Volume 1, No. 1, Art. 7 – January 2000
Ethnography and Health Care: Focus on Nursing
Abstract: Ethnography is one of the oldest forms of qualitative social research. It is a research methodology suited to the exploration of cultures, and is usually the chosen method for anthropological investigation. This paper will provide a brief background to ethnography, and will discuss the method in the light of current healthcare research, focusing on HIV. The discussion will emphasise the value of ethnographic findings in the field of healthcare, as a tool that provides the means for gathering insights into the cultural perception of health and illness, and an explanation of knowledge, attitudes and behaviour of health care workers.
Key words: ethnography, anthropology, nursing, health care, qualitative research
Table of Contents
2. Ethnography: Philosophy and Theory
3. Key Concepts in "Doing" Ethnography
4. Ethnography in Healthcare: A Brief Overview
"Ethnography" is an ambiguous term, but it is essentially a form of social research that includes some or all of the following characteristics: the exploration of a social phenomena; "unstructured" data; small number of cases; analysis that involves and interpretation of meanings of human action (ATKINSON & HAMMERSLEY, 1994). Culture can be defined as a set of guidelines which individuals inherit as members of a particular society, which "tells them how to view the world, how to experience it emotionally, and how to behave in relation to other people to supernatural forces or gods, and to the natural environment" (HELMAN, 1994 pp.2-3). The special focus of ethnography is "the work of describing a culture, and to understand another way of life from the [other person's] point of view" (SPRADLEY, 1980). 
Ethnography seeks to explain both explicit aspects of a culture (what all members are aware of and take for granted), and tacit elements (outside of awareness). This may include space and spatial cues (SPRADLEY, 1980), or "largely unarticulated contextual understanding that is often manifested in nods, silences, humour and naughty nuances" (ALTHEIDE & JOHNSON, 1998 p.297). 
Ethnography was probably the first example of qualitative research, used extensively by anthropologists over 100 years ago. It is an approach that balks at rigorous, quantitative analysis, in favour of a more descriptive, explanatory approach. It is not surprising that ethnography is the preferred research methodology for anthropology, with which it has the common aim of identifying rules, rituals and beliefs within a given population (MORSE, 1992). Other disciplines, however (for example, sociology) do utilise ethnography, and recently there has been an increasing tendency to undertake studies in applied fields such as education, health care (ATKINSON & HAMMERSLEY, 1994). 
Rather than studying people, ethnography means learning from people ñ thus (unlike more positivistic approaches) knowledge gained from data is intended to inform understanding, rather than control. The ethnographic interaction results in a free exchange of ideas, and a mutual sharing of information (SORRELL & REDMOND, 1995). The ethnographic researcher is "participating covertly or overtly in people's lives for an extended period of time, watching what happens, listening to what is said, asking questions" (HAMMERSLEY & ATKINSON, 1995 p.1). 
Philosophically, ethnography falls within the emic, as defined by KIM (1993), and from a methodological perspective primarily utilises unstructured interviews, and differing levels of observation, ranging from simple description, to full participant observation. 
Ethnographers would tend to reject the positivistic approach, for it posits that physical science (the logic of the experiment) and the demonstration of social laws should be the basis for the social sciences. Ethnography rests more comfortably within the naturalist approach, in which the world should be examined in its "natural" state, and in which the researcher should adopt an attitude of "respect" or "appreciation" for the social world. 
To illustrate, two theoretical foundations that can be invoked when addressing ethnographic data are interpretivism and symbolic interactionism. 
Interpretivism was born out of a reaction against the rise of logical empiricism and instrumental rationality in the 1930s and 1940s, and as an approach, overlaps with phenomenology, and semiotics. A key concept is that of verstehen (from the actor's point of view), and the work of SCHUTZ (1967) focuses on the experiential form of common-sense knowledge of human affairs, and is an approach that enriches ethnographic data. 
Interestingly, some writers, arguing from an essentially interpretivist point of view, suggest that it is mistaken to get bogged down in the -isms and the -ologies. Rather, the thing to ask is: what is the importance of the observed phenomenon. What does it mean? One illustration of this is the many and varied interpretations of a wink—an ethnographer decide which was the "true" one by sorting out the structures of signification (GEERTZ, 1993). The ethnography of Michelle ROSALDO (1980), using an interpretive phenomenological approach, sought notions of self and social life in a group of head-hunters. Her results demonstrated the place of patience and passion within the group, and is a prime example of the application of theory to practice (STRATHERN, 1981). 
A second theoretical approach by which ethnographic data can be analysed emerges from the work of G.H. MEAD, who, as a "social thinker", also had a profound affect on sociology. Symbolic interactionism rests on three premises (in BLUMER, 1969):
People act towards objects and beings, based upon the meanings they have for them.
These meanings derive from interactions (i.e. communication).
Meanings are established through an interpretive process. 
Human beings are purposive; they confront and interpret the world in order to act. A necessary requisite of social study, therefore, is careful observation of overt behaviours and behaviour settings of actors and their interactions. Significant "gestures", and what a social group understands by the gesture, is an example of the basic unit of currency in symbolic interactionism (SCHWANDT, 1994). A classical example of symbolic interactionism is manifested in the studies of Irving GOFFMAN, and his seminal work Asylums (1961), which is still used as a model for effective and detailed ethnography. 
In common with other qualitative research methods, ethnography has been challenged over the past 30 years by questions of validity, contexts, goals, and representation. The epicentre of this development (at least for ethnography) is the emergence of the "reflexive turn". Modern ethnographic studies are developing a paradigm that is an amalgam of the "classic" approach (observation and interpretation) with the more recent emphasis that includes the place of the researcher within the field. The resulting new "ethnographic ethic" is itself in a state of flux, and the next 10 or so years could result in other configurations of qualitative research (ALTHEIDE & JOHNSON, 1998). Another potential problem with ethnography is the creation of "false" cultures (SCHILLER, CRYSTAL et al., 1994), and this must always be born in mind to avoid stereotyping. 
Elements central to ethnographic activity include:
Reflexivity—a relatively recent addition to the philosophical matrix of qualitative research, and signifies the researcher's part in the social world that is being investigated. Thus, the researcher can him/herself can become one of the more refined research tools in the process of data collection—subjects' responses to the presence of the researcher, and the researcher"s response to the context, are as valuable as any other aspect of the study. Bias and subjectivity are a risk, but it allows a richer vein of data to be appraised, and is valuable in contexts in which "natural history" is central (HAMMERSLEY & ATKINSON, 1995 p16). 
Participant observation—a primary part of the methodology. This is the process whereby as a researcher, one: "[subjects] yourself, your whole body your whole social situation, to the set of contingencies that play upon a set of individuals, so that you are close to them while they are responding to what life does to them, not just to listen to what they talk about, but pick up their minor grunts and groans as they respond to their situation" (GOFFMAN, 1989). 
Various levels of participation exist (see HAMMERSLEY & ATKINSON, 1995 p.139) the final arbiter being the nature of the study. The researcher is advised to consider the following elements: behaviour; knowledge; and artefacts, all of which will help shed light on the underlying architecture of knowledge. According SPRADLEY (1980 p.10) this is the bedrock of a culture, and help form the framework that allows members of a culture to "generate behaviour [and] interpret experience". 
The ethnographic interview in which the purpose is to "discover cultural meanings which exist within a social group, emphasising interaction, social context, and social construction of knowledge" (LOWENBERG, 1993). 
Cultural analysis—The raison d'etre of ethnography, and the final element of participant observation. The threads of meaning gained from participant observation and interviews coalesce into an understanding of cultural activity, and the "process" entails: notes; focused observation; selected observation and/or interview; analysis (domain analysis and semantic analysis); cultural themes (see SPRADLEY, 1980). 
Ethnography within the healthcare context is valuable for a number of purposes ñ including the exploration of cultural perceptions of the people affected by illness, and even cultures of health care workers (though studies in this field are sparse). There is a growing interest in the application of anthropological approaches in nursing, though MULHALL (1996) suggests that a true understanding of "culture" is necessary before it is possible to fully integrate the discipline into a nursing knowledge base. 
Ethnography has been used in a large number of studies relating to perceptions of illness, including:
exploring the illness experience (NICHTER, 1987),
the utilisation of explanatory models of illness, and the absorption of new illnesses into pre-existing frameworks (WEISS, 1988),
and (tangentially) the role of narrative in the construction of meaning (GOOD, 1994),
the value in understanding illness perception prior to health promotion interventions (NICHTER, 1993),
and in the practice of nursing, recent published examples include:
to observe record keeping (ALLEN, 1998),
the transition from student to qualified status (HOLLAND, 1999),
exposing ritualistic practices in an operating theatre (MACQUEEN, 1995),
investigating the role of nurses in the delivery of community care (RAPPORT & MAGGS, 1997),
the investigation of curtain positioning in a maternity ward, and the "signals" from in-patients that are manifest (BURDEN, 1998). 
Ethnography in health care is especially valuable when considering illnesses that are multi-factorial, or multi-cultural. Human-immunodeficiency virus (HIV) for many people defies precise classification: it inflicts the developed and developing world in different ways; has a long period of apparent inactivity (making analysis of cause and effect difficult); and any of a large number of symptoms can present as the immune system weakens, then revives. An association with sexual behaviour and death result in people being forced to depend upon cultural models of illness, constructed from existing mythical frameworks and illness narratives, in order to provide meaning and guide behaviour. 
Ethnography has elicited valuable data, and include:
the personal experience of AIDS, as expressed in narrative (HASSIN, 1994),
risk assessment (DOWNE, 1997; GROVE, KELLY et al., 1997),
the integration of AIDS into existing explanatory models of illness (FARMER, 1994)
the feeling of alienation amongst people with HIV (SOBO, 1997). 
A fruitful area for future research would consider the "matrix of meaning" within cultures that is often embedded within mythical frameworks (including "ancient" myths, and more modern narratives). Ethnographic techniques, utilised within the health care area, would be invaluable in discovering the cultural influences upon the cultural construction of HIV amongst health care workers. This is an area for future studies, and addresses calls to discover what HIV actually means to health care workers (AGGLETON, 1998). This is the area with which this writer is concerned. 
This paper has provided a brief insight into ethnography, and its value as research method that provides the means to study cultural functioning. Ethnography epitomises a central tenet of qualitative research, as defined by ALTHEIDE (1998 p.290): "[qualitative research] is carried out in ways that are sensitive to the nature of human and cultural social contexts, and is commonly guided by the ethic to remain loyal to the phenomena under study". 
Ethnography was originally a tool used by early anthropologists to examine "native" cultures. The recent, more eclectic application of the method (for example to professional groups in the West) should not detract from the value in data shedding light on the inequality between developed and developing countries (e.g. FARMER & KIM, 1991), and be a potential tool for political and social change. This provides a resonance with critical theory, as espoused by HABERMAS (1971). 
The current ascendancy of transcultural nursing, and the increasing awareness that culture is as powerful as anything else in determining a person"s understanding of health and illness, demonstrates the need for a research methodology and philosophy that focuses on this aspect of individual perception. Culture is a "lens" though which people view the world (HELMAN, 1994): an ignorance of this "view" (in this case relating to HIV) is cogently illustrated by ten BRUMMELHUIS and HERDT (1995 p.ix):
"culture defines much of the world in which people situate themselves and live. If we do not enter and attempt to understand this world [as carers and in health promoters], our efforts to convince, change or console others will be ineffective, even harmful." 
Ethnography will assist in this process. 
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Lecturer in Nursing
School of Health Studies
University of Bradford
Hodgson, Ian (2000). Ethnography and Health Care: Focus on Nursing [26 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 1(1), Art. 7, http://nbn-resolving.de/urn:nbn:de:0114-fqs000172.