23 April 2019 4 min read

Ethnography: observing the everyday complexity of healthcare

“What are you writing?”

The doctor looked at me curiously before turning his eyes to the semi-legible scribbles in my notepad.

He was working a hectic on-call shift covering multiple medical wards, and I was shadowing him as part of an ethnographic study about the pressures hospitals face on weekends. Up until that moment, he’d graciously allowed me to follow him from ward to ward. But after hours of me watching and taking notes, he just had to ask.

I get that question a lot as an ethnographer studying healthcare improvement, and I understand why. I’m not sure how I’d react if I were watched all day at work. And for people in healthcare, who are constantly being assessed and evaluated, it’s easy to see an ethnographer as just another outsider trying to tell them how to do their job.

[The doctor] seemed surprised by how factual – even mundane – the notes were.

So I showed him my notes. They described how he was beeped five times while attending to a patient he had never met before, how he was covering a ward where he did not normally work, and how he hadn’t had anything to eat or drink for hours. He seemed surprised by how factual – even mundane – the notes were. He cracked a hint of a smile, shrugged, and we continued with our day.

That doctor was right to be surprised about my notes. The things I write in the field are often just a memory aid to guide more complete notes I write up later. They can read like a dry description of what I see. But his reaction also speaks to the magic of ethnography. Those details that seem mundane to someone inside a culture – in this case, a hospital – can actually bring important elements of that culture to light.

Formally, ethnography is a qualitative research approach that draws upon close observations of – and involvement with – a given community in order to describe its social and cultural organisation. It mainly grew out of the field of anthropology, and is now used across a wide range of disciplines.

Those details that seem mundane … can actually bring important elements of culture to light.

The word ethnography literally means ‘writing culture’, but I prefer to borrow a description from Clifford Geertz: ethnography is like ‘deep hanging out’. As ethnographers, we go into an environment that’s somewhat unfamiliar to us and spend time with the people there. We join them in their everyday activities – the good, the bad and the boring. After time, we build relationships with people and get to know them. But we’re still outsiders at the end of the day, and that distance can help us see things they might take for granted.

That outsider lens is helpful when you’re trying to understand something as complex as healthcare. Every healthcare organisation has its own deep-rooted culture, with its own way of doing things. Though these cultural norms are often unremarkable to people working in that environment, they may be extraordinarily powerful in explaining why things happen the way they do. Sometimes, these unseen ‘rules of the game’ can explain the rationale between seemingly irrational processes. And they are much more likely to be revealed in the small hours of a night shift on the ward or on the corridor rushing to the emergency department than they are in a formal interview.

Ethnography can be especially valuable for research about how to improve healthcare. Improvement efforts in healthcare are driven by multiple forces – everything from political pressure, to targets, to how a powerful person wants things done. But these efforts may not be successful without a good awareness of what is actually happening at the sharp end of care. By providing a deeper understanding of why things happen the way they do in healthcare, ethnographic research can help ensure that improvement efforts are rooted in that understanding.  

My colleagues and I have spent a lot of time in UK maternity units recently, hoping to gain that kind of understanding. We’ve been there doing ethnographic work for two THIS Institute projects: one project aimed at improving electronic fetal heart monitoring, and another about replicating and scaling a successful maternity improvement programme. We’re learning so much about the ins and outs of maternity care – things we never could have learned solely from reviewing the literature or conducting interviews. We had to be there.

I will always be grateful to the many people I’ve met while doing ethnographic studies.

That’s what appealed to me about ethnography back when I was doing my master’s in organisational psychology. I wanted to be there with people. But being there isn’t always easy. It requires a great deal of social and emotional labour from the researcher to be accepted in a new environment, and a great deal of patience and tolerance from the people in that environment. For that, I will always be grateful to the many people I’ve met while doing ethnographic studies. 

After many hours of observations, I still get butterflies in my stomach the morning before my first day. Will people like me? Will they let me get what I need out of the observations? Where are the toilets? I have so many questions going in, and, of course, people inevitably have questions for me about who I am and what I’m there to accomplish.

I always try and convey that I’m not there to judge them or tell them how to do their job. When my colleagues and I observe in maternity units for our project on improving electronic fetal heart monitoring, for example, we’re not there to judge how well midwives and obstetricians interpret cardiotocography (CTG) traces. Instead, we’re hoping that our outsider perspectives can help us understand the social and cultural forces that influence how CTGs are classified, interpreted and responded to.

If we’re successful, that understanding could help inform an intervention that helps address these unseen forces. And maybe then, we can work together with maternity unit staff toward a goal we all share: safer maternity care for women and babies.