Symposium 15 Context, culture and contradictions: The contribution of ethnography to understanding practice

Symposium lead and chair: Joy Merrell, Professor of Public Health Nursing, University of Wales Swansea, School of Health Science, Swansea, United Kingdom J.a.merrell@swansea.ac.uk

Symposia focus

The aim of this symposium is to highlight the contribution which ethnography can make to aiding understanding of the reality of nursing practice. Whilst for sometime ethnography has been used and applied by nurse researchers (e.g Williams 1989, Johnson 1993) to explore how patients’ and practitioners’ interpret their experiences of care, there is a perception from a preliminary search of the UK nursing journals that the use of ethnography by nurse researchers over the last decade has been less prominent than the use of other qualitative approaches.

Ethnography involves the use of multiple methods but principally participant observation which enables researchers to more readily expose theory/ practice gaps, identify cultural influences and constraints on practice. Whilst there are challenges to practicing ethnography it is argued that this approach enables nursing practice to be understood as it is experienced in the dynamic, often resource constrained and multidisciplinary context of contemporary healthcare services. The relevance of ethnography for practice and practitioners as well as for the research community (Hammersley 1992) will be demonstrated throughout the papers presented. Three papers are presented from recently completed doctoral studies.

All the studies involved participant observation for periods of over twelve months, individual interviews and a review of documentary evidence. The papers all focus on the contribution ethnography makes to understanding the context, culture and contradictions in practice in a range of clinical setting including an intensive care unit, an Acute Medical Admissions Unit , Early Pregnancy Unit and two gynaecological wards. Each paper explores one of these issues in more detail

References

  • Hammersley M (1992) What’s Wrong with Ethnography? Routledge: London
  • Johnson M (1993) Unpopular Patient Reconsidered; An Interpretive Ethnography of the Process of Social Judgement in a Hospital Ward
  • Unpublished PhD Thesis, University of Manchester, Manchester Williams A (1989) Interpreting an Ethnography of Nursing: Exploring Boundaries of Self, Work and Knowledge
  • Unpublished PhD Thesis, University of Manchester, Manchester

Source of funding: N/A

Level of funding: N/A

Abstract  one: Nursing patients in transition: understanding the context of practice

Dr Pauline Griffiths, Senior Lecturer, School of Health Science, Swansea University

This paper, drawing on a reflexive ethnography which explores the nurse’s role in an Acute Medical Admissions Unit, presents the developed understanding of the reality of the nurse’s role in an acute setting. The ethnography entailed participant observation over a twelve month period, interviews with a purposive sample (n=19) of doctors, nurses, paramedics and patients and an examination of documentary evidence.

In giving a voice to the contemporary practice of nursing, the construct of the theory-practice gap is exposed as inadequate. The findings indicate that the nurses were engaged in a socially constructed practice, displaying skills of emotional and instrumental care giving in a time short environment. By prolonged engagement in the field I was able to appreciate the locally negotiated resources and ways of being that were adaptations to the real world demands the nurses faced. My role in the field changed as I came to know the culture of the nurses’ community of practice (Wenger, 1998), from a watcher of care to a person who understood the construction of nursing I was privileged to study. Responding to managerial and professional drivers the nurses responded to their disempowered position by creating a novel and effective approach to managing the clinical space. An ethnographic approach with data collected by participant observation, semi-structured interviews, and scrutiny of documents and artefacts enabled the culture of this nursing space to be described.

I argue that nursing ethnographies can develop nursing scholarship by witnessing care delivery rather than just hearing what informants say they do. Further, participant observation is the signature of ethnography (Brink and Edgecombe, 2003) and its use can help us understand nursing reality rather than outdated rhetoric.

References

  • Brink, P. J. and Edgecombe, N. (2003) What is becoming of ethnography? Qualitative Health Research, 13 (7), 1028-1030
  • Wenger, E. (1998) Communities of Practice. Learning, Meaning, and Identity, Cambridge University Press: Cambridge

Abstract two: Rationality and ritual in nursing work: uncovering their meanings through ethnography

Dr Sue Philpin,Senior Lecturer, School of Health Science, Swansea University

This paper also illustrates the ways in which ethnography uncovers the reality of nursing practice, exemplified in this case by an exploration of nursing culture in an Intensive Therapy Unit (ITU). The ethnography was accomplished through participant observation in an ITU over a twelve-month period followed by interviews with fifteen members of the nursing staff; it also included the examination of documentary material present in the field. I sought to understand the culture of this area in terms of what it meant to the people involved, drawing on Weber’s (1968) conception of verstehen, referring to understanding the act from the point of view of the actor. An ethnographic approach facilitated the identification and interpretation of specific aspects of culture – the notions of ritual and symbolism – in order to understand the meanings underpinning nursing actions in this setting. The findings indicate that whilst nursing work in this ITU was undoubtedly grounded in the much vaunted rhetoric of rationality of evidence-based practice, elements of symbolism and ritual were also an integral part of the nurses’ work and of their working environment. That is to argue that these two, seemingly contradictory aspects of nursing work, coexisted in this unit. Hence a core component and important theme arising from the findings is that many nursing actions have a dual purpose, one, essentially practical and grounded in science, whilst the second purpose entails responding to various other needs stemming from the nature of nursing work. The paper will demonstrate that using ethnography, it is possible to unravel the ‘webs of significance’ (Geertz, 1993) which constitute a culture, teasing out and make explicit the values inherent in nursing work.

References

  • Geertz, C. (1993) The Interpretation of Cultures London
  • Hutchinson Weber, M. (1968) Economy and Society Ed. G.Roth & C. Wittich New York: Bedminster Press

Abstract three: Contradictions and discrepancies: using ethnography to examine practice in context

Dr Fiona Murphy,Senior Lecturer, School of Health Science, Swansea University

Aim

This paper will discuss the potential of ethnography to examine nursing care in context which more accurately reflects the realities of practice. It will draw on the findings of an ethnographic study, which aimed to explore the management and care of women having an early miscarriage within a hospital setting.

Methods

The methods included 20 months participant observation in a United Kingdom hospital gynaecological unit and in-depth interviews with a purposive sample of eight women experiencing early miscarriage and 16 health professionals (10 nurses, 3 doctors and 3 ultrasonographers).

Results

The observations from the fieldwork, compared with the interview data from the nurses revealed an important discrepancy. This was between what nurses espoused as appropriate care, what is recommended in the literature in caring for these women and what was observed in practice. The perspective from the literature is that early miscarriage is a significant, traumatic, bereavement event in women’s lives (Moulder 1998). Similarly, the nursing response from the interview data was located within a theoretical framework of care and caring in which patient’s emotional needs are considered paramount. However, it was noted that there was a clear discrepancy between this and what was practised in the ward settings. There was clearly not the time to afford women with early miscarriage a high priority and attend to their emotional needs. Additionally, the backstage activity and behaviours of some of the nurses provided clear examples of the discrepancy between the caring values advocated in the literature and that observed in practice. Using ethnography, in particular a prolonged period of participant observation facilitated the identification of this gap between espoused theories and the theories in action that some nurses use (Argyris and Schön 1974).

References

  • Argyris C, Schön DA (1974) Theory in practice: increasing professional effectiveness. Jossey-Bass: London
  • Moulder C (1998) Understanding pregnancy loss. perspectives and issues in care. Macmillan: Basingstoke