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This study utilised an ethnographic approach, alongside a mixed-methods review. It focused on the routine work of continence care for PLWD admitted to acute hospital settings in the wider context of the everyday care carried out by nurses and HCAs. We provide a detailed understanding of social and institutional forces shaping and influencing continence care. Our ethnographic approach enabled us to understand how staff respond to the continence care needs of PLWD and to follow the consequences of their actions. We examined how staff account for and make sense of the needs of PLWD in these contexts.107
Ethnography provides a sophisticated toolkit for exploring the complexities of the everyday, forging better understandings of daily meaning-making92 in organisational structures and settings. Ethnography delivers detailed understandings of organisational culture, organisational change and the inter-relationships between different elements of an organisation. In health-care settings, ethnography allows researchers to take into account perspectives across the clinical experience, exploring the perceptions of patients and carers; medical, nursing and care teams; and wider auxiliary, administrative and managerial staff.108,109 It is particularly useful to examine research questions that aim to access the unspoken and tacitly understood, as well as complex and highly sensitive, topics that are not easy or appropriate to measure.110
Our approach to ethnography is informed by the symbolic interactionist tradition, which aims to provide an interpretive understanding of the social world. This places an emphasis on interaction, understanding how action and meaning are constructed in a specific setting, and acknowledging the mutual creation of knowledge by both the researcher and those researched.111 The study aimed to deliver understandings of everyday continence care for PLWD in the acute hospital setting, focusing on how the wide range of social actors in these settings (i.e. the large number of ward staff that patients will come into contact with during an admission) respond to continence care needs of PLWD and to follow the consequences of their actions. Ethnography allows us to examine these elements and, importantly, the interplay between them. Ethnography examines ‘up close and in person how work is organized and how the organizing organizes people’.92
Ethnography, at its core, is the in-depth study of a small number of cases. By exploring people’s actions and accounts in their natural everyday settings, ethnographers can collect relatively unstructured data from a range of sources, including observation, informal interviews and documentary evidence.112 Ethnographers ‘hold that an appreciation of the extraordinary-in-the-ordinary may help to understand the ambiguities and obscurities of social life’.92 This approach provides a depth of understanding and theory generation.113 There is long tradition of ethnography in health-care settings,111 and there are many examples of ethnographic studies that have had a significant impact on policy and practice.114–117
Our aim in utilising ethnography was to explore the otherwise unnoticed details of everyday life, in other words what is tacitly acknowledged, but rarely discussed, around ordinary and, in the case of continence care, hidden activities. Starr118 notes the importance of examining organisational infrastructure and the ‘hidden mechanisms’ constructed and embedded in the technical and procedural work carried out within it.118 The articulation work of people in organisational and institutional settings was examined (i.e. how people in organisational and institutional settings account for and make sense of their actions). An ethnographic approach allowed us to explore both the front-stage performance and also the backstage work practices,119 while always maintaining the dignity and privacy of both patients and staff.
In any organisation, there are groups of people whose everyday work is unrecognised formally, often unnoticed and invisible.118 In the hospital setting, such groups include carers, nurses, HCAs and auxiliary staff, for example those working in domestic services. In the context of our research questions, ethnography can examine how social and institutional forces shape and influence the work of health-care providers (HCPs)120 and the everyday routine behaviours of individuals, both within and across multidisciplinary teams.121
This study focuses on the routine work of continence care for PLWD admitted to acute hospital settings. This study considers the wider context of the everyday care carried out by nurses and HCAs, and provides a detailed understanding of the social and institutional forces that shape and influence continence care. Our ethnographic approach enables us to (1) understand how staff respond to the continence care needs of PLWD and (2) follow the consequences of their actions. We examine how staff make sense of the needs of PLWD in these contexts.107 In presenting our findings, utilisation of ethnographic ‘thick description’ enables the reader to connect concepts, policies and practice to detailed empirical examples.122 This approach allows the reader to develop not only a strong connection to the social world of these wards, but also an understanding of the complex social relations within them; the personal impacts of continence care on patient, carers and ward staff; and how this connects with wider issues in the organisation and delivery of care in these institutional settings.122
Prior to data collection, in January 2018, Deborah Edwards and Jane Harden carried out a mixed-methods systematic review and thematic synthesis of the literature to identify successful strategies in care settings that could inform innovations in continence care for PLWD in the acute hospital setting. This approach bridged the gap between research, policy and practice123 and was useful in examining the complexities of health service settings. The generated synthesis was used to refine our approach to fieldwork and analysis, and to inform the development and feasibility of the interventions.