Abstract
Implications for Practice, Research, or Policy
Uncovering the meaning patients’ attribute to their lived experience beyond a diagnostic label has profound implications to redefine the holistic, caring art of nursing practice. Applying interpretive phenomenology to nursing practice can enable nurses to understand the essence that patients’ attribute to their lived experience. Contained within stigmatized diagnoses (e.g., liver cirrhosis) are opportunities to challenge nurses’ and patients’ preunderstandings, which can transform one's authentic, caring
Introduction
Through lived experience, one is continuously acquiring new understandings about the world in which one exists (Frechette et al., 2020). As a concept, lived experience is not only something that is experienced; it contains impressions with lasting importance that can expose the centrality of meaning (Frechette et al., 2020; Gadamer, 2004). This article will analyze how a nurse may care for a patient with the stigmatizing diagnosis of liver cirrhosis. Diagnostically, liver cirrhosis refers to progressive, irreversible liver disease that occurs as a result of hepatitis, alcohol misuse, autoimmune diseases, and/or many other factors, which can significantly hinder one's quality of life (Yoshiji et al., 2021; Zhang et al., 2019). Societal beliefs about liver cirrhosis are grounded in stigmatization about substance misuse (Vaughn-Sandler et al., 2014); these beliefs are known to impede nurses’ and other health-care providers’ ability to deliver authentic person-centered care (Schomerus et al., 2022). According to Vaughn-Sandler et al. (2014), alcoholism, defined as the inability to stop or control alcohol use despite its adverse social, occupational or health consequences (National Institute on Alcohol Abuse and Alcoholism, 2025), is one of the most stigmatized diagnoses, due to societal blaming of patients’ responsibility for their disease. From this perspective, it is imperative that health-care providers are aware of their preunderstandings in order to avoid negative patient interactions and promote high-quality, person-centered, and ethical care (Vaughn-Sandler et al., 2014).
Interpretive phenomenology proposes that everyday phenomena are obscured by multiple layers of forgetfulness, to which lies the possibility of recollection and self-discovery (Frechette et al., 2020; Heidegger, 1962). Applying interpretive phenomenology to nursing practice can cultivate an understanding of how nurses position themselves in relation to patients, which has profound implications for the delivery of care (Norlyk et al., 2023). Interpretive phenomenology invites nurses to understand the meaning patients’ attribute to their lived experience beyond a diagnostic label and how this exploration can transform nursing practice. By understanding how nurses can uncover the meaning patients’ attribute to their lived experience, it is argued that this can positively influence the delivery of authentic, person-centered care.
This article will: (1) explore the philosophical tenets of interpretive phenomenology, (2) present a case description of caring for a patient diagnosed with liver cirrhosis, (3) explore how interpretive phenomenology can enable nurses to understand lived experience beyond a diagnostic label, and (4) discuss the implications that understanding the meaning patients’ attribute to their lived experience has to inform nursing practice and research.
Phenomenological Understanding
Phenomenology is a philosophical perspective dedicated to the description of phenomena, which can facilitate an understanding of how things appear in the world in which they exist (Emiliussen et al., 2021). For the purpose of this article, interpretive phenomenology will be used to guide a philosophical analysis of how nurses can understand the meaning of patient experience beyond a diagnostic label in clinical practice.
Ontological and Epistemological Considerations
Critical to understanding any philosophical perspective are its ontological and epistemological underpinnings (Laverty, 2003; Neubauer et al., 2019; Rawnsley, 1998). Ontology refers to the nature and structure of being, emphasizing what exists according to distinct philosophical perspectives (Rawnsley, 1998). Epistemology considers the origin and production of knowledge in the context of the particular philosophical tradition (Rawnsley, 1998). Ontologically, interpretive phenomenology assumes that existence contains multiple realities and that lived experience is an interpretive process unique to every individual (Heidegger, 1962; Laverty, 2003; Neubauer et al., 2019). Epistemologically, interpretive phenomenology recognizes that the essence of any phenomenon is the result of a relationship between the knower (e.g., nurse) and the known (e.g., patient), which emphasizes the relational importance of this philosophy (Heidegger, 1962; Laverty, 2003; Neubauer et al., 2019). An interpretive phenomenological orientation can unearth both
Principles of Phenomenology: Husserl and Heidegger
Phenomenology is a philosophical perspective that aims to explore the essence of lived experience and is frequently utilized in nursing and other social science disciplines (Frechette et al., 2020; Norlyk et al., 2023). Phenomenology's founding father, Edmund Husserl, believed that in order to understand the meaning attributed to another's lifeworld, reality must be viewed as separate from the person (Husserl, 1980; Laverty, 2003). According to Laverty (2003), Husserl proposed that in order to capture the essence of lived experience, one must attempt to view things “as they are lived in everyday existence” (p. 22). The process of understanding human experience as it is lived can be achieved through bracketing—the conscious act of separating one's outer world from internal bias (e.g., preunderstandings) (Laverty, 2003). Martin Heidegger, a mentee of Husserl, argued that one's preunderstandings are an integral component of how we understand lived experience, and cannot be separated from our interpretive world (Heidegger, 1962; Laverty, 2003). As such, Heideggerian phenomenology proposes that one's own lived experience is an imperative aspect in understanding the lifeworld of others, emphasizing the interpretive nature of this philosophy (Heidegger, 1962; Laverty, 2003).
Critical to Heidegger's interpretive phenomenology is
Gadamerian Contributions to Interpretive Phenomenology: Hermeneutics
Hans-Georg Gadamer expanded on Heidegger's contributions to phenomenology by exploring the practical applications of hermeneutics (Gadamer, 2004; Laverty, 2003). Gadamer describes hermeneutics as an interpretive approach that moves from the individual parts of a phenomenon, to the whole, in a continuous, back and forth process (Gadamer, 2004; Laverty, 2003). In the hermeneutic process, language is the universal medium by which understanding is achieved, which illustrates a dialectical interaction between one's preunderstandings and what is learned through dialogue with others (Gadamer, 2004; Laverty, 2003). In Gadamer's pursuit of understanding the meaning attributed to lived experience, he describes a horizon as a range of vision that includes all phenomena from a particular standpoint (Corcoran & Cook, 2021; Laverty, 2003). In order to facilitate new understandings about the world, a fusion of one's old horizon (i.e., preunderstandings) must permeate one's new horizon (e.g., what is learned through dialogue), resulting in a new depth of
Case Presentation: Caring for a Patient With Liver Cirrhosis
The featured case throughout this article is based on the first author's (Doucette) experience of caring for a patient diagnosed with liver cirrhosis who was admitted preoperatively for a liver transplant. The patient was a 40-year-old male with a past medical history of hypertension, diabetes, obesity, alcoholism, post-traumatic stress, and depression. Additionally, the patient's social history included being unemployed, divorced, and having no family or peer support. Preunderstandings about patients diagnosed with liver cirrhosis are often grounded in perceptions about substance misuse that are profoundly influenced by societal stigmatization (e.g., having little social support, lack of willpower to change) (Vaughn-Sandler et al., 2014). These preunderstandings further obscure what is contained within lived experience and constricts what can be learned from and about patients in nursing practice.
During the patient's admission assessment and social history, he shared the unexpected loss of his daughter in a motor vehicle accident 10 years ago that preceded his alcohol misuse. Prior to the loss of his daughter, the patient reported drinking alcohol between three to five times per month, with no stated dependence. In fear of being labeled as an alcoholic due to societal stigmatization, the patient was afraid to seek treatment (e.g., counseling) for coping with this loss, resulting in approximately 10 years of progressive alcohol misuse. Despite alcoholism contributing to this patients’ liver cirrhosis, he ascribed significant meaning to the sudden loss of his daughter and identified this event as a catalyst for years of substance misuse. Despite the patient's fears related to liver transplantation, he perceived this surgery to have symbolic implications for coping with the loss of his daughter. He shared that receiving a functional liver motivates him to seek treatment to deal with his traumatic loss through evidence-based interventions (e.g., addictions therapy, grief counseling), without reverting to alcohol.
After months of caring for this patient, a number of situations made apparent how nurses’ preunderstandings about liver cirrhosis impede the delivery of authentic, patient-centered nursing care. Considering various statements made by nurses in clinical practice about the patient's eligibility for liver transplantation, such as “he just did not know how to cope” and “an alcoholic should not take this organ from someone more deserving,” affirmed the importance of understanding the meaning patients’ attribute to their diagnosis as a way of transforming the caring art of nursing practice. According to Smith and Cottler (2018), individuals with post-traumatic stress disorder use alcohol and experience alcoholism more frequently than those who do not, which may reflect the self-medication hypothesis. Understanding the relationship between trauma and alcohol misuse can provide insightful opportunities to understand the meaning patients’ attribute to their diagnosis of liver cirrhosis; however, this relationship should not be assumed without exploring their lifeworld. Uncovering the traumatic event that catalyzed the patient's alcohol misuse can challenge nurses’ preunderstandings that are grounded in negative views of alcoholism and ultimately, transform the delivery of holistic, person-centered nursing care (Heidegger, 1962; Laverty, 2003).
An Interpretive Phenomenological Analysis
The philosophical applications of Husserl's, Heidegger's, and Gadamer's interpretive phenomenology to this case unearthed various opportunities to inform the way that nurses may care for patients presenting with stigmatized diagnoses, such as liver cirrhosis. The analysis of this case will explore liver cirrhosis in the context of being a stigmatized diagnosis and how a fusion of horizons as well as a holistic approach to care can enable nurses to look beyond diagnostic labels to uncover the meaning patients’ attribute to their lived experience.
Liver Cirrhosis: A Stigmatizing Diagnosis
Stigma is a cross-cultural phenomenon and cognitive process that labels someone according to personal, social, or institutionally established norms that often, marginalize others (Castro & Farmer, 2005; Goffman, 1963). Stigma profoundly impacts the way patients are treated within health-care systems, particularly amongst those diagnosed with what are perceived to be behavior-induced clinical presentations (Schomerus et al., 2022; Vaughn-Sandler et al., 2014). Examples of such diagnoses include lung cancer (perceived as caused by smoking), obesity (perceived as caused by unhealthy diet), and liver cirrhosis (perceived as caused by alcohol misuse), each of which remain heavily stigmatized within health-care settings (Schomerus et al., 2022). Stigmatized diagnoses are often constructed by broader societal ideologies in which the distribution of resources is unequal, associated with negative patient experiences and hesitancy to access care (Grossman et al., 2021). Notably, patients presenting with liver cirrhosis already experience stigma in their everyday lives, further implicating the care they receive once admitted to hospital (Schomerus et al., 2022). In a study exploring perceived stigma among patients presenting with liver cirrhosis, 89% of participants reported being stigmatized in at least one aspect of their personal, social, or professional lives (Vaughn-Sandler et al., 2014). Considering the featured case, nurses’ preunderstandings are often informed by societal beliefs that do not reflect an authentic, patient-centered approach to care. For example, approaching care from a stigmatized perspective can profoundly obscure what nurses uncover about a patient's clinical presentation (e.g., emotional, spiritual, and/or social considerations), which can result in missed opportunities to provide holistic, patient-centered care. This phenomenological analysis made apparent how preunderstandings about liver cirrhosis can hinder nurses’ ability to understand a patients’ lifeworld. The opportunity for nurses to find meaning beyond patients’ diagnoses can profoundly influence their approach to care in future clinical situations (Van der Zalm & Bergum, 2000).
A Fusion of Horizons
By considering a Gadamerian fusion of horizons, nurses can uncover insightful opportunities to better understand themselves in relation to the patients they encounter in clinical practice (Gadamer, 2004). Nurses’ preunderstandings often mimic broader societal beliefs (i.e., behaviour-induced disease progression), without considering patients’ unique lived experiences (Van der Zalm & Bergum, 2000). Gadamer emphasizes that one's preunderstandings represent an old horizon, while the new contextual information learned throughout the hermeneutic process epitomizes a new horizon (Debesay et al., 2008; Gadamer, 2004). The intersection of these two distinct perspectives precipitates a new sense of understanding that can enhance nurses’ ability to authentically care for patients, irrespective of their clinical diagnosis (Debesay et al., 2008; Gadamer, 2004). For example, uncovering the deeply emotional and personal determinants of a patient's diagnosis of liver cirrhosis (e.g., use of alcohol as a coping strategy) can unearth new opportunities for nurses to transform their delivery of care. It is imperative that nurses recognize the incompleteness of their preunderstandings (e.g., internal bias) in order to broaden their horizons and optimize the delivery of holistic, person-centered care. By understanding patients lived experience in a non-reductionist manner, nurses are able to transform the quality of care provided and find greater meaning in their nursing practice (Van der Zalm & Bergum, 2000).
Holistic Nursing Care
Historically, nursing care is grounded in Westernized biomedical models that prioritize positivistic ideologies and shifts nurses’ focus away from patients’ lived experience (Norlyk et al., 2023). By engaging in the hermeneutic phenomenological process, lived experience can be brought to the forefront of nursing practice, re-emphasizing the importance of holistic, person-centered care (Norlyk et al., 2023). Holistic nursing care emphasizes the importance of not only acknowledging the physical ailments of the patient, but considering all intersections of health, including their emotional, spiritual, and social wellbeing (Hawthorne & Gordon, 2020).
As nurses, understanding that a patients’
Reflexivity: Authors’ Positionality
Although reflexivity has been defined variably, Olmos-Vega et al. (2023) define it as the continuous, collaborative, and multifaceted practices by which researchers self-consciously critique, appraise, and evaluate how their positionality influences the research process (p. 242). In accordance with interpretive phenomenology, one's preunderstandings are an inseparable component of lived experience (Heidegger, 1962; Laverty, 2003), which affirms our inability to neutralize all aspects of oneself (i.e., pre-existing theories, personal views, etc.) through bracketing (Olmos-Vega et al., 2023). Offering a discussion of the first author's (Doucette) reflexivity will provide insight into the subjectivities that shaped this philosophical discussion, which can significantly enhance the rigor and scientific merit of this article.
The first author came to this exploration because of his commitment to provide empathetic, person-centered care to all patients across the lifespan. With more than 3 years of practice experience as a Registered Nurse in the transplant setting, various situations affirmed his desire to explore gaps in the delivery of relational care to patients presenting with liver cirrhosis. Witnessing the ways nurses viewed patients diagnosed with liver cirrhosis who have a history of alcohol misuse compared to those without, revealed evident opportunities to explore how stigmatization can implicate the delivery of care. The case presented in this article offers insight into how nursing care provided to patients can be impacted by societal stigmatization and individual preunderstandings, particularly amongst patients with what are perceived to be behavior-induced diagnoses. Exploring this gap in nursing care and its relationship to the philosophical underpinnings of interpretive phenomenology motivated the exploration of this meaningful clinical practice experience. The underpinnings of interpretive phenomenology continue to guide his everyday nursing practice, centering around understanding patients’ lived experience, creating and maintaining authentic nurse–patient caring relationships, and reflexively understanding the influence of preunderstandings on the delivery of holistic, patient-centered care. His hermeneutic phenomenological positionality shaped this discussion and the importance of understanding lived experience as a way of enhancing his clinical practice, research, and mentorship to undergraduate and graduate nursing students.
Implications for Nursing Practice and Research
Unearthing the meaning patients’ attribute to their lived experience beyond a diagnostic label is a reflexive practice that begins with challenging nurses’ preunderstandings. When nurses’ understandings of their patients are restricted to diagnoses, multiple aspects of patients’ lifeworld are obscured, which has profound implications to nursing practice and research.
Implications for Nursing Practice
Interpretive phenomenology serves as a starting point for how nurses get to know their patients (Norlyk et al., 2023), which can positively inform the delivery of care. By recognizing their own preunderstandings, nurses can provide authentic person-centered care, which is critical to the development of meaningful therapeutic relationships (Van der Zalm & Bergum, 2000). Understanding lived experience beyond a diagnostic label can further promote positive patient outcomes by looking beyond prescribed clinical presentations to recognize the holistic importance of nursing care (Hawthorne & Gordon, 2020; Norlyk et al., 2023; Van der Zalm & Bergum, 2000). In a profession that is predominantly governed by evidence-based interventions, understanding the meaning that patients’ attribute to their lived experience can offer nurses a unique opportunity to re-prioritize caring in nursing practice, while reflexively furthering their understanding about themselves and the patients they encounter. Reflecting such a meaningful practice, nursing responses include various opportunities to enhance the way they engage with patients, which in turn, can result in a more thoughtful and patient-oriented way of
Implications for Research
Understanding the meaning patients’ attribute to their lived experience has widespread implications to inform nursing research, which is primarily governed by positivistic and reductionist perspectives that fail to acknowledge lived experience (Norlyk et al., 2023; Van der Zalm & Bergum, 2000). Amongst qualitative research methodologies, phenomenology is a frequently utilized philosophical perspective within nursing disciplines (Norlyk et al., 2023). Methodologically, phenomenology is both descriptive and interpretive, which can enable researchers to understand lived experience rather than provide causal explanation (Van der Zalm & Bergum, 2000). Notably, phenomenology is regarded for its ability to describe aspects of health and illness, which makes unearthing the meaning patients’ attribute to their lived experience a tangible objective (Norlyk et al., 2023). A phenomenological inquiry provides nurse scholars with the opportunity to find meaning in patients’ everyday situations throughout the research process, while yielding an empirical and practically relevant knowledge base to inform clinical practice (Van der Zalm & Bergum, 2000). As pressures within the nursing profession continue to favor standardized regimens, nurse scholars can resist such positivistic perspectives by adhering to phenomenological research designs that strive to theorize patients’ lifeworld (Norlyk et al., 2023; Van der Zalm & Bergum, 2000).
Conclusion
Unearthing the meaning patients’ attribute to their lived experience beyond a diagnostic label can significantly enhance nurses’ ability to provide authentic, holistic, patient-centered care. While considering the case presented about caring for a patient with liver cirrhosis, this article proposes that the philosophical applications of interpretive phenomenology can uniquely inform the way nurses understand patient experience beyond a diagnostic label. Interpretive phenomenology is a relational way of being that seeks to uncover the meaning patients’ attribute to everyday lived experience (Frechette et al., 2020; Heidegger, 1962). Emphasis must be placed on how nurses’ preunderstandings about patients can hinder the delivery of care, particularly among those presenting with heavily stigmatized diagnoses, such as liver cirrhosis. From this perspective, nurses can unearth the essence patients’ attribute to their lived experience as a way of establishing and maintaining authentic therapeutic relationships to re-prioritize the holistic and caring art of nursing practice (Van der Zalm & Bergum, 2000). By recognizing the philosophical importance of interpretive phenomenology, nurses can find meaning in their everyday clinical practice, which can motivate positive patient outcomes and a continuous evolution as a member of the nursing profession.
Footnotes
Acknowledgment
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