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Qualitative research: Qualitative research methodologies: Ethnography

Authors:
  • Kingston University & St George's, University of London

Abstract

The previous articles (there were 2 before this 1) in this series discussed several methodological approaches commonly used by qualitative researchers in the health professions. This article focuses on another important qualitative methodology: ethnography. It provides background for those who will encounter this methodology in their reading rather than instructions for carrying out such research. Ethnography is the study of social interactions, behaviours, and perceptions that occur within groups, teams, organisations, and communities. Its roots can be traced back to anthropological studies of small, rural (and often remote) societies that were undertaken in the early 1900s, when researchers such as Bronislaw Malinowski and Alfred Radcliffe-Brown participated in these societies over long periods and documented their social arrangements and belief systems. This approach was later adopted by members of the Chicago School of Sociology (for example, Everett Hughes, Robert Park, Louis Wirth) and applied to a variety of urban settings in their studies of social life. The central aim of ethnography is to provide rich, holistic insights into people’s views and actions, as well as the nature (that is, sights, sounds) of the location they inhabit, through the collection of detailed observations and interviews. As Hammersley states, “The task [of ethnographers] is to document the culture, the perspectives and practices, of the people in these settings. The aim is to ‘get inside’ the way each group of people sees the world.”1 Box 1 outlines the key features of ethnographic research. #### Box 1 Key features of ethnographic research2
QUALITATIVE RESEARCH
Qualitative research methodologies: ethnography
Scott Reeves,
1
Ayelet Kuper,
2
Brian David Hodges
3
The previous articles in this series discussed several
methodological approaches commonly used by
qualitative researchers in the health professions. This
article focuses on another important qualitative meth-
odology: ethnography. It provides background for
those who will encounter this methodology in their
reading rather than instructions for carrying out such
research.
What is ethnography?
Ethnography is the study of social interactions,
behaviours, and perceptions that occur within groups,
teams, organisations, and communities. Its roots can be
traced back to anthropological studies of small, rural
(and often remote) societies that were undertaken in the
early 1900s, when researchers such as Bronislaw
Malinowski and Alfred Radcliffe-Brown participated
in these societies over long periods and documented
their social arrangements and belief systems. This
approach was later adopted by members of the
Chicago School of Sociology (for example, Everett
Hughes, Robert Park, Louis Wirth) and applied to a
variety of urban settings in their studies of social life.
The central aim of ethnography is to provide rich,
holistic insights into peoples views and actions, as well
as the nature (that is, sights, sounds) of the location they
inhabit, through the collection of detailed observations
and interviews. As Hammersley states, The task [of
ethnographers] is to document the culture, the
perspectives and practices, of the people in these
settings. The aim is to get insidethe way each group of
people sees the world.
1
Box 1 outlines the key features
of ethnographic research.
Examples of ethnographic research within the health
services literature include Strausss study of achieving
and maintaining order between managers, clinicians,
and patients within psychiatric hospital settings; Taxis
and Barbers exploration of intravenous medication
errors in acute care hospitals; Costellos examination
of death and dying in elderly care wards; and
Østerlunds work on doctorsand nursesuse of
traditional and digital information systems in their
clinical communications.
3-6
Becker and colleagues
Boys in White, an ethnographic study of medical
education in the late 1950s, remains a classic in this
field.
7
Newer developments in ethnographic inquiry
include auto-ethnography, in which researchersown
thoughts and perspectives from their social interactions
form the central element of a study
8
; meta-ethnogra-
phy, in which qualitative research texts are analysed
and synthesised to empirically create new insights and
knowledge
9
; and online (or virtual) ethnography,
which extends traditional notions of ethnographic
study from situated observation and face to face
researcher-participant interaction to technologically
mediated interactions in online networks and
communities.
10
What should I be looking for in an ethnographic study?
Ethnographers typically gather participant observa-
tions, necessitating direct engagement and involve-
ment with the world they are studying. Owing to the
complex nature of social life, ethnographers need to
record a variety of elements in their field notes
(box 2).
This is the third in a series of six
articles that aim to help readers to
critically appraise the increasing
number of qualitative research
articles in clinical journals. The
series editors are Ayelet Kuper and
Scott Reeves.
For a definition of general terms
relating to qualitative research,
see the first article in this series
Box 1 Key features of ethnographic research
2
A strong emphasis on exploring the nature of a
particular social phenomenon, rather than setting out
to test hypotheses about it
A tendency to work primarily with
unstructured data
that is, data that have not been coded at the point of
data collection as a closed set of analytical categories
Investigation of a small number of cases (perhaps
even just one case) in detail
Analysis of data that involves explicit interpretation of
the meanings and functions of human actions; the
product of this analysis primarily takes the form of
verbal descriptions and explanations
Box 2 Nine observational dimensions and their
descriptions
11
Space
Physical layout of the place(s)
Actor
Range of people involved
Activity
A set of related activities that occur
Object
The physical things that are present
Act
Single actions people undertake
Event
Activities that people carry out
Time
The sequencing of events that occur
Goal
Things that people are trying to accomplish
Feeling
Emotions felt and expressed
1
Department of Psychiatry, Li Ka
Shing Knowled ge Institute, Centre
for Faculty Development, and
Wilson Centre for Research in
Education, University of Toronto,
200 Elizabeth Street, Eaton South
1-565, Toronto, ON, Canada
M5G 2C4
2
Department of Medicine,
Sunnybrook Health Sciences
Centre, and Wilson Centre for
Research in Education, Univer sity
of Toronto, Toronto, ON, Canada
M4N 3M5
3
Department of Psychiatry, Wilson
Centre for Research in Education,
University of Toronto, Toronto,
ON, Canada M5G 2C4
Correspondence to: S Reeves
scott.reeves@utoronto.ca
Cite this as:
BMJ
2008;337:a1020
doi:10.1136/ bmj.a1020
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512 BMJ |30 AUGUST 2008 |VOLUME 337
During their observations, ethnographers routi-
nely use informal or conversational interviews,
which allow them to discuss, probe emerging issues,
or ask questions about unusual events in a naturalistic
manner. Because of the casualnature of this
type of interview technique it can be useful in
eliciting highly candid accounts from individuals.
Ethnographers also gather formal in-depth inter-
views and documentary data such as minutes of
meetings, diaries, and photographs.
Participants or situations are sampled on an oppor-
tunistic or purposive basis. It is also usual for
ethnographers to focus upon specific features (for
example, medical ward rounds) that occur within a
research setting.
Analysis of ethnographic data tends to be under-
taken in an inductive thematic manner: data are
examined to identify and to categorise themes and
key issues that emergefrom the data. Through a
careful analysis of their data, using this inductive
process, ethnographers generate tentative theoretical
explanations from their empirical work.
Reflexivity (that is, the relationship a researcher
shares with the world he or she is investigating) is a
central element of ethnographic work, owing to the
relationship the ethnographer shares with participants
and the ethical issues that flow from this close relation-
ship. Within research reports, reflexivity is presented in
the form of a description of the ethnographers ideas
and experiences, which can be used by readers to judge
the possible impact of these influences on a study.
To enhance the quality of their work, ethnographers
will often provide a detailed or thick descriptionof
the research setting and its participants, which will
typically be based on many hours of direct observation
and interviews with several key informants.
12
Box 3 Triangulation in ethnography
Triangulation is a term linked to navigation or surveying:
people discover their position on a map by taking bearings
on landmarks, and where the lines intersect is where they
are positioned. As well as methodological triangulation,
Denzin
14
outlines three other types:
Data triangulation, which uses different sources of data to
examine a phenomenon in several different settings and
different points in time or space
Investigator triangulation, which uses multiple
researchers to generate a complex range of perspectives
on the data
Theory triangulation, in which researchers approach data
with different concepts and theories to see how each
helps to understand the data
Box 4 An ethnographic studyof professional relationships
This ethnographic study took place in a large general
hospital in the United Kingdom.
15
It aimed to understand,
in depth, the nature of hospital based nurse-doctor
relationships in the wake of changes to health policy and
to the delivery of professional education.
The author, a nurse, undertook participant observations
for 10 months, during which she worked as a nurse (on an
unpaid basis) with doctors, nurses, managers, and
auxiliary staff on both a surgical and a medical ward. To
gain a candid insight into these professionals
views, she
undertook informal interviews with staff while they worked
together. She also collected 57 tape recorded interviews,
each lasting 60 to 90 minutes, with nurses, doctors,
auxiliaries, and managers. These explored in more depth
participants
views of their interprofessional
relationships. Documentary data were also generated
through analysis of organisational documents and
through attendance at professional and managerial
meetings.
The author undertook an inductive approach to data
analysis, in which meanings emerged from the data
through exploration of all data sets. In addition, she used
data from different sources (observations, interviews,
documentary data) to generate a more comprehensive
understanding in the emerging analysis. The author drew
upon negotiated order perspective
a sociological theory
developed by Strauss to frame and illuminate the findings
from her analysis. She also discussed her reflexive role in
the study, and as a nurse, how that helped her secure
access into this clinical setting, and how it helped her
attain richer insights into the nature of nurse-doctor
relationships in relation to how they negotiate
professional boundaries in their clinical work.
Further reading
Books
Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, eds.
Handbook of ethnography. London: Sage, 2001.
Fetterman D. Ethnography: step by step.2nded.London:
Sage, 1988.
Fielding N. Ethnography. In: Researching social life.
London: Sage, 1993:155-71.
Hammersley M, Atkinson P. Ethnography: principles in
practice. 2nd ed. London: Routledge, 1995.
Spradley J. The ethnographic interview. New York: Holt,
1979.
Journal articles
Atkinson P, Pugsley L. Making sense of ethnographic
research in medical education. Med Educ
2005;39:228-34.
Charmaz K, Oleson V. Ethnographic research in medical
sociology: its foci and distinctive contributions. Sociol
Methods Res 1997;25:452-94.
Fine G. Ten lies of ethnography. J Contemp Ethnogr
1993;22:267-94.
Jeffrey B, Troman G. Time for ethnography. Br Educ Res J
30:535-48
Savage J. Ethnography and health care. BMJ
2000;321:1400-2.
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In addition, ethnographic work commonly uses
methodological triangulation
a technique designed
to compare and contrast different types of methods to
help provide more comprehensive insights into the
phenomenon under study. This type of triangulation
can be very useful, as sometimes what people say about
their actions can contrast with their actual behaviour.
13
Box 3 provides further information about triangulation
and the different types that can be employed within
ethnographic research.
Ethnographers often draw upon social sciences
theory
for example, interactionism, feminism, and
postmodernism, to strengthen their research focus and
analyses. (The use of theory within qualitative research
is examined in more depth in another paper in this
series.) See box 3 for an example of an ethnographic
study.
Why choose ethnography?
Ethnographic research offers several advantages. For
example, the use of participant observation enables
ethnographers to immersethemselves in a setting,
thereby generating a rich understanding of social
action and its subtleties in different contexts.
Participant observation also gives ethnographers
opportunities to gather empirical insights into social
practices that are normally hiddenfrom the public
gaze. Additionally, since it aims to generate holistic
social accounts, ethnographic research can identify,
explore, and link social phenomena which, on the
surface, have little connection with each other.
Ethnographic research can be problematic. Owing
to the relatively long periods of time ethnographers
spend talking to participants and observing actions, it
can be difficult to secure repeated access, especially if
institutional gatekeepers are concerned that the
research may cast their organisation in a poor light.
Obtaining formal approval from research ethics
committees can be complicated. The direct inter-
action that occurs between ethnographers and
patients or clinicians during fieldwork can be
regarded with suspicion, as traditional notions of
health services research rest on researchersdetach-
ment rather than involvement. Comprehensively
recording the multifaceted nature of social action
that occurs within a clinic or ward is a difficult task, as
a range of temporal, spatial, and behavioural
elements need to be documented (see box 1). In
addition, the unpredictability of social (and clinical)
life often means that ethnographers have to be
flexible, patient, and persistent in their work, as
data collection activities can be disrupted or access
withdrawn as local circumstances and politics
change.
Conclusion
Ethnography is a highly useful methodology for
addressing a range of research questions within the
health professions. In particular, it can generate rich
and detailed accounts of cliniciansprofessional and
interprofessional relationships, their interactions with
patients, and their approaches to delivering care, as
well as in-depth accounts of patientscare experiences.
Understanding the foundations of ethnography and its
key elements will help readers when they come across
reports that use this methodology. A later article in this
series will provide readers with a more formal frame-
work to use when critically appraising qualitative
research papers, including ethnographies. Readers
interested in undertaking such research should refer
to the works listed in box 4.
Funding: None.
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
1HammersleyM.What
s wrong with ethnography? Methodological
explorations. London: Routledge, 1992.
2 Hammersley M, Atkinson P. Ethnography: principles in practice. 2nd
ed. London: Routledge, 1995
3 Strauss A, Schatzman D, Ehrlich R, Bucher M, Sabshin C. The hospital
and its negotiated order. In: Freidson E, ed. The hospital in modern
society. New York: Free Press, 1963:147-69.
4 Taxis K, Barber N. Causes of intravenous medication errors: an
ethnographic study. Qual Saf Health Care 2003;12:343-7.
5 Costello J. Nursing older dying patients: findings from an ethnographic
study of death and dying in elderly care wards. JAdvNurs
2001;35:59-68.
6
Ø
sterlund C. Genre combinations: a window into dynamic
communication practices. J Manage Inf Syst 2007;23:81-108.
7 BeckerH,GeerB,HughesE,StraussA.Boys in white: student culture
in medical school. Chicago: University of Chicago Press, 1961.
8Reed-DanahayD.Auto-ethnography: rewriting the self and the social.
London: Berg, 1997.
9 Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R. Using
meta-ethnography to synthesise qualitative research: a worked
example. J Health Serv Res Policy 2002;7:209-15.
10 Hine C. Virtual ethnography. London: Sage, 2000.
11 Spradley J. Participant observation. New York: Holt, 1980
12 Geertz C. The interpretation of cultures: selected essays.NewYork:
Basic Books, 1973.
13 Strong P.The ceremonial order of the clinic. London: Routledge, 1977.
14 Denzin N. The research act in sociology. London:Butterworth, 1970.
15 Allen D. The nursing-medical boundary: a negotiated order? Sociol
Health Illn 1997;19:498-520.
SUMMARY POINTS
Ethnography is the study of social interactions, behaviours,
and perceptions that occur withinteams, organisations,and
communities.
Ethnographic studies typically gather participant
observations and interviews; through using these methods
ethnographers can immerse themselves in settings and can
generate rich understanding of the social action that occurs
Owing to the relationship the ethnographer shares with
research participants, reflexivity (whereby ethnographers
describe the relationship they shares with the people and
world they are studying) occupies a central element of this
type of research
Ethnographers commonly triangulate (that is, compare and
contrast)interview and observation methods to enhance the
quality of their work; this technique is important as what
people say about their behaviour can contrast with their
actual actions
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... Rationale for selecting focused ethnography for the qualitative phase Ethnography can be described as the study of social interactions, behaviours and perceptions that occur within groups, teams, organisations and communities (Reeves and Hodges 2008). Traditional or classical ethnography originates from anthropological studies in the early 1990s, whereas focused ethnography has emerged more recently (Knoblauch 2005). ...
Thesis
Background: Urinary tract infection is a leading cause of healthcare associated infection in hospitals with around half of these being attributable to indwelling urinary catheters. Overuse of urinary catheters in healthcare settings is a known problem yet the extent to which it is possible to avoid catheter use is unclear. Urine output monitoring is one of the main indications for short-term catheter use, with acute kidney injury (AKI) and sepsis as key drivers to detect oliguria (low urine output). However, published guidance lacks clarity on when a catheter is needed for urine output monitoring, fueling uncertainty and potential for overuse in clinical practice. Aim: The aim of this research is to explore how and why urine output is monitored in acute medical environments. Methods: A sequential, explanatory mixed methods study was designed. Two approaches to data collection were used: a point prevalence survey of 17 medical wards, using the whole source population as the sample and analysed using descriptive statistics, followed by a focused ethnography in an acute medical unit and a medicine for older people ward using a purposive sample and reflexive thematic analysis. Findings: The prevalence survey identified 107/389 (27.5%) patients had an indwelling urinary catheter. Almost half (n=49/107; 46%) were placed solely for the purpose of urine output monitoring. Most (n=87/107; 81%) catheters had a urine meter attached to enable 1-2 hourly measurements, but only 12% (n=7/60) were utilised for this purpose outside of critical care. The focused ethnography revealed how clinicians were influenced both by clinical and non-clinical rationales when justifying the need for a urinary catheter to monitor urine output. Distrust in the use of non-invasive collection methods was a significant contributing factor to catheter use. Conclusion: Urinary catheters are thought to champion the accuracy of urine output monitoring, but it is debatable whether the drive for accuracy is jeopardising rather than improving patient safety. The redundancy of most urine meters outside of critical care in one hospital reveals considerable potential for reduction in urinary catheters and thereby in catheter-associated infections. However, uncertainty about the reliability and practical application of non-invasive approaches for urine output monitoring is likely to hinder such reduction and requires further investigation.
... knowledge is relative to differences in perception, and is mind-dependent) and epistemological constructivism (i.e. knowledge is constructed) were used to provide rich qualitative understandings of the social dynamics within a community PA exercise setting (Reeves, Kuper, and Hodges 2008). Ethnography is rooted in anthropology, and involves the application of fieldwork, including various methods, such as participant observation, for understanding and making sense of cultural and social life (Coffey 2021). ...
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For an occupational therapist unfamiliar with a culturally diverse treatment population, ethnographic interview is described as an appropriate method for assessing client group needs. This study describes the use of ethnographic interview as a tool which was culturally sensitive to the occupational behaviors of American Indians and Alaska Natives of the Northwest involved in drug and alcohol treatment. Results of the interviews helped the researcher identify sociocultural factors in the acquisition and maintenance of maladaptive behaviors. Recurring themes of the extended family network, the strength and complexity of social norms and codes, and the pervasiveness of alcohol use among this population are described in review of the literature and results of the interviews. Results of the Tennessee Self-concept Scale revealed an overall measure of self-esteem significantly lower than that of the normed population, and enerally supported rehabilitation issues originally identified by the f iterature and expanded on in the interviews. Implications for treatment discuss acceptance of the therapist by members of the culture, the concept of nonmterference, the role of purposeful activity, cultural identification and assimilation, and the use of group work.
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In a recent paper in Sociology of Health and Illness, Svensson (1996) makes the case for adopting the negotiated order perspective as the most appropriate theoretical framework for understanding patterns of doctor-nurse interaction. Analysing interview data with nursing staff from surgical and medical wards in five Swedish hospitals, Svensson identifies key changes in the health care context which he suggests have created ‘negotiation space’ for nurses, leading to the evolution of new working relationships with doctors. In examining the relationship between negotiation processes and the wider structural context, Svensson addresses a theme that has remained an enduring interest of critics and supporters of the negotiated order perspective alike. Drawing on data generated on a surgical and a medical ward in a UK District General Hospital, this paper attempts to make a further contribution to this debate and also to sociological understanding of doctor-nurse relationships, by analysing some features of hospital work which inhibited face-to-face inter-occupational negotiations but which nevertheless resulted in the modification of the formal division of labour between nursing and medicine. The implications of these findings for the negotiated order perspective are considered, and the question is raised as to what researchers working within this tradition understand by ‘negotiation’ and how it can be studied.