DISCUSIÓN

An anthropologically informed research design provided the overall methodological framework for this investigation. The medical anthropologist and health services researcher Elisa Sobo (2009) outlined the fundamental aspects of an anthropologically informed research design in her recent text ‘Culture and Meaning in Health Services Research: A Practical Field Guide’. In this text, Sobo (2009) recognised the practical limitations on full immersion in clinical settings and defined an anthropologically informed approach as “ethnographic in aim, even when contingencies mean that it cannot be truly ethnographic in scope (i.e., when immersion cannot happen)” (p. 77). As Sobo (2009, p. 76) notes, “most HSR (Health Services Research) cannot qualify as ethnography per se, simply because of the nature of what the communities under study are engaged in and the necessity for researchers to respect their workplace, health and rehabilitation, and sickroom and deathbed needs”. Like ethnographic research, an anthropologically informed approach places priority “on holism and a systems perspective that favours emic points of view, achieves critical distance, and takes a reflexive stance toward the research context” (Sobo, 2009, p. 77). Anthropologically informed research subsumes an ethnographic epistemology-even though it does not entail the fully- fledged ethnographic research process. Although this PhD study was not traditionally ethnographic, it “was anthropologically informed; anthropology’s ‘signature’ was valid” (Sobo, 2009, p. 76).

102 An anthropologically informed design underpinned this study, as ethical and access contingencies meant that immersion in and observation of student nurses’ ‘multicultural clinical interactions’ (Fitzgerald, 1992) was not feasible. In terms of ethical contingencies, there was the concern that observing student nurses in clinical situ would increase the level of anxiety for the students and alter their clinical placement experience. Gaining consent and access to carry out ethnographic research in clinical placement settings would have been difficult, and observation of student nurses’ clinical interactions could have added to the distress of service users. The level of anxiety for both student nurses and service users is likely to be heightened in mental health care settings. Indeed, the student nurses’ own ‘critical incident’ (Fitzgerald, 2000) accounts collected for this study, conveyed the everyday stresses of working in such pressured, and in many cases, distressing conditions. When considering the lack of power in certain occupational groups-such as junior healthcare staff (e.g., student nurses), these challenging ethical questions may be heightened (Savage, 2000). Similar concerns have been raised by Spence (1999) in her hermeneutical research on the experiences of New Zealand based nurses caring for culturally diverse service users. At the same time, the lack of opportunity to observe the actual practices of student nurses in ‘multicultural clinical interactions’ was a limitation of this study. As Lambert and Mckevitt (2002, p. 211) explain; “what people (including health professionals) say can be different from what they think and do”. Clinical interactions are shaped by contingent circumstances and forms of practical reasoning that are not always expressed orally in interview type situations. This project was anthropologically informed in other important respects. The student nurses’ ‘multicultural clinical interactions’ were contextualised in the wider ‘health care system’ (Kleinman, 1978; 1980; 1984) and the fluid culture of mental health nursing (Suominen, Kovasin and Ketola, 1997). Thus, the study was holistic and systems focused. The perspectives of the participants’ were prioritised by using methods that evaded, as far as was possible, the unnecessary imposition of researcher-driven categories on the data collection and analytical processes. As I will discuss in the following sections of this chapter, the primary method of this study drew upon ‘critical incident’ (Fitzgerald, 2000) focused ethnographic interviews (Spradley, 1979). ‘Critical incidents’ are a subset of the narrative technique (Fitzgerald, 2001) that is often used in anthropologically informed and ethnographic

103 health services research. The ‘critical incident’ focused ethnographic interview, “generates ‘thick’ description, uncovers tacit dimensions of practice and generates whole chunks of data” (McAllister, et al., p. 371-372). This approach also minimises the social response bias that may occur when discussing issues of research interest in general terms (Laws and Fitzgerald, 1997), and allows for the understanding of meaning in context (McAllister, et al., 2006). Furthermore, the analytical categories which emerged from this study were grounded in the data-an analytical process known as ‘inductive category development’ (Lincoln and Guba, 1985).

By taking a critically applied medical anthropological position (Shaw, 2005), critical distance (Browner, 1999) was attained in this PhD study. According to Sobo (2009), critical distance “entails the ability to question categories from an outside or detached perspective” (p. 72) and promotes an awareness of their socially and culturally constructed dimensions. This study critically examined the student nurses’ frames of reference (Tebbutt and Wade, 1985), the culture of mental health nursing, and the clinical placement settings in which the students were situated. Thus, I sought to escape the critical conundrum posed by the unnecessary opposition between ‘applied’ and ‘theoretical’ medical anthropology17

(Shaw, 2005; Hahn and Inhorn, 2009). My non-clinical background also meant that technically I was an outsider, and by this very status, I could maintain a critical distance. A reflexive stance was taken to the research context and to decisions about methodology, data collection, and the analytical process. As such, I have striven to present the methodological process in enough detail-so that others are able to arrive at similar conclusions.

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While scholars and practitioners in the health and nursing sciences (e.g., Kim, 1991; Brach and Fraser, 2002; Betancourt, 2004; Papadopoulos, Tilki and Lees, 2004) have shown a keen interest in the concept of ‘culturally competent’ health care (there are literally thousands of academic articles), the engagement of medical anthropologists (with important exceptions) has been less notable (Stone, 1992; Santiago-Irizarry, 1996; 2001; Lambert and Sevak, 1996; Laws and Fitzgerald, 1997; Fitzgerald, Clemson and Mullavey-O’Byrne, 1997; 2001; Fitzgerald, et al., 1997a; Hunt, 2001; 2005; Bonder, Martin and Miracle, 2001; 2002; 2004; Wayland and Crowder, 2002; Briggs, 2003; Taylor, 2003a; b; 2010; Manderson and Allotey, 2003; Sobo and Seid, 2003; Sobo, 2004; 2009; Fox, 2005; Hudelson, 2005; 2006; Hunt and DeVoogd, 2005; Shaw, 2005; Dein, 2006; Kleinman and Benson, 2006; Galanti, 2008; Sobo and Loustaunau, 2010; Willen, Bullon and Good, 2010; Good, et al., 2011). Shaw (2005) notes two broad medical anthropological approaches to the issue of cultural competence-those who seek to modify clinical practice and attempt to make it more culturally appropriate, and those who critique the models of culture and identity mobilised in such programs.

104 The methodological perspective of this PhD study also shared some characteristics with ‘focused clinical ethnography’ (Leininger, 1985; Kleinman, 1992; Muecke, 1994; Morse and Field, 1995; Roper and Shapira, 2000; Germain, 2001). Like focused ethnography, this study defined the notion of ‘key informants’ (nursing educators), as persons with a store of knowledge and experiences to share, relative to the phenomenon of inquiry (Roper and Shapira, 2000). This notion of ‘key informant’ is different to how the concept is interpreted in traditional ethnography, where the ethnographer has the opportunity to develop close relationships with their informants over time (Emerson, 1983). Like focused ethnography, this study was concerned with a delineated form of inquiry and with a relatively narrow band in the cultural spectrum of local worlds (Leininger, 1985). The cultural phenomena relevant to this study arose out of specific ‘cultural scenes’(Spradley and McCurdy, 1972), ‘social dramas’ (Turner, 1974), and ‘critical incidents’ (Fitzgerald, 2000), which were drawn

from accounts of ‘multicultural clinical interactions’ in placement settings.