Ethnographic Study of a Military Family Medical Center
Ethnography Report -Technical Writing
Ethnographic Project -- Military Family Medical Center
Project Purpose & Setting:
This report addresses the workings of a family care center located in a large military hospital on a joint operations military base. The hospital serves active duty members of the military, family members and dependents of active duty soldiers, citizens who work for the military in some capacity, and retired members of the military. A considerable number of wounded warriors are treated at this military hospital, including those who have been diagnosed with PTSD. The military hospital is situated on a joint command post that is receiving a great many warriors who have returned from fighting down range.
Using a grounded theory ethnographic approach, a series of six observation sessions in the waiting room of the family care center were conducted, along with two longer sessions in the emergency waiting room of the same hospital (Guba & Lincoln, 1994). During these sessions, administrative staff was observed communicating with patients during check in, while patients were waiting to be seen -- often for extended periods of time -- and following their sessions with medical staff. Some observation of interactions between medical staff and patients occurred as medical staff ushered soldiers or dependents out of the treatment rooms and down the corridors to the general waiting room of the family medical center.
Over the course of the observations, several well-regarded qualitative research strategies were used to assist with the identification of emergent themes. Memo-writing was used to capture immediate impressions and insights when reading over the field notes. As the researcher reads and annotates the data in a process called memoing, he moves "back and forth between the logical construction and the actual data in search for meaningful patterns" (Paton, 1990, p. 411). Reflective journaling was used to triangulate the data from the observation field notes and the memo-writing. Both methods promoted deeper probes in subsequent observations.
A constant comparison technique was used during the structured analysis of the data. The technique known as constant comparison is a conventional strategy for ensuring that each bit of information or data is considered on its own merit and in comparison with every category established for coding the data. Glaser and Strauss (cited in Lincoln and Guba, 1985, p. 339) describe the constant comparison method as a four-stage procedure. The four stages are as follows: (1) comparing data that is applicable to each category, as the categories emerge; (2) integrating the categories and their properties to reduce the data set and data noise; (3) further delimiting the theory based on reduced data set; and (4) writing the theory. The main data patterns are identified, categorized, and coded as the meanings "emerge out of the data rather than being imposed on them prior to data collection and analysis" (Patton, 1990, p. 390).
The data analysis required the researcher to "wallowing in the data" (Glasser & Strauss, 1967). In the process of writing memos, noting emergent patterns, and changes to the categories as a result of the constant comparison refining process, an awareness of the use of self in the data collection and data analysis is crucial (Coffey & Atkinson, 1996). Categorical definitions can be expected to change as data is grouped and regrouped in the analysis (Glasser & Strauss, 1967; Lincoln & Guba, 1985). "In defining categories, therefore, we have to be both attentive and tentative - attentive to the data, and tentative in our conceptualizations of them" (Dey, 1993, p. 102). Finally, the concepts of validity and reliability are foreign to the field of qualitative research -- the concepts are not a good fit -- and the construct of trustworthiness of the data is substituted instead (Kvale, 1995; Lincoln & Guba, 1985).
Qualitative research is not based on positivist theory and, as such, does not use a hypothesis as the basis of the research design. However, qualitative research does employ research questions that -- along with the selection and narrowing of a topical focus -- guide the inquiry process. The following research questions were identified over the course of the study:
1. Do staffing levels appear to be adequate to the number of patients who pass through the family medical clinic each day?
2. What coping mechanisms and rationalizing measures do administrative staff -- as street-level bureaucrats -- appear to employ when demand surpasses supply?
3. Do dependent family members appear to be satisfied with the administrative processing that precedes and follows their medical treatment and health care?
4. Do dependent family members appear to receive disparate levels of attention, explanation, and care when presenting at the family medical center?
Discussion & Findings
An aspect of the integrity of qualitative research process is for the researcher to consider his role as an instrument of inquiry. Doing so obligates the researcher to move forward with an attitude of circumspection and to consider how his perceptions, pre-conceived notions, and biases may impact data collection, data analysis, and research conclusion. From the start of this inquiry, a mildly negative valence has been attached to the activity, which upon deeper reflection was viewed as anticipation that quality of care received by dependent family members would not be adequate. Further, there was a decided expectation that differences would appear with regard to administrative interactions with dependent family members based on the rank of the soldiers, on intangibles or on the tangible representation of socio-economic status, race, and ethnicity. Moreover, since a silent culture of compliance is yoked to a tacit culture of the privilege of rank, dependent family members were seen as unlikely to protest in their own behalf -- in fact, they were expected to be chameleon-like in their behavior, blending in with the milieu and the regimented context.
In fact, careful and unobtrusive observation showed that dependent family members were skilled at calling attention to their needs and to helping establish an informal triage in the family medical center waiting rooms. Moreover, administrative staff, while notably deferential to active duty soldiers, appeared to be careful not to exhibit any discriminatory behavior or even more subtle attitudes with regard to the race, ethnicity, or socio-economic status of patients in the family medical center waiting rooms. However, de facto preferential treatment did occur according to the rank of active duty soldiers -- and further observation revealed that the link between rank and economic-status was substantive, thereby negating the need to overlay any additional perspective over the proceedings. That is to say, that if a member of the medical administrative staff was at all inclined to express status consciousness, the military system of discrimination between officers and enlisted men ipso facto pre-empted any such need.
The following themes were identified through data analysis:
Active duty soldiers (uniforms are required in the family medical center) receive priority service by administrative staff
Dependent spouses receive priority service when accompanied by their active duty spouses
Dependent spouses and active duty soldiers receive priority service when accompanied by dependent children who are obviously ill
Administrative staff exhibited many coping mechanisms and rationalizing strategies due to the mismatch between patient numbers and administrative staff capacity.
The first three themes listed above were, as previously noted, supported by the military hierarchical system of officers and enlisted men. The privileges and the expression of routine treatment carried over into the family medical center. Future research could potentially examine if this pattern followed military dependents in their transactions off-post. The last theme generated the most interesting findings and even served to alter the focus of the research (that this can legitimately happen is one of the appealing aspects of qualitative research) from the patient experience -- which turned out to be remarkably stable and true to form -- to…