Ethnography: challenges and opportunities
=========================================

* Janice Jones
* Joanna Smith

*   paediatrics
*   paediatric surgery
*   paediatric neurosurgery
*   health services administration & management
*   quality in health care
*   nursing

## Introduction

Collectively qualitative research is a group of methodologies, with each approach offering a different lens though which to explore, understand, interpret or explain phenomena in real word contexts and settings. This article will provide an overview of one of the many qualitative approaches, *ethnography*, and its relevance to healthcare. We will use an exemplar based on a study that used participant-as-observer observation and follow-up interviews to explore how occupational therapists embed spirituality into everyday practice, and offer insights into the future directions of ethnography in response to increased globalisation and technological advances.

## What is ethnography?

Qualitative research methodologies are inductive and focus on meaning; approaches are diverse with different purposes, reflecting differing ontological and epistemological underpinnings.1 With roots in sociology and anthropology, *ethnography* is one of the early qualitative approaches and is concerned with *learning about people*, in contrast to *studying* people, through immersion in native populations.2 3 Traditionally ethnography is characterised by in-depth observation of groups of individuals, being cognisant of the influences of historical and cultural contexts on social interactions.4 This process of immersion in the real world context and detailed analysis enables the researcher to discover and describe the complexities and shared cultural nuances of the social world, and to interpret the meaning of the phenomenon under investigation. Exploring health and care organisations at a macro level can result in better understanding of the processes, activities and practices through the researchers’ observations and engagement with participants and the setting. Although it has been argued that ethnography is purely a data collection method, epistemologically it is about immersion in a culture and the artistry of seeing, learning and interpreting reality by engaging with participants, either overtly or covertly in their natural environment.3 5 

## What research methods do ethnographic researchers adopt?

Ethnographic methods are diverse and a range of approaches can be adopted; they are based on observation, often complemented with interviews, and detailed analysis often at a micro level. Although the methods used are not exclusive to ethnography, it is the depth of fieldwork and the continuous process of engaging with participants and their natural environments that is central and adds strength to the findings of ethnographic studies.6 Participant observation requires immersion in the setting under investigation, and observing the language, behaviours and values of the participants.7 Consequently, paramount to undertaking an ethnographic study is the role of the researcher in data collection.

Engaging with participants in the real world poses several challenges; first the researcher must decide whether to adopt an overt or covert approach to data collection and observation. In an overt approach the participants know they are being observed, whereas in a covert approach the participants are unaware they are being observed. The rationale for undertaking covert data collection in healthcare contexts needs careful consideration because of ethical implications, and the tensions with the principles of good research governance such as the right to choice whether to participate, information provision and gaining consent.8 Second, the researcher must consider ‘their position’ either as an ‘insider’ (emic) or ‘outsider’ (etic).5 Broadly, an emic approach is aligned with immersing into the culture, observing and recording participants’ way of life and activity, in contrast to the etic approach that observes and describes communities and cultures (table 1). Both methods produce rich, in-depth data aiming to make sense of the context or phenomena under investigation, and require the researcher to be reflexive when undertaking fieldwork, accounting for their own assumptions and presuppositions to strengthen the findings.5 

View this table:
[Table 1](http://ebn.bmj.com/content/20/4/98/T1)

Table 1 
Approaches to participant observation7 

Ethnographic approaches to data collection produce voluminous unstructured data from a range of sources, for example fieldwork notes, diary entries, memos and, where appropriate, interview transcripts. The volume of data can be challenging to analyse and we would recommend a structured approach such as the framework approach.9 The framework approach is rigorous, logical and transparent, and is particularly suitable to manage large amounts of textual information, while remaining close to the original data.10 Framework approach supports the process of crystallisation, where the multiple facets of an ethnographic study are iteratively analysed, and constantly reviewed to identify patterns and associations across the data.9 While the final stage in the framework approach aims to present the data in a way that is meaningful to the reader by grouping findings into categories and themes, the role of the researcher is to offer explanations about ‘how and why’ events, actions and interactions occur.9 10 

Table 2 outlines the methods adopted, rationale for decisions made and challenges of undertaking an ethnographical study that explored how occupational therapists incorporate spiritual care into their everyday practice.11 Data were collected through participant-as-observer, recognising JJ’s role as an occupational therapist and knowledge of the study setting, with semistructured interviews used to explore with participants their decisions and thoughts by reflection on the observational data collected. Several key findings emerged; first spirituality is more meaningfully described than defined for occupational therapy practice. Second, central to occupational therapy practice is supporting patients during times of vulnerability; addressing the spiritual constructs of practice is essential to holistic person-centred care. Finally, organisational and contextual factors influenced how the occupational therapists framed their practice, and adopted strategies to retain their commitment to holistic, person-centred practice.11 

View this table:
[Table 2](http://ebn.bmj.com/content/20/4/98/T2)

Table 2 
Methods, rationale for decision and challenges undertaking ethnographical research

## How flexible is ethnography to social changes, globalisation and technological advances?

Rapidly advancing technology and increased globalisation require healthcare organisations to adapt and change; similarly approaches to undertaking qualitative research must evolve.12 The increased use of web-based platforms as a means of sharing information, offering support networks and monitoring patients is creating opportunities for health researchers to study the naturally occurring and vast amount of data generated online. The rapid advancement of online communities has resulted in the emergence of online research methodologies such as netnography.13 Netnography is rooted in ethnographical methods that aim to explore the social interactions of online communities, and can be adapted across the spectrum of online activities.14 

The emergence of team-based ethnography, as a departure from the traditional lone researcher working ‘*in the field’*, is in part in response to the globalisation of societies, economies and ororganisations.15 Multisite or global ethnography is a new way of conceptualising ethnography that offers opportunities to study the interconnectedness of modern society,15 and could be appropriate to study healthcare systems globally.

In summary, it is not surprising that qualitative research has been widely adopted as a means of understanding healthcare from the patient experience, and exploring service provision, care delivery and organisational cultures. The value of focused ethnographic studies in healthcare is essential to develop an in-depth understanding of healthcare cultures and explore complex phenomenon in real world contexts.

## Footnotes

*   Competing interests None declared.

*   Provenance and peer review Commissioned; internally peer reviewed.

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