Reflections and Guidance on Using Ethnographic Approaches in Health and Care Research – Ten Researchers’ Diverse Insights

Abstract

Ethnographic approaches to health and care research are invaluable. They offer rich insight into contextual and cultural factors that influence the health service, as well as the delivery of care within any given community, and recognise the centrality of the researcher in the process. Understanding the unfolding of real-life events, as well as interactions between people, space, technology and other affordances, is crucial to developing impactful and contextually sensitive interventions. Information derived from ethnography may also be unreachable by other, retrospective research approaches. By combining a collection of ten researchers’ diverse first-hand experiences relating to past studies, with collaborative reflections on conceptual, theoretical, methodological, and ethical issues pertaining to ethnographic inquiry in health and care research, this paper offers a unique, accessible and revealing ‘backstage’ introduction to ethnographic approaches. It aims to de-mystify ethnography and prepare researchers planning to adopt ethnographic approaches to health research, by describing how it can look and feel in practice with empirical illustrations. This is perhaps particularly valuable for researchers new to ethnographic approaches across disciplines and expertise levels (e.g., clinical researchers and PhD students), as well as any stakeholder who may wish to be involved, or support such work in health and care settings.

Introduction

This paper provides a collaborative, reflective account from ten researchers, with over 140 years of collective experience in ethnographically inspired health and care research. The authors have diverse backgrounds and expertise spanning patient safety, quality improvement, organisational change, prison healthcare, health worker migration, dementia care, social science, anthropology, and qualitative methodology, as well as clinical backgrounds in nursing, psychology and social care across physical and mental health and care settings. Some reflections relate to individual studies (Creese et al., 2021; Canvin et al., 2009; Canvin et al., 2007; Ramsey, Waring, et al., 2025; Ramsey et al., 2025a, 2025b; Ramsey et al., 2024; Mackintosh & Sandall, 2016; Mackintosh et al., 2014; Martin, 2012; Martin, 2009; O’Hara et al., 2025; Spiliopoulos et al., 2021; Kelley et al., 2019; Waring et al., 2006; Waring & Bishop, 2010). Other reflections are not limited to any individual study but draw upon cumulative researcher experiences. This paper, from its very conception, was designed to provide practical advice. It emerged from an invitation to the lead author to deliver a training session focussing on ethnographic approaches to health research. After seeking reflections to share from other experienced researchers with expertise in the field, insights were collated to form the basis of the training, which was enthusiastically welcomed. Contributors felt that the content could be useful to others besides the small group of researchers attending the training – particularly other researchers new to ethnographic approaches – such as PhD students or clinical researchers, as well as any stakeholder who may wish to be involved, or support such work in the context of health and care. Hence, we developed this article. While there is an existing literature offering guidance on using ethnographic approaches to research generally (e.g., Hammersley & Atkinson, 2019), and some articles relating to specific health settings such as nursing (e.g., Shattnawi, 2025) and medical education (Pope, 2005), to our knowledge, this is the first article to present a diverse collection of both researchers’ insights and guidance spanning diverse studies in the field of health and care.

Ethnography and Culture: Working Definitions

In this section, we propose ‘working definitions’ of ethnography and culture, acknowledging the wide range of existing interpretations and the absence of singular, universally accepted understandings. We seek to explore several foundational principles that consistently underpin ethnography, and the study of cultural norms, as highlighted by scholars such as Hammersley and Atkinson (2019). We explore concepts throughout this article, including positionality, reflexivity, relationships, ethical tensions, and fieldwork.

Ethnography is rooted in anthropological tradition. It uses a contextual approach to gain emic understanding of both ‘remarkable’ and ‘everyday’ social actions and meanings within natural settings (Dixon-Woods, 2003). This dual lens helps to see the ordinary in the extraordinary, and vice versa, enabling the challenging of assumptions, disruption of binaries, and creation of rich, and nuanced inquiry. Central to ethnography is a commitment to holism and describing the language, actions, routine and rules that characterise any given culture and community. Early conventional ethnography, often linked to colonialism, involved lone anthropologists spending months, or years, experiencing different cultures via the lens of broad research questions (Fetterman, 2010). Evans-Pritchard’s The Nuer (1940) demonstrated the value of such situated, intensive and contextually rich understanding in helping to explain complex social systems. In this way, ethnography enabled rich engagement with how knowledge, rationality and experiences were produced, sustained and contested through everyday practice. This allowed researchers to become culturally embedded over time to gain a deep and nuanced understanding of a culture’s social norms and structures. Bronislaw Malinowski, an anthropologist working in the Trobriand Islands of New Guinea during the First World War, was one of the first to establish this style of embedded ‘participant observation’ research to develop an understanding of “the whole extent of the tribal culture… the totality of all social, cultural and psychological aspects of the community” (1922 [2002], xvii).

Nevertheless, ethnography, and the essence of what makes research ‘ethnographic’, is notoriously difficult to pinpoint (Pachirat, 2017). In the absence of a standardised, widely accepted definition, there are also confused commitments to realist ontology or social constructivism. In a second edition of Forgive and Remember, an ethnographic piece focussing on the training and lives of surgeons, Charles Bosk reflected on the “debate about standpoint, voice and authorial authority” and how his original work “is quite evidently a produce of an academic climate untroubled by this debate”. He notes his subsequent reflections on his “doubts that [he] had neither the courage nor the cognitive categories to make articulate” (1973; 2003).

Ethnography is also a term often used interchangeably with observations, despite ethnography being much more than a method (Jowsey, 2016). Observational methods can be used in a way that is not ethnographic (e.g., simply counting something without inquiring about culture and meaning), and research relating to culture and meaning can be attended to without observation (e.g., analysing everyday documents and artefacts). We support the notion that as researchers, we don’t ‘do ethnography’. Rather, ethnography is a methodology, an epistemology and a product (Geertz, 1973). It is based upon assumptions that to understand human behaviour, we must first understand humans as they are embedded within culture, and in doing so, we must recognise and reflect upon our own positionality as researchers through reflexivity. Ethnographic fieldwork often involves an observational element but may also draw upon a range of other methods, such as interviews, informal conversations, archival and documentary data, as well as reflective diaries. Forsythe (1999) noted a misconception that ethnographic fieldwork is just common sense – and that anyone can do it. This undermines the breadth and depth of invisible work required, which Bosk likened to a “body contact sport” (1979). The metaphor helps to emphasise how ethnography is active, messy and embodied. It is also intensively immersive, relational, interpersonal, and emotionally demanding. Dixon-Woods (2003) agreed that “Ethnography is not for the faint hearted. It is a time consuming and demanding research process and can be a profoundly uncomfortable experience for the researcher.”. Ethical tensions may surround identity and emotion, and the blurring of boundaries between research life and private life, both for the researcher and the researched.

Krysia Canvin provides an empirical illustration of the conflicting emotions that can be raised during ethnographic fieldwork:

I hate doing observations and avoid it. I was using ‘ethnography’ (very loosely) on a project about resilience and health inequalities in poor households and communities and I felt conflicted the whole time – during and after. I was working in communities like the one I grew up in, which was disorientating and felt inherently judgemental (Canvin et al., 2007, 2009). I discovered that one of the residents used to live in my hometown and work in the same factory as my dad (indeed, most of my family) which blurred the boundaries of my identity even further . Coincidentally, I was just reading Imogen Tyler’s book, Stigma (2020), in which she talks about her own encounter at the start of her research career which ethnographers who had researched her hometown and the shame and stigma she experienced as a result - she’s from a working-class background like me. Really interesting and important reading, I think.

Despite having core foundational underpinnings, it has been argued that a consensus definition of ethnography is not necessary (Bosk, 2003), and rather we need to better share what ethnography involves and its purpose to different stakeholders. Speaking to this aim, Mikulak et al. (2022) produced an easy-read resource describing ethnography for people with learning disabilities and their carers, but with potential utility for cross-discipline researchers in describing ethnographic approaches simply and more widely. Much like ethnography, definitions of culture vary, and no unified understanding has yet been reached (Mannion & Davies, 2013; Schein, 2006). Graves-Brown (2000) suggested that “culture exists neither in our minds, nor does it exist independently in the world around us but rather is an emergent property of the relationship between persons and things”. Dixon-Woods et al. (2014) further noted that definitions of culture tend to commonly emphasise “the shared basic assumptions, norms, and values and repeated behaviours of particular groups into which new members are socialised, to the extent that culture becomes ‘the way things are done around here’.” Margaret Mead’s seminal ethnographic work, exploring the adolescence of Samoan girls to challenge Western assumptions about developmental experiences, attributed differences to cultural, not biological, factors, supporting the notion that human behaviour is shaped by sociocultural environments. This demonstrated how ethnography may allow us to gain deeper understandings of contexts, which might not be uncovered by alternative, retrospective approaches to research (Mead, 1928). Nonetheless, Mead’s findings were subsequently questioned on the basis of ethnographic research by Derek Freeman decades later (1983), which is perhaps an important reminder of the fallible nature of all research findings as scientific knowledge is provisional, revisable and shaped by human interpretation.

Evolution of the Ethnographic Approach: Developments and Applied Challenges

As health services researchers, it could be challenging to convince funding bodies, ethics committees and healthcare organisations, to support us to use traditional ethnographic approaches, i.e., spend months, or years, observing social norms and gaining insights into the culture of a hospital, for example – with only loosely defined exploratory research questions about the culture, social organisation or lived experiences of care. This illuminates various applied challenges, which span the need for time, access and wide-ranging ethical considerations. However, some scholars argue that traditional ethnography has conceptually evolved, and rather than necessarily needing to travel across the globe, learn a new language and persuade communities to accept the notion of research, there is now a wide range of more accessible ethnographic approaches which particularly suit health and care settings. For instance, short-term ethnography (Pink & Morgan, 2013), focussed ethnography (Knoblauch, 2005) and rapid ethnography (Vindrola-Padros & Vindrola-Padros, 2018) are all approaches which aim to improve the efficiency, feasibility and timeliness of intervention delivery in healthcare. Nonetheless, Cupit et al. (2018) reflected on the perhaps “unhelpful elasticity in the label of ethnography” and what it means for the future of approaches to studying healthcare improvement, but they perhaps need to be thought of less as pole positions, and more an evolution of approach but with a commitment to the central tenets of ethnography. Waring and Jones (2016) further highlighted the importance of maintaining the link between methodology and method in ethnographic health services research, suggesting that the speed or depth of the research is less important than the commitment to understand the culture and social organisation of a community through a focus on what it is like from an insider’s perspective.

There are also a range of digital ethnographic approaches, such as video reflexive ethnography which combines the video recording of real-life interaction with collaborative reflections (McHugh et al., 2022), digital diary methods which allow the sharing of real-time experiences (Johnson et al., 2017) and net-nography which studies cultures, communities and social interactions in digital spaces (Roland et al., 2017). Further, mobile instant messaging ethnography (Creese et al., 2023) enables the study of social behaviours, experiences and communication as they occur though mobile messaging. Such approaches could be used to gain access to a broader range of health and care contexts, such as the home, community or in virtual wards, for example. However, they may also risk transitioning too far away from traditional ethnographic fieldwork.

Jennifer Creese reflects on developing the ‘mobile instant messaging ethnography’ approach during Covid-19 and offers related theoretical insights:

In 2020 I relocated across the world to explore what working life was like for Irish doctors. Covid-19 was a major disruption to ethnographic research. However, this was an opportunity for me to really think about what ethnography meant for me and my practice. In thinking about ethnography as an approach, rather than just a method, I came to see ethnography less as traditional presence-based “observation”, and more broadly as a way of making sense of lived experience from a contextualised emic perspective – one that could be done in person but could equally be done in partnership. We developed mobile instant messaging ethnography to be able to ‘follow’ doctors through their days, through WhatsApp, creating context through their reflections and developing insights into working life and conditions collaboratively (Creese et al., 2023). While I would go back to in-person fieldwork in a heartbeat, the opportunity COVID afforded me – to reconsider the ethnographic approach as less “being there” and more “being together” – has broadened my horizons about how knowledge and understanding can be made, and the spaces and collaborative relationships in which this can happen. This can only make me a more capable ethnographer – whether on ward or on WhatsApp.”

Other approaches used in a health and care context include institutional ethnography which investigates how everyday experiences are shaped by larger institutional structures (e.g., Cupit et al., 2020), auto-ethnography which combines autobiography with ethnographic principles to explore cultural, social and political meanings (Ellis et al., 2011) and meta-ethnography as an approach to interpreting findings from multiple ethnographic studies (Sattar et al., 2021). Additionally, proxy-ethnography relies on secondary sources of access to a social group (Launer, 2017) and team-based ethnography involves multiple researchers collaboratively conducting fieldwork (Parkin et al., 2021). Each of these strays from traditional ethnographic approaches in different ways, bringing its own challenges to navigate, and they are underpinned by different methodological and political orientations. It has been argued that while innovative approaches to ethnography have their benefits, it is also important to consider what is lost when steering too far from the ‘essence’ of what makes ethnographic research ethnographic (Wolcott, 2003). For those reasons, researchers may be hesitant to call themselves ‘ethnographers’ or claim that their work sits firmly within the realm of ethnography but rather may describe themselves as using an ethnographic approach, or state that they conduct ethnographically informed studies.

Making it Work in Health and Care Settings

Despite potential challenges to the use of ethnography in health and care settings, these environments have been identified as particularly well-suited to draw upon ethnographic approaches for multiple reasons (Leslie et al., 2014; Savage, 2006). Firstly, there is often a push to rush to solutions in health services, but ethnography allows us to take the time to really understand where problems lie first, which is often in unexpected places (Savage, 2000). Without a prior in-depth understanding of contextual complexity, efforts to develop interventions may fall at the first hurdle (Langley & Denis, 2011). Ethnographic approaches may help to provide deep insight into cultural, social and contextual factors that shape factors such as health behaviours, beliefs and systems of care. In turn, this may provide powerful insights that may be important when developing interventions for various reasons, including unspoken norms and power dynamics, understanding locally relevant practices, exploring how people navigate health systems and ensuring that interventions are culturally appropriate. Ethnography also enables exploration of health systems which are typically complex, requiring people to make them work, within their own dynamic environments and with many culturally rooted barriers to change (Leslie et al., 2014). Research has highlighted the importance of influences on care delivery, including human performance, organisational and cultural dynamics, complex power relations between individuals and teams, and interactions with things like infrastructure and technology (Dixon-Woods, 2003; Greenhalgh & Swinglehurst, 2011). In this way, ethnography can provide rich insight and understanding in the contextual and cultural factors that influence the organisation and delivery of care as well as the variable spread and uptake of innovations.

Secondly, interventions designed to improve health and care have often led to limited or no change, and for those that are successful, spread, scale and sustainability is difficult to achieve (Dixon-Woods et al., 2013). Ethnography, with its focus on actions, context and meaning, offers a powerful lens for interrogating why an intervention worked and how it might have been adapted locally, or why it failed, and how such failures could be addressed contextually. Closely inquiring about how people engage with an intervention in real-world settings, the lived experiences, varied interpretations, and the adaptive behaviours, may help to reveal how context helps to shape both the implementation of an intervention, and how that intervention is received. Dixon-Woods et al. (2013) found, when evaluating a patient safety initiative adapted from the United States for use in England, that outcomes are shaped as much by national and local context, as by the technical components themselves. Ethnography can also help us to understand current pathways and processes, subjective experiences and how interventions might (or might not) fit into existing systems. For example, in an evaluation of co-designed guidance to support the meaningful involvement of patients and families after healthcare harm within organisations that had indicated ethical commitment to the idea (O’Hara et al., 2025), there remained contextual challenges within the system that were difficult to overcome (Ramsey, Waring, et al., 2025). This provided insight not only into why that particular intervention was not used as intended, but also that wider change was required to support the effective implementation of any intervention tackling a similar problem.

Finally, while it is a complex and strongly debated concept across scholarly disciplines, ‘culture’ is a widely used term within the context of ethnography and has been identified as an essential contributory factor to aspects of healthcare across settings, such as patient safety (Berzins et al., 2018; Lawton et al., 2012; Waring, 2005) and is often blamed for care failings. For example, The Bristol Royal Infirmary Inquiry concluded that a flawed ‘club culture’ was implicated in the deaths of over 30 children undergoing heart surgery (Department of Health, 2001). Therefore, ethnographic approaches to health research may offer powerful insights.

Practicalities - ‘Warts and all’

Positionality and Reflexivity: Personal and Professional Perspectives

Jowsey (2016) argued that positionality is a central feature of ethnography, recognising the inevitable influence of both the researcher and the researched as experiencing human beings, and highlighting the essential role of continual reflexivity. This supports Van Maanen’s (1988) early call for more transparency in ethnographic approaches, in which reflexivity should be emphasised. More recently, Gold (2002) suggested that “confronting positionality means negotiation of conflicting worldviews - different understandings of reality rooted in philosophical principles distant from the dominant orthodoxies. Such conflicts, if engaged in creatively, have the capacity to challenge beliefs, values and thought patterns.”.

Despite being multifaceted, neither binary nor static, and evolving over time, researcher positionality is often described in relation to the extent of ‘insider-ness’ (e.g., a trained midwife studying midwives), ‘outsider-ness’ (e.g., a non-clinician studying clinical practice) and negotiating the ‘hybrid’ spaces in-between (Seim, 2024). Based on our identity, we each have different sensitivities that can be challenging to navigate (Ergun & Erdemir, 2010; Dwyer & Buckle, 2009). Equally, having different and simultaneous identities can add to the value of reflexive work, and contribute to building trust (Carling et al., 2014).

As a clinical researcher, Charlotte Overton provides an empirical illustration relating to the study of the implementation of standardised tools in healthcare. The ethical tensions between legal, professional and moral motivations to participate versus methodological motivations to limit participation are described:

In my PhD (Overton, 2020) I had ‘outsider’ status in so much as I was there as a researcher. But, as a nurse, I was focused on aspects of organisational life I had experienced first-hand. Given my background there was the risk that my own interpretations would influence my understanding of the implementation of standardised tools. Therefore, I needed to be aware of how such a priori understandings might silently influence the research work by making conscious and consistent efforts to avoid privileging a single favoured angle (Alvesson, 2003). I knew I might find this tension difficult. I was able to connect and bond quickly with staff, but the research role felt alien. I tried to do tasks that felt comfortable and occupied me. I limited my involvement to cleaning trollies between patients which helped with informal conversations and the awkwardness of hanging around. It was also driven by my psychological and emotional needs to feel part of a setting I was so used to working in. However, I was in clinical settings as an observer so knew that if negligence or illegal behaviour was revealed or a clinical emergency arose, as a Nursing and Midwifery Council registered nurse I was legally, professionally, and morally bound to adhere to the correct policies and practice guidelines. As I developed a reflexive awareness and embraced the idea of multiple realities and experiences, increased awareness brought new challenges as I continued on the journey to a new dual ‘practitioner-researcher identity’ (Allen, 2004).

Identifying as an ‘insider’, researchers might have a largely familiar perspective, allowing them to understand things more effortlessly, and gain respect more easily from participants. However, they might be less able to question the very fundamentals of how things are done, and participants may be more likely to feel betrayed by subsequent analysis and publications (Bosk, 2003). Identifying as an ‘outsider’, on the other hand, might afford the privileged position of seeing things with fresh eyes and elicit richer data when questioning the very basic assumptions that people have, or the things they do and say, and why. However, this may pose more difficulties gaining access and require researchers to undergo a ‘crash course’ in understanding language and things going on around them.

Elisa Liberati shares theoretical reflections surrounding positionality, and provides methodological advice to overcome challenges and tensions:

At the beginning of fieldwork, I often worry that I don’t know enough about the ‘clinical’ side of things, while also being aware that maintaining some degree of naivety is often useful in ethnography. I worry I will draw simplified conclusions, with no appeal for healthcare staff. My sense now is that to create knowledge that is both sociologically rich and clinically useful requires truly involving participants in the process of shaping our data. In practice, I learnt to spend a great deal of my time in the field asking participants ‘I noticed this – have I got this right?’

It is often the case that navigating ‘personally perceived positionality’ (i.e., factors we see in ourselves and our identity) and reflecting on ‘externally perceived positionality’ (i.e., factors about ourselves and our identity others see in us) are equally important, as well as multifaceted and dynamic. They may also diverge, sometimes significantly, and be tempered by the context in which researchers are entering. To some extent, we can manipulate our ‘externally perceived positionality’ by choosing to reveal or conceal parts of ourselves or consciously foregrounding certain aspects of our identity to establish familiarity and trust with participants (Carling et al., 2014). Goffman (1949) argued that social presentation resembles theatre, whereby people strategically control how they are perceived by others ‘frontstage’, and Glesne and Peshkin (1992) further emphasised how researchers may manage multiple ‘selves’ dependent on factors such as social context, relationships and ethical considerations. However, at other times, our positionality may be cast in ways that we did not, and perhaps could not, expect (e.g., Kasstan, 2016).

Lauren Ramsey shares an empirical illustration of the mismatch between ‘personally perceived’ and ‘externally perceived’ positionality, experienced during ethnographic fieldwork in a patient safety study:

Throughout a virtual ethnographic and interview project I was involved in, focussed on maternity safety amongst other things, there were challenging, and sensitive topics being discussed relating to traumatic labour, baby loss and maternal death (Ramsey et al., 2025a; Ramsey et al., 2023, 2024; O’Hara et al., 2025). For those reasons, I chose not to reveal to participants that I was pregnant during fieldwork. This was a luxury afforded to me, that wouldn’t have been if the project was done in-person as planned. A separate challenge I had to navigate, and one thing that particularly surprised me, was how my ‘externally perceived positionality’ differed between participants and groups, and how at odds it sometimes was with my ‘personally perceived positionality’. For example, as an academic employed by an NHS Trust, both my ‘Dr.’ title and NHS email address had been misconceived for clinical expertise – despite attempts to clearly introduce who I was, my non-clinical background and my affiliations, affecting how participants engaged with me and their expectations. With hindsight, this is perhaps unsurprising in health services research context but is important to learn from the impressions different factors give off.

Reflexivity is essential to understand positionality and its fluidity before, during and after fieldwork and in different contexts and situations. Abu-Lughod (1990) conceptualised potential additional complexities experienced by those who identify as ‘halfies’, with dual identities.

Nicola Mackintosh provides methodological advice and theoretical reflections based on how a ‘halfie’ identity affected her approach to ethnographic interviewing, as well as the need for peer support in relation to positionality, and more generally during fieldwork:

“Coming from a nursing background, I miss the feel and nitty gritty nature of healthcare work. Managing this clinical background can be tricky as an ethnographic researcher and it took me a long while to relax into and embrace my ‘halfie’ identity. As I’ve become more experienced, I’ve found it much easier to relax into just hanging around as opposed to needing to observe certain activities. In one project (Mackintosh & Sandall, 2016; Mackintosh et al., 2014; Mackintosh et al., 2012), I studied everyday practice in medical wards, obstetric units and midwifery led units. What was accessible varied so much across these settings, but this tied into distinctions between private and public, and I was able to understand how the everyday is shaped by wider social, cultural and political factors across the settings. Generally, I try and tune into what I can see but also what lies outside - what am I missing? What is prioritised and talked about and what is taken for granted? Fieldwork is always full of contradictions and tensions which can be tough to deal with. Having the chance to debrief and process the significance of what you see and feel afterwards is so important, a community of ethnographers to share experiences with is so valuable! One last tip is that I have also come to learn that my particular questions in the field reveal to my informants that some everyday occurrences are of more consequence and interest to me than others. I have learnt that questioning in the field involved balancing the finding out of what I want to know with enabling informants to still have opportunities to introduce and pursue their own topics.

Building and Re-building Relationships

Another central component of ethnographic research is building trust and relationships. As researchers, we might find ourselves needing to invest significant time and resources into relationship building prior to fieldwork, to negotiate access to the places we want to study. Those early relationships might prove to help or hinder our research as it unfolds, in ways including determining what people choose to reveal or conceal, aiding or preventing access to others and colouring the views we are able to capture, as reflected upon below.

Studying the use of online patient feedback in health settings, Lauren Ramsey shares methodological advice, reflecting on the interplay between perceived positionality and the need to (re)build relationships during ethnographic fieldwork:

Working with an industry partner, Care Opinion ( https://www.careopinion.org.uk/ ), helped me to gain access to NHS Trusts, and identify named senior staff to build relationships with on a project I worked on exploring how healthcare organisations responded to and used online patient feedback (Ramsey et al., 2022, 2023a, 2023b). However, I was also aware of how people may view me because of my perceived affiliation with Care Opinion. I had some groundwork to do to (re)build relationships to enable people to share their views openly and honestly with me, along with seeking out others at different levels of the organisation, such as frontline clinical staff, who perhaps had different views. Robinson (2014) noted the importance of building relationships with those such as the gatekeepers, the typical people, the deviant people, and those with insight into organisational influences. In my experience, particular value was also found in seeking out people who were seemingly uninterested in the phenomena that I was studying. Surprisingly, these people sometimes had the most to say.

A common experience of ethnographers is the blurring of the private life and the researcher life. This is also, true of ethnographic approaches that transcend the traditional approach of physically ‘being there’, such as digital ethnography or mobile instant-messaging ethnography, where the researcher’s immersion in and connection to the research ‘field’ can occur in private time and space and lead to a feeling of being “always on” (Creese et al., 2023). This blurring of research and private life can also feel a privilege, as reflected upon below.

As a researcher with a clinical background, Georgia Spiliopoulos reflects on studying migrant care workers and the importance of building relationships, gaining trust, being flexible and remaining open to learning by taking on different roles:

I find ethnography a real privilege. I appreciate participants’ trust, openness time, and invitations to get a glimpse of their world. In one study (Spiliopoulos et al., 2021), often, the participants would show me photos of their relatives, of special occasions like weddings, or invite me to have lunch with their families. Being half-Greek, half-English and a former care worker, provided some common ground, of being both an insider and an outsider, or as an insider-by-proxy, to establish trust. Something I learnt through the experience of spending time with a Thai domestic worker, at her local Thai store, and at her daughter’s birthday party, was that I was being ‘tested’ - I was encouraged to buy Thai ingredients to make a green Thai curry and at the party I was encouraged to sing karaoke (badly)! Both were new experiences for me. Participating, or being invited to participate, are important elements of spending time and again, building trust with local communities.

While ethnographers are often forced to define whether they intend to undertake ‘participant’ or ‘non-participant’ fieldwork, for example to gain necessary ethical approvals, in reality where they fit on this continuum is often highly variable. In some cases, active participation may reduce over time as researchers become more embedded within the setting, and people are perhaps less likely to question why they are there, or feel the need assign specific tasks. In other ways, participation may increase over time as relationships are built in the field. Where warranted, Seim (2024) argues that ethnography should include participating in certain activities. Moeran, 2007 also described the shift from passive observation to active and engaged participation in ethnographic research, whereby deeper immersion helps to build trust, gain ‘backstage’ insights and co-construct meaning with participants through relational fieldwork. Striking a balance between participant and non-participant can be an ongoing negotiation with participants and has long sparked debate within the methodological literature (e.g., Laurier, 2010), raising ethical tensions and challenges along the way for both the researcher and the researched.

Rachael Kelley reflects on being asked to participate in ways she had not intended to as a clinical researcher studying dementia, the tensions that raised and what it meant for her research:

What was interesting was the different roles that I adopted or were given to me and the different relationships that developed during fieldwork (Kelley et al., 2019). My role was a ‘researcher’ in that I was spending time with people, being curious, asking questions and joining activities and events I felt I could learn more from. But this was by no means my only ‘role’ as I found myself adopting or being given multiple. People often like to ‘place’ you to feel that you have a purpose. What that looked like in practice varied quite a bit, and depending on who I was with. For patients, as well as a researcher, I was sometimes seen as a friend, confidant or someone to spend time with. During our conversations, families would sometimes seek my advice, or felt reassured that when they couldn’t be there, I was there with their relative. On occasions I took or was given a sort of assistant’s role – helping out at mealtimes, refreshing water, buzzing people in through the door to speak to staff and that sort of thing. I’m a mental health nurse by background, which meant that sometimes staff on the ward would almost see me as a bit of an expert, particularly as I used to work with people with dementia out in the community. If that became apparent in our conversations or I told somebody that, they would sometimes seek my advice. I was invited to an adult protection meeting once, partly because I had spent more time with the person the meeting was about than anyone on the ward. Some potential roles and relationships, such as that one, needed careful consideration and could feel a bit uncomfortable. What was quite interesting was stopping to reflect on that, often with more experienced others, and asking myself what it was telling me in relation to the research or whether any changes or re-emphasis of my role were needed. As well as being a researcher, I was seen and ‘used’ in different ways by different people and at different times. My advice to anyone new to ethnographic research in healthcare is to speak to others who have done similar work, include sufficient time for relationship building, and carefully consider roles and ethical tensions that may arise. In complex and often fast-paced healthcare environments challenging scenarios are commonplace and often require decision-making in the moment so be as prepared as you can be for what is to come!

Fieldwork, Observations and Fieldnotes

Observations are one of the characteristic methods drawn upon in ethnographic fieldwork, aimed at deeply understanding human experiences, practices, and cultures to interrogate what may appear “ordinary” (e.g., routine practices, habits, and social norms), to reveal complexities, contradictions, and structures that may go otherwise unnoticed (e.g., power dynamics and identity formations). Malinowski (1922 [2002]) emphasised that to truly understand a culture, researchers must delve into the subtle, mundane and often unconscious, aspects of daily life. Conversely, ethnography also engages with the extraordinary (e.g., rituals, innovations, subcultures) to explore how this sheds insight on broader cultural norms. Observational fieldwork involves skills in listening, watching and zooming in and out of the most and least salient elements of what is going on in everyday settings. While observations can be commonplace in healthcare contexts, particularly in clinical settings where students or trainees from medicine, nursing and other healthcare professions come on placement to observe more experienced healthcare professionals working, sometimes, people feel uncomfortable being observed. It is important to understand where this discomfort stems from. In some instances, it may require a clear explanation about the purpose of the research, re-emphasising that observations are not being carried out for auditing or regulatory inspection purposes, examinations, or as a judgement of their competence or fitness to practice – which may be what they are used to or fearful of.

As a patient safety researcher, Justin Waring reflects on the complexities of conducting observations, both practically and emotionally when studying in a surgical environment:

This study (Waring et al., 2007, 2006) was physically and emotionally challenging as a field researcher. It was the first time I directly observed surgery, and it can be very bloody and noisy. And people die. It also smells and I remember going home with the smell of diathermy in my hair. Whilst theatres are busy places I was also out of place and didn’t have a clear role. People often thought I was doing a time and motion study, and I had to find ways to explain what I was doing. But for the most part, I didn’t have a clue. It really was a sense of discovery about the surgical team and myself. But over time I learned some things that stuck with me which included scaling or zooming, so I would shift my focus between the micro interactive to the wider flow of work during an observation. I now have a 5-7 step process.

Indeed, Liberati explained that “a non-reactive position is an achievement rather than a given status” (2016). Discomfort with being observed may lead people to conceal certain things of potential value for analysis. However, over time, there may be ways of overcoming these issues, such as keeping a steady and benign presence, interviewing prior to observations to make people feel more comfortable, renegotiation, finding alternative activity to observe, and keeping fieldnotes when and where it feels most appropriate.

Jusin Waring reflects on strategies he has learned during fieldwork, to collate fieldnotes in ways that felt appropriate and most comfortable for participants while studying patient safety:

We looked at how people experienced and talked about safety in this study (Waring & Bishop, 2010). A key challenge was being invisible or not noticed so we could better observe how they talked about difficult issues. Time, trust and the art of not looking at what you want to look at were important, and not taking notes (I spent a lot of time going to the toilet or sitting in my car writing down observations because I couldn’t do them there and then). I also like this study because I tried to relate an everyday workplace concept to something that people think is mysterious or special to show that in many ways healthcare is both ordinary and extraordinary- familiar strange, and strange familiar!

Fieldnotes are a central way to capture researcher’s observations, reflections and interpretations during ethnographic fieldwork. Traditionally, ethnographers would keep real-time ‘private’ and unfinished jottings, using a field notebook and pen. But sometimes, researchers cannot or do not want to be seen taking fieldnotes in the moment – and so find other methods, such as taking regular breaks to write notes as soon as possible after observed events, quickly jotting down key words or phrases to act as reminders for later, or creating audio or video recordings. Researchers also recognise fieldnotes as essential for analysis, writing them mindful of using, sharing, or iterating them over time. Some researchers may take real-time and/or retrospective fieldnotes, adopt digital and manual methods of recording them, and use varying levels of breadth and depth of note taking. Others may illustrate with doodles, note down ‘lightbulb’ flashes of analytical insight or potential theory, or keep them purely descriptive.

Graham Martin reflects on the trade-off between keeping detailed fieldnotes while studying public participation in healthcare and shares methodological advice about getting a ‘feel’ of events unfolding (Martin, 2009, 2012):

I’m not sure it can really be called ‘ethnographic’- my PhD study was largely interview-based but also included a lot of meeting observations, and the data from those observations was particularly important. It looked at the dynamics of those meetings and how these affected the form taken by deliberation and the outcomes of the process. I still remember the meetings quite vividly – as an amateur observer I was keen to capture every detail, and the amount I wrote down (describing each item in detail, capturing snatches of verbatim discussion, and so on) became a running joke among the members of the group. This helped to make the data collection process a bit easier as people got used to what I was doing and understood the purpose. Looking back, though, I think I could have relaxed a bit more, written a bit less and just immersed myself in the moment – for everything I gained with my scribbles, I probably lost a sense of the feel and mood of the meetings that could have been just as valuable for my analysis, if not more so.

Conclusions

In this paper, authors offer a collection of diverse first-hand reflections relating to past ethnographic studies in the context of health and care research. Reflections are combined with insights on conceptual, theoretical, methodological, and ethical issues aiming to de-mystify ethnography and prepare researchers planning to adopt ethnographic approaches. The paper illuminates the value of ethnography for both improving services and researchers themselves individually, but also the challenges faced. This includes an exploration of concepts including culture, positionality, reflexivity, relationships, ethical tensions, and fieldwork. Cross-cutting themes include identity, blurring of boundaries between private and research life to afford understanding and the rewarding yet emotional and uncomfortable situations people find themselves in – both the researcher and the researched. The paper has utility for researchers considering using an ethnographic approach across disciplines and expertise levels, including PhD students and clinical researchers, as well as any stakeholders who may wish to be involved, or support such work – particularly in a health and care contexts.