Education and debate

Ethnography and health careJan Savage

Development of a culture of evidence based medicinedepends on a body of research that draws from bothqualitative and quantitative approaches.1 Recent BMJarticles have usefully questioned a stark polaritybetween qualitative and quantitative research andhelped to demystify qualitative approaches.2 3 4 Therehas been little mention of ethnography, however, andlittle argument for its use in health research.

I have examined some of these omissions, giving abroad indication of the nature of ethnography andarguing for its greater use within health care. I havegiven examples of ethnographic studies to suggestsome of the issues that ethnography can help toexplore, together with a brief outline of limitations ofthe approach.

What is ethnography?Perhaps one of the reasons for the neglect ofethnography is that there is no standard interpretationof what it is. Ethnography is, confusingly, both a proc-ess and a product: the term can apply both to a meth-odology and to the written account of a particularethnographic project. It is not, as is often implied, apseudonym for qualitative research in general or a wayof describing studies premised solely on semistruc-tured interviews. On the contrary, an ethnographicapproach usually incorporates a range of methods andcan combine qualitative and quantitative data. Formany, the defining feature of ethnography is the use ofparticipant observation,5 entailing prolonged field-work. Box 1 provides an example of an ethnographic

study that uses mixed methods, including participantobservation, to explore complex clinical and organisa-tional issues.

Ethnography has its earliest roots in social anthro-pology, which traditionally focused on small scale com-munities that were thought to share culturally specificbeliefs and practices. The motives for much earlyethnographic work and the neutrality of the whiteethnographer in an era of Western imperialism arenow viewed with some scepticism.7 Political change,both globally and within the academic world, hasmeant that the ethnographer’s authority to provide theonly, or most legitimate, account is no longeraccepted.8

Although the issue of authority is not simplydefused by a change in location, the focus for manyWestern ethnographers has shifted from remote com-munities to settings “at home,” such as corporateorganisations. At the same time, phenomena such asnew information technologies, new national and localidentities, and the development of theoretical perspec-tives that reject assumptions about social coherencehave challenged the traditional view that “culture” is amatter of shared beliefs and practices. Instead, recogni-tion is given to the differences existing within socialgroups, with some social scientists arguing that“culture” marks a process of struggle to determinemeaning on the part of individuals with unequal access

Box 1: Ethnography as a mixed methodapproach

A team of ethnographers were invited to look atclinical decision making by staff at a mental healthcentre who were concerned by the possible impact ofmanaged care on professional status and provision ofservice.6 Participant observation allowed analysis ofactivities such as staff meetings and the tracing of aclient’s path through the clinic’s administrative process.Interviews and informal discussions with cliniciansprovided data on professional backgrounds,therapeutic orientation, and clinical activities. Findingssuggested that clinicians were not becomingde-professionalised, so much as re-professionalised. Inshifting from their stance as critics to promoters ofmanaged care they were apparently losing sight of amoral vision of good treatment for mental health.

Summary points

Ethnography has been overlooked as a qualitativemethodology for the in depth study of healthcareissues in the context in which they occur

An ethnographic study can utilise a range ofqualitative and quantitative methods

The methods of ethnographic research raiseethical and other issues, which means that skilledsupervision is essential

Ethnographers do not usually aim to producefindings that can be generalised

Ethnography can be useful in a predesign stage ofresearch and can generate questions for researchthat can be followed up by other methodologies

Royal College ofNursing, LondonW1M OABJan Savagesenior research fellow

Correspondence to:jan.savage@rcn.org.uk

BMJ 2000;321:1400–2

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to power.9 For example, an ethnography of a surgicalfirm focusing on infection control practices, if shapedby an “old” view of culture, might identify collectiveunderstandings of the team’s practices, such as itsagreed methods and rationale for creating a “sterile”field. In contrast, a “new” understanding of culturewould suggest greater emphasis on the activities andexplanations of different team members and in identi-fying who had the power to impose their particularpractices on other staff.

Most ethnographers today would agree that theterm ethnography can be applied to any small scalesocial research that is carried out in everyday settings;uses several methods; evolves in design throughout thestudy; and focuses on the meanings of individuals’actions and explanations, rather than their quantifica-tion.10 In addition, ethnography is viewed as contextualand reflexive: it emphasises the importance of contextin understanding events and meanings and takes intoaccount the effects of the researcher and the researchstrategy on findings.11 There is also wide agreementthat ethnography combines the perspectives of boththe researcher and the researched.11

The way in which ethnography is used, however,depends on several factors, including the philosophicalstance of the researcher or the practicalities of researchfunding.12 There is, for example, no overall consensusamong ethnographers about the epistemology, ortheory of knowledge, that underpins an ethnographicaccount. Instead, different kinds of ethnographies reston different ideas of what constitutes legitimate knowl-edge.12 Some ethnographers, for example, use an inter-pretive approach, drawing on experiential knowledgegained from physical participation in the field,13 knowl-edge that others might discount as unverifiable.

It might be argued that such an approachrepresents a narcissistic shift of focus from the experi-ence of the participants in the research to that of theethnographer,8 yet it offers one response to the crisis ofrepresentation in the social sciences. This crisis hasarisen partly because of uncertainty about how todescribe social reality and partly because of thechallenge to traditional assumptions, referred toearlier, about whose voice has authority. Additionally,there is growing acknowledgement that the knowledgegenerated by an ethnographic approach is stronglyshaped by the nature of the relationship between theresearcher and the researched.14 This has promptedthe development of new forms of ethnography, such ascritical ethnography, which attempt to restructure theresearch process in ways that promote the views ofthose who are often silent or marginalised.15

Awareness of the diverse positions within ethno-graphic research is important for at least two reasons.Firstly, many researchers agree that the epistemologi-cal foundations of an ethnography should continue toexert a strong influence throughout the entire researchprocess.11 Take the example of an ethnographyconcerned with the implications of physical intimacy inclinical encounters. This study was based on an episte-mology that extended legitimacy to knowledge fromall the senses, not only sight, which suggested theresearcher’s participation in, rather than mere observa-tion of, clinical work, to collect experiential data.13

Ethnography is thus not a simple matter of the ad hocmixing of several methods.

Secondly, these diverse epistemological stancesraise questions about the evaluation of ethnographicresearch and the appropriateness of criteria such asrelevance and validity. These questions are particularlyimportant for the broader acceptance and funding ofthis methodology in healthcare research, but provisionof set criteria for the assessment of ethnographicresearch is notoriously difficult. While Hammersleymakes some helpful proposals in this respect (box 2), itis doubtful that every ethnographer would accept allhis suggestions or give them equal emphasis.10 Perhapsthe best way of examining this complex issue here is byreference to more detailed discussions of theevaluation of qualitative research.4 16

The various perspectives encapsulated by the termethnography can be bewildering, but the versatility ofthis approach is also one of its strengths, not least inthe study of healthcare issues.

Ethnography and health careEthnography can be applied to healthcare issues innumerous ways. It has been seen as a way of accessingbeliefs and practices, allowing these to be viewed in thecontext in which they occur and thereby aiding under-standing of behaviour surrounding health andillness.11 17 It is therefore particularly valuable aspatients’ views on the experience of illness or deliveryof service are becoming recognised as central to amodernised NHS. Ethnography can show, for exam-ple, how the effectiveness of therapeutic interventionscan be influenced by patients’ cultural practices18 andhow ethnocentric assumptions on the part ofprofessionals can impede effective health promotion(box 3).19

Box 2: Possible criteria for assessingethnographic research10

• The consistency of claims compared with empiricaldata• The credibility of the account to readers and thosestudied• The extent to which findings have relevance to thosein similar settings• The extent to which the influence of the researchdesign and strategy on findings is considered (thereflexivity of the account), and the existence of anaudit trail

Box 3: Ethnography and the delivery of healthcare

A study of clinics serving low income, predominantlyAfrican-American women in mid-west America foundthat experiential knowledge held by clinic attenderswas overlooked by clinic professionals, who wereprimarily of European-American descent.19 This wasparticularly important for those women with lactoseintolerance, which in the United States is far morecommon among African-Americans. Data oninteractions in the clinic showed that there were oftenbarriers that rendered differences between staff andclinic attenders invisible or invalid and prevented theconsideration of alternative dietary approaches.

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In addition, ethnography is particularly useful inunderstanding the organisation of health care.17 Forexample, communication and information manage-ment within the NHS have been described as chaotic.20

Understanding why this is the case and how it can beimproved is seen to demand methods that go beyondquestionnaires and surveys. Through the nature andrange of methods it can adopt, ethnography can providea nuanced understanding of an organisation and allowcomparison between what people say and what they do.It can, for instance, help to identify the ways that anorganisation’s formal structure (its rules and decisionmaking hierarchies) are influenced by an informalsystem created by individuals or groups within theorganisation or indicate how professional knowledge islocally produced in particular settings (box 4).21

Like all approaches to research, however, ethnogra-phy has its limitations. These are amply spelt outelsewhere,10 but some examples that are particularlypertinent to healthcare research are worth raising here.

Funding bodies for research in health services areoften not receptive to ethnography on the basis that, asa qualitative methodology, it does not lead to general-isable findings. Some researchers dispute this argu-ment, claiming that qualitative research requires itsown criteria for generalisability.22 Others, however, donot consider generalisation to be the purpose of quali-tative research and point instead to the in depthunderstanding that ethnography can achieve and theway it can identify groundbreaking questions orhypotheses that can be further explored through othermethodologies.16

Other problems are those associated with observa-tion of participants. This method provides rich data buttakes considerable time and sustained supervision tore-cast what might be familiar and apparentlyirrelevant as strange and interesting. The labour inten-sive nature of fieldwork also means that it is relativelycostly. Some healthcare researchers deal with theseproblems by carrying out focused ethnographies inwhich fieldwork is shortened by entering the field withestablished research questions and less emphasis onparticipant observation. Finally, participant observa-tion raises challenging ethical questions and practicali-ties with regard to informed consent that may beheightened by the lack of power seen in certain groupssuch as patients or junior staff. Informed consenttherefore needs to be carefully considered, negotiated,and regularly reconfirmed with study participants.23

ConclusionEthnography is a complex and contested activity draw-ing on a range of epistemological positions and meth-

ods and often demanding different modes ofevaluation from other methods more commonly usedin healthcare research. As a detailed way of witnessinghuman events in the context in which they occur, eth-nography can help healthcare professionals to solveproblems beyond the reach of many researchapproaches, particularly in the understanding ofpatients’ and clinicians’ worlds.

Contributors: The need for a paper on ethnography and healthcare was initially identified by members on the Ethnographyand Health Care Group (ethnog-health@egroups.com). HelenAllan, Alison Crombie, Kathryn Ehrich, Daniel Kelly, and SusiePearce contributed to the conceptualisation and early revisionsof the paper.

Competing interests: The academic department in which Iam based enters the Research Assessment Exercise. Publicationof this paper may therefore benefit my employing organisation,although the benefits would be marginal and indirect.

Funding: None.

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to qualitative methods in health and health services research. BMJ1995;311:42-5.

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2000;320:50-2.5 Holy L. Theory, methodology and the research process. In: Ellen RF, ed.

Ethnographic research: a guide to general conduct. London: Academic Press,1984:13-34.

6 Ware NC, Lachicotte WS, Kirschner SR, Cortes DE, Good BJ. Clinicalexperiences of managed mental health care: a rereading of the threat.Med Anthropol Q 2000;14:3-27.

7 Said E. Culture and imperialism. London: Vintage, 1994.8 Ahmed AS, Shore C. The future of anthropology: its relevance to the contempo-

rary world. London: Athlone, 1995.9 Wright S. Politicisation of “culture.” Anthropology in Action 1998;5:3-10.10 Hammersley P. Reading ethnographic research: a critical guide. Harlow:

Longman, 1990.11 Boyle J. Styles of ethnography. In: Morse J, ed. Critical issues in qualitative

research methods. Thousand Oaks, CA: Sage Publications, 1994.12 Atkinson, P, Hammersley M. Ethnography and participant observation.

In: Denzin N, Lincoln Y, eds. Handbook of qualitative research. ThousandOaks, CA: Sage, 1994:248-61.

13 Savage J. Participative observation: standing in the shoes of others? QualHealth Res 2000;10:324-39.

14 Marcus G, Fischer M. Anthropology as cultural critique: an experimentalmoment in the human sciences. Chicago: University of Chicago Press, 1986.

15 Rose D. Doing critical ethnography. Qualitative research methods series 26.Newbury Park: Sage Publications, 1993.

16 Murphy E, Dingwall R, Greatbatch D, Parker S. Qualitative researchmethods. Health Technol Assess 1998;2:1-273.

17 Morse J, Field P. Nursing research: the application of qualitative approaches.2nd ed. London: Chapman and Hall, 1996.

18 Prout A. Actor-network theory, technology and medical sociology: anillustrative analysis of the metered dose inhaler. Sociol Health Illness1996;18:198-219.

19 Kingfisher C, Millard A. “Milk makes me sick but my body needs it”: con-flict and contradiction in the establishment of authoritative knowledge.Med Anthropol Q 1998;12:447-66.

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21 Atkinson P. Medical talk, medical work. London: Sage Publications, 1995.22 Morse J. Qualitative generalisability. Qual Health Res 2000;9:5-6.23 Association of Social Anthropologists of the Commonwealth. Ethical

guidelines for good practice, 1999. www.asa.anthropology.ac.uk/ethics2.html(accessed 5 Sept 2000).

(Accepted 20 September 2000)

Box 4: Ethnography in the study of professional groups

Atkinson used an ethnographic approach to study the clinical reasoning ina group of haematologists through observing activities such as grandrounds and clinical lectures.21 He showed how the expert knowledge ofthese physicians emerged as a local and joint production through clinicaltalk that was simultaneously characterised by confidence, dogmatism, anduncertainty. From this, Atkinson raises important issues about the use ofalgorithms and decision making models within medicine and whether theseacknowledge the complexities of practical work and clinical reasoning.

EndpieceFrom the auditorAudit is Auden spelt incorrectly

Once, twiceBut still three out of five

That’s 60%That’s audit

Auden is something else

Submitted by Jim Watters, clinical medical officerin community paediatrics, Wigan

Education and debate

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