Clinical Ethnography: Negotiating Reflexivity as a Clinician Researcher

Purpose: With increasing focus on translating evidence based practices, more research is being conducted in real world settings on how interventions are effective. Qualitative methods lend themselves to this type of investigation, as they can explore implementation processes (Shaw, 2003). In addition to conducting qualitative interviews, utilizing ethnographic methods in clinical settings can be valuable at capturing process factors, such as social interaction, by observing clinicians and clients “in-vivo”. Researchers with experience as clinical social workers can enhance the rigor of ethnographic methods by bringing a nuanced understanding of the setting and the clinical task. However, the clinician researcher is also presented with challenges in terms of how to handle issues of their reflexivity and how to “blend in” with the service environment (Lawlor, 2003). This qualitative study exploring how case managers engage clients, conducted by social workers who have case management experience, provided important insights into clinical ethnography and the much debated distinctions between the role of clinician and researcher (Gilgun, 1994; Padgett, 1998).

Method: The study setting was a program providing housing and support services for clients with co-occurring disorders experiencing homelessness using an assertive community treatment model. Researchers were in the field for a year, following 10 clients, who recently enrolled in the program, and 14 case managers from two treatment teams. Using ethnographic methods, that included observation and ad hoc interviews, researchers sampled key events in the engagement process, including service contacts in the office, community and client's home. In depth field notes were recorded on the social interaction between case managers and consumers.

Findings: The key aspects of negotiating reflexivity for clinician researchers were: • When and when not to engage participants in the research relationship: researchers needed to connect with clients to build trust and empower them in the research task but had to preserve the integrity of the clinical encounter • How much to be involved in the clinical encounter: researchers' familiarity with the setting facilitated them "blending in" and being part of the encounter but they had to balance this with the need to observe and distinguish oneself as a researcher • Monitoring tendencies to be a clinician: being mindful of inclinations to take a clinical role and respond to the needs of the consumers • Awareness of the clinical lens: utilizing clinical insight but also maintaining the more open lens of the researcher when recording and interpreting field observations

Implications: This study provides important insight into clinical ethnography, both the strengths of this type of research and the challenges. Being able to integrate clinical insight into research observation with care will enhance the quality of the observational data. As social workers conduct more implementation research, focusing on how to increase the rigor of ethnographic methods is vital given its potential to illuminate the translation of evidence based practice to real world settings.