Scandinavian Journal of Occupational Therapy. 2014; 21: 80–88
ORIGINAL ARTICLE
Qualitative approaches in occupational therapy research Previously published in Scandinavian Journal of Occupational Therapy 2012; 19: 521–529
LENA BORELL1, LOUISE NYGÅRD1, ERIC ASABA1, ANDERS GUSTAVSSON2 & HELENA HEMMINGSSON3 1
Department of Neurobiology, Caring Sciences and Society, Division of Occupational Therapy, Karolinska Institutet, Sweden, 2Department of Education, Stockholm University, Sweden, and 3Faculty of Health Sciences, Department of Social and Welfare Studies, Linköping University, Sweden
Abstract Objective: Development of research in occupational therapy requires a continuous critical discussion concerning methodological approaches. In this paper the authors wish to contribute to such a discussion by introducing the Formal Data-Structure Analysis approach (FDSA) as a method for understanding people’s experiences. Methods and results: A review of selected publications from occupational therapy journals between 2003 and 2005 illustrated that qualitative articles within occupational therapy publications were mainly descriptive in nature. This finding raises questions about how to develop new knowledge that contributes to occupational therapy. Conclusions: In this paper the authors suggest that it is possible to apply the FDSA approach not only when describing and categorizing qualitative phenomena, but also when aiming to reach an in-depth understanding of issues related to human meaning-making; for example, how we understand engagement in occupations or living with a disability. Examples of the application of the FDSA approach are included and discussed.
Key words: qualitative analysis, phenomenology, meaning, interpretation, hermeneutics, ethnography
Introduction This paper builds on the idea that, epistemologically, a broad genre of research traditions, methodologies, and queries characterize occupational therapy research. For instance, occupational therapy research appears to be influenced by biomedical paradigms as well as social and human science traditions. Consequently, myriad research traditions and approaches could be valid for the development of knowledge within occupational therapy research. Moreover, it has been argued that methodological multiplicity can be seen as complementary rather than in conflict, and thus can contribute to the development of a field (1). Nevertheless, approaches in occupational therapy research need to be refined and developed continuously in order to remain relevant (2). In order to explore qualitative approaches used in occupational therapy research, a literature review was conducted of
studies that have adopted a qualitative research approach and have been published in international occupational therapy journals. The methods and results are presented in this paper. In an attempt to contribute to methodological development within occupational therapy research, the authors introduce and describe central aspects of an interpretative approach referred to as Formal Data-Structure Analysis (FDSA) (3,4). This approach is exemplified with studies from occupational therapy research where FDSA was applied, and is thought to contribute with a different type of understanding than descriptive analyses. Philosophical underpinnings Philosophy of science suggests that before we can causally explain or predict a phenomenon, for example change, we need to understand the phenomenon in
Correspondence: Professor Lena Borell, Karolinska Institutet, Department of Neurobiology, Caring Sciences and Society, Division of Occupational Therapy, Fack 23200, 14183 Huddinge, Sweden. E-mail: [email protected]
ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2014 Informa Healthcare DOI: 10.3109/11038128.2014.952910
Qualitative approaches in OT research a scientific sense; in other words, what and how questions have priority over questions starting with why (5). What and how questions pertain to the knowledge interest of understanding, while the why question frequently used for explanations of a causal type can be linked to an interest founded in the discipline of natural science (6,7). In the natural sciences, as in bio-medicine, knowledge is produced in terms of predictions, for example concerning cause–effect relationships between variables. While this kind of knowledge is invaluable in occupational therapy research, it is not applicable when we want to better understand something. Human occupation is not restricted to “what can be simplified and reduced in order to be measured precisely”, as Yerxa argued (8). In occupational therapy, the professional core values urge scholars and practitioners to view people as integrated and contextualized beings that are guided in their daily living by intentions and goals (8). Mattingly (9) suggested that occupational therapists’ clinical reasoning could be seen as applied phenomenology, since occupational therapists demonstrate a strong interest in learning and understanding clients’ living conditions. Occupational therapists maintain a social view of clients as they try to understand each individual’s unique living situation. Since a person’s engagement in an occupation is motivated by his or her intentions, based on his or her interpretation of a particular, contextualized, and temporal situation, this engagement could be understood through an ordinary and everyday understanding assigned by the person (10,11). This calls for an approach that can support occupational therapists in understanding their clients’ meaning-making, rather than taking a perspective based merely on the clients’ bodily condition (8,12). Meaning-making guides people’s activities in daily life since it involves individual intentions and goals. Based on this background, this paper intends to advance further the discussion concerning qualitative research in occupational therapy. The aim is to present a specific methodological approach, the Formal Data-Structure Analysis approach, that has the objective to provide an understanding of phenomena in focus for occupational therapy research. An overview of previously published qualitative occupational therapy research will serve as a starting point for the presentation and following discussion. Overview of empirical, qualitative research in occupational therapy 2003–2005 To gain an overview of qualitative approaches used in occupational therapy research, studies that adopted a
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qualitative research approach published in an international selection of peer-reviewed occupational therapy journals in the years 2003–2005 were reviewed. By mapping trends within the field, we also hoped to identify critical knowledge gaps. The following six journals were included based on impact factor and global geographical representation: Asian Journal of Occupational Therapy, Australian Occupational Therapy Journal (AOTJ), American Journal of Occupational Therapy (AJOT), Canadian Journal of Occupational Therapy (CJOT), Scandinavian Journal of Occupational Therapy (SJOT), and Occupational Therapy Journal of Research: Occupation, Participation and Health (OTJR). Journals that published less than five studies with a qualitative approach during the years 2003–2005 were not included, which led to the exclusion of the Asian Journal of Occupational Therapy. Based on the following 12 terms, a search for publications that had adopted a qualitative methodology was conducted in the identified five occupational therapy journals: Qualitative, Thematic, Narrative, Phenomenology, Grounded theory, Constant comparative approach, EPP (Empirical Psychological Phenomenology), Hermeneutic, Ethnography, Observation, Focus groups, Case study. The literature search in the five journals covering three years resulted in identification of 90 publications with a qualitative approach. The 90 publications comprised 40 publications from AJOT, 13 from OTJR, 14 from CJOT, 13 from SJOT, and 10 from AOTJ. The differences in numbers of publications were related to the size of the edition, where AJOT represented the most frequently published journal including six issues per year. On average about one publication that used a qualitative methodology was found in each issue of each journal. Development of criteria for categorization of publications A systematic and extensive exploration of the 90 publications was conducted in several steps (13). The first step in the review process was to identify descriptive criteria for categorisation of the approaches applied in the publications, representing (A) type of methodological approach and (B) area of interest represented in each publication. For this purpose 30 publications were initially reviewed by three of the five authors. Based on an analysis of these 30 publications and discussions between all authors three categories of methodological approaches were then developed to guide the next step in the review. The categories were (1) studies that provided findings in the format of descriptive categories; (2) studies that presented patterns of categories or themes; and (3) studies that provided an understanding of the
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Table I. Definitions of the categorization of methodological approaches. 1.Studies resulting in descriptive categories The first type consists of descriptive sorting of data into piles of descriptive categories. Labels of the categories could be pre-determined (deductively generated) and the study could be seen as deductive or categories could have been generated in an inductive manner. In these cases the categories are named with the content of the category. The aims/purposes/objectives in the studies are often framed in terms of to explore, to discover, to identify, and to describe. Grounding in theory or philosophy is not always clear for the reader 2.Studies resulting in patterns of categories or themes The second type also includes sorted piles of descriptive categories, but the categories are grouped together or held together by a relationship between the categories. The relationship between the categories is clearly described, sometimes in the format of a model. The categories are not pre-given but emerge from data in a comparative process of analysis. That is, categories are discovered or inductively developed from the data. Aims included in studies of the second type could also be named in terms of explore and identify, just as in the first type. Studies with the aim to explore experiences, to discover, and to identify can also be part of this type. However, in the conclusions of the second-type studies there are no clear enhanced understanding or explanations of the findings. The second type of analysis often confirms knowledge found in previous studies 3.Studies resulting in understanding Characteristics for studies of the third type are that these studies provide an understanding of the meaning of a phenomenon or provide new knowledge of descriptive findings. In order to fulfil these goals there is a need to include rich, detailed data in the studies and also to make discoveries that further our understanding of a specific phenomenon. Interpretations of the findings are the most frequently used analytical tools in this type of studies. The interpretations could be based on a preconceived theory for explanation of the findings
content area under study. These three categories are presented in Table I. The authors subsequently met on a regular basis to reach consensus regarding the use of terminology and refine the definitions of these categories. In addition to the categorization into the three types of qualitative approaches, a categorization was made based on the content area of interest in the publications. Four broad content areas were identified: (a) studies of living conditions, when the study focused on life situations for individuals or groups of people, (b) studies of therapy, when the focus was on clients’ experiences of therapy, (c) studies of professional issues, when the paper highlighted professional issues related to education, practice, research, or general policy, and (d) others, i.e. studies with a focus on topics outside of a–c, most often theory or research methods.
Categorization of papers based on criteria In the next step, all 90 publications were evenly distributed among the four authors with a professional occupational therapy background and subsequently categorized based on the categorizations of methodologies and content areas already described. About 20% of randomly chosen publications were reviewed by two researchers independently of each other in order to ensure inter-rater agreement. When there was a discrepancy, which occurred in a few cases, each author reviewed the categorization once more and if there was still no consensus a third author reviewed the publication. Moreover, if a publication that was written by one of the authors was identified, two other authors served as reviewers. Table II shows the distribution of the categorized publications according to methodological approach
Table II. Distribution of publications based on categorization of methodological approach and content area of interest. Type of methodological approach
Number of articles
1. Descriptive categories; a descriptive sorting of data into categories
37
2. Patterns of categories/themes; also including sorted descriptive categories, but the categories are relational
38
3. Understanding; providing an understanding of a phenomenon. Rich data and new discoveries that reveal coherent meaning are characteristic
10
4. Excluded
5
Total
90
Area of interest (a) Living conditions: focus on life situation for persons or groups
32
(b) Therapy: focus on patient/client experiences with regard to therapy
31
(c) Professional issues: focus on education, and professional issues within practice, research, and/or policy
17
(d) Other: focus on topics not elsewhere defined
11
Total
90
Qualitative approaches in OT research and content area of interest. Overall most publications were categorized for methodological approach as type 1 (descriptive categories) and as type 2 (categories and themes where the relationships between the categories were described). Type 3 was rare; only 10 of the 90 included articles were categorized as type 3 where an understanding of a phenomenon was required. The distribution of methodological approaches of type 1, 2, and 3 was evenly distributed among the five occupational therapy journals with the exception of the AOTJ where the majority of the articles were categorized as type 1. The categorization into content area of interest revealed that about 30 studies, i.e. about one-third, focused on each of Living conditions for persons or groups and Therapy as experienced by the clients, as shown in Table II. The studies’ area of interest showed more variation between the journals than did the type of methodological approach. The majority of publications in SJOT and CJOT concerned Therapy as experienced by the clients. In OTJR studies concerning Living conditions for persons and groups dominated and in AJOT Professional issues were most common. The articles in AJOT dominated in the number of publications. The content areas of interest Living conditions for persons and groups and Therapy as experienced by the clients were similarly common in AJOT. Articles categorized as Others (i.e. methodology, theory) were identified only in AJOT. Comments on the findings It is possible to make two remarks based on the findings. First there seems to be a strong interest in occupational therapy research to study people’s living conditions by applying a qualitative approach and also how daily life, as well as therapy, is experienced. However, it is evident that occupational therapy researchers have to a limited extent utilized methods that can facilitate a better understanding of the occupations or the impact of occupational therapy programmes within people’s daily lives. The low frequency of interpretative studies (Type 3, see Tables I and II) that could enhance understanding was remarkable, since there is a strong interest in the profession of occupational therapy to understand occupation, therapy, and other professional issues (14,15). It was also surprising to find such a low frequency of studies with the explicit aim of contributing new theoretical understanding. In response to the need for additional qualitative approaches that allow theoretical analysis in occupational therapy research, the Formal Data-Structure Analysis approach (FDSA) will be introduced next, followed by an illustration of how it has been applied.
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FDSA is situated epistemologically within the hermeneutic tradition (7), where the aim is to understand people’s activities and spoken words (16). The Formal Data-Structure Analysis (FDSA) approach The Formal Data-Structure Analysis (FDSA) approach was first described by Trankell (4,18) in an attempt to investigate how people’s actions and statements can be analysed and understood through an analysis of the structure of all available data (3). The FDSA can be seen as a specific empirical approach within the hermeneutic tradition (3). In a number of studies (19-22) from the Division of Occupational Therapy at Karolinska Institutet the FDSA research approach has been applied. The studies were conducted under the guidance of Professor Anders Gustavsson from the Stockholm group of hermeneutical social science studies (23,24) and represent a multi-level interpretative approach (3,16) in the qualitative research tradition. The studies share an interest in aiming at understanding phenomena of relevance to the practice of occupational therapy, for example, how older people with a dementia disease manage and relate to challenges in everyday living (22), the conditions for learning among school children with disabilities (20,21), as well as how occupational programming in a day-hospital context could be understood (19). As a background to the FSDA some concepts of pivotal importance will be introduced and thereafter an example from occupational therapy research applying this approach is provided. The concept of meaning Meaning as a scientific concept has a long history in the hermeneutic tradition, referring primarily to a systematic analysis of different kinds of human expressions in order to make visible understandings of a person in a specific context or more or less de-contextualized understandings of different sorts of texts. In occupational therapy, meaning is used both in an everyday sense by therapists and patients and in a more hermeneutic, human science sense. In addition to this, meaningful occupation is often used as a synonym for relevant, interesting, or valued occupation in occupational therapy. When we consider everyday meaning in occupational therapy research here, our point of departure is that all occupations have some kind of significance to the individual, in that specific culture at that specific point in time. In other words, people constantly intentionally search for meaning in every act of consciousness. For application in occupational therapy this view suggests
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that it is possible to interpret the significances in human acts and engagement in occupations when we learn about people’s goals, aims, and purposes and the conditions for engaging in the intended occupations. The study of meaning has drawn on the phenomenological approach of understanding people’s lived experiences (25,26). In this respect it is not possible to isolate meaning from what constitutes people’s life-world (26,5). Humans are in this tradition seen as intentional beings (26,27) and this view guides the hermeneutic study of human actions, thoughts, and feelings as embedded in meaning. The hermeneutic understanding of human expressions also implies that it is not possible to reduce acts, thoughts, or feelings into categorizations or measurements for study in research without losing the specific meaning of the acts, thoughts, and feelings (3). Meaning is not something that can be found in the open; it is expressed indirectly through actions, words, or other kinds of human productions and, as a consequence, the meaning of human occupation needs to be interpreted to enhance our understanding. Pre-understanding and interpretation Some qualitative methods, e.g. phenomenology, advocate that the researcher should “bracket” his or her pre-understanding in order to reach the essential understanding of a phenomenon (5). In an FDSA approach it is argued that, in order to understand, we have to compare the unfamiliar (or that which is different) with something already known by relating the unfamiliar to our own experiences and our own world. Without pre-understanding it is not possible to fully understand a phenomenon (7,28). In order not to be caught in a vicious circle, the hermeneutic researcher needs to become aware of her/his preunderstanding and how this pre-understanding and its perspective on the world might influence the understanding of the issues under study. By critical reflection it is possible to increase the awareness of our own cultural preconditions, which in turn makes possible genuine understanding of the unfamiliar. According to Ödman (2), to interpret is to see something unfamiliar as something familiar; when we interpret we name something. This is also what we do when we translate something from another language. In translating from English into Swedish, for example, we interpret what the words could mean in Swedish. Interpretations in everyday life or research often have the form of metaphors where something is seen and configured as something. In occupational therapy understanding a patient or a therapist implies a need to learn about people’s daily lives and what they need and want to do, i.e. their conditions for occupation. For example, Hemmingsson, Borell, and
Gustavsson (21) conducted field observations in mainstream schools of pupils with physical disabilities who had access to a teacher’s assistant. Through interviews it was possible to gain insight into how these pupils experienced the specific situations documented in field notes from observations, and how the assistance influenced participation. In the analysis and interpretation of the findings, all data were used since interpretation requires rich data, including the lived experiences that people speak of in interviews and show in their actions in a specific context. As occupational therapy research often investigates context-dependent issues (8), an ethnographic approach is often preferable, and data collection in the home and observations of people participating and engaging in occupations provide important information in combination with in-depth interviews.
Two models of interpretation: texts and traces Ricoeur (27) has devoted much of his work, as a philosopher, to a close analysis of the traditions of hermeneutics. One line of hermeneutics, which he identifies, is based on the reading and interpretation of texts. Basically a written text is a de-contextualized expression of signs, open for interpretation through a process where the reader decodes the code of signs in order to discover or find its possible inherent meanings. In the process of writing, the text is decontextualized from specific contexts intended by the author, and other persons who might have inspired the author. Thus, the text model of interpretation is used in interpretation of such de-contextualized, more general phenomena. From a methodological perspective this demands a structured and systematic analysis of the text itself. A text, e.g. a transcribed interview or a book, can be re-read over and over again and analysed in detail, and over time also be understood in new ways. The text tradition of hermeneutics has been developed in – apart from literary text analysis – areas such as anthropology and narrative analysis. The second model of interpretation identified by Ricoeur (29) is the historical trace model. A trace is different from the signs of a text since traces refer back to a specific context where the trace was left. The trace model is applied to understand unique, individual human occupation and action in a specific context through systematic analysis of the traces left by an actor or agent in a specific historical context. A text, conversely, is read as detached from the actor, as something that has a meaning of its own. Photographs, field notes, observations, interviews, and diaries are all examples of possible data sources for both models of interpretation. However, the text model is
Qualitative approaches in OT research the most frequently used in human and social sciences. The special contribution of Trankell (7,17), outlined in FDSA, was to develop the trace model into a personal-historical method to interpret individual human actions and statements. Drawing on, among others, Clifford Geertz, Gustavsson (23,28) has developed FDSA further as a model for interpretation based in both the text model and the trace model interacting in a dialectic manner. Gustavsson (23,28) has suggested that this approach can be fruitful for interpretation of individual human actions and for interpretation of speech. The meaning of human actions as shown in, for example, human occupations as well as in stories or statements can be investigated and analysed both as traces of an agent and as a text that transcends the agent’s lived worlds. The FDSA offers a systematic way to conduct scientific interpretations through an analytic process where the researcher applies both models of interpretation. In an analysis of the two models used in FDSA, Gustavsson has identified two basic types of interpretation interests (3). The trace model of interpretation is guided by a historical interest. The text model is guided by a generalized, theoretical interest of interpretation. When reading a text, we tend to bracket the author and her or his historical experience and context in order to search for a meaning of its own in the text. We draw on a repertoire of earlier experiences in terms of events or people that we have met before or of which we have heard (our pre-understanding). However, text interpretations are not based on specific experiences of specific persons, but rather on generalized – one could even assert theoretical – types of possible “beings-in-the-world”. Gustavsson (30) refers to this as a theoretical interest of interpretation. The historical interest is directed towards understanding a certain person’s or group’s experiences, actions, or statements in their particular life circumstances in past or present time. Drawing on Geertz, Gustavsson (30) states that the historical interest focuses on experience-near interpretations, i.e. interpretations which stay close to the informants’ own understanding of an action or an utterance. In comparison, theoretical interests attempt to understand a phenomenon more generally, transcending the informants’ own experience and understanding, generalizing it on a more abstract or theoretical level. Geertz (31) makes a distinction between experiencenear and experience-distant concepts in anthropological interpretations and Gustavsson (30) applies this as a distinction between experience-near and experience-distant interests of interpretation. Thus, the experience-distant interest of interpretation deals with the same data as the historical, experience-near interpretations, the second on a more concrete
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personal-historical level and the first on a more comparative, abstract, and theoretical level. The basic idea of the FSDA is that all these interests are combined within a systematic analysis of the existing data relating to a specific research question. Thus the researcher can move from one of these different interpretation interests to another. A study often starts from an interest, for example a theoretical question in the relation between Alzheimer’s disease and a patient’s awareness. Later the researcher might decide to shift focus and instead carry out a case study with a strong historical, experience-near interest of interpretation. Figure 1 and the following example illustrate the different interpretation interests and how the researcher moves between different interpretation interests in the process of analysis. An empirical example of applying the FDSA approach In a study of two women diagnosed with Alzheimer’s disease, Astrid and Linnea (22), the first impression was that the two women shared a similar situation; both lived by themselves, were the same age, and had the same diagnosis, and from the assessments we learned that their disease severity and ability in IADL/ADL were similar, as well as their ability to Theoretical interest
Empirical/person history interest
Analysis of the two women with dementia
Understanding blocked by theory: agnosia, unawerness; i.e. the medical perspective New interpretations and analysis focused on how they acted and what they said
Theory of selfimages and impression control
New understanding: images of occupational self Figure 1. An illustration of different interpretation interests and the hovering between these based on the empirical example.
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compensate for difficulties in daily life. However, what made us interested in learning more from and about them was that the illness seemed to bring about very different consequences for each of them. One of them, Astrid, continued with her life based on a perception of mainly being capable and hence well, although she was well aware of having this disease, while Linnea’s life had come to a point where she avoided every challenge that placed her at risk of experiencing and showing that she had this disease, although she too knew about it all the time. The question that was raised in research was: How could this difference in how the two women experienced and managed living with the dementia disease be understood? The research process into this puzzling question started by our following one of the research interests: the personal-history interest. Since we had been educated on dementia in biomedicine, our preunderstanding led us at first to rule out the possibility that the differences were related to differences in their disease and their awareness of their disease. Hence, our first understanding of the two participants’ ways of reflecting on their own ability was linked to the theoretical concepts of agnosia or unawareness of deficits (32,33). However, both women demonstrated frequent signs of simultaneously being both aware and unaware, which puzzled us even more, as we found no logical relationship between their awareness of deficits and their way of relating to the disease, as a traditionally medical perspective would indicate. While we could comprehend this from an existential, emphatic perspective, acknowledging that theoretical concepts such as awareness may not present themselves distinctively in the empirical world, these concepts seemed to block our further understanding of how Astrid and Linnea related to their situation. This led us to a further investigation of how the differences could be understood, in a search for an alternative understanding of the simultaneous presence of both awareness and unawareness of deficits and of the differences between the two individuals regarding the consequences of the disease. In the next step we therefore analysed how each woman communicated issues concerning herself to others, and found that there was a clear difference between how the two women presented themselves when acting and talking in everyday life, indicating differences also in the understanding they had of their predicament and its effect on their perception of themselves. The approach we applied in this step was of a constant comparative nature (34), which enabled a back-andforth process between how they acted (shown from observations in daily life) and what they said (shown from interview data). Through this step in the analysis we tried to grasp the intentions that were
communicated in their daily living concerning the present as well as the past, seeking further information from their empirical, personal history. Eventually, we also turned to theory in this step, as we could understand this from the theoretical explanations of how people strive to control impressions in social interaction (35-37). This meant that the analysis moved between a theoretical and an empirical, personalhistory interpretation interest. Through the continued analysis we found that Astrid, who had strong images of herself as a competent person from before, could now lean on these past experiences, and to her the recent experiences of disability and failure meant relatively little in relation to this solid base. In contrast, Linnea seemed to lack a similar strong perception from before of being competent and capable, and her recent experiences of the consequences of dementia seemed to overwhelm her with a perception of being incapable, leading to an increasingly limited daily life and a continuous struggle to hide her predicament from others. We interpreted the difference between Astrid and Linnea to be related to competing images of the occupational self, which also resulted in the concept of images of occupational self (22). This new concept was built on empirical thick descriptions in data and on the theory of self-images and how these are created, maintained, and communicated, as presented in socio-psychological writing (35,37). This interpretation seemed to be very fruitful compared with the more commonly applied concept of awareness, when the aim was to try to understand how the two women related to the disease’s influence on how they perceived themselves, and what the consequences of the disease meant to them. The new understanding of how images of the occupational self in people with dementia may be expressed can assist occupational therapists when they try to understand the consequences that the disability may have for an individual. This can help the occupational therapist to plan supportive interventions that reach beyond the medically based identification of symptoms and ADL/ IADL ability. Concluding remarks Our examination of empirical research in occupational therapy journals over three years showed that most of the published qualitative studies aimed to describe and categorize data. The high frequency of type I studies could be a sign of how occupational therapy scholarship (38) during this period was still not well defined. Whether or not the same pattern appears in current OT research requires a replication of this study. However, the aim of this study was not to examine or critique current OT research or OT journals, but rather to discuss qualitative approaches
Qualitative approaches in OT research as well as to illustrate an approach (FDSA) that aims at understanding human experiences. The categorization of methodological approaches developed for the purpose of this article may not only be used for a replication of empirical results but may also be helpful when reviewing and reflecting on qualitative research by peers or students within occupational therapy. The limitations in philosophical underpinnings in methodological design in the publications reviewed also mirror the short academic tradition in occupational therapy. There have so far only been a few attempts (see for example 2,10) to further discuss and develop qualitative methodology grounded in philosophy for the new discipline. This paper suggests that it is possible to apply the FDSA approach when we want not only to describe and categorize phenomena but also to reach a more in-depth understanding of, for example, engagement in occupations or living with a disability. The overall goals in occupational therapy practice to enable activity and participation and empower people also require such an in-depth understanding (10,11). Welldeveloped methods are required for the study of how patients and therapeutic processes can be understood. Christiansen and Townsend (11) stressed the importance of meaningful occupations, defined as occupations that generate experiences of importance and personal value. However, occupational therapy research has not yet made any substantial contributions to the methodological approach for the study of personal meaning (39). What makes the FDSA approach interesting and particularly appropriate to occupational therapy research is the interpretative approach not only to spoken words or written texts but also to people’s actions. We argue that an approach that allows in-depth study of a combination of dimensions of human occupation is particularly well suited for the field of occupational therapy. This is of special interest for research that aims to enable a better understanding of people’s living conditions, and for knowledge development in a field such as occupational therapy that has the goal of enabling people to engage in and participate in activities. For further development of in-depth methodological knowledge, critical analysis and reflections are tools that can be applied as proposed by Reilly (1). Such analyses are also required to nurture a general discussion concerning quality in research in occupational therapy. The responsibility for developing methodologies appropriate for the study of people’s lived experiences and meaning-making should also be on the agenda for all occupational therapy journals. This is of utmost importance since a new discipline is especially vulnerable during its first attempt to develop unique knowledge (39). In order to monitor and critique how occupational therapy journals fulfil
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this responsibility reviews of qualitative publications and qualitative methodology developments are needed. The approach applied in this paper could serve as a model for such forthcoming studies. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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19. Borell L, Gustavsson A, Sandman PO, Kielhofner G. Occupational programming in a day hospital for patients with dementia. Occup Ther J Res 1994;14:219–38. 20. Hemmingsson H, Borell L, Gustavsson A. Temporal aspects of teaching and learning: Implications for pupils with physical disabilities. Scand J Disabil Res 1999;1:26–43. 21. Hemmingsson H, Borell L, Gustavsson A. Participation in schools: School assistants creating opportunities and obstacles. Occup Ther J Res 2003;23:88–98. 22. Nygård L, Borell L, Gustavsson A. Managing images of occupational self in early stages of dementia. Scand J Occup Ther 1995;2:24–33. 23. Gustavsson A. The role of theory in disability research: Springboard or strait-jacket. Scand J Disabil Res 2004;6: 55–70. 24. Ödman P-J, Selander S. editors. Text och existens. Hermeneutik möter samhällsvetenskap [Text and existence: Hermeneutics meets the social sciences] (in Swedish). Göteborg: Daidalos; 2005. 25. Husserl E. Logical Investigations. New York: Humanities Press; 1970/1900–1. 26. Merleau-Ponty M. The phenomenology of perception. London: Routledge; 1962/1945. 27. Ricoeur P. The model of the text: Meaningful action considered as a text. Soc Res 1971;38:529–56. 28. Gustavsson A. Att förstå andra genom att förstå sig själv [To understand others by understanding oneself] (in Swedish). In Gustavsson A, Ödman PJ,. editors. Den Trankellska vändningen – ett levande hermeneutiskt arv [Trankell’s approach- a living hermenutical heritage]. Stockholm: Pedagogiska institutionen; 2005.
29. Ricoeur P. Temps et récit III [Time and narrative]. Paris: Seuil; 1985. 30. Gustavsson A, Bergström H. Pendlingen mellan olika tolkningsintressen [The dialectics between different interests of interpretation] (in Swedish). In Ödman P-J, Selander S, editors. Text och existens. Hermeneutik möter samhällsvetenskap [Text and existence: Hermeneutics meets the social sciences] (in Swedish). Göteborg: Daidalos; 2005. 31. Geertz C. The interpretation of cultures. New York: Basic Books; 1973. 32. McGlynn SM, Schacter DL. Unawareness of deficits in neuropsychological syndromes. J Clin Exp Neuropsychol 1989; 11:143–205. 33. McGlynn SM, Kaszniak AW. When metacognition fails: Impaired awareness of deficit in Alzheimer’s disease. J Cogn Neurosci 1991;3:183–9. 34. Strauss A, Corbin J. Basics of qualitative research: Grounded theory procedures and techniques. 2nd ed. Newbury Park, CA: Sage Publications; 1998. 35. Lange A, Westin C. Etnisk diskriminering och social identitet [Ethnic discrimination and social identity] (in Swedish). Stockholm: Liber; 1981. 36. Snyder M. Impression management. In Wrightsman LS, editor. Social psychology. Belmont, CA: Brooks-Cole; 1977. 37. Snyder M. Self-monitoring process. In Berkowitz L, editor. Advances in experimental social psychology. New York: Academic Press; 1979. 38. Hocking C, Wright-St Clair V, Bunrayong W. The meaning of cooking and recipe work for older Thai and New Zealand women. J Occup Science Australia 2002;9:117–27. 39. Törnebohm H. What is worth knowing in occupational therapy. Am J Occup Ther 1991;5:451–4.
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ORIGINAL ARTICLE
Qualitative approaches in occupational therapy research Previously published in Scandinavian Journal of Occupational Therapy 2012; 19: 521–529
LENA BORELL1, LOUISE NYGÅRD1, ERIC ASABA1, ANDERS GUSTAVSSON2 & HELENA HEMMINGSSON3 1
Department of Neurobiology, Caring Sciences and Society, Division of Occupational Therapy, Karolinska Institutet, Sweden, 2Department of Education, Stockholm University, Sweden, and 3Faculty of Health Sciences, Department of Social and Welfare Studies, Linköping University, Sweden
Abstract Objective: Development of research in occupational therapy requires a continuous critical discussion concerning methodological approaches. In this paper the authors wish to contribute to such a discussion by introducing the Formal Data-Structure Analysis approach (FDSA) as a method for understanding people’s experiences. Methods and results: A review of selected publications from occupational therapy journals between 2003 and 2005 illustrated that qualitative articles within occupational therapy publications were mainly descriptive in nature. This finding raises questions about how to develop new knowledge that contributes to occupational therapy. Conclusions: In this paper the authors suggest that it is possible to apply the FDSA approach not only when describing and categorizing qualitative phenomena, but also when aiming to reach an in-depth understanding of issues related to human meaning-making; for example, how we understand engagement in occupations or living with a disability. Examples of the application of the FDSA approach are included and discussed.
Key words: qualitative analysis, phenomenology, meaning, interpretation, hermeneutics, ethnography
Introduction This paper builds on the idea that, epistemologically, a broad genre of research traditions, methodologies, and queries characterize occupational therapy research. For instance, occupational therapy research appears to be influenced by biomedical paradigms as well as social and human science traditions. Consequently, myriad research traditions and approaches could be valid for the development of knowledge within occupational therapy research. Moreover, it has been argued that methodological multiplicity can be seen as complementary rather than in conflict, and thus can contribute to the development of a field (1). Nevertheless, approaches in occupational therapy research need to be refined and developed continuously in order to remain relevant (2). In order to explore qualitative approaches used in occupational therapy research, a literature review was conducted of
studies that have adopted a qualitative research approach and have been published in international occupational therapy journals. The methods and results are presented in this paper. In an attempt to contribute to methodological development within occupational therapy research, the authors introduce and describe central aspects of an interpretative approach referred to as Formal Data-Structure Analysis (FDSA) (3,4). This approach is exemplified with studies from occupational therapy research where FDSA was applied, and is thought to contribute with a different type of understanding than descriptive analyses. Philosophical underpinnings Philosophy of science suggests that before we can causally explain or predict a phenomenon, for example change, we need to understand the phenomenon in
Correspondence: Professor Lena Borell, Karolinska Institutet, Department of Neurobiology, Caring Sciences and Society, Division of Occupational Therapy, Fack 23200, 14183 Huddinge, Sweden. E-mail: [email protected]
ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2014 Informa Healthcare DOI: 10.3109/11038128.2014.952910
Qualitative approaches in OT research a scientific sense; in other words, what and how questions have priority over questions starting with why (5). What and how questions pertain to the knowledge interest of understanding, while the why question frequently used for explanations of a causal type can be linked to an interest founded in the discipline of natural science (6,7). In the natural sciences, as in bio-medicine, knowledge is produced in terms of predictions, for example concerning cause–effect relationships between variables. While this kind of knowledge is invaluable in occupational therapy research, it is not applicable when we want to better understand something. Human occupation is not restricted to “what can be simplified and reduced in order to be measured precisely”, as Yerxa argued (8). In occupational therapy, the professional core values urge scholars and practitioners to view people as integrated and contextualized beings that are guided in their daily living by intentions and goals (8). Mattingly (9) suggested that occupational therapists’ clinical reasoning could be seen as applied phenomenology, since occupational therapists demonstrate a strong interest in learning and understanding clients’ living conditions. Occupational therapists maintain a social view of clients as they try to understand each individual’s unique living situation. Since a person’s engagement in an occupation is motivated by his or her intentions, based on his or her interpretation of a particular, contextualized, and temporal situation, this engagement could be understood through an ordinary and everyday understanding assigned by the person (10,11). This calls for an approach that can support occupational therapists in understanding their clients’ meaning-making, rather than taking a perspective based merely on the clients’ bodily condition (8,12). Meaning-making guides people’s activities in daily life since it involves individual intentions and goals. Based on this background, this paper intends to advance further the discussion concerning qualitative research in occupational therapy. The aim is to present a specific methodological approach, the Formal Data-Structure Analysis approach, that has the objective to provide an understanding of phenomena in focus for occupational therapy research. An overview of previously published qualitative occupational therapy research will serve as a starting point for the presentation and following discussion. Overview of empirical, qualitative research in occupational therapy 2003–2005 To gain an overview of qualitative approaches used in occupational therapy research, studies that adopted a
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qualitative research approach published in an international selection of peer-reviewed occupational therapy journals in the years 2003–2005 were reviewed. By mapping trends within the field, we also hoped to identify critical knowledge gaps. The following six journals were included based on impact factor and global geographical representation: Asian Journal of Occupational Therapy, Australian Occupational Therapy Journal (AOTJ), American Journal of Occupational Therapy (AJOT), Canadian Journal of Occupational Therapy (CJOT), Scandinavian Journal of Occupational Therapy (SJOT), and Occupational Therapy Journal of Research: Occupation, Participation and Health (OTJR). Journals that published less than five studies with a qualitative approach during the years 2003–2005 were not included, which led to the exclusion of the Asian Journal of Occupational Therapy. Based on the following 12 terms, a search for publications that had adopted a qualitative methodology was conducted in the identified five occupational therapy journals: Qualitative, Thematic, Narrative, Phenomenology, Grounded theory, Constant comparative approach, EPP (Empirical Psychological Phenomenology), Hermeneutic, Ethnography, Observation, Focus groups, Case study. The literature search in the five journals covering three years resulted in identification of 90 publications with a qualitative approach. The 90 publications comprised 40 publications from AJOT, 13 from OTJR, 14 from CJOT, 13 from SJOT, and 10 from AOTJ. The differences in numbers of publications were related to the size of the edition, where AJOT represented the most frequently published journal including six issues per year. On average about one publication that used a qualitative methodology was found in each issue of each journal. Development of criteria for categorization of publications A systematic and extensive exploration of the 90 publications was conducted in several steps (13). The first step in the review process was to identify descriptive criteria for categorisation of the approaches applied in the publications, representing (A) type of methodological approach and (B) area of interest represented in each publication. For this purpose 30 publications were initially reviewed by three of the five authors. Based on an analysis of these 30 publications and discussions between all authors three categories of methodological approaches were then developed to guide the next step in the review. The categories were (1) studies that provided findings in the format of descriptive categories; (2) studies that presented patterns of categories or themes; and (3) studies that provided an understanding of the
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Table I. Definitions of the categorization of methodological approaches. 1.Studies resulting in descriptive categories The first type consists of descriptive sorting of data into piles of descriptive categories. Labels of the categories could be pre-determined (deductively generated) and the study could be seen as deductive or categories could have been generated in an inductive manner. In these cases the categories are named with the content of the category. The aims/purposes/objectives in the studies are often framed in terms of to explore, to discover, to identify, and to describe. Grounding in theory or philosophy is not always clear for the reader 2.Studies resulting in patterns of categories or themes The second type also includes sorted piles of descriptive categories, but the categories are grouped together or held together by a relationship between the categories. The relationship between the categories is clearly described, sometimes in the format of a model. The categories are not pre-given but emerge from data in a comparative process of analysis. That is, categories are discovered or inductively developed from the data. Aims included in studies of the second type could also be named in terms of explore and identify, just as in the first type. Studies with the aim to explore experiences, to discover, and to identify can also be part of this type. However, in the conclusions of the second-type studies there are no clear enhanced understanding or explanations of the findings. The second type of analysis often confirms knowledge found in previous studies 3.Studies resulting in understanding Characteristics for studies of the third type are that these studies provide an understanding of the meaning of a phenomenon or provide new knowledge of descriptive findings. In order to fulfil these goals there is a need to include rich, detailed data in the studies and also to make discoveries that further our understanding of a specific phenomenon. Interpretations of the findings are the most frequently used analytical tools in this type of studies. The interpretations could be based on a preconceived theory for explanation of the findings
content area under study. These three categories are presented in Table I. The authors subsequently met on a regular basis to reach consensus regarding the use of terminology and refine the definitions of these categories. In addition to the categorization into the three types of qualitative approaches, a categorization was made based on the content area of interest in the publications. Four broad content areas were identified: (a) studies of living conditions, when the study focused on life situations for individuals or groups of people, (b) studies of therapy, when the focus was on clients’ experiences of therapy, (c) studies of professional issues, when the paper highlighted professional issues related to education, practice, research, or general policy, and (d) others, i.e. studies with a focus on topics outside of a–c, most often theory or research methods.
Categorization of papers based on criteria In the next step, all 90 publications were evenly distributed among the four authors with a professional occupational therapy background and subsequently categorized based on the categorizations of methodologies and content areas already described. About 20% of randomly chosen publications were reviewed by two researchers independently of each other in order to ensure inter-rater agreement. When there was a discrepancy, which occurred in a few cases, each author reviewed the categorization once more and if there was still no consensus a third author reviewed the publication. Moreover, if a publication that was written by one of the authors was identified, two other authors served as reviewers. Table II shows the distribution of the categorized publications according to methodological approach
Table II. Distribution of publications based on categorization of methodological approach and content area of interest. Type of methodological approach
Number of articles
1. Descriptive categories; a descriptive sorting of data into categories
37
2. Patterns of categories/themes; also including sorted descriptive categories, but the categories are relational
38
3. Understanding; providing an understanding of a phenomenon. Rich data and new discoveries that reveal coherent meaning are characteristic
10
4. Excluded
5
Total
90
Area of interest (a) Living conditions: focus on life situation for persons or groups
32
(b) Therapy: focus on patient/client experiences with regard to therapy
31
(c) Professional issues: focus on education, and professional issues within practice, research, and/or policy
17
(d) Other: focus on topics not elsewhere defined
11
Total
90
Qualitative approaches in OT research and content area of interest. Overall most publications were categorized for methodological approach as type 1 (descriptive categories) and as type 2 (categories and themes where the relationships between the categories were described). Type 3 was rare; only 10 of the 90 included articles were categorized as type 3 where an understanding of a phenomenon was required. The distribution of methodological approaches of type 1, 2, and 3 was evenly distributed among the five occupational therapy journals with the exception of the AOTJ where the majority of the articles were categorized as type 1. The categorization into content area of interest revealed that about 30 studies, i.e. about one-third, focused on each of Living conditions for persons or groups and Therapy as experienced by the clients, as shown in Table II. The studies’ area of interest showed more variation between the journals than did the type of methodological approach. The majority of publications in SJOT and CJOT concerned Therapy as experienced by the clients. In OTJR studies concerning Living conditions for persons and groups dominated and in AJOT Professional issues were most common. The articles in AJOT dominated in the number of publications. The content areas of interest Living conditions for persons and groups and Therapy as experienced by the clients were similarly common in AJOT. Articles categorized as Others (i.e. methodology, theory) were identified only in AJOT. Comments on the findings It is possible to make two remarks based on the findings. First there seems to be a strong interest in occupational therapy research to study people’s living conditions by applying a qualitative approach and also how daily life, as well as therapy, is experienced. However, it is evident that occupational therapy researchers have to a limited extent utilized methods that can facilitate a better understanding of the occupations or the impact of occupational therapy programmes within people’s daily lives. The low frequency of interpretative studies (Type 3, see Tables I and II) that could enhance understanding was remarkable, since there is a strong interest in the profession of occupational therapy to understand occupation, therapy, and other professional issues (14,15). It was also surprising to find such a low frequency of studies with the explicit aim of contributing new theoretical understanding. In response to the need for additional qualitative approaches that allow theoretical analysis in occupational therapy research, the Formal Data-Structure Analysis approach (FDSA) will be introduced next, followed by an illustration of how it has been applied.
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FDSA is situated epistemologically within the hermeneutic tradition (7), where the aim is to understand people’s activities and spoken words (16). The Formal Data-Structure Analysis (FDSA) approach The Formal Data-Structure Analysis (FDSA) approach was first described by Trankell (4,18) in an attempt to investigate how people’s actions and statements can be analysed and understood through an analysis of the structure of all available data (3). The FDSA can be seen as a specific empirical approach within the hermeneutic tradition (3). In a number of studies (19-22) from the Division of Occupational Therapy at Karolinska Institutet the FDSA research approach has been applied. The studies were conducted under the guidance of Professor Anders Gustavsson from the Stockholm group of hermeneutical social science studies (23,24) and represent a multi-level interpretative approach (3,16) in the qualitative research tradition. The studies share an interest in aiming at understanding phenomena of relevance to the practice of occupational therapy, for example, how older people with a dementia disease manage and relate to challenges in everyday living (22), the conditions for learning among school children with disabilities (20,21), as well as how occupational programming in a day-hospital context could be understood (19). As a background to the FSDA some concepts of pivotal importance will be introduced and thereafter an example from occupational therapy research applying this approach is provided. The concept of meaning Meaning as a scientific concept has a long history in the hermeneutic tradition, referring primarily to a systematic analysis of different kinds of human expressions in order to make visible understandings of a person in a specific context or more or less de-contextualized understandings of different sorts of texts. In occupational therapy, meaning is used both in an everyday sense by therapists and patients and in a more hermeneutic, human science sense. In addition to this, meaningful occupation is often used as a synonym for relevant, interesting, or valued occupation in occupational therapy. When we consider everyday meaning in occupational therapy research here, our point of departure is that all occupations have some kind of significance to the individual, in that specific culture at that specific point in time. In other words, people constantly intentionally search for meaning in every act of consciousness. For application in occupational therapy this view suggests
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that it is possible to interpret the significances in human acts and engagement in occupations when we learn about people’s goals, aims, and purposes and the conditions for engaging in the intended occupations. The study of meaning has drawn on the phenomenological approach of understanding people’s lived experiences (25,26). In this respect it is not possible to isolate meaning from what constitutes people’s life-world (26,5). Humans are in this tradition seen as intentional beings (26,27) and this view guides the hermeneutic study of human actions, thoughts, and feelings as embedded in meaning. The hermeneutic understanding of human expressions also implies that it is not possible to reduce acts, thoughts, or feelings into categorizations or measurements for study in research without losing the specific meaning of the acts, thoughts, and feelings (3). Meaning is not something that can be found in the open; it is expressed indirectly through actions, words, or other kinds of human productions and, as a consequence, the meaning of human occupation needs to be interpreted to enhance our understanding. Pre-understanding and interpretation Some qualitative methods, e.g. phenomenology, advocate that the researcher should “bracket” his or her pre-understanding in order to reach the essential understanding of a phenomenon (5). In an FDSA approach it is argued that, in order to understand, we have to compare the unfamiliar (or that which is different) with something already known by relating the unfamiliar to our own experiences and our own world. Without pre-understanding it is not possible to fully understand a phenomenon (7,28). In order not to be caught in a vicious circle, the hermeneutic researcher needs to become aware of her/his preunderstanding and how this pre-understanding and its perspective on the world might influence the understanding of the issues under study. By critical reflection it is possible to increase the awareness of our own cultural preconditions, which in turn makes possible genuine understanding of the unfamiliar. According to Ödman (2), to interpret is to see something unfamiliar as something familiar; when we interpret we name something. This is also what we do when we translate something from another language. In translating from English into Swedish, for example, we interpret what the words could mean in Swedish. Interpretations in everyday life or research often have the form of metaphors where something is seen and configured as something. In occupational therapy understanding a patient or a therapist implies a need to learn about people’s daily lives and what they need and want to do, i.e. their conditions for occupation. For example, Hemmingsson, Borell, and
Gustavsson (21) conducted field observations in mainstream schools of pupils with physical disabilities who had access to a teacher’s assistant. Through interviews it was possible to gain insight into how these pupils experienced the specific situations documented in field notes from observations, and how the assistance influenced participation. In the analysis and interpretation of the findings, all data were used since interpretation requires rich data, including the lived experiences that people speak of in interviews and show in their actions in a specific context. As occupational therapy research often investigates context-dependent issues (8), an ethnographic approach is often preferable, and data collection in the home and observations of people participating and engaging in occupations provide important information in combination with in-depth interviews.
Two models of interpretation: texts and traces Ricoeur (27) has devoted much of his work, as a philosopher, to a close analysis of the traditions of hermeneutics. One line of hermeneutics, which he identifies, is based on the reading and interpretation of texts. Basically a written text is a de-contextualized expression of signs, open for interpretation through a process where the reader decodes the code of signs in order to discover or find its possible inherent meanings. In the process of writing, the text is decontextualized from specific contexts intended by the author, and other persons who might have inspired the author. Thus, the text model of interpretation is used in interpretation of such de-contextualized, more general phenomena. From a methodological perspective this demands a structured and systematic analysis of the text itself. A text, e.g. a transcribed interview or a book, can be re-read over and over again and analysed in detail, and over time also be understood in new ways. The text tradition of hermeneutics has been developed in – apart from literary text analysis – areas such as anthropology and narrative analysis. The second model of interpretation identified by Ricoeur (29) is the historical trace model. A trace is different from the signs of a text since traces refer back to a specific context where the trace was left. The trace model is applied to understand unique, individual human occupation and action in a specific context through systematic analysis of the traces left by an actor or agent in a specific historical context. A text, conversely, is read as detached from the actor, as something that has a meaning of its own. Photographs, field notes, observations, interviews, and diaries are all examples of possible data sources for both models of interpretation. However, the text model is
Qualitative approaches in OT research the most frequently used in human and social sciences. The special contribution of Trankell (7,17), outlined in FDSA, was to develop the trace model into a personal-historical method to interpret individual human actions and statements. Drawing on, among others, Clifford Geertz, Gustavsson (23,28) has developed FDSA further as a model for interpretation based in both the text model and the trace model interacting in a dialectic manner. Gustavsson (23,28) has suggested that this approach can be fruitful for interpretation of individual human actions and for interpretation of speech. The meaning of human actions as shown in, for example, human occupations as well as in stories or statements can be investigated and analysed both as traces of an agent and as a text that transcends the agent’s lived worlds. The FDSA offers a systematic way to conduct scientific interpretations through an analytic process where the researcher applies both models of interpretation. In an analysis of the two models used in FDSA, Gustavsson has identified two basic types of interpretation interests (3). The trace model of interpretation is guided by a historical interest. The text model is guided by a generalized, theoretical interest of interpretation. When reading a text, we tend to bracket the author and her or his historical experience and context in order to search for a meaning of its own in the text. We draw on a repertoire of earlier experiences in terms of events or people that we have met before or of which we have heard (our pre-understanding). However, text interpretations are not based on specific experiences of specific persons, but rather on generalized – one could even assert theoretical – types of possible “beings-in-the-world”. Gustavsson (30) refers to this as a theoretical interest of interpretation. The historical interest is directed towards understanding a certain person’s or group’s experiences, actions, or statements in their particular life circumstances in past or present time. Drawing on Geertz, Gustavsson (30) states that the historical interest focuses on experience-near interpretations, i.e. interpretations which stay close to the informants’ own understanding of an action or an utterance. In comparison, theoretical interests attempt to understand a phenomenon more generally, transcending the informants’ own experience and understanding, generalizing it on a more abstract or theoretical level. Geertz (31) makes a distinction between experiencenear and experience-distant concepts in anthropological interpretations and Gustavsson (30) applies this as a distinction between experience-near and experience-distant interests of interpretation. Thus, the experience-distant interest of interpretation deals with the same data as the historical, experience-near interpretations, the second on a more concrete
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personal-historical level and the first on a more comparative, abstract, and theoretical level. The basic idea of the FSDA is that all these interests are combined within a systematic analysis of the existing data relating to a specific research question. Thus the researcher can move from one of these different interpretation interests to another. A study often starts from an interest, for example a theoretical question in the relation between Alzheimer’s disease and a patient’s awareness. Later the researcher might decide to shift focus and instead carry out a case study with a strong historical, experience-near interest of interpretation. Figure 1 and the following example illustrate the different interpretation interests and how the researcher moves between different interpretation interests in the process of analysis. An empirical example of applying the FDSA approach In a study of two women diagnosed with Alzheimer’s disease, Astrid and Linnea (22), the first impression was that the two women shared a similar situation; both lived by themselves, were the same age, and had the same diagnosis, and from the assessments we learned that their disease severity and ability in IADL/ADL were similar, as well as their ability to Theoretical interest
Empirical/person history interest
Analysis of the two women with dementia
Understanding blocked by theory: agnosia, unawerness; i.e. the medical perspective New interpretations and analysis focused on how they acted and what they said
Theory of selfimages and impression control
New understanding: images of occupational self Figure 1. An illustration of different interpretation interests and the hovering between these based on the empirical example.
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compensate for difficulties in daily life. However, what made us interested in learning more from and about them was that the illness seemed to bring about very different consequences for each of them. One of them, Astrid, continued with her life based on a perception of mainly being capable and hence well, although she was well aware of having this disease, while Linnea’s life had come to a point where she avoided every challenge that placed her at risk of experiencing and showing that she had this disease, although she too knew about it all the time. The question that was raised in research was: How could this difference in how the two women experienced and managed living with the dementia disease be understood? The research process into this puzzling question started by our following one of the research interests: the personal-history interest. Since we had been educated on dementia in biomedicine, our preunderstanding led us at first to rule out the possibility that the differences were related to differences in their disease and their awareness of their disease. Hence, our first understanding of the two participants’ ways of reflecting on their own ability was linked to the theoretical concepts of agnosia or unawareness of deficits (32,33). However, both women demonstrated frequent signs of simultaneously being both aware and unaware, which puzzled us even more, as we found no logical relationship between their awareness of deficits and their way of relating to the disease, as a traditionally medical perspective would indicate. While we could comprehend this from an existential, emphatic perspective, acknowledging that theoretical concepts such as awareness may not present themselves distinctively in the empirical world, these concepts seemed to block our further understanding of how Astrid and Linnea related to their situation. This led us to a further investigation of how the differences could be understood, in a search for an alternative understanding of the simultaneous presence of both awareness and unawareness of deficits and of the differences between the two individuals regarding the consequences of the disease. In the next step we therefore analysed how each woman communicated issues concerning herself to others, and found that there was a clear difference between how the two women presented themselves when acting and talking in everyday life, indicating differences also in the understanding they had of their predicament and its effect on their perception of themselves. The approach we applied in this step was of a constant comparative nature (34), which enabled a back-andforth process between how they acted (shown from observations in daily life) and what they said (shown from interview data). Through this step in the analysis we tried to grasp the intentions that were
communicated in their daily living concerning the present as well as the past, seeking further information from their empirical, personal history. Eventually, we also turned to theory in this step, as we could understand this from the theoretical explanations of how people strive to control impressions in social interaction (35-37). This meant that the analysis moved between a theoretical and an empirical, personalhistory interpretation interest. Through the continued analysis we found that Astrid, who had strong images of herself as a competent person from before, could now lean on these past experiences, and to her the recent experiences of disability and failure meant relatively little in relation to this solid base. In contrast, Linnea seemed to lack a similar strong perception from before of being competent and capable, and her recent experiences of the consequences of dementia seemed to overwhelm her with a perception of being incapable, leading to an increasingly limited daily life and a continuous struggle to hide her predicament from others. We interpreted the difference between Astrid and Linnea to be related to competing images of the occupational self, which also resulted in the concept of images of occupational self (22). This new concept was built on empirical thick descriptions in data and on the theory of self-images and how these are created, maintained, and communicated, as presented in socio-psychological writing (35,37). This interpretation seemed to be very fruitful compared with the more commonly applied concept of awareness, when the aim was to try to understand how the two women related to the disease’s influence on how they perceived themselves, and what the consequences of the disease meant to them. The new understanding of how images of the occupational self in people with dementia may be expressed can assist occupational therapists when they try to understand the consequences that the disability may have for an individual. This can help the occupational therapist to plan supportive interventions that reach beyond the medically based identification of symptoms and ADL/ IADL ability. Concluding remarks Our examination of empirical research in occupational therapy journals over three years showed that most of the published qualitative studies aimed to describe and categorize data. The high frequency of type I studies could be a sign of how occupational therapy scholarship (38) during this period was still not well defined. Whether or not the same pattern appears in current OT research requires a replication of this study. However, the aim of this study was not to examine or critique current OT research or OT journals, but rather to discuss qualitative approaches
Qualitative approaches in OT research as well as to illustrate an approach (FDSA) that aims at understanding human experiences. The categorization of methodological approaches developed for the purpose of this article may not only be used for a replication of empirical results but may also be helpful when reviewing and reflecting on qualitative research by peers or students within occupational therapy. The limitations in philosophical underpinnings in methodological design in the publications reviewed also mirror the short academic tradition in occupational therapy. There have so far only been a few attempts (see for example 2,10) to further discuss and develop qualitative methodology grounded in philosophy for the new discipline. This paper suggests that it is possible to apply the FDSA approach when we want not only to describe and categorize phenomena but also to reach a more in-depth understanding of, for example, engagement in occupations or living with a disability. The overall goals in occupational therapy practice to enable activity and participation and empower people also require such an in-depth understanding (10,11). Welldeveloped methods are required for the study of how patients and therapeutic processes can be understood. Christiansen and Townsend (11) stressed the importance of meaningful occupations, defined as occupations that generate experiences of importance and personal value. However, occupational therapy research has not yet made any substantial contributions to the methodological approach for the study of personal meaning (39). What makes the FDSA approach interesting and particularly appropriate to occupational therapy research is the interpretative approach not only to spoken words or written texts but also to people’s actions. We argue that an approach that allows in-depth study of a combination of dimensions of human occupation is particularly well suited for the field of occupational therapy. This is of special interest for research that aims to enable a better understanding of people’s living conditions, and for knowledge development in a field such as occupational therapy that has the goal of enabling people to engage in and participate in activities. For further development of in-depth methodological knowledge, critical analysis and reflections are tools that can be applied as proposed by Reilly (1). Such analyses are also required to nurture a general discussion concerning quality in research in occupational therapy. The responsibility for developing methodologies appropriate for the study of people’s lived experiences and meaning-making should also be on the agenda for all occupational therapy journals. This is of utmost importance since a new discipline is especially vulnerable during its first attempt to develop unique knowledge (39). In order to monitor and critique how occupational therapy journals fulfil
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this responsibility reviews of qualitative publications and qualitative methodology developments are needed. The approach applied in this paper could serve as a model for such forthcoming studies. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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