curtain

In the classic movie The Wizard of Oz there is a memorable scene where, thanks to wonder dog Toto, Dorothy looks behind a curtain and finds out what is really going on. In healthcare clinicians pull curtains around patients to provide privacy while performing clinical tasks such as a physical assessment or some procedure such as turning a patient. While no one would ever suggest that privacy be eliminated, by closing the curtain clinicians deprive their peers of learning from each other, including possibly alternative ways of performing tasks or celebrating together practice expertise.

There are four guiding principles of video reflexive ethnography: exnovation, collaboration, reflexivity, and care. Exnovation is the topic of this blog and is the principle that helps us “see” what’s behind the curtain so that we can learn from one another and identify how quality care is provided. Exnovation is defined as the explication of hidden strengths of practice. Exnovation makes visible strengths and potentials of practice to an entire healthcare team. For any mathematicians who are reading this blog, exnovation = excavation + innovation. A core assumption underlying exnovation is that clinicians already have the tools they need to provide quality care but are unaware of all of the resources in their toolkit because their practice is invisible either to themselves or to others. It occurs behind a curtain, literal or figurative. Although the concept of innovation in healthcare is all the rage, innovation or new practices may not be what’s needed, but rather exnovation…greater visibility of those practices already in use. Unlike innovation, exnovation does not bring new elements into clinical practice but aims to explicate and use practices that are commonly available.

Performance improvement requires first identifying current practices but sometimes it can be difficult to identify current practices. Ordinary, dull, boring routines of practice become invisible over time especially when they are repeated daily or more frequently. Exnovation requires uncovering every day practices or “digging out what is there” for clinicians to use to support improvement. Exnovation is characterized by a positive focus on potential (strength of practice) and also how we conduct those practices in the here-and-now (existing practices). Many times such practices are so mundane that no one would ever consider them worth a deeper look or excavation. For example, as a critical care nurse I used to turn my patients every two hours to prevent the development of pressure ulcers (also known as bed sores). While turning the patient, I would also inspect the linens for wrinkles and smooth away any wrinkles that were under the patient or otherwise touching the patient’s skin, scanning the patient from head to toe to make sure all wrinkles were eliminated. While smoothing linens with my hands I would also sometimes find objects in the bed and remove those as well: crumbs from an earlier meal, syringe needle caps, tissues, etc. But were someone to ask me about what I was doing, I would say I was turning my patient every two hours without mentioning the accompanying activity that may have also contributed to pressure ulcer prevention.

As Carroll and Mesman explain, exnovation requires an outsider’s view to notice something in what to insiders is very ordinary and routine. But insiders’ knowledge is required to understand the practice in context and recognize the ordinary as an extraordinary accomplishment.

Video reflexive ethnography (VRE) is the methodology used to uncover exnovation. A group of clinicians decide that they want to inspect or examine a specific clinical practice for any potential for improvement. Keeping the pressure ulcer analogy going, let’s imagine that a hospital unit has recently experienced quite a large increase in patients who have developed pressure ulcers while in hospital. The clinicians decide to tackle this problem by video recording each other as they turn their patients every two hours. After about 10 or so such videos have been taken, a group of clinicians get together to watch short video clips that are strung together into one longer clip of various members of the group turning their patients. In watching the video clinicians can see variations in their practice and learn from one another. An outside facilitator who also watches the clips will see aspects of practice that the clinicians in the group take for granted, such as the fact that everybody smooths wrinkles and removes hidden objects from the bed. By bringing attention to those aspects of practice the facilitator makes explicit practice strengths for clinicians to then comment on. Perhaps the videos are taken during an organizational transition from one type of under pad to another. Underpads or “lifters” are typically placed under patients’ buttocks to facilitate moving patients in bed and absorb excretions, so that if the patient has an “accident” in bed, only the under pad has to be changed, and not the entire bottom sheet. Clinicians notice on the video that some patients were lying on the “old” under pads while another group were lying on “new” under pads. Someone in the group mentions that the new under pads, while saving money, do not seem to wick away moisture in quite the same way as the old under pads, providing the clinicians with another avenue to explore in their quest to reduce the incidence of pressure ulcers on their unit. Of course, viewing video clips and commenting on them is a description of a reflexivity session, which will be the topic of another blog!

References

Carroll, K., & Mesman, J. (2018). Multiple Researcher Roles in Video-Reflexive Ethnography. Qualitative Health Research, 28(7), 1145–1156. https://doi.org/10.1177/1049732318759490

Hung, L., Phinney, A., Chaudhury, H., & Rodney, P. (2018). Using Video-Reflexive Ethnography to Engage Hospital Staff to Improve Dementia Care. Global Qualitative Nursing Research, 5(July), 233339361878509. https://doi.org/10.1177/2333393618785095

Mesman, J., Walsh, K., Kinsman, L., Ford, K., & Bywaters, D. (2019). Blending video-reflexive ethnography with solution-focused approach: A strengths-based approach to practice improvement in health care. International Journal of Qualitative Methods, 18, 1–10. https://doi.org/10.1177/1609406919875277

December Blog: What’s behind the curtain?