Ethnographical research frame

Since the aim of the study was to reassess the substance of person-centeredness in assisted living for older people, an ethnographical research frame suited this research well (cf. Geertz 1973; Hammersley & Atkinson 1995). I needed to understand assisted living surroundings and residents’ experiences of it to understand what residents were able to do and be in their living surroundings. Based on my own background as a practical nurse I knew the world I was entering, which had both advantages and drawbacks. I had to “make the familiar strange and the strange familiar”, like Riikka Lämsä (2013), a former hospital nurse who studied hospital wards or Bethel Ann Powers (1995), who worked as a gerontological nurse while studying an institutionalized care setting. My background made it easy to enter the setting and I did not have to use my observation time to understand the basic structures of daily life in the home. However, my background also highlighted the need to make the familiar strange to understand it in a different way. I had previously seen care settings largely through the eyes of a practical nurse, although I conducted participant observation in a care facility already in my master’s thesis (Pirhonen 2015a). The familiar became strange when I studied the setting from different perspectives, concentrating on the residents’ view.

Ethnography may be described both as a method and a methodology (Hammersley & Atkinson 1995; Ojajärvi 2015). As a method it aims to deepen the understanding of social phenomena in a social setting and to explore how people make sense of the world in everyday life and how they act on the basis of that understanding (Agar 1986; Gubrium 1995; Hammersley & Atkinson 1995; Lämsä 2013). I studied the phenomena in question in one setting but from different perspectives, aiming to reach “thick” descriptions on which to base the new understanding (cf. Geertz 1973; 1984; Honkasalo 2008). Ethnography as a methodology refers to the entirety of data collection, analysis, interpretations, and writing the reports (Hammersley & Atkinson 1995; Honkasalo 2008; Ojajärvi 2015).

There are probably as many ways to conduct an ethnographical study as there are

specific research orientation. These are fieldwork, the position of the researcher, and the purpose of the study.

The first ethnographers were European anthropologists who usually spent years among unfamiliar cultures in other continents in the late 19^th and early 20^th century, trying to understand how human cultures develop (Grönfors 1982; Roper & Shapira 1999). The idea was that by observing “primitive” cultures researchers could discover the “laws” that guide the evolution of cultures from the primitive to modern Western ones. Ethnography was thus perceived as part of positivist science. The First World War wrecked the perception of the nobility of Western culture and ethnography lost its genuine purpose. Following this, ethnographers in the US found the subcultures inside the US society, and ever since ethnographers have largely studied segments of their own societies and cultures. However, the importance of fieldwork as a method remained.

The importance of fieldwork emphasizes the position of the researcher in ethnography. The researcher herself is the most important research “device”. Being in the field personally among the participants makes ethnography embodied and inevitably emotional, too. What seems to be the weakness of ethnography in a scientific, objective sense, becomes the strength of the methodology when we consider the purpose: to deepen insights of the studied phenomenon. Ethnography is not about providing new information but new understanding (Gubrium 1995).

Tom Kitwood (1997a) has gone even further, defining the aim of ethnography as

“from understanding to standing under”. Kitwood conducted studies among older people with dementia illnesses to try to understand the experience of dementia (Kitwood 1997a; 1997b). By “from understanding to standing under” he means that the researcher may even go beyond understanding and touch the participants’

experiences by standing in the same circumstances with them. Although other individual’s experience is beyond the researcher’s reach as such, she may reach a similar experience when “standing under”.

Nursing homes became the scenes of ethnography in the 1970’s in the US and developed into a distinctive genre during the 1990’s (Henderson & Vesperi 1995).

The rise of nursing ethnography was parallel with the rise of other institutional ethnography and the study of different subcultures inside the US society (Smith 2005; Roper & Shapira 1999). The catalysts that pushed me towards ethnographic research were two books written by sociologists Jaber Gubrium (1997, originally 1975) and Timothy Diamond (1992). These two nursing home ethnographies inspired my methodology in my master’s thesis (Pirhonen 2015a) and encouraged me to continue with this study. Gubrium (1997), who spent time in a nursing home

without any prior experiences of them or the people connected to them wrote a thick description of daily life in a care facility. As Gubrium says in the introduction to the second edition of Living and dying in Murray Manor (1997, p. xii), “The research opened my eyes to a sad world, but also one that revealed the complicated meanings of living and dying in an institution. My aim in writing the book was to bring those complicated meanings to light, to document that from the participants’

perspectives”. Diamond conducted his study unconventionally. He first took a course for six months to become an assistant nurse and then worked in several care facilities to understand the growing nursing home business from inside. His book, Making Gray Gold, narratives of nursing home care (1992), presents a deep insight of how seeing elderly care as a business affects the lives of those working and living in care facilities. Diamond’s book shows how numbers in profit and loss accounts, balance sheets, and GDPs transfer into the lives of people occupying nursing homes. Both studies highlight the strength of ethnography in seeing how people (have to) make sense of their current lives in their current physical-social-cultural living surroundings.

In Finland, some recent ethnographical studies have been conducted in care settings (Järnström 2011a; 2011b; Koivula 2013; Lämsä 2013). Riitta Koivula (2013) interviewed and observed the relatives of people with dementia to understand how the relatives’ agency was constructed in long-term care facilities. The relatives’

agency seemed to construct randomly depending on various issues such as their and their close ones’ life histories, physical structures and spaces of the facility, interaction with other people on site, and expectations regarding their roles as set by themselves and the staff. She discovered that although relatives affected older people’s quality of life positively when being cared for in inpatient wards, there were no explicit plans or instructions to affirm the relatives’ agentic role in care settings.

Koivula’s ethnographic research inspired me to keep an eye on the role of relatives in many issues related to assisted living residents’ good life.

Riikka Lämsä (2013) conducted an ethnographic study in three hospital wards to understand how patienthood was constructed in everyday life. She made interesting observations of how the ideal and the actual patient were two different categories.

The ideal patient was either an active decision maker on her treatments or a consumer exactly as the laws and recommendations presented in chapter 2 presume.

However, hospital practices, such as patient clothing, time management by the organization, or discussing patients’ issues publicly during doctor’s rounds objectified patients, which is interesting with regard to their recognition as persons.

Lämsä discovered, through spending time in patient rooms, for example how

patients’ agency was passive by nature and how patients learned to understand what was happening in the ward just by listening to its sounds. These findings highlight the core idea of ethnography – the contradictions between the ideal and actual patienthood, the nature of patients’ agency, and the importance of sounds were revealed by spending time in the field observing everyday life.

Sanna Järnström (2011a) studied how customer orientation was fulfilled in a geriatric hospital by taking part in ten doctor’s rounds. Customer orientation is one of the guiding values of person-centered care, which highlights self-determination and individuality, yet in everyday life in a geriatric hospital it seemed to be an ideal that was rarely reached. At worst, decisions about older patients’ follow-up treatments and even transfers to nursing homes were made in the absence of the patient herself. Sometimes, when the patient was present, a doctor would ask a nurse if there was something to consider in the case of the patient in question. Written documents and other professionals got emphasized instead of the older people themselves, which again makes one wonder about patients’ recognition as persons.

We will return to this issue in assisted living surroundings later in chapter 6.3 on recognition.