STEPHANIE KUMPUNEN

Long-form ethnography is a long-term investment…but rapid ethnography can help sometimes

Traditional long-form ethnography on health and care services has proven essential to understanding the social and cultural aspects of illness and care provision. As a research approach for quality improvement, ethnography has been described as able to help us to identify conditions of risk and complex areas where there are long chains of causation (Dixon-Woods, 2003) and “expose the nuances of culture and what actually happens in the setting (work as done rather than work as imagined)” (Cupit et al., 2018, p.2). Ethnography has also been described as a route to understanding the professional, organisational and cultural aspects of context, which can ultimately reveal the ‘what and how’ of improving patient care, as well as the barriers to doing so (Black et al., 2021; Leslie et al., 2014). Yet, in most cases, traditional long-form ethnography is a long-term investment of time and energy, with regular observation occurring over weeks, months and years (Wolcott, 2005).

Despite the value and wide use of traditional long-form ethnography in health and care research, in some circumstances, there is a need to provide rapid evidence to policymakers and practitioners (Black et al., 2021; Leslie et al., 2014). An example of which is hotspots of drug-related loss of life arising across the United State and a national agency sending in a multidisciplinary research team to investigate the risk environment and make recommendations on how deaths can be prevented. Alternatively, think of a multi-country nurse researcher team joining forces to explore how fellow nurses provide information about newborn home care to parents in Kenya in response to reported challenges. Rapid ethnographies allow for the production of rapid evidence while not losing the depth on social processes and context provided by ethnographic approaches.

As a health and care policy researcher who has worked in a range of settings, including academia, NHS services, and government, I am particularly interested in rapid ethnographies because of their ability to contribute not only academic findings but also make practical recommendations for change and improvement in services and policies. Rapid ethnographies can provide a fruitful route to knowledge exchange and translation among key stakeholders across health and care, which is an important goal for university-based researchers.

What are rapid ethnographies?

Rapid ethnographies developed when researchers from various disciplines, but especially from within public health, began adapting traditional long-form ethnography to address their research needs and inform decision-making (Wall, 2014). The work they were doing was described as ‘sociological ethnography in applied research’ or ‘ethnographically-informed rapid research’. But quickly new terminology arose to describe the approaches including examples such as: ‘rapid ethnographic assessment’, ‘participatory rural appraisal’, and ‘rapid assessment procedures’. These approaches often relied on inexperienced teams without backgrounds in disease-based research skills or qualitative research and included people from the cultural group of interest. Some of the main criticisms of the approaches were that they relied too heavily on structured field guides, limiting the scope for serendipity in fieldwork and lacked theory in their analyses (Vindrola-Padros, 2020).

In the contemporary literature on health and care services research, the umbrella term ‘rapid ethnographies’ encompasses approaches with similar characteristics, including focused ethnography, quick ethnography, rapid ethnography, short term ethnography, among other labels. These approaches share a range of common characteristics, such as:

• exploring shared practices and meanings of a group of people from a cultural lens;
• using short project timelines and short fieldwork visits (often under six months);
• having aims to make academic contributions but also practical recommendations for health and care services;
• employing multi-disciplinary teams to collect and analyse multiple types of qualitative and quantitative data; and
• harnessing the multi-disciplinary research team’s familiarity with the research topic and/or research setting to appropriately narrow the field of interest and make the most of researcher time in the field through intensive data collection.

Other key features of rapid ethnographies include: undertaking parallel iterative data collection and analysis; recording fieldwork in audio or video formats and fieldnotes; combining different types of data and triangulating them during analysis; and regularly disseminating findings to decision makers at critical timepoints (Vindrola-Padros, 2020). Many (but not all) also argue that a key feature of rapid ethnographies should involve drawing on anthropological and social science theories (Pink and Morgan, 2013).

How have rapid ethnographies be applied in the NHS?

Rapid ethnographies are carried out all over the world examining a range of clinical conditions and services among patient populations and clinical staff. For the purposes of our seminar on Ethnographies in the NHS, I took a deep dive into five rapid ethnographies on the NHS to examine their contributions to health and care services and policy in the UK.

Example 1: Bradshaw and colleagues (2022) aimed to explore the personal and social experiences of people on palliative care participating in hospice-based Tai Chi (including its impact in mitigating experiences of social death). They carried out their fieldwork in six months at one site using observation and formal and informal interviews. They used ethnographic creative non-fictions to analyse data and present the lived experiences of illness in palliative and hospice care populations. While previous research is available on the physical and psychological health benefits of Tai Chi, this study illustrated its social and relational value as a non-pharmacological intervention that complements holistic care aims of palliative care.

Example 2: Burgess and Choudhary (2021) aimed to identify the psychosocial factors and resources that enable successful coproduction (e.g., development of health services with service users) of community-based mental health services with minority communities in England. Over four months they carried out observation, formal interviews, participatory learning appraisal workshops, and focus groups – and analysed these using thematic network analysis. Their study analyses were informed by theories including Campbell and Cornish’s (2010) contexts of successful participation and mobilisation; Bovaird and Loeffler’s (2013) four levels of involvement in service improvement; and Foucault’s (1980) framework of power. They provided recommendations for future coproduction efforts.

Example 3: Burton and colleagues (2021) aimed to explore the factors influencing participant engagement with a UK-wide children’s obesity prevention programme using Damschroder and colleague’s (2009) Consolidated Framework for Implementation Research. They undertook fieldwork in five weeks across five children’s centres across the UK, carrying out observations, formal interviews, and focus groups. Using framework analysis, they suggested making changes to the funding and planning of the national childhood obesity programme at a local level as a priority before attempting to improve participant engagement.

Exmaple 4: Isaac and colleagues (2019) aimed to gain insight into the challenges faced by Welsh paediatric nurses when adopting a new nationally-standardised approach to ‘aseptic non-touch techniques’ (used to provide intravenous therapy). The team were guided in tehir observations and interviews across two paediatric wards in NHS Wales by Kirkpatrick’s (1994) model of training evaluation. They used qualitative content analysis to identify that levels of quality assurance in the adoption of standardised best practice varied based on workplace cultures, and thus more attention was needed on local staff training and development needs.

Example 5: Kordowicz and Hack Polay (2021) aimed to provide insight into community assets, multimorbidity and the dynamics of the relationship between them by describing the patient journey. They carried out three micro studies in two inner-London boroughs examining local planning documents, interviewing general practitioners and voluntary care providers working on multimorbidity, and examining community multimorbid patient stories with published online underlying the challenges they faced. Their total study duration was six months. They used framework analysis to describe some of the attitudes and perceptions towards multiple long-term conditions in communities to help to begin to reconceptualise the way that multimordibity is understood and managed locally in urban settings.

Looking across the five examples, the topics examined were complex. They ranged from research using a sociological lens to examine an intervention to mitigate a psychological phenomenon known as ‘social death’ among palliative care patients through to biomedically-focused research examining the challenges faced by nurses providing intravenous therapy. Despite the complexity of their research aims, sensitive nature of research, and potential vulnerability among patient participants, these studies managed to rapidly engage with local groups and collect data to answer their research questions. Three of the five examples used theory and frameworks to analyse their findings and provide useful academic contributions, but also provided practical recommendations around priorities for health services for healthcare providers as well as national and local health service planners.

What are the criticisms of rapid ethnographies?

As illustrated in the examples above, the benefits of rapid ethnographies, in brief, include their possible application to a variety of settings, their applied and practical nature, their increased affordability relative to long-term fieldwork because of their short duration (often up to six months), and their ability to make research findings available to practice and policy in a more timely way than long-form ethnographic approaches (Vindrola-Padros, 2020).

There are also many challenges to carrying out rapid ethnographies: one set linked to their relatively short durations, the other linked to their use of teams (Vindrola-Padros, 2020). Regarding duration, while there are no agreed standards, many anthropologists argue that ethnographic research takes time. Time is needed to build trust and relationships with participants and obtain greater insight into the lives of their participants and their own predispositions. This allows for detailed accounting surrounding both the emic (insider view) and the etic (outsider view) perspectives and therefore acknowledges the existence of multiple realities, an essential feature of an ethnography. A short duration may make it challenging for researchers to capture changes over time, find representative samples, be serendipitous in the field, or check against reactivity (e.g., the Hawthorne effect, in which research participants are assumed to alter their behaviour in response to being observed). Furthermore, short fieldwork durations may make it challenging to understand all relevant sociocultural factors at stake or document conflicts and contradictions in findings. It may also be challenging on short timelines to use Geertz’s technique of ‘thick description’ and critically reflect on findings; undertake member checking; explore additional topics with participants; and transform the data into socio-culturally acceptable solutions.

Another set of challenges relates to the use of teams in rapid ethnographic research. While teamwork is widely used in health services research, scholars who prefer lone (often traditional long-form) ethnographies suggest that having multiple team members might influence the reliability of the data. This is because researchers may have different levels of understanding of the topic and may collect and analyse data in different ways. Team working additionally requires recruitment, skills training or alignment, team-building activities and clear delineation of members’ roles – which can be difficult to arrange under time pressures.

Yet many of these time- and team-related challenges have been rebutted in the literature, and in particular by Vindrola-Padros (2020). Because rapid ethnographic fieldwork is captured in detail in audio and video recordings, data can be transcribed and line-by-line coded, leading to thick description. Proponents of rapid ethnographies and team-based research also argue that multidisciplinary teams bring different expertise and perspectives to a research project, leading to more comprehensive interpretations of findings. Additionally, several strategies can encourage standardisation of data collection and analysis within teams, including: (i) the use of standardised data collection tools; (ii) team training and discussions; (iii) shared processes of data collection;  (iv) cross-checking during team meetings; and (v) designating a member of the team to act as a cross-checker across collected data. Moreover, within teams it is possible to minimise potential biases through ‘team reflexivity’ whereby team members evaluate their positionality during fieldwork, discuss potential biases and ethical issues and reach consensus on how to move forward. Team-based reflexivity has been said to improve teamwork and contribute to the analysis of positionality in the fieldsite, a known challenge in rapid study timeframes.

Should my next ethnography be rapid?

Rapid ethnographies provide a useful route to making both academic and practical contributions to health and care services and research. They have been successfully applied in a range of settings and across a range of topics, including the few examples I provided on the NHS. However, rapid ethnographies should only be carried out under suitable conditions. Aiming for both rigour and rapidity is fundamental.

Here are a few questions researchers can ask themselves when deciding whether their next ethnographic study could be carried out as a rapid ethnography.

Does the researcher or team…

• have sufficient information about the research topic AND study setting to design an intensive but rapid data collection period (e.g., times and locations of interest to capture phenomenon under investigation)?
• have training in ethnography, sociological theory or anthropological theory?
• have processes or plans ready to engage in reflexive practice?

Is the research topic…

• sufficiently narrow or focused to enable a viable study plan within the allocated time?

Does the project…

• have sufficient budget for most or all members of the team to be involved throughout the phases of research to contribute their multidisciplinary expertise?

Has the potential study site shared…

• when they need research data to inform key decision making? If yes, does this align with a possible study design?

If interested in more information or training on rapid ethnographies, an introduction to rapid ethnography course is regularly available through Rapid Research Evaluation and Apprailsal Lab (RREAL). The course covers the information above in critical detail and situates rapid ethnographies among other types of rapid research, and is taught by one of my PhD supervisors, Prof Cecilia Vindrola-Padros. The course also offers some advice on how to report rapid ethnographies in health and care – as this is a known challenge. In due course, more developed guidance on transparent reporting of rapid ethnographies will be available, as this is the focus of my ongoing PhD work. I plan to add to the above checklist as well as produce detailed reporting and methodological guidance. Please feel free to get in contact with any questions or for updates at stephanie.kumpunen.19@ucl.ac.uk

References

Black, G.B., van Os, S., Machen, S., Fulop, N.J., 2021. Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review. BMC medical research methodology 21, 1–12.

Cupit, C., Mackintosh, N., Armstrong, N., 2018. Using ethnography to study improving healthcare: reflections on the ‘ethnographic’ label. BMJ Publishing Group Ltd.

Dixon-Woods, M., 2003. What can ethnography do for quality and safety in health care? BMJ Quality & Safety 12, 326–327. https://doi.org/10.1136/qhc.12.5.326

Leslie, M., Paradis, E., Gropper, M.A., Reeves, S., Kitto, S., 2014. Applying ethnography to the study of context in healthcare quality and safety. BMJ Qual Saf 23, 99–105. https://doi.org/10.1136/bmjqs-2013-002335

Pink, S., Morgan, J., 2013. Short-term ethnography: Intense routes to knowing. Symbolic Interaction 36, 351–361.

Vindrola-Padros, C., 2020. Rapid ethnographies: A practical guide. Cambridge University Press, Cambridge.

Wall, S.S., 2014. Focused Ethnography: A Methodological Adaptation for Social Research in Emerging Contexts. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research 16. https://doi.org/10.17169/fqs-16.1.2182

Wolcott, H.F., 2005. The art of fieldwork. Rowman Altamira.