Ethical and methodological challenges in conducting institutional ethnography within South African long-term care facilities

Abstract

Institutional ethnography offers a critical framework for examining how institutional structures coordinate everyday experiences, yet its application in long-term care settings introduces unique ethical and methodological challenges. This paper reflects on the first author's experiences in conducting an institutional ethnographic study in five South African government-subsidized long-term care facilities, where the quality of life of older residents is coordinated by complex social and ruling relations. Using a triangulated approach that combines in-depth interviews, participant observation, and institutional text analysis, the study identifies key methodological and ethical tensions: navigating ethical complexities, negotiating institutional gatekeeping, managing multiple data sources, and maintaining researcher reflexivity and positionality. Practical strategies to address these challenges are proposed, contributing to the methodological discourse on conducting research in resource-limited and structurally constrained environments. These reflections underscore the necessity for methodological flexibility, ethical responsiveness, and critical reflexivity in resource-limited and structurally constrained environments. The insights provided herein offer valuable guidance for researchers aiming to employ institutional ethnography in similar social care contexts.

Introduction

The following reflections are based on a doctoral Institutional Ethnography study that aimed to understand the social relations shaping the quality of life (QoL) of older people in government-subsidized long-term care (LTC) facilities in South Africa. Data were gathered through a combination of observations, in-depth interviews with informants, and the analysis of institutional texts across five purposively sampled LTC facilities. The fieldwork, conducted from February 2023 to September 2023, was approved by the Stellenbosch University Health Research Ethics Committee (reference number: S22/06/105) and authorized by the Department of Social Development (DSD), which governs LTC facilities. In this paper, we highlight key tensions and propose strategies for navigating the complexities of IE. In doing so, we seek to advance methodological discourse and provide practical guidance for researchers undertaking similar studies in structurally constrained environments.

IE has emerged as a powerful sociological approach to revealing the social organization of everyday life, particularly within complex institutional settings (Campbell and Gregor, 2002). Developed by Smith (2005), IE challenges conventional research methodologies by shifting the focus from abstract theoretical constructs to the lived experiences of individuals, and how these experiences are coordinated by institutional structures. This approach has gained some traction in health and social care research, where it provides critical insights into how institutional structures coordinate the delivery of care, frontline work, and the experiences of marginalized populations (Ferdinands et al., 2022; Isiaka, 2024; Morton-Ninomiya, 2015; Rankin, 2017). However, while IE offers a unique and valuable lens for examining institutional dynamics, its implementation presents a set of ethical and methodological challenges that require careful navigation, particularly in settings involving vulnerable populations (Bisaillon and Rankin, 2013).

Given the structural inequalities and resource constraints characteristic of the South African healthcare and social welfare sectors, conducting research in these settings raises important considerations related to power dynamics, informed consent, participant vulnerability, and the role of a researcher in an institutional setting (Akpa-Inyang and Chima, 2021; Ngene et al., 2023; von Köppen, 2025). Additionally, IE's epistemological stance of beginning the inquiry from people's standpoints, rather than from positivist claims of objectivity, unsettles conventional methodological approaches. It therefore requires reflexive, relational, and context-responsive strategies for data generation and analysis (Carpenter and Mojab, 2024; Kearney et al., 2019; Smith, 2005). In engaging with these challenges, this paper contributes to the growing body of literature on the application of IE in diverse global contexts, extending discussions on ethical research conduct, methodological rigor, and the implications of institutional inquiry for policy and practice (Cupit et al., 2021; Isiaka, 2024, 2025; Karlsson et al., 2024).

Institutional ethnography as a methodological approach

IE is a distinct mode of inquiry grounded in a particular ontology, epistemology, and theory of the social, and focuses on exploring institutions from the perspective of marginalized and disempowered groups (Smith, 1987). This approach aims to map out ruling relations and understand how institutional powers produce, organize, govern, and coordinate people's local social environments, knowledge, practices, and activities (Campbell and Gregor, 2002). The primary goal of IE is to uncover ‘how things are actually put together’, and ‘how things work’ within an institutional framework dominated by these ruling relations (Smith, 2006b: 1; see also Ion, 2020). Smith defines ruling relations as the broad institutional, managerial, and professional systems that govern and organize society and social life, these being textually mediated (Smith, 1987). IE researchers uncover and explain how ruling relations regulate, organize, and coordinate people's behaviors, practices that are often beyond conscious awareness (Rankin, 2017). Ruling relations are not explicit; rather, they are subtly produced through texts, particularly when texts are linked to the social organization of power (Campbell and Gregor, 2002). Texts can be written, oral, or visual, examples include films, newspapers, policies, reports, computer programs, social media, patient chart forms, and other institutional documents (DeVault and McCoy, 2006).

IE has gained increasing recognition as a sociological approach that critically interrogates institutional structures and ruling relations from the standpoint of those affected by them (Smith, 2005, 2006b). Despite its contributions, IE has been the subject of methodological critique, particularly regarding its theoretical underpinnings, engagement with agency and resistance, reliance on textual coordination, and its applicability across diverse institutional settings (DeVault and McCoy, 2006; LaFrance, 2019). These critiques raise important considerations for researchers employing IE, particularly in the context of healthcare and social policy research. A recurring critique of IE concerns its positioning as an approach rather than a fully developed methodology or theory (Malachowski et al., 2017; Walby, 2013). Smith (2005) explicitly rejected the classification of IE as a theory, arguing instead that it constitutes a way of investigating social organization by tracing how ruling relations coordinate everyday life. However, some scholars contend that research is situated within theoretical paradigms and that IE implicitly draws from critical ethnography, Marxist political economy, and ethnomethodology (Carpenter and Mojab, 2024; Grace, 2019; Walby, 2007). Additionally, while IE critiques positivist epistemologies for their detachment from lived experience, its own epistemological stance has been questioned with regard to its reliance on a ‘problematic’ rather than a hypothesis-driven inquiry (Babuç, 2023; DeVault and McCoy, 2006; LaFrance, 2019). Unlike traditional ethnographic or phenomenological approaches, IE does not aim to interpret meaning, but rather to map institutional coordination. This distinction, while valuable, has been critiqued for lacking a systematic analytic framework (Malachowski et al., 2017; Rankin, 2017). Some scholars have argued that IE's analytic process remains too fluid and under-theorized, which may contribute to inconsistencies in application across studies (Tummons, 2017; Walby, 2007).

IE's emphasis on ruling relations has been critiqued for potentially marginalizing individual agency. That is, by focusing on how institutions coordinate experiences, it risks portraying individuals as passive subjects of institutional power rather than as active agents of change (Eastwood, 2006). While Smith (2005) maintained that IE does not deny agency, but rather reveals its institutional structuring, the methodology has been challenged for its limited engagement with resistance and contestation. This critique is particularly relevant in healthcare settings, where patient and practitioner agency play a critical role in shaping care delivery. In response, recent IE studies have sought to incorporate resistance as a central analytical category, examining how actors engage in micro-level negotiations within institutional frameworks (Foo et al., 2021; Sutton, 2023). IE posits that institutional coordination occurs primarily through texts, policies, forms, regulations, and digital records, that link local practices to translocal power structures. While this textual analysis is a distinguishing strength of IE, it may overdetermine the role of texts in shaping institutional life, thereby underestimating the significance of non-textual, interpersonal, and affective dimensions of social organization. Additionally, scholars have raised concerns that IE's textually mediated approach may be less applicable in contexts where oral traditions, embodied knowledge, and informal networks play a dominant role in institutional coordination (Caspar et al., 2016; Morton-Ninomiya, 2015). This limitation is particularly relevant in contexts such as South Africa, where cultural and traditional structures play a central role in social organization. In such settings, indigenous governance, informal caregiving networks, and traditional healing practices often coordinate institutional coordination in ways that may not be primarily mediated through texts.

Furthermore, IE's commitment to context-specific inquiry has led to questions regarding its generalizability. Unlike positivist approaches that seek replicability and statistical representativeness, IE prioritizes an in-depth analysis of particular institutional settings (DeVault and McCoy, 2006). While this methodological orientation allows for rich, situated insights, it limits the broader applicability of findings, particularly in comparative research. However, IE scholars argue that the methodology's strength lies in its transferability rather than statistical generalizability. By situating findings within broader translocal processes, IE can offer insights that resonate across institutional settings without making universalizing claims. It is for this reason that some applications of IE have demonstrated its utility in comparative analyses by tracing similar ruling relations across diverse institutional environments (Grace, 2013; Rudrum, 2016). The practical demands of conducting IE research have been noted as a significant challenge. Our study has evidenced that this methodology, or, as some scholars may term it, ‘approach’, requires extensive ethnographic engagement, institutional mapping, and textual analysis, making it resource-intensive and time-consuming. This has led some scholars to argue that IE is best suited for well-funded research teams rather than individual researchers with limited resources (Reid et al., 2018).

In healthcare, and more so in academic research, where time and funding constraints are particularly pronounced, the feasibility of IE studies remains a concern. However, strategies to mitigate and overcome some of these challenges can be applied. In our study, the following strategies were employed: phased research designs, selective and purposive sampling, and iterative data collection, while maintaining methodological rigor. Additionally, literature pertaining to IE supports interdisciplinary collaborations as a means of enhancing the scope and impact of IE research, particularly in policy-oriented studies.

In summary, while IE offers a powerful framework for uncovering the institutional coordination of everyday life, it is not without methodological challenges. Key critiques highlight concerns regarding its theoretical positioning, engagement with agency and resistance, reliance on textual mediation, generalizability, and feasibility. The current study, rather than solely providing a critique of institutional structures, foregrounds the agency and experiences of older adults while contextualizing them within broader institutional processes. Despite its limitations, IE remains a valuable methodological approach for researchers seeking to critically analyze the social organization of institutional life. Our reflections focus on four key areas, highlighting our experiences in conducting IE, the challenges encountered, and the strategies employed. These areas include: navigating ethical complexities, institutional gatekeeping and access to data, managing multiple data sources, and researcher reflexivity and positionality.

Navigating ethical complexities

Confidentiality and anonymity challenges during observations

IE has emerged as a critical approach for uncovering the hidden social relations and ruling structures that coordinate everyday experiences within care settings (Smith, 2005). Its application in LTC facilities, however, presents unique methodological and ethical challenges, particularly concerning participant observation. Unlike conventional healthcare institutions, LTC facilities serve a dual function as both healthcare spaces and residential homes. This dual role necessitates heightened ethical sensitivity, particularly regarding privacy, autonomy, and the power dynamics that structure daily interactions. The current study employed participant observation as a method of inquiry, thus embedding ourselves within the daily routines of both residents and care workers. Observations involved at least 60 min of engagement per standpoint informant (older adult), documenting their participation in everyday activities. Additionally, care workers were shadowed during routine tasks, yielding approximately 30 h of observational data collection (Hlongwane and Ned, 2025). However, conducting participant observation in LTC settings required negotiating access at multiple institutional levels, navigating managerial oversight, regulatory policies, and hierarchical structures that govern care work.

A critical concern in IE's use of participant observation is the potential for the observer effect, whereby the presence of the researcher may alter the behaviors of both staff and residents (Hammersley and Atkinson, 2019; Roitenberg, 2022). This challenge is particularly pronounced in institutionalized settings, where structured routines and formalized protocols coordinate interactions. Unlike traditional ethnographic approaches that assume researcher neutrality, IE's explicit focus on mapping ruling relations means that institutional actors may self-regulate their behavior in response to perceived expectations (Balcom et al., 2021; Hildwein, 2024). This raises questions regarding whether observations capture authentic institutional coordination, or merely a performative enactment of care work under research scrutiny. To address these methodological concerns, we implemented a layered consent approach to uphold voluntary participation while ensuring the authenticity of institutional dynamics. Initial verbal consent was obtained from facility managers for general observations in communal areas. This was complemented by ongoing verbal assent from staff and residents to reinforce their agency in the process. For observations involving personal care activities or private conversations within resident rooms, written consent was required, ensuring that all stakeholders, including residents, care workers, and visitors, had the option to opt out. Despite these measures, institutional routines, hierarchical decision-making, and limited individual autonomy constrained participants’ ability to independently negotiate their involvement in the research. Furthermore, the institutional constraints of LTC facilities coordinated the research process in profound ways. Workforce shortages, high workloads, and rigid scheduling structures limited care workers’ availability for in-depth engagement. Observations revealed that care workers frequently exceeded their formal roles, managing physically demanding tasks such as transferring frail residents, addressing dementia-related behavioral challenges, and responding to medical emergencies. The rigid ‘clock-time’ structuring of LTC routines ensured efficiency in care provision, but simultaneously constrained research opportunities, limiting the flexibility required for spontaneous engagement.

Privacy and confidentiality were additional ethical concerns in conducting IE observations in LTC. Unlike traditional ethnographic settings, where researchers can foster informal, trust-based relationships over time, LTC facilities are characterized by constant institutional surveillance, managerial oversight, and structured break times, which limit private spaces for interaction. Papoutsi et al. (2010) concur, noting that observation work, particularly in small or closed institutions, can render difficulties in maintaining anonymity. The unique characteristics of participants may inadvertently reveal their identities, particularly in sensitive care environments. Residents frequently shared living spaces, and their autonomy in making personal choices, such as meal preferences, daily routines, and social interactions, was often constrained by institutional policies and funding limitations. The absence of private spaces made confidential interviews challenging, necessitating alternative strategies, such as conducting interviews under trees in secluded outdoor areas or requesting temporary access to private offices. For care workers, the presence of institutional monitoring further complicated engagement. The structured nature of LTC work meant that staff often hesitated to participate in discussions that might be perceived as critical of institutional policies. Unlike settings where researchers can engage in informal conversations to build rapport, LTC research requires the continuous negotiation of power dynamics and strategic alignment with institutional workflows to facilitate meaningful participation. Given these constraints, conducting ethical IE in LTC required an adaptive and context-sensitive research approach. Observations were strategically timed to engage care workers during quieter periods, thus minimizing stress-related barriers to participation. Transparency was maintained throughout the study by clearly communicating the researcher's role, continually reinforcing the voluntary nature of participation, and addressing concerns about surveillance.

Scholars critique the challenge of accurately capturing non-verbal, bodily interactions in ethnographic research, thus highlighting the limitations of observational methods, as researchers may experience difficulty in articulating these experiences, which can lead to incomplete or biased accounts (Förster, 2022; Roitenberg, 2022). In this study, particular attention was given to non-verbal cues of discomfort among residents, pausing observations when necessary, and consulting staff when ethical concerns arose. In addition, building trust with both facility managers and care workers was essential for navigating institutional hierarchies and minimizing gatekeeping barriers. Moreover, research activities were carefully framed within existing institutional workflows to ensure alignment with routine care practices, rather than disrupting them. These adaptive strategies were critical in negotiating the complexities of IE within LTC settings, ensuring ethical engagement, and preserving the integrity of institutional ethnographic inquiry.

Obtaining informed consent in institutional settings

Conducting IE in LTC facilities presents ethical challenges regarding obtaining informed consent, particularly when engaging with older adults who may have cognitive impairments. Ethical concerns surrounding autonomy, decision-making capacity, and voluntary participation are particularly complex in these environments, where cognitive abilities fluctuate over time and where institutional routines coordinate the ability of residents to express consent freely (Smebye et al., 2015). Scholars have long debated how to uphold meaningful consent in contexts where vulnerability is compounded by institutionalized power structures and cognitive decline (Greer et al., 2023; Healy, 2023; Iacono and Murray, 2003; Silva, 2017). However, these debates often challenge individualistic, Western bioethical models of informed consent, which emphasize self-determination. Such frameworks fail to adequately capture the relational and communal nature of decision-making in many non-Western settings (Tham et al., 2022). In African contexts, the ethical complexities of consent are further coordinated by deeply embedded social and cultural norms that privilege collective decision-making, hierarchical respect, and deference to authority figures (Akpa-Inyang and Chima, 2021; Osuji, 2014; Wasunna et al., 2014). This collectivist approach often contrasts with Western bioethics, which assumes individual autonomy as the basis for ethical research participation. Research has critiqued the assumption that decision-making should be entirely individual, pointing out that in African communities, older people, religious leaders, family members, and institutional authorities often play a significant role in decision-making processes (Akpa-Inyang and Chima, 2021). While this communal approach can offer additional layers of protection and support, it can also create ethical dilemmas, particularly when gatekeepers exert excessive control, limiting individuals’ ability to freely accept or refuse participation. To navigate these complexities, we adopted a continuous consent approach, recognizing that cognitive capacity and willingness to participate can fluctuate. Prior to participation, residents’ capacity to consent was assessed in collaboration with LTC staff, ensuring that only those who could meaningfully engage in the research were included. However, critiques of proxy decision-making in LTC research highlight concerns that institutional staff may act in the interest of the facility rather than the individual, raising questions about how power asymmetries influence the consenting process (Lord et al., 2015; Roach et al., 2023). In some cases, staff and managers framed consent as an institutional endorsement rather than an individual right, reinforcing institutional control over research participation. Research has also shown that residents, even when cognitively capable, may feel pressured by the presence of staff or family members, complicating their ability to provide authentically voluntary consent (Altawalbeh et al., 2020; Law, 2016). This aligns with broader critiques in qualitative research ethics, which emphasize the context-dependent nature of consent rather than viewing it as a static, one-time agreement (Kadam, 2017; Klykken, 2022; Plankey-Videla, 2012). For this reason, we ensured that consent was continuously obtained and rapport was built so as to ensure a trusting relationship where residents, staff, and facility managers could voice any concerns regarding the research process.

Thus, given these structural and cultural complexities, a context-sensitive, culturally responsive approach to informed consent is crucial in African LTC research. It requires active trust-building with institutional actors, continuous dialogue with participants, and flexible consent models that account for fluctuating cognitive capacities and social influences. Furthermore, this study brought to light the mechanisms by which power structures coordinate access and participation, alerting us, as researchers, to ensure that consent was not merely an administrative requirement but an ethically meaningful process. Conducting IE in African LTC settings necessitates a balance between ethical rigor and cultural sensitivity, ensuring that informed consent processes align with local realities while upholding the rights and agency of older residents.

Institutional gatekeeping and access to data

The legacy of South Africa's apartheid-era segregation and systemic neglect continues to influence perceptions of government-managed care institutions, while more recent events, such as the Life Esidimeni tragedy, have further deepened public mistrust (Durojaye and Agaba, 2018; Makgoba, 2017). The Life Esidimeni case, when over 140 patients with mental illness died due to neglect following their transfer from state psychiatric hospitals to under-resourced non-governmental organizations, exposed critical failures in institutional care and left a lasting impact on how families, residents, and communities perceive government-run facilities (Dhai, 2018). This history of institutional failure complicates the research process, particularly for studies involving vulnerable populations such as older adults, where concerns about neglect, abuse, and systemic inefficiencies remain prevalent (Jacobs, 2023; Lloyd-Sherlock, 2019). As novice institutional ethnographers conducting research in such settings, it was necessary to adopt an approach that was both ethically reflexive and methodologically adaptive to navigate these complexities. Research in LTC facilities requires careful engagement with participants who may have experienced institutional harm, necessitating trust-building strategies that acknowledge historical trauma. Scholars argue that gatekeeping in institutional research is coordinated by broader power structures that regulate what can and cannot be studied (McAreavey and Das, 2013; McFadyen and Rankin, 2016). What we observed in the current study, with the focus being a methodological critique of IE, is that access negotiations in hierarchical institutions are rarely neutral rather, they are embedded within organizational concerns about external scrutiny, reputational damage, and institutional control. Furthermore, the historical context of institutional neglect exacerbated these challenges, as administrators were often wary of research exposing systemic failures.

Balcom et al. (2021) note that IE is particularly vulnerable to ‘managed access’, where gatekeepers selectively regulate researcher entry points, shaping the scope of observational data and potentially skewing findings. For the current, broader, study, eight government-subsidized LTC facilities, registered with the DSD in a peri-urban South African community, were identified for potential participation, however, only five ultimately participated (Hlongwane and Ned, 2025). These facilities were selected based on their affordability and their role in providing government-supported care, making these critical sites for examining the institutional organization of QoL. However, accessing these closed institutions required prolonged negotiation, with the process spanning 6 months. The post-Life Esidimeni climate resulted in administrators being highly cautious, resulting in resistance from institutional authorities who expressed concerns about research uncovering systemic issues. Negotiating access to LTC facilities is not a linear process; rather, it is coordinated by institutional power structures and administrative and governance gatekeeping. Initially, engagement occurred at high-ranking levels of the DSD, where institutional fears regarding external scrutiny led to protracted discussions on ethical safeguards, confidentiality, and the protection of institutional reputations. This reflects broader concerns in institutional research, in that administrative control over access can significantly coordinate the scope and direction of ethnographic inquiry (Bisaillon and Rankin, 2013). Following approval from the DSD, the next challenge was physical entry into the research sites, requiring negotiation with multiple layers of institutional and informal gatekeeping. Within LTC settings, access had to be renegotiated at various entry points, including facility managers, frontline care workers, and informal influencers within the community. Gatekeepers in managerial positions often act as the primary channel of communication between researchers and lower-tier participants, potentially compromising ethical principles such as confidentiality and voluntary participation. This study revealed that gatekeeping in hierarchical institutions can lead to ‘curated access’, where managers control what aspects of institutional life researchers can observe. This presents a fundamental challenge to IE's objective of mapping ruling relations, as research data may be biased by managerial perspectives rather than reflecting the lived realities of lower-tier institutional actors. In this study, access negotiations required a multi-tiered approach, wherein trust was built, not only with formal institutional authorities, but also with informal leaders who held influence among residents and staff. This ensured the broader acceptance of the research process; however, gaining access was time-intensive and required ongoing negotiation, reflecting the inherent complexities of conducting IE in LTC settings. To mitigate the influence of curated access, strategies included: embedding informal interactions into daily observations to capture the subtleties of institutional life beyond official narratives; triangulating observational data with semi-structured interviews and informal conversations to validate findings and counteract potential bias, identifying ‘hidden’ gatekeepers, such as long-serving staff members or trusted residents, who could provide alternative perspectives on institutional power dynamics; and emphasizing participant agency, ensuring that both staff and residents could opt in or out of participation at multiple stages to maintain ethical integrity (Balcom, 2020; Meadows, 2024; Roitenberg, 2022).

Managing multiple data sources

IE is a dynamic and reflexive approach that involves managing multiple data sources, each aimed at uncovering the mechanisms by which institutional structures coordinate individuals’ everyday experiences (Smith, 2006b). The complexity of data sources exists in the interplay between institutional texts, participant interviews, and observation, each offering distinct insights into the social relations governing an institution. As Rankin (2017) notes, these data sources, when used in combination, reveal the complexities of institutional power that may not be visible through any single method. However, managing these sources effectively is not without its challenges, particularly in collating the amount of data collected, and in the contradictions existing between formal institutional structures and the lived experiences of participants. Notably, therein lies the strength of the methodology, as it is through these contradictions that the ‘problematic’ is brought to light. For instance, policies in LTC settings emphasize autonomy and dignity for residents, yet interviews and observations reveal how institutional constraints, such as rigid schedules, limit the practical realization of these ideals. The capacity of IE to reveal incongruities between institutional texts and actual practice is well documented in the IE literature, being identified as a strength (Grace, 2019; Walby, 2013). Furthermore, the literature supports the use of multiple data sources in IE to ensure the triangulation of findings and a more comprehensive understanding of the institutional dynamics at play (Marlina et al., 2025). Triangulation is a critical strategy in IE, as it allows researchers to cross-check data from interviews, observations, and institutional texts, thus enhancing the validity of the findings and making evident the analytical threads. For instance, in our broader study, while observation offered the necessary context in which to assess what was taking place, the interviews provided insights into the residents’ self-reported experiences, thus revealing whether residents’ actual, observable practices aligned with what residents themselves described. This combination of methods assisted in uncovering the often-invisible ruling relations that coordinate daily life in institutional settings. Additionally, textual analysis played a crucial role in linking the local (individual experience) to the translocal (institutional structures), as policies and guidelines directly influence behaviors in local settings (Smith, 2006a). By examining institutional texts, as researchers we were able to uncover how these documents regulate behavior, often revealing systemic issues that were not immediately apparent via interview or observation alone.

Some scholars argue that focusing on the power dynamics embedded in texts may obscure the capacity of individuals to resist or reinterpret institutional rules in ways that coordinate their experiences (Teghtsoonian, 2016; Tummons, 2017). In contrast, proponents of IE, such as Campbell and Gregor (2002), maintain that the methodology does not ignore individual agency, but instead seeks to uncover how institutional power coordinates the possibilities for action within a given context. By examining how individuals navigate, resist, or conform to institutional structures, IE highlights the dynamic relationship between individual agency and institutional power. Furthermore, the literature suggests that the integration of multiple data sources strengthens IE's ability to capture both the constraints and possibilities within institutional settings, ensuring that the analysis remains grounded in the lived experiences of participants (Smith and Griffith, 2022; Walby, 2013). The combination of interviews, observation, and textual analysis is what makes IE a powerful methodology for studying institutions. Each data source provides a unique layer of understanding, contributing to a more nuanced picture of how institutional practices and power dynamics unfold. While each method has its limitations, when used in combination, they offer a robust framework for uncovering the complex ways in which institutions govern and coordinate individual experiences. This multi-dimensional approach is particularly valuable in settings such as LTC, where the alignment or lack thereof between institutional texts and actual practices can significantly impact the quality of care and the well-being of residents. The use of triangulation, combining interviews, observation, and textual analysis, enables us to critically examine how institutional structures coordinate the everyday experiences of residents.

Researcher reflexivity and positionality in institutional ethnography

This section is based on the first author's reflections on the process of conducting this study. The pronoun ‘I’ is used to represent the first author, the principal investigator, as this discussion is largely grounded in her personal experiences, reflections, and interactions throughout the research process. IE emphasizes the need for deep researcher reflexivity and attention to positionality, particularly when conducting research in complex settings such as LTC facilities. Reflexivity in IE is twofold: researchers must critically reflect on how their own values, beliefs, and behaviors coordinate both the research process and their interpretation of data. Furthermore, researchers need to acknowledge how the study itself influences them, particularly when dealing with vulnerable populations (Isiaka, 2025; Reid, 2017). Reflexive practice is critical in understanding how institutional power dynamics, social hierarchies, and cultural practices coordinate the data collection process, as well as the researcher's emotional engagement with the participants. In African LTC settings, care practices are deeply rooted in cultural values and traditional familial structures, where care for the elderly has historically been a familial responsibility rather than an institutional one (Agyemang, 2021; Fan, 2007). The complexity of our role within this framework was exacerbated by having to navigate not only institutional norms, but also the broader cultural expectations of respect, hierarchy, and care. Johnson and Waterfield (2004) clearly articulate the researcher's contribution to the interpretative process, and the importance of the experiences, beliefs, and personal history that inform the research being acknowledged. These subjective biases, combined with critical reflection, are key to establishing the researcher's integrity and critical skills within the research process to ensure that the interpretation is valid and evidence-based. Reflexivity in IE involves a critical examination of how the researcher's personal, professional, and social context influences their interactions with the research participants and the overall research process (Rankin, 2017). This perspective aligns with Watt’s (2007) assertion that our viewpoints coordinate the questions we ask, the methods we use, and how we interpret data. Throughout the study, we acknowledged the limitations of my particular ‘standpoint’, or who I am and how I see myself in relation to others, and in relation to society (Williams, 2019). In this study, my personal biography has undeniably influenced my research focus on QoL for older people, particularly within the context of LTC facilities. Both my academic background in Occupational Therapy and Public Health, combined with my personal experiences of having a family member in an LTC facility, have led to a scholarly curiosity about the gap between the idealized expectations of care and the lived realities of residents. This convergence of personal, academic, and professional experiences has coordinated my research trajectory and the theoretical lens through which I analyze institutional QoL for older people. The notion of being an ‘insider’ in research is not static; rather, it is coordinated by the researcher's positionality within the institution and social context (Trowler, 2020). In this study, I navigated multiple identities, both as an ‘insider’ with professional experience in healthcare settings and as an ‘outsider’ in the research context, with my role as a researcher placing me in a complex power dynamic with both staff and residents. Trowler (2020) critiques the assumption of a fixed insider–outsider dichotomy, instead suggesting that positionality is fluid and context-dependent. This fluidity requires constant reflexive practice to manage the influence of personal biases while maintaining an objective and ethical research stance. As a researcher, it was crucial to acknowledge that my role in the study was not that of an objective, detached observer; rather, I brought one perspective among many in the co-construction of the lived realities of older residents in LTC settings (Campbell and Gregor, 2004). A key critique of IE research is the risk of researcher bias stemming from emotional immersion in the research environment. While close engagement with participants can lead to deeper insights into their lived experiences, it may also result in the researcher's personal emotions influencing their analysis. This is particularly problematic in emotionally intensive contexts such as LTC facilities, where researchers might develop empathy for residents that could color their interpretation of the data. To mitigate these risks, we advocate that scholars be continuously self-aware, ensuring that they critically examine how their positionality may impact their work (Isiaka, 2025; McFadyen and Rankin, 2016). Maintaining a reflective distance is challenging, yet necessary, to safeguard the integrity of the research process.

In addition, power dynamics within LTC facilities complicate the researcher's positionality. The role of gatekeepers such as facility managers and staff can significantly influence the researcher's access to residents and the data they collect. In African LTC facilities, where caregiving is deeply embedded in cultural and communal norms, the hierarchical relationships within the institution can affect the research process. These power structures often blur the divide between individual autonomy and communal decision-making, particularly when family members or institutional staff assume decision-making authority over residents (Smith and Griffith, 2022). Researchers must navigate these dynamics with sensitivity, ensuring that residents’ voices are genuinely heard and that informed consent is obtained in a manner that reflects the residents’ authentic autonomy, rather than being influenced by family or staff decision-making (Walby, 2013). Reflexivity and positionality are fundamental to conducting IE research in LTC settings, especially within African contexts. The complexities of working with vulnerable populations, the influence of power dynamics within the institution, and the need for culturally sensitive ethical practices contribute to the challenges of conducting research in these settings. While the insider–outsider dynamic remains fluid and context-dependent, the use of ongoing reflexivity, transparency, and sensitivity to local norms can facilitate mitigation of the potential biases and ethical challenges inherent in IE research.

Conclusion and implications

This study provides critical methodological reflections on conducting IE in South African LTC facilities, offering insights into the ethical and practical challenges encountered. By engaging with the institutional aspects of QoL, this research highlights the complexities of negotiating access, navigating gatekeeping structures, ensuring ethical engagement with key populations, and managing multiple data sources in institutional settings. Our reflections underscore the importance of continuous ethical reflexivity, and adaptive research strategies, when applying IE in structurally constrained environments. The negotiation of informed consent, the influence of institutional power on data access, and the ethical dilemmas inherent in participant observation necessitate a research approach that is both contextually sensitive and methodologically rigorous. This study contributes to the growing body of literature on IE by demonstrating its applicability in under-researched, resource-constrained settings. It emphasizes the role of researchers as active participants in shaping the research process, and as advocates for reflexivity as a critical tool for maintaining ethical integrity. Future research employing IE must further interrogate the impact of researcher positionality, institutional constraints, and the intersection of power and agency within care environments. Ultimately, this study advances methodological discourse by providing practical strategies for conducting IE in LTC settings while reinforcing the need for ethical commitment and critical engagement. By centering the voices of older adults and care workers, IE offers a powerful lens for uncovering the institutional structures that coordinate QoL, with implications for both policy and practice in LTC.