Synergy among Multiple Methodologies: Investigating Parents' Distress after Preterm Birth

Philosophical Orientation

Interpretive approaches share common “family resemblances” (Willis, 2007), but distinct genres are grounded in unique epistemological and ontological traditions. These unique foundations drive the design and methods and affect research findings, though the findings are often enriched by combining analytical forms. Depth of understanding about the epistemological and ontological focus of a methodological approach forms the basis for rigor in this setting (Seaton, 2005). Before delving into the nuanced differences between methodologies, we will describe the main tenets that form the philosophical background of each methodological approach. Each of the chosen methodologies will be described, and principle aspects of each technique will be compared.

Hermeneutic Phenomenology

Phenomenology was first described by Edmund Husserl as the exploration of a phenomenon, specifically what is experienced and how it is experienced by a person (Wertz et al., 2011). Hermeneutic phenomenology, as informed by Heidegger, countered several main tenets of Husserl's philosophy, particularly the focus on one's experiences and “bracketing,” which is the putting aside of one's background beliefs and assumptions (Dowling & Cooney, 2012). Heidegger's focus expanded past descriptions to the illumination and interpretation of experience through “being-in-the-world” (Heidegger, 1927/1962). Heidegger used the term “Dasein” to describe the inextricability between phenomena and interpretation; Dasein represents the inability of a person to separate themselves from the world in which they live and the preconceptions they bring to every life event (Lopez & Willis, 2004). Key philosophical assumptions from Heidegger's work are that background and context are key to understanding the meaning of an experience, that language is the vehicle for understanding meaning, and it is impossible to remove oneself from the influences of the surrounding world (Lopez & Willis, 2004; Munhall, 2011; Vandermause & Fleming, 2011). Capturing the lived experience situated within the context of everyday life is essential to this form of phenomenology (Baker et al., 1998). The Husserlian concept of bracketing, by which the researcher separates out any preconceived ideas and biases to limit his or her influence on “hearing” participants' recollections of their experiences, is disregarded (Vandermause & Fleming, 2011; Wertz et al., 2011, Chapter 5).

The analysis process in interpretive phenomenology involves an iterative and repeated course by which the data (in the form of language and text) are read, summarized, and re-read by the researchers. In this process, the researcher ascribes meaning to common experiences that are uncovered during the course of skilled interviewing and analysis (Benner, 1994; Diekelmann & Ironside, 2006; Healy, 2011; Smythe, 2011;Vandermause & Fleming, 2011). This engagement with the data, along with conscious recognition of their own background and experience, allows the researcher to question and challenge interpretations along the way (Baker et al., 1998). Besides the circling process by which the researcher examines the data, there is a concept described as the hermeneutic circle, an assumption that humans are always in a constant and ever-changing circle of understanding, with experiences changing based on the influence of the surrounding world (Lopez & Willis, 2004). Between the circling process of the researcher and the understanding that the participants' experience of a phenomenon is fluid, there is the assumption that this interpretive process is a continuous one that is never-ending (Baker et al., 1998; Diekelmann & Ironside, 2006).

Foucauldian Discourse Analysis

Discourse analysis as a methodology has primarily focused on the role of language in constructing reality, with emphasis on the impacts through society, culture, and power (Willig, 2008). Although there are many different types of discourse analysis, we used a conceptualization of discourse based on the works of Michel Foucault, a French philosopher. In Foucauldian discourse analysis attention is focused on how discourses shape a person's reality and control opportunities for social action. The subject is somewhat peripheral to the institutions and social controls imposed by discourse. This is in contrast to discursive psychology, which is more focused on the individual subject and the choices made among available discursive resources to achieve social objectives (Willig, 2008).

Discourses are comprised of a set of statements that are constructed within a society that influence how and what is said and experienced within a social context (McCloskey, 2008; Powers, 1996; Willig, 2008). Through discourse analysis, the individual (or subject) is positioned in relation to the discourse itself, as well as to the object of discourse (Willig, 2008). Positioning, a key concept in discourse analysis, describes where the participant sees themselves from within (or outside of) the dominant cultural or societal group (Willig, 2008). Through relationships among the discourses, identification of the subject and object of discourse, and the relative positioning of the participant within the social structure, patterns related to power and knowledge differentials within a societal context can be identified, with the ultimate goal of social action. Discourse analysis falls under the philosophical backdrop of critical social theory, a philosophical framework describing how power and assumed knowledge originate from the dominant social group in a given setting (Meleis, 2011).

There are several predominant philosophical assumptions that are inherent with Foucauldian discourse analysis. The main assumption is that discourses form ideals that help subjects understand the world (Wertz et al., 2011, Chapter 7). Often, these discourses are assumed or taken for granted as part of a subject's reality. This makes understanding discourse analysis more challenging to some as it essentially deconstructs reality. Another assumption is that language and text are key elements in the understanding of discourse (Wertz et al., 2011, Chapter 7). Through language, the interaction between the subject and object, the participant and the discourse, is produced (Wertz et al., 2011, Chapter 7; Willig, 2008). Another assumption noted in using this approach is that the uncovering of discourses through analysis is in itself a social action (McCloskey, 2008; Powers, 1996). Discourse analysis is often considered a methodology that aligns with participatory action research, feminist research, and race theory because the intent behind the research is often related to changing social norms or power differentials (Baker et al., 1998).

The analysis process in Foucauldian discourse analysis is not rigidly prescribed, but there are often common features seen in studies using this methodology. These common features usually involve identifying the discursive object and subject in the text, revealing the predominant discourses, and then exploring the relative positioning of the subject in relation to the object and discourses (Willig, 2008). Through identifying other potential subject positions, the research then can identify alternative ways of viewing the world, as well as see the consequences from taking different positions, creating a subjective version of reality that may reveal possibilities for social change.

Similarities and Differences

Comparing and contrasting hermeneutic phenomenology and Foucauldian discourse analysis proves challenging, although there are several aspects that distinguish these two methodologies: (a) context, (b) intent, and (c) focus. Similarly, both of these methodologies rely on the background and context of the world in which the participant lives as an integral part of their experience. Discourse analysis relies on this context, and the societal or institutional influences involved, and the interaction of research participants with these influences. This emphasis is the main focus of the methodology. In contrast, hermeneutic phenomenology draws attention to the experience of the participant, with the person in engagement in the world as the focus of inquiry. This underlines one of the main differences between methodologies with regard to context.

The difference in intent behind these methodologies should be understood when considering the purpose of the research and the expected contribution to scientific knowledge. Hermeneutic phenomenology seeks understanding about how a phenomenon manifests itself and the meaning of a phenomenon; discourse analysis seeks to reveal underlying societal structures and processes that influence the construction of a phenomenon (Wertz et al., 2011, Chapter 10). Thus, there is a distinctive and different purpose for using each approach. Regardless of intent, these approaches rely on the researcher's subjective interpretations of what the text is “saying” and acknowledge that there are multiple ways to view an experience or phenomenon (Baker et al., 1998).

Demonstration of Approach

We will demonstrate how these methodological approaches can contribute to the research question, data collection, and data analysis of a study using excerpts from one interview transcript. These data were selected from an investigation of parents' accounts of distress after preterm birth. This study was designed and implemented using Foucauldian discourse analysis, and included parent dyads in separate interviews at two different times, an initial interview and a second incorporating photo-elicitation. Detailed methods are published elsewhere (Kantrowitz-Gordon, 2013). The texts presented here are from an interview with a woman, identified as “Karla,” who gave birth to twins at 29 weeks gestation and spent several months in the Neonatal Intensive Care Unit (NICU). She was interviewed six years after the birth. Human subjects review was performed during the initial study; this secondary analysis fits within the ethical considerations for the original research.

The Research Question

In examining parents' distress after preterm birth, the research question was framed in accordance with the methodology chosen, and its underlying philosophical approach. The language used in developing a research question is instrumental in creating congruency between the methodology and the line of inquiry (McCloskey, 2008). The research question in a Foucauldian discourse analysis would use language associated with the social construction of the phenomenon, which, in our study, was distress: “How is distress constructed in the parents' accounts after preterm birth?” In contrast, a study using Heideggerian hermeneutic phenomenology would focus the research question on the meaning of the experience: “What is the meaning of the experience of distress for parents who've experienced a preterm birth?”

Language plays an important part in portraying the methodological direction for the study, and also contributes to the methodological integrity of the study. There should be linguistic consistency from the research question through the data collection, analysis, and report of findings (De Witt & Ploeg, 2006; Sandelowski & Barroso, 2003). Regardless of when the research question is formulated, a priori or iteratively, the words used to convey the intent of the study should clearly reflect the chosen methodology.

Data Collection Methods

Data collection methods are very similar across interpretive methodologies. Interpretive methodologies such as Foucauldian discourse analysis and Heideggerian hermeneutic phenomenology both rely on text as the primary source of data (Baker et al., 1998; Wertz et al., 2011, Chapter 10). Text, which is often in the form of interview transcripts, represents language situated in the context of the participant and experienced in conversation with the researcher. Other sources of text can be used as data, such as written literature, other written statements, photo elicitation, and art (Benner, 1994; McCloskey, 2008). Both methodological forms may be used on existing text or research generated text because the analysis processes are the same. However, awareness is needed as to the intent behind the choice of text source because that may provide rationale for the chosen methodology. In the context of this study on parents' distress after preterm birth, research generated text in the form of transcribed interviews provided the data used for this analysis.

The interpretive interview provides an example of how these two methodologies differ. The overall structure of the interview is similar: open ended, participant driven, and interactive between the participant and the researcher (Vandermause & Fleming, 2011). However, there is a subtle, yet important, difference regarding the intent and motivation for the interview. Discourse analysis aims to uncover underlying influences and perceived societal ideals, which influence language (Willig, 2008). Interpretive phenomenology, in turn, intends to uncover the meaning of the phenomenological experience and what it means “to be” (Vandermause & Fleming, 2011). In conducting the interview, researchers using discourse analysis may use more directed language as a tool to elicit resistance or agreement, in order to expose discourses that otherwise may be hidden. In contrast, researchers using a hermeneutic phenomenological approach would proceed in an easy-going conversational manner rather than a confrontational manner, so as to best capture the recognized experiences of the participant. Clarity in the approach used during the interview process, including the opening question(s) and any strategies for eliciting information, is often lacking in published reports, yet it is an important element in demonstrating methodological rigor.

An example of a directed interview approach used in discourse analysis is shown in the following excerpt. When Karla was hospitalized on the antepartum ward a few weeks before the premature birth of her twins, she wanted to talk to her caregivers about her fears. Her nurses were resistant to talking about the possible bad outcomes with her. Once the twins were born very early, however, Karla became numb and lost her desire to talk about the fears that had been realized. This discrepancy was highlighted and questioned by the interviewer.

The interplay between interviewer and interviewee in this excerpt demonstrates the provocative nature of questioning used in discourse analysis to elicit additional information around the construction of discourses and to test beliefs by pointing out contradictions (Brinkmann, 2007). The inclusion of the interviewer's contribution to the conversation in data collection and analysis is a characteristic of discourse analysis techniques to explicate the subject's active acceptance or resistance to a given discourse. In this case, the interviewer questions the contradiction between Karla's desire to talk about her fears before the birth and her shutting down after the birth. This is important background because the interview moves into the power dynamics and interactions between the participant and hospital staff. In contrast, hermeneutic phenomenological interviewing would less likely include such pointed elicitation techniques, but rather would let the story unfold as representative of the phenomenon in question. For example, such questions as “What was it like being a parent in the NICU?” or “I'd like to hear what that was like for you once you came home with [him]” provide an avenue for the participant to delve deeper into her understanding of the phenomenon without particular direction.

Analysis

We will demonstrate differences in data analysis between Heideggerian hermeneutic phenomenology and Foucauldian discourse analysis using a later excerpt from Karla's interview. This excerpt provides an example of interactions between a mother and NICU staff, which allows for different interpretations based on each methodology.

Analysis of this text using Heideggerian hermeneutic phenomenology begins with a full reading of the transcript from start to finish, to gain an overview of the conversational exchange. Next, the transcript is re-read, looking more closely for underlying meaning based on the structure, content, and inferences manifesting in the dialogue. Using quotes directly from the text, an interpretive summary is written of the experience of distress understood as a result of the analysis. Using the above excerpt, the summary included a description of this participant not feeling like a parent and experiencing a lack of control as evidenced by her statements about the nurses' schedule preempting her role as a parent. Going back to the text and staying close to the text when using a Heideggerian hermeneutic approach are key strategies to ensure adequate representation of the experience (Benner, 1994). Often a group of researchers analyzes the same text, and then meets to share summaries and interpretations, which adds a richness and thoroughness to the overall interpretation. Interpretations are written across texts and include refined discussions among researchers. At some point in the interpretive process, patterns and themes, represented as dynamic understandings using verb forms, are revealed through the analysis and confirmed by returning to the original summaries and transcripts. For this phenomenon, if we were to report patterns using this excerpt as a paradigm case, we would consider such patterns as “being/not being Mom” or “NICU care as hindering mothering.” Although multiple participant experiences are most often used to develop patterns, these provide examples of what can be seen using this exemplar.

In contrast, our analysis using Foucauldian discourse analysis focused on the construction of distress in the excerpt. The analysis began similarly with a thorough read through of the text for context and large picture perspective. The second review involved identifying all explicit and implicit instances of distress, along with quotes from the text as evidence. In this case, distress was apparent in the participant's repeated comments of her children not being hers and through her acknowledgement that the nurses were in control of how she parented, with power and knowledge laying in the hands of the medical providers instead of with her as a mother. Using the language of discourse analysis, distress is the object and Karla is the subject (Willig, 2008). We were able to relate these discourses to the discourses that had been described in other contexts. For example, there is a “biomedical” discourse, which establishes the unequal power relationship between patients and the medical system, and there is a “good mother” discourse, which prescribes the expected attitudes and actions of mothers (i.e. selfless, caring, loving, attending to needs of child) (Choi, Henshaw, Baker, & Tree, 2005; LaFrance & Stoppard, 2006). Both of these discourses are evident in this excerpt. Once the discourses are noted, we examined the text to identify how these discourses positioned the subject (the participant). Karla expressed resistance to the nurses' power over her access to her twins, a power given to the nurses by biomedical discourse. Karla also expressed how the good mother discourse positioned her as present in the NICU and active in infant care. Both discourses contributed to her distress because of the difficulty in meeting the discursive expectations for action.

The following excerpt illustrates the subtle differences between hermeneutic phenomenology and discourse analysis around interpretation. This example captures the story of a participant's experience with her baby.

Following the same analysis technique described above, patterns consistent with Heideggarian hermeneutic phenomenology would be pulled from the text. The pattern of “losing the perfect birth experience” is resonant with the above example, as the participant relays her feelings of loss around not having the birth experience described in media and society. Congruent with hermeneutic phenomenology, this pattern can be supported by other examples in text from other participants, such as the following:

A baby book commemorates milestones in a birth and an infancy unmarred by complications, and the participant feels the loss of this experience through what the book represents for her.

In contrast, Foucauldian discourse analysis brings the interpretation in a different direction, representing the discourse of the “perfect child.” The perfect child discourse illustrates the expectation that a child will be “normal,” will be without flaws or disability, and will conform to society's standard of how a child should act. A preterm birth, a child's face not appearing as expected, or a lack of the first cry symbolizes a failure in that “perfect child” expectation. The perfect child discourse is also apparent in a participant's description of preventing disability through occupational therapy (OT):

The participant places high value on her concept of a normal and healthy child, and is resistant to accept disability.

There are differences in implications in both types of interpretive findings. Implications for practice gained from the hermeneutic phenomenological analysis include increased compassion and awareness of distress for parents of infants in the NICU, and the need to listen to parents as they share their experiences (Vandermause & Wood, 2009). In contrast, discourse analysis, through use of the identified discourses and subject positioning, provides implications for action to enact social change within the NICU system, such as parent empowerment and involvement in care (Kantrowitz-Gordon, 2013; Willig, 2008). The implications from these two different interpretive approaches provide complementary strategies for improvement of care.

Evaluative Differences

Discourse analysis and hermeneutic phenomenology offer similar strengths and limitations. It is well documented that strengths associated with the interpretive traditions are based in continuity of understanding the philosophical foundations throughout each phase of the research process (De Witt & Ploeg, 2006; Sandelowski & Barroso, 2003; Seaton, 2005). Criticism of these interpretive methodologies has often focused on such concepts as narrow use of language, member checking, and researcher bias.

These interpretive methodologies focus on analysis of language and text, which has been criticized by those in other research genres as being too limited in focus. Although text is the conduit for analysis, many supporters believe that using text for interpretive processes, including the background and expert knowledge of the participant and researcher, allows for a deep and meaningful understanding to be reached (Baker et al., 1998). Also, allowing the “voice” of the participant to show through the interpretations and staying close to the text in revealing the experience is essential in these types of interpretive methodologies (Mazzei & Jackson, 2009).

Validation of interpretations by returning to the participants to “member check” is a practice seen most often in many qualitative methodologies. Having the participant verify the findings and the interpretations is used as a mechanism for improving the representativeness of the study; however, the use of this practice in both methodologies discussed here is questionable as it limits the ability of the researcher to interpret, especially if the interpretation of discourses does not fall within the realm of the participant's understanding. Member checking in discourse analysis may serve as a tool for elucidating further acceptance of or resistance to unveiled discourses, but we hesitate to consider it a method for validation of findings. The concept of member checking nonetheless has been documented as a method of validation for discourse analysis by some (McCloskey, 2008). In hermeneutic phenomenology, member checking with the participant or with others with similar experiences may be a useful tool that can verify resonance with the findings (Benner, 1994), but it is a reductive activity by nature, and antithetical to some approaches including Heideggerian hermeneutic phenomenology.

One additional criticism described for both hermeneutic phenomenology and discourse analysis is the potential bias from the researcher. The concepts of bracketing and epoché have been used in descriptive phenomenological methodologies to attempt to control for this bias (Wertz et al., 2011); however, both discourse analysis and hermeneutic phenomenological approaches reject the idea that separation of prior knowledge from the inquiry process is appropriate. In discourse analysis, the researcher's biases are clearly and explicitly stated in the line of questioning, and the researcher is intimately involved in the interview itself and unable to be outside discourse (Willig, 2008). With both hermeneutic phenomenology and discourse analysis, the forestructure (preconceptions and presuppositions) and the context play a large role in the interpretive process. Acceptance that this type of interpretive work is not objective, and will not fit into the post-positivist paradigm, is crucial to knowing engagement in this level of inquiry (Baker et al., 1998).

Conclusion

Using the practical application of two different interpretive methodologies to an exemplar transcript, we have illustrated the different, yet symbiotic relationship between Heideggarian hermeneutic phenomenology and Foucauldian discourse analysis. Although methodological differences exist, the interpretations combined create a deepening understanding of the phenomenon and construction of distress around preterm birth. Awareness of how each interpretive tradition influences the language around the research question, the data collection and analysis, and the overall integrity of the level of inquiry is crucial to maintaining a rigor in both traditions; yet, recognition of multiple “truths” allows for a more holistic representation to be created. This synergistic blending of methodological approaches can be useful when constraints limit access to a specific community or population.

It is important to note that the original methodology used for this study was discursive in nature, necessitating a level of interpretive extrapolation to describe the findings using a different methodological structure, hermeneutic phenomenology. However, given the nature of both discourse analysis and hermeneutic phenomenology, the analysis of text to extract meaning was compatible for this type of comparative work. Defining the methodology prior to the research activities is essential to maintain the integrity of the study, and while this article represents an exercise in methodological fluency, it should not be assumed that data are interchangeable between interpretive methodologies in research settings. It is essential that researchers be well versed in the philosophical underpinnings of their chosen methodology when conducting interpretive research because the differences pointed out in this article are nuanced, but critical to the integrity of the methodological approach (Baker et al., 1998; Seaton, 2005). Our experience in this project has demonstrated that bringing together a research team with expertise in different interpretive methodologies can deepen the understanding of phenomena and broaden the researchers' fluency in alternative approaches.