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Practical tips for conducting ethnography in a hospital environment

Researchers from South Africa and India share their experience of using ethnography as a research method in AMS and what they learnt from their study.
Hello, everyone. Welcome to this presentation. My name is Oluchi, and presenting with me are some of my colleagues, Vrinda and Surya. We are working on the ASPIRES project at research sites in South Africa and India. In the previous sessions, you will have been introduced to the use of qualitative methods to understand antibiotic prescribing in hospitals. In our research sites, we have employed ethnographic tools to explore antibiotic decision-making in selected surgical pathways, observing an interview with some health care professionals and patients involved in surgery. Whilst collecting data, we also commenced some preliminary analysis. And in this presentation, we share a bit of what we have learned.
Gaining access. For an ethnographic study, ethics approval is relevant. Following this approval, hardcore researchers contacted the selected surgical teams through key surgical team members. These key surgeons facilitated introduction to the rest of the teams. Meetings were held with these teams, where the study was introduced and a general overview was given. The specific objectives, that is to look at antibiotic prescribing and infection management, were not relayed, as this could lead to data bias. However, on being approached for an interview, or if any of the participants asked for specific objectives, we provided such. In both study sites, the teams gave approval for the researchers to observe practise and conduct interviews as required. Data collection and processing.
For data collection, we received extensive training with one of the study leads through pilot observations and interviews. We had discussions and reflections on the data collected. This highlighted our biases and assumptions. They also helped reorient us to the environment of the respective teams, and gave us some insight into the initial data quality. A data collection guide helped us to keep track of the research objectives. Ethnography is about observing participants in their natural environments. So we collected observational data as we shadowed the teams in their respective work environments. At times, we thought we seemed obtrusive, given that we were outsiders and non-participants to the research setting. Nevertheless, we showed up consistently.
We think such consistency enabled the researchers and participants get used to each other. Initially, we shadowed the same teams together, and compared notes after typing up our observations. With time, we grew more comfortable to split between subspecialties when it made errors. We’ve also learned to type up our observations promptly to aid detailed recall. For interviews, we approached the participant clinicians and patients individually with our request. Following this, we sent more formal invitation through email. We conducted interviews after informed consent was obtained. We used a semi-structured interview guide, and tried to keep our questions open-ended. This enabled participants to give detailed responses. With detailed responses to open-ended questions, participants seemed to become more at ease with the interview process.
We also learned that pauses are very important, enabling the subject to think more about the question posed in order to provide further insight. In all kinds of research, data management and storage is important. We anonymized participants to maintain confidentiality and stored data in password-protected spaces from where such data was extracted for processing and analysis. We also have a clear instruction for data storage and sharing. For data analysis, we are doing this even as we collect more data. Line by line coding of data facilitates clarity, development of coding framework, and helps us tailor future data collection. Reflexivity. Why is it important? Reflexivity enables the researcher to account for his or her presence in the data collection exercise.
As an instrument of the research, the ethnographer may be prone to compromised objectivity. Therefore, the researcher should approach the data with an open mind and awareness of one’s own biases. This helps the researcher learn from the data and remain faithful to participants’ experiences. To facilitate reflexivity, we endeavour to separate our observations from our reflections. For the observational data collection, two researchers were informed at each study site. Compared to data collection by one researcher, this offers a wider perspective. Such wider perspective can be an advantage when tailored within the confines of the research objectives. It also flagged assumptions related to our different backgrounds which we may have brought into the research.
As an example, I’m a clinical pharmacist and I had worked in the hospital prior to the study. Being acquainted with the study setting, I tended to overlook certain events during observational data collection, as I considered them routine. The same events were captured by Surya, who was new to the setting. But as an anthropologist with no prior clinical experience, I had difficulty interpreting the conversation among surgical teams, especially the medical terms used. This was better captured by Vrinda, whose clinical knowledge enabled her to grasp the context of the interactions. Hence, having more than one researcher conduct observations and compare notes helped us to validate observations and to learn from each other.
We are aware that data collection by more than one researcher may contribute to wider spread but less specificity. We address this by using a data collection guide, which helps ensure consistency in data quality. We also validated data using more than one data source, that is, multiple observations, case studies, and interviews. In addition, we collected quantitative data, which provided some background for our qualitative data. In observational research, participants modified their behaviour in response to researchers’ presence. For this, we spent time familiarising ourselves with and to the environment in which we conduct research. Furthermore, we took some of our anonymized observations and interview data back to the health care professionals and patients during the interviews.
This gave us a platform to validate our observations or explore alternate reasons for these. As a research method, ethnography has provided insight into the context in which the study teams work. We have noted that antibiotic-related decisions may depend on different factors, an example of which is team hierarchy. In one of our study settings, we saw that a patient’s financial status may influence antibiotic prescribing. These rich observations and insights have been made possible through shadowing of our teams and interactions with them, a very important aspect of ethnography. In our research, we seek to understand work cultures among surgical teams of interest and how this may affect antibiotic prescribing.
By affording us opportunities to observe recurrent practises at close range, ethnography has provided some insight into the context of antibiotic decision-making within the surgical teams studied. It has also given valuable feedback on key decision-makers and their influence on team practise. We think this research will help us bring well-contextualised snapshots of current practises, which we can feed back to the teams for their input. This, we think, will help identify pressure points in care, possibly opening opportunities for proactive management of such pressures. If interventions are deemed necessary, we plan to introduce these with input from the target teams, whose buy-in would enhance success of the intervention.
Since this is a multi-centre study, we also have opportunities to learn and adopt successful practises from one setting to another. We would like to say that, even though Antimicrobial Resistance, AMR, is a highly researched area mostly dominated by scientific researchers, this study has made us understand that incorporating social science methods can add a whole new perspective that may influence AMR. We, therefore, believe that in any environment where humans are involved, be it clinical or non-clinical, ethnography will be a valuable tool to explore various factors in the environment which could have an impact on the research in question. We would like to thank our sponsors, our lead and co-researchers for their support thus far in this study.
We would also like to express our sincere appreciation to our participants, the health care workers and patients who gave us the privilege and space to observe practises at close range and interact with them. Thank you for listening. We look forward to hearing your thoughts on this.

Listen to researchers from South Africa and India describe their experiences of conducting ethnography across surgical teams to better understand antibiotic use in surgical specialities.

Gaining insight from real life examples of the challenges faced in the field, and the solutions they developed, you will learn from the researchers who represent diverse backgrounds (nursing, pharmacy, and anthropology) about what ethnographic research entails and what can be learnt from it.

The basic principal of ethnography is observing participants in their natural, respective environments.

It is important to, when collecting data, be reflective and open-minded (especially being aware of your own personal bias). However, it is also necessary to separate observations from personal reflections.

The study was very useful and showed that antibiotic prescribing can depend on many factors. The perspective on work cultures and social dynamics, team hierarchies and the circumstances of patients (e.g. their financial situation), can all influence it.

The information learned can be used when introducing new interventions, and the team of researchers in this video believe that ethnography is a viable tool that can be used as a new perspective to influence AMR.

Please find a pdf of the PowerPoint slides in the downloads section below.

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Tackling Antimicrobial Resistance: A Social Science Approach

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