Elise Paradis

Applying ethnography to the study of context in healthcare quality and safety

Background Translating and scaling healthcare quality improvement (QI) and patient safety interventions remains a significant challenge. Context has been identified as a major factor in this. QI and patient safety research have begun to focus on context, with ethnography seen as a promising methodology for understanding the professional, organisational and cultural aspects of context. While ethnography is used to investigate the context of a variety of QI and safety interventions, the challenges inherent in effectively importing a qualitative methodology and its social science practitioners into this work have been largely unexamined. Method and results We explain ethnography as a research practice grounded in theory and dependent on observations gathered and interpreted in particular ways. We then review the approach of health services literature to evaluating this sort of qualitative research. Although the study of context is an interest shared by both social scientists and healthcare QI and safety researchers, we identify three key points at which those ‘exporting’ ethnography as a methodology and those ‘importing’ it to deal with QI and safety challenges may diverge. We describe perspectival divergences on the methodologys mission, form and scale. At the level of mission we demonstrate how ethnography has been adapted to a ‘describe and feed back’ role in the service of QI. At the level of form, we show how the long-term embedded observation at the heart of ethnography can be adapted only so far to accommodate QI interests if both data quality and ethical standards are to be upheld. Finally, at the level of scale, we demonstrate one ethnographic study design that balances breadth of exposure with depth of experience in its observations and so generates a particular type of scalable findings. Summary The effective export of ethnography into QI and safety research requires discussion and negotiation between social scientific and health services research perspectives, as well as creative approaches to producing self-reflexive data that will allow clinicians to understand their own context and so improve their own processes.

Interprofessional collaboration and family member involvement in intensive care units: emerging themes from a multi-sited ethnography

Abstract This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach – gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature.

Louder than words: power and conflict in interprofessional education articles, 1954-2013

Interprofessional education (IPE) aspires to enable collaborative practice. Current IPE offerings, although rapidly proliferating, lack evidence of efficacy and theoretical grounding.

Beyond a good story: from Hawthorne Effect to reactivity in health professions education research

Observational research is increasingly being used in health professions education (HPE) research, yet it is often criticised for being prone to observer effects (also known as the Hawthorne Effect), defined as a research participants altered behaviour in response to being observed. This article explores this concern.

Key trends in interprofessional research: A macrosociological analysis from 1970 to 2010

The field of interprofessional research has grown both in size and in importance since the 1970s. In this paper, we use a macrosociological approach and a Bourdieusian theoretical framework to investigate this growth and the changing nature of the fields research. We investigate publication trends at the aggregate (field) level, using an original dataset of 100 488 interprofessional-related articles published between 1970 and 2010 and recorded in the PubMed database. Articles were coded using a list of 638 codes that were then analyzed thematically and longitudinally. Our results are presented in two main sections. Initially, we consider the growth and reach of the interprofessional field. Second, we explore the five different trends (“terminological issues”, “rising management rhetoric”, “expansion of psychometrics”, “shift from individualism to collectivism” and “emerging issues”) that emerged out of our thematic analysis of publications over time. These findings are discussed in the light of Bourdieus framework to provide an indication of what we argue is a growing legitimacy of the field of interprofessional research as a scholarly domain in its own right.

Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context

Abstract Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study’s multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study’s findings to other settings.

Sociology Is a Martial Art

Loïc Wacquant’s article ‘Homines in Extremis’ outlines five propositions about habitus that support a broader and richer use of Bourdieu’s famous concept. His article was a response to a new edited volume by Sanchez and Spencer under the title Fighting Scholars. In this article, I support Wacquant’s argument, but suggest that he undersells habitus as a topic of and tool for inquiry. I point to previous conversations about habitus and suggest that we may learn more about social phenomena by engaging the relational aspects of habitus and the social aspects of the incorporation of habitus.

Understanding the Nature of Interprofessional Collaboration and Patient Family Involvement in Intensive Care Settings A Study Protocol

Although effective interprofessional collaboration is a key component of patient safety and quality improvement initiatives, little is known about the nature of collaboration in ICU settings. Through ethnographic research, this study will explore interprofessional care in 8 ICUs (6 based in the United States and 2 based in Canada), develop an empirically based readiness/diagnostic tool to assess the quality of team-based care delivery, and develop interventions to strengthen team-based care and patient family involvement. Our study has 3 iterative phases and will involve: a scoping review of the literature on team dynamics in the ICU, an ethnographic study (observation, shadowing, interviews) across 8 sites over 2 years and the collection of clinical outcomes data to inform the development of a “diagnostics” tool for interprofessional collaboration and family member involvement in ICU care, as well as interprofessional intervention development. The importance of ethnographic and other forms of qualitative...

A Typology of ICU Patients and Families from the Clinician Perspective: Toward Improving Communication

ABSTRACT This paper presents an exploratory case study of clinician–patient communications in a specific clinical environment. It describes how intensive care unit (ICU) clinicians’ technical and social categorizations of patients and families shape the flow of communication in these acute care settings. Drawing on evidence from a year-long ethnographic study of four ICUs, we develop a typology of patients and families as viewed by the clinicians who care for them. Each type, or category, of patient is associated with differing communication strategies, with compliant patients and families engaged in greater depth. In an era that prioritizes patient engagement through communication for all patients, our findings suggest that ICU teams need to develop new strategies for engaging and communicating with not just compliant patients and families, but those who are difficult as well. We discuss innovative methods for developing such strategies.

The Tools of the Qualitative Research Trade

References: 1. Chen C, Teherani A. Common qualitative methodologies and research designs in health professions education. Acad Med. 2016;91. doi: 10.1097/ACM.0000000000001392. 2. Green J, Thorogood N. Qualitative Research Methods for Health Research. 3rd ed. Los Angeles, CA: SAGE; 2014. 3. Brinkmann S, Kvale S. InterViews: Learning the Craft of Qualitative Research Interviewing. 3rd ed. Thousand Oaks, CA: SAGE; 2015. 4. Stalmeijer RE, McNaughton N, Van Mook WN. Using focus groups in medical education research: AMEE guide no. 91. Med Teach. 2014;36:923–939. 5. Mays N, Pope C. Observational methods in health care settings. BMJ. 1995;311:182–184. 6. Kuper A, Whitehead C, Hodges BD. Looking back to move forward: Using history, discourse and text in medical education research: AMEE guide no. 73. Med Teach. 2013;35:e849–e860. Author contact: elise.paradis@utoronto.ca Choosing the right qualitative research method is like choosing the right tool: When trying to cut a plank, a hammer is mostly useless. A key question to ask when attempting to choose the right qualitative research method is thus, What are you trying to do? Identifying your goal should help you choose the right method. Remember, however, that (1) your tools will be more useful if carried in the right toolbox (i.e., methodology or approach),1 (2) your research will be more impactful if you join a scholarly conversation by using theory and relating your work to that of others, and (3) each method has pros and cons.