Health Science Journal

This paper draws attention to the political urgency of identifying a critical approach in nursing research. Through the inductive logic of ethnography in uncovering meaning or a web of meanings, it is hoped to illustrate the value of examining the micro-levels of interaction among individuals, as it is a critical approach that gives body and presence to silent or less vocal representations of human behavior and social life. Critical ethnography is defined both as a process and as a product [1]. It is a social act and a systematic process that involves intensive and long-term participant observation, journaling (field-notes), study of any documentation (i.e. nursing reports, observation charts) and interviewing (ad-hoc or scheduled) [2].

A major limitation of traditional ethnography is the detachment between the researcher and participants, which contributes to the creation of a-historical and a-political stories in the past [3]. However in its revised format as “critical” ethnography, the close relation between researcher and participants is an advantage rather than a limitation, as it helps to portray the insider’s perspective of culture. A crucial role in this re-validation can be attributed to what we call reflexivity or critical reflection, an ongoing process in which the researcher acknowledges the social and historical factors that shape who the researcher is, thus, allowing the problematic representation of the participants and ownership of the research to be, at least partly, addressed [4]. In terms of data collection, the social researcher not only collects but also “produces” data through the process of critical reflection. This introspective and demanding process leads to the elicitation of powerful indigenous stories, always in collaboration with the study participants. This approach allows “multiple voices” to be heard and results in meaningful textual ethnographic accounts [3].

Therefore, critical ethnographers recognize the history of the research setting and take into consideration the political dimensions of the research–participant endeavour, unlike other research approaches which fail to acknowledge the power relations that exist among individuals [5]. In nursing research, the critical part intends to “inform nursing activities on the understanding that society is unequally constructed and regulated by dominant ideologies (i.e. biomedical model) that suppress alternate understanding” [3]. In a seminal research paper on reconstructing nursing relationships, where Manias and Street supported that critical ethnography was increasingly adopted by nurses as a legitimate research methodology, the researchers concluded that they were able to generate “valuable insights about previously hidden areas of nurse participants in a research group during all stages of the research group” [4]. Indeed, a significant number of studies have drawn from this approach and contributed to the build-up of substantial body of knowledge on suffering and caring [6,7,8]. Overall, these studies confirm up to an extent that the type of activities nurses do or not do in various work environments are profoundly affected by the encompassing discourses of ideology, gender and power.

Clinical decision-making offers a unique platform for illustrating the value of ethnographic approach. In order to allow the context in which decision-making takes place to inform any of our research activity, critical ethnography offers a valid “vehicle” in capturing a snapshot of the ICU “lifeworld” [9]. This approach allows a shift of our attention to less apparent but equally distinctive inter-subjective facets of daily hospital reality, where individuals seem to negotiate and re-affirm their professional identities every day, especially when formal organizational rules fail to do so [10].

In conclusion, critical ethnography can help nurse researchers in advancing theory, in generating future research questions, in acknowledging and highlighting “hidden” meaning and issues that usually lie in the periphery of the problem at hand. At the same time, critical ethnography may provide a “forum” in which nurses can work together in order to understand and mentally restructure their “clinical practice”, within certain culture and from a personal perspective in the participants’ own voice [11]. In other words, critical ethnography “unmasks” a web of contextual factors that stems from subjectivity, bringing to full visibility the art and science of nursing.

Acknowledgements

I am grateful to Dr Elizabeth Manias, Research Professor at Deakin University (School of Nursing and Midwifery) in Australia, for kindly accepting to review an earlier draft of this paper. I thank her for her insightful comments and suggestions.

References

1. Coughlin C. An ethnographic study of main events during hospitalisation: perceptions of nurses and patients. Journal of Clinical Nursing 2012; 22:2327–2337.
2. Morse JM, Field PA. Nursing research, the application of qualitative approaches. 2nd ed. Eds., Chapman & Hall, London, 1996.
3. Clifford J, Marcus GE. Writing culture: the poetics and politics of ethnography. Eds., University California Press, Berkeley, 1986.
4. Manias E, Street A. Rethinking ethnography: reconstructing nursing relationships. J AdvNurs 2001; 33(2):234-242.
5. Hammersley M. What’s wrong with ethnography? methodological explorations. Eds., Routledge, London, 1992.
6. Allen D, Hughes D. Nursing and the division of labour in healthcare. Eds., Palgrave Macmillan, England, 2004.
7. Coombs M. Power and conflict in intensive care clinical decision making. Intensive Crit Care Nurs 2003;19:125–135.
8. Liu W, Manias E, Gerdtz M. Medication communication through documentation in medical wards: knowledge and power relations. NursInq 2013;.doi: 10.1111/nin.12043.
9. Habermas J. The theory of the communicative action Volume 2, lifeworld and system: a critique of functionalist reason. Eds., Beacon Press, Boston, 1987.
10. Bucknall TK. The clinical landscape of critical care: nurses’ decision-making. J AdvNurs 2003; 43(3):310–319.
11. Robinson SG. The relevancy of ethnography to nursing research. NursSci Q 2013; 26(1):14-19