Ethnography is the science of describing (graphic) a group of people and their culture (ethno) (Fetterman, 2010; Oliffe, 2005). There is no agreed definition for ethnographic methodology but there are core assumptions that characterise the approach. A key element is researching people in their natural settings to gain the perspective of those being studied and to understand the meaning people apply to their own experiences (P. Oliver, 2010). The researcher’s first-hand experience
enables a personal understanding of the context and culture of the environment and of the participants’ roles and narratives. Common features include the study of societies and cultures everyday and already existing conditions, criterion-based and purposeful sampling, extended fieldwork, participant observation, and analysis of textual data to gain the perspective of those being studied (Creswell, 2007).
The inherent features of ethnography for assisting in the exploration and understanding of social settings and social phenomena make it the most appropriate approach to achieve the research aim and objectives of this study. Care homes (nursing) are secluded communities, each with their own rituals, routines and cultural value systems (Jakobsen & Sørlie, 2010). It has been identified that the culture of a care home shapes the care provided (André, Sjøvold, Rannestad, & Ringdal, 2014; Fear, 2009), including medication management (Nazarko, 2002). Therefore nursing practice in care homes (nursing) is intrinsically linked to and uniquely influenced by the care home culture. Using an ethnographic methodology provides the best approach for identifying the social reality of nurses’ decision-making, using the exemplar of PRN medication. PRN medication use is multi-dimensional. It requires resident participation, discourse between professionals, nursing records of reason for administration and medication response and of non-pharmacological interventions used (Lindsey & Buckwalter, 2012). PRN medication provides an opportunity to identify what takes place in terms of decision- making, the role of the nurse, and resident involvement.
Ethnography is an established research approach used in the understanding of social and cultural constructs associated with nursing practice, patient experiences, care delivery and organisational issues (Barton, 2008; Baumbusch, 2011; Oliffe, 2005; Savage, 2000; Seymour, Ingleton, Paynes, & Beddow, 2003). For example, Savage (2004) explored nursing accountability, Murphy and Dingwell (2007) researched the application of informed consent, Thomas and Lambert (2008) studied intermediate care services in Wales, and Brooks (2008) examined the relationship of the nursing profession to public participation. Ethnographic
research has also been undertaken in care homes (nursing), for example in Holland and New Zealand (Bland, 2002; Hertogh et al., 2004) to identify culture and understand nursing practice.
The ethnographic process focuses on the researcher learning the meaning that the study population hold about a topic (Creswell, 2009). Spradley (1979, p. 25) referred to the study population who are the ‘source of information’ as ‘informants’ rather than the term ‘participants’ now regularly used (Pollner & Emerson, 2007, p. 119; Ritchie, Lewis, McNaughton Nicholls, & Ormston, 2014, p. 55). In this study, the participants providing that information are staff and residents of the care home (nursing) (Burns & Grove, 2005).
In order to answer the research aim and objectives of this study, 3 key data collection methods have been identified and utilised: a review of care home documents and participating residents’ records (phase 1), observation of nurses’ and carers’ management of PRN medication (phase 2), and in-depth staff interviews (phase 3). The alignment of research objectives with the data collection methods is summarised in Table 4.1. Hockley, Dewer and Watson (2005) likewise used documentary review, observations, and interviews in an action research study that focused on EoLC conducted in care homes (nursing) involving nursing staff and resident participants with dementia.
Data collection and analysis were integrated during each phase, which is usual in ethnographic research as it allows the researcher to go back and refine questions and develop lines of inquiry in further depth (Pope, Ziebland, & Mays, 2000). Additionally, phase 1 was completing before phase 2 commenced and phases 2 and 3 ran concurrently but marginally offset. In this manner, each phase provided the opportunity to inform subsequent phases. The individual phases, data collection methods, and data analysis techniques are described in detail in Sections 4.6, 4.7, and 4.8.
Documentary evidence, observation and interviews are the main methods used in qualitative research (P. Atkinson & Pugsley, 2005) but in this study the documentary review was also used to yield quantitative data from residents’ records (e.g., resident population and medical demographics, PRN prescribing
rates). In this study, the quantitative data provides important data for ascertaining the potential scale of PRN medication management and the transferability of the results identified in the care home (nursing) studied to the general population of care homes (nursing).
Table 4.1 Alignment of Research Objectives with Data Collection Methods
Research objectives Data collection methods
Phase 1 – documentary review Phase 2 - observations Phase 3 - interviews
1. To identify the drugs prescribed for PRN
use in the care home (nursing). ü
2. To examine the social context in which the
use of PRN medication has evolved. ü
3. To examine the extent to which care home activities, customs, and the working culture influences the registered nurses’ clinical practice in relation to PRN medication management.
ü ü
4. To understand how ancillary staff and members of the primary care team influence PRN medication management in the care home (nursing).
ü ü
5. To investigate the involvement in decision- making of older people resident in the care home with the registered nurse in relation to PRN medication management.
ü ü
The use of observations of nurses’ and carers’ PRN medication management and in-depth staff interviews align fundamentally with an ethnographic methodology, enabling research of care home (nursing) staff in their natural medication management setting and understanding the meaning the staff apply to their own medication management experiences. The involvement of residents and focusing on a key practice or ritual of care home life reveals the culture and practice of care home nurses. Further, the methods align with the ethnographic ethos; that is the methods should not be intrusive, interfere with care, impact on relatives, friends or carers, or require active participation from residents who may lack mental capacity.
What the researcher decides to annotate is important as decisions made can have “a profound impact on the final ethnographic report” (Wolfinger, 2002, p. 85). Reflective
records were written by the researcher from the point of initial selection of the site until the completion of data collection. These were reviewed and further annotated as soon as possible after their creation because as Walford (2009, p. 127) writing on ethnographic field notes states:
“All recognise the limitations of memory and seek to record what they see and hear. Especially where the original notes are just brief, their meaning rapidly disintegrates unless they are expanded quickly after the event.”
The study design also allows for data triangulation, which is crucial in interpretivist, and, thus, ethnographic studies. Thorne (2000, p. 69) states:
“Ethnographic analysis uses an iterative process in which cultural ideas that arise during active involvement “in the field” are transformed, translated, or represented in a written document. It involves sifting and sorting through pieces of data to detect and interpret thematic categorisations, search for inconsistencies and contradictions, and generate conclusions about what is happening and why.”
Data triangulation enables the identification of inconsistencies and contradictions, and thus strengthens the study and increases the researcher’s ability to interpret the findings. According to Laine (1997, p. 49), Denzin (1978) identified data triangulation as using “a variety of data sources in a study”. More specifically Bowling (2009, p. 223) states Denzin (1978) proposed data triangulation as data collected “at different times, places, from different people or groups”. Data triangulation in this study means from 3 data sources at different times, as outlined above. Just as Hertogh et al. (2004, p. 1686) undertook participant observation in phase 2 of their study, stating “The aim was to supplement, specify and confirm the findings of phase 1”, so the aim of triangulation in this study is to increase the richness of the data and trustworthiness of the results by providing more vantage points.
An ethnographic methodology is not without potential issues. Angrosino (2007) supports the view that “Ethnographic research can be done wherever people interact in ‘natural’ group settings” but Froggatt (2004, 2005) warns how complex the care home (nursing and residential) context is, while Bland (2002) refers to it as challenging. The studies by Bland (2002) and Hertogh et al. (2004) reinforce that consenting
residents and following an ethnographic approach is lengthy. As detailed in Sections 4.5 to 4.8, this was also found to be the case here, with consent of participants being obtained over a 2-year time frame and data collection occurring over 15 months.