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Foundations, strengths and limitations, process considerations, conclusions, understanding meta-ethnography in health professions education research.

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Victoria Luong , Margaret Bearman , Anna MacLeod; Understanding Meta-Ethnography in Health Professions Education Research. J Grad Med Educ 1 February 2023; 15 (1): 40–45. doi: https://doi.org/10.4300/JGME-D-22-00957.1

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The number of qualitative studies published in the health professions education (HPE) literature has grown exponentially over the past few decades—as has the acceptance of this type of research as a credible form of inquiry. Therefore, HPE researchers require rigorous approaches to the synthesis of multiple qualitative studies to integrate findings and interpret their collective meaning. Qualitative synthesis methods, such as meta-ethnography , may lead to more effective forms of knowledge transfer and more refined approaches to medical education research and practice.

Using meta-ethnography, researchers choose, analyze, and interpret qualitative studies to increase understanding of a phenomenon. The goal is to arrive at new insights and, possibly, conclusions on a topic. For example, recent meta-ethnographic research has been used to illuminate the range of intended and unintended consequences of accreditation for medical teachers and students, 1   to theorize how foundation year and internship experiences shape physicians' career choices, 2   and to develop a conceptual model of the barriers that international medical graduates face after migration. 3  

With roots in education 4   and well-established applications in health research, 5 - 9   meta-ethnographic approaches have significant potential in the realm of HPE. Yet, with a few notable exceptions, 10 , 11   this approach has not been widely used in our field. This article encourages HPE researchers to consider meta-ethnography and provides essential information about the foundations of the approach, strengths and limitations, and process considerations. Box 1 illustrates the Case of Dr. Smith, which continues throughout this special review series, considering the same question using different review methodologies.

Dr. Smith, a program director, has been tasked to develop an interprofessional education (IPE) experience for the residency program. Dr. Smith decides that conducting a literature review would be a savvy way to examine the evidence and generate a publication potentially useful to others.

After running a Google search using the term “interprofessional education,” Dr. Smith finds more than 11 million hits. Turning to PubMed and using a general subject search with the same term, “interprofessional education,” Dr. Smith identifies 24 000 matches. Dr. Smith randomly samples a few papers and notes the huge diversity of types and approaches, including randomized trials, qualitative investigations, and critical perspectives.

With Dr. Smith's interest in the sociocultural factors that influence the effectiveness of IPE programs, Dr. Smith decides to complete a meta-ethnographic review of the literature. Specifically, the purpose of Dr. Smith's review is to synthesize what the qualitative research literature reveals about student and teacher perceptions of IPE. Meta-ethnography seems like the right choice because it is grounded in research focusing uniquely on the how and what questions of IPE (ie, it is an interpretive synthesis method that reviews purely qualitative research), and it has the potential to lead to new models and interpretations that could shape the way Dr. Smith approaches IPE with the program's residents.

Synthesizing evidence from existing qualitative work is increasingly recognized as a powerful way to make sense of complex social phenomena. In HPE, qualitative insights can help decision-makers understand why certain educational policies are successful, why certain professionals behave in particular ways, or how diverse learners experience an educational innovation. Synthesizing quantitative evidence helps us understand if something works; however, synthesizing qualitative evidence helps us understand what things work and how , through descriptions of the complex and nuanced range of human experience.

The field of HPE has adopted several approaches to qualitative evidence synthesis, each method underpinned by distinct goals and assumptions. For instance, meta-narrative research seeks to compare and contrast different ways researchers approach a topic over time 12 , 13   ; meta-studies focus on interpreting qualitative research in light of differences in findings, methods, and theories 14   ; and realist syntheses ask how and why complex interventions (both qualitative and quantitative) may or may not produce intended outcomes in different contexts. 15  

Meta-ethnography distinguishes itself from these approaches in 3 distinct ways. First, meta-ethnography focuses only on qualitative data and social science phenomena; it does not draw from quantitative evidence. Second, it uses original interpretations from primary qualitative studies as data. Third, it seeks to interpret through analytic synthesis by translating the synthesized studies into new and unique insights about the social phenomena under study.

The ultimate goal of meta-ethnography is to arrive at new interpretations that transcend the findings of individual studies. Noblit and Hare described this as “making a whole into something more than the parts alone imply.” 4(p28) For example, Krishnasamy and colleagues used meta-ethnography to explore empathy ( Table ). 11   Each study included in their review offered a unique explanation of how empathy is experienced in medical school. Using meta-ethnographic methods, Krishnasamy and colleagues were able to interpret these interpretations as a collective and reconceptualize empathy as something that is derived through the complex interplay between medical culture, role models, atmosphere, and time. 11  

Examples of Meta-Ethnographic Studies Involving Health Professions Education

Meta-ethnography, then, is useful for researchers who seek to study the literature interpretively and for educators and policymakers who may be struggling to make sense of multiple (and often conflicting) studies. Most importantly, meta-ethnography is valuable to those seeking to go beyond single accounts to explore the analogies, patterns, and variations within qualitative findings. If rigorously conducted and reported, meta-ethnography can facilitate novel conceptual understandings of complex issues.

As meta-ethnography is a method of synthesizing qualitative research, its roots are in the interpretivist paradigm within the social sciences. Through interviews, observations, and document analyses, qualitative studies aim to provide deep insights into the subjective experiences of patients, learners, and health care professionals, and the contexts within which they operate. Hence, meta-ethnographies, like qualitative studies, focus on how and what questions and seek to uncover meaning. They are designed to add in-depth, interpretive insights to questions, such as “How do students learn about empathy in HPE?” and “What is the role of facilitators in interprofessional education?”

Meta-ethnography was introduced by Noblit and Hare in an “attempt to develop an inductive and interpretive form of knowledge synthesis.” 4(p16) By inductive and interpretive, they meant research that explores social phenomena through the perspectives and experiences of the people involved in it. Many approaches to knowledge synthesis, such as systematic reviews, are oriented in the positivist paradigm. These positivist approaches generally assume that knowledge accumulates and, thus, their methods aim to derive causal relationships and generalizable conclusions based on the aggregation of data. Noblit and Hare argued that this may be ill-fitted to the synthesis of qualitative evidence. The authors demonstrated how aggregating findings from 5 ethnographic studies failed to offer novel insights into the phenomenon they were investigating. 4   In response, Noblit and Hare proposed a synthesis approach that translates studies into each other and makes sense of the analogies and inconsistencies found within them.

Meta-ethnography is now one of the most common qualitative synthesis approaches in health research 16 - 19   and is increasingly common in education research. 7   Within these fields there is growing recognition that high-quality meta-ethnographic work can be invaluable with respect to program design, development, and policy making (see the Table for examples). 6 , 8 , 20 , 21  

High-quality meta-ethnographies are ideal for synthesizing information from multiple studies about people's experiences of a particular phenomenon. The approach of bringing together a range of qualitative studies allows for a more contextual and comprehensive exploration of an issue. Other strengths of meta-ethnographic methods for synthesis include that meta-ethnography has clear origins in the interpretive paradigm and is thus consistent with the studies it synthesizes; it can add breadth and depth to existing systematic reviews; and it may help to mitigate duplication in qualitative research. 6 , 16 , 18   This synthesis approach also helps generate higher-level analysis, comprehensive theory, new models or frameworks, and new research questions beyond what can be found in the individual studies it synthesizes.

Limitations

The reporting quality of published meta-ethnographies is variable and sometimes poor. Recently, the eMERGe Reporting Guidelines collective has been working to develop guidelines to increase reporting quality. 16   Challenges in detailing analytical processes are particularly apparent. Low-quality reporting makes it difficult to assess the quality and thoroughness of a meta-ethnographic review and leads to a lack of trust.

Researchers engaging with meta-ethnography must recognize that meta-ethnography seeks to synthesize sometimes widely differing qualitative studies. 20 - 24   Thus, in the process of interpreting interpretations, salient ideas or contextual nuances can be lost. 20 , 24   Because meta-ethnography is a relatively new approach, debates and uncertainties remain around the best process, such as how to decide which studies to include or exclude, and the appropriate number of studies to include within a single review. 18 - 20   Similarly, reporting guidelines for meta-ethnography are recent, and recommendations for good practices in design and implementation of meta-ethnographies are still in development. 16   As meta-ethnography is limited to synthesizing qualitative evidence, other approaches may be more appropriate for researchers seeking to broadly map the literature on a topic. Finally, meta-ethnography does not offer immediate practical advice for medical educators, but rather frames new ways of considering the phenomenon at hand.

Meta-ethnography is generally conceptualized as an iterative 7-phase process (see Box 2 ). While it is tempting to see these steps as distinct and chronological, in reality, phases 4 through 6 are often happening at the same time. Phase 1 describes the period of exploration in which researchers identify an appropriate topic “worthy of the synthesis effort.” 4(p27) In phase 2, the researchers compile a list of potential studies and justify which to include based on criteria developed in relation to the focus of the synthesis. In phase 3, the researchers read each study multiple times; and in phase 4, they relate studies with one another and create lists that help make sense of their similarities and differences.

▪ Describe the gap in research or knowledge to be filled

▪ Describe the meta-ethnography aim(s)

▪ Describe the meta-ethnography review questions (or objectives)

▪ Explain why meta-ethnography was considered the most appropriate qualitative synthesis methodology

▪ Describe the rationale for the literature search strategy

▪ Describe how the literature search was carried out and by whom

▪ Describe the process of study screening and selection, and who was involved

▪ Describe the results of study searches and screening

▪ Describe the reading and data extraction methods and processes

▪ Describe characteristics of the included studies

▪ Describe the methods and processes for determining how the included studies are related:

▪ Which aspects of studies were compared

▪ How the studies were compared

▪ Describe the methods of translation:

▪ Describe steps taken to preserve the context and meaning of the relationships between concepts within and across studies

▪ Describe how the reciprocal and refutational translations were conducted

▪ Describe how potential alternative interpretations or explanations were considered in the translations

▪ Describe the methods used to develop concepts

▪ Describe how potential alternative interpretations or explanations were considered in the synthesis

▪ Summarize the main interpretive findings of the translation and synthesis and compare them to existing literature

▪ Reflect on and describe the strengths and limitations of the synthesis:

▪ Methodological aspects

▪ Reflexivity (impact of the researchers on the review process and vice-versa)

Phases 5 through 7 center on comparing studies, deriving higher order meaning from these comparisons and communicating these findings. Meta-ethnographic analysis involves treating the various theories and interpretations presented in each qualitative study as research “data.” Hence, a key concept relevant to this type of analysis is the idea of levels of interpretation. 25   Researchers undertaking qualitative synthesis often consider first-order interpretations as the common sense and everyday explanations of research participants (ie, raw research data); second-order interpretations as the constructs and theories explaining those experiences (ie, research interpretations); and third-order interpretations as the holistic meanings drawn from the synthesis of those studies (ie, meta-ethnographic interpretations). Third-order interpretations thus remain consistent with first- and second-order interpretations, but also extend beyond them (see the Table ).

Meta-ethnography uses a process called translation to build third-order interpretations. This involves exploring analogies and metaphors that explain how findings from different studies relate to one another. By comparing and integrating these ideas, holistic meanings are preserved throughout the process. More in-depth discussion of the development of third-order interpretations through “translation” is available for researchers. 4  

Markers of Rigor

Strike and Posner 26   described 3 criteria that can be used to evaluate the quality of literature syntheses. They proposed that high-quality syntheses (1) do not oversimplify or obscure differences between findings and ideas but clarify and resolve them; (2) involve reinterpretation and conceptual innovation; and (3) result in theoretical explanations that are consistent, parsimonious, elegant, and fruitful. In other words, syntheses should be “not just encyclopedias of current knowledge, but represent a creative and progressive transformation of current knowledge.” 25(p355)

Rigorous meta-ethnography, through its careful interpretive work, meets these standards. Although not always successful, the initial aim of meta-ethnographic synthesis is to generate new interpretations or a new model or framework. However, some meta-analyses will fail to produce robust causal explanations or new interpretations that advance our understanding of the theoretical underpinnings of the studied phenomenon.

Achieving such desired rigor is no simple task. To address the inconsistent reporting quality of meta-ethnographies in health literature, a group of meta-ethnographers (eMERGe collective) have come together to develop a set of reporting standards, tailored to the broad spheres of health and social care. 16   The 19-item reporting criteria is related to the 7 phases of meta-ethnography. 16   It is intended to help researchers design and communicate their studies, but also help readers interpret the quality of meta-ethnographic design. The eMERGe Reporting Guidelines emphasize transparency in the reporting of results and justification of methodological and interpretive decisions.

Synthesizing qualitative research—that is, research that examines what phenomena occur and how they are experienced—is complex and requires deliberate and thoughtful procedures to undertake successfully. Many HPE researchers may be unfamiliar with meta-ethnography, but it is an approach that has significant potential for our field. Based in interpretive foundations, meta-ethnographies “translate” concepts and interpretations from multiple qualitative studies into one another, and thus effectively advance the how and what questions beyond what any one study can accomplish. Overall, meta-ethnography may provide an effective way to explore complex and persistent questions in HPE.

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© 2011, National Health Personnel Licensing Examination Board of the Republic of Korea

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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INTRODUCTION

Uses of ethnography, ethnographic studies in healthcare and medical education, limitations of ethnography, article information.

• Research in healthcare settings and medical education has relied heavily on quantitative methods. However, there are research questions within these academic domains that may be more adequately addressed by qualitative inquiry. While there are many qualitative approaches, ethnography is one method that allows the researcher to take advantage of relative immersion in order to obtain thick description. The purpose of this article is to introduce ethnography, to describe how ethnographic methods may be utilized, to provide an overview of ethnography’s use in healthcare and medical education, and to summarize some key limitations with the method.
• Keywords : Ethnography ; Qualitative Research ; Medical Education ; Healthcare

Define a problem when the problem is not yet clear.

Define a problem when it is complex and embedded in multiple systems or sectors.

Indentify participants when the participants, population sectors, stakeholders, or the boundaries of the study population are not yet known or identified.

Clarify the range of settings where a problem or situation currently occurs when not all of the possible settings are fully identified, known, or understood.

Explore the factors associated with a problem in order to indentify, understand, and address them either though research or intervention studies, when they are not known.

Document a process.

Identify and describe unexpected or unanticipated outcomes.

Design measures that match the characteristics of the target population, clients, or community participants when existing measures are not a good fit or need to be adapted.

Answer questions that cannot be addressed with other methods or approaches.

Ease the access of clients to the research process and its products.

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Disruption in the space–time continuum: why digital ethnography matters

Jennifer cleland.

1 Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, 308232 Singapore

Anna MacLeod

2 Division of Medical Education, Dalhousie University, Halifax, Canada

There is increasing interest in the use of ethnography as a qualitative research approach to explore, in depth, issues of culture in health professions education (HPE). Our specific focus in this article is incorporating the digital into ethnography. Digital technologies are pervasively and increasingly shaping the way we interact, behave, think, and communicate as health professions educators and learners. Understanding the contemporary culture(s) of HPE thus means paying attention to what goes on in digital spaces. In this paper, we critically consider some of the potential issues when the field of ethnography exists outside the space time continuum, including the need to engage with theory in research about technology and digital spaces in HPE. After a very brief review of the few HPE studies that have used digital ethnography, we scrutinize what can be gained when ethnography encompasses the digital world, particularly in relation to untangling sociomaterial aspects of HPE. We chart the shifts inherent in conducting ethnographic research within the digital landscape, specifically those related to research field, the role of the researcher and ethical issues. We then use two examples to illustrate possible HPE research questions and potential strategies for using digital ethnography to answer those questions: using digital tools in the conduct of an ethnographic study and how to conduct an ethnography of a digital space. We conclude that acknowledging the pervasiveness of technologies in the design, delivery and experiences of HPE opens up new research questions which can be addressed by embracing the digital in ethnography.

Introduction

“ All forms of interaction are ethnographically valid, not just the face to face ” (Hine, 2000 , p.65).

All of our lives, to some degree, take place in digital spaces. We tweet, we blog, we use Facebook, we text, we WhatsApp, we are “tagged” in something posted by a third party, we are part of online communities. At work, we use email, have remote meetings, upload tasks onto the digital learning management system, use online systems to share data, and so on. Health professions education is increasingly constituted through digitized practices where social interactions and cultural meaning-making processes occur in virtual and online spaces, or in a combination of online and face-to-face spaces (Hine, 2000 ; Boellstorff et al., 2012 ; Gatson, 2011).

Digital technology shapes the way we interact, behave, think, and communicate and, in doing so, it has changed the roles of space, place and time in human and material interactions. Space is no longer defined as the congregation of people in any specific place but rather is defined beyond the physical. In other words, space is digitally mediated as well as direct contact with other people (Murthy, 2008 ). Digital technologies have thus extended the nature of human interactions to encompass “distanced” and dispersed communication and different types of proximity in ways that no other technology has done to date (e.g., Murthy, 2008 ). Time is fluid and flexible, with asynchronous options for engaging online meaning people participate when it works for them, rather than during mandatory, prescribed periods (Burcks et al., 2019 ).

If social interactions are no longer solely co-located in time and space, we must extend ethnographic study to settings where interactions are technologically mediated, not just face-to-face (e.g., Bengtsson, 2014 ; Hine, 2015 ). Ethnographers who rely principally on face-to-face interviewing and in-person observation are now unlikely to obtain a sufficiently rich picture of their informants’ lives because it is increasingly difficult to separate the online from the embodied, and the digitally-mediated aspects of life now are not amenable to (traditional) observation (Beaulieu, 2010 ; Czarniawska, 2008 ).

This ontological shift necessitates thinking differently about ethnographic practices, including the questions that can be addressed, the methods that can be used, and the ethical challenges to consider. What remains the same and what is different when conducting an ethnography of a digital space, compared to “analogue”, or traditional ethnography (Boellstorff et al., 2012 ; Seligman & Estes, 2020 )?

Before discussing this further, it is useful to explain what we mean by digital ethnography. Different authors use different terms to describe their approaches to ethnographic research on digital culture and practices (e.g., ‘digital ethnography’ (Murthy, 2008 ), ‘virtual ethnography’ (Hine, 2000 ), ‘cyberethnography’ (Robinson & Schulz, 2009 ), ‘netnography’ (Kozinets, 2010 )) and even different definitions within each of these labels (for example, there are many subtly different definitions of digital ethnography (Hines, 2000 , 2008 , 2015 ; Murthy, 2008 ; Pink et al., 2015 )). Common to all these definitions, and the position we take in this paper, is that digital ethnography is research ‘on online practices and communications, and on offline practices shaped by digitalisation’ (Varis, 2016 , p.57), and involves human beings studying other human beings (rather than software collecting data: see Kozinets et al., 2018 ).

Our experience and knowledge of the literature suggests that broadly speaking, the aims of ethnography and digital ethnography are the same: to provide detailed, in-depth descriptions of everyday life and practices (Hammersley & Atkinson, 2007 ; Hoey, 2014 ). The practicalities, use of theory and the need for reflexivity are also unchanged. However, the role of the researcher, the notions of field/place and data collection tools differ across traditional and digital ethnography (e.g., da Costa & Condie, 2018 ; Markham, 2005 ). Additionally, digital ethnography opens up both new ethical considerations and new opportunities, specifically to examine the complex ways in which culture—the everyday practices, experiences, and understandings of persons interacting digitally—shapes and is shaped by the technological platforms where it occurs (Hine, 2000 , 2008 ).

Despite the fact that bringing the digital into ethnography opens up new vistas of health professions education research (HPER) possibilities, our field has been slow to embrace digital ethnography. A focused search of two mainstream databases identified only six empirical studies which could be considered broadly related to medical education or training (not patient care, or the organisation of care) and which included analysis of some form of digital data (see Box ​ Box1). 1 ). In this era of physical distancing, in which so much of the work of HPE is accomplished online, it is time to foreground digital ethnography.

Example: Digital ethnography in medical education research

To address this gap and extend understanding of digital ethnography, therefore, we discuss each of three key areas—the use of theory, “new” ethical considerations and digital ethnography practices. We then suggest directions for the development of digital ethnographic studies and best practices in the field of HPE via two detailed examples and other suggestions of how this approach could extend knowledge and understanding in health professions education.

Theory in digital ethnography

Oversimplified, atheoretical perspectives on the role of technology in research on learning have long characterized the field. Several decades ago, Lave and Wenger noted, “in general, social scientists who concern themselves with learning treat technology as a given and are not analytic about its interrelations with other aspects of a community of practice” (1991, p. 101).

Sociomaterial theoretical perspectives, based on the related concepts of situated learning (Lave & Wenger, 1991 ), distributed cognition (Hutchins, 1995 ), and activity theory (Engeström, 1999 ), offer a robust theoretical starting point for making sense of online activities in the realm of HPE. Now recognized as an important perspective for understanding the active role of digital technologies (MacLeod et al., 2015 , 2019 ), sociomaterial perspectives allow for the theorizing of the entanglement of both social (human) and material (digital) elements—in other words, a sociomaterial assemblage. This, in turn, allows a researcher to explore the social complexities of a digital environment while acknowledging the foundational materiality shaping it.

Orlikowski and Scott ( 2008 ) note that the distinction between social and material, or human and technology, is “analytical only, and done with the recognition that these entities necessarily entail each other in practice” (p. 456). Given that technology, the digital environment, and contemporary learning and working practices are inextricably linked, any effort to theorize online HPE activities would be enriched by deliberately attuning to such intra-actions. Well-conceptualised digital ethnographic work should illuminate the ways in which technological elements derive meaning through social agency, and vice-versa. For example, Wesch ( 2012 , p. 101) states that different platforms “create different architectures for participation” and “every feature shapes the possibilities for sociality.” People engage with multiple social media platforms for different purposes, so one sees different content, interactions, and levels of impression management in work emails, WhatsApp, on public platforms like Twitter and more private platforms that may require “friending” someone to see their content (Facebook, Instagram). Different interactions may take place in relatively stable and bounded socio-technical contexts (e.g., discussion forums), compared to more “volatile environments” (Airoldi, 2018 p.662) such as Twitter’s trending topics. Indeed, “specific practices and ways of being human are as likely to differ between online and off, between one form of online activity and another, as between physically located cultures” (Wilson & Peterson, 2002 , p 450).

Ethical considerations

As the amount of human activity on digital media has increased, so too have ethical concerns about doing research within digital spaces. How can a researcher obtain informed consent in digital spaces given the flow of information and flow of users, not all of whom read all messages (Barbosa & Milan, 2019 )? What issues need to be negotiated when it comes to friending participants for the purposes of participant observation (Robards, 2013 )? These and many other questions have led authors to propose that embracing digital spaces for research purposes challenges “existing conventions of ethics” and requires new ways of approaching such concerns (Markham, 2005 ; Thompson et al., 2020 ).

For example, there are different schools of thought about what is public and what is private in the digital sphere (West, 2017 ). Some researchers posit that messages posted in blogs, chat rooms and any other accessible online forums should be treated as in the public domain and thus do not require informed consent to access. Others argue that just because information is accessible online does not mean participants do not consider it as private or available only to a restricted audience, and therefore informed consent should be required. The concept of contextual integrity (Nissenbaum, 2004 ) helps here. Briefly, contextual integrity assumes that privacy is related to, and modulated by, the flow of information based on norms that are context-dependant. What context is remains fuzzy, but contextual integrity is based on the notion that individual platforms (e.g., Twitter, Facebook, a workplace) constitute cultural spaces with different practices around privacy and anonymity (Ozkula, 2020 ).

Second, online practices bring privacy risks (Buglass et al., 2017 ; Politou et al., 2018 ). Incidences of “zoom bombings” (e.g., Ling et al., 2021 ) where people find their way into digital spaces that were intended to be private, including classrooms and PhD defences, are a significant challenge. The increasing sophistication of web search engines mean that quotes that might appear in ethnographic texts can be traced back to the original postings in the public forums, increasing the potential of identification. Researchers may need to paraphrase the participants’ quotations, paying careful attention to changing details of the data, and the social media platform, to assure confidentiality and privacy (e.g., Thompson et al., 2020 ).

On the other hand, digital communication increases the potential to access, recruit, and engage individuals in one’s research (Caliandro, 2018 ). Where engagement is purely digital, there are no geographic or social barriers to participation—so hard-to-reach groups may be more accessible (e.g., Morison et al., 2015 ). Participants may also be more likely to allow a researcher access to sensitive topics where they are already engaging in these discussions online (e.g., the content of a trauma support forum’s online discussion) rather than recalling difficult experiences in a traditional interview. Moreover, social media, messaging apps, and digital tools allow researchers to engage informants/participants in the research process and allow for collaborative ethnography to emerge more easily (Collins & Durington, 2014 ). Finally, when a data collection period is over, people may keep in touch, providing the researcher with updates via, for example, WhatsApp. These updates can enable follow-up and longitudinal data collection that might not have been possible using more traditional ethnography methods. For example, Robards and Lincoln ( 2017 ) in a study of Facebook timelines, or traces, remained friends with their informants after the main data collection period. This allowed them to go back into profiles, revisit particular posts, and clarify events during data analysis.

We also direct readers to Christensen, Larsen and Wind’s ( 2018 ) comprehensive guide to the literature on ethical challenges when working with different types of digital data (e.g., social media, online communities, Twitter).

The practices of digital ethnography

The similarities and differences between analogue and digital ethnography are summarised in Table ​ Table1. 1 . (Those wishing a deeper dive into the basic tenets of ethnography will find these references helpful [Reeves et al., 2013 ; MacLeod, 2016 ; Bressers et al., 2020 ]). We discuss the field site and the role of the researcher in more detail here.

Similarities and differences between traditional and digital ethnography

The field site

The concepts of space and a field site are reconceptualised in digital ethnography. The field site is not a single, discrete geographical place but is a “stage on which the social processes under study take place” (Burrell, 2009 ). This stage may be digital, or it may be part of broader configurations, straddling digital and face-to-face interactions (see Box ​ Box2). 2 ). Examining the entanglement of online and “offline” interactions by “following the thing” (Marcus, 1995 ) allows fieldworkers to shed new light on the nuanced ways that people engage with different media, how people combine different modes of communication, and the potentially conflicting information that each may yield.

Communication may be digital or may combine digital and face-to-face interactions

As always in ethnography, digital ethnographers must determine how to apply boundaries in virtual and other spaces in which they will do their work, but these boundaries are not determined by a physical space. Researchers may decide in advance only to engage with certain content and/or groups, limit their sample size or research question, and provide practical and theoretical reasons for such decisions (Hine, 2015 ; Markham, 2005 ). They may also decide to apply boundaries by focusing only on a particular digital platform (see earlier).

The role of the researcher

Like “traditional” fieldwork, digital ethnographic methods draw on the researcher’s experience as an observer to gain understanding of (digital) culture and communicate the meaning system and practices of its members (Kozinets, 2010 ). In digital ethnography participation can vary from being identified as a researcher and actively engaging with the participant(s) to covert presence—that is, remaining invisible to the people whose activities are being observed (e.g., Barbosa & Milan, 2019 ). This lack of visibility—impossible in traditional embodied ethnography where the research is present in space and time—may be an artifact of the challenges of maintaining presence in digital spaces. What we mean by this is that the researcher may disclose their presence, inform participants about the research, and consistently and overtly interact with informants (Murthy, 2008 ). However, the speed and volume of online activity can mean the researcher fades into the background—participants are often only aware of the people with whom they are directly and actively interacting. On the other hand, “invisibility” may be a conscious decision on the part of the digital ethnographer. This raises the notion of ‘lurking’ (Hine, 2000 )—mining for data without interaction, or acting as a participant without researcher transparency. Views on the legitimacy of lurking as a digital ethnographic endeavour vary, from the positive (an opportunity to collect data on unfiltered behaviour), to the wary (can lurking be regarded as ethnographic observation given it is not participatory?) (Varis, 2016 ), to caution that purely observing interaction increases the risk of misunderstanding the observed (Gold, 1958 ; Hines, 2000 ), to considering this unethical research behaviour (e.g., (Doring, 2002 ). There are also nuances to consider. For example, is it acceptable for a researcher to use covert approaches for a brief period during the planning and early stages of a project, to orient themselves with the digital presence of communities, forms of practice, language, and so on (Hine, 2008 )? We cannot offer definitive guidance but raise these issues for consideration.

Researchers need to consider what they bring to the field, and to analysis, in terms of formal, reflexive practices including their personal and social assumptions but also their digital and media persona, and how these may shape the relationship between researcher and participants (Gershon, 2010 ; Tagg et al., 2017 ; see also Bourdieu & Wacquant, 1992 ). Hine ( 2000 ) cautions that even the screen name one chooses is an important consideration because it might affect participant engagement. It is also important for researchers to consider their own digital footprint (i.e.,—what information is findable with a Google search), as this may lead to stereotypisation of the researcher, initial distrust or suspicion (Numerato, 2016 ).

Applications and opportunities

Given the pervasiveness of digital technologies in the design, delivery and experiences of health professions education, it follows logically that attuning to the digital as an artefact of, and a substrate for, culture will open up new research inquiries and extend knowledge in the field. To illustrate this, we provide two in-depth examples of possible research questions and potential strategies for using digital ethnography to answer those questions. One example looks at how to conduct an ethnography of a digital space and draws on sociomaterial theory. The second example looks at using digital tools in the conduct of an ethnographic study and draws on a theory of social interaction which has been used previously in both traditional and digital ethnographic studies (Kerrigan & Hart, 2016 ; Leigh et al., 2021 ) (Boxes ​ (Boxes3 3 and ​ and4 4 ).

Ethnography of a digital space

Using digital tools to conduct an ethnographic study

These examples are illustrative. Those wishing to find out more about different approaches to digital ethnography may wish to delve into the empirical references identified in our search and reported in Box ​ Box2 2 (Chretien et al., 2015 ; Henninger, 2020 ; Macleod & Fournier, 2017 ; Meeuwissen et al., 2021 ; Pérez-Escoda et al., 2020; Wieringa et al., 2018 ). We also suggest some outstanding research questions and topics which could be explored using various different digital ethnographic practices in Table ​ Table2. 2 . These suggestions are by no means exhaustive. Rather they reflect our own interests and observations and should be regarded as a springboard to help readers consider diverse ways in which digital ethnography may add knowledge and richness in our field. They also illustrate how the many different approaches encompassed within the broad heading of digital ethnography allow researchers to tailor a methodology according to the research problem.

A typology of some mainstream digital ethnographic approaches and their actual or potential application to HPER

Digital ethnography has much to offer in untangling the social and material complexities of health professions education. Bringing the digital into ethnography opens up new research vistas, and allows us to identify and answer questions which are emerge as our practices and interactions become increasingly digitalized. As Hallett and Barber ( 2014 ) state, ‘it is no longer imaginable to conduct ethnography without considering online spaces’ (p.307).

Acknowledgements

Our thanks to the anonymous reviewers and Editors whose comments on earlier drafts much improved the focus of the paper.

Authors’ contributions

JC had the original idea for this paper. Both authors contributed equally to the development of the content and revising the paper.

This work was unfunded.

Declarations

Ethical permission was not required for this paper, which is a synopsis of publicly-available literature.

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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ORIGINAL RESEARCH article

Beyond technology acceptance—a focused ethnography on the implementation, acceptance and use of new nursing technology in a german hospital.

• 1 Department for Patient Orientation and Health Education, Institute for Epidemiology, Social Medicine and Health System Research, Hannover Medical School (MHH), Hanover, Germany
• 2 Department of Digital Medicine, Medical Faculty OWL, Bielefeld University, Bielefeld, Germany

Introduction: Hospitalised patients could benefit from the emergence of novel technologies for nursing care. There are numerous technical products available, but these rarely find their way into practice. Further knowledge is required about the circumstances under which technology in nursing is accepted and used. In the research project “Centre for Implementing Nursing Care Innovations”, technical innovations are implemented on a trauma surgery inpatient ward in Germany. After implementation, it was investigated: Which implemented technologies are accepted/rejected, and which factors influence the acceptance/rejection of technology for nurses?

Material and methods: A focused ethnography was used, containing two approaches: First , participant observation was conducted to examine nurses’ and patients’ interaction with technologies. Observations were fixed in a field research diary and analysed using evaluative qualitative content analysis. Second , a questionnaire was used by nurses to provide information about the use frequency and technology suitability. The results of the study were consolidated and analysed using the UTAUT model.

Results: S even studied technologies can be summarised in four result categories: (1) A Mobilising mattress, a Special projector and a Sound pillow are accepted and used by nurses and patients, because they offer a way to provide high quality care with little additional effort. (2) A Fall prevention system is consistently used in patient care as a work obligation, but since nurses consider the system error-prone, acceptance is low. (3) An Interactive therapy ball is accepted but nurses cannot use it due to the high workload. (4) An App for nurse-patient communication and a work-equipment tracking system are not used or accepted because nurses do not see a practical benefit in the systems.

Discussion: Acceptance or rejection of a product does not necessarily equate to use or non-use of the technology. Before implementation, technology acceptance among users occurs as prejudice—when users are given time to experiment with technology, intention-to-use can stabilize into sustained use. Accepted and used technologies can serve to mask problems (such as staff shortages) and encourage problematic developments, such as the reduction of contact time at the bedside. Therefore, technology acceptance should be qualified in asking to what accepted technology contributes.

1 Background

1.1 nursing, technology and acceptance.

With the growing use of digital technologies in healthcare, new technologies become increasingly available for nursing in recent years. For this profession in particular, technology is one possible response to the challenges of an ageing population being cared for by a decreasing number of available professionals ( 1 , 2 ). Technology uptake in nursing care needs to accelerate to use the potential benefits of new technologies, and enablers and barriers related to technology implementation should be investigated and understood. Potential factors are numerous, e.g., a lack of fit between technology output and user need, inappropriate design for use needs, misguided implementation efforts or institutional limitations ( 3 , 4 ). These could have an impact on the use and acceptance of nursing technologies.

Behavioural intention or actual use of technology has been studied regarding the acceptance of nursing technology. However, while new technology is implemented, the user's perspective may change due to the occurrence of unintended or unanticipated consequences of technology use ( 5 ), the social and contextual influences of implementation or facilitating conditions. For instance, through getting to know a new device and getting used to its functions and abilities, a negative expected usefulness and ease of use may shift to a positive attitude and vice versa. More research is needed to learn how and why behavioural intention shifts to a sustained and accepted actual use or a disruption of use and rejection of technology.

1.2 State of research

The adoption of new technologies in nursing is related to various determinants of technology acceptance. In the case of tele-nursing and remote visual monitoring of patients, studies have indicated that while the technology may reduce the number of falls, the acceptance of technology may only be moderate ( 6 ). Similarly, in the case of mobile healthcare communication tools, it has been shown that promoting early adopters can significantly influence user's behavioural intention to use the technology ( 7 , 8 ). Similarly, in the case of mobile healthcare communication tools, it has been shown that promoting early adopters can significantly influence user's behavioural intention to use the technology ( 9 ). Users tend to favour mobile tools for inter-professional or professional-patient communication when tools are easy to use and efficient ( 10 , 11 ). For AI technology that improves decision-making, another study have found that technology acceptance may be high among nurses and other professionals if the technology incorporates professional expertise and evidence into decision-making ( 3 ). However, such a technology may be associated with fears of loss of autonomy and expected negative impact on clinical workflows ( 12 ).

Only some studies have investigated how and why the intention to use technology in nursing may shift towards accepting or rejecting it after implementation. One study in a critical care nursing unit has demonstrated in a pre/post comparison of technology implementation that self-concern and expectation for ease of use decreased for nurses after adapting the technology ( 13 ). However, concerns about technology's impact on practice and perceived usefulness increased at the same time (ibid.). Another study has investigated the implementation of a digital oral healthcare intervention in Norway. As users adopted the new technology, they gradually changed their mode of use from—what the authors described as—“norm-based to routine-based behaviour”, highlighting the relevance of familiarisation with technology and the corresponding shift of user behaviour ( 14 ). For tele-nursing technology, it has been shown that only the performance expectancy was significant for caregivers’ behavioural intentions. After introducing the technology, the facilitating conditions and the performance became relevant for caregivers ( 15 ).

1.3 Research project and research question

The “ Centre for Implementing Nursing Care Innovations ” study (Funding: German Federal Ministry of Education and Research, funding number 16SV7892K) aims to implement new technologies in a trauma surgery inpatient ward of a university hospital in Germany. After technology introduction, we investigate the modes nurses’ use technologies and how patient care and nursing processes will change during technology implementation. The research question is:

Which implemented technologies are accepted/rejected by nurses, and which factors influence the acceptance/rejection of these technologies?

We conducted an ethnographic study and evaluated and reported the results using the Unified Theory of Acceptance and Use of Technology 1 -model ( 16 ). The advantage of this model, which unifies eight separate models, is the provision of various explanatory factors that can predict or explain both the intention to use technology and the actual use ( 17 ). UTAUT conceptualises acceptance and use not merely as individual user decisions but places user behaviour and intentions in the context of institutional, organisational, and social environmental factors that may be influenced by mediating factors (age, gender, experience and voluntariness of use).

The study's implementation strategy allows to investigate how behavioural intention to use technology may shift to actual acceptance or rejection. Following Greenhalgh et al., this strategy involves two approaches: (1) We cooperated with the study hospital and managerial nursing staff to create institutional conditions for a successful and sustainable introduction of new technology to facilitate change of working structures (implementation) ( 18 ). (2) To select suitable technologies, we involved nurses from the study ward in a participatory manner by consulting them about potential technology and its usefulness (dissemination) (ibid.). For this purpose, we identified areas of nursing care on the project ward that could be supported with technical solutions—these areas involved, for instance, assistance with geriatric patients, dangers related to falls or pressure ulcers, inefficient patient communication or long walking distances ( 19 ). Based on these areas of need, the research project first took a closer look at potentially useful technologies and examined their implementability. For this purpose, an internal guideline was developed that included the IT perspective, nursing science, ethical, legal and social implications and the known study literature on the technology ( 19 , 20 ). Once the potential technical and organizational implementability of the technology had been confirmed, it was presented to nursing staff. In workshops, they reflected on their behavioural intention to use the technology within their daily working routine ( 21 , 22 ). If nurses showed their interest in using the presented technology and therefore articulated their intention to use it, the implementation of the product followed. Afterwards, the use of technology and patterns of acceptance or rejection has been observed. All costs that are associated with the purchase and maintenance of the technology were covered by the project budget as part of the research project. In the case of maintenance and repair work, the corresponding effort was shared between employees of the project station and the research project (see Limitations).

1.4 Overview of implemented technology in the research project

During the research and implementation activities, seven technologies were implemented and researched at the project ward, the technologies can be found in Table 1 .

Table 1 . List of implemented and studies technologies.

2 Materials and methods

2.1 study design.

The study used a focused ethnographic, multi-methods investigation with a distinct qualitative emphasis. Focused ethnography is suitable for investigating social fields with high degrees of professionalism and functional differentiation by studying the entanglements and interactions between individual actors, institutional processes, settings and technologies ( 23 ). A main goal is to investigate social and cultural processes that are implicit or difficult to articulate for those being studied ( 24 , 25 ). Compared to anthropological ethnography, the focused account is characterised by short field stays and an intense data collection phase ( 26 ). The following methods were applied:

1. Participant observation of nursing workflows to explore the use of implemented technologies and

2. Questionnaire survey to explore the nurses’ perspective on the usability of the implemented products.

The steps of data collection, processing and analysis are described in the following sections, an overview of the research design can be found in Figure 1 .

Figure 1 . Research Design.

2.2 Methods 1: data collection

(a) Participant observation

The observation aimed to follow professional nurses during their workday for several hours to explore work processes and interactions with patients and other nurses with the introduced technologies. The observation was carried out by the author RK and conducted as an “observer as participant”, which means that the observer role tends to be passive, yet transparent to all participants in the field. The choice of non-functional, everyday clothing and a restrained accompaniment was intended to keep the observer passively in the background while enabling the investigation of a native perspective of the observed concerning specific “situations, activities and actions” ( 26 ).

One of the members of the research project (not the observer and no co-author) acted as a gatekeeper to gain access to the field, as he also worked as a nursing professional on the project ward. In the course of the observations, it was possible to establish personal relationships with other nursing staff who allowed access to the ward to observe shifts. In terms of recruitment, all nurses were eligible to participate whom: (1) worked as professionally trained on the project ward, (2) were currently using a technology of interest, (3) would like to be accompanied and (4) gave written consent to be observed (see Ethical Considerations section).

At the beginning, fixed time points for the observations were set. However, this pattern needed to be adjusted, e.g., because some technology was not used for an extended period and then used intensively for a short period. These required spontaneous station visits outside the fixed observation pattern until sufficient information for each technology was gathers. Another way of achieving data saturation was to present and discuss the results with the nursing staff on the ward (see section Quality Assurance).

An observation guideline (see Table 2 ) with specific questions was designed to help the observer during the field stay ( 27 ). These questions were developed deductively from existing models on technology implementation ( 28 ), adoption ( 29 , 30 ), technology acceptance ( 16 ) and intention ( 31 )—the guideline is shown in Table 2 . The instrument was developed based on multiple theoretical starting points to integrate different perspectives on technology use. The categories were later integrated into the UTUAT model, which can also be found in Table 2 (see also 2.4, Methods III ). The guiding questions were discussed by the research team and field tested before its initial use—no changes were needed afterwards.

Table 2 . Deductive categories and guiding questions for the observational units.

During the field stays, handwritten notes containing summaries, situation descriptions, reflections and ideas were taken. After each observational unit, the observation questions listed in Table 2 were used to structure the writing of open-ended, chronological fieldwork diary entries that reflect observed situations in detail, reproducing dialogues, and characterising people, technologies and situations ( 32 ).

(b) Questionnaire-based survey on technology suitability

A technology suitability questionnaire was used to investigate the range of opinions of the nursing professionals. This instrument was used additionally to the observations, because the observation could only incorporate the views of individual employees (who were working at the times observed), rather than obtain the diversity of opinions on a technical product. Therefore, a questionnaire was used that descriptively included the respondents’ views on the suitability of the technology for use. Since no meaningful case numbers can be obtained on the project ward, the use of the questionnaire can only be classified as a supplement and contextualization of the qualitative results from the observation. This instrument was developed and used in another research projects ( 22 , 33 ). The questionnaire was provided to all nurses on the project ward for each implemented product. It contained four sections:

1. Three items on the general use of the product since its introduction (use yes/no, frequency of use and, reasons for not using the technology).

2. General questions covering usability, workflow, compatibility, functionality, product quality and patient well-being.

3. Questions specific to the technology covering power supply, alarms, screens, mobility, consumables, and reprocessing.

4. Further comments on the device to be entered in free text entries.

In the general and specific sections, the questions were answered using a five-point Likert scale from ’Strongly agree’ to “Do not agree at all”—or “not applicable”.

This is a measurement instrument for technology suitability and not an instrument from the field of technology acceptance/UTAUT research. Therefore, the findings of the suitability survey are classified under the UTAUT category of (observed) effort.

All nurses received the questionnaire for each of the implemented technologies three months after the first deployment of the given technology, either in workshops or in their mailboxes on the ward. In the case of using the individual post box, they were notified at the time of distribution and with a reminder by E-Mail. Due to the long implementation phase in the study, the number of employees on the project ward varied significantly, but on average 22 full-time staff are employed on the ward. However, this number varies, mainly due to staff shortages. As the study design was set up in such a way that only one ward was equipped with technology, the questionnaire could only be used in one setting and comparisons with other wards/settings were not planned in the study design (see also Limitations).

2.3 Methods II: initial data analysis

(a) Qualitative data analysis—evaluative qualitative content analysis

The entries from the open field research diaries and the free text entries from the technology suitability survey were analysed using evaluative qualitative content analysis ( 34 ). While applying this method, each deductive main code received a set of at least three sub codes for (1) a positive manifestation, (2) a negative manifestation and (3) a neutral or non-evaluative category ( 35 ). For example, the main code of “work integration” received the sub codes (1) “smooth integrated”, (2) “problems with integration” or (3) “other”—in this care, a forth sub code for ambivalent observations were also used.

The guiding questions in Table 2 were used to develop the main codes deductively. Only one inductive main code was added for “Expectations of new technologies”. Through this approach, a code system of main codes and sub codes (see Supplementary Data Sheet ) were developed that helped to organise the data material and to perform a pre-analysis.

(b) Quantitative data analysis

In the questionnaire-based survey on technology suitability, the answers to the second and third areas (general and specific aspects of the technology) were analysed quantitatively ( 33 ). For this purpose, the scores achieved by the technology in each area were first expressed as a percentage of the maximum possible score. These two percentage results were then weighted according to the number of items in each area, and an average, general value were given. If a technology achieved up to 49%, it is considered unsuitable ; if it achieved 50%–69%, it is rated as suitable to a limited extent ; and if it achieved 70% or more, the technology is rated as very suitable .

2.4 Methods III: data consolidation

Quantitative results were compared with the qualitative analysis of the observation data and the free-text entries of the appropriate questionnaires. The data collection and analysis was performed parallel rather than sequentially. We merged and compared the data to identify consistencies, inconsistencies or complementarities ( 36 ). The basis for data consolidation and analysis was the UTAUT model, initially presented by Venkatesh in 2003 ( 16 ). Four main categories are presented in this model:

▪ “ Performance expectancy is defined as the degree to which an individual believes that using the system will help him or her to attain gains in job performance.” (ibid.)

▪ “ Effort expectancy is defined as the degree of ease associated with the use of the system.” (ibid.)

▪ “ Social influence is defined as the degree to which an individual perceives that important others believe he or she should use the new system.” (ibid.)

▪ “ Facilitating conditions are defined as the degree to which an individual believes that an organizational and technical infrastructure exists to support use of the system.” (ibid.)

The use of the UTAUT model in our study served two purposes. (1) To arrange and summarise the results along these categories for transparent reporting. (2) To use a mix of qualitative and quantitative findings to explore how much influence each category had on technology use, acceptance, rejection, and adaptation. Therefore, the observation categories from Table 2 were assigned to one of the four main categories, which can be found in the same table. The survey results were assigned to effort expectance based on the construct “Suitability”. In our study, the UTAUT model was used to evaluate observed user behaviour (therefore “Observed Performance” etc.), not used to predict user intention or behaviour. The four mediators’ gender, age, experience, and voluntariness of use (ibid.) will be addressed in the results section if relevant to the reporting.

2.5 Ethical considerations

The research project was approved by the Ethics Committee of the Hannover Medical School on the 6th of July, 2018, ID: 7933_Bo_K_2018 (amended 16th of July, 2020). The procedure was reviewed by the hospital's staff council and the clinic data protection officer. The data protection-compliant processing of research results (above all with the aim of protecting study participants) was carried out in accordance with the guidelines of the University Hospital, above all with the help of lockable rooms in the case of hard copies and password-protected drives in the case of digital data. Raw data was only shared with research project participants, and patient care leaders were merely given access to analysed, non-personal, summarized data as required, making re-identification implausible.

The scheme for situationally appropriate privacy expectations was used to identify which individuals in the field should be asked for written consent to observation ( 37 ). Written informed consent was obtained from professional nurses observed during their shifts. Before giving their consent, nurses received an introduction to the study's goals and reasons. If possible, participants in the field were informed of the observer's presence, especially to patients when first entering the patient's room ( 38 ).

Nursing professionals who completed the questionnaire also filled out a written consent form. Sociodemographic data (such as years of professional experience or age) were not collected due to the small size of nursing staff to avoid re-identification.

2.6 Quality assurance

For the reporting on methodical decisions and processes in this paper, the COREQ-Checklist was used ( 39 )—all relevant information are provided in the dedicated section of the paper or in Supplementary Image S1 .

(1) Key observational findings on the impact of technology implementation were presented, discussed and again documented in dedicated validation workshops as a form of “respondent validation” ( 40 ). (2) The research team reviewed and discussed result plausibility and implications at periodic meetings internally and in external research workshops. (3) Parts of the results have already been presented regarding individual technologies and selective research questions at conferences ( 41 , 42 ). (4) The observed nurses were offered to read the diary entries after completing them; however, no participant used this offer. Coding and consolidation of the data material was performed independently by two authors (RK & DK) and then compared. Intercoder reliability was not numerically calculated.

Two independent data entries were made to ensure no errors occurred during the transfer. The main results of this survey were presented in the validation workshops to the nurses mentioned above. All results from the questionnaire survey were presented, interpreted and discussed within the interdisciplinary team of the research project.

3.1 Participant observation

Observations began in July 2020. New technology has been explored in 23 observation units, representing 38.5 h of observation time. The author RK conducted all observations. The average time of an observation unit is two hours. These observations resulted in 132 pages of field research diary entries. Member validation workshops were protocolled. The results of these data collections are summarised in this chapter. In the course of the participant observations, fifteen nurses could be accompanied on their shift. All but one of the nurses responded positively to be observed—the person who did not wish to participate has been omitted from all observational descriptions.

Table 3 provides an overview of the observations’ results on the implemented technologies reported by UTAUT's main categories. The boxes in the table are marked with colours and indicate whether the observation results for the corresponding UTAUT category are characterised as favourable for the use of the technology (green box), adverse and unfavourable (red box), or both positive and negative and thus ambivalent (yellow box). Categories with no effect are left blank.

Table 3 . Results of ethnographic observations analysed by UTAUT-categories.

3.1.1 (Observed) performance

The mobilisation mattress and the special projector provide a positively perceived performance from the point of view of nurses and patients. The mobilising mattress is frequently used on the project ward. The individual risk assessment for the development of pressure ulcers is not the sole deciding factor for whom, when and how the system is used:

While we walk to the next patient room, the nurse says that the mattress: “almost does not matter during the day”. She explains that many patients lying in the systems require intensive care anyway, such as patients with incontinence pads that need to be changed regularly. For these patients the mattress is advantageous at night because using the system helps position patients less frequently, and one needs to wake them up less often. […] Patients who suffer from much pain are an exception: People who have suffered trauma will experience less pain due to the system’s movement. (Field Research Diary_Mobilization mattress-BE04, p. 2)

Other nurses run the system on all patients and use the system’s pause function instead to perform interventions. The special projector is primarily used in patients with dementia or agitated behaviour in two different ways: One is to calm nervous patients and address challenging behaviour. The other way is by reactivating apathetic patients, in whom the use of the projector activates memories. According to the nurses, both ways can help improve care of these patients, making care delivery easier. The decision-making is biography-based or stems from getting to know the patients' behaviour. The special projector and the mobilisation mattress are often used together.

Technologies that have shown mixed and thus ambivalent performance in the ward are observed for the sound pillow, the fall prevention system and the communication app. The sound pillow functions according to its intended purpose, as the following situation description shows:

A mask for inhalation is placed on the patient’s face—the sound pillow lies on his chest. The nurse seems surprised and says this was not easy in the last few days because the patient kept pulling the mask off his face. The patient now seems sleepy—about 2 min pass. The patient gets quieter and finally almost falls asleep. The patient seems so calm that the nurse wants to leave him alone to return in 15 min. (Field Research Diary_inmu-BE01, p. 28)

Most patients lose interest in the technology after a few days due to its repetitive sound. Therefore, an actual benefit is limited to a time range that is shorter than the patient's hospital stay. For the communication app, situations are observed where patients send their requirements, nurses read them and can react according to the current workflow, for instance to take medication with them to the room. However, the app is rarely used since some nurses question whether the app makes a difference in everyday work. For the fall prevention system, it is observed that nurses respond immediately to a bed exit. However, the perceived performance of the system is low as users report frequent false alarms or missing alarms, resulting in low system confidence.

The nurse reports that the system was running overnight but did not activate even when the patient already stood in the room. (Field research diary_SaSe-BE01, pos. 9)

The perceived performance of the system for equipment tracking is low. The system proves to have no technical problems in practical tests, so non-use initiates from a lack of practical relevance for the users. Communication and teamwork among nursing colleagues to find equipment is easier to realise according to nurses.

The interactive therapy ball is rated as neutral regarding its perceived performance because users cannot operate the technology as intended (this will be explained in detail below).

3.1.2 (Observed) effort

Nurses perceive the mobilising mattress and the special projector as easy to use. Both systems are perceived to be reliable and supportive of work processes, saving effort on time-consuming tasks and helping cope with work process-related requirements. They are perceived as being easy to install and are considered part of daily work routines. The devices do not need to be operated constantly but can be used partly autonomously (in the background), as the following entry illustrates:

While documenting, the nurse said, “On days like today, the system is worth its weight in gold.” I asked what she meant by that. She explained that with the system, she could sit at the PC for as long to document. Repositioning the patient to prevent pressure ulcers would require her to interrupt her current activity regularly. I asked her if she was confident the system was doing a good job in the background. She confirmed this and said that it was a great relief. (Field Research Diary_Mobilization mattress-BE04, p. 3)

The nurses repeatedly emphasise that using the mattress and the projector does not mean patients are left alone for long periods and interactions between nurses and patients are not reduced. Instead, it changes the nature of the interaction by removing specific tasks perceived as unpleasant, such as positioning patients.

Positive effects and ease of use are identified with the sound pillow and the interactive therapy ball, but to a limited extent. Nurses evaluate that the sound pillow has a calming effect on patients. This calming effect, in turn, directly influences patient adherence to specific therapeutic measures and makes it easier for patients to cope with difficult emotions or pain. However, many patients lose interest in the technology after a few days of use. A patient can use the pillow without the constant supervision of a caregiver. For the therapy ball—that in contrast needs the permanent presence of a caregiver –, no sustainable use can be observed. Nurses and trainees use this device in a few instances and have positive experiences, but could not use it in everyday practice due to a lack of time. Therefore the technology's easing effect could not be realised under the given work organisation.

In the case of the communication app, the tracking and fall prevention systems, findings suggest that the devices require additional effort for little to no benefit . Nurses do not see any practical benefit for the tracking system. However, an expansion within the entire hospital could be beneficial. For the communication app, some nurses find the additional smartphone impractical in everyday practice, because they are not always within reach or their pocket are already packed with other items. While the fall prevention system is used in practice, nurses mention frequent technical problems, most of the users see the product as having little overall benefit:

The nurse currently has a patient lying in the fall prevention system. This patient has not tried to get up recently, but the system has been alarming at regular intervals. This makes the system unusable; she adds “You make an effort to set it up, and then it does not even work”. (Sound pillow_Fragment 01)

3.1.3 (Observed) social influence

Four of the introduced technologies positively influenced the interaction between nurses and patients. The three technologies for patients with challenging behaviour performed similarly in this area. Teamwork is performed merely when a nurse seeks advice from colleagues on selecting suitable patients. After that, the nurses work with the technology without further cooperation. The technologies have a positive impact on nurse-patient interactions, as the following two research notes demonstrate:

For the special projector, the nurse likes the forest-walk module. She had a patient with dementia who used this module and, while watching, tried to find out where the shots might have been taken. (Special projector_Fragment_01, pos. 13)

The nurse had a night shift, and a patient could not find rest and walked around the room for several hours. She gave him the sound pillow. After that, the patient slept soundly for hours. (Field Research Diary_Communication app _BE02, Pos. 5)

Nurses also emphasise a module that displays a night sky with shining stars that is selected for patients to fall asleep at night. Nurses say that the calming and activating use of the sound pillow and special projector enable easier interaction with these patients and fewer challenging situations and conflicts. While using the mobilizing mattress, patients find better sleep than those who have to be woken several times during the night for positioning. Nurses describe that sleep improvement also improves relationships with patients.

An ambivalent influence of technologies on the social interaction of users is found in the fall prevention system and communication app. The fall prevention system does not directly affect the relationship between nurses and patients. Although patients are repeatedly surprised that nurses quickly enter the room when they try to stand up. Repeated technical problems, malfunctioning components, or the system installation lead to negatively perceived collaboration between nurses. The mediator category voluntariness of use explains why the product is frequently used on the project station. It seems plausible that the nursing supervisor requires the system to be used for liability. This factor is part of why the device is frequently used, but the overall satisfaction is low. While the Patient-nurse communication app is used, some patients particularly emphasising the benefit of additional information, such as how long they must wait for a response. The following conversation is observed between a nurse and a patient:

A feature of the app that both consider useful is task prioritisation. Both talked about how it can make sense if you know that a request such as “close the window” occurs in one room and “severe pain” in another. Both agree that it is good to process first the pain and then the window request. (Field Research Diary_Communication app_BE01, Pos. 21)

For other patients, the app has no advantage because the waiting time does not change. In addition, nurses are cautious in selecting the appropriate patient to use the app. They are concerned about low-skilled patients who send requests by accident. Others fear that the app suggests professional nursing to the patients as a (hotel) service.

None of the technologies introduced have an overall negative impact on the users’ social relationships. Regarding the tracking system, nurses find no support for the technology because communication between colleagues is more effective. Therefore, the social factor is still a robust explanatory category for non-use of technology.

3.1.4 (Observed) facilitating conditions

For the special projector, the sound pillow and the mobilisation mattress, sufficient resources for using the technologies—like technical infrastructure—are provided. Therefore, no conflicts about too few devices are found for these technologies. All nurses receive detailed training for these devices. The mobilising mattress had a problematic feature at the beginning that deactivated the system if the patient raised the head of the bed by more than 30 degrees. This often leads to unintended deactivation by patients. After consultation with the manufacturer, the limit was elevated to 50 degrees. Since this update, nurses reporte fewer problems. The sound pillow and the special projector are easy to integrate into existing facilities. All three systems can be cleaned with the regular disinfectant on the ward and no severe technical malfunctions are reported.

For the tracking system and the communication app, the findings indicate that facilitating conditions have both positive and negative influences on the use of technology. Although nurses receive training on how the technologies work, in practice, there are regular uncertainties about use. The tracking system and the communication app run mostly without technical problems. The wi-fi coverage on the station is sufficient to provide both services most of the time. In a few instances, there have been examples of the tracking system showing the wrong location of the tracked equipment:

The nurse says there was an incorrect location in the system for an electronic rail. He says that it was indicated in a different room than it was. […].The access points are installed too close to each other […].’ (Field Research Diary_Communication app_BE02, item 31)

Nurses suspects that messages from the communication app sometimes do not get through in real-time. For patients, there are currently no input devices for the app on the ward so patients must bring their smartphones to use the app. Nurses must explain the downloading and functioning to patients if they require assistance. The nurses receive this point critically since they have no time to train patients. For this reason, nurses select patients in particular by anticipating their technical abilities and patients must be motivated to use the app.

The technical and organisational conditions are limiting factors for the therapy ball and the fall prevention system:

“I have no time for [the therapy ball]. An everyday companion would have time.” “I dealt with it once and then I knew how it worked, but now I have already forgotten about it.” (Protocol of member validation meeting, June 2023)

Hence, the device's menu navigation is seen as complicated. The nurses would like to use the therapy ball and would enjoy working with it but do not see the time for this. The fall prevention system exhibits system errors and false or outstanding alarms that hinder its use. Caregivers repeatedly report that the device's correct installation and operation is complicated, resulting in uncertainties.

3.2 Technology suitability from nurses’ perspective

The survey on technology suitability could be conducted on all technologies. The results can be found in Table 4 .

Table 4 . Results of the suitability survey by nurses that used implemented technology.

The number of participants varies because the average number of nurses working on the project ward varied during the research project and not all nurses participated in the survey. Similarly, not every technology was used by all employees; in particular, temporary workers often stated that they had not used the technology due to short training periods on the ward. Other people also stated informally that they did not have time to complete the questionnaires during daily work. For these reasons, the number of participants in the surveys varied from five to twelve employees (as described above, an average of twenty-two people work on the ward at full-time employment).

The comparison between the observational results and the standardised survey shows a coherent picture. The technologies are described as easing and beneficial (mobilisation mattress and special projector) are also evaluated positively. In contrast, the ambivalent (sound pillow and therapy ball) and unfavourable technologies (fall prevention system, communication app, and tracking) receive mixed evaluations. The frequency of use is also consistent to qualitative results; The technology that stood out in the observations as accepted and used received a higher frequency in the survey, like for the mobilization mattress (used daily or multiple times a week).

3.3 Summary of results

A summary of results can be found in Table 5 . The results are consistent with the observational data and the survey on technology suitability.

Table 5 . Summary of results according to use and acceptance.

4 Discussion

4.1 how accepted and not used technology can (not so easily) be distinguished.

The observation results of the study were summarised along the four main UTAUT categories and the positive, negative or ambivalent influence on technology acceptance per category per product was identified. These results can be compared with the technology suitability survey, which provides information on the assessment of nurses and the frequency of use. But how to answer which technology was used, which was not and how to distinguish the influencing factors as enabling or hindering factors?

The conclusion of whether a technology was accepted or rejected cannot be based solely on the positive, negative or ambivalent results of individual UTAUT categories, because this would confuse the phenomena to be explained (explanandum) with what it is explained by (explanans) ( 43 ). Until the outcome of the implementation process is uncertain, classifying the influential factors from the UTAUT categories in the implementation process is unattainable. At this point, frequency of use could be utilised as a proxy for general product acceptance but little data could be collected on this. In addition, a technology may be highly accepted even though it does not need to be used regularly.

To solve this problem, we use ethnographic sensibility. This term refers to a feeling or impression towards the ethnographic , i.e., the lived and experienced reality in the research field, about its “complexity, contradictions, possibilities, and grounds [for the observed] cultural group” [( 44 ), see also ( 45 )]. This sensitivity was gained by the observer over years of field research activity and enables knowledge about the users’ general attitude towards the technologies, which was needed to situate the results eventually.

The above presented summary of four result categories leads to the follow consequences:

(1) A predominantly positive influence of the technology in terms of the UTAUT categories (see Table 3 , green fields) strongly indicates that the technology is used and accepted.

(2) Use and acceptance cannot be equated. The fall prevention technology—acceptance low, but regularly used—and the interactive therapy ball—high acceptance, but not used—shows that these outcomes do not have to exist simultaneously.

(3) The occurrence of more than one origin of negative and ambivalent influence of the technology (see Table 3 , red and yellow fields) strongly indicates that the technology is not accepted or used regularly.

(4) The main categories of the UTAUT model can be a strong indicator for explaining technology acceptance. However, they should be distinct from explanatory factors because factors like perceived usefulness or ease of use occur within broader socio-technical constellations and contexts of actualised technology use ( 46 ). Explanatory power unfolds with an understanding of the use context. This context was approached in our study by using ethnographic sensitivity.

To conclude the four consequences, it takes more than adding variables to predict user acceptance towards technologies. Instead, acceptance emerges as the result of complex socio-technical arrangements in which users must convince themselves of the benefit of technology for their actions by constantly trying, failing and succeeding.

4.2 Intention to use technology must be stabilized by experimenting

Some expectations users set regarding a technology's usefulness were not met after implementation. The intention to use technology indicates a necessary curiosity that motivated the start of technology use. However, this is no guarantee that a sustainable technology acceptance will occur. Users take cautious first steps in using novel technologies when familiarity with and skill to use technology still needs to be established. In this initial, critical experimentation phase, users renegotiated attitudes toward the technologies through positive or negative experiences.

On the one hand, unanticipated adverse effects—such as frequent false alarms—could change a high expectation into scepticism or reservation ( 5 ). On the other hand, surprising or hoped-for effects that turn out to be true could result in positive attitudes among users. This was frequently observed, for instance, when nurses asked whether they could be supplied with more system mattress, sound pillows or special projectors to cover demands.

Different users face the introduction of technologies with different skills and prior experience and with varying degrees of optimism or scepticism. Age and experience as mediator variables in the UTAUT model provided a valuable orientation for our analysis. However, introducing a helpful technology can transform existing work conditions, changing how a work field and a social reality functions ( 47 ). While the different preconditions among users may provide clues to different levels of acceptance and rejection, a helpful technology can change these preconditions among users [for the case of generalised distrust among nurses towards technology, see ( 48 )]. Thus, it is more plausible to assume that a rejected technology does not bring any actual benefit instead of assuming a primordial attitude of rejection among users who would not give valuable technologies a chance (and vice versa).

4.3 Acceptance may not be sufficient

Our results show that four technologies—the mobilising mattress, the special projector, the sound pillow and the fall prevention system—offer a way to mitigate the high demands of a professional nursing work environment that is increasingly characterised by staff shortages and a growing number of multi-morbid patients. The other three technologies—the tracking system, the communication app and the therapy call—could not meet these demands. From an acceptance perspective, this can be understood as fulfilled or unfulfilled device performance expectations.

Alternatively, these results can also be explained by the fact that the successful technologies can be operated in a background mode. A “background relation” between a technology and a user can be explained by a device that the user does not continuously operate—i.e., it works in the background—but nonetheless shapes the environment and the user's experience ( 49 ). A background technology does its work without the need for permanent operation. Solely in case of a malfunction, users are reminded about its importance and have to act in an effort to repair it—an example would be an air conditioning system. It is opposed to a technology that requires the user's constant input.

The features of the mobilising mattress, the fall prevention system, the special projector and sound pillow can be utilised without constant manipulation and nurses’ presence, which makes them handy on stressful workdays. The communication app, the tracking system and the interactive therapy ball cannot be used similarly. For the therapy ball, for instance, nurses emphasised that the permanent input needed for the system’s operation is the reason they were not using the system after all.

However, when viewed from the perspective of patients, the background characteristic is problematic. After all, this implies that patients receive parts of care by technology. For instance, in the case of the mobilising mattress, re-positioning a patient to prevent pressure ulcers is not executed by a human but by the technical system, changing the caregivers’ task from an active part of doing the reposition to the passive part or controlling the technologies output. At the same time, nursing action as interaction work consists of more components than executing a nursing care action ( 50 ). As such, it also consists of emotional and sentimental labour, in which the nurse can recognise the patient's needs through interaction and communication with them and then react based on these encounter (ibid.).

The mere adoption of tasks by technology is no evidence of less social interaction between professionals and patients—also we did not collect data on contact times. However, technology that is successful because it is usable in the background may eventually reduce opportunities for interaction. The evidence of successfully implemented technology that supports nurses in managing their increasingly demanding workday under staff shortages might indicate that technology is accepted because it enables them to continue working under problematic conditions. Implementing technology may therefore reinforces problematic developments (more missing human resources) rather than questioning it. For this reason, looking purely at acceptance as a measure of successful use of technology in care may fall short. Instead, the potential change in the levels of interaction and resonance between nurses and patients caused by technology use would be a possible outcome for qualifying technology acceptance ( 51 ).

4.4 Limitations

 (1) Effects were primarily perceived by the observers and the perspective of the observed is only described from “outside” No interviews were conducted—at the time of reporting—to involve the individual perspectives. However, at least in their validity, results could be discussed and confirmed with nursing professionals.

 (2) The results from the questionnaire are subject to substantial limitations since participation varies to a high degree.

 (3) The study's argument is based on the assumption that, due to a participatory introduction process, only those technologies found their way onto the ward that the nurses also desired. However, it was impossible to verify whether this assumption could be applied to all nurses.

 (4) The narrow patient population on the project ward influenced the selection and the use of the technologies. In the example of the communication app, little benefit for the nurses could be seen because too few patients had the skills to use an app. In this respect, the (qualitative) transferability of the results to other clinical settings is limited.

 (5) Patients’ perspective is marginally represented in this paper because patients in the case of the project station are mostly passive technology users or beneficiaries and have no direct experience with the devices or cannot verbalise this, for example, due to dementia.

 (6) All costs associated with the acquisition, operation, malfunction and repair of the technologies were covered by project funds. Therefore, the transfer of interpretations to other health care settings is restricted, particularly in terms of (sufficient) resources. In other health care institutions, for instance, budget restrictions could trigger negative usage effects. The German healthcare system continues to lack sustainable, cross-setting and comprehensive solutions for financing innovative technologies. The same applies to the amount of work required for maintenance, servicing and in the event of malfunctions and repairs. In non-research settings, this must be carried out by employees and can have additional, negative consequences for the use of innovative technologies.

 (7) The decision to equip one ward with technology in the course of the implementation activities was designed to achieve a summative (qualitative) effect through the combination of different technology approaches. Although this decision enables the investigation of interaction of technologies in one setting, it disqualifies cross-setting comparisons of the effect of technology.

 (8) The seven selected systems are not integrated into existing hospital IT-systems—either because they have their own technical infrastructure (e.g., the app for communication or the tracking system) or because they do not need to communicate with other systems. This limits the implications of the study through the selection of technologies, as it was not possible to make any statements about the usage effects of interoperable systems and their advantages and disadvantages. The decision in favour of isolated solutions was made due to closed hospital IT systems that did not allow the installation of integrated systems.

 (9) A direct calculation of the frequency of technology use (e.g., how often nurses used technologies or on how many patients the technologies were used on) was not achieved. The main reason for this is that it would only have been possible to count on site, but the research team could have not been permanently on the side and the nursing staff refused to document the frequency of use due to a lack of time. For this reason, the feedback from the observation and validation workshops and the corresponding item in the written survey were used. Although these are merely indications and no hard figures, they are not of primary interest in the context of the research question, as the aim is to identify qualitative reasons for use and non-use.

(10) The influence of the mediator variable gender cannot be systematically evaluated in this study, as most employees on the ward are female. However, a direct comparison of the data with the few (three to four) male nurses does not reveal any relevant differences in use patterns or attitudes toward technology.

5 Conclusion

In the research project “ Centre for Implementing Nursing Care Innovations ”, we explored the implementation and use of seven technologies intended to support nursing care in a hospital-based trauma surgery ward. The question was investigated which of these technologies are used and accepted or not used and rejected and which factors are responsible for this.

A Mobilising mattress, a Sound pillow and a Special projector were accepted and used, whereas a Fall prevention system was used but technology acceptance among nurses were low do to a perceived low technology quality. A system to track work equipment and an communication app for patients and nurses were neither used nor accepted because users were not able to find a suitable use case, whereas an Interactive therapy ball was accepted among nurses but work condition prevented its application.

The following practical implications can be drawn:

▪ The finding indicates that acceptance of a technology should not be confused with the use of a technology. The technology might be used but acceptance is low, if, for instance, the use of the product is expected as a work obligation. In this case, users may find the technology not helpful and sustainable transfer of technology in routine practice is weak. Likewise, a technology may be accepted and users would like to transfer it into routine practice but circumstances hinder its use. In this case, an institution should facilitate chancing working conditions if the technology is desired.

▪ The categories of performance, effort, social influence, and facilitating conditions provide a practical analytical approach to identifying acceptance or rejection factors. However, they merely provide indications of actual usage and acceptance patterns. The analysis and thus the understanding of the context of technology application itself is necessary in order to be able to classify and qualify overall acceptance.

▪ Experimenting with technology stabilises the intention-to-use into a sustainable use of technology that is adapted to the application context. If users do not find a way to transform this intention into a helpful benefit or if negative unintended or unanticipated consequences emerge, acceptance of the technology remains low. Intention-to-use is not a solid characteristic among users. Users should be given the opportunity to experiment with a new technology to stabilize an intention to use.

▪ In the practical field of nursing, the outcome of technology acceptance should not be viewed simply as the realised use of technology but rather against the background of whether nursing tasks and goals have been achieved through the use and acceptance of technology, such as the improvement of emotional, sentimental and interactive work between nurses and patients.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Ethics Committee of the Hannover Medical School. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

RK: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. U-VA: Conceptualization, Data curation, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. DK: Data curation, Formal Analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. M-LD: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article.

The study was funded exclusively by the German Federal Ministry of Education and Research, 16SV7892K. All material costs for technologies involved were purchased using these funds.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fdgth.2024.1330988/full#supplementary-material

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Keywords: ethnography, technology acceptance, UTAUT, participant observation, nursing care, implementation, technical innovations, Germany

Citation: Klawunn R, Albrecht U-V, Katzmarzyk D and Dierks M-L (2024) Beyond technology acceptance—a focused ethnography on the implementation, acceptance and use of new nursing technology in a German hospital. Front. Digit. Health 6:1330988. doi: 10.3389/fdgth.2024.1330988

Received: 31 October 2023; Accepted: 11 April 2024; Published: 25 April 2024.

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© 2024 Klawunn, Albrecht, Katzmarzyk and Dierks. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ronny Klawunn [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Article contents

Ethnographic methods for researching innovative education.

• Karen Borgnakke Karen Borgnakke Department of Communication, University of Copenhagen (UCPH)
• https://doi.org/10.1093/acrefore/9780190264093.013.542
• Published online: 29 July 2019
• This version: 18 October 2023
• Previous version

Ethnographic research in innovative education settings has shown the practical impact and conditions on both research and professional development of curriculum and teaching strategies.

Following the process of innovation in the educational sector, themes that are high on political and institutional agendas have included “information technology–enhanced learning” and currently show how organizational and pedagogical development also becomes a matter of digitalization. In online learning projects the curriculum development and the process of didactization are already digitalized and refer to the new digital learning culture.

Ethnographic methodology enables ongoing interpretation of educational development as reflected by professionals and teacher teams, thereby facilitating elucidation of changes and consequences. The general question can be expressed as follows: How can innovative education, associated online and/or offline learning processes, embedded digitalization, and the context be understood, described, and explored in a practical sense?

Against this background, ethnographic research is challenged to go beyond the rhetoric to explore the practical implications of the innovative process and associated discourse. The challenge has been approached in terms of research facing the innovative practice and renewing the ethnographic approaches across the spectrum from the policy and organizational levels to practical learning-level investigation. The challenge is also embedded in research contributing to mapping the field of practice or "mapping the paradigm” and cross-case studies covering different learning contexts.

The common highlighted theme is that changes in educational systems and practices are necessitating changes in ethnographic practices.

• innovative full-scale projects
• ethnographic fieldwork
• digital culture
• multisited studies
• authentic complexity
• mapping the field of practice
• institutional ethnography
• ethnography in learning
• ethnographic methodology

Updated in this version

The title of this entry changed from the previous "Ethnographic Methods for Researching Online Learning and E-Pedagogy." The author has updated the text to include the impact of more recent events on the topic.

Facing the Main Challenge, Full Scale

In this article, ethnographic studies of innovative full-scale initiatives exemplify how the challenges for research include navigation in what can be regarded as experiments in the digitalization of educational institutions. In these experiments, all parts of involved organizations, at every level (school leaders, teacher teams, and students), are affected by, and must respond to, digitalization.

The main challenge seems to be posed by the new orders of magnitude. Initiatives range from the establishment of upper secondary information technology (IT) schools crammed with technology from cellar to ceilings ( Borgnakke, 2012 ) to online nursing education programs providing net-based teaching and learning from start to finish ( Borgnakke & Lyngsø, 2014 ). Digitalization affects not just one class, module, or academic subject but whole educational courses, full scale. When addressing the new full-scale magnitude of these experiments, it is necessary to consider not only a school or sector but trends and demands concerning the educational system as a whole. In such innovative and practical applications of the technologies, researchers can observe how the Internet, websites, and learning platforms become everyday tools for professional development of curricula and teaching strategies. Case studies and analyses also show how digital literacy or technacy of leaders and teacher teams is regarded as crucial for development of schools, education in general, and contributions to digitally oriented transformation ( Borgnakke, 2011b , 2017b ). Furthermore, shifts between the positions of educators as “teachers” and students as “learners” are also posing challenges in terms of description and understanding. As shown in close-up analysis ( Borgnakke, 2012 ), the digital literate teachers’ and students’ roles and action repertoires must be described both as innovative IT-based and as conventional school-based. In the IT-based classroom, there is a double logic to be understand before ethnographic research can conceptualize the learning context in a practical sense ( Borgnakke, 2021 ).

As discussed by Biesta (2005) , the political discourse and “new language of learning” prevail in connection with the learning industry the modern educational positions. These positions are by critical analysts regarded as the dominant, but narrow technical and instrumental argument for information communications technology (ICT)–oriented learning ( Haugsbakk & Nordkvelle, 2007 ; Player-Koro, 2012a ). Further, the scale is widening, as broader socio-techno-politico-economic changes are necessitating critical reflections on the pedagogical issues arising from the increasing virtuality of the social world ( Shumar & Madison, 2013 ). This is manifested in reflections on “the digital ages” and a challenge for attempts to understand technology-saturated society and its new media as a digital culture, or set of subcultures ( Coffey et al., 2006 ; Dicks et al., 2005 ). It is also manifested in studies of issues associated with distance learning in medical education ( MacLeod et al., 2015 ; Tummons et al., 2015 ) and development of bachelor’s and master’s degrees in dentistry and nursing ( Gwozdek et al., 2011 ; Lyngsø, 2019 ; Springfield et al., 2012 ).

This background highlights the necessity of coping with both digital learning culture in a broader sense and digital technologies as learning tools in a narrow sense. At the same time, educational ethnographic researchers are challenged to go beyond the political and educational rhetoric to explore the practical implications and associated discourses ( Borgnakke, 2015b ).

When ethnographic researchers try to meet the challenge, the basic concepts of “the field, the context and the space” ( Borgnakke, 1996a , 1996b ; Marcus, 1995 ) have to be renewed without losing the classically ethnographic approach to fieldwork ( Hammersley, 2006 ; Hernández et al., 2013 ; Webster & Marques da Silva, 2013 ). However, at the same time, in this article I also stress the necessity of moving beyond place-based ethnography. Leander and McKim (2003) identified this need and developed ethnographic methodologies for following the “moving, traveling practices of adolescents on- and off-line” (p. 211). The cited authors questioned not only conventional ethnographic approaches to issues such as place, identity, and participant observation, but also what they called “a common misconception of the Internet” as being radically separate from everyday life. Methodologies are underlined as ways of following connections and circulations in research “that travel across online- and offline spaces,” “tracing the flows of objects” and the multiple contexts. Tracing the flows of objects embedded in multiple contexts is important but not new.Indeed it is already integrated in the basic ethnographic framework (e.g., Borgnakke, 1996a , 1996b ; Marcus, 1995 ).

Accelerating e-pedagogical developments have made Leander and McKim’s observations, published in 2003 , increasingly salient. Ongoing projects mapping academic and profession-oriented learning contexts, have clearly confirmed that the Internet is no longer radically separate from everyday life, but a highly integrated element of everyday life at school, work, and home ( Borgnakke, 2015a ). For example, fieldwork in a project called NET education, designed to develop full-scale, innovative digital education in nursing (at VIA University College in Denmark) has shown that students are using the NET educational platform on a daily basis, integrated in both school settings and their own homes. They are also adding their own daily routines, using resources including combinations of the Internet, digital platforms, and mobile phones, for both working on their own assignments and networking with fellow students ( Lyngsø, 2019 ).

In a broader sense, the daily routine for teaching and learning is confirmed as a mix of media used in situations that can be conceptualized as “mediated” ( Hjarvard, 2008 ) and as a mix of online and offline situations where the flows of texts and multimodalities are in use ( Borgnakke, 2015a , p. 14). If daily situations are highly technologized, as shown by fieldwork in Danish IT-upper secondary schools, digitization permeated all didactical teaching and learning phases, from curriculum planning to course monitoring and evaluation ( Borgnakke, 2011b , 2012 ). In these cases, daily school routines are performed like living digital school life. . In other cases , the technologization is only high in specific professional training activities as observed, for example, in studies of cases in the healthcare sector. ( Borgnakke, 2016a ). In such cases, a physical space is set aside for mixed-media suites of “simulation-based learning” and the wide spectrum of IT-enhanced learning situations can be observed and related to the participative integration of students in healthcare teams and clinical practice. Borgnakke (2016a) analyzes this as an example of a mixed-media professional learning platform in a case study, called Case Canada.

Descriptions of the observed mixed-media situations as blended learning provide a needed overview of learning situations. Next, portraying the serial use of technological tools and platforms are important for rigorous ethnographic fieldwork and analysis. However, analysts of IT-enhanced platforms for either teaching or professional training in higher education face the same challenge: how can we conceptualize the platforms in practical use and contextualize the learning situation in terms of its authentic complexity?

I use the term “authentic complexity” in both general and specific senses. Generally, I suggest that we conceptualize learning as suchas learning processes situated in a practical (educational/work/professional) context. In an ethnographic study, the authentic complexity of this practical context is described in terms of (for example) “an ordinary day in the clinic,” by observing nursing students (and/or other participants) in their clinical practice ( Noer, 2016 ). “An ordinary day in the clinic” is filled with use of various healthcare technologies, procedures and interactions with other professionals and patients. It is, of course, also filled with different professional demands and positions as well as with emotional reactions. However, whatever the actors (or fieldworkers) choose to describe as embedded in “an ordinary day in the clinic,” it is still a part of “the authentic complexity” of the everyday context.

For example, a key element of the educational program at The Art Institute in San Francisco was “learning by participation in authentic artistic communities,” as highlighted by the program leader in an interview ( Borgnakke, 2013b , pp. 40–42). Another example is related to the previously mentioned Case Canada, where the claimed “necessity of authentic complexity” was encapsulated by Dierdre Jackman in an interview regarding the Rural Medical Care project ( Borgnakke, 2016b ). 1 She stated that you can have the best simulation technology, but “Unless you give them [healthcare students] the lived experience [of clinical practice] it makes no sense” ( Borgnakke, 2016b , p. 7). From an ethnographic perspective, this provides a crucial reminder of the need to consider what IT-enhanced profession-oriented learning means in the practical context.

In relation to case studies in which IT-enhanced organizational frameworks are investigated, we are confronted with a mixed-media blended strategy already integrated in the organizational development of online learning. This means that both the group of teachers, students and researchers worked within thecommon framework, coping with innovations as digital everyday conditions ( Innovation og Uddannelse, 2016 ). These are characteristics of the current innovative context, but as Hammersley (2006 , 2018) points out, ethnography follow processes of developmental changes in response to (blends with and follows) developments. Thus, developments in their investigated contexts become characteristics of ethnography too.

From an organizational perspective, the ethnographic framework encompasses the complex sets and interactions of policy, innovation, and e-pedagogical practical issues. Hence, ethnographic methodology must cope with the aforementioned double logic between IT-based and conventional school-based teaching and cope with embedded new conditions that teaching as a process of didactization also is a process of digitalization ( Borgnakke, 2021 ). In addition, it must cope with different political and institutional agendas and, as stressed in field studies of national and sectorial educational programs, with multiple interacting micro- to macro-level implications ( Borgnakke, 2010a , 2010b ). Policy and educational developments are no longer aimed at single schools or innovative interventions but rather at whole sectors across institutions, schools, and professionals. Thus, there are full-scale practical consequences (across the spectra of levels), and corresponding adjustments of ethnographic approaches are clearly required (as discussed in the special issues Seminar.net, 2015 ; Innovation og Uddannelse, 2016 )

Summarizing the main challenge for ethnographic methodology, there is a need to clarify and to understand the double logic and the full spectrum of developments, their interactions, and the meaning of full scale in late modern educational terms. In terms of analytical strategies, empirical overview and detailed close-up analysis are required. In general this means thatethnographic methodology capable of responding to “the new orders of magnitude” is required, sharpening thick descriptions of the field with critical discourse analysis and analysis of the learning practices. Let me therefore start the clarification by reiterating that the basic aims and traditions of ethnographic educational research are oriented toward practice, as manifested by action research, ethnographic education research, micro-ethnography, and classroom research (see, e.g., Beach et al., 2003 ; Borgnakke, 2013a ; Greenwood, 2009 ; Greenwood & Levin, 2007 ; Hiim, 2007 ; Klette, 1998 , 2007 ; Larson, 2006; Lindblad & Sahlström, 2003 ; Nielsen & Nielsen, 2005 , 2006 ).

Returning to Research Traditions Oriented Toward Practice

To understand practice orientation as a common feature, it can be emphasized thatresearch background and referenceshad interdisciplinary origins and practice-oriented aims. For example, in action research, rooted in Kurt Lewin’s thoughts and sociopsychological concepts, the American pragmatism propounded by Collier and Dewey, or the anthroposociological approaches pioneered by Foote Whyte, both the research strategy and object are strongly practice oriented ( Nielsen, 2012 ). This also applies to Scandinavian “critical classroom research,” where research is linked with strategies for experimental and development work, maintaining constant focus on practice and exploration of “what is happening in the inner world of classrooms” ( Borgnakke, 2013a ).

Tradition-rich lines of Scandinavian contributions to ethnographic methodology and theory have also been informed by critical theory and the research strategy propounded by Habermas (1968 , 1981 , pp. 548–593). Subsequent extensions include the critical constructive action research strategy described by Klafki (1977 , 2002) , a major aim of which was to remain “close to the school practice”.. The objective of this practice-oriented strategy was D evelopment of a critical constructive didactic , as stated in the title of a seminal article ( Klafki, 1977 ). In Klafki’s research, the classroom research tradition was maintained side by side with the Habermas-inspired tradition of ideology-critical strategies for empirical analysis. This strategy has also been applied in critical communications analysis ( Borgnakke, 1996a , 1996b ; Mortensen, 1972 , 1976 ) and can be considered a precursor to critical discourse analysis ( Fairclough, 1995 , 2005 ). Another seminal theoretical contribution, by Engeström (1996) , focused on corporate development work and was strongly inspired by works of Lev Vygoytsky. Engeström’s work has informed action research addressing not only the education system but also business organizations, and organizational development more generally.

The cited research programs are not recalled simply to confirm the orientation toward practice and treatment of practical issues in previous decades. Rather, they are recalled to emphasize the need to broaden current orientations in empirical, methodological, and analytical senses. Klafki´s conceptualization of research challenges the narrow foci of current political agendas, such as “ICT and learning,” “learning styles,” and “class management.” Further, it reinforces the requirement to reestablish critical basic empirical research, encompassing the whole school environment and organizational development.

To renew Klafki’s critical constructivism in empirical research, the new broader spectrum of ethnographic methods and field studies must be applied. Furthermore, in educational ethnographic environments, interest in participating in the production of knowledge of “what works,” a key concern in political circles, can also be traced. In this context, interest is seen in efforts to develop so-called meta-ethnography in the form of empirical cross-case analyses, with results and practice-oriented contributions of practical value for politicians, administrators, and policymakers ( Borgnakke, 2017a , 2021 ; Noblit & Hara, 1988 ; Uny et al., 2017 ; Hughes & Noblit, 2017 ).

Against this background, interest in research-based evaluation has been expanded, but methodical needs have arisen to implement case studies and empirical analyses at both the educational policy (macro-) level and practical, pedagogical meso-/micro-levels. Moreover, innovation and implementation of the new technologies are already important parts of the educational system’s “own experiments”. That range from the emergence of new learning resources to full-scale innovative institutions, like the Danish upper secondary IT schools and online learning–based professional bachelor’s degree programs.

The full-scale development efforts have a characteristic implementation process. Involving school leaders, faculties, teacher teams, and students, the common orientation toward practice is matched by an orientation toward practical implementation by different parties at different stages of work on curriculum design, teaching, and learning strategies. This reveals complexities that often can be missed in narrow analysisof specific issues or components . In the process of implementation all are part of the authentic complexity (to use the previously mentioned formulation), which cannot be properly grasped without considering the broader contexts.

Research being “oriented toward practice” is no longer sufficient, as there is a clear need to explore the practical processes, and different organizational levels and multiple actors simultaneously. Hence, there is a move from orientation toward practice to being consistent with the aim of exploring the field of practice , recognizing that “practice” and “practical actions” are continual processes at multiple organizational levels.

With such examples, the field of practice recalls the need for what has been characterized as multimethods and called multisited ethnography in research literature since the 1990s. However, regardless of the focus, the basic phrase “oriented toward practice” still requires clarification in terms of concepts, combination of methods, and framework. This clarification represents a new (or perhaps, more strictly, ongoing) challenge for ethnography. In attempts to meet it all, the fundamental ethnographic principles and methods are still applied, but they need to be (and are being) renewed and broadened as underlined in an overview by Beach (2017) . Therefore, let me follow this section on lines of traditions with examples of how ethnographic researchers have responded to the renewal of traditions and conditions.

Ethnographic Methodology Renewed, but Still Focused on Field and Practical Context

In the process of methodological development, ethnographic methods in recent decades were expanded but still closely related to the classical approaches. For example, although the Malinowskian tradition was criticized and renewed, it was still commonly referenced in the research literature, both in anthropology, social science, and cultural sociology generally (e.g., Marcus, 1995 ; Willis, 2000 ) and in specific research areas like education (e.g., Borgnakke, 1996a , 1996b ; Hammersley & Atkinson, 1983 ; Spindler, 1987 ; Walford, 2008 ; Woods, 1996 ). Looking back at these examples, despite differences in cited research, ethnographers engaged in a continuous dialogue about the basic methodological principles. These were highlighted as the principle of contextualization, exploration of the field, and the tradition of “long-term fieldwork.” These authors described and/or cited both new interpretations and new clarifications. For example, smaller formats of long-term fieldwork were specified, such as “intensive field work” ( Woods, 1996 ), and new clarifications were linked to data and the question of validity. Notably, criteria such as a need for data to have “ecological validity” were highlighted ( Borgnakke, 1996a , pp. 147–149; Hammersley & Atkinson, 1983 ) and data collection processes were clarified in connection with an extension of concepts of what constitutes “a field” and what “a field” means for the ethnographic framework.

In these examples, an empirical-analytical reflection and extension of what “a field” means for the ethnographic framework could be discerned. In addition, examples of a theoretical reflection and extension could include Pierre Bourdieu’s concept of “field” (French: champ ), Michel Foucault’s discourse concept, and Thomas Kuhn’s paradigm concept ( Bourdieu, 1994 ; Foucault, 1966 ; Kuhn, 1970 ). These contributions enable comprehensible reference to areas of research like “the medical field,” “the Western European Union discourse,” or pedagogical paradigms, like the “problem-Project based paradigm.”

Such extensions renew the tradition and broaden field research, while keeping classical fieldwork alive. In contrast, a new interpretation developed during the 2000s, so-called virtual ethnography or NET ethnography, tends to reject the contextualization principle and field concept ( Hine, 2000 ; Landri et al., 2014 ; Webster & Marques da Silva, 2013 ). Focusing on the virtual, the contextual anchor is jettisoned, and the field concept becomes infinite and partially redundant. As in the previously mentioned statement by Leander and McKim, when moving beyond place-based ethnography, I follow the NET-ethnographic argument. However, I still maintain, with online education serving as an example, that for ethnographic education research neither requirements for contextualization nor the validity of the field concept have been revoked. Both are still essential. Indeed, an online education platform like the worldwide Coursera has a market-based economic context, an academic context and university site (e.g., Stanford), and practical contexts (e.g., students’ own homes, libraries, cafés, or trains). Thus, the Coursera platform, the Internet, work in front of the computer, and associated interactions are all elements of the learning context, which is virtual, physical, manual, and social ( Borgnakke, 2015a ).

Ethnographic studies in the previously mentioned online NET education project (Nursing Education) show how ethnographic fieldwork has to consistently perceive and follow these changing online/offline contexts, including observations of students studying at home. However, confirmation of the ethnographic contextualization principle is accompanied by a need to extend and sharpen the framework, in relation to both the broader field and the whole sector, in order to address the changes and diversity of contexts. For example, in large-scale Scandinavian educational research projects, the classical fieldwork approach has been developed to cover school communities, multiple educational sites, and intensively studied development projects in specific selected schools or educational projects (e.g., Beach & Dovemark, 2007 ; Innovation og Uddannelse, 2016 ; Ôhrn & Holm, 2014 ; Player-Koro, 2012b ; Søndergard & Hasse, 2012 ).

In associated development of fieldwork methodology, participant observation, material/product collection, spontaneous conversations, and systematic interviews have been coupled, focusing on specific cases, innovative projects, or issues. In addition, empirical data and material related to the institutional or organizational levels involved have been collected, with explicit reference to:

Management level (policy materials, action strategy documents);

Employee/colleague level, teacher/teacher relations (curricula delivery plans, or innovative projects); and

Teaching and learning practice level, teacher/student-groups (courses and series of activities) ( Borgnakke, 1996a , 1996b , 2013a ).

The methodological challenge for ethnographic research is to cope with these levels and allocated activities while resisting fragmentation by maintaining a holistic view of the educational context and school life. This also applies to incorporation of specialized elements of ethnographic research, for example, organizational ethnography ( Ybema et al., 2009 ) or institutional ethnography ( Smith, 2005 ). Various inspiring methods to apply, and aspects to consider, in explorations of organizational contexts and leader/management-level phenomena have been published. For example, Tummons (2017) applied Dorothy Smith’s ideas on institutional ethnography, recognizing the value of document analysis in a study on information communications technology–based medical education. My previous fieldwork confirms the need to construct what I have conceptualized, in line with Smith (2005) , as “the institutional text-corpus” and integrate “the authoritative texts”in ethnographic analyses covering the levels outlined here ( Borgnakke, 1996b ).

In case studies of higher education that started with fieldwork at IT schools between 2000 and 2007 , the institutional text-corpus was even more important for the ethnographic process. Described in line with Darnton (1982) and Van der Weel (2001) in relation to the digital communications circuit, the text corpus and circuit was a multimodal digital version, including home pages with documents, pictures, and movies produced by the schools “about the schools” and learning platforms used in the classrooms. However, despite the importance of these text (and media) collections it should be stressed that the ethnographic principle of contextualization still encompasses a need to understand the embedded textualized and mediated interactions and relations between the involved institutional actors, such as professionals, leadership teams, teachers, and/or students ( Borgnakke, 2015a , pp. 13–14).

The ethnographic tradition and renewed aim of “being there—among professionals and learners” requires further clarification of consequences. But, most of all, clarification of the relationships between the ethnographic “field,” “place,” and “time” is required. In addition, as discussed in the next section, renewed reflection on “time” in relation to the classic ideal-type “long-term fieldwork” is needed.

Long-term Fieldwork and the Renewed Reflection on “Time”

The phrase “long-term fieldwork” recalls the Malinowskian tradition of the field researcher spending years in the field and acting as sole researcher ( Malinowski, 1922 ). Besides “being there,” the main demand is “time.” The potential of fieldwork is realized by staying “in” the field, collecting materials “from” the field “about” the field, with the objective of acquiring a holistic understanding of social and cultural practices. The classic recognition of the importance of time is also applicable to the new broad field research, as I have previously shown ( Borgnakke, 1996a , 1996b , 2012 , 2013a ).

Long-term fieldwork offers unique potential for exploration of processes, such as exploration of the process of innovation or exploration of the ongoing teaching and learning processes (e.g., Borgnakke, 1996b , pp. 465–638). In addition, the field researcher’s large empirical collections mean that the researcher is in empirical surplus. With this, the ethnographic potentials as a background, the possibilities of short-term fieldwork can be considered. In a framework with observations spanning only weeks or months, an intensive field study can be focused on a school or an education project, or different learning contexts can be explored (e.g., Borgnakke, 2013a , pp. 31–33). In such cases, cross-class or cross-context fieldwork may boost the potentials to acquire holistic understanding and the “empirical surplus” may confirm that even short periods of intensive fieldwork can meet the key traditional Malinowskian time criterion.

However, a larger time frame is required for fieldwork on processes such as implementation of major reforms in compulsory and secondary schools, which may take as long as five to ten years. For example, the 2000s have been labeled “the Decade of Reform” for all levels in Danish upper secondary schools. To navigate in this process one has to distinguish between the official time and milestones of the reform decade and the time references of the teachers involved. For example you can hear professionally involved refering to ‘the pioneer years,’ meaning the first year of the reform or ‘the trouble maker decade,’ meaning the whole period of the reform , followed by a reference to the ‘busy scheduling’ limitating curriculum plans for that year, month, and so on. The ethnographic point is that if there is ‘a decade of reform’ there is also a world of schooling, teaching and learning already labeled and institutionalized. This, the institutionalized school-life and time frame provide the social cultural foundation ( Borgnakke, 2006 , 2011b ).

Therefore, from an ethnographic perspective, the schools’ “own interpretations, labeling, time and timing” is the starting point. Next, and in terms of the pragmatic decision, the time spectrum of fieldwork can range from “just a visit” through “a normal school week (Monday–Friday)” and monthly stay to long-term contact with the field, covering the case full scale. In all these cases the classic Malinowskian rationale can be maintained, at least in the sense of basing fieldwork and observation on the field’s practical holistic terms and timing. This holistic timing has consequences for research, as also stressed by Hammersley (2006) and Jeffrey and Troman (2004) . If long-term fieldwork is maintained as a methodological reflection and characteristic element of the ethnographic practice, in addition to intensive field studies, it can provide extensive, valuable archives of empirical material and analyses. Conversely, archives from such research bear testimony to the value of long-term fieldwork. Particularly production of large quantities of empirical data, enable multiple analyses , including explorations of issues that were not considered during planning and data collection phases (e.g., Borgnakke, 1996b , pp. 643–712).

Maintaining the basic features of classical fieldwork ensures maintenance of contextualization and appropriate time frames of researchers’ contact with the field. However, it also raises needs for new interpretations and innovatory adjustments of principles and tools to address new themes and categories of ethnographic educational research. Along with a Marcus-inspired reinterpretation of multisited ethnography, these types of themes and categories are on the current agenda for the ethnographic project as a whole.

The Current Multisited Agenda

In 2001 and 2017 , Margaret Eisenhart presented overviews of the current state of the educational ethnographic project, primarily with references to American research. In “Educational Ethnography Past, Present and Future: Ideas to Think With” ( Eisenhart, 2001 ), she criticized current ethnography, and asked researchers to reconsider old views and basic categories such as “culture, gender, class, ethnicity” in relation to late modern conditions and their consequences. The demand by Eisenhart was important, but perhaps already met—at least in the Nordic critical tradition. Since the 1990s, rethinking of these basic categories has been a vivid element of educational gender, youth, and media research, which has generated various ethnographic methods and studies, based on a new generation of, for example, gender questions ( Öhrn & Holm, 2014 ). In this respect, ethnographic researchers have updated the research agenda. Against the updated background, basic categories in different generations can be examined in relation to both educational research and relevant aspects of media, IT, and youth culture. This has triggered reappraisals of concepts of youth culture, school culture, and formal and nonformal learning across a spectrum from classic studies and cases ( Hebdige, 1979 ; Willis, 1977 ) to late modern examples, such as The Digital Youth ( Buckingham, 2008 ; Drotner & Duud, 2009 ; Erstad, 2012 ; Ito et al., 2008 ). Recent studies focusing on the young generation’s use of social media have furthermore demonstrated the importance of having issues associated with digital literacy on the agenda, combining a sociocultural approach with an educational “bildungs-approach.” This is important for encouraging researchers and schools to participate in pedagogical developments focusing on social cultural dimensions rather than merely technical dimensions.

In this manner, ethnographic educational researchers not only update the research agenda from the 1970s but also construct a new platform and add new practical issues, as discussed by Webster and Marques da Silva (2013) . These efforts have opened paths for extensions and explorations of broad themes and contexts, in multisited ethnographic, meta-ethnographic, and comparative case study approaches, as described by Eisenhart in her later state-of-the-art review ( Eisenhart, 2017 ). In this review, she characterizes Marcus-inspired ethnography with illustrative references to multisited research projects and frameworks. For example, investigations of (school) political and cultural production, involving observations of politicians, school administrators, teachers, parents, and students. Researchers follow an innovative discourse or reform as it is transported away from the original source into new places, and educational reforms as they are formulated by decision-makers, implemented by teachers, and experienced by students and parents.

The ethnographic point is that multisited studies of cultural production provide means to understand how educational activities, values, and results of a group at a specific time are designed, limited, and changed by connections or processes across groups, places, and times. Such studies may encompass (for example) activities and settings of policymakers who design a education reform, teachers involved in its implementation, young people directly affected by it, and parents hoping to observe beneficial effects ( Eisenhart, 2017 , p. 137). The influence of Marcus on such approaches is summarized by the following quotation:

“The past habit of Malinowskian ethnography has been to take subjects as you find them in natural units of difference. . . . [T]he habit or impulse of multi-sited research is to see subjects as differently constituted, as not products of essential units of difference only, but to see them in development—displaced, recombined, hybrid . . ., alternatively imagined. Such research pushes beyond the situated subject of [traditional] ethnography toward the system of relations that defines them” ( Marcus, 2009 , p. 184).

This quotation not only outlines multisited investigation as a context-sensitive strategy enabling ethnographic follow-up research but also enables a Nordic-German, rather than American, exemplification. In many ways, the strategy presented by Eisenhart through Marcus has strong elements of the critical constructivism propounded by Klafki (1977 , 2002) , and the qualitative research methodologies inspired by critical theory and social constructivism (see Borgnakke, 1996a , 1996b ; Kvale, 1997 ; Nielsen & Nielsen, 2005 ).

Against this broader background, I confirm the validity and value of Eisenhart’s presentation of current ethnography but suggest a further step, using experiences of multisited ethnography gained to date. These experiences can be used to refine the foundations in several respects. First, they can help to clarify the relationship between field research and discourse analysis. Second, they can help development of a strategy for cross-case studies crossing learning contexts, including both online and offline settings. Third, they can highlight common foci or themes for ethnographic studies. Finally, they can reinforce experimental methodological frameworks for ethnographic research. In the following examples, I review these contributions (actual and potential) in relation to what is characterized as “mapping the field of practice/mapping the paradigm,” and “case studies crossing learning contexts,” with the broader objective of sharpening the focus on the educational system in change.

Mapping the Field of Practice/Mapping the Paradigm

Clarification of the term “mapping the field of practice/paradigm” and what it may entail can be exemplified by my own research. My extensive fieldwork from the 1980s was done at Aalborg University (AUC), one of the Danish “reform universities,” offering full-scale bachelor and master programs based on problem-oriented project work. My approach to the long-term fieldwork was simple and consistent: I followed one of AUC’s basic programs, participating from start to finish. In this version of the practice, long-term fieldwork refers to observations of activities associated with the entire program, from the teacher teams’ preliminary planning of “next year” and the first welcoming of new students to the actual project and course periods.Empirical data were mainly collected by following a group of 50 students and seven project groups through three periods of project work, including close-up studies during the period with final examinations.

The book Educational Field Research ( Borgnakke, 1996a ) presents and discusses the fieldwork and results in detail, while the article “Cardinal Writing: Following the Observed Process” ( Borgnakke, 2018 ) describes and exemplifies the practice-analytical framework and close-up analyses in detail. Therefore, in this section, I skip details and concentrate on the status of long-term fieldwork as “a type” with distinct potentials.

First and foremost, fieldwork following full-scale education in real time and authentic complexity is a strong concept for mapping the field of practice. Since all institutional levels, parties, and pedagogical phases are included, the overview and empirical collections provide detailed background for practice analysis. The empirical data collection also provides important background for analyses of the learning processes at a micro-level, with close-up analyses of milestones and learning strategies ( Borgnakke, 1996b ). Hence, classic long-term ethnographic fieldwork provides foundations for developing an overview of what it means to explore the field of practice and exploit the empirical material in analyses of practices and learning processes.

In methodological terms, such full-scale studies can sharpen both requirements and opportunities to develop interplay between classical fieldwork and methodological renewal. Classical fieldwork’s combination of participant observation, spontaneous conversations, and interviews is crucial for grasping authentic complexity, through following courses, activities, and ever-changing contexts of study-life chronologies.. Being among professionals and learners, and engaging in conversations and interviews with groups and key informants in the field, provides access to the participants´ own interpretations of the process and teaching and learning practices. In this regard, the perspectives of participants and references to their life world ( Kvale, 1997 ) are integrated in the ethnographic approach. With the classical ethnographic design as a background,ethnographic fieldwork show the possibilities of incorporating use of new digital technologies in the processfor instance, to augment data collection via key informants’ video diaries ( Noer, 2014 , 2016 ). In addition, micro-ethnographic studies have already shown the potentials of video recordings as background for close-up analysis of teaching and learning situations, focusing on interactive and communicative patterns ( Alrø & Dircink-Holmfeld, 1997 ; Sahlström, 1999 ). Last but not least, full-scale studies addressing the entire field have generated digitized archives of empirical material, including references to focal institutions’ websites and learning platforms. For example, in case studies on innovative projects in higher education conducted by the INNOVA research group, the e-pedagogical profile is embedded in such platforms and the online education. 2 Hereby the digital communications circuit is the starting point for everyone involved.

In these cases, the methodological renewal is IT-based, but the research interest in the next step, transforming “the observed field of practice” to empirical analysis, is still related to principles known from long-term fieldwork. That said, it is still fruitful to return to the practical context to recall how the same classical framework for mapping the field of practice is also a strong concept for mapping the educational or pedagogical paradigm. Further, it is fruitful to focus on different levels and the interplay between macro-, meso-, and micro-levels.

Clarifying strategies for the empirical analysis, the main point here is to develop an ethnographic analysis by using inspiration from Thomas Kuhn’s concept of paradigm. Kuhn’s descriptions of components are used to map the paradigms and characterize them in terms of their relative dominance in the field and relative strength in scientific grounding, educational framing, and curriculum. 3 Against this background, mapping the field of modern university pedagogy ( 1970–2010 ) was described as the main task and the paradigm maps, as I called them, captured the results ( Borgnakke, 2011a ). The results showed the relative functional strengths of the paradigmatic traits and identified transformations of rules, norms, and values of the educational community in the learning context. In addition, examples of best practice were identified.

The paradigm maps showed that Danish higher education was dominated by two strong and shifting paradigms during the period 1970–2010 . The “Project Pedagogical Paradigm,” dominated most strongly during the 1970s, while the “Learning Paradigm,” which was related to the Bologna process and is now defined as “The Learning Outcome Paradigm,” was dominant from 2000 to 2010 ( Borgnakke, 2011a , pp. 14–21). The new learning and goal-oriented paradigm even turned to be the powerful paradigm dominating the educational system as a whole not only for one but two decades.

The Learning Outcome Paradigm has therefore had a huge impact, not manifested (unlike effects of the former Project Pedagogical Paradigm) in new campuses, buildings, or educational centers, but embedded in universities, higher education, and the educational system as a whole. In this sense, mapping the paradigm refers to identification of all relevant political and educational processes, participants and associated programs, documents, and requirements interactively involved at macro-, meso-, and micro-levels. It refers also to the possibilities to focus on specific issues going across the paradigm. As an example, the article Cross-Case Analysis of Changes in Teacher Role and Didactic Function in Denmark, 1980–2020 ( Borgnakke, 2021 ) combines results from the broader field research with focused close-up analysis of paradigmatic teaching situations. The cross-case analysis shows how the project-based pedagogical paradigm from the 1970s generated alternative concepts of the professional teacher and bottom-up strategies for teacher collaboration. During the 2000s and 2010s, the new powerful learning paradigm marked the shift to top-down directed demands for “high professionalism.” The shift, shown in close-up analysis, led to an accumulation of functions and functional overheating rather than alternative practices. At the same time, demands for multifunctionality in the classroom were politically highlighted as a professional readiness for change and innovation.Against this background, the ethnographic analysis, both in broader and focused sense, refers to the paradigm and the paradigm shift over time as a political discourse and an educational practice with programs, demands, and documents in circulation between levels and parties. Hereby the communicative circuit in total is of interest. And hereby the ethnographic analytic framework refers to the empirical collection and the archive, similar in total as illustrated in Figure 1 .

Figure 1. Mapping the paradigm. The ethnographic analytical framework exemplified in a Danish version of the Learning paradigm shows the potential for coping with the archive and characteristic “three-level text collection.”

The Archive and the Ethnographic Analytical Framework

Referring to the figure, the ethnographic analytical framework can be exemplified in a Danish version of the powerful Learning Outcome Paradigm showing the potential for coping with the archive and characteristic “three-level text collection.” Overall analysis and close-up analysis will focus on (a) collected documents, literature, and archives regarding the background theory and concepts, (b) documents regarding the educational policy and institutional arrangements, and (c) data collected from fieldwork and case studies with (d) materials and tools from the process of didactization and the process of digitalization.

Analysis of collections and documents enables the basic learning concept to be positioned in relation to the background theory with traditions of English-American-Australian educational research as dominant representatives of the paradigm. Here, works by Paul Ramsden and John Biggs in particular are in focus as theoretical and conceptual background.

Through their research environments, research, books, and dissemination Ramsden (1991) , Biggs (1999) , and Biggs and Tang (2007) can be used to refer both to Kuhn’s four components (to conceptual development, textbooks, development work) and link to what in the paradigm is regarded as “best practices” and have been reproduced in the profile of universities’ education courses and centers. Ramsden and Biggs formed, in this sense, a tradition in the Learning Outcome Paradigm matching the current political demands, but with origins in the conceptual development of surface and deep learning that can be traced back to the 1970s research environment at Gothenburg University ( Marton & Saljö, 1976 , 1984 ) and studies done together with Noel Entwistle (1997) and Entwistle et al. (2001) . At the same time conceptual developments presented in Teaching for Quality Learning at University ( Biggs, 1999 ) provided the foundation for the center for university pedagogical development at the University of Aarhus and University of Southern Denmark, as well as at the University of Copenhagen’s Department of Natural Sciences Didactics (IND).

Ramsden’s and Biggs’s books are in this sense already included as a matrix for course development, as illustrated by the IND-book Improving University Science Teaching and Learning ( Christiansen et al., 2010 ). Ramsden’s main concept, with presentations of the two learning strategies, deep and surface strategies, as well as the conceptual development of what Biggs called “constructive alignment,” has also been reproduced in the profile of the university education centers and courses for associate professors, doctoral students, and heads of departments. Finally, the Biggs tradition was brought to life in an award-winning video production ( Brabrand, 2006 ), in which his basic concepts are dramatized and personified, in a story about two students: Susan, representing deep learning strategies, and Robert, representing surface strategies. The expressed, visualized, and personified version of the Learning Outcome Paradigm can therefore also be seen on YouTube.

Considering the paradigms in terms of their origins and effects, political and institutional, the currently dominant Learning Outcome Paradigm have had extraordinary structural impacts on the academic learning context. Not only curriculum and teaching strategies are affected but also organizational development, teacher-student relations, and the learning process. Further, e thnographic analysis has shown that practical consequences observed in profession-oriented higher education include structural enhancement of schoolification and conventional teaching and learning strategies, rather than innovative and student-oriented strategies ( Kirketerp Nielsen, 2018 ; Lyngsø & Kirketerp Nielsen, 2016 ).

The framework described corresponds to exploiting the combined potential of classical fieldwork and critical discourse analysis. As illustrated by full-scale studies (as examples of broad field research) this provides potency by imbuing empirical analysis with ecological validity, rooted in authentic complexity and synergistic application of multiple methods in a practice-oriented strategy. Mapping the educational programprovides the required overview and evidence of main trends. However, for the empirical analysis, it is essential to observe and characterize relative strengths of paradigmatic traits and identify transformations of rules, norms, and values of the educational community. It is also crucial to identify these features in the full range of regulations, curricula, teacher functions, and textbooks, as well as examples of best practice.

Currently following the paradigm, as illustrated in Figure 1 , will yield an almost identical archive in digitized form, including empirically collected data, references to the institutions’ websites and learning platforms, material from sources such as YouTube, and self-directed groups on Facebook as objects for the analysis. This means that almost “all” material linked to the practical management of the Learning Outcomes paradigm or to the implementation of Danish reforms is on the Internet or on the institutions’ intranet. This is digitization full scale!

It could be added that in 2018 , the Ministry of Education realized that the cultural transformation of the learning outcomes paradigm into curricula, teaching, and testing strategies had gone too far. Despite critiques, and even deletion of goal-oriented material and models from the Ministry of Education’s homepage, the learning outcome–based curricula are still deeply embedded in the Danish educational system both in formal regulations and in living educational systems.

Hence, full-scale studies are clearly forced by digitalization to be renewed but still inspired by a classical fieldwork framework and challenges in terms of developing a critical analytical strategy to cope with the digitized processes and phenomena. That said, another important type of full-scale research needs to be elaborated, rooted in what was called intensive fieldwork and cross-case studies focusing on curriculum development in different learning contexts. As exemplified in the next section, intensive cross-case studies can be characterized in connection within the spectra of practice-oriented research, in which research teams were involved in quality development and evaluative research in higher education.

Cross-Case Studies Crossing Learning Contexts

The type of evaluative research involving intensive field study and comparative cross-case studies can be exemplified by the Danish “Project Quality Development of Teaching” from the 1990s. Education projects focused on the mechanical engineering program at the Technical University of Denmark (DTU), the English program at the University of Copenhagen (UCPH), and the marketing economics program at the Copenhagen Business School (CBS) were all included ( Borgnakke, 2004 , 2005 , pp. 156–216).

During the case studies, I followed the development efforts, exploring the academic context and the teaching and learning strategies. Through observationand interviews with teachers and students, I followed the varied teaching forms and learning strategies from classic lectures in modern classroom settings to late modern project work in business- and profession-oriented project work. Furthermore, I observed the characteristic settings and situations from one scientific area to the next, starting with the technical area (DTU), continuing with the humanistic area (UCPH), and ending with the social and business science area (CBS).

Armed with material, text collections, and fieldnotes from observations in the different academic areas, I could grasp the issues connected to the institutional traditions for teaching and learning and compare the radically different academic cultures and learning contexts. At the same time, a common issue became clearly expressed as the dilemma of the movement from elite university to mass university. This refers to the difficulty of reconciling strong influences of conventional school tradition and teacher/pupil relations with attempts to meet demands and expectations for the survival of classic university traditions and research-based teaching for “the future professional.” The dilemma posed major conflicts of interest and orientation for the late modern university ( Borgnakke, 2005 , pp. 157–167).

The observations, spontaneous conversations, and interviews revealed strong identifications of the teachers' and the learners' own representations (and interpretations) of these conflicts. Furthermore, the comparative case study approach proved to have potent capacity for identification and documentation of (a) the diversity in learning strategies; (b) the educational cultures’ impact on teaching and learning; and (c) the learning contexts’ influence on learning subjects, knowledge, and learning interests.

Interestingly, the dilemma and pedagogical issues were divided into three sets. Grounded in the humanistic-, technical-, and business-oriented approaches to education three different scientific cultures and learning strategies could be identified.. Against this background the case analysis provided documentation and references to the old maxim “learning by doing” ( Dewey, 1910 ). Further, referring to the academic context as ‘a learning context’ ( Borgnakke, 2004 ), concepts formulated by Lave and Wenger (1991) could shape examples of situated learning and communities of practice. .

Thus, a clear empirical conclusion from the comparative case analysis was that ‘the common pedagogical issues and reflections on academic learning’ were expressed in three versions closely related to the three different learning contexts. On a deeper level, we need to express the point in a Habermasian manner. The pedagogical reflections and goals set for the developmental work, or courses, were influenced by the technical, humanistic, and social scientific knowledge interests, or “erkenntnisinteresse” in German ( Habermas, 1968 ). In each observed learning process, I recognized the tendencies to highlight the learning interests in either ‘to master a technique,’ ‘to understand’ or to ‘act and change.’ That expressed in Habermas’ wording makes the learners perspective clearer. From the learner’s viewpoint confronting a specific academic subject area seem to be driven by the strongest dimension in the learning context.

However, as learners, the students also shift between aims ‘to master,understand or to change.’ As observations and conversations with the students show, the learners themselves typically signaled how, when, and which dimensions were too strong (see Borgnakke, 2004 , 2005 , pp. 177–216).

Following learning processes in different academic learning contexts, as in the above example, adds deeper layers of learning as an ongoing life matter and a matter of crossing contexts physically and mentally. With references to case studies in profession-oriented learning process, shifting between scholastic practice and professional (e.g., clinical, for nurses) practice is a basic principle. In this respect, focusing on the learner’s “erkenntnisinteresse” implies focusing on a fundamental contrast between the scholastic and professional contexts as well as the contrast between theory and practice (Borgnakke, 2014; Noer, 2016 ). Research focusing on profession-oriented learning is methodologically challenged by this contrast as well as by the fact that the two contexts are experienced as two separate forms of learning. Field research carried out in online learning programs is challenged in additional ways ( Lyngsø, 2019 ). First, the shifts from formal learning strategies (e.g., lessons in school and through textbooks) to informal learning (e.g., self-directed learning strategies, at home, and peer-oriented use of social media) are a challenge. Second, the e-pedagogical settings and shifting online/offline learning situations, pose further challenges.

Following the learner through these different phases of scholastic and professional learning demands observation and empirical data fromthe ongoing process. With this as an addition to the methodological background, the summarized reflections—the next section—are related to a research trend rather than single research projects. This is the increasing involvement of fieldwork and case studies in the political process of innovation andorganizational development.. As research teams, we are confronted directly with the new order of magnitudes related to the common theme “the educational system in change” as well as the common demands associated with professionalization and digitization.

Meeting Challenges From the Educational System in Change

A requirement for reinforcing an ethno-methodologic experimental framework is reinforcement of the interdisciplinary scientific background to meet challenges by bridging methods and traditions from learning research, profession- and organizational research. In addition, ethnographic research already has links to research in media, IT, and youth culture and can benefit from experience of diverse methods. Moreover, current ethnographic studies by interdisciplinary research groups emphasize the necessity of developing qualitative in-depth studies producing alternatives to the work of the evidence movement. In such studies, practice-oriented research crossing learning contexts meets the new challenges but confirms the strength of classical fieldwork.

Ethnographic case studies develop combinations of methods based on classic traditions but renewed by relations to innovative cases. This sharpening the analytical framework for focusing on interplays between the political (macro-) and the institutional and practical (meso- and micro-) levels. Hence, the empirical results can inform both overall analyses of innovative processes and detailed aspects of cases, educational cultures and learning situations..

Currently, in the wake of the COVID-19 pandemic, educational institutions are expected to master the shifting offline/online culture. Moreover, professional teacher teams are expected to be ready to transform any didactic action to an innovative digital learning culture. But these processes of didactization and digitalization demand that not only teachers but also the organization be able to manage the complexity.

Against this background, ethnographic research is challenged to go beyond demands and expectations facing the practical implications in the complex process. The starting point for ethnographic analysis is that the practical process is rooted in an “authentic mix” of IT-based strategies, demands, and expectations positioned at multiple organizational levels and parties. The “authentic mix” will have ecological validity through reference to relevant policy documents, programs, curricular material, and plans for pedagogic processes. However, the “authentic mix” will also have a reference to dilemmas and problems in the process having an impact on the flows of learning tools and objects.

Tracing the flows of objects therefore challenge ethnographic research to explore the practical use of technology across different situations and contexts. In an analytical sense this crossing contexts is both a starting point and a driver to clarify how the ethnographic methods can delve deeper into the ongoing process of innovation. But going deeper into the process is also a wakeup call, that implies a concrete critique of technology in use as basic learning tools. Where the paradigmatic slogan in recent decades has been ‘IT-enhanced learning,’ both trade unions and professionals (school leaders and teachers) are now more skeptical and demand genuine research into the practical benefits and possible costs of learning technology. This means that the challenges to ethnographic method development must not only provide a technology-critical, but a paradigm-critical contribution to the practice-oriented research.

Further Reading

• Borgnakke, K. (2012). Challenges for the next generation in upper secondary school—Between literacy, numeracy, and technacy. In W. Pink . (Ed.), Schools for marginalized youth . Hampton Press.
• Borgnakke, K. (2015). Coming back to basic concepts of the context. Seminar.net: Media, Technology and Lifelong Learning , 11 (1), 3, 7, 8.
• Borgnakke, K. (2021). Cross-case analysis of changes in teacher role and didactic function in Denmark, 1980–2020. Oxford Research Encyclopedia of Education . Oxford University Press.
• Borgnakke, K. , Dovemark, M. , & Margues da Silva, S. (Eds.). (2017). The postmodern professional contemporary learning practices, dilemmas and perspectives . Tufnell Press.
• Buckingham, D. (Ed.). (2008). Youth, identity and digital media . MIT Press.
• Dicks, B. , Mason, B. , Coffey, A. , & Atkinson, P. (2005). Qualitative research and hypermedia: ethnography for the digital age (New Technologies for Social Research Series). SAGE.
• Hammersley, M. (2018). What is ethnography? Can it survive? Should it? Ethnography and Education , 13 (1), 1–17.
• Hasse, C. (2017). Technological literacy for teachers . Oxford Review of Education , 43 (3), 365–378.
• Haugsbakk, G. , & Nordkvelle, Y. (2007). The rhetoric of ICT and the new language of learning: A critical analysis of the use of ICT in the curricular field . European Educational Research Journal , 6 (1), 1–12.
• Hernández, F. , Fendler, R. , & Sancho, J. M. (Eds.). (2013). Rethinking educational ethnography: Researching on-line communities and interactions . ESBRINA—RECERCA Universitat de Barcelona.
• Hine, C. (2000). Virtual ethnography . SAGE.
• Hjarvard, S. (2008). The mediatization of society. A theory of the media as agents of social and cultural change. Nordicom Review , 29 (2), 105–134.
• Ito, M. , Horst, H. , Bittanti, M. , Boyd, D. , Herr-Stephenson, B. , Lange, P. G. , Pasco, C. J. , & Robinson, L. (2008). Living and learning with new media: Summary of findings from the Digital Youth Project . The John D. and Catherine T. MacArthur Foundation Reports on Digital Media and Learning.
• Landri, P. , Maccarini, A. , & De Rosa, R. (Eds.). (2014). Networked together: Designing participatory research in online ethnography . CNR IRPPS E-Publishing.
• Marcus, G. (1995). Ethnography in/of the world system: The emergence of multi-sited ethnography. Annual Review of Anthropology , 24 , 95–117.
• Player-Koro, C. (2013). Hype, hope and ICT in teacher education: A Bernsteinian perspective . Learning, Media and Technology , 38 (1), 26–40.
• Tummons, J. (2017). ICTs and the Internet as a framework and field in ethnographic research. Acta Paedagogica Vilnensia , 39 , 132–143.
• Webster, J. P. , & Marques da Silva, S. (Eds.). (2013). Doing educational ethnography in an online world: Methodological challenges, choices and innovation [Special issue]. Ethnography and Education , 8 (2), 2, 7.
• Ybema, S. , Yanow, D. , Wels, H. , & Kamsteeg, F. (Eds.). (2009). Organizational ethnography studying the complexities of everyday life . SAGE.
• Alrø, H. , & Dirckinck-Holmfeld, L. (Eds.). (1997). Videoobservation . Aalborg Universitetsforlag.
• Beach, D. (2017). Ethnographic lenses and possibilities: International trends and developments in the ethnography of education. Acta Paedagogica Vilnensia , 39 , 15–30.
• Beach, D. , & Dovemark, M. (2007). Education and the commodity problem: Ethnographic investigations of creativity and performativity in Swedish schools, ethnography and education . Tufnell Press.
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1. Jackman was the leader of a project on the value of preceptorship for health profession students (mainly medical and nursing students); see Jackman et al. (2012) .

2. The research group Ethnographic Studies in Innovative Learning Context conducts fieldwork and case studies in scholastic, profession-oriented, and academic learning contexts. Full scale case studies are related to teacher and nursing programs, inter-professionalism (in the InterTværs project), online learning (in the NETeducation project), and game-based profession learning (in the Innovation project in veterinarian study). Overviews see Special Issues, Seminar.net. (2015) , Innovation og Uddannelse (2016) , Borgnakke (2016c) , and Borgnakke et al. (2017) . The research is continuingly expanding, recently with doctoral projects focusing on professional Bildung and ethnographic based curriculum development. .

3. See Kuhn (1970) . The four components are (a) nature-like symbolic generalizations, (b) metaphysical beliefs about the real structure, (c) standards of scientific activity, and (d) role models and examples. See also Figure 1 ( Borgnakke, 2011a , p. 98). On the use of Kuhn to develop the critical analysis of the current learning outcomes paradigm, see Borgnakke (2011a , pp. 14–39).

Related Articles

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Driving Innovations in Biostatistics with Denise Scholtens, PhD

“I'm continually surprised by new data types. I think that we will see the emergence of a whole new kind of technology that we probably can't even envision five years from now…When I think about where the field has come over the past 20 years, it's just phenomenal.”  —  Denise Scholtens, PhD  

• Director, Northwestern University Data Analysis and Coordinating Center (NUDACC)  
• Chief of Biostatistics in the Department of Preventive Medicine  
• Professor of Preventive Medicine in the Division of Biostatistics and of Neurological Surgery  
• Member of Northwestern University Clinical and Translational Sciences Institute (NUCATS)  
• Member of the Robert H. Lurie Comprehensive Cancer Center  

Episode Notes 

Since arriving at Feinberg in 2004, Scholtens has played a central role in the dramatic expansion of biostatistics at the medical school. Now the Director of NUDACC, Scholtens brings her expertise and leadership to large-scale, multicenter studies that can lead to clinical and public health practice decision-making.    

• After discovering her love of statistics as a high school math teacher, Scholtens studied bioinformatics in a PhD program before arriving at Feinberg in 2004.  
• Feinberg’s commitment to biostatistics has grown substantially in recent decades. Scholtens was only one of five biostatisticians when she arrived. Now she is part of a division with almost 50 people.  
• She says being a good biostatistician requires curiosity about other people’s work, knowing what questions to ask and tenacity to understand subtitles of so much data.   
• At NUDACC, Scholtens and her colleagues specialize in large-scale, multicenter prospective studies and clinical trials that lead to clinical or public health practice decision-making. They operate at the executive level and oversee all aspects of the study design.  
• Currently, Scholtens is involved with the launch of a large study, along with The Ohio State University, that received a $14 million grant to look at the effectiveness of aspirin in the prevention of hypertensive disorders in pregnancy.  
• Scholtens first started her work in data coordinating through the Hyperglycemia Adverse Pregnancy Outcome (HAPO) study, which looked at 25,000 pregnant individuals. This led to a continued interest in fetal and maternal health.   
• When it comes to supportive working environments, Scholtens celebrates the culture at Feinberg, and especially her division in biostatistics, for being collaborative as well as genuinely supportive of each other’s projects. She attributes this to strong leadership which established a culture with these guiding principles.   

Additional Reading  

• Read more about the ASPIRIN trial and other projects taking place at NUDACC   
• Discover a study linking mothers’ obesity-related genes to babies’ birth weight, which Scholtens worked in through the HAPO study   
• Browse all of Scholtens recent publications 

Recorded on February 21, 2024.

Continuing Medical Education Credit

Physicians who listen to this podcast may claim continuing medical education credit after listening to an episode of this program..

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

• Identify the research interests and initiatives of Feinberg faculty.
• Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.50  AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

All the relevant financial relationships for these individuals have been mitigated.

Disclosure Statement

Denise Scholtens, PhD, has nothing to disclose.  Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose.  FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

Read the Full Transcript

[00:00:00] Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. Northwestern University Feinberg School of Medicine is home to a team of premier faculty and staff biostatisticians, who are the driving force of data analytic innovation and excellence here. Today, we are talking with Dr. Denise Scholtens, a leader in biostatistics at Northwestern, about the growing importance of the field, and how she leverages her skills to collaborate on several projects in Maternal and Fetal Health. She is the Director of the Northwestern University Data Analysis and Coordinating Center, NUDACC, and Chief of Biostatistics in the Department of Preventive Medicine, as well as Professor of Preventive Medicine and Neurological Surgery. Welcome to the show.  

[00:01:02] Denise Scholtens, PhD: Thank you so much.  

[00:01:02] Erin Spain, MS: So you have said in the past that you were drawn to this field of biostatistics because you're interested in both math and medicine, but not interested in becoming a clinician. Tell me about your path into the field and to Northwestern.  

[00:01:17] Denise Scholtens, PhD: You're right. I have always been interested in both math and medicine. I knew I did not want to be involved in clinical care. Originally, fresh out of college, I was a math major and I taught high school math for a couple of years. I really enjoyed that, loved the kids, loved the teaching parts of things. Interestingly enough, my department chair at the time assigned me to teach probability and statistics to high school seniors. I had never taken a statistics course before, so I was about a week ahead of them in our classes and found that I just really enjoyed the discipline. So as much as I loved teaching, I did decide to go ahead and invest in this particular new area that I had found and I really enjoyed. So I wanted to figure out how I could engage in the field of statistics. Decided to see, you know, exactly how studying statistics could be applied to medicine. At the time, Google was brand new. So I literally typed in the two words math and medicine to see what would come up. And the discipline of biostatistics is what Google generated. And so here I am, I applied to grad school and it's been a great fit for me.  

[00:02:23] Erin Spain, MS: Oh, that's fantastic. So you went on to get a PhD, and then you came to Northwestern in 2004. And so tell me a little bit about the field then and how it's changed so dramatically since.  

[00:02:36] Denise Scholtens, PhD: So yes, I started here at Northwestern in 2004, just a few months after I had defended my thesis. At the time there was really an emerging field of study called bioinformatics. So I wrote my thesis in the space of genomics data analysis with what at the time was a brand new technology, microarrays. This was the first way we could measure gene transcription at a high throughput level. So I did my thesis work in that space. I studied at an institution with a lot of strengths and very classical statistics. So things that we think of in biostatistics like clinical trial design, observational study analysis, things like that. So I had really classic biostatistics training and then complimented that with sort of these emerging methods with these high dimensional data types. So I came to Northwestern here and I sort of felt like I lived in two worlds. I had sort of classic biostat clinical trials, which were certainly, you know, happening here. And, that work was thriving here at Northwestern, but I had this kind of new skillset, and I just didn't quite know how to bring the two together. That was obviously a long time ago, 20 years ago. Now we think of personalized medicine and genomic indicators for treatment and, you know, there's a whole variety of omics data variations on the theme that are closely integrated with clinical and population level health research. So there's no longer any confusion for me about how those two things come together. You know, they're two disciplines that very nicely complement each other. But yeah, I think that does speak to how the field has changed, you know, these sort of classic biostatistics methods are really nicely blended with a lot of high dimensional data types. And it's been fun to be a part of that.  

[00:04:17] Erin Spain, MS: There were only a handful of folks like you at Northwestern at the time. Tell me about now and the demand for folks with your skill set.  

[00:04:26] Denise Scholtens, PhD: When I came to Northwestern, I was one of a very small handful of biostatistics faculty. There were five of us. We were not even called a division of biostatistics. We were just here as the Department of Preventive Medicine. And a lot of the work we did was really very tightly integrated with the epidemiologists here in our department and we still do a lot of that for sure. There was also some work going on with the Cancer Center here at Northwestern. But yeah, a pretty small group of us, who has sort of a selected set of collaborations. You know, I contrast that now to our current division of biostatistics where we are over 20s, pushing 25, depending on exactly how you want to count. Hoping to bring a couple of new faculty on board this calendar year. We have a staff of about 25 statistical analysts. And database managers and programmers. So you know, when I came there were five faculty members and I think two master's level staff. We are now pushing, you know, pushing 50 people in our division here so it's a really thriving group.  

[00:05:26] Erin Spain, MS: in your opinion, what makes a good biostatistician? Do you have to have a little bit of a tough skin to be in this field?  

Denise Scholtens, PhD: I do think it's a unique person who wants to be a biostatistician. There are a variety of traits that can lead to success in this space. First of all, I think it's helpful to be wildly curious about somebody else's work. To be an excellent collaborative biostatistician, you have to be able to learn the language of another discipline. So some other clinical specialty or public health application. Another trait that makes a biostatistician successful is to be able to ask the right questions about data that will be collected or already have been collected. So understanding the subtleties there, the study design components that lead to why we have the data that we have. You know, a lot of our data, you could think of it in a simple flat file, right? Like a Microsoft Excel file with rows and columns. That certainly happens a lot, but there are a lot of incredibly innovative data types out there: wearables technology, imaging data, all kinds of high dimensional data. So I think a tenacity to understand all of the subtleties of those data and to be able to ask the right questions. And then I think for a biostatistician at a medical school like ours, being able to blend those two things, so understanding what the data are and what you have to work with and what you're heading toward, but then also facilitating the translation of those analytic findings for the audience that really wants to understand them. So for the clinicians, for the patients, for participants and the population that the findings would apply to.   

Erin Spain, MS: It must feel good, though, in those situations where you are able to help uncover something to improve a study or a trial.  

[00:07:07] Denise Scholtens, PhD: It really does. This is a job that's easy to get out of bed for in the morning. There's a lot of really good things that happen here. It's exciting to know that the work we do could impact clinical practice, could impact public health practice. I think in any job, you know, you can sometimes get bogged down by the amount of work or the difficulty of the work or the back and forth with team members. There's just sort of all of the day to day grind, but to be able to take a step back and remember the actual people who are affected by our own little niche in this world. It's an incredibly helpful and motivating practice that I often keep to remember exactly why I'm doing what I'm doing and who I'm doing it for.  

[00:07:50] Erin Spain, MS: Well, and another important part of your work is that you are a leader. You are leading the center, NUDACC, that you mentioned, Northwestern University Data Analysis and Coordinating Center. Now, this has been open for about five years. Tell me about the center and why it's so crucial to the future of the field.  

[00:08:08] Denise Scholtens, PhD: We specialize at NUDACC in large scale, multicenter prospective studies. So these are the clinical trials or the observational studies that often, most conclusively, lead to clinical or public health practice decision making. We focus specifically on multicenter work. Because it requires a lot of central coordination and we've specifically built up our NUDACC capacity to handle these multi center investigations where we have a centralized database, we have centralized and streamlined data quality assurance pipelines. We can help with central team leadership and organization for large scale networks. So we have specifically focused on those areas. There's a whole lot of project management and regulatory expertise that we have to complement our data analytics strengths as well. I think my favorite part of participating in these studies is we get involved at the very beginning. We are involved in executive level planning of these studies. We oversee all components of study design. We are intimately involved in the development of the data capture systems. And in the QA of it. We do all of this work on the front end so that we get all of the fun at the end with the statistics and can analyze data that we know are scientifically sound, are well collected, and can lead to, you know, really helpful scientific conclusions.  

[00:09:33] Erin Spain, MS: Tell me about that synergy between the clinicians and the other investigators that you're working with on these projects.  

[00:09:41] Denise Scholtens, PhD: It is always exciting, often entertaining. Huge range of scientific opinion and expertise and points of view, all of which are very valid and very well informed. All of the discussion that could go into designing and launching a study, it's just phenomenally interesting and trying to navigate all of that and help bring teams to consensus in terms of what is scientifically most relevant, what's going to be most impactful, what is possible given the logistical strengths. Taking all of these well informed, valid, scientific points of view and being a part of the team that helps integrate them all toward a cohesive study design and a well executed study. That's a unique part of the challenge that we face here at NUDACC, but an incredibly rewarding one. It's also such an honor and a gift to be able to work with such a uniformly gifted set of individuals. Just the clinical researchers who devote themselves to these kinds of studies are incredibly generous, incredibly thoughtful and have such care for their patients and the individuals that they serve, that to be able to sit with them and think about the next steps for a great study is a really unique privilege.  

[00:10:51] Erin Spain, MS: How unique is a center like this at a medical school?  

[00:10:55] Denise Scholtens, PhD: It's fairly unique to have a center like this at a medical school. Most of the premier medical research institutions do have some level of data coordinating center capacity. We're certainly working toward trying to be one of the nation's best, absolutely, and build up our capacity for doing so. I'm actually currently a part of a group of data coordinating centers where it's sort of a grassroots effort right now to organize ourselves and come up with, you know, some unified statements around the gaps that we see in our work, the challenges that we face strategizing together to improve our own work and to potentially contribute to each other's work. I think maybe the early beginnings of a new professional organization for data coordinating centers. We have a meeting coming up of about, I think it's 12 to 15 different institutions, academic research institutions, specifically medical schools that have centers like ours to try to talk through our common pain points and also celebrate our common victories.  

[00:11:51] Erin Spain, MS: I want to shift gears a little bit to talk about some of your research collaborations, many of which focus on maternal and fetal health and pregnancy. You're now involved with a study with folks at the Ohio State University that received a 14 million grant looking at the effectiveness of aspirin in the prevention of hypertensive disorders in pregnancy. Tell me about this work.  

[00:12:14] Denise Scholtens, PhD: Yes, this is called the aspirin study. I suppose not a very creative name, but a very appropriate one. What we'll be doing in this study is looking at two different doses of aspirin for trying to prevent maternal hypertensive disorders of pregnancy in women who are considered at high risk for these disorders. This is a huge study. Our goal is to enroll 10,742 participants. This will take place at 11 different centers across the nation. And yes, we at NUDACC will serve as the data coordinating center here, and we are partnering with the Ohio State University who will house the clinical coordinating center. So this study is designed to look at two different doses to see which is more effective at preventing hypertensive disorders of pregnancy. So that would include gestational hypertension and preeclampsia. What's really unique about this study and the reason that it is so large is that it is specifically funded to look at what's called a heterogeneity of treatment effect. What that is is a difference in the effectiveness of aspirin in preventing maternal hypertensive disorders, according to different subgroups of women. We'll specifically have sufficient statistical power to test for differences in treatment effectiveness. And we have some high priority subgroups that we'll be looking at. One is a self-identified race. There's been a noted disparity in maternal hypertensive disorders, for individuals who self identify according to different races. And so we will be powered to see if aspirin has comparable effectiveness and hopefully even better effectiveness for the groups who really need it, to bring those rates closer to equity which is, you know, certainly something we would very strongly desire to see. We'll also be able to look at subgroups of women according to obesity, according to maternal age at pregnancy, according to the start time of aspirin when aspirin use is initiated during pregnancy. So that's why the trial is so huge. For a statistician, the statisticians out there who might be listening, this is powered on a statistical interaction term, which doesn't happen very often. So it's exciting that the trial is funded in that way.  

[00:14:27] Erin Spain, MS: Tell me a little bit more about this and how your specific skills are going to be utilized in this study.  

[00:14:32] Denise Scholtens, PhD: Well, there are three biostatistics faculty here at Northwestern involved in this. So we're definitely dividing and conquering. Right now, we're planning this study and starting to stand it up. So we're developing our statistical analysis plans. We're developing the database. We are developing our randomization modules. So this is the piece of the study where participants are randomized to which dose of aspirin they're going to receive. Because of all of the subgroups that we're planning to study, we need to make especially sure that the assignments of which dose of aspirin are balanced within and across all of those subgroups. So we're going to be using some adaptive randomization techniques to ensure that that balance is there. So there's some fun statistical and computer programming innovation that will be applied to accomplish those things. So right now, there are usually two phases of a study that are really busy for us. That's starting to study up and that's where we are. And so yes, it is very busy for us right now. And then at the end, you know, in five years or so, once recruitment is over, then we analyze all the data,  

[00:15:36] Erin Spain, MS: Are there any guidelines out there right now about the use of aspirin in pregnancy. What do you hope that this could accomplish?  

 Prescribing aspirin use for the prevention of hypertension during pregnancy is not uncommon at all. That is actually fairly routinely done, but that it's not outcomes based in terms of which dosage is most effective. So 81 milligrams versus 162 milligrams. That's what we will be evaluating. And my understanding is that clinicians prescribe whatever they think is better, and I'm sure those opinions are very well informed but there is very little outcome based evidence for this in this particular population that we'll be studying. So that would be the goal here, would be to hopefully very conclusively say, depending on the rates of the hypertensive disorders that we see in our study, which of the two doses of aspirin is more effective. Importantly, we will also be tracking any side effects of taking aspirin. And so that's also very much often a part of the evaluation of You know, taking a, taking a drug, right, is how safe is it? So we'll be tracking that very closely as well. Another unique part of this study is that we will be looking at factors that help explain aspirin adherence. So we are going to recommend that participants take their dose of aspirin daily. We don't necessarily expect that's always going to happen, so we are going to measure how much of their prescribed dose they are actually taking and then look at, you know, factors that contribute to that. So be they, you know, social determinants of health or a variety of other things that we'll investigate to try to understand aspirin adherence, and then also model the way in which that adherence could have affected outcomes.  

Erin Spain, MS: This is not the first study that you've worked on involving maternal and fetal health. Tell me about your interest in this particular area, this particular field, and some of the other work that you've done.  

[00:17:31] Denise Scholtens, PhD: So I actually first got my start in data coordinating work through the HAPO study. HAPO stands for Hyperglycemia Adverse Pregnancy Outcome. That study was started here at Northwestern before I arrived. Actually recruitment to the study occurred between 2000 and 2006. Northwestern served as the central coordinating center for that study. It was an international study of 25,000 pregnant individuals who were recruited and then outcomes were evaluated both in moms and newborns. When I was about mid career here, all the babies that were born as a part of HAPO were early teenagers. And so we conducted a follow up study on the HAPO cohort. So that's really when I got involved. It was my first introduction to being a part of a coordinating center. As I got into it, though, I saw the beauty of digging into all of these details for a huge study like this and then saw these incredible resources that were accumulated through the conduct of such a large study. So the data from the study itself is, was of course, a huge resource. But then also we have all of these different samples that sit in a biorepository, right? So like usually blood sample collection is a big part of a study like this. So all these really fun ancillary studies could spin off of the HAPO study. So we did some genomics work. We did some metabolomics work. We've integrated the two and what's called integrated omics. So, you know, my work in this space really started in the HAPO study. And I have tremendously enjoyed integrating these high dimensional data types that have come from these really rich data resources that have all, you know, resulted because of this huge multicenter longitudinal study. So I kind of accidentally fell into the space of maternal and fetal health, to be honest. But I just became phenomenally interested in it and it's been a great place.  

[00:19:24] Erin Spain, MS: Would you say that this is also a population that hasn't always been studied very much in biomedical science?  

[00:19:32] Denise Scholtens, PhD: I think that that is true, for sure. There are some unique vulnerabilities, right, for a pregnant individual and for the fetus, right, and in that situation. You know, the vast majority of what we do is really only pertaining to the pregnant participant but, you know, there are certainly fetal outcomes, newborn outcomes. And so, I think conducting research in this particular population is a unique opportunity and there are components of it that need to be treated with special care given sort of this unique phase of human development and this unique phase of life.  

[00:20:03] Erin Spain, MS: So, as data generation just really continues to explode, and technology is advancing so fast, faster than ever, where do you see this field evolving, the field of biostatistics, where do you see it going in the next five to ten years?  

[00:20:19] Denise Scholtens, PhD: That's a great question. I think all I can really tell you is that I'm continually surprised by new data types. I think that we will see an emergence of a whole new kind of technology that we probably can't even envision five years from now. And I think that the fun part about being a biostatistician is seeing what's happening and then trying to wrap your mind around the possibilities and the actual nature of the data that are collected. You know, I think back to 2004 and this whole high throughput space just felt so big. You know, we could look at gene transcription across the genome using one technology. And we could only look at one dimension of it. Right now it just seems so basic. When I think about where the field has come over the past 20 years, it's just phenomenal. I think we're seeing a similar emergence of the scale and the type of data in the imaging space and in the wearable space, with EHR data, just. You know, all these different technologies for capturing, capturing things that we just never even conceived of before. I do hope that we continue to emphasize making meaningful and translatable conclusions from these data. So actionable conclusions that can impact the way that we care for others around us. I do hope that remains a guiding principle in all that we do.  

[00:21:39] Erin Spain, MS: Why is Northwestern Medicine and Northwestern Feinberg School of Medicine such a supportive environment to pursue this type of work?  

[00:21:47] Denise Scholtens, PhD: That's a wonderful question and one, honestly, that faculty candidates often ask me. When we bring faculty candidates in to visit here at Northwestern, they immediately pick up on the fact that we are a collaborative group of individuals who are for each other. Who want to see each other succeed, who are happy to share the things that we know and support each other's work, and support each other's research, and help strategize around the things that we want to accomplish. There is a strong culture here, at least in my department and in my division that I've really loved that continues to persist around really genuinely collaborating and genuinely sharing lessons learned and genuinely supporting each other as we move toward common goals. We've had some really strong, generous leadership who has helped us to get there and has helped create a culture where those are the guiding principles. In my leadership role is certainly something that I strive to maintain. Really hope that's true. I'm sure I don't do it perfectly but that's absolutely something I want to see accomplished here in the division and in NUDACC for sure.  

[00:22:50] Erin Spain, MS: Well, thank you so much for coming on the show and telling us about your path here to Northwestern and all of the exciting work that we can look forward to in the coming years.  

[00:22:59] Denise Scholtens, PhD: Thank you so much for having me. I've really enjoyed this.  

[00:23:01] Erin Spain, MS: You can listen to shows from the Northwestern Medicine Podcast Network to hear more about the latest developments in medical research, health care, and medical education. Leaders from across specialties speak to topics ranging from basic science to global health to simulation education. Learn more at feinberg. northwestern.edu/podcasts.  

Dr. Abigail Konopasky Received Funding for Medical Education Research Project

Abigail (Abby) Konopasky, PhD, director of medical education research and scholarship and associate professor of medical education at Geisel School of Medicine, has received a Medical Education Scholarship Research and Evaluation grant from the Northeast Group on Educational Affairs (NEGEA) to initiate a new project.

NEGEA, one of four regional groups of the Association of American Medical Colleges, fosters excellence in medical education and is interested in promoting collaboration across and within institutions to stimulate the development of a community of medical education scholars.

Geisel’s Konopasky and her research partner Carmen Black, MD, assistant professor of psychiatry and director of Social Justice and Health Equity (SJHE) Education at Yale School of Medicine, are investigating the generational impact of racial trauma.

Although medical education is beginning to address racism through its research and practices, the field has not fully addressed the generational impact of racial trauma. Current Diversity, Equity, Inclusion, and Justice (DEIJ) efforts still apply “Black or African American” to all Black racialized physicians or trainees regardless of historical or cultural background. This approach ignores the experiences of those whose ancestors were enslaved here within the U.S.— Historically Black Americans (HBAs), while many DEIJ leaders are themselves HBAs.

The purposes of this critical qualitative interview study, Konopasky explains, are to examine how DEIJ leaders’ historical and cultural identities and resources influence their exercise of agency to resist white supremacy and, based on those findings, to work collaboratively with HBAs in medicine to develop recommendations for integrating historical and cultural perspectives into DEIJ work.

“This grant will allow us to see and honor the full historical identities of those doing the important work of Diversity, Equity, Inclusion, and Justice,” Konopasky says, “so that future work in medical education—ours and that of others—can move from the homogenizing category, ‘underrepresented in medicine’ to seeing the full identity of each member of our community.”

Drawing on both linguistics and psychology, Konopasky’s research centers on linguistic tools to better understand inequity, agency, and resistance with currently and historically marginalized individuals. Her Critical Approaches to Language and Equity (CALE) Lab brings together linguistic and narrative tools with critical theories such as Black Feminist Theory, Queer Theory, and Critical Disability Studies to both uncover and understand experiences of inequity and injustice.

Black’s research focuses on promoting historically informed racial justice within academic medicine and addressing iatrogenic (unintentionally induced) influences of poor patient care—specifically racism and mental health discrimination within daily clinical practice. She is a national advocate for patient and provider safety promoting the equitable treatment of behavioral emergencies by removing police- and security-based interventions from general hospital medicine.

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• Research Rounds
• Faculty Development
• Grand Rounds
• Abby’s Article Alcove

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UGA breaks ground on new medical education and research building

The groundbreaking was a "transformational moment at the University of Georgia"

The University of Georgia broke ground Friday on a new medical education and research building that will significantly expand teaching and research capabilities at the university’s future School of Medicine .

Located on UGA’s Health Sciences campus, preliminary plans for the building include medical simulation suites, standardized patient rooms, clinical skills labs, a gross anatomy lab, and a medical library. The building will also feature student support spaces like conference rooms, study spaces, lounges, and faculty and staff offices dedicated to student support.

In total, the proposed building will measure approximately 92,000 square feet. Roughly 67,000 square feet of the building will be dedicated to medical education while the remaining 25,000 square feet will house biomedical research laboratories.

Gov. Brian Kemp speaks at the groundbreaking ceremony for the Medical School Building on the Health Sciences Campus. (Andrew Davis Tucker/UGA)

The new building will complement existing facilities and provide the UGA School of Medicine with capacity to expand from 60 students per class to 120 in the future.

“Today is an exciting and transformational moment at the University of Georgia,” said UGA President Jere W. Morehead. “As a land-grant university and Georgia’s flagship research institution, the University of Georgia is uniquely positioned to address the health care needs of our state through world-class medical education, research and community outreach.”

Following the recommendation of Governor Brian Kemp, the Georgia General Assembly passed a fiscal year 2024 amended budget that includes $50 million in funding for a new University of Georgia School of Medicine facility.

President Jere W. Morehead speaks along with USG Chancellor Sonny Perdue and Gov. Brian Kemp at the groundbreaking ceremony for the Medical School Building on the Health Sciences Campus. (Andrew Davis Tucker/UGA)

The $50 million in state funding will be matched by private contributions to fund the $100 million medical education and research building.

The University System of Georgia Board of Regents authorized the University of Georgia to establish a new independent School of Medicine in Athens in February.

In March, Dr. Shelley Nuss was named founding dean of the UGA School of Medicine. She previously served as an associate professor of internal medicine and psychiatry in the Augusta University/University of Georgia Medical Partnership. In 2016, she was named campus dean of the Medical Partnership, which has been educating physicians in Athens since 2010.

“The fact is, Georgia needs more doctors, and we need them now,” said Nuss. “The new UGA School of Medicine will increase the number of medical students in the state, translating to more practicing physicians to help address Georgia’s greatest health care challenges.”

The creation of the UGA School of Medicine marks the natural evolution of the longest-serving medical partnership in the United States. Similar programs founded around the same time have already transitioned to independent medical schools.

USG Chancellor Sonny Perdue speaks from the podium along with Gov. Brian Kemp at the groundbreaking ceremony for the Medical School Building on the Health Sciences Campus. (Andrew Davis Tucker/UGA)

UGA will continue to work closely with the Medical College of Georgia to ensure a smooth transition for current medical students as UGA seeks accreditation from the Liaison Committee on Medical Education (LCME).

The development of a new public school of medicine at UGA promises to help address a significant shortage of medical professionals. Georgia’s growing population tops approximately 11 million residents, straining the state’s existing medical infrastructure.

Now the nation’s eighth largest state, Georgia is forecasted to experience further population growth in the coming years, and nearly one-third of the state’s physicians are nearing retirement.

“Georgia is growing,” said Sonny Perdue, chancellor of the University System of Georgia. “We may only be only eighth today, but in just a few short years Georgia could be the fifth largest state. And that means we are going to need more health care, and people are going to get it here and across the state.”

Founding Dean of the School of Medicine Shelley Nuss, middle, is surrounded by medical students at the groundbreaking ceremony for the Medical School Building. (Andrew Davis Tucker/UGA)

Georgia currently ranks No. 40 among U.S. states for the number of active patient care physicians per capita, according to the Association of American Medical Colleges (AAMC), while it ranks No. 41 for the number of primary care physicians and No. 44 for the number of general surgeons per capita. The shortage of medical providers is particularly acute in rural and underserved areas, where access is even more limited.

UGA faculty are already engaged in human health research, and the establishment of a school of medicine will bolster their efforts.

“Our flagship institution, the University of Georgia, is tasked with the vital mission of educating and preparing the next generation of leaders,” said Gov. Brian Kemp. “To that end, one of our top priorities is building a strong health care workforce pipeline. This UGA facility will be an essential part of those efforts.”

Alongside funding from state government, strong private support will fortify efforts to create a School of Medicine at UGA. Donors have demonstrated robust support for UGA initiatives in recent years. In fiscal year 2023, UGA raised over $240 million in gifts and pledges from alumni, friends and foundation and industry partners. The university’s three-year rolling fundraising average is now a record $235 million per year, with annual contributions exceeding $200 million for the past six consecutive years.

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Ethnography in qualitative educational research: AMEE Guide No. 80

Affiliation.

• 1 Center for Innovation in Interprofessional Education, University of California, 520 Parnassus Avenue, CL112 San Francisco, CA 94143, USA. [email protected]
• PMID: 23808715
• DOI: 10.3109/0142159X.2013.804977

Ethnography is a type of qualitative research that gathers observations, interviews and documentary data to produce detailed and comprehensive accounts of different social phenomena. The use of ethnographic research in medical education has produced a number of insightful accounts into its role, functions and difficulties in the preparation of medical students for clinical practice. This AMEE Guide offers an introduction to ethnography - its history, its differing forms, its role in medical education and its practical application. Specifically, the Guide initially outlines the main characteristics of ethnography: describing its origins, outlining its varying forms and discussing its use of theory. It also explores the role, contribution and limitations of ethnographic work undertaken in a medical education context. In addition, the Guide goes on to offer a range of ideas, methods, tools and techniques needed to undertake an ethnographic study. In doing so it discusses its conceptual, methodological, ethical and practice challenges (e.g. demands of recording the complexity of social action, the unpredictability of data collection activities). Finally, the Guide provides a series of final thoughts and ideas for future engagement with ethnography in medical education. This Guide is aimed for those interested in understanding ethnography to develop their evaluative skills when reading such work. It is also aimed at those interested in considering the use of ethnographic methods in their own research work.

Publication types

• Anthropology, Cultural
• Data Collection / methods
• Education, Medical*
• Qualitative Research*
• Research Design*