Janice M. Morse
13
CONCEPT IDENTIFICATION USING QUALITATIVE INQUIRY
What is wrong with health care are its concepts and words, rather than its picayune—but rather costly—procedures.
—Ivan Illich (1994)
Concept identification is a crucial process within all qualitative methods, and the goal of most. As described in Chapter 12, qualitative methods inductively use the description necessary for identifying and constructing attributes and defining boundaries, and use techniques of categorization and comparison for delineating concepts. This chapter consists of examples of concept identification and development using data. It is divided into three sections. In the first section, data-derived concepts, the concept is identified and developed directly from data, using the example of compathy. In this chapter, concept-supporting data in which data (or indices) seeking a concept are applied directly from data to develop concepts, uses the example of disembodiment for the self-management of excruciating pain.
DEVELOPING A CONCEPT FROM DATA: THE EXAMPLE OF COMPATHY
In the 1990s, with funding from the National Center for Nursing Research (NCNR; now the National Institute of Nursing Research [NINR]) to critically assess the meaning and role of comfort in nursing, we initiated phenomenological research into enhancing endurance in acutely distressed patients. We began to investigate how burned and traumatized patients themselves attained comfort (i.e., self-comfort) and how nurses sought to nonpharmaceutically provide it. In this research, experiential descriptions of responses to the distress of others began to surface. These descriptions did not fit the standard conceptions of empathy in the literature. Initially, inquiry focused on the suppression of such responses—of steeling or bracing oneself, and controlling one’s expressions of dismay, distress, or disgust, in order to continue providing care. Eventually, however, we realized that we had data that did not fit descriptions of empathy, and recognized that they were in the presence of an experience of singular importance—one (with the exception of Hoffman [1990]) that had not been discussed in the literature.
We were using phenomenology, the goal of which is to understand, to elicit the meaning or the essence (van Manen, 1990) of the concept. But those interested in concepts take this one step further: Phenomenology enables the development of adequate description to identify behavioral concepts, and to explore the context and produce rich descriptions that will enable the development of attributes.
Examples From Data: Nurses’ Descriptions of Compathy and the Compathetic Response
Interviews with nurses about aspects in patient care that evoked a compathetic response were:
• Providing emergency care, such as doing mouth to mouth if a mouthpiece is not available—especially if the patient vomits
• Having to inflict pain, especially when the person does not really understand what you are doing, such as having to take blood from a small child
• Shaving around a wound that has to be sutured, such as a scalp lacerations “makes me feel weak and sweaty, especially if there is dried blood that I have to wash away.”
Many nurses reported that the smell of burned flesh, fecal vomiting, blood, melena, and amniotic fluid all evoked a physical response. These noxious odors were different from the compathetic response, because patients’ distress was not the trigger for the nurses’ response. Similarly, sounds were also offensive, such as: someone blowing his or her nose and about to spit; bones grating, scraping, but removed from a distressed person, but again, removed from signals of distress, they were not the same as a compathetic response. Interestingly, although the sound of vomiting has been reported in an international Internet survey and was ranked as the “most horrible sound” (Cox, 2008), nurses reported that “it was not so bad” and “you got used to it.”
Nurses reposted that the sight of trauma was not so distressing if the person was not behaviorally and emotionally distressed:
One sight sticks in my mind. I remember a gentleman who had been riding a motorcycle and took out a metal guardrail along the side of a road—no one felt sick—it was kind of intriguing for the anatomy, because he came in ventilated and the whole of his chest was open. So every time you bagged him and gave him a breath, you could see his lungs inflate and deflate. It was interesting, but you didn’t have time to feel sick.
Describing Compathy
In the next section, I will use these data to illustrate the process of developing a concept from phenomenological data. In this case the concept was identified from the phenomenological study, but I will continue beyond identification to develop the concept anatomically to the level of model building.
Data Summary
When an individual is injured or experiences a painful condition, the injury or pain may be immediately manifested in various ways. Persons may posture to guard or to protect the painful part, may grimace and become pale, sweat, and display other indices of physical distress. They may also express pain by crying out or describing it to others. The posturing, physiological signs, sounds, and verbal descriptions all communicate to others (and to some degree to oneself) the level of distress or nature and intensity of the pain being experienced. Furthermore, in the case of injury, disfiguring disease, or illness, such signs as damaged tissue, bleeding, the sounds of grating bones or labored breathing, the odor of blood or decaying tissue, and the cold, clammy sensation of the skin of a person in shock all indicate aspects of the severity of a condition and the character of its experience. Someone may thus perceive not only the extent and possible ramifications of the injury, which may cause shock and horror, fear, anxiety, sympathy, and compassion, and would amount to emotional empathy; but in addition to this, someone may have a sense of what the experience of such injury must feel like to the sufferer.
Through experience and training, especially among professional caregivers, it is possible for persons to learn to control for the compathetic response. Caregivers are motivated and guided by compathy to give better care, but they also have to learn to shield or otherwise protect themselves from some aspects of the compathetic response, at least in its stronger forms. Physicians and nurses must learn not only to limit empathetic identification with their patients but also to control for compathetic identification.1 When a patient reminds the caregiver of a relative or a friend—or in fact is a relative or friend—the compathetic response is not so easily controlled, and shielding mechanisms readily break down. In one instance a nurse reported having to leave the room to maintain control: “And when I looked at him, I thought it was my dad. And I just lost it … I just had to leave the room. I could not nurse in that room. I could not work on this guy.”
Triggers for Compathy
The notion of contagion of physiological response is not new, but has been relatively ignored in the literature. What is the result of this “contagion?”
The triggers for the compathetic response (i.e., the antecedents) usually arise from directly viewing the person suffering. The response is particularly strong if the observer has a close relationship, that is, is embodied with the sufferer. It can be conceptualized as a contagion of physiological response. The various responses that occurred in the individual as a result of the compathetic arousal, identified from observations, personal knowledge, and the literature, may be sorted into four levels, and evident in various degrees:
• By seeing the illness/suffering
• By hearing descriptions of illness/suffering
• By reading descriptions of illness/suffering, or
• When the phenomena is dissociated from a known person, even by thinking about it
Level 1. Mimicking of Physical Behaviors
The first level is evident in infant development as the modeling of nurturing/comforting behaviors that form the basis of socialization of infants and children. In the first year of life, infants are taught to respect others and not to cause pain; that others feel as they themselves feel; that when they are hurt, others “make them feel better”; and that they too may comfort others. These behaviors are taught by modeling and by imitating others (Davis, 1985; Hoffman, 1981) and by the repetitive instruction that occurs in the parent–child relationship. Infants are taught not to bite, push, or to hit others, and mothers may even give their own infant a small hit “to see how it feels.” Small children are constantly reminded to “be gentle with others” and not hurt others. This learning continues as parents try to monitor playground and keep older children from observing violence on TV.
An example of modeling is shown on Figure 13.1, a newspaper photograph of a grandson imitating his grandmother while she receives a flu shot.
FIGURE 13.1
Learning by modeling: grandson vicariously experiences his grandmother’s flu shot.
Level 2. Contagion of Physiological Responses
The contagion of involuntary responses to pain is evident in this level, with some of these responses based on shared emotions. For example, uncontrolled giggling (especially in adolescents) is classic, and serves a function of reducing social stress (Glenn, 1989). Other emotional responses that are manifest physiologically, such as, crying, sadness, and group hysteria are also common. These behaviors are stimulated by triggers, which occur in groups and are involuntary.
Not all of these contagious physiological responses are based on pain. Yawning is of particular interest for a contagious physiological response that can be easily triggered by observing a yawn in another (i.e., a yawn-evoked yawn [Provine, 1986]), and one that has even been well described by Dr. Seuss (Geisel 1962, p. 2). A yawn may be triggered, or the desire to yawn stimulated, even by thinking or reading about yawning; because once initiated the response must go to completion, it is known as a released fixed action pattern (Provine, 1986).
Level 3. The Contagion of Physiological Conditions; Often Pathophysiological
These syndromes, or set of physiological symptoms, are more complex. For example, psychogenic epidemics in the workplace have been documented, with symptoms including dizziness, vomiting, fainting, hyperventilation, skin disorders, and epileptic-type seizures. Such mass psychogenic illness has been attributed to hysteria and stressors in the workplace (Olkinuora, 1984).
Another excellent example of the transference of physical responses occurs with couvade; when a husband experiences a range of pains and discomforts similar to those experienced by his pregnant wife (Bogren, 1986; Strickland, 1987; Trethowan & Conlon, 1965). And in many cultures an expectant father may require rest and recuperation after their ordeal in the postnatal period, while his wife returns to her work roles (Bogren, 1986; Clinton, 1985). Couvade is not restricted to exotic cultures; males in our culture are sometimes affected by symptoms that are similar to the physical discomforts of pregnancy and labor (Trethowan & Conlon, 1965). Despite the chronological relationship of pregnancy to the occurrence of symptoms, the relationship between these events may not be perceived by expectant fathers. Yet certain pregnancy symptoms are “mimicked in a manner that is quite remarkable” (Trethowan & Conlon, 1965, p. 59).
Detached from personal experience and actual people with the illness, medical and nursing students are notorious for developing symptoms of diseases they are studying. In medicine, when learning about diseases, hearing descriptions of symptoms, they compared their own body and any symptoms they might have been experiencing, with those diseases. They self-diagnose the same symptoms in themselves, or recognize them in their own healthy bodies—usually with a grim prognosis. Medical students in their first course of anatomy, when dissecting cadavers (Gustavson, 1988), particularly had somatic symptoms when dissecting the hands, genitals, and face.
Finally, the contagion of pain is evident in some at the scene of accidents. Children in a school yard may gather around a friend with a scraped knee, feeling the pain in their own knee, even holding their own knee, and experiencing the stinging with a voiced implosive (“Oooh!” or with a vocalized sucking sound in the throat).
TO DO 13.1. ANALYZING BYSTANDER BEHAVIORS AT ACCIDENT SCENES
Look for newspaper photos of accident scenes, and study the expressions and physical posturing of bystanders. Often the shared pain experience injured victims of pedestrian or a motor vehicle accident is reflected on the faces of the bystanders.
The contagion of nausea and vomiting, although not well documented, is a phenomenon with which we may all identify. In interviews, nurses report struggling against the urge to “throw up” as they assist the vomiting patient. Other nurses refuse this task and leave the room, send in another nurse, or ignore the patient’s distress until the episode passes. Several movies have recently exploited this phenomena—most notably the story of Lard Butt and barf-o-rama in The Pie-Eating Contest (Evans, Scheinman, & Reiner, 1986) and Mr. Creosote and the French restaurant vomiting scene from Monty Python’s Meaning of Life (Goldstone & Jones, 1983).
Level 4. Suppression of the Response
In the fourth level, the response becomes disabling, intolerable and is suppressed. We are taught to treat other humans (and some animals) respectfully as living, feeling entities. When this principle must be violated, we must deliberately then relearn to detach ourselves from the reality and depersonalize the person to the status of an object. This is a learned process, one that allows us to inflict pain. By treating the person as an object, we convince ourselves that the person does not feel; and as an object without feeling, the compathetic response is inhibited or blocked. Alternatively, we justify our actions as essential for the other’s health and recovery, as being “for their own good” and “will be better (for the person) in the long run.”
Examples of this behavior are taught to us as adolescents when learning to dissect frogs in the biology lab (Shapiro, 1990). Similarly, surgeons must depersonalize patients—and make patients into cases, concealing their faces and all areas but the sterile, operative area with drapes, before being able to cut the skin. Even then the learning process is slow, and medical students fainting in their first exposure to surgery is classical.
Suppression of compathetic responses is also important for medical students learning in the anatomy lab. The stress responses that develop while learning dissection are well documented (Finkelstein & Mathers, 1990). Students report “strong negative arousal (that is, feelings of anxiety, disgust and dislike) with first incisions” and with dissection of the genitals, female breast, face, and hands (Gustavson, 1988, p. 62). Symptoms include a close identification with the cadaver and describing the cadaver “as an image of the self in a morbid condition” (p. 63). In extreme cases, students have recurring “death images” and become “preoccupied with their own health” with “persistent thoughts of their own death” and “the increasing fragility of their tissues as they age” (Finkelstein & Mathers, 1990, p. 223). Students must learn detachment and to distance themselves, or leave medicine.
Shielding or Blocking the Compathetic Response
When physicians order nurses to conduct particularly painful procedures, nurses often rationalize or justify these actions to themselves as “for the patient’s own good.” On occasion, such a rationalization can become so pervasive as to preclude seeing what is obvious. This narrow focus is a structural feature of medicine regarding attitudes toward patients. The social distance between physician and patient is culturally prescribed. Posture, formality of address, and strict norms regarding acceptable types of touch are professionally prescribed. In medicine, a person is first cognitively perceived as a patient, and then as a case. In the operating room, a person is further distanced by the covering of drapes, concealing all but the operative area. Medical dialogue focuses on disease rather than the afflicted person.
When the patient is first brought into the trauma room, prior to the administration of any analgesic, and in pain and distress, we noted that any observers postured, holding one arm around their chest and the other hand over their mouth, to contain their own distress, and in a posture that we now recognize as enduring, almost at transition (Morse, Beres, Spiers, Mayan, & Olson, 2003).
Suppression of the compathetic response is seen daily. Persons learn to block the response and “hold themselves together.” They put their arms around their chest and hold themselves, and place a hand over their mouths, as if to block the news. A recent example of this posturing is the file photos of the National Security staff observing the attack on Bin Laden (Sept 28, 2011). Secretary of State Hillary Clinton portrays a compathetic response while the others passively observe, perhaps blocking this response.2
The extreme of this level is the detachment manifest in psychotic behavior with murderers and rapists treating their victims as objects, rather than human. This phenomenon is also documented with advice given to protect victims as to make themselves human to their attackers, as this will reverse this process of depersonalization, and hence stop the attack.
Developing Types of Compathetic Response
From the previous discussion, we can schematically represent the types of compathetic response and their relationship to compathy, as we further delineate it from empathy (see Figure 13.2).
Formally Developing the Concept Structure
Once we are convinced that we have a new and unique concept, the next task is to develop its definition: its attributes, boundaries, antecedent, and consequences.
Defining Compathy
Our definition, derived from data, is as follows:
A compathetic response is the response/arousal that is evoked in an individual observing the suffering. The suffering and symptoms experienced by the observer mimic those experienced by the individual with the affliction. Although the distress is precipitated by the experiences of the other, it is something that is reflexively simultaneously occurring in the observer. Compathetic response may therefore be considered a psychogenic contagion. (Morse & Mitcham, 1997; Morse, Mitcham, & van der Steen, 1998)
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
