Anthropology is concerned with culture, and ethnography differs from other approaches by this emphasis. Culture can be defined as the way of life of a group – the learnt behaviour that is socially constructed and transmitted. The life experiences of members of a cultural group include a shared communication system. This consists of signs such as gestures, mime and language as well as cultural artefacts – all messages that the members of a culture recognise, and whose meaning they understand. Individuals in a culture or subculture hold values and ideas acquired through learning from other members of the group. The researchers’ responsibility is to describe the patterns of beliefs and behaviour and the unique processes in the subculture or culture they study. It must be stressed, however, that the values and beliefs of cultural members depend on their location in the culture or subculture in which they live, on their gender, age or ethnic group. Indeed, sometimes conflicting value systems may exist.

Social anthropologists aim to observe and study the modes of life in a culture. This they do through the method of ethnography. They analyse, compare and examine groups and their rules of behaviour. The relationship of individuals to the group and to each other is also explored. The study of change, in particular, helps ethnographers understand cultures and subcultures. In areas where two cultures meet, they might focus on the conflict between groups if this is seen as important, for instance, in studies of interaction with doctors and other health professionals.

Applying ethnographic methods – especially observation – helps health professionals to contextualise the behaviour, beliefs and feelings of their clients or colleagues. Through ethnography, nurses and midwives become culturally sensitive and can identify the cultural influences on the individuals and groups they study. The goals of ethnographers in the health arena, however, differ from those of researchers in a subject discipline such as anthropology or sociology. Much ethnography in education, for instance, was intended to improve practice. Health professionals too, see the production of knowledge only as a first step; on the basis of this, they seek to improve their clinical practice.

Sometimes health researchers examine subcultures and situations with which they are familiar.

Researchers distinguish between several types of ethnography, some of which overlap. The main ways of using this approach is through the following:

• Descriptive or conventional ethnography
  
• Critical ethnography
  
• Autoethnography

Descriptive or conventional ethnography focuses on the description of cultures or groups and, through analysis, uncovers patterns, typologies and categories. This is used in most ethnographic studies.

Critical ethnography has its basis in critical theory and, as discussed by Thomas (1993), Carspecken (1996) and Madison (2005), it involves the study of macro-social factors such as power and examines common-sense assumptions and hidden agendas and is therefore more political. Thomas (p: 4) states the difference: ‘Conventional ethnographers study culture for the purpose of describing it; critical ethnographers do so to change it’. Critical ethnography can be important for health researchers, particularly nurses, physiotherapists and mid-wives, because they are concerned with the empowerment of people. Indeed, Hardcastle et al. (2006) suggest that critical ethnography is used in healthcare research to address this issue of power in particular to emancipate the research participants. Using Carspecken’s approach, the researchers studied renal nurses’ decision-making and describe it.

Autoethnography implies that researchers centre their studies on their own selves, their thoughts and feelings rather than focusing exclusively on others. Of course, any qualitative study is reflexive and takes into account the feelings and thoughts of the researcher, but in autoethnography they tell their own experiences rather than those of others. Anderson (2006) distinguishes between evocative and analytic autoethnography; the former focuses on the feelings and experiences of the researcher, the latter is more analytic than descriptive and designed to discuss social phenomena reaching beyond the researcher’s own experience. The genre is often used in healthcare research (See discussion in Anderson (2006)).

Streubert Speziale and Rinaldi Carpenter (2007) cite many more specific types of ethnography, and they claim that there is no standard form. These approaches to ethnography might arise from different ideological or procedural bases, but they are similar in data collection and management.

Ethnographic methods were first used in healthcare, specifically in nursing in the United States. One of the best known nursing ethnographers is Janice Morse who has written several well-known texts and is probably the best-known qualitative researcher in the nursing arena and has qualifications in anthropology. Leininger (1985) uses the term ‘ethnonursing’ for the use of ethnography in nursing. She developed this as a modification and extension of ethnography. Ethnonursing deals with studies of a culture like other ethnographic methods, but it is also about nursing care and specifically generates nursing knowledge. Nurse ethnographers differ from other anthropologists in that they only live with informants in their working day and spend their private lives away from the location where the research takes place. Nurses, of course, are familiar with the language used in the setting, while early anthropologists rarely knew the language of the culture they examined from the beginning of the research, and even modern anthropologists are not always familiar with the setting, the terminology and the people they study.

Ethnography in the healthcare arena is applied research. Chambers (2000) uses this term in approaches that are linked to making decisions in the interest of clients and in the area of decision-making. In nursing and midwifery the method is used as a way of examining behaviours and perceptions in clinical settings, generally in order to improve care and clinical practice.

The ethnographic approach can also be a useful way of studying health promotion issues as it provides the social context and explores the social conditions in which participants live and by which they are influenced (Cook, 2005). In particular, critical ethnography offers an understanding of the differences and inequalities in the health of people.

Ethnographies in this field incorporate studies of healthcare processes, settings and systems. They are typified by observations of wards or investigations of patient perspectives or specific groups whose members have experienced a condition or illness. Socialisation studies are also important in the field of professional practice. They often examine the negotiation and interaction in the subculture of clinical practice or ward and classroom settings.

Schensul et al. (1999) give useful advice to ethnographers that might be adopted by nurse and midwife researchers too. They can take a number of steps:

• They describe a problem in the group under study.
  
• Through this, they understand the causes of the problem and may prevent it.
  
• They help the cultural members to identify and report their needs.
  
• They give information to affect change in clinical or professional practice.

Ethnographers do not always investigate their own cultural members. In modern Britain, health professionals care for patients from a variety of ethnic groups and need to be knowledgeable about their cultures. Culture becomes part of all aspects of healthcare because both professionals and clients are products of their group in a particular social context. Savage (2006) gives examples from the field of healthcare such as research carried out in hospice settings, studies on rules and rituals, pain and illness experience.

The main features of ethnography are the following:

• Data collection through observation and interviews
  
• The use of ‘thick’ description
  
• Selection of key informants and settings
  
• The emic–etic dimension

Data collection through observation and interviews

Researchers collect data by standard methods, mainly through observation and interviewing, but they also rely on documents such as letters, diaries and taped oral histories of people in a particular group or connected with it.

As in other qualitative approaches, the researcher is the major research tool. Direct participant observation is the main way of collecting data from the culture under study, and observers try to become part of the culture, taking note of everything they see and hear as well as interviewing members of the culture to gain their interpretations. Huby et al. (2007) make the point that data can be collected both formally and informally, which is one of the advantages of being immersed in setting.

Health researchers commonly observe behaviour in clinical or educational settings. The decisions about inclusion and exclusion depend on the research topic, the emerging data and the experiences of the researchers. The participants and their actions are observed as well as the ways in which they interact with each other. Special events and crises, the site itself and the use of space and time can also be examined. Observers study the rules of a culture or subculture and the change that occurs over time in the setting. It does not suffice, however, to use the fieldnotes for description only and add a description of the interview data. The participants’ accounts are transformed and translated by the researcher into more abstract and theoretical concepts as in most qualitative research reports.

Observations become starting points for in-depth interviews. The researchers may not understand what they see, and ask the members of the group or culture to explain it to them. Participants share their interpretations of events, rules and roles with the interviewer. Some of the interviews are formal and structured, but often researchers ask questions on the spur of the moment and have informal conversations with members. Often they uncover discrepancies between words and actions (‘words and deeds’)–what people do and what they say – a problem originally discussed by Deutscher (1970). On the other hand there may be congruence between the spoken work and behaviour. If any discrepancies exist, they must be explained and interpreted.

Ethnographers take part in the life of people; they listen to their informants’ words and the interpretation of their actions. In essence, this involves a partnership between the investigator and the informants.

The use of ‘thick description’

One of the major characteristics is thick description, a term used by the anthropologist Geertz (1973) who borrowed it from the philosopher Ryle. It is description that makes explicit the detailed patterns of cultural and social relationships and puts them in context. Ethnographic interpretation cannot be separated from time, place and events. It is based on the meaning that actions and events have for the members of a culture within the cultural context. Description and analysis have to be rooted in reality; researchers think and reflect about social events and conduct. Thick description must be theoretical and analytical in the sense that researchers concern themselves with the abstract and general patterns and traits of social life in a culture. Denzin (1989) claims that thick description aims to give readers a sense of the emotions, thoughts and perceptions that research participants experience. It deals with the meaning and interpretations of people in a culture.

Thick description can be contrasted with ‘thin description’, which is superficial and does not explore the underlying meanings of cultural members. Any study where thin description prevails is not a good ethnography.

Selection of key informants and settings

As in other types of qualitative research, ethnographers generally use purposive sampling that is purposive (criterion-based) and non-probabilistic. This means ethnographers adopt certain criteria to choose a specific group and setting to be studied, be it a ward, a group of specialists or patients with a specific condition. Some of researchers use samples from such subcultures as groups of recovering alcoholics and patients with myocardial infarction, or from professional education such as an investigation of mentoring. The criteria for sampling must be justified in the study and be explicit. Researchers should choose key informants carefully to make sure that they are suitable and representative of the group under study. Key actors often participate by informally talking about the cultural conduct or customs of the group. They become active collaborators in the research rather than passive respondents.

The sample is taken from a particular cultural or subcultural group. Ethnographers have to search for individuals within a culture who can give them specific detailed information about the culture. Key informants hold special and expert knowledge about the history and subculture of a group, about interaction processes in it and cultural rules, rituals and language. These key actors help the researcher to become accepted in the culture and subculture. Researchers can validate their own ideas or perceptions with those of key informants by going back to them at the end of the study and asking them to check the script and interpretation; this is called member check. (See also Chapter 18)

The bond between researcher and key informant strengthens when the two spend time with each other. Through informal conversations, researchers can learn about the customs and conduct of the group they study, because key informants have access to areas which researchers cannot reach in time and location. For instance, a midwife might wish to gain information about midwifery during the Second World War or a physiotherapist to discover the problems of working abroad, and have no access themselves to the past or the location. These researchers use informants who have this special knowledge, in these instances midwives who practised during the war or physiotherapists who have worked extensively abroad. Key informants may be other health professionals or patients. Patients are most often the cultural group being studied. They tell the nurses of their culture or subculture, and of the expectations and health beliefs that form part of it. Spradley (1979) advises ethnographers to elicit also the ‘tacit’ knowledge of cultural members – the concepts and assumptions that they have but of which they are unaware.

Fetterman (1998) warns against prior assumptions which key informants might have. If they are highly knowledgeable they might impose their own ideas on the study and the researcher; therefore the latter must try to compare these tales with the observed reality. There might be the additional danger that key actors might only tell what researchers wish to hear. This danger is particularly strong in the health system. Clients are aware of labelling processes and often want to please those who care for them or deal with them in a professional relationship. However, the lengthy contact of interviewer and informants and ‘prolonged engagement’ in the setting help to overcome this.

The emic-etic dimension

Ethnographers use the constructs of the informants and also apply their own scientific conceptual framework, the so-called emic and etic perspectives (Harris, 1976). First, the researcher needs an understanding of the emic perspective, the insider’s or native’s perceptions. Insiders’ accounts of reality help to uncover knowledge of the reasons why people act as they do. A researcher who uses the emic perspective gives explanations of events from the cultural member’s point of view. This perspective is essential in a study, particularly in the beginning, as it prevents the imposition of the values and beliefs of researchers from their own culture to that of another. The outsider’s perspective, the etic view, has been prevalent for too long in health care and health research. Outsiders, such as health professionals or professional researchers, used to identify the problems of patients and described them rather than listening to the member’s own ideas. Now, those who experience an illness are allowed to speak for themselves as they are ‘experts’ not only on their condition but also on their own feelings and perceptions; as Harris (1976: 36) states, ‘The way to get inside of people’s heads is to talk with them, to ask questions about what they think and feel’.

The emic perspective corresponds to the reality and definition of informants. The researchers who are examining a culture or subculture gain knowledge of the existing rules and patterns from its members; the emic perspective is thus culturally specific. For health researchers who explore their own culture and that of their patients, the ‘native’ view is not difficult to obtain because they are already closely involved in the culture. This prior involvement can be dangerous, because health professionals, by being part of the culture they examine, lose awareness of their role as researchers and sometimes rely on assumptions which do not necessarily have a basis in reality. Therefore reflection on prior assumptions is important.