Theoretically Informed Hospital Ethnography: Reflecting on Method

Abstract

Disciplines anchor themselves using a particular kind of epistemology and ontology to produced it’s knowledge. In healthcare, quantitative research has been dominant were in social sciences, qualitative research was. However, in the last two decades, we have seen a mixing (better said in French with the word métissage) of strategies within those two disciplines. Despite the newfound acceptance of qualitative research within the healthcare field, some criticism about those strategies still exists and still impact the feasibility of conducting qualitative research, especially in hospital setting. More particularly, when it comes to the systematisation of the method, when conducting ethnography. In this paper, I argue that ethnography does remain scientifically rigorous, especially when it is informed by theory and used consistently. This article presents the ways in which I negotiated the uncertainties of doing a hospital ethnography on the use of the ventilator by using concepts from Latour’s (2005) Actor’s Network Theory, of ‘mediators’ and ‘intermediaries’. Staying attuned to various actors in the healthcare setting and taking care to ensure that whatever my research brought into the field maintained an intermediary status enabled me to alter my methods in the field while still respecting the necessity to gather data systematically.

Introduction

Aside from using different datasets, the social and healthcare sciences have distinct approaches to planning and conducting research. Prior to beginning research, healthcare researchers must plan and propose methodologies that follow established protocols, while the methods adopted by social scientists need to remain flexible. Social scientists employing ethnographic, or participant observation methods thus face many challenges when conducting research in a hospital setting. This was what I discovered when I first proposed and then conducted doctoral research as a medical socio-anthropologist on decision-making processes concerning using or discontinuing use of the ventilator (specifically the hybrid couple ventilator), commonly referred to as ‘life-support’ or the ‘respirator’. I planned to follow the hybrid couple ventilator/patients (intubated patients) using a Science and Technology Studies (STS) framework, specifically Latour (2005), to describe how patients came to be put on the ventilator and how different actors influenced that decision. The intubated patient, is referred to the hybrid couple, because it is the merging of machine and human that make possible this entity (Lock, 2002). Latour (2005) was chosen for the project, because this was the only theory at the time that was given equal attention to objects (non-human) and human actors.

I choose the ventilator as a technology of interest for a few reasons. Firstly, before I began my academic career, I was an allied healthcare worker, namely a Respiratory Therapist (RT), so had already mastered use of the ventilator as a medical technology. Secondly, because the ventilator mechanically takes over the breathing of the individual, it is an object with an ambiguous identity. On the one hand, it can be a powerful technological asset for saving lives. On the other hand, it can be seen as a futile technology when it fails to prevent the occurrence of death. The ventilator research project was therefore located at the boundary between life-saving measures and end-of-life decision-making processes. I then became increasingly interested in the subject of the ventilator and its usage when I noticed a large gap between what I was reading in the medical literature and what I was seeing and hearing in the hospital where I was still working as an RT.

My decision to concentrate on the ventilator as a technology influenced the context in which my project evolved. In Canada, the ventilator technology is exclusively used in critical care settings, so there are only certain areas within Canadian hospitals that have the capacity to accept and care for hybrid couple ventilator patients; when a human relies on a machine (non-human) to conduct. One of the most common places is the Intensive Care Unit (ICU). Although the ventilator can be used in the emergency room (ER) and post-operative areas, ventilated patients are usually shortly transferred to the hospital ICU. Since the ICU is a highly specialized biomedical unit with mostly unstable patients, access to this part of the hospital is limited, even for family members. Gaining access to and conducting ethnographic research within an ICU therefore comes with some unique challenges discussed in this article.

After receiving ethic approval from both the University (case #H03-15-15) and the hospital, I was able to move forward with my research. I did 705 hours of participant-observation (6 months) in an ICU in Ontario, Canada in 2017, I recruited and consulted with 121 people, including doctors, nurses, respiratory therapists, and patients’ family members and friends, to track their decisions around providing care to 15 hybrid couple ventilator/patients. Conversation and events were noted as they were unfolding using an IPAD. More specifically, during conversations, I was writing notes, then after the conversation I would rewrite as verbatim. Events were also detailed on IPAD and after were rewritten with more detailed. Memos were also noted after each day and discussed with supervisor during bi-weekly meetings. Based on events that occurred before and during my fieldwork, this article addresses some of the challenges of using ethnographic research strategies in the hospital setting and discusses how I overcame such challenges by using Latour’s (2005) Actor’s Network Theory (ANT) to adapt my methods. In highlighting some notions that are taken for granted by social scientists but not accepted in the biomedical world, the concrete examples presented in this article should be helpful to non-clinicians who want to conduct research in a biomedical setting as well as young scholars who have a healthcare background and now want to become social scientists. In proposing ways of grounding fieldwork practices in theory, this article will also be of interest to broader anthropological audiences.

Challenges of Conducting Fieldwork in the Intensive Care Unit (ICU)

Research challenges can present themselves at any stage of a project, even before the fieldwork has begun. I encountered my first problem when I proposed the ethnographic research project to the Research Ethics Board (REB) at the university and at the hospital. The comments I received on my proposal from these two REBs revealed some confusion amongst board members about what ‘participant-observation’ entailed. The main concern for them being that I would be participating, as a healthcare professional capacity. I also reassured both ethics committees that, even though I was a healthcare professional, as a student researcher, I was not going to be “participating” at the hospital in that capacity or executing any of the responsibilities of a Respiratory Therapist.

Once I began research in the ICU, I encountered further confusion over my research method, although this time my interlocutors challenged the ‘observation’ aspect of participant-observation, were they thought that I was not allowed to interact/talk to them during my study. I told the healthcare professionals that I was not just observing, but that I was “participating” in the ICU as a researcher because I was interacting with them as a human. That is, I was having conversations and sharing my opinions in the field. It was not until I began writing my doctoral thesis that I realized my reassurances to the two ethics boards (not participating) had been inconsistent with my answers to the two healthcare professionals (participating) (Wind (2008). I had inadvertently provided somewhat contradictory information about my research strategy to different people at different stages in my project.

Initially, I attributed these contradictions to my having failed to properly explain my research strategies in the first place. Writing about similar difficulties, Wind (2008) and Mulemi (2008); (2010) have noted that participant-observation seems to have two slightly opposed purposes in that it puts the researcher in an external position from which to observe at the same time as it puts the researcher inside the field as a participant. The participant-observation research strategy requires the researcher to inhabit and be incorporated into a community for a considerable time while participating in people’s daily activities. Participation becomes a form of role-playing in which the researcher assumes a role in the community to gain acceptance (Wind, 2008, p. 79). The problem for a social scientist in a hospital is that hospital participant roles are limited to three: that of the health care professional, that of the patient, and that of the visitor, that is, the family member or friend of the patient (Wind, 2008, p. 82). Wind (2008) and Mulemi (2010) argue that none of these roles are positioned to enable someone to study the hospital or healthcare field in any depth; only the researcher role is appropriate for conducting research. But because of how participation is defined within the hospital environment, the researcher is inherently a non-participant. Wind (2008, p. 87) attempts to get out of this circuitous trap by suggesting that researchers replace the term “participant observation” with “negotiated interactive observation”.

At first, I agreed with (Wind, 2008) that changing the term would enable researchers using ethnographic methods in healthcare settings to prevent future confusion. Upon further reflection, I have come to see that such misunderstandings do not merely arise from terminology alone. Rather, this miscomprehension has deeper roots. I believe it persists because we are dealing with two disciplines that sometimes employ the same method but come from different epistemological positions that are never clearly articulated. Said differently, the same method is being used under a different methodology, if methodology “refers to the rational and the philosophical assumption that underlies any natural, social or human science study” (McGregor & Murnane, 2010, p. 2) and method refers to the tools and techniques used by researchers (Campbell, 2016). The tool of participant participation is used in both health and social sciences, but with different underlying philosophical assumptions about the position of the researcher in the field (Giacomini, 2010; Ingold, 2014).

In healthcare, the ‘outsider’ position is favoured since it is supposed to give researchers enough ‘distance’ to gain knowledge of the ‘inside’. This resonates with a distinction made by Ingold in discussing the demarcation between “being in the world” and “knowing the world” (Ingold, 2014, p. 387). To know the world, the researcher must become invisible by taking on an already existing role such as a healthcare worker. This is meant to ensure ‘non-bias.’ Similarly, Mol (Mol, 2002, p. 152) draws on feminist critiques of research epistemologies (Code, 2014; Haraway, 1988) to argue that the “legislative” approach is pervasive in the healthcare field because researchers concerned with obtaining ‘valid’ knowledge often purge the context and subject from the research itself. To achieve this legislative approach, everything must be meticulously planned, and all risks must be evaluated before the research begins. Specific protocols must be followed to ensure that the data gathered will not be contaminated. Indeed, the concern to limit sources of bias came up in some of the other questions raised by the ethics boards before I entered the field and in inquiries from the healthcare team after I gained access to the ICU. However, I, like other social scientists who have preceded me, believe that the assumption that one can obtain uncontaminated data is false (Haraway, 1988; Ingold, 2014; Mol, 2002; Wind, 2008).

The epistemological position I take in my research is that there is no demarcation between “being in the world” and “knowing the world,” to borrow Ingold’s (2014) construction. My methodological concerns therefore fall under what Mol (2002) has identified as being of the “normative” kind. That is, I am concerned with acquiring “good knowledge” that “does not draw its worth from living up to reality. What we should see, instead, are worthwhile ways of living with the real” (p. 158). Ingold (2014) equates such “normative” research with the ontological commitment to doing participant observation, where there is always an “intimate coupling in perception and action of the observer and observed” (p. 388). He thus positions participant observation as simultaneously a way of knowing the world and a way of being in the world.

The main critique from the health sciences regarding this philosophical underpinning for doing this kind of fieldwork is that it may no longer be considered scientific. Scientists who are more on the positivist end of the spectrum are often unfamiliar with the findings derived from ethnographic research, which may seem to have resulted from random decisions on the part of the researcher. That is, ethnographic data may appear unsystematic, anecdotal, and lacking rigor (Chowdhury, 2015). These views can have a significant impact, first on the ability of social scientists to enter the healthcare field to conduct research, second on young scholars who have healthcare professionals on their evaluation team.

The ethics committees in hospital settings mainly comprise healthcare professionals or interdisciplinary teams trained under a biomedical framework; it becomes difficult to convince them that ethnographic research is legitimate. The difficulty of entering the field becomes even more of a challenge when the fieldsite is highly specialized or dealing with vulnerable populations or situations, as is the case at sites of palliative, pediatric, intensive, or emergency care. Even when researchers are able to gain research to fieldsites such as ICUs, they may find it difficult to publish their findings without being discredited.

In what follows, I argue that an ethnographic method philosophically based on living with the real and being concerned with the good does have scientific merit. The examples below are problems that I encountered during my research in an ICU. To solve them, I had to adjust and change my method as I encountered each one. Altering one’s method in the middle of fieldwork is normally viewed with concern, as the results may lack systematicity. I here refute this assumption by arguing that as long the researcher’s decision has a solid theoretical grounding, systemization is not breached. That is, researchers do not necessarily have to follow a strict, predetermined protocol in which every step has been specified and is followed throughout the research period. Instead, researchers should identify a methodological theory to help orient their decisions in the field, although how they implement the theory will depend highly on the field context and particular situations they encounter. In a sense, I am attempting to demonstrate how researchers might find a compromise between the social sciences and health sciences that is suitable for both disciplines. To illustrate this decision-making process, I begin by describing the theory I used to guide my research, then present a series of incidents in which I adjusted my method of conducting participant-observation based on this theoretical grounding.

Theory Used to Guide my Research

Conceptual Grounding

The main concepts presented here are not new to STS. This field of research postulates that scientific practices as a whole are shaped by the history, organization, and context in which they are applied (Law, 2004, p. 8). In other words, scientific knowledge is anchored and built upon practices. Several scholars have promulgated arguments following this line of thought, but the concepts that I found most useful for this discussion were presented by Latour in Reassembling the Social: An Introduction to Actor-Network-Theory (Latour, 2005). Latour argues, among other things, that the actors within any field of human behavior can operate as either mediators or intermediaries in any given situation. Latour’s use of the term ‘actors’ warns us that we are entering an uncontrolled environment. Each action might be borrowed, suggested, or influenced in many ways, so the action itself becomes uncertain (Latour, 2005, p. 46). Furthermore, no actor acts alone; there are always interactions happening between different actors. The word ‘actor’ in Latour’s sense thus suggests that we can never be clear on who or what is responsible for any action that occurs in the field. Latour, prefer the word ‘actors’ to ‘participants’ when referring to the humans who agree to be observed, interviewed, or otherwise participate in an ethnographic research project.

Actors can be humans, but they can also be non-human things, such as objects or animals (Callon, 1986). The importance of actors is not bound to human characteristics, but on whether they are acting as intermediaries or mediators (Latour, 2005, p. 46). An intermediary actor is one that does not change the action but acts exactly the way it must. Since the intermediary transports an action without mediation, the cause of the action can be detected. According to Latour, “for intermediaries, there is no mystery since inputs predict outputs fairly well: nothing will be present in the effect that has not been in the cause” (Latour, 2005, p. 58). For example, I push a book on the table and the book moves. The book is the intermediary to the action. No mediators are involved that might interrupt, modify, complicate, or otherwise transform the action of pushing the book.

By contrast, when the actor acts as a mediator, knowing the cause does not permit us to predict the effect. This is because the actor modifies the possibilities for action and reaction. As Latour explains, “for mediators, the situation is different: causes do not allow effects to be deduced as they are simply offering occasions, circumstances, and precedents. As a result, lots of surprising aliens may pop up in between” (Latour, 2005, pp. 58–59). Said differently, mediators change future possibilities in unpredictable ways and in multiple directions. Such changes are often subtle, but they leave traces of the social, which Latour refers to as the assemblage. Latour makes the compelling argument that the role of the researcher during fieldwork is to follow the mediators precisely because they are the source of the assemblage: they are the ones making connections.

Although Latour (2005) provides some guidelines as to what researchers should be studying, he does not indicate how the researchers themselves should behave during fieldwork. To put Latour’s Actor Network Theory into practice, I propose that researchers following mediators should acknowledge and remain attuned to the possibility that we or anything we bring into the field might become mediators. Since one of my methodological goals was to minimise the influence of whatever I brought into the field, I attempted to remain an intermediary myself and ensure that any objects I brought with me also remained intermediaries. When I realised that I or something I had brought with me had become a mediator, I systematically changed my behaviour and research strategies so that each mediator would return to and remain an intermediary thereafter.

Putting Theory into Practice

As a researcher, it is important to acknowledge that our presence does have an influence on the world we are trying to describe. It is also important to acknowledge the importance of the objects that we bring with us into the field. When we stay attuned to these we can achieve “good” and useful interactions with other actors involved in the fieldwork setting. To exemplify these points, I next reflect on four situations that arose during my field research in the ICU. All names used are pseudonym to respect confidentiality. The first two examples involve non-human actors—specifically, consent forms and audio recorders—that became powerful mediators when brought into the research field. The second two examples show how I inadvertently became a mediator myself, first by my very presence as a researcher and second by holding a double identity as a Respiratory Therapist and socio-anthropologist. I adopted different strategies for transforming the status of the actor from inadvertent mediator to intermediary in each of the four instances. Even though I changed my method so that I and things I brought with me maintained intermediary positions, my method remained systematic in that each change was made to remedy an unpredictable factor encountered in the field.

Geneviève: Consent Form as a Mediator

[I had just exited a restroom when suddenly a Registered Nurse (RN) called me over.]

RN: I think this is going to be really interesting for you.

Me: What’s going on?

RN: I’m not sure, but I think she [a patient on a ventilator] is in Vtac [ventricular tachycardia] and they are going to shock her.

[I approached the patient’s room, but it was difficult to see who was doing what because so many healthcare professionals were gathered around the patient. Some were even standing outside the room looking in through the glass door that separated it from the hallway. I could not understand why so many people were involved. Everything seemed disorganized. Monitors were ringing alarms and people were talking over one another. A man at the centre of the chaos was the only person near the patient who wore a shirt and clean pants instead of a hospital uniform. I assumed he was the presiding doctor because he seemed to be giving orders.

I noticed someone at the back of the room who did not seem to be a healthcare professional. She was not wearing a hospital uniform and was not interacting with anyone who was. She was just standing there with her eyes turned toward the patient and her mouth slightly open, as if she were witnessing something horrible. She held a cell phone tightly in her hands against her chest. I entered the room, approached this person, and asked her name.]

Geneviève: My name is Geneviève. I am Joannie’s [the patient’s] daughter.

Me: How are you feeling? Do you need anything?

Geneviève: I am really worried for my mother, but I do have confidence she is at the right place. Look at all the people that are taking care of her.

Me: It is impressive to see all those people working together.

Geneviève: Yes, for sure.

[I introduced myself.]

Me: I am a sociology student. I am doing some research on the process of making decisions about the breathing machine. Would you allow me to make observations?

Geneviève: No problem. There are always some difficult decisions and I find it really important to have research done on that subject. I have no problem with you making your observations.

Me: Thank you, this is really appreciated. This is the consent form that will need to be signed.

[I handed her the standard research consent form I had been using to recruit people for my study. She hesitated.]

Geneviève: You want me to sign this?

Me: Yes, it is a question of formalities.

Geneviève: No, I am not signing anything. It is too much! My mother is not doing well and you want me to sign something. My brothers should be consulted before I sign anything for my mother.

Me: I am really sorry. I did not mean to upset you. I will talk to you another time.

Geneviève: Okay.

[Two days later, I passed Geneviève in the hallway. She recognized me.]

Geneviève: You’re the student that is conducting research about the ventilator. Where is your form? I can sign it if you still need it.

Me: But I thought you did not want me to make the observations.

Geneviève: No, I had no objection to you watching. When you took out that paper, I got scared. I thought I had to sign something that would stop the treatment. I thought I had to make the decision right away.

Me: No, I do not make the decisions. I observe the decisions that are being made.

Geneviève: Now I understand. I think I was just too worried the other day.

[She signed my research consent form.]

Anthropologists have long recognized that consent forms can become powerful mediators, especially in situations where life and death are at stake. Lykes (1989) argued over three decades ago that some of the language used on standard scientific research consent forms may be perceived as paternalistic and might therefore be inappropriate for qualitative research, especially in a non-Western context (p.178). Fluehr-Lobban (1994) agreed with Lykes (1989) that the rules of engagement and giving consent may be quite different in different countries. Sometimes signing a consent form may be interpreted as something other than giving consent to collaborate with the researcher. According to Guillemin and Gillam (2004), the potential for misunderstanding the purpose of a consent form arises from the difference between procedural ethics and ethics in practice. Procedural ethics are rooted in institutional ways of defining what consent should be and what form such consent should take, usually a signature on a piece of paper. In Western countries, a written signature is the ultimate symbolic representation of a person agreeing to the terms indicated on the form (Chou, 2015). The form is understood to represent the consent process itself and signing it is the same as giving consent (Brittain et al., 2020). The consent form should be an intermediary, in Latour’s (2005) sense of the term.

Putting procedural ethics into practice adds complexity to the fieldwork situation, however. My research was conducted in a hospital setting in North America, where I fully expected that the rules of engagement and collaboration would be so well understood that asking someone to sign a research consent form could not possibly be misconstrued. Following procedural ethics ensures that the language used on the consent form is appropriate and that the information therein accurately reflects the proposed research to be done. And yet, in my interaction with Geneviève, the question arose: consenting to what?

One problem is that the timing of consent (i.e., when the form should be presented to an individual to be signed) is not an inherent part of the procedure. This problem relates to the ethics of practice. It is exemplified in the above situation when mistiming of the request for consent resulted in the consent form becoming a mediator to the situation. Geneviève ceased to understand that she was being asked to give permission to me to be a researcher observing decision-making processes around use of the ventilator. Instead, she thought I was asking for her consent to withhold treatment for her mother.

In the ICU context, the use of a research consent form requires some reflexivity and tinkering on the part of the researcher. To minimize such potential for misinterpretation, I decided to only ask for verbal consent to observe while life-threatening situations were in progress, then wait a day or two before asking for a written signature on the consent form. Delaying the timing for obtaining written consent (i.e., signatures on forms) made it more likely that the research consent form would remain an intermediary rather than become a mediator acting unpredictably on the situation.

Tomas, MD: Audio Recorder as Mediator

[I was sitting in the hallway outside a patient’s room when a doctor named Tomas passed me and entered the room. I could hear the doctor talking to the mother of the patient in the room. I reconstructed their conversation from notes I took on my tablet at the time.]

Tomas: Good day, I am the doctor that is responsible for the ICU today. Your son is really sick. He will need surgery. As per the CT scan, they will need to do a pancreatectomy using laparoscopy. We don’t do this surgical procedure here, so he will need to be transferred. We already gave him some blood [because] his hemoglobin was below 7 g/dL. Can you sign here? This document indicates that you are okay with us giving him the blood.

Mother: Yes, okay, just do the best for him.

Tomas: This is exactly what we are doing.

[The doctor left the room. About 15 minutes later, I asked the mother if she would be willing to answer some of my research questions. She agreed.]

Me: What did you understand from the conversation with the doctor?

Mother: My son is really sick. They gave him blood and they’re doing their best to save his life. I think he needs surgery, but I don’t know what that is about.

Me: What did you sign?

Mother: I don’t know. I think it was for the blood that they had already given him. I am not sure. I just want him to get better.

[I left the room and sought out the doctor to ask him some follow-up questions. I took notes during our conversation, but did not record it using an audio or video device.]

Me: Do you realize that she did not really understand what she signed?

Tomas: I know, but I don’t think she will understand much anyway. She is in shock. She just wants her son to get better. For now, that is what we are doing. Why bother her with something she does not have the capacity to understand?

Me: Why do you give her a consent form for blood if you have already given the blood? What is a consent form?

Tomas: It is a formality. This is a hospital and we are in a bureaucratic world and at times, the form is part of the things we need to do to make sure we are protected.

[A week later, I recorded a formal, semi-structured interview with the same doctor, in which I asked essentially the same questions.]

Me: What does consent mean?

Tomas: It is when we explain to the family or the patient the risk and benefits of doing a treatment. To verify if the person has understood, you always need to make them explain to you what they are signing.

Me: Does it ever happen that you make someone sign consent for something you have already given?

Tomas: Absolutely not. A consent [form] needs to be done before a procedure unless the patient is in a life-threatening situation.

Me: Is a patient with hemoglobin below 7 g/dL in a life-threatening situation?

Tomas: No. We would expect the family to come in or the patient to sign consent before giving blood [in that situation].

Before entering the field of the ICU as a social scientist, I did an extensive literature review on end-of-life decision-making processes. I noticed a large gap between what I was reading in the academic literature and what my peers at the hospital were telling me while I was still working alongside them as a Respiratory Therapist. At the time, I wondered if the discrepancies were a result of my own positionality. As a working healthcare professional, I thought I might not yet understand the sociological implications of what was happening around me. I also noticed that most of the academic literature reported data from semi-structured interviews, so I also wondered if the problem was with the types of standardized questions that were being asked in the interviews. It was only until I started researching as a social scientist that I began to understand that researchers are adding another actor into the mix when they record interviews: the audio recording device itself. This is exemplified in the scene above when the doctor responded differently to similar questions when the recorder was present compared to when it was not. When he spoke without being recorded, he described the consent form as just a bureaucratic formality and he did not object to my mentioning that he had only gotten the form signed after the treatment had been given. However, when he was being recorded, he said that consent involved verifying that people understand what they are giving signing, and that they are never given consent forms to sign before the treatment is given.

The gold standard for interviewing people for qualitative research projects is to record all interactions so the audio can later be transcribed and coded as data (Wengraf, 2001). Audio recordings are seen as more objective, hence more scientific, than typing or writing notes during informal conversations or formal interviews. In health sciences, if researchers cannot provide audio (or better yet video) recordings of what occurred, then the scientific validity of the data and the integrity of the researcher may be called into question. Researchers in various other fields have long realized that recording affects interview responses (Al-Yateem, 2012; Belson, 1967; Tessier, 2012). I witnessed this myself while doing research for my Master’s degree in sociology. I was conducting semi-structure interviews with family members involved in the decision to withdraw life support treatment from ventilated patients. The last question on the questionnaire was about whether the interviewee had any regrets. One time, the person I was interviewing answered the question unemotionally while the recorder was running but started crying as soon as I stopped the recorder. He then opened up, telling me all about regrets that he had not mentioned while the recorder was on.

Academics have proposed various explanations for the changes in recorded responses, including the Hawthorne effect, subject reactivity, and social desirability bias (Al-Yateem, 2012; Tessier, 2012). Attributing the difference in recorded responses merely to “bias” keeps researchers stuck in the quest for valid or “true” knowledge. However, since my endeavour for this project was to acquire “good” knowledge in addition to valid data, I neither discounted nor valorized the recorded data. For the first few weeks of conducting field research in the ICU, I asked the same questions to the same people about the same topics at various times, the only difference being whether or not I was making audio recordings of the conversations. I soon realized that I was getting a lot more of the kinds of responses that I was looking for and wanted to analyse when I did not use an audio recorder than when I did. I came to realize that the audio recorder is a powerful mediator that alters people’s behaviour (i.e., what they say) in the field. Moreover, by not using the strategy of semi-structure interviews and the format that comes with it, I was getting better interactions with others and thus acquiring ‘good’ knowledge.

Since I could not see any way to turn the audio recorder into a neutral intermediary, I stopped using the device for the remainder of this research project. Acknowledging that recording devices are mediators does not necessarily mean researchers should never use them, however. In some cases, it might be important to have recorded verbatim data, while in other circumstances the recording device might interfere with acquiring substantive data. For other projects, alternating between recording and not recording conversations might be useful for comparative purposes. Researchers should reflect on the capacity of the audio recorder to become a mediator and decide if its presence is desirable in each specific study.

Loreina, RN: The Presence of the Researcher as Mediator

One day, there was only one patient requiring mechanical ventilation. I sat near the room in the nursing post observing the patient and writing notes on the patient’s position. A nurse named Loreina sat next to me making small talk. Then she abruptly turned toward the computer that was on a little stand on the desk and told me she had some work to do. I smiled to indicate there was no problem and returned to typing observation notes on my tablet.

Then I looked up and noticed her looking at me. She became agitated and started sliding the computer mouse in different directions, tapping heavily on the keyboard and the mouse, standing up and moving her chair, sitting back down, looking at the patient, looking down the hallway, then looking at me and sighing. All her gestures seemed abrupt and random. She went back to typing at the computer, then stopped and returned to our conversation. After I replied to her questions, she again went back to working at the computer. She did this a couple of times – interrupting her own work to talk to me, then returning to work for a short while – until finally, I asked her if I was bothering her. She said no, but her body language suggested otherwise. I changed seats so I would be a bit farther away from her post in the room.

She continued to react the same way whenever she got up and left the room and then returned to see me still sitting there. Each time, she became more agitated. After awhile, I left the room and took a seat near the main nurses’ station from which I could still observe the ventilated patient. Loreina continued to behave awkwardly, so eventually I decided to take a break from my observations and left the unit for the day.

The next day, as I was stashing my bag in the employee room, Loreina stopped by to apologize for her reactions the previous day. She explained that it had been her first day working with a ventilated patient. She thought I was looking at her to judge how well she was taking care of the patient. I showed her my notes from the previous day to demonstrate that I had been observing the patient, not judging her. After this incident, she seemed to become comfortable with my presence in the ICU and never again assumed I was there to evaluate her.

Consent forms remain static in time – they are signed once, then archived - but ethnographic research is conducted over a relatively long time period. During this time, the researcher will have multiple encounters with people who have agreed to be observed or interviewed. Even though those people have signed consent forms early in the project, they may become noticeably disturbed by the researcher’s presence in the field, especially when the field site is a hospital. The incident with Loreina is a case in point. My being in the room taking notes on my observations of the patient made her uncomfortable and she reacted in various unpredictable ways. My presence as an ethnographic researcher had turned me into a mediator.

This happened other times during my fieldwork, but unlike Loreina, most people hardly ever explicitly explained or directly voiced their concerns to me. Instead, they used non-verbal cues to implicitly communicate their discomfort. Ethnographers strive to establish rapport and not make anyone uncomfortable so they can continue to remain in the field, observing activities and asking questions. It is therefore essential for them to notice people’s subtle behaviors and expressions whenever they are at a field site. Even after someone has signed a consent form accepting the presence of the researcher, the researcher must remain attuned to how their presence might be mediating, that is, influencing behaviours of others.

It is also important for researchers to remain attuned to their own levels of discomfort. Another time, something happened in the ICU that made me very angry, but I knew that voicing my concerns about the event would do no good. I would only have jeopardized the rapport I had built with some of my research informants. Rather than continue my observations under such conditions, I decided to leave the hospital and go home for the day. This is also what I did when I realized Loreina had become agitated by my presence. In both cases, I knew that if I mentioned anything, I would have most probably become a mediator. Since I wanted to remain an intermediary, it was best to leave and come back once things had settled down even if it meant I was not going to be able to follow the actors during that timeframe.

Bosk (1979) once commented that “one discovers what one learns in the field often only after one has left the field” (p. 208). I found that occasionally abandoning my research schedule and leaving the field site for a short period of time (a day or two) was a useful fieldwork strategy. Spending a little time away from the field reflecting on what had occurred allowed me to learn more about how to handle others and myself. I realized that sometimes my presence as an observing, note-taking ethnographer is not always wanted, especially when people do not know what I am putting in my fieldnotes. I later decided to tell my informants what kind of information I was including in my fieldnotes. I discovered that this ameliorated some of the fear and anxiety they seemed to feel when interacting with a researcher (Cassell, 2005, p. 180). This in turn seemed to mitigate the mediating effect of my presence, as I noticed more people going about their work without paying much attention to me. While some modifications are necessary to adjust to the unpredictability of the social world, if the intention is so that the researcher and the objects that they bring into the field remain intermediaries, and the researcher stays committed to the same theoretical goal, the research itself does remain systematic.

Fred, RT: Healthcare Profession as Mediator

[Just after I arrived in the ICU one morning, I looked at the board to see which patients were ventilated. I was writing down their room numbers when an RT named Fred approached me.]

Fred: Come with me.

Me: Okay, thanks.

Fred: This is what we need to fill out for every ventilated patient. The system is really done well here. We don’t have to write [things] down in charts, everything is electronic. The system can also be used as a reminder since what you need to verify is all there. Look, it says to verify the chest x-ray, so we are going to go look at the x-ray. Can you point out where the [broncheal] carina is?

Me: It is right there.

Fred: Good answer. Where is the tube?

[With a feeling of déjà vu, I remembered that Fred used to ask me the same questions when I had been an RT student at the hospital a few years earlier.]

Me: The tube is here.

Fred: Do you think it is at the right place?

Me: I think the tube is a bit high. The tube is supposed to be 2–3 cm from the carina, but it is placed at 4–5 cm. I would be afraid that this patient will take the tube out.

Fred: Come with me. You are going to say this to the doctor and you are going to pull the tube down.

[I stopped Fred from leading me out the door and told him I was not there as a student of respiratory therapy, but as a graduate student doing a project in medical sociology. I also explained that, even though I was now a certified RT, I was not an employee of the hospital and I was not permitted to take any action with patients as a healthcare professional while conducting my research.]

When I was planning my research strategy before I entered the field, I thought it would be a good idea to shadow some of the healthcare professionals as they went about routine work activities. “Job shadowing” is an adaptation of the “go-along” method, “a form of in-depth qualitative interview method…conducted by researchers accompanying individual informants…in their familiar environments” (Carpiano, 2009, p. 264). While following nurses, doctors, and respiratory therapists around as they did their jobs, I planned to ask them questions about what they were doing and why they were doing it. I also thought this would be a good strategy for getting to know everyone at the ICU at the beginning of my fieldwork.

Soon after entering the field, I realized that this method was becoming a source of confusion because it was already known to the healthcare professionals at the hospital that I was an RT. As exemplified by my interaction with Fred, whenever I shadowed other respiratory therapists, they treated me as if I was an RT student. When I was with nurses, they would spend a lot of time explaining the differences between nursing and respiratory therapy. Despite all my efforts to reorient the conversations that occurred during job shadowing, I was not getting the answers to my questions about the social practices and decisions that revolved around the use of the ventilator. In this situation, my identity as a healthcare professional had quickly turned me into a powerful mediator. After some reflection, I decided to drop the job shadowing method for the remainder of my field research and limit my participation in the field to observations and informal interviews of family members and healthcare professionals involved in the decisions about mechanical ventilation. After I stopped shadowing hospital personnel, my RT identity seemed to be neutralized and I returned to being an intermediary. Here again the decision to modify my method was done to preserve the intermediary actor role and thus retain data gathering systematicity in the field.

Conclusion

Conducting research and being present in each fieldwork setting of interest comes with different challenges. Socio-anthropologists and other social scientists trying to obtain access and acceptance in a healthcare setting are taxed with negotiating the philosophical underpinnings of the biomedical sciences. Social scientific and medical research methods are not operationalised in the same way. With quantitative research, most research protocols and the steps to be taken are well-established before conducting research, while theory is followed throughout all stages of qualitative research, especially when it includes ethnographic methods. Theory orients the research while providing flexibility in the methods. Since anthropology and biomedicine have somewhat opposing epistemological and ontological methodologies, we are required to clarify and justify our research strategies and our presence in the field site in ways that are coherent with the philosophical underpinnings of our field of choice. Researchers need to remain attuned to each situation and modify their methods if they wish for their research to remain good. Drawing on the specific theoretical concepts of mediator and intermediary enabled me to respond systematically to problems that arose in the field.

The theoretical grounding proposed herein does come with limitations. I used Latour’s ANT to design an STS project, but those concepts might not be adequate for a different theory. Furthermore, this article is based on a single study at an ICU in Canada; similar applications of methodological theory in practice should be attempted in other settings for comparison. Finally, the field experiences presented here were heavily influenced by my positionality, in that I was a healthcare professional before I was transformed into a socio-anthropologist and qualitative researcher. Nevertheless, the approach to adjusting methods during ethnographic fieldwork proposed in this article can be added to our toolbox of strategies. This should help social scientists and their research findings become more widely accepted by scientists in other disciples.