Institutional ethnography as a unique tool for improving health systems

Abstract

Qualitative research in the health system has made tremendous developments in the last decade to better understand patient experiences. What is often overlooked, are the influences that the internal structures, policies and people have on the individuals that use health services. Institutional ethnography is a qualitative approach that aims to capture the social organization of "everyday life" at various system levels. An institutional ethnographic framework was applied to two research studies exploring how families experience care in neonatal intensive care units. Data were collected to develop a deep understanding of the social contexts that exist within institutional boundaries. This paper provides evidence that how care is organized and delivered can significantly influence patient experiences, perceptions and ultimately health outcomes. Adopting institutional ethnographic techniques as a common research method is a valuable tool for health leaders seeking to understand and develop recommendations for health system reform.

Introduction

The value qualitative inquiry can provide has become increasingly recognized by health leaders and researchers due to its deep examination of complex systems and relationships.^1,2 It provides unique insights that quantitative methods alone cannot achieve.^3,4 Researchers use qualitative inquiry to elicit emotions and perspectives, identify beliefs and values, and examine human behaviours. In qualitative inquiry, one can facilitate understanding individuals’ responses to health and illness, the meanings they construct about their health experiences, and their subsequent actions.^5,6 Qualitative research explores phenomena by providing researchers with tools to examine the deeper meanings of experiences and relationships.^7,8 It is less focused on predicting outcomes and is grounded within the social context in which phenomena occurs.^7,9 In an effort for leaders and scientists to create meaningful change in the health system, we need to consider the effects of institutional culture and rules that drive behaviour. This means examining discourse and social interactions to understand how patients are influenced by internal structures, policies, and people in the health system.

The purpose of this article is to establish the value of adopting Institutional Ethnographic (IE) frameworks for health leaders. Although IE is traditionally used as a research methodology, the outcomes can be beneficial beyond its traditional use in academia. It is an impactful tool for leaders seeking to improve processes and systems in a variety of disciplines.^10,11 Institutional ethnographic is most commonly used in healthcare to explore individuals’ experiences at different levels of the healthcare system.^11,12 One area in which IE has been implemented to inform health system improvement strategies is within the Neonatal Intensive Care Unit (NICU). Neonatal Intensive Care Units have been a common unit of analysis for many research and quality improvement initiatives.^13

–17 This is likely as a result of the relationship between in-hospital care provided by parents and the health outcomes of the infant.^{13,14,16,18

–21} For example, there is significant evidence supporting the value of skin-to-skin contact between parents and premature infants^22
–24 as well as the implementation of early breastfeeding interventions.^25
–27 The ways in which these behaviours are encouraged or governed drastically differ depending on the health provider, the unit policies, and the overarching culture of the hospital. Using two studies from NICUs, this article will demonstrate how institutional ethnographies can be adopted by health leaders to make informed, meaningful decisions.

What is institutional ethnography?

Institutional ethnography is a method of inquiry developed by Dorothy Smith that aims to explore social relations through examination of everyday activities.²⁸ It is a means to examine, explain, and understand the experience of others who are subject to “ruling relations.”²⁹ The concept of “ruling relations” is based upon the notion that peoples’ experiences are constructed by levels of power that may not be explicitly communicated but are always present through discourse and action.^10,29,30 Institutions are not meant as social organizations but rather a complex web of social structures and rules based on how power is exercised within determined boundaries.^31,32 One of the main tenants of IE is that the social architecture is mediated by text which can include written, oral, or visual materials.^10,33 Institutional ethnographic aims to explore these ruling relations that exist institutionally to shift focus away from questions related to administrative concerns and objectified knowledge, toward the puzzles of peoples’ everyday lives.^31

–34

Using lived or common experiences as units of analysis are common in IE, where “the intent is to bring forward voices and experiences from the margins, with a view toward offering rich material for reflection and identifying topics for future research (pp. 792).”¹² This approach facilitates understanding the beliefs, attitudes, and behaviours of a culture sharing group which form a traditional ethnography,⁷ as well as taking into consideration the impacts of institutional values and processes.³⁰ In an institutional ethnography, the aim of the researcher is to “take the standpoint” of the individuals whose experiences provide the initial catalyst for investigation.^29,35 For example, a previous IE study interviewed young homosexual men not as a population of subjects but rather as informants knowledgeable about the experiences of school life for homosexual youth.³⁴

This particular methodological design is a good fit for process improvement initiatives in healthcare, as it identifies specific organizational and institutional practices that can be adapted to improve patient experiences. This is achieved by analyzing the text-mediated discourses that emphasize these ruling relations and power differences that exist in the institutional culture. Two studies in which IE has been successful in identifying opportunities for improvement include two research studies that took place in NICUs. These studies used IE to examine how certain practices in the health system can influence not only the patient experiences but also health outcomes.

Example 1: Institutional ethnography in transitions of care

The purpose of this project was to study the management of Transitions of Care (ToC) of neonatal patients from the perspectives of the patients’ families and Healthcare Professionals (HCPs; see Table 1). The focus of this study was the current ToC process and the healthcare providers and their effect on the patients’ experience of ToC. Using an IE approach, this study included observations of the patients, collection of artifacts (document analysis), and experiential interviews with the parents/guardians of the babies being observed and their healthcare team. This study clearly pointed out that the fragmented ToC communication that existed between HCPs at the NICU and those in the community was stressful and unfavourable during discharge. It also demonstrated that having a clear understanding of what information should be transferred during a ToC will prevent unnecessary tests and misunderstandings. Increasing HCPs’ knowledge of available community resources will aide in transitioning infants to community care and thus freeing bed space and decreasing costs at the hospital. In addition, it was made clear that including parents early in the ToC planning process helps parents feel they’re a part of the interprofessional care team, in-charge of their infant’s care, and thus better equipped mentally to handle their infant’s ToC. The study concluded that communication and education in an interprofessional context is critical for more effective ToC. The interprofessional team should include HCPs on the NICU and in the community as well as the neonate’s family members to ensure a seamless transition from the NICU back to the community.

Table 1.

Managing transitions of care of neonatal patients from the neonatal intensive care unit: Perspectives of the patients’ families and health professionals

Purpose	To identify the enablers and challenges of the ToC of neonatal patients
Methods	This research used institutional ethnography as the guiding framework. Data were collected via document analysis, non-participant observations, experiential interviews with the parents and HCPs, and deliberative workshops
Results	Including parents early in the ToC planning process helps parents feel they are a part of the interprofessional care team, in-charge of their infant’s care, and thus better equipped mentally to handle their infant’s ToC. Mechanisms need to be in place to ensure that communication regarding ToC is consistent and clear between all HCPs and the patients’ families
Clinical implications	It is believed that communication and education in an interprofessional context is critical for more effective ToC. The interprofessional team should include HCPs on the NICU and in the community as well as the neonate’s family members to ensure a seamless transition from the NICU back to the community

Abbreviations: HCPs, healthcare professionals; NICU, neonatal intensive care unit; ToC, transitions of care.

Example 2: Explorations of the maternal experience in an NICU

The objective of this research was to explore mothers’ experiences of caring for infants in the NICU using an IE approach. This study focused on three institutional elements: the structure, processes, and healthcare providers. This facilitated a critical exploration of how these elements work in tandem to construct an experience in the NICU. Data were collected using nonparticipant-observations, interviews, and collection of text-based artifacts, including posted signage in the unit. There is clear evidence that caring for an infant in the NICU can result in significant increases in maternal stress and associated negative outcomes.^{15
–17,21,36,37} Results from triangulation of the data indicated that being physically separated from the infant and learning to mother in the unit was particularly salient experiences expressed by the participants. These experiences were affected, both positively and negatively, by different elements of this clinical microsystem including consistency in communications, increased opportunities for mothers’ to be included in care processes, and lastly, access to more support resources. Implementing improvements to the microsystem, that is by changing certain structures and policies carried out by HCP could empower mothers adjusting to parenthood within the NICU context. Table 2 provides a summary of this research study.

Table 2.

The influences of the neonatal intensive care unit microsystem on mothers’ experiences

Purpose	To explore the influences of the NICU microsystem on mothers’ experiences
Methods	The research was guided by an institutional ethnographic framework. Data were collected using non-participant observations, interviews, and collection of discourse artifacts
Results	Meaningful themes identified from the research included the physical separation from the infant and developing a maternal identity. These experiences were affected, either positively or negatively, by different elements of the microsystem including consistency in communications, increased opportunities for mothers’ inclusion in decision-making and infant care and lastly, access to more support resources
Clinical implications	Implementing changes to the microsystem could better empower mothers adjusting to parenthood within the NICU context. Clinical improvements need to be made to clarify the boundaries between mothers and the care team

Abbreviation: NICU, neonatal intensive care unit.

Discussion

While there were a number of themes within each of these two studies, they had three prominent commonalities that were identified via participant interviews and through analysis of text-based artifacts.

These three themes included (1) inclusion in care, (2) clear, consistent communication, and (3) processes and policies that are practiced dependably and remain the same across the system.

In both studies, parents identified the need to be invited and included in their infants’ care as much as possible. In the mother’s experiences study, mothers described feeling included when they were asked to provide or help with care such as bathing, feeding, and cuddling. They expressed feeling more like a mother and less as a bystander when they were able to complete these tasks independently. Nurses facilitated this by educating and coaching mothers how to provide care safely and without interrupting the medical equipment. Further, mothers made comments about the meaningfulness of being referred to as “mom” during rounds and or care conferences. In the ToC study, parents stressed the need to be included by (a) informing them of potential care plans and giving them the freedom to choose or (b) for the health team to provide an explanation as to why they (the team) chose a particular care pathway over another. Being involved helped parents to stay informed of their infants’ progress and also to be better prepared upon discharge. These opportunities to be included suggest there is a deeper need for parents to identify as the caregivers and decision-makers, particularly for mothers.

Secondly, these studies identified that communications were not always provided in the same way. There was very little consistency or regularity with communication among HCPs. The process in which information was shared was also an issue as not all health providers use the same communication tools. For instance, discharge rounds occurred once a week on the NICU, and HCPs agreed that it was the best source to get updated information on their patients. Not everyone, however, was able to attend the rounds regularly and there was no way of obtaining the information that was shared. Another barrier was the lack of healthcare providers using the on-line tool to update their notes or taking the time to read notes that were written by the patient’s other providers. There were significant differences in the level of details and specificity some HCPs provided in their notations than others. When communications were offered regularly, mothers and families reported feeling more positive about caring for their infant and readier for discharge. Parents in the ToC study expressed feeling comfortable speaking to healthcare providers to obtain updates about their infants or to ask any questions that they may have. In both studies, however, the parents also indicated that most of the time they were the ones having to actively seek the information and that if they didn’t, they would otherwise not be notified.

Thirdly, there were several unit processes and hospital policies that were carried out differently by providers as well as institutions. For example, parents were told they could not bathe or feed their infant at certain times with some nurses and other nurses did not follow the same rules. The lack of consistency in the delivery of care was frustrating for mothers, emphasized the feelings of exclusion and reinforced who had authority. In the ToC study, parents expressed irritation over the lack of consistency in care with the frequent physician turnover. With neonatologists changing every 2 weeks on the unit, so did the care plans. This caused confusion for parents mostly regarding the changes and also doubting the competencies of the physicians.

The themes identified by these studies point to three opportunities for process improvements: increased inclusion in care for parents, consistent communications for health providers, and a system with shared policies and processes. These two studies reinforce the role of power and social rules that exist within clinical microsystems and the broad influence they have. It is from the power differentials that the themes were experienced. For example, the lack of communication with mothers or the differences in how transitions were discussed and planned by nurses emphasize who was in charge of the infant. It was the health providers in the unit that have the information and knowledge that hold the power. The ruling relations that exist in these NICUs could come from broader departments of neonatology, the overall hospital level, or the provincial health system but all communicate a set of rules or social norms. These two studies demonstrate that it is how these rules are applied that directly influences the individuals within these institutions. This is where IE can be particularly valuable for health leaders seeking for ways to make meaningful change.

Another benefit to using IE as an improvement tool is the ease with which recommendations for ameliorating actions emerge. By understanding the experiences from the perspective of the patient or family member structural and systemic challenges will become more apparent. Institutional ethnographic moves beyond oral accounts of the experience and challenges the messaging that is communicated through various mediums. It focuses on the importance of mediated-texts and how this shapes experiences. In the case of these research studies, texts and policies related to the ToC of neonates were studied to see how they constrain the everyday experiences for parents and HCPs.

Conclusion

This article demonstrates the value of employing institutional ethnographies as meaningful tools to facilitate change in healthcare. As mentioned before, the power dynamic that exists between the HCP and the patient’s family is one that is hard to fully understand and ultimately overcome. These power relationships need to be explored and understood as patients and their families will eventually be discharged back into their home or community without the guidance from health providers or safety of the unit. It is important for these patients and families to feel capable of continuing care and feeling empowered to do so. Health leaders need to understand the social architecture that exists in their unit, department, or system to identify the structures that facilitate or hinder positive patient experiences.

Footnotes

Acknowledgements

The authors wish to thank the Canadian Health Human Resources Network (CHHRN) and the Telfer School of Management for their immense support. Further, they would like to extend gratitude to all the families and staff in the NICUs that participated and contributed to these research studies.

ORCID iD

Emily Rowland, MSc, PhD(c)

References

Greenhalgh

Annandale

Ashcroft

. An open letter to the BMJ editors on qualitative research. BMJ [Internet]. 2016;352:I563. Available at: https://dx-doi-org.web.bisu.edu.cn/10.1136/bmj.i563.

Al-Busaidi

. Qualitative research and its uses in healthcare. Sultan Qaboos Univ Med J. 2008;8(1):11.

Bradley

Curry

Devers

. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758–1772.

Pope

van Royen

Baker

. Qualitative methods in research on healthcare quality. BMJ Quality Safety. 2002;11(2):148–152.

Bourgeault

Ivy Lynn

Dingwall

Robert

de Vries

Raymond

. The SAGE Handbook of Qualitative Methods in Health Research. 2010. Available at: https://books.google.com/books/about/The_SAGE_Handbook_of_Qualitative_Methods.html?%20id=sGFn6q-VbeAC. Accessed October 12, 2018.

Gergen

Josselson

Freeman

. The promises of qualitative inquiry. Am Psychol. 2015;70(1):1–9.

Creswell

. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 3rd ed. Thousand Oaks, California: Sage publications; 2013.

Green

Thorogood

. Qualitative Methods for Health Research. London: SAGE; 2013:361.

Saks

Allsop

. Researching Health: Qualitative, Quantitative and Mixed Methods. London: SAGE; 2012:505.

10.

Adams

Carryer

Wilkinson

. Institutional ethnography: an emerging approach for health and nursing research. Nurs Prax N Z. 2015;31(1):18.

11.

Campbell

. Institutional ethnography and experience as data. Qual Sociol. 1998;21(1):55–73.

12.

McCoy

HIV-positive patients and the doctor-patient relationship: perspectives from the margins. Qual Health Res. 2005;15(6):791–806. Available at: https://journals-sagepub-com.web.bisu.edu.cn/doi/abs/10.1177/1049732305276752.

13.

Craig

Verbeek

Schwartz

. Evidence-based optimization of urban firefighter first response to emergency medical services 9-1 -1 incidents. Prehosp Emerg Care. 2009;14(1):109–117.

14.

Gooding

Cooper

Blaine

Franck

Howse

Berns

. Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol. 2011;35(1):20–28.

15.

Montirosso

Provenzi

Calciolari

Borgatti

. Measuring maternal stress and perceived support in 25 Italian NICUs. Acta Paediatrica. 2012;101(2):136–142.

16.

Mendelson

Cluxton-Keller

Vullo

Tandon

Noazin

. NICU-based interventions to reduce maternal depressive and anxiety symptoms: a meta-analysis. Pediatrics. 2017;e20161870.

17.

Skene

Franck

Curtis

Gerrish

. Parental involvement in neonatal comfort care. J Obstet Gynecol Neonatal Nurs. 2012;41(6):786–797.

18.

Finlayson

Dixon

Smith

Dykes

Flacking

. Mothers’ perceptions of family centred care in neonatal intensive care units. Sexual Reprod Healthc. 2014;5(3):119–124.

19.

Russell

Sawyer

Rabe

. Parents’ views on care of their very premature babies in neonatal intensive care units: a qualitative study. BMC Pediatrics [Internet]. 2014;14(1): 1-10. Available at: http://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-14-230.

20.

Mäkelä

Axelin

Feeley

Niela-Vilén

. Clinging to closeness: the parental view on developing a close bond with their infants in a NICU. Midwifery. 2018;62:183–188.

21.

Aagaard

Hall

. Mothers’ experiences of having a preterm infant in the neonatal care unit: a meta-synthesis. J Pediatr Nurs. 2008;23(3):e26–e36.

22.

Craig

Glick

Phillips

Hall

Smith

Browne

. Recommendations for involving the family in developmental care of the NICU baby. J Perinatol. 2015;35(suppl 1):S5–S8.

23.

Feldman

Eidelman

Sirota

Weller

. Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics. 2002;110(1):16–26.

24.

Gonya

Ray

Rumpf

Brock

. Investigating skin-to-skin care patterns with extremely preterm infants in the NICU and their effect on early cognitive and communication performance: a retrospective cohort study. BMJ Open. 2017;7(3):e012985.

25.

Sankar

Sinha

Chowdhury

. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatrica. 2015;104(467):3–13.

26.

Boucher

Brazal

Graham-Certosini

Carnaghan-Sherrard

Feeley

. Mothers’ breastfeeding experiences in the NICU. Neonatal Network. 2011;30(1):21–28.

27.

Cricco-Lizza

. Rooting for the breast: breastfeeding promotion in the NICU. MCN Am J Matern Child Nurs. 2009;34(6):356.

28.

Quinlan

. The ‘actualities’ of knowledge work: an institutional ethnography of multi-disciplinary primary healthcare teams. Sociol Health Illn. 2009;31(5):625–641.

29.

Smith

. Institutional Ethnography as Practice. Lanham, Maryland: Rowman & Littlefield; 2006:280.

30.

Campbell

Gregor

. Mapping Social Relations: A Primer in Doing Institutional Ethnography. Toronto, Ontario: University of Toronto Press; 2002:148.

31.

Campbell

. Intersectionality, policy-oriented research and the social relations of knowing. Gender, & Work Org. 2016;3(23):248–260.

32.

Bisaillon

Webster

. Blurring the boundaries: using institutional ethnography to inquire into health professions education and practice. Med Educat. 2017;51(1):51–60.

33.

Rudrum

Institutional ethnography research in global south settings: the role of texts. Int J Qual Methods [Internet]. 2016:1–8. Available at: https://journals-sagepub-com.web.bisu.edu.cn/doi/abs/10.1177/1609406916637088.

34.

Devault

McCoy

. Institutional ethnography: using interviews to investigate ruling relations. In: Institutional Ethnography as Practice. Lanham, Maryland: Rowman & Littlefield; 2006:15–44.

35.

Rankin

Campbell

. Institutional ethnography (IE), nursing work and hospital reform: IE’s cautionary analysis. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research [Internet]. 2009;10(2). Available at: http://www.qualitative-research.net/index.php/fqs/article/view/1258.

36.

Heermann

Wilson

Wilhelm

. Mothers in the NICU: outsider to partner. Pediatr Nurs. 2005;31(3):176–81, 200.

37.

Mianaei

Karahroudy

Rassouli

Tafreshi

. The effect of creating opportunities for parent empowerment program on maternal stress, anxiety, and participation in NICU wards in Iran. Iran J Nurs Midwifery Res. 2014;19(1):94–100.