Ethnography

Ethnography is considered to be an interpretive form of social research concerned with understanding (Crotty 1998) rather than the causality links of empiric research studies such as the studies of Meade et al. (2006). According to ethnographic methodology (Hammersley and Atkinson 2007 p1) involves:

‘The ethnographer participating, overtly or covertly, in people’s daily lives for an extended period of time, watching what happens, listening to what is said, asking questions – in fact, collecting whatever data are available to throw light on the issues that are the focus of the research.’

The use of ethnography in the health care setting is promoted for its capacity to understand the organisation of healthcare as well as accessing beliefs, behaviours and practices of those within the healthcare organisation (Savage and Scott 2005). Ethnography provides data with richness and depth in order to understand the social meaning of a particular setting, showing the everydayness that surrounds us; which can make a significant contribution to understanding a particular strategy or intervention (Brewer 2000). This methodology is particularly useful where information is new and unfamiliar or, where the special focus of the work is describing a culture, in a complex setting, to understand and capture different viewpoints (patients and staff) (Brewer 2000; Spradley 1980).

The over reliance of quantitative studies has already been discussed in this chapter as a rationale for choosing my differing ethnographic approach for the study. However further justification for utilising ethnographic methods to meet the study aim and objectives relates to the culture of rounding in the NHS and the local organisational context. The background to the study locally and in the NHS has been explored in chapter 2, rounding practice was championed by government policy and national senior nurse leaders. This led to a Trust wide implementation of rounding in 2012. However on examining the literature there is also a body of work, ableit a small body of work which prose a differing view to Meade et al. (2006) and replicant studies. These studies raised concerns which highlighted barriers to the successful implementation of rounding and the sustainment of effective rounding

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practice (Deitrick et al. 2012; Harrington et al. 2014; Fabry 2015; Walker et al. 2015; Toole et al. 2016). Staff feedback identified problems associated with rounding practice as burdensome documentation, lack of staff engagement, ritualistic processes and lack of time (Deitrick et al. 2012; Harrington et al. 2014; Fabry 2015; Walker et al. 2015; Toole et al. 2016). These studies were uncovering the beliefs, behaviours and practices of staff who performed rounding. The findings of the studies warrant further exploration as potentially they are exposing a different paradigm of rounding practice. Rounding processes could be subject to local assertions and beliefs which influence rounding practice. Therefore utilising an ethnographic methodology, with its capacity to understand social meaning would meet the aim and objectives of the study by describing and understanding the culture of rounding in the study setting.

A further important consideration is the context of the NHS and the local organisation as part of the NHS to the chosen study methodology of ethnography. Within the NHS literature the potential of rounding as a quality improvement tool for safety and quality is clearly articulated (Lowe and Hodgson 2012; Dewing and Lyons O’Meara 2013; Forde- Johnson 2014; Stoddart et al. 2014). In chapter 2 the link to rounding practice is made to other approaches used to improve patient safety and quality, Harm Free Care (DH 2011a), the NHS Safety Thermometer (HSCIC 2015) and the 6 C’s (DH 2012c). Therefore rounding practice is promoted as a means to improve practice and is located within main stream policy for the NHS and my own organisation. However this opinion of rounding may only be the case for senior nurses and managers. The understanding of rounding as a quality improvement tool and its policy context to frontline clinical staff may be different, particularly if the implementation of rounding practice lacked staff engagement. It maybe that staff viewed the implementation of rounding as additional documentation, additional work and a move away from individualised care. Therefore understanding the culture and value attached to the practice of rounding was an important way of meeting the study aim and objectives. The ethnographic method allowed for the observation of practice and seeking the viewpoint of staff and patients within a robust scientific framework.

Within my organisation, as discussed in chapter two, rounding or a version of rounding had been implemented prior to 2012, however the organisation wide roll out was in 2012.

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Within the organisation as with many other NHS organisations the Trust used service improvement methodology as a tool to improve patient safety and quality, the organisation was signed up to Harm Free Care (DH 2011a), the NHS Safety Thermometer (HSCIC 2015) and the 6 C’s (DH 2012c). Plus there was a degree of training to promote the use of quality improvement methods with staff. Attention had been given to the implementation of rounding and initially some training did take place, as discussed in chapter two, however within the organisational processes little emphasis was placed on appreciating the relationship between the nurse and patient to understand the process of rounding. Hence my studies aims and objectives sought through ethnographic methods examine and identify this relationship in order to seek its impact on patient safety and quality.

Ethnographic studies have been utilised in nursing previously when the examination of nurse/patient relations and practice has required in-depth observation (Sorrell and Redmond 1995; Burden 1998; Manias and Street 2001; Hill 2003; Savage and Scott 2005; Dixon–Woods et al. 2012). The focus here has been in relation to exploring fundamental aspects of nursing/patient care, including patient safety, nutrition, communication, privacy and dignity (Sorrell and Redmond 1995; Burden 1998; Manias and Street 2001; Hill 2003; Savage and Scott 2005; Dixon–Woods et al. 2012). These studies have congruence with my study on rounding which also investigates the meaning of actions and events related to nurse/patient care, communication and safety.

Ethnographic methods have the scope to examine a complex series of relationship interactions within the clinical setting. As such the nature of rounding can be explored in depth over a sustained period, potentially uncovering hidden practices associated with rounding that have previously remained unacknowledged. Methods of data collection involve observation, informal and formal interviews plus the collection of texts and imagines. This provides data from field notes, transcripts and documentary evidence designed to discover the cultural meaning of a social situation.

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