Do We Practice What We Preach?

As an emergency nurse with three years' full-time experience working in a medium-sized hospital in a regional city. I decided to undertake an honours degree in nursing. I wanted to explore the culture of emergency nursing, as it seemed to me that it is a unique style of nursing. After some preliminary reading and discussion, it became evident that the most appropriate methodology to employ would be ethnography.

As my research project unfolded. I began to think of myself as a little like Alice in Through The Looking-Glass (Carroll 1872). Alice looks from a room in her house through the mirror into 'Looking-glass House'. Everything appears to be the same in the room she can see (albeit back to front), until Alice manages to pass through the mirror, where she discovers an entirely new perspective: 'Then she began looking about, and noticed that what could be seen from the old room was quite common and uninteresting, but that all the rest was as different as possible.'

Like Alice in Through The Looking-Glass, as an ethnographic researcher investigating my own workplace and therefore inevitably my colleagues, I found myself in an alternate world in which I could view the same environment from a different perspective.

I found that occupying this space brought with it tensions pertaining to being, in ethnographic terms, both an 'insider' and an 'outsider' at the same time. These are tensions that are well documented within the ethnographic literature (Bruni 1995, Hanson 1994, Kauffman 1994, McInerney and Robinson 2001. Rudge 1996, Walker 1997a). Additionally. various tensions emerged for me throughout the course of the research, specifically because I undertook research in a familiar nursing context, and it is these tensions that will form the subject of this article.

Ethnographic research in nursing could be described as having two levels for nurses who choose to conduct their research in the 'field' of nursing. The first involves nurses undertaking research in nursing contexts that were previously unfamiliar to them, but in which they have shared understandings because of their history of working in other settings as nurses; the second involves nurses undertaking research in their own familiar workplaces. This distinction is not made explicit within the nursing literature on ethnography to date, and each level of familiarity involves different (although not exclusive) tensions.

Ethnographies, including those conducted within nursing, have traditionally involved researchers, as outsiders, going into the field to study an unfamiliar cultural group and attempting to portray the insider's perspective of that culture (de Laine 1997, Rudge 1995, Streubert and Carpenter 1995). In recent years, this practice has been critiqued and challenged, with a move in nursing towards valuing the contribution that nurses can make if they study their own culture, or a part of that culture (Atha et al 1989. Bruni 1995, Rudge 1995). Despite this impetus, nurses have thus far conducted scant research in their own workplaces, although there have been a number of ethnographic studies conducted by nurses in the wider culture of nursing (for example, Campbell 1999, Malone 2000).

Thus I found myself in an unusual position: as an 'insider' trying to study my own cultural group, or 'going to the field by staying at home' (Bell 1993). I foresaw at the outset of the research project that my insider position might cause tensions for me, as shown in my first journal entry, which describes my first meeting with my supervisor:

'I discussed how I feel… I have been "encultured" … [and this] may be a limitation in my research, ie, the fact that I have been immersed in the culture for three years and am now a "native" means that I might not be able to "see" as much as if I was freshly entering the area…' (Cudmore 2001a).

Because I was so familiar with the nursing context in which I chose to undertake my study, it might be said that I viewed my own and others' practice as normal and taken for granted, or as 'common and uninteresting' (Carroll 1872). I was interested in examining these assumptions and the 'taken-for-grantedness' inherent in the culture of emergency nursing. Therefore, I felt that my ethnographic study must have a critical intent. With the development of a more reflexive approach to ethnography and the addition of a critical focus to the research, this was achieved (Lont 1995, Manias and Street 2001, Street 1992). To be reflexive is to acknowledge the social and historical factors that shape who I am, as researcher, thus allowing the problematic nature of my representation of the participants and ownership of the research to be, at least partly, addressed (Manias and Street 2001, Probyn 1993, Walker 1993).

One of the core requirements of any ethnographic or critical research is the keeping of field notes, or a journal. The journal extracts I have used to describe the tensions brought about by the research process are woven through the narrative of this article. These tensions emerged not only because I conducted the research in a familiar nursing context, but also because of the critical intent of the research itself.

The process of critical reflection has been appropriated by nursing, particularly in the last 20 years, as a means of resisting and transforming the oppression seen as inherent in nursing culture (Roberts 1983, Street 1992), and as a way of nurses 'finding their voices' (Thompson 1987). Reflection may be defined as 'the process of internally examining and exploring an issue of concern… which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective' [emphasis added] (Boyd and Fales 1983). To engage in critical reflection then, as it applies to nursing, is to 'stand apart from the prevailing order of the world and ask how that order came about' (Cox 1981), while reflecting on nursing practice. 'Journalling', therefore, is one such method nurses may use to reflect critically on their practice (Cox et al 1991).

Holly (1992) and Kobert (1995) argue that the act of keeping a journal permits a dialogue between the 'objective' fact world and 'subjective' interpretations. The process of keeping a journal starts to raise the 'consciousness' of the nurse about his or her practice, as it serves to uncover the 'auto pilot' at work in everyday practice (Crotty 1998, Street 1990).

My journal was therefore vitally important in serving to uncover my "auto pilot'. The process of keeping a journal, revisiting the entries and discussing them with other researchers and academics, served to give the research a critical intent. Because of this critical intent, I found myself increasingly using my journal to reflect on those aspects of practice that became extraordinary when viewed 'through the looking-glass' as a researcher or 'outsider'.

As clinician and researcher, I became what Walker (1997a) terms a 'border ethnographer', being a researcher who found herself in 'the "in between" space of clinician/academic… one who inhabits the "slash" rather than the territory on either side'. The 'borderlands' (Walker 1997a) has developed as a metaphor within nursing ethnography to describe the constant tension experienced by nurses as they try to assume both these roles within their identities. While this may be true, undertaking research within my own 'field' of practice had many advantages for me, with particular regard to participants' honesty in sharing their practice as emergency nurses (Manias and Street 2001). However, tensions became evident as I began to feel that I could become isolated in my role as researcher. During the first few months of the research project, I reflected on this in my journal:

'One of my nursing colleagues said to one of our other colleagues, "we're not talking to her anymore, she's deserted us". Even though I knew he was only joking, I felt pangs of isolation immediately…' (Cudmore 2001a).

This experience signified how I was seen as an outsider by my colleagues as a result of adapting my role to include that of researcher. This offhand comment had the immediate effect of making me feel isolated. Somehow, through undertaking my research, I had 'deserted' the other nurses with whom I worked, and further, I might be being viewed with some suspicion. I reflected with my supervisor that this concept of desertion might be indicative of my move to the borderlands. It might be that I immediately felt isolated because the borderlands are lonely places: not fully understood or 'owned' by either the clinical or research 'institutions' in nursing, hence the tensions of occupying that space.

As I began to immerse myself in the ethnographic literature, I found myself relating to the concept of 'the competing agendas of each institution' (Walker 1997a). Indeed, depending on whose company I was in, I felt compelled to keep privileging one aspect of my clinician/researcher role over the other, an experience shared by Walker (1997b), another nurse/ethnographer. He asserted that "total escape" from the crisis is an insoluble problem' because of these competing agendas. This constant movement within the borderlands meant that I was not conducting my study from a static perspective, and made the notion of achieving a 'critical distance' from the field under study somewhat farcical and unachievable.

This issue of achieving a 'critical distance' when undertaking research in a familiar context has been well articulated within the ethnographic literature (Hanson 1994, Bell 1993). Ethnographers have traditionally been encouraged to 'immerse' themselves in the culture they are studying, so they can portray the insiders' perspective through their research, and yet somehow maintain this critical distance to guard against the danger of 'going native' (Baillie 1995, Bruni 1995, 1994, Roper and Shapira 2000).

The argument against undertaking research in a familiar context is based on the notion that the researcher will be biased by his or her personal point of view, whereas to conduct 'true' ethnography requires the suspension of the researcher's own viewpoint (Hanson 1994). Inherent in this argument is the assumption that if the researcher goes 'tramping about the world' in order to conduct research in an unfamiliar environment, they will be able somehow to suspend their own viewpoint (Probyn 1993). Since the mid1980s, this assumption has been the subject of extensive critique (Clifford 1998, Clifford and Marcus 1986, Probyn 1993, Rudge 1996). Reinharz (1992) discusses how 'the setting, rather than [the] methodological ideology, defines the appropriate role' between the 'researcher' and the 'researched'. She further argues that 'any stance is acceptable as long as research findings are analysed in terms of the particular types of relationship that occurred' (Reinharz 1992).

A strong case can therefore be made for undertaking ethnographic research within a familiar nursing context. Greenwood (1984) argues that in researching nursing practice, it is imperative that an insider who has shared understandings of the research setting conducts the research, so that the behaviours of the participants are not misinterpreted. Similarly, Reinharz (1992) argues that 'closeness' is necessary for a greater understanding of the participants involved in the research. Nurses undertaking research within their own field of practice may also avoid 'culture shock', and have a greater sensitivity towards their participants' behaviours (Byerly 1969).

As discussed, I indeed found that my insider status in the nursing context in which the study was situated was advantageous, especially with regard to the openness of my participants. I also found that the wider body of my nursing colleagues was accepting of my evolving identity as both nurse and ethnographer:

'It makes life so much easier and more pleasant when you take a risk and do something a bit different lie the research], and feel so supported by your workmates' (Cudmore 2001a).

Even though I had the widespread acceptance of my colleagues, it became apparent that I was different from them, as evidenced when I tried to explain the methodology behind my study to my participants at the focus group I conducted:

'I thought I explained ethnography and critical theory in quite easy-to-understand terms, however I found that at the end of my spiel. I had four faces looking at me very blankly around the table, and no interaction with what I was saying…' (Cudmore 2001a).

Further, I found that because of my expectations of how my colleagues would respond to my research and my role as researcher, I consistently underestimated them in their responses to me and acceptance of me. Ironically, and importantly, there were times when my participants helped me get back on track in realising the worth of the study. Collaborating in this way with research participants has important ramifications for the use of ethnography in nursing research, as it moves towards recognising and valuing the contributions and meaning that both 'researcher' and 'researched' bring to the research process (Playle 1995).

I often felt an acute sense of tension during the research process that it might be construed that I was 'spying' on my colleagues, and thus betraying them by subjecting their practices to scrutiny. In relation to journalling, I wrote early in the honours year:

'I feel a bit like a traitor because I am watching everyone's practices and then commenting on them, or at least thinking about them, in [my journal]' (Cudmore 2001a).

As I continued to journal, however, I found that my entries ended up being more about myself than any of my colleagues. Nevertheless, the word 'betrayal' came up repeatedly in my journalling accounts of the experience of conducting the research, and the feeling of being a spy was never far from my mind. The concept of being seen as a possible spy when undertaking ethnographies in nursing is reported by Roper and Shapira (2000). Further, the tension of undertaking research with friends and colleagues is described by Williams (1995), who found she was 'confronted by issues of friendship with participants leading to the potential for their "betrayal and manipulation" in the research process'.

Indeed, some of my feelings of betrayal seem to have been due to a 'crisis of representation' (Denzin and Lincoln 1994); that is, not wanting to portray my colleagues in a 'bad light' in the outcome of the research. The term 'crisis of representation' also marks a period in the development of ethnography that included critiques of the ethnographer's privileged position, and of the legitimacy of the ethnographer speaking for the participants through the research (de Laine 1997). This crisis has been used increasingly to legitimise claims for 'insider' ethnographers conducting research in their own cultures, as discussed above. Despite this, I was acutely aware of the power this position gave me over my participants, and I did not want to betray them by using this power, intentionally or otherwise, to portray them badly in the research product.

This was a tension which I thought had been resolved during the research process until it came to writing the data-analysis chapters of my thesis. The process of writing served to return this tension to the surface, to the point where my supervisor could tell from the drafts of my analysis that I was trying to 'protect' my participants. For example, initially I did not want to include the following data excerpts:

'There are lots of genuine people that would really like to go somewhere to be seen quickly, and then home again, there's just no option for them.., to do anything else but come to the hospital. And they are then forced to mingle with the likes of the homeless, and… the multiple presenters…' (Cudmore 2001b).

'What about us, trying to deal with them ["psych" patients] and trying to deal with these sick people? You know, it is very difficult, and it's very time consuming, and I don't think that we, nurses, have got time to worry about… "psych" admissions' (Cudmore 2001b).

These excerpts were included, but a further source of tension for me was that I did not want participants to feel that I was criticising them in the data analysis. The nature of critical research makes data analysis uncomfortable given any setting. However, this seemed to be amplified because the research was undertaken in a familiar context where the participants were also friends.

Despite this added tension, I believe that ethnographies conducted within familiar nursing contexts are able to meet the tenets of a critical inquiry, perhaps more so than those where the researcher is unfamiliar with the setting. In those cases, it could be said that the researcher 'grabs' the data from the field and 'runs' with it back to the safety of their own familiar 'world' once the study is completed (Tarling et al 1998, Walker 1993). Through conducting my study in a familiar nursing context, not only have I given back to the culture that generated the study, but I have also stayed around to work through any consequences the study may have within the culture and for the participants.

I believe this article raises awareness of the tensions that the 'duplicitous' role of clinician/researcher may create for a nurse ethnographer researching in a context with which they are familiar, and even one in which they may work. Despite these tensions, ethnographic research is a valuable research methodology because of the diversity that exists within nursing, and the local culture of each individual clinical setting (Bruni 1995). However, it is clear that, although uncomfortable, critical intent and reflection form an important part of the research process when conducting an ethnographic study in a familiar nursing context. By incorporating a critical approach, the nurse researcher is able to subject his or her viewpoint to scrutiny, as well as the familiar nursing field that forms the subject of the inquiry. Not only does this result in new understandings of the clinical context being researched, but the nurse researcher is able to learn more about him or herself (personally and professionally) through the process.

Further, it would appear that although such research endeavours essentially critique the practices of the participants and their colleagues within the research context, it is possible for such a critique to be well received by them. In returning through the looking glass to the 'real' world, I found that following the results of my research being made public, the response from my colleagues, some of whom were also participants in the study, was very positive. Despite the critique of their practice, my colleagues talked to me with interest and enthusiasm about my findings, and gave no impression of being offended. This may be because nurses value research that is generated from 'within', as the researcher is already 'one of them'. Therefore the findings are ascribed a certain degree of validity, credibility and trustworthiness that would not be granted to an "outsider' researcher (Walker 1997b).

It is evident that there are a number of advantages to be gained from using a critical ethnographic research methodology to study familiar nursing contexts, as discussed within the body of this article. Moreover, it would seem that such a research methodology is especially suited to nurse researchers who would like to study their own unique field of nursing practice.

This article has been subject to double-blind review

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