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Epistemological Oppression and the Road to Awakening

Increasingly, it is becoming evident that qualitative research methodologies have much to contribute to producing health knowledge. Notwithstanding such advances, some would say the “paradigm war” continues, privileging postpositivist epistemologies. Our own experiences working within a post-positivist-dominated health research arena inspired the implementation of an “Epistemological Boot Camp” qualitative research training series. The central goal of the boot camp was to query the hypothesis that we are still in a paradigmatic “war zone” while imagining productive ways to both survive and thrive in the current climate. Moving forward, our hope is that our boot camp methodology can inspire other scholars to develop creative local initiatives that provide a platform to work toward recognizing the unique contributions of qualitative health research.


Introduction
Qualitative health research is being studied and practiced across a variety of disciplines and is contributing to the way health care is understood, experienced, and delivered (Eakin, 2015;Morse, 2012). Notwithstanding such advances, qualitative health researchers continue to experience the consequences of a health research arena that privileges postpositivist 1 ways of knowing (Eakin, 2015). The pitting of postpositivist health research (that typically but not exclusively employs quantitative methods) against nonpositivist health research (that relies chiefly on qualitative methods; Guba & Lincoln, 1994;Morse, 2006Morse, , 2012 has led to what some authors have summed up as a "paradigm war" 2 (Gage, 1989).
In this "war zone," nonpositivist qualitative health research emerging from paradigms including critical, constructivist, and participatory perspectives (Lincoln & Guba, 2000) is experiencing a form of "epistemological oppression" (Nagel, Burns, Tilley, & Aubin, 2015, p. 370), which refers broadly to the systematic devaluing of qualitative ways of knowing. Furthermore, qualitative health researchers are facing unique challenges and uncertainties as they struggle to remain committed to qualitative traditions in research arenas where generalizability, objectivity, and the randomized control trial are viewed as "gold" standards (Christ, 2014;Eakin, 2015;Nagel et al., 2015).
Although some scholars have argued that the paradigm war metaphor is overdrawn (Bryman, 2008;Guba & Lincoln, 1994), in agreement with Given (2017), our experiences suggest it is "alive and well" (p. 1). We are members of a group of qualitative health researchers who came together to strategize around our own experiences of epistemological oppression in relation to working in a climate that privileges postpositivist epistemologies. Guided by the rhetorical question, "Is the paradigm war still going on?" we used the platform of the McGill Qualitative Health Research Group (MQHRG; https:// www.mcgill.ca/mqhrg/) to design and deliver an "Epistemological Boot Camp" for the qualitative health research community in Montreal, Canada.
Following is a brief discussion of epistemological oppression and an analysis of how it has manifested in health research. We then describe our boot camp methodology, which we hope inspires other communities to develop creative local initiatives that help ensure qualitative health researchers not only survive but thrive in the academy and beyond.
In facing what can feel like almost daily encounters with the epistemological unconscious in academic settings, qualitative researchers have not remained silent. Some have shared strategies on how to best work within the confines of postpositivist dominance, offering practical tips such as how to downplay the subjective, and critical aspects of research traditions to appear more objective and thus credible to postpositivist reviewers (Graham et al., 2011); how to maneuver "ethics creep" (Haggerty, 2004) by adapting the language in research ethics proposals to be more in line with postpositivist assumptions (e.g., indicating the sample size a priori; Janjua et al., 2016;Nagel et al., 2015;Staller, 2012); and providing tips on how to get published in high-ranking peer-reviewed health journals (Clark & Thompson, 2016). Some have gone so far as to declare a "call to arms" (Denzin, 2010), while others have rallied together, writing manifestos directing collective concern at funding bodies and scientific journals (e.g., Graham et al., 2011;Greenhalgh et al., 2016).
Recently, an unprecedented example of collective mobilization and resistance to epistemological oppression occurred on the social media platform Twitter. A flurry of activity erupted in response to a rejection letter issued to a qualitative health researcher by the, formerly, British Medical Journal (BMJ), a high-impact peer-reviewed publication. The rejection letter, shared over 30,000 times on Twitter, reads: Thank you for sending us your paper. We read it with interest but I am sorry to say that qualitative studies are an extremely low priority for the BMJ. Our research shows that they are not as widely accessed, downloaded or cited as other research. We receive over 8000 submissions a year and accept less than 4%. We do therefore have to make hard decisions on just how interesting an article will be to our general clinical readers, how much it adds, and how much practical value it will be. (BMJ Editors, 2016) In response to the BMJ's rejection letter, the global qualitative health research community rapidly took to action. Under the hashtag #BMJnoQual (Bekker, 2015;Clark & Thompson, 2016), a subsequent letter to the BMJ editor signed by over 75 researchers went viral (Greenhalgh et al., 2016). This global virtual mobilization effort eventually led to the BMJ formally calling for more qualitative research and increasing their expertise in reviews boards: Over the next few months we will be consulting with qualitative researchers to learn more about how we can recognise the very best qualitative work, especially that which is likely to be relevant to our international readers and help doctors make better decisions. In addition, we will shortly issue a formal call for research methods and reporting articles about qualitative research. We hope that proposals for these articles will come from some of the authors of the Greenhalgh et al. letter. (Loder, 2016) The BMJ controversy provided a clear and concrete example of how epistemological oppression was affecting qualitative research in the peer-reviewed publishing world. The three of us had experienced epistemological oppression in overt ways (e.g., similar to the BMJ example), as well as more covert, "unconscious" ways. Further, we realized that we lacked a space to discuss, work through, and respond to experiences related to its impact in a local context. As one response, we conceptualized and implemented an innovative "Epistemological Boot Camp" qualitative research training series.

Epistemological Boot Camp Methodology: From Paradigms to Knowledge Translation (KT)
The authors of this article came together first through MQHRG. Founded in 2003, MQHRG is an interdisciplinary group of researchers, aiming to provide advanced, yet informal learning environment for qualitative health researchers at McGill University as well as the broader community in Montreal, Quebec. Members range from junior trainees (master and doctoral students) to senior researchers, including practitioners from various health fields with diverse paradigmatic commitments to research and training. Approximately 15-25 members meet several times per semester to discuss issues related to qualitative health research (e.g., the peer review process), as well as to provide a constructive safe space for trainees to present works in progress, and explore methodological questions. Our LISTSERV has increasing reach, with over 250 members from North and South America and Europe.
Our goal for the boot camp was two-fold: (1) to explore the question is a "paradigm war" still going on? and (2) to collectively share, grapple with, strategize around, and awaken participants to epistemological tensions commonly faced by qualitative health researchers within post-positivistdominated research domains.
To address these goals, we conceptualized our boot camp into four thematic "drills." The content for each drill stemmed from our real-life experiences of "bumping up against the epistemological unconscious" (Staller, 2012, p. 3) in relation to the following themes: (1) the nature of the qualitative paradigms, (2) rigor, (3) sample size, and (4) knowledge translation (KT).
The first author coordinated and facilitated each drill, beginning with an introductory 30-to 45-min analytic overview of the assigned and recommended readings. For three of the drills, we invited guest speakers to share their experience on the topic at hand. Following the introductory presentations, we allowed time for interactive group discussion during which participants had the opportunity to share their reflections and questions related to the preassigned readings and guiding questions. Facilitation and participation in the boot camp was voluntary, and we provided no formal credits. Although our title makes specific reference to epistemology, we also focused on the paradigmatic tensions present at all levels of qualitative research including ontology, epistemology, methodology, and methods.
The first drill, titled Surveying the paradigmatic battlefield: Articulating and nourishing your paradigm, had three overarching aims: (1) to highlight the importance of ensuring that each element of research design fits within its overarching paradigm, (2) to demonstrate how this "fit" is a sound determinant of the overall study quality and rigor, and (3) to provide examples of real-life consequences when paradigmatic worldviews clash, such as when nonpositivist research is evaluated from a postpositivist standpoint. Lincoln and Guba's (2000) widely cited "Paradigmatic Controversies, Contradictions, and Emerging Confluences" was assigned to provide an overview of four main paradigms commonly referenced in qualitative health research (positivism/ postpositivism, critical realism, constructivism, and participatory research). For some novice participants, this article was their first introduction to research paradigms. Thus, while we highlighted the pioneering nature of the article, we discussed how the field has evolved in the 20 years since, and foregrounded critiques of what some suggest is an oversimplification of the complexity of the research landscape.
This session reinforced the importance of a study having a well thought out "vertical hierarchy" (Staller, 2012), meaning that all aspects of a research design vertically fit together, starting from the most abstract (ontology and epistemology) to the more concrete (methodology and methods). Nagel et al. (2015) brought the discussion of paradigms to a concrete level by providing practical strategies to navigate common epistemological tensions that occur when conducting constructivist grounded theory studies in postpositivist institutional contexts. Nagel (doctoral candidate in nursing) cofacilitated the discussion via Skype.
The second drill, Is your research "rigorous"? Interpreting and articulating rigor within your paradigm, built on the first drill by exploring some of the contentions and debates concerning the "beguiling problem of rigor" (Sandelowski, 1993, p. 2). Participants were asked to come prepared to discuss how and why they have previously understood, used, and articulated rigor in their research and how it had changed (or not) after reading the three assigned articles. Sandelowski's (1993) "Rigor or Rigor Mortis" was helpful to enter the rigor debate, interrogating the concept of rigor and contending that qualitative researchers need to move away from the rigidity of an orthodox checklist approach that makes fetish of technique "at the expense of perfecting a craft and of making rigor an unyielding end in itself" (p. 1). She goes on to write: It is as if, in our quasi-militaristic zeal to neutralize bias and to defend our projects against threats to validity, we were more preoccupied with building fortifications against attack than with creating evocative, true-to-life, and meaningful portraits, stories, and landscapes of human experience that constitute the best test of rigor in qualitative work. (p. 1) Davies and Dodd's (2002) "Qualitative Research and the Question of Rigor" complemented the discussion by offering a doctoral student perspective that argued for critical awareness of the postpositivist bias in the concept of rigor. The two authors suggest that rather than viewing rigor as an afterthought, it should be integrated into one's ethical stance, by continually approaching each research encounter with attentiveness, empathy, carefulness, sensitivity, respect, and reflection.
Similarly, Eakin and Mykhalovsky's (2003) "Reframing the Evaluation of Qualitative Health Research: Reflections on a Review of Appraisal Guidelines in the Health Sciences" provided a novel reframing of rigor, making a convincing case to shift away from postpositivist language and checklist approaches to what they call a "substantive approach." Such an approach involves transparent explanations regarding planning, implementation, and dissemination of the study (e.g., how and why the research question changed over the course of the research, sampling rationale, and linking findings to existing theory).
In contrast, Morse (2015) offered an important counterargument by suggesting that appropriating a parallel language of rigor, such as "trustworthiness" (Lincoln & Guba, 1985) paradoxically acts to further marginalize qualitative health research. Morse suggests a more promising strategy to gain legitimacy vis-à-vis mainstream science would be for qualitative health researchers to adapt postpositivist terminology of reliability, validity, and generalizability.
The third drill, titled Sample size, saturation, and participant selection: Locating your justifications within your paradigm, addressed a common question of novice qualitative researchers: How big does my sample size have to be? Two McGill alumni (from nursing and social work) cofacilitated the discussion, sharing their experiences with determining sample size in their respective ethnographic and phenomenological doctoral research projects. We began the drill by discussing Mason's (2010) empirical study that brought attention to the arbitrary nature of sample size (Christ's 2014) "gold" standards in qualitative research as found in a number of handbooks (e.g., Creswell & Poth, 2017). Sandelowski's (1995) insights added further depth to the discussion by suggesting that sample size is not simply the number of participants but can include "numbers of interviews, and observations conducted or number of events sampled" (p. 180). Finally, Baker and Edwards (2012) provided a helpful compilation of 14 senior scholars' responses to the question: How many qualitative interviews is enough? Among the varying expert accounts, Charmaz, a constructivist grounded theorist, suggested that the number of interviews is best determined by assessing excellence in one's own field. In contrast, Becker, a phenomenologist, argued that the decision to continue interviewing should be based on whether the researcher feels the evidence is strong enough to convince the most "ardent critics" (p. 6) and that an "n" of one is sometimes sufficient. Given the heterogeneity of disciplines, paradigmatic orientations, and research designs among MQHRG members, this article provoked a particularly fruitful discussion.
The fourth and final drill, titled Ending the mission: Knowledge mobilization and making use of qualitative research, used four diverse readings on the topic of KT to inspire reflection and discussion. I. D. Graham and colleagues' (2006), "Lost in Knowledge Translation: Time for a Map?," provided a number of useful definitions and helped unpack the complex web of KT terminology and related theoretical models. Botorff's (2015) editorial, "Knowledge Translation: Where Are the Qualitative Health Researchers?," further illuminated the complexity and some of the unique KT challenges in health-related fields (i.e., long delays between end of study and findings being taken up in health policy and practice). Greenhalgh and Wieringa (2011) interrogated the concept of KT from a more critical perspective, suggesting that assumptions about KT are often too narrow and overlook important clinical components.
Finally, Kontos andPoland (2009) extended Greenhalgh andWieringa's (2011) critique by presenting a creative artsbased KT model: critical realism and the arts research utilization model. The two authors contend that arts-based KT is a particularly promising approach because the "arts nurture empathy" (p. 1) and also make research findings more accessible to a wider audience. This final drill concluded with a presentation by Franco A. Carnevale (third author) who described how the findings from one research project were creatively translated into a song in collaboration with study participants.

A Call to Action
The Epistemological Boot Camp series was developed to engage and awaken MQHRG members and the broader Montreal qualitative research community to issues and challenges related to epistemological oppression. During the boot camp's final drill, we returned to our initial guiding question: "Is the paradigm war still going on?" There was a general consensus that a paradigm war was indeed "alive and well" (Given, 2017, p. 1). However, some participants argued against the war metaphor, suggesting it was time to rethink this entrenched divide and wondering if it would be more fruitful to proactively work on educating "the other side." In contrast, others were committed to the idea that postpositivist and nonpositivist health research is ultimately "incommensurable" (Lincoln & Guba, 2000, p. 172), contending that qualitative health researchers should focus more time, energy, and resources on developing parallel tracks for funding and knowledge mobilization activities.
In responding to Given's (2017) recent question: "So, how can we stop the paradigm wars?," while our singular boot camp effort certainly will not end the paradigm war, it is a promising step forward in terms of "educating research students and colleagues about the nature of the qualitative paradigms and how it influences our methods, our analyses, and our writing techniques" (p. 2). Clearly, if qualitative researchers are going to make any progress in the paradigm war, additional networks and spaces are needed to ensure qualitative researchers are able to acquire advanced-level training and mentorship, two necessary components to performing high-quality research (Eakin, 2015). In addition to providing vital qualitative research skills training, creating local qualitative health research initiatives such as the boot camp may create networks that help foster change on a larger scale, as the #BMJnoQual mobilization efforts demonstrated.
Until qualitative health research gains more formal recognition of its worth within academia (e.g., more funding, advanced supervisory training, and explicit inclusion in curricula), we hope that by sharing our boot camp experience we can inspire qualitative research communities to implement their own grassroots initiatives and/or become involved with existing networks around the globe. 3 Importantly, whether it is face-to-face or virtual interactions, we encourage qualitative health researchers to continue rallying together in local and global contexts to collectively promote research that values nuance, complexity, and human experiences.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article. Notes 1. For textual simplicity, the term postpositivist is used to refer to both positivism and postpositivism. The authors recognize the complex distinctions that have been drawn between these terms. 2. In acknowledging there are flaws in construing the issues discussed in this article as warlike, we are using war metaphors that are already prevalent in the cited literature.