Abstract
Mental illness represents a substantial global public health crisis, marked by high prevalence, significant economic costs, and profound impacts on individuals’ lives. Institutional ethnography (IE) is an approach to qualitative public health research that offers a methodologically rigorous way of addressing complex social problems. IE differs from many other qualitative research methods in its materialist, social ontology, which guides researchers to reveal and explicate the ruling relations that organize everyday life and which work against the interests of people at the standpoint location. Rather than focusing on populations, IE researchers focus on investigating processes and protocols that are activated locally through people’s everyday work and trace up into translocal ruling relations. The focus on social organization and empirically grounded analysis set IE apart from other qualitative methods and allow for different knowledge to be gained. IE is a methodology concerned with illuminating the voices of the marginalized and vulnerable and with increasing health equity by showing, as a first step, precisely how, when, and where systems are organized to benefit powerful institutional interests rather than people. The empirically grounded insights gained from IE research can inform the development of more equitable and responsive ways to run clinics that rely on the knowledge of those people who operate and use the services. They can also be used to develop policy frameworks that direct ongoing attention to the subjectivities of those whose work is implicated in planned health care reforms. We draw on our recent public health research to share our experiences of using IE methods and provide practical insights relating to each stage of the research process that may be valuable to novice researchers.
Keywords
Introduction
Mental illness constitutes a significant global public health crisis due to its extensive prevalence, substantial economic burden, and profound impact on individuals’ quality of life. Worldwide, more than one billion people live with a mental illness or substance use disorder, encompassing conditions such as depression, anxiety, bipolar disorder, and schizophrenia (Rehm & Shield, 2019). The ramifications are substantial: mental illness accounts for 16% of global disability-adjusted life years; in 2019, the estimated worldwide value of mental illness-related economic losses amounted to $5 trillion USD (Arias et al., 2022). Furthermore, mental illnesses are associated with increased morbidity and mortality, often exacerbating chronic physical conditions and leading to a reduced life expectancy (Walker et al., 2015).
Given the scope, complexity, and multifaceted nature of mental illness as a public health crisis, there is a need for robust qualitative research in this area. Moreover, qualitative research methods that insert a focus on the textual and discursive organization of mental health care systems can provide insight which quantitative methods alone and qualitative approaches reliant on experiential self-reports may not fully capture. This is especially salient in light of growing evidence that addressing social and structural determinants of mental health in the clinical setting, including poverty, houselessness, violence, and discrimination, contributes to improved patient outcomes (Alegría et al., 2018) and is cost-effective (Dawes et al., 2024).
An institutional ethnography (IE) approach to public health research in mental health offers something different from other qualitative methods: using IE, researchers can describe and explicate the social relations and power dynamics, which IE researchers consider “ruling relations”, embedded within the institution of mental health care. IE has been championed as a useful methodology for investigating complex problems in health care and a powerful tool for those who wish to understand and develop recommendations for health care reform (McLiesh et al., 2024; Rowland et al., 2019). IE is increasing in popularity as a qualitative method for research in clinical health care, particularly in nursing, as well as in social work (Kearney et al., 2019). By highlighting everyday experiences and institutional contexts, an IE approach offers an empirically grounded analysis of how mental health care is organized – and thus offer practical insight into how it could be re-organized to address this public health issue. IE researchers investigate people’s knowledge of “work” as an entry point into explicating the ways in which institutional processes and practices organize the everyday realities of people living with mental illness. Instead of adopting the more common categorization of systemic “barriers” and “facilitators”, IE focuses on work processes across the sector (from government planners to front-line workers) that undermine caring professional expertise. Examination of policies and practices reveal how people’s work activates practices that dictate paradoxical interventions that may undermine accessibility, quality, and outcomes of care (Deveau, 2008). By examining data related to people’s material activities of work (described in more detail in the section below) rather than on feelings or impressions, IE provides a critical perspective and precise description of what happens on a day-to-day basis. Moreover, this approach allows researchers to illuminate very specific junctures in processes and protocols that introduce ruling interests that are at odds with work that “expert knowers” (in the case of mental health care, these are mental health service users and/or frontline providers) know should be done. Using our study of psychiatric mental health nurse practitioners (PMHNPs) working in community mental health care as our exemplar, we explain what IE is and how using this approach allowed us to uncover findings we would not have otherwise been able to illuminate. We also offer practical insights into how we used this research approach for the benefit of aspiring IE researchers.
Institutional Ethnography as a Research Approach
The Basics of Institutional Ethnography
Institutional ethnography (IE) is an alternative, critical sociology research approach with roots in symbolic interactionism, ethnomethodology, feminism, and Marxism (Smith, 2005). Developed by sociologist Dorothy E. Smith, IE is a research approach that focuses on understanding how everyday life is organized through institutional processes and discourses (Smith, 2005). This approach allows researchers to explore power relations and coordination and organization of ideology as it shows up in particular settings, tied to local work processes, and anchored in material social relations (Campbell & Manicom, 1995). IE is an empirical research strategy that draws upon interview, observation, and texts to first describe, and then to investigate the material actualities of people’s lives. The aim is to develop analytic descriptions of ruling relations that govern local practices which are often invisible to those working within them (DeVault & McCoy, 2002). Ruling relations are defined as the multiple activities of individuals, organizations, professional associations, agencies and the discourses they produce and circulate that are organized around a particular function such as healthcare or education (Smith, 1987). IE inquiry is fundamentally concerned with discovering how specific people’s purposeful activities may be marginalized, hidden, and overlooked within current conceptions of power dynamics. IE rigorously attends to processes and practices embedded in institutional operations (Smith, 2005).
The ontology of IE views the social world as a complex network of happenings; social relations that are shaped by institutional practices and policies. The “institution” being explored does not connote a physical building or organization, but rather a complex of tied governance practices (e.g. the “institution” of mental health care practices) (Smith, 1987). The institution being studied extends from local settings into the relevant regulatory, economic, national, and international relations that coordinate practices. The institutional relations include informal social arrangements that structure individuals’ experiences. The work of IE is to demonstrate “the institution” as a matrix of practices that is accomplished locally and translocally by people who occupy different institutional locations (Rankin, 2017a).
Unlike other approaches to qualitative research, the goal of IE is not to generate theory but to empirically link, describe, and explicate tensions embedded in people’s practices (Rankin, 2017a). The product of an IE research project is a map: an explication of exactly how translocal ruling processes govern processes and practices at the local level, often against the interests of those on the ground – in this care, those receiving care and/or those providing care. As Smith (2005) emphasizes, IE is a research approach for people, not about people; it offers people information about how the world around them is organized by the ruling relations that they cannot see, and allows them to talk back to these ruling relations by taking action and effecting change.
Specific Features of Institutional Ethnography
Key Terms in institutional Ethnography.
Exemplar: An Institutional Ethnography of Community Mental Health Care for Patients Facing Structural Barriers to Access and Recovery
The original question that generated this study was influenced by the circulating discourse about “structural competency” with an interest in how structural competency is operationalized in clinical mental health care (Melino et al., 2023). Once IE was adopted as the method of inquiry, the term structural competency (as an abstract theory/concept) needed to be interrogated. The way we were using the term at the outset was congruent with the discourse that references the ability of healthcare providers to understand and address the social and structural determinants of health that impact patients’ well-being (Metzl & Hansen, 2014). Ideas about the structural determinants of health are vested in how issues of racism, sexism, poverty, and other forms of oppression can lead to mental health problems as well as complicate access to mental health care due to discrimination. Activists and scholars who study these forms of oppression understand them as “factors” that need to be addressed to provide effective care (Neff et al., 2017). Most of the research on structural competency focuses on using this framework in health care education. There is sophisticated and useful scholarship that suggests that building structural competency is the key to making health care and health systems more equitable, and thus has far-reaching consequences for transforming clinical care and improving patient outcomes (Treloar et al., 2021).
It was in thinking through who we wanted our research to serve that we landed upon IE as our research approach. As a research approach for people rather than about people, IE produces a knowledge that preserves people’s subjectivities (rather than rendering them objects) and helps ordinary people make sense of the aspects of their lives that are abstracted in language of power, knowledge, and capitalism. We wanted to do this work to show people and their mental health providers how their mental health care is organized and thus how it can be changed to serve them better. Adopting an IE approach required us to shift our thinking from the initial stages toward disrupting dominant ideas about structural barriers and the categories of race, class, sex, and other categories of oppression. IE looks to see how institutional practices “land” in the experience of people, who cannot be defined within categories of oppression while maintaining their subjectivity, but for whom it can be shown are subject to racist, classist, heteronormative, and otherwise oppressive institutional practices. People’s experiences in community mental health care – or within any other institution -- exist at the nexus of interrelated social processes that organize what can happen.
It quickly became clear that exploring the social organization of community mental health care would allow for mapping what was already being done, how it was coordinated, and whose interests were being served by the way it was coordinated. The objective of the study was to empirically describe the work of caring for people experiencing chronic mental illness to examine the often implicit and invisible social and ruling relations coordinating community mental health care services. Using IE allowed us to demonstrate how participants’ accounts of their everyday work practices uncovered the institutional ruling relations that organize their work, specifically the work they do to mediate barriers for patients experiencing chronic mental illness within conditions of poverty, violence, discrimination, and houselessness. Our results showed that addressing structural barriers in community mental health care remains a largely conceptual goal because the institution of community mental health care is not socially organized to support the always located, always contingent and specific needs of each person who is seeking help. Additionally, conceptual frameworks embedded in understandings about structural barriers that are expected to address these tensions do not explicate how work processes and practices are socially organized to happen as they do.
While PMHNPs did manage to achieve personalized, targeted responses to the living conditions and circumstances of patients, they were often in breach of the design of the official systems and required them to “break the rules”. IE allowed us to show how current institutional rhetoric, reforms, and mandates are at odds with what patients need, and how the system obfuscates the real work that frontline providers in community mental health care, such as PMHNPs, are doing to get their patients the care that they need. These results can be applied to making concrete change in public health systems.
Practical Insights
In this section, we outline considerations and steps used in conducting this study, in the interest of offering practical insights into conducting an institutional ethnography for novice researchers. We explain how we went about understanding the method, developing the research design, and collecting and analyzing data. For other peer-reviewed literature that offers pragmatic guidance on IE for researchers, we recommend Rankin’s (2017a & 2017b) work as well as Campbell and Gregor’s (2002) book, DeVault and McCoy’s (2002) chapter on interviewing, and Ferdinands et al.’s (2002) reflection on using IE in their work on weight-related stigma with young women.
Conducting a Literature Review
In beginning to formulate this research study, I (K.M.) conducted a literature review as is customary to establish knowledge of the field, gaps, and what the proposed research would contribute. Not yet fully versed in the critical approach to reviewing the literature that IE demands, my initial inquiry into structural competency in clinical mental health care led me to develop a concept analysis of structural competency. My goal at that time was to establish clarity on the concept and its uses (Melino et al., 2023). As part of this work, we reviewed structural competency and related concepts including cultural competency, social determinants of health, cultural humility, structural violence, social justice, and health equity (Melino et al., 2023). Moving into the planning of this research study, we learned how our “flat” reading of the literature was incongruent with IE’s foundational critical stance that examines the social organization of knowledge. Rather than simply providing a review of various frameworks that have been used to guide provision of mental health care to vulnerable populations, my analytic reading of the literature began to problematize these frameworks in service of demonstrating what an institutional ethnographic (IE) approach to this topic could offer (Alvesson & Sandberg, 2011). This was consistent with IE researchers’ distinct approach to reviewing the literature as a form of discourse analysis, rather than summarizing extant literature on the topic (Koralesky et al., 2023). This analytic stance allowed me to see the wholly conceptual nature of the available literature, as well as how it was foundationally built upon abstractions that covered over and collapsed the everyday realities of how people with mental illness attempt to receive care and achieve wellness in the community in the context of living within poverty, violence, houselessness, and discrimination.
Sample Design
Key to sample design in IE research is understanding that IE is sampling an institutional process rather than a population (Webster et al., 2015). The goal is to describe how institutional practices enter into the work processes of that group of people rather than represent core characteristics of a population. PMHNPs were chosen as participants because as frontline providers, they activate ruling relations by slotting patients into existing institutional processes, protocols, and categories (DeVault & McCoy, 2002). For this study, we recruited nine PMHNPs working in public outpatient community mental health clinics in a large West Coast city via purposive and snowball sampling. Participants varied in age, gender, sexual orientation, ethnicity, and ranged in years of experience in practice from three to 19 years. The “site” for this investigation was adult outpatient community mental health care system writ large. Most outpatient mental health clinics in this city employ 1-2 PMHNPs in addition to several psychiatrists and allied health staff. The goal of IE is to develop a rich, thick description of the knowledge that is generated in a standpoint location. Interviewing informants from more than one clinic supported this description. Moreover, it supported investigation of the “generalizing relations” that are discoverable as replicated practices that are activated at different times, in different settings, and that insert standardizing, ruling practices that arise elsewhere. These similar work processes can become the clues that lead to the broader set of institutional practices that the IE must “sample”. As Rankin (2017a) points out, the processes and practices illuminated via IE transcend individual workplaces: mental health care providers across the city, state, and/or country are subject to the same ideological practices and thus experience similar tensions and contradictions in their everyday work. The wider mental health/structural competency discourses; the generic practices/goals embedded in electronic health records; and the practices for consultations, referrals, follow-ups, and broad mental health infrastructures are discoverable and describable across a broad array of institutionalized mental health services in the economically privileged global north.
Collecting Data
Interview Questions.
Using observation as an additional data collection strategy added depth to our capacity to describe the practices being undertaken at the clinic. Observation is used in IE to provide context for data gathered through interviews and texts and to discover whether people’s practices and accounts of their practices match up with what is observed happening (Balcom et al., 2021). It is often the case that people’s training and their beliefs about their work (that they talk about in interviews) is not congruent with what is observed, a phenomenon which Smith (1987) referred to as bifurcated consciousness. These inconsistencies point to disjunctures that can be investigated as illustrated further below in the Analytic Chunks and Writing Accounts section. For this study, we engaged in ethnographic observation at each of the outpatient community mental health clinics where participants worked, participating in team meetings, patient visits, and engaging in informal conversations with other members of the care team as opportunities presented themselves. We began data collection with observation rather than interviews to help us to understand the context for our inquiry and grounded our interview questions in the materiality of the practices that we observed (Holloway & Galvin, 2005). We acted as participant-observer during these observation sessions, interacting with providers, staff, and patients in the clinic (LaFrance & Nicolas, 2012).
Rigour and Institutional Capture
Rigour in IE is determined by the researcher’s ability to produce accurate accounts about what is happening. More importantly, the rigour of a study is judged by how well the researcher explicates how what happened is organized to transpire as it did (Webster et al., 2015). One model for ensuring rigour in qualitative research, including in IE, is that of verification, which refers to the process of “checking, confirming, making sure, and being certain” (Morse et al., 2002, p. 17). Verification requires the researcher to weave mechanisms that incrementally contribute to study validity and reliability into every step of the inquiry. This requires the researcher to take an iterative approach to design, implementation, and analysis, offering continual opportunities to continue, pause, or modify the research process to ensure congruence and focus between the problematic, data collection strategies, and data analysis (Morse et al., 2002). Receiving regular consultation from mentors, peers engaged in similar work, and participants/other PMHNPs working in the field was crucial in ensuring that we remained faithful to the social ontology of the method and that we accurately captured participants’ experiences.
In IE, there is an additional component to rigour, which is the degree to which the research can avoid or manage a phenomenon called institutional capture. This occurs when a researcher who is socialized in the same professional discourse as their participants is unable to critically engage with this discourse and push past it to get at the actual happenings, instead taking it for granted (Smith, 2005). It is not uncommon for novice IE researchers to be pulled back into their previous socialization and education that has emphasized the paramount importance of theory and concepts in qualitative research, and to lose fidelity to the social ontology at some point during the data analysis (Rankin, 2017a). IE researchers call this “analytic drift” (McCoy, 2006, p. 110). Our reflexive work to avoid ideological capture started when we recognized our flat reading of the literature. As the research proceeded, IE demanded we interrogate the “shell terms” we encountered within participants’ and institutional discourses (Smith, 2005). Shells are materially empty terms, like “psychosocial risk factors” or “treatment planning”, which readers and listeners instinctively fill in with assumptions about the everyday experience subsumed under these terms (Ferdinands et al., 2022). As a PMHNP who has spent my own career working in community mental health settings, I (K.M.) was highly susceptible to this phenomenon and had to work diligently to maintain my awareness of it and avoid it. In my first interview, the participant used the shell terms above repeatedly – and I, having practiced in this field myself, failed to interrogate her use of these phrases because of my familiarity with them. My IE mentor kindly pointed this out as something to avoid in future interviews. Keeping a sticky note on my computer that read “Remember to find and ask about the shells!” helped to course correct in real time during later interviews.
We kept reflective memos and journaled after each day’s work, writing about the preliminary analytic connections we had made and the questions that remained. Remembering to keep people and the institution in view (McCoy, 2006) seemed like straightforward guidance, but in practice was more challenging than anticipated. One important lesson I (K.M.) learned was that my previous qualitative training had made it so easy to extrapolate reasoning and conclusions for what I was seeing and hearing during the data collection. My IE mentor reminded me to stay with the data, and that if you can’t explain how you built an argument by tracing the data, you need to question the argument (e.g., have you imported an abstraction or explanatory framework) and/or get more data. Observational field notes were transcribed and uploaded to NVivo (2023) for data indexing, where we grouped observational, experiential and documentary data to reflect work practices and actions.
Data Analysis
In IE, data collection, analysis, and “writing up the research” are all integrated processes (Rankin, 2017a). Concurrent collection and analysis of data allows the researcher to understand what is known and what needs to be known, thus forming an iterative interaction between the two processes and extending and deepening the capacity to describe and to join the dots into the institution (Morse et al., 2002; Webster et al., 2015). IE researchers go back and forth between data collection and analysis, wherein analysis reveals what additional data are needed to fully explore and explicate the threads of ruling relations. The goal of data analysis in IE is to explicate how something (troubling) happening in local settings is socially organized within the ruling relations of the institution that extend beyond the setting and informants (Smith, 2005).
Interviewing the Data
“Interviewing the Data” (McCoy, 2006, p. 111).
Indexing
As part of the iterative data collection and analysis process, we indexed the data, using NVivo (2023) to stay organized. Unlike coding and thematic development, which focus on ideas shared by participants that are conceptually linked, indices in IE focus on grouped actions and practices that are empirically linked. Indexing is a useful tool to begin preliminary work with the data and allows the researcher to discover and cross-reference linked work practices and happenings, people, settings, and texts (Rankin, 2017b). It is a strategy to support the empirical analysis that is critical to an institutional ethnography. We approached this part of analysis by using five high-level indices: work (what people were doing and their interactions with others), talk (language people used), texts (documents revealed in informants’ talk), people (those informants interacted with), and institutions (Bisaillon, 2012). A sub-index for “talk”, for example, included phrases such as “meeting people where they are at” that participants routinely used in describing their work.
Analytic Chunks and Writing Accounts
Once we had organized the data into indices, we used NVivo (2023) to view the data across participants and see what had come up, looking for threads that we wanted to trace and that we potentially needed to collect more data on to do so. We picked sub-indices to focus on and began to write “analytic chunks”. This process involves selecting a work practice or process highlighted by participants and detailing how this practice is socially organized, thus connecting local to translocal social relations (Ferdinands et al., 2022). One analytic chunk that we developed was around PMHNPs’ work of facilitating appointments for patients for whom attending appointments was difficult, either because of lack of access to technology, overwhelming mental health symptoms, or challenges related to transportation. To write this analytic chunk, we drew upon the interview and observation data to describe how PMHNPs made room in their schedule for drop-in appointments, maintained flexibility with punctuality, and combined clinical and social interventions into the same visit to maximize patient’s time in the clinic.
With several analytic chunks written, the next step for us was to begin to write the account. Writing an account involves “selecting an instance of activity from the ethnographic data and describing how it is socially organized” (Rankin, 2017b, p. 5). This aspect of analysis allows the researcher to expose latent work processes and continue to develop and reformulate the problematic at the heart of IE inquiry (Campbell & Gregor, 2002).The analyst’s task is to move from analytic chunks and, using empirical evidence, to knit them together into a bigger account of institutional practices – looking for the organizing ruling relations (Rankin, 2017b). Guiding questions during this process were: What are the threads of institutional processes here? How do the texts, regulations, and policies referenced by the participants enter into and organize their work? Where are the disjunctures between institutional policies and practices and the everyday work of those who have expert knowledge about what patients in community mental health care settings need? One of the accounts we wrote for this study built from participants’ practices around the “every door is an open door” (described in the interviews) into the agency documents and, more broadly, to the scholarly discourse. To expand the IE sophistication of this analytic chunk, we examined the state/local policies, regulations, and memos about mental health care mentioned by and/or shared with me by participants around access to care and this specific phrase of the “open door”. We traced this phrase up through participants’ talk, work processes, and governing institutional texts, and found that the institutional rhetoric around regulatory reforms promoting “every door is an open door” was linked to technological systems for managing appointments within an organizational definition of “access”. We discovered, and could empirically describe, how these systems and assumptions are at odds with patient/provider realities: being organized through this appointment system that introduced technologically embedded restrictions did not match patient needs. Not only did this reveal a disjuncture between the institutional rhetoric of expanding access to care in the name of mental health equity but how these reforms were in fact restricting access for the most vulnerable patients (reference paper #1). Regulatory efforts to streamline services for efficiencies, within the rhetoric of building a more accessible system, introduced serious tensions into the capacity of clinicians to activate their clinical judgment. A set of ruling relations were discoverable and had entered the talk of the PMHNPs. Even though PMHNPs could describe the new tensions in their work, they activated the institutional rhetoric of “every door is an open door”, using and perpetuating the ideological language that had infiltrated their lexicon.
Knitting together the empirical data into a fulsome account was undoubtedly the most difficult part of the process. This was where I (K.M.) learned my most important lesson about conducting an IE: for me, the writing is where learning and truly understanding the IE method happened. It’s not simply the final step in pulling together the data for dissemination. Writing the IE is how you learn the entire method. And so, it behooves the researcher not to procrastinate nor rush the writing. While establishing a theoretical understanding of IE by reading background texts is important, nothing is a substitute for doing it. There was a great deal of writing, re-writing, erasing, and reconfiguring under the guidance of my IE mentor. For the paper focused on rhetoric and realities of access to mental health care in community settings, I initially fell back on my previous qualitative training and structured the paper so that all the interview excerpts were put in the results section, without any textual data woven in. I saved weaving in the texts for the discussion portion. My IE mentor advised me to re-draft the paper and weave in the descriptions of governing texts into the “results” section to empirically describe how the computer fields, clinic policies, state public health insurance plan, government strategy and funding arrangements generated disjunctures that the aspirational language suggested would be fixed. I needed to explicate how the ruling relations entered practice, activated by the PMHNPs, and knit those practices back into the textual practices being activated elsewhere in the “slice” of the institution that I was “sampling”.
Upon reflection, I realized that one of the reasons the IE writing process was so challenging was that I was trying to force entirely too much data into each analytic tracing. For me, the key to generating a strong IE was to trace a sliver of data and do so carefully and defensibly. A seemingly common stumbling block for novice IE researchers is that so much data is collected but often, it is a very small, specific piece of data that becomes the focus of building the account: the required explication of the ruling relations. For researchers studying public health issues, the conditions of people’s lives are so multifactorial and complex that writing the “grand unified account” is far too complex for one piece of writing, for one manuscript, or for one chapter. Researchers must not be afraid to leave a lot of data on the cutting room floor.
Discussion
We share insights from conducting our IE study on community mental health care for patients facing structural barriers to access, recovery, and wellness to illustrate how and what IE can contribute as a qualitative approach to researching public health issues. IE’s approach to investigating institutional processes allowed us to access empirical knowledge about the coordination of knowledge and practices in working with vulnerable populations, such as those who live with chronic mental illness within conditions of poverty, discrimination, violence, and houselessness.
Unique Contributions of IE
Using an IE lens for this research allowed us to identify exact locations, processes, and protocols which dis/allow the so-called “structural barriers” to be addressed in clinical care. Using IE, we could describe “structures” empirically (those structures such as computerized appointment systems; billing systems; and diagnostic categories from the DSM-V). We could describe how these arose as “barriers” for users and practitioners. We could populate the abstract language with people and their practices, rather than working them up as categories and concepts. We could bypass the understanding nods that are produced when the term “structural barriers” elicits conceptual, objectifying ideas about racism, poverty, and other oppressions. We can add something to the body of literature reviewed for this project, where, most often, once something had been named a “structural barrier”, it could not be linked back (empirically) into actual experiences and practices. This is the unique contribution of IE. It is why researchers must work to ruffle the discursive terms and the ideologies that gather wide circulation within the disciplinary constructs of the problems to be solved.
Common critiques of qualitative research include concerns that these approaches are small scale, anecdotal, and/or lacking rigour (Anderson, 2010). Lack of generalizability is also often cited as a major limitation of qualitative research. IE as a qualitative (alternative) research approach offers a way to avoid these potential pitfalls. IE is neither small scale nor anecdotal: it allows for a research focus on specific local processes as they are governed by translocal processes, texts, and ruling relations. The iterative approach to study design, implementation, data collection and analysis that IE requires is commensurate with best practices for ensuring rigour in qualitative research (Morse et al., 2002). IE’s ability to allow researchers to illuminate translocal processes also offers a solution to the generalizability problem: as Grace (2013) states, “By examining institutional complexes, this mode of ethnographic inquiry allows one to interrogate transnational networks of text-mediated social relations” (p. 591). Using IE allows us to point to concrete problems and therefore specific, implementable solutions for people. Grounded in empirical, material data, IE allowed us to show exactly how and where problems related to “access” (the realities and conditions of people’s lives that make it difficult to connect people to services) are generated, reproduced, and re-enforced. In terms of activism or creating change, this map becomes the starting point from which to examine where changes can be made to transform inequitable processes and/or highlight hidden processes (Kinsman, 2006; Smith, 1990).
Challenges with IE
There are a few potential challenges with using IE as an approach to investigation. As IE inserts a focus on institutional ruling relations that organize how and what care is given and received, other methods may be better suited for research focused on exploration of feelings, emotions, and lived experience outside of material experiences of “work”. As mentioned above in the Rigour section, IE researchers must remain acutely attuned to staying with the actual, everyday happenings and material realities that participants encounter as part of their daily work and avoid being waylaid by conceptual explanations or “shell terms” (Smith, 2005). Additionally, the open-ended, minimally structured, and iterative interviewing process used in IE may be more challenging than using the same semi-structured interview guide with each participant. Finally, much IE research takes place inside highly bureaucratic organizations with many policies, regulations, and restrictions that make research access difficult. Gaining access to the participants, settings, and texts that an IE researcher requires to collect data may present challenges.
Conclusion
Mental illness remains an important public health issue across the globe. This paper demonstrates the contribution of IE’s alternate approach to qualitative research that can be helpful to those seeking to transform inequitable processes in service of improving care for vulnerable populations. We use this study as an exemplar to illustrate IE’s strengths as a qualitative methodology for approaching public health research. Our analysis goes against the grain of conventional knowledge: the institutional ideologies currently circulating build approaches to “access” that are harnessed to efficiency systems that standardize, monitor, and generate metrics that stand in for “outcomes”, upon which future decisions are made. The knowledge that an IE generates is exciting because it highlights concrete issues faced by people with serious mental illness who live within conditions of poverty, violence, discrimination, and houselessness and points to possible solutions to address them. The research we conducted highlights the importance of understanding the material realities of mental health care provision and the disjunctures between institutional rhetoric and practice. The insights gained from this research can inform the development of more equitable and responsive ways to run clinics that rely on the knowledge of those people who operate and use the services. They can also be used to develop policy frameworks that direct ongoing attention to the subjectivities of those whose work is implicated in planned health care reforms. By focusing on the actualities of work and the ruling relations that govern it, IE provides a robust framework for identifying and addressing the socially organized systemic issues that perpetuate mental health inequities. Future research should continue to employ IE to explore other facets of mental health care and other public health issues, ensuring that the knowledge about what happens, gathered from those most affected by and knowledgeable about these systems, is the basis for meaningful change (Campbell & Gregor, 2002; Rankin, 2017a; Smith, 2005).
Footnotes
Ethical Statement
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was supported by funding from the Canadian Institutes of Health Research Vanier Canada Graduate Scholarship.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.