Received: 9 April 2019 | Revised: 19 July 2019 | Accepted: 31 October 2019

DOI: 10.1111/medu.14033

RESEARCH APPROACHES

Ethnography in health professions education: Slowing down

and thinking deeply

Guusje Bressers1 | Madison Brydges2 | Elise Paradis3

1
Department of Educational Research and
Development, Faculty of Health Medicine Abstract
and Life Sciences, Maastricht University, Context: Ethnography has been gaining appreciation in the field of health professions
Maastricht, the Netherlands
2 education (HPE) research, yet it remains misunderstood. Our article contributes to
Department of Health, Aging and Society,
McMaster University, Hamilton, Canada this growing literature by describing some of the key tensions with which both aspir-
3
Leslie Dan Faculty of Pharmacy, University ing and seasoned ethnographers should productively struggle.
of Toronto, Toronto, Canada
Methods: We respond to the injunction made by Varpio et al (2017) that HPE re-
Correspondence searchers should ground their methodological ventures in their historical and philo-
Elise Paradis, Leslie Dan Faculty of
Pharmacy, University of Toronto, 144
sophical tenets. To do so, we first review core ethnographic texts that provide a
College Street, Toronto, Ontario, Canada. background for ethnographic research in HPE, then provide an orienting definition
Email: Elise.paradis@utoronto.ca
to bind the specificities of ethnographic research. Finally, we review core theoretical
Funding information
and practical considerations for ethnographic research.
Madison Brydges’ PhD studies are funded
by a Joseph-­Armand Bombardier Canada Results: Ethnography is a slow and deep approach to knowledge production, and as
Graduate Scholarship. Elise Paradis received
such it requires careful engagement with theory and deliberate choice of methods.
support for this work from the Canadian
Institutes of Health Research Project Grant Core theoretical tensions include the ontological, epistemological and axiological di-
(award number: 363239), and the Canada
mensions of ethnography, and concerns with quality and rigour. Practical tensions
Research Chair in Collaborative Healthcare
Practice. include the scope and remit of ethnography, the importance of observing naturally
occurring behaviour and the crafting of rich field notes.
Conclusions: We encourage ethnographers to pursue scholarship that challenges
the status quo. Ethnographers should favour deep encounters with research par-
ticipants, dig deep into the cultural and structural aspects of HPE and be reflexive
about knowledge outputs. At a time in HPE when the pressures to publish are high,
using ethnography as a research methodology offers an opportunity to slow down
and think deeply.

1 | I NTRO D U C TI O N using triangulation in a post-­positivistic way within a critical theory

In health professions education (HPE) as elsewhere, trends matter.
Others before us have noted how in the interdisciplinary field of HPE,
the topics, research tools and forms of knowledge we value all evolve
over time, for better … and for worse.1,2 Although importing meth-
odologies from related fields can lead to innovations and insights
3
in their field of adoption, the consequences of importing ‘trendy’
methodologies can have unintended impacts. Indeed, as noted by
Varpio and colleagues, ignoring the underlying assumptions and his-
torical trajectories of certain approaches might lead to incoherence:
project, for instance. 2 Read against our field's increasing pressures
to publish4 and increasing respect for qualitative approaches, Varpio
et al's injunction to ground methodology and methods into ontology
and epistemology can be seen as a countercultural message to slow
down and think deeply. It can be read as an invitation to read widely,
pause and think critically about the way we conduct our research.
In this article, we make a contribution to the literature on one
specific methodology—ethnography—by describing some of the
core considerations with which aspiring ethnographers should pro-
ductively struggle: their ethnographic approach and ethnographic

Medical Education. 2020;00:1–9. wileyonlinelibrary.com/journal/medu

© 2020 Association for the Study of Medical | 1
Education and John Wiley & Sons Ltd
2 |
methods. Others before us have written introductory guides to
ethnography, for example Atkinson and Pugsley and Reeves and
5,6
colleagues. We build upon these to propose a slow and deep ap-
proach that is particularly fitting in the case of ethnography. Indeed,
ethnographers have long advocated for prolonged immersion in
a culture-­sharing group, for the rich exploration and description
of context, and for serious introspection.7,8 Moreover, they have
recently pushed back against trends that minimise its remit to do
‘quick’ assessments of culture.9,10 Our contribution thus engages in
11
‘boundary work’ to define and legitimate ethnography as a spe-
cific approach to research by tracing boundaries around what eth-
nography is and what it is not. We also guide readers away from a
naïve methodologism that over-­emphasises methods12 and instead
towards greater consideration of the ontological, epistemological,
practical and political dimensions of research.12
Debate has been raging in anthropology, sociology and education
about the role, nature and future of ethnography: some questioning
whether it can survive the push for increasing output, managerial-
ism and neoliberalism,10,13 and others asking for methodological and
axiological flexibility.14 By contrast, the HPE community has not par-
ticipated in these conversations over what ethnography actually is
or could be. This is why after engaging with the core underpinnings
of ethnographic work we suggest directions for the development of
ethnographic studies and best practices in the field of HPE, includ-
ing around fieldwork. Many topics deserve ethnographic attention;
to be credible, however, ethnographic research needs to be more
reflexive and explicitly wrestle with questions of ontology, episte-
mology and axiology. Ultimately, ethnography and ethnographers in
HPE need to slow down and think deeply.
2 | H E A LTH PRO FE S S I O N S E D U C ATI O N
CO NTE X T
Ethnography generally seeks to investigate, document and explain cul-
ture and structure as manifested in behaviour. Ethnography literally
means writing (graph-­) about culture or groups of humans (ethno-­).15
Culture and human behaviour are therefore the cornerstones of what
it means to do ethnography and central to the writing of ethnographic
work. Ethnography aims to represent the complexity of social life and
therefore tell rich and sensitive stories about a specific culture-­sharing
7,16
group.
Early ethnographic studies on medical education, such as the
1957 ‘Student-­Physician’ compendium written by Robert Merton
and colleagues17 and the 1961 classic ‘Boys in White’ volume by
18
Howard Becker and colleagues, deeply influenced our under-
standing of the training of students in the profession of medicine
and inspired a full generation of studies on the care professions.
Over the past 15 years, there has been a continued interest in
5
ethnography in HPE. In 2005, Atkinson and Pugsley published an
article introducing readers of Medical Education to ethnography, in-
viting them to use the then-­marginal approach to understand the
social and cultural aspects of HPE. Their article was followed by a
BRESSERS et al.
2013 Association for Medical Education in Europe guide by Reeves
and colleagues,6 who repeated the invitation, defined ethnography
and described how one would plan, undertake and write an ethno-
graphic project for an HPE audience. These two high-­quality pub-
lications and other recent ethnographic studies19-22 highlight how
ethnography can be used to question the taken-­for-­granted aspects
of HPE's culture and social structure (see Table 1 for an overview
of a few selected ethnographic studies and their core cultural and
methodological insights).
Although the boundaries of ethnography are by no means rigid,
some broad features help to distinguish ethnography from other
qualitative approaches. According to Hammersley's10 review of defi-
nitions of ethnography in the educational literature, the following
seven dimensions best describe the approach. Ethnography:
• is a relatively long-term data collection process;
• occurs in natural settings (ie ‘naturalistic’ observation);
• relies on participant observation or personal engagement more
generally;
• uses a range of types of data;
• aims to document what actually goes on in the setting (rather than
only what people say happens);
• emphasises culture (the significance of the meanings people give
to objects and people in the course of their activities); and
• is holistic rather than reductionist in focus.
Although these dimensions should not be seen as either suffi-
cient or necessary, ethnographers deviating from one or many of
these should reflect on and justify their departures. For instance,
an ‘ethnography’ that reports only on interview or documentary ev-
idence would need to justify why it does so, because dimension 3
would not be met. In ethnography as elsewhere, a strong research
design needs to balance tradition with flexibility.3 Yet, innovation
is arguably stronger when one knows the tradition and can justify
points of departure.
2.1 | Positionality
We are writing this piece from three distinct perspectives (MB and
GB as PhD candidates and EP as a faculty member), but share a
strong belief in the importance of social scientific knowledge to the
health professions and HPE, and in interdisciplinary research more
broadly. MB works clinically as a paramedic in Ontario, Canada,
and is a PhD candidate who is specialising in the sociology of the
professions. First exposed to medical anthropology during her un-
dergraduate studies, she uses ethnography to document the socio-
cultural context and history of complexity in health care delivery.
GB is a trained medical anthropologist and sociologist currently
working as a communication adviser for a medical specialist in the
Netherlands. Her PhD in human performance uses ethnography to
study patient safety culture in postgraduate medical training. EP
obtained her PhD in sociology of education in the United States
BRESSERS et al.
TA B L E 1 Selected ethnographic studies with cultural and methodological insights
Reference
17
Merton RK et al (1957)
Becker HS et al (1961; 2002)18
Bosk C (1979; 2003)51
Manias E and Street A (2001)52
Key cultural insights
• The book documents the attitudes of
medical students towards their studies,
faculty, patients, the medical profession
and specialisation across three medical
schools
• The more qualitative contributions
helped foreground the uncertainties
around medical knowledge
• This book started conversations about
access to medical education
• Medical school is an intense process of
socialisation
• In preclinical years, students feel more
like learners than they do doctors, but
this reverses during clinical years
• Medical students are deeply influenced
by their peers’ behaviour, values and
aspirations
• Becoming a physician requires intense
juggling of demands, which leads some
to adopt a pragmatic, ‘what faculty
members want’ approach to learning
• Bosk spent 18 months as an ethnogra-
pher in a surgical residency programme,
examining the socialisation process of
surgical residents and, specifically, how
errors were managed
• His findings highlighted how power
and social control mediated the types
of errors made by trainees that were
deemed acceptable, such as techni-
cal mistakes, which can be addressed
and therefore forgiven, or normative
mistakes, which are the consequence of
a lack of conscientiousness. A hierarchy
within the surgical field determined the
consequences of making each type of
error
• Bosk's work provided a foundation for
future study of medical errors and the
sociology of the medical profession
• This study is a critical ethnography that
examines interactions between nurses
and doctors concerning knowledge and
decision making in critical care
• Their ethnography demonstrates how
professional power mediates decision
making between nurses and physi-
cians. For example, decision making
was highly dependent on the nurses’
visibility
• Their work shows how social theory
can unpack the complexity of interpro-
fessional relationships, and in doing so
enable the individuals being studied
to explore the meaning behind their
actions
| 3
Key methodological insights
Combining observations with quantitative data:
• This collection of essays approaches the socialisation of
medical students from a range of research perspectives and
across different medical schools
• It contributed to the theory of the professions as a socialisa-
tion process into a specific set of knowledge and attitudes.
• By combining quantitative data with observations, this book
studied medical school as the intervention that transforms
medical students into physicians
Group ethnography:
• Much can be learned about the culture of medicine from
observing medical students, and ethnographic approaches
can be fruitfully supplemented by quantitative approaches
• Group ethnography—where multiple observers study the
same group—can lead to deeply valuable insights
• Studying the same group of students over time offers
great longitudinal and processual insights about learning
processes
Revealing methodological messiness:
• In a later edition of the book, Bosk self-critiques his first
published version. For example, the interview data were not
used in the analysis of student perspectives because there
was a marked difference between the observed and the in-
terview data. In the interview the students adopted a more
‘mature attitude’
• Bosk also underplayed the role of gender in his analysis. He
admitted to changing the gender of a woman surgical trainee
(to a man) in the 1979 version to avoid her identification,
and overlooked how gender mediated the social interactions
between surgical trainees and excluded women
• By providing this information he gives readers a second lens
through which to view his findings and raises ethical, moral
and methodological implications for researchers
Activist-­oriented research:
• The researchers focus on the interrelationship between
power and knowledge. The researcher had an explicit
axiological goal of empowering the nursing profession to
reflect upon its agency in interactions with physicians
• Their approach emphasised the nurses’ emic perspective
by encouraging nurses to share their perceptions of their
relationships with physicians openly across a range of data
collection methods: participant observation, journalling, and
individual and focus-group interviews
• By challenging the nurses to explore their assumptions
about their relationship to physicians, the authors high-
lighted the taken for granted aspects of agency and how
nurses in their everyday work challenge medical dominance
with their knowledge and role in health care delivery
(Continues)
4 | BRESSERS et al.

TA B L E 1 (Continued)

Reference Key cultural insights Key methodological insights

53
Gillespie et al (2013)
Webster et al (2015)37
• This study is an ethnography of team
communication in the operating room
(OR). The primary author was an insider
given her former experience working as
an OR nurse
• With the aim of understanding and
then improving the interprofessional
culture of OR teams, analyses showed
how individual perceptions of a safe
and cooperative team were inconsistent
with the observed actions of the team,
which were hierarchical and limited the
collaboration of some health profes-
sionals on the team
• Webster and colleagues explore
collaboration between physicians in
the emergency department (ED) and
those from general internal medicine
(GIM). Prior to the study, the Ontario
government mandated limits on the
time patients can stay in the ED. The re-
searchers examined the impact of these
changes on clinical practice and trainee
education
• They found that medical trainees were
concerned about the effect of the new
law on both their education and on
patient care. They also sensed a shift in
focus on efficiency as a new definition
of ‘good’ care. A new concept, high-
needs patients’ ‘failure to cope,’ became
part of the hidden curriculum, and
shows a shift in priorities from teaching
and delivering good care to meeting
organisational performance measures.
This created conflict and tension be-
tween ED and GIM physicians
• Informal and casual language plays
a role in how patients and care are
perceived. In this instance patients
themselves became a problem for the
clinical team rather than the focus of
care
Insider research and reflexivity:
• To mediate the impact of her insider status on her findings,
the first author expertly used several methodological and
epistemological tools, including a diary that allowed her to
examine her own preconceived notions about the study and
how her previous experience shaped her views and knowl-
edge production
• In the final analysis, Gillespie's diary became a source of
data that allowed the entire research team to compare her
perceptions and preconceived ideas with other sources of
data, such as fieldwork and individual interviews
Institutional ethnography to inform policy:
• This ethnographic study took place at a time of policy
change in Ontario, and used participant observation to
document its impact on consults between GIM and ED
physicians in an urban teaching hospital
• Institutional ethnography (IE), a specific framework for eth-
nographic analysis, was used to frame this study. Concepts
from IE were used to code and analyse the data, and com-
bined with the concept of the hidden curriculum to frame
the impact of policy change on language and education
• This study shows that policy changes often have unplanned
effects on both care and medical trainee education, and
successfully weaves context with local practices to make a
compelling argument about their interdependence. It could
be used by policymakers to refine or revise their policies

(US) and has been studying interprofessional collaboration since

2012. Her ethnographic research has explored team dynamics in 3.1 | Ethnographic approaches: Slowing down and
the intensive care unit, in the operating room, in primary care and thinking deeply
with the US military.
3.1.1 | Knowledge production in ethnography

3 | CO R E CO N S I D E R ATI O N S
In the following sections, we divide the core considerations of eth-
nography into an imperfect dichotomy between ethnographic ap-
proaches, which are theoretical and meta-­theoretical in nature, and
ethnographic methods, which are more practical in nature. We invite
our readers to consider them together and as they should inform
each other.
A first thing that aspiring ethnographers should consider is the as-
sumptions that will structure and inform their work. For instance:
What is ethnographic knowledge? How is it created? What roles
does it serve? A brief foray into the philosophical foundations of
ethnography illuminates an enriching, although chaotic, history of
attempts to define ethnographic knowledge, its production and
its purpose. 23,24 These questions have prompted intense debate
amongst ethnographers along three dimensions: ontological (What is
BRESSERS et al.
real?); epistemological (How do we know it to be real?), and axiologi-
10,25,26
cal (What is the role of values in guiding research?). Reflecting
about these aspects is critical for researchers to be able to assess the
quality of the work they produce and read. As Pierre Bourdieu noted
before, reflexive practice is what distinguishes scientific knowledge
27,28
from lay understandings. If we want to elevate our research, we
must question our assumptions, or else risk providing banal, self-­
evident or wrong accounts.
Although largely abandoned now in the social sciences, early
thinking in ethnography was closely aligned with positivism, mean-
ing that ethnographers sought to produce an objective account of
what a culture really was.29 However, using statistical or universal
laws was insufficient to explain the complexity and diversity of
social and cultural meanings or to address differences in research
methodologies, such as accounting for the subjective experience of
the ethnographer in the research findings. 30 (p. 6) Although debate
persists, contemporary ethnographic knowledge production can be
grounded in a wide range of different paradigms, including but not
limited to realism, constructivism, interpretivism, relativism or post-­
modernism. 29 These different paradigms have important conse-
quences methodologically and axiologically, guiding the questions
researchers may ask, the values explicit or implicit in their work, the
level of participant engagement and choices around data collection
and analysis. For instance, Hammersley's ‘subtle realist’ approach
takes a stance on knowledge production where the ethnographer
aims to understand (rather than judge) and represent (rather than
reproduce) a multiplicity of views (rather than a singular truth)
through claims about the social phenomenon for which evidence
is credible and plausible. 29 (p. 73) In Hammersley's terms, much
ethnography aims to be constructivist at the level of a sociocul-
tural phenomenon (ie multiple, legitimate realities or understand-
ings exist) as well as retaining a degree of objectivity at the level of
production of knowledge. Alternatively, critical paradigms ground
knowledge production in a theoretical foundation that acknowl-
edges the role of power, oppression and hierarchy in governing so-
cial life. 31,32 Controversial ethnographer Nancy Scheper-­Hughes25
(p. 414) expects ethnographers to adopt a critical paradigm to be
more than mere objective ‘spectators’ of their subjects, and adopt
a political, morally committed approach to ethnography where
critical reflection and human liberation are paramount.
By highlighting the diversity of approaches within ethnogra-
phy, we aim to invite HPE scholars to be explicit and transparent in
their approach to knowledge production in their published research.
Uncertainty and ambiguity around the epistemology and axiology
of the work being produced have consequences for the end users
of the research (researchers, policymakers and the participants in
the research), who may misinterpret or make assumptions about the
conclusions of the work. 26 As others have noted before us, a lack
of clarity around the epistemological and axiological approach to
research can result in misalignment with methodology, how reflex-
ivity will be used, and the voice and representation of participants
in the final research. 2,33 Before committing to a specific set of data
collection or analytic methods, aspiring ethnographers should slow
| 5
down, read widely and reflect thoughtfully on the implications of
the paradigm they deem most fitting to their research purpose. Only
once these debates have been explored and digested will the bud-
ding ethnographer be able to align study aims, use of theory and
methodological choices. 2
3.1.2 | Quality in ethnography
All producers and consumers of ethnographic research should be
concerned with quality. The push to create checklists for the qual-
ity of qualitative research, which would include ethnographic ap-
proaches, has resulted in the import of standards for rigour and
quality that are often misaligned with those of traditions that are
not on the positivistic end of the ontological and epistemological
spectrums, such as ethnography.34–36 In our reading of ethnogra-
phies in HPE, we found a focus on the description of methods to
achieve validity and objectivity (such as data verification proce-
dures), a heightened concern with researcher ‘bias’ or influence, and
an under-­representation or little mention of reflexivity or positional-
ity. Although concerns about bias and data quality are essential and
checklists may assist with this, they tell us little about how and why
key decisions were made during the research process, and how the
final ethnographic truth claims were made.34 To illuminate this point,
we draw on the concepts of triangulation and reflexivity to highlight
the importance for ethnographers in HPE to shift their focus on the
alignment between epistemology and knowledge production in ad-
dition to methodology.
Ethnography often involves the collection of different sources
of data, such as interviews, field notes or documents. The rationale
for collecting these different sources of data has methodological
and analytical implications. It is common to see the term triangu-
lation used to describe the collection of different sources of data
as a means of ‘checking’ one source of data against another to en-
hance rigour or validity. This interpretation of triangulation adopts
the view that a single truth (or close to it) about the phenomenon can
be found and enhanced by studying the phenomenon from multiple
perspectives, which is a positivistic claim. By contrast, one of the
strengths of ethnography is that it can highlight the nuances and dif-
ferences that exist around a particular phenomenon from different
stakeholders’ perspectives. 22,34,37,38 (p. 183-4) From this perspec-
tive, collecting data from multiple sources helps develop analytical
insights between individuals or social groups, which is aligned with
the subjective epistemology of ethnography.
Secondly, in our view, the HPE community may be overly con-
cerned with methodological reflexivity as a measure of quality, de-
fined as how the researcher's behaviour influences research findings
during data collection39 and data analysis. There has been, for exam-
ple, the rise of ethnographies with multiple observers or ethnogra-
phies where the data are coded by multiple coders—the idea being
that having many researchers limits bias and increases the validity
of findings. Obtaining more data on more sites is often a good idea
when the data are analysed comparatively to identify meaningful
6 |
variations.40 However, methodologism12 and an obsession with ‘ob-
jective’ data collection or coding can blind us to more important re-
flexive issues.
All ethnographers should instead adopt an epistemologically and
axiologically-­reflexive lens. Researchers should consider first how
their epistemic beliefs are shaped by their own social, cultural and
historical location, and second, the implications of these beliefs and
15,23,41
other values throughout the research. Epistemic reflexivity
views critical reflection as a knowledge-­generating exercise, occur-
ring as the researcher examines previous and current contradictions
in their ways of thinking, which then informs future discovery and
analysis.42 With axiological reflexivity, researchers explore their own
values and what they aim to achieve through their work. Reframing
reflexivity in this way shifts a consideration of the researcher's in-
sider or outsider status away from something to be minimised or
deemed problematic, to part of the research in itself and a critical
part of the final output. By focusing on epistemic and axiological
reflexivity (how the researcher relates to the topic investigated, in
what manner are claims true and generalisable, and which values
drive the inquiry) researchers are more likely to achieve the analytic
depth and complexity essential in ethnography, in HPE and beyond.
The above examples of the use of triangulation and of reflexivity
illustrate how the researcher's epistemological orientation should
influence both the research process and final product, and therefore
standards of rigour and quality. This stance on rigour means that re-
searchers will have to engage deeply with the epistemological foun-
dations of the ethnographic approach they choose, and learn how
these influence the knowledge production process. We suggest that
ethnographers in HPE reflect on one of the fundamental purposes
of ethnography and qualitative research more generally: to make the
familiar strange by offering a theoretically informed perspective on
an everyday phenomenon and by capitalising on the essential depth
and complexity that define the ethnographic approach.
3.2 | Ethnographic methods: Doing well and
diving deep
3.2.1 | Observing naturally occurring behaviour
Ethnography is conducted in everyday, naturalistic settings (by contrast
with experimental conditions), where ethnographers can engage in the
observation of ordinary behaviour. In contemporary society, observing
human behaviour is not limited to face to face studies and could also
involve the observation of online behaviour. During ‘fieldwork’ or ob-
servations, the researcher tries to learn what life is like for an ‘insider’
of the culture they are studying when trying to remain a somewhat de-
tached ‘outsider’43,44 guided by an analytic puzzle. Ethnographers often
focus on ‘making the familiar strange rather than the strange familiar,’
45
in the classic terms of van Maanen, and researchers familiar with the
context they study should be particularly attuned to this tenet.
At the start of fieldwork, observations aim to understand the
space and the culture, and field notes aim to describe the research
BRESSERS et al.
site and the behaviours observed. Then, as a narrower analytic puz-
zle is constructed out of iterative data collection and analysis, the
focus narrows, and both observations and notes become more tar-
geted. The ethnographer then seeks to develop and refine a story or
theory about culture as it is created in interactions, and to provide
readers with convincing examples of both when it is instantiated and
when it is not (this is ‘negative case analysis’).46,47
3.2.2 | Diving deep
Ethnography is an immersive, intensive and deliberate practice. Most
ethnography does not lend itself to short-­term work, because pro-
longed time in the field is crucial to gain an adequate understanding
of the cultures, structures and local behaviours.17 Indeed, an ethnog-
rapher needs to spend a significant amount of time ‘hanging out’ with
the culture-­sharing group of people they are studying, whether this
group ‘lives’ online or in three-­dimensional spaces, because building
trust takes time.10 The ethnographer should gain access to the field
site, get to know the participants and generally get known by them.
By being ‘in the field’ with their informants, ethnographers experi-
ence the culture themselves (sometimes as outsiders, sometimes as
insiders) and can question what ‘native’ participants take for granted.
By slowing down, digging deep and documenting the intersections
of culture, structure and human behaviour, ethnographers can make
the obvious visible, and can analyse and problematise it.
We have already pointed to issues with ethnography's impera-
tive for prolonged exposure in the current academic climate. Those
who may want to conduct ethnography on a shorter timeline may
want to consider short-­term ethnography as an alternative,36 and
those who were unable to use observational methods should adopt
a label that is more closely aligned with the actual approach they
used. 20 Conditions that increase the likelihood of successful short-­
term ethnography include focused and deliberate immersion, the
bounding of the study object to a smaller scope, and earlier and
greater interaction with participants from the outset. A more deduc-
tive approach that limits the focus of the ethnography to a subset
of behaviours or experiences, or makes significant use of theory to
structure fieldwork, may also be warranted.
3.2.3 | Writing up high-­quality field notes
Recent ethnographies in HPE have generally focused their analyses
on interview data, and thus published ethnographies have often re-
sembled interview studies. We believe that this is partly because
people do not know how to write high-­quality field notes that can
then be analysed for publication. We suggest some steps below, in-
spired by Emerson, Fretz and Shaw,48 and provide examples of jot-
tings and different kinds of field notes, with commentary, in Table 2.
First, when in the field, the researcher will take careful record-
ings of all accounts and observations as jottings in a field notebook,
and jottings will be rewritten as field notes. Jottings are short phrases
BRESSERS et al.
TA B L E 2 Sample jotting and field notes, with comments
Type of note Sample
Jotting P3 Janice Stevens Johnson
Lori RN outside room
Looks in pain; pulls on feeding tube. Lori ‘Janice,
don't pull it out.’ Repeats
‘Janice, Honey. What's going on?’ walks in
Struggle with breathing, manual pump. L coaches
Janice, when ok stops pumping
Field note; only what Lori, RN: ‘Janice, don't pull it out. Don't pull it out.
people said Don't pull it out’
‘Janice, Honey. What's going on?’
Field note; shallow Lori's (RN) second patient is Janice, who has
description Stevens Johnson syndrome. Janice is awake, and
starts pulling at her feeding tube. Lori notices
and calls out: ‘Janice, don't pull it out.’ She then
repeats her injunction a couple of times
Then Lori walks over into the room and says:
‘Janice, Honey. What's going on?’ She realises
that Janice is struggling to breathe, and she takes
out the manual pump. She lets go once Janice
can ventilate herself
Field note; thick Today, Lori's (RN) second patient is Janice, the
description patient with Stevens Johnson syndrome whom I
had seen before. Janice looks better today; she
is actually awake, sitting with her bed at about
a 70-­degree angle. Her hair has started to grow
back, and her skin looks less inflamed
After a few minutes, however, Lori and I notice
that Janice has started pulling on her nasogastric
feeding tube. At first Lori directs Janice from the
hallway: ‘Janice, don't pull it out.’ She repeats her
injunction a couple of times, but Janice keeps
pulling. She has started looking worse, her whole
face has turned red, blotchy and more swollen;
she is sweating
Lori walks into the room, bends over her patient,
and gently asks: ‘Janice, Honey. What's going
on?’ Janice's body language—she still isn't
speaking—tells Lori that she can't breathe well,
and Lori bounces to get the manual pump. She
places it on Janice's face, then shows her how to
operate it herself. Slowly Janice calms down, and
once she's in control of her own ventilation, Lori
presses her shoulder in support, lets go of the
pump and walks back out of the room
or words that include sensory information such as initial impressions,
important events, reaction to events (both the researcher's and par-
ticipants’) and patterns of behaviour.
Second, to maximise the quality of the field notes, it is best
practice to rework field jottings into full field notes as soon as pos-
sible, so that the ethnographer's memory is fresh and only in a lim-
ited way fills in the blanks or embellishes events witnessed earlier.
Third and finally, field notes should not be mere recordings of
what people say (see also Table 2). The ethnographer needs to flesh
out what he or she sees, to write thick descriptions that can bring the
reader along on the cultural exploration journey.7 Thick descriptions
| 7
Comments
This is the first stage of field note taking, when the researcher is
in the field. Key players are identified (the patient, pseudonym
‘Janice,’ with her condition—Stevens Johnson syndrome. Core
elements of the story written down to revive memory later
Citable materials are in quotes, to confirm what has been heard
Here the dialogue is a monologue, because Janice is not speak-
ing. There is no real richness in this kind of data, and it will
be difficult to either write a compelling story from this, or to
analyse these data later
With this vignette we get a better sense of what happened than
in either the jotting or the field note that merely transcribed the
conversation. But the description is pretty shallow and we don't
have much to go by to create this situation in our minds, and to
analyse what is going on beyond actions
In this richer vignette, we see the patient and the nurse interact-
ing to create a shared understanding of what is going on. We
can see the first line of response from Lori—assuming that the
patient is either nervous or unconsciously playing with the
tube—changing once she gets more signals that something is
wrong. We see her reading her patient's bodily presentation to
refine her understanding of what is happening, and using her
skills to solve the problem satisfactorily for both
We also see a level of kindness and connection that was not
really visible when the story was not as well fleshed out. This is
why it is important to write field notes soon after observations:
to add this kind of texture
The ethnographer is also written into the field notes. Practices
around this will vary based on the ethnographer's epistemic
views, but here the narrative is partly written in the first per-
son, suggesting a constructionist orientation
include but are not limited to what the ethnographer sees, smells,
hears, feels, etc. High-­quality ethnographic observations are thus
generally not structured observations that merely document the
what, who and when of events. Indeed, if researchers know ex-
actly what they are recording ahead of time, they are not engaged
in the inductive co-­construction of knowledge (or emic-­etic conver-
sation) 49 that underpins most ethnography, but instead conducting
other forms of more deductive observational research. Moreover, it
is critical for researchers and appraisers of ethnographic research
to know that field notes generally reflect a situated set of interests
and specific interpretations of events. For instance, someone with
8 |
TA B L E 3 Key questions and considerations for researchers,
reviewers and editors conducting or reviewing research
For researchers: Encouraging reflexivity, rigour and quality
• H ave you considered your own ontological, epistemological
and axiological positions?
• Could you situate your work within these traditions and com-
pare it with others’?
• Have you articulated this in your manuscripts?
• Can you explain your methodological decisions in light of your
metatheoretical positions?
•D
 oes your research project meet the seven dimensions of
ethnography outlined by Hammersley?10 If not, why did you
decide to deviate from them?
• Can you justify these choices based on your metatheoretical
positions?
• A
 re you confident that you know the people, activities and
culture you studied well enough to describe them in ways they
would at once recognise and find insightfully 'strange'?
• Is your written ethnography connecting the specifics of
your study site with broader dynamics through theory or
comparison?
For reviewers and editors: Assessing reflexivity, rigour and
quality
•  Have the authors stated their ontological, epistemological and
axiological positions, and anchored their work within an ethno-
graphic tradition that aligns with these positions?
• Have the authors contributed to theory or mobilised theory to
make sense of their data?
• W
 hen the authors of a study call it 'ethnographic,' have they
met the seven dimensions outlined by Hammersley?10 If not, do
they justify why they call their work ethnographic?
• Do their writing and data show familiarity with their study par-
ticipants and site, and a deep understanding of the activities
and culture of their site?
• H
 ave the authors described and justified their methodological
choices in the manuscript and during the review process?
clinical knowledge in an area will ‘see’ different things in the field to
someone with social scientific knowledge faced with the same situ-
ation. Neither is more true or valid, but readers should have a sense
for the ethnographer's perspective and its relationship to the claims
made.
High-­quality field notes are essential for the data analysis stage
of ethnographic research (see Table 3 for examples), as they will
complement interview data and documentary evidence to create
a holistic, rich portrait of the culture under study. Approaches to
ethnographic data analysis will vary based on the researchers’
ontology, epistemology and axiology, and could be informed by
grounded theory, 50 the constant comparative method40 where
types of data sources are compared and contrasted, or even more
deductive approaches such as directed content analysis. 33 Most
ethnographers will want to engage in iterative data analysis, cir-
cling between data collection and data analysis and following
insights as they arise. 50 Critical here, as with other qualitative re-
search approaches, will be the quality of the connection between
data and inferences, 50 as well as the quality of analytic insight and
theoretical contributions. 36
BRESSERS et al.
4 | CO N C LU S I O N S
Throughout this paper, we have advocated for ethnographers to slow
down and think deeply about the theoretical and practical implications
of their craft. The increasing usage of ethnography and its various iter-
ations is a signal of increased legitimacy of social scientific approaches
in HPE. In their current form, however, the ethnographies published
in the field of HPE do not yet maximise the potential of the approach.
Others before us have noted that ‘slow’ approaches to research often
fail to align with current pressures for high-­velocity research.10,13,35
A narrow view of scholarly accountability and productivity that pri-
oritises ‘demonstrated impact’ and regular, frequent publications,
is particularly troubling for the slow, fluid, ‘hanging out’ approach of
ethnography.10 Our overall recommendations can be found in Table 3.
Despite these unavoidable challenges, ethnography has much to
offer in untangling the complex sociocultural aspects of HPE. At the
individual level, researchers, reviewers, graduate supervisors and edi-
tors can advocate for the potential of ethnography, and encourage best
practices such as those that we have laid out here. Aspiring ethnogra-
phers should build complementary skills that enable them to balance
faster-­turnaround outputs with ethnographic ones. Collectively, how-
ever, we can push back against exacting standards, and promote the
value of slowing down, thinking deeply, doing well and knowing differ-
ently. We hope this piece can serve as a starting point for such conver-
sations and for valuing strong relationships to create strong scholarship.
C O N FL I C T S O F I N T E R E S T
Not applicable.
AU T H O R C O N T R I B U T I O N S
GB suggested the collaboration, helped create and revise outlines, drafts,
contributed to the intellectual contents, gave approval of the version to be
published, and agrees to be accountable for the work. MB helped create
and revise outlines, drafts, contributed to the intellectual contents, gave
approval of the version to be published, and agrees to be accountable for
the work. EP coordinated the collaboration, helped create and revise out-
lines, drafts, contributed to the intellectual contents, gave approval of the
version to be published, and agrees to be accountable for the work.
E T H I C A L A P P R OVA L
Not applicable. This article is not human research but instead a
methodological contribution.
ORCID
Elise Paradis https://orcid.org/0000-0001-9103-4721
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How to cite this article: Bressers G, Brydges M, Paradis E.
Ethnography in health professions education: Slowing down
and thinking deeply. Med Educ. 2020;00:1-9. https​://doi.
org/10.1111/medu.14033​