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Conducting ethnography in primary care

Qualitative research enjoys a rich history in family medicine and medicine more broadly (1,2). The term ‘qualitative research’ refers to a particular approach to research that comprises many differing methodologies, each with its own set of disciplinary commitments, epistemological interests and methods (3). Ethnography is among the most well known of these and combines field work and observations with interviews, a strategy that makes it unique and allows for the study of groups in their natural environments. Among other possibilities, it therefore offers the opportunity to observe phenomena that may be difficult for participants to describe in interview situations because it is a taken for granted aspect of their experiences. 
 
In this article, we provide a brief introduction to ethnography. We then discuss key methodological issues that are of particular relevance in understanding how to undertake this approach, focusing on issues related to ‘insider/outsider’; debates about authorial voice; time commitment; and evaluation. This article is not intended as a ‘how-to’ but does include some excellent references regarding how to properly conduct ethnographic research.


Introduction
Qualitative research enjoys a rich history in family medicine and medicine more broadly (1,2). The term 'qualitative research' refers to a particular approach to research that comprises many differing methodologies, each with its own set of disciplinary commitments, epistemological interests and methods (3). Ethnography is among the most well known of these and combines field work and observations with interviews, a strategy that makes it unique and allows for the study of groups in their natural environments. Among other possibilities, it therefore offers the opportunity to observe phenomena that may be difficult for participants to describe in interview situations because it is a taken for granted aspect of their experiences.
In this article, we provide a brief introduction to ethnography. We then discuss key methodological issues that are of particular relevance in understanding how to undertake this approach, focusing on issues related to 'insider/outsider'; debates about authorial voice; time commitment; and evaluation. This article is not intended as a 'how-to' but does include some excellent references regarding how to properly conduct ethnographic research.

What is ethnography?
Ethnography originally arises from the discipline of anthropology, although it is also extensively practised and developed within sociology. For a full description of the history of ethnography, see Gullion (4). Ethnography refers to the overall methodological approach; within this broad category, there is a diverse range of types-such as video ethnography, institutional ethnography, multisited ethnography and so forth. What these various approaches share is an analytic interest in the study of behaviour at the group level 'in the context in which it occurs' (5).
Methods are distinct from methodology and refer to the particular tools used to conduct research, such as interviews or focus groups. Ethnography uses standard qualitative tools, such as interviews, but is unique in adding observations (both participant and non-participant), field notes, textual analysis and the collection of what are called artefacts. Through these methods, data are collected over time and analysis proceeds through looking for the social meanings people assign to their work or lives (6).
Theory plays an important role in ethnographic research. There are many definitions of theory, and it is important to develop a sound understanding of both what theory is and how it is used in qualitative research. Theories provide us with well-worked-out conceptual understandings of how things work (7). Theories can also help us to understand our own assumptions about the world, which is an important step toward becoming reflexive, a key practice that is essential to the conduct of rigorous qualitative research of any type (8).

Why ethnography in primary care?
Ethnography is well suited to primary care research because it captures complex, naturally occurring social interactions in contexts that are not subject to experimental control (9). The utility of ethnography for family medicine research has consequently been recognized for several decades (10)(11)(12).
Ethnography in primary care settings is not fundamentally different from ethnography carried out elsewhere. However, the power relations that characterize health care settings-for example, hierarchies between physicians and patients and also between physicians and researchers-are in some ways unique and can influence all stages of the research process. Physicians-especially those at advanced career stages-are often unaccustomed to being observed and may mistakenly feel that they are being evaluated by ethnographers unless the researcher has clearly conveyed the objective of the research. Patients may similarly feel scrutinized unless they have been made aware that the goal of ethnography is not to identify and critique individual behaviour. Furthermore, in health care settings, there are practical limitations to how involved the researcher can be in the research setting (13). For example, with appropriate ethical approvals and consents, a researcher may quietly observe physicianpatient interactions in clinical appointments. In most circumstances, however, it would be highly inappropriate for the researcher to participate in this dialogue.

How do I conduct an ethnographic study?
Observations Ethnographers talk about field work and also participant observation. This involves conducting a series of observations through a process known as 'immersion' (14). Immersion refers to the need to spend a large amount of time in environments in order to conduct a comprehensive account. Prolonged exposure in the field allows the ethnographer to build relationships and gain an understanding of the broader social context in which the research is embedded. This allows the researcher to contextualize what people say, thereby augmenting our understanding from how people describe what they do. Analysing what people say alongside what they do in practice can offer a richer understanding of complex social phenomenon. This means that the research topic should entail components that can be observed.
What we see often depends on what we believe and presume to be real, and so ethnographers must be attuned to their own assumptions and theoretical worldviews. This is achieved through the practice of reflexivity (8). Reflexivity involves examination of one's assumptions and is critical to the success of ethnographic projects. Especially in health-focused research, this can be enhanced by working in multidisciplinary groups that include social scientists trained in ethnography alongside individuals with other domains of expertise. Iteratively, you can refine your (situated) understanding of phenomena through ongoing observations.
What you observe may vary in relation to your research question. It helps here to remember the concept of 'immersion', which means that you are making observations over time. Therefore, there is not just one observation that will conclusively define your evolving understanding of the phenomena you are studying. For example, if you were observing a clinic, you may want to focus on patients at one time, and then physicians at another and then nurses. You may want to focus on interactions between people. Many good guides abound to provide guidance (15). Over time, you will develop a better understanding of how to approach your observations while maintaining reflexivity and begin to better understand what you are seeing from the perspective of insiders to the situation.

Field notes
During observations, the researcher takes field notes to capture their observations and to guide their understanding (16). Field notes are accounts describing experiences and observations. There is no one natural or correct way to write what one observes. However, what is important is that writing these notes is done discreetly so as to not disturb the actors in the field. Often, they are written immediately after an observation while the information is still fresh. We also recommend speaking observations into a tape recorder and then having these notes transcribed. The field notes will become the data that will be analysed by the research team. They should be as detailed as possible. For example, rather than writing 'the head nurse came into the room', the observer would write, 'a woman who was addressed by others more formally enters the room I learn from later queries that she is the head nurse' or 'I assume she is the head nurse'. Such detailed writing helps keep separate one's assumptions and on what they are based, which is a matter of interpretation, from facts 'I learned from later queries'.
In summary, what is observed ('data') is inseparable from the observational process. Researchers should give special attention to indigenous meanings. Field notes are an essential grounding for writing a broader, coherent account. They should detail the social and interactional processes of people's everyday lives and activities (17).

Insider/outsider
Ethnographers talk about their role as 'insider/outsider'. They are insiders insofar as they are immersed in a particular setting, yet they are outsiders as they do not hold a permanent place there. The degree to which some participates in a study setting can vary from complete participation (for example, a nurse studying care in her own field) to complete observation (for example, a social scientist studying clinical work in a family practice unit). Ethical concerns regarding power dynamics are different depending on who is doing the observing and who is being observed. This is particularly salient for physicians wishing to undertake observations related to patients given power inequities.

Authorial voice
An important and ongoing debate in ethnography relates to the question of whose voice should guide analysis, the observed or the observer (18). It is important to always distinguish in our accounts 'the facts' of what people are doing and our interpretation of their actions. For this reason, ethnographers often identify a 'key informant' from within the setting in which they are observing in order to 'test out' their assumptions and perceptions. Member checkingthe process of confirming one's analysis with those who are members in the field-is another important way to ensure that the voice of the researcher does not dominate any account.

Time
Social science ethnographies typically take place over an extended period of time (typically 1 year or more). Ethnographic studies in health care can range from a few days (rapid cycle evaluation) to a few months. Generally, shorter time frame has a more directed focus, such as the evaluation of an intervention or tool such as a guideline. For primary care research, however, the quality of observations in part is determined by the length of time in the field. As a general rule, longer is better because it offers more in-depth data. This usually means striking a balance between richness of data and fiscal constraints.

How do we evaluate quality?
Research should be evaluated according to its own paradigmatic standards (19) (epistemological and methodological standards). In qualitative research, meanings are not intended to be generalizable but rather transferable. Therefore, qualitative research requires different criteria for assessment. We might distinguish between procedural criteria and substantive criteria. Procedural criteria might refer to things such as how the team practised and reported reflexivity; did they describe adequately how themes, concepts and categories were developed from the data; were the data collection, record-keeping and analysis systematic and documented clearly (transparency)? In addition to such procedural criteria, we urge researchers to consider substantive criteria such as substantive contribution ('Does the piece contribute to our understanding of social life?') and impact, to name but a few (18).

Putting it all together
• Ethnography is a qualitative methodology that uses 'qualitative methods' such as observation (participant and non-participant), interviews and textual analysis. It is the 'emphasis on observation alongside' other qualitative methods as well as the 'analytic focus on culture' that are the cornerstones of ethnography. • As with all qualitative research, 'theory' is integral to all stages of qualitative research, from study design through the analysis phase. • Ethnographers recognize that it is impossible for the researcher to be truly removed from the ethnographic research process; objectivity is neither feasible nor desirable. Accordingly, ethnographers must be attuned to their own assumptions and theoretical worldviews and must think critically about how these shape the research process. This process is called 'reflexivity'.
• In primary care research, ethnographers often work in multidisciplinary groups so as to benefit from the perspectives and expertise of a range of disciplines. • Prolonged exposure in the field through immersion allows the ethnographer to build relationships and gain an understanding of the broader social context in which the research is embedded. • Researchers take 'field notes' to capture their observations. Field notes are accounts describing experiences and observations. • In qualitative research, meanings are not intended to be generalizable but rather transferable. The epistemological and methodological standards for evaluating qualitative research are therefore different from those used to measure rigour in quantitative studies.

Conclusion
Ethnographic research is an important approach for gaining insights that may have great significance to family medicine, such as patient experiences and clinical practice. Conducting good ethnographic research also requires experience and training. In our opinion, because of this, researchers who engage this approach may find that it often leads to many wonderful opportunities for interdisciplinary collaboration between clinicians and medical sociologists and anthropologists, social scientists and qualitative researchers, greatly enhancing the reach and expertise of all. Those interested in learning more about how to design and execute an ethnographic study may wish to consult the many references we have included in this article.