Abstract
Healthcare researchers are increasingly using ethnographic methods to understand the social dynamics and cultural contexts of specific groups, such as clinical teams in hospitals and community clinics. Critical ethnography is a subtype of ethnography that mobilizes critical social theory to expose and challenge group inequities and power dynamics shaped by broader social, economic, and political conditions. Critical ethnography is particularly useful for understanding how providers interact with one another in complex and high-acuity environments such as emergency rooms and intensive care units. Given the varied approaches to critical theory and ethnographic methods, this critical review summarizes how critical ethnography has been conceptualized and applied to study providers in acute care settings. After conducting a comprehensive cross-database search, we extracted the following information from the 27 reviewed publications: paradigm, theoretical framework, axiology, positionality, data collection and analysis methods, approach to rigor, and research ethics considerations. After synthesizing key trends in literature, we identified and critically interpreted several themes, contradictions, and tensions present across the studies. Drawing on social science commentary on theoretical and methodological coherence, axiology, and citational practices in critical theory, this article provides several conceptual, ethical, and methodological considerations for the use of critical ethnography in healthcare research.
Keywords
Introduction
In the late 20th century, social science disciplines such as sociology and anthropology moved beyond strictly positivist and quantitative approaches to understanding the social world and began incorporating interpretive and qualitative methodologies to better articulate people’s experiences and narratives (Denzin & Lincoln, 1994). Applied health and social science fields such as nursing and education have followed suit, recognizing the capacity of these methodologies to understand the perspectives of individuals that provide and receive care (Maher, 2025; Paradis-Gagné & Pariseau-Legault, 2022). Drawing from methodologies such as interpretive description and grounded theory, many healthcare scholars use data collection methods such as interviews and focus groups to examine patient and family perspectives about how healthcare systems and clinicians can improve patient care. Others work with providers, examining the conditions that shape their well-being at work and ability to provide care. Since institutional policies, organizational contexts, ward subcultures, and team dynamics affect providers’ experiences and actions, many healthcare researchers explore the social dimensions within specific healthcare settings such as hospitals, wards, or clinics (Pyo et al., 2023).
Ethnography is a useful qualitative method for studying clinical subcultures because it allows for a comprehensive examination of the cultural, interpersonal, and institutional layers shaping group interactions. Ethnographers use a variety of methods, including observation, interviewing, video recording, and document analysis to understand a group’s shared and consistent practices, habits, beliefs, opinions, rituals, behaviors, and norms (Hammersley & Atkinson, 2019). Scholars in the healthcare disciplines are turning to ethnography to study patient and provider experiences in contexts such as emergency rooms, intensive care units, and psychiatric wards (Black et al., 2021).
A cursory Google Scholar search indicates that critical ethnography has gained momentum across fields such as nursing, medicine, and public health. Critical ethnographies employs critical social theory throughout research design. Centering critical social theory supports ethnographers to notice, examine, and analyze how power dynamics and inequities shape and are reinforced by everyday interactions, such as those between and among patients, staff, and visitors. In doing so, critical ethnography aims not only to expose but challenge and undermine systems of oppression (Carspecken, 1996; Madison, 2005; Thomas, 1993). In contrast to traditional ethnography’s often depoliticized focus on empirical description, critical ethnography’s normative stance is arguably essential for addressing historical and contemporary manifestations of colonial and intersectional violence and marginalization in healthcare institutions – including that which arises from provider beliefs and practices (see Paradis-Gagné & Pariseau-Legault, 2022; Rashid & Goldszmidt, 2024; Shaheen-Hussain, 2020).
This critical review focuses on how critical ethnography is used to study healthcare providers in acute care units. Acute care settings in particular stand to benefit from critical ethnographic research given their complex, high-intensity, and high-stakes nature; racist and colonial power dynamics in emergency departments, for example, have harmful and lethal consequences for marginalized patients (see, for example, McLane et al., 2022). Understanding how critical ethnography has been conducted in these settings also provides an opportunity to consider the socioeconomic, cultural, and geopolitical influences that shape the production and interpretation of qualitative evidence. This review also focuses on ethnographies of healthcare providers because of the value of “researching up” – understanding exactly how professional narratives and practices (and the policies and processes that affect them) (re)produce health inequity (Brown & Strega, 2015).
Given the diversity of approaches to theory and method within critical ethnography (Johais & Leser, 2024), this review has two aims. The first is to examine how critical ethnography has been done – approaches to data collection and analysis. Second, this review analyzes how critical ethnography has been framed – how the “critical” in critical ethnography has been introduced and mobilized, and toward what ends.
Background
Ethnography originated in Euro-American anthropology and sociology disciplines, with social scientists studying cultural environments unfamiliar to them to understand their social dynamics, customs, and ways of life (Hammersley & Atkinson, 2019). Historically, ethnographers have gone “undercover” and embedded themselves in new communities without disclosing their role as a researcher to gain a deep insider perspective. In doing so, many ethnographers have produced and perpetuated colonial, racist, and otherwise dehumanizing narratives about the communities they studied (Johais & Leser, 2024; Morton-Ninomiya et al., 2018; Simpson, 2007). Ethnography continues to be criticized for this tendency, though more social scientists are using ethnography to understand lived experiences and structures of inequity (see Desmond, 2016). New forms of ethnography have also emerged to address these issues, including institutional ethnography (Smith, 2005) and decolonial ethnography (Alonso-Bejarano et al., 2019; Morton-Ninomiya et al., 2018).
Like these strands of ethnography, critical ethnography makes the shift from being descriptive to normative – to challenging, not just naming, the power dynamics and inequities that influence, are embedded within, or reinforced by the group being studied (Carspecken, 1996; Madison, 2005; Thomas, 1993). Scholars in education introduced the term critical ethnography to link ethnography to the assumptions and imperatives embedded within critical social theory, with Carspecken (1996) being one of the most cited scholars for his elaboration on critical ethnographic theory and method. Critical ethnography is the “performance of critical theory,” where critical theory can be described as a paradigm or theoretical perspective that, in its broadest sense, involves the critique of social oppression (Madison, 2005, p. 3; see Kincheloe & McLaren, 2011). A common assumption in critical theory is that truth, experience, and knowledge are mediated by and contingent upon historical and ongoing forms of social, political, and economic power dynamics (Guba & Lincoln, 1994). Although ethnographers may study micro- and meso-level social relationships, critical ethnographers “link social phenomena to wider socio-historical events to expose prevailing systems of domination, assumptions, ideologies, discourses” (Hardcastle et al., 2006, p. 151). In other words, “a critical ethnography is a conventional ethnography with a political purpose” – its axiology is one of emancipation (Thomas, 1993, p. 4). Critical ethnographers range from focusing on restructuring macro-political conditions to collaborating directly with their participants to liberate them from the context they find themselves in; this micro-political approach is also a key aspect of other critical qualitative methodologies such as Participatory Action Research (Guba & Lincoln, 1994). As Simon and Dippo (1986) stress, critical ethnography must challenge conditions of inequity and support individuals and groups to reflect on how lived experiences are “constituted and regulated through” these social and material phenomena (p. 197).
Despite these common underpinnings, “critical theory” is not a monolithic paradigm or theoretical perspective. Rather, it describes a diversity of paradigmatic, theoretical, methodological, and axiological approaches to critiquing power (Kincheloe & McLaren, 2011). This diversity warrants a further exploration of the ways in which the growing number of critical ethnographers in the healthcare disciplines have adhered to, built upon, or diverged from the frameworks offered by early critical ethnographers. Scholars have commented on the themes, gaps, and possibilities in critical ethnographic health research, but there has not yet been a robust review of the conceptual, axiological, and methodological trends in its use, as has been done with focused ethnography (Shannon et al., 2023), rapid ethnography (Vindrola-Padros & Vindrola-Padros, 2018), and ethnography as a whole (Black, et al., 2021; Rashid et al., 2015). Existing commentaries discuss the utility of critical ethnography and Carspecken’s (1996) method in nursing research (Hardcastle et al., 2006; Ross et al., 2016; Smyth & Holmes, 2005); the need for poststructural critical ethnographies (Jager et al., 2024; Manias & Street, 2001a); methodological and ethical tensions in critical ethnography (Cudmore & Sondermeyer, 2007; Manias & Street, 2001a; Vandenberg & Hall, 2011); the necessity of critical ethnographic work for medical education research (Rashid & Goldszmidt, 2024); and more recently, the paradigmatic pitfalls of relying on the Frankfurt School and related schools that overlook more-than-human analyses of and insights into experiences of marginality (Adam et al., 2024). Building off these commentaries, as well as scholarship on theoretical and methodological coherence, citational practice, and axiology, this review synthesizes and critically analyzes how and through what lens critical ethnography has been used to study providers in acute care settings.
Methodology
Critical reviews can be thought of in relation to scoping reviews, which aim to relatively quickly scan and summarize a field – often to inform future research directions or practical actions (Arksey & O’Malley, 2005). Arksey and O’Malley’s (2005) guideline for conducting scoping reviews has supported thousands of researchers in performing quality syntheses and adapting their approaches to diverse contexts and specific aims (Levac et al., 2010; M. D. J. Peters et al., 2020). Critical reviews are similar in that they synthesize and analyze or evaluate a body of literature; however, they go beyond synthesis to offer an exploratory, critical, and inherently subjective interpretation of key themes and trends. While scoping reviews often rely on relatively standardized and systematic approaches to thematically analyzing findings, critically-oriented reviews such as narrative reviews, critical interpretive syntheses, and integrative reviews favor critical, interpretive, and theory-forward approaches (Ferrari, 2015; Perlman et al., 2025; White & Beagan, 2020) As White and Beagan (2020) write, critically-oriented reviews such as integrative reviews prioritize “thoughtful, in-depth, critically reflective engagement with ideas” to “explore trends, contradictory evidence, gaps in research, and conceptual or theoretical complexities” (p. 202). In doing so, they can offer new directions and provocations for future research (Garrod, 2023).
Although there is no exemplar introduction to critical reviews and their approaches, scholars have loosely defined “critical reviews” through robust analyses and typologies of the aims, methods, and analyses employed in diverse types of literature reviews (Grant & Booth, 2009; Paré et al., 2015). With even greater methodological flexibility than critical interpretive syntheses and narrative reviews, critical reviews can be thought of as a flexible umbrella of literature reviews that prioritize critique and challenge existing approaches and assumptions in the field. Critical reviews often engage “meta-analytic” discussions (Ralph & Baltes, 2022, p. 1634) about how research is conducted, analyzed, framed, and presented, providing a “launch pad” (Grant & Booth, 2009, p. 3) for future research.
Critical reviews vary in approaches to systematicity, quality appraisal, and descriptive synthesis (Grant & Booth, 2009), highlighting the need for transparency in one’s approach to help readers contextualize and interpret the analysis (Paré et al., 2015). While critical reviews do not require a comprehensive sample, we sought to capture the relevant academic literature on our topic and thus conducted a systematic search. The search, extraction, and analysis were guided by our practical and conceptual research aims, where we sought to understand existing approaches to critical ethnography in acute care research, alongside their paradigmatic, theoretical, and axiological underpinnings.
Search Strategy
The first author (ET) consulted with the second author (LP) and a health sciences librarian to strategize the search. The search was conducted in February 2025 through an institutional cross-database search engine that included databases such as CINAHL, Health Source: Nursing/Academic Edition, Scopus, and Education Research Complete. Search terms included “critical ethnograph*” in the abstract field and an extensive list of healthcare workers in the title field (e.g., “medical practitioner*”; “healthcare professional*”; “gastroenterologist*”; “social worker*”). Boolean operators and truncation symbols were used to capture concept combinations, for example, (“critical ethnograph*”) AND (“healthcare professional*” OR “physician*” OR “social worker*”). The search was limited to eBooks, books, peer-reviewed journal articles, theses, and dissertations written in English. No limits were imposed on publication year. The search initially yielded 184 results. After removing duplicates, ET screened 87 publications by title, abstract, and if necessary, full text. Only original empirical articles or methodological commentaries on empirical critical ethnographic research were eligible for inclusion. Additionally, the critical ethnographic studies were required to be conducted in acute care settings (e.g., emergency or inpatient medical wards) and to focus on the experiences, behaviors, and interpretations of clinicians. Studies conducted exclusively in outpatient or educational contexts, or those centered primarily on patient perspectives, were excluded. The final sample included 27 publications (23 articles, two MSc theses, one book, and one PhD dissertation). See the Supplementary File for details on the search strategy and Figure 1 for the selection diagram.
Search and selection flowchart.
Data Analysis
ET deductively extracted basic study information (e.g., clinical setting and participants) as well as information based on the research aims of (1) understanding authors’ theoretical framing (e.g., ontology, epistemology, axiology, and theoretical framework), and (2) their methods (e.g., data collection and analysis). During this process, useful – but unaccounted for – topics emerged, such as discussions about rigor and reflexivity.
Study Details.
While methodological reviews often examine the reviewed articles’ modes of data collection and analysis (see Black et al., 2021; Shannon et al., 2023), our additional focus on understanding authors’ paradigmatic assumptions and utilization of critical theory was shaped by our commitments to the ethical and political implications of research theory and method. We derived our paradigmatic and theoretical inquiries from critical commentaries on coherence (Denzin, 2016; Maher, 2025; Mayan, 2016, 2023; St. Pierre, 2022) and the citational politics of critical theory (Ahmed, 2013; Todd, 2016). Tuck’s (2009) work on theories of change, alongside Peers’ (2018) emphasis on axiological considerations in research, guided us to inquire about each paper’s axiological orientation and its commitment to ameliorating injustice. In addition, we come into this research topic with an understanding of how healthcare systems, providers, and practices perpetuate and produce health and social inequities – particularly in settler colonial contexts (see Shaheen-Hussain, 2020). Our various experiences receiving, witnessing, and enacting harmful health and social service practices also influence the lens through which we attend to the publications’ approaches to criticality and injustice. Taken together, these frameworks sensitized our analysis, which examines the publications’ “weaknesses, controversies, contradictions, and inconsistencies” (Paré et al., 2015, p. 189) and what they reveal about the healthcare disciplines’ abilities to use critical ethnography to uncover and challenge structures of marginalization in acute care contexts.
We interpreted the extracted information (results) using abductive analysis – the interplay of conceptual frameworks and close engagement with the literature (Collins & Stockton, 2018; Timmermans & Tavory, 2012). ET reviewed the extraction sheet several times, identifying commonalities, tensions, and gaps in the approaches and revisiting the readings to clarify these interpretations. LP and TB triangulated the analysis and supported the interpretation and discussion. The themes for the discussion section were developed through the reading of results alongside our familiarity with the aforementioned social theories about healthcare and critical research. This phase required an interpretation of the “ideas, assumptions, and conceptualizations” that may be “underpinning what is actually articulated in the data,” leading us to consider why and how certain topics might be omitted, emphasized, or framed in particular ways (Timmermans & Tavory, 2012, p. 85). Drawing on this critical interpretation, the discussion offers several points for further consideration in critical ethnographic research on healthcare providers within and beyond acute care. This study did not require approval from the research ethics board because it did not directly involve human or animal research participants.
Author Positionality
Positionality and reflexivity statements offer important interventions into the tendency for academic literature to claim objectivity despite being necessarily shaped by researchers’ worldviews and structural locations. Yet, these statements do not come without their tensions. As Sibbald et al. (2025) remind, disclosing one’s “shopping list” of identities raises questions about the assumptions, theories of change, and impacts of these statements. First, positionality statements differentially benefit and/or harm authors and readers; they are apologetic performances for some while putting others at risk of being singled-out, stereotyped, stigmatized, and discriminated against. Second, these statements, particularly when utilized by White, elite, cisgender, and otherwise structurally advantaged authors, can absolve us from reflexive process – especially when we emphasize our marginalities more than our advantages, using the former as a means of marking ourselves as innocent. Third, these statements often rely on static, rigid, and homogenizing approaches to identity rather than analyses about dynamic and contextual processes of subjugation and its impacts. Still, these statements – and the processes behind them – can be crucial for reminding that – or how – one’s social location and worldviews un/consciously shape our research questions, methods, analyses, and conclusions, and the insights and limitations this offers.
With these considerations in mind, we situate some aspects of our positionality, with an emphasis on our structural advantages, in order to contextualize the approach and analyses in this article for readers. The three of us are White, cisgender settlers living and working on Treaty 6 territory in amiskwaciwâskahikan (commonly known as Edmonton, Alberta, Canada), whose research broadly focuses on intersectional matters of inequity in healthcare. Our racial and settler social locations, alongside our geopolitical and socioeconomic advantages as a graduate student (ET) and clinician-researchers (LP and TB) in the so-called “Global North” certainly shape our orientation to this research and the kinds of injustice we attend and do not attend to in our analyses. Our reflexive processes for this article have included taking the time to discuss among ourselves and with others topics such as the strengths and limitations of critical ethnography, the academic politics of critical theory, reading alternative approaches to literature reviews, our own and each other’s citational tendencies and assumptions about “coherence” in qualitative research, and among others that may or may not be well expressed in writing. As Sibbald et al. (2025) argue, reflexivity statements can never exhaustively represent our individual and collective un/conscious processes, so we use this statement to remind ourselves and readers about the importance of engaging in reflexive praxis – in creating, reading, and reflecting on our own and others’ publications
Results
Four of the 27 publications were commentary pieces rather than original research studies but were included given the details with which they discussed using critical ethnographic methods to study providers in acute care settings. Notably, studies led by Hardcastle, Liu, Manias, Mahon, and Ross were published in more than one article; 18 studies were represented across 27 publications. The results are thus described in terms of study methodology rather than publication methodology. See each study’s key characteristics.
The studies were published between 1992 and 2024. Half of the studies were based on research done in acute care contexts in urban Australia (n = 9); the remaining studies were based out of urban and rural settings in Canada (n = 3), Uganda (n = 2), Columbia (n = 1), Fiji (n = 1), Iran (n = 1), Ghana (n = 1), and New Zealand (n = 1). For the studies conducted in single settings, wards included adult and pediatric intensive and critical care units (Jenkins, 2014; Mahon, 2014; Mahon & McPherson, 2014; Manias & Street, 2000, 2001a, 2001b, 2001c, 2001d, 2008), renal units (Hardcastle, 2004; Hardcastle et al., 2006), emergency rooms (Cudmore & Sondermeyer, 2007), obstetrical wards (Boakye, 2022), hematology/oncology wards (Mahon, 2018), and acute surgical units (Sharp et al., 2018). Some were situated in urban teaching or regional referral hospitals (Batch & Windsor, 2015; Harrowing & Mill, 2009; Liu et al., 2012, 2016; Sadati et al., 2016; Street, 1992), and others studied providers working in both acute and community-based settings (Bedoya-Ruiz et al., 2020; Jones, 1993; MacLellan et al., 2016; Ross & Rogers, 2017; Ross et al., 2019; Stewart & Usher, 2010). Six studies included multiple types of healthcare professionals (Bedoya-Ruiz et al., 2020; Boakye, 2022; Jenkins, 2014; Liu et al., 2016; Mahon, 2018; Manias & Street, 2000, 2001a, 2001b, 2001c, 2001d, 2008), two included patients and/or caregivers (Liu et al., 2012; Sadati et al., 2016), and the remaining 11 focused on nurses’ experiences. Most studies were led by clinician-scholars and published in clinical journals, though the current or previous clinical roles of authors was not always clearly stated. Common aims of the studies were to understand the relationships and communication among providers as well as their experiences of their workload and specific clinical practices such as shift handovers.
Nine of the 18 studies relied upon all or some of Carspecken’s (1996) five-stage approach to conducting a critical ethnography, either entirely applying his theoretical and methodological approach (see Hardcastle et al., 2006), or combining his theory, data collection, and/or data analysis processes with other theories and methods such as critical realism, Willis’ (1981) cultural reproduction theory, Browne’s (2000) approach to Critical Social Theory, analytic autoethnography, focused ethnography, and thematic analysis (see Jenkins, 2014; MacLellan et al., 2016; Mahon, 2014, 2018; Sadati et al., 2016; Stewart & Usher, 2010).
Paradigmatic and Theoretical Approaches
Nine studies explicitly stated their paradigmatic assumptions, drawing from critical realism (Sadati et al., 2016), critical hermeneutics, (Bedoya-Ruiz et al., 2020), critical postmodernism (Jenkins, 2014; Manias & Street, 2008), critical interpretivism (Hardcastle, 2004), Browne’s (2000) four tenets of Critical Social Theory (Mahon, 2014, 2018), or Habermasian ontologies and epistemologies (Hardcastle et al., 2006; Jones, 1993; Street, 1992). Street (1992) elaborated extensively on her reliance on Frankfurt, poststructural, neo-Marxist, feminist, critical pedagogical, and several other critical theories to frame her approach to emancipatory research. Eight studies stated that they took an interpretivist lens, emphasizing how participants made sense of their experiences in the context being studied (Batch & Windsor, 2015; Hardcastle, 2004; Harrowing & Mill, 2009; Mahon, 2014, 2018; Ross & Rogers, 2017; Sharp et al., 2018; Stewart & Usher, 2010).
The remaining 10 studies implied that they were operating from a critical paradigm or framework when they introduced critical ethnography, critical theory, or “taking a critical focus” (Cudmore & Sondermeyer, 2007, p. 27). These authors emphasized interactions between social forces and lived experiences, and that critical research must challenge power dynamics. Some elaborated on the relationship between power, knowledge, and experience (see Mahon, 2014; Sharp et al., 2018) while others limited their description to a sentence or two (see Batch & Windsor, 2015; Boakye, 2022). All 10 of these studies excluded references to particular lineages of critical theory and instead turned to other critical ethnographers’ or applied scientists’ definitions of criticality, which mainly draw on scholars from the Frankfurt School, as well as poststructural, feminist, and dialectical materialist perspectives (see Browne, 2000; Carspecken, 1996; Madison, 2005; Thomas, 1993).
In addition to describing “critical” in critical ethnography in these diverse ways, 11 studies outlined the specific theoretical frameworks through which they approached their research and/or analyzed their data. These schools of thought included poststructuralism, specifically Foucault’s (1979) conceptualizations of power, knowledge, discipline, and subjectivity (MacLellan et al., 2016; Manias & Street, 2001a, 2008); Breilh (1989) and Menéndez’ (2002) neo-Marxist critical medical anthropology (Bedoya-Ruiz et al., 2020); Giddens’ (1991) structuration theory (Hardcastle, 2004); Walker’s (2007) theory of moral understanding (Boakye, 2022); Fairclough’s ([2010] 2013) critical discourse analysis (a poststructural method, see Liu et al., 2012, 2016); Habermas’ (1985) theory of communicative action (Jones, 1993; Stewart & Usher, 2010; Street, 1992); Willis’ (1981) cultural reproduction theory (Stewart & Usher, 2010), Keyton’s (2004) “lenses” for categorizing organizational communication (Batch & Windsor, 2015), and for Street (1992), a number of theoretical frameworks.
Axiology and Aims
One’s use of critical theory is closely related to their axiology, or the underlying values that shape what, why, and how researchers choose to study a particular topic (Peers, 2018). Embedded in critical schools of thought, for example, is a normative axiology toward emancipation. Simultaneously, viewing research as a mechanism for social equity may drive a researcher to ground their work in a paradigm or framework – often critical – that allows for at least analysis, if not transformation, of unjust conditions. The interplay between ontology, epistemology, and axiology broadly shapes not only why and what one studies, but how one thinks social change happens, and how or if research may contribute to this change. The latter two points fall under what Unangax̂ education scholar Tuck (2009) refers to as “theories of change” and are key components of axiology. Without using the term axiology, the authors all described critical ethnography as inherently normative, necessitating that researchers take a stance about what needs to change to improve people’s lives. While some studies spoke generally to the need for critical research to challenge injustice (see Boakye, 2022; Harrowing & Mill, 2009; Ross & Rogers, 2017), others emphasized that research should contribute directly to the emancipation and empowerment of their participants (see Batch & Windsor, 2015; Harrowing & Mill, 2009; Jenkins, 2014; Sharp et al., 2018). Six studies did so by using collaborative methods that encouraged reflexivity among participants and researchers so that they could analyze and challenge the power dynamics affecting participants in their workplace (see Cudmore & Sondermeyer, 2007; Hardcastle, 2004; Jones, 1993; Liu et al., 2012, 2016; Manias & Street, 2000, 2001b, 2001c, 2001d; Street, 1992). Three commentary pieces were written about the need for critical ethnographers to attend to the power dynamics between researchers and participants (see Cudmore & Sondermeyer, 2007; Mahon & McPherson, 2014; Manias & Street, 2001a).
The primary normative emphasis was on improving specific infrastructural and interpersonal issues within a single unit or local healthcare system. Given the number of studies about nurses, there were many calls for addressing misogynistic assumptions about nurses’ supposed inferiority to or dependency on physicians and managers (see Batch & Windsor, 2015; Hardcastle, 2004; Jones, 1993; Liu et al., 2012, 2016; Mahon, 2014; Manias & Street, 2001b, 2001c, 2001d, 2008; Street, 1992). While participants in Stewart and Usher’s (2010) study discussed the impact of British colonialism on the Fijian healthcare system and its providers, no mention was made of this in their discussion, which focused on the limitations of this “developing” country’s healthcare system. Eight studies linked improved professional dynamics and practices to improved patient care, for example, by researching midwifery care to improve inequities in maternal morbidity and mortality (Bedoya-Ruiz et al., 2020) or understanding physician-patient experiences to improve patient-centered care (Sadati et al., 2016). Six studies strongly connected these institutional issues to forces beyond the healthcare system, such as the political climate, neoliberal economics, and societal misogyny (Bedoya-Ruiz et al., 2020; Jenkins, 2014; Jones, 1993; MacLellan et al, 2016; Sharp et al. 2018; Street, 1992).
Positionality and Reflexivity
The specific positionalities held by researchers doing data collection varied. Mahon’s (2014) study and Batch and Windsor’s (2015) publication indicated that the primary authors were clinician-researchers embedded within their current workplace. Although being an insider provided fruitful insight into the context being studied, it also required ongoing reflection about the influence of the researcher’s pre-existing assumptions during on the data collection and analysis. Jenkins (2014) separated their professional role in the unit by conducting research while not on shift. Hardcastle (2004) resigned from their role before conducting research in the unit. Several other teams included clinicians who may have had some familiarity with the type of work but were either not actively involved with the setting or practicing clinically. The study conducted by Sadati et al. (2016) was led by sociologists but included authors with medical degrees situated in health policy research.
Ten studies discussed reflexivity in-depth by describing strategies for both epistemological and personal reflexivity and emphasizing their importance for ensuring rigor (Batch & Windsor, 2015; Bedoya-Ruiz et al., 2020; Hardcastle, 2004; Hardcastle et al., 2006; Jones, 1993; Liu et al., 2012, 2016; Mahon, 2014, 2018; Mahon & McPherson, 2014; Manias & Street, 2000, 2001b, 2001c, 2001d, 2008; Sadati et al., 2016; Street, 1992). Mahon and McPherson’s (2014) commentary emphasizes that being reflexive also requires working toward changing social conditions, not merely individual participants or their experiences. Reflexive practices included collaborative and reflexive data collection and analysis, informing participants about the researchers’ positionalities and aims, being empathetic and fair to participants, and taking field notes or having collaborative discussions with colleagues about one’s own biases, assumptions, interests, and values - and how they all might be shaping the research process. No researchers specifically discussed the influence of their social location (such as race, gender, and socioeconomic status) on their research, though Street (1992) discussed the limitations of her homogenous sample of White women.
Cudmore and Sondermeyer (2007) noted that conducting ethnography as a clinician-scholar allowed researchers to be more sensitive to participants’ perspectives without misinterpreting them based on lack of knowledge about their clinical contexts (see also Mahon & McPherson, 2014). However, being an insider can also be challenging if coworkers feel that the researcher is “spying” on them (Cudmore & Sondermeyer, 2007, p. 31). Being an insider (and to a lesser extent an outsider) can also amplify power dynamics between researchers and participants, particularly when disagreements occur (Manias & Street, 2001a). For Manias and Street, a poststructural perspective helped researchers and participants to understand that there is no single truth, but multiple messy truths, and to acknowledge that the need for a coherent research product is shaped by institutional requirements. Still, their participants did not necessarily want to engage with poststructural analysis, which posed a challenge for collaborating on critical analysis.
Data Collection
Authors varied in their description of data collection procedures (for elaborate detail, see Ross & Rogers, 2017). Once in the field, sampling methods were mostly purposive, with other methods including theoretical sampling (Bedoya-Ruiz et al., 2020), open sampling (Liu et al., 2012, 2016), stratified purposive sampling (Mahon, 2018), and convenience sampling (Stewart & Usher, 2010). Sample sizes ranged, with Manias and Street (2000, 2001b, 2001c, 2001d, 2008) interviewing and observing six nurses, and others interviewing up to 40 people and observing close to 100.
All studies involved observation and interviewing, two core methods of ethnography. While some spent extensive time (up to 3 years) in the field, others conducted limited observations due to timing or because they were researching providers across clinical and geographic settings (see MacLellan et al., 2016). Observations within single units often involved shadowing or accompanying clinicians throughout their shift (including when interacting with patients) and took place during both day and night shifts to ensure in-depth coverage. While observing, researchers took field notes, with some describing a generalized approach and others detailing the different types of field notes they took, such as thick description, analytical memos, methodological notes, and reflexive journaling (see Hardcastle, 2004; Jenkins, 2014; Ross & Rogers, 2017; Ross et al., 2019; Sharp et al., 2018).
The most common approach to interviewing was semi-structured, though three research teams conducting structured or unstructured interviews (Hardcastle, 2004; Jones, 1993; Ross & Rogers, 2017) and three teams used reflexive interviews to engage participants in their findings, analysis, and ability to make changes to their environment (Hardcastle, 2004; Liu et al., 2012, 2016; Street, 1992). Focus groups were only used in six studies, and the focus groups in Liu et al.’s (2012, 2016) study had reflexive and collaborative components (see also Batch & Windsor, 2015; Harrowing & Mill, 2009; Manias & Street, 2000, 2001b, 2001c, 2001d, 2008; Sadati et al., 2016; Sharp et al., 2018). Document analysis was also employed to analyze electronic communications, medical documentation, memorandums, and care planning documents (Batch & Windsor, 2015; Ross & Rogers, 2017; Ross et al., 2019). Additional methods included spatial and temporal mapping of the unit (Jones, 1993), video recordings to assess nonverbal communication (Liu et al., 2012, 2016), systematic recording of daily routines and rituals (Hardcastle et al., 2006), and solicited participant diaries (Jones, 1993).
Beyond naming participants’ professional roles and experiences, five studies presented the demographic characteristics of their participants (Bedoya-Ruiz et al., 2020; Mahon, 2014, 2018; Sadati et al., 2016; Stewart & Usher, 2010; Street, 1992). The demographics shared focused on participants’ age and sex or gender (with the two being conflated and presented as a male/female binary). While Bedoya-Ruiz et al. (2020) presented the occupation, marital status, education, socioeconomic status, housing status, and source of income for patient participants, they only reported the sex and age of provider participants.
Data Analysis
Authors described a variety of methods for the analysis itself and its relationship to critical theory. Authors used approaches such as Carspecken’s (1996) methods, theory-informed thematic analysis, theoretical sensitization, thematic narrative analysis, thematic coding alongside analysis, researcher analysis triangulated with member checking and second rounds of data collection, Keyton’s (2004) lens for categorizing communication, and Holloway and Wheeler’s (1996) method for textual analysis. The studies using Carspecken’s method described iterative cycles between data collection and analysis as well as micro- and macro-level analyses. Two research teams took inductive approaches to data analysis (Ross & Rogers, 2017; Ross et al., 2019; Stewart & Usher, 2010), and the remaining described an “interplay of inductive and deductive” approaches (Boakye, 2022, p. 3). This interplay might also be referred to as abductive analysis, where researchers come informed by conceptual frameworks and their exploration of the data helps them develop new theories in relation to these frames (Timmermans & Tavory, 2012).
For those that took a more deductive or abductive approach, 11 studies used specific theories or theorists to guide their analysis, albeit to different degrees (see the aforementioned theoretical frameworks). Manias and Street (2001c) used one of the most deductive approaches, asking direct questions of the data that were informed by poststructural theories about the “effects of speech and silence, surveillance, and the power-knowledge relations of dominance” (p. 132). While still iterative and cyclical, Batch and Windsor (2015) also took a relatively deductive approach by applying Keyton’s (2004) frames for categorizing communication to their dataset.
Rigor
Several authors were critical of translating quantitative criteria to qualitative research and described their study’s rigor in relation to qualitative criteria such as Lincoln and Guba’s (1985) transferability, trustworthiness, credibility, dependability, and confirmability (see Bedoya-Ruiz et al., 2020; Boakye, 2022; Hardcastle, 2004; Jenkins, 2014; Jones, 1993; Manias & Street, 2000, 2001a, 2001b, 2001c, 2001d, 2008). Morse (2015) has since built upon Lincoln and Guba’s framework, and many of her suggestions were adopted in the reviewed studies. Triangulating different data collection methods was the most common method cited for achieving rigor, with several researchers emphasizing the importance of prolonged engagement in the field, member checking or respondent validation, and researcher reflexivity and responsiveness to emerging data and participants’ sense-making. Other methods for ensuring rigor included methodological coherence, conducting data collection and analysis concurrently and iteratively, thick description in field notes, incorporating verbatim text, analyzing negative cases, and collaborating with supervisors and experts for external debriefing and evaluation.
Research Ethics
11 of the 27 publications reported details about their research ethics considerations beyond the required statement that institutional ethical approval was received (Batch & Windsor, 2015; Bedoya-Ruiz et al., 2020; Boakye, 2022; Hardcastle, 2004; Harrowing & Mill, 2009; Jenkins, 2014; Jones, 1993; MacLellan et al., 2016; Manias & Street, 2001a, 2008; Sadati et al., 2016; Street, 1992). For the researchers who were clinicians, a few made notable points about researcher intervention in patient care as well as the complexity of methods for recruitment and consent. Jenkins (2014) reported that during shadowing, they would assist providers with basic care such as repositioning patients but would not provide medical intervention nor question clinical decisions while they were acting as a researcher (see also Bedoya-Ruiz et al., 2020).
Sadati et al. (2016) stated that they would not interview patients who were deemed to be in critical condition, and Jenkins (2014) described how they received patient assent for observing provider-patient interactions. They would assure patients that none of their medical information would be documented, and that they were observing the general processes of the ward (Jenkins, 2014). Several of these 11 publications that described their research ethics processes discussed the importance of ongoing informed consent, starting with recruitment. Manias and Street (2008), for example, started by approaching participants through informal meetings and giving them a “cool-off” period wherein they could also call researchers with any questions before deciding if they wanted to participate. Bedoya-Ruiz et al. (2020) stressed that researchers must clarify their interests and positionality at the start of research, and Hardcastle (2004) used different consent processes for informants, key participants, and other participants being observed more generally. To obtain passive consent for observational methods, several researchers ensured that all staff were aware of the research by scheduling observation dates well in advance, posting signs about the research in the unit, leaving information sheets in staff offices, and wearing a researcher identification badge instead of scrubs (Batch & Windsor, 2015; Boakye, 2022; Jenkins, 2014; MacLellan et al., 2016; Ross & Rogers, 2017; Ross et al., 2019). Researchers also anonymized hospital information and otherwise scrambled information about providers’ roles so that their information could not be triangulated to identify them (Boakye, 2022; Harrowing & Mill, 2009; Stewart & Usher, 2010). Jenkins (2014) noted that they would record their field notes outside of patient rooms or wards if necessary, and Jones (1993) allowed participants to review and refute or redact portions of their interview transcripts. While not explicitly tied to ethics, Batch and Windsor (2015) reminded that conducting ethnography in busy, shift-based settings can be challenging. For example, finding time for interviews and focus groups during participants’ working hours is difficult, leaving room for improvement in ensuring that this type of research is both accessible for participants and conducive to maintaining adequate care in their settings.
Discussion
Our discussion focuses on the interrelated conceptual and ethical topics of theoretical and methodological coherence, the use of critical theory, and axiology. We conclude with a few queries about data collection and analysis methods and research ethics considerations for future critical ethnographic research.
Coherence
In the first and second editions of her book Essentials of Qualitative Inquiry, qualitative researcher Mayan (2016, 2023) calls for greater attention to methodological and theoretical coherence in qualitative research. Coherence refers to the alignment of one’s paradigmatic stance with the research design, including theoretical framework, methodology, and methods (e.g., data collection, analysis, and knowledge translation). Coherence asks social scientists to spend less time proving the replicability of their methods and more time engaging rigorously and thoughtfully with the paradigmatic assumptions driving their modes of data collection and analysis. Qualitative researchers such as Denzin (2016) and Maher (2025) have similarly emphasized the importance of theoretical coherence, as well as cohesiveness between theory, methodology, and axiology – what qualitative research values and how it contributes to social change. We note that this is a complex epistemological topic; our discussion holds multiple contradictions and meanders its way through a few key tensions regarding coherence. On the one hand, congruence between paradigm, theory, and methods is essential for ensuring that one’s research questions, methods, theories, and paradigms are appropriate for one another rather than haphazardly combined and articulated. On the other hand, this emphasis on coherence can imply that there is a “pure” way to interpret and apply theory, as if researchers are not always producing new paradigms, theories, and methodologies in each iteration of research. Coherence, then, might refer more to thoughtfulness and perhaps transparency about one’s reasoning process rather than strict or transcendent adherence to previous researchers’ or theorists’ frameworks or paradigms (Denzin, 2016; Maher, 2025).
Incoherence occurs when researchers introduce critical theory without incorporating integral elements of a critical orientation in their research. In the reviewed articles, this occurred when researchers described critical ethnography without mentioning any link between participants’ contexts and broad socio-historical forces (see Manias & Street, 2000, 2001b, 2001d; Ross & Rogers, 2017). Another type of incoherence occurs when researchers’ paradigmatic stance contradicts the theoretical framework they are using, or vice versa. When critical theory is introduced from one paradigmatic stance, followed by a framework grounded in another school of thought, it can become unclear how researchers are conceptualizing knowledge, power, and social change. For example, dialectical materialist framings of critical theory do not necessarily align with the paradigmatic assumptions of scholars in the Frankfurt School or poststructuralism, even as they share a commitment to the analysis of power; this has implications for one’s methods, analyses, aims, and conclusions because paradigms inform why we want to understand a certain phenomenon, the way we want to understand it, and how we respond to what we learn about (Maher, 2025).
Mayan argues that the rigor and trustworthiness of qualitative research diminishes when one uses certain methods for data collection and analysis without explicating the theoretical origins and orientation behind these methods. For example, Liu et al. (2012) introduced critical theory through broad claims about the relationship between social forces and experiences, with limited discussion about the paradigmatic or theoretical orientation within which they were situating their study. While they discussed how disciplinary communication styles and transfers of knowledge through language used at the nursing handover can involve power dynamics, they moved on to applying Fairclough’s critical discourse analysis method without attending to its poststructural underpinnings about language, power, knowledge, and discipline – and how they inform analysis processes and research conclusions.
Incoherence also occurs when researchers state or imply that they are operating from a certain paradigmatic and/or theoretical perspective, but collect data, analyze data, and make recommendations in ways that are antithetical to that paradigm or theory. Mayan (2016) describes how researchers say they hold an interpretivist epistemology but report the quantities of codes or themes generated to reach a more (post)positivist notion of rigor. In another context, education scholar St. Pierre (2009) critiques how many qualitative studies claim to apply poststructural theory, while using conventional humanist methods that contradict poststructural assumptions about truth, knowledge, and voice. For example, emphasizing participants’ voices through interviews and focus groups – as many of the researchers did – relies on a Cartesian, humanist, and representational assumption of language as being a rational, agentic, and essential expression of knowledge. This overlooks the poststructural imperative to deconstruct language itself and attend to the meanings generated not only by human voice, but through literary, affective, nonverbal, non-anthropocentric, and institutional forms of inquiry and communication (see also St. Pierre, 2022).
In this review, several studies privileged participants’ own sense-making in their analysis and recommendations without critically interpreting them and linking them to broader socio-historical forces, a process integral to critical research. Mahon’s (2014) introduction of Critical Social Theory pointed to these broader analyses, but in describing their method, wrote that the main aim was “to understand and expose meaning of the relationships of [participants’] world, without meaning being imposed on them externally” (p. 47). However, taking providers’ perspectives at face value or solely emphasizing participants’ desires for emancipation risks decontextualizing the broader social forces that consciously and unconsciously produce their opinions and recommendations. Healthcare workers’ narratives must be read not only as valuable lived experience, but as discourses derived from and that contribute to systems of power (Rashid & Goldszmidt, 2024). A critical approach arguably requires analyzing healthcare providers’ perspectives in relation to broader institutions and systems of power, for example, by interrogating underlying colonial assumptions about where the problem lies and what the possible solutions are (Deleuze & Guattari, [1972] 2009; Gilmore, 2022; Puar, 2017; Tuck, 2009). Street (1992), for example, addressed the “false consciousness” present in people’s accounts of their experiences, supporting participants to challenge their assumptions and liberate themselves from internalized oppression (Freire, 2000). This analysis could have been extended to consider the intertwined nature of providers’ and patients’ oppression and explore possibilities for resistance that do not reinforce how healthcare providers and institutions oppress structurally marginalized patients and staff.
With these critiques in mind, we pivot to the idea that full coherence between theory and methodology may not be possible or desired; claims of theoretical or methodological purity reassert the notion of a truth that exists outside of the social processes producing the evolving field called “critical theory,” what is considered theory and what is relegated to being data, and the ends toward which theory and data are used (Maher, 2025) As Conquergood (1991) and Kincheloe and McLaren (2011) assert, there is no unified critical theory, Frankfurt School, or reading of Marx or Foucault. Furthermore, as much as philosophers tease out the radical differences between Marx’s dialectics, Foucault’s notions of power and discourse, and Deleuze’s immanent ontology of desire, Deleuze and Foucault take many epistemological, political, and axiological insights from each other and from Marx, building on his work to complexify or reconsider how domination and resistance occur. Ontologically, regardless of one’s origins or foundations, all interpretations or mobilizations of a certain theory or theorist are not applications of existing theories, but productions of new ones that are merely in conversation with others (Deleuze & Guattari, [1972] 2009).
This view calls into question the practice of claiming or applying a singular school of thought rather than allowing one’s own paradigm and conceptual frame to be shaped by a variety of theorists and experiences: “What you will rarely read, if ever, is a clear and convincing articulation of how these philosophies, theories and methods were melded together and tensions navigated to ensure coherence and cohesion” (Maher, 2025, p. 5). For example, Street (1992) brought poststructural, materialist, Frankfurt School, and feminist scholarship together, explicating their divergences and similarities as was useful for her own project. Scholars more grounded in critiques of racism and colonialism – major pitfalls in the aforementioned theorists – draw on historical materialist, poststructural, and/or new materialist approaches, while asserting, for example, the ontological weight of racism (see Gilmore, 2022; Puar, [2012] 2020, 2017; Weheliye, 2014).
Claiming Methodology
One approach to addressing coherence is to be transparent about one’s unique paradigmatic approach to prevent major contradictions between one’s ontological, epistemological, and axiological claims – and how they are mobilized in the research process. Transparency requires researchers to articulate how they are conceptualizing and pursuing their critique and analysis, rather than relying on the mere statement that critique is occurring or that a theory is being used (see Puar, [2012] 2020 on this issue with intersectionality). The rejection of purity and invitation to share one’s thought process thus calls into question the common practice of using a pre-existing methodology such as critical ethnography and assuming its name speaks for itself.
In fact, our review may not have encountered ethnographies that study healthcare providers in acute care settings through a critical lens that were not labelled as critical ethnographies. The term critical ethnography is becoming more widely used in the applied health and social sciences but seems to be less often invoked in sociology and the humanities, where using ethnographic methods in critical ways is a standard practice (see Desmond, 2016; Puar, 2017). Several other approaches to ethnography are also explicitly critical of injustice, such as institutional ethnography and decolonial ethnography, even as they differ in their paradigmatic assumptions and methodological emphases (Alonso-Bejarano et al., 2019; Morton-Ninomiya et al., 2018). Across disciplines, the term critical ethnography may not be used if there are other indications of criticality, if scholars are engaging in social critique in ways that do not align with how critical ethnography has been framed in the applied sciences, and/or if they are hesitant to claim that their study fits within a certain methodological “camp.” Clearly one can use interviews, observation, textual analysis, and photovoice to interrogate power dynamics in a variety of ways. As Mayan (2023) acknowledges: It is possible that someone you know or have worked with has done excellent, ‘legitimate; qualitative research for which there is yet no name [. . .] choosing a methodology might not be necessary; a researcher may be guided by the tenets of a meta-theory/theoretical orientation (e.g., feminist, Foucault) throughout the research process and not need to choose a specific methodology (p. 50; see also Law, 2004).
Refusing to name one’s method may foster theoretical, methodological, and axiological transparency and thoughtfulness and intervene in the common practice of saying that one is committed to justice-oriented research without doing so in substantial ways or by perpetuating the injustices embedded within academic knowledge production (Ahmed, 2013; Puar, [2012] 2020).
Criticality and Citational Practice
If critical ethnographers in healthcare are to take seriously this issue of how power constructs knowledge, then we need to pay attention to how we are defining and mobilizing critical theory – whose critical theories and lineages we are centering and whose we continue to leave out (Ahmed, 2013; Todd, 2016). While it is perhaps not practical or useful for all research articles to trace the entire lineage of critical theory or of a specific theoretical framework, inadequately attending to the political struggles and knowledges grounding what it means to be critical risks erasing the key political and epistemological contributions to our contemporary mobilizations of different schools of critical theory (Gilmore, 2022). How we cite our definitions of critical theory can disrupt or reinforce Western dominant conceptions of knowledge in the academy. Most authors discussed critical theory in relation to applied scholars in health and education and their references to the Frankfurt School (Browne, 2000; Carspecken, 1996). This common teleology of the critical theory canon reasserts its epistemological locus in European continental philosophy, which, although influential, is not the only place where critical thought has been occurring (Burawoy, 2021; Johais & Leser, 2024). Critical praxis has long been developed alongside or prior to European critical theory, for example, by Indigenous feminist, Latin American decolonial, African American critical race, Black feminist, postcolonial, and a variety of other scholars and thought leaders around the world (Ahmed, 2013; Hancock, 2016; Todd, 2016). Even our own emphasis on coherence between methods and specific continental philosophies reasserts German and French scholars at the center of critical theory as well as the individuality of theorists like Foucault and Marx; this aligns with the longstanding tendency of White academics to group scholars such as Frantz Fanon, Homi Bhabha, and Gyatri Spivak into sweeping categories such as postcolonialism despite their unique contexts and diverging perspectives.
Furthermore, healthcare critical ethnographers’ reliance on theorists that are critical of capitalism and the state, but who do not engage with issues of racism, cis-hetero-patriarchy, settler colonialism, imperialism, and racial capitalism, limits our ability to interrogate power and inequity in healthcare. While not all research can account for everything, the dearth of intersectional analysis throughout all processes of these research designs reflects and perpetuates the narrow conceptions of justice in various critical theories, as well as how they are taken up. Even when moving beyond the Frankfurt School, the researchers’ immense focus on sexism and misogyny reflects a broader feminist academic tradition of making gender the primary lens through which to understand oppression – as if it is separable from and or somehow more consequential than racism, colonialism, ableism, and so on (Puar, [2012] 2020).
These epistemological elisions may help us to understand why it is that critical ethnography in healthcare has a lot to say about providers’ victimization, and little to say about providers’ complicity in the marginalization and premature death of structurally precaritized patients. As Eaker (2021) describes, the White-laden emphasis on nurses being “oppressed by gender has been weaponized to cast [them] solely as victims unable to perpetrate harm against others” (p. 5). This may also lead us towonder why adhering to lineages of critical ethnography that evade analyses of settler colonialism is popular among healthcare scholars in settler colonial countries like Australia and Canada, and to consider how else, where else, and by whom, critical ethnographic methods might be mobilized, even if under a different name.
Axiology
This question of what we are being critical of and why relates directly to axiology and theories of change, which Tuck (2009) and Peers (2018) have noted receive minimal attention in social science research. This raises questions not only about paradigmatic coherence in critical theory, but the ability for research to contribute to social change. Tuck’s (2009) notion of theories of change urges researchers to interrogate their assumptions about how social change occurs and how research can contribute to or foreclose to change. She uses the example of “damage-centered” theories of change, where social scientists implicitly or explicitly assume that exposing the painful experiences of marginalized communities will “convince” those in power to make changes; this theory of change (re)locates power within dominant institutions and can contribute to stereotypes about communities being agentless victims rather than people that are affected by power but have their own ways of living that resist and exist outside of dominant structures.
In the analyzed articles, most scholars did not connect institutional issues such as the relationship between doctors and nurses to broader social forces. As such, many of the recommendations also remained within institutions. This narrow approach may reflect a trust in institutions rather than a skepticism of their ability to create meaningful change without broader societal transformation (Gilmore, 2022; Puar, 2017). Changing communication styles in handovers (Liu et al., 2012; Manias & Street, 2000), for example, may make important changes within the ward but do little to address the ways in which misogyny, white supremacy, and labor exploitation continue to affect dynamics between different staff members in acute care settings. Another theory of change might be to “refuse” linear, colonial modes of progress rooted in an optimistic view of institutions (Tuck & Yang, 2014) or to challenge participants’ “false consciousness” (Freire, 2000). A materialist theory of change such as consciousness raising would involve critical discussion and activism with providers about the political and economic systems producing inequities among and between providers and patients. Such an analysis necessarily prompts intersectional considerations about which nurses and staff members (such as healthcare aides or custodial staff) are most affected by power dynamics, and how their oppression is linked with the oppression of marginalized patient groups rather than a separate phenomena (Gilmore, 2022). Here, the eradication of all forms of inequity would be valued more than a narrow improvement in one group’s experiences at work and ability to provide a certain form of care.
Finally, axiology involves not only our theories of change, but our imaginations of social justice – the ends toward which we want to change (Deleuze, [1990] 1992; Gilmore, 2022; Tuck, 2009). Emphasizing the improvement of providers’ experiences at micro- and meso-levels detached from broader analyses might work toward improved communication in ICUs or decreased sexism within a hospital, but another end might be decolonial approaches to the provision of care.
Methods
Although different settings warrant different methods, the diversity of approaches to critical ethnography in this review may call for greater transparency not only about one’s paradigmatic assumptions, but about one’s methods – to the extent that the peer-reviewed journals invite, expect, or allow room for (Shannon et al., 2023). Greater description of data collection methods and research ethics approaches may be useful so that researchers can learn from one another’s experiences of doing ethnography in high-acuity settings while protecting patients and providers in the process. For example, Horrill et al. (2024) encouraged critical observational researchers to intervene and advocate if they witness a patient receiving inadequate or discriminatory care.
Transparency and further reflection on criticality and axiology is also necessary when collecting and presenting participant demographics – or when describing reasons not to. While Ross et al. (2019) emphasized that “specific demographic data of the participants [. . .] was not crucial to the research question,” clinicians’ perceptions and behaviors are not neutral nor do they operate in a vacuum only influenced by their professional role or, as a few mentioned, their gender. Health disciplines should be well aware of the importance of considering intersectional factors that shape clinical settings and the experiences of those who provide and receive care. While debates remain about extracting and emphasizing individual subject positions, critical ethnographers might reconsider processes of differentiation beyond profession and gender – and the critical question of when and how to take them into account in the research design (Dhamoon & Hankivksy, 2011). Furthermore, gender-based reporting and analysis must move beyond Western, colonial, and patriarchal binaries and the conflation of sex and gender, both of which have been discussed at length (see M. R. Peters & Slade, 2023).
We also propose that non-clinician researchers may at times be better able to challenge the implicit assumptions embedded within these settings and disciplines than clinician-providers. Healthcare providers’ identification with their profession – and their mainstream framings as benevolent and altruistic – may prevent clinician-researchers from analyzing what lies under the surface of providers’ perspectives – particularly if they are personally familiar with clinician participants (see Jager et al., 2024; Mahon & McPherson, 2014; Rashid & Goldszmidt, 2024). Providers’ perpetuation of misogynist, racist, colonial, and other forms of oppression fall within critical ethnography’s scope to interrogate, and yet seems to be inadequately explored in critical ethnographic healthcare research. Other social science and healthcare researchers are using ethnography to expose providers’ discriminatory practices and perspectives without claiming the methodology, calling into question critical ethnography’s ability to live up to its name, at least in these research settings (see Black et al., 2021).
Limitations
This review is limited in that any lack of detail about paradigm, theory, methodology, or research ethics may be due to factors outside of authors’ control, such as journal requirements, word limitations, and reviewer feedback. The most extensive reports on paradigm, theory, and method were in theses and dissertations which have different requirements and expectations. The publications reviewed thus do not necessarily reflect the extent to which authors took these topics into consideration or reported them elsewhere. Nor do these critical ethnographic pieces represent these researchers’ scholarship as a whole, or the progression of their work over time. There is also the potential that some articles did not name critical ethnography in their abstract and thus would not have been included in this review. Finally, this review offers limited insight into critical healthcare research around the world, given the English language inclusion criteria and other infrastructural, financial, and geopolitical constraints imposed on researchers in the “Global South” (Groenewald & Teise, 2024).
Conclusion
Critical ethnography can produce in-depth understandings, uncover surprising findings, and develop rich data that elucidates local and translocal power differentials within acute care contexts. While the diversity of approaches to framing and conducting critical ethnography cannot be synthesized into a single approach, the common themes, tensions, contradictions, and gaps in these studies indicate areas for further discussion and reflection about how critical ethnography is mobilized, for whom, and toward what ends. By more clearly explicating the relationship between paradigm, theory, data collection, data analysis, and recommendations, researchers can improve rigor by showing congruence across the research process, avoiding the tendency to inconsistently apply criticality or to leave it behind in the introduction. In addition, more attention to the varied origins, axiological orientations, and mobilizations of critical theory, particularly in relation to health inequity, is crucial for critical healthcare research to be able to address inequity as it espouses to do. These analyses may apply to other tendencies in qualitative health research. As such, further exploration of how and to what end qualitative methodologies have been mobilized are warranted and may further the health disciplines’ abilities to attend not only to the lived experience of patients and providers but to the structural and institutional processes shaping them. Finally, the predominance of nursing scholarship in critical ethnographic healthcare research points to the need for other healthcare researchers to join in this necessary endeavor while taking into consideration these issues of axiology, citational practice, and the complicity of healthcare professionals in injustice.
Supplemental Material
sj-docx-1-gqn-10.1177_23333936261438610 – Supplemental material for Using Critical Ethnography to Study Acute Care Clinicians: A Critical Review
Supplemental material, sj-docx-1-gqn-10.1177_23333936261438610 for Using Critical Ethnography to Study Acute Care Clinicians: A Critical Review by Erin Tichenor, Lesley Pritchard and Tim Barlott in Global Qualitative Nursing Research
Footnotes
Acknowledgements
We thank Liz Dennett and Eduan Breedt for their guidance and support through the research process and writing of this manuscript. ChatGPT 4.0 was used in the editing process to revise sentences for clarity and brevity, as well as to identify a few background texts, which were validated by the authors.
Ethical Considerations
This study did not require approval from the research ethics board because it did not directly involve human or animal research participants.
Author Contributions
ET conceptualized the paper, with support from LP and TB. ET conducted the search with guidance from the LP as well as medical librarian. ET led the analysis, drafted the paper, and led the revisions. LP and TB triangulated the analysis and supported with refining the draft and revisions.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data analyzed in this study are academic journal articles that can be accessed through search engines such as Google Scholar. Some articles are published Open Access and others require payment unless accessible through an institutional subscription. The articles were originally accessed via the University of Alberta library.
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