of the text—what he calls units of significance (Ricoeur, 1976). A remarkable strength by the researcher’s movement between understanding and explanation is that it includes the advantage of uniting both languages in what can be considered as rich phenomenological descriptions.

Singsuriya (2015) made a comparison of four studies, each using a different method of analysis developed around Ricoeur’s theory. They highlight that although the structure of the hermeneutic arc in the process of interpretation is adopted in all four studies, its essential function to bridge explanation and understanding is not adequately rendered. As a result, it is argued that this affects the appropriate understanding in a negative way considering the intended meaning in Ricoeur’s philosophy (Singsuriya, 2015). In our approach, we argue that the bridge between explanation and understanding derives from dialectical movements in a process between explanation and understanding—thus bringing the interpretation from the individual to the universal level. Following this thinking, it is beneficial to investigate and reflect on patients’ experiences by involving both participant observation and interviews during data generation. However, this entails a rigorous and structured research design, including researcher reflections on, for example, inclusion/exclusion criteria, setting, and study period. According to Malterud, method triangulation has been recognized and recommended for many decades, with a view to strengthening qualitative research design (Malterud, 2001).

We have illustrated that texts consisting of field notes and transcribed interviews can be interpreted in one coherent analysis, with inspiration from Ricoeur’s theory of interpretation. The interpretation is conducted in a three-level process that includes a detailed description (in the researcher’s words) of being-in-the-world that patients afflicted by a minor heart attack experience to become a member of an edifying fellowship during in-hospital rehabilitation. This theme is further interpreted by critical discussion to reveal that being a part of the fellowship provides the heart patients with a hope that is crucial to having the confidence to endure exercising and dare live life. We argue that during such a process of analysis and interpretation, the researcher is moved by various responses. One strength of such an interpretation is that it is based on data triangulation, whereby insight is achieved from both observations and interviews. Furthermore, findings can be validated across the data.

Lindseth and Norberg (2004) argue that when we narrate our lived experiences and write down the narration, we produce an autonomous text that expresses its own meaning. However, they describe narration (interviews) as the only way to derive in-depth knowledge of being-in-the-world (Lindseth & Norberg, 2004). With reference to the presented study example and the described approach in this article, it is elaborated and argued how the combination of narration during interviews and participant observation gives more comprehensive in-depth knowledge about patients’ lived experiences when diagnosed with an illness and receiving health care services. It can be considered a strength that the findings achieved by the approach are disclosed by phenomenological descriptions that reflect patients’ lived experiences in a realistic and enriching way. The conclusions of studies using this approach are accordingly highly informative about real-life experiences. Thus, the knowledge gained is of unique value to nursing and clinical practice.

Alsaker and Josephsson (2009) illustrate how a narrative approach with participant observation led to a set of data material consisting of observations and reflections among women with chronic rheumatic conditions. They argue that, in taking their approach, they identified ways of understanding how the participants’ doings and experiences played a significant part in how meaning was constituted and communicated during their everyday actions (Alsaker & Josephsson, 2009). In the present article, we have illustrated that what is expressed in interviews can confirm what is described in field notes, and vice versa.

A longitudinal study design including both participant observation and interviews allows the researcher to follow the participants at different points while they are receiving health care services. Furthermore, our approach provides an opportunity to empirically test the interpretation by following up on themes or issues in subsequent interviews or observations (Agerskov et al., 2015; Andersen et al., 2017; Simonÿ, Dreyer, et al., 2015; Simonÿ, Pedersen, et al., 2015; Specht et al., 2015), resulting in new and significant findings. Moreover, the ongoing time perspective—especially continuous field observations over the course of weeks or months—provides access to knowledge about changes in patient’s self-image that occur during courses of treatment, care, or rehabilitation.

The approach for which we are arguing does not include patient evaluation as to the level of their perceived correctness of the interpretation. According to Ricoeur, narration allows for a process of reflection in the participants; this provides new perspectives into their lives, and this renders validation among the participants inappropriate (Morse, Olson, & Spiers, 2002; Ricoeur, 1973). Dreyer et al. (2009) argue that it is through the distancing—made possible by the language—that a Ricoeur-inspired interpretation can lead to a deeper understanding of what a text refers to in the world. In this way, the interpretation is conducted with use of both ordinary and scientific language. However, in the end, the interpretation is expressed in the words of the researcher, and the findings must be read with this premise in mind.

The knowledge that is achieved by the described approach is important when clinical protocols and settings are developed within nursing (Agerskov et al., 2015; Simonÿ, Dreyer, et al., 2015; Simonÿ, Pedersen, et al., 2015; Specht et al., 2015). Moreover, it is expected to be useful in theory making because it illuminates patients’ lived experiences and adds valuable new knowledge to the field.

When reflecting on Ricoeur’s thinking around narrative and interpretation of a text, an advantage is the open-minded approach to challenging preconceptions. In phenomenological studies, preconceptions can be bracketed to ensure a neutral approach to the topic. However, from the perspective of Ricoeur’s philosophy, preconceptions get qualified through interpretation, which means not to let it dictate anything before the text is appropriated. Ricoeur states that an sophisticated understanding of a text includes guesswork and a continuous validation of what is understood from the text (Ricoeur, 1976). Thus, the interpretation has to be sufficiently open-minded because it could be a source of error to think thematically in advance. Therefore, coauthors must be involved at all stages of the data analysis and interpretation process to provide the intended credibility of the interpretation and ensure trustworthiness and, thus, to eliminate misinterpretation or overinterpretation of the research findings.

Conclusion

In this article, we have illustrated and discussed a specific approach that has been shown to provide solid, in-depth knowledge of patients’ lived experiences. The approach draws on the phenomenological-hermeneutical thinking of the French philosopher Paul Ricoeur and includes a three-level interpretation of one collective text that includes field notes and transcribed interviews that cover the phenomena under investigation.

We have elaborated theoretical aspects, supported by extensive empirical explorative research, to show the strength of combining participant observation and interviews. Furthermore, we have argued for and discussed the advantage of conducting analysis and interpretation of patients’ lived experience, investigated from several angles, to achieve a unique in-depth knowledge. By using this approach, the patients’ perspectives are more clearly and comprehensively brought into the light.

We have demonstrated how the approach allows for an investigation of subtle areas of health care research and for a presentation of broad and nuanced findings covering topics within nursing and clinical practice.

Author Biographies

Charlotte Simonÿ, Ph.D., MES, RN is a Post.doc at Institute of Regional Health Research at The University of Southern Denmark, Odense. Denmark & the Department of Physiotherapy and Occupational therapy, Slagelse Hospital, Denmark & Institue of Health, Section of Nursing Sience, Aarhus University, Denmark.

Kirsten Specht Ph.D. MPH RN CRNA is a Postdoctoral Fellow at The Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark, Odense, Denmark & Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark.

Ingrid Charlotte Andersen, P.hD. MScN, RN is a researcher at The Department of Medicine, Slagelse Hospital, Denmark.

Kirsten Kjær Johansen, MSc Public Health, MSc Chiropractic is a Ph.D-student at The Research Unit, Mental Health Service Esbjerg, Denmark & OPEN, Institute of Clinical Research, University of Southern Denmark, Odense Denmark.

Charlotte Nielsen, RN, MScN is a Ph.D.-student at The Department of Nephrology, Odense University Hospital, Odense, Denmark & Department of Clinical Research, University of Southern Denmark, Odense, Denmark & Centre for Innovative Medical Technology, University of Southern Denmark & Odense University Hospital, Odense, Denmark.

Hanne Agerskov, Ph.D, MSc (Health), RN is an Assistant Professor at The Department of Nephrology, Odense University Hospital, Denmark and Department of Clinical Research, University of Southern Denmark, Denmark.