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Ethnographic Case Study Research

Cases on Quality & Safetyunderstanding how risks are constructed & controlled

Justin Waring

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Introduction• Ethnographies are commonly focussed on interesting ‘cases’

– Communities– Organisations– Work roles

• Ethnography provides a way of acquiring the holistic depth and detail typically associated with case study research– Understanding the organisation of social life in context and from

the perspective of those involved

• Illustrate this through two examples of how ethnography can help us understand the complexity of living cases

The Case Study Approach

• Case study research is about depth of understanding:– “…the case study allows and investigation to retain holistic and

meaningful characterisation of real-life events” (Yin, 1989:14)

• Case study research is less about method and more about theoretical focus, study design & sampling– “A case study is not a method but a research strategy.” (Hartley,

2004: 323)

• An approach for focusing in a purposively selected ‘case’ to understand how & why it is organised, practiced or experienced

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Cases & Case Studies• Case study research is diverse

– Organisations or organisational change– Occupations or groups– Communities or Cultures– Events, Processes or Situations

• Key questions– Why a case study approach?– What is the case or unit of analysis?– Why was the specific case selected?– What does it tell us about the wider issue?

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A contested approach?• Points of debate?

– It is difficult to generalise or develop general propositions from case study research?

– There is a lack of external validity or control?– Case study research is better for generating rather than testing

hypotheses?

• Such debates, perhaps, say less about the case study approach and more about the underlying epistemologies (or insecurities) of the discipline…what counts as evidence!

Ethnography

• For understanding how a particular organisation, culture or people (cases) are socially ordered– Shared meanings, actions and interactions– Symbols, rituals and ceremonies that order social practice – Prevailing social structures, rules and organised practices

• Most ethnographic research is case study research– A particular community or group– A specific organisation or workplace– A particular place, setting or event

Ethnography as methodology• A set of assumptions about the nature of the social world and

how it can be researched

• Common principles & design features– Exploratory & Open to the unexpected– Holism – Relativism– Constructivism & Interpretivism– Emic or insider perspective

• ‘Making the familiar strange and the strange familiar’

Ethnography as a method• A set of practices & techniques for collecting data

• Common methods & techniques– Prolonged & in-depth engagement & immersion– First-hand (participant) observations – Small chats, conversations, informal interviews– Unique & changing research roles– Analysis of materials, documents & archives– The process of ‘becoming’ or getting to understand the people

• Akin to being a tourist on holiday…we are all ethnographers!

Ethnography as an account

• A descriptive and explanatory account of a particular case, culture or community

• Common features of an ethnography– ‘Thick description’ of a set of people in time and place– Empirically diverse and rich in detail– Move from empirical description to conceptual and theoretical

statements– Often inductive, providing grounded theoretical accounts– Theoretically & Analytically diverse

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Ethnographic case studies on quality & safety• Series of ethnographic case studies

– Introduction of new incident reporting & RCA practices

– Threats to safety in the operating theatre & discharge processes

– Communication & problem-solving in clinical settings

• Two illustrations of the ethnographic case approach– How clinicians make sense of risk (organised meaning)

– Ritualistic behaviours in response to risk (organised action)

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1. Making sense of clinical risk• Increased policy & research on defining & measuring risk

– Taxonomies & risk registers

• But knowledge & sense-making are ‘situated in practice’– Emerges through co-construction & interaction– Reflects shared beliefs and values

• So, how do clinicians perceive, interpret and make sense of risk or safety?– Do different views suggest cognitive bias, or rather different

cultures or processes of sense-making?

Researching the social construction of risk

• Close observations of everyday clinical work– As clinicians recognise and react to ‘issues’ or ‘uncertainties’– As clinicians discuss with others ‘unfolding events’ – As clinicians engage in formal or expected procedures

• Conversations and informal interviews– What is going on here?– Why do you seem agitated?– How could this be different

• Focus on People, Events, (re/inter) Actions!

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Example of common interaction

• Reporter [scrub nurse]: I still don’t know what happened to it [surgical swab]. It doesn’t make sense.

• Sister: Well we’ve checked the theatre, twice.

• Reporter: The count was correct before we started. Suzie made the count with me. I just don’t now what happened. I really don’t.

• Sister: Don’t worry these things happen. You still need to complete an incident report.

• Reporter: I know. That’s why I’m here. But I just don’t know what to put. I can’t put it just disappeared can I.

• Sister: Just give as much detail as possible. And put down all the steps that we took to find it.

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Making sense of risk• Uncertainty & Ambiguity

– Not always possible to understand or articulate events

• Emotional– Feelings of guilt, regret, sadness and blame common

• Responsibility– Causation, reasoning & blame

• Interactive & co-constructed– Cycles of discussion, inter-subjective sense-making,

confirmation,

Why is this important?• Risk knowledge reflects underlying cultural and moral institutions

– Shared cognitive frameworks for determining what is right or wrong (risky) behaviour or what should happen after identifying a risk

• Key individuals act as ‘sense-givers’ or ‘moral entrepreneurs’– Those with seniority, experience or influence reinforce norms

• Clinicians’ expectations can diverge from formal classifications– Failure to report or follow organisational policy– Doctors, nurses & managers all make sense of risk in different ways

according to their shared cultures

• The ‘case’ focus moves from the event, to the interactions, to the sense-making, to the meaning, to the culture, because they are all inter-connected

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2. Ritualistic behaviours

• Policies emphasise the importance of a ‘safety culture’– Shared understanding, attitudes and behaviours that support

safety & learning

• But cultures & cultural practices are difficult to change & often operate at a tacit or taken-for-granted level

• So, what are the ritualistic type responses to uncertainty or hazard– Rituals as culturally prescribed & customary practices– Rituals reinforce shared norms & values and denote membership

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Researching ritualistic behaviours

• Close observations of clinical practices in the operating theatre– What happens on an everyday basis – what are the ‘normal’

practices or rituals of work– What are the outlier events – things out of the ordinary or that

garner special attention– How do people respond in these circumstances – how do

behaviours work to reinforce & restore normality?

• Follow-up interviews– Find out what was going on– Explore how others might respond in similar cases?

Ritualistic behaviours

• Tolerate – Where events are accepted with little reaction or change– Normal, everyday, part of the job!

• Accommodate– Where events require small modifications in normal practice– Expected to cope, with parameters of good practice

• Innovate– Where new or unorthodox practices are experimented to respond

to unexpected events– Balance of risks, based on experience & “judgement call”

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Why are these important

• Demonstrates a particular way of constructing risk ‘in situ’– The close connections between sense-making (tacit) and action

• Highlights the normalisation of risk & emphasis on fire-fighting– Suggests that it is important to get on with the job at hand (surgery)

rather than stop procedures

• Ritualistic behaviours reinforce expected behaviours – what it means to be professional!– Professionals should be able to cope with the uncertainty

• Knowledge about the ‘case’ is deepened through focusing on behaviours & inferring about the meanings and cultural norms

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The ethnographic case approach

• In-depth, inclusive & holistic approach– Attention to what happens in context– Need to infer from meanings and actions to culture and social

organisation

• Ability to vary focus & explore inter-connections– zooming-in and zooming-out– People, places, events

• Ability to draw upon different methods, but maintaining attention to the socio-cultural dimensions

• Enables the identifying & elaboration of emergent issues & testing & clarifications of existing theories

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