554231
research-article2014
QHRXXX10.1177/1049732314554231Qualitative Health ResearchHandberg et al.
Article
Revisiting Symbolic Interactionism as a Theoretical Framework Beyond the Grounded Theory Tradition
Qualitative Health Research 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314554231 qhr.sagepub.com
Charlotte Handberg1, Sally Thorne2, Julie Midtgaard3, Claus Vinther Nielsen1, and Kirsten Lomborg1
Abstract The tight bond between grounded theory (GT) and symbolic interactionism (SI) is well known within the qualitative health research field. We aimed to disentangle this connection through critical reflection on the conditions under which it might add value as an underpinning to studies outside the GT tradition. Drawing on an examination of the central tenets of SI, we illustrate with a field study using interpretive description as methodology how SI can be applied as a theoretical lens through which layers of socially constructed meaning can help surface the subjective world of patients. We demonstrate how SI can function as a powerful framework for human health behavior research through its capacity to orient questions, inform design options, and refine analytic directions. We conclude that using SI as a lens can serve as a translation mechanism in our quest to interpret the subjective world underlying patients’ health and illness behavior. Keywords interpretive description; research design; research, qualitative; symbolic interactionism, qualitative analysis Despite Blumer’s argument that every study has an empirical offset, a theoretical framework typically represents the point of departure from which a qualitative study begins (Blumer, 1969). Symbolic interactionism (SI) has often been identified as a component of the theoretical underpinnings for applied qualitative health research. However, for the most part, its application has been limited to its historic contribution to grounded theory (GT) methodology (Lomborg & Kirkevold, 2003). Indeed, the association between SI and GT has become so tightly entwined that applied researchers often conflate the two in their theoretical justifications for design decisions (Chamberlain-Salaun, Mills, & Usher, 2013; Milliken & Schreiber, 2012). The implications of this conflation therefore seem ripe for critical reflection. In this article, we attempt to disentangle this tight connection, such that SI can be considered, distinct from its GT progeny, as a viable theoretical framework for other kinds of applied qualitative inquiries. The epistemology of SI derives from American pragmatism within the discipline of sociology, reaching back almost half a century (Blumer, 1969). SI builds on three relatively simple assumptions: (a) people strive and act toward what represents meaning for them, (b) meaning arises out of social interaction, and (c) meaning is being dealt with and modified through interpretive processes.
Thus, a central feature of SI is the inseparability of the individual and the context within which the individual exists. Because of this, SI has been considered a powerful framework to guide research that is intended to lead toward an understanding of human health behavior within a social context (Meltzer, Petras, & Reynolds, 1975). The term “applied qualitative health research” reflects the subset of the qualitative health research enterprise that is fundamentally and foundationally driven by the knowledge needs of the health practice disciplines (Thorne, 2011). Its priority is an exploration of health and illness as experienced from the perspective of the people themselves rather than from the theoretical orientation of a researcher (Morse, 2012). In the tradition of methods that have been widely adopted within the applied health research world, sociologists Glaser and Strauss were 1
Aarhus University, Aarhus, Denmark University of British Columbia, Vancouver, British Columbia, Canada 3 Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 2
Corresponding Author: Charlotte Handberg, Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark. Email: [email protected]
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early proponents of an inquiry approach explicitly shaped by an understanding of SI. Their collaborations in the field of Awareness of Dying (Glaser & Strauss, 1966) represented the first application of trying to use both inductive and deductive thinking to build theory from field observational data rather than beginning with a hypothesis of any kind. On the basis of the constant comparative technique they worked out during this pioneering study, they published their seminal text, The Discovery of Grounded Theory (Glaser & Strauss, 1967). GT has gone on to become one of the most widely popularized methods in the qualitative health research spectrum (Morse, 2009). It has been taken up as an ideal approach for documenting the core processes associated with change in social groups, and for explicating what is happening within a social context. It is an approach to research that formalizes and informs theorizing from data. A review of the literature confirms that different investigators use GT as their methodological grounding for studies that take quite different forms. Furthermore, the full scope of the method as originally designed is sometimes obscured in the multiple modern applications we see in the applied health literature. However, although the investigators might not fully appreciate its importance or benefit from its influence (Milliken & Schreiber, 2012), GT researchers almost universally cite the historic roots of SI and acknowledge it as the intellectual tradition within which their methodological approach belongs (Aldiabat & Navenec, 2011; Crooks, 2001; Jeon, 2004; Lomborg & Kirkevold, 2003). Thus, because the conceptual linkage between SI and GT has become so tightly bound within the qualitative health research literature, SI is assumed as an underpinning of any GT study, and it has become correspondingly difficult to envision what a study informed by SI would look like apart from GT methodology. Increasingly, applied health researchers are exploring alternatives to conventional qualitative methods in recognition of the limits imposed by their theoretical origins (Sandelowski, 2000, 2010). GT, for example, sets up a tension between the subjective interpretation and observed social processes that applied researchers may find constraining. It furthermore requires as its endpoint an assumption of theoretical saturation that may seem antithetical to the more open-ended conceptualizations that are sought by practitioners in the applied fields, where the ongoing evolution of thinking is expected (Thorne, 2008). We approach this challenge of disentangling SI from GT by drawing on an example of an applied qualitative study (under review elsewhere) that explicitly departed from GT methodology despite being directly informed by a SI theoretical framework. Critical reflection on the evolution of this application surfaces some of the conditions
under which we believe SI may add depth and richness to the analytic potential and ultimate integrity of applied field studies regardless of their methodological positioning. By differentiating the theoretical underpinnings of SI from the design applications with which many have become so familiar, we aim to unpack the kinds of insights and ideas that SI can impart to the process of seeking to improve health care practice. Toward this end, we aim to illuminate specific ways in which SI can strategically inform design options, analytic lenses, and findings as an illustration of its strategic theoretic potential across various methodological approaches.
The Nature of the SI Contribution Capturing the nature of human health behavior is complex and, consequently, applied health researchers often approach qualitative research with a holistic attitude designed to obtain the most comprehensive depiction possible of this complexity. Theoretical frameworks serve as a mechanism through which this holistic approach is operationalized and the field is rendered more approachable. Used as a theoretical framework in this way, SI can help to guide the research process, maintain focus, and enhance quality during all phases of the study, including the fieldwork (such as participant observation or interviews) and throughout the analysis of data. Naturally, where such a theory is used, it must be deployed thoughtfully to guide the data collection and analysis processes without compromising them. In particular, it should never be used prescriptively, as a “cookbook” of a priori information, as this would violate the fundamental principle of induction that is a hallmark of all qualitative inquiries (Carter & Little, 2007; Morse, 2002; Oliver, 2012).
Subjective Meaning as Social Process As a theoretical perspective on which to frame a qualitative inquiry outside the GT methodological context, SI offers a rich and diverse sense of perspective (Benzies & Allen, 2001; Oliver, 2012). The direction it can provide in this regard derives from the three basic premises that underpin it (Blumer, 1969). The first is that human beings act toward things on the basis of the meanings the things have for them. People interact individually but also collectively; they do not respond directly to objects but attach meaning to them, modify that meaning, and act on the basis of that meaning. The world and the individual human are separate but the world is interpreted by the individual through symbols and during interaction. The second is that, individually or collectively, the meaning one makes of things arises from the social interaction one has with one’s fellows. Because meaning is
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Handberg et al. founded on the way other individuals act, SI presumes that individuals act on the basis of a shared understanding of meaning in their environment. The third is that these meanings are handled in, and modified through, an interpretive process. In SI, meaning becomes a core element of a health phenomenon in its own right. There is freedom of choice in human behavior; however, this choice is in some way being defined by society and cultural norms. Through choices and interpretations, people form new meanings and lines of new actions to shape their future course in the process of interpreting meaning (Benzies & Allen, 2001; Blumer, 1969). These three basic premises reflect SI’s broad perspective within social psychology, making it especially well suited for exploring and understanding human beings on a micro level within their interaction. Essentially, they emphasize that the vital context is not the perspective of the whole society per se, as much as it is the immediate social environment surrounding that particular individual (Blumer, 1969; Burbank & Martins, 2010). In this way, SI locates individually constructed meaning within coconstructed social experience. The interpretive processes that are always involved in a person’s use and/or creation of meaning consist of two steps. In the first step, the person indicates things he or she is acting toward, which, through interpretation, represent his or her own meaning. Through this action, the person apprehends, whether consciously or subconsciously, what represents meaning within the given situation. The person intentionally acts toward an aim that serves as the direction for action and consequently becomes implicit in actions. This process is inherently social in that, even when the person is alone or wants to be independent, he or she remains dependent on others to some extent. In the second step of this process, communication with his or her self creates an interpretation of the meaning that includes a determination of the importance of handling it. In this way, meaning takes on importance and holds a central role throughout the process of self-interpretation. To illustrate this idea with a case in point, we draw on a field study (currently under review) aimed at expanding our understanding of how masculinities shape patient barriers on and subsequent participation in cancer rehabilitation. Data were generated during a 5-month long fieldwork that took place in three different Danish oncology clinics. Included were 35 men who did not want to participate in cancer rehabilitation services after hospital discharge. Data for this study were collected using various approaches, including participant observation, semistructured interviews, focus group interviews, ad hoc individual conversations, observations, documents, and field notes. SI informed the design decisions throughout the phases of fieldwork, data collection, analysis, and interpretation. For example, both the interview and
observation guide were developed with SI and “meaning” as the core of the research questions. As we did not assume we were seeking a singular social process and instead sought to explore and interpret both diversities in individual experience and unique meanings, we chose not to use GT methodology for this study. Instead, we created a design logic informed by SI as the intellectual scaffolding constituting its theoretical framework. Because it invites critical reflection toward the identification of theoretical perspectives that may have relevance for the specific phenomenon under consideration, and accommodates a non-prescriptive approach to applied design decisions, we used interpretive description (Thorne, 2008; Thorne, Kirkham, & MacDonald-Emes, 1997; Thorne, Kirkham, & O’FlynnMagee, 2004) as our methodological orientation for this project. The objective of this line of inquiry was to establish an applied knowledge that might assist clinicians to better support men’s participation within the rehabilitation services that are increasingly offered to cancer survivors, and we sought to do this by describing and analyzing their distinctive and gendered perspectives. The SI lens tells us that interaction occurs through the use of symbols starting with one’s self and others within a particular reference group (Burbank & Martins, 2010). The researcher using SI is therefore curious not only about the specific meanings that arise but also about how meaning actually functions as a core element in the phenomenon under study. Exploring this would include considerations on how male cancer survivors acted on the basis of meaning, how meaning arose from their social interaction, and how that meaning was then being modified and handled through interpretation until a new meaning was formed. In our study, for example, the analysis revealed such themes as “fear of losing control” and “striving for normality” as core elements of the meanings that the male cancer survivors formed with respect to the potential role and value of cancer rehabilitation. For those male cancer survivors, we determined that the decision to opt out of participation could be directly linked to the interpretive processes associated with these two elements. Participation in rehabilitation conflicted with their competing priority of striving for as normal a daily routine as possible, as well as subjecting themselves to another health service with all that it entails confronted them with the specter of potential loss of control. A plausible and coherent interpretation of this phenomenon was that the individual meanings these men formed with respect to cancer rehabilitation could be gender based (in the sense of selecting an approach more consistent with their understanding of masculinity) or collective (in keeping with the actions of other male cancer patients they had encountered in treatment, within
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Qualitative Health Research STUDY EXAMPLE (Control + Normality = Meaning) (study reported elsewhere)
THEORY (Blumer, 1969) 1) Human beings act towards things on the basis of the meanings that the things have for them
1) The male cancer survivors act and make choices (gender based) individually or collectively in groups, for instance with other patients, relatives, or colleagues on the basis of meaning, by trying to stay in control and strive for normality
2) Meaning arises out of the social interaction that one has with fellows
2) Meaning and understanding for the male cancer survivors arise by the above mentioned actions and choices individually or socially through social interaction: Control and Normality The men reach an agreement, intentionally or unintentionally on these meanings and understandings
3) Meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he encounters
3) They men handle and modify meanings by opting out of help in shape of a rehabilitation service which might enhance their life quality and chances of survival. The choice of opting out might already be defined by society, norms, gender (identity, socially, and existentially) and is therefore not necessarily actual and deliberate Even so, new meanings are emerging and through these new actions—to opt out of rehabilitation—shaped through choices and interpretations New meaning = No rehabilitation (Control + Normality)
Figure 1. Symbolic interactionism—Meaning as the core element.
their families, in the workplace and/or in society). Their experiences of coming to a particular meaning within these social interactions were manifest in different ways (as depicted in Figure 1). Their accounts revealed that these meanings arose from both intentional and unintentional social interactions, and they demonstrated that making modifications within these meanings helped explain not participating in cancer rehabilitation as a means by which to enhance their chances for survival and life quality. Although these men interpreted their decision to abstain from participation in cancer rehabilitation as an entirely individual choice, it seemed apparent that they were taking up social norms and gendered role definitions as part of the meaning-making process that justified their eventual decision.
SI’s Analytic Lens on Meaning Construction By building on meaning making as a fundamental premise, SI provides an analytic depiction that can guide increasingly refined understandings of various aspects of the human society on which we draw when we seek to build contextualized or holistic knowledge in applied qualitative health research. For researchers seeking to explore meaning in the actions of their study participants, SI becomes a framework for making this possible. SI is a theoretical way of thinking that contributes to the generation of understandings associated with clinical practice
implications, thus making it suitable for both empirical and clinical studies. Blumer (1969) stated that you cannot observe persons or objects or the interaction between them without acquiring an insight into how those interactions reflect on the individuals as people. As is evident in the research context, society consists of individuals engaged in action, and those actions will inform and guide us in our research, much as they do in practice, if we are open to the insights they reveal. As human actors, both the study informant and the researcher will inevitably interpret their own actions as well as the actions of others. Keeping this dynamic interaction in mind throughout the research process, we can see that SI has tremendous potential to enhance our understanding and complement other theoretical perspectives that are currently used in applied qualitative health research. Furthermore, rather than focusing our expectations on searching for the core categories and basic social processes toward which GT methodology inevitably orients us (Benoliel, 1996; Glaser, 1978), a SI lens can help us do justice to multiple and intersecting meanings that may be at play in explaining what appear to be patterns within the process data. Its distinctive role lies in its demand that we remain open throughout our data collection and analysis to this relevant social context within which individual subjective experience is shaped. In this manner, it therefore provides us a unique form of guidance in our knowledge generation (Benzies & Allen, 2001).
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Handberg et al. By fragmenting the more general notion of meaning into three distinct elements, SI makes meaning accessible in the sense of understanding both the meaning itself and also what the informants are striving for in relation to it. It is admittedly a complex challenge for a researcher to enter a field and study human beings who are often in difficult life circumstances and furthermore to try to understand the intension underlying their actions. When we study how people act toward the things that represent meaning for them, it can be a tremendous advantage to remember that the meanings of such things derive from the social interaction they have with their fellows and, moreover, that those meanings are being modified through an interpretive process. In other words, actions begin to make a particular kind of sense when one seeks an understanding of what is driving human beings in different directions and shaping their choices. Digging even deeper into an understanding of the interpretive process that is inherent in the human search for meaning can help the researcher to furthermore understand how a person (such as a patient, relative, nurse, or doctor) signals the things toward which he or she is acting. A mechanism through which to understand what meaning is based on, how it is handled by humans through internal communication processes, and how it plays a central role through the processes of both self-interpretation and interpretation with fellows. It allows us to expand our capacity to grasp the reasons underlying a specific group opportune or inopportune actions by people in the present state of their particular treatment or disease. Thus, SI can provide the researcher with the opportunity to explore and examine the health behavior of human beings in the context of the substantive relationships of this behavior in their quest for understanding. In the male cancer survivor study, participant observation helped the researcher to gain insights into the world of the observed phenomena. In several instances, the understandings that were ultimately generated would not have been possible through interview alone, and required the opportunity to closely observe social interaction in contrast to individual account. For example, the idea that the meaning of control was highly relevant for these individuals became apparent early in the participant observation fieldwork. It was noticed that some of the men were keeping exhaustive records on such things as their medication intake, appointments at the ward, and what was being said by the nurses and doctors. Others kept meticulous notes, even down to the smallest deviation, on their medications or oral intake. In several instances, they carefully arranged medications in annotated little boxes, or sequenced their food intake into small portions with the elements consumed almost ritualistically in the same sequence. It was also observed that some of the men were acting in ways that were very controlling toward their
relatives, orchestrating such things as when they could visit, what they wanted help with, what they could ask and not ask, and so on. Although our initial impression that a few of the male cancer survivors were acting this way individually could have led to an assumption that we had happened upon a particularly compulsive sample of individuals, over time, a pattern emerged in how they all acted in the group. As they interpreted and modified their behaviors over time, their actions around control emerged into what we came to recognize as a shared understanding. In our study, within the various cancer groups, it also became apparent that this shared understanding between the men represented an important form of meaning and a means of understanding that enabled them to control whatever was possible in their surroundings and therefore to minimize the feeling of loss of control. Observing lengthy discussions among them about how these things mattered, we began to trace the particular meanings that individuals were forming as having origins in the social interaction between the men in the group. Thus, in this particular study context, the SI lens allowed us to surface an increasingly coherent and understandable gendered pattern of how meaning constructions evolve within the context of the social interaction among male cancer patients.
Expanding Meaning Using Root Images To achieve a deep appreciation for the researched field, the researcher might need to take yet another step into the world of theory seeking by extending the analysis with an even sharper focus. SI is based on a set of fundamental ideas called “root images.” As proposed by Blumer, these root images refer to and illustrate the nature of human groups or society, social interaction, objects, human beings as actors, human action, and the interconnection associated with lines of action. The six root images are as follows: “Nature of human society or human group life,” “Nature of social interaction,” “Nature of objects,” “The human being as an acting organism,” “Nature of human action,” and “Interlinkage of action.” Blumer described these root images as ideas representing how SI envisions society and social conduct. The root images constitute an explicit framework for study and analysis and are useful for leading the researcher along the difficult path of understanding and exploring and analyzing without losing sight, for example, of the directionality of the interlinkage of data and findings. Through the root images, Blumer viewed human society as a site in which people are engaged in living, developing lines of action in all of the different and challenging situations they encounter. People are caught up in this social interaction, making indications to others of their
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own actions and, at the same time, interpreting the indications made by others. People are living in a world of objects, including objects that are symbolic of themselves as well as the objects that arise from and are influenced and shaped by social interaction with other people. People are led by their own orientation and actions toward the meaning of these objects. These activities and actions are formed through a process of description and interpretation, defined in any certain situation by humans as they are living in different groups and worlds with different meanings. As we see it, several aspects of the root images might be considered as applicable tools to enhance analytic processes in a range of qualitative health research projects. SI drives us to understand meaning as a social product that arises through interaction, an idea that can have broad utility in the qualitative health research context, where we are studying human beings in all different kinds of situations, trying to understand how they act, why they do so, and what represents meaning for them. The view that social action is constructed through an interpretive process requires that those processes of construction be observed to be analyzed. The everyday experience of the empirical world consists of individuals and objects, each of which has a distinctive and particular character, which must be included to achieve a fulsome analysis (Blumer, 1969; Stryker, 2002). To illustrate how the root images, along with other elements of SI, can shape an analysis, create insight, and serve as a helpful theoretical framework for applied health research where interpretation of context is desired, we focus on three exemplars from our work. Nature of social interaction. The fundamental idea of “Nature of social interaction” is based on how group life necessarily presupposes interaction between group members. It can therefore contribute a useful perspective to any focus of inquiry where insights about group interactions might be relevant. Social interaction between people is a process that forms and sculptures human behavior instead of being simply a means or setting for the expression or release of human conduct. Blumer referred to two forms of social interaction: “the conversation of gestures” and “the use of significant symbols.” The first, according to Blumer, was a “non symbolic interaction” based on the fact that no interpretation in response to meaning is taking place. It is like a reflex action without actual thinking involved. In contrast, the second, “the use of significant symbols,” is considered a “symbolic interaction” in that an interpretation is taking place in response to meaning. By this, we come to recognize that the person is responding to acts on basis of what the gesture or action means. In SI terms, we conclude that actual understanding occurs
when this gesture or action has the same meaning and significance for two persons. For Blumer, observation was a vitally important contribution to the capacity to understand the field or phenomenon we are studying. In our study, we looked for these symbolic interactions where interpretation was occurring, and our explorations at this level helped us discern the paths to understanding the explored field. We found it was often enlightening to observe actions using participant observation, and then follow up on the observations and analysis by having the informants to reflect on and interpret their actions and choices. In one of our study sites, for example, the hospital ward, we observed various manifestations of the nature of social interaction that seemed to shape the behavior of individual male cancer patients. In the head and neck clinic, the men used significant symbols such as gestures to communicate an acceptance of their illness. These gestures between group participants prompted similar responses from other group members. Such gestures seemed to lead to additional gestures or actions that signaled shared understandings. To elaborate, Patient A, who had been in cancer treatment for a long period of time would tell Patient B about various symptoms and side effects, such as problems with eating. On one occasion, Patient A demonstrated to Patient B how he was “feeding himself” through a gastrointestinal tube and explaining that “eating normal” was insufficient to provide adequate energy. Patient B was clearly uncomfortable with this interaction, looking scared, and had no questions, although he was carefully observing. This situation would be one for which Patient B had no “raw” understanding deriving from experience in everyday society, and for which he would have had no occasion to anticipate in relation to himself. However, over the next few weeks, the two would continue discussing g-tube feeding, and Patient B would begin to ask questions, demonstrating more bravery and less fear about the situation, allowing it to become more normalized in his thinking. These interactions, involving talking, discussing, and sharing information, resulted in Patient B developing a new understanding. When a new patient was admitted to the clinic, Patient B seemed to take over Patient A’s role, now being the experienced patient, seeing meaning in what he was doing, and illustrating that he understood the nature of the social interaction. Nature of objects. A second root image, “Nature of objects,” is based on the idea in which the “worlds” that exist for humans are composed of “objects” that are the product or objects of SI. These objects are described by Blumer as being physical objects (e.g., hospital beds, syringes, drips), social objects (e.g., a nurse, a patient, a
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Handberg et al. priest), or abstract objects (e.g., morals, principles, ideas; Blumer, 1969). These three types of objects can be indicated directly or referred to in a more indirect manner. The societal context of relevance to any inquiry consists only of the objects that the given human beings recognize and know in their world. Such objects can be seen as social creations among the human beings who inhabit that world, in that meaning of anything and everything has to be shaped, learned, and conveyed through a process of indication. In this way, human group life is understood as a social process in which objects are being created, acknowledged, transformed, and even perhaps rejected. In the research context, this root image helps to explore and illuminate objects as they arise and are created within a social context. The meaning that these objects have begins and is formed through processes that themselves may be important to our capacity to understand the informants, their actions, and their choices in relations to their world. Applying this root image to the clinical example described above, we see that these male cancer survivors exist in a world composed of objects of a physical, social, and abstract nature. Within their social world within this clinic, these objects include the social context, such as the actual group of patients present at one time, and also abstract objects, such as the moral, principles, and ideas that become of particular importance in this context of the cancer ward. Many of these objects are indicated directly or indirectly within the observable environment. Others can only be observed through the lens of a third party, in this case, the researcher. In our study, the meanings associated with the pattern we termed “striving for normality” were expressed by the male cancer survivors both directly and indirectly, and we could observe the ways in which their verbal or behavioral comparisons with “normal” were aligned with the way they were handling their cancer. However, we also recognized that the communications between the patients, the nurses, and the relatives were also shaped by norms and expectations in society. These became less visible social processes that nevertheless additively shaped the ideas and understandings associated with how to act as a male cancer patient. The analytic theme of striving for normality therefore extended beyond what they sought individually, such as forgetting and moving on. As an abstract object, this striving for normality was being acknowledged by the other patients and arose in the social context of the group; we might say that was formed through group processes of importance among the male cancer survivors, and in return acted to shape their individual actions, choices, and understandings. Nature of human action. The third root image that we will describe as an example of application to the qualitative
health research context is the “Nature of human action.” The fundamental idea in this root image is that human individuals encounter the world as a world they must interpret to act toward meaning. Because we recognize that a person has to muddle through the situation in which he is called on to act, that action can be traced back to such matters as motives, attitudes, role requirements, and situational demands. While engaging in this decisional process, the person considers the various things that he has made note of before drawing a line of conduct on the basis of how he interprets each of them. His conduct is then shaped and led through a process of indication and interpretation. These interpretive processes take place through the mechanism of informants making indications to one another and not merely to themselves. These interpretive interactions within the social interaction lead to the outcome of joint or united action. As a researcher, this root image appears useful in understanding certain situations that a human might be put in. For example, where a patient has fallen ill with a mortal disease, it helps us understand that patients are trying to interpret meaning and cope within the context of being situated within their surroundings and the people orbiting around them. Their actions will not only be based on their own interpretations, but also on the social interaction associated with the particular location in which they might be placed. We are seeking to understand what actions mean to people as well as the meaning that arises from them. For the male cancer survivors in our study, we recognized that their world must be interpreted for them to act toward meaning. As researchers observing the patients, we could see that their actions could, to some extent, be traced back to such matters as motives, attitudes, and social roles within the patient group. For instance, the more experienced patients had more power because of their knowledge of treatment, side effects, and processes within the cancer world. Therefore, the more experienced patients often set the standard for social interaction. An example, again observed within the head and neck cancer group, was where the patients late in the treatment period would experience pain in their mouth and throat because of radiation damage. For the newer patients, it often seemed incomprehensible that they would end up with that as well. Through various interactional processes about which SI had triggered our curiosity, it was observed how patients would share various forms of knowledge from experienced to new patients, introducing them to what was to be expected. The more experienced patients would orient the patients to the pain that hindered their eating, sleeping, or doing anything at all. They would tell the new patients that the only thing that will help is morphine, and that they should start the medication before the pain starts.
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This would lead to a process of indication whereby the new patients would interpret information and guidance from the more experienced ones based on motives, attitudes, and roles. By interpreting meaning through social interaction, the new patients would end up acting based on this co-constructed meaning. Patients socialized in this manner therefore recognized that they did not want to lose control because of pain and were able to initiate morphine early in the process. As we have attempted to illustrate using these three examples, the root images can offer the applied qualitative health researcher a frame or a base for expanding the analytic potential through approaches beyond individual interpretation to understand what meanings people are striving toward. On the basis of our immersion in this process, we came to believe that all of the SI root images could have potential as usable tools within qualitative studies of complex human health and illness phenomena for the interpretive construction of robust findings, regardless of the explicit methodological approaches deployed.
Value Added From SI to Analytic Quality Our experience illustrates that SI can serve as a theoretical framework to expand capacity in qualitative health research and give voice to complex interpretations in an applied field study beyond the GT context. We see no reason why it could not be applied across a diverse range of methodological options, such as qualitative description or ethnographic studies using participant observation as a means through which to push for expansion of the understanding of how people live in a world of objects and act toward those objects based on the specific meaning the objects have for them (Aberg, Sidenvall, Hepworth, O’Reilly, & Lithell, 2004; Burbank & Martins, 2010; Carlson, 2013; Dennis, 2011; Tourigny, 1994). Using SI as a theoretical framework in research, we acquire a mechanism through which to systematically search out and identify these objects, categorize our thinking about them, and understand their meaning. This kind of depth and integration of interaction can add value beyond the reporting limits of a more conventional qualitative report, steering us toward findings of an order that can offer powerful insights into such goals as practice change. For instance, in the interpretive description study on the male cancer survivors, SI helped us identify barriers around maintaining control and normality that ought to be accounted for in the future rehabilitation of this population. SI respects the nature of the empirical world and organizes a methodological stance that reflects that respect. This positioning becomes important in the choice of SI as a framework for qualitative health research. In taking up
this perspective, the researcher accepts a commitment to respect the empirical world as the basis for everything else in the researched field because, according to Blumer (1969), this was where the real world resides. The shape of the real world is made apparent to us in the social interactions that will be empirically discovered within it and cannot be specified in advance. The researcher is charged with trying to grab the empirical nature of the field under study, and this is only possible through being there, closely observing, and experiencing the social interaction (Blumer, 1969). Thus, SI adds particular relevance to studies in which participant observation and being in the field are understood as fundamental to an appreciation for the researched phenomenon. Through application of the SI lens in an applied qualitative health study, new angles of vision and conceptual options in relation to the researched field can be achieved, with the advantage of adding layers of complexity to qualitative research reports. From our perspective, the SI framework consists of exceptionally useful mechanisms that can help researchers in an applied health study to understand what people are striving toward in relation to social interactions and meaning in their health behaviors. By helping the researcher operate in a heightened and focused explorative manner, SI can guide the formation of an extended knowledge of the social world that is influencing the health phenomena we seek to understand. It does so by providing mechanisms through which to develop and refine our research questions, so that they reflect the kinds of depth and complexity that are consistent with an informed applied practice approach. Moreover, it can also guide the specific data collection and construction processes that we will use to answer the questions we pose. When researchers in the applied health professional fields state a practice problem or challenge and define a qualitative research question, they are making a claim that the focus of their research reflects a specific problem requiring exploration and elaboration. Understanding the empirical world and the problems in it through a certain theoretical lens can sharpen the focus of vision, and provide direction for the exploration, conduct, and analysis in a research project. It can enable the researcher to explore exhaustively within a complex field without losing directional focus. Thus, the rationale for using such a lens is that it makes distinct not only what can be observed in the field but also the underlying mechanisms and relationships that might explain the conditions of occurrence, such as why human beings act as they do in different situations. Thus, SI provides the explicit advantage of helping channel the researcher’s angle of analysis toward the broad concept of meaning and what it is that human beings will strive for or try to avoid through their actions and interactions.
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Perceptions of informal caregivers. Qualitative Health Research, 14, 792–815. doi:10.1177/1049732304265854 Aldiabat, K., & Navenec, C. (2011). Philosophical roots of classic grounded theory: Its foundations in symbolic interactionism. The Qualitative Report, 16, 1063–1080. Retrieved from http://files.eric.ed.gov/fulltext/EJ940800.pdf Benoliel, J. Q. (1996). Grounded theory and nursing knowledge. Qualitative Health Research, 6, 406–428. doi:10.1177/ 104973239600600308 Benzies, K. M., & Allen, M. N. (2001). Symbolic interactionism as a theoretical perspective for multiple method research. Journal of Advanced Nursing, 33, 541–547. doi:2048/10.1046/j.1365-2648.2001.01680.x Blumer, H. (1969). Symbolic interactionism: Perspective and method (1st ed.). Berkeley: University of California Press. Burbank, P. M., & Martins, D. C. (2010). Symbolic interactionism and critical perspective: Divergent or synergistic? Nursing Philosophy, 11, 25–41. doi:10.1111/ j.1466-769X.2009.00421.x Carlson, E. (2013). Precepting and symbolic interactionism? A theoretical look at preceptorship during clinical practice. Journal of Advanced Nursing, 69, 457–464. doi:10.1111/ j.1365-2648.2012.06047.x Carter, S. M., & Little, M. (2007). Justifying knowledge, justifying method, taking action: Epistemologies, methodologies, and methods in qualitative research. Qualitative Health Research, 17, 1316–1328. doi:10.1177/ 1049732307306927 Chamberlain-Salaun, J., Mills, J., & Usher, K. (2013). Linking symbolic interactionism and grounded theory methods in a research design. SAGE Open, 3(3), 1-10. doi:10.1177/21582440-13505757 Crooks, D. L. (2001). The importance of symbolic interaction in grounded theory research on women’s health. Health Care for Women International, 22, 11–27. doi:10.1080/073993301300003054 Dennis, A. (2011). Symbolic interactionism and ethnomethodology. Symbolic Interaction, 34, 349–356. doi:10.1525/ si.2011.34.3.349 Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press. Glaser, B. G., & Strauss, A. L. (1966). Awareness of dying. London: Weidenfeld & Nicolson. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine de Gruyter. Jeon, Y. H. (2004). The application of grounded theory and symbolic interactionism. Scandinavian Journal of Caring Sciences, 18, 249–256. doi:10.1111/j.14716712.2004.00287.x Lomborg, K., & Kirkevold, M. (2003). Truth and validity in grounded theory—A reconsidered realist interpretation of the criteria: Fit, work, relevance, and modifiability. Nursing Philosophy, 4, 189–200. doi:10.1046/ j.1466-769X.2003.00139.x Meltzer, B. N., Petras, J. W., & Reynolds, L. T. (1975). Symbolic interactionism: Genesis, varieties and criticism. Boston: Routledge.
Our experience with SI, apart and distinct from the context of GT methodology, has convinced us that it can work well and add a strategic advantage in strengthening focus, adding layers of contextual understanding, and— most especially—unraveling the complexities of how meaning is co-constructed by interpretive agents in interaction with their social world. So much of what we seek to understand in the applied health disciplines involves some aspect of social process, even when social process is not in itself the apparent focus of our inquiry. Beyond the subjectivities and narrative interpretations that we seek to uncover in much of our qualitative health inquiry, there exists a world of social interaction within which meaning is deeply influenced. By allowing for multiple layers of understanding, we can overcome some of the limitations associated with overreliance on either self-report or observation, thereby reducing the likelihood of overly simplistic findings and interpretive errors. From our perspective, a curiosity about what SI might have to offer can serve as an enhancement to the foundations of a wide range of popular qualitative approaches to knowledge construction, strengthening the caliber and comprehensiveness of knowledge products in the field. If we believe that people are not islands, but rather are very much shaped by the social worlds that they live in, then a mechanism through which to interrogate what we see may help us find meanings and understandings that extend well beyond that which would likely be uncovered through conversational interview and casebased data collection approaches alone. Using a lens such as SI, the subjective world of patients becomes increasingly fascinating, and our options for surfacing and then translating knowledge into the applied world are expanded exponentially. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research and article was supported by the foundation “Public Health in the Middle” [Folkesundhed i Midten], Denmark; “The Health Insurance Foundation” [Helsefonden], Denmark; and “Public Health and Quality Improvement” [Folkesundhed og Kvalitetsudvikling], Denmark.
References Aberg, A. C., Sidenvall, B., Hepworth, M., O’Reilly, K., & Lithell, H. (2004). Continuity of the self in later life:
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Milliken, P., & Schreiber, R. (2012). Examining the nexus between grounded theory and symbolic interactionism. International Journal of Qualitative Methods, 11, 684– 696. Retrieved from https://ejournals.library.ualberta.ca/ index.php/IJQM/article/view/11027 Morse, J. M. (2002). Theory innocent or theory smart? [Editorial]. Qualitative Health Research, 12, 295–296. doi:10.1177/104973202129119883 Morse, J. M. (2009). Tussles, tensions, and resolutions. In J. M. Morse, P. N. Stern, J. Corbin, B. Bowers, K. Charmaz, & A. E. Clarke (Eds.), Developing grounded theory: The second generation (pp. 13–19). Walnut Creek, CA: Left Coast Press. Morse, J. M. (2012). Qualitative health research: Creating a new discipline. Walnut Creek, CA: Left Coast Press. Oliver, C. (2012). The relationship between symbolic interactionism and interpretive description. Qualitative Health Research, 22, 409–415. doi:10.1177/1049732311421177 Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334– 340. doi:10.1002/1098-240X(200008)23:43.0.CO;2-G Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing & Health, 33, 77–84. doi:10.1002/nur.20362 Stryker, S. (2002). Symbolic interactionism: A social structural version. Caldwell, NJ: Blackburn Press. Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press. Thorne, S. (2011). Toward methodological emancipation in applied health research. Qualitative Health Research, 21, 443–453. doi:10.1177/1049732310392595 Thorne, S., Kirkham, S. R., & MacDonald-Emes, J. (1997). Interpretive description: A noncategorical qualitative alternative for developing nursing knowledge. Research in
Nursing & Health, 20, 169–177. doi:10.1002/(SICI)1098240X(199704)20:23.0.CO;2-I Thorne, S., Kirkham, S. R., & O’Flynn-Magee, K. (2004). The analytical challenge in interpretive description. International Journal of Qualitative Methods, 3(1) 1-11. Retrieved from http://www.ualberta.ca/~iiqm/backissues/3_1/pdf/thorneetal.pdf Tourigny, S. C. (1994). Integrating ethics with symbolic interactionism: The case of oncology. Qualitative Health Research, 4, 163–185. doi:10.1177/104973239400400203
Author Biographies Charlotte Handberg, RN, MPH, is a PhD student at the Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, Denmark, and at the Marselisborg Center, Public Health and Quality Improvement, Central Denmark Region, Denmark. Sally Thorne, PhD, RN, FAAN, FCAHS, is a professor, at the School of Nursing, University of British Columbia in Vancouver, Canada. Julie Midtgaard, PhD, is an associate professor and psychologist at the University Hospitals’ Center for Health Research (UCSF) at Copenhagen University Hospital Rigshospitalet, Denmark. Claus Vinther Nielsen, PhD, MD, is a professor at the Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, Denmark, and at the Marselisborg Center, Public Health and Quality Improvement, Central Denmark Region, Denmark. Kirsten Lomborg, PhD, MSN, RN, is a professor at the Department of Clinical Medicine and Department of Public Health, Aarhus University, and at the Aarhus University Hospital, Denmark.
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research-article2014
QHRXXX10.1177/1049732314554231Qualitative Health ResearchHandberg et al.
Article
Revisiting Symbolic Interactionism as a Theoretical Framework Beyond the Grounded Theory Tradition
Qualitative Health Research 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314554231 qhr.sagepub.com
Charlotte Handberg1, Sally Thorne2, Julie Midtgaard3, Claus Vinther Nielsen1, and Kirsten Lomborg1
Abstract The tight bond between grounded theory (GT) and symbolic interactionism (SI) is well known within the qualitative health research field. We aimed to disentangle this connection through critical reflection on the conditions under which it might add value as an underpinning to studies outside the GT tradition. Drawing on an examination of the central tenets of SI, we illustrate with a field study using interpretive description as methodology how SI can be applied as a theoretical lens through which layers of socially constructed meaning can help surface the subjective world of patients. We demonstrate how SI can function as a powerful framework for human health behavior research through its capacity to orient questions, inform design options, and refine analytic directions. We conclude that using SI as a lens can serve as a translation mechanism in our quest to interpret the subjective world underlying patients’ health and illness behavior. Keywords interpretive description; research design; research, qualitative; symbolic interactionism, qualitative analysis Despite Blumer’s argument that every study has an empirical offset, a theoretical framework typically represents the point of departure from which a qualitative study begins (Blumer, 1969). Symbolic interactionism (SI) has often been identified as a component of the theoretical underpinnings for applied qualitative health research. However, for the most part, its application has been limited to its historic contribution to grounded theory (GT) methodology (Lomborg & Kirkevold, 2003). Indeed, the association between SI and GT has become so tightly entwined that applied researchers often conflate the two in their theoretical justifications for design decisions (Chamberlain-Salaun, Mills, & Usher, 2013; Milliken & Schreiber, 2012). The implications of this conflation therefore seem ripe for critical reflection. In this article, we attempt to disentangle this tight connection, such that SI can be considered, distinct from its GT progeny, as a viable theoretical framework for other kinds of applied qualitative inquiries. The epistemology of SI derives from American pragmatism within the discipline of sociology, reaching back almost half a century (Blumer, 1969). SI builds on three relatively simple assumptions: (a) people strive and act toward what represents meaning for them, (b) meaning arises out of social interaction, and (c) meaning is being dealt with and modified through interpretive processes.
Thus, a central feature of SI is the inseparability of the individual and the context within which the individual exists. Because of this, SI has been considered a powerful framework to guide research that is intended to lead toward an understanding of human health behavior within a social context (Meltzer, Petras, & Reynolds, 1975). The term “applied qualitative health research” reflects the subset of the qualitative health research enterprise that is fundamentally and foundationally driven by the knowledge needs of the health practice disciplines (Thorne, 2011). Its priority is an exploration of health and illness as experienced from the perspective of the people themselves rather than from the theoretical orientation of a researcher (Morse, 2012). In the tradition of methods that have been widely adopted within the applied health research world, sociologists Glaser and Strauss were 1
Aarhus University, Aarhus, Denmark University of British Columbia, Vancouver, British Columbia, Canada 3 Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark 2
Corresponding Author: Charlotte Handberg, Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark. Email: [email protected]
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early proponents of an inquiry approach explicitly shaped by an understanding of SI. Their collaborations in the field of Awareness of Dying (Glaser & Strauss, 1966) represented the first application of trying to use both inductive and deductive thinking to build theory from field observational data rather than beginning with a hypothesis of any kind. On the basis of the constant comparative technique they worked out during this pioneering study, they published their seminal text, The Discovery of Grounded Theory (Glaser & Strauss, 1967). GT has gone on to become one of the most widely popularized methods in the qualitative health research spectrum (Morse, 2009). It has been taken up as an ideal approach for documenting the core processes associated with change in social groups, and for explicating what is happening within a social context. It is an approach to research that formalizes and informs theorizing from data. A review of the literature confirms that different investigators use GT as their methodological grounding for studies that take quite different forms. Furthermore, the full scope of the method as originally designed is sometimes obscured in the multiple modern applications we see in the applied health literature. However, although the investigators might not fully appreciate its importance or benefit from its influence (Milliken & Schreiber, 2012), GT researchers almost universally cite the historic roots of SI and acknowledge it as the intellectual tradition within which their methodological approach belongs (Aldiabat & Navenec, 2011; Crooks, 2001; Jeon, 2004; Lomborg & Kirkevold, 2003). Thus, because the conceptual linkage between SI and GT has become so tightly bound within the qualitative health research literature, SI is assumed as an underpinning of any GT study, and it has become correspondingly difficult to envision what a study informed by SI would look like apart from GT methodology. Increasingly, applied health researchers are exploring alternatives to conventional qualitative methods in recognition of the limits imposed by their theoretical origins (Sandelowski, 2000, 2010). GT, for example, sets up a tension between the subjective interpretation and observed social processes that applied researchers may find constraining. It furthermore requires as its endpoint an assumption of theoretical saturation that may seem antithetical to the more open-ended conceptualizations that are sought by practitioners in the applied fields, where the ongoing evolution of thinking is expected (Thorne, 2008). We approach this challenge of disentangling SI from GT by drawing on an example of an applied qualitative study (under review elsewhere) that explicitly departed from GT methodology despite being directly informed by a SI theoretical framework. Critical reflection on the evolution of this application surfaces some of the conditions
under which we believe SI may add depth and richness to the analytic potential and ultimate integrity of applied field studies regardless of their methodological positioning. By differentiating the theoretical underpinnings of SI from the design applications with which many have become so familiar, we aim to unpack the kinds of insights and ideas that SI can impart to the process of seeking to improve health care practice. Toward this end, we aim to illuminate specific ways in which SI can strategically inform design options, analytic lenses, and findings as an illustration of its strategic theoretic potential across various methodological approaches.
The Nature of the SI Contribution Capturing the nature of human health behavior is complex and, consequently, applied health researchers often approach qualitative research with a holistic attitude designed to obtain the most comprehensive depiction possible of this complexity. Theoretical frameworks serve as a mechanism through which this holistic approach is operationalized and the field is rendered more approachable. Used as a theoretical framework in this way, SI can help to guide the research process, maintain focus, and enhance quality during all phases of the study, including the fieldwork (such as participant observation or interviews) and throughout the analysis of data. Naturally, where such a theory is used, it must be deployed thoughtfully to guide the data collection and analysis processes without compromising them. In particular, it should never be used prescriptively, as a “cookbook” of a priori information, as this would violate the fundamental principle of induction that is a hallmark of all qualitative inquiries (Carter & Little, 2007; Morse, 2002; Oliver, 2012).
Subjective Meaning as Social Process As a theoretical perspective on which to frame a qualitative inquiry outside the GT methodological context, SI offers a rich and diverse sense of perspective (Benzies & Allen, 2001; Oliver, 2012). The direction it can provide in this regard derives from the three basic premises that underpin it (Blumer, 1969). The first is that human beings act toward things on the basis of the meanings the things have for them. People interact individually but also collectively; they do not respond directly to objects but attach meaning to them, modify that meaning, and act on the basis of that meaning. The world and the individual human are separate but the world is interpreted by the individual through symbols and during interaction. The second is that, individually or collectively, the meaning one makes of things arises from the social interaction one has with one’s fellows. Because meaning is
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Handberg et al. founded on the way other individuals act, SI presumes that individuals act on the basis of a shared understanding of meaning in their environment. The third is that these meanings are handled in, and modified through, an interpretive process. In SI, meaning becomes a core element of a health phenomenon in its own right. There is freedom of choice in human behavior; however, this choice is in some way being defined by society and cultural norms. Through choices and interpretations, people form new meanings and lines of new actions to shape their future course in the process of interpreting meaning (Benzies & Allen, 2001; Blumer, 1969). These three basic premises reflect SI’s broad perspective within social psychology, making it especially well suited for exploring and understanding human beings on a micro level within their interaction. Essentially, they emphasize that the vital context is not the perspective of the whole society per se, as much as it is the immediate social environment surrounding that particular individual (Blumer, 1969; Burbank & Martins, 2010). In this way, SI locates individually constructed meaning within coconstructed social experience. The interpretive processes that are always involved in a person’s use and/or creation of meaning consist of two steps. In the first step, the person indicates things he or she is acting toward, which, through interpretation, represent his or her own meaning. Through this action, the person apprehends, whether consciously or subconsciously, what represents meaning within the given situation. The person intentionally acts toward an aim that serves as the direction for action and consequently becomes implicit in actions. This process is inherently social in that, even when the person is alone or wants to be independent, he or she remains dependent on others to some extent. In the second step of this process, communication with his or her self creates an interpretation of the meaning that includes a determination of the importance of handling it. In this way, meaning takes on importance and holds a central role throughout the process of self-interpretation. To illustrate this idea with a case in point, we draw on a field study (currently under review) aimed at expanding our understanding of how masculinities shape patient barriers on and subsequent participation in cancer rehabilitation. Data were generated during a 5-month long fieldwork that took place in three different Danish oncology clinics. Included were 35 men who did not want to participate in cancer rehabilitation services after hospital discharge. Data for this study were collected using various approaches, including participant observation, semistructured interviews, focus group interviews, ad hoc individual conversations, observations, documents, and field notes. SI informed the design decisions throughout the phases of fieldwork, data collection, analysis, and interpretation. For example, both the interview and
observation guide were developed with SI and “meaning” as the core of the research questions. As we did not assume we were seeking a singular social process and instead sought to explore and interpret both diversities in individual experience and unique meanings, we chose not to use GT methodology for this study. Instead, we created a design logic informed by SI as the intellectual scaffolding constituting its theoretical framework. Because it invites critical reflection toward the identification of theoretical perspectives that may have relevance for the specific phenomenon under consideration, and accommodates a non-prescriptive approach to applied design decisions, we used interpretive description (Thorne, 2008; Thorne, Kirkham, & MacDonald-Emes, 1997; Thorne, Kirkham, & O’FlynnMagee, 2004) as our methodological orientation for this project. The objective of this line of inquiry was to establish an applied knowledge that might assist clinicians to better support men’s participation within the rehabilitation services that are increasingly offered to cancer survivors, and we sought to do this by describing and analyzing their distinctive and gendered perspectives. The SI lens tells us that interaction occurs through the use of symbols starting with one’s self and others within a particular reference group (Burbank & Martins, 2010). The researcher using SI is therefore curious not only about the specific meanings that arise but also about how meaning actually functions as a core element in the phenomenon under study. Exploring this would include considerations on how male cancer survivors acted on the basis of meaning, how meaning arose from their social interaction, and how that meaning was then being modified and handled through interpretation until a new meaning was formed. In our study, for example, the analysis revealed such themes as “fear of losing control” and “striving for normality” as core elements of the meanings that the male cancer survivors formed with respect to the potential role and value of cancer rehabilitation. For those male cancer survivors, we determined that the decision to opt out of participation could be directly linked to the interpretive processes associated with these two elements. Participation in rehabilitation conflicted with their competing priority of striving for as normal a daily routine as possible, as well as subjecting themselves to another health service with all that it entails confronted them with the specter of potential loss of control. A plausible and coherent interpretation of this phenomenon was that the individual meanings these men formed with respect to cancer rehabilitation could be gender based (in the sense of selecting an approach more consistent with their understanding of masculinity) or collective (in keeping with the actions of other male cancer patients they had encountered in treatment, within
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Qualitative Health Research STUDY EXAMPLE (Control + Normality = Meaning) (study reported elsewhere)
THEORY (Blumer, 1969) 1) Human beings act towards things on the basis of the meanings that the things have for them
1) The male cancer survivors act and make choices (gender based) individually or collectively in groups, for instance with other patients, relatives, or colleagues on the basis of meaning, by trying to stay in control and strive for normality
2) Meaning arises out of the social interaction that one has with fellows
2) Meaning and understanding for the male cancer survivors arise by the above mentioned actions and choices individually or socially through social interaction: Control and Normality The men reach an agreement, intentionally or unintentionally on these meanings and understandings
3) Meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he encounters
3) They men handle and modify meanings by opting out of help in shape of a rehabilitation service which might enhance their life quality and chances of survival. The choice of opting out might already be defined by society, norms, gender (identity, socially, and existentially) and is therefore not necessarily actual and deliberate Even so, new meanings are emerging and through these new actions—to opt out of rehabilitation—shaped through choices and interpretations New meaning = No rehabilitation (Control + Normality)
Figure 1. Symbolic interactionism—Meaning as the core element.
their families, in the workplace and/or in society). Their experiences of coming to a particular meaning within these social interactions were manifest in different ways (as depicted in Figure 1). Their accounts revealed that these meanings arose from both intentional and unintentional social interactions, and they demonstrated that making modifications within these meanings helped explain not participating in cancer rehabilitation as a means by which to enhance their chances for survival and life quality. Although these men interpreted their decision to abstain from participation in cancer rehabilitation as an entirely individual choice, it seemed apparent that they were taking up social norms and gendered role definitions as part of the meaning-making process that justified their eventual decision.
SI’s Analytic Lens on Meaning Construction By building on meaning making as a fundamental premise, SI provides an analytic depiction that can guide increasingly refined understandings of various aspects of the human society on which we draw when we seek to build contextualized or holistic knowledge in applied qualitative health research. For researchers seeking to explore meaning in the actions of their study participants, SI becomes a framework for making this possible. SI is a theoretical way of thinking that contributes to the generation of understandings associated with clinical practice
implications, thus making it suitable for both empirical and clinical studies. Blumer (1969) stated that you cannot observe persons or objects or the interaction between them without acquiring an insight into how those interactions reflect on the individuals as people. As is evident in the research context, society consists of individuals engaged in action, and those actions will inform and guide us in our research, much as they do in practice, if we are open to the insights they reveal. As human actors, both the study informant and the researcher will inevitably interpret their own actions as well as the actions of others. Keeping this dynamic interaction in mind throughout the research process, we can see that SI has tremendous potential to enhance our understanding and complement other theoretical perspectives that are currently used in applied qualitative health research. Furthermore, rather than focusing our expectations on searching for the core categories and basic social processes toward which GT methodology inevitably orients us (Benoliel, 1996; Glaser, 1978), a SI lens can help us do justice to multiple and intersecting meanings that may be at play in explaining what appear to be patterns within the process data. Its distinctive role lies in its demand that we remain open throughout our data collection and analysis to this relevant social context within which individual subjective experience is shaped. In this manner, it therefore provides us a unique form of guidance in our knowledge generation (Benzies & Allen, 2001).
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Handberg et al. By fragmenting the more general notion of meaning into three distinct elements, SI makes meaning accessible in the sense of understanding both the meaning itself and also what the informants are striving for in relation to it. It is admittedly a complex challenge for a researcher to enter a field and study human beings who are often in difficult life circumstances and furthermore to try to understand the intension underlying their actions. When we study how people act toward the things that represent meaning for them, it can be a tremendous advantage to remember that the meanings of such things derive from the social interaction they have with their fellows and, moreover, that those meanings are being modified through an interpretive process. In other words, actions begin to make a particular kind of sense when one seeks an understanding of what is driving human beings in different directions and shaping their choices. Digging even deeper into an understanding of the interpretive process that is inherent in the human search for meaning can help the researcher to furthermore understand how a person (such as a patient, relative, nurse, or doctor) signals the things toward which he or she is acting. A mechanism through which to understand what meaning is based on, how it is handled by humans through internal communication processes, and how it plays a central role through the processes of both self-interpretation and interpretation with fellows. It allows us to expand our capacity to grasp the reasons underlying a specific group opportune or inopportune actions by people in the present state of their particular treatment or disease. Thus, SI can provide the researcher with the opportunity to explore and examine the health behavior of human beings in the context of the substantive relationships of this behavior in their quest for understanding. In the male cancer survivor study, participant observation helped the researcher to gain insights into the world of the observed phenomena. In several instances, the understandings that were ultimately generated would not have been possible through interview alone, and required the opportunity to closely observe social interaction in contrast to individual account. For example, the idea that the meaning of control was highly relevant for these individuals became apparent early in the participant observation fieldwork. It was noticed that some of the men were keeping exhaustive records on such things as their medication intake, appointments at the ward, and what was being said by the nurses and doctors. Others kept meticulous notes, even down to the smallest deviation, on their medications or oral intake. In several instances, they carefully arranged medications in annotated little boxes, or sequenced their food intake into small portions with the elements consumed almost ritualistically in the same sequence. It was also observed that some of the men were acting in ways that were very controlling toward their
relatives, orchestrating such things as when they could visit, what they wanted help with, what they could ask and not ask, and so on. Although our initial impression that a few of the male cancer survivors were acting this way individually could have led to an assumption that we had happened upon a particularly compulsive sample of individuals, over time, a pattern emerged in how they all acted in the group. As they interpreted and modified their behaviors over time, their actions around control emerged into what we came to recognize as a shared understanding. In our study, within the various cancer groups, it also became apparent that this shared understanding between the men represented an important form of meaning and a means of understanding that enabled them to control whatever was possible in their surroundings and therefore to minimize the feeling of loss of control. Observing lengthy discussions among them about how these things mattered, we began to trace the particular meanings that individuals were forming as having origins in the social interaction between the men in the group. Thus, in this particular study context, the SI lens allowed us to surface an increasingly coherent and understandable gendered pattern of how meaning constructions evolve within the context of the social interaction among male cancer patients.
Expanding Meaning Using Root Images To achieve a deep appreciation for the researched field, the researcher might need to take yet another step into the world of theory seeking by extending the analysis with an even sharper focus. SI is based on a set of fundamental ideas called “root images.” As proposed by Blumer, these root images refer to and illustrate the nature of human groups or society, social interaction, objects, human beings as actors, human action, and the interconnection associated with lines of action. The six root images are as follows: “Nature of human society or human group life,” “Nature of social interaction,” “Nature of objects,” “The human being as an acting organism,” “Nature of human action,” and “Interlinkage of action.” Blumer described these root images as ideas representing how SI envisions society and social conduct. The root images constitute an explicit framework for study and analysis and are useful for leading the researcher along the difficult path of understanding and exploring and analyzing without losing sight, for example, of the directionality of the interlinkage of data and findings. Through the root images, Blumer viewed human society as a site in which people are engaged in living, developing lines of action in all of the different and challenging situations they encounter. People are caught up in this social interaction, making indications to others of their
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own actions and, at the same time, interpreting the indications made by others. People are living in a world of objects, including objects that are symbolic of themselves as well as the objects that arise from and are influenced and shaped by social interaction with other people. People are led by their own orientation and actions toward the meaning of these objects. These activities and actions are formed through a process of description and interpretation, defined in any certain situation by humans as they are living in different groups and worlds with different meanings. As we see it, several aspects of the root images might be considered as applicable tools to enhance analytic processes in a range of qualitative health research projects. SI drives us to understand meaning as a social product that arises through interaction, an idea that can have broad utility in the qualitative health research context, where we are studying human beings in all different kinds of situations, trying to understand how they act, why they do so, and what represents meaning for them. The view that social action is constructed through an interpretive process requires that those processes of construction be observed to be analyzed. The everyday experience of the empirical world consists of individuals and objects, each of which has a distinctive and particular character, which must be included to achieve a fulsome analysis (Blumer, 1969; Stryker, 2002). To illustrate how the root images, along with other elements of SI, can shape an analysis, create insight, and serve as a helpful theoretical framework for applied health research where interpretation of context is desired, we focus on three exemplars from our work. Nature of social interaction. The fundamental idea of “Nature of social interaction” is based on how group life necessarily presupposes interaction between group members. It can therefore contribute a useful perspective to any focus of inquiry where insights about group interactions might be relevant. Social interaction between people is a process that forms and sculptures human behavior instead of being simply a means or setting for the expression or release of human conduct. Blumer referred to two forms of social interaction: “the conversation of gestures” and “the use of significant symbols.” The first, according to Blumer, was a “non symbolic interaction” based on the fact that no interpretation in response to meaning is taking place. It is like a reflex action without actual thinking involved. In contrast, the second, “the use of significant symbols,” is considered a “symbolic interaction” in that an interpretation is taking place in response to meaning. By this, we come to recognize that the person is responding to acts on basis of what the gesture or action means. In SI terms, we conclude that actual understanding occurs
when this gesture or action has the same meaning and significance for two persons. For Blumer, observation was a vitally important contribution to the capacity to understand the field or phenomenon we are studying. In our study, we looked for these symbolic interactions where interpretation was occurring, and our explorations at this level helped us discern the paths to understanding the explored field. We found it was often enlightening to observe actions using participant observation, and then follow up on the observations and analysis by having the informants to reflect on and interpret their actions and choices. In one of our study sites, for example, the hospital ward, we observed various manifestations of the nature of social interaction that seemed to shape the behavior of individual male cancer patients. In the head and neck clinic, the men used significant symbols such as gestures to communicate an acceptance of their illness. These gestures between group participants prompted similar responses from other group members. Such gestures seemed to lead to additional gestures or actions that signaled shared understandings. To elaborate, Patient A, who had been in cancer treatment for a long period of time would tell Patient B about various symptoms and side effects, such as problems with eating. On one occasion, Patient A demonstrated to Patient B how he was “feeding himself” through a gastrointestinal tube and explaining that “eating normal” was insufficient to provide adequate energy. Patient B was clearly uncomfortable with this interaction, looking scared, and had no questions, although he was carefully observing. This situation would be one for which Patient B had no “raw” understanding deriving from experience in everyday society, and for which he would have had no occasion to anticipate in relation to himself. However, over the next few weeks, the two would continue discussing g-tube feeding, and Patient B would begin to ask questions, demonstrating more bravery and less fear about the situation, allowing it to become more normalized in his thinking. These interactions, involving talking, discussing, and sharing information, resulted in Patient B developing a new understanding. When a new patient was admitted to the clinic, Patient B seemed to take over Patient A’s role, now being the experienced patient, seeing meaning in what he was doing, and illustrating that he understood the nature of the social interaction. Nature of objects. A second root image, “Nature of objects,” is based on the idea in which the “worlds” that exist for humans are composed of “objects” that are the product or objects of SI. These objects are described by Blumer as being physical objects (e.g., hospital beds, syringes, drips), social objects (e.g., a nurse, a patient, a
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health research context is the “Nature of human action.” The fundamental idea in this root image is that human individuals encounter the world as a world they must interpret to act toward meaning. Because we recognize that a person has to muddle through the situation in which he is called on to act, that action can be traced back to such matters as motives, attitudes, role requirements, and situational demands. While engaging in this decisional process, the person considers the various things that he has made note of before drawing a line of conduct on the basis of how he interprets each of them. His conduct is then shaped and led through a process of indication and interpretation. These interpretive processes take place through the mechanism of informants making indications to one another and not merely to themselves. These interpretive interactions within the social interaction lead to the outcome of joint or united action. As a researcher, this root image appears useful in understanding certain situations that a human might be put in. For example, where a patient has fallen ill with a mortal disease, it helps us understand that patients are trying to interpret meaning and cope within the context of being situated within their surroundings and the people orbiting around them. Their actions will not only be based on their own interpretations, but also on the social interaction associated with the particular location in which they might be placed. We are seeking to understand what actions mean to people as well as the meaning that arises from them. For the male cancer survivors in our study, we recognized that their world must be interpreted for them to act toward meaning. As researchers observing the patients, we could see that their actions could, to some extent, be traced back to such matters as motives, attitudes, and social roles within the patient group. For instance, the more experienced patients had more power because of their knowledge of treatment, side effects, and processes within the cancer world. Therefore, the more experienced patients often set the standard for social interaction. An example, again observed within the head and neck cancer group, was where the patients late in the treatment period would experience pain in their mouth and throat because of radiation damage. For the newer patients, it often seemed incomprehensible that they would end up with that as well. Through various interactional processes about which SI had triggered our curiosity, it was observed how patients would share various forms of knowledge from experienced to new patients, introducing them to what was to be expected. The more experienced patients would orient the patients to the pain that hindered their eating, sleeping, or doing anything at all. They would tell the new patients that the only thing that will help is morphine, and that they should start the medication before the pain starts.
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This would lead to a process of indication whereby the new patients would interpret information and guidance from the more experienced ones based on motives, attitudes, and roles. By interpreting meaning through social interaction, the new patients would end up acting based on this co-constructed meaning. Patients socialized in this manner therefore recognized that they did not want to lose control because of pain and were able to initiate morphine early in the process. As we have attempted to illustrate using these three examples, the root images can offer the applied qualitative health researcher a frame or a base for expanding the analytic potential through approaches beyond individual interpretation to understand what meanings people are striving toward. On the basis of our immersion in this process, we came to believe that all of the SI root images could have potential as usable tools within qualitative studies of complex human health and illness phenomena for the interpretive construction of robust findings, regardless of the explicit methodological approaches deployed.
Value Added From SI to Analytic Quality Our experience illustrates that SI can serve as a theoretical framework to expand capacity in qualitative health research and give voice to complex interpretations in an applied field study beyond the GT context. We see no reason why it could not be applied across a diverse range of methodological options, such as qualitative description or ethnographic studies using participant observation as a means through which to push for expansion of the understanding of how people live in a world of objects and act toward those objects based on the specific meaning the objects have for them (Aberg, Sidenvall, Hepworth, O’Reilly, & Lithell, 2004; Burbank & Martins, 2010; Carlson, 2013; Dennis, 2011; Tourigny, 1994). Using SI as a theoretical framework in research, we acquire a mechanism through which to systematically search out and identify these objects, categorize our thinking about them, and understand their meaning. This kind of depth and integration of interaction can add value beyond the reporting limits of a more conventional qualitative report, steering us toward findings of an order that can offer powerful insights into such goals as practice change. For instance, in the interpretive description study on the male cancer survivors, SI helped us identify barriers around maintaining control and normality that ought to be accounted for in the future rehabilitation of this population. SI respects the nature of the empirical world and organizes a methodological stance that reflects that respect. This positioning becomes important in the choice of SI as a framework for qualitative health research. In taking up
this perspective, the researcher accepts a commitment to respect the empirical world as the basis for everything else in the researched field because, according to Blumer (1969), this was where the real world resides. The shape of the real world is made apparent to us in the social interactions that will be empirically discovered within it and cannot be specified in advance. The researcher is charged with trying to grab the empirical nature of the field under study, and this is only possible through being there, closely observing, and experiencing the social interaction (Blumer, 1969). Thus, SI adds particular relevance to studies in which participant observation and being in the field are understood as fundamental to an appreciation for the researched phenomenon. Through application of the SI lens in an applied qualitative health study, new angles of vision and conceptual options in relation to the researched field can be achieved, with the advantage of adding layers of complexity to qualitative research reports. From our perspective, the SI framework consists of exceptionally useful mechanisms that can help researchers in an applied health study to understand what people are striving toward in relation to social interactions and meaning in their health behaviors. By helping the researcher operate in a heightened and focused explorative manner, SI can guide the formation of an extended knowledge of the social world that is influencing the health phenomena we seek to understand. It does so by providing mechanisms through which to develop and refine our research questions, so that they reflect the kinds of depth and complexity that are consistent with an informed applied practice approach. Moreover, it can also guide the specific data collection and construction processes that we will use to answer the questions we pose. When researchers in the applied health professional fields state a practice problem or challenge and define a qualitative research question, they are making a claim that the focus of their research reflects a specific problem requiring exploration and elaboration. Understanding the empirical world and the problems in it through a certain theoretical lens can sharpen the focus of vision, and provide direction for the exploration, conduct, and analysis in a research project. It can enable the researcher to explore exhaustively within a complex field without losing directional focus. Thus, the rationale for using such a lens is that it makes distinct not only what can be observed in the field but also the underlying mechanisms and relationships that might explain the conditions of occurrence, such as why human beings act as they do in different situations. Thus, SI provides the explicit advantage of helping channel the researcher’s angle of analysis toward the broad concept of meaning and what it is that human beings will strive for or try to avoid through their actions and interactions.
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Perceptions of informal caregivers. Qualitative Health Research, 14, 792–815. doi:10.1177/1049732304265854 Aldiabat, K., & Navenec, C. (2011). Philosophical roots of classic grounded theory: Its foundations in symbolic interactionism. The Qualitative Report, 16, 1063–1080. Retrieved from http://files.eric.ed.gov/fulltext/EJ940800.pdf Benoliel, J. Q. (1996). Grounded theory and nursing knowledge. Qualitative Health Research, 6, 406–428. doi:10.1177/ 104973239600600308 Benzies, K. M., & Allen, M. N. (2001). Symbolic interactionism as a theoretical perspective for multiple method research. Journal of Advanced Nursing, 33, 541–547. doi:2048/10.1046/j.1365-2648.2001.01680.x Blumer, H. (1969). Symbolic interactionism: Perspective and method (1st ed.). Berkeley: University of California Press. Burbank, P. M., & Martins, D. C. (2010). Symbolic interactionism and critical perspective: Divergent or synergistic? Nursing Philosophy, 11, 25–41. doi:10.1111/ j.1466-769X.2009.00421.x Carlson, E. (2013). Precepting and symbolic interactionism? A theoretical look at preceptorship during clinical practice. Journal of Advanced Nursing, 69, 457–464. doi:10.1111/ j.1365-2648.2012.06047.x Carter, S. M., & Little, M. (2007). Justifying knowledge, justifying method, taking action: Epistemologies, methodologies, and methods in qualitative research. Qualitative Health Research, 17, 1316–1328. doi:10.1177/ 1049732307306927 Chamberlain-Salaun, J., Mills, J., & Usher, K. (2013). Linking symbolic interactionism and grounded theory methods in a research design. SAGE Open, 3(3), 1-10. doi:10.1177/21582440-13505757 Crooks, D. L. (2001). The importance of symbolic interaction in grounded theory research on women’s health. Health Care for Women International, 22, 11–27. doi:10.1080/073993301300003054 Dennis, A. (2011). Symbolic interactionism and ethnomethodology. Symbolic Interaction, 34, 349–356. doi:10.1525/ si.2011.34.3.349 Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press. Glaser, B. G., & Strauss, A. L. (1966). Awareness of dying. London: Weidenfeld & Nicolson. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine de Gruyter. Jeon, Y. H. (2004). The application of grounded theory and symbolic interactionism. Scandinavian Journal of Caring Sciences, 18, 249–256. doi:10.1111/j.14716712.2004.00287.x Lomborg, K., & Kirkevold, M. (2003). Truth and validity in grounded theory—A reconsidered realist interpretation of the criteria: Fit, work, relevance, and modifiability. Nursing Philosophy, 4, 189–200. doi:10.1046/ j.1466-769X.2003.00139.x Meltzer, B. N., Petras, J. W., & Reynolds, L. T. (1975). Symbolic interactionism: Genesis, varieties and criticism. Boston: Routledge.
Our experience with SI, apart and distinct from the context of GT methodology, has convinced us that it can work well and add a strategic advantage in strengthening focus, adding layers of contextual understanding, and— most especially—unraveling the complexities of how meaning is co-constructed by interpretive agents in interaction with their social world. So much of what we seek to understand in the applied health disciplines involves some aspect of social process, even when social process is not in itself the apparent focus of our inquiry. Beyond the subjectivities and narrative interpretations that we seek to uncover in much of our qualitative health inquiry, there exists a world of social interaction within which meaning is deeply influenced. By allowing for multiple layers of understanding, we can overcome some of the limitations associated with overreliance on either self-report or observation, thereby reducing the likelihood of overly simplistic findings and interpretive errors. From our perspective, a curiosity about what SI might have to offer can serve as an enhancement to the foundations of a wide range of popular qualitative approaches to knowledge construction, strengthening the caliber and comprehensiveness of knowledge products in the field. If we believe that people are not islands, but rather are very much shaped by the social worlds that they live in, then a mechanism through which to interrogate what we see may help us find meanings and understandings that extend well beyond that which would likely be uncovered through conversational interview and casebased data collection approaches alone. Using a lens such as SI, the subjective world of patients becomes increasingly fascinating, and our options for surfacing and then translating knowledge into the applied world are expanded exponentially. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research and article was supported by the foundation “Public Health in the Middle” [Folkesundhed i Midten], Denmark; “The Health Insurance Foundation” [Helsefonden], Denmark; and “Public Health and Quality Improvement” [Folkesundhed og Kvalitetsudvikling], Denmark.
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Author Biographies Charlotte Handberg, RN, MPH, is a PhD student at the Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, Denmark, and at the Marselisborg Center, Public Health and Quality Improvement, Central Denmark Region, Denmark. Sally Thorne, PhD, RN, FAAN, FCAHS, is a professor, at the School of Nursing, University of British Columbia in Vancouver, Canada. Julie Midtgaard, PhD, is an associate professor and psychologist at the University Hospitals’ Center for Health Research (UCSF) at Copenhagen University Hospital Rigshospitalet, Denmark. Claus Vinther Nielsen, PhD, MD, is a professor at the Section for Clinical Social Medicine and Rehabilitation, Department of Public Health, Faculty of Health, Aarhus University, Denmark, and at the Marselisborg Center, Public Health and Quality Improvement, Central Denmark Region, Denmark. Kirsten Lomborg, PhD, MSN, RN, is a professor at the Department of Clinical Medicine and Department of Public Health, Aarhus University, and at the Aarhus University Hospital, Denmark.
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