Hermeneutics in Nursing Studies : An Integrative Review

Aim: To review nursing studies using hermeneutics as a methodology in different dimensions including practice, education, and administration. Background: Hermeneutics is a qualitative research methodology that focuses on interpreting the meanings of experiences in individual’s life. It is a major philosophy and research method in the humanities, human sciences and arts disciplines with a central goal of describing people’s experiences. Data sources: A review of relevant literature using electronics databases including EBSCO, SCOPUS, MEDLINE, CINAHL, and PUBMED. Review methods: Using an integrative method, peer-reviewed research and discussion papers published between 2013 and 2018 and listed in the CINAHL, SCOPUS, Science Direct, PubMed and Google Scholar databases were reviewed. Findings: A final review of 13 studies that used hermeneutic phenomenology as a philosophical background and research methods was done. Conclusions: Hermeneutic phenomenology has been used as a qualitative method in numerous nursing studies with different domain including practice, education and administration. The ability of the nurses to make decisions related to implementing evidence in education, practice, research, and admiration is reliant on the clinical expertise of the nurse. The review of the literature identified that the capability to correlate research findings to these three categories in nursing and the willingness and inclination to improve current practice were crucial factors for knowledge translation.


Introduction
Evidence, knowledge, and facts in nursing studies are ascertained and concluded as a result of using different scientific research approaches.The scientific method is the most powerful tool for world truths discovering, exploring and validating human inquiry and new theories [1].Previous literatures on nursing studies and evidence in nursing research have indicated that most studies used quantitative research methods, and few qualitative studies exist [2] [3].
The most common qualitative approaches used in nursing studies include: phenomenology, ethnographic, grounded theory, historical, case study, and action research [4].Phenomenology is recognized as a critical, accurate, logical applicable qualitative investigation research method to study phenomena significant to nursing discipline [4].Among phenomenological qualitative studies, few that have evaluated the lived experience in nursing studies involved in education, practice, and administration using the phenomenological method [5] [6].Therefore, the main aim of this review is to highlight the use of Hermeneutics in nursing studies in the three domains of practice, education, and administration.
Phenomenology: Phenomenological inquest brings to language perceptions of human experience with all types of phenomena [7].As several authors have noted, phenomenology, both as philosophy and research approach, allows nursing to explore and describe phenomena important to the discipline [8]- [14].The central structure of an experience is its intentionality, its being directed toward something, as it is an experience of or about some object.An experience is directed toward an object by virtue of its content or meaning (which represents the object) together with appropriate enabling conditions [15].The phenomenology was initiated by Husserl (1859-1838) as a philosophy.Later, it was developed by Heidegger (1889Heidegger ( -1976)), to focus on essences of phenomena and consciousness, moving from discipline towards hermeneutic and existential dimensions [16].Phenomenology has been influenced by multiple philosophical perspectives and theorists, which inform hermeneutic phenomenological research.The phenomenology movement is commonly divided into three phases: the Preparatory Phase, the German Phase, and the French Phase [17].
The purpose of phenomenology is to describe a particular phenomenon, or the appearance of things as a lived experience; it is both a way of thinking or perspective, that is, a philosophy, and a research method [4].Phenomenology is also considered a careful examination of the human experience, and understanding the essential qualities of the experience in turn can illuminate the experience for others.To accomplish this, one must focus on the particular object in its own right, and then move the focus to the perception of the object and away from the object itself [18].
Phenomenology studies conscious experience as experienced from the subjective or first person point of view.This field of philosophy is then to be distinguished from, and related to, the other main fields of philosophy: ontology (the study of being or what is), epistemology (the study of knowledge), logic (the study of valid reasoning), and ethics (the study of right and wrong action) [19].
Hermeneutic Phenomenology: Hermeneutic phenomenology offers a different approach to qualitative understanding through the interpretive process of the written and spoken word [20].Hermeneutics is not exterior to phenomenology but is substitute way of seeing a pre-understanding of a body of knowledge.Hermeneutics is described as "an attempt to show the pre-philosophical understanding of human in the world that is basic to various disciplines so that this understanding can become the basis of philosophical reflection" [21] (p. 145).Phenomenological-hermeneutic approach is essentially a philosophy of the nature of understanding a particular phenomenon and the scientific interpretation of phenomena appearing in text or written word [4].The early philosophers of phenomenology were faced with several questions, including what is true (epistemology) and what it means to be alive or not alive ontology) [22].Heidegger rejected the theory of knowledge known as epistemology, and adopted ontology, the science of being and developed interpretive phenomenology by extending hermeneutics, the philosophy of interpretation [23].Hermeneutic (interpretative) phenomenology is a research approach that is built on the descriptive phenomenology of Husserl [15].Heidegger expanded this to include understanding the phenomena of the world, how we go about understanding the world presented to humans, and understanding the being itself [24].
Heidegger's hermeneutics interpreted as being concerned with the interpretation of language [25].According to van Manen [26], a hermeneutic phenomenology is an approach in which the researcher goes beyond the words of the participants to achieve abstraction through interpretation.Van Manen [26] highlighted that phenomenological writing can help find meaning to all actions.
The position of hermeneutic phenomenology is rooted in the belief of the importance of subjective consciousness and the judgment of consciousness as powerful, and the researcher gains direct knowledge of the consciousness by reflection [27].

Search Strategy
In this review, relevant articles that have been published from the period between January 2008 and November, 2018 were reviewed by the researcher using different international databases including EBSCO, SCOPUS, CINAHL, and PUBMED databases host.The keywords which have been used were "phenomenology", "nursing", "lived experience", and "hermeneutic".The reviewed studies focused on the following three domains: practice, education, and administration, which used hermeneutic phenomenology to guide nursing experience studies.

Inclusion Criteria
The relevant articles in this integrative review were limited to: written in English

Search Strategy Outcomes
The reviewed studies were initially evaluated through titles and abstracts, duplicated articles were removed.Furthermore, the total articles search resulted in 1146 articles which were matching the subject of interest, then; after removing the duplicated articles 732 articles remain.The initial evaluation for their title's abstracts took place, 599 excluded by title, 133 screened by abstract, 94 excluded by abstract, only 39 were found to be related to the topic of interest.Then, related articles were printed and read in full, following a secondary evaluation, excluded non-research articles; 13 articles were exactly identified to cover the inclusion criteria and were included in this review (Figure 1).

Results
Among the 13 articles, 4 articles focused on using hermeneutic phenomenology as a research method in education domain, and 7 articles discoursed the outcomes The result of the reviewed articles, were used as a codes to identify, summaries synthesis and discuss of findings for clarifying the interpretation themes.Thirteen relevant articles have been reviewed.From each article the following data have been extracted: domain, title, author, study aim, strength of evidence and findings; all articles presented in Appendix.
The authors relate and interpret the research findings to identify themes based on their domains similarities.Overall, the thirteen reviewed research articles published between 2008 and 2018; all of the nursing studies were guided by hermeneutic phenomenology.All of the articles are presented in Appendix.

Hermeneutic Phenomenology in Nursing Education
Nursing education is an important area of research that can be studied using qualitative approaches [7]; such as educational experiences, developing cultural sensitivity, or the effect of evaluation on student performance in the clinical setting.Four studies concerned with lived experience in nursing education revealed multiple themes which have significant role in nursing practice.The study of Ransea et al. [28] to the third-year nursing students' lived experience

Hermeneutic Phenomenology in Nursing Practice
Regarding the second part of practice; phenomenology as a qualitative research method has been used to realize a variety of practice-related experiences and enables understanding of personal interactive experiences [32] [33] [34] [35] [36].The study of Valizadeh et al. [37] to the challenges of the preceptors working with new nurse; which amid to explore the lived experiences of nurse preceptors working with new nurses; the results revealed three main themes: preceptorship as a challenging and stressful role, lack of support, and lack of appreciation.While the main themes that have been emerged from Mendes [38] in the study of the impact of critical illness news on the family; revealed several themes; unexpected news death of the sick person impact the well-being, care of family members, and their ability for analysis and decision making.Blomberg et al. [39] conducted a study of responsibility for patient care in perioperative prac- tice; the results shown two main themes: a formal external responsibility, and personal ethical value.Imani et al. [40] of Iranian hospital nurses' lived experiences of emotional intelligence study; presented one main theme; normative interactive management.The three subthemes were: resorting to spiritualties, self-protection and intelligent resilience.The study of lived experiences of elderly patients with Coronary Artery Disease of Karimooi et al. [41] shown one main theme: living with ups and downs, with sub-themes: losing calmness, trying to achieve calmness through spirituality, losing health, trying to promote health through modification of lifestyle, perceiving family support, living in fear, and living with a damaged heart.However, Bright [42] had explored and examined the phenomenon of nursing presence through the hermeneutic lenses.Theoretical categories include: narrative identity, play and solicitude, whereas, Koskinen and Nystrom [43] contributed to the development of the hermeneutical application research design in its epistemological, ontological and ethical perspective, by articulating and clarifying the central foundations in the application.Theory of caring become evident and implemented in a clinical practice through moments when the participants find a common understanding and consensus on the knowledge of care and caring.

Hermeneutic Phenomenology in Nursing Administration
The qualitative research literature addressing issues uniquely related to nursing administration is limited, possibly because many of the issues that lend themselves to qualitative education in nursing administration overlap with the practice arena [7].The first study of Thompson et al. [44] found; little is known about nursing home nurses' perceptions and experiences of working within this context.Participants' responses suggested that nurses are required to modify their care activities to account for career differences.Participants proposed that they are isolated and excluded from the rest of the healthcare workforce group.
These issues led participants to feel uncertain about work identity, while last study of Liden et al. [45] described and interpreted the experiences of learning to live with medically unexplained symptoms as narrated by patients in primary health-care settings.The finding revealed is presented in two themes.The first, feeling that the symptoms overwhelm life.The second, gaining insights and moving on, was based on subthemes describing the patients' search for explanations.The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.

Discussion
Utilizing hermeneutic phenomenology for nursing practice, education, and administration has made a significant contribution to the substantive body of nursing knowledge.Qualitative methods acceptance as effective approaches to nursing knowledge discovery continues to develop; evidenced by increasing nursing research guided by hermeneutic phenomenology; to investigate phenomena of interest experiences.
Education Domain: The study of Ranse et al. [28] has provided insight into the experiences of third-year nursing students preparing for the transition to practice as graduate nurses.When reflecting on experiencing loss, students questioned their own actions, acknowledged the value of relationships and identified ways to cope.The second study of Packard and Hoffman [29] to the students' reflections and shared conversations; become human science text for this hermeneutic phenomenological exploration of the lived experience of pre-nursing students.Regarding the study of Coatsworth et al. [30] data reflected participants' realities and how the researcher related findings of the study to demonstrate and resonate with a construction of overseas volunteering assisted student nurses to reconnect with their empathy and compassion, and explore the humanistic and interpersonal nature of nursing rather than the technical skill-based components of nursing identity.Additionally, the participants were forced to enact their nursing skills to the very boundaries of their capabilities and to be more innovative.Furthermore; Porteous & Machin [31] study; revealed developing undergraduate students own skills of coping and survive with considerable variation in their experience that influenced their motivation and behavior to meet the demands of academic life.
Practice Domain: Experience of working with new nurses, working experiences with chronic daises ill patients, adapting to new strategies as emotional intelligence in nursing practice are central phenomenon to nursing practice that can be enriched when examined from a qualitative lens.Therefore, phenomena unique to the practice of professional nursing need investigative approaches suitable to their unique nature [7].
Valizadeh et al. [37] described the preceptors experience of working with new nurses as "being left alone", with no adequate support from nurse managers and bedside nurses.They felt that the workload involved in the preceptorship role was often underestimated and new nurses were assumed as full working forces.
On the hand, the preceptors were critiqued for shortcomings and errors caused by new nurses.Mendes, [38] study of the humanity of nurses was revealed in response to the needs of the family.In view of the requirements for information, it was verified that the information transmitted allowed them to become aware of themselves, to become empowered in their daily lives and to alleviate the emotional burden experienced.While Blomberg et al. [39] study showed personal ethical value by confirming the patient as a person, caring for the patient and preserving the patient's dignity.A new understanding emerged that the operating theatre nurses always have the patient in mind.Karimooi et al. [41] indicated that the coronary artery disease led patients to experience ups and downs for the participations.After the disease, they were trying to achieve calmness through some strategies.Members of the treatment team, especially nurses should provide self-care education for to make them be having successfully in this field.Imani et al. [40] revealed that nurses that work in unstable and stressful conditions, provide better understanding about the concept of nurses' intelligent resilience.And by this may enhance to achieve calmness through some strategies to make them behaving successfully.While; Bright [42]

Conclusions
Evidently, practice-related research domain is growing and expanding into various nursing areas, with significant and extensive development of related-researches in education and administration domains.
Examples of hermeneutic phenomenological research applied to the areas of nursing practice, education, and administration emphasize the important con-tribution that phenomenological research has made to nursing's substantive body of knowledge.
Hermeneutic phenomenology method provides a road for investigation that allows interpretation of numerous experiences.The interpretations of nurses in practice, education, and administration domains can be a remarkable foundation of data that need to be more fully explored and make significant contribution to body of nursing knowledge.Incorporating data extracted in the domains of clinical practice, education, and administration can help significantly in improving patient care.From the research five emergent themes were emerged from the participant's experiences:

Appendix
1) Student nurses experienced growth of their nursing capabilities.
2) Student nurses experienced volunteering as building empathy, compassion and caring.
3) Student nurses' experienced education and health promotion within their nursing identity.Three main themes • Preceptorship as a challenging and stressful role.
• Lack of support.
• Lack of appreciation.
Three main themes Data analysis revealed three themes: 1) preceptorship as a challenging and stressful role; 2) lack of support; and 3) lack of appreciation.Preceptorship as "a challenging and stressful role" was the constitutive pattern that unified the themes.

Critical Illness
News on the Three essential themes • Unexpected.
• Pronouncement of death.
• Impact on self-caring within the family.

Three essential themes
The unexpected news and death of the  On the basis of Gadamer's hermeneutical thinking and Levinas ethical thinking, the central foundations in the application research are ethics, creation of a hermeneutical room, dialogue and common understanding and appropriation and action.When theoretical understanding turns into praxis, knowledge also becomes activity and theory and practice become one.Participants' responses suggested that nursing "residents" is different to nursing "patients", and nursing home nurses are required to modify their care activities to account for these differences.Participants also proposed that they are isolated and excluded from the rest of the healthcare workforce group.These issues led participants to feel uncertain about work identity.Many participants attempted to strengthen their work identity by aligning their role with what they perceived the "nurse identity" to be.Administration [45] The
of caring for the dying; the study findings identified three themes: being caring, unexpectedness in witnessing an expected death and experiencing loss.Also, the students demonstrated family-centered care but recounted unexpectedness in both the dying trajectory and physical changes in the dying patient.The second study of Packard and Hoffman[29] calling the hermeneutic circle: A Place of Belonging to the Pre-Nursing Students shown that themes of longing, belonging, vulnerability, and comfort emerge, in which being in caring circles offers radical possibilities for a pedagogy of being and becoming in nursing education.While the third study of Coatsworth et al.[30] to student nurses volunteering in Nepal: have their experiences altered their understanding of nursing.The participants reported their experience of delivering healthcare in the context of a developing country forced them to get creative and "think outside the box".The study themes were student nurses experienced: growth of their nursing capabilities; volunteering as building empathy, compassion and caring; education and health promotion within their nursing identity; the need to use creativity in overcoming barriers to delivering health care effectively, and experienced gaining new capabilities to utilize in Australia.The forth study ofPorteous & Machin [31], to the lived experience of first year undergraduate student nurses.Their study aimed to understand how one group of undergraduate nursing students perceived their experiences of the transition into higher education and nursing.Five themes emerged from the data: uncertainty; expectations; learning to survive; seeking support; and moving forward.The undergraduate students of the first year had demonstrated developing self-efficacy and successful transition.
has clarified the role of ethical orientation, creativity and connection with the human experience through exploration of self and other.However, Koskinen & Nystrom[43] had central foundations in the application of research which are ethics, creation of a hermeneutical room, dialogue and common understanding and appropriation and action.When theoretical understanding turns into praxis, knowledge also becomes activity and theory and practice become one.Administration Domain: Studies related to professional nurse behavior and work activities, satisfaction, successful leadership strategies, and perspectives on nurse empowerment would cross over between administration and practice and little.Thompson et al.[44] study findings of nurses' work activities and professional group identity influence their work identity.When work activities and professional group identity do not align with role expectations, as can be the case for nursing home nurses, work identity may be compromised.These nurses may attempt to change work practices to strengthen their work identity.While last study of Liden et al.[45] found patients' suffering from MUS constantly engage in a reflective process involving reasoning about and interpretation of their symptoms.Their efforts to describe their symptoms to healthcare professionals are part of this reflection and search for meaning.The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.
in caring circles offers radical possibilities for pedagogy of being and becoming in nursing education.Students' reflections and shared conversations become human science text for this hermeneutic phenomenological exploration of the lived experience of pre nursing students.Themes of longing, belonging, vulnerability, and comfort emerge.Being in caring circles offers radical possibilities for pedagogy of being and becoming in nursing education.

4 ) 5 )
Student nurses experienced the need to use creativity in overcoming barriers to delivering health care effectively.Student nurses experienced gaining new capabilities to utilize in Australia.

F
from the data: uncertainty; expectations; learning to survive; seeking support; and moving forward.Findings identify that the participants had developed skills to survive however considerable variation in their experience, influenced motivation and behavior.They developed their own skills of coping to deal with the demands of academic life and those of the practice setting.An explanatory student journey model demonstrated that developing self-efficacy was key to their successful transition through the first year of undergraduate study sick person influence the well-being and self-care of family members, affecting their ability for analysis and decision making.It was observed that the family experiences the news with suffering, mainly due to the anticipation arising from the events.
using the concept of work identity can support understanding of how workers make sense of their work.