The poiesis of the question in philosophical hermeneutics: Questioning assessment practices for alcohol use disorders

Abstract

Philosophical hermeneutics is a way of thinking and a research method that is an in depth analysis of experience. It illuminates often-overlooked practices, generates understandings, and informs practice by raising new questions that analyse, modify, and extend extant knowledge. In this analysis, the experience of questioning is explored as it relates to philosophical hermeneutics and as it is uncovered in a study using philosophical hermeneutic research methods. The current study revealed questioning practices that are useful in the assessment and diagnosis of alcohol use problems. This paper explores the hermeneutic concept of “the question” by explicating the methodological steps of a philosophical hermeneutic study and, through the study example, shows how the hermeneutic questioning process informs and also results from a poiesis, or putting together, of the known and the unknown through hermeneutic inquiry.

• Philosophical hermeneutics
• interpretive phenomenology
• alcohol use disorders
• Heidegger
• Gadamer
• hermeneutic methods

Introduction

There are complex problems in healthcare and, specifically, in the area of substance abuse that require multiple avenues of inquiry and attention. It is clear by recent work in the field of addictions that assessment practices for alcohol and other substance use disorders are insufficient and that health care providers must improve in their assessment and intervention practices so that persons in need of intervention are identified (Haack & Adger, 2002; National Institute for Alcohol Abuse and Alcoholism, 2000; The National Center on Addiction and Substance Abuse at Columbia University, 2000; US Department of Health and Human Services, 2000). This has been a focus in recent years, resulting in the dissemination of various effective screening tools for use in primary care settings (Brown, Leonard, Saunders, & Papasouliotis, 2001; Fiellin, Reid, & O'Connor, 2000; Fornili & Haack, 2005). However, the use of these tools by primary care providers remains limited (Armstrong & Holmes, 2005) and practitioners identify challenges to incorporating screening protocols in practice (Lock, 2004; Vandermause, 2007; Vinson, Elder, Werner, Vorel, & Nutting, 2000). One way to examine this problem is to address the questioning process itself.

The questioning process is an interactive exchange but there are multiple ways to think about questioning. In the health care environment, there is a tendency to use structured approaches to gather data for assessment and diagnostic purposes. Consistency is valued in these approaches, which deduce information that leads to accurate diagnoses and evidence based interventions. However, in the everyday experiences of healthcare practitioners, questioning often becomes a dialogic interaction, where questions and responses are interpretable. The value of thinking anew about this questioning process was revealed using philosophical hermeneutics in a study that called into question the assessment practices of advanced practice nurses in primary care settings. In addressing the problem of missed diagnoses for alcohol use disorders (AUD), the study revealed questioning as an important dynamic practice leading to disclosure about alcohol use by women to their practitioners (Vandermause, 2007). It is not the purpose of this article to describe this study in detail. The reader is referred elsewhere for a thorough explication of the work (Vandermause, 2005). However, the possibilities for hermeneutic questioning by healthcare providers, uncovered by a research style using hermeneutic questioning and analysis, is a useful example of how interpretive thinking can shape healthcare practices today. This paper will address the questioning process as a phenomenon, by showing the influence of philosophical hermeneutics as research comportment and as practice, through a history and description of hermeneutic research and an exploration of alcohol use assessment in primary care as understood using hermeneutic inquiry.

Hermeneutics

The word “hermeneutics” is historically associated with the theory and practice of interpretation. During the Renaissance and Reformation eras, it was used in the discipline of theology to describe the scholarly interpretation of biblical texts. In traditional literary circles, the “hermeneutic code” is one method of text analysis that provides a linear structure toward closure so as to obtain meaning (Cohen & Shires, 1988). However, the term has evolved in nursing research to reflect a more ancient origin and use, derived from pre-Aristotlean Greek thought and a Continental philosophy of thought with historical roots in European phenomenological philosophy and American philosophy of pragmatism (Thompson, 1990).

The Greek verb hermeneuein (to interpret) and the noun hermeneia (interpretation) come from the name of the wing-footed messenger god, Hermes, described in Greek mythology. Hermes was responsible for translating, or laying-out the word of the gods (the unknown) in ways that humans could understand (Pascoe, 1996; Thompson, 1990). This derivation influences nursing research through the importance of the use of language as a tool to convey meaning.

Philosophical background

The philosophical writings of phenomenological philosophers are integral to the interpretive phenomenological method used in nursing research. Such writings inform all aspects of the method, from the research question through analysis and interpretation and dissemination. Notable phenomenological philosophers include Edmund Husserl (1859–1938), Martin Heidegger (1889–1976), Hans-Georg Gadamer (1900–2002), and Marcel Merleau-Ponty (1908–1961), twentieth century Continental philosophers who influenced modern thinking in a shift away from logical positivism and the Cartesian model of subject-object dualism, which underpins empirical scientific inquiry. This shift involves an attention to understanding phenomena as they show up in the world, as integral, temporal elements of a dynamic situation.

The German philosopher Edmund Husserl is often referred to as the “father of phenomenology” as his philosophical search involved a look at experience through consciousness, a logical interpretation of phenomena. His “transcendental” school of philosophy included an analysis of the subject and “object-as-the-object-appears-through-consciousness,” an emphasis on bracketing (epoche) so as to suspend conventional habitual understandings, and a focus on description (Thompson, 1990). Such foci result in distinct ways of conducting and interpreting research, although the phenomenological attention to experience in context is common to all philosophies in phenomenological thought. Husserl's contribution was considered a culmination of the Cartesian tradition, which is a base for modern empirical analytic science. Therefore, methodological forms derived from Husserlian philosophy are considered positivistic by some (Annells, 1996; Koch, 1995).

The thinking derived from the philosophy of Martin Heidegger, a student of Husserl, differs in significant ways. Heidegger redefined phenomenology, thereby influencing contemporary evolution of hermeneutics. This shift has been referred in the literature as the “Heideggerian turn,” a revision and extension of Husserlian thought (Thompson, 1990). The shift from transcendental phenomenology to philosophical hermeneutics in contemporary academe is a reflection of the “Heideggerian turn,” although there are Husserlian scholars who underscore more similarities than differences between Husserlian and Heideggerian thinking (Dahlberg, 2002).

Heidegger's student, Hans-Georg Gadamer, maintained strong Heideggerian influences in his work, adding to and complementing the work of Heidegger. Therefore, philosophical hermeneutics is typically associated with the work of Heidegger and Gadamer and represents a dramatic shift from other phenomenological forms, particularly in its rejection of categorization, thematization and theory generation. Rather, Heideggerian (philosophical) hermeneutics focuses on ontological questions of experiencing over epistemological questions of knowing (Diekelmann & Magnussen Ironside, 1998). The attention to consciousness is preempted by an awareness of language, temporality and historicity as the medium through which we come to be (Annells, 1996; Thompson, 1990).

Although the term hermeneutics is often used interchangeably with phenomenology, there are philosophical distinctions among phenomenological philosophers. The Encyclopedia of Nursing Research favors a Heideggerian/Gadamerian philosophical perspective (Diekelmann & Magnussen Ironside, 1998). Distinctions between Husserlian and Heideggerian/Gadamerian traditions are important with respect to methodological applications. Heidegger moves away from Husserl's conception of pure consciousness and his notion of “bracketing” the natural world, taking the view that phenomenology is a process of being whereby persons and the world are engaged in an indissoluble unity. Gadamer's extension of this idea is signified in his “fusion of horizons,” a metaphor describing the engagement between historical concepts and personal acquisition of the concepts, a horizon of interpretation (Annells, 1996; Pascoe, 1996). Heidegger's speculations were deep and intrinsic aspects of his major work, expressed through the creative and strange use of words and a return to ancient Greek word origins, a way of being that marks this idea of insolubility (Heidegger, 1962, 1999). It is through the process of reading these works, by experiencing and thinking along, that a Heideggerian awareness is engaged. Thus, the way that researchers approach, reflect upon, and interpret a project depends upon which tradition provides the guiding influence.

Philosophical hermeneutic research

In philosophical hermeneutics, the approach toward understanding human experience is focused upon what it means to be human and how the world is intelligible to us. A paradigmatic view is that no privileged point of objective knowing exists, but that all knowledge emanates from persons who are already in the world, seeking to understand other persons already in the world. Persons are essentially interpretive beings sharing everyday practical understandings by virtue of shared language, culture, and practices. All knowledge is temporal and contextual. Persons are viewed to be self-interpreting, relational, and meaning seeking (Heidegger, 1962; Leonard, 1994). In this way of thinking, truth is viewed as fluid. Awareness is derived from that which reveals itself through study and interpretation. Phenomena (from the Greek phainomenon, meaning what shows itself) are seen by paying attention and allowing a situation, as it presents itself, to be known or recognized.

A hallmark of philosophical hermeneutic research is the generation of new understandings through a rigorous process of thinking, one that is both focused upon particulars and that opens to broad, perhaps hidden, possibility. This way of thinking must permeate the entire research process and requires a departure from positivist thinking, though it may include aspects of such, in that positivist influences make up the pre-understandings that influence researchers and participants. Heidegger distinguishes calculative thinking and meditative thinking, asserting that facility with both leads to knowing awareness (Heidegger, 1966). His student, Gadamer, asserts that limitations in thinking occur when one does not see far enough or overvalues what is familiar (Spence, 2001). In order to access this thinking in a research project, it is necessary for a researcher to remain continually aware that there are known and unconscious sociolinguistic and historical influences that shape understanding, recognizing that one cannot separate from them, yet all the while staying open for that that is yet inconceivable.

In the study example here, the approach is ontological and the research steps are congruent with the thinking of Heidegger and Gadamer. Since the interest in a philosophical hermeneutic study is human experience or, more specifically, what it means to be in a particular experience, this method of inquiry is useful for understanding the ontological question: What does it mean to assess for alcohol dependency in women? In keeping with the hermeneutic process, the interest in the how rather than the why of this concern drove the study example discussed here.

The poiesis of the question

In philosophical hermeneutics, HOW questions are posed about the phenomena of interest will make a difference with regard to the understandings and new questions generated because of the research. In Gadamer's (2003)) discussion of the historicity of understanding and the hermeneutic priority of the question, he explores the nature of dialogue and the necessity of bringing into the open that which is already present. It is a way of being that anticipates without expectation; it exposes what is not known, thus creating the space for truth, or what is, to manifest. Gadamer's discussion includes prejudice, or thinking humans bring to any situation, as a part of the understanding process.

It is impossible to make ourselves aware of a prejudice while it is constantly operating unnoticed, but only when it is, so to speak, provoked … For what leads to understanding must be something that has already asserted itself in its own separate validity. Understanding begins when something addresses us. This is the first condition of hermeneutics. We now know what this requires, namely the fundamental suspension of our own prejudices. But all suspension of judgments and hence, a fortiori, of prejudices, has the logical structure of the question. The essence of the question is to open up possibilities and keep them open. If a prejudice becomes questionable in view of what another person or a text says to us, this does not mean that it is simply set aside and the text or the other person accepted as valid in its place. Rather, historical objectivism shows its naiveté in accepting this disregarding of ourselves as what actually happens. In fact our own prejudice is properly brought into play by being put at risk. Only by being given full play is it able to experience the other's claim to truth and make it possible for him to have full play himself. (Gadamer, 2003, p. 299.)

Gadamer is not saying here that persons can come to a situation free of personal views. Rather, he is speaking about a manner of readiness whereby understanding can occur. That readiness to the question (of what comes next) is a different kind of question than the semantic question and answer, which often dominates the familiar solution-focused healthcare environment. Readiness to the question is an openness that allows dialogue, authentic exchange. When applied to research, such an approach will allow unanticipated understandings to show themselves.

It is the task of hermeneutic research to translate our understandings of experience into language that, in turn, can build and create a practice. This is the poiesis or putting together, creating the explication and presenting understanding that the hermeneutic process offers. It is in this poiesis that common practices and shared meanings are identified, experience is interpreted, and questions are generated. If it is possible to bring into the open what is already present, to anticipate without expectation, and to expose what is not consciously known, we create space in a hermeneutic awareness, for “what is” to manifest. In this process, data can be perceived in new and untraditional ways.

The questions of research

Let us look at the pragmatics of the practice of research. Traditional research in the field of nursing has been dominated by positivist and post-positivist methods of scientific inquiry (Willis 2007), which require specific and categorical steps in the research process. Alternatively, the Heideggerrian/Gadamerian perspective rejects Cartesian dualism and its categorical offshoots. However, in the realm of science, where clarity and systematic scholarly inquiry are required for audience, fashioning the steps of hermeneutic inquiry requires a sensitive “ordering” that both resembles yet departs from positive/postpositive perspectives. Using a research “method” can be viewed as antithetical to the hermeneutic process. Perhaps research comportment would be a better description. Thinking about “method” in this way, the researcher stands as instrument, translator, and questioner. Gadamer's description of understanding as a “fusion of horizons” provides a language for this idea (2003; 1976). The “fusion” of past to present, known to unknown, is a way to recognize the enormity of the influence of history, conventional thinking, common language, and situatedness on the perception and experience of the immeasurable and possible, that which is not yet recorded or documented. The dynamic interplay between “horizons” creates an opening, a vacuum for new thinking. The many questions of research, the research question, the interview question, the questions raised in analysis, are all places where new inquiries and, thus, possibilities for novel actions, emerge. The question becomes, in the manner of research that is philosophical hermeneutics, how do we conduct research in a way that holds open readiness to perceive the findings that are embedded in the research? In the research study about women and AUD, the focus on missed assessments prompted a myriad of questions. To name some: Why are we missing diagnoses? What are the barriers to assessment? What enhances our abilities to assess? Who is missing diagnoses? What does it mean to miss diagnoses? What does it mean to assess? However, a more interesting question may be, “how do we approach this problem with an open stance, asking the questions that lead to a hermeneutic awareness?”

In the example study, the research question “What are common practices in the primary care setting regarding the identification of alcohol dependency in women?” was chosen as a suitable representation of the phenomenon to be studied. This research question was asked from a hermeneutic perspective; that is, while common research “conventions” would be engaged, there was also an openness or readiness to hear something about the whole experience of the phenomenon of assessment. Therefore, the questions asked of the participants throughout the interviews and the questions asked of the text throughout the analysis became part of a process of inquiry leading to new understandings about the experience of AUD assessment.

Fashioning the questions of research

To study common practices, an opening interview question, “As a nurse practitioner, can you tell me what it's like to assess for or identify a woman with alcohol dependency? Can you think of a situation or a patient that comes to mind?” was posed in this example study. As an opener this question was meant to elicit a narrative account of an experience that, when told in its context, would represent the experience of assessment. Thus, meaning is conveyed through the narrative account.

The value of a philosophical hermeneutic study lies in the researcher's ability to relax (not eliminate) pre-understandings and conjecture about outcomes. The initial interview question is a starting point from which the interview conversation develops. There must be a willingness to hear all perspectives and to engage subsequent conversation as it shows itself so that fidelity to the philosophical assumptions is maintained. Thompson (1990) explores the part that “genuine” questions play in hermeneutic inquiry, those questions for which there are multiple answers and directions, those that do not answer themselves, referring to a surrendering on the part of the researcher. She links this surrendering (to a dialogue, inquiry, or study outcome) to Gadamer's work. It is found throughout the works of Heidegger as well and is particularly well relayed in his essay, On the Way to Language (Heidegger, 1971). It is the foundation for the entire hermeneutic inquiry. As Thompson reminds:

Gadamer asserts that, in dialog (and analogously in hermeneutic experiences), understanding occurs when we surrender to the movement of question and answer. It is important to note the reciprocity involved in this account. It is not just that scholars ask a question of a text or of a participant. It is that scholars open themselves to the question that the material or the participants ask of them. (Thompson, 1990, p. 249.)

In a hermeneutic study, it is not only the research question, but all interview questions that follow, that must remain open and reflexive.

Thus, as the conversation unfolds, the researcher, who will act as facilitator and translator, goes along with the meaning embedded in the participant narratives and does not impinge or impose. By assimilating this philosophical stance, the researcher becomes the instrument through which the phenomenon manifests.

Questions as findings

As the hermeneutic process unfolds, analysis continues by holding open to possibility the idea of the hermeneutic question. The practice of questioning continues throughout the analysis and into the findings so that the findings themselves are questions generated by hermeneutic thinking. In this way, the interpretive process calls us to stay observant and to pay attention to the phenomena as they show themselves. It is from this open stance that new ideas arise from the data and the interpreter refashions the inquiry. The results are a coalescence of the phenomena that manifest, the participants’ and researcher's influences, and the background information that grounds the study. By fashioning the questions that bring us to awareness, we are putting together the inquiry we ultimately strive to understand. This is the interpretive element, the poiesis of the questioning process.

In the study example, the findings were expressed as patterns and as associated themes that reflected overlapping ideas recurrent in the texts of interviews. Subsumed in a pattern manifested by all the participants, Recognizing alcohol in everyday life, were ideas we called Hesitancy to diagnose, Is alcohol a problem?, and Alcohol and me. Subsumed in the pattern Attending to HER story, were ideas we called Daily life and life events, The right questions at the right time, and Alcohol and her (Vandermause, 2007). The naming of these common patterns and themes allowed conversation about the phenomena. The themes were not to be viewed as mutually exclusive or concrete in any way. Two of the themes, those that relate easily to the conversation about the poiesis of the question, are explored here because they involve the process of questioning literally, highlighting differences between literal and hermeneutic questioning, and allow for an exploration of the process: Recognizing alcohol in everyday life: Is alcohol a problem? and Attending to HER story: The right questions at the right time.

Recognizing alcohol in everyday life: Is alcohol a problem?

An understanding of AUD assessment emerged in this study through an attention to the questions typically posed by practitioners, those that relate to diagnosing AUD. When practitioners were asked about their experiences assessing for AUD, they did not discuss traditional methods of screening, which include rote question and answer formats. That is, they did not talk about asking patients directly about alcohol use nor did they talk about using typical screening tools, such as the CAGE questionnaire, simple use/frequency questions, or other prescribed questions. Rather, when they suspected alcohol problems, they were more concerned about how they could ask questions of women whom they suspected could not or would not readily disclose their alcohol use habits. Their own questioning habits were revealed by using a particular style of research interview, one that allowed the participants to relay their experiences freely. This is a way that meaning can emerge in the phenomenological sense, a way for the experience itself to manifest and present for interpretation. Thus, it became clear, through participants’ stories of assessment, that the question “Is alcohol a problem?” was always in the background of their experience, always posing as a question, eliciting a spoken or unspoken question on the part of the practitioner. For example, one nurse admits,

So for two-to-three years, I saw her THAT often and NEVER suspected that there was an alcohol problem, except once in a while I would SWEAR that I could smell alcohol. And that was all, just that little smell of alcohol … . So then, once or twice I think I said to her: ‘You know, I think I smell alcohol. Do you?’ Well, dumb as a doorknob I was. Finally I found out that she WAS an alcoholic (Marilyn, 22–32).

By allowing this practitioner's story to unfold and by looking more closely at her process, we can glimpse the background questioning that is taking place just below the surface of her awareness. She smells alcohol, a trigger, one would think, for an observant practitioner, yet she does not ask a direct question of her patient about alcohol use. Rather, she asks a covert and indirect question, “I think I smell alcohol. Do you?” When the patient denies smelling alcohol, the genuine question is dropped. In this and other interviews in this study, the lingering question, “Is alcohol a problem?” became a theme as the texts were analysed. This question, the one central to diagnosis, is not asked outright. Other questions pose as decoys (“I think I smell alcohol. Do you?”) and shut down the essential (Gadamerian) question, “Is alcohol a problem?”

This deconstruction of the questioning process, revealed via hermeneutical analysis and elicited via hermeneutic questioning, is important because we are then able to see, in other interviews and situations, ways in which the questioning process can be a barrier to proper assessment.

Upon further analysis of the texts, we learn that practitioners ask many questions that act as decoys, both of their patients and of themselves or their colleagues. These ancillary (decoy) questions are reasonable but they are not essential with respect to rendering a diagnosis. For example, a typical question posed by a practitioner might go like this:

If people are functioning, I mean if they're able to work and they're taking care of their families and children and jobs, no gross negligence, is it a problem because I say it is and she doesn't think it is? (Cindy, 200–206)

This conundrum affects practitioners who wish to respect their patients. It is common for practitioners to leave these dilemmas alone, for many acceptable reasons (Vandermause, 2007). Nevertheless, the lingering question, the essential hermeneutic question “Is alcohol a problem?” remains unanswered. The question in the data becomes a theme that recurred across interviews as practitioners gave their storied examples. Thus, the texts address us, as hermeneutic researchers, to respond in the fashion that Gadamer describes (noted previously) when he talks about the essence of the question. By allowing our prejudices (or the way we typically think about proper diagnosis and assessment) to come into play, that is, to acknowledge our background thinking, and by remaining open to the phenomena (the silent question “Is alcohol a problem?”), we are required to ask a new question if we are to make sense of our findings: What gets in the way of our calling alcohol a problem? To answer this new question we return to our original, pragmatic question about missing diagnoses. By circling the data in this way, we begin to get a glimpse of what is happening in the everyday practice situation and, because we continually re-address or question the data in this way, we become open to new possibilities, revealed through the stories of study participants.

Attending to HER story: The right questions at the right time

The answer to these circling questions emerges from the data itself. For instance, we know that it is a common response for many practitioners to avoid, for various reasons, a direct question regarding suspected alcohol problems. The data in this study revealed that this common practice could be a barrier, but, by a slight shift in approach, some practitioners displayed the dynamic interplay of question and answer that characterizes hermeneutics. In the second pattern that emerged, Attending to HER story, it became evident that attending to patients’ unique life concerns was particularly successful in guiding women to become aware of the effects of drinking on their lives. These practices arose from a question embedded in the research: How is it that diagnoses are missed? This question, ever present in the background throughout the data gathering and analytic process, allowed us, as researchers, to be more conscious of the issue, evoking a “prejudice” in the sense that the unspoken question “Is alcohol a problem?” has no immediate response. It calls into awareness, in the Gadamerian sense, the intersection between what is already known (in this case, that there is a question in need of a particular answer) and the unknown (the response itself). By calling this prejudice into play, a new possibility opens up. We were able to see the participants’ focus on an underlying experience that they could describe. They were able to talk about how they responded or could have responded to the question of whether or not alcohol is a problem. They illuminated the theme, “The right questions at the right time”.

What we find in the practices of these primary care providers, whether these practices are consciously understood or not, is that there is a particular kind of questioning that is nuanced (this may be consciously thought about or habitual, natural, automatic), and this particular style can affect whether or not a woman will disclose her alcohol use habits. In this study example, it was found, by looking closely at experience, that the essential question could be asked and it could be answered in particular ways.

Thus, the second pattern in this study, Attending to HER story, contained a theme that illustrates what it is like to find the essential question. In a number of interviews, practitioners described a manner of questioning that addressed the ambiguous, uncomfortable, and controversial issue of diagnosing AUD. For example, Rose says:

I will just say: ‘Sometimes people will ask me how much is too much,’ or ‘Sometimes people that do enjoy a cocktail with their dinner, or wine or beer, will ask me what a safe drinking pattern is? Do you ever wonder about that?’ (Rose, 217–226)

Rose goes on to talk about how she is then able to talk frankly with her patient about her health habits and decide upon ways to address the problem.

In analyzing the texts, we learned that women make statements in the course of their conversations that may be tiny openings for dialogue. Practitioners told many stories of how they skillfully and sensitively had turned a conversational question into a therapeutic agreement. Nurses have discovered that they can use personal information about a patient's life and health, present that back to the patient, and accompany them through a process of discovery. They recognize (or suspect) the effect of alcohol, hesitate over the course of the interaction, ask the right questions at the right time, and guide a patient to her own awareness (Vandermause, 2007). We come back to the practical, semantic representation, the question a nurse will voice to a patient in practice, the question that leads to diagnosis and, perhaps, intervention. This question, the right question at the right time, is an interactive exchange that is contextual and temporal. It is not part of a checklist in a history or a routine screening question. In this way, a hermeneutic analysis calls into question our current understandings about diagnoses and points to possibilities that shift and modify established habits of assessment.

Applying hermeneutics to practice

As a result of this study, the semantic or literal questions and answers that transpire between primary care practitioners and their patients may be thought about in new ways. Thus, the purpose of hermeneutics, to reveal and translate new understandings of previously unseen practices, leads us to incorporate practices that enrich current protocols.

In the field of addictions, screening tools for use by practitioners are advocated and have been shown to be effective in many situations. Asked in the right way at the right time, they will be useful. However, as we learn to incorporate the use of these tools, the hermeneutic question must also be asked if we are to get to the heart of the problem of missed diagnoses of AUD. This means engaging a patient in discreet and subtle ways.

By paying attention to the often-overlooked experiences of practicing nurses, there was seen a turning point when practitioners perceived an opening to broach the alcohol issue and patients could comfortably disclose. Many stories in this study revealed unique ways practitioners addressed alcohol use. These findings were learned through a hermeneutic research questioning that led us from and to the practical questions and opened up possibilities for intervention not described in extant literature.

The hermeneutic contribution

As we think deeply about these issues and remain open to the hermeneutic question, we are drawn back to the idea of question and answer that so permeates the typical history taking and assessment process. We are called to think about the covered over questions that are not part of the typical screening process, those that, if asked, compel new and innovative responses. We begin to fashion the “new question” that the phenomenon calls us to answer. For example, in the study example, the identified themes helped us to fashion new questions. As we looked at the theme, “Daily life and life events,” we asked, “How is alcohol embedded in women's lives?” The assessment took on a new dynamic when this was the central, albeit unspoken, question practitioners considered. When thinking about the theme, “The right questions at the right time”, the natural response, “How do my questions help her awareness?” emerged. When thinking about the theme, “Alcohol and her” it was natural to ask, “What is HER story? How is alcohol part of her life?” It is in these obvious but often overlooked questions and responses that the hermeneutic question shows itself and the intervention is revealed.

In the hermeneutic sense, there is always a new question. This is the aim of such a study, to ask the new question. As data is explored through the hermeneutic lens, through a “fusion of horizons” that allows for that which is questioned to make itself visible in the face of conscious and unconscious historical influences, findings stimulate new thinking that relate directly to practice and research both. The question in AUD assessment thus becomes: How does a practitioner listen and attend so that a patient will respond to a diagnosis and offer of help? The typical solution is replaced with a question and suggestion for a pathway or process of intervention.

Other contextual and overarching questions are also raised and these are the seeds for engaging a deeper professional awareness that fosters the thinking process. For example, the question in educating primary nurse practitioners becomes: How does an educator stay open to the learning need and respond in such a way that students can prepare for the complexities of practice, the ways to recognize and attend, and hear their own call to listen and respond? The sociopolitical question becomes: How do practitioners and educators behave in a way that shifts inattention over alcohol use to awareness of the ways alcohol dependency affects individual and community health? These contextual and overarching questions represent thinking processes that stimulate response. In this way, the hermeneutic contribution, proffered through hermeneutic research comportment, affects practice immediately.

The hermeneutic inquiry

The assessment protocols and screening tools available to health care practice must be used well and consciously. The hermeneutic inquiry, a manner of reflection and response, must be considered as well to balance healthcare practice. It is the hermeneutic inquiry that will allow for a responsive assessment that opens up possibility, especially in challenging situations like AUD.

As we use these methods to address the pragmatic and complex healthcare issues of our day, we must continually remind ourselves to ask the new question. By focusing our awareness on what presents or shows up in our practice environment, by allowing that which shows itself to insinuate itself in our thinking, we can begin to refashion the recurring questions about health and well-being. In the case of AUD, we are ready to use current protocols while adding new ways to respond to the old recalcitrant problem; in the case of other healthcare issues we do the same, circling practice and research experiences to respond anew.

Acknowledgements

The author gratefully acknowledges the tutelage of Nancy Diekelmann, and the interpretive analytical contributions to the study by Nadine Nehls, Elizabeth Rice, and Jolanda Sallmann. Funding for the original study, which was published by the Journal of Addictions Nursing, was granted by the International Nurses Society on Addictions. This paper on the study methodology was presented at the Qualitative Health Research 12th International Interdisciplinary Conference, Edmonton, Alberta, Canada, April 2006. Further acknowledgements are owed the reviewers for the International Journal of Qualitative Studies on Health and Well-being, who offered stimulating commentary to improve the article.