Narratives as alternative in health research

Abstracts

The potential of narratives in understanding the meanings people attach to the environment and to themselves contribute to their use in qualitative research. However, few procedural details of these surveys are found, especially those that integrate reports into a single story. This work describes the production of knowledge in qualitative health research coming from the study of pleasure, suffering and illness in higher education teachers. The experiences reported in 25 interviews were the guide of an interpretive analysis based on the hermeneutic-dialectic and the construction of a new narrative by the researchers. The material was discussed and reviewed by the participants in a validation workshop. The data that was collectively built and the dynamics observed in the workshop confirmed the potentiality offered by this kind of investigation as a methodological alternative in qualitative health research.

Narrative; Teaching work; Pleasure and pain at work; Educational practices in health

O potencial das narrativas na compreensão dos significados que as pessoas atribuem ao ambiente e a si mesmas contribui para sua utilização em pesquisas qualitativas. Entretanto, são escassos os detalhes procedimentais dessas pesquisas, especialmente daquelas que integram os relatos em uma única história. Este trabalho descreve a produção de conhecimento na pesquisa qualitativa em saúde a partir do estudo sobre prazer, sofrimento e adoecimento em docentes do ensino superior. O conjunto das vivências relatadas em 25 entrevistas orientou, em análise interpretativa fundamentada na hermenêutica-dialética, a construção de uma nova narrativa pelos pesquisadores. O material elaborado foi discutido e revisado pelos participantes em oficina de validação. Os dados construídos coletivamente e a dinâmica observada na oficina corroboraram a potencialidade desse tipo de investigação como alternativa metodológica em pesquisas qualitativas em saúde.

Narrativa; Trabalho docente; Prazer e sofrimento no trabalho; Práticas educativas em saúde

El potencial de las narrativas en la comprensión de los significados que las personas atribuyen al ambiente y a sí mismas contribuye para su utilización en investigaciones cualitativas. No obstante, son escasos los detalles procedimentales de esas investigaciones, principalmente de aquellas que integran los relatos en una única historia. Este trabajo describe la producción de conocimiento en la investigación cualitativa en salud a partir del estudio sobre placer, sufrimiento y enfermedad en docentes de la enseñanza superior. El conjunto de las vivencias relatadas en 25 entrevistas orientó, en análisis hermenéutico-dialéctico, la construcción de una nueva narrativa por parte de los investigadores. El material elaborado fue discutido y validado por los participantes en taller de validación. Los datos construidos colectivamente y la dinámica observa en el taller corroboran el potencial de ese tipo de investigación como alternativa metodológica en investigaciones cualitativas de salud.

Narrativa; Trabajo docente; Placer y sufrimiento en el trabajo; Prácticas educativas en salud

Introduction

Narratives permeate people’s life since childhood - in the family, at school - and eventually encompass great narratives about the world and life. Many fields are interested in them, such as the arts and sciences¹. They are cultural reports on what makes human beings pulsate, and contribute to organize the structure of human experience and the memory of events through stories, myths, and through reasons for doing something or not²,³.

In the field of sciences, they have been employed in qualitative research by means of different approaches - life histories, biographies, testimonies, oral or written reports - that share the importance given to the participants’ subjectivity based on the experiences they narrate to the researcher. In this context, the dialogic process is prioritized, as well as its relational and collective nature in which subjectivity is considered a social construction⁴.

In publications about the use of narratives in research, the areas of education and health stand out. In education, narratives have approached the work performed by teachers, mainly teacher training⁵. In health, studies have focused on the understanding of the health-disease process¹,⁶,⁷, on the life history or experiences related to the work of health professionals⁸,⁹,and on evaluative research in collective health programs¹⁰,¹¹.

However, few publications, in qualitative research, have provided details that can help readers to clarify their understanding of the methodological procedures related to the use of narratives, especially those that intend to integrate, into a single story, the material produced by subjects, either individually or collectively.

Thus, the aim of this study is to describe, in detail, the process of construction of a narrative used in a qualitative study that investigated pleasure and suffering in the work of teachers at a public higher education institution.

In this study, data produced by subjects in individual interviews were integrated into a new narrative report constructed by the researchers. The report was collectively validated by the same subjects, and resulted in a narrative that portrays the pleasure and suffering experiences of this group of workers. In the present study, we decided to conduct a validation workshop with the same participants to deepen the findings. However, it would be possible to conduct it with other subjects, in the same context, with the same inclusion criteria, if the objective was to expand the findings. Anyway, the aim, apart from validation, is that the research subjects also participate in the analysis of the data and of the findings. In both situations, when there are new contributions, the operational process is: the new content is added to the initial report.

According to Bolívar⁴, the use of narratives as a way of building knowledge has a specific investigation focus, with its own characteristics of credibility and legitimacy, which differ from logical-scientific methods. The author argues that such differences do not reduce their main contribution: to represent a relevant set of dimensions of human experience that include feelings, intentionality, desires and singularity, among others⁴. Polkinghorne¹²states that narrative research intends to produce knowledge that is not within the reach of the traditional methods of scientific investigation, like the meanings people attach to their experiences and to situations and actions of their lives, as part of a group and of a collectivity.

Bolívar⁴distinguishes two types of narrative research according to the method of analysis. The first uses a paradigmatic appraisal of the narrative data through typologies or categories, aiming to reach generalizations of the studied group. The second type - which is the focus of this study - employs the typical narrative analysis. According to Bolívar⁴, this type of research also uses the personal testimony of different informants, but the product of the analysis is a new narrative, produced by the researcher, with the aim of integrating and giving meaning to the data without manipulating the informants’ voice. The researcher notices the singular elements that configure the stories and does not intend to generalize this meaning.

To Bolívar⁴, narrative research is based on the “hermeneutic spin” (p. 4), which fosters an interpretive perspective in which the value and meaning of the report are conferred by subjects’ self-interpretation in first-person narratives, in which the temporal and biographic dimension occupies a central position. In this context, Minayo¹³ reinforces the idea that hermeneutics-dialectics does not establish techniques; it offers, to the treatment of the data in this kind of research, “a path of thought” (p. 231). Therefore, the challenge is to discover how to tread this path.

Minayo¹³ and Bolívar⁴ look for support in Gadamer¹⁴, who argues that “the hermeneutic task is converted, by itself, in a questioning based on the thing, and is always determined by this questioning” (p. 405). Gadamer¹⁴clarifies the researcher’s role in the task of understanding the “path of thought”, and emphasizes the importance of not surrendering to the casualness of one’s previous opinions, ignoring what is narrated by the other person. Instead, the researcher should constantly assume the sensitive attitude of letting the person say something spontaneously and be receptive to the peculiarity of what is communicated.

This attitude does not presuppose neutrality, as the researcher’s task includes noticing his/her own previous opinions and prejudices, appropriating them precisely to separate them from what is communicated by the other, and opening space for the other to introduce him/herself and be understood¹⁴. Thus, it is not possible to ignore the fact that the actors involved in narrative research are also marked by history, time, social group, and culture. Onocko-Campos¹⁵, referring specifically to researchers in the field of Collective Health, who are usually part of the context they investigate, argues that the researcher must remain attentive to his/her capacity for not taking for granted what is familiar to him/her.

Narrative research occurs in the space and moment of the relation between the informant’s and the researcher’s action, in an attempt to understand the meanings of what is narrated by the informant. Gadamer¹⁴argues that such understanding is achieved through interpretation of what is narrated, in a dialectic process of question and answer mediated by language, which focuses on dialog and exchange, in the sense of finding arguments.

About the researcher’s tasks of interpreting and understanding, Minayo¹³ states that:

the union of hermeneutics with dialectics leads the interpreter to try to understand the text, the speech, the testimony, as the result of a social process and a knowledge process, both deriving from multiple determinations, but with a specific meaning. This text is the social representation of a reality that is revealed and hidden in communication, in which the author and the interpreter are part of the same ethical-political context and in which agreement subsists simultaneously with social tensions and disturbances. (p. 227-8)

This conception enables the reconstruction of the subject’s perspective about the social reality of a certain group of individuals, in a process grounded on hermeneutics and which occurs in the interaction. Through dialectics, this process enables the action of constructing and deconstructing, a successive agreeing and disagreeing by the actors involved.

The use of narrative in an investigation about pleasure and suffering in the work of teachers

The research that originated this study proposed the use of narratives according to an interpretive approach, in an investigation of pleasure, suffering and illness experiences in the work of higher education teachers from a public institution. In addition, the analysis grounded on hermeneutics-dialectics was used to guide the development of pedagogical materials.

After all the ethical requirements concerning research involving human beings were met (Opinion 891,234 of the Research Ethics Committee of the Federal University of Mato Grosso do Sul), 25 teachers were interviewed individually. The technique of topic life history was employed, emphasizing a certain stage or sector of personal life¹³. A script was developed for the interview and the sentence that guided the story was: Tell me about your experience of pleasure, suffering and illness here at the University.

With the objective of expanding and deepening the reflections, depending on the answer to the central theme, two auxiliary questions were created to be used in case of need: a) What individual and organizational factors would you relate to teachers’ pleasure, suffering and illness at this university? b) What coping strategies do you use to deal with individual and organizational factors related to suffering at the workplace in this university?

The interviews were audio-recorded and transcribed by the researchers. The notes taken by the researchers during the interviews were included at the end of the transcription or, when it was considered pertinent, among brackets in the interviewee’s report. The reports were organized according to two criteria: a) the order in which the interviews were conducted (I1, I2...I25; b) according to the investigated theme, parts of each interview were highlighted in different colors, depending on whether they referred to pleasure, suffering, illness or coping strategies. These parts were systematized in tables according to the content narrated by the interviewee. Thus, four tables were created, one for each investigated theme (pleasure, suffering, illness and coping strategies). This procedure also allowed the verification of the saturation criterion, as proposed by Fontanella et al¹⁶.

Table 1 shows how this process was carried out with one of the investigated themes - pleasure experiences at the workplace - through a hypothetical example that uses part of the research data. In the situation portrayed in the Table, saturation concerning pleasure experiences at the workplace occurred in the fifth interview. It is important to mention that the record of recurrences was used only to verify saturation; for the construction of the narrative, all the argumentation nuclei were taken into account, as described below.

Table 1
Hypothetical example of data organization in the interviews

	Utterances of the argumentation nuclei	Interviews (I)										Total recurrences
		1	2	3	4	5	6	7	8	9	n
Pleasure experiences at the workplace	Fulfilment through work	X	x		x	x	x	x		x	x	8
	Flexible working hours	X		x		x	x					4
	Students’ recognition	X	x	x		x			x	x		6
	Interaction with a younger generation		X		x			x				3
	Peer recognition		X					x				2
	Different possibilities of professional action			X		x			x			3
	Autonomy				X	x			x		x	4
	Remuneration					X				x	x	2
Total of new utterances per interview		3	2	1	1	1	0	0	0	0	0	---

• Key: X – new utterance; x - recurrences.
• Based on the proposal of Fontanella et al (2011, p. 391)

During the transcriptions and the data organization process, and after all the interviews were transcribed, the texts were read many times and the necessary adjustments were made. This process was similar to what Minayo¹³called classification downsizing, as the first ones have not been polished yet and, as the data are constructed during the research process, it is possible to notice repeated reports, peculiarities and discrepancies. Thus, the most relevant argumentation nuclei are gradually defined. Peculiarities also emerge, such as events in which the informants reported having experienced, at the same time, pleasure and suffering, or events that, for some, were sources of pleasure, while others viewed them as sources of suffering and illness. Therefore, the hermeneutic-dialectical approach enables to express, in the constructed narrative, how individuals experience these apparent contradictions and incoherences which, in fact, subjectify and enrich the repertoire of human experiences.

After this initial process, based on the investigative narrative proposed by Bolívar⁴and also on the participatory design produced by Onocko-Campos¹⁰,¹⁵, the researchers constructed a new narrative as part of the treatment of the material produced in the interviews. This process followed the argumentation nuclei that were gradually “weaved” to one another, together with the researchers’ remarks, in an attempt to reproduce the natural come-and-go of the participants’ report, their self-questionings, amazements, enchantments, agreements, disagreements. After the first construction, the text was read again many times, the argumentation nuclei were checked and the transcribed reports were revisited until the narrative succeeded in integrating, consistently, the material produced in the interviews.

To outline the process of joining the argumentation nuclei of the interviews to construct the narrative, Table 2 provides an example of how the material produced in the interviews was used to compose a fragment of the narrative. It is important to explain that, due to space limitations, some of the interviews in which there is reference to the cited argumentation nuclei were not included.

Table 2
Example of construction of a fragment of the narrative

Interviews		Narrative
I1	[...] in the afternoon, I do some activities at home, because the University doesn’t have much space for teachers [...]	The majority of us take work to do at home because we do not have a reserved space here to work in, mainly when our activities demand concentration, like reading, writing articles, reports, and preparing for classes. Some courses have one room to all the teachers; some teachers share rooms with 2, 3 or 4 colleagues. Can you imagine two, three teachers in the same room, one trying to supervise his students, the other trying to prepare for a class, and the third discussing a project with a colleague? Some activities simply cannot be developed here, in the physical space of the university. People going in and out all the time… And the problem is not only physical space! Technology also hinders our work. The Internet does not function properly, sometimes there is no connection, or the Internet stops working. There are periods in which, when the Internet is OK, the telephone is not… The power goes out; when the telephone and the Internet are functioning, there is no paper; when there is paper, there is no toner; when there are both, we have already exceeded the quota.
I3	[...] the part in which we have to stop, think and read, this part we end up, at least I end up doing at home. […] the teachers’ room, where I stay, I stay there with three or four other teachers, depending on the day […] we’re working here and suddenly the Internet is slow, then there’s no Internet connection, the power goes out.
I11	[...] the Internet system is bad or even horrible [...] to print copies, you must have printing quotas […] when your quota hasn’t ended, they’ve run out of paper. […] then, when you receive more paper, there is no toner […].
I16	[...] I stay here in the morning, teaching classes, writing projects and assisting my students, and in the afternoon I need my time, I need to stay at my room, in my house, to prepare for my classes, to concentrate […].

• Created by the authors.

It is important to highlight that, in this construction process, in addition to the care that was taken not to manipulate the informants’ voice, there was a significant concern about the researchers’ bonds with the interviewees and also with the organizational context, as some are employees of the institution. One of them works in a sector related to workers’ health and is a student of a Master’s program in which some of the interviewees work as teachers. These implications emphasized, even more, that the researchers needed to assume a sensitive and receptive attitude towards the material that was constructed by the participants during the interview, listening attentively to the peculiarities of each narrative and not taking what was familiar for granted¹⁵.

An additional challenge was to transform more than 200 pages of individual reports into a single text of 15 pages that included all the relevant elements of the collected material, in order to favor its collective reading¹⁵ in the validation group.

After the narrative was finished, it was presented to the same teachers who had participated in the interviews, as they accepted to share a second meeting, now collective and organized as a validation workshop, in which the discussion was triggered by the narrative constructed by the researchers.

In this workshop, after pens and copies of the narrative were provided for everybody, the participants were invited to make a collective reading, highlighting, in the text, the points they would like to deepen, change or clarify. After the reading, the discussions about the highlighted points started, and they revealed that the participants agreed and identified with the presented content. Thus, it was possible to deepen some aspects. The workshop was also audio-recorded and the researchers made notes that were included at the end of the transcribed text, just like in the interviews.

The organization of the workshop followed the proposal of participatory design of the studies carried out by Onocko-Campos¹⁵, who calls this type of meeting hermeneutic group. The purpose of the hermeneutic group is to validate the researcher’s production and generate intervention effects.

These intervention effects were especially interesting in the workshop, as the participants showed they identified with their stories when they heard them through an integrated collective of stories, which reflected not only their experience, but also other relevant elements to the understanding of the context in which they were included. As expected, they reported they identified, in the narrative, with elements they remembered to have reported in the interviews. However, they also identified with elements they had not reported, which were included by their colleagues or by the researchers - based on their observations during the interviews.

Thus, they highlighted points about which they agreed and disagreed with their colleagues, points in which they put themselves in the others’ shoes to try to understand parts of the report with which they did not identify, points that made them engage in the debate about the vicissitudes of the teachers’ work at the institution, suggesting alternatives, drawing analogies, and using metaphors that enriched and deepened the discussion. This dynamics emphasized the importance and potential of this moment, recognized by the participants themselves.

The participants were informed that as many workshops as they deemed necessary could be carried out until they considered that the narrative was finished. However, at the end of this one, which lasted approximately two hours and thirty minutes, the teachers considered that the process was complete and there was no need for other meetings.

Finally, the construction of the narrative was complemented by the changes suggested by the workshop participants and integrated a thesis, as part of the produced material was used in its analysis and in the development of didactic-pedagogical materials related to the investigated theme.

Final remarks

At the end of the process described here, the potentiality of narratives as a methodological course in qualitative health research became even more evident. Furthermore, it is possible to visualize the interactive and catalytic potential of the didactic-pedagogical materials that narratives will help to develop.

Even so, it is important to highlight that the complexity of the path, the delicacy of the relationships involved, and the care with which ethical issues and the validity of the products are dealt with are concerns intensified by doubts that emerge as the work is performed, and also by reading the few references about the construction of narratives as an interpretive resource in qualitative research.

In this context, it is important to emphasize that it was not easy to the researchers, aware of their involvement with the object of study, not to take for granted what was familiar to them, being cautious not to create, but to choose to make selections and place emphases in order to fulfil the objective of the study. The choice, in this study, was to deepen and validate these selections and emphases, in a movement of densification. This choice implied leaving aside elements that might be significant to the subjects of the study. Likewise, it is probable that the narrative plot would be different if other theoretical choices had been adopted for the analysis and understanding of the approached phenomena. There is, in this, an inherent and recognized risk and, at the same time, an action of facing uncertainties.

In addition, this study, because of its nature, enabled the participants, while they were building their narratives, while they were bringing their reports to life, while they were telling their stories, while they were sharing their experiences, to reflect on their insertions and practices. In this movement, they had the opportunity to transform themselves and to modify their daily relationships, in a process of mediation “between what is ‘internal’ and what is ‘external’ to the ‘self’, in the being-in-the-world relation”¹ (p. 1068). However, these possible transformations were not exhaustively explored in this study, even though they were considered significant.

Therefore, we aimed to describe, in detail, the methodological course taken during the construction of a narrative and the few references that helped us in this process, without intending to conclude the issue or indicate a path that excludes other possibilities, as narratives can be useful in different contexts. Thus, it is necessary to rethink this process of construction, considering its limits and potentialities.

Referências

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Publication Dates

• Publication in this collection
  03 July 2017
• Date of issue
  Jan-Mar 2018

History

• Received
  19 Sept 2016
• Accepted
  22 Feb 2017