Conducting ethnography in primary care

Etiquette of the antibiotic decision-making process for surgical prophylaxis in Ethiopia: a triangulated ethnographic study

Background

Prophylactic antibiotics reduce surgery-associated infections and healthcare costs. While quantitative methods have been widely used to evaluate antibiotic use practices in surgical wards, they fall short of fully capturing the intricacies of antibiotic decision-making in these settings. Qualitative methods can bridge this gap by delving into the often-overlooked healthcare customs that shape antibiotic prescribing practices.

Aim

This study aimed to explore the etiquette of the antibiotic decision-making process of surgical prophylaxis antibiotic use at Tikur Anbessa Specialized Hospital (TASH).

Methods

The observational study was carried out at TASH, a teaching and referral hospital in Addis Ababa, Ethiopia, from 26 August 2021 to 1 January 2022. Overall, 21 business ward rounds, 30 medical record reviews, and 11 face-to-face interviews were performed sequentially to triangulate and cross-validate the qualitative observation. The data were collected until saturation. The data were cleaned, coded, summarized, and analyzed using the thematic analysis approach.

Result

Surgical antibiotic prophylaxis (SAP) discussions were infrequent during surgical ward rounds in TASH, leading to practices that deviated from established recommendations. Clear documentation differentiating SAP from other antibiotic uses was also lacking, which contributed to unjustified extended SAP use in the postoperative period. Missed SAP documentation was common for emergency surgeries, as well as initial dose timing and pre-operative metronidazole administration. Importantly, there was no standardized facility guideline or clinical protocol for SAP use. Furthermore, SAP prescriptions were often signed by junior residents and medical interns, and administration was typically handled by anesthesiologists/anesthetists at the operating theater and by nurses in the wards. This suggests a delegation of SAP decision-making from surgeons to senior residents, then to junior residents, and finally to medical interns. Moreover, there was no adequate representation from pharmacy, nursing, and other staff during ward rounds.

Conclusion

Deeply ingrained customs hinder evidence-based SAP decisions, leading to suboptimal practices and increased surgical site infection risks. Engaging SAP care services and implementing antimicrobial stewardship practices could optimize SAP usage and mitigate SSI risks.

Verbal and Nonverbal Expressions of Persons Living With Dementia as Indicators of Person-Centered Caregiving

BACKGROUND AND OBJECTIVES

Improved measures capable of capturing the influence of person-centered caregiving by staff in formal care settings on people living with dementia beyond deficit-oriented outcomes such as absence or reduction of symptoms are important for measuring progress toward improvements in well-being. This exploratory ethnographic study aimed to identify verbal and nonverbal expressions evidenced by people living with dementia surrounding person-centered caregiving approaches and to consider their use in informing temporally specific observational measures.

RESEARCH DESIGN AND METHODS

This study adopted a microethnographic approach through secondary analysis of 5.3 h of audiovisual observations of people living with dementia (N = 9) in nursing home settings at mealtimes. We observed expressions surrounding person-centered caregiving approaches. A systematic review of audiovisual observations generated codes (observable indicators) of expressions that were characterized at their most discrete and unambiguous level.

RESULTS

Drawing from 82 observable verbal and nonverbal expressions by people living with dementia, 14 discrete observable indicators were identified, broadly evidencing shifts in engagement and communication. We found that people living with dementia's expressions served both responsive and initiatory communicative purposes.

DISCUSSION AND IMPLICATIONS

Efforts to expand positive outcome measurement for people living with dementia should extend beyond characterizing them as passive respondents toward active participants in their lived experiences. Identified observable indicators can inform efforts to refine and validate measures of expressions among people living with dementia. Further research can extend this inquiry into different contexts and engage input from people living with dementia and caregivers.

"Eating healthy": Distrust of expert nutritional knowledge among elderly adults

Elderly adults in southern Ecuador often distrust nutritionists' advice when implementing changes to their dietary practices. This distrust is no overt disregard for expert nutritional knowledge but rather the result of structural and situated practices that combine suspicion, misinformation, financial limitations, and family care. In this article, we examine eating practices among elderly adults in southern Ecuador in order to understand how nutrition distrust is constructed. In doing so, our aim is to understand how elderly adults incorporate-or not-expert nutritional knowledge into their eating practices. By ethnographically documenting daily eating practices among elderly adults in their homes, alongside expert nutritional discourses, our findings reveal that there is first, a local understanding of "eating healthy" connected to lived realities (e.g. farming practices, agricultural toxicity, age, education, polypharmacy, kinship ties), and second, a disconnect between expert nutritional knowledge and eating practices linked to how knowledge is produced and disseminated (e.g. power relations, scientific vocabulary, perceptions of health). Understanding how elderly adults build trust around eating can be a fertile ground for promoting more effective and suitable dietary advice among specific communities or groups like elderly adults.

Taking sides with patients using institutional ethnography

Purpose

The main purpose of this paper is to document the first author's experience of using institutional ethnography (IE) to “take sides” in healthcare research. The authors illustrate the points with data and key findings from a study of cardiovascular disease prevention.

Design/methodology/approach

The authors use Dorothy E Smith's IE approach, and particularly the theoretical tool of “standpoint”.

Findings

Starting with the development of the study, the authors trouble the researcher's positionality, highlighting tensions between institutional knowledge of “prevention” and other locations where knowledge about patients' health needs materialises. The authors outline how IE's theoretically and methodologically integrated toolkit became a framework for “taking sides” with patients. They describe how the researcher used IE to take a standpoint and map institutional relations from that standpoint. They argue that IE enabled an innovative analysis but also reflect on the challenges of conducting an IE – the conceptual unpicking and (re)thinking, and demarcating boundaries of investigation within an expansive dataset.

Originality/value

This paper illustrates IE's relevance for organisational ethnographers wishing to find a theoretically robust approach to taking sides, and suggests ways in which the IE approach might contribute to improving services, particularly healthcare. It provides an illustration of how taking a patient standpoint was accomplished in practice, and reflects on the challenges involved.

An ethnography of chronic pain management in primary care: The social organization of physicians' work in the midst of the opioid crisis

BACKGROUND

This study reports on physicians' experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities.

METHODS

Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings.

FINDINGS

In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.

INTERPRETATION

Our findings show that care providers find the treatment of patients with chronic pain-especially those patients also experiencing poverty-to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients' social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.