Ethnographic Study of a Military Family Medical Center

Introduction and Project Purpose

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, civilians 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 large number of warriors who have returned from combat deployments.

Methodology

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 were 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 reviewing 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" (Patton, 1990, p. 411). Reflective journaling was used to triangulate the data from the observation field notes and the memo-writing. Both methods promoted deeper inquiry 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 piece 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:

(1) comparing data 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 the reduced data set; and (4) writing the theory. The main data patterns are identified, categorized, and coded as 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 engage in "wallowing in the data" (Glaser & Strauss, 1967). In the process of writing memos, noting emergent patterns, and refining categories through constant comparison, an awareness of the use of self in data collection and analysis is crucial (Coffey & Atkinson, 1996). Categorical definitions can be expected to change as data is grouped and regrouped during analysis (Glaser & 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 not well suited to qualitative research, and the construct of trustworthiness of the data is substituted instead (Kvale, 1995; Lincoln & Guba, 1985).

Research Questions

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 and Findings

An aspect of the integrity of the qualitative research process is for the researcher to consider his role as an instrument of inquiry. Doing so obligates the researcher to proceed with circumspection and to consider how his perceptions, preconceived notions, and biases may impact data collection, analysis, and conclusions. From the outset of this inquiry, a mildly negative valence was attached to the activity, which upon deeper reflection was understood as an anticipation that the quality of care received by dependent family members would not be adequate. There was also a decided expectation that differences would appear in administrative interactions with dependent family members based on the rank of soldiers and on tangible or intangible representations of socioeconomic status, race, and ethnicity. Moreover, since a silent culture of compliance is bound to a tacit culture of the privilege of rank, dependent family members were expected to be unlikely to advocate for themselves — in fact, they were expected to blend into 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 at helping establish an informal triage in the family medical center waiting rooms. Administrative staff, while notably deferential to active duty soldiers, appeared careful not to exhibit discriminatory behavior or more subtle discriminatory attitudes with regard to the race, ethnicity, or socioeconomic status of patients in the waiting rooms. However, de facto preferential treatment did occur according to the rank of active duty soldiers. Further observation revealed that the link between rank and economic status was substantive, thereby negating the need to apply any additional analytical lens. That is to say, if a member of the medical administrative staff was inclined to express status consciousness, the military system of distinction between officers and enlisted personnel ipso facto pre-empted any such need.