Qualitative methodologies in health research : interpretive referential of Patricia Benner

Objective: this article reports on the experience of using the interpretive phenomenological framework of Patricia Benner in a Brazilian context. Benner’s interpretive phenomenology, based on existential and interpretative philosophy, aims to understand human experiences in the particular worlds of research participants. Data were collected through interviews with nine nurses in November and December 2014. Results: data analysis process according to Benner’s framework consisted of: transcription, coding, thematic analysis, and search for paradigmatic cases and examples. Therefore, the prior knowledge of the researcher is an important part of the study, consisting in manners of the research conduction. Conclusion: The use of this methodological framework entailed a great challenge for the researcher, however, it also enabled a unique opportunity to illuminate important existential phenomena related to the daily lives of research participants.


INTRODUCTION
The recognition of qualitative research in the area of health sciences, as well as its popularity, has increased significantly in recent decades (1)(2) .It is known that, historically, the quantitative approach was predominant in health, being of utmost importance to the data understanding of persons, issues related to diseases, and the occurrence of certain health problems (2) .
The increasing popularity of qualitative research has demonstrated a crisis in traditional epidemiological evaluations known in the health sciences.The qualitative research, largely narrative, it is primarily firm on data based on language and behavior, which is not significant relevance through numerical calculations and statistical procedures (3) .
In this context, several qualitative traditions emerged, such as grounded theory, phenomenology, hermeneutics, ethnography, feminist theories, critical post-structuralism, ethnomethodology, postmodern narratives, among many others.Each one has different and specific methodologies for collecting and analyzing data (4) .
Phenomenology initiated by Husserl was born as a philosophical movement that is concerned with the subjective dimension of the phenomena in human nature and has at that time, a purely descriptive character.In this process, the focus is to describe the phenomena in the way how they are presented in their essence.Husserl was interested in knowing the phenomena of human existence through pure perception (5) .
In hermeneutic phenomenology, Heidegger adds to Husserl´s ideas the idea of "being in the world" as the way in which human beings are significantly situated in the world over time.Heidegger also says that interpretation is in a critical process to get an understanding.This interpretive process is achieved through the hermeneutic circle, which moves the parts of the experience for the whole, and turns to the parties, and so on, giving depth to the understanding (5) .
Among the various phenomenological research fields, this article aims to report the use of interpretative experience of qualitative methodology on Patricia Benner´s framework.This is a research linked to a masters thesis entitled: "moral distress and moral experiences of nurses who care for children with special healthcare needs", which was developed with an internship period at McGill University in Montreal, Canada, under the advisor Professor Dr. Franco Carnevale.This thesis is nearing completion and was approved by the institution ethics committee in research.

The Phenomenological Interpretative Framework of Patricia Benner
The interpretive phenomenological method, described by Benner, is guided by the philosophical concepts of seeking an understanding of the human condition, the experiences and the ways on how we know and understand the world (6) .These concepts are coming from the existential phenomenology of philosophers Kierkegaard, Heidegger, Merleau-Ponty, Wittgenstein, Dreyfus, and Taylor, as well as the traditional hermeneutics method (6) .
To study the phenomenon in its essence, the phenomenon and its context structure the interpretive project of understanding the world of participants and the events related to it.The interpretive researcher must create a dialogue between the practical concepts and experiences relating the clinical reasoning and imagination to the lived world of the participants (6) .
When using the interpretive phenomenological method, the researcher seeks understand the world of concepts, habits, and practices presented through narratives of participants and specific actions.These insights are then used to contrast similarities and differences inserted in the speeches of the participants and specific actions (6) .
Understanding human concerns, meanings, experiential learning, the skilled practical behavior of everyday life, when they are function without any problem or when they are in crisis, it is the objective as opposed to the explanation or prediction through casual laws and formal theoretical propositions (6) .Thus, it is recognized that, in the life sciences, the understanding becomes richer than just the explanation since the understanding is more linked to human experience and their meanings (6) .
For Benner, interpretive researchers should be interested in the distinctions and similarities between the various worlds of the study participants.For this, they must understand that human conditions, and commonalities, these similarities are possible. (6)enner (6) describes five sources of similarities that should be recognized by the interpretive researcher in the narratives of the participants: 1. Situation: understanding of how individuals are situated in different circumstances, considering their history and current context; 2. Embodiment: understanding of individuals as a body donated with knowledge, practices, and skills; 3. Temporality: it considers the experience of a way to project into the future and be understood in the past, but not in a linear way, but considering the experience in its temporality; 4. Concerns: how the individual is situated significantly in the situation, what matters to the person; 5. Meanings in common: common linguistic and cultural meanings that are presented and show what are the potential problems, agreements, and disagreements among people (6) .
In this sense, prior knowledge of the researchers is part of the structure of the interpretive project, constituting the conduction pathways of the study.For this, the researcher estudio.Conclusión: el uso de ese referencial teórico y metodológico constituye en un desafío para la investigadora, sin embargo demostró excelente potencial para el desarrollo de fenómenos existenciales relacionados al cotidiano de los participantes.Palabras clave: Metodología; Método; Investigación Cualitativa; Enfermería; Ética en Enfermería.needs to develop the ability to engage, through clinical reasoning, in different situations narrated by the participants.However, it is important in this process that the researcher can maintain a constant movement back and forth to their initial concepts, understanding that doubts and misunderstandings are part of the search process by as wide as possible understanding (6) .

Procedures for Data Collection, Organization and Analysis
For the development of the research project, the initial objective was to understand the moral distress experiences of nurses who care for children with special health care needs.The development of this objective was given from the research question: how is moral suffering presented in the professional routine looking after these children?This study had their data collection conducted in November and December 2014.
The phenomenon and its context were the interpretive projects to understand the lived world of research participants.In the line of research bases, the researcher can use text sources and a group of situations that may include individual or group interviews, participant observation, documents, and other data sources.Seek also the understanding, multiple interviews are possible for the interviewer having the opportunity to review carefully and revisit the material for the development of a next interview.This allows the researcher and the participant having a second chance in the searching for understanding the phenomenon and many others as necessary (6) .
The interview is used as a strategy so the researcher can access the participant's world, seeking to understand the inserted object of study in the context of living (6) .The purpose of the interview in the interpretive phenomenology is to establish a real dialogue between researcher and participant.In this dialogical movement, the researcher is immersed in the commitment to listen and represent the participant's voice.Thus, the researcher needs to develop a critical and reflective process, allowing a gap between this and the study participant; besides exercising the ability to hear questions and face challenges to their initial research questions, which he previously did not consider to meet with the study of the context (6) .
The use of the interview to recognize and give voice to the participants was developed seeking the reporting of stories of their worlds and practical concepts so that they describe, naturally, the daily practice of care.The role of reporting the stories is essential to the interpretive phenomenology because when people build their stories, they can immerse in their immediate experience, and risk of creating generalizations or ideologies is reduced (6) .
The interview moments required concentration and researcher´s attentive listening since the participants in their individuality, ranged from those who had much to say, thus needing a careful listening from the researcher to the object of study continued to pervade and permeate the dialogue and also those who responded objectively, requiring an thorough effort by the researcher to the object of study, however without interference from pre-established concepts by the researcher in the speech of the subjects.To this end, questions such as "how was that for you?"; "Could you tell me more about that?"; "What do you think this means for you?"; were used for the participants to immerse deeper into their experiences, giving clarity to the narrative.
During this process, there were moments of uncertainty and concern by the researcher to the scope of the research objectives.This time required concentration, reading moments as well as meetings with mentor teachers, who pointed out that the conduction of the interviews was going on satisfactorily.However, the search for the object of study by the phenomena presented by the participants should be exploited as much as possible.The interpretive dialogue begins with the first interview and, from that, data collection, research and analysis do not walk farther apart, allowing the researcher to establish lines of inquiry constituted by their empirical data, ensuring the quality of research (6) .
Thus, it is recognized that, besides the dimensions of the initial search object, there were other enlarged dimensions that were described by participants in a movement in which the search question launched was initially confronted.This provided space and opportunity for the phenomenon studied showed its different facets.In this sense, the interviews were conducted to hear what mattered to the participants, needing to listen to them.This means that not always their speeches were centered on moral suffering.However, there was an interest by the researcher to deepen the relevant points for participants, considering their prior knowledge to the care ethical issues.In this sense, the narratives of the participants brought situations of moral suffering, for example, related to the feeling of helplessness regarding the impossibility of an attitude that reduces the child´s pain, difficulty in dealing with death in childhood, difficulties in the relationship with the medical staff, among others.Also in the understanding movement, situations associated with job satisfaction at seeing the positive return of the child´s treatment, the feeling of dilemmas sharing with co-workers which reaffirms the morality of the nursing actions and the moral agency of nurses to pediatric patients, advocating on behalf of children's well-being were analyzed and included in the results as a dimension that amplifies the understanding of the moral suffering and the engagement of nurses who care for children with special health care needs.
This moment appears as a key movement in interpretive phenomenology because it reaffirms that the analysis of the data does not constitute a step that is isolated from the moment of collection.This is because the researchers use their prior knowledge to create the course of research, but they are committed to the non-imposition of assumptions to phenomena studied, allowing them to take various compliances (6) .IN hermeneutics research, there is always a concern in developing a cyclical movement "correctly", considering the way the researcher understand the phenomenon earlier.However, it is necessary that the researcher is open to respecting the possibility that the phenomenon studied show up in different ways during interpretation (7) .
At the end of the data collection process, nine interviews were conducted.In a phenomenological approach, the end of the interview can be understood as one in which the speeches of the participants have sufficient structures for the understanding of the subject matter obtain maximum clarity, and thus its unveiled directions and objectives achieved (8) .
After transcribing the interviews, first there was an initial and superficial reading of each one.Then, an attentive and careful reading of each interview was held separate from the essence of the participants could be captured.The individual reading of each interview is in an important stage in interpretive phenomenology, as is sought by the apprehension of the meanings of phenomena in their individuality, considering the subjectivity of each participant (6) .
Reading the entire interview is done to have a global understanding of the story and then topics, concerns, and events are selected for a more detailed reading of the text (6) .At this stage, through a careful reading it is sought to find in each interview, codes to identify important parts to be observed in the text.The codes correspond to a more focused look at a specific part of the narrative, being able to create an analogy to what would be an optical zoom in a certain part of the text.The encoding occurred in every interview separately.
It is noteworthy that the encoding process has not ended at this stage, and, with each new look the researcher on the data provided by the interviews, the codes could be changed, since the process of interpretation does not have a limit set at first, middle and end, but rather is configured as a cyclical process of understanding, interpretation, and criticism (6) .It should create a systematic movement between the parts and the whole of the text, allowing the researcher to check for inconsistencies and repeated unifies concepts (6) .
During this stage, there was a recognition by the researcher that the experiences described by the participants had a range of meanings beyond the moral suffering.Thus, it was noticed that in addition to the moral suffering of experiences, participants brought in their speeches variety of situations involving moral experiences that cannot be disconnected for understanding in a way the deepest possible.It should be noted that the explanation of the concepts of moral experience and moral suffering is beyond the scope of this work.Therefore, they will not be addressed at that time.
Thus, besides the phenomena related to moral suffering, the situations described by the participants regarding the moral experiences were also analyzed in this research, seen as a new object of study.This movement is extremely important because it is considered that the interpretive project design must have enough opening for the initial research questions to be confronted, altered and reshaped over the interpretation process (6) .
After coding of each interview, a summary for each of the narratives of the participants was elaborated using the encrypted items.The summary of the interviews allows the researcher, although focused on important parts of the text, not disregarding the whole, facilitating the movement of going and coming with the important parts highlighted and the whole process that is extremely important in the interpretation.
At the end of each interview coding, similar codes were grouped into categories in the interviews.These categories of meaning were from the grouping of codes describing situations related to the same phenomena described by the participants.
For the analysis, the strategy is to identify structures and processes present in the narratives, which are aspects that present similarities and contrasts in the different worlds of the participants.Thus, the objective is in close reading and attentive of the texts, searching for paradigmatic cases and examples (6) .
Paradigmatic cases come from solid examples of concepts or particular patterns.By identifying a paradigmatic case, the researcher can understand how the concepts are put into practice in the lived world, and this case is a possibility of the widest possible understanding of the perception of the phenomenon (6) .Paradigmatic cases assist the interpretive researcher through a rich example of meanings arising from the participant's experience of narrative that enhance understanding of how a certain phenomenon may occur (9) .In this study, two paradigmatic cases were found, which helped to elucidate how the moral experiences of nurses are presented with the various levels of engagement of these professionals in their care practice.
The exemplary help the researcher to demonstrate intent and concepts within various contexts and situations in which the objective assigned to the situation may be different (8) .The largest part of the analysis of this study is based on the understanding of the specimens found in the texts.Once the researcher has found patterns of meanings and situations in common, the specimens should be extracted from the text to demonstrate the similarities and differences between the experiences found in the narratives of participants (6) .
After the interpretative analysis of each interview, everything is observed again searching for topics covering the whole.The thematic analysis in interpretive phenomenology has the objective to look for patterns of meanings, examples or concepts that should be considered more than just basic units, such as words or phrases (6) .Also, there is the thematic analysis to attempt to articulate the broad understandings arising from the constant comparison and read abreast of different paradigmatic cases and exemplary (7) .In this study, four subjects related to moral experiences were listed and described in the data analysis.

CONCLUSION
The use of interpretive phenomenology for the unveiling and understanding of the object of this research proved to be a rich theoretical and methodological and potentially able to contribute to a better understanding of nursing practice related to ethical care in pediatrics.It was found that the use of the interpretation in Benner´s referential unveiled meanings still not explored and identified with important repercussions in nursing care, and the quality of life of children with special health care needs.
Still, the use of reference presented several challenges related to the need to lose translation of concepts because there is still no official translations of this reference in Portuguese.
It is noteworthy that this referential is concerned to understand human experiences, as well as the meanings of these experiences to the various actors of the scenario study, placing human beings at the center of the investigation.Thus, in addition to nursing, various research fields can be interested in this methodology for achieving their goals.
It is suggested that further studies using this reference are carried out in Brazil intended to the possibility of contribution to the Health Sciences and Nursing, as well as other studies that seek to understand the skills, concepts, practices, and worlds of different actors in the health area.