Hermeneutics and Human Interplay: A Clinical Caring Science Research Method

The Characteristics of Play

The term hermeneutics is derived from the name Hermes, the ancient Greek god who was believed to have invented many types of gambling, and was therefore the god of players. He protects and takes care of all travellers, sprinters, and injured athletes who need his help. Hermes delivered messages from Olympus to the mortal world. In Greek, a lucky find was a hermaion, and an interpreter who removed the communication barrier between strangers was known as a hermeneus. Since then, hermeneutics has come to mean both the art of understanding and the science of interpretation (Senior, 1985).

Gadamer claimed that his intention was to expand the concept of play and how we can understand and interpret the play in which we participate as an alternative to the concepts of modern science and aesthetic pleasure (Gadamer, 1986, 2004). Gadamer demonstrated that the most basic feature of play is the back and forth movement between the “players” from which the hermeneutic circle emerges. Consequently, Gadamer (2004) held that play has a hermeneutic structure in which the highest level of understanding can be achieved. He wrote, “Here, it becomes clear why starting from the concept of play is methodologically advantageous” (Gadamer, 2004, p. 115).

For something to be called play and not just an aesthetic pleasure, it must be linked to a model (Gadamer, 2004). Without a model, play will be unrecognizable or inert and reduced to a game without a history and a future. But, if play is guided by models, the hermeneutic inquiry will not be cut off from vital connections with the past and the future because it is informed by meanings and insights from the past and enriched by anticipations of the future. The recurrent back and forth interplay between the past and present horizons, in which a model is applied, gives play direction and substance so that a living relationship between the idea and the performance can emerge (Gadamer, 2004).

In moving beyond assumptions of aesthetic pleasure, Gadamer (2004) declared, “Seriousness in playing is necessary to make the play wholly play. Someone who doesn't take the game seriously is a spoilsport” (p. 103). Playing seriously requires theoretical knowledge as well as practical skills; an inherent expectation of the game is that it should be played to the best of one's ability. Similarly, to achieve the intended good, the best play presupposes familiarity with the research context and hermeneutic insight, which means participation in the experiences of the other (Gadamer, 2004). What is demanded is not the elimination of all our pre-understandings but to bring them to the game and risk them by remaining in play, which is the constant task of the hermeneutic researcher.

Gadamer (1986, 2004) particularly emphasized the researcher's position of “being present” in the essence of play. Here, he freed the concept of play from the Cartesian model and brought it into the dimensions of participation and dialogue. Dialogue does not necessarily imply an exchange of words, but involves treating the other's “otherness” with respect. It also means treating the other as someone who has something to say so that play can continue. As we move within this back and forth “dialogic play” with the other, our horizon shifts and merges with their horizon of understanding, although their situation might be very different from our own. Therefore, one cannot participate in play from a distance or with an uncommitted attitude. Nor can the other's otherness be considered a problem or allowed to become the subject of curious gazes. Gadamer (2004) claimed, with reference to Huizinga, that the domain of play is always a restricted, protected world—a sealed hermeneutic playground where the other's inviolability constitutes the ethos (Huizinga, 2004, p. 38). In other words, understanding relies on ethical conditions that we must become aware of by being present. The game must go on (Vilhauer, 2010).

Although Gadamer (2004) was of the opinion that writing is of secondary importance, he held that the play remains incomplete until it has been transformed into words and subjected to hermeneutic text interpretation. This emerges through a language game that rests on the insight that one's partner, even if they have not taken part in the play, can contribute new and valuable perspectives that go beyond what has already been understood. As mentioned above, to start any game it is essential to bring and risk one's own pre-understanding, and in this respect the language game is no different. Nothing can be seen in the absence of pre-understanding. Revealed truth is the meaning of tradition (Gadamer, 2004).

Development and Formation of the Research Idea

The basic idea was that the method should follow the hermeneutic tradition, while at the same time be situated within a caring science paradigm. The first author (SL) discussed the issue of how to bridge the gap between research and caring activities with the two coauthors (IvP and KE), both of whom are academic researchers. This guided our idea of testing the concept of play as a participatory research method for children with special needs.

Pre-Understanding and Perspective

Hermeneutics requires a declaration of the researchers' pre-understandings, including their theoretical perspectives (Mitchell, 1994). The authors' pre-understandings are based on a caring science perspective (Eriksson, 2006b), comprising knowledge, experience, and commitment as nurse anaesthetists and nursing researchers, and on encounters with suffering human beings and the suffering of care. In addition, the first author has 30 years of experience working with children with special needs in her profession as a nurse anaesthetist. Hence, the author's pre-understanding should not be understood as purely existential or ubiquitous, but rather as professional (Lindwall et al., 2010), which can generally be described in terms of the researcher's familiarity with the research field in question. More specifically, a nurse's pre-understanding is the result of professional education and experience as well as part of the subculture of nursing (von Post & Eriksson, 1999).

The theoretical perspective is based on the ontological assumption of caritative caring science theory, which holds that playing is the substance of caring, and human suffering is the basic category that motivates all care (Eriksson, 2006b). If artistically applied, play has the potential to allow us to enter more deeply into the reality of the suffering human being, the patient, as well as alleviate human suffering in caring situations (Eriksson, 2006a). Such searching for knowledge implies that ethics precedes ontology (Lévinas, 1969) and involves attitudes and assumptions based on the caritative ethos of love, responsibility, and sacrifice (Eriksson, 2002).

Deciding On a Model

Different models for the application of play (Gadamer, 2004) were discussed, and the perioperative dialogue seemed the most appropriate in the given context. The perioperative dialogue presents an ideal model that fulfils the requirement for continuity in anaesthesia care and is based on caritative caring theory (Eriksson, 2002; von Post, 1999). The perioperative dialogue encompasses the caring process and is described as a nurse anaesthetist or operating room nurse's pre, intra, and postoperative dialogue with their patient in connection with anaesthesia and surgery. The purpose is to protect the dignity of the patient, alleviate suffering, and create safe nursing and a feeling of well-being (Lindwall & von Post, 2009). The perioperative dialogue can be traced to Plato's philosophy of dialogue (von Post, 1999), which investigates the idea of the good, created, recreated, and developed in accordance with human interactions and interplay (Huizinga, 2004). The methodological value of the perioperative dialogue is that it allows the nurse anaesthetist not only to collect data but also to be the patient's nurse, the one who cares for the patient during the whole perioperative process (Lindwall et al., 2010). This is of great importance for preserving human dignity in clinical research. However, the perioperative dialogue has to be further developed for children and play, as will be described in the Research Course section.

Participants

Four nurse anaesthetists, three female and one male, conducted the study; all had vast experience taking care of children with special needs. The nurse anaesthetists, from this point on referred to as nurse researchers, were trained to use the perioperative dialogue by means of a 10 week, full-time course with a focus on the nursing process and Gadamer's hermeneutics. Because the main goal was to introduce the concept of play in a caring context, we decided on a project that would make the nurse researchers familiar with this method of inquiry and relate it to caring science. Five meetings were arranged in which one academic researcher (SL) and all four nurse researchers participated. The first three meetings familiarized them with the method and its philosophical and theoretical foundations and the last two examined various ways play can be incorporated into perioperative praxis so that the new understanding can be applied to the child. After the course, the nurse researchers were considered to have adequate professional pre-understanding (von Post & Eriksson, 1999) and hence able to play the game seriously (Gadamer, 2004). The nurse researchers, who were responsible for the children during the perioperative dialogue (i.e., as the children's nurse anaesthetists), volunteered to transcribe, as carefully as possible, what was actually played out between themselves and the child.

After formal approval had been obtained from the relevant Research and Ethics Committee (No. Ö, 147-07), twelve children with special needs and their parents were invited to participate in the study. The children, four girls and eight boys aged between 5 and 16 years, were scheduled for elective outpatient surgery and/or dental treatment requiring general anaesthesia. Inclusion criteria were that the parents should be of sound mental health, able to understand and speak Swedish, and willing to share their experiences in an interview with the first author of what was played out between the child and the nurse. First, the child's physician or dentist asked the parents and the children if they were interested in receiving information about the study. Thereafter, the first author contacted those who had expressed an interest by telephone and provided them with more detailed information. A letter containing information for adults and the same information in developmentally appropriate terms for children was distributed to the parents. On the day of the preoperative dialogue, the information about the study aim and data collection procedure was provided again.

Ethical Considerations

An ethical approach to research with children who have special needs requires considerations beyond those of general ethical theories. In concrete terms, this means that individual researchers must be able to respond to the circumstances in the field and that what is ethically acceptable has to be decided on a pragmatic basis with reference to the situation (Beauchamp & Childress, 2001). As the nurse researcher performed the play (as the child's nurse anaesthetist), an ethical decision was that the call to serve should take precedence over the research aims (Lévinas, 1969). The nurse researchers strove to protect human dignity, safeguard integrity, and maximize benefits to ensure that the children and the parents viewed their participation as positively as possible (Beauchamp & Childress, 2001).

In addition, we did our utmost to obtain informed parental consent, thereby ensuring that they understood the purpose and procedure of the research. We explained that we wanted to explore what took place between the child and the nurse researcher during the perioperative dialogue. The carrying out of the perioperative dialogue was merely regarded as a change in routine, because the child's anaesthesia would have been administered anyway. It was clearly stated that the child's care would not be affected if the participants wished to withdraw from the study.

Voluntary, informed written consent was obtained from all parents, together with written consent for their children. Parents were aware that they could control the interviews and were free to divulge as much or as little information as they wished. It was impossible to obtain verbal or written child assent due to developmental limitations and lack of language proficiencies on the part of the children. The participating nurse researchers provided written informed consent. All participants completed the study. Permission was obtained from parents and nurse researchers to use anonymous quotations from the perioperative dialogue.

The Preoperative Dialogue

The preoperative dialogue started when a child was booked for a procedure requiring general anaesthesia. The nurse researcher then contacted the parent; a telephone dialogue was conducted and the parent's concerns about anaesthesia were discussed. Although dialogue is regarded as a back and forth dialogic play with the parent for the purpose of gaining hermeneutic insight, listening is the hallmark of a good researcher (Gadamer, 2004), who through interpretation comes to understand what is best for the particular child in the situation in question. Nevertheless, it is important to understand that interpretation in Gadamer's sense always involves the application of that which has been understood, because without it the play of understanding will not occur. Thus, this step should not be delegated to others, such as colleagues.

For the child, the preoperative dialogue started with a letter containing a photograph of the nurse researcher's face and continued when the child and parent visited the ward and met the nurse researcher approximately five days before the surgical procedure. The nurse researcher explained what would happen, showed the equipment to the child, and assisted the child in practising any required activity. As Gadamer stated, understanding emerges when agreement about the possible meanings is achieved between the partners involved in play, thus leading to a fusion of horizons. It might not always be possible to achieve a fusion of horizons in this clinical situation, and the fear experienced by some children might make it extremely difficult for the nurse researcher to explain to them what professional pre-understanding requires the nurse researcher to do. However, in accordance with Gadamer (2004), when carrying out the interpretation it is essential for the nurse researcher to remember to approach the other, in this case the child, with openness, treat his or her claim seriously, and allow it to challenge the researcher's pre-understanding, and thus the researcher is prepared to understand something new. This does not mean to “do blindly what the other,” the child, desires (p. 355) but to engage in the highest form of I-Thou relationship, which makes true play possible. Gadamer (2004) stated that the I-Thou relationship includes a moral obligation to our fellow actor, which in this context means ensuring safe nursing care and the alleviation of suffering. There is also a close etymological connection between playing and caring for, in the sense of engaging in someone's health (Huizinga, 2004).

The Intraoperative Dialogue

The intraoperative dialogue started when the child and parent were greeted by the nurse researcher on the day of the operation. The nurse researcher again explained what would happen and cared for the child during the whole intraoperative dialogue, which meant that the nurse researcher was “present” in a way that differs from merely registering the child's behaviour from a distance (Gadamer, 2004). During this back and forth dialogic play, the child's responses to the nurse researcher's interactional attempts helped refine the latter's evolving interpretations. A child's reluctance or unwillingness to respond to the nurse researcher's interactional attempts might be understood as disagreement with the nurse researcher's interpretation of what is meaningful to the child in the actual research context, whereas a child's acceptance might affirm it. The affirmation or fusion of horizons between the child and the nurse researcher means that although their horizons are merged, they nevertheless retain their identity as two unique individuals with separate horizons. The child's “otherness” should be approached if the game is to be morally praiseworthy (Gadamer, 2004).

The Postoperative Dialogue

Following the operation, the postoperative dialogue began when the nurse researcher returned to the child and parent. It is important to emphasize this dialogue because the final back and forth dialogic play might throw new light on the preceding dialogues, and an unexpected comment or event might constitute the starting point for new understanding (Gadamer, 2004). What the nurse researcher should understand is not the child's psychology or private being but the truth of what the child is trying to express. By appropriating this truth and applying it to a concrete situation, the nurse researcher, in this case a nurse anaesthetist, can grasp the truth of their own tradition (Gadamer, 2004).

Hermeneutic Text Interpretation

The interpretation of the text was conducted by means of collaboration between the first (SL) and the second author (IvP), bearing in mind that understanding of a text is not a solo undertaking but always occurs in a three way dialogic interplay between the interlocutors and the text, thus addressing inter-rater reliability (Kvale & Brinkmann, 2009). The methodological considerations were guided by a constant play with the aforementioned concept of professional pre-understanding (Lindwall et al., 2010; von Post & Eriksson, 1999) to allow the texts to present themselves in all their otherness (Gadamer, 2004). In this study, the text to be interpreted came in two forms: transcripts of conversational interviews with the parents and the nurse researchers' fieldnotes. To probe more deeply into the text (Gadamer, 2004), the interpretative process was governed by three main questions: What does the text say? What does the text mean? What is the deeper meaning and implications imparted by the text? Through movements between the parts and the whole of the text and dialogue, and between the researchers and the texts, significant expressions and quotations were organised, reorganised, and systematised. Common features emerged and themes were formulated. Finally, the entire text was read once again in an attempt to understand and reach agreement on a new view as well as a more comprehensive and consistent whole for the purpose of identifying what makes true play possible.

Sparking the Movement of Human Interplay

The play began with the preoperative dialogue, and all parents' statements were consistent in expressing that they valued it. Parents related their child's story, and all stressed the importance of being taken seriously, of fruitful dialogues, and of the need for the nurse researchers to show respect by acting in a caring manner and demonstrating creativity. From the parents' perspective, human interplay was sparked when the nurse researcher asked relevant questions and responded to their answers by adapting the perioperative dialogue in line with minor details that only a parent could provide. As Gadamer (2004) has shown, the back and forth movement of questions and answers is crucial in order to simultaneously open up the way to understanding and spark human interplay. This interplay is based on the recognition that one's interlocutor is able to contribute insights that are worth taking seriously, as revealed in the following quotation from a parent:

Sparking the movement of human interplay is a consequence of acting on what has been understood and wishing to show that one is willing to play fair with the child. The following quotation illustrates this aspect from a nurse researcher perspective:

The statements above are consistent with Gadamer's (2004) assertion that true understanding does not generalize but concretizes; further understanding is only achieved in and through the application of understanding. Hence it follows that the play, the substance or idea of caring, was directed toward the child through the nurse researchers' conscious willingness to take the parents seriously as well as the conscious act of participating in being-at-play (Eriksson, 2006b; Vilhauer, 2010) with the child in the movements of human interplay. In the movements of human interplay “word and idea first became what they are” (Gadamer, 2004, p. xxxvii).

The Play of Art

Play disrupted the vicious circle of misunderstandings and paved the way for a subtle interplay between the child and nurse researcher. The child practised different tasks such as moving between the waiting room and the operating table. The parents could see that the nurse researcher had mastered the art of being firm but gentle to build a relationship with the child. For the parent it was relaxing to stand aside and watch the back and forth movement in play that was perfected to a fine art by means of the perioperative dialogue. Gadamer (2004) revealed that human play finds its perfection in the back and forth movement between players and is the play of art. This is illustrated by the following quotation from a parent:

The nurse researchers were aware of what to avoid if the child rejected the interplay because lack of engagement or force ultimately destroys the play movements that are central to the hermeneutic circle (Vilhauer, 2010). The play of art requires commitment and the will to remain with the other in difficult circumstances as well as doing one's best for the patient (Eriksson, 1987). The following quotation illustrates this aspect from a nurse researcher's point of view:

According to Gadamer (2004), the hermeneutic circle and the beauty of play emerge in and through a subtle interplay between players. This can be seen when a nurse researcher's head and heart rule their hands, the professional hands without which play disintegrates into nothing (Carse, 1996). As Eriksson (1987) stated, “The basic substance is made more beautiful and is completed in the hands of a master, and vice versa is destroyed by insensitive hands” (p. 72).

The Play of Truth

According to the parents, the play of truth emerged when the nurse researchers' way of interpreting the child's responses to their attempts at interaction was imbued with dignity and seriousness, which Eriksson (2003) described as reading the patient like a secret script. This meant actively waiting for the child's responses in order to understand the truth of what she or he was trying to express. The play of truth seemed to be approached at two levels, one related to activities and the other to loyalty, making it possible to achieve the main critical attribute of an ethical approach toward the other—the highest form of I-Thou relationship (Gadamer, 2004). The following quotation illustrates this aspect from a parent's perspective:

From Gadamer's ontological quest for play we learn that to play in the creation of a truth means allowing oneself to be played, which presupposes relinquishing one's subjective desire to control the game. In play, no subjective desire steers the back and forth movement. The following quotation illustrates this aspect from a nurse researcher's perspective:

What appears most essential to the play of truth is that nobody can take the nurse researcher's place with the child because continuity of care promotes truth in this special research context. The unbroken process of being at play with the other is exactly what Gadamer's ethics of play is about (Vilhauer, 2010). Therefore, the play of truth only comes to life through the thoughtful interpretation of the nurse researcher who is present (Gadamer, 2004) and views the child as a secret script, even if the nurse researcher only catches a brief glimpse (Eriksson, 2003).