Ethnography and health care

British Medical Journal, Dec 2, 2000 by Jan Savage

Summary points

Ethnography has been overlooked as a qualitative methodology for the in depth study of healthcare issues in the context in which they occur

An ethnographic study can utilise a range of qualitative and quantitative methods

The methods of ethnographic research raise ethical and other issues, which means that skilled supervision is essential

Ethnographers do not usually aim to produce findings that can be generalised

Ethnography can be useful in a predesign stage of research and can generate questions for research that can be followed up by other methodologies

Development of a culture of evidence based medicine depends on a body of research that draws from both qualitative and quantitative approaches.[1] Recent BMJ articles have usefully questioned a stark polarity between qualitative and quantitative research and helped to demystify qualitative approaches.[2 3 4] There has been little mention of ethnography, however, and little argument for its use in health research.

I have examined some of these omissions, giving a broad indication of the nature of ethnography and arguing for its greater use within health care. I have given examples of ethnographic studies to suggest some of the issues that ethnography can help to explore, together with a brief outline of limitations of the approach.

What is ethnography?

Perhaps one of the reasons for the neglect of ethnography is that there is no standard interpretation of what it is. Ethnography is, confusingly, both a process and a product: the term can apply both to a methodology and to the written account of a particular ethnographic project. It is not, as is often implied, a pseudonym for qualitative research in general or a way of describing studies premised solely on semistructured interviews. On the contrary, an ethnographic approach usually incorporates a range of methods and can combine qualitative and quantitative data. For many, the defining feature of ethnography is the use of participant observation,[5] entailing prolonged fieldwork. Box 1 provides an example of an ethnographic study that uses mixed methods, including participant observation, to explore complex clinical and organisational issues.

Box 1: Ethnography as a mixed method approach

A team of ethnographers were invited to look at clinical decision making by staff at a mental health centre who were concerned by the possible impact of managed care on professional status and provision of service.[6] Participant observation allowed analysis of activities such as staff meetings and the tracing of a client's path through the clinic's administrative process. Interviews and informal discussions with clinicians provided data on professional backgrounds, therapeutic orientation, and clinical activities. Findings suggested that clinicians were not becoming de-professionalised, so much as re-professionalised. In shifting from their stance as critics to promoters of managed care they were apparently losing sight of a moral vision of good treatment for mental health.

Ethnography has its earliest roots in social anthropology, which traditionally focused on small scale communities that were thought to share culturally specific beliefs and practices. The motives for much early ethnographic work and the neutrality of the white ethnographer in an era of Western imperialism are now viewed with some scepticism.[7] Political change, both globally and within the academic world, has meant that the ethnographer's authority to provide the only, or most legitimate, account is no longer accepted.[8]

Although the issue of authority is not simply defused by a change in location, the focus for many Western ethnographers has shifted from remote communities to settings "at home" such as corporate organisations. At the same time, phenomena such as new information technologies, new national and local identities, and the development of theoretical perspectives that reject assumptions about social coherence have challenged the traditional view that "culture" is a matter of shared beliefs and practices. Instead, recognition is given to the differences existing within social groups, with some social scientists arguing that "culture" marks a process of struggle to determine meaning on the part of individuals with unequal access

to power.[9] For example, an ethnography of a surgical firm focusing on infection control practices, if shaped by an "old" view of culture, might identify collective understandings of the team's practices, such as its agreed methods and rationale for creating a "sterile" field. In contrast, a "new" understanding of culture would suggest greater emphasis on the activities and explanations of different team members and in identifying who had the power to impose their particular practices on other staff.

Most ethnographers today would agree that the term ethnography can be applied to any small scale social research that is carried out in everyday settings; uses several methods; evolves in design throughout the study; and focuses on the meanings of individuals' actions and explanations, rather than their quantification.[10] In addition, ethnography is viewed as contextual and reflexive: it emphasises the importance of context in understanding events and meanings and takes into account the effects of the researcher and the research strategy on findings.[11] There is also wide agreement that ethnography combines the perspectives of both the researcher and the researched.[11]